Study of Psychosocial Profile of Male Patients with Sexual Dysfunctions

INTRODUCTION

Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure.(DSM-5,2013)

India is often known as the land of Kamasutra, but as far as sexuality research is concerned, there is a paucity of relevant data from India. (Kalra et al., 2015)

Sexual dysfunction can arise as a result of biological problems, relationship problems, conflicts, lack of proper sexual knowledge, or a combination of any or all of these. They can be frequently associated with other psychiatric and or medical disorders, personality types, and disorders. (Kaplan and Sadock's,2017) Sexual problems despite being prevalent have been accorded low priority. Physicians either show no interest or tend to ignore the patient's psychosexual complaints.(Avasthi and Nehra, 2000)

Unfortunately, the aspect of human development and sexual functioning has received very little attention from the researcher in India. The area of psychosexual research in India suffers from general inhibition on the part of the sufferers to seek medical help and indifference on the part of researchers to study these problems. (Kulhara and Avasthi,1995)

Human sexuality is a basic force that can affect every aspect of life. Sexual feelings, desires, and activities extend from childhood through adolescence, adulthood, and old age. Sexual function can be closely coupled with the quality of life. When the sexual function is disrupted by medical therapy, illness, other stress, or anxiety, quality of life worsens. (Arrington et al., 2004)

Psychosexual development is not limited to childhood and adolescence but extends through adult life. Young children show behaviors that indicate awareness of sexual organs. By the age of 3 years, they become aware of their gender and aspects of gender roles. (Daines, 2015)

School-age children are usually able to understand basic information about sexuality and sexual development and may look to various sources for information, such as friends and the Internet. (Daines, 2015)

Early teenage development can be characterized by concerns about normality, appearance, and attractiveness. As girls' physical development is usually more advanced than that of boys of the same age, they may experience sexual feelings earlier and be attracted to older, more physically mature boys. (Daines, 2015)

In late adolescence, there is an acceptance of sexual identity and intimate relationships are based more on giving and sharing, rather than the earlier exploration and romanticism. (Daines, 2015)

The main developmental tasks for young adults are completing the development of adequate sexual confidence and functioning and establishing the potential for desired couple relationships.

Impairment or delay in psychosexual development can be caused by several factors, including:

- physical developmental disorders
- some chronic illnesses and treatments
- lack of appropriate educational opportunities
- absent or poor role models

Sex is a basic human function and a fundamental part of life. Sex involves physical, psychological, and emotional factors and affects general well being and overall quality of life.(Kaiser, 1991;Masters & Johnson, 1966)

When it is good, sex can impart pleasure, contentment, and emotional closeness. Studies have shown a relationship between sexual dysfunction and worse quality of life in patients with a variety of disorders. (Watts, 1982)

Even short-term disruptions to sexual functioning can create frustration and distress, and chronic disruption can lead to anxiety and depression, damage relationships with sexual partners, and disrupt functioning in other aspects of life.

Satisfaction with sexual life has been shown to be an important predictor of overall satisfaction with life, so it is not surprising that quality of life (QoL) is decreased in men with sexual dysfunction. (Fugl-Meyer et al., 1997)

In men with ED, overall QoL is diminished. The presence of ED can exacerbate the impaired QoL in men with comorbid medical illness.(Rosen, 1998) Improvements in the QoL domains of mental and social health and self-esteem have been reported in men receiving treatment for ED. (Althof, 2002)

PE is associated with increased anxiety and depression, frustration, anger, and loss of sexual confidence. (Dunn et al.,1999)

Erectile dysfunction (ED) is a common condition among men that increases in prevalence with age. The Massachusetts Male Aging Study carried out between 1987 and 1989 found that the annual incidence rate for men 40-49 years old was 12.4 cases per 1,000 person-years, whereas the rate for men aged 60-69 years increased to 46.4 cases per 1,000 person-years. That study also found ED to be associated with common diseases of aging, such as hypertension, heart disease, and diabetes (Johannes CB et al.,2000), and mood disorders, anger, and lower educational levels (Johannes CB et al,2000; Feldman HA,1994; Caspari D et al,1999). Depression is also significantly associated with ED, after controlling for age and physical illness. (Shabsigh R et al.,1998; Araujo AB et al., 1998)

Erectile dysfunction has a profound effect on a man's sense of self and quality of life. (Bokhour BG et al.,2001; Latini DM et al.,2002)

Men also report that ED affects not only the emotional intimacy in their primary relationship but also their daily interactions with women or other potential partners. (Bokhour BG et al.,2001)Besides its impact on the sexual experience, for many men, ED creates psychological distress that affects their relationships with their family and friends. (NIH Consensus Conference,1993)

While evaluating sexual functioning of an individual it is important to incorporate family, societal and religious beliefs, health status, personal experience, ethnicity and sociodemographic conditions, and psychological status of the person/couple. In addition, sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction.( Avasthi et al.,2006)

Culture and belief also play an important role in addressing men's sexual health along with the individual and his religion, community, and nation. In our culture, sexual dysfunction is a taboo and culturally restricted topic. Therefore, instead of seeking appropriate treatment, men seek alternative methods of self-medication and rely on traditional medicine.(Christopher et al.,2011)

Although some efforts have been made to understand the causal direction between psychological impairment and ED, further research is required to understand their relationship.

