Adolescence

Adolescence is simply a transition stage from childhood to adulthood. It is a stage which all young people go through to become biologically and sexually mature. In girls it may start as early as 9 or 10 years and in boys it begins around 12 or 13 years. Adolescence is a time of rapid change in the body, emotions, attitudes, values, intellect and relationship.

Adolescence changes are triggered by hormones of the pituitary gland and the gonads. The hormones bring about the development and maintenance of the secondary sex characteristics.

Adolescence are passionate people and are apt to be carried away by impulse. They can experience irrepressible joy or inconsolable sadness, gregariousness or loneliness, altruism or self-centeredness, insatiable curiosity , confidence or self doubt.

An adolescent is expected to

_ become independent of his/her parents.

_ establish a new social and working relationship with peers of both sexes as well as with adults.

_ adjust to sexual maturity and changing roles

_ decide on future goals.

SENSATE FOCUS

(Mutual Pleasuring by touching)

Basis

Touch is a vital of personal human communication.

Tenderness, affection, solace, understanding, desire, warmth, comfort, any feeling can be conveyed to the partner by touching. Thus a fullness of sexual expression can be achieved.

No goal orientation

Elimination of pressure of performance and hence fear of failure.

Procedure: Both the partners are equally involved. The entire act should be slow, steady and full of love and understanding. There should be no time limit.

Step1

Both the partners take off their clothes

One partner (either one)gives experience of pleasurable touching to the other; massages or fondles the other

A soothing lotion is used for application

The Getting partner gives verbal/non verbal directions about preferences for the location and the intensity of touching

The giving partner provides pleasure accordingly to the getting partner

The getting partner should inform the giving partner if anything is unpleasant, irritating or distracting

Both should think and feel sensuously

Avoid touching the breasts and genitals at this stage

The couple should Not proceed to intercourse

The entire procedure is reciprocated by the other partner

The procedure is repeated daily for 3-4 days.

Step 2

The previous procedure is repeated by both the partner

They proceed to the touching the breasts and genital

The couple should Not proceed to intercourse

Touching is reciprocated by the other partner

This is repeated daily for next 3- 4 days.

Step 3

Touching is done to each other by both in a simultaneous and mutual way.

Note: In Indian situation, Sensate Focus Exercise can be done by taking bath together and using oil for massage, provided there is availability of enough of water and privacy.

Posted by Dr. Ramesh Maheshwari, Wnho Clinic, 2014 sadashiv peth, Tilak road, Pune. Free to call for further information.

Coital Postures

Objects:

The Individual need variation and break the monotony. Certain postures may promote or prevent fertility. Certain postures compensate incompatibility due to overweight, protuberant belly, fleshy thighs and indifference in stature of both partners.

Limitations: Coital Postures base on Sexual Response

1) Alfred Kinsey writes “Sexual responses involve steady and convulsive building-up of neuromuscular tensions. As action develops, abrupt build-up of tensions at the approach of orgasm, remarkable rigidity develops before orgasm, explosive discharge of neuromuscular tensions at orgasm and abrupt cessation of tension after the orgasm….

…… The attention of individual is so centered on the sexual activity that he is not consciously aware of the sensory stimulation.”

Therefore, it would not be easy to maneuver the desired coital posture.

Second Limitation of Coitus.

2) The alignment of penis with the vaginal canal is must for intromission.

3) Seeing the pictures of coital postures is stimulating, but their practical performance is not easy.

4) Most of coital postures shown in books are like acrobatics.

Do coital postures enhance the pleasure?

Eating ice-cream in sitting, standing, or Shirshasan does not improve taste. Same rule applies here.

Ideal Coital Posture:

1) Should be easy for complete intromission.

2) Should be convenient for pelvic movements.

3) Should be comfortable for both.

4) Should be giving pleasure for both.

5) Should be suitable for fertility.

Coital Postures:

There are certain advantages and limitations to every coital posture.

1) Un consummation Position: Women keeps her legs straight and wide apart. Man sleeps on top. This is unsuitable for coitus. As alignment is wrong, the semen is spilled on the vulva. This may lead to un consummation and infertility.

2) ‘T’ Position: Woman sleeps on cot. She is brought down to the foot end of bed. Man kneels on floor between her two thighs so that he is perpendicular to her. A pillow is kept under his knees to raise his torso. Man can see genitals of both and maneuver the alignment. He holds her thighs to make pelvic movements, and stimulate clitoris simultaneously. Posture suitable for beginners and obese people.

3) ‘L’ position: Suitable for those who sleep on ground. Women sleep with pillow under her buttocks, separates her thighs apart and bends them towards her belly. Man sits in Vajras an between her thighs, perpendicular to her and moves forwards so that his thighs are under her thighs. This posture is also for beginners and obese persons.

4) Male superior coital position: Woman sleeps on bed with pillow under her buttocks, separates her thighs wide apart and bends them towards her belly. Man sleeps on her, inserts penis in vagina and makes pelvic movements by embracing her. Because of close contact man gets orgasm faster. Woman is pinned down and devoid of clitoral stimulation. She may not get orgasm in this position.

5) Knee-elbow Position: Woman supports her body on her knees and elbows. Man kneels behind her.

6) Training position for Ejaculatory control: Man sleeps on bed with his knees bent and separated. Woman sits between his thighs and extends her legs on the side of his body and stimulates his penis. Used in treatment of premature ejaculation to train the penis for delaying the ejaculation.

7) Position for female stimulation: Woman sits on bed and separates her thighs. Man sits behind her with his legs outside her. Suitable for stimulation of breasts and clitoris.

8) Female superior coital posture: Man sleeps on bed. Woman sits on him with her thighs outside his. She inserts penis in vagina and makes sliding movements so that her clitoris is rubbed against his pubis. Woman can have orgasm quicker. Man can last longer. Man is pinned down. Not suitable for fertility.

9) Lateral Position: Both lie laterally in face-to-face position. Both are free to move. Coital act lasts longer.

Note:

· After insertion coition lasts for 1-3 min.

· Simultaneous orgasm of both is not possible.

· Woman should have orgasm prior to man, during fore play by stimulation of breast and clitoris. This will lubricate vagina and enhance stimulation of penis. If he has orgasm prior to her’s, he loses erection and she remains half way.

· It is man who initiates activity.

· Man is interested more in orgasm, while woman is interested in more in foreplay.

Medico Legal Aspects of Sex Therapy

INTRODUCTION

Sex and human sexuality are sensitive subject. To deal effectively with any problem of human sexuality , one has to constantly evaluate its merits and demerits from social , scientific , moral , ethical and most importantly from the legal angle. Following are some of the guidelines for therapist to keep in mind while dealing with clients with sexual problems.

CONSENT

Taking informed and expressed consent is of utmost importance while managing any patient. Examining and / or treating a patient without consent would amount to assault and battery which is punishable under criminal law irrespective of absence of negligence or successful outcome of treatment. The consent should be free willed, informed, intelligent , specific and express. Person giving consent should be competent to do so, failing which, consent should be obtained from the lawful guardian of the patient(In cases of minor and/or Mentally retarded).

EXAMINATION OF A FEMALE CLIENT

Besides obtaining a valid consent, in case of female patient, the therapist should always have a female assistant present when examining a female patient This is important for the therapist in order to protect himself from a possible charge of indecent behaviour molestation or even sexual offence like rape ect. Being llevelled against him . Mere presence of husband or any male companion of the female patient is not enough. A sex therapist, in particular, is most vulnerable and therefore should be most careful.

USE OF SURROGATE PARTNERS

Use of surrogate Partners for sex therapy is questionable both ethically as well as legally. Sexual involvement of the therapist is universally accepted as unethical. There have been a number of cases where the therapists themselves, having acted as surrogates, have been punished for sexual molestation of their patients. It may also invite a criminal charge of adultery in some countries, including India .there are cases on record where the therapists have been charged with and convicted of rape.

Unlike some other countries, the socio cultural set up in India is different. The laws governing sexual behaviour are neither liberal nor evolved as much as in some of the western countries. Besides, surrogacy is likened to prostitution by many. Even if one were to consider surrogate partner as a therapist, then the ethical code prevents a sexual relationship with a client. Moreover, there is every possibility of a disease being transmitted. Particularly the HIV infection, in view of sex with multiple partners by a surrogate person.

Therapist should have uppermost in mind the special values of intimacy and love that our culture teaches us to nurture.

PROFESSIONAL COMPETENCY

It is the ethical responsibility of every sex therapist to maintain high standards of Professional competence and integrity. Competence without integrity or integrity without competence is an unsatisfactory compromise of professionalism. It is most important to protect the public and the other professionals from persons who represent themselves as sex therapists who are in fact lacking in competence and integrity.

Competence in another primary discipline such as psychology, psychiatry or counselling is not equivalent to competence in sex therapy.

A sex therapist should possess adequate knowledge of the following:

1. Sexual and reproductive anatomy and physiology.

2. Developmental sexuality from a psychobiological point of view.

3. Marital, Family and Interpersonal Relationship and Socio-cultural factors in sexual values

4. Physiological and medical factors that may influence sexual functions such as pregnancy, contraception and fertility, illness, disability, medications .

5. Multimodal techniques and theory of sex therapy and psychotherapy.

6. Pharmacology of the medications used to treat sexual dysfunctions particularly with respect to their adverse effects and interactions with the drugs being consumed for other ailments.

7. Ethical issues in sex therapy and principles of evaluation and referral.

8. Laws related to sexual behaviour.

POINTS TO BEAR IN MIND

· All forms of sex therapy which violate the local laws should be handled with care recommending oral sex as a part of therapy is violative of section 377 of the indian penal code which deal with unnatural sexual offences.

· The Hippocratic oath forbids the physician to take advantage of the therapeutic context in order to engage in either homosexual or heterosexual relationship.

· It is a universal rule that whenever dealing with reproductive functions is involved, express consent of both the spouses should be obtained.

· Proof of competence is the ability to provide objective and responsible services to the clients.

· There does exist a potential liability under the laws of the land prohibiting consensual conduct such as prostitution, fornication, lewd and lascivious behaviour and adultery which might arise from therapeutic or nontherapeutic sex research activities.

· Sex between therapist and client is always unethical. No matter how therapeutic the rationale might appear, there is no justification for a therapist having sex with a client. The purpose of sex therapy is to improve function, not to change values or beliefs of the client.

Frigidity

Frigidity is inhibited sexual excitement during sexual activity. Frigid means cold. The term frigid refers to non-response to emotion, applied especially to inability on the part of the woman to feel sexual desire. A frigid female is devoid of sexual feelings and cannot achieve an orgasm.

Aphrodisiacs

These are substances thought to increase the sexual drive or ability of the individual. They are mainly desired by males.There is constant search for aphrodisiacs. Over the centuries human beings have used extracts of trees, roots, flowers, insects, animal parts, Spanish fly, strychnine, alcohol, and drugs for this purpose. However, according to scientific research there is no effective aphrodisiac available.

Foreplay

The best aphrodisiac can be a caring, sharing partner and foreplay. This is the stimulation of sensitive body parts to get the partners into the excitement stage. The sensitive body areas different in individuals. Therefore the partners have to explore each other to find out sensitive areas that will lead to sexual excitement.

These areas could be the ear lobes, neck, lips, inside skin of the upper arms or things, toes, fingertips, soles of the feet, breasts, and genitals. These sensitive areas are called erogenous zones. These areas can be stimulated by stroking, squeezing, tickling, licking etc. the partners must communicate and express to each other what is pleasurable to them and what is not. A woman usually takes a longer time to get aroused than a man; so foreplay should take this into consideration.

Once the two partners have agreed to have a sexual relationship then it is the responsibility of each partner to satisfy the needs of the other. This should be done with care, understanding and respect.

Conception

Conception is the physical and physiological process of a sperm fusing with an ovum. Conception occurs as a result of sexual intercourse. The society requires a child to have a father and a mother, not just so that they contribute a sperm and an egg cell, but so that they can nurture a child after it is born. Therefore, society expects children to be born in marriage. However, a man and a woman who are not married are capable of sexual intercourse and of making a baby. But this baby may be socially at disadvantage if brought up by a single biological parent.

When a man and a woman want to have a baby, vaginal intercourse provides a kind of sharing. The timing is important as the egg in a woman has a life span of only 12 to 24 hours. Hence, the period during which the egg and the sperm can unite is limited to about 2 days in a month, around the time of ovulation. May differ in some women. However, sperms are produced in millions each day, facilitating fertilization since only one sperm is required to fuse with the egg cell. The moment of the ovum by the sperm is called conception. It normally takes place in the outer part of the Fallopian tube.

