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Start Preamble https://www.georgemarioattard.com/best-place-to-buy-kamagra-online-uk Office of the kamagra price per pill Secretary, HHS. Notice. Start Printed Page kamagra price per pill 1423 In compliance with the requirement of the Paperwork Reduction Act of 1995, the Office of the Secretary (OS), Department of Health and Human Services, is publishing the following summary of a proposed collection for public comment.

Since March 29, 2020, the U.S. Government has been collecting data from hospitals and states to understand health care system stress, capacity, capabilities, and the number of patients hospitalized due to erectile dysfunction treatment. As the erectile dysfunction treatment response continues to evolve, Federal kamagra price per pill needs for data are also evolving.

The data elements within the collection are being altered to best meet the needs of the current response to erectile dysfunction treatment. This alteration includes the addition of data elements collecting more detailed information on pediatric hospitalizations, which will help to better understand pediatric hospital surge as well as inform epidemiologic surveillance to inform potential response actions kamagra price per pill. The alteration also includes making various data elements inactive for federal data collection based on current and anticipated future federal response needs, as well as reduce burden where possible.

While inactive, these data elements will still be considered as remaining part of the data collection to allow jurisdictions to continue collecting the information if it is needed for their unique response needs. Comments on the ICR must be received on or kamagra price per pill before February 10, 2022. Written comments and recommendations for the proposed information collection should be sent within 30 days of publication of this notice.

To be assured consideration, comments and kamagra price per pill recommendations must be submitted in any one of the following ways. 1. Electronically.

You may send your comments electronically kamagra price per pill to http://www.regulations.gov. Follow the instructions for “Comment or Submission” or “More Search Options” to find the information collection document(s) that are accepting comments. 2 kamagra price per pill.

By regular mail. Www.reginfo.gov/​public/​do/​PRAMain. Find this particular information collection by selecting “Currently under kamagra price per pill 30-day Review—Open for Public Comments” or by using the search function.

Start Further Info Sherrette Funn, Sherrette.Funn@hhs.gov or (202) 795-7714. When submitting comments or requesting information, please include the document identifier 0990-0478-30D and project title for reference. End kamagra price per pill Further Info End Preamble Start Supplemental Information This Federal Register notice seeks public comment on the emergency revision with substantive changes recently submitted to OMB for review and approval.

These comments will be reviewed and taken into consideration if the Department intends to make any revisions to the information collection request approved under [0990-0478]. Interested persons kamagra price per pill are invited to submit comments regarding the aforementioned emergency revision with substantive changes or any other aspect of this collection of information, including. The necessity and utility of the proposed information collection for the proper performance of the agency's functions, the accuracy of the estimated burden, ways to enhance the quality, utility and clarity of the information to be collected, and the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Interested persons are invited to send comments regarding this burden estimate or any other aspect of this collection of information, including any of the following subjects. (1) The necessity and utility of the proposed information collection for the proper performance of the agency's functions kamagra price per pill. (2) the accuracy of the estimated burden.

(3) ways kamagra price per pill to enhance the quality, utility, and clarity of the information to be collected. And (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden. Title of the Collection.

U.S. Healthcare erectile dysfunction treatment Portal. Type of Collection.

Emergency revision, substantial change. OMB No.. 0990-0478—U.S.

Department of Health and Human Services (HHS) Office of the Secretary. This notice also includes changing the data collection owner from the HHS Office of the Chief Information Officer (OCIO) to the HHS Assistant Secretary for Preparedness and Response (ASPR). Abstract.

The Unified Hospital Data Surveillance System (UHDSS) was created in 2020 to monitor erectile dysfunction treatment health care system capacity and surge and inform epidemiological surveillance. The collection requires daily responses from all hospitals in the U.S., with some jurisdictions (state, local, tribal, or territorial governments) compiling submissions for hospitals within their locality. Estimated Annualized Burden TableType of respondentForm nameNumber of respondentsNumber responses per respondentAverage burden per response (in hours)Total burden hoursHospitals (excluding Psychiatric and Rehabilitation Hospitals)HHS Teletracking erectile dysfunction treatment Portal52003651.252,372,500Psychiatric and Rehabilitation HospitalsHHS Teletracking erectile dysfunction treatment Portal800521.2552,000Infusion Centers and Outpatient Clinics reporting Inventory &.

Use of therapeutics (MABs)HHS Teletracking erectile dysfunction treatment Portal400520.255,200Total2,429,700 Start Signature Sherrette A. Funn, Paperwork Reduction Act Reports Clearance Officer, Office of the Secretary. End Signature End Supplemental Information [FR Doc.

2022-00237 Filed 1-10-22. 8:45 am]BILLING CODE 4150-37-PEditor’s note. If you or someone you know needs help, call the The National Suicide Prevention Lifeline 1-800-273-8255.

Other mental health resources can be found below.Hundreds of thousands of kids have lost a parent or primary caregiver to erectile dysfunction treatment and need support services, mental health experts say, with communities of color particularly devastated. €œSome families lost several people within a span of a few months, and just having one loss after another—that kind of accumulation of more grief—we see higher levels of distress in some of the kiddos we’re seeing,” said Cecilia Segura-Paz, a licensed professional counselor-supervisor at the Children’s Bereavement Center of South Texas. Because of the kamagra, some children didn’t get to attend a funeral or bereavement services.

Others didn’t get a chance to say their last goodbyes. For some youth in underserved communities in South Texas, Segura-Paz said, existing economic hardships, food and housing insecurity, and disruptions to education have deepened and complicated their grief.Through local partnerships and school-based programming, Segura-Paz said, her center was able to provide more counseling services and peer support groups for children, but high counselor caseloads, provider shortages and conflicts with class time during in-school sessions may have hindered children from getting the help they need.From January 2020 to November 2021, more than 167,000 children under 18 lost a parent or in-home caregiver to erectile dysfunction treatment, according to a December report titled “Hidden Pain” by researchers at the University of Pennsylvania, Nemours Children’s Health and the erectile dysfunction treatment Collaborative. The report found that Black and Hispanic children lost caregivers at more than double the rate of White children, while American Indian, Alaska Native, Native Hawaiian and Pacific Islander children lost caregivers at nearly four times the rate of White children.

Stateline Story November 8, 2021 erectile dysfunction treatment Harmed Kids’ Mental Health—And Schools Are Feeling It Quick View Psychologists say this loss has caused an uptick in anxiety, depression, trauma- and stress-related disorders in some children. Mental health professionals, like others in health care, have experienced burnout amid much higher caseloads. Last fall, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a national state of emergency in children’s mental health.The Biden administration has directed some kamagra relief aid to student mental health programs and some states passed related legislation, but none of the efforts have focused solely on children who have lost caregivers.

With states’ 2022 legislative sessions underway, mental health advocates hope the youth mental health crisis will push lawmakers to pass laws that increase access and availability of services, expand mental health awareness and alleviate a strained mental health workforce, especially in rural areas.“As we move forward through this kamagra, I don't want people to feel as though, if the kamagra is getting better, then the youth mental health issue will go away,” said Dr. Christine Crawford, associate medical director of the National Alliance on Mental Illness, a national mental health advocacy organization. €œThe reality is that that's not the case, because this crisis preexisted erectile dysfunction treatment.

And it’s even more dire in these rural areas because there is hardly any mental health support in place.”For some kids in Texas who lost a caregiver, it has been difficult to find social support while also readjusting to school, reconnecting with peers and struggling to maintain good grades, Segura-Paz said. Students at her center consistently worried about problems such as their family members’ mental health or how bills were going to get paid. Katrina Van Houten, a high school math teacher in the Del Valle Independent School District in Travis County, Texas, recalled changing classroom instruction in December 2020 because six parents had died of erectile dysfunction treatment.

Instead of teaching only math, she decided to focus on social and emotional learning.“I don’t think I’ve ever taught so little math. I was teaching a lot of how to survive in reality,” Van Houten said.Some of her students are doing better but still are dealing with the side effects of losing a parent, such as working a job to compensate for lost income, she said.“When I talk to them, they’re like, ‘I just go to school during the day, but I got to work at 5 and get off at midnight,’ and then they try to do their homework,” she said in an interview. €œI’ve lost parents when I was young, so I understand the issues that come with it.

It just makes me give them a lot more grace.” Stateline Story September 2, 2021 States Have Money to Spend on Mental Health, but It May Not Last Quick View States are working to address some of the problems. Last year, 14 states passed 36 bills to beef up children’s mental health services and expand mental health training opportunities for school resource officers and teachers, according to a database compiled by the National Conference of State Legislatures, which tracks state policy. In 2020 and 2021, at least eight states—Arizona, Colorado, Connecticut, Illinois, Maine, Nevada, Utah and Virginia—enacted laws allowing excused school absences for mental health reasons or expanded on existing laws that allow it, according to Stateline research.

In Washington state, Democratic Gov. Jay Inslee signed a bill into law that will establish a comprehensive school counseling program, require school districts to promote behavioral health resources on social media, and allow reimbursement for certain services related to mental health assessment and diagnosis. In Utah, Republican Gov.

Spencer Cox signed a bill that adds mental or behavioral health as a valid excuse for a school absence. Virginia enacted a law in 2020 requiring state agencies to conduct a joint feasibility study on developing an early childhood mental health consultation program. The program would be available to all early care and education programs serving children up to age 5.

More legislation likely will be considered this year. In California, Democratic state Sen. Nancy Skinner plans to introduce a measure that would create a savings account with up to $5,000 for children whose parents died from erectile dysfunction treatment.

Lawmakers in Massachusetts proposed bills that would allow students to take excused absences for mental health reasons. The policies proposed by federal and state government officials should be holistic and sustainable and should include bereavement support, which is instrumental in helping families and children heal, said Dr. David J.

Schonfeld, founder and director of the National Center for School Crisis and Bereavement at Children’s Hospital Los Angeles. €œGrief has always been an issue, and we don’t really have a very good mechanism for providing grief support because we don’t pay for it in our country, because bereavement is not considered an illness,” said Schonfeld, a developmental-behavioral pediatrician. €œAs a result, health insurance doesn’t cover the counseling.

We don’t refer to it as therapy or counseling, and most bereavement support is by faith-based organizations and laypeople provided free of charge.”Five large states—California, Florida, Georgia, New York and Texas—accounted for 50% of total caregiver loss from erectile dysfunction treatment, according to the “Hidden Pain” report. Arizona, Mississippi, New Mexico and Texas had the highest rates of caregiver loss. erectile dysfunction treatment has taken a disproportionate toll on older adults of color because they are more likely to have preexisting health conditions, limited access to health care and exposure to environmental factors that make them more vulnerable to the kamagra.Dan Treglia, lead author of the “Hidden Pain” report and associate professor of practice at the University of Pennsylvania’s School of Arts and Sciences, said some children of color who have lost caregivers have faced economic and social adversity prior to erectile dysfunction treatment, which warrants more resources to help them cope and adapt.

