Digest of recent discussions on ISSM mail (Sept 2009 - Dec 2009)

VI

PATRICIA WEERAKOON

Subcontinental Male with Masturbation and Premature Ejaculation Concerns

October 26, 2009: 4 Messages

1

Any advice on the following would be very much appreciated: Rahul is a 26 year old male working as an export officer at a local firm in India. Basically, he is a shy person and has never exposed any of his sexual feelings to anyone. At the age of 14, he first experienced nocturnal emission and started to masturbate regularly.  He considers masturbation a dirty act and has tried occasionally to stop but without success.  He expressed guilt over his sinful masturbatory habit and linked it to both sexual and non-sexual problems. Rahul attributes the following to his masturbatory habits: acne, weak eyesight, weakness of muscles and dark complexion. In the last two months, his ejaculations have been quick (less than a minute). He considers it (premature ejaculation) a punishment for his long years of bad habits (masturbation). A more recent complaint was decrease in the amount of semen which makes him very anxious and stressed about his masculinity and fertility especially when his parents are keen to get him married.  Rahul did contact some web-based services that offer advices for sexual problems. Some of the advice offered was to stop thinking about sex, drink plenty of water, do some exercises and even to try sexual intercourse as an alternative to get over his masturbatory habit. Rahul found these pieces of advice to be unsatisfactory and ineffective. He also has a strong belief and value that premarital sex is bad and he would never try it and add more to his existing guilt and remorse.  Rahul’s ultimate goal was to lead a satisfying and healthy life and prepare himself for his future married life. He desperately wants advice on how to (i) Stop his masturbation habit, (ii) Treat his premature ejaculation (iii) Improve his semen quality: all this in a short time so he could go into an arranged marriage and satisfy his wife. Thank you very much.

                                                                  Patricia Weerakoon (p.weerakoon@usyd.edu.au)

2

Hi Patricia:  While we might be tempted, based on our own values, to suggest considering alternative treatment goals, respect for Rahul's culture and presumably his deeply held religious beliefs complicates what might otherwise guide my treatment with him, at least initially. Here are some preliminary thoughts on how I might proceed, given the complexities of the situation you have described. If Rahul’s arranged marriage is relatively soon, reassure him that you will be able to provide counseling, guidance and/or medication which will effectively treat his self-identified premature ejaculation. Reassure him that despite his guilt, your own experience and that of your colleagues around the world, makes you certain that his experience with masturbation will in no way hinder his capacity and performance as a husband. Reassure him that reducing the frequency of his masturbation will indeed increase his semen quantity. While you have not described his actual masturbation frequency, one can presume the previous statement will be true, especially if he is masturbating more than once per day at this point. His guilt, anxiety, and obsessive observation of his semen quantity will all negatively impact quantity of ejaculation as well as quality of orgasm. Discussions with you will minimize some of those factors which should likely result in improvement in semen quantity. When he does `err’ and fail to control his masturbation (inevitable and understandable), reframe the experience as an opportunity to learn about his semen quantity, rather than joining his view of his `failure.’ Such interventions will begin to break up some of his ritualized thinking. If you have the opportunity for a few sessions with him, explore the triggers to masturbation. Given his work description, he may be using a computer and finding himself triggered by porn that is even more stimulating and intoxicating for him than the average person. His feeling and response can be `normalized’ even if you help him find strategies for not `triggering’ his masturbation response as frequently. Finally, I would recommend referring him to a good urologist who you know to be culturally sensitive to Rahul's values, yet able to work in a collegial manner with yourself. The referral to the urologist can be veiled under the `heading’ of making sure that he has not damaged himself (exceedingly unlikely). However, that urologist can encourage him to masturbate in order to produce a semen sample so that the exact quantity and quality of his semen can be ascertained. Rahul can be motivated and become receptive to do this so that he is able `to lead a satisfying and healthy life and prepare himself for the future married life’. There are of course multiple therapeutic benefits to such an intervention, which the patient may not appreciate, but you will.  In this manner, three important treatment opportunities are accomplished: (1) Further reassurance of Rahul's anxiety. (2) Confirmation that there is no organic factor responsible for the diminished semen (highly unlikely, but he does not know that) based on evaluation by the urologist. (3) Provide what might be a culturally acceptable reason to `produce a sample for medical evaluation’ or masturbate, which may ease some of the obvious pressure/compulsion he will experience as he tries to decrease the frequency. The above can be done within the context of being explicitly sensitive to his values and help Rahul reduce the frequency of his masturbation (joining his resistance) while still educating him as to the `normality’ of both his masturbatory desire and his nocturnal emissions. The nocturnal emissions should be redefined as an indication of his health and readiness to marry successfully, as well as an indication of his progress in reducing his masturbation frequency. Hopefully, in terms of my own values, you may be able to use your positive relationship with him to alter his view toward masturbation, without making him feel unduly challenged. Finally, perhaps beyond basic education you might be able to use your therapeutic alliance with him to assist him with his shyness and find greater peace with his conflicting feelings and behaviors. By the way, exercise might actually help in a variety of ways, not the least of which would be a reduction in his overall anxiety level which is probably pretty high at this point in time.

