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A prospective study on sexual dysfunctions in depressed males and the response to treatment

Thakurdesai, Abha; Sawant, Neena1,

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doi: 10.4103/psychiatry.IndianJPsychiatry_386_17
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Healthy sexual functioning is an integral part of a happy life. Problems in sexual functioning are commonly seen in cases of depression.[1] The clinical features of depression have been known to impair sexual functioning. For instance, anhedonia, or the inability to experience pleasure, the easy fatigability seen in patients with depression, and the poor self-esteem that patients with depression often suffer from can predictably affect normal sexual functioning.[23] To complicate matters, antidepressants which are routinely prescribed for treating depression are also often associated with sexual dysfunctions.[4567]

In India, speaking about sex is considered taboo. The patient's awkwardness and the physician's difficulty in handling sexual issues often make both parties reluctant to discuss sexual problems. The youth are rarely formally educated regarding sexuality and sexual health and their knowledge comes from friends and media, leading to the perpetuation of multiple myths and misconceptions regarding various domains of sexual health ranging from sexual anatomy and physiology, masturbation, intercourse, sexually transmitted diseases, and well-being.[8]

While some studies examine sexual functioning in depression as a whole, some others inspect the effects of antidepressants on patient's sexual life. Few studies in India have addressed the prevalence and types of sexual dysfunctions seen in the depressed male population vis-à -vis the general population.[91011] Myths and misconceptions, so commonly encountered too, have been inadequately studied.

Hence, we undertook this study to evaluate and compare sexual functioning and prevalent myths and misconceptions in drug-naïve depressed male patients with the general male population. We studied and compared the prevalence of sexual dysfunctions in both groups, the association of depression with sexual functioning, and the improvement or worsening in sexual functioning and the depressive symptoms after treatment with a serotonin-specific reuptake inhibitor (SSRI) in the depressed males at the end of 6 weeks.


The study was a prospective study with a follow-up period of 6 weeks conducted in the outpatient clinic of the psychiatry department of a tertiary care hospital over 18 months after approval from the Institutional Ethics Committee. The sample size for the patient group was decided as per universal sampling. A total of 115 depressed male patients who attended the outpatient department (OPD) during the period from March 2014 to August 2015 were screened. Only those patients in the age group of 18–45 years; who were newly diagnosed as depression as per the International Classification of Diseases (ICD) 10 criteria by the consultant psychiatrist; and who were drug naive, sexually active, and willing to participate in the study were then enrolled in the study after valid informed consent. Patients with medical comorbidity, substance use, or other comorbid psychiatric disorders with a history of previous treatment with antidepressants or those patients who had severe depressive episode with psychotic symptoms and/or suicidal ideations were excluded from the study. The patient sample size was thus 56 patients who satisfied the inclusion and exclusion criteria.

The control group consisted of age-matched males who were accompanying other patients in the psychiatry outpatient department. A total of sixty males aged 18–45 years, literate, sexually active, and willing to participate in the study were enrolled as the control group after valid written informed consent and ensuring that they had no major medical, surgical, or psychiatric illness, which could contribute to sexual dysfunctions. These details were inquired into at the time of enrollment in the study, but no screening instrument was used. Those individuals already having any psychiatric disorder or on any psychotropic medication were excluded from the study.


Semi-structured pro forma

Two semi-structured pro formas inquiring into the sociodemographic details, medical history, and psychiatric history were designed for the patient group and the control group, which recorded the sociodemographic details.

Beck's Depression Inventory

This is a widely used self-report scale, devised by Beck in 1996.[12] It is reliable and valid across multiple cultural groups in psychiatric and nonpsychiatric populations. It has 21 items, each assessing a symptom of depression, wherein each statement is scored on a 4-point scale and a total score is obtained by summing the ratings for each item. The maximum score possible is 63. A score of 17 or above indicates the presence of depression, with a score between 17 and 20 indicating borderline depression, 21 and 30 indicating moderate depression, 31 and 40 indicating severe depression, and more than 41 indicating extreme depression.

Arizona Sexual Experiences Inventory

It is designed to measure 5 items identified as the core elements of sexual function.[13] These elements are sexual drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm, and satisfaction from orgasm. The items are rated on a 6-point Likert scale ranging from 1 (hyperfunction) to 6 (hypofunction). Possible total scores range from 5 to 30, with higher scores indicating more sexual dysfunction. A total score of >18 on the Arizona Sexual Experiences Inventory (ASEX) or a score of 5 or greater on any one item or a score of 4 on 3 or more items is associated with clinical sexual dysfunction.

