BY

AZIZ AHMED KHATTAB, D. (obs:.) R.c.0.G., mm.

Professor of Fertility and Sterility,
Former Head of Clinical Pathology Department,
NGO, Consultant and Lecturer ln Sexual Medicine,
Ain Shams Faculty of Medicine,
and University Hospitals
Cairo, Egypt
 THIS BOOK IS DEDICATED
To
My Family,
The Medical Profession
And
EGYPT

Published 1986, l·irst edition.

Copyright ( c) W86 by AZIZ AHMED KHATTAB
Second edition IOW
Third edition. NW9
All rights reserved. No part of this bool; may be reproduced
in miForm nr lov mtv el€Cit"0t‘tiC or mechanical IlICZll1S_

y including information storztgc and retrieval s

without permission in writing from the author.
 FOREWARD

Although it is true that there are regional, cultural

dif`f`ereih respect to human sexuality, the science of sex
he universal tongue of science. The science
gy, mercan sexology or the sexology of any nationality.
When sexual medicine is not scientific it replaces sexoloth
gy,rome tescience, with sexosophy, the philoso
family, the community, the religion — yes from h
even te traditions of medicine.

ln the l8"` and l9"` centuries, Western sexual rnedieine w

on scientific sexology, but on a medical sexosophy which wa
medical doctrine of degeneracy
pcause odegeneracy. asthethe
Total abstinence was cause of
doctrinal
ideal. Sexual intercourse was recommended for procreafion o
once a month was considered excessive!. Masturbation and seminal
emissions .in sleepthey(spemiatorrhea)
e egeneracy caused could be passed on to all were c
subsequent generations, it was taught!.

The change away from this absurd sexosophy toward the rati
y sexual science was occasioned by one thing more
thng was the discovery of the industrial processing of rubber. l
commercial production ofthe first rubber condom. That was in the
true beginning ofthe contraceptive age was in the
ruer condoms were produced. That was barely halfa century ago.
late l92
Half a century is not time enough for a society to reformulate i
s sexosophy. lt takes longer to accommodate to the new sexua
made possible to human beings by birth control and plan
toay, therefore people
osexosophy andin all countries are caught
the new.

The medical profession like all of society, is caught up

Consequence, it is not possible for any book
psexoogcay scientific. No matter who the author may be. h
in sexu
e cannot help but lean now on this side, now on
y, n r. Azz Khattalfs book, you will lind some concepts to
agree with, and some to argue with. Fine l that is why it is a good book
 A good book is always one that makes you think, and challenges your
intellect, and changes what you think. ln sexosophy you should take nothing for
granted, for it is regionally relativistic, and historically subject to change.
Examine your own attitudes, and revise them if they are anachronistic. In that
way you will serve your patients best.

ln sexology also you should take nothing for granted. Like all sciences.
sexology is constantly being updated as new experiments are done, and new
evidence produced. The rate of change in sexology today is very rapid, especially
in the sexology of neuroscience, hormones, and the brain.

Professor Khattab has done a great job in bringing modern sexual

medicine into the Egyptian medical school curriculum. lt takes courage to
contravene the old sexosophy with the new.

Good Luck to This Book.

May it have many readers.

Dr. JOHN MONEY

Professor of Medical Psychology &
Associate Professor of Pediatrics,
The Johns Hopkins University
and Hospital
Baltimore, MD 2l205
U.S.A — l98l
 lt is well known that writing a book about sexology is not an easy task,
but to publish a medical one especially in Egypt 1 realised is an even har
. Back from London 1977, 1 took the opportunity to start editing this v
the benefit of the medical profession in Egypt as well as in the Arab World

The idea to publish this work was in my mind all the time since the y
1964; at that time, 1 was teaching a modest course of sexology as part of
graduate medical curriculum. Only in 1977 did I succeed to convince my m
colleagues about the values of a sexology course for the Ain Shams medical
students. lt is true, 1 must admit that very few professors were aggressive and
even highly critical of this endeavor, but the majority to be honest were
encouraging and very enthusiastic, realizing the great need for my scientific
adventure specially in Egypt. Now, the book is ready for the thousands of medica
students and doctors, who were asking for it and expressing their honest deman
for this reference, as such I had to put my lectures on paper. 1 present this m
work for all, to read, to learn and may be to benefit, so that they may have a
stable and happy family life.

Forgive me, this book is not meant only for medical students or doctors.
No, it is for all adults, it is for everybody especially parents and teachers. As a
matter of fact, it is for everyone male or fernalc who is interested to know the
truth about our human sexuality long forgotten in this good part ofthe world.
I sincerely hope that this piece of scientific work will not offend anyone
because of its frankness in such a very sensitive and highly vital medical iss
but 1 can assure everybody that 1 have done my utmost to present an hones
knowledgeable explanation of such a delicate part of our sexual physiolo
anatomy. My friend, Professor Dr. John Money, who is an international author
in the entire field of sexology and a world expert on gender identity kindly
forwarded this book while he was in Cairo, 1981. His famous lecture in the Ain
Shams Faculty of Medicine, inspired me to complete this work and to write more
on the dangers of female circumcision in Egypt and in some parts of Africa.
1 have tried through this third edition to add what was recently discover
in the field of sexual medicine over the past ten years. The normal physi
mechanisms of erection in the male is quite evident and well documented now
. Male erectile dysfunctions. are amenable to better treatment with mo
available eg. Viagra (Sildenatil citrate), pharmacogenic intracavernosal
injections for diagnosis and treatment are on the market but must be under
medical care. Female genital mutilation has become a national sensitive issue in
Egypt especially after the lC`l’D conference in 1994; and a new tlcrrree is issued
by the Minister of llealth prohibiting its practice by anybody, medical or n
medical. '1`he vital role ofthe external female genitalia in achieving orgasm in
non—eircumcised females was confirmed by Johnson and Kaplan. The recent
advances in the research of All)? virus and the possible role of new drugs e.g.
AZT to combat the virulence of this epidemic. The unfortunate widespread of
AlDS virus (40 millions) in the year 2000 in Africa and Southeast Asia, as well
as STDs (sexually transmitted diseases) 320 millions last year (WHO reports).
The possible role of olfaction in human sexuality through the sex attractant
pheromones was discovered in human vaginal secretions reported by Beiber et al.

The {CPD recommendations enforced the NGO (non govemmental

organizations) to speed their efforts in the field of sex education, reproductive
health and the fight against (FGM) female genital mutilation. The question of
clitoral versus vaginal orgasm theorised by Freud was finally resolved by the
research started by Masters and confirmed by HS. Kaplan proving that the
clitoris is the transmitter and conductor of erotic sensations in females. The
international sexual scandal of Monica Lewinsky is mentioned in the chapter of
the paraphilias. The reader will note more information through reading, which
will add useful and recent sexual knowledge in this third edition.

My experience in this field of medicine as a gynaecologist for the past

fifty years, since l was graduated in 1948 (Ksr El Aini) Faculty of Medicine, is
presented within this manual together with the sexual research perfomied
internationally. References to most medical statements and research are at hand in
my library for any more information.

To replace widespread falsehood with the written truth... To explode

many of the old myths of human sexual life... To guide married couples to more
complete happiness. l invite the attention of all adult readers to a sober and
dignified discussion of female and male sexual behavior.

Dr. Aziz Ahmed Khattab

Address: 28, 26 July Street.
(`aim, PL`; l l I l l
Telephone (Clinic): 5742l52
 CONTENTS

FOREWARD By Professor Dr. John Money (U.S.A)

INTRODUCTION .

. SEX EDUCATION IN MEDICINE

THE DEVELOPMENT OF SEXUAL BEHAVIOR .

MALE AND FEMALE SEXUAL ANATOMY . 25

. THE PHYSIOLOGY OF COITUS IN THE HUMAN FEMALE 37

. THE PHYSIOLOGY OF COITUS IN THE HUMAN MALE 59

POSITIONS OF SEXUAL INTERCOURSE 75

MALE SEXUAL INADEQUACY (DYSFUNCTIONS) 81

FEMALE SEXUAL INADEQUACY (DYSFUNCTIONS) IO4

SEXUALITY AND FEMALE CIRCUMCISION 122

10. SEXUAL PERFORMANCE IN DIABETES 139

ll. EFFECT OF DRUGS ON SEXUAL PERFORMANCE 147

12. IIOMOSEXUALITY AND LESBIAN LOVE . 161

13. MASTURBATION OR THE SECRET SIN 176

14. SEXUAL GLOSSARY AND THE PARAPHILIAS 184

 SEX EDUCATION IN MEDICINE

¥Vhy teach doctors sexoiogy

Milestones in the history of sexology.
 SEX EDUCATION IN MEDICINE
Why Teach Doctors Sexology ?.
lt has been proved that doctors were inadequately traine
treat patients with sexual problems and that the physicia
eing inadequately trained by most medical schools. With in
more and more medical schools added sex education to
fortunatey it was started in Ain Shams Medical School during the
the students of the final years; although l
orensc, Skin and Venereal departments since the year 1964. taught th
Statistics in U.S.A and Europe revealed that an estimated one te
adult patients the physician sees in his clinic have s
aoamarried couples, experience at one time or another ma
maajustments; the severity ofthe problem is reflected in
rae omarriage failure or separation and divorce.

Sexual problems are among the most sensitive and embarr

complaints that patients bring to their physicians in
nvuaanfamily values. The doctor who received training and kno
human sexuality during his medical training, can help to alleviate m
unnecessary suffering and to preserve many ofthe growin
wch are in
o noteacsexual serious
medicine trouble today. Unfortunately most
up till now..

ln recognition ofthe growing need to prepare a good number o

for the task of helping patients with problems related to sexuality, a
books in the field of sexology especially designed to
ucaton program were prepared. Most of the sexual medicine books were
g
eveloped and written to operate on three levels:

l`he acquiring of healthy sexual information through these medical

The modification of personal attitudes and the proper correc
wrong beliefs and sex taboos, particularly in view of the fact that me
students, whether males or females are also subject to embarrassm
discomfort in dealing with sexuality like anybody else.
The learning
marital problems.
of the necessary skills in dealing with patient’s sexu

For several years, it was with concern that many professors noted th
medicar profession is not trained to deal with sexual problems. We all kn
doctors that problems conceming sexuality is brought
cncs and hospitals or unfortunately
proems concerning the following very sensitive issues: never brought at all
 Sex education of our children from infancy to adulthood conceming healthy
medical information to protect them against drug misuse, abnormal sexual
behavior and sexual harassment.
Adults sexual information before marriage for both males and females.
3) Unwanted repeated pregnancies and the dangers of criminal abortion.
Problems of infertility and its treatment; as well as the right advice as regards
the suitable methods of contraception accepted by both husband and wife to
avoid population explosion.
Babies born with sexual anomalies e.g. kryptoorchidism and true or
pseudohermaphrodite.
Questions about masturbation and noctumal enurcsis.
Questions about female circumcision, described properly now as female
genital mutilation and its drastic complications.
Questions about sexual perversion e.g. homosexuality, lesbianism and oral
eroticism.

How to deal with marital sexual dysfunctions reflected upon many marriages
to avoid divorce, separation and marital disruptions.
10) Male sexual inadequacy e.g. erectile dysfunction in the husband, premature
ejaculation and ejaculatory incompetence.
ll) Female sexual inadequacy e.g. frigidity, lacking orgasmic capacity, non
resolved sexual tension, vaginismus, dyspareunia and apareunia.
12) The normal physiology and anatomy of coitus in both males and females.
13) T`he endocrinological, nervous and physiological responses of the sexually
stimulated male and female e.g. sexual dysfunctions in the diabetic and
hypertensive patients; not forgetting heart diseases.
14) The immense values of precoital petting and the importance of the erogenous
zones.

15) Effect of prescribed drugs on sexual performance and the false role of
aphrodisiacs e. g. Hashish, bango and heroin etc.
16) Sexual performance in old age.
17) How to avoid sexually transmitted diseases (STDs), as well as AIDS.
18) Mental hygiene in sexual behavioral development; the critical phases of
lactation and its importance, weaning, toilet training and infantile correction
last but not least the critical puberty problems faced by our children.

Conclusion

Not only patients but plenty of people including husbands, wives and
couples bring these questions and thousands other problems to their doctors
because they are sure that the doctor is an expert '? All too often he is not
and the doctor is unfortunately is as ignorant as his or her patient !

To be honest, most physicians know more about the anatomy and

physiology of the sexual and reproductive organs than their patients who come to
them for help. But, few doctors know enough about sex problems and fewer still
have been properly trained in the practical and clinical management of sexual
problems.
 Worst of all, too many physicians still share with their patients the very
wrong and false ideas that give rise to sexual problems in the first place. As
example, among the most established principles in the entire sexual field is the
discovery that guilt feelings about masturbation rather than the act of
masturbation itself, that causes emotional distress. Yet, as late as l949 in the
U.S.A. a study among medical students in the Philadelphia Medical School,
revealed that half of the medical students still believed that masturbation itself is
a frequent cause of mental illness. Worse yet, one fifth of the medical staff of this
same medical school shared the same false idea.,

lt is very hard to see what good can be accomplished, when a patient in

need of reassurance consults a doctor who shares his groundless anxieties and
ignorance. When branches of medicine are taught in medical schools. progression
from the normal physiology to pathology has proved to be the most effective way
to teach. Students team first how the normal heart functions and the many ways
in which it can malfunction. In the area of sexual medicine, however, we have
had no sure or established framework ofthe normal physiology of sex to presen
But now, that the gap is being bridged by the Masters and Johnson research, it is
high time to start the teaching of normal sexology in the human male and female.

Another defect in our teaching of sexology. is the embarrassment the

physician feels when dealing with the sexual problems brought to him by his
patients. Now, unless the doctor is competent and not biased i.e. knowledgeable
and honest, not forgetting being comfortable i.e. he has the time and interest
while dealing with these problems, his patients will feel it and the possibility ofa
successful sex therapy will be diminished or even tail altogether.

By perfomiing sex research in precisely the same way in which research

on the heart, the lungs, the kidneys is performed: Masters and Johnson have made
it easier for the physician to face sexual problems with the sarue spirit he applie
to other medical problems. They have shown that the intimate facts ofthe sexual
response can be discussed openly and frankly between doctor and patient with
dignity as well as respect. This is a valuable lesson for both the medical student
and the general practitioner. Finally, specialists and sexologists concerned with
medical education have needed a therapeutic model - an example of how a clinic
or a physician in private practice can successfully diagnose and treat the common
forms of sexual inadequacy, sexual incompatibility and sexual frustration

Since 1959, Masters and Johnson have been engaged in the treatment of
patients complaining of these conditions. One novel and new feature of this
approach is that they as a male—female team of therapists treat husband and wife
as a patient team. A second feature is their use of retraining procedures - the
actual training of husband and wife to use new techniques described in detail for
achieving mutual sexual satisfaction. ln addition to this the Masters and Johnson
techniques provide simultaneously a sort of a psychotherapy treatment for their
patients even ifit is not structured and formalised in the traditional ways. By their
own confidence and frankness, they reduce their patients`anxiety and shyness.
 This makes it possible for a husband and wife to talk freely about their
sexual problems with the sexolegist and with each other and then to do something
about it. Once patients feel they have made even a little progress as the result of
this combination of psychotherapy and retraining. they feel encouraged to
continue further training. Thus, the underlying psychological factors are of great
importance in the total approach of sexologists and other doctors as well, to the
treatment of sexual inadequacies and psychosexual problems.

Medical students have created much of the momentum of medical sex

education, because they are sufficiently different from students ofa few decades
ago to want this change and similar enough to need it. Like an increasing number
of their teachers, many feel that sexuality is part of healthy emotional and
physical function in a· range of subjects from premarital counselling to post
coronary treatment and counselling. Many experienced practicing physicians are
also seeking greater knowledge of sexuality, because they have been confronted
by the daily demand for it. This need is now being met to some degree by new
efforts in continuing sex education. The aims of health-care professionals at all
ages and professional levels increasingly include the ability to:

- Be comfortable with sexual topics and put patients at ease in discussing them.
Listen well, remember to take a sexual history and know how to take an
accurate and useful one.
Remain aware of patient`s feelings and thus avoid creating shame and
embarrassment.
Recognize masked psychosexual problems and the sexual implications of
various dysfunctions and courses oftreatment.
Judge whether the sexual implications or problems are within the physician’s
competence; if they are not refer the patient to an appropriate professional expert.
Within the competence of an expert, a plan of treatment is set up with the
patient`s full knowledge and consent.
Take advantage of the educational and preventive aspects of medical sexual
knowledge.

Milestones in the History of Sexology

ln the year l787, the German society was shocked when a famous
headmaster by the name of Herr Sprengel published a scientific paper with the
following daring title: "lVIystery of nature in the fertilization of flowers". The
poor headmaster was immediately sacked from his post and the paper was
condemned and described as trash,.

ln the Victorian era, at the time of Queen Victoria ruling the British
Empire. any wife reaching an orgasm during an act of coitus was considered by
some as loose and described as a whore or prostitute because sex is for men’s
pleasure and not for women !
 During the late 19th century and in the early twenties, Sigmun
presented hisunfortunately
e was escried famous sex theory,
as a crazy which
man and ought tocaused
be handedquite
to the
police!.

ln the year 1930 in England, Professor ll. Ellis was put in prison af
published his masterpiece book in sexology, namely, "The Psycho
With the advent of time Professor Alfred Kinsey, an entom
presented two great books dealing with sex research. "Sexual beha
human male, which was published in 1948 and he put forward his seco
in the year 1952, namely, "Sexual behavior in the human female". T
books entailed 18.000 interviews with male and female volunteers, w
most remarkable sex discoveries namely:

l. True frigidity is only 2% among women while the rest sexual

inadequacy was truly lacking orgasmic capacity.
2. ln the pre-Kinsey era a person was described as either a homosexual
heterosexual but when the facts were published about the sexual life of th
American people, it was found that 4% were true homosexuals and anothe
has to be added who have had more than several homosexual encounters l
. 3. Bestiality i.e. making or attempting sexual contact with animalswas
, prevalent among the American public especially with house pe
to what was believed.

The publication ofthe Masters and Johnson report in 1966, on the "Hum
Sexual Response" marks a tuming point in the history of sex research. lt
lot of knowledge and scientific data concerning the sexual behavior of t
male and female through their sex research, the physiology of coitus an
stages of the male and female sex cycle were revealed.

ln their book "lIuman Sexual Inadequacy", more was described about

premature ejaculation and impotency in the male as
te female. Their latest research deals with Lesbianism i.e. female
well as t
homosexuality. ln 1979, Kaplan`s manual "New Sex Therapy" w
towards the successful treatment of male and female sexual dysfunc
H3[l(lb00k of Sex thet‘apy” by Joseph Lopiccolo, "Human S
Morton G. Harmataz. "Textbook
valuable as well in this field of sexual medicine.
of Sexual Medicine" by Robert C

The societies nowadays have taken a giant step towards the day
human sexuality can be openly taught - to the married and young
going to be married, who need such insight so despera
wo neeit even more, not forgetting our medical students as well as their
medical staff.
THE DEVELOPMENT OF SEXUAL BEHAVIOR
Sigmund Freud and the development of sexuality.
Infant and childhood sexual behavior.
Mental hygiene in sexual development.
Early conditioning and sexual development.
Patterns of sexual behavior.
Endocrine aspects of sexual behavior.
 Today, it is generally accepted that sexual behavior does not come
naturally to human beings, but is in fact shaped by social conditioning and
learning, mainly through this conditioning which produces different results in
different individuals and societies. Also, there is no longer any doubt that
children are capable of sexual responses and that certain early childhood
experiences can have a crucial influence on a person’s later sexual development.
What is true of human physical growth also applies to the development of human
sexual behavior. Masculine and feminine attitudes and the preference of certain
sexual partners or certain forms of sexual activity are not established once and for
all at one particular moment, but are acquired gradually over a period of time.
The outcome of this process depends not only on a child’s inherited abilities, but
also on social influences, such as the reactions of parents, teachers, playmates,
and friends. For example, an infant boy may consistently be treated like a girl by
his family and thus leam to consider himself a female !... This early role
assignment may then become irreversible and lead to lifelong difficulties. To put
it another way, children whose sex is misdiagnosed at birth for one reason or
another learn to identify with the sex that is assigned to them. Furthermore, once
a certain critical period of their age has passed, this identification is permanent
even ifthe mistake is later discovered. After a certain age, a boy raised as a g
will continue to consider himself female and in most cases, feel sexually attract
to males, while a girl raised as a boy will continue to consider herself male and,
in most cases, feel sexually attracted to females. That is why a person’s sexual
development has at least three aspects to consider.

l. The male or female characteristics ofthe body = (biological sex).

2. The social role given as male or female = (gender role).

3. The preference for male or female sexual partners = (sexual orientation).

Even boys and girls who develop the nomial and appropriate sexual self
identification may later have traumatic experiences that prevent them from attain
ing their full sexual potential and lock them into narrow patterns of compulsiv
destructive behavior. Also, there are many adults who, after an otherwise heal
development, find themselves strongly inhibited, poorly coordinated, and thus
sexually inadequate.

Now, the realization that adult sexual behavior results from a long,
complex, and often hazardous development is relatively new. Until about the
beginning of our century, sex was believed to be largely instinctive, i.e. the result
of biological heredity. Most people simply assume that, at some time after
puberty, sexual desire and sexual activity "come naturally" to every male and
female, and that no social conditioning was involved or necessary. Sexuality wa
thought to be a "force of nature" which appeared suddenly and then, al
itself] found its full "natural" expression. People believed that society could
suppress this force, but had no part or role in shaping it. The first serious
challenge of this view came from Sigmund Freud (1856 - 1939 ) and his
followers.

According to psychoanalytic thinking, there is a basic sexual instinct or

drive present universally in all human beings from the moment of birth. This
instinct, which strives for sexual pleasure, is at first diffuse and attains its
eventual proper direction and focus only through a process of "psychosexual
maturation". Human infants first seek their gratification in a direct, unhampered
and undiscriniinating way, until they leam to modify and control their instinctual
urges through social conditioning. Human sexuality thus unfolds under the
influence of two opposing forces: the "pleasure principle" and the "reality
principle". ln other words, a child`s personality development can be described as
a contest or struggle between biological drive and cultural constraint or
limitation. This contest proceeds in three major steps, which are coordinated with
the child’s physiological maturation: the oral, anal, and phallic phases, which
will be described fully within Freud`s theory.

Sigmund Freud and Sexuality Development

"Repressed sexual feelings were at the root of all mental illnesses; while
in normally adjusted people, sexuality played a predominant part in the
functioning of the mind". 'l his daring statement by Freud was pretty
inflammatory stuff and so his opponents reacted with horror and disgust. ln l9l(l,
ata neurological conference when Freud`s name was mentioned. people believed
he was crazy and that he saw sex in everything, and ladies blushed when they
mentioned his name!. A famous German neurologist stated that, it is a matter for
the police to deal with Sigmund Freud and his name should not be mentioned in a
scientific meeting..

What Freud really said was that sexual life does not begin at puberty
only, but it starts with clear manifestations soon afier birth and that the stages o
sexual manifestations are:

l. During the first year of life. the mouth is the center of pleasurable
excitation, that is why it was termed the "oral phase" or "oral eroticism". lt is
divided into two phases, the first is where pleasure involves "sucking" the
mothcr`s breasts, but later "bitting" the breast`s nipples becomes an important
issue. Most mothers who are breast feeders, know too well these two phases and
the tendency for everything to go into the mouth of the baby regardless of
suitability and the second painful phase of "oral sadism". As the infant sucks the
mother’s breast, it finds not only nourishment, but deep physical and
psychological satisfaction. ln this phase, the month also serves as an organ of
exploration, the infant when he puts everything in its mouth is doing so. in order
to get to know it. "Taking in" the world. is the first attempt at mastering it.
 2. During the third year of life, the anus becomes the chief center of sex
- citation and hence it is described as the "anal phase". Here, acc
the child gets pleasure "expelling" his faeces at the
aer n ts pase, from retainingits faeces. The child now gaining control ov
the bowel movements and thereby, indirectly, over the attending adu
can now please or displease by eliminating or withholding faeces. At the
time, the child learns to grant or withhold affection,
maser te world by holding backand "letting go". lt is interesting to note tha
the anal phase is often coincident with the time of "toilet training"
3. While the oral and anal phases, which extend roughly through the
three years of life, are the same for both sexes, the now
pase(from Greek phallos: penis) brings an increasing awareness of sexual
differences between the male and female sex organs. The most pleasurab
of the body are no longer the mouth or the anus. but the penis Hur boy
clitoris for girls. This is the phase in which children become actively
about their surroundings, they poke their fingers into things, look
by taking them apart, and also investigate their own and each other’s bodi
worth reminding
pens anthe clitoris at thishere
age, is that the
different andpleasure
divorced fromderived from th
ideas of sexual
intercourse. and the child is completely ignorant of modes or techniqu
adult mature sexuality. Boys for instance, become interested in the size of their
penises and they may even compete as regards the power oftheir urination!.
4. At around the age of five years, the phallic phase is inhibited by
complexes, namely, the Oedipus and castration complexes, who tend
the infantile sexuality. The term "Oedipus complex" is the child’s erotic
attachment to the parent ofthe opposite sex as well as a feeling of riva
the parent of the same sex. The name was related to the legendary G
Oedipus who unknowingly killed his father and married
t is the rule for a four- year—old boy to be deeply in love with his mother. Sh
for him, the only woman he knows and cares to know, however, this wom
already has a husband—the father. The boy is jealous of him and would like to
push hirn aside in order to assume his position. This desire is usually expre
openly and spontaneously, as for instance when the boy climbs into his mother`s
bed announcing: "when l grow up. l'll marry you!." Obviously this situati
through the normal development ofa child takes anothe
hs desire to marry his mother with the wish to marry a woman like his mother
, and his urge to take the place of his father turns into the determination to becom
a man like his father. The boy can make this transition easily, if the father
provides an attractive model to follow, and if he actively encourages his s
become a healthy man. At the same time, it is the mother`s task to hel
realize that she has already chosen and is no longer available as a se
.normally
This elsewhere
healthywhen
parental attitude
he is mature.
will lead the boy to seek his sexual grati
 5. ln the case of a girl, the development takes the opposite course; she
loves her father and is jealous of her mother. The respective psychoanalytic term
is "Electra complex", after Electra, a legendary Greek princess who, after t
death of her beloved father helped to kill her mother who had murdered him.
Freud believed that every child normally progressed from the oral to the
anal phase and finally to the phallic phase, unless some negative influen
interfered with this sexual development. However, if the particular needs of any
one of these phases were either unfulfilled or gratified to excess, the ch
become "fixated", and thus hampered in its psychosexual growth. For example
child’s too rigid or over indulgent toilet training could lead to a fixat
anal level of satisfaction. As an adult such a child would then tum into an anal A
character", i.e. a person who is obsessed with discipline, order, and cleanli
who hoards money, (the unconscious equivalent of faeces, which can be
"withheld" from others) and who prefers anal stimulation to all other forms of
sexual intercourse. An "oral character", on the other hand, would continue to
depend mainly on his mouth even for sexual satisfaction such as deep ki
and/or abnormal oral genital contact. He or she might become a compulsive ea
smoker, or drinker, not forgetting bitting nails or lips and thumb sucking. Ora
eroticism could be expressed directly in our society and may be of no harm wi
our culture, but anal eroticism, however, has almost no overt expression oth
than sexual perversion i.e. sodomy or anal intercourse. One ofthe few anal
eroticism direct expressions is the excessive interest in bowel movements
cleverly exploited by drug manufacturers in our society. Children
become tixated in this manner eventually reach "genital maturity. That is to
w
say, after a so-called latency period, during which obvious sexual interes
largely suspended, the sexual urge reawakens with puberty arrival an
satisiaction through genital intercourse. Oral and anal stimulation may still
joyed but to a limited extent, because they now take second place to
for adults, is the one truly "mature" fomi of sexual expression.
 Infants of both sexes may be observed rubbing their sex organs against the
bed, the floor, or some toy in a thrusting motion, and there is no doubt that they
derive physical pleasure from it. For sometime, they are still unable to coordinate
their movements and to use their hands for a more direct stimulation. However,
after a while they may leam to do so and begin to masturbate. Quite often, such
deliberate masturbation is carried through to the point of orgasm. Kinsey and his
co—workers reported that orgasm during masturbation occurred in nine males less
than 1 year old. "The behavior involved a series of gradual physiologic changes,
the development of rhythmic body movements with distinct penis throbs and
thrusts, an obvious change in sensory capacities, a final increased tension of
muscles, and a sudden release with convulsions, including rhythmic contractions
followed by disappearance of all symptoms". Bakwin described masturbation in
three infant females that appeared to result in the physiologic manifestations of
orgasm, including abrupt general relaxation and sweating. Havelock Ellis, cites a
paper by West written in l895, "Masturbation in Early Childhood", and one
written by Townsend in 1896 on, "Thigh—Friction in children under one year"
Infant Masturbation

Certainly masturbation to the point of orgasm is not a frequent behavior in

infancy, but as the child grows, it is likely that identification of genital
stimulation as a source of pleasurable sensations leads to repetitive and more
attention is given to erotic gratification. As children become able to verbalize
their feelings and needs, typically between the ages of 2 and 4 years, quite
specific explanations ofthe pleasing physical and emotional sensations occurring
from genital manipulations can be discovered. The child is quick to sense parental
attitudes of disapproval toward genital play and may be confused by parental
encouragement to be aware of his or her body, but to exclude the genitals from
such awareness!. The contradictory messages that the child learns in such a
situation may be among the earliest recognizable common determinants of future
adult sexual problems.

Childhood hlasturbation

A chi|d`s orgasmic capacity increases with advancing age, by their fifth

birthday, more than half of all boys have reached orgasm, and for boys between
l0 and I3 years of age the figure rises to nearly 80%. Naturally, the orgasms of
these boys are not yet accompanied by ejaculation, since no seminal fiuid is
produced before puberty, (even then the ejaculated semen may not contain any
sperm cells for sometime). On the other hand, some boys are capable of several
orgasms in quick succession, they normally lose, this capacity as they grow older.

10
 By the time boys and girls reach the age of l5 years, only about 25% of all
girls have masturbated to orgasm, while the comparative figure for boys is nearly
l00%!. It can be said therefore, that masturbation is a universal experience of
male adolescence. However, there is much individual variation as regards the
frequency and technique. Some boys masturbate regularly and of`ten, others only
occasionally or for a short period of their lives. As for technique, many boys use
one or both hands to squeeze and stroke the penis. Some rub it against the bed
mattress, a blanket, or a pillow. Others try to approach the feelings of coitus by
inserting the penis into the wide mouth of a bottle, a toilet paper tube, or a pa
rolled-up socks. Still others try to take their own penis into their mouth, althoug
they normally find this to be anatomically impossible, (only about l% of all
males can do it). It is not unusual for a boy to experiment with these and similar
masturbation techniques and to switch from one to the other, according to the
circumstances. However, no matter w·hat method is used, the adolescent male
soon learns how to reach orgasm at will.

Female Masturbation

Girls also employ different masturbation techniques. ln most cases, they

move a finger or the whole hand gently over the clitoris and the surrounding area.
Since a prolonged direct stimulation of the clitoris can become painful, many
girls prefer to caress the entire vulva. Some of them insert a finger or some round
cylindrical object into the vagina and thereby try to approach the experience of
coitus. They may also rub the vulva against the corner of a chair, some firm
cushion, or mount any suitable seat, e.g. bicycle. There are girls who reach
orgasm simply by pressing their thighs closely together while rhythmically
moving one leg or contracting the muscles of their buttocks. Hardly any two girls
masturbate in quite the same way, or in similar fashion..

lt seems that on the whole, fewer girls than boys masturbate to orgasm at
any early age. One reason for this may be found in the different anatomy of the
two sexes. A penis is comparatively easy to manipulate, and its erection is more
difficult to ignore than the mere lubrication ofthe vagina, A second reason, may
be the passive nonsexual attitude that girls learn to adopt as a result of our social
conditioning. In our culture, little girls are usually not encouraged to be sexual
beings, while many boys are taught how to masturbate by others (mostly older
boys), girls usually develop the practice by themselves. Actually, in some
instances girls masturbate regularly for years before they find out that this is what
they have been doing. They may then be quite shocked and feel guilty about it..
Society and Masturbation

After all, rtl0Sl people ltr Our culture Corrsicler rrinslirrbntimt wrong, and in
spite of all the propaganda tothe contrary, many adolescents still adopt the moral
values of their elders. Since most adolescent boys masturbate, the moral problem
11
is particularly acute for them; they are told not only that masturbation is sinful,
but also that it may cause physical or mental ailment. They are sometimes wamed
that excess masturbation can somehow weaken the body; as a result, many boys
feel a double guilt. They seem to displease God and to ruin their health at the
same time.

Since ages, the case against masturbation rests mainly on religious

grounds; traditionally Jews, Christians and Moslems have always disapproved of
the practice. In any case, masturbation is definitely bad if it causes fear, shame,
anxiety, and guilt. Finally, it should perhaps be mentioned that, occasionally,
some adolescents masturbate almost obsessively because they are frustrated,
feeling lonely, or bored. They may be under great pressure at home or at school,
or they may be experiencing some other nonsexual problem. Masturbation may
then become a false escape or an excuse for not facing up to a difficult situation.
Obviously, in such a case the underlying problem should be solved, if necessary,
with the help of medical counselling.

Parents and Masturbation

Parents who see their boys or girls masturbate make a serious mistake if
they become alamied and shocked about it, reacting wrongly by forcing them to
stop under the threat of severe punishment. This will only create needless feelings
of guilt in the children because they continue to perform the practice of
masturbation in secret, (hence the name). The sexual response is a normal
function of the human body at any age and, as such, for many children
masturbation is simply part of growing up sexually, and there is no medical
reason why they should not be able to stop practicing it.

Another potential source of trouble is the reaction of some parents who are
horrified when they discover that their child has been involved in sex play and, in
some cases, they feel that such bad behavior deserves drastic and severe
punishment. This attitude is incomprehensible to children at such an age, and
thus they may for the first time in their lives, feel misunderstood, betrayed, and
abandoned. They also may become so fearful and suspicious of anything sexual
that their further personality development is seriously impaired. Some sensitive
children never outgrow such an early traumatic experience. lt is therefore very
fortunate that, in recent years, adult healthy sex education has made great
progress and parents generally have now become more understanding and
tolerant in these sexual matters.

12
 Mental Hygiene in Sexual Development
For healthy sexual development to maturity, the factors and conditions
involved are nearly the same for both sexes.

Special Periods in Emotional Development

From the start, the relationship and interaction that a child has with his or
her parents is imbalanced. Prior to the baby’s birth and even after, the father
observer only, without direct physical contact with the growing child
in some families the father is present at his child’s birth, whether in a
at home, more typically the father does not share this experience with his wife
with the newborn. lt is regrettably all too common that in most modem societie
, this imbalance is accentuated during infancy and childhood, with the father
spending significantly less time and having fewer chances and actual instances of
physical contact with the child than does the mother. The consequences o
discrepancy of parental contact with the child are not discovered yet, bu
feedback from parent to child and from child to parent may prove to
sources for learning important adaptive social behaviors.
Lactation

Precise information about the erotic components of early parent-child

interaction is quite sparse, but at least one component of this interaction
lactation and nursing — must be recognized as possessing sexual elements. lt is
common for women to become sexually aroused during nursing and suckling
their infants, and such erotic arousal may precipitate reactions ranging fr
pleasure, satisfaction, guilt or fear. While many men regard suckling o
simply a natural means of providing nutrition, some men may be upset b
they interpret the act ofnursing or suckling as a sexual stimulus to their wife or to
their child; others find the act of nursing to be sexually stimulating to the
Nursing in the presence of others similarly produces, in those others, varied
reactions that presumably have nothing to do with the actual act of feedin
child, since publicly bottle feeding an infant provokes no cries of indecenc
sexual symbolism of the breast and the act of suckling are not easily sepa
from our evolutionary heritage as mammals.

Since lactation is the only source for the existence ofthe infant, this animal
existence and dependence upon the breasts of the mother or the milk bottle
, continues and last till the critical time of weaning. Now, the baby learns
first time the feelings of rage, anger. fear, anxiety and hate; because she or he was
deprived of the breast or the bottle. Substitute gratilication is the only
consolation for the baby at this critical time. no wonder, thumb sucking or the
rubber tcat become their sole pleasure for sometime to come, even to aduIt—hood
and a good example is the lolly—pup sweets preferred by some adults!.

13
 Both ends of the gastro-intestinal tract are pleasurable to the baby and are
accepted well by his or her mother or nanny; suddenly, the mother or the society
approves only of one end, namely the mouth and describes the other end, the anus
and the excreta as disgusting and aversion linked. Also, the genitals are
considered private all of a sudden and secretive, then; the threats and punishment
the baby receives during toilet training may be mild or severe. But, the sexual
organs will always remain associated with dirt, secrecy, privacy and guilt
feelings, depending upon the degree ofthreats and the punishments severity.

Infantile Correction

Naturally, the infant explores his or her body and the sex organs as well; at
once, he or she is met with disapproval, even horror, and sometimes punishment
depending upon the culture and the mentality of the parents involved. This severe
infantile correstion reinforces the previous lesson of toilet training in linking and
associating the sexual organs with dirt, not nice and private, including masturba
tion. No wonder that the sexual urge at maturity is usually associated with a sense
of guilt, defilement, sin and penance. A good example, is the resultant frigidity of
many women who submit sexually to their husbands only as a duty and not for a
pleasurable coitus. They may stiffer as such from dyspareunia, vaginismus and
they sometimes refuse coitus altogether (apareunia).

Anatomical Loss

Girls become aware and conscious very early about their anatomy and they
feel mutilated and anxious for the loss of the penis. They phantasize plenty and
compensate for this inferiority complex or mutilation complex by the
spectacular sexual achievements of puberty and they then feel better than boys
due to the development of the secondary sexual characters, eg. breasts.

Puberty

Since the physical changes of puberty may appear early or late, quickly or
slowly; individuals of the same chronological age may find themselves in very
different stages of development. For an adolescent, this is often a matter of great
concern, boys may worry about their height, the breadth of their shoulders, the
strength of their muscles and the size of their penis. Girls may be afraid of
growing too tall, and they may anxiously measure the size of their breasts and the
width of their hip. Indeed, during this period, young people tend to become
extremely sensitive and self—conscious about their appearance, especially if they
gain too much weight or due to the presence of acne. Another potential source of
embarrassment is the heightened sexual responsiveness, for example, boys may
resent the fact that they have sudden erections at very awkward moments.
Paradoxically, the sexual awareness of girls lags well behind that of boys. While
the secondary sexual characteristics may appear much earlier in females than in

14
 males, the female capacity for sexual arousal and
aer. nortunatey, many parervs still allow their girls to menstruate for the tirs
time without knowledge or ed.=cation; it is a major
appen around menarche, which is seldom forgotten or fo
gr.

Libido at Maturity

At maturity, the sexual urge is present but under the surfaceit is f

, ,nevertheless, but restrained due to society rules and f
oys and girls do not easily accept these restraints, no wonder, t
older generations are alamied as well as puzzled. Tr
socety need not to be worried, because they should remember and realiz
long delay young people in our culture face to get married. Many
achieve complete legal and economic independen
puery. o a great extent, this delay is of course, unavoidable because of
the growing complexity of the modern world. As a result, th
through a difficult period of sexual frustration and there can be no do
sexual oppression of the young creates much genuine misery.
Thus, for many adolescents solitary masturbation is the only av
outlet, although some boys may occasionally masturbat
o experiment with various petting techniques, and others turn to homos
Contacts aswitha various
ave sexuacontact temporary
animals. substitute. A f`ew boys who l
"On the whole, adolescent girls engage in much less sexual
adolescent boys; one reason for this is the double standard o
threatens females with much harsher punishment for sexual infracti
males... lt is true that they are taught to be sexually attractive
, to dress seductively, to experiment with beautiful hairstyles, and to
makeup. Indeed, they tend to fantasize about their fiiture roles as br
. and mothers; at other times, they dream about some ideal lover or so
situation, in short, they
with its social implications.
are less concerned with the physical aspects of s

15
 Apart form theoretical considerations regarding infant sexual physiology, a
number of observations provide an instructive view. Personnel working in a
delivery ward such as doctors and nurses or in a newbom nursery are all familiar
with the fact that newbom males have spontaneous erections; newbom females
have vaginal lubrications which parallel the vasocongestive mechanism that
produces erections in the male. These examples of early physiologic function in
the sexual apparatus are clearly not learned events but represent an activation of
inbom reflex responses in just the same way that an infant does not learn to
sweat, to breathe, to digest, or to urinate. The implications of this statement are
clear "Sexual functioning is a natural process"

As the newbom grows and is exposed to relationships with others,

including parents, as the personality and psyche of the child pass through
adolescence and into childhood; and as cultural taboos are translated into personal
values and attitudes about sex, many complicating variables will potentially exert
harmful effects on the naturalness of sexual function. As a result, sexual problems
or sexual dysfunction can appear. .lust as the price of civilization over a primitive
society may be increased. cardiovascular mortality or a higher incidence of peptic
ulcer disease, so the corn; lexities of civilization lead eventually to sexual
difficulties.

lt is, of course true that all hurnarr beings are born with the capacity to
respond to many kinds of sensual stimulation. We also mentioned that erections
ofthe penis, the lubrication of the vagina, muscular contractions, and rhythmic
pelvic movements can be observed in very young infants. ln short, nobody has to
learn the physiological responses that lead to orgasm. Still, everybody does learn
under which specific circumstances these responses may be triggered. From their
first years of life, children learn to react positively to certain stimuli and
negatively to certain others. As a result of their personal experiences, they then
acquire their individual sexual behavior patterns. Thus. lmnran beings learn to be
masculine or feminine, heterosexual or homosexual. They also learn to
masturbate, to engage in coitus, and to feel happy or guilty about sox. They learn
to prefer younger or older partners, blondes or brunettes, Europeans, Africans or
Asians. Some persons develop a strong attachment to one particular partner and
arc unable to respond to anyone else, others change their partners frequently.
Some like variety in their erotic techniques, others stick to a single approach
throughout their lives. Some men and women depend on complete privacy for
their sexual responsiveness, others find additional stimulation in the knowledge
that they are being watched. There are people whose sexual advances are
passionate. inconsideratc, and even brutal: and there are others who enjoy making
love slowly. gently. and deliberately. Certain individuals may even prefer solitary
masturbation to any sexual intercourse. and certain others may seek sexual
contact with aninralsn

16
 Since these and many other personal sexual interests, choices, and
preferences are developed through learning, they may appear natural, reasonab
and indeed, inevitable to the person involved. Even sexual behavior which se
outrageous, fantastic, meaningless or absurd to most peo
anrewarding to a certain individual because of the way in which he has been
conditioned. A man who becomes excited sexually at the sight of a wood
horsel, may merely reflect some early experience in childhood in which sex
pleasure was associated with a merry—go round, and his behavior
no more difficult to explain than that of another man who becomes
aroused while watching a striptease show'?. The latter male sexual re
have a certain advantage over the fomier, because we consider it nonnal for the
majority of males, but neither of them should be of any social concern. On the
other hand, it is clear that every society has a right to protect itself aga
acts that involve force or violence, or which take place in front of un
witnesses. Such acts may be satisfying to the person who commits them, bu
they obviously violate fundamental rights of others, they are socially
unacceptable. Traditionally, they have always been treated as serious crimes
which deserved severe punishment. However, in modern titties there has been
growing tendency to view such acts as symptoms of mental illness rather tha
crimes. Psychiatrists began to argue in court that certain sexual offenders shou
not be sent to prison but to a mental hospital, and that they should not be
punished but cured of their illnesses..

Nevertheless, it cannot be denied that some people develop behavior

patterns which are unacceptable even to themselves. For example, a m
realize that his sexual acts are harmful to others, but he may have
controlling himself. ln another case, such cotnpulsive behavior may not
antisocial, but since it creates a sense of helplessness
stfind it highly disturbing, such as masturbation. There are also men and
women who feel guilty and apprehensive about any kind of sexual activity
some others
inadequate.
are so self—conscious and inhibited that their sexual respo

lt is fair to say that all of these people are sexually maladjusted. In other
words, their particular learning experiences have rendere
sexuacommunication. They either have become insensitive to the needs of
others, or are unable to fulfill them. They cannot relate to their sexu
complete persons, or adapt their own desires to different circumstances a
situations. They seem condemned to repeat the same frustrati
defeating acts, in short, they fail to achieve the hill amount of physica
emotional satisfaction of which tnost human beings are capable.
There is now a greater awareness than ever before that men and women are
capable of learning, unlearning, and relearning many sexual attitudes and
reactions throughout their lives. "Nevertheless, the importance of sexual
conditioning in infancy and childhood remains well recognizcd". There is also
HO doubt that parents and Close relatives have a great influence on a child's
17
development. The discipline they demand, the routines they establish and the
examples they set give boys and girls the first concept of sexual differences and
teach them how to relate to their own bodies. Adults convey their sexual attitudes
to children in a thousand different ways; through their sense of modesty and
privacy, the way they answer questions about sex, the words they use for sexual
organs and sexual activity, their tone of voice, their gestures and fascial
expressions while reacting.

All babies are bom with a certain physical equipment which enables them
to respond to sexual stimulation. They feel pleasure when their sex organs or
other erogenous zones are touched, and they may even reach orgasm fairly early
in life. Nevertheless, infants are still "sexually inarticulate". They respond rather_
indiscriminately to all kinds of stimuli, and their responses are not yet fully
integrated and coordinated as we mentioned before. Only gradually, and under
the influence of social conditioning, do children begin to structure their sexual
behavior in a way that is acceptable to the culture in which they grow up. ln other
words, they not only learn the "proper" responses, but also suppress and forget
the "improper" ones. ln fiact, when they try later to increase their sexual
responsiveness through treatment, they may spend a great deal oftime and energy
releaming the very responses they were once taught to suppress.

For infants, the main source of sensual stimulation is the mother. As they
are being touched, caressed, and nursed, they learn to feel loved and accepted and
to gain confidence in the world. Physical closeness gives them the sense of
security they need for a healthy development. lt is therefore very unfortunate that
some hospitals still separate newborn infants from their mothers, thus depriving
both of the first essential communication. Later, this initial mistake may be
compounded by the mothers themselves when they avoid any skin contact with
their infants and keep them clothed even while playing with them. By the same
token, a mother who does not breast feed her baby misses an important
opportunity to build a more intimate relationship. Babies want more than just
nourishment, they also hunger for human warmth and reassurance. Some working
mothers realize their chi|dren's needs in this respect, but refuse to meet their
natural demands and stop lactation after a rather short time because of many
excuses unfortunately. However, just as infants cannot learn to speak unless they
are spoken to, they cannot learn to show love and affection unless they are
hugged, stroked, tickled, and kissed by their parents or nurses. Parents who deny
their children such physical and emotional gratification leave them frustrated,
and in fact teach them to feel uncomfortable with their bodies. There is no doubt
that such negative early experiences can deeply affect the chiId's future attitude
toward sex.

Once we reali7e how social conditioning influences our development as

males and females, we have taken then the first step toward understanding the
development of our sexual behavior. Moreover, we can now make another useful
distinction, "sexual orientation" broadly indicate an erotic preference for male
or female partners. llowever, most people know that erotic preferences are

18
 usually much more specific. For example a "typical
attracteto all females, but only to those of a certain age,
coor, etc., In fact, he may prefer not only a special type of female, but
h
special type of sexual intercourse under special cond
preerences and tastes within the general framework of a person's sexua
orientation are best
result of conditioning.
described as personal "sexual interests". The

Patterns of Sexual Behavior

TWO pieces of recent work on the subject of sexual developme

shown that these problems of early conditioning are shared not
but even by animals aswell. One is by Ford and Beach, "Pattern
Behavior, the research was done by an anthropologist and psych
sexual behavior ofa number of mammalian species and of l9O human soc
well. Strangely enough, it was discovered that there is al
opresent day so called perversion, which is not practice
or y oter species of animal. These facts are bound to influence our future
evaluations and perhaps ultimately even our considerations; for
acts which are part of the biological heritage of man c
nrnscay unnatural or abnormal. ln some societies of the
nan tres, certain males were allowed or even encoura
anve as shamans, alyhasor "berdaches". They
wore female clothes, married some great warrior or other important
community, and took care of his household. Very of
presge temseves because they were believed to possess mag
.ony
Oviously, this social arrangement at that time provide
for those transsexuals, but also for the other sexual minoritiessuch
, as hermaphrodites, transvestites, and effeminate homosexuals.
homosexuals, on the other hand, could find sexual fulfillment with
masculine role by marrying a "berdache"

We know of various primitive societies, such as the "Siwan

the "Arandain Australia, and the "Keraki" in New Guine
maes engage in both heterosexual and homosexual intercourse. In ancient
Greece, homosexual behavior was widely accepted as
sexuaactivity, and it was never considered an obsta
. tat tme, the very word, "homosexuality" was unknown
, peope spoe of paiderastia(literally love of boys from pals: b
rater here male adolescent, and eran: to love) whi
. owever, neiter the older lover (called "the inspirer") nor the
younger beloved (called "the listener") was ever assumed
normarelationships with women. Nowadays, the tertnino
mae homosexual performing anal penetration during
nsererwhile the passive male homosexual is termed the "recelver"
sodo
.sown
llistorical and cross-cultural studies about some ancien
that male homosexuality was associated not with weakness and
19
 effeminacy, but with virility, bravew, and heroism. As a matte
famous of all Greek military elite troops, called the "sacred band" of
es, which was finally defeated by Philip of Macedonia, is sa
entirely of male lovers... This example shows that t
may vary considerably from one time and place to another; it al
demonstrates once again that there is no such thing as a "typical" h
The second research project was the recording by cinema of som
done by psychiatrists in Chicago upon chimpanzees. This piece o
ave shown that in animals observed, sexual urges
persstent operation of fear and hunger. lt was decided
g unger orce them into a seemingly dangerous situation. Some male
chimpanzees had been "c0nditioned" to ring for
n anoter. They were photographed vt hen for the first time a t
was pushed into the feeding cage as they ate. "Fear", repeatedly ca
run away, and relatively they came to prefer serious degrees o
rsoseeing the snake.

During the weeks of these experiments other aspects of the anim

instinctive behavior" became markedly altered. Chimpanzees wh
formerly led normal sexual lives turned
grnasturatory activities, disregarded the wooing of t away f
he females, and homosexual interests became more a
ones... ln other words, their "character" too, was changed, wild chim
panzces became docile, clinging to their keepers,
acto their feeding cages. the presence and reassurance o
essentabefore the ordeal was endurable to them. ln other
trats , had developed similar to those which only too commonly arise
severe stress in human beings at llltl€S Olifliflittully and excessive Strait!.

