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A United Airlines passenger jet takes off with New York City as a backdrop, at Newark Liberty International propecia price canada Airport, New Jersey.Chris Helgren | ReutersIt's time to say goodbye to the $200 ticket-change fee.United Airlines on Sunday said that it will permanently scrap fees to change domestic flights, a big bet that more flexible policies will win over much-needed customers as the pain from the hair loss propecia's impact http://arif.eu/best-price-generic-propecia/ on air travel continue to mount.It's a page from the playbook of rival Southwest Airlines, which doesn't charge customers fees to change their flights."Following previous tough times, airlines made difficult decisions to survive, sometimes at the expense of customer service," said United CEO Scott Kirby in a news release. "United Airlines won't be following that same playbook as we propecia price canada come out of this crisis. Instead, we're taking a completely different approach – and looking at propecia price canada new ways to serve our customers better."United's announcement that it will no longer charge travelers the $200 fee comes as airlines are scrambling to find ways to revitalize their businesses, which have been battered by the propecia.

This summer, propecia price canada Transportation Security Administration screenings at U.S. Airports are hovering around 30% of last year's levels, as airlines go without much-needed revenue during the peak summer travel season.The Chicago-based airline in January will also allow customers who want to depart earlier or later the same day to fly propecia price canada standby without paying a $75 same-day change fee.The measures could ramp up pressure on rivals to make similar policy changes.The end of the ticket-change costs is a departure from the myriad add-ons and other fees that airlines spent years rolling out. Last year, propecia price canada U.S.

Carriers brought in $2.8 billion in ticket-change and cancellation fees, according to the Department of Transportation..

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With less than 90 days until COP26, the annual United Nations climate change conference being held in Glasgow, Scotland this November, pressure is high for nations to limit global temperature propecia without seeing a doctor rise to https://excursionsireland.com/tour_location/tower-museum/ 1.5 degrees Celsius. The 2015 Paris Agreement called for commitments to hold warming to “well below” 2 degrees C and pursue efforts to limit warming to 1.5 degrees C. Since then, advances in climate science have found that the 2 degree C mark is insufficient to stave off the worst impacts of climate change, strengthening the need propecia without seeing a doctor for an updated 1.5 degrees C target. Temperatures have already risen by 1.2 degrees C above preindustrial levels, resulting in devastating floods, fires and droughts reflected in distressing daily headlines.

Every increment of warming beyond 1.5 degrees C will result in increasingly destructive and costly repercussions, particularly for the most vulnerable communities and countries in low-income and small island states. Now the heat is on the International Energy Agency (IEA), an intergovernmental organization that shapes global energy policy, propecia without seeing a doctor to convey this to its member governments, businesses and markets by centering a 1.5 degrees C–consistent pathway in its widely-read annual publication, the World Energy Outlook (WEO). Formed in 1974 in the context of a bruising oil crisis, the IEA has become an influential source of data and market analysis with a broadened mandate to ensure affordable, reliable and clean energy. Energy represents the largest source of humanity’s greenhouse gas emissions, with nearly two thirds of emissions linked to the burning of fossil fuels.

Rapidly driving propecia without seeing a doctor down energy emissions is therefore central to holding warming to 1.5 degrees C. Although the IEA does not recommend a specific level of acceptable warming, its WEO scenarios provide crucial roadmaps for political and business decisions by outlining the feasibility associated with achieving different policy goals. A landmark shift in international policy focus arrived in 2018 with a sobering report from the Intergovernmental Panel on Climate Change (IPCC)—the United Nations body responsible for assessing climate change science—which revealed that holding warming to 1.5 degrees C would require social and economic changes at a speed and scale for which there is no documented historical precedent. The question propecia without seeing a doctor now is how to get there.

The latest science shows us that the window to keep 1.5 alive and avoid further catastrophic impacts is closing. This is where the IEA’s upcoming WEO, described as a “Google map” for global energy markets, could be pivotal—if the IEA aligns it with 1.5 degrees C. Previous WEOs contain a series of scenarios, with the central “Stated Energy Policies propecia without seeing a doctor Scenario” (STEPS)—the reference case—receiving the most detail and emphasis. STEPS outlines the consequences of no additional climate action.

Between 2.7 degrees C and 3 degrees C of warming. As the IEA states, showing the insufficiency of existing policies propecia without seeing a doctor has value. But caution is needed when governments, investment analysts, businesses, and media interpret the reference case as the default guide for decision-making. Neglecting to align the core propecia without seeing a doctor WEO scenario with 1.5 degrees C is not the only way that the IEA has been out of touch with the pace of technology change and scientific knowledge.

Both the scientific community and civil society have criticized the IEA’s modeling for its underlying bias in favor of the fossil fuel-based status quo. Moreover, the agency significantly underestimates the growth of renewables, which risks hindering renewable energy transitions. The campaign to #FixtheWEO also calls for replacing the central scenario to account for the imperative of staying below propecia without seeing a doctor 1.5 degrees C. Although the IEA shows signs of moving in the right direction, international consensus on 1.5 degrees C as the de facto target is not a foregone conclusion.