This study will be an attempt to contribute to India's sexuality research. Therefore this study will be justified and conducted.

AIMS AND OBJECTIVES

1. To study the psychosocial profile of male patients presenting with sexual dysfunction.
2. To study the relation of male dysfunction with life events.
3. To study the psychiatric co morbidity in male patients presenting with sexual dysfunction.

REVIEW OF LITERATURE

Human sexuality is inherently related to psychological, social and community health problems in India. These health problems have a significant impact on existing health infrastructure and budget in India . (Prakash and Rao, 2010)

Sexual dysfunction is difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including physical pleasure, desire, preference, arousal or orgasm. According to the DSM-5, sexual dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum duration of 6 months on almost all or all (approximately 75%-100%) occasions of sexual activity in identified situational contexts or, if generalized, (excluding substance or medication-induced sexual dysfunction). Sexual dysfunctions can have a profound impact on an individual's perceived quality of sexual life (Nolen-Hoeksema, 2014)

A thorough sexual history and assessment of general health and other sexual problems (if any) are very important. Assessing (performance) anxiety, guilt, stress, and worry are integral to the optimal management of sexual dysfunction. Many of the sexual dysfunctions that are defined are based on the human sexual response cycle, proposed by William H. Masters and Virginia E. Johnson, and then modified by Helen Singer Kaplan (Kaplan, 1974)

It is essential to understand how these sexual attitudes, beliefs, myths, misconceptions, and values act and influence these problems. Our cultural perspective also plays a role in understanding these disorders . (Prakash, 2007)

Sexual dysfunctions are highly prevalent, affecting about 43% of women and 31% of men. Hypoactive sexual desire disorder has been reported in approximately 33.4 % of women and 15. 8% of men in population-based studies, and is associated with a wide variety of medical and psychological causes. (Laumann et al., 1994)

The prevalence of SD is 40% among people of 40 or more years of age and 70% among those of 70 years or above. Indeed, 52% of men, aged 40 to 70 years, experience some degree of Erectile Dysfunction (ED) and, in about two-thirds of that group, it is of moderate-to-complete severity.(Stevenson, 2004)

Numerous epidemiological studies show that these disorders tend to increase in direct proportion with the age of the population, and with the age-related associated risk factors (cardiovascular, metabolic, psychiatric, genitourinary, lifestyle).

In both men and women, not to be able to initiate, take part in or experience pleasure during sexual intercourse, can cause unhappiness, frustration, and the sense of sexual inadequacy in intimate relationships. This can undermine confidence in themselves and cause a difficulty in relating to others, thus impacting on the quality of life of the patient, as well as his or her partner and family (Diaz and Close, 2010)

Only a small part of the SD is caused exclusively by psychological or organic disorders: most clinical situations are the result of a “mix”, a combination of psychological, biological, interpersonal and cultural factors.(Chung and Brock, 2012)

History of Sexuality in India

India is a vast country depicting wide social, cultural and sexual variations. Indian concept of sexuality has evolved over time and has been immensely influenced by various rulers and religions. India played a significant role in the history of sex, from writing the first literature that treated sexual intercourse as a science, to in modern times being the origin of the philosophical focus of new-age groups' attitudes on sex.

Term sexuality appeared after 1800 AD in the field of botanics and was first adopted in the title of a German monography by August Henschel “Von der Sexualität dermPflanzen (On the sexuality of plants)” in 1820(Schultheiss 2010).Term sexuality has variable meaning. Most of them simply relate it to the act of sex and sexual practices, but some mean sexual orientation and some could mean desire and eroticism. Thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships represent sexuality.(Chakrabortyand Thakurata, 2013)

Kama Sutra was the first text on eroticism written by Vatsyayana (300 to 400 AD).He described Kama as enjoyment of appropriate objects by five senses-hearing, feeling, seeing, tasting and smelling-assisted by mind together with the soul. The Kama Sutra describes in detail the act of kissing and embracing, lovebites, nail marks.(Upadhayaya, 1984)

Vatsayan’s Kamasutra classifies men and women into three categories according to size of their sexual organs, Lingam (Penis) and Yoni (Vagina). The union between corresponding pairs was considered as equal and affording mutual sexual satisfaction. The unequal union between man and woman is known as High union i.e. between bull and deer; Horse and Mare. Highest discrepancy is found in the union of horse and deer. The union between Mare and Hare and Elephant and Bull are known as low unions and lowest union is between Elephant and Hare.

During 10th century to 12th century, some of India's most famous ancient works of art were produced, e.g. Khajuraho complex in the Indian state of Madhya Pradesh. The medieval Hindu and Jain temples in Khajuraho are famous for their erotic sculptures. During these periods, boys lived in Ashramas following Brahmacharya until they completed their education. After their education, they could learn about the world and prepare themselves to become householders through watching these sculptures and the worldly desires they depicted.

In Ratirahasya' Kokkoka (A.D. 1000 TO A.D. 1200) described, a fourfold classification of women, erogenous zones and days when women are more easily aroused. Padmashri,a Buddhist monk, wrote ‘Nagara-Sarvasvam’ and described ‘sanket’,means gestures having important role in expressing love.

Jyotirisa wrote “Panchsayaka” which mention ingredients helpul for enhancing sexual pleasure and medicine for lifiting of sagging breasts.

