When Dhat Syndrome is Delusional: A Case Series.

The Dhat syndrome is a culture-bound syndrome associated with anxiety and somatic and mood symptoms related to semen loss. It sometimes occurs in women, in whom it comes with vaginal discharge. Only a single case has been reported whereby Dhat delusion was associated with schizophrenia. In this case report, we dwell on two individuals suffering from a somatic-type delusional disorder with Dhat-like symptoms who had initially presented classical symptoms of the Dhat syndrome. Further studies are needed to explore the intersections of Dhat syndrome and psychoses, as well as the risk factors involved in mutual predisposition.

Dhat Syndrome: Epidemiology, Risk Factors, Comorbidities, Diagnosis, Treatment, and Management.

Dhat syndrome is a culture-bound psychiatric syndrome most commonly found in the Indian subcontinent. It has been characterized as the experiential fear of losing semen through ejaculation, nocturnal emission, or other means. While Dhat syndrome is common in the Indian subcontinent, given the lack of representativeness, generalizability, and closer connection to Ayurvedic system, there have been limited studies or recognition of symptoms among healthcare providers around the world. In this review, we describe Dhat syndrome, its epidemiology, risk factors, comorbidities, diagnosis, treatment, and its management. For patients with Dhat syndrome, it becomes important to appreciate how generalized depression and anxiety may persist alongside the disorder and those symptoms can be common and non-specific. Related to its strong cultural connection with South Asia such as the belief on Dhat's role in health and vitality influence, it also becomes important to recognize that the syndrome can be found in other populations and the importance of cultural humility and nonconfrontational approach for patient care. In summary, this review provides an informative understanding of Dhat syndrome for non-Indian clinicians who may not be prepared for a patient encounter with vague somatic symptoms in the context of semen loss. Treatment for Dhat syndrome is the same as treatments for major depressive disorder.

Quality of Life and Disability in Patients with Dhat Syndrome: A Cross-Sectional Study.

Background: Dhat syndrome (DS) is considered a culture-bound syndrome of South East Asia. It is often associated with multiple sexual and psychiatric comorbidities. We aimed to assess the quality of life (QoL) and disability in patients of DS with and without comorbidity. Methods: This cross-sectional study included 117 patients with DS and 117 matched controls. DS was diagnosed based on the International Classification of Diseases, 10 version, Diagnostic Criteria for Research diagnostic criteria. Comorbidities were assessed on MINI 6.0.0, and the patients were divided into two groups (with and without comorbidity). The QoL and disability were estimated and compared between patients with and without comorbidity and their respective control groups consisting of healthy volunteers, using standardized tools. Result: Most of the patients were unmarried males aged 18 to 25 years and from rural backgrounds. Most of the patients (72.64%) had comorbidities (psychiatric/sexual). The QoL of patients with DS was poor compared to healthy individuals. The QoL of patients with comorbidity was worse than that of those without them (P < o.ooo). The disability of patients with DS was more than that of healthy individuals (significant in all domains of the World Health Organization Disability Assessment Schedule [WHODAS]). Conclusion: Patients having DS had poor QoL and higher disability than healthy controls. Patients having psychiatric or sexual comorbidities had less QoL and higher disability compared to healthy controls and those without comorbidities.

A 47-year-old man passing putrid semen through saliva and sweat: A case of Dhat syndrome.

Dhat syndrome is a culture-bound syndrome in which patients believe that they pass Dhat (semen) with their urine, feces, sweat, and saliva that causes lethargy, apathy, dysphoria, and depression. Here, we report a case of a 47-year-old man who presented with complaints of burning sensation in the whole body, especially in the pubic region, and insomnia for the last 5 years. This case could be enlightening for clinicians in South Asia in daily clinical practice and family physicians in Western countries where immigrants from Dhat syndrome prevailing countries could present with complex cultural myths and superstitious beliefs.

Dhat syndrome: Systematic review of epidemiology, nosology, clinical features, and management strategies.

