Prevalence and association of sexual dysfunction in male patients with alcohol dependence syndrome

Abstract

Background:

Chronic use of alcohol is usually associated with poor sexual functioning. Sexual dysfunction is often associated with disharmony in relationships, which ultimately leads to an increase in alcohol consumption.

Aim:

This study aimed to find out about various aspects of sexual dysfunction related to alcohol dependence syndrome (ADS).

Material and Methods:

A cross-sectional observational study was conducted among married males and living with their families and admitted to a tertiary care center. The patients consuming alcohol were assessed using psychometric tools, including the alcohol use disorders identification test, the severity of alcohol dependence questionnaire, and the international index of erectile function. Data from 234 male patients were analyzed using descriptive statistics.

Results:

The study found a high prevalence of sexual dysfunction among the participants. Specifically, 41.5% of patients reported decreased sexual desire, 40.6% experienced a loss of overall satisfaction, and 38.9% suffered from erectile dysfunction. Patients with ADS showed significantly higher levels of dysfunction in orgasmic function, sexual desire, erectile function, and overall satisfaction compared to those without ADS. However, there was no significant difference in terms of intercourse satisfaction between the two groups. Longer durations of alcohol use were associated with a greater degree of sexual dysfunction across all domains of sexual functioning.

Conclusion:

The study highlights the significant association between alcohol dependence syndrome and sexual dysfunction. Routine assessment and intervention for sexual health issues should be integral to the management of alcohol dependence.

Sexual functioning is a requisite biological process, and it also involves a complex interaction among biological, socio-cultural, and psychological factors.[1] Sexual dysfunction in men is a spectrum of presentations that encompasses decreased sexual desire, difficulty with erection, premature ejaculation, and difficulty in achieving orgasm.[2] In many clinical contexts, a precise understanding of the etiopathogenesis of sexual dysfunction is still unknown. It further requires an explanation of sexual dysfunction regarding the effects of alcohol.[1] It has been observed that erectile dysfunction is very common in men who consume more than three standard units of alcohol (12 g ethanol) on a daily basis.[1]

Only 26% of men discussed their sexual problems with a physician.[3] It is a common belief that alcohol and other substances overcome sexual performance anxiety and improve sexual functioning.[4] However, contrary to their belief, chronic and persistent use of alcohol causes sexual dysfunction.[5] Problems in sexual functioning are often associated with disharmony in relationships, anger, and marital discord, which ultimately led to worsening and increasing alcohol consumption.[6] The prevalence of sexual dysfunction was reported from 8% to 95.2% in the medical literature.[6] Some factors, such as old age, lower education, unemployment, early age of onset of alcohol use, longer duration of alcohol dependence, tobacco use with alcohol, more amount of alcohol use, and the presence of liver disease, are found to be predictors of sexual dysfunction.[4,7] However, a few studies found no association between sexual dysfunction and alcohol intake.[8] This study is aimed at finding out the prevalence of sexual dysfunction in patients with alcohol dependence syndrome (ADS) and the association of sexual dysfunction with other variables of alcohol use.

MATERIAL AND METHODS

This is an observational cross-sectional study carried out at a tertiary care center. The study protocol was initially approved by the institution ethical committee (IEC/2021/474 dated August 28, 2021). The study population was limited to male inpatients because the de-addiction facility was provided only for male patients. The study subjects were selected randomly (every 3^rd patient) from the study population over a duration of two and a half years after obtaining written informed consent. The sample size for an infinite population: n = Z² × p × q/e² where n = sample size for an infinite population, Z = Z score, p = population proportion, q = 1 − p, e = margin of error. Sexual disorders ranging from 8% to 95.2% have been reported in males with chronic alcohol use.[6] Therefore, a sample size of more than 73 was considered.

All the male patients with a history of consuming alcohol were evaluated as per the International Classification of Disease (ICD)-10 criteria. The sociodemographic details were collected, and psychometric tools, including the alcohol use disorders identification test (AUDIT) to screen for dependence, the severity of alcohol dependence questionnaire (SADQ) to assess the severity of dependence, and the international index of erectile function (IIEF) to assess sexual functioning, were administered. The study subjects were included for analysis after consideration of the inclusion and exclusion criteria.

Inclusion criteria:

1. Individual in the age group of 18–60 years.

2. Individual with a history of consuming alcohol.

3. Individual is married or sexually active and living with the partner.

Exclusion criteria:

1. An individual has co-morbid medical/surgical illnesses that led to sexual dysfunction (Diabetes, Metabolic syndrome, Cirrhosis, Spinal injury, Neurological disorder, etc.) and a history of sexual dysfunction prior to the onset of alcohol consumption.

2. Individual has been having a history of psychiatry illness and consuming substances other than alcohol (Marijuana, Cocaine, Opioids, etc.).

