Lack of anatomic knowledge leads to fear of giving injury or being injured by the sexual partner. E. Podolosky, 1953 INTRODUCTION The lack (or incomplete) knowledge about male and female sexual organs and the changes during sexual activity leads to misconceptions in general population. Educa- tion about the anatomy (especially functional anatomy) of human sex organs becomes an essential part of the management for patients with sexual disorders. This chapter briefly discusses functional anatomy of organs asso- ciated with sex. It also highlights the role of various regions of brain in sexual functioning. SEX ORGANS OF MALE The genitalia of the normal adult male include the penis, scrotum, testes, epididymis and parts of vas deferens. Internal components include the vas deferens, seminal vesicles, ejaculatory ducts and prostate gland. Penis The penis is the male copulatory organ. It is meant for the passage of both urine and semen to the exterior. It has two partsthe root and the body. The root of the penis is the fixed part and consists of two crura one on each side, Anatomy of Sex Organs Sudha Chhabra, Vishal Chhabra 1 Let my love, like sunlight, surround you and yet give you illuminated freedom. Love remains a secret even when spoken, For only a lover truly knows that he is loved. Ravindranath Tagore Fireflies and a bulb. They are made up of erectile tissue and are attached to the inferior surface of perineal membrane in the superficial perineal pouch. It has a body, which is free, cylindrical and pendulous measuring 7.5 to 10 cm in length. It consists of three parts, the two cor- pora cavernosa situated dorsally and corpus spongiosum lying ventrally and containing the penile urethra. The anterior end of corpus spongiosum is expanded dorsally and hollo- wed out to form glans, a conical cap fitting over the blunt ends of corpora cavernosa. 3,13 The skin is thin, delicate, dark and hairless outermost covering. It is loosely connected to underlying fascia, so as to allow free move- ment of the skin over the fascia. It is folded upon itself to form a hood over the glans called the prepuce which is continuous with skin covering the glans at the neck of penis. The prepuce is retractable fold of skin and the space between it and the glans is the preputial sac. There are preputial glands in the skin of corpora glandis; they secrete the smegma, which collects in the preputial sac. 3,4,13 There are two ligaments of penis, one is called fundiform ligament that is attached to the median raphe of scrotum. The other is the suspensory ligament deep to the fundiform ligament.

INTRODUCTION The reproductive organs including the glands are primarily involved in the preservation and well being of the species. Multiple differences between males and females depend on the Y- chromosome. The presence or absence of this chromosome determines the differentiation of gonads, maturation and sexual behaviour. In human females, ovarian function regresses over the years and sexual cycle ceases. But in males, there is only a decline in function. SEX DIFFERENTIATION The process of sexual differentiation produces the most fundamental and obvious difference between genders. Until the first 5 weeks of gestation, the gonads and genital tracts are not differentiated and appear indistinguishable. They consist of the bipotential gonads that later give rise to the ovaries or testes, primo- rdial internal genitalia and neutral external genitalia. The internal genitalia consist of a pair of wolffian ducts that give rise to the male genitalia and mullerian ducts that give rise to the female genitalia. The external genitalia develop from common analgen, which are urogenital sinus, the genital tubercle, the genital swelling and the genital folds. The presence of Y-chromosome is the posi- tive and single most important determinant of maleness, without which neither the testis nor masculine genital pattern develops. It may be noted that the presence of autosomal alleles and X-chromosome gene are essential for complete maleness. 6 The absence of Y-chromo- some and presence of both the X-chromosome define the growth of normal ovaries, though the second X-chromosome is normally inacti- vated early in all extragonadal tissues. But if an abnormality results in an XO karyotyping, there will be female phenotype, but with defective gonads. 6 In males, Sertoli cells in the testis produce mullerian inhibiting hormone (MIH) that causes atrophy of the mullerian system. Testo- sterone secreted from the Leydig cells of each testis acts unilaterally on its wolffian duct to differentiate it into vas deferens, epididymis, ejaculatory ducts and seminal vesicles. MIH also helps in the descent of the testis. In females, the absence of MIH allows the mullerian system to differentiate into the female genital tract and this process is complete by 20 weeks of gestation. 1 The external genitalia of both sexes begin to differentiate between 9-10 weeks of gestation.

INTRODUCTION Life seems to have originated on earth some 2000 million years ago and its continuation is possible by the unique activity of reproduc- tion. Reproduction is possible due to sexual development and is practically impossible if any abnormality in sexual development occurs. It is now clear that the primitive bipo- tential sex gland, i.e. the gonad (gone-seed) differentiates into either a male gonad, (testes) or female gonad, (ovary); and the predo- minant determining factor is solely a single chromosome, i.e. the Y chromosome. 4,18,30 The formation of genitalia depends on the secretion of the testes. In the presence of functional testes the genitalia become male type and in the absence of functional testicular tissue the general features and the genitalia become female type. 20 Hence, the most important factors for the sexual development are (i) genetic, and (ii) endocrinal. 24 GENETIC ROLE IN SEXUAL DEVELOPMENT The genetic control of sexual development is very often called the sex determination. In humans, there are 46 chromosomes. Out of 46 chromosomes, 44 are autosomes or somatic chromosomes and the other two are sex chromosomes. The genetic sex (sex genotype) depends on these two sex chromosomes. These are named as X and Y. In females the sex chromosomes are XX whereas in males it is XY. The Y chromosome is sufficient for production of testes, i.e. male gonad. The testes determining gene product in Y-chromosome is called sex determining region of the Y- chromosome (SRY). SRY is a DNA binding regulatory protein. It binds the DNA and acts as a factor that initiates transcription of a series of genes, which are required for testicular differentiation. The gene for the SRY is present in the tip of the short arm of Y chromosome. During the process of gametogenesis the haploid cells like ovum and sperm contain only 23 chromosomes each, i.e. 22 somatic chromosomes and one sex chromosome. In male the spermatogonia may be 22X or 22Y but in female it is only 22X. 24 In males 50% of sperm contain 22X and the other 50% contain 22Y. The process of gametogenesis consists of two-stage meiotic division which produces the haploid cells containing 22 autosomes and a sex chromosome, i.e. X or Y. But there is a difference in male and female. In females in the two-stage division, only one cell survives as the mature ovum containing 22X and in Genetic and Endocrinal Factors in Sexual Development Umakant Satapathy, Niharika Panda, Lucy Das 3 In former days wed both agree, That you were me, and I was you What has now happened to us two, That you are you and I am me.

INTRODUCTION Human sexual development involves a complex series of eventsinvolving bio- logical, psychological and social change. 4 Study of human physiology has provided us with considerable information about the vicissitudes in human development as the infant is transformed into a fully functional sexual being. Such changes include neural, maturational, cognitive developmental and neurohormonal changes particularly at puberty. 10,33,44 Accompanying these biological changes are changes in social behaviour. 34 The infant progresses from being a relatively asocial figure to a stage of developing social peers and finally onto the stage of establishing mature adult relationship with a sexual partner. Taking into account the various theories on offer, i.e. biological, sociological, cognitive social learning and psychoanalytical models, it is the latter which has had the most impact on our understanding of sexual develop- ment. 4,33 Biologically, psychosexual develop- ment begins prenatally. Genetic factors, effects of the reproductive hormones and physio- logical maturation all play a role. 5,47,48 Sexual development begins at the chromosomal level leading on to organisation of the gonads, development of the internal sexual organs and external sexual genitalia. The surge in hor- mones at puberty leads to the development of secondary sexual characteristics. 37 At all times, parallel to the above process, takes places the sexual differentiation of the brain that contributes to overall psychosexual development. 46 Social learning theories of psychosexual development are essentially based on the learning theories of reward and punishment and are, therefore, not confined to human beings unlike cognitive learning theories. 34 Cognitive learning theories are more complex, particularly so in relation to psychosexual development. 29 They are essentially based on the human ability to categorise and concep- tualise and to use verbal language. 13 Piagets genetic epistemology model emphasised the importance of stepwise cogni- tive growth at each developmental stage. 39 Right from the early phase of sensori-motor development cognitive development drives the development of emotion and pleasure for a caregiver (usually parent). With further development comes the ability to think symbolically, build conceptual bridges, control impulses, acquire a stable emotional tone and importantly achieve a self-other representational differentiation. 40 Strangely, Piaget ignored the application of this cognitive Psychosexual Development and Human Sexuality Subodh Dave, Ananta Dave 4 Really what keeps us apart at the end of years is unshared Childhood. ....

