A narrative review on sexual wellbeing and dysfunctions: Research in the past 15 years

Abstract

Background:

Psychosexual health is an important aspect of mental and physical wellbeing. Though Indian culture has a rich history of sexuality, over the years, our population has been reticent in talking about the same. With the advent of technology and new legislations protecting the rights of LGBTQIA population, awareness is also on the rise.

Methods:

This review focuses on research published by Indian authors over the past 15 years, with search of databases like PubMed, Scopus, Google Scholar, and Litmaps to include original articles and case reports.

Results:

Most studies focus on male sexual dysfunctions. Some emerging research showed promise in female sexual dysfunctions, the elderly, and the LGBTQIA population. The majority of research in sexual health continues to concentrate on dysfunctions, primarily prevalence, associations, or risk factors. Several studies investigated various medical/psychiatric comorbidities associated with sexual dysfunctions. A few studies have explored management strategies as well.

Conclusion:

This review highlights the need for a more holistic approach to management to sexual health issues. It further underscores the importance of grassroots-level initiatives working on improving the training of all medical practitioners and postgraduate students, increasing the availability of services for sexual disorders, promoting sexual health research in areas with gaps, and raising awareness in the general population.

INTRODUCTION

Psychosexual health is an important aspect of mental and physical wellbeing that is slowly getting recognition and significance. Research in this area in India has now become a focal point of attention and has expanded beyond the past updates provided by the Indian Psychiatric Society (IPS) in 2010[1] and Avasthi et al.[2] Sexual medicine has evolved into a specialty with fellowship courses commencing in India, marking a significant milestone. The emphasis on enhancing postgraduate training and the knowledge of practicing psychiatrists through Continuing Medical Education (CME) sessions, workshops, and conferences on sexual dysfunctions (SDs) and sexual health has contributed to raising awareness about the various nuances of sexual wellbeing.

Indian culture has a rich history of expressing sexuality through art, architecture, literature, and poetry but has always been reticent in talking about the same. The influence of technology over the past 2 decades has broken down barriers and opened doors for communication, although this progress has largely occurred at the individual level rather than within families, where hesitancy to discuss sexuality and dysfunctions still persists. Concepts like gender fluidity, sexual orientation, and peer acceptance are evolving norms today. Despite the challenges, contemporary Indian society is gradually accepting these changes, marking a significant step forward in the Indian subcontinent. The enactment of the Transgender Act was a landmark decision for the country as it addressed the sexual wellbeing of all its citizens.[3]

Numerous studies have reported a high prevalence of SDs in the general population. Indian researchers have found prevalence rates ranging from 10% to 60% for both male and female SDs, including Dhat syndrome.[4] Often, these issues go unaddressed because people are hesitant to discuss their sexual lives. This communication barrier exists not only among patients but also among physicians who may feel uncomfortable inquiring about sexual complaints. Psychiatrists also often lack the necessary communication skills to address such complaints, which is a reflection of the lack of training pertaining to sexual health history and management given to the postgraduate students. Institutions or departments that collaborate and engage in research on sexual health and dysfunctions are likely to provide better training to their postgraduates. This emphasizes the importance of developing sexual health as a subspecialty so that the general population benefits from well-trained doctors, rather than seeking help from self-proclaimed and unqualified experts like sex gurus and quacks. Sexual medicine is an emerging specialty as nearly every individual is likely to encounter some sexual health issues at some point of time in their life.

While research in the field of sexual health and dysfunctions is ongoing across India, there are very few studies examining the various psychosocial factors that have a profound impact on sexual beliefs and functioning. Studies with both qualitative and quantitative or mixed methods approaches would offer deeper insights into lived experiences, psychopathology, comorbid medical conditions, relationship challenges, and perceived solutions.

SEARCH METHODOLOGY

A manual search was done using the electronic databases of PubMed, Scopus, Google Scholar, and Litmaps on relevant publications or cross-references from January 2011 till June 2023. The search terms used were sexual health, sexual well-being, male SDs, female SDs, erectile dysfunction, premature ejaculation, Dhat syndrome, myths and misconceptions on sexuality, vaginismus, dyspareunia, ((“Sexual Health”[Mesh]) OR (“Sexual Dysfunction, Physiological”[Mesh] OR “Sexual Dysfunctions, Psychological”[Mesh])) AND “India”[Mesh] in various combinations, and all those studies which seemed relevant to our topic were included.

This review focuses on research published by Indian researchers over the past 15 years, which has contributed to filling the existing knowledge gaps. No meta-analysis was available. We reviewed only original articles and case reports from India and have summarized important highlights from the same. We did not include other review articles from India which reported western findings and focused on those articles related to SDs. Paraphilias are beyond the scope of this discussion.

Tools for assessment of sexual dysfunction

Tools are an integral part of measurement in quantitative research. Though several tools are available for evaluation of sexual dysfunction, cross cultural validity is a major limiting factor in their use. Krishna et al.[5] validated Sexual Functioning Questionnaire (SFQ) in Indian population and reported 14 as the cutoff score on SFQ to define sexual dysfunction (sensitivity of 91.7% and specificity of 86.4%). Dhat syndrome is also an entity that is unique to our region, and Grover et al.[6] developed a comprehensive questionnaire for its assessment with good content validity. Further work is required in this area to improve the standardization and quality of research in the field of sexual medicine from our subcontinent.

Sexual dysfunctions in males

Male SDs, the most common being erectile dysfunction (ED) and premature ejaculation (PME), are common presenting complaints among men visiting sexual health clinics in India. These issues are often associated with significant distress, impairments in marital life, disharmony, and interpersonal problems. The prevalence reported from such centers is likely to be only the tip of the ice berg. Even today, despite progress in discussions about sexuality and SDs since their first mention in Indian literature in the 1950s, several major concerns, such as ignorance, superstitions, and guilt about sex persist.[1] A sexuality research update by Prakash and Rao reviewed articles from the 1950s to 2010 with most studies reporting ED (23.6% to 48%) and some studies reporting PME (12% to 71.3%) as the most common psychosexual disorder.[1]

Over the past decade, several studies have examined the prevalence, nature, and associated factors of SDs in various regions of the country [Table 1]. These studies have brought out the high gender disparity among patients attending psychosexual clinics[7,8] (predominantly males) and also stressed on increased training in sexuality related issues and provision of sex education in general population to address the needs of ever-increasing sexual health morbidity.[4,7]

Table 1.

Summary of prevalence studies on male sexual dysfunctions

Author - Year	Location and study design	Study population	Tools/scales used	Key results
Thangadurai et al. (2014)[9]	General health clinic, South India; Cross-sectional	270 men attending general health clinic	- International Index of Erectile Function-5 (IIEF) - Chinese Index of Premature Ejaculation-5	- 47.8% reported ED - 43% reported PME
Sathyanarayana Rao et al. (2015)[4]	South Indian rural population (Suttur village, Mysuru); Epidemiological study (door-to-door survey)	1529 total sample; 742 males	- Arizona Sexual Experiences Scale (screening tool) - Detailed interview in those screened positive	- 21.15% males, i.e., 1 in 5 diagnosed with at least one sexual disorder - 15.77% reported ED - 2.56% male HSDD - 2.56% with PME
Pal et al. (2017)[7]	Special clinic for sexual dysfunctions in OPD of a GHPU in urban (Kolkata) Eastern India	235 male patients	- Diagnosis as per ICD - 10	- 20.7% reported ED - 30% reported PME - 16.5% reported ED+PME - 8.5% reported decreased desire
Singh et al. (2018)[10]	Rural community of Haryana; Cross-sectional, community-based with multistage random sampling	894 men	- Diagnosis as per ICD – 10	- 81% reported at least one sexual health disorder - 64.4% self-perceived defect in semen - 21% loss of libido - 20.8% masturbation guilt - 5% ED - 4.6% PME
Vivekanandan et al. (2019)[11]	Villages in Kaniyambadi Block, Vellore district, Tamil Nadu; Cross sectional with stratified random sampling of villages	211 men	- International Index of Erectile Function (IIEF) - Chinese Index of Premature Ejaculation	- 29.9% reported ED - 19.4% reported PME
Tripathi et al. (2021)[12]	Patients with ED attending marital and psychosexual OPD in the Dept. of Psychiatry of a tertiary care hospital in North India; Cross sectional	102 men	- International Index of Erectile Function-5 (IIEF) - Arizona Sexual Experiences Scale	Severity of ED (as per IIEF-5 Score) - Mild to moderate (12–16): 26.5% - Moderate (8–11): 50.0% - Severe (5–7): 23.5%
Parkar et al. (2021)[8]	Psychosexual clinic in Mumbai, Maharashtra; Audit of patient case record forms for 1 month	55 total; 53 males	- Diagnosis as per ICD – 10	- 37.7% had 2 or more sexual disorders occurring together - 45.3% reported PME (alone or in combination with other symptoms) - 28.3% reported ED

