European Journal of Cardiovascular Medicine

Alcohol dependence syndrome and sexual dysfunction are two prevalent and interrelated conditions that significantly impact individuals' physical, psychological, and social well-being. [1] The co-occurrence of these disorders presents complex challenges for healthcare professionals, necessitating a nuanced understanding of their intricate relationship. [2]

Alcohol dependence syndrome, characterized by a compulsive need to consume alcohol despite adverse consequences, affects millions worldwide. [3] Its ramifications extend far beyond mere intoxication, permeating various aspects of life, including interpersonal relationships and sexual function. It became the most popular drug of abuse in the 21st century. [4]

Concurrently, sexual dysfunction encompasses a spectrum of difficulties related to sexual desire, arousal, performance, and satisfaction. It manifests differently in individuals, often causing distress and impairing intimate relationships. Sexual dysfunction (SD) is quite common in the general population, with one in five males suffering from it. [5]

The correlation between alcohol dependence and sexual dysfunction is multifaceted. Chronic alcohol abuse can lead to physiological changes in the body, disrupting hormonal balance, neurochemical pathways, and vascular function, all of which contribute to sexual dysfunction. [6] Moreover, alcohol-induced cognitive impairment may exacerbate sexual performance anxiety and impair sexual decision-making. [7] The rates of SD in the alcohol-dependent population extend between 8 and 95.2%. The typical SDs reported have been erectile dysfunction followed by premature ejaculation, delayed ejaculation, and decreased sexual desire. [8]

Psychosocial factors also play a significant role in this nexus. Alcohol dependence can contribute to relationship discord, diminished self-esteem, and mental health issues, all of which can further exacerbate sexual dysfunction. [9] Conversely, sexual difficulties may serve as triggers for alcohol use as individuals seek to alleviate distress or enhance sexual performance. Chronic cytotoxic effects of alcohol on general health, endocrine, and hepatic function might be a mediator between the association of high alcohol consumption and SD. [10] Advancing age, education level, unemployment, and cigarette use may be the other correlates of SD in men with alcohol dependence. [11]

Despite the evident overlap between alcohol dependence syndrome and sexual dysfunction, comprehensive understanding and effective management strategies remain lacking. This article aims to elucidate the complex interplay between these conditions, exploring underlying mechanisms, clinical implications, and evidence-based interventions. By synthesizing current knowledge, we endeavour to provide insights that guide healthcare professionals in addressing these intertwined challenges and optimizing patient care.

There are a limited number of studies that have evaluated the SD in patients with alcohol dependence. There are only a few studies reported from India. Hence, this study was planned to assess sexual dysfunction in patients with alcohol dependence in comparison with controls

This is a prospective and case control study was conducted among the patients with the history of alcohol dependence admitted in a tertiary care hospital over a period of 6 months.

Inclusion criteria

1. Patients with 21 years of age and above.
2. Patients who give informed consent.
3. Patient who fulfilled criteria for alcohol dependence or alcohol harmful use, according to ICD-10.
4. Patients who are married and have a regular sexual partner.

Exclusion criteria

1. Patients who refuse to give informed consent.
2. Patients with history of primary sexual dysfunction prior to initiation of alcohol use.
3. Patients using other substance other than alcohol and tobacco (Cannabis, opioids, Stimulants)
4. Patients with other medical conditions like diabetes mellitus, hypertension, signs and symptoms suggestive of alcoholic cirrhosis, a clinical diagnosis of endocrine disorders, other systemic illness, history of genitourinary surgery and neurological and spinal cord lesions.
5. Co-morbid psychiatric disorders: schizophrenia, delusional disorder, anxiety disorders and mood disorders including dysthymia.
6. Patients currently on medications affecting sexual function (antipsychotics, antidepressants, antihypertensive, steroid, disulfiram etc)

Written informed consent in the local language was taken from all study subjects, before enrolment in the study. The nature and the purpose of the study were explained briefly to the study population in the informed consent form and then the study population was recruited according to inclusion-exclusion criteria as mentioned above. During the study period, all the recruits were given standardized self- answering questionnaires as mentioned below in the instruments used. ICD-10 F52 criteria were used to diagnose sexual dysfunction.

