Marital and psychosexual problems are among the more common disorders, but are infrequently brought to clinical attention. Issues of privacy and a general embarrassment in discussing marital and psychosexual problems often lead to overlooking these problems and disorders in clinical settings. The patient may not volunteer information, particularly if adequate efforts are not made to put the patient at ease. At the same time, marital and psychosexual disorders are a cause of intense distress to the patient as well as his or her partner. These disorders are a cause of concern for patients for several reasons and affect their day-to-day functioning. Hence, there is a need for dealing with these disorders in an appropriate manner.

Sexual problems are common in both males and females (Simons and Carey 2001). These disorders are present in populations who seek medical help, as well in those who do not seek medical help. Initial studies from India suggested a rate of sexual dysfunction of around 10 % in psychiatric outpatient services (Bagadia et al. 1972; Nakra 1971). The rates may be even higher in patients being treated with psychotropic medications (Krishna et al. 2011). Patients with psychosexual disorders are often referred from other specialties like urology. A large proportion of these patients can be helped effectively.

Similarly, marital problems are common in cohabitating couples. When two people live together, there are bound to be instances when opinions differ, and differences expressed verbally and non-verbally. A successful marriage requires a considerable degree of adjustment, and either of the partners may be unwilling or unable to adjust. The difficulties in adjustment can manifest in many ways—as an outburst on the other partner, or a silent displeasurable suffering, or a combination of the two. Though intermittent tiffs are common among most couples, matters spiral downwards when relations deteriorate, at times to physically alarming proportions. Marital functioning has been seen to be impaired in psychiatric patients (those suffering from depression or dysthymia), as compared to healthy controls (Subodh et al. 2008).

Having an estimate of the problem of sexual dysfunction would help in understanding the gravity of the situation and would also help in planning concerted efforts made to deal with the issue. However, drawing accurate inferences about the prevalence of sexual disorders is a challenging task. Patients with sexual disorders may not be forthcoming due to a general secrecy about the matter. Also, the quality of sexual experience is a subjective concept and comparing sexual functioning between individuals poses difficulties in ascertainment. Moreover, some conditions, which are encountered in clinical settings in India (e.g. apprehension about sexual potency), do not find mention in the current diagnostic systems (Kulhara and Avasthi 1995). Nonetheless, many clinic-based studies (Bagadia et al. 1972; Nakra 1971; Nakra et al. 1978, 1977) have been conducted in India looking at the rates of sexual disorders, primarily erectile dysfunction and premature ejaculation.

In one of the earlier studies, Bagadia et al. (1972) evaluated cases coming with complaints of sexual dysfunction to a teaching hospital in the general outpatient setting. They found that in the married group of patients, impotence, premature ejaculation and passage of semen in the urine were the most frequent presenting complaints. In the unmarried group, nocturnal emission and passage of semen in urine were the commonest presenting complaints.

Nakra and colleagues (Nakra 1971; Nakra et al. 1978, 1977) studied sexual disorders in male subjects and found that these were present in 9.2 % of all patients seen in the psychiatric outpatient. The commonest disorder was impotence, followed by premature ejaculation. Nearly 20 % of the patients were diagnosed as having the Dhat syndrome. Sexual behaviours of patients prior to the development of sexual problems were also explored (Nakra et al. 1978). It was found that nearly 75 % of the patients had practiced masturbation before developing the sexual problems, and a sizeable number of them had associated guilt. Nocturnal emissions were reported by 95 % of the subjects with 60 % of them having associated guilt feelings. Loss of semen was thought to be injurious to health by 64 % of the participants.