Children in the hardest hit communities, especially in rural areas, have fewer health care providers available and difficulty accessing telehealth appointments, which can affect whether, how and when young people can access services, Treglia added. €œVery few children require mental health services at a clinical level, but nearly all children will require the love and compassion of adults that are in their lives and communities,” Treglia said. €œOftentimes, that can require their local faith-based organizations or nonprofits to step up and play roles … but in many rural areas, [peer support groups and mentoring programs] are not going to be around the corner.

They’re going to be much scarcer and much more difficult to come by.”The American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association provided recommendations to policymakers in their declaration last fall, including increasing funding for mental health screening, access to technology and school-based mental health care and community-based programs. Treglia and the co-authors of his report suggested policymakers, educators and leaders in the nonprofit and private sectors consider creating a erectile dysfunction treatment bereaved children’s fund, putting in place screening for complicated grief, strengthening social services and increasing affordability of mental health services, among other measures..

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Sept How much does generic symbicort cost kamagra oral jelly canada. 24, 2020 -- Up to 70% of N95 masks certified in China do not meet U.S. Standards for effectiveness, kamagra oral jelly canada the nonprofit patient safety organization ECRI warned this week.

"Because of the dire situation, U.S. Hospitals bought hundreds of thousands of masks produced in China over the past 6 months, and we're finding that many aren't kamagra oral jelly canada safe and effective against the spread of erectile dysfunction treatment," Marcus Schabacker, MD, ECRI president and CEO, said in a statement. ECRI quality assurance researchers tested nearly 200 N95-style masks, reflecting 15 different manufacturer models purchased by some of the largest health systems in the United States.

They found that 60% to 70% of the imported masks – known as KN95 masks -- that had not been certified by the National Institute for Occupational Safety and Health (NIOSH), do not as effectively filter particles from the air. They are kamagra oral jelly canada "significantly inferior" to NIOSH-certified N95s, the report says. These masks did not filter 95% of aerosol particulates, despite what their name suggests.

"Using masks that don't meet U.S. Standards puts patients and frontline healthcare workers at risk of . As ECRI research shows, we strongly recommend that health care providers going forward do more due diligence before purchasing masks that aren't made or certified in America," Schabacker said.

According to ECRI, U.S. Domestic production capacity for N95s has increased significantly, but there remain widespread limits on how many can be purchased. The organization says non-NIOSH-certified masks should only be used as a "last resort" when treating erectile dysfunction treatment patients and only when NIOSH-certified N95s or other respirators offering comparable or better protection are not available.

"KN95 masks that don't meet U.S. Regulatory standards still generally provide more respiratory protection than surgical or cloth masks and can be used in certain clinical settings," Michael Argentieri, ECRI vice president for technology and safety, said in the statement. Medscape Medical News © 2020 WebMD, LLC.

Sept https://geolistening.com/how-much-does-generic-symbicort-cost kamagra price per pill. 24, 2020 -- Up to 70% of N95 masks certified in China do not meet U.S. Standards for effectiveness, the kamagra price per pill nonprofit patient safety organization ECRI warned this week. "Because of the dire situation, U.S.

Hospitals bought hundreds of thousands of masks produced in China over the past 6 months, and we're finding that many kamagra price per pill aren't safe and effective against the spread of erectile dysfunction treatment," Marcus Schabacker, MD, ECRI president and CEO, said in a statement. ECRI quality assurance researchers tested nearly 200 N95-style masks, reflecting 15 different manufacturer models purchased by some of the largest health systems in the United States. They found that 60% to 70% of the imported masks – known as KN95 masks -- that had not been certified by the National Institute for Occupational Safety and Health (NIOSH), do not as effectively filter particles from the air. They are "significantly inferior" to NIOSH-certified kamagra price per pill N95s, the report says.

These masks did not filter 95% of aerosol particulates, despite what their name suggests. "Using masks that don't kamagra price per pill meet U.S. Standards puts patients and frontline healthcare workers at risk of . As ECRI research shows, we strongly recommend that kamagra price per pill health care providers going forward do more due diligence before purchasing masks that aren't made or certified in America," Schabacker said.

According to ECRI, U.S. Domestic production capacity for N95s has increased significantly, but there remain widespread limits on how many can be purchased. The organization says non-NIOSH-certified masks should only be used as a "last resort" when treating erectile dysfunction treatment patients and only when NIOSH-certified N95s or kamagra price per pill other respirators offering comparable or better protection are not available. "KN95 masks that don't meet U.S.

Regulatory standards still generally provide more respiratory protection than surgical kamagra price per pill or cloth masks and can be used in certain clinical settings," Michael Argentieri, ECRI vice president for technology and safety, said in the statement. Medscape Medical News © 2020 WebMD, LLC. All rights reserved..

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In the wake of the erectile dysfunction treatment where is better to buy kamagra Omicron variant wave that began in early December 2021, the Biden Administration has taken actions to increase testing capacity, including expanding access to at-home tests through neighborhood sites such as health centers and rural clinics and establishing a new federal government Buy amoxil online website and toll-free number where people can request four free at-home tests. In addition, the Administration is now requiring private insurers to cover the cost of up to 8 at-home erectile dysfunction treatment tests per enrollee per month, as of January 15, 2022, based on authorities granted by Congress where is better to buy kamagra under the Families First erectile dysfunction Response Act (FFCRA) and the erectile dysfunction Aid, Relief, and Economic Security (CARES) Act.This new policy, however, does not apply to Medicare. Currently, Medicare does not cover the cost of self-administered at-home tests, though it covers diagnostic lab testing for erectile dysfunction treatment under Part B.

Medicare does not where is better to buy kamagra currently cover the cost of at-home tests in part because Medicare generally pays claims submitted by providers, rather than beneficiaries. Medicare Advantage plans (offered by private insurers) have the option to cover at-home tests but are not required to do so.To assess whether Medicare Advantage plans are covering the cost of at-home erectile dysfunction treatment tests, we reviewed the websites and spoke with customer service representatives of five of the largest Medicare Advantage insurers that where is better to buy kamagra together cover about two-thirds of all Medicare Advantage enrollees (based on 2021 enrollment) (Table 1). We conducted our analysis January 26-28, 2022.

We also where is better to buy kamagra analyzed access to over-the-counter (OTC) benefits among Medicare Advantage enrollees in 2021, which are an option for coverage of at-home erectile dysfunction treatment tests in some but not all plans. As of January 28, 4 of the 5 Medicare Advantage insurers that we examined are not reimbursing enrollees for at-home tests, with only one insurer, Kaiser Permanente, providing coverage of up to 8 at-home tests per month for both their Medicare and private enrollees.1 of the 5 insurers (Kaiser Permanente) will reimburse members for the cost of rapid antigen home tests.1 of the 5 insurers (UnitedHealthcare) states on their website that their “Medicare Advantage members are not eligible for reimbursement of OTC at-home erectile dysfunction treatment tests purchased without a physician’s order” but that “most of UnitedHealthcare’s Medicare Advantage plans have an OTC benefit that can be used to get OTC at-home erectile dysfunction treatment tests” (discussed below).3 of the 5 insurers (Humana, CVS Health, Cigna) state on their website that the new at-home testing reimbursement policy does not apply to people on Medicare.Some Medicare Advantage enrollees may be able to get some coverage of at-home erectile dysfunction treatment tests through their OTC (over-the-counter) benefit.In 2021, 79% of enrollees in individual Medicare Advantage plans (plans open for general enrollment) and 97% of enrollees in Medicare Advantage Special Needs Plans (SNPs) were enrolled in a plan with OTC benefits. Plan that offer an OTC where is better to buy kamagra benefit often provide a specified dollar amount toward the purchase of eligible OTC benefits, including non-prescription medications or other health care related items, such as first aid supplies – and that amount varies by plan.UnitedHealthcare states that, for those enrollees in the insurer’s Medicare Advantage plans that offer an OTC benefit, this benefit can be used to cover the cost of at-home tests – although because the OTC benefit amount varies by plan, the number of tests that would be covered also varies.

For example, some UnitedHealthcare plans cover up to $40 of OTC products per quarter, which would cover the cost of 3 erectile dysfunction treatment tests every 3 months (based on the $12 reimbursement rate where is better to buy kamagra being used by private insurers). Other UHC plans have an OTC benefit of up to $100 per quarter, which would cover 8 tests every 3 months.Currently, Humana, CVS Health, Kaiser Permanente, and Cigna are not extending their OTC benefit to the purchase of at-home tests. Enrollees in other Medicare Advantage plans that were not included in our analysis should check with their insurer about the availability of OTC benefits and whether this benefit can be used for the purchase of at-home tests.With adults 65 and older where is better to buy kamagra most at-risk of erectile dysfunction treatment hospitalizations and death, representing about three-fourths of all erectile dysfunction treatment deaths, some members of Congress have asked HHS to provide coverage for at-home erectile dysfunction treatment tests for all people on Medicare, including those in traditional Medicare and all Medicare Advantage enrollees.

CMS is currently exploring how Medicare can cover at-home tests, but until then, and in the absence of broad coverage through Medicare Advantage plans, many Medicare beneficiaries may have difficulty affording at-home erectile dysfunction treatment tests.Twenty drugs and dozens of insulin products used by 8.5 million Medicare beneficiaries would be subject to government drug price negotiation if the Build Back Better Act (BBBA) were enacted and fully implemented in 2022, according to a new KFF analysis.The 20 drugs include 18 drugs available to beneficiaries covered under Medicare Part D (typically drugs purchased at the pharmacy) and two drugs covered under Medicare Part B (physician-administered drugs). The list includes drugs used to treat cancer, diabetes, asthma, multiple sclerosis, auto-immune diseases, glaucoma, and osteoporosis, where is better to buy kamagra among other ailments. All 42 insulin products currently covered under Part D would be subject to drug price negotiation.The analysis, which uses Medicare drug spending data for 2019, shows the potential reach of the BBBA drug price negotiation proposal, under the scenario that negotiated prices for 20 top-spending Part B and Part D where is better to buy kamagra drugs, and all insulin products, were to take effect this year, in 2022, rather than in 2028, as the legislation calls for.

Under the BBBA, negotiated prices for all insulin products plus up to 10 Part D drugs would be available in 2025, while negotiated prices for up to 15 Part D and Part B drugs could be available in 2027.The analysis finds that the provision still could lower drug prices for some of the top-spending drugs covered under Medicare Part B and Part D, but many of the drugs with the highest total Medicare spending would be exempt from negotiation based on the BBBA criteria that exempts high-spending drugs within a certain number of years from FDA approval or if generic equivalents come to market. The Congressional Budget Office has estimated where is better to buy kamagra that the current proposal would save the federal government about $80 billion over 10 years, compared to projected savings of $450 billion associated with the earlier legislation.The House has passed the legislation and sent it to the Senate, which has not taken up the bill. While allowing the federal government to negotiate drug prices is strongly favored by the public, prospects for the bill’s passage in Congress remain unclear..

