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Prof. Dr. 

Ahmed Khattab 




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WVHM 



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M^BI 



HUMAN SEXUALITY 



BY 

AZIZ AHMED KHATTAB, D. (Obst.) R.C.O.G., PhD 

Professor of Fertility and Sterility, 

Former Head of Clinical Pathology Department, 

NGO, Consultant and Lecturer In 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, first edition. 
Copyright ( c ) 1^86 by AZIZ AHMED KHATTAB 

Second edition. I 00 * 

Third edition, 1^9 

All rights reserved. No pari of this book may be reproduced 

in anv Form or bv anv electronic or mechanical means, 

including information storage and retrieval systems or translated 
without permission in writing from the author. 



FORE WARD 



Although it is true that there are regional cultural » n A r • 
differences with respect «o human sexuality, d^e S» spe^ wttnT 
universal tongue of science. The science of sexology is ft. ame tvhe.he i, t 
Egyptian sexology, American sexology or .he sexology of any natality 

When sexual medicine is not scientific it replaces sexology the science 
with sexosophy, the philosophy of sex. Everyone has his / her own „ e sona i 
sexosophy. It „ assimilated from the family, the community, the refill, ye 
even from the traditions of medicine. engion yes 

„,.• ■ •<-'" ' he ,' 8 '" a ? d l9 "' cenh,ries > w «'"n sexual medicine was based not on 

m di 'aMo^me^f'd "' °" a ^ ■ 3l SeXOS ° P " y W " ich ™ itMlf b - d "" * 
dain^H 1T1 * e &«°™y *> «« cause of all disease. Sexual indulgence was 
claimed to be the prune cause of degeneracy. Total abstinence was the doctrinal 
SSt^™! commended for procreation only, and more ' 
once a month was considered excessive!. Masturbation and seminal emissions in 
leep (spermatorrhea) were classified as diseases, all required drast c da„ eer ons 
and pumhve treatment. The degeneracy .hey caused could be pt e'd on to al 
subsequent generations, it was laugh.!. P 

sexual sciencewT "^ f T,' hiS """""^ "*>"<>& «™ard ,he rationality of 
sexual science was occasioned by one thing more than all the others This on- 

-hmg was the discovery of the industrial processing of rubber Tied „ I he 
commerca production of the firs, rubber condom. That was in the'l 870s Bu, he 

,hht eg "T 8 ° f ' he com r e P' ive ^ «» - the late 1920s, when the firs, ae x 
rubber condoms were produced. That was barely half a cenlury ago. 

sexosonltv'fiHk,?, 1 ' ' 'V* Hme T"*" f ° r * soci <^ *° «fe™»l«te its 
sexosophy I takes longer to accommodate to the new sexual values and ethics 

made possible ,o human beings by birth control and planned paren.lmod Sfil 
oday, therefore people in all countries are caught up in a great dispute r° wrdinL 
the merits and demerits of the old sexosophy and the new. regarding 

conseaue T n h r , iHs C n'r ,r "M 0n r' ikC "". ° f S ° CiC ' y ' is ca "8 lu "" "' "" s ^"rc. >" 
Z H^H . not possible for any book in sexual medicine to be lolal y one- 

hundred percent sexologically scientific. No matter who (he author may be he 

",« Th I", ' ea " T T .""' S SMe ' "° W °" ,ha! ' " f «" Srea. sc^osophic 
issues. Tl at is why, in Dr. Am Khattab's book. you will fi„d some concepts to 

agree with, and some to argue with. Pine ! that is why i, is a good book. 



A good book is always one that makes you think, and challenges your 
intellect, and changes what you think. In 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. 

In 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. It 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 21205 

US, A- 1981 



INTRODUCTION 



It is well known that writing a book about sexology is not an easy task, 
but to publish a medical one especially in Egypt I realised is an even harder job...' 
Back from London 1977, I took the opportunity to start editing this volume for 
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 year 
1964; at that time, I was teaching a modest course of sexology as part of the post- 
graduate medical curriculum. Only in 1977 did I succeed to convince my medical 
colleagues about the values of a sexology course for the Ain Shams medical 
students. It is true, I 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 medical 
students and doctors, who were asking for it and expressing their honest demands 
for this reference, as such I had to put my lectures on paper. I present this modest 
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 female who is interested to know the 
truth about our human sexuality long forgotten in this good part of the 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 issue, 
but I can assure everybody that I have done my utmost to present an honest 
knowledgeable explanation of such a delicate part of our sexual phvsiology and 
anatomy. My friend, Professor Dr. John Money, who is an international authority 
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. 

I have tried through this third edition to add what was recently discovered 
in the field of sexual medicine over the past ten years. The normal physiological 
mechanisms of erection in the male is quite evident and well documented now. 
Male erectile dysfunctions, are amenable to better treatment with more new drugs 
available e.g. Viagra (Sildenafil 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 <he ICPD conference in 1Q94; and a new decree is issued 

by the Minister of Health prohibiting its practice by anybody, medical or non 
medical. The vital role of the external female genitalia in achieving orgasm in 



non-circumcised females was confirmed by Johnson and Kaplan. The recent 
advances in the research of AIDS virus and the possible role of new drugs e.g. 
AZT to combat the virulence of this epidemic. The unfortunate widespread of 
AIDS 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 ICPD recommendations enforced the NGO (non governmental 
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 H S. 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 I was graduated in 1948 (Ksr El Ami) Faculty of Medicine, is 
presented within this manual together with the sexual research performed 
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. I invite the attention of all adult readers to a sober and 
dignified discussion of female and male sexual behavior. 

Di\ Aziz Ahmed Khattab 

Address: 28, 26 July Street. 

Cairo, P.C.: II 111 
Telephone (Clinic): 5742152 



CONTENTS 



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

INTRODUCTION 

1. SEX EDUCATION IN MEDICINE 1 

2. THE DEVELOPMENT OF SEXUAL BEHAVIOR 6 

3. MALE AND FEMALE SEXUAL ANATOMY 25 

4. THE PHYSIOLOGY OF COITUS IN THE HUMAN FEMALE 37 

5. THE PHYSIOLOGY OF COITUS IN THE HUMAN MALE 59 

6. POSITIONS OF SEXUAL INTERCOURSE 75 

7. MALE SEXUAL INADEQUACY (DYSFUNCTIONS) 81 

8. FEMALE SEXUAL INADEQUACY (DYSFUNCTIONS) 1 04 

9. SEXUALITY AND FEMALE CIRCUMCISION 122 

10. SEXUAL PERFORMANCE IN DIABETES 139 

11. EFFECT OF DRUGS ON SEXUAL PERFORMANCE 147 

12. HOMOSEXUALITY AND LESBIAN LOVE 161 

13. MASTURBATION OR THE SECRET SIN 176 

14. SEXUAL GLOSSARY AND THE PARAPHILIAS 184 




SEX EDUCATION IN MEDICINE 

Why teach doctors sexology ?. 
Milestones in the history of sexology. 



SEX EDUCATION IN MEDICINE 
Why Teach Doctors Sexology ?. 

!t ha f been proved that doctors were inadequately trained in the past to 
treat patients with sexual problems and that the physicians of the future are still 
being inadequately trained by most medical schools. With increasing success 
more and more medical schools added sex education to their curricula and 
fortunately ,t was started in Ain Shams Medical School during the year 1978 for 
he students of the final years; although I taught the post-graduate students in the 
lorensic, Skin and Venereal departments since the year 1964. 

Statistics in U.S.A and Europe revealed that an estimated one tenth of all 
adult patients the physician sees in his clinic have significant sexual problems 
Ha f of all married couples, experience at one time or another major sexual 
maladjustments; the severity of the problem is reflected in the current escalating 
rate of marriage failure or separation and divorce. 

Sexual problems are among the most sensitive and embarrassing 
complaints that patients bring to their physicians involving as they do, profound 
individual and family values. The doctor who received training and knowledge in 
human sexuality during his medical training, can help to alleviate much 
unnecessary suffering and to preserve many of the growing number of marriages 
which are in serious trouble today. Unfortunately most medical schools in Egypt 
do not teach sexual medicine up til! now. . . P 

I, .1 l! l re . COg ; ,i , tic ; n . of the g rowi »g » e ed «° prepare a good number of physicians 
for the task of helping patients with problems related to sexuality, a series of 
books in the field of sexology especially designed to grasp the vital goals of a sex 

ducation program were prepared. Most of the sexual medicine books were 

eveloped and written to operate on three levels. 

1. The acquiring of healthy sexual information through these medical books. 

2. The modification of persona! attitudes and the proper correction of alreadv 
wrong beliefs and sex taboos, particularly in view of the fact that medical 
students, whether males or females are also subject to embarrassment and 
discomfort in dealing with sexuality like anybody else. 

3. The learning of the necessary skills in dealing with patient's sexual and 
marital problems. 

For several years, it was with concern that many professors noted that the 
medical profession is not trained to deal with sexual problems. We all know as 
doctors that problems concerning sexuality is brought by patients daily to our 
clinics and hospitals or unfortunately never brought at all... Questions and 
problems concerning the following very sensitive issues: 



1) Sex education of our children from infancy to adulthood concerning healthy 
medical information to protect them against drug misuse, abnormal sexual 
behavior and sexual harassment. 

2) Adults sexual information before marriage for both males and females. 

3) Unwanted repeated pregnancies and the dangers of criminal abortion. 

4) 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. 

5) Babies born with sexual anomalies e.g. kryptoorchidism and true or 
pseudohermaphrodite. 

6) Questions about masturbation and nocturnal enuresis. 

7) Questions about female circumcision, described properly now as female 
genital mutilation and its drastic complications. 

8) Questions about sexual perversion e.g. homosexuality, lesbianism and oral 
eroticism. 

9) 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. 

11) 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) The 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 1949 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... 

It 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 learn 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 of the normal physiology of sex to present. 
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 of a 
successful sex therapy will be diminished or even fail altogether. 

By performing 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 same spirit he applies 
to other medical problems. They have shown that the intimate facts of the 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. In addition to this the Masters and Johnson 
techniques provide simultaneously a sort of a psychotherapy treatment for their 
patients even if it is not structured and formalised in the traditional ways. By their 
own confidence and frankness, they reduce their patientsanxiety and shyness. 



This makes it possible for a husband and wife to talk freely about their 
sexual problems with the sexologist 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 of a 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 theni. 

- 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 of treatment. 

- 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. 

- fake advantage of the educational and preventive aspects of medical sexual 
knowledge. 

Milestones in the History of Sexology 

In the year 1787, the German society was shocked when a famous 
headmaster by the name of Herr Sprengel published a scientific paper with the 
following daring title: "Mystery 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... 

In 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, Sigmund Freud 
presented his famous sex theory, which caused quite a sensation internationally 
but he was described unfortunately as a crazy man and ought to be handed to the 
police!. 

In the year 1930 in England, Professor H. Ellis was put in prison after he 
published his masterpiece book in sexology, namely, "The Psychology of Sex". 

With the advent of time Professor Alfred Kinsey, an entomologist 
presented two great books dealing with sex research. "Sexual behavior in the 
human male", which was published in 1948 and he put forward his second book 
in the year 1952, namely, "Sexual behavior in the human female" The two 
books entailed 18.000 interviews with male and female volunteers with three 
most remarkable sex discoveries namely: 

1. True frigidity is only 2% among women while the rest sexual 
inadequacy was truly lacking orgasmic capacity. 

2. In the pre-Kinsey era a person was described as either a homosexual or 
heterosexual but when the facts were published about the sexual life of the 
American people, it was found that 4% were true homosexuals and another 37% 
has to be added who have had more than several homosexual encounters !. 

3. Bestiality i.e. making or attempting sexual contact with animals was 
prevalent among the American public especially with house pet animals, contrary 
to what was believed. 

The publication of the Masters and Johnson report in 1966 on the "Human 
Sexual Response" marks a turning point in the history of sex research It added a 
lot of knowledge and scientific data concerning the sexual behavior of the human 
male and female through their sex research, the physiology of coitus and the 
stages of the male and female sex cycle were revealed. 

In their book "Human Sexual Inadequacy", more was described about 
premature ejaculation and impotency in the male as well as types of frigidity in 
the female. Their latest research deals with Lesbianism i.e. female 
homosexuality. In 1979, Kaplan's manual "New Sex Therapy" was a great step 
towards the successful treatment of male and female sexual dysfunctions 
Handbook of sex therapy" by Joseph Lopiccolo, "Human Sexuality" by 
Morton G. Harmataz, "Textbook of Sexual Medicine" by Robert C. Kolodny are 
valuable as well in this field of sexual medicine. 

The societies nowadays have taken a giant step towards the dav when 
human sexuality can be openly taught - to the married and young people who are 
going to be married, who need such insight so desperatelv and to their parents 
who need it 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. 



THE DEVELOPMENT 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 if the mistake is later discovered. After a certain age, a boy raised as a girl 
will continue to consider himself female and in most cases, feel sexually attracted 
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. 

1 . The male or female characteristics of the 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 norma! 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 compulsive or 
destructive behavior. Also, there are many adults who, after an otherwise healthy 
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 was 

thought to be a "force of nature" which appeared suddenly and then, all by 

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 learn 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". In 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". This daring statement by Freud was pretty 
inflammatory stuff and so his opponents reacted with horror and disgust. In 1910, 
at a 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 after birth and that the stages of 
sexuul manifestations are: 

I. 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". It is 
divided into two phases, the first is where pleasure involves "sucking" the 
mother'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. In this phase, the mouth 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 ex 
citation and hence it is described as the "anal phase". Here, according to Freud 
the child gets pleasure "expelling" his faeces at the first part of the anal stage and 
later in this phase, from "retaining" its faeces. The child now gaining control over 
the bowel movements and thereby, indirectly, over the attending adults whom it 
can now please or displease by eliminating or withholding faeces At the same 
time, the child learns to grant or withhold affection, say yes or no in short to 
master the world by "holding back" and "letting go". It is interesting to note that 
the anal phase is often coincident with the time of "toilet training". 

3. While the oral and anal phases, which extend roughly through the first 
three years of life, are the same for both sexes, the now following "phallic 
phase" (from Greek phallos: penis) brings an increasing awareness of sexual 
differences between the male and female sex organs. The most pleasurable zones 
of the body are no longer the mouth or the anus, but the penis for boys and the 
clitoris for girls. This is the phase in which children become actively curious 
about their surroundings, they poke their fingers into things, look inside their toys 
by taking them apart, and also investigate their own and each other's bodies ft is 
worth reminding here that the pleasure derived from their sexual organs namely 
the perns and the clitoris at this age, is different and divorced from ideas of sexual 
intercourse, and the child is completely ignorant of modes or techniques related to 
adult mature sexuality. Boys for instance, become interested in the size of their 
pemses and they may even compete as regards the power of their urination!. 

4. At around the age of five years, the phallic phase is inhibited by two 
complexes, namely, the Oedipus and castration complexes, who tend to repress 
the infantile sexuality. The term "Oedipus complex" is the child's erotic 
attachment to the parent of the opposite sex as well as a feeling of rivalrv toward 
the parent of the same sex. The name was related to the legendary Greek King 
Oedipus who unknowingly killed his father and married his mother. For example 
it is the rule for a four- year-old boy to be deeply in love with his mother. She is 
for him, the only woman he knows and cares to know, however, this woman 
already has a husband-the father. The boy is jealous of him and would like to 
push him aside in order to assume his position. This desire is usually expressed 
openly and spontaneously, as for instance when the boy climbs into his mother's 
bed announcing: "when I grow up, I'll marry you!." Obviously this situation 
through the normal development of a child takes another course. The boy replaces 

his 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 become 
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 son to 
become a healthy man. At the same time, it is the mother's task to help her son 
realize that she has already chosen and is no longer available as a sexual object 
This healthy parental attitude will lead the boy to seek his sexual gratification 
normally elsewhere when he is mature. 



8 



5 In 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 the 
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 influence 
interfered with this sexual development. However, if the particular needs of any 
one of these phases were either unfulfilled or gratified to excess, the child could 
become "fixated", and thus hampered in its psychosexual growth. For example, a 
child's too rigid or over indulgent toilet training could lead to a fixation at the 
anal level of satisfaction. As an adult such a child would then turn into an "anal 
character", i.e. a person who is obsessed with discipline, order, and cleanliness; 
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 kissing 
and/or abnormal oral genital contact. He or she might become a compulsive eater, 
smoker, or drinker, not forgetting bitting nails or lips and thumb sucking. Oral 
eroticism could be expressed directly in our society and may be of no harm with 
our culture, but anal eroticism, however, has almost no overt expression other 
than sexual perversion i.e. sodomy or anal intercourse. One of the few anal 
eroticism direct expressions is the excessive interest in bowel movements 
cleverly exploited by drug manufacturers in our society. Children who do not 
become fixated in this manner eventually reach "genital maturity". That is to 
say, after a so-called latency period, during which obvious sexual interests seem 
largely suspended, the sexual urge reawakens with puberty arrival and seeks 
satisfaction through genital intercourse. Oral and anal stimulation may still be en- 
joyed but to a limited extent, because they now take second place to coitus which, 
for adults, is the one truly "mature" form of sexual expression. 



Infant and Childhood Sexual Behavior 

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 learn 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 I 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 1895, "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 of the 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 Masturbation 

A child's orgasmic capacity increases with advancing age, by their fifth 
birthday, more than half of all boys have reached orgasm, and for boys between 
10 and 13 years of age the figure rises to nearly 80%. Naturally, the orgasms of 
these boys are not yet accompanied by ejaculation, since no seminal fluid 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 



Male Masturbation 

By the time boys and girls reach the age of 15 years, only about 25% of all 

girls have masturbated to orgasm, while the comparative figure for boys is nearly 
100%!. 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 often, 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 pair of 
rolled-up socks. Still others try to take their own penis into their mouth, although 
they normally find this to be anatomically impossible, (only about 1% 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 what method is used, the adolescent male 
soon learns how to reach orgasm at will. 

Female Masturbation 

Girls also employ different masturbation techniques. In 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 comer 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... 

It 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 of the 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, most people in our culture consider masturbation wrong, and in 

spite of all the propaganda to the 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 warned 
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 alarmed 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. It 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 unbalanced. Prior to the baby's birth and even after, the father is an 
observer only, without direct physical contact with the growing child. Although 
in some families the father is present at his child's birth, whether in a hospital or 
at home, more typically the father does not share this experience with his wife or 
with the newborn. It is regrettably all too common that in most modern societies, 
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 of this 
discrepancy of parental contact with the child are not discovered yet, but 
feedback from parent to child and from child to parent may prove to be important 
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. It is 
common for women to become sexually aroused during nursing and suckling 
their infants, and such erotic arousal may precipitate reactions ranging from 
pleasure, satisfaction, guilt or fear. While many men regard suckling or nursing as 
simply a natural means of providing nutrition, some men may be upset because 
they interpret the act of nursing or suckling as a sexual stimulus to their wife or to 
their child; others find the act of nursing to be sexually stimulating to themselves. 
Nursing in the presence of others similarly produces, in those others, varied 
reactions that presumably have nothing to do with the actual act of feeding a 
child, since publicly bottle feeding an infant provokes no cries of indecency. The 
sexual symbolism of the breast and the act of suckling are not easily separated 
from our evolutionary heritage as mammals. 

Since lactation is the only source for the existence of the 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 for the 
first time the feelings of rage, anger, fear, anxiety and hate; because she or he was 
deprived of the breast or the bottle. Substitute gratification is the onlv 
consolation for the baby at this critical time, no wonder, thumb sucking or the 
rubber teat become their sole pleasure for sometime to come, even to adult-hood 
and a good example is the lolly-pup sweets preferred by some adults!. 



13 



Toilet Training 

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 of threats and the punishment's 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 correction 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 suffer 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, e.g. 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 orgasm often develops much 

ater. Unfortunately, many parent still allow their girls to menstruate for the first 

time without knowledge or education; it is a major psychological crime that 

happen around menarche, which is seldom forgotten or forgiven by the unhappy 

Libido at Maturity 

At maturity, the sexual urge is present but under the surface it is fierce 

nevertheless but restrained due to society rules and family laws. The teenagers 

boys and girls do not easily accept these restraints, no wonder, they revolt and the 

older generations are alarmed as well as puzzled. Truly the parents and the 

society need not to be worried, because they should remember and realize the 

long delay young people in our culture face to get married. Many of them cannot 

achieve complete legal and economic independence until 5, 10, or even 20 years 

after puberty. To a great extent, this delay is of course, unavoidable because of 

he growing complexity of the modern world. As a result, they are forced to go 

through a difficult period of sexual frustration and there can be no doubt that the 

sexual oppression of the young creates much genuine misery. 

Thus, for many adolescents solitary masturbation is the onlv available 
outlet, although some boys may occasionally masturbate in small groups Some 
do experiment with various petting techniques, and others turn to homosexual 
contacts as a temporary substitute. A few boys who live in the countryside mav 
also have sexual contact with various animals. 

"On the whole, adolescent girls engage in much less sexual activity than 
adolescent boys' ; one reason for this is the double standard of morality which 
threatens females with much harsher punishment for sexual infractions than 
males... It is true that they are taught to be sexually attractive, to move gracefullv 
to dress seductively, to experiment with beautiful hairstyles, and to use fascial 
makeup Indeed, they tend to fantasize about their future roles as brides wives 
and mothers; at other times, they dream about some ideal lover or some romantic 
situation, in short they are less concerned with the physical aspects of sex than 
with its social implications. 



15 



Early Conditioning and Sexual Development 

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 newborn nursery are ail familiar 
with the fact that newborn males have spontaneous erections; newborn 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 
inborn 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 newborn 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. Just as the price of civilization over a primitive 
society may be increased, cat ''Avascular mortality or a higher incidence of peptic 
ulcer disease, so the cnui| iexities of civilization lead eventually to sexual 
difficulties. 

It is, of course true that all human beings are born with the capacity to 
respond to many kinds of sensual stimulation. We also mentioned that erections 
of the penis, the lubrication of the vagina, muscular contractions, and rhythmic 
pelvic movements can be observed in very young infants. In 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, human 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 sex. 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, inconsiderate, 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 animals... 



16 



Since these and many other personal sexual interests, choices and 
preferences are developed through learning, they may appear natural, reasonable 
and indeed, inevitable to the person involved. Even sexual behavior which seems 
outrageous, fantastic, meaningless or absurd to most people may be meaningful 
and rewarding 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 wooden 
horse!, may merely reflect some early experience in childhood in which sexual 
pleasure was associated with a merry-go round, and his behavior as such may be 
no more difficult to explain than that of another man who becomes sexuallv 
aroused while watching a striptease show?. The latter male sexual response may 
have a certain advantage over the former, because we consider it normal 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 against sexual 
acts that involve force or violence, or which take place in front of unwilling 
witnesses. Such acts may be satisfying to the person who commits them, but since 
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 times there has been 
growing tendency to view such acts as symptoms of mental illness rather than 
crimes. Psychiatrists began to argue in court that certain sexual offenders should 
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 man may 
realize that his sexual acts are harmful to others, but he may have great difficulty 
controlling himself. In another case, such compulsive behavior may not be 
antisocial, but since it creates a sense of helplessness in the individual, he may 
still find it highly disturbing, such as masturbation. There are also men and 
women who feel guilty and apprehensive about any kind of sexual activity and 
some others are so self-conscious and inhibited that their sexual responses are 
inadequate. 

It is fair to say that all of these people are sexually maladjusted. In other 
words, their particular learning experiences have rendered them incapable of full 
sexual communication. They either have become insensitive to the needs of 
others, or are unable to fulfill them. They cannot relate to their sexual partners as 
complete persons, or adapt their own desires to different circumstances and 
situations. They seem condemned to repeat the same frustrating and self- 
defeating acts, in short, they fail to achieve the full amount of physical and 
emotional satisfaction of which most 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 recognized". There is also 

no doubt that parents and close relatives have a great influence on a child's sexual 
17 



development. The discipline they demand, the routines they establish and the 
examples they set give boys and uirls 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 born 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. In other 
words, they not only learn the "proper" responses, but also suppress and forget 
the "improper" ones. In fact, when they try later to increase their sexual 
responsiveness through treatment, they may spend a great deal of time and energy 
relearning 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. It 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 children'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 child's future attitude 
toward sex. 

Once we realize 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, However, most people know that erotic preferences are 

18 



usually much more specific. For example a "typical male" is by ho means 
attracted to all females, but only to those of a certain age, height, weight, hair 
color, etc.. In fact, he may prefer not only a special type of female, but also a 
special type of sexual intercourse under special conditions. These particular 
preferences and tastes within the general framework of a person"* sexual 
orientation are best described as personal "sexual interests". They too are the 
result of conditioning. 

