Wednesday, February 3, 2010

Sexual Disorders

I've treated hundreds of sexual disorders and been asked thousands of times about sexual matters. Sex is as much a part of the human condition as family, community, religion and politics. And equally it is full of secrets. There is usually a shyness that comes with the questions. People are afraid to expose themselves, their ignorance, their fantasies or their past to someone else. Sex has been a thing terribly judged by others. And we now know that those who were the worst judges of sexuality were the most deviant from normal themselves.

The richest, most powerful and those with the most leisure have always had the opportunity for the greatest deviation and yet for some reason those very same groups and individuals have enslaved the rest with decrees and codes and taboos. State and religious control of sexuality is nothing new.

Sex is powerful. It's through sex naturally that the group grows. Historically the size of the group defined the power and wealth of the group. The more members the greater the army, the more hands, the less work.

But sex has always been two fold, pleasure and procreation. Indeed studies of chimpanzees and primitive cultures strongly indicate that pleasure came first. Long before there was an association between the sexual act and raising children there was the pleasure and pain of sex.

As people have asked me about their own peculiarities, tastes and eccentricities over the years I've grown less interested in the details or even the deviation. There is little new under the sun. In all of medicine there is too much, too little, or something out of place and maybe even out of balance. Sex is little different from other dis-eases. There are the physical symptons. Then there are the psychological ones. Ultimately social and spiritual factors come to play.

Children play with themselves and are told not to do it in public. And like urinating and defecating the sexual behavior is made private. This alone is not cause for shame but the process of this education so commonly leads to so much pain. The 'shy bladder' is well known, people whose education around urination was so affected that later they can not pee in company. Nudity frightens as many people. And whatever way a person is, they would have others believe that is the 'normal' way so that groups collect and congratulate themselves on 'their' peculiarities and eccentricities. Over the years there have been so many 'normals' that there is no 'real' normal but what is 'convention'.

Yet how a person 'masturbates' and 'what he or she thinks about' can be a wealth of work for therapy as people associate various fantasies with their own pleasure and later 'ask' if they even dare to share, if they are alone in this. To date I have never heard anything unique though in my early years of work I certainly heard a lot of what I found new and unusual. Clinical experience is a great leveler. And because one is only consulted on the unusual eventually the conventional itself seems strange. In marriage therapy I began to question if a happy marriage existed but then I only saw the unhappy ones at work and in public could doubt the honesty of those who said they were happy.

Not so with physical medicine because there I saw the healthy and the unhealthy. Thanks to Anna Freud I came to appreciate 'lines of development' and recognize that those who were advanced in one area naturally would show deficit in another. The strong man who devotes himself to the body beautiful is usually less well read that the intellectual.

Poor people sexually are either too tired to invest much energy in sexuality devoting their lives to existence or alternatively enjoying the pleasures of sexuality for compared to the truly illicit pleasures of wealth and power, sexual pleasure is free.

Body dysmorphia is a common concern. People wonder about the 'look' of their organs. One day I realized I'd examined literally hundreds or more penis and vagina and frankly seen clinically there wasn't all that much deviation. Many men have been concerned that their penis is too small but only one or two have caught my attention as such like a drawf in a crowd of Swedes. Most are rather usual and the man who had the greatest concern about his 'size' surprised me by having the largest family. In a way he 'made' up for his problem. Women increasingly expressed concern about the appearance of their labia and had real anxieties after child bearing.

Plastic surgery has solutions yet in all my years of practice it was noses and breasts and the public accoutrements of sex that called for the most referrals to my colleagues in the business of remodeling. The future is an unknown matter given the extraordinary advances in plastics and size and shape will one day be no different a matter than teeth are for dentists, with all the modern braces, implants and correctives in dentistry. The young and adolescent will increasingly be given plastic surgery options unheard of today.

The matter of 'function' is then a wholly different problem. Individually the most sexual dysfunctions occur. Lack of sexual interest or too much sexual interest and commonly these come together to give rise to a social conflict where neither is 'right' or 'wrong' but clearly they can not cohabit the same space. Individually I have seen so many who have complained of too little or too much interest or as commonly a partner who they compare with themselves, thinking themselves somehow normal, as abnormal in the matter of the desire.

