An internationally recognised authority on sexual medicine and impotence, Dr Sudhakar Krishnamurti has been working in the field since 1984, establishing India's first andrology centre in 1989, in Hyderabad. He speaks to Omair Ahmad about his patients and their most common sexual problems, the changing nature of Indian sexuality, and his new book, Sex is Not a Four Letter Word.

Impotence seems to be the most common complaint that you deal with. Can you tell us why?

India is the impotence capital of the world, not just in sheer numbers but also in prevalence rates. Impotence affects over 50 per cent of males above 40, and contributing causes are heart disease, hypertension, excessive smoking and drinking. In India there has been a steep rise in heart ailments, and this has also been reflected in the rise in levels of impotency. And it isn't an all-or-nothing scenario. You can have decreasing levels of rigidity, and even if a person isn't completely impotent they might not be able to perform. Now we have machines that can measure rigidity, and we have moved beyond early thinking on the subject.

You also have a lot of clients obsessed with the idea that their penis is too small. Is that an Indian thing?

At some level, most men have some issues about size. You see it in nature—if you're a small elephant you don't mess with the bigger elephant, and people believe the same about penis size. Most people also don't know what is a normal size—about four inches when rigid—and they tend to get information only through porn films, in which most actors are chosen for the length of their penises. It isn't a particularly Indian problem; I get e-mails from all over the world about it.

How often do you have to deal with partners with differing libidos?

This is the rule rather than the exception. It's only during the initial honeymoon period that libidos tend to match, but after babies, and when work starts taking more of a person's time, the couple become less involved with each other, and don't take the time to look good. It's rarely the "happily ever after" that is written in storybooks, except for couples that keep working at it.

Have sexual practices changed significantly since you began practising? How?

There is a whole new openness about things. People are more willing to talk about sex; it isn't a taboo subject. Before you couldn't talk about oral sex, now it isn't a big deal, and people are increasingly experimental. You have missionary position aunties trying out garters and whips to rekindle the spark in their sex lives. I think it's all for the good as long as these things are practised safely.

How important is love in sex?

Beyond a one-night-stand, you must have some connection to the other person if you are going to continue a sexual relationship; lust alone doesn't last long. You develop this by talking, holding hands, and learning to live with each other. And you don't have to have a six-pack or to have breasts jutting out to have good sex. I've known a number of plain Janes and plain Jacks who have a great sex life, and it has to do with how they relate to each other.

How does pre-marital sex affect relationships after marriage?

Any pre-marital sex moulds your future relationships by setting benchmarks. Traumatic relationships—involving rape or molestation—can often affect future relationships. This is especially true if such relationships are combined with great sex, because people will seek fulfilment in ways that are bad for them. In such cases you need to talk to an expert, rather than tell all to your partner. Today almost everybody has a past, and so the best policy is 'don't ask, don't tell' or to keep it brief.

What role does masturbation play, if any, in sexuality?

Autoeroticism is an important part of your sexuality, and for a number of people who wish to remain sexually self-sufficient this is very important, as fantasies are often better than the real thing. I know people who have been cleaned out in a divorce; for them this is a way to deal with things. Especially for men, many of whom wouldn't be able to concentrate on their day-to-day work if it wasn't for a quick trip to the loo.

Does sex addiction really exist?

Of course; among both men and women, although it is more common among men. These are people you feel sorry for, and I receive such cases quite regularly. It does not even have to be practised sex, and can be limited to dirty talk over the phone, or checking out porn on the Internet. I know many 'porn widows', whose husbands have become addicted to chatting to strangers on the Internet, with a morphed picture of Marilyn Monroe or some other sex symbol, while they have a completely asexual relationship with their wife. These people need therapy, and there are Sex Addicts Anonymous groups, as well as rehab centres. It can become a very serious problem, destroying marriages and the finances of a person.

Can you tell us about male menopause?

I usually see at least one case every day. It usually begins with a complaint of reduced vitality, listlessness, mood swings—and hidden within it is the sexual complaint, of reduced interest and capability. People take some time to accept that such a thing is happening to them because they are unused to thinking in this regard.

You mention that women seem to be better informed about both their own, and their partner's, sexual issues. Why is that?

A quarter of the cases that I see are brought in by women. This is often because men and women are educated at different levels, and women are much more assertive if they are better educated; and if there is a problem they are willing to bring their husbands to the clinic. Sometimes the husbands are busy, or unwilling to face the issue, and in the much more open atmosphere that we live in, wives are willing to schedule the appointments.

What is the state of sex education in India? Where do most people pick up their knowledge of sex?

The state of sex education is pathetic. The official books are too dry. Kids want to have multiple orgasms, but also safety. They want to know whether oral sex is all right. But none of the sexual education tools address these issues. The only ones that do are serials like The Bold & the Beautiful or Sex and the City on TV, and this is where children are learning their sexual mores—in which mothers-in-law run off with their sons-in-law, or the image is given that people are just born to copulate. Our politicians add their own hypocrisy. In Bangalore recently, there was a front-page story of a politician who opposed sex education, caught red-handed with his mistress. That's why I wrote my book, in a way to take the law into my own hands and help educate people on common issues.

What is the typical profile of your patients? Has that changed over the last decade?

In 1989—when I opened my clinic—it had a glass door, and men would slink about, and slip in when they saw nobody looking. By '94, it was largely single men coming in, but much more upfront about their problems. By 1999, I had families and even panchayats bringing patients. And now, I have families, and even wives booking the appointments for their husbands. I have villagers who can't speak English, and executives who fly in on their private jets, and even a lot of medical tourists. My oldest patient is an 86-year-old man, so I truly have people coming from all walks of life, of all ages! I also have patients coming to me for the micro-surgical technique I pioneered to deal with Peyronie's disease. This is a condition in which a lump or nodule develops in the penile shaft. I was awarded the Herbert Newman award—the highest honour given for original research in the field of impotence—and the technique is now named the 'Krishnamurti procedure'.