During vaginal intercourse the erect male penis enters the vagina of the female. Sperms are ejaculated near the cervix of the uterus. The sperms swim from the uterus into the Fallopian tube and to the ovum. The head of the sperms enters the ovum and its tail is dropped off. The nuclei of the male and the female cells then fuse to form the zygote. This is called fertilization and leads to conception.

The directions for making a new baby are contained in the zygote. So both partners contribute to the characteristics of the baby.

5 Ways to Enlarge Your Penis

Men are always concerned about their size and in extreme cases, this concern is also a cause of anxiety disorders. Even though, a large penis does not provide men any edge in terms of sexual pleasure, still it is big cause of concern for most of them. Other factors like erectile function and length of sexual intercourse play a more important role in sexual pleasure.

Here are the 5 ways to enlarge your penis:

1. Have lots of fruits and vegetables: For a healthy and long penis, you need to have fruits and vegetables high in antioxidants. These elements are very helpful in fighting free radicals (elements that damage your body) that form in the blood vessels. Additionally, antioxidants also help in strengthening the blood vessels.
2. Say yes to exercise: Exercising regularly can significantly affect your penis size and cause you to have a long and healthy penis. By exercising from time to time, you end up improving blood flow to the organ as well as clearing up the blood vessels.
3. Cut down on your stress levels: Stress and anxiety can also reduce the size of your penis. This happens as negative feelings cause blood to flow from the penis. As a result, it becomes very difficult to increase the size of the organ. Another reason that can contribute to the small size of your penis may be sexual performance anxiety.
4. Quit or reduce smoking: Smoking can considerably affect the size of your penis due to the blockage that small tobacco smoke particles create in the arteries that supply blood to the penis. Moreover, since smoking is associated with heart diseases, the flow of blood to several organs in the body gets affected including the penis.
5. Take a warm shower: A warm shower can aid in increasing blood flow to not only your body but also the penis. The warmth of the water aids in augmenting blood flows into the organ, enabling the growth of the penis.

Male Orgasmic Disorder

Definition:
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity.

In this disorder, a male cannot reach orgasm during intercourse although can ejaculate by partner's manual or oral stimulation. Some can ejaculate only during masturbation. Some have ejaculation during sleep but not in waking period.
Orgasm and ejaculation though occur simultaneously, are different entities. Orgasm can occur in the absence of ejaculation and vice versa.

Causes:

Dislike for a partner.
Testosterone deficiency.
Religious restrictions.
Myopathy, Neuropathy.

Masturbation guilt.
Spinal cord lesion.
Guilt regarding nocturnal.
Retrograde ejaculation.
Emission.
Fear of pregnancy.
Drugs.
Inadequate sexual stimulation.
High threshold of ejaculatory reflex.
Low Libido.
Mental Block.

Treatment:

Sensate Focus exercise (mutual pleasuring) is employed daily for first 3 days. Since sex is not allowed, it eliminates the pressure to perform.

Once this is achieved, she stimulates him to the highest degree and as a man approaches ejaculation she inserts penis in the vagina in a woman on top position. If a man is unable to ejaculate she again stimulates him manually and again reinserting when ejaculation is imminent.

Vibrators:

Used for stimulation of the penis.

Common sexual problem in the male erectile dysfunction

Erections. Morning erection.
Certain drugs may impair libido-b-blockers, spironolactone, metoclopramide, cimetidine, opiates (addiction), butyrophenone, anticholinergic drugs (impair erection).

Management
1. Correction of any organic etiological factor-endocrine, vascular, , metabolic, neurological disease, local lesion or alcoholism.
2. Psychotherapy and counselling: emphasis must be on communication between the partners and not on achieving an erection.
3. Approach recommended (masters and Johnson) in stages:(a) the stimulation of each partner's body by the other to learn how best to arouse the other genitals must not be touched at this stage. (b) when both partners are non-anxious in the first situation, genital stimulation is introduced. (c) commencing intercourse with the husband lying supine.
4. Androgen therapy if evidence (clinical or biochemical) of hypogonadism:
Note: testosterone treatment is contraindicated in men who want to have children because it tends to suppress sperm production. Also it tends to precipitate cancer of the prostate in the elderly. Androgen replacement may enhance libido without improving potency. Sex tonics or aphrodisiacs have little or no effect on sexual function except perhaps by way of suggestion.
5. Other hormones: if increase male sexuality: certain exercises can strengthen muscles of the pelvis, in particular those surrounding the penis. They increase the blood circulation in genital area and may enhance quality of erection. The person is advised to check his flow of urine when urinating and then start again repeating this about 5 times. This can be done at least 3 times a day. Once this is learnt, it can be carried out even without urinating.

Premature ejaculation.
1. Anesthetic ointment rubbed into the head of the penis.
2. Wearing a condom. Benzocaine condoms can be used.
3. Fixing the mind during intercourse on non-sexual activity such as business matter or sports.
4. Deep breathing and conscious relaxation of genitals may be tried.
5. Alcohol in small quantity may like a depressant and prolong Ejaculation.
6. Preparing wife by sexual stimulation while keeping genitals away from touch helps in increasing control and time of sexual activity.
7. Ejaculatory control-(i) first phase

(a) without a partner

First step: the man is advised to masturbate himself by to and for of the hand. He must stop before the stage of ejaculation and allow the erection to decline. This should be repeated a number of times of different occasions before going on to the next step.

Second step: (b) ejaculatory control with the partner: the man lies down on his back. The female sits between his legs and masturbates him. When he reaches the stage of ejaculation, he asks her to stop and the erection is allowed to subside. When the sexual excitement has receded sufficiently he asks the partner to repeat the same procedure. This should be done for a total of at least 15 to 20 minutes. After this, the man should ejaculation after reaching the stage of orgasm. When he has attained sufficient confidence of ejaculatory control for about 15 minutes, he goes on to (ii) second phase - this involves intravaginal containment using the stop-start technique or removal and squeezing of the penis.

1. Stop-start technique - at first the exercise of step 1 is begun and when erection is achieved, the female assumes female above position and places the penis in the vagina. She remains motionless. When the man has the feeling of impending ejaculation, he asks her to dismount. The man may go to toilet or keep lying till the excitement subsides. This should be repeated for about 15 minutes before going on to the next stage the procedure is the same as above but this time the female moves to and gradually instead of remaining motionless. When the man feels the ejaculatory urge, he asks her to stop. When the excitation has subsides, the process is repeated. Once the ejaculatory control is achieved by the above methods, it would be possible to have sexual intercourse in any position.

2. Squeeze technique - this is a modification of stop start technique in that instead of letting go the penis at the feeling of ejaculation, partner holds the penis between the index and middle fingers. The thump is placed on the frenulum and the two fingers on the opposite side of the coronal ridge. The partner squeezes the thump and fingers for 4 seconds. The pressure makes the man to lose his erection. After doing this 2-3 times the female adopts the woman above position, and inserts the penis into the vagina. The no motion technique and later the to and motion technique is than adopted as described above.

Note: in men with concomitant ed. The erectile dysfunction should be treated first.

Retarded or absent ejaculation - in less common and has several possible organic causes. However it may be caused entirely by psychological or emotional factors that are amenable to behavior therapy or individual psychotherapy.

Retrograde ejaculation - is due to bladder neck incompetence. It invariably occurs after transurethral resection of the prostate and may occur in diabetic autonomic neuropathy or para-aortic lymphadenectomy.

Delayed ejaculations or failed emission can occur due to spinal trauma and surgical procedures such as radical prostatectomy, proctocolectomy or para-aortic lymphadenopathy.

Inhibited ejaculation is the psychological variant of delayed ejaculation. Ejaculation usually occurs rapidly with solitary masturbation but not during intercourse. A variety of psychological factors may be responsible including fear of pregnancy, guilt and depressed or repressed hostility towards the partner.

Painful ejaculation can be caused by acute genitourinary infection, particularly acute prostatitis or seminal vesiculitis. It may also have a psychogenic basis. Infection can be treated with antibiotic, nsaids prostatic decongestants eg. Bromhexine and if indicated prostatic massage.

SEXUAL PROBLEMS ARISE

Sex is a natural function like digestion and like digestion can be upset by a whole variety of problems, usually not involving physical factors.

We all accept that faulty eating, stressed, anxious or in a bad mood can lead to complaints like loss of appetite, indigestion, constipation even though the body is basically healthy. We also know that if we eat normally, our digestive system works naturally and we enjoy our food.

In a similar way if sex is allowed to happen naturally and in a relaxed way our bodies will respond normally without any conscious effort on our part.

Common examples of problems

1. Misunderstanding or lack of information about sex – how to act

2. Bad feelings about sex or its consequences

Fear of pregnancy or pain

Fear of failing to perform normally or well, Guilt (Believing that sex is wrong)

Disgust (feeling that sex is dirty or messy)

3. Problems in relationship

Feeling angry, bitter or resentful towards your partner

Feeling insecure or frightened of being hurt

4. Bad feelings about yourself

Feeling depressed, worthless, not deserving pleasure

Feeling unattractive, unhappy with your body

5. Unsuitable circumstances

Feeling too tired, or hurried, or preoccupied with other things

6. Alcohol, some drugs or medicaments

7. Being in generally poor condition

How Do These Problems Affect Sexual response?

It is well known that sexual problems are caused by inhibition of the natural response, but not understood that it is usually performance anxiety that keeps the problem going.

Basic principles

1. Improve communication within the relationship.

2. Correct ignorance and misunderstanding about sex.

3. Allow yourself to relax and enjoy your natural responses.

Communication Guidelines

It is never too late to learn new ways of communication, improved communication is essential if a sexual problem is to be resolved.

Here are some basic principles of communication:

1. Aim to communicate with each other as two adults. In many marriages the husband communicates like a father and wife like a child------ and in others the wife behaves like a mother to her husband who reacts like a son. Such ‘parent and child’ relationships do not promote or encourage healthy adult sexual responsiveness.

2. Encourage your partner to use term ‘I’ and allow him or her express feelings of hurt without your reacting too violently and discouraging self expression.

3. Praise and encouragement work better than criticism. SEXUAL RESPONSES

These responses can result from all sorts of factors from fantasies, from seeing an attractive person, hearing nice music, masturbating, touching, kissing and caressing each other and from full intercourse.

These bodily responses usually go through three phases:

1. Arousal or excitement.

2. Climax or orgasm.

3. Resolution or returning to where we started.

1)AROUSAL PHASE

In the man, erection of the penis may be the first thing to happen. As arousal is increased, he feels more excited, In the women, slight swelling of the outer lips of the vagina and increased lubrication inside the vagina occur at an early state, as with the man’s erection.

2)CLIMAX PHASE

As arousal increases, the man reaches a point of no return after which he will ejaculate, whatever happens. The fluid ejaculate can vary in quantity but is usually about a teaspoonful. It is perfectly clean and contains good things like sugar to feed the sperm. As he ejaculates so he experiences a climax, a sudden buildup and release of tension followed by a feeling of well being and calm

The women may or may not come to orgasm or climax. She does not ejaculate like the man but she experiences a similar buildup and release of sexual tension-rather like a sneeze, though much more enjoyable. It lasts approximately 5-15 seconds. There are usually contractions of the vagina wall and surrounding muscle which the woman may be aware of. Most woman need caressing of the clitoris before they reach a climax.

3)RESOLUTION PHASE

This is the after the storm when the body settles down and both partners feel fulfilled and calm, often pleasantly sleepy and relaxed. In the woman, the feeling of fullness or congestion in her pelvis and her general sense of excitement may take longer to settle, particularly if she has not experienced a climax.

GUIDELINES TO HELP IMPROVE YOUR LOVEMAKING

Stage One

The equally important for improving sexual relationships.

If you are doing the caressing, assert yourself. Touch your partner where you want to touch in a way that is nice for you and for as long as you wish. It is nice to touch and feel close to your partner.

Stage Two

This stage is similar to stage one. Each session has two parts with one person starting to caress first in a pleasing for him or her; Protecting – if you don’t like what’s being done, move your partner.

Stage three:

Sensate focus with genital contact.

Exactly the same basic principles apply for stage of the programmer.

1. intercourse persists but now genital contact with the hands and/or mouth is permitted.

2. Each session is in two parts as before: A caressing B-then B caressing A.

3. As before, alternate partners initiate the session, touching in the way he or she wants to touch, with the partner protecting himself or herself from anything that is disliked and guiding the hand to show what is particularly pleasurable

4. Do not concentrate solely on the genital regions spend as much time before on general body caressing and kissing as well.

5. The use of body lotion or KY jelly can enhance the pleasure both to the caresser and the caressed, especially when touching genital areas.

6. The only goal is to be able to relax and enjoy what is happening. Check for spectatoring and learn ways of getting back to being fully relaxed and involved.

7. The partner being caressed may not become aroused and many or may not ejaculate or reach a climax. The response will vary from session to session and this is normal. Do not aim for a climax or orgasm but if it does occur it does not matter and need not mean the end of a session.

