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CHARLES MOSER, MD, PhD Demystifying alternative sexual behaviors Many forms of sexual behavior are poorly understood by large sectors of society. Some physicians may be unaware of their patients’ sexual activities or may feel ill at ease discussing them. Provided with a basic knowledge of these activities and their associated slang terms, a physician can better communicate with the patient, allowing for accurate and thorough diagnosis, treatment, and ongoing care.

✒ KEY POINTS Bringing up sex Not every practitioner is comfortable dis- ■ There is a lack of awareness among physicians concerning alternative cussing sexual issues. For them, referral is an sexual behavior. appropriate option. Those practitioners who feel at ease having these discussions may ■ Physicians treat the medical aspects of sexual concerns choose to become a resource for their local and the sexual aspects of medical concerns, which include the general medical community. The general medical care medical care of practitioners of alternative sexual behavior. They have a of practitioners of unusual sex behavior is in- clear and comfortable understanding of sexual practices and terms. cluded in the new medical specialty of Sexual Medicine. ■ By providing a comfortable and sympathetic clinical environment, a Before meeting the physician, the patient physician encourages the patient to be open and honest. This can help will gauge his or her openness to discussing the physician provide the best diagnosis and treatment. sexual issues by the manner of the office staff ■ While alternative sexual practices may result in injury, it is important that and the intake forms. These will influence the the physician be able to distinguish these from those injuries received in patient’s decision to disclose his or her sexual an instance of abuse. practices. An important first step for the prac- titioner is to make your intake forms sympa- thetic to a spectrum of sexual activities. At the atients are often reluctant to discuss very least, these forms should allow patients or even acknowledge the specific sex- to indicate with whom they have sex (men, ual activities in which they engage. women, both, or neither) and their own pre- These activities often have medical ferred (male, female, trans- Pconsequences or provide important clues to sexual, , or other). Individuals do not other diagnoses. Discussion of these acts is necessarily define themselves by the sex of hampered further by a lack of vocabulary and their sexual partners, so it is best to avoid terms knowledge of what these sexual behaviors en- like homosexual, heterosexual, and bisexual. tail. Patients may perceive physicians as unin- Similarly, some people choose not to define Charles Moser, MD, PhD, FACP formed or judgmental of alternative sexual ac- their gender as dictated by their genitals or Professor and Chair tivities. Therefore, the tolerant and educated chromosomes. Common courtesy is to refer Department of Sexual Medicine physician’s initiation of a conversation con- to the patient in the manner of their choosing. Institute for Advanced Study cerning sexual matters creates an environ- During the review of systems, consider of ment where the patient feels safe to disclose adding just three words: “Any sexual con- San Francisco, CA information that may benefit his or her care. cerns?” This phrase is deliberately broad and © 2006 American Society Some guidelines on approaches to opening open-ended. To elicit a more specific re- for such conversations follow and basic descrip- sponse, the practitioner might add, “Do you Published by Elsevier Inc. tions of associated slang are also provided. have any medical questions about any of the

86 Sexuality, Reproduction & Menopause VOL. 4, NO. 2, OCTOBER 2006 Demystifying alternative sexual behavior sexual activities in which you engage?” Some is wrong for others. physicians make a statement such as, “Sex is Someone who is coming out (exploring uring often difficult to discuss even with a physician, the activity or beginning to accept the identi- the but I want you to know that I am open to your ty) is called a novice or newbie. Someone who D questions.” loves sex is called a . Sometimes a specific review of The individual who arrives at the emer- type of sex or activity is particularly desired, gency room with an object in his or her rec- eg, pain slut, fuck slut, rope slut, or anal slut. systems, tum is always asked how this occurred. The Sexual interactions are called , but direct answer rarely falters: “I slipped in the show- genital stimulation is not necessary. consider er.” The important question is rather, “Was the Individuals who wish to live or pass as adding just activity consensual?” Your ability to obtain the members of the other sex are TG (transgen- answer to that question is compromised even dered). Those that want SRS (sex reassign- three words: by asking the first naive question. If the mech- ment surgery) are TS (). MTFs anism is important, then explain why it is im- (male-to-female TS or TG) call themselves “Any sexual portant to obtain the needed information. trans or transwomen to distinguish themselves concerns?” It is important not to guess or assume too from natal women, also called GGs (genuine much. Patients can feel violated if they think girls) or