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

Dear Editor,

The study “Sexual Dysfunction and Its Correlates Among Men Dependent on Natural Opium” by Kumar et al., ¹ fills a vital evidence gap on the association between natural opium use and sexual health. ¹ The study findings report a high prevalence of sexual dysfunction among natural opium users, with severity of opium use as a predictor. These findings are particularly relevant in the Indian context, where opium is commonly perceived as having aphrodisiac properties.

The study was conducted on a homogenous sample of pure natural opium users, which is scarce in existing research. The study is further strengthened by including multifaceted psychometric scales to assess sexual functioning and hormonal assays to support the biological basis.

We would like to comment on the sampling method, the tools used to assess sexual dysfunction, and the potential selection bias in this study. The study states that it has used convenience sampling, and patients were recruited from the outpatient department (OPD), with the inclusion criteria of being married or in a stable sexual relationship for six months and having a patient score of less than five on the Clinical Opiate Withdrawal Scale (COWS). It does not explicitly mention whether the patients were seeking treatment for opium related issues or sexual issues. The clarity on chief complaints or motivation to seek treatment is essential for readers to contextualize the findings of a very high prevalence of sexual dysfunction in this sample. This would better inform the clinical relevance of the findings by indicating whether clinicians must be more proactive in assessing sexual functioning or if patients are already recognizing and seeking help for this side effect.

We also note a striking discrepancy in the calculated prevalence rates of sexual dysfunction with the Arizona Sexual Experience Scale (ASEX) and the International Index of Erectile Function (IIEF) (46.7% vs. 90.7%). This quantitative difference in prevalence requires careful consideration, as both tools are self-reported screening tools to assess sexual functioning. The IIEF’s high sensitivity is driven by its focus particularly on erectile function, a domain affected in 89.7% of cases in this study. ² This could overrepresent the physiological outcome of erectile dysfunction due to hypogonadism, which is a prevalent condition among chronic opioid users.^3,4 The ASEX, being a broader measure of sexual drive, arousal, and orgasm satisfaction, may be a better indicator of subjective sexual health. ⁵

However, it raises the question of what is the best way to capture the sexual experiences that drive non-adherence, treatment abandonment, or relapse among opium users, which is the primary justification for understanding sexual health among those with substance use disorder. If the patients have reported to OPD with chief complaints of opioid dependence, the study findings of sexual dysfunction may not be adequate to guide the clinical decision of intervention. Therefore, subsequent research in this domain should consider including a formal measure of sexual distress and establishing a definitive clinical diagnosis through a structured interview.^6,7

Furthermore, the clinical interpretation must be tempered by confounding by indication and inherent Berksonian bias in clinical settings. ⁸ The authors rightly note the cultural belief in some communities that natural opium possesses aphrodisiac properties. Patients with pre-existing sexual difficulties may have initiated or increased opium use in a self-medication attempt, thus confounding the correlation between the substance and the outcome by introducing selection bias. Also, both opium use and sexual difficulties would increase the likelihood of seeking treatment. Readers will better understand this if the authors clarify the chief complaints for which the patients have come to the OPD. Future research should consider a longitudinal study design, community-based participant recruitment, the addition of a control group, and the quantification of dose-response to minimize biases and establish a firm causal link between natural opium use and sexual dysfunction.

Citation Diversity Statement

The authors made conscious efforts to ensure equitable citation practices, including representation across genders, geographic regions (including the Global South), career stages, and historically marginalized groups.

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