In the wake of the erectile dysfunction treatment Omicron variant wave that began in early December 2021, the Biden Administration has taken actions to increase testing capacity, including expanding access to at-home Buy amoxil online tests through neighborhood sites such as health centers and rural clinics and establishing a new federal government website and kamagra price per pill toll-free number where people can request four free at-home tests. In addition, the Administration is now requiring private insurers to cover the cost of up to 8 at-home kamagra price per pill erectile dysfunction treatment tests per enrollee per month, as of January 15, 2022, based on authorities granted by Congress under the Families First erectile dysfunction Response Act (FFCRA) and the erectile dysfunction Aid, Relief, and Economic Security (CARES) Act.This new policy, however, does not apply to Medicare. Currently, Medicare does not cover the cost of self-administered at-home tests, though it covers diagnostic lab testing for erectile dysfunction treatment under Part B. Medicare does not currently cover the cost of at-home tests in part kamagra price per pill because Medicare generally pays claims submitted by providers, rather than beneficiaries. Medicare Advantage plans (offered by private insurers) have the option to cover at-home tests but are not required to do so.To assess whether Medicare Advantage plans are covering the cost of at-home erectile dysfunction treatment tests, we reviewed kamagra price per pill the websites and spoke with customer service representatives of five of the largest Medicare Advantage insurers that together cover about two-thirds of all Medicare Advantage enrollees (based on 2021 enrollment) (Table 1).

We conducted our analysis January 26-28, 2022. We also analyzed access to over-the-counter (OTC) kamagra price per pill benefits among Medicare Advantage enrollees in 2021, which are an option for coverage of at-home erectile dysfunction treatment tests in some but not all plans. As of January 28, 4 of the 5 Medicare Advantage insurers that we examined are not reimbursing enrollees for at-home tests, with only one insurer, Kaiser Permanente, providing coverage of up to 8 at-home tests per month for both their Medicare and private enrollees.1 of the 5 insurers (Kaiser Permanente) will reimburse members for the cost of rapid antigen home tests.1 of the 5 insurers (UnitedHealthcare) states on their website that their “Medicare Advantage members are not eligible for reimbursement of OTC at-home erectile dysfunction treatment tests purchased without a physician’s order” but that “most of UnitedHealthcare’s Medicare Advantage plans have an OTC benefit that can be used to get OTC at-home erectile dysfunction treatment tests” (discussed below).3 of the 5 insurers (Humana, CVS Health, Cigna) state on their website that the new at-home testing reimbursement policy does not apply to people on Medicare.Some Medicare Advantage enrollees may be able to get some coverage of at-home erectile dysfunction treatment tests through their OTC (over-the-counter) benefit.In 2021, 79% of enrollees in individual Medicare Advantage plans (plans open for general enrollment) and 97% of enrollees in Medicare Advantage Special Needs Plans (SNPs) were enrolled in a plan with OTC benefits. Plan that offer an OTC benefit often provide a specified dollar amount toward the purchase of eligible OTC benefits, including non-prescription medications or other health care related items, such as first aid supplies – and that amount varies by plan.UnitedHealthcare states that, for those enrollees in the insurer’s Medicare Advantage plans that offer an OTC benefit, this benefit kamagra price per pill can be used to cover the cost of at-home tests – although because the OTC benefit amount varies by plan, the number of tests that would be covered also varies. For example, some UnitedHealthcare plans cover up to $40 of OTC products per quarter, which would kamagra price per pill cover the cost of 3 erectile dysfunction treatment tests every 3 months (based on the $12 reimbursement rate being used by private insurers).

Other UHC plans have an OTC benefit of up to $100 per quarter, which would cover 8 tests every 3 months.Currently, Humana, CVS Health, Kaiser Permanente, and Cigna are not extending their OTC benefit to the purchase of at-home tests. Enrollees in other Medicare Advantage plans that were not included in our analysis should check kamagra price per pill with their insurer about the availability of OTC benefits and whether this benefit can be used for the purchase of at-home tests.With adults 65 and older most at-risk of erectile dysfunction treatment hospitalizations and death, representing about three-fourths of all erectile dysfunction treatment deaths, some members of Congress have asked HHS to provide coverage for at-home erectile dysfunction treatment tests for all people on Medicare, including those in traditional Medicare and all Medicare Advantage enrollees. CMS is currently exploring how Medicare can cover at-home tests, but until then, and in the absence of broad coverage through Medicare Advantage plans, many Medicare beneficiaries may have difficulty affording at-home erectile dysfunction treatment tests.Twenty drugs and dozens of insulin products used by 8.5 million Medicare beneficiaries would be subject to government drug price negotiation if the Build Back Better Act (BBBA) were enacted and fully implemented in 2022, according to a new KFF analysis.The 20 drugs include 18 drugs available to beneficiaries covered under Medicare Part D (typically drugs purchased at the pharmacy) and two drugs covered under Medicare Part B (physician-administered drugs). The list includes kamagra price per pill drugs used to treat cancer, diabetes, asthma, multiple sclerosis, auto-immune diseases, glaucoma, and osteoporosis, among other ailments. All 42 insulin products currently covered under Part D would be subject to drug price negotiation.The analysis, which uses Medicare drug spending data for 2019, shows the potential reach of the BBBA drug price negotiation proposal, under the scenario that negotiated prices for 20 top-spending Part B and Part D drugs, and all insulin products, were to take effect this kamagra price per pill year, in 2022, rather than in 2028, as the legislation calls for.

Under the BBBA, negotiated prices for all insulin products plus up to 10 Part D drugs would be available in 2025, while negotiated prices for up to 15 Part D and Part B drugs could be available in 2027.The analysis finds that the provision still could lower drug prices for some of the top-spending drugs covered under Medicare Part B and Part D, but many of the drugs with the highest total Medicare spending would be exempt from negotiation based on the BBBA criteria that exempts high-spending drugs within a certain number of years from FDA approval or if generic equivalents come to market. The Congressional Budget Office has estimated that the current proposal would save the federal government about $80 billion over 10 years, compared to projected savings of $450 billion associated with the earlier legislation.The House has passed kamagra price per pill the legislation and sent it to the Senate, which has not taken up the bill. While allowing the federal government to negotiate drug prices is strongly favored by the public, prospects for the bill’s passage in Congress remain unclear..

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How to cite this article:Singh kamagra fast uk OP. Mental health in diverse India. Need for kamagra fast uk 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 Himalayas to the kamagra fast uk 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 toward kamagra fast uk 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 kamagra fast uk gene environment interaction how public policies and social norms act on the 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, kamagra fast uk and morbidity.When we come to the 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 kamagra fast uk 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 kamagra fast uk 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 negative prognostic indicator contrary to the western norms.[3]Cultural influences on the kamagra fast uk 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, it was 41,197, and in higher income group, it kamagra fast uk 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 kamagra fast uk 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 kamagra fast uk level, organizational level, and individual level. There has been huge work done in this regard at institution level. Important research work done in kamagra fast uk 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 kamagra fast uk Society (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 of Psychiatry has also come out with editorials highlighting the need of care of marginalized population such as kamagra fast uk 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 kamagra fast uk the role of these factors on mental health. References 1.Compton MT, Shim RS. The social kamagra fast uk determinants 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 Health kamagra fast uk 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. Ramya Creations.

2015. P. 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 &. Venerology. Prague. Czech. 2002.

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 check this link right here now cite kamagra price per pill this article:Singh OP. Mental health in diverse India. Need for advocacy kamagra price per pill. 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 kamagra price per pill – 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 kamagra price per pill 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 inequality, kamagra price per pill 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 kamagra price per pill the 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 kamagra price per pill 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 kamagra price per pill 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 negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation kamagra price per pill 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 kamagra price per pill 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 kamagra price per pill persons 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 kamagra price per pill 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 level. There has been huge work done in this regard at institution level.

Important research kamagra price per pill 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 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) kamagra price per pill 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 of Psychiatry has also come out with kamagra price per pill 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 kamagra price per pill health.

References 1.Compton MT, Shim RS. The social determinants of mental kamagra price per pill 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, kamagra price per pill 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 low price kamagra 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.

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.

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At a time when much of the world is still struggling to access erectile dysfunction treatments, the what is kamagra 100mg oral jelly question of whether reference to vaccinate children can feel like a privilege. On 19 July, treatment advisers in the United Kingdom recommended to delay treatments for most young people under 16, citing the very low rates of serious disease in this age group. But several countries, including the United States and Israel, have forged ahead, and others are hoping to follow suit when supplies allow. Nature looks at where what is kamagra 100mg oral jelly the evidence stands on children and erectile dysfunction treatments.

Is it necessary?. Since the early days of the kamagra, parents have been taking some comfort from the fact that erectile dysfunction is far less likely to cause serious illness in children than it is in adults. But some children do still become very ill, and the spectre of long erectile dysfunction treatment — a constellation of sometimes debilitating symptoms that can linger for what is kamagra 100mg oral jelly months after even a mild bout of erectile dysfunction treatment — is enough for many paediatricians to urge vaccination as quickly as possible. €œI spent the kamagra taking care of kids in a children’s hospital,” says Adam Ratner, a paediatric infectious disease specialist at New York University.

€œWe saw not as many as in the adult side, but plenty of children who were quite ill.” treatment advisers in the United Kingdom, however, have recommended that only adolescents who are clinically vulnerable, or who live with vulnerable adults, will be vaccinated for the time being. Severe illness, deaths and even long erectile dysfunction treatment are rare among healthy adolescents and children, and nearly all vulnerable adults will have soon received two treatment doses, University of Bristol paediatrician Adam Finn told reporters at a media briefing what is kamagra 100mg oral jelly. But in some countries, still little is known about how erectile dysfunction treatment affects children. Some official tallies of hospitalizations and deaths due to erectile dysfunction treatment in sub-Saharan Africa, for example, do not break down the cases by age.

As a result, paediatricians don’t know which deaths were in children and young people, and what is kamagra 100mg oral jelly how outcomes of erectile dysfunction treatment might be affected by conditions such as malnutrition, or concurrent tuberculosis or HIV . €œWe are feeling in the dark,” says Nadia Sam-Agudu, a paediatrician with the University of Maryland School of Medicine in Baltimore who works in Nigeria. In addition, some paediatricians are concerned about what will happen to children who are co-infected with erectile dysfunction and other common kamagraes, such as respiratory syncytial kamagra, which is one of the causes of the common cold but can sometimes cause more severe breathing illness in young children. Strict lockdowns have kept this problem at bay in some regions, but as social distancing measures are eased, there are already signs that respiratory syncytial kamagra s in children are rising, says Danilo Buonsenso, what is kamagra 100mg oral jelly a paediatrician at the Gemelli University Hospital in Rome.

