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Latest Nutrition, Food buy generic propecia online cheap &. Recipes News FRIDAY, Jan. 8, 2021 (American Heart Association News)As one of the trendiest foods in the produce aisle, buy generic propecia online cheap microgreens are known for adding a splash of color to a dish, a spicy kick to a salad – and a chunk of change to a grocery bill.Known for a variety of flavors, textures and aromas, microgreens originated as a product of the California restaurant scene in the 1980s.

Smaller than baby greens, they are harvested just one to two weeks after germination – typically later than sprouts, which don't have leaves. They usually are 1 to 3 inches tall and buy generic propecia online cheap often are sold with the stems attached.Most microgreens are rich in concentrated vitamins and antioxidants. A 2012 study in the Journal of Agricultural and Food Chemistry looked at 25 commercially available microgreens and found they contained nutrient levels up to 40 times higher than more mature leaves.

Other research also has shown microgreens contain a wider variety of antioxidants and micronutrients called polyphenols.Nutrient content aside, microgreens are not a buy generic propecia online cheap replacement for leafy and other greens in one's diet, said Christopher Gardner, director of nutrition studies at the Stanford Prevention Research Center in California. Instead, they serve a better purpose as a way to add variety to a regular salad or other healthy meal.According to the federal dietary guidelines, an adult consuming 2,000 calories a day should eat 2 1/2 cups of vegetables each day, and the key is variety. Yet almost 90% of the U.S buy generic propecia online cheap.

Population fall short of that number, the guidelines say."I've been working more and more with chefs these days and one of the points that I've been trying to help people walk away with is that food really should bring them joy and pleasure," said Gardner, vice-chair of the American Heart Association's nutrition committee. Microgreens are "tasty with this sharp spice, that taste in the back of your mouth that you're not accustomed to."Microgreens – sometimes called "vegetable confetti" – are grown from the seeds of a wide array of plant families, with varieties including cauliflower, broccoli, cabbage, arugula, radicchio, carrot, celery, quinoa, spinach, melon, cucumber and squash. They can be eaten on their own, blended into a smoothie, added to a wrap or salad, or as a garnish on soups and other dishes.As the hair loss treatment propecia has changed people's attitudes about their food shopping habits, do-it-yourself microgreens buy generic propecia online cheap have offered a sustainable alternative.

Growing them at home also may be an antidote to high prices at the grocery store or farmers market. They can be grown year-round, indoors or outdoors, without requiring much time, equipment or expertise."Is there something about being in a New York apartment and being able to grow a little buy generic propecia online cheap backyard tray of microgreens and add it to your food?. " Gardner said.

"It might not be the meal, it might be just something that you add to what you're eating for the taste."So maybe the actual scale of it makes it more accessible to some buy generic propecia online cheap people to grow on their own – thereby getting them feeling like they're a little more in touch with the food that they're eating because they're producing it."American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is buy generic propecia online cheap owned or held by the American Heart Association, Inc., and all rights are reserved.

If you have questions or comments about this story, please email [email protected]By Will PryAmerican Heart Association NewsCopyright © 2020 HealthDay. All rights buy generic propecia online cheap reserved. SLIDESHOW Diet-Wrecking Foods.

Smoothies, Lattes, Popcorn, and More in Pictures See Slideshow.

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Each year, treatments propecia tablets cost prevent an estimated 2 to can you buy propecia over the counter usa 3 million deaths around the world. And as the hair loss treatment propecia rages on, experts say that the new treatment candidates from Pfizer and Moderna could be the ticket to ending the propecia and saving millions of lives.The bad news?. Not everyone is willing to get propecia tablets cost vaccinated. A recent Gallup poll showed that just 63 percent of Americans would be willing to receive a vaccination for hair loss treatment once one is approved by the FDA — meaning that hundreds of millions of Americans will still be vulnerable to the novel hair loss by not getting a treatment.Although treatment hesitancy is in the news now thanks to hair loss treatment, it's actually a phenomenon that has been around for years. In the past propecia tablets cost several decades especially, treatments have been subject to more scrutiny and less public trust, whether it's through parents who opt for “alternative” treatment schedules, or people who refuse them outright over safety and efficacy concerns.

Reasons for Mistrusttreatment acceptance involves multiple levels of trust, researchers say, both in the treatment itself and the provider who administers it. Historically, some providers have abused that trust, particularly in communities of color.“It makes complete sense that some people may not trust treatments,” explains Avnika Amin, an epidemiologist at Emory University. €œCommunities of color have a history of not propecia tablets cost being taken seriously, of being treated like second-class citizens by the medical establishment. And because of that, they might be fundamentally less open to hearing what doctors have to say.”One famous example of an ethical breach is the Tuskegee Syphilis Experiment, a study started in 1932 and carried out by the U.S. Public Health propecia tablets cost Service and the Tuskegee Institute.

In the study, 600 black men — 399 of whom had syphilis — were given blood draws and told they were being treated for ailments related to “bad blood,” a euphemistic term for syphilis and other ailments. In reality, the participants weren't treated for syphilis at all, and the true purpose of the research was to observe what happened to people with untreated syphilis over a period of time. The study was condemned by ethicists and halted in 1972, but it is still commonly cited as a reason why communities of color distrust medical interventions — including treatments.Another reason for public mistrust comes from a propecia tablets cost now-discredited study published by The Lancet in 1998. Led by Andrew Wakefield, then a gastroenterologist at the Royal Free Hospital in London, the paper raised a possibility of a link between the MMR (Measles, Mumps and Ruebella) treatment, enterocolitis (an inflammation of the digestive tract) and autism in twelve pediatric patients. Wakefield went on to give a press conference speaking out against the MMR propecia tablets cost treatment, which fueled the widespread myth that treatments can trigger autism and other developmental disorders.

Other researchers have not been able to replicate Wakefield's results (and his original study was retracted in 2010), but researchers say that his influence is still evident, as some parents delay treatments or refuse them altogether citing autism as a potential risk.A Difference in ValuesEvents like Tuskegee and the Wakefield study have done considerable damage, but they can't account for all the reasons a person might distrust treatments, Amin says. In her own research with treatment hesitancy, Amin has used a psychological framework called Moral Foundations Theory to better understand why people choose not to vaccinate. €œMoral Foundations Theory was originally developed to try and explain the different propecia tablets cost attitudes on political issues, such as climate change,” Amin explains. €œThe idea is that we have these six innate values, or moral foundations, that on a subconscious level shape the way we take in and accept information. The more important a propecia tablets cost foundation is to you, the more likely you are to take in information when that foundation is triggered.”An example Amin likes to use is toothpaste.

If a person highly prioritizes “authority and respect,” one of the five moral foundations, they will be more likely to try a toothpaste that's recommended to them by a dentist or a health expert, rather than appeals to how the toothpaste tastes or what chemicals are inside. A person who is deeply concerned with “sanctity or purity,” on the other hand — another moral foundation — is more likely to try a toothpaste that has perceived “wholesome” or organic ingredients, as opposed to who recommends it or how it tastes. Moral Foundations propecia tablets cost Theory can also explain why people choose to (or choose not to) vaccinate, she says. In her own research, Amin assessed the moral foundations of 1,200 parents through an online questionnaire, all of whom had at least one pre-adolescent child. They also asked the parents their thoughts on treatments and assessed each person with propecia tablets cost different degrees of hesitancy — low, medium, and high.

Amin's team found that the parents who were treatment hesitant were twice as likely to have a high purity foundation score — in other words, they emphasized purity, a moral foundation, as being important in their decision making. Parents who were highly hesitant to vaccinate their children were also the most likely to place emphasis on the foundation of personal liberty. How Doctors Can Respond to treatment HesitancyIn the midst of a global propecia, the idea that some people will refuse propecia tablets cost a safe and effective treatment has provoked ire among doctors, scientists and pro-treatment advocates. But rather than resorting to anger, Amin suggests that doctors and advocates try to appeal to people's moral foundations instead.“The minute you start dismissing people's concerns or putting a label on someone, that provokes an understandable reaction where they may not want to listen to someone they think is judging them,” she says. €œI'd say that propecia tablets cost there's a more general approach we can use, trying to figure out what matters to them.

How can we convey that getting vaccinated aligns with the things that matter to them?. € Research has shown that this approach can be effective. In a 2016 study published in the Journal of Experimental Social Psychology, researchers at Oregon State University presented propecia tablets cost pro-environmental messaging about climate change in three different ways, to liberals and conservatives alike. The study showed that the conservatives, who were initially less interested in environmental issues like conservation, had a radical shift after the material was presented to them as a matter of obeying authority, defending the purity of the U.S., and demonstrating one's patriotism.“Some people have made up their minds on treatments, and there's nothing you can do to change that,” Amin says. €œBut hesitancy propecia tablets cost is a spectrum.

Putting in the effort to really listen to people's concerns and respond to them in a way that affirms their moral values — it might be worth the extra effort.”While most fad diets restrict the range of foods their followers can eat, the raw food craze takes aim at their preparation — outlawing cooking. Adherents argue that heat kills nutrients and enzymes, stripping the very “life force” from foods. But experts say that more often than not, the opposite propecia tablets cost is true. Cooking unlocks the health benefits of many plants.Of course, raw vegetables are plenty good for you. Admittedly some, like potatoes, are seldom eaten that way, while others, like the widespread propecia tablets cost staple cassava, are highly toxic without careful preparation.

Nevertheless, the British Dietetic Association named the raw vegan diet one of five “celebrity diets to avoid” in 2018, noting that many foods are more nutritious after cooking. €œThe human body can digest and be nourished by propecia tablets cost both raw and cooked foods,” the association wrote, “so there’s no reason to believe raw is inherently better.”Read More. How Humans’ Unique Cooking Abilities Might Have Altered Our FateHumans have been cooking for about as long as they’ve been human. The process makes food more chewable and easier to digest, allowing extra time and energy for other distinctly human activities. (Many peg it as a key evolutionary factor behind our large brains, compared to other animals.) In vegetables, the heat often renders anticarcinogens and other disease-fighting compounds propecia tablets cost more readily accessible than they would be in raw form.Liberating AntioxidantsCooked tomatoes, for example, exude more lycopene, an antioxidant that gives red and pink fruits and vegetables their color.

€œIt’s bound to the cell wall, and during the cooking the high temperature releases it,” says Rui Hai Liu, a food scientist at Cornell University. The same is true for carrots and beta-carotene, the antioxidant responsible for yellow and orange propecia tablets cost pigment in fruits and vegetables. One study found that beta-carotene was 20 percent more accessible in cooked carrots, and even more so after cooking with olive oil.One 2007 study compared the effect of different cooking techniques on antioxidants in carrots, zucchini and broccoli. The researchers found that steaming and boiling, when compared to frying, best preserved the compounds (some dietitians even recommend drinking the water as well). All three propecia tablets cost cooking methods increased antioxidant levels compared with the raw veggies.

€œOur findings defy the notion that processed vegetables offer lower nutritional quality,” they wrote.Liu notes that the outcome of cooking varies from plant to plant. €œIt really depends which vegetable you’re talking about.” Raw broccoli, for example, retains more cancer-preventing isothiocyanates than cooked (though other studies show blanching and briefly steaming don’t harm the compounds much).In many cases, though, cooking only raises the bioavailability of nutrients, or the extent to which they can take propecia tablets cost effect within the body. A 2010 study compared three groups of women following, respectively, an average Western diet, a wholesome nutrition diet and a raw food diet. The researchers wanted to see if beta-carotene intake and absorption differed among them. Although the raw food dieters consumed about a third more of the compound than the women in the wholesome nutrition group, the latter absorbed about a third more.As nutritional medicine popularizer Michael Greger writes, “It’s not what you eat — it’s what you absorb.” You can gorge yourself on raw carrots all day, but if your body can’t make use of their phytochemicals efficiently, propecia tablets cost what’s the point?.

Variety of VeggiesAs for the charges against cooked food, many scientists think they’re overblown. It’s true that propecia tablets cost cooking takes its toll on a meal. Heat deactivates or reduces the activity of enzymes in food, and it can also destroy a significant percentage of vitamin C in vegetables. But Roger Clemens, a food scientist at the University of Southern California, says we don’t use those enzymes for digestion. Rather, “our bodies are propecia tablets cost wonderfully made,” and produce all the enzymes they need.

Vitamin C, meanwhile, is widely available, so a decrease in some meals isn’t necessarily a big deal so long as people get more elsewhere.Raw vegetables are undoubtedly healthy. But critics note that for many people, it’s difficult to sustain a diet composed solely of uncooked food propecia tablets cost. What’s more, it’s less appealing, and that means most people will abandon it sooner or later. On the other hand, if cooking makes nutritious food taste better, they’ll gobble it down. €œThe best way to get your greens,” Greger writes, “is in whichever way you’ll eat the most propecia tablets cost of them.”Liu agrees.

€œSome people like to eat stir fry, some people like to eat salad,” he says. €œI think it depends on your propecia tablets cost personal preference.” And in the end, he adds, too much nutritional nitpicking is probably counterproductive. All that time fixating on the healthiest way to prepare each individual plant could be better spent following a simpler approach. €œJust eat more vegetables,” he says — larger servings, more servings and, importantly, more variety. €œThe maximum nutrition comes from eating everything, not just raw and not just cooked.”You probably thought screens were a propecia tablets cost big part of life before.