Kalyanamalla(1600 AD) wrote “Ananga Ranga” and gave recommendation for enhancing marriage and suggested various ways for seducing new partner. Yashodhara(1000-1300 AD) wrote “Jayamangala” on the Kama Sutra which contains interpretations of terms used by Vatsyayana.In ancient India, kama was stated as a science (shastra) and was studied in a systematically and scientifically. According to the authors of the erotic texts, kama, was an art needed instructions to be practised properly.

Vajikarana, described by Charaka in “CharakSamhita”,is one of the eight major specialities of Ayurveda. It is a process or a drug which enhances sexual function several times. It is achieved by Ahaara (diet), Aushadha (drugs), Vihar (Environment and activities). It involves pharmacological and non-pharmacological ways like behavioral patterns and life styles. Olfactory inputs which stimulates or depress sexual desire and L-dopa containing M.Pruriens to enhance sexual arousal have also been described. (Brahmbhatt, 2014)

Dr. A P Pillay, pioneering sexologist from Bombay, put effort to establish sexology as a branch of medical science and struggle to make the word 'sex' respectable. His contribution to sexology is remarkable because it involved dealing with a lot of prejudice and traditional taboos. He authored book "Disorders of Sex and Reproduction" which was published by H K Lewis and Company Limited, London. He started the journal 'Marriage Hygiene', in 1934 and 'The Journal of Family Welfare' in 1954, with the aim of reaching and educating more people about sexology. For, the greater part of his life, he studied, the problems related to sex and the ways to bring relief to patients in this special field of medicine practice.

In 1979, the first National Conference of sexology was organized by Dr. C S Agrawal of Vatsyayan Institute of Sexology. After three workshops, the Indian Academy of Sexology was constituted. The Indian Association of Sex Education, Counselling and Therapy (IASECT) was founded in 1979 under the leadership of Dr Prakash Kothari. In 1980, the first National Conference of IASECT was organized. In 1981, the first department of sexual medicine was established at Nair Hospital, Bombay. (Brahmbhatt, 2014)

WESTERN CONTRIBUTION

Plato gave a unique idea that there is tendency to get reunited between male and female after being separated into two halves following rebel against Zeus. According to him, Man was created as a hermaphrodite, a male-female unit, with four arms, four legs as well as two faces. Zeus punished Man by cutting in half.

Origin of sexual medicine started with the beginning of an anti -masturbation campaign. Around 1712 an anonymous author, most likely the quack doctor and medical pornographer John Marten, published the pamphlet “Onania; or, the Heinous Sin of Self Pollution, and all its Frightful Consequences, in both SEXES Considered, with Spiritual and Physical Advice to those who have already injured themselves by this abominable practice.” that experienced several re-editions and translations and resulted in a first public awareness for a new medical entity, i.e. masturbation which also included involuntary seminal loss often referred to as spermatorrhoea. (Schultheiss 2010)

In 1758 the Swiss physician Simon Auguste David Tissot (1728-1797) published a book entitled “L'Onanisme, Dissertation sur les Maladies produiites par la Masturbation” (“Onanism, Treatise on the Diseases produced by Masturbation”). Tissot's work helped reshape medicine's attitude towards sexuality and provided an additional scientific basis upon which the process of pathologization of sexual anatomy and sexual functions could proceed. (Schultheiss 2010)

Paolo Mantegazza (1831-1910), an Italian professor of pathology and antthropology, was probably the founder of the modern sexual medicine. He developed experimental work and had formulated new sexual theories, founding a new science, which Mantegazza called “science of embrace”; curiously he referred to love (amore) when he was talking of sexual relation. He never used the term sexual. Mantegazza wrote about female sexuality, sexuality in children, masturbation, erectile dysfuncttion, vaginism, and male and female infertility. He had tried gonad transplantations in frogs and he had measured the blood flow and temperature increase during penile erection. (Schultheiss 2010)

Conrad Eckhard (1822-1905), a German physiologist from Giessen, conducted basic anatomical and physiological research on the erection process in animals and showed that it was possible to produce an erection through electrical stimulation of the nervous structures of the brain and spinal cord. He described the “nervi erigentes” and claimed that erection did not depend only on venous congestion, the general belief at his time. (Schultheiss 2010)

Richard Freiherr von Krafft-Ebing (1840-1902), an Austrian-German psychiatrist, wrote “Psychopathia Sexualis” in 1886.It was one of the first monographies to study sexual topics as clitoral orgasm and female sexual pleasure, consideration of the mental states of sexual offenders, and homosexuality. In contrast to the popular and scientific belief at that time, Krafft-Ebing was one of the first authors to point out that homosexuals did not suffer from mental illness or perversion. (Schultheiss 2010)

Marquis De Sade (A.D. 1740 TO A.D.1814) wrote a novel 'The 120 days of Sodom'. Kraft-Ebbing used his name to describe a particular sexual impulse seven decade after his death. 'Sadism' is a term used to describe an act of sexual arousal produced by inflicting pain and degradation on a human 'Sex Object'.

Leopold von Sacher-Masoch wrote his most famous autobiographical novel 'Venus in Furs' which was published in 1886. According to his second wife, he had a fetish for furs and his love of punishment had root in childhood. His adult sex life consisted of a series of liaisons with women who were willing to enact private dramas by keeping him in bondage and physically abusing him. Whipping was crucial to his sexual arousal. Kraft-Ebbing, the Viennese sexologist, coined the term 'masochism', after reading Sacher-Masoch's work. Masochism can be defined as the desire to suffer pain and be subjected to force.

