Why straight men have sex with each other

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The range of sexual dysfunctions encountered in gay men and lesbians is the same as that found in men & women in general, and the skills needed lớn help them are the same. That said, there are areas of concern, both for patients & doctors, that merit particular consideration.


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People may encounter problems when they become aware of their homosexual orientation and try lớn match it khổng lồ their view of an igiảm giá self. If this occurs in adolescence it may be useful to offer counselling lớn help with the readjustment in life that may be required. However tolerant our society may become, being openly gay still has major implications for future career and family life. Help at this time can include (for men especially) information about safer sex, since sexual exploration may present a greater risk of exposure lớn HIV.

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Although many gay men và lesbians are aware of their orientation from their earliest sexual thoughts, a sizeable minority bởi vì not discover their orientation until later in life, perhaps in a failing marriage and with the responsibilities of parenthood. These people require careful & compassionate counselling. Some choose to remain married, & the couple may need help to reorganise the basis of their heterosexual relationship. The counsellor must be seen khổng lồ be completely impartial & not encourage any particular outcome.


Avoiding prejudice

Presumptions—When counselling gay people about sex, it is important not to have preconceived ideas about their sexual repertoire. Perhaps as many as a third of gay men choose not to practise penetrative anal sex on a regular basis,1 và the traditional division of gay men inkhổng lồ “active” and “passive” is not born out by experience—most gay men who vị have sầu anal sex will play either role. The assumption that the passive partner is somehow less “male” or less “aggressive” is also largely a myth. Similarly, in lesbian sex either partner can be psychologically “active” regardless of whether sex play includes penetration with a dildo.


Counselling gay men and women

Be honest with yourself; if you are uncomfortable with gay people refer the patient to lớn someone else

If an adolescent is confused about his or her sexuality try to help the patient to adjust

Do not have preconceived ideas

Take the opportunity lớn discuss safe sex with gay men

A married man or woman might benefit from couples counselling

Sexual orientation is not always fixed. Some people change their mind


Disapproval—The days when physicians would try to impose their own moral standards on their patients should be long past. If individual clinicians are aware that they are uncomfortable with the issues of gay sex and relationships then they should refer the patient on khổng lồ somebody else. It is difficult to lớn focus on the relevant clinical issues if you are having khổng lồ concentrate on your own discomfort và trying not lớn express it.

Inaccurate advice—It is unwise to advise patients on subjects that they may know more about than you vì chưng, & if anal sex is not something that you know much about it is better lớn admit this rather than offer inaccurate or misleading advice. Local genitourinary medicine clinics should be aware of what services are available locally and which are considered as “gay friendly” & can be used as a source of reference.

Patients’ reticence—Even if a doctor is comfortable with homosexual patients it does not follow that such patients are comfortable with the doctor. Gay men face practical problems, such as a future application for life insurance, which mean that some patients will not wish lớn discthua their sexual orientation to their general practitioner, no matter how sympathetic and confidential.


Sexual activities

It is unclear what proportion of men & women have same sex experiences in their lives. Studies have been fraught with methodological errors & with researchers trying lớn confirm their own preconceptions. Recently, the national survey of sexual attitudes & lifestyles estimated that 1% khổng lồ 6% of the male population had had such experiences, depending on how homosexuality was defined.2 These values are lower than many other estimates, probably because of the method of the study.

Gay men & lesbians have sầu as wide a range of sexual lifestyles as does the general community. Some homosexuals live in a stable partnership and never have sầu sex elsewhere. Others have a strong, committed relationship but with an open acknowledgment that one or both partners also have sầu sexual liaisons elsewhere. Infidelity in a supposedly closed relationship is probably just as comtháng as among muốn heterosexuals. Single gay men have sầu a reputation for having many sexual partners, và in urban communities the opportunities for this are widespread. Casual or anonymous sex can provide sexual gratification without the complications of a relationship.

Sexual dysfunctions should be assessed objectively without a moral stance being taken on the manner in which sexual expression is likely occur.3 Similarly, casual sex can be the reason for patients, male or female, khổng lồ seek help, realising that, although they are sexually fulfilled, they are “missing out” on the emotional aspects that can be associated with sex as part of a relationship. There can also be considerable dibít tất tay for those who find it difficult to establish same sex relationships that could progress lớn become sexual & committed.