Can beauty be understood Beauty of the human body is difficult to define but can easily be recognised in an instance. It is straight and simple; overpowering and direct. And the impact is breathtaking. What is beauty Does it serve any tangible purpose in life Why is history awash with faces that launched a thousand ships Why is ugliness so difficult to put up with We want even our shirts to be tailored elegantly. We are revolted, benumbed, by the other extreme: horror and ugliness! srutamicchanti pitarau, dhanamicchanti maatara baandhavaa kulamicchanti, roopamicchanti kanyakaa [From neeti saaram] Roughly translated, the above verse means: Father seeks fame; mother, fortune; kin seek lineage and the maiden, looks. Cutting across cultures, beauty has undou- btedly occupied a central position in the life of man. But many still believe that enquiry into such subjects lie outside the limits of our rational intellect. They believe it is the business of the poet, artist or philosopher. Beauty is a mystifying experience. A poet said Beauty lies in the beholders eyes. True. But how was the beholder engineered by great nature to be alive to this abstract but easily recognised reality To put it in a Darwinian fashion, how does beauty increase our fitness for survival How did it become a universally recognised aspect of human perception Beauty can be Understood and Explained Beauty plays an important role in the sexual selection of not only humans but also animals. Something as universal as a sense of beauty must obviously have a survival value. Studies have shown that even two-month-old infants prefer to gaze at faces that are attractive to adults. 3 Therefore, the sense of beauty must be a part of our instinct. Some kind of an aesthetic sensibility is engraved in our genes. More than a century ago, in 1878, a scientist Francis Galton tried to superimpose images in order to create composites of faces. His chief idea was to arrive at a criminals prototype. 3 He superimposed the faces of several cri- minals but the attempt at arriving at the prototypical criminal face never materialised. However, to his amazement, the composite figure that emerged from the blend of cri- Beauty of the Human Body: Its Meaning and Purpose MK Unnikrishnan 5 The moon, long gazing, at will, At the faces of lovely women Sweetly slumbering on whitened terraces, At night, is doubtless over-eager.

I expose to men the origin of their first, and perhaps second, reason for existing. Leonardo da Vinci (1452-1519) wrote these works above his drawing The Copulation around 1493. INTRODUCTION Human sexual activity is a manifestation of complex interaction of various social, psycho- logical, interpersonal and biological elements. The activities during love-making are influ- enced by the adherence to the so called societal norms for such behaviour, expectations of the partners, perception of self image, their biological responsiveness and the quality of relation between them. Mature heterosexual love is marked by the intimacy that is a special attribute of the relationship between a man and a woman. An ability of active receiving wherein a person while loving, permits himself to be loved, is the quality of intimacy in a mature sexual relationship. 9 Sexuality and ability to love have reciprocal effects on each other. In a loving relation sex acts as a catalyst. Values of sexual love are an expansion of ones self-awareness, the experience of tenderness, increase of self affirmation and pride, and sometimes, at the moments of orgasm, even loss of feelings of separateness. It is in this setting that sex and love are reciprocally enhancing and healthily fused. 9 In this chapter the psychophysiological responses during the sexual love and activity are discussed. Sexual stimulation leads to a sequence of physiological responses which are described in various phases like excitement, plateau, orgasm and resolution. Before the excitement begins and definite physiological responses ensue there is a appetitive phase recognized by various authors where men and women remain oriented and interested for sexual activity. These phases are arbitrarily defined, for clearer understanding of the processes. They are not clearly separated. They vary considerably in one individual at different periods and in different persons. They are influenced very much by the mood and thought of the person and change in the course of any particular time. In addition the Sexual Response Cycle and its Determinants Nilamadhab Kar 6 Not tonight- not even if your creep foam-footed into the bed, offering the salt- taste of your flesh. ...... A man should come to his woman whole- not when the mind, like a perverted sunflower, turns its face to darkness only.

INTRODUCTION Among the various emotional and behavioral states in children and adolescents, sexual behavior is the most understudied. Hitherto, sexuality had largely been described in relation to issues such as pregnancy, sexually transmitted diseases and sexual violence. As a result, not much is known about normal sexual behavior. Information about how children and adolescents construct knowledge with regards to their own gender and identity is lacking. This chapter is an endeavor to cover the various aspects of sexual behavior of children and adolescents and briefly touch upon related areas. SEXUAL DEVELOPMENT Children, right from birth, have occasional erections or vaginal secretions. Of course, the feelings or thoughts associated with it are still unknown. However, by age five, a child is capable of experiencing sexual feelings. Children, through ages of 7-12 years, continue to mature sexually. Although their main focus is to establish peer relationships, they begin to experiment with sexual behaviors and may have alternating sexually open and sexually secret periods. From ages of nine or ten, most boys engage in a rich form of experimentation referred to as silent sex. They may sit and fantasize for hours about the differences between males and females. On the surface, these children may appear to be less interested in sexual topics. This is usually due to the strong adult deterrent to discuss sexual matters. As a result, they become more secre- tive and private about their sexual thoughts, feelings and behavior. Preadolescents engage in sexual play with other children of the same age. This increases from 5% at 5 years of age to about 65% at 13 years of age. 30 Sexual acti vity usually makes its debut in adolescence and young adulthood, as evidenced by open mouth kissing, sexual fondling and inter- course. Children and adolescents are more likely to take on the cultures values about sex and nudity, sometimes at variance with their families values. The cultures moral, religious and health restrictions do seem to have a tempering effect on sexual activity. 30 Adolescence, a time of individuation and transition into adulthood, is a trying time for most youngsters. It also signals the onset of puberty (10 to 16 yrs of age), which results in rapid changes in sexual development. Puberty is a time when the body becomes capable of reproducing. For girls, puberty begins when they first have their menstrual period. Secondary sex characteristics, such as increase in breast size and pubic hair, precede this. For boys, the signs of puberty are subtler. These include development of facial, pubic and other Child and Adolescent Sexual Behaviour Rajeev Jayaram, Shekhar P Seshadri 7 As now she enters the ways of love. Sometimes she gazes at her blossoming breasts Hiding them quickly, then forgetting they are there. Childhood and girlhood melt in one And new and old are both forgotten.

