Psychosexual disorders are one of the common psychological disorders in the general population¹. Sex is an important aspect of life and human well-being². Sexual dysfunctions are characterized by clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure³. The psychological component is more prominent in these disorders in the absence of any pathological disease⁴. Psychosexual disorders include erectile disorder, erectile dysfunction, premature ejaculation, delayed ejaculation, hypoactive sexual desire disorder, and Dhat syndrome. Erectile dysfunction refers to difficulty getting and maintaining an erection or a marked decrease in erectile rigidity. Erectile disorder is the presence of erectile dysfunction for at least 6 months and causes distress in the individual. Premature ejaculation is a persistent or recurrent pattern of ejaculation occurring within 1 minute following vaginal penetration and before the individual wishes it. Delayed ejaculation is defined as a marked delay in ejaculation or absence of ejaculation³.

The definition of Dhat syndrome is not included in any of the classification systems. It is a culture-based syndrome characterized by vague symptoms of fatigue, weakness, lack of physical strength, body pains, and guilt attributed to semen loss during micturition or nightfall^4,5.

Masturbatory guilt is associated with semen loss due to masturbation. All religions prohibit masturbation and consider it as an act of immorality⁶. The impact of these cultural myths associated with masturbation is masturbatory guilt⁵. The individual attributes symptoms like small size of penis, erectile dysfunction, loss of sexual desire to masturbation.

Small penis anxiety (SPA) has been described in men dissatisfied or excessively worried about their penis size which is in normal range⁷.

These disorders may arise due to factors like ignorance, misinformation, superstition, and improper sex education⁴. Also, emotional factors such as anxiety, guilt, stress, low mood, anger, worry, depression, emotional trauma, and distorted body image may play a role⁸. Due to the cultural and religious beliefs prevalent in our country about sex, people suffering from these disorders may not consult a qualified doctor and discuss their sexual life⁴. Many patients visit local quacks or sexual clinics⁹. Patients suffering from sex-related symptoms mostly consult doctors of the Indian system of medicine rather than allopathic doctors¹⁰. Poor knowledge of the problem, lack of sufficient health facilities, lack of an adequate number of professionals in the field, and cultural influences has a negative impact on the management of psychosexual disorders⁴. In allopathic medicine, specialist services are available at tertiary level mostly by psychiatrist and urologist.¹⁰ In day to day practice patients with these problems often consult dermatologists as the patients believe that these problems are caused by sex organ dysfunction⁸. Dermatologists and venereologists may have an important role in preventing, detecting and management of psychosexual disorders⁴.

The nature of these problems and their psychological consequences make it difficult to assess the exact prevalence of these disorders in developing countries like India⁸. Large-scale epidemiologic studies are lacking in relation to psychosexual disorders. Many of the existing studies speak about the profile of such patients presenting to the Department of Psychiatry. Very Few studies are available in the literature describing the profile of such patients presenting to the Department of Dermatology.

Aim: This study aimed to describe the demographic profile and clinical presentations of male patients with psychosexual disorders presenting to the outpatient Department of Dermatology.

Study Type and Setting: This is a prospective observational study conducted in the outpatient Department (OPD) of Dermatology at a tertiary care hospital. Approval was taken from the institutional ethics committee with Ref No: RIMS/IEC/Teach. Staff/2020-21/13. Patients presenting to dermatology OPD with complaints of psychosexual problems were evaluated. Patients were informed about the study participation and consent was taken. Those patients with age more than 18 years old diagnosed with psychosexual disorders were included in the study. The criteria for diagnosing erectile disorder, erectile dysfunction, premature ejaculation, or delayed ejaculation was according to the DSM 5 TR classification³.

The patients with premature ejaculation having symptoms for a few months’ duration (<6 months), patients with premature ejaculation having latency time of more than 1 minute, those patients having organic or pathologic causes for sexual dysfunction, those taking drugs which can cause sexual dysfunction were excluded from the study.

Sample size calculated was 226.

Data was noted in a proforma prepared for the study. History was taken regarding age, marital status, education status, referred from, and personal history related to alcoholism, smoking, masturbation, and associated co morbidities. A detailed history was taken about their sexual problems-duration, associated problems in different phases of the sexual cycle, any performance anxiety, and information regarding sexual intercourse and pleasure. Detailed physical and genital examination was done to rule out any pathological problems.

Statistical analysis: The collected data was tabulated in Microsoft excel sheet version 2021 and analyzed using IBM SPSS statistics software version 22. Descriptive analysis of qualitative data was performed and chi-square test was used to calculate p value.

