Double your Pleasure:the Health Benefits of the Magical Mystical Orgasm

Double your Pleasure: the Health Benefits of the Magical Mystical Orgasm

Once a topic strictly relegated to hushed conversations, research has taken the orgasm from bedroom to clinic, elucidating the many positive benefits of these happy endings. Great news, right? But before I get into that, I want to talk about the definition and history of the orgasm. What you don’t know might surprise you. 

Because it’s hilarious, my favorite clinical description of orgasm is ‘a temporary state of neuromuscular euphoria and paroxysmal climax, often accompanied by vocalization, and generally with the ejaculation of semen in the male and vaginal contractions in the female.’ 

If you’ve ever wondered, the sensation of an orgasm is basically the same for men and women. This is because the penis and clitoris are homologous organs, meaning they arise from the same tissue in a developing embryo. Whichever part you have is connected to the spinal cord, and hence the brain, through a pair of nerves called the pudendal nerves. It’s a horrible name for the same nerves in males and females, so it makes perfect sense that we have the same perfect sensations of pleasure.

From fascination to repulsion and everything in between, orgasm has been the subject of speculation and debate since the Big Bang. Aristotle actually wrote about orgasm and female ejaculation in the first-century BC… and you thought he was just into philosophy! By the way, that’s not a typo: women can ejaculate, though research estimates that only 10% to 50% of women do; actually a small number considering that the woman must reach orgasm in the first place in order to ejaculate. The moral of that story? Don’t let the pornos fool you- it’s a pretty rare event whose presence or absence says nothing of a male’s or female’s sexual prowess. 

In ancient times in Western Europe, women could be medically diagnosed with a disorder called “female hysteria,” during which they exhibited symptoms of nervousness, insomnia, irritability, loss of appetite for food/ sex, and “a tendency to cause trouble.” (this elicited a what-ever! and an eye roll from my wife Debbie) Women diagnosed with the condition would sometimes undergo the proscribed treatment of “pelvic massage” by a medical professional until they experienced “hysterical paroxysm,” which immediately, but not permanently, “cured” them. Captain Obvious says that this diagnosis is no longer recognized as a medical condition. In the early 1900’s, the first electric vibrators hit the market- a decade before vacuum cleaners and electric clothes irons! Evidently, women had gotten their priorities straight. And the rest, as they say, is history. 

Thankfully, we’ve clearly come a long way in narrowing the orgasm perception gap. But questions persist: how long does it last, does a woman need one to get pregnant, can all women have them, can men/ women have multiples, what’s the G-spot, where’s the G-spot, do women fake it and how to tell??? Time for answers.

I’ll just get the less pleasant news out of the way first. 10% to 15% of all women are anorgasmic, meaning they cannot orgasm… at all. It can be global, meaning there is no means by which she can orgasm, or it can be situational, meaning she can only orgasm under certain circumstances. In some cases, age and circumstance are factors in the ability to orgasm for both women and men. (Un)Fun fact: Marilyn Monroe was actually anorgasmic until the age of 36, when she reported to her psychiatrist that she had finally had her first orgasm. A sadly ironic circumstance for America’s biggest sex symbol was that her first orgasm, and possibly last, had been just months before her death. In men, anorgasmia typically manifests in an inability to ejaculate, called anejaculation, and usually occurs as part of erectile dysfunction, which can be organic or a side effect of medication.

Fast facts from peer-reviewed studies:

-75% of women never reach orgasm from intercourse alone. 

-75% of men and 29% of women always reach orgasm with their partner. 

-Women are far more likely to orgasm alone than with a partner. Ouch.

Are orgasms like potato chips? Experts say that if women can have one, they can have more than one. In fact, studies have shown that most women are not only capable of multiples, but they are actually capable of two different types of multiples: sequential and serial multiples. Sequential multiples are a series of orgasms that come fairly close together. Usually from 2 to 10 minutes apart, sequential orgasms have a drop-off in arousal in between; they’re like a roller coaster, with a dip after the first hill before a climb back up the next. According to studies, women report that the most common scenario for sequential multiples is an oral sex orgasm followed by another orgasm during intercourse. In contrast, serial multiples are orgasms that come one after another and are separated by just seconds; with no interruption in arousal, serial orgasms are more like a set of waves breaking on a beach. It’s a different story for men, who have what’s called a refractory period. This is the time needed for a break- and sometimes a nap- between orgasms, but given the right amount of time, male multiples aren’t entirely unusual.

The average length of a man’s orgasm is approximately 10 seconds, though it is possible for them to last up to 30 seconds. A woman’s orgasm may last slightly longer or much longer than a man’s, with an average length of 20 seconds, but possibly up to 30 seconds or more. There is a very rare and misunderstood disorder called Persistent Genital Arousal Disorder (PGAD) found in women. PGAD is spontaneous, persistent, unwanted, and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and which is typically not relieved by orgasm. Women with this disorder report feeling constantly and uncomfortably on the brink of orgasm for weeks or months at a time. If you’re thinking that would be cool, you’re wrong; for the sufferer, it is a very debilitating and embarrassing disorder with no cure and little potential for future therapeutic intervention. There is concern that the word ‘arousal’ in the title may be misleading, because it connotes pleasure, and having PGAD is the polar opposite of pleasure. Though vastly more common in women, PGAD is considered an analogous version of priapism, and is called such; this is when men have persistent and often painful erections for various reasons, the most well known being a side effect of the ‘little purple pill’ Viagra.

According to a published study, straight women only have orgasms 62% of the time they have sex, while lesbians orgasm 75% of the time they have sex. I guess there’s something to be said about being familiar with the tools you’re working with.  

G-whiz! There’s much ado about the female G-spot, and most people don’t even have a clue what the G in G-spot stands for. The Gräfenberg Spot was named for German gynecologist Ernst Gräfenberg, who unknowingly started a furor when he characterized an erogenous area of the vagina that, when stimulated, can lead to strong sexual arousal, powerful orgasms, and potential female ejaculation. While some people think the G-spot is as real as a unicorn, most say that every woman has one, but that it’s not necessarily the magical button of fable and lore. So for reals, what is it? The G-spot is a quarter-sized area in the vagina that swells with blood when women are aroused, and some “experts” say it is directly connected to the ‘orgasm center’ in the brain. For the record, I call bullshit on this ‘orgasm center’ stuff- it sounds like it comes from a Cosmo article. Being board certified in psychiatry and neurology, I know a few things about the brain, and there isn’t an ‘orgasm center.’ In reality, orgasms are not localized, discrete events. Researchers have used PET-scans and functional-MRI’s to show that up to 30 major brain systems are activated during orgasm, so it’s more like a wave that washes over the brain in a global manner. There is an analogous male G-spot called the P-spot, where P stands for prostate. This organ is located internally, between the base of the penis and the rectum, and produces pleasant sensations on stimulation.  

Though an orgasm isn’t strictly necessary to feel pleasure, most people will admit that reaching the big “O” with a partner or ‘Han Solo’ is a great added bonus. But beyond just feeling great, an orgasm also brings with it a host of unexpected health benefits, from lowering stress levels and heart attack risk to giving skin a fabulous natural glow. Read on to learn all the good stuff that comes from the fun stuff.

Several hormones are released during orgasm in both males and females, including oxytocin and DHEA. Studies suggest that these hormones could have protective qualities against cancers and heart disease. Oxytocin and other endorphins released during male and female orgasm have also been found to work as relaxants, in both a physical sense and psychological sense, as a mood elevator. Oxytocin is the bonding and cuddling chemical, aka the ‘tend and befriend’ chemical, and makes both sexes feel a desire to be closer to their partner during and after sex. Women actually release four times the normal amount of oxytocin on orgasm. In fact, evidence shows that the bonding and cuddling mechanism is so reliable and predictable that if a woman doesn’t feel cuddly after sex, it is strongly suggestive that she faked her orgasm. Whoa, people.

Orgasms can help lower the risk of prostate cancer in older men. Ward off prostate cancer by having sex? True story! A decade-long and well-reviewed study demonstrated that regular and frequent ejaculation (defined as at least four times per week) in men over age 50 can lower the risk for prostate cancer by up to 30%. One of the authors of the study said, “We know that having sex and orgasms is beneficial for every aspect of male health. The male reproductive system fares best with regular use, and the prostate belongs to that system. The more ejaculations, the better off he’ll be.” Hey, no argument here. 

Orgasms can help regulate the female menstrual cycle, even during times when women are not actively on their periods. According to a published and peer-reviewed scientific journal, the mechanism is linked to the apparent circadian rhythm of ovaries and their response to inflammation. Regular orgasms in females lower inflammation, improving immune health, mental health, and circadian health, which fosters regular cycles.

Orgasms can also help boost female fertility.

Regular sexual activity triggers physiological changes in the body that increase a woman’s chances of getting pregnant, even outside the window of ovulation, meaning that orgasms bring benefits at any and all points in the fertility cycle.

An associated concept is that female orgasm appears to improve the odds of conception. Now, I’ve been surprised and frightened by the prevailing ignorance on this topic, so let me be clear here: a female orgasm is not required for a woman to get pregnant; all that is required is the male’s sperm (part of the ejaculate) to meet the female’s egg(s), which is/ are released automatically and independently each month during ovulation. The basic premise of orgasm improving the odds of conception centers on the vaginal and cervical contractions during orgasm. It is believed that the ligaments involved in the muscular pulsations and contractions from the female orgasm cause the cervix to dip down and pull in any semen pooled in the vagina. That brings in more sperm, and more sperm means it’s more likely for one or more of those wiley guys to win the race to any unsuspecting egg that may be hanging out up there. This is all borne out by findings in women who have had intercourse with orgasm having more sperm in their cervical mucus than women who have had intercourse without orgasm. The moral of this story is that orgasmic pulsations are some next-level shit, and those baby-making parts have minds of their own, grabbing around in the dark to continue the genetic line. Science, people! 