INTRODUCTION Love is probably one of the most elusive and yet perhaps the most common theme under- lying interactions in personal relationships. However, its enigmatic nature has not deter- red behavioral scientists from attempts at understanding its myriad meanings, origins and consequences. What is Love Despite decades of love-research, there is no single answer to this question. The following are a few approaches that attempt to define and elaborate upon the concept of love, primarily from psychosocial perspectives. Love versus Mere Liking Rubin 30,31 differentiated love from liking and developed separate scales to assess them. Rubins three-component theory of love includes affiliative and dependent need, predisposition to help and exclusiveness and absorption. Cunningham and Antill 7 descri- bed the ways in which feelings change as one moves from liking to loving: change in the feelings about equity (decreased monitoring of who owes what/ keeping tabs, enhanced sense of equality and interdependence irres- pective of objective assessment of inequality, shared identity/strong we feelings and pleasures in giving without consideration of costs/extent of reciprocation. Sternberg and Grajek 37 proposed that a general factor of love is consistent across various forms of close relationships e.g. romantic/filial/friendship) although the concomitants of the core experiences might be quite different. Real Love and In -Love Experience/Falling in Love Tennov 38 differentiated between love and limerence. Love was described as being characterized by mutual affection and con- cern. Limerence was described as passionate love which may start off as a spark of interest and get highly intensified under certain conditions, taking the form of intrusive cognitive activity, acute longing and depen- dency, often unrealistic hope of reciprocation, euphoria associated with a sense of perfect union, disengagement of reasoning processes and eventual sense of dysphoria when the emotions have run their course and real Understanding Love Seema Mehrotra 8 When I went away I thought, she would try to stop me attempt to reconcile. The wind billowed through our cloths. I thought she would ask me not to go When she unraveled her limbs I though she would come to call me back.

INTRODUCTION Relationships have certain qualities that influence an individuals life experiences and health in very special and unique ways. Decades of international psychological resear- ches have confirmed the significance of close relationships for general health, mental health, and well-being of both men and women. Relationship problems are also the most commonly occurring presenting problem in young adults seeking help. It is perhaps the most frequently occurring theme in clinical interviews in India as well. Moreover, it domi- nates session process in a large part of individual, couple and family therapy ses- sions. Marital relationship, in particular, happens to be the most prominent relationship in the entire adult life span. Thus, theorists, researchers as well as clinicians have contri- buted to professionals understanding of this as well as similar intimate relationships. Specifically, research evidence points towards the fact that while a happy marriage decreases the risk for developing a mental or physical illness, an unhappy marriage increa- ses this risk. 13,17,31,32 Marital conflict is defi- nitely associated with depression, and is also prominent in physical and psychological abuse, alcoholism in men, early onset drink- ing, as well as in eating disorders in women. 9 Life events research also points out that after death in the immediate family, marital distress and divorce are the most severe commonly occurring stresses in adult experiences. 3 Research has also confirmed that marital distress actually increases risk for developing certain psychological disorders including depression in women, alcohol abuse in men, higher rates of sexual dysfunctions in both sexes, increased behavioral problems in chil- dren, and conduct disorder in boys. 14 This association is not one way. Long-standing and severe psychological disorders reduce the chances of someone developing a satisfactory relationship. Family medicine research also suggests that married individuals are healthier, that marital conflict is associated with poorer health, 8 and marital conflict is associated with specific illnesses like cardiac diseases, chronic pain, and cancer. 9 Burman and Margolin 6 also confirm that the psychological quality of marriages is linked to mortality and morbi- dity, although the effects are indirect and nonspecific. They report that individuals in satisfying relationships are less vulnerable to Couple Relationship and Sexuality Anisha Shah, Rathna Isaac 9 Some love and get lost in marriage, Some search love in it, Some remain confused If love means marriage or marriage love. Blessed are those who get love in marriage, And those who can still believe.

INTRODUCTION Human sexuality is a multidimensional activity. In this chapter an attempt would be made to understand the actual sexual beha- vior. Many medical textbooks on sexualities deal in great detail with many aspects of human sexual biology like functioning and problems of sex but they are least likely to deal with the basic facts on actual sexual behavior. Sir James Paget had recognized, as early as 19th century, that ignorance about sexual affairs seems to be a notable characteristic of the more civilized part of the human race. 39 Even to this day that situation has hardly changed. Making love involves emotional union on the one hand while the other depends on ones knowledge of oneself, anatomy, physiology of sex and the techniques to achieve the union. 6,14,16 Ultimately, the sexual intercourse, referred variously as coitus, coition, copulation, mating etc., involves physical union-between the male and female. 40 Before the sexual intercourse, sexual foreplay is usually indulged in such as kissing, fondling, petting etc. To put it in simple terms, it means that people express their sexuality in many ways. 13 The emotions and meanings attached to these sexual behaviors also vary widely. 6,14,16,41 In this chapter, we will follow the broad definition of sexuality behavior as all of those activities and behaviors that produce sexual excitation. 13 This definition includes sexual activities like masturbation and fantasies so also interpersonal activities such as kissing, touching, sexual intercourse, oral, anal, genital stimulation, etc. (Table 10.1). EROTIC DREAMS AND SEXUAL FANTASY These are a form of autoerotism. These happen within a persons mind, with or without associated sexual behavior. Our imaginations so also current and past life experiences are important here. Erotic sexual fantasies are very common and are considered very important for sexual arousal. 28 Kinsey et al reported 84% of men and 67% of women having sexual fantasies. 13 Another study reported that 74% of men and 80% of women having fantasies of intercourse with a loved one. 23 Other common fantasies involved having intercourse with the stranger, intercourse with more than one person, being forced for the sex, forcing someone to have sex and having sex with someone of the same sex etc. 23 Common fantasies involve somebody paying great deal Sexual Methods TS Sathyanarayana Rao 10 Getting a man to love you is easy, Only be honest about your want as Woman. Stand nude before the glass with him, So that he sees himself the stronger one And believes it so, and you so much more , Softer, younger, lovelier. Admit your Admiration ..

INTRODUCTION The Hindu conception of a full life postulates the harmony of three activitiesDharma, Artha and Kama. The fullness of a normal, mature life could not be achieved by neglec- ting any one aspect. Kama is the life of the senses and it is conceived as the human counterpart of creation with the union of Purusha (matter) with Prakriti (energy) and Shiva and Shakthi. 5 This has led to the concept of Ardhnarishwara . The rules for regulating lives of men and women with regard to the sexual life was laid down by Nandi, the follower of Mahadeva in one thousand chapters under seven heads: 1. Sadharana (general topics) 2. Samprayogika (embraces, etc.) 3 . Kanya Samprayuktaka (union of males and females) 4. Bharyadhikarika (on ones own wife) 5. Paradika (on the wives of other people) 6. Vaisika (on courtesans) 7. Aupamishadika (on the arts of seduction, tonic medicines, etc.) The seven heads were abridged by Shveta Ketu and further by Babhravya and each head was elaborated by Suvarnanabha, Ghotaka- mukha and others. As many of the works were not easily accessible, Sage Vatsyayana compo- sed his Kama Sutra as a compact volume. Vatsyayanas personal name was Malla- naga of Vatsyayana Gotra and hence, he was known by his Gotra. The Kama Sutra was composed in the period first to fourth centu- ries AD. Kalidasa who belonged to the fifth century AD makes numerous allusions to the Kama Sutra in his works. According to Vatsyayana, Kama is the enjoyment of appropriate objects by the five senses of hearing, seeing, feeling, tasting and smelling assisted by the mind together with the soul. The work is not merely one on erotics sensuality and seduction like Ovids The art of love. But, major part of Vatsyayanas work deals with courtship, marriage and wifely duties and conjugal happiness. In his own words at the conclusion of his treatise, Vatsyayana says: after reading and consi- dering the works of Babhravya and other ancient authors, the thinking over the meaning of the rules given by them, the Kama Sutra was composed, according to the precepts of Holy Writ, for the benefit of the world by Vat- syayana, while leading the life of a religious student and wholly engaged in the contem- plation of the Deity. This work left its impressions in art. The maithuna or the union sculptures are to be found in the temples of Konark, Khajuraho, Belur, Halebidu, etc. Such scenes are also Sexuality in the Kama Sutra of Vatsyayana O Somasundaram 11 Love between me and this lady is like bond between soul and body.

