Question: Dear doctor, i cannot get over the fact that sex is absolutely and completely dirty and filthy because of :
1. Its immoral mechanics involving penetration
2. The disgusting and filthy look of a wrinkled scrotum
3. Its association with excretory organs like the penis and its closeness to the anus
4. The confusion is so XXXXXXX that it renders me ineffective from the fear of having these images in front of my eyes when i have to give for example a presentation which would not alow me to feel uncomfortable for any reason.
Please suggest the path that i should follow to attend to this problem of mine as it has been bothering me since i was in class 8th. Iam brilliant at my work and sometimes feel that i cannot dojustice to my full potential because of this problem which bothers me all the time.
Iam a 32 year old male. Thanks

Thank you for the revert doctor.
My answers to your questions are as follows: -

How often do you keep having these / images?

ANS: Since this is the constant skeleton in my life’s closet, constantly frightening me, the disturbing thoughts become most profound, especially at times when I have to perform, as in presenting a case to a court (I am a lawyer practicing in Delhi High Court), when there is no breathing space to entertain these thoughts. The crushing problem I face is on the one hand, I am never sure as to whether I can keep these thoughts away for certain while on the other hand, I have no scope or space to entertain them (as while presenting a case, the court does not stop for you to think about the XXXXXXX issues of your life, which trouble you). Therefore, to answer your question in a sentence, these disturbing images threaten me most when I have to absolutely perform and I can’t afford to have them.

How did it start? (suddenly or gradually?)

ANS :All I can remember is that I grew up in a very conservative household in India (New Delhi) in a Punjabi Family. My Mom was a teacher and My Dad was / is a lawyer. I distinctly remember growing up being told what was moral / right and what was profane and developed a clear sense that affection between sexes was somehow bad (Eg. I did not watch any movies thinking that it was bad when people in the movies kissed etc.- there was a strict code of refraining from watching any such television serials).
Therefore I think that I grew up with a rigid mental picture of the world as also involving immorality which had to be avoided.
All was going well, in the sense that uptill the age of 12 years I was excelling at school and doing very well over all, while being a "good boy".
The problem erupted, when one day (which i can remember like it was yesterday), while in school, one boy in my school / same class (7th Standard), when we were aged 13 years, told me how children were born / conceived. It made immediate sense after i envisioned the corresponding and complementing shape of the genitals. That single knowledge was clearly the most traumatic incident of my life as i felt that the world had cheated me, when one of the most fundamental processes that permeate life was shockingly abhorrent and disgusting. I could not understand that how could anybody act or live normally with the full knowledge of this fact which amongst other things involved penetrating someone’s body, with the most vile and disgusting organ (penis), which also looks utterly ugly, its disgust enhanced by the wrinkled and dark texture of the scrotum. Moreover the act in itself seemed inherently domineering, involving the overpowering of the female and inserting the penis in her body. The TRUTH WAS TOO COMPELLING TO BE IGNORED AND TOO DISGUSTING / REVOLTING TO STOMATCH OR BEFRIEND.

As expected my mind was possessed by the shock of this most vile and revolting revelation and I remember every single day of my life from the age of 13 thinking about it. It plagued by life every single day and every hour of it. My grades plummeted and over the years things only worsened and in my mind the single most source of all agony was this disease which had gripped my mind.

Have your symptoms been improving or worsening through these years?

ANS: The symptoms have remained from being too intense (when I am rendered totally in operational / functional) to being moderate (when I can as if place it on the back burner with constant negative flow of feelings but still somehow ineffectively operate / function). I don't know how but over the years I have in some way adjusted to his constant psychological pain, perhaps with the efflux of time but it still frightens me because when it is most intense I cannot do anything about it. Perhaps I have rationally tried to address it by reading about evolution and anatomy but sometimes i feel that irrational origins of disgusting feelings can only be addressed in a limited manner rationally.

Do you believe that these disgusting thoughts about sex are rational or correct?

ANS: I think co mingling of excretory and sexual organs, the manner of copulation (involving penetration) and the look of the genitals, at lease makes sex at some level objectively disgusting or dirty. That perhaps explains that universal taboo surrounding it, in all cultures. So yes I think on a rational basis the process is disgusting and in a very big way contaminating life and its purity (in some poetic sense). What has particularly shocked me over the years is as to how, particularly girls by pass this brute truth to be not touched by it, as I feel it should be harder for a girl to accept it than a boy, for reasons set out above (eg. penetration etc.).

