Sexual health concerns

What are sexual health concerns?

Sexual health is part of overall health. The World Health Organization describes it as physical, emotional, mental and social well-being in relation to sexuality, not simply the absence of disease. When something gets in the way, such as worry, pain, low interest, or difficulty with erections or ejaculation, it can affect confidence, mood and relationships.

Sexual difficulties are common in men and women of all ages and in every kind of relationship. Yet in India many people never discuss them with a doctor. Embarrassment, family pressure and myths about semen, masturbation and “manhood” keep people silent, or push them towards advertised clinics and “sex power” products.

A psychiatrist is well placed to help, because mind and body work closely together in sex. Stress, anxiety, depression, relationship strain, alcohol, tobacco and some medicines are among the most frequent causes. The World Health Organization’s classification of diseases (ICD-11) reflects this. It recognises that physical health, psychological factors, medicines and substances, lack of information, relationship factors and cultural factors can each play a part.

Care is respectful and non-judgemental, whatever your gender, sexual orientation, age or relationship status. Being lesbian, gay, bisexual, transgender or questioning is not an illness, and you can speak openly.

Common concerns

People most often seek help for:

• Low sexual desire. Little or no interest in sex, which causes distress. It can affect anyone. A difference in desire between partners is common and not an illness in itself, but it can create strain worth talking about.
• Erection difficulties. Trouble getting or keeping an erection firm enough for sex. Occasional difficulty is common, especially with tiredness, stress or alcohol. When it happens often, it deserves attention, because it can be an early sign of diabetes, high blood pressure or heart disease.
• Early (premature) ejaculation. Ejaculating sooner than wished, most of the time, with frustration or distress. Expectations are often shaped by myths and pornography rather than by reality.
• Performance anxiety. Fear of “failing” during sex, which itself makes difficulties more likely. It is especially common in new relationships and around marriage.
• Pain or difficulty with intercourse. Pain during sex, or finding penetration difficult or impossible because of fear and involuntary tightening of the muscles. Some couples are unable to have intercourse for months after marriage. This is treatable, and a physical examination is an important first step.
• Difficulty reaching orgasm or feeling little pleasure.
• Worries about semen loss, nightfall or masturbation, often called Dhat syndrome (see below).
• Sexual behaviour that feels out of control.

It is common to have more than one concern at the same time. For example, early ejaculation can lead to anxiety, which can then cause erection difficulties.

How the mind and body work together

Sexual response depends on the brain, hormones, nerves and blood vessels working together, and on feeling relaxed and safe. Anxiety switches on the body’s “fight or flight” response, which works against arousal.

This creates a familiar cycle. One difficult experience leads to worry about the next time. During intimacy, the person anxiously watches their own body instead of being in the moment. The worry makes difficulty more likely, which seems to confirm the fear. Over time some people begin avoiding closeness altogether, and partners may misread this as rejection.

Depression and anxiety are closely linked to sexual problems in both directions. Depression commonly reduces desire and pleasure, and anxiety interferes with arousal. In turn, long-standing sexual difficulties can lower mood and self-esteem. Indian Psychiatric Society guidelines advise that when depression or anxiety is prominent, it should be treated first and adequately. Sexual function often improves as mood does.

Why does it happen?

Usually several factors combine:

• Physical health. Diabetes, high blood pressure, heart and blood vessel disease, obesity, kidney disease, hormonal problems, and nerve damage or surgery can all affect sexual function.
• Mental health. Depression, anxiety, obsessive worries, past trauma and poor sleep.
• Stress and tiredness. Long working hours, financial worries, and study or job pressure.
• Relationship factors. Unresolved conflict, poor communication, lack of privacy in a joint family, or pressure to conceive.
• Lack of accurate information. Many adults never receive reliable sex education and learn instead from friends, the internet or advertisements.
• Cultural beliefs and guilt. Beliefs that semen is precious, that masturbation is harmful, or that a “respectable” woman should not show interest in sex can create lasting anxiety.
• Past experiences. A painful or frightening early experience, or past sexual abuse.
• Medicines, alcohol, tobacco and other substances, described below.

Medicines, alcohol, tobacco and other substances

Medicines. Several commonly used medicines can affect desire, arousal, erections or orgasm. These include some antidepressants, some antipsychotic and mood-stabilising medicines, sedatives and sleeping pills, and some blood pressure medicines and water pills. If you notice a change after starting a medicine, tell your doctor. Do not stop the medicine on your own. Stopping suddenly can cause withdrawal symptoms or bring the original illness back. Your doctor can often adjust the treatment, switch to a medicine less likely to cause the problem, or add help for the side effect.

