Confessions of a Sexologist
In my second year of medical school, one of my classmates confessed that he had
once witnessed a rather disturbing scene in his family. Upon returning home from
his school for summer vacation some four years ago, he had inadvertently seen his
father hitting his mother with a leather belt and violently forcing himself upon her.
For a typical Indian teenager brought up to believe all sexual acts were taboo,
seeing his own father involved in this sadistic behavior rattled him to his core,
scarring him deeply. It also put him in a very conflicted position where he felt
immense guilt, disgust, and hatred towards his father, while simultaneously
seeking validation from him like as he had been conditioned to do all throughout
his childhood. He spent the rest of his days pretending he had not seen anything,
and went back to school two whole weeks before the vacation ended, hoping he
would forget the whole ordeal once he got back with his friends.
Little did he know, however, that the memory of the events he had seen would only
grow further into a feeling of deep, lasting shame regarding his family. As the days
passed by, the furrows in his self-esteem deepened and he started to lose interest
in all sorts of sexual and romantic pursuits. Shortly afterwards, he ended his
relationship with his girlfriend of two years, and by the end of the year, he was in
a state of deep depression and anxiety.
Adolescence is a time when the prefrontal cortex, which is the rational part of the
brain responsible for impulse control, organization, and decision-making, is still
developing. However, the amygdala, the emotional part of the brain, grows much
earlier. This makes teenagers process everything on a deeply emotional scale,
making them much more vulnerable to mental illnesses than adults when they are
exposed to emotional trauma. My friend, too, was just a young boy keen to grow
and connect with his father, but had succumbed slowly to the aftermath of what
he saw but could not process. Over the years, we lost touch and I never met him
again, but the feeling of regret for not being able to offer him any help troubles me
to this day.
Four years later, I came across another incident that made me feel equally helpless.
Another close friend of mine had died by suicide, and in the suicide note he left his
family, he had written that he was unable to bear his wife’s constant taunts and
nagging, ridiculing him for not being able to last longer in bed. Each of us has an
important psychological need for self-esteem. While praise builds it, being
constantly told off or shown that we are incapable of performing a role, like in the
case of my friend, can shatter it, making us vulnerable to depression and self-harm.
As I sat in the living room with his mourning family watching the swollen eyes of
his inconsolable elderly parents, I couldn’t help feeling guilty for not approaching
him sooner for about the issues he had been going through all alone. Had he been
able to tell me he was suffering from premature ejaculation, not only would he
have been alive, but he would also have been able to enjoy a stronger and healthier
relationship with his partner.
These are, unfortunately, just two among many of these instances. In my years of
working as a sexologist, I have become a prime witness of thousands of stories like
these, all revolving around the pain that arose from unresolved issues connected
to human sexuality, begging some very important questions as to why this has
been happening, and what we can do to prevent it.
***
Sex continues to be a big taboo in India. For all other matters concerning health,
our society has ensured that there is help available in the form of proactive support
structures with a range of treatment options. Research across various disciplines
of medicines, too, has always been encouraged. When it comes to our most
intimate desires, however, there is a dead silence, an awkwardness, and a sense of
shifty avoidance. Most households gleefully pretend sex does not exist at all, and
proper sex education is a rare privilege denied to many. This collective censorship
has manifested into a paucity of understanding, treatment options, and support
for victims of psychological and sexual ailments who fear societal ostracization
merely for seeking help.
As a practicing sexologist, I know that a vast majority of patients who visit a
sexology clinic arrive to seek help with psychosexual issues, which often relate to
the mental, emotional, and behavioral aspects of sexual development. To address
this, we need dedicated experts working exclusively in this specialty, as is the case
in many developed parts of the world. In countries like India where we need these
experts the most, however, we still suffer from an extreme shortage of trained
professionals. Things were even worse when I started working in the 80s, where
when we had no clear directions, treatment options, or protocols for a wide range
of psychosexual diseases. Even in the 90s, I often felt like I was on my own when it
came to finding treatment methods.
One of the most challenging cases I faced during this time was of Prasad, a 34-yearold man from Mumbai. On the outside, it seemed he had his life all figured out. He
lived with his parents in a plush city apartment and ran a successful business.
