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Comprehensive Psychiatry 60 (2015) 114 – 118
www.elsevier.com/locate/comppsych

Depression and anxiety in men with sexual dysfunction: a retrospective study

Ravi Philip Rajkumar a,⁎, Arun Kumar Kumaran b
a
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantari Nagar, Pondicherry, 605 006, India
b
Lakeshore Hospital, Ernakulam, Kerala, India

Abstract

Background: Comorbid anxiety disorders and depression are commonly seen in men with sexual disorders such as erectile dysfunction (ED)
and premature ejaculation (PE). However, they are often undiagnosed and untreated, and their relationship to sexual dysfunction is complex.
This study examines the frequency and correlates of comorbid anxiety and depression in men with ED or PE.
Methods: The case records of 64 men with ED or PE attending a clinic for psychosexual disorders in a general hospital psychiatry unit
during the period 2010–14 were reviewed. Information on comorbid anxiety disorders and depression was extracted from these records, and
their clinical and demographic associations were analyzed.
Results: Eight (12.5%) men had comorbid depressive disorders, and fifteen (23.4%) had anxiety disorders. These disorders predated the
onset of sexual dysfunction in the majority of patients. Generalized anxiety disorder was the commonest anxiety disorder. Men with
comorbid depression had significantly elevated rates of suicidal ideation or behavior related to their sexual dysfunction, and were more likely
to report a lack of libido. Men with pre-existing anxiety disorders were more likely to experience performance anxiety related to sex, and to
have PE without comorbid ED.
Conclusions: Depression and anxiety affect a substantial minority of men with sexual dysfunction. Men presenting for the evaluation of ED
and PE should be carefully screened for these disorders. The links between anxiety disorders and sexual performance anxiety merit further
investigation in this patient group.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction depression may also experience ED [9,10]. The relationship

Premature ejaculation (PE) and erectile dysfunction (ED)
are the two most common forms of sexual dysfunction in
men [1,2]. Though these disorders, particularly ED, have
traditionally been divided into “organic” and “psychogenic”
categories [3,4], the distinction between these two is not
clear, as neurobiological and psychological factors overlap
substantially in individual cases [4–8].
Depression is strongly associated with male sexual
dysfunction. Major depression is mainly associated with
reduced sexual desire, though 25% of male patients with
Conflicts of interest: The authors report no conflicts of interest with
regard to the work presented in this paper.
Declaration of sources of funding: No funding from any source was
obtained by either author for the work presented in this paper.
⁎ Corresponding author at: Department of Psychiatry, Jawaharlal
Institute of Postgraduate Medical Education and Research, Pondicherry,
605 006, India. Tel.: +91 9884713673.
E-mail addresses: ravi.psych@gmail.com (R.P. Rajkumar),
drarunkumark@yahoo.com (A.K. Kumaran).
http://dx.doi.org/10.1016/j.comppsych.2015.03.001
0010-440X/© 2015 Elsevier Inc. All rights reserved.
between depression and ED is bi-directional: depressed
affect can impair sexual arousal and cause ED [11], while
decreased sexual activity and lack of satisfaction with one's
sexual life can trigger depressive symptoms [12,13]. Further
complicating this relationship are the well-documented
sexual side-effects of antidepressants [10,14]. Symptoms of
depression are commonly associated with ED even in the
absence of syndromal depression [15,16]. Depression has
also been associated with PE [17,18] and may reflect the
impaired self-esteem caused by PE [19].
Various anxiety disorders have also been associated with
sexual dysfunction. Social phobia, a condition associated
with significant anxiety in social or performance situations,
is strongly associated with PE [20–22], and panic disorder
has been linked to ED in several studies [22–24]. Likewise, a
significant number of men with generalized anxiety disorder
(GAD) experience erectile dysfunction [25]. Anxiety related
specifically to sexual performance can be a significant
contributor to both ED [7,26] and PE [27] even without a
diagnosed anxiety disorder, and “free-floating” anxiety of
 R.P. Rajkumar, A.K. Kumaran / Comprehensive Psychiatry 60 (2015) 114–118
the type seen in GAD has also been documented in this
patient population [28].
