Demystifying alternative sexual behaviors

Bringing up sex 

Not every practitioner is comfortable discussing sexual issues. For them, referral is an appropriate option. Those practitioners who feel at ease having these discussions may choose to become a resource for their local medical community. The general medical care of practitioners of unusual sex behavior is included in the new medical specialty of Sexual Medicine.

Before meeting the physician, the patient will gauge his or her openness to discussing sexual issues by the manner of the office staff and the intake forms. These will influence the patient's decision to disclose his or her sexual practices. An important first step for the practitioner is to make your intake forms sympathetic to a spectrum of sexual activities. At the very least, these forms should allow patients to indicate with whom they have sex (men, women, both, or neither) and their own preferred gender identity (male, female, transsexual, intersex, or other). Individuals do not necessarily define themselves by the sex of their sexual partners, so it is best to avoid terms like homosexual, heterosexual, and bisexual. Similarly, some people choose not to define their gender as dictated by their genitals or chromosomes. Common courtesy is to refer to the patient in the manner of their choosing.

During the review of systems, consider adding just three words: “Any sexual concerns?” This phrase is deliberately broad and open-ended. To elicit a more specific response, the practitioner might add, “Do you have any medical questions about any of the sexual activities in which you engage?” Some physicians make a statement such as, “Sex is often difficult to discuss even with a physician, but I want you to know that I am open to your questions.”.

The individual who arrives at the emergency room with an object in his or her rectum is always asked how this occurred. The answer rarely falters: “I slipped in the shower.” The important question is rather, “Was the activity consensual?” Your ability to obtain the answer to that question is compromised even by asking the first naive question. If the mechanism is important, then explain why it is important to obtain the needed information.

It is important not to guess or assume too much. Patients can feel violated if they think their appearance or manner suggests their hidden sexual desires. Prefacing the question with an explanation of the medical importance of the information tends to increase their comfort level. Some considerations to keep in mind when expanding one's practice to incorporate Sexual Medicine are included in the box titled, “Some general rules for discussing unusual sexual acts” on this page.

“Unusual” sex acts 

Unusual is in quotations because these sexual interests are not really unusual. Although research data on their incidence and prevalence are not available, in practice there are relatively few patients (or physicians), who do not engage in some sexual act that others would view as unusual.

The range of human sexual behavior is so broad, that this article can only touch upon some interests. It has been said that anything and everything can be eroticized. Why would someone enjoy X or find Y erotic? The answer is the same reason you find whatever it is that you find erotic, erotic. How humans develop any sexual interest is a basic and unanswered question in psychiatry and sexology.

General terms 

Sexual minorities (everyone but the traditionally heterosexual) may call themselves or their activities queer, perv, pervert, kink, kinky, or fetish. Those who are not sexual minorities are called vanilla or straight; vanilla is also used to describe non-kink sexual activities. To be squicked is to be personally upset or disgusted by a given behavior, but does not imply a judgment that the behavior is wrong for others.

Someone who is coming out (exploring the activity or beginning to accept the identity) is called a novice or newbie. Someone who loves sex is called a slut. Sometimes a specific type of sex or activity is particularly desired, eg, pain slut, fuck slut, rope slut, or anal slut. Sexual interactions are called play, but direct genital stimulation is not necessary.

Individuals who wish to live or pass as members of the other sex are TG (transgendered). Those that want SRS (sex reassignment surgery) are TS (transsexual). MTFs (male-to-female TS or TG) call themselves trans or transwomen to distinguish themselves from natal women, also called GGs (genuine girls) or fish. FTMs are female-to-male TSs (the TG/TS distinction is not clear in this group) and may call themselves transmen. A man who is erotically aroused by dressing as a woman is a TV (transvestite), some of whom will become trans. Drag queens are gay men who dress as women, but more for theater than gender dysphoria. She-males (a type of TG MTF) are interested in male sex partners and are expected to get an erection and use their penis during sex. Drag kings, lesbians who dress as men, also exist.

Anal 

Stimulation of the anus/rectum is called ass play. Butt plugs (objects used for anal insertions) are held in the rectum by the anal musculature and can be used during sex or worn for longer periods of time. Anal beads are devices for anal insertion consisting of a series of beads connected by a string or molded plastic which are inserted into the rectum and pushed in and pulled out the anus. The mix of fecal matter and lubricant, a common result of ass play, is santorum.