Orgasms as the next homeopathic treatment for colds and flu? Consider going to the bedroom instead of the drugstore. Orgasms are killer for your immune system, no pun intended. A small German study found that immediately after sexual arousal and masturbation to climax, men showed increased levels of leukocytes, which are the white blood cells that help protect the body from illness and infectious disease. But the ladies haven’t been left out here. Another study demonstrated a correlation between female sexual activity, and therefore female orgasm, and levels of Helper T cells, which help to activate the cells the body needs to fight off foreign invaders that cause disease and illness. In addition, orgasm in both males and females releases those feel-good hormones called endorphins, and these are known to reduce general inflammation, the arch enemy of the immune system and other biological pathways. Reduction of inflammation, wherever it may be, does a body good. 

In both men and women, orgasm is shown to help alleviate pain and increase one’s threshold for pain. This is also due to the release of those feel-good endorphins and their ability to reduce inflammation. Studies have shown a direct link between sexual activity and migraines, with 60% of participants reporting some improvement of their migraine attack, and 70% reporting moderate to complete relief. It is believed that orgasm impacts perceived pain through the down-regulation of pain sensitization pathways and by modulating the immune system to reduce levels of inflammation, thus reducing pain levels. Orgasm as an anti-inflammatory once again… O-lieve?

Evidently, orgasm is also useful for relieving the pain of menstrual cramps. In addition to the reduction of inflammation for general pain relief, the pleasurable muscular pulsations and contractions of the female orgasm also use up specific lipid compounds called prostaglandins, which are the cause of menstrual cramps. Lower concentrations of free prostaglandins translates to less cramping-type muscle pain, which is a very good thing.   

Orgasms can help keep your brain sharp. The flood of hormones released in both male and female orgasm sends a ton of messages throughout the body, increasing brain activity. This is particularly true in women. An imaging study of brain function and orgasm showed that while masturbating and upon orgasm, women’s brains light up with activity in the cortical, subcortical, and brainstem regions. The researchers stated that these benefits are more powerful than doing challenging crossword puzzles. Hmmm… Sunday New York Times puzzle, roll in the hay; New York Times, roll in the hay… Frustration, satiation… Duh- this one’s what you call a no-brainer. At least, that’s the technical term.

Orgasm reduces levels of stress and anxiety in males and females. Though an orgasm initially releases a flood of stress hormones, studies have shown that the end-game effect is stress reduction. Experts have long agreed that the post-coital payoff in terms of anxiety reduction is also major, as during an orgasm, the parts of the brain that process fear shut down. All of this is thanks to our friend oxytocin, the bonding, snuggling, tend and befriend chemical.  

What makes for a happy heart can also make for a healthy heart. Since any sort of physical activity helps your heart pump more efficiently, it’s no surprise that sex can too. But published studies indicate that regular sexual activity seriously benefits heart health, helping to lower cardiovascular risk in older men and women. More specifically, they demonstrated that frequent sex and orgasms reduced instances of cardiovascular disease, hypertension, and rapid heart rate among those over age 65, especially in comparison to those that don’t have frequent sex and orgasms. This study didn’t define “frequent,” so take away from that what you will. Or what you can get away with.

Orgasm as the mystical fountain of youth? That radiant flushed look is post-coital glow; it’s for reals, and all thanks to the increased blood flow from your orgasm. The skin is the body’s largest organ, and also the biggest tell. If you’re under stress, it shows by way of a sallow, stressed out complexion. But when men and women climax, blood vessels throughout the body open up, allowing them to carry greater quantities of blood, which is the source of the flushed and blushed look. The increased blood flow also helps to stimulate the production of collagen, a protein that keeps skin looking plumped and youthful, which is why orgasms may be the quickest- and cheapest- way to gorgeous skin. Some British shrink did a survey of 3,500 people, including both men and women, and determined that regular orgasms were the second most common factor/ cause for people looking younger, the first being regular exercise. Nobody called me, so I don’t know who appointed this guy the chief judge of orgasm and youngness, but it is what it is. 

Orgasms can help boost your self-esteem and well-being. When your desires are being satiated, it makes sense that you would feel better about yourself, but it turns out that there’s a proven and demonstrable link between sexual health and self-esteem. So say researchers at Johns Hopkins (well…la tee da) as they found that sexual pleasure among young adults (ages 18-26, both male and female) is linked to healthy psychological and social development. They specifically looked at measures of self-esteem, autonomy, and empathy, and found that sexual pleasure increased all three of these measures in both males and females. However, they also found that the level of increase was not uniform: measures of self-esteem increased the most in young women particularly, while young men showed higher levels of empathy. The explanatory hypotheses for these findings are similar: that the effect of a female’s orgasm on self-esteem is circular, so the ability to easily achieve orgasm increases a woman’s self-esteem, which, in turn, better facilitates her achieving orgasm, which again feeds her self-esteem, and so on. In an analogous way, empathetic males are more responsive to their partner’s needs, and this initiates a positive feedback cycle: being more responsive to their partner’s needs increases the male partner’s ability to reach orgasm, which feeds the male’s empathetic nature and makes them more responsive to their partner’s needs, and so on… Now, I can’t say that I’m calling bullshit on this, but it seems to me that this is back-asswards: while I totally buy that orgasm in both men and women would lead to increases in all three measures, I would think that levels of self-esteem would be more increased in men, resulting from a sort of evolutionary caveman pride ‘look what I can do’ kind of thing. And I would think that greater empathy levels would be higher in women, because of the super intensive release of oxytocin that results in the huggy cuddly ‘oh how I love this person’ feelings. Then again, maybe it’s that women have a higher increase in self-esteem because their orgasm assures them that they are sexually attractive, and men have a higher increase in empathy because their partner has had a simultaneous orgasm? I’m not sure, and you probably don’t care, so we’ll just step away from this one for now.

Orgasms can help you live longer, so say some experts. Additionally, the health benefits of orgasm increase with age, and extend throughout a person’s life. Some Brits studied men between the ages of 45 and 59, and found that those with “high orgasmic frequency” lowered their mortality risk by as much as 50%. The men that had two or more orgasms a week died at a rate that was half the rate of the men who had orgasms less than once a month; in other (less confusing) words, the men that had fewer than one orgasm per month died twice as fast as the men that had eight or more orgasms per month. Like wow, people! These findings prove that sexual activity and orgasm have a protective effect on men’s health. As for the ladies: over the course of an eight-decade study on married, heterosexual couples, researchers found a demonstrable link between orgasms, health, and longevity: specifically, results indicated that women who orgasmed frequently lived longer than their female counterparts who didn’t, though they did not disclose a longevity estimation or definitive ratio of the number of orgasms required to attain greater longevity. 

Orgasms aren’t exactly a miraculous method for weight loss, but getting there might be a different story. Sex is an aerobic activity; it gets your heart rate up, and there’s no better way to burn calories than when your heart is pumping. Beats a treadmill, stairclimber, or pilates any day of the week. Researchers have attempted to measure the number of calories burned during sex for many years and on numerous occasions, but the results have varied wildly. Accepted averages indicate that most people burn about 150 to 200 calories each time they have sex, but there are some really fun ways to set that number on fi’ya… a heated make-out session can burn as many as 85 calories per hour in a 150-pound person, while 15 minutes of heavy foreplay will burn about 25 calories. So, figure you make-out for 15 minutes, then another 15 minutes of foreplay, followed by intercourse, will burn about 250 calories- that’s the same number burned in a 30-minute run, but it’s way more fun than a run. If that’s not enough burn for you, add in a sensual and arousing massage at a burn rate of 80 calories per hour. Or, employ the magic of multiples: reaching a second orgasm can burn an additional 60 to 100 calories, depending on the amount of work required to get there; and since it’s a bonus score, why stop after just one? The ultimate formula for burning more calories during sex is fairly simple: just pour on more heat and more passion for a longer period of time. 

You have probably always known that orgasms are awesome, but now you know the why and how of everything orgasmic, and are all set to impress and amaze your friends with your dazzling sexual intellect at the next cocktail party.

And even though I wrote this blog on the benefits of orgasm, I don’t want to contribute to society’s historical relationship with sex and orgasm: typically seen as goal-based, a skill to be practiced and reward to be achieved, rather than something to explore, experience and enjoy. So go forth, explore, experience, enjoy, orgasm, and spread the word, people! 

But first, google ‘Dr. Mark Agresti YouTube’ to check out my videos, leave comments, like, and subscribe to my YouTube channel. As always, you can find tons of content and patient stories in my book, Tales from the Couch, available in office or on Amazon. Thanks people.

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steroids:Seductive Today,Sinister Tomorrow

Steroids: Seductive Today, Sinister Tomorrow

An Appointment and Cautionary Tale

I got a new patient who came into my office- we’ll call him Rocky- and he said to me, “Ya know, I’m here because I’ve been having trouble with rage.” And then he just looks at me expectantly. After eleven words, he’s waiting for me to open my desk drawer and take out my magic wand. Bing! You’re cured! He’s clearly never been to a shrink. We talk here. 

In all honesty, I didn’t even need a magic wand at that point, because between those eleven words and my eyes, I had already diagnosed him. I should’ve waved my pen at him like a wand and said “Stop using steroids. You’re cured.” Instead, I said, “Let’s explore this a bit.”  