Alcohol. A drink may seem to ease shyness, but heavy or regular drinking harms sexual function. It affects the nerves and blood vessels involved in erections and can lower testosterone.

Tobacco. Smoking cigarettes or bidis damages blood vessels, including those needed for erections.

Other substances. Heroin (smack), other opioids such as tramadol and codeine cough syrups, cannabis (charas, ganja, bhang) and sleeping pills can all reduce desire and sexual function with regular use. Some men start using opium (afeem), bhang or tramadol hoping to “last longer”. This can quickly lead to dependence, and long-term use harms sexual health rather than helping it.

Cutting down or stopping often brings real improvement. If you drink heavily or use opioids or sleeping pills every day, do not stop suddenly without a doctor’s advice, as withdrawal can be risky.

Dhat syndrome and worries about semen loss

In South Asia, many young men, and some older men, worry deeply about losing semen through night emissions (nightfall or swapnadosh), through masturbation, or through a whitish discharge they notice with their urine. This concern is known in medicine as Dhat syndrome.

These worries have deep cultural roots. Old texts and traditional healers taught that semen is precious and that a single drop is made from many drops of blood or bone marrow, so losing it drains strength. Such ideas are still repeated by relatives, friends and advertisements.

People with Dhat syndrome commonly experience:

• Weakness and tiredness
• Poor sleep and a pounding heartbeat
• Anxiety, low mood, guilt and poor concentration
• Worries about erections, early ejaculation, marriage or fertility

The facts, explained simply:

• The body makes semen continuously. Losing it through nightfall or masturbation does not cause weakness, illness or infertility, and it does not drain blood or strength.
• Night emissions are a normal part of growing up and of adult life.
• A whitish appearance in the urine has other explanations, and a simple urine test can check for infection or other causes.
• The weakness and tiredness are real, but they usually come from anxiety and depression, not from semen loss.

Dhat syndrome is treatable. Care includes kind, clear sex education that corrects myths, reassurance, relaxation techniques, supportive and cognitive behavioural therapy, and treatment of any depression or anxiety. Some women have similar worries about a whitish vaginal discharge; a gynaecological check-up together with support for anxiety or low mood helps.

When sexual behaviour feels out of control

Having a high sex drive, or enjoying sex, is not a disorder. Some people, however, find that sexual urges and behaviour, including excessive pornography use, have become very hard to control. ICD-11 calls this compulsive sexual behaviour disorder when, over a long period (usually six months or more):

• Sexual activity becomes the centre of life, pushing aside health, work and relationships
• Repeated efforts to cut down do not succeed
• The behaviour continues despite harm, or even when it brings little satisfaction
• It causes marked distress or problems in daily life

Feeling distressed only because sexual urges conflict with your moral or religious values does not, by itself, mean you have this disorder. A psychiatrist can help you make sense of what is happening. Treatment focuses on regaining control, often with CBT, and on treating any depression, anxiety or substance use alongside it.

When to see a psychiatrist

Consider seeking help if:

• A sexual difficulty keeps happening or is causing you distress
• Worry about semen loss, masturbation or performance is affecting your sleep, mood, studies or work
• You are avoiding intimacy, or your relationship is under strain
• Sexual problems began after starting a medicine
• You are drinking or using substances to cope, or to “improve” sex
• You feel low, anxious or hopeless
• Marriage is approaching and anxiety is building

There is no need to feel ashamed, and early help is usually simpler. Young people under 18 are seen with a parent or guardian.

How sexual health concerns are assessed

The first consultation is a private conversation. The psychiatrist will ask about the concern and when it began, your general health, medicines, alcohol, tobacco and other substance use, mood, stress, sleep, your relationship and what you would like to change. Questions are asked respectfully, and you share only what you are comfortable with. If you come as a couple, each partner may also be seen separately for part of the time.

Because physical and psychological causes often overlap, you may be advised blood tests, such as blood sugar, cholesterol and hormone levels. Where a physical examination is needed, for example for pain during intercourse or persistent erection problems, you may be referred to a gynaecologist, urologist, physician or other specialist. Working together gives the fullest picture.

Treatment

Treatment is tailored to the person or couple, and it usually combines the following.