Tools for assessment 

• Socio-Economic Scale (S. E. Gupta and B.P. Sethi 1978, Kuppusamy 1961): - This scale was devised by Kuppuswamy and consists of composite score, which includes the education and occupation of head of the family along with income per month of the family, which yields a score of 3-29. This scale classifies the study population into 5 SES: upper, upper middle, lower middle, upper lower, lower. [12]

• Alcohol Use Disorders Identification Test (AUDIT): - The AUDIT (Babor et al. 2001) focused on evaluating three key domains included in the ICD-10 for disorders related to alcohol use. They are harmful drinking, alcohol dependence and hazardous drinking. Further the ten-item core self-report or clinician-administered covered three different areas of drinking, they are as follows:
  • Quality and frequency of alcohol use which indicates hazardous use of alcohol (item 1-3)
  • Indicators of dependence (items 4-6)
  • Adverse consequences suggesting harmful use (items 7-10). The items were scored on 004 scale (0 being ‘never’ and 4 being ‘daily or almost daily) for most of the items added together; and the total score ranged from 0-40. [13]

• International Index of Erectile Functioning (IIEF):- It is a 15 item self- report inventory which was designed with the purpose of providing brief, valid and reliable measure of erectile function and capacity. Erectile function, Sexual desire, Orgasmic function, Overall satisfaction and Intercourse satisfaction are the five key domains for measuring IIEF. Different screening studies focusing on erectile dysfunction by using Erectile Function domain determined a score of 25 as cut-off for erectile dysfunction. Here specificity came out to be 0.88 and sensitivity was 0.97. [14]

• Premature Ejaculation Diagnostic Tool (PEDT):- It is a commonly used and accepted tool that was developed with the objective of standardizing the diagnosis of premature ejaculation in research studies. One of the main purposes of the tool was find out the main constituents of DSM IV- TR, including the likes of frequency, distress, control, interpersonal difficulties, and minimal sexual stimulation. Cut-off score for premature ejaculation was set to be 11; and therefore, any score above the cut-off point was interpreted as definite PE, while scores of nine and ten were termed as borderline PE. Scores of eight and below showed low likelihood of PE among the patients. [15]

STATISTICAL ANALYSIS

Data was collected and tabulated using Microsoft excel. Statistical analyses were performed using IBM SPSS Statistics for Windows. Frequency and percentages were calculated for all qualitative measures. Mean and the standard deviation were calculated for quantitative measures. Chi-square test and Student ‘t’ test were used to analyse categorical values and check the association between two variables. A p-value of <0.05 is considered as statistically significant.

Socio-Demographic profiles of the Case and Control Groups were matched for age, education, locality, occupation, income and religion (Table-1). There was no statistically significant difference between the Case and Control Groups with regard to Socio-Demographic profile matching

The current study determined occurrence of at least one sexual dysfunction among case (76.6%) which is higher than that of control (36.6%). Furthermore, occurrence of more than one sexual dysfunction in case (63.3%) came out to be higher than that of control (23.3%). [Table 2].

From table 3 it can be seen that a comparison of the five main domains for measuring IIEF was carried out among the case and control group. There is no statistical difference among the case and control group was found with domain of IIEF. But, on the other hand, researcher found a statistically significant difference in the domains of Intercourse satisfaction (IS), Sexual Desire (SD), Orgasmic Function (OF), and Overall Satisfaction (OS) among the case and control groups. As per table 3, no vast difference between case (54.3%) and control (71.4%) can be found with regards to premature ejaculation. In addition, researcher did not find any significant difference

On the basis of findings of the Table-4, it can be said that intercourse satisfaction, sexual desire, overall satisfaction, and orgasmic function are significantly lower among the patients with alcohol dependence syndrome, as compared with the people who do not drink alcohol

A negative association between erectile function, sexual desire, overall satisfaction, and intercourse satisfaction domains of IIEF and duration of alcohol consumption was observed [r = -0.015, -0.271, -0.04, and -0.168, respectively]. This means an increase in the scores of sexual desire and intercourse satisfaction can be observed with the duration of alcohol consumption, while scores of overall satisfactions tend to decrease. On this basis, it can be said that if the duration of alcohol consumption is having no significant difference. (Tables 5 and 6).

The study further revealed a positive relationship between orgasmic function domains of IIEF, PEDT and duration of alcohol consumption [r = 0.058 and 0.078, respectively]. Therefore, the scores of premature ejaculation and orgasmic function also increase. (Table 6).

During the study, it was determined that there is a positive relationship between alcohol consumption duration and orgasmic function domains of IIEF and PEDT, with r = 0.078, r=0.058 respectively. This indicates that with an increase in the consumption of alcohol, orgasmic function and premature ejaculation also increases. Further, with an increase in the duration of alcohol consumption, the orgasmic dysfunction will increase along with premature ejaculation. As per Table 6, there was no significant relationship found.