Clinical Parameters (Table 1)

The most common psychosexual disorder diagnosed was erectile disorder seen in 63(28%) patients followed by erectile disorder with premature ejaculation (ED+PE) seen in 47(21%) patients. Thirty-eight patients (17%) presented with erectile dysfunction and 36 (16 %) with premature ejaculation (PE) alone. Twenty-one patients (9%) had complaints related to Dhat syndrome. Ten patients had problems with their existing size of penis (small penis anxiety) and eight patients were having guilt about their habit of masturbation. Two patients complained of delayed ejaculation and one patient with hypochondriasis.

Table 1: Clinical Parameters

Psychosexual Disorders and Age (Table 2)

Out of a total of 226 patients studied, 75 (33%) patients with psychosexual disorders were in the middle age group of 31-40 years. Sixty-nine patients (30%) were in the age group of 21-30. Forty-one patients (18%) belonged to the age group of 41-50 years. Only six patients (2.6%) were aged more than 60 and six patients aged less than 20.

The most common complaint in the middle age group (31-40 years) was ED+PE seen in 22 patients (29%) followed by premature ejaculation in 19 patients (25%) and erectile disorder in 19 patients (25%). The most common complaint of patients in the age group of 18-30 is Dhat syndrome observed in 19 patients (25%) followed by erectile dysfunction seen in 18 patients (24%). There were 6 patients between the ages 18-20 among the study participants and 4 among them had Dhat syndrome. The most common complaint in the age group of 41-50 years was erectile disorder seen in 15 patients (36%) followed by premature ejaculation in 11 patients. Patients in the age group of 51-60 years mostly complained of erectile disorder seen in 21 patients (72%). three out of six patients aged above 60 years had erectile disorder.

Table 2. Psychosexual Disorders and Age

Psychosexual Disorders and Marital Status (Table 3)

Among the study participants 177(78 %) were married and 49(22%) unmarried. Erectile disorder was the most common complaint seen in 56 married individuals (32%) and ED+PE was seen in 45 (25%) married individuals. Maximum number of unmarried individuals (19) had complaints related to Dhat syndrome (p value 0.0001).

Table 3: Psychosexual Disorders and Marital Status

Psychosexual Disorders and Education (table 4)

Among the individuals included in the study, 90 patients (40%) were educated till secondary schooling, 70 patients (31%) were graduates and 66 were uneducated. Erectile disorder was found to be the most common complaint among all classes of education (p-value 0.018).

Table 4: Psychosexual Disorders and Education

Among the study participants, existing diabetes mellitus was noted in 25 patients, 6 patients were on treatment for hypertension. Seven patients were having both diabetes mellitus and hypertension. Five patients were both smokers and alcoholics. Nine patients were alcoholic and three were smokers.

Our study observed erectile disorder as the most common psychosexual disorder (p-value 0.0001) seen in 63 patients (28 %) followed by ED+PE in 47 patients (21%). Erectile dysfunction was diagnosed in 38 (17%) individuals. In a study of 698 patients conducted by Verma Et al.⁹, the most common psychosexual disorder was erectile dysfunction seen in 206 patients (29%) followed by premature ejaculation in 172 patients and ED+PE in 122 patients (17.5%). In our study erectile disorder (> 6 months) and erectile dysfunction (<6 months) were considered as separate entities according to DSM 5 TR classification³. This is the reason for the differences in the percentages. Our study also observed 9 (3.98%) individuals with performance anxiety, which is described as erectile failure that occurs during their initial encounters with sexual intercourse with an unknown partner like soon after marriage ³. Verma et al. also reported performance anxiety in 33 (4.7 %) patients⁹. Patients with performance anxiety usually present within 2-3 days of marriage complaining of unable to maintain erection or attain erection. They are anxious about their erection problem, because they have to face their partners during sexual intercourse. These patients need proper counseling regarding performance anxiety rather than treatment for erectile dysfunction.