Despite the large number of studies linking depression
and anxiety to sexual dysfunction, it is unclear how
depression and anxiety relate to other psychological factors
in this patient group, or if they affect the presentation of ED
or PE. In order to investigate these relationships, we
performed a chart review of 64 men with a diagnosis of
ED or PE of presumed psychogenic origin, to assess the
frequency, chronology, and correlates of comorbid anxiety
and depressive disorders in this patient population. Our study
was confined to ED and PE as these are the sexual disorders
which have the best documented associations with anxiety
and depression, and because none of the other patients
attending our clinic, as described below, were diagnosed
with these conditions.
2. Methodology
The current study is a retrospective chart review of men
presenting to a clinic for psychosexual disorders at a general
hospital in Pondicherry, India. Patients are referred to the
clinic from other departments, particularly urology and
general surgery, after “organic” causes of sexual dysfunction
have been ruled out. At the clinic, patients are evaluated
using a semi-structured interview schedule that includes
details of sexual dysfunction, comorbid psychiatric disorders
or substance abuse, performance anxiety related to sexual
function, details of current and past relationships, and any
past history of parental loss, separation or marital discord.
All interviews were carried out by a psychiatry resident, and
all diagnoses were confirmed by one of the authors using
ICD-10 clinical descriptions and diagnostic guidelines.
We reviewed 110 case records of patients attending the
clinic in the period 2010–2014. Twelve case records were
excluded as these patients had sexual dysfunction related to
the use of antipsychotics or antidepressants; we did not
encounter any patients whose sexual dysfunction was related
to the use of other drugs, such as anti-hypertensives or
hormonal agents. Thirty-four case records were excluded as
patients did not have ED or PE, and sought consultation
either for marital disharmony or for doubts and misconcep-
tions related to sexual functioning. None of these patients
had comorbid depression or anxiety. We finally extracted
information from the case records of 64 men who attended
the clinic during this period and received a diagnosis of
sexual dysfunction (ED or PE) of presumed psychogenic
origin. Though lack of sexual desire is known to be
associated with depression, we did not include patients
with this presenting complaint in our review, as only one
such patient consulted us for this complaint during the study
period. He was eventually diagnosed to have dysthymia and
comorbid major depression, with no other sexual dysfunc-
tion, and his lack of libido resolved with antidepressant
treatment. The study was conducted in accordance with the
115
institute’s Scientific Advisory Committee, which permits
chart reviews of clinical data as long as confidentiality is
not violated.
Information on diagnoses of ED and PE, their age at
onset, comorbid anxiety and depression, and the temporal
relationship between the two were tabulated and analyzed.
PE was subtyped according to Waldinger's classification
[29]. We also included information on the presence or
absence of semen-loss anxiety, sometimes termed Dhat
syndrome, as this is a common explanatory model for sexual
dysfunction in Indian culture [30,31]. The independent
samples t-test was used to compare normally distributed,
continuous variables, and the chi-square test or Fisher's
exact test was used for categorical variables. All statistical
tests were two-tailed, and a value of p b 0.05 was considered
statistically significant.
3. Results
3.1. Description of the study sample
The mean age of the 64 patients studied was 31.3 ±
6.2 years (range 22 to 46 years). Of these men, 30 were
single, 31 married, one divorced and two were widowers.
They had been educated for an average of 10.3 ± 4.1 years
(range 0–18 years). Thirty-seven of these men (57.8%) had a
diagnosis of premature ejaculation, and forty-four (68.8%)
had erectile dysfunction; 17 patients (26.6%) had both PE
and ED. The mean age at onset for ED was 27.2 ± 5.6 years,
while it was 28.5 ± 4.6 years for PE. Semen-loss anxiety
was documented in thirteen (20.3%) men, and was not
significantly associated with any diagnostic category.
