Comorbidities of male patients with sexual dysfunction in a psychiatry clinic: A study on industrial employees.

Background: Previous studies assessed the association of sexual dysfunction (SD) in cases of specific organic and psychiatric disorders separately as risk factors of SD, but the extent of association of various disorders in cases of SD was rarely evaluated. This study was conducted to assess almost all types of comorbidities to find out their effects on SD in male patients and to make complete diagnoses. Materials and
Methods: All male patients aged between 18 and 60 years reporting with sexual problems to the psychiatry outpatient department were evaluated with Arizona sexual experiences scale (ASEX) for males. Their assessment included detailed medical and psychiatric history including medicine intake, physical and mental status examination. Relevant biochemical investigations were done including sex hormone assessment.
Results: Among 104 males diagnosed as cases of SD according to the ASEX scale in 1 year period only 75 patients completed all the biochemical and hormonal assessments. It was observed that 38.67% were diagnosed as SD without any comorbidity, 25.33% had biochemical or hormonal or physical comorbidities, 21.33% had psychiatric comorbidities and 14.67% had psychiatric as well as biochemical or hormonal or physical comorbidities (n = 75). The severity of SD was higher in the patients with comorbidity and the age of the patients predicted its severity.
Conclusion: All cases of SD should be assessed in detail for physical, biochemical, hormonal, and psychiatric comorbidities to treat them holistically. Psychiatrists should play a key role in assessing, diagnosing, treating, and referring them to the appropriate treatment provider. Copyright:

Sexual dissatisfaction, as well as sexual dysfunction (SD) at present, occur at such a high rate that those who come for help represent only the tip of the iceberg.[1] Various studies conducted worldwide mentioned that the prevalence of SD has been around 10%–25% among men.[2] In males, SD usually presents with premature ejaculation (PE), erectile dysfunction (ED), and lack of sexual desire.[3]

ED has many possible etiologies, including vascular insufficiency as a result of atherosclerosis, neurologic disorders, hormonal imbalances, and has been found to be associated with many long-lasting conditions such as metabolic syndrome (MetS), obesity, diabetes mellitus (DM), cardiovascular disease (CVD), hypogonadism, lower urinary tract symptoms as well as psychiatric or psychological disorders, specifically depression. ED is also a well-known indicator of CVD as both may share the same etiology like endothelial dysfunction, especially in the case of coronary artery disease.[456] Metabolic disorders may act as triggers for increased inflammatory conditions leading to endothelial dysfunction as a result of chronic immune system activation.[7] Lifestyle factors as well as social and cultural factors were also found to be associated with SD.[68] However, these studies did not evaluate if the specific associated risk factors were causative factors or not. The studies did not even evaluate the extent of these associated risk factors in a sample of SD.

The occurrence of ED in patients with MetS was found to be almost 2–2.6 times more than in patients without MetS, whereas 40% of patients with ED were having MetS.[910] All specific constituents of MetS except high-density lipoprotein (HDL) levels were found to be significantly associated with an increased occurrence of ED too. Among those factors, raised fasting blood sugar was associated with the maximum frequency for ED.[10] In cases of DM, though ED occurred as one of the first problems, men experienced ejaculatory dysfunction and loss of libido also; in addition to that, it had psychological aspects too.[11] The prevalence of ED was found to be increased with age, disease duration, and poor glycemic control.[12] In hyperthyroidism, ED was detected often with a frequency even up to 70% but treatment restored normal erectile function.[1314] It was also found to be connected to an obvious increase in the occurrence of hypoactive sexual desire (HSD), PE, ED, and delayed ejaculation (DE).[1516] Hypothyroidism was found to be associated with ED too and it even adversely affected sperm parameters such as sperm count, motility, and morphology.[17] It was associated with decreased libido and hypogonadism was found to be common in cases of primary hypothyroidism.[181920] When sexual behavior was assessed both before and after treatment with thyroid hormone, hypothyroid males showed noticeable improvement in cases of HSD, DE, ED, and PE after reaching euthyroidism.[1415] In hyperprolactinemic men, SD was found in 88% of cases, particularly ED, and was typically accompanied by a decreased sexual desire almost every time as well as delayed, even absent orgasm in some cases. On the other hand, a very low prevalence of hyperprolactinemia was found in cases with ED (1%–5%).[21] However, the studies did not mention if associated SD were caused by the metabolic, biochemical, and hormonal abnormalities. Each study assessed the association of SD in case of a specific condition, but the reverse evaluation was not done to find out the association of all these abnormalities in cases of SD.