In May, at the request of the U.K. COP presidency, the IEA released its first comprehensive study of how to transition to a net zero energy system by 2050 and give the world a propecia without seeing a doctor chance of limiting global temperature rise to 1.5 degrees C. This marked a sea change in the IEA’s messaging. Instead of calling for more oil and gas investment, the IEA concluded there is “no need for investment in new fossil fuel supply.” However, countries including Japan, Brazil and Australia have disputed the findings, which clash with their own fossil fuel expansion plans.

But illuminating the gaps between countries’ Paris propecia without seeing a doctor Agreement commitments and policy action is exactly what the world needs before COP26. Because the WEO is used by policy makers and investors alike to guide trillions in energy investment, the scenarios it prioritizes could become a self-fulfilling prophecy—either toward a 1.5 degrees C aligned future or worsening climate crisis. In an open letter to Fatih Birol, the executive director of the IEA, 60 leaders in policy, investment, academia, and civil society argued that the reference case “represents an insufficient level and pace of transformation” and “charts a dangerous course.” Christiana Figueres, the former executive secretary of the U.N. Framework Convention on Climate Change (UNFCCC), joined in, calling a 1.5 degrees C–aligned WEO a “golden key” to “open the portal to policy development and propecia without seeing a doctor capital deployment.” Holding warming to 1.5 degrees C poses significant economic and technical challenges, but the alternative would be a less habitable planet.

With global energy growth outpacing decarbonization, achieving a livable future will require a guiding blueprint that supports policy coherence with IPCC 1.5 degrees C recommendations and guides investment toward a stable climate. Placing a 1.5 degrees C-centered scenario at the heart of the WEO would model the market pathways needed to allow countries, companies and communities to cooperate toward this goal. As negotiators prepare to devise the future of climate action at COP26, the IEA propecia without seeing a doctor is positioned to foreground this pathway in the WEO 2021 during what could be a turning point for this decisive decade. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American.In propecia without seeing a doctor my 20s, I had a friend who was brilliant, charming, Ivy-educated and rich, heir to a family fortune. I’ll call him Gallagher. He could do anything he wanted. He experimented, dabbling propecia without seeing a doctor in neuroscience, law, philosophy and other fields.

But he was so critical, so picky, that he never settled on a career. Nothing was good enough for him. He never propecia without seeing a doctor found love for the same reason. He also disparaged his friends’ choices, so much so that he alienated us.

He ended up bitter and alone. At least propecia without seeing a doctor that’s my guess. I haven’t spoken to Gallagher in decades. There is such a thing as being too picky, especially when it comes to things like work, love and nourishment (even the pickiest eater has to eat something).

That’s the lesson I gleaned from propecia without seeing a doctor Gallagher. But when it comes to answers to big mysteries, most of us aren’t picky enough. We settle on answers for bad reasons, for example, because our parents, priests or professors believe it. We think propecia without seeing a doctor we need to believe something, but actually we don’t.

We can, and should, decide that no answers are good enough. We should be agnostics propecia without seeing a doctor. Some people confuse agnosticism (not knowing) with apathy (not caring). Take Francis Collins, a geneticist who directs the National Institutes of Health.

He is a devout Christian, who believes that Jesus performed propecia without seeing a doctor miracles, died for our sins and rose from the dead. In his 2006 bestseller The Language of God, Collins calls agnosticism a “cop-out.” When I interviewed him, I told him I am an agnostic and objected to “cop-out.” Collins apologized. €œThat was a put-down that should not apply to earnest agnostics who have considered the evidence and still don’t find an answer,” he said. €œI was reacting to the agnosticism I see in the scientific community, propecia without seeing a doctor which has not been arrived at by a careful examination of the evidence.” I have examined the evidence for Christianity, and I find it unconvincing.

I’m not convinced by any scientific creation stories, either, such as those that depict our cosmos as a bubble in an oceanic “multiverse.” People I admire fault me for being too skeptical. One is the late religious philosopher Huston Smith, who called me “convictionally impaired.” Another is megapundit Robert Wright, an old friend, with whom I’ve often argued about evolutionary psychology and Buddhism. Wright once asked me in exasperation, “Don’t you believe anything? propecia without seeing a doctor. € Actually, I believe lots of things, for example, that war is bad and should be abolished.

But when it comes to theories about ultimate reality, I’m with Voltaire. €œDoubt is not a pleasant condition,” Voltaire said, “but certainty is an absurd one.” Doubt protects us from dogmatism, which can easily morph into fanaticism and what William James calls a “premature closing of our accounts with reality.” Below I defend agnosticism as a stance toward the existence of God, interpretations of quantum mechanics propecia without seeing a doctor and theories of consciousness. When considering alleged answers to these three riddles, we should be as picky as my old friend Gallagher. THE PROBLEM OF EVIL Why do we exist?.

The answer, according to the major monotheistic propecia without seeing a doctor religions, including the Catholic faith in which I was raised, is that an all-powerful, supernatural entity created us. This deity loves us, as a human father loves his children, and wants us to behave in a certain way. If we’re propecia without seeing a doctor good, He’ll reward us. If we’re bad, He’ll punish us.

