Sexual disorders in specific populations
The role of culture in sexual
dysfunction
Kamran Ahmed
Dinesh Bhugra
Abstract
Culture affects sexual dysfunction in terms of presentation, causation
and understanding, and treatment. Differences have been noted in the
prevalence and presentation of sexual disorders across cultures, includ-
ing a number of ‘culture-bound syndromes’. Culture can influence various
aspects, including beliefs, perceptions and attitudes to sex. Education,
tailored therapy and a flexible approach are the cornerstones of ­effective
treatment.
Keywords culture; culture-bound syndromes; explanatory models;
­presentation; sexual dysfunction; tailored therapy
Culture can be defined as unique behaviour, lifestyle and atti-
tudes which are formed as a result of customs, habits, beliefs
and values that are common to a group and shape their emo-
tions, behaviours and life patterns; it serves as a core behaviour
that regulates life. This is particularly apparent in the context
of sexual dysfunction since sexual behaviour and beliefs are so
open to cultural and social influences. Culture can be pathogenic,
pathoprotective or pathoplastic and cultural ideas and practices
are important in the presentation, causation, understanding and
treatment of sexual dysfunction (Figure 1).
Sexual dysfunction and culture
Differences have been noted between cultural groups in the
prevalence and presentation of sexual disorders. For example,
Kamran Ahmed MBBS BSc is a Senior House Officer in Psychiatry and
Honorary Researcher in the Section of Cultural Psychiatry at the
Institute of Psychiatry, London, UK. He qualified from Guy’s, King’s &
St Thomas’ Medical School and is currently training on the St Mary’s
psychiatric scheme. His research interests include cultural psychiatry,
self-harm and suicide, depression, and religion. Conflicts of interest:
none declared.
Dinesh Bhugra MBBS FRCPsych is Dean of the Royal College of
Psychiatrists, UK, and Head of the Section of Cultural Psychiatry at
the Institute of Psychiatry, London, UK. He currently runs the Sexual
Dysfunction and Couple Therapy Clinic in the Maudsley Hospital. His
research interests include social and cultural psychiatry, spirituality,
sexual dysfunction and diversity. Conflicts of interest: none declared.
PSYCHIATRY 6:3
What’s new?
• Psychogenic causes of sexual dysfunction have become
more accepted
• Progress has been made in understanding the role that
culture plays in the aetiology and treatment of sexual
dysfunction
• Research carried out in developing countries has
highlighted some of the problem areas that need
addressing within them
a study of the prevalence of erectile dysfunction in community-
based populations in Brazil, Italy, Japan and Malaysia found that
the age-adjusted prevalence of moderate or complete erectile
dysfunction was 34% in Japan, 22% in Malaysia, 17% in Italy
and 15% in Brazil.1
In Asian males, masturbation is a particular problem area,2
and in Arab males a high level of performance anxiety has been
found.3 One sexual health clinic in the UK found a disproportion-
ate preponderance of men from Islamic and Asian backgrounds
with premature ejaculation.4
Studies have indicated that erectile dysfunction is a common
problem among men in Ismaila, Egypt,5 in Casa Blanca, Morocco
(54% prevalence)6 and Nairobi, Kenya (57.1% prevalence).7 In
Casa Blanca, the prevalence of sexual dysfunction in women
was 26.6% and the most common finding was hypoactive sexual
desire disorder.8 Vulvar pain with some relationship to sexual
intercourse appears to be a significant problem among Ghanaian
women.9
In younger married couples living in rural Hunan, China,
28.2% of husbands and 45.6% of wives had at least one sex-
ual dysfunction respectively.10 In a survey of three cities in
China, the age-adjusted prevalence of erectile dysfunction was
28.34%.11 In Chinese sex therapy clinics, a greater proportion
of retarded ejaculation cases and a lower proportion of female
The role of culture in sexual dysfunction
Culture Practicalities Pathoprotective
Beliefs
Customs
Concepts
Pathogenic
Perceptions
Acculturation
Restrictions
Explanatory models Treatment
Figure 1
115 © 2007 Elsevier Ltd. All rights reserved.