Patterns of Sexual Behavior 

Two pieces of recent work on the subject of sexual development have 
shown that these problems of early conditioning are shared not only by all races 
but even by animals as well. One is by Ford and Beach, "Patterns of Sexual 
Behavior , the research was done by an anthropologist and psychiatrist, on the 
sexual behavior of a number of mammalian species and of 190 human societies as 
well. Strangely enough, it was discovered that there is almost nothing in the wav 
of present day so called perversion, which is not practiced sometimes by other 
races or by other species of animal. These facts are bound to influence our future 
evaluations and perhaps ultimately even our considerations; for obviously sexual 
acts wh.ch are part of the biological heritage of man can hardly be regarded as 
intrinsically unnatural or abnormal. In some societies of the past, including 
American Indian tribes, certain males were allowed or even encouraged to adopt 
a feminine gender role and live as "shamans", "alyhas" or "berdaches" They 
wore female clothes, married some great warrior or other important man in the 
community, and took care of his household. Very often they also enjoyed great 
prestige themselves because they were believed to possess magical powers. 
Obviously this social arrangement at that time provided a convenient outlet not 
only for those transsexuals, but also for the other sexual minorities, such as 
hermaphrodites, transvestites, and effeminate homosexuals. More virile 
homosexuals on the other hand, could find sexual fulfillment within their false 
masculine role by marrying a "berdache". 

a m A WC ^ n ?, W of various Primitive societies, such as the "Sinan?" in Africa 
the Aranda" in Australia, and the "Keraki" in New Guinea, where nearly all 
males engage in both heterosexual and homosexual intercourse In ancient 
Greece, homosexual behavior was widely accepted as a normal part of a man's 
sexual activity, and it was never considered an obstacle to his future marriage or 
fatherhood. At that time, the very word, "homosexuality" was unknown to them 
instead people spoke of "paiderastia" (literally love of boys from pais: boy or 
rather here male adolescent, and eran: to love) which was cultivated as a socially 
healthy custom. However, neither the older lover (called "the insplrer") nor the 
younger beloved (called "the listener") was ever assumed to be incapable of 
normal relationships with women. Nowadays, the terminology has changed the 
active male homosexual performing anal penetration during sodomy is called the 
inserter while the passive male homosexual is termed the "receiver" 
Historical and cross-cultural studies about some ancient Greek city states have 
shown that male homosexuality was associated not with weakness and 



19 



effeminacy, but with vinl.ty, bravery, ,nd heroism. As a matter of fact, the most 
famous of all Greek military elite troops, called the "sacred band" of Thebes 
which was finally defeated by Philip of Macedonia, is said to have consisted 
entirely of male lovers... This example shows that the social stereotype of the 
homosexual may vary considerably from one time and place to another; it also 
demonstrates once again that there is no such thing as a "typical" homosexual. 

, np . The s~ond research project was the recording by cinema of some work 
done by psychiatrists in Chicago upon chimpanzees. This piece of work have 
shown that in animals observed, sexual urges were distorted or obliterated bv the 
persistent operation of fear and hunger. It was decided to upset the animals by 
letting hunger force them into a seemingly dangerous situation. Some male 
chimpanzees had been -conditioned" to ring for their food in one cage and 
receive it in another. They were photographed when for the first time a toy snake 
was pushed into the feeding cage as they ate. "Fear", repeatedly caused them to 
run away and relatively they came to prefer serious degrees of "hunger" to the 
risk of seeing the snake. e 

During the weeks of these experiments other aspects of the animal's 
msttncfve behavior" became markedly altered. Chimpanzees who Tad 
formerly led normal sexual lives turned away from their usual habits- they 
became engrossed ,n masturbatory activities, disregarded the wooing of the 
females and homosexual interests became more acceptable than the normal 
ones... In otl d ? thdr « charac , er „ too> wm cha l chimpan7 ee 

became doc.le clinging to their keepers, and when finally they were induced 
back to their feeding cages, the presence and reassurance of their keepers was 

" z » t:r: th r °t ] t endurabie to them - '» ^ ™*. ••»" 

ra.ts had developed similar to those which only too commonly arise from 
severe stress m human beings at times of difficulty and excessive strain. 



20 



Endocrine Aspects of Sexual Behavior 

The importance of hormonal influences on reproduction and sexual 
behavior has been recognised since the early part of this century. Although it was 
initially thought that the pituitary gland was the primary focus of control over 
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 gonads. For example, these hormones act on sexual 
differentiation of the brain during fetal life, initiate puberty, and play a role in the 
regulation of sexual behavior. 

Testosterone 

In a normal adult male, testosterone is produced primarily by the testes, 
with less than 5 percent normally contributed by the adrenal cortex. The average 
testosterone production rate for adult men is 6 to 8 mg per day. There 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 
levels has now been discarded by most researchers, and clinicians are in favor of 
direct measurement of circulating hormone by radioimmunoassay techniques, 
lyrical values tor circulating testosterone concentration (ng/'dl) are: 385- ! .000 in 
adult males, 20-28 in prepubettal children, 120-600 in pubertal boys, 100-300 in 
hypogonadal adult males, 20-80 in adult females, 45-125 in females using oral 
contraceptives (Fig, I). 

'Testosterone appears to be the major biologic determinant of the sex drive 
in both sexes, it is the "libido" hormone for 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 
addition, since the prostate and seminal vesicles are androgen-dependent, seminal 
fluid volume is diminished when a severe testosterone deficiency is present. Most 
men with impotence have normal levels of testosterone, reflecting the fact that 
many instances of sexual dysfunction arc of psychogenic rather than biologic 
origin. 

The precise relationship between hormones and sexual behavior is not clearly 
understood at present. In a variety of nonprimate animal species, plasma testosterone 
concentrations increase after coitus or ejaculation. In monkeys, however, although 
access of adult males to receptive females reportedly leads to increased circulating 
testosterone, neither testosterone nor luteinizing hormone increases significantly 
alter coitus or ejaculation. Conflicting results have been leported in regard to 
:u.*mar.s. Although *ome studies indicate that testosterone levels do not increase after 
coin. 1 '- or masturbation, still other reports fail to document a positive correlation 
?vA -. -?!: ; .■:?!:?! c sxunl activity or sexual interest and scrum testosterone le\eh. There 
aic studies indicating increased testosterone after masturbation, during and after 
coilus, and in response to viewing erotic movies. 

21 



Stress 



Love-i 



i 




a 



Testosterone 




Figure 1 . Testosterone and the brain 
Schematic representation of the reciprocal influences between testosterone and the brain 
(a) a the cortex which responds to life experiences, (b) represents the hypothalamus 
which is intimately connected to (c) the pituitary gland which secretes follicle-stimulating 
lormone (FSH). This hormone regulates testosterone production by the male testes (d) 
and in turn, the level of testosterone profoundly affects cerebral functioning and beh; 



lavior. 



Persky and his colleagues have recently suggested interrelationships between 
hormone levels and the sexual behavior of couples; in addition, evidence 
indicating that there may be a seasonal cycle of plasma testosterone in men 
further compounds the methodological difficulties in investigations of this type' 
Endocrine regulation 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. In 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 activity 
throughout the menstrual cycle in women whose periovulatory testosterone levels 
reached higher peaks than in a group of women with lower peak periovulatory 



22 



testosterone levels. They alcn reported that women showed a greater degree of 
sexual responsiveness and - 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. It is uncertain how important olfaction 
may be as an occasional mechanism of sexual arousal. In a wide variety of animal 
species, sex-atfractant 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 
some 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 lias long been established 
ox^ a clear anatomical basis. Infrahuman mammals secrete odoriferous substances 
which stimulate and release sexual responses in the opposite sex. In human 
beings, the potent and unrecognised influence of smell on sexual functioning was 
not often fully appreciated. However, recently it has been recognised that humans 
also secrete pheromones. Humans therefore have the power of being turned "On" 
and "OfF\ by genital odors of the opposite sex. Reiber and co-workers stated 
that, there is no doubt that a tantalizing aroma is a powerful aphrodisiac e.g. 
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 ah, 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 olfactory 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 endorphins, dopamine, and 
serotonin promise to bring about further progress in understanding human 

sexuality. 



23 



Luteinizing hormone-releasing farter 

Recent evidence indicates that (LH-RF), the small peptide molecule of the 
luteinizing hormone - releasing factor, may enhance sexual desire even in the 
absence of testosterone or when testosterone is ineffective. This finding has 
raised interesting questions, such as: Does LH-RF act directly on the sex centers 
of the brain ?. Can it be used clinically to increase libido ?. As yet, LH-RF is a 
mystery, but it has important implications and merits further investigation. 
Evidence suggests that serotonin, or 5-1 IT (hydroxy-tryptamine) acts as an 
inhibitor, and dopamine as a stimulant to the sexual centers of the 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 rapidly 
and very well. The presence of the beloved is an aphrodisiac; the smell, sight, 
sound, and touch of the lover - especially when he or she is excited - are powerful 
stimuli to sexual desire. In physiologic terms, this may exert a direct physical 
effect on the neurophysiologic system in the brain which regulates sexual desire. 
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 after performing 
< mnn-us sexual activity typically when orgasm has occurred. This may be due to 
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 (e.g. 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 during or 
immediately after sexual activity in some women. It is unfortunate that normal 
physiological galactorrhea is treated wrongly by some doctors and they give these 
phsyiologically normal women bromocriptine in the form of Parlodel and other 
medications e.g. Dopergin on the assumption that it is pathological ... 



24 




MALE AND FEMALE SEXUAL ANATOMY 

• I. Male sexual anatomv. 

• II. Female sexual anatomy. 

• III. Anatomy of the 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 cavernosa lie parallel to each other and just above the corpus spongiosum, 
which contains the urethra. The erectile tissues consist of irregular sponge like 
networks of vascular spaces interspersed between arteries and veins. The distal 
portion of the corpus spongiosum expands to form the glans penis. Each cylindrical 
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 of the internal pudendal arteries (Figs. 2 - 4). 



Glans 



Dorsal 
Coronal surface 
ridge 



Corpus cavernosum 



Urethral 
meatus 




/ Corpus spongiosum 

Ventral 
surface 



Bulb 




Figure 2. The penis: (lateral view). 
Mechanism 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 of the 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 of the increased blood against this sheath 

hardens the penis and makes it erect. The increased penile flow of blood during 



25 



25 



excitement is known to be caused by the dilatation of the penile arteries this is 
brought about by parasym noetic impulses from the erection centers' which 
cause the muscles in the artenal walls to relax. The mechanism responsible for 
decreasing pemle outflow is caused by reflex constriction of the penile veins An 
alternate hypothesis suggests that special penile valves control the outflow while 
still another hypothesis postulates that the outflow and also the shunting of blood 
to the cavernous sinuses are controlled by "polstenT, which are small smooth 
muscle structures located only on the penile blood vessel walls which hinder the 
venous outflow. 

The erectile response is primarily a parasympathetic, although surgical 
and pharmacological evidence suggests that some sympathetic component is also 
required for potency, possibly by controlling the outflow of erectile blood 
However. ,t is well-known clinically that an intense sympathetic response such as 
that produced by fear and anxiety, can instantly drain the penis of extra blood and 
so cause a psychogenic loss of erection. 



Dorsal 
veins 



Fibrous 
envelope 

Septum penis 
(pectiniform) 

Corpus 
spongiosum 




Dorsal artery and nerve 



Integument 



Corpora 
cavernosa penis 



Urethra 



^PVWMMtf 



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

The vascular events that produce erection are under the control of neural 
impulses, Although it has been speculated that parasympathetic fibres in sacral 
cord roots (S 2 , S 3 . and S 4 ) mediate erection, this theory was a matter of some 
controversy but is well established now. The skin that covers the penis is freel y 
movable and forms the foreskin or prepuce at the glans. Inflammation or infection 
ot the foreskin or glans may cause pain during sexual activity. There is much 
controversy and little data surrounding the question of the effect of circumcision 
on male sexual function. There is also a great deal of confusion as regards to 
perns size and sexual function. With rare exceptions due to conditions of a true 
microphallus, the marked variation in the size of the flaccid penis from man to 
man is less apparent in the erect state, because a greater percentage volume 
increase typically occurs during erection in the smaller penis than in a larger one 



1 



26 



: ■■/■:•/: 



^W^W/.-J > ''M'/./,'' ■■■' /U: ■: 







r y- ■ ! 

4> 



"7 T^ 






■^A " 






Jit — J^lAyiAi 







Rectum 

Urinary bladder 

Vas deferens 

Seminal vesicle 
Ampulla 
Prostate gland 
Ejaculatory duct 

Prostatic urethra 
Membranous urethra 

Cowper's gland 
Anus 

Penis 

Penile urethra 

Epididymis 

Glans penis 

Prepuce 

Meatus (urethral opening) 
Testis 



5crotum 



Figure 4. External and internal ^x uigans 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 scrota! skin; these muscle fibres contract 
as a result of exercise or exposure to cold, causing the testes to be drawn upward 
against the perineum. In hot weather, the scrotum relaxes and allows the testes to 

hang more freely away from the body. These alterations in the scrotum position 
are important thermo-regulators. Since spermatogenesis is temperature sensitive, 
elevation of the testes in response to cold provides a warmer environment by 
virtue of body heat, whereas loosening of the scrotum permits the testes to move 
away from the body and provides a larger skin surface for the dissipation of 
intrascrotal 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 t^tis, the two functions are under separate control 
from the pituitary gland. H' r Me synthesis may proceed in a completely normal 
fashion even if the seminifV- o • tubules are dysfunctional, but spermatogenesis is 
generally disrupted if testosterone 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 urinary 
bladder. The rectum is directly behind the prostate, permitting palpation of this 
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 of the prostate arises in the glandular portion, whereas benign 
prostatic hypertrophy usually results from enlargement of the fibromuscufar 
component of th&firostaie. 



?"■' ■*» 



p.itthl veftcl^ft 



The seminal vesicles are paired structures that lie nsalnst the posterior 

aspect of the base of the bladder and join with the ertd of the vasa differentia 

(which are the tube like structures that carry the sperrhatozoa from the testes) to 
form the ejaeuSatory ducts. The ejaculatory ducts open into the prostatic urethra; 
the major fluid volume of the ejaculate derives from the seminal vesicles' 
Cowper'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 of the 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 external female 
genitals, although their anatomic position is not in fact external. (Fig. 5), 



Clitoral shaft 
Clitoral glans 



Labium majus 




Clitoral hood 

Labium minus 

Urethral 
meatus 

Vaginal outlet 



Perineum 
Figure 5. Virgin female external genitalia (spread manually). 
Labia majora 

The appearance of the genitals varies considerably from one female to 
another, including: (1) 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. In the sexually unstimulated state, the 

labia majora usually meet in the midline, providing mechanical protection for the 
opening of the urethra and the vagina. 

Histologically, 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 in females will be discussed fully in the chapter of the sexually stimulated 
female. 

Clitoris 

The clitoris, which is located at the point where the labia majora meet 
anteriorly, is made up of two small erectile cavernous bodies enclosed in a 
fibrous membrane surface and ending in a glans or head. Histologically the tissue 
of the clitoris is very similar to that of the penis. The clitoris is richly endowed 
with free nerve endings in contrast with vagina, where they are extremely sparse 
within the interior of vagina. These free nerve endings are not known to have any 
function other than serving as a receptor and transducer for erotic sensations in 
the human female. The very important role that the clitoris plays during sexual 
excitement will be discussed fully in the chapter of the physiology of coitus in the 
female; while the loss of the clitoris and the labia minora due to the drastic and 
tragic operation of female circumcision will be strongly criticized in the chapter 
of female circumcision. 

( B ) The internal genitals of the 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 differences as well as reproductive history, 
age and presence or absence of disease. 

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 vagina are dry 
collapsed together. The vaginal introitus is surrounded by an exterior muscle, the 
bulbocavernosus which acts as a sphincter for the vagina. The introitus is highly 
reactive to both pain and pleasure. At a slightly deeper muscular level the 
mtroitus and outer third of the vagina is surrounded by the muscular ring of the 

pubococcygeus. 

The walls of the vagina are completely lined with a mucosal surface that is 
now known to be the major source of vaginal lubrication; there are no secretory 
glands within the vaginal walls, although there is a rich vascular capillary bed 
The vagina is actually a muscular organ, capable of contraction and expansion it 
can accommodate to the passage of a baby and can adjust in size to accept a much 
smaller object. 

Hymen 

I he entrance to the vagina is partially obstructed bv a thin and delicate 
membrane called hymen (Fig. 6), it has perforations in it that allow menses to be 

eliminated monthly. Although the hymen appears to have no biological function. 



yet it has tremendous cultural significance as well as it appears in different shapes 
and types in its various pk r ivps. 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 born 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 torn. The act of 
"defloration" which is the removal of the hymen is associated with considerable 
cultural ceremonies in the past and present. In old Australian tribes and other old 

uultuiu difluiuliun ii uj pti funned bj oldu Tiuintn iiliu tim iliu ii/inun unu 

week prior marriage using animal horns ! or stone penises ! termed "plucking of 
the maidenhead". In some parts of upper 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 of the future husband... (Figure 6) 









CIBA 



Annular hvmen 



Septate hymen 



Cribriform hymen 



ntroitus (after intercourse) 



Figure 6 The appearance of the 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 cribriform). In the 
sexually experienced woman, the introitm 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 into the 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 



Uterus 

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. If 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 dovrt, resulting in the menstrual flow as a means of 
shedding the previously proliferated endometrial tissue, which will regenerate 
under appropriate hormonal stimulus if? the next menstrual cycle. Endometrial 
biopsy may be undertaken as pan of an ir fertility evaluation to determine if 
ovulation has occurred and to observe ,vhs;Ucr 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 produced (oestrogen and progesterone) play a 
role in the sexual behavior of females. 

Bartholin's glands 

A pair of glands located just inside the inner lips (labia minora) on either 
side of the 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 ; mportance of the external female genitalia in the 
physiological responses of t'«e 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. 2nd TO 3rd MONTH 
OF PREGNANCY 



MALE 



CLANS AREA 

URETHRAL GROOVE 

ANAl PIT 

TAIL (CUTAWAY) 




FEMALE 



B. 3rd TO 4th MONTH 
OF PREGNANCY 




CLANS 

UROGENITAL GROOVE 

LABIO-SCROTAL SWELLING 

ANUS 




C. FULLY DEVELOPED 




OPENING OF URETHRA 

PREPUCE OR FORESKIN 
GLANSOF PENIS 
GLANS OF CLITORIS 

BODY OF CLITORIS 

BODY OF PENIS 

MINOR LIP 
MAJOR LIP 
SCROTUM 

VAGINA 
-ANUS — 




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

show the similarity early in life. 



33 



III. Anatomy of the Sexual Nervous System 



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). 




Figure 8. Cerebral localization of erection. 
Positive loci for penile erection are found in parts of three corticosubcortical subdivisions of the 
limbic system that are schematically depicted in above drawing and labeled 1,2 and 3. The septum 
(SEPT) and medial part 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 mid 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, mammillary 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, \ -th 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. It may be speculated that eating and sex 
and being in love i.e. behaviors which are experienced as pleasurable, produce 
this sensation by stimulation of the 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 the neurotic inhibition of libido. 

It may also be speculated that neural connections exist between the central 

sex centers and the spinal reflex centers that govern 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 lubrication are 
full and rapid and orgasm is easily achieved. In 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 of the sexual 
response denotes that the sexual desire or libido, also termed "the sexual drive", is 

35 



produced by the activation of the neural system in the brain, while the excitement, 
plateau and orgasmic phnsc > 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 reflex centers 

In both males and females two spinal cord reflex centers are located at T n , 
T| 2 , Li and L 2 ; the second center is located at S 2 , S 3 and S 4 (T = thoracic; L - 
lumbar & S = sacral). 



36 




THE PHYSIOLOGY OF COITUS 
IN THE HUMAN FEMALE 

Physiological responses of the sexually stimulated female 

Ciitoral versus vaginal orgasm. 

Non resolved sexual tension in females. 

Artificial vagina and vaginal agenesis. 

The erogenous zones and preeoital petting. 



THE PHYSIOLOGY OF COITUS 

IN THE HUMAN FEMALE 

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, 9-20). 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- 
sideration 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 
demarcated 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. 




Ovary 

Fimbriae 

FaJtopian tube 
Uterus 



Cervix 

Urinary bladder 



Bmr>* 



1 1 



Urethra 
Clitoris 

Minor lips 

Vagina 
Anus 



Major Mps 



Figure 9. External and internal sex organs of the 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 *he sexual behavior of men and women under scientific 
laboratory conditions; they observed and recorded approximately 14.000 sexual 
acts. They took, photographs of the external and internal 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 of the 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. 

It 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. It seems, however, that during ihe fir«;t Qtappc nf c^vnai ormioi 

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. In 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.: It is very important to remind the reader that all these sex experiments "vere 
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 activation 
of many physiologic processes of the body occurs as a result of thought or 
emotion. For example, salivation and gastric acid production may be initiated by 

tliiiii'iiiM Alwui Ucliiiim AMI, yuiyyimy, wnpiMll, AW paeons may De 

preclpirated by fear or anger. At times, the excitement phase may be of short 

dun * ion, quickly merging into the plateau phase; 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". In 

response to effective sexual stimulation, which may occur very suddenly taking 
from 10 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. It is important to recognize that there 
are no secretory glands in the vagina! 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. It 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 vagina! sweating not knowing the 
essentia! values of this luhrication (Fi^ lf)^ 



#•• 



Network of 

blood vessels 

Lubricating 
droplets 




Symphysis 
Clitoris , t( 



Uterus 



Rectum 



^.^i. -at. -»_ iiir in'. |i-ti rn i i ■■ * i ~ 





Cervix 



No lubrication 

Vagina 



Colon 




Figure 10. Vaginal lubrication in the 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 It 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 °!ement play an important role, when 
contractions of this ligament do accomplish the lifting of the 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. 



i 



* N 



Early uterine ^ 
elevation \ Ss 




\^ Lengthening 
/> N of vagina 



Labia minora size increase 

a Labia majora separation 
and elevation 



Figure 1 1, 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% of the original length. 
(Fig. U). 

Changes in externa! 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 



■■ ^ ) * i ri i ? 



r\. a*~t 



lirj 



nor 



■jjp™« M , ™ r ~ V p^~ iw wojj.-.,ni Hirrlvi "'Wt ftfrtiii Tht lutrin 

rnajora in a multiparous woman are large and now they grow even larger as a 
result of engorgement and do expose the vaginal orifice in an exaggerated manner 
because tbev become elevated and separated, 



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



The clitoris, just like the penis increase* in size as its erectile tissue 
becomes filled with blood and it gets firm in consistency as a result of the process 
of vasocongestion, although a true erection does ?jot y occur literally, because of 
the marked difference between the size of penis artd clitoris. The increase in the 
size of the clitoris is most noticeable in tfce diameter of the clitoral shaft, while its 
length increases 2 to 3 times as much as the original one which is 4 x 4.5 mm in 
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). 




Clitoral 
j)shaft 

^Clitoral 
hood 

Clitoral 
glans 

iMinor 
Jips 




Shaft diameter 
increase 



EngorgernenL 
of minor lips 



raction 
reaction 




litoral hood 
Glans and shaft 

ngorgement 
f minor 1 1 ps 



Unstimulated Baseline 



Excitement Phase 



Plateau Phase 



Figure 12. Changes in the shape and position of the clitoris during sexual arousal. 
Changes in other organs 

During the sexual excitement phase, erection of the 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 dark 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. In the late excitement 
phase, surface venous patterns of the breast become more visible and there may 
be a further increase in the size of the breasts, (Fig. 13). 



41 



nwww^ 



Increase in 
breast size 



Nipple 




Unstimulated Excitement 

baseline 



Plateau 
through 

orgasm 



Resolution 



imVHWMT^ 



Figure 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.li 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 of the pulse rate has not been due to 

mechanical Work exerted hut mostlv due to pmnfinnjil fnntnre 

In addition to all the mentioned signs of growing sexual excitement, most 
women, not all show the so-called "sex flush", it appears late in the excitement 
phase or early in the plateau phase. It 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 of the 
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. v 

In 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 e.g. a sharp knock on the door, a shift in 
position, or a muscle cramp, for example, are types of distraction that may occur. In 
addition, changes of tempo or manner of direct sexual stimulation can also 
temporarily disrupt the process of sexual arousal. The vasocongestive mechanisms of 



42 



Hit lALiiaiiun iJlid&e uu iiui uiiiuiuue a quaiuiuiLlve n|ipini»ul uf mm\ aruusai. ill 

fact, an erection may be diminishing in Firmness at just the time that excitation is 
heightening; likewise, vspinal lubrication may appear to have ceased, although 
neuromuscular tension is clearly nearing the plateau phase. It 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 physiologically 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; it is often exceptionally brief in men who are 
premature ejaculators. In 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 of the 
inner two-thirds of the vagina with a minor additional expansion in its size, and 
there is a corresponding increase in elevation of the uterus. The rate of vaginal 
lubrication often slows during this phase as compared to excitation, especially if 
the plateau phase is prolonged, (Fig. 14). 



Uterine 



m-ifrv^Qi 




body 
elevatio 



Full 

vaginal 

expansion 



Org:asmic 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%. This 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 actuall> 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 
o'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 muciparous 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 180° 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. It 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 to the general vicinity of 
the mons pubis or the labia will result in pleasurable clitoral sensations. In the past, 
it was not always understood that this retraction of the 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). 



Minor 
labium 



/Clitoral 
shaft 

£litoral 

</xss hood 

/^^SClitoral 
^ ^ glans 



Unstimulated 

baseline 



Shaft diameter 

increase 
A 

Glans, 

tumescent 

reaction 

Labial 
engorgement 

II 

Excitement 

phase 





Retraction 
reaction, 

Glans and shaft 
Clitoral hood 



Labial 
engorgement 



III 

Plateau 

phase 



f igure 15. The clitoris in the female sexual response cycle (Plateau phase). 



44 



The greater vestibular glands (Bartholin's glands), which correspond to 
the bulbo-urethral glands (Cowper's glands) in the male, may secrete a small 

omnnnt r\f flutrl fahrMit r\«^ tr\ tKrp*^ rlrnpc^ Hurinrr thte pIot**€iii pKaco nr lot** in flit* 

excitement phase. It i? interesting to note that the secretions of the Apocrine 
glands in the prepuce are meant to keep this area lubricated because direct tactile 
stimulation when dry may be intolerable since the clitoris is* exquisitely sensitive 
to touch at this stage of sexual excitation. 