20
 The importance of hormonal influences on reproduction and sexual
behavior has been recognised since thc early part of this century. Although it was
initially thought that the pituitary gland was thc primary focus of control aver
those processes, it is now known that the brain itself acts as the major regulator,
with the hormones that are secreted in the hypothalamus controlling the functions
of the pituitary. The brain is also a target for the sex steroid hormones
manufactured in the gcnads. For example, these hormones act on sexual
differentiation ofthe brain during fetal life, initiate puberty, and play a role in thc
regulation of sexual behavior.

Testosterone

In :1 normal adult male, testosterone is produced primarily by the testes,

with icss than S percent normally contributed by the adrenal cortex. The average
testosterone production rate for adult men is 6 to 8 mg per day, Thcrc is a diurnal
variation in circulating levels of testosterone, with peak concentrations measured
in the morning hours, (prior to 10.00 A.M.). Measurement of urinary testosterone
Scvcks has now been discarded by most researchers, and clinicians are in favor 0f
direci Yi3€3;!¥liT€Hl€I1I of circulating hormone by rmii0in1n1uu0asr=ny techniques.
grim} vaiucs for circuiatiny testosterone concentration (ug/dl) arc; 385—l.0UO in
admit males, 20-ZR in prepubertzal children, IZO-600 in pubcrtal boys, }()O~}0() in
hypngonncial adult males, 20-80 in adult females, 45-l25 in females using oral
contraceptives (Fig. I).

'¥`e¤mstcr0ne appears to be the mzgirwr biologic determinant of the sex drive

in iwvh sexes. it is the "libido" hormone {br both sexes, Marked testosterone
deficiencies in the male are usually accompanied by depressed libido and
impotence, which improve with restoration of normal hormone levels. In
;xdditiun_ since thc prostate and seminal vesicles are 3lldFOg€I1·d€p€lld€Y]Y, seminal
fluid volume is diminished when 21 scvcrc testosterone dcfkicxncy is present. Must
men with impotence have normal levels nf tcstostcroxwc, refkcting the fact that
mamy instances 0f sexual dysfunction arc of psychogcnic rather than biologic
origin.

The precise relationship between hormones and sexual behavior is rmt clearlx
:m< icrstmvd at present. ln Il variety cwfnmnpx imntc animal species. plasma testosterone
concentrations increase after cmitus or ejaculation. In monkeys, however, although
ncccws of adult males t0 receptive females reportedly leads to increased circulating
2<:$ms,tmunc, neither testosterone 1mr Iutcinizing hormone increases SigHimCiHl{l§
Qiif :te¤Et: >:¤ aw <;§aculz1ti<m, Cbnflicfing results have hmm ¤e·pm*z<e<_i in wgzir
;>—;zz::m:~TA t~§f!20a1g?: inns =:uciics indicate that testosterone ¥@\‘@ls d¤ um incrc:2¤c nffcr
gw 5¤§E`€“Q?l}i'??I%?i(“¥L STE!} other reports {hi} to document za nwdiixe correlation
‘¥‘·
<r;r·;12::} activity or sexuni in!m·<~¤t mu! scrum e¤¤t<~¤tm ~¢» kwin "!!»-we
;=::· ·—·im$i<::<1 %mli£:w1mg SsxCr<:&S;cd \€$i0¢<?<é:·<>m· :ai`i<—r· vn:1<t11xlwzzt
Lzmaus, mus i:1mr:p<m2cm viewing cmtic xmwicc

21
 Stress
Love

k gr \_/( C
FSH

Testosterone

/ \ fix d . {**2-} /
Figure l. Testosterone and the brain
Schematic representation of the reciprocal influences between testosterone an
(a) is the cortex which responds to life experiences. (b) represents the hyp
which is intimately connected to (c) the pituitary gland w
orne (). This hormone regulates testosterone production by the male testes
, and in tum, the level oftestosterone profoundly affects cerebral functioni
Persky and his colleagues have recently suggested interrelationships
hormone levels and the sexual behavior of couples; in addition, evid
indicating that there may be a seasonal cycle of plasma testosterone in men
, nocrne
further compounds the methodological difficulties
reguaton in women is somewhat more complex than in men, since
women undergo a series of cyclic hormone changes from the onset Of
menstruation until the time of menopause.
Ovulation

Mechanisms of female sexual behavior in animals have been reviewed in

detail in two recent surveys. ln humans, some evidence indicates that female
sexual receptivity and initiatory behavior may be greatest around the time of
ovulation. Persky and co—workers found a greater frequency of sexual a
throughout the menstrual cycle in women whose periovulalory !€StOSl€
reached higher peaks than in a group of women with lower peak periov
22
testosterone levels. They also reported that women showed a greater degree of
sexual responsiveness and s greater need for affection and love around the time of
ovulation. These findings must be interpreted cautiously since only a few number
of women were studied and blood samples were obtained only twice per week.
Adams, Gold, and Burt reported a rise in female initiated sexual activity at the
time of presumed ovulation and found that this behavioral pattern was not present
in women using oral contraceptives. On the other hand, a number of other studies
failed to document a midcycle peak in female sexual behavior or arousal.
Resolution of these differences must await carefully designed studies that will
integrate sequential endocrine data with precise sexual behavioral measures.
Olfaction

An additional factor in the relationship between human sexual behavior

and neuroendocrine changes is olfaction. lt is uncertain how important olfaction
may be as an occasional mechanism of sexual arousal. ln a wide variety of animal
species, sex—attractant chemical substances, "pheromones", serve as a means of
communication between members of the same species have been identified. The
possible finding of similar chemical substances in human females has permitted
SOYIIC speculation about the role that pheromones may play in human sexuality.

Human neurophysiological investigations have shown that there is a close

anatomic relationship between olfactory and sexual functioning. The power of
olfactory impulses for sexual arousal in lower animals has long been established
on a clear anatomical basis. lnfrahuman mammals secrete odoriferous substances
which stimulate and release sexual responses in the opposite sex. ln human
beings, the potent and unrecognised influence of smell on sexual functioning was
not often fully appreciated. llowever, recently it has been recognised that humans
also secrete pheromones. Humans therefore have the power of being tumed “On"
and “Off`, by genital odors of the opposite sex. Beiber and co—workers stated
that, there is no doubt that a tantalizing aroma is a powerful aphrodisiac eg.
perfumes, while an unpleasant odor emanating from a sexual partner may be a
powerful inhibitor to the enjoyment of sex. They found similar substances
"pheromones" in human vaginal secretions permitting the possible role that
pheromones may play in human sexuality. Again, Kaplan, et al., explained the
abnormal sexual acts of cunnilingus and fellatio, because, although olfaction may
be an important stimulus in certain aspects of normal sexual behavior; in other
situations, involving abnormal olhictory acuity are frequently met with in certain
aspects of perversion involving males and females. Such is the case in the queer
sex position of "69" where both partners perform fellatio and cunnilingus at the
same time Our understanding of the recent physiologic control mechanisms
related to neuroendocrinology and reproductive behavior is advancing rapidly.
New data about the role of peptides in brain and endocrine function and better
delineation of neuroregulatory substances such as endnrplnins, dopamine. and
serotonin promise to bring about further progress in understanding human
sexuality.

23
 Recent evidence indicates that (LH-RF), the small peptide molecule of the
luteinizlng hormone - releasing factor, may enhance sexual desire even in the
absence of testosterone or when testosterone is ineffective. This finding h
raised interesting questions, such as: Does LH-RF act directly on the sex cen
of the brain ‘?. Can it be used clinically to increase libido ‘?. As yet, LH-RF is
mystery, but it has important implications and merits further investigation.
Evidence suggests that serotonin, or 5-HT (hydroxy-tryptami-ne) acts as an
inhibitor, and dopamine as a stimulant to the sexual centers ofthe brain.
Bonding

The connection to an attractive and receptive male. stimulates the sexual

centers in all animals which reproduce by sexual union, including humans.
Female rabbits ovulate and become sexually receptive in the presence of an
attractive male. And when we are in love, libido is high, every contact is sensuous
and exciting, thoughts turn to Fros i.e. love, and the sexual reflexes work r
and very well. The presence ot the beloved is an aphrodisiac; the smell, sight,
sound, and touch ofthe lover — especially when he or she is excited - are powe
stimuli to sexual desire. ln physiologic terms, this may exert a direct physical
effect on the neuroplrysiologic system in the brain which regulates sexual desi
But again, we must not forget, that there is no sexual stimulant so powerful, even
love. that it cannot be inhibited by fear and pain.
Galactorrhea

An interesting phenomenon that is not generally known is the fact that

some women have brief episodes of galactorrhea shortly alter performing
·*i<rorr~us sexual activity typically when orgasnr has occurred. This may be due
elevations in circulating prolactin that occur as a result of breast manipulations
and that is associated with orgasm. This type of galactorrhea is physiological and
unlikely to be a reflection of underlying pathology, although if it changes from a
transient to a more persistent pattern or is associated with other symptoms that
might be indicative of intracranial tumour (eg. headaches, visual changes,
alterations in the sense of smell), diagnostic studies would be warranted.
Galactorrhea, apart from a wide variety of causes, may be more evident d
immediately after sexual activity in some women. lt is unfortunate that normal
physiological galactorrhea is treated wrongly by some doctors and they give t
plrsyiologically normal women bromocry ptine in the form of l’ar·lotlel and other
medications e.g. Dopergin on the assumption that it is pathological .

24
NIALE AND FENIALE SEXUAL ANATOIVIY

l. Male sexual anatomv.

ll. Female sexual anatomy.
lll. Anatomy ofthe sexual nervous system.
 MALE AND FEMALE SEXUAL ANATOMY

I. Male Sexual Anatomy

Penis

The penis consists of three cylindrical bodies of erectile tissue, the paired
corpora cavemosa lie parallel to each other and just above the corpus spongiosum
which contains the urethra. The erectile tissues consist of irregular sponge l
networks of vascular spaces interspersed between arteries and veins. The distal
portion ofthe corpus spongiosum expands to fonn the glans penis. Each cylindr
body is covered by a fibrous coat or tissue, the tunica albuginea, and all three
corpora are enclosed in a covering of dense fascia. At the base of the penis the
corpora cavernosa diverge to form the crura, which attach firmly to the pubis and
ischium (the pubic arch). The blood supply to the penis derives from terminal
branches ofthe internal pudendal arteries (Figs. 2 - 4).

Dorm] Corpus caverrtosum

Corona} Surface
Giang
Mdse
“

Q ;·__ ,l

e" ‘~~
..,
··,T)ti,r·-L,:{jgj—;_E
K Y ¢,v_j»§\gt»l;J jyféiéri M9” .

Urethral :`

· ¥Z--if-»-7 x meatus Urethre / Corpus

"‘t‘spongxosum
/\Bulb
Ventral
surface /Scrotum ‘

Figure 2. 'l he penis: (lateral view).

hlechanism of erection

Erection is attained and maintained by a complex physiologic system,

which produces an increased flow of blood to the penis while at the same time
decreasing the flow of blood out ofthe erect organ. This increases the amount of
blood and traps it inside the penis at a relatively high pressure. The increased
amount of blood is shunted into the cavernous sinuses which distend, thus
enlarging the penis. The enlargement is contained by the tough fascia which
encases the penile cylinder, the pressure ofthe incrcasetl blood against this she
liardens the penis and makes it erect. The increased penile flow of blood du
25 25
 excitement is known to be caused by the dilatation of the penile
brought about by parasynrpa*’&etic impulses from the erecti
cause the muscles in the arterial walls to relax. The m
ecreasng penile outflow is caused by reflex constriction of
aternate hypothesis suggests that special penile valves control the outf
still another hypothesis postulates that the outflow and also the s
to the cavernous sinuses are controlled by "polsters", which are small smoo
muscle structures
venous outflow.
located only on the penile blood vessel walls which h

The erectile response is primarily a parasympathetic, althou

and pharmacological evidence suggests that some sympathetic co
required for potency. possibly by controlling the outflow of erectile blood
. However, it is well-known clinically that an intense sympathetic resp
that produced by fear and anxiety, can instantly drain the penis of extra b
so cause a psychogenic loss of erection.

DOIYSZU Dorsai artery and nerve

veins

Fib1·0u5
IHlZ€gUI`Y1€YliZ
Q;. envelope /,{g;I-°_‘?>$<`?5Y
Septum penis { m' T l `
( Ectiniform) p
'\ §,,, C0FD01`&
eavernosa penis
Corpus
" §: Urethra
spongaosum

Figure 3. The penis: normal anatomy (transverse section).

The vascular events that produce erection are under the control of ne
impulses, Although it has been speculated that parasympathetic Hbres in
cord roots (S;. S;. and S4) mediate erection, this theory was a matter of som
controversy but is well established now. The skin that covers
movae and forms the foreskin or prepuce at the glans. lnflammation or infecti
of the foreskin or glans may cause pain during sexual activity. Th
controversy and little data surrounding the question of the effect of circumci
on male sexual function. There is also a great deal of c
pensze and sexual function, With rare exceptions due to conditions of a tru
microphallus, the marked variation in the size of the flaccid penis f
man is less apparent in the erect state, because a grea
ncrease typically occurs during erection in the smaller penis than in
(Fig.4).

26
 { .T
___3/‘:;
\ ‘V\/ /
‘/ »$ /r// `{ Rectum

Urinary bladder
\1 g ” *4\/ ’
_/
_`\? 5 \‘··~
,T{g;*?’}i;逰¢l /_
§_{g{ ,-» Y {Ae! ,_ wr- -’Q3\J<¤ Vas defcrens

Seminal vesncle

¥\ - \\\:_$*1* ‘`·.‘··—·\» \ __ _‘ \ \\ _ \`N\ V I 3 FQFQTQQK Ampulla

‘ `‘ i· Prostate gland
#4. .·—t; »»;;~s» ¤., xx
\— \\Z
X M YYY` I ` Ejaculatury duct
‘.’ V_/
Pronatic urethra
. _ . .,~<2;.,Q>\ ` ‘
Membranous urethra
\ 4%;-/ ~·· ~

/_;,/·¤//, QQ —_g_; lF..$ <,;;:.~, C0wper’s gland

, lu 4 W7]4r/'V, V}WV:2
>! \ l
Anus

Penis

Penile urethra
¤Y\ `
Epididymis
’ 5/ V \ /»/%/ _-
.xw @3%, /
Z Y NEW $`!:=7? Glans penis
Prepuce

xl {3 3 } {xx ' ’€i*;.

xl
V
Meatus (urethralopening)
Testis

Scrotum

Figure 4. External and internal Mx tngans of the male (side view).

Scrotum

The scrotum is a thin sac of skin containing the testicles. Involuntary

muscle fibres are an integral part of the scrotal skin; these muscle fibres contract
as a result of exercise or exposure to cold, causing the testes to be drawn u
against the perineum. In hot weather, the scrotum relaxes and allows the testes to
hang more tieely away from the body. These alterations in the scrotum position
are important thermo-regulators. Since spemiatogenesis is temperature sens
elevation of the testes in response to cold provides a warmer environmen
virtue of body heat, whereas loosening ofthe scrotum pennits the testes to move
away from the body and provides a larger skin surface for the dissipation of
iutrascrotal heat. The scrotum is divided into two compartments by a septum.
Testes

Although the testes differentiate embryologically as intra—abdominal

organs, they ordinarily descend to their scrotal position prior to birth. The testes
function as the site of spermatogenesis and also play an important role in the
production of sex steroid hormones. Spermatozoa are produced in the
seminiferous tubules of the testes, while steroid hormone production occurs in the
27
Leydig cells located in the interstitial tissue. Although architecturally these
tissues are admixed within the testis, the two functions are under separate contro
from the pituitary gland. Hrt r we synthesis may proceed in a completely norma
fashion even ifthe seminit? nv r tubules are dysf`unctional, but spermatogenesis i
generally disrupted iftestosterone synthesis is seriously impaired.
Prostate

The prostate gland, which is normally about the size of a chestnut, consists
of a fibrous muscular portion and a glandular portion. The prostate is located
directly below the bladder and surrounds the urethra as it exits from the u
bladder. The rectum is directly behind the prostate, permitting palpation of t
gland by rectal examination. The prostate produces clear alkaline fluid that
constitutes portion of the seminal fluid, the prostate is also a major site of
synthesis of chemical substances. known as prostaglandins, which have a wide
variety of metabolic roles. Prostatic size and function are largely androgen
dependent. Cancer ofthe prostate arises in the glandular portion, whereas benig
prostatic hypertrophy usually results from enlargement of the tibromuscular
component of tltésprostate.

—»>m£:·ml vesicles

The seminal vesicles are paired structures that lleittgalnst the posterior
aspect ofthe base of the bladder and join Zvlth the end ofthe vasa dllferentla
(which are the tube like structures that carry the spermatozoa from the testes) to
form the cjaculatory ducts. The ejaculatory ducts open into the prostatic urethra;
the major Huid volume of the ejaculate derives from the seminal vesicles,
C`owper's glands, which may produce a pre-ejaculatory mucoid secretion, are
otherwise of unknown function.

28
28
 II. Female Sexual Anatomy
( A ) The external genitals of the female

They consist ofthe labia majora, the labia minora, the clitoris, and the
perineum. The Bartholin's glands, which open on the inner surfaces of the labia
minora, may be considered functionally within the context of the extemal female
genitals, although their anatomic position is not in fact external. (Fig. 5).

Clitoral shaft M

Cl`t l I Ora hood

. Clitoral glans
Labium minus
Labium magus
~_wrU1_€thI_a1
meatus

·~t $§igi;;7*~··<··—·Vaginal outlet

{ rf" · ‘~ - §“\ \
Perineum

Figure 5. Virgin female external genitalia (spread manually).

Labia majora

The appearance of the genitals varies considerably from one female to

another, including: (l) Marked variation in the amount and pattern of distribution
of pubic hair; (2) Variation in size, pigmentation, and shape of the labia; (3)
Variation in size and visibility of the clitoris; and (4) Variation in the location of
the urethral meatus and the vaginal outlet. ln the sexually unstimulated state, the
labia majora usually meet in the midline, providing mechanical protection for the
opening of the urethra and the vagina.

llistologically, the labia majora are folds of skin composed of a large

amount of fat tissue and a thin layer of smooth muscle. (similar to the muscle
fibers present in the male scrotum). Pubic hair grows on the lateral surfaces, both
the medial and lateral surfaces have many sweat and sebaceous glands.
Labia minora

The labia minora have a core of vascular, spongy connective tissue without
fat cells; their surfaces are composed of stratified squamous epithelium with large
sebaceous glands. Its very essential role as one of the three primary erogenous

29
 zones
female.
in females will be discussed fully in the chapter of the sexually stimula

Clltoris

The clitoris, which is located at the point where the labia majora mee
anteriorly, is made up of two small erectile cavemous bodies enclosed in a
flbrous membrane surface and ending in a glans or head. Histologically
of the clitoris is very similar to that of the penis. The clitoris is richly
with free nerve endings in contrast with vagina, where they are extrem
within the interior of vagina. These free nerve endings
uncton other than serving as a receptor and transducer for erotic
the human female. The very important role that the clitoris plays dur
excitement will be discussed fully in the chapter ofthe physiology ofcoitu
female; while the loss of the clitoris and the labia minora due to the drastic and
tragic operation of female circumcision will be strongly c
ofemale circumcision.

( B ) The internal genitals ofthe female

They include the vagina, cervix, uterus, fallopian tubes, and ovaries. These
structures may show considerable variation in size, spatial relationship, and
appearance as a result of individual
age and presence or absence of disease.
differences as well as reproductive histo

Vagina

The vagina exists functionally more as a potential space than as a balloon

like opening. In the sexually unstimulated state, the walls of the vagi
collapsed together. The vaginal introitus is surrounded hy an exterior muscl
bulbocavernosus which acts as a sphincter for the vagina. The intro
reactive to both pain and pleasure. At a slightly deeper muscular level, the
introitus and
pubococcygeus.
outer third ofthe vagina is surrounded by the muscular r

The walls ofthe vagina are completely lined with a mucosal surface that is
now known to be the major source of vaginal lubricati
gans within the vaginal walls, although there is a rich vascular capillary b
The vagina is actually a muscular organ, capable of contraction _and
can accommodate
smaller object.
to tl1e passage ofa baby and can adjust in size to accept

Hymen

The entrance to the vagina is partially obstructed by a thin and delicate

membrane called hymen (Fig. 6), it has perforations in it that allow menses to
eliminated monthly. Although the hymen appears to have no biological functio
yet it has tremendous cultw al significance as well as it appears in different shapes
and types in its various pirgrwas. In a majority of cultures as well as ours an intact
hymen or "maidenhead" ha been an important indicator of virginity, although
very rarely some females may be bom without a hymen, and indeed some women
only lose their hymen after they give birth to a child because their hymen is very
stretchable and allows gentle penile penetration without being tom. The act of
“deiloration" which is the removal of the hymen is associated with considerable
culturai ceremonies in the past and present. ln old Australian tribes and other olci
uuliuiui iltliuiutiuu nua pufuiuwd by uldu uumui uliu ttul thu I1 yiiwii wuu
week prior marriage using animal homs ! or stone penises ! termed "plucking of
the maidenhead". in some parts ofupper Egypt and the Sudan, defloration is still
being carried out by the "Daya" while marriage festivities do not start till a piece
of gauze soaked with blood from the torn hymen is publicly shown to the
relatives ofthe future husband... (Figure 6)

Ié
fg éa ‘
5i
`(ii if
V.
tf/T ii‘i ‘ Q,
y. _ _ 37

._ _
{ ti xg N °**:°
x·{
V Nl ’
M

Z g Q; CIBA

Annular hymen beptate hymen Cribriform hymen Introntus (after intercourse)

Figure 6 The appearance ofthe hymen varies considerably from individual

to individual. In some cases, it encircles the entire rim of the vagina (annular),
and in others it may have several smaller openings (septate and cribriforrn). ln the
sexually experienced woman, the introitns appears larger, although remnants of
hymen tissue are still present.

Cervix

The cervix is the part of the uterus that protrudes into the vagina, while the
cervical os provides a point of entry for the spermatozoa intonthe upper female
genital tract and also serves as an exiting point for the menstrual flow. The
endocervical canal contains numerous secretory crypt's like glands that produces
mucus. The consistency of cervical secretions varies during various phases of
hormonal stimulation throughout the menstrual cycle. Just prior to or at the time
of ovulation. cervical secretions become thin and watery; at other times of the
cycle, these secretions are thick and viscous, forming a mucus plug that blocks
the cervical os.

31
 The uterus is a muscular organ that is situated in close proximity to the
vagina, the two linings of the uterus, namely the endometrium and the
myometrium function quite separately. The myometrium is important in the onset
and completion of labor and delivery, with hormonal factors thought to be the
primary regulatory mechanism. The endometrium changes in structure and
function depending on the hormonal environment. Under the stimulus of
increasing estrogenic activity, the endometrium thickens and becomes more
vascular in preparation for the possible implantation of a fertilized egg. lf the
fertilized ovum implants, the endometrium participates in the formation of the
placenta. When fertilization and implantation do not occur, the greatly thickened
endometrium begins to break dov resulting in the menstrual flow as a means of
shedding the previously proliferateci enciometrial tissue, which will regenerate
under appropriate hormonal stinmitis in the nexi menstrual cycle. Endometrial
biopsy may be undertaken as part of an ieizrtiaty evaluation to determine if
ovulation has occurred and to observe. .v§:»s::·feci· appropriate progesterone secretion
has been present.

Fallopian tubes

The fallopian tubes or oviducts originate at the uterus and open near the
ovaries, terminating in finger—like extensions called fimbriae. The fallopian tube
is the usual site of fertilization; the motion of cilia within the tube combined with
peristalsis in the muscular wall results in transport of the fertilized ovum to the
uterine cavity.

Ovaries

The ovaries are paired abdominal structures that periodically release eggs
during the reproductive years and also produce a variety of steroid hormones.
These two small oval bodies (4 cms x 3 cms) are located in the lower abdomen,
held in place by the ovarian ligaments which are attached to the uterus. The
female sex hormones which are prodasced (oestrogen and progesterone) play a
role in the sexual behavior of females

Barth0Iin’s glands

A pair of glands located just inside the inner lips (labia minora) on either
side ofthe vaginal entrance. A small amount of fluid is produced by these glands
only after a woman is thoroughly aroused sexually and the act of intercourse has
been particularly prolonged .

Embryology

The external genitalia of both sexes are developed from the same genital
tubercle embryologically at around the sixth week of gestation. The genital
tubercle eventually differentiates into a clitoris in the female and a penis in the
32
male. This point of embryological development is of medical interest
sexologically denoting the importance of the extemal female genitalia in the
physiological responses ofthe sexually stimulated female as well as the dramatic
loss of these vital organs through the serious operation of female circumcision
(Fig. 7).

DEVELOPMENT OF MALE AND FEMALE SEX ORGANS

A. Znd TO 3rd MONTH
OF PREGNANCY

MALE GLAN5 AREA FEMALE

URETHRAL GROOVE

I P T / =‘ ANA I

TAIL (cur AWAY)

T

B. 3rd TO 4th MONTH

OF PREGNANCY

GLANS

UROGENITAL GROOVE

LABIO-SCROTAL SWELLING
ANUS asm mar Me

C. FULLY DEVELOPED

OPENING OF URETHRA \
PREPUCE OR FORESKIN AA 3%% ` AA

GLANS OF PENIS

GLANS OF CLITORIS

BODY OF CLITORIS {ifi

BODY OF PENIS
gg, _ Qjyglig L
‘“‘‘* ;1T... MINOR LIP
w· ~·»,.,,,»»»»».,__ M
MAJOR LIP

scR0TuM

VAGINA

ANUS

Figure 7. Development of external sex organs in both males and females to

show the similarity early in lite.
 The anatomy of the sexual nervous system is fairly well understood; the
sex center of the brain consists of a network of neural centers and circuits both
inhibitory and activating, and have been well identified. They are known to be
located within the limbic system, with important nuclei in the hypothalamus and
in the preoptic region. The limbic system is located in the limbus or rim of the
brain, it is an archaic system which governs and organizes the behavior that
ensures not only individual survival but also the reproduction of the species.
Towards those ends it contains the neural apparatus that generates and regulates
emotion and motivation. The limbic system exists even in primitive vertebrates
and has remained essentially unchanged even in man. However, it has been
integrated into our complex brains so that it often seems to have disappeared, yet
it is very much alive and influential and comprises the biological substrate of our
complex emotional and sexual experience (Fig. 8).

\)`.`£
·= {Q3 ///Z(;)q?uS CALLOSU
(I,

G}! ‘¥
Mo

Gy/RUS QF
WS ' C'
t2> QC X
K5

»-·""‘\\\·’

`·?‘?jqggf‘f’$Y'\\. T

Figure 8. Cerebral localization of erection.

Positive loci for penile erection are found in parts of three corticosubcortical subdivisions of thc
limbic system that are schematically depicted in above drawing and labeled 1,2 and 3. The septum
(SEPT) and medial pan of medial dorsal nucleus (MD) are nodal points with respect to erection.
The medial forebrain bundle (MFB) and inferior thalamic peduncle (ITP) are important descending
pathways. The drawing also schematizes recently demonstrated connections (5) of the
spinothalamic pathway with the medial dorsal nucleus and intralaminar nuclei. Scratching of the
genitals and / or ejaculation have been elicited by stimulation at various points along this pathway
and regions of its termination in the foregoing structures. Other abbreviations: AC, anterior
commissure; AT, anterior thalamus; M, matnmillary bodies. (From Paul D. MacLean).

34
 The sexual system has extensive neural connections with other parts of the
brain, it is highly probable that the sexual centers have significant connections,
neural and / or chemical, with the pleasure and the pain centers of the brain.
When we have sex, the pleasure centers are stimulated and this accounts for the
pleasurable quality of erotic behavior. But when we are in pain, we do not feel
like sex because the pain centers inhibit the sexual system. Indeed, all of human
behavior is organised around the seeking of pleasure and the avoidance of pain
i.e. the seeking of stimulation of the pleasure center and the avoidance of pain
center stimulation.

Endorphin

Recent studies have indicated that chemical receptor sites are located on
the neurons of the pleasure centers which respond to a chemical that is produced
by brain cells. This substance is called "endorphin" because it resembles
morphine in its chemical characteristics, as well as, its physiologic effects of
causing euphoria and alleviating pain. lt may be speculated that eating and sex
and being in love i.e. behaviors which are experienced as pleasurable, produce
this sensation by stimulation ofthe pleasure center, electrically or by causing the
release of endorphins, or by both mechanisms.

Sexual desire must also be anatomically and /or chemically connected with
the pain centers, for if a sexual object or situation produces pain - i.e. is
experienced as destructive or dangerous - it will cease to evoke desire, in other
words, pain has the capability of inhibiting sexual desire. Because our brains are
organised so that pain has priority over pleasure, which makes sense from an
evolutionary perspective, hence, individual survival must come before
reproduction. When we perceive that we are injured i.e. (in pain) or in danger
(fear), the pain center becomes activated and governs our functions, so that all
our energies are focused on finding solutions e.g. (fighting, running,
outmaneuvering, finding alternative strategies), instead of becoming distracted by
sex and vulnerable because of our sexual urges. The ability of the pain centers to
inhibit the sexual centers, which has clear adaptive value, is also the biological
basis for me neurotic inhibition oflibido.

It may also be speculated that neural connections exist between the central
sex centers and the spinal reflex centers that govem genital functioning. Input
from the higher centers can enhance or diminish the genital reflexes, thus, when
libido is high, when a person feels sexy and sensuous, erection and lubrica
full and rapid and orgasm is easily achieved. ln fact, erection and even orgasm
may at times be achieved purely on the basis of external stimuli and fantasy
without any physical stimulation of the genitals. But the opposite is also true,
when desire is absent and the sexual experience is flat and joyless, the threshold
for the genital reflexes is much higher. When one is not "turned on", it can take
"forever" and the physical stimulus must be intense enough before the genitals
will be able to function. A summary to the anatomy and physiology ofthe sexual
response denotes that the sexual desire or libido, also termed "the sexual drive", is

35
produced by the activation ofthe neural system in the brain, while the excitement,
plateau and orgasmic phase: involve the genital organs. In both males and
females, the excitement and plateau phases are produced by reflex vasodilatation
of genital blood vessels. By contrast, orgasm essentially consists of reflex
contractions of certain genital muscles. The two genital reflexes are served by
separate reflex centers in the lower spinal cord.

Spinal cord rellex centers

In both males and females two spinal cord reflex centers are located at TH,
Tu, L, and L; ; the second center is located at S2, S; and S., (T = thoracic; L
lumbar & S = sacral).

36
 THE PHYSIOLOGY OF COITUS
IN THE HUMAN FEMALE

Physiological responses of the sexually stimulated female.

Clitoral versus vaginal orgasm.
Non resolved sexual tension in females.
Artificial vagina and vaginal agenesis.
• The erogenous zones and precoital petting.
 THE PHYSIOLOGY OF COITUS
lN THE HUMAN llElVlALllJ

Physiological Responses of the

Sexually Stimulated Female

The physiological responses discussed in the sexually stimulated human

female are based upon those mainly discovered by Masters and Johnson in 1966,
(Figs. 9-2G). They introduced the idea of a human sexual response cycle on the
basis of extensive laboratory observations. Understanding well, the anatomic and
physiologic changes that occur during sexual functioning is facilitated by con
gsideration of this discovered model. However, it is important to recognize that the
various phases of the response cycle are arbitrarily defined, are not always clearly
dernarcated from one another, and may differ considerably both in one person at
different times and between different people. That is why the duration of a single
phase may vary from person to person and within the same person dependent
upon a complex of factors namely; psychological, emotional and physiological.
Again the male and female sexual responses are essentially the same though there
are some marked differences because during all varieties of sexual activity, the
human body undergoes a number of physiological changes which form a typical
definite pattern.

·<5 o: T p`__. ,.. ;_ ¤ J /é

0‘‘‘
12 n.T.> '
,si'¤j*

aes'}
Ovary
/

Au,
_ _ Frmbriae

Fallopian tube
Uterus
/

E ( , < —"?¢ ‘ M “ / rg } lli

}
Ccrvix

Urinary bladder
k\ \
xi.vI"?. X Dnriulll

f A V I ';··| ij; A. X.-, im"

__ N5; K i _ \¤\}-"; \ I Vx \ `
,_,__

Urethra
Clitoris

Minor lips

Vagina

Anus

Major lips

Figure 9. External and internal sex organs ofthe female (side view).

37
 Very little was known about the physiology of the female sexual response
till Masters and Johnson undertook their brilliant sexual research. For two
decades, they studied the sexual behavior of men and women under scientific
laboratory conditions; they observed and recorded approximately l4.000 sexual
acts. They took, photographs of the extemal and intemal female organs during
various sexual activity which revealed the dramatic physiological and anatomical
changes which prepare the female body for sexual intercourse. Johnson devised
an artificial phallus made of clear plastic and equipped it with light and camera;
as the woman copulated with the artificial penis, it was possible to photograph
and record the various reactions of the clitoris, the labia, the vagina and the uterus
during the fours stages ofthe sexual response cycle.

Their observations included a wide spectrum of sexual behavior under

every imaginable sexual condition. They studied coitus in various sex positions,
between strangers and between happily married couples; between couples who
had sexual dysfunctions and /or interpersonal difficulties. Different techniques of
erotic stimulation were applied; such as visual and tactile eroticism during
masturbation, homosexuality and lesbianism. All such sexual experiments were
studied at different ages; from adulthood to old age in both males and females.

lt used to be believed that females were slower to respond to sexual

stimulation than males, however this belief is mistaken. Not only men but also
women can become sexually aroused very suddenly, and some of them may
experience one or more orgasms within few minutes. As a matter of fact, there
are women who reach orgasm fifteen to thirty seconds after they begin sexual
intercourse. lt seems. however. that during the fir¤r emgpe nf emma! amnaai
women are more easily distracted than men and depend more on continued direct
physical stimulation. For this reason, many females seem to need a longer time to
reach orgasm during coitus than their male partners, whose excitement is often
sustained and increased by psychological factors. ln general, females are less
easily stimulated by mere erotic sights and sounds, or by erotic fantasies and
anticipations. On the other hand, when the average female is able to concentrate
on her preferred method of sexual stimulation (during masturbation for instance),
she achieves orgasm just as quickly as the average male.
N.B.: lt is very important to remind the reader that all these sex experiments =¤ ere
performed on non—circumcised females .

( 1 ) Excitement phase

Excitation occurs as a result of sexual stimulation, which may be either

physical and / or psychic in origin. Sexual stimulation arising in situations
without direct physical contact is neither unusual nor unexpected, since activatio
of many physiologic processes of the body occurs as a result of thought or
einomgzn. For example, salivation and gastric acid production may be initiated by
tliiuiiiig AUUlll LlEllLlUUL IUUU, lilllllllllllg, lllUllllMl'lll!l, M
precijiliated by fear Or auger. At times, the excitement phase may be of sh
dur2··°~;»n, quickly merging into the plateau pbase; at other times however, sexual
38
excitation may begin slowly and proceed in a gradual manner over a long time
interval.

Changes in internal sex organs

In females, the first and most obvious sign of sexual excitement is the
"lubrication of the vagina", known also as "sweating of the vagina". ln
response to effective sexual stimulation, which may occur very suddenly taking
from l0 to 20 seconds, the vaginal walls which is relatively dry in the
unstimulated state, soon provides a moist coating for the entire vagina in
preparation for penetration. Without such lubrication, the insertion of a man's
erect penis into a woman’s vagina is painful for both. Few causes of vaginal
dryness are insufficient or clumsy pre-coital petting or unwillingness of the
female partner to join in the act of coitus. lt is important to recognize that there
are no secretory glands in the vaginal mucosa or submucosa but instead there is a
well developed capillary system that surrounds the basal membrane. During
sexual excitement transudation of fluid do occur as a result of vasocongestion
producing this lubrication within the vagina and that the secretory glands lining
the cervix do not contribute meaningfully to vaginal lubrication. The
corresponding first sign of excitement in males is the erection of the penis, in
short, as the penis becomes ready to enter the vagina, the vagina becomes ready
to receive it. lt is interesting to know that in cases of pronounced sexual
excitation in some women with a resultant profuse vaginal lubrication, some male
partners do complain about this excessive vaginal sweating not knowing the
essential values ofthis lubrication. (Fig lm

Uterus

/cum S (

N k f etwor 0
H jymphysis
'\ w /gg
( ) x, 1 Cervix

_, gg blood vessels
’\ c , A ‘ 6l’ °c
. . \ Lubricating/rib 5 ,,, _§_6 h S X
{ drsplsts ""¥°‘f"""`““i‘j*§_/~»47 " No lubr
Vagina
KJ · · Colon Rectum /Z`•`L‘\\

Figure 10. Vaginal lubrication inthe excitement phase.

39
 With continued sexual arousal, the inner two thirds of the vagina increase in
both length and width creating a tenting balloon effect, namely what is called the
vaginal barell, lt is interesting to note that the vagina in its unexcited state, is a
collapsed tube i.e. its walls are touching. It is not known precisely which muscles
are involved in this phenomenon but the pubovesical ligament which contains a
large proportion of smooth muscular element play an important role, when
contractions of this ligament do accomplish the lifting ofthe anterior wall. It is
very important to keep this fact in mind of all gynaecologists while fitting a woman
with the vaginal diaphragm, to choose the right sized cap, often used as a local
method of contraception. The color of the vagina change from the usual purple red
to a deep purple color that becomes even darker during the following stages of
excitement.

L_ __`` /,;;,»tVagina
Lengtlrxening
Early uterine __,»T.__ ~_’,.·
elevation \ (

II

>`}`\J°Z

xx G `
\,j%/ . I
\Labia minora size increase
'\Labia majora separation
and elevation

Figure ll. Female pelvis: excitement phase.

The uterus begins to enlarge due to the process of vasocongestion and is

pulled upwards into the abdomen, thus contributing further to the lengthening of
the vagina which was found to be increased by about 30% ofthe original length.
(Fig. ll).

Changes in external sex organs

The response of the labia majora in the female depends on her parity, if
she is a nulliparous woman, sexual excitement will cause her major lips to flatten
sl-; Ann tr? ¤nl·••·m¤•n¤¤+ nail nvpnrn h¤•· w¤Hi¤¤l hw"-,lTG`»'•E
a·na.icra in a multiparous woman are large and new they grow even larger as a
viii cfengorgeinent and do expose the vaginal criice in an exaggerated manner
evizs-¢ river become elevated and separated.

40
 The Iabia minora swell considerably in size in all females with sexual
stimulation and they do change their color to a progessively deeper red while
extending outwards all the time..

The clitoris, just like the penis increases in as its erectile tissue
becomes filled with blood and it gets firm in consistency as a result of the proce
of vasocongestion, although a true erection does not loccur literally, because of
the marked difference between the size of penis and clitoris. The increase in t
size ofthe clitoris is most noticeable in the diametenof the clitoral shaft, while its
length increases 2 to 3 times as much as the original one which is 4 x 4.5 mm
the average adult female in the flaccid non stimulated state. There is a
pronounced increase as well in the size of the glans which becomes quite obvious
in the sexually stimulated female (Fig. 12).

m/`i*/.#
sU
(4ON (VW .
{5 Clitoral
/l(
K_i
l {
v 5
M lm
,J li
Sha t diameter l
r‘ (> l/(, i.
y`{ \Nshaft N ncrease \ b\\,\\ reaction 7 ’ J
\ \ - ° _' Cl/ my _. ·. ~;;.
. l i, l Y \
ll¥0F3l
litoral hood

I —*=-`}_ itora
i/l/ Glans and shaft

V. _ SIMS ’· /” Engorgement
Of mingr Iipg
Engorgement
of |'Y`|l¤Ol' lips

\‘
¢ Minor
r lips W lr _ </

i dll lil tl
Kh* lx /

Unstimulated Baseline Excitement Phase Plateau Phase

Figure l2. Changes in the shape and position of the clitoris during sexual arousal.
Changes in other organs

During the sexual excitement phase, erection of tlie nipples is

characteristic for most women, although both the nipples may not achieve full
erection simultaneously, ‘but this erection is found to be maintained throughout
the other sexual phases. However, since the clark area around each nipple, and
indeed the whole breast soon also becomes engorged and swollen so much so the
nipple erection itself gradually becomes less conspicuous. ln the late excitement
phase, surface venous patterns of the breast become more visible and there may
be a further increase in the size ofthe breasts, (Fig.l3).

41
 Increase in
breast size

i wig .X’¥r
xVascular

I/
‘

__,

Nipple

N _ , . \ Ji 4 fhg .~. . ¤ · t"=

4

l · **9013

t ‘·~Ml
·. .

“ ~ \;ie, ¤ · · ‘ - F · ·. `
£"r'?·
»; 9;,}
_V_V O s . ex
S

1J'`L
Unstimulated Excitement Plateau Resolution
baseline through
orgasm

l·'igure 13. The breasts in the female sexual response cycle.

In the excitement phase, there is a marked increase in sexual tension

above baseline (unaroused) levels and with mounting sexual tension, it produces
voluntary and involuntary muscular contractions in various parts of the
woman's body. There is an increase in the heart rate during the course of sexual
stimulation whi:.:h may reach as much as 180 beat per minute, this maximal rate
was recorded during the act of masturbation in contrast to lower rates reached
during orgasm achieved while having coitus. The rapid fall of pulse rate after
achieving orgasm indicates that the rise ofthe pulse rate has not been due to
l1l€CllHl]lC8l work CX€l‘l€t'l l')lll mOsflV (THE ln Ptnntinnsil f`¤r·tnr¤

ln addition to all the mentioned signs of growing sexual excitement, most

women, not all show the so-called "sex llush", it appears late in the excitement
phase or early in the plateau phase. lt is a red rash resembling measles,
developing in 50 to 75 percent of women and in a smaller percentage of men.
This sex flush generally begins in the epigastrium and then spreads rapidly over
the breasts and anterior chest wall, but it may also be noted on other parts ofthe
body, including the buttocks, back, extremities, and face. This rash lasts through
the orgasmic phase and is most obvious in fair ladies and naturally not apparent
in dark or black women.

ln both men and women, the physical changes of the excitement phase are
neither constant nor always ascending. Distractions of either a mental or a physical
nature are quite likely to decrease the buildup of sexual tension, which is the
hallmark of excitation. An extraneous sound eg a sharp knock on the door, a shift in
position, or a muscle cramp, for example, are types of distraction that may occur. ln
addition. changes of tempo or manner of direct sexual stimulation can also
temporarily disrupt the process of sexual arousal. The vasocongestive mechanisms of

42
uu. uuuuiuu plum uu nut LUll5lllUl! u uuauuwuw uuululsul uf sexual uruukul
fact, an erection may be diminishing in firmness at just the time that excitation is
heightening; likewise, vaginal lubrication may appear to have ceased, although
neuromuscular tension is clearly nearing the plateau phase. lt is advisable therefore,
not to use lubricants unnecessarily unless prescribed, while noting all the time that
the best natural lubricant for fertility purposes is the human saliva.

(2 ) Plateau phase

The word plateau is meant to indicate that a certain level of excitement has
been reached which is then maintained for a while before orgasm occurs. This
phase physiblogically and sexologically is the continuation of the excitement
phase because it describes a higher degree of sexual arousal that occurs prior to
reaching the threshold levels required to trigger orgasm. The duration of the
plateau phase varies widely; if is often exceptionally brief in men who are
premature ejaculators. ln women, a short plateau phase may precede a
particularly intense and powerful orgasm.

Changes in internal sex organs

During this phase there is further increase in the length and width ofthe
inner two-thirds of the vagina with a minor additional expansion in its size. and
there is a corresponding increase in elevation ofthe uterus. The rate of vaginal
lubrication often slows during this phase as compared to excitation, especially if
the plateau phase is prolonged, (Fig. I4).

,\_ I.]-'EQPTUE
,/elevation

`~"`.,FuH
{5 vaginal
}'l9XP?m$1On
r—n+m»ar rpohfihg \\ \.
body effect: \ \‘~ //\" /{-_!
elevatio

Q
H X V _`-' \Orgasm1c platform
`°;~§§
Labia minora size increase
(sex skin)

Figure 14. Female pelvis: plateau phase.

43
 Prominent vasocongestion occurs in the outer third of the vagina, as a result,
this part of the vagina becomes narrower by about 33%. T`his congestion and
tightening of the outer third of the vagina has been named the "orgasmic
platform". This narrowing action is one reason why the size of the penis is
relatively unimportant to the physical stimulation received by the woman during
late intercourse, since there is actually a "gripping" action of the outer portion of
the vagina around the penis. Other reasons include the expansion of the inside of
the vagina, which decreases direct stimulation received distally from penile
thrusting regardless of penis length. Also the .fact that the inner two-thirds of the
vagina contains few sensory nerve endings, whereas, there is a richer concentration
of` such sensory nerve endings in the area in which the orgasmic platform forms.
The uterus undergoes still further increase in size and is pulled further
upwards into the abdomen.

Changes in external Sex organs

While the labia majora show no further changes during the plateau phase,
the labia minora increase further in size and continue to darken in color,
especially in multiparous women. This marked color change is a sign that orgasm
is approaching, so much so, that if stimulation continues orgasmic release occurs
a minute or a minute and half after the labia became bright red in color.

Once a certain level of excitement has been reached, the clitoris already
erect, both the shaft and the glans become angulated and rotate ventrally l80° and
retract under the symphysis pubis disappearing under the clitoral hood. This
change, coupled with the vasocongestion occurring in the labia, makes it difficult
to visualize the clitoris in this new situation and also partially masks the location of
the clitoris to touch. lt is interesting to note that direct touching of the clitoris now,
may cause pain and discomfort but there is no loss of pleasurable clitoral
sensations during these changes however, and stimulation tothe general vicinity of
the mons pubis or the labia will result in pleasurable clitoral sensations. ln the past,
it was not always understood that this retraction ofthe clitoris indicates an increase
and not decrease of sexual excitement because the clitoris in this new position is
indirectly squeezed by the male pubis in the lithotomy position (Fig. 15).

Clitoral Shaft diameter

fshm lngrgage
_ R€t.I'2}ClZ10I'l
reaction,
\’(}1jt,m·8l
hood
Glang, Glans and shaft
ood
/ E tumescent / \*7"··Clitoral hClitoral reaction Lablal
Labial
_ [ \` glans MIND! ` engol-gernent €ng`OI`g`€HIEI`lt
labiuni
II III
Unstimulated Excitement Plateau
baseline phase phase

lligure lS. 'llie clitoris in the female sexual response cycle (Plateau phase).
44
 The greater vestibular glands (BarthoIin's glands), which correspond to
the bulbo-urethral glands (Cowper's glands) in the male, may secrete a small
nmnurnf nf Hum uhmn nm- fn elw-¤¤
r} HrncAm-inmae
gl ·.\¤e»¤¤• Plus. m- Ian. in ems
excitement phase. lt is interesting to note that the secretions ofthe Apocrine
glands in the prepuee are meant to keep this area lubricated because direct tactile
stimulation when dry may be intolerable since the clitoris isexquisitely sensitive
to touch at this stage of sexual excitation.

Changes in other organs

The sex Hush, if it did occur, may now become more intense in color and
cover a wider area of the body. Voluntary and involuntary muscular tension
greatly increases throughout the body because of a generalized myotonia. Other
extragenital features of the plateau phase common to both women and men
include; tachycardia, hyperventilation, and an increase in blood pressure,
these changes are primarily seen during the late plateau phase.

The areolae of the breasts begin to become engorged late in the

excitement phase but during the plateau phase this areolar turnescence becomes
so prominent. that it masks the already erected nipples. Increases in breast size
during this phase are less pronounced in women who have previously nursed and
lactateci. ln women who have not breast-fed a child increases in breast size of 20
to 25 percent above baseline levels are not uncommon.

l~or ceniuries. males have been concerned alwoul penile me. lo llns (lay,
the fear of having a smaller than normal penis is still a source of great anxiety.
This fear is reflected in women’s concern over clitoral size too, however here the
concern takes two forms, fear that the clitoris is too large or that it is too small. lf
grotesquely large, partial excision may be recommended but the less drastic
measure of imbedding the clitoris in the surrounding tissue is recommended
surgically. lftoo small, hormones may be recommended but with great care.

(3 ) Orgasmic phase

The word "orgasmos" in Greek means "Lustful excitement", and an

orgasm in the female is the sudden release of muscular and nervous tension. in
other words, it is the climax of sexual excitement. "The experience represents
the most intense physical pleasure of which human beings are capable of and
is basically the same for both males and females". The specific
neurophysiologic mechanisms of orgasm are not presently known. nevertheless, it
can be postulated that orgasm is triggered by a neural reflex arc once the
orgnsmic threshold level has been reached or exceeded. An orgasm lasts only a
M Ausitinti intl it IU; .¤.n uiutli Ulu A suits utuiiiuilsiuan uliitli iunilu tht
sin hotly and sewer lead to complete relaxation and often sleep. ln sexually
zr2"tf’~:; ntaisrs. zwrgzrsns is accsunpouiefl by the ejaculation of semen. and since
c·*i<.>=i dc rust pir>d¤_:r·e semen, hence, they do not eiziculatc. llonever. in all other
respects, the physiological processes are cotnparablc in both sexes. Although the

45
 experience of orgasm is essentially the same in men and women, still, it see
that nature did equip females to have more than one orgasm within a
time. This capacity of being a "multiorgasmie female" is quite common i
healthy females and is described as having a series of identifiable or
responses without dropping below the plateau phase of sexual arousal.
enough, recent research proved that it is muscular endurance rather than femin
responsivity which is the limiting factor in a woman's coital responses
this power of multiorgasmic capacity. Men, however, do not share th
Immediately following ejaculation, the male enters a "refractory perio
, during which further ejaculation is impossible, although partial or full
may sometimes be maintained. This refractory period may last for a few minut
, Or it may last for many hours; for most men, this interval lengthens
is typically longer with each repeated ejaculation within a time span of s
hours. There is a great variability in the length ofthe refractory period
within and between individual men. The refractory period is not present i
female sexual response cycle, although most women are not rnultiorg
There is one further difference, while the orgasmic pattern of males p
never varies, females may experience orgasm in a number of ways, (Fig
some women, orgasm is rather short and mild, in others it is extended and violent
i.e. lasts longer and is rather powerful. Even one and the same wom
herself responding quite differently on various and different occasions of sex
stimulation. However, the basic physiological processes underlying th
variations remain unchanged.

