ORIGINAL ARTICLE

Sexual Dysfunction in Alcohol Dependence

Syndrome
S. Kumar, Suprakash Chaudhury, S. Sudarsanan,
Kalpana Srivastava, Santosh Kumar

ABSTRACT

Background: Though an adequate volume of ethanol relieves nervousness and enhances sexual
desire, acute administration of a great deal of ethanol suppresses central nervous system and
causes sensory torpor and penile erectile dysfunction. Long term and excessive intake of ethanol
too causes multiple direct and indirect changes in the body leading to sexual dysfunctions
including infertility. In patients with alcohol dependence syndrome, sexual dysfunction is not
uncommon and may occur even in the absence of liver dysfunction. Psychological changes (like
direct depressant effect of alcohol) are known to cause sexual dysfunctions in alcohol dependents
and vice versa are also true. This aspect of the alcoholism should be highlighted. Aim: To study
the prevalence of sexual dysfunction in alcohol dependence syndrome. Methods: A total of 30
patients admitted to psychiatry ward Command Hospital (Southern Command) and meeting the
ICD 10 criteria for alcohol dependence syndrome formed the study group. Equal number of age
and sex matched healthy subjects formed the control group. All subjects gave informed consent.
All patients filled a specially designed proforma and the following psychiatric rating scales: Hilton
drinking behavior questionnaire, sexuality scale, state trait anxiety inventory and Carroll rating
scale for depression. Results: Analysis of the result showed that 30% of the alcohol dependent
patients had reduced libido despite having normal liver function tests. In addition, 26.7% patients
also complained of disturbed sleep. On the sexuality scale though the alcohol dependent patients
had lower sexual esteem and higher sexual depression scores the differences were not statistically
significant. The alcohol dependent patients had significantly higher state and trait anxiety and
depression scores as compared to the normal controls. Conclusions: During psychiatric
treatment and follow up of patients with alcohol dependence syndrome the psychiatrist should
specifically inquire about sexual and sleep functions apart from looking for co-morbid anxiety and
depression.

Key words: alcohol dependence syndrome; sexual dysfunction

RINPAS JOURNAL 2011; 3 (2): 304 - 309

Sexuality has always been shrouded in secrecy and mysticism. Over the ages various
kinds of exotic substances and love potions have been proclaimed to increase sexual
desire and performance, but the true aphrodisiac remains elusive. Intoxicating
substances like alcohol and cannabis, have often been used as aphrodisiacs because all
of them produce disinhibition. This lack of inhibition produces a sense of amorousness
and desire, and also gives an erroneous feeling that performance is heightened. Alcohol,
by virtue of being a socially and legally acceptable drug, is more often involved in sexual
interaction than any other drug. William Shakespeare has recorded its effect on sexual
activity for posterity: “ It provoketh and it unprovoketh; it provoketh the desire but
taketh away the performance.” Though an adequate volume of ethanol relieves
nervousness and enhances sexual desire, acute administration of a great deal of ethanol
suppresses central nervous system and causes sensory torpor and penile erectile

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dysfunction. Long term and excessive intake of ethanol causes central and/or
peripheral neuropathy and sexual dysfunction; atrophy of testicles, low serum level of
testosterone, impaired spermatogenesis and penile erectile dysfunction (Taniguchi &
Kaneko, 1997).
Sexual dysfunction is not uncommon in patients with alcohol dependence
syndrome and may occur even in the absence of liver dysfunction. Hormonal changes
attributable to alcohol abuse have been linked to diminished libido, impotence,
testicular degeneration, and decreased fertility in men. High blood alcohol level impairs
erection by a direct pharmacological effect. Heavy drinkers who repeatedly fail to
maintain an erection become anxious about their sexual performance, which itself leads
to further failure. Alcohol also has direct toxic effects on the Leydig cells of the testis,
resulting in reduced testosterone production, impaired spermatogenesis, infertility and
testicular atrophy. A significant improvement in sperm count and fertility was noted in
a sample of men attending an infertility clinic when they reduced their alcohol intake
(Bruce & Ritson, 1998). In non-alcoholic men, acute, low-dose alcohol intake has been
found to lower serum testosterone levels. In women, the frequency of menstrual
disturbances, spontaneous abortions, and miscarriages increases with the level of
drinking, and alcohol abuse has adverse effects on fertility and sexual function. In
addition sexual dysfunction in alcoholics may be due to the depressant effects of alcohol
itself, to alcohol related disease or to psychological causes (Agarwal & Katiyar, 1992).
There is very sparse literature on this aspect of alcohol dependence and no study has
been undertaken in the security forces. In view of the paucity of Indian studies in this
field the present work was undertaken.