ED – Erectile dysfunction; PME – Premature ejaculation; HSDD - hypoactive sexual desire disorder; OPD – outpatient department; GHPU – General hospital psychiatric unit; ICD – 10 – International classification of diseases 10th edition classification of mental and behavioral disorders

Certain studies went beyond prevalence and attempted to study various factors associated with male SDs, including psychosocial variables [Table 2]. These studies highlight the impact ED has on the psychological wellbeing of the patients and their partners/spouses. They further emphasize the need for a holistic approach during evaluation and management of cases with SD, including assessment of the partner as well and work on improving the quality of their relationship.[13,14,15]

Table 2.

Summary of studies on factors associated with male sexual dysfunctions

Author - Year	Location and study design	Study population	Tools/scales used	Key results
Thangadurai et al. (2014)[9]	General health clinic, South India; Cross sectional	270 men attending general health clinic	- International Index of Erectile Function-5 (IIEF) - Chinese Index of Premature Ejaculation-5	- Most common perceived causes: Loss of semen due to masturbation and nocturnal emission - Factors associated with ED: DM, financial stress, a history of psychiatric treatment, depression, and anxiety. - Factors associated with PME: common mental disorders, older age and financial debt. - Herbal remedies from traditional healers were popular treatments reported.
Bhagat et al. (2017)[13]	Tertiary care center at Raigarh, Chhattisgarh; Cross sectional	196 men with ED	- Erectile Dysfunction – Effect on Quality of Life (ED-EQoL)	Significant correlations reported with: - dissatisfaction on household income, - blame themselves, - feeling of guilt, - feeling less desirable, - feeling hurt, - feeling of anger or bitterness, - depression, - feeling like a failure, - worry that ED would affect closeness with a partner - worry for future relationships.
Langer et al. (2017)[14]	Urology OPD of a tertiary care center (3-month period); Cross-sectional	155 patients with ED	- Self-administered semi structured questionnaire - International Index of Erectile Function (IIEF) - Perceived stress scale - Rosenberg self – esteem scale - Erectile Performance Anxiety Index	- Life style variables like consumption of drugs and physical activity showed significant association with orgasmic function (P=0.0017) and intercourse satisfaction (P=0.045) domains of IIEF respectively - Statistically significant correlation of all domains of IIEF (except domain of overall satisfaction) with perceived stress, self-esteem and erectile performance anxiety - Erectile performance anxiety more in those performing light physical activity as compared to moderate to heavy activity
Sujith et al. (2017)[16]	Tertiary care centers at Bengaluru, Karnataka; Comparative cross-sectional study	25 men with sexual dysfunction (study group); 25 age, education, marital status & religion matched normal controls.	- Stereotypes about Male Sexuality Scale (SAMSS) - Demographic Clinical Data Sheet (SDCDS)	- Significant difference in stereotypes about male sexuality between men with sexual function and normal controls with more negative stereotyped beliefs in men with sexual dysfunctions
Singh et al. (2018)[10]	Rural community of Haryana; Cross-sectional, community-based with multistage random sampling	894 men	- Diagnosis as per ICD – 10	Factors significantly associated with sexual health disorders were - being never married, - smoking, - cannabis use, - diabetes, and - hypertension.
Vivekanandan et al. (2019)[11]	Villages in Kaniyambadi Block, Vellore district, Tamil Nadu; Cross-sectional with stratified random sampling of villages	211 men	- International Index of Erectile Function (IIEF) - Chinese Index of Premature Ejaculation	- ED associated with single marital status, PME, worry about nocturnal emission and loss of semen, and punishment by God as causal beliefs. - PME associated with DM, alcohol use, ED, anxiety and depression, guilt about masturbation, and belief that nocturnal emission is causal. - Sexual misconceptions stood out prominently in perceived causes
Avasthi et al. (2010)[17]	Marital and psychosexual clinic of a tertiary care multispecialty in North India; Comparative cross-sectional study	Index group: 50 spouses of males with nonorganic ED of at least 6 months; Control group: 50 spouses of sexually functional males	- KDS-15 Marital questionnaire - Quality of Life Enjoyment and Satisfaction Questionnaire - Sexuality scale - Symptom questionnaire - Dyadic adjustment scale - Dysfunction analysis questionnaire	Spouses of men with ED have - Significantly lower levels of marital and sexual satisfaction and higher levels of psychiatric symptoms than controls - Report poor quality of life in most domains of life and had a higher level of dysfunction
Manjula V. et al. (2021)[15]	3 setups of a Metropolitan city in India: (a) the outpatient and inpatient clinical services of a tertiary psychiatric hospital, (b) clinical services of psychiatrists/clinical psychologists in private practice, (c) psychiatry, gynecology, urology, and dermatology outpatient departments of general hospitals; Cross-sectional study	155 individuals with sexual dysfunction (73 couples and 9 individuals)	- MINI v5.0 - Marital Quality Scale - Marital Intimacy Questionnaire - Dyadic Sexual Communication Scale - Sexual Interaction Inventory	- ED and PME in men and HSDD in women were the most common sexual dysfunctions. About 82% of the sample had moderate-to-severe levels of marital distress. - High levels of intimacy problems were seen with no significant gender differences in the overall marital quality or intimacy. - Difficulty in the overall sexual interactions was found with higher levels of dissatisfaction with the frequency of sex and lower self-acceptance reported by men compared to women. - Significant interrelationships found between marital quality and intimacy, sexual interaction, and sexual communication.

ED – Erectile dysfunction; PME – Premature ejaculation; HSDD - hypoactive sexual desire disorder; DM – Diabetes Mellitus; OPD – outpatient department; GHPU – General hospital psychiatric unit; ICD – 10 – International classification of diseases 10th edition classification of mental and behavioral disorders; Mini International Neuropsychiatry Interview, English Version 5.0

Psychiatric and medical comorbidities in men with sexual dysfunctions

Mental and physical health are both significantly associated with SDs. Conditions like anxiety, depression, and diabetes mellitus are often comorbid with SDs.

Table 3 summarizes various studies in the past decade that have looked into various psychiatric comorbidities associated with male SDs.[12,18,19,20,21,22] Whether mental health issues like depression or anxiety play a causal or perpetuating role in SDs or are the result of marital discord and dissatisfaction in sexual intimacy is as yet undetermined with several studies describing the association either way.

Table 3.

