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Sexual Health

Sex is central to our well-being (mostly) and can be ranked right up there with money, a job and family in its importance. So not getting it right is going to really interfere with ones wellbeing. Hence this opinion piece on treating sexual dysfunction. Sexual dysfunction (SD) for this article will not include organic or structural causes of Erectile Dysfunction (ED).

SD in patients without an organic cause it is not a disease, it’s a symptom of a disease. Treating SD with drugs alone is a lot like chaining an addict to the wall and saying he no longer takes drugs. He is still an addict as we have no treated the underlying issue. It does not cure the patient. Medication may fix the sex bit temporarily but will create the potential for major relationship issues down the line. The key to fixing this is information.

In a very clichéd saying we learn in medical school, history is all important.

Patients openness and communication is key as often when we ask and listen, we will uncover a linked psychological cause which is causing some form of mental distress.  These issues often lead to feelings of guilt, anxiety, fear, shame, depression or a combination of such which will lower sexual desire and lust. Feeling down does not turn someone on!

The combination of these negative feelings with the resultant loss of sexual desire usually ends badly with either erectile dysfunction or vaginismus. I have chosen to explore this topic with a few common scenarios seen in my practice.

In writing this opinion piece I have consciously chosen to ignore political correctness, as sexuality has nothing to do with it, please keep this in mind.

In my practice, the following scenario is depressingly extremely common where I have a young couple who are perfectly healthy and appear to be in a good relationship. They come to me as they wish to have kids. All test and examinations usually look normal. Often when I ask about their sex life, the common scenario is that they have not been having sex at all, often from day one.

They will tell me that even with extensive foreplay, the husband can’t maintain an erection sufficient for sex, often even PDE5 (Viagra etc.) won’t work or work partially at best. Normally, what we would do is cheat and prescribe enough hormone shots with PDE5 that the sex will happen due to an increased arousal, where the guy will have sex with someone (may not be the wife), but once it wears off the underlying problem will re-exert itself.

Or we can just have conception without sex. If they are unlucky at this point they meet a good gynecologist who uses IVF to get them a kid, at which point they will go on to be good parents and terrible lovers. And we throw a baby into an already stressful situation.

What I often find is the husband has a good morning erection, can masturbate but can’t have sex with the wife. The issue is, he does not think of the wife in a sexual manner. Often, it’s because the change in role from girl friends to wife, may bring out aspects of the female personality that is more maternal and dominating, aspects that are not know to stimulate desire for many.

For the husband the wife has become someone very like a mother or a boss, but not someone who is sexually desirable. In short, he has lost his “Manliness or Mojo” as a guy in the home.

He loses interest in the wife sexually. Hence the common complaints from wife’s that its they who have to imitate sex, a situation likely to exacerbate the dominating situation even more. What we have here is often the loving girlfriend who objected to nothing becoming the wife who nags the husband to pick up his clothes and wash the kitchen.

Often the wife will tell me that they have no choice as someone has to be the grownup. However, this leads to a lot of males at this point feeling harassed, dominated or just plain annoyed. In short the feeling that they are no longer in control. None of these feelings will cause arousal.

The Pope has said, if you look at a woman licentiously, including your wife, it is a sin. As well as a miracle.” Over time the wife has been moved into the compartment of the male brain which contains all the female family members, friends and colleagues who he has no interest in having sex with but with whom he interacts with daily. So what we now have are roommates. (I am writing the situation as described, there is no judgment rendered on anyone). These men often have no problem having sex outside with other women as they get treated like kings, giving them a sense of control over their lives and making the women highly desirable.

The other option is seeing a psychologist for counseling, both of them coming to terms with the issue, i.e. identifying the cause and decide if they want to fix it which will probably be a happier long-term outcome for both. Not addressing the underlying causes of the wife’s changed behavior from girlfriend to wife and its effects on the husband will just cause relationship stress which will just blow up in the future.

If they can adjust their behavior, they may rekindle the sexual aspect of their relationship. At this point medication given to help speed up the process a bit would be a fair option, as the couple understands that it’s short term and just a boost, not a fix.

A quick divorce or a proper adjustment of lifestyle would be better. A messy divorce or a long-term acrimonious relationship in the long term is worse. Estelle Getty of the golden girls put it well, “Women marry men thinking they’re going to change them, and they never do,” she said. “Men marry women hoping they will never change, but they invariably do”.

Then there are couples who are aroused but issues from the past get in between. Medication looks really tempting at this point, as they know they have issues and are working it out, so adding medication sounds tempting. There are pitfalls to this.