He says “I’m worried, I might be bipolar….” How did I just know he was going to say that? It is so typical. At 32 years of age, Rocky’s a big boy, unnaturally bulky, looks like he’s been lifting a lot of weights. Compared to his trunk, his head looks like somebody washed it in hot water. His face is oily, pock-marked with acne and scars. I’m noting all these things, jotting them down on my pad, jot jot, as he goes on. “…and I like to go to the gym to blow off some steam…” Rages jot. Acne jot. Oily skin jot jot. Bacne jot. Receding hairline jot jot. “…and lately everybody just pisses me off and I can’t…” Angry jot jot.“…I mean, I can bench a lot. So the other day, I was with my buddy and I finally figured it out; I realized that he’s jealous; that’s his problem with me…” Paranoia jot jot. “…and I know I’m his competition. I undercut him all the time. He would love to see me fail and close up shop, but…” Ah ha. Psychotic? jot jot. All of this is very typical with steroid use and abuse. “…so anyway, I can push harder, lift more, ya know? I work at it! The steroids help, but the work is all me.” Bingo! Finally! Now we’re getting somewhere. 

So tell me about that…the steroids. Who’s prescribing? “Oh no, I am buying it at the gym.” Well, how much are you using? “I’m doing 200mg every two days.” Injecting testosterone cypionate, 200mg Q 2 days jot jot jot jot jot. Buys at gym jot jot. And how long have you been using them? “Uhh, maybe about three years?” Times 3+ years jot jot jot. Do you think maybe you have a problem? “Oh, no. No.” Denies problem jot jot. I explain that he’s at a max dose for someone who has virtually no gonad function. Confusion jot. I explain that means someone who produces no natural testosterone. I spell it out. You’re taking the max dose that a person with no gonad function, zero testosterone would take, and that’s on top of your normal testosterone levels. Or I should say your natural testosterone levels. So you would be way above normal- ten times normal levels or more. And you’re wondering why you’ve been having these rages? Losing control? Loses control jot jot. Banging on s÷=%t at home jot jot jot. Screaming at wife jot jot. Have you ever hit her? “No. I haven’t hit her. But I’ve wanted to hit something. My fists are clenched and I want to tear something apart with my bare hands.” Denies hitting wife jot jot. Clenched fists jot jot jot. Believes he’s bipolar jot jot. I tell him that he’s not bipolar. Steroids are the problem here. He says, “No, it’s not. Can’t be.” No. It’s the steroids, I’m sure. Rocky says, “Ya know, I’ve been reading, and I’m saying it’s probably bipolar.” He’s just holding on to the bipolar excuse. Addicted jot jot. I mean, he would rather be bipolar- actually fight to be bipolar- than admit that his precious steroids are the sole root of his many issues. Denial jot. Steroids don’t cause a typical high, it’s more of an exhilarating positive feeling, an energized, almost super power feeling. For dudes like Rocky, with his temperment, he is all about that musclebound feeling of power. 

Have you noticed your hairline is receding. “Oh. You can tell?” Umm, yeah, I can tell- it’s like three inches back from where it should be- that’s why I mentioned it. That’s what steroids do. “Really?” Really. Bipolar doesn’t do that. Have you noticed your oily skin and acne on your back? “Yeah, I have.” Yeah. Bipolar doesn’t do that either. Guess what does. You get really argumentative and pissy. Some people actually become psychotic. “Oh, I’m not psychotic, man.” Really?  But, you know, in our conversation, you said you’re always worried about people at the gym being jealous and giving you side eye and you said people are trying to destroy your business. You know, maybe you’re getting a little paranoid. “Oh, I am not paranoid.” Uh huh, yeah. I tried to explain. When you’re getting paranoid, you don’t know you’re getting paranoid. He saw all these deep meanings and he was making these deep connections, why people would be tracking him and why government agencies would be interested in monitoring his business. Rocky is in the nursing home business. He’s not even actually running a nursing home, he just provides services to nursing homes. It’s not like he’s involved with any government agencies. He’s contracted to bring in ancillary services to nursing homes. It’s a fairly big business and he’s been pretty successful financially, but there was no root in reality for the paranoia he was demonstrating. 

I asked him if he noticed anything else, like maybe breast enlargement? “Ahh, maybe a little bit, but no big deal.” Mmm hmm. + breast development jot jot jot. He says, “You know, my muscles got bigger, I got leaner, and my endurance increased. I felt trimmer, more energetic.”   You said your endurance went up, how much cardio do you do, Rocky? He says, “Well, I used to do more, but man, I’ve gotten so much bigger that it’s hard to breathe when I do heavy cardio, you know?” No, I don’t know, because I don’t abuse steroids. Androgenic erythrocytosis jot jot jot. That means that you have increased the number of red blood cells in your blood, so your blood becomes thick and viscous like oil. You have so many red blood cells, it’s tough for your heart to beat, it’s tough for your lungs to get oxygen, because there’s drag from the increased viscosity, so when you do cardio, you can’t breathe. “Yeah, yeah. I can barely run. I used to do triathlons. I can’t do them anymore, but I can lift way more weight.” Yeah, because not only are the steroids making your blood thick like oil with RBCs, the thick blood makes the left heart ventricle- the one that does most of the pumping of the blood- thick. It’s a muscle, so the thick viscous blood overworks it as it tries to pump that thick gross blood through, so it makes that left ventricle wall thick, really thick. So instead of having a thin elastic pump that pumps blood in and out easily, you get this thick, wide left ventricle wall that cannot pump effectively. It enlarges the left ventricle wall, so you can’t pump good oxygen rich blood through. It’s called hypertrophy. With all those factors going on, it’ll cause hypertension. “Oh, yeah, I take medicine for that.” Like no, big deal. Aah, I just take medicine for the damage that I’m causing myself. Duh! + hypertension jot jot jot. + medication jot jot. And did you tell the doctor that prescribes that med that you’re using steroids? “No.” Nice. Prescribing Dr. unaware of illicit steroid use jot jot jot jot jot. Do you know that hypertension leads to kidney disease? “Really? My kidneys work good I think.” I’m thinking ‘maybe for now’ to myself. You think you look good on the outside, although you’re balding, your skin is oily, you have pitted acne scars on your face and acne on your back and you’re growing boobs like a teenage girl and your testicles are microscopic and you have low to no sperm and your penis doesn’t work… and you can’t breathe with any amount of exertion because your blood is thick and gross so your heart is all enlarged and your blood pressure is so high you have to take medication like a man more than twice your age. And you’re causing all of it! Through your steroid addiction. And as if the physical side isn’t bad enough, now it’s affecting you mentally. You’re paranoid, on the verge of psychosis…really you’ve got a toe or two over that line if you want the truth. So no matter how big your muscles are, no matter how good you think you look (and my raised eyebrows were clearly saying that was debatable) you are destroying your body. “Um, like what? How?” Now he’s really listening. I continued. Do you understand what hypertension actually is and does? Cause and effect? How about atherosclerotic plaques. What are those? What do they mean? The arteries in your heart become lined with plaques that are basically made of fat. These fat plaques are sticky, so as your thick gross blood slogs through the arteries, the fat plaques gather and narrow the arteries, so you cannot push blood through the arteries. Eventually, they clog off. It’s like a tunnel being filled with more and more muck, so there’s not enough room for blood to flow through and you get a heart attack and die. But before that happens, you’re incapacitated with high blood pressure because your thick oversized left ventricle is trying to push your thick gross blood through arteries that are filled with fatty muck, athersclerotic plaque filled arteries. “I didn’t know all that.” I’m sure you don’t, but I’m not done educating you yet. It gets better. Well, actually worse. 

Education jot. Steroids decrease HDL, which is the good cholesterol that helps keep your arteries open. And it also raises the LDL, which is the bad cholesterol that causes the fatty plaque to build up. So lowers the good while raising the bad. Got that? “Yep. Got it.” So that causes hypertension, and makes you prone to heart attacks and strokes. Did you know that hypertension also makes your kidneys malfunction? I didn’t think so. Right now, your kidneys are trying to pump under hypertension, and that kills them. The gross viscous blood thick with red blood cells kills them. So your kidneys shut down. Do you like to be able to take a piss? To be able to clean your thick slaggy blood of all the toxins you make? He nodded that yes, he rather liked to be able to take a piss and clear his thick slaggy blood of all the toxins he makes. I thought so. Enjoy it while it lasts. Before long, a machine will do that for you: four hour sessions, three times a week…if you’re lucky enough to live that long. If the massive heart attack doesn’t kill you first. Honestly, Rocky looked like he was about to have a heart attack right now. I know I’m hitting him pretty hard with all of this at once, but this guy was in a romantic relationship with his precious steroids, and I need him to break it off, clean and quick like. But wait, there’s more!

Now, with all this bad stuff going on, the little vessels throughout your body do not pump blood as well because they are clogged and they are hypertensive. So all those tissues, joints, and bones are starved of nutrients and oxygen. You get something called avascular necrosis. Avascular means without vasculature- blood vessels- and necrosis means death. It’s everywhere, but especially in the hips, with the ball and socket joint. The little vessels that feed the balls of your hip joints, where the femur meets your hip? Hello, the blood supply gets occluded- it gets starved- and then it gets dead. So you can recognize all the steroid abusers out there: they’re the 40 year olds using wheelchairs and walkers, whining about the pain in their hips. Balding, acne, boobs, erectile dysfunction, heart problems, kidney issues, disability, chronic pain. On and on. Oh yeah, it’s pretty bad, but it gets worse. His face fell. I couldn’t let up now. You enjoy being able to lift weights? You enjoy being physically capable? Like a zombie, he mumbled on a sigh “Yes…” I’m glad you do. But don’t get too used to it. Because if you keep this crap up, keep injecting that garbage, you’ll build your muscles up beyond what your body can handle. You’ll build them up- your muscles will get bigger- but your ligaments and tendons can’t be built up, and they can’t support these unnaturally large muscles. Do you know what muscles without ligaments and tendons do? Not much. Without healthy ligaments and tendons, big muscles are useless for anything but causing pain, debilitating pain. When you’re pumping iron, lifting really heavy weights, your ligaments and tendons get damaged. In no time, the muscle size supercedes the ability of the damaged ligaments and tendons, so you get irreversible chronic muscle pain. Sounds great, right Rocky? Oh, wait, and to top it all off, now you’re having psychological effects. You’re having rages. You want to tear something apart with your bare hands. You said that. What’s scary is that right now, at this moment, you have the physical ability to do that. If somebody pushed you too far on a bad day, you might go there. You could kill someone. I’ve seen it happen to a patient. A guy a lot like you. He came in here young and dumb and I explained everything to him, just like I’ve done with you. For several years, I begged him to stop. He refused to listen; didn’t believe me. Ultimate in denial. He’s in prison now for the next 30 years; that equals a life sentence for him. It’s scary. What’s even scarier is that if you keep this crap up, keep sticking yourself with that needle, you won’t be able to tear somebody apart for long. You might want to, but you’ll be too debilitated. That guy in prison? He’s in a wheelchair now 90% of the time. He uses a walker sometimes- when he can stand the pain- which isn’t often. 