Cultural Variations in Sexual Practices Nilamadhab Kar 12 INTRODUCTION Various sexua l behaviours, expressions, disorders even fantasies are very specific to some cultures, w hich are noticed in the writings, arts, and sculptures. Various issues like educational level, economic consi- derations, religion, adherence to specific cult, politics, power in society, value teaching, societal learning, social permissiveness, prohibitions and censorship, taboos, repre- ssion and many other factors besides the biological need shape and influence the sexual behaviour. 43,26,22,24,16 A complete picture of the sexual practices and disorders in different cultures is vast and merits an independent study. This chapter tries to highlight the fact that in various issues the sexual practices of different cultures differ. MORALITY AND SEX Sexual activity is unquestionably one of the most powerful animating human drives and its story reveals much about the people we are and we might become. 4 Though from a psychological stand point, the desire for sex is precisely analogues to the desire of food and drink, 43 it has been associated with so many complicating controversies. Issues whether gender or reproductive roles are natural or they are socially constructed; whether morally permissible sex must have only one function; whether it should be only heterosexual; whether it should be only within the confines of the institution of marriage; whether it should be associated with requisite emotions such as love and intimacy; these are greatly debated topics; and opinions vary greatly across cultures. Sexual permissiveness and morality is also dictated by the religious rules and regulations and degree of adherence to them. Sexual morality affects childhood, adolescence, and even old age, in all kinds of ways, good or bad according to circum- stances. 43 Understandably, the issue has unimaginable variation across cultures in the world. Considering many issues that affect sexual morality, Belliotti proposes a theoretical frame-work for a Sexual Morality Quotient which is LA x (MC + SE TP + 1/2 SC); where LA is libertarian agreement, MC is general moral consideration, SE is sexual exploitation, third party effects (TP) and SC is wider social context. 4 This illustrates that various factors differentially influence the sexual morality of a society and that will obviously be different Speak to me, my love! Tell me in words, what you sang. The night is dark. The stars are lost in clouds. The wind is sighing through the leaves, I will let loose my hair. My blue clock will cling round me like night.

Sexual Dysfunctions in Males S Haque Nizamie, Sayeed Akhtar, K Jagadheesan 13 INTRODUCTION Epidemiological and clinical studies amply demonstrate male sexual disorders to be common clinical conditions. 120,121 These dis- orders affect most people at least once during their life cycle. 68 Generally, sexual disorders involve desire, arousal and orgasm phase of sexual cycle. 6 Frequently, occurrence of one disorder results or culminates in another sexual disorder. A wide range of negative consequences is documented with male sexual disorders, ranging from personal distress to divorce to onset of other psychiatric disorders. Clinicians often tend to overlook sexual dysfunctions until and unless a patient presents with a complaint. 68 Psychosexual therapies are important therapeutic strategies for sexual disorders, but recent studies docu- ment many newer drugs are effective in these disorders. This chapter purports to give an overview of recent knowledge about male sexual disorders. SEXUAL DESIRE DISORDERS Hypoactive Sexual Desire Disorder Hypoactive sexual desire disorder (HSD) is a highly prevalent disorder, with prevalence rate of up to 15%, 95 though rates are relatively less in men 112 and in community population. 120 HSD manifests as deficiency or absence of sexual fantasies and desire of sexual activity, with resultant marked distress or inter- personal difficulty. 6,132 Low sexual desire may be a primary phenomenon or secondary to disturbed sexual excitement and orgasm, and some men with HSD retain the capacity for adequate sexual excitement and orgasm. DSM-IV states HSD should be accounted neither by other psychiatric (except another sexual dysfunction) and medical disorders nor by substance intake. HSD can present as one of the following subtypes-lifelong versus acquired, generalized and situational and due to psychological or combined factors. Pro- longed HSD often leads to poor marital relation and adjustment. Poor sexual desire may take either a continuous or episodic course depending upon psychosocial or relationship factors. An episodic pattern of loss of sexual desire occurs in some individuals with problems in intimacy and commitment. 6 Both psychological factors such as negative emotions, 12,13,114 sexual identity problems, separation of love and sexuality, past sexual ..... You smell of gin and cigarette ash. Your breasts, sharp with desire, hurt my fingers. .... The ashes are all thats left of the flesh and brightness of youth. My life has come full circle: I am thirty.

INTRODUCTION The interface between psychiatry and womens reproductive and sexual health has till date focused mainly on psychiatric problems related to menstrual cycles and child birth. Although problems related to womens sexual performance have been known since long, not much attention has been paid to it. 4,14 One of the reasons for this may be that women may not report these problems unless speci- fically asked. We clinicians tend to overlook female sexuality as a problem area and hence do not enquire adequately. A detailed clinical description of dyspare- unia in the Raesseum Papyri IV scrolls of ancient Egypt suggests that it may be one of the earliest recognized sexual dysfunctions. 9 Knowledge about other disorders have subsequently followed. Masters and Johnson in 1970 2 used only 2 categories of problems for their female patients: organic dysfunction and vaginismus. Kaplan in 1974 2 criticized this scheme and suggested 2 main categories for women: disorders of arousal and disorders of orgasm. She nevertheless regarded orgasmic difficulty as the most frequent cause of complaint. Sexual Dysfunction in Females Arti Dogra, Hema Tharoor, Kanti Muttineni 14 Certain basic differences underlie the attitudes of men and women towards their sexual relationship. In a consecutive series of 200 patients seen in Edinburgh by Kaplan 2 , a striking sex difference emerged. Of the men 77% complained of problems with erection or ejaculation; only 23% complained of lack of interest or enjoyment; thereby focusing usually on their physiological responses. Of the women 80% complained principally of low interest and lack of enjoyment. Hence, women were more likely to focus on the subjective quality of the sexual interaction than on their physiological responses. There are some obvious reasons for this difference; absence of erection or inability to control ejaculation has a much more limiting effect on sexual activity than impaired vaginal response or organic difficulty in the woman. While male sexual problems can be more readily attributed to physiological barriers, females sexual dysfunction is more often difficult to quantify as a physical problem. In women, the effect of anxiety on orgasm is strikingly different than that in men, usually resulting in a delay (in contrast to men who usually have premature ejaculation due to anxiety). During our first serious marriage quarrel she said Why did you take my viginity from me I would gladly have returned it, but not one of the books I had read instructed me how.

INTRODUCTION When sexual behaviour is compulsive and continues despite serious adverse conse- quences, it is an addiction. Sexual addiction is a comparatively new disorder, which has been recognised as a separate entity only recently. The concept has been slowly developing over the past two decades. Though major inter- national classificatory systems namely ICD10 and DSM IV 1 still do not recognise it as a disorder, but associated disorders like nymphomania, satyriasis are mentioned in ICD 10. 20 Many clinicians do report of this disorder from all over the world. Various studies have been done especially in the West to recognise the signs and symptoms of this disorder. According to the National Council on Sexual Addiction and Compulsivity, in 1999, 16 to 21.5 million Americans were identified as sexually compulsive. 12 It is characterised by compulsive seeking of sexual behaviour, which causes impairment of persons personal, family, social and occupational dysfunctioning. 6 The concept has been derived from the models of addiction, whether its chemical like alcohol, opioids, etc. or behavioural like gambling. 8 As in other forms of addiction, sexual addiction causes Sexual Addiction Vishal Chhabra 15 psychological dependence, physical depen- dence and a withdrawal syndrome if its not available. 6,15 Also, despite being well aware of the consequences of their behaviour, these patients are unable to control their impulses as seen in other type of addictions also. Inter- estingly, sexual addiction can coexist with chemical dependency and can cause relapse of drug dependency if left untreated or unrecognised. These patients not only endan- ger themselves but also their family members to the risk for sexually transmitted disease, mainly AIDS. 15 Treating physician or psychia- trist can help these patients and their family members by learning about this phenomenon that is finding worldwide acceptance slowly but steadily. In this chapter besides talking about the sexual addiction, we will also look at some associated conditions like nymphomania, satyriasis, Internet sex addiction and sexual anorexia. Also, we will briefly touch over the family history and coaddiction related to it. DIA GNOSIS When patients present with multiple somatic complaints, depression, dependency on And he said further, In the past you embraced my neck as we lay on our bed, you called out something in your sleep and woke up.

