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 Table of Contents    
PRESIDENTIAL ADDRESS  
Year : 2019  |  Volume : 61  |  Issue : 6  |  Page : 552-563
Sex, love, and relationships: My journey of 40 years


Director, Samvedana Happiness Hospital, Ahmedabad, Gujarat, India; National President, Indian Psychiatry Society; Direct Council Member, Indian Association of Social Psychiatry; Consultant, Family Planning Association of India -SECRT, India

Click here for correspondence address and email

Date of Web Publication5-Nov-2019
 

How to cite this article:
Vaishnav M. Sex, love, and relationships: My journey of 40 years. Indian J Psychiatry 2019;61:552-63

How to cite this URL:
Vaishnav M. Sex, love, and relationships: My journey of 40 years. Indian J Psychiatry [serial online] 2019 [cited 2019 Nov 22];61:552-63. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/6/552/270348




Respected Chairman Dr. Ajit Bhide and Dr. Vidhyadhar Vatve.

At the outset, I am thankful to Dr. Ajit Bhide for being so kind and liberal in giving my introduction.

I wish to express my deep appreciation to both of them for leading our society very successfully through troublesome waters with exemplary firmness, conviction, and courage.

I am grateful to everyone who wished, voted, and supported me and my campaign to contest for the post of vice president cum president elect. This election was the most special for me as this was the first fully online contested election in the history of Indian Psychiatric Society (IPS), and I will be more than humbled to digest this precious pie of becoming the first online elected president of the IPS.

I express heartfelt gratitude to all the fellows and members of IPS for bestowing upon me the responsibility of the office of president of IPS. I am sure that your blessings and guidance will help me to do justice to the confidence conferred on me.

My interest in psychiatry was sparked in 1976 when a close friend of mine fell in love with a lady 15 year elder than him. I was shocked and surprised to know this. I performed my duty as a good friend, but, instead of leaving her, he left me.

I was trying to find out the reasons for the same and came across the book Three Essays on Sexuality by Sigmund Freud. I came to know about Oedipus complex and decided to step in to psychiatry with special interest on sex, love, and relationships. My journey begun in 1979. Today, I will be talking on this topic which will include the ancient Indian heritage and practices in sex, love, and relationships to the modern era of social media, Tinder®, sex toys, and Commercialization of sexuality, with a remark that we still need to revisit the ancient Indian heritage and work on emotional bonding between two individuals.


   Introduction Top


Sex is the subject on which ancient and modern literature is available in almost all the languages. Writing about sex is now not privilege of Masters and Johnson, Helen Kaplan, Hartman and Fithian, Shere Hite or Alfred Kinsey even Clinton and Monica, Donald Trump and Harvey Weinstein (the cause of Me Too movement) can also contribute a lot to it.

Lord of the beings – “Brahma”

As per the Hindu mythology, Brahma the creator of being created men and women and in the form of commandments in one hundred thousand chapters, laid down rules for regulating their existence with regard to Dharm, Arth, Kama, and Moxa.[1],[2]

The Hindu tradition has the concept of the Purusharthas which outlines the “four main goals of life” that are necessary and sufficient for a fulfilling and happy life:[3],[4]

  • Dharma – Signifies behaviors that include duties, rights, laws, conduct, virtues, and right way of living[5]
  • Artha – Signifies the “means of life,” activities and resources that enable one to be in a state one wants to be in[6]
  • Artha – Incorporates wealth, career, and activity to make a living; financial security; and economic prosperity
  • Kama Signifies desire, wish, passion, emotions, pleasure of the senses, the esthetic enjoyment of life, affection, or love, with or without sexual connotations.[7] Gavin Flood explains[8] Kama as “love” without violating dharma (moral responsibility), artha (material prosperity), and one's journey toward moksha (spiritual liberation)[9],[10]
  • Moksha – Signifies emancipation, liberation, or release.[11] In some schools of Hinduism, moksha connotes freedom from saṃsāra, the cycle of death and rebirth, whereas, in other schools, moksha connotes freedom, self-knowledge, self-realization, and liberation in this life.[12]


Kamasutra: The aphorism on love

[Figure 1] shows a Kamasutra manuscript page preserved in the vaults of the Raghunatha Hindu temple in Jammu and Kashmir.
Figure 1: Page from Kamasutra Manuscript

Click here to view


  • Commandments related to kama were compiled by Nandi in 1000 chapters[13]
  • After that over a period of 3500 years, Udvakala abbreviated the same in 500 chapters
  • Babhravya of Panchala – South Delhi now, abridged it in 150 chapters, in seven parts. Seven different authors expounded each part separately
  • Vatsayana (400 AD) compiled this work in a small volume, namely, Kamasutra.[14],[15]


Some facts about Vatsyayana

Vatsyayana[16] was the most famous Hindu philosopher in the world who is believed to have lived during time of the Gupta Empire in India. His book “Kaamsutra” is as popular in the West, as it is in India. It is considered the most authentic work in the study of sexual activity and has been translated into several foreign languages.