I’ll make this very plain. You are addicted to steroids. They are physically wrecking your body, the body you seem to worship. Oily skin, acne, bacne, boobs, receding hairline, balding, teeny tiny testicles, a penis that you can’t get up…and no sperm to come out of it anyway. And that’s just the stuff on the outside that people can see! Your insides get wrecked too. Thick slaggy gross blood, hypertension, atherosclerosis, heart attack, stroke, kidney dysfunction, erectile dysfunction, avascular necrosis, chronic pain. And now you’re raging, scaring the crap out of your wife, you’re paranoid, becoming psychotic. You have nothing positive happening in your life. So it’s your call, Rocky. I can help get you off the train here before it runs your ass over. He was nodding very slowly, but clearly shell-shocked. Look, how about this. Don’t use for two weeks and see me again. You’ll have some time to digest all of this. Can you do it? If you can’t- if you feel like you’re gonna hit that needle- I’ll see you sooner. Here’s my cell number. Call me anytime, but especially if and when you’re tempted to use. Deal? “Deal.” We shook on it.  

Dx: steroid addiction, assoc features jot jot jot jot

Pt agrees to d/c use jot jot jot

F/up 2 weeks, will call/ see sooner prn jot jot jot jot jot

Here’s the bottom line on steroids people. Your body just does not like these drugs in excess. There may be some use for them in people with anemia, in people who have wound healing problems, a temporary use in people with HIV or cancer who do not want to eat, and in muscle wasting diseases for short periods of time and in very regulated doses, okay…fine.  

But, for my Olympic athlete patients, my professional athlete patients: you all know who you are. All of my Rocky’s out there: cut it out! You’re sterile, can’t get it up, scared everyone’s gonna see your breasts, hello, they are! I know you’re saying ‘but I cycle them on and off, doc!’ I say bullshit. No, it causes permanent damage to heart, kidneys, tendons, and ligaments. Not to mention the cosmetic aspects: the oily skin, the acne on your face and back, the balding, receding hairline… and you say ‘oh, but to minimize the breasts I use an estradiol’ (an anti-estrogen, because testosterone breaks down to estrogen, so if you use an anti-estrogen in someone who is abusing testosterone or testosterone-like drugs, you will not get the breast enlargement) Yes, that’s true. I’ll give you that. But, you still get all that other crap, guys! Hellllo!! All my elite athletes, you all whine like ‘No, no, no, I need it to stay competitive, because everybody else is doping!’ Whatever! You are addicted to the high, the performance, and the cosmetic enhancement. You get big muscles, tiny balls, and tinier brains. You also get limp and sterile, permanent damage to the ventricles, the heart, and the kidneys, hypertension, and its host of other problems. You are predisposing yourself to coronary disease, heart attack, and stroke. You become delusional, and you fly into rages when the wind blows.  

As you are my patients, I’ve probably told you about other patient stories. For those that haven’t heard them: one steroid abuser was very paranoid and psychotic, but of course didn’t know it, because you will not see yourself becoming psychotic. He was stopped at red light. I don’t know what he was doing, but when the light changed green, he didn’t go right away. So the car behind him honked. He started ticking like a time bomb, and the car kept honking, but for whatever reason, he still didn’t go. Instead, with the light still green, he got out of his car. With a golf club. He went off, banging on the guy’s car with the golf club, and he just didn’t stop. Eventually, they called the police.  The police came and they had to subdue him with a tazer because he was out of control. When he was transported to the emergency room, he continued there, even continuing to spit and scream, even after being put in four-point restraints. Finally, he had to be pharmacologically restrained with a freaking rhino dart. Unbelievable. I mean, he was all black and blue, like he had been beaten, but he did it by thrashing, all by himself. His whole affect was totally inappropriate. I know that some people are beaten by police for no reason; they don’t deserve it, but this maniac was taking every opportunity to hit the police officers for absolutely no reason. In the hospital, he was arguing with nurses, disturbing the entire emergency department for no reason. His wife finally came in, but even she couldn’t calm him. He just lost it, in every sense. He was (or had been) on the road to being Mr. Olympia or some such title. He was 190 pounds, and bench pressing over 450 pounds. It was just crazy. Eventually, but not long after, he went into kidney failure. But it wasn’t from the steroids. Yeah, right. Denial!! jot jot

You know, it also causes immune suppression, so you don’t fight off pathogens like viruses, like COVID-19, like any bacteria. I had someone who had a heart attack and died. He was 25. Another stroked out in his late 30’s. These patients are Olympians, professional athletes, and really elite level people. They’re so hyper-disciplined about their diets and their training and supplements and sleep patterns and all of that. But they’re abusing steroids. It’s a crazy dichotomy. Some have made it. Big success stories that stopped and then did it the right way. But many don’t. Right now I have a 45-year-old man who is just going into kidney failure. And the one with psychosis that killed the guy that set him off. He’ll die in prison. Now I have Rocky. I hope I opened his eyes. 

Remember, people… just because you cannot see what’s going on doesn’t mean the steroids aren’t destroying you. They are. But you can get there without them. And PS, for those that are wondering, there is a steroid withdrawal: headaches, drowsiness, decreased appetite, weight loss, fatigue, depression, dizziness. It’s a mess when I get them off, especially when they do high dose. It takes two to four weeks, and they are miserable, cranky, irritable, and obnoxious people to deal with when they are in withdrawal. I use benzodiazepines, things to help them sleep; I sometimes add anti-psychotics because they can’t see themselves drifting to the psychotic lane, sometimes hearing voices and seeing things. It’s a spectrum. And lots of misreading events in reality… “Those people are talking about me. They’re plotting against me. Those police officers are here to get me, or that group of people talking over there are planning something against me or these workers are not working because they are all in a grand plot against me. They are very faint signs and forms of psychosis. Hearing voices and seeing things, disorganized speech and behavior is the extreme. But there can be the unextreme, the misreading, the over-emotional abnormal response to normal events, thinking people are plotting.  

Probably from age 10 to 30 is when most people started and abused the steroids. And too often, it’s a one way trip, once they start, they get lost in it. You know, “I am superman now” and they don’t stop, and then they stroll into my office and then I deal with them when they are 45 to 50 and that’s when their kidneys shut down, when they get a heart attack, when they are debilitated with degenerative disk disease from lifting too heavy weights, their ligaments and tendons go, they become sterile, they cannot have kids, they’re in constant horrible chronic pain. They have heart problems and kidney problems, and that’s what gets them. If they have heart and kidney failure, to the point where the organs have just given up, that’s what kills them.

Hopefully not Rocky jot jot jot

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The Truth About Gender Dysphoria

The Truth About Gender Dysphoria

Gender dysphoria is basically a mismatch between a biological sexual assignment, i.e. the gender one is born into, and what gender they feel they are psychologically and desire to be physically. Until several years ago, it was termed “gender identity disorder,” but, for three reasons, I never liked that nomenclature: first, it was/ is not a disorder, second, the term ‘disorder’ was further stigmatizing to a group of people who frankly were already dealing with such huge stigma by simply existing, and third, the term ‘dysphoria’ is a more accurate term, for reasons I’ll explain shortly. So, good riddance to bad rubbish. 

And speaking of rubbish, we’ve all heard people say how this “phenomena” is a “trend” and how “these young people think it’s cool to say they are something they’re not.” Can I just say, I’ve found that anything following “these young people…” is bound to be crap 99% of the time, and this is just another perfect example. A lot of people also say that “it’s a phase” and that kids will “grow out of it.” To be clear, GD is not acne or puberty or a shoe size. It is not a phase, not a growing pain, not a cool trend, and most certainly not a choice. But what it is, is a very confusing, very painful, very disturbing state of being, especially when first realized and explored. In my experience, the later in life that the realization happens, the greater the pain, ramifications, and complications that will manifest in the person’s life. 

First awareness of gender dysphoria historically begins around the age of four, but can be even earlier. In some people, it might be more into early adolescence, and in a very small percentage, even into young adulthood, though I believe those are likely cases of severe repression and/ or denial. Regardless of the age, it is always very psychologically distressing to the person with GD and their parent(s)/ family, but for very different reasons that are age dependent: if a five-year-old has enough awareness to tell their parents about it, his/ her parents will react very differently than parents of a nineteen-year-old. It’s potentially the difference between the six-year-old maybe being ignored or hopefully going to a physician for discussion, and the nineteen-year-old possibly getting thrown out of the house. And of course the potential parental and/ or family reactions to the news vary widely across a huge spectrum, regardless of the age of awareness or realization; and those reactions can either encourage the process or forbid it, or anything in between. 