8. If premature ejaculation is a problem, you will be given additional suggestions on deal with this.

Stage Four

Sensate focus with genital contact and simultaneous caressing

1. Sex is a natural response if you let it happen.

2. Be on guard for spectating.

Stage five

Vaginal containment

Once sensate focus with genital contact is going well and the male partner is getting reasonably firm erection you are ready to enter

allow the freedom to experience sensations physical contact with each other without performance anxiety, failure to achieve a particular goal.

After a period of mutual caressing, involving the genital area, when you feel that you are ready, and when you feel your partner has a reasonably firm erection, you are invite the penis into your vagina……..

If you wish, you can then resume genital caressing and perhaps repeat the process over again. Remember that you are both to concentrate on the sensations you are feeling from your genital region and relax and not start any thrusting movements.

Initially you should only allow vaginal containment for a brief period. The period of containment can be gradually lengthened on each occasion.

Stage six

Vaginal containment with movement

You should be touching and being touched in a way that is pleasant for both of you and with no particular performance in mind other than of giving and receiving pleasure.

As before, start with mutual caressing involving both non-genital and genital areas in a way that feels good for both of you and although the man may have erection fairly quickly, it is important that both of you should feel aroused and receptive before vaginal entry takes place.

After a period of vaginal containment, you may try some limited thrusting movements to see how this affects your sensations. Only do this briefly to stage with but if you are enjoying the feelings this produces, allow the movement to continued.

The movements of intercourse feel different In the different positions you can try and it is important to experiment to find ways that suit you both. This is normal for both sexes. Many women find that they respond better at particular time of the month. Many women enjoy clitoral stimulation in additional to the thrusting of the penis and most find that they reach a climax most comfortably and pleasurably in this manner.

PREMATURE EJACULATION

This problem can be first tacked during stage. As mentioned earlier every man has a point of no return after which he cannot avoid ejaculation. During your partner’s caressing of your penis, you may feel yourself getting aroused to such a degree that you can predict that you will ejaculate shortly. This is a learning process which every male has to undertake at some stage in his life and it is never too late to learn control of ejaculation. It will, however, take time and practice and will require the full understanding and cooperation of your partner.

If you have difficulty in gaining control using this method take time because you are changing what is probably a long-established pattern then you can try the squeeze technique.

SEX THERAPY

Sex therapy is based on behavior therapy. It is a type of re-educative therapy. The fundamental of behavior therapy is that all the behaviors are learned, even the maladaptive behaviors. The behavior therapist helps the client to unlearn the unadaptive behavior and replaces it with newly learned adaptive behavior. The aims of behavior therapy are primarily educational and techniques facilitate improved self control.

From amongst several techniques that are used in behavior therapy, ‘systematic desensitization technique’ is used in sex therapy. Prior to 1970 sexual dysfunctions were managed by psychiatrists. After 1970, the masters and Johnson model of sex therapy made it possible to treat sexual dysfunction by psychologists, social workers, nurses, counsellors, and medical doctors.

Their approach included :

1. Instead of treating the affected individual, the couple is treated. It is the relationship that is affected. This strategy provides an opportunity to gain the co-operation and understanding of both the partners in overcoming the problem.

2. Two therapist-a man and a woman work together as a team. This gives each partner a same sex therapist to whom he or she can relate more easily.

3. Masters and Johnson recognized that it was important to identify organic conditions that might require medical or surgical treatment instead of sex therapy.

4. They also found that explaining the anatomy and physiology of sexual response to the clients often had important therapeutic benefits.

5. To individualize the therapy so as to meet the specific needs of each couple.

6. The therapist must avoid imposing his own values on the client.

7. the fear of performance and ‘spectatoring’ are often central to the cases of sexual dysfunction. The pressure of performance is removed initially by banning sexual contact. Couples are then helped to rediscover the sensual pleasures of touching and being touched without the goal of particular sexual response(Sensate Focus Exercise).

8. Blaming each other for the sexual problem is discouraged.

9. When a couple’s relationship improves outside the bedroom, it is apt to have positive results in the bedroom too.

Basis :

Sexual response is the function of Autonomic nervous system and is a physiological change when effective sexual stimuli are present , and a person is psychologically prepared to respond to them.

All the sense organs are to be used to create a situation conducive to sexual response . (touch is most important).

Systematic Desensitization : A mode of psychotherapy where all the anxiety provoking stimuli are arranged in an ascending level, and the client is exposed to, one by one, Both the partners are to be involved.

Relaxation: Deep breathing, deep muscle relaxation and pleasant imagery are incorporated.

Reassurance.

Stages :

1. Sensate focus

2. Woman superior position

3. Lateral position

4. Men superior position

Format :

No rigid format

Variations in time, frequency and structure depending upon the dysfunction, the patient and the therapist.

Results:

Not as definite as in pharmacotherapy

As you shall sow and water, so you shall reap

A skilled and knowledgeable therapist is like a good seed

Client’s receptive min is like fertile soil

Compliance and cooperation by wife is like watering by gardner

When all the three factors combine, the results are good.

When sex therapy works, it does wonders and results are unparalleled for that particular couple.

Contraindications:

Severe Depression

Active psychopathology

Substance abuse

illness

Hostility in couple-interaction.

MASTURBATION

Definition

Masturbation is deliberating self-stimulation, which effects sexual arousal.

Males:

About 94 percent males are involved in masturbation which leads to orgasm. Some individual does not masturbate because they do not have sufficient sex drive. There are some slow reacting individuals who find it impossible to attend orgasm in masturbation.

Masturbation provides the chief source outlet in early adolescence.

There are few males who masturbate only once or twice in their lives; and other are who have frequencies that may average seven to twenty or more in a week for long periods of years. There are few males who are still masturbating at 75 yesrs of age.

Masturbation after marriage is confined to those periods when wife is away. Sometimes masturbation is product of fact that wife does not want sexual relations as frequent as male would like to have, or that periods of pregnancy, menstruation or illness interfere with regular intercourse.

There are definite taboos against masturbation, with the explanation that it will drive you crazy, give pimples, make one weak, bend the penis, cause impotence, affect vision or do some other harm, more often masturbation is simply rejected because it is considered unnatural.

Masturbation usually does not continue for more than a minute or two. Some individuals achieve orgasm in 10-20 seconds. In males masturbatory techniques are largely manual. Some boys masturbate by moving penis against a bed or against some other object. All males experience sexual fantasies during masturbation. Some use erotic pictures for stimulation during masturbation. Many individuals find some additional stimulation in observing their own genitalia.

Boys learn to masturbate through friends or literature. Frequency of masturbation is inversely proportional to nocturnal emission. Males with high frequency of masturbation may have low rate of nocturnal emission and vice versa.

Masturbatory activity does not do any harm to the individual. It is the conflict, fearful social disgrace, guilt-feeling that harms. It ultimate sexual capacities, occasionally attempting suicide. On the other hand masturbation provides a regular sexual outlet which alleviates nervous tension and body live a balanced life. There is no evidence to prove that masturbation interferes with high mental physical or moral efficiency.

There is tremendous individual variation in the capacity to engage in this sexual activity without undue fatigue. Therefore it is not possible to define excess. Secondary the Autonomic Nervous system has control over the sexual activity. Like salivation or perspiration the response is adequate according to the simulation.

For most males, coitus is primary and masturbation is secondary. For young people masturbation is the chief source of sexual outlet up to the time of marriage. Masturbation is an alternative for coitus.

Females:

Masturbation is the one activity in which the second largest number of females engages both before and after marriage. In coitus, a female may be delayed or completed prevented from the most specific and quickest means of achieving orgasm.

Masturbation has not been as frequent and regular a source of sexual outlet for females as it has been for the males. Many males are inclined to overestimate the incidence and frequencies of masturbation among females. In females, masturbation may or may not be pursued to point of orgasm, and it may not have orgasm as its objective. Erotic satisfaction and some release from erotic tension are its objective.

Most of the females discover how to masturbation as a result of the exploration of their own genitalia. Females do not discuss their sexual experience in the open way as males do. Many females do not begin masturbation till the age of thirty while most of males begin masturbation after the onset of adolescence. About 94 percent of males masturbate, while only 62 percent of females masturbate a sometime in the course of their lives.

There is higher incidence of masturbation among the older females since there is an actual increase in erotic responsiveness at older ages, reduction of inhibition and they might have learnt by experience of obtaining similar satisfaction though self –masturbation. This is in contrast to males who reach their peak incidence in teenage. In elderly females as the estrogen level falls, The sex stimulating testosterone hormone (produced by suprarenals) level increases.

Some women who fail to reach orgasm in coitus are then stimulated manually by their husbands, or they masturbate themselves until they reach orgasm. Some of the married females , on the other hand, confine their masturbation to period when their husbands are away from home.

The frequency of masturbation in single females is once in every two to three weeks and in married females it is once in a month. There is individual variation in any type of sexual activity. There are some females who regularly masturbate to the point of orgasm several times in immediate succession as often as 10 to 20 and even more times within single hour. Many women often fear that masturbation would do them physical harm, and consider it morally wrong and biologically abnormal. The scientific truth is that masturbation does not harm in any way.

Females choose more types of technique of masturbation than males do. Females most frequently involve in manipulation of clitoris is and /or labia minor. Clitoris is a small bud-like structure-a homologue of male penis, which is located at the upper end of vertical cleft of female genitalia. Labia minor are the paired inner lips and represent body of the penis in male. In masturbation the females usually moves a finger gently and rhythmically over the sensitive areas, or applies rhythmic or steady pressure with several of her fingers or with her whole hand.

Frequently one or two fingers are moved forward between the labia in manner, which brings each stroke against the clitoris. Sometimes the labia are gently and rhythmically pulled to stimulate them. Because these structures are attached to the clitoris. She simultaneously stimulates the organ. Occasionally, her heel or some other object is used to press on the sensitive areas. Clitoris and labia minor are the portions of genitalia which are best supplied with the end organs of touch. Females do not masturbate by penetration of vagina, since walls of vagina are practically without nerves, although there may be some sensory nerves close to the entrance of vagina. Deep vaginal penetration is men’s fantasy and is not the sexual need of women. Major lips of female genitals are involved in masturbation much less frequently. The above mentioned techniques are used by 84 percent of females; while 10 percent of females masturbate by crossing their legs and pressing them to exert steady and rhythmic pressure on the whole genital area. Such pressure affects the clitoris, labia minora and majora. During masturbation the female may lie face down or with her knees drawn against her belly. Her buttocks may then move rhythmically forward and against each other. In face down position the female presses her genitalia the bed or against the pillow, which is placed under her pelvis or between her pelvis or between her thighs. Thus the clitoris and other portions of genitals are stimulated. The speed with which the orgasm is achieved through the use of such technique is equal or superior to that with which orgasm may be achieved by any other method.

Nipples of the breast are erotically sensitive in nearly half of the females. The females may stimulate them with her hand simultaneously while manipulating her genitals. Breast stimulation alone is not sufficient to effect orgasm.

In connection with the above-mentioned techniques of masturbation, most of the females make only occasional vaginal insertion by their finger. Females do not use dildoes as men imagine.

Unlike males, females do not fantasize about coitus while masturbating. Females masturbate for the sake of immediate satisfaction and as a means of resolving physiologic disturbances, which arise when they are aroused sexually. After masturbation, they function more efficiently in their everyday affairs.

Some females believe that pimples, mental dullness, poor posture, stomach upsets, ovarian pains, infections, weak eyes, headaches and several ailments are due to masturbation. Physicians have not been able to relate these disturbances to masturbation. Thus, masturbation is a safe sexual outlet for females as well as for males. Fatigue after masturbation is like that which follows after any other activity utilizing energy. They recover from exhaustion within a matter of minutes or after a night of sleep.

Sex researches have come to a conclusion that the tremendous amount of damage done is due to the worry over masturbation and attempts to abstain from this activity, rather than the activity itself. When no guilt, anxiety or fear is involved, the physical satisfaction due to sexual activity leaves an individual well-adjusted psychologically. It has been observed that premarital experience in masturbation actually contributes to the female’s better capacity to respond during coitus after her marriage. It has been experienced by many women that premenstrual pain is relieved after masturbation. The reason is that as a result of orgasm achieved through masturbation, the blood flow in the genital area is diverted to the rest of the body and the congestion of blood that causes pain is relieved. It has also been observed that if a female gets orgasm during coitus chances of pregnancy increase since the mouth of the uterus opens wider, allowing more sperms flowing in.