International Index of Erectile Functioning

This is a 15-item self-report scale with specific questions assessing sexual functioning across the following five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction on an Likert scale. The higher the score, the better the sexual functioning.[14]

Myths and Misconceptions

This is a validated questionnaire consisting of 26 questions, which assesses the myths and misconceptions across domains such as semen, masturbation, penis, circumcision, and vasectomy, designed for use in India as per the cultural background and has been used previously by the principal investigator in other studies. Each question has a 3-point rating scale with 1 = no, 2 = not sure, and 3 = yes and gives domain scores.[8]

All scales were translated into Marathi and Hindi and these translations were validated by a three-member committee including two psychiatrists and one psychologist.

Patient group

All the details of the 56 patients enrolled in the study were recorded with the help of a pro forma and the various scales to study the prevalence and severity of the psychopathology and beliefs regarding male sexuality. Patients were then started on tablet escitalopram, a SSRI which is dispensed free of cost in the hospital dispensary, the dose of which was titrated depending on the clinical response and side effects seen. Most of the patients were given doses ranging from 5 to 20 mg. They were also enrolled in a psycho-educational group where they were provided with information regarding sexual anatomy and physiology. Various myths and misconceptions prevalent in the society were also discussed in an effort to clarify them. This involved attending two sessions, each lasting 45 min conducted by the investigators at an interval of 1 week. In the first session, essential concepts regarding sexual anatomy and physiology were explained to the patients and, in the second session, various myths and misconceptions were clarified. These sessions provided a chance for the patients to gain scientifically correct knowledge regarding their sexuality and have their queries answered.

All the patients were followed up regularly on a weekly/fortnightly basis and all the scales were applied at the end of 6 weeks of treatment to study the improvement in mood and sexual functioning.

Eight patients dropped out of the study as they were lost to follow-up in the following order: three patients dropped out at the end of week 3, two patients at the end of week 4, one patient at the end of week 5, and two patients at week 6. Hence, the sample of patients available for analysis at the end of 6 weeks was 48. The assessment of improvement in depression and sexual functioning at the end of 6 weeks after treatment with SSRI in the depressed males was done as per protocol analysis.

Control group

The sociodemographic details of the individuals enrolled in the control group were recorded on the pro forma and they were assessed only for the prevalence of sexual dysfunctions and myths and misconceptions. Beck's Depression Inventory (BDI) was not applied to the control group.

The control group was not taken up for psycho-education as part of the study. However, they were referred to the psychiatry OPD if they were found to have myths and misconceptions and expressed a desire to have these clarified. Furthermore, those found to have depressive symptoms or symptoms suggestive of a sexual dysfunction were referred to the psychiatry OPD for further management.

Statistical analysis

Statistical analysis was done using Statistical Package for Windows, Version 17.0. (SPSS Inc., Chicago, USA) at 5% significance. Group differences were analyzed with the help of frequency distribution, Chi-square test, and t-test wherever applicable. The association between depression and sexual dysfunctions was done using Pearson's correlation coefficient. The changes in sexual functioning and depression after treatment were studied by paired t-test in the patient group as per protocol analysis.


Demographic variables

Both groups were matched for age. More than 70% of both the group participants were married. A majority of the study population were Hindus by religion (50% of patient population; 61.67% of control group), while the rest were Muslims or Christians. One-third of the participants of both the groups lived in nuclear families. Approximately 62% of the participants in both the groups had secondary education and above. Only nine patients in the patient group were unemployed as compared to two individuals in the control group. More than 95% of both the group participants belonged to lower and middle income groups [Table 1].

Table 1:
Socio-demographic variables

Severity of depression

The patients were diagnosed to be having depression as per the ICD 10 criteria and nearly 46% (n = 26) of the patients were having mild depressive symptoms with or without somatic symptoms, 41% (n = 23) had moderate depressive symptoms, and 12.5% (n = 7) had severe symptoms without psychotic symptoms.

When these patients were rated for the severity of the depressive symptoms on the BDI, then our clinical findings were nearly in keeping with the BDI scores, with 30 (53.57%) patients having mild clinical depression, 15 (26.79%) having moderate depression, and 11 (19.65%) patients having severe-to-extreme depression.