Descriptions of scales

AUDIT is a 10 items questionnaire. Each question is scored 0–4, and the maximum score is 40. A total score of 8–12 is considered hazardous or harmful drinking. A score of 13 or above is considered alcohol dependent. Internal reliability (Cronbach’s α) was 0.84.[9]

SADQ has 20 items. Each item is scored 0–4. A score of 31 or higher indicates severe, 16–30 indicates moderate, and below 16 indicates only mild physical dependency. Internal reliability (Cronbach α) was 0.914.[9]

IIEF Questionnaire with 15 questions have a score of 0–5 for each question. It examines the four main domains of male sexual function: erectile function, orgasmic function, sexual desire, and intercourse satisfaction, along with overall satisfaction. Internal reliability (Cronbach α) was 0.94.[10]

A total of 250 patients were included in this study during an 18-months period. Out of these, 16 patients (10 patients with multiple substance use, 6 patients with medical comorbidity) were excluded as per the exclusion criteria. A total of 234 patients were included for analysis. The data were analyzed using Microsoft excel and SPSS version 20. The frequency and percentage were calculated using descriptive statistics for categorical data. The mean and standard deviation were calculated for continuous variables. Chi-square and fisher’s exact test were used to compare categorical variables using cross-tabulation. The P value was adjusted using the Bonferroni method for small values with the Z test and considered significant if it was < 0.05.

RESULTS

The mean age (SD) of the study population was 35.6 (5.23) years.

Table 1 depicts the maximum number of study population in the 30–39 years age group. The majority are from the Hindu religion. There are 65.4% of the study population who are educated up to higher secondary. The majority of study participants were skilled workers. The majority of participants (62.4%) have been consuming alcohol for a duration of 1–10 years. Mild dependence was found to be the maximum in study participants. Loss of sexual desire was highest among the different sexual functioning domains.

Table 1.

Frequency of sociodemographic variables

Sociodemographic variables		n	%
Age group	18–29 years	36	15.4
	30–39 years	144	61.5
	40–49 years	54	23.1
Religion	Hindu	225	96.2
	Muslim	3	1.2
	Others	6	2.6
Education	Middle school (6th–8th)	6	2.6
	Secondary (9th–10th)	45	19.2
	Higher Secondary (11th–12th)	153	65.4
	Graduate (B.A., B.Sc., etc.)	30	12.8
Occupation	Semi-skilled worker	33	14.1
	Skilled worker	159	67.9
	Arithmetic skill jobs	36	15.4
	Professional	6	2.6
Monthly Income (INR)	21,376 to 35,626	15	6.4
	35,627 to 53,439	156	66.7
	53,440 to 71,253	54	23.1
	71,254 to 1,42,507	9	3.8
Duration of alcohol use	1–10	146	62.4
	11–20	70	29.9
	>20	18	7.7
Alcohol Dependence	No	107	45.7
	Yes	127	54.3
Severity of dependence (n=127)	<16=Mild dependence	97	76.4
	16–30=Moderate dependence	21	16.5
	>30=Severe Dependence	9	7.1
Sexual Dysfunction (n=234)	Erectile Dysfunction	91	38.9
	Orgasmic dysfunction	86	36.8
	Loss of sexual desire	97	41.5
	Loss of intercourse satisfaction	83	35.5
	Loss of overall satisfaction	95	40.6

This study found that 61 out of 127 patients with ADS had higher erectile dysfunction, compared to 30 out of 107 patients without ADS, suggesting a significant difference (P < 0.05). Patients with ADS had a significantly higher incidence of medium to low and severe orgasmic dysfunction compared to those without ADS (P < 0.05). The study showed a statistically significant difference in sexual desire between patients with and without ADS (P < 0.05). This study indicated no significant difference in intercourse satisfaction (P > 0.05), but a significant difference in overall satisfaction (P < 0.05) between patients with and without ADS [Table 2].

Table 2.

Association of Alcohol Dependence Syndrome (ADS) with sexual functioning (n=234)

Sexual functioning		ADS absent	ADS present	Chi (χ2)	95% CI		P
					Lower	Upper
Erectile Function	No Dysfunction	77	66	11.567	0.140	0.341	0.021
	Low Dysfunction	10	22
	Medium to low dysfunction	6	19
	Medium dysfunction	8	12
	Severe Dysfunction	6	8
Orgasmic Function	No Dysfunction	81	67	15.095	0.161	0.362	0.002
	Low Dysfunction	13	21
	Medium to low dysfunction	6	23
	Medium dysfunction	7	16
Sexual Desire	No Dysfunction	73	64	10.430	0.038	0.276	0.034
	Low Dysfunction	11	30
	Medium to low dysfunction	11	13
	Medium dysfunction	7	9
	Severe Dysfunction	5	11
Intercourse Satisfaction	No Dysfunction	77	74	5.365	−0.004	0.249	0.252
	Low Dysfunction	10	21
	Medium to low dysfunction	8	15
	Medium dysfunction	7	9
	Severe Dysfunction	5	8
Overall Satisfaction	No Dysfunction	76	63	11.215	0.120	0.340	0.024
	Low Dysfunction	10	18
	Medium to low dysfunction	8	17
	Medium dysfunction	7	16
	Severe Dysfunction	6	13

There is increase in the number of sexual dysfunctions with an increase in the duration of alcohol use, which was found to be statistically significant (P < 0.05) [Table 3].