Changes in other organs 

The sex flush, 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 tumescence 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 
lactated. In women who have not breast-fed a child increases in breast size of 20 
to 25 oercent above baseline levels are not uncommon. 

l^nr centuries, males have been concerned about penile sire lo this day, 

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. If 
grotesquely large, partial excision may be recommended but the less drastic 

measure of imbedding the clitoris in the surrounding tissue is recommended 
surgically. If too 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 
orensmic threshold level has been reached or exceeded. An orgasm lasts onlv a 

it juinliiu anil if. UK an niiiLli !iki a mi in uriuiitukiuw uliiili intulii Hn 

whole body and s^^n lead to complete relaxation and often sleep. In sexuallv 
iriHiVM: males, orgn^rn l< necompnnied by the ejaculation of semen, and since 
^ ri ,,j ? „ { i nQ | produce semen, hence, they do not ejaculate. However, in all other 
respects, the physiological processes are comparable in both sexes. Although the 

45 






experience of orgasm is essentially the same in men and women, still, it seems 
that nature did equip females to have more than one orgasm within a very short 
time. This capacity of being a "multiorgasmic female" is quite common in 
healthy females and is described as having a series of identifiable orgasmic 
responses without dropping below the plateau phase of sexual arousal. Strange 
enough, recent research proved that it i 9 muscular endurance rather than feminine 
responsivity which is the limiting factor in a woman's coital responses as regards 
this power of multiorgasmic capacity. Men, however, do not share this capacity. 
Immediately following ejaculation, the male enters a "refractory period", 
during which further ejaculation is impossible, although partial or full erection 
may sometimes be maintained. This refractory period may last for a few minutes 
or it may last for many hours; for most men, this interval' lengthens with age and 
is typically longer with each repeated ejaculation within a time span of several 
hours. There is a great variability in the length of the refractory period both 
within and between individual men. The refractory period is not present in the 
female sexual response cycle, although most women are not multiorgasmic 
There is one further difference, while the orgasmic pattern of males practically 
never varies, females may experience orgasm in a number of ways, (Fig 16) In 
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 woman may find 
herself responding quite differently on various and different occasions of sex 
stimulation. However, the basic physiological processes underlying these possible 
variations remain unchanged. 



Orgasm 



Plateau 



Excitement 




ABC 



figure 16. Various types of the female sexual response cycle. 
Changes in sex organs 

In human females, orgasm begins with simultaneous involuntarv strong 
rhythmic contractions of the three following organs; the orgasmic platform, 



46 



(outer third of the vagina) the uterus and the rectal sphincter, beginning at 8 
second intervals. These contractions, which may number from three to fifteen 
first recur within less tn«n a second, then they become weaker and at longer" 
intervals, thus diminishing in intensity, duration, and regularity. The uterine 
contractions are known to be irregular, they do start at the fundus working their 
way downwards, not unlike the contractions that occur during the first stage of 
labour but naturally not painful. The cervix gapes its external os and remains 
open for nearly 20 to 30 minutes after orgasm. Surprising^, the sphincter 
muscles of the rectum contract also for few times at the san w intervals as the 
orgasmic platform, (Fig. 1 8). 



Clitoris 



Uterine 
'--contractions 



Lengthening 
\ of cul-cle-sac 




Rectal 
sphincter 

COllllAUlWI 



Orgasmic platform 
"""\ Labia minora 
Labia majora 



Figure I 7. Female pelvis: orgasmic phase. 
Changes in other organs 

Since orgasm is a total body response, not just a response localised to the 
pe vis, the presence of great neuro-muscular tension is not only in the entire 
pelvic area but is also present in the neck, arms, hands, legs and feet. Dorsal 
lexion of the big toe as well as the foot appears occasionally, while the four 
lateral toes are kept in the flexion position for a long period. Electro- 
encephalogram patterns measured during orgasm have shown significant changes 
in hemispheric laterality, as well as changes in rates and types of brain wave 
activity Contractions of peripheral muscle groups have also been carefullv 
measured, while the pulse rate and blood pressure rise greater than the levels 
reached during the plateau phase. Surface electrodes fixed on the thorax of female 
volunteers made electrocardiograms recording possible, while breathing rate is 

Very fast indeed. It is worth noting that the intensity of all these physical reactions 



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 bu* *+ 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 Johnson f s research disproved in a 
way Sigmund Freud's 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 orgasm... 




Figure 18. The female genitals and muscles during orgasm. 
The perineal (a), bulbocavernosus (b) and pubococcygeus (c) muscles contract with a 
.8/second rhythm causing pulsations of the orgasmic platform (d) and the vagina (e). The 
uterus (f) 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. The 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. In humans, the physiological 
significance of oxvtocm 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 indulge in forcible 
coitus !... ° 

Experienced couples can sometimes time their orgasm to arrive together a 
consummation desired by all and is termed "synchronised orgasmic release'" 

;- ™m»l orgoom bctwtui (lit male ailU ftJIIiaifi m farthers is a goal to be 

striven for, if it happens naturally and without trouble, but to search for this timed 
orgasm and to work hard for its occurrence is not advisable because this may 
deprive the act of its beauty and dehumanizes the process of coital love The 
discharge of tension during the orgasm in both sexes and its extent varies 
immensely, both in different individuals and in the same person from time to 
time In both sexes when the fullest pitch of orgasm is reached, sensations mount 
greatly till muscular movements become automatic which is quite apparent 
during pelvic thrusting. Feeling replaces thinking actually, and a blending of 
sensations occur such as blurring of vision. Sometimes, physical and emotional 
ecstasy may be so overwhelming that consciousness is very nearly lost among 
some females. Pleasure may be experienced throughout the whole body and need 
not to be limited only to the genital region. 

It is strange that in some women so much feeling can be felt with so little 
outward manifestations apparent. By no means all husbands can perceive the 
moment of orgasm in their wives; indeed, many women can and do simulate 
orgasmic release, sometimes even without knowing exactly why thev do so i e 
pretending to have had an orgasm!. Similarly, although a small proportion of 
women are able to feel semen as it reaches the vaginal walls, a far greater number 
cannot do so and admit feeling nothing. 

( 4 ) Resolution phase 

In the resolution phase, the anatomic and physiologic changes that occurred 
during the excitement and plateau phases reverse. After orgasm, the sex organs and 
with them the whole body need sometime to return to their unexcited state 
(Fig.19). 

Changes in sex organs 

The congestion in the outer third of the vagina, namely the orgasmic 
platform disappears between 5 to 8 minutes as the muscular contractions of 
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 
circumvagtnal musculature's involuntary, rhythmic contractions in response to 
sexual arousal and orgasm come to a standstill. 



49 



■*-f. 






Uterine 
descent 



Loss of 

v//'\ vaginal 

,;expansion 




Clitoral 

body 

descent 



\ 



Loss of labia minora 
size increase 



Loss of labia majora 
separation and elevation 

Figure 19. 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 
return 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 of the vagina is eliminated. Amazingly the 
cervix now dips into the seminal pool collected in the posterior fornix 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 5 
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. 

It 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. Jn 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. It is a rare condition of uncontrollable sexual desire in females; 

fortunately the condition is not common. It is actually very rare. 

50 



Clitoral Versus Vaginal Orgasm 

There has beeit ? great deal of controversy and confusion regarding the role 
of the clitoris and the vagina in female sexuality which unfortunately was a major 
source of clinical error in the past. Is female orgasm clitoral or vaginal ? ... This 
specific controversial question really should be: Is it vaginal or clitoral stimulation 
that produces orgasm in females ?. In the past, according to Freudian 
psychoanalyses, clinicians believed that clitoral sexual sensations were considered 
as a sign of neurosis !, while clitoral eroticism was diagnosed pathological ... Until 
Masters and Johnson demonstrated the fallacy of this theory in 1966. Recent 
studies by H. Kaplan and S. Fisher suggests that stimulation of the clitoris may 
always be crucial in producing female orgasmic discharge during coitus as well as 
other forms of love, making 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. It could be applied directly or 
indirectly to the target area through stroking, squeezing or mere pressure whether 
rhythmically or arrhythmic to the primary or the secondary erogenous zones. 
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. It has a rich nerve supply with a distribution 
similar to that of the glans penis with specialized sensory nerve endings, namely 
the Pacinian corpuscles. Touching the clitoris is experienced as intensely 
pleasurable by most females, however, the clitoris is so exquisitely sensitive to 
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 lateral 
stroking of the clitoral shaft through the labia minora. Incidentally, this is exactly 
what happens during the plateau phase of the sexually stimulated female when the 
angulated erect clitoris rotates ventrally 1 80° and retracts under the symphysis pubis 
while covered by its clitoral hood to become squeezed indirectly by the male pubic 
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 by Prof. 
Hunt with the percentage of 75% in favor, in contrast to a research done by Kinsey 
et al. in the fifties reaching 45% only. These women confess to the fact that the 
astride position enhances their orgasmic release due to theirerotic satisfaction in 
response to the (Kinesthetic sense) which is the sense of active body movements 
namely the active pelvic thrusting. Some authorities attributed the popularity of this 
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 males 

and for ejaculatory incompetence of the partner during their sex therapy because 

51 



it alleviates possible performance Anxiety. Women who are lacking orgasmic 

capacity and not truly frigid benefit enormously from this face to face woman 
above during their treatment. 

In 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 O clock at the entrance and the outer third of the 
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; while pure vaginal stimulation does not lead to 
orgasm unless it is accompanied and augmented bv highly erotic fantasies !... 
Clitoral stimulation regularly produces orgasmic release, perhaps this is evidenced 
most convincingly by the 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 phallic 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 coitus the powerful 
thrusting of the penis exerts rhythmic mechanical traction of the labia minora and 
so provides stimulation for the clitoris via movements of the clitoral hood. In the 
final analysis, it is stimulation of the clitoris via the pubic bone pressure and bv 
the labia minora- clitoral hood mechanisms and not pure stimulation of the 
vaginal introitus which produces the ultimate coital 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 itself plays no role in its actual execution ... 

It is now believed by all authorities that all female orgasms are 
physiologically identical, triggered by stimulation of the clitoris and expressed by 
vaginal, uterine and anal contractions Accordingly, regardless of how friction is 

applied to the clitoris, by the phallus of the male, bv the woman's finders durint* 

masturbation or even by a vibrator or any other desired object; female orgasm is 
almost always evoked by clitoral stimulation. Thus the phvsiologv of the female 
orgasm is analogues to that of the male; because tactile stimulation of the glans 
penis and the penile shaft triggers the male orgasm at the end of the plateau phase 
once a certain level of sexual excitement lias been reached or exceeded. 



52 



vz&mm ; 



■ •■■ ■'^:-:->:v:'Xv:vXv<-'-'--j?- , ' , ?k 
.-:•:,. v,.v,,,,,-, :;,,,, :^:fe| 



■ :■■■ •:•:« :=S. *:^ : fe' :: i^v;.:^;:c:::;; 

;..;.,... : :^-t •-^:^:-:-!?:- o^. : . v>:<- *•'•>■:-: 




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

It is worth mentioning here this starking 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 awful practice of female circumcision better named female genital 
mutilation (FGM). 



53 



Non Resolved Sexual Tension in Females 

Atiorgasmia 

If 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 interruptus 
develop what is known as "protective frigidity". In 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 

colon..., are quite common findings. 

54 



The well known condition of nervous strain termed "Anxiety neurosis", 
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 often than 
women, because with them orgasm of some sort usually occurs whether by 
orgasm during sleep or by masturbation. In females spontaneous 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 18.000 females in the U.S.A. are born without a vagina annually 
recorded in 1960, surgery is known to create an artificial vagina by grafting skin 
from her thigh or abdomen. It 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 of the 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 

°" "fT" * -jimilttt viiih a limp pinio iiQ. non greet puiij.. nliili nilli ulliiu 

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 

Human beings can be sexually aroused at nearly all times, in many 

different vvays and by a great variety of objects. For example, man's excitement 

may be triggered at any hour of the 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 of the 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 shaft in the male; the clitoris, the two labia 
minora and the orgasmic platform in the female; these are the primary 
erogenous zones. (Figure 21). 

In 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, the 
neck, the mouth namely the lips and tongue and lastly the ears; these are the 
secondary erogenous 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... 

In 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 
different degrees of sensitivity, since negative mental associations can prevent 
any sexual response to touch. In 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... 
56 



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4> 



In 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 !. 

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 

It follows from these observations that there are no constant erotic sights, 
sounds or smells as such, they only become so through certain erotic experiences. 
It 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 thht 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. 

It 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, 

58 




THE PHYSIOLOGY OF COITUS 
IN THE HUMAN MALE 

Physiological responses of the sexually stimulated male. 

Size of the penis. 

Relation between anger and sex. 

Orgasm during sleep. 



THE PHYSIOLOGY OF COITUS 
IN THE HUMAN MALE 

Physiological Responses of the 
Sexually Stimulated Male 

hi a physiological research laboratory recordings of (he extra-genfta! 
reactions, as well as, observations of genital responses were recorded before, 
during and after sexual stimulation. The basic male human sexual responses fail 
into five different phases, which were described by Masters and Johnson in the 
year 1966, These phases were tenned: Fxcitemcnt phase, plateau phase, orgasmic 

phase, refractory phase and the resolution phase, (Figs, 22 - 29). 




Skin 



Corpora cavernosa 



Corpus spongiosum 
Urethra 



Cross Section 




Transverse Section 



Cooper's glands 
MftrnhraJicus urethra 
Gu ILf uf |jcnii 

Root 



Body 



Corpora cavernosa 



Corpus spongiuSLirn 



Penile urethra 



Coronal rrdge 
GJans penii 

Prepuce 

Meatus (urethi*i 

upening) 



figure 22. T he internal structure nf the penis as viewed from a cross 

section and transverse section. 



5? 



It should be pointed that the presented diagrams of female and mate sexual 

«h£Z S A C l ■ r- mMnt ° nly aS schcmatic conceptualizations of commonly 
observed physiologic Patterns, while the clinical implications of disruptions of 
these patterns are discussed in greater detail in the chapter of Sexual 
Inadequacy. 

( 1 ) The excitement phase 

The most obvious sign of sexual excitement in the male is penile erection 
because the initial response of the human male to sexual stimulation is the 
vasodilation of the arteries running into (he penis, resulting in erection This 
occurs as a direct result of vasocongestive changes within (he sponge like tissue 
of the perns. It is helpful to realize, however, that physical as well as 
psychological arousal may be present without a firm erection, particularly when 
anxiety or fatigue are present. 

Spinal cord tenters 

In both men and women the physiologic signs of sexual excitement are 
produced by the reflex vasodilatation of (he genital blood vessels. During sexual 
arousal, two centers in the spinal cord, one at S 2 , S,, and S 4 and one at T„ T„ L, 
and U become activated and cause the arterioles which invest the genitals to 
oHate This vasodilatation causes these organs to become swollen and distended 
and changes Iheir shape to adapt them to their reproductive function The reflex 
dilatation occurs in boih genders, however, because of anatomic differences in the 
male and female genitals, this swelling takes different terms and so produces 
changes which are different but complement^?. The penis becomes hard and 
enlarged to penetrate the vagina while the vagina balloons and becomes wet to 
accommodate the erect penis. 

The penis 

The cavernous spaces of the corpora cavernosa of the penis till with blood 
and distend the penis against its tough, rigid outer sheath. This changes the 
llacud. soft penis into a hard and erect organ capable of penetrating the vagina 

The perns is maintained hard and erect by a high pressure hydraulic system 

which uses blood as its fluid.,. 

Normal mechanisms of erection: 

Erection ofthc penis depends on the adequate filling of the paired corpora 
cavernosa with blood at systolic pressure or slightly above. Arterial blood enters 
bom ihe paired cavernosal arteries, which are terminal branches of the internal 
1 1 Hie arteries. Numerous corkscrew- shaped helicrnc arteries branch off each 
cavernosal artery within the corpora and empty into the lacunar spaces Frection 
occurs wh e „ the tonicaUy contracted cnvcrnosnl and helicine arteriPB relav 
increasing blood flow to the lacunar spnees and resulting in engorgement of the 



penis. The enlargement is contained by the tough fascia which encases the penile 
cylinder while the pressure of the increased blood against this sheath hardens the 
penis and makes it rigi f TTie increased penile flow of blood during excitement is 
known to be caused by relaxation of the penile arteries; this is brought about by 
parasympathetic impulses from the erection centers. 

Relaxation of the trabecular smooth muscle of the corpora cavernosa is 
mediated by acetylcholine released by the parasympathetic nerves. Acetylcholine 
acts on endothelial cells causing them to release a second non-adrencrgic non- 

cholinergic carrier of the relaxation signal. This carrier is proved to be nitric 
oxide, possibly of neural origin, but other candidates for example; vasoactive 
Intestinal polypeptide- have not been conclusively excluded. Nitric oxide may 
exert a relaxing effect un the trabecular smooth muscle through stimulating 
gu any late cyclase to produce cyclic guanosine monophosphate (c-GMP\ which 
would then function as a second messenger. 

Systemic blood pressure expands the relaxed trabecular walls against the 
rigid tunica albuginea, compressing the plexus of subtuitical venules and 
restricting venous drainage from the lacunar spaces. Erection is therefore the 
result of an equilibrium between arterial inflow from the cavernous arteries and 
the resistance to blood outflow from the lacunar spaces resulting from these veiiu- 
occlusive mechanisms, Detumescence is accomplished by a reversal of these 
processes. Increasing sympathetic tone, which is also involved in mediating 
orgasm and ejaculation, causes the cavernosal and helicine arteries to contract, 
restricting blood flow into the lacunar spaces. Fading rnrralacunar pressure then 
decompresses the subtunical venules, allowing increased venous outflow and 
restoring ihe penis to its normal state of flaccidity. We can see now that the 
erectile response is primarily a parasympathetic one, although surgical and 
pharmacological evidence suggests that minor sympathetic component is also 
required for potency by controlling the outflow of erectile blood. However, it is 
well known clinically that an intense sympathetic response such as that produced 
hy fear and anxiety, can instantly drain the penis of extra blood and so cause a 
psychogenic loss of erection. 

Sexual excitement may mount rather unexpectedly and quickly especially 
in young men, but it may also build up gradually and over a longer period of 

time. In fact, some males deliberately distract themselves repeatedly from their 

mounting feelings o^ immense sexual pleasure, in order to prolong the act and to 
savor or enjoy more their experience of becoming sexually aroused. Again, 
sexual arousal especially in its early stages, can be easily reduced by some 
outside interference such as sudden worry nr anxieties, also fear and pain have 
the same effect. But, with the increasing magnitude of sexual tension, such 
negative influences become less and less effective, while the ability for sexual 
self control is impaired and sexual inhibitions arc swept away with the inevitable 
occurrence of the orgasmic release and ejaculation. 



61 



The penis is formed of three bodies of cavernous tissue with erectile 
capacity, and after the start of sexual stimulation whether by tactile, visual or 
olfactory means, thr- occurs a slight increase in the si*e of the penis which 
affects its shape and position. The stiffness of the penis occurs first in (lie paired 
parallel lying corpora cavernosa and not until further and stronger sexual 
stimulation takes place, does the corpus spongiosum which forms the glans 
become fully erected. The glans penis shows a color change acquiring a more 
deep red tone. When the penis is fully erected, the urethra is stretched out, while a 
droplet of fluid is seen often in the urethral opening. This fluid is secreted from 
(he urethral glands among which is the Cowpers gland placed some 15 cms from 
the opening. A point of great importance is the presence of few very active 
sperms sometimes in this fluid, and this droplet of fluid may be noted though the 
perns is not fully erect, ( Fig. 23). 




Erection 
(reversible) 



Testicular elevation 
ial) 

Skin and 
tunica dartos 
(thickening-) 



Figure ?3. Male pelvis: excitement phase. Key to abbreviations T = testis- E 
- epididymis; U - urethra; CG - Cnwper's gland;' P = prostate; PU - prostatic 
utricle: PD - ejaculatory duct; VD - vas deferens; SV - seminal vesicle; UB - 

urinary bladder; SP = symphysis pubis; R = rectum. 
The capacity fnr erection 

It is worth mentioning here thai the same stimuli that bring about the 
penile erection in the male result in vaginal lubrication in the female, because 
these two phenomena are absolutely necessary for a normal penile intromissio 
into the vagina and are both based upon the same physiological mechanism Th 
capacity for erection is present at all ages in the male, the neonate penis L 
dominated by the glans and experiments done on a (wo day old bov, proved that 
erection did occur when provoked by slight touching of the Rcnital area. It should 
be noted again that erection in the male may be evoked -by cerebral or spinnl 
activation, because in males with high spinal coid transection, erection may be 



ion 
le 

is 



62 



evoked by spinal reflexes alone. The same is true of vasodilation during erection, 
the arterial vessels running to the corpora cavernosa are almost closed; 
parasympathetic cholinergic nerves innervate these blood vessels. The dilation 
that ensues fills the cavernous spaces with blood, the pressure rises as a result 
until it reaches that of the arterial blood pressure with maximal stiffness and 
rigidity following. 

The scrotum 

The normal appearance of the scrotum begins to change as vasocongestion 
produces a smoothing out of skin ridges on the scrotal sac; the scrotum shape also 
flattens because of an internal thickening of the scrotal integument. Later, the 
scrotum Rnd the testes are partially elevated toward the perineum. The 
physiological significance of this phenomenon is not completely understood, 
because this elevation occurs rn 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 sut rounding temperature is neutral, 
the scrotal skin is richly folded and freely movable in relation to the underlying 
structures. But if the temperature of the environment is lowered, the muscles of 
the scrotum are activated and alternate between contraction and relaxation while 
the testes move into a posterior position as the organ is elevated. Contraction of 
the crernaster muscle, known as the "cremasteric refle*" or "withdrawal 
reflex", may be evoked also when the inner surface of the thigh is scratched. 
'I hese changes resemble those occurring during sexual arousal in the male, partial 
elevation of both testes toward the perineum occurs in the excitement phase, 
Latei, when the sexual response cycle has continued into the plateau phase, the 
testes become enlarged by vasocongestion, merging their size by about 50 
percent. They are kepi in close apposition to the perineum and lower abdomen 
through the shortening of the spermatic cords, mediated by the cremasteric 
muscles. The pulse i >t e in this phase reaches about |Q" 120 per minute as 
compared with the male resting pulse; JfciCG recordings were 'measured through 
electrodes fixed on the thorax of male volunteers. The blood pressure rises and 
therp is hyperventilation as well as Generalized myotonia. 



( 2 ) The plateau phase 



In the excitement phase, there is a marked increase in sexual tension above 
the baseline (unarouscd) levels. The plateau phase represents a leveling off of the 
increments in sexual tension that are occurring, although there is a further 
intensification if effective stimulation continues. This phase therefore describes a 
high degree of sexual arousal that occurs prior to reaching the threshold levels 
required to digger orgasm. The duration of the plateau phase is variable, but it is 
often exceptionally brief in men who a»e premature ejaculators. 



63 



The penis 

During the plateau phase, there is a minor increase in the diameter of the 
proximal portion of the glang penis, where there is frequently a visible deepening 
in color due to venous stasis. 

The testes 



Vasocongestion causes further increases in the size of testes during this 
phase, with increments of 50 to 100 percent of baseline size are typically seen. As 
sexual tension mounts towards orgasm, the testes continue not only the process of 
elevation initiated in the excitement phase but also a process of anterior rotation 

so that the posterior testicular surfaces rest in firm contact with the perineum 

(Fig. 24), 



Cowper's gland 
secretion Pinal 

Corona gvjengorgemen 




elevation 



Testicular 
size increase 



Skin and 
tunica dartos 



figure 24. Male pelvis: platemi phase. 
Extragenital changes 

Other extragenital features of the plateau phase common to both women 
and men include gene rallied myotonia, tachycardia, hyperventilation and an 
increase in blood pressure. These changes are primarily a continuation seen 
often during the late plateau phase. 

A number of males, not all, do experience what is known as a sex flush it 
is a red rash that usually begins in the area of the lower abdomen and that spreads 
to the neck and face or even to the shouldeis, arms and thighs.' The sex flush may 
start only late in [he excitement phase hut it is more likely to appear in the plateau 
phase while sometimes it may appear as lale as the orgasmic phase. In many 



64 



cases, however, there is no sex flush at ail, the same is true for the human female. 
The physiological mechanism underlying the appearance of the sex rash, which 
may be of a maculo-papular character is not known up till now, and it may very 
quickly disappears in the resolution phase. 

Not all males experience the erection of their breast nipples, which is 
brought about by direct physical stimulation of the breasts unlike females whose 
breast nipples become erect involuntarily once the lady is sexually stimulated. It 
usually appears toward the end of the excitement phase or during the plateau 
phase and it usually remains visible and erected for sometime after the resolution 
phase. 

( 3 ) The orgasmic phase 

It is simply the sudden release of muscular and nervous tension at the climax 
of sexual excitement. This experience represents "the most intense physical 
p|pA*nre nf which human beings are capable of and is basically the same for 
males and females". As mentioned before, the specific neurophysiology 
mechanisms of orgasm are not known presently, nevertheless, it can be postulated 
that orgasm is triggered by a neural reflex arc once the orgasmic threshold level has 
been reached or exceeded. This speculative model, based on the physiology of 
other body systems, will be important in the context of later clinical discussion. An 
orgasm lasts "iily a few seconds and is felt very much like a short seizure or rather 
like a quick succession of convulsions which involve the whole body and soon lead 

to complete relaxation. 
t 

Mechanism of ejaculation 

In sexually mature males, orgasm ts accompanied hy ejaculation of semen 
and since women do not produce semen, hence they do not ejaculate. I he same is 
true for boys before puberty, they do have orgasms but without ejaculation. The 
male orgasm is triggered by the buildup of sexual tension to the point where the 
genital ducts and accessory sex organs begin a series of strong involuntary 
rhythmic contractions, namely: Vasa deferentia, seminal vesicles, prostate gland, 
the anterior and posterior urethra, urinary bladder sphincter, Ihe muscles at the 
base of the penis and finally the penis itself. The first three or four forceful 
contractions recur within less than a second, actually (0,8) of a second, then they 
become weaker and occur at longer intervals. As a result df these contractions, 
the seminal fluid is pooled in the prostatic urethra forming a pressure chamber, 
\v\\h a proximal closure towards the urinary bladder. This fluid, with its 
concentration of live sperm cells, is formed from three 'different sources; the 
prostate, the seminal vesicles, and the vas deferens The amount of semen 
ejaculated duiing one orgasm Is- usually about a teaspoonful, nearly 5 ml, but it 
vnrres especially if repeated ejaculations are performed- within a short time, 
because the male then produces less and less seminal fluid. 