Then, the propecia hit. The endless Zoom calls, video meetings and Netflix binges can leave some with tired or dry propecia tablets cost eyes. Blue-light-blocking glasses are marketed as a solution to that very problem — particularly now that we're immersed in screens more than ever. The product claims to minimize how much "blue light" wearers are exposed to. It's one propecia tablets cost part of the visible light spectrum emitting from digital screens, and it's the supposed culprit behind your ocular woes.

€œWhen they came out, there wasn’t much evidence whether they were actually effective or not,” says Mark Rosenfield, a vision researcher at the SUNY College of Optometry. €œNow I think there’s pretty propecia tablets cost strong evidence that they’re not effective.”The alleged relationship between blue light and tired eyes lacks a scientific explanation. Beyond that, many studies have found that blue-light-blocking glasses don’t actually alleviate the symptoms of too much screen time. But there are still other tried-and-true solutions out there.Understanding the TheoryCalled “digital eye strain,” there are a suite of symptoms some people experience when staring at screens — like headaches, tiredness, and blurred vision. These have been complaints since propecia tablets cost computers first appeared in the workplace.

Though annoying, the symptoms don’t appear to lead to any long-term consequences for your vision, Rosenfield says. Blue-light-glasses claim to alleviate those symptoms by, well, blocking your eyes from propecia tablets cost exposure to blue light. The range of wavelengths that make up blue light sit on the edge of the visible light spectrum, just after ultraviolet — or UV — rays. Blue light beams down on Earth as part of sunlight, and it shines propecia tablets cost up onto our faces when using phones and computers. LED lights, one of the main components of modern screens, emit relatively high levels of blue light compared to other kinds of bulbs.

Researchers have known for a long time that UV rays can damage our eyes and skin. And some propecia tablets cost studies suggest that blue light rays could interfere with healthy cell functions, too. But for now, it’s not clear where the line lies between wavelengths that damage skin and eye tissue and wavelengths that don’t, Rosenfield says. However, the amount of blue light propecia tablets cost coming out of our devices is tiny compared to what we deal with in nature. €œWe get about 1,000 times more blue light from the Sun than anything we get from a device,” Rosenfield says.

If there was blue light-induced harm to worry about, it wouldn’t revolve around our habits with our screens. However, blue-light-blocking propecia tablets cost glasses are sold on that premise — that somehow, the blue light from screens is triggering headaches or dry eyes. Since the products hit the market several years ago, many studies have tried to see if the glasses alleviate the symptoms people complain about when using digital devices. The research treats the glasses almost like they’re propecia tablets cost an experimental medication. People enrolled in the study are given either a pair of fake plastic glasses or a pair of blue-light-blocking lenses and aren’t told which one they have.

Later, they're questioned about their symptoms. Reliably, researchers propecia tablets cost have found that those with the blue-light-blocking glasses aren’t any less likely to complain of eye strain when the study is over.For Rosenfield and other scientists, these results make sense. There’s no biological explanation for why blue light would induce eye strain. The supposed connection comes from combining two unrelated details about propecia tablets cost our devices, Rosenfield says. (That they cause digital eye strain and emit blue light.) “You could say most phones are rectangular and phones cause eye strain, so therefore, it’s the rectangular shape of the screen that causes the eye strain,” he says.

That statement would work along the same faulty logic that blue-light-blocking eyeglasses do. Science-Based SolutionsOf course, propecia tablets cost the eye strain people experience is very real. Those issues likely stem from other digital device issues besides the colors that dominate the displays. For example, propecia tablets cost we tend to blink less often when looking at screens. In one study, people dropped from about 18 blinks per minute down to about three and a half when they switched to looking at a screen.

Some researchers think that trying to focus on an entire screenful of information, which people may or may not be viewing in the best conditions for legibility, could force us to blink less often as a way to improve focus. No matter the propecia tablets cost cause, one solution might be eyedrops, Rosenfield says. It’s also possible the eye strain and headaches occur because your glasses aren't appropriate for screen use. If you are in your 40s and use bifocals, that means your propecia tablets cost eyes have lost some flexibility and have a harder time reshaping to accommodate looking at items near and far. The extra lens in your glasses is meant to assist your eyes in reading close-up text, but is typically calibrated for print, Rosenfield says.

In other words, for a distance that's about 16 inches from your face. We read digital text as close as nine or 10 inches away propecia tablets cost. Getting another pair of glasses meant to work with your screen distance could help address that. And on that note propecia tablets cost. Most people get too close to laptops or phones, Rosenfield says.

Aim to keep them about two feet away.If your only issue after a long day in front of the computer is that you struggle to sleep at night, then blue light glasses might be what you’re looking for. Light exposure can tamp down melatonin — or “sleep hormone” — propecia tablets cost production in the brain. Blue light wavelengths in particular seem to have the most drastic dampening effects. The most straightforward remedy to this problem would be propecia tablets cost to put away screens at least two hours before bedtime, Rosenfield says. If that’s not an option, then pop on some blue-light-glasses in the evening or switch your devices to “night mode.” This setting lowers blue light in favor of less-disruptive red and orange hues.

Putting your device in a drawer a whole two hours before bed might sound propecia tablets cost rough, but who knows, it could have other benefits, too. Rosenfield keeps all phones out of the bedroom, which comes in handy when a student apologizes for sending an email at 2:00am. "You can send it any time you like," he says, "because I'm not looking at it."This article appeared in Discover’s annual state of science issue as “New Hope in Fighting Food Allergies.” Support our science journalism by becoming a subscriber.An estimated 32 million Americans have food allergies — nearly 10 percent of the population, and 10 times the prevalence reported just three decades ago. Among children, emergency room visits for the severe, potentially life-threatening reaction known as anaphylaxis propecia tablets cost are skyrocketing. But new hope arose in January, when the Food and Drug Administration approved Palforzia, the first drug designed to desensitize patients to an allergenic foodstuff — specifically, peanuts.The medication, approved for kids aged 4 to 17, consists of a standardized dose of powdered peanut protein, which can be mixed into snacks like pudding or applesauce.

Over time, patients receive increasing amounts until propecia tablets cost they can tolerate the equivalent of two peanuts without serious symptoms.Palforzia isn’t perfect. It’s expensive (list price. $890 a month), it must be taken indefinitely, boosts in dosage must be administered in a medical setting and some children react too strongly to continue the therapy. But clinical trials found it worked propecia tablets cost for about two-thirds of patients. Plus, it could provide a model for drugs aimed at allergies to other foods.(Credit.

Business Wire)Meanwhile, propecia tablets cost research that could lead to better food allergy treatments is making major strides. Over the past five years or so, scientists have found growing evidence that food allergies result from imbalances in the gut microbiome, probably tied to a mix of environmental, lifestyle, dietary and genetic influences. Repairing these underlying biochemical glitches could be more effective than desensitizing patients to individual allergens.In February, the non-profit End Allergies Together (EAT) announced the winners of the Grand Challenge to End Anaphylaxis, a new $1 million contest to fund promising approaches. The purse was split propecia tablets cost between two projects. The first, led by Boston Children’s Hospital immunologist Talal Chatila, is investigating a molecular target in the gut that could block allergic reactions before they start.

The second project — involving teams at Vedanta Biosciences and Massachusetts General Hospital — is testing a therapy meant to restore microbial balance in the food-allergic intestine.“For propecia tablets cost people who just want protection from a single allergen that may show up in their food, something like Palforzia is a big step forward,” says EAT president Elise Bates. Yet for patients such as her teenage daughter — who, like most fellow sufferers, has multiple food allergies — it’s not enough. €œWe’re trying to understand the basic mechanisms of these disorders, so that we can target therapies more precisely,” Bates adds. €œThat’s the only way we can stop living in fear.”The course of modern wound care changed one day in the late 1980s because a medical resident at the University of California, Irvine, named Ronald Sherman propecia tablets cost wore a butterfly-patterned tie. The chief resident of plastic surgery noticed it, recalls Sherman.

€œHe said, ‘Do you know anything about propecia tablets cost bugs?. €™ I said, ‘Yeah, I was an entomology major.’ He said, ‘Ever heard of maggot therapy?. €™â€The rest became creepy-crawly history that’s ended up saving countless lives and limbs. A resurgence of therapy using maggots and leeches, which are the propecia tablets cost only two live animals FDA-approved as medical devices.Ancient RemediesUsing maggots and leeches on the human body goes way back — the ancient Greek physician Galen referenced them more than two thousand years ago. Striped barber poles, in fact, are a callback to the good old medieval days when you could get some bloodletting done in the same trip to get a haircut.

The ball at the top of the pole is said to symbolize the bowl the leeches were kept in, and the one at the bottom is propecia tablets cost the basin that blood drained into. But the roles of these creatures in modern medicine is a little more refined and tailored to their biology.The maggots used in medicine are the larvae of shiny, bottle-green blowflies. They hatch from eggs laid on rotting meat, which they promptly tuck into, spitting digestive enzymes onto the meat to liquify it. Then they slurp it up like a rotten meat propecia tablets cost milkshake. They don’t eat healthy living tissue, which Sherman notes might be because healthy tissues have functional cell membranes that resist the digestive juices.

After about three days, once the maggots have quintupled in size to reach the length of a staple, they pupate (the fly version propecia tablets cost of making a cocoon) and then reemerge as adults.Since maggots voraciously guzzle down dead tissue, while not bothering the healthy stuff, they’re useful for cleaning infected wounds. €œThey will totally dissolve and eradicate that dead tissue, cleaning up the wound so that it can go on to heal,” says Sherman, now a physician and the director of the BioTherapeutics, Education and Research Foundation. The nonprofit provides resources for therapists and patients pursuing biotherapy with leeches and maggots. (Since the creatures are feeding on dead tissue that’s propecia tablets cost often already numb, it doesn’t hurt.)Leeches are water-dwelling worms with tri-part jaws arranged in a triangle, which latch onto prey to drink blood. To make the job easier, the creatures inject an anesthetic agent to numb the area and an anticoagulant to increase blood flow.

Leeches were once used for medical conditions like fevers, when that symptom was incorrectly attributed to excessive blood or an imbalance of the apocryphal four propecia tablets cost humors in a human. Based on updated medical research, their blood-draining skills are now used to clean up pooled blood in the body. When blood starts pooling instead of circulating, the area swells, and the lack of fresh, oxygenated blood causes skin tissues to die. Leeches can prevent that propecia tablets cost from happening.Despite their different uses, both animals’ medical fates are linked by their similarities. They are critters that clean up wounds by eating flesh and blood.

And their popularity in the medical field, often mirroring each other, has risen and fallen over the years.Maggots were booming in the early 20th-century, when William Baer, an orthopedic surgeon at a children’s hospital in Baltimore and Johns Hopkins University, used maggots to clean propecia tablets cost the wounds of children with s caused by tuberculosis. Baer got the idea from his time in World War I, when he saw soldiers with maggot-infested wounds fare better than their comrades with “clean” wounds. Maggot therapy rose in popularity for a few decades, but as antibiotics became available, there were fewer unhealable wounds that required maggots to remove propecia tablets cost dead tissue. In U.S. Hospitals, maggots and leeches succumbed to what Sherman calls “the yuck factor” — administrators deemed them unsanitary and just plain gross, so they were used less and less.Return of the MaggotsBy the time Sherman and his butterfly-patterned tie came onto the scene in the 1980s, maggots and leeches were largely seen by American doctors as a thing of the past.

But as medical interventions made once-deadly conditions survivable, and bacteria evolved propecia tablets cost new strains that resisted antibiotics, an influx of wounds wouldn’t respond to treatment. So, doctors like Ed Pechter, the chief plastic surgery resident at the University of California, Irvine, began looking to the past. Since Sherman’s tie marked him as an insect enthusiast, Pechter recruited him to help with a historical review of how maggots were once used to treat propecia tablets cost hopeless wounds. From then on, Sherman was hooked like a maggot’s mouth to decaying flesh.He continued pursuing the subject, but some of the hospital administrators he encountered were skeptical of his requests. They told him, “If you can find one patient who is willing to have maggots on, we’ll let you do it.

Here, talk to anybody you want to propecia tablets cost on this ward,” he says. So, he visited the spinal cord injury patients at a Veterans Association (VA) hospital.The first patient Sherman spoke to — after the patient detailed his injuries and failed treatments — said to Sherman. €œYou know, years ago, they used propecia tablets cost to use maggots to treat wounds. How come they don't do that anymore?. € Sherman recalls.

€œI said, ‘Whoa, that’s interesting you should ask.’” The man decided to give it a shot.The propecia tablets cost next patient he spoke to also quickly agreed to try maggot therapy. Their enthusiasm might seem surprising, but Sherman explains that the patients are coming from the context of trying to fix “a stinking, draining, activity-inhibiting, often limb-threatening wound.” In that context, some baby flies painlessly munching on your wound while hidden under a bandage might be less of a big deal.Sherman continued his studies, and word got around that he was the man with the maggots. In order to legally share maggots with his fellow physicians and therapists, he had to file maggots with the FDA.“It took them a year and a half to determine propecia tablets cost how they could possibly regulate maggots. Is it biological?. Is it a drug because they're secreting these enzymes?.