3.2. Frequency and correlates of comorbid depression
Depressive disorders were present in 8 (12.5%) of the
entire sample: five men had dysthymia (ICD code F34.1),
five had a mild or moderate depressive episode (ICD codes
F32.0 and F32.1), and one had depressive disorder not
otherwise specified (F32.9). Depressive preceded the onset
of sexual dysfunction in five (62.5%) patients. Men with
depression did not differ from the rest of the sample on any
demographic variables, and comorbid depression did not
affect the age at onset of sexual dysfunction or the
presentation of PE or ED. However, comorbid depression
was associated with a significantly elevated rate of suicidal
ideation or behavior (4/8 vs 5/56; p = 0.01, Fisher's exact
test), which was attributed in all cases to the inability to
"perform" sexually. None of these associations changed
when only those with pre-existing depression were
considered separately.
Though it was not a presenting complaint in any case,
lack of libido was reported by three of eight men with
comorbid depression, as against one in the remaining group;
this difference was statistically significant (p = 0.005,
116 R.P. Rajkumar, A.K. Kumaran / Comprehensive Psychiatry 60 (2015) 114–118
Fisher's exact test.) In all three cases, this symptom occurred
only after the onset of depression.
Only one patient had both anxiety and depression.
Performance anxiety was seen in 3 of 8 men with depression
(37.5%) and semen-loss anxiety was seen in one of these
patients (12.5%); the small numbers involved prevented us
from studying the characteristics of these subgroups.
3.3. Frequency and correlates of comorbid
anxiety disorders
Anxiety disorders were present in 15 (23.4%) of the
patients. Generalized anxiety disorder (GAD, F41.1) was the
most common diagnosis, seen in seven men (10.9%); other
categories included anxiety disorder not otherwise specified
(F41.9) (n = 5, 7.8%) and social phobia (F40.1) (n = 3,
4.7%) Anxiety disorders preceded the onset of sexual
dysfunction in ten (66.7%) patients. Men with comorbid
anxiety were younger at the time of presentation to the clinic
(mean 28.3 ± 4.8 vs 32.2 ± 6.3 years; t = −2.232, p =
0.029) but did not differ in terms of any other demographic
or clinical variables, including rates of sexual performance
anxiety (8/15 vs 17/49; χ 2 = 1.68, p = 0.2). In the ten men
whose anxiety disorder preceded the onset of sexual
dysfunction, sexual performance anxiety was significantly
more frequent (7/10 vs 18/54; p = 0.039, Fisher's exact
test), as was “pure” PE without any comorbid ED or
semen-loss anxiety (5/10 vs 9/54; p = 0.033, Fisher's
exact test).
There was no relationship between the presence of an
anxiety disorder and semen-loss anxiety, which was seen in
2/15 men with anxiety disorders and 11/49 without this
comorbidity (p = 0.44, Fisher's exact test). No patient had a
co-occurrence of anxiety disorder, performance anxiety and
semen-loss anxiety, suggesting a lack of association between
these phenomena.
Concurrent anxiety disorders and sexual performance
anxiety were seen in eight (12.5%) men. These men were
younger at presentation (26.5 ± 4.7 vs 32.0 ± 6.1 years;
t = −2.43, p = 0.018), had a shorter duration of PE at
presentation (1.6 ± 1.2 vs 4.9 ± 4.3 years; t = −3.66, p =
0.001), and were significantly more likely to have a family
history of alcoholism in a first-degree relative (5 of 8 vs 14 of
56; p = 0.044, Fisher's exact test). They were likely to begin
smoking at an early age (15 vs 21.4 years; t = −2.67, p =
0.019), but this result must be interpreted with caution as the
total number of smokers in each group was low. None of
these men had the lifelong type of PE as per Waldinger's
classification, but the small numbers involved precluded an
analysis of the significance of this finding.
3.4. Other associations
On comparing men with anxiety alone (n = 14) and those
with depression alone (n = 7), we did not find any
significant differences in terms of demographic and clinical
variables; however, the numbers in each group were small.
Finally, none of the patients with comorbid anxiety or
depression had been diagnosed as having a psychiatric
disorder prior to our evaluation.
4. Discussion
4.1. Frequency of comorbid anxiety and depression
Approximately one-third of men in our sample had a
comorbid anxiety or depressive disorder at the time of
presentation. This figure is comparable to the 30.1% estimate
of comorbid anxiety and depression reported in a sample of
103 Greek men with ED [32]. However, comorbid anxiety
and depression were seen in 7 (6.8%) patients in the latter
study, and in only one patient (1.6%) in ours. The reason for
this difference is unknown, but may reflect characteristics of
the study sample and clinic setting.