65 



Secondary organ contractions 
( first stapre orgasm) 




'■'\ *.■;=:' 



-A 

Externa] sphincter 

contractions 

Skin and 
tunica dartos 



^ - r - 

] igure 25. Male pelvis: orgasmic phase 

At the first stage of the ejaculatory process, tlie veiv excited male 
experiences a sensation or ejaculatory inevitability, when (he changing pressure 
dynamics are perceived as the start or ejaculation, althoupb the external 
propufsion of semen will be delayed for several seconds This^ime lag between 
the onset of ejacuhtion and appearance of seminal fluid from the penis, is a result 
of the distance the ejaculate must travel through the urethra, as we J I as the 
interval required for the build up of sufficient contractile pressure to push the 
semirftil fluid pool In an anterior fashion. The internal sphincter or the neck of the 
urinary bladder is tightly closed during ejaculation, ensuring that the seminal 
fluid bolus moves anteriorly, toward the path of least resistance. Rhythmic 
contractions of the prostate, the perineal muscles, and the shaft of the penis 
combine to assist the propulsion process of ejaculation during the second stage of 
the orgasmic ejaculatory process (Fig 25). The first ejaculate leaves the urethra 
to the outside emerging in several quick spurts, at a velncitv of about 4 times the 
mean velocity of the blood in the aorta. At times, it '.„ av be projected a 
considerable distance, while at other times, the semen may now out rather gently; 
the force of a particular ejaculation is not related to a mans strength or virility' 
(fig. 26). 



It is important to remember a I! the time that the whole hndy is involved 
physiologically, for example, the anal sphincter muscles contract at the same 
intervals as the sex organs, Tn fact, there is great neuromuscular tension 
thioughout the whole body, because besides the muscles directly involved in the 
act of orgasmic release, whether through coitus or masturbation, almost all groups 
of muscles may react involuntarily, rhythmically or with single contractions. 
While the sexual stimulation proceeds, the restlessness increase and it is die 
sudden, convulsive relertnc from this overall tension that constitutes the orgasm 
As a mailer of fact, at the time nf sexuni climax, ^....d, arc often produced 



66 



whether from the male or female partner, such as screaming or moaning or 

incoherent noises. Sometimes tossing of the head sideways is noted Among some 
females during this pha". Breathing become very fast and the pulse rate mounts 
to about 140, while the blood pressure rises even higher than during the plateau 

phase. 




Figure 26. The male genitals and muscles during urgnsm. 
Phasc !- Fmission: This phase is perceived as the sensation uf tL ejaiaihtlury inevitability'. 
The internal male reproductive viscera [prostate (a), vas deferens (b)„ seminal vesicles(c)| 
eontiact and collect the ejaculate in the urethra! bulb (d). Phase 2- Cxputaion: The perineal 
(e), and bulboc^'prnosirs (f) muscles contract with a R/sprnnd rhyrhm enuring pulsations of 
the penis and expulsion of the ejaculate The penite urethra (g) contracts also. 

( 4 ) The resolution phase 



During the resolution phase, the anatomic and physiologic changes that 
occurred during the excitement and plateau phases; reverse. Immediately 
foil owing ejaculation, the man enters a "refractory period", during which 
furLhtrr 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 tor many hours. For most men, this refractory 
period lengthens with age and is typically longer with each repeated ejaculation 
within a time span of several hours. There is great variability in the leu^Lh of the 
refractory- phase both within and between individual men, while it is not present 
in the female sexual response cycle. (Figure 27). 

67 



Orgasm 



Pla 



can 



Excitement 




Refraetury 
! period 



Refractory 
period 



1 

1 



I 



Figure 27. Hie male sexual response cycle. 

Immediately after the last ejaculatory contraction the muscular movements 
cease, while the scrotal and testicular elevation reverses into a downward 
movement. 1 he testes decrease in size and descend into the scrotum unless sexual 
stimulation is continued. The tumescence of the penis starts to decrease and 
incidentally the length of this resolution time is proportionate to that of the 
excitement phase. Ihus, in men the crecfion diminishes in two stages- a prompt 
major loss of polenny that occurs immediately after ejaculation due in penile 
contractions <Iunn R orgasm (hat quickly reduce vasocongestion and a second 
stage »r detumescence corresponding to a slowe. process of return to normal 
vascular flow. Thus, one can note that the penis still retains some firmness which 
may persist for sometime especially if the excitement and the plateau phases were 
prolonged. On the other hand, it is well known that rion sexual activities or 
distraction e.g. a knock on the door for example can complete the loss of erection 
very rapidly, (Fin.2 8). 



YD 



¥—■ E D 



v 




--PU 



\ 



v 



(i 





V. 



Loss of tofiUcuIarv 
Fiuure 28, Mule pelvis: rcsnlutiuii pha^- 



.■ . ■ ■-■■ I - ' 

E&Jp Testicular descent 



[_ '■ y \-L~- *-'' ci et u mo s cence 







68 




Thalamus 
Limbic System 



Cortex -i 




Figure 29. The sexual response reflexes. 
This is a diagrammatic representation of the reflex pathway of the expulsion component 
of ejaculation, fa) is a representation of the sensory pathway from the glans penis; (b) 
shows a motor titrve to (lie muscles at the base oflhe penis which contract reflexly during 
rtrgflQm; and {r} is a diagram of a cross section of the spinal cord, showing a schematic 

representation of the various influences which impinge on the internuncial neurone pool. 

Size Qf The Penis 



History 

Recent discoveries in the field of experimental sexology have exploded 
several sexual myths and wrong beliefs about the size of the penis (Masters and 
Johnson). So much has been said, and a lot was written about the importance of 
the size of the penis and its rule during coitus. In every country and in every 
known language, not just recently but since ages this myth was well recorded at 
the time of the Phamohs. Their temples all over Egypt are full of phallic 
inscriptions and paintings, some of which are even abnormally exaggerated 
erections, a good example is the God of fertility (Menn), beautifully painted and 
well reported in Upper Egypt and in Abnu-Simbel, 

In "Pompeii", the old Roman town destroyed by the volcanic eruptions of 
the famous volcano "Vesuvius" in 79 A.D., tourists could still cusily Net the 
daring Roman philosophy painted clearly on the gate of the house of pleasures. A 
big balance, with unc scale full of all Ihe world's known treasures but still not 
capable of tipping the other scale which contained the image of an enormous 

sized fully erect penis.... 

69 



In some ancient temples of India, China and Japan and among the text of 
some of their numerous religions, there were similar erotic ideas and sexual 
beliefs- So much so, that their ancient civilizations have confirmed the widely 
held belief that the size of the erect penis is related to sexual efficiency and it 
greatly influences the sexual performance in coitus. Many famous and sexually 
explicit works of art and architecture testify to this belief, indeed, one of the best 
known early sex manuals, the "Kamasutra" written in the 2nd century B.C. 
treats sexual intercourse as a means of spiritual enrichment. Phallic worship in the 
form of deep respect for the "LingairT an artistic representation of the penis, 
continues to this day. 

In many parts of Asia, openly erorir images acquired a religious meaning 

in the past, a mingling of the so-called "ianfric movements" which can be found 

in both the "Hinduism** and "Buddhism" religions. Hiphly erotic images can he 
seen in many Hindu temples, for example, the "lingam" (male sex organ) set in 
the "Yoni" (female sex organ}, representing the double sexed deity or their God 
who is double sexed!. (so they believed).. 

Sexual performance and size of the penis 

For reasons that are not entirely clear, many males in our culture seem 

+ ■**■ 

quitf* concerned about the Ki?.e of their penises, however, such concern is 
completely unwarranted sometimes. The average normal length of die penis in 
the flaccid ptnte is variable, it is usually about 3 to f inches but when fullv erect 
the length im. i eases by approximately 50 percenf reaching from 5 to 7 inches or 
more however, it should be noted (hat this increase in length occurs stepwise. Il 
his been found that there may be great variations in the size of the penis from one 
individual to the other. Contrary to some widely accepted mjths, the size of the 
penis is not related to a man's body build, skin color or his sexual power, for 
example, a very short man may have a larger penis than a tall man (and vice 
versa), a white man may have a larger penis than a black man (and vice versa ) ? 
and a man with a small penis may have more orgasms than a man with a large 
penis (and vice versa) Furthermore, some penises which greatly differ in size 
when they are flaccid, may be of identical size when they are erect, liven a penis 
lhat remains relatively small during an erection serves every function of a larger 
penis, A woman's vagina for instance, adjusts lo any penis, no matter what its size 
and since the vaginal walls contain few or no nerve endings in its inner two 
thirds, any difference in the woman's sensations depends on the firmness of her 
muscles surrounding the outer vaginal walls as well as many psychological 
factors. This fact, anatomically is also true, and holds good as regards sensations 
inside (he rectum, during anal intercourse or sodomy, there is practically no 
feelings at ail beyond the anal sphincter muscles, this is incidentally the reason 
why some individuals who introduce long and hard objects into the rectum, may 
seriously hurt themselves without realizing it, This may happen as well during 
fnicihle anal intercourse which occurs during the act oi raping a male e £. in 
prisons and mental hospitals or between homosexuals. The manufachueTs of 
sexual aids did make use of (he huge penis sexual tahoo and produced in the 

70 



market different sized and variable shaped phallic like structures to attract their 
customers, which were meant for both males and females. A famous theatrical 
play which deals with this point was performed in London, (1960). 

Abnormal sized penis 

Recently, the laboratory experiments performed by Masters and his 
colleagues proved that the differences in size of the penis are to a very large 
degree leveled out by the degree of erection, so much bo, that a smaller penis 
increasing in length impressively, is more efficient than a larger nun efficient one 
provided naturally that it is not the congenital anomaly of a microphallus ♦.♦!* 
Because, the human vagina accommodates the actual penile si*e and no more, so 

that an abnormal sized penis could not go further than the actual size of the 
vagina when stretched maximally during the various stages of sex stimulation, 
FuitheiiiHire, there is danger nf vaginal rupture or tears commonly occurring rn 
the posterior fornix, if an abnormally sized penis is pushed wrongly deepei than 
necessary or while being used with undue force. Post coital bleeding, apart from 
torn hymen injuries on the wedding night, accompanied with excessive pafn or 
unexplained shock should be taken seriously into consideration by doctors in such 
races, because if there is a vaginal tear it requires immediate surgical intervention 
and repair under general anaesthesia. 



71 



Relation Between Anger and Sexual Physiological Responses 



Sexual Response 

I- Reduced sensory perception. 

2. Pupil dilatation. 

3, Involuntary vocalization. 
4 + Salivary secretion. 

5. Hyperventilation. 

6. Irregular breathing. 

7. Increased blood pressure. 

8. Increased pulse rate. 

9. Increased peripheral circulation. 

10. Reduced bleeding. 

1 1 Inhibited gastric function, 
1 2, Adrenaline secretion. 

13. Rhythmic muscular movement. 

14. Tumescence nf sex organs. 

15. Ciemtal secretion and discharge 

16. Ejaculation in ndult males. 

17. Muscular tension. 

18. Increased muscular capacity. 

19. Involuntary muscular activity. 



Anger Response 

Reduced sensory perception. 

Pupil dilatation. 

Involuntary vocalization. 

Salivary secretion. 

Hyperventilation. 

Irregular breathing 

Increased blood pressure. 

Increased pulse rale. 

Increased peripheral circulation 

Reduced bleeding. 

Inhibited gastric function. 

Adrenaline secretion. 

None. 

None. 

None, 

None. 

Muscular tension. 
Increased muscular capacity. 
Involuntary muscular activity. 



Kmsey discovered that many of the bodily responses in anger and during 
sexual arousal were in many aspects simitar. Freudian analysts in particular 
argued that anger, both concealed and expressed, was often the result of repressed 
scxualily. Klnsey showed that there is certainly fl dose parallel between sexual 

response and the physiology of anger Only fuur bodily functions differentiate 
between both and so he put the hypothesis that, if certain physiological elements 
were prevented from developing, the Individual might be left in a state of anger 
As such, the fact that frustrated sexual responses so readily turn into anger could 
be easily explained. 

As Kinsey pointed out, in lower mammals and in man, anger and fighting 
easily turn turn sexual response I. Could this be Hie clue and the answer to the 
mysterious "hate-love relationship" ? 



72 



72 



Orgasm during Sleep 

It has always been well known that human beings arc capable of 
experiencing sexual responses while they arc asleep. In the past, people ascribed 
this capacity only to males and there was no comparable requirement for women. 
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 "nocturnal emission". 

History 

In ancient times, it was thought that involuntary orgasms occurred during 
the night when a demon visited people in their sleep!. During the middle ages, it 
was believed that the devil himself cnuld seduce good believers at night by 
appearing as an incubus (i.e. lying upon a woman) or a succubus (i.e lying 
under a man)... 

Terminology 

It was nut until around the middle of our century that Kinsey and his 
associates presented some reliable statistics as to the frequency of this type of 
sexual outlet. The figures showed 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 "nuiturnal emissions 1 ', but of 
"nocturnal sex dreams". This was a term that could be applied to both sexes 
However, it also covered cases where no orgasm was reached. In uider to be 
more precise, other sex researchers therefore replaced Kinscy's term with 
''nocturnal orgasm", (i.e. orgasm during the night). Unfortunately, this now 
popular expression is very misleading, because in our culture most orgasms occur 
at night, including those reached by coitus. Sexual dreams on the other hand, may 
veiy well occur during an afternoon nap, in which case they would have to be 
ailed "diurnal set dreams 1 *, (i.e. sex dreams during the day). It seems then that 
orgasm during sleep 1 ' is the simplest and most accurate term available, it was 

also termed "wet dreams" in the past. 



ca 



Involuntary orgasms are almost always accompanied hy sexual dreams, 
especially in males. These dreams may depict unusual or forbidden behavior, 
such as sexual intercourse with close relatives, children or animals, group sex, 
exhibitionism, and many other activities that the individual could never perform 

or contemplate while in his or her waking hours. However, during sleep our 
normal inhibitions and learned controls are much less effective and many of our 
unconscious wishes may thus be acted out in a harmless symbolic fashion. The 

!nck of conscious restraints also accounts for another phenomenon, and that in 
many people, (particularly women) reach orgasm much faster in (heir sleep than 
while thev are awake. 



73 



Medical opinion 

Certain psychiatrists once used to regard involuntary orgasms in women as 
symptoms of some neurotic disorder, but in due time, this curious opinion has 
been completely discarded. Instead, there is now a widespread belief that orgasms 
during sleep are necessary and healthy, and that they can even provide a 
"natural" compensation for sexual abstinence. In other words, it is assumed that 
persons who do not engage in any sexual activity will instead find sexual relief 
while asleep. This popular assumption seems to be false however. For instance 
according to Kinsey's findings women who suddenly lost the opportunity for 
several coital orgasms per week, has only a few more orgasms in their sleep per 
year.. As a matter of fact, for some women the number of involuntary orgasms 
increased only when they also had more voluntary orgasms. In short, an orgasm 
during sleep is a possible natural function of hunum bodv, but it is no substitute 
for conscious sexual activity. 



74 




POSITIONS OF SEXUAL INTERCOURSE 



* History and Research. 

• Advantages and Disadvantages. 



POSITIONS OF SEXUAL INTERCOURSE 
History 

In 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 "missionary position". Kinsey's research' found 
that the male-above position was the most frequently practiced among Americans 
born before 1930 (Kinsey et 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 positrons especially those who were brought up 
more recently, mostly young and uninhibited couples. 

Research 

A recent national American sex survey found evidence that since the time 
of Kinsey's research, variation in sexual positions has become common piactiee 
between marriage partners (Hunt. 1974) The research found that the "female- 
above position" is frequently being used by 75 percent of married couples 
nowadays (versus only 45 percent in Kinsey's research). A "side-to-side 
position" is frequently used by 50 percent of married couples (versus only 31 
percent in Kmsey's research). The "rear-entry position" is frequently used by 
40 percent of married couples (versus only !S percent in Kinsey's research). 
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 unmarried college 
students (Allgeier and Fogel, 1978). Half of the students were shown slides of a 
couple having sexual intercourse in the female-above position and the other half 
were shown slides of a couple having sexual intercourse in the mote conventional 
female- be low position. All the students were then asked to give their impressions 
of the personalities of the man and woman using a scale of descriptive adjectives 
Surprismgly, the research found that the female students (but not the male 
students) rated both the man and woman in the female-above position 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 the man during sexual intercourse. The female students raten" 
the man in the female-above position in a similarly negative way.. This iesearch 
seems to indicate that young unmarried women as compared with men tend to 
hold more traditional erotic role expectations regarding positions of sexual 
intercourse. Negative emotional responses to the female-above position may 
reflect the reluctance of women to accept a role of sexual assertive ness. That 
position allows the woman a greater control over the pacing of hei own sexual 



75 



arousal. It is possible, of course, that such a clear-cut difference between the 
opinion of men and women might not have been found if the research had been 
done with "married couples instead of the 1 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 of the men were not satisfied with the amount of sexual experimentation 
which they experienced (Travis, 1978 ) i.r. L iiey wanted moie variations. 

Position variations 

Much too much importance can be attributed to positions fur sexual 
intercourse. An over-concern about coital positions can easily result in a 
minimization of sexual forepfay or precoital petting. 

There arc hundreds of possible positions for intercourse, However, as a 
practical matter, the positions found to he most pleasurable for continual pursuit 
are those which are: (1) Comfortable and relaxing, (2) Do not cause muscular 
strp;p, and (3) Enable a reasonable freedom of movement (Masters and Johnson, 
t'^-6). Choice of position is also affected by a couple's body size and weight as 
wet! as their athletic ability at the end of a tiring day's work, Each position has 
certain practical advantages and disadvantages. In addition, each offers somewhat 
different kinds of sensations uf bodily movement and touch, 

Advantages and disadvantages 

'the most common position for sexual intercourse among Americans as 
well as among most other people is the "face-lo-faec'\ "man-ahnve position" 
(lord and Beach, 1951) (Fig. 30). This may be because it is convenient and 
relaxing especially for the woman. It also allows for some possibilities of manual 
and oral caressing while offering a maximum of body contact. The ^face-to- face" 
relationship facilitates communication and easily observed expressions of 
pleasure providing a greater sense of intimacy. Finally, it may provide greater 
friction to the clitoris than is possible in some other sexual positions. On the other 
hand, this position presents difficulties for some people. It may present 
difficulties for people who ore very obese, or for women in the last stages of 
pregnancy. It also may not be sufficiently relaxing for some men who ejaculate 
too quickly The muscular tension needed to balance and move the man and the 
considerable body contact with the body of the woman can provoke premature 
ejaculation in some males. 

I here are numerous variations of the "man-above position^. Instead of 
resting tier tegs straight or holding open at the sides, a woman can rest her legs on 
her partner's shoulders by folding them upward so that her thighs rest on her 
stomach. 



76 



-x^Q 





Figure Ml. Coitus in lithotomy 
position (face to face, man 
above:). The ilhisrrmion show*; 
the path of the sperm cells from 
the testicle through the vas 
deferens. At the end of this 
journey they are ready tu be 
released through sexual 

activity. During coitus, the 
available sperm cells enter the 
prostate gland where they 
become pail of the SL-men 
which is ejaculated into the 
vagina close to the cervix. 
1 Testicle 

2. Vas deferens 

3. Seminal vesicle 

4. J J rostate 

5. Urethra 

ft. Seminal pool 

7. Cervix 
N R. Note the position of The 
cervix and the seminal poo] 



This can otter variation in feelings of skin contact and motion. Another 
alternative is for the man to kneel between the woman's legs, holding her 
buttocks and bringing her to him for adequate support. This position incidentally, 
is the one which is most common in many Pacific island societies (Ford and 
Beactu 1951). 



A "sitting position" involves the use of a chair without arms. With one 
partner resting against the back of the chair for support, the couple can have 
intercourse seated face-lo-facc with their legs overlapping the sides i^ the chair. 
In this position, the couplers hands are free for caressing while they are also able 
to kiss, Penile penedatiuii in this "sitting position" is deep, and there is 
considerable skin contact in the genital area. However, the deep penetration may 
be painful for some women if their partner s penis bumps against their cervix. 

I he most common alternative to the "missionary position", i.e. lithotomy 
position is one in which the couple arc "lace-to-face 1 \ "with the woman 
above* 1 . This position offers advantages similar to the missionary position but is 
more relaxing (or the man. He can fie hack comfortably exerting little eneiyv to 

77 



maintain himself in that position and nse 1m hands To caress his partner's body. In 
so doing, he can concentrate more easily on his own sensations. It may also offer 

certain advantages to a woman, ]f her partner is exceptionally heavy, this position 
literally lakes the weight off of her. In addition, she can more easily regulate the 
pace of movement toward orgasm in rhythm with her own build up of sexual 
sensations. Hnally, it may be very 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 for this reason that the woman-above position is often 
counseled and advised strongly in cases of frequent premature ejaculation. 

The woman-above position also has certain disadvantages, it is more 
fatiguing for The woman especially for fragile females. She may have to kneel in a 
position which causes muscular strain in her thighs. In addition, where there is 
vigorous movements with deep penetration in this position, some women find 
that ir is internally discomforting or even painful especially with strong pelvic 
thrusting. 

The most common arrangement for the "woman-above position' 1 is for the 
woman to kneel astride her husbands hips and squat down on his erect penis. She 
can then use her kneeling legs to move herself up and down according to her 
desire. Her husband can make her more comfortable and relieve some of the strain 
by holding her by the waist to assist her up and down movements, there are 
numerous variations of the ' L woman-above position". The woman can lie flat on lop 
of her partner but unfortunately, movements in such a position may be difficult. 
She may have to use her elbows as a balance point to create movement, or her 
partner may have to move her with his anus. A moie unusual vaiiation is for the 
woman to squat above her partner but face toward his legs. Such a position offers 
less friction to the clitoris unless it is provided manually. It is also less 
psychological ly intimate because the man faces his partner's back and buttocks, 

The final sel of variations are "rear-entry positions". One arrangement is 
for both partners to kneel with the man behind the woman and between her legs. 
This position provides the man with considerable freedom to move his hands in 
caiessing his partner's body. It also provides the man with a full-bodied feeling of 
motion during the thrusting movements of intercourse (This increases stimulation 
to the kinesthetic sense - the sense of body movement). In addition, the soft 
pressure of his partner's buttocks against his whole genital region may provide 
exciting tactile stimulation. 

■ 

Unfortunately, the "rear-entry position" does not offer many advantages for 
women* Friction to the clitoris may be inadequate and may have to be provided 
manually during intercourse. Body contact for her is minimal 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 may not provide a sense of intimacy for a couple because partners are 
unable to view each other's facial expressions. This position is perhaps, the most 
tabooed in American eulluru because it attributes symbolic associations with 
animal sexual behavior as well as a possible degradation of women.,, 

78 

78 



A variation of the "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. He is free to move his hands and manually caressing her, 
however, genital movement in this position is difficult, A variation of the "rear- 
entry position", for the more 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 support for her balance. I he man stands behind her, 
holding her by her waist for balance. Such a position can be very difficult to 
manage if the sizes and body shapes of the couple are inappropriate for it. 

Such variable positions are for most people only considered as a rare 
amusement, when circumstances and mood permit some good humored sex play. 
I here are a great many other possible positions for sexual intercourse. However, 
the basic patterns have been described here and others are simply modifications 
of them. 

Another set of variations are "side to side positions" A couple may have 
intercourse lying on their sides and facing each other. The woman can raise her 
upper leg and rest it across her husband's hip enabling him to entet her vagina. In 
this position, both partners are free to use their hands and mouth in caressing each 
other. In this position, also, it is easy for a couple to ma in tain their contact after 
orgasm as they fall asleep. 

Yet the "side to-side position" also presents some difficulties. It may be 
very difficult to manage if the body shapes of a couple arc inappropriate for it e.g. 
obesity. In addition, such a position does not allow for vigorous genital 
movement because the couple's bodies are nearly locked into a constricted 

position. 

An alternative "side-to-side position 11 is one in which the man lies on his 
side facing the woman's hack. Thi«? position rs perhaps, the one which is most 
relaxing for a couple. It is a variation particularly appropriate for times when a 
couple are very tired or on sleepy mornings or when there is mild illness or 
during pregnancy. However, in cases wheie one, or both of a couple are obese 
this position may be very difficult to manage. In addition, while this position 
enables the man to have a maximum of possibilities for manually caressing his 
wife, she is left with few possibilities for active sexual participation. If manual 
caressing is not provided, she may feel Httle sensuous contact and inadequate 
friction to her clitoris. 

Religious view 

There is nothing more instructive and reliable than the beautiful meaning, a 
couple -would benefit from and make use of following this holy statement out of 
the Koran; namely, the feasibility of any desired sexual position, and at any lime 

they like provided it is vaginal intercourse and preceded by sexual foreplay. 



7V 



Coitus during pregnancy 

It is worth mentioning here that there is no reason that a couple should 
refrain from coitus in the first three months of pregnancy provided that the 
pregnancy is normal and the couple 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 the judge all the time especially in (he 
last months of pregnancy and during lactation, providing vital advise as regards 
possible contraception as well. 



80 




MALE SEXUAL INADEQUACY 

(DYSFUNCTIONS) 



I m potency. 

Premature Ejaculation. 
Ejaculatory Incompetence. 
• Mixed Sexual Dysfunctions. 