Freud postulated that disturbances in maturation through the various phases of childhood sexuality were the root cause of sexual problems. His work showed that children too were sexual being and regarded sexual dyfunctions as relatively resistent to therapy. If available, treatment usually consisted of lengthy psychoanalysis or insight-oriented psychotherapy. According to Freud, all pleasure seeking activity was in a wide sense erotic. He called this sexual energy the 'libido' and argued that if it was prevented, it must find some alternative means of expression. The alternative channel could be a kind of creative activity (sublimation). But, sexual energy with no other outlet would express itself in disturbance of the mind, body or both.

In 1953, Aserinsky and Kleidman first described rapid eye movement sleep and noted that nocturnal erections corresponded to REM sleep levels. Karacan (1966) subsequently confirmed the report of a high nocturnal penile tumescence correlation. Later Karacan (1969) introduced a simple, and at the time inexpensive, method for measuring penile erection during sleep. In 1970 Karacan described the clinical value of NPT recording as a method to diagnose organic erectile dysfunction. For Karacan, if penile circumference change was not adequate for penetration the individual was diagnosed organically dysfunctional. In subsequent studies (Karacan, Hursch and Williams, 1972) the correlation between sleep and nocturnal erections in an elderly population was examined. The authors concluded, with advancing age, nocturnal erections become less of a function of REM sleep.

Sandor Ferenczi, an early student of Freud, believed for a man who was impotent the substitute for copulation is a fantasy of returning into the mother's womb (Ferenczi, 1956). This fantasy is regressive and replaces the sex organ with the entire person. The underlying unconscious desire is a return, via the penis, to the womb. When this fantasy fails, impotence occurs as a symptom of continued regression to a more infantile state (Freud, 1957).

Havelock Ellis published seven volumes of his "Studies in the Psychology of Sex" between 1896-1928 and described the physical aspects of sexual function, discussed significance of touch, smell, sight and hearing in sexual courtship and mating. He wrote about sadism and masochism as well as fetishism and exhibitionalism. He worked for early sex education for children, for birth control and for the repeal of criminal laws against homosexual acts between consenting adults. "Autoeroticism" and "Narcissism' were terms coined by him. In 1890, he published "The Criminal" and "The New Spirit", the first of his efforts to introduce criminology and sexology as sciences.

Magnus Hirschfeld was a German psychiatris and studied homosexuality. He founded the first scientific journal on sexual pathology in 1899. He was the first person to make a proper distinction between homosexuality and transvestism. He established Institute of Sexology in 1919. It was a place for public information and education, treatment of patients and scientific research located in the centre of Berlin. (Schultheiss 2010)

Ernst Gräfenberg (1881-1957) was another German-born physician who imigrated to the USA during World War II. He is known for developing the intrauterine device (IUD), and for his studies on the role of the woman’s urethra in orgasm, describing the controversial female ejaculation and an erogenous zone where the urethra is nearest to the vaginal wall, which was later named the Grafenberg spot or G-spot by John D. Perry and Beverly Whipple in his honour. (Schultheiss 2010)

Alfred Kinsey published “Sexual Behaviour in Human Male” and “Sexual Behaviour in Human Female” and reported that 96% of men masturbate, as did 85% of all women. Only 4% of American males were exclusively homosexual but 37% had at least one homosexual experience to the point of orgasm. Among women, 28% had some lesbian experience by age 45.

In 1956, Semans published a classical article on the treatment of premature ejaculation. He was the first to describe a direct, behavioral treatment for premature ejaculation, the stop-start technique.

Masters and Johnson published his book in 1966.He not only confirmed some of the controversial findings of the Kinsey reports, it exploded three more myths. It proved that a man's sexual performance is in no way related to the size of his penis. It proved that there is no such thing as a vaginal orgasm and also that, women are capable of multiple orgasms. It also described a four-phased cycle relating to male and female sexual responses. In 1970, 'Human Sexual Inadequacy' by Masters and Johnson described a very different approach based partly on studies of sexual response. It is unique combination of behavioural, psychotherapeutic and educational elements that provide the approach to the sexual problems of couples. The focus of therapy was on the couple and the relationship between the partners. It was called 'Sex Therapy'. Ivan Pavlov's “Conditioned Reflexes” findings have been applied in various kinds of sex therapy, notably by Masters and Johnson.(Schultheiss 2010)

In 1958, Wolpe suggested the method of systemic desensitization as therapeutic approach. There was an isolated report of a novel approach described by Semans called the “stop-start-technique” for the treatment of premature ejaculation.

