A 47-year-old man passing putrid semen through saliva and sweat: A case of Dhat syndrome.

Dhat syndrome is a culture-bound syndrome in which patients believe that they pass Dhat (semen) with their urine, feces, sweat, and saliva that causes lethargy, apathy, dysphoria, and depression. Here, we report a case of a 47-year-old man who presented with complaints of burning sensation in the whole body, especially in the pubic region, and insomnia for the last 5 years. This case could be enlightening for clinicians in South Asia in daily clinical practice and family physicians in Western countries where immigrants from Dhat syndrome prevailing countries could present with complex cultural myths and superstitious beliefs.

INTRODUCTION

Dhat syndrome is a culture‐bound syndrome characterized by the false belief of losing semen with urine, feces, sweat, and saliva resulting in extreme lethargy, palpitation, apathy, lack of physical strength, anorexia, and psychological manifestations such as depression, anxiety, dysphoria, insomnia, and sexual dysfunctions. , , It widely prevails in South‐East Asian culture because of enduring cultural beliefs about Dhatu. Many religious and cultural myths say that semen is a precious body fluid and needs to be preserved; otherwise, its loss would cause diseases. Studies have found depression, anxiety, and somatic and hypochondriacal symptoms as common psychiatric presentations of Dhat syndrome, which may further be associated with erectile dysfunction and premature ejaculation. , , , , Here, we present a case of Dhat syndrome accompanied by superstitious beliefs presented with somatic symptoms and thinking that his semen has been passing through his saliva and sweat. We aimed to report the complex presentation of the culture‐bound syndrome and the long‐term suffering of the patient so that family physicians could consider the cultural origin and associated superstitious beliefs while managing patients with Dhat syndrome.

CASE PRESENTATION

A 47‐year‐old married Muslim man currently unemployed with secondary education and living in a suburb was referred to a psychiatric sex clinic with complaints of burning sensation in the whole body starting in the pubic region and insomnia for the last 5 years. For these complaints, he has consulted numerous physicians and performed lots of investigations repeatedly. During the course of his treatment, he is found noncompliant with the medications and advice, albeit he has a higher level of anxiety regarding the symptoms and treatments. After consulting the physicians, he used to take the suggested medication as per his wish without following the instructions of drug dose, duration, and schedule. He has been treated with several antidepressants, antipsychotics, sedative‐hypnotics, and pain killers. However, symptoms were deteriorating day by day. At this point, it is challenging to interpret whether the medications have been effective because of irregular dosage schedules.

He is normotensive, nondiabetic, nonasthmatic, nonsmoker, and nonalcoholic, and has no remarkable past medical and psychiatric history. All routine and special investigations reveal nothing contributory to his symptoms. His childhood upbringing was normal in a joint family in a rural area, and there was no history of childhood sexual abuse. He has no significant family history of psychiatric illness.

He married 10 years ago and had a good sex life before the illness. After evaluating the detailed history, it revealed that in one fine night, he had an intercourse with his spouse during her menstruation. About 3 months later, he started having a burning sensation in his penis and pubic region. Then, he discussed this problem with his local religious persons and friends, and started thinking that her wife's menstrual blood mixed with harmful germs entered into his body during intercourse. Later on, the symptoms became worse and he felt weakness, headache, body ache, and insomnia. Now, he avoids any form of sexual activity and he has not met his wife for the past 2 years. He thinks that his semen has been accumulating in the buccal pouch and is excreting through saliva, sweat, feces, and urine. He experiences a bad odor of his sweat and attributes it to the presence of rotten semen in the sweat.

His Mental State Examination (MSE) revealed that his beliefs had delusional intensity; however, no other diagnosis could be assigned. As per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM‐5), we considered somatic symptom disorder with delusional intensity as a differential diagnosis. However, he firmly believed that all his symptoms started because of his intercourse during menstruation of his wife. Therefore, we considered delusional disorder as another differential diagnosis. We considered Dhat syndrome as a provisional diagnosis as the patient has beliefs that he has been losing his semen through his saliva, sweat, feces, and urine, which is the reason for his current illness. We prescribed him tablet mirtazapine 15 mg, tablet olanzapine 10 mg, and tablet diazepam 10 mg at night with gradually downtitration of diazepam. It is judicious to note that we suggested the medications even though the diagnosis was Dhat syndrome to ensure symptomatic relief and anxiety reduction, not to treat the other differential diagnoses such as delusional disorder and/or comorbid depression. We advised him on breath‐holding relaxation techniques, proper sleep hygiene, and physical exercise in the morning. We provided interpersonal psychotherapy targeting his misconceptions regarding sex during menstruation, and the mechanism of semen expulsion. After 3 months of treatment, his insomnia was relieved and his burning sensation improved more than 75%. Lastly, we focused on joining his work and re‐establishing his sexual life with his wife.

Ethical approval

This case has been reported in accordance with the Helsinki Declaration of 1975. Informed written consent was taken before submitting the manuscript.

DISCUSSION

Here, we presented a 47‐year‐old Muslim man with complaints of burning sensation in the whole body starting in the pubic region and insomnia for the last 5 years. After evaluating the detailed history and MSE, we diagnosed him as a case of Dhat syndrome with superstitious belief and kept somatic symptom disorder and delusional disorder as differential diagnoses because of the temporal relationship between symptoms and intercourse during menstruation and his beliefs regarding the symptoms. Usually, Dhat syndrome is more prevalent in men aged 20–38 years, living in rural areas with poor educational attainment. , However, in our case patient age is 47 years, which is not only beyond the average age but also rare. A study of 780 patients older than 16 years, recruited from 15 centers of India, and assessed by the Dhat syndrome questionnaire revealed that the most common presentation was passing of semen as a night falling (60.1%), with urines (59.5%), excessive masturbation (55.1%), and sexual dreams (47.3%). In our case, we found that the patient complained that a major portion of semen is excreting through saliva and sweat, then urine and stool, respectively, which is an unusual presentation.

Poor health literacy, unawareness, faulty sociocultural beliefs, traditional healers and unqualified practitioners, and religious gurus have a potential role in creating and maintaining cultural misconceptions such as Dhat syndrome. In our patient, he initially consulted with the traditional healers, religious gurus, and relatives who misguided him and reinforced the superstitious belief that somehow her wife's menstrual blood along with harmful substances and pathogens entered into his body and created these problems. Our patient also feels guilt as he performed sex during menstruation, which is not permitted in Islam. This situation could be explained by the Dhat syndrome itself, educational attainment, and cultural beliefs of Bangladesh.

CONCLUSION

Bangladesh is a sexually conservative country with sexual myths and misconceptions where evidence‐based service for the sexual misconception is in a nascent stage. This case would raise awareness regarding the complex presentation of Dhat syndrome among the clinicians of Bangladesh, which in turn would reduce the sufferings of the patients. It would help the clinicians of countries in South Asia where Dhat syndrome is a regular issue to formulate the cases of sexual misconceptions. Additionally, it could be enlightening for clinicians in Western countries where immigrants from Dhat syndrome prevailing countries could present with complex cultural myths and superstitious beliefs.

CONFLICT OF INTEREST

The authors have stated explicitly that there are no conflicts of interest in connection with this article.