Disorders Associated with Sexual Development and Orientation Sujata Sethi 16 Since I hardly touched her. The first caw and the excitement of crows as they looked at us in bed from the chimney, Bees rushed into the room, the sun pulled up, And the girl next door wrung her underwear; She knew I admired her ankles even in sleep. Arvind Krishna Mehrotra A letter to a friend INTRODUCTION Human sexual behavior is complex as well as varied. It has not only the biological deter- minants; social and environmental factors influence it considerably. Society controls the range and expression of sexual behavior. Some sexual behaviors are condemned while others are considered normal. This chapter is con- cerned with the topic of disorders associated with sexual development and orientation. Psychosexual development encompasses three components. The first is the earliest awareness by the child of belonging to one of the two categories of human beings: male or female. The second component is sex-typed behavior and comprises activities those discriminate males and females at various ages in a given culture. The third component is the sexual orientation. 10 Sexual orientation refers to the various aspects of sexual attraction towards members of the opposite or the same sex. 7 Sexual preference ranges from exclusively hetero- sexual to exclusively homosexual and in between are those who experience varying degrees of both homosexual and heterosexual attractions and fantasies; behaviors and relations. 16 The expression of homosexual and heterosexual behavior varies in the same person with age and circumstances. Ado- lescents tend to show more of bisexual preference than adults. PREVALENCE Kinsey et al 16 estimated that 10% of men were more or less exclusively homosexual for at least 3 years and that 4% of men were exclusively homosexual throughout their lives. Further, 4% of single women were continuously homosexual from the ages of 20 to 35 17 while Kenyon 14 concluded that about one in forty-five of the adult female population was predominantly homosexual. Subsequent studies suggest that figure may be 3% for men and 1% for women. 18 Sex surveys are not reliable. Although the results are valuable, but they cannot be generalized as the subjects do not represent the general population. True expression of sexual orientation varies according to societal and cultural factors. Before the high Middle Ages, homosexuality was well tolerated throughout Europe.

Gender Identity Disorders Saji S Damodaran 17 INTRODUCTION Gender identity disorder (GID) is a relatively new term which includes a group of disorders where the fundamental feature is a strong and persistent cross-gender identification and associated with persistent discomfort about ones own assigned gender or a sense of inappropriateness to the gender role of that sex. 16 GID has attracted only a minimal pro- fessional attention and research over many years and this is attributed to the negative attitude towards transgender lifestyle, con- fusion regarding gender role and gender identity, cultural and societal apathy and at times antipathy to the conditions. Over the past two decades, the scientific interest in GID is increasing. This is partly triggered by the influential book by Harry Benjamin, 4 the advocacy and research by Harry Benjamin International Gender Dysphoria Association (HBIGDA), 14 surgical and endocrinological advancements and public health awareness in transgender health care. 17 Terminology Gender identity is defined as ones basic sense of self as a male or female, whereas gender role is the public statement of gender identity as the behaviours, attitudes and personality traits which are typically expected from or preferred by persons of ones sex or the other. Gender dysphoria describes the emotional aspects and impact of any degree of gender identity disturbance. The term transsexual was first used in psychiatric literature by Hirschfield in 1923 and appeared in DSM-III 1 as a diagnosis though DSM-IV 2 abandoned the term instead of GID. ICD-10 25 still lists trans- sexualism as a diagnostic category besides dual-role transvestism and gender identity disorder of childhood under GID. Male to female (MF) and female to male (FM) are self- explanatory, and there are multiple specifiers in the DSM system like sexually attracted to males, females, both, and neither. DSM IV has different codes depending upon the indivi- duals current age: GID in childhood (302.6) and GID in adolescence or adulthood (302.85). 2 EPIDEMIOLOGY There are no specific epidemiological studies looking at prevalence of GID and most of the data are projected from studies on attendees at specialist clinics, primary care surveys and surveys of specialist psychiatrists in this area. The reported figures vary widely depending on methodology, definition of GID, location of study and the period in which study was conducted. Two recent studies from Singapore 22 and Netherlands 3,8 reported a prevalence of 1:10,000 for MF and 1:30,000 for FM and the earlier studies reported a lower ...with that absurd determined air Find a priest. Find any beast in the wind for a husband. He will give you a houseful of legitimate sons. It is too late for sin.

Disorders of Sexual Preference Manoj Kumar Mohanty, Shameera Rehman, Nilamadhab Kar 18 In your navels smell I discover my death, overwhelmed in fragments of song the waters darkness wipes the blood from my hands, crossing the land of my body where does your body go Soubhagya Mishra in Suicide INTRODU CTION Disorders of sexual preference have important connotations in the study of sexuality as in various forms and severity, they are observed in the continuum of health and illness. They are known as Paraphilia which is derived from the Greek, para meaning alternative, and philos meaning loving. It can be defined as recurrent abnormal sexual activity or fantasy directed towards orgasm, when normal sexual activity, as approved by the society is possible. They manifest in specia- lized fantasies, requirement of sexual partner or objects, masturbatory practices and sexual props. Paraphilia may involve non-human objects, the suffering or humiliation of self or others, children or non-consenting persons. Paraphiliac act is commonly followed by arousal and orgasm. One paraphilia is distin- guished from the other by the method chosen. Often these disorders are not well recognized and difficult to treat because people suffering from these disorders usually conceal them or have financial or legal problems. There are many types of paraphilias (Table 18.1). The nomenclature is confusing, with their Greek, Latin, French and Portuguese origin. The list given in Table 18.1 is not exhaustive. Epidemiology There is dearth of information on the epide- miology of paraphilias. However they are not uncommon. This condition is more common in males. Most of the patients are aged 15-25 years and this disorder rarely occurs in individuals older than 50 years. More than 50% of paraphiliacs have their onset before age 1 8 . 28 Considering the victims proportion, the prevalence of paraphilias can be guessed. As many as 10-20% of children may have been molested by age 18; and 20% of women report of being targets of exhibitionism and voyeu- rism. For many paraphiliac persons, these deviations may be transient acting out of impulses, especially during period of stress and conflict. However, the course of para- philias is usually chronic in nature. INDIVIDUAL PARAPHILIAS Fetishism It is defined as recurrent, intense, sexual fantasies or sexual urges or behavior involving the use of a non-living object that are intima- tely associated with the human body. The term, from the Portuguese fetisso means an object or image invested with ma gical power.