SEXUAL INADEQUACY 



Terminology 



Some men and women are restricted in their sexual activity by physical 
malformations, handicaps, diseases or injuries and there are also physically 
healthy individuals who cannot fully enjoy sexual intercourse because their sexual 
responses have become weakened, inhibited or even completely blocked for 
psychological reasons. Today, such a person is usually said to suffer from sexual 
dysfunction or sexual inadequacy. 

Obviously, the distinction between physical and psychological causes of 
sexual dysfunction is to a certain extent arbitrary, since body and mind are so 
closely interrelated that a sharp dividing line between them cannot be drawn 
Furthermore, it may be an oversimplification to speak of sexual inadequacy in any 
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 inadequate 
sexual relationship between two persons. Consequently, sex therapists today insist 
on treating both partners together. It has recently been estimated that in more than 
half of all American marriages at least one partner suffers from some form of 
sexual inadequacy; I wonder how many are in Egypt ?... Curiously enough, sexual 



misery seems lo be widespread and while one can argue about precise figures, the 
importance of the problem is no longer in doubt all over the world... 

History 

In the past, a man's sexual dysfunction was often ascribed to witchcraft or 
some evil curse!, in Arabic it is termed Marboot!! (if he was believed to be 

innocent) or to degeneracy, self-abuse, immorality and excess, (if he was held 
responsible for his condition). Today, we have learned however, that both kinds 
of explanation are false and that the real causes be elsewhere. In fact, people may 
become sexually inadequate mainly because of a very rigid upbringing, traumatic 
"xnal experiences, ignorance about sex, narrow religious beliefs and bad advice 
uom ill informed professionals, such as marriage counselors, doctors, sometimes 
psychotherapists and teachers or even parents. 

It seems that sexual dysfunctions of one kind or another have plagued many 
people in many societies since the dawn of history. We know for example, that 
ancient and medieval physicians studied the problem and sought various medical 
remedies. However, it also seems that these dysfunctions have become more 
severe and widespread in modern times. In the 19th and 20th centuries, thev were 
often treated by psychiatrists and the rate of cure was not always encouraging?. 
Today, we can see that this could hardly have been otherwise, since the 
physiological processes involved in sexual functioning were still poorly 
understood. Masters and Johnson approached sexual dysfunctions directly, instead 
of treating 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 inborn 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 participation 
in sexual activity- may lead to subsequent sexual dysfunction; and sexual 
dysfunction - such as impotence- may create ancillary sexual problems. 

Mslle Sexual Dysfunctions 

The two well-knovvn categories of male sexual dysfunction, namely, 
disorder^ of erection and disturbances of ejaculation are considered from the 
viewpoints of etiology, diagnosis and treatment. 



Im potency 

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. 
Isolated, transient 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 pattern of impaired erectile function is indicative of the 
presence of a sexual dysfunction that requires diagnostic and therapeutic 

attention. 



Etiology 

In the past it was Relieved that approximately 10 to 15 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. 



82 



Physical Causes of Secondary Impotence (Organic) 



(1) Anatomic Causes: 

Congenital deformities. 

Hydrocele. 

Testicular fibrosis. 



(2) Cardiorespiratory Causes 

Angina pectoris. 
Coronary insufficiency. 
Emphysema. 
Myocardial infarction. 
Pulmonary insufficiency. 

Rheumatic fever. 



(3) Drug Ingestion: 

Addictive drugs. 
Alcohol. 

Alpha-methyldopa. 
Amphetamines. 

Antiandrogens (cyproterone acetate) 

Atropine. 

Barbiturates. 

Chlordiazepoxide . 

C h 1 orproth ixe n e . 

Cimetidine. 

Clofibrate. 

Clonidine. 

Digitalis (rarely). 

Guanethidine. 

Imipramine. 

Marihuana. 
Methanthline bromide. 

Monoamine oxidase inhibitors. 
Nicotine (rarely). 

Phenothiazines. 

Propranolol. 

Reserpine. 
Spironolactone. 
Thiazide diuretics. 
Thioridazine. 



(4) Endocrine Causes: 

Acromegaly. 

Addison's disease. 

Adrenal neoplasms (with or without 

Cushing's syndrome). 

Castration. 

Chromophobe adenoma. 
Craniopharyngioma. 

Diabetes mellitus (very common). 

Eunuchoidism (including Klinefelter's 
syndrome). 

Feminizing interstitial-cell testicular tumors. 

Hyperprolactinemia. 

Infantilism. 

Ingestion of female hormones (estrogen). 

Myxedema. 

Thyrotoxicosis. 

Old age produce less testosterone. 

(5) Genitourinary Causes: 

Cystectomy; 

Perineal prostatectomy (frequently). 

Peyronie's disease. 

Phimosis. 

Priapism. 

Prostatitis. 

p 

Suprapubic and transurethral 
prostatectomy (occasionally). 
Urethritis. 



(6) Hematologic Causes: 

Hodgkin's disease. 
Leukemia, acute and chronic. 

Pernicious anemia. 

j 

Sickle cell anemia. 



(7) Infectious Causes: 

Elephantiasis. 
Genital tuberculosis. 
Gonorrhea. 
Mumps. 



83 



(8) Neurologic Causes: 

Amyotrophic lateral sclerosis. 
Cerebral palsy. 

Spinal cord tumors or transection 
Electric shock therapy. 
Multiple sclerosis. 
Myasthenia gravis. 
Nutritional deficiencies. 
Parkinsonism. 

Peripheral neuropathies affecting 
S2-4 outflow. 

Spina bifida. 
Sympathectomy, 

Tabes dorsalis. 

Temporal lobe lesions. 
Cauda equina lesions. 

Prolapsed intravertebral disc. 



(9) Vascular Causes: 

Impaired blood flow (main cause). 

Excessive venous leakage (main cause) 

Aneurysm. 

Arteritis. 

Atherosclerosis. 

Thrombotic obstruction of aortic 

bifurcation. 



(10) Miscellaneous Causes: 

Chronic renal failure. 

Cirrhosis. 

Obesity. 

Toxicologic agents (Lead, Herbicides). 
Chronic alcoholism. 

P-blockers (antihypertensive drugs). 
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 if the 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 the 
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 falling into four 
major categories: development, affective, interpersonal and cognitional. The 
most common elements of these categories are summarized in the following table. 



84 



Major Categories of Psychogenic Impotence 



MH 



M* 



(1) Developmental factors: 

Maternal or paternal dominance. 
Conflicted parent-child relationship. 
Severe negative family attitude toward 
sex (often associated with religious 
orthodoxy). 

Traumatic childhood sexual experience. 
Gender identity conflict. 
Traumatic first coital experience. 
Homosexuality, 

(2) Affective factors: 

Anxiety (particularly fears of 

performance, anxiety about size of penis) 
Guilt. 

Depression. 
Poor self-esteem. 
Hypochondria. 
Mania. 

Fear of pregnancy. 
Fear of venereal diser 
Sudden fear. 
Acute pain. 



(3) Interpersonal factors: 

Poor communication. 
Hostility toward partner or sj 
Distrust of partner or spouse. 



partn 



or spouse. 

Divergent sexual preferences or sex 

value systems (regarding types of 
sexual activity, time of sexual activity ; 
frequency of sexual activity etc..) 
Sex role conflicts. 



(4) Cognitional factors: 

Sexual ignorance. 
Acceptance of cultural myths. 
Performance demands. 



HHH^HWI 



(5) Miscellaneous factors: 

Premature ejaculation. 

Isolated episodes of erectile failure. 

(often due to fatigue, inebriation, 

acute illness, or transient anxiety). 

Iatrogenic influences. 

Paraphilias. 



*MK^wn 



It must be stressed that such etiologies are conjectural or guessing in that 
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 quite the 
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 of the remarkable extent 
to which sex is a natural function. 

Masters and Johnson described overt mother-son sexual encounters over a 
prolonged period of time (extending from childhood until beyond the time of 
puberty), as a factor of significance in some cases of primary impotence. Undue 
dominance of one parent may create a sense of inadequacy leading to erectile 
dysfunctions because of either lack of an effective male figure with whom to 
identify, (in cases of maternal dominance) or the impossibility of measuring up to 
the seemingly omnipotent father (in cases of paternal dominance). Other aspects 
of development that may be implicated in the genesis of impotence include, 
restrictive and rigid attitudes towards sex impressed upon the 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 after the onset of impotence; nevertheless, therapeutic 
attention should be focused on such problems when they are present regardless of 
the cause that initially precipitated the dysfunction. Phobias related to sexual 
functioning are infrequently seen but are important determinants of therapeutic 
strategy, while the paraph i lias-conditions in which sexual arousal is impossible 
without a particular abnormal stimulus e.g. (dressing in women's clothes, being 

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 previously 
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 to 
cope with impotence including (rationalization, projection, emotional insulation, 
intellectualization, sublimation, avoidance, and denial of reality) are likely to 
create relationship difficulties that require direct therrpeutic intervention. 

Iatrogenic influences can lead to impotence in a number of different ways. 
In each instance, the common element is that a respected health-care professional 
plays a causative role in the development of erectile disturbances. This may come 
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 authority; or 
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. Impaired 

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 ejaculatory difficulties. 
Iatrogenic impotence can also occur when males misinterpret articles or books 
they have read about sexuality... 



P6 



Widower's syndrome 

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 characteristically a 

prolonged period of little or no sexual activity in conjunction with a lengthy and 

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 of a 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 mourning 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 example, impotence is not 
uncommon after divorce as well as after sudden death of a spouse but the 
underlying dynamics of these situations appear to be different from the specifics 

of the 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 

If 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 7 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 of the man who has no difficulty achieving a firm erection, only to lose it 



problem. 



strong 



firm 



norma 



The clinical significance that can be placed on self-reports of morning erections is 

limited however. Some men may be unaware of such erections even though they 

are present. In other circumstances, it is the pattern of the relative frequency of 
morning erections viewed in the context of each man's history that is most 
important. A report of infrequent or absent morning erections is of no diagnostic 
assistance if the patient had a similar pattern 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. If firm erections are frequently 
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, becoming 
slowly and progressively more troublesome. In contrast, psychogenic impotence 

is likely to be of sudden onset - at times, the patient may be able to identify the 

specific date on which his difficulties began. However, some organic causes of 
impotence such as trauma (post-surgical or neurological injury) or drug use, can 
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 affair sexually with someone, after the death of a parent or a 
child, after divorce or after a stressful change at work. If the patient is not seen 
until long after the onset of his dysfunction, he may not remember the temporal 
relationship at all, but his wife or partner may recall the association if questioned. 
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 pattern. 
This may be the case when continued frustration, diminishing self-esteem and 

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 dysfunctional state 

may progressively deteriorate until appropriate treatment is instituted. 



88 



recognize that impotence is not synonymous 



transient; other men have a pattern 



firm 



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 who is 
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 to 
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 psychological 
origin of sexual dysfunction, careful assessment of physical factors should also be 
conducted. 



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

impossible to determine with any hope of accuracy the specific mechanism (or 

mechanisms) that precipitated erectile failure. Nevertheless, evaluation of the 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 
ination in a more detailed fashion than is usuaHy 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. In 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 of impotence 

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 



AH impotent men with equivocal histories should undergo an oral glucose 
tolerance test after adequate dietary preparation (including at least 300 gm of 
carbohydrates daily for three days) for the detection of diabetes mellitus, which 
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 does 
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 diurnal 
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. If 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. If improvement in the potency problem 

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. 

If an impotent man is using a drug that may be contributing to his sexual 
problem, it is advisable to discontinue the medication e.g antihypertensive 
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 
ual difficulties to have multiple determinants, it is helpful to avoid the use of 

potentially compromising pharmacologic agents during a course of sex therapy 
as well. 



90 



NPT 



One of the most promising techniques to be developed for the diagnostic 

assessment of impotence is the physiologic monitoring of erection patterns 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, internal conflicts, or other psychological 
factors that may impede erection during wakefulness 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) patterns in various groups of 
men with and without potency disorders. These workers utilized simultaneous 
electroencephalograph 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 patterns 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 patterns 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 of the time. It 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 neurophysiology testing 
to evaluate the neurologic factor. Colour Dopier sonography is of great diagnostic 
values to detect organic vascular lesions both arterial and venous. Intracavernosal 
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. In 
some instances, the patient and his wife may benefit from ancillary counselling or 



91 



psychotherapy aimed at improving depression, self esteem, communication 
patterns, or other aspects of psychosocial health. However, when physical or 
metabolic conditions preclude the possibility of coital functioning, this fact must 
be pointed out to the couple and alternative suggestions for sexual expression 
should be discussed. In selected cases, consideration may be given to the 
implantation of a penile prosthetic device to permit participation in intercourse. 

Although many cases of impotence are attributable to psychogenic factors, 
significant numbers of men, are impotent because of irreversible organic causes! 
In the past decade, increasing interest in sexual function coupled with advancing 

technology has led to the development of a variety of penile prosthetic devices 
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 or neurologic 
disorders and various types of operations (for example, impotence due to 
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 used or 
whether an inflatable prosthetic device is employed. Fixed rod devices made of 
different materials, such as Silastic (silicone rubber), acrylic, or polyethylene 
have been used by a number of surgeons. These devices have the advantage of 
relative simplicity of surgical technique of insertion but they result in a perpetual 
state of semierection once the operation has been carried out, potentially creating 
both psychological distress and physical discomfort, (Fig. 31). 



92 



Figure 3 1 . Three pairs of Small-Carrion penile prostheses. 



The inflatable penile prosthesis produces an erection only when it is 

desired; the appearance of the penis in both the flaccid 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 cavernosa. 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 fluid 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. 



***n 




A 




B 



Figure (32): An inflatable penile prosthesis after 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 
surgery. 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 intensive 
exposure to sex therapy before considering operative techniques to cure their 
impotence. In addition, it should be recognized that diabetic men may be 
predisposed to a higher rate of surgical complications postoperatively with this 
procedure due to microvasculr problems and impaired immunity. Thus, penile 
implants should be undertaken in this population only when the potential risks as 
well as benefits have been carefully described to the patient. 

Treatment of psychogenic impotence 

In cases of psychogenic impotence or in situations in which a significant 
component of psychosocial difficulty contributes to the etiology or perpetuation 
of impotence, sex therapy is indicated if counselling attempts have not reversed 
the dysfunction. Sex therapy ideally includes both the impotent man and his 
partner, since therapeutic cooperation of the wife appears to be an important 
determinant of the outcome of therapy. The partner's presence during therapy 
sessions provides an opportunity for observation of patterns of communication 
within the relationship as well as a source of information about sexual function 
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 features 

include the following points: 

1 . It is not useful to blame one's partner or oneself for the occurrence of sexual 

dysfunction. 

2. There is no such thing as an uninvolved partner when sexual difficulties exist 
3 Sexual dysfunctions are common problems and do not usually indicate 

psychopathology always. 

4. It is not always possible to be certain of the precise origin of a sexual 
dysfunction, but treatment can frequently proceed successfully even when such 

knowledge is lacking. 

5. In general, cultural stereotypes about how men and women should behave 
or function sexually are misleading and counterproductive. 

6. Sex is not something a man does to a woman or for a woman- it is 
something a man and a woman do together. 

. 7 - J eX < ?°" not on, y mean intercourse, apart from procreative purposes; there 

is nothing inherent in coitus that makes it always more exciting, more gratifyine 
or more valuable than other forms of physical contact. 

8. Sex can be a form. of interpersonal communication at a high intimate level 

when sexual communications are not satisfactory, it often indicates that other 

aspects of the relationship might benefit from enhanced communication as well 

9. Using past feelings or behaviors to predict the present is not likely to be 

helpful, since such predictions tend to become self-fulfilling prophecies or may 

limit the freedom to change. 



94 



10. Developing awareness of one's feelings and the ability to communicate 

feelings and needs to one's partner sets the stage for effective sexual interaction. 

11. 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- In some cases marriage 
counselling is the predominant theme of therapy, in other cases, improving self- 
esteem, 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 Inadequacy showed a 
failure rate of 40.6 percent of primary impotence and 30.9 percent for secondary 
impotence. Between 1971 and 1977, at the Masters & Johnson Institute, a failure 
rate of 21.1 percent was recorded while treating primary impotence, at the same 
time, the failure rate while treating secondary impotence was 14.6 percent only. It 
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 



I- 

Recent advances in the treatment of impotence 

mi S info^»tJon X , CdUCati •" is . required to counter th * considerable ignorance and 
misinformation concerning impotence not only among the general public but 

pSL ' "• often re,uctant to * scuss Sexual ™ tt ^ *" th2 



In* 



phentolam 



-Ttritoil phurniuiutliei H|jy : 

Smooth muscle relaxant papaverine, a-blocker phenoxybenzamine 

famine and nroctg<rl<> n ^; n c i _*i__^ . . y jv*='miuuue, 



related .u-u. i—~~e»-— » -i «»u umcr arugs such as calciton n gene 

an erecSon T^^o 8 ™^ tC& >?*™ hljected ^avernosal.y they produce 

?n e ^ 1 ?"7 % T S a " d fy ? W ° f drUg USed arc ad -» usted to su " each patient. 
The mam side effect assoc.ated with self injection is a prolonged erection or even 

pr.ap.sm sometimes. The development of painless, fibrotic nodules that m!v 
cause penile curvature is reported, also Peyronie's disease occasionally develops 
A newly developed combination of a drug called (Invicorp) is effectfve 
diSr^ I n WhCn m ™»"*~« -»c" Lcti,: rP dUnc^n i 

• Transurethral suppository: 

tr M »i Fr ° Sta ^ ,andin E ! administered transurethral is a novel svstem designed for 

3 22 sr sr xlt name " Muse " which ° >"'• "-«*•»» *> 



• Medical treatment: 

1- The ann^nl nf * ™M 



enormous 



wivi* coU fu , . ° ' -^ ttllwrcu u > UIC enormous word 

wrte sales of homoeopathic remedies claiming to have this effect. Fortunately 

f wdruss have been ^ H,-™,^ mm{ fl|Ml||J|fl| J 

^ 50 and 00 T m , h,b,t ° r ° f P hos P hodies terase 5, available in doses of 
ire fl.LTnl H mg) and ,s ^P^d b V the FDA, 1998. Its main side effects 
are flushing, dyspepsia, headache mild or moderate but it must be used under 
medical supervision because some patients complained of nasal congestion 

abnormal v.s.on, diarrhea, dizziness and possible rash. Viagra is' 
icSe 3 " 1 ; eT. anae ^^ 7", ^ ""*" ^ " VW Cirrh ° sis > ™ al ™U 

s.ckle eel anaemia, mult lp le myeloma, leukemia, Peyronie's disease 
cavernosa flbros.s, anatomical deformity of the penis, active peptic u. cer ' 
retuut.s Pigmentosa and patients using nitric oxide donors or nifraL in any 
form. The reported percentage of success among users is nearly 77% The 

Zr ^ b V aki " 8 " 3S a " a P hrod '^ or to be more virile by healthy 

ordinary males leads to the contrary and ultimately they end with erec tie 
dysfunctions !...(R. Kirby, 1998). wra erectile 

2- Oral phentolamine (Vasoma*): Phentolamine is commonly used 
.ntracavernosaly usually in combination with papaverine but when used orallv 

s tivaZ h n a f nta80n,S '" ° f a 'P. ha " a » d a 'Ph^ adrenergic receptors, as well 

as actuation of a non-adrenerg.c mechanisms to induce relaxation of th 



e 



96 



corpus cavernosum smooth muscle to produce erection. Its side effects are 
similar to Viagra but with more dizziness, tachycardia, nausea and 
hypotension. 

3- Oral Apomorphine: Apomorphine is a dopaminergic drug that was found to 
have a central erectoeenic activity when taken suhlinatml 



4- Topical prostaglandin Ei 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 burning sensations and 

irritation, further research is needed before a final positive conclusion is 
reached. 



5- 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 fit 

men. 



Surgical treatment: 

Only fair results have been reported after excision and ligation of the deep 

dorsal vein in men with venous leakage. Revascularisation of the corpora is 
now technically feasible, with success rates of 50-60% in young patients 
but microsurgery is time consuming and expensive. Long term follow up of 
veno-Iigation 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. In 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 premature ejaculation is a common sexual dysfunction, there is 
no precise definition of this problem that is clinically satisfactory at present; 
partly because of the relative nature of the timing of ejaculation in the context of 
the female partner's sexual response cycle. If the man's rapid ejaculation limits his 
partner'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. If 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 ?. If 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 1 5 thrusts after 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 10-15 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 : "It is of course, demanding 
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 only 
premature ejaculation is difficult to define, but the precise cause is not known 



Martin 



studied ejaculated within 3 minutes of vaginal containment. But these data may 
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 primary 
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, not 
for the woman's), may be found cutting across cultural and socio-economic 

Itn^Q f 



■*>■:-., 



Severe cases of premature ejaculation are easy to diagnose, because they 
are marked by a pattern 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 of the 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!. In 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, premature ejaculation is seen as a primarily psychophysiologic 
disorder. 



99 



Past theories of organic origins of premature ejaculation usually 
identified prostatic or other genito-urinary inflammation as the cause; however, 
more recent examination of large series of patients has not supported such a view! 
Some authors have suggested that; relationship problems, unconscious hostility 
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 practice. 

Treatment 



The general principles of sex therapy outlined earlier in the treatment of 
psychogenic impotence apply to the couple for whom premature ejaculation is a 
problem. The therapeutic approach is optimal when working with the couple, 
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 persistently 
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 effective practices may simply convince the woman of her partner's 
selfishness. 



After thorough psychosexual histories are obtained, treatment begins with 
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 couple is 
told that rapid ejaculation is a common sexual problem that has an excellent 
prognosis with short term theraov. 



With 



I 



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 performance 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 of a specific physiologic method 
for reducing the tendency for rapid ejaculation. In this procedure, known as the 

"squeeze technique", the wife should avoid pinching the penis or scratching it 

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. In Human Sexual Inadequacy, a failure rate of only 2.7 
percent was reported in a series of 186 men with premature ejaculation; other 

workers describe excellent therapeutic outcomes as well. 



Summary 

To summarize the evidence regarding premature ejacuiation: 

1 . 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 women's rising expectations of 
sexual satisfaction. 



Ejaculation Incompetence 



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 lenethv episodes of coitus. The functional problem mav be 



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), the 
most common form of ejaculatory incompetence is primary, (never having 
been able to ejaculate intravaginally). There is variability in the pattern of 
noncoital ejaculations. Some men with ejaculatory incompetence can ejaculate 

with solitary masturbation, others can ejaculate by noncoital partner sex 
stimulation, (manual or oral) while still others are unable to ejaculate by any 
means. In 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, the 
desire not to have children, and specific psychosocial trauma, (the discovery by a 
man that his wife has been having an afTair with another man or that she has been 
raped, for example) have also been described as important in the development of 
ejaculatory incompetence. 



Treatment 



It is important to explain the etiology of the 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 oerceives her 
HUSbatld afi Wllllully preventing conception. Since the woman will be called upon 
to play an active role in the reversal of the ejaculatory incompetence, neutralizing 
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 wife is 
encouraged to stimulate the penis in a deliberate and demanding fashion, with the 

man communicating to her information about timing, pressure, and types of 
stimulating motions that he finds most arousing sexually. The first objective is for 
the woman to Induce ejaculation by maniia* stimulation. Once this has been 

accomplished, sex play in the fenale-astride position is recommended and insert 
102 



the penis vaginally as ejaculation becomes imminent. A single occasion of 
intravaginal ejaculation is usually all that is required to reverse the dysfunction 
permanently. In cases in which intravaginal ejaculation has not occurred despite 
repeated attempts with therapeutic suggestion and analysis, the woman should 
bring the husband to ejaculation by the use of manual stimulation, in a position 
that allows the ejaculate to spurt onto the external female genitalia As the 
husband becomes more comfortable seeing his ejaculatory fluid in genital contact 

with his wife, intravaginal ejaculation may occur more easily. Throughout the 

treatment of the couple in whom ejaculatory incompetence is present, emphasis 
must be placed on effective patterns of communication. In instances of patients 
who do not respond to sex therapy, referral for in depth individual therapy may be 



beneficial. 



Mixed Sexual Dysfunctions 



It is not surprising that combinations of sexual dysfunctions may exist in 
the same man, since common etiologic factors appear to underlie many of these 
disorders The most frequently encountered combination is premature ejaculation 
and impotence; indeed, it appears that anxiety over sexual performance result.ng 
from rapid ejaculation is a cause of impotence. Much less frequently, ejaculatory 
incompetence may coexist with impotence. 

Treatment , . , 

In treating these conditions, it is generally necessary to deal initially with 

the erectile failure and to institute appropriate management of the ejaculatory 
dysfunction only after security has been gained in erectile function. The exception 
to this strategy is the instance in which a man ejaculates prematurely while the 
penis is flaccid, in this situation, the squeezy technique must be used to provide 
ejaculatory control before adequate erections can be attained. 



103 




FEMALE SEXUAL INADEQUACY 

(DYSFUNCTIONS) 

Frigidity, 

Important Facts Concerning Women'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 frigid us : 



term 



lacking diagnostic precision. Up till 1970, frigidity was variably applied to 
women who were uninterested in sex, women who never experienced orgasm and 
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 of 
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 organs 
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 fails 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 very 
reserved .or even prudish, and may behave in public with the utmost strictness all 
her life; indeed, she may fear and disapprove of the whole sexual side of her sexy 
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 



It 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 to 

have strong sexual feelings because virility is a matter of the spirit more than the 

104 



UUllJ. Hui, iJ il uutoin that a man r i1h r ~ r *-— *™ p— *'"»*y « ™**™\y 

either sexually comptent 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. It 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 nonnal sexual desire but cannot attain an orgasm; the 
term "lacking orgasmic capacity" is suitable scientifically. 