Summary of studies on psychiatric comorbidities with male sexual dysfunctions

Author - Year	Location and study design	Study population	Tools/scales used	Key results
Sexual dysfunctions and psychiatric comorbidities:
Rajkumar et al. (2014)[18]	Marital and Psychosexual (MAPS) Clinic of the Department of Psychiatry at a GHPU; Cross-sectional (review of case records)	Case records of 28 men presenting with PME	- Waldinger and Schweitzer taxonomy of subtypes of PME - comorbid psychiatric diagnoses based on the ICD-10–CDDG criteria.	- Comorbid diagnoses were present in 15 of the 28 patients; the most common in order of frequency were psychogenic erectile dysfunction (n=10), Dhat syndrome (n=6), nicotine dependence (n=5), anxious-avoidant personality disorder (n=5), generalized anxiety disorder (n=2), and depression (n=2) - Performance anxiety during intercourse was significantly associated with the acquired subtype of PME (P=0.011, Fisher exact test)
Rajkumar et al. (2015)[19]	Clinic for psychosexual disorders in a GHPU; Cross-sectional (review of case records)	Case records of 64 men with ED or PME	-	- Eight (12.5%) men had comorbid depressive disorders, and fifteen (23.4%) had anxiety disorders. - The disorders predated the onset of sexual dysfunction in the majority of patients. - Generalized anxiety disorder was the commonest anxiety disorder. - Men with pre-existing anxiety disorders were more likely to experience performance anxiety related to sex and to have PME without comorbid ED.
Dudi et al. (2019)[20]	Psychiatric OPD at District Hospital in Western India; Cross-sectional study	156 subjects diagnosed with PME (as per DSM-5 criteria)	- Depression Anxiety and Stress Scale (DASS 21) - Beck Depression Inventory (BDI II)	- 30% subjects were depressed, 35% were anxious and 47% were stressed. - Subjects between 20 and 30 years of age were significantly more depressed than other age groups.
Chepure et al. (2019)[21]	OPD, Department of Psychiatry, Government Medical College, Maharashtra; Cross-sectional study	95 males with main presenting symptoms of PME and/or ED (over a 2-year period)	- Diagnosis as per ICD – 10	41 (43.15%) patients were found to have the diagnosis of anxiety disorders and 23 (24.21%) with depression
Tripathi et al. (2021)[12]	Psychosexual OPD in a tertiary care center in North India; Cross sectional study	102 patients	- MINI - IIEF-5 - Arizona Sexual Experience - HAM – D - HAM – A - Investigations for metabolic syndrome [blood pressure, lipid profile, blood sugar, and body mass index ([BMI)]	- Majority had a moderate level of ED (50%) followed by mild-to-moderate ED (26.5%) and severe ED (23.5%). - PME (46.1%) and depression (28.4%) – most common sexual and psychiatric comorbidities. - Obesity common (62.7%), and only a minority had other metabolic dysfunction, namely, dyslipidemia (7.8%), diabetes (5.9%), and hypertension (4.9%). - Tobacco dependence and alcohol dependence present in 37.3% and 6.9% cases, respectively.
Vasu P et al. (2022)[22]	Urology OPD, South India; Cross sectional study	30 sexually active male patients	- International Index of Erectile Function Questionnaire - The Mini International Neuropsychiatric Interview	- 26 of the 30 study subjects had psychiatric comorbidity, commonly anxiety spectrum disorder (46.15%), depressive spectrum disorder (38.46%), and substance use disorder (15.38%). - 11 patients of the 26 had symptoms suggestive of psychiatric disorder before the onset of ED, though untreated. - 15 patients developed psychological symptoms after the onset of ED, predominantly anxiety disorder, and depressive disorder.
Psychiatric conditions/treatment with comorbid sexual dysfunctions
Krishna et al. (2011)[23]	Multispecialty, teaching tertiary-care hospital, North India; Cross-sectional comparative study	100 patients of diagnosed depressive episode on treatment with antidepressants for the last 3 months and in remission for at least 4 weeks	- MINI - HAM - HAM-A - Global Assessment of Functioning Scale (GAF) - Compliance Rating Scale (CRS) - Arizona Sexual Experience Questionnaire (ASEX)	- 23% prevalence of sexual dysfunction - Highest dysfunction reported in patients receiving paroxetine and imipramine (50%), followed by sertraline (22.72%), venlafaxine (22.22%), escitalopram (21.73%), and mirtazapine (8.3%). - None of the patients receiving fluoxetine (6), fluvoxamine (1), duloxetine (2), desvenlafaxine (1), milnacipran (1), and dosulepin (1) reported sexual dysfunction.
			- World Health Organization Quality Of Life scale (WHOQOLBREF Version) - Dyadic Adjustment Scale (DAS)
Lahon et al. (2011)[24]	Psychiatry OPD of a tertiary care teaching hospital; Cross-sectional – retrospective (review of case records)	169 patients on antidepressant medication	- ADR monitoring data	- Four patients (2.36%) developed sexual dysfunction associated with duloxetine, mirtazapine, trazodone, and sertraline. - Noted prevalence of antidepressant-associated sexual dysfunction lower than that quoted in Western literature, which might be due to the retrospective nature of the study design.
Thakurdesai and Sawant (2018)[25]	OPD of the psychiatry department of a tertiary care hospital; Prospective study (follow-up over 18 months)	56 male patients with depression (ICD–10 criteria); age-matched males control group	- Beck’s Depression Inventory - Arizona Sexual Experiences Inventory - IIEF - Myths and misconceptions	- Most of the patients had mild-to-moderate grades of depression. - 62.5% of patient group had sexual dysfunctions with significant differences with decreased sexual desire, orgasmic problems, and overall dissatisfaction - Myths about masturbation and penile size and shape were higher in the depressed population. - Depression was significantly associated with sexual functioning and treatment with escitalopram showed improvement in depression and satisfaction with intercourse and overall sexual life.
Preeti et al. (2018)[26]	Adult OPD of the Department of Psychiatry of a tertiary care hospital, Karnataka; Prospective study (assessment at baseline, after 2 weeks and 6 weeks)	230 patients with anxiety or depressive disorders who were prescribed antidepressant monotherapy	- Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ)	- At baseline, 138 (66%) of the 209 patients were diagnosed with depressive disorder and 71 (34%) with anxiety disorder; - 29% of patients had sexual dysfunction (in any domain of PRSexDQ). - By week 6, the percentage had increased to 41% – though sexual desire improved, erectile and ejaculatory function in men and orgasmic function in women worsened. - Fluoxetine and sertraline were associated with impaired sexual function, whereas mirtazapine was with favorable sexual function, which remained the case even at week 6.
Atram et al. (2019)[27]	OPD, Dept. of Psychiatry, Tertiary care hospital, Maharashtra; Cross-sectional study	53 married male patients with psychiatric illness (DSM-V criteria) and on regular psychotropic medications for at least 2 months	- PRSexDQ	- The majority of the sample had a diagnosis of schizophrenia - Changes in sexual activity noted by a patient on exposure to psychotropic in the patient - Prevalence of sexual dysfunction noted the highest in patients receiving antipsychotic drugs followed by antidepressants.
Nebhinani et al. (2012)[28]	Multispecialty teaching tertiary care hospital, North India; Cross-sectional study	100 men with psychotic illness receiving trifluoperazine, risperidone or olanzapine for at least 3 months’ duration	- ASEX - PRSexDQ - Sexual side-effects section of modified UKU (Udvalg for Kliniske Undersogelser)	- Rate of sexual dysfunction varied based on scale used (25% on the ASEX, 37% on the PRSexDQ, and 40% on the UKU) - Risperidone showed the highest rate of sexual dysfunction (43%, 50% and 50% on ASEX, PRSexDQ and UKU respectively) followed by trifluoperazine and olanzapine
Grover et al. (2014)[29]	Lithium clinic of a tertiary care teaching hospital, North India; Cross-sectional study	100 married clinically stable patients of bipolar disorder receiving lithium for at least 2 years	- Global Assessment Scale for Functioning - Hamilton Depression Rating Scale - Young Mania Rating Scale - ASEX - Brief Adherence Rating Scale	- Mean duration of lithium use was approximately 119.62 (SD, 99.6) months and mean dose of lithium was 799.5 (SD, 251.4) mg/d - One third of patients (n=37) were found to have SD - Those with SD were older, had lower level of functioning, higher number of other adverse effects with lithium, and poor medication adherence
Grover et al. (2021)[30]	OPD of a tertiary care teaching institute; Cross-sectional study	63 participants diagnosed with Bipolar (I) disorder who were married and/or in a heterosexual relationship and receiving valproate/valproic acid for at least 6 months	- ASEX - UKU other side effect subscale - Brief adherence rating scale	- Three fourth of participants were male (76.2%) - One fourth (28.6%) were found to have SD - Among males, 13.33% to 35.41% reported problem with sexual desire and ED was reported in 13.33% to 31.25% - Those with SD had significantly longer duration of illness, higher prevalence of abnormal blood pressure, and higher mean scores on UKU other side effects scale
Venkatesh et al. (2014)[31]	Drug De-addiction and Treatment Centre (DDTC) of the Department of Psychiatry of a tertiary care multispecialty teaching hospital, Chandigarh, India; Cross-sectional comparative study	Study group: 100 men with opioid dependence for at least 1 year (as per DSM-IV & MINI) for at least 1 year; 50 healthy controls (not dependent on any substance except tobacco)	Both groups: - ASEX - IIEF - Changes in Sexual Functioning Questionnaire Short-Form (CSFQ14) - DAS - HDRS - STAI OD group additionally on: - Clinical Opiate Withdrawal Scale (COWS) - Severity of Opioid Dependence Questionnaire (SODQ)	In men seeking treatment for opioid dependence, in comparison with healthy controls, sexual dysfunction was recorded in - 48% by ASEX, - at least one of the domains in 92% by IIEF - in 90% by CSFQ - prevalence of sexual dysfunction in patients with opioid dependence was significantly higher by each measure
Pendharkar et al. (2016)[32]	Drug De-addiction and Treatment Centre (DDTC) of the Department of Psychiatry of a tertiary care multispecialty teaching hospital, Chandigarh, India; Cross-sectional comparative study	Study group: 101 men with alcohol dependence for at least 1 year (as per DSM-5 & MINI) for at least 1 year; 50 healthy controls (not dependent on any substance except tobacco)	Both groups: - MINI - ASEX - Dyadic Adjustment Scale (DAS) - HDRS - State Trait Anxiety Inventory (STAI) AD group additionally on: - Severity of AD Questionnaire - CIWA-Ar.	- Sexual dysfunction in 58.4% of patients in the AD group - Highest frequency among domains for dysfunction for arousal (57.4%), followed by problems in desire (54.4%), erection (36.6%), satisfaction with orgasm (34.6%) and ability to reach orgasm was least affected (12.87%). - Significant difference in overall dyadic adjustment, in the domains of dyadic satisfaction and affective expression among patient and control groups
Grover et al. (2014)[33]	Drug De-addiction and Treatment Centre (DDTC) of the Department of Psychiatry of a tertiary care multispecialty teaching hospital, Chandigarh, India; Cross-sectional comparative study	48 patients of alcohol use disorder abstinent from alcohol for at least 1 month: Group 1–30 receiving disulfiram; Group 2–18 on baclofen, receiving either medication for at least 1 month	- ASEX	- One-fifth of the patients receiving pharmacoprophylactic medications for alcohol dependence develop sexual dysfunction as a side effect of these medications - Frequency of sexual dysfunction was more in patients receiving baclofen compared with those receiving disulfiram (38.9% in baclofen group vs 10% in disulfiram group)

Several studies have explored the association of psychiatric conditions and their treatment with SDs [Table 3]. A review by J S Manohar et al.[34] mentions SD as one of the common symptoms seen in depression, with complex bio-psycho-social factors playing a role in the same. The difficulty in delineating SD as a result of depression itself or as an adverse effect of antidepressants was brought out in the discussion, and an increased need for awareness regarding the same among professionals was stressed upon.

Psychotropic medications, both antidepressants and antipsychotics, have been associated with SD.[23,24,26,27] Though Thakurdesai and Sawant[25] reported an improvement in satisfaction with intercourse and overall sexual life with treatment for depression, the possible explanation being improvement in libido with improvement in depression, most other studies have reported SD with use of psychotropic drugs with higher prevalence among antipsychotics in comparison to antidepressants.[27] There was a difference among antipsychotics as observed by Nebhinani et al.,[28] though the rate of sexual dysfunction appeared to vary based on the tool used for assessment. The most likely cause implicated for SDs in patients on antipsychotics is hyperprolactinemia and/or monoaminergic dysfunction, and this is often a cause for treatment nonadherence. Reducing the dose of medication and shifting to second-generation antipsychotics with a relatively lesser risk of hyperprolactinemia might be alternative options but may not be feasible in patients with a high risk of relapse or not in remission. Use of PDE5 inhibitors (sildenafil, tadalafil, etc.) has also been advocated in review articles.

Literature on mood stabilizers and sexual dysfunction is sparse. Available studies report SD in some patients, but this is associated with a lower level of global functioning, higher other adverse effects of medication, and poor medication adherence, with the SD thus likely to be the outcome of poorly treated illness rather than the side effect of medication.[29,30]

Substance abuse, especially long-term use of alcohol and opioids, has often been associated with SD. A review article showed higher rates of SD among subjects addicted to heroin (34–85%)/on methadone maintenance treatment (14–81%)/buprenorphine maintenance treatment (36–83%), and naltrexone maintenance (90%) in comparison to general population. Similarly, rates of SD are much higher in alcohol-dependent population (40–95.2%). Common SDs reported among men have been erectile dysfunction followed by premature ejaculation, retarded ejaculation, and decreased sexual desire.[35] A similar trend has been echoed in other studies too.[31,32] A recent systematic review by Sarkar et al.[36] summarized 24 Indian studies on sexual dysfunction among patients with substance use disorders. Most of the studies were pertaining to alcohol dependence and reported that sexual dysfunction ranged from 22.2% to 76% among these patients, while the proportion was between 40 and 90% among those with opioid dependence, though most studies did not report efforts to address bias and confounders. Sexual dysfunction has been reported not just with substance use but also as a side effect of medications used in treatment of alcohol dependence (baclofen, disulfiram).[33]

SDs have been associated with medical conditions as well; for example, ED and coronary artery disease (CAD) are known to share common risk factors. Studies by Kumar et al.[37] and Desai et al.[38] postulate that ED may serve as a clinical marker for cardiovascular disease and advocate further research in this realm. Another common medical condition in India is diabetes mellitus (DM), with India being home to the world’s second largest number of diabetic patients. Studies have found ED to be associated with DM[39,40] and report poor glycemic control as an independent predictor of ED among diabetics.[40] Hence, in metabolic disorders like CAD and DM, periodic evaluation for ED and SD should form a part of routine checkups in view of its predictive value and effect on quality of life. Table 4 summarizes studies reviewed on medical comorbidities and SDs.

Table 4.

Summary of studies on medical comorbidities with male sexual dysfunctions

Author - Year	Location and study design	Study population	Tools/scales used	Key results
Kumar et al. (2013)[37]	Super-Specialty Teaching and Training Medical Institution, Chandigarh; Cross-sectional	175 male Asian Indian patients undergoing coronary angiography	- IIEF -5	- ED reported in 70% male patients undergoing coronary angiography - Patients with ED had a higher incidence of multivessel CAD, diffuse CAD, and a higher number of mean coronary vessels involved compared to those without ED. - The onset of symptoms of ED preceded symptoms of CAD by a mean of 24.6 months in 84% of patients, and presence of severe ED was associated with a 21-fold higher risk of having triple-vessel disease and an 18-fold higher risk of having diffuse angiographic CAD
Desai et al. (2020)[38]	Department of Cardiology, Medical College Hospital, Goa; Cross sectional	92 males <45 years who underwent coronary angiography	-	- ED prevalence was 46.2% - Diabetes, hypertension, and alcohol intake showed significant association with ED - Patients with ED were almost three more likely to have a coronary blockade compared to those not reporting ED
Dan et al. (2014)[39]	Diabetic clinic of a tertiary care teaching hospital in Eastern India; Cross-sectional study	113 male married diabetic patients	- IIEFQ-5 - Dyadic Adjustment Scale (DAS) - Beck’s Depression Inventory (BDI)	- Prevalence of ED was 38.94% - ED group significantly differed from non-ED group in current age, family type, type of treatment for diabetes, presence of micro/macrovascular complications, history of current tobacco use, quality of marriage, and presence of depressive symptoms. - Current age, BMI, and presence of depressive symptoms – significant predictive role on occurrence of ED
Nutalapati et al. (2020)[40]	OPD diabetes clinic at a tertiary care center of South India; Cross-sectional study	720 men who had been diagnosed with type 2 DM	- IIEF-5	- 68.6% of subjects had varying degrees of erectile dysfunction, of which 54.6% had moderate to severe ED. - 55.8% had poor glycemic control (HbA1c ≥7%). - Subjects with ED had a longer duration of DM than those without ED - Longer duration of DM, poor glycemic control, hypertension, peripheral arterial disease, and testosterone deficiency were all independent predictors ED (P<0.05).

Treatment of male sexual dysfunctions

Treatment options for SD have been explored in the past with PDE-5 inhibitors ruling the roost, especially in the treatment of ED. Most practiced pharmacological treatment is use of on demand PDE-5 inhibitors. A prospective randomized comparative study by Ali et al.[41] evaluated the effect of once daily dose of Tadalafil (5 mg) versus on-demand Tadalafil (10 mg) on IIEF score and found Tadalafil 5 mg daily provides a significant increase in score as compared to on demand 10 mg Tadalafil. This study was conducted in the department of urology and followed up the subjects for a period of up to 4 weeks after initiating treatment. They advocated the need for longer duration studies to evaluate for side effects in each group. Review articles also mention use of medications such as Yohimbine and L–arginine and other herbs[42] and alternative therapies like yoga[43] in the management of SDs, but evidence for the same needs further exploration in the form of randomized control trails (RCTs) and larger trials.

Dhat syndrome/Myths related to sex

An intriguing condition characterized primarily by complaints of loss of semen through urine, nocturnal emissions, or masturbation, accompanied by vague symptoms of weakness, fatigue, palpitations, and sleeplessness, was coined as Dhat syndrome by Dr. N.N. Wig. This is primarily seen in the Indian subcontinent and nearby regions and has no physical or metabolic etiology. In their review, Prakash and Rao[1] reported Dhat syndrome to often be associated with myths and misconceptions regarding sexual behavior and practices and sometimes associated with SDs like ED, PME, and psychiatric illnesses such as depression, anxiety states, or phobias. Faith healers and social media often serve as media disseminating myths and misconceptions in our country whose population is still reluctant to talk freely about sexuality and sexual health.[44]

In the past decade, various researchers continued to shed more light on Dhat syndrome and its associated myths and impact on sexual functioning. Studies on prevalence of Dhat syndrome, associated factors, and psychiatric comorbidities are summarized in Table 5. These studies illuminate various myths related to sexuality that are rampant in our society and demonstrate the need of psychoeducation in patients of Dhat syndrome addressing all the aspects related to sexuality and the negative attitude toward sex.[45,46] It is the norm rather than the exception for Dhat syndrome to be associated with comorbidities, the most common being SDs, followed by depression and anxiety,[47,48,49,50] and it is shown to affect the sexual functioning and quality of life adversely.[50,51] There are significant delays in seeking psychiatric care for the complaints with the majority preferring treatment from indigenous practitioners and general practitioners.[52,53] Psychoeducation regarding basic anatomy of male and female genitalia, common sexual practices, and busting of myths and misconceptions is the primary treatment approach in Dhat syndrome, though there continues to be a lacuna in research regarding interventions and treatment aspect.

Table 5.

Summary of studies on Dhat syndrome

Author - Year	Location and study design	Study population	Tools/scales used	Key results
Sawant and Nath (2012)[45]	Psychiatry clinic of a general municipal hospital; Cross-sectional comparative study	32 patients with Dhat syndrome in study group; 33 healthy males in control group	- Questionnaire regarding sexual myths and misconceptions. - BDI	- All patients with Dhat syndrome diagnosed as having depression in comparison to only 30% of the controls - Myths and misconceptions on sexual issues identified in both cases and controls; less common in the control group - Masturbation related myths were most frequent
Grover et al. (2015)[46]	Psychosexual clinic of a tertiary care hospital; Retrospective study	Treatment records of all patients registered with the clinic (January 2006 to July 2014) – 264 cases of Dhat syndrome	- Sex Knowledge and Attitude Questionnaire (SKAQ-II)	- A higher level of education was significantly association with better sexual knowledge and a liberal attitude with a significant positive correlation between sexual knowledge and attitude. - About half (51.9%) of patients had at least one comorbid psychiatric disorder (the most common - depressive disorders) and/or SD - Psychiatric disorders (PME most common) with symptoms of Dhat syndrome preceded the onset of other disorders. - Poor sexual knowledge involved several spheres of sexuality, including semen formation and masturbation.
Grover et al. (2016)[54]	15 centers across India (5 in North India, 4 from eastern India, 2 from Central India, 2 from western India, and 2 from South India); Cross-sectional study	780 patients with Dhat syndrome	- Dhat Syndrome Questionnaire	- The most common reasons for passage of Dhat were excessive masturbation (55.1%), sexual dreams (47.3%), excessive sexual desire (42.8%), and consumption of high energy foods (36.7%). - Passage of Dhat is experienced mostly through ‘night falls’ (60.1%) and while passing stools (59.5%). - The most common consequence due to passage of Dhat was weakness in sexual ability (75.6%). - The most common psychological/somatic symptoms included bodily weakness (78.2%); feeling tired or having low energy (75.9%); feeling down, depressed, or hopeless (67.9%); and little interest or pleasure in doing things (63.7%). - About half of the patients (49.1%) expected that energizing medications like vitamins/tonics/tablets were required; more than one-third (38.2%) expected there was a need for taking energizing injections
Grover et al. (2015)[47]	15 centers across India; Cross-sectional study	780 patients with Dhat syndrome	- ICD–10 criteria	- About one-third (32.8%) of the cases had no comorbidity. - One-fifth (20.5%) of the patients had comorbid depressive disorders, and another one-fifth (20.5%) had comorbid neurotic, stress-related, and somatoform disorders. - Half (51.3%) of the study sample had comorbid SD - more than one-fourth (28.7%) of the patients had only comorbid SD; one-sixth (15.9%) had only comorbid depressive/anxiety disorders, and a little more than one-fifth (22.6%) had comorbidity of both SD and depressive/anxiety disorders.
Chakraborty et al. (2020)[48]	Psychiatric OPD in a tertiary care medical college hospital, West Bengal; Cross-sectional study	122 patients with Dhat syndrome	- Semistructured proforma - MINI	- Routes of passage of semen were night falls in 62.3% patients and through urine in 52.5% patients with many reporting passage through more than one route. - All patients (100%) complained about generalized weakness and thinning of semen. - 66.4% had generalized body ache, 55.7% headache, 60.7% decreased body glow, 50% loss of appetite, 98.4% had decreased self-confidence, sleep disturbance in 34.3%, 58.2% reported that their penis was becoming smaller, and 49.2% patients reported decreased sexual capability. - The most common comorbid condition was SD (39.3%) with PME in 54.17% and ED in 33.33%, followed by depressive disorders (27.9%).
Bamania et al. (2021)[49]	Psychosexual clinic in the Psychiatry Department of a tertiary health care center in Ahmedabad; Cross-sectional study	54 patients with Dhat syndrome	- HAM – D - HAM – A	- 25.93% had mild symptoms of depression, 14.81% had moderate severity, and 9.26% had severe symptoms of depression. - 74% had anxiety of mild severity, 19% had mild to moderate severity, and 7% moderate to severe intensity of anxiety. - 51.85% had comorbid SDs (ED and PME).
Shahi et al. (2022)[51]	Psychiatry OPD of a tertiary care center in North India; Comparative cross-sectional study	117 cases of Dhat syndrome and 117 matched controls	- ICD – 10 DCR - WHO QoL-BREF - WHODAS 2.0.	- Most of the patients (72.64%) had comorbidities (psychiatric/sexual). - QoL of patients with DS was poor compared to healthy individuals, and QoL of those with comorbidity was significantly worse than that of those without. - The disability of patients with DS was more than that of healthy individuals (significant in all domains of WHODAS.
Singh et al. (2016)[52]	Psychiatry outpatient services of a tertiary care hospital; Cross-sectional study	55 patients with Dhat syndrome	- WHO pathway study encounter form (modified)	- The mean duration of illness was 6.48±5.64 years. - The mean time to first seeking help was about 1.85±2.14 years. - The time between first seeking help and seeing a psychiatrist was about 4.63±5.35 years - Patients saw about 3–4 care providers before reaching a psychiatrist. - The majority of the patients (49.1%) first contacted unqualified practitioners. - Seeking treatment from a psychiatrist was majorly by self-referral (40%).
Grover et al. (2016)[53]	Psychosexual OPD of a multispecialty teaching tertiary care hospital in North India; Cross-sectional study	47 patients with Dhat syndrome	- List on information regarding previous help/treatment taken for symptoms	- Comorbidity – any psychiatric illness or SD present in 61.7% of the patients. - The mean age at onset of symptoms was 20.38±6.91 years - The mean duration of symptoms of Dhat before the patients presented to psychosexual clinic was 6.78±6.94 years - The mean number of agencies/helps contacted before reaching OPD was 2.85±1.40. - The favorite choice for the first contact was indigenous practitioners (Ayurvedic doctors most preferred), followed by asking for help from friends or relatives, allopathic doctors, and traditional faith healers or pharmacists. - Absence of comorbid SD in patients with Dhat syndrome predicted an earlier visit to center as compared to those with comorbid SD.
Manore et al. (2020)[50]	Psychiatry OPD in a tertiary care general hospital in western India; Cross-sectional study	100 patients of Dhat syndrome	- PHQ–9 - Semistructured questionnaire (for beliefs and help seeking)	- Depression was found in 38% cases. - Patients reported a significant decline in sexual functioning after the onset of Dhat. - Associated complaints: 18 had PME, 28 had ED, and 20 reported a small penis size - Most patients had consulted nonpsychiatry ‘experts’ – quacks, general practitioners, or practitioners of Ayurveda/homoeopathy/Unani, and dermatologist–venereologist. - Most patients believed that Dhat can cause the somatic symptoms commonly seen in depression and SDs.

A recent review by Kar et al.[55] sums up that though Dhat syndrome is a commonly diagnosed entity, research in the area is sparse and of poor quality, with several articles citing a lack of representativeness of the population and poor generalizability. There is scope for a lot more work on the disorder, especially regarding building awareness and education regarding common myths and misconceptions.

Sexual dysfunctions in females

The awareness regarding female SDs has increased in the past decade, with there being more openness to talk and approach a doctor for the same. The impact of media and the influence of OTT platforms has created awareness and started discussion forums among young females. Women have, in general, become more aware of their needs and desires and are open to experimenting with their partners. Female SDs do primarily present to the gynecologist than the psychiatrist as compared to male sexual disorders. Overall, the studies done by Indian psychiatrists in this area are picking up. In their last update (2010), Prakash and Rao[1] described studies in women in the late seventies, with some research being generated around 2007 to 2009. However, this number has improved, though the various nuances of female SD remain unexplored. Table 6 gives the various studies done by Indian researchers on SD in females with some studies highlighting the factors that could impact the SD.

Table 6.

Studies of sexual dysfunctions in females in the past 15 years

Author - Year	Population/Sample size	Tools used/Evaluation	Key Results	Factors impacting FSD	Factors not impacting FSD
Singh et al. (2009)[56]	149 women attending a medical clinic in South India	FSFI	73% had FSD as per FSFI with difficulties related to: • desire (77.2%) • arousal (91.3%) • lubrication (96.6%, achieving orgasm (86.6%) poor satisfaction (81.2%) pain (64.4%)	age, years of education, monthly income, and years since marriage	menopausal status, living in a nuclear or joint family, and the presence of genitourinary complications
Varghese et al. (2012)[57]	150 young married females of South India	DSM IV criteria WHO QOL-BREF	49 women had FSD: • hypoactive desire disorder (17%) arousal disorder (15%) • orgasmic disorder (18%), • genital pain disorder (8%) • vaginismus (7%). 42.86% of them had a single disorder, whereas 30.61% reported two conditions FSD impacted quality of life in social and environmental domains.
Viswanathan et al. (2014)[58]	282 women in rural Tamil Nadu	FSFI SEMI GHQ12	64.3% had FSD as per FSFI 4.7% considered it a problem, 5.8% expressed dissatisfaction 2.5% sought medical help	unhappy marriage, stress and physical problems
Mishra et al. (2016)[59]	153 fertile females attending obstretics and gynecology OPD	FSFI	55.55% had FSD as per FSFI with difficulties related to: • desire (73%) • arousal (78%) • lubrication (71%, • achieving orgasm (70%) • poor satisfaction (61%) • pain (73%)	Middle level of education, more than 16 years since marriage	Gynecological or medical disorders
Jain et al. (2019)[60]	110 postmenopausal women of North India	FSFI	80.9% of the sample had FSD as per FSFI with difficulties related to: • desire (98.3%) • arousal (95.45%) • lubrication (89.09%, • achieving orgasm (89.09%) • poor satisfaction (86.36%) • pain (60%)	increasing age, menopause the presence of a joint family structure, low socioeconomic and education status	Parity, substance use, past medical and gynecological disorders, partner factors like medical disorders, substance use and sexual disorders
Sharan et al. (2019)[61]	22 married women	ICD11	• hypoactive sexual desire dysfunction -15 • reduction in sexual arousal-18 • marked infrequency of orgasms-10 • sexual pain penetration disorder-16

A qualitative study done by Sharan et al.[61] for the field testing of ICD-11 diagnoses for female dysfunctions revealed that of the 22 married participants, most had sex to please the husband or do the duty of a wife. Many had no prior knowledge about sex or what to do or whom to ask before marriage. Reporting of sexual difficulties was done partially and mostly to the husband as they did not want to be misunderstood; they would talk about lack of desire but not about difficulty in achieving orgasm. None of the participants had reported their difficulties to a doctor. Many also found it difficult to understand the sexual terminologies in the Hindi language as they had never heard the terms. The study highlighted the reticence seen in the culture of this country where even if the women wanted emotional intimacy, they could not talk about sex to their partner. These factors impact the diagnostic criteria which may not look at these core issues and cultural attributes.

A lot of review articles on female sexuality and the assessment of female SDs do talk about the need to still create awareness in society about these problems.[62,63] Marital problems and social difficulties affected the female sexual response cycle. Hence, the social restrictions faced by the women and the taboo and stigma associated with speaking about sex-related issues need to be tackled at the forefront.

Medical and psychiatric comorbidities in women with sexual dysfunctions

Apart from studies done in the general population, there have also been studies done on female SDs in mental illnesses like schizophrenia, depression, and substance use disorders, which give us insights into the prevalence of the problem.[64,65,66,67,68,69,70,71,72,73] Table 7 describes the association between various psychiatric comorbidities like depression, schizophrenia, and the impact of antidepressants on the sexual functioning.

Table 7.

Medical and psychiatric comorbidities in women with sexual dysfunctions

Psychiatric Conditions and Sexual functioning
Author - Year	Morbidity, number of patients	Results
Abhivant and Sawant (2012)[64]	Major Depression – Drug-naïve – 49 patients	33 (67.34%) had clinical sexual dysfunction: 26 (53%) had lubrication dysfunction, 25 (51%) had orgasmic dysfunction, 24 (49%) had pain and 22 (45%) had dysfunction of desire, arousal and sexual satisfaction
Grover et al. (2012)[65]	First episode or Recurrent Depression Disorder on stable dose of single antidepressant – 80 patients	All the domains of sexual functioning were impaired by antidepressants.
Grover et al. (2014)[66]	Patients on antidepressant medication for at least 3 months with no or minimal symptoms – 71 patients	About four-fifths of those receiving antidepressants have sexual dysfunction; higher prevalence of dysfunction in domains of sexual desire and arousal.
		Only 12% discussed these side effects with the treating psychiatrist, when asked and only 4% spontaneously reported the same.
Abhivant and Sawant (2014)[67]	Depression in remission but on antidepressant escitalopram/sertraline - 49 patients	Significant improvement in sexual functioning
Roy et al. (2015)[68]	Major Depression – Drug-naïve patients	70% had sexual dysfunction
Sreelakshmy et al. (2017)[69]	Major Depression - 40 patients	90% of the patient’s sexual dysfunction
	Medical comorbidities	27.5% of the participants; diminished sexual desire
Roy et al. (2019)[70]	Depression in remission but on antidepressant escitalopram - 50 patients	90% of them had decreased desire, 86% had decreased arousal, 54% had decreased lubrication, 68% complained of decreased orgasm, 62% had decreased satisfaction, and 32% complained of pain during sexual activity
Penubarthi et al. (2022)[71]	Depression in remission but on antidepressant SSRIs-50 patients	56% had sexual dysfunction most sexual dysfunction was in the domains of lubrication and orgasm.
Simiyon et al. (2016)[72]	Schizophrenia	44 of 63 schizophrenic women, with predominantly decreased desire reported by all women, decreased arousal by 58 (92.1%), poor lubrication by 30 (47.6%), impaired orgasm by 48 (76.2%), poor satisfaction by 44 (69.8%), and pain by 23 (36.5%).
Bn AK et al. (2017)[74]	Alcohol dependence	55% had one or more sexual dysfunctions, as per Arizona Sexual Experience Questionnaire[ASEX]. Most complained of low sexual desire (55%), inability to reach orgasm (52.5%), and dissatisfaction with orgasm (50%)
Medical Conditions and Sexual Functioning
Karan et al. (2015)[75]	Epilepsy	Women with epilepsy had lower scores (indicating poorer sexual functioning) on all FSFI subscales
Kunkeri et al. (2017)[76]	Patients taken for tubal ligation	Pre tubal ligation: 36.7% of the women had sexual dysfunction, including difficulties in orgasm (75%), lubrication (73.3%), desire (70%), arousal (66.7%), and satisfaction (57.14%), as per FSFI. Only 28% experienced pain symptoms
		Post tubal ligation: 71.1% of women complaining of sexual dysfunction in the domains of orgasm, arousal, and desire

Abhivant and Sawant[57] studied the prevalence of FSD in drug-naïve depressed women along with prevalent myths and misconceptions in Indian culture. There was significant association between SD and depression. The study found that the entire sample had several myths and misconceptions about menstruation and sexuality, whereas 98% had myths about pregnancy, and 84% about breast size. There are not many studies looking into the prevalent myths regarding sexuality in females. A similar study by Sreelakshmy et al.[69] done in 40 women with major depressive disorder found SD in 90% of the patients. Medical comorbidities were seen in 27.5% of the participants with a significant association between patients with both depressive and medical comorbidities and diminished sexual desire. Roy et al.[68] also found a prevalence of 70% SD in drug-naïve depressed women and an early age of onset of SD, that is, 18–25 years, with the onset of depression. The authors reported that ASEX-F was a better tool in determining female SD in depression than FSFI.

On the other hand, a study done in 50 patients to assess sexual functioning in females with depression in remission revealed that nearly half the sample had higher SD scores on FSFI. The authors inferred that SD persisted even after remission of depression, which could be an aftermath of depression or antidepressant-induced sexual side effects.[70] Another study by Abhivant and Sawant[67] noted significant improvement in sexual functioning in depressed women treated with escitalopram or sertraline in 6 weeks. Grover et al.[65,66] reported that SD was quite prevalent in married female patients receiving antidepressants, and all the domains of sexual functioning were impaired by antidepressants.

Penubarthi et al.[71] thought that SSRIs were responsible for SD in the domains of lubrication and orgasm in their sample of women with depression in remission on SSRIs.

Simiyon et al.[72] reported SD in 44 of 63 schizophrenic women with a poor marital quality and an impact of side effects of the antipsychotics such as weight gain, menstrual disturbances, galactorrhea, and dryness of vagina on sexual functioning. Kumar PNS et al.[73] also found significant SDs in two groups of patients receiving risperidone (93%) and olanzapine (83%), respectively, which affected all domains of sexual functioning on the Changes in Sexual Functioning Questionnaire. Krishnegowda et al.[77] studied the association between the dose of antipsychotics and SD and concluded that occurrence of SD with atypical antipsychotics was not dose-dependent, and risperidone was a major reason, with olanzapine having lesser sexual side effects, whereas data with quetiapine were inconclusive.

Bn AK et al.[74] studied SD in women with alcohol dependence and found that predictors of developing SD in alcohol dependence included low educational qualification, initiation of alcohol at earlier age, longer duration of alcohol consumption, and dependence on the substance.

A study on SD in women with epilepsy also found significant impairment on all domains of FSFI as compared to controls. Those with a longer duration of seizures had poorer sexual functioning, whereas the type of seizure, antiepileptics, or other demographic variables did not affect overall sexual functioning.[75]

Kunkeri et al.[76] studied the impact of tubal ligation on sexual functioning and reported that despite a high prevalence, none of their samples felt the need to discuss the issue with their treating doctors. Indian women need to be made aware and sensitized to the pleasurable effects of sexual function. They should be informed about their physiological and psychological states, which could impact sexual function and thereby affect their quality of life.

An interesting study on yoga to improve female SDs reported significant improvement across all domains of sexual functioning on FSFI after completion of a 12-week yoga course.[78] The improvement was also more pronounced in older compared to younger women. The authors concluded that yoga seemed an alternative effective method to help with SDs.[78]

Couple/marital relationships and sexual health

There are limited available data on couples receiving treatment for SDs or on research related to marital and sexual functioning. This scarcity could be attributed to the cultural taboos that persist or the lack of awareness among couples to seek help and treatment for sexual issues.

One of the earliest studies on patients attending marriage or sex clinics in India revealed that the majority of the patients were males aged between 20 and 29 years for problems such as premature ejaculation (76%), impotence (36%), misconceptions (46%), anxiety symptoms (32%), and somatic symptoms (40%), among others. Additionally, patients with marital problems often had primary issues related to their relationship with their spouse. The study also noted that educated males from urban backgrounds were more likely to seek medical help for their sexual problems, while only 2% of females sought help in this context.[79]

A study on couple satisfaction in urban and rural Dharwad showed that couples in the early years of marriage reported higher satisfaction levels, with urban couples being generally more satisfied than the rural ones. Interestingly, there was no significant association of satisfaction with the duration of marriage, economic status, or the number of children.[80]

Sawant et al.[81] described a case report involving sex therapy for an unconsummated marriage, with both male and female therapists. The couple underwent about 8 weekly sessions, during which they learned communication skills, engaged in sensate focus with touching exercises, and employed behavioral techniques to reduce fear and facilitate dilatation using fingers. Vaginismus and dyspareunia, though common problems, rarely present to psychiatrists, with many females often seeking gynecological opinions instead. There is limited Indian literature on the treatment techniques used for these disorders.

Maitra et al.[82] conducted a study aimed at improving women’s sexual health as part of a multilevel community, clinical, and counseling intervention project, in association with gynecological services, in a low-income community in Mumbai, India. This intervention included group couples’ sessions (four single-gender and two mixed-gender) addressing marital dynamics, aiming to enhance women’s sexual and marital health. The study identified challenges related to male participation and observed changes in couple and family dynamics, sexual health knowledge, and emotional wellbeing.

Aggarwal et al.[83,84] conducted a comparative study on marital functioning, SD, and sexual satisfaction among 76 patients with schizophrenia and 58 patients with depressive disorder, along with their respective spouses. The findings revealed poor marital adjustment and low-quality marriage among patients with schizophrenia, as compared to those with depressive disorders. Patients with schizophrenia also reported significantly lower sexual satisfaction, although there was no significant difference in the prevalence of SD between the two groups. Another study on marital adjustment among remitted patients with schizophrenia, depression, bipolar disorders, and their spouses showed that patients, especially those with schizophrenia, perceived poor marital adjustment and expressed high marital dissatisfaction, though no such view was shared by their spouses.[85]

Sahu et al.[86] conducted a study on marital adjustment in 30 spouses of male schizophrenic patients and 30 matched controls, finding significant differences in sexual adjustment within the patient group.

