I know this because I ask my patients if their physicians have done various examinations when the patient has presented with various complaints. Invariably the answer is no. The physicians send them for costly less accurate blood work and xrays and ultrasound but forego a simple palpation.
Further it takes time for patients to disrobe so that busy physicians in the business of ‘fee for service' "walk in clinic" medicine cut corners by taking the least time possible for each patient all the while smiling and being ‘caring’ in a politically correct way. Make the ‘customer’ comfortable.Avoid complaints at all costs. Do the least for the most financial return. Good business model government and corporate model health care.
Women especially complain that physicians no longer are willing to do pelvic examinations or pap tests and many tell me it’s been years since they had examinations appropriate for their age and complaints.
Now the same is increasingly true in psychiatry with respect to sexual history.
At first I just thought my colleagues, male and female, were not recording these histories for confidentiality reasons, to protect the patients. Yet, when I asked the patients about other psychiatrists histories I was shocked that no one had ever asked them.
Consequently patients told me, and told me sadly and tragically for the first time.
2) I’ve never had sex. I’ve been depressed for years and seen several psychologists and psychiatrists and no one has asked me about that.
3) I masturbate all the time, many many times a day. No one ever asked me about that.
4) I’ve never masturbated.
5) I can only have an orgasm when I fantasize about sex with children.
6) I have rape fantasies when I masturbate.
7) I fantasize about orgies when I masturbate.
8) l feel really badly after I masturbate.
9) I have sex with animals.
And the list goes on and on. In the standard psychiatric ‘history’ there is a simple heading. It’s called “sexual history”. Everyone is supposed to have this taken. I actually did these cursory questions in general practice. “How are things sexually?” “Is your sex life okay”. “Are you having any problems sexually?”
Increasingly my depressed female patients are disclosing that their doctors just give them pills for their depression but never talk to them and don’t ask any questions. Then they go on and tell me through sobs and tears about their abortions.
Others tell me about their years as escorts. Others tell me about their sexual abuse. Men seem equally upset but it's usually about their partners refusal to have sex or their sexual abuse. Real men aren't sexual abused just normal men.
In my introductory survey questions I ask if they have ever been sexually abused as a child and then what age was their first sexual intercourse. With men and women , so many patients with drug and alcohol histories were sexually abused. So were the patients with depression especially bipolar and almost all the patients with borderline personality disorders and some of the antisocial personality disorders.
What has always been fascinating is that men over and over deny sexual abuse but then go on to tell me of an older male or female usually late teens or 20’s or older having sex with them when they were just pubescent or prebescent. Boys are sexually abused with a rather high frequency by women and men but they are not asked, and they are commonly ashamd to tell, don’t know they were sexually abused and often are further shamed by the caregivers if the matter is ever discovered.
When I began asking about sexual frequency in the 70’s it was common for the number of sexual partners to be 1-3 with 10 or more unusual among my patients. Now among young people, it’s not uncommon for women patients to have 50 or more sexual partners and further to break down crying as they attest to unprotected sex when I ask them about any ‘risk taking behaviour’.
All the while the sexual perversion of the Sexual McCarthyism of the medieval administration was occurring, the internet was exploding with misinformation about sex, pornography was spreading like wild fire, and countless societies had sprung up including the various dungeon groups, swingers clubs, S&M parties, and various on line dating services for whatever preferences one might entertain.
Meanwhile I have muddled on pedantically asking questions always in terror that the authorities would again swoop down upon me and threaten my license and livelihood for taking a sexual history. So many people, especially radical feminists and their male equivalents radical religionists , get ‘offended’ by questions about sexuality not because of the questions but simply because ’the lady protestest too much.’ After hearing that a person is offended by being asked even a cursory sexual history, I’m not stupid, I avoid the subject like the plague, only to have learned countless times as I continue to see the person, that the woman works as an escort or has some major ’sexual secret’ and that the very religious man has indeed had homosexual affiliations that bother him considerably.
The reason it behooves me to ask these questions is that I’m a consultant and commonly my patients have seen several physicians, psychologists, counsellors and psychiatrists before they see me. The principal complaint in my office is that the ‘medications are no longer working’.
It normally follows that the ‘depression’ that some rich and shallow knee jerk prescription pad physician or psychiatrist has treated them for years or the stupid hand holding gushing counsellor has sympathized with, is directly a consequence of an undiscussed never touched on underlying issue, like grief, post traumatic stress disorder, drug and alcohol abuse, sexual perversion or compulsion etc. CBT is a marvellous therapy that also works well if one wants to avoid discussing the elephant in the living room. Pills, further, are like band aids in these cases and eventually the ‘pus will out’ as we learned in my days as a general practitioner.
Specifically I ask about masturbation. Not everyone. It arises when an otherwise smart, attractive,educated, intelligent male or female remains single and is unable to find a mate. It also arrises in questions for people in recovery because sexual cross addiction is so prevalent especially in those who have had cocaine addictions. Having subspecialized in trauma and addiction I am also seeing a lot of people who are in recovery from one addiction and I ask specifically about sexuality because sex addiction is a common problem and sexual trauma is also a common problem for those who have had any addiction. It almost goes without saying that if a woman has been a black out drunk or commonly 'legless' or 'blotto' that she has been sexually abused while in this state, especially the young and pretty. It's also true for young and especially attractive men who suffer addiction. The young and attractive are particularly vulnerable in this area but anyone can be a victim.