Patients may prepare for ass play by douching (a series of enemas). Various substances (wine, other alcoholic spirits, coffee, and illicit substances) can be added to the enema solution, resulting in a very rapid and powerful drug effect.

Analingus or rimming involves oral stimulation of the anus. Felching is when one partner sucks the ejaculate out of the anus or vagina of the other partner. Snowballing is when the ejaculate (from either fellatio or coitus) is passed from the mouth of one partner to the mouth of the other partner. Anal intercourse followed by fellatio of the inserter (without washing) is called licking clean, ATM or A2M (ass to mouth), and is more common than you think. Inserting an entire hand into either the vagina or rectum is called hand balling, fisting, or fist-fucking. Practitioners of these behaviors often cut their fingernails exceedingly short to prevent any inadvertent lacerations, which can be a clue to the behavior found on physical exam.

A dildo (artificial phallus) or strap-on can be used for vaginal or anal insertions; it is not uncommon for them to be referred as the owner's cock. A strap-on is a dildo, worn in a harness that allows one to engage in coitus with one's partner regardless of anatomy or sexual dysfunction.

BDSM 

BDSM is an acronym for Bondage and Discipline (B&D), Dominance and Submission (D/S), and Sadism and Masochism (SM or S&M); it describes people (players) who eroticize bondage, a power differential, physical, or psychological pain (sometimes called intensity). BDSM play is called a scene. Leather can be a fetish object and is also synonym for BDSM, especially Gay BDSM.

Players who take the active role are called dominant, dom, domme, domina, top, master, mistress, and sadist. Players who take the passive role are called submissive, sub, subbie, bottom, masochist, boy or girl, and slave. (In some SM interactions, it may not be immediately obvious which partner identifies as the top and which as the bottom, although the practitioner may feel strongly about the label.) Switches can take either role.

There is intense debate concerning the distinctions among these terms; for example, someone may say “I am a masochist; I will be submissive if my partner enjoys it, but I am no one's slave.” Simplistically, a masochist primarily seeks physical sensations. The submissive primarily enjoys the psychological aspects, but maintains options to control the intensity and duration of the scene. The slave wishes to serve and/or give up as much control as possible. Other sexual minorities use the term bottom to describe the one penetrated or the receiver of the intensity or play, without implying a BDSM relationship. Similarly, a top is the one who penetrates or applies the intensity.

Mixed play implies a BDSM interaction between people who would not usually have sex together (a gay man with a lesbian, for example). BDSM partners engage in negotiation, the process of agreeing on what will constitute the specifics of their scene. They decide upon a safe word (a word or gesture that will stop the scene), and mutually define the limits (activities not to be included in the scene). Violating someone's limits is a serious faux pas.

Toys are small items used during sex, in contrast to large items called equipment (slings, tables, bondage furniture). Toys include whips, handcuffs, vibrators, cock rings (a leather, metal, rubber or latex ring tightly cinched at the base of the penis to prevent detumescence, which actually works), rope, chains, violet wand (i.e., a device with a purplish glow using static electricity to stimulate the body), and chastity belts (devices that prevent someone from stimulating themselves, achieving an erection, or engaging in coitus).

There are other toys that limit some sensory input (blindfolds) or prevent individuals from speaking (gags) or closing their mouths. Hoods may have zippers or snaps, allowing the attachment of objects or blocking the mouth or nose. Padded bits, blinders, and bridles are used during pony-play (i.e., role-playing being a pony).

People who want to incorporate BDSM into their lifestyle are 24/7 (24 hours a day, 7 days a week); a more intense form of this is called TPE (total power exchange). Those who only engage in SM during sexual interactions do EPE (erotic power exchange) or “keep it in the bedroom”. Players usually adhere to the SSC (safe, sane and consensual) creed, though some people frame it as RACK (Risk Aware Consensual Kink). Consensual non-consent is a conscious, negotiated suspension of one's limits. A play party is a social gathering where semi-public BDSM activities take place; the party space (venue) provides equipment and usually DM's (dungeon monitors, individuals who assure compliance with SSC and other party rules). Players usually bring their own toys. First date scenes often take place at a party as additional safety.