  • Vatsayana was not a road side Romeo but a pious and saintly person from Banaras
  • Vatsayana never wanted people to be over excite about sex
  • He took Param Samadhi and never had sex in his entire life
  • Vatsyayana has stated in his book, “This work is not to be used merely as an instrument for satisfying our desires. A person acquainted with the true principles of this science, who preserves his Dharma (virtue or religious merit), his Artha (worldly wealth), and his Kama (sensual gratification), and who has regard to the customs of the people, is sure to obtain the mastery over his senses”
  • Unlike the gluttony of the Western civilization or Barbarism of the Middle East, Indians stressed on moderation. Vatsyayana says “Sexual pleasures are to be followed with moderation and caution.”[17],[18]


Kamsutra of Vatsayana

The Kama Sutra (Sanskrit: ) is an ancient Indian Sanskrit text on sexuality, eroticism, and emotional fulfillment in life.[19]

Although written between 400 BC and 200 AD, the most widely known English translation of the Kamasutra was privately printed in 1883. The author was Sir Richard Francis Burton, where the chief work was done by an Indian archeologist Bhagwan Lal Indraji.

Kama Sutra is neither exclusively nor predominantly a sex manual on sex positions,[16],[17] but written as a guide to the “art of living” well, the nature of love, finding a life partner, maintaining one's love life, and other aspects pertaining to the pleasure-oriented faculties of human life.[20]

(i) Sculptures of ancient caves

These teaching in Sex and sexuality was not given in Private chambers or class rooms but were depicted openly in the ancient caves of Konark, Khajuraho & in many Hindu temples.[21]

(ii) Changing Attitude towards Sexuality

  • But unfortunately, in 17th century the Britishers invaded India and brought obscenity with them hence sex education was discontinued.
  • Even teenagers were deprived of knowledge about anatomy and physiology of their Sex organs[22]
  • When boys have first nocturnal emission, they were never taught what it is
  • When girls started menstruation, they were never explained the physiological aspects behind it.
  • I observed tremendous lack of sex education when I started my career
  • If an average person knew as little about eating as he/she does about sex, he/she will quickly starve to death
  • This is what I have concluded after reading several thousand letters at least 300 per month to my sex education columns in Gujarati and English dailies and news magazines from 1984 to 2019.



   Improper and Unscientific Sex Education Can Cause Disaster Top


From my own clinical observations, I feel that a large number of incidences of clinical problems, scholastic underachievement, anxiety, depression, marital maladjustments, broken homes, divorce, and other marital illnesses could have been prevented if proper sex education would have been provided to the child, adolescents, youth, and married couples.


   As Many Myths About Sex and Sexuality as Many Mouths Are Top


  • 100 myths about masturbation
  • Still, the most frequently asked question is how much masturbation is normal?
  • Myths about semen, nocturnal emission, and loosing Dhat in sleep or passing it in urine are considered as disease. Semen is considered the most precious fluid
  • Myths about the size/length and hardness of the penis. How much big is bigger?
  • Myths about intercourse, a man can will an erection
  • Myths about homosexuality, sexually transmitted infections (STIs), HIV, and AIDS
  • Myths about menstruation, size of the breast, virginity, orgasm, infertility, and sex of the child
  • Oral contraceptive pill causes cancer, Copper T leads to profuse menstruation, and vasectomy leads to impotence
  • Myths about body built and vitality.



   Relationships Myths Top


  • Myth: Best marriages mean mutually satisfying sexual encounters occur every time
  • Truth: It is in Bollywood, not all sex is romantic, mutual, functional, and satisfying
  • Myth: Only intercourse is sex. Satisfaction is a pass–fail test
  • Truth: Outercourse, special pleasuring, and relationship are also satisfying
  • Myth: If romantic love is gone, it is all over in sex
  • Truth: Romantic love is fragile, it seldom lasts more than 2 years, starts decreasing after 6 months
  • Myth: There is a good guy and a bad guy in a relationship
  • Truth: No, its intimacy that includes emotional closeness, trust, affection, sensuality, arousal, and bonding
  • Myth: If male wants or needs her help, he is impotent
  • Myth: Spouse should be the source of all sexual desires
  • Myth: Sexual desire is something you are born with which cannot be changed. People with low desire are deficient or abnormal. Men are supposed to be sexual experts and initiators
  • Truth: Sexual desire is complex and has many dimensions; it can be facilitated and strengthened or damaged and destroyed
  • The so-called and self-poised sex quacks
  • Before 40 years when I came to the field of psychiatry, sexual medicine was dominated by quacks
  • They were/are strengthening the myths and enjoy luring shy, ignorant, and innocent youths
  • “Khoi hui takat aur javani vapis lane ke liye mill to le”
  • “Agar Aap Kahe bhi Nahi Sakate Hai aur Sahe Bhi Nahi Sakate Hai to Ham Hai Na”
  • Potency was sold in famous Palang Tod Pan
  • Still, they are operating in rural India.



   Sexuality Education by Columns, Books, Dvds, Seminars, Training Teachers, and Youtube Channels Top


I proudly say that Gujarati newspapers were among the first dailies to start sex education columns, “Mugdhavastha ni Munzavan,” in the mid-eighties. More than 2000 articles were written about sex education by me. The Times followed it in the late nineties. I have arranged more than 500 public lectures and seminars about sex education in schools and colleges in different parts of Gujarat. In addition, I have published books and DVDs. Many of my friends have done similar work in different parts of the country.