Asking about masturbation may or may not occur in a whole discussion that follows as one addresses issues of sexuality. Many rape patients have disclosed that they can only orgasm in masturbation replaying sexual abuse or rape fantasies. This has to be worked through in therapy and a positive outcome is a later history of orgasm within a less traumatic context. It also comes up when patients are describing sexual difficulties and relationship conflicts they have with their partners. One wants something the other doesn't and sometimes they don't even know what each is asking because of the ignorance surrounding language and difficulties that still exist in the area of sexuality despite our putting men and women in space stations and sending rockets to Mars. Society will always be limited by the slowest, and too often these people aggregate from fear in positions of control in administrations , courts and high office. Cross culturally many men and women aren't even 'allowed' to discuss sex and in their countries discussion of sexual matters has resulted in them being imprisoned and sometimes tortured.
When I trained psychanalytically in Freudian and Jungian psychotherapy I was trained to focus on ‘sexual fantasies’ and ‘sexual dreams’. Fantasies and dreams were considered a royal road to the unconscious. Patients conflicts were conceptualized as unresolved conflicts and the richness of material which flowed from the interviews was rife. So many of my patients sexual abuse followed from exploring themes that arose in these discourses. So many patients who had suffered anorgasmia, social phobia, and sexual promiscuity responded to the insight therapy. Others addressed faced their homosexual fears and even others had marriages that were restored.
In marriage therapy discussion of sexual issues was central as the three principal areas around which marriages conflicts arise are sex, money and family. At one time I my success with marriage therapy was as high as Goffman’s research statistics but my own marriage broke down so I left my work with marriage and turned to the area of trauma.
Patrick Carne’s book Out of the Shadows is one of the classics of sexual psychiatry, right up there with Judith’s Herman’s Trauma and Recovery. It was Patrick Carne’s that first clued me into an interesting aspect of masturbation that I’d never thought to question. This is specifically how one felt ‘after masturbation’. I had naturally thought that people felt good. What Carnes noted was that some people felt ‘badly’ not physiologically but psychologically, either within hours after or the next day. Indeed I learned that many of my patients had guilt and shame attached to masturbation only by asking ‘how one felt’.
This was an important area for both men and women.
As to the frequency, there isn’t any very good literature on how much one should or shouldn’t masturbate. Clearly when men tell me they ‘masturbate more now that they’re married’ than before when they were single there is a serious concern. At University of British Columbia, there’s a specific Sexual Medicine department and I’ve referred couples there because of this disclosure. Marriages that would have otherwise failed have been revived because the specific sexual disorders have been addressed as a couple by the specialists who thankfully have also been experienced and empathic.
In the asylum I’ve had to bandage men’s hands to stop them from harming themselves from compulsive masturbation. I’ve also had to use anti testosterone drugs in these contexts so there really is an upper limit. Despite libertarian fantasies, there really can be too much of a good thing. ‘too much masturbation’ is not good. Seeing a penis that is raw and bleeding will hopefully even change the mind of the most aggressive sexual libertarians.
That said I don’t know if ‘no masturbation’ is good. Religous there has been all manner of rot around the subject, specifically the perverted misinterpretation of the ‘Sin of Onan’ in which the real sin was the “sin of levy” , ‘failure to have sex with the dead brother’s wife to keep all the land to oneself.”
With the proliferation of pornography and the ability to call up sexual parners like pizza through apps like Grinder, I’ve increasingly encountered people whose ‘depression’ appears directly linked to the sexual compulsion. It’s not different from the depresions that I saw which were not responding to a pharmacy of medication because no one asked the patient about their drinking 26 of whiskey daily or the daily 2 bottle of wine habit (alcohol a depressant counteracting any antidepressants). The same seems to hold for masturbatory and sexual compusion.
Female patients have admitted to masturbating many times a day but to date I’ve not been able to note the same apparently ‘physiologically based’ depressive 'quality that men have presented who are doing this. I suspect I’ve been biased by the belief that men are ‘loosing’ some sort of ‘essence’ because their bodies have to produce this fluidd whereas women don’t produce an equivalent compound but have spoken to 'feeling badly' or 'being depressed' about masturbation. Often one has to address religious taboos and more and more the issue of 'body shame' is becoming apparent with both women and men.
I’m interested in the question of ‘frequency “ of masturabation for men and women. If we say ‘masturbation’ is not ‘unhealthy’, then what ‘frequency is ‘unhealthy’ or even 'normal’. Because of political correctness sexual research is more often confined to the dark anecdotal realm of the internet than academia. Asking the question at what point is a bodily function a contributing factor to depression or not is of interest especially as recent research confirms that psychopharmacological treatment of depression has been shown as less successful than psychotherapy and psychopharmacology. We all knew this but the prescription pad pushers with the support of the authorities made a fortune avoiding talking to patients.The authorities meanwhile have all but outlawed talking with patients about anything relevant to psychiatry.
Life style turns out to underline much of medical illness and now if we take complete rather than 'politically correct' histories we can learn once again that life style underlies much of psychiatric illness.
( I just watched Vacation with Chevy Chase, and the new Griswold family and almost died laughing over the sketch and confusion and hilarity around the term 'rim job' so in a way that contributed my sharing here because there's such a gross disconnect between the world of patients, especially the young and the world of administration, regulation, clinical medicine and psychiatry. Rim job appears as a comedy sketch on one of the best family rated shows but a doctor could lose his license if he asked about this today despite increasing awareness of the untold morality and mortality that are a direct and indirect consequene of political correctness and the thankfully declining reign of era of terror some term Sexual McCarthyism. Perhaps now we can learn medically more about masturbation considering that it does go hand in hand with pornography, which today is more often called more fashionably 'erotica'. )