Overview of Research

Bagadia et al., (1959) was first to report literature in male sexual dysfunctions and observed ignorance, superstitions, fears and guilt feelings about sex as major areas of concern. He developed a method of educational group therapy for minor sex disorders. Bagadia et al. studied 258 male outpatients of teaching hospital setting, most of the patient were between 15-35 years, with sexual problems as main concerns and found 12-14% incidence over ten year. They found anxiety over nocturnal emission (65%) and passing semen in urine (47%) as main problems in the unmarried group; while impotence (48%), premature ejaculation (34%) and passing semen in urine (44%) were common in married group. Anxiety state (57%), schizophrenia (16%) and reactive depression (16%) were common psychiatric diagnosable conditions in that sample . Most of the patient has belief that semen loss (72%) and masturbation (13%) are the cause of illness. He used behavioral techniques to treat 26 married males with PME and secondary impotence; 58% patients improved with those techniques. (Bagadia et al., 1972)

Gupta and her colleagues (1989) described the application of Modified Masters and Johnson technique in the treatment of sexual inadequacy in 21 married males.76.2% patients showed improvement after this technique. (Gupta et al., 1989)

In a Czechoslovakian study which examines the family situation during childhood of dysfunctional males, Mellan (1974) concludes that males with organic dysfunction differ significantly from psychogenically dysfunctional males. In this study 250 dysfunctional males received a psychiatric interview and were administered a ten point Family Scale where the highest grade corresponded to a hypothetically ideal family situation. Those males who suffer from primary erectile dysfunction had the most disturbed family of origin.

Nakara and his colleagues (1977) studied sexual disorders in 150 males attending psychiatric unit of a teaching general hospital. They reported that 9.2% of all patients seen had potency disorders. The commonest psychosexual disorders were impotence (acute onset 11.3%; insidious onset 24%), premature ejaculation (acute onset 10%; insidious onset 15.3%), Dhat syndrome (with impotence/PME 10.7%; without 10%) and apprehension about potency (18%).

Nakara et al., (1978) did another study using same cohort and observed sexual behavior of male patient having potency disorder prior to the onset of illness. Masturbation (74.4%) and nocturnal emission (95.3%) were present significantly. About 43% had guilt towards masturbation and 60% had moderate to severe guilt feeling regarding nocturnal emission. Masturbation was more in subjects of higher socio-economic status. The authors also found adolescent homosexual contacts in 16% of the subjects. About 39% and 6% of the patients reported premarital and extramarital heterosexual intercourse. In premarital group, 47.5% had more than one partner,39% had with close relative,30.5% had it with wife of elder brother and 10% frequently visited prostitutes. About 64% of the subjects considered loss of semen harmful to health. (Nakara et al.,1978).

Kar and Verma (1978) studied the sexual lives of 72 married psychiatric patients and compared with 80 married relatives or friends from the same socio-cultural background. Amongst the psychiatric group, 63% of subjects had schizophrenia,24% had mood disorder,7% had neurosis and about 1% had psychosis.48.5% of the patients failed to perform sexually on suhaag-raat compared with 18.7% of the controls who faced similar problem. Most common cause for failure were early masturbatory guilt 78.8%(33% in control),resentment from life 54.5%, premature ejaculation 48.5%(40% in controls), dissatisfaction in marriage 36%(20% in controls),ignorance 30%,lack of penile erection 27%(13% in control).About 63% of patient had dissatisfying relationship with wife as compared to 2.5% of controls. Various other causes like loss of semen(71%),religious attitude(36%), hostility, resentment and suspiciousness towards wife(27%),lack of hardness of penis(24%), social inhibition and restriction(22%),premature ejaculation(18%) were found to be associated with dissatisfying sexual relationship.(Kar and Varma, 1978).

Kumar and his colleagues (1983) conducted a study on 40 married male neurotics and 22 healthy controls from teaching hospital setting. They found that the sexual behavior of the neurotics was similar to healthy controls before the onset of illness. Frequency of coitus, sexual satisfaction of self, perceived sexual satisfaction of the spouse and sexual adequacy was significantly decreased in patients.

Avasthi and his colleagues (1994) conducted an outcome study of 66 male patients with psychosexual dysfunction in the context of socio-demographic and clinical variables. Short term outcome (of one-year duration) and long term outcome(of seven years’ duration) of those patients were recorded. Most of the the subjects reported combination of ED and PME(45%) than Erectile dysfunction (30%) and PME(12%). Dhat syndrome, with ED/PME, was reported by 9% of the subjects. Nearly 38% of the patients dropped out of the treatment (‘dropout group’). At one year follow-up, nearly 44% of the patients perceived improvement (‘improved at one year group’), while rest did not (‘no change at one year group’). After seven years, 70% of the original 66 patients could be recontacted. Significantly, a greater number of subjects from the ‘drop-out group’ had active sexual dysfunction than other two groups. The study proved that improvement in the short term outcome indicated favorable long­term outcome.(Avasthi et al., 1994).

Verma and his colleagues (1998) analyzed data on 1000 consecutive patients with sexual disorders attending the psychosexual clinic at the tertiary care setting in North India. Most of the patients were educated belonging to middle class male between 21 and 30 years of age. Most of the participants were married.52% had pre marital or extra marital sexual contact; less than 5% had homosexual intercourse and 10% had no sexual contact. Most of the subjects reported more than one complain. They found premature ejaculation (77.6%) and nocturnal emission (71.3%) frequent problems followed by a feeling of guilt about masturbation (33.4%), small size of the penis (30%) and erectile dysfunction (23.6%). Excessive worry about nocturnal emission, abnormal sensations in the genitals, and venereophobia was reported in 19.5%, 13.6% and 13% of patients, respectively. (Verma et al., 1998)

A file review of 178 male patients with sexual dysfunction by Avasthi and his colleagues (2003) revealed that high income, married status, presence of partner at evaluation, and liberal attitude towards sexuality increased the chances of selection of behavioral sex therapy. The outcome of therapy was associated with treatment adherence.

