Mr. A, 30 years old, small and shy, was born in a north-western Portuguese village near an internationally renowned Casino-beach-resort and lived there until the age of 18. He is the only son of a working-class couple, both in employment. Mr. A attended a college in Lisbon, which was a three hour drive from his parent's home. None of his peers from the village went to college. Mr. A was a driven individual and achieved his goal of pursuing further education.
At home his parents "always quarreled" about his father's infidelities but they stayed together to finance his studies. When they divorced after his graduation, he felt sad and developed gradually a depressed mood. His symptoms lasted for one year before he came for a consultation to the first author Fatima Gysin.
Additionally, he broke two toes kick-boxing, causing him to stop practicing his favorite sport. During this period he also started to date a girl who had a poor education and no fixed job. She envied him for his higher income and she was unfaithful to him. For these reasons and with a noticeable low performance in his engineering job, he was encouraged by his friends and pressured by his superiors at work to see a psychiatrist, whom he selected from a health insurance list.
During his first sessions in September 2011 he showed low mood, he was resentful for not being promoted at work, had lack of motivation, social isolation and criticized his bizarre feelings when he was irrationally afraid of being attacked in a familiar and secure night club. He had outbursts with friends, anhedonia, a lesser sexual drive, fear of losing his hair and of gaining weight against the evidence and he was excessively dysphoric of his small height of 1.59m. He wanted help but without medication.
For Mr. A, paid sex was not a problematic issue, nor a direct motive for his consultation. When questioned about his sex-life he was comfortable talking about his experiences, and showed a consumer pride in prostitution. At the age of 22, after breaking up a four-year relationship, out of curiosity and revenge, he purchased for the first time sexual services in a sex-worker's apartment. This use of prostitution escalated when back in his native village, where a Saturday night ritual with a group of friends started. After dinner they would bring home their official girlfriends and then, only the four or five boys, visit a brothel, have a drink, have fun and sometimes have paid sex with prostitutes, using protection. This kind of prostitution use became a peer group standard and, for Mr. A, an easy victory over his shyness.
Mr. A became hooked and hyper-seduced  by a specific prostitute, and he fantasized about living with her in an exotic land. However, to have or to maintain a full erection during paid sex he needed to think and imagine that he was making love to a romantic partner. The patient referred to exclusive heterosexual orientation and sexual desire, however revealed that he would suffer a loss of erection when either nervous or stressed.