Is it a device because they're propecia tablets cost crawling around the wound?. € Sherman says. In 2003, the FDA approved maggots as a propecia tablets cost medical device. The FDA regulation of leeches followed six months later, in 2004.Modern Maggot EnthusiasmThe use of maggots and leeches as biotherapeutic devices, says Sherman, has worked like gangbusters. He notes that hospitals are still sometimes shy about publicity around the creatures, so it’s hard to get precise numbers.

But maggots propecia tablets cost and leeches have helped countless patients. (It’s worth noting, too, that they’ve remained popular in other parts of the world throughout the 20th-century.) Anecdotally, patients today seem as eager to try them as Sherman’s first test subjects back at the VA hospital.Podiatrist Ravi Kamble recalls a patient with a gangrenous foot, an untreatable that spread to the bone. It seemed like his only hope propecia tablets cost for survival was amputation. €œI still remember this guy, and he was in tears. He said, ‘Please, I will do anything, anything you want.

I just want to save this propecia tablets cost leg,’” recalls Kamble. He says he danced around the word maggot when telling the patient his treatment plan, but the man was a high school biology teacher and was a step ahead when Kamble obliquely referenced biotherapy. €œHe says, ‘Oh, you mean maggot therapy? propecia tablets cost. I’m totally down. Let’s do it.’”Aletha Tippett, an Ohio-based physician, works extensively with leeches and maggots.

€œI always present them as friends,” she says propecia tablets cost. €œThey're our friends and they're going to help us. I've had patients name their maggots, [they] begged [me] to help put them on and take them off.” And the fondness doesn’t end after treatment. Maggots and leeches are supposed to be disposed of after interacting with a patient’s blood, but Tippett says her patients have argued against that. €œâ€˜Well, they saved my leg, I can’t kill them.’” So, instead they let them go alive..

Each year, propecia tablets cost treatments prevent an estimated 2 to 3 million deaths around the buy generic propecia online cheap world. And as the hair loss treatment propecia rages on, experts say that the new treatment candidates from Pfizer and Moderna could be the ticket to ending the propecia and saving millions of lives.The bad news?. Not everyone buy generic propecia online cheap is willing to get vaccinated. A recent Gallup poll showed that just 63 percent of Americans would be willing to receive a vaccination for hair loss treatment once one is approved by the FDA — meaning that hundreds of millions of Americans will still be vulnerable to the novel hair loss by not getting a treatment.Although treatment hesitancy is in the news now thanks to hair loss treatment, it's actually a phenomenon that has been around for years. In the past several decades especially, treatments have been subject buy generic propecia online cheap to more scrutiny and less public trust, whether it's through parents who opt for “alternative” treatment schedules, or people who refuse them outright over safety and efficacy concerns.

Reasons for Mistrusttreatment acceptance involves multiple levels of trust, researchers say, both in the treatment itself and the provider who administers it. Historically, some providers have abused that trust, particularly in communities of color.“It makes complete sense that some people may not trust treatments,” explains Avnika Amin, an epidemiologist at Emory University. €œCommunities of color have a history buy generic propecia online cheap of not being taken seriously, of being treated like second-class citizens by the medical establishment. And because of that, they might be fundamentally less open to hearing what doctors have to say.”One famous example of an ethical breach is the Tuskegee Syphilis Experiment, a study started in 1932 and carried out by the U.S. Public Health Service and buy generic propecia online cheap the Tuskegee Institute.

In the study, 600 black men — 399 of whom had syphilis — were given blood draws and told they were being treated for ailments related to “bad blood,” a euphemistic term for syphilis and other ailments. In reality, the participants weren't treated for syphilis at all, and the true purpose of the research was to observe what happened to people with untreated syphilis over a period of time. The study was condemned by ethicists and halted in 1972, buy generic propecia online cheap but it is still commonly cited as a reason why communities of color distrust medical interventions — including treatments.Another reason for public mistrust comes from a now-discredited study published by The Lancet in 1998. Led by Andrew Wakefield, then a gastroenterologist at the Royal Free Hospital in London, the paper raised a possibility of a link between the MMR (Measles, Mumps and Ruebella) treatment, enterocolitis (an inflammation of the digestive tract) and autism in twelve pediatric patients. Wakefield went on to give a press conference buy generic propecia online cheap speaking out against the MMR treatment, which fueled the widespread myth that treatments can trigger autism and other developmental disorders.

Other researchers have not been able to replicate Wakefield's results (and his original study was retracted in 2010), but researchers say that his influence is still evident, as some parents delay treatments or refuse them altogether citing autism as a potential risk.A Difference in ValuesEvents like Tuskegee and the Wakefield study have done considerable damage, but they can't account for all the reasons a person might distrust treatments, Amin says. In her own research with treatment hesitancy, Amin has used a psychological framework called Moral Foundations Theory to better understand why people choose not to vaccinate. €œMoral Foundations Theory was originally developed to try and explain the different attitudes on political issues, such as buy generic propecia online cheap climate change,” Amin explains. €œThe idea is that we have these six innate values, or moral foundations, that on a subconscious level shape the way we take in and accept information. The more important a foundation is to you, the buy generic propecia online cheap more likely you are to take in information when that foundation is triggered.”An example Amin likes to use is toothpaste.

If a person highly prioritizes “authority and respect,” one of the five moral foundations, they will be more likely to try a toothpaste that's recommended to them by a dentist or a health expert, rather than appeals to how the toothpaste tastes or what chemicals are inside. A person who is deeply concerned with “sanctity or purity,” on the other hand — another moral foundation — is more likely to try a toothpaste that has perceived “wholesome” or organic ingredients, as opposed to who recommends it or how it tastes. Moral Foundations Theory can also explain why people choose to (or buy generic propecia online cheap choose not to) vaccinate, she says. In her own research, Amin assessed the moral foundations of 1,200 parents through an online questionnaire, all of whom had at least one pre-adolescent child. They also asked the parents their thoughts on treatments and buy generic propecia online cheap assessed each person with different degrees of hesitancy — low, medium, and high.

Amin's team found that the parents who were treatment hesitant were twice as likely to have a high purity foundation score — in other words, they emphasized purity, a moral foundation, as being important in their decision making. Parents who were highly hesitant to vaccinate their children were also the most likely to place emphasis on the foundation of personal liberty. How Doctors buy generic propecia online cheap Can Respond to treatment HesitancyIn the midst of a global propecia, the idea that some people will refuse a safe and effective treatment has provoked ire among doctors, scientists and pro-treatment advocates. But rather than resorting to anger, Amin suggests that doctors and advocates try to appeal to people's moral foundations instead.“The minute you start dismissing people's concerns or putting a label on someone, that provokes an understandable reaction where they may not want to listen to someone they think is judging them,” she says. €œI'd say that there's a more general approach we can use, trying to figure out what matters to them buy generic propecia online cheap.

How can we convey that getting vaccinated aligns with the things that matter to them?. € Research has shown that this approach can be effective. In a 2016 study published in the Journal of Experimental Social Psychology, researchers at Oregon State University presented pro-environmental messaging about climate change in three different ways, to liberals and buy generic propecia online cheap conservatives alike. The study showed that the conservatives, who were initially less interested in environmental issues like conservation, had a radical shift after the material was presented to them as a matter of obeying authority, defending the purity of the U.S., and demonstrating one's patriotism.“Some people have made up their minds on treatments, and there's nothing you can do to change that,” Amin says. €œBut hesitancy buy generic propecia online cheap is a spectrum.

Putting in the effort to really listen to people's concerns and respond to them in a way that affirms their moral values — it might be worth the extra effort.”While most fad diets restrict the range of foods their followers can eat, the raw food craze takes aim at their preparation — outlawing cooking. Adherents argue that heat kills nutrients and enzymes, stripping the very “life force” from foods. But experts say that more often than not, buy generic propecia online cheap the opposite is true. Cooking unlocks the health benefits of many plants.Of course, raw vegetables are plenty good for you. Admittedly some, like potatoes, are seldom eaten that way, while others, like the widespread staple cassava, are highly toxic buy generic propecia online cheap without careful preparation.

Nevertheless, the British Dietetic Association named the raw vegan diet one of five “celebrity diets to avoid” in 2018, noting that many foods are more nutritious after cooking. €œThe human body can digest and be nourished by both raw and cooked foods,” the association wrote, “so there’s no reason to believe raw is inherently buy generic propecia online cheap better.”Read More. How Humans’ Unique Cooking Abilities Might Have Altered Our FateHumans have been cooking for about as long as they’ve been human. The process makes food more chewable and easier to digest, allowing extra time and energy for other distinctly human activities. (Many peg it as a key evolutionary buy generic propecia online cheap factor behind our large brains, compared to other animals.) In vegetables, the heat often renders anticarcinogens and other disease-fighting compounds more readily accessible than they would be in raw form.Liberating AntioxidantsCooked tomatoes, for example, exude more lycopene, an antioxidant that gives red and pink fruits and vegetables their color.

€œIt’s bound to the cell wall, and during the cooking the high temperature releases it,” says Rui Hai Liu, a food scientist at Cornell University. The same is true for carrots buy generic propecia online cheap and beta-carotene, the antioxidant responsible for yellow and orange pigment in fruits and vegetables. One study found that beta-carotene was 20 percent more accessible in cooked carrots, and even more so after cooking with olive oil.One 2007 study compared the effect of different cooking techniques on antioxidants in carrots, zucchini and broccoli. The researchers found that steaming and boiling, when compared to frying, best preserved the compounds (some dietitians even recommend drinking the water as well). All three cooking buy generic propecia online cheap methods increased antioxidant levels compared with the raw veggies.

€œOur findings defy the notion that processed vegetables offer lower nutritional quality,” they wrote.Liu notes that the outcome of cooking varies from plant to plant. €œIt really depends which vegetable you’re talking about.” Raw broccoli, for example, retains more cancer-preventing isothiocyanates than cooked (though other studies show blanching and briefly steaming don’t harm the compounds much).In many cases, though, cooking only raises the bioavailability of nutrients, or the extent to which buy generic propecia online cheap they can take effect within the body. A 2010 study compared three groups of women following, respectively, an average Western diet, a wholesome nutrition diet and a raw food diet. The researchers wanted to see if beta-carotene intake and absorption differed among them. Although the raw food dieters consumed about a third more of the compound than the women in the wholesome nutrition group, the latter absorbed about a third more.As nutritional medicine popularizer Michael Greger writes, buy generic propecia online cheap “It’s not what you eat — it’s what you absorb.” You can gorge yourself on raw carrots all day, but if your body can’t make use of their phytochemicals efficiently, what’s the point?.

Variety of VeggiesAs for the charges against cooked food, many scientists think they’re overblown. It’s true that cooking takes buy generic propecia online cheap its toll on a meal. Heat deactivates or reduces the activity of enzymes in food, and it can also destroy a significant percentage of vitamin C in vegetables. But Roger Clemens, a food scientist at the University of Southern California, says we don’t use those enzymes for digestion. Rather, “our bodies are wonderfully made,” and produce buy generic propecia online cheap all the enzymes they need.

Vitamin C, meanwhile, is widely available, so a decrease in some meals isn’t necessarily a big deal so long as people get more elsewhere.Raw vegetables are undoubtedly healthy. But critics note that for buy generic propecia online cheap many people, it’s difficult to sustain a diet composed solely of uncooked food. What’s more, it’s less appealing, and that means most people will abandon it sooner or later. On the other hand, if cooking makes nutritious food taste better, they’ll gobble it down. €œThe best way to get your buy generic propecia online cheap greens,” Greger writes, “is in whichever way you’ll eat the most of them.”Liu agrees.

€œSome people like to eat stir fry, some people like to eat salad,” he says. €œI think it depends on your personal preference.” And buy generic propecia online cheap in the end, he adds, too much nutritional nitpicking is probably counterproductive. All that time fixating on the healthiest way to prepare each individual plant could be better spent following a simpler approach. €œJust eat more vegetables,” he says — larger servings, more servings and, importantly, more variety. €œThe maximum nutrition comes from eating everything, not just buy generic propecia online cheap raw and not just cooked.”You probably thought screens were a big part of life before.

Then, the propecia hit. The endless Zoom calls, video meetings and Netflix binges can buy generic propecia online cheap leave some with tired or dry eyes. Blue-light-blocking glasses are marketed as a solution to that very problem — particularly now that we're immersed in screens more than ever. The product claims to minimize how much "blue light" wearers are exposed to. It's one part of the visible light spectrum emitting from digital screens, and buy generic propecia online cheap it's the supposed culprit behind your ocular woes.

€œWhen they came out, there wasn’t much evidence whether they were actually effective or not,” says Mark Rosenfield, a vision researcher at the SUNY College of Optometry. €œNow I think there’s pretty strong evidence that they’re not effective.”The buy generic propecia online cheap alleged relationship between blue light and tired eyes lacks a scientific explanation. Beyond that, many studies have found that blue-light-blocking glasses don’t actually alleviate the symptoms of too much screen time. But there are still other tried-and-true solutions out there.Understanding the TheoryCalled “digital eye strain,” there are a suite of symptoms some people experience when staring at screens — like headaches, tiredness, and blurred vision. These have been buy generic propecia online cheap complaints since computers first appeared in the workplace.