The first National Conference of Sexology was organized at Ahmedabad in 1986. With pioneers in this field like Dr. Mahinder Watsa, Dr. J. V. Bhatt, Dr. Vitthal Prabhu, Dr. Narayan Reddy, Dr. Raj Brahmbhatt, and me self-started the academic journey. Later on, Dr. T S S and others joined and the 1st National Continuous Medical Education of IPS with the theme “Psychiatrist as sexologist” was also organized at Ahmedabad in 2009.


   Popular Books by Other Authors Top


  • Dr. Raj Brahbhambhatt's Therapy for Common Sexual Problems, a handbook published in 1998 in which I have written a chapter “Principles of Sex therapy”
  • Different Strokes, an IPS publication, in which I have written a chapter on “Sex Therapy for sexual interest/arousal disorder in women: A new perspective”
  • Dr. R. H. Dastur's “Sex Power”
  • Dr. Vitthal Prabhu's “Sexology for medical Practitioners”
  • In Indian Journal of Psychiatry, a large number of articles are printed on sex education and sexual dysfunctions. Late Prof. N. N. Wig, Prof. A. K. Agrawal, Prof. Ajit Avasthi, my friends TSS and OP, and many others have done extensive research in this field.



   Sexual Medicine in Clinical Settings Top


  • Health-care professionals often lack the knowledge themselves that impacts upon imparting information to the adolescent, adults, and old-age couples who seek it[23]
  • Often, comprehensive sexual histories are not taken, and sexual health is not openly discussed due to cultural and traditional norms in the society[24]
  • Incorrect information has the potential to create misunderstanding in the youth, making them less likely to adopt healthy practices and attitudes toward sex, enabling them to maintain lifelong sexual health[25]
  • Often, psychiatrists who frequently prescribe psychotropics do not ask patients about their sexual health.[25]



   Sex Education in India during My Journey as a Psychiatrist and a Sexologist Top


  • The National Council of Educational Research and Training initiated sex education; they structured it as a part of the existing studies, rather than a separate subject. However, teachers tried to avoid teaching the topic. A school in Gujarat implemented a system where students could anonymously drop letters into a box for trained counselors to read[27]
  • After years of debate and persuasion in 2007, when sex education curriculum was promoted by the Union Ministry of Human Resources and Development, controversy developed[28],[29]
  • Opponents argued that sex education in schools and colleges will lead to sexual experimentation
  • Sex education at any stage will lead to morally liberated and sexually corrupt society
  • Gujarat, Madhya Pradesh, Maharashtra, Karnataka, Kerala, Rajasthan, Goa, and Chhatisggarh banned sex education in school[30],[31]
  • In April 2009, a Parliamentary committee had disfavored introduction of sex education in schools and suggested inclusion of appropriate chapters in biology syllabus
  • An nongovernmental organization (NGO) which continued to impart sex education, Family Planning Association of India (FPAI)/Sexuality Education Counselling Research Therapy/Training, is a leading organization in India, in which I am a consultant since 1986.



   Why Sex Education was Rejected? Top


Sex education covers human reproduction only, that is, physical aspects and related issues such as contraception, sexually transmitted diseases (STDs)/HIV/AIDS. It did not teach the student to differentiate between right and wrong, proper and improper, beautiful and ugly, healthy and unhealthy, and the beauty of relationships and responsible sexual, reproductive behavior.


   Adolescent Sex Education is the Need of the Hour Top


There are three types of sex education in India:

(1) The sex education modules which are targeted at adolescents, (2) family planning for adults, and (3) HIV/AIDS prevention education.

  • There are about 243 million adolescents in India – more than 50% living in urban area
  • Parents are often reluctant to teach accurate and relevant information about sex to adolescents because of the stigma associated with the topic. More than taboo, mothers especially feel like talking about sex is embarrassing and dirty
  • The same attitude is held by teachers
  • Surveys have shown that adolescents learn a significant amount about sex from the media, including books and movies, social media, and porn sites, which are inaccurate and do not help in emotional growth or responsible adulthood.[7],[32]


S “Sex education” – On Netflix

  • The online series – Sex Education – has been praised for not treating its young characters in a patronizing tone, but rather treating them as real humans grappling their emotional and physical transition in life
  • We need more such subtle depictions with our cultural point of view without making such a series a sloppy sex comedy. Such a series which is written and directed scientifically by a professional body like IPS is the need of the hour.


A coffee that showed bad and faulty sex education

The famous cricketers talking vulgar and demeaning words for females is lack of sex education. I am referring to the recent uproar of Coffee with Karan Show.

Remember what Vatsyayana said before 1600 years, “Sexual pleasures are to be followed with moderation and caution.” Those who are worshiped by youth as heroes and role models can never be such irresponsible and irrationals.

#Me Too

  • The #Me Too movement has generated the much-needed discussion about inappropriate sexual behavior and what constitutes consent to any sexual encounter
  • This will involve conversations about the building blocks of respect for both men and women
  • Consent will become the most part of sex education after this landmark and eye-opening social media event.



   Education in Human Sexuality Top


It is an educational program aimed at promoting the individual's fulfillment both in personal living and in his/her family and social relationship by integrating sexuality into the total personality.[8]

When to start sexuality education

  • Sexuality education starts right from birth in the form of giving correct training and answers to the child about the reproductive and sex life curiosity in the way they can accept and understand
  • Sexual maturity is different at different age


    • 0–3: Age of innocence
    • 3–6: Age of ignorance
    • 6–10: Age of curiosity
    • 10 to marriage: Age of desire and experimentation
    • After marriage: Happy married life, sexuality


      • Intimacy and relationships.