4.2. Chronology of comorbid diagnoses
Anxiety and depression were more likely to precede
sexual dysfunction than to develop subsequent to it. We
cannot comment on a possible causal relationship; however,
when we compared those men with pre-existing anxiety or
depression to the rest of the sample, they did not differ
overall in terms of other potential contributory factors, such
as life stressors or performance anxiety. This suggests that a
simple, linear relationship is unlikely.
4.3. Depression and sexual dysfunction
Depression was associated with elevated rates of suicidal
ideation and behavior, which our patients attributed to their
sexual dysfunction and inability to "satisfy their partners".
Men with sexual dysfunction may themselves be at an
elevated risk of suicide, especially in traditional societies
where "the ability to 'perform sexually' and to have children
is the ultimate test of masculinity" [33]. Such a vulnerability
would then be amplified by depression. Lack of sexual desire
was also significantly more common in men with depression,
though it post-dated the onset of depression in all instances.
Due to the retrospective design of our study, we cannot
comment on whether treatment of the underlying depression
led to an amelioration of this symptom.
4.4. Anxiety disorders and other forms of anxiety
We did not find a link between semen-loss anxiety and
either anxiety or depression in our patients. To a certain
extent, this contradicts the results of earlier research,
including a study from our own center [30,34,35]; however,
this may reflect the fact that semen-loss anxiety is a
culturally derived "idiom of distress" which is not linked
to depressive or anxiety disorders per se [29]. On the other
hand, we found a significant association between pre-
existing anxiety disorders and sexual performance anxiety.
This could reflect a process in which pre-existing anxiety
triggers sexual dysfunction, leading to performance anxiety
 R.P. Rajkumar, A.K. Kumaran / Comprehensive Psychiatry 60 (2015) 114–118
and causing a vicious cycle of anxiety → sexual dysfunc-
tion → anxiety [7,26,36].
4.5. The link between anxiety disorders and
premature ejaculation
Unlike previous studies [20,22], the most common anxiety
disorders in our sample were generalized anxiety disorder and
anxiety disorder NOS. The latter diagnosis is common in
general and public mental health settings [37,38]. We used the
diagnosis of anxiety disorder NOS when patients had symptoms
of GAD which fell short of the ICD-10 diagnostic criteria, but
still caused significant impairment and distress. In other words,
there was substantial overlap between GAD and anxiety
disorder NOS, with patients experiencing anxiety symptoms
continuously, rather than episodically. This provides some
support for an association between male sexual dysfunction and
"free-floating" anxiety [28]. It is possible that treating the
underlying anxiety disorder may also lead to an improvement in
sexual dysfunction in these patients, though this remains to be
tested in large samples [39].
Given the apparent association between pre-existing
anxiety disorders and PE, the possibility of a shared
underlying mechanism or vulnerability factor for both
conditions must be considered. One such factor may involve
polymorphisms in the promoter region of the serotonin
transporter (5-HTTLPR) gene. The short (s) allele of this
gene is associated with an increased risk of premature
ejaculation [40,41], and has also been linked to higher levels
of trait anxiety [42,43], suggesting that genetically-
influenced abnormalities in serotonergic transmission may
play a role in both these conditions.
4.6. Limitations
The results of this study must be interpreted with caution
due to certain limitations: the retrospective study design, the
absence of a representative control group of men without
sexual dysfunction, and the assessment of PE and ED using a
clinical interview rather than a structured rating scale.
Moreover, as our results are based on a small, hospital-based
sample of men from South India, their application to other
settings and cultures is limited.
5. Conclusions
Despite certain shortcomings, our study replicates the
findings of earlier research in this patient population, though it
did not generate any new results. Anxiety disorders and
depression both affect a substantial minority of men with sexual
dysfunction, and are often undiagnosed and untreated. Though
their exact role in the pathogenesis of ED or PE is unknown, our
data provide some evidence for a link between pre-existing
anxiety disorders, sexual performance anxiety, and premature
ejaculation. These results require replication in larger, prospec-
tive samples to confirm their applicability in clinical settings.
117
Acknowledgment
None.
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