BACKGROUND: Dhat syndrome is a culture-bound syndrome prevailing in the Indian subcontinent, first described in the 1960s. Over time, newer studies are exploring various aspects of Dhat syndrome, including its epidemiology, nosology, clinical features, and management predominantly in South Asia. We aimed to review the epidemiology, nosology, clinical presentation, and management of Dhat syndrome over the last six decades through a systematic review of studies. METHODS: We searched PubMed and Scopus using the following search terms - "Dhat syndrome," "Semen loss syndrome," "Semen loss anxiety" together with the Boolean operator OR. We collected the articles from inception till March 2021. We included articles in the English language published in peer-reviewed journals. RESULTS: A total of 89 articles were included in the analysis. Most of the articles were published in the last decade (2011-2020). Most of the publications were cross-sectional studies and of unsatisfactory quality. Most of the studies lack representativeness of the population; hence the generalizability of the findings was poor. Most of the articles discussed phenomenology (64%), overview (52.8%), and cultural basis of Dhat syndrome. The comorbidities associated with Dhat syndrome were discussed in 37.1% of the articles. The nosological status of Dhat syndrome and management of Dhat syndrome was discussed in 18% of publications each; whereas, the outcome of Dhat syndrome was discussed in 5.6% of articles. CONCLUSION: Though Dhat syndrome is a commonly diagnosed entity in the South Asian population, the research on Dhat syndrome is sparse and of poor quality.

History and mystery of Dhat syndrome: A critical look at the current understanding and future directions.

Sexual health, an essential component of individual's health, is influenced by many complex issues including sexual behavior, attitudes, societal, and cultural factors on the one hand and while on the other hand, biological aspects, genetic predisposition, and associated mental and physical illnesses. Sexual health is a neglected area, even though it influences mortality, morbidity, and disability. Dhat syndrome (DS), the term coined by Dr. N. N. Wig, has been at the forefront of advancements in understanding and misunderstanding. The concept of DS is still evolving being treated as a culture-bound syndrome in the past to a syndrome of depression and treated as "a culturally determined idiom of distress." It is bound with myths, fallacies, prejudices, secrecy, exaggeration, and value-laden judgments. Although it has been reported from many countries, much of the literature has emanated from Asia, that too mainly from India. The research in India has ranged from the study of a few cases in the past to recent national multicentric studies concerning phenomenology and beliefs of patients. The epidemiological studies have ranged from being hospital-based to population-based studies in rural and urban settings. There are studies on the management of individual cases by resolving sexual myths, relaxation exercises, supportive psychotherapy, anxiolytics, and antidepressants to broader and deeper research concerning cognitive behavior therapy. The presentation looks into DS as a model case highlighting the importance of exploring sexual health concerns in the Indian population in general and in particular need to reconsider DS in the light of the newly available literature. It makes a fervent appeal for the inclusion of DS in the mainstream diagnostic categories in the upcoming revisions of the diagnostic manuals which can pave the way for a better understanding and management of DS and sexual problems.

Female Dhat syndrome in primary care setting.

AIM: The study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome. METHODOLOGY: Sixty-nine females considered to have nonpathological vaginal discharge after detailed gynecological evaluation, including required investigations, attending a rural community clinic were assessed for their belief about the vaginal discharge. The study subjects were also evaluated on the proposed criteria of female Dhat syndrome by using a semi-structured interview. RESULTS: The mean age of onset of vaginal discharge was 36.1 (standard deviation - 8.5) years. Most of the females considered the loss of vaginal fluid as loss of a vital fluid from the body. Consumption of warm foods and drinks (75.8%) was the most common reason reported for vaginal discharge followed by eating unbalanced food/inappropriate food (73.5%). A majorty of the subjects considered vaginal discharge responsible for bodily weakness (87.0%), backache (71.0%) and stomache (66.7%). About two-third of the participants considered the taking energizing medications like vitamins/tonics/tablets and treatment from a gynecologist the treatment for vaginal discharge. CONCLUSIONS: Significant proportion of females with non-pathological vaginal discharge have a belief that they are losing a vital fluid of the body. The subject attributes their symptoms to factors such as consumption of warm foods and drinks, and eating unbalanced food/inappropriate food. Accordingly, assessment and management of women with Dhat syndrome require addressing these important issues.

A qualitative study on psychopathology of dhat syndrome in men: Implications for classification of disorders.

BACKGROUND: Dhat syndrome is regarded by many as a culture bound syndrome of the Indian sub-continent. However the nosological status, conceptual understanding of the condition as well as the diagnostic guidelines are all mired in controversy. AIMS: The current study aims to study the psychopathology of Dhat syndrome in men by using a qualitative approach and to arrive at an operational definition for diagnosing Dhat syndrome. METHOD: The qualitative approach consisted of five Focus Group Discussions (FGD) and five Key Individual Interviews (KII) with participants, consisting of patients as well as doctors - both allopathic as well as traditional. RESULTS: Detailed analysis revealed valuable data regarding the symptoms, causes, treatment measures, socio-cultural context, psychiatric co-morbidity, nature of the disorder and various other phenomenological dimensions. Ideas for future nosological positioning were also specifically looked for. Operational definition and diagnostic guidelines were also arrived at based on the analysis as well as on previous literature. CONCLUSION: Although lot of agreement existed among various stakeholders about symptoms and presentation, they varied significantly in their opinion on nature of the condition and treatment. Suggestions for ICD 11 have been made.