A study from the Postgraduate Institute of Medical Education and Research (PGIMER) explored the prevalence of various sexual disorders in 66 patients attending a marital and psychosexual clinic (MPC) (Avasthi et al. 1994). Erectile dysfunction was the main diagnosis in 30 % of the cases, premature ejaculation in 12 % of cases and a combination of erectile dysfunction and premature ejaculation in 45 % of the cases. Nearly 38 % of the patients dropped out even before treatment was instituted. Initial dropout was associated with chronic and continuous sexual dysfunction. Of those patients who could be treated, about 44 % had improvement. It was observed that better outcome was associated with the greater number of visits to the clinic. Better short-term outcome (within 1 year) indicated good long-term outcome (at 7 years). Another study examined the prevalence of various sexual disorders in a set of 464 new patients examined in the MPC of PGIMER over a period of 7 years (Avasthi et al. 1998a). It was observed that erectile dysfunction was the most common disorder encountered, closely followed by a combination of erectile dysfunction and premature ejaculation. Marital discord was present in 8 % of the patients. A fifth of the patients dropped out of treatment after evaluation, before therapy could be instituted. Of the patients who followed up, about 30 % had partial and complete improvement, while no improvement was noticed in about 40 % of the patients.

In another study from Ranchi, Kar and Varma (1978) looked at the sexual and marital functioning in patients with psychiatric disorders and compared them to controls who were the healthy relatives of these patients. They found that patients with psychiatric disorders had greater rates of premature ejaculation and erectile dysfunction at the time of consummation of marriage. The state of marriage was described to be unpleasant by a considerably greater number of patients than controls. In another clinical sample attending a psychosexual clinic, premature ejaculation was reported to be the commonest disorder encountered, followed by erectile dysfunction study (Kendurkar et al. 2008). Certain other studies focusing on specialised groups like opioid- and alcohol-dependent patients have found significant rates of sexual dysfunction in these group of patients (Arackal and Benegal 2007; Mattoo et al. 2010; Ramdurg et al. 2012). It is thus evident from the literature that sexual dysfunction is a common reason for seeking psychiatric consultation in India and that premature ejaculation and erectile dysfunction are the commonest disorders encountered.

In any culture, the way sexuality is discussed or remains a taboo determines the knowledge people have about sexual matters. Inadequate sexual knowledge can give rise to misconceptions and doubts, leading to untamed curiosity or frustration. It may also cause embarrassment or confusion about sexual matters. Since a degree of apprehension surrounds any discussion of sexuality, more so in the Indian culture, the knowledge about sexual matters in both the genders may be questionable. Also, the attitude towards sexual matters, which includes beliefs, liking–disliking as well as action tendencies, may differ between people with the same degree of knowledge. Clinical experience suggests that in many cases of psychosexual disorders, sexual ignorance, misconceptions and attitudes play a significant role in the causation and perpetuation of the disorder. Hence, understanding a person’s knowledge and attitude towards sexuality is useful for treatment planning.

One of the earlier studies (Singh et al. 1987) aimed to find the differences in sexual attitudes and knowledge in medical and non-medical postgraduate students. The investigators assessed sexual knowledge and attitude using a modified version of Sexual Knowledge and Attitude Test (SKAT) among male hostel-residing students at Panjab University and PGIMER, Chandigarh. The results showed that as compared to medical students, non-medical students had poorer knowledge and a relatively conservative attitude towards sexual matters. This suggested that knowledge and attitude differences existed between medical and non-medical students, presumably due to exposure to accurate anatomical and physiological information among medical students.

Various scales have been in vogue for measuring sexual knowledge and attitude. The Sex Knowledge and Attitude Questionnaire II (SKAQ II) was among the first such validated instrument developed in India. It was developed after Hindi translation of SKAT was done to create SKAQ I. The numbers of items were reduced further to yield a 55-item scale in Hindi. This well-validated scale measures sexual knowledge and attitudes (Avasthi et al. 1992). Out of the 55 items, 35 pertain to sexual knowledge (rated in a ‘yes’ or ‘no’ format) and 20 to sexual attitudes (rated on a Likert scale). The scale is easy to administer and score. Higher scores reflect a greater knowledge and a liberal attitude. Test–retest reliability of the test has been evaluated in a sample of 60 subjects (20 with psychosexual disorder, 20 normal males and 20 normal females) and was found to be fair. The validity of the scale was checked in 80 subjects (20 experts, 20 patients with psychosexual disorders, 20 normal males and 20 normal females). It was seen that males were more liberal in their attitudes towards sex than females, and experts had the most liberal attitudes among all the groups (Avasthi et al. 1992).