That said, performance is it's own area of concern. And the matters of performance aren't usually Olympian in their concern but tremendously mundane, more akin to the inability to walk. It won't stay up or it hurts because I'm dry.

Physiology is a part of so much of these matters as is psychology and eventually sociology. Sexual dysfunction quite commonly is an early sign of disease. Tragically because of the terrors of politics these days doctors are afraid to ask about sexuality yet so many diseases present first and I mean 'first', with problems of sexuality. Sex is one of natures greatest thermometers.

Over the years questions about sexuality have lead me to diagnose diabetes, anemia, heart disease, pituitary disorders, thyroid conditions, skin disorders, sexual diseases, systemic infections, local and systemic cancers and a wide range of psychiatric disorders. Early diagnosis has lead to early treatment with the question about sexuality and function leading to countless life saving resolutions.

Once the individual issues are addressed the social and psychological domains come alive with sexuality so commonly being the critical area where the function of a couple, family or community can be most readily understood. A couple with a 'happy' or 'satisfied' sexual life are most commonly like the 'engines' that have a 'happy' sound. It denotes that things are 'running smoothly'. Again sex is a sensitive instrument. At the couple level the 'comfort' of the sexual life is one of the best markers regarding so many of the other decision making in the family, from satisfaction regarding distribution of finances, decisions of role and how child rearing is managed. The sex of a couple and the 'role play' of the common experience is an amazing microcosm for the macrocosm of the individuals and their sharing. The conflicts in the bedroom mirror the conflicts of the living room.

Sexual deviance or exploration is as much a question of what is being sought elsewhere as what is being left behind. The origins of any oddities, while sometimes derive from recent history, as often as not find origin in deep or distant past. The understanding of these in turn can lead to understanding of many other disparate aspects of social and work life.

Milton Erickson, the leading American psychiatrist was famous for his expression regarding 'change'. To paraphrase him, he would say, once a change was recognized as necessary it was like realizing the pot on the stove was boiling. Obviously it now had to come off. Too many people thought the handle was on the pot when he said, the truth was the handle was an extension of the hand that was set to removing it.

Sexually a minute change in relationship or behavior can like any change impact dramatically on all other aspects of the life.

Ultimately there are the 'sexual addictions and compulsions" which exact a toll not dissimiliar to the crack addict. Of course there are far too many who would outlaw even the drinking of near beer and justify it on the basis of the alcoholism in society, their own 'sins of omission' and 'judgementalisms' serving too well the psychopaths and sociopath predators who would gladly have the police wholly involved in handing out tickets for jay walking. Sadly the extension of concern and the reduction of resources is the aim of those who themselves in secret gain power to conceal their own shames and guilts.

At the other end of the spectrum where medicine is most assured, the sexual addictions and compulsions require treatment as much for the individual as the group. The control helps more than hinders when sensitivity is applied. And here 'change' brings 'freedom' and frankly 'grace' because the addictions are such 'slavery' in themselves.

'Creativity' is not 'deviance' though neither is conventional. One step ahead of the crowd, you are a leader, two steps ahead of the crowd you are a martyr.

The Hippocratic oath, demands that the doctor, "do no harm". It's an amazing oath for those who begin in surgery and end up in the realm of social medicine. So many of those others in the realm of the 'social' have not taken such an oath and it's not surprising that in matters of sexuality people are afraid to talk to another about their private worlds. They are indeed wise to be discrete and yet I am thankful over the years that I have been able to help so many because of the bond of trust that I and my colleagues have been able to establish in this world.

I do hope that this will continue. I won't quickly forget my Indian colleague in Bombay talking to a woman on the other side of a screen asking her and her husband to describe what they were seeing because this man and woman came from a place where no one, not even doctors, could be trusted.

As often today the doctor is afraid to ask a patient about sex. In the darkness death and disease flourish.

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