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Sexual Dysfunction in Young Men due to Unusual Masturbatory Practice
Etiology, Diagnosis, and Treatment


Semir A. S. Al Samarrai


Introduction:

Masturbation is very common Sexual practice.

The Masturbation is attributed to "Sin" of Onan, who spilled his semen on the ground, and therefore. God killed him.

Masturbation is therefore judged as being a moral and religious sin by Islam and Christianity.

In the late 18th Century, the idea that masturbation is immoral and unhealthy stemmed from observations of institutionalized patients who sometimes masturbated in public, promoting the nation that masturbation is the cause for their psychopathology.

In the 18th Century, a swiss physician, Simon Auguste David Tissot, published a book entitled L� Onanisme. His book gave the erroneous impression that there was a consensus among Leading European physicians that masturbation was a dangerous disease and a threat to well-being (1).

In 1886 Richard von Kraft-Ebing (2) wrote the following in his famous book "Psychopathia Sexualis":

�Nothing is so prone to contaminate� the source of all noble and ideal sentiments� as the practice of masturbation� It despoils the unholding bud of perfume and beauty, and leaves behind only coarse, animal desire for sexual satisfaction� in an unfavorable manner, even causing, under certain circumstances the desire for the opposite sex to sink to nil�

This viewpoint on masturbation was intimidating and probably influenced the attitude of ordinary people as well as medical professionals toward masturbation for many years, with intercourse being perceived as the only healthy sexual behavior. Accordingly, masturbation was blamed for homosexuality, insanity, sterility and variety of other mental and physical disorders (3).

The attitude toward masturbation became gradually more tolerant throughout the 20th Century. When Alfred Kinsey�s statistical finding appeared in 1948 and 1953, it became apparent that masturbation was highly prevalent in the general population; nearly all men (92%) reported masturbating during their lifetime (4,5).

Many years later, Nazareth et al. (6) reported that 63.3% of 477 men attending London general practioners declared practicing autoeroticism in the previous 4 weeks, and 8% of them reported masturbating at least once a day.

In a representation survey, 73% of British men aged 16-44 years stated that they had masturbated during the month prior to the interview (7).

Masturbation was also a common practice according to the national representative sample of 2,936 U.S. men (aged 14-94 years). About two-thirds of the younger men (aged 25-29), half of those aged 40-49, and one-third of older men (60-69) reported masturbating during the past month (8).

An aged-dependent reduction of the frequency of masturbation was also reported in a large study involving 1,455 community-dwelling men, aged 57-64 years, with 63.4% of subjects aged 57-64 years reporting masturbation in the past year in comparison with 27.5% of those aged 75-85 years (9). Dekker and Schmidt (10) compared the sexual behavior of university students in Germany in 1966, 1981, and1996. Those authors found that students began to masturbate considerably earlier in the 1990s than in the 1960s and 1980s. Interestingly, the frequency of masturbation in the 1990 survey was irrespective of whether the students had intercourse often or rarely.

Masturbation is no longer perceived as a behavioral aberration. Some authorities even consider autoeroticism as a mode to reduce the risk of sexually transmitted diseases (11). In spite of its being so ubiquitous, it is often omitted in the evaluation process of patient with sexual problems.

Gerressu et al. found that men reporting at least one sexual function problem (e.g. lacking interest in sex, anxiety about performance, inability to experience orgasm, premature orgasm) were significantly more likely to report masturbation (7). They also found that men reporting vaginal sex in the last 4 weeks were less likely to report masturbation than those who reported no vaginal sex. Thus, inquiring about masturbation may imply on some problems in sexual function.

Corona et al. (12) investigated Psychobiological correlates of masturbation in 2,786 men (mean age 48.4 � 13.2 years) who came for consultation for erectile dysfunction (ED). Masturbation was a relatively frequent behavior among these men, and 61.9% had masturbated at the least once per month in the preceding 3 months, and 274 (15.4%) patients reported a feeling of guilt during masturbation. Indeed, feeling guilty during masturbation was associated with Psychological disturbances and relational problems in that study. In�� their study, 76.4 % of men reported ED during masturbation.

Interestingly, subjects reporting an erectile problem during autoeroticism showed a higher organic component of ED, implying that men with organic ED have it during both masturbation and intravaginal partnered sexual intercourse. Those authors concluded that inquiring about masturbation is an important issue for understanding the overall patient�s sexual attitude and behavior.

Perelman (13-17) has been publishing on this topic for many years, and his studies highlight the association between male delayed ejaculation (DE) and �idiosyncratic� self-stimulation. Perelman has identified three factors associated with DE; higher frequency of masturbation (more than three times per week), idiosyncratic masturbatory style, and a disparity between the reality of sex with his partner compared with his preferred sexual fantasy during masturbation. Although correlated with high-frequency masturbation, the primary factor causing DE, according to Perelman, is an �idiosyncratic masturbatory style�, which is defined as a technique not easily duplicated by the partner�s hand and mouth, or vagina (15). This style may involve special masturbatory rituals, self-stimulation that is striking in terms of the speed, pressure, intensity and duration, sophisticated, and unrealistic erotic masturbatory fantasies or selfmanagement routine to stop ejaculation at the last pre orgasmic moment.

Apfelbaum also refers to masturbation and suggests that men presenting with DE may actually possess an �autosexuall� orientation in that they experience greater enjoyment in solo masturbation, rather than partnered sex (18).