Some people find it very difficult to believe (read: don’t) that a child of four could ever have the awareness of GD, or of being in the ‘wrong’ body, but they absolutely can. Let’s be clear, a four-year-old girl doesn’t look in the mirror and think “Gee, I hate this dress; I’d rather wear jeans. Hmmm, I must have gender dysphoria. I’ll tell the parental units, riiiight after I finish my chicken nuggets.” It doesn’t happen that way. GD is also not about little girls refusing tea parties in favor of tonka trucks or little boys preferring their sister’s tutus to GI Joes. If only it were actually that simple and easy to diagnose! In reality, gender dysphoria can be a confusing conglomerate of signs that can be very misleading. Depending on the age and psychological state of the child with GD, it may be less confusing and more acceptable to them, because younger well-adjusted kids typically have greater acceptance of things they feel but haven’t seen or had exposure to…nobody has tainted them, inoculated them with cynicism, self-doubt, or guile; in short, they’re innocent. If they’re of an age that Santa and the Tooth Fairy are real, how much of a stretch is it to honestly feel they belong in a different body? I know all the questions from listening to the parental/ familial perspective for years. They always wonder if their child is lying. The truth is that children under age ten to twelve-ish likely don’t even know about the existence of GD, much less enough to lie about it. And if they’re asking about older children, adolescents, or even young adults lying, I always wonder (and ask) why on earth anyone would want this, or intentionally insert themselves into this situation? Who would relish this scary, confusing, and troublesome state of being? The answer is no one. Parents exploring GD want to know when “it” happened, like it’s the big bang. They wonder aloud when a girl child is more Tom than just tomboy, what are the signs, and how do they recognize and read those signs? The problem is that they’re usually looking for proof in a situation that is inherently difficult to prove without a crystal ball and related accoutrements. I generally tell them to not try to read any signs; that it’s much better to simply listen when a child speaks. Invariably, it comes down to this: “But how does my child know they’re not the gender they were born, or that they’re in the wrong body? How does my daughter know she’s not a female/ my son know he’s not a male?” I always answer that question with a question: “How do you know you are a female/ are a male?” The answer is that you just know. It’s an inherent thing. Children more readily accept it because they don’t have all of the hang-ups that come as standard equipment with adulthood. But please don’t misunderstand, when I say that children more readily “accept” it, I don’t mean that little Johnny realizes he doesn’t belong in the body he was born in and then he skips off in bliss. Not at all. With gender dysphoria, there is plenty of angst to go around, and every person in the family gets a heaping helping. It is difficult on the person with GD because they were born, named, and recognized as one sex, but have always known they were supposed to be the other sex. It is difficult on the parents and on the family system, because someone who was born, named, and recognized as one sex, (seemingly) suddenly wants to be the other sex. And all of them must choose to adapt to it or fight it, neither of which are easy roads to hoe. And what seems to the parents and family to be a snap decision on the gender dysphoric person’s part is actually anything but; this knowledge came only after long and serious consideration and great internal debate, relative to, but regardless of, their age at the time. In any case, it’s an inherently difficult situation to adapt to for everyone, and that’s one of the main reasons why gender confirmation (aka gender reassignment) is a multiple years-long process, not an overnight thing. Incidentally, the preference was changed from gender ‘reassignment’ to gender ‘confirmation’ by leaders in the field because they (and people with GD) say it isn’t reassigning another sex to the person, it is actually and truly confirming the sex the person was meant to have been in the first place. But both terms are still used interchangeably for the most part.

The Harris Institute says 0.3-0.4% of the US population, approximately 1.3 million people, are affected by gender dysphoria. That’s a pretty significant number; certainly high enough to deserve better care than what’s primarily available. There are a couple centers of excellence with a few big-shot surgeons that handle confirmation surgeries currently in the US, but there really should be several more in strategic parts of the country. I treat about three to four patients with gender dysphoria a year, so figure approximately 100 total throughout my career. To put that into perspective, I’ve treated about 20,000 depressed/ bipolar patients and 8,000 to 10,000 schizophrenia patients. It doesn’t come very close comparatively, but it’s enough to say that I’ve definitely seen an increase in the last ten years or so. And as attitudes change and acceptance becomes more widespread, I expect that trend to continue. It may sound strange to say, but I hope those numbers do continue to go up, because the alternative is frightening…it means that more people with GD are suffering silently, being marginalized, either severely in denial or repressed, hopeless and suicidal, mutilating, and ultimately, opting for suicide rather than confronting the issue headlong. And that is simply unacceptable if we are to call ourselves an enlightened society in this day and age.  

As hard as it is on the parents and family, the most difficult path is that of the individual with gender dysphoria. This goes back to my earlier reference of dysphoria being a more accurate term than identity disorder. The reason why is because of the presence of dysphoria in relation to one’s gender. Dysphoria is defined as a state of unease or a generalized feeling of dissatisfaction with life; in gender dysphoria, this state of unease and dissatisfaction is caused by one’s gender, of being born in and living in a body of the wrong gender. 

Let’s take my patient Thomas, who preferred to be called Tommy. Born male, Tommy was thirteen, and had started puberty several months before his parents brought him to my office. They said they were concerned because he “had stopped eating recently for no reason.” That piqued my interest, because I had a thirteen-year-old son once upon a time, and he never stopped eating “for no reason.” So I performed a stat parentectomy and brought Tommy into my office. Appearance-wise, he looked like any regular thirteen year old, but psychically he looked down, troubled, and on edge. I asked him what was going on with the not eating thing, and at first, he looked like he was running through a list of answer options, i.e. lies, and was trying to decide which would get him out of here with the least fuss. I quickly added, “the truth, Tommy. You’re never going to be done with me until you tell me the truth and we work through it, so you might as well start now. I can assure you that whatever you tell me won’t shock me.” After a long breath, he wisely chose the truth and started talking. For length’s sake, I’ll paraphrase what he said: he had stopped eating because he had hoped to stop puberty, basically to starve it of nutrition to try to prevent it, because it was so painful for him to gain weight and take on male characteristics. He was so distressed to see facial hair, pubic hair, muscles developing, his penis enlarging, and his voice deepening. He said it was wrong, he had known it was wrong since he was three, that this feeling was one of his earliest memories. Obvi, I had a good idea where he was going, but I had to encourage him to be more specific, and I told him that he couldn’t mince words, that he needed to voice it in his own words; so after a couple of beats, he did. With a few tears, he pointed to his lap and told me that he didn’t belong in “this” body. I really felt for this kid. He went on, the words choking him, saying that every morning he gets up for school and goes to the bathroom, and he looks down and has a panic attack. If I live to be 112, I’ll never forget the next thing he said; he tried to just slide it in, but it made my blood run cold. He said that he was going to find a way to cut it off, that he’d cut it with a nail clipper, but he didn’t have the guts to really do it. I had to bite the inside of my cheek. Every once in a very, very, very great while, maybe three times in my career, for a split second, I’ve thought to myself, “I can’t do this right now.” Looking at Tommy, I had that thought right then. It passed quickly, but the mental picture of what he was describing hit me like a ton of bricks. I asked him if he still had those feelings, and he said that he just didn’t know what to do. That was too vague for me, and in any case, it didn’t answer my question. I needed to know if he was going to hurt himself. I told him that I was going to help him, but to do that, he had to be 100% honest with me. When he agreed that he would be, I asked him point blank if he was going to hurt himself, cut himself, or mutilate himself in any way. He said no, and I believed him. Tommy was clearly depressed; it was clear to me that this scared little kid had the weight of the world on his shoulders. In his mind, he was female; his body disagreed, but he knew with every fiber of his being that his body was wrong. He wanted to be female. He wanted a female voice, a female body, a female top and a female bottom, to match his female mind. For Tommy, it was not a trend, not a passing thought, not a stage, not a lie, not a ploy, and nothing he asked for. This female being in a male body was a condition, one he had suffered with his entire life. He said he hadn’t told his parents, that he didn’t know how. When I asked if he needed my help to do that, he said yes. Tommy’s was my last appointment before lunch, so I had some time. When I asked if he wanted to tell them now or next appointment, he said now. I was on board, so I went out to the waiting room and called them into my office. 

Once Tommy’s parents made themselves comfortable, I explained to them everything that Tommy and I had talked about. Suffice it to say there was shock, disbelief, tears, and many questions. Tommy answered some and I took the rest. I explained all about the diagnosis of gender dysphoria and the reason Tommy had stopped eating. There were some protestations and some denial that I did my level best to dissuade, or, if I’m honest, maybe something more akin to shut down. All in all, they took it relatively well, or at least better than some parents have at any rate. I explained that there is a very proscribed path to follow, and I made it very clear that Tommy’s physical and psychological well being was very likely at stake. I told them that he was very anxious and depressed, and that I could treat him for those things, but that I suspected that the only way to make him better was to fix the underlying issue, the gender dysphoria, through hormonal and surgical means. That freaked them out, but they relaxed a little when I said that today’s appointment was only the first of many steps that would be taken before that could happen. I still needed to talk to Tommy a lot more, as well as the entire family, before finalizing any diagnosis. I told them that today was a good start, that I was very proud of Tommy, and that they should be too. I gave them my cell number and told them to call anytime if they needed anything and suggested they go home and keep the dialog going. We made a follow up appointment for two weeks. I shook Tommy’s hand, patted him on the shoulder, gave him my card with my cell number, and looked him in the eye and told him to call me if he needed to talk. He got the message and said he would. He looked like twenty pounds had been lifted off his shoulders. I was hoping that the communication trend would continue when they were back at home. Lots of parents say they’ll do something in my office, but then don’t follow through at home. I didn’t think that would happen in this case. I really hoped for Tommy’s sake that I was right, and that in two weeks they’d say that they were willing to start on the long road to exploring Tommy’s issues, potentially with a view toward gender confirmation surgery. In two weeks, I’d know if they were willing to allow us to explore that potential diagnosis. 

