Psychiatric Presentations of Sexual Dysfunction in Pakistan
Journal:
January-June 2010 Volume 7(1)Original Article
Author(s):
Syed Ahmer, Faheem Khan, Mukesh BhimaniPage No:
18
ABSTRACT
Objective: To
study the clinical and sociodemographic characteristics of people
presenting with sexual difficulties to a psychiatric outpatient clinic.
Design: Case-notes review
Place & duration of study: Psychiatry outpatient clinic, Aga Khan University Hospital (AKUH), Karachi, from January 2008 to May 2009.
Subjects & method:
Case notes of all patients presenting to the psychiatry outpatient
clinic of the AKUH for a sexual problem during the study period
were reviewed. The details of socio-demographic data, presenting
problems, past history, sexual history, investigations and treatment
were extracted from the case notes.
Results: A
total of 48 patients (47 males and one female) presented to the clinic
with a sexual problem during the study period. The most frequent
presenting problems were erectile problems (34 %), premature
ejaculation (24 %) and non-consummation of marriage (18 %). After
assessment the most frequent diagnoses were erectile dysfunction (29 %),
premature ejaculation (27 %) and depression (23 %). Most of the
patients (64%) were prescribed SSRIs, while sex therapy was recommended
in about 30 % of cases.
Conclusion: The
patterns of sexual dysfunction in clinical samples in Pakistan are very
similar to patterns found elsewhere. However, considering the
large proportions reported in surveys only a few of these people see a
psychiatrist to seek appropriate help. We need to break down barriers
that inhibit a patient to approaching appropriate health professionals
for seeking help, and inhibit doctors in exploring these phenomena in
appropriate depth.
Key words: Sexual dysfunction, Erectile dysfunction, Pakistan
INTRODUCTION
The
term “Sexual Dysfunctions” has been used in Diagnostic and Statistical
Manual of Mental Disorders, fourth edition, (DSM-IV) to refer to a group
of disorders “characterized by disturbances in sexual desire and in the
psychophysiological changes that characterize the sexual response cycle
and cause marked stress and interpersonal difficulty.”1 It includes
sexual desire disorders, sexual arousal disorders, orgasm disorders,
premature ejaculation and sexual pain disorders.
There
are three main population groups that have been studied in terms of
sexual dysfunction. The first group includes general population and the
most robust method in terms of representativeness in this group is
survey like the National Health and Social Life Survey (NHSLS) and the
Massachusetts Male Aging Study (MMAS)2 3. The NHSLS results showed that
as many as 43 % of women and 31 % of men may be suffering from sexual
dysfunction. Among men between age of 40 to 70 years about 35 % were
suffering from moderate to complete erectile dysfunction (ED). Although
survey yields results that are most representative of the true picture
of the problem in the population but they are known to be associated
with problems like reporting bias, use of different operational
definitions of sexual dysfunction in different surveys that make
comparison of different surveys results difficult4. Also, as people are
not being asked for the details of the phenomenon it is unclear whether
their ideas of sexual dysfunction conform to clinical categories of the
same. This issue is resolved by qualitative interview technique.
The
second kind of population in which sexual dysfunction was studied is
clinical population with a medical or psychiatric problem in which
sexual dysfunction was revealed as comorbidity. For example men
attending primary clinics in Nigeria, Egypt and Pakistan reported
ad-adjusted prevalence rates of erectile dysfunction of 57 %, 64 % and
81 % respectively.5 Perlman et al found a prevalence rate of sexual
dysfunction of 17 % in psychiatric inpatients.6 Other studies have
reported much higher prevalence rates of sexual dysfunction, 90 % in
women suffering from depression7, 78 % in patients
taking antidepressants8 and 30-54 % in patients taking antipsychotics9.
The problems again are those of operational definitions and accuracy of
diagnostic categories.
The
third population that has been studied is people presenting to sexual
or marital dysfunction/disorder clinics specifically with a sexual
problem.10. These are very self-selected samples which may not be
representative of the general population as help-seeking for sexual
problems is very likely to be influenced by sociocultural and religious
factors.11 On the positive side studying this population is likely to
produce most accurate data about details of pathology and diagnostic
categories as it presents itself for the most thorough study regarding
sexual dysfunction.
A
few studies have been conducted in Pakistan on sexual dysfunction. Most