DIAGNOSIS:
  1. Sexual history: Sexual dysfunction due to unusual masturbation habits.
  2. Specific masturbation style:
    1. Age of onset
    2. Frequency
    3. Erectile function during masturbation
    4. Feelings accompanying the masturbatory act.
  3. Sexual Activity include the masturbation:
    1. How often is the sexual activity including the masturbation, the intercourse, oral sex, or any other type of sex.
  4. Masturbatory Technique: this may shed light on the sexual dysfunction in some patients and may pave the way toward successful sexual rehabilitation.
This article will intensify to show the role of inquiring about masturbation by all patients with ED and SD to diagnose the etiology of the SD by these patients.

ETIOLOGY:
  1. Hypoactive Sexual Desire Disorder (HSDD)
  2. Inhibited Orgasm with normal desire, arousal, and erectile function.
  3. Orgasmic disorder and absence of satisfactory sensation of orgasm despite normal desire, arousal, erectile function.
A literature search revealed that there are scant studies on masturbatory practices and their possible deleterious effect on the male sexual function and intimate relationships (7, 10, 12, 14, 19).

Perelman (14) found that high frequency masturbation was correlated with retarded ejaculation in 85 men and aged 19-77 years. He also noted that over 40% of these men masturbated by using distinctive technique that could not easily be replaced by their partner�s hand, mouth or vagina.

There are several distinct aspects of masturbation that have clinical relevance; frequency, firmness of erection, time of orgasm with self-stimulation, fantasies during masturbation, and masturbatory technique. Many of these patients have a variety of SD�s complicated by unusual masturbatory practices concerning these elements.

The majority of these patients appears healthy on routine examination (Urogenital, neurological, hormonal and vascular). Interestingly each of the aforementioned masturbatory practices was associated with different SDs (i.e. HSDD, ED, anhedonic ejaculation and retarded ejaculation).

The findings of Corona et al. (12) and Perelman (14) confirm that enquiries about masturbation and the quality of erection during autoeroticism add relevant information to the clinical characterization of patients referring for ED or DE.

Sank (19) based on case study, defined traumatic masturbatory syndrome as a habit of masturbating prone, which in his clinical experience leads to severe SD, mainly ED.

By all patients with ED, a thorough sexual history taking and query into masturbatory practices lead to a comprehensive diagnosis of the underlying problem and to successful treatment especially by young men with ED, SD or DE. It is obvious that without such important information, the source of the SD would have remained obscure, thereby limiting our ability to optimally assist each patient suffering from ED, SD or DE.

PRIMARY PREVENTION:

The sexual health education of young adults and adolescents with sexual dysfunction play an important role in the primary prevention of these diseases. The main educational message is, the masturbation should resemble sexual relationship in the real world by involving caressing manual movements with a use of a lubricant.

In addition, youngsters should know that it is acceptable to use sexually explicit material together with their own imagination. Sank�s case study (19) raised the level of awareness to the problematic practices of masturbation and lead to an initiative called �healthy strokes� (http:/www.healthystrokes.com) designed to assist young men in enjoying their sexuality.

TREATMENT:

Changing the patient�s masturbatory practice to be more compatible with sex with a partner lead to a beneficial impact on the sexual function of these patients and enable them to engage in normal intimate relationships

REFERENCE:

1) Schuktheiss D, Glina S. The history of sexual medicine. In: Porst H, Reisman Y, eds. The ESSM syllabus of sexual medicine. Amsterdam: Medix Publishers; 2012:14-27.
2) Von Kraft �Ebing R. Psychopathia sexualis. New York: Bell; 1965:188-9. Original edition, 1886, trans.
3) Bullogh VL. Masturbation: A historical overview. J Psychol Hum Sex 2002; 14:17-23.
4) Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human male. Philadelphia: Saunders; 1948.
5) Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. Sexual behavior in the human female. Philadelphia: Saunders; 1953.
6) Nazareth I, Boynthon P, King M. Problems with sexual function in people attending London general practitioners: Cross sectional study. BMJ 2003;327:423.
7) Gerressu M, Mercer CH, Graham CA, Wellings K, Johnson AM. Prevalence of masturbation and associated factors in the British national probability survey. Arch Sex Behavior 2008;37:266-78.
8) Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behavior in the United States: Results from the national probability sample of men and women ages 14-94. J Sex Med 2010;7 (5 suppl): 255-65.
9) Lindau ST, Schumm LP, Laumann EO, Levinson W, O�Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762-74.
10) Dekker A, Schmidt G. Patterns of masturbatory behavior: Changes between the sixties and nineties. J Psychol Hum Sew 2003; 14:35-48.
11) Donovan B. The repertoire of human efforts to avoid sexually transmissible diseases: Past and present. Part 1: Strategies used before or instead of sex. Sex Transm Infect 2000; 76:7-12.
12) Corrona G. Ricca V, Boddi V, Bandini E, Lotti F, Fisher AD, Sforza A, Forti G, Mannucci E, Maggi M. Autoeroticism, mental health, and organic disturbances in patients with erectile dysfunction. J Sex Med 2010; 7:182-91.
13) Perelman MA. Rowland DL. Retarded ejaculation. World J Urol 2006;24:645-52.
14) Perelman MA. Masturbation is a key variable in the treatment of retarded ejaculation by health care practitioners. J Sex Med 2006;3 (1 suppl): 51-2.
15) Perelman MA. Idiosyncratic masturbation patterns: A key unexplored variable in the treatment of retarded ejaculation by the practicing urologist. J Urol 2005;173 (1 suppl): 340.

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae