Abstract
Background
The existing literature on alcohol-induced sexual dysfunction has mainly deliberated on erectile dysfunction and premature ejaculation, ignoring other important domains of sexual dysfunctions (viz sexual pleasure, sexual desire, arousal, orgasmic function). This study was undertaken to assess the extent of alcohol-associated sexual dysfunction and to compare their severity with the severity of alcohol dependence in males.
Methods
A cross-sectional descriptive study design recruited 78 male patients and an assessment was conducted using the Changes in sexual functioning questionnaire male clinical version, International index of erectile function scale, Severity of Alcohol Dependence Questionnaire, Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) and International Classification of Diseases-10 (ICD-10). A correlation between years of alcohol consumed and its effect on various domains of sexual dysfunction was also carried out using Pearson's correlation coefficient.
Results
Seventy-seven percent of the study population had complaints of sexual dysfunction in one or more domains, with reduced sexual pleasure (71.8%) as the most common followed by low sexual desire (in terms of frequency) in 61.5% and erectile dysfunction in 43.6%. The severity of the sexual dysfunction was found to be directly proportional to the severity of alcohol dependence with almost 100 percent of the patients with severe alcohol dependence having sexual dysfunction in all the domains.
Conclusion
The most common sexual dysfunction reported in the current study was decreased sexual pleasure (71.8%) followed by low sexual desire 61.5% (in terms of frequency). These findings emphasize the fact, that alcohol significantly compromises almost all domains of sexual functioning in addition to erectile dysfunction.
Keywords: Alcohol Drinking/epidemiology, Sexual dysfunction, Erectile dysfunction
Introduction
The search for sex-enhancing drugs or aphrodisiacs has been a human fascination throughout history and alcohol being the most commonly and universally consumed substance, has been related to sexuality since time immemorial. Although alcohol may contribute to the initiation of sexual activity by subduing inhibitions and relieving anxiety,1 prolonged and heavy use can lead to alcohol-induced sexual dysfunction.2 Masters et al,3 proposed a four-phase human sexual response cycle – excitement, plateau phase, orgasm, and resolution which forms the basis for classifying various domains of sexual dysfunction in the latest Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5)4 as well as ICD-10.5
The relationship between alcohol and sexual dysfunction depends on a myriad of biopsychosocial factors. These include direct toxic effects of alcohol on the endocrine system, leading to derangements in the hypothalamo–pituitary–adrenal and the hypothalamo–pituitary–gonadal axis and neurotransmitters imbalance (increased GABA and reduced glutamate), psychosocial factors such as anxiety/depression/psychotropic medications, unemployment, illiteracy, poor socioeconomic status, and so on.6,7
There is a significant variation in the reported prevalence of alcohol-induced sexual dysfunction in the available literature, which could be due to ignorance, under-reporting fearing humiliation or insignificance exhibited by the clinicians. An epidemiological study by Rao et al 8 (2015) showed that 63.8% of alcoholic males suffered sexual disorders. In a review of 19 studies by Grover et al 9 (2014), sexual dysfunction in alcohol-dependent males was reported to be ranging from 40 to 95.2%, the most common being erectile dysfunction followed by premature ejaculation (PE). However, most of the available literature does not comment on the remaining domains of sexual functioning, especially in Indian settings.
The present study was undertaken to assess the degree of alcohol-associated sexual dysfunction in various domains. We also tried to find the association if any, between the severity of sexual dysfunction and the severity of alcohol dependence.
Material and methods
It was an observational, descriptive, non-interventional, and cross-sectional study. The study included consecutively admitted males with alcohol dependence syndrome between 20 and 50 yrs of age who were married or having a regular heterosexual associate.
The exclusion criteria were the presence of co-morbid psychiatric disorders viz. schizophrenia, other psychotic disorders (delusional disorder), mood and/or anxiety disorders (even subsyndromal), history of primary sexual dysfunction preceding the initiation of alcohol use in the dependent pattern, co-morbid organic/physical disorders by history, examination, and relevant investigations (for Cirrhosis, Hypertension, Diabetes, Endocrine disorders, other systemic illnesses, history of genitourinary surgery/trauma, and spinal cord lesions), any other substance use disorder (except alcohol) including tobacco use in a dependent pattern and the use of drugs with known sexual side-effects (antipsychotics, antidepressants, antihypertensives, steroids, and disulfiram).
The sample size was calculated as follows:
Sample size n = [Design effects x Np(1-p)]/[(d2/Z21-α/2 x (N-1)+p x (1-p)].
Population size (for finite population correction factor or fpc) (N): 5000.
Prevalence: Hypothesized % frequency of outcome factor in the population based on previous studies (p): 71% ± 10.
Confidence limits as % of 100 (absolute ± %) (d): 10% Design effect (DEEF) (for cluster surveys-DEFF): 1.
Substituting the values in the formula, a sample size of 78 was derived. The sample size of the present study was thus estimated to be 78 at 95% confidence interval.
After the Hospital Ethics committee's approval, all consecutive cases meeting the study criteria admitted to a tertiary care general hospital psychiatry unit over a period of 18 months were recruited in the study with their written and informed consent. The diagnosis of Alcohol Dependence Syndrome was established as per the ICD-10 Classification of Mental and Behavioural Disorders (Diagnostic criteria for research).5 To rule out other medical/organic causes of sexual dysfunction, detailed medical history; physical, systemic and mental status examination and relevant tests (biochemical, endocrinological, and radiological) were carried out. Investigations comprised of complete hemogram, blood-sugar profiles, lipid profile, hepatic and renal function tests, thyroid function test, ultrasonography abdomen, infections of the urinary tract, and sexually transmitted diseases viz. HIV (Human Immunodeficiency Virus), HBsAg (Hepatitis B antigen), Anti HCV (Anti Hepatitis C Antibody), and Venereal Disease Research Laboratory test for syphilis.
Out of 153 consecutive male patients of alcohol dependence syndrome admitted, 75 were excluded as per exclusion criteria (primary sexual dysfunction = 07, diabetes mellitus = 08, hypertension = 11, chronic liver disease = 10, comorbid mood disorder = 12, comorbid anxiety disorders = 16, other comorbid medical/psychiatric conditions = 04, prior sexual dysfunction = 07) (Fig. 1). Finally, 78 male patients were included in the study and were evaluated using specially designed proforma and validated rating scales. Those with sexual dysfunction were diagnosed to have a substance-induced sexual dysfunction using DSM-5 criteria through a clinical interview with a psychiatrist. The severity of sexual dysfunction was then assessed with the Changes in sexual functioning questionnaire male clinical version (CSFQ-MC)10 and the International index of erectile function scale (IIEF-15).11 Patients were then assessed for severity of alcohol dependence with the Severity of Alcohol Dependence Questionnaire (SADQ-C).12
Fig. 1.
ADS, Alcohol dependence syndrome; SADQ-C, Severity of alcohol dependence questionnaire; IIEF-15, International index of erectile function-15; CSFQ-MC, Changes in sexual functioning questionnaire-male clinical version.
The CSFQ has good face and concurrent validity and moderate to high internal consistency with Cronbach's alpha coefficient above 0.60 and the mean correlation coefficient of 0.69 for test-retest reliability.10 The scale was administered after adequately treating the patients for alcohol withdrawal features. The scale has been translated into more than 75 languages and the English version of the scale was used in our study. CSFQ-14 gives an overall measure of sexual functioning as well as scores on a set of five scales corresponding to important dimensions of sexual functioning corresponding to the phases of the sexual response cycle.13
The SADQ-C was developed at the Maudsley Hospital in London12 in the late 1970s. SADQ is a 20-item questionnaire based upon the premise formulated by Edwards and Gross that alcohol dependence comprises a cluster of symptoms which derive from a single syndrome centered around a “drive” to consume alcohol. The SADQ is a measure of degree of dependence rather than the presence or absence of ‘Alcoholism’. Stockwell 14 (1983) suggested a range that a score of 31 and above should be taken to indicate severe dependence. A score of 16–30 indicates moderate dependence and a score of 15 and below indicates a mild or none physical dependency. The SADQ has the maximum evidence of reliability and validity of all the major self-report questionnaires and has been shown to have high test-retest reliability and good evidence of construct validity.14
Statistical analysis
Descriptive and inferential statistical analyses were carried out in the present study. Results on continuous variables were presented on Mean ± SD and results on categorical variables were presented in number (%). The level of significance was fixed at p = 0.05 and any value less than or equal to 0.05 was considered to be statistically significant. Chi-square analysis was used to find the significance of study parameters on a categorical scale. A correlation between years of alcohol consumed and its effect on various domains of sexual dysfunction was also carried out using Pearson's correlation coefficient.
The Statistical software IBM SPSS statistics 20.0 (IBM Corporation, Armonk, NY, USA) was used for the analyses of the data and Microsoft Word and Excel were used to generate graphs, tables, and so on.
Results
The demographic characteristics revealed that the study population was relatively younger with a mean age of 36.19 ± 5.924 years (range: 24–50 years) and the majority (82%) had education up to or above the 10th standard. All the patients were employed in a stable Government job. As per SADQ scores, the percentage of subjects having mild, moderate, and severe alcohol dependence were 52.6%, 32.1%, and 15.4%, respectively (Table 1).
Table 1.
Socio-demographic characteristics.
| Socio-demographic variables | Sub-groups | n (%) |
|---|---|---|
| a) Age in years (n = 78) (Mean ± SD) 36.19 ± 5.924 |
≤ 30 | 16 (20.5%) |
| 31–40 | 44 (56.4%) | |
| 41–50 | 18 (23.1%) | |
| b) Marital status (n = 78) | Married | 75 (96.2%) |
| In relationship | 03 (3.8%) | |
| c) Marital disharmony (n = 75) | Yes | 45 (60.0%) |
| No | 30 (40.0%) | |
| d) Education (n = 78) | Below 10th Std | 06 (7.7%) |
| 10th Std | 32 (41.0%) | |
| 11th Std | 06 (7.7%) | |
| 12th Std | 26 (33.3%) | |
| Graduate | 08 (10.3%) | |
| e) Family history of alcohol use | Yes | 44 (56.4%) |
| No | 34 (43.6%) | |
| f) Years of alcohol use (Mean ± SD) = 11.82 ± 4.245 |
1–10 | 34 (43.6%) |
| 11–20 | 39 (50.0%) | |
| >20 | 05 (64%) | |
| g) Lifetime alcohol use in kgs (Mean ± SD) | 180.18 ± 45.297 | |
| h) SADQ (Severity of Alcohol dependence questionnaire) | Mild (<15) | 41 (52.6%) |
| Moderate (16–30) | 25 (32.1%) | |
| Severe (>30) | 12 (15.4%) | |
Out of 78 patients, 18 (23.07%) patients had no complaints of sexual dysfunction while the remaining 60 patients (76.93%) had complaints of sexual dysfunction in one or more domains. The most common sexual dysfunction reported as per CSFQ, was reduced sexual pleasure in 71.8% followed by low sexual desire (in terms of frequency) at 61.5%. Sexual desire (in terms of interest) was low at 55.1%. Sexual arousal/excitement was low in 59%. Sexual orgasm/completion scores were low at 48.7% of alcohol-dependent male patients. Erectile dysfunction was quantified using an IIEF in which 43.6% of alcohol-dependent male subjects were found to have erectile dysfunction (Table 2).
Table 2.