Among psychiatric patients, SD was found to be due to disorder-related factors and/or side effects related to medicines. During treatment with medications, SD was mentioned in patients with schizophrenia (30%–60%), depression (up to 78%), and anxiety disorders (up to 80%).[22] Substance abuse was also attributed to be a risk factor for SD in the case of males.[823] In most of the cases of alcohol-dependent males, mild to moderate ED was reported; the predictors being starting alcohol consumption at an early age, duration of alcohol intake, and associated long-term cigarette smoking.[24] Smoking cigarettes was also found to be a risk factor for ED whereas increased quantity, as well as the duration of smoking, augmented the risk further.[4] Although these studies assessed the association of SD in cases of specific psychiatric disorders separately, the extent of association of various psychiatric disorders in cases of SD was not evaluated. On the other hand, very few studies done in the Indian setup found that various types of SD were associated with 74.2% cases of major depressive disorder (MDD), 56.2% cases of generalized anxiety disorder (GAD), and 53.6% cases of obsessive–compulsive disorder (OCD) while MDD was seen in only 16% of the cases presenting with SD.[2526] However, the studies were limited to the anxiety and depression spectrum of psychiatric disorders only.

None of the studies evaluated the patients for physical comorbidities. Even the cases of SD were not assessed separately for the association of the metabolic, biochemical, and hormonal abnormalities as well as all types of psychiatric disorders. Consequently, a combined assessment of psychiatric disorders and physical comorbidities, as well as biochemical and hormonal abnormalities in cases of SD, were absent too. Hence, there was a need for an integrated assessment of psychiatric, physical as well as biochemical, and hormonal abnormalities to find out the effect of comorbidities on the cases of SD and to make a complete diagnosis for their holistic treatment. Moreover, there was a need to evaluate the extent of psychiatric and nonpsychiatric comorbidities separately. This study is an endeavor to assess the profile of almost all these comorbidities simultaneously in male patients of SD to the extent of the availability of the facilities in our hospital.

MATERIALS AND METHODS

The study was conducted at the psychiatry outpatient department (OPD) of the ESIC hospital situated at Rohini, Delhi, India. It is a 300 bedded government general hospital and has got all basic specialties. The catchment area of this hospital is the whole northern part of Delhi state. Patients are the employees at various industries and they are referred from various dispensaries in this part of Delhi or from various other departments of the hospital for psychiatric consultation. The subjects were recruited by purposive sampling technique over a period of 1 year from August 2015 to July 2016 to assess the profile of comorbidities in cases of male patients with SD. Prior consent was taken from each and every patient and clearance was taken from the hospital ethics committee for conducting the study.