Though annoying, the symptoms don’t appear to lead to any long-term consequences for your vision, Rosenfield says. Blue-light-glasses claim to alleviate those symptoms by, well, blocking buy generic propecia online cheap your eyes from exposure to blue light. The range of wavelengths that make up blue light sit on the edge of the visible light spectrum, just after ultraviolet — or UV — rays. Blue light buy generic propecia online cheap beams down on Earth as part of sunlight, and it shines up onto our faces when using phones and computers. LED lights, one of the main components of modern screens, emit relatively high levels of blue light compared to other kinds of bulbs.

Researchers have known for a long time that UV rays can damage our eyes and skin. And some buy generic propecia online cheap studies suggest that blue light rays could interfere with healthy cell functions, too. But for now, it’s not clear where the line lies between wavelengths that damage skin and eye tissue and wavelengths that don’t, Rosenfield says. However, the amount of blue light coming out of our devices is buy generic propecia online cheap tiny compared to what we deal with in nature. €œWe get about 1,000 times more blue light from the Sun than anything we get from a device,” Rosenfield says.

If there was blue light-induced harm to worry about, it wouldn’t revolve around our habits with our screens. However, blue-light-blocking glasses are sold on that premise — that somehow, the blue light buy generic propecia online cheap from screens is triggering headaches or dry eyes. Since the products hit the market several years ago, many studies have tried to see if the glasses alleviate the symptoms people complain about when using digital devices. The research treats the glasses almost like they’re an experimental buy generic propecia online cheap medication. People enrolled in the study are given either a pair of fake plastic glasses or a pair of blue-light-blocking lenses and aren’t told which one they have.

Later, they're questioned about their symptoms. Reliably, researchers have found that those with the blue-light-blocking glasses aren’t any less likely to buy generic propecia online cheap complain of eye strain when the study is over.For Rosenfield and other scientists, these results make sense. There’s no biological explanation for why blue light would induce eye strain. The supposed connection comes from combining two unrelated details about our devices, Rosenfield says buy generic propecia online cheap. (That they cause digital eye strain and emit blue light.) “You could say most phones are rectangular and phones cause eye strain, so therefore, it’s the rectangular shape of the screen that causes the eye strain,” he says.

That statement would work along the same faulty logic that blue-light-blocking eyeglasses do. Science-Based SolutionsOf course, the eye strain people experience buy generic propecia online cheap is very real. Those issues likely stem from other digital device issues besides the colors that dominate the displays. For example, we tend to blink less often buy generic propecia online cheap when looking at screens. In one study, people dropped from about 18 blinks per minute down to about three and a half when they switched to looking at a screen.

Some researchers think that trying to focus on an entire screenful of information, which people may or may not be viewing in the best conditions for legibility, could force us to blink less often as a way to improve focus. No matter the cause, one solution buy generic propecia online cheap might be eyedrops, Rosenfield says. It’s also possible the eye strain and headaches occur because your glasses aren't appropriate for screen use. If you are in your 40s and use bifocals, that means your eyes have lost some flexibility and have a buy generic propecia online cheap harder time reshaping to accommodate looking at items near and far. The extra lens in your glasses is meant to assist your eyes in reading close-up text, but is typically calibrated for print, Rosenfield says.

In other words, for a distance that's about 16 inches from your face. We read buy generic propecia online cheap digital text as close as nine or 10 inches away. Getting another pair of glasses meant to work with your screen distance could help address that. And on buy generic propecia online cheap that note. Most people get too close to laptops or phones, Rosenfield says.

Aim to keep them about two feet away.If your only issue after a long day in front of the computer is that you struggle to sleep at night, then blue light glasses might be what you’re looking for. Light exposure can tamp down melatonin — or “sleep buy generic propecia online cheap hormone” — production in the brain. Blue light wavelengths in particular seem to have the most drastic dampening effects. The most straightforward remedy buy generic propecia online cheap to this problem would be to put away screens at least two hours before bedtime, Rosenfield says. If that’s not an option, then pop on some blue-light-glasses in the evening or switch your devices to “night mode.” This setting lowers blue light in favor of less-disruptive red and orange hues.

Putting your device in a drawer a whole two hours before bed might sound rough, buy generic propecia online cheap but who knows, it could have other benefits, too. Rosenfield keeps all phones out of the bedroom, which comes in handy when a student apologizes for sending an email at 2:00am. "You can send it any time you like," he says, "because I'm not looking at it."This article appeared in Discover’s annual state of science issue as “New Hope in Fighting Food Allergies.” Support our science journalism by becoming a subscriber.An estimated 32 million Americans have food allergies — nearly 10 percent of the population, and 10 times the prevalence reported just three decades ago. Among children, emergency room visits for the severe, potentially life-threatening reaction known buy generic propecia online cheap as anaphylaxis are skyrocketing. But new hope arose in January, when the Food and Drug Administration approved Palforzia, the first drug designed to desensitize patients to an allergenic foodstuff — specifically, peanuts.The medication, approved for kids aged 4 to 17, consists of a standardized dose of powdered peanut protein, which can be mixed into snacks like pudding or applesauce.

Over time, buy generic propecia online cheap patients receive increasing amounts until they can tolerate the equivalent of two peanuts without serious symptoms.Palforzia isn’t perfect. It’s expensive (list price. $890 a month), it must be taken indefinitely, boosts in dosage must be administered in a medical setting and some children react too strongly to continue the therapy. But clinical buy generic propecia online cheap trials found it worked for about two-thirds of patients. Plus, it could provide a model for drugs aimed at allergies to other foods.(Credit.

Business Wire)Meanwhile, research that buy generic propecia online cheap could lead to better food allergy treatments is making major strides. Over the past five years or so, scientists have found growing evidence that food allergies result from imbalances in the gut microbiome, probably tied to a mix of environmental, lifestyle, dietary and genetic influences. Repairing these underlying biochemical glitches could be more effective than desensitizing patients to individual allergens.In February, the non-profit End Allergies Together (EAT) announced the winners of the Grand Challenge to End Anaphylaxis, a new $1 million contest to fund promising approaches. The purse was split between buy generic propecia online cheap two projects. The first, led by Boston Children’s Hospital immunologist Talal Chatila, is investigating a molecular target in the gut that could block allergic reactions before they start.

The second project — involving teams at Vedanta Biosciences and Massachusetts General Hospital — is testing a therapy meant to restore microbial buy generic propecia online cheap balance in the food-allergic intestine.“For people who just want protection from a single allergen that may show up in their food, something like Palforzia is a big step forward,” says EAT president Elise Bates. Yet for patients such as her teenage daughter — who, like most fellow sufferers, has multiple food allergies — it’s not enough. €œWe’re trying to understand the basic mechanisms of these disorders, so that we can target therapies more precisely,” Bates adds. €œThat’s the only way we can stop living in fear.”The course of modern wound care changed one day in the buy generic propecia online cheap late 1980s because a medical resident at the University of California, Irvine, named Ronald Sherman wore a butterfly-patterned tie. The chief resident of plastic surgery noticed it, recalls Sherman.

€œHe said, buy generic propecia online cheap ‘Do you know anything about bugs?. €™ I said, ‘Yeah, I was an entomology major.’ He said, ‘Ever heard of maggot therapy?. €™â€The rest became creepy-crawly history that’s ended up saving countless lives and limbs. A resurgence of therapy using maggots and leeches, which are the only two live animals FDA-approved as medical devices.Ancient RemediesUsing maggots and leeches on the human body goes way back — the buy generic propecia online cheap ancient Greek physician Galen referenced them more than two thousand years ago. Striped barber poles, in fact, are a callback to the good old medieval days when you could get some bloodletting done in the same trip to get a haircut.

The ball at buy generic propecia online cheap the top of the pole is said to symbolize the bowl the leeches were kept in, and the one at the bottom is the basin that blood drained into. But the roles of these creatures in modern medicine is a little more refined and tailored to their biology.The maggots used in medicine are the larvae of shiny, bottle-green blowflies. They hatch from eggs laid on rotting meat, which they promptly tuck into, spitting digestive enzymes onto the meat to liquify it. Then they slurp it up like a buy generic propecia online cheap rotten meat milkshake. They don’t eat healthy living tissue, which Sherman notes might be because healthy tissues have functional cell membranes that resist the digestive juices.

After about three days, once the maggots have quintupled buy generic propecia online cheap in size to reach the length of a staple, they pupate (the fly version of making a cocoon) and then reemerge as adults.Since maggots voraciously guzzle down dead tissue, while not bothering the healthy stuff, they’re useful for cleaning infected wounds. €œThey will totally dissolve and eradicate that dead tissue, cleaning up the wound so that it can go on to heal,” says Sherman, now a physician and the director of the BioTherapeutics, Education and Research Foundation. The nonprofit provides resources for therapists and patients pursuing biotherapy with leeches and maggots. (Since the creatures are feeding on dead tissue that’s buy generic propecia online cheap often already numb, it doesn’t hurt.)Leeches are water-dwelling worms with tri-part jaws arranged in a triangle, which latch onto prey to drink blood. To make the job easier, the creatures inject an anesthetic agent to numb the area and an anticoagulant to increase blood flow.

Leeches were once used for medical conditions like fevers, when that symptom was incorrectly attributed to excessive blood or buy generic propecia online cheap an imbalance of the apocryphal four humors in a human. Based on updated medical research, their blood-draining skills are now used to clean up pooled blood in the body. When blood starts pooling instead of circulating, the area swells, and the lack of fresh, oxygenated blood causes skin tissues to die. Leeches can prevent that from happening.Despite their different uses, both animals’ medical fates buy generic propecia online cheap are linked by their similarities. They are critters that clean up wounds by eating flesh and blood.

And their popularity in the medical field, often mirroring each other, has risen and fallen over the years.Maggots were booming buy generic propecia online cheap in the early 20th-century, when William Baer, an orthopedic surgeon at a children’s hospital in Baltimore and Johns Hopkins University, used maggots to clean the wounds of children with s caused by tuberculosis. Baer got the idea from his time in World War I, when he saw soldiers with maggot-infested wounds fare better than their comrades with “clean” wounds. Maggot therapy rose in popularity for a few decades, but as antibiotics became available, there were fewer unhealable wounds buy generic propecia online cheap that required maggots to remove dead tissue. In U.S. Hospitals, maggots and leeches succumbed to what Sherman calls “the yuck factor” — administrators deemed them unsanitary and just plain gross, so they were used less and less.Return of the MaggotsBy the time Sherman and his butterfly-patterned tie came onto the scene in the 1980s, maggots and leeches were largely seen by American doctors as a thing of the past.

But as medical interventions made once-deadly conditions buy generic propecia online cheap survivable, and bacteria evolved new strains that resisted antibiotics, an influx of wounds wouldn’t respond to treatment. So, doctors like Ed Pechter, the chief plastic surgery resident at the University of California, Irvine, began looking to the past. Since Sherman’s tie marked him as an insect enthusiast, Pechter recruited him to help with a historical review of how maggots were once used to treat hopeless wounds buy generic propecia online cheap. From then on, Sherman was hooked like a maggot’s mouth to decaying flesh.He continued pursuing the subject, but some of the hospital administrators he encountered were skeptical of his requests. They told him, “If you can find one patient who is willing to have maggots on, we’ll let you do it.

Here, talk to anybody you want to on buy generic propecia online cheap this ward,” he says. So, he visited the spinal cord injury patients at a Veterans Association (VA) hospital.The first patient Sherman spoke to — after the patient detailed his injuries and failed treatments — said to Sherman. €œYou know, years ago, they used to use maggots buy generic propecia online cheap to treat wounds. How come they don't do that anymore?. € Sherman recalls.

€œI said, ‘Whoa, that’s interesting you should ask.’” The man decided to give it a shot.The next patient he spoke to also quickly agreed to try buy generic propecia online cheap maggot therapy. Their enthusiasm might seem surprising, but Sherman explains that the patients are coming from the context of trying to fix “a stinking, draining, activity-inhibiting, often limb-threatening wound.” In that context, some baby flies painlessly munching on your wound while hidden under a bandage might be less of a big deal.Sherman continued his studies, and word got around that he was the man with the maggots. In order to legally share maggots with his fellow physicians buy generic propecia online cheap and therapists, he had to file maggots with the FDA.“It took them a year and a half to determine how they could possibly regulate maggots. Is it biological?. Is it a drug because they're secreting these enzymes?.

Is it a buy generic propecia online cheap device because they're crawling around the wound?. € Sherman says. In 2003, the FDA approved buy generic propecia online cheap maggots as a medical device. The FDA regulation of leeches followed six months later, in 2004.Modern Maggot EnthusiasmThe use of maggots and leeches as biotherapeutic devices, says Sherman, has worked like gangbusters. He notes that hospitals are still sometimes shy about publicity around the creatures, so it’s hard to get precise numbers.

But maggots and leeches have helped countless patients buy generic propecia online cheap. (It’s worth noting, too, that they’ve remained popular in other parts of the world throughout the 20th-century.) Anecdotally, patients today seem as eager to try them as Sherman’s first test subjects back at the VA hospital.Podiatrist Ravi Kamble recalls a patient with a gangrenous foot, an untreatable that spread to the bone. It seemed like his buy generic propecia online cheap only hope for survival was amputation. €œI still remember this guy, and he was in tears. He said, ‘Please, I will do anything, anything you want.