fish. FTMs are female-to-male TSs their appearance or manner suggests their (the TG/TS distinction is not clear in this hidden sexual desires. Prefacing the question group) and may call themselves transmen. A with an explanation of the medical importance man who is erotically aroused by dressing as a of the information tends to increase their woman is a TV (transvestite), some of whom comfort level. Some considerations to keep in will become trans. queens are men mind when expanding one’s practice to incor- who dress as women, but more for theater porate Sexual Medicine are included in the than gender dysphoria. She-males (a type of box titled, “Some general rules for discussing TG MTF) are interested in male sex partners unusual sexual acts” on this page. and are expected to get an and use their penis during sex. Drag kings, “Unusual” sex acts who dress as men, also exist. Unusual is in quotations because these sexual interests are not really unusual. Although re- Anal search data on their incidence and prevalence Stimulation of the anus/ is called ass are not available, in practice there are rela- play. Butt plugs (objects used for anal inser- tively few patients (or physicians), who do not tions) are held in the rectum by the anal mus- engage in some sexual act that others would culature and can be used during sex or worn view as unusual. for longer periods of time. Anal beads are de- The range of human sexual behavior is so vices for anal insertion consisting of a series of broad, that this article can only touch upon some interests. It has been said that anything and everything can be eroticized. Why would Some general rules for discussing someone enjoy X or find Y erotic? The answer unusual sexual acts is the same reason you find whatever it is that you find erotic, erotic. How humans develop • Use understandable, common terms, but resist using slang or any sexual interest is a basic and unanswered repeating back the patient’s own terms. The patient may say question in psychiatry and . that her cunt hurts, but you would respond with questions about her pelvic or vaginal pain. This is an opportunity to ed- General terms ucate. Slang terms can have different meanings or pejorative Sexual minorities (everyone but the tradi- implications when used by someone outside the patient’s tionally heterosexual) may call themselves or community. In most situations, you will be misunderstood! their activities queer, perv, pervert, , • Do not assume that someone’s stated lim- kinky, or fetish. Those who are not sexual its his/her sexual activities. Some lesbians do have sex with minorities are called vanilla or straight; vanil- men. can have a male wife, a female wife, or both. la is also used to describe non-kink sexual • The definitions of slang terms are seriously debated within activities. To be squicked is to be personally sexual minority communities and vary from place to place, upset or disgusted by a given behavior, but subgroup to subgroup, and over time. does not imply a judgment that the behavior

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beads connected by a string or molded plastic Players who take the active role are called which are inserted into the rectum and dominant, dom, domme, domina, top, master, pushed in and pulled out the anus. The mix of mistress, and sadist. Players who take the pas- fecal matter and lubricant, a common result sive role are called submissive, sub, subbie, of ass play, is santorum. bottom, masochist, boy or girl, and slave. (In Patients may prepare for ass play by some SM interactions, it may not be immedi- douching (a series of enemas). Various sub- ately obvious which partner identifies as the stances (wine, other alcoholic spirits, coffee, top and which as the bottom, although the and illicit substances) can be added to the practitioner may feel strongly about the label.) enema solution, resulting in a very rapid and Switches can take either role. powerful drug effect. There is intense debate concerning the Analingus or rimming involves oral stim- distinctions among these terms; for example, ulation of the anus. is when one part- someone may say “I am a masochist; I will be ner sucks the ejaculate out of the anus or vagi- submissive if my partner enjoys it, but I am no na of the other partner. Snowballing is when one’s slave.” Simplistically, a masochist prima- the ejaculate (from either or coitus) is rily seeks physical sensations. The submissive passed from the mouth of one partner to the primarily enjoys the psychological aspects, but mouth of the other partner. Anal intercourse maintains options to control the intensity and followed by fellatio of the inserter (without duration of the scene. The slave wishes to washing) is called licking clean, ATM or A2M serve and/or give up as much control as pos- (ass to mouth), and is more common than you sible. Other sexual minorities use the term think. Inserting an entire hand into either the bottom to describe the one penetrated or the or rectum is called hand balling, fist- receiver of the intensity or play, without im- plying a BDSM relationship. Similarly, a top is the one who penetrates or applies the in- often have individuals consult with me, simply tensity. to discuss the safety of a particular behavior, Mixed play implies a BDSM interaction I between people who would not usually have