All male patients referred from either dispensaries or various other departments of the hospital to the psychiatry OPD for sexual problems as well as the patients who had been found having sex-related problems during initial assessment in psychiatry OPD were evaluated subsequently by a male psychiatrist throughout the study. First, they were assessed with Arizona sexual experiences scale (ASEX) for males.[27] The patients who had SD according to the scale (on the ASEX male version) were included in the study. The patients who did not have SD according to the scale (on the ASEX male version), as well as the patients aged below 18 years and above 60 years, were excluded from the study. Sex-related problems and socio-demographic parameters were recorded in a specially designed proforma. Their detailed medical and psychiatric history including medicine intake, if any, the findings of physical examination, and mental status examination were noted in the psychiatric case record file. If the patients were on any medication, the duration of medications and side effects were also noted. The diagnosis of psychiatric disorders as well as SD was made according to the International Classification of Diseases-10 DCR criteria and its F-52 category was used to diagnose the various types of SD.[28] In physical examination, special emphasis was given to secondary sexual characters, blood pressure, waist circumference, the presence of a hernia and hydrocele and were noted on the proforma. Biochemical investigations and sex hormone assessments which were available in the hospital had been done to get the profile in terms of fasting blood sugar level, thyroid function test, lipid profile, liver function test, serum testosterone, serum prolactin, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels. Diagnosis of MetS was made based on 3 or more of the 5 criteria: (i) fasting glucose >110 mg/dL, (ii) blood pressure >130/85 mm Hg, (iii) triglycerides >150 mg/dL, (iv) HDL cholesterol <40 mg/dL and (v) waist circumference >102 cm.[10]

The ASEX Scale: The ASEX is a brief and 5-item questionnaire designed to measure sexual functioning over the past week in the following five domains: sexual drive, arousal, penile erection or vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm. It consists of a 6-point scale from 1 to 6 to rate the items towards increasing severity. Total scores vary from 5 to 30 and higher scores indicate more severe SD. A total score of >18 or a score of ≥5 on any single item or individual scores ≥4 on any three items suggests clinically significant SD. The scale has one version for males and another for females where only question 3 differs and mentions penile erection and vaginal lubrication for males and females respectively. The scale may be utilized to evaluate the current level of sexual functioning as well as to assess the changes in sexual functioning resulting from clinical interventions over a period of time. The scale has very high test-retest reliability and strong validity too. Both heterosexual, as well as homosexual populations, can be assessed with this scale and it can be used even for the persons without sexual partners.[27]

Statistical analysis

Descriptive analysis was done for socio-demographic and clinical data. Linear regression analysis for the patients with SD (n = 104) with ASEX score as dependent variable whereas age and the duration of SD as independent variables was performed using separate entry and stepping method with F value of 3.84 for entry and 2.71 for removal. In addition, a linear regression analysis was also performed with the duration of SD as the dependent variable and age as the independent variable. Subsequently, we computed Pearson correlation coefficients for the patients (n = 104) between age and ASEX score, duration of SD and ASEX score as well as age and duration of SD. For diagnostic break up into various groups only those patients who completed all investigations (n = 75) were included for further descriptive analysis and their grouping. The patients were divided into four groups: Group A = SD without any comorbidity, Group B = SD with nonpsychiatric comorbidities (biochemical or hormonal or physical comorbidities or their any combination), Group C = SD with Psychiatric comorbidities and Group D = SD with psychiatric + nonpsychiatric comorbidities. The patients without any comorbidity and the patients with comorbidities were compared on the clinical variables using independent t-tests. P < 0.05 was considered statistically significant. Statistical analysis was done using Statistical Package for Social Sciences of International Business Machines Corporation, New York, USA (SPSS Statistics 23).

RESULTS

One hundred and four males were diagnosed as cases of SD according to the ASEX scale in 1 year period. Age varied from 21 years (minimum) to 57 years (maximum) and the mean age was 35.67 ± 8.54 years. They all were employed in industries or business organizations at various lower positions and belonged to lower socioeconomic status. Various particulars of the patients are summarized in Table 1. Age-wise breakup of the patients is shown in Figure 1 and their referral pattern from various departments and dispensaries is presented in Figure 2.