In this study, the exclusive focus on males with alcoholism is entailed by the fact that the frequency of alcohol use by females in India, and concurrent alcohol dependence is exceedingly low. [16-18] Co-morbid nicotine use is not excluded in the present study as it is widely prevalent in most of the patients with alcohol dependence. [19] The socio-demographic profile of the sample is similar to previous studies done in the same region. [20] Controls are drawn from the hospital population; however, they are not matched with regard to the number or characteristics of the cases. There is a significant difference between the two groups with regards to age, domicile, religion, and family type. The majority of the men in the case group belong to the 4th and 5th decades (mean 42.44 ±8.82), while most of the controls are in their 4th decade. 70% of patients with alcohol dependence belong to the rural area. Therefore, drug abuse in India as an exclusively urban phenomenon is a myth as told by a national survey on the extent, pattern, and trends of drug abuse in India. [21] Muslims are predominant in the control group rather than the case group, maybe because of religious restrictions in substance use. [22]

About three-fourths of the patients in the case group have started alcohol use before 25 years, with nearly one-third before 18 years. Though they started early, only 7% developed dependence patterns before 25 years. Thus, the majority (more than 90%) has Clolinger type 1 (milieu limited) alcohol dependence, which means the addiction is less hereditary and more influenced by the environment. [23] These findings are similar to study in Bangalore, which showed the mean age of onset of initiation was 21.39±5.34 years, and the mean age of onset of dependence was 27.8±5.7 years. [24] The mean quantity of alcohol consumption per day is 14.74 (±7.22) standard units of drinks per day and preferred drink being whisky. The amount is smaller compared to other studies from the same region (20.6 ± 9.07 units in Bangalore’s study and 21.23 ± 10.10 units in Kerala’s study). [25]

Total 26% of men with alcohol dependence complain of one or more problems with sexual functioning. This finding is similar to results reported in earlier studies. The rates of SD in these studies have ranged 8-95.2%. SD was present in 37% of the study population (with a mean age of 39years) in another study using the ASEX scale in South India.[26] The difference may be due to an increased quantity of alcohol taken, i.e., about 21 standard units per day compared to 15 units in our study. [27] 72% of the sample reported dysfunction in multiple sexual domains in the previous study using the same scale of our research. The high prevalence of SD may be due to more quantity (20.6SD per day) and longer duration of 8.6years, though the mean age of the sample is less (37years) compared to our study. [28]

The most common SD reported by men with alcohol dependence in our study is low sexual desire followed by premature ejaculation. Different types of SDs were reported as the commonest in men with alcohol dependence in the earlier studies. They include erectile dysfunction, premature ejaculation, delayed ejaculation, and decreased sexual desire. Studies each by Akhtar, Jensen, and Vijayasenan reported low sexual desire as the most frequent problem similar to our study. [29] The finding is further confirmed in our research when men with alcohol dependence having SD compared with healthy controls on each domain of sexual dysfunction. Low sexual desire is significantly prominent in men with alcohol dependence.

The relationship between alcohol dependence syndrome and sexual dysfunction is complex and multifactorial. Chronic alcohol use can lead to both physiological and psychological changes that contribute to sexual dysfunction. These changes may include alterations in hormone levels, impaired nerve function, and psychological factors such as anxiety, depression, and relationship problems. It emphasizes the need for clinicians to routinely assess the risk of sexual problems, which is often missed, unexplored, however, very important for the management of addiction to alcohol. Moreover, Clinicians dealing with alcohol-dependent patients must be knowledgeable about the associated sexual dysfunction and should address both the problems simultaneously to improve their functioning and quality of life

1. Introduction: The History of Drug Abuse. In: The Encyclopedia of Drug Abuse. (Ed) Gwinnell E, Adamec C. Facts on File, Inc: West Street, New York; 2008.
2. Sathyanarayana Rao TS, Darshan MS, Tandon A. An epidemiological study of sexual disorders in south Indian rural population. Indian J Psychiatry 2015;57(2):150-7.
3. Cheng JY, Ng EM, Chen RY, Ko JS. Alcohol consumption and erectile dysfunction: meta-analysis of population-based studies. Int J Impot Res 2007;19(4):343-52.
4. Grover S, Mattoo SK, Pendharkar S, Kandappan V. Sexual Dysfunction in Patients with Alcohol and Opioid Dependence. Indian J Psychol Med 2014;36(4):355-65.
5. Benegal V, Arackal BS, Prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian J Psychiatry 2007;49(2):109–12.
6. Prabhakaran DK, Nisha A, Varghese PJ. Prevalence and correlates of sexual dysfunction in male patients with alcohol dependence syndrome: A cross-sectional study. Indian J Psychiatry 2018;60:71-7.
7. Pendharkar S, Mattoo SK, Grover S. Sexual dysfunctions in alcohol-dependent men: A study from north India. Indian J Med Res 2016;144(3):393–9.
8. The International Classification of Diseases, tenth revision, Classification of Mental and Behavioural Disorders. World Health Organization. Geneva.1992.
9. National Centre for Classification in Health. The international statistical classification of diseases and related health problems, 10th revision, Australian modification (ICD-10AM). Sydney: National Centre for Classification in Health, Faculty of Health Sciences, University of Sydney, 1998.
10. Singh, Ichhpreet; Patkar, Prajakta; Dhamija, Sana; Chaudhury, Suprakash; Javadekar, Archana; Saldanha, Daniel. Sexual dysfunction in men with alcohol dependence. Industrial Psychiatry Journal 2023;32(Suppl 1):p S68-S71.