I have had a fair number of patients like Tommy, including genetically male patients of similar age who have been sent to me after attempting suicide and/ or mutilating their penises in a misguided attempt to fix themselves, or at least make life more tolerable. Unfortunately, that is not uncommon. It’s a very sad situation for all of them, but especially heartbreaking for the ones that have no support from their parents; or worse, the ones whose parents chide them, scold them, or do anything within their power to try to “change” them or make them see “the error of their ways,” including horrible and illegal things that make decent people want to vomit. I have had young female patients who, when they get their periods, develop severe anxiety disorders. For eight to ten days a month, they have a painful reminder of everything that is “wrong” with them and the bodies they are trapped in. When they start to narrow at the waist and get the weight distribution of a woman, they become intensely alarmed and anxiety ridden; and when their breasts begin to develop, they band them up or they tie them up so severely that they form a band of deep bruising, connecting continents of black and blue contusions. And sadly, breast mutilation in genetic females with gender dysphoria is nearly as common as penile mutilation in genetic males with gender dysphoria. It’s a devastating fact that most people would rather not consider. 

Most of my practice is young people, so patients with gender issues, unknown psych issues, or even undiagnosed GD come to my office when they’re usually 12-15 years of age, a time when they are doing everything in their power to block puberty because it is so deeply disturbing to them. When I speak to them about it, I find that they are not afraid of changing their sex, they are not afraid of having top surgery, or of having bottom surgery, which is a major procedure, a very painful one with a long recovery period. What they fear is living in the wrong body, disappointing their parents, and feeling the wrath of siblings, strangers, bullies, and anyone who disagrees with their choices or state of being. Gender dysphoria is the only psychiatric condition that can be cured through surgery rather than through psychiatric intervention. My job is to guide them and treat the depression, the anxiety, and the panic of the unchanged being. Once they are on the introduced hormones and have the confirmation surgery, they do much better. It’s the only psychiatric condition that is like a broken bone, once it’s fixed, it’s fixed…it can never be broken in the same place ever again. Once you confirm the patient’s gender with surgery and change their outward appearance to match the sense of self they have always felt inside, they are dramatically better. They are whole, and they will not break in that place ever again. It is an amazing metamorphosis, one I have been privileged to be a part of many times. 

Now, what is involved in this process of diagnosis and surgical intervention of gender dysphoria? I can tell you that it’s a long road, and not an easy one. Basically, there is a long list of criteria required to move forward on the path toward gender confirmation surgery. To meet the psychological criteria, there must be a documented history of gender dysphoria by a psychiatrist for a minimum of six consecutive months. By the time 90% of my GD patients get to my office, they have been tormented by the issue for years, and they are beyond ready to disclose it and take any steps necessary to move forward. I always make sure that the patient’s pediatrician is on board, and that they’ve done labs to look at general blood cell counts and hormone levels, and I also make sure there’s nothing significant in the medical history that might be pertinent to potential diagnosis. Assuming I make a diagnosis of GD, genetic females are put on testosterone, and they develop male characteristics: facial hair, a male weight distribution pattern, increased muscle mass with exercise, and lower voice tone. Then in due time (but never soon enough for them) they start having surgeries. The earlier surgeries are typically mastectomy (aka “top surgery”) and various facial plastic procedures, i.e. mandible (jaw) implants to square off the face and chin implant to accentuate the profile. Some may decide to break from surgery at this point and live this way for a period of time. Eventually, most genetic females undergo “bottom surgery” to complete gender confirmation. This is where female tissue is surgically altered and converted into a penis with varying sensitivity and functionality. Once healed, there can be numerous revisions to improve aesthetics and achieve better function over a period of several years if the person so desires. There can even be surgeries to alter the length of vocal cords to change the pitch and tenor of the voice to sound more characteristically male. 

Post diagnosis, genetic males are put on female hormones estradiol and micronized progesterone, and these decrease the male penis, testes, and the sperm product. There are other drugs that can be used to demasculinize male facial features. Then there is laser hair removal for the face and body, and hair implants to lower the hairline to appear more feminine. There are many plastics procedures to make the face less masculine and more feminine, such as narrowing the nose, shaving down the forehead, reducing the chin, reducing the ears, adding cheek implants, shaving down the Adam’s apple, and all sorts of injections and fillers to feminize the face. Breast implants, various body implants, and liposuction feminize the body shape, and there are millions of different facial peels, laser treatments, and lotions and potions to remove the ruddiness that’s more typical of male skin and feminize skin tone. There are many procedures regardless of gender change direction, so a team approach with everyone on board and on the same page, and with constant communication is critical.  

As with many medical issues, the sooner you can start therapy, the better. Hormonal therapy in gender confirmation is no different. The sooner you put a GD patient on testosterone or on estradiol/ progesterone, the better the result will be. But before that can start, many things have to happen, and those things take time. First, if the patient with GD is sub-adult (which they usually are), the parent has to get them to a doctor, which means that the child has either told them what’s going on, or the parent notices that there’s a problem, as Tommy’s parents did. That all takes time. Then, the next step is either a pediatrician’s office, who runs tests and then sends the patient to me, or the parent brings the child directly to me for evaluation first. More often than not, the entire process begins in earnest in a psychiatrist’s office. My problem as a psychiatrist is that children of age 10, 11, 12 do not yet have fully formed brains, yet they are asking to make permanent changes to their sexual assignment; to go from a genetic boy to a girl, or genetic girl to a boy. It’s best to start hormone therapy at this age, I know that, but what if you’re wrong? The odds of being wrong are pretty low because of exhaustingly thorough therapeutic examination of the issue, and the fact that really no one pretends that they have this problem, it’s not a fad, not a lie, not cool, not fake, etc. That is all plain to see in these patients. They are suffering and in great emotional distress. Their psychiatric problems are not about having the actual sex confirmation surgery or taking on characteristics of the opposite sex. Their problems either surround not being able to tell their parents, or dealing with family issues, of their parents rejecting them, siblings who may reject them, bullies at school, and/ or being isolated and depressed in their skin, thinking about not having friends, etc. These individuals have much higher suicide rates. The rate of depression, anxiety, and panic disorder are dramatically higher as well. So for the patient with GD, we have to intervene with parental counselling, and we have to intervene with family therapy. The whole family, as a unit, needs to process the potential changes in gender assignment. And of course there must be a great deal of individual therapy to help the GD patient navigate the waters of the process. As I mentioned before, the least of their worries is the surgeries; more importantly, they must learn how to tell people about their status if they wish, and learn how to deal with other people’s reactions, and with society’s reactions as a whole. For example, being forced to use the wrong bathroom, one that does not go with their true internal gender. Or dealing with someone using the wrong pronoun, referring to them as sir or mister when they prefer miss or ma’am. Driver’s licenses list the genetic gender that doesn’t match their true gender. These things are all very painful, very traumatizing for a person with gender dysphoria. Every stage or every place where society labels someone male or female is distressing for people with gender dysphoria. Even after they’ve had confirmation surgery, it can be painful. Obviously, Social Security records and birth certificates always list the gender a person was born under. If they want to change it, it’s not easy. They need lawyers for practically everything, they have to threaten to sue to go to the right bathroom, to get records changed, every little thing. But these things are very important to them, so they often choose to do them, no matter the expense or pain involved. And how do they apply for a job? What gender do they check? Because if that job includes health insurance and life insurance, it all has to match up. They can’t have their genetic/ birth gender on one document and confirmed/ inside/ new gender on another one. And speaking of health insurance, you can pretty much forget them paying for any of it, so you better hope somebody is independently wealthy or wins the lottery, because you’re looking at about a quarter million to get through just the basic therapy, testing, meds, and surgeries. Then tack on a lot more for potential revisions and all of the necessary plastics surgeries and other refining procedures and upkeep.

As a psychiatrist, I am usually the first hoop to jump through. I treat GD patients for depression, anxiety, sleep problems, addictions, attempted mutilation trauma, attempted suicides, and the physical/ emotional/ sexual abuse they may go through, as most do have harrowing abuse histories. I give my stamp of approval to move them forward on the gender confirmation pathway, and continue to follow them throughout. As the person that sees them first and last, I have a front row seat to before and after, so I have seen that things get much better for patients as their sexual transition progresses. It sounds like it happens quickly, but it doesn’t; even all the approvals can take years to put together, and then there are often surgical waiting lists, as there are only a few super-specialists who do the most major part of the process. It also has to be a team approach, with every physician trusting each member of the team. On that team, you need psychiatric therapy for the individual, parents, and siblings. You need a pediatrician for general medical, a pediatric endocrinologist to monitor hormonal changes, urology and urology surgery to deal with the plumbing, specialty surgery to do the actual reassignment/ confirmation, along with plastic surgery of all sorts to deal with function and aesthetics, the list is never ending. And again, you have to go to a center of excellence to find all of these surgeons, because these super-specialists don’t grow on trees…you’ve gotta go to them, for every procedure and every follow-up visit. With so few centers and so few super-specialist surgeons, that involves a lot of time in the air…lots of frequent flier miles. We desperately need more surgical centers and more super-specialists, and we have to maintain the team approach to treating GD. Because the psychiatrist is usually the first hoop to jump through, they lead the team. They are the ones to say “I have thoroughly evaluated this patient, and I certify that they have gender dysphoria and believe that they require gender confirmation surgery.” It’s really not so easy; it’s one thing to confirm a diagnosis, but it’s quite another to say “I am going to lead this team, and I am confident that making this permanent surgical transition is the only path to psychological health for this person. I will work with them, their parents and siblings, separately and together, for the duration.” To say that to a group of ten plus physicians, all of whom are counting on that original diagnosis, putting themselves on the line legally and ethically is a big deal, and not one I take lightly. I have to be pretty secure in what I’m saying, and to be honest, it takes me a while before I’m willing to make that play. I am required to certify the circumstances of GD for a period of six months, but it takes me a lot longer than that. I hate to say it, and maybe I should do it in less time, but it takes me over a year of working with that patient before I’m ready to lay it all on the line with a diagnosis of gender dysphoria. And patients get, ironically, well, very…impatient. Whenever I look back at my GD patients, I always think I should’ve pulled the trigger sooner. Sooner really is better in these cases, less traumatic, fewer mutilations borne of frustration, fewer attempted suicides, more effective hormone treatment, and with better final outcomes. I always say I’m going to shorten the time to diagnosis when I get the next case, but then I’m drawn in by an overabundance of caution. It’s not the worst thing ever, but maybe not the best? It’s really hard to say. Next time I have a GD patient, I’ll make a mental note to read this blog, and maybe that will decrease the length of time it takes for me to put my chips down on the GD diagnosis. A lot of it depends on the patient’s age of realization and their willingness, as well as their parent’s willingness, to undergo all of the therapy it takes to come to the diagnosis in the first place. 

