Introduction
Sex plays an important role in human life across different cultures. Culture creates and impacts beliefs and myths about sexuality, masculinity, and sexual prowess and behavior. Different cultures view sexuality with different perspectives. Western cultures consider the act of sex as recreational (sex positive societies), while Asians are more likely to view it as procreational (sex negative societies). Contrasting views in different cultural settings have impacted the quality and quantity of research on sexuality in different cultures. Until recently, sexual health has taken a back seat in the planning and implementation of health care. There is more research on human sexuality in East-Asian countries when compared to South Asia. The ample research about sexuality in the West cannot be extrapolated to the Asian context due to differences in sociocultural domains.
The rates of sexual dysfunction vary in different populations. Studies have shown that the prevalence of erectile dysfunction (ED) is more in Asians when compared to Europeans. A community-based survey found the age-adjusted prevalence of ED to be 34% in Japan and 22% in Malaysia. Some studies have shown increased prevalence of sexual dysfunction across both genders. Studies on sexual dysfunction in women have had challenges of sociocultural differences in various constructs, such as gender roles, gender expression, normal sexual functioning, and sexual distress.
Etiology
Culture
Knowledge about the impact of culture on sexual functioning is important for clinicians not only for diagnosis but also for management. Culture shapes the norms of behavior and threshold of tolerance and to a certain extent defines abnormality and deviance of behavior. The important aspects of relationship of culture and sexual health include gender roles, gender role expectations, explanations of sexual behavior, explanatory models of sexual dysfunction, and personal and cultural beliefs of healing. Cultural beliefs, apart from affecting the prevalence of sexual dysfunction, also dictate the mode of presentation to the professionals and also the notion of what constitutes a disorder. Expressed emotions and privacy issues also influence sexual functioning. Relatively restrictive and sex negative attitudes, more common with the Asian population, are likely to be less conducive to coping and help-seeking. Though the impact of acculturation on sexual response is under-researched, the degree of acculturation seems to be a key potential determinant in formulating sexual dysfunction.
Ancient texts of Hindu, Buddhist, and Jain literature are perhaps the oldest surviving accounts documenting cultural attitudes and perspectives toward sexuality and sexual expression. Vatsyayana’s classic work, “Kamasutra” talks about the three pillars of life according to the Hindu religion: Dharma: religious duty, Artha: worldly welfare, and Kama: sensual aspects of life. It placed sexuality as a central and natural component of the Indian culture, psyche, and life. The period between the 10th and the 12th centuries produced some of India’s most famous works of art, often colored with romantic themes and situations. Nudity in art was socially acceptable and the society was fairly liberal regarding sexuality. The advent of colonialism in the Indian subcontinent made the British the official guardians of morality. Victorian values stigmatized Indian sexual liberalism, condemning it as inferior and barbaric. Even though this newfound conscientiousness led to social reformation and women empowerment on the one hand, it also led to a more conservative attitude toward sex, on the other.
Gender
Women perceive increasing age, physical weakness, attainment of menopause, hysterectomy, child birth, living in a joint family and lack of personal space and privacy, depression, and having thoughts with predominantly sexual content as factors contributing to sexual dysfunction. Women are also shy and reluctant to discuss sexual problems with therapists. The gender of the assessor thus also may play an important role. It is likely that female patients may prefer to disclose sexual concerns to same sex professionals when compared to male professionals. Historically, there has been a steady decline in the importance that women hold, both in the household as well as society. Child marriage, purdah, and dowry are still prevalent in certain parts of the Indian subcontinent. Asian women generally take a backseat in patriarchal societies like India. So, sexual dysfunctions in females might go unreported. Asian men tend not to report their sexual dysfunction unlike their Western counterparts, suggesting that cultural differences relate to the perception of masculinity as an underlying cause.
Sex Education
A descriptive study in India found that 70% students felt there was a need to have proper educational content on sexual and reproductive health at schools. Only 54.2% respondents felt that the current education available was adequate. Only 37.7% students felt comfortable discussing their doubts about sexual health. This indicates a clear education gap that needs addressing regarding sex-education in countries like India. Most adolescents acquire knowledge about sex from friends and acquaintances, often through pornography. This may lead to misconceptions about sex and predispose to sexual problems in the future.
Physical Comorbidity
Erectile dysfunction (ED) is commonly associated with cardiovascular disease, diabetes, and depression. As these conditions can go unrecognized, ED can be a marker for these diseases. In Asian-Indian population the incidence of premature coronary heart disease is among the highest when compared to other major ethnic groups; vasomotor angina is more common in East Asia when compared to their Western counterparts. For the working-age population, cardiovascular morbidity rates are markedly higher in low-and-middle-income countries than in high-income countries. Sexual dysfunction is highly prevalent in individuals with cardiovascular diseases. Recent studies have suggested that impaired penile blood, which can cause ED, can predict major cardiovascular adverse events in patients free of clinical atherosclerosis. This predictive value is independent of both severity of hypertension and levels of testosterone in blood.