Recently, there has been an emerging interest in studying sexual functioning during the COVID-19 pandemic and associated restrictions. An online survey conducted by Grover et al.[87] found a reduction in the frequency of sexual intercourse and intimacy (in the form of fondling, caressing, touching, or kissing partner when not doing sexual intercourse) during the pandemic. However, it also noted an improvement in overall relationship quality and communication with partners, along with a decrease in interpersonal conflicts. Sahoo and Grover[88] in their comparative analysis of patients availing marital and psychosexual clinic services in pre-COVID and COVID era reported around 1.75 times increase in cases during the COVID period through telemode with younger population, females, and those from urban localities reaching out. Furthermore, significantly higher numbers of patients were diagnosed with premature ejaculation (PME) and PME + erectile dysfunction as compared to the pre-COVID timeframe. The long-term impact of this period is yet to be thoroughly studied.

Geriatric sexual health

Research on the sexual functioning of the elderly is minimal due to common beliefs that sexual needs for both sexes are reduced due to aging, retirement, physical and medical comorbidities, and so on. Consequently, sexual health is often neglected, potentially affecting interpersonal relationships. Rao et al.[89] conducted a door-to-door survey in a small village near Mysore, enrolling 259 participants, with the majority in the age group of 66–75 years. Only 27% of the participants were sexually active, that is, had engaged in sexual intercourse at least once in the past year, and as age increased, sexual activity decreased to nil. Among the sexually active participants, 49% had SD as per ASEX, with 43% experiencing erectile dysfunction, 10% premature ejaculation, 28% female arousal dysfunction, 16% hypoactive HSSD, 20% anorgasmia, and 8% dyspareunia. The prevalence of SDs also increased with medical comorbidities.

A qualitative explorative study by Banerjee and Rao[90] involving 20 participants above 60 years of age revealed various perceptions related to sexual encounters in later life, expectations from partner, barriers in discussing sexual health issues, and unmet needs related to sexuality. Themes that emerged included touch as an index of intimacy, perceived satisfaction beyond physical pleasure, personal meanings attached to sex, companionship and support, continuity of care, physical proximity and intimacy, stigma, social stereotypes about sex in later life, dismissal in healthcare services, lack of audience/understanding, and orientation and age-based discrimination. Their study concluded that older people enjoyed sexuality and retained their sexual desire and interest, though the manner of expression varied. The authors emphasized the need to recognize older adults’ sexual needs, which should be respected and implemented in healthcare training, services, research, and policy interventions.

A review article by D’cruz et al.[91] on expression of intimacy and sexuality in people with dementia highlights the fact that sexual health is a fundamental right of older adults. However, dementia can lead to the cessation of sexual life due to the loss of capacity to consent to intimacy or a lack of desire. Nevertheless, until they lose the capacity to consent in moderate stages of dementia, individuals affected by dementia can continue to be sexually active. Dementia can also lead to inappropriate sexual acts and behaviors, and there is an increased risk of sexual abuse, especially in residential care settings, which needs to be addressed with sensitivity.

The Clinical Practice Guidelines (CPG) of IPS on the management of Sexual Disorders in the Elderly[92] provide a detailed account of the factors, assessment, investigations, and management of sexual disorders in the elderly. Various psychotherapeutic and pharmacological treatments are elaborated upon in detail for the elderly. The focus is on understanding the various nuances of geriatric sexual health and the physiological and environmental factors that affect sexual expression. Improving lifestyle modifications with advocacy and effective coping strategies will enhance the quality of life and intimacy among the elderly.

LGBTQIA and sexuality

Research on the LGBTQIA population is very limited. Most of the articles have focused on gay rights[92] and the transgender status in India,[93] which, despite the Transgender Persons (Protection of Rights) Act, 2019 and Rules, is still not accepted by the Indian public at large. There is still a significant need for creating awareness about the harm caused by stigmatization and discrimination against the same sex-oriented people. Laws regarding same-sex marriage are also yet to be established in India.

A qualitative study on the challenges faced by transgender adults above 60 years of age during the COVID-19 pandemic in India revealed the difficulties they encountered due to both their age and their identity as the third gender. They had limited access to healthcare, which increased their physical and psychological vulnerabilities.[94] Such studies are essential for understanding the unmet needs of this population.

Aqeel et al.[95] studied the sexual health problems and health-seeking behaviors of MSM (Men having sex with men) population. They found that nearly 71% of the participants complained of sexual health problems, such as anal and perineal problems (26.9%), genital/oral vesicles (26.9%), burning micturition and genital ulcers (19%), and oral ulcers (11%). Most of the participants (70%) sought help from allopathic doctors, while one in five MSM sought from an ayurvedic doctor. The study highlighted the need for comprehensive healthcare facilities for the third gender to address their sexual health problems.

The way forward

Although training in sexual health is lacking in most medical colleges, there is a gradual change, with some recognized hospitals now offering fellowship and certificate courses in sexual medicine.[96] Additionally, certificate courses are conducted by institutes of sexology and obstetrics and gynecology. Most psychiatry departments do offer sex clinics where patients with conditions like Dhat syndrome are attended to. Couple and marital counseling or dealing with the couple SDs are usually done in places where the faculty is more oriented toward sexual medicine. However, there is still a gap in teaching and learning that exists pan-India, which can be partially overcome by conducting Continuing Medical Education (CME) programs and workshops focused on SDs and understanding human sexuality.

Improving history-taking skills is crucial as there are very few laboratories in the country that monitor the physiological changes related to the sexual response cycle. Hence, a detailed history remains the primary tool for establishing the same. Raising awareness and developing the soft skills of every undergraduate (UG) and postgraduate (PG) student in the medical curriculum is the need of the hour.

Most of the tools used to identify SDs, like the various scales, are often not diagnostic and not standardized for the Indian population. The multitude of dialects in India and individual and cultural variations make it challenging to understand the SD that individuals are experiencing. There is a strong need for researchers from India to devise simple scales that can be understood by the general population. Having visual analog scales to assess the intensity and emotions associated with SDs could aid in research in this country [Figure 1].

Figure 1.

Scope for improvement in psycho-sexual health

There is a definite need for more research in this area, especially concerning the elderly and the LGBTQIA population, to better understand the problems they face. Organizations like the Indian Psychiatric Society (IPS), which has a Sexual Medicine Specialty Committee, have played a significant role in increasing awareness among various practicing disciplines about sexual health problems and their management through regular programs over the past 3–4 years. The committee has also conducted full-day interactive workshops to train PGs in various parts of India, enhancing their knowledge and skills.

The IPS has also published several Clinical Practice Guidelines in the past 15 years on the management of SDs,[97] child sexual abuse,[98] therapies for SD,[99] forensic and legal aspects of sexuality and offences,[100] and sexual health in consultation liaison.[101] These guidelines are easy to follow and accessible when in doubt. Additionally, the IPS Textbook of Sexuality and Sexual Medicine is a comprehensive reference book.[102]

Moreover, the Journal of Psychosexual Health is the only sexuality-focussed journal in the whole of Asia and Oceania countries, published in India. It provides an opportunity to publish psychosexual health-related research and serves as a repository for archived articles that can be accessed.[103]

CONCLUSION

This review has highlighted the available research in the field of psychosexual medicine in India over the past 12 years. The studies included quantitative and qualitative research conducted in both urban and rural settings across various age groups and special populations. However, research is still limited for a vast country like India, with numerous religious and cultural variations that can impact the psychosexual health of its population. These areas need to be addressed, along with unmet needs. While many studies have identified problems, there have been relatively few studies on the management and treatment of psychosexual issues. Researchers and those trained in psychosexual health need to develop guidelines for various age groups and special populations as these are currently lacking in India.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.