Orgasm
t!\I1
l ,’
‘/ l ’
` IF

Plateau
;xx\
` \ \§
\ €sO
/ \ xg
cu \ xf0b x\
Excitement w \ \m \
pg

E5.
X`?
5. F
l¤
0 Ye

ABC

liigure lo. Various types ofthe female sexual response cycle.

Changes in sex organs

ln human females, orgasm begins with simultaneous involuntary

rhythmic contractions of the three lollowing organs; the orgasmic p
46
 (outer third of the vagina) the uterus and the rectal
secontervas. These contractions, which may number from three to fifteen
s
first recur within less tl=··m a second, then they be
nervas, tus diminishing in intensity, duration, and regularity. The uterin
contractions are known to be irregular. they do start at the fundus w
way downwards, not unlike the contractions that
unaturally not painful. The cervix gapes its external os and remains occu
open for nearly 20 to 30 minutes after orgasm. Surprisingly, the sp
muscles ofP_the rectum contract also for few times at the saint intervals as t
orgasmic platform, (Fig. 18).

Uterine
scontractions

Lengthening
;~·',·’ `\_0f cul-de—sac
, Vi <.;;,__`_.:._ X R)
n\\¤ ,
\ Qty:
Clitoris
{".llV) }
XJBX
·i Rectal

( ‘ in spliincber
wiitizitriull
ly ` Orgasmic platform
`\ Labia minora
Labia majora

Figure l7. Female pelvis: orgasmic phase.

Changes in other organs

Since orgasm is a total body response, notjnst a response localised to

pelvis, the presence of great neuro-muscular tension is
pevc area, but is also present in the neck, arms, hands, legs and feet. Dorsa
flexion of the big toe as well as the foot appears
ateratoes are kept in the flexion position for a long period. Electro
occas
- encephalogram pattems measured during orgasm
emsprlaterality, as well as changes in rates and types of brain wave
activity. Contractions of peripheral muscle groups hav
measure, while the pulse rate and blood pressure rise greater than the levels
reached during the plateau phase. Surface electrodes fixed on the thorax of fem
volunteers made electrocardiograms recording possible, Wlllle breath
very fast indeed. It is worth noting that the intensity of all these physica
47
depend, of course, on the degree and duration of the sexual tension achieved
earlier. It is interesting to note that orgasm occurs naturally in women who have
had a hysterectomy hu' it may not occur in those females who have had surgical
excision of the clitoris or after the traditional and cruel operation of female
circumcision. It is worth mentioning here that .lohnson's research disproved in a
way Sigmund Freud'; theory about the two kinds of female orgasm namely;
clitoral and vaginal. The research experiments proved that there is only one type
of orgasm from the physiological point of view and that it is a sexual orgasm
irrespective of how and where the stimulation has been applied. But, in recent
research findings it was found that about 60 — 70% of women require manual
clitoral stimulation during intercourse in order to reach orgasms

{ig €{1'§Q¤T{ 3}* Ei

__

ELZ·& F
j.=eE 9
» _,jy{4`_[_
‘-‘>y:·.‘*;._¤.>.:·»

IV

" `.··, `'‘' . ```¤ Sl A i UM A z

b tl
y x Y \< /v/·

Figure 18. The female genitals and muscles during orgasm.

The perineal (a), bulbocavemosus tb) and pubococcygeus (c) muscles contract with a
.8/second rhytlun causing pulsations of the orgasmic platform td) and the vagina (e). The
uterus (O contracts also.

Hormone release

The pupils get marked dilatation as a result of sudden activity of the

sympathetic nervous system with the release of epinephrine. 'l`he release of the
hormone oxytocin provoked by genital stimulation has been demonstrated in
animals. and the oxytocin released was measured in the blood but the amount
released during copulation was very low. ln humans, the physiological
significance of oxytocin release during sexual stimulation has not been clarified
but it is possible and well documented that the release of oxytocin may precipitate
labour in the pregnant woman, No wonder, some women in early labour believe
48
 in enhancing their delivery by deliberately making love and indulg
coitus !..

Experienced couples can sometimes time their orgasm to arriv

consummation desired by all and is termed "synchronlsed orgasm
··

. mutual urguum bcmwl tlrt uml! dllll lEllllllE SE! Mili

striven for, if it happens naturally and without trouble, but to search for t
orgasm andand
pe acots beauty todehumanizes
work hard for its
the process occurrence
of coital love. The is not ad
discharge of tension during the orgasm in both sexes and its extent var
immensely, both in different individuals and in the same person from
time. ln both sexes when the fullest pitch of orgasm is reached, sens
greatly till muscular movements become automatic whic
urng pelvic thrusting. Feeling replaces thinking actually,
sensatons occur such as blurring of vision. Sometimes, physical and emotional
ecstasy may be so overwhelming that consciousness
some emaes. Pleasure may be experienced throughout the whole body and is
not to be limited only to the genital region.

lt is strange that in some women so much feeling can be felt with so l

outward manifestations apparent. By no means all husbands can perceiv
rnornent of orgasm in their wives; indeed, many women can and do simulate
orgasmic release, sometimes even without knowing exactly why they
pretending to have had an orgasm!. Similarly, although a small propo
women are able to feel semen as it reaches the vaginal walls, a far greater num
cannot do so and admit feeling nothing.
(4 ) Resolution phase

ln the resolution phase, the anatomic and physiologic changes tha

during the excitement and plateau phases reverse. Af
wtthem the whole body need sometime to return to the
(z..

Changes in sex organs

The congestion in the outer third of the vagina, namely the or

platform disappears between 5 to 8 minutes as the muscular contractions
orgasm pump blood away from these tissues. While there are small almost
trembling movements of the vaginal outlet and the area around it, thus the
circumvaginal musculature's involuntary,
sexual arousal and orgasm come to a standstill.
rhythmic contractions in re

49
 Loss of

Uterine yvagmal
‘€XpanS1On
descent

Clitoral
body
descent
2 t ‘.» \ /

is "K +

\Loss of labia niinora

size increase

Loss of labia majora

separation and elevation

Figure l9. Female pelvis: resolution phase.

The labia majora and the labia minora assume their former shape and size,
while the clitoris remerges from under the clitoral hood taking about 5 minutes to
retum to its normal size and colour. The uterus also shrinks back to its normal size
and as it descends from its elevated position in the abdomen, the tenting or
ballooning effect in the inner two thirds ofthe vagina is eliminated. Amazingly the
cervix now dips into the seminal pool collected in the posterior fomix if coitus was
performed in the lithotomy position. With the uterus back into the true pelvis, the
vagina is shortened in both width and length; the uterus and the vagina take about
to 8 minutes to return to their normal size, shape and position.

Changes in other organs

The sex flush vanishes slowly, while the nipples of the breasts and the
breasts themselves slowly return to their normal state of non excitement. With the
release of muscular tension, the pulse rate as well as the blood pressure
decrease while the breathing rhythm becomes normal again.

lt should be pointed out that unlike men, many women do not seem to have
a refractory period like men or at least it is not as obvious. kin many cases
continued or repeated sexual stimulation can bring a woman to a second and third
orgasm immediately following the first one. Indeed, many women are capable of
having many orgasms in·quick succession. Obviously in this case, the resolution
phase as described previously does not begin until after the last of these orgasms.
This is the physiological explanation of a multiorgasmic female, which is quite
different from the rare morbid condition known as "Nymphomania", which
means excessive sexual desire in the female who could not be satisfied, i.e. never
satisfied sexually. lt is a rare condition of uncontrollable sexual desire in females;
fortunately the condition is not common. lt is actually very rare.
S0
 There has been :· great deal of controversy and confusion regarding the ro
of the clitoris and the vagina in female sexuality which unfortunately was
source of clinical error in the past. ls female orgasm clitoral or vaginal ? This
specific controversial question really should be: Is it vaginal or clitoral stimulatio
that produces orgasm in females '?. In the past, according to Freudian
psychoanalysits, clinicians believed that clitoral sexual sensations were considered
as a sign of neurosis !, while clitoral eroticism was diagnosed pathological
Masters and Johnson demonstrated the fallacy of this theory in 1966. Recen
studies by H. Kaplan and S. Fisher suggests that stimulation of the clitoris
always be crucial in producing female orgasmic discharge during coitus as
other forms of lovemaking and sexual foreplay.
Of all human senses, the sense of touch whether light or deep seems to be
the one most often responsible for erotic arousal. lt could be applied directly
indirectly to the target area through stroking, squeezing or mere pressure wheth
rhythmically or arrhythmic to the primary or the secondary erogenous zone
Johnson have clearly defined the function of the clitoris as the "transmitter and
conductor" of erotic sensations. Anatomically, the clitoris is a small knob of
spongy tissue, shaft and glans, 4 x 4.5 mm (Diknson atlas of sexual anatomy)
, located below the symphysis pubis. lt has a rich nerve supply with a distr
similar to that of the glans penis with specialized sensory nerve endings, na
the Pacinian corpuscles. Touching the clitoris is experienced as intensely
pleasurable by most females, however, the clitoris is so exquisitely sensitiv
touch that direct tactile stimulation of that area may be intolerable, especially
when it is not well lubricated, but the natural presence of the secretions of the
Apocrine glands is quite sufficient for such lubrication. Most females prefer
indirect clitoral stimulation, either by pressure on the mons veneris or by late
stroking of the clitoral shaft through the labia minora. incidentally, this is
what happens during the plateau phase of the sexually stimulated female when the
angulated erect clitoris rotates ventrallyl 80° and retracts under the symphysis
while covered by its clitoral hood to become squeezed indirectly by the mal
bone in the lithotomy position. The same squeezing happens during the female
astride position which is the face to face woman above. This sex position
incidentally is preferred by a lot of American women nowadays as proved b
. Hunt with the percentage of 75% in favor, in contrast to a researc
et al. in the fifties reaching 45% only. These women confess to the fact that the
astride position enhances their orgasmic release due to their*erotic satisfaction in
response to the (Kinesthetic sense) which is the sense of active body movemen
namely the active pelvic thrusting. Some authorities attributed the popula
sex position nowadays due to the increase of women’s rising expectations of
maximum and full sexual satisfaction during coitus.

As a matter of fact, this female astride position is advised strongly by most

sex therapists to be used during the treatment of premature ejaculation in mal
and for ejaculatory incompetence of the partner during their sex therapy because
51
it alleviates possible performance anxiety. VVomen who are lacking orgasmic
capacity and not truly frigid benefit enormously from this face to face woman
above during their treatment.

ln contrast, with the exquisite sensitivity of the clitoris, the vagina is

sensitive to touch only near its entrance. The vagina anatomically is a flexible
barrel of smooth muscles with some striated musculature near the introitus; lined
with a mucous membrane which is supplied with touch fibers only within its
entrance as well as proprioceptive and stretch sensory nerve endings in the deeper
tissues especially in the outer third. Contraction. palpation, distention and deep
pressure especially at 4 and 8 ()`clock at the entrance and the outer third of thc
vagina are reported by many investigators as highly pleasurable and erotic by many
women. Some women report that they respond to a combination of vaginal and
clitoral sensations. but the majority reveal that clitoral stimulation makes the most
important contribution to orgasm; xyhile pure vaginal stimulation does not lead to
orgasm unless it is accompanied and augmented by highly erotic fantasies
Clitoral stimulation regularly produces orgasmic release, perhaps this is evidenced
most convincingly by thc fact that female automanipulation such as during
masturbation and lesbian love is almost universally directed at stimulation of the
clitoris. Strangely enough it has been proved that few women attempt achieving
orgasm by inserting phallie like objects into the vagina such as vibrators or an
artificial penis

Many authorities now are sure that even during coitus. it is clitoral
stimulation that triggers the female orgasm because the clitoral hood is connected
to the labia minora anatomically. Significantly during eoitus the powerful
thrusting ofthe penis exerts rhythmic mechanical traction ofthe labia minora and
so provides stimulation for the clitoris via movements ofthe clitoral hood. ln the
final analysis. it is stimulation of the clitoris via the pubic bone pressure and by
the labia minora- clitoral hood mechanisms and not pure stimulation of the
vaginal introitus which produces the ultimate eoital orgasm in most women.
Maclean, Kaplan and Money confirmed Masters discovery that 60-70% of
women investigated require manual clitoral stimulation during sexual intercourse
in order to reach orgasm. Strange enough. although stimulation of the clitoris
seems to be the crucial element in the production of female orgasm. it is
surprising that the clitoris itselfplays no role in its actual execution

lt is now believed by all authorities that all female orgasms are

physiologically identical, triggered by stimulation ofthe clitoris and expressed by
vaginal. uterine and anal contractions. Accordingly. regardless of how friction is
applied to the clitoris. by the pliallus ofthe male. by the uoman`s fingers during
masturbation or ex en by a vibrator or any other desired object; female orgasm is
almost always evoked by clitoral stimulation. lhus the physiology of the female
orgasm is analogues to that of the male; because tactile stimulation ofthe glans
penis and the penile shaft triggers the male orgasm at the end ofthe plateau phase
once a certain level of sexual excitement has beett reached or exceeded,

52
 s mama ~

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Figure 20. External female genitals after intercourse (non circumcised woman)
Conclusion

lt is worth mentioning here this stmking recent evidence which was proved
beyond doubt of how valuable and important the critical role played by the
external genitalia namely; the clitoris and labiae during coitus in order to achieve
orgasm; to convince forever the public in Egypt and Africa to stop and abolish
their 3\‘v’illl practice of female circumcision better named female genital
mutilation (FGM).
 Non Resolved Sexual Tension in Females

Anorgastnia
lf the orgasmic release has been obtained successfully, then there is rapid
detumescence from the naturally accumulative physiological processes, namely,
what happens actually during the resolution phase. Sometimes, the loss of muscle
tension and its decrease, as well as the process of drainage of venous blood from
the state of congestion is much slower and is definitely retarded if an orgasm has
not been experienced. A good example of this condition is the practice of coitus
interruptus chronically, because there will be signs and symptoms of residual
sexual tension as well as non resolved vasocongestion. They are manifested
commonly as bilateral adnexal pains, low backache with increased varicosity
and the possible formation of varicocele when the condition becomes chronic.
Low abdominal pain indicative of uterine vasocongestion in females, long
neglected and misdiagnosed oftenly is indicative of non-orgasmic coitus and / or
long exhaustive making love. Masters and Johnson reported in 1979, that this
pain was well pronounced in women who practiced sexual excitation only,
without proceeding to full consummation of the whole coital process; typical of
this condition also is Lesbian love making and Teaser's sexual play.
It is fair to add to this medical syndrome of non-resolved sexual tension
that in Egypt; the majority of handicapped females who were circumcised and
who are unable to achieve orgasm (Karim and Ammar, 1966).
The nervous strain commonly produced by the practice of coitus
interruptus is by no means limited to the husband, because it may produce little or
no disturbing effect on a woman who is able to achieve an orgasm before or in
spite of the interruption of intercourse. Nor, will it disturb a woman who is
equally frigid whether intercourse is interrupted or not. But if the woman is
capable of orgasm and misses it because her husband withdraws his penis out of
the vagina, it can be said with certainty that nervous strain will ensue and mount.
The repetition of this technique of withdrawal leads to vasocongestion of the
pelvic organs. Most males know that repeated sexual frustration produces aching
testicles, often associated with low backache, an equivalent process is found in
women. The vague low abdominal pain caused by congestion of the uterus and
the ovaries is puzzling to the woman and sometimes - if he is not told the full
facts- to her gynaecologist, too,.

Most women, when they are repeatedly subjected to"coitus intermptus

develop what is known as "protective frigidity". ln such a state, they generally
suffer nervous upsets of bodily health or of mood, the condition may be slight or
severe, but the most common complaints doctors are all aware of perhaps are
attacks of depression or irritability, excessive worrying about unimportant things,
anxiety attacks including claustrophobia and, generally an increasing sexual
disinclination or frank frigidity. Physical disturbances such as early fatigue,
digestive disturbances e.g. dyspepsia, palpitations, insomnia and the famous spastic
colonn., are quite common findings.

S4
 ii`he weii known condition of nervous strain termed "A
occur often when emotional or sexual tension is allowed to pile up with a high
pitch of erotic desire is repeatedly reached and fails for some reason or another to
be released by an orgasm. Men experience acute sexual frustration less ofien than
women, because with them orgasm of some sort usually occurs whether by
orgasm during sleep or by masturbation. In femalesspontaneous relief may be
less easy to achieve and hence it is one of the reasons why anxiety neurosis is a
condition more often found in females than in males.

Artificial Vagina and Vaginal Agenesis

About l8.000 females in the U.S.A. are born without a vagina annually
recorded in l960, surgery is known to create an artificial vagina by grafting skin
from her thigh or abdomen. lt was suggested by Masters that the use of non
surgical techniques, namely the application of perineal dilators, which by gentle
stretching of a small dimple of skin where the vaginal orifice should be,
ultimately creates a vaginal barrel. During long term follow ups of detailed
physiological and psychological results ofthe artificial vagina, they found that
despite the fact that the artificial vagina is lined with skin and not with mucous
membrane as a true vagina, over weeks and months the skin lining comes more
and more to resemble the lining of a true vagina and at last even transudates a
lubricating fluid. In fact, in almost all significant aspects, vaginal agenesis and
patients with artificial vaginas are found to respond to sexual stimulation in
precisely the same way as other women. Some do conceive and bear children if
the rest of the genital tract is normal, delivery is either by the normal route or by
surgical intervention.

The Erogenous Zones and Precoital Petting

In Greek Eros means love, while genesthai means to produce, so literally it
means love producing zones. Now, every healthy and sane person is able to
respond to sexual stimulation, while the response is never exactly the same in any
two individuals, its basic physiological patterns is the same and is shared by all
men and women. However, the intensity of these physiological reactions are
never exactly identical in any two persons or even in the same person on different
occasions. Also, the specific responses of a particular individual are bound to
show some individual variations, for example, it is possible for some men to get
’*" "

'g‘“‘"* ’"‘¢' ejimllnti Willi I limp pllllifl ilu. HUH UIUEI |Jl}lllJ.. ll
it may be nye impossible. The same holds good for women, one female could be
multiorgasmic, while her sister cannot achieve even sexual arousal.

When

lluman beings can be scxually aroused at nearly all times, in many

different ways and by a great variety of objects. For example, man's excitement
may be triggered at any hour ofthe day or night, by sight or touch of certain
persons or things, by certain smells or sounds or simply by some thoughts,
55
recollections or mere sex fantasies. Since the possible sources of sexual
stimulation are so numerous and varied, they are not easily listed or classified,
nevertheless, it is very useful to know the obvious stimuli that can produce sexual
responses.

Of all human senses, the sense of touch seems to be the one most often
responsible for erotic arousal. Some areas ofthe body surface in the skin and
some deeper tissues, contain more nerve endings than others and hence more
sensitive to the touch whether light or deep. A good example, is the glans of the
penis and the glans of the clitoris, they both contain the Pacinian corpuscles,
which are highly specialised nerve cells and they are both especially receptive to
sexual stimulation.

Where

The best known and well established erogenous zones in the human body
are the glans penis and the penile shalt in the male, the clitoris, the two labia
minora and the orgasmic platform in the female; these are the primary
erogenous zones. (Figure 21 ).

ln both women and men other erogenous zones are known to be among the
areas between the sex organs and the anus, the anus itself but not the rectum, the
buttocks, the inner surfaces of the thighs, the breasts especially the nipples, thc
neck, the mouth namely the lips and tongue and lastly the ears; these are the
secondary erogcnous zones.

How

Touching, stroking, tickling, rubbing, slapping, kissing or licking these

areas can often create or increase sexual excitement. However, this response is by
no means automatic because a great deal depends on the person`s previous
conditioning and on the circumstances under which the sexual stimulation occurs.
For example, when a doctor touches a patient`s erogenous zones in the course of
a physical examination there may be no sexual response at all e.g. gynaecological
examination, neither is such a sexual response likely to happen in cases of rape..

ln short, psychological factors usually play a decisive role in tactile

stimulation although there are some exceptions to this medical rule, as in certain
cases of spinal cord injury, the injured man can have an erection when his penis is
fondled, although the stimulation may not register in his brain. No wonder,
because of their different experiences, different individuals are likely to develop
dilfercnt degrees of sensitivity, since negative mental associations can prevent
any sexual response to touch. ln fact, there are people who want to be touched as
little as possible even during sexual intercourse. On the other hand, pleasurable
sexual encounters can develop a welcome sensitivity almost anywhere in the
body and thus lead to the discovery of new erogenous zones unknown to both
husband and wife.

S6
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 ln the final analysis, people making love have to find out for themselves
which parts of their own or their partner's bodies most readily respond to caresses
and sexual stimulation No wonder, successful and efficient precoital petting is a
must for vaginal lubrication and pleasurable easy penile penetration. However, it
was found that women are more easily distracted from sexual activity even when
aroused and many of them reach orgasm only as a result of sustained and
continuous direct physical stimulation. Also, the average healthy female is less
easily stimulated sexually by mental images alone unlike males. Please refer to
the chapter of female dysfunctions discussing the treatment of frigidity and
wonder at the beautiful words of our Prophet Mohamed teaching us the great
values of sexual foreplay since nearly fourteen hundred years l
Other senses

Most people are well aware of the fact that they can become sexually
aroused not only by persons or things they touch but also by what they may see,
hear, smell or taste. The sight of a beautiful body, the sound of a musical voice,
the smell of a perfume, the taste of certain foods or of a lover's glandular
secretions can be powerful sex stimulants. However, their effect depends entirely
on mental associations, for instance, a particular person becomes excited by a
particular sight, sound, smell or taste because he or she associates it in his or her
mind with a previous pleasant sexual experience. On the other hand, unpleasant
associations produce negative reaction, they can reduce or extinguish sexual
excitement, no wonder, male sexual inadequacy is so prevalent.
Culture

lt follows from these observations that there are no constant erotic sights,
sounds or smells as such, they only become so through certain erotic experiences.
lt is not surprising therefore, that at different times and cultures people have felt
attracted to very different ideals of sexual beauty e.g. in the past, Arab men
usually preferred well padded women!. A certain piece of music may appear
stimulating to some males but not others e.g. Jazz music appeals plenty to young
Western cultured people. While the "el-zarr" music have a stimulating effect on
some of our backward women; the African drums would be said to have the same
stimulating effect on most of our African inhabitants.

Human beings in general depend very much on psychological factors in

their sexual responses and many people become aroused sexually by mental
images alone. Indeed, there are some individuals who are able to reach orgasm
simply by fantasizing about sexual matters. It seems however that erotic thoughts,
sexual fantazies and anticipations have a more stimulating effect on males than
on females, that is why during sexual activity, most females reach orgasm only as
a result of continued direct physical stimulation.
lt should be mentioned here that certain sexual responses can occur for
entirely non—sexual reasons, for example, many men know that they may have
erections when lifting heavy weights or when a full urinary bladder causes some
physical irritation. Also the state of priapism, which is the painful inability to lose
erection which could seriously damage the penis unless treated immediately.
S8
 THE PHYSIOLOGY OF COITUS
IN THE HUMAN MALE

• Physinlngical responses ofthe sexually stimulated male.

• Size of the pcnis.
• Relation between anger and sex.
• Orgasm during sleep.
 THE PHYSIOLOGY OF COITUS
IN THE HUMAN MALE

Physiological Responses of thc

Sexually Stimulated Male

In u phycinlogimtl research laboratory recordings of the cxtru-genital

reactions. as well as, observations of gctviml respt»n<c< were- recorded before
, during and éher sexual stimulation, lhe basic mule human sexual response
into five different phases. which u ere decmibed by Masters and Johnson in the
year 1966i These phases were tcnncd: Fxciternenz phase, plateau phase, nrga
phase, relractnry phase and the resolution phase. (Figs, 22 — 2=>).

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Figure 22. 'Ihe interim] stiuulure til the penis ns xieuerl Front a cross
Secltml and transverse section,
 It should be pointed that the presented dingmms of female and ma
response cycles ure meant Only as schematic Ccnceplualizalions of |l]
C0mmOy observed physiologic rmttems,
n greater detail in thc chapter of Sexual whil
lnudequncy.

( 1 ) The cxchcmcnt phase

The mm! obvious sign of sexual excitement in thc mal: is penile

because the initial rcspnns: uf the human male to sexual stimulation is
vasodilation of the urtcrics running into the penis, resulting in erection.
occurs as n direct result of vasocongeseive changes
oe pens. lt is helpful tu realize, however, that physical as well as
within t
psychological
anxey arousal may be present without a Hun crnct
Or fatigue arc prcscm

Spinal cord centers

In both men and women the physiologic signs nf cexual excitement are
produced by the reflex vusndilatation ofthe genital blood vesscls. Du
arousal, twn centers in the spinal cmd, one at S2, S`, and S, and one at TTL
,,,uac,u,Ts.vasodilatatiun
and L2, causeshecmue activated
these organs to becomeand cause
swollen thc artc
and distended
and changes thr-ir shape to adapt them to their reproductive function. Th: rcf
dHa\atE<vr1uccuv¤in hoth genders, however, becnusc of anatomic differenc
male and fémafe genitals, this swelling takes diftbrent tbrms and so p
ulmngee which are dtfferent but cmuplcmcntany. The penis hccomes hard
enlarged to penetrate lhs vagina while the vagina balloons and bccumcs w
nccmnmodnte the crcct penis.

'l he penis

The cavcrnnus spaces ofthe corpora caveruusa of thc penis fill with hlncd
and distend the penis against its tough. rigid outer sheath
1acc, sqft pcni< intn a hard and erect organ cnpnblc nf penetrating the
The penis
wcuses blood is maintained hard and erect by a high pressu
as tts fluid.,

Normal mechanisms ofurcctinn:

Ercctirm ufths penis depends on the adequate filling ofthe pai

envemnm with blood nt systolic pres<ur¤ nr uagmty abme. Artcrinl blood enters
hmm the paired cavcrnosal arteries, which are terminal hmurhes ofthe interna
ilinc arteries. Nunnemus cork<orew-shaped hclicinc artcrics hmnch ¤{`f smh
caverunsal artery within the corpora and empty intu the Iacunnr spaces, Erc
occurs when the tnnicnlly contracted cnvcrrmsnl and hclicine mmriv; relzw
, mcven¤ing blood flaw tu the lucurmr cpnces and resulung in sngorgcmcn
penis. The enlargement is contained bythe tough fascia which encnses the penile
cylinder while the ptessure uf the increased blood against this sheath hardens the
penis and makes it rigii! The increased penile flow uf blood during excitement is
krmwn to be caused by relaxation of the penile arteries; this is brought about by
pnrasympnthetlc Impulse: from the erectiun centers.

Relaxation cf the trabccular smooth muscle of the corpora cavemcsa is

mediated by acetylcholine released by the parasympathetie nerves. Aeetylelmline
acts on endothelial cells causing them to release a second non-adrenergic ncn—
cholinergic carrier nf the relaxation signal. This carrier is proved to be nitric
oxide, possibly uf neural origin, but other candidates fm example; vusoactive
intestinal polypeptidcr have not been conclusively excluded. Nitric oxide may
exert a relaxing effect un the ttubecular smooth muccle thmngh stimulating
guanylnte cyclase to produce cyclic guanosine monophosphate (c—GMP), which
would then functiun as an seumd messenger

Systemic blond pressure expands the relaxed trabecular walls against the
rigid tunica albuginea. compressing the plexus uf subtunieal venules ant!
restricting venous drainage from the lncunar spaces. Erection is therefore the
result nf an equilibrium between nnerial inihnw from the czvemous arteries and
the rcsistanee to blood outflow from the Iueunar spaces resulting from these venu
ccclusive mechanisms. Detumescence is accomplislted by a reversal of these
processes. Increasing synipathetie tune, which is also involved in mediating
tvrgastn and ewvtilzatinn, causes the cavernusnl and helicinc artcrics to contract,
restricting hlnmi l`lnw lntn the lmznnar spaces Falling intralacunar pressure then
decnrnprcsscs the subtunical venules, allowing increased venous outflow and
restoring the penis to its normal state of Haccidity. We can see now that the
erectile response is primarily an parasytnputhetic nm-, zilthnngh surgical and
phnrinncnltxgicnl evidence suggests that minor sympathetic component is also
required fnr potency by controlling the outflow of erectile blond. However, it is
well known clinically that an intense sympathetic response such as that produced
by fear and anxiety. can instantly drain the penis of cxtra blood and so cause a
psychugenic loss nfereetinn

Sexual excitement may mnnnt rather unexpectedly and quickly especially

in vnung vncn, but it may also build up gradually and nver a itmgcr period uf
time. ln fact, some males deliberately distract themselves rcpcatcdly from their
mounting feeling: of immense sexual pleasure, in order to prolong the act and tv
savor or enjoy more their experience of hccoming sexually amused. Again.
sexual arousal especially in its early stages. can be easily reduced by some
outside inter ference such ns <ndt|en worry nr anxieties. ztlsn fear and pain have
the same ellect But, with the increasing magnitude of scxtml tension, such
negative inflttencew hecnme les= and less ellbctive, while the ability lor sexual
self control is impaired and <c><unl inhibitions me swept awhy with the inevitable
mvnrrenre ofthe nrgaemic releme and qjaculatiott
 The penis is formed of three bodies of cavcmous tissue with erectile
capacity, and aner the start of sexual stimulation whether by tactile, visual or
olfactory means, th~- occurs a slight increase in the sive ofthe penis which
affects its shape and position. The stiffness of the penis
pareyng corpora eavernosa and nut until further and stronger sexual
stimulation takes place, does the corpus spongiosurn which forms the gl
become fully erected The glans penis shows a color change acquiring a nrore
deep red tone. When the penis is fully erected, the urethra is stretched out, w
droplet of fluid is seen chen in the urethral opening This fluid is secreted from
the urethral glands among which is the Cowpers gland placed some I5 cms from
the opening. A point ot great importance is the presence of few very active
sperrns sornutirrres irt this fluid, and this droplet ot lluid nray bc noted thorrglr the
penis is not ltrlly erect, ( Fig. 23).

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tunica aartas
(thickening)

Figure 7] Male pelvis: excitcrncnt plrasc. Key to ahbrevirrtiorrs T T testis; E

epididynris; U 7 uretlua. CG — Fnwper's gland; P Z prostate; PU - prostatic
utricle: FD = ciaeulatory duct; VD — vas rlclcrens, SV rr scrninal vesicle; UB
urinary bladder; SP = synrphysis puhis; R > rectum.
The capacity fnr erection

It is north rnentioning here that thc sarnc stimuli that bring about the
penile erection in the male result in vaginal lubrication in the female, hecausc
these two phenomena are absolutely necessary for a rrorrrral penile intromission
into the vagina and are both based upon thc saute physiological mechanism 'llre
capacity hir erection is present at all ages in the male. tlte nconatc penis is
dominated bythe glans and cxpcriments done on a two tlay old hoy, proved that
erection did occur when provoked by slight touching ol the izcnilal area. lt should
he noted again that crcction in the tnale nury he esoked hy cerebral or spinal
activation, because in rnalcs with high spinal cortl transcctinn, ercction may he
 evoked by spinal reflexes alone. The same is true of vasodilation during erection
the arterial vessels nmning to the corpora cavemosa are almost closed;
parmympathetic cholinergic nerves innervate these blood vessels. 'lhe dilation
that ensues tills the cavemous spaces with blood, the pressure rises as a result
until it reaches that ofthe arterial blood pressure with maximal stiffness and
rigidity following.
The scrotum

The normal appearance ofthe scrotum begins to change as vasocongestion

produces a smoothing out of skin ridges on the serotal sac; the scrotum shape also
flattens because of an internal thickening ofthe scrotal integument. Later, the
scrotum and the testes are partially elevated toward the perineiun. The
physiological significance of this phenomenon is not completely understood
. because this elevation occurs in other situations besides sexual arousal.
Incidentally, it so parallels the vaginal tenting effect, well noticed in the sexually
stimulated female, both have in common a preceding phasic period and a
characteristic fixation in position. When the surrounding temperature is neutral,
the srrotal skin is richly folded and freely movable in relation to the underlyin
structures. But ifthe temperature of the environment is lowered, the muscles of
the scrotum are activated and alternate between contraction and relaxation while
the tcstes move into a posterior position as the organ is elevatedr Contraction of
the crernaster muscle, known as the "crenmxterie retin" or "withdrawal
reflex", may be evoked also when the inner surface of the thigh is scratched
. 'l hese changes resemble those occurring during sexual arousal in the male
elevation of both testes toward thc perineum occurs in the excitement phase
. Later, when the sexual response cycle has continued into the plateau phas
testes become enlarged by vasocongestion, iricresclrig their size by about 50
pcrcenr. They are key: in close apposition to the oerizrcuirt and lower abdomen
through the slmrtenimi of the spermatic cords, mediated by the crcrnasteric '
muscles lhe pulse i ·te in this phase reaches abo rt If>'· l20 per minute as
coinparerl with the male resting pulse; ECG recordings were measured tluougli
electrodes tixed on the thorax ofmale volunteers The blood pressure rises and
then- is Iiyperventilation as well as generalized myotoi-ria.
(2 ) The plateau phase

ln the excitement phase, there is a marked increase in sexual tension above

the baseline (unaroused) Icvcls. The plateau phase represents a leveling off ofthe
increments in sexual tension that are occurring, although there is a further
intensification if effective stimulation continues 'l his phase therefore describes a
high degree of sexual arousal that occurs prior to reaching thc tlneshold levels
required to trigger orgasm 'l'he duration ofthe plateau phase is variable, but it is
olien exceptionally brief in men who are premature ejaculators.
 During the plateau phase, there is a minnr increase in the diameter ot the
proximal
n coor due to venousportion
stasis. ot` the glans penis, where there is frequ
The testes

Vasocnngestiou causes further increases in the size of testes during

plinse, with increments 0f50 tu l00 percent of baseline size are typically se
sexual tension mounts towards orgasm. the testes continu
eevatiun initiated in the excitement phase but also a process of anterior rotati
so
(g. ). that the posterior testicular surfaces rest in nrrrr contac

UB CuP , r·
smmtion mm.; ED 1 it SP % M WPE S
°Z’,'2%°"""“'“°V· OG!
{·
Ur ‘·' V if . · R
· esticular elevation ··
: ~> (full)
'
» Skin earl
vgI ·.>;»;c# ‘_ s S tuniu dnrmu
size increase "

figure 24, Male pelvis. plateau: phase

Extrngcnital changes

Other exlratgenital features ofthe plateau phase common to bolll uunten

and men include generalized myntunin, tachycardia, hyperveittilntion, and an
increase in hlucd pressure. These changes are primarily a continuation seen
Often during the late plateau phase.

A number ofmales, not nll, do experience what is known as a sex flushit

, is rt red rash that usually hegins in the area ofthe lower abdomen and
ta the neck and face or cvcn tothe shoulders, arms and thighs, The sex tln
start only lrtte iu llte excitement phase but it t= more likely
pase while sometimes it may appear as late as the nrgasmtc phase. In many
cases, however, there is no sux flush at ull, the same is true for the human female.
The physiological mechanism underlying the appearance of the sex rush, which
may be of n maculo-papulnr character is nut known up till now, and it may very
quickly disappears in th: resolution phase.

Nut all innlcs experience the erection of their hrcust nipples, which is
brought about by direct physical stimulation of the breasts unlike females whose
breast nipples become erect involuntarily unc: thc lady is sexually stimulated. lt
usually appears toward the end of the excitement phase nr during the plateau
phase and it usually remains visible and erected for sometime aflcr lh: rcsulutinn
phase:

(3 )The urgasmic phase

It is simply the sudden release of muscular and nervous tension at the climax
cl sexual excitement. This experience represent; "thn mm! Intense physical
pleasure nf which humun beings are capable of and is basically the snmc for
mules and fcmules". As mentioned before, the specific neumpliysinlugirx
mechanisms nf orgnsm are nm known presently, nevertheless. it can hc postulated
that orgasm is triggcrcd by an neural reflex arc ance the orgasmic threshold level has
been reached or exceeded This speculative mmlel, lvasud un lhs physiology of
nther body systems. will bc important in llic context of later clinical discussion, An
orgasm lasts »·niy zi ibw seconds and is halt very much like a short seivurs or rather
like :1 quick succession nf cnnvulsinns which involve the whulc burly and soon lead
lu Uumpivtc relaxation.

Mechanism bf cjuculatlnn

In sexually mature male=, nrgzwvn is avmrnpnnierl hy cjnculminn nf scyncn

and since wmncn dm not produc: scmcn, hcncc llicy do not einculme. The same is
true kar buys before puberty, they do have orgasms but without ejnculmimi The
nmlé orgasm i< rriggvrsrl hy the buildup uf sexual tension to the point whcrc thc
genital ducts and accessory sex organs begin a series of strung involuntary
rhythmic contractions, namely Vasa def:-renria, seminal vesicles, prostate gland,
thc anterior and poslcriur urethra, urinary bladder sphincter, me vnusclcs al me
base of the penis and finally Ilic penis itself. Tlic first three or Fnur forceful
rzumrnuliuns incur within less lhnn a sscnnd. actually (0.B) ofa sccnnd. thcn they
bccnm: weaker and occur at longer inlcrvnis. As u result of these contractions,
the seminal fluid is pooled in the prostatic urethra tbmiing a pressure chamber,
_wiih a pmxinial closure towards thc urinary bladder. ’l his fluid. with its
concentration of live sperm cells, is lbrmed from threerdifferent sources: the
prostate, the scminal vesicles. and the vas deferens 'Ilie mnnum nf ssincn
qiuuulaierl dining one orgasm is usually al-mnt a ieaspnrmliil, ncnrly 5 ml, but it
varies eqvecially if repealed ajnculmimis are permrmerl within a slmrt time,
because the mulr:ll1<:n pruduces less and less seminal fluid.
 Secondary organ contractions
(Ent staze orgasm)

» ‘ —li``;`
Si,-*%`.ttr»
Mit SP \( UB in »""
contractions l` p . ' ED d
_ _'/
(seconstage ,. U V PU orgasm) J , ·
. ge

` 1 r?#*{5;§ gérjx
' **52 Pix) / R i
External sphincter " ‘ i ermtraetiam
4 :· 7
skin and
·' tuniea dartos

ligure 25. Male pelvis: orgasurrc phase

At the tirst stage of the eiaculatory process, the very excited male
experiences a sensation ofejaculntnry inevitability,
yare perceved as the start ulejaculation, although the extemal w
propulsion of sernerr will be delayed for scveral seconds Thiserjrne lag
the onsct of ejaculation and appearance of seminal fluid lrom the penis, is a r
ofthe distance the ejaculate must travel through the urethra, as well as the
interval required for the build up of sullicient contractile pressure to p
seminal fluid pool in an anterior fashion The internal sphincter ofthe neck ofthe
urinary bladder is tightly closed during eiaculation, ensuring that the semin
fluid bolus moves anreriorly, toward the path of least resistance. Rhythmic
contractions ol the prostate, the perincal muscles, and the shall ol the penis
cornhine to assist thc propulsion process ofcjaculation duri
e orgusmic ejaculatory process (Fig 25), The first ejaculate leaves thc urethra
to the ontsidc emerging in several quick spurts, at a velocity of about 4 times the
rncan velocity ol the blood in the aorta. At times, it may be projected a
considerable distance. while at other times, the semen may H
e orce ola particular ejaculation is not related to a rnan's strength ur virility,
(Fig. 26).

It is important to rememher all the time that the nhole hotly is involve
physiologically, Iiir example, the anal sphincter muscles contract at the manic
intervals as the sex organs. ln fact, there is great neuromuscular tension
tlnoughout the whole body, because besides the muscles directly involved in t
act oforgasrnie release, whether through coitus or masturb
muscemay react involuntarily, rhythmically or with
We the sexual stirnularion proceeds, the restlessness increase and it is the single con
sudden, convulsive release from this overall tension thm
s zi matter of fact, at the time ol sexual climax, surrrrds are ollen produced
whether from the male or lemale partner, such as screaming or moaning or
incoherent noises. Stunetintes tossing ofthe head sideways is noted among some
females during this plncc Breathing become very fast and the pulsc rate mounts
to about l40, while the blood pressure rises even higher than during the plateau
phase

f— /»}f` ` \_ r_’ 7 l
\ gm
-:;:\_
X‘
L * ·-·f %
# / c·‘~·i~ r
, - ·.-4;-;;;;E;:. ;EE{;;;;E;.;V;

lf
hk7`>&>.>t
se `

Figure 26. 'l he male genitals and muscles during orgzistn

Phase t· Fniission This phase is pctccitlcti as the seusulitut t»f"eiutnl¤ttoty int:titabiIit;".
‘lltc internal male reproductive vtscera [prostate (a)_ vas delerens tb), seminal vestclestcyj
ctntttact and collect the eiaculate in the urethral bulb td). Phase 2» lixpulsion: The perittcal
t»—)_ and bttlhocauernosits (tj muscles contract with a R/second rhythm Causing pttlsatinns of
the penis and expulsion ofthe ejaculate ’lhe penile urethra tgt contracts also

( 4 ) The rcsolution phase

During the resolution phase, tlte anatomic and physiologic changes that
occurred duiing the cxciteineut and plateau phases reverse Immediately
following ejaculation, the man enters a "rcfract0ry period", during which
further ejaculation is impossible, although partial or full erection may sometimes
be maintained. This characteristic feature of the male resolution phase may last
for a few minutes or it may last lor many hours. For most mcn, this refractory
period lengthcns with age and is typically longer with each repeated ejaculation
within a time span of scvcral hours. There is great variability iu the length ofthe
relractory phase both within and between individual men, while it is not prcscnt
Ill the female sexual response cycle (Figure 27)
 Orgasm

Plateau //*-·_Refractory ·
71 `
Rerrsptnry l'
I pertud
cxate».;¤t/ ¤·=r*¤¤ fa Ng

Figure 27. lhe male sexual response cycle.

lnunetliately after the last ejaculatory contraction the muscular moveme
cease. wltilc the scrotal and testicular elevation reverses into a downward
movement. T he testes decrease in size and descend into the scrotum unless scx
stimulation is continued The tumescenee nl` the
ncienay the length of this resolution tune ts proportionate to that of the
penis
excitement phase lltus, tn men the erection tllminisllcs in two stage
major loss of ylotenry tltat occurs immediately atter eiae
contractons during orgasm that quickly reduce tasocongestton and a second
stage of tletumeseence corresponding to a slower process of` return to normal
vascular llow Thus. one can note that the penis still reta
may persst for sometime cspecially ifthe excitement
proongeUn the other hand. it is yxell kutlwu that non sexual aettvtttes or
and
distraction
ery rapidly, (Fi;;.28I. e E, a knock on the door for example can com

f¥—»
. SVN

/ / / ) /\
<.. s l VB VU SI'~’ ~/ /
)Pt.! t~:1> / JV
lU

,\;\ , PU ,/ lll 2 l
l lwlla. Wee/l lll ,e·\~ R
’ »

l ` "T ` J. { Iafé
\\ 2 j*Testteular descent
\;_y T; skltltat \\ ylxl l;y.
Loss el testictxlmy EL./Qs?/<*“““‘°‘*‘°*““““
vaeoenngestion / *1
Figure 18, Mule peltts rcioluuou plutst
 0Th0I0mus
Lim bic System
C 0 rt e x

` {ya K`? l~
»\ vt—
N7/‘ § ,1/

4/ C

Figure 29, The sexual response reflexes.