Cultural aspects of anxiety disorders in India.

Cultural factors have influenced the presentation, diagnoses, and treatment of anxiety disorders in India for several centuries. This review covers the antecedents, prevalence, phenomenology, and treatment modalities of anxiety disorders in the Indian cultural context. It covers the history of the depiction of anxiety in India and the concept of culture in the classification of anxiety disorders, and examines the cultural factors influencing anxiety disorders in India. We review the prevalence and phenomenology of various disorders, such as generalized anxiety disorder, panic disorder, social anxiety, and phobic disorder, as well as culture-specific syndromes such as dhat and koro in India. Finally, the review examines the wide range of therapeutic modalities practiced in India, such as faith healing, psychotherapy, ayurveda, psychopharmacology, Unani medicine, homeopathy, yoga, meditation, and mindfulness. We conclude by emphasizing the significance of cultural factors in making relevant diagnoses and offering effective and holistic treatments to individuals with anxiety disorders.

Por varios siglos, Ios factores culturales han influenciado la presentación, diagnóstico y tratamiento de Ios trastornos de ansiedad. Esta revisión abarca Ios antecedentes, prevalencia, fenomenología y modalidades terapéuticas de Ios trastornos de ansiedad en el contexto cultural de India. También incluye la historia de la descripción de la ansiedad en India y el concepto de cultura en la clasificación de Ios trastornos de ansiedad, como asimismo examina Ios factores culturales que influyen en Ios trastornos de ansiedad en India. Se revisa la prevalencia y la fenomenología de varios trastornos, como el trastorno de ansiedad generalizada, el trastorno de pánico, la ansiedad social y el trastorno fóbico, como también síndromes culturales específicos en India como el dhat y el koro. Por ultimo, el artículo revisa el amplio rango de modalidades terapéuticas practicadas en India, como la curación por la fe, la psicoterapia, el ayurveda y la psicofarmacología. Se concluye enfatizando en el significado de Ios factores culturales que son relevantes para realizar diagnósticos y ofrecer tratamientos efectivos y holísticos para individuos con trastornos de ansiedad.

Depuis plusieurs siècles, des facteurs culturels influent sur la présentation, le diagnostic et le traitement des troubles anxieux en Inde. Cet article parcourt les antécédents, la prévalence, la phénoménologie et les modalités de traitement des troubles anxieux dans le contexte culturel indien. Il traite de l'histoire de la représentation de l'anxiété en Inde et du concept de culture dans la classification des troubles anxieux et analyse les facteurs culturels influant sur les troubles anxieux en Inde. Nous examinons la prévalence et la phénoménologie des différents troubles, comme les troubles anxieux généralisés, le trouble panique, l'anxiété sociale et les troubles phobiques, ainsi que les syndromes culturels spécifiques comme le syndrome du Dhat et du koro en Inde. Enfin, l'article analyse la large gamme de modalités thérapeutiques pratiquées en Inde, comme la guérison par la foi, la psychothérapie, l'ayurvéda, la psychopharmacologie, la médecine Unani, l'homéopathie, le yoga, la méditation et la pleine conscience. Nous concluons en soulignant l'importance des facteurs culturels dans l'établissement de diagnostics pertinents et en proposant des traitements efficaces et holistiques aux individus ayant des troubles anxieux.

Where Lies the Fault in Diagnosing Dhat Syndrome among Females? Understanding through a Case Study.

Dhat syndrome is a culture-bound syndrome of South-East Asia, common in young men. However, similar entity has also been described in female patients who attribute their symptoms to nonpathological or physiological vaginal discharge. The current diagnostic system for psychiatric illnesses does not encompass Dhat syndrome in females, and so these group of patients receive alternative diagnoses such as somatoform disorder or depression. As a result of which the focus of unique Dhat syndrome-centered management gets weakened, affecting the clinical outcome. This case study focuses on the diagnostic dilemmas related to Dhat syndrome in females and pitfalls in the current diagnostic system.

A study on phenomenology of Dhat syndrome in men in a general medical setting.

