Dhat is an illness most commonly found in the Indian culture. Its symptoms include hypochondria, weakness and fatigue, and anxiety due to the fear of loss of semen. This fear comes about when the patient notices white or clear fluid in their urine. Dhat is similar to sukra prameha in Sri Lanka and shen-k'-uei in China. ^[1] The first instance of Dhat was described in 1960. ^[2]

Dhat is a culture-bound sex neurosis. Dhat patients hold the belief that semen is being lost through "nocturnal emissions" and that semen becomes mixed with their urine and expelled from the body. Some maintain that semen loss is harmful. This belief is more frequent in lower socioeconomic classes. The symptoms of dhat usually subside if the misconceptions about semen loss are confronted. Many believe that the occurences of dhat syndrome will begin to subside due to the increases in sexual education.^[3] A study of 93 dhat patients was conducted to learn their symptoms. Of those studied, 71% reported weakness, 69% reported fatigue, 69% reported palpitations, and 62% reported sleeplessness. ^[4] Dhat has been described since the 1960's and consists of symptoms that are medically unexplained. Not much is known about the risk factors of dhat or any simultaneously occuring/comorbid disorders. Other studies have reported similar symptom findings. Approximately 77% of the patients attribute their symptoms to semen loss occuring because of masturbation, extramarital affairs, or premarital sexual activity. ^[5] Dhat meets some of the criteria to be classified as a functional somatic syndrome, which include symptoms such as sleeplessness, fatigue, and weakness. Dhat, as well as other functional somatic disorders, share a high comorbidity of anxiety and depression disorders. ^[6]

It is common for dhat patients to call upon healers to cure their perceived semen loss. The majority of dhat sufferers respond well to placebo treatments and simple reassurance. Counseling has not been proven to be effective. ^[7] Dhat is linked to the commonly held belief that semen is "precious" and the loss of semen is harmful to men. Men believe the loss of semen makes them weak and are often overcome with guilt. Guilt sets in when men believe that their symptoms are the direct result of excessive masturbation, intercourse, or night-time emissions. Symptoms usually cease when patients are educated about the how the endocrine system works and are convinced the situation is not making them ill. ^[8]

Dhat symptoms are not exclusive to non-Western cultures. In Europe during the 19th century, symptoms similar to dhat were reported due to beliefs regarding semen loss and masturbation. The cause of these symptoms have been attributed to poor sexual education and physiological misunderstandings. ^[9] Syndromes that are similar to dhat include "jiryan" in India and "sukra prameha" in Sri Lanka. Symptoms include severe anxiety and hypochondria due to weakness and exhaustion believed to be caused by excessive semen loss in men as well as women. In women, excessive semen loss is believed to occur in urine which appears whitish.^[10] Wen & Wang define shen-k’uei as vital or kidney deficiency. In early Chinese medicine, shen (kidney) was considered the reservoir of vital essence in semen (ching.) k’ueii means deficiency. Those affected by Shen-k’uei complain of excessive semen loss due to frequent intercourse, masturbation, nocturnal emission or passing of white fluid in their urine that is believed to be semen. People who believe they are experiencing shen-k’uei become anxious and panic stricken. They complain of somatic symptoms such as fatigue, dizziness, backache, weakness and insomnia. These symptoms parallel the symptoms of individuals suffering from dhat. Wen & Wang studied 87 patients at a urology clinic in Taiwan. They found that 23 patients had sexual neurosis with shen-k’uei syndrome. Of the remaining 64 patients, 80% blamed their condition on masturbation. Over 23 cases of shen-k’uei came from lower socioeconomic classes. All shen-k’uei patients reported masturbation or nocturnal emissions and were anxious, depressed, and hypochondriacal.^[11] In China, a common belief is that women have the ability to steal vital fluid from men. This loss may lead to disease (Bottéro, 1991).^[12]

Doctors at the India Institute of Medical Sciences studied 30 patients at the psychiatric department of a local hospital for their complaints about semen loss during urination. Patients with symptoms of depression were evaluated using DSM-IV and the severity of depression was further evaluated using the 17-item Hamilton Depression Rating Scale for Depression (HAM-D). Patients who were diagnosed with depression were given a capsule of fluoxetine, which is a serotonin reuptake inhibitor, and administered between 20 and 40 milligrams per day. Patients were followed up on and reevaluated for therapeutic response using the HAM-D. The results were as follows: Thirty patients (age = 20-40 years; mean age = 29 years; mean age of onset = 19 years; mean duration of illness = 11 months) were studied. 64.2% of patients were unmarried. 70% were educated to the 5th grade or above. Twenty out of 30 patients met DSM-IV guidelines for depression. Ten patients were found suffer from premature ejaculation and two patients reported erectile dysfunction. Patients showed statistically well response to fluoxetine. In conclusion, depression according to DSM-IV guidelines is common in dhat patients and responds well to fluoxetine therapy.^[13] Dhat is most prevalent in men ranging from 20-38 years of age. Women in India have also been diagnosed with dhat. These women had somatic symptoms similar to leucorrhoea. Dhat is classified as a neurotic disorder and a culture-specific disorder using ICD-10.^[14] Some do not consider dhat a culture bound syndrome for the following reasons: 1. The term dhat is misleading. In professional Asian medical texts (Ayurveda), the word dhatu means "seven bodily constituents". Only one of these constituents is semen (sukra). 2. Concerns about semen loss are also prevalent in European American societies. Galen and Aristotle made references to semen as a "soul substance" and the consequences of semen loss. ^[15] Galen: "Certain people have an abundant warm sperm which incessantly arouses the need of excretion: however, after its expulsion, people who are in this state experience a languor at the stomach orifice, exhaustion, weakness, and dryness of the whole body. They become thin, their eyes grow shallow." ^[16]

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