This is a diagrammatic representation ofthe reflex pathway of tlte expulsion component
of ejaculation (a) is zi representation of the sensory pathway from thc glans penis; (lv)
shows a ruutut nerve tu the muscles at the base ofthe penis which contract teilexly during
nrg:i<m; and (r) i= a diagram nf a crm: eocttnn nt the epinal cord, slimving a celiernatic
representation of the various influences which irnpinge on the internuncial ncuronc pool,

Size 0f'l`he Penis

History

Recent discoveries in tlte field of experimental sexology have exploded

several sexual myths and wrong belietis about the size of the penis (Masters and
Johnson). So much has been said, and a lot was written about the importance oi
the size of the penis and its role tluring coitus. ln every country and in every
known language, not just recently but since ages tltis mytlt was well recorded at
llte time ofthe Pharaohs. Their temples all over Egypt are full of phallic
inscriptions and paintings. some of which are even alyttonnally exaggerated
erections, a good example is llte God of fertility (Menn), beautilully painted and
well reported in Upper Egypt and in Abou-Simbel.

ln "Pompeii", the old Roman town deslro) ed by the xolcanic eruptions of

thc famous volcano "Vesuvius" in 79 A,D., tourists crntltl still easily see the
daring Roman philosophy painted clearly on the gate of the house of pleasures A
hig Lnalztnee, with one scttlt: l`ull <il`2tll llte ur»rlrl's knonn treasures but still not
capable of tipping the other scale wltich contained the image of an enortntnts
sized fully erect penis
In some ancient temples oflndist, China and Japan and among the text of
some of their numerous religions, there were similar erotic ideas and sexual
beliefs. So much st-. that their ancient civilizations have confirmed the widely
lteld belief that the size of the erect penis is related to sexual etiiciency and it
greatly influences the sexual perforrttartce itt cuitus Many Famous and sexually
explicit works of art and architecture testify to this belief indeed, one ofthe best
krntwrt early sex manuals, the "Knmasutr¤“ written irt the 2nd century BC.
treats sexual intercourse as a means 0i` spiritual enrieltntent Phallie worship in the
Form of deep respect for the "Lingsm"' an artistic representation ofthe penis,
continues to this day.
ln rrtany parts of Asia. openly erotic intztges acquired a religious meaning
irt the past. a tttingling ofthe sn-called "t:rntrit· rnnvt-nt2nts" which can he tbnttti
itt both the "lIitttlttisnt" and "l3uddltisnt" religions. lligltly erotic images eatt he
sr-en in ntatty llirtdtt temples. for example. thc "liugttm" (rtta|e sex organ) set in
the "Yrtni" (tentale sex organ), representing the double sexcd deity or their (iod
who is double sexedl. (sn they believed)
Sexual perfnrmrrnee and si1e ofthe penis
For rcztsrtrts tltat are not entirely cleat. tttany rrrzrlvs itt our culture seettt
qnne bnttcertterl about the sire ttl their penises, ltnweter, such concern is
completely ttnwartattted sontetirttes. The average notntal length of the penis irt
the tlaceid state is variable, tt ts usually about 'l to tl inches but when lull; crcct
the length itt· tenses by apptuxitttately it) percent rrttrltittg lrottt i rn 7 inches ar
more Itnwescr, it should be noted tltat this increase in length occurs stepwise. ll
has been found that there may be great variations in tlte size ottlte penis liottt one
ittdividnal tn tlte other. Cttrttrztry to some widely accepted nryths, the size nf the
penis is not related to a rrtan’s body build. skin color or his sexual power. For
example, zt ter) short rttart may hate a larger penis than 2t tltll rttart {and tice
in-rsa). a w ltitc ntan may have a larger penis than a black ntan (and vim- versa),
and a rttart with a srttall penis may have more orgrtsrtts than a man with a large
penis (and tice versa) Ftttrltertttttrt-_ sottte pettises which greatly differ in size
w lten they are tlacctd, may he nfidentical size when they are crcct liven a penis
llntt rerttains relatively small during an erection serves every function ol a larger
penis. A wornzttt`s vagina Rtr instance. adjusts to any penis. nn matter tt hat its sive
anrl since the sagittal walls contain few or no nerve endings itt its inner twin
thirds. arty dilfcrcuce itt the wnntan`s sensatittns depends nn the Hrtttness of lter
tttuscles surrounding the outer vaginal walls tts wcll as rttart) psyctmlogical
factors This mr-t. attatomirally is also true, attd holds good as regards sensations
inside the rccttutt, during anal intercourse or sodomy. 'llrere is practically nu
lbclittgs at all beynnd the anal sphincter muscles, this ts incidentally the reason
w hv smite individuals who intrnducc long and ltztrtl oltients into the rectunt, rttay
seriously hurt themselves without realizing tl. lltis may Itappen as well during
lbttilile anal intercourse which occurs during the act ol` taping a tttale eg in
prtsorts artd mental hospitals or hetwccn ltorttnsextrals llie rnanulitctntets ttl
sexual aids dict make use ol` the huge penis sexual taboo and produced in the
70
market different siz.ed and variable shaped phallic like structures to nttract their
customers, which were meant For both males and females. A famous theatrical
play which deals with this point was performed in London, (l960).
Abnormal sized penis
Recently. the lahnramry experiments perfomieci by Masters and his
colleagues proved that the differences in size ofthe penis are to a very large
degree leveled out by the degree of erection, so much so. that a smaller penis
increasing in length impressively. is more efficient than a larger nun c(Ticient one
provided naturally that it is not the congenital anomaly of a microphallus
Because. the human vagina accommodates the actual penile size and no more, so
that an abnormal sizcd pcnis could not go further than the actual size of the
vagina when stretched maximally during the various stages of sex stimulation.
Fmtheunure, there is danger nf vaginal rupture or tears commonly occurring in
thc posterior fomix, if an abnormally sized penis is pushed wrongly dccpci than
necessary or while being used with undue force. Post cnital bleeding, apart hom
tom hymen injuries on the wedding night. accompanied with excessive pain or
unexplained shock should be taken seriously into consideration by doctors in such
cases, hecause ifthcre is a vaginal tear it requires immediate surgical intervention
and repair under general anaesthesia.
71
Relation Between Anger and Sexual Physinlugical Responses
Sexual Response Auger Response
I. Reduced sensory perception. Reduced sensory perception.
2. Pupil dilatation. Pupil dilatation.
3. Involuntary voealization. Involuntary voealization.
4. Salivary secretion. Salivary secretion.
5. Hyperventilarion Hyperventilation.
6. Irregular breathing. Irregular breathing
7. Increased blood pressure. Increased blood pressure.
8 Increased pulse rate. Increased pulse rate.
9. Increased peripheral circulation. Increased peripheral circulation.
I0. Reduced bleeding. Reduced bleeding.
I I. Inhibited gastric function. inhibited gastric function.
12. Adrenaline secretion. Adrenaline secretion.
I]. Rhythmic muscular inovenient None.
I4. 'I`unrescenee ofsex organs None
I5. Genital secretion and discharge None.
I5. Ejaculation ni adult males. None
17. Muscular tension. Muscular tension.
IS. Increased muscular capacity. Increased nruseular capacity.
19. Involuntary muscular activity. Involuntary muscular activity.
Kinsey discovered that many ofthe bodily responses in anger and during
Sexual arousal were in many aspects sirnilar. Freudian analysts in particular
argued that anger, both concealed and expressed, was often the result otrcprcxscd
sexuality. Kinsey showed that there is certainly a close parallel between sexual
response and the physiology of anger. Only l`nnr bodily functions ditlerentiztte
hetween hoth and so he put the hypothesis that, ifcertain physiological elements
were prevented from developing, the individual might be let! in a state of anger.
As such, the fact that frustrated sexual responses so readily tum into anger could
he easily explained `
/\s Kinsey pointed out, in lower mammals and in man. anger and fighting
easily turn into sexual response I. Could this be the clue and the answer to the
mysterious "lmte-lovc relationship" ’?
72
72
Orgasm during Sleep
lt has always been well known that human beings are capable ol`
experiencing sexual responses while they are asleep, ln the past, people ascribed
this capacity only to males and there was no comparable requirement for wotnen.
Since women do not ejaculate anything, nobody paid any attention to their
spontaneous orgasms. indeed, until fairly recently the medical staff were used tu
discuss it under the heading of "nnrturnal emission".
History
ln ancicnt times, it was thought that involuntary orgasms occurred during
tlte night when a demon visited people rn their sleep!. During the middle ages, it
was believed that the devil himself corrld seduce good believers at night by
appearing as an incubus (i.e. lying upon rr woman) or a succubus (i.e lying
under a mau)...
Terminology
It was nut until around the middle of our century that Kinsey and his
associates presented some reliable statistics as to the freqrrerrcy of this type of
sexual outlet. 'I he ligures shrrweri that not only males. but also many females
have orgasms in their sleep, (although the percentage of females is smaller) As a
consequence, Kinsey no longer spoke of "nucturnal ernissions“, but of
"nncturnal sex dreams? This was a term that could be applied to both sexes
llowever, it also covered cases where no orgasm was reached In urder to bc
more: precise. other sex researchers therefore replaced Kiuscy's term with
"nortnrnal orgasm", (i,e, orgasm during the night). Unfortunately. this now
popular expression is very misleading, because in orrr culture mrrsr orgasms occur
at night, including those reached hy cuilux. Sexual dreams on the other hand, may
very well occur during an alternoon nap, in which case they would have tu he
called "1liurnnls¤x tlreams‘°, (i e sex dreams during the day). lt scents tlrcrr that
"nrgasm during sleep" is the simplest and most accurate tenn available, it was
also termed "wet clrearns" in the past
involuntary orgasms are almost always accompanied by sexual dreams.
especially in males. These dreams may depict unusual or tor-hidden behavior.
srrclt as sexual intercourse with close relatives, children or animals, group sex,
exhibitionism, and many uther activities that thc individual could never perform
or contemplate while in his or her waking hours. llunever. during sleep our
normal inhibitions and learned controls arc much less ellective and many of our
unconscious wishes may thus be acted out iu a harmless symbolic faslriorr. The
tack of corrseinrrs restraints also accrrrrrrts Err another plrerrorrrcrrorr, and that is
many people, (particularly wornctt} reach orgasm much faster in their sleep than
while they are arrnke
73
Medical opinion
Certain psychiatrists once used to regard involuntary orgasms in women as
symptoms of some neurotie disntder, but in due time, this curious opinion has
been completely discarded. Instead, there is now n widespread heliefthat orgasms
during sleep are necessary and healthy, and that they can even provide a
"naturnl" compensation for sexual abstinence. ln other words, it is assumed that
persons who do not engage in any sexual activity will instead lind sexual relief
while asleep. This popular assumption seems to be lalse however. For instance,
according to Kinsey’s findings women who suddenly lost the opportunity tbr
several coital orgasms per week, has only a few more orgasms in their sleep per
yearn As a matter of fact, for sorne women the number ol' involuntary orgasms
increased only when they also had more voluntary orgasms ln short, an orgasm
during sleep is a possible natural hmction of human body, but it is no substitute
for conscious sexunl activity.
74
POSITIONS OF SEXUAL INTERCOURSE
• History and Research.
• Advantages and Disadvantages.
POSITIONS OF SEXUAL INTERCOURSE
History
ln Western societies in the past only one sexual position was considered
"normal“ for decent people. Because of the religious sanction it received, it has
come to be referred to as the "rnlssionary posit·lnn", Kinsey`s research found
that the male»above position was the most frequently practiced among Americans
bom before 1930 (Kinsey ct al. 1953). A small proportion of couples (9 percent)
never even strayed from it in their lifetimes. However, most couples did practice
some variations in their sexual positions especially those who were brought up
more recently, mostly young and uninhibited couples,
Research
A recent rratronnl American sex survey found evidence that since the time
of Kinsey”s research, variation in sexual positions has bccorne common practice
between marriage partners (Hunt. 1974) The research found that the "l’enralr>
above position" is frequently bcing used by 75 percent of married couples
nowadays (versus only 45 percent in Kinsey’s research). A "side—t0-side
position" is frequently used by 50 percent of married couples (versus only 3I
percent in Kinsey`s research), The "rcar-entry position" is freqrrently used by
40 percent of married corrples (versus only IS percent in Kirrsey’s rcscarclr).
Finally, a "sitting position" is frequently used by 25 percent of married couples
(versus pnly 9 percent in Kinsey's research ). Frequent variation in sexual
positions is found to be most common among younger couples.
Research studies of male and female attitudes toward different sexual
positions is virtually non existent. One recent study, however, did investigate
attitudes toward the female-above position in a sample of 1 19 unrnarried college
studcnts(A11geier and Fogel, 1978). llalf ofthe students were shown slides ofa
couple having sexual intercourse in the female-ahove position and the other half
were shown slides ofa couple having sexual intercourse in the more conventional
female-below position, All the students were then asked to give their impressions
ofthe personalities ofthe man and woman using a scale ofdescriptive adjectives.
Surprisingly, the research found that the female students (but not the male
students) rated both the mart artd woman in the female-above positron quite
negatively, Specifically, the female students regarded the woman as, "dirtier,
less respectable, less moral. less good, less desirable as a wife and mother"
when she was above tlte man during sexual intercourse. The female students rated
the man in the female—above position in a similarly negative way.. This research
seems to indicate that young unmarried women as compared oitlr men tend to
hold more traditional erotic role expectations regarding positions of sexual
intercourse. Negatixe emotional responses to the fernaIe—ahove position may
rellcrr the reluctance ot nornen to ucccpl rr role of sexual assertlveness. `I hat
position allows the wmnan a greater control over thc pacing of her trwrt sexual
75
arousal. lt is possible, of course, that such a clear-cnt difference between the
opinion of men and women might not have been hnmd if the research had been
done with‘married eouplcs instead ofthe l 19 unmarried college students.
Men may still be more interested than women in varying their sexual
activity and coital positions. A questionnaire study of 40.000 men found that 65
percent ot the men were not satistied with the amount of sexual experimentation
which they experienced (Travis, l978 ) i *1. toey wanted more variations.
Position variations
Much too much importance can he attributed to positions for sexual
intcrctnrrse. An overeconcem about coital positions can easily result in a
rnnrnnrzation of sexual foreplay or precoital petting.
'lhcrc are hundreds of possible positions tor intercourse. However. as a
practical matter, the positions found to he most pleasurable for corrtirrual pursuit
are those which are (l) Comfortable and relaxing, (2) Do not cause muscular
strain. and (3) Enable it reasonable freedom of movement (Masters and Johnson,
li¥s—ni Choice of position is also affected by a cnnple`s hotly size and weight as
well ns their athletic ability at the cnd of a tiring day`s ooik. Each position has
certain practical advantages and disadvantages In addition. each ottbrs somewhat
ditlerent kinds of sensations oflroilily movement and touch.
Advantages and disadvantages
'lhe most rrnnrnorr position hir scxnzrl intercourse among Arnericnus as
ocll as among most other people is thc "face-tu-fat-e". “nmneutnrve positiurr"
(lord and Beach, 1951) (fig. 30). This may be because it is rorwenierrt and
relaxing especially hir the vroman. lt also allows for some possibilities of manual
and oral caressing while offering at maximum ofbody contact. the "faee~to-face"
relationship facilitates communication and easily observed expressions of
pleasure providing a greater sense of intimacy. Finally. it may provide greater
friction tothe clitoris than is possible in sorrre other sexual positions. On the other
hand. this position presents difficrrliies Gar some people. lt may present
diflicultics for pcoplc who are very obese. or lor women in the last stages of
pregnancy. lt also may not be suiliciently relaxing for some tnen who eiaculate
mo quickly The muscular tension needed to balance and move the man and the
considerable body contact with the body ot the womzrn can provoke premature
ejacularion in some males
llrere are nmnerous vnrirrtions ofthe "m:rn-above pnsitiun" Instead of
resting her lens srraighr or lrolding open ar the sides. a womarr crm rest her lugs on
her partner`s shoulders by folding them opurrrd so that her thighs rest on her
stomaclr.
76
Yrgure JU Liurtus rrr trthotcmy
position (face to faee, rnarr
above) The illucrrarrun shows
the path et the sperm cells from
the testiele through me tas
deterens At the end of this
joumey they are ready ro he
' ` armor rrrmrrgrr sexual
activity Drrrir-rg eortus. the
__/**9 available sperm rells unter the
/ A prostate gnrrd where tire)
é es beeome rmrr or the wrrrrgrr
which is erracrrlrrted into the
vagina close to the cervix
5_ I Tesricle
( `\ 2. Vas deterens
\’ .. `~» 2. serrrarrrrr meas
7 . - f ` / + 4 Prostate
,=; \ r . S Urcthrn
`\ \\ fr serrrrrrarpaor
V \\ _ (__ 7. cervrx
` » \ —¥" N n Nrrre rrre prrsrrrrrrr rrrrrru
\ L 2/ cervix and the sernrual pool
X7

Tlrrs can 0Her variation in feelings ol` skin contaet and motion. Another
alterrrutive is for the man to kneel between the viornans legs, holding her
buttocks and bringing her to him for adequate support lhis position incidentally.
is the one which is most common in many Pneitie island societies (Ford and
Beach, l95l).
A "sitting position" involves the use of a chair without arms. \rVith one
partner resting against the hack of the chair for support, the couple can have
intercourse seated tace—t0et`acc with their legs overlapping the sides nl` the chair
ln this position, the couples hands are free ter caressing while they are also able
to kiss. Pcnile penetration irr this "<ining position" is deep, and there rs
considerable skin contact in the genital area However. the deep penetration may
he painful for sorne women iftherr partners penis bumps against their cervix.
the most ernnrnon alternative to the "missi0nary position". i e. litlrotorny
prrsirinrr is one in which the couple are "t'aee-torfacc". "with the woman
:th0ve" This position offers advantages suurlnr to the ruissionary position hut rs
more relaxing lor the ruan llc can lie back eonrtortahly exerting little energy to
77
maintain himself m that positron and use his hands to caress his partner `s body ln
so doing. hc can concentrate more easily on his own sensations. It may also otier
certain advantages to a woman. lf her partner is esceptionally lrearvy, this position
literally takes the weight off of her ln addition. she can more easily regulate the
paec of movcrncnt toward orgasm in rhythm with hcr own build up of sexual
settsattons. l·maIly. it may be xery useful for a couple in which the man tends to
ejaculate too quickly The man’s relaxed position as such is less likely to promote
rapid ejaculation. It is lor this reason that the womaneabovc positron is otten
counseled and ady ised strongly in cases of frequent premature ejaculation.
The womaneabove position also has certain disadvantages, rt ts more
fatigtiing for the woman especially for fragile females She tnay have to kneel in a
position which causes mttscular strain in her thighs ln addition, where there is
vigorous movements with deep penetration in this position, some women Gnd
that it is internally disconrllrrting or even painful especially with strong pelvic
thrttsting
The must common arrangement for the “woman-above position" is for the
woman to kneel astride her husbands hips and squat down on his erect penis. She
cart then use her kneeling logs to move herself up and down according to her
desire. Her husband can make her rtrorc comfortable and relieve some ofthe strain
by holding her by the waist to assist her up and down movements. lhere are
numerous variations ofthe `wyornan-above position" 'l`he woman can lie {lat on top
of her partner but rrrrfonunatcly, movernents in such a position may be difficult.
She may have to use her elbows as a balance point to create movementr or her
partner may have to rmwc her with his arms. A more unusual variation is for the
woman to squat above `her partner but lace toward his legs. Such a positron otlers
less friction to tlte clitoris unless it is provided manually. It is also less
psychologically intimate because the man faces his partnet's back and buttocks.
The final cet of variations are "rear-etrtry positions". One arrangement is
for both partners to knecl with thc man behind thc woman and between her legs.
'lhrs position provides the man with considerable freedom to move his hands in
caressing his partners body. It also provides thc man with a fulhbodied feeling of
motion during the thrusting movcrrtcnts of intercourse (This increases stimulation
to the kincsthctic sense — the sense of body rrrovernenr). In addition, the soft
pressure of his partner’s buttocks against his whole genital region may provide
exerting tactile stimulation.
Unfortunately; the “rear—entry position" does not oiier many advantages for
women. Friction to the clitoris may be inadequate and may have to be provided
manually during intercourse. Body contact tor her is minirttal and possibilities of
active participation are limited to mere thrusting backward movement. The deep
penetration for some women may result in discomfort or even pain Finally. such
a position rnav not provide rr sense of intimacy for tr couple because partners are
unable to view each other`s facial expressions. This position is perhaps, the most
tahooert in American culture because it attributes symbolic associations with
animal sexual behavior as well as a possible degradation ofwomcn...
78
78
A variation ofthe “rear-entry position" is a sitting arrangement. The man
can sit in a chair or on the edge of the bed with his wife seated on his lap, her
back toward him. lle is Free to move his hands and manually caressing her,
however, genital movement in this position is diflicult. A variation ofthe "rear-
entry position”, for the nrore athletic, is a partial standing arrangement. The
woman stands and bends the upper part of her body at the hips, grasping the back
of a chair or some other snppon for her balance. the man stands behind her,
holding her by her waist for balance. Such a position can he very dilticult to
manage ifthe sizes and body shapes ofthe couple are inappropriate for it.
Such variable positions are tor most people only considered as a rare
amusement, when circumstances and mood pem1it some good humored sex play.
lhere are a great many other possible positions hir sexual intercourse. However,
the basic pattems have been described here and others are simply modifications
of them.
Another set of variations are "alrIe—toeaide poaltions". A couple may have
intercourse lying on their sides and facing each other 'lhe woman can raise her
ripper leg and rest it across her husbnnd`s hip enabling him to enter her vagina. ln
this position, both partners are free to use their hands and mouth in caressing each
other. ln this position, also. it is easy for a couple to maintain their contact after
orgson as they ant asleep.
Yet the "suic to—side position" also presents some rlillicnlties lt may be
very dillicult to manage ifthe body shapes ot a couple Arc inappropriate for it e.g.
obesity ln addition, such a position does not allow for vigorous genital
movement because the couple's bodies are nearly locked into a constrirted
position
An altemative "side—toeside position" is one in which the man lies on his
side facing the woman`s hack This position is perhaps, the one which is most
relaxing for a couple. lt is a variation particularly appropriate for times when n
couple are very tired or on sleepy mornings or when there is mild illness or
during pregnancy. llowever, in cases where one, or both of a couple are obese
this position may be very ditlicult to manage. In addition, while this position
enables the man to have a maximum ul` possibilities for manually caressing his
wife, she is left with few possibilities Rvr activc sexual participation ll` manual
caressing is not provided, she may feel httle sensuous contact and inadequate
friction to hcr clitoris.
Religious view
There is nothing more instructive and reliable than thc beautiful meaning, a
conplemould lrcnelit from and make use of following this holy statement out of
the Koran; namely, the fensibilitv of nn) desired sexual position mul at any time
they like provided it is vaginal intercourse and preceded by sexual lnreplay
79
. .rrr;A.,ls,ulzJ,...—‘.,,snL;l,11l__s_,JL.;at.lLJu
:,,rs._,llQ...a_)llal•l(...+4 Hs)! Qkl¤,..!.llO.alil1rhy;l
·(,»¤S ue`! ,»e···¤ll) -'é···¤Y l.•·—>¥.• o-ll }—$L»= lib 2-Sl ·i·J$ }~$JL?··?
Cnitus during pregnancy
lt is worth mentioning here that there is no reason thataeouple should
refrain from coitus in the first three months of pregnancy provided that the
pregnancy is normal and the oouple apply the proper pregnant sex position and-
without due force or pressure The same holds good for the next three months of
gestation, since the obstetrician should be thejudge all the time especially in the
last mmnhs ot` pregnancy and during lactation, providing vital advise as regards
possible contraception as well.
80
 MALE SEXUAL INADEQUACY
(DYSFUN.CTIONS)
• lmpctency.
Premature Ejaculation.
Ejaculatory lncompetence.
• Mixed Sexual Dysfunctions.
 SEXUAL INADEQUACY
Terminology

Some men and women are restricted in their sexual activity by

malformations, handicaps, diseases or injuries and there are also ph
healthy individuals who cannot fully enjoy sexual intercourse because their s
responses have become weakened, inhibited or even completely blocked fo
psychological reasons. Today, such a person is usually said to suffer from s
dysfunction or sexual inadequacy.

Obviously, the distinction between physical and psychological caus

sexual dysfunction is to a certain extent arbitrary, since body and mind are
closely interrelated that a sharp dividing line between them cannot be drawn
. Furthermore, it may be an oversimplilieation to speak of sexual in
individual, because as a rule, it manifests itself only in relation to another
individual. Indeed, in many cases it may be useful to speak of an ina
sexual relationship between two persons. Consequently, sex therapists
on treating both partners together. lt has recently been estimated that in more tha
half of all American marriages at least one partner suffers from some fomi
sexual inadequacy; l wonder how many are in Egypt 7... Curiously eno
misery seems to be widespread and while
mportance ofthe problem is no longer in doubt all over the world,. one can argu
History

ln the past, a man's sexual dysfunction was often ascribed to witchcraft or

some evil cursel, in Arabic it is termed Marbootll (if he was believed to be
innocent) or torlegeneracy, self—abuse, immorality and excess, (if he w
responsible for his condition). Today, we have leamed however, that both kinds
of explanation are false and that the real causes be elsewhere. ln fac
become sexually inadequate mainly because of a very rigid upbringin
sexual experiences, ignorance about sex, narrow religious beliefs and bad advic
from ill informed professionals, such as marriage counselors, doctors, sometim
psychotherapists and teachers or even parents.

lt seems that sexual dysfunctions of one kind or another have plagu

people in many societies since the dawn of history. We know for exampl
ancient and medieval physicians studied the problem and sought various m
remedies. However, it also seems that these dysfunctions have become, more
severe and widespread in modern times. ln the l9th and 20th centuries, th
often treated by psychiatrists and the rate of cure was not always enco
. Today, we can see that this could hardly have been otherwise, since the
physiological processes involved in sexual functioning were still p
understood. Masters and Johnson approached sexual dys
otreating them as symptoms of something else; they also pioneered the male
female "dual team" of therapists and treated couples rather than individuals
81
 Sexual function involves the activation of a variety of inbom reflex
responses that are ordinarily integrated into a psychological matrix. The basic
physiologic mechanisms of normal sexual function may be impaired by a variety
of factors of organic or psychogenic origin. An understanding of these conditions
is facilitated by a classification presented by Masters and Kolodny; it
distinguishes sexual dysfunctions (marked by impaired physiologic response)
from other sexual problems (marked by alterations or conflicts in behavior,
attitude, or feelings), but not accompanied by impaired sexual function in a
physiologic sense. To be sure, sexual problems — such as guilt about participatio
in sexual activity- may lead to subsequent sexual dysfunction; and sexual
dysfunction — such as impotence- may create ancillary sexual problems.

Male Sexual Dysfurictions

The two well—known categories of male sexual dysfunction, namely,
disorders of erection and `disturbances of ejaculation are considered from the
viewpoints of etiology, diagnosis and treatment.

Impotency

The term "impotency" literally lack of power, from Latin impotens;

powerless, is the inability to obtain or maintain an erection of sufficient firmness
to permit coitus to be initiated or completed. impotence may be classified as
either primary or secondary. The male with primary impotence has never been `
able to have intercourse, whereas the male with secondary impotence is
experiencing erectile dysfunction after a previous period of normal function.
lsolatedytransient episodes of inability to obtain or maintain an erection
(transient impotency) are normal occurrences that do not warrant diagnostic
evaluation or treatment. Such erectile failure is usually attributable sometimes to
fatigue, distraction, inebriation ( drunken ), acute illness or transient anxiety.
However, a persistent pattem of impaired erectile function is indicative of the
presence of a sexual dysfunction that requires diagnostic and therapeutic
attention.

Etiology

ln the past it was believed that approximately l0 to l5 percent of men

affected by impotence appear to have a primarily organic basis for their sexual
dysfunction, this percentage has risen to nearly 40% or 50% nowadays. The most
common organic causes of impotence are listed in the following table.
 Physical Causes of Secondary Impotence (Organic)

(1) Anatomic Causes: (4) Endocrine Causes:

Congenital deformities. Acromegaly.
Hydrocele. Addison's disease.
Testicular fibrosis. Adrenal neoplasms (with or without
Cushing's syndrome).
(2) Cardiorespiratory Causes: Castration.
Angina pectoris. Chromophobe adenoma.
Coronary insufficiency. Craniopharyngioma.
Emphysema. Diabetes mellitus (very common).
Myocardial infarction. Eunuchoidism (including Klinefelter's
Pulmonary insufficiency. syndrome).
Rheumatic fever. Feminizing interstitial-cell testicular tumors.
Hyperprolactinemia.
(3) Drug Ingestion: Infantilism.
Addictive drugs. Ingestion of female hormones (estrogen).
Alcohol. Myxedema.
Alpha—methyldopa. Thyrotoxicosis.
Amphetamines. Old age produce less testosterone.
Antiandrogens (cyproterone acetate).
Atropine. (5) Genitourinary Causes:
Barbiturates. Cystectomy;
Chlordiazepoxide. Perineal prostatectomy (frequently).
Chlorprothixene. Peyronie's disease.
Cimetidine. Phimosis.
Clofibrate. Priapism.
Clonidine. Prostatitis.
Di gitalis (rarely). Suprapubic and transurethral
Guanethidine. prostatectomy (occasionally).
lmipramine. Urethritis.
Marihuana.
Methanthline bromide. (6) Hematologic Causes:
Monoamine oxidase inhibitors. Hodgkin's disease.
Nicotine (rarely). Leukemia, acute and chronic.
Phenothiazines. Pernicious anemia.
_Propranolol. Sickle cell anemia.
Reserpine.
Spironolactone. (7) Infectious Causes:
Thiazide diuretics. Elephantiasis.
Thioridazine. Genital tuberculosis.
Gonorrhea.
Mumps.

83
 (8) Neurologic Causes: (9) Vascular Causes:
l Amyotrophic lateral sclerosis. lmpaired blood flow (main cause).
Cerebral palsy. Excessive venous leakage (main cause).
Spinal cord tumors or transection. Aneurysm.
Electric shock therapy. Arteritis.
Multiple sclerosis. Atherosclerosis.
Myasthenia gravis. Thrombotic obstruction of aortic
Nutritional deficiencies. bifurcation.
Parkinsonism.
Peripheral neuropathies affecting (10) Miscellaneous Causes:
SH outflow. Chronic renal failure.
Spina bifida. Cirrhosis.
Sympathectomy. Obesity.
Tabes dorsalis.
Toxicologic agents (Lead, Herbicides).
Temporal lobe lesions. Chronic alcoholism.
Cauda equina lesions. B—blockers (antihyperteiisive drugs).
Prolapsed intravertebral disc. Antipsychotic & antidepressant drugs
(sometimes)

When impaired erectile function occurs as a result of physical or metabolic

causes, it is common for psychological or behavioral changes to develop over
time in reaction to the dysfunction. Such changes may themselves affect sexual
function so that even ifthe primary cause is discovered and successfully treated,
sexual difficulties may persist on a psychogenic basis.

Similarly, although 45 to 50 percent of patients with impotence appear to

have a primarily psychogenic origin for their dysfunction, physical or metabolic
factors may contribute to the difficulty as well in a Significant number of
instances. Some men with sexual dysfunction that is already marginal may be
pushed into frankly dysfunctional status by the onset of illness, by the use of
sexually depressing drugs, or by physical changes ( including aging ) that would
not ordinarily be sufficient grounds for impotence. The sexual urge and pleasure
is present from infancy to old age, hence there is no age limit for erotic arousal
and sexual performance. Naturally, libido diminishes after the menopause and th
andropause due to the diminished secretion of testosterone; but it was found by
Masters and Johnson that some couples in their sixties, seventies and even
eighties were capable of coital activities when they were perfectly healthy
physically and sexually aroused.

There is currently no means of identifying men who are particularly

susceptible to the subsequent development of impotence or other sexual problems
The psychogenic causes of impotence may be conceptualized as Calling into
major categories: development, affective, interpersonal and cugnitional. The
most common elements of these categories are summarized in the following table.

84
 Major Categories of Psychogenic lmpotence

(1) Developmental factors: (3) Interpersonal factors:

Maternal or patemal dominance. Poor communication.
Conflicted parent—child relationship. llostility toward partner or spouse.
Severe negative family attitude toward Distrust of partner or spouse.
sex (often associated with religious Lack of physical attraction to partner
orthodoxy). or spouse.
Traumatic childhood sexual experience. Divergent sexual preferences or sex
Gender identity conflict. value systems (regarding types of
Traumatic first coital experience. sexual activity, time of sexual activity,
Homosexuality. frequency of sexual activity etc...)
Sex role conflicts.
(2) Affective factors:
Anxiety (particularly fears of (4) Cognitional factors:
performance, anxiety about size of penis). Sexual ignorance.
Guilt.
Acceptance ofcultural myths.
Depression. Performance demands.
Poor self—esteem.
llypochondria. (5) Miscellaneous factors:
Mania.
Premature ejaculation.
Fear of pregnancy. Isolated episodes of erectile failure.
Fear of venereal disease.
(often due to fatigue, inebriation,
Sudden fear.
acute illness. or transient anxiety).
Acute pain. latrogenic influences.
Paraphilias.

lt must be stressed that such etiologies are conjectural or guessing in th

they are based on clinical impression. No inference is made that all men or even
many men, with similar histories will be impotent. In fact, it appears that qu
opposite is true. Men frequently overcome potentially negative background
factors that might appear to place them at substantial risk for the development of
sexual difficulties. This phenomenon may be a reflection ofthe remarkable extent
to which sex is a natural function.

Masters and Johnson described overt motlrer—son sexual encounters over a

prolonged period of time (extending from childhood until hc) ond the time o
puberty), as a factor of significance in some cases of primary impotence. Undu
dominance of one parent _may create a sense of inadequacy leading to erec
dysfunctions because of either lack of an effective male figure with whom to
identify, (in cases of maternal dominance) or the impossibility ofrneasurin
tlte seemingly omnipotent father (in cases of paternal dominance). Other aspe
of development that may be implicated irt the genesis of impotence include,
restrictive and rigid attitudes towards sex impressed upon tlte child in the home
environment frequently found in association with religious orthodoxy. Traumatic
85
 childhood sexual experiences including, punishment for masturbation or
participation in sex play with other children, gender identity conflict, traumatic
first attempts at intercourse and homosexuality.

Sometimes merging with such developmental factors in the occurrence of

impotence are a number of intrapsychic or affective elements that may also arise
independently. Anxiety, guilt, depression, and poor self-esteem are often
intertwined in cases of sexual dysfunction; it may be virtually impossible to
determine the temporal sequence that led to the difficulty. In some situations these
components may arise only alter the onset of impotence; nevertheless, therapeutic
attention should be focused on such problems when they are present regardle
the cause that initially precipitated the dysfunction. Phobias related to sexua
functioning are infrequently seen but are important determinants of therap
strategy, while the paraphilias-conditions in which sexual arousal is impossible
without a particular abnormal stimulus e.g. (dressing in women's clothes, bein
spanked or humiliated, or wearing rubber garments) either fantasized or in
actuality- are thought to be rare but are of indeterminant frequency.
The importance of interpersonal factors in the genesis of sexual
dysfunction has been widely acknowledged in the last decade but had previo
received little attention. Most cases of impotence involve these factors either as
contributors to or original causes of the problem or as ramifications of the guilt
frustration and anger that may be generated by the sexual dysfunction overtime.
The ego—defense mechanisms that both men and women frequently employ t
cope with impotence including (rationalization, projection, emotional insulation,
intellectualization, sublimation, avoidance, and denial of reality) are likely to
create relationship difficulties that require direct therapeutic intervention.

Iatrogenic influences can lead to impotence in a number of different ways.

ln each instance, the common element is that a respected health-care professional
plays a causative role in the development of erectile disturbances. This may co
about through direct statements or through the omission of an anticipated
statement; by misperceptions on the part of the patient about instructions or
explanations he is given. By the perpetuation of myths by a respected authori
by undue anxiety or over interpretation on the part of the professional. At times,
impotence may occur iatrogenically in the context of treating another problem
such as infertility, heart disease, or prostatic disorders requiring surgery. Imp
erectile function may be the result of injudious or incompetent sex therapy,
developing either in situations in which the male has no prior history of
dysfunction or when the male is under treatment for ejaeulatory difficulties.
latrogenic impotence can also occur when males misinterpret articles or books
they have read about sexuality..

86
 An interesting category of psychogenic impotence that has only recently
been recognized is aptly described by the term: Widower's syndrome. In this
disorder, generally involving men over the age of 50, there is characteristi
prolonged period of little or no sexual activity in conjunction with a lengthy
eventually fatal physical illness of the wife. During this protracted illness- cancer
being the most frequent variety- the male often becomes a caretaker of his
spouse, providing increasing physical and psychological ministration to his
partner as she becomes more and more severely debilitated and dependent on
him. The husband may be frustrated by the lack of sexual outlet but avoids sexual
contact with his sick wife except on infrequent occasions. His combined sense of
_conjugal duty and guilt over his wife is usually sufficient to restrain him from
seeking extramarital sexual involvement; a few men in this category may seek out
the services ofa prostitute, an experience that typically proves unsatisfactory and
tends to engender more guilt. After his wife finally dies and he observes what he
considers to be an appropriate mouming period, the widower’s first attempt at
resuming sexual activity with his new wife or a partner ends in erectile failure, a
situation that is as embarrassing as it is frustrating. From this point on, his
performance anxieties are mobilized; in general, no matter how alluring or
cooperative his subsequent partner (s) may be, he continues to be locked into a
cycle of performance pressures, spectatoring, and subsequent erectile insecurity
Variants of the widower’s syndrome may occur in men whose histories are not
precisely the same as the one just outlined — for exarnplc, impotence is not
uncommon af`ter divorce as well as after sudden death of a spouse but the
underlying dynamics of these situations appear to be different from the specifics
ofthe widower’s syndrome.

Diagnosis:

Normal penile erections do not usually occur unless there are reasonably
intact anatomic, neurologic, circulatory, and hormonal support mechanisms. For
this reason, ascertaining whether an impotent man experiences erections under
any special set of circumstances is an important aspect of the process of
differential diagnosis. The initial objective is to determine whether impaired
erectile function is due primarily to psychogenic factors or to physical ones; the
sexual history is the most useful single indicator of this.

Historical clues for determining the etiology of impotence

lf a man achieves erections under certain conditions but not others, the
likelihood is high that the impotence is psychogenic. Thus, the impotent man
who experiences erections with masturbation, during homosexual activity,
during extramarital sex, in response to reading or looking at erotic materials or
with certain types of abnormal sexual activity (fellatio, sadomasochistic acts, or
wearing particular items of clothing, for example) is unlikely to have a physical
or metabolic explanation for his difficulties. For the same reason, the common

87
 history ofthe man who has no difficulty achieving a firm erection, only to los
promptly upon attempting vaginal insertion is strong evidence for a psychog
problem.

Similarly, the presence of a firm erection at the time of awakening

indicates that the capacity for normal erectile response is present phys
The clinical significance that can be placed on self-reports of moming erectio
limited however. Some men may be unaware of such erections even
are present. In other circumstances, it is the pattem of the relative frequency o
moming erections viewed in the context of each man's history that is most
important. A report of infrequent or absent moming erections is of no di
assistance if the patient had a similar pattem prior to the onset of erectile
difficulties. However, if a man has noticed a significant reduction in the
frequency of his awakening with an erection since the onset of impotence, the
possibility of an organic etiology is suggested. lf firm erections are frequentl
present on awakening, it is unlikely that an organic cause for impotence exists.
The history will also reveal important information about the Onset and
progression of impotence that will aid in the diagnostic process. Impotence
resulting from organic causes typically begins in an insidious fashion, bec
slowly and progressively more troublesome. ln contrast, psychogenic im
is likely to be of sudden onset - at times, the patient may be able to identify t
specific date on which his difficulties began. However, some organic causes
impotence such as trauma (post-surgical or neurological injury) or drug u
lead to impotence abruptly, so this point of differentiation needs to be balanced
carefully with other bits of clinical and historical evidence. There may be a
temporal association between the onset of psychogenic impotence and a stressful
event. A man may first experience difficulty with erections after finding out that
his wife has had an af`fair sexually with someone, after the death ofa parent or
child, after divorce or after a stressful change at work. lf the patient is not seen
until long after the onset of his dysfunction, he may not remember the tem
relationship at all, but his wife or partner may recall the association if questio
Although the stressful event initially impairs sexual responsiveness, subsequent
anxieties and fears of performance become the perpetuating mechanism, so that
when there is recovery from the stress sexual function may continue to be
impeded.

Although organic impotence most frequently follows a progressively

downhill course, psychogenic impotence may mimic and resemble this pat
This may be the case when continued frustration, diminishing self—esteem a
interpersonal problems lead to a pattern of avoidance of sexual activity as a
means of coping; libido may or may not be reduced in such situations. Likewise
, when depression occurs in relation to sexual difficulties, the dysfunct
may progressively deteriorate until appropriate treatment is instituted.

88
 It is important to recognize that impotence is not synonymous with the
absence of erections. Many impotent men experience erections that are quite f
but are only transient; other men have a pattem of impaired penile rigidity but
able to obtain or maintain a partial degree of erection. Care should be used in
interpreting the clinical significance of such variations. Although a patient wh
able to have intercourse with one woman but not another is probably
psychogenically impotent. There is also the possibility that the degree and
firmness of his erections are the same with both women, but that differences
between the women in vaginal size, muscle tone, and physical cooperation lead
differences in the man's ability to have intercourse. The temporal association of
the onset of impotence with a major psychological stress may be related to the
onset of a medical problem that was precipitated by the stress, rather than being
indicative of a purely psychogenic origin of the dysfunction. Certain types of
organic impotence may be episodic, rather than persistent and worsening, for
example, the impotence caused by multiple sclerosis follows such a waxing and
waning course. For such reasons, more reliable methods for differential diagnosis
are desirable, and even when the history appears compatible with a psychologic
origin of sexual dysfunction, careful assessment of physical factors should also be
conducted.

Impotence of long standing may have obscure origins. lt is frequently

impossible to determine with any hope of accuracy the specific mechanism (or
mechanisms) that precipitated erectile failure. Nevertheless. evaluation ofthe pa
tient's current physical and psychological status is important in determining the
best course of treatment.

The physical examination as a source of diagnostic information

The utility of a thorough physical examination in evaluating possible

organic etiologies of impotence is considerable. Assessment of the signs of
systemic disease is at least as important as diagnostic attention to the
genitourinary tract. Detecting such organic impairments that may be relevant to
erectile failure requires specific attention to the vascular and neurologic
examination in a more detailed fashion than is usually attendant upon a general
physical examination. When the history is suggestive of physical or metabolic
cause underlying a potency disorder, the inability to detect concrete evidence of
disease by the physical examination is not sufficient reason to decide that the
problem must be psychological. ln such cases and in other instances when
information obtained from the history and physical examination is inconclusive, it
is necessary to employ more specific testing to complete the diagnostic process.
Diagnostic testing for organic causes ofimpotence
At the present time, psychogenic impotence is usually diagnosed by a
process of exclusion after organic factors have been eliminated from
consideration. The following methods selectively applied, may be helpful in
pinpointing specific organic etiologies of impotence.

89
 All impotent men with equivocal histories should undergo an oral gluc
tolerance test after adequate dietary preparation (including at least 300 gm of
carbohydrates daily for three days) for the detection of diabetes mellitus, whi
appears to be the single most common disease causing erectile failure. Even in
men with no other symptoms that suggest the presence of diabetes, an increased
rate of abnormal carbohydrate tolerance has been found. Detecting diabetes do
not automatically imply that is the cause of impotence, since diabetic men may
also be impotent for psychogenic or other organic reasons; but the presence of
diabetes coupled with a history suggestive of an organic process indicates the
need for further testing to evaluate neurologic and circulatory mechanisms.
Men with impotence accompanied by low libido or with a history
compatible with an organic origin of dysfunction should have a measurement of
circulating testosterone concentrations. The blood sample should be obtained in
the early morning hours (between 7:00 and 10:00 A.M.), because there is diumal
variation of testosterone levels that makes it difficult to interpret low values
obtained at other hours. Subnormal levels of testosterone may indicate the
presence of hypogonadism and depending on the clinical context may require
further diagnostic testing. lf no medical contraindications exist, a trial of
testosterone replacement therapy is warranted for a period of two to four months
when a low testosterone value is found. lf improvement in the potency proble
does not occur during this time and no other medical explanation of the
dysfunction is present, it is possible that the depressed testosterone level was a
result of psychological stress, a course of sex therapy should then be
recommended.

The use of laboratory testing for impotent men must be viewed within a
context of the expense of such procedures. Modern laboratory methods permit
economical screening profiles that include assessment of a spectrum of
biochemical parameters that may be of diagnostic assistance. Evaluation of the
fasting blood sugar, liver function, serum electrolytes, lipid levels, thyroid
function, creatinine and sex hormone binding globulin and a complete blood
count (CBC) may be useful. More specialized endocrine testing may be helpful
in certain cases of hypogonadism; specifically, measurement of LH, FSH, and
prolactin may be used in differentiating between hyper and hypogonadotropic
hypogonadism.

lf an impotent man is using a drug that may be contributing to his sexual

problem, it is advisable to discontinue the medication eg, antihypcrtensive
drugs- and if necessary, to change to a different treatment program with less
likelihood of impairing erectile response for a period of one or two months to
observe possible improvement in sexual functioning. Since it is common for
sexual difficulties to have multiple determinants. it is helpful to avoid the use of
potentially
as well.
compromising pharmacologic agents during a course of sex thera

90
 One of the most promising techniques to be developed for the diagnostic
assessment of impotence is the physiologic monitoring of erection pattems during
sleep. Based on observations showing that normal men have periodic reflex
erections during the sleep cycle, the measurement of nocturnal penile
tumescence (NPT) derives its usefulness from the fact that men with organic
impotence have impaired erections or no erections at all during sleep, whereas
men with psychogenic impotence have normal erection patterns. Presumably, the
removal by the state of sleep of anxiety, intemal conflicts, or other psychological
factors that may impede erection during wakefiilness allows normal body reflex
pathways to take over and produces measurable episodes of penile tumescence. In
an extensive series of investigations conducted in a sleep research laboratory,
Karacan and his colleagues have analyzed (NPT) pattems in various groups of
men with and without potency disorders. These workers utilized simultaneous
electroencephalograpli tracings (EEG) with continuous measurements of
changes of penile circumference during sleep. From the findings of these studies,
a simplified instrument has been developed to measure NPT pattems outside the
sleep research laboratory. This device records changes in penile circumference
during sleep that permit evaluation of the organic versus psychogenic origins of
impotence. Although further systematic study is required to determine whether
the reliability of this simplified instrument is comparable to the more complete
data obtained from a sleep research laboratory, it is an accessible and more
economical method of diagnostic screening that holds significant potential.
Questions that need to be answered in regard to either technique include the
validity of NPT measurements in depressed patients (since depression) is known
to interfere with normal sleep pattems and the effects of drugs on erections
associated with sleep. The Rigiscan device is of great use in diagnosis.

The NPT tracing does not distinguish between various types of organic
impotence, although it appears to discriminate successfully between psychogenic
and organic forms of impotence most ofthe time. lt is usually necessary, if organic
impotence is documented, to perform additional diagnostic studies to determine the
exact mechanism leading to impotence, since this may have important implications
for the treatment. Techniques that may be useful in this regard include:
arteriography or penile pulse and blood pressure measurements to assess
vascular competency and cystometrography or direct neurophysiologic testing
to evaluate the neurologic factor. Colour Dopler sonography is of great diagnostic
values to detect organic vascular lesions both arterial and venous. lntracavernosal
injections; with muscle relaxants e.g. pappaverine can be used to produce erections
for diagnostic and treatment purposes as well.

Treatment of organic impotence

Cases of impotence arising primarily from organic causes must be

medically or surgically managed in accord with the principles of the etiology. ln
some instances, the patient and his wife may benefit from ancillary counselling or

91
psychotherapy aimed at improving depression, self esteem, communication
pattems, or other aspects of psychosocial health. However, when physical
metabolic conditions preclude the possibility of coital functioning, this fac
be pointed out to the Couple and alternative suggestions for sexual exp
should be discussed. In selected cases, consideration may be given to th
implantation of a penile prosthetic device to pennit participation in intercour
Although many cases of impotence are attributable to psychogenic fact
, significant numbers of men, are impotent because of irreversible organ
In the past decade, increasing interest in sexual function coupled with
technology has led to the development of a variety of penile prosthetic dev
that are implanted surgically in men with organic impotence to facilitate their
participation in coital function. Candidates for such surgery include men with
impotence resulting from diabetes, penile or pelvic trauma, vascular o
disorders and various types of operations (for example, impotence due
prostatectomy, cystectomy, colectomy or aneurysm repair).
Penile prostheses

Different types of penile prostheses are available for the treatment of

impotence. The basic difference involves whether a fixed rod prosthesis is u
whether an inflatable prosthetic device is employed. Fixed rod devices made of
different materials, such as Silastic (silicone rubber), acrylic, or polyethyl
have been used by a number of surgeons. These devices have the advanta
relative simplicity of surgical technique of insertion but they result in a
state of semierection once the operation has been carried Out, potentially
both psychological distress and physical discomfort, (Fig. 31).

92 Figure 31. Three pairs of Small-Carrion penile prostheses.

 The inflatable penlle prosthuis produces an erection only when it is
desired; the appearance of the penis in both the tlaccid and erect states is
completely normal (Fig. 32). Although the surgical insertion of this device is
technically more difficult than implantation of the fixed rod, there appears to be a
reduced risk of tissue erosion or perforation because of the more favorable
pressure dynamics. Both the patient and his wife seem to indicate a greater degree
of acceptance of the inflatable device, which actually consists of two tapered
inflatable cylinders, which are placed within the tunica albuginea adjacent to the
corpora cavemosa. These cylinders which come in varied sizes, are connected by
tubing to a simple pump that is placed low in the scrotum outside the tunica
vaginalis. A fluid storage reservoir is implanted in the prevesical space. The
patient activates the pump by compressing the bulb in the scrotum, radioopaque.
fluid is then transferred from the fluid reservoir to the penile cylinders, causing
the cylinders to expand and producing penile tumescence. The erection is
released and abolished mechanically by pressing a valve in the lower portion of
the scrotal bulb, which allows tiuid to be evacuated from the penile cylinders
back to the reservoir. The operation now appears to be an accepted method of
treatment for organic impotence.

{ to Ei

· — fri i ‘ ‘‘‘: "i .. \

f, ,M

?»y;»;}]’_‘ iv- j W **1;;; { up iw J M?

a i iié

Figure (32): An inflatable penile prosthesis alter implantation.

(A) Fluid is in the reservoir; the penis is flaccid. (B) Fluid is in the penile cylinders; the
penis is erect. (Courtesy of American Medical Systems Inc.)

Further study is needed to become fully informed about patient acceptance

of penile prosthetic devices and to assess the psychological impact of this type of
sur·gery. Although some authors advocate the use of such a therapeutic approach
for men with psychogenic impotence, it seems wisest to exercise considerable
93
 caution in this regard; such patients should probably be given an inte
exposure to sex therapy before considering operative
mpotence. In addition, it should be recognized that diabetic men ma
te
predisposed to a higher rate of surgical complications
proceure due to microvasculr problems and impaired i
mpans shoulbe undertaken in this population only when the potential ri
well as benefits have been carefully described to the patient.
Treatment of psychogenlc impotence

ln cases of psychogenic impotence or in situations in which a

component of psychosocial difiiculty contributes to th
ompotence, sex therapy is indicated if counselling attempts have not reversed
the dysfunction. Sex therapy ideally includes both the impotent man and
partner, since therapeutic cooperation of the wife appea
determnant of the outcome of therapy. The partner's
sessons provides an opportunity for observation of pattems of communication
within the relationship as well as a source of information about sexual func
and related behavior occurring between therapy sessions.
Psychotherapy

The psychotherapeutic approach to impotence shares certain common

features with the approach to the treatment of sexual dysfunction. These
include the following points:

l. lt is
dysfunction.
not useful to blame one's partner or oneself for the occurrence o
2. There is no such thing as an uninvolved partner when sexual difficult
3. Sexual dysfunctions
psychopathology always.
are common problems and do not usuall
4. lt is not always possible to be certain of the precise origin of a se
dysfunction, but treatment can frequently proceed successfully even wh
knowledge is lacking.
5. ln general, cultural stereotypes about how men and women should be
or function sexually are misleading and counterproductive.
6. Sex is not something a man does to a woman or for a woman;
something a man and a woman do together.
7. Sex does not only mean intercourse, apart from procreative purp
is nothing inherent in coitus that makes
or more valuable than other forms of physical contact.
it always more excitin
8. Sex can be a form.of interpersonal communication at a high inti
; when sexual communications are not satisfactory, it often indica
aspects of the relationship might benefit from enhanced communication as wel
9. Using past feelings or behaviors to predict the present is not likel
helpful, since
mt te freedom to change. such predictions tend to become self-f
94
 l0. Developing awareness of one's feelings and the ability to communicate
feelings and needs to ones partner sets the stage for effective sexual interaction.
l l. Assuming responsibility for oneself rather than delegating this
responsibility to one's partner is often an effective means of improving the sexual
relationship.

The specific aspects of treating impotence by sex therapy, beyond the

general approaches mentioned before, depend in large part on the historical detail
of each case. Factors such as the etiology of the dysfunction, the presence or
absence of other dysfunctions or sexual problems, the status of the relationship
and intrapsychic dynamics are all important determinants of specific strategies
that may be employed.

Most cases of impotence are characterized by fears of performance, a

debilitating set of sexual anxieties that arise when the male is unable to obtain or
maintain a normal erection and begins pressuring himself to improve his
functioning. Sometimes the wife contributes to such anxieties — either purposely
(by making sexual demands or humiliating remarks for example) or
unintentionally (by pretending that nothing is wrong or by attempting to be
supportive) - and may complicate the difficulties The three approaches to
reducing performance anxieties include the prohibiting of any direct sexual
activity, the process of identification and verbalization, the third - and usually the
most important approach - involves the introduction of the principles of sensate
focus.

Attention is given throughout the therapy program to verbal

communication skills, education about sexual anatomy and physiology, attitude
changes and other aspects of psychological management. ln some cases marriage
counselling is the predominant theme of therapy, in other cases, improving self
esteern, reducing guilt, modifying maladaptive ego—defense mechanisms, and
altering problems of imagery are some areas likely to receive a major degree of
therapeutic focus.

Success rate

The treatment statistics reported in Human Sexual lnadequacy showed a

failure rate of 40.6 percent of primary impotence and 30.9 percent for secondary
impotence. Between 197] and 1977, at the Masters & Johnson Institute, a failure
rate of 21 .l percent was recorded while treating primary impotence, at the same
time, the failure rate while treating secondary impotence was I4.6 percent only. lt
is likely that as more effective diagnostic methods become available and further
delineation of the mechanisms causing impotence takes place, there will be great
gains in treatment outcome.

95
 More sex education is required to counter the considerab
misinformation conceming impotence not only among t
among doctors, who are of’ten reluctant to discuss sexua
paens.

• ¥····-··
··wrn¤u•l pharmutullltlllllyl
Smooth muscle relaxant papaverine, ot-blocker phenox
phentolamine and prostaglandin E, and other drugs such as calc
onmo.gene related peptide are being evaluated
e oses and types of drug used are adjusted to suit each pati
.. The main side effect associated with self injectio
prapsm sometimes. The development of painless, fibrotic nodules that
ay cause penile curvature is reported,
comnan oa drug called (lnvicorp) is effective also Pe
mtracavernosally when "venogenic and arteriogenic" erectile dsfuncti
yon is difficult to treat. lnvicorp is a comb
pmesyate.

• Transurethral suppository:
Pfostaglandin E. administered transurethral is a novel sy
treating impotence
oses (0, 500, 1000 pg). under the name "Muse" which is
• ltiedical treatment:

I- The appeal of a pill for restoring potency is attes

we sales of homoeopathic
Jcvrerii
remedies claiming to
lt is an orally active inhibitor of phosphodiesterase 5
(, S0 and 100 mg) and is approved by the FDA, 19
are usng, dyspepsia, headache mild or moderate but it must be used
er medical supervision because some patients co
anormavision, diarrhea, dizziness and possible rash. Via
contrancatein patients with any cardiac
, mupe myeloma, leukemia, Peyronie's diseaserisk, liver
, cavemosal fibrosis, anatomical deformity ofthe pe
pgnosa and pgosuccess
patientsamong
using nitric oxide
users is nearly 77%. The
donors or n
misuse of Viagra by taking it as an aphrodi
conrary and ultimately they end with erectile
dysfunctions !... (R. Kirby, 1998).

2- Oral phentolamine (Vasomax): Phentolamine

y usuay in combination with papaverine but when used
it acts through antagonism of alpha], aud alpha; adrenergic
as activation of a non—adrenergic mechanisms to induce relaxation
 corpus cavemcsum smooth muscle to producc crcction. lts sidc effects arc
similar to Viagra but with more dizziness, tachycardia, nausea and
hypotension.

Oral Apomorphlne: Apomorphine is a dopaminergic drug that was found to

have a central erectogenic activity when taken sublingual.

Topical prostaglandin E, gel: Topical (Alprostadil) gel when applied on the

glans penis, patients responded by achieving an erection. The only local adverse
effect was erythema of the glans penis; sometimes buming sensations and
irritation, further research is needed before a final positive conclusion is
reached.

