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Abstract
Background and Aims: Sexual dysfunction is often associated with substance use disorders. This study aimed to synthesize Indian literature on sexual dysfunction among patients with substance use disorders.
Materials and Methods: Electronic search engines were used to identify studies of the last 20 years that reported sexual dysfunction with different substance use disorders. Information was extracted using a predefined template. Quality appraisal of the included studies was carried out using Joanna Briggs Institute checklist.
Results: Twenty-seven relevant papers were identified that pertained to 24 distinct studies. Most of them were in patients with alcohol dependence, and fewer were in patients with opioid dependence. The study designs were primarily single-group cross-sectional, though many case–control, cross-sectional studies were also identified. The proportion of participants with sexual dysfunction ranged from 22.2% to 76% for studies related to alcohol dependence and 40% to 90% for studies pertaining to opioid dependence. Varied types of sexual dysfunctions were identified, including poor satisfaction, lack of desire, premature ejaculation, and erectile dysfunction. Efforts to address bias and confounders were not reported in most studies.
Conclusion: Sexual dysfunction affects a substantial proportion of patients with substance use disorders. Clinicians can make an effort to ascertain and address sexual dysfunction in their routine clinical practice while dealing with patients with substance use disorders.
Keywords: India, sexual dysfunction, substance use disorder, substance-related disorder
How to cite this article: Introduction 
Sexuality is an important part of an individual's life. Perceived adequate sexual functioning is associated with good self-esteem and a sense of fulfillment.[1],[2] On the other hand, sexual dysfunction has been associated with psychological distress and may adversely impact the quality of life.[3],[4],[5] Sexual dysfunction can be of different types and may affect sexual arousal, attainment of the plateau during the sexual act, achieving orgasm, and subsequent resolution.[6],[7] The nature and rates of sexual dysfunction vary across the genders and age groups.[8],[9],[10],[11] In addition, several other conditions and risk factors may lead to situational or sustained sexual dysfunction.[12],[13],[14]
Substance use disorders are one of the important determinants that may affect sexual functioning and lead to sexual dysfunctions.[15],[16],[17],[18] Psychoactive substances are often used to initiate or enhance the sexual encounter.[19],[20] However, chronic and sustained substance use may affect sexual functioning adversely.[17],[20] Each individual substance may have a different profile of effect on sexual functioning. While chronic alcohol use disorder may lead to hypogonadism and decreased sexual desire, opioids have been associated with delayed ejaculation and even anorgasmia.[21],[22] Understanding the sexual dysfunction associated with different substance use disorders may help the clinicians to make targeted inquiries about sexual functioning, and attend to sexual dysfunctions when required.
Over the last few decades, literature on sexual dysfunction associated with substance use disorder has gradually expanded. There is now adequate literature from India that merits a synthesis in the form of review. Though there are previous reviews that do talk about sexual dysfunction associated with substances,[15],[23] a review focused on the findings from Indian clinical settings is likely to provide more clinically relevant messages to the practitioners. The present review thus aims to appraise the literature from India on substance use and sexual dysfunctions and also tries to assess the quality of the included studies in a descriptive manner.
Materials and Methods The PRISMA guidelines for systematic reviews and meta-analysis were employed for the conduct of the literature search following a systematic and structured approach [Figure 1]. This review used Medline and Google Scholar databases for searching literature pertaining to sexual dysfunction and substance use in the population. Additional studies were identified from the cross-references of the full texts of the studies identified relevant in the review. The keyword combination used was (”sexual dysfunction”) AND (substance OR alcohol OR opioid OR cannabis) AND (dependence OR abuse OR disorder OR “harmful use”). The review was open to include varied types of studies including systematic reviews and meta-analysis and observational and interventional studies, provided that they reported rates or characteristics of sexual dysfunctions associated with substance use disorders in Indian clinical setting. Studies reporting sexual dysfunction in any context other than substance or assessing other aspects of sexuality in the context of substance (e.g., risky sexual behavior, paraphilias) were excluded. Studies done in psychosexual clinic for assessing substance use were excluded. Articles written in languages other than English and studies carried out in places other than India were also excluded from the review. Hand searches and contacting of experts were not done as a part of the review. The searches were carried out in May 2020 and were limited to last 20 years. After assessing the titles and abstracts, the full texts of the seemingly suitable articles were retrieved for further assessment of the studies to determine their final inclusion in the review. Furthermore, the reference lists of the selected articles were also examined for additional suitable publications that might have been overlooked in the previous search. Data search and extraction were carried out by three authors (SS, NC, and AT) independently. Quality appraisal of the included studies was carried out using Joanna Briggs Institute (JBI) checklist (https://jbi.global/critical-appraisal-tools) for quantitative studies by three authors (AT, PMP, and MSS). Parameters explored by each author included authors with the year and place of study, type of study and settings, study participants, and the results of each study using a pre-defined table template. Compilation by each author was compared, and any discrepancies were resolved by mutual consensus. The findings were summarized and synthesized and presented in the form of tables. Quantitative synthesis (meta-analysis) of the literature was not done as a part of the review.