Although single, Prasad visualized himself as a father who could dote on his wife
and nurture his children. As was often the case with many young people in India,
his parents, too, were keen to see him married and have children. In fact, hHe had
received several proposals from women, but to the surprise of his family, he had
turned all of them down.
“Doctor, I am not attracted to men or women, not even children or animals,” he
told me when we met, pausing to check my reaction. Having visited many
therapists in India and in the US without any results, he already knew the
questions I might ask him, as well as the fact that his problem was not
conventional. His facial expressions therefore, therefore, made no attempt to hide
his reservations about therapy.
“I am sexually aroused only when I caress or fondle an artificial male wig.” he
added, “And before you ask me, please don’t misunderstand this for any sexual
attraction to men who wear wigs.” Although he tried to appear tough on the
outside, the mix of sadness and frustration in his eyes was impossible to miss when
he said this. I knew I could not let him return empty empty-handed.
As we talked further, it became clear to me that Prasad wasn’t entirely asexual. In
his private moments, in fact, he would often fondle with one of his wigs to
masturbate. I recogniszed and recognized the diagnosis the instant he gave me this
information, but knowing he suffered from a severe form of fetishism wasn’t
enough to help him. The real problem lay in the fact that there was no standard
line of treatment for this condition, so the challenge for me was to not only help
him get rid of his wig fetish, but to also ensure that his faith in therapy and
therapists remained unharmed.
Over the next few weeks, Prasad and I started unravelling this story further.
When he was 12 years old, his daily routine involved going to school and returning
by 2 in the afternoon. His parents only came home from work at around 7 in the
evening, giving him about five hours of time alone, which he would spend watching
cartoons or playing games by himself. This was routine for a few years until his
maternal uncle came to stay with them for a few months. A single man in his
thirties, his uncle wore a wig and had a particularly flamboyant air to him. Prasad
soon found a friend in him and they started spending a lot of time together after
school. From sharing snacks to helping Prasad with his homework, the uncle made
him feel immensely safe and loved. Instead of an empty house, Prasad was now
returning home excited to watch his favorite cartoons with someone who would
be waiting for him.
One day, on a hot summer afternoon, the uncle introduced Prasad to a new game.
He insisted, however, to swear that the game would be kept a secret between the
two of them, or else they could not play. In his naivety, Prasad gleefully agreed. The
game would begin with the act of undressing, after which the uncle would ask
Prasad to relax and lie down. He would then proceed to gently massage his body
and slowly begin masturbating the boy. All that Prasad was expected to do was lie
back and enjoy being pleasured by his uncle.
Alone in the house for five hours, the game became an everyday affair. Afraid of
speaking out and unaware of the meaning or significance of the assault, Prasad
would uncomfortably look at his uncle's face and gradually shift his gaze to his wig.
This made his young and impressionable mind form an association between wigs
and sexual pleasure without him even realising realizing it. Eventually, it became
a fetish that he did not register was unnatural.
Soon, Prasad’s uncle received a job offer and moved to another country.
Unfortunately, it had been too late for Prasad who had already developed a
penchant for masturbation. He would return from school every day and visualize
those moments with his uncle as he pleasured himself. As the years passed, the
uncle’s face faded but the habit of gazing at the wig remained. Eventually, he
reached a point where he could not get aroused and enjoy sexual release without
using the fantasy of a male wig
It took us several sessions and over four months of time to find this the source of
his fixation. One of the key features of therapy for fetishism is finding the root of
where it arises. It is a time-consuming and intricate job, but the arduous effort and
patience eventually paid off, and Prasad managed to share the secrets he had
unconsciously prohibited himself to revisit, let alone share with someone else.
While this was a massive step in the right direction, what remained now was to
cure Prasad of this condition, which I suspected was going to be even trickier.
If Prasad had visited a psychiatric ward in the 1970s or even the 80s, he would
have been given Electroconvulsive Shock Therapy (ECT), a controversial
technique of passing electricity through the brain as a form of treatment. Contrary
to popular beliefs, ECT is actually a tremendously useful technique proven to safely
and successfully treat patients with uncomplicated but severe and prolonged
depression, bipolar disorder, acute mania, and certain schizophrenic syndromes.