Table 1

Details of the patients (n=104)

	n (%)
Total number of new male patients attended psychiatry OPD in 1 year period (age between 18–60 years)	475
Total number of males having sexual dysfunction (SD) as per ASEX Scale (age between 18 and 60 years)	104
Percentage of SD in males (age between 18 and 60 years)	21.89
Age of the patients having SD (years), mean±standard deviation	35.67±8.54
Education
Illiterate	2 (1.92)
Primary	48 (46.15)
Secondary	37 (35.58)
Higher secondary	14 (13.46)
Graduate	3 (2.88)
Marital status
Married	96 (92.3)
Unmarried or single	8 (7.69)
Duration of SD
Minimum (months)	6
Maximum (years)	20
Median (years)	2
ASEX Scale Score (mean±standard deviation)	20.11±2.83
Types of SD	ED and/or PE, lack or loss of sexual desire
Total number of cases of ED	25 (24.03)
Total number of cases of PE	26 (25)
Total number of cases of ED+PE	53 (50.96)
Lack or loss of sexual desire (associated with ED+PE)	2 cases

ASEX – Arizona Sexual Experiences Scale; OPD – Out patient department; SD – Sexual dysfunction; ED – Erectile dysfunction (failure of genital response); PE – Premature ejaculation

Figure 1

Age-wise breakup of the patients (n = 104)

Figure 2

Referral pattern of the patients from various departments and dispensaries (n = 104)

Regression and correlation analysis

Linear regression analysis found age (R = 0.205; constant = 17.683; P < 0.05) as a predictor variable for the ASEX score in the patients with SD. Age (R = 0.294; constant = −1.849; P < 0.01) also predicted duration of SD in the patients with SD (n = 104). However, no significant correlation was found between duration of SD and ASEX score.

Among 104 patients only 75 patients (72.12%) completed all the biochemical and hormonal assessments and 29 patients did not turn up with the reports of investigations. The profile of comorbidities is shown in Table 2. Liver function test, HDL cholesterol, serum testosterone, serum FSH, and serum LH levels were found within the normal range in the case of all the patients (n = 75). Only 3 cases (4%) could fulfill the requisite criteria for MetS. Two patients were on antihypertensive drugs (Amlodipine, Enalapril) for 3 and 2 years respectively, two patients were on oral hypoglycemic drugs (Metformin, Glimepiride) for 1 and 1 year 5 months respectively and one patient was on Levothyroxine for the last 7 years. None of them reported any side effects of drugs. Six patients had a family history of psychiatric illness suggestive of depression (4 patients) or substance use-related disorders (2 patients). Out of these 75 patients, 38.67% were diagnosed as having SD without any comorbidity (Group A), 25.33% were diagnosed as SD with biochemical or hormonal or physical comorbidities or their any combination (Group B: Nonpsychiatric), 21.33% were diagnosed as SD with psychiatric comorbidities (Group C: Psychiatric) and 14.67% were diagnosed as SD with psychiatric comorbidities but were also associated with biochemical or hormonal or physical comorbidities or their any combination (Group D: Psychiatric + nonpsychiatric). The details of the 4 groups are shown in Table 3 and the relationships among the groups are illustrated in Figure 3. Moreover, the patients without comorbidity (Group A) and the patients with comorbidities (combined Group B + Group C + Group D) were comparable on age, duration of SD as well as ASEX scale score and all three parameters of the patients with comorbidities were found to be significantly higher than those without any comorbidity [Table 4]. The patients with psychiatric comorbidities (Group C) had a significantly longer duration of SD than those without any comorbidity. However, the patients of Group D (psychiatric + nonpsychiatric) had significantly higher age and higher ASEX scores than those without any comorbidity [Table 4].

Table 2

Profile of comorbidities (n=75)

Comorbidities	n (%)
No comorbidity	29 (38.67)
Psychiatric comorbidities (few patients had>1 comorbidities)
Depressive episode (F32) and recurrent depressive disorder (F33)	15 (20)
Substance use related disorders (F10: 7, F17: 3, F13: 1, F12: 1, F19: 1)	13 (17.33)
OCD (F42)	1 (1.33)
Panic disorder (F41.0)	1 (1.33)
Physical comorbidities (few patients had >1 comorbidities)
Hydrocele	6 (8)
HTN	3 (4)
Cystitis	1 (1.33)
Biochemical or hormonal co-morbidities (few patients had >1 comorbidities)
Hyperlipidemia	12 (16)
Hyperprolactinemia	11 (14.67)
DM	5 (6.67)
Hypothyroid	4 (5.33)
MetS	3 (4)