€œWe don’t know yet what will be the burden of co-s in children when we have a massive circulation of routine kamagraes and erectile dysfunction treatment,” he says. Is vaccinating children safe?. A handful of treatments have been tested in young people over the age of 12, including mRNA treatments what is kamagra 100mg oral jelly made by Moderna and Pfizer–BioNTech, and two Chinese treatments made by Sinovac and Sinopharm. And several countries, including the United States, Israel and China, are now offering treatments to this age group.

Other studies are expected to report results in young people over the age of 12 soon, including studies on the Zydus Cadila treatment and the Covaxin inactivated erectile dysfunction treatment, both made in India. Thus far, the treatments seem to be safe in adolescents, what is kamagra 100mg oral jelly and some companies have moved on to carrying out clinical trials in children as young as 6 months old. In the United States, treatments for those under 12 might be available later this year, says paediatrician Andrea Shane at Emory University in Atlanta, Georgia. A potential link between the Pfizer treatment and heart inflammation — conditions called myocarditis and pericarditis — has emerged since Israel and the United States began vaccinating young people.

However, researchers have yet to establish that the treatment caused the what is kamagra 100mg oral jelly inflammation. Most of those affected have recovered, and the data suggest that the risk of these conditions is “extremely low”, says paediatrician David Pace at the University of Malta in Msida — on the order of about 67 cases per million second doses in adolescent males aged 12–17, and 9 per million in adolescent females in the same age group. How will vaccinating children and young people affect the kamagra?. Malta has fully vaccinated 80% of its population — one of the highest vaccination rates in the world what is kamagra 100mg oral jelly — and is now also vaccinating adolescents over the age of 12.

There, the decision to vaccinate young people was shaped, among other factors, by the close-knit family structures in a country where adolescents often have frequent contact with their grandparents, says Pace. €œOn a population level, vaccinated adolescents may result in a reduction in transmission to vulnerable older people,” he says. Young people in Malta also often travel abroad what is kamagra 100mg oral jelly for school, potentially importing erectile dysfunction s and variants from abroad, he adds. Data show that children and particularly adolescents can play a significant part in erectile dysfunction transmission, says Catherine Bennett, an epidemiologist at Deakin University in Melbourne, Australia.

And concerns about transmission by children and adolescents are growing as new erectile dysfunction variants emerge. It’s possible that more-transmissible variants will develop a way to push through whatever it is what is kamagra 100mg oral jelly in a young person’s immune response that makes them more resistant to , says Bennett, making it all the more important that they are vaccinated. Hopes of achieving herd immunity through immunization have waned, so countries need to do the best that they can to keep transmission low, she adds. €œYou only need one poorly vaccinated population to generate global variants.” Is vaccinating children fair?.

Chile, another country with one of the highest erectile dysfunction treatment vaccination rates in the world, is also what is kamagra 100mg oral jelly rolling out treatments to those aged 12 and older. But Miguel O’Ryan, a former member of two advisory committees to the government there who has pushed for aggressive vaccination campaigns, now finds himself wondering whether it’s time to slow down. €œProbably countries should not move forward with paediatric vaccinations so fast,” says O’Ryan, who is a paediatric infectious disease specialist at the University of Chile in Santiago. €œOther countries, even our neighbours, are struggling very hard to get enough treatments for their high-risk groups.” O’Ryan is not the only one concerned what is kamagra 100mg oral jelly about using valuable treatments to inoculate children, when more vulnerable populations around the world are still struggling to secure supplies.

In May, World Health Organization chief Tedros Adhanom Ghebreyesus said that wealthier countries that are vaccinating children are doing so at the expense of health-care workers and high-risk groups in other countries. But advocates for vaccinating children and young adults argue that it need not be a case of one or the other. €œThis is sort-of a false what is kamagra 100mg oral jelly dichotomy,” says Ratner. Sam-Agudu agrees, pointing out that some wealthy countries bought more than enough doses to fully vaccinate their populations.

€œThe argument for sending treatments outside the country should not preclude vaccinating children in higher-income countries,” she says. And there are other steps that what is kamagra 100mg oral jelly could be taken to improve the supply of treatments to needy countries, says Bennett. More could be done to better target donations, she notes. For example, rather than allocating donated treatment doses to countries based solely on how many people live there, they could be distributed based on other factors, such as the need to preserve health-care services in the face of an oncoming malaria season, or ongoing measles outbreak.

€œWe probably still haven’t had the deep epidemiological war room that we need to map out the problem and the best way what is kamagra 100mg oral jelly to address it,” she says. €œThere’s a whole range of ways you could look at this.” This article is reproduced with permission and was first published on July 20 2021.After almost three decades of fighting, queer people in India won a long overdue battle when the Supreme Court of India decriminalized same-sex sexual acts among consenting adults in 2018. Since then, I have often been asked where I see India’s queer movements going. Is it going to be marriage equality?.

Something else? what is kamagra 100mg oral jelly. With recent celebrations of Pride Month in mind, I argue for the need of queer people to demand a better, more inclusive and more affordable public health care system. Honestly, this shouldn’t come as a surprise. We know what is kamagra 100mg oral jelly that queer people have been disproportionately affected by the current erectile dysfunction treatment kamagra and the lack of a robust public health care system.

During the kamagra, working-class transgender people in India have lost major sources of income (sex work and ceremonial begging) and are at a risk of being evicted from their rented houses. Many queer people have had to stay at their homes with abusive family members for an extended period of time during the lockdowns, and this has had a severe effect on their mental health. Many working-class what is kamagra 100mg oral jelly queer and transgender people live in communes with a large number of other people, which makes maintaining physical distancing quite a task, increasing the chance of erectile dysfunction treatment transmission. Also, queer and transgender people who are living with HIV are at a higher risk of severe illness from the erectile dysfunction.

Moreover, many queer and transgender people are refused health care at public hospitals, and many cannot afford expensive private hospitals. Even when health what is kamagra 100mg oral jelly care is available at an affordable price, queer people are met with infrastructural issues. For example, most public hospitals are not equipped with specific wards for transgender people, or do not allow transgender people to be accommodated in wards of the gender that they identify with. The medical and nonmedical staffs in these hospitals are rarely sensitized and trained to handle issues specific to queer and transgender people.

While stigma and discrimination make it very difficult for most queer and transgender people in India to access health care, even during the kamagra, the situation is compounded by the government’s apathy, nonimplementation of policies, and a systemic and systematic breakdown of the public what is kamagra 100mg oral jelly health system. Both the 2013 NALSA vs. Union of India judgment from the Supreme Court and the Transgender Person’s (Protection of Rights Act) 2019 mention that the government should work towards providing affordable and accessible health care to transgender individuals, while also training health care staff to be sensitive towards issues faced by transgender persons. Similar provisions are also suggested by what is kamagra 100mg oral jelly the 2018 judgment of the Court.

However, these provisions have not been implemented. Moreover, the public health infrastructure in India is terribly understaffed. To compound the issues of access further, the public health system in India is being increasingly privatized what is kamagra 100mg oral jelly. This privatization limits the access of health care for those who cannot afford private health care.

Decision-making about health care has become increasingly centralized, with the Prime Minister’s Office and the Ministry of Health and Family Welfare making most of the decisions, while voices from the margins and the grassroots are increasingly being ignored. The irony in not asking for an affordable and accessible health care system is the fact what is kamagra 100mg oral jelly that there is a huge intersection between various Indian public health movements and queer-rights movements. An example of this is the queer and trans mobilizations that happened around the HIV/AIDS kamagra in the late 1980s, 1990s and 2000s. As HIV/AIDS was recognized as an epidemic in the country and the various phases of the National AIDS Control Program were being implemented, certain queer and transgender communities ( “men who have sex with men” and “transgender”) were identified as high-risk groups.

Various public health and civil rights what is kamagra 100mg oral jelly groups, nongovernmental organizations (NGOs) and community-based organizations (CBOs) not only received international and government funding for targeted intervention in these “MSM” and “TG” groups, but also used these funds to build solidarity and awareness, as well as employing queer-trans people as outreach workers. During a time when it was the state’s and the society’s firm belief that both homosexuality and HIV/AIDS are foreign imports because the moralistic Indian society has no space for them, the queer movement could articulate itself publicly through the HIV/AIDS narrative. In fact, the first few petitions asking for the decriminalization of same-sex sexual acts between consenting adults were filed by NGOs and civil-rights groups whose focus was HIV/AIDS intervention. Of course, this almost solitary focus what is kamagra 100mg oral jelly on HIV/AIDS is not without critique.

The intervention approach was biologically essentialist and reduced queer and transgender people to the kinds of sex they were having rather than engaging with larger questions of identity and politics. Public articulations of queerness became primarily focused on gay men and some transfeminine identities, while leaving out lesbian and bisexual women, and many transmasculine and nonbinary identities. The focus what is kamagra 100mg oral jelly on HIV/AIDS has also limited what demands queer and transgender people can make from the public health system. The demands have gotten restricted to accessible antiretroviral therapy (ART), hormone replacement therapy (HRT) and sex-reassignment surgeries (SRS).

There are various problems with NGOization of the queer movement in India as well. Some of these NGOs have been called out for what is kamagra 100mg oral jelly corruption. Moreover, most of the NGOs that gained prominence through the HIV/AIDS intervention movement were led by elite, metropolitan queer- (and sometimes) trans people, which alienated NGOs and CBOs from rural and suburban places. These NGOs also did not engage with caste-class dynamics, therefore leading to the queer-trans mobilizations losing out on intersectional nuances.

These NGOs often also functioned in an exploitative what is kamagra 100mg oral jelly manner. Outreach workers, who primarily consisted of working-class queer and transgender people, were paid meager salaries while putting in most of the effort at the ground. Moreover, there was hardly any push for a better public health care system from these NGOs barring calls for an increased number of HIV-testing centers and ART centers. In moves that further affect queer people negatively, the Indian government has also canceled the registration of many NGOs that were working what is kamagra 100mg oral jelly for the rights of queer and transgender people.

Along with this, according to the current regulations of the Indian government, any NGO participating in “political activities” cannot accept foreign or transnational funding. Moreover, despite India having the third-highest number of people living with HIV/AIDS in the world (2018 data), the broadcasting of condom ads has been prohibited from 6 A.M. To 10 P.M. what is kamagra 100mg oral jelly. In these moments, it is crucial that queer people mobilize and call for a robust, affordable and accessible public health system—a public health system that does not just intend to intervene, but that involves queer and transgender people in the decision-making process.

We need a public health system where queer and transgender people are not discriminated against, and a public health system that not only promises free ART, HRT and SRS, but also engages with sexual and mental-health care needs, has sensitized staff in public hospitals and does not harm the dignity of queer and transgender people. Not all of us will benefit from rainbow-dyed hair, free offers from corporate businesses, and marriage equality, but all of us will benefit from a kind, supportive and accessible public health care system. I would like to thank Chayanika Shah, Aniruddha Dutta, L Ramakrishnan, Aqsa Shaikh and Avinaba Dutta for conversations that were crucial to the writing of this piece. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American..