Vacuum devices: Vacuum constrictive devices are non-invasive, inexpensive

and simple treatment for patients who do not respond to intracavernosal
injections. Some patients complain that the erection produced is cold and
lifeless and the ring necessary to retain the erection may cause discomfort
especially during ejaculation but it is particularly _useful in the older and less tit
men.

Surgical treatment:
Only fair results have been reported alter excision and ligation ofthe deep
dorsal vein in men with venous leakage. Revascularisation ofthe corpora is
now technically feasible, with success rates of 50-60% in young patients
but microsurgcry is time consuming and expensive. Long term follow up of
veno-ligation operations is not promising.

Summary points:
The public and many doctors are ignorant about available treatments for
impotence. The disorder is strongly related to age, with an estimated
prevalence of 2% at age 40 years, rising to 25 — 30% by the age of 65
years. ln men over 75 years it is probably over 50%.
Impotence often has multiple causes and diagnostic evaluation should
include: psychosexual, neurological, endocrinological, vascular (venous
and arterial), traumatic and iatrogenic causes including drugs and
surgery.
Risk factors for vasculogenic impotence are smoking, hypertension,
hyperlipidaemia, diabetes mellitus and other vascular diseases.

Premature Ejaculation
Although prematureejaculation is a common sexual dysfunction, there is
no precise definition of this problem that is clinically satisfactory at present;
partly because ofthe relative nature of the timing of ejaculation in the context of
the female partner's sexual response cycle. Ifthe man's rapid ejaculation limits his
panner's ability to reach high level of sexual arousal or orgasm, then a
problematic situation do exist. However, in some couples rapidity of ejaculation
97
does not impede the coital responsiveness of the woman; thus, it does not appear
needed to label this pattern arbitrarily as sexual dysfunction.

Definition

The subjective nature of evaluating the length of time a man is able to

participate in coitus without ejaculating is further complicated by sociocultural
and personality factors. Dr. Helen S. KapLan, (1974 ) stated that premature
ejaculation is the most common presenting male symptom in clinical practice;
"the combination of dysfunctions encountered most frequently in clinical
practice is premature ejaculation in the husband and some degree of sexual
dysfunction in the wife"

Unfortunately, sex therapists have found that even defining premature

ejaculation is not a simple task. Among the factors to be considered are the
questions of: "when, where, and with whom" ?. Premature ejaculation clearly
exists if the male has an orgasm prior to penetration. lf orgasm occurs within a
few seconds after intromission, it is also usually considered premature. Beyond
that, definition becomes considerably more complex. For example, if the partners
have orgasms with equal rapidity, then it would not necessarily be a case of
premature ejaculation. The question then becomes premature for whom, or with
whom '?. lf a firm erection can be maintained for 5 minutes, but the partner
requires an even longer period in order to have an orgasm, the male could be
considered a premature ejaculator- with that particular partner. However, the
same man having intercourse with a woman who has an orgasm within 2 or 3
minutes after penetration, cannot be considered a premature ejaculator.
Therefore., the question is relative and also relates to the attitudes of the sex
partner.

Research

Sex researchers use many different definitions of premature ejaculation.

Masters and Johnson do not consider it a problem, unless it occurs 50% or more
of the times coitus is attempted. Dr. Meyer of Johns Hopkins claims that a man
who ejaculates before 15 thrusts af`ter penetration is a premature ejaculator. Dr. H.
Kaplan maintains that a man should be able to exert voluntary control over his
ejaculatory reflex. Another definition based, not in terms of length of time in
intromission but whether the sexual partner is satisfied with the length of the
coital thrusting. The American Psychiatric Association Task Force on
nomenclature provides yet another definition; ejaculation occurring before the
individual wishes it, because of persistent and recurrent absence of
reasonable voluntary control during sexual activity.

Trained as a zoologist, Kinsey noted that most mammals including

primates, ejaculate almost instantly upon penetration. He therefore saw this as a
problem for humans since some women require IO -l5 minutes or longer of
intense stimulation in order to reach orgasm... Kinsey noted, regarding the longer

98
time period of stimulation needed by some women : "lt is of course, dema
that the male be quite abnormal in his ability to prolong sexual activity without
ejaculation, if he is required to match the female partner". Unfortunately, not o
premature ejaculation is diiiicult to define, but the precise cause is not known.

Kinsey, Pomeroy and Martin reported that 75 percent of the men they
studied ejaculated within 3 minutes of vaginal containment. But these data
have been influenced by their belief that rapid ejaculation was a biologically
superior trait, as well as by the fact that their study was conducted more than
three decades ago. The timing of rapid ejaculation may simply reflect a prim
focus on the sexual gratification of the male, an attitude that seems to
predominate in men from low socio-economic levels or with limited education.
_ However, this double standard regarding sex; (Sex is for the man's pleasure,
for the woman's), may be found cutting across cultural and socio-economic
lines...!

Severe eases of premature ejaculation are easy to diagnose, because they

are marked by a pattem of ejaculation before penetration or during the actual act
of penile introduction, or shortly after insertion of the penis into the vagina. In
men with a less virulent problem of ejaculatory rapidity, premature ejaculation
has been defined as the inability ofthe male to control ejaculation long enough to
satisfy his partner in at least 50 percent of their coital opportunities, provided
there is no female sexual dysfunction, or inability of the male to exert voluntary
control over the ejaculatory reflex. LoPiccolo suggests that it is easier to define
what is not premature ejaculation: "Both husband and wife agree that the
quality of their sexual encounters is not influenced by efforts to delay
ejaculation". Despite the difficulty of formulating a precise definition of
premature ejaculation that will be applicable in all cases, as a practical matter it is
not very complicated to decide when lack of ejaculatory control is problematic.
Etiology

There is no reliable research documentation of the cause or causes of

premature ejaculation. Ejaculation is a reflex phenomenon regulated by
neurologic and possibly endocrine pathways; nevertheless, clinical evidence
indicates that there is a strong learned component to the process as well. Common
historical patterns have been found in men with long-standing histories of
premature ejaculation, with the central feature being early coital experiences in
which the men ejaculated rapidly. Typical histories included first coital
experiences under circumstances of fear of being discovered, (such as in the back
seat of a car, in a teenager's home while parents were away or in an awkward
position) or encouragement for rapid ejaculation from a prostitute interested in
quick turnover of customers!. ln effect, the man became conditioned to fast
ejaculation and in subsequent (more relaxed) sexual encounters he was often
unable to alter the pattern that has been established. Viewed from this
perspective,
disorder.
premature ejaculation is seen as a primarily psychophysiologic

99
 Past theories of organic origins of premature ejaculation usually
identified prostatic or other genito-urinary inflammation as the cause; howe
more recent examination of large series of patients has not supported such a view.
Some authors have suggested that; relationship problems, unconscious h
toward or fear of women, or hidden female sexual arousal problems are all
processes underlying premature ejaculation. But these dynamics appear
infrequently in couples seen at the Masters and Johnson Institute and in pract
Treatment

The general principles of sex therapy outlined earlier in the treatment of

psychogenic impotence apply to the couple for whom premature ejacula
problem. The therapeutic approach is optimal when working with the c
since premature ejaculation is usually a matter of sexual distress to the woman in
addition to being a male dysfunction. The woman may harbor resentment or
hostility toward her partner, as a result of a long-term sexual frustration she has
experienced and the lack of intimacy that has characterized their sexual
relationship. The latter situation is found particularly if the man has persis
tried to overcome his ejaculatory difficulty by mental distraction (such as
counting backwards or thinking about work) shortening the time of noncoital sex
play, or using other techniques to limit his arousal. Such well—meant and innocent
but not
selfishness.
effective practices may simply convince the woman of her partne

After thorough psychosexual histories are obtained, treatment begins w

an explanation of the evolution of the problem of premature ejaculation. The
specialists carefully delineate the fact that the man has not been capable of
voluntarily controlling the timing of ejaculation, and they stress that this situation
does not automatically equate with selfishness, fear, or hostility. The co
told that rapid ejaculation is a common sexual problem that has an excellent
prognosis with short term therapy.

concurrent attention to relationship dynamics and the ex

other sexual problems, the couple is then given basic information about the
physiology of ejaculation. They are informed that although the precise
neurophysiologic events that trigger ejaculation in the male are not known, a
program of reconditioning the ejaculatory reflex response can be easily
undertaken. Because perfomrance anxiety typically develops in men with
premature ejaculation, particularly when their wives are dissatisfied sexually,
early attention is devoted to techniques of anxiety reduction in a manner similar
to that outlined earlier in the treatment of psychogenic impotence.
When genital touching is to be incorporated into sensate focus
opportunities, the woman is instructed in the use ofa specific physiologic me
for reducing the tendency for rapid ejaculation. ln this procedure, known as the
"squeeze technique", the wife should avoid pinching the penis or scr
with her fingernails. For unknown neurophysiologic reasons, this maneuver
100
reduced the urgency of ejaculatory tension and when used with consistency,
reconditions the pattern of ejaculatory timing to improve control surprisingly
well. The squeeze technique works considerably less effectively when the man
attempts to apply it to himself. When improved ejaculatory control is attained
gradually and if no other sexual problems are present, another version of the
squeeze technique is applied to the base of the penis hence called the "Basilar
squeeze" or "Semans grip".

Success rate

Most men have considerable improvement in control over ejaculation prior

to the end of the two week program of sex therapy, typically experiencing 10 to
15 minutes of intravaginal containment with active thrusting. In general, couples
need to continue the use of the squeeze technique for three to six months after the
intensive phase of therapy to achieve a permanent reconditioning of the
ejaculatory response. ln Human Sexual inadequacy, a failure rate of only 2.7
percent was reported in a series of l86 men with premature ejaculation; other
workers describe excellent therapeutic outcomes as well.

Summary

To summarize the evidence regarding premature ejaculation:

l. Medical data indicate that organic factors may account for about 10% of
the causes of this syndrome.
2. This is in keeping with psychiatric findings that premature ejaculation
has an emotional basis in about 90% of the cases; the most frequently
encountered factor in clinical practice is anxiety.
3. The emotional basis of premature ejaculation in many cases is further
demonstrated by the more than 90% success rate in treating the syndrome by sex
therapy.
4. The use of condoms or topical anaesthetics by circumcised or non
circumcised males has little or no effect in reducing premature ejaculation.
5. All evidence suggests that the problem is increasing in sex clinics, at
present, it is the most frequent presented male problem.
6. Some authors attributed the increase to w0men's rising expectations of
sexual satisfaction.

Ejaculation lncompetence
Terminology

The male sexual dysfunction that is least frequently encountered in clinical

populations (and is presumed to be of correspondingly low prevalence) is
ejaculatory incompetence. or the inability to ejaculate intravaginally. Men with
this disorder rarely have difficulty with erection and typically are able to maintain
a firm erection during lengthy episodes of coitus. The functional problem may he
101
 conceptualized as being the opposite of premature ejaculation; Although
secondary ejaculatory incompetence is sometimes Seen, (loss of ability to
ejaculate intravaginally after a previous history of normal coital ejaculation),
most common fomi of ejaculatory incompetence is primary, (never having
been able to ejaculate intravaginally). There is variability in the pattem of
noncoital ejaculations. Some men with ejaculatory incompetence can ejacula
with solitary masturbation, others can ejaculate by noncoital partner sex
stimulation, (manual or oral) while still others are unable to ejaculate by any
means. ln a small percentage of cases, ejaculatory incompetence may be
situational, occurring with one partner but not another.

Etiology

Organic causes of ejaculatory incompetence include congenital anatomic

lesions of the genitourinary system, spinal cord lesions, damage to the lumbar
sympathetic ganglia, and use of drugs that impair sympathetic tone, such as
guanethidine. The phenothiazines may also delay or prevent ejaculation.
However, most instances of ejaculatory incompetence are of psychogenic
origin. Etiologic factors that may be seen include the effects of severe religious
orthodoxy during childhood, which instills attitudes of sex as sinful, the genitals
as unclean, and the act of masturbation to ejaculation as evil and destructive.
Hostility toward or rejection of the spouse, homosexuality, fear of pregnancy,
desire not to have children, and specific psychosocial trauma, (the discovery
man that his wife has been having an affair with another man or that she has been
raped, for example) have also been described as important in the development
ejaculatory incompetence.

Treatment

It is important to explain the etiology ofthe dysfunction carefully to both

partners, since the woman's attitudes towards her husband's failure to ejaculate
may be quite negative, particularly if she wants to have children and perceives her
lllléballd QS Wlllllllly preventing conception. Since the woman
to play an active role in the reversal ofthe ejaculatory incompetence, neutral
initial hostilities or distrust is a necessary early therapeutic concern.
The sensate focus exercises are employed in a fashion similar to that used
in the treatment of impotence. The goal is to facilitate the man's awareness of his
own physical sensations, improve nonverbal communication patterns, and
eliminate the pressure of performance. When genital touching occurs the wif
encouraged to stimulate the penis in a deliberate and demanding fashion, with
man communicating to her information about timing, pressure, and types of
stimulating motions that he finds most arousing sexually. The first objective is
the woman to induce ejaculation by manual stimulation. Once this has been
accomplished, sex play in the fe-nale-astride position is recommended and insert
102
the penis vaginally as ejaculation becomes imminen
intravaginal ejaculation is usually all that is required to r
permanently. In cases in which intravaginal ejaculation
repeated attempts with therapeutic suggestion and analy
bring the husband to ejaculation by the use of manual sti
that allows the ejaculate to spurt onto the extemal female genitalia. As t
husband becomes more comfortable seeing his ejaculatory fluid in genital
with his wife, intravaginal ejaculation may occur more easily. Through
treatment of the couple in whom ejaculatory incompetence is present,
must be placed on effective pattems of communication. In instance
who do not respond to sex therapy, referral for in depth individual the
beneficial.

Mixed Sexual Dysfunctions

lt is not surprising that combinations of sexual dysfunctions may e

the same man, since common etiologic factors appear to underlie many
disorders. The most frequently encountered combination is premature ej
and impotence; indeed, it appears that anxiety over sexual perform
from rapid ejaculation is a cause of impotence. Much less frequent
incompetence may coexist with impotence.
Treatment
ln treating these conditions, it is generally necessary to deal in
the erectile failure and to institute appropriate managemenj of the ejacula
dysfunction only after security has been gained in erectile fun
to this strategy is the instance in which a man ejaculate
penis is ilaccid, in this situation, the squeezy technique must be u
ejaculatory control before adequate erections can be attained.

103
 FEMALE SEXUAL INADEQUACY
(DYSFUNCTIONS)
• Frigidity.
Important Facts Concerning Womcn’s Sexuality.
• Vaginismus.
 FEMALE SEXUAL DYSFUNCTIONS

Frigidity

There was a time when we used a single word to describe all possible
female sexual dysfunctions; frigidity (literally coldness, from Latin fri
. cold). Today we know that this vague term is no longer acceptable because
lacking diagnostic precision. Up till 1970, fiigidity was variably applied to
women who were uninterested in sex, women who never experienced orgasm a
women who purportedly experienced clitoral instead of vaginal orgasms (a
distinction that is now known to be erroneous).
Orgasmic dysfunction and frigidity:

The great disparity which people experience in their sexual feelings,

provides one of the most baffling aspects of sex. No side of human nature is so
unpredictable or so varied and impossible to tell from people's appearances or
bearing or clothing, what their erotic nature is really like’?..
Variations can range from states of extreme sexual desire, with or without
the ability to have their sexual desires fulfilled; to those of complete absence o
any sexual feeling what so ever. For instance, it is by no means uncommon for a
female never to experience those changes of sex feelings in her sexual org
which some other female may experience daily or perhaps almost hourly... Far
more common than this, is the female who has never experienced genital
pleasurable sensations, and who has therefore no understanding whatever of the
ordinary desires and sexual needs of others.

Clearly therefore, it may be most difficult for people to understand each

other, since quite intimate discussion often hails to reveal such differences, each
taking for granted that the other's experience is identical.

Again, the sexual feelings of people and their daily behavior often show
curiously little correlation. Thus, a female with strong sexual desires may be
reserved .or even prudish, and may behave in public with the utmost strictness all
her life; indeed, she may fear and disapprove ofthe whole sexual side ofher
nature. While a frigid female may be very well satisfied with spinsterhood or she
may make an excellent wife, yet frigid women are well known to go quite to the
other extreme, taking prostitution as a career. Quite often, it is women of this
type. who find and even need reassurance, in a continuous change and
replacement of her sexual partners.
Sexual desire

lt is by no means necessary to assume that because a man is healthy or in

the prime of his life, perhaps even an athelete or a champion, that he is bound
have strong sexual feelings because virility is a matter of the spirit more than the
104
Uutly. llut, Lt it uutuin that tt man with t· ···r··*··*‘~· f~ pr~·~*¤····i*y is ¤··res¤¤rily
either sexually eomptent or virile and potent e.g. Casa Nova or Don Juan, because
history has proved that he could be impotent or even homosexual sometimes...
Even experienced observers may fail to recognise that a person is suffering
from a sexual disorder; indeed, it may be impossible to guess from the bearing or
behavior of an intimate couple whether their marriage has been consumated or
not. The late Sir Green Armittage reported a 3% of female infertility cases are due
to an intact hymen...
Some women experience such a slight orgasm and they get satisfied, while
other women are desperately disturbed if they are deprived of it for any reason, it _
all depends upon her sexual threshold and the prevailing circumstances. lt is a
curious fact that although orgasm is an essential part of the reproductive process
in the male, namely, the deposition of semen in the vagina during the process of
ejaculation; it has no equivalent value in the female. Perhaps, it is not surprising
therefore, that so many women fail to achieve it ‘?.
True frigidity
The term frigidity which was used to describe any woman who is unable to
obtain an orgasm, no matter how ardent and strong her sexual feelings may be is
not truely correct. Criticism here is justified because frigidity should be reserved
for those women who lack emotional and physical responses to such sexual
relationship. Thus, a woman may be frigid throughout all her life, or only in a
certain limited time (for example during pregnancy or through the perpurium). As
well, she may be frigid to one certain man but not to another (for example some
prostitutes are known to get their orgasm only with one particular lover!). So, for
these women who have a normal sexual desire but cannot attain an orgasm; the
temt "lacking orgasmic capacity" is suitable scientifically.
Although there is no uniform agreement on the precise diagnostic
epnaanatamu m he use-rl in reference to women who do not experience orgasm,
many professionals have adopted the classification suggested by Masters and
Johnson.
Varieties of anorgasmia
Primary orgasmic dysfunction or primary anorgasmia is defined as, the
condition of a female who never has attained orgasm under any circumstances.
The classification of situational orgasmic dysfunction or situational
V anorgasmia applies to women who have achieved orgasm on one or more
occasion, but only under certain circumstances- for example, women who are
orgasmic during masturbation but not during stimulation by their husbands.
Women who are orgasmic by many special means but are nonorgasmic during
intercourse, are described in a subcategory of situational orgasmic dysfunction
knmvrt as, coital orgasmic inadequacy or coital anorgasmia. Random
105
orgasmic dysfunction refers to women who have experienced orgasm in different
types of sexual activity but only on an infrequent basis. Secondary orgasmic
dysfunction describes women who are regularly orgasmic at one time but no
longer are.
Percentage of anorgasmla
There is some controversy at the present time regarding the number of
women who are anorgasmic, however, the available data are in good agreement.
Kinsey and his colleagues reported that 10 percent of married women never
experienced coital orgasm. Chesser found that l0 percent of British women rarely
experienced orgasm, while 5 percent never experienced orgasm during
intercourse. Fisher reported that approximately 6 percent of married women
never experienced orgasm. Levine and Yost reported that 5 percent of patients
seen in a general gynaecologic clinic had never been orgasmic with a sexual
partner, while l7 percent had difficulty reaching orgasm with a partner. From a
clinical perspective, women who are unhappy about lack of orgasmic
responsiveness are far more likely to seek treatment than women who are
nonorgasmic but do not feel dissatisfied sexually. These percentages relate only to
non circumcised females, with an average percentage of 9%.
Etiology
Much less is known about organic factors causing female sexual
dysfunction than is the case with male sexual dysfunction.
Organic Causes:
l. Conditions that affect the nerve supply to the pelvis, for example,
multiple sclerosis, spinal cord tumors or trauma, amyotrophic lateral sclerosis,
nutritional deficiencies, or diabetic neuropathy and female circumcision.
2. Conditions that impair the vascular integrity of vaginal circulation,
for example, abdominal aneurysm, thrombotic obstruction, arteritis. or severe
arteriosclerosis and risk factors of vasculogenic causes are sometimes responsible
for loss of orgasmic responsiveness.
3. Endocrine disorders, for example, Addison's disease, Cushing’s
syndrome, hypothyroidism, hyperthyroidism, hypopituitarism, or diabetes .
mellitus may likewise interfere with female sexual response and usually are
correctable by appropriate medical treatment ofthe underlying disorder.
4. Gynaecologic factors, including the impact of extensive surgical
procedures or female sex mutilation, chronic vaginal infection and congenital
anomalies. `
5. Some chronic illnesses impair orgasmic responsiveness indirectlyrby
affecting libido and general health in the diseased woman.
106 C
Psychogenic causes
Analysis of large series of cases of orgasmic dysfimction seen at the
Masters & Johnson Institute, indicates that 90 percent or more are psychogenic in
origin.
lt is frequently difficult to trace the etiology of orgasmic dysfunction
because so many women have been exposed to negative cultural conditioning in
regard to sexuality. Until recently, the prevailing message most women received
throughout childhood, adolescence and adulthood was that sexuality must be
repressed. While the male has the society's blessing in becoming sexual and
exploring his own sexuality, females are expected to be "good", "pure" that is to
postpone sexual feelings or sexual participation until alter marriage. The growing
girl was traditionally permitted to develop only simulated facets of her sexuality,
namely, those aspects having to do with symbolic romanticism and rehearsals of
matemalism. To these cultural limits must be added the constraints imposed by
rigid social traditions in which the male has been expected to initiate both
courtship and sexual behavior; the female has been placed into a chronic role of
the relatively passive partner in both social and sexual aspects of development.
Aside from the broad cultural influences on female sexuality just
mentioned, a number of specific developmental factors appear to have relevance
to orgasmic dysfunctiw· or frigidity. Childhood exposure to a home environment
of rigid religious orthodoxy and its accompanying negative attitudes toward sex
and nudity is a frequently recurring theme in women with orgasmic inadequacy.
Traumatic sexual experiences during childhood or adolescence, such as incest
or rape, may also be associated with orgasmic dysfunction. However, it must be
emphasized that sexual dysfunction in adulthood does not uniformly follow from
such developmental histories; why one woman copes successfully with potentially
negative influences and another female develops long-range sequelae is not well
understood. ·
Affective factors may also be implicated in the etiology of orgasmic
V dysfunction. Although guilt related to sexual practices may be a residual hallmark
uf utvtluuuttutttl tuuuitiuuiug, guilt utuy uliu lit. u mult ut uthu dyuumiua
reflecting either intrapsychic or interpersonal processes. Anxiety has been less
widely recognized as a contributor to sexual dysfunction in women than in men;
however, women are frequently victims of performance anxieties that arise not
only from their self—perceptions but from the demands placed on them by their
partners. The man who attempts to measure his own virility by the frequency or
intensity of his partner's orgasmic responses may be contributing significantly to
her fears of performance. Anxiety may also be related to physical attractiveness,
worry about a partners sexual adequacy (particularly in relation to impotence, in
which case the woman may view the rrran's dysfunction as a sign of her own
inability to excite him sexually) or concern over loss of control while being
orgasmic.
107
ln a small number of women who have never been orgasmic, anxiety
related to fear of loss of control during orgasm results in deliberate blocking of
sexual arousal. Such women may voice concem about becoming convulsive
during orgasm, being incontinent, losing consciousness, or having other
manifestations that resemble sickness or cause embarrassment. These women
often have low self-esteem and view themselves as incompetent, dependent on
others and unable to control their own lives.
Depression is a frequent cause of impaired orgasmic responsiveness, the
precise cause is not known, since libido is typically decreased in depressed
women, it may be difficult to determine which is which if a true frigidity is
present. Depression may be a cause of secondary frigidity but is unlikely to be the
principal factor in primary frigidity, sitnilarly, depression is unlikely to account
for situational orgasmic problems.
ln many instances, orgasmic dysfunction stetns from interpersonal factors
that include ineffective communication, hostility toward the partner or spouse,
distrust of the partner or husband, and divergent sexual preferences. The
importance of communication as a means of interpersonal relating cannot be
stressed too highly; the consequences of poor cotnmunication patterns include
tiustration. feeling hurt, anger, clisinterest and withdrawal. Many women with
sexual problems have not been able to communicate their preferences for a
particular type of touch, position, or timing related to sex with their partner. This
inability to communicate may result from lack of learned lacility in sexual
communications, a feeling that it is improper for the woman to tell the man what
she might like, for fear that the husband will be offended by such suggestions...
Boredom or monotony in sexual practices may be an important element in
the genesis of secondary orgasmic dysfunction. Women who are orgasmic by
masturbation but not in sexual activity with their husbands may be so because of
anxieties. or probably at least as frequently, because the partner controls the
initiation, timing and type of sexual activity that occurs.
ln some cases, sexual ignorance appears to be a major element of
orgasmic dysfunction, because it is surprising how many women are unfamiliar
with their own anatomy or have no idea of what type of sexual activity is
pleasurable for them. ln other instances, misconceptions and ignorance about
personal hygiene or male sexual needs become dominant elements dictating a
woman's sexual behavior patterns.
Diagnostic considerations
Care must be taken to identity any organic factors contributing to
organic dysfunction. Dyspareunia should always be careliilly investigated in a
systematic fashion, since organic lesions are frequently missed on a routine
pelvic examination. For example, sometimes the female sexual response during
coitus is impaired by a wide and slack vaginal entrance. ln other words, the
108
muscles surrounding the vaginal entry are in such poor condition that there is
not enough friction between the penis and the outer one third of the vaginal
wall. Indeed, neither of the partners may even feel very distinctly whether the
insertion has taken place or noll. lhe mam muscle allecled is the
pubococcygeus which is described as the master sphincter of the entire pelvic
area and it runs from the pubic bone in the front all the way to the coecyx in the
back. A gynaecologist by the name of Arnold H. Kegel, developed some
exercises for this particular muscle which can be practiced by any woman at
anytime and anywhere. The superficial muscular layer is called the
bulbocavernosus.
Kegel's exercises .
The patient must Ieam first how to identify the muscle for herself. ln
order to do this, she is advised to sit on the toilet with her legs spread as far
apart as possible. lf she then starts and stops the flow of urine, she becomes
aware of the pubococcygeus action because it is the only muscle that can stop
urine under this circumstance. Once the muscle is identified, the woman can
practice contracting it repeatedly whenever she has the time. She simply flexes
this muscle twenty times in a row three to five times every day till it is firm. As
a result, coitus becomes much more enjoyable for both partners because the
contact between penis and vagina is closer. While it is tme that the inner two
thirds of the vaginal walls themselves contain hardly any nerve endings and
therefore no feeling, the muscles surrounding the vaginal entry and the outer
third of the vagina do contain nerve endings and if these muscles are firm and
strong, their stimulation can be felt and enjoyed. The ability to control her
vaginal muscles is bound to be welcomed by any woman who wants to make the
best of her sexual relationships.
Diagnosis of systemic disease
A detailed medical and surgical history, accompanied by a complete
physical examination and appropriate laboratory testing, will assist in the
diagnosis of systemic disease that may impair sexual responsivity. Every
woman with a history of secondary frigidity and a close relative with diabetes
mellitus should have an oral glucose tolerance test. Evaluation of steroid
hormone status and thyroid function tests is most likely to be beneficial for
patients with depressed libido or with vaginal atrophy.
Combined male and female sexual dysfunctions
ln cases in which male sexual difficulties coexist with lack of female
orgasmic responsiveness, it is not always possible to make a precise diagnosis.
For example, the wife of a man with premature ejaculation cannot be diagnosed
as having eoital orgasmic inadequacy, since rapidity of ejaculation seriously
hinders her opportunity for exploring coital patterns of sexual arousal. However,
il` the woman remains unable to have orgasms during coitus alter the rnan's
109
ejaculatory control has been improved, then the diagnosis may be correctly
applied. Similarly, a woman whose husband is impotent may be handicapped in
her sexual responsivity in proportion to both the man's dysfunction and her own
loss of spontaneity or sense of responsibility for overcoming his distress.
The truth about female orgasm
Some women are unsure about whether or not they have ever experienced
orgasm". In some instances, the history may reveal enough precise information-
for instance, a pattem of sexual arousal culminating in rhythmic, pulsating
contractions of the vagina and a general sense of relaxation and tension release-
to determine that orgasm has actually occurred. ln other cases, the woman's
description of her past sexual response pattems is quite inconclusive; while it has
been said that if a woman is not sure if she has ever been orgasmic, then she
probably has not, this generalization is not always accurate. Some women have
expectations of orgasm as an earth shattering eventl; in these cases, which may
reflect the unrealistic portrayals of female sexuality in many popular movies,
magazines and books, the woman may in fact be orgasmic frequently, yet not
realizing that she is...
A detailed history of each w0man's ability to be orgasmic by
masturbation is important from both diagnostic and therapeutic perspectives.
Facility with masturbatory orgasm but lack of orgasm and frigidity occurring with
her husband points to the likelihood of interpersonal factors being of primary
importance. lf a woman has not been orgasmic with self-stirnulation or has never
attempted masturbation, it is more likely that attitudinal problems exist that
require therapeutic attention.
lt may be difficult to determine whether low libido accompanying
orgasmic dysfunction is etiologically important, (for example, as a symptom of
depression, drug use, or chronic illness) or whether it has been a secondary
reaction to a longstanding pattern of sexual frustration. Claims of low interest in
sex may also indicate pervasive guilt associated with sexual activity or
performance anxieties.
Additional aspects of each clinical situation that require careful diagnostic
assessment to permit a rational formulation of treatment plans include
information about the following factors:
l. Contraceptive practices and reproductive goals.
2. Sexual responsiveness in other relationships.
3. Quality ofthe present sexual relationship.
4. Sexual attitudes of both partners.
— 5. Concurrent psychopathology. A
6. Previous experiences in psychotherapy.
7. Sellieslcem.
8. Body—image.
1 10
Treatment
Because of differences in the socialization of men and women in our
culture in regard to sex, it is usually important to encourage the frigid woman to
think of herself as a sexual being - in effect, to give her permission to be sexual!.
Cultural attitudes putting women to a secondary role in sexual activity are
discussed at length with the doctor, pointing out where these rules have
influenced the particular woman developmentally as well as identifying any
current constraints on sexual attitudes or behavior that originate from such
cultural conditioning. Thus, the woman who has been taught to believe that men
have a greater sexual capacity than women is informed that physiologically the
reverse is true, because there is no refractory period following orgasm in women.,
lt is equally important as a part of therapy to correct misconceptions that men
have and believe about female sexuality, which is most effectively accomplished
in the context of the conjoint therapy model. In this format, both the male and
female partners have an opportunity to see the female cotherapist openly
discussing sexual matters in a knowledgeable fashion; this provides an effective
model for the female patient and reinforces the concept that women can think or
talk about sex. Necessarily, many details of treatment depend on the histories,
personalities and objectives ofthe patients, the discussion here will focus on
the components of therapy that are usually applicable.
lt is important to identity each couple's sexual value system and to
approach therapy within the boundaries of what is acceptable to them. Although
attitudinal change may be necessary to therapeutic progress in some cases,
doctors should refrain from imposing arbitrary values on their patients and should
recognize the dimensions of each couple's moral and sexual values. Thus, a
woman and the wife who feels that masturbation is "dirty" but wants to change
this feelings may be counselled in ways to become comfortable with self-
stimulation but a woman who objects to masturbation on moral grounds should
never be urged to masturbate as a requirement of therapy.
Education is employed to provide accurate information related to sexual
anatomy and physiology, l\iany women as well as their partners, are uncertain
about aspects of their own sexual anatomy. Some women do not know or are
uncertain about where the clitoris is; even when the anatomy is familiar to them,
they may not understand changes that occur during the sexual response cycle.
Discussing the facts that direct clitoral manipulation may be sometimes
uncomfortable, that vaginal lubrication comes and goes normally, and that
nongenital accompaniments of sexual arousal such as tachycardia, sweating or
carpopedal spasm are normal physiological responses, such discussion may be
» directly beneficial in certain cases. ·
Sexual education is also directed at informing both the woman and her
husband about patterns of female orgasm. In particular, it must be stressed that
the intensity of orgasm may vary considerably from time to time; the search for a
· 111
body shaking explosive orgasm is likely to block the acceptance of any less
dramatic response as authentic. Similarly, it is usually helpful to address the
erroneous notion of vaginal versus clitoral orgasms by explaining that all
female orgasms, regardless of the source of stimuli have the same physiologic
manifestations. Education should include a thorough explanation of sexual
anatomy and physiology without artificially separating the biologic components
of sexuality from psychosocial factors. Therefore, it should be pointed out that
regardless how the body is responding, the way in which physical sensations are
integrated into the subjective emotional experience of each person has a great
deal to do with what is perceived as pleasurable. Factors such as mood
interfering or preoccupylng thoughts and physical discomfort due to feelings
such as fatigue, soreness, or hunger, all contribute to the perception of the quality
of a sexual experience.
Anxiety reduction is accomplished by several different approaches.
Encouraging couples to verbalize their concerns about sex allows for a modest
degree of anxiety reduction by the simple process of ventilation. Sensate focus
exercises are employed to remove performance pressures, increase
communication skills (which typically lowers anxiety by improving both
competence and self-confidence) and induce physical relaxation. In addition,
because anxiety may result from irrational labelling of a behavior, situation or
feeling as negative or dangerous, interventions that have been temied cognitive
rclabelling are sometimes used successfully. For example, labelling a sexual
encounter as a failure if it does not result in orgasm — and simultaneously
reinforcing feelings of personal inadequacy by this labelling process- can
obviously lead to anxiety in anticipation of sexual activity. Helping the woman to
learn that a sexual experience may be enjoyable even if orgasm does not occur is
likely to contribute to a reduction in anxiety and a subsequent increase in sexual
responsivity.
. Anxieties about sex often derive from the notion that sex is in a category
completely apart from all other aspects of our lives. The process of cognitive
relabelling can be facilitated by using analogies drawn from nonsexual aspects of
life to indicate the unrealistic nature of many expectations women (and men)
have about sex. For example, if a couple is concerned because the with is not
"ready" for sex just when her husband is, they might be asked if they only sit
down to a meal when both have an equal appetite. The nonsexual analogy might
be developed further by stating: "lf one of you is hungry and the other is not, you
might join each other at the table; then, if your appetite develops you are free to
decide if you wish to have a meal"... Many women are concemed that even a
slight degree of physical intimacy (a hug, a kiss, cuddling), will be taken by the
man as a signal to progress to intercourse!. ln this situation, the woman might be
, asked if it is not ever possible to have a bowl of soup or a salad without having to
eat Z1 complete dinner. The concept behind such examples, of course is to
highlight the inflexibility and irrationality of certain maladaptive sexual beliefs,
while pointing out that common—sense principles that the patient often uses on her
own can be equally applicable to sexual situations.
1 12
As mentioned previously, sensate focus provides a frame—work for
reducing anxiety, increasing awareness of physical sensations and transferring
communication skills from the verbal to nonverbal domains. While one important
aspect of these processes derives from specifically altering previous sexual habit
pattems by initially prohibiting genital or breast stimulation, another point of
significance involves specific skills in nonverbal communication that are taught
to the couple through the slight pressure of their touching hands. This exercise
facilitates the concept of sex as a matter of mutual participation — not something
the man does "to" or "for" the woman! ....
Using such nonverbal messages, a hand can be moved from one spot to
another to know what kind of touch, at what location and for how long. As such, `
the woman is able to explore her own sensations, since the goal is not to produce
an orgasm but to identify and discover interesting or pleasurable sensations. As
the woman becomes more knowledgeable about her own body, she is better able
to convey her feelings and needs to her husband. ln this regard, it must be
stressed to both patients that it is not the man's job to make or force his partner
orgasmic, although this is frequently the attitude couples have prior to beginning
treatment. A man is no more able to make a woman orgasrnic than he is able to
make her digest her l`ood!... Orgasm is a natural psychophysiologic response to
the build-up of neuromuscular sexual excitation; when the body is allowed to
function in a positive emotional matrix (unhindered or impeded by anxiety, anger,
or excessive cognition) orgasm will occur spontaneously.
Except in the case ofa woman with primary orgasmic dysfunction, the use
of vibrators as a sexual aid in sex therapy is problematic and unadvisable for
several reasons (refer to the chapter of masturbation and the use of sexual aids),
First, the intensity of physical stimulation delivered by the vibrator cannot be
duplicated by the man. Second, the use of the vibrator may alarm the woman if
t she perceives it as unnatural and abnormal. Third, use ofthe vibrator may have a
distracting effect on the couple- either one or both partners may view it as
reducing their intimacy. Finally, repeated use of a vibrator for long time may
result in a degree of either psychological or physical dependency on this device as
the only possible source of orgasmic release.
lf the couple can learn to interact sexually by focusing on their feelings,
communicating openly together, and avoiding routinized sexual patterns, orgasm
is likely to occur. ln fact, women often are told that orgasm may occur when they
least expect it; the fact being of course that pushing to reach orgasm is much
more likely to inhibit overall sexual responsiveness.
1 13
Sensate focus (sexual foreplay)
The basic themes of sensate focus are:
Explore feelings without a goal, communicate openly, assume responsibility
for yourself, not for your partner and the female superior position is utilized. The
woman is asked to start intercourse only if she feels ready for it, (both mentally and
physically): thus having intercourse is not assigned. 'Ihe husband is told to
continue touching during intercourse, with guidance from his wife as to what feels
pleasurable. Clitoral stimulation may be employed during coitus asameans of
additional sensory input to facilitate orgasmic responsiveness. Depending on the
individual circumstances of each case, the woman may be asked to experiment
with fantasy during sexual play and precoital petting, particularly if she has
difficulty freeing herself from distracting thoughts.
Using these methods, an overall failure rate of 20.8 percent in a series of
women with orgasmic dysfunction who were not eircumciscd was reported by
Masters & Johnson.
Religious view
Many years ago, our Prophet Mohamed described precoital petting
beautifully through his following advice:
:"(`L.j Agile. Jil All (j,....J Ljli
L-e dydll Us dei · dyn o$·$.» ·’*~=eHl* 53 L5 ·*i=ld-¤l ade 66-—¤=~l cia Y"
` ."(.)\SllJ Yabill :LjL§9 All Ljyuj
·u-“)*—“ rL·?‘-l
Sexological analysis
The words of our Prophet indicated and proved very important and
sensational facts conceming female sexuality
l. Coitus without preroital petting is animal like.
2. Coitus not preced··d by sexual foreplay is unadvisable because it will not
be satisfying to the wife.
3. Kissing (light and deep) between husband and wife is an excellent method
of communication (non-verbal).
4. The mouth and tongue are very important secondary erogenous zone in
both males and females. A
5. Love talk between husband and wife is appreciated by all females and
evidently it is a successful way of verbal communication.
1 14
In conclusion p
The overall analysis of such very concise but marvelous sexual advice is to
achieve a satisfying orgasmic coitus and hence the absence of coital anorgasmia
afflicting many of our circumcised wives nowadays.
It is a well known fact that mutual sexual satisfaction in marriage is of paramount
importance during the wonderful stability of such sacred bondage between males and
females. As a matter of fact our God stated the following in the Koran:
‘,.é:._)]i Q.a:._)]i aisl ran.; W
··¤»,, ay asa aa, an ·,¢~s~»¤¤ any an ra is as al am au
As such, a lot of marriage failures, divorce, adultery and even polygamy
could be easily avoided by following and carrying out these scientific, medical
and humane traditions oflslam conceming our wives and their important rights in
marital relations.
1 1S
Important Facts Concerning Women's Sexuality
lt is worth remembering some facts conceming women’s sexual relations
in general, namely, direct sexual interests i.e. coitus or masturbation are of far
less concern to females than to males. Thus, females can live more easily without
sexual activity, they think less about sex and are much more readily deterred from
it. In general, females cherish emotional relations far more than sex, while puritan
love is their dream. They do require a very individual approach sexually before
they are likely to be fully aroused because they are liable to have great variations
in their erogenous zones. By far, it is not straight-forward erotic desire that
usually motivates females towards sexual activity, but a feeling of being needed,
admired and preferred is ot`ten much more important. Hence. most women are
greatly stirred emotionally by courtship and personal attentions e.g. birth-day
presents, gitts and love talk and failure to do so is exceedingly common on part of
the husbands with consequent marital disharmony and sexual failures... Many
women do prefer the initial caressing and the elaborate precoital petting
especially if the husband is experienced well with the various erogenous zones of
his wife`s body. Women actually enjoy this sex play sometimes more than the
actual coital act; contrary to the male impulse of penetration and impregnation. lf
the woman lacks the capacity for orgasm the husband should avoid her criticism
because it means doubting her affection and devotion, since physical pleasure is
by no means a measurement of her love and should not be so judged. lt is
interesting to note that some females could achieve an orgasm while listening to a
musical concert!. while others get wet in the presence oftheir beloved.,
Phases of increased sexual urge
ln females as a whole, there are phases of increased sexual desire at
different times related to their menstrual cycle. As a matter of fact it has been
proved recently that there is an increase in female initiated sexual activity at the
time of ovulation exactly like some female animals on heat. Obviously this rise in
sexual desire becomes less premenstrually, then it diminishes during the
menstrual tlow and becomes least atter mensis. A wise lover should take a good
advantage at these times". lt is worth noting as well, that during the premenstrual
phase, sexual and ordinar3 crimes of violence are recorded mostly during this
period. ln females with pronounced premenstrual syndrome, committing
suicides, divorce and heme troubles are prevalent during this critical period.
Males should be warned that female breasts get engorged and become tender
during this phase, as a matter of fact some women and girls too. do complain
severely of this phenomenon during the premenstrual phase of their cycle.
Naturally, the fondling of these tender breasts during sex play should be avoided
by their husbands. Vaginal lubrication or moistening is a must for a normal act of
penetration and coital activity but if it is deticient, artificial lubricants should be
prescribed. Vaseline or grease are most unsuitable for this purpose but a water
soluble jelly is the answer for this problem, artificial lubrication should be applied
to the vaginal outlet or to the glans penis and not in excess. Saliva is most
efficient especially for purposes of fertility enhancement, since, the enzyme
1 16
amylase has been proved to enhance the motility of the sperms as well as the
mayma hyulorinidum. fi piuuliuul LAdlll|JlC WUI lll lll!llllUlllllQ ll that the
mounting ofa bitch on heat by the male dog is always preceded by the elaborate
deposition of saliva during the act of precoital sniffing.
Vaginismus
Terminology
Vaginismus is a condition of involuntary spasm or constriction of the
musculature surrounding the vaginal outlet and the outer third of the vagina, (Fig.
33). This psychophysiologic syndrome may affect women of any age, from the
time of earliest attempts at sexual activity to the geriatric years, and may vary
considerably in severity. The most dramatic instances of vaginismus of`ten present
as unconsumated marriages since penile insertion into the vagina may not be
possible due to spasm, resistance and attendant pain. At the other end of the
clinical spectrum are cases in which coitus is possible but painful The frequency
of vaginismus among females is so far not recorded statistically but
gynaecologists are quite familiar with it. Although the woman with vaginismus
may be quite fearful of sexual activity, thus limiting her sexual responsivity, more
commonly women with vaginismus have little difficulty with sexual arousal.
Vaginal lubrication occurs normally, noncoital sexual activity may be pleasurable
and satisfying and orgasmic responsiveness is often intact. Females with
Vagilnismus usuallv have normal libido and mp Ai¤m·¤¤¤A ky than :.mi,`i|iU· m
participate pleasurably in active coitus.
Etiology
Vaginismus may arise from a natural protective reflex to pain originating
from any lesion of the external genitalia or vaginal introitus. The percentage of
cases of vaginismus that are initially attributable to organic problems oftliis type
is not certain; one difficulty is that repeated episodes of such pain may produce a
conditioned response so that even if the original lesion heals spontaneously or is
eliminated by proper medical therapy, the vaginismus may remain. Thus, a
woman who initially experiences vaginismus in association with a poorly healed
episiotomy may continue to be dysfunctional after the perineal and vaginal tissues
have healed normally. Transient or subacute vaginismus in association with
pelvic pathology often does not require psychotherapy but chronic vaginismus.
even if it is attributable to organic processes usually requires such treatment.
Organic causes
Among the frequent organic causes of vaginismus are hymenal
=·*·····r·M'*·*···i °··~'··r""g rimn ntu uf thu liyuiui llml Jul. !·lll!lLl|Ell Lllllllllg
attempts at vaginal penetration. genital herpes or other infections that cause
. ulcerations near the opening of the vagina or on the labia, obstetric trauma
with painful episiotomy; and atrophic vaginitis. not forgetting complicated
circumcision operations eg. tight introitus and entangled neuroma.
1 17
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118
Psychosocial factors
More commonly however, no organic cause can be implicated as the cause
of vaginismus. in these cases. a variety of psychosocial factors may be operative.
There appears to be more than a chance association between a background of
negative conditioning to sex fostered by intense childhood and adolescent
exposure to religious orthodoxy and the later occurrence of vaginismus. It
should be emphasized that the development of vaginismus (or any sexual
dysfunction) from this background has little to do with the specific theological
content of religious upbringing; rather. the maior difficulty seems to stem from
the rigid often wrong thinking that regards sex as dirty, sinful and shameful.
This background pattern is frequently encountered in women with
unconsummated marriages. and indicates that they have difficulty in making the
psychic transition from viewing sex as evil (prermaritally) to viewing sex as good
(upon marriage). Interestingly. women from such backgrounds often marry men
of similar upbringing and a high incidence of secondary impotence has been
found among such couples when the woman has vaginismus.
Vaginismus may also stem from a severely traumatic experience.
Although this etiology is seen most typically in the case of women who were
raped during childhood or adolescence. the occurrence of rape at any age may
precipitate a subsequent pattern of secondary vaginismus, even when previous
sexual function had been well established. Vaginismus may also oceiir as a
consequence of traumatic sexual experiences other than rape. Incest. repeated
sexual molestation as a child. or a pattern of psychologically painful sexual
episodes at any age may predispose to this condition.
Other factors that may be impoitant in the genesis of vaginismus include;
homosexual orientation. traumatic experience with an early pelvic
examination. pregnancy phobia. venereal disease phobia. or cancer phobia.
The precise role of negative maternal conditioning in regard to menstruation.
riprtiduutltili ulltl JLA llll$ IIUI llEEll Ullllllilllly Ullblolléd hui may sometimes lie a
factor in the subsequent development of vagiuismus.
Treatment
The diagnosis ofy .iginismus can be made if involuntary spasm or constriction
of the musculature surr< unding the outer portion of the vagina is detected. lf this
diagnosis is made it is not usually necessary to go on to a more detailed pelvic
examination at this time. including deep palpation. insertion of a speculum and
obtaining Pap smears or vaginal cultures. These procedures can be performed Z1 day
or two later. once the patient and her husband have been educated about her
condition thoroughly. Because many patients who may have vaginismus are
extremely fearful of having a pelvic examination. some gynaecologists conduct such
an examination under general anaesthesia. Although this procedure may be helpful
in detecting organic pathology that would otherwise be difficult to identify. the
muscle relaxation induced by anaesthesia makes it impossible to diagnose
x aginism us even if it is present. y
119
A second pelvic examination is performed with the woman's consent, her
husband is present in the examining room so that the nature of the involuntary
constriction about the vagina can be demonstrated to both partners. The woman is
encouraged to watch the examination in a mirror held by a medical assistant. The
purpose of this examination apart from allowing the woman to become accustomed
to the physical contact and to realize that nothing is being hurried, is to introduce
the use of a series of graduated vaginal dilators, named after Fenton's (Fig. 34).
· These dilators are made of glass, porcelain or better plastic and they will be used to
reprogram the maladaptive muscular constriction of the vaginismus response. lf
voluntary guarding occurs among the muscles along the interior of the thighs or
along the perineum, care should be taken to discuss the problem furthermore and to
use other techniques such as breathing exercises. Over several cessions, the woman
is taught how to relax her pelvic muscles after voluntary tightening for 3 to 4
seconds, and then let go. The contrast between deliberate, intense voluntary
muscle constriction and the unavoidable degree of relative relaxation that occurs
when the woman is no longer straining to hold her pelvic muscles in contraction is
the simplest and most effective way of providing an active means for the woman to
gain a degree of pelvic relaxation. The gynaecologist, with the consent of the
patient, gently and slowly introduces the well lubricated dilator No. 1 into the
introitus just as his finger is withdrawn with a slight posterior pressure. The dilator
is inserted at a slight angle, with its tip aimed toward the coccyx: and it is
important to move the dilator very slowly and gently.
Ii
Figure 34. Plastic clilators used in the treatment of vaginismus. The dilators (from
smallest to largest) are nos. l. l%, 2, 3, 4 and 5.
120
Depending on the severity of vaginismus, the emotional state of the woman
and the ease with which it is able to insert the No.l dilator, the procedure is
repeated by herself or by the physician leaving the dilators intravaginally for l0
to 15 minutes. More than 90 percent of the time, the woman is able to accomplish
intravaginal insertion of the dilators easily, this procedure is then repeated several
times to allow her to gain confidence and experience. Needless to say any pelvic
pathologic condition that is detected should be appropriately treated and by the
lllllt! UIU WUlllllll IU UUIU lU IIIUUH lllt! NU.ll UlllllUl' UUllllUllllUI}’ !lllU !§!UllllllQ lllhl
the husband is having reasonably nonnal erective function, the couple is able to
make the transition to coitus. The female superior position is always suggested
for this purpose to allow the woman the greatest degree of freedom of motion and
control. She is instructed to insert the penis just as she has been doing with the
vaginal dilators; including the use of an artificial lubricant applied to the penis if
she wishes. i
Necessarily, particular issues related to either the etiology of the
vaginisrnus or to marital discord, negative sexual attitudes, poor self esteem or
similar factors must be dealt with during the course of treatment since it is not a
simple mechanical process of dilatation. With this type of combined approach,
vaginismus can be reversed in all motivated patients except those who have an
irreversible organic pathological condition underlying the problem.
121
SEXUALITY AND
FEMALE CIRCUMCISION
(FEMALE GENITAL MUTILATION)
• Terminology and History.
• Immediate and Delayed Complications.
• Sexological analysis.
• l\Iedical ()pinion.
• Anatomical and Physiological Sexual Dysfunctions.
SEXUALITY AND FEMALE CIRCUMCISION
The term "female circumcislon" is confusing, because it is often applied
to a wide variety of female genital surgeries. Originally, anthropologists
categorized a number of different clitoral operations perfomied in primitive
societies under the umbrella term, female circumcision. It is important therefore
to define tht term accurateiy. As defined medicaily, female circamcision is
similar to its maie counterpart and when it involves cutting off all or pzgrt of the
clitoral foreskin also called prepuce or hood. This surgery is employed by very
few Third World societies and is called female circumcision (Fig. 35).
Terminology · ·
Far more often in the Third World especially in Africa and the Middle
East, when the clitoral foreskin is removed part or all ofthe clitoris is also cut off.
This is called clitoridectomy or excision. ln many underdeveloped countries, as
an obligatory, religious or puberty rituals clitoridectomy is further extended to
include the cutting away of part or all ofthe small or large labia. The most drastic
operation includes all ofthe above plus sewing up the genital area (lntibulation).
This is known also as (Pharaonic circumcision). The extent of the surgery
involved varies from country to country and from one ethnic group to another
within a given country. Their net effect and aim is the reduction or suppression of
the sexual pleasure ofthese future women !...
Types of surgery
The following list gives the medical term for each surgical procedure:
• Cutting of all or part ofthe clitoral foreskin = circumcision.
• Cutting off part of the clitoris = clitoridotomy.
• Cutting off all ofthe clitoris = clitoridectomy.
• Cutting off part of the labia = partial vulvectomy.
• Cutting offthe entire labia = complete vulvectomy.
• Cutting off all the external genitalia and suture it = lnfibulation.
History
As in the case of male circumcision, no one knows where, when, how or
why the various female surgeries began. They were known in antiquity and
according to some researchers and folklore, may even predate male circumcision.
Speculation as to the origin of and reasons for this primitive genital surgery is
rather fruitless. Clitoral surgery has been employed for hundreds if not thousands
of years. lt has been estimated that at the present time there are around 160
million women who have undergone clitoridectomy in Africa alone, and in
dozens of other places throughout the worlds.! (WHO report).
122
_ ai v'
V Mompubis
\ `/, • r . ` I I
( l Qi Q "‘» ·r'¢·‘r» r`/·~r Prepucc
it/i ji, {__; `· ` ·(< tf, it Clitoris
lips (Spl‘€3d)
/ I', l, yr l #,J/·-·Urethra| opening
/ nj _. rx Sl<enesgland
V lp) A S i Q} -_?1i—,;‘i r l) Minor lips (spread)
_ 3 . ` |ntr0itus(vagmz·1l opening)
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, `g_5;// //,r x
rr .' X i /» [ \
4// 7 ( \\_ 1 .
I y §··—" ‘‘‘*’ r —*··Anus;_ _ /