MATERIAL AND METHOD

The study was carried out at the Department of Psychiatry AFMC and CH (SC), Pune
during the period Sep 03 to Jan 04. The study group consisted of thirty consecutive
patients from armed forces admitted to the psychiatry ward and meeting the ICD 10
diagnostic criteria of Alcohol dependence syndrome. Patients with co-morbid psychiatric
illnesses were mot included in the study group. A similar number of age and sex
matched healthy service personnel without any physical or psychiatric disorders served
as the control group. All patients gave informed consent. During the initial interview
demographic and historical data were recorded on a specially designed proforma.
Details regarding their alcohol habits along with data about sexual function were also
recorded. All the patients and control subjects were subjected to a thorough physical
and mental status examination. All the patients underwent the following laboratory
investigations (hemogram, urinalysis, LFT, SGOT, SGPT, Alkaline phosphatase, urea,
creatinine, and VDRL) and the following psychiatric rating scales:
1. Hilton’s Drinking behaviour Questionnaire is a well validated questionnaire. In
the initial study the mean score of the alcoholic subjects was 107 (Hilton & Lokare,
1978).
2. Sexuality scale (Snell & Papini, 1989): The Sexuality Scale (SS) consists of three
subscales. Higher scores correspond to greater sexual esteem, sexual depression, and
sexual preoccupation.
3. State-Trait Anxiety Inventory (STAI) (Speilberger et al., 1983): The STAI has been
extensively used in research and clinical practice. It comprises separate self-report
scales for measuring state and trait anxiety. The S-Anxiety scale (STAI form Y-1)
consists of twenty statements that evaluate how respondents feel “right now, at this
moment”. The T-Anxiety scale (STAI form Y-2) consists of twenty statements that assess
how people generally feel. Each STAI item is given a weighted score of 1 to 4. Scores on
both the scales can vary from a minimum of 20 to a maximum of 80.
4. Carroll rating scale for depression (CRSD) (Carroll et al., 1981): The CRSD is a 52
item self-rating version of the Hamilton Depression Rating Scale for the measurement of
depression. Each item has a forced choice response alternative of yes or no. The scores
are summed up to give a total score. The possible range of scores varies from 0 to 52.
The CRSD has acceptable face validity and reliability. The concurrent validity of CRSD
is also acceptable based on comparisons with the Hamilton Depression Rating scale and
Beck Depression Inventory.

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The data which was collected was tabulated and statistically analyzed using chi-square
test and Mann Whitney U test as applicable.

RESULTS

A total of 30 patients were admitted for alcohol dependence syndrome during the period
of study and were included in the study with their consent. The mean (+SD) age of the
alcohol dependence patients and healthy control was 37.2 (+ 4.1) years and 36.9 (+ 4.2)
respectively. The age of the patients and controls ranged from 30 years to 46 years. All
the subjects of the present study were male. All the patients were serving armed forces
personnel, since the study was conducted at a military hospital. Mean monthly income
of the patients and controls was Rs 6,150 (+ Rs 1376.6) and Rs 6085 (+ Rs 1307)
respectively. The monthly income of the subjects ranged from Rs 5000 to Rs 10,000.
Demographic characteristics and habits of the subjects are given in Table 1.

