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A Pilot Survey of Sexual Functioning and Preferences in a Sample of English-Speaking Adults from a Small South Indian Town

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Introduction.  There is a dearth of recent information on sexual functioning and preferences from an Indian population.Aim.  To study sexual functioning and preferences in a sample of English-speaking adults in a small town in South India.Method. 
  A Pilot Survey of Sexual Functioning and Preferences in a Sampleof English-Speaking Adults from a Small South Indian Town Nilamadhab Kar, MD, DPM, DNB, MRCPsych,* and Maju Mathew Koola, MD † *Wolverhampton City Primary Care Trust, Wolverhampton, UK;  † Department of Psychiatry, University of New Mexico,Albuquerque, NMDOI: 10.1111/j.1743-6109.2007.00543.x A B S T R A C T  Introduction.  There is a dearth of recent information on sexual functioning and preferences from an Indianpopulation.  Aim.  To study sexual functioning and preferences in a sample of English-speaking adults in a small town in SouthIndia.  Method.  Responses were obtained through a postal questionnaire method and were analyzed. Study document included an explanation of the study, sociodemographic details, a sexual functioning questionnaire, a semistructuredsexual preference questionnaire, and meanings of terms used in the questionnaires.  Main Outcome Measure.  Frequency of various sexual functions, difficulties, and preferences over a period of 1month.  Results.  Sixty-one subjects out of 200 English-speaking persons from a south Indian town returned the question-naire. Common sexual difficulties included decreased interest in sex (16.4%), arousal difficulties (21.3%), orgasmicdifficulties in females (28.6%), and premature ejaculation in males (15.2%). Masturbation was considered wrong by 18% of respondents; with almost 40% of females and 6% of males reported to have never masturbated. There weremany differences in the sexual functioning of married compared to unmarried persons and other sociodemographicgroups. Practice of various sexual preferences was reported: voyeurism (41.0%), fetishism (18.0%), frotteurism(11.5%), homosexuality (11.5%), telephone scatology (9.8%), and incest (8.2%) being more common. In a smallminority, telephone scatology (3.3%), voyeurism (1.6%), and fetishism (1.6%) were reported to be the only methodof sexual gratification. Conclusions.  Sexual difficulties were similar to other reports in different cultures. Varieties of preferences werepracticed, and there were variations among different sociodemographic groups.  Kar N, and Koola MM. A pilot survey of sexual functioning and preferences in a sample of English-speaking adults from a small south Indian town. J Sex Med 2007;4:1254–1261.  Key Words.  Sexual Functioning; Sexual Preferences; Sexual Dysfunction Introduction S exual problems are widely prevalent as ob-served in epidemiological studies [1], althoughonly a few seek medical help [2,3]. Most of themcontinue to remain under-recognized and under-treated [4]. It is known that sexual dysfunctionshave negative effects on quality of life [5,6], and areoften associated with psychological ill health [7]. The attitude of subjects toward sexuality has beenchanging over the years [8], which necessitatesperiodic review of sexual functioning and difficul-ties in the general population. A large percentage of individuals experiencesexual problems, with estimates between 10–52%of men and 25–63% of women in population-based studies [1]. Many recent epidemiologicstudies report variable figures up to 54% of  women and 50.9% of men reporting sexual dys-function [9]. In another report, about 40–45% of adult women and 20–30% of adult men had at least one manifest sexual dysfunction [10]. Consider-1254  J Sex Med 2007;4:1254–1261 © 2007 International Society for Sexual Medicine  ableproportionsareknowntohavemultiplesexualdysfunctions. Among Swedish help-line callers with sexual dysfunction, 33% of men and 41% of  women had more than one dysfunction [11].Prevalence estimates in different studies vary depending upon various factors including defini-tion of dysfunctions and classificatory system usedfor diagnoses, time frame of the study, and