Who should give sexuality education?

  • Parents
  • Teachers
  • Family physicians
  • Sexuality counselors
  • Psychiatrists.


The person who is comfortable with his or her own sexuality should only give sexuality education to children. If you are not, first be and then educate.

(iii) Age-Appropriate Sexuality Education

Based on typical cognitive, emotional, behavioral, physical, and sexual development for a particular age group

- It is important to enhance a child's growth in all developmental areas, including laying the foundations for a child's sexual growth

- Adults have a responsibility to help children understand and accept their evolving sexuality.[11]

At this stage of my life and career, I'm getting a lot of questions as mentioned below, from friends and colleagues about touching “down there.” When a toddler touching too much to their genitals.

  • Chintu loves to pull on his penis all the time. Is this normal?”
  • “Twinkle wants to play with her baby brother's penis in the bath. What should I do?”
  • “Jimmy has started putting his finger in his anus. His anus! This can't be good”
  • “Pinky wants to pull on my nipples and then hers and then mine. Ummm… help?”
  • “Riya pulls on her labia every time she uses the potty. This has to be stopped, right?


The short answer to all of these fears is “Relax, your kids are completely normal!”

Why do young kids touch their genitals?

Young children love exploring the human body, whether it be their own or their mom's or siblings', etc.

Babies start out touching eyes and noses and move on to other parts as they discover them.

And you know what that means? Genitals are no different. Hence, if your toddler is feeling her vulva during a diaper change or stretching his penis in the bathtub, it is all about figuring out what those parts do.

Infants play with genitals when feel neglected, to derive pleasure, and to overcome insecurity.

Sexploration

  • They are curious about physical differences between boys and girls
  • Play with dolls
  • Doctor–patient game
  • Dress and undress their dolls or each other.


Don't worry, genital exploration among young kids is not sexual per SE. There are just millions of nerve endings that make genitals more sensitive than other body parts. During infancy, toddlerhood, and early childhood, genital arousal is recognized by the brain as comfort by releasing endorphins. It is not triggering the sexual response cycle. However, at some point during childhood, and certainly during puberty, genital arousal does trigger the sexual response cycle to prepare the body for orgasm. In short, if sexual abuse is not in the picture, you don't need to worry about your child being “too sexual too soon” because they are exploring their bodies.

What to do about it?

1.Don't panic!:

  • Parents might react with fear and disgust by gasping, yelling, or swiping a hand away which sends the message that the child is wrong or there is something wrong with them
  • Masturbation at any age is normal, causes no physical harm, poses no risk for disease, releases endorphins, and promotes a sense of self-connection
  • I realize and respect that there are religious beliefs that are staunchly against any masturbation of any kind. If you hold these beliefs, I challenge you to remain positive as you approach this topic with your child because sexual shaming is damaging and is not easily overcome
  • Bottom line, shaming a child around sexuality creates an association of pleasure with guilt and shame, which you can imagine creates all sorts of sexual problems throughout adulthood regardless of abstinence beliefs and practices.


2.Ignore it:

  • As long as you remain calm and caring, simply not acknowledging the touch during a diaper change, nakey time, or bath time is a great approach
  • It sends the message that this type of touching is no big deal which sets the tone of approachability for future conversations about bodies and sex.


3.Acknowledge curiosity:

  • Suppress your instinct to say urgently, “That's not nice. “No..no.. Shame…shame. don't touch, it's dirty”
  • “I know that feels good” and continue on with diapering
  • Acknowledge that anuses, vaginas, penises, nipples, etc., are super cool! They feel sensitive compared to other parts, they are different colors than other body parts, they are the source of life… be profound if you want! Talking about private parts can be tricky though. I recommend dramatic anatomy if you can't say the word “penis” without blushing.


4.Distract if needed

: Although it is completely normal to touch your own genitals, it is private behavior, which means you likely don't want your child exploring their genitals on a playdate, at the library, etc. Simply offer up a toy.

Early childhood (3–6 years)

  • Children may explore other children's and adults' bodies out of curiosity.-Lifting skirts and pulling down pants
  • By age 4, children may show significant attachment to the opposite-sex parent
  • For many children, genital touching increases, especially when they are tired or upset
  • Child masturbation may be considered nonsexual.


How can I stop my child from masturbating?

Some preschool boys seem to touch their penis constantly

  • Some toddlers and preschool girls seem to “hump” every stuffed animal and couch arm they pass
  • Preschoolchildren touch their genitals simply because it feels good and it is comforting
  • I know that it feels good to touch your penis/vagina. But, you should only do it in a private place


    • Which means that we touch them in bedrooms and bathrooms only and we don't touch other peoples' genitals
    • Using more words when explaining, transforms the interaction. For example, “Don't touch that!” versus “Please don't touch your vulva right now. We are eating and there are germs we don't want to get in our food.” or “Please don't touch your penis right now. We are at the library which is a public place and your penis is a private part
    • Teach care: Explain that genitals need extra care
    • Keep trying and don't worry if you make mistakes.


Where did I come from?

  • This is frequently the first question a small child ever asks about the fact of life
  • Child is very self-centered, and a simple answer will satisfy his/her curiosity
  • Question arises when you are expecting a baby or they have seen something on TV
  • Don't shrink from telling your child the truth
  • Give honest and open answer without fear or being embarrassed.


