Psychosocial Profile Of Subjects Presenting With Sexual Dysfunctions In Psychiatry Outpatient Department Of A Teaching Hospital In Nepal

Introduction: Sexuality is way people experience and express themselves sexually. It influences psychological, physical and social well-being of both men and women. Sexual dysfunctions are believed to be among the commonly prevalent psychological disorders in the general population but there is a lack of published research papers and literature related to sexuality and sexual medicine from Nepal. The aim of the present study was to descriptively analyze the nature of sexual dysfunctions in a teaching hospital. Material And Method: Retrospective analysis of data from subjects attending the psychiatry outpatient department in Nepalgunj Medical College Teaching Hospital, Kohalpur over the calendar year 2019 was done. Sociodemographic and clinical parameters of the subjects were obtained from the OPD register. Diagnosis was made using the DSM-5. Results: Out of total 54 subjects, 92.6% were male while 7.4% were female. Married subjects constituted 79.6% while single/unmarried 20.4%. Premature ejaculation was the most common sexual dysfunction encountered (55.5%) followed by erectile disorder (33.3%) and female sexual interest/arousal disorder (5.5%). Male hypoactive sexual desire disorder was seen in 3.7% and genito-pelvic pain/penetration disorder was seen in 2%. Conclusion: Males more commonly seek medical help for sexual dysfunction than females. People especially females, hesitate to discuss and seek medical help for sexual dysfunctions. There is lack of research on sexual medicine and sexuality from Nepal and prevalence of various sexual dysfunctions is not known.


INTRODUCTION
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. 1 Sexuality has always been a subject of importance to the medical community. It is determined by anatomy, physiology, culture in which a person lives, relationships with others and developmental experiences throughout the life cycle. Sex has been a consistent source of motivation and focus of interest to humankind. 2 Sexual dysfunctions/disorders are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure. 3 Sexual problems are widespread in society and are influenced by both health-related and psychosocial factors. 4 Literatures from western world have shown sexual dysfunctions are highly prevalent in both sexes, more in women (25% to 63%) than men (10%-52%). 4-7 An epidemiological study from India have found that one in five males and one in seven females have one or more sexual disorders. 8 There is a dearth of research and published papers in the field of sexual medicine from Nepal. Prevalence of sexual dysfunctions has not been estimated,

ORIGINAL ARTICLE
and even basic clinical data are not available. The present study is an attempt to contribute to this lacuna in Nepalese sexual medicine research.

MATERIAL AND METHOD
This study was a retrospective analysis of data from subjects attending the psychiatry outpatient department (OPD) in Nepalgunj Medical College Teaching Hospital, Kohalpur, over the calendar year of 2019. The hospital caters to the states of Lumbini, Karnali and Sudirpaschim which consists of 31 districts of Nepal. Data of the subjects attending the psychiatry OPD are recorded in the OPD register. The sociodemographic data, diagnosis and treatment given are thoroughly recorded in the OPD register for all subjects. For this study, all subjects who presented primarly with sexual complains and without any other diagnosed psychiatric disorders, were enrolled for this study.
Sociodemographic and clinical parameters of the subjects were obtained from the OPD register. The information was obtained from the subject and their spouse/partner when available. Diagnosis was made using the DSM-5 3 and data was analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0 for Windows. Fisher's exact test was used for analysis of categorical data.

RESULT
Out of 54 subjects presenting with sexual dysfunctions, 92.6% were male while 7.4% were female. Married subjects constituted 79.6% while single/unmarried 20.4%. Majority of the subjects were from urban domicile and Hindu by religion. (Table 1)