Results In our literature search, we found 27 papers of relevance pertaining to 24 distinct studies. The studies pertaining to association of alcohol use disorder and sexual dysfunction are presented in [Table 1].
Table 1: Studies assessing relationship of alcohol and sexual dysfunctionMost of the studies were conducted in Karnataka and Chandigarh. The study design was cross-sectional, observational in almost all the studies. Most of the studies were single groups though some of them were case–control studies, where comparisons were made with healthy controls. The sample sizes ranged from 48 to 151. While the majority of the studies were conducted exclusively among males, only one study was conducted among females.[35] The age of the study sample was largely in the late thirties, reflecting the usual age of presentation of cases with alcohol dependence in the treatment-seeking population.
The findings suggest that sexual dysfunction may be present in 22.2% to 76% of the population [Table 1]. Ascertainment of sexual dysfunction was done most commonly by the Arizona Sexual Experiences Scale (ASEX) and International Index of Erectile Functioning (IIEF). In case–control studies, the cases with alcohol use disorders generally had greater rates of dysfunction than controls. Clear commonalities in the pattern of sexual dysfunction were difficult to establish, given the varied findings, though poor overall sexual satisfaction, erectile dysfunction, and premature ejaculation were commonly reported. Coital pain and orgasmic dysfunction were uncommonly reported. It was seen that longer duration of alcohol use and more severe alcohol use were generally associated with sexual dysfunction.
Among the five distinct studies on opioid use disorders [Table 2], two were conducted in Chandigarh. The sample sizes of these studies ranged from 60 to 120. Three of the studies were of case–control design. The sample comprised exclusively in males and the participants were generally in early thirties. The rates of sexual dysfunction ranged from 40% to 90%. It was seen that the rates of sexual dysfunction were higher than that of the controls. Lack of desire was a common complaint among the cases, though premature ejaculation and erectile dysfunction were also reported. It was seen that premature ejaculation was most common during the abstinence and withdrawal phase, while erection difficulty was more common during the intoxication phase.
Table 2: Studies assessing relationship of opioid use and sexual dysfunctionThere was one study which looked at the relationship of polysubstance use and sexual dysfunction in India.[50] This study was conducted in Ludhiana among 25 male individuals with polysubstance “abuse syndrome” and a mean age of 35.8 years. The International Index of Erectile Dysfunction was used to assess for sexual functioning. Intercourse satisfaction was most affected (88%), followed by overall satisfaction (64%), sexual desire (44%), and finally orgasmic and erectile dysfunction (32% each).
The quality assessment of the studies using JBI checklist is shown in [Table 3] and [Table 4]. As per JBI, the elements which were comprehensively taken care of in most of the studies were describing the inclusion criteria, descriptive and the outcome data in the results, attempts at matching cases and controls (in case of case–control studies), and use of appropriate statistical tests which was found in almost all the articles included in the review. Majority of the studies also had reasonable information in their abstract and a structured background for their research and described the settings, participants, and the main findings. The elements which were most infrequently reported and discussed included efforts to address potential sources of bias or confounders, explaining how the sample size was arrived at, explaining how missing data were addressed (if any), and explaining the number of individuals at each stage (e.g., potential eligible candidates, those examined for eligibility, those confirmed eligible, and reasons for exclusion).
Table 3: Quality assessment of included cross-sectional studies Joanna Briggs Institute checklist
Table 4: Quality assessment of included case-control studies Joanna Briggs Institute checklist Discussion The present review presents Indian literature pertaining to sexual dysfunction associated with substance use disorders. Sexual dysfunction seems to be present in a substantial proportion of patients with alcohol and opioid use disorders. A wide variety of sexual dysfunction has been reported, including a lack of satisfaction with sex, impairment of desire, premature ejaculation, and erectile dysfunction. The findings echo the results from other studies which suggest that sexual dysfunction may be common in patients with substance use disorders, particularly alcohol and opioid use disorder.[15],[18] One would reckon that the pattern and extent of the sexual dysfunction might differ across the lifespan and natural course of the illness. That is why it is important to take into consideration the setting and phase of treatment of the patient while interpreting the findings.
Among individual substances, alcohol seems to be associated with several types of sexual dysfunction. Lack of sexual desire and dissatisfaction with sexual encounter has been reported commonly, along with premature ejaculation and erectile dysfunction. Erectile dysfunction can be a consequence of hormonal imbalances caused by chronic use of alcohol.[51] Furthermore, marital conflict may accompany alcohol dependence, which may additionally impact the sexual relationship.[52] This may also additionally contribute to overall sexual dissatisfaction and lack of desire. Patients with alcohol use disorders may have affective symptoms, which may also manifest as anhedonia, loss of libido, and fatigue.[53] This may reduce the pleasure from sexual experience and may affect the desire to have a sexual encounter. Thus, the genesis of sexual dysfunction in patients with substance use disorders may have bio-psycho-social complex relationship.[54],[55] Similarly, patients with opioid dependence, including those on maintenance treatment, may have sexual dysfunction primarily in the form of impairment in desire and erectile difficulty. The continuing opioid use disorder may augment salience on opioid use to get a high, and other previously pleasurable activities (including intimate relationship) may be relegated to the background. In addition, opioids delay ejaculation and may lead to difficulty in maintaining prolonged erections as the individual is unable to ejaculate after a long duration of penetrative intercourse.