Table 3.

Association of sexual dysfunction with duration of alcohol use (n=234)

Sexual dysfunction		Duration of alcohol use			Fisher Exact	95% CI		P
		1–10 years	11–20 years	>20 years		Lower	Upper
Erectile Function	No dysfunction	113	28	2	48.827	0.352	0.567	0.001
	Dysfunction	33	42	16
Orgasmic Function	No dysfunction	114	32	2	44.129	0.328	0.549	0.001
	Dysfunction	32	38	16
Sexual Desire	No dysfunction	112	23	2	56.638	0.377	0.597	0.001
	Dysfunction	34	47	16
Intercourse Satisfaction	No dysfunction	114	36	1	44.580	0.340	0.540	0.001
	Dysfunction	32	34	17
Overall Satisfaction	No dysfunction	113	24	2	56.264	0.387	0.598	0.001
	Dysfunction	33	46	16

DISCUSSION

This study was conducted with the aim to identify the prevalence of sexual dysfunction in patients with alcohol dependence and to identify socio-demographic and clinical variables associated with sexual dysfunction.

We studied a total of 234 patients with a history of alcohol consumption after excluding those with co-morbid medical, surgical, or psychiatric illness that could independently cause sexual dysfunction. Of these 234 males, 127 met the criteria for alcohol dependence. Based on SADQ scores, 97, 21, and 9 had mild, moderate, and severe dependence, respectively. The mean age of study participants was 35.6 years, which is comparable to that studied previously by many authors.[11]

Sexual dysfunction was noted in all domains of sexual functioning in the patients studied. Loss of sexual desire was most affected (41.5 percent), followed by loss of overall satisfaction (40.6 percent) and erectile dysfunction (38.9 percent). Orgasmic dysfunction was noted in 36.8 percent, and 35.5 percent reported loss of intercourse satisfaction. Published literature on sexual dysfunction in alcohol-dependent men have reported a wide range of prevalence, ranging from 8 to 95.2 percent.[2,4,11,12] Our results are in line with previously reported high rates of sexual dysfunction in patients with alcohol dependence. Similarly, as previously reported, we found dysfunction in all domains of sexual functioning.[6,12] In our study, we found that the loss of sexual desire was the most commonly affected domain, which is similar to what was reported by Soni et al.[13] However, others have found erectile dysfunction to be the most common sexual dysfunction amongst alcohol-dependent men.[12,14] Others have reported premature ejaculation to be the most common.[2]

Those with ADS had more severe erectile dysfunction in our study compared to those without ADS, and the difference was statistically significant (P = 0.021). Similar findings have been reported by other authors in the past, where alcohol-dependent men had more sexual dysfunction compared to controls and social drinkers.[4] Furthermore, there was a statistically significant difference in all other domains of sexual functioning except for intercourse satisfaction between alcohol-dependent and non-dependent men.

We also found that the duration of alcohol use was significantly associated with sexual dysfunction. A longer duration of alcohol use was associated with higher rates of sexual dysfunction, which was statistically significant. Interestingly, this was seen across all domains of sexual functioning. Similar findings, where a longer duration of alcohol use was associated with a greater risk of sexual dysfunction, have previously been reported by many authors.[6,11,15] This finding is significant in that it indicates that long-term alcohol use has harmful effects on the body and physical consequences, with higher chances of sexual dysfunction.

This study had various strengths. Firstly, it had a large sample size, which increases the overall power of the study. Secondly, we were able to compare the results in alcohol-dependent versus non-dependent males in our study, providing us with an internal comparison group.

Limitations

The study had the following limitations. We did not recruit a formal control group, and only alcohol-dependent men were studied. This limits the causal power of the study. Further, with recent trends of increasing alcohol use among females, there is a need to include females in future studies.

Implications

The findings from this study have some major implications. Sexual dysfunction is very common among alcohol-dependent men and likely affects their quality of life. It is therefore imperative that assessment of sexual functioning is routinely performed in alcohol-dependent men and appropriate intervention advised. Further, the negative impact of alcohol on sexual functioning needs to be included in information, education, and communication activities against the use of alcohol.

CONCLUSION

It is highlighted that the sexual functioning of alcohol-dependent men is often overlooked. Findings from this and other studies on this aspect reveal sexual dysfunction to be a common association in this subset of patients. Detrimental effects of alcohol on the domains of sexual functioning should be part of the assessment and therapeutic work while working with patients of alcohol dependence.

Authors’ contributions

All authors contributed equally in concept, design, definition of intellectual content, literature search, data acquisition, data analysis, manuscript preparation, editing and review.

Ethical statement

This study adhered to institutional ethical guidelines.

Data availability statement

Data can be made available on request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.