Although there is no uniform agreement on the precise diagnostic 
tP-rtninolngv to he used 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 

anorgasmia applies to women who have achieved orgasm on one or more 
occasion, but only under certain circumstances- for example, women who are 
orgnsmic 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 orgnsmic dysfunction 

known 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 anorgasmia 

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 10 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 17 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: 



1. 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 of the 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 indirectly by 
affecting libido and general health in the diseased woman. 



106 



Psychogenic causes 

Analysis of large series of cases of orgasmic dysfunction seen at the 

Masters & Johnson Institute, indicates that 90 percent or more are psychogenic in 
origin. 

It 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 after 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 
maternalism. 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 dysfunction 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 
dysfunction. Although guilt related to sexual practices may be a residual hallmark 

uf ilLVLlupinuilfll LUiiililiuiiing, guilt muj utou bi u luult uf utliti djimmiw 

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 partner's sexual adequacy (particularly in relation to impotence, in 

which case the woman may view the man's dysfunction as a sign of her own 

inability to excite him sexually) or concern over loss of control while being 

orgasmic. 



107 



In 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 concern 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, similarly, depression is unlikely to account 
for situational orgasmic problems. 

In many instances, orgasmic dysfunction stems from interpersonal factors 
that include ineffective communication, hostility toward the partner or spouse, 
distrust of the partner or husband, and divergent 



1 preferences. The 

importance of communication as a means of interpersonal relating cannot be 
stressed too highly; the consequences of poor communication patterns include 
frustration, feeling hurt, anger, disinterest 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 facility 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. 

In 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 anatotm or have no idea of what type of sexual activity is 
pleasurable for them. In other instances, misconceptions and ignorance about 
personal hygiene or mate sexual needs become dominant elements dictating a 

woman's sexual behavior patterns. 
Diagnostic considerations 

Care must be taken to identify any organic factors contributing to 
organic dysfunction. Dyspareunia should always be carefully 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. In 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 not!. 1 he main muscle attected 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 coccyx 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 learn first how to identify the muscle for herself. In 
order to do this, she is advised to sit on the toilet with her legs spread as far 
apart as possible. If 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 true 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 tin mid function tests is most likely to be beneficial for 
patients with depressed libido or with vaginal atrophy. 



Combined male and female sexual dysfunctions 



In 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 coital orgasmic inadequacy, since rapidity of ejaculation seriously 
hinders her opportunity for exploring coital patterns of sexual arousal. However, 

if the woman remains unable to have orgasms during coitus after the man'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 pattern 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. In other cases, the woman's 
description of her past sexual response patterns 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 event!; 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 woman'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. If a woman has not been orgasmic with self-stimulation or has never 
attempted masturbation, it is more likely that attitudinal problems exist that 
require therapeutic attention. 

It 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: 

1. Contraceptive practices and reproductive goals. 

2. Sexual responsiveness in other relationships. 

3. Quality of the present sexual relationship. 

4. Sexual attitudes of both partners. 

5. Concurrent psychopathology, 

6. Previous experiences in psychotherapy. 

7. Self-esteem. 

8. Body-image. 



110 



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. 
It 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 of the patients, the discussion here will focus on 
the components of therapy that are usually applicable. 

It is important to identify 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 



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. Many 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 clltoral 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 preoccupying 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 termed cognitive 



relabelling 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 wife 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: "If 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 concerned 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!. In 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 a 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. 



112 



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 

patterns 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. In 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 orgasmic than he is able to 
make her digest her food!... 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 of a 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 aidsV 

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 
she perceives it as unnatural and abnormal. Third, use of the vibrator mav 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. 

If the couple can learn to interact sexually by focusing on their feelings, 
communicating openly togcfher, and avoiding routinized sexual patterns, orgasm 
is likely to occur. In fact, women often are told that orgasm may occur when they 
least expect it; the fact being of course that pushing tQ reach orgasm is much 
more likely to inhibit overall sexual responsiveness. 



113 



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. The 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 as a means 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 circumcised was reported by 
Masters & Johnson. 



Religious view 



Many years ago, our Prophet Moharned described precoital petting 
beautifully through his following advice: 



^J^ii 



.V^ASllj^yil :JU? ail J 




Sexological analysis 

The words of our Prophet indicated and proved very important and 
sensational facts concerning female sexuality ... 
1. Coitus without precoital 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. 

S.Love talk between husband and wife is appreciated by all females and 
evidently it is a successful way of verbal communication. 



114 



In conclusion 

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: 






w 



ft 



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 of Islam concerning our wives and their important rights in 
marital relations. 



115 



Important Facts Concerning Women's Sexuality 



It is worth remembering some facts concerning 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 activitv, 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 often much more important. Hence, most women are 
greatly stirred emotionally by courtship and personal attentions e.g. birth-day 
presents, gilts 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. If 
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. It is 
interesting to note that some females could achieve an orgasm while listening to a 
musical concert!, while others get wet in the presence of their beloved... 



Phases of increased sexual urge 



In 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 flow and becomes least after mensis. A wise lover should take a good 
advantage at these times... It is worth noting as well, that during the premenstrual 

phase, sexual and ordinan crimes of violence are recorded mostly during this 

period. In 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 deficient, 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 



116 



amylase has been proved to enhance the motility of the sperms as well as the 

tnr/mt hjoIorinidaEO, i\ piuUiuil lAAIIipIC IVUIlll IllWIlIOning 15 that Ihe 

mounting of a 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 often 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 vyomen with vaginismus have little difficulty with sexual arousal. 



norm 



and satisfying and orgasmic responsiveness is often intact. Females with 



norma 



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 of this 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 

ahnnrmo,ifiM J — '»-«« g mnrmmo of tlio hjmui Hull Ml MIIILllBl! UlHIIiy 

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 e.g. tight introitus and entangled neuroma. 
117 



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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 anv sexual 
dysfunction) from this background has little to do with the specific theological 
content of religious upbringing; rather, the major 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 thev have difficulty in making the 
psychic transition from viewing sex as evil (prermaritallv) to viewing sex as good 

(upon marriage). Interestingly, women from such backgrounds often marrv 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 anv age may 
precipitate a subsequent pattern of secondary vaginismus, even when previous 
sexual function had been well established. Vaginismus mav also occur 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 important 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 

itpntduotlOli and jLA iUU IIUI D«ll Wlcllllly 1 cUplMed but mav sometimes be a 

factor in the subsequent development of vaginismus. 

Treatment 

The diagnosis of \ .iginismus can be made if involuntary spasm or constriction 
ot the musculature suit- unding the outer portion of the vagina is detected If this 
diagnosis is made it is -ot 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 a 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 mav be helpful 
in detecting organic pathology that would otherwise be difficult to identify the 
muscle relaxation induced by anaesthesia makes it impossible to diagnose 
v amnismus even if it is present. fclU!,e 

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. If 
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. 



** 



rt. 




*"- 



j — 



H-J 



H 



*= 



3- 



MM 



Figure 34. Plastic dilators used in the treatment of vaginismus. The dilators (from 

smallest to largest) are nos. 1, 1 !4, 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. 1 dilator, the procedure is 

repeated by herself or by the physician leaving the dilators intravaginally for 10 

to 1 5 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 

nine me wuiiihii is awe iu in we wu.4 uiiwur cumiunaoiy aim assuming mat 

the husband is having reasonably normal 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. 



Necessarily, particular issues related to either the etiology of the 
vaginismus 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. 

Medical Opinion. 

Anatomical and Physiological Sexual Dysfunctions 



SEXUALITY AND FEMALE CIRCUMCISION 



The term "female circumcision" is confusing, because it is often applied 
to a wide variety of female genital surgeries. Originally, anthropologists 
categorized a number of different clitoral operations performed in primitive 

societies under the umbrella term, female circumcision It is important therefore 
to define th term accurately. As defined medically-, female circumcision is 
similar to its male counterpart and when it involves cutting off all or part 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 of the clitoris is also cut off. 
This is called clitoridectomy or excision. In many underdeveloped countries, as 
an obligatory, religious or puberty rituals clitoridectomy is further extended to 
include the cutting away of part or all of the small or large labia. The most drastic 
operation includes all of the above plus sewing up the genital area (Infibulation). 
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 of these future women !.„ 



Types of surgery 

The following list gives the medical term for each surgical procedure: 

Cutting of all or part of the clitoral foreskin - circumcision. 
Cutting off part of the clitoris - clitoridotomy. 

ttine; off all of the clitoris = clitoridectomy. 

tting off part of the labia ~ partial vulvectomy. 

tting off the entire labia = complete vulvectomy. 

tting off all the external genitalia and suture it = Infibulation 



Ci 

Ci 

Ci 

Ci 



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. It 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 world. .! (WHO report). 



122 




Mons pubis 

Prepuce 

Clitoris 

Major lips (spread) 
Urethral opening 
Skene's gland 

Minor lips (spread) 
Introitus (vaginal opening) 
Hymen 

Bartholin's gland 



$ 



Anus 




Figure 35. Normal external genitals of the female 

Proponents of clitoridectomy present the surgery in a positive light; Jomo 
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 (1962): 

[The operator... takes out .... the operating razor .... nnd in quick 
movements, with the efficiency of a Harley Street surgeon proceeds ...♦ with 
a stroke cut off the clitoris]. 



In 1972, a French physician provided a very different picture of pharaonic 
circumcision as currently practiced in Somalia. (It takes a strong stomach even to 
read the description)... 

"After separating the outer and inner lips (labia majora and Inbia minora) 
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 the job 
by entirely pulling out the clitoris and then cuts it to the bone with the kitchen 
knife. Her helpers again wipe off 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 flesh. 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, 1972.... In Minneapolis, U.S.A. (1982), my film was shown in the 
"International 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 inftbulation is practiced widely) described the clitoris 
in its natural state as being as, "long as a goose's neck"!. 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 uncircumcised girl". I 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 faithful. 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 



Islam "tolerates female circumcision", which of course is not true. Lip till the year 
1977, 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 
of the world including Egypt have protested this ritual. They are struggling 

against these cruel practices in their own countries and in the international arena. 



124 



I he elimination of (centuries-old) practices, especially those that are degrading to 
women, is often a difficult and protracted effort. It is interesting to note 
historically that there are some similarities between African clitoridectomy and 
Jewish circumcision practices. In Ethiopia for example, it is startling to note that 

tilt upufltiui! Ull gills IS pHJlRjfflgfl On fflt eighth day while in some areas of 

Nigeria the clitoris is nicked, i.e. incised or notched not ablated, only to draw 
blood following a Jewish custom. In several countries, the infant is named after 
the excision ceremony. Whether these similarities are simply coincidences or a 

reflection of a common origin is unknown. 

The World Health Organteation (W.H.O.) had a seminar on 
clitoridectomy and infibulation in Khartoum, Sudan In 1979, realizing the 
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 (10 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.H.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. 

In 1994, the (ICPD) 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 nnn. 
governmental 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 of the 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 ol wives in Sub-Saharan Africa. While in Egypt, Sudan 
Ethiopia and Somali" 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 of most women is to have as many children as possible It is wid-ly 

•""— r in Mali and till orcr n c it Afiiui, llul Hie ulluilly UUIIIIQKS And impfv 

maleness, while the prepuce of the penis means femaleness!. 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 modern 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. 

Infibuiation 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. In the Sudan, 
infibuiation traditionally is called "Tahur", similar to the Arabic word applied 
among Egyptians which means cleansing or purity. It is performed at a family 
and neighborhood gathering of women in the most populous areas of the Sudan, 
including the capital Khartoum and Omdurman, all along the Nile valley. It is 
interesting to mention that the knife used often by the operator is called "The 
knife of honour"... 



In West Africa, infibuiation is documented at the present time in Mali by 

several Moslem population groups, though the practice goes back to pre-Moslem 

times. Intentional infibuiation is said to be decreasing in Mali, a medical source 

states that infibuiation is also practiced in Northern Nigeria (Moslem area). A 

country by country estimate adds up to more than 160 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 f operated, this 

would mean 25 million females in Nigeria alone. Documentatioti shows that the 

majority of the female population in most Nigerian states are excised In 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 1 1.5 million women are infibulated. In 
Egypt, one of the most populous countries in Africa, about 93% of the group. of 

women investigated were circumcised, the percentage reported here holds good 



126 



with other statistics documented by different investigators. It is estimated that 
about half of the 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 15-49 years!... 



1 1 * A 




Mgure 36. African countries performing (I GM) (In 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. 



L 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 



100 years that circumcision pain is of minor significance and that circumcision 

trauma is of no consequence, are to say the least of great medical concern 

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 common, since no proper 
sterilization or aseptic surgical technique is used. Speticaemia is reported 

sometimes, as well as fatal cases of tetanus and maduromycosis. 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 

1UU IU IIIIKIUIHY III UIH riilUIB. 



128 



- Acute retention of urine do happen because of the burning sensation 
when urinating, trauma to the adjacent tissues, reactionary oedema and early 

ItlTAAtiAMl A 1L^_^ L.1 J! i ft " 



these factors ored 



ion. 



- 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 
vagina! introitus with additional complications especially if the operating woman 
is weak sighted or not skilful. Bartholin cysts are reported when the glands duct 
is injured or due to local infection. 

- In 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 of the 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 

fact. Anv surjiral prrv^Hur^ ™ moH. k„„, |jmp | f |arrJ0[| ^j^ jt Jumi ^ 

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 

t 

- Chronic urinary infections are common among women suffering from 
the severe types of genital mutilation, such as infibulation and excision 

circumcision, dysuria is a frequent complaint. 

- Vaginal calculi are formed sometimes in the posterior fornix as a result 
of the obstruction of the proper flow of the stream of urine and retention of part 

of (his urine in the vagina due to the abnormal 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 disfiguring size that require surgical interference. 



- Vaginismus is reported by gynaecologists, often among females who 

sustained psychological and / or organic complications of the 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 malformations are numerous and disfiguring. 



- Haematocolpos and haematometra were reported by gynaecologists as 
a result of closure of the vaginal introitus in severe cases of the operation due to 
scar tissue formation. 



II. Obstetrical complications 

- Difficulties in child-birth are often met with, causing damage to both 

the mother and the baby, especially reported among primiparas. In cases of 
complicated excision and infibulation, 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. 



- In cases of infibulation, unassisted child-birth is neatly 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 
perineal 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 fistulae 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. 

III. 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 



rm 



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-economic 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 circumcised. 

- The effects of the excruciating pain inflicted during the circumcision 
process to which often very young girls are subjected by their own families or in 

o^her words, by those they love and trust have to date been quite ignored. 

- The harmful effects of the genital trauma; of fear, the bleeding, the 
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 dhe to sexual 
violence and physical assault during tfre forcible intercourse, to which very 
young brides are subjected to, by some husbands who have acquired their 
services in return for a brideprice... Many cases of bleeding yomig 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 ordea! of painful intercourse and childbirth, have 

been reported in tipper Volta medical literature. 



131 



- Depression and psychotic disorders were reported among some women 
J" nf, g adulthood especially if they are sufferine from chrnnir nnn.r« n i.^ 
SMUal tension, Oiese 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 investieated 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 thev 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 of the operation since it 
may lead to non harmony in the marriage relations of a husband and wife 
(male and female gender struggle !). 

- The syndrome of "non-resolved sexual tension" with its morbid 
psychological and physical complications is often met with among circumcised 
temales during gynaecological medical practice. 

IV. Long range sexual complications 

- Many coital or sexual dysfunctions are reported, especially when drastic 
circumcision operations are practiced, for example when infibulation and 
Sudanese operations are done. Often the bride must be cut open before penile 
penetration can take place, which causes farther injury and more added 
mfect.ons. It is reported that the bride-groom perform* 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 of the excision wound 

th,s ,s reported ,„ West Africa and elsewhere in countries where infibulation is not 
performed with resultant apareunia rarelv and oftenly dvspareunia 



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... It 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-circumcised 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 of the 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 



sations; while the orgasmic platform comes next in culminating the orgasmic 
release of neuromuscular tension. This orgasm is triggered mainly by clitoral 

stimulation either by direct stimulation of the clitoris or by indirect stimulation of 
this organ via the clitoral hood tension mechanism exerted during coitus. Masters 
research confirmed that ^0-70% 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 minora which is transmitted to the fold of 
skin (hood) that cradles the clitoris providing as such tactile stimulation to the 
shaft and glans clitoris (Kaplan, Sherfy and Johnson). Incidentally, (Miller & 
Leif) research about female masturbation techniques reported that orgasm is 

triggered in most females by stroking the clitoral shaft laterally or by simply 

133 



rubbing the whole vulva! area with one hand. Some females apply the vibrator 
(sexual aid) superficially on their vulva to achieve sex stimulation maximally and 

ultimately to get orgasmic release. 



Medical conclusion 



Certainly, the medical profession bears responsibility to accept female 
circumcision as a "national cultural trait", as much as do lay people. With ample 
medical evidence at hand to disprove any prophylactic benefits, on the contrary, It 
is proved that there are many dangers and unfortunate complications of this 
surgery. The medical profession and other interested parties have responsibility to 
stop and abolish this practice. The pretense of neutrality is a negative stance 

because it is a real hazard to the health and well-being of millions of young girls 
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). 

It is worth mentioning here the starking recent evidence which was proved 
beyond doubt of how valuable and important the role played by the external 
genitalia, namely, the clitoris and labia minora during coitus in order to achieve a 
successful orgasm; with a resultant pleasurable satisfying sexual and emotional 



encounter between a husband and wife; to convince forever the public in Egypt to 
stop and abolish their awful practice of female circumcision better named female 
genital mutilation (FGM). The minister of Health and Population issued a decree 
in 1996 prohibiting any form of female circumcision by medical or non-medical 
personnel. It is a step on the road: but my strongest belief is that sex education to 
the public is the answer for this very old harmful problem because I was 

compaining against its dangers since nearly 30 years. 

Comment 



In the final analysis, scientifically and medically, I confront those people 
(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 girls 
and in our future wives. I present therefore the embryology of the genital organs 
m the following diagram (well established since many years), to show them once 

and for all that to perform excision on females is equal to the excision of the 

penis and scrotum in males !... Since the external sex organs in both sexes 
develop embryologicaily from one and the same organ namely; the genital 
tubercle at around the sixth week of gestation, differentiating later in utero into 
male and female external sex organs according to the chromosomal pattern of the 
foetus. As such, I 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 sexual 

urge !... What a mockery..., truly those proponents of female genital mutilation 
are following the same ridiculous old sex taboo proclaiming: "Sex is for the 

man's pleasure and not for the woman !..." dating 300 years ago. Evidently, such 

an old taboo is an insult to both genders in our eternal human sexuality. 



134 



Glans area — 

Urethral fold 

Urethral grove 

Anaf pit ' 
Anal tubercule 



Undifferentiated 




>- Genital tubercule 



ifc-- 



f Tail (cut-away) 



Mate 



Female 



■ ^-fa-fc^-fc ■ 



Gians 



^P^^*W^-4rh^ 




Site of future origin of prepuce 



Urethra! fold 



— Urogenital groove 



-Labio-scrotal swelling — 



~ Urethral folds partly fused 



Anal tubercule 



Anus 




Urethral meatus 




Glans penis 




IL4 



Prepuce 



Shaft or body 
of perm 



Corpus clitoris 

Prepuce 

Glans clitoris 



Scrotum 



Urethral meatus- 



Labium minus 
Vagina 

Labium majus 




Anus 




\ 




Figure 3 7. Development oi m;ile an ! Irmak* sex or^: ,f i^ 



135 



Anatomical And Physiological Sexual Dysfunctions 

Among Female Genital Mutilation 

Unless we repeat the physiological responses of the 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: 

1 . 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 of the following surgical 
procedures: 1) Clitoridotomy which is partial excision of the clitoris. 2) 



Clitoridectomy entails complete excision of the 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 of a high percentage of 
coital anorgasmia as compared with the normal non circumcised females. 



• Again the human female has been endowed with three primary erogenous 
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 orgasmic platform (the third primary erogenous zone). This orgasmic 
platform develops only after successful sexual stimulation during the plateau 

phase of the 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 platform 
and I repeat if, 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, (efficient 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 "sensnte focus" reported in 1966 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 external 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 damage 
they received physically at circumcision, as well as the immense multiple 
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 20-30 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 10-15 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 penetration". 
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 1979, 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: 1) 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 sexual 
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 anorgasmia which means, repeated non orgasmic, (no 
muscular contractions), with subsequent residual neuromuscular tension as well 
as chronic vasocongestion may 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 180° ventrally and retracts under its clitoral hood 
(prepuce) against the bony symphysis pubis. In 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 if the 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 of the female sexual 

response cycle. 



138 



10 



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 impotence 
among men with diabetes have usually ranged from 40 to 60 percent, 
approximately one out of every two men with clinically apparent diabetes is 
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.- thus, 
nearly 50% are impotent as a result of the complications of this 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. A 
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 of the erection occurs over a period of 6 to 18 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. In 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 by an 
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 



Pathogenesis 

It is now reasonably certain that the impotence of diabetes mellitus is 
caused principally by diabetic neuropathy, a process of microscopic damage to 
nerve tissue that occurs throughout the body of the diabetic. Investigators have 
found that autonomic nerve fibres in the corpora covernosa of the penis showed 
morphologic abnormalities of varying degrees due to the accumulation of 
"polyols". These chemical substances produce segmental demyelination and 
defective myelin synthesis, a process that results primarily from hyperglycemia. 
Clinical studies revealed a much higher rate of abnormal cystometrograms, 
indicating neurogenic bladder dysfunction in diabetics with impotence (37 of 45 
men), than in nonimpotent subjects (3 of 30 men). In most reports, a higher 
percentage of impotent diabetic men have been found to have evidence of 
peripheral neuropathy on clinical examination than age matched diabetic men 
without impotence. 

In some diabetic men, microvascular or microvascular changes resulting 
from diabetes may be important causes of impotence. The small blood vessel 
disease that produces many of the complications of diabetes, (e.g, retinopathy and 
nephropathy) is known as diabetic microangiopathy. This abnormality is 
characterized by a thickening of the basement membranes of capillaries, a process 
that may be due to genetic factors as well as to increased carbohydrate content. 
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 arteriosclerotic 
lesions would also affect the process of erection severely. 

Evaluation 

Most impotence associated with diabetes mellitus is not curable by known 
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 by an 
organic process apart from the diabetes itself. Diabetics are just as susceptible as 

others to the psychic stresses of life, therefore causes of impotence such as 

depression and anxiety should be considered. Diabetic men with impotence that is 
psychogenic will respond just as well to competent psychotherapy as nondiabetic 
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 erectile 
capacity. Since drug-induced impotence is usually reversible, when the offending 
pharmacologic agent is either discontinued or reduced in dosage, the prognosis in 
such instances is good. 



140 



Diabetics have an increased risk for many other diseases, including 
infection, various forms of endocrine disease (especially disorders of the thyroid 
and adrenal cortex) and cardiovascular disease. Since such associated pathology 
at times may be the major etiologic factor in sexual dysfunction, the presence or 
absence of these conditions must be assessed by a careful medical history 



exam 



Treatment 

When impotence is an early symptom of diabetes, it is usually a reflection 
of poor metabolic control. In these instances, careful attention to appropriate 
dietary management and the use of insulin or oral hypoglycemic agents will 
frequently produce relatively rapid amelioration of the disturbed potency. If 
impotence persists despite good metabolic control, consideration should be given 
to whether this problem is the result of anxieties, (fears of performance for 
example) that may remain even though the metabolic status of the individual has 
improved considerably. One should note that these anxieties mav have come 
about only after the beginning of sexual dysfunction, in such cases, it is important 
to tell the patient that the impotence began as a manifestation of a specific health 

problem but is being perpetuated by the psychological reaction to that problem 

Brief counselling to assist in anxiety reduction, coupled with a supportive 
approach to participation in sexual activity, will frequently be enough to 
overcome this pattern of impotence. 

If 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 reversal of 
the sexual problem is much poorer. Nevertheless, either in this situation or in 
dealing with impotence that occurs years after the onset of diabetes when 
underlying organic factors such as neuropathy, vascular disease, or hormonal 
disturbances can not be identified, diabetic men will often respond to sex therapy. 

Management 

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

psychotherapeutic reversal, the following points may apply: 

1. Is the history suggestive of a primary organic etiology ?. If a man can 
attain full erections with masturbation or in response to certain types of erotic 
stimuli, (e.g. reading erotic material), it is likely that the impotence is primarily 
psychogenic. 

2. Are there indications of significant personality or interpersonal factors that 
may be contributing to the sexual dysfunction ?. The presence of depressive 
symptoms- including decreased libido, may signal the existence of an intrapsychic 

process requiring prompt therapeutic intervention. Guilt, anxiety, poor self-esteem 
phobias may also indicate a nonphysica! cause for sexual disturbances I ikewise' 

marital conflict, financial problems and difficulties at work may point to important 

mechanisms underlying the occurrence of sexual problems. 



