Dhat Syndrome by Proxy: An Underreported Entity

Prim Care Companion CNS Disord 2022;24(2):21cr02993

To cite: Hafi B, Uvais NA, Varughese A, et al. Dhat syndrome by proxy: an underreported entity. Prim Care Companion CNS Disord. 2022;24(2):21cr02993.
To share: https://doi.org/10.4088/PCC.21cr02993

© Copyright 2022 Physicians Postgraduate Press, Inc.

^aIQRAA Center for Sexual Medicine, Kozhikkode, Calicut, India
^bInstitute of Sexual and Reproductive Medicine, Kozhikkode, Kerala, India
^cKozhikkode Medical College, Kozhikkode, Kerala, India
*Corresponding author: Bishurul Hafi, MD, IQRAA Center for Sexual Medicine, Kozhikkode, Calicut, India (bishuru@gmail.com).

Dhat syndrome is a culture-bound syndrome more commonly reported among young males from low to medium socioeconomic backgrounds.¹ It is a “semen loss”–related psychological distress seen mainly in the Indian subcontinent. Semen was glorified in the past as a most perfected component of food by Aristotle and as the equivalent to 40 oz of blood by Andrew Tissot.² In Indian mythology, it was also regarded as a most powerful and perfect bodily substance that guarantees health and longevity.³ This exalted ideation about the importance of semen has led to undue mental pressure in preserving it, resulting in many psychological comorbidities. Although Dhat syndrome is a well-established entity, not ignoring the debate on the nosology, the literature is scarce regarding the types and extent of the disease. Here, we report a common yet underreported entity of Dhat syndrome.

CASE REPORT

A 13-year-old boy was brought to the clinic by his father, a conservative Muslim, with the complaint that the boy was masturbating frequently. The father alleged that semen was observed on his night pajamas, which was regarded as proof of the mischief. He was furious with the son not only because he was violating the religious ethos but also because, according to him, the boy was not gaining weight, his eyes were sunken, and his hair was losing its luster due to frequent masturbation. He was also worried about his son’s future sexual ability, fertility, and general health. He hoped that the clinician would urge his son to refrain from masturbation reinforced with scientific facts. On detailed sexual history, the boy firmly denied the habit and attributed it to involuntary nocturnal emission. When that was explained to the father, he was again very much concerned about the amount of blood and good body elements the boy was losing through these emissions. He wanted to start the boy on some medication to decrease his desire and stop nocturnal emission. We diagnosed the condition as Dhat syndrome by proxy. The father was educated about male sexuality and scientific facts about semen and ejaculation. His anxiety level decreased after a detailed discussion with some religious insights.

DISCUSSION

Masturbation is still a culturally unacceptable behavior in many cultures. Parental anxiety about their child’s masturbation habits is nearly universal to varying extent.⁴ Religious beliefs of the caregiver and culture of the society play important roles in invoking such stress. Dhat syndrome is a poorly defined condition characterized by vague symptoms like fatigue, weakness, anxiety, loss of appetite, and guilt attributed to semen loss through nocturnal emissions, urine, and masturbation. In this syndrome, hypochondria, anxiety, and depressive symptoms become subsumed in the major visible “pathology” of semen loss.⁵ Diagnosis of the syndrome is limited by the absence of a clear definition. A wide range of presenting symptoms adds to the confusion in diagnosing it properly and in prevalence studies.

The case reported here is unique since the symptoms of Dhat syndrome were alleged by the boy’s caregiver. Although Dhat syndrome by proxy may be a common occurrence in conservative societies, it is rarely discussed in academia and, to the best of our knowledge, no case reports have been published. Strict parenting and immensely restricting sexual activities may have ill effects on a child’s sexual development. Incorrect information and popular myths advocated by influential figures, due to religious or political reasons, act as a catalyst to this attitude. We report this case of Dhat syndrome by proxy to highlight this issue so that clinicians understand that knowledge of the cultural and religious ideas about sexual activities is essential in diagnosing the condition as well as in providing adequate psychoeducation.

Published online: April 21, 2022.
Relevant financial relationships: None.
Funding/support: None.
Patient consent: Consent was received from the patient’s guardian to publish the case report, and information has been de-identified to protect anonymity.