Reply to the Comments on “Sexual Dysfunction and Its Correlates Among Men Dependent on Natural Opium”

Dear Commentators,

We appreciate your interest in our published manuscript “Sexual Dysfunction and Its Correlates Among Men Dependent on Natural Opium.” ¹ We have reviewed your comments, and here is our response.

Regarding clarification of the sample and the main reasons for seeking treatment, the study population consisted of patients at our outpatient department (OPD) who sought help primarily for opioid dependence. Sexual issues were not the primary motivation or chief complaint at presentation. However, there is a possibility that these patients experienced sexual dysfunctions that may have contributed to opioid dependence or prolonged use. Therefore, clinicians should proactively evaluate sexual functioning in these patients.

Confounding by indication is possible, but aside from sexual performance enhancement—including managing pre-sex performance anxiety, improving sexual performance, and self-treating sexual problems ² —studies in India have shown that the main reasons people start using natural opium include curiosity and experimentation, peer pressure, relief from physical pain, increasing work efficiency, and having family members who also use opioids.^3,4 Continuous use is often associated with the belief that opium enhances work ability and mental focus, is less harmful, more accessible, and socially acceptable.^4,5 The main motivators to quit are the unavailability of opioids and financial problems, as per existing literature.^3,4 Though sexual problems may have played a role in the decision to stop using opioids. An Indian study with heroin users reported that approximately 39% of participants cited sexual issues as a factor in their choice to quit opioids. ⁶ However, there are no known studies on natural opium users regarding this aspect.

Regarding tool selection, discrepancies in prevalence estimates and patterns of sexual dysfunction between scales can arise from differences in the weighting of factors across scales. ASEX covers a broader range, while IIEF offers a superficial assessment beyond erection. ⁷

Assessing sexual dysfunction in opium users and incorporating this information into psychoeducation and motivational interviews may encourage them to stay abstinent from opium in the long term and help prevent treatment non- adherence and dropout. However, future research could include measures of sexual distress, use structured interviews, and conduct long-term assessments to establish a precise clinical diagnosis. This would improve understanding of how sexual experiences relate to non- adherence, treatment dropout, or relapse among opium users.

Regarding confounding by indication and selection bias, we mentioned that higher rates of sexual dysfunction could also be influenced by confounding by indication, as natural opium is commonly used in our cultural context to enhance sexual performance. However, the findings of a significant correlation between the duration of dependence and sexual dysfunction can be considered a proxy marker for the effect of increasing opium exposure on worsening sexual functioning. Future studies should assess sexual functioning before starting opium, the reason for initiation of opium, and examine this phenomenon longitudinally, with assessments conducted at multiple time points.

In limitation, we mentioned that the dose-effect relationship was not evaluated because measuring the exact dosage of natural opium was difficult due to its availability in various forms and strengths. However, future studies could minimize biases by quantifying opioids in body fluids to assess dose-response.

The commentator has correctly noted that the high rate of sexual dysfunction observed in our study should be viewed with caution, as it might not accurately represent the prevalence among opioid users in the general community. Nonetheless, the clinical significance of the findings is that sexual dysfunction in this patient group is unquestionably high, which highlights the need for structured assessments and targeted therapeutic interventions. Addressing these sexual issues is likely to enhance overall quality of life, improve treatment adherence, and support long-term abstinence in patients dependent on natural opium. However, this potential benefit should be confirmed through longitudinal research.

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