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One of the most emotionally charged words in the sexuality vocabulary is the word masturbation. Just seeing or hearing the word can arouse feelings of anxiety, shame, embarrassment, or disgust. For most people, the origin of these reactions, which can be extreme, goes back to what they were taught as children. Parental injunctions often warn of the variety of afflictions that can result from children touching their genitals—blindness, hair on the palms of the hands, retardation—and children are often shamed and even punished for touching themselves.

In 1922 suggested treatments for “the secret vice” included the following:

“Curative Treatment of Self Abuse: Bandaging the parts has been practiced with success. Tying the hands is also successful in some cases. Covering the organs with a cage has been practiced with entire success. A remedy which is almost always successful in small boys is circumcision. The operation should be performed by a surgeon without administering an anesthetic, as the pain attending the operation will have a salutary effect upon the mind, especially if it be connected with the idea of punishment. In females the application of pure carbolic acid to the clitoris is an excellent means of preventing the occurrence of the practice. Probably no single agent will accomplish more than electricity when skillfully applied.” (Jefferis, 1922)

Messages like these exert a powerful influence on thinking and beliefs even today. Consider that Joycelyn Elders, MD, former Surgeon General of the U.S., was fired by former President Clinton for suggesting that masturbation be included as a part of sex education in schools.

In 1997, Dr. Elders wrote:

“Masturbation: It’s Not a Four-Letter Word, but the President fired me for saying it. In this so-called ‘communications age,’ it remains a sexual taboo of monumental proportions to discuss the safe and universal sexual practice of self-pleasure. No doubt, future generations will be amused at our peculiar taboo, laughing in sociology classes at our backwardness, yet also puzzled by it given our high rates of disease and premature pregnancy. We will look foolish in the light of history. Over the months since I left Washington and settled into my home in Little Rock, I have pondered the rage, embarrassment and shock with which the word ‘masturbation’ is met in our culture. What other word, merely voiced, can provide justification to fire a surgeon general-- or anyone?” (Elders, 1997).

Sexuality Factoid
More than half of women ages 18 to 49 reported masturbating during the previous 90 days. Rates were highest among those 25-29 and progressively lesser in older age groups. 
Source: National Survey of Sexual Health and Behavior (NSSHB). Findings from the National Survey of Sexual Health and Behavior, Centre for Sexual Health Promotion, Indiana University. Journal of Sexual Medicine, Vol. 7, Supplement 5.


It has jokingly been stated that 99% of men masturbate and the other 1% lie. While this may be a bit exaggerated, the figures probably closely reflect the prevalence of the practice. For women the figure is somewhere around 66%, (possibly higher according to the 1993 Janus Report), and this number increases with education. Women with more education are more likely to believe that the practice is acceptable and more willing to explore masturbation as a normal component of their sexuality.

Other beliefs about masturbation influence self and relationship behaviors. For example, while some people might be accepting of masturbation prior to marriage, they may believe that once someone is married, there should no longer be the need to masturbate.

A man with this belief may begin wanting sexual contact with his wife more frequently than she desires. Both people may become frustrated. While research is clear that many married couples masturbate, there is less certainty about how many married couples are comfortable talking about it.

Another question, that sometimes inserts itself into therapy, concerns the acceptable ways to touch one’s body. Some women are willing to touch their genitals with an object and not with their hands. This seems to relieve them of the notion that they are doing an unacceptable behavior—touching oneself with an object may seem less intimate and more like a prescribed, permissible method.

For other women, the idea of touching their genitals with an object is offensive, and they are more amenable to touching with their hands. Other women are opposed to touching themselves in any way, but having their genitals touched by a partner is acceptable. Also, there are some women who will only allow their genitals to be touched by a penis (Bockting & Coleman, 2003; Cornog, 2003).

The differences in what women consider acceptable in this one area illustrate the broad range of beliefs and values that impact sexual behaviors: some are okay with their own hand, others prefer an object, others may insist on a partner’s hand, others will only allow touch with a penis.

Sexuality Factoid

Nearly 85% of men and 45% of women who were living with a sexual partner reported masturbating in the past year

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press (Also reported in the companion volume, Michael et al, Sex in America: A Definitive Survey, 1994).

As clinicians, it is important to understand the origins of the ingrained, sustained beliefs in individuals and in society and also to appreciate the power these hold for clients. Some clients may be open to new ways of viewing masturbation, while others have much difficulty and will cling tenaciously to old beliefs, and attempts to sway them will be met with strong resistance.

Bringing up the topic for discussion and then providing some resource materials on the subject may be a way of beginning to address some of the concerns related to masturbation. Often, having a trusted healthcare professional bring up the topic will give permission for clients to talk about it. Clinicians may discover that some clients have never before talked with anyone about masturbation.


Oral sex (cunnilingus on a woman, fellatio on a man) is a very common practice among heterosexual as well as same sex couples. Oral sex can be performed with one partner stimulating the other individually, or both partners can stimulate each other’s genitals simultaneously. This sexual position is commonly referred to as “69” because the body position of a couple having mutual oral sex resembles the numeral 69. Oral sex is very appealing to some and very unappealing, even repellent, to others.

