“Let me educate you, dear colleague”

– How to educate a patient in tough scenarios like (husky voice) Sexual issues.

Sex, penis, vagina, orgasm, masturbation, condom, OCP, menstrual pads, periods etc. Go on, you’re free to add more words of the genre in your brain. Okay. Don’t get too excited or too embarrassed. This is not erotica. (At least that’s what we were told)

But there’s a need for people to get comfortable in the usage of these words so that the stigma associated with them could be reduced. 

(Oh, come on! These are private and intimate things that are supposed to be talked about in a hush tone. These liberals and their attitudes. God!)

No. This is not about the freedom and liberty to talk about these. This is because the stigma associated brings about a lot of complications making one end up in an STD clinic, Gynaecology OPD or the Psychiatry OPD. And the latter is again attached with added stigma. Okay, let’s not touch that nerve. For now.

Coming back. Repeat aloud after me. “Sex, penis, vagina, orgasm, masturbation, condom, OCP, menstrual pads, periods etc”. Also know them in the native and local languages where you are, not the abusive slang versions but the polite, acceptable ones.

Fun Fact: So many words associated with sex down there, but do you know which the best sex organ is? “Brain”. Yes, such a gender-neutral thing. But it’s true. Not kidding. More on this in some other edition.

Sex Education (not the Netflix series); proper inclusive sex education is important because there are numerous myths and misconceptions about sex derived from picking up knowledge on sex via improper means like ignorant peers, pornographic websites, uneducated religious netas, social media etc. (Maybe that Netflix series would help?)

In India, we come across a certain culture-bound syndrome called ‘Dhat Syndrome’. Usually seen in young males who present with non-specific symptoms which do not have any objective signs. Underneath they would have dysfunctional beliefs like blaming themselves for masturbation, that nocturnal emissions are bad and that fatigue is caused due to loss of semen through these means. In addition, they have anxiety symptoms, feeling that there is loss of semen through urine and faeces, burning sensation in the penis, difficulties in sexual intercourse, excessive scrutiny of the external genitalia about the size, shape and appearance. They refuse to marry because they feel like they can’t have satisfactory intercourse with their partners. In order to check themselves, they go towards illicit encounters like unprotected intercourse with commercial sex workers and when the combination of pre-existing anxiety and fear of failure, discovery and associated guilt results in a failed sexual intercourse, their beliefs get reinforced. They also reinforce their beliefs by seeking validation of their theory from friends, relatives and medical practitioners. There’s a fairly large amount of literature available on Dhat Syndrome. Since it takes a whole long time before the patient ends up in a Psychiatry OPD, it would be far better for the patient if there were simple treatment techniques available that could be administered by the first medical practitioner that he comes across. 

This is the purpose of this article. To educate you, dear colleagues about a brief psychotherapeutic technique to help the patients with Dhat Syndrome. 

It comprises just two sessions. One where the patient visits you and the other where you ask the patient to visit you. 

During the first session, if you pick up on points favouring Dhat syndrome, try to create a good rapport with the patient. For this to be achieved, you need to ask and actively listen without showing signs of dismissal or that would embarrass the patient. It is for this purpose that the clinician needs to familiarise oneself with respectful, decent vocabulary for penis, vagina, penetration, semen, masturbation, nocturnal emission etc. The key to asking a sexual history is to be frank and straightforward. (Lot of people have this doubt. How to get sexual history? The answer is: Just ask like any other history. Ensure privacy and confidentiality. That’s all.)  If you hesitate and treat it like a taboo topic, you can’t win the trust of the patient neither the history nor obtain therapeutic alliance. If you’re a female, educate the patient that you’re a professional and have experience in these areas. 

In this session itself, finish a physical examination and order the necessary investigations to rule out any other differential diagnosis. Reassure the patient and ask him to come for a follow-up visit on a specific date when you can spare 30-40 minutes on the patient.

The second session is going to be a dialogue between you and the patient in the following steps:

Step 1: Restate and summarise the patient’s complaints. Let them know that you have understood them and verify with them. Explain that the symptoms are caused because of some psychological factors but which does not mean that he or she is ‘mad’ or ‘crazy’. Most importantly, state that relief is available for this problem.

Step 2: Prepare for a dialogue. “I am going to take you through a discussion that may seem a little odd or different. Bear with me, because it has a direct connection with your condition.”

Step 3: Challenge the belief that semen loss is deleterious to health. Introduce the concept of “process vs. cause.” Put it in a Question and Answer type dialogue like : is loss of blood harmful? Does the way in which it is lost matter? Hence if semen loss causes weakness, how come married men who have regular intercourse not become weak? Make sure the patient answers and comes to a realisation and it is not a session where you are just telling him things.

Step 4: Validate the symptoms while challenging the cause. The pain and weakness is true, but the cause is not probably semen loss. Does the patient agree? If not, listen patiently for other explanations.

Step 5: Psychoeducate about the physiology of semen (using analogies). With various analogies depending upon the educational background of the patient, the concept of normal nocturnal emissions and masturbation can be explained. Like ‘overflowing bladder’, seeking a ‘release’ etc.

Step 6: Explain the mind-body link. Similar to the above dialogue, give analogies on how the body reacts to emotions like fear and that the body’s reaction can be reverted back by managing the emotion.

Step 7: Address the concerns about changes in genitalia.

Step 8: Conclude and summarise.

This was the explanation of a simple psychotherapy session to deal with a common condition encountered in the Indian Scenario. Similarly, various conditions related to sex can be addressed by clarifying the basic myths and misconceptions.

Did it feel like a session by the protagonist’s mom in the Sex Education series? No, because they don’t show what goes on inside the therapy room most of the time, right?

The bottom line is you need not be a sex therapist to provide sex education to the patients.

P.S. We thank Prof. Deepa Ramaswamy for teaching this simple OPD approach to Dhat syndrome. 

P.P.S. For more information, check up on this reference article: 

Innamuri R, Ramaswamy D. Demystifying Dhat Syndrome: A Two-Session Therapy Proposal. Journal of Psychosexual Health. 2021 Jul;3(3):270-4.

Link: https://journals.sagepub.com/doi/full/10.1177/26318318211023876

Written by:

Dr. Usha Nandini M

Stumbled upon Psychiatry after her MBBS, fell in love with it and decided to marry it by taking up MD Psychiatry. Honeymoon period is yet to begin, wonders will it ever begin? Been in Lexicon for a longtime now; enjoys writing anything other than exams. I’m Kidding, even exams. Enjoys reading fiction because she gets her dose of non-fiction from her textbooks. Binging on sitcoms is an understatement to her.

Dr. Raviteja Innamuri 

Dr Raviteja Innamuri is an Assistant Professor of Psychiatry at the Government Medical College and Hospital, Nizamabad, Telangana. He holds DPM, DNB, & MD in psychiatry from CMC, Vellore, and has done his postgraduate diploma in medical law from National Law School, Bangalore. He is the Director and Co-founder of the Lexicon medical magazine and academic coordinator in the Training Initiative for Psychiatry Postgraduate Students (TIPPS) group. He has won research grants/ awards from ICMR, NIH-USA, RN Moorthy Foundation, and MINDS Trust Mysore. He enjoys teaching and believes in holistic patient care.

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