Sexual dysfunction in different domains (as per CSFQ) (n=78).
| Variables | CSFQ scores | n (%) |
|---|---|---|
| Sexual pleasure | Low | 56 (71.8%) |
| Normal | 22 (28.2%) | |
| Sexual desire/frequency | Low | 48 (61.5%) |
| Normal | 30 (38.5%) | |
| Sexual desire/interest | Low | 43 (55.1%) |
| Normal | 35 (44.9%) | |
| Sexual arousal/excitement | Low | 46 (59.0%) |
| Normal | 32 (41.0%) | |
| Sexual orgasm/completion | Low | 38 (48.7%) |
| Normal | 40 (51.3%) |
The association of severity of alcohol dependence with different domains of sexual functioning (using CSFQ MC) is as shown in (Table 3). Sexual pleasure scores were low in 71.8% of the study population. As per the severity of alcohol dependence, sexual pleasure scores were low in 48.8% of mild, 96% of moderate and 100% of severe alcohol dependence patients (p-value < 0.001). Sexual desire/frequency scores were low in 61.5% of the study population. As per the severity of alcohol dependence, sexual desire/frequency was low in 34.1% of mild, 88% of moderate, and 100% of severe alcohol dependence patients (p-value < 0.001). Sexual desire/interest scores were low in 55.1% of the study population. As per the severity of alcohol dependence, sexual pleasure scores were low in 24.4% of mild, 84% of moderate, and 100% in severe alcohol dependence patients (p-value < 0.001). Sexual arousal/excitement scores were low in 59.0% of the study population. As per the severity of alcohol dependence, sexual pleasure scores were low in 26.8% of mild, 92% of moderate, and 100% of severe alcohol dependence patients (p-value < 0.001). Sexual orgasm/completion scores were low in 48.7% of the study population. As per the severity of alcohol dependence, sexual pleasure scores were low in 22% of mild, 72% of moderate, and 91.7% of severe alcohol dependence patients (p-value < 0.001).
Table 3.
Association of severity of alcohol dependence with changes in sexual functioning questionnaire male clinical version (CSFQ-MC) subscales.
| (CSFQ Subscale) |
|||||||
|---|---|---|---|---|---|---|---|
| Low sexual pleasure scores | Low sexual desire/frequency scores | Low sexual desire/interest scores | Low sexual arousal/excitement scores | Low sexual orgasm/completion scores | |||
| Severity of alcohol dependence (SADQ scores) |
Mild (SADQ<15) (n = 41) |
No of Patients | 20 | 14 | 10 | 11 | 9 |
| % within group | 48.8% | 34.1% | 24.4% | 26.8% | 22.0% | ||
|
Moderate (SADQ 16–30) (n = 25) |
No of Patients | 24 | 22 | 21 | 23 | 18 | |
| % within group | 96.0% | 88.0% | 84.0% | 92.0% | 72.0% | ||
|
Severe (SADQ>30) (n = 12) |
No of Patients | 12 | 12 | 12 | 12 | 11 | |
| % within group | 100.0% | 100.0% | 100.0% | 100.0% | 91.7% | ||
| Chi square value | 22.672 | 27.894 | 33.852 | 37.128 | 26.042 | ||
| p value | <0.001∗∗ | <0.001∗∗ | <0.001∗∗ | <0.001∗∗ | <0.001∗∗ | ||
p < 0.05, Significant∗, p < 0.001, Highly significant∗∗
The years of alcohol use by the patients showed statistically significant negative correlation with different domains of sexual functioning (p < 0.001). The negative correlation was greatest for IIEF overall score followed by intercourse satisfaction, overall satisfaction, sexual desire and orgasmic function in descending order (Table 4).
Table 4.
Correlation between years of alcohol use and different domains of sexual functioning.