 Sexual disorders in specific populations

patients have been reported in comparison with the West.12

One study suggested that the age-adjusted prevalence of erec- Examples of culture-bound syndromes
tile dysfunction among Korean men can be estimated as 32.2%
and early ejaculation and erectile difficulties were the sexual Dhat syndrome Nocturnal emissions leading to severe
problems most frequently reported. These conditions were more (India) anxiety, hypochondriasis and, often,
common in Korea than in other Asian regions. The sexual prob- sexual impotence. Patient may believe
lems most frequently reported by women in Korea were lack of that semen is also lost through urine.
sexual pleasure and inability to reach orgasm.13 In Hong Kong, Symptoms of fatigue, weakness,
sexual problems were prevalent among male (50.9%) and female headache, depression and anxiety are
(54%) respondents; approximately 50% were dissatisfied with also common
their sexual life.14 According to the results of a community-based
survey, the prevalence of erectile dysfunction among Taiwanese Loss of semen Concerns about loss of semen
men aged 40 or over was 17.7%.15 syndrome (Sri Lanka) through masturbation, wet dreams,
Data from the 2001–2002 National Health and Nutrition excessive sex or spermatorrhoea. This
Examination Survey in the USA showed that erectile dysfunction may also cause symptoms such as
affected almost 1 in 5 respondents. After controlling for other aches and pains, poor concentration
factors, Hispanic men were more likely to report erectile dys- and memory, erection problems and
function.16 A study which sampled non-Hispanic white, African premature ejaculation, anxiety about
American, Hispanic, Chinese and Japanese women in the USA sexual function, hypochondriasis and
found that African American women reported higher frequency avoidance of sex/marriage
of sexual intercourse than white women; Hispanic women Ascetic syndrome Morbid concerns with moral and
reported lower physical pleasure and arousal. Chinese women (India) physiological aspects of sexuality,
reported more pain and less desire and arousal than the white leading to psychosocial withdrawal,
women, as did Japanese women, although the only ­ significant severe sexual abstinence and
difference was for arousal.17 Another study found that the considerable loss of weight
pre­valence of certain sexual concerns among white, African
­American and Asian American women differed significantly and Koro syndrome Morbid belief that the penis is
concluded that healthcare providers should exercise caution (China, Hong Kong, retracting into the abdomen and that
when generalizing the sexual concerns of women from different Singapore, Taiwan, the this may prove fatal. There is often
racial/ethnic backgrounds.18 Chinese in Malaysia) an underlying belief that the problem
has been caused by semen loss in
Culture-bound syndromes the form of wet dreams, excessive
Certain syndromes described under the heading of sexual dys- sex or masturbation. This may lead to
function are said to be associated with particular cultures and are behaviours such as holding onto the
often referred to as ‘culture-bound syndromes’ (see Table 1).19–23 penis or attaching weights to it
In many of these ‘culture-bound syndromes’ it is the perceived Supernatural impotence Belief that ‘binding’ (a curse by a
value of semen and the feared consequences of its wanton loss (Christian and Jewish supernatural force such as a ghost)
which lead to sexual anxiety presenting in different ways.24 traditions) has the power to inflict impotence
Although there is a strong cultural component to such syndromes resulting in a form of psychogenic
it has been noted that they may occur in many cultures and coun- impotence
tries in various forms and should be seen as manifestations of
basic physiological or psychological dysfunction.25 For example, Table 1
the concept of Dhat syndrome has been described historically in
other cultures, including Britain, the USA and Australia.26 Such
a perspective will also prevent the therapist from attributing the pleasurable activity, resulting in low sexual drive.28 Furthermore,
illness to a fault in the culture. It has also been proposed that the some believe that women are temptresses and sex with them will
stresses involved in creating the contemporary phenomenon of drain men of vital energy. This may result in symptoms of Loss
syndromes such as koro is neither culture-specific nor culture- of semen/Dhat syndrome.24 On the other hand, couples may be
inherent, but generated by a feeling of powerlessness caused by pressurized to procreate as children are culturally significant, and
perceived threats to ethnic survival.27 this pressure may itself lead to performance anxiety and erectile
dysfunction. Such conflicting messages about sex may well lead
Attitudes towards sex to confusion, particularly in young adults, resulting in sexual dif-
Culture plays a crucial role in influencing attitudes towards and ficulties. The absence of proper sex education in schools means
beliefs about sex. The way sex is perceived is very important that these beliefs go unchallenged and the effects unmodified.24
since beliefs that interfere with normal sexual function can cause In certain cultures sex may not be perceived as important, and
pathology. For example, in Hindu philosophy, a 100-year life- this can result in low sexual satisfaction and sexual dysfunction.29
span is divided up into four quarters, the first of which is a period In Hong Kong, 23.9% of men and 5.9% of women perceived sex
of celibacy where the youth should concentrate on his educa- as important, and in China, 64% of women thought that sex was
tion.24 Marital sex may therefore be seen as a duty rather than a not important to them.14,30

PSYCHIATRY 6:3 116 © 2007 Elsevier Ltd. All rights reserved.