Have you had any sexual relationship so far? Do your masturbate? When engaging in any sexual act, do you have any difficulties because of these thoughts?
ANS:After finishing my LLB (Law), I got married to my wife, whom I had known since my college days. I have not had sex with any other woman. My sex life with her is not satisfactory to say the lease. The reasons perhaps are my general disgust with this process at the intellectual and emotional level. Surprisingly I have always felt great sexual desire for the female form / body and am easily aroused by its magnetic pull. Yes I masturbate fantasizing that sexually appealing form of the female body, by drawing from imagery supplied by pornography which I heavily indulge in. Though I love my wife very very much, I somehow don’t get very aroused by her body and her looks, which are rather ordinary and she is slightly obese. Yes a combination of all these factors do inhibit a satisfying sexual experience with her and make it difficult, for which reason it is seldom and sporadic. At present she is pregnant with our first child, which is at some emotional level, eagerly anticipated by both of use, as she suffered two previous miscarriages.


Do you have any other such repeated thoughts or images or do you have to do certain actions repeatedly e.g. washing your hands, checking doors, locks, etc.

ANS : Though this problem has been the constant ache / pain for my life, I tend to get stuck on moral quite strongly. For example, amongst other things I have had horrendous episodes in dealing with the following moral / intellectual / emotional issues which were realized subsequently and which I have though extensive research managed to keep at bay:-
(a)     Regarding my use of “English”, when it was imposed by the conquering British: This also happened while having a flash of though telling me that there is some difference between natural languages and imposed languages and since natural languages are a natural extension of ones identity, originated by the interaction of time and people who have common ancestry and share a space amongst each other. This posed a moral dilemma, as to why should I only not speak Hindi / Punjabi and give up speaking a foreign imposed tongue like English. Through my years of research on the subject I realized that speaking in English was not unreasonable on account of (i) on grounds of merit it as a language which had sufficient XXXXXXX inertia in term of lexicon of science and technology which made it claim as a world lingua franca worthy, (ii) It was less rigid and loosely accommodating which perhaps explained its fitness as it did not shy frown free borrowing of words and meanings from other tongues., (iii) On grounds of practicality, it is well nigh impossible to erase it from records of government, administration and is the only fit means to exchange knowledge on scientific, political and technological issues internationally. And many other reasons covering areas of linguistics (everything going back to a common proto language), genetics (everyone having an innate ability to master any language that he or she is exposed to), the lazy politics of India which never invested time or effort in developing our local languages, the natural tendency of languages to change over time and be dominated or absorbed by the dominant language, etc. etc.
This process of research started and took some 4 years before I was somewhat satisfied that my pursuit of English was not immoral. The problem is at some level similar, as in this case also, just another thought like why should be pursue or speak English, threatened to eclipse my world as I was training for law when this occurred and English being the language of law, made me feel very very nervous, as I felt scared that how would I become a pursuacive lawyer if the medium in which I convey my persuasion (English), is not truly mine and I have no mastery over it.

(b)     Regarding my needing to work more than what satisfies my basic needs. This thought that why should one be more ambitious than what satisfies ones needs and should not strive or push to succeed to gather excesses which are only delusions imposed by society by spinning a rat race. Though I have some how come to an adhoc conclusion in the terms that to know ones potential is the only way to self realize and you have to exert control to know ones own reality, this problem has as of now not bothered me that much. I read concerning this the Marslows pyramid of needs which rates self-actualization as the highest.

(c)     Regarding whether there is a God or not : this quest was more recent as it tends to give a perspective or worldview though which one can actually weigh all confusions. For example, if there is no god then the sexual process, being an outcome of blind evolutionary processes / natural selection appear at some intellectual level explanatory. I am at present wrestling with this problem, as on the one hand objectively it appears that God does not exist looking at the (i) reasons of Evil (natural & Man inflicted, pointless and excess as it is, (ii) Hidenness of god, (iii) Life in science and by scientists is considered to be material and not supernatural, (iii) there are studies showing that prayer does not work, (iv) Science, without the supernatural is effective in alleviating disease, surgeries successful, (v), all religions conflict in their fundamental claims about the nature of god, all in all, the world appears to be better explained without resorting to a “benevolent, caring merciful god”. ON THE OTHER HAND, by reasons that limitations of rationality, science and living in a world of meanings, aspirations where one has to interact with this mindboggling nature of complex, functioning reality, there appears to be a very strong pull to believe. My stumbling block for belief in God is the problem of evil, but I do understand that not believing in God also does not solve all problems of life at the emotional or intellectual level as rationality itself can scarily travel in any direction without ones control. So something is needed to ground your beliefs, but the problem is that doing that in a caring, merciful caring god is most unreliable.