Age-adjusted prevalence of diabetes was found to be 8.4% in Asian-Americans, 11.8% in Hispanic Americans, and 33% in Native Americans. Sexual dysfunction prevalence in diabetic patients can vary from 20% to 75%; it can be due to autonomic neuropathy and microvascular complications. Also diabetes adversely affects the individual psychologically which may add to the severity. The loss of sexual desire has been a proven consequence of diabetes mellitus in both men and women. Drugs used to control diabetes may also cause ED. Metformin, commonly used in the treatment of diabetes mellitus, leads to significant reduction of blood testosterone levels, libido, and low testosterone-induced ED; however, sulfonylureas, another class of anti-diabetic drugs, lead to a significant elevation in the testosterone levels, leading to an increased sex drive and improved erectile function. Smoking, excessive alcohol consumption, lack of physical activity, poor dietary habits are strongly associated with pro-inflammatory states that result in decreased availability of nitric oxide which in turn leads to endothelial damage resulting in ED. Hence, lifestyle modifications such as regular exercise, healthy diet, control of substance use, and good sleep habits improve sexual function.
Testosterone has proven to be effective in both men and women in the treatment of sexual dysfunction. Testosterone replacement therapy has shown improvement in multiple aspects of sexual functioning. Non-hormonal treatment like Flibanserin has also been effective in the treatment of female sexual dysfunction., In females, endometriosis doubles the risk of sexual dysfunction. Some studies have found a higher prevalence of endometriosis in Asian women.
Mental Illnesses
Mood Disorders
In a community study done on Asian-Americans, the prevalence of major depressive disorder was found to be low when compared to Non-Hispanic Whites; however, depression tends to be persistent, lasting for longer periods and was less likely to be treated. The prevalence of sexual dysfunction in people suffering from depression is estimated to be around 70% to 80% in various studies. Comparative studies reveal higher sexual dysfunction in depressed patients than in nondepressed individuals. Depression severely affects all phases of sexual functioning. A recent study assessing depression in drug naïve female depressed patients found that more than 70% of drug naïve depressed females had sexual dysfunction. The study also found that sexual dysfunction also was proportional to the severity of depression. Following the onset of depression, the incidence of sexual dysfunction started at an early age in women.
Bipolar Disorder and Sexual Functioning
Unlike depression, about 40% of individuals with bipolar disorder experience increased libido during the manic phase. Studies comparing hypersexuality in bipolar I, bipolar II and healthy individuals found that there was increase in implicit sexual interest in bipolar 1, while there were no differences in explicit sexual interest or sexual dysfunction among the groups.
Neurotic Disorders
Asian-Americans are less likely to be diagnosed with generalized anxiety disorder or post-traumatic stress disorder than Hispanic Americans; Asian-Americans when compared to White American populations are less likely to be diagnosed with social anxiety disorder, generalized anxiety disorder, panic disorder, or post-traumatic stress disorder. However, Asian men achieve ejaculation quicker than Caucasians and Afro-Caribbeans, and Indian men are more prone to premature ejaculation. A recent large-scale population-based study using stringent criteria to explore the association between ED and panic disorder in an Asian population showed patients with panic disorder having 2.18 times higher risk for ED when compared to normal population. Although precise mechanism of association between panic and sexual dysfunction is unclear, possible hypotheses include patient’s sensitization to autonomic arousal symptoms. The conditional fear response to certain symptoms of autonomic arousal and sexual arousal itself share many same physical sensations. Patients may limit their sexual arousal because of the same feared response.
Schizophrenia
African-Americans, Hispanics, and Asians are more likely to be diagnosed with Schizophrenia when compared to Whites. Studies have found conflicting reports of increased risk of schizophrenia in immigrant Asian population. The East London First Episode Psychoses (ELFEP) study concluded that the incidence rate for Indians was similar to that in the White British group. However, Pakistani and Bangladeshi women were at 4 to 5 times higher risk for Schizophrenia when compared to White British women. Sexual functioning in schizophrenia varies depending on the illness, drugs received, and the attitude of the treating team. Although psychiatrists agree that sexual functioning is important, two-thirds of them did not enquire routinely about sexual functioning. Some recent studies report the different rates of sexual dysfunction among men and women. Most studies found men reporting sexual dysfunction more often than women. In studies which included both men and women, 42% of men and 24% of women with schizophrenia had sexual dysfunction. Men with schizophrenia are usually single and did not have a sexual partner. The negative symptom paradigm of anhedonia, limited social initiative, social anxiety, and deficits in social perception also lead to loneliness. Sexual dysfunction itself may be the source of demoralization and discouragement in seeking sex with appropriate partners. A lack of interest, single status, physical illness or sexual dysfunction in the spouse, and spiritual involvement are the reasons quoted by both sexes for sexual malfunctioning. In a recent study which included only women with schizophrenia found 70% of women with schizophrenia having sexual dysfunction. In this study, impaired desire was reported by all women, 92% of them reported impaired arousal, 48% of them reported poor lubrication, 76% reported impaired orgasm, 69% reported poor satisfaction and 37% of them reported pain.,
Dhat Syndrome
The ancient Indian scripture Charaka Samhitha mentions that the imbalance of bodily humors or excessive orgasmic ejaculations may cause damage to the dhatus (i.e., “metal” or “elixir” or basic seven types of tissues which make the human body). Sukra or semen supposed to be nutritional in origin, is believed to be all pervading in the body. Many believe food is progressively transformed into blood, marrow, and then semen. Wig in 1960 coined the term Dhat syndrome, a culture bound syndrome characterized by excessive preoccupation with loss of Dhat (which is a representative of semen; hence, “semen loss anxiety”) through urine, nocturnal emissions, or masturbation with or without any evidence of loss of semen. The Dhat syndrome is characterized by somatic symptoms of weakness, fatigue, anxiety, decreased appetite, and guilt attributed to semen loss. This syndrome is predominantly seen in the Indian subcontinent; however, similar syndromes have been noted in other countries, like “Shen-k’uei” in China and historically in the 19th century in other places like Europe, Australia, and United States. Dhat may be associated with depression, anxiety, or sexual dysfunction. It is believed that excessive loss of Dhat may render an individual infertile. Dhat is also considered as a somatic presentation of depressive illness by some authors. Hence, a sexual syndrome which is culture bound gets channelized into universal models of somatization. Some believe cavernosal blood is lost as semen following ejaculation and some men have reported passage of Dhat through anal route as well. Some authors have argued for the Dhat syndrome in females as well.