| Domains of sexual functioning (IIEF Subscale) | Years of alcohol use |
|
|---|---|---|
| r (correlation coefficient) | p value | |
| a) Orgasmic function | −0.695 | <0.001∗∗ |
| b) Sexual desire | −0.695 | <0.001∗∗ |
| c) Intercourse satisfaction | −0.742 | <0.001∗∗ |
| d) Overall satisfaction | −0.727 | <0.001∗∗ |
| e) IIEF Overall (total) score | −0.792 | <0.001∗∗ |
Discussion
The study subjects included only consecutive male patients with alcohol dependence syndrome (as female alcohol-dependent patients reporting at our center are very infrequent). PE was not assessed in view of significant subjectivity and unrealistic perceptions in men which itself may lead to sexual disappointments and sexual dysfunctions.15
Sexual dysfunction in one or more domains as per CSFQ was present in 76.93% of the study population, which is significantly high compared to sexual dysfunction in the general population as per Consensus Statement from the Fourth International Consultation on Sexual Medicine 2015.7 The association was also significantly higher than a recent study on the same subject, which reported only 37% alcohol-induced sexual dysfunction.6 This was despite the fact that majority of the study population was relatively young, educated and had a stable job, thus eliminating confounding variables of old age,16 illiteracy and unemployment17 which are recognized major factors with a negative impact on sexual health. Furthermore, tobacco use in dependence pattern, which is a known cause of erectile dysfunction,18 were also excluded from the study sample to ensure that the sexual dysfunctions assessed were solely due to the effects of alcohol. However, another significant psychosocial factor in the current study was a high rate of marital disharmony (60%), which could have influenced the prevalence of sexual dysfunction (Table 1). Thus, this could be regarded as a limitation of the study; nevertheless, a precise cause and effect could not be established as marital disharmony could be due to alcohol use leading to decreased sexual functioning or vice versa. This is noteworthy for a de-addiction setting in which the relationship between marital discord, substance use and sexual dysfunction must be thoroughly evaluated and managed to achieve an ideal outcome.
The most commonly affected domain of sexual dysfunction was reduced sexual pleasure (71.8%) followed by reduced sexual desire/frequency (61.5%), sexual arousal/excitement (59.0%), reduced sexual desire/Interest (55.1%), sexual orgasm/completion (48.7%), and Erectile dysfunction in 43.6% in descending order (Table 2). Thus, the entire spectrum of sexual functioning was found to be significantly affected. These findings are in contrast to previous studies which mentioned erectile dysfunction and PE as the most common.9,19 The frequency of sexual dysfunction for specific domains is found to be high in the current study, which could be attributed to the use of validated scales. This observation warrants screening for the entire spectrum of sexual dysfunction in a de-addiction setting wherein an unidentified sexual dysfunction may be perpetuating alcohol dependence with a suboptimal response to therapy.
The alcohol use in the current study sample was found to be 11.82 (± 4.245 SD) mean years of alcohol use with 180.18 kg (± 45.297 SD) of lifetime alcohol use, suggesting prolonged heavy alcohol use. The severity of the sexual dysfunction was found to be directly proportional to the severity of alcohol dependence with almost 100% of the patients with severe alcohol dependence having sexual dysfunction in all the domains. This finding aligns with the available literature,20 however, the current study has brought out a clear negative correlation with all the domains of sexual functioning unlike most previous studies, especially in Indian studies.
The study findings are significant as the association of sexual dysfunction was found to be high (77% at least in one domain) despite the majority of the sample (approximately 85%) having mild-moderate alcohol dependence. This finding warrants us to be vigilant regarding sexual dysfunction even in patients with mild-moderate alcohol dependence and hence we recommend screening for the same irrespective of the severity of alcohol dependence. Secondly, sexual dysfunction was assessed exclusively due to alcohol as the study subjects were homogenous in terms of sociodemographic variables and without any physical/psychiatric confounding factors.
The limitations were a relatively small sample size consisting only of males without any dyadic assessment because spouses were not assessed for any sexual dysfunction, which could be a confounding factor. Second, since the study period was time bound, reassessment of the subjects after a period of alcohol abstinence could not be done to further determine if sexual dysfunction persists. A longitudinal study with a larger sample size with community follow-up for reassessment after abstinence is envisaged in the future.
Conclusion
The frequency of various domains of alcohol-associated sexual dysfunction was found to be significant in addition to erectile dysfunction necessitating sensitization and screening of the entire spectrum in clinical settings. Second, the severity of alcohol dependence dictated the severity of alcohol-associated sexual dysfunction with almost all the patients with severe alcohol dependence manifesting sexual dysfunction across all the domains.
Disclosure of competing interest
The authors have none to declare
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