of these studies belong to the second category i.e. surveys of sexual
dysfunction in different patient populations such as patients with
depression7 12 13, men taking antipsychotics14, and men attending
primary care clinics.5 There have been two surveys of general
population reporting sexual behaviour of women in Pakistan15 and
different ethnic groups of Punjab16, the largest province of Pakistan,
but neither of these studies assessed sexual dysfunction. We have not
come across any study reporting data from people presenting specifically
for treatment of sexual problems in Pakistan.
SUBJECTS & METHOD
Participants
This
study is a case notes review of all patients presenting to the
psychiatry outpatient clinic of the AKUH specifically for a sexual
problem, from January 2008 to May 2009.
Measures
Data
was collected retrospectively from case notes. We devised a data
collection form which recorded basic demographic details like age,
gender, marital status, education and occupation. We then recorded their
presenting complaint(s), duration of problem, who had referred them,
history of substance misuse, psychiatric illness or medical illness,
what physical investigations they had gone through already, which
sources of medical or alternative help they had tried before presenting
to the psychiatry clinic, what treatments they had already received and
whether depressive symptoms were present on mental state examination.
It also recorded history of their sexual experiences, if there was a
history of masturbation, their sexual orientation, and in case of
males whether nocturnal penile tumescence was present around the time of
presentation. The form then recorded which phase of the sexual cycle
their presenting complaint corresponded to, the diagnosis at the end of
assessment, and the treatment that was prescribed. It also recorded
history of their sexual experiences, if there was a history of
masturbation, their sexual orientation, and in case of males whether
nocturnal penile tumescence was present around the time of
presentation.
Data analysis
The
data were entered into SPSS 16.0. As the sample was very small we have
reported frequencies and percentages, and not attempted statistical
analyses as it would have been misleading to extrapolate results from
this small sample to the entire population.
RESULTS
A
total of 48 people, 47 men and one woman, were seen at the clinic for
sexual problems during this time. The median age of patients was 25.5
years with an inter-quartile range of 26-34 years. Seventy nine % (34/
43) of the patients had higher than secondary school (10 years)
education. Thirty five (73 %) were married, 11 (23 %) were single, and 2
(4 %) were divorced. In terms of current occupation 18 (38 %) were
professionals (doctors, nurses, engineers, teachers), 15 (32 %) were
businessman, 10 (21 %) were skilled or unskilled labourers, 3 (6 %)
were students and 1 (2 %) was unemployed. It means this was a group
which consisted predominantly of young, well educated, married, males
who were either professionals or businessmen.
The
source of referral of the patients to the clinic was as follows;
urologist 25 (52%), self-referrers 17 (35%), others e.g. acquaintances 3
(6%), other doctors 2 (4%), and spouse 1 (2%).
General psychiatric and medical histories
Only
15 % (n=7) of patients had history of psychiatric illness (all were
suffering from depressive disorder except one who was suffering
from schizophrenia). On assessment 23 % of patients meet the diagnostic
criteria of a depressive episode. About 70 % of people had no history of
substance use, 17% were smokers, and about 8% each had a history of
alcohol and gutka/chaalai use. One patient was suffering from Diabetes
Mellitus, Hypertension and Ischaemic heart disease, one from Diabetes
Mellitus and Hypertension, and two from hypertension.
Sexual histories
About
9 % of patients (4/43) reported a history of childhood sexual abuse.
Ninety six percent (45/47) reported having engaged in masturbation at
some point in their life. Nineteen % (n=9) of patients had premarital
sexual experience, 6 % (n=3) were homosexual, and 4 % (n=2) had
extramarital sexual experiences.
Information
about sexual orientation was found in 39 patients and 79.5 % (n=31) of
them described their sexual orientation as heterosexual, 13 %
(n=5) described as exclusively homosexual and 8 % (n=3) described as
bisexual.
In
terms of frequency of sexual intercourse 27 % (12/44) of patients
reported that they had never had sexual intercourse in life (married
4/32, divorced 1/2, single 7/10), 23 % said they had sex once a year or
less, about 18 % each every week or less than once a month, 9 % less
than once a week and 4.5 % daily.
Presenting problem
The breakdown of patients’ primary reason for presentation to the clinic (presenting complaints) is given in table 1.