DIPLOMA IN SEXUAL MEDICINE & PSYCHO SEXULAL THERAPY

DISTANCE LEARNING COURSE (ONLY FOR REGISTERED DOCTORS)
DIPLOMA IN SEXUAL MEDICINE & PSYCHO SEXULAL THERAPY
Affiliated to ICM &IBCM .
Details -Course Co-ordinator - WNHO CLINIC ,
TILAK ROAD ,
PUNE 411030.
Ph. No.-(020)4121108,
(020) 24463540,
Mobile No- 9822006427.

Course covers following contents:
*Introduction
*Basics
*Values in Sexuality
*Anatomy & Physiology
*Sexual Response Cycle
*Psychology of Sexual Response
*Neural Mechanism of Sex
*Hormones in Sex
*Sexual Problems
*History Taking
*Physical Examination
*Investigations
*Counseling
*Psychotherapy
*Sex Therapy
*Sensate Focus
*Pharmacotherapy
*Coital Postures
*Man-Women =Similarities & Differences
*What Man / Women Wants?
*Masturbation
*Homosexuality
*Oral &Anal Sex
*Unconsummation
*Sex Factors Helpful in Treating Infertility
*Male Infertility
*Myths & Misconception
*FAQ
*Hypoactive Sexual Desire
*Sexual Aversion Disorder
*Male Erectile Disorder (Impotence)
*Premature Ejaculation
*Male Orgasmic Disorder
* Female Sexual Arousal Disorder (Frigidity)
* Vaginismus (Painful Coitus)
*Dyspareunia
*Sexuality in the Ageing
*Sex in Some Common Conditions
*Premarital Guidance
* Sexuality Education
*Sharing with You
--------------------------------------------------------------------------------------------------------------------------

INSTITUTE OF COMPLEMENTARY MEDICINE(ICM)
Affiliated-IBCM-INTERNATIONAL BOARD OF COMPLEMENTARY MEDICINE & GLOBAL EDUCATION(WNHO) AUTONOMOUS
EDUCATIONAL TRUST REGISTRATION NO.382/11985 GBBSD BPT 1950F-10581,MUMBAI.
APPLICATION FORM
I wish to apply for online certificate courses
1) Diploma in cosmetology and Dermatology , Laser.
2) Diploma in Sexology and Psychosexual medicine.

Name-.............................................................................................................
Age ....................... Address........................................................................... ......................................................................................................... ............................................................................................................. .............................................................................................................
Date of Birth-...........................................Mob-..............................................
Email-..................................................................................

DECLARATIONS.
I hereby declare that the above information is true. I have read the rules of discipline. I agree to fully abide by them and also rules made by the authorities of the institute from time to time .I know that fees once paid will not be refund or transferred on any account. further I, wish to begin this unique course for my Skill enhancement . I cannot prescribed any medicine unless and until I had registration in that Branch.

Signature of student.



Address
Course Co-Ordinator
WNHO clinic, Sadashiv Peth,Opp ICICI Bank, 3 Dhanwantari Building, Tilak Road, Pune-411030 , Mob-9822006427 Email:drrameshm2@gmail.com

INDIAN SOCIETY OF SEX MEDICINE DERMATOLOGY, COSMETOLOGY

Indian Society of Sex Medicine with collaboration of Institute of Complementary Medicine & IBCM PG Diploma & Certificate course, Pune. India.
Dear Member,
On behalf of our President, and the Educational Committee of the IBCM International Board of complementary Medicine we invite you to apply for the ISSM School of Sexual Medicine programed. Only for qualified doctors & counsellors.
1day/3day/10 days therapy training course.
PG certificate training in Sexology Therapy Online………. Rs. 15000/ For Doctors.

Fellowship course…………………………………………….Rs. 30,000/ For Doctors.

.
Three Days- PG Diploma Course certificate training in Sexual Medicine therapy. Rs. 10,000/ for doctors Three Days- Three Days -PG Diploma Course certificate training in Sexology counselling Rs. 10,000/ for Counsellors.
Ten days Detail Fellowship Certificate Course in Sexual Medicine……………. Rs. 20,000/ equivalence to PHD. Only for Doctors only and registered medical practitioners.
The application is available here: www.wnhoclinic.com

For further information, please e-mail the Programme Directors drrameshm2@gmail.com/ contact@wnhoclinic.com


Background
The ISSM School of Sexual Medicine was a joint venture established by the IBCM – International Board of Complementary Medicine & Institute of Complementary Medicine, Pune.

Our programmer is intended for clinicians seeking to acquire the knowledge and skills essential for practice in Sexual Medicine and Clinical Sexology.
Medically-qualified participants should find the programmed helpful when preparing for the Fellowship of the Sexual Medicine.
Psychologists will also find the program helpful for qualification as Psych sexologist.
Programme & Requirements
The Programme is intended for persons with post-graduate experience in any relevant clinical specialism. Interest in and enthusiasm for Sexual Medicine are the essential qualifications; whilst previous experience in the clinical practice of Sexual Medicine is an advantage, the programme is also suitable for those starting out in this fascinating and rapidly developing area of medicine.
All sessions during the programme will be conducted in the English language; participative learning techniques for skill development will be used, as well as interactive teaching.
There will be practical training in Sexual Medicine consultation techniques and history-taking, and in the basic use of sex therapy techniques in Clinical Sexology.
The academic programme will include
• sexual development
• psychology and physiology of sexual desire, arousal and response
• impact of gender on sexuality
• ageing and sexuality
• sexual dysfunctions in men and women
• problematic sexual behavior
• gender identity disorders
• impact of medical treatments and other health problems on sexuality
• clinical skills in Sexual Medicine
• clinical management of sexual disorders
• genital anatomy.
• ethical and legal aspects of Sexual Medicine
• standards of care in Sexual Medicine.

The course not only aims to add to your knowledge of Sexual Medicine but also to enable you to change your clinical practice with the acquisition of new skills to apply to providing services for patients and to have more confidence in assessing and helping men and women with common sexual concerns.
Moreover, there will be an optional and very informal social programme run throughout the course. This is a friendly course and we hope that participants will make new friends, as well as learn about Sexual Medicine. Because the number of participants is strictly limited, there is plenty of opportunity to meet and talk informally with teaching faculty members. Group members have the option of joining us for evenings together during and after dinner.

For further information, please email the Programme Directors drrameshm2@gmail.com/ contact@wnhoclinic.com

SEXOLOGY COURSE FOR MEDICAL PRACTITIONERS ONLINE
Indian Society of Sex Medicine ISSM- distant education course in sexology counseling and therapy for Medical practitioners, consultants and medical students. The practical’s and demonstrations will be arranged in Pune .The course curriculum is developed according to the demands of Indian people about this subject.
A short course in anatomy and physiology is taught about sex and reproductive organs of men and women. The physiological process of penile erection.
The physiology of human sexual response is discussed in great details as this form fundamental platform of clinical sexology.
The main emphasis will be on sexual problems, sexual inadequacy, and miss-match in sexual matters.
The study of male sexual inadequacy includes
-Impotence. Insufficiency of penile erection. The diagnosis and treatment according to modern medicine, Behavioral therapy, sensate focusing according to the great sexology researchers Dr. Masters & Johnson. Vacuum erector device, Penile injection to induce immediate erection lasting for 30 minutes to 30 hours, Stuffing method and other useful treatment methods will be explained in detail.
-Pre-mature ejaculation. The physiology of ejaculation, and the concept of point of inevitability of ejaculation, is explained. The treatment methods of behavioral therapy, the treatment method of Dr. Masters & Johnson's, The famous Squeeze method is explained in great details.
-Loss of Desire. The psycho-sexual methods are explained to help such cases.
-Andropause and sexual problems of old age. The physical disability is dealt with in detail.
The study of Female sexual inadequacies includes
-Anorgasmia or inability to achieve orgasm in the sexual intercourse. The physical as well as psychological causes are discussed. Different techniques for training the body to achieve orgasm are detailed.
-Dyspareunia, or painful coitus. The physical and psychological causes are discussed with treatment methodology.
- Vaginismus. The situation where, an involuntary contraction of vaginal muscles makes it impossible for man to insert his penis in the vagina to have sex.
-Loss of desire. The psychological causes and treatment strategy is explained.
The study of sexual inadequacies of the couple includes
-Sexual positions for different situational difficulties due to shape of the body, physical disabilities, painful condition, psychological issues, illness etc. There are more than 108 positions explained.
-Loss of desire. Psychosexual methods of treatment are explained.
The other aspects of general human sexuality including History of sex, deviations of sexual behavior, changing patterns of sexual behavior, Sexercises, beautification of sexual organs, methods of increasing size of the penis (as per paper presentation by Prof. Dr. Ramesh Maheshwari at the 28th national conference of Sexology in Mumbai in October 2013.), Evaluation Effect of Physical therapy on Male Erectile Dysfunction is explained.
The course explains in detail every problem and the curative treatment according to modern medicine and the therapy that will help.
The duration of the course is three months.
The course material will be available online on the web site of www.wnhoclinic.com. The students will need to submit tutorials and a thesis on the subject of any aspect of human sexuality. A certificate of completion will be issued by Institute of Complementary Medicine & IBCM & ISSM & WONHO Clinic as center.
The course material is formulated according to the need of students. This is arranged in the form of distant education, which will be extremely useful for the students.
The course coordinator is Prof. Dr. Ramesh Maheshwari who is Sex counselor, therapist and educator for last 30 years. Some of his credentials are as follows:-
–Dr. Maheshwari R.M

MBBS, MD, FCCP, DHPh (Homeopathy UK), ND (Naturopathy), TCY & DYEd(Yoga) MICIA- training from Indian College of Allergy & Immunology, V.P. Chest, New Delhi).
DMLS- Diploma in medico-Legal System from Symbiosis (Deemed University) Pune & DPM (Psychiatry) CPS, Mumbai. MCSPI (SEX THERAPY COURSE)]
Honorary Sexual Medicine Consultant at Aditya Birla Memorial hospital, Chinchwad, Pune.
Honorary Assistant professor in Bronchial Asthma & Allergy (T.B & chest) Department at D.Y.Patil Medical college, Pune, Ex. Clinical research Assistant at Bombay Hospital Mumbai & Pune.
–Member of The International Scientific Committee of World Association of Sexology, Caracas, Venezuela, South America.
–Member Consultant on The Forum Board of Consultants, London. United Kingdom.(17Years)


Sexology course for medical practitioners

Normal Sexuality
Normal person's sexual attraction to another, the passion and love that follows are deeply associated with the intimate happiness which is determined by anatomy, physiology, living style, relationship with the other person and developmental experience throughout the life Normal sexual behavior brings pleasure to oneself and one's partner, involves stimulation of the primary sex organs including coitus; it is devoid of inappropriate feelings of guilt or anxiety and is not compulsive.
Sexual Dysfunction
The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or in the objective performance. Either type of disturbance can occur alone or in combination. They can be lifelong or acquired, generalized or situational, and result from psychological factors, physiological factors, or combined factors. Sexual disorders can lead to or result from relational problems, and patients invariably develop an increasing fear of failure and self-consciousness about their sexual performance. Sexual dysfunctions are frequently associated with other mental disorders, such as depressive disorders, anxiety disorders and personality disorders etc. Sexual function can be adversely affected by stress of any kind, by emotional disorders, or by ignorance of sexual function and physiology. The dysfunction may be lifelong or acquired that is, it can develop after a period of normal functioning. The dysfunction may be generalized or limited to a specific partner or a certain situation.

Welcome to the Sex Therapy Postgraduate Training Institutes. We are certified sex therapists and supervisors providing sex therapy certification training for medical and mental health professionals.

We offer three unique and stimulating educational Institutes -- Medical Sex Therapy: integrating sexual medicine and the practice of sex therapy in a one week program; the Florida Postgraduate Sex Therapy Training Institute: a one year, once a month course offered via live webcast from our Palm Beach campus; and the Sex Therapy Postgraduate Training Institute of New York: held at the prestigious Faculty House of Columbia University, meeting five times a year for two years.
What is Sex Therapy Certification?

Professional training in sex therapy was established in 1970 with the publication of Masters and Johnson’s book “Treating Sexual Inadequacy.”


Many medical and mental health experts have since written extensively in the sexual field, and have defined specific behavioral and cognitive approaches across a wide range of disciplines. Sex therapy is a specialized psychotherapeutic modality often utilizing a short term approach.