I’ve had a bunch of patients undergo these sexual reassignment/ confirmation surgeries, and I’ve had pre-op genetic males end up looking like post-op females and vice versa, and at every stage in between, so when they would come to see me during the process and would be in the waiting room, sometimes my secretaries wouldn’t recognize them. They would see a name they recognized on the chart, but sometimes not the face, which has led to some confusion…so these hormone therapies and procedures, when done well, can be very convincing. Over the years, some of these patients were thrilled when the girls up front didn’t recognize them! One such patient was Tommy. Remember him…the 13-year-old genetic boy I talked about earlier? Well, when her surgeries were all said and done, she looked amazing as a nearly 20-year-old woman. The day finally came when Tommy (she kept the nickname btw) caused a bunch of confusion with my secretaries. When she walked back into my office, she was smiling ear to ear because my secretaries didn’t have a clue who she was. It was pretty awesome to see, and I felt good being a part of something that was so clearly right. Tommy walked that long, and often dark, path to acceptance, and came out the other side beautifully, with all of her familial relationships intact. It doesn’t always happen that way. I’ve had patients who had to wait until they were out of their childhood homes because they were told they couldn’t have the surgery while they lived there. So they left as soon as possible. I recall even helping two GD patients emancipate themselves at 17 years old in order to get started that one year earlier. Ultimately, it comes down to the individual patient and the lengths they are willing and able to go to in order to feel comfortable in their own skin. As with any other aspect of life, we each have our own path to take, and I’m just privileged to be a guide.    

If you like this blog, make a comment, give it a like, and pass it along. From now on, I’ll be doing a video to go with the blogs on dragresti.com. You can also subscribe to my YouTube channel for all of it! And of course, you can always check out my book, Tales from the Couch, available on Amazon.com. 

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Frotteurism

Frotteurism refers to a paraphilic interest in rubbing, usually one’s pelvis or erect penis, against a non-consenting person for sexual gratification. It may involve touching any part of the body including the genital area. A person who practices frotteurism is known as a frotteur. The majority of frotteurs are male and the majority of victims are female, although female on male, female on female, and male on male frotteurs exist. Adult on child frotteurism can be an early stage in child sexual abuse. This activity is often done in circumstances where the victim cannot easily respond, in a public place such as a crowded train or concert.

Usually, such nonconsensual sexual contact is viewed as a criminal offense: a form of sexual assault albeit often classified as a misdemeanor with minor legal penalties. Conviction may result in a sentence or psychiatric treatment.

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Pedophilia

As a medical diagnosis, pedophilia (or paedophilia) is defined as a psychiatric disorder in adults or late adolescents (persons age 16 or older) typically characterized by a primary or exclusive sexual interest in prepubescent children (generally age 13 years or younger, though onset of puberty may vary). The child must be at least five years younger in the case of adolescent pedophiles (16 or older) to be termed pedophilia. The term has a range of definitions, as found in psychiatry, psychology, the vernacular, and law enforcement.

The International Classification of Diseases (ICD) defines pedophilia as a “disorder of adult personality and behaviour” in which there is a sexual preference for children of prepubertal or early pubertal age. According to the Diagnostic and Statistical Manual of Mental Disorders(DSM), pedophilia is a paraphilia in which a person has intense and recurrent sexual urges towards and fantasies about prepubescent children and on which feelings they have either acted or which cause distress or interpersonal difficulty. The current DSM-5 draft proposes to add hebephilia to the diagnostic criteria, and consequently to rename it to pedohebephilic disorder.

In popular usage, pedophilia means any sexual interest in children or the act of child sexual abuse, often termed “pedophilic behavior.” For example, The American Heritage Stedman’s Medical Dictionary states, “Pedophilia is the act or fantasy on the part of an adult of engaging in sexual activity with a child or children.” This common use application also extends to the sexual interest in and abuse of pubescent or post-pubescent minors. Researchers recommend that these imprecise uses be avoided; people who commit child sexual abuse commonly exhibit the disorder, but some offenders do not meet the clinical diagnosis standards for pedophilia, which only pertain to prepubescents. Additionally, not all pedophiles actually commit such abuse.

Pedophilia was first formally recognized and named in the late 19th century. A significant amount of research in the area has taken place since the 1980s. Although mostly documented in men, there are also women who exhibit the disorder, and researchers assume available estimates underrepresent the true number of female pedophiles. No cure for pedophilia has been developed, but there are therapies that can reduce the incidence of a person committing child sexual abuse. In the United States, following Kansas v. Hendricks, sex offenders that are diagnosed with certain mental disorders, particularly pedophilia, can be subject to indefinite civil commitment, under various state laws (generically called SVP laws) and the federal Adam Walsh Child Protection and Safety Act of 2006. At present, the exact causes of pedophilia have not been conclusively established. Research suggests that pedophilia may be correlated with several different neurological abnormalities, and often co-exists with other personality disorders and psychological pathologies. In the contexts of forensic psychology and law enforcement, a variety of typologies have been suggested to categorize pedophiles according to behavior and motivations.

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Sadomasochism

Sadomasochism broadly refers to the receiving of pleasure—often sexual—from acts involving the infliction or reception of pain or humiliation. The name originates from two authors on the subject, Marquis de Sade and Leopold von Sacher-Masoch. A subset of BDSM, practitioners of sadomasochism usually seek out sexual gratification from these acts, but often seek out other forms of pleasure as well. While the terms sadist and masochist specifically refer to one who either enjoys giving pain (sadist), or one who enjoys receiving pain (masochist), many practitioners of sadomasochism describe themselves as at least somewhat of a switch, or someone who can receive pleasure from either inflicting or receiving pain.

The acronym S&M is often used for sadomasochism, although practitioners themselves normally drop the & and use the acronym SM or S/M. Sadomasochism should be differentiated from the clinical paraphilias which require that such practices lead to clinically significant distress or impairment for a diagnosis. Similarly, sexual sadism within the context of mutual consent should not be mistaken for acts of sexual violence or aggression.

The combination of sadism and masochism, in particular the deriving of pleasure, especially sexual gratification, from inflicting or submitting to physical or emotional abuse. 1. (Psychology) the combination of sadistic and masochistic elements in one person, characterized by both aggressive and submissive periods in relationships with others 2. sexual practice in which one partner adopts a sadistic role and the other a masochistic one Abbreviation SM Compare sadism, masochism

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Transvestic Fetishism

Transvestic fetishism is having a sexual or erotic interest in cross-dressing. It differs from cross-dressing for entertainment or other purposes that do not involve sexual arousal and is categorized as a paraphilia in the Diagnostic and Statistical Manual of the American Psychiatric Association. (Sexual arousal in response to donning sex-typical clothing is homeovestism.)

Transvestic fetishism refers specifically to cross-dressing; sexual arousal in response to individual garments is fetishism. Occurrence of transvestic fetishism is uncorrelated to occurrence of gender identity disorder. Most men who have transvestic fetishism do not have a problem with their assigned sex.

Some male transvestic fetishists collect women’s clothing, e.g. nightgowns, babydolls, slips, brassieres, and other types of nightwear,lingerie, stockings, pantyhose, shoes, and boots, items of a distinct feminine look and feel. They may dress in these feminine garments and take photographs of themselves while living out their secret fantasies. According to the DSM-IV, this fetishism has been described only in men.

There are two key criteria before a psychiatric diagnosis of “transvestic fetishism” is made:

1. Recurrent, intense sexually arousing fantasies, urges, or behaviour, involving cross-dressing.
2. This causes clinically significant distress or impairment, whether socially, at work, or elsewhere.

Thus, transvestic fetishism is not diagnosed unless it causes significant problems for the person concerned.

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Exhibitionism

Exhibitionism refers to exposing bare female breasts and/or buttocks of either a male or female. When genitalia is exposed the behavior is more commonly described as indecent exposure. Exhibitionism is an overall psychosocial concept that, when applied to physical actions, denotes two separate phenomena.

The first, colloquially referred to as flashing, involves the exposure of a person’s “private parts” to another person, in a nonthreatening manner, in a situation where these would not normally be exposed, such as in a social situation (in front of other people) or in a public place. The act of flashing, particularly when done by females involving the breasts but also when involving her vagina and also her buttocks, may be at least partially sexual in intention, i.e. to prompt the sexual arousal of those being flashed (in turn giving the flasher an ego boost). However, flashing may also simply be intended to attract the non-aroused ‘attention’ of another or others, or for shock value.

The second, indecent exposure, involves the same sorts of exposure done in a threatening manner or in a manner perceived by those being exposed-to as threatening. Indecent exposure, when it is assessed to be this, is sometimes prosecuted under laws designed to criminalise it, such as public nuisance laws and indecent-exposure laws. Such laws vary by locality worldwide, including within different parts of the United States.

There is somewhat of a double standard here as concerns the two different types of exhibitionism, since “indecent exposure” has a tendency in the Western world to be equated with a male exposing his genitalia to a female, when such acts are perceived by the female as threatening, while at the same time a female exposing her breasts (“flashing”) to male or female viewers is almost always seen as nonthreatening and in fact is often even requested to occur by those wanting to see bare breasts, such as the non-parade-related celebrations surrounding Mardi Gras and other similar festivals.