F10 – Mental and behavioural disorders due to use of alcohol; F17 – Mental and behavioural disorders due to use of tobacco; F13 – Mental and behavioural disorders due to use of sedatives or hypnotics; F12 – Mental and behavioural disorders due to use of cannabinoids; F19 – Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances. DM – Diagnosed as per fasting plasma glucose≥126 mg/dL; Hypothyroidism – Diagnosed as FT4<0.16 ng/dl (the lowest hospital laboratory normal range); Hyperprolactinemia – Diagnosed as serum prolactin level>13.13 ng/mL (the highest hospital laboratory normal range); Hyperlipidemia – diagnosed as per plasma level of any one of total cholesterol ≥200 mg/dl; LDL cholesterol≥100 mg/dl; Triglyceride≥150 mg/dl; (the highest hospital laboratory normal range) or any combination. OCD – Obsessive compulsive disorder; HTN – Hypertension; MetS – Metabolic syndrome; DM – Diabetes mellitus; LDL – Low-density lipoprotein

Table 3

Break up according to various co-morbidities (n=75)

	n (%)
No co-morbidity (Group A)	29 (38.67)
Physical and/or biochemical and/or hormonal co-morbidities only (Group B=Nonpsychiatric)	19 (25.33)
Psychiatric co-morbidities only (Group C)	16 (21.33)
Psychiatric + nonpsychiatric co-morbidities (Group D)	11 (14.67)

The diagnostic breakup of the cases (n=75). Group A – SD without any co-morbidity; Group B (nonpsychiatric) – SD with biochemical or hormonal or physical co-morbidities or their any combination; Group C (psychiatric) – SD with psychiatric co-morbidities; Group D (psychiatric+nonpsychiatric) – SD with psychiatric+biochemical or hormonal or physical co-morbidities or their any combination. SD – Sexual dysfunction

Figure 3

The diagnostic breakup of the cases (n = 75). Group A = SD without any comorbidity, Group B (nonpsychiatric) = SD with biochemical or hormonal or physical comorbidities or their any combination, Group C (psychiatric) = SD with psychiatric comorbidities, Group D (psychiatric + nonpsychiatric) = SD with psychiatric + biochemical or hormonal or physical comorbidities or their any combination. SD – Sexual dysfunction

Table 4

Comparison of clinical characteristics of the patients with comorbidities and without comorbidity (n=75)

Patients without comorbidity (Group A) versus patients with comorbidities (Group B+C + D)
	Mean±Standard deviation		t (df=73)	P
	Without comorbidity (n=29)	With comorbidities (n=46)
Age of the patients	33.55±7.61	38.57±8.67	−2.554	0.013*
Duration of SD	2.43±2.52	4.80±5.66	−2.121	0.037*
ASEX score	19.34±2.68	20.63±2.72	−2.006	0.049*
Group A versus Group B
	Without comorbidity (n=29)	With nonpsychiatric comorbidities (n=19)	t (df=46)	P
Age of the patients	33.55±7.61	38.26±9.40	−1.909	0.062
Duration of SD	2.43±2.52	4.55±6.06	−1.675	0.101
ASEX score	19.34±2.68	20.42±2.29	−1.439	0.157
Group A versus Group C
	Without comorbidity (n=29)	With psychiatric comorbidities (n=16)	t (df=43)	P
Age of the patients	33.55±7.61	37.75±8.00	−1.739	0.089
Duration of SD	2.43±2.52	6.44±6.33	−3.02	0.004**
ASEX score	19.34±2.68	19.88±3.01	−0.609	0.546
Group A versus Group D
	Without comorbidity (n=29)	With psychiatric + nonpsychiatric comorbidities (n=11)	t (df=38)	P
Age of the patients	33.55±7.61	40.27±8.84	−2.386	0.022*
Duration of SD	2.43±2.52	2.86±3.06	−0.453	0.653
ASEX score	19.34±2.68	22.09±2.63	−2.912	0.006**