141 



3. Can evidence be found supporting the existence of neuropathy or 



damage as a cause of impotence?. The 



* * ««iv»»i pi win i3i i ik sinifie lesr Tor 

Z C £rr,r eSSm ? nt iS thC ?° nitorin 8 or "octumal Penile tumescence patterns 

(NPTl. If normal naffpmn «r —»«*:«- - ... . . ^ v,uo 



, . ... ««.,..£ ji^^p, 11 can uc assumed mat 

there is no organic basis for the impotence. Further tests include 

cystometrograms, selective arteriography, nerve conduction velocity measures or 

other electrophysiologic techniques. Color Dopier sonography is very valuable 



abnorm 
obstruction causing imnm 



~ v ~~ w "wiwu uy unc ui several surgical 

approaches. At present, there is no known medical cure for impotence due to 
diabetic neuropathy apart from the treatment mentioned before in the chapter of 
male sexual dysfunctions. y 

S 

Whenever possible, counselling should include the wife of the diabetic 
22 J2 ™? Ti FreqUent . , y im P°^e » mistakenly assumed to mean that a 

wife Z u'r f, attraCt ' Ve ° r ' eSS SeXUa " y s,imul «ting. At another time, a 

2« oTLi ' T Ve J ^ ha V mp , 0t T e ^^ ' homosexual tendency on her husband's 
part or that .t md.cates that he is having an affair with another female' Such 

assumptions are obviously detrimental to the trust and closeness of the 



otherwise 



about the disease and its complications is an important preparatory step in helping 
a couple seek sexual options that can be satisfying to them. When counselling is 
available for the couple, rather than for the diabetic patient alone, an important 
opportunity for ventilation, including the expression of guilt or anger, is provided 

Z^r TV* abmty t0 fU " CHOn SeXUaHy is an im P° rtan " — « of ego 
strength and self-esteem, recognition of this fact by the physician is a necessary 

component of providing effective patient management. 

ln ,..,! t f °"' d be St, ; essed ^ the Physician, that impotence does not mean 
mabil y robe aroused or to obtain gratification from sexual activity, because 

foraet I" rt ^T ° f 'T* 6 *" diabetic men ars able to «i«culatc nonuallv. not 
foigettmg the values of sexual intimacy which should be encouraged 

wS Z "^ gK ' en f' SO t0 the perSOnal ' cultural a » d reli gious fetors 

wh ch are very .mportant to the couple's sexual value system while counselling 



Surgical approaches to treatment 

imnl,n? a T ently r' th -r ha \ been Creasing experience with the surgical 
mplantat.on of penile prosthetic devices to provide a more satisfactory sohuion 
■n the sexual problems facing men with organic impotence that is irreversible bv 
other u-eam.ent methods. For selected diabetic men, this approach may be 
extremely beneficial. It ,s likely to he of most usefulness in the following cases- 
function sexuX" inVCSted a maj ° r POrti ° n ° fhiS Se ' f - eSt6em in his abi,i * "> 

2. Significant depression occurs as a consequence of diabetic impotence 

3. Sexual dysfunction is materially affecting the quality or stability of 
marriage or long-term relationship. ^ u 



142 



4. There is no major loss of libido 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 pattern 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 
1 to 2 percent of diabetic men. The cause of the problem in these men is an 
autonomic neuropathy that has progressed to the involvement of the neck of the 
urinary bladder. Normally the neck of the 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. In affected diabetic men, because the internal 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 Seminal 
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 durine intercourse. 



Prognosis 

Diabetic men with his condition may or may not be impotent. If they are 
not impotent, there is a high probability that erective dysfunction will occur in the 

future, since the underK ing neuropathy is likely to worsen. However, diabetics 

with retrograde ejaculation still experience orgasm, although the sensations 

fl " nriatpH u/ifh thA r cco (T ^"Hiinnl fluid through the distal urethra an bUjliii, 

so that a man with this condition may describe an altered set of orgasmic 
sensations. Rhythmic contractions of the 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 first postcoital urine specimen. If such an approach is taken, 

it is advisable to alkalinize the urine prior to ejaculation, (the usual acidity of 
urine is spermicidal) by having the man ingest sodium bicarbonate. 



143 



Female Sexual Dysfunction in Diabetes 



ANORGASMIA 



n is surprising to note that, inspite of the detailed research information 
concerning impotence in diabetic men, nothing appeared in the literature 
concerning females until 197!. A recent survey, comparing 125 sexually active 
diabehc women with a group of 100 sexually active non-diabetic women all 
subjects were between the ages of 18 and 42 years. There was a marked similarity 
between the two groups in terms of: age, religion, education, marital status, age at 
menarche, incidence of dysmenorrhea, parity, frequency of coital activity self- 
estimation of sexual interest and any history of psychiatric care. It was noted that 
35.2 percent of the d.ahctic women reported being completely non-orgasmic in 
the preceding year, whereas only 6 percent of the nondiabetic women reported 
complete absence of orgasmic response during the same time period. 

Natural history 

The onset of orgasmic difficulties is gradual and progressive, usually 
developing over a period of six months to one year. Most typicallv the time of 
onset is four to eight years after the diagnosis of diabetes is made A gradual 
decrease m the frequency of orgasmic response, sometimes accompanied by a 
not.ceable lessening of the intensity of orgasm. Sexual interest usually is not 
diminished but a minority of women complain that it seems to require longer 
periods of direct sexual stimulation for them to reach high levels of arousal 
whether engaged m masturbatory or coitnl activity. Vaginal lubrication is not 
significantly altered in most diabetic women. 

Pathogenesis 

Hither neuropathic or microvascular changes or both mav be responsible 
since both of these complications occur at greater rates with disease of longer 

chromcity. Evidence of other autonomic nervous system impairment can be found 
by careful examination, it is possible that most diabetic women do not "lose" the 
capacity to be orgasmic but simply require higher levels of stimulation to set off 
the orgasmic reflex. Studies with a small number of diabetic women who have 
experienced orgasmic difficulty that was overcome by the use of a vibrator have 
indicated that this may be the case. An element of possible etiologic importance 
is the greater susceptibility to infection in the vaginal are a and urinary tract 
Although acute vaginitis can be extremely uncomfortable, psychologically as 
well as physically, chronic infection remains a greater cause of sexual problems 
Moniliasis seems most troublesome because it produces tissue tenderness 
malodorous discharge, pruritus, and decreased vaginal lubrication. Psychogenic 

dysfunction ™'g"t be expected when accompanied bv diminished libido and a 

higher occurrence of dyspareunia and it might also be noted by a pattern of more 

abrupt onset, particularly in association with pregnancy. 



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 managerhent. 

Vaginal LUILUIU IIIUSl M VPIIM » «ttHide vaginal infection since vlsua. 

inspection or microscopic examination are not sufficient. When infection is 
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 

h -Hiti nrri oinn throe disorders product slaimI djslMllUW, ll In 

important to consider them in the process of differential diagnosis. These 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 sharing 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. 



nnn 



145 



1. 



i 1 Jf.£ 0l, °r ing P '"* 8 may be useful in the management of diabetic women- 
nabi ity to be orgasmic does not alter a woman's reproductive capacity 
i. inability to be orgasmic does not mean inability to enjoy sex 
3. Limitations to orgasmic responsiveness are not necessarily due to emotional 



5. 
6. 



limitation. 



primary 



4. Intimacy sharing and gratification-sexually and non-sexually-within a 
relationsh.p e.g. marriage, do not depend on being orgasmic 
One's femininity or attractiveness is not reduced by not being orgasmic 
The husband of the diabetic woman who is sexually dysfunctional may need 
reassurance in knowing that he is not the cause of the 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 



PERFORMANCE 



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 pharmacologic 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 
and interaction with other drugs; and to nonbiologic factors, such as compliance 
with a medication schedule and patient suggestibility. 



In 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 ) DIURETIC ACFNTS 



Thiazide diuretics 



Clinical observation indicates that 5 percent of men using thiazide diuretics 

on chronic basis experience disturbances of potency that are attributable to the 
drug. Ejaculation is not known to be affected by diuretics. The impotency may be 

due to the hyperglycemic effect of the thiazides, whereas in other cases it may be 
caused by the potassium depletion (hypokalemia), 

Ethacrvnic acid and furosemide 



Two non-thiazide 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 difficulties 
because of diuretic induced hypokalemia, a trial of potassium supplementation 
may produce rapid amelioration of the problem. 

Spironolactone 



It is a competitive antagonist of aldosterone that conserves potassium and 

exninus an antmypenensive eneci. I Ins drug causes decreased libido, impotence, 
atid gynecomastia in men and menstrual irregularity and breast tenderness in 
women. These effects appear to be somewhat dose-dependent and reverse 

promptly on cessation of drug use, except gynecomastia. 



147 



DIURETIC BLOOD PRESSURE-LOWERING 



Alpha-methyl dopa 



One of he most widely employed of drugs used to treat hypertension but 
unfortunately ,t » also a common inhibitor of sexual function. At dosage levefc 
below 10 gm per day, decreased libido and / or impotence in 10 to 15 percent of 
men, and depressed libido and / or impaired arousal occurs in a like proportfon of 

Z7Z I 8 ' l T ClS ° f 2 ? m Pef day ° r more ' proximately 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 

b2 T hT 7^ e J acu,ation - ™* <*™ of these problems may relate to 
both catecholamine depletion in the central nervous system and the production of 

nerv. S H " euro t tra " s ^ ,tter ' w "ich may have a direct effect on the peripheral 

nerves that con rol the processes of erection and vaginal vasocongestion it was 

proved that alpha-methyl dopa does not affect circulating testosterone levels in 
men. 



Guanethidine 



of inhihv aUS< V US f n ! ,ad, ; ener g ic Properties, its primary effect sexually is one 
of.nn.b.tion of ejaculation ,n the male, which is a dose-dependent phenomenon 

t JTT ? mg - P f day ' a PP roximate, y 50 to 60 percent of men have 
retarded ejaculat.on 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 10 percent of men report decreased 
libido and sometimes accompanied by impotence. This loss of libido may be th- 

at Wh / ^ Tl ™ emblm & s y stemic lu P us erythematosus that can develop 
at h.gh doses with this drug or ,t may be due to a pyridoxine deficiency that has 
been described in association with the use of hydralazine. 

Rescrpine and other rauwolfia alkaloids 

These drugs deplete stores of catecholamines in many tissues, including the 

enonelTto pr ° d,,C r h a H ma r k , ed Se f ative efTect ™« »*•«- ««**« can be stfong 
enough to lower hbido 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 sexua 
dysfunction as well as depressed libido. 

Propranolol 

It is a well known a beta-adrenergic agent that is used primarily in the 
re tment of cardiac arrhythmias bu, has recently enjoyed a broader range of uses 

Ing foment of hypertension. Although some authors have claimed 
that „o sexual problems are attributable to the use of this drug, more recently 
several mstances of propranolol-induced impotence have been reported 



148 



Clonidine 

Current evidence indicates that 10 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 15 percent of men and women, but impotence 
occurs infrequently with this drug and it may be a useful alternative therapeutic 
agent for patients experiencing sexual difficulties with other blood pressure- 
lowering drugs. 

( C ) GANGLIONIC BLOCKING AGENTS 



Pentoliniuin 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 "silent" 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 of the possibilities of sexual impairment as a consequence 

ur uiuu w may lie une my luwaiu ueuei iiiaiiageiiieiu. me luiiuwiiiy 

recommendations are pertinent: 

1. 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 drug-awoclated side effects, the key for a successful 
prescnpt.cn „ hav.ng the patient realize that drug-related sexuafprc blems he o 
she may experience are reversible. P ' ° 

dmac ^T ^^ Sym P toms arise duHn 8 * patient's use of antih, pertensive 
Zl ' * a !f Ume automatica,, y that ^ey are a result of these drugs Inquhe 
about other med.cat.ons or illicit drugs the patient may be using Be sure the 
problem ,s not a reflection of marital difficulties, ah ohol use, or an intercurrent 

SZJEf" i0 ^ P0SSibUity th3t PSyCh0 ^ ica ' factors -derlle te seS 



5. Reversal of «pthoI 



^eversa, o, <„„„, r9}flim a>1 ;,n t Jalu! wjl|| (||(} m ^ 

ant.hypertensrve drug can be achieved by eliminating the offending drug entirely 
or by reducing the dosage of the drug in question. entirely 

. 6 B e certain to inquire about sexual problems at each follow-uo visit 
Such rnqmry w,H aid in determining the dosages of particular drug lea 
well tolera ted and will be he.pful in detecting sexual difficulties before hev 
d,scourage the patient from seeking or continuing treatment. * 

7. More careful attention to the sexual side effects of antihvp-rtensive 
drugs wdl surely be of assistance in helping to improve patient complLce a d 
consequently to lessen the morbidity and mortality rates of hypertension 



Effect of Hormones on the 

Sexual Function 



Androgens 

hi 



I liese hormones do not ordinarily increase libido or potency in men with 
normal endogenous testosterone production, although in men with testoste one 
denc.enc.es, an androgen treatment can often restore libido and pZTcyto 
base hne levels The administration of exogenous androgens suppresses the 
hypothalam.c-p.tmtary-gonadal axis in men, so that te„ic-,£ TJ' 



testicular atrophy 



,t ! , ? an ? r ? gen doses on a chro ™ basis. Since some of the androgens 
s It f om r,l f" 1 C arC metab ? ,Zed t0 eStr ° genS ' gynecomastia may 

result from the use of exogenous androgens for a long period Prostatic 
hypertrophy and possible exacerbation of prostatic cancer a e also f^s 
associated with androgen use. 

hv tJ"? "!?"' h, "f dOSCS ofaMdr °g en ''urease libido, hut this effect is limited 
b 3 the side effects that accompany its use. Hirsutism, acne, clitoral hypert "pIv 
and sodium retention are particularly troublesome. If androgen i Ted bv a' 
woman wlule she ,s pregnant, there is a significant risk of virilization o a fennle 
fetus, dependmg on timing, duration, and dosage Of androgen used 



150 



Estrogens 

When used by men, (e.g. in the treatment of prostatic cancer V. it produces a 
prompt reduction or obliteration of libido and almost invariaMy result in 
impotence. This effect is probably attributable to depression of testosterone 

piuiluiiiuu. Iiupuiiiiiuii uf ijaiulaiiuii is miuiliu luihiiiuii iuuIl uf 'suugcii use, 

when ejaculation does occur, the volume of seminal fluid is significantly reduced. 
Spermatogenesis is disrupted, gynecomastia is convnon, 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 pharmacologic 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 of the 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 low-red by 
administration of this drug, which will typically induce a temporary Fterility 

within six to eight weeks after it is begun; in fact, research is currenth being 
conducted attempting to isolate the sexual and reproductive consequences of the 
antiandrogens to provide a male contraceptive agent. Gynecomastia may occur in 

BSSflftlMIAH Willi M use of cyproterone acebte. All these ellecls appear lo b 

reversible upon cessation of drug use. 



e 



Medroxyprogesterone acetate (MPA) 

It 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. Long-acting (MPA) can cause a dramatic reduction in sexual fantasies 
in pathologic psychosexual states such as obsessive pedophilia. 



Corticosteroids 

A chronic daily dose greater than the equivalent of 20 mg of Cortisol is 

sufficient to suppress the hypothalamic-pituitary-adrcnal axis, hut a higher do 

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 atroohv. depression and other mental disturbances, and sunnression of 



151 



kl^ 8 ° n t ad0t :° Pin SeCreti0n - ACTH ° r s y nthetic corticotropin analogues 
lower circulating testosterone levels in adult males. dialogues 

Effect of Tranquilizers, Sedatives and Hypnotics 

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 enhanci S 
performance, whereas sedation usually diminishes sexual 
libido. 



responsiveness and 



Meprobamate 



It has specific effects on the limbic system and therefore may directly alter 
libido and sexual functioning. y UIIceuy a,uer 



The Benzodiazepine compounds 



Chiordiazepoxide and Diazepam 

drue mavTnIr 6 - edatiVC ' ant r xiet y and muscle-relaxing properties. Either 

reduced arTxT,t TT" °' ^^^ '" ' ibid °' Wh ' Ch "»* be a«ributable to 
reduced anx.ety and sedation respectively, impotence may occur only at hich 

dose levels and then infrequently. y 8 



Barbiturates 



They somet.mes lower sexual inhibitions and in this sense may -nhance 
sexual fi.nct.on, but more commonly barbiturate users describe depressed libido 
impotence, or loss of orgasmic responsiveness associated with drug use. 

Metliaqualone 

It is a „ „.h,*i..,™,. K )T „„. : „ „, n| mmt|j ||nJ 1|U||ulU a ( 

«^^::t:,r"' n " araone illici ' usm - a " hough ■*-- —' ■*** 



Psychiatry 



Phenothiazines 



These drugs produce a sedative effect on both emotions and motor activity 
and are active at all levels of the nervous system. activity 



Chlorpromazine 



or ' ' ovulation, cause menstrual irregularities, induce galactorrhea 

or gynecomasty and decrease testicular size. Despite these effects sexual 
dysfunc ion ,s not a common complication to the use of phenothiazuTe 
med.cat.ons; when impotence occurs, it is usually at doses equivalent to 400 mg 
per day or greater. Decreased libido is found more frequently" approximately 10 
to 20 percent of patients, while hypersexua. behavior will oRen abate w i h 
phenoth.az.ne therapy. Inhibition of ejaculation and a decrease in vaginal 
lubncnt.on in response to sexual arousal has also been reported. 



Haloperidol 

Interestingly enough this drug increases testosterone production in men 

when given in low doses, but suppresses testosterone when high doses ire used. 
Impotence occurs in 10 to 20 percent of men using this drug and rrenstrual 
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 10 to 15 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 (Itnipramine and Amitriptyline) 

These drugs are highly effective in the treatment of depression. It should be 
remembered .hat depressed libido and impaired sexual functioning are frequent 
findings in depression. In 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. It 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 

A powerful drug which causes impotence, gynecomastia, impairs sperm 
production and alters the hypothalamic-pituitary-gonadal axis. 



153 



Clofibrate 



[t J S ° ftC " " Sed tf> | OWef SCrUm cho,esteml or friglj/rAi-i^c ^:~ 1 j n j | j lf0 

HBIdo and impairs potency in some patients by unknown mechanisms. 



Disulfiram 



patients ^ ***" rep ° rted aS *" occasional <*use of impotence among the male 

Digitalis and other glycosides 

These well known medicines can cause impotence and gynecomastia, the 
mechanism of act.on 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. 

■4 



Antihistamines 



It was found that these drugs can produce depressed libido in either men or 

ZnT Z Y eSU,t °! 'J 1 ? SCdative aCtion ' and va g jnal '"brication may be 
significantly decreased while antihistamines are being used. 



L-Dopa 



While this medicine is extremely useful in the treatment of patients with 
Parkinsonism; m.t.al reports pointed toward a possible aphrodisiac action but 
latent 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 
ot a trustrating and incaoacitatinff chrnnir Jlln^c 

Alcohol and Sexual Performance 

Alcohol and its effects on sexuality have been the subject of considerable 
conjecture and research for centuries. In "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 

in three different doses to college-age men and measured the increased in penile 

tumescence 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 w that alcohol acts as a depressant to the central nerTons system, thus 
nterfenng with pathways of reflex transmission of sexual arousal. In addition to 

these acute effects of alcohol use, which certainly occur in situations that 

°r p " ,hl ' ng PQttCm ' nIlUllUl ,Ui ^ "WHHBIV Men shown [ 

lower e,rculat.„ g testosterone and luteinizing 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 th<it alcohol 

has a dbinhibition offcot that io to oayj it loTrcro certain ncmal inhi* itionn a 

person ordinarily have, so that in some people the feelings of relaxation and 

increased openness to sex may combine to facilitate sexual response In 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 from their sexual 
feelings. It 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. In 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. If, 
however this balance is exceeded, the person involved may be too drunk to care 
very much!... 



Cigarettes and Sex 



Although cigarette smoking is a common practice, widely acknowledged to 
be linked with a number of health problems, very little systematic study has been 

KuiiuueiiHi Mndeming ine impai'i ur yrnokiny on mm\ nineuun. mere is rewni 



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 

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 "Hashish" and Indian Hemp or Pot, it is 
tetrahydrocannabinol (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 m order to be accepted socially. In this regard, one of t'e re sons 

ofsZ ^ y fe C eH„^nd itlatin ? *" "" "»*"* is * "P^ion as an Enhance 
ot sexual fee mgs and experiences, so that the user often has positive exr ectatinn* 

°/ c Z H nJ ° yab i e ?™ B effcCt If iS dmCUh t0 Se P* rate *° ex^eclt^ f^m th e 

actual drug effect except under rigorous research conditions, (e.g. a doub e-N nd 
drug-placebo admmistration experiment), which have not been used to date 
When such a project was proposed, in a format similar to the alcohol experiments' 
mermoned previously that measured penile tumescence in response Tv^u 
erotic st,muh, ,t was stopped because of political pressures!!. The research tha 
has been done thus far, has been difficult to interpret because of many issues of 

itZ U^ ^^ « difficuIt to so,ve ° r to ^"trol, because of the facMna many 
people who use marihuana also use other drugs, such as alcohol and tobaccTas 
well as psychoactive substances. It may be helpful to look at the biologic and 
behav.oral aspects of the effects of marihuana on sex separately in orderTo ea .n a 
clear understanding of the variables involved. 8 



Animal studies 



It has been shown that marihuana or its active ingredients can decrease 

itorv behavior in moL -,.*„ :„u:l:* . . ° . . gadC 



sperm atog 



Xrsr , r h r a has »'^-=™™2 

stud.es, leaves httle doubt that marihuana is endocrinological^ active 



Human studies 



I In studies in men during both acute and chronic administration freauent 
marihuana use has been shown to depress circulating levels of testosteroneTn 

esto^roT? Th A th ° U ? h °" e StUdy did n0t find a -PPression ofnorning 
del ^ that e 'r e V n t ri dUr,ng hfee Weeks / f dai, y mari "^na use, a similar study 
des gn that extended over a longer period of drug use, showed significant decreases 
m testosterone beginning with the fifth week of daily marihuana use The 

bflT? °' teStOSt 1 !T ne iS n0t ' ° f COUrse ' a,wa y s significant in terms of either 
u e XeTe Tr™ S"k °^ Nevertheless ' so ™ ".en who are chronic marihuana 

a few week! ft" 1° bC ,mP ° tent ' and t0 eXperience a ret »™ to Potency within 
a few weeks after discontinuation use of the drug. Furthermore inhibited 

spermatogenesis a.so, has been observed in association with ch^ mar mua„a 



2. Studies of acute marihuana use by women who were either nost 

;s;: r ho had • previous,y removed their — ^-..v ^jz 

hat marihuana owers pituitary gonadotropin levels by approximately 35 percent 

nd.cat.ng that the effect of marihuana is centrally mediated. In studies of chronic 

mar.huana use by healthy women aged 18 to 30. users wem found to hale 

somewhat shorter menstrual cycles than nonusers, although LH and FSH level, 



156 



were 



„w not significantly different between the two groups. Interesting y, 
testosterone levels were higher in the women who used marihuam- chronically 
(probably reflecting the adrenocortical contribution to testosterone synthesis) and 
prolactin levels were significantly lower. 

3 Five 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 
orgasmic 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... 

In this same series of interviews, it was found that while fewer than 10 
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 impotent .. 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 
onctinnc *r P frequently reported, but these changes may not correspond to 

actuality. Thus, the marihuana user may well be perceiving an enhancing effect 



of this drug on „—, . . . 

impaired In 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. In some people, of course the relaxation 
produced by this drug progresses rapidly to somnolence or sleep!, which is not an 
ideal state for sexual activity ?... 

1 

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 19 men addicted to heroin, 12 reported impaired 

libido, 10 were impotent, and 15 had delayed ejaculation time. Cicero -md 

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 patency problems and retarded ejaculation or failure to 

ejaculate in both drug using groups. It is clear now that heroin and methadone are 

capable of exerting an active endocrine effect that predisposes, to 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: amenorrhea (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 sitpporting their drug habit. 
They may subsequently have negative feelings toward sex 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 

* • « « m J. 



drug use will not restore sexual and reproductive function to normal immediately; 
endocrine or psychological problems may persist for months before improving. 



158 



.t> 



*~ 



*aine and sex 



■s/ 



air- 5s r^rruted to rcssess sexually rtrau!atmfc r roperies, deluding 



i 



^.^><j^ 



. 1 1 



^ %' j -j' 




i.-»rafsc!*ic? rjpc-r* i^^r^'iriP hnrr^s ^ind aurabi sK' of erection 

*2 orgasm "br both men arc women, ^owe^er 14 of 39 men reported 



-— :::' e^c^n^ -s^cc^aied wrt'^ -.:cc«^ne use. Fnapism !:as £;SO occurrec as ? 

.—■?■> :.■' ■-"ritiv^e :se< Research ■Evolving ;ne ■■/a.r.ja- - r ^-::is cf thr.s c)nig ts 

-■■--v^^-v ^-,:-^- - -,Hi .* ■'* -r>r»r ^r^sj^ip ?- mT^^v ^?'iv ^cne'US*nHS git tb?3 *MT!!5 

. **._*+ -u tt ^.y,, r ^ r ^ ofnnatMsm, "Crack* 8 is another product -of cocaine. r~oduced 






■— ^; : :-'■/ "r-;^ -miners to oe cheaper ic sen &ne r*ore aitecnve 

.ixortunateiv st *s more damaging as well!... 



tiscellaneous Drugs 



■■-*•—■ S 



:ese drugs were studied by Bell and Trethowan and they noted some 
degree of "sexi-ai abnormality^ amone its users. These authors and others have 
senerailv concluded that amphetamines use leads to an increase of libido and they 
reported a higher rate of Promiscuity " , among its users. 



A my I nitrate 

■K 

Thi*= "ubstance is a rapid-acting vasodilator that achieved \ery recently 
aotonetv as an aphrodisiac that wouid intensify the orgasmic experience for both 

-,nen *-ind vomen. The dnm is inhaled and produces tachycardia and local 
vasodilation; headaches and hypotension are frequent side effects. Syncope, S-T 
segment depression of the electrocardiogram, and other cardiovascular effects 
may also occur. These effects are not necessarily innocuous, but the drug should 

not oe used recreationally at all, especially bi 

or cerebrovascular disease. 



JW3MS 



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". In 

interviews at the Masters and Johnson Institute with 85 men and 55 women who 

had used LSD on three or more occasions, fewer than 15 percent of each group 

claimed that LSD enhanced sexual participation. It is one of the most famous 
group of hallucinogens. 



Spanish fly 

It is a bright green insect, when dried it is used for raising blisters; its 

medical pharmacological equal name is Cantharides, in greek, Cantharis blister 

fly. As an aphrodisiac it is highly toxic and dangerous through irritation of the 

genitourinary tract. 