AS TO ANY RITUALS OF WASHING OR LOCKING – Though I have no such compulsions, whenever I am dogged by these disgusting thoughts, I tend to give myself rational arguments to neutralize the effect as in:-

(i)     There is no god and it is a blind mechanical process, fixed by historical accident and thus having no intention behind it. For reason of it having no intention it cannot be “BAD”.
(ii)     From whatever I have read in the Internet, I tell myself that the penis and the vaginal if ordinarily cleaned have less bacterial than other parts of the body. The urine is said to be sterile. And even a washed anus is stated to be clean.
(iii)     So I try to tell myself these facts and thoughts culled out of the Internet.

Do you consume alcohol or any other substances of abuse?

ANS :I tend to be a moderate smoker, something which I am absolutely dependent upon. I rarely drink.

Do you suffer from any known medical problems or are you under any treatment currently?

ANS: No I am not under treatment for either this problem, herein described, or any other problem..

Have you consulted a psychiatrist before regarding these problems? If, so, what treatment were you on?

ANS: Dear Doctor, I tried following up on this problem with a therapist, but the experience was very discouraging, as she even use to sleep during our sessions while hearing me. The only thing she did ask me to do was to draw sketches of the penis and the vagina, as I had told her that the images are in the nature of the male organ copulating with the female organ, especially the flashes of the scrotum which I find very repulsive.

Please get back to me with these clarifications, so that I can advise you in a better way

Thank you for your revert. I really need help. Please guide me. My present survivor kit to stand up in court and argue is to for example tell myself that :-
(a)     I have left sex and become celibate, so sex is none of my concern.
(b)     That as far as excretion is concerned, I have told myself, from whatever I have read, that one can invariably control bowl movement and it cannot involuntarily get splattered out. That control is more than one controls being alive at an given moment.
(c)     So I try to tell myself that for this moment when I have to argue a case, and I cannot have any such thoughts, problem of sex is gone, as I have left it and excretion is gone as I can control it from feces to flow out anytime. Moreover the fact of the disgusting nature feces does tell me and reconfirms my doubt regarding the existence of a good God who has a good aesthetic sense.

I must also mention that when these thoughts dont bother me, after consentrating on diagrams succinctly depicting the above referred solutions and telling myself that I have to argue like god (the fact which I only come to know when I stand up to argue)I generally tend to be very effective and am as such known to be a very persuasive advocate at the bar in the court.

Dear Doctor, as you can tell, I really need your help. I don’t know what to do, here there are so many psychologists but I don’t know whom to contact and my past experience was very very poor and discouraging.

For your reference and assistance, I could also send to you my previous correspondence with a professor over the Internet on the same issue.
Dear Doctor, Could you please reply, after an assessment of my submission. I need your help urgently. Could you please tell me if this problem is curable with medication / therapy, or just by your guidance and advise. This has been bothering me a lot and seems to have peaked today.

Thanking You

XXXXXXX

Dear doctor,

Thank you so very much for a detailed assessment of my problem. Could i please ask you the following:

1. Could you suggest to me a suitable psychiatrist/therapist in Delhi-NCR who is experienced and effective at handling such complex issues and above all somebody who would genuinely be interested in solving a complex case like mine not just professionally but also at a personal level as i have not had a very good experience in past and thus naturally feel a little apprehensive about it.

2. Please guide me as to how much of time given the right professional and medical
help would a total recovery take?

3. How soon would i start feeling the positive effect of medication and therapy?

Thanks again for your timely response and i would have loved to have you as my doctor if that was possible but i must take the XXXXXXX of saying that i would like to keep in touch with you through this medium and keep taking your guidance.
Thanks!!

Dear Doctor,

At the outset, I must thank you once again for guiding me. I intend to maintain contact with you, though this medium, if that is fine with you.

As suggested by you earlier, I today went for my First session to a XXXXXXX Consultant at Medanta. His diagnosis was the same as you had diagnosed, i.e. OCD. Though he did say that my case is a little difficult and complex (as also diagnosed by you), since my compulsions are internalized and have become part of my system.
____________________________________________________________________
COULD YOU PLEASE GUIDE ME WITH RESPECT TO THE FOLLOWING:-

1. Is the doctor (whose profile i have pasted below), apt to address "The complex nature of my OCD". This is only to assure myself that I am with the right person, as the band of time that this Doctor has outlined for me WITH MEDICATION, is about 5 years at least. So thats a lot of time to invest in one person, and if I can be sure about his credentials then investing even double that much would not be a problem.