Prevalence of sexual dysfunctions

When the patient and control groups were compared for the prevalence of sexual dysfunctions as per ASEX (total score of >18 or a score of 5 or greater on any one item or a score of 4 on 3 or more items), a highly statistically significant difference was seen with sexual dysfunctions present in 35 (62.5%) depressed male patients as compared to only 11 individuals of the control group (P < 0.0001, Chi-square test, Chi-square statistic = 23.612). The mean score on ASEX in the patient group (17.696 ± 6.4) was also significantly higher than that in the control group (11.183 ± 3.4).

When both the groups were further assessed for their sexual functioning as per the International Index of Erectile Function (IIEF) scale, a highly statistically significant difference was seen on orgasmic functioning (t = 2.249, P < 0.02), sexual desire (t = 3.1, P < 0.002), and overall satisfaction (t = 5.4, P < 0.0001), with the control group having better functioning than the patient group. No statistically significant differences were seen on the domains of erectile functioning and intercourse satisfaction [Table 2].

Table 2:
Types of Sexual Dysfunctions as per International Index of Erectile Functioning

Association of depression and sexual functioning

When the patient group was analyzed for the association between depression and sexual dysfunctions using Pearson's correlation coefficient, we found a highly statistically significant association of ASEX and BDI (r = 0.35, P > 0.007).

Similarly, with IIEF and BDI, a negative correlation was seen on the subdomain scales of sexual desire (r = −0.269, P < 0.04), intercourse satisfaction (r = −0.33, P < 0.01), and overall satisfaction (r = −0.329, P < 0.01), thus showing that if a person is depressed, then there is impaired sexual functioning [Table 3].

Table 3:
Correlation between depression and sexual functioning with Pearson's Correlation Coefficient

Myths and misconceptions

Myths and misconceptions were seen to be prevalent in both patient and control groups. A highly statistically significant difference was seen between the two groups, with the patient group having more misconceptions as compared to the control group in the beliefs about masturbation (t = 2.97, P < 0.003) and the beliefs about the size and shape of the penis (t = 2.10; P < 0.03). No significant differences were seen in both the groups in their beliefs about semen, circumcision, and vasectomy [Table 4].

Table 4:
Myths and Misconceptions in both groups

Changes in depression and sexual functioning after 6 weeks of treatment in patient group

After treatment with SSRIs, data were analyzed for the 48 patients who followed up for the entire study duration. The prevalence of sexual dysfunctions reduced from 68.7% to 47.9%. There was no significant change in the prevalence of erectile dysfunction and decreased sexual desire; however, the prevalence of dissatisfaction with intercourse and overall sexual life decreased from 70.8% to 52% and 66.6% to 52%, respectively. Although no patients complained of problems achieving orgasm at baseline, seven patients had complaints of the same at 6-week follow-up.

After 6 weeks of treatment with SSRIs, the patient group showed a very significant improvement from the baseline in the total BDI (t = 6.8, P < 0.0001) and ASEX scores (t = 3.262, P = 0.002). On the IIEF subdomains of sexual functioning, patients were more satisfied with sexual intercourse (t = 3.164; P = 0.003) and overall sexual interactions (t = 3.643, P = 0.0007) though orgasmic function had worsened significantly (t = 2.351, P = 0.023). No significant improvement was seen in the domains of erectile functioning and sexual desire, though there was a reduction in the scores after treatment indicating sexual dysfunction [Table 5].

Table 5:
Changes in depression and sexual functioning after 6 weeks of treatment with SSRI in patient group


Both the groups were comparable in terms of sociodemographic variables. Our finding of a higher prevalence of mild-to-moderate depressive symptoms in the patient group is in keeping with the general epidemiological findings.[15]

Prevalence of sexual dysfunctions

Problems in sexual functioning were found in 62.5% of the patient group and 18.33% of the control group enrolled in our study. These findings are in keeping with literature for both the patient and the control groups.[191016171819] In our study, sexual dysfunctions were 3.2 times more prevalent in the depressed population as compared to the control group. Similar findings were reported by Kendurkar and Kaur[10] and the Zurich prospective study.[1] We found a decrease in sexual desire and problems in ejaculation and in achieving orgasm more commonly in the depressed population compared to the general population. Dissatisfaction with overall sexual life and relationship with sexual partner too was reported more often by those with depression. Studies by Thakurta et al.,[11] Kendurkar and Kaur,[10] Cassidy et al.,[20] and Kennedy[21] have found 33%–45% of depressed males to have a decreased libido, 29%–33% to have erectile problems, and 20% to have problems in ejaculation and/or orgasm. The variations in prevalence can be due to differences in the inclusion criteria and techniques of assessment.