TABLE 1. Characteristics of the alcohol dependence syndrome patients and

control subjects

Characteristics Alcoholic patients Normal controls Significance

Age distribution
30-34 years 5 (16.7) 5 (16.7)
35- 39 years 17(56.7) 18(60.0) NS
40-45 years 7(23.3) 6(20.0)
46-49 years 1(3.3) 1(3.3)
Marital status
Married 29(96.7) 30(100)
Widower 1( 3.3) 0(0.0)
Education
Up to 10 class 19(63.3) 19(63.3)
11-12 class 7(23.3) 9(30.0) NS
Graduates 4(13.3) 2(6.7)
Food habits
Vegetarian 8 (26.7) 11(36.7) NS
Non-vegetarian 22(73.3) 19(63.3)
Smoking
Non-smoker 6(20.0) 11(36.7)
<10 cigarettes/day 19(63.3) 14(46.7) NS
10-19 cigarettes/day 3(10.0) 4(13.3)
20/more cigarettes/day 2 (6.7) 1 (3.3)
Duration of Alcohol consumption
Nondrinker 0 (0.0) 9(30.0)
Occasional drinker 0(0.0) 6(20.0) S
1 peg/week 0(0.0) 7(23.3)
2-3peg/week or more 30 (100) 8(26.7)
Family income/month
Rs 5000-Rs 6499 24(80.0) 24(80.0)
Rs 6500-Rs 8999 4 (13.3) 4(13.3) NS
> Rs 9000 2 (6.7) 2 (6.7)
NS=not significant; S=significant

A family history of hypertension, was present in 6 patients, cerebro-vascular accident in

two, fits in one and peptic ulcer in two patients. Father or sibs of 7 patients consumed
alcohol in excess. None of the patients or control subjects had a past or family history of
psychiatric disorders. Among the alcohol dependent patients 7 gave history of major
injuries, 6 had history of fits, two patients were known cases of hypertension, one
patient had leprosy while one was HIV positive.
Hypertension was present in five patients on admission while eight had tachycardia.
The liver function tests of all the patients were within normal limits. Nine patients
compared to one control subject complained of reduced libido (Difference statistically
significant). Eight patients complained of decreased sleep while three were depressed
and one had transient hallucinations.

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TABLE 2. Psychological test results of the alcohol dependence patients and
control subjects

Psychiatric rating scale Alcoholic Normal Controls Mann-Whitney

Patients Score Score U
Mean (+SD) Mean (+SD) Test
Hilton drinking behaviour 67.9(15.3) 43.7(10.2) S
questionnaire
Sexuality scale:
Sexual esteem 17.9(1.4) 19.5(2.2) NS
Sexual depression 24.9(1.3) 19.4(1.5) NS
Sexual preoccupation 15.9(2.1) 15.5 (1.6) NS
State-Trait Anxiety Inventory:
State anxiety 50.2 (7.3) 33.8 (9.2) S
Trait anxiety 46.7 (9.7) 31.3 (7.6) S
Carroll rating scale for depression 9.7 (4.3) 0.9 (1.3) S
S=Significant; NS = Not significant

The results of the psychological tests given to the alcohol dependent patients and
healthy control subjects are shown in Table 2. On the Hilton drinking behavior
questionnaire the score of the alcohol dependence patients was significantly higher
compared to normal controls. On the Sexuality scale though the alcoholic patients had
higher mean scores, the difference was not statistically significant. Compared to the
healthy controls the alcoholic patients had statistically significantly higher scores on
state and trait anxiety as well as depression.

DISCUSSION

Drugs of abuse, like alcohol, opiates, cocaine and cannabis, are used by many young
people for their presumed aphrodisiac properties (Saso, 2002). Alcohol produces
psychological effects of expectation and pharmacological effects on sexual performance.
In low doses it may have a disinhibiting effect and enhance sexuality, however in
increasing doses it impairs arousal and ejaculation. In women the physiological changes
are similar to those in men; however they may report a positive subjective effect.
Alcoholism may severely damage relationships and sexuality in both sexes. Alcohol
affects the hypothalamic-pituitary-gonad axis causing features of hypogonadism and
low serum testosterone levels. Alcohol has direct toxic effects on the gonads (testes and
ovaries) and the liver (it increases the catabolism of testosterone and its transformation
in estrogens). The peripheral metabolism of testosterone and sex-steroid binding
globulin is also affected. Other factors, which may play a role in libido and sexual
function, are liver function abnormalities, higher serum estrogen levels, associated
polyneuropathy and interpersonal and marital problems. Alcoholism can have a wide
range of disruptive effects on family systems (Athaniasadis, 2003). The knowledge of
these effects should be better disseminated among subjects at risk for deterrent
purposes.