BACKGROUND: "Dhat syndrome" is believed to be a culture-bound syndrome of the Indian subcontinent. Although many studies have been performed, many have methodological limitations and there is a lack of agreement in many areas. AIMS: The aim is to study the phenomenology of "Dhat syndrome" in men and to explore the possibility of subtypes within this entity. SETTINGS AND DESIGN: It is a cross-sectional descriptive study conducted at a sex and marriage counseling clinic of a tertiary care teaching hospital in Northern India. MATERIALS AND METHODS: An operational definition and assessment instrument for "Dhat syndrome" was developed after taking all concerned stakeholders into account and review of literature. It was applied on 100 patients along with socio-demographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. STATISTICAL ANALYSIS: For statistical analysis, descriptive statistics, group comparisons, and Pearson's product moment correlations were carried out. Factor analysis and cluster analysis were done to determine the factor structure and subtypes of "Dhat syndrome." RESULTS: A diagnostic and assessment instrument for "Dhat syndrome" has been developed and the phenomenology in 100 patients has been described. Both the health beliefs scale and associated symptoms scale demonstrated a three-factor structure. The patients with "Dhat syndrome" could be categorized into three clusters based on severity. CONCLUSIONS: There appears to be a significant agreement among various stakeholders on the phenomenology of "Dhat syndrome" although some differences exist. "Dhat syndrome" could be subtyped into three clusters based on severity.

A follow-up study of patients with Dhat syndrome: Treatment pattern, outcome, and reasons for dropout from treatment.

AIM: The aim of this study was to evaluate the treatment pattern and satisfaction with treatment provided to patients with Dhat syndrome. It was also aimed to study the follow-up rates and reasons for dropping out of treatment in patients with Dhat syndrome. MATERIALS AND METHODS: Sixty-four subjects diagnosed with Dhat syndrome were prospectively contacted to evaluate treatment satisfaction and reason for dropout after 6 months of baseline evaluation. Sociodemographic, clinical details were recorded at initial intake and Sex Knowledge and Attitude Questionnaire was applied. After 6 months, information on treatment received, number of follow-up visits to the clinic and the outcome were extracted from the treatment records. Treatment satisfaction using Patient Satisfaction Questionnaire and reasons for dropping out from treatment were assessed by a telephonic interview. RESULTS: Twenty-three patients were categorized as treatment completers, 14 as early drop-outs and 27 as late drop-out. The mean (standard deviation) number of visits over the period of 6 months was 3.81 (3.06). The outcome at 6 months was no change in 45.3%, improved in 32.8% and recovered in 21.9%. Higher proportion of treatment completers (52.2%) sought psychiatric help on their own compared to those who dropped out early from the treatment (7.1%). Treatment completers had better knowledge, and more positive attitude toward sex compared to late drop-out group. 34.4%of the subjects were fully satisfied with the various components of treatment. Level of satisfaction was highest for treatment completers. The most common reasons given by those who dropped out early were "not able to spare time for consultation" (21.4%) and "not prescribed medications" (21.4%). The most common reason given by those belonging to "late drop-out" group was 'no improvement with treatment in symptoms of Dhat syndrome (40.7%). CONCLUSIONS: Patients with Dhat syndrome frequently drop-out of the treatment network. There is a need to reorganize the services for these patients and understand their expectations from the treatment so as to provide better care.

Do female patients with nonpathological vaginal discharge need the same evaluation as for Dhat syndrome in males?

AIM: The aim of this study was to evaluate the concept of female Dhat syndrome characterized by the complaint of nonpathological vaginal discharge in association with somatic, anxiety, and depressive symptoms. MATERIALS AND METHODS: A total of 26 female subjects with nonpathological vaginal discharge along with depressive and somatic complaints were assessed on a self-rated questionnaire modified from Comprehensive Questionnaire for Assessment of Dhat Syndrome designed for males. They were also assessed for psychiatric comorbidity as per ICD-10. RESULTS: All female subjects received an ICD-10 psychiatric diagnosis, with somatoform/dissociative disorder (57.7%) being the most common. The mean age of onset of vaginal discharge was 24.6 (standard deviation - 7.0) years, noted every day or for 2-3 times per week by more than two-third of the participants. Two-fifth (61.5%) of the women described it as a milky discharge. The most common reason reported for passage of vaginal discharge was that of urinary infection or problems of urinary tract infections (42.3%) followed by vaginal infection/disease (34.6%). More than half (53.8%) of the subjects considered vaginal discharge to be responsible for weakness in the body, weakness in stamina and thinness of physique, while slightly more than two-third (69.2%) of them reported bodily weakness and sleep disturbances. Overall the clinical picture in females was similar to male patients with Dhat syndrome on most of the account. CONCLUSIONS: Subgroup of patients with vaginal discharge attribute their somatic and mental symptoms to the passage of whitish vaginal discharge and are distressed due to the same. The clinical picture is similar to Dhat syndrome in males. There is a need to recognize female variant of Dhat syndrome as a culture-bound syndrome. Identification of the same may help in managing this subgroup of patients seeking help from the gynecologists for their nonpathological vaginal discharge or from mental health professionals for their symptoms of common mental disorders.