Spectrum of activity

Gay men—Anal sex remains a taboo subject even for many professional sexual discussions; however, it is widely practised in most communities. Sexual activity is protean in all groups, & gay men are no different in this. Mutual masturbation, oral sex, & anal sex can be considered core activities, although many gay men vị not practise anal sex at all.

Lesbians—Mutual masturbation, oral sex, caressing, và penetration with fingers or sex toys can be considered as core activities. Some couples may choose more vigorous forms of penetration such as “fisting,” in which the h& và part of the forearm is introduced into the vagina, though this is probably no more comtháng than in heterosexual couples.


Terminology

Once they have sought help, gay men và women are often less reticent in discussing at length and in detail specific sexual acts. It is therefore useful for a doctor to lớn be forearmed with a basic vocabulary of gay sex, although many men và women who perform these activities will lack the words to describe them, and few people of any orientation are likely to have all the activities in their personal behavioural repertoire.


A gay sexual vocabulary

B/D—Bondage và domination. The use of power play, but not pain,  for sexual pleasure

Baông chồng room—That part of a sleaze bar (see below) where sex can take  place

Cottaging—The use of public toilets as a venue for meeting sexual  partners

Cruising—To be actively looking for a sexual partner

Fisting—The insertion of a whole hvà inlớn the rectum or vagimãng cầu for  sexual stimulation

Rimming—Oro-anal liên hệ for sexual stimulation

Sleaze bar—A bar or pub where sex can be performed on the premises

S/M—Sadomasochism, the use of pain in consensual sexual acts

Vanilla—Sex that does not extend beyond affection, mutual  masturbation, and oral & anal sex. This is the commonest mode  of gay sexual expression

Water sports—Urination as a sexual pleasure


The terms “active” & “passive” are best avoided if a doctor needs to lớn determine the nội dung of a sexual act, such as when considering the risks of sexually transmitted disease. The doctor’s concerns are anatomical placement và not the psychological roles implied by these words. Most gay men will not fit exclusively into lớn either of the roles implied by the old fashioned heterosexual model, and if the words are applied lớn oral sex great confusion may result. Gay male oral sex includes two sexual acts, fellatio & irrumation—cock sucking & face fucking respectively—depending on whether it is the mouth sucking or the penis thrusting that is the main act. In both cases there is a penis in the mouth, but the “active” partner differs. When it is necessary to determine who did what, it is easier khổng lồ talk about insertive & receptive partners lớn avoid confusion.


Problems

Erectile dysfunction is being seen increasingly, usually of an organic type, in those with late stage HIV infection, although whether this is an effect of the vi khuẩn or of the antiviral drugs is not yet clear.


Facts & figures

Two thirds of gay men have anal sex

Ten per cent of heterosexual couples regularly have anal sex

The estimate that 6% of the male population are gay may be an underestimate

No one knows how comtháng sexual problems are in this group

Their presentation varies widely from clinic lớn clinic

Erectile dysfunction is increasingly seen in men infected with HIV

Retarded ejaculation is common

Piles và anal fissures are no more common in gay men than in the general population

Vaginismus, anorgasmia, & low sex drive occur in lesbians as in heterosexual women


Retarded ejaculation is common in gay men and may be related to lớn fears of contagion induced by the “safer sex” campaigns.

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Piles caused by dilation of an anal venous plexus are no more common in those having receptive sầu anal sex, and are usually caused by straining at stool.

Anal fissures usually arise from constipation rather than receptive anal sex. However, if they are a sexual problem they generally respond khổng lồ the use of an anal dilator. The medical St Mark’s type is readily available, và the self retaining version is sold as a sex toy called a “butt plug.” The smallest size works well if left in situ for several hours each evening. A topical anaesthetic (such as EMLA cream) may be used on the first few occasions, until healing is under way.

Female sexual problems—Like heterosexual women, lesbians can suffer from vaginismus, primary or secondary, và from anorgasmia and low sexual drive sầu (see earlier article by Butcher).