Homosexuality N Kumaraswamy, Aruna Kumari P 19 Let your hands be octopus and crush me. Let your feet be a pillory and clasp me. Let the ten petals of my palms be gashed by the cactus of your breasts. Let your body be quicksand and devour me. Jagannath Prasad Das Goddess INTRODUCTION The term homosexuality was coined in the late 19th century by a German Psychologist, Karoly Maria Benkert. 21 Homosexuality occurs as a normal phase in development during adolescence. It may persist to adult life as a specific failure of emotional maturation or reappear under condition of stress or depri- vationsfor example in prison. Twin studies suggest that constitutional feature is more important than environmental contributions to its aetiology. The problem of homosexuality involves much more than simply a sexual act. It can be better understood in four components of behaviour, psychic response, identity and lifestyle. 29 Definition and Concept The word homosexuality is derived from the Greek word for same, and generically refers to any sexual activity between members of the same sex. It is used for the sexual pattern of preferential or exclusive erotic attraction or sexual activity between persons of the same sex, regardless of the availability of willing hetrosexual partners. Today a person is often said to have a homosexual or a heterosexual orientation, a description intended to defuse some of the long-standing sentiments among many Westerners that homosexuality is immoral or pathological. Homosexual prac- tices are not afforded any special moral or psychological significance in many other cultures. A survey of 190 societies around the world reported that homosexual practices were considered acceptable behavior in approximately 70% of them. 25 The description of homosexuality as an orientation also suggests, as some contem- porary theorists have argued, that the boun- daries between homosexual and hetero- sexual are not necessarily rigid. Some studies have indicated that most individuals have some erotic interest in both sexes, whether overt or not. The open statement of interest in both sexes is known as bisexuality . Trans- sexuals are distinguished from homosexuals by the feeling that they are really members of the opposite sex. Male and female homo- sexuals are now commonly known as gays and lesbians, respectively. Ego-dystonic and Ego-syntonic Homosexuality The term ego-dystonic homosexuality appea- red under the general category of psycho- sexual disorders. The reasoning was that only in those troubled by their homosexuality did it constitute a psychological disorder.

Sexual Disorders in the Elderly Duddu Venugopal, RS Biradar 20 In her youth she hath comforted lover and son, In her weary old age, O dear God, is there none To bless her tired eyelids to rest... Sarojini Naidu, The old woman INTRODUCTION Advancements in medical care and longer life expectancies are expected to manifest as rapid increases in the elderly population in most countries, and this would be most evident in the developing world. Therefore, the scientific community needs to be geared up to the needs of this population so as to ensure the best possible quality of life. 11 Medical science has advanced in many respects so as to cater to the illness related needs of this population. However, there is precious little known about healthy aspects of life among these subjects. This is best evidenced in the field of sexual health and illness. Sex constitutes a crucial element of an individuals self-esteem, and is, therefore, an important determinant of ones quality of life. Studying sexual attitudes and behaviours facilitates an understanding of the sexual health of the population. However, sexual health (and illness) has aroused limited interest in academic and clinical circles among the elderly in India, and little has been written and said about this issueboth in lay and scientific literature. Hence, most literature in this chapter has a Western research basis, but attempts have been made to include what little is known about the Indian scenario. There are a number of myths and mis- conceptions regarding sexuality of the elderly. 10,15,3 Firstly, it is generally assumed that the elderly do not and/or cannot enjoy sexual activities. The second myth is that they do not need sex in the way that young people do. There are also some who believe that beauty, sex and physical attractiveness are attributes that belong exclusively to the young. Many elderly people themselves often share this belief and studies have indeed found elderly people to have a poor self-image. 3 As a result, when a woman becomes menopausal, it is assumed that her ability to experience and enjoy an active sex life has ceased as well. Older men talking or discussing about sexual matters are labelled as being dirty old men. Sexually active older adults are often at conflict with society and the young in this regard; because the young all too often believe sex to be enjoyable only to them. A similar belief is endorsed by society in general, resulting in significant guilt, anxiety and a pressure on the elderly to conform to societal expectations. The result has been a society with an asexual or sexually inhibited elderly population, with an unsatisfactory quality of life and low self-esteem. A lack of under- standing from health care professionals can compound the situation, making it difficult for an elderly person to talk about sexual prob- lems. On the other hand, elderly people tend to see themselves as being less attractive than younger people, and less entitled to sexual pleasure. They are conservative, less informed.

Sexual Problems in Physical Disorders PN Suresh Kumar 21 Your soft breath, your quiet eyes may hide many strange desires; while I assume you speak of love, perhaps you speak of nothing Tell me what this chance encounter means so that I may turn to words- for I am alien, a stranger to your city, I know not what your favours mean Sahir Ludhianvi Avarice INTRODUCTION Sexual problems are common in men and women. The majority of them may be charac- terised as psychological, urological, gyneco- logical or neurological according to their etiologies. Until a decade ago, most physicians assumed that sexual problems usually deve- loped because of psychological problems, but experience over the past 10 years has revealed an increasing number of medical problems for sexual dysfunctions. Even in individuals with obvious psychological conflicts, should be evaluated and investigated from a neurouro- logic or neurogynecologic perspective. This chapter will enumerate various medical causes of sexual dysfunction with a brief discussion of the management of each condition. Diagnostic Criteria for Sexual Dysfunction due to a General Medical Condition 1 a. A clinically significant sexual dysfunction that results in ma rked distress or inter- personal difficulty predominates in the clinical picture. b . There is evidence from the history, physical examination or laboratory findings that sexual dysfunction is fully explained by the direct physiological effects of a general medical condition. c . The disturbance is not better accounted for by another mental disorder (e.g. major depressive disorder). ERECTILE DYSFUNCTION DUE TO GENERAL MEDICAL CONDITION Erectile dysfunction (ED) or impotence has been defined as the inability of the male to attain and maintain erection of the penis sufficient to permit satisfaction sexual pefor- mance. 11 Organic ED is the result of an acute or chronic physiological condition, including endocrinologic, neurologic, or vascular etio- logies. 14 Unless related to trauma or surgery, organic ED is associated with a gradual progressive decline in sexual, masturbated, and nocturnal erectile rigidity. 3 Approxi- mately 80% of ED is secondary to organic disease, 70% of those due to arterial or venous abnormalities.

Sexual Dysfunctions in Psychiatric Disorders Jisu Nath, Somnath Sengupta 22 Now he will return: you must prepare something for him and re-arrange yourself like a well-kept house. It is of no avail that your mans domestic or docile- suspicion may still strike him. Chandrakanta Deotale for a woman alone at home INTRODUCTION Sexuality is a highly complicated area of human behaviour in which biological, psycho- logical and sociological factors all play a role simultaneously. The final result is a single, fused, unitary phenomenon that is, by nature, not exclusively biological, psychological or sociological. 19 The sexual act itself is a complex psycho- motor behaviour, which involves various modalities of perception, emotion and memory of previous associations. Feeding and reproduction, which are required for survival of self and species respectively, are the two most basic instincts of an organism. Though, reproduction can be asexual in lower order organisms, sexual activity is required in human being for natural reproduction. Human race is unique in the sense that they are the only organisms that engage in sexual activity for pleasure throughout all the seasons. Neurobiological Basis of Sexual Behaviour Neuroanatomically, the limbic system, consis- ting of the hippocampus, amygdala, hypo- thalamus and the related parts control the basic drives such as aggression, emotion and sexuality. Electrical stimulation of the area of hypothalamus and septum may provoke aggression, flight or sexuality. Input to these structures come directly from the hippo- campus and amygdala, which in turn receive information from the sensory association cortex. 9 As these structures also serve other instincts and behaviors, any damage to them leads to behavioral syndromes characterized by altered sexuality and abnormal behaviour, e.g. the Kluver-Bucy syndrome, discussed later. This truly reflects functional and struc- tural overlap of sexual behaviour and the various mental functions. Neocortex, mainly the frontal lobe, regulates adult sexual behaviour. Primary sexual urges are normally inhibited by the frontal lobes to conform to social rules and customs. Lesion in certain parts of the frontal lobe, (e.g. orbital area) thus leads to sexually disinhibited behaviour as seen in certain types of frontal lobe syndromes.