The causality of the relationship between substance use disorder and sexual dysfunction may also invite closer scrutiny. Whether substance use disorder leads to sexual dysfunction or whether sexual dysfunction elicits substance use requires consideration. The directionality of the association has been seldom evaluated systematically and requires organized inquiry. However, a common theme emerged that more severe alcohol use was associated with greater severity of sexual dysfunction, suggesting a dose–response relationship. Biological plausibility has been established for some of the sexual dysfunctions that can be easily replicated and studied in the laboratory. However, for subjective experiences such as satisfaction, indirect inferences would have to be relied upon. Overall research suggests that there appears to be a causal relationship between substance use disorders and sexual dysfunctions.
Assessment for sexual dysfunction also merits some consideration. In general, assessments were conducted using the ASEX and IIEF. In addition, a checklist of items used by Arackal and Benegal[24] has been used frequently. The appeal of the structured questionnaires (ASEX and IIEF) lies in brevity and providing a comprehensive picture of sexual functioning. However, generalizing from only five questions of ASEX is liable to be influenced by the subjectivities of response generation and interpretation. Furthermore, the thresholds determined for cutoff values may change the extent of sexual dysfunction in the sample population. One way to address this by many researchers has been to report the extent of sexual dysfunction at different cutoff points.
The quality of the included studies can have implications on the generalizability of the results. This makes it important to assess the quality of studies in a review. Sample size calculation was not attempted in many studies, while many studies did not report any attempts to address potential bias. Missing data was also found in many studies. However, how they addressed the same was not mentioned. The reporting structure was poorly followed in a few studies, with some studies even failing to report the number of participants at each stage of the study.
There are several implications for practice from the present review. First, sexual dysfunction seems to be commonly present in patients with substance use disorders. Because clinical encounter may not afford time and privacy, inquiry and reporting about sexual functioning may be limited. To avoid continued distress due to sexual issues, the clinicians may inquire about sexual functioning where feasible and suggest remedial measures as applicable. Second, the different patterns of sexual dysfunction with substance and stage of treatment may dictate the line of clinical inquiry about sexual dysfunction and the subsequent management. Third, sexual functioning is intertwined with relational functioning. A comprehensive approach for helping patients effectively may require psychological and counseling-based approaches apart from medications.
Some gaps in the current literature include limited evidence in female substance users and lack of prospective studies. Prospective assessment of sexual dysfunction individuals who are treatment naïve for substance use disorder and the response over time with treatment may be assessed. Similarly, retrospective assessment (based on recall) of sexual functioning may help in understanding the impact of premorbid sexual functioning on the current state, but with obvious risk of recall bias. The assessments may be compared between male and female users to estimate the differential effects of gender on sexual dysfunction associated with substance. In addition, a variety of instruments have been used for assessment, which makes comparisons difficult, and concurrence of sexual dysfunction according to various scales should also be studied. Another gap in the current literature is lack of clinical correlates, such as personality, quality of relationship with the partner/spouse, and sexual quality of life with sexual dysfunction. Moreover, an individual's perception about the effect of substances on his/her sexual functioning, which may be indicative of his/her continuing substance use or relapses, has not yet been assessed by any researcher. In addition to the observed lacunae, future research may also focus upon interventional studies and trials to assess the response in sexual dysfunction in substance-using population.
Some limitations of the present review should be considered while drawing inferences from the findings. The review has not conducted a meta-analysis of the study findings, which did not allow summary analysis. In addition to Medline, only Google Scholar was the database used in searching the articles. Thus, it is possible that some of the studies might have been missed, though we attempted to gather all relevant literature. Furthermore, we did not venture into studies of substance use or disorders in patients coming to a psychosexual clinic. The samples comprised generally males (except one study), which is in consonance with the usual treatment-seeking population in the country. Studies apart from those presenting with alcohol and opioid use disorders were negligible.
Conclusion The review suggests that sexual dysfunction might be common in patients with alcohol and opioid use disorders. Clinicians looking after patients with substance use disorders should inquire a patient about distressing sexual dysfunction and provide management as required. Future research may look at the longitudinal course of sexual functioning, especially in connection to the relational function. Studies may also look at the distress levels and help seeking regarding the sexual dysfunction associated with substance use disorders.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Nishtha Chawla
Room 4096, Academic Block, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/psychiatry.IndianJPsychiatry_716_20
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