Infections

Sexually transmitted diseases are common in people with many sexual partners, which includes some homosexual men. The ease of transmission of most sexual infections is similar for vaginal và anal sex, with the exception of HIV, which is much more easily spread by anal sex. Strong condoms greatly reduce this risk. Oral sex, while a recognised route of transmission, is considered khổng lồ be relatively safe for HIV, but it is a common means of acquiring gonorrhoea và non-specific urethritis. Lesbians are considered a low risk group for HIV infection.


Infections associated with homosexual activity

Sexually transmitted diseases are common in all gay people with a high number of different partners

Their management is the same as in the heterosexual community

The transmission of infection through vaginal và anal intercourse is no different, apart from HIV

Hepatitis A và Giardia are spread through oro-anal contact

The greater incidence of hepatitis B is an indicator of a large number of partners, not of specific sexual practices


Faeco-oral spread of pathogens such as Giardia and hepatitis A are well recorded from oro-anal sexual tương tác. Minor episodes of diarrhoea may be related to lớn faecal exposure, và are often self limiting. If they persist, stool culture will usually pick up any bacterial cause, and if the culture is negative it is better khổng lồ treat for presumed giardiasis than vì chưng extensive investigations to attempt khổng lồ prove the diagnosis.

Hepatitis B, though commoner in gay men, has not been shown to be spread by specific sexual practices & may simply be a marker of exposure khổng lồ a greater number of sexual partners. The orthodox sexually transmitted diseases are managed as in the heterosexual community, although contact tracing for gay men with non-specific urethritis is less important given the rarity (2%) of chlamydia as a causative sầu agent in gay men.

Immunisation against hepatitis A and B is recommended by the Department of Health for all men with male sexual contacts.


Anal sex

About a third of heterosexual couples in Britain are thought to lớn use anal sex as an occasional method of sexual expression, with about 10% using it as a preferred or regular method.2 Perhaps two thirds of gay men practise anal sex as a regular part of their sexual repertoire. This means that, in absolute numbers, there are more heterosexuals having anal sex than there are gay men. There are little published data on how many heterosexual men would like their anus khổng lồ be sexually stimulated in a heterosexual relationship. Anecdotally, it is a substantial number. What data we vị have sầu almost all relate to lớn penetrative sexual acts, và the superficial tương tác of the anal ring with fingers or the tongue is even less well documented but may be assumed khổng lồ be a comtháng sexual activity for men of all sexual orientations.


Anatomy of the anus

The nerve sầu supply to the anal margin is the same as that khổng lồ the genitalia, coming from S4, and the pectinate line roughly marks the division between sensitivity to touch và temperature externally and perception of little more than stretch internally. The external anal sphincter is made of striated muscle và can be brought under voluntary control, whereas the internal sphincter, which is a thickening of the intrinsic muscle layer of the gut, is made of smooth muscle và is autonomic, opening in response to stretch stimuli.


Advice for patients

• Cheông chồng that the patient really wants khổng lồ try and is not being pressured by a partner

Anal relaxation is better than pushing harder

Reinforce the use of condoms with water based lubrication as a protection against HIV

Give sầu instructions for anal dilatation và relaxation exercises.


Anal dilatation và relaxation exercises

• Do these exercises on your own until you are confident you can accommodate a penis

Start doing exercises in bed lying on a towel or lying on your baông chồng in a warm bath

Raise your knees towards your chest

Explore the perianal area with a finger covered in lubrication. Petroleum jelly is a good choice at this stage, but it must be substituted with a water based lubricant before intercourse with a condom is attempted

Gentle pressure with a finger moving in a circle round the anus will relax the sphincter enough khổng lồ be able to lớn insert one digit

Once the finger can be comfortably accommodated, begin khổng lồ stretch the sphincter with circling motions inside the anus

After several sessions, it will be possible to insert another finger and lớn continue

Further dilation by relaxation, not stretching, can be achieved by the use of an anal dilator of the St Mark’s type or a self retaining “butt plug” left in situ on a regular basis.



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Lesbians may choose khổng lồ be a “penetrator” in lovemaking by using a dilvị & harness or other sex toys


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Casual or anonymous sex can provide sexual gratification without the complications of a relationship


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Mutual masturbation, oral sex, caressing, and penetration with fingers or sex toys can be considered as core activities of lesbian sex. (“Anything is possible!” from La Grenouillère (1907) by Franz von Bayros)