It is evident from Table 1 that the alcohol dependence patients and control subjects
were well matched on the socio-demographic variables like age, sex, rank, education
levels, marital status and income. Thus we may conclude that the two groups were well
matched. However, unlike the controls, among the alcohol dependent patients seven
gave a past history of major injuries, six had history of fits, two patients were known
cases of hypertension, one patient had leprosy while one was HIV positive. It is evident
that in at least the first three conditions (viz. injury, hypertension and fits) alcohol must
have played an important role.

The major finding of the study was that despite normal liver function tests nine patients
complained of reduced libido. Undoubtedly depression must have played a role in some
of these patients, but clinically only three were depressed. Therefore in the remaining
patients the reduced libido must be attribute to alcohol. This finding is consistent with
Royal College of Psychiatrists (Royal College of Psychiatrists, 1986) and others

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(Abolfotouh & al-Helali, 2001), though opposite findings have also been reported by
(Gumus et al., 1998; Johnson et al., 2004).

The finding of significantly higher scores in alcoholics on the Hilton drinking behavior
questionnaire was on the expected lines and is in agreement with an earlier study on
Armed Forces personnel (Patra et al., 2003). However, on the sexuality scale though the
alcohol dependent patients obtained lower sexual esteem scores and higher sexual
depression scores the differences was not statistically significant (Table 2). The finding
of significantly higher trait and state anxiety scores in alcohol dependent individuals
(Table 2) are in support of the findings of earlier studies (Neeliyara et al., 1989; Schuckit
& Hasselbroch, 1994) and indicates that this aspect may be etiologically significant in
alcohol dependence. Anxiety has been suggested to be an important factor in the initial
development and subsequent maintenance of alcohol abuse and dependence. Some
patients use alcohol as a medication for the treatment of anxiety. The identification of
this subpopulation of alcoholics may be important from a treatment perspective as they
may require different or additional treatment for concurrent psychiatric disorders.
Unfortunately accurate diagnosis of anxiety disorders is difficult to make, since current
anxiety symptoms may be secondary to alcohol withdrawal rather than reflecting
underlying anxiety disorders (Thevos et al., 1991). The findings of the present study also
reveal that the alcohol dependent individuals are different from anxiety neurotics, since
they have high state anxiety unlike the anxiety neurotics who have high trait anxiety.
This indicates that anxiety in alcohol dependent individuals is transitory and varies in
intensity and fluctuates over time and can be easily modified. One of the sources of
anxiety is a low level of self-esteem, fear of disapproval from significant people, loss of
position, prestige, stature or self-esteem (Laughlin, 1967). Thus these findings also
support our finding that alcoholics have low sexual self-esteem, which underlies the
need for reducing anxiety using suitable therapeutic interventions.

The finding of significantly higher depression scores in alcohol dependents (Table 2) is

in agreement with earlier work (Graham & Strenger, 1988; Hayne & Loaks, 1991). While
some patients may use alcohol as a self-medication for their depression, alcohol itself
may produce clinically significant depression. Clinicians obviously need to carefully
assess alcohol dependent individuals for anxiety and depression, which must also be
treated.

CONCLUSION

The present study showed that 30% of the alcohol dependent patients had reduced
libido despite having normal liver function tests. In addition, 26.7% patients also
complained of disturbed sleep. On the sexuality scale the alcohol dependent patients
had lower sexual esteem and higher sexual depression scores though the differences
were not statistically significant. The alcohol dependent patients had significantly higher
state and trait anxiety and depression scores as compared to the normal controls. In
view of high levels of decreased libido, disturbed sleep and increased anxiety and
depression in alcohol dependent patients it is recommended that these should be
carefully enquired for during therapy and follow up of patients with alcohol use
disorders. The knowledge of these adverse effects should be better disseminated among
subjects at risk for deterrent purposes.