KJ rows
Figure 35. Normal external genitals ofthe female
Proponents of clitoridectomy present the surgery in a positive light; rlomo
Kenyatta, the late western—trained leader of Kenya, not only encouraged the
surgery but also wrote of it in such glowing terms in his thesis at the London
School of Economics described the operation (l962):
[The operator". takes out .... the operating razor .... and in quick
movements, with the efliciency of a Harley Street surgeon proceeds .... with
a stroke .... . cut off the clitoris].
ln l972, a French physician provided a very different picture of pharaonic
circumcision as currently practiced in Somalia. (lt takes a strong stomach even to
read the description)...
"Af`ter separating the outer and inner lips (labia maiora and labia rninora)
with her fingers, the old woman (Daya`) attaches them with large thorns onto the
flesh of each thigh. With her kitchen knife the woman then pierces and slices
open the hood of the clitoris and then begins to cut it out. While another woman
wipes off the blood with a rag, the woman digs with her fingernail a hole the
123
length of the clitoris to detach and pull out that organ. The little girl screams in
extreme pain, but no one pays the slightest attention. The operator finishes thejob
by entirely pulling out the clitoris and then cuts it to the bone with the kitchen
knife. Her helpers again wipe of`f the spurting blood with a rag. The woman then
lifts up the skin that is left with her thumb and index finger to remove the
remaining fiesh. She then digs a deep hole amidst the gushing blood. The
neighbor women who take part in the operation then plunge their fingers into the
bloody hole to verify that every remnant of the clitoris is removed" .....
Thousands of women and girls have died or sustained serious injuries or
infections as a result of such wild surgery...
The photographer (a Greek lady), of my movie film entitled: "Female
Circumcision in Egypt", fainted all of a sudden while photographing the
circumcision procedures performed by a native Daya in Ain Shams district near
Cairo, l972 .... ln Minneapolis, U.S.A. (l982), my film was shown in the
"lnternational congress on family sexuality", it is sad to report that quite a
number of the feminine audience left the show room unable to continue watching
the cruel operations presented in my film.
Proponents of clitoridectomy established a medical rationale, describing a
non—excised woman as unclean; the clitoris is said to interfere with menstruation,
childbirth, and impregnation, and is considered the cause of impotence in males!.
In sum the clitoris is dirty, dangerous and disgusting; by far, the most important
"medical" reason for clitoridectomy is the claim that the clitorises of the Third
World women if not cut off, will grow to monumental proportions... One early
traveler in Ethiopia, (where infibulation is practiced widely) described the clitoris
in its natural state as being as, "|ong as a goose’s neck"l. Few carried this
exaggeration to that extreme. ..
What man in his right mind would want to marry a dirty, ugly woman who
was sterile and who would make him impotent'?. Jomo Kenyatta wrote that “No
Kikuyu man would think of marrying an uncircurncised girl". l was not surprised
to know of this statement, because many of our Egyptian or Sudanese men would
equally say the same up till this moment". But Kenyatta and many others added
another important aspect, clitoridectomy was said to subdue sexual urges and
make the woman more liiithful. The reduction of female sexuality was, and is an
important element in the acceptance of female circumcision in our society and in
underdeveloped countries as well.
There is no doubt that female circumcision and various clitoridectomy
procedures described continue to be practiced up till now, because it is said that
lslam "tolerates female circumcision". which ofcourse is not true. Up till the year
I977, 90% of Somalian teenagers had undergone pharaonic circumcision
including infibulation. Many Westerners have been shocked by this mutilation of
women and have protested against the practice. Recently, women in many parts
ofthe world including Egypt have protested this ritual. They are struggling
against these cruel practices in their own countries and in the international arena.
124
The elimination of (centuries-old) practices, especially those that are degrading to
women, is often a difficult and protracted effort. lt is interesting to note
historically that there are some similarities between African clitoridectomy and
Jewish circumcision practices. ln Ethiopia for example, it is startling to note that
{lll} UpLlllllUll Ull glll§ IQ llUllUllll!ll Uh lllé eighth day while in some areas of
Nigeria the clitoris isinicked, i.e. incised or notched not ablated, only to draw
blood following a Jewish custom. ln several countries, the infant is named after
the excision ceremony. Whether these similarities are simply coincidences or a
reflection ofa common origin is unknown.
The VVorld Health Organization (W.H.().) had a seminar on
clitoridectomy and intibulation in Khartoum, Sudan in 1979, realizing tlte
dangers of the operations and its complications, under the title "Traditional
Practices Affecting the Health of Women". Most of the male delegates wanted
the circumcision practices and argued that the surgery should be done in
hospitals. The women delegates were adamant in calling for total discontinuance
of the practices. Although the attendance was sparse (l0 countries) only,
resolutions were passed calling for the abolition of all female genital mutilation.
This does not mean that such surgeries will cease forthwith, but it is at least the
first step by the (W.l·l.O.) to eliminate the practices. Many groups who practice
female circumcision believe it to be analogous to male circumcision, but this is
far from the case.
ln l994, the (ICPl)) was held in Cairo (International Congress for
Population and Development); two related hot issues were discussed and
documented, namely; female circumcision, agreed to be named Female Genital
Mutilation (FGM) and sex education as well as reproductive health The mm-
Qovetntnenlal organizations (NGOs) joined hands to gain national and
international support for their efforts to deal with these two major problems to
protect our young girls and women ofthe future against this discrimination.
Reasons given
Excision is practiced to reduce or extinguish sexual sensitivity in girls, it is
traditionally performed just before marriage "in order to preserve the family" and
assure faithfulness ot wives in Sub—Saharan Africa. While in Egypt, Sudan,
Ethiopia and Somalia the age of operation is variable, from few days after birth
till the age of puberty Moral behavior of females is often given as a reason. The
operation traditionally was connected with puberty rites, however there are many
puberty rites that do not include excision. Most Africans who practice these
operations believe that excision is a custom decreed by the ancestors, therefore it
must be complied with. Most often men refuse to marry girls who are not excised.
Since marriage is still the only usual career for a woman in most parts of Africa,
the operations continue. Excision is also perceived as a way to increase fertility
and the wish ofmost women is to have as many children as possible. lt is widely
*~c'*·=·’¤t‘ in Mali und till mtr util l`ll|lLll, lll.ll lll! Ullllllls Ulllllllllél llld imply
maleness. while the prepuce ofthe penis means temalenessl. Hence, both have to
125
be removed before a person can be accepted as an adult in his or her proper sex in
society.
Excision operations are at present practiced in the modem sector in
addition to the backward villages or towns including the cities throughout East
and West Africa. Fathers who make the decisions insist on the operations, as they .
believe that their daughters will not be marriageable if they are not operated
upon. It is also believed that a girl who is not operated will run wild and disgrace
her family. The wrong belief among both Moslems and Christians, that their
religions favor excision is another element that bless and encourage the
performance of this practice, no wonder, the mildest procedure which is called
"Sunna or traditional circumcision", involves removal of the prepuce and tip of
the clitoris or only part of it.
Geographic distribution (Fig. 36)
Excision is practiced in a broad area all across Africa parallel to the
Equator; from Egypt, Ethiopia and Somalia, Kenya and Tanzania in East Africa
to the West African Coast, from Sierra Leone to Mauritania, and in all countries
in between including Nigeria.
Infibulation is practiced on all females, almost without exception in all of
Somalia and whenever ethnic Somalis live (Ethiopia and Kenya). The operation
is performed on much younger children than excision, usually on four to eight
year old girls long before puberty with no ritual ceremonies. ln the Sudan,
infibulation traditionally is called "Tahur", similar to the Arabic word applied
among Egyptians which means cleansing or purity. lt is performed at a family
and neighborhood gathering of women in the most populous areas of the Sudan,
including the capital Khartoum and Umdurman, all along the Nile valley. lt is
interesting to mention that the knife used often by the operator is called "The
knife of honour"...
ln West Africa, infibulation is documented at the present time in Mali by
several Moslem population groups, though the practice goés back to pre-Moslenr
times. Intentional infibulation is said to be decreasing in'Mali, a medical source
states that infibulation is also practiced in Northern Nigeria (Moslem area). A
country by country estimate adds up to more than l60 million women
circumcised already, even though the figures of several countries in Central
Africa are not yet available and therefore are not included. For instance, Nigeria
has well over 100 million people if only half of the women are·operated, this
would mean 25 million females in Nigeria alone. Documentation shows that the
majority of the female population in most Nigerian states are excised ln Sudan,
Upper Volta, Mali, Kenya and Ethiopia, more than three—quarters· of the female
population are operated upon, this means many millions more. Almost all of the
female inhabitants of Somalia, more than l l.5 million women are infibulated. ln
Egypt, one ofthe most populous countries in Africa, about 93% of the group,of
women investigated were circumcised, the percentage reported here holds goorl
126
with other statistics documented by different investigators. lt is estimated that
about half ofthe Egyptian girls continue to be excised up till now. No estimate
can be made at present of the actual number of women and children operated
- upon in Indonesia and Malaysia, nor how many women and girls are involved in
the South of the Arab Peninsula and along the Persian Gulf. Latest national
demographic study reported in 1995 that 97% of women in Egypt were excised
between the ages of l5-49 yearsln.
itt‘ `%s§
-» e ` t`“` ’

t. - Y
.lt..·-an ~*“—*
l-gel? ° ' ` UJ_,·>,;
M .. .
A _ * Ry 4 gr W
»‘··~~»‘ W tcccc t \

E
~atr
·¤** ,

liigure 36. African countries performing (FGM) (ln white).

127
Complications of the Operation
Until quite recently, these variable mutilating operations were ignored by
the medical profession and by governments of the countries in question, even in
countries which had maternal and child health government entities. Concerning
the damage to the physical health and psychological well being of women and
young girls who are operated upon usually by non-medical personnel, who
perform the surgery with non or limited surgical experience is severe and
profound.
I. Immediate complications
- Primary fatalities resulting from bleeding especially when the
haemorrhage is uncontrolled, quite common due to severing of the dorsal artery
of the clitoris. Many young girls must have lost their lives due to the bleeding,
unless transferred to a blood transfusion center or hospital.
— The shock sustained during the surgery and after is profound because the
little girl is operated upon without anaesthesia or even analgesia. She is usually
overpowered, her screaming and agony are neglected and if the haemorrhage is
severe the state of shock is paramount. Except for very few lucky girls who are
operated upon by proper medical staff and under general anaesthesia, the fact is
that the majority or nearly all of the young girls are operated upon without any
anaesthesia.
— Pain is felt severely, because the clitoris and the labia minora are among
the most sensitive parts of the genital external organs; when excised usually by
crude and primitive instruments such as an old razor blade, kitchen knife or even
a piece of glass, the trauma is immense!. Recognizing the potential dangers of
pain and trauma only recently, the statements made repeatedly during the past
IOO years that circumcision pain is of minor significance and that circumcision
trauma is of no consequence, are to say the least of great medical concem
nowadays.
— With increasing attention to the knowledge of sexual development.
evidence has emerged that both circumcision pain and the psychological trauma
inflicted may well be matters of grave effect in later development of these
unfortunate girls.
— Infection of the wound area is quite cormnon, since no proper
sterilization or aseptic surgical teclmique is used, Speticaemia is reported
sometimes, as well as fatal cases of tetanus and marluromycosis. Ascending
infection apart from the local sepsis do occur in a number of cases leading to
undiagnosed chronic cases of adnexitis, with possible tubal damage which may
lt.1UlUlllll!llllll}l lll lllll llllllll!.
128
— Acute retention of urine do happen because of the buming sensation
when urinating, trauma to the adjacent tissues, reactionarv oedema and early
II__
llll8CllOll§ all ll’\eSe l8Cl0rS predlspose to such a common complication.
— Accidental injury to the genital tract is encountered sometimes because
the girl being non-anaesthetized struggles powerfully to run away from this
ordeal. Trauma is reported as a result sometimes to the urethra, anus, vulva and
vaginal introitus with additional complications especially ifthe operating woman
is weak sighted or not skilful. Bartholin cysts are reported when the glands duct
is injured or due to local infection.
— ln some areas of West Africa, the operator (possibly a quack or an old
native woman), throw dust, sand or dirt on the wound area to stop the bleeding if
it is troublesome!. Ashes, pulverized animal faeces, powdered Coffee granules are
sometimes used to pack the raw area of the wound in order to control the
bleeding... with evident local infection ofthe wound.
- The local treatment applied to the wound in these backward communities
increases the damage and risks of the operation and may lead to failure of the
wound to heal altogether.
— A number of cases were reported in the medical literature, including few
cases discovered and reported by myself in the infertility clinic, Ain Shams
Hospitals, where a small penis was excised wrongly, because it was mistaken
for a large clitoris by an ignorant operator. An unfortunate mistake with
subsequent dramatic sex role confusion in adulthood played by the victim".
II. Delayed complications
That female circumcision entails risk is not a debatable question, it is a
l`HCl. ADV Sllrglrzll prrwnrlutrnj nn mnttnr kn", Fimpli am-Ting -H-ith JUHIL
minimal to be sure- but risk nevertheless. that is very true when performed in
hospital and performed by a qualified surgeon. But because this female genital
mutilation is nearly always operated by non-medical women (Daya), barbers,
quacks and many others a wide variety of serious complications are related and
medically documented.
Long range physical complications
I. Gynaecological complications
— Chronic urinary infections are common among women suffering from
the severe types of genital mutilation, such as iniibulation and excision
circumcision, tlysuria is a frequent complaint.
- Vaginal calculi are formed sometimes in the posterior fornix as a result
of the obstruction ofthe proper flow of the stream of urine and retention of part
oftliis urine in the vagina clue to the abnomtal scar tissue formed.
129
- Chronic pelvic inflammatory disease was reported among a good
number of females who were unfortunate to sustain a spread of infection from the
site of wound due to the absence of proper medical care.
- Labial adhesions and vulval scarring are frequently met with, following
most of the circumcision operations due to infection or as a result of a clumsy
technique.
- Dyspareunia (painful intercourse) is a frequent complication when
penetration is performed during coitus among these women.
- Painful entangled neuroma in the scar tissue. _
- Keloid and scar formation are common among the drastic types of genital
mutilation such as Sudanese circumcision, a painful scar is a common cause of
dyspareunia as well as a tight introitus if excision is complicated or severe.
- Inclusion cysts of the clitoris are often the result of clitoridectomy or
clitoridotomy, the cysts vary in size, sometimes getting infected and may reach a
large disiiguring size that require surgical interference.
— Vaginismus is reported by gynaecologists, often among females who
sustained psychological and / or organic complications ofthe operation.
- Sometimes performing a simple vaginal examination is a painful
procedure to some circumcised patients, while it is impossible even to put a
vaginal speculum when needed due to excessive scarring.
- Catheterization of the urinary bladder is so difficult sometimes
especially during labour. The changes in the anatomy of genital area produced by
the scar tissue and malfomiations are numerous and disiiguring.
- Haematocolpos and haematometra were reported by gynaecologists as
a result of closure ofthe vaginal introitus in severe cases of the operation due to
scar tissue formation.
ll. Obstetrical complications
- Difficulties in child-birth are often met with, causing damage to both
the mother and the baby, especially reported among primiparas. ln cases of
. complicated excision and inlibulation, the following complications are described;
delay in labour and a prolonged second stage because the hard circumcision scar.
tissue usually fails to dilate and as such, holds the head of the baby back delaying
the labour.
— ln cases of iniibulation, unassisted child-birth is nearly impossible, if
there is no one at hand to cut the infibulation scar tissue in time. some cases were
130
reported where the head ruptured out of the anal opening!. leading to complete
perlneal tear. ..
— Circumcision scar tissue easily tears during prolonged labour, unless
surgical interference is introduced, causing extensive perineal tears and
bleeding with possible injury to the urethra.
- Cases of obstructed labour are reported and uterine inertia sometimes
lead to brain damage of the foetus or to the loss of baby completely.
— Formation of vesico-vaginal or recto·vaginal tistulae are known to
result due to obstructed labour, with consequent urine incontinence. This mishap
makes the women outcasts to their husbands and families even their society, as
they are continuously dribbling urine or faeces.
Ill. Psychological complications
» The psychological effects of sexual castration often done at a very young
age, on the personality development of a female has been quite ignored in the
past. Yet, the permanent deprivation ofa human being`s most powerful instinct,
while forcing her to serve the sexual satisfaction of her husband must have
adverse permanent psychological results.
— An inferiority complex or mutilation complex due to the actual loss of
part of their external genitalia is found among some of the educated women and
those of the high socio—econornic group who were subjected to the traumas of
these operations while they were young and helpless. They actually admit feeling
inferior to women who were not circurncised.
— The effects of the excruciating pain inflicted during the circumcision
PFOCESS to which often very young girls are subjected by their own families or in
Other words, by those they love and trust have to date been quite ignored.
— The harmful effects of the genital trauma; of fear, the bleeding, thc
extreme pain and prolonged sufferings in the genital area have been investigated
recently by many authors, with no doubt it was found that it did create deep
psychological wounds as well as the visible physical ones.
- Severe traumatic psychological damage occurs often clue to sexual
violence and physical assault during the forcible intercourse, to which very
young brides are subjected to, by some husbands who have acquired their `
services in return for a biidcpriccn. Many cases of bleeding young brides with
their genitalia torn apart as a result of the sexual attentions of their clumsy
husbands are recorded in Ethiopia and Nigeria. Some suicidal attempts by young
women. unable to cope with the ordeal of painful intercourse and childbirth, have
been reported in Upper Volta medical literature.
131
— Depression and psychotic disorders were reported among some women
during adulthood especially if they are suffering from chronic ¤¤¤-»¤.·.r.,..i
|I
§éXll2l l€l'lSlOn, these conditions may lead to social and marriage problems.
— An increased rate of marital disruption, family quarrels and divorce,
especially among the low socio-economic group of couples investigated was
documented recently.
- Performance anxiety was reported among circumcised females who
were afraid of being unfit and handicapped sexually to cope with their husband`s
male sexual demands.
— The presents and money given to the young girls by their parents or
relatives during the celebrations and festivities performed on the occasion cannot
and would not erase the horrors of being overpowered and the agony of having to
watch the cutting knives, the blood and the feelings of severe pain and sometimes
the unavoidable complications of the circumcision.
— The effects of the psychological trauma due to this operation may last for
life among many women who lose for good the faith and trust they have given
to their beloved when they were young, associating hatred and painful
memories with their parents.
, - Submission to male domination during the girl’s childhood when
circumcision is enforced upon them, is another drawback ofthe operation, since it
may lead to non harmony in the marriage relations of a husband and wife
(male and female gender struggle l).
— The syndrome of "non·resolved sexual tension" with its morbid
psychological and physical complications is often met with among circumcised
females during gynaecological medical practice.
IV. Long range sexual complications
— Many coital or sexual dysfunctions are reported, especially when drastic
circumcision operatiom are practiced, for example when infibulation and
Sudanese operations are done. Often the bride must be cut open before penile
p€‘n€lT3IlOn can lake place, which causes further injury and more added
infections. lt is reported that the bride—groom performs such cutting with the tip
of his sharp dagger on the wedding night! And then indulges in forcible repeated
coitus to keep the scar wide open... the least effect of this miserable coitus on
the bride is devastating sexually and psychologically harmful. ..
— Severe excision forms of circumcision can also result in an almost
complete closure of the vaginal opening by the adherence ofthe excision wound,
this is reported in \wVest Africa and elsewhere in countries uhcre intibulatlon is not
performed with resultant apareunia rarely and oftenly dyspareunia.
132
- Anorgasmia amounts to nearly 51% of the women investigated; as a
matter of fact in some female societies, it was shocking to discover that they are
not aware that sexual intercourse can be pleasurable for them. .. lt is important to
. record here that anorgasmia in non—circumcised females is only 9%.
- Anal intercourse was reported among some couples, knowingly or
accidentally, because the usual normal vaginal intercourse was not feasible due to
a tight vaginal opening, painful vulval scarring, and labial adhesions.
— Vaginismus was encountered among women who had suffered a past
painful trauma due to a complicated operation.
- Circumcised women were found to indulge in coitus less frequently as
compared with non-circurncised women and only to please the husband,
submitting to his sexual advances in order to get pregnant fast (population
explosion among low socioeconomic group of women) or giving false excuses to
avoid the sexual act altogether leading to frank sexual aversion sometimes.
— Males are encouraged to addiction of drugs such as Hashish and
alcohol, etc. on the assumption that it would prolong the coital act and delay
orgasmic ejaculation in order to please their frigid wives.
- Adultery is reported by some authors as another sequalae of female
circumcision, especially among the low socio·economic group of married
couples.
Recent research in sexology
The vital role ofthe clitoris to produce the female orgasm in the sexually
stimulated female was established through the live laboratory experiments in
female sexological behavior which was recently documented. The final
conclusion is that the clitoris is the "Conductor and transmitter" of erotic
sensations; while the orgasmic platform comes next in culminating the orgasrnic
release of neuromuscular tension. This orgasm is triggered mainly by clitoral
stimulation either by direct stimulation ofthe clitoris or by indirect stimulation of
this organ via the clitoral hood tension mechanism exerted during coitus. Masters
research confirmed that 60-70% of women investigated sexually require manual
clitoral stimulation during coitus in order to reach orgasm. While Prof. Hunt
statistics estimated that the female astride position i.e. face to face woman above
position is preferred now by nearly 75% of females investigated. Because in this
position, maximum pressure is exerted by the pubic bone directly on the clitoris.
At the same time, clitoral hood traction occurs with each thrust of the erect
phallus exerting tension on the labia rninora which is transmitted to the fold of
skin (hood) that cradles the clitoris providing as such tactile stimulation to the
shalt and glans clitoris (Kaplan. Sherly and Johnson). Incidentally, (Miller &
Leif) research about female masturbation techniques reported that orgasm is
triggeretl in most females by strol<ing the clitoral shaft laterally or by simply
133
 rubbing the whole vulval area with one hand. Some females apply the v
(sexual aid) superficially on their vulva to achieve sex stimulation max
ultimately to get orgasmic release.

Medical conclusion

Certainly, the medical profession bears responsibility to accept fema

circumcision as a "national cultural trait", as much as do lay people. W
medical evidence at hand to disprove any prophylactic benefits, on th
is proved that there are many dangers and unfortunate complications o
surgery. The medical profession and other interested parties have responsib
stop and abolish this practice. The pretense of neutrality is a negative stan
because it is a real hazard to the health and well·being of millions of y
no wonder, the World Health Organization in 1979, recognized female
circumcision as a health issue impinging upon the lives of many millions of
women and truly described it later as Female Genital Mutilation (FGM).
lt is worth mentioning here the starking recent evidence which was p
beyond doubt of how valuable and important the role played by the exte
genitalia, namely, the clitoris and labia minora during coitus in order to achieve
successful orgasm; with a resultant pleasurable satisfying sexual and emotional
encounter between a husband and wife; to convince forever the public in E
stop and abolish their awful practice of female circumcision better named female
genital mutilation (FGM). The minister of Health and Population issued a
in l996 prohibiting any form of female circumcision by medical or non—medic
personnel. It is a step on the road; but my strongest belief is that sex education
the public is the answer for this very old harmful problem because I was
compaining against its dangers since nearly 30 years.
Comment

ln the final analysis, scientifically and medically, l confront those pe

(medical and non-medical) who are in favor of female circumcision on the
assumption that the operation is done to reduce and lessen the sexual urge in
and in our future wives. l present therefore the embryology of the genit
in the following diagram (well established since many years), to show them
and for all that to perform excision on females is equal to the excision of
penis and scrotum in males l... Since the external sex organs in both sexes
develop embryologically from one and the same organ namely; the
tubercle at around the sixth week of gestation, differentiating later in utero
male and female external sex organs according to the chromosomal patte
foetus. As such, l believe it is fair enough to do the same, i.e. excision of the
penis and scrotum of our young males in order to lessen and reduce their sexu
urge l... What a mockery ..., truly those proponents of female genital mutilation
are following the same ridiculous old sex taboo proclaiming: "Sex is for the `
mans pleasure and not for the woman dating 300 years ago. Evidently
an old taboo is an insult to both genders in our eternal human sexuality.
134
 Glams area

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135
 Anatomical And Physiological Sexual Dysfunctions
Among Female Genital Mutilation

Unless we repeat the physiological responses ofthe sexually stimulated

female reported earlier in chapter (4); the reader will not be able to grasp the full
medical and sexological facts afflicting our circumcised females. Since the
publication of Masters brilliant sexual research (1979), among non circumcised
females, which was confirmed later by Johnson and Kaplan, it was revealed that
the organic and physical etiology of female anorgasmia is among the following
causes:

l. Any condition that affects the nerve supply to the female genitalia.
2. Any condition that endangers the vascular blood supply and integrity of
the female genital organs.
3. Extensive surgical operations traumatizing the external female sexual
organs.

Circumcised females are subjected to many varieties ofthe following surgical

procedures: l) Clitoridotomy which is partial excision of the clitoris. 2)
Clitoridectomy entails complete excision ofthe clitoris. 3) Amputation of both
the clitoris and labia minora is termed partial vulvectomy. These three
different operations destroy for ever the nerve supply to the external genitals
as well as their blood supply; with an expected result ofa high percentage of
coital anorgasmia as compared with the normal non circumcised females.

Again the human female has been endowed with three primary erogenons
zones before exposing her to the operation of sex mutilation; compared with
the male one primary erogenous zone only, namely the penis. Through FGM
procedures she loses the clitoris and /or the labia minora as well; that is to say
two thirds of her primary erogenous zones, while she is left only with the
vaginal orgasrnic platform (the third primary erogenous zone). This orgasmic
platform develops only after successful sexual stimulation during the plateau
phase ofthe sexually stimulated female.

As such these handicapped females have missed the first two most important
primary erogenous zones, and if they achieve the vaginal orgasmic platfonn
and I repeat il`, they may not have a successful orgasmic coital release.

One of the most established principles in the entire field of human

sexuality is the fact that pre—coital petting, (efiicient and not clumsy), is a must to
achieve natural vaginal lubrication (through a process of transudation), for the
possible pleasurable penile penetration by the husband. Sexologists know for sure
that sexual foreplay as well as “sensate focus" reported in l966 by Masters and
Johnson, entails manual (tactile) clitoral stimulation (light or deep), so much so,
that 60-70% of American females could only reach orgasm during coitus unless
manual clitoral stimulation is performed.

136
 • Now, we can realise how defective and unfortunate are circumcised females
because they have lost forever these vital extemal sex organs which were
created for this one and single vital goal, namely (sexual foreplay).
Incidentally, one of the most common causes of dyspareunia (painful
intercourse) is a relatively dry vagina (deficient lubrication) and inefficient
clumsy precoital petting.

• The actual fact that circumcised females are slow to respond to sex
stimulation, advanced by their hasty husbands, is another proof of the d
they received physically at circumcision, as well as the immense mult
everlasting psychological traumas they may have had when operated upon at
such an early young age. Masters reported the fact that non circumcised
females respond to sex stimulation as quick as males and that there is no such
fallacy that females are slow in their sexual response. As a matter of fact, there
were documented cases of many females who became orgasmic during their
experiments after only 2()~3O seconds from coital penetration !... Kinzey et al.
reported as early as 1952: "That there is a critical problem for human males
since some women require IO-I5 minutes or longer of intense sexual
stimulation in order to reach orgasm “Pomeroy and Martin reported later,
confirming Kinzy`s statement that, "75% of the men they studied during
coitus ejaculated within 3 minutes of vaginal containment after peuetration"
We must not forget that the above statements are related to non circumcised
females; now we can see why many males use Marijuana in this part of the
world on the assumption that it helps to delay ejaculation in order to be able to
satisfy their frigid wives.

• The signs and symptoms of the "Non resolved sexual tension syndrome"
reported by Masters in l979, were among non circumcised females who
practice: coitus interruptus, teasers love, long exhaustive coitus and among
prostitutes. The severity of this syndrome may be mild or severe according to
its chronicity. These same signs and symptoms of non orgasmic release
complained of are: I) Bilateral adnexal pain. 2) Low backache. 3) Low
abdominal uterine pain. These complaints were long neglected and
undiagnosed by gynaecologists and they are nearly identical among our
circumcised females due to the physically defective physiological and sexua
response of chronic non resolved sexual tension, namely, coital anorgasmia.

The normal healthy coital orgasm denotes the sudden release of great
neuromuscular tension, as well as the powerful involuntary rhythmic contractions
of the fundus of the uterus, the orgasmic platform and the anus as well;
simultaneously at the speed of 0.8 of a second. These orgasmic powerful
contractions. amounting from three to fifteen contractions, pump the
vasocongested accumulated blood from the genital organs back to the state of
normality during the resolution phase, followed by relaxation and immense
satisfaction. Chronic anorgasrnia which means, repeated non orgasmic, (no
muscular contractions), with subsequent residual neuromuscular tension as well
as chronic vasocongestion ruay lead to varicosity and even a frank varicocele.
137
• Manifestations of chronic anorgasmia, whether mild or severe are reported by
the medical profession as the following complaints: palpitations, insomnia,
dyspepsia, early fatigue, anxiety attacks, depression, excessive worrying,
emotional tantrums; last but not least, the famous spastic colon. Sexologically
these females may present with: vaginismus (unconsumated marriage),
dyspareunia, protective frigidity, lacking orgasmic capacity, sexual aversion
and may be refusing coitus altogether (apareunia).

• The most important discovery reported by Johnson related to our subject was
the vital role played by the clitoral hood (prepuce) during the female sexual
response cycle. For those people who advocate the performance of proper
female circumcision equivalent to the male operation i.e partial removal of the
prepuce to minimize FGM complications, I present the following facts proved
by Johnson. During the excitement phase the clitoris gets erect and emerges
from under the prepuce, while later in the plateau phase, this erect clitoris gets
angulated and rotates l80° ventrally and retracts under its clitoral hood
(prepuce) against the bony symphysis pubis. ln such a safe position it is well
protected and completely covered by its prepuce to avoid any direct touch,
because all females reported that direct touch at this stage of sexual
excitement causes pain and discomfort especially ifthe area is dry. The natural
secretions of the Apocrine glands in the prepuce keeps this area well
lubricated; now we can see for sure the values and the importance of the
clitoral hood and its crucial role during this phase ofthe female sexual
response cycle.

138
SEXUAL PERFORMANCE IN DIABETES

Male sexual dysfunctions.

Female sexual dysfunctions.
 SEXUAL PERFORMANCE IN DIABETES

Male Sexual Dysfunctions

I. IMPOTENCE

For almost two hundred years, it has been recognized that diabetes mellitus
is frequently associated with impotence. Estimates of the frequency of impote
among men with diabetes have usually ranged from 40 to 60 percent,
approximately one out of every two men with clinically apparent diabetes
sexually dysfunctional. The significance of this fact is more apparent when it is
realized that there are at least few million men with diabetes in the U.S.A.— t
nearly 50% are impotent as a result of the complications ofthis metabolic disorder,
now how many diabetic men are suffering in Egypt ?.. The minister of Health and
Population anounced recently that 5% of the Egyptians are diabetics .

The impotence associated with diabetes can occur at any age, but with a
prevalence rate of impotence from 50 percent in men over the age of 50 years.
This may be due in part to changes in circulation secondary to accelerated
arteriosclerosis, which occurs more noticeably in the aging diabetic population.
lower prevalence of this problem is found in diabetics in their thirties or forties,
(probably 25 to 30 percent in this age group are impotent).
Natural History

The most frequently observed and earliest manifestation is a mild to

moderate decrease in firmness of the erection, although vaginal intromission is
usually possible still. Attention to sporadic episodes of impotence or by
diminished responses to erotic stimuli during sexual activity may be recorded.
Gradual deterioration in the quality of the erection (i.e. decreased firmness), as
well as in the durability ofthe erection occurs over a period of 6 to l8 months.
The ability to ejaculate or to be aware of orgasmic sensations is not lost however,
and libido is usually unimpaired.

A Less common pattern of impotence associated with diabetes may

precede the actual diagnosis of this disorder. ln such circumstances, the
impotence is a manifestation of a general catabolic state and is typically
accompanied by other highly noticeable symptoms, such as excessive hunger
(polyphagia), excessive thirst (polydipsia), excessive urination (polyuria),
pruritus and weight loss; This form of diabetic impotence is characterized b
abrupt onset, can occur at any age, and may be marked by loss of libido. When
sufficient metabolic control is established to correct the catabolic state, the loss of
potency (as well as the alteration in libido) quickly reverses.

139
 It is now reasonably certain that the impotence of diabetes mellitus is
caused principally by diabetic neuropathy, a process of microscopic damage t
nerve tissue that occurs throughout the body of the diabetic. lnvestigators have
found that autonomic nerve fibres in the corpora covemosa of the penis show
moiphologic abnormalities of varying degrees due to the accumulation of
"polyols". These chemical substances produce segmental demyelination and
defective rnyelin synthesis, a process that results primarily from hypergly
Clinical studies revealed a much higher rate of abnormal cystometrogram
, indicating neurogenic bladder dysfunction in diabetics with impoten
men), than in nonimpotent subjects (3 of 30 men). In most reports, a high
percentage of impotent diabetic men have been found to have evidence of
peripheral neuropathy on clinical examination than age matched diabetic men
without impotence.

ln some diabetic men, macrovascular or microvascular changes result

from diabetes may be important causes of impotence. The small blood vessel
disease that produces many of the complications of diabetes, (eg. retinopath
nephropathy) is known as diabetic microangiopathy. This abnormality is
characterized by a thickening ofthe basement membranes ofcapillaries, a p
that may be due to genetic factors as well as to increased carbohydrate cont
Since the process of penile erection reflects a dynamic state of circulatory
responses, it is possible that disease involving the network of small blood vessels
in the body of the penis would result in impairment of erectile capacity.
Obviously large vessel damage such as that produced by major arteriosclerot
lesions would also affect the process of erection severely.
Evaluation

Most impotence associated with diabetes mellitus is not curable by know

methods. Above all. one should remember that impotence occurring in a man
with diabetes is not necessarily caused by the diabetes. Diabetic men who are
experiencing potency problems must be evaluated thoroughly to determine
whether or not distress is primarily psychogenic or whether it is caused b
organic process apart fiom the diabetes itself. Diabetics arejust as susceptible
others to the psychic stresses of lite, therefore causes of impotence such a
depression and anxiety should be considered. Diabetic men with impote
psychogenic will respond just as well to competent psychotherapy as nondi
men. Another significant factor is that the medications being used by the man
with diabetes may be the triggering mechanism for loss or impairment of erect
capacity. Since drng—inducecl impotence is usually reversible. when the off
pharmacologic agent is either discontinued or reduced in dosage. the progn
such instances is good.

140
 Diabetics have an increased risk for many other diseases, inclu
infection, various forms of endocrine disease (especially disorders o
and adrenal cortex) and cardiovascular disease. Since such associat
at times may be the major etiologic factor in sexual dysfunction, the p
absence of these conditions must be assessed by a careful medical h
physical examination and laboratory evaluation.
Treatment

When impotence is an early symptom of diabetes, it is usually a refle

ofetary
poor metabolic control. ln these instances, carefu
management and the use of insulin or oral hypoglycemic agent
_ frequently produce relatively rapid amelioration of the disturbed
impotence persists despite good metabolic control, consideration sh
to whether this problem is the result of anxieties, (fears of performance f
example) that may remain even though the metabolic status of the individual has
improved considerably. One should note that these anxieties may hav
about only after the beginning of sexual dysfunction, in such cases
to tell the patient that the impotence began as a manifestation of a speci
problem but is being perpetuated by the psychological reaction to t
. Brief counselling to assist in anxiety reduction, coupled with a suppo
approach to participation in sexual activity, will frequently be enough
overcome this pattern of impotence.

lf impotence is present early in the course of diabetes even when control of

the blood sugar appears good, the chances are that the prognosis for re
the sexual problem is much poorer. Nevertheless, either in this situation o
dealing with impotence that occurs years after the onset of diabetes, wh
underlying organic factors such as neuropathy. vascular disease, or hormonal
disturbances can not be identified, diabetic men will often respond
Management

ln deciding whether or not impotence in the diabetic may be amenable to

psychotherapeutic reversal. the following points may apply:
l. ls the history suggestive ofa primary organic etiology 7. lf a man ca
attain full erections with masturbation or in response to certain typ
stimuli,
psychogenic.
(e.g. reading erotic material), it is likely that the impote

2. Are there indications of significant personality or interpersonal hic

may be contributing to `the sexual dysfunction ?. The presence of dep
symptoms- including decreased libido, may signal the existence of an i
process requiring prompt therapeutic intervention. Guilt, anxiety, poor self-esteem
, phobias may also indicate a nonphysical cause for sexual disturbances. likewise
, marital conflict, financial problems and difficulties at work may
mechanisms underlying the occurrence of sexual pl”Oi7l€Hl5.
141
 3. Can evidence be found supporting the existence of ne
vascular damage as a cause of impotence?. The
sucan assessment is the monitoring or noctumal penile tumescence att
most p
pems (NPT). lf normal pattems of erection occur during slee
there is no organic basis for the impotence. Further tests include
, cystometrograms, selective arteriography, nerve conductio
oer electrophysiologic techniques. Color Dopler sonography is
e for diagnosis of vascular abnormalities; arterial or venou
obstruction causing impotence can be corrected
pp. present, there is no known medical cure for impotence due t
by
o diabetic
mae neuropathy apart from the treatment men
sexual dysfunctions.

Whenever possible, counselling should include the wife of the diab

man with impotence. Frequently impotence is mistakenly assumed to
man finds his wife less attractive or less sexually stimulating. At anoth
,paor
wife may believe that impotence reflects a homosexu
tat it indicates that he is having an affair with another female!. Such
assumptions are obviously detrimental to the must and closeness of th
e relationship, both sexually and otherwise. Givin
aoue disease and its complications is an important pre
peesexuaoptions that can be satisfying to them. When cou
avaae or the couple, rather than for the diabetic patient alone, an
opportunity for ventilation, including the expression of gui
many men, the ability to function sexually is an importa
strengtand self-esteem,
pg eecve patent managemeni recognition of this fact by
lt should be stressed by the physician, that impotence does not mea
inability to be aroused or to obtain gratification from sexual ac
more than 95 percent of impotent diabetic men are able t
forgettng the values of sexual intimacy which should be en
. (onsideration must be given also to the personal, cultu
wch are very important to the couple's sexual value syste
Surgical approaches to treatment
Recently, there has been increasing experience with the surical
gimplantation of penile prosthetic devices to provide a mo
n in the sexual problems facing men with
. or seected diabetic men, this approach may be org
extremely beneficial. lt islikely to be of most useful
. man as invested a major portion of his self—estecm in his abili
function sexuallv.

2.. exuadysfunction
Significant depression Occurs as a consequence o
is materially affecting the quality or stabil
marriage or long-term relationship.
1 12
 4. There is no major loss oflibido or impairment in the ability to ejaculate.
5. There are no medical contraindications to surgery.

It is necessary to realize whichever prosthetic device is utilized, a totally

physiologic sexual response pattem will not occur, so that some men may be
disappointed by the postsurgical results. Furthermore, because of the difficulties
of wound—healing and great susceptibility to infection that accompany diabetes
mellitus, there may be a higher rate of operative and postoperative risk associated
with this surgery than in nondiabetic patients. Nevertheless, this approach may be
warranted in carefully selected cases as a last resort.

II. RETROGRADE EJACULATION

Etiology

Retrograde ejaculation is a condition in which seminal fluid flows

backwards into the urinary bladder at the time of orgasm rather than being
propelled in a forward fashion through the distal urethra. This disorder is found in
l to 2 percent of diabetic men. The cause of the problem in these men is an
autonomic neuropathy that has progressed to the involvement ofthe neck ofthe
urinary bladder. Normally the neck ofthe bladder closes tightly during orgasm
and seminal ejaculation, with the result that pressure posterior to the prostatic
urethra is so high that the seminal fluid moves anteriorly in the direction of least
resistance. ln affected diabetic men, because the intemal sphincter of the bladder
does not close effectively, then there is more resistance in the forward direction
(resistance created normally by the walls of the urethra) and less resistance
backwards into the bladder, since the distance is considerably shorter. Serninal
fluid therefore mixes freely with the urine in the bladder and is expelled from the
body with urination. The diagnosis is established by finding numerous sperm
cells in a postcoital urine specimen after having demonstrated the absence of an
ejaculate or spermatozoa in a condom used during intercourse.
Prognosis

Diabetic men with his condition may or may not be impotent. lf they are
not impotent, there is a high probability that erective dysfunction will occur in the
future, since the underlving neuropathy is likely to worsen. However, diabetics
with retrograde ejaculation still experience orgasm, although the sensations
¤¤=·~·"*a*~* with **··· p ¤¤=¤ ge of srrtinnl fluid through thu dhtml u
, so that a man with this condition may describe an altered set of orgasmic
sensations. Rhythmic contractions ofthe prostate and seminal vesicles occur in a
normal fashion. For obvious reasons, retrograde ejaculation may be a cause of
infertility. One potential solution to this problem is to perform artificial
insemination, using an aliquot of seminal fluid and sperm cells obtained by
centrifugation of the tirst postcoital urine specimen. lf such an approach is taken,
it is advisable to alkalinize the urine prior to ejaculation, (the usual acidity
urine is spennicidal) by having the man ingest sodium bicarbonate.

143
 Female Sexual Dysfunction in Diabetes
ANORGASMIA

lt is surprising to note that, inspite of the detailed research informat

conceming impotence in diabetic men, nothing appeared in the literature
conceming females until l97l. A recent survey, comparing l25 sex
diabetic women with a group of IOO sexually active non—diabeti
subjects were between the ages of l8 and 42 years.
en e two groups in terms of: age, religion, education, marital status
menarche, incidence of dysmenorrhea, parity, frequency of coital acti
estimation of sexual interest and any history of psychiatric care. lt was not
35.2 percent ofthe diabetic women reported being compl
e preceding year, whereas only 6 percent of the nondiab
compete absence of orgasmic response during the same time period.
Natural history

The onset of orgasmic difficulties is gradual and progressive

developing over a period of six months to one year. Most typicall
onset is four to eight years after the diagnosis of diabet
ecrease in the frequency of orgasmic response, someti
notceae lessening of the intensity of orgasm. Sexual intere
dminished but a minority of women complain that it se
peros odirect sexual stimulation for them to reach high lev
wether engaged in rnasturbatory or coital activity. Vaginal lubrication is n
significantly altered in most diabetic women.