Participation of the spouse resulted in lower dropout rates. Gupta and his colleagues (2004) attempted to assess clinical profiles of 150 patients attending skin OPD for psychosexual problems. Among them, erectile dysfunction (34%) was the commonest problem, followed by premature ejaculation (16.6%), Dhat syndrome (15.3%), and nocturnal emission (14%).

Bhargav et al found that incidence of psychogenic impotence was higher in Indian patient and the mean age was lower as compared to patients from developed countries.

Kendurkar and his colleagues (2008) assessed the pattern of sexual dysfunction in the patients attending a marriage and sex clinic from 1979 to 2005 by looking into their medical records. After reviewing the data of 1242 patients, they found premature ejaculation being the most common complaint and the most commonly diagnosed clinical entity, followed by male erectile problems and Dhat syndrome. (Kendurkar et al., 2008)

Gautam and Batra (1996) found frequency of Erectile Dysfunction similar to premature ejaculation (6%) in a group of males seeking divorce and loss of interest was found to be 2%.

Kool et al did his study on English speaking Indian and found that 18% considered masturbation as wrong, 6% did not masturbate, 9% did not experienced orgasm during sex and 16% had premature ejaculation.(Brahmbhatt, 2014)

Singh et al did his study on 7267 men in Uttar Pradesh and observed lack of knowledge about sexual morbidity conditions in these group. Some husband reported to have sexual experience outside of marriage and most of them sexual relationship with more than one partner. Men who had reproductive morbidity symptoms did not seek treatment. Results found a pressing need for reproductive health education that targets both sexes.( Brahmbhatt, 2014)

Most cultures view premarital sex activities as a potential threat towards subsequent marriage relationships and are likely to have harmful psychological and physical effects (Finer LB,2007). Others assert that people who engage in sex before marriage are more prone to infidelity. (Ogunsola MO,2012).

Traditionally, premarital sex activity is not accepted in India although it gets its original name (Bharat) from the legendary Bharata who was born from premarital relationship between Shakuntala (Daughter of Sage Kanva), and King Dushyanta. A comprehensive review of Asian sexuality research concluded that most Asians are likely to have more conservative attitude. Mixed views about premarital sex have also been found in some studies. In one of the studies, some young Indian men accepted premarital sex while others reported that they had chosen not to have sex before they were married. Indian men are more likely than women to have parental permission to explore sex.(French RS et al,2005)

In another study of South Asians, fewer than half the men subscribed to the value of abstinence before marriage or claimed that it was a strong South-Asian value. (Groetzinger, 2004)

Bell and Bell and Masters and Johnson found that sexual satisfaction was associated with both life satisfaction and well-being. (Bell R et al,1972 )

Categories (Classification)

According to DSM 5,Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito- pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature (early) ejaculation, substance/medication induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction.(DSM-5,2013)

Sexual dysfunction disorders may be classified into four categories, (1) sexual desire disorders, (2) arousal disorders, (3) orgasm disorders and (4) pain disorders.(Hatzimouratidis and Hatzichristou, 2007)

Subtypes of sexual dysfunctions according to DSM-5

Abbildung in dieser Leseprobe nicht enthalten

The approach to sexual dysfunctions is mainly oriented along the linear model of Masters and Johnson (excitement, plateau, orgasm) with the addition of the concept of desire disorders. Researchers in India have consistently reported existence of culturally determined sexual clinical conditions such as, Dhat syndrome and Apprehension about potency. Dhat syndrome has been coded in ICD-10 under other neurotic disorders. The diagnosis of apprehension about potency doesn't find mention.

Sexual desire disorders

Sexual desire disorders or decreased libido are characterized by a lack or absence for some period of time of sexual desire or libido for sexual activity or of sexual fantasies. The condition ranges from a general lack of sexual desire to a lack of sexual desire for the current partner. The condition may have started after a period of normal sexual functioning or the person may always have had no/low sexual desire (Coretti and Baldi 2007,).

Sexual desire is the result of a positive interplay among internal cognitive processes (thoughts, fantasy and imagination), neurophysiological mechanisms (central arousability) and affective components (mood and emotional states), the biological basis of which is almost unknown in humans.

Levine define desire as ‘the motivation or inclination to be sexual and suggested that this construct be considered in terms of the following components

Drive: The biological component. This includes anatomy and neuroendocrine physiology.

Motivation: The psychological component. This includes the influences of personal mental states (mood), interpersonal states(e.g. mutual affection, disagreement) and social context (e.g. relationship status).

Wish: The cultural component. This considers cultural ideals, values and rules about sexual expressions which are external to the individual.

According to the classification of the Diagnostic and statistical manual of mental disorders (DSM-5), male HSDD is considered a sexual dysfunction and is characterized as a persistent or recurrent lack (or absence) of sexual fantasies and desire for sexual activity, as judged by a clinician taking into account factors that affect sexual functioning (e.g. age, general and socio-cultural contexts of the individual's life). Symptoms have persisted for a minimum of 6months.The disturbance must cause marked distress or severe interpersonal difficulties; cannot be better accounted for by another major mental disorder (except another sexual dysfunction); and is not due solely to the effects of a substance or general medical condition. HSDD, as defined by DSM, has garnered much criticism. The main problem is that the concept of sexual desire is poorly defined in this diagnosis as well as in the current literature.