 Sexual disorders in specific populations
Explanatory models
Stresses of acculturation and cultural/religious restrictions
can result in dysfunction. In a recent study in London examining
the aetiology of premature ejaculation in men from Islamic back-
grounds, anxious first sexual experience (due to fear of being
discovered and wanting to finish early); sex before marriage;
sex outside of marriage; religion; ‘stress’; exposure to Western
images; living in the UK; and the subsequent feeling of freedom
were themes that emerged.31
Cultural practices and customs can have a negative impact on
a person’s psychosexual life. In Egypt, women who were circum-
cised complained more significantly of vaginal dryness during
intercourse, lack of sexual desire and satisfaction, less initia-
tive during sex and more orgasm problems than uncircumcised
women.32 In Arabic males, high levels of performance anxiety
are seen and can be explained or perpetuated by strong social
and familial pressure to consummate a marriage and the custom
that failure on the man’s part would lead to the wife returning to
her family home.3
Personal understanding of why an illness has occurred is often
strongly influenced by culture. For example, Ayurvedic doctrine
prescribes the loss of semen in Dhat syndrome to a deficiency
in one of the substances involved in its formation, such as food,
blood, flesh, fat, bone or marrow.33 It has been suggested that in
an African setting questions pertinent to bewitchment are impor-
tant with regard to sexual dysfunction, as this may form part of
the patient’s personal understanding of the illness.7
Positive effects may also be seen as a result of cultural influ-
ence on ideas and culture can be pathoprotective. The acceptance
of homosexuality in Western culture means that homosexuals
are less likely to experience symptoms due to anxiety or con-
cerns about their sexuality. Also in certain faiths, such as Islam,
problems such as nocturnal emissions may be ascribed to the
‘Will of God’, sometimes protecting against adverse cognitions
or symptoms developing. In a study of erectile dysfunction in
Indian, Chinese and Malay men in Malaysia, Malay and Chinese
men tended to blame their wives for their problem and thought
that the problem might lead to extra-marital affairs, unlike the
Indian men, who attributed their condition to fate.34
There are a number of practical culture-specific factors which
go a long way to contributing to or perpetuating sexual dysfunc-
tion. In a Chinese study, sexual dysfunction was significantly
associated with sharing a bedroom with non-spouse family
members.29 In South Asian men, it is thought that premature
ejaculation is not necessarily due to lack of experience but lack
of opportunity and privacy, which contribute to performance
­anxiety.35 Parental dominance is also a common theme.28 In
South Asian women, a number of factors have been identified
which may cause women to freeze up or react with irritation or
rejection before sex:36
• familial pressures
• lack of privacy
• urgency to perform and conceive
• interference from in-laws (especially in joint family set-ups)
• ignorance of sex
• fear of pregnancy
• marital disharmony
PSYCHIATRY 6:3
• poor accommodation
• forced marriages
• family quarrels (e.g. with mother-in-law)
• love marriages.