the possible medical problems that could occur, sex together (a gay man with a , for example). BDSM partners engage in negotia- and how to avoid them. tion, the process of agreeing on what will con- stitute the specifics of their scene. They de- ing, or fist-fucking. Practitioners of these be- cide upon a safe word (a word or gesture that haviors often cut their fingernails exceeding- will stop the scene), and mutually define the ly short to prevent any inadvertent lacerations, (activities not to be included in the which can be a clue to the behavior found on scene). Violating someone’s limits is a serious physical exam. faux pas. A (artificial phallus) or strap-on can Toys are small items used during sex, in be used for vaginal or anal insertions; it is not contrast to large items called equipment uncommon for them to be referred as the (slings, tables, furniture). Toys in- owner’s cock. A strap-on is a dildo, worn in a clude whips, handcuffs, vibrators, cock rings harness that allows one to engage in coitus (a leather, metal, rubber or latex ring tightly with one’s partner regardless of anatomy or cinched at the base of the penis to prevent de- . tumescence, which actually works), rope, chains, violet wand (i.e., a device with a pur- BDSM plish glow using static electricity to stimulate BDSM is an acronym for Bondage and Disci- the body), and chastity belts (devices that pre- pline (B&D), vent someone from stimulating themselves, (D/S), and Sadism and Masochism (SM or achieving an erection, or engaging in coitus). S&M); it describes people (players) who eroti- There are other toys that limit some sen- cize bondage, a power differential, physical, sory input (blindfolds) or prevent individuals or psychological pain (sometimes called in- from speaking (gags) or closing their mouths. tensity). BDSM play is called a scene. Leather Hoods may have zippers or snaps, allowing the can be a fetish object and is also synonym for attachment of objects or blocking the mouth BDSM, especially Gay BDSM. or nose. Padded bits, blinders, and bridles are

88 Sexuality, Reproduction & Menopause VOL. 4, NO. 2, OCTOBER 2006 Demystifying alternative sexual behavior used during pony-play (i.e., role-playing being a pony). When to intervene People who want to incorporate BDSM into their lifestyle are 24/7 (24 hours a day, 7 Physicians are often concerned that a patient may be involved days a week); a more intense form of this is in an abusive relationship. In a BDSM relationship, where the called TPE (total power exchange). Those results of the behavior may appear similar to abuse, it is easy to who only engage in SM during sexual interac- confuse a loving consensual BDSM relationship with an abu- tions do EPE (erotic power exchange) or sive one. Just because patients inform you that they are in a “keep it in the bedroom”. Players usually ad- BDSM relationship does not mean that it is not an abusive re- here to the SSC (safe, sane and consensual) lationship as well. Just because patients deny participating in a creed, though some people frame it as RACK BDSM relationship does not mean they were abused. Some of (Risk Aware Consensual Kink). Consensual the physical differences are: non- is a conscious, negotiated sus- • BDSM rarely results in bruising or marks that are re- pension of one’s limits. A is a social ceived on the forearms (defensive marks). gathering where semi-public BDSM activities take place; the party space (venue) provides • Marks obtained during a BDSM scene usually have a pattern equipment and usually DM’s (dungeon mon- and are well-defined, indicating the submissive partner re- itors, individuals who assure compliance with mained still. In abuse, the marks are more random and the SSC and other party rules). Players usually soft-tissue bruising rarely focused in one area. bring their own toys. First date scenes often • The common areas for BDSM stimulation are the buttocks, take place at a party as additional safety. thighs, upper back, , or the genitals. The fleshy parts Some individuals especially enjoy play in- of the body can be stimulated intensely and pleasurably. volving a specific area of the body, e.g., tit tor- Marks involving the lower back, bony areas, eyes, and ears ture, CBT (cock-and-ball torture), and cunt are unusual. torture. Edge play (i.e., activities that tend to squick people) require more experience to en- gage in safely. These activities are not inher- pearance, but not to the extreme. ently abusive, criminal or self-destructive. women appear more androgynous. Stone They are typically loving, intimate and well- butch women tend to be masculine in ap- thought-out in terms of safety. pearance and may dislike any vaginal pene- BDSM play often results in skin redness, tration themselves. /butch couples bruising, or welts. Some recipients like these exist, but other pairings are not unusual. marks and wear them as a badge of honor; Men who like lesbians are called others dislike them. Some people engage in daddies, but sometimes this term is used in- , temporary placement of hypo- stead to mean butch lesbians. Heterosexual dermic needles in the skin. These can also women who like gay men are called fag hags leave distinctive marks. Scrotal or labial infla- or flies, but these terms do not usually tion (insuffulation with sterile saline) can be imply sexual interaction. Some