Disorders such as depression or erectile dysfunction frequently coexist with low sexual desire. It is now recognized that sexual desire can be responsive, occurring after arousal or physical stimulation, rather than a spontaneous event before arousal. Accordingly, recent studies found that sexual desire and sexual arousal are overlapping constructs as both depend on the ability of an individual to process sexual information during sexual activity.

The International Society for Sexual Medicine propose to use the term LSD/I(Low Sexual Desire/Interest) as a general term for the symptom/syndrome that might be caused by medical conditions such as depression or endocrine abnormalities, relationship factors, medications or drugs abuse and to reserve the DSM-5 HSDD for the cases where other etiological factors have been appropriately excluded.

Epidemiology

HSDD has been historically either not identified or erroneously diagnosed and presented as another sexual dysfunction such as erectile dysfunction. The most important population-based studies report that the prevalence of reduced sexual interest ranges from 3% to more than 50%. Interestingly, the populations’ level of sexual interest appears quite stable from the late teens and up to about 60, thereafter it decreases markedly.

In a multicentre survey study involving 374 men (mean age 48.8 years), recruited for a pharmaceutical study, 30% met the DSM criteria for HSDD as a primary diagnosis. A survey conducted in the United States in 2004 involving 1455 men aged 57-85 years showed 28% of men reported lack of desire, with 65% of them feeling bothered about it. According to expert opinion, it seems to be that the acquired and situational form of HSDD is the most common subtype for men.

Hypoactive sexual desire disorder has been reported in approximately 33.4 % of women and 15. 8% of men in population-based studies, and is associated with a wide variety of medical and psychologic causes (Laumann et al., 1994).

AETIOLOGY

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Androgens such as testosterone appear to be necessary for a man's sexual desire. It appears that a minimum level of androgen is required for a man to be able to experience sexual desire.

Severe hyperprolactinaemia has a negative impact on sexual function, impairing sexual desire, as well as erectile function and testosterone production.

A PRL-induced hypogonadism could explain, at least partially, this association. Hypothyroidism is another endocrine condition previously associated with male hypoactive sexual desire (HSD). The reasons for this association are unknown.

In case of hyperprolactinaemia, the modification of the drug used is advisable. Dopamine-agonist agents are the first-choice treatment in case of pituitary secreting adenomas. Testosterone replacement therapy may be beneficial only in hypogonadal patients (Total testosterone < 12 nM).Thyroxin therapy is indicated in cases of hypothyroidism.

Sexual arousal disorders

For both men and women, these conditions can manifest themselves as an aversion to, and avoidance of, sexual contact with a partner. In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity. (Laan et al., 2008).

Erectile dysfunction (ED) is the major sexual arousal disorder in men. Persistent genital arousal dysfunction is spontaneous, intrusive, and unwanted genital arousal (i.e., tingling, throbbing, pulsating) in the absence of sexual interest and desire. Any awareness of subjective sexual arousal is typically but invariably unpleasant. The arousal is unrelieved by one or more orgasms and the feeling or arousal persists for hours or days.

Sexual arousal disorders in women are divided into three subtypes.

Genital sexual arousal dysfunctions are absent or impaired genital sexual arousal; self-report may include minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensation from direct stimulation of genitalia. Subjective excitement still occurs from nongenital sexual stimuli.

Subjective sexual arousal dysfunction is the absence of or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure), from any type of sexual stimulation. Vaginal lubrication or other signs of physical response still occur.

Combined genital and subjective arousal dysfunction is the absence of markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation as well as complaints of absent or impaired genital sexual arousal (vulval swelling, lubrication). (Lewis et al., 2010)

Sexual arousal disorders, including erectile dysfunction in men and female sexual arousal disorder in women, are found in 10% to 20% of men and women, and is strongly age related in men (Laumann et al, 1999; Laumann et al, 1994).

Erectile dysfunction

Introduction

According to DSM-5, Erectile disorder is marked difficulty in obtaining an erection during sexual activity or marked difficulty in maintaining an erection until the completion of sexual activity or marked decrease in erectile rigidity experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all context for a minimum duration of approximately 6 months.

Erectile dysfunction (ED) is a very distressing condition that not only has a negative impact on the man's physical and psychosocial health but also has damaging repercussions on the couple's quality of life. ED leads to depression, anxiety and loss of self-esteem and can contribute to marital breakdowns. Men are reluctant to seek help for fear of not being taken seriously or out of embarrassment and become isolated within their relationship, which may lose all aspects of intimate contact. A stepwise approach in the assessment of ED helps clinician to arrive at a proper diagnosis, which in turn may lead to better management. The treatment for ED is readily available and highly effective, yet is underutilized. (Pramod KR, 2014)

Penile erection is a complex neurovascular phenomenon under hormonal control that includes arterial dilatation, trabecular smooth muscle relaxation and activation of the corporeal veno-occlusive mechanism. Year 1998 marked the milestone introduction of the first effective oral drug treatment, sildenafil citrate, for the treatment of erectile dysfunction. Sildenafil belongs to a group of well-characterized drugs that are called selective phosphodiesterase type 5 inhibitors (PDE5-Is). These drugs were developed on the basis of a conceptual understanding of the fundamental role of nitric oxide (NO) smooth muscle relaxation in penile cavernous tissues. Recognition of the important part NO plays in signaling smooth muscle relaxation in penile tissue led to a dramatic expansion of research focused on sexual dysfunction in men (Kouvelas et al., 2009).