Some individuals especially enjoy play involving a specific area of the body, e.g., tit torture, CBT (cock-and-ball torture), and cunt torture. Edge play (i.e., activities that tend to squick people) require more experience to engage in safely. These activities are not inherently abusive, criminal or self-destructive. They are typically loving, intimate and well-thought-out in terms of safety.

BDSM play often results in skin redness, bruising, or welts. Some recipients like these marks and wear them as a badge of honor; others dislike them. Some people engage in play piercing, temporary placement of hypodermic needles in the skin. These can also leave distinctive marks. Scrotal or labial inflation (insuffulation with sterile saline) can be the cause of subcutaneous emphysema.

Gay subcultures 

Men interested in bears (big, barrel-chested and usually bearded men) are called cubs, though it is not uncommon to see two bears together. Men attracted to men with large penises are called size queens; men attracted to Asian men are called rice queens. Daddy/boy or boi role-plays imply a BDSM relationship; the same terms can be used by women.

Women who are interested in sex with other women are lesbians or dykes. High femme or lipstick lesbians are women who appear stereotypically feminine (lipstick, make-up, high heels, frilly clothes, etc.). Femme women also have a decidedly feminine appearance, but not to the extreme. Soft butch women appear more androgynous. Stone butch women tend to be masculine in appearance and may dislike any vaginal penetration themselves. Femme/butch couples exist, but other pairings are not unusual.

Men who like lesbians are called dyke daddies, but sometimes this term is used instead to mean butch lesbians. Heterosexual women who like gay men are called fag hags or fruit flies, but these terms do not usually imply sexual interaction. Some lesbians will interact erotically with gay men and/or in gay male environments.

Alternative relationships 

When your partner is aware that you have or could have more than one partner, you have an open relationship. Many open relationships have a designated S.O. (significant other) or primary partner; other relationships are called secondary or fuck buddies. Those who are open to more than one primary relationship are called poly or polyamorous. Fluid-bonded describes a relationship in which safer sex precautions are not used with that partner or partners, but are mandatory with other partners. Swingers are male-female couples who seek others primarily for sex. Although many swingers are polyamorous and vice versa, each is often quite dismissive of the other's lifestyle. Cucks or cuckholds are men who want to see or know that their wife or girlfriend is having sex with other men.

Gay male group sex often occurs at the baths or a bathhouse. These often contain glory holes – a hole cut in a partition through which they can engage in anonymous sex. Venues for swinging or group sex are called sex clubs. Female-only sex clubs also exist but are less common.

Medical complaints 

Despite the common belief that unusual sexual behavior often leads to injury, this has not been my experience. A review of the Emergency Medicine literature does not reveal specific problems resulting from unusual sexual acts. STIs (sexually transmitted infections) can be the outcome of any sex act, but in my experience these are no more likely than what is observed among vanillas. I see many more injuries related to the travel to and from the sex party than injuries received at the sex party.

Nonetheless, individuals left in bondage too long can develop a neuropathy from nerve compression. More important is to warn your patients who have neuropathy not to aggravate the injury with bondage. Some patients are well aware of the possible consequences of their sexual activities and use a variety of strategies to minimize the risk; others are either unaware of the potential problems or the strategies for minimizing them. Few physicians or other medically trained individuals discuss the safety issues of a particular activity with patients. I often have individuals consult with me, simply to discuss the safety of a particular behavior, the possible medical problems that could occur, and how to avoid them. Safety is an important issue at lay conferences where these behaviors are discussed, but they rarely involve health care personnel. In my experience, there are more kinky individuals who have first aid and CPR training than those in the general public.

Most of the advice given is an extrapolation from other disorders. For example, there may be an entity called Flogger's Shoulder, resulting from repeatedly swinging a flogger (a device similar to a cat-of-nine tails). The evaluation and treatment of this entity is no different than other shoulder injuries.

Differences in types and areas of bruising or marks can indicate whether the relationship is abusive or not. (See box title, “When to intervene” on preceding page.)

Conclusion 

Sexual behavior is as diverse as one can imagine. As stated, anything can be eroticized. While a physician's personal opinions of alternative sexual behavior are legitimate, the imposition of those beliefs is not; the medical practitioner's primary responsibility is the health and care of his or her patients. A range of descriptions of terms and practices affords the reader a level of comfort with potentially difficult material. With this information as a launching pad, a physician is equipped to begin the discussion of sex with the patient; in turn, the patient will likely feel relief at the opportunity to be open, and to receive the best treatment.