In the 60s to 80s, there was a blatant misuse of this technology, with many
physicians prescribing it as the first line of treatment to almost anyone including
patients of with mild depression, anxiety, or even psychosis, for whom much
simpler treatment options were available. ECT had become so popular by the 70s
that many suspicious family members insisted that doctors give ECT to their
patients, and some physicians even threatened patients with ECT. In fact, in the
year 1981, when I completed my medical degree, ECTs were still being provided
by obsolete machines operated by ignorant and uncaring psychiatrists. Even in the
developed west back then, less than half the clinics met the minimum standard
guidelines set by the Royal College of Psychiatrists. We can only imagine what the
condition would have been like in India for Prasad.
I knew, therefore, that I would have to go beyond what was established and
innovate to help my patient. Before looking forward, however, I decided to take a
look back at some past principles in psychotherapy that had been overshadowed
by the rise of ECT and were no longer in popular use, hoping one of them would
show some promise. I knew of a tool called Transactional Analysis (TA) that can
be of a good use in Prasad’s case. TA is a unique method of therapy inspired by
Sigmund Freud’s psychoanalysis and developed by a Canadian psychiatrist, Dr.
Eric Berne. This technique requires exploring the interactions that the patient has
had throughout the years with the people closest to him, and analyses analyzing
this information to understand the inner mechanics of how his psyche is
functioning and perceiving the world. Along with this, I employed a series of
psychotherapeutic interventions such as Robert Carkhuff’s model of counseling,
Rational Emotive Behaviour Therapy, and Gestalt therapy in my counseling
sessions. These psychotherapeutic techniques are unique in the sense that they
are targeted and personalized, which makes sense considering how every patient’s
psychosexual issue has an intensely personal origin behind it. In many ways, they
are far gentler and safer than ECT ensuring that millions can benefit from
specialized therapy and live meaningful lives.
As the weeks rolled away, Prasad slowly started showing improvement with these
techniques, and only a year after starting the treatment, he was completely healthy
again. Inspired by Prasad’s case, I have successfully used a combination of TA,
Robert Carkhuff model, REBT, and Gestalt therapy in many other cases of fetishes
and paraphilias since then.
When I share with psychiatrists today how the use of counseling and a series of
psychotherapeutic interventions helped Prasad ultimately get married and raise a
child, they confess that they have never heard about any of these techniques
developed and practiced since the 1950s. In fact, nNone of the counseling
techniques I used, including Robert Carkhuff’s model, Rational Emotive Behavior
Therapy, Gestalt therapy, and TA, are part of a medical or psychiatry curriculum at
an undergraduate or graduate level, even today.
As there are hardly any clinical trials on fetishism, this treatment is still based
almost entirely on the experience between the therapist and patient in the clinic
and scattered research conducted on it. It has therefore become especially
important that we share our experiences as therapists to seek solutions, and
understand how sometimes innovation means looking back at what we have
already done and trying to see if there are loose ends whichthat, when connected,
can provide us with new answers.
In saying all this, I must admit that the real solution to Prasad’s conundrum did not
begin with my quest to try something new. It began with my patient’s own
determination and perseverance in standing up against unjust stereotypes and
taboos. None of this would have been possible had Prasad not been bold enough
to admit that something was wrong and seek treatment, risking immense
judgement and isolation from the people around him. Therefore, in the field of
sexual medicine, perhaps the greatest innovation we need is not just in technology,
but in the minds of our patients and our society as well.
Innovation scale
1970: Prasad would have believed that he was an outcast. Insensitivity from
others, be it a professional therapist or friends, would reaffirm his
negative beliefs, and Prasad wouldn't realize that he could be a loving father, a
devoted lover, and a generous human being. ECT could be performed as well,
though it would not produce any results.
2020: Therapy helps him realize, among many things, that he was not at fault
and must now focus on taking care of himself. The sexologist would also derive
immense confidence from a documentation of success stories with valuable
therapy tips and techniques.
2070: Undergraduates and graduates in medicine will be trained in basic
counseling techniques. They will relieve therapists from treating primary
psychiatric disorders. This is likely to allow the sexologist treating Prasad to feel
supported and less burdened.