*P<0.05, **P<0.01. SD – Sexual dysfunction; ASEX – Arizona Sexual Experiences Scale

DISCUSSION

In our sample, more than one-fifth (21.89%) of all new male patients aged between 18 and 60 years were having SD of various types. Though one study reported almost the same percentage of patients with SD in a psychiatry OPD, other studies did not mention it.[22629] The figure is substantial and it indicates that in a psychiatry OPD, sexual history should be explored in the case of all adult males, whether the patients reveal on their own or not. Our data shows that a large number of young patients presented with SD compared to patients aged more than 50 years [Figure 1]. It might be due to the presence of more young patients visiting our psychiatry OPD as a whole. Moreover, the age of the patients predicted the duration of SD. With the increment in the age of the patients, the duration of SD also increased significantly, i.e. in older patients, the illness persisted for a longer time as compared to the younger patients. In addition, age also predicted the ASEX score. As the age of the patients increased, the ASEX score or the severity of SD also increased. It suggests that in older patients the severity of SD was more than the younger patients. Similar findings were found in previous studies and they indicated that the prevalence of SD increased with age.[25262930]

In this study, the number of cases of ED was 24.03% (n = 104) which was almost similar to the findings of the previous studies but the cases of PE (25%) and ED with PE (50.96%) varied significantly.[2629] In our study, more than one-third (38.67%) of the patients (n = 75) were having no comorbidity, whereas around two-thirds (61.33%) of them were having at least one among psychiatric, physical, biochemical, and hormonal comorbidities or their various combinations. The higher average age in patients with comorbidities might be a result of ever-increasing health-related issues as well as comorbidities with the advancement of age. As the age of the patients with comorbidities was higher, they also lived with SD longer which explained the higher duration of SD in patients with comorbidities. But in cases of patients with comorbidities, more emphasis should be given to the significantly higher ASEX scale scores which indicated that the presence of comorbidities might have increased the severity of SD. This 61.33% of patients with various comorbidities, needed special attention from the treatment point of view and we think comorbidities should be targeted first as the specific treatment for them are available. Moreover, treating the comorbidities might convert the cases of SD from more severe ones to less severe ones. After managing the primary medical condition, further interventions should be done for the psychiatric disorders which might lead to significant improvement, even complete recovery in some of the cases as the previous studies suggested.[111314151631]

The most common physical comorbidity (n = 75) was hydrocele (8%), followed by hypertension (4%) whereas the most common biochemical or hormonal comorbidity was hyperlipidemia (16%), followed by hyperprolactinemia (14.67%), DM (6.67%) and hypothyroidism (5.33%). However, MetS could be diagnosed in 4% of cases only. As DM has got detrimental effects on the sexual function of patients, the physicians dealing with them primarily should focus on their sexual complaints along with proper glycemic control to promote early detection and treatment.[1112] When presenting with ED, it may be used as a good motivating factor for men to control the main conditions for instance MetS and DM, and to improve their health-related choices. The patients should be well informed about this underlying association with ED to limit their cardiovascular risk and stimulated to give importance to the lifestyle changes for improving their status of health in general too.[910] In this study, we found a substantial number of cases (14.67%) having hyperprolactinemia and it was not so uncommon whereas very low prevalence (1.16%–1.5%) was reported by the previous review.[21] All patients of SD should be screened with thyroid hormone profile as both hypothyroidism and hyperthyroidism have got a high association with ED and PE.[151617] In the case of hyperthyroid males after restoring euthyroid state, they should be kept under observation for at least 6 months before starting any treatment for ED as normal erectile function comes back spontaneously.[14]