159 



Yohimbine 

One of the few drugs that have been formally studied for the treatment of 

erectile dysfunction. It is an indole alkaloid which has ctrreceptor blocking 
activity in vitro and is derived from the bark of the Pausinystalia yoMimbe tree, fn 
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 LOVE 



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 journal 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 of the 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 Islam 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. In 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 known to have had strong 



homosexual leanings are: Socrates (the famous Greek philosopher), Gaius Juli 
Caesar, King Richard (the lion hearted), Leonardo da Vinci, Michelangelo, 
Tchaikovsky, Hans Christian Anderson and Somerset Maugham. In 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 alarming 
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. Marmor and 

Green state, homosexuality is a preferential attraction to members of the 
same sex. 



In their pioneering study, ,f Sexual Behavior in the Human Male", 1948, 
which included the sexual histories of 12.000 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 sanr* sex". AH 

over history, the term homosexual has had an endless list of synonyms: 
homogenic love, contrasexuality, homo-erotism, the third sex, gay, que-r, faggot, 
sissie, pansy, sexual inverts, psychosexual hermaphrodites. 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 concern 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 of the 
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 predominant^ 
homosexual for at least three years between the ages of 16 and 55, and 37 percent 
had at least one homosexual experience leading to orgasm after the time of puberU . 
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 inflated 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. Indeed, 37% of all males (and 13% 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 of the 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 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 1 - 5). Thus the exact breakdown is as follows: 

0. Exclusively heterosexual. 

1. 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. Predominantly homosexual, but only incidentally heterosexual. 

6. Exclusively homosexual. 



r 








Exclusively 

heterosexual 

behavior 



Incidenta 

homosexual 

behavior 



More than 
incidental 
homosexua 
behavior 



Equal amount of 
heterosexual 
and homosexua 
behavior 



More than 
incidental 
heterosexua 
behavior 



Incidental 

heterosexual 

behavior 



I* ■■!*■ 11 MJI 



- Ambisexual behavior — 



Exclusively 

homosexual 

behavior 



Fig. 38. The Heterosexual and Homosexual Behavior (Kinsey et al.) 



163 



Theories of Etiology 

Is homosexuality a single disease ?. Is it a symptom of neurosis ?. Is it an 
inevitable manifestation of a disturbed home or a disturbed society ?, Can it be a 
social ritual ?. 



BIOLOGIC CONSIDERA1 IONS 



Genetic 



There has been much historical conjecture concerning 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 



ormon 



sexual behavior that appear to be proportionate with homosexuality. Several 
studies in humans indicated that there were differences in the urinary excretion 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 confirming 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 



rm 



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. Information gained froi^ 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 hormonal 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 inborn 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 inborn 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 100 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 

g~nT|r ?f Y7 humuotnunl mm and 01 married men ttIio thjic [JllJUiiiid lu Ui 

heterosexual; she found that the homosexual subjects more frequently had poor 
relationships with their fathers who tended to be ineffective and poor role- 
models. At the same time, 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. Siegelman 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 Marrnor in 1065, that homosexuality is "multiply determined by 

psychodynamic, socioculturat, 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. In 
support of this concept, Whitam found that male homosexuals described 
childhood patterns showing interest in dolls, cross-dressing, preference for girls 
as play-mates, preference for being in the company of adult women r?ther than 
men. Usually regarded as "sissy" 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 
whs 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 1957. In this investigation, 30 
homosexuals and 30 heterosexuals, (neither psychiatric patients or prisoners !) 
were matched by age, education and IQ. 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 of their 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". In 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 attempted suicide. In both populations, however, the majority of 
homosexual subjects were well-adjusted and productive persons. 



166 



The Homosexual Patient Diseases 



are 



physicians deal with homosexual patients on a daily basis in the West. A 
relatively high rate of venereal disease in homosexual men has been documented 
by several screening programs. Judson and co-workers found that 48 of 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 who engage 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 male 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 of a variety of colonic and rectal 
disorders in homosexual men has been termed the "Gay bowel syndrome" ! by 
Sohn and Robilotti. 



Other studies indicate that homosexuality mav predispose to the 
development of hepatitis B infection. In 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 patterns 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 of the patients seen by Sohn 
and Robilotti, who also found non specific proctitis in 12 percent, anal fistula in 
1 1.5 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 of a dildo or vibrators (i.e. sexual aids) by homosexual 
women may result in laceration of the v»ain» If anpli^H „n«,icDi Vl - Hl 

irtbadism. 



167 



r 



Again, anai Incontinence has been recorded t:;/non£ those who nad 



-j'- 



heatedly traumatized the anal sphincter by the performance of soden 



^ _.-*, 






(introduction of sexual aids or sohd object? rene 









However, the sexual practices of homosexual men and lesbian? do cr -.-■:■■ e 
special health hazards that the attending physician should know c T n :?: forgetting 
AIDS patients of course.:. 



Psychological and Sociological Aspects 






Homosexuals, mate or female, may have problems related 
legal cr economic pressures that they face m nny part of vhe worid. T'-*e ,r 
experience emotional problems too, especiady when pressured to change the 
direction of their sexual orientation. Unless the homosexual wishes ^erlousiv to 






hange, such alteration is not undertaken. In fact, ^ex therapists ~re astonished 
realizing that some homosexuals seek treatment in order to enhance their 
homosexuality!- a realization at marked variance with, the therapist's previous 
practice of attempting to eradicate homosexual behavior. 

A recent report by Bell and Weinberg provide? a large amount of 
knowledge concerning homosexuality, the behavior of homosexuals and their 
emotional stability. In this study, 686 homosexual men and 293 homosexual 
women were interviewed. The data led the authors to the delineation of five 
different homosexual typologies based on sexual experience: (1) close-coupled 
(living in a quasi-marriage), (2) open-coupled (living in a quasi-marriage hut 
continuing to have a large number of other sexual partners), (3) functional (rot 
coupled, having a large number of sexual partners with little regret over 
homosexuality and few sexual problems), (4) dysfunctional (not coupled, having 
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 relativelv low levels of 



sexual interest). The overall diversity of the group of study subjects was highly 
apparent, both from a socio-economic and from a psychological perspective. It 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 

In 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. 
In few countries penalties are extremely severe and depending on the country,, it 
may range up to life imprisonment. In 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 



"sodomy" 



A close look at ancient and medieval history reveals th?t the term 

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. 



r^jSB -utiS ^ J^u j»l JIS 



uai i jiu J vi -u* dj, o^ Ui jauu fS^u ^ ^b, o^Jt u>^ 



^u 



. (jjaolwaJI ^j^» CLu£ (jl Ai\ ^jiiao 



(YA : Cj^SixJI) 



Christian Roman emperors enacted the first European laws against male 
homosexual behavior, offenders were burned at the stake. In 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 stake is 
equipped with a penis-shaped peg which is placed between the legs ol' the 
condemned holding up the body while it burns !. 

In 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 of the 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 Chief Justice, 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. In their physiologic 
studies, 94 homosexual men (age range 20 - 54) were investigated during sexual 
activity in the laboratory in a fashion analogous to the methods employed for 
heterosexual men and women in the "Human Sexual Response" experiments. 
When the observations of homosexual 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. In 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 anorgasmia, 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 11.1 percent. There were relatively 
few differences in techniques of sex therapy for the reversal of sexual dysfunction 



in homosexual and heterosexual couples. 

In a second clinical group, homosexual men and women who wished to 

convert or revert to heterosexual functioning were treated. In 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, although 
behavior may still be changed. In 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: 



It is very unfortunate that the Western 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 



using 



AIDS: A Lethal Mystery Disease 

J he Racily disease first broke out in the homosexual communities of New 

Z r ; Sa " F r ancisco / nd L °8 A "geles in 1 98 1 . Later, it cropped up among heroin 
add.cts, Haitian refugees and v^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 
torm ot Kaposi's sarcoma, previously unknown in the USA AIDS victims 
also face the nsk of lethal infections such as Pneumocystis carinii pneumonia 
(1 CP) and mycobacterial infection. 

Etiology 

What makes the immune system go awry ?. An early theory linked the 
problem to amyl 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 „,.„* 
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 .t 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 invariablv 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 of the population !". 

a hn,.t ^ h nnn mber °J ?" °/ AIDS ' S doubMn 8 each J™, which would mean 

th? w u ^ u CaS u, S r hC ^ ° f " eXt yeaf iP the USA - on^ C983). 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 

lanzama and Kenya. But those suffering from AIDS itself are only part of the 
picture. Because for every victim, there are five to ten more people who suffer 

from a less severe form of the disease that is not fatal, and more than 50 to 100 



O 



. ..—^ ..., ,,vm , t ,Lcii. tlMU mure man ?u to KM) 

thers who have been mfected with the AIDS virus but show no symptom, - 



171 



600,000 to 1.2 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 
vvel. a^eVr etches and it was named: HTLV-3 or LAV by the French 
researchers. It was described as the No. one U.S.A public health ^W«"^ d J« 
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. S range 
Tough the vir'us wa! recently found in the brain cells in the epithelial ce Is ^tha 

Hue the eyes and evelids, but it is certain now that the v.rus » also pre** m 
aliva 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 
„ whTch saliva is exchanged could well transmit the disease, if the uninfected 

person has any cuts, sores or bleeding gums. Homosexual men account feu 73 

percent of U.S. adult cases, intra-venous drug abusers account for 17 percent 
while blood transfusion recipients compose nearly 2 percent hem °P h,1, "«^" , 2 
I 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 10 percent of childhood cases are in people who fit 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 Aey 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 !!. Studies at the 
Walter Reed Army Institute of Research of U S. m ^.^ m ;}™**™ 
also implicated prostitutes, as do studies of African and Ha, .an AIDS patient^ 
Many experts sav the risk to the heterosexual population will increase over the 
next five to ten'vears, with those who have many sexual partners in greatest 



danger. 



The most popular hypothesis prevailing so far is that AIDS 1 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 specie* known as 
the African green monkey carries a virus very similar to the AIDS virus. Tests of 
Z • moleculaf structure show that it differs only slightly from the AIDS vinu, 1 h s 
monkey virus causes an AlDS-like disease among several species of monke>s, 
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 of the past, still it is much more deadly. Bubonic 
plague and cholera killed about half their 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 100 percent!., no 
one has been cured. Once you get the disease it is essentially, uniformally 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 unborn child during gestation or 
just after birth. 

The slower pace of AIDS epidemic is offset bv a potentially more 
frightening uncertainty about who is infected and what may happen to them. The 
U.S. government best estimates suggest that 5 to 10 percent of those 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 Ivmph nodes 
diarrhea and weight loss. Any where from 5 to 20 percent of ARC cases mav go 
on to get AIDS, but for the rest the symptoms of ARC 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 12 years. And because the virus may insert itself into the host's 
own genes, the effects of the 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 others. 

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 AIDS-infected T4 cells growing in a test 
tube can live indefinitely, dying only when exposed to some unrelated foreign 
protein that stimulates them info action. As such, it is possible that a human 
infected with the virus could at least postpone the onset of AIDS if he avoided 
ordinary infections ?. 



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 
"er exposed. A prototype vaccine that has been given to rhesus moneys 
produced antibodies in their bodies, now, scientists in U.S.A. Scot and 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 
bv changing any abnormal sexual behavior and particularly by avoid.ng multiple 
sexual parmers Pentamidine has proved to be effective ,n the treatment of 
pneumonitis pneumonia as well as Interferon, but treatment .sst.ll tricky and 

prevemion is the most effective way of dealing with AIDS wh.ch 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 ,ts repl.cat.on 
and those that are aimed" at rebuilding the immune system. The antivira 
preparations under research now are: The Pasteur Inst.tute HPA-23, but 
uXunatdy it causes serious blood clotting problems, Suramin, R.bavmn 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 anned at arrestmg the 
virus, have failed so far to influence the course of this fatal disease. 

Religi Xn e L Christianity prohibited anal intercourse strictly because of its 
dangers and serious complications. 

y\o : aJ t\j*A\ % jy * .^>il 3J& J J^ M ^ 

aja. \li /j-aJ*.^)Ji -"ill P***-? 



Recent Research in AIDS / HIV 



Considerable progress has recently been achieved in understanding the 
pathogenesis of (HIV-1) and in improving the efficacy of antiretrov.ral therapies 
for the treatment of patients with AIDS. The pharmacological properties of new 
drues ee (AZT) are veiy effective in establishing a long-term suppress.on of 

HIV-1) replication and have remarkably increased the survival period of patients 

with ADS However, current therapies are still far from eradtcatmg (HIV-1) 

from patients and do not prevent the development of A,DSrdated '^^"^ 
which affect 40% (HIV-1) individuals e.g. Kaposi s sarcoma. non-Hodgkm 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-1 ) 
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 influences on risky sexual behavior. 

Treatment of (HIV-1) 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 
of the protease inhibitors e.g. (Saquinavir) raise the possibility of disarming 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. In 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) ! 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 Southern 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 1997 

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 

r 

International Congress for the Prevention of AIDS that the (HIV) virus may have 
been transmitted to humans from the Chimpanzees in West Africa... 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); 17 millions are men 

while 12 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 HIV 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. 
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 modern sex researchers 
speak of masturbation, we refer to: "any deliberate bodily self-stimulation that 
produces a sexual response 1 *. 

Technique 

Such deliberate stimulation can take many different forms. In 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. It 
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. In 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 of the 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. Fiovvever, today there are also 
special masturbation gadgets, termed sexual 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 

A 1 * * ■ * Art.*,* 



orm 



bodily movements then cause the balls to click together and to send then pleasant 
vibrations through her entire pelvic region. It is not certain, however, whether 
they can cause much sexual arousal or lead to orgasm, because they (the two 

balls), never touch the clitorh at all, and the vagina itself contains virtually no 

nerve endings. Onlv, the outer third foreasmic nlatfnnnjt hac pph/a *r>A\np*\ n A 

narrows m 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 \n 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 

opi In contrast, girlj iin muie likely iu dlyuuvw fflUflltbalion alone and b y 

chance, while some of them 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 then 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 most 
common or even the onlv sexual outlet. However, this does not mean that it is 

typical for the earlier phases of human sexual development and that it is practiced 

only during adolescence. It 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 
well as the catholic church, it was the Protestant who singled masturbation out as 
a substitute for the devil!. In 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- 
stirnulation, 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 brother's 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. 



In 1760, Tissot, a respected Swiss physician published an influential book 

entitled: "Onanism and the disorders produced by masturbation". Hie author 
claimed that masturbation was not only a sin and a crime but that it was directly 
responsible for many serious diseases such as: "deterioration of eyesight, 

disorders of digestion, impotence. ... and insanity". His views became official 
medical doctrine and physicians all over the West found masturbation at the root 



178 



of almost every disease !. In the 18th and 19th 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 
150 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 I". 

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 loss of memory"... 

Indeed, 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 18th 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!. It was also believed that a hard mattress, a thin blanket 

freauent washing with ™IH w «tAr, ™a ^ , ]y )fTf nom tcmpciQlUlU mil 

helpful in breaking the secret habit. In 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 
and irritate the sex organs!. 



warm 



In the 19th century, Henry Maudslcy 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 of the disease. Parents 
were therefore advised to tie the hands of their children to the sides of the bed !, 
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 

179 



fantastic "erection detector"!, 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 infibulation for males (i.e. putting a metal ring 
through the foreskin, thus preventing an erection)!, 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 interested in 

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 harmful 
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. 



It 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-productive, non-creative and parasitic habit. They warn 
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 Lief, 1978), related the following facts about masturbatory attitudes, 

knowledge and experience on 30,000 volunteered medical students in the U.S.A. 

It 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 



- Agree. 

- Uncertain. 

- Disagree. 

- Strongly disagree. 

(2) Frequency of masturbation ? 

- Less than once per week. 

- Two to three times per week. 

- Four to five times per week. 

- More than five times per week. 

(3> n^ZbZ^ "' ° f me " ,a ' '"* e " 1 °" < """ "•'«"*«* »" — by 



- True. 

- False. 



Conclusions 



Shldent !.e. /emale doctors are morJ.h f? lia " U ' ^^ »«"ale 

the practice of masturba^n "' ^ *" **" male doctors ab °* 

The sexual attitude about masturbation whether male or fr„. a . „ 
knowledge and exnerienrc ahrmt u ; , r ma,e or lemale, the 



less knowledgeable about it. 



s sexual habit and are 



a- 19 percent masturbate actively before the age of 10 years 

b. 34 percent started masturbation before the age of 13 -w (natur,!. 

must remember here the effect nf n,»„ i I y (naturally, one 

girls). ° f menarc he on the sexual activities of 

c About 45 percent, masturbated before the age of 1 6 years. 



181 



• It 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 if they 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 turn 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 



arlier 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 rupture of the external sphincter muscle fibers 
with consequent anal incontinence. "Fist fucking" is the term 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. 

* 

It 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 spermatic 
vein. This occurs whenever a true 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 Dopier sonography greatly helps in the 
diagnosis of varicosity or varicocele. Surgical suprainguinal ligation of the 
internal 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". 

- Dearborn, 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 and 



abnormal 



Erotic: Sexually stimulating. 

Erogenous zones: Sexually stimulating areas of the human body, such as, 
the mouth, lips, tongue, breasts, nipples, buttocks, genitals and anus. 

Auto-eroticism: Self induced sexual pleasure, masturbation is a gross 
pie in both males and females, while a mild example is intentional dressing 
i,f ^*+;«rr ;oo«o mini rv^rv Qhrtrfv skirts and tinv sexv underwear. 



Oral eroticism: Mouth sexual pleasures, a good example is kissing both 
light and deep kissing. 

Anal eroticism: It 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. It 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 followed by 
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. 

Impotency: It is an example of male sexual dysfunction, a variety of male 
sexual inadequacy. It is divided into primary and secondary types, it was believed 
in the past that about 85% of cases are psychogenic while the rest are considered 
organic. A good example of organic causes are the neuropathies of diabetes 
amounting to 59% and some endocrinal syndromes. Recent research estimated 
organic causes to be nearly equal to psychogenic causes. Impotency 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 a result, especially when repeated failures are recorded with 
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: It is a condition of involuntary spasm or constriction of the 
musculature surrounding the vaginal outlet and the outer third of the vagina. This 
psychophysiologic syndrome may affect women at any age and may vary 
considerably in severity. The most dramatic instances of vaginismus often present 
as unconsummated 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 (dyspareunia). 

Karezza or coitus reservatus: A certain religious group of the past 
actively encouraged men to practice coitus without ejaculation. This kind of 
coitus was supposed to last for several hours, aiming at furthering a couple's 
spiritual growth!... 

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. Its occurrence is rare and it should be well differentiated 
from the healthy normal multiorgasmic capacity of many normal females. 

Satyriasis: Unsatisfied sexual appetite in the male, unsatiated, it should be 
differentiated from hypersexuality. As a matter of fact nymphomania and 
satyriasis are extremely rare and abnormal states of hypersexuality. 

Tongue kissing: Inserting the tongue into the mouth of the sexual partner 

for the purpose of increasing sexual excitement, sometimes referred to as deep 
kissing. 

Bitting kiss: The act of bitting and kissing the flesh of a person during 
increased sexual excitement, an exaggeration of this condition is bitting the breast 
nipples during sexual excitement. 

Orgenitalism: Various forms of mouth and genital contact aiming at 

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 cunnilingus. 

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 Lewmisky is a proof of the spread of this perversion in the world due 

to its prevalence in abnormal sex films. 

Cunnilingus: The act of licking, tonguing, sucking or mouthing the 
external female genital organs namely the vulva, clitoris and labia. 

Anilingus: A sexual deviation wherein the person male or female derives 
sexual excitement and satisfaction by licking the anal area of another person. 

Fetishism.- In this condition, sexual arousal occurs principally in response 
to an object or body part that is not primarily sexual in nature. The fetish object is 
generally used during masturbation or incorporated into sexual activity with 

another person in order to produce sexual excitation. Often the fetishist collects 

such objects; in some cases, the behavior involves stealing the objects which 
appears to contribute an added sense of risk and mystery. In 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 be 
admired by most American males, no wonder, they are mocked and described for 

fun as immature sexually being bosom attracted!. 

Transvestitism (Fetishistic cross dressing): It 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 
transsexualism. 

Transsexualism: The word comes from transsexual (from Latin trans: 
across and sexualis: sexual). It is a disturbance of gender identity, in which 
persons are convinced that their gender identity is different from their physical 

identity. In 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 modern 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: It 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 



While a hole or a cavity may be symbolic of the vagina or the female sex organs. 

Electra complex: A strong neurotic attachment or fixation of a daughter 

for her father, it is termed after "Electra" a legendary Greek princess who after 
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 of the same sex. It 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 19 th 
century. It denotes the feeling of sexual pleasure when being humiliated or 
experiencing physical or mental pain. 

Sadism: After the French writer De Sade in the 18 th century; it is acquiring 
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 to 
sexual assault or even murder. 

Sadomasochistic: 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 suiTer" (masochistic), as a means of attornment i.e. sexually pleased, the 
end result being sexually satisfied. 

Bondage: It 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: It is excessive self-love, tendency to self-worship, excessive 
or erotic interest in one'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 revealed 
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 engage 
sexually with dogs performing various sexual activities including actual coitus. 
This perversion is also termed Zoophilia. 

Homosexuality: It 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 be used to describe 
187 



someone who is erotically attracted to partners of both sexes. 

Sexual apathy: It is the dislike sexually of one of the opposite sex i.e. 
loves his or her own sex. 

Lesbianism: 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 Sapphism. 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 and the 
adjacent area brings about 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 victimizing, 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. 

Pedophilia: 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: It is the use of animals as a preferred sexual object or when it is 
the only exclusive method of producing sexual excitement... 

Biological sex: It is defined as a person's maleness or femaleness. It 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 individuals 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: It is defined as a person's masculinity or femininity. It 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 decree 

188 



in which they conform to their gender roles. Most individuals clearly conform to 
the gender role appropriate to their biological sex. However, a minority partially 
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: It is defined as a person's heterosexual ity or 
homosexuality. It is determined on the basis of preference for the sexual partners. 
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 (heterosexual ity). 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 term "sixty nine" or French spoken "soixante-neuf" is used 



rm 



each other's sex organs. In 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: It 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). 

Gerontophilia: 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 or she 
derives sexual satisfaction mainly from setting fires (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. 



rm 



derives sexual satisfaction mainly from playing with own or partner's feaces. 

Exhibitionism: It is the deliberate exposure of sex organs under 
inappropriate conditions with the intention of evoking a response in the observer. 



ormer 



exhibitionism, it is not invariably present even if desired; further, although 



189 



exhibitionism has been generally regarded as a paraphilia exclusive to males, 
there are isolated reports of female genital exhibitionism. If 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 coincidcntally with exposing himself- in a significant percentage of 
cases, the exhibitionist may be impotent or have other sexual problems in 
heterosexual relations. In 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 pattern of behavior leading up to his 
genital exposure (for example, returning to the same street corner or using his 
automobile, ostensibly to permit a quick getaway)!. 

Lingam: It 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. In some instances, the phobic nature of the 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. 

Inhibited sexual desire: It 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 16 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 of two 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 some couples a workable solution is reached bv 

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 porne; 
prostitute and grapheln: to write). Often called obscene material; .t could be a 
'ex show, movies, records, pictures, books and magazines. Pornograph.c 



entertainment 



and even intentionally obscene stage shows date back to Greek and Roman 
antiquity. About 250 years ago, European aristocrats attended such <*»—»» «v 
shows in their own private theaters. 



abnormal 



term 



r nanism, i"^ t^i*i* F"«r ,j — * A1 , v •* u Q 

erection that is usually independent of sexual arousal. Although it may be 
impossible to determine the etiology of priapism, the most common causes 
include sickle cell anemia, polycythemia and leukemia. In these cases, altered 
microvascular blood flow dynamics occur as a result of sludging of blood; the 
resulting venous stasis blocks normal mechanisms of penile detumescence 
Priapism may also result from venous obstruction due to malignancy, from spina 
cord injuries, from penile trauma resulting in hematoma formation and from loca 
reflex stimuli such as those associated with phimosis, urethral polyps, urethral 
calculi or prostatitis. In some instances, priapism may be drug-induced, 
thioridazine, heparin, testosterone, and hydralazine have been reported to cause 
this disorder. It may happen as well due to an over dose during therapeut.c 
treatment either orally or by intracavernosal injections for impotency. 

Priapism is an emergencv. since venous drainage to the corpora cavernosa 
must be restored and damage to erectile tissue must be minimized, if the disorder 
is not brought under control, ischemic changes may occur in penile tissue. 
Treatment range from the application of ice packs and sedation to the use of a 
variety of surgical shunt approaches. Therapeutic defibrination by the use of 
proteolytic enrymes given intravenously has also been reported to be successful. 
Anesthetic blocks, corporal aspiration of trapped blood, and use of low- 
molecular-weight dextran have also been advocated. However, there is no single 
approach that will alleviate the priapism, while guaranteeing successful 
restoration of the erectile mechanism. 



Treatment of the Paraphilias 

The literature describing treatment approaches to the paraphilias is rather 
fragmentary Most reports discuss results obtained in a small number of cases, 

have no formal control group or fail to provide specific criteria for evaluating the 

outcome Onlv brief mention will be made of the range of therapeutic techniques 
that have been utilized, since this area appears to be under current reappraisal. 

Aversion therapy is a type of treatment used to produce a reduction in an 

undesired behavior via' a conditioned emotional response, by suppression of a 
punished response or by the development of an avoidance response. Aversion 
therapy methods have included the use of electric shock and chemical induction 
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. 

In Norway 



firmed 



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. In addition, combined 
approaches utilizing pharmacologic therapy (in particular, with the use ot 
antiandrogens such as cyproterone acetate or medroxyprogesterone acetate) and 
psychotherapy cr 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 tuture 
development of a greater understanding of these behavioral patterns. 



192 



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