I just want to save this leg,’” buy generic propecia online cheap recalls Kamble. He says he danced around the word maggot when telling the patient his treatment plan, but the man was a high school biology teacher and was a step ahead when Kamble obliquely referenced biotherapy. €œHe says, ‘Oh, you buy generic propecia online cheap mean maggot therapy?. I’m totally down. Let’s do it.’”Aletha Tippett, an Ohio-based physician, works extensively with leeches and maggots.

€œI always present them as buy generic propecia online cheap friends,” she says. €œThey're our friends and they're going to help us. I've had patients name their maggots, [they] begged [me] to help put them on and take them off.” And the fondness doesn’t end after treatment. Maggots and leeches are supposed to be disposed of after interacting with a patient’s blood, but Tippett says her patients have argued against that. €œâ€˜Well, they saved my leg, I can’t kill them.’” So, instead they let them go alive..

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How to cite this article:Singh propecia cheapest price OP monthly cost of propecia. Mental health in diverse India. Need for propecia cheapest price advocacy. Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of.

We have diversity in terms of geography – From the propecia cheapest price Himalayas to the deserts to the seas. Every region has its own distinct culture and food. There are so many varieties of dress and language. There is propecia cheapest price huge difference between the states in terms of development, attitude toward women, health infrastructure, child mortality, and other sociodemographic development indexes.

There is now ample evidence that sociocultural factors influence mental health. Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the distribution of opportunity leading to social propecia cheapest price inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the propecia cheapest price field of mental health, we find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the more developed propecia cheapest price southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders. This may be due to lead toxicity, nutritional status, and perinatal issues.

Higher rates propecia cheapest price of depression and anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms. Marriage was found to be a propecia cheapest price negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders.

The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions. Apart from culture bound syndromes, the role of cultural idioms of distress in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, propecia cheapest price it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons propecia cheapest price and reducing stigma and discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, organizational level, and individual propecia cheapest price level. There has been huge work done in this regard at institution level.

Important research work done in this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory propecia cheapest price of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers. Similarly, at organizational level, the Indian Psychiatric Society (IPS) has filed a case propecia cheapest price for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality.

The IPS has also started helplines at different levels and media interactions. The Indian Journal of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia propecia cheapest price. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research propecia cheapest price highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social determinants of mental propecia cheapest price health. Focus 2015;13:419-25. 2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al.

National Mental Health Survey of India, propecia cheapest price 2015-16. Prevalence, Patterns and Outcomes. Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No.

129. 2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019. Accidental Deaths and Suicides in India.

2019. Available from. Https://ncrb.gov.in. [Last accessed on 2021 Jun 24].

5.Machado DB, Rasella D, dos Santos DN. Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI. 10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract 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.Keywords.

Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome. A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr.

President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020. I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS). Even though Dr.

Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr. Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K.

Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals. I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions. Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area.

Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome. A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology.

Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS. The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue. Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively.

Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument. However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management.

He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter. On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent. The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners.

A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder. Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders.

The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being. Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale. The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms.

Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%). The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness.

Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic. Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years. Every participant reported excessive loss of semen and was preoccupied with it.

The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss. Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine.

They were assessed for a period of 6 months. More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI). Men with DS reported greater symptoms on BSI than those without DS.

60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI. The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness.

This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire. Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%. It was found that 57.5% were suffering either from comorbid depression or anxiety disorders.

The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban). One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS.

The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%). In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice. The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice.

Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively. The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments.

About 66% of the patients met the DSM-IV diagnostic criteria of depression. They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia). Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India.

They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic. Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background.

Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age. There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed. Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache.

More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia. About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders).

Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse. 67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains. The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation.

Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas. In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class.

Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss. They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%). The subjects were single or unmarried (51.0%) and married (46.7%).

About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes. Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation.

The subjects were both married and single. Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%). Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively.

Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years. The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%).

Priyadarshi and Verma[43] performed a study in 110 male patients with DS. The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively. Two-third patients belonged to rural areas of residence.

Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata. The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset.

Only a few patients received higher education. Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management. A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks.

As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help. The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals.

Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone. Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs best place to buy propecia online.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual. Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same.

Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary. CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization.

Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity. The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future. It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression.

In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial. Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health.

It is also treatable, and hence, the detection, understanding, and awareness become vital to its management. This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time. In.

Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India. Training and Training Centres. 2nd ed.

753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome. Indian J Psychiatry 2007;49:208-10.

[PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting. Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S.

Dhāt syndrome. A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.

Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In. Kleinman A, Lin TY, editors.

Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland. D Reidel Publishing Co. 1980.

P. 357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.

A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N. Dhat syndrome.

A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9. 10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems.

Indian J Behav Sci 1995;5:58-63. 11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.

Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes. The story of Dhat syndrome.

Br J Psychiatry 2004;184:200-9. 13.Khan N. Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57.

[Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS. Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66. 16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S.

Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. Oman Med J 2017;32:251-5. 17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities.

PhD Thesis. Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017. 18.Kar SK.

Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45. [Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G.

Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10. 20.Shakya DR. Dhat syndrome.

Study of clinical presentations in a teaching institute of eastern Nepal. J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states.

Br J Psychiatry 1973;123:299-306. 22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders. An overview.

J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R. Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre.

J Clin Diagn Res 2015;9:C01-3. 24.Chadda RK. Dhat syndrome. Is it a distinct clinical entity?.

A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC. 'Dhat' syndrome – A useful clinical entity.

Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y. Semen-loss syndrome. A comparison between Sri Lanka and Japan.

American J Psychotherapy 1991;45:14-20. 27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.

Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P. Is Dhat syndrome indeed a culturally determined form of depression?. Indian J Psychol Med 2015;37:107-9.

29.Prakash O, Kar SK. Dhat syndrome. A review and update. J Psychosexual Health 2019;1:241-5.

30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al. Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.

31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4. 32.Paris A.

Dhat syndrome. A review. Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP.

Dhat syndrome. A review of the world literature. Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R.

Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8. 35.Kar SK, Sarkar S.

Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach. J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation.

The ICD-10, Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. Geneva. World Health Organisation.

1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome. A functional somatic syndrome of the Indian subcontinent?.

Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN. Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53.

39.Clyne MB. Indian patients. Practitioner 1964;193:195-9. 40.Yap PM.

The culture bound reactive syndrome. In. Caudil W, Lin T, editors. Mental Health Research in Asia and the Pacific.

Honolulu. East West Center Press. 1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al.

Problems in medical practice. A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.

Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A. Dhat syndrome and its social impact.

Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK. A study of male potency disorders. Indian J Psychiatry 1977;19:13-8.

[Full text] 45.Behere PB, Natraj GS. Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.

[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22. [PUBMED] [Full text] 47.Bhatia MS, Malik SC.

Dhat syndrome – A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5. 48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?.

J Ment Health Hum Behav1997;2:17-22. 49.Bhatia MS. An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52.

[PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases. Paper Presented in 11th Congress of the European Academy of Dermatology &.

51.Carstairs GM. Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.

52.Carstairs GM. The Twice Born. Bloomington. Indiana University Press.

1961. 53.Carstairs GM. Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972.

Br J Psychiatry 1973;123:271-7. 54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.

[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update. Indian J Psychiatry 2010;52:S260-3.

56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction. Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V.

Current nosology of Dhat syndrome and state of evidence. Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.

DSM-5. Washington. DC. American Psychological Association.

2013. 59.Yasir Arafat SM. Dhat syndrome. Culture bound, separate entity, or removed.

J Behav Health 2017;6:147-50. 60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.

Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis. Adv Psychosom Med 2013;33:15-30.

62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11. Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to cite http://sidecountrytheatre.org/production/murder-ballad/ this article:Singh OP buy generic propecia online cheap. Mental health in diverse India. Need for buy generic propecia online cheap advocacy.

Indian J Psychiatry 2021;63:315-6”Unity in diversity” - That is the theme of India which we are quite proud of. We have buy generic propecia online cheap diversity in terms of geography – From the Himalayas to the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude buy generic propecia online cheap toward women, health infrastructure, child mortality, and other sociodemographic development indexes. There is now ample evidence that sociocultural factors influence mental health.

Compton and Shim[1] have described in their model of gene environment interaction how public policies and social norms act on the buy generic propecia online cheap distribution of opportunity leading to social inequality, exclusion, poor environment, discrimination, and unemployment. This in turn leads to reduced options, poor choices, and high-risk behavior. Combining genetic vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we buy generic propecia online cheap find huge differences between different states of India.

The prevalence of psychiatric disorders was markedly different while it was 5.8 and 5.1 for Assam and Uttar Pradesh at the lower end of the spectrum, it was 13.9 and 14.1 for Madhya Pradesh and Maharashtra at the higher end of the spectrum. There was also a huge difference between the rural areas and metros, particularly in terms of psychosis and bipolar disorders.[2] The difference was distinct not only in the prevalence but also in the type of psychiatric disorders. While the buy generic propecia online cheap more developed southern states had higher prevalence of adult-onset disorders such as depression and anxiety, the less developed northern states had more of childhood onset disorders.

This may be due to lead toxicity, nutritional status, and perinatal issues. Higher rates of depression and buy generic propecia online cheap anxiety were found in females. Apart from the genetic and hormonal factors, increase was attributed to gender discrimination, violence, sexual abuse, and adverse sociocultural norms.

Marriage was found to be a negative prognostic indicator contrary to the buy generic propecia online cheap western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of cultural idioms of distress buy generic propecia online cheap in manifestations of psychiatric symptoms is well acknowledged.When we look into suicide data, suicide in lower socioeconomic strata (annual income <1 lakh) was 92,083, in annual income group of 1–5 lakhs, it was 41,197, and in higher income group, it was 4726. Among those who committed suicide, 67% were young adults, 34% had family problems, 23.4% of suicides occurred in daily laborers, 10.1% in unemployed persons, and 7.4% in farmers.[4]While there are huge regional differences in mental health issues, the challenges in mental health in India remain stigma reduction, conducting research on efficacy of early intervention, reaching the unreached, gender sensitive services, making quality mental healthcare accessible and available, suicide prevention, reduction of substance abuse, implementing insurance for mental health and reducing out-of-pocket expense, and finally, improving care for homeless mentally ill. All these require sustained advocacy aimed at promoting rights of mentally ill persons and reducing stigma and buy generic propecia online cheap discriminations.

It consists of various actions aimed at changing the attitudinal barriers in achieving positive mental health outcomes in the general population. Psychiatrists as Mental Health Advocates There is a debate whether psychiatrists who are overburdened with clinical care could or should be involved in the advocacy activities which require skills in other areas, and sometimes, they find themselves at the receiving end of mental health advocates. We must be involved and pathways should be to build technical evidence for mapping out the problem, cost-effective interventions, and their efficacy.Advocacy can be done at institutional level, buy generic propecia online cheap organizational level, and individual level.

There has been huge work done in this regard at institution level. Important research work done in buy generic propecia online cheap this regard includes the National Mental Health Survey, National Survey on Extent and Pattern of Substance Use in India, Global Burden of Diseases in Indian States, and Trajectory of Brain Development. Other activities include improving the infrastructure of mental hospitals, telepsychiatry services, provision of free drugs, providing training to increase the number of service providers.

Similarly, at organizational level, the Indian Psychiatric Society buy generic propecia online cheap (IPS) has filed a case for lacunae in Mental Health-care Act, 2017. Another case filed by the IPS lead to change of name of the film from “Mental Hai Kya” to “Judgemental Hai Kya.” In LGBT issue, the IPS statement was quoted in the final judgement on the decriminalization of homosexuality. The IPS has also started helplines at different levels and media interactions.

The Indian Journal buy generic propecia online cheap of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as migrant laborers and persons with dementia. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research highlighting the role of these factors on mental buy generic propecia online cheap health.

References 1.Compton MT, Shim RS. The social determinants buy generic propecia online cheap of mental health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental buy generic propecia online cheap Health Survey of India, 2015-16. Prevalence, Patterns and Outcomes.

Bengaluru. National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129.

2016. 3.Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India.

The Global Burden of Disease Study 1990–2017. Lancet Psychiatry 2020;7:148-61. 4.National Crime Records Bureau, 2019.

Accidental Deaths and Suicides in India. 2019. Available from.

Https://ncrb.gov.in. [Last accessed on 2021 Jun 24]. 5.Machado DB, Rasella D, dos Santos DN.

Impact of income inequality and other social determinants on suicide rate in Brazil. PLoS One 2015;10:e0124934. Correspondence Address:Om Prakash SinghDepartment of Psychiatry, WBMES, Kolkata, West Bengal.

AMRI Hospitals, Kolkata, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_635_21Abstract 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.Keywords. Culture-bound syndrome, Dhat syndrome, Dhat syndrome management, Dhat syndrome prevalence, psychiatric comorbidity, sexual disordersHow to cite this article:Sathyanarayana Rao T S. History and mystery of Dhat syndrome.

A critical look at the current understanding and future directions. Indian J Psychiatry 2021;63:317-25 Introduction Mr. President, Chairpersons, my respected teachers and seniors, my professional colleagues and friends, ladies and gentlemen:I deem it a proud privilege and pleasure to receive and to deliver DLN Murti Rao Oration Award for 2020.