2. I have been prescribed Paxidep CR/Xet CR 12.5 mg to begin with for 1 week, and then 25 mg of the same medicine for 5 more weeks. One tablet a day has been prescribed to be taken after dinner. The doctor has also cautioned me to look out for side effects. DOCTOR, IS THIS THE RIGHT MEDICINE FOR MY KIND, PLEASE ADVISE.

3. The doctor also said that in light of my complex problem and its difficulty in view of its long history of 20 years, a suitable therapist would be assigned to me after 6 weeks, till then i have to immediately take the medicine above mentioned. IS THAT THE RIGHT WAY TO GO.

4. When upon my asking him that "is this curable", I was told that all patients normally feel improvement, without really confirming the level or degree of successful treatment. DOCTOR PLEASE ANSWER IF IS OCD OF MY KIND TREATABLE TO THE LEVEL OF FULL RECOVERY.

THANK YOU ONCE AGAIN FOR ALL THE HELP AND SUPPORT. IT MEANS THE WORLD TO ME.
XXXXXXX KAPUR
_____________________________________________________________________
THE DOCTORS PROFILE, AS LISTED ON HIS OFFICIAL HOSPITAL WEBPATE, I VISITED TODAY IN THAT HOSPITAL, IS AS UNDER:-

Dr. Achal Bhagat Medanta Division of Mental Health and Quality of Life

Dr. Achal Bhagat is a XXXXXXX Consultant, Psychiatrist and Psychotherapist. He has been practicing in Delhi since 1995. He heads the Division of Mental Health and Quality of Life at Medanta-The Medicity and leads our team of psychologists, social workers, cognitive behaviour therapists and family therapists.
He has been previously associated with Indraprastha Apollo Hospitals, Delhi. He is also the Founder Director of Saarthak, a voluntary organization working on the issues of mental health in South Asia. He received his training at PGIMER, Chandigarh and Oxford, UK.
Dr. Bhagat has authored many books and manuals on mental health. He contributes frequently for the lay press and has had columns in The Times of India, The Hindustan Times, Society and Business World.

Medical Qualification     
MBBS     UCMS, Delhi University     1986
MD (Psychiatry)     PGIMER, Chandigarh     1991
MRCPsych     Royal College of Psychiatrists, UK     1994
Training in Family Therapy, Group Therapy, Psychoanalysis and Cognitive Behaviour Therapy     --     1991-1994
Department Institute      Medanta Division of Mental Health and Quality of Life
Expertise     
Psychiatry, Psychotherapy, Child and Adolescent Psychiatry and Psychotherapy, Marital and Family Therapy, Rehabilitation Psychiatry, Substance Abuse.
Contact Information     Doctor's Phone : +91-0000
Email Address : YYYY@YYYY
Doctor's Experience Memberships & Certifications Awards & Accomplishments Publications
PGIMER, Chandigarh
1988-1991
Registrar, National Health Service, Oxford Region, UK.
1991-1995 XXXXXXX Consultant Psychiatrist and Psychotherapist, Apollo Hospital, Delhi
1995-2011
Founder Director, Saarthak
1995-2011
Consultant Mental Health, UNIFEM, UNICEF, UNODC, Groupe Development,
Apne Aap, AADI, DFID, XXXXXXX
Between 1995-2011
Consultant Organization Development, Reebok, GECIS, Cummins
1995-2001
Advisory and Honorary Positions

Chairperson, Saarthak

Member, Governing Board, AADI

Member, Governing Board, School of Rehabilitation Sciences, Delhi University

Member, Governing Board, XXXXXXX XXXXXXX

Member, Monitoring Committee appointed by Delhi High Court for overseeing the development of rehabilitation services for persons living with mental illness

Advisor, XXXXXXX Foundation, Mental Health Projects

Dear doctor,
Thanks for a very detailed reply, it was very reassuring to read it.

I have one more question, when i read about the prescribed medicine(Paxidep) on the internet, it mentions some very scary side effects like depression, anxiety, insomnia etc. Are these rare side affects or all taking these medicine will suffer it.

What are the possible side affects that i should be on the look out for?

Thanks once again.

Regards
XXXXXXX