The sex therapist deals openly and directly with sensitive issues. Clinicians who treat individuals or couples of any orientation, families of any configuration, persons dealing with gender issues, or victims and perpetrators of sexual abuse gain expertise practicing specific sex therapy techniques.
______________________________________
Areas of Concentration
Our program covers a wide variety of sex therapy topics including:
• Sexual Dysfunctions and Disorders
• Psychosexual Assessment
• Sexual Trauma
• Treatment of Sexual Problems
• Sexual/Relationship Problem

care
career opportunities

Our graduates have established careers in the fields of sex therapy, sex education and consultancy, child and elder protection, sexual health policy development, human rights, disability, cyber-safety training, health promotion, youth work, academia, medical management, risk management, forensic assessment, sexual research and many others. ECOLOGY COURSE FOR MEDICAL PRACTITIONERS ONLINE
Nashikdoctors.com launches a distant education course in sexology counseling and therapy for Medical practitioners, consultants and medical students of Nasik and surrounding area. The practical’s and demonstrations will be arranged in Nasik.
The course curriculum is developed according to the demands of Indian people about this subject.
A short course in anatomy and physiology is taught about sex and reproductive organs of men and women. The physiological process of penile erection, the mechanism of abner pads as found out by my teacher Dr. Germ Wagner of Denmark is explained.
The physiology of human sexual response is discussed in great details as this forms fundamental platform of clinical sexology.
The main emphasis will be on sexual problems, sexual inadequacy, and miss-match in sexual matters.
The study of male sexual inadequacy includes
-Impotence. Insufficiency of penile erection. The diagnosis and treatment according to modern medicine, Behavioral therapy, sensate focusing according to the great sexology researchers Dr. Masters & Johnson. Vacuum erector device, Penile injection to induce immediate erection lasting for 30 minutes to 30 hours, Stuffing method and other useful treatment methods will be explained in detail.
-Pre-mature ejaculation. The physiology of ejaculation, and the concept of point of inevitability of ejaculation, is explained. The treatment methods of behavioral therapy, the treatment method of Dr. Masters & Johnson's, the famous Squeeze method is explained in great details.
-Loss of Desire. The psycho-sexual methods are explained to help such cases.
-Andropause and sexual problems of old age. The physical disability is dealt with in detail.
The study of Female sexual inadequacies includes
-Anorgasmia or inability to achieve orgasm in the sexual intercourse. The physical as well as psychological causes are discussed. Different techniques for training the body to achieve orgasm are detailed.
-Dyspareunia, or painful coitus. The physical and psychological causes are discussed with treatment methodology.
- Vaginismus. The situation where, an involuntary contraction of vaginal muscles makes it impossible for man to insert his penis in the vagina to have sex.
-Loss of desire. The psychological causes and treatment strategy is explained.
The study of sexual inadequacies of the couple includes
-Sexual positions for different situational difficulties due to shape of the body, physical disabilities, painful condition, psychological issues, illness etc. There are more than 108 positions explained.
-Loss of desire. Psychosexual methods of treatment are explained.
The other aspects of general human sexuality including History of sex, deviations of sexual behavior, changing patterns of sexual behavior, Sexercises, beautification of sexual organs, methods of increasing size of the penis The course explains in detail every problem and the curative treatment according to modern medicine and the therapy that will help.
The duration of the course is three months.
The course material will be available online on the web site of www.nashikdoctors.com The students will need to submit tutorials and a thesis on the subject of any aspect of human sexuality. A certificate of completion will be issued. The course material is formulated according to the need of students. This is arranged in the form of distant education, which will be extremely useful for the students.
–Faculty Member International Collage of Alternative Medicine. Ontario CANADA.
–International License. In Accordance to WHO Curriculum.
Contact for more information- Dr Ramesh Maheshwari, MBBS,MD Wnho Clinic, 2014 Sadashiv Peth, Tilak Road, Dhanwantari Building office no.3, Pune 411030. Mobile 9822006427.
Sexology course for medical practitioners

Dr. Dr.Ramesh Maheshwari

Director WNHO Health Care Pvt.Ltd.

Honorary Sexual Medicine Consultant at Aditya Birla Memorial hospital, Chinchwad, Pune.

Honorary Assistant professor in Bronchial Asthma & Allergy (T.B & chest) Department at D.Y.Patil Medical college, Pune, Ex. Clinical research Assistant at Bombay Hospital Mumbai & Pune.

Dr. Ramesh Maheshwari, widely regarding the pioneer in the holistic care. As Maheshwari's WNHO CLINIC health programmed, treat the individual not symptoms.

Our franchises are all over India as per WHO norms. According world health organization -health is not merely absence of disease, it is the to achieve balance state of physical, mental, social, & additional dimension spiritual well-being. Our WNHO CLINIC take care of all above four states.

Director Dr. Maheshwari is passed out MBBS in 1983 from Govt. Medical College Nagpur & later on work at Bombay Hospital in chest medicine department & completed FCCP fellowship of college of chest physician. Then he completed MD. Doctorate in Respirator medicine & Ph.D. he works at psychiatry department of D.Y. Patil Medical College & complete diploma in psychosexual medicine. He had several 45 papers presentation at National & International conferences.

The guiding vision of WNHO " Look good Feel Good" We imply that in today's world one's appearance & Personal beautiful & healthy skin not only helps an individual look good but feel even better by Natural Way, this is the core value of our WNHO-CLINIC. Sexology & Cosmetology and Asthma is our extensive twenty-five years research work with zero relapse rate. We had advanced equipment’s available today in the field of Sexology, Dermatology /Cosmetology. Our training institute guides our students improve their skills & understand the subject in the right perspective under the guidance of qualified trainers Mission Statement.

Our clinics mission is to provide comprehensive Laser & Cosmetic Medicine for men and women having any skin problem & also spread awareness about the growing skin diseases in today's world. Our equipment division works hard to provide the latest technology equipment at the right price & of the right quality. Our Academy aims at imparting high-quality cosmetology training with more emphases on practice & hands on experience for our students.

Awards and Recognitions Faculty & Expert At National Conference Of Sexology, Mumbai - 2014
WNHO Clinic Registered Under Government Of India As Trade Mark - 2011
Post Graduate Course HIV /aids & Std's - 2005
Speaker Indian Androphile Society - 2006
National Conference of Sexology CSEPI - 2007
IMA Management Of Infertility Couple - 2012
IMA Fitness Medicine - 2012

Memberships Indian Medical Association (IMA)
Council of Sex Education & Parenthood International (CSEPI)
Indian Society Of Sex Medicine
All India Yoga Research Federation
Association of Physicians of India

Sex Module No-1 For PG Diploma In Sexual Medicine & Fellowship.

SEXUAL PROBLEMS

A. Sexual desire disorders:

Hypoactive sexual desire disorder

Sexual aversion disorder

B. Sexual Arousal Disorders:

Male Erectile Disorder (Impotence)

Female Sexual Arousal Disorder (Frigidity)

C. Orgasmic Disorders:

Male Erectile Disorder (inhibited male orgasm)

Premature ejaculation

Female Orgasmic Disorder (inhibited female orgasm)

D. Sexual Pain Disorders :

Vaginismus

Dyspareunia

E. Common Functional problems:

Penis anxiety

Masturbation guilt

Dhaat syndrome

Unconsummated marriage

Myths & Misconceptions about sexuality etc.

F. Paraphilias:

Homosexuality

Transvestism

Fetishism

Pedophilia

Sadism

Masochism etc.

G. Gender Identity Disorder

Transsexualism

H. Sexual Dysfunction due to General medical Conditions

Diabetes

Hypertension

Heart attack

Endocrinal diseases

Psychiatric illness

Malignacy

Pregnancy

Menopause

HISTORY TAKING

1. General

Sexual problems do occur in persons who do well in the other areas of health.

Sexual Dysfuction may have its root in a simpler problem e.g.

a. Pressure of performance or fear of failuar

b. Fear of rejection by the partner

c. Imaginary demand of sexual performance

d. Negative attitude towards sex

e. Homosexual orientation

f. Traumatic sexual experience in the past

g. Dislike for the partner

Sexual appetite varies depending upon:

a. Basic biological drive

b. Psychological need

c. Physical & mental health

d. Anxiety / Depression

e. Defective interpersonal relationship

Take the history of both the partners since it is the relationship to be treated and not the individual.

2. Identification data (of both)

Name Age Sex

Address Occupation Education

Single/ Married No.of children

Religion Marital Status

Tel. No. Email ID

Attendance Single/Couple

3. General Information

O.D.P. Of the problem

Male : Attitude towards Masturbation, Nocturnal emission,Size of Penis , Semen, Libido

Female : Mastrubation, Menstruation, Pregnancy, Coitus.

4. Past History

H/O Diabetes, Hypertension, Tuberculosis, IHD,

Liver/Kidney disease, mumps, STI/HIV infection

H/O pre/Extra marital intercourse, sexual abuse

Homosexual experiences (Attitude)

Sex Games ( Punished)

H/O Surgery

5.Personal History

Interpersonal relationship between the partners

Drugs, Smoking, Alcohol, Medications,

Diet, Exercise,Sleep

Parents attitude towards sexuality

Fatigue, Fear, Guilt

6. Psychiatric History

Anxiety: Headache, Palpitation, Anger, Insomnia

Depression : Crying spells,Sad mood, Suicidal ideas Personality disorder, Paranoid behavior, Schizophrenia

7.Cotial History

Privacy, communication, lights, (On/off) , foreplay (yes/No)

Frequency, Duration, Peno-vaginal, Oral, Anal, Posture

Male : Desire, Erection, Penetration, Movements Enaculation

Female : Desire, Lubrication, Intromission, Orgasm

8. History relevant to specific Sexual Dysfunction :

a. Hypoactive sexual desire &Sexual aversion

H/O sexual abuse ( rape)

Homosexual orientation

Partner repulsive?

Extra marital affair?

b. Erectile Dysfunction:

Morning erection?

Problem in obtaining / maintaining erection?

Loss of erection is partial or total?

c. premature ejaculation:

His concept of premature ejaculation

ejaculation: before, during or after intromission?

d. Male orgasmic disorder (ejaculatory incompetence)

His attitude towards sex (negative?)

His attitude towards partner(Dislike?)

Is she responsive?

e. Female orgasmic disorder (inhibited female orgasm)

Her expectations

Her sexual value system

His co-opration

f. vaginismus

Her fears: penis, husband, pregnancy

Genital experience : masturbation, intercourse

H/O Sexual abuse

Sex Module No-3 For PG Diploma In Sexual Medicine & Fellowship.

PHYSICAL EXAMINATION

Nutrition : Good/Fair/Poor

Built : Good /Fair/Poor

Weight: Kg

Height : Cms

B.P : mm Hg.

Pulse : per min

Lymph nodes : palpable/ not palpable

C.N.S. : Reflexes

Autonomic N.S. : Valsalva maneuver:

Take the pulse rate at rest

Blow through the B.P. apparatus tube to raise the mercury

upto 40mm and maintain for 15sec.

Take the pulse rate again.

Take the ratio of the two readings.

Normal : ratio > 1.5

Neuropathy : if the ratio is <1.1

Postural hypotension:

Take systolic B.P.in sleeping position (after rest for 15 min)

After standing for 3 min, take systolic B.P. again

Normally B.P. falls by about 10 mm

In Neuropathy , B.P. falls by about 30mm

Pupillary reaction to light:

Normally, pupils react to light

In Neuropathy , pupils do no react to light.

Other signs

No sweating,

Constipation

R.S. :

A.S. : P.R. Exam

U.G.S. : Secondary sex characters : Genital development, Hair

Male: change in voice nocturnal emissions

Female : Breast development, Menstruation

Genital Exam :

Male : scrotum;

Testes- size, consistency

Penis- skin,

Urethral meatus,

Prepuce- phimosis?

Glans- ulcer, smegma,

Consistency of corpora, chordee?

Pulsation of dorsal arteries(?)

Cremastric & Bulbocavernosus reflexes

Penile B.P.

Female : mons, clitoris, labia majora & minora

Urethral meatus,

Vaginal opening, Hymen

P.V.-1 or 2 fingers dilatation

Vaginismus?

INVESTIGATIONS

Heamogam

Urine- routine examination

Blood sugar estimation : fasting & post prandial

Lipid profile

Serum creatinine

Blood : VDRL, Elisa for HIV, P.S.A.

X Ray chest

ECG

Hormonal studies: FSH, LH, Testosterone (free) Estrogen, prolactin

Semen analysis:

Special Tests :

Stamp test

Peno Brachial Index

Rigiscan Test

Penile Ultrasound (Doppler)

Cavernosometry

Canvernosography

Biothesiometry

Electromyography (EMG)

Never conduction studies

Phalloarteriography

Cytogenetic studies

COUNSELING

Many people think of counselling as giving or offering solutions to the problem. However, counselling is neither of these. When the client comes for help with a problem he has to change something in himself to solve it. This may be a change of attitude, of perception of self or of others, of habit or a change of behavior. Counselling is teaching the client ‘life-coping skills’.