An example is, I had a patient who had severe vaginismus every time she tried sex and it really demoralized her. She loved her boyfriend and really wanted it to work, however if they could not have sex the wedding was off. She had tried everything including lignocaine gel, sedatives and vaginal dilators. She was even contemplating Botox injections to paralyze the vaginal muscles. Extensive detailed history did not show me any underlying issues.

I needed help (as was truly stuck) and discussed her case with her psychiatrist, with her permission. She was already on treatment for depression. The psychiatrist did not know of her sexual issues, as she did not mention it, thinking it was not related. With the added information he found a link to an encounter with a colleague that while not sexual or physically violent, did leave a huge mental scar which was enough to cause a mix of depression, anxiety and fear.

Her body actively rejected any physical contact with men.

With this understanding of the issues, we got control of her depression through extensive counseling. She was also prescribed anxiolytics in the initial phase with relaxants. But within a very short space of time she weaned herself off those aids and was able to have a healthy sex life.

A follow-up with her almost a year later was informative, after identifying that the problem arose from a past issue that had no significance to her current partner, she was able to relax enough to have sex eventually with no medication.

Also, her identifying the underlying anxiety and depression brought about by her hidden suspicions of males in general, solved the depression issues as well. Her improved sex life also gave her a confidence boost and improved outlook. This would not have been the outcome if I had just injected Botox into the vaginal muscles or if she had just continued with anti-depressants.

It would almost have been like a form of forced sexual intercourse (rape?) to use Botox in this case, that would have added to her mental trauma and created further issues down the line.

Now this last case is about us the doctors preconceptions and biases and the patients. We, i.e. a psychologist colleague of mine and myself counseled a young couple that were very supportive of each other.

The problem was one of them had a fetish which was making that person feel an immense amount of guilt about how abnormal and perverted they were. Discussing the fetish with my colleague, who then brought in the other partner. To the partner it was not a big deal. The partner was open to trying it. It took a bit of effort but and it resulted in several partially successful attempts at sexual intercourse. At this point I intervened to add medication to increase the confidence of the couple in having sex successfully.

The point of this last case is actually not the patient but our views and how it may block our efforts to treat patients.

Most of us have some form of fetishes to get it on; it’s just that they are socially acceptable so we feel no guilt. For example, a female colleague is only aroused by a hairy male partner, very common, so no guilt, or my male colleague will only have an erection at the sight of a 46DD bosom, again we would accept this as normal and feel no guilt, so sex is not a big deal.

The list goes on for some every day fetishes, a large rear end, high heels, tight jeans, big biceps, huge lips, oral sex to get started etc., these things society accepts as there is no guilt attached to this and sex is not an issue both partners.

60 years oral sex was taboo, and probably caused some guilty feelings which may have caused sexual dysfunction. Oral sex is still against the law. Imagine the feelings of guilt one would have if to have sex one must have oral sex first!

Which brings me back to my earlier point, to help a patient we have to put prejudice aside, discuss their history including issues and fetishes and help them get over the guilt and get them on with having sex, on the assumption their partner is willing.

Medication as first line or the only line will not work. Giving a person meds to increase his libido will increase his desire for sex but he will still need to resolve his issues and have his fetishes or he will not have an erection.

A crude example would be using medications to increase the sex drive of a gay male, he is still not going to have sex with a woman no matter how much medication I use or how aroused he is. Some people will say let fix the fetishes rather than fix the guilt associated with it, a valid point. However, from a therapy point of view, it’s extremely difficult to fix a fetish, getting over feelings of guilt is a lot easier.

From a moral point of view, my personal view is that what two consenting adults do in the privacy of their own room is not for me to judge. As long as they are of legal age and are okay with it, that’s fine. Key words for this view are “consenting”, “Adult” and “in private”. To successfully treat patients we can’t impose our prejudices on them. If you can’t put aside your moral objections, a referral to a colleague would be the way forward.

A discussion on this point is outside the scope of this article. But it is important in this group of patients that we keep an open mind. On a side note, the article mentioned below puts forward the discussion on conscientious objection in medicine for those who wish to read further. Conscientious objection in medicine by Julian Savulescu, under ethics which was published in the BMJ.2006 Feb 4; 332(7536): 294–297.

Sexual dysfunction is common, and all we are now seeing is the tip of the iceberg. There are a lot of people we can help if they know that they have a problem and we have the means to get them better.

Thank you to my hardworking colleagues in the field of mental health who showed me what I was missing.



This article is published at Berita MMA December 2018 Issue (Page 22- 24). 

Kindly click on below link to view the original article.

Berita MMA December 2018 (web)-Pg 22-24.pdf

Sunday, 24 March 2019 by Dr. Muhilan Parameswaran (Consultant Urologist)

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