Exhibitionism is not automatically a compulsion, but some people do have a distinct psychological tendency to sexually expose themselves, whether it is to “flash” (the nonthreatening form) or to “indecently expose” (the threatening form). When it is a compulsion, it is a condition sometimes called apodysophilia.

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Female Sexual Arousal Disorder

Female sexual arousal disorder (FSAD), commonly referred to as frigidity, is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity, or an adequate lubrication-swelling response that otherwise is present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.

Although female sexual dysfunction is currently a contested diagnostic, pharmaceutical companies are beginning to promote products to treat FSD, often involving low doses of testosterone.

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Gender Identity Disorder

Gender identity disorder (GID) is the formal diagnosis used by psychologists and physicians to describe persons who experience significant gender dysphoria (discontent with their biological sex and/or the gender they were assigned at birth). It describes the symptoms related to transsexualism, as well as less severe manifestations of gender dysphoria.

 

Gender identity disorder in children is usually reported as “having always been there” since childhood, and is considered clinically distinct from GID that appears in adolescence or adulthood, which has been reported by some as intensifying over time. As gender identity develops in children, so do sex-role stereotypes. Sex-role stereotypes are the beliefs, characteristics and behaviors of individual cultures that are deemed normal and appropriate for boys and girls to possess. These “norms” are influenced by family and friends, the mass-media, community and other socializing agents. Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them. In many cases, transgendered individuals report discomfort stemming from the feeling that their bodies are “wrong” or meant to be different.

Many transgendered people and researchers support the declassification of GID as a mental disorder for several reasons. Recent medical research on the brain structures of transgendered individuals have shown that some transgendered individuals have the physical brain structures that resemble their desired sex even before hormone treatment. In addition, recent studies are indicating more possible causes for gender dysphoria, stemming from genetic reasons and prenatal exposure to hormones, as well as other psychological and behavioral reasons.

One contemporary treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one’s perception of mental (psychological, emotional) gender identity, rather than vice versa.

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Hypoactive Sexual Desire Disorder

Hypoactive sexual desire disorder (HSDD), is considered as a sexual dysfunction and is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug (legal or illegal), or some other medical condition.

HSDD is listed under the Sexual and Gender Identity Disorders of the DSM-IV. It was first included in the DSM-III under the name Inhibited Sexual Desire Disorder, but the name was changed in the DSM-III-R.

There are various subtypes. HSDD can be general (general lack of sexual desire) or situational (still has sexual desire, but lacks sexual desire for current partner), and it can be acquired (HSDD started after a period of normal sexual functioning) or life-long (the person has always had no/low sexual desire.)

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Erectile Dysfunction

Erectile dysfunction (ED, “male impotence”) is sexual dysfunction characterized by the inability to develop or maintain an erection of thepenis during sexual performance.

A penile erection is the hydraulic effect of blood entering and being retained in sponge-like bodies within the penis. The process is often initiated as a result of sexual arousal, when signals are transmitted from the brain to nerves in the penis. Erectile dysfunction is indicated when an erection is difficult to produce. There are various circulatory causes, including alteration of the voltage-gated potassium channel, as in arsenic poisoning from drinking water. The most important organic causes are cardiovascular disease and diabetes, neurological problems (for example, trauma from prostatectomy surgery), hormonal insufficiencies (hypogonadism) and drug side effects.

Psychological impotence is where erection or penetration fails due to thoughts or feelings (psychological reasons) rather than physical impossibility; this is somewhat less frequent but often can be helped. Notably in psychological impotence, there is a strong response to placebo treatment. Erectile dysfunction, tied closely as it is about ideas of physical well being, can have severe psychological consequences.

Besides treating the underlying causes such as potassium deficiency or arsenic contamination of drinking water, the first line treatment of erectile dysfunction consists of a trial of PDE5 inhibitor drugs (the first of which was sildenafil or Viagra). In some cases, treatment can involve prostaglandin tablets in the urethra, injections into the penis, a penile prosthesis, a penis pump or vascular reconstructive surgery.

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Anorgasmia

Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm, even with adequate stimulation. In males the condition is often related to delayed ejaculation. Anorgasmia can often cause sexual frustration. Anorgasmia is far more common in females than in males and is especially rare in younger men.

The condition is sometimes classified as a psychiatric disorder. However, it can also be caused by medical problems such as diabetic neuropathy, multiple sclerosis, genital mutilation, complications from genital surgery, pelvic trauma (such as from a straddle injury caused by falling on the bars of a climbing frame, bicycle or gymnastics beam), hormonal imbalances, total hysterectomy, spinal cord injury, cauda equina syndrome, uterine embolisation, childbirth trauma (vaginal tearing through the use of forceps or suction or a large or unclosedepisiotomy), vulvodynia and cardiovascular disease

A common cause of situational anorgasmia, in both men and women, is the use of anti-depressants, particularly selective serotonin reuptake inhibitors (SSRIs). Post-SSRI sexual dysfunction (PSSD) is a name given to a reported iatrogenic sexual dysfunction caused by the previous use of SSRI antidepressants. Though reporting of anorgasmia as a side effect of SSRIs is not precise, it is estimated that 15-50% of users of such medications are affected by this condition. The chemical amantadine has been shown to relieve SSRI-induced anorgasmia in some, but not all, people.

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Premature Ejaculation

Premature ejaculation (PE) is a condition in which a man ejaculates earlier than he or his partner would like him to. Premature ejaculation is also known as rapid ejaculation, rapid climax, premature climax, or early ejaculation. Masters and Johnson defines PE as the condition in which a man ejaculates before his sex partner achieves orgasm, in more than fifty percent of their sexual encounters. Other sex researchers have defined premature ejaculation as occurring if the man ejaculates within two minutes of penetration; however, a survey by Alfred Kinsey in the 1950s demonstrated that three quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters.

Most men experience premature ejaculation at least once in their lives. Because there is great variability in both how long it takes men to ejaculate and how long both partners want sex to last, researchers have begun to form a quantitative definition of premature ejaculation. Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18-30 year olds. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about 2 minutes. Nevertheless, it is well accepted that men with IELTs below 1.5 minutes could be “happy” with their performance and do not report a lack of control and therefore would not be defined as having PE. On the other hand, a man with 2 minutes IELT may have the perception of poor control over his ejaculation, distressed about his condition, has interpersonal difficulties and therefore be diagnosed with Premature Ejaculation.

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Vaginismus

Vaginismus, sometimes anglicized vaginism is the German name for a condition which affects a woman’s ability to engage in any form of vaginal penetration, including sexual intercourse, insertion of tampons, and the penetration involved in gynecological examinations. This is the result of a reflex of the pubococcygeus muscle, which is sometimes referred to as the “PC muscle”. The reflex causes the muscles in the vagina to tense suddenly, which makes any kind of vaginal penetration—including sexual intercourse—painful or impossible.

A woman suffering from vaginismus does not consciously control the spasm. The vaginismic reflex can be compared to the response of the eye shutting when an object comes towards it. The severity of vaginismus and the pain during penetration, including sexual penetration, varies from woman to woman.

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Voyeurism

In clinical psychology, voyeurism is the sexual interest in or practice of spying on people engaged in intimate behaviors, such as undressing, sexual activity, or other activity usually considered to be of a private nature.

Voyeurism (from the French voyeur, “one who looks”) can take several forms, but its principal characteristic is that the voyeur does not normally relate directly with the subject of their interest, who is often unaware of being observed. The practice of making a permanent image of an intimate activity has been made easier with modern photographic and video technology, and is considered an invasion of privacy. However, in today’s society the concept of voyeurism has evolved, especially in popular culture. Non-pornographic reality television programs such as Survivor and The Real World, are prime examples of voyeurism, where viewers (the voyeur) are granted an intimate interaction with a subject group or individual. Although not necessarily “voyeurism” in its original definition, as individuals in these given situations are aware of their audience, the concept behind “reality TV” is to allow unscripted social interaction with limited outside interference or influence. As such, the term still maintains its sexual connotations.

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Sexual Disorders and Dysfunction

Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm.

To maximize the benefits of medications and behavioural techniques in the management of sexual dysfunction it is important to have a comprehensive approach to the problem, A thorough sexual history and assessment of general health and other sexual problems (if any) are very important. Assessing (performance) anxiety, guilt (associated with masturbation in many Indian men), stress and worry are integral to the optimal management of sexual dysfunction. When a sexual problem is managed inappropriately or sub-optimally, it is very likely that the condition will subside immediately but re-emerge after a while. When this cycle continues, it strongly reinforces failure that eventually make clients not to access any help and suffer it all their life. So, it is important to get a thorough assessment from professionals and therapists who are qualified to manage sexual problems. Internet-based information is good for gaining knowledge about sexual functioning and sexual problem but not for self-diagnosis and/or self-management.

Disorders in this Category

• Exhibitionism
• Fetishism
• Frotteurism
• Pedophilia
• Sadomasochism
• Transvestic Fetishism
• Voyeurism

Dysfunctions in this Category

• Dyspareunia
• Female Orgasmic Disorder
• Female Sexual Arousal Disorder
• Gender Identity Disorder
• Hypoactive Sexual Desire Disorder
• Erectile Dysfunction
• Orgasmic Disorder (Anorgasmia)
• Premature Ejaculation
• Hypoactive Sexual Desire Disorder
• Vaginismus

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Sexual Fetishism

Sexual fetishism, or erotic fetishism, is the sexual arousal a person receives from a physical object, or from a specific situation. The object or situation of interest is called the fetish, the person a fetishist who has a fetish for that object/situation. Sexual fetishism may be regarded, e.g. in psychiatric medicine, as a disorder of sexual preference or as an enhancing element to a relationship causing a better sexual bond between the partners. Arousal from a particular body part is classified as partialism.

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