A scale has also been developed to assess the knowledge and attitude towards condoms (Avasthi et al. 1998b). This scale has a special relevance with the increasing number of patients with sexually transmitted diseases (STDs) and acquired immunodeficiency syndrome (AIDS). The scale was developed by pooling items relating to the awareness and attitudes towards condoms. The final form of the scale had 62 items: 26 items pertaining to knowledge and answered in a ‘yes’ or ‘no’ format, and 36 items relating to attitudes rated on 5-point Likert format. The scale was field-tested in a set of 60 healthy controls, 30 patients with STDs and 15 resident doctors. The scale was found to have good validity and reliability (Avasthi et al. 1998b).

A study was conducted at the PGIMER (Avasthi et al. 2005) to evaluate the impact of sexual knowledge and attitude on treatment outcome. The sample comprised of patients with premature ejaculation, erectile dysfunction or the combination of two. Knowledge and attitude was measured using the SKAQ. It was seen that patients in all the three groups had poor knowledge and a conservative attitude towards sexual matters. There were no significant relationship between the overall knowledge and attitude scores and the outcome. In an effort to improve the sexual knowledge of subjects attending the clinic, a guide book on sex education was developed by Avasthi and Banerjee (2002).

The term Dhat syndrome was coined by Prof Wig (1960), referring to a common culture-bound preoccupation with loss of semen in the Indian subcontinent. It is considered a form of culture-bound sexual neurosis (Bhatia and Malik 1991), which commonly affects young adult and adolescent males.

The evolution of the concept of Dhat syndrome can be traced to the teachings of Ayurveda. Ayurveda states that there are seven essential components of the body (the seven Dhatus). Semen is considered as the most concentrated and precious of these components. It is said that 40 meals make one drop of blood, 40 drops of blood make one drop of marrow and 40 drops of marrow make one drop of semen. Sushrut samhita writes that loss of semen in any form leads to draining of physical and mental energy. Charak samhita describes a disorder of shukrameha (draining of the semen), an entity similar to the present-day Dhat syndrome. Thus, ancient scriptures give paramount importance to conservation of semen.

The Dhat syndrome is usually presented as the loss of semen in young men, while passing urine or straining for stools. The associated symptoms commonly include vague and multiple somatic and psychological complaints like fatigue, listlessness, loss of appetite, lack of physical strength, poor concentration and forgetfulness (Avasthi and Jhirwal 2005). These symptoms are usually accompanied by anxious or dysphoric mood. These patients may also have other disorders of sexual dysfunction, like premature ejaculation or erectile dysfunction. The patient ascribes his symptoms, including sexual dysfunction, to the passage of Dhat (semen or some whitish substance presumed to be semen) in the urine, or excessive indulgence in sexual activity, masturbation or nocturnal emissions. Apart from a whitish discharge with urine, there are no other urinary symptoms. The patient may insist on passage of semen in the urine, though there is no objective evidence of the presence of semen. Neurotic depression (dysthymia) and generalised anxiety disorder are the commonest disorders encountered in patients with the Dhat syndrome (Avasthi and Jhirwal 2005).

The Dhat syndrome is encountered not only in India, but also in other countries in the subcontinent like Nepal, Bangladesh and Pakistan (De Silva and Dissanayake 1989; Mumford 1996). Masturbation, excessive indulgence in sexual activities, venereal diseases, urinary tract infections, overeating, constipation, worm infestation, disturbed sleep or genetic factors are believed to be the main aetiological factors (Bhatia and Malik 1991). A majority of the patients get information about the Dhat syndrome from friends, colleagues or relatives, whereas some from posters, advertisements in mass media, magazines or quacks. The Dhat syndrome has also been described in females (Rajpal et al. 2013; Singh et al. 2001).

Standardised instruments have been developed for the assessment of the Dhat syndrome (Grover et al.; Sharan et al. 2003). The Dhat Syndrome Questionnaire (DSQ) is a comprehensive instrument looking at various aspects of the Dhat syndrome, including situations of passage of semen, reasons for passage, consequences of passage, accompanying symptoms and common comorbidities (Grover et al. n.d.). The other instrument comprises of 13-item semi-structured questionnaire and is meant to be used as an interview schedule (Sharan et al. 2003).