Goals :

To help reduce the level of anxiety when confronted with a stressful situation

To help bring about a meaningful change in the client and function more successfully

To facilitate client’s decision-making process

To help client to plan his solution for his problem using his value system

Essentials:

Listen actively, and question effectively

Accept the client , respect him, his ideas and feelings

Show empathy ( recongnition of another’s feelings)and warmth

Be honest and non-judgmental

Counter the myths and misconceptions

Maintain confidentiality

Counselling can never be hurried (average time: 30 min)

Hold the counselling session in a private place.

PLISSIT Model :

Sexual problem, where there is no organic cause, can be effectively tackled by the use of PLISSIT madel of sexual counseling. This is behavior treatment for sexual problems. This is based on the belief that human behavior is a learned process. Maladaptive behavior can be unlearned and positive behavior can be substituted.

PLISSIT Model was formulated john anon in 1976 .this model suggests therapeutic interventions 4 levels:

Treatment level I P: Permission:

The counsellor asks questions about client sexuality e.g. sexual thoughts , fantasies, dreams, feeling, sexual arousal, masturbation, nocturnal emission etc. The counsellor assures the client that he is O.K. and to continue doing what has been doing.

Level II : LI: limited information ;

At this level the counsellor explains why the client is O.K. the counselor counters myths and misconceptions related to his sexual problem and provides scientific information on the concerned topic e.g. masturbation, oral sex, breast and genital size during menstruation/ pregnancy etc.

Level III : SS : Specific Suggestion:

At this level the counsellor provides alternative explanation for the problem (learning & conditioning) and offers specific suggestions to the client to manage the sexual situation e.g. specific coital position during pregnancy; sensate focus; kegel exercise.

Level IV: IT: Intensive therapy:

At this level analysis and treatment of attitude, reinforcing and discriminative function of stimuli that elicit inappropriate emotional responses are required. Paraphilia, marital discord, substance abuse required this level of therapeutic intervention.

Additional instruction to the client :

1. Tobacco : To stop smoking or any other use of tabacco. Nicotine in tabacco causes vasoconstriction and enhances atherosclerosis.

2. Balance diet : To avoid excessive consumption of fats, sugars and salts and to take plenty of proteins ( egg white, pulses, fish, skimmed milk) , green vegetables and fruits. Udid contains natural testosterone and soyabean contains natural estrogen. Idli made from udid and rice is a nutritious food item. Vegetarian and non-vegetarian diet are equally good provided extra milk is consumed by vegetarians. Balance diet provides enough energy for sexual activity.

3. Exercise : The aim is to achieve physical fitness and not the body building. Exercise should be done on empty stomach. It should be gradual. If pain occurs in the chest during the exercise, it should be discontinued immediately and seek physician’s advice.

The four components of physical fitness are:

(a) Cardio-respiratory efficiency : Running, swimming, fast walking, cycling or spot running, ,minimum for 20 min and at least for 5 days in a week. The pulse rate should be 220- age *4/5

(b) Flexibility : Yogasnas. Each asana should be done for 2 min. Difficult and painful asanas need not be done.

(c) Endurance : sit ups, push ups

(d) Strength: Wait lifting, bulwarker.

4. Body weight: Excessive body weight may cause difficulties in the sexual activities. Optimum body weight is calculated by the formula of body mass Index (BMI)

B.M.I. – Body weight in kg/ ( Height in meters) 2

The resultant Should be 25.

Both, Dieting and exercise are necessary for the weight reduction.

PSYCHOTHERAPY

Sex Module No-4 For PG Diploma In Sexual Medicine & Fellowship

PHYSICAL EXAMINATION

Nutrition : Good/Fair/Poor

Built : Good /Fair/Poor

Weight: Kg

Height : Cms

B.P : mm Hg.

Pulse : per min

Lymph nodes : palpable/ not palpable

C.N.S. : Reflexes

Autonomic N.S. : Valsalva maneuver:

Take the pulse rate at rest

Blow through the B.P. apparatus tube to raise the mercury

upto 40mm and maintain for 15sec.

Take the pulse rate again.

Take the ratio of the two readings.

Normal : ratio > 1.5

Neuropathy : if the ratio is <1.1

Postural hypotension:

Take systolic B.P.in sleeping position (after rest for 15 min)

After standing for 3 min, take systolic B.P. again

Normally B.P. falls by about 10 mm

In Neuropathy , B.P. falls by about 30mm

Pupillary reaction to light:

Normally, pupils react to light

In Neuropathy , pupils do no react to light.

Other signs

No sweating,

Constipation

R.S. :

A.S. : P.R. Exam

U.G.S. : Secondary sex characters : Genital development, Hair

Male: change in voice nocturnal emissions

Female : Breast development, Menstruation

Genital Exam :

Male : scrotum;

Testes- size, consistency

Penis- skin,

Urethral meatus,

Prepuce- phimosis?

Glans- ulcer, smegma,

Consistency of corpora, chordee?

Pulsation of dorsal arteries(?)

Cremastric & Bulbocavernosus reflexes

Penile B.P.

Female : mons, clitoris, labia majora & minora

Urethral meatus,

Vaginal opening, Hymen

P.V.-1 or 2 fingers dilatation

Vaginismus?

Sex Module No-4 For PG Diploma In Sexual Medicine & Fellowship

INVESTIGATIONS FOR EVALUATION OF SEXUAL PROBLEM

Heamogram

Urine- routine examination

Blood sugar estimation: fasting & post prandial

Lipid profile

Serum creatinine

Blood: VDRL, Elisa for HIV, P.S.A.

X Ray chest

ECG

Hormonal studies: FSH, LH, Testosterone (free) Estrogen, prolactin

Semen analysis:

Special Tests :

Stamp test

Peno-Brachial Index

Rigiscan Test

Penile Ultrasound (Doppler)

Cavernosometry

Canvernosography

Biothesiometry

Electromyography (EMG)

Never conduction studies

Phalloarteriography

Cytogenetic studies

SEX MODULE NO-5 FOR PG DIPLOMA FOR SEXUAL MEDICINE & FELLOWSHIP

PSYCHO SEXUAL COUNSELING

Many people think of counselling as giving or offering solutions to the problem. However, counselling is neither of these. When the client comes for help with a problem he has to change something in himself to solve it. This may be a change of attitude, of perception of self or of others, of habit or a change of behavior. Counselling is teaching the client ‘life-coping skills’.

Goals :

To help reduce the level of anxiety when confronted with a stressful situation

To help bring about a meaningful change in the client and function more successfully

To facilitate client’s decision-making process

To help client to plan his solution for his problem using his value system

Essentials:

Listen actively, and question effectively

Accept the client , respect him, his ideas and feelings

Show empathy ( recongnition of another’s feelings)and warmth

Be honest and non-judgmental

Counter the myths and misconceptions

Maintain confidentiality

Counselling can never be hurried (average time: 30 min)

Hold the counselling session in a private place.

PLISSIT Model:

Sexual problem, where there is no organic cause, can be effectively tackled by the use of PLISSIT model of sexual counseling. This is behavior treatment for sexual problems. This is based on the belief that human behavior is a learned process. Maladaptive behavior can be unlearned and positive behavior can be substituted.

PLISSIT Model was formulated john anon in 1976 .this model suggests therapeutic interventions 4 levels:

Treatment level I P: Permission:

The counsellor asks questions about client sexuality e.g. sexual thoughts, fantasies, dreams, feeling, sexual arousal, masturbation, nocturnal emission etc. The counsellor assures the client that he is O.K. and to continue doing what has been doing.

Level II : LI: limited information ;

At this level the counsellor explains why the client is O.K. the counselor counters myths and misconceptions related to his sexual problem and provides scientific information on the concerned topic e.g. masturbation, oral sex, breast and genital size during menstruation/ pregnancy etc.

Level III : SS : Specific Suggestion:

At this level the counsellor provides alternative explanation for the problem (learning & conditioning) and offers specific suggestions to the client to manage the sexual situation e.g. specific coital position during pregnancy; sensate focus; Kegel exercise.

Level IV: IT: Intensive therapy:

At this level analysis and treatment of attitude, reinforcing and discriminative function of stimuli that elicit inappropriate emotional responses are required. Paraphilia, marital discord, substance abuse required this level of therapeutic intervention.

Additional instruction to the client :

1. Tobacco : To stop smoking or any other use of tobacco. Nicotine in tobacco causes vasoconstriction and enhances atherosclerosis.

2. Balance diet : To avoid excessive consumption of fats, sugars and salts and to take plenty of proteins ( egg white, pulses, fish, skimmed milk) , green vegetables and fruits. Udid contains natural testosterone and soyabean contains natural estrogen. Idli made from udid and rice is a nutritious food item. Vegetarian and non-vegetarian diet are equally good provided extra milk is consumed by vegetarians. Balance diet provides enough energy for sexual activity.

3. Exercise : The aim is to achieve physical fitness and not the body building. Exercise should be done on empty stomach. It should be gradual. If pain occurs in the chest during the exercise, it should be discontinued immediately and seek physician’s advice.

The four components of physical fitness are:

(a) Cardio-respiratory efficiency : Running, swimming, fast walking, cycling or spot running, ,minimum for 20 min and at least for 5 days in a week. The pulse rate should be 220- age *4/5

(b) Flexibility : Yogasnas. Each asana should be done for 2 min. Difficult and painful asanas need not be done.

(c) Endurance : sit ups, push ups

(d) Strength: Wait lifting, bulwarker.

4. Body weight: Excessive body weight may cause difficulties in the sexual activities. Optimum body weight is calculated by the formula of body mass Index (BMI)

B.M.I. – Body weight in kg/ ( Height in meters) 2

The resultant Should be 25.

Both, Dieting and exercise are necessary for the weight reduction.

PSYCHOTHERAPY

Psychotherapy is essentially a conversation which involves listening to and talking with those in trouble with the aim of helping them understand and resolve their predicament. Therapeutic listening is not passive but involves alert and sympathetic participation in what troubles the client. Psychotherapy is not superficial chat and does not seek quick, temporary relief by suggestion. It involves talking honestly and with increasing familiarity and intimacy between people who are equally committed to understanding the sufferer and his problem, with the aim of bringing about the change . It is difficult to draw a line of demarcation between psychotherapy and counselling.

Psychotherapy is classified broadly into three categories: Supportive psychotherapy, Re-educative psychotherapy and Reconstructive Psychotherapy. Though all the categories are equally effective in treating psychological problems, supportive psychotherapy is found to be simple, easy to implement and effective in solving sexual problems.

Supportive Psychotherapy :

The objectives are (a) strengthening the existing defenses (b) restoring to an adaptive equilibrium (c) elaborating new and better mechanisms of maintaining control.

Approaches applied under supportive psychotherapy are : Guidance : It aims at a specific disturbing problem that interferes with the adjustment . This includes education about the problem and social relationship.

Tension control: Tension provokes a variety of psychological symptoms that divert the person from concentrating on the tasks. Of the methods used to control this tension are self relaxation, self hypnosis , meditation and yoga. All these methods have basically 4 principles namely , minimization of external stimuli , focus on single stimulus , a state of passivity and comfortable position.

Externalisation of interests : By providing varied types of activites such as sports, crafts, games, fine arts the client is enocouraged to resume activities that were once meaningful to him. This contributes to lessening of the neurotic symptoms .

Reassurance : it is particularly valuable in cases of severely distressed clients who lack the capacity to handle their anxiety through their own resources.

Prestige suggestion : the suggestion is accepted when it comes from prestigious authority. Hypnosis is important for reinforcing prestige suggestion.

Ventilation : this is most common method of relieving emotional tension. One talks over his problems with a professional person. The beneficial effects are due to the release of pent up feelings and emotions.

Somatic therapy : this is an adjunct rather any from of psychotherapy, and has a positive effect on the morale of the client. It includes pharmacotherapy, psychosurgery, convulsive therapy etc.

SEX MODULE NO-6 FOR PG DIPLOMA FOR SEXUAL MEDICINE & FELLOWSHIP

PSYCHOTHERAPY

Psychotherapy is essentially a conversation which involves listening to and talking with those in trouble with the aim of helping them understand and resolve their predicament. Therapeutic listening is not passive but involves alert and sympathetic participation in what troubles the client. Psychotherapy is not superficial chat and does not seek quick, temporary relief by suggestion. It involves talking honestly and with increasing familiarity and intimacy between people who are equally committed to understanding the sufferer and his problem, with the aim of bringing about the change . It is difficult to draw a line of demarcation between psychotherapy and counselling.

Psychotherapy is classified broadly into three categories: Supportive psychotherapy, Re-educative psychotherapy and Reconstructive Psychotherapy. Though all the categories are equally effective in treating psychological problems, supportive psychotherapy is found to be simple, easy to implement and effective in solving sexual problems.

Supportive Psychotherapy :

The objectives are (a) strengthening the existing defenses (b) restoring to an adaptive equilibrium (c) elaborating new and better mechanisms of maintaining control.