Evaluation of Sexual Problems K John Vijaysagar 23 When I awake (he said) I shall be lonely, O feel my loneliest ever by your side; For I have dropped my root, and stuck you only Move through a night of sleep, conscious of right. Beloved conquering bride, My kisses lanced your veins with veins of light. O take my angel in your sleeping flesh, I killed him from me, wrestling with your belly Dom Moraes Being married INTRODUC TION Sexual feelings are an inevitable part of life. People within the privacy of their own home are quite interested in reading or hearing about sexual issues that may have a direct bearing on their lives. Treatment rituals, folk remedies, advice and sex manuals have been discovered among the writings of the ancient Greek physicians, Islamic and Talmudic scholars, and Chinese and Hindu practi- tioners. 1 Although people are bombarded daily with sexual references, pictures, articles, and exploits of both famous and infamous individuals, actual sexual comfort and effortless sexual performance tend to be rather rare. The term sex is not limited just to intercourse, and can also refer to a variety of intimate sexual activities such as fondling, self- stimulation (masturbation) and oral sex. Sexual problems are generally defined as any problem that occurs in the course of sexual activity. Sexual difficulties are extremely prevalent among both men and women, occurring in about 43% of women and 31% of men. They are associated with a number of biological, medical, and psychological risk factors and increase markedly with aging. Sexual difficulties are also a significant source of emotional and relationship dissatisfaction. 7 They are not life threatening and most of them are painless, but they can lead to dysfunction in many areas of life. Sexual problems often manifest and, mask themselves in depression, anxiety, failure to achieve, low self-esteem and the inability to engage in intimate relation- ships. Assessment of a sexual dysfunction requires a careful history from the client with a corroborative history from the partner. It is a process that deals with intimate and sensitive issues of patients life and upon successful completion improves the doctor-patient relationship. CONCERNS DURING SEXUAL HISTORY TAKING Concerns of Patients Often patients are willing to approach a doctor for help for sexual matter, but they are not sure whom to approach.

Evaluation of Erectile Dysfunction Arun Chawla, Joseph Thomas 24 For the first time I realised that nakedness is a drastic measure against becoming blind Dhoomil Lying beside that woman INTRODUCTION Erectile dysfunction, defined as insufficient rigidity of the penis to penetrate, is broadly classified into two categories: organic and psychogenic. In reality, most of the patients demonstrate a combination of organic and psychogenic component. 13 The purpose of evaluation is to select patients for specific surgical treatments. SURGICAL EVALUATION OF ERECTILE DYSFUNCTION Erection is a complex vascular event governed by the integrity of the smooth muscle in the arteriolar walls and the trabeculae of the corpora cavernosa. In the flaccid state, the arteries, the arterioles and the sinusoids are contracted with free flow through the emissary veins which exit through the tunica albuginea. Neurotransmitters and local modulators released during sexual stimulation result in smooth muscle relaxation. 30 NEUROLOGICAL EVALUATION The main aim of neurological evaluation is to identify or exclude a hidden or under- estimated neurological lesion. The aim of neuro-urological testing is to: 27,30 i. uncover reversible neurological disease such as dorsal nerve neuropathy secon- dary to long distance bicycling; i i . assess the extent of neurological defi- ciency from known neurological disease like diabetes mellitus or pelvic injury; and iii. determine whether referral to neurologist is necessary in a possible disease like spinal cord tumor. SOMATIC NERVOUS SYSTEM Biothesiometry This test is designed to measure the sensory perception threshold to various amplitudes of vibratory stimulation produced by hand held electromagnetic device placed on the pulp of index finger, both sides of penile shaft and the glans penis. However, sophisticated neuro- physiological tests are more useful for evaluation of penile innervation as vibration is not an adequate stimulus to the glans which contain mainly free nerve endings and hardly any vibration receptors. 5 Sacral Evoked Response (SER) Bulbocavernous Reflex Latency (BCR) This test is performed by placing two stimu- lating ring electrodes around penis near the corona, and other 3 cms proximal to it. Concentric needle electrodes placed in right and left bulbocavernous muscle record the response when square wave impulses are delivered via a direct current stimulator.

Comprehensive Sexuality Education Indira Kapoor, Annette Britton 25 The third time is always the most difficult. Or so I have been told. The first time you do not know. Your innocence is your strength. The second time you are hurt and thus prepared. But the third time, my friend, is when you are quite totally unaware. And, therefore, so completely vulnerable. And it was on the third time that she entered my poetry. Pritish Nandy Love INTRODUCTION Sexuality education is crucial to help young people prepare for healthy and fulfilling lives. Without it, young people are left to struggle alone, often picking up misinformation and lacking the negotiation skills necessary for responsible and healthy sexual behaviour. Sadly, due to tradition, religion, culture, denial and embarrassment, many young people are denied access to comprehensive sexuality education. As a result, millions of young people across the world are left lacking access to important information, such as how to prevent unwanted pregnancies and sexually transmitted infections (STIs) including HIV. There are already an estimated 165 million new cases of STIs annually among young people aged 15-24, and at least a quarter of all unsafe abortions are to girls aged between 15 and 19. 31,32 Sexuality education is a highly contro- versial area. Throughout the world, those involved in sexuality education programmes have encountered defensive reactions and in many cases, outright opposition. 11,18,20,24 Many complaints stem from false ideas that sexuality education exposes young people to inappro- priate information, that it is not effective or that it encourages adolescents to become sexually active. In actual fact, research has frequently demonstrated that comprehensive sexuality education helps young people delay their first sexual contact and also avoid unprotected sexual activity. Interestingly, the countries with the lowest number of teenage pregnancies, sexually transmitted infections and abortions are those in which sexuality education is common place and where there is an open approach to discussing sexuality. In contrast, those countries with ambivalence towards sexuality education tend to have the highest rates. 5,22 Sexuality education is not about destroying childrens moral fibre, as many opponents suggest. Rather, it is about providing support to young people so that they engage in personal reflection and make responsible choices about matters that affect their lives. It is not about teaching young people the various positions or styles of sexual intercourse. Rather, it addresses the biological, psycho- logical, and spiritual dimensions of a persons being, and thus helps young people to form attitudes, beliefs and values about their own identities and relationships. 23 Sexuality education can take place in many forms and settings, both formal and informal, both for in and out of school youth.

Psychological Management of Sexual Dysfunctions KB Kumar 26 Women, who are neither beloved nor prostitutes, are washed away the next morning like stains on a sheet. Only one womans fragrance and the day cascading from her bangles remain. (Or, I lie with her and the day descends from the bed) Shrikant Varma One Day INTRODUCTION Sex therapy came into pr actice formally in 1970 with the publication of Masters and Johnson book, Human Sexual Inadequacy . Since then, several cognitive and behavioral tech- niques have been validated in clinical popu- lation and their principle and mechanisms have been well studied. Sex therapy though initially was outlined as treatment techniques to be implemented with individuals having a regular partner, today several of these techniques are employed in treating indi- viduals without a regular partner. Sex therapy utilizes a broad range of cognitive and behavioral strategies or techniques tailored to the specific sexual problem. Based on the work of Masters and Johnson, 6 Annon, 1 and McCarthy and McCarthy 8 three major compo- nents of sex therapy have been identified. 7 These are: a) replacement of sexual anxiety with sexual comfort; b) adopting positive sexual attitudes and learning sexual skills; and c) a program of individually designed sexual exercises to be done between therapy sessions. This chapter outlines some of the cognitive and behavioral approaches commonly employed in the treatment of a variety of sexual dysfunc- tion in men and women. Before we proceed on to this area, it should be kept in mind that several social factors, particularly the increa- singly liberated attitudes towards sexual relationships and increased expectations, have led to enhanced demands for professional help in married as well as unmarried couples. There is a dramatic change of emphasis towards sexual pleasure in marital relationships, in the last 3-4 decades. Because of these social changes, sex therapy though has realized its potential on a worldwide basis, it has become a field to be treaded along cautiously. Practic- ing of sex therapy requires in the present day the therapist take into consideration all dimensions of human sexuality-psychological, physiological, social, cultural and ethical and their relationship to one another.