1. Clear information and reassurance

Understanding how the body works, and letting go of myths, is often the first step and sometimes a large part of recovery. This includes accurate information about sexual response, normal variation, masturbation and nightfall.

2. Sex therapy and CBT techniques

Sex therapy is a structured talking therapy. It never involves any physical contact with the therapist. Depending on the concern, it may include:

• Cognitive behavioural therapy (CBT): noticing and changing anxious thoughts and unrealistic expectations
• Relaxation training: calming the body’s stress response
• Step-by-step exercises done privately at home: removing the pressure to perform and gradually rebuilding comfort and closeness, often called sensate focus
• Techniques for early ejaculation: learning to recognise and manage rising arousal
• Gentle, gradual approaches for pain or fear of penetration, sometimes alongside a gynaecologist or physiotherapist

3. Couples and relationship therapy

Sexual problems affect both partners. Sessions together help couples communicate, reduce blame, handle differences in desire and work as a team. All couples, including same-sex couples, are welcome.

4. Treating depression, anxiety and substance use

When depression, anxiety, obsessive worries, or alcohol and drug use are part of the picture, treating them is essential. If a current medicine is causing sexual side effects, your psychiatrist will review it with you, balancing your mental health and your sexual health. Where alcohol or drug use is severe, supervised detox or a period of inpatient care may be advised.

Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, where inpatient care is available when substance use needs it, and online.

5. Medicines, when needed

Some people benefit from medicines, for example to help with erections, to delay ejaculation, or to treat an underlying condition. A doctor chooses these only after checking your heart health, other illnesses and current medicines, because some are unsafe with certain heart conditions or heart medicines. Medicines work well alongside therapy but are rarely the whole answer. Never start, change or stop them without your doctor.

In person or online?

• In-person consultations suit a first assessment, especially when an examination or tests may be needed.
• Online consultations offer privacy and convenience for discussion, therapy and follow-up.

A warning about “sex power” medicines and advertisements

Advertisements for “weakness”, “stamina” and “sex power” appear on walls, in newspapers and across social media. The capsules, oils and powders they sell are often unregulated and promoted as herbal or natural. The US Food and Drug Administration has warned that many such products contain hidden prescription drugs and can cause severe health problems and hospitalisation. They are especially risky for people with heart problems or those taking other medicines.

Fears about semen loss have long been spread by traditional healers and advertisers, and some clinics sell costly courses of treatment for problems that are really anxiety or myths. Treat any product or clinic that promises quick, dramatic or permanent results with caution, and speak to a qualified doctor first.

Recovery and setbacks

With the right support, many people see steady improvement, although progress is usually gradual. Setbacks can happen, especially at stressful times. They are part of the process, not a sign that treatment has failed.

Continuing to use what you learnt in therapy, keeping communication open with your partner, and looking after your physical health all help maintain progress. Regular exercise, good sleep, limiting alcohol and avoiding tobacco matter for sexual health too.

For partners and families

Sexual concerns are rarely one person’s problem alone. A few things help:

• Partners: try not to take difficulties personally; they are rarely a sign of lack of love or attraction. Talk at a calm moment, and consider attending together
• Parents: if your son or daughter is worried about nightfall, masturbation or body changes, reassure them that these are normal and avoid shaming them
• Avoid pressuring a young couple about pregnancy, or suggesting marriage as the answer to someone’s sexual anxiety
• Do not buy advertised remedies for a family member
• Never give medicines secretly. It is unsafe and damages trust

You are welcome to consult Dr. Tarwani on your own, or together as a couple, to plan the next steps.

Common myths

• “Masturbation causes weakness, infertility or damage to the body.” Masturbation is common and normal, and it does not harm health. It is a concern only if it feels out of control or causes distress.
• “Losing semen drains blood and strength.” Semen is made continuously. Nightfall and masturbation do not cause weakness.
• “Real men never have sexual problems.” Sexual difficulties are common health concerns, and seeking help is sensible.
• “Women don’t have sexual problems.” Women experience low desire, pain and other concerns too, and deserve the same care.
• “Pornography shows what normal sex looks like.” It often creates unrealistic expectations about bodies and performance.
• “Herbal ‘sex power’ products are natural, so they must be safe.” Some contain hidden drugs that can cause serious harm.
• “Marriage will sort it out.” Anxiety often grows under the pressure of marriage. Timely help works better.
• “If the cause is in the mind, the problem isn’t real.” Psychological causes are real, common and treatable.