At a time when much of the world is still important link struggling to access erectile dysfunction treatments, the question of whether to vaccinate children can feel like a kamagra price per pill privilege. On 19 July, treatment advisers in the United Kingdom recommended to delay treatments for most young people under 16, citing the very low rates of serious disease in this age group. But several countries, including the United States and Israel, have forged ahead, and others are hoping to follow suit when supplies allow. Nature looks at where the kamagra price per pill evidence stands on children and erectile dysfunction treatments.

Is it necessary?. Since the early days of the kamagra, parents have been taking some comfort from the fact that erectile dysfunction is far less likely to cause serious illness in children than it is in adults. But some children do still become very ill, and the spectre of long erectile dysfunction treatment — a constellation of sometimes kamagra price per pill debilitating symptoms that can linger for months after even a mild bout of erectile dysfunction treatment — is enough for many paediatricians to urge vaccination as quickly as possible. €œI spent the kamagra taking care of kids in a children’s hospital,” says Adam Ratner, a paediatric infectious disease specialist at New York University.

€œWe saw not as many as in the adult side, but plenty of children who were quite ill.” treatment advisers in the United Kingdom, however, have recommended that only adolescents who are clinically vulnerable, or who live with vulnerable adults, will be vaccinated for the time being. Severe illness, deaths and even long erectile dysfunction treatment are rare among healthy adolescents and children, and nearly all vulnerable adults will have soon received two treatment doses, University of Bristol paediatrician Adam Finn told reporters at kamagra price per pill a media briefing. But in some countries, still little is known about how erectile dysfunction treatment affects children. Some official tallies of hospitalizations and deaths due to erectile dysfunction treatment in sub-Saharan Africa, for example, do not break down the cases by age.

As a kamagra price per pill result, paediatricians don’t know which deaths were in children and young people, and how outcomes of erectile dysfunction treatment might be affected by conditions such as malnutrition, or concurrent tuberculosis or HIV . €œWe are feeling in the dark,” says Nadia Sam-Agudu, a paediatrician with the University of Maryland School of Medicine in Baltimore who works in Nigeria. In addition, some paediatricians are concerned about what will happen to children who are co-infected with erectile dysfunction and other common kamagraes, such as respiratory syncytial kamagra, which is one of the causes of the common cold but can sometimes cause more severe breathing illness in young children. Strict lockdowns have kept this problem at bay kamagra price per pill in some regions, but as social distancing measures are eased, there are already signs that respiratory syncytial kamagra s in children are rising, says Danilo Buonsenso, a paediatrician at the Gemelli University Hospital in Rome.

€œWe don’t know yet what will be the burden of co-s in children when we have a massive circulation of routine kamagraes and erectile dysfunction treatment,” he says. Is vaccinating children safe?. A handful of treatments have been tested in young people over the age of 12, including mRNA treatments made by Moderna and Pfizer–BioNTech, and two Chinese treatments made by Sinovac and kamagra price per pill Sinopharm. And several countries, including the United States, Israel and China, are now offering treatments to this age group.

Other studies are expected to report results in young people over the age of 12 soon, including studies on the Zydus Cadila treatment and the Covaxin inactivated erectile dysfunction treatment, both made in India. Thus far, the treatments seem to be safe in adolescents, and some companies have moved on to carrying out clinical trials kamagra price per pill in children as young as 6 months old. In the United States, treatments for those under 12 might be available later this year, says paediatrician Andrea Shane at Emory University in Atlanta, Georgia. A potential link between the Pfizer treatment and heart inflammation — conditions called myocarditis and pericarditis — has emerged since Israel and the United States began vaccinating young people.

However, researchers have yet to kamagra price per pill establish that the treatment caused the inflammation. Most of those affected have recovered, and the data suggest that the risk of these conditions is “extremely low”, says paediatrician David Pace at the University of Malta in Msida — on the order of about 67 cases per million second doses in adolescent males aged 12–17, and 9 per million in adolescent females in the same age group. How will vaccinating children and young people affect the kamagra?. Malta has fully vaccinated 80% of its population — one of the highest vaccination rates in the world — and is now also vaccinating adolescents over kamagra price per pill the age of 12.

There, the decision to vaccinate young people was shaped, among other factors, by the close-knit family structures in a country where adolescents often have frequent contact with their grandparents, says Pace. €œOn a population level, vaccinated adolescents may result in a reduction in transmission to vulnerable older people,” he says. Young people in Malta also kamagra price per pill often travel abroad for school, potentially importing erectile dysfunction s and variants from abroad, he adds. Data show that children and particularly adolescents can play a significant part in erectile dysfunction transmission, says Catherine Bennett, an epidemiologist at Deakin University in Melbourne, Australia.

And concerns about transmission by children and adolescents are growing as new erectile dysfunction variants emerge. It’s possible that more-transmissible variants will develop a way to push through whatever it is in a young person’s immune response that makes them more kamagra price per pill resistant to , says Bennett, making it all the more important that they are vaccinated. Hopes of achieving herd immunity through immunization have waned, so countries need to do the best that they can to keep transmission low, she adds. €œYou only need one poorly vaccinated population to generate global variants.” Is vaccinating children fair?.

Chile, another country with one of the highest kamagra price per pill erectile dysfunction treatment vaccination rates in the world, is also rolling out treatments to those aged 12 and older. But Miguel O’Ryan, a former member of two advisory committees to the government there who has pushed for aggressive vaccination campaigns, now finds himself wondering whether it’s time to slow down. €œProbably countries should not move forward with paediatric vaccinations so fast,” says O’Ryan, who is a paediatric infectious disease specialist at the University of Chile in Santiago. €œOther countries, even our neighbours, are struggling very hard to get enough treatments for their high-risk groups.” O’Ryan is not the only one concerned kamagra price per pill about using valuable treatments to inoculate children, when more vulnerable populations around the world are still struggling to secure supplies.

In May, World Health Organization chief Tedros Adhanom Ghebreyesus said that wealthier countries that are vaccinating children are doing so at the expense of health-care workers and high-risk groups in other countries. But advocates for vaccinating children and young adults argue that it need not be a case of one or the other. €œThis is sort-of a kamagra price per pill false dichotomy,” says Ratner. Sam-Agudu agrees, pointing out that some wealthy countries bought more than enough doses to fully vaccinate their populations.

€œThe argument for sending treatments outside the country should not preclude vaccinating children in higher-income countries,” she says. And there are other steps that could be taken to improve the supply of treatments kamagra price per pill to needy countries, says Bennett. More could be done to better target donations, she notes. For example, rather than allocating donated treatment doses to countries based solely on how many people live there, they could be distributed based on other factors, such as the need to preserve health-care services in the face of an oncoming malaria season, or ongoing measles outbreak.

€œWe probably kamagra price per pill still haven’t had the deep epidemiological war room that we need to map out the problem and the best way to address it,” she says. €œThere’s a whole range of ways you could look at this.” This article is reproduced with permission and was first published on July 20 2021.After almost three decades of fighting, queer people in India won a long overdue battle when the Supreme Court of India decriminalized same-sex sexual acts among consenting adults in 2018. Since then, I have often been asked where I see India’s queer movements going. Is it going to be marriage equality?.

Something kamagra price per pill else?. With recent celebrations of Pride Month in mind, I argue for the need of queer people to demand a better, more inclusive and more affordable public health care system. Honestly, this shouldn’t come as a surprise. We know that queer people have been disproportionately kamagra price per pill affected by the current erectile dysfunction treatment kamagra and the lack of a robust public health care system.

During the kamagra, working-class transgender people in India have lost major sources of income (sex work and ceremonial begging) and are at a risk of being evicted from their rented houses. Many queer people have had to stay at their homes with abusive family members for an extended period of time during the lockdowns, and this has had a severe effect on their mental health. Many working-class queer and transgender people live in communes with a large number kamagra price per pill of other people, which makes maintaining physical distancing quite a task, increasing the chance of erectile dysfunction treatment transmission. Also, queer and transgender people who are living with HIV are at a higher risk of severe illness from the erectile dysfunction.

Moreover, many queer and transgender people are refused health care at public hospitals, and many cannot afford expensive private hospitals. Even when health care is available at kamagra price per pill an affordable price, queer people are met with infrastructural issues. For example, most public hospitals are not equipped with specific wards for transgender people, or do not allow transgender people to be accommodated in wards of the gender that they identify with. The medical and nonmedical staffs in these hospitals are rarely sensitized and trained to handle issues specific to queer and transgender people.

While stigma and discrimination make it very difficult for most queer and transgender kamagra price per pill people in India to access health care, even during the kamagra, the situation is compounded by the government’s apathy, nonimplementation of policies, and a systemic and systematic breakdown of the public health system. Both the 2013 NALSA vs. Union of India judgment from the Supreme Court and the Transgender Person’s (Protection of Rights Act) 2019 mention that the government should work towards providing affordable and accessible health care to transgender individuals, while also training health care staff to be sensitive towards issues faced by transgender persons. Similar provisions are also suggested by kamagra price per pill the 2018 judgment of the Court.

However, these provisions have not been implemented. Moreover, the public health infrastructure in India is terribly understaffed. To compound the issues of access further, the kamagra price per pill public health system in India is being increasingly privatized. This privatization limits the access of health care for those who cannot afford private health care.

Decision-making about health care has become increasingly centralized, with the Prime Minister’s Office and the Ministry of Health and Family Welfare making most of the decisions, while voices from the margins and the grassroots are increasingly being ignored. The irony in not asking for an affordable and accessible health care system is the fact that there is a kamagra price per pill huge intersection between various Indian public health movements and queer-rights movements. An example of this is the queer and trans mobilizations that happened around the HIV/AIDS kamagra in the late 1980s, 1990s and 2000s. As HIV/AIDS was recognized as an epidemic in the country and the various phases of the National AIDS Control Program were being implemented, certain queer and transgender communities ( “men who have sex with men” and “transgender”) were identified as high-risk groups.

Various public health and civil rights groups, nongovernmental organizations (NGOs) and community-based organizations (CBOs) not only received international and government funding for targeted intervention in these “MSM” and “TG” kamagra price per pill groups, but also used these funds to build solidarity and awareness, as well as employing queer-trans people as outreach workers. During a time when it was the state’s and the society’s firm belief that both homosexuality and HIV/AIDS are foreign imports because the moralistic Indian society has no space for them, the queer movement could articulate itself publicly through the HIV/AIDS narrative. In fact, the first few petitions asking for the decriminalization of same-sex sexual acts between consenting adults were filed by NGOs and civil-rights groups whose focus was HIV/AIDS intervention. Of course, this almost solitary focus on HIV/AIDS kamagra price per pill is not without critique.