Pathway of care among patients with Dhat syndrome attending a psychosexual clinic in tertiary care center in North India.

AIM: The aim of this study was to understand the pathway to care among patients with Dhat syndrome and to study the factors leading to delay in seeking professional psychiatric help. MATERIALS AND METHODS: Forty-seven patients diagnosed with Dhat syndrome as per the International Classification of Diseases-10 criteria were assessed for sociodemographic and clinical details and information regarding previous treatment taken to determine the pathways to care at their first contact with the outpatient psychosexual clinic. RESULTS: Majority of the patients were single (70.2%), received formal education for at least more than 10 years (66.0%), were employed (59.6%), followers of Hinduism (68.1) and from middle socio-economic class (59.6%), nuclear family setup (53.2%), and rural locality (63.8%). Comorbidity in the form of any psychiatric illness or sexual dysfunction was present on 61.7% of the patients. The mean age at onset of symptoms of Dhat syndrome was 20.38 years (standard deviation [SD] - 6.91). The mean duration of symptoms of Dhat before the patients presented to our psychosexual clinic was 6.78 years (SD - 6.94) while the mean number of agencies/help contacted before was 2.85 (SD - 1.40; range: 1-5). The favorite choice for the first contact was indigenous practitioners, followed by asking for help from friends or relatives, allopathic doctors, and traditional faith healers or pharmacists. The preference to visit indigenous practitioners gradually declined at each stage. Ayurvedic doctors remained the most preferred among all indigenous practitioners. The absence of any comorbid sexual dysfunction in patients with Dhat syndrome predicted an earlier visit to our center as compared to the patients with any comorbid sexual dysfunction. CONCLUSIONS: Majority of the patients with Dhat syndrome present very late to specialized psychosexual clinics. There is a need for improving the sexual knowledge and attitude at the community level which will facilitate the early help seeking in patients with Dhat syndrome.

Relevance of culture-bound syndromes in the 21st century.

Culture-bound syndromes were first described over 60 years ago. The underlying premise was that certain psychiatric syndromes are confined to specific cultures. There is no doubt that cultures influence how symptoms are perceived, explained and from where help is sought. Cultures determine what idioms of distress are employed to express distress. Rapid globalization and industrialization have made the world a smaller place and cultures are being more influenced by other cultures. This has led to social and economic changes in parts of the world where such syndromes were seen more frequently. In this review we illustrate these changes using the example of dhat syndrome (semen-loss anxiety). The number of syndromes in the DSM-5 has been reduced, acknowledging that these syndromes may be changing their presentations. Clinicians need to be aware of social and economic changes that may affect presentation of various psychiatric syndromes.

Phenomenology and beliefs of patients with Dhat syndrome: A nationwide multicentric study.

AIM: To assess the phenomenology and associated beliefs in patients with Dhat syndrome. METHODS: A total of 780 male patients aged more than 16 years were recruited from 15 centers spread across the country and were assessed on Dhat Syndrome Questionnaire. RESULTS: The most commonly reported reasons for passage of Dhat were excessive masturbation (55.1%), sexual dreams (47.3%), excessive sexual desire (42.8%) and consumption of high energy foods (36.7%). The most common situation in which participants experienced passage of Dhat were as 'night falls' (60.1%) and 'while passing stools' (59.5%). The most common consequence due to passage of Dhat was weakness in sexual ability (75.6%). In terms of psychological and somatic symptoms, the common symptoms included bodily weakness (78.2%); feeling tired or having low energy (75.9%); feeling down, depressed, or hopeless (67.9%); and little interest or pleasure in doing things (63.7%). In terms of treatment expectations, about half of the patients (49.1%) expected that energizing medications like vitamins/tonics/tablets were required and more than one-third (38.2%) expected that there was a need for taking energizing injections. CONCLUSION: Present study shows that Dhat syndrome is a distinct clinical entity seen all over India, with its characteristic features.