Age-appropriate answer in our culture

Don't make a story that you were brought by stork

  • 2–4 years: You were made in mom's tummy and you grew in there safely until it was time for you to be born
  • 4–6 years: You were made from a seed from daddy and egg from mummy. Both joined together in mummy's tummy to make you. So, you are a very special and lovely mixture of dad and mom
  • 6–10 years: Daddy's seed which is called sperm is made in his testes. Millions of sperms are being made there. They are mixed with a white liquid called semen. Mammy's egg grows inside her body in an egg maker called ovaries. When mummy and daddy made you, semen from daddy's penis carried sperm in mummy's womb. One of the millions of sperm joined up with mummy's egg to start a new baby – which is you
  • 10–14 years: Talk to them about what is penis, what is vagina, what is intercourse, what is uterus and ovum, what is pregnancy, how the sex of the child is determined. Try to give them the knowledge of anatomy and physiology of genitals.


Does the baby grow inside you?

  • Children are intrigued by the way a new baby develops in the womb
  • If you are expecting a baby, help your older children share the experience as soon as the question arises
  • Give them as much information as possible at every stage of the pregnancy
  • This is an opportunity for a simple anatomy lesson.


Age-appropriate answer

  • 3–6 years: Your baby has its own nest in mummy's tummy. It is very warm. Cosy and dark, the baby is safe and happy. It kicks, sucks its thumb, opens and closes its eyes, and it rests
  • 6–10 years: When the baby in the womb is a month old, its size is of your thumbnail. By the time, its 6 weeks old, its heart is beating and its brain is forming too. At 12 weeks, the baby will look like a tiny human of my forefinger length. It takes 9 months for the baby to grow. Food and oxygen come to it through a special tube attached to its tummy and connected to the mother's womb
  • 10–14 years: When sperm and ovum joins, the baby is of pinhead size
  • In 3 months, within the uterus, it looks like a real baby. Mother's blood reach the baby through the umbilical cord. The cord leads to a part of the uterus called the placenta. The baby gets its food and oxygen and gets rid of waste through placenta.


How does the baby get out?

Children are as fascinated as adults by the process of birth. They accept simple explanations. Other relevant questions can be:

  • Does it hurt to have a baby?
  • How long does it take to be born?
  • Will you still love me when the baby is born?
  • How does the baby know when to born?
  • What happens when a baby is born?
  • Will the baby have hair and teeth?
  • Why do you have to go to hospital?


Answers to the small kids can be: When your baby is too big for mummy's tummy, it has to be born.

What is vagina?

  1. What is vagina for?
  2. Why haven't I got a penis?
  3. What is penis for?
  4. Why does boys not have vagina?
  5. When will I be able to have a baby?
  6. What are breasts for?
  7. Do boys have breast?
  8. Does urine come out of the vagina?


What is penis?

  1. Why have I got a penis?
  2. Why haven't I got a vagina?
  3. Why don't girls have penis?
  4. Do all boys have same kind of penis?
  5. What are testicles for?
  6. Why hasn't daddy got breast?
  7. What is foreskin?


What is sex?

  • What is making love?
  • Is it nice?
  • Do you (mummy and daddy) have sex?
  • Why do people have sex
  • Will I have sex?
  • Do you make a baby every time you have sex?
  • Why do people kiss and cuddle?


Late childhood (6–10 years)

General traits and behavioral pattern

  • They vary in physical maturity. It is rapid in girls
  • They are social and form groups and gangs
  • They become more aware of gender differences and tend to choose same-sex friends and playmates
  • They may drop their close attachment to their opposite-sex parent and become more attached to their same-sex parent
  • During this time, children, especially girls, show increased awareness of social norms regarding sex, nudity, and privacy
  • They frequently use sexual slang or four-letter words when communicating with their peers.


Parental role

  • Parents have to be good role models and do what they expect their children to do
  • They need to review their own values regarding sexuality
  • Open and healthy discussion on human sexuality will bring parents and children close
  • Children will learn to trust and rely on their parents for future guidance.


Early adolescence (10–14 years)

  • This is the period of rapid physical growth triggered by pituitary and gonadal hormones
  • Development of primary and secondary sexual characteristics
  • Maturation of reproductive functioning.


    • In girls between 9 and 11 years
    • In boys between 12 and 13 years.


Behavioral pattern

  • Both boys and girls feel awkward and self-conscious
  • Girls are anxious about menstruation, pimples, breast size, and general appearance
  • Boys are anxious about their height, beard, pimples, voice break, penis size, and nocturnal emission
  • Spend lot of time looking at the mirror, dressing up, and making attractive to opposite sex
  • They deliberately adopt behavior which will irritate parents/teachers.


What does puberty mean?

  1. Why is Tony's voice going funny?
  2. What are hormones?
  3. When will I start to grow breast?
  4. Why am I growing hair between my legs?
  5. When did you start to shave?
  6. What does fertile mean?


What is period?

  1. Why are you (mummy) bleeding?
  2. Why don't boys have periods?
  3. Do periods last a long time?
  4. When will I start my periods?
  5. Will I ever stop having periods?
  6. Do periods hurt?
  7. Can I do physical education when I have period?


What is masturbation?