Approaches applied under supportive psychotherapy are : Guidance : It aims at a specific disturbing problem that interferes with the adjustment . This includes education about the problem and social relationship.

Tension control: Tension provokes a variety of psychological symptoms that divert the person from concentrating on the tasks. Of the methods used to control this tension are self relaxation, self hypnosis , meditation and yoga. All these methods have basically 4 principles namely , minimization of external stimuli , focus on single stimulus , a state of passivity and comfortable position.

Externalisation of interests : By providing varied types of activites such as sports, crafts, games, fine arts the client is enocouraged to resume activities that were once meaningful to him. This contributes to lessening of the neurotic symptoms .

Reassurance : it is particularly valuable in cases of severely distressed clients who lack the capacity to handle their anxiety through their own resources.

Prestige suggestion : the suggestion is accepted when it comes from prestigious authority. Hypnosis is important for reinforcing prestige suggestion.

Ventilation : this is most common method of relieving emotional tension. One talks over his problems with a professional person. The beneficial effects are due to the release of pent up feelings and emotions.

Somatic therapy : this is an adjunct rather any from of psychotherapy, and has a positive effect on the morale of the client. It includes pharmacotherapy, psychosurgery, convulsive therapy etc.

SEX MODULE NO-7

FOR PG DIPLOMA FOR SEXUAL MEDICINE & FELLOWSHIP SEX PHARMACOTHERAPY

A. PDE 5 inhibiters

(PDE 5 inhibiter prevents the breakdown of cGMP causing enhanced relaxation of cavernosal smooth muscles, increased arterial flow into corpora cavernosa, compression of subtunical veins and finally penile erection. It helps in maintaining the erection and not the initiation. Erotic literature, fantasy or foreplay helps in initiation of erection.

Contraindications: Nitrates, cardiac diseases, Hypotension, Optic neuropathy, Erythromycin, Rifampicin)

1. Sildenafil (Viagra, Penegra) : 25, 50, 100mg tab. 30 min after dinner.

2. Vardenafil (Levitra) : 5,10,20 mg tab 30 min after dinner. Onset of action after 30 min

2. Tadalafil (Forzest, Megalis) 10, 20 mg tab after dinner

Onset of action after 30 min.

3. Intracevernosal ing. Papaverine: 3 to 80 mg

B. Alpha Blockers

Alpha adrenergic receptor blocker dilates the arteries and reduces the venous return.

(Beta adrenergic Blocking agents are contraindicated since they may cause sexual dysfunction).

Contraindication: Hypotension

1. Prazosin (prazopress): 0.25, 0.5mg. tab H.S.

2. Terazosin (Hytrin): 1, 2, 5, mg tab. H.S.

3. Indoramine (Doralese) : 20 mg tab H. S.

4. Tolazoline (priscoline) 25 mg tab .

5. Yohimbine: 2mg: 1 to 2 tab T.D.S.

6. Dihydroergotamine: 1 mg tab T.D.S

7. I.C. Ing. Chlorpromazine: 0.06 to 0.6 mg

8. I.C. Ing . Phentolamine mesylate : 0.05to 1mg

C. Dopamine Agonists

(These drugs stimulate the Dopamine receptors. Dopamine is aneurotransmitter . It causes vasodilatation and has effects on motor, behavioral and endocrine system)

1. Bromergocriptine

2. fenfluramine

3. Inj. Apomorphine

D. Antidepressants

(These are selective serotonin reuptake inhibitors . It takes 3 to 6 weeks of continuous treatment for suppression of symptoms. They delay the orgasm. This effects is made use of in the treatment of Premature Ejaculation for which the drug is given 2 to 4 hours before the coitus)

1. Fluoxetine : 10 , 20, 30 mg in the morning

2. Paraxetine : 10, 30, 40, mg tab in the morning

3. Trazodone : 25, 50 mg tab after meal

4. Dapoxetine : 30, 60 mg tab o.d. 3 hours before coitus

E. Peripheral Vasodilators

( Vasodilators dilate the blood vessels and cause erection. They are also used in Hypertension)

1. Hydrallazine sulphate ( Nepresol): 25 mg tab B.D.

2.Nifedipine ( Nifelat) : 5, 10, 20 mg tab T.D.S.

3. Amlodipine (Amlodac) 2, 5, 5, 10 mg tab O.D.

4. Pentoxifylline( Trental) 400 mg tab T.D.S.after meals

5. Cyclandelate ( Cyclasyn) : 200 , 400 mg. tab T.D.S.

6. Xanthinol nicotinate(Complamina)150, 500 mg tab TDS with meals

7. L- Arginine (Arginitric) 500 mg cap

F. Local Vasodilators

( For local application. Drug should be washed off before coitus)

1. Nitroglycerin Ointment

2. Minoxidil (Mintop): 2%, 5% Solution. Apply <2ml

G. Nitrates

(Nitrates are converted to Nitric oxide that relaxes smooth muscles and causes vasodilatation. Nitrates are used for Angina. Sildenafil/ Tadalafil should NOT be given to the person who are on Nitrates)

1. Pentaerythritol Tetranitrate (Peritrate) : 10 mg tab

2. Isorbide Dinitrate(Sorbitrate): 5, 10mg tab

H. Prostaglandin

(Prostaglandin E1 causes smooth muscle relaxation and vasodilatation. Not effective orally in Sexual dysfunctions.)

1. I.C. INJ. PGE1(Prostin VR): 2.5 to 40 mcg

2.PGE1 Pallet (alprostadil): 125 to 500 mcg by muse (medicated Urethral system for erection)

I. Hormones

(testosterone increases the life span and fertilizing power of spermatozoa. It helps in final maturation of spermatozoa during spermatogenesis. In hypogonadism it stimulates libido and improves E.D. serum P.S.A. should be estimated and digital PR should be done prior to giving testosterone . in normal individuals, it does not improve libido or erection.)

1. testosterone ( nuvir) : 40 mg cap, T.D.S. with fatty meals for 3 weeks

2. Inj. Testosterone enanthate (testoviron depot) : 100,250 mg, deep intramuscular, 1ml every 2 weeks

3. Inj. Human chorionic gonadotropin ( profasi): 5000, 10000, 20000 I.U. Powder with diluent. Uses for ovulation, spermatogenesis & for undescended testis.

4. Levonorgestrel (Ecee2, Norlevo, I pill) : 750 mcg tab . two tabs taken together, preferably within 12 hours (no longer than 72 hours) after unprotected sex.

5. Tibolone ( livial , tibomax ): 2.5 mg tab O.D. for 3 months for menopause.

6. clomiphene citrate (clomid, fertyl): 25,50mg tab.

Female: for ovulation. 50mg O.D. For 5 days (from 5^th to 9^th day of menstrual cycle. For 3 menstrual cycles only.

7. Male: for Oligospermia : 25mgO.D. For 3 months only estrogen (evalon , Dienoestrol) cream for intravaginal use in senile atrophic vaginitis, once daily, for not more than 2 weeks.

J. Antioxidents

(antioxydents are substances that protect the cells against the effects of free radicals. These include vit . A,C,E, Coenzyme Q 10, Zinc , selenium, lycopene and L- Carnitine . they improve the sperm count and / motility and hence proved be effective in oligo – asthenospermia that leads to male infertility . antioxidants are also available in vegetables, fruits , tomato, papaya, water melon, fish & egg)

1. lycopene, zinc, selenium (Lycored) Cap . 2B.D.for months (lycotin) cap.1B.D. for 3 months .

2. L-Carnitine (Carnivit , L-tine ) Tab. 2 T.D.S. for 3 months

3. Coenzyme Q 10 (CoQ10, Zyme Q10 ) Cap .1 T.D.S. For 3 months

4. Vit. A,C,E, Zinc , Selenium (Cytovit, Oxyvit) Cap . 1 T.D.S. For 3 months

K. Antimicrobials

For mixed Vaginal infection

Fluconazole + Ornidazole+ Azithromycin ( Medikit, Zocon –AS) 4 tabs. Given orally for vaginal candidiasis, Trichomoniasis & Bacterial vaginitis

For male genital tract infection / Chlamidial infection

Doxycycline (Doxt, Doxy1) : 100mg O.D. For 15 days. Both are treated.

L. Ayurvedic Adjuvants(Empirical)

1. Chyavan prash: Tonic

2. Vigomax Forte: 1B.D. With milk. for ED

3. Confido : 1T.D.S. For Oligo- asthenospermia

4. Vivadona : 1B.D. For female libido

Drugs causing Sexual Dysfunction

1.Anticholinergic Atropine, Propantheline

2.Antihypertensive Beta blockers, Methyldopa,

Ganglion blockers, Ace

Inhibitors

3.Antimicrobials Ethionamide, Vidarabine

4.Antipsychotics Tranquilizers

5.C.N.S. Depressants Barbiturates, Opiates

6.Diuretics Thiazides,

Spironolactone

7.H2 receptor antagonists Cimetidine

8.Hormones Estrogen

9.Recreational drugs Alcohol, Tobacco

Course Module no-08

MAN –WOMEN SIMILARITIES & DIFFERENCES

Man and women are not ‘opposite’ sexes but complementary sexes.

Man & women form one unit of the Homo-sapiens species.

Though both can survive & function Independently, involment of both is essential for reproduction and thus propagation of the species. To understand the similarities and differences of two on has to start from embryology .

Embryology

The external genital are similar in male and Female embryos till 3months of Pregnancy, External genital are developed from 3 bodies

1. Genital Tubercle

2. Genital folds

3. Genital swelling

During 7th month of pregnancy

1. In male, Genital Tubercle develops into Penis enveloping the urethra, and in female it develops into Clitoris.

2. In males, the two Genital Folds unite from anus to the glans of penis. This union can be seen as a median raphe in the new born, In Female embryo, the two folds partly unite and partly remain open and develop into labia minora. Urethral and vaginal opening are developed in the space between the two

folds

3. In males, the Genital Swellings of two sides unite to form scrotum. The Gonads(Testes) descend into the scrotal sac during 7th month of pregnancy. In females, the Genital swelling remain separate and develop into Labia Majora. The gonads (ovaries) remain in the abdomen.

These changes in the male embryo about by foetal testosterone. As a result of these changes, in the male the organ of procreation and pleasure remain the same while, in the female, they remain separate. There is a distance of about 1.5 inches between clitoris and vagina. Therefore, when women engages in vaginal intercourse, she may not get the pleasure and when she wants erotic pleasure she need not engage in vaginal intercourse. Perhaps this is one the reasons for paucity of male sex workers. The other reasons could be scarcity of testosterone, a desire stimulating hormone, in the female vagina is developed from endoderm and therefore, like esophagus , the touch sensation, expert in outer one inch, is absent.

Glans of clitoris is erotically as sensitive as the glans of penis and is the seat of orgasm. During intercourse clitoris is not stimulated since the women is pinned down. Women can get orgasm only when clitoris is stimulated manually during the foreplay or when the women is on the top during the intercourse.

If women gets lubricated by clitoral stimulation, then man gets better stimulation of penis and faster orgasm. Therefore women should have clitoral stimulation/ orgasm prior to penetrative sex.

Man: sex chromosomes xy

Hair on face,

Hair on pubic region: up to umbilicus

Muscular body, nocturnal emission

Breasts: rudimentary

Penis: organ for coitus, erotic micturition & ejaculation

Gonads (testes)are outside the

Lubrication produced by bulbo – urethral glands

Sexual hormone: Testosterone

Sexual response: Monotonous

Sexual Response is essential for fertility

Orgasm: Possible every time

Associated with ejaculation & followed by refractory Period .

Explosive –mid or explosive

Erotic stimulation is through five sense organs stimulated by nudity, blue film , seeing female genital and beauty

Most of the male Masturbate

Aim: Sexual pleasure

Oral Sex – Most of them are interested.

Deep interest in coitus

Any women would do for coitus

Attraction of extramarital relation

As the age advance, the Sexual Attraction decreased

Total Sexual outlet are more

Satyriasis is not uncommon

Interested in sexual posture

Interested in sex tonic

Coitus: How often , when and how long is decided by man

Andropause is gradual and does not pose a problem

Paraphilia is common

Sexual dysfunction is common

Man is more interested in sex

Man gives loves to get sex

Man is dependent upon women for sexual Pleasure

Man is rational, steady & dashing

Man seek any women for short term relationship

Man want a Virgin & younger by age

Man’s sexual pleasure is genital oriented

Women

Sex chromosomes XX

No hair on face

Hair in triangular region

Delicate body, Menstruation, broad waist

Breast Prominent

Sensitive to erotic stimulation

Produces milk after delivery

Clitoris for erotic sensation: urethra for micturition & Vagina for coitus

Gonads (ovaries) are inside the body

Produces one ovum per months

Lubrication produced by vestibular glands & vaginal wall

Sex hormones are Estrogen, Progesterone, Prolactin

Sexual response is varies

Fertility is possible in absence of sexual response

Orgasm: may or may not or Multiple orgasms. No refractory period.no ejaculation.