Michael A. Perelman (perelman@earthlink.net)

3

Dear Patricia: I agree with Michael’s excellent suggestions. In Egypt we face Rahul’s complaint almost daily as a result of prevalent cultural myths related to masturbation. Interestingly I debated this issue today with a group of medical students who were not aware that masturbation is harmless!  I would like to highlight 2 practical points of management: (1) Patient education is the cornerstone: It is important to stress that masturbation is a healthy sexual behaviour practiced by 99% of unmarried men.  It causes no harm except guilty feelings if it interferes with their beliefs.  Psychosomatic complaints, e.g. `weakness of muscles’, are not related to masturbation, but possibly to the anxiety. (2) Guard against honeymoon impotence in anxious patients: Patients with anxiety related to their sexual abilities are prone to honeymoon impotence which is prevalent in conservative societies.  After reassurance we suggest PDE5 inhibitors for the first few days of marriage (1-4). Hope this is helpful.

1.      Hussein Ghanem, Refaat El Dakhly & Rany Shamloul.  Alternate-day tadalafil in the management of honeymoon impotence.  J Sex Med Volume 5, Issue 6, June 2008, Pages: 1451-1454

2.      H Ghanem, A Zaazaa, I Kamel and A El Guindi. Short-term use of sildenafil in the treatment of unconsummated marriages. International Journal of Impotence Research 2006 (1):52-4.

3.      Badran W, Moamen N, Fahmy I, El-Karaksy A, Abdel-Nasser TM, Ghanem H. Etiological factors of unconsummated marriage. Int J Impot Res. 2006, 2006; 18: 458–463

4.      Ghanem,-H; Sherif,-T; Adbel-Gawad,-T; Asaad.  Short term use of intracavernous vasoactive drugs in the treatment of persistent psychogenic erectile dysfunction. -T Int-J-Impot-Res. 1998 Dec; 10(4): 211-4

Hussein Ghanem (hmghanem@hotmail.com)

4

Dear Dr. Weerakoon: Masturbation-related `weaknesses' are pandemic to the Indian sub-continent, and are easily the most common sexual medical condition in this part of the world. Most sufferers languish in the clutches of quacks, but increasingly, especially in urban areas, many are now seeking professional sexual medical help. These `weaknesses' are usually a consequence of lack of sex education and mythical beliefs propagated over centuries. In some, they are amenable to education, counseling, and placebos/ anxiolytics. However, in many others, there is a serious (refractory) neuropsychiatric variant that is impossible to address with these regular treatment methods. These latter patients are resistant to all forms of treatment, keep moving from doctor to doctor in their quest for a cure that always eludes them, and suffer all their lives. `Cured' or not, most eventually get married, and make their situation worse. I run a few Q & A columns in this part of the world and this same question gets asked every time, often by many people in the same questions' set, despite the fact that I give the same answer each time ! I have also devoted three entire chapters to this subject in a book I've recently written for the general public, but people seek appointments for help with this `problem' even after reading these. So, I wish you luck with your patient!

Sudhakar Krishnamurti (sudhakar1957@gmail.com)