Lack of knowledge and information about sex are important
factors which may apply to patients of any cultural background
but are particularly associated with developing countries. In
Hong Kong, a study concluded that deficient sexual knowledge
is the commonest cause of sexual dysfunction, especially with
respect to the sexual problems of the aged.12 A Chinese study
discovered that 85.7% of women in the sample believed that
they did not have adequate sex-related knowledge.30
Gender inequality in certain cultures can also play an important
part. In Hanan, China, it was found that gender relationships,
including poor quality of the marital relationship, mistrust and
imbalance in relationship control and decision-making power,
had a significant negative effect on sexual dysfunction in both
husbands and wives.10
The role of culture in physical and lifestyle factors and their
subsequent effect on sexual dysfunction, must not be ­overlooked.
The difference in disease prevalence and lifestyle parameters
between different ethnic groups will lead to a variety of pre­valence
rates of certain sexual dysfunctions. For example, multiple ­factors
associated with erectile dysfunction have been reported from
around the world, such as chronic disease, socioeconomic status,
smoking, quality of life and physical exercise. Differences in these
factors between cultural groups may result in different rates of
­dysfunction.
Treatment
There are several difficulties in treating patients from ethnic
minority backgrounds. For example, dropout rates are high
amongst Asians and they are also more likely to miss appoint-
ments. In one survey, 83% of non-white couples dropped out
of therapy, compared with 29% of white couples. It has been
stated that the pursuit of organic explanations along with educa-
tional and language barriers may explain low uptake and success
rates.25 Problems related to differences of language and culture
have also been found in Asian attenders at a sex and marital
problems clinic.37 Only 17% of women wsith sexual dysfunc-
tion in Casa Blanca asked for help, although they were aware of
their disorder and its negative impact on their lives.8 Only 2% of
men and women in Korea had talked to a medical doctor about
their sexual problems. This was due largely to believing that the
problem was not serious, not being bothered by the problem,
difficulties regarding access to or affordability of medical care
and/or a lack of awareness of available treatments.13 A survey
on male health issues in six countries found men in all countries
agreed that erectile dysfunction was a source of great sadness
for themselves and their partners, and half of all men reported
they would do ‘nearly anything’ to cure their erectile dysfunc-
tion. However, men in the USA and the UK were less willing
to accept the problem, more motivated to find a cure and less
likely to consider erectile dysfunction a result of psychological
problems.38
117 © 2007 Elsevier Ltd. All rights reserved.
 Sexual disorders in specific populations
Traditional methods of treatment have a strong following in
developing countries and in certain ethnic sub-groups in devel-
oped countries. Thirty-three different medicinal plants were
found to be used in the management of sexual impotence and
erectile dysfunction in Western Uganda.39 In Ayurvedic treat-
ments, diet is often manipulated; in Dhat syndrome, patients
are advised to avoid hot and spicy food, and foods with cooling
effects are recommended.
In the UK, the most commonly used approach to relationship
difficulties is that of Masters and Johnson,40 based on learning
theory. However, problems become apparent when applied to
patients from non-Western cultures (Table 2).