Love, romance & touch are essential for erotic stimulation

Stimulated by romanticism & personality.

Not stimulated by seeing male genital.

Most of them do not masturbate.

Aim: to relieve vascular congestion

Oral sex: most if them are not interested

Interested in partner’s company, his close contact& motherhood.

Not much interested in coitus

Meticulous selection of partner.

Emotional involvement necessary for coitus. Any man would not do

No attraction of extramarital relation

Sexual attraction is the same throughout.

No change according to age.

Total sexual outlets are less.

Nymphomania is very rare.

Neither interested in sexual postures,

Not interested in sex tonic

Woman is passive. She does not take a lead.

Menopause is sudden and poses a problem in some women.

Paraphilia is very rare

Sexual dysfunctions : less common

Women is more interested in love & motherhood

Woman gives sex to love

Women is not dependent upon man

For sexual pleasure ;but for love, romance & motherhood.

Women is creative, instinctual, & affectionate

Women seeks a man for permanent

Women wants a sincere man who would offer stability , & is senior by age

Woman sexual pleasure is entire body – oriented.

Sexual transmitted disease Treatment

1. Gonorrhea

Cefixime 400mg

Or

Cetriaxone 125 mg im in a single dose

Complicated gonococcal infection

(complicated by peri-urethral abscess, prostatitis, epididymitis, Cervicitis or salpingitis.

Ceftirazone 1 g im bd x 7 days

Or

Spectinomycin (Togamycin) 2 g in daily x 3 day

Note; fluoroquinolones not recommended because of high resistance.

2. Syphilis

Note – not less than these recommended dosages should be used

Early syphilis (syphilis of less than one year duration)

- Early syphilis ( syphilis of less than one year duration )

- Benzathine penicillin G (pendiure LA )-2.4 million units total by IM injection as a single dose.

Syphilis of more than one year duration

Early syphilis

-Doxycline 100 mg BD14 days

Azithromycin 500 mg daily x 10 day

Early Prenatal syphilis

-Inj Aqueous crystalline Penicillin G 50,000 units/ kg 6-12 hrsx10 day

Or

Inj Procaine Penicilline G 50,000 units/kg x10 day

Late prenatal syphilis

- Inj Benzathine Penicillin G 50,000 units/kg upto 2.4 million units

- Syphilis for more than one year

- Tetracycline 500 mg 4 times a day for 30 days

- For pregnant women allergic to penicillin

Early Syphilis :

Erythromycin 500 mg 4 times a day for 15 days.

Syphilis of more than one year.

Erythromycin 500 mg 4 times a day for 30 days.

Note; Use of erythromycin has doubtful value in protecting the fetus from the infection

Always rule out HIV. If patient HIV +ve use Aqueous penicillin.

Late syphilis

-Tetracycline 500 mg adsx30 days

Or

Erythromycin 500 qds x 30 days

Or

Doxycycline 100 mg BD x 30 day

Congenital Syphilis

Almost Eradicated due to testing of mother during pregnancy .

Early congenital syphilis ( less than two year of age )

Inj Aqueous Penicillin G 50,000 units / kg body weight as a single dose.

Inj Aqueous Penicillin G 5,00,000 units/ kg body weight IM daily in divided does for 10 days.

Or

Inj aqueous procaine Penicillin G 50,000 units /kg body weight IM daily for 10 days.

Late congenital syphilis (above 2 year of age )

As for early adult syphilis.

3. Chancroid

Single-dose regimens:

- Erythromycin 500 mg qdsx7 days

- Azithromycin 1 gm P.O

- Or

- Inj. Cetriaxone 250 mg i.m

- Or

- Ciprofloxacin 500 mg od x 3-5 days.

- Multiple dose regimen:

- Trimethoprim 160 mg+ Sulphamethoxazole 800 mg po bd for 2 weeks.

- Or

- Ciprofloxacin 500 mg b.d .p.o for 3 day

- Or

- Doxycycline 100 mg .b.d for 14 days.

Local treatment

Clean ulcer with soap and water.

Aspirate inguinal bubo with wide bore needle after spraying with ethyl chloride spray from non –dependent site . Apply Neosporin or soframycin ointment twice a day

4. Genital Herpes

Lesion not complicated by secondary infection:

Local hygiene

- Acyclovir cream+

- Neosporin or Fucidin ointment Apply 2-4 times a day

Frequent saline bathing and ice packs.

-Analgesic

Tab Acyclovir 200 mg 5 times a day for 5 day

Or

Famciclovir 250 mg tds x10 days

Episodic therapy

- Famciclovir 125 mg bd x 5 days

- Valacyclovir 500 mg bd x 3 day suppressive therapy

- If < 10 recurrences per year

- Famciclovir 250 mg bd x 5 days

- Valacyclovir 500 mg od

- If > 10 Recurrences per year

- Acyclovir 400 mg bd

Recurrent genital herpes:

Treatment should be stopped after one year to see whether recurrences are occurring with same frequency.

If secondary infection

- Doxycycline 100 mg bd x8-10 day

Vaginal Candidosis

First rule out Diabetes

Treatment

- Clotrimazole 100 mg vaginal tabs x 7 days.

- Clotrimazole 100 mg 2 tabs daily x 5days.

- Or

- Miconazole 2 % cream intravaginally x 7 day

5. Herpes Simplex

Initial or primary infection

- Acyclovir ( Cyclovir or Herpex ) cream 5 % apply 3-5 times daily at about 4 hourly intervals for 5 day

- Tab Acyclovir 100 mg bd x 10 day

- Or

- Tab Valacyclovir

- Primary Infection :100 mg bd x 10 day

- Recurrent infection 500 mg bd x 5 day

- Or

- Famciclovir 250 mg t.d.s

Secondary Infection

- Acyclovir 200 mg 5 times / day x 7 day

- Prophylaxis : 400 mg bd for prolonged period

- Foscarnet 40 mg /kg qds for 2-6 wks in acyclovir resistant mucocutaneous HSV infection

- Or

-

- Primary infection: 250 mg tds x 10 day

- Recurrent infection 125 mg bd x 5 days

- For recurrent genital herpes suppressive therapy

- (> 10 recurrence per year )

- Acyclovir 400 mg bd

- Famciclovir 250 mg tds x 7 days

- Valacyclovir 500 mg od

Local treatment

- Acyclovir cream applied qds

- Prophylaxis genital :

- Valacyclovir 1 g.b.d x 10 days

- Advice to avoid /multiple sexual partner

- Use of condom

- Avoid use of alcohol and drugs.

- Note : Primary herpes simplex infection ( types I )

- It mostly occurs on lip & perioral region remains 3-4 day and disappears

- They sometime occurs with fever above 100 F

6. Viral Warts

Condyloma accuminata

- Podophyllum (resin) 20 % in Tinct. Benzoin co. Apply carefully with glass of road to the surface of the Warts . leave if for1- hours. Then wash it out with soap and water. Can be repeated every 5 to 7 day if required

- Note Podophyllum is contraindicated in pregnancy and lactating mother

- TCA- Trichlor acetic acid 80-90%nto be applied directly to the warts

- Imiquimod ( Imiquod ) 5% cream applied overnight thrice a week for external genital and Perianal warts

- For Postherpeitc neuralgia : Gabapantin 300 mg /d in 3 divided doses for 3 weeks increased to 600 mg/d for 4 week

- Cidofovir gel for local application

- Imiquimod 5% cream local application

- Electrocauterisation or Cryosurgery ( liquid Nitrogen)

- Common warts

- 1) Keratolytics: Salicylic acid paint or Salicylic acid with Lactic acid

- 2) CO2 Laser surgery for recalcitrant , chronic lesions.

Cutaneous warts:

- Surgical excision / Cryosurgery or Chemical cauterization Or Electrocauterisation

- Pure Carbolic acid- Apply with glass rod

- Or

- Trichloracetic acid pure to be painted on warts.

- Or

- Salicylic acid 2.5

- Lactic acid 2.5

- Flexible collodion 15

- For external use

- Salicylic acid 3.5

- alcohol (40%)120

- Paint daily at night till wart fall off

(7 to 10 application)

Or

Glycolic acid 10-20% occlusion one/wkx 3-4 wks.

7. HIV Infection

With rational use of antiretroviral therapy (ART), HIV infection has been transformed into a chronic manageable illness like diabetes and Hypertension.

Guidelines for use of Antiretroviral therapy in adults

All Initial HIV regimens should consist of the use of 3 drugs from two different classes:

1. Stavudine (d4T) 300 mg bd +

Lamivudine (3TC) 150 mg bd +

Nevirapine (NVP) 200 mg bd OR

Efavirenz (EFV) 600 mg od

2. Zidovudine (AZT) 300 mg bd +

Lamivudine 150 mg bd +

Nevirapine 200 mg od OR

Efavirenz 600 mg bd

3. Indinavir (IDV) 800 mg bd +

Ritonal 100 mg bd to be combined with NRT

Note- Avoid Efavirenz based regimen in Pregnancy and in women of child bearing age.

Time of Initiation of ART

All Patient with CD 4 count <200.

In all Patient with CD4 count<550. ART can be deffered.

Patient with high viral Loads, CD4 between 200-350.

Starting ART depends on plasm viral load. If > 50,000

copies/ ml,there is a faster progress to AIDS.

In Patients with opportunistic infections, ART must be combined with therapies for Ols. However it is preferable to defer ART until tr. Of Ol medication is completed, or until patient has been stabilized on Ol medication used.

Plasma HIV RNA level is strong predictor of Progression rate except in patient having low CD4+T counts. Therapy is advised in patient with plasma HIV RNA level > 30,000 copies ml.

In Patients with opportunistic infections. ART must be combined with therapy.

Initial treatment:

Zidovidine 300 mg bd+

Lamivudine 150 mg bd +

Nevirapine 200 mg bd or

Etavirenz 600 mg od or

Stavudine 300 mg bd +

Lamivudine 150 mg bd +

Nevirapine 200 mg bd or

Efovirenz 600 mg od

Post –exposure prophylaxis

Local treatment with needle wash with normal saline and soap ART should be started within an hour.

Therapy for 1 month

Basic Regimen:

1. ZDV 300 mg bd or 200 mg tds x 4 weeks +3TC 150 mg bd x 4 weeks.

2. ZDV 300 mg bd + Emtricitabine 200 mg od.

3. TDF 300 mg bd+ 3 TC 300 mg od.

Extended regimen: Basic regimen + Indinavir 800 mg tds or any other protease inhibitor or combination of Lopinavir / Ritonavir.

Regimen to reduce Perinatal transmission of HIV

- Single dose of Nevirapine 200 mg to the mother at onset of labor and 3[4 mg / kg bd to neonate within 24 hrs of birth.

- Zidovudine 100 mg 5 times a day after 14-34 weeks of pregnancy until beginning of labor.

- During Labor: AZT 2 mg / kg iv over one hr followed by continuous iv infusion of 1 mg / kg/ h till clamping of umbilical cord post delivery

- Neonates : 2 mg / kg Po ( syrup 50 mg / 5l) q6h starting within 12 hrs. after birth and continuing to 6 weeks of age.

Monitoring efficacy of ART

CD4 count – Pretreatment ( preferably 2 and after 4 weeks post-treatment and then every 3 months).

Viral load: Twice before starting therapy and then monthly for 3 months and then every 3 months and then every 3 months. Viral load of 50-500 copies / ml shows good response, If <50 copies/ ml indicates durable viral suppression.

Lymphocytes counts: if CD4 not available

Monitoring side effects of ART

- LFT Liver function test

- KFT Kidney function test

- Serum amylase

- For Patients on Protease inhibitors:

- Serum lipids

- Blood sugar

- Serum sodium bicarbonate level ( to detect lactic acidosis)

ARV Adverse events (AEs) ARV drugs may be associated with acute and long-term AEs.

Recognizing and managing these are essential because they may compromise adherence or necessitate switching of drugs which may result in exhausting treatment options.

Additionally, many of the concomitant drugs used are associated with overlapping toxicities making it difficult to identify the true offending agent. Patients should also be educated about these so that they are recognized early since many long – term AEs may not reverse or take years to improve.

ART in Pregnancy

In selection of drug following should be remembered

1. Zidovudine should be include as one of the components unless there are absolute contraindication for use of the same

2. Efavirenz should be avoided because of possible teratogenic effect in first trimester of pregnancy.

3. Combination of d4T+ddI should be avoided because of risk of development of fatal lactic acidosis.

4. Do not use NVP as part of ART regimen if mother’s CD4 count <250/mm3 due to risk of fatal hepatotoxicity.