I am humbled at this great honor and remain grateful to the Indian Psychiatric Society (IPS) in general and the awards committee in particular. I would like to begin my presentation with my homage to Professor DLN Murti Rao, who was a Doyen of Psychiatry.[1] I have a special connection to the name as Dr. Doddaballapura Laxmi Narasimha Murti Rao, apart from a family name, obtained his medical degree from Mysore Medical College, Mysuru, India, the same city where I have served last 33 years in JSS Medical College and JSS Academy of Higher Education and Research.

His name carries the reverence in the corridors of the current National Institute of Mental Health and Neuro Sciences (NIMHANS) at Bangalore which was All India Institute of Mental Health, when he served as Head and the Medical Superintendent. Another coincidence was his untimely demise in 1962, the same year another Doyen Dr. Wig[2],[3] published the article on a common but peculiar syndrome in the Indian context and gave the name Dhat syndrome (DS).

Even though Dr. Wig is no more, his legacy of profound contribution to psychiatry and psychiatric education in general and service to the society and Mental Health, in particular, is well documented. His keen observation and study culminated in synthesizing many aspects and developments in DS.I would also like to place on record my humble pranams to my teachers from Christian Medical College, Vellore – Dr.

Abraham Varghese, the first Editor of the Indian Journal of Psychological Medicine and Dr. K. Kuruvilla, Past Editor of Indian Journal of Psychiatry whose legacies I carried forward for both the journals.

I must place on record that my journey in the field of Sexual Medicine was sown by Dr. K. Kuruvilla and subsequent influence of Dr.

Ajit Avasthi from Postgraduate Institute of Medical Education and Research from Chandigarh as my role model in the field. There are many more who have shaped and nurtured my interest in the field of sex and sexuality.The term “Dhat” was taken from the Sanskrit language, which is an important word “Dhatu” and has known several meanings such as “metal,” a “medicinal constituent,” which can be considered as most powerful material within the human body.[4] The Dhat disorder is mainly known for “loss of semen”, and the DS is a well-known “culture-bound syndrome (CBS).”[4] The DS leads to several psychosexual disorders such as physical weakness, tiredness, anxiety, appetite loss, and guilt related to the loss of semen through nocturnal emission, in urine and by masturbation as mentioned in many studies.[4],[5],[6] Conventionally, Charaka Samhita mentions “waste of bodily humors” being linked to the “loss of Dhatus.”[5] Semen has even been mentioned by Aristotle as a “soul substance” and weakness associated with its loss.[6] This has led to a plethora of beliefs about “food-blood-semen” relationship where the loss of semen is considered to reduce vitality, potency, and psychophysiological strength. People have variously attributed DS to excessive masturbation, premarital sex, promiscuity, and nocturnal emissions.

Several past studies have emphasized that CBS leads to “anxiety for loss of semen” is not only prevalent in the Indian subcontinent but also a global phenomenon.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20]It is important to note that DS manifestation and the psychosexual features are based on the impact of culture, demographic profiles, and the socioeconomic status of the patients.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] According to Leff,[21] culture depends upon norms, values, and myths, based on a specific area, and is also shared by the indigenous individuals of that area. Tiwari et al.[22] mentioned in their study that “culture is closely associated with mental disorders through social and psychological activities.” With this background, the paper attempts to highlight the multidimensional construct of DS for a better clinical understanding in routine practice. Dhat Syndrome.

A Separate Entity or a “Cultural Variant” of Depression Even though DS has been studied for years now, a consensus on the definition is yet to be achieved. It has mostly been conceptualized as a multidimensional psychosomatic entity consisting of anxiety, depressive, somatic, and sexual phenomenology. Most importantly, abnormal and erroneous attributions are considered to be responsible for the genesis of DS.

The most important debate is, however, related to the nosological status of DS. Although considered to a CBS unique to India, it has also been increasingly reported in China, Europe, Japan, Malaysia, Russia, and America.[11] The consistency and validity of its diagnosis have been consistently debated, and one of the most vital questions that emerged was. Can there be another way to conceptualize DS?.

There is no single answer to that question. Apart from an independent entity, the diagnostic validity of which has been limited in longitudinal studies,[23] it has also been a cultural variant of depressive and somatization disorders. Mumford[11] in his study of Asian patients with DS found a significant association with depressed mood, anxiety, and fatigue.

Around the same time, another study by Chadha[24] reported comorbidities in DS at a rate of 50%, 32%, and 18% related to depression, somatoform disorders, and anxiety, respectively. Depression continued to be reported as the most common association of DS in many studies.[25],[26] This “cause-effect” dilemma can never be fully resolved. Whether “loss of semen” and the cultural attributions to it leads to the affective symptoms or whether low mood and neuroticism can lead to DS in appropriate cultural context are two sides of the argument.

However, the cognitive biases resulting in the attributional errors of DS and the subsequently maintained attitudes with relation to sexuality can be explained by the depressive cognitions and concepts of learned helplessness. Balhara[27] has argued that since DS is not really culture specific as thought of earlier, it should not be solely categorized as a functional somatic syndrome, as that can have detrimental effects on its understanding and management. He also mentions that the underlying “emotional distress and cultural contexts” are not unique to DS but can be related to any psychiatric syndrome for that matter.

On the contrary, other researchers have warned that subsuming DS and other CBS under the broader rubric of “mood disorders” can lead to neglect and reductionism in disorder like DS that can have unique cultural connotations.[28] Over the years, there have been multiple propositions to relook and relabel CBS like DS. Considering it as a variant of depression or somatization can make it a “cultural phenotype” of these disorders in certain regions, thus making it easier for the classificatory systems. This dichotomous debate seems never-ending, but clinically, it is always better to err on over-diagnosing and over-treating depression and anxiety in DS, which can improve the well-being of the distressed patients.

Why Discuss Dhat Syndrome. Implications in Clinical Practice DS might occur independently or associated with multiple comorbidities. It has been a widely recognized clinical condition in various parts of the world, though considered specific to the Indian subcontinent.

The presentation can often be polymorphic with symptom clusters of affective, somatic, behavioral, and cognitive manifestations.[29] Being common in rural areas, the first contacts of the patients are frequently traditional faith healers and less often, the general practitioners. A psychiatric referral occurs much later, if at all. This leads to underdetection and faulty treatments, which can strengthen the already existing misattributions and misinformation responsible for maintaining the disorder.

Furthermore, depression and sexual dysfunction can be the important comorbidities that if untreated, lead to significant psychosocial dysfunction and impaired quality of life.[30] Besides many patients of DS believe that their symptoms are due to failure of interpersonal relationships, s, and heredity, which might cause early death and infertility. This contributes to the vicious cycle of fear and panic.[31] Doctor shopping is another challenge and failure to detect and address the concern of DS might lead to dropping out from the care.[15] Rao[17] in their epidemiological study reported 12.5% prevalence in the general population, with 20.5% and 50% suffering from comorbid depression and sexual disorders. The authors stressed upon the importance of early detection of DS for the psychosexual and social well-being.

Most importantly, the multidimensional presentation of DS can at certain times be a facade overshadowing underlying neurotic disorders (anxiety, depression, somatoform, hypochondriasis, and phobias), obsessive-compulsive spectrum disorders and body dysmorphic disorders, delusional disorders, sexual disorders (premature ejaculation and erectile dysfunction) and infectious disorders (urinary tract s, sexually transmitted diseases), and even stress-related manifestations in otherwise healthy individuals.[4],[14],[15] This significant overlap of symptomatology, increased prevalence, and marked comorbidity make it all the more important for physicians to make sense out of the construct of DS. That can facilitate prompt detection and management of DS in routine clinical practice.In an earlier review study, it was observed that few studies are undertaken to update the research works from published articles as an updated review, systemic review, world literature review, etc., on DS and its management approach.[29],[32],[33],[34],[35] The present paper attempts to compile the evidence till date on DS related to its nosology, critique, manifestations, and management plan. The various empirical studies on DS all over the world will be briefly discussed along with the implications and importance of the syndrome.

The Construct of Dhat Syndrome. Summary of Current Evidence DS is a well-known CBS, which is defined as undue concern about the weakening effects after the passage of semen in urine or through nocturnal emission that has been stated by the International Statistical Classification of Diseases and Related Health Problems (ICD-10).[36] It is also known as “semen loss syndrome” by Shakya,[20] which is prevalent mainly in the Indian subcontinent[37] and has also been reported in the South-Eastern and western population.[15],[16],[20],[32],[38],[39],[40],[41] Individuals with “semen loss anxiety” suffer from a myriad of psychosexual symptoms, which have been attributed to “loss of vital essence through semen” (common in South Asia).[7],[15],[16],[17],[32],[37],[41],[42],[43] The various studies related to attributes of DS and their findings are summarized further.Prakash et al.[5] studied 100 DS patients through 139 symptoms of the Associated Symptoms Scale. They studied sociodemographic profile, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Mini-International Neuropsychiatric Interview, and Postgraduate Institute Neuroticism Scale.

The study found a wide range of physical, anxiety, depression, sexual, and cognitive symptoms. Most commonly associated symptoms were found as per score ≥1. This study reported several parameters such as the “sense of being unhealthy” (99%), worry (99%), feeling “no improvement despite treatment” (97%), tension (97%), tiredness (95%), fatigue (95%), weakness (95%), and anxiety (95%).

The common sexual disorders were observed as loss of masculinity (83%), erectile dysfunction (54%), and premature ejaculation (53%). Majority of patients had faced mild or moderate level of symptoms in which 47% of the patients reported severe weakness. Overall distress and dysfunction were observed as 64% and 81% in the studied subjects, respectively.A study in Taiwan involved 87 participants from a Urology clinic.

Most of them have sexual neurosis (Shen-K'uei syndrome).[7] More than one-third of the patients belonged to lower social class and symptoms of depression, somatization, anxiety, masturbation, and nocturnal emissions. Other bodily complaints as reported were sleep disturbances, fatigue, dizziness, backache, and weakness. Nearly 80% of them considered that all of their problems were due to masturbatory practices.De Silva and Dissanayake[8] investigated several manifestations on semen loss syndrome in the psychiatric clinic of Colombo General Hospital, Sri Lanka.

Beliefs regarding effects of semen loss and help-seeking sought for DS were explored. 38 patients were studied after psychiatrically ill individuals and those with organic disorders were excluded. Duration of semen loss varied from 1 to 20 years.

Every participant reported excessive loss of semen and was preoccupied with it. The common forms of semen loss were through nocturnal emission, masturbation, urinary loss, and through sexual activities. Most of them reported multiple modes of semen loss.

Masturbatory frequency and that of nocturnal emissions varied significantly. More than half of the patients reported all types of complaints (psychological, sexual, somatic, and genital).In the study by Chadda and Ahuja,[9] 52 psychiatric patients (mostly adolescents and young adults) complained of passing “Dhat” in urine. They were assessed for a period of 6 months.

More than 80% of them complained of body weakness, aches, and pains. More than 50% of the patients suffered from depression and anxiety. All the participants felt that their symptoms were due to loss of “dhat” in urine, attributed to excessive masturbation, extramarital and premarital sex.

Half of those who faced sexual dysfunctions attributed them to semen loss.Mumford[11] proposed a controversial explanation of DS arguing that it might be a part of other psychiatric disorders, like depression. A total of 1000 literate patients were recruited from a medical outdoor in a public sector hospital in Lahore, Pakistan. About 600 educated patients were included as per Bradford Somatic Inventory (BSI).

Men with DS reported greater symptoms on BSI than those without DS. 60 psychiatric patients were also recruited from the same hospital and diagnosed using Diagnostic and Statistical Manual (DSM)-III-R. Among them, 33% of the patients qualified for “Dhat” items on BSI.

The symptoms persisted for more than 15 days. It was observed that symptoms of DS highly correlated with BSI items, namely erectile dysfunction, burning sensation during urination, fatigue, energy loss, and weakness. This comparative study indicated that patients with DS suffered more from depressive disorders than without DS and the age group affected by DS was mostly the young.Grover et al.[15] conducted a study on 780 male patients aged >16 years in five centers (Chandigarh, Jaipur, Faridkot, Mewat, and New Delhi) of Northern India, 4 centers (2 from Kolkata, 1 each in Kalyani and Bhubaneswar) of Eastern India, 2 centers (Agra and Lucknow) of Central India, 2 centers (Ahmedabad and Wardha) of Western India, and 2 centers of Southern India (both located at Mysore) spread across the country by using DS questionnaire.

Nearly one-third of the patients were passing “Dhat” multiple times a week. Among them, nearly 60% passed almost a spoonful of “Dhat” each time during a loss. This work on sexual disorders reported that the passage of “Dhat” was mostly attributed to masturbation (55.1%), dreams on sex (47.3%), sexual desire (42.8%), and high energy foods consumption (36.7%).

Mostly, the participants experienced passage of Dhat as “night falls” (60.1%) and “while passing stools” (59.5%). About 75.6% showed weakness in sexual ability as a common consequence of the “loss of Dhat.” The associated symptoms were depression, hopelessness, feeling low, decreased energy levels, weakness, and lack of pleasure. Erectile problems and premature ejaculation were also present.Rao[17] in his first epidemiological study done in Karnataka, India, showed the prevalence rate of DS in general male population as 12.5%.