Erectile dysfunction of a few months’ duration is usually seen in younger age groups. Erectile disorder of several months’ duration is seen usually in the elderly as compared to erectile dysfunction. As the age increases the condition becomes chronic. Erectile disorder is associated with hypertension, diabetes mellitus, hyperlipidemia, and metabolic syndrome⁴. So, it is necessary to evaluate patients with erectile disorder for these associations with increasing age.
In a study of 100 patients¹¹, premature ejaculation was the most common psychosexual dysfunction seen in 55 patients followed by erectile dysfunction in 27 participants. In a study with a sample size of 55, maximum patients (45.28%) presented with complaints suggestive of premature ejaculation and 28.3% had erectile dysfunction¹⁰. In our study ED+PE was observed in 47 patients (21%) and premature ejaculation alone (PE) was seen in 36 patients (16%). We considered PE and ED+PE as separate entities. Erectile dysfunction is a common comorbidity associated with PE¹². Maximum numbers of individuals with PE are in the age group of 31-40 years (p-value 0.0013). The frequency of PE decreases with age because of learned sexual experience and decreased sensitivity of the glans penis. This finding was supported in a study by Dwivedi Et al.¹². The latency time of ejaculation is the time taken by an individual to perform intercourse before ejaculation. The latency time decreases as the frequency of sexual intercourse decreases.

The frequency of psychosexual disorders is less in old age as compared to middle age because as the age advances individuals are not so bothered about sexual dysfunctions.

Our study observed Dhat syndrome in 21(9%) patients mostly below 30 years of age (p-value 0.0001). 19 patients were unmarried. Verma et al. reported Dhat syndrome in 126 patients (18%) mostly in unmarried individuals. Another study on 55 patients observed Dhat syndrome in 2 (3.77%) patients¹⁰. Patients with Dhat syndrome complained of generalized weakness, back pain, erectile dysfunction, premature ejaculation, and lack of desire. Some patients may have anxiety and depressive symptoms. Muslim individuals are more concerned with Dhat syndrome during the holy month of Ramzan as it is considered negative.
In this study, 10 patients complained about the smaller size of their penis. 9 of them were unmarried and thought their penis size would interfere in normal sexual life after marriage. All 10 patients were educated. None of the uneducated patients had concerns with their penis size. Educated individuals are more concerned about the size of their genitals.
Masturbatory guilt was seen in 8 patients all educated (p-value 0.0177) and 7 among them were unmarried. Educated individuals refer to the internet and gather false information and attribute their sexual problems to masturbation. Masturbation is associated with negative moral values in India⁵. People who practice masturbation have complained of guilt feelings⁵. Our patients complained of hair loss, decreased sperm count and decreased penis size, low semen volume, and erectile dysfunction. One patient of masturbatory guilt was in severe stress before marriage and even after marriage and was referred to a psychiatrist. These patients cannot avoid the act of masturbation. Masturbatory guilt may contribute to development of psychopathology⁵.

Patients with psychosexual disorders are in severe distress. Sexual dysfunctions are associated with psychiatric disorders and psychiatric disorders may lead to psychosexual dysfunctions¹³. Any problem in sexual functioning affects the quality of life and relationship between couples. ¹⁴ So, it is necessary to identify these disorders early and treat them accordingly by a qualified specialist. However, such patients are hesitant to consult a psychiatrist in a sex clinic. They usually consult a dermatologist, because they assume their problems to be associated with sexual organs. As observed in our study 197(87%) patients came for consultation to the dermatology OPD by self and 23(10 %) were referred by friends. Psychiatrists are trained enough to pay attention about the presence of psychiatric comorbities like depression or anxiety. Other specialty doctors usually ignore the impending psychiatric morbidity. The treating physician must provide sufficient time and privacy for the patients to discuss their problems. As patients may contact unreliable sources for sexual information, treating physicians should be able to provide accurate information and proper sex education. He should address the myths and mis-understandings associated with sexual intercourse, like those associated with Dhat syndrome and masturbation or those associated with immediate post-marriage performance anxiety.

Dhat syndrome, masturbatory guilt, and to some extent small penis anxiety are common psychosexual disorders presenting in young and unmarried individuals. However, in married individuals’ erectile disorder, ED+PE and premature ejaculation are the common presenting complaints. Patients suffering from psychosexual disorders do consult a psychiatrist but also dermatologists. Dermatologists as venereologists play an important role in preventing and detecting these disorders in the initial stages. These patients are at risk of developing psychiatric complications because of severe distress associated with psychosexual dysfunctions. A dermatologist should have the patience to hear these patients. They should receive training to counsel and reassure the patient to have a sexual experience devoid of guilt, fear, and anxiety, and in time referral to a psychiatrist is important. Psychiatrist and dermatologist must work in liaison to manage these patients in liaison clinics.

Declaration of Conflicting Interests

The authors have declared no conflicts of interest

Funding

The authors have not received any financial support for the research.

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