The most common psychiatric comorbidity associated with SD (n = 75) was found to be depression (20%), followed by substance use (17.33%), OCD (1.33%), and panic disorder (1.33%). Previous studies also reported the association of SD with MDD, GAD, OCD, and other anxiety disorders, but the rate was higher in most of the studies.[222526] In cases of substance use disorders such as alcohol dependence and smoking, each of them was associated with ED, but when both were associated, the risk increased further.[524] Longer duration of illness in the group of patients with psychiatric comorbidities may be explained by the lack of awareness about psychiatric disorders and reluctance to get them treated. Higher age among the patients with both psychiatric and nonpsychiatric comorbidities might be due to the fact that as the age advances the physical and metabolic comorbidities also increase and the condition was worsened by the addition of psychiatric comorbidities. On the other hand, higher ASEX scores in patients with both psychiatric and nonpsychiatric comorbidities groups indicate that the combination might have an additive effect on the severity of SD, making them more complicated.

SD without any comorbidity (38.67%) (Group A), SD with psychiatric comorbidities (21.33%) (Group C) and SD with psychiatric + nonpsychiatric comorbidities (14.67%) (Group D) covered around three fourth of the cases and they were assessed and diagnosed by the psychiatrist first, and should preferably be treated by psychiatrists but in liaison with other specialties wherever indicated. On the other hand, SD with biochemical or hormonal or physical comorbidities or their any combination (Group B = Nonpsychiatric) which comprised only one-fourth of the cases, should preferably be referred to the appropriate specialties for proper treatment while proper counseling should be done by a psychiatrist before referral. Hence, the psychiatrist should play the key role and work as the primary care physician for managing SD as a whole.

It has been observed that 48.08% or almost half of the patients (n = 104) were referred from various dispensaries but a substantial number of patients (37.5%) came to us from the Surgery OPD. It is necessary for the doctors at the dispensaries who are the primary care physicians to be able to identify and be aware of the different factors that contribute to SD and refer appropriately. For this, the authors feel that there is a need to train primary care physicians so that the cases of SD can be sent for proper assessment including an evaluation by a psychiatrist. Although almost half of the patients were referred to the psychiatry OPD directly from the dispensaries, our data suggest that the treating physician should remain unbiased while dealing with this type of case as SD may be biological too while around two-thirds (61.33%) of the cases (n = 75) were associated with various biological comorbidities and since psychiatric, biochemical, hormonal, as well as physical abnormalities can be treated by pharmacotherapy or by other physical methods of treatments. People often do not seek treatment and try to live with the problem because of the nature of the problem and its psychological consequences. In India treating physicians often give less attention or no importance to patients’ sex-related problems.[32] The influence of social and cultural issues on sexual function cannot be denied and requires more research.[8] However, the findings of the study indicate that exploration of comorbidities and targeting to treat them may increase the outcome of treatment of SD in addition to accepted methods of managing SD.

Strengths and limitations of the study: In the absence of studies on a combined assessment of physical, biochemical, hormonal, and psychiatric comorbidities in cases of SD, the integrated assessment of all these factors to make a complete diagnosis for their holistic treatment, use of a homogeneous group of male patients and assessment of the severity of SD added credibility to our findings. However, in this study, we focused mainly on biological problems, medical disorders and psychiatric disorders apart from social and lifestyle factors as well as relationship and family-related issues. The investigations were restricted to the facilities available in our hospital. Future studies with a bigger sample size and drug naïve or drug-free patients with inclusion of psychological, social, and relationship issues and comparison with a control group might provide more robust evidence.

CONCLUSION

Primary care physicians should be trained properly so that they can send cases of SD directly to psychiatrists for assessment and in a psychiatry clinic, sexual history should be explored in the case of all adult males. More emphasis should be given to the patients with comorbidities as their presence increased the severity and duration of SD. Thus, all cases of SD should be assessed in detail for physical, biochemical, hormonal, and psychiatric comorbidities to treat them holistically. Treating the comorbidities might convert the cases of SD to less severe ones leading to a better outcome. Psychiatrists should play a key role in assessing, diagnosing, treating, and referring them to the appropriate treatment provider.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors to do the study and to prepare the manuscript.

Conflicts of interest

There are no conflicts of interest.