Pathogenesis

Either neuropathic or microvascular changes or both may be r

since both of these complications occur at greater rates with d
chronicity. Evidence of other autonomic nervous system impairment can be
by careful examination, it is possible that most diabetic women do not "los
capacity to be orgasmic but simply require higher levels of stimulation to s
the orgasmic reflex. Studies with a small number of diabetic women
€XpCfiCnC€d orgasmic difficulty that was overcome by the use of a vi
indicated that this may be the case. An element of pos
e greater susceptibility to infection in the vaginal area and ur
ougacute vaginitis can be extremely uncomfortable, psychologically a
well as physically, chronic infection remains
onass seems most troublesome because it produces tissue tenderness
a greater
, ysuncon
malodorous discharge, pruritus, and decreased vaginal
might be expected when accompanied by diminished libido and a
lu
higher occurrence of dyspareunia and
arupt onset, particularly in association with pregnancy. it might also be
144
Management
A detailed medical and psychosocial history supplemented by information
from the physical examination and the laboratory will provide the predominance
of psychosocial factors in the etiology compared to primary organic
components. information related to drug use, medical problems, contraceptive
and reproductive history, marital conflicts, other interpersonal difficulties, self
esteem and attitudes toward sexuality will be of assistance to formulate an
accurate diagnosis and plan of management.
`V'dglllHl |JllllUlE§ lllU§l ll! Hlllllléll lll élléllide vaginal infection since visual
inspection or microscopic examination are not sufficient. When infection i_s
diagnosed, follow—up cultures at the conclusion of a treatment regimen are
mandatory, since many infections in diabetics are resistant to treatment. Particular
care should be exercised in looking for monilial infections which are frequently
present in diabetics especially if the woman continues to complain of
dyspareunia, urethritis, cystitis, or vaginal abscesses.
The most common causes of “dyspareunia" associated with diabetes are
poor vaginal lubrication (after infection), atrophic vaginitis (estrogen-
deficient). infrequently diabetic neuritis. Poor vaginal lubrication may result
from impaired microcirculation in the vagina or chronic infection and estrogen
deficiency as well; but it should be kept in mind that this condition may also be a
side effect of the use of antihistamines.
Addison`s disease, Cushing`s syndrome, hypothyroidism, hypopituitarism,
and multiple endocrine adenomatosis occur more frequently in diabetics than in
·~~· r'*~·*r#·tirr mul minus ttmmu dncrrlcra product retinal tlysfulltlltllls, ll ll
important to consider them in the process of differential diagnosis. 'lhese diseases
generally produce decreased libido and difficulty associated with sexual arousal
in contrast to the situation in which sexual dysfunction is caused by diabetes.
Treatment
Counselling the sexually dysfunctional woman is best approached by
working with her together with her husband. Careful metabolic control of
hyperglycemia and glvcosuria will protect her against the development of
complications. Whether or not the development of neuropathy can be prevented
or at least delayed, it is clear that controlling blood sugar levels and urinary
glucose concentrations will be important in diminishing the frequency and
severity of infections that a diabetic woman will experience. The physician
should attempt to eliminate possible correctable conditions causing or shari_ng in
the causation of the sexual dysfunction, such as drug effects, infection or other
physical disease. Personality patterns or psychoneuroses recognized by the
counselor should be referred to psychotherapy.
145
The following points may be useful in the management ofcliabetic women:
1. Inability to be orgasmic does not alter a woman’s reproductive capacity.
2. Inability to be orgasmic does not mean inability to enjoy sex.
3. Limitations to orgasmic responsiveness are not necessarily due to emotional `
problems; physical factors can be the primary or sole source of this
limitation.
4. Intimacy, sharing and gratification-sexually and non—sexually-within a
relationship eg. marriage, do not depend on being orgasmic.
5. One’s femininity or attractiveness is not reduced by not being orgasmic.
6. The husband ofthe diabetic woman who is sexually dysfunctional may need
reassurance in knowing that he is not the cause ofthe problem of his wife.
146
EFFECT OF DRUGS ON
SEXUAL PERFORMANCE
• Anti-hypertensive drugs.
• Hormones.
• Psychiatric drugs.
• Tranquilizers, sedatives and hypnotics.
• Alcohol and cigarettes.
• Hashish, cocaine and heroin.
• Miscellaneous prescribed drugs and aphrodisiacs.
EFFECT OF DRUGS ON SEXUAL PERF URMANCE
A great mystique surrounds the topic of the sexual impact of
pharmacologic substances. Historically, many have pursued the search for an
aphrodisiac but have met only varying degrees of satisfaction. Although the
twentieth century has been a time of tremendous expansion of our pharmacopoeia
therapeutica, the elusive aphrodisiac has not been found. Instead. clinicians
realize that many phamiacologic agents may be potent inhibitors of sexual
function. The effects that any pharmacologic agent will have vary greatly from
person to person. This variability is due to biologic factors, such as absorption
rate, rate of metabolism, body weight, rate of excretion, dosage, duration of use,
and interaction with other drugs; and to nonbiologic factors, such as compliance
with a medication schedule and patient suggestibility.
ln most instances, the research that has been conducted regarding drug
effects on sexual response focuses on the male; clearly, this reflects the fact that it
is easier to assess sexual functioning in the male because erection and ejaculation
are more visible than lubrication and orgasm in the female.
Effect of Antihypertensive Drugs on Sexual Performance
(A ) l)lURE'I`IC AGENTS
Thiazicle diuretics
(`linical observation indicates that 5 percent of men using thiaride diuretics
on chronic basis experience disturbances of potency that are attributable to the
drug. Ejaculation is not known to be affected by diuretics. The impotcncy may be
due to the hyperglycemic effect ofthe thiazides, whereas in other cases it may be
caused by the potassium depletion (hypokalemia).
Ethacrynic acid and furosemide
Two non—tliiazide diuretics that are similar pharmacologically, have also
been observed to be associated with impotence in about 5 percent of men using
these drugs chronically. The role of hyperglycemia and hypokalemia may be
applicable to these drugs as well; so when a patient develops sexual diliiculties
because of diuretic induced hypokalemia. a trial of potassium supplementation
may produce rapid amelioration ofthe problem.
Spironolactone .
lt is a competitive antagonist of aldosterone that conserves potassium and
|l»l lla l ~ lll'll l — l rll'l~'(l'
ex n 1 s an an iiyper ensive e ec . ns t rug causes cecrease i i o, impotence,
and gynecomastia in men and menstrual irregularity and breast tenderness in
women. These elle-cts appear to be somewhat dose-dependent and reverse
[}fOlll[)ll}’ Oll C€SSllllOll of (lfllg USC, except Q}/llE‘C()lllI`lSll2’l.
147
( B ) NON-DIURETIC BLOOD PRESSURE-LOWERING AGENTS
Alpha—methyl dopa
One of the most widely employed of drugs used to treat hypertension, but
unfortunately it is also a common inhibitor of sexual function. At dosage levels
below 1.0 gm per day, decreased libido and / or impotence in l0 to l5 percent of
men, and depressed libido and / or impaired arousal occurs in a like proportion of
women. At dosage levels of 2 gm per day or more, approximately 50 percent of
persons using this drug experience significant disruptions in sexual function;
some women report loss of orgasm as well as decreased arousability, and some
men experience delayed ejaculation. The cause of these problems may relate to
both catecholamine depletion in the central nervous system and the production of
a "f`alse" neurotransmitter, which may have a direct effect on the peripheral
nerves that control the processes of erection and vaginal vasocongestion. lt was
proved that alpha—methyl dopa does not affect circulating testosterone levels in
men.
Guanethidine
Because of its antiadrenergic properties, its primary effect sexually is one
of inhibition of ejaculation in the male, which is a dose—dependent phenomenon.
At doses above 25 mg per day, approximately 50 to 60 percent of men have
retarded ejaculation or inability to ejaculate, erectile difficulties do occur too but
in a somewhat lower percentage of men.
Hydralazine
At dosages above 200 mg per day, 5 to l0 percent of men report decreased
libido and sometimes accompanied by impotence. This loss of libido may be the
result of a syndrome resembling systemic lupus erythrematosus that can develop
at high doses with this drug or it may be due to a pyridoxine deficiency that has
been described in association with the use of hydralazine.
Reserpine and other rauwollia alkaloids
These drugs deplete stores of catecholamines in many tissues, including the
brain, and produce a marked sedative effect. This sedative ef`fect can be strong
enough to lower libido indirectly, or it may be complicated-even at very low
dosages—by the occurrence of a clinically significant depression. When such a
depression occurs, a high percentage of affected patients will have sexual
dysfunction as well as depressed libido.
Propranolol
lt is a well known or beta—adrenergic agent that is used primarily in the
treatment of cardiac arrhythmias but has recently enjoyed a broader range of uses,
including the treatment of hypertension. Although some authors have claimed
that no sexual problems are attributable to the use of this drug, more recently
several instances of propranolol—induced impotence have been reported.
148
Clonidine
Current evidence indicates that l0 to 20 percent of men using this agent
experience impotence or diminished libido.
Metoprolol
Although sexual dysfunction is infrequent while using this drug, except in
those cases of patients who become depressed and subsequently sexually
affected.
Prazosin
This drug lowers blood pressure by peripheral vasodilatation and causes
impaired libido in approximately I5 percent of men and women, but impotence
occurs infrequently with this drug and it may be a useful altemative therapeutic
agent for patients experiencing sexual difficulties with other blood pressure-
lowering drugs.
(C ) GANGLIONIC BLOCKING AGENTS
Pentolinium and Mecamylamine
These drugs cause sexual problems in a large number of the patients
receiving them. Urinary retention from parasympathetic blockade may also be a
side effect of such drugs.
General Sexual Considerations in The
Management of Hypertension
Treatment of hypertension is a major public health problem, with one of
the biggest difficulties being poor patient compliance with medication programs.
This problem occurs partly because hypertension is a "silcnt" disease- people
with hypertension Often do not feel ill, and frequently the annoying side effects of
the drugs used may seem worse than the condition that requires treatment!...
Knowledge by doctors ofthe possibilities of sexual impairment as a consequence
lll UIUQ USE lllllll lll} Ulllf SIHH lUWlllll Ulfllbl llllllllillbllllllll. Till! lUllUWlll}g
recommendations are pertinent:
l. Before starting any patient on a medication program to regulate his or
her blood pressure, obtain a baseline history of sexual functioning. This history
will be important in helping to decide if subsequent reports of sexual symptoms
are drug related or not, and it will also give the patient an indication of the fact
that it is permissible to talk about sexual function.
2. Attempt to select your drug on the basis of common sense as well as
medical guidelines. For example, do not select reserpine for a patient with a past
history of depression, and do not choose guanithidine for a man who is trying to
impregnate his wife.
149
3. About the possible drugmssociated side effects, the key for a successful
prescription is having the patient realize that drug-related sexual problems, he or
she may experience are reversible.
4. When sexual symptoms arise during a patient’s use of antihp pertensive
drugs, do not assume automatically that they are a result of these drugs. lnquire
about other medications or illicit drugs the patient may be using. Be sure the
problem is not a reflection of marital difficulties, al¤ ohol use, or an intercurrent
illness. Be alert to the possibility that psychological factors underlie the sexual
dysfunction.
5. Reversal nf ser---* prelrlcmu tmociutttl wllll lllll USG ol an
antihypertensive drug can be achieved by eliminating the offending drug entirely
or by reducing the dosage ofthe drug in question.
6. Be certain to inquire about sexual problems at each f`ollow—up visit.
Such inquiry will aid in determining the dosages of particular drugs that can be
well tolerated and will be helpful in detecting sexual difficulties before they
discourage the patient from seeking or continuing treatment.
7. More careful attention to the sexual side effects of antihypertensive
drugs will surely be of assistance in helping to improve patient compliance, and
consequently to lessen the morbidity and mortality rates ofhypertension.
Effect of Hormones on the
Sexual Function
Androgens
l'.......
lliese hormones do not ordinarily increase libido or potency in men with
normal endogenous testosterone production, although in men with testosterone
deficiencies, an androgen treatment can often restore libido and potency to
baseline levels. The administration of exogenous androgens suppresses the
hypothalamic—pituitary—gonadal axis in men, so that testicular atrophy
accompanied by severe depression of spermatogenesis may result from the use of
moderate or high androgen doses on a chronic basis. Since some ofthe androgens
in the circulation of the male are metabolized to estrogens, gynecomastia may
result from the use of exogenous androgens for a long period. Prostatic
hypertrophy and possible exacerbation of prostatic canccr are also risks
associated with androgen use.
ln women. high doses of androgen increase libido, but this effect is limited
by the side effects that accompany its use. llirsutism, acne, clitoral hypertrophy,
and sodium retention are particularly troublesome. lf androgen is used by a
woman while she is pregnant. there is a significant risk ofvirilization ofa female
fetus, depending on timing, duration, and dosage of androgen used.
150
Estrogens
When used by men, (e.g. in the treatment of prostatic cancer`!. it produces a
prompt reduction or obliteration of libido and almost invariably result in
impotence. This effect is probably attributable to depression of testosterone
piutluuiuu. lllllllllllllblll uf bjllbllldllllll is uuulllu LUlllll|Ull ltsull Ul lstlugtll usc,
when ejaculation does occur, the volume of seminal fluid is significantly reduced.
Spermatogenesis is disrupted, gynecomastia is cominon, especially at moderate or
high doses, and fascial hair growth often decreases substantially. Estrogens used
by women do not typically exert a direct effect on libido, although this is not
always the case. When an estrogen deficiency exists, estrogen replacement
therapy supports vaginal lubrication, the integrity of the vaginal mucosa, and
maintenance of breast tissue mass.
Antiandrogens
These drugs are substances that oppose the phamiacologic effects of
androgens. The synthetic steroid compound, "cyproterone acetate" is the
prototype of antiandrogens. This drug acts by competitive inhibition of androgens
at all androgen target organs, including the brain, resulting in the "shutting down"
of the hypothalamic-pituitary—testicular axis, because the cyproterone acetate
molecule is recognized falsely as being equivalent to testosterone. Cyproterone
acetate reduces libido, impairs erectile capacity, and decreases the ability to be
orgasmic in men. These are not side effects but the therapeutic effects ofthe drug.
which is used in Europe and U.S.A. as a treatment for deviant or abnormal
sexuality committed by sex criminals. Sperm production is markedly lowered hy
administration of this drug, which will typically induce a temporary sterility
within six to eight weeks after it is begun; in tact, research is currentlv being
conducted attempting to isolate the sexual and reproductive consequences of the
antiandrogens to provide a male contraceptive agent. Gynecomastia may occur in
llssbélalltill wllll lhé use ol cyprolercme acelale. All lhasa elleels appear lp be
reversible upon cessation of drug use.
Medroxyprogesterone acetate (MPA)
lt is another type of antiandrogen that is currently used for treating male
precocious puberty and sex-offending behavior. MPA lowers production of
testosterone, and libido; the effects on pituitary function appear to be most
specific for gonadotropin suppression, although the pituitary—adrenal axis is also
affected. l,ong—acting (MPA) can cause a dramatic reduction in sexual fantasies
in pathologic psychosexual states such as obsessive pedophilia.
Corticosteroitls
A chronic daily dose greater than the equivalent of 20 mg of cortisol is
sufficient to suppress the hypothalamic—pituitary—adrenal axis. but a higher dose
leads to more frequent occurrence of many of the side effects of corticosteroids.
The complications most likely to have impact on sexual function include,
hyperglycemia and the precipitation of previously latent diabetes mellitus,
increased susceptibility to infections (including vaginitis). muscle weakness, and
muscle &ltODllV. (l€Dt€SSlOll and Olltct mental disturbances. and sunpression of
151
pituitary gonadotropin secretion. ACTH or synthetic corticotropin analogues
lower circulating testosterone levels in adult males.
Effect of Tranquilizers, Sedatives and Hypn otics
` on Sexual Function
Drugs used to lower anxiety are difficult to assess in terms of their effects
on sexual function, because reductions in anxiety typically enhance sexual
performance, whereas sedation usually diminishes sexual responsiveness and
libido.
Meprobamate ·
lt has specific effects on the limbic system and therefore may directly alter
libido and sexual functioning.
The Benzodiazepine compounds
Chlordiazepoxide and Diazepam
They share sedative, antianxiety and muscle—relaxing properties. Either
drug may produce increases or decreases in libido, which may be attributable to
reduced anxiety and sedation respectively, impotence may occur only at high
dose levels and then infrequently.
Rarbiturates
They sometimes lower sexual inhibitions and in this sense may enhance
sexual function, but more commonly barbiturate users describe depressed libido,
impotence, or loss of orgasmic responsiveness associated with drug use.
Methaqualone
It is a rron-h¤r*~i¤··r¤•e *·yp··~*‘c "mt rtnntl] luu uLlllLULLl A l!UUlllllUll Els {lll
enhancer of sexual experience among illicit users, although adverse sexual effects
were reported as well.
Effect of Drugs Used In Psychiatry
Phenothiazines
These drugs produce a sedative effect on both emotions and motor activity
and are active at all levels ofthe nervous system.
Chlorpromazine
lt can block ovulation, cause menstrual irregularities, induce galactorrhea
or gynecomastia, and- decrease testicular size. Despite these effects, _ sexual
dysfunction is not a common complication to the use of phenothiazine
medications; when impotence occurs, it is usually at doses equivalent to 400 mg
per day or greater. Decreased libido is found more frequently, approximately, l0
to 20 percent of patients. while hypersexual behavior will often abate with
phcnothiazine therapy. Inhibition of eiaculation and a decrease in vaginal
lubrication in response to sexual arousal has also been reported.
152
Haloperidol n
Interestingly enough this drug increases testosterone production in men
when given in low doses, but suppresses testosterone when high doses are used.
Impotence occurs in l0 to 20 percent of men using this drug and menstrual
irregularities also occur.
Monoamine oxidase inhibitors (MAO Inhibitors)
Autonomic side effects that are dose-related are common, with delayed
ejaculation or loss of ability to ejaculate affecting 25 to 30 percent of men users,
while impotence occur in approximately l0 to l5 percent. These effects typically
are reversible within several weeks after discontinuance of the drug because there
are indications that MAO inhibitors may decrease testosterone production in the
male. `
Tricyclic antidepressants (Imipramine and Amitriptyline)
These drugs are highly effective in the treatment of depression. It should be
remembered what depressed libido and impaired sexual functioning are frequent
findings in depression. ln most instances, successful treatment of the mood
disorder will result in amelioration of the sexual difficulties; although in
approximately 5 percent of cases inhibition of ejaculation may occur.
Lithium carbonate
This new drug is used in the treatment of mania and hypomania and it can
produce a wide spectrum of changes in sexuality, including both hypersexual and
hyposexual behaviors. lt is known to have a variety of endocrine effects,
including suppression of serum testosterone levels in adult men with consequent
impotence in some individuals.
Effect of Miscellaneous Prescribed Drugs
Anticholinergic drugs
These medicines are used primarily in the treatment of gastrointestinal
disorders such as peptic ulcer disease and irritable colitis. The inhibition of
acetylcholine that makes these drugs therapeutically useful in the gastrointestinal
tract also results in inhibition of the parasympathetic nervous system, leading to
impairment of reflex vasocongestion in the penis (which ordinarily produces and
maintains erection). Because of this effect, impotence is a frequent side effect in
men receiving this type of medication. Women may experience decreased vaginal
lubrication and interference with sexual arousal as a result of the use of
anticholinergics because these phenomena are partly dependent on
vasocongestive changes occurring in vaginal tissues.
Cimetidine n
A powerful drug which causes impotence, gynecornastia. impairs sperm
production and alters the hypothalamic-pituitary—gonadal axis.
15]
Clolibrate
lt is often used to lower serum cholesterol nr triHIy»—»·riA»¤ Ainmniihan
Illlldo and impairs potency in some patients by unknown mechanisms.
Disulflram
lt has been reported as an occasional cause of impotence among the male
patients.
Digitalis and other glycosides
These well known medicines can cause impotence and gynecomastia, the
mechanism of action may be related to the finding that digoxin lowers circulating
levels of testosterone, although this effect may have more to do with chronic
illness and altered circulatory dynamics than with drug use alone.
Antihistamines
lt was found that these drugs can produce depressed libido inieither men or
women as a result of their sedative action, and vaginal lubrication may be
significantly decreased while antihistamines are being used.
L—Dopa
While this medicine is extremely useful in the treatment of patients with
Parkinsonism; initial reports pointed toward a possible aphrodisiac action, but
later it was shown that it does not raise testosterone levels in man although it
inhibits prolactin and raises circulating growth hormone levels. The probable
explanation for the improved libido in patients receiving L—dopa is the alleviation
ofa frustrating and incanacitating chronic lllooaa
Alcohol and Sexual Performance
Alcohol and its effects on sexuality have been the subject of considerable
conjecture and research for centuries. ln "Macbeth", Shakespeare reported that "it
provokes the desire but it takes away the performance"... Since that time, research
has primarily substantiated the poet's observation. Farkas and Rosen gave alcohol
ltt three dlfferellt d0S€S to COlleg€—age men and measured the increased in penile
turnescence that occurred in response to erotic films. They found that blood
alcohol concentrations well below levels of intoxication produced marked
suppression of erection. Similarly, Wilson and Lawson, administered varying
doses of alcohol ranging from 0.3 to 4.3 ounces of 80—proof alcohol to university
women and found a significant negative effect on vaginal pulse pressure in
response to watching an erotic film. Other studies have obtained similar findings
in both animals and humans. The probable basis for the suppressing effect of
alcohol is that alcohol acts as a depressant to the central nervous system, thus
interfering with pathways of retiex transmission of sexual arousal. ln addition to
these acute effects of alcohol use, which certainly occur in situations that
¤<>··r¤¤p~···* tc wid Mtihlng puttunu, nltullul lus ulsu luwllllll Mén slmwn lc
lnxver circulating testosterone and Iuteinizing hormone levels in healthy young
men.
154
The acute effects of alcohol on sexuality are more complex than the
preceding facts imply, however. Some researchers have suggested that alcohol
haa a tllzninhibitian affaat that in ta nay; it Imran] curtain annual lnhihitinnn a
person ordinarily have, so that in some people the feelings of relaxation and
increased openness to sex may combine to facilitate sexual response ln one
study, 68 percent of women and 45 percent of men queried reported that alcohol
enhanced their sexual pleasure, which can be seen as substantiation of the
“disinhibition" theory. More recently, data from a series of interviews conducted
at the Masters & Johnson institute revealed that fewer than 35 percent of women
claimed that alcohol had a positive effect on their sexual experience, whereas
approximately 55 percent reported that alcohol detracted them fiom their sexual
feelings. lt is not surprising that widespread differences in individual responses
were noted here, since only a portion of the attributed "drug effect” may actually -
come from the pharmacologic activity—including central nervous system
depression- that alcohol is known to possess. The expectations of the user and the
setting of alcohol use are both important ingredients in defining the perception of
effects that an individual will note. ln addition, if a person is able to use just
enough alcohol to overcome anxieties or guilt associated with sex, but not
enough to impede sexual performance, the net effect may be a beneficial one. lf,
however this balance is exceeded, the person involved may be too drunk to care
very much!
Cigarettes and Sex
Although cigarette smoking is Z1 common practice, widely acknowledged to
be linked with a number of health problems, very little systematic study has been
Ulllllllwlllll EllllUl!l'llllll! lll! llll[l!lUl lll Elllllllllll.! llll EERUQI ll|llUllllll. lllEl'l! IE Twill!
evidence indicating an association between smoking and an early onset of
menopause and cancer of the cervix. But a report suggesting that plasma
testosterone may be suppressed by cigarette smoking has not been substantiated
by another study that found that acute cigarette smoking correlated with increased
plasma testosterone concentrations. Studies in both clinical and research
populations failed to reveal a difference in circulating testosterone levels between
smokers and nonsmokers; in addition, a low incidence of cigarette smoking was
found in 246 men with impotence than in age-matched men with normal potency.
The experimental animal literature regarding the effects of nicotine or smoking
r on sex and fertility is generally inconclusive and methodologically imprecise. Of
signal importance, however, is the extensive set of data indicating that smoking
during pregnancy is associated with decreased birth weight, an increased risk of
spontaneous abortion, and elevated perinatal mortality.
Effects of Marijuana or Marihuana on Sexual Function
Also known as "}lashish" and lndian llcmp or Pot, it is
tetrahydrocannahinol (THC). Considerable controversy has surrounded the issue
of the effect of marihuana on sex. There are numerous reasons why this is so.
Although marihuana is an illegal drug, in many circles its use is the norm rather
155
than the exception, and nonusers may unfortunately be under pressure to
experiment in order to be accepted socially. In this regard, one of the reasons
frequently cited for initiating the use of marihuana is its reputation as an enhancer
of sexual feelings and experiences, so that the user often has positive exr ectations
of an enjoyable drug effect. It is difticult to separate the expectations from the
actual drug effect except under rigorous research conditions, (e.g. a double—blind
drug—placebo administration experiment), which have not been used to date.
When such a project was proposed, in a format similar to the alcohol experiments
mentioned previously that measured penile tumescence in response to visual
erotic stimuli, it was stopped because of political pressuresll. The research that
has been done thus far, has been difficult to interpret because of many issues of
methodology that are difficult to solve or to control, because of the fact that many
people who use marihuana also use other drugs, such as alcohol and tobacco, as
well as psychoactive substances. lt may be helpful to look at the biologic and
behavioral aspects ofthe effects ofrnarihuana on sex separately in order to gain a
clear understanding of the variables involved.
Animal studies
lt has been shown that marihuana or its active ingredients can decrease
copulatory behavior in male rats, inhibit spemiatogenesis and depress circulating
levels of testosterone. Marihuana has also been reported to suppress LH and
prolactin in female rodents and primates. The weight of such evidence, even after
making appropriate allowances for mcthodologic differences in interspecies
studies, leaves little doubt that marihuana is endocrinologically active.
Human studies
l. In studies in men during both acute and chronic administration, frequent
marihuana use has been shown to depress circulating levels of testosterone in
healthy young men. Although one study did not find a suppression of morning
testosterone levels during three weeks of daily marihuana use, a similar study
design that extended over a longer period of drug use, showed significant decreases
in testosterone beginning with the fifth week of daily marihuana use. The
depression of testosterone is not, of course, always significant in terms of either
biologic function or behavior. Nevertheless, some men who are chronic marihuana
users have been found to be impotent, and to experience a return to potency within
a few weeks after discontinuation use of the drug. Furthermore, inhibited
spemratogenesis also, has been observed in association with chronic marihuana
use.
2. Studies of acute marihuana use hy women who were either post
menopausal or who had previously removed their ovaries surgically demonstrated
that marihuana lowers pituitary gonadotropin levels by approximately 35 percent,
indicating that the effect of marihuana is centrally mediated. ln studies of chronic
marihuana use by healthy women aged l8 to 30, users were found to have
Somewhat shorter menstrual cycles than nonusers, although LH and FSH levels
156
were not significantly different between the two groups. lnterestingly,
testosterone levels were higher in the women who used marihuana chronically,
(probably reflecting the adrenocortical contribution to testosterone synthesis) and
prolactin levels were significantly lower.
3. Flve years of interviewing subjects at the Masters and Johnson
Institute has resulted in a data base of information about the effects of marihuana
on sex in 800 men and 500 women between the ages of 18 and 30. Briefly
summarized, the majority of both men (83 percent) and women (81 percent)
indicated that marihuana enhanced the enjoyment of sex for them. However, the
responses to specific questions regarding how this effect occurred were revealing.
For example, most men denied that marihuana increased their sexual desire,
increased the firmness of their erection, made it easier to get or maintain
erections, gave them a greater degree of control over ejaculation, or increased the
intensity of orgasm. Similarly, the majority of women stated that marihuana did
not increase their interest in sex, increase their arousability, increase the amount
of vaginal lubrication, increase the intensity of orgasm or allow them to be
orggsmic more frequently. Instead, both men and women attributed the enhancing
effect of marihuana on sex to factors such as an increased sense of touch, a
greater degree of relaxation (both physically and mentally) and being more in
tune with one's partner. Most people said that if their sexual partner was not
"high" at the same time they were, the effect was unpleasant or dyssynchronizing
rather than enhancing...
ln this same series of interviews, it was found that while fewer than l0
percent of a control group of men who had never used marihuana and a group
who used marihuana once or twice a week experienced potency disorders, almost
one—fifth of the men using marihuana on a daily basis were impotentu. No
statistically significant relationship was found between sexual dysfunction and
chronic intensive marihuana use by women.
What is very clear, out of all this, is that marihuana is a drug that hightens
suggestibility. Alterations in time perception and in the perception of tactile
C.-mmeinnq me Frequently reported. but these changes may not correspond to
actuality. Thus, the marihuana user may well be perceiving an enhancing eiieci
of this drug on sex, but in reality, sexual performance may be unaltered or even
impaired... ln instances in which marihuana relaxes inhibitions and loosens
ordinary restraints on sexual behavior, people who are normally very anxious or
guilty regarding sex may benefit. ln some people, of course the relaxation
produced by this drug progresses rapidly to somnolence or sleepl, which is not an
ideal state for sexual activity 7...
4. Medical marijuana is the name given recently to a research project
carried out in the U.S.A for the medical application of cannabinoids-marijuana`s
active components as being effective to alleviate pain, nausea and loss of appetite
in patients suffering from advanced cancer as well as AIDS. Smoking offers an
immediate delivery while the patients themselves can "titrate" the dose as needed.
157
An inhaler will eliminate the toxicity of smoke while it maintains a quick entry
into the blood stream. As pills, it will take an hour to be effective. "Marinol" is
the only synthetic legal cannabinoid available on the American market.
Effect of Heroin and Methadone on Sex Performance
Drug addicts have long been known to experience disruptions in sexual
function, but the cause of such problems has been obscure. On the one hand, a
wide variety of theoretical intrapsychic factors relating to the significance of
mainlining as a substitute for sex have been discussed. Chessick has suggested
that the intensely pleasurable sensation of intravenous injection of heroin
constitutes a "pharmacogenic orgasm", which is related to a feeling of
increased ego mastery and decreased libidinal needs. On the other hand, practical
factors involved in addictive behavior, such as preoccupation with the use of the
drug, decreased social interaction, and the exhausting daily search for drugs or
money to buy the drugs, may be viewed as significant behavioral components of
diminished sexual activity or interest in sexual activity. More recently however, a
clearer understanding of some of the biologic factors involved in drug addiction
has emerged to help explain the sexual difficulties of the person addicted to
drugs.
Azizi and his colleagues demonstrated lowered serum testosterone in
male (heroin and methadone addicts), this finding has since been substantiated by
others. Heroin addiction also lowers pituitary gonadotropin levels in serum.
Cushman found that out of l9 men addicted to heroin. l2 reported impaired
libido, I0 were impotent, and l5 had delayed ejaculation time. Cicero and
coworkers described serum testosterone levels in methadone users that were 43
percent lower than normal. They reported that libido was suppressed in 100
percent of heroin addicts and 96.5 percent of methadone users, they also noted a
high frequency of potency problems and retarded ejaculation or failure to
ejaculate in both drug using groups. lt is clear now that heroin and methadone are
capable of exerting an active endocrine effect that predisposesto the development
of sexual inadequacy.
Although fewer studies have been done with female addicts, Bai and
coworkers reported that decreased libido was seen in 60 percent of women in their
series. along with the following findings: ameaorrhea (45 percent), infertility (90
percent), galactorrhea (25 percent ). and reduction in breast size (30 percent). Many
addicted women resort to prostitution as a means of supporting their drug habit.
They may subsequently have negative feelings toward sax that reflect guilt, loss of
self—esteem, or hostility toward men. Poor nutrition is a common finding in addicts
and may be contributing to sexual problems. One should? remember that cessation of
drug use will not restore sexual and reproductive function to normal immediately;
endocrine or psychological problems may persist for months before improving.
158
1 SQSEHQ hilt}
Ss »·er·t;tet: To xessess sexuaélir I?/TiT`IEL€litl.”¥Ci!'l_g properties Mciudtng
”"‘°*§ "'tC¥%‘€¥€?i'?Q ~i¥?FT“‘*?. iE”:“é'Zl"}`-’h“‘Q i’l‘!`??’i*’?SS IN] f'Jll!"2iJlil‘i"*r t?E`€Cil€lil.
··’ V frag tor men are women id E9 men reported
tve:·~is ssgzxwstaterj ».vr:~ -.··t»t:;>se arse. occeered as
ii t` tower Research ’};*»`@ng .;:12 —;‘°'°&::‘€s #::5 it
·;‘·· ~ 3: rect T"T?5`l%‘i<'! ~.:r;<\· cencitzstozts at t:*t·e
T'Jif?‘Z Ttfcers przactsm, "Crac§»{’“ is another pros rc? or rrriiuced
#2*. . ii; an ee ;E:eaper nrt sei} arte more e:"€’eezexe
.rrQx;~R2:f&;;tezv lit .s were damaging as welih.
fvlisceilaneotis Drugs
Arnpaetantines
Diese drugs were studied by Bell and Trethowan and they noted some
degree ot "sex:=al ahnorrnality" among its users. These authors and others have
generatly concluded that atnphetamines use leads to an increase of libido and they
Z`t"DC¥I“iC¢Qli a higher rate of "oromtscuity ` among its users.
Amyl nitrate
ihés substance is a rapid—acting vasodilator that achieved yery recently
.n»rorrety as arthrodisiac that would intensify the orgasmic experience for both
men and iwosnert. The drug is inhaled and produces tachycardia and local
vasodilation; headaches and hypotension are frequent side effects. Synccpe. S-T
segment depression of the electrocardiogram. and other cardiovascular effects
may also occur. These effects are not necessarily innocuous. but the drug should
noi be used recreahonally ai all, especttllly by lléllsdlls Willi EAl'lllllVll§Ull|lll', UUUlHl
or cerebrovascular disease.
Lysergic acid diethylamide ( LSD )
Related psychedelic compounds as well as ( LSD ) have been purported to
act as aphrodisiacs, but the scanty research literature fails to substantiate this
view. Piemme points out that: "taking LSD to initiate sexual relations is
useless because the user can’t remain focused on what he started to do“. ln
interviews at the Masters and Johnson Institute with 85 men and 55 women who
had used LSD on three or more occasions, fewer than l5 percent of each group
claimed that LSD enhanced sexual participation. lt is one of the most famous
group of hallucinogens.
Spanish Hy —
lt is a bright green insect, when dried it is used for raising blisters; its
tnedical pharmacological equal name is Cantharides, in greek, Cantharis blister
fly. As an aphrodisiac it is highly toxic and dangerous through irritation of the
genito—urinary tract.
159
Yohimbine
One of the few drugs that have been fomially studied for the treatment of
erectile d_vsfunction. lt is an indole alkaloid which has ot;-receptor blocking
activity in vitro and is derived from the bark of the Pausinystalia yowimbe tree. ln
a prospective double blind study in patients with organic impotence, yohimbine
was not very effective, but a similar study in patients with psychogenic erectile
dysfunction it showed useful activity.
Conclusion
Although drug use has been pursued for centuries as a means of increasing
sexual interest and enjoyment, there is little objective data to support the
existence of a true aphrodisiac. Drug effects are highly variable both from person
to person and for the same person at different times, and it is certain that
subjective sexual perceptions may be widely altered as a result of drug use. All
doctors and health care professionals should be familiar with the possible
deleterious effects that pharmacologic agents may have on sexual function, since
these effects may influence both the patient’s quality of life and his or her
compliance with a treatment program.
160
HOMOSEXUALITY AND LESBIAN LOVE
• History and Definition.
• Theories of Etiology.
• The Homosexual Patient.
• The Law and Religious Views.
• AIDS: A Lethal Mystery Disease.
HOMOSEXUALITY AND LESBIAN LU VE
Historical background
Few topics in human sexuality have received as much attention in the past
fifteen years as has homosexuality, no wonder that dozens of books and hundreds
of joumal articles have dealt with the increasing degree of research and the
clinical recognition of this sexual problem. Homosexual behavior is depicted in
the art, literature and histories ofthe most ancient civilizations, for example in the
Greek and Roman empires. The legal and social acceptability has varied with
time, culture, and circumstances; for example, male homosexuals could be
regarded as model citizens in Pagan Greece; but for the believers; in lslam and
Christianity, they have always been the scum of earth and were described as
sinners. The old Testament demanded the death penalty for sex performance
between males, and so did the Christian Roman emperors, Spanish inquisitors,
past English monarches and American colonists. Later, psychiatrists declared
homosexuals to be sick and proceeded to treat them with shock or aversion
therapy, psychosurgery and even castration. ln the past time homosexual behavior
was a felony in most states of the U.S.A. and homosexuals were either sent to
prison or committed to mental hospitals as sexual psychopaths. Recently, cross-
cultural aspects of homosexuality were discussed by Ford and Beach, who found
that 49 out of 76 societies approved some form of homosexuality, the same
results were recorded by Marshal and Suggs.
Some famous historical personalities who were imown to have had strong
homosexual leanings are: Socrates (the famous Greek philosopher), Gaius Julius
Caesar, King Richard (the lion hearted), Leonardo da Vinci, Michelangelo,
Tchaikovsky, Hans Christian Anderson and Somerset Maugham. ln the present
time, it is worth mentioning few homosexuals who are famous for such
perversion; Rock Hudson (most famous American actor who died of AIDS); four
ministers in the labour government in the U.K. and many others, to indicate that
homosexuality and Lesbianism is spreading allover the West in an alamting
fashion...
Definition '
There is considerable diversity in the way homosexuality is defined in the
scientific literature. Some authors restrict the term to describing sexual contact
between persons of the same sex, whereas others extend the definition to
include, sexual desire or fantasy as well as overt sexual behavior. Marmot and
Green state, homosexuality is a preferential attraction to members of the
same sex.
ln their pioneering study, "Sexual Behavior in the Human Male", 1948,
which included the sexual histories of l2.00() males and is still the most
comprehensive statistical documentation of the sexual behavior of American
161
men, Alfred C. Kinsey and co-workers offered the following definition, "sexual
relations either overt or psychic, between individuals of the sam.· sex". All
over history, the term homosexual has had an endless list of svnonyms:
homogcnic love, contrasexuality, homo-erotism, the third sex, gay, que —r, faggot,
sissie, pansy, sexual inverts, psychosexual hemiaphrodites. Female homosexuals
are better called Lesbians, especially in America. Lesbian love or Sapphism is
meant to describe female homosexuality and to show that homosexual females do
not necessarily identify with every concem of homosexual males and that in
many respects, their situation is unique.
Kinsey, devised a numerical scale for describing a person‘s sexual
orientation on the basis of both behavior and fantasy. This seven-point
heterosexual-homosexual rating scale, (Fig. 38), emphasizes the continuity ofthe
spectrum of sexual orientation, with some persons living their entire lives in a
single category while others shift along the spectrum from time to time.
Kinsey and his associates gathered cumulative estimates of the incidence of
homosexuality by recording interview data from 5.300 white males and 5.940
white females. According to these workers, 4 percent of white males were
exclusively homosexual from puberty onwards, 10 percent were predominantly
homosexual for at least three years between the ages of l6 and 55, and 37 percent
had at least one homosexual experience leading to orgasm after the time of puberty.
Primarily or exclusively homosexual behavior in females was approximately half
of that found in males according to the Kinsey data. More recently, Gebhard
estimated that the cumulative incidence of overt homosexual experience for the
adult female population as a whole is between 10, and 12 percent.
When Kinsey‘s statistics were first published since fifty years ago, they
caused a great deal of public rage, first of all many people simply refused to
accept the great number of reported homosexual acts. Indeed, even now various
experts continue to challenge these figures as infiated and unrepresentative but
the recent work published by Gebhard did show an even greater incidence of
homosexual behavior especially among American females. By far the greatest
shock for the public however, was the conclusion which the statistics revealed
that; homosexual acts were believed to be so rare as to represent nothing more
than unnatural and freakish exceptions. Kinsey and his followers showed that this
traditional view was quite mistaken. For example, his statistics revealed that by
the time they reach middle age (about 50% of all males), and (20% of all
females) have had some sort of overt erotic experience with members of their
own sex... This accounts for every second man and every fifth woman in the
U.S.A. lndeed, 37% of all males (and l3% of all females) have at least few
homosexual experience to the point of orgasm between adolescence and old age.
This applies to nearly two males out of every five and to more than one female
out of every eight. Thus, concerning human sexual behavior, Kinsey spelled out
his theory that a heterosexual or homosexual activity may better be used to
describe the nature ofthe overt sexual relations or of the stimuli to which an in-
dividual erotically responds.
162
The Kinsey Heterosexual-Homosexual Rating Scale
A seven point rating scale with categories ranging from 0 to 6 which
measured the balance of heterosexual and homosexual behavior in the American
population as a whole, was presented by Kinsey and his co·workers. At the one
end of this scale (in category 0), they placed those whose experiences are
exclusively heterosexual, and at the other end (in category 6), they placed those
whose experiences are exclusively homosexual. Between those two extremes are
those who have both heterosexual and homosexual experiences in various degrees
(categories l - 5). Thus the exact breakdown is as follows:
0. Exclusively heterosexual.
l. Predominantly heterosexual, but only incidentally homosexual.
2. Predominantly heterosexual, but more than incidentally homosexual.
3. Equally heterosexual and homosexual behavior.
4. Predominantly homosexual, but more than incidentally heterosexual.
5. Predorninantly homosexual, but only incidentally heterosexual.
6. Exclusively homosexual.
Q ~2345 3
II I gl OI IO O9 IO
MM M lll l
Exclusively Incidental More than Equal amount of More than Incidental Exclusively
heterosexual homosexual incidental heterosexual incidental heterosexual homosexual
behavior behavior homosexual and homosexual heterosexual behavior behavior
behavior behavior behavior
Ambisexual behavior
Fig. 38. The Heterosexual and Homosexual Behavior (Kinsey et al.)
163
Theories of Etiology
ls homosexuality a single disease '?. ls it a symptom of neurosis: ?. ls it an
inevitable manifestation of a disturbed home or a disturbed society 7. Can it be a
social ritual ?.
BIOLOGIC CONSIDERA1 IONS
Genetic
There has been much historical conjecture conceming the origin of
homosexuality but no current agreement that satisfactorily explains its etiology.
Many homosexuals claim that their sexual orientation is the result of biologic
factors over which they have no control or choice. Although a report by Kallman
in 1952, postulated a genetic origin for homosexuality based on a study of
concordance for sexual orientation among identical and nonidentical twins,
subsequent studies have not supported this claim up till now.
Hormonal
More recently, interest has revived in the investigation of hormonal factors
that may play a role in the development of human sexual behavior. Animal
research has shown that hormonal manipulations can produce variations in adult
sexual behavior that appear to be proportionate with homosexuality. Several
studies in humans indicated that there were differences in the urinary excreti» ·n of
sex hormone metabolites between heterosexual and homosexual men.
Homosexual men excreted lower amounts of urinary testosterone than
heterosexual men and their circulating testosterone levels were lower in young
men who were exclusively or almost exclusively homosexual than in age-
matched heterosexual men. Subsequent studies have produced conflicting results
however. A number of reports have failed to demonstrate a difference between
circulating testosterone concentrations in homosexual and heterosexual men,
whereas a contimting report has also reappeared. Some investigators have found
other endocrine differences between homosexual and heterosexual men, including
higher levels of estradiol in male homosexuals, also higher levels of luteinizing
hormone in male homosexuals, also differences in serum lipid concentrations
and urinary hormone metabolite patterns. One report that found no difference in
total plasma testosterone between homosexual and heterosexual men, found
significantly lower free plasma testosterone in homosexual subjects,
accompanied by elevated circulating gonadotropins.
A similar controversy exists in regard to the hormonal status of
homosexual women. Although some reports describe elevated levels of
testosterone in the urine and blood of homosexual women as compared to
heterosexual controls, other reports have failed to find any differences.
164
The possibility of hormonal mechanisms influencing sexual behavior in
humans is not simply a theoretical exercise. lnfonnation gained fro1»· instances of
excesses or deficiencies of prenatal androgen; for example, the discussion into the
adrenogenital syndrome and testicular feminization etiology. Also, research into
the effects of prenatal exposure to female hormones indicate the probability that
important aspects of sexual orientation and other components of behavior may be
susceptible to early homional influence.
Psychosocial considerations
Classic psychoanalytic theory views the determinants of adult
homosexuality as disordered parent-child relationship or as disruption of the
normal process of psychosexual development. Freud postulated an innate
bisexuality in the human psyche, paralleling the early embryonic bisexuality of
the human fetus. Freud believed that elements of this inbom bisexuality
contributed to the universal presence of latent homosexual tendencies that might
be activated under certain pathological conditions. These classic analytic
concepts were derived from clinical impression rather than from research data.
Later, analysts have moved away from the idea of inbom psychic bisexuality and
have focused instead on ways in which childhood and adolescent experiences
may lead to subsequent homosexuality.
A number of investigators have examined the family backgrounds of
homosexuals in an attempt to elucidate theories of the cause of homosexuality.
Bieber and co—workers examined questionnaire data provided by 77
psychoanalysts on 106 homosexual and lO0 heterosexual male patients. A
parental pattern consisting of a close—binding, seductive, overindulgent mother
who was dominant over the detached, ambivalent or hostile father was found to
characterize the histories of many of the homosexual subjects. Bene studied a
gasp rf Yi? lmmnnmunl msn and Ul mnrriud lllUll lTllU 11010 p1L1Ju111LLl lU UL
heterosexual; she found that the homosexual subiects more frequently had poor
relationships with their fathers who tended to be ineffective and poor role-
models. At the same tirne, there was no evidence that the homosexual men were
more strongly attached to or overprotected by their mothers than heterosexual
men. Other studies have also documented disturbed parental relationships in
association with homosexuality. However, Greenblatt found that fathers of
homosexual men were good, generous, dominant, and underprotective while
mothers were free of excessive protectiveness or dominance. Sicgelman reported
that in groups of homosexuals and heterosexuals who were low in neuroticism, no
differences in family relationships could be seen. Siegelman's findings are
compatible with the view stated by Hooker: "Disturbed parental relations are
neither necessary nor sufficient conditions for homosexuality to emerge?
In recent years, investigators have increasingly come to accept the view
stated by l\/larmor in l()6S, that homosexuality is "multiply determined by
psychodynamic, sociocultural, biological and situational factors". Green
theorizes that children who consistently show atypical sex—role behavior are more
165
likely than other children to develop a homosexual orientation as adults. ln
support of this concept, Whitam found that male homosexuals described
childhood pattems showing interest in dolls, cross—dressing, preference for girls
as play—mates, preference for being in the company of adult women rather than
men. Usually regarded as "slssy" by other boys and childhood sexual interest in
boys rather than girls significantly are more frequently noted than male
heterosexuals.
The search for a Cause of homosexuality continues to be hindered both by
methodolgical difficulties and by lack of homogeneity in the homosexual com-
munities or "gay populations" as recently described.
Psychological adjustment of homosexuals
Until very recently, homosexuality was viewed as an emotional disorder.
This belief was partially a reflection of early research done on the subject that
was conducted principally among populations of psychiatric patients and
prisoners, hardly environments where one could expect to find psychologically
healthy individuals. Nevertheless, the view that homosexuality is a disease is
still held by some professionals.
Hooker provided one of the first balanced studies assessing the
psychological concomitants of homosexuality in l957. ·ln this investigation, 30
homosexuals and 30 heterosexuals, (neither psychiatric patients or prisoners l)
were matched by age, education and lQ. The subjects were given a variety of
psychological tests, the results of which were shown to a panel of expert clinical
psychologists who were asked to rate each subject’s personality adjustment and to
identify each subject's sexual orientation from their analysis of the test results.
The personality ratings for homosexual and heterosexual subjects were not
significantly different and the judges were unsuccessful in identifying subject's
sexual orientation at better than a chance level.
Saghir and co-workers conducted an extensive set of investigations on
male and female homosexuality. An important innovation oftheir research was in
comparing homosexual subjects (male or female), with unmarried heterosexual
controls, since the prevalence of certain psychiatric illnesses is higher in single
persons. They reported that "there was little difference demonstrated in the
prevalence of psychopathology between a group of 89 male homosexuals and a
control group 35 unmarried men". ln their sample of homosexual women, these
workers found "slightly more clinically significant changes and disability" than
among the heterosexual controls primarily reflected in an increased rate of
alcoholism and attemptedsuicide. ln both populations. however, the maiorityvof
homosexual subjects were well-adjusted and productive persons.
166
The Homosexual Patient Diseases
lf current estimates of the prevalence of homosexuality are accurate, most
physicians deal with homosexual patients on a daily basis in the West. A
relatively high rate ofvenereal disease in homosexual men has been documented
by several screening programs. Judson and co-workers found that 48 ot`419 men
(11.5 percent) screened in Denver homosexual steam baths had asymptomatic
gonorrhea and 6 men (1.4 percent) had early syphilis. Ritchey found 4 new cases
of early syphilis and 13 cases of gonorrhea in an outreach program to control
venereal disease among homosexuals. Because the primary lesion in syphilitic
homosexual men may be oropharyngeal or rectal, it may go unnoticed by the
patient and may only present as fulminant secondary syphilis. Similarly,
homosexual men whoengage in anal intercourse should have rectal cultures
obtained to detect gonorrhea in addition to urethral and pharyngeal cultures.
Schmerin, Gelston and Jones reported on an increasing occurrence of
amebiasis among nrale homosexuals who had not traveled outside the New York
area. They pointed out that anal intercourse followed by oral—genital sex or oral-
anal contact is the probable mechanism for the transmission of the infecting
organism. Two cases of venereal transmission in homosexual men of multiple
enteric pathogens resulting in amebiasis. shigellosis. and giardiasis have also
been reported recently. The increased incidence ofa variety of colonic and rectal
disorders in homosexual men has been termed the "Gay bowel syndrome" 1 by
Sohn and Robilotti.
Other studies indicate that homosexuality may predispose to the
development of hepatitis B infection. ln a study of male homosexuals, 51.5
percent had serologic evidence of hepatitis B as contrasted with only 20.4 percent
among male heterosexuals. A correlation was found between pattems of sexual
behavior and the occurrence of serologic evidence of hepatitis B, with higher
rates in those with involvement in anal intercourse primarily and those with large
numbers of sexual partners. A similar survey conducted in England has
confirmed these findings. However, it should be pointed out that sexual
transmission of hepatitis B can also occur in heterosexuals.
Anal intercourse among homosexual or heterosexual couples can result in
infections or trauma that may require medical or surgical intervention.
Condyloma acuminata were noted in 51.5 percent ofthe patients seen by Solm
and Robilotti, who also found non specific proctitis in 12 percent. anal fistula in
ll.5 percent and perirectal abscesses in 6.9 percent of 260 male homosexuals.
Chlamydia trachomatis has been isolated from the throat and rectum of
homosexual men. The use ofa dildo or vibrators (i.e. sexual aids) by homosexual
women may result in Iaeeration of the vagina if amtripa r·»mtat—¤rj»' TIS]
Trlbadrsm.
167
fgain. anal incontinence has zrecerdea tiwase vr:=·‘
teaeatediy traumatized the anal schincter by the eertiorrrzatxte of iodcairs ct rc
introduction of sesttxat ctr soiid J1;. eeixzm
ttowever, the sexual practices cf homosexual do at
health hazards that the attending of ET it
patients of courses.
Fsychologicai and Soeioiogicai aspects
ilemosexuals, mate or female. have FT io:
iegai cr economic pressures that they tn any oi? ite ¢¤¤·:·;; T’·e*e
experience emotional problems too, especzaziv When pressured to =;?tar·;e itze
direction of their sexual orientation. Uzviees t1·:¤¢<>sex2:ai <.v€·=i:es seriziusiv *0
change. such alteration is not undertaken. in fact. sex therarcxsts are astcrzzsheri
realiring that some homosexuals seek treatment in order enhance their
hovnosexuaiityh a realization at marked variance arti; ?he therapists previous
practice of attempting to eradicate homosexual behavior.
=’\ recent report by Bell and Weinberg provides a `arge amount of
knowledge concerning homosexuality. the behavior of étornoscxuals and their
emotional stability. ln this study. 686 homosexual men and 293 homosexual
women were interviewed. The data led the authors to the delineation of tive
dillerent homosexual typologies based on sexual experiencet =’l) closewoupled
(living in a quasi-marriage), (2) open·coupled (living in a quasianarriage isnt
continuing to have a large number of other sexual partners), (3) functional (not
coupled. having a large number of sexual panners with little regret der
homosexuality and few sexual problems), (4) dysfunctional (not coupled. hai ing
a large number of sexual partners but with many sexual problems and significant
regret about their homosexuality) and (5) asexual (not coupled. having low levels
of sexual activity- with frequent sexual problems- and relatively low levels of
sexual interest). The overall diversity ofthe group of study subjects was highly
apparent, both from a socio-economic and from a psychological perspective. lt is
still widely accepted and generally believed that homosexual men are effeminate
and homosexual women are musculine and that homosexuals make occupational
_ choices on the basis of their sexual orientation.
The Law and Homosexuality
ln the past, "Sodomy" or sometimes termed "crimes against nature"
were treated as serious offenses in the U.S.A., "oral" and "anal" intercourse as
well as sexual contact with animals were grouped together under such category.
ln few countries penalties are extremely severe and depending on the country., it
may range up to life imprisonment. ln addition, offenders may be declared to be
"sexual psychopaths" and may be imprisoned or sent to a mental hospital.
Recently however, the law in the U.S.A. and Europe has become very soft indeed
with homosexuals of both sexes while then the criminal code has changed to
appear very mild unfortunately or no crime at all".
168
History and Religion
A close look at ancient and medieval history reveals that the term
"sodomy" is derived from the Old Testament. The early Christians believed that
the biblical city of "Sodom" was destroyed by God because its male inhabitants
has engaged in homosexual intercourse. We, as Muslims do believe the same
since it is mentioned more than once in the Koran our holy book.
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Christian Roman emperors enacted the first European laws against male
homosexual behavior, offenders were burned at the stake. ln medieval Europe
"sodomites" were persecuted with equal zeal, they were publicly burned alive
after the confiscation of their property. Modern viewers may be especially
intrigued by a curious detail when shown the method of execution; the stale is
equipped with a penis-shaped peg which is placed between the legs ot the
condemned holding up the body while it bums !.
ln recent years, the society in some countries for example, in England,
Europe and U.S.A. has become more lenient with homosexuals, allowing them
the freedom to have their own bars, clubs and villages (gay populations). While
a number of states in America and England have repealed their sodomy laws, the
Supreme Court ofthe U.S.A. refused to change the existing laws against sodomy
in the past. No wonder, a deeply distressed president of the American Psychiatric
Association pointed out in a letter to the Chieflustice, that not only 20 million
Americans are homosexuals but they are also branded as criminals !. Nowadays,
in America and most European countries. homosexuals and Lesbians are accepted
socially and that is a catastrophy while legally it is allowed and naturally it is
disastrous...
Treatment
Masters and Johnson described a research program focusing on
homosexuality from the perspectives of both the physiology of the sexual
response and the results of participation in sex therapy. ln their physiologic
studies, 94 homosexual men (age range 20 — 5-4) were investigated during sexual
activity in the laboratory in a fashion analogous tothe methods employed for
heterosexual men and women in the "Hurnan Sexual Response" experiments.
When the observations ofhornosexual male and female subjects were compared
169
with data from a subset of subjects previously reported in their book the Human
Sexual Response, there were only minor differences in the rates oi functional
efficiency of sexual response cycles.
Masters and Johnson described two different clinical situations in which
homosexuals were treated. ln one group, homosexual men and women who were
sexually dysfunctional were treated in the dual-sex therapy team format for the
specific dysfunctions of impotence or anorgasmla, respectively. In 57 impotent
homosexual men. the overall failure rate after five years of follow up was 10.5
percent. Similarly, in 27 nonorgasmic female Lesbians, the overall treatment
failure rate after five years of follow-up was ll.l percent. There were relatively
few differences in techniques of sex therapy for the reversal of sexual dysfunction
in homosexual and heterosexual couples.
ln a second clinical group, homosexual men and women who wished to
convert or revert to heterosexual functioning were treated. ln contrast to more
traditional psychotherapeutic approaches to this situation, relatively good
outcomes were found. These results must be interpreted cautiously, since the
patients who were treated were a highly motivated group but it is clear that
homosexuals who are dissatisfied with their sexual orientation may turn to their
physicians with greater confidence about the prospects of obtaining effective
treatment than they could have done in the past. A number of psychotherapeutic
approaches have been employed with varying degrees of success. Some may
argue that sexual orientation is essentially irreversible in adults, althovgh
behavior may still be changed. ln any event, it is clear that physicians and
sexologists must no longer stigmatize homosexuals or deprive them of needed
treatment, and must not leave them to rot in prisons or mental institutes. As a
matter of fact. many of the homosexuals males or females, are openly maltreated
in some of these prisons since several cases of rape have been reported
repeatedly.
Conclusion:
lt is very unfortunate that thc WCStC[`l] civilization has accepted
homosexuality and Lesbianism as a normal way of life. We must try to avoid
such calamity by increasing our efforts to spread proper sex education within the
frame of our religion.
170
AIDS: A Lethal Mystery Disease
The deadly disease first broke out in the homosexual communities of New
York, San Francisco and Log Angeles in 1981. Later, it cropped up among heroin
addicts, Haitian refugees and \·ic*i·ns of Hemophilia. Experts call the new
disease, acquired immune deficiency syndrome (AIDS), meaning a breakdown
in the body's natural defenses that often leads to fatal forms of cancer and lethal
bouts of infection. The cause of this illness was unknown but was thought to be
caused by an infectious organism and the mortality rate is 50 percent!.
The disease begins with malaise, a low grade fever, night sweats, weight
loss and swollen lymph glands. In about 40 percent of cases. it leads to a deadly
form of Kaposi's sarcoma, previously unknown in the U.S.A.. AIDS victims
also face the risk of lethal infections such as pneumocystitis carinii pneumonia
(PCP) and mycobacterial infection.
Etiology
What makes the immune system go awry '?. An early theory linked the
problem to arnyl nitrite, a substance widely used by homosexuals to enhance
sexual pleasure. The pattern of AIDS closely resembles the occurrence of
hepatitis B which commonly strikes homosexuals, drug addicts using
contaminated needles and sometimes patients getting blood transfusion. All
attempts to isolate an infectious agent failed until recently when the suspected
agent a cytomegalovirus was discovered, it is an organism known to be found in
Kaposi's sarcoma tissues. CMV can be transmitted by blood, it can be transmitted
sexually and it is capable of causing immune suppression, scientists are already
looking for CMV antibodies in the serum of AIDS patients.
Recent research suggests that AIDS may be transmitted in more ways than
originally believed, i.e. through male homosexuals, drug abusers and those
infected by contaminated blood or blood products. But, it is proved to be a
sexually transmitted disease, the only one that is almost invariably fatal, that can
be caught and passed on by persons of either sex. In the U.S.A., the National
Cancer Institute stated that: "Given enough time and heterosexual contact, this
virus will move gradually into all parts ofthe population !".
The number of cases of AIDS is doubling each year, which would mean
about 35,000 cases by the end of next year in the U.S.A. only (1983). In Europe,
the World Health Organization reported many new cases in 17 different
countries. Because. it is now clear that chiefly in Africa. AIDS is a heterosexual
disease, since about half the victims are women. Contact with prostitutes is a
common factor in many of the African cases reported in Zaire, Rwanda, Uganda,
Tanzania and Kenya. But those suffering from AIDS itself are only part of the
picture. Because for every victim, there are tive to {C11 lllOl'€ people \\l1<) stllilef
from a less severe form ofthe disease that is not fatal. and more than $0 to 100
others who have been infected with the AIDS virus but show no symptoms -
171
600,000 to l.2 million in the U.S.A. only. No one knows how far or fast the `
epidemic will spread.
French scientists at the Pasteur Institute in Paris, have isolated the virus as
well as other researchers and it was named: HTLV-3 or LAV by the French
researchers. It was described as the No. one U.S.A. public health problem and the
most diabolical virus ever discovered in history because it knocks off the very
cells that are supposed to protect the human body.
Mode of Infection
Scientists up till now are unsure of the origin of the AIDS virus, how it
works and why it targets the white blood cells known as T4 lymphocytes. Strange
enough the virus was recently found in the brain cells, in the epithelial cells that
line the eyes and eyelids, but it is certain now that the virus is also present in
saliva, tears and urine in addition to blood and semen. However, anal intercourse
is believed to be the most efficient mode of transmission. Intimate deep kissing,
in which saliva is exchanged could well transmit the disease, if the uninfected
person has any cuts. sores or bleeding gums. Homosexual men account for 73
percent of U.S. adult cases. intra—venous drug abusers account for I7 percent
while blood transfusion recipients compose nearly 2 percent, lremophiliacs almost
I l percent, Heterosexual men and women about I percent, through sexual contact
with infected bisexuals and heroin addicts. So far about 6 percent of adult cases
and I0 percent of childhood cases are in people who tit none of the known risk
groups ‘?.
Research
Much of the current concern focuses on heterosexual transmission, but
researchers caution that it may take several years for a clear discovery. A key link
may be prostitutes, who are often drug abusers and therefore at risk for AIDS.
Nearly one-third of a sample of about 80 male AIDS patients classified as being
in the "no known risk" group admitted to prostitute contact ll. Studies at the
Walter Reed Army Institute of Research of U.S. military personnel with AIDS
also implicated prostitutes, as do studies of African and Haitian AIDS patients.
Many experts say the risk to the heterosexual population will increase over the
next tive to ten years, with those who have many sexual partners in greatest
danger.
The most popular hypothesis prevailing so far is that AIDS is indeed a
fairly new disease, and that the AIDS virus originated during 1960 in central
Africa as an evolutionary descendant of a monkey virus. The species known as
the African green monkey carries a virus very similar to the AIDS virus. Tests of
its molecular structure show that it differs only slightly from the AIDS virus. This
monkey virus causes an AIDS—like disease among several species of monkeys.
which is called SAIDS, for simian, or monkey AIDS.
172
Epidemiology
Epidemiologists tracking AIDS found that while it spreads more slowly
than the fearsome plagues ofthe past, still it is much more deadly. Bubonic
plague and cholera killed about halftheir untreated victims, smallpox as many as
40 percent. The death rate for all the U.S. AIDS cases to date is 50 percent. Truly
the disease takes years to kill its victims, but among those patients discovered
during the early years of reporting, the death rate approached l00 percentl., no
one has been cured. Once you get the disease it is essentially, unifomially fatal.
Doctors at the various centers for disease control were alarmed at the rapid
spread, but reassured at least at first, that the disease appeared to be transmitted
only through sexual transfer of semen or blood, through sharing hypodermic
needles, transfusion of blood products or to an unbom child during gestation or
just after birth.
The slower pace of AIDS epidemic is offset by a potentially more
frightening uncertainty about who is infected and what may happen to them. The
US. government best estimates suggest that 5 to l0 percent ofthose infected will
come down with AIDS in five years. About 25 percent will get a syndrome, also
over a five—year period, now known as ARC or (AIDS related complex), which
causes vague symptoms such as fatigue, low grade fever, swollen lymph nodes,
diarrhea and weight loss. Any where from 5 to 20 percent of ARC cases may go
on to get AIDS, but for the rest the symptoms ofARC persist.
Incubation Period
Because AIDS is so new, its incubation period is vague, blood-transfusion
cases now average about two and half years from the time of exposure to
development of the disease, but some cases can take more than five years even
lasting beyond I2 years. And because the virus may insert itself into the host's
own genes, the effects ofthe dormant AIDS virus, may not show up for decades,
perhaps not until old age when the immune system normally weakens. We have
to assume that anybody, who is truly positive on the blood test is potentially
infectious to otliers.
Most people in the hardest hit groups already have infections from other
sexually transmitted viruses, such as hepatitis B virus and the Epstein—Barr virus
that causes mononucleosis. These groups include not only homosexual men and
heroin addicts who share needles but the African victims as well.
Experiments have shown that AlDS—infected T4 cells growing in a test
tube can live indefinitely, dying only when exposed to some unrelated foreign
protein that stimulates them into action. As such, it is possible that a human
infected with the xrirus could at least postpone the onset of AIDS if he avoided
ordinary infections 7.
173
Treatment _
Better understanding of the virus is helping scientists design drugs to
interfere with its survival, and ultimately, a vaccine that would protect those not
yet exposed. A prototype vaccine that has been given to rhesus monkeys
produced antibodies in their bodies, now, scientists in U.S.A. Scotland and
Sweden are waiting to see whether these antibodies would prevent the AIDS
virus from invading the monkey cells.
Health officials urge the public to reduce the risk of spread of the disease
by changing any abnormal sexual behavior and particularly by avoiding multiple
sexual partners. Pentamidine has proved to be effective in the treatment of
pneumocystitis pneumonia as well as Interferon, but treatment is still tricky and
prevention is the most effective way of dealing with AIDS which has already
struck terror throughout the homosexual populations all over the world.
The only real hope for AIDS patients lies in two categories of drugs: those
that attack the AIDS virus directly, generally by interfering with its replication,
and those that are aimed‘ at rebuilding the immune system. The antiviral
preparations under research now are: The Pasteur Institute HPA-23, but
unfortunately it causes serious blood clotting problems, Suramin, Ribavirin and
Foscarnet which are described truly as not being miracle drugs. To revitalize the
weakened immune systems of AIDS patients, bone marrow transplants and
infusion of interferons and interleukin-2, which is another substance produced
naturally by white blood cells. But such efforts, like those aimed at arresting the
virus, have tailed so far to influence the course of this fatal disease.
Religious view
Islam and Christianity prohibited anal intercourse strictly because ofits
dangers and serious complications.
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Recent Research in AIDS / HIV
Considerable progress has recently been achieved in understanding the
pathogenesis of (HIV-l_) and in improving the efficacy of antiretroviral therapies
for the treatment of patients with AIDS. The pharmacological properties ofnew
drugs e.g. (AZT) are very effective in establishinga long—term suppression of
(IIIV-I) replication and have remarkably increased the survival period of patients
with AIDS. However, current therapies are still far from eradicating (I-IIV·l)
from patients and do not prevent the development of AIDS~related malignancies
which affect 40% (HIV-I) individuals e.g. Kaposi`s sarcoma, non—IIodgkin’s
174 '
lymphoma, intraepithelial cervical carcinoma and anal neoplasia. The cost of
therapy is very high and expecting the number of individuals affected by (HIV-l)
by the year 2000 to be 40 million !... while some 90% of these individuals are in
developing countries which can not afford the cost of antiretroviral therapies and
not even sure to have a proper follow up of patients with AIDS.
Among youth, the association of alcohol and drugs to HIV/AIDS risk is
significant and that prevention programs need to target alcohol and drug use as
important inf`Iuences on risky sexual behavior.
Treatment of (HIV-I) infection with (Zidovudine) does not exert uniform
selective pressures in multiple organs with the likelihood of different resistance
patterns being present in multiple sites within the same individual. The new drugs
ofthe protease inhibitors e.g. (Saquinavir) raise the possibility of disamiing the
HIV critical enzymes.
The HIV/AIDS epidemic has put men`s sexual behavior in the spotlight.
Prevention is the only solution. Yet, too many men still engage in risky sexual
practices, such as having multiple sex partners, including other men (homosexual
behavior), and not using condom consistently. ln some countries, such as
Thailand many married men frequent sex workers and do not use condoms with
prostitutes. In Asia and Africa, some older men seek out virgin girls, known as
(cherry girls) I whom they believe to be safe from HIV. ..
Condom use has to be increased among adolescents because of the
widespread awareness of AIDS and sexually transmitted diseases (STDS).
Information and sex education about safe sexual practices should continue to
protect the high risk males and females.
The global AIDS epidemic provides the starkest contrast between the
planets halves and have nots... In parts of Southem Africa, the infection rate is
25% and rising. In Uganda considered ground zero of the plague, life expectancy
has fallen to 43 years !... The WHO report on the highest AIDS cases in l997
are: Subsaharan Africa 71%, South and Southeast Asia 20%, Latin America 4%,
North America 3%, West Europe 2%, East Asia & Pacific 1% and Caribbean 1%,
India has got more than 4 millions infected with HIV.
Latest research by scientists at Alabama University U.S.A reported in the
International Congress for the Prevention of AIDS that the (HIV) virus may have
been transmitted to humans from the Chimpanzees in West African. The virus
has been discovered in a dead chimpanzee while the speculated possible role of
transmission is through eating the flesh of these chimpanzees. Thirty million
humans are infected now with this virus (WHO report); I7 millions are men
while I2 millions are women. Scientists hope to prepare a vaccine now that they
know the HIV virus is present in these animals without causing them any harm or
epidemic". With the help of genetic engineering applied on the IIIV virus, their
results to find this hopeful vaccine have failed so far; but another trial is being
carried out in Uganda with a new vaccine given to a few human volunteers.
175
MASTURBATION OR THE SECRET SIN
• Terminology and Technique. y
• Religion and History.
• Sexual Aids and Research.
• Medical Opinion and Conclusions.
MASTURBATION OR THE SECRET SIN
Terminology
The word masturbation is derived from the Latin verb masturbare; which
means to defile by hand or to disturb by hand. The term was introduced into the
English language only about 200 years ago. Before that time, people used other
descriptions, such as "youthful passions" or "solitary pleasures". It is also
termed "Onanism" and the "secret sin". Still, it is important to realize that the
term is actually quite imprecise and misleading, because both males and females
can masturbate without using any hands. Therefore, when modem sex researchers
speak of masturbation, we refer to: "any deliberate bodily self-stimulation that
produces a sexual response".
Technique
Such deliberate stimulation can take many different forms. ln a great
number of cases, of course, the hands are indeed used. Thus, males may fondle,
rub, or stroke their erect penis with their hands until they reach orgasm. At the
same time, they may also use one hand to manipulate other erogenous zones of
the body. For instance, in order to increase their overall sexual arousal, they may
touch and lift their scrotum. There are some rare cases in which men insert a solid
thin object into their urethra or into their anus for further sexual stimulation. lt
goes without saying that this latter practice is potentially dangerous.
Females may also use one or both hands to masturbate. Most often they
manipulate the entire vulva, or gently stroke the shaft of the clitoris and the labia
minora. Some women simultaneously play with the nipples of their breasts, and
in some females, this breast stimulation alone may lead to orgasmic release.
Instead of using their hands, both males and females may also simply rub
their sex organs against some object, such as a pillow, a towel, the bed covers, or
the mattress. Indeed, some females reach orgasm by riding a bicycle or a horse!.
Many females can also masturbate by crossing their legs or pressing them together
while moving rhythmically back and forth. ln certain instances, rhythmic muscular
tension alone is sufficient to produce an orgasm among some very excitable
females.
Many men imagine that women always insert their fingers or some
cylindrical object into the vagina when they do masturbate. However, only
relatively few women do so, because there is almost no sensation in the inner two
thirds of the vagina itself since its walls contain hardly any nerve endings.
Instead, the most sensitive and excitable female organs are the clitoris and the
minor lips. Thus, females may on occasions, insert a finger into the vaginal
opening which is sensitive to touch and palpation in order to gain a firm hold for
the rest ofthe hand, which then stimulates the external sex organs.
176
Sexual Aids
Those females who insert various solid or semisolid objects deep into the
vagina often do so to please themselves more, or to entertain and please their
company. The objects used for this purpose are usually simple household items;
such as candles, cucumbers, or bananas and hundred other variable objects that
may suit and fulfill their personal requirements. However, today there are also
special masturbation gadgets, termedgsexual aids, the most popular of these is the
artificial penis, also known as a "dildo", (probably from the Italian word diletto:
delight). Dildos are made of wood, rubber, or plastic, and some of them can even
be filled with warm liquid, which, when suddenly released, simulates an
ejaculation of the male... Penis shaped, electric or battery operated vibrators,
have appeared recently in many American and European drugstores and sex
shops all over the world.
The Japanese have developed still another strange sexual device called
"benwa" or "rin-notama", it consists of two hollow metal balls, one of which
contains a smaller ball made of lead or mercury. The two balls are introduced into
the vagina when needed and held in place by a tampon; the wornen's normal
bodily movements then cause the balls to click together and to send then pleasant
vibrations through her entire pelvic region. lt is not certain, however, whether
they can cause much sexual arousal or lead to orgasm, because they (the two
balls), never touch the clitoris at all, and the vagina itself contains virtually no
nerve endings. Onlv, the outer third (orcasmie nlatfmrm) me mma anaangs ....1
narrows in response to sexual stimulation. Finally, there are invented recently
some electric vibrators or battery operated massagers (penis-shaped or otherwise)
under the pretext of body massage, which are meant to be used on the female
external sex organs, where with different adjustable vibration speeds, it provides
a much more effective sexual stimulation than could be achieved by vaginal
insertions only.
Age of masturbation
(infant and childhood masturbation is mentioned in detail in the chapter of
the development of sexual behavior).
While still in their infancy, both males and females may start to masturbate
all by themselves, as they play with their sex organs, they may discover some
pleasurable feeling and then simply they try to repeat the experience. However. in
most cases, conscious and regular masturbation does not begin until adolescence.
Boys are often taught how to masturbate by other boys, or they hear about it in
their conversations. Since boys seem to discuss sexual matters much more openly
than girls in our society they usually obtain more sex information at an earlier
ngtu In contrast, girl; mt mute lilwly tu UIUUUUM lllllllllilulma alms and by
chance, while some ofthem are introduced to it through "petting" or "sex play",
and some others read about it in erotic books or magazines. There are many
recorded cases of girls who masturbate for years before they realize what they are
doing, they may llren be quite shocked and feel guilty about it. After all, most
177
people in our culture consider masturbation wrong and sinful, as a result many
boys and girls feel a double guilt. They seem to displease God and to ruin their
health at the same time. In some medical textbooks, masturbation is seen almost
exclusively as an adolescent activity, in actual fact, however, it is also practiced
by many adults, including some married couples as well. At some time, sexual
research indicated that addiction to masturbation was considered as a sign of
sexual immaturity, and an end result of the individual’s mal-sex development.
However, up till now, guilt complexes over masturbation are still remaining as
a very significant factor in the psychosexual development of many individuals in
our society.
We know that for many teenagers in our culture masturbation is the mos_t
common or even the only sexual outlet. However, this does not mean that it is
typical for the earlier phases ofhuman sexual development and that it is practiced
only during adolescence. lt simply means that adolescents do not have sufficient
opportunity for sexual intercourse because they are not yet married, as such,
adults who sometimes masturbate when they cannot or have not got the chance to
get married, have no reason to feel that they are immature.
Religion and History
Although masturbation was considered a major sin by the ancient Jews, as
A well as the catholic church, it was the Protestant who singled masturbation out as
a substitute for the devil!. ln actual fact. all religions condemn the practice of
masturbation, because only the proper sexual relations between males and
females can lead to reproduction and thereby ensure the survival of the species
and of the social group. Any society that developed a bias in favor of sexual self-
stimulation, homosexual intercourse, or sexual contact with animals would
simply condemn itself to extinction.
In the 18th century (1710), an anonymous pamphlet appeared in England
under the title, "Onania, or the Heinous Sin of Self-Pollution and its Frightful
Consequences in Both Sexes". The author, named Bekker, offered his readers a
summary of the old theories about the dangers of "wasting" semen. He called this
behavior "Onania" in reference to Onan, a biblical character who was punished
by God for refusing to impregnate his brothers widow. As required by custom, he
engaged in coitus with her, but prevented any possible pregnancy by practicing
the withdrawal method of contraception (coitus interruptus). Bekker's pamphlet
was translated into several European languages and went through more than
eighty editions.
ln 1760, Tissot, arespected Swiss physician published an influential book
entitled: "Onanism and the disorders produced by masturbation". The author
claimed that masturbation was not only a sin and a crime but that it was directly
responsible for many serious diseases such as: "dcterioration of eyesight,
disorders of digestion, impotence. and insanity". llis views became oilicial
medical doctrine and physicians all over the West found masturbation at the root
178
of almost every disease !. In the l8th and l9th centuries, physicians believed that
masturbation caused a variety of illnesses, (Gilbert); these diseases we now
diagnose as tuberculosis, rheumatic fever, epilepsy and gonorrhea... For about
l50 years, most medical authorities seemed to agree with Tissot, the famous
Swiss physician, who stated that: "the loss of one ounce of seminal fluid was
equivalent to the loss of forty ounces of blood l".
Old Medical opinion
By 1812, when Bejamin Rush, known as the father of American
psychiatry, published his "Medical Inquiries and Observations Upon the Diseases
of the Mind", the harmful effects of masturbation were taken for granted.
According to Rush, -onanism caused not only insanity but also "seminal
weakness, impotence, tabes dorsalis, pulmonary consumption, dyspepsia, vertigo,
epilepsy and lpss of memory"...
lndeed, till some years ago, the Venderbilt Clinic in the Presbytarian
hospital, a weekly held "Masturbation clinic", where patients paraded before
attending physicians and medical students, as examples of the evil and
pathological consequences of "Sexual self-abuse", namely masturbation and its
complications. In the l8th century, the medical profession pointed the way to
discover the secret masturbators; general apathy and laziness, dim or shifty eyes,
a pale complexion, a slouching posture, or trembling hands were considered
symptoms of secret "self-abuse".
Old medical treatment
Once the diagnosis had been established, the "therapy" could begin, a
confirmed masturbator was usually given a special diet. Different doctors
recommended different diets, not unlike their modern colleagues who fight
obesity nowadays!. lt was also believed that a hard mattress, a thin blanket,
freouent VVHShlI'lY with Phil" \l/¤f¤rI QHA Unnnrnlljv |i•I·|·
helpful in breaking the secret habit. ln addition, simple and practical clothing was
considered essential, as a matter of fact, there was even a trend to introduce skirts
for men and to abolish wearing trousers altogether, because they are too warm
and irritate the sex organs!.
In the 19th century, Henry Maudsley the greatest British psychiatrist of
his time, described masturbators as mad and potential killers and it seemed only
prudent to have them locked up in an asylum, because "masturbatory insanity"
was considered incurable in its later stages... All medical science could really do
was to concentrate on the prevention and early detection ofthe disease. Parents
were therefore advised to tie the hands of their children to the sides of the bed l,
or to make them wear mittens or gloves spiked with iron thorns!. Special
bandages and "chastity belts" were to render the sex organs inaccessible.
Doctors invented ingenious contraptions and bizarre devices to protect people
from abusing themselves, (one of the more bizarre of these inventions was a
l*"9
fantastic "erection detector"l, which rang a little bell in the parent's bedroom as
soon as their son had an erection in his sleep!).
Old surgical treatment
Finally, if everything else failed, surgery was recommended. The most
popular surgical treatment was lniibulation for males (i.e. putting a metal ring
through the foreskin, thus preventing an erecti0n)!, and clitoridectomy for
females (i.e. cutting out the clitoris)... As late as 1910, this operation of
clitoridectomy was done as a treatment of chronic masturbation for females in
England. One cannot help but feel that the medical authorities who administered
these painful, dangerous and useless treatment were not so much interestedtin
preventing masturbation as in punishing their unfortunate patients. Indeed, some
guilt ridden patients punished themselves by mutilating their bodies and sexual
organs or even committing suicide sometimes
Frequency
Over the last hundred years, one can observe a gradual softening of the
original harsh psychiatric attitude toward masturbation. As a result, past
description of "self-abuse" was perhaps only a "bad habit", or a symptom of
"arrested sexual development". Still, masturbation remained potentially hamiful
because many doctors insist that a young man's proper physical growth depend on
the preservation of his semen and that he could therefore weaken his body by
wasting it prematurely; up till now this theory lacks enough evidence.
lt became safe to warn only against "excessive" masturbation, and this
proved to be a comfortable fallback position, because "excess" is a relative term
and it was never clearly defined and any prospective masturbator was
nevertheless deterred. While some people never masturbate at all in their entire
lives, others masturbate several times a day, thus, certain doctors denounce
masturbation as a non—pr0ductive, n0n—creative and parasitic habit. They warn
A that any excess will turn into a false lead like alcoholism and compulsive
gambling. Some educational writers also hint that masturbation might lead to
egoism, loneliness, or a hatred of the opposite sex. ,
Recent research
A summary of a recent research about masturbation performed by (Miller
and LiefQ 1978), related the following facts about masturbatory attitudes,
knowledge and experience on 30,000 volunteered medical students in the U.S.A.
lt revealed that male masturbators amounted to 97% among the male American
population, while female masturbators were only 79%. (The tests applied were
termed SKAT for shortening).
180
Questionnaire
The types of questions put forward to the male and female medical students
whether they were white, black or Latin American were:
(1) Relieving sexual tenslon by masturbation is a healthy practice ?
- Strongly agree.
- Agree. ·
- Uncertain.
— Disagree.
— Strongly disagree.
(2) Frequency of masturbation ?
— Less than once per week.
— Two to three times per week.
- Four to live times per week.
— More than five times per week.
(3) Certain conditions of mental and emotional instability are caused by
masturbation?
- True.
— False.
Conclusions
• The outcome of this research revealed that males have more liberal attitudes
lOW8r(lS Imasturbation than females] on the Umm Imuu, lemale
Sllltlenis 1.e. female doctors are more liberal and free than male doctors about
the practice ofmasturbation.
• The sexual attitude about masturbation whether male or female, the
knowledge and experience about it, increase with education. Naturally, those
who never masturbated are more conservative about this sexual habit and are
less knowledgeable about it.
• I6 percent of the medical students believe that masturbation is a cause of
mental illness, while more resident doctors share this view.
• The incidence of masturbation among males is 97 percent and among
females is 79 percent; out ofthese females:
a. l9 percent masturbate actively before the age of l0 years. I
b. 34 percent started masturbation before the age of l3 years; (naturally, one
must remember here the effect of menarche on the sexual activities of
girls).
c. About 45 percent, masturbated before the age of l6 vears.
181
lt is interesting to record here that early female masturbators have less
heterosexual experiences as compared with late masturbators, (i.e. they were
not interested in coitus).