useof particular criterion like distress [12,13]. Thereported prevalence and types of sexual dysfunc-tions also vary widely across cultures and racialbackgrounds [2,3,8,14–18] and between studies,both epidemiological and clinic based. The differ-ent methods employed in these studies mean that it is not clear whether differences in the reportedprevalence of sexual dysfunctions are really be-cause of cultural and racial differences or simply because of differences in study designs. There is a dearth of information on the practiceof various sexual preferences, and specifically theprevalence of disorders of sexual preferences.However, these behaviors are not uncommon [19]. As many as 10–20% of children may have beenmolested by the age of 18 years, and 20% of  women report of being targets of exhibitionismand voyeurism [19]. The issues discussed earlier suggest periodicevaluation of the true burden of male and femalesexual dysfunction in the general population of different cultures is important. Literature onprevalence of sexual functioning in India has beenlargely limited to clinic populations and to only afew selected sexual dysfunction or culture-specificsyndromes [20,21]. Aims  We intended to study the sexual functioning anddifficulties in a sample of English-speaking adultsin a small south Indian town. We also tried to findout the prevalence of sexual preferences. In addi-tion, there was a need to assess the feasibility of astudy addressing the issues on sexuality in generalpopulation, which appear to be inhibited in dis-cussing personal sexual issues even in a clinicalsetup. Methods  The study was conducted by a postal questionnairemethod. We prepared an evaluation document, which included an explanation of the study, socio-demographic details, sexual functioning question-naire [22], sexual preference questionnaire, andmeanings of terms used in the questionnaires. Thesexual activity over a period of one month wasstudied. Asexualfunctioningquestionnaire[22]wasusedfor the evaluation of sexual functioning and associ-ated problems. This questionnaire had true orfalse responses to questions relating to sexualfunctioning during the past month. It containedadditional gender-specific questions. The ques-tionnaire covered a wide range of sexual function-ing and was used in the clinic population at thedepartment of psychiatry of Kasturba MedicalCollege. We analyzed the positive and negativeresponses to the questions asked to determinesexual functioning and the presence of sexual diffi-culties, instead of one standard deviation cutoff-pointcriterion,whichwasusedbySmithet al.[22]. We designed an 18-item, semistructured ques-tionnaire to study the presence of sexual prefer-ences.Foreachpreference,anexplanatoryquestioncheckedthepresenceofsexualpreferencebehavior,and a second question checked whether it is theonly way of sexual gratification or enjoyment. The sample recruitment for the study wascarried out at three sites: at a college, in an office,and in a hospital, where students and teachers,office workers, and accompanying relatives of patients,respectively,wererecruited.Twoqualifiedpsychiatrists (of both genders) approached indi- vidualsandcheckediftheywouldbeinterestedinaquestionnaire study, whether they were conversant inreadingandspeakingEnglish(asthestudymate-rialwasinEnglish)andiftheybelongedtothelocaltown. Persons who fulfilled these criteria wereinformed in detail about the study. They wereassured of confidentiality of information. Follow-ing this, the persons who verbally consented toparticipate were given the study document along with a stamped envelope addressed to the researchunit. It was suggested to the participants that they should not write any identifiable personal informa-tion. The evaluation document was given to 200adults (100 males and 100 females). The study protocol was approved by the ethicscommittee of Quality of Life Research and Devel-opment Foundation. It was also reviewed in thedepartment of psychiatry, Kasturba MedicalCollege and was categorized as a non-inter- ventional study. The responses were entered into a database and were analyzed by one of the authors (qualifiedpsychiatrist)bypreviouslyagreedcriteria.Incaseof uncertainty, the issue was resolved by discussion