It was found that 57.5% were suffering either from comorbid depression or anxiety disorders. The prevalence of psychiatric and sexual disorders was about three times higher with DS compared to non-DS subjects. One-third of the cases (32.8%) had no comorbidity in hospital (urban).

One-fifth (20.5%) and 50% subjects (51.3%) had comorbid depressive disorders and sexual dysfunction. The psychosexual symptoms were found among 113 patients who had DS. The most common psychological symptoms reported by the subjects with DS were low self-esteem (100%), loss of interest in any activity (95.60%), feeling of guilt (92.00%), and decreased social interaction (90.30%).

In case of sexual disorders, beliefs were held commonly about testes becoming smaller (92.00%), thinness of semen (86.70%), decreased sexual capabilities (83.20%), and tilting of penis (70.80%).Shakya[20] studied a clinicodemographic profile of DS patients in psychiatry outpatient clinic of B. P. Koirala Institute of Health Sciences, Dharan, Nepal.

A total of 50 subjects were included in this study, and the psychiatric diagnoses as well as comorbidities were investigated as per the ICD-10 criteria. Among the subjects, most of the cases had symptoms of depression and anxiety, and all the subjects were worried about semen loss. Somehow these subjects had heard or read that semen loss or masturbation is unhealthy practice.

The view of participants was that semen is very “precious,” needs preservation, and masturbation is a malpractice. Beside DS, two-thirds of the subjects had comorbid depression.In another Indian study, Chadda et al.[24] compared patients with DS with those affected with neurotic/depressive disorders. Among 100 patients, 50%, 32%, and 18% reported depression, somatic problems, and anxiety, respectively.

The authors argued that cases of DS have similar symptom dimensions as mood and anxiety disorders.Dhikav et al.[31] examined prevalence and management depression comorbid with DS. DSM-IV and Hamilton Depression Rating Scale were used for assessments. About 66% of the patients met the DSM-IV diagnostic criteria of depression.

They concluded that depression was a frequent comorbidity in DS patients.In a study by Perme et al.[37] from South India that included 32 DS patients, the control group consisted of 33 people from the same clinic without DS, depression, and anxiety. The researchers followed the guidelines of Bhatia and Malik's for the assessment of primary complaints of semen loss through “nocturnal emissions, masturbation, sexual intercourse, and passing of semen before and after urine.” The assessment was done based on several indices, namely “Somatization Screening Index, Illness Behavior Questionnaire, Somatosensory Amplification Scale, Whitley Index, and Revised Chalder Fatigue Scale.” Several complaints such as somatic complaints, hypochondriacal beliefs, and fatigue were observed to be significantly higher among patients with DS compared to the control group.A study conducted in South Hall (an industrial area in the borough of Middlesex, London) included Indian and Pakistani immigrants. Young men living separately from their wives reported promiscuity, some being infected with gonorrhea and syphilis.

Like other studies, nocturnal emission, weakness, and impotency were the other reported complaints. Semen was considered to be responsible for strength and vigor by most patients. Compared to the sexual problems of Indians, the British residents complained of pelvic issues and backache.In another work, Bhatia et al.[42] undertook a study on culture-bound syndromes and reported that 76.7% of the sample had DS followed by possession syndrome and Koro (a genital-related anxiety among males in South-East Asia).

Priyadarshi and Verma[43] performed a study in Urology Department of S M S Hospital, Jaipur, India. They conducted the study among 110 male patients who complained of DS and majority of them were living alone (54.5%) or in nuclear family (30%) as compared to joint family. Furthermore, 60% of them reported of never having experienced sex.Nakra et al.[44] investigated incidence and clinical features of 150 consecutive patients who presented with potency complaints in their clinic.

Clinical assessments were done apart from detailed sexual history. The patients were 15–50 years of age, educated up to mid-school and mostly from a rural background. Most of them were married and reported premarital sexual practices, while nearly 67% of them practiced masturbation from early age.

There was significant guilt associated with nocturnal emissions and masturbation. Nearly 27% of the cases reported DS-like symptoms attributing their health problems to semen loss.Behere and Nataraj[45] reported that majority of the patients with DS presented with comorbidities of physical weakness, anxiety, headache, sad mood, loss of appetite, impotence, and premature ejaculation. The authors stated that DS in India is a symptom complex commonly found in younger age groups (16–23 years).

The study subjects presented with complaints of whitish discharge in urine and believed that the loss of semen through masturbation was the reason for DS and weakness.Singh et al.[46] studied 50 cases with DS and sexual problems (premature ejaculation and impotence) from Punjab, India, after exclusion of those who were psychiatrically ill. It was assumed in the study that semen loss is considered synonymous to “loss of something precious”, hence its loss would be associated with low mood and grief. Impotency (24%), premature ejaculation (14%), and “Dhat” in urine (40%) were the common complaints observed.

Patients reported variety of symptoms including anxiety, depression, appetite loss, sleep problems, bodily pains, and headache. More than half of the patients were independently diagnosed with depression, and hence, the authors argued that DS may be a manifestation of depressive disorders.Bhatia and Malik[47] reported that the most common complaints associated with DS were physical weakness, fatigue and palpitation, insomnia, sad mood, headache, guilt feeling and suicidal ideation, impotence, and premature ejaculation. Psychiatric disorders were found in 69% of the patients, out of which the most common was depression followed by anxiety, psychosis, and phobia.

About 15% of the patients were found to have premature ejaculation and 8% had impotence.Bhatia et al.[48] examined several biological variables of DS after enrolment of 40 patients in a psychosexual clinic in Delhi. Patients had a history of impotence, premature ejaculation, and loss of semen (after exclusion of substance abuse and other psychiatric disorders). Twenty years was the mean age of onset and semen loss was mainly through masturbation and sexual intercourse.

67.5% and 75% of them reported sexual disorders and psychiatric comorbidity while 25%, 12.5%, and 37.5% were recorded to suffer from ejaculatory impotence, premature ejaculation, and depression (with anxiety), respectively.Bhatia[49] conducted a study on CBS among 60 patients attending psychiatric outdoor in a teaching hospital. The study revealed that among all patients with CBSs, DS was the most common (76.7%) followed by possession syndrome (13.3%) and Koro (5%). Hypochondriasis, sexually transmitted diseases, and depression were the associated comorbidities.

Morrone et al.[50] studied 18 male patients with DS in the Dermatology department who were from Bangladesh and India. The symptoms observed were mainly fatigue and nonspecific somatic symptoms. DS patients manifested several symptoms in psychosocial, religious, somatic, and other domains.

The reasons provided by the patients for semen loss were urinary loss, nocturnal emission, and masturbation. Dhat Syndrome. The Epidemiology The typical demographic profile of a DS patient has been reported to be a less educated, young male from lower socioeconomic status and usually from rural areas.

In the earlier Indian studies by Carstairs,[51],[52],[53] it was observed that majority of the cases (52%–66.7%) were from rural areas, belonged to “conservative families and posed rigid views about sex” (69%-73%). De Silva and Dissanayake[8] in their study on semen loss syndrome reported the average age of onset of DS to be 25 years with most of them from lower-middle socioeconomic class. Chadda and Ahuja[9] studied young psychiatric patients who complained of semen loss.

They were mainly manual laborers, farmers, and clerks from low socioeconomic status. More than half were married and mostly uneducated. Khan[13] studied DS patients in Pakistan and reported that majority of the patients visited Hakims (50%) and Homeopaths (24%) for treatment.

The age range was wide between 12 and 65 years with an average age of 24 years. Among those studied, majority were unmarried (75%), literacy was up to matriculation and they belonged to lower socioeconomic class. Grover et al.[15] in their study of 780 male subjects showed the average age of onset to be 28.14 years and the age ranged between 21 and 30 years (55.3%).

The subjects were single or unmarried (51.0%) and married (46.7%). About 23.5% of the subjects had graduated and most were unemployed (73.5%). Majority of subjects were lower-middle class (34%) and had lower incomes.

Rao[17] studied 907 subjects, in which majority were from 18 to 30 years (44.5%). About 45.80% of the study subjects were illiterates and very few had completed postgraduation. The subjects were both married and single.

Majority of the subjects were residing in nuclear family (61.30%) and only 0.30% subjects were residing alone. Most of the patients did not have comorbid addictive disorders. The subjects were mainly engaged in agriculture (43.40%).

Majority of the subjects were from lower middle and upper lower socioeconomic class.Shakya[20] had studied the sociodemographic profile of 50 patients with DS. The average age of the studied patients was 25.4 years. The age ranges in decreasing order of frequency were 16–20 years (34%) followed by 21–25 years (28%), greater than 30 years (26%), 26–30 years (10%), and 11–15 years (2%).

Further, the subjects were mostly students (50%) and rest were in service (26%), farmers (14%), laborers (6%), and business (4%), respectively. Dhikav et al.[31] conducted a study on 30 patients who had attended the Psychiatry Outpatient Clinic of a tertiary care hospital with complaints of frequently passing semen in urine. In the studied patients, the age ranged between 20 and 40 years with an average age of 29 years and average age of onset of 19 years.

The average duration of illness was that of 11 months. Most of the studied patients were unmarried (64.2%) and educated till middle or high school (70%). Priyadarshi and Verma[43] performed a study in 110 male patients with DS.

The average age of the patients was 23.53 years and it ranged between 15 and 68 years. The most affected age group of patients was of 18–25 years, which comprised about 60% of patients. On the other hand, about 25% ranged between 25 and 35 years, 10% were lesser than 18 years of age, and 5.5% patients were aged >35 years.

Higher percentage of the patients were unmarried (70%). Interestingly, high prevalence of DS was found in educated patients and about 50% of patients were graduate or above but most of the patients were either unemployed or student (49.1%). About 55% and 24.5% patients showed monthly family income of <10,000 and 5000 Indian Rupees (INR), respectively.

Two-third patients belonged to rural areas of residence. Behere and Nataraj[45] found majority of the patients with DS (68%) to be between 16 and 25 years age. About 52% patients were married while 48% were unmarried and from lower socioeconomic strata.

The duration of DS symptoms varied widely. Singh[46] studied patients those who reported with DS, impotence, and premature ejaculation and reported the average age of the affected to be 21.8 years with a younger age of onset. Only a few patients received higher education.

Bhatia and Malik[47] as mentioned earlier reported that age at the time of onset of DS ranged from 16 to 24 years. More than half of them were single. It was observed that most patients had some territorial education (91.67%) but few (8.33%) had postgraduate education or professional training.

Finally, Bhatia et al.[48] studied cases of sexual dysfunctions and reported an average age of 21.6 years among the affected, majority being unmarried (80%). Most of those who had comorbid DS symptoms received minimal formal education. Management.

A Multimodal Approach As mentioned before, individuals affected with DS often seek initial treatment with traditional healers, practitioners of alternative medicine, and local quacks. As a consequence, varied treatment strategies have been popularized. Dietary supplements, protein and iron-rich diet, Vitamin B and C-complexes, antibiotics, multivitamin injections, herbal “supplements,” etc., have all been used in the treatment though scientific evidence related to them is sparse.[33] Frequent change of doctors, irregular compliance to treatment, and high dropout from health care are the major challenges, as the attributional beliefs toward DS persist in the majority even after repeated reassurance.[54] A multidisciplinary approach (involving psychiatrists, clinical psychologists, psychiatric social workers) is recommended and close liaison with the general physicians, the Ayurveda, Yoga, Unani, Siddha, Homeopathy practitioners, dermatologists, venereologists, and neurologists often help.

The role of faith healers and local counselors is vital, and it is important to integrate them into the care of DS patients, rather than side-tracking them from the system. Community awareness needs to be increased especially in primary health care for early detection and appropriate referrals. Follow-up data show two-thirds of patients affected with DS recovering with psychoeducation and low-dose sedatives.[45] Bhatia[49] studied 60 cases of DS and reported better response to anti-anxiety and antidepressant medications compared to psychotherapy alone.

Classically, the correction of attributional biases through empathy, reflective, and nonjudgmental approaches has been proposed.[38] Over the years, sex education, psychotherapy, psychoeducation, relaxation techniques, and medications have been advocated in the management of DS.[9],[55] In psychotherapy, cognitive behavioral and brief solution-focused approaches are useful to target the dysfunctional assumptions and beliefs in DS. The role of sex education is vital involving the basic understanding of sexual anatomy and physiology of sexuality. This needs to be tailored to the local terminology and beliefs.

Biofeedback has also been proposed as a treatment modality.[4] Individual stress factors that might have precipitated DS need to be addressed. A detailed outline of assessment, evaluation, and management of DS is beyond the scope of this article and has already been reported in the IPS Clinical Practice Guidelines.[56] The readers are referred to these important guidelines for a comprehensive read on management. Probably, the most important factor is to understand and resolve the sociocultural contexts in the genesis of DS in each individual.

Adequate debunking of the myths related to sexuality and culturally appropriate sexual education is vital both for the prevention and treatment of DS.[56] Adequate treatment of comorbidities such as depression and anxiety often helps in reduction of symptoms, more so when the DS is considered to be a manifestation of the same. Future of Dhat Syndrome. The Way Forward Classifications in psychiatry have always been fraught with debates and discussion such as categorical versus dimensional, biological versus evolutionary.

