Spermatophagia Associated with Dhat Syndrome in a Patient with Schizophrenia: A Case Report

To the Editor,

Dhat syndrome is common among young men of the Indian subcontinent, who often present with anxiety and somatic symptoms related to semen loss. ¹ Cultural beliefs about semen being an “elixir of life” lead people to place a high value on preserving it. Their worries about the potential loss of semen give rise to a variety of psychological problems, including depression, anxiety disorders, decreased libido, premature ejaculation, and erectile dysfunction. ² Also, dhat syndrome may present as a prodromal symptom of psychosis. ³ Stress due to dhat syndrome may contribute to the development of psychosis. ³ Atypical presentations are not uncommon among patients with dhat syndrome. Here, we discuss spermatophagia in the context of dhat syndrome in a patient with schizophrenia. Written informed consent was obtained from the patient.

A 35-year-old, unmarried, unemployed male from a lower socioeconomic background, who was a high school dropout, was brought by his mother to the psychiatry outpatient clinic of a tertiary care center. There was a 10-year history of ongoing suspiciousness, hearing voices others could not hear, irritability, aimless wandering, poor self-care, and disturbed sleep. The illness had never remitted and had fluctuated from time to time. For his illness (which was diagnosed as psychosis/schizophrenia by different psychiatrists over the past eight years), he had received multiple psychotropic medications over the years, with frequent nonadherence. He has been occasionally consuming tobacco in chewable form for the past five years. He currently did not have a partner but reported a history of a casual sexual contact. His sexual orientation was bisexual. There was no family history of any psychiatric or neurological illness. Mental status examination revealed decreased psychomotor activity, decreased tone and volume of speech, and shallow affect. Initially, the patient was guarded. However, further exploration revealed persecutory delusions and auditory hallucinations giving running commentary on his behavior. It was also revealed that he used to masturbate since his adolescence. However, later (in his 20s), he realized that it causes weakness in his body. He attributed the weakness to semen loss during masturbation. So, he tried to reduce his frequency of masturbation. He also consulted faith healers for the same and received some traditional herbal products for that. Following the onset of schizophrenia (over the past 10 years), his frequency of masturbation increased, and he would save his semen to drink it back to replenish his “energy.”

He had partial insight into his illness. He rationalized his semen drinking behavior by the popular cultural belief in India that “semen consists of vital energy of the body.” Even on giving evidence contrary to his belief, his conviction was firm and fixed. He also described an experience when he was around 20 years old in which he had oral intercourse with a young man and ejaculated in the partner’s mouth so that the semen would not be wasted. He liked the experience and also tried autofellatio, but failed. However, he continued spermatophagia. The patient was diagnosed with paranoid schizophrenia—continuous course as per ICD-10 diagnostic criteria, with dhat syndrome. His physical examination did not reveal any abnormality. His routine blood investigations were normal. He was prescribed Tab. Risperidone 4 mg daily for an initial two weeks. However, the patient did not turn up for follow up, and treatment response could not be assessed.

Spermatophagia is rarely reported in the context of dhat syndrome. ⁴ In this case, the odd behavior may have been influenced by the culturally derived overvalued ideas regarding dhat. Manifestation of psychopathology is known to be affected by cultural influences (pathofacilitative effect). Substance use disorder, suicide rates, and paraphilia rates (among both types and content) can all be influenced in this way. ⁵ Thus, a good understanding of the cultural concepts of distress helps the clinician understand phenomenology better and plan the management in a culturally appropriate manner. In this case, the features of dhat syndrome were present before the onset of schizophrenia. They continued even after the onset of schizophrenia, and hence is unlikely to have been a prodromal symptom of schizophrenia as previously reported in a case study. ³ During the course of schizophrenia, the symptoms of dhat syndrome were altered (spermatophagic behavior to restore energy). Dhat syndrome has been discussed in association with various psychiatric disorders, ranging from neurotic illness to psychotic illness, including personality disorders. ⁶ The clinician needs to be aware of several possibilities of the association of dhat syndrome with other psychiatric disorders. Besides, this case highlights the myriad presentations of dhat syndrome and co-occurrence with psychiatric illnesses different from the commonly occurring affective and anxiety illnesses, in this case, paranoid schizophrenia.