Pharmacological Treatment of Psychosexual Disorders JK Trivedi, Rajul Tandon 27 It began as a colour which took form, the form was made flesh and then it was reduced to a bed in the corner of the house. A bed unrolled by the suffocated solitude at all odd times used half heartedly and rolled back again. Nida Faazil Love Man survives earthquakes, experiences the horrors of illness and the tortures of the soul. But the most tormenting tragedy of all time is, and will be the tragedy of the bedroom. Leo Tolstoy INTRODUCTION Before the advent of andrology, it was thought and taught that all the sexual problems in males notably impotence were psychological in origin. Epoch making andrological research in last few years has shattered this myth and today it is known that in many of such cases there is a physical cause rather than a purely psychological one. This better understanding of male and female sexual physiology has led to the development of specific biological treatments including pharmacotherapy and surgery. These advances have significantly augmen- ted the therapists catalogue of approaches. The two most frequently encountered sexual disorders in males are erectile dysfunction and premature ejaculation, which are frequently treated by drugs. Most of the recent advances, however, involve male sexual dysfunctions, especially erectile dysfunction. Studies are currently focused on the way to test pharmacological treatment of sexual dysfunctions in women. PHARMACOTHERAPY OF MALE SEXUAL DISORDERS Pharmacotherapy of Erectile Dysfunction National Institute of Health consensus development conference 24 advocates that the term erectile dysfunction (ED) should be used in place of impotence and defines ED as an inability of the male to achieve an erect penis as a part of the overall multifaceted process of male sexual function. This definition de- emphasizes intercourse as the sine qua non of sexual life and gives equal importance to other aspects of male sexual behaviour. ED is an age- dependent disorder.

INTRODUCTION Last two decade s have seen tremendous advances made in the understanding of erectile dysfunction. It consequently evolved numerous modalities of treating the condition. Surgery is one of them. Surgery is offered in organic type of erectile dysfunction. Hence, it is necessary to confirm its organic nature and differentiate it from being psychogenic. Besides a good clinical examination and a detailed history, this confirmation can be achieved through the use of one or both of the following two tests. 1. Nocturnal penile tumescence and rigidity (NPTR) testing 2 . Pharmaco-diagnostic testing with intra- cavernosal injection of vasoactive drugs (ICIVAD) Since these tests are covered in other chapter, its repetition is avoided. Once the organic nature is established, its severity and response to other therapies is assessed. Simpler non-surgical options are always tried first. Every case is assessed according to the individual needs and prefe- rences. It is then that the surgical intervention is undertaken. There are broadly two types of surgical procedures: vascular surgery and penile prosthesis. VASCULAR SURGERY Since erection is essentially a haemodynamic event (albeit neurotransmitted), either one or both of its components are implicated: arterial and venous. Causes A. Primary (congenital) l . Arterial dysplasia 2. Veno-occlusive insufficiency 3. Arterio-venous malformation B . Secondary (acquired) 1. Atherosclerosis of penile arteries: due to diabetes, hypertension, generalised atherosclerosis, hyperlipidemia, smo- king, idiopathic 2 . Veno-occlusive insufficiency due to cavernosal fibrosis, endothelial dys- function, tunica albuginea weakening 3. Trauma- pelvic, perineal, penile 4. Aorto-iliac disease 5 . Iatrogenic damage to internal iliac/ pudendal arteries 6. Embolic occlusion Investigations Investigations are carried out to fulfil two objectives: (1) to determine whether the problem is organic or psychogenic, and if Surgical Interventions for Erectile Dysfunction Vijay Kulkarni 28 What remained unsaid is now my verse, my song; Your lips untouched by mine are intoxicated, warm. Your eyes are aflame, your youth impassioned: Everything around you melts in your warmth.

Gender Reassignment Surgery Ashok Raj Koul 29 The moments stacked against each other turn incandescent with a running flame we both know what we here for beneath your skin of wild talk you are tense, beneath the cindering ask of my body your body is a surprise for as I fall upon the earth-crust that is you we spin, we spin, we spin your feet pointed to the skies. Keki N Daruwala, Love among the pines INTRODUCTION The phenomenon of sex reassignment surgery is one of the most dramatic and at the same time controversial applications of plastic surgery. It is dramatic because it can make a cataclysmic change in a persons life and lifestyle. It is controversial because the indications, the criteria of patient-selection, and the surgical techniques are not completely standardized. Also, the lifelong hormone replacement therapy, which is an inevitable part of sex reassignment surgery, is cumber- some, and has significant potential side effects. The surgical transformation of body parts is more or less permanent and irreversible. The change in the body appearance and function brought about by hormone adminis- tration and surgery is only a part of the definitive therapy for trans-sexualism or gender dysphoria syndrome. There are other important aspects to this process like changes in the lifestyle, body image, social, emotional, sexual and vocational adjustments. These aspects need to be paid due attention in the overall plan of rehabilitation of the patient. ETIOLOGY AND DIFFERENTIAL DIAGNOSIS By definition gender dysphoria syndrome connotes a condition which is of purely psychological origin. 7 It denotes a person whose genetic make up and external and internal body anatomy are clearly of one sex, while he or she psychologically belongs to the other sex. This condition though quite clear and well defined, can have a great deal of overlap with a group of conditions loosely grouped as intersex or ambiguous genitalia. This overlap occurs not only in terms of presentation but also in terms of treatment modalities and public perception at large. The sex of an individual is based on the following criteria: 1. Chromosomal sex 2. The gonads 3. Internal genitalia 4. External genitalia 5. Sex hormonal patterns 6. Pattern of neural behaviour centers 7. Sex of assignment and rearing 8.

Infertility Jayaraman Nambiar M, Pratap Kumar N 30 A sheet of white light drapes you like the autumn sky, the blue peacocks of twilight dance on your eyelids, the strings are roots of darkness desperately clutching at your swift fingers. Sitakanta Mohapatra Woman with sitar INTRODUCTION Infertility is define d as inability to achieve pregnancy after one year of unprotected intercourse. It affects about 10-15% of married couples. Primary infertility is a term used for a couple who have never achieved pregnancy and secondary infertility refers to a couple who previously have succeeded in achieving a pregnancy even if this ended in spontaneous abortion. General Factors that Affect Fertility There are many factors, which can affect fertility. In the female, the first few cycles after menarche and last few cycles before meno- pause are anovulatory. Fertility in the female is at its best in early twenties and declines after the age of 35. In the male, however, spermato- genesis is active after puberty and only slight reduction occurs after the age of 60. Anxiety and stress are underestimated factors in infertility. These psychological factors can cause changes in the neuroendocrine control of ovulation. Requirements for Normal Fertility For normal fertilization to occur, there should be production of gametes (gametogenesis), transport to the sites of their fusion (gamete transport), and appropriate mechanisms for their fusion and development (fertilization and development). Faults at any of these levels will cause infertility. CAUSES FOR INFERTILITY Infertility can occur due to faults in male, female or both. Infertility is due to female factors in 40% of cases and male factors in another 40%. The remaining 20% can be the result of faults in both partners or because of unexplained causes. Causes for Infertility in the Male Male infertility is responsible for infertility in 40% of cases. 2 In the majority of cases of male infertility, no identifiable cause is found and is called idiopathic. Specific causes of male infertility are as follows. Varicocele Varicocele is an abnormal dilatation of veins within the spermatic cord. The affect of varicocele on testicular function appears to be the result in an increase in the local rise of temperature.