The treatment of Dhat syndrome poses some challenges. Explanation and reassurances do not prove to be of much use as they do not match with the culturally ingrained beliefs. Hence, some workers have recommended emphatic listening, a non-confrontational approach, reassurance and correction of mistaken beliefs, along with the use of placebo, anti-anxiety and anti-depressant medications, wherever required (Wig 1998). A standardised treatment package for single males presenting with the Dhat syndrome has been developed (Avasthi and Gupta 2002), which mainly includes sex education and relaxation exercises. Sex education mainly focuses on anatomy and physiology of sexual organs, with reference to masturbation, semen, nocturnal emissions and the functioning of genito-urinary system. Relaxation therapy includes the Jacobson’s Progressive Muscular Relaxation Technique along with biofeedback. If there is the presence of associated anxiety or depressive symptoms that may impede the process of therapy, anxiolytics and/or antidepressants can be added for the minimum possible time and in minimum possible doses. This kind of treatment has been found to be quite useful for patients with the Dhat syndrome. A cognitive behavioural model of treatment has also been developed and tested for patients with the Dhat syndrome and comprises of assessment, psycho education and cognitive behavioural interventions (Abdul Salam et al. 2012).

Occasional case reports have also reported a female counterpart of the Dhat syndrome, which is characterised by subjective complaints of excessive passage of discharge per vaginum, associated with complaints of weakness and lethargy. These symptoms are attributed to passage of discharge per vaginum (Singh et al. 2001; Rajpal et al. 2013).

Sexual intimacy can be considered an integral part of married life and can be a mutually satisfying experience. Hence, sexual disorders are likely to have an impact on the well-being of the marital unit and the spouse may also be affected. Moreover, various forms of marital and sexual therapies require the active cooperation of spouses. Here, we enumerate some studies that have assessed the impact of psychosexual disorders on spouses.

Kumar et al. (1999a, b) assessed the level of distress among wives of patients with psychosexual dysfunction and its relationship to marital adjustment. Their sample comprised of wives of 30 male patients with psychosexual dysfunction. The PGI Health Questionnaire N1 was used to ascertain the physical and psychological distress, the Dyadic Adjustment Scale was used to assess marital functioning, and the Dysfunctional Analysis Questionnaire was used to assess the dysfunction. A majority of the male patients suffered from combination of premature ejaculation and failure of genital response. Wives were found to be significantly more distressed than husbands and exhibited higher degree of psychosocial dysfunction. However, wives still had normal marital adjustment. There was a significant and positive association between distress and psychosocial dysfunction. Marital adjustment showed a significant negative association with both the distress experienced and psychosocial dysfunction. These findings have important implications for the management of these disorders, as wives with more distress were likely to have poorer marital functioning and greater dysfunction.

A study by Avasthi et al. (2010) aimed to examine the psychosexual functioning of spouses of men with non-organic erectile dysfunction in terms of their sexual satisfaction, psychological problems, marital adjustment, quality of life and level of dysfunction. This study was a methodological advancement over the previous study (Kumar et al. 1999a, b). Fifty spouses of men with erectile dysfunction were compared with fifty spouses of men without any psychosexual dysfunction. A wide variety of variables, which could affect sexual functioning were taken into consideration in this study. The Marital Questionnaire was used for assessing marital adjustment, the Quality of Life Enjoyment and Satisfaction Questionnaire was used to assess the degree of enjoyment and satisfaction, the Symptom Questionnaire was used to measure degree of distress and hostility, the Dyadic Adjustment Scale was used to assess marital adjustment, the Dysfunction Analysis Questionnaire was used to measure present level of functioning, and the Sexuality Scale was utilised to assess sexuality. It was seen that spouses of men with erectile dysfunction had significantly lower levels of marital and sexual satisfaction, and higher levels of psychiatric symptoms than controls. Furthermore, spouses of men with non-organic erectile dysfunction also reported poor quality of life in most domains and had a greater level of dysfunction. The study emphasised that spouses of men with erectile dysfunction faced many difficulties, which also need to be recognised and attended to in clinical practice.