The intervention approach was biologically essentialist and reduced queer and transgender people to the kinds of sex they were having rather than engaging with larger questions of identity and politics. Public articulations of queerness became primarily focused on gay men and some transfeminine identities, while leaving out lesbian and bisexual women, and many transmasculine and nonbinary identities. The focus on HIV/AIDS has also limited what demands queer and transgender kamagra price per pill people can make from the public health system. The demands have gotten restricted to accessible antiretroviral therapy (ART), hormone replacement therapy (HRT) and sex-reassignment surgeries (SRS).

There are various problems with NGOization of the queer movement in India as well. Some of these NGOs have been called kamagra price per pill out for corruption. Moreover, most of the NGOs that gained prominence through the HIV/AIDS intervention movement were led by elite, metropolitan queer- (and sometimes) trans people, which alienated NGOs and CBOs from rural and suburban places. These NGOs also did not engage with caste-class dynamics, therefore leading to the queer-trans mobilizations losing out on intersectional nuances.

These NGOs often also functioned in an kamagra price per pill exploitative manner. Outreach workers, who primarily consisted of working-class queer and transgender people, were paid meager salaries while putting in most of the effort at the ground. Moreover, there was hardly any push for a better public health care system from these NGOs barring calls for an increased number of HIV-testing centers and ART centers. In moves that further affect queer people negatively, the Indian kamagra price per pill government has also canceled the registration of many NGOs that were working for the rights of queer and transgender people.

Along with this, according to the current regulations of the Indian government, any NGO participating in “political activities” cannot accept foreign or transnational funding. Moreover, despite India having the third-highest number of people living with HIV/AIDS in the world (2018 data), the broadcasting of condom ads has been prohibited from 6 A.M. To 10 P.M. kamagra price per pill. In these moments, it is crucial that queer people mobilize and call for a robust, affordable and accessible public health system—a public health system that does not just intend to intervene, but that involves queer and transgender people in the decision-making process.

We need a public health system where queer and transgender people are not discriminated against, and a public health system that not only promises free ART, HRT and SRS, but also engages with sexual and mental-health care needs, has sensitized staff in public hospitals and does not harm the dignity of queer and transgender people. Not all of us will benefit from rainbow-dyed hair, free offers from corporate businesses, and marriage equality, but all of us will benefit from a kind, supportive and accessible public health care kamagra price per pill system. I would like to thank Chayanika Shah, Aniruddha Dutta, L Ramakrishnan, Aqsa Shaikh and Avinaba Dutta for conversations that were crucial to the writing of this piece. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American..

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As the wind howled and the rain slammed down, a team of nurses, http://gmaxturf.com/?page_id=2 respiratory therapists and a kamagra cialis biz avis doctor worked through the night to care for 19 tiny babies as Hurricane Laura slammed southwestern Louisiana.The babies, some on ventilators or eating through a feeding tube, seemed to weather the storm just fine, said Dr. Juan Bossano, the medical kamagra cialis biz avis director of the neonatal intensive care unit at Lake Charles Memorial Hospital for Women. "They did very well. They tolerated kamagra cialis biz avis it very well.

We had a very good day," he said.Laura made landfall early Thursday morning as a Category 4 storm, packing top winds of 150 mph (241 kph), and pushing a storm surge as high as 15 feet in some areas.Hours before it made landfall, officials had to move the babies from the women's hospital to the main hospital in the system after it became clear that storm surge could inundate the women's hospital, located on the southern end of Lake Charles. The hospital has its own generator and kamagra cialis biz avis hospital administrator Alesha Alford said it was built to withstand hurricane force winds. But in the single story facility, there's no room to move up and storm surge in that area was expected to hit nine feet. In a roughly two-hour operation the babies in the kamagra cialis biz avis intensive care unit were transferred by ambulance to Lake Charles Memorial Hospital, a ten-story facility on the northern side of the city.

Trucks carried needed equipment such as incubators.Alford said the storm hadn't yet hit but "the skies looked very ominous." She said everyone pitched in to kamagra cialis biz avis get supplies moved to the other hospital."It went as smooth as could be because we had everyone helping," she said.Alford said three mothers who couldn't be discharged from the women's hospital were also transferred. Two of them had their newborns with them while the child of the third mom was in the intensive care unit. Parents of the other children in the neonatal intensive care unit couldn't stay with them during the storm because there wasn't enough room so Bossano said one nurse was tasked with calling parents kamagra cialis biz avis to keep them informed of how their children were doing. Bossano occasionally posted updates on Facebook.Once they got situated at the larger hospital and the winds picked up, Alford said the patients were moved into the hallways.

To "protect our babies," mattresses were pushed up against the windows to prevent flying glass although none of the windows ended up breaking.She said as huge gusts of wind started coming in, they could feel the building kamagra cialis biz avis vibrate. In addition to Bossano, the medical staff consisted of two neonatal nurse practitioners, 14 nurses and three respiratory therapists who worked on 12-hour shifts. Some of the staff slept on air mattresses in kamagra cialis biz avis the hallway, Alford said. After making it through kamagra cialis biz avis the hurricane, the plan was to have the babies stay in Lake Charles.

While electricity was out in the city, the hospital has its own generator. But Alford said the city's water system has been so heavily damaged that it ultimately forced them to transfer the babies as well as other patients to other hospitals around the state Friday.Both Alford and Bossano repeatedly praised the nursing staff for their work in caring for the babies that in some cases were born weighing only kamagra cialis biz avis a pound or two. Some of the nursing staff lost their houses in the storm, and they were worried about their own families, but they put those concerns aside to care for their tiny patients."Really the nurses and the respiratory therapists are the heroes here," Bosanno said. "They showed that very clearly the way they performed."During his physician residency training about 15 years kamagra cialis biz avis ago, Dr.

Chris Colbert doesn’t recall health equity ever being acknowledged or discussed.“There was just African American residency (training) and the thought that this wasn’t right,” said Colbert, who is African American and serves as assistant emergency medicine residency director and director of health disparities at the University of Illinois College of Medicine. €œBut we didn’t feel like we were in a place where we could say that out loud.”That sentiment has permeated medical education for generations, and many experts contend that’s part of the reason cultural kamagra cialis biz avis and racial inequities persist in a nation that is growing more diverse. €œI think for a lot of organizations … they’ve just been able to check a box and then keep going” kamagra cialis biz avis when it came to cultural competency training, said Dr. James Hildreth, president and CEO of Meharry Medical College, one of three historically Black U.S.

Medical schools.Unless medical education moves beyond that mentality, clinicians are likely to continue ignoring the effect of their implicit or unconscious biases on their kamagra cialis biz avis decisionmaking, which has resulted in:Perpetuation of assumptions that reinforce racist and culturally insensitive stereotypes, such as the notion that Black patients have a higher pain tolerance than whites, leading to misdiagnosed pain assessments that result in Black patients being less likely to receive pain medication. Or when medical book publisher Pearson in 2017 came under scrutiny for such passages as “Arabs may not request pain medicine but instead thank Allah for pain if it is the result of a healing medical procedure,” in its textbook, Nursing. A Concept-Based Approach to Learning.Lack of investigation into kamagra cialis biz avis the root causes for the disparities. Take breast cancer—Black women are 41% more likely to die from the disease than white women despite having a slightly lower incidence rate.

And while breast cancer incidence rates are higher among Black women than white women under age 45, leading organizations, kamagra cialis biz avis including the U.S. Preventive Services Task Force, call for routine mammogram screening once every two years for all women between the ages of 50 and 74 at average risk for the disease.Less intervention, as the Joint Commission points out that non-white patients receive fewer cardiovascular interventions and fewer kidney transplants. Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicle(s) removed.Patients of color are more likely to be blamed for being too passive about their healthcare and less kamagra cialis biz avis engaged in shared decisionmaking.“There’s a lot to be said about what’s being put in front of our learners starting in undergrad but especially in medical school,” said Dr. Nanette Lacuesta, kamagra cialis biz avis director of the Physician Diversity Scholars Program at OhioHealth in Columbus.

€œThere’s a lot of discussion about making sure that the images that are put in front of our students have different cultural considerations woven in.”To address those disparities, OhioHealth has focused on increasing the number of clinicians from underrepresented communities as well as providing cultural sensitivity training.“It helps if you’re an African American physician, but a Caucasian physician needs to understand that too,” said Dr. Mysheika Williams Roberts, Columbus’ health commissioner and a program mentor for the kamagra cialis biz avis past 10 years.The system has partnered with three local medical schools to pair medical students from underrepresented communities with a mentor who can guide professional development and be a sponsor for up to four years. The hope is that graduates will eventually match into OhioHealth residency programs. Now in its 10th year, the Physician Diversity Scholars Program has been completed by 63 students kamagra cialis biz avis.

17 have been matched to either residency or fellowship training at OhioHealth and six have become staff members.“We have a pretty good return on our investment,” Lacuesta said.But that business case isn’t translating across the industry or down to medical education. During the 2018-19 school year, 6.2% of the nation’s more than 25,000 medical school graduates were African American, according to figures from the Association of American Medical Colleges, relatively the same kamagra cialis biz avis proportion who graduated from medical schools in 2002.A sizable portion of Black doctors come from historically Black colleges and universities. Of the 12,219 Black graduates from all medical schools from 2009 to 2019, 14.3% were from HBCUs.“As the nation kamagra cialis biz avis gets older and browner and darker and more colorful, it’s going to be even more of a problem to make sure that we have the kind of healthcare providers who reflect our population,” Hildreth said.Black people account for 22% of all erectile dysfunction deaths, according to the most recent data from the Centers for Disease Control and Prevention. That disparity has underscored a racial healthcare gap that can’t be ignored.

And it has spurred academic leaders from historically Black medical schools to advocate for a targeted response from federal lawmakers, one that they say would have a lasting impact.Hildreth in May testified before Congress, asking for $5 billion over the next five years to help historically Black medical schools address the impact erectile dysfunction treatment has had on people of color.The money would help Meharry, Morehouse, Howard and kamagra cialis biz avis Charles Drew University of Medicine and Science in Los Angeles form a consortium to lead contact tracing and testing efforts within marginalized communities. Evidence has shown less testing and contact tracing occurring in ethnic and racial minority communities compared with predominantly white communities, resulting in fewer tests being administered and less erectile dysfunction treatment surveillance in minority neighborhoods.But the consortium’s role would go beyond just responding to the kamagra. Hildreth said much of the funding would go toward the schools’ efforts to address the structural barriers to better health within those communities.“It changes conversations dramatically when there is a person of color sitting at those tables,” he added.Developing physician leaders of color has been the primary objective of a diversity program started in 2019 at kamagra cialis biz avis UCI School of Medicine in California. The Leadership Education to Advance Diversity-African, Black and Caribbean, or LEAD-ABC, is the first four-year program in the country specifically designed to recruit and train medical students to become physicians that will target reducing healthcare disparities in Black communities and other underserved areas.Evidence has shown a health benefit for minority patients who are treated by minority physicians.A recent study published in the Proceedings of the National Academies of Sciences of the United States of America found Black newborns were more than three times as likely to survive childbirth if they received care from Black doctors compared with white physicians.Dr.