REFERENCES

Abolfotouh MA, al-Helali NS.(2001). Effect of erectile dysfunction on quality of life. East Mediterr Health
Journal;7(3):510-8.
Agarwal, A.K. , Katiyar, M.K. (1992). Sexual dysfunction and substance abuse: Any association. Proceedings of
the National CME on Drug abuse and dependence, Trivandrum.
Athaniasadis, L. (2003). Alcoholism, marital problems and sexual dysfunction. Annals of General Hospital
Psychiatry; 2(Suppl 1) S 40.
Bruce, M. & Ritson, B. (1998). Substance misuse. In Companion to Psychiatric studies. Johnstone, E.J.,
Freeman, C.P.L., Zealley, A.K.eds. 6th ed. Edinburgh: Churchill Livingstone.
Carroll BJ, Feinberg M, Smouse PE, Rawson SG, Greden JL. (1981). The Carroll rating scale for depression.
British Journal of Psychiatry; 138: 194-200.

308
Graham, J.R. & Strenger, V.R. (1988). MMPI characteristics of alcoholics: A review. Journal of Consulting and
Clinical Psychology, 56: 197-205.
Gumus B, Yigitoglu MR, Lekili M, Uyanik BS, Muezzinoglu T, Buyuksu C. (1998). Effect of long-term alcohol
abuse on male sexual function and serum gonadal hormone levels. Int Urol Nephrol. 30(6):755-9.
Hayne, G.H. & Loaks, J.L. (1991). Dysphoria in male alcoholics with a history of hallucinations. Journal of
Nervous and Mental Disease, 197: 416-419.
Hilton. R.M and Lokare, V.C. (1978). The evaluation of questionnaire measuring severity of alcoholism. Br J
Psychiat 132: 42-48.
Johnson SD, Phelps DL, Cottler LB. (2004). The association of sexual dysfunction and substance use among a
community epidemiological sample. Arch Sex Behav. 33(1):55-63.
Laughlin, H.P. (1967). The Neuroses. Washington: Butterworth.
Neeliyara, T., Nagalakshmi, S.V. & Ray, R. (1989). Personality characteristics of individuals with alcohol
dependence. In: Proceedings of the Indo-US symposium on alcohol & drug abuse. Ray,R & Pickens,
R.W. (eds). Bangalore: NIMHANS: 197-205.
Patra, B., Kutty, P.R., Sarkar, P. (2003) Psychotic disorders in alcohol dependence syndrome. Industrial
Psychiatry Journal, 12: 124-126.
Royal College of Psychiatrists. (1986). Alcohol related disabilities: Alcohol our favorite drug. London: Tavistock
Publications.
Saso L. (2002). Effects of drug abuse on sexual response Ann Ist Super Sanita. 38(3):289-96.
Schuckit, M.A. & Hasselbroch, V. (1994). Alcohol dependence & anxiety disorder: What is the relationship.
American Journal of Psychiatry, 151: 1723-1734.
Snell, W. & Papini, D. (1989). The sexuality scale: An instrument to measure sexual esteem, sexual depression
and sexual preoccupation. The Journal of Sex Research 26: 256-263.
Speilberger CD, Gorsuch RL, Lushene R, Vogg PR, Jacobs GA. (1983). State Trait Anxiety Inventory.
California: Consulting Psychological Press 1-12.
Taniguchi N, Kaneko S. (1997). Alcoholic effect on male sexual function. Nippon Rinsho. 55: 3040-4.
Thevos, A., Johnston, A.L., Lathain, P.K., Randall, U., Adihoff, K. & Malcolm, R. (1991). Symptoms of anxiety
in inpatient alcoholics with and without DSM III R anxiety diagnosis. Alcoholism: Clinical and
Experimental Research, 15:102-105.

S. Kumar, Medical Cadet; S. Sudarsanan, Prof & HOD; Kalpana Srivastava, Scientist „F‟, Dept of Psychiatry,
Armed Forces Medical College, Pune -411040; Suprakash Chaudhury, Prof & Head; Santosh Kumar,
Research Officer, Dept of Psychiatry, Ranchi Institute of Neuropsychiatry & Allied Sciences, Kanke, Ranchi
834006

Paper presented at the 9th Annual Conference of Indian Psychiatric Society, Jharkhand State Branch,
2010 at Ranchi.

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