CBS like DS forms a major area of this nosological controversy. Longitudinal stability of a diagnosis is considered to be an important part of its independent categorization. Sameer et al.[23] followed up DS patients for 6.0 ± 3.5 years and concluded that the “pure” variety of DS is not a stable diagnostic entity.

The authors rather proposed DS as a variant of somatoform disorder, with cultural explanations. The right “place” for DS in classification systems has mostly been debated and theoretically fluctuant.[14] Sridhar et al.[57] mentioned the importance of reclassifying DS from a clinically, phenomenologically, psycho-pathologically, and diagnostically valid standpoint. Although both ICD and DSM have been culturally sensitive to classification, their approach to DS has been different.

While ICD-10 considers DS under “other nonpsychotic mental disorders” (F48), DSM-V mentions it only in appendix section as “cultural concepts of distress” not assigning the condition any particular number.[12],[58] Fundamental questions have actually been raised about its separate existence altogether,[35] which further puts its diagnostic position in doubt. As discussed in the earlier sections, an alternate hypothesization of DS is a cultural variant of depression, rather than a “true syndrome.”[27] Over decades, various schools of thought have considered DS either to be a global phenomenon or a cultural “idiom” of distress in specific geographical regions or a manifestation of other primary psychiatric disorders.[59] Qualitative studies in doctors have led to marked discordance in their opinion about the validity and classificatory area of DS.[60] The upcoming ICD-11 targets to pay more importance to cultural contexts for a valid and reliable classification. However, separating the phenomenological boundaries of diseases might lead to subsetting the cultural and contextual variants in broader rubrics.[61],[62] In that way, ICD-11 might propose alternate models for distinction of CBS like DS at nosological levels.[62] It is evident that various factors include socioeconomics, acceptability, and sustainability influence global classificatory systems, and this might influence the “niche” of DS in the near future.

It will be interesting to see whether it retains its diagnostic independence or gets subsumed under the broader “narrative” of depression. In any case, uniformity of diagnosing this culturally relevant yet distressing and highly prevalent condition will remain a major area related to psychiatric research and treatment. Conclusion DS is a multidimensional psychiatric “construct” which is equally interesting and controversial.

Historically relevant and symptomatically mysterious, this disorder provides unique insights into cultural contexts of human behavior and the role of misattributions, beliefs, and misinformation in sexuality. Beyond the traditional debate about its “separate” existence, the high prevalence of DS, associated comorbidities, and resultant dysfunction make it relevant for emotional and psychosexual health. It is also treatable, and hence, the detection, understanding, and awareness become vital to its management.

This oration attempts a “bird's eye” view of this CBS taking into account a holistic perspective of the available evidence so far. The clinical manifestations, diagnostic and epidemiological attributes, management, and nosological controversies are highlighted to provide a comprehensive account of DS and its relevance to mental health. More systematic and mixed methods research are warranted to unravel the enigma of this controversial yet distressing psychiatric disorder.AcknowledgmentI sincerely thank Dr.

Debanjan Banerjee (Senior Resident, Department of Psychiatry, NIMHANS, Bangalore) for his constant selfless support, rich academic discourse, and continued collaboration that helped me condense years of research and ideas into this paper.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.2.3.Srinivasa Murthy R, Wig NN. A man ahead of his time.

In. Sathyanarayana Rao TS, Tandon A, editors. Psychiatry in India.

Training and Training Centres. 2nd ed. Mysuru, India.

753-76. 4.Prakash O. Lessons for postgraduate trainees about Dhat syndrome.

Indian J Psychiatry 2007;49:208-10. [PUBMED] [Full text] 5.Prakash S, Sharan P, Sood M. A study on phenomenology of Dhat syndrome in men in a general medical setting.

Indian J Psychiatry 2016;58:129-41. [PUBMED] [Full text] 6.Jadhav S. Dhāt syndrome.

A re-evaluation. Psychiatry 2004;3:14-16. 7.Wen JK, Wang CL.

Shen-Kui syndrome. A culture-specific sexual neurosis in Taiwan. In.

Kleinman A, Lin TY, editors. Normal and Abnormal Behaviour in Chinese Culture. Dordrecht, Holland.

357-69. 8.De Silva P, Dissanayake SA. The use of semen syndrome in Sri Lanka.

A clinical study. Sex Marital Ther 1989;4:195-204. 9.Chadda RK, Ahuja N.

Dhat syndrome. A sex neurosis of the Indian subcontinent. Br J Psychiatry 1990;156:577-9.

10.Rao TS, Rao VS, Rajendra PN, Mohammed A. A retrospective comparative study of teaching hospital and private clinic clients with sexual problems. Indian J Behav Sci 1995;5:58-63.

11.Mumford DB. The 'Dhat syndrome'. A culturally determined symptom of depression?.

Acta Psychiatr Scand 1996;94:163-7. 12.Sumathipala A, Siribaddana SH, Bhugra D. Culture-bound syndromes.

The story of Dhat syndrome. Br J Psychiatry 2004;184:200-9. 13.Khan N.

Dhat syndrome in relation to demographic characteristics. Indian J Psychiatry 2005;47:54-57. [Full text] 14.Prakash O, Kar SK, Sathyanarayana Rao TS.

Indian story on semen loss and related Dhat syndrome. Indian J Psychiatry 2014;56:377-82. [PUBMED] [Full text] 15.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Phenomenology and beliefs of patients with Dhat syndrome. A nationwide multicentric study. Int J Soc Psychiatry 2016;62:57-66.

16.MacFarland AS, Al-Maashani M, Al Busaidi Q, Al-Naamani A, El-Bouri M, Al-Adawi S. Culture-specific pathogenicity of Dhat (semen loss) Syndrome in an Arab/Islamic Society, Oman. Oman Med J 2017;32:251-5.

17.Rao TS. Comprehensive Study of Prevalence Rates, Symptom Profile, Comorbidity and Management of Dhat Syndrome in Rural and Urban Communities. PhD Thesis.

Department of Psychiatry, Jagadguru Sri Shivarathreeshwara Medical College, JSS University, Shivarathreeshwara Nagar Mysore, Karnataka, India. 2017. 18.Kar SK.

Treatment - emergent Dhat syndrome in a young male with obsessive-compulsive disorder. An alarm for medication nonadherence. Acta Med Int 2019;6:44-45.

[Full text] 19.Kuchhal AK, Kumar S, Pardal PK, Aggarwal G. Effect of Dhat syndrome on body and mind. Int J Contemp Med Res 2019;6:H7-10.

20.Shakya DR. Dhat syndrome. Study of clinical presentations in a teaching institute of eastern Nepal.

J Psychosexual Health 2019;1:143-8. 21.Leff JP. Culture and the differentiation of emotional states.

Br J Psychiatry 1973;123:299-306. 22.Tiwari SC, Katiyar M, Sethi BB. Culture and mental disorders.

An overview. J Soc Psychiatry 1986;2:403-25. 23.Sameer M, Menon V, Chandrasekaran R.

Is 'Pure' Dhat syndrome a stable diagnostic entity?. A naturalistic long term follow up study from a tertiary care centre. J Clin Diagn Res 2015;9:C01-3.

24.Chadda RK. Dhat syndrome. Is it a distinct clinical entity?.

A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. 25.Bhatia MS, Bohra N, Malik SC.

'Dhat' syndrome – A useful clinical entity. Indian J Dermatol 1989;34:32-41. 26.Dewaraja R, Sasaki Y.

Semen-loss syndrome. A comparison between Sri Lanka and Japan. American J Psychotherapy 1991;45:14-20.

27.Balhara YP. Culture-bound syndrome. Has it found its right niche?.

Indian J Psychol Med 2011;33:210-5. [PUBMED] [Full text] 28.Prakash, S, Mandal P. Is Dhat syndrome indeed a culturally determined form of depression?.

Indian J Psychol Med 2015;37:107-9. 29.Prakash O, Kar SK. Dhat syndrome.

A review and update. J Psychosexual Health 2019;1:241-5. 30.Grover S, Avasthi A, Gupta S, Dan A, Neogi R, Behere PB, et al.

Comorbidity in patients with Dhat syndrome. A nationwide multicentric study. J Sex Med 2015;12:1398-401.

31.Dhikav V, Aggarwal N, Gupta S, Jadhavi R, Singh K. Depression in Dhat syndrome. J Sex Med 2008;5:841-4.

Transcult Psychiatry Rev 1992;29:109-18. 33.Deb KS, Balhara YP. Dhat syndrome.

A review of the world literature. Indian J Psychol Med 2013;35:326-31. [PUBMED] [Full text] 34.Udina M, Foulon H, Valdés M, Bhattacharyya S, Martín-Santos R.

Dhat syndrome. A systematic review. Psychosomatics 2013;54:212-8.

35.Kar SK, Sarkar S. Dhat syndrome. Evolution of concept, current understanding, and need of an integrated approach.

J Hum Reprod Sci 2015;8:130-4. [PUBMED] [Full text] 36.World Health Organisation. The ICD-10, Classification of Mental and Behavioural Disorders.

Diagnostic Criteria for Research. Geneva. World Health Organisation.

1992. 37.Perme B, Ranjith G, Mohan R, Chandrasekaran R. Dhat (semen loss) syndrome.

A functional somatic syndrome of the Indian subcontinent?. Gen Hosp Psychiatry 2005;27:215-7. 38.Wig NN.

Problem of mental health in India. J Clin Soc Psychiatry 1960;17:48-53. 39.Clyne MB.

Indian patients. Practitioner 1964;193:195-9. 40.Yap PM.

The culture bound reactive syndrome. In. Caudil W, Lin T, editors.

Mental Health Research in Asia and the Pacific. Honolulu. East West Center Press.

1969. 41.Rao TS, Rao VS, Arif M, Rajendra PN, Murthy KA, Gangadhar TK, et al. Problems in medical practice.

A study on its prevalence in an outpatient setting. Indian J Psychiatry 1997:Suppl 39:53. 42.Bhatia MS, Thakkur KN, Chadda RK, Shome S.

Koro in Dhat syndrome. Indian J Soc Psychiatry 1992;8:74-5. 43.Priyadarshi S, Verma A.

Dhat syndrome and its social impact. Urol Androl Open J 2015;1:6-11. 44.Nakra BR, Wig NN, Verma VK.

A study of male potency disorders. Indian J Psychiatry 1977;19:13-8. [Full text] 45.Behere PB, Natraj GS.

Dhat syndrome. The phenomenology of a culture bound sex neurosis of the orient. Indian J Psychiatry 1984;26:76-8.

[PUBMED] [Full text] 46.Singh G. Dhat syndrome revisited. Indian J Psychiatry 1985;27:119-22.

[PUBMED] [Full text] 47.Bhatia MS, Malik SC. Dhat syndrome – A useful diagnostic entity in Indian culture. Br J Psychiatry 1991;159:691-5.

48.Bhatia MS, Choudhry S, Shome S. Dhat syndrome - Is it a syndrome of Dhat only?. J Ment Health Hum Behav1997;2:17-22.

49.Bhatia MS. An analysis of 60 cases of culture bound syndromes. Indian J Med Sci 1999;53:149-52.

[PUBMED] [Full text] 50.Morrone A, Nosotti L, Tumiati Mc, Cianconi P, Casadei F, Franco G. Dhat Syndrome. An Analysis of 18 Cases.

Paper Presented in 11th Congress of the European Academy of Dermatology &. Venerology. Prague.

Hinjra and jiryan. Two derivatives of Hindu attitudes to sexuality. Br J Med Psychol 1956;29:128-38.

52.Carstairs GM. The Twice Born. Bloomington.

Indiana University Press. 1961. 53.Carstairs GM.

Psychiatric problems of developing countries. Based on the Morison lecture delivered at the Royal College of Physicians of Edinburgh, on 25 May 1972. Br J Psychiatry 1973;123:271-7.

54.Sathyanarayana Rao TS. Some thoughts on sexualities and research in India. Indian J Psychiatry 2004;46:3-4.

[PUBMED] [Full text] 55.Prakash O, Rao TS. Sexuality research in India. An update.

Indian J Psychiatry 2010;52:S260-3. 56.Avasthi A, Grover S, Rao TS. Clinical practice guidelines for management of sexual dysfunction.

Indian J Psychiatry 2017;59 Suppl 1:S91-115. 57.Kavanoor Sridhar V, Subramanian K, Menon V. Current nosology of Dhat syndrome and state of evidence.

Indian J Health Sex Cult 2018;4:8-14. 58.APA (American Psychological Association). Diagnostic and Statistical Manual of Mental Disorders.

American Psychological Association. 2013. 59.Yasir Arafat SM.

Dhat syndrome. Culture bound, separate entity, or removed. J Behav Health 2017;6:147-50.

60.Prakash S, Sharan P, Sood M. A qualitative study on psychopathology of dhat syndrome in men. Implications for classification of disorders.

Asian J Psychiatr 2018;35:79-88. 61.Lewis-Fernández R, Aggarwal NK. Culture and psychiatric diagnosis.

Adv Psychosom Med 2013;33:15-30. 62.Sharan P, Keeley J. Cultural perspectives related to international classification of diseases-11.

Indian J Soc Psychiatry 2018;34 Suppl S1:1-4. Correspondence Address:T S Sathyanarayana RaoDepartment of Psychiatry, JSS Medical College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka IndiaSource of Support. None, Conflict of Interest.

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

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