Tailored therapy: the key to successful treatment is tailoring
t­herapy to suit the cultural background and personal characteristics
of the patient or couple. Many modifications to Masters and
­Johnson’s therapy packages have been tried (Table 3). One suc-
cessful variation of the therapy was tried in the East London with
Bangladeshi couples: D’Ardenne used modifications such as draw-
ings and diagrams, involving other members of the family and
being ‘authoritative’.41 The instructions were given didactically via
the family head and therefore compliance was high. It has also
been suggested that with careful integration of the therapeutic
techniques with Chinese sex concepts, sex therapy can be applied
to Chinese couples experiencing problems in sexual functioning.42
Problems encountered with Masters and Johnson’s
therapy
• Men who attend are often convinced of a physical aetiology
of their problems and therefore come looking for physical
treatments
• Men from a number of patriarchal societies may be
uncomfortable talking with female therapists
• Some patients want a quick solution to their problem
(e.g. in the Middle East there is a tremendous pressure to
improve quickly, so stepwise behavioural instructions are not
well received)
• There is a clear reluctance of women from certain cultures to
attend
• Women may not discuss sexual matters openly, particularly
with a male therapist
• It has been suggested that in some cases, a fear of
pregnancy underlies women’s reluctance to be treated
• There is a reluctance of male spouses to involve their
partners (e.g. in Asians) as they may not want their wives
to discuss intimate matters with an outsider, making joint
therapy difficult
• Compliance with homework can be problematic due to
practical issues such as lack of privacy (e.g. due to living
with extended families) or shortage of space, preventing the
couple from sleeping in a room separate from the children
• Some aspects simply may not be suited to certain cultures
(e.g. the woman taking the initiative could be a problem for
some)
Table 2
PSYCHIATRY 6:3
Modifications to Masters and Johnson’s therapy
• Educational sessions
• Keeping a daily diary
• Audio-taping instructions when women do not attend
• Using female therapists for women patients
• Supportive psychotherapy
• Group therapy
• Drugs as placebos
• Physical treatments (e.g. tranquillizers)
• Psychoanalytical interpretations
• Confrontation of the male partner and encouraging him to
indulge in erotic fantasy
• Paying greater attention to emotional reactions and to
individuals’ subjective appraisal of their changed sexual
functioning
Table 3
Gender differences: special attention needs to be paid to the role of
women in a given culture. In certain societies the role of the woman
is that of a passive and subjugated partner and this may well affect
the clinical presentation. In the case of men, various expectations,
pressures and underlying complexes may be important. It is impor-
tant to realize that men of any culture who present with dysfunc-
tion may report feeling depressed anxious and worried.
Traditional therapies: knowledge of how the sexual problems
have been tackled in the patient’s own culture is also useful.
It is thought that contradicting the patient’s beliefs can jeopar-
dize the therapeutic relationship. Instead, ways of explaining
the problem within their belief system may be more effective.43
­Traditional healers’ explanations are compatible with the patient’s
­understanding, making them popular. They also have the time to
listen, and this may be the therapeutic core in efficacy.44
Ethnic matching has been suggested as a solution to obtain-
ing concordance in belief systems but is impractical and, fur-
thermore, some patients actually prefer therapists from another
­ethnic background.25
Mixed marriages are becoming more common in the UK,
(­currently 13% of the total ethnic minority population) and a
­flexible approach has become even more important. ­Mainstream
services should have an inbuilt cultural sensitivity and there should
be sufficient resources and flexibility to provide ­competent care for
new ethnic groups (all with different needs) as they emerge.25
Policy: advances on a national and global level must be made
for the treatment of sexual dysfunction to improve. In recent
years, the number of hospitals with sexual dysfunction clinics
has increased in major cities in China. The treatment approaches
used combine psychotherapy, behavioural therapy, medication
and the ­application of physical aids. The government is still quite
­stringent on the control of drugs for treatment of sexual dysfunc-
tions and also sees many sex aids as obscene. However, ­significant
advances are being made in view of the rapid ­development, the
118 © 2007 Elsevier Ltd. All rights reserved.
 Sexual disorders in specific populations
Chinese readiness to accept new ideas, the diligence of the Chi-
nese medical professionals and the establishment of the Chinese
Sexology Association in 1994.42
Conclusion
It is important for the therapist to arrive at a formulation of the
problem that is robust enough to provide the basis of effective
therapy. Information on predisposing feelings, precipitating and
maintaining factors is crucial. The therapist must understand the
problem in all its dimensions and deal with it using a set of
effective therapeutic strategies that have the best chance of being
acceptable to the patient or couple. This will require knowledge
and sensitivity, ingenuity and a flexible application of thera­
peutic techniques.24
It is clear that treatment methods evolved in one culture
must be modified for application in another cultural setting. It
is ­ important to ascertain whether the elements of the therapy
package are suitable. If there are reservations, alternatives may
be used or reasons for the patients’ hesitation explored and
­overcome. Education should be included as needed.24 ◆
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