Epidemiology

Erectile dysfunction is a common medical disorder that primarily affects men older than 40 years of age. A recent extensive analysis of published work on the prevalence of erectile dysfunction, reported by the International Consultation Committee for Sexual Medicine on Definitions/Epidemiology/Risk Factors for Sexual Dysfunction, showed that the prevalence of erectile dysfunction was 1-10% in men younger than 40 years.

Prevalence of erectile dysfunction ranges from 2% to 9% in men between the ages of 40 and 49 years. It then increases to 20-40% in men aged 60-69 years. In men older than 70 years, prevalence of erectile dysfunction ranges from 50% to 100%. (Lewis et al., 2010)

In another large-scale multicentric male health survey carried out in the United States, Europe, Mexico, and Brazil, it was found that the prevalence of ED increased with age and comorbid medical conditions (e.g., hypertension, hypercholesterolemia, heart disease, and diabetes) were higher in men admitting to ED than in the overall sample.

In a long-term follow-up investigation of the landmark population-based survey, the Massachusetts Male Aging Study, of over 1,200 men carried out between 1987 and 1989, found that 52% of men between the ages of 40 and 70 years reported some degree of ED. The MMAS also showed that the prevalence and severity of ED increases with age. The study found that 40% of the men at age 40 and over 60% of the men at age 70 experienced some degree of erectile dysfunction (Feldman et al, 1994). The age-related results of MMAS were also reported by the National Health and Social Life Survey (NHSLS), a nationally representative probability sample of men and women aged 18 to 59 years. The NHSLS found that the oldest cohort of men, aged 50 to 59 years, was approximately three times more likely to experience erection problems and to report low sexual desire than were men aged 18 to 29 years. In this study there was prevalence of a higher sexual dysfunction in men who had never married or were divorced. Experience of sexual dysfunction was more likely among men with poor physical and emotional health (Laumannet al., 1999).

Men's Attitudes to Life Events and Sexuality (MALES) study, which included 27839 patients spanning over eight countries, found an overall prevalence of self-reported ED of 16% in men aged 20-75 years. Differences were noted between the various countries, with the highest prevalence seen among men in the US (22%) and the lowest in Spain (10%). The study confirmed the increased prevalence of ED with both increasing age, and other co-morbid conditions (hypertension, diabetes, ischaemic heart disease, hypercholesterolaemia and depression) as noted in earlier studies (Rosen et al., 2004).

The third National Survey of Sexual Attitudes and Lifestyle survey (Natsal-3) studied 4913 UK men and reported ED rates of 13.4% (45-54 years), 23.5% (55-64 years) and 30% (65-74 years) with only one in four having sought medical help. (Wylie, 2015) Although the prevalence of ED varies from study to study, self-reported data more likely underestimate the true dimensions of the problem. As per one report, the current global prevalence of ED is more than 150 million. Given the advancing median age in Western industrial countries, together with population growth in developing nations, this figure is projected to increase to more than 320 million by the year 2025 (Aytac, 1999). Available literature suggests that erectile dysfunction is common, increases with age and is associated with chronic physical illnesses (Levine and Kloner, 2000).

The researchers also found that in subjects with ED, the most frequent barriers to medical evaluation were the intermittent nature of ED, with the belief that the ED was temporary, as well as the embarrassment brought on by discussing the condition (Niederberger & Lonsdale, 2002). Some studies have also studied the prevalence of ED in subjects with lower urinary tract symptoms (LUTS). The Multinational survey of the aging male (MSAM-7) study investigated the association between LUTS and ED in men aged between 50 and 80 years. The researchers found that the prevalence of ED in men with no LUTS was 24.8%, compared to 43.3, 65.8 and 81.9% ED in men with mild, moderate and severe symptoms, respectively (Rosen et al, 2003). Other researchers have also reported a similar association between LUTS and sexual dysfunction (Tubaro et al, 2001; Namasivayam et al , 1998 ; Boyle et al, 2003). Other sociodemographic and clinical factors, which have been linked with the increase in prevalence of erectile dysfunction, include education (Nicolosiet al, 2003; Akkus et al, 2002), smoking (Shiri et al, 2004), alcohol use (Gambert, 1997) obesity andsedentary life style (Shiri et al, 2004; Chung et al, 1997).

Erectile dysfunction is more prevalent in men with certain non-organic risk factors, such as emotional, couple related, and socioeconomic factors, creating a complex picture when the epidemiology of erectile dysfunction is discussed in certain specific populations. A good example of an emotional risk factor for erectile dysfunction is depression. In a study by Shiri et al., the incidence of erectile dysfunction was 59/1000 person-years in men with depressive mood and 37/1000 person-years in those without depression. These authors also found that the association of depression and erectile dysfunction is bidirectional. (Kupelian V, et al, 2008)

Classification of erectile dysfunction

Erectile dysfunction is divided into two etiologic categories: psychogenic and organic. Most causes of erectile dysfunction were once considered to be psychogenic, but current evidence suggests that up to 80 percent of cases have an organic cause. (Willke RJ et al.,1997)

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