The
largest group was people with erectile problems (34 %) followed by
those with premature ejaculation (24 %). We have listed
‘non-consummation of marriage’ separately as this was the specific
reason these people had come to the clinic for. The ‘other’ group
included three males, two single, one divorced who had no current
sexual dysfunction on assessment but had concerns regarding sexual
problems they may have in the future, one person with internet porn
addiction, one asking if there were ways to increase the size of penis,
and complaining of testicular pain.
When
we classified the presenting complaints according to the stages of the
sexual response cycle1 the breakdown was as follows; arousal disorders
(39.6 %), orgasmic disorders (35.4%), desire disorders (10.4 %) and
sexual pain disorders (8.3%).
Five
patients attributed problems to their sexual partners; four said that
the partner experienced significant pain during intercourse and one
said that the partner had minimal sexual desire.
Table
2 shows what physical investigations patients had already gone through
presenting to the clinic. About 44 % of patients had had their
serum testosterone levels checked, followed by levels of other hormones
(FSH, LH, thyroid hormones) in 33 % of cases.

Working diagnosis and treatment prescribed
Table
3 shows the final diagnoses reached at the end of assessment. The
percentages add upto more than 100 as some patients received more than
one diagnosis e.g. erectile dysfunction and depression.
Table
4 shows how association between presenting problems (categorized as
stage of sexual response cycle) and presence and absence of depression.

The
most common diagnosis was Erectile Dysfunction (29.2%), closely
followed by Premature Ejaculation (27.1%) and Depression (23 %). A
query has been placed in front of Vaginismus as it was directly
diagnosed only in the case of the solitary female in this group. In the
other two cases the diagnosis was made provisionally on the basis of the
husband’s account.

About
23 % (11) of attendees were diagnosed as suffering from depression. Of
these four had depression comorbid with ED, depression was the only
diagnosis in 3 people, two had depression comorbid with premature
ejaculation, and two people who had presented to get their sexual
orientation changed had depression.
Table 5 shows the treatments that were prescribed at the end of the initial assessment.

Most
of the patients (64%) were prescribed SSRIs. This was not only for
treatment of depression but they are also a mainstay treatment for
premature ejaculation 17. Sex therapy refers to Masters & Johnson’s
technique18. Sex education was provided in every case but in the table
sex education category refers to those cases where it was the only
remedy that was provided. Psychotherapy category refers to those cases
in which in it was felt the patients needed individual psychotherapy
unrelated to sexual problems.
DISCUSSION
In
this study of patterns of sexual dysfunction presenting at a
psychiatric outpatient clinic in a tertiary care university hospital was
assessed. Most of the attendees were young, well educated married males
who were either professionals or businessmen. The largest diagnostic
group was erectile dysfunction (29%), closely followed by premature
ejaculation (27 %) and depression (23 %).
Our
sample was almost exclusively male. This is in accordance with a
similar though much larger study from this region in which the
proportion of males among people presenting to a marriage and sex clinic
in India was around 98 %10. There could be several explanations for
this male preponderance. The sexual health clinic from which these data
are reported is run by a male psychiatrist. Females may have been
inhibited from seeking help from a male on sexual issues because of
cultural reasons. There is also a dearth of female psychiatrists in
Pakistan. It is possible that Pakistani females may be more comfortable
seeking help regarding sexual health from gynecologists who are
overwhelmingly female in Pakistan.
In
our sample ED was the most common presenting problem as well as the
working diagnosis reached after complete assessment, followed by
premature ejaculation. This is in contrast to the Kendurkar study 10 in
which the prevalence were exactly the opposite though the percentages
are very close in both the studies.
Depression
was the 3rd most common diagnostic category in our sample. This is in
concordance with several other studies rates of sexual dysfunction
in patients with depression as high as 78 % in patients treated with
antidepressants 8, and 90 % in women suffering from depression 7.
However, surprisingly in the Kendurkar study 10 none of the 1,242 cases
were diagnosed as suffering from depression.
There
have been few studies from this part of the world that have reported
data on sexual behaviour of the population. There have been two studies
which have reported data on sexual behaviour of Pakistani population
but both have restricted themselves to frequency of sexual thoughts and
acts, one in women 15 and the other in different ethnic groups of
Punjab16. In our study almost 95 % of people admitted having engaged in
masturbation at some time during their life though many of them
considered it to be against their religious beliefs. Twenty-nine percent
of people had engaged in sexual experiences outside of wedlock.
Thirteen
percent of people described their sexual orientation as exclusively
homosexual and 8 % as bisexual. Alfred Kinsey, in his landmark surveys,
had reported rates of exclusive homosexuality of about 4 % in both
males19 and females 20. Our rates may be higher as this was a clinical
sample coming to seek help for sexual problems, unlike Kinsey’s figures
which come from general population surveys.
Limitations
In
this study we have presented a retrospective collection of data from
case notes. As data collected for clinical purposes is many times
incomplete or insufficient for research purposes it is a limitation of
this study.
The
number of participants in the study was very small. Therefore, the
findings are unlikely to be generalisable. However, considering the
prevalence of sexual dysfunction as high as 90 % reported in some
studies from Pakistan 7 it does beg the question why only less than 50
people came to seek help for sexual problems while about 3500 initial
patients had attended the same clinics for general psychiatric problems
over the same year.
The
sample was self-selected and is therefore unlikely to be representative
of the real prevalence of sexual health issues in the Pakistani
community.
However,
at this time we were only attempting to describe who comes to seek help
regarding sexual health issues from a psychiatrist in Pakistan.
CONCLUSION
In
Pakistan neither the doctors nor the patients feel comfortable talking
about sex21. Surveys done in Pakistani clinical populations have shown
quite significant numbers being affected by sexual problems but at
least at this hospital the numbers of people presenting with sexual
problems were a very tiny fraction of all the people presenting to the
psychiatry clinic.
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