  1. Can I touch myself down there?
  2. What is mutual masturbation?
  3. Is it dirty to touch myself down there?
  4. Do you masturbate?
  5. Does it matter if Swati touches my penis?
  6. Does every one masturbate?


Late adolescence (14–19 years)

Behavioral pattern

  • Establishing their own identity
  • Fluctuating emotions. Can be angry, aggressive, and rebellious
  • Body image, appearance, size of genitals, erection, and ejaculation can make them depressed
  • Shy individuals avoid boy–girl relationships, others may involve in eve teasing and flirting
  • Sexual urges may result in masturbation, viewing pornographic material, anjd visiting commercial sex worker and also leads to physical relations with opposite sex.


Education to human sexuality

  • To build self-esteem
  • To develop skills in


    • Decision-making
    • Resisting negative peer pressure
    • Handling negative emotions
    • Protecting themselves from eve teasing, rape, sexual harassment
    • Building up and maintaining healthy and satisfying sexual relationships.


    • To learn about


      • Sexual and reproductive health (SRH)
      • Safe sex
      • The harmful side of sex
      • Different forms of sexual behavior.


WHO defines sex education and sexual health

  • Sex education is defined as a broad program that aims to build a strong foundation for lifelong sexual health by acquiring information and attitudes, beliefs and values about one's identity, relationships, and intimacy
  • Sexual health is considered to be a state of physical, emotional, mental, and social well-being in relation to sexuality and not merely the absence of disease or infirmity as defined by the WHO.


Adolescent sex education is the need of the hour

Adolescent Education Program launch

Adolescent Education Program launch in Gujarat

AEP of FPAI launched the adolescent education program in Gujarat State in association with Samvedana Foundation, FPAI Government of Gujarat and Ahmedabad Municipal Corporation. The education minister inaugurated it in 2013. This program was launched in 2002, and stopped in 2007. And, relaunched in 2013. After relaunch, until now, 700 school teachers are trained and more than 10,000 students are directly given adolescent education. Now, education minister has given green signal to relaunch the modified program. Dr. Vaishnav has also taken up research in this area to evaluate the long-term effects of AEP; this will cover all the district and major cities in Gujarat with FPAI, education department, health department, municipal corporations, nongovernmental organization, etc. AEP has different modules of adolescent education for standards 8 to 10 and 11 and 12.

Growing up is fun

This comprehensive sexuality education module covers the following components:

  1. Growing up is fun – Developing an understanding of self as an individual and factors that affect in self-development. Understanding the importance of adolescence in one's time and the changes associated with this time in the life of any individual
  2. Gender and Diversity – Difference between gender and sex; exploring gender roles and attributes; understanding perceptions of masculinity and femininity within the family and across the life cycle; society's changing norms and values; manifestations and consequences of gender bias, myths; and inequality. Recognizing and understanding the range of diversity in our lives (e.g., faith, culture, ethnicity, socioeconomic status, ability/disability, HIV status, and sexual orientation); recognizing discrimination, its damaging effects and being able to deal with it; developing a belief in equality
  3. SRH and HIV – Knowing your body; sexuality and the life cycle, anatomy; reproductive process; conception; legal and safe abortion; understanding STIs and HIV, including transmission and symptoms, prevention; living with HIV; social expectations
  4. Rights and Responsibilities – Knowledge of international human rights; rights-based approach to SRH; social, cultural, and ethical barriers to exercising SRH rights; understanding that sexuality and culture are diverse and dynamic; available services and resources and how to access them; different sexual identities; advocacy; protection; negotiation skills; and the right to freely express and explore one's sexuality in a safe, healthy, and pleasurable way.
  5. Abuse – Problems during adolescence – Addiction, pornography, sexual harassment; exploring various types of violence and how they manifest, particularly gender-based violence; nonconsensual sex and understanding what is unacceptable; support options available and seeking help; community norms (power and gender) and myths; prevention, including personal safety plans; self-defense techniques; understanding the dynamics of victims and abusers; handling peer pressure.
  6. Life skills – Skills required to deal with changes during adolescent; being positive about self; being assertive; communication skills; decision–making skills; managing stress and emotions
  7. Relationships – Different types of relationships (e.g., family, friends, sexual, romantic, etc.); that relationships are constantly changing; recognizing healthy and unhealthy relationships; choosing friends; trust and honesty in relationships; expression of love; girl–boy relationship; love and sex are not the same.
  8. Pleasure – Importance of pleasure in life; hobbies for pleasure; pleasure and responsibility; pleasure time with family and friends; and pleasure in relationships.


Adult sexuality issues

Psychiatrists also have to address adult sexuality issues:

  • Problems of adjustment in sexual and emotional behavior
  • Extramarital relations
  • Midlife crisis
  • Divorce
  • Low sex and no sex marriages
  • Unconsummated marriages
  • Sexual dysfunctions
  • STDs
  • Unwanted pregnancy.


Old-age sexual issues

  • Lack of sexual stimulation
  • Multiple physical illnesses
  • Death of spouse
  • Cultural myth about sex in the elderly
  • Sometimes, doctors are not comfortable with their patients in their 60s, 70s, and above asking for help, but this population seeking help in clinical setting is increasing.


The role of technology in the transformation of sexuality

Contraception technologies, and, to a lesser degree, assisted reproductive technologies, freed sexuality from the needs of reproduction and played an important role in the emergence of plastic sexuality. Plastic sexuality is characterized by an increasing sexual equality, which is not only limited between heterosexual men and women but also expands to nonheteronormative forms of sexuality.