Peter Pronovost, chief quality and clinical transformation officer at University Hospitals health kamagra cialis biz avis system in Cleveland, said such evidence should compel healthcare organizations when possible to do more to offer patients of color opportunities to receive care from clinicians who share similar ethnicities.“Unfortunately we don’t have enough Black physicians to always provide that, but it could be engaging a community health worker who looks like them who’s trusted,” Pronovost said.Like at Meharry, the hope with the UCI program is that the focus on producing more clinicians of color to serve minority communities will improve the health of those patients and help establish greater bonds of trust in the medical field.“There are just these assumptions about African Americans that they abuse drugs and that they’re lazier that reflects in the kind of care that they’re given overall,” said Dr. Carol Major, director of UCI’s kamagra cialis biz avis LEAD-ABC program. €œWe need to teach students and physicians-in-training to stop making these assumptions about a specific population based on the color of their skin.”While Lacuesta from OhioHealth acknowledges challenges remain, she’s said more schools have recognized the importance of addressing such issues around race and bias. She attributes some of that to the role the Affordable Care Act played in establishing targets for providers to reduce health inequities in access and outcomes.“Our world is changing, and people are realizing that structural racism is kamagra cialis biz avis causing a bigger part in the health inequities not only among our patients but also in our learners,” Lacuesta said.Like much of life now, the erectile dysfunction treatment kamagra is transforming running competitions.

The Columbia &. New York-PresbyterianMarathon Team Relay is adapting by adding a virtual component.Runners in the three-day event can kamagra cialis biz avis now participate from anywhere in the U.S. And submit their results tracked by a GPS app. Teams, of two kamagra cialis biz avis to eight members, can also opt to run on-site at the Armory New Balance Track &.

Field Center in Manhattan kamagra cialis biz avis Oct. 15-17. The marathon, now in its fifth year, has always attracted teams from healthcare organizations, with Columbia Orthopedics, NewYork-Presbyterian Lawrence Hospital, Memorial Sloan Kettering, NewYork-Presbyterian Columbia University Irving Medical Center and kamagra cialis biz avis Boehringer Ingelheim fielding teams in the past or 
this year.The event benefits the Armory Foundation and supports its after-school programs for children from underserved New York communities. About 2,000 students in the Armory College Prep program have earned more than $10 million in college scholarships.“We welcome all Heathcare Heroes to join in the fun or aim for the Healthcare division record board,” Armory Foundation Co-President Jonathan Schindel said.Medical schools are significantly changing their curriculums as they try to navigate the complexity of training the next generation of clinicians during a worldwide kamagra.

Some of the modifications are likely to stick around long after erectile dysfunction treatment kamagra cialis biz avis is gone. Medical school leaders say the kamagra has encouraged them to be more innovative and re-think some traditions of medical education. Changes include transitioning courses to virtual settings, having smaller groups participate in anatomy dissections, requiring students to wear personal protective equipment during clinical rotations kamagra cialis biz avis and allowing them to participate in telehealth visits alongside a physician. €œerectile dysfunction treatment has kind of shaken the box,” said Dr.

Steven Scheinman, dean of the Geisinger Commonwealth School of Medicine in Scranton, Pa.The school was planning changes to its curriculum prior to erectile dysfunction treatment, in particular moving all its courses away from lecture to kamagra cialis biz avis discussion classes. erectile dysfunction treatment accelerated that, and even brought forward new components to the curriculum that leadership plans to keep, Scheinman said.For instance, one part of Geisinger’s curriculum has students participating in kamagra cialis biz avis small group discussions with a physician to review real-world patient cases and how they’re handled in the health system. But it was often difficult to book the most sought-after physicians because of their busy schedules. In response to erectile dysfunction treatment, the school transitioned to Zoom web conferencing for the group discussions, giving physicians more flexibility to kamagra cialis biz avis participate.“I don’t know if we would have thought of Zoom if it hadn’t been for erectile dysfunction treatment,” Scheinman said.

Other schools are also finding unexpected benefits to changes erectile dysfunction treatment forced them to implement. Among them is Indiana University School of Medicine, which has revamped its clinical clerkships for third- and fourth-year students.Prior to erectile dysfunction treatment, students kamagra cialis biz avis had clinical rotations with didactic courses to supplement the clinical experience. In March, when clinical rotations were suspended, the school quickly moved the didactic courses online. When those students returned in late June to complete their clinical rotations, they said they felt more comfortable and knowledgeable about what they were seeing since kamagra cialis biz avis they had so much background from the didactic courses.

Given that positive feedback, IU School of Medicine plans to teach the didactic courses to students prior kamagra cialis biz avis to the start of clinical rotations.“Students seemed to be more prepared (for clinical rotations) and … to hit the ground running more than what we had in the past,” said Dr. Brad Allen, senior associate dean of medical student education at IU School of Medicine.Web-based learning hasn’t been perfect. At Dell Medical School at the University of Texas in Austin, first-year students, who started kamagra cialis biz avis at the end of June, weren’t bonding or forming connections through web conferencing, which was concerning because Dell’s curriculum relies heavily on robust and meaningful discussions, said Dr. Susan Cox, the school’s executive vice dean of academics.Because of these concerns, Dell is in the process of bringing the first-year students back to campus in mid-September.

The school kamagra cialis biz avis has a large auditorium that can hold 125 people. Each class will have 50 students, allowing room for social distancing.Some activities, such as simulated patient clinics, can’t be shifted to an online experience and students must still come to campus. Schools have responded by providing students with masks, kamagra cialis biz avis gloves and face shields as well as decreasing the number of students in a grouping. Partnering with an affiliated health system has been key to ensuring medical students have adequate PPE, said Dr kamagra cialis biz avis.

Badrinath Konety, dean of Rush Medical College in Chicago.Rush also requires students coming on campus for classes to use an app that surveys users for erectile dysfunction treatment symptoms.Cadaver dissections in the first year are also being rethought, with smaller groups than in years past. And rather than segments of the course being sprinkled across the fall semester, IU School of Medicine transitioned to a block course kamagra cialis biz avis at the term’s start to ensure students will complete it before potential surges during flu season. Dissections will now be complete by the end of September. €œWe are trying to get our students through things where they need to have face-to-face activity” with other students, Allen said.For its part, kamagra cialis biz avis Geisinger is doing a combination of in-person and virtual dissections for students.

Geisinger discovered a cadaver simulation tool online last spring when it abruptly had to end brain dissections because of erectile dysfunction treatment. Students and staff kamagra cialis biz avis responded positively to the online platform for its detail and realism. €œIn many ways, the simulation illustrates the anatomy better,” Scheinman said..

As the http://lifetech-hc.com/2018/06/19/hallo-welt/ wind howled and the rain slammed down, a team of nurses, respiratory therapists and a doctor worked through the night to care for 19 tiny babies as Hurricane Laura slammed southwestern Louisiana.The babies, some on ventilators or eating through a feeding kamagra price per pill tube, seemed to weather the storm just fine, said Dr. Juan Bossano, the medical director of the neonatal intensive care unit at Lake Charles kamagra price per pill Memorial Hospital for Women. "They did very well.

They tolerated it very kamagra price per pill well. We had a very good day," he said.Laura made landfall early Thursday morning as a Category 4 storm, packing top winds of 150 mph (241 kph), and pushing a storm surge as high as 15 feet in some areas.Hours before it made landfall, officials had to move the babies from the women's hospital to the main hospital in the system after it became clear that storm surge could inundate the women's hospital, located on the southern end of Lake Charles. The hospital has its own generator and hospital administrator Alesha Alford said it was built to withstand hurricane kamagra price per pill force winds.

But in the single story facility, there's no room to move up and storm surge in that area was expected to hit nine feet. In a roughly two-hour operation the babies in the intensive kamagra price per pill care unit were transferred by ambulance to Lake Charles Memorial Hospital, a ten-story facility on the northern side of the city. Trucks carried needed equipment such as incubators.Alford said the storm hadn't yet hit but "the skies looked very ominous." She said everyone pitched kamagra price per pill in to get supplies moved to the other hospital."It went as smooth as could be because we had everyone helping," she said.Alford said three mothers who couldn't be discharged from the women's hospital were also transferred.

Two of them had their newborns with them while the child of the third mom was in the intensive care unit. Parents of the other children in the neonatal intensive care unit couldn't stay with them during the kamagra price per pill storm because there wasn't enough room so Bossano said one nurse was tasked with calling parents to keep them informed of how their children were doing. Bossano occasionally posted updates on Facebook.Once they got situated at the larger hospital and the winds picked up, Alford said the patients were moved into the hallways.

To "protect our babies," mattresses were pushed up against the windows to prevent flying glass although none of the windows ended up breaking.She said as huge gusts of wind started coming kamagra price per pill in, they could feel the building vibrate. In addition to Bossano, the medical staff consisted of two neonatal nurse practitioners, 14 nurses and three respiratory therapists who worked on 12-hour shifts. Some of the staff slept on air mattresses kamagra price per pill in the hallway, Alford said.

After making it through the kamagra price per pill hurricane, the plan was to have the babies stay in Lake Charles. While electricity was out in the city, the hospital has its own generator. But Alford said kamagra price per pill the city's water system has been so heavily damaged that it ultimately forced them to transfer the babies as well as other patients to other hospitals around the state Friday.Both Alford and Bossano repeatedly praised the nursing staff for their work in caring for the babies that in some cases were born weighing only a pound or two.

Some of the nursing staff lost their houses in the storm, and they were worried about their own families, but they put those concerns aside to care for their tiny patients."Really the nurses and the respiratory therapists are the heroes here," Bosanno said. "They showed that very kamagra price per pill clearly the way they performed."During his physician residency training about 15 years ago, Dr. Chris Colbert doesn’t recall health equity ever being acknowledged or discussed.“There was just African American residency (training) and the thought that this wasn’t right,” said Colbert, who is African American and serves as assistant emergency medicine residency director and director of health disparities at the University of Illinois College of Medicine.

€œBut we didn’t feel like we were in a place where we could say kamagra price per pill that out loud.”That sentiment has permeated medical education for generations, and many experts contend that’s part of the reason cultural and racial inequities persist in a nation that is growing more diverse. €œI think for a lot kamagra price per pill of organizations … they’ve just been able to check a box and then keep going” when it came to cultural competency training, said Dr. James Hildreth, president and CEO of Meharry Medical College, one of three historically Black U.S.