lesbians will the cause of subcutaneous emphysema. interact erotically with gay men and/or in gay male environments. Gay subcultures Men interested in bears (big, barrel-chested Alternative relationships and usually bearded men) are called cubs, When your partner is aware that you have or though it is not uncommon to see two bears could have more than one partner, you have together. Men attracted to men with large an open relationship. Many open relationships penises are called size queens; men attracted have a designated S.O. (significant other) or to Asian men are called rice queens. / primary partner; other relationships are called boy or role-plays imply a BDSM relation- secondary or fuck buddies. Those who are ship; the same terms can be used by women. open to more than one primary relationship Women who are interested in sex with are called poly or polyamorous. Fluid-bonded other women are lesbians or dykes. High describes a relationship in which safer sex pre- femme or lipstick lesbians are women who ap- cautions are not used with that partner or pear stereotypically feminine (lipstick, make- partners, but are mandatory with other part- up, high heels, frilly clothes, etc.). Femme ners. Swingers are male-female couples who women also have a decidedly feminine ap- seek others primarily for sex. Although many

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be the outcome of any sex act, but in my ex- t is important not to guess or assume too much. perience these are no more likely than what is Patients can feel violated if they think their observed among vanillas. I see many more in- I juries related to the travel to and from the sex appearance or manner suggests their hidden party than injuries received at the sex party. Nonetheless, individuals left in bondage sexual desires. too long can develop a neuropathy from nerve compression. More important is to warn your swingers are polyamorous and vice versa, each patients who have neuropathy not to aggravate is often quite dismissive of the other’s lifestyle. the injury with bondage. Some patients are Cucks or cuckholds are men who want to see well aware of the possible consequences of or know that their wife or girlfriend is having their sexual activities and use a variety of sex with other men. strategies to minimize the risk; others are ei- Gay male often occurs at the ther unaware of the potential problems or the baths or a bathhouse. These often contain strategies for minimizing them. Few physi- glory holes – a hole cut in a partition through cians or other medically trained individuals which they can engage in . discuss the safety issues of a particular activi- Venues for swinging or group sex are called ty with patients. I often have individuals con- sex clubs. Female-only sex clubs also exist but sult with me, simply to discuss the safety of a are less common. particular behavior, the possible medical prob- lems that could occur, and how to avoid them. Medical complaints Safety is an important issue at lay conferences Despite the common belief that unusual sex- where these behaviors are discussed, but they ual behavior often leads to injury, this has not rarely involve health care personnel. In my ex- been my experience. A review of the Emer- perience, there are more kinky individuals gency Medicine literature does not reveal spe- who have first aid and CPR training than those cific problems resulting from unusual sexual in the general public. acts. STIs (sexually transmitted infections) can Most of the advice given is an extrapola- tion from other disorders. For example, there may be an entity called Flogger’s Shoulder, re- Resources sulting from repeatedly swinging a flogger (a device similar to a cat-of-nine tails). The eval- Gay and Lesbian uation and treatment of this entity is no dif- Medical Association ferent than other shoulder injuries. www.glma.org Differences in types and areas of bruising or marks can indicate whether the relationship Harry Benjamin International is abusive or not. (See box title, “When to in- Gender Dysphoria Associations tervene” on preceding page.) (organization for health care providers who work with TGs and TSs) Conclusion www.hbigda.org Sexual behavior is as diverse as one can imag- National Coalition ine. As stated, anything can be eroticized. for Sexual Freedom While a physician’s personal opinions of alter- (includes the Kink-Aware native sexual behavior are legitimate, the im- Professionals list) position of those beliefs is not; the medical www.ncsfreedom.org practitioner’s primary responsibility is the health and care of his or her patients. A range Charles Moser, MD, PhD, Support Site of descriptions of terms and practices affords FACP www.polychromatic.com the reader a level of comfort with potentially Professor and Chair difficult material. With this information as a Department of Sexual Medicine -Aware Professionals launching pad, a physician is equipped to Institute for Advanced Study www.bizone.org/bap of Human Sexuality begin the discussion of sex with the patient; in 45 Castro Street, #125 Moser, C. (1999). Health care without turn, the patient will likely feel relief at the op- San Francisco, CA 94114 . San Francisco: Greenery Press. portunity to be open, and to receive the best [email protected] treatment. ■

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