For some, oral sex is a more intimate form of connection and sexual expression than is penile-vaginal intercourse; for others it can be more impersonal than a casual handshake. Those who hold with the American idea of sex, i.e., that intercourse is the only “real” form of sexual expression, will say that oral sex is not really sex at all. Former President Clinton lent credence to this belief when he denied having sex with Monica Lewinsky and it was later revealed that they had engaged in oral sex.

Sexuality Factoid

27% of men and 19% of women have had oral sex in the past year

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press (Also reported in the companion volume, Michael et al, Sex in America: A Definitive Survey, 1994).

Some people are uncomfortable performing fellatio because they have a sensation of gagging when they take the erect penis into their mouth. This real physiological event, known as the gag reflex, is triggered by pressure at the back of the tongue or in the throat. If a man, in his excited state, pushes his penis too far into his partner's mouth, the gag reflex may take over. One way to avoid this problem is for the person giving the oral sex to grasp the penis along the shaft to control how much of it enters the mouth.

Another common objection to fellatio is having the man ejaculate in his partner's mouth. A couple can agree in advance to have the man remove his penis from his partner's mouth before ejaculation. Others do not seem to mind. They either rinse the ejaculate from their mouth right away or they swallow it.

The ejaculate, on average about 4-5 cc (1 tsp), consists of fructose sugar, water, vitamin C, citric acid, enzymes, protein, phosphate and bicarbonate buffers, zinc, and sperm (200-500 million). Caloric content is 5-7 calories (Columbia University’s Health Q & A Internet Service, 2002).

Some people prefer not to receive oral sex but are willing to perform oral sex on their partners. Others want to receive and not give, for varying reasons. One of the most common reasons for not wanting to perform oral sex on a partner is a dislike of body odors and tastes. Exploration of this issue will sometimes elicit negative messages received in the past or negative experiences from the past.

Not everyone has or enjoys oral sex. Many people who try it enjoy oral sex, but others have reservations about it. These reservations tend to fall into three arenas: first, that oral sex is unhygienic; second, that there is a taboo against it; third, that it is not a true expression of femininity or masculinity. Oral sex, just like any other sexual behavior, is a matter of personal preference.

As recently as 1960 every state in the U.S. had an anti-sodomy law. The term sodomy generally refers to the practices of oral and anal sex. Interestingly, these practices were still illegal in some states (between same sex couples in 4 states and for all people in 9 other states) until 2003. In November 2003, the U.S. Supreme Court struck down the Texas sodomy law, a decision that will apparently invalidate most laws governing private sexual conduct between consenting adults. The decision also establishes a benchmark in privacy that had not existed prior to this time (Lawrence & Garner vs. Texas, 2003).

One fact about oral sex that is becoming apparent is that the practice has reached near-epidemic proportions in the adolescent community. The topic has inspired a controversial book entitled “Rainbow Party” which describes a party where oral sex is given to guys by multiple girls who are wearing different colors of lipstick. The object is for each girl to leave her color on the guy, hence the term “rainbow.”

The book’s message is that oral sex “really is sex,” and that teens can contract sexually transmitted infections (STI) from what they often consider to be a safe, benign behavior. Herpes, gonorrhea, and syphilis are examples of STIs that can be transmitted during oral sex with an infected partner (Ruditis, 2005).


Anal sexuality is an area often not talked about in our society. Anal sex refers to a variety of sexual acts involving the anus. These acts encompass penile penetration of the rectum, fingering the anus and rectum, anal fisting, rimming (oral sex for the anus), anal 69 (rimming for two), anal penetration with dildos and other objects, and augmentation of conventional sexual intercourse with butt plugs, anal beads, or other assorted objects.

Although practiced by heterosexual as well as homosexual individuals, anal sex is associated primarily with male homosexual behavior. The actual numbers of heterosexual people who engage or have engaged in the practice are unknown, but recent survey research seems to indicate that today there is more acceptability in reporting anal sex (Silverberg, 2006a). Anal sex and oral sex are referred to in the legal system as sodomy.

Sexuality Factoid

10% of men and 9% of women have had anal sex in the past year.

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press (Also reported in the companion volume, Michael et al, Sex in America: A Definitive Survey, 1994).

The reasons people have for practicing anal sex include: 1) pleasurable sensations from stimulation of nerve endings in the anus and between the rectal wall and the vagina; 2) there is a lower risk of unwanted pregnancy, although semen can leak from the anus across the perineum and enter the vagina; 3) anal sex is sometimes seen as preserving female virginity; 4) avoiding vaginal sex during menses; 5) the anus is considered to be “tighter” than the vagina and provides more tactile stimulation for the penis; 6) possible power differentials in relationships (Friedman, et. al, 2001).

Unprotected anal sex carries a high risk for sexually transmitted infections, and the use of latex or polyurethane condoms is strongly recommended as a way to lessen this risk. The use of a water-based lubricant is necessary, because the anal canal does not produce natural lubricant.

Silicone or petroleum based products should be avoided due to their tendency to cause irritation. Objects inserted into the anus may be sucked into the rectum. It is important to make sure that these objects have a flange to prevent this from happening (Silverberg, 2006b).

Note: The term “barebacking” describes the practice of gay men who have unprotected anal intercourse. This practice appears to be on the increase (Grossman, 2006).