Psychological correlates and psychiatric morbidity in patients with Dhat syndrome.

AIM: The aim of this study was to examine psychological factors in the form of somatosensory amplification, alexithymia and hypochondriasis in patients with Dhat syndrome. Secondary aims of the study were: (1) To evaluate the influence of psychiatric comorbidity on the psychological correlates; (2) to compare the prevalence of psychological correlates in those with Dhat syndrome and in those with depression and somatoform disorders. MATERIALS AND METHODS: A total of 106 subjects diagnosed with Dhat syndrome as per International Classification of Diseases-10 (ICD-10) criteria were assessed on Toronto Alexithymia Scale (TAS-20), Somatosensory Amplification Scale (SSAS) and Whitely Index (WI). Psychiatric comorbidity was diagnosed as per ICD-10. Data on 50 patients with depression and 119 patients with somatoform disorder was used for comparison. RESULTS: The age at onset of Dhat syndrome was 22.54 (standard deviation [SD] - 7.5) years, and duration of illness was 5.04 (SD - 4.2) years. Depressive disorders were diagnosed in 13.2%, anxiety disorders in 15.1%, erectile dysfunction in 14.2% and premature ejaculation in 17% of cases. The mean SSAS total score was 23.12 (SD - 7.99), mean total TAS-20 score was 63.3 (SD - 13.3) and mean WI score was 8.23 (SD - 2.7). About two third of the patients had alexithymia (n = 67; 63.2%) and hypochondriasis (n = 69; 65.1%). Comparison of the psychological correlates between those with Dhat syndrome alone (n = 59) and those with comorbid psychiatric disorder (n = 47) revealed no significant differences. Patients with only Dhat syndrome had significantly higher scores for somatosensory amplification when compared with those with somatoform disorders, but no difference was seen between those with depression and Dhat syndrome alone. Compared to patients with Dhat syndrome alone, those with depression had higher prevalence of alexithymia and hypochondriasis. CONCLUSION: There are differences in the prevalence of somatosensory amplification, hypochondriasis and alexithymia between those with Dhat syndrome alone and those with depression and somatoform disorders.

Dhat syndrome: Evolution of concept, current understanding, and need of an integrated approach.

Dhat syndrome has often been construed as a culture-bound sexual neurosis of the Indian subcontinent. Symptoms similar to that of Dhat syndrome has been described in other cultures across different time periods. The present paper looks at the evolution of the concept of Dhat syndrome in India. The review also takes an overview of the current understanding of this syndrome in terms of nosological status as a distinct entity and its "culture-bound" status. The narrative finally attempts to discuss the integrated approach for the treatment of this disorder.

Comorbidity, knowledge and attitude towards sex among patients with Dhat syndrome: A retrospective study.

This study aimed to assess the knowledge about sex, attitude towards sex, prevalence of psychiatric comorbidity and relationship of the comorbidity with onset of symptoms of Dhat syndrome. Treatment records of 264 patients diagnosed with Dhat syndrome were reviewed for clinical profile including psychiatric comorbidity and sexual dysfunction and information on sexual knowledge and attitude using Sex Knowledge and Attitude Questionnaire (SKAQ-II). None of the patients gave all the correct responses on the SKAQ-II. Poor knowledge about sexual matters was not limited to the semen formation only, but also involved other aspects of sexuality, like masturbation, relationship of pregnancy with orgasm in women, breast feeding and pregnancy, relationship of sexual desire with addictive drugs and sexually transmitted diseases can be cured by having sex with a virgin girl. Higher level of education showed significant association with better sexual knowledge and liberal attitude. There was significant positive correlation between sexual knowledge and attitude. About half (51.9%) of patients had at least one comorbid psychiatric disorder and/or sexual dysfunction. Among the psychiatric disorders, depressive disorders were the most common and premature ejaculation was the most common comorbid sexual dysfunction. Among those with comorbidity, symptoms of Dhat syndrome preceded the onset of other disorders. Patients with Dhat syndrome have high rates of comorbidity and poor sexual knowledge and less liberal attitude, which was not only limited to loss of semen but also involves other spheres of sexuality. Accordingly psychoeducation in patients of Dhat syndrome should not be limited to addressing the myths and lack of knowledge about semen formation, but also should address poor sexual knowledge on all the aspects related to sexuality and the negative attitude towards sex.