As patients do not spontaneously report sexual issues, inquiring for sexual history as a part of thorough assessment becomes important. Addressing sexual problems would make management more comprehensive.

Association of depression and sexual functioning

We found a significant association between depression and sexual functioning, which has also been reported by Thakurta et al.[11] However, Kennedy et al.[21] did not find any association between the two. Depression and sexual functioning have a bilateral relationship with each other. The low mood, anhedonia, fatigue, and impaired social functioning in depression can lead to impairments in sexual functioning. Often, problems in sexual functioning themselves can lead to depressive features.[222324]

A higher score on IIEF indicates good sexual functioning, while a higher score on BDI implies greater severity of depression. Thus, as the severity of depression increases, there is a decrease in libido and a decrease in satisfaction with intercourse and overall sexual life, which was seen in our patients. These findings were in keeping with those of Thakurta et al.[11] who found depression to have a correlation with all subdomains of sexual functioning except arousal/erection. Several studies have shown that libido gets adversely affected in patients with depression.[25] Studies have also found poor sexual satisfaction to be associated with depression.[2627]

Myths and misconceptions

In our study, beliefs that masturbation can harm physical health and cause wastage of precious semen and misconceptions about the size and shape of the penis and its effect on sexual satisfaction were more in the depressed population as compared to the control group. Surprisingly, though there were beliefs about semen loss and vigor, it being equivalent to “40 drops of blood” resulting in weakness if there were nocturnal emissions, no significant differences were noted in both the groups. Similarly, effects of circumcision/vasectomy on sexual satisfaction though expressed were not statistically significant. There is a dearth of literature about the prevalent sexual myths and misconceptions. Sawant and Nath[8] have found myths and misconceptions to be prevalent in dhat syndrome, keeping in with our findings. Exploring for and correcting these faulty beliefs is important as often they can lead to cultural syndromes like dhat syndrome which are characterized by having symptoms of depression and anxiety, which can complicate the clinical picture.

Changes in depression and sexual functioning after 6 weeks of treatment

We found a significant improvement after treatment in both depression and sexual functioning in our patients. On IIEF subdomains, though there was a greater satisfaction with intercourse and overall sexual functioning, a significant deterioration in orgasmic functioning was seen after treatment. There was also a reduction in the mean scores on the domains of erectile functioning and sexual desire, indicating a worsening though it was not statistically significant.

The improvement in BDI scores indicates that the patient group responded favorably to tablet escitalopram that was prescribed to them. Patient satisfaction regarding sexual intercourse and overall sexual life also improved significantly possibly due to decreased anhedonia and improved energy levels and social functioning. A worsening in the other domains could be possible if the sexual problems are independent of the depression or could be due to SSRI-induced sexual side effects.[28] Piazza et al.[29] also reported SSRI-induced anorgasmia in their study. This indicates that sexual functioning needs to be given importance for if unaddressed, could hamper the quality of sexual life and thus lead to an increase in depressive features.[30] Patients may also become nonadherent to medications, leading to resurgence of symptoms.


Sexual dysfunctions and myths and misconceptions were found to be more common in depressed males than in the general population. Depression was found to correlate with sexual functioning and, more severe the depression, the greater the intensity of problems in sexual functioning, specifically sexual desire and sexual satisfaction. Sexual functioning also improved when depression was treated. Thus, mental health-care professionals must inquire regarding sexual functioning sensitively, ensure that they psycho-educate those with misconceptions, and be watchful for changes in sexual functioning when they prescribe antidepressants.

Our study has several limitations. The sample size was small and reflected a selection bias of the patient group seen at a tertiary care hospital. Though the patients were assessed by psychiatrists, we did not use diagnostic criteria for the detection of sexual dysfunctions in the patients. Studies using structured clinical interview for sexual history taking with a long-term follow-up to see the effect of the antidepressants on sexual functioning will definitely help in understanding the associations of depression and sexual functioning.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Antidepressants; depressed males; male sexual dysfunctions; myths and misconceptions

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