With the introduction of new technology in transforming pornography in quantitative and qualitative terms, couples' sexual needs and dysfunctions have changed that requires to open new dimension in sexuality education.[33]

Changing clinical scenario: Internet and infidelity

It is without doubt that the advent of the Internet has had a profound impact on human sexuality. In the mid-1990s, it was reported that sexuality was a part of the role of playing games in multiuser domains where the participants' characters occasionally became sex partners in fictive milieus.

Over the last 20 years, a significant number of empirical studies have shown that people use the Internet for a variety of sexual activities, and some have shown that how this may influence sexual behavior offline.[34],[35],[36]

The size of the World Wide Web (The Internet)

  • The Indexed Web contains at least 5.17 billion pages (Sunday, January 27, 2019) The Dutch Indexed Web contains at least 286.37 million pages (Sunday, January 27, 2019)
  • India has the second-biggest population of Internet users in the world, after China
  • There were more than 2.5 billion web searches for porn
  • 30% of mobile device searches are for porn
  • 90% of boys and 60% of girls are exposed to the Internet porn by age 18.[37],[38]


How social media have changed the clinical presentations of patients

“But why did he like her Selfie on Instagram?”

I am sure you have heard something like this from your patients. Twitter, Facebook, Snapchat, Instagram, and so on have not only become a vital part of our day-to-day lives, but also a part of our friendships and intimate relationships.

Social media has the ability to make relationships both easier and more difficult. It can connect us when we are far away, or it can hinder our ability to focus on what truly matters in the relationship.

  1. Social media and jealousy: There is influx of what we get jealous of. Who she has on her Snapchat best friends, who is the girl that tweeted your boyfriend, who commented on her Instagram picture, and so on. This creates such a strain on relationships that they usually are more likely to fail. Without the use of social media, relationships would focus less on jealousy and more on caring for the other individual
  2. Tendency to increase unfaithfulness: With social media, boyfriend or girlfriend is lying about who they talk to or who they have feelings for
  3. There is also a lack of privacy when it comes to relationships now
  4. Bottom line, don't let a third party ruin your relationship.


Why we Love Why we cheat? Helen Fisher

  • Helen Fisher, an anthropologist at Kinsey Institute, refers to an experiment on “Why we love, why we cheat” (Fisher, 2006), which seeks to prove that romantic love is not an emotion; it is a drive. It is much more powerful than the sex drive
  • Many other studies corroborate the notion that love operates as a motivational system in our brains (Aron et al., 2005; Fisher et al., 2010). So, if romantic love is rewarding, what drives humans to cheat on people they fall in love with? Fisher (2006) explains that there are three areas in the brain attached to love: the sex drive, romantic love, and attachment. So, it is possible to feel deep attachment to a long-term partner, while at the same time feeling intense romantic love toward someone else, and sexual attraction toward another person. Therefore, human beings are capable of cheating the people they love
  • Personality factors related to cheating are impulsity and sensation seeking and empathetic perspective taking are related to competitive cheating, self-cheating, school cheating, and relationship cheating.[39]


Generation Z and low sex society

  • People now in their early 20s are two and a half times as likely to be abstinent as Gen Xers were at that age
  • Gen Xers and Baby Boomers may also be having less sex today than previous generations did at the same age
  • From the late 1990s to 2014, Twenge found, drawing on data from the General Social Survey, the average adult went from having sex 62 times a year to 54 times.


The age of sex recession

From 1991 to 2017, the Centres for Disease Control and Prevention's Youth Risk Behavior survey studies show that the percentage of high school students who would had intercourse dropped from 54% to 40%. Delay in teen sex may have been the first indication of a broader withdrawal from physical intimacy that extends well into adulthood.

Low sex rates across globe

  • One of the most respected sex studies in the world, Britain's National Survey of Sexual Attitudes and Lifestyles, reported in 2001 that people aged 16–44 were having sex more than 6 times a month on an average
  • By 2012, the rate had dropped to fewer than five times.
  • Over roughly the same period, Australians in relationships went from having sex about 1.8 times a week to 1.4 times
  • Finland's “Finsex” study found declines in intercourse frequency, along with rising rates of masturbation
  • In the Netherlands, the median age at which people first have intercourse rose from 17.1 in 2012 to 18.6 in 2017
  • My own clinical observations in Indian newly married and middle-aged couples suggest that low sex and no sex marriages are increasing in our country.


Japan's sex crisis

  • In 2005, a third of Japanese singles aging between 18 and 34 were virgins; by 2015, 43% in this age group were added to this
  • A related survey found that 47% of married people hadn't had sex in at least a month, i.e., low sex marriages.


Japan – The hub of porn production

  • Japan is among the world's top producers and consumers of porn, and the originator of whole new porn genres, such as anime, hentai, bukkake (don't ask)
  • It is also a global leader in the design of high-end sex dolls
  • Excessively masturbating to internet porn is addictive, causes structural changes in the brain, and is producing an epidemic of sexual dysfunctions and unrealistic expectations of genitals of self and partners.


The most worrying signs

  • The most searched word for porn on the Internet is Lesbian
  • The second most is “hentai,” ” anime,” other animated porn
  • This animated porn basically creates a hallucinatory world where cartoon characters with oversized breast and genitals are shown having intercourse in a gore and unrealistic manner.