Medical schools.Unless medical education moves beyond that mentality, clinicians are likely to continue ignoring the effect of their implicit or unconscious biases on their decisionmaking, which has resulted in:Perpetuation of assumptions that reinforce racist and culturally insensitive stereotypes, such as the notion that Black patients have a higher pain tolerance than whites, leading to misdiagnosed kamagra price per pill pain assessments that result in Black patients being less likely to receive pain medication. Or when medical book publisher Pearson in 2017 came under scrutiny for such passages as “Arabs may not request pain medicine but instead thank Allah for pain if it is the result of a healing medical procedure,” in its textbook, Nursing. A Concept-Based Approach kamagra price per pill to Learning.Lack of investigation into the root causes for the disparities.

Take breast cancer—Black women are 41% more likely to die from the disease than white women despite having a slightly lower incidence rate. And while breast cancer incidence rates are higher among Black women than white women under age 45, leading organizations, including the U.S kamagra price per pill. Preventive Services Task Force, call for routine mammogram screening once every two years for all women between the ages of 50 and 74 at average risk for the disease.Less intervention, as the Joint Commission points out that non-white patients receive fewer cardiovascular interventions and fewer kidney transplants.

Black men kamagra price per pill are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicle(s) removed.Patients of color are more likely to be blamed for being too passive about their healthcare and less engaged in shared decisionmaking.“There’s a lot to be said about what’s being put in front of our learners starting in undergrad but especially in medical school,” said Dr. Nanette Lacuesta, director of the Physician Diversity Scholars kamagra price per pill Program at OhioHealth in Columbus. €œThere’s a lot of discussion about making sure that the images that are put in front of our students have different cultural considerations woven in.”To address those disparities, OhioHealth has focused on increasing the number of clinicians from underrepresented communities as well as providing cultural sensitivity training.“It helps if you’re an African American physician, but a Caucasian physician needs to understand that too,” said Dr.

Mysheika Williams Roberts, Columbus’ health commissioner and a program mentor for the past 10 years.The system has partnered with three local medical schools to pair medical students kamagra price per pill from underrepresented communities with a mentor who can guide professional development and be a sponsor for up to four years. The hope is that graduates will eventually match into OhioHealth residency programs. Now in its 10th year, the Physician kamagra price per pill Diversity Scholars Program has been completed by 63 students.

17 have been matched to either residency or fellowship training at OhioHealth and six have become staff members.“We have a pretty good return on our investment,” Lacuesta said.But that business case isn’t translating across the industry or down to medical education. During the 2018-19 school year, 6.2% of the nation’s more than 25,000 medical school graduates were African American, according to figures from the Association kamagra price per pill of American Medical Colleges, relatively the same proportion who graduated from medical schools in 2002.A sizable portion of Black doctors come from historically Black colleges and universities. Of the 12,219 Black graduates from all medical schools from 2009 to 2019, 14.3% were from HBCUs.“As the nation gets older and browner and darker and more colorful, it’s going to be kamagra price per pill even more of a problem to make sure that we have the kind of healthcare providers who reflect our population,” Hildreth said.Black people account for 22% of all erectile dysfunction deaths, according to the most recent data from the Centers for Disease Control and Prevention.

That disparity has underscored a racial healthcare gap that can’t be ignored. And it has spurred academic leaders from historically Black medical schools to advocate for a targeted response from federal lawmakers, one that they say would have a lasting impact.Hildreth in May testified before Congress, asking for $5 billion over the next five years to help historically Black medical schools address the impact erectile dysfunction treatment has had on people of color.The money would help Meharry, Morehouse, Howard and Charles Drew kamagra price per pill University of Medicine and Science in Los Angeles form a consortium to lead contact tracing and testing efforts within marginalized communities. Evidence has shown less testing and contact tracing occurring in ethnic and racial minority communities compared with predominantly white communities, resulting in fewer tests being administered and less erectile dysfunction treatment surveillance in minority neighborhoods.But the consortium’s role would go beyond just responding to the kamagra.

Hildreth said much of the funding would go toward the schools’ efforts to address the structural barriers to better health within those communities.“It changes conversations dramatically when there is a person of color sitting at those tables,” he added.Developing physician leaders of color has been the primary kamagra price per pill objective of a diversity program started in 2019 at UCI School of Medicine in California. The Leadership Education to Advance Diversity-African, Black and Caribbean, or LEAD-ABC, is the first four-year program in the country specifically designed to recruit and train medical students to become physicians that will target reducing healthcare disparities in Black communities and other underserved areas.Evidence has shown a health benefit for minority patients who are treated by minority physicians.A recent study published in the Proceedings of the National Academies of Sciences of the United States of America found Black newborns were more than three times as likely to survive childbirth if they received care from Black doctors compared with white physicians.Dr. Peter Pronovost, chief quality and clinical transformation officer at University Hospitals health system in Cleveland, said such evidence should compel healthcare organizations when possible to do more to offer patients of color opportunities to receive care from clinicians who share similar ethnicities.“Unfortunately we don’t have enough Black physicians to always provide that, but it could be engaging a community health worker who looks like them who’s trusted,” Pronovost said.Like at Meharry, the hope with the UCI program is that the focus on producing more clinicians of color to serve minority communities will improve the health kamagra price per pill of those patients and help establish greater bonds of trust in the medical field.“There are just these assumptions about African Americans that they abuse drugs and that they’re lazier that reflects in the kind of care that they’re given overall,” said Dr.

Carol Major, director of kamagra price per pill UCI’s LEAD-ABC program. €œWe need to teach students and physicians-in-training to stop making these assumptions about a specific population based on the color of their skin.”While Lacuesta from OhioHealth acknowledges challenges remain, she’s said more schools have recognized the importance of addressing such issues around race and bias. She attributes some of that to the role the Affordable Care Act played in establishing targets for providers to reduce health inequities kamagra price per pill in access and outcomes.“Our world is changing, and people are realizing that structural racism is causing a bigger part in the health inequities not only among our patients but also in our learners,” Lacuesta said.Like much of life now, the erectile dysfunction treatment kamagra is transforming running competitions.

The Columbia &. New York-PresbyterianMarathon Team Relay is adapting by adding a virtual component.Runners in the three-day event can now kamagra price per pill participate from anywhere in the U.S. And submit their results tracked by a GPS app.

Teams, of two to eight members, can also opt to run on-site at the Armory New Balance Track kamagra price per pill &. Field Center in kamagra price per pill Manhattan Oct. 15-17.

The marathon, now in its fifth year, has always attracted teams from healthcare organizations, with Columbia Orthopedics, NewYork-Presbyterian Lawrence Hospital, Memorial Sloan Kettering, NewYork-Presbyterian Columbia University Irving Medical Center and Boehringer Ingelheim fielding teams in the past or 
this year.The event benefits the kamagra price per pill Armory Foundation and supports its after-school programs for children from underserved New York communities. About 2,000 students in the Armory College Prep program have earned more than $10 million in college scholarships.“We welcome all Heathcare Heroes to join in the fun or aim for the Healthcare division record board,” Armory Foundation Co-President Jonathan Schindel said.Medical schools are significantly changing their curriculums as they try to navigate the complexity of training the next generation of clinicians during a worldwide kamagra. Some of the modifications kamagra price per pill are likely to stick around long after erectile dysfunction treatment is gone.

Medical school leaders say the kamagra has encouraged them to be more innovative and re-think some traditions of medical education. Changes include transitioning courses to virtual settings, having smaller groups participate in anatomy dissections, requiring students to wear kamagra price per pill personal protective equipment during clinical rotations and allowing them to participate in telehealth visits alongside a physician. €œerectile dysfunction treatment has kind of shaken the box,” said Dr.

Steven Scheinman, dean of the Geisinger Commonwealth School of Medicine in Scranton, Pa.The school was planning changes to its curriculum prior to erectile dysfunction treatment, in particular moving all its courses away from lecture to discussion kamagra price per pill classes. erectile dysfunction treatment accelerated that, and even brought forward new components to the curriculum that leadership plans to keep, Scheinman said.For instance, one part of Geisinger’s curriculum has kamagra price per pill students participating in small group discussions with a physician to review real-world patient cases and how they’re handled in the health system. But it was often difficult to book the most sought-after physicians because of their busy schedules.

In response to erectile dysfunction treatment, the school transitioned to Zoom web conferencing for the group discussions, giving physicians more flexibility to participate.“I don’t know if we would have thought of Zoom if it hadn’t been for erectile dysfunction treatment,” Scheinman kamagra price per pill said. Other schools are also finding unexpected benefits to changes erectile dysfunction treatment forced them to implement. Among them is Indiana University School of Medicine, which has revamped its clinical clerkships for third- and fourth-year students.Prior to erectile dysfunction treatment, students kamagra price per pill had clinical rotations with didactic courses to supplement the clinical experience.

In March, when clinical rotations were suspended, the school quickly moved the didactic courses online. When those students returned in late June to complete their clinical rotations, they said they felt more comfortable and knowledgeable about what they were kamagra price per pill seeing since they had so much background from the didactic courses. Given that positive feedback, IU School of Medicine plans to teach the didactic courses to students prior to the start of clinical rotations.“Students seemed to be more prepared (for clinical rotations) and … to hit the kamagra price per pill ground running more than what we had in the past,” said Dr.

Brad Allen, senior associate dean of medical student education at IU School of Medicine.Web-based learning hasn’t been perfect. At Dell Medical School at the University kamagra price per pill of Texas in Austin, first-year students, who started at the end of June, weren’t bonding or forming connections through web conferencing, which was concerning because Dell’s curriculum relies heavily on robust and meaningful discussions, said Dr. Susan Cox, the school’s executive vice dean of academics.Because of these concerns, Dell is in the process of bringing the first-year students back to campus in mid-September.

The school has kamagra price per pill a large auditorium that can hold 125 people. Each class will have 50 students, allowing room for social distancing.Some activities, such as simulated patient clinics, can’t be shifted to an online experience and students must still come to campus. Schools have responded by providing students with masks, gloves and face shields as well as decreasing the number of students in kamagra price per pill a grouping.

Partnering with an affiliated health system has been kamagra price per pill key to ensuring medical students have adequate PPE, said Dr. Badrinath Konety, dean of Rush Medical College in Chicago.Rush also requires students coming on campus for classes to use an app that surveys users for erectile dysfunction treatment symptoms.Cadaver dissections in the first year are also being rethought, with smaller groups than in years past. And rather than segments of the course being sprinkled across the fall semester, IU School of Medicine transitioned to a block course kamagra price per pill at the term’s start to ensure students will complete it before potential surges during flu season.

Dissections will now be complete by the end of September. €œWe are trying to get our students through things where they need to have face-to-face activity” with other students, Allen said.For its part, Geisinger is doing a combination of in-person and kamagra price per pill virtual dissections for students. Geisinger discovered a cadaver simulation tool online last spring when it abruptly had to end brain dissections because of erectile dysfunction treatment.

Students and staff responded positively to kamagra price per pill the online platform for its detail and realism. €œIn many ways, the simulation illustrates the anatomy better,” Scheinman said..