DSM-5 and Its Implications in Understanding Sexual disorders in Asians
DSM-5 still allows the use of social norms in healthy sexual practices. This makes it interesting to understand DSM-5 in the context of the Asian population. Challenges of cross-cultural consultation are well known, which becomes more challenging if consultations involve sexual functioning. Having a good rapport and therapeutic alliance, relevant leading questions, and cultural sensitivity are some of the tools that could help the clinician to obtain information about sexual functioning, especially in females.
When compared to DSM-IV TR, DSM-5 has fewer categories describing sexual dysfunction and continues to classify sexual dysfunction based on gender. Minimum duration required for diagnosis of sexual dysfunction in DSM-5 is six months with the frequency ranging from 75% to 100%. In females, sexual desire and arousal disorders have been combined into one disorder; vaginismus and dyspareunia come under genito-pelvic pain/penetration disorder. DSM-5 has done away with sexual aversion disorder. Various types of sexual dysfunctions have been categorized based on the onset and the context. DSM-5 includes lifelong versus acquired subtypes and situational versus generalized subtypes. Psychological versus combined subtypes have been dropped; medical versus other non-medical correlates have been added; cultural and religious factors have been significantly highlighted. Culture-related diagnostic issues have been mentioned separately for each diagnosis (including factors related to Asian population).
A separate diagnostic entity, gender dysphoria, with separate criteria for children and adolescents has been added in DSM-5, emphasizing incongruence instead of cross-gender identification as in DSM-IV. Subtyping based on sexual orientation has been removed which is a positive step toward removing stigma for the lesbian and gay population, which is more in the Asian population.
Diagnosis and Treatment of Sexual Dysfunction in Asians
Factors important for the diagnostic process include cultural sensitivity, awareness of cultural issues, beliefs, attitudes of the culture toward sex, in general and various sexual practices in particular. For example, in certain cultures, there exists a belief that the simple practice of drinking milk on the nuptial night would lead to better sexual vigor and hence would guarantee good sexual performance. This belief can lead to sexual dysfunction if one is unable to perform adequately due to factors such as nuptial night anxiety in the male partner. Assessment of knowledge, attitude, and practice toward sex thus plays an important role in the diagnosis and the management of sexual dysfunction in the Asian population or of any cultural group for that matter. Poor knowledge, negative attitude toward sex, and cultural practices play an important role in causation of perceived sexual dysfunction. Validated scales like sexual knowledge, attitude questionnaire, and Dhat syndrome questionnaire can help in structured assessment and documentation.
In the management of Dhat syndrome, the assessment of comorbid psychiatric disorders as well as sexually transmitted disorders and urinary tract infections are important. If the symptoms persist, psychoeducation is the mainstay of treatment. Behavior therapy has been considered as the first line of treatment in the management of premature ejaculation. Lifelong subtype of premature ejaculation should be treated with combined behavior therapy and pharmacotherapy. Behavior therapy techniques which are usually used are start-stop or squeeze technique. Pharamacotherapy of premature ejaculation includes topical anesthetics, tricyclic antidepressants, and selective serotonin reuptake inhibitors. The treatment for ED includes oral supplements such as phosphodiesterase (PDE) five inhibitors (sildenafil, tadalafil, udenafil, and vardenafil) apomorphine, trazodone, yohimbine, phentolamine, L-arginine, and testosterone. Intracavernosal injections with phentolamine, intraurethral therapy with alprostadil, transdermal therapy with testosterone, vacuum constriction devices, penile prosthesis, and reconstructive surgeries are the other available treatment options for ED in Asian countries.
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