What this shows about your mind

  • Men and women alike are searching and consuming fantasy and unrealistic porn
  • The whole idea of porn being an adult and healthy entertainment has been replaced by fantasy characters doing unimaginable things which is overtly enjoyed by people
  • This makes them lose contact with reality of sex, sexual behavior, and even sexuality.


Kinder Garden to Tinder Garden

  • Dating apps originated in the gay community; Grindr and Scruff, which helped single men link up by searching for other active users within a specific geographic radius, launched in 2009 and 2010, respectively
  • With the launch of Tinder in 2012, iPhone-owning people of all sexualities could start looking for love, or sex, or casual dating, and it quickly became the most popular dating app on the market.


How can Tinder change love and sex

  • Gamification of love and relationships
  • More people finding virtual solutions for real-life emotional needs
  • Reduced social skills as match making can be done by swiping instead of actually developing an emotional bond
  • Promiscuity in an ongoing relationship due to constant curiosity and excitement on availability online
  • Poor physical bonding as sex is converted to an act rather than recreation.


Sex toys

  • A very controversial territory
  • Forbidding partner, relationships, or emotionality for the sake of sex toys is again a perversion
  • Among unmarried individuals, safe and responsible use is advisable
  • In married couples, use of sex toys with openness, understanding, and curbing expectations can spice up a stagnant sex life.


In India, there is no licensed shop for sex toys, but what about online availability? It is freely available online and people are using it

Bollywood and sex toys

  • 2018 saw Bollywood break the barrier by the depiction of sex toys
  • Two films Lust Stories and Veere Di Wedding showed the use of sex toys among female lead like a vibrator.


The final verdict

In the end, any sex toy would promote:

  1. Social isolation
  2. Objectification of partner
  3. Deterioration of emotional bonding in relationships by overuse.


The Digisexuals – Age of sex boats

  • Many people will soon be identifying as “digisexuals” and taking their sexual identity from having sex with robots
  • Sex robots, or sexbots, are lifelike dolls made for the purpose of sex.
  • They are designed for a higher level of, what is essentially masturbation.


The advocates of sex bots

  • According to the Anxiety and Depression Association of America, social anxiety disorder affects 15 million adults, or 6.8% of the US population, making them less capable of having sexual or emotional relationships with other humans
  • For them, a sex bot is much better than a person as she won't betray you
  • The companies producing them are trying to promote sexbots as sex surrogates to help people deal with certain sexual problems.


The stark reality of artificial intelligence as sex surrogate

  • Human emotions can be imitated but not reproduced
  • Bots objectify women as mere means of getting pleasure rather than a bond between couple
  • Sex bots take away the whole idea of pleasing your partner and simply promotes narcissism of self-enjoyment, self-love, and mechanical manipulation of self-gratification through a robot
  • It is alarming that men consider women like a machine to get pleasure.


Is technology killing the human touch?

Only before 5 years, most of the couples used to look forward to the evenings – the times when husband and wife would catch up, watch some television, and mutually unwind from the day.

Today, the two spend more evenings staring at their phones than they do at each other. And though it frustrates both of them to no end, they have accepted it as the new normal.

“Between the time we spend on Facebook, Twitter, and words with friends, I feel like we sacrifice the time we used to use to bond – but it is not like either of us is willing to give up those things,” he said.

Changing trend in practice as sexologist, psychiatrist

  • The Indian society has lot of contradictions like in other fields
  • At one end, we need to give basic sex education to remove the myths and misconception about sex and sexuality
  • At the other end, we have to manage the fast technological advances in the field of sexuality
  • We need to have our own guidelines and programs for sexuality education from cradle to grave.


What is the way ahead?

  • We have to revisit Kamsutra and accept its principles in giving sex, love, and relationship education to our younger generation
  • We have to define screen time for all the generations, i.e., from Baby boomers to generation Z
  • We should make positive use of technological advances and give up double standard about sexuality.



   Conclusions Top


  • India pioneered the use of sexuality education through art and literature
  • Improper and unscientific sex education can cause disaster
  • Myths and misconceptions about sex and sexuality are highly prevalent in our society
  • Sex education was rejected, but sexuality education is the need of the hour
  • Toddlers and children explore their sexuality as a natural process of achieving sexual maturity
  • Age-appropriate sexuality education should start from parents. Sexuality education should be considered as a natural and healthy part of living
  • Sexuality includes physical, psychological, social, emotional, ethical, and spiritual dimensions
  • Sexual relationships should be based on mutual trust, honesty, commitment, and respect
  • Sexual behavior must be responsible and self-disciplined
  • Technology in its current use has transformed sexuality and is killing the human touch
  • Psychiatrists and sexologists have to update sexual medicine as per the newer technological trends and make them scientifically viable
  • Like Central Mental Health Authority & State Mental Health Authority, Central Sexual Health Authority & State Sexual Health Authority should be formed which should be headed and governed by a psychiatrist.
  • The subject of sexual medicine should be a separate subject/section in undergraduate-postgraduate medical education and superspecialization after psychiatric postgraduation.


Thanks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Mrugesh Vaishnav
Samvedana Happiness Hospital, 3rd Floor, Satya One Complex, Opp R 3 Mall, Helmet Circle, Memnagar, Ahmedabad -380 052, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_619_19

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