Virgin males and virgin females are more likely to have never masturbated,
but ifthey did, then it is done later in life and with lower frequencies and they
are more conservative and less knowledgeable about masturbation than the
non—virgin males or females.

76 percent of these medical students believe that masturbation is healthy; in

another sex research performed by Prof. Hunt in 1974, 80 percent of his
volunteers confessed that masturbation to them was not wrong. Comparing
these percentages with other research volunteers of a lower social level of
society and with less education and more conservative attitudes, it was found
that both Prof. Kinsey and Prof. Cotton reported much lower percentages. No
wonder that in the last few years there has been a demand for greater female
sexual liberalism as regards marriage and sexual experience.,

An interesting finding of this research suggests that there is nowadays a

group of females, who are early masturbators and who have inhibited
heterosexual attitudes and behavior. This group of women are narcissistically
invested, who turn to their own bodies as a defense mechanism against the
anxiety of heterosexual experiences and its unfortunate failures or usual
disappointments. They may tum out to become homosexually oriented,
developing later a full lesbian attitude. They are usually the victims of
parental repression and punishment, sometimes due to a very harsh infantile
correction during their sexual development and usually with minimal or no
stable family ties or parental love.

Another finding about males, was that they were found as we mentioned
earlier to have a higher incidence of masturbatory activity, extramarital
relations, violent sex crimes, premarital sex, and are more homosexuals than
females. They indulge more in coitus during adolescence, as well as having
more sexual adventures.

Deformity of the penile shaft when fully erected, has been noticed among
some chronic manual masturbators, synstroposed deformity was recorded
among right hand masturbators, while the opposite was noted with left hand
chronic masturbators, namely dextroposed penile inclination when fully erect.
Sometimes ejaculatory incompetence, as a complication of chronic
masturbation was mentioned before in the chapter of sexual inadequacy.

When the anus is penetrated chronically during various abnormal sex acts,
such as: sodomy (receiver), or manually by the fingers for additional sexual
pleasure, e.g. during masturbation. or through introduction of solid objects
e.g. vibrators, for the achievement of anal sexual pleasure; and strangely
enough, to conceal valuables or small smuggled objects e.g. drugs and

182
 diamonds. Over time and as a result, the repeated trauma inflicted causes
excessive dilatation or even mpture of the extemal sphincter muscle fibers
with consequent anal incontinence. "Fist fucking" is the temt used when the
whole hand is passed into the rectum,.

• The fashionable very tight jeans, frequently worn nowadays, by both males
and females are possible signs sometimes of expression of voluntary or
involuntary masturbatory activities. The results of a research published
recently denoted that there were reported cases of unexplained leucorrhoea,
pruritus vulvae as well as pruritus ani, caused by the continuous friction and
excessive heat developed, because of the continuous usage of these very tight
jeans.

• lt is worth mentioning here, that some types of male infertility are

successfully treated nowadays, since new investigational methods have been
developed to show a substantial retrograde flow down the internal spermati
vein. This occurs whenever a tme varicocele is palpable, the techniques
include retrograde phlebography of the internal spermatic vein, infrared and
contact thermography; the idea behind is to show a temperature increase over
the affected half of the scrotum. Color Dopler sonography greatly helps in
diagnosis of varicosity or varicocele. Surgical suprainguinal ligation of the
intemal spermatic vein is the method of choice, with claims of subsequent
improvement in the seminal picture, ranging from 30% up to the impressive
percentage of 80%. Because heat is considered to be detrimental to the
sperms, influencing the metabolism of spermatogenesis; males are advised to
wear baggy underwear, avoiding the usage of tight pants, as well as the
continuous application of iced cold water, through scrotal dip baths for
several months.

Comment

"No other form of sexual activity has been more frequently discussed,
more roundly condemned, and more universally practiced than
masturbation"
- Dearbom, 1967.

183
 SEXUAL GLOSSARY AND
THE PARAPHILIAS

Sexual Terminology.
Abnormal Sexual Activities.
• Treatment.
 SEXUAL GLOSSARY AND THE PARAPHILIAS
Paraphilias: Sexual deviations or sometimes called sexual perversions
abnormal sexual acts.

Erotic: Sexually stimulating.

Erogenous zones: Sexually stimulating areas ofthe human body, such
the mouth, lips, tongue, breasts, nipples, buttocks, genitals and anus.
Auto-eroticism: Self induced sexual pleasure, masturbation is a gross
example in both males and females, while a mild example is intentional d
in tight fitting jeans, mini (very short) skins and tiny sexy underwear.
Oral eroticism: Mouth sexual pleasures, a good example is kissing both
light and deep kissing.
Anal eroticism: lt is sexual pleasurable sensations felt in the region of the
anal orifice.

Libido: The sexual impulse or sexual hunger or desire, it is also referred to

as the sexual energy or the sexual desire of a person male or female. lt is
experienced as specific sensations which move the individual to seek out or
become receptive to sexual experiences. These sensations are produced by the
physical activation of the specific neural system in the brain.
Orgasm: The pleasurable sexual climax of the sexual act of any sexual
activity; in the male, it results in the ejaculation of semen in the adult mature
man. While in females. it is characterized by contractions of the uterus, anus and
orgasmic platform and a satisfying state or states of sexual pleasure follow
relaxation after an already vaginal transudation.
Sexual petting or foreplay to coitus: Also referred to as precoital petting
is the act of exploring and touching each other’s erogenous zones including the
sex organs; in other words, it is sexual contact that stops short of coitus.
lmpotency: It is an example of male sexual dysfunction, a variety of ma
sexual inadequacy. lt is divided into primary and secondary types, it was believ
in the past that about 85% of cases are psychogenic while the rest are consid
organic. A good example of organic causes are the neuropathies of diabetes
amounting to 59% and some endocrinal syndromes. Recent research estim
organic causes to be nearly equal to psychogenic causes. lmpotency is not an
absolute hindrance to perform a sexual act because some males could get an
orgasm and ejaculate with a limp penis, while many others cannot and are
severely frustrated as al result, especially when repeated failures are recorde
a non-cooperative or sexually ignorant female partner.
Frigidity: The inability of a female to achieve or reach an orgasm during
any type of sexual activity; it should be differentiated from the condition termed
"lacking orgasmic capacity"; frigidity is an example of female sexual
inadequacy or dysfunction.

184
 Vaginismus: lt is a condition of involuntary spasm or constriction of the
musculature surrounding the vaginal outlet and the outer third of` the vag
psychophysiologic syndrome may affect women at any age and may
considerably in severity. The most dramatic instances of vaginismus
as unconsummated marriages, since penile insertion into the vagina may n
possible due to spasm, resistance and attendant pain; at the other end of the
clinical spectrum are cases in which coitus is possible but painful (
Karezza or coitus reservatus: A certain religious group of the pas
actively encouraged men to practice coitus without ejaculation. This kind o
coitus was
spiritual growth!.
supposed to last for several hours, aiming at furthering a
Erotomania: An excessive sexual urge which could never be satisfied in
both sexes e.g. nymphomania and satyriasis.
Nymphomania: Excessive sexual desire in the female, which, is not
satiated, never satisfied. lts occurrence is rare and it should be well differentia
from the healthy normal multiorgasmic capacity of many normal females.
Satyriasis: Unsatisfied sexual appetite in the male, unsatiated, it should b
differentiated from hypersexuality. As a matter of fact nymphomania
satyriasis are extremely rare and abnormal states of hypersexuality.
Tongue kissing: inserting the tongue into the mouth of the sexual pa
for the
kissing.
purpose of increasing sexual excitement, sometimes referre
Bitting kiss: The act of bitting and kissing the flesh of a person
increased sexual excitement,
nipples during sexual excitement.
an exaggeration of this condition is bitti

Orgenitalismz Various forms of mouth and genital contact aimi

sexual pleasure, it is referred to sometimes as buccal onanism, which is an act of
oral masturbation and it generally refers to the acts of fellatio and cunn
Fellatio: The act of taking the penis erect or flaccid into one’s mouth and
sucking it by a male or female partner or by himself...! The international scandal
of Monica Lewinisky is a proof of the spread of this perversion in the world d
to its prevalence in abnormal sex films.

Cunnilingus: The act of licking, tonguing, sucking or mouthin

external female genital organs namely the vulva, clitoris and labia.
Anilingus: A sexual deviation wherein the person male or female derive
sexual excitement and satisfaction by licking the anal area of another p
Fetishism: Inithis condition, sexual arousal occurs principally in r
to an object or body part that is not primarily sexual in
generaly used during masturbation or incorporated into
anoter person in order to produce sexual excitation. Often the fetishist collects s
such objects; in some cases, the behavior involves stealing the objec
appears to contribute an added sense of risk and mystery. ln some men and
185
women, sexual arousal to the point of orgasm can occur only in response to the
fetish object, real or fantasized. Objects such as: articles of clothing e.g. gloves,
shoes, panties, female nickers (underwear) and suspenders; all these articles enter
into masturbation fantasies or other sexual activities but they are always
necessary for sexual gratification.
Breast fetishism: The breasts of a female as the preferred part of a
woman’s body, capable of arousing the greatest amount of sexual pleasure, other
examples are buttock’s fetishism. The breasts in U.S.A. are well known to he
admired by most American males, no wonder, they are mocked and described for
fun as immature sexually being bosom attracted!
Transvestitism (Fetishistic cross dressing): lt is the act of wearing
clothes belonging_ to the opposite sex for erotic purposes and for sexual
stimulation. Transvestitism is more common among males than among females,
contrary to popular belief, most transvestites are heterosexual in orientation
mainly but it is also practiced by homosexuals and lesbians. Stoller, defines the
condition as : "a condition in which a man becomes genitally and sexually excited
by wearing feminine garments", it should be clearly differentiated from
transsexualisrn.

Transsexualism: The word comes from transsexual (from Latin trans:

across and sexualis: sexual). lt is a disturbance of gender identity, in which
persons are convinced that their gender identity is different from their physical
identity. ln other words, there are persons with male bodies who consider
themselves females and there are persons with female bodies who consider
themselves males. Particularly after puberty, such people become very
uncomfortable with their anatomical appearance and they try everything in their
power including "sex change operations" and modem hormone therapy to make
the body conform to their self—image. Thus, a man may acquire so many female
physical characteristics including breasts and an artificial vagina, that he can
generally pass for a woman after surgery. To a lesser extent, the reverse is also
possible, it is easier for a surgeon to construct a vagina in a male than a penis in a
female. There are gender identity clinics in various parts of the world and as
much as few thousands have undergone sex change surgery. Unfortunately, there
are also some rare cases where parents simply refuse to accept the biological sex
of their child, one example is the mother who deliberately forces her infant
daughter into the role of the son she had really wanted with an evident disastrous
sexual role assignment in the future.
Penis envy: lt is the envious feeling of a female and her deep passion to
posses a penis, it is also known as Castration complex, Mutilation complex and
Anatomical loss; most girls feel it mildly and come out of it during their normal
sexual development. The condition is manifested openly among active lesbians,
one being aggressive, mounts a passive lesbian and penetrate her while using an
artificial penis simulating coitus (tribadism), as such they do satisfy their ego.
Dream symbolism: The mechanism of substituting an object or a person
for another, during sleep for example, elongated objects like a pencil or a broom
or a snake may represent the penis and are symbolic of the male sex organs.

186
 Electra complex: A strong neurotic attachment or fixation of a daughter
for her father, it is termed after "Electra" a legendary Greek princess who afte
the death of her beloved father helped kill her mother who had murdered him.
Oedipus complex: A strong emotional and erotic attachment of a son for
his mother and a feeling of rivalry toward the parent ofthe same sex. lt is after
the legendary Greek king Oedipus, who unknowingly killed his father and
married his mother.

Masochism: After the famous Austrian writer Baron Masoch in the I9"`
century. lt denotes the feeling of sexual pleasure when being humiliated or
experiencing physical or mental pain.
Sadism: After the French writer De Sade in the l8"‘ century; it is acquir
sexual pleasure while causing your sexual partner or someone else physical or
psychic pain. Sadism can be very harmful because in some cases it may lead
sexual assault or even murder.

Sadomasoclristic: One who at times is cruel (sadistic) and causes another

person pain and at other times develops feelings of self-pity or experiences a
"need to sufl`er" (masochistic), as a means of attonement i.e. sexually pleased
end result being sexually satisfied.
Bondage: lt is the attainment of sexual gratification through being tied,
restrained, imprisoned or humiliated by another person or by oneself.
Flagellation: A sexual deviation involving the act of whipping the other
sexual partner or one’s self.

Narcissism: lt is excessive self-love, tendency to self`—worship, excessive

or erotic interest in orre’s own personal features, hence Narcissus from the Greek
(Narkissos) a youth who fell in love with his reflection in water. When the mirror
is used extensively by both a male or female person afflicted by this condition
staying long hours admiring his or her naked body is another example.
Incest: A sexual deviation where sexual relations are practiced between
members of one`s own family, such as, between father and daughter, son and
mother, brother and sister.

Bestiality: A form of sexual deviation that involves sexual contact between

a human being and an animal or a bird. Kinsey`s report about home pets
that bestiality is prevalent in the farms where there is common sexual contact
with the sow and the calf for males while in some countries, females eng
sexually with dogs performing various sexual activities including actual coitu
This perversion is also termed Zoophilia.
Homosexuality: lt denotes sexual relations between persons of the same
sex, the prefixes hetero- and homo-simply mean "different" and "same" in the
Greek language.

Bisexual: A sexual interest in both sexes. the capacity for sexual

pleasurable relations with either sex. Also, ambisexual may he used to describe
187
someone who is erotically attracted to partners of both sexes.
Sexual apathy: lt is the dislike sexually of one of the opposite sex i.e.
loves his or her own sex.

Lesblanlsm: A female homosexual love, female homosexuality, the erotic

love of one female for another or a girl for another female. The term was started
after the island of Lesbos, home of the homosexual ancient Greek poetees
Sappho, the relation is also known as Sapphlsm. The relationship may consist of
kissing by all its degrees, breast fondling, mutual masturbation i.e. they
masturbate for each other or they may apply cunnilingus or tribadism.
Tribadism, tribade: The act of one female lying on top of another female
while simulating coital movements so that the friction of the clitoris andthe
adjacent area bringsabout sexual excitation and ultimately an orgasm to her or to
both of them. One female is usually active, simulating or taking the active role of
the male and the other is passive or acting as a passive female usually preferring
to lie in the lithotomy position.
Troilism: The word is derived from the French language "Troi", meaning
three, denoting a sexual deviation in which three people participate in a series of
paraphiliac or pervert sexual practices. The sexual alliances may consist of two
men and one woman or two females and one male.

Sexual criminal or the sex offender: Men whose sexual behavior is

destructive and vietimizing, violating as such the society rules. The offenses may
include, incest, child molestation, rape, exhibitionism, obscene phone calls or
literature and voyeurism.
Voyeurism: A voyeur or "Peeping Tom" is a person who obtains sexual
gratification by witnessing other persons in a sexual or non—sexual state of nudity.
Voyeurs are often sexually frustrated individuals who feel too inadequate to
establish a normal regular sexual relationship.
Pedophiliac An adult and a child sexual relationship, performing abnormal
sexual activity, it may include heterosexual or homosexual activity. Pederasty
also means love relationship between a man and a male preadolescent involving,
oftenly sexual intercourse, they are also called child molesters or pedophiles.
Zoophilia: lt is the use of animals as a preferred sexual object or when it is
the only exclusive method of producing sexual excitement.
Biological sex: lt is defined as a person`s maleness or femaleness. lt is
determined on the basis of five physical criteria; chromosomal sex, gonadal sex,
hormonal sex, internal accessory reproductive structures and the external sex
organs. People are male or female to the degree in which they meet the physical
criteria for maleness or femaleness. Most indix iduals are clearly male or female
by all five physical criteria. However, a minority fall somewhat short of this test
and their biological sex is therefore ambiguous (hermaphroditism).
Gender role: lt is defined as a person`s masculinity or femininity. lt is
determined on the basis of certain psychological qualities that are nurtured in one
sex and discouraged in the other. People are masculine or feminine to the degree
188
in which they conform to their gender roles. Most individuals clearly conform t
the gender role appropriate to their biological sex. However, a minority partia
assume sometimes a gender role that contradicts their biological sex
(transvestitism), and for an even smaller minority such a role inversion when
complete is called (transsexualism).
Sexual orientation: lt is defined as a pers0n’s heterosexuality or
homosexuality. It is determined on the basis of preference for the sexual partne
People are either heterosexual or homosexual to the degree in which they are
erotically attracted to partners of the other or same sex. Most individuals develop
a clear erotic preference for partners of the other sex (heterosexuality). However,
a minority are erotically attracted to both men and women (ambisexuality) and an
even smaller minority are attracted mainly to partners of their own· sex
(homosexuality).
69: The slang temi "sixty nine" or French spoken "soixante-neuf" is used
to describe a form of oral intercourse in which the partners simultaneously lick
each other’s sex organs. ln doing so, the position of their bodies in relation to
each other is similar to that of the inverted numerals in the number "69"

Sodomy: lt means anal intercourse, after the ancient bililical city of

"Sodom" also known as "buggery" after a heretical sect in the country of
Bulgaria, the members of which were denounced as “buggers" (from Bulgars).
Gerontophiliaz Choosing sexual activity with an old woman.
Necrophilia: Choosing sexual activity with a dead body.
Pygmalionism: Choosing sexual activity with a statue.
Frottage: A person deriving his sexual satisfaction mainly from rubbing
his body and sex organs against that of his partner or someone else.
Oralism: A person deriving maximal sexual satisfaction from engaging in
oral intercourse mainly, (fellatio).
Analism: A person deriving maximal sexual satisfaction from engaging in
anal intercourse mainly.
Kleptolagnia: A pervert who instead of engaging in normal coitus, he or
she derives sexual satisfaction mainly from stealing something.
Pyrolagnia: A pervert who instead of engaging in normal coitus, he Of she
derives sexual satisfaction mainly from setting tires (Arson).
Urolagnia: A pervert who instead of performing normal coitus, he or she
derives sexual satisfaction mainly from playing with own or partner’s urine.
Coprophilia: A pervert who instead of performing normal coitus, he or she
derives sexual satisfaction mainly from playing with own or partner's feaces.
Exhibitionism: lt is the deliberate exposure of sex organs under
inappropriate conditions with the intention of evoking a response in thc observer.
Although sexual excitation is usually produced in the performer by the act of
exhibitionism, it is not invariably present even if desired; tirrther, although
189
exhibitionism has been generally regarded as a paraphilia exclusive to males,
there are isolated reports of female genital exhibitionism. lf exhibitionism
occurring as a result of organic brain disease or psychosis is excluded, most cases
involve the deliberate attempt to obtain sexual gratification via the act of
exposure and the unwilling viewer’s response. The exhibitionist may or may not
masturbate coincidentally with exposing himself- in a significant percentage of
cases, the exhibitionist may be impotent or have other sexual problems in
heterosexual relations. ln some cases, the exhibitionist is impotent even during
the act of genital exposure. Most authorities suggest that exhibitionists are usually
outwardly passive, shy or dependent and they are unlikely to commit rape. The
exhibitionist often follows a particular pattem of behavior leading up to his
genital exposure (for example, retuming to the same street comer or using his
automobile, ostensibly to permit a quick getaway)!.
Lingam: lt is the abnormally huge erect penis as a symbol of creative
entity, known also as "Phallic symbols", represented often in old Greek
sculpture as v *ell as in Ancient Egypt e.g. God Menn (god of fertility) in Upper
Egypt temples.

Sexual aversion: This condition is a consistent negative reaction of phobic

proportions to sexual activity or even to the thought of sexual activity. Although
it may be situational, occurring only with a particular partner or only in a
heterosexual contact but not during homosexual activity. The typical case of
sexual aversion involves a spreading negative reaction to all aspects of sexual
contact with another person. ln some instances, the phobic nature ofthe response
is manifested physiologically by profuse sweating, nausea or vomiting, diarrhea,
or palpitations, but in other instances the phobic components are internalized and
do not appear in this drastic manner. Sexual aversion may occur in either males or
females, but the preponderance of cases involves females.
lnhibited sexual desire: lt appears realistic to view libido as a complexly
determined phenomenon combining certain aspects of biologic (instinctual)
components, probably mediated largely by hormonal stimuli, with elements of
psychosocial conditioning. It is uncertain whether there are any people who are
truly asexual in the sense of never having feelings of sexual desire; however,
clinicians are well aware that some people repress or suppress their sexual feelings
so thoroughly that it may appear that they have no sexual desire. Frank and
colleagues recently found that 35 percent of women and I6 percent of men, in a
group of relatively well-adjusted and well—educated married couples reported
disinterest in sexual activity. Low libido may be the result of either organic
processes e.g. any chronic disease or psychosocial factors. Although low libido is
likely to be a sexual problem when a marked discrepancy exists between the levels
of sexual interest oftwo persons in a marriage, there are certainly instances in
which an acceptable accommodation is made to such a divergence and no problem
results. For example, a person with low libido may agree to participate in sexual
activity when his or her partner requests this, regardless of the person’s general
lack of interest. Alternatively, in sorrre couples a workable solution is reached by
allowing- or even encouraging- the partner with higher libido to pursue sexual
activity outside the relationship i.e. to have another wife in addition.

190
 Pornography: (literally: writing about prostitutes, from Greek po
prostitute and graphein: to write). Often
sex show, movies, records, pictures, books and magaznes. gp called ob
entertainment is not an invention of our time because in Europe se
and even intentionally obscene stage shows date back to Greek and Ro
antiquity. About 250 years ago, European aristocrats attended su
shows in their own private theaters.

Priapism: The term priapism refers to a persistent

erection that is usually independent of sexual arousal. Although it may e
s
impossible to determine the etiology of priapism, the most
include sickle cell anemia, polycythernia and leukemia. In these cases, aere
c
microvascular blood flow dynamics occur as a result of sludging of blo
resulting venous stasis blocks normal mechanisms of pe
Priapism may also result from venous obstruction due to malignancy
cord injuries, from penile trauma resulting in hematoma formati
reflex stimuli such as those associated with phimosis, urethral polyps, ur
calculi or prostatitis. In some instances, priapism may be drug-ind
thioridazine, heparin, testosterone, and hydralazine have been reported
this disorder. lt may happen as well due to an over dose during thera
treatment either orally or by intracavernosal injections for impotency.
Priapism is an emergency. since venous drainage to the corpora cavem
must be restored and damage to erectile tissue rnust be minimized, if the
is not brought under control, ischemic changes may occur in penile t
Treatment range from the application of ice packs and sedation to th
variety of surgical shunt approaches. Therapeutic de
proteolytic envymes given intravenously has
Anesthetic blocks, corporal aspiration of trapped blood, anuse o also bee
moleculanweight dextran have also been advocated. However, the
approach that will alleviate the priapism, while guaranteeing s
restoration of the erectile mechanism.

Treatment of the Paraphilias

'l`he literature describing treatment approaches to the paraphilias is rather
fragmentary. Most reports discuss results obtained in a small number
have no formal control group or fail to provide specific criteria for eva
outcome. Only briefmention will be made ofthe range of therapeutic t
that have been utilized, since this area appears to be under current reappraisa
Aversion therapy is a type of treatment used to produce a reduction in
, undesired behavior via a conditioned emotional response, by suppress
punished response or by thc development of an avoidance respon
therapy methods have included the use of electric shock and chemic
of nausea and vomiting. usually in combination with exposure to photographs
depicting the undesired behavior.

191
Other behavior modification techniques that have been used to treat the
paraphilias include positive conditioning of desired behavior, systematic
desensitization and biofeedback and penile plethysmography. A promising
method that utilizes principles of aversion therapy without electric shock or other
physical harm is a technique known as covert sensitization. The subject
imagines aversion scenes, (such as being caught by the police or being discovered
by family members) immediately after being confronted with a sexually arousing
scene, either visually or by fantasy. Another novel approach offering some
promise is the use of boredom in the reduction of undesired sexual interests via a
procedure involving verbalizing such fantasies while engaging in prolonged
masturbatory episodes.
ln Norway, asexualization was tried in the past as a method of treatment
for confirmed sex criminals especially those who were confirmed sex rapists and
serial sex killers. Oestrogen was given to these males in prison to change and
abolish their viscious sexual character; evidently they ended with gynaecomastia
and impotency
Both hypnosis and psychotherapy have been employed with varying
degrees of success in the treatment of paraphilias. ln addition, combined
approaches utilizing pharmacologic therapy (in particular, with the use of
antiandrogens such as cyproterone acetate or medroxyprogesterone acetate) and
psychotherapy or behavior modification have been gathering proponents and
appear to offer a high degree of efficacy. However, there is no single approach
that will suit all such cases. At the moment we can only hope for the future
development of a greater understanding of these behavioral patterns.
192
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