withthesecondauthorandbyarrivingataconsen- Sexual Functioning and Preferences—A Survey from India   1255  J Sex Med 2007;4:1254–1261  sus.Chi-square( c 2 )testwasusedtotestassociationbetween categorical variables, and  t  -test for con-tinuousvariables.Significancevaluewassetat0.05. Main Outcome Measures Frequency of various sexual functions, difficultiesand preferences in the sample studied. Results Sixty-one subjects returned the questionnaire(response rate: 30.5%). Their mean age was26.6  6.1 years (range: 20–58, median: 26). There were 33 males and 28 females with meanage of 28.6  6.4 and 24.3  4.8 years, respec-tively ( t  : 2.91, df: 59,  P   =  0.005). The sample char-acteristics are mentioned in Table 1. The sample was more represented by young, unmarriedpersons from the upper-middle socioeconomicstrata. Among the respondents, females from reli-gions other than Hindu were significantly morerepresented. Considering the occupation, com-paratively more females were students and moremales were unemployed. Sexual Functioning  Rates of males and females who found otherpeople sexually desirable were comparable (81.8% vs. 78.6%, respectively). Most of the males(78.8%) thought about sex at least once per day compared to 42.9% females; rates for three times a week, less than once per week, and less than oncea fortnight in male and female were 15.2% vs.28.6%, 3.0% vs. 17.9%, and 3.0% vs. 10.7%,respectively ( c 2 : 9.2, df: 3,  P   =  0.027). Most commonly reported frequency of mastur-bation for males was around three times a week (48.5%); and in females, it was once per week (17.9%); 21.2% males and 7.1% females reportedmasturbating at least once a day. Eighteen percent of the participants (18.2% males and 17.9%females) felt masturbation was wrong. Compara-tively more females (39.3%) than males (6.1%)reported to have never masturbated ( c 2 : 9.9, df: 1,  P   =  0.002). More females (60.7%) than males (51.5%)reported to have enjoyed sex in the previousmonth (not significant). Significantly more males(75.8%) reported being easily aroused sexually than females (35.7%) ( c 2 : 9.9, df: 1,  P   =  0.002);12.1% males reported taking longer than usual tobecome sexually aroused compared to 25.0% of females. Significantly more males (84.8%) thanfemales (39.3%) reported orgasm or ejaculationsas often as they wanted ( c 2 : 13.6, df: 1,  P   =  0.000).Similarly, a considerable proportion of males(90.9%) reported orgasm or ejaculation every timehaving sex/masturbation compared to that (46.4%) of females ( c 2 : 14.4, df: 1,  P   =  0.000). Sexual Difficulties Responses suggestive of the presence of sexual dif-ficulties are mentioned in Table 2. The majority of males (93.9%) reported being always able toachieve a full erection if wanted. Two men (6.1%)felt that erections were not as full as they used to Table 1  Sample characteristics VariablesMale Female TotalN  =  33 N  =  28 N  =  61% % %Marital statusUnmarried 63.6 75.0 68.9Married 36.4 25.0 31.1Religion*Hindu 84.8 60.7 73.8Others 15.2 39.3 26.2Education*College 21.2 25.0 23.0Post graduation 39.4 67.9 52.5Professional 39.4 7.1 24.6Occupation*Unemployed 39.4 17.9 29.5Employed 45.5 35.7 41.0Student 15.2 46.4 29.5Socioeconomic statusLower middle 27.3 17.9 23.0Upper middle 72.7 82.1 77.0 * P   <  0.05. Table 2  Prevalence of sexual difficulties Sexual difficultiesMale Female TotalN  =  33 N  =  28 N  =  61% % %Never thought about sex 0.0 7.1 3.3Did not want to have sexualintercourse6.1 14.3 9.8Not been particularlyinterested in sex*3.0 25.0 13.1Completely unable tobecome sexually aroused3.0 3.6 3.3Aroused mentally, nophysical arousal**6.1 35.7 19.7Not achieved orgasm/ ejaculation by any meansat all**0.0 28.6 13.1Sexual pain 3.0 7.1 4.9Premature ejaculation 15.2Delayed ejaculation 9.1 * P   <  0.05; ** P   <  0.01. 