Abstract
Psychosexual disorders tend to be ubiquitous phenomena across the globe. Unfortunately, there is lack of good quality epidemiological data from India, with only a recent study from rural South India reporting sexual problems to be present in 21% of males and 14% females. 1 Despite the fact that females too experience relatively high prevalence of these disorders, they are overwhelmingly underrepresented in the patient profile presenting to any psychosexual clinic. More than 99% of patients presenting for treatment of psychosexual disorders are males as shown in studies from different parts of India.2- 5
Another unique feature that has been observed in the males who are presenting to the clinics and centers for the management of their psychosexual problems is that they tend to be ‘single’. This write-up shall be focusing on the ‘single males’ and the unique assessment and management issues that are encountered with them. We shall be trying to put them in perspective with a review of the available literature from the Indian perspective, coupled with a brief sharing of our experiences.
Typical ‘single males’ will either come directly to the psychosexual services/psychiatric clinic or are referred from other specialties/departments (most commonly – surgery, urology, dermatology, and endocrinology). They commonly present with erectile dysfunction, premature ejaculation, Dhat syndrome or a combination of these disorders.2- 5
Any trained practicing psychiatrist (or behavioral mental health professional) would be aware and recall that the mainstay of management of these disorders is non-pharmacological in the form of behavior therapy; most common and popular being the Masters and Johnson (MJ) technique. The MJ therapy typically (and traditionally) operates on the dysfunctional couple and proceeds in a stepwise manner aiming to remove obstacles that hinder the sexual performance. The couples are helped to experience the pleasures of touching or being touched, that is, sensate focusing. Thus, the partners discover the acts which make them more comfortable and through this they are able to overcome the sexual dysfunction. 6
The MJ therapy has been successfully applied for ‘single males’ presenting for treatment in the West due to the concept of surrogate partners. 7 However, due to sociocultural differences existing between a traditional country like India and the West, this concept has not been applicable in India due to its inherent moral and ethical issues and complications so generated. 7 However, this is not the sole or predominant reason for the male to present by himself (or without a partner) for therapy. A host of other potential reasons can be identified due to which the traditional (or classical) model of MJ therapy cannot operate. Before coming onto their discussion, it needs to be clarified that ‘single males’ can be married or unmarried/divorced/separated.
Unmarried males, despite having a partner, often feel shy to bring their female partners (fiancées/girlfriends or otherwise) to the clinic. Majority of the presenting males are married,2- 5 but most of them still do not bring their female partners while seeking treatment. Whatever may be the category (unmarried or married), there is a commonality attached to the several different reasons that are given by them.
First, they tend to hide their problem(s) from their partners, and they think that she should not know that they are suffering from any kind of sexual problem and/or receiving treatment for the same. Second, there is invariably limited communication between the male and his partner on sex-related issues. Third, the male tends to take on the responsibility for the onset, perpetuation, and treatment of his sexual problem, due to which he feels that his partner has no/minimal role to play in the management process. Fourth, among the patients coming to hospitals and clinics in the government and rural setups, majority have a lower socioeconomic status, with a low education level leading onto low psychological sophistication. It may be pertinent to mention here that in our catchment area of work, we tend to get patients who are migrant workers from rural areas of other states (Bihar, UP and others) who stay alone in the city (Chandigarh) for work and visit their wives after several months for a short period of time, and hence they cannot bring their wives from their villages/places of residence for the purposes of therapy. Lastly, there is a subgroup of married males comprising patients who are separated from their wives due to the presence of underlying psychosexual disorders. In such situations, their female partners are generally uncooperative and unwilling to come for, and participate in, therapy. Hence, due to a multitude of reasons as outlined in this write-up, the management of these disorders in ‘single males’ in the Indian context has to be implemented through the concept of ‘singles’ rather than ‘couples’.
The initial attempt was made by Kuruvilla to manage with behaviorally oriented techniques in single impotent males; he reported that 9 out of 18 patients had considerable improvement. 8 Unfortunately, no further attempts were made to address this vexing issue of ‘management of sexual dysfunctions in single males’. It was not until 2002 that a manual, Standardized Management of Single Males with Sexual Disorders, was developed from PGIMER, Chandigarh. 7 The manual is based on modified MJ behavior therapy and incorporates the authors’ clinical experiences. It outlines the approach to managing the common male sexual dysfunctions (erectile impotence, premature ejaculation, Dhat syndrome or a combination of these disorders, and homosexuality). The authors have outlined various steps and provided flowcharts for the management of these disorders. They discuss about measures to rule out organic causes for sexual disorders and identification of comorbidity associated with them. Following assessment, appropriate pharmacological and/or non-pharmacological management is instituted. Additionally, for comprehensive assessment of sexual knowledge and attitude, the Sex Knowledge and Attitude Questionnaire (SKAQ) can be administered. 9 This questionnaire helps in determining the level of sexual knowledge, the attitude, sexual myths, and the areas where sexual knowledge is deficient or incorrect. In the authors’ clinical experiences, this manual has been found to be quite utilitarian and effective. However, it has not been subjected to any clinical effectiveness trial in comparison to waitlist, placebo, or other therapies. Despite this major lacuna in terms of evidence-based research related to the management of psychosexual problems of single males, it is heartening yet vexing to note that the latest clinical practice guidelines of the Indian Psychiatric Society recommend the use of this therapy for the management of single male psychosexual disorders. 10
It is of utmost importance that delivery of this therapy is based on patient convenience/comfort and is practical in nature. By this way, drop-out rates too would remain minimal. Restoration of sexual functioning using classical MJ therapy in couples is fraught with difficulties; the same will probably be on the higher side in ‘single males’. We strongly advocate the use of tested therapies, including proper evaluation of untested therapies. Without a proper evidence base, the concern would be that sexual medicine may stand like ruins (rather than as a rock) on the face of time.