Table 1: Socio-Demographic parameters
Premature ejaculation (PME) was the most common sexual dysfunction encountered (55.5%) followed by erectile disorder (33.3%) and female sexual interest/arousal disorder (5.5%). Male hypoactive sexual desire disorder (MHSDD) was seen in 3.7% and genito-pelvic pain/penetration disorder (GPPD) was seen in 2%. Interestingly all of the sexual dysfunctions most commonly occurred in 30-39 years age group (59.3%). Only 5.5% of the subjects aged 50 years and more. (Table 2) Married males constituted 40% of subjects with PME and 34% with ED. Table 3 shows relationship of PME and ED respectively with under 40 years subjects. Both PME and ED were more common in males < 40 years and the association was statistically significant. The mean age of the subjects was 34.61 ± 9.08 years.  Indian studies have reported that compared to males, very few female subjects present with sexual dysfunctions (0-3.6%) 10,11 which is in accordance with the present study. Embarrassment and shame to come forth with sexual problems and discuss the issues with clinician, stigma related to sexuality, females presenting their sexual problems to gynecologist only and lack of knowledge about sexual functions and disorders in females may be some of the factors that attributed to low turnout of female subjects in this study. Married subjects constituted 79.6% of the subjects. Various studies have reported that sexual dysfunctions are more commonly presented by those who are married. 8,10 Married subjects having more opportunities for sexual interactions may be the major reason for them presenting with sexual dysfunctions more commonly than compared to single/unmarried. In this study majority of the subjects were from urban background which is in accordance with other studies. 10 Awareness and importance of one's sexual functions in urban community, ignorance about availability of treatment facilities for sexual dysfunctions in rural community and stigma/shame or lack of knowledge about sexual dysfunctions in rural community may be some of the factors for this reported finding in this study.

Sexual dysfunctions:
This study found PME (55.5%) as the most common sexual dysfunction followed by Erectile Disorder (33.3%). PME is reported as the most common sexual dysfunction in various Western 12-15 and Indian studies. 11,16,17 Higher prevalence of PME was found by Verma et al.
(77.6%) 11 and Jain et al. (66%). 18 Some studies have also reported Erectile disorder (ED) as the most common sexual dysfunction. 8,10,19 Outpatient based studies have shown rates of ED as high as around 30%. 10 while Indian epidemiological study has show the prevalence to be 15.77%. 8 Not only ED, the differences in estimates of various sexual dysfunctions exists for almost all sexual dysfunctions which can be attributed to difference in methodology adopted in various studies. Based on these findings we can fairly conclude that PME and ED are two of the most common sexual dysfunctions encountered. MHSDD was seen in 3.7% of the subjects. Studies have reported the prevalence rates of MHSDD to be ranging from 1% to 7% which is in accordance with our study. 8,20,21 Present study found female sexual interest/arousal disorder (FSIAD) was the third most common sexual dysfunction (5.5%) encountered; and the most common among females. Sexual dysfunction related to desire and arousal (FSIAD as per DSM-5 3 ) has been consistently demonstrated as the most common sexual dysfunction among females in others studies. 8,22 GPPD was seen in 2% of the subjects. Rao et al. reported the prevalence of dyspareunia (GPPD) to be 2.34% which is similar to our study. 8 In this study both PME and ED were more common in younger age group (<40 years) compared to older age group (≥40 years) and the relationship was statically significant. All the sexual dysfunctions including both PME and ED were more common in 30-39 years age group. This age group being more likely to have a sexual partner and thus increased awareness about their sexual functions, might have resulted them seeking medical help leading to increased prevalence of sexual dysfunctions. PME has shown to occur in individual of younger age in other studies. 17,23 Rao at al. in an epidemiological study found ED was least among 26-30 years age group and highest among 51-60 years age group. 8 Kinsey et al. found that erectile disorder occurs in <1% of the male population before age 19, increasing to 25% by age 75 suggesting that as age increases sexual disorders also increase. 24

CONCLUSION:
This study found PME and ED were the most common sexual dysfunctions respectively. Comparative to males, very few females presented with sexual dysfunctions. Sex and sexuality is still considered a taboo in Nepal. People hesitate to discuss and seek medical help for sexual dysfunctions. Tough sexual dysfunction is common in both sexes; in our country males more commonly seek medical help for sexual dysfunction than females. Female may feel more shame and stigma discussing their sexual problems to a clinician.
This study reflects the current sexual health scenario in Nepal. Research on sexual medicine and sexuality from Nepal is lacking and the prevalence of various sexual dysfunctions is not known. There is a need to address these issues through community based studies and research.