1256  Kar and Koola  J Sex Med 2007;4:1254–1261  be. One of them and another man reported rarely achieving a full erection. However, erectile diffi-culty leading to inability to have sexual intercourse was not mentioned by any male respondent.No desire was reported by 16.4% respondentsconstituting three men (9.1%) and seven women(25%). Difficulty in arousal was mentioned by 21.3% constituting three men (9.1%) and 10 women (35.7%). Premature ejaculation wasreported by 15.2% of men, and 9.1% of men men-tioned delayed ejaculation. No orgasm by any means at all was reported only by the unmarriedfemales (N  =  8; 28.6%); out of them, five individu-als (62.5%) reported to have never masturbated,enjoyed sex, or indulged in any sexual preferencebehavior. Two females (7.1%) mentioned that sexhas been difficult or painful because of no physicalresponse. Orgasm/ejaculation was reported to bepainful by one male (3%). Sexual Preferences  A considerable proportion of respondents re-ported having various sexual preferences (Table 3). There were four (6.6%) individuals who men-tioned the sexual preference behavior as their only  way of sexual gratification. There was no responseon items on sexual preferences suggesting zoo-philia, asphyxiophilia, undinism, preferences foranatomical anomaly, or erotic interest in dead. Sociodemographic Profile and Sexuality  We compared the sexual functioning of the sub- jects who were married and unmarried, presumingthat a sexual partner was always available for those who were married. Married individuals were sig-nificantly older compared to those who were un-married (32.1  2.38 vs. 24.1  8.1 years,  t  :  - 5.9,  P   =  0.000). The significant differences in sexualfunctioning are mentioned in Table 4. There were few differences observed in therespondents based on religious background. Sig-nificantly more Hindus reported having an orgasmas often as they wanted (71.1% vs. 43.8%,  c 2 : 3.83,df: 1,  P   =  0.050); orgasm/ejaculate every timehaving sex/masturbation (77.8% vs. 50.0%,  c 2 : Table 3  Sexual preferences Sexual preferencesMale Female TotalIndulgedOnly way forgratification IndulgedOnly way forgratification IndulgedOnly way forgratificationVoyeurism* 54.5 3.0 25.0 0.0 41.0 1.6Fetishism 12.1 3.0 25.0 0.0 18.0 1.6Frotteurism 9.1 0.0 14.3 0.0 11.5 0.0Masturbation in public places 9.1 0.0 0.0 0.0 4.9 0.0Sex with same gender 9.1 0.0 14.3 0.0 11.5 0.0Telephone scatology 6.1 0.0 14.3 7.1 9.8 3.3Transvestism 3.0 0.0 7.1 0.0 4.9 0.0Exhibitionism 3.0 0.0 10.7 0.0 6.0 0.0Sexual gratification with urine, faeces 3.0 0.0 0.0 0.0 1.6 0.0Sex with close blood relative (incest) 3.0 0.0 14.3 0.0 8.2 0.0Pedophilia 0.0 0.0 7.1 0.0 3.3 0.0Sadism** 0.0 0.0 10.7 0.0 0.0 0.0Inserting objects into the body duringmasturbation*0.0 0.0 14.3 0.0 6.6 0.0 * P   <  0.05; ** P   =  0.054.Figures are in percentages. Table 4  Sexual functioning that were significantlydifferent in married and unmarried persons Unmarried Married TotalN  =  42 N  =  19 N  =  61% % %Found other people sexuallydesirable*88.1 63.2 80.3Enjoyed sex*** 35.7 100.0 55.7Not achieved orgasm/ ejaculations by anymeans at all*19.0 0.0 13.1Orgasm/ejaculation hasbeen different thanbefore*4.8 21.1 9.8Erections not as full now asthey used to be*0.0 10.5 3.3Rarely achieve a fullerection*0.0 10.5 3.3Ejaculation happens tooquickly**0.0 26.3 8.2Amount of fluid less thanbefore*0.0 10.5 3.3Sexual pleasure in exposinggenitalia to stranger****2.4 15.8 6.6Sexual preference forchildren*0.0 10.5 3.3Inserting objects to rectum/ penile urethra****2.4 15.8 6.6 * P   <  0.05; ** P   <  0.01; *** P   <  0.001; **** P   =  0.05. Sexual Functioning and Preferences—A Survey from India   1257  J Sex Med 2007;4:1254–1261  4.37, df: 1,  P   =  0.036); always being able to achievefull erection (60% vs. 25.0%,  c 2 : 5.78, df: 1,  P   = 0.016) compared to respondents from other reli-gions. Significantly more respondents from otherreligious backgrounds reported taking longer thanusual to get sexually aroused (37.5% vs. 11.1%,  c 2 :5.56, df: 1,  P   =  0.018); although aroused mentally,nothing happened physically (37.5 vs. 13.3%,  c 2 :4.36, df: 1,  P   =  0.037); not achieved orgasm at all(31.3% vs. 6.7%,  c 2 : 6.26, df: 1,  P   =  0.012); neverhad an orgasm or ejaculation (31.3% vs. 8.9%,  c 2 :4.69, df: 1,  P   =  0.030); erections were not as full asthey used to be (12.5% vs. 0.0%,  c 2 : 5.81, df: 1,  P   = 0.016); difficult or painful sex (female only) (12.5% vs. 0.0%,  c 2 : 5.81, df: 1,  P   =  0.016); sexual excite-ment on exposing genitalia to strangers (18.8% vs.2.2%,  c 2 : 5.26, df: 1,  P   =  0.022); and insertingobjects into rectum or penile urethra during mas-turbation (18.8% vs. 2.2%,  c 2 : 5.26, df: 1,  P   = 0.022) compared to Hindu respondents. Achieving a full erection always was reportedleast frequently by postgraduates (34.4%) andmostly by professionals (86.0%) among the educa-tional groups ( c 2 : 11.2, df: 2,  P   =  0.004). Delayedejaculation ( c 2 : 9.7, df: 2,  P   =  0.008) and change inphysical response to sexual stimulation ( c 2 : 6.85,df: 2,  P   =  0.033) were most frequently reported by postgraduates. Considerably more respondents with college education (21.4%) reported insertingobjects into rectum or penile urethra during mas-turbation ( c 2 : 6.72, df: 2,  P   =  0.035) compared topostgraduates and professionals. There were no major differences betweensocioeconomic categories. However, compared tothe upper-middle group, more respondents fromthe lower-middle group reported taking longerthan usual to become sexually aroused (35.7% vs.12.8%,  c 2 : 3.84, df: 1,  P   =  0.050); rarely achievinga full erection (14.3% vs. 0%,  c 2 : 6.9, df: 1,  P   = 0.008); and having sexual preference for children(14.3% vs. 0%,  c 2 : 6.9, df: 1,  P   =  0.008). Discussion  This is the first study of its kind to look into sexualfunctioning and preferences in an Indian sample,as far as we are aware. It assessed sexual difficultiesin both men and women in a defined population,and compared these in various sociodemographicgroups. Conducted through a postal questionnairemethod, it had a response rate of 30.5%, which iscomparable to similar kind of studies elsewhere[2]. Although complete anonymity and confiden-tiality were assured, and the educational level of the participants were college or more, the responserate was low. One of the reasons for the low response rate could be the uncomfortable feelingattached with discussing personal sexuality andreporting the difficulties, which is a common expe-rience in clinical setups in India. Notwithstandingthese factors, the index study suggested that it isfeasible to conduct studies of such nature ingeneral population; however, with a possibility of preponderance of younger adults as respondents.Frequency of thinking about sex was higher inmen than in women in the index study, which issimilar to the reported findings [8]. However, theproportions of both genders finding the othersexually desirable were comparable. A considerable proportion of the respondentsfelt masturbation was wrong and reported to havenever masturbated. In a study in South India, only 30% of women surveyed had masturbated some-time in their life, with 40% having no idea about it [23]. In another study in North India, the most common cause for being unsuccessful in the first sexual encounter after marriage in psychiatricpatients was early masturbatory guilt (78.8% vs.33.3% in controls) [24]. There are many miscon-ceptions surrounding masturbation in India [25]. Many individuals consider it to be a sin or that onebecomes “dirty” by masturbation [25]. These con-ceptions might have influenced the responses;however, we have not studied these specifically inthis study.Desire difficulties were present in 16.4% of therespondents; this included one in four women.Prevalences of lack of sexual interest in femalesrange from 12% to 48% in various studies [2,8,17,26,27]. The reported rates for men rangingfrom 8.0% to 24.9% [2,8,17,26,28] have been con-stantly lower than that for women, as observed inour study. A considerable proportion (35.7%) of females reported arousal difficulties in our study, which is toward the higher side of reported rates of 13–40.9% in other studies [3,17,29].In the index study, 6.1% of men felt they hadinadequate erections. Erectile dysfunction preva-lence figures ranged from 8% to 22% in variousstudies [2,3,8]. However, as erection problemsreported by the respondents in the index study didnot lead to the inability to have sexual intercourse,they are unlikely to be erectile dysfunctions con-sidering International Classification of Mental andBehavioural Disorders: version 10 criteria forerectile dysfunctions [30]. Report of a relatively lower rate of erectile difficulties is probably because of the fact that most of the respondents in1258  Kar and Koola  J Sex Med 2007;4:1254–1261
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