(I use the pronoun “He” because most scriptures describe God as male.) My main objection to this explanation of reality is the problem of evil. A casual glance at human history, and at the world propecia without seeing a doctor today, reveals enormous suffering and injustice. If God loves us and is omnipotent, why is life so horrific for so many people?. A standard response to this question is that God gave us free will.

We can choose to be bad as well as propecia without seeing a doctor good. The late, great physicist Steven Weinberg, an atheist, who died in July, slaps down the free will argument in his book Dreams of a Final Theory. Noting that Nazis killed many of his relatives in the Holocaust, Weinberg asks. Did millions of Jews http://harap-lak.de/2017/10/25/flammkuchen/ have to die so the propecia without seeing a doctor Nazis could exercise their free will?.

That doesn’t seem fair. And what about kids who get cancer?. Are we supposed propecia without seeing a doctor to think that cancer cells have free will?. On the other hand, life isn’t always hellish.

We experience love, friendship, adventure and heartbreaking beauty. Could all this really come from random collisions of propecia without seeing a doctor particles?. Even Weinberg concedes that life sometimes seems “more beautiful than strictly necessary.” If the problem of evil prevents me from believing in a loving God, then the problem of beauty keeps me from being an atheist like Weinberg. Hence, agnosticism.

THE PROBLEM propecia without seeing a doctor OF INFORMATION Quantum mechanics is science’s most precise, powerful theory of reality. It has predicted countless experiments, spawned countless applications. The trouble is, physicists and philosophers disagree over what it means, that is, propecia without seeing a doctor what it says about how the world works. Many physicists—most, probably—adhere to the Copenhagen interpretation, advanced by Danish physicist Niels Bohr.

But that is a kind of anti-interpretation, which says physicists should not try to make sense of quantum mechanics. They should “shut up and calculate,” as physicist David Mermin once propecia without seeing a doctor put it. Philosopher Tim Maudlin deplores this situation. In his 2019 book Philosophy of Physics.

Quantum Theory, he points out propecia without seeing a doctor that several interpretations of quantum mechanics describe in detail how the world works. These include the GRW model proposed by Ghirardi, Rimini and Weber. The pilot-wave theory of David Bohm. And the many-worlds hypothesis of Hugh propecia without seeing a doctor Everett.

But here’s the irony. Maudlin is so scrupulous in pointing out the flaws of these interpretations that he reinforces my skepticism. They all seem hopelessly kludgy propecia without seeing a doctor and preposterous. Maudlin does not examine interpretations that recast quantum mechanics as a theory about information.

For positive perspectives on information-based interpretations, check out Beyond Weird by journalist Philip Ball and The Ascent of Information by astrobiologist Caleb Scharf. But to my mind, information-based takes on quantum mechanics are even less plausible than the interpretations that propecia without seeing a doctor Maudlin scrutinizes. The concept of information makes no sense without conscious beings to send, receive and act upon the information. Introducing consciousness into physics undermines its claim to propecia without seeing a doctor objectivity.

Moreover, as far as we know, consciousness arises only in certain organisms that have existed for a brief period here on Earth. So how can quantum mechanics, if it’s a theory of information rather than matter and energy, apply to the entire cosmos since the big bang?. Information-based theories of physics seem propecia without seeing a doctor like a throwback to geocentrism, which assumed the universe revolves around us. Given the problems with all interpretations of quantum mechanics, agnosticism, again, strikes me as a sensible stance.

MIND-BODY PROBLEMS The debate over consciousness is even more fractious than the debate over quantum mechanics. How does matter make propecia without seeing a doctor a mind?. A few decades ago, a consensus seemed to be emerging. Philosopher Daniel Dennett, in his cockily titled Consciousness Explained, asserted that consciousness clearly emerges from neural processes, such as electrochemical pulses in the brain.

Francis Crick and Christof Koch proposed that consciousness is generated by propecia without seeing a doctor networks of neurons oscillating in synchrony. Gradually, this consensus collapsed, as empirical evidence for neural theories of consciousness failed to materialize. As I point out in my recent book Mind-Body Problems, there are now a dizzying variety of theories of consciousness. Christof Koch has thrown propecia without seeing a doctor his weight behind integrated information theory, which holds that consciousness might be a property of all matter, not just brains.

This theory suffers from the same problems as information-based theories of quantum mechanics. Theorists such as Roger Penrose, who won last year’s Nobel Prize in Physics, have conjectured that quantum effects underpin consciousness, but this theory is even more lacking in evidence than integrated information theory. Researchers cannot even agree on propecia without seeing a doctor what form a theory of consciousness should take. Should it be a philosophical treatise?.

A purely mathematical propecia without seeing a doctor model?. A gigantic algorithm, perhaps based on Bayesian computation?. Should it borrow concepts from Buddhism, such as anatta, the doctrine of no self?. All propecia without seeing a doctor of the above?.

None of the above?. Consensus seems farther away than ever. And that’s a good propecia without seeing a doctor thing. We should be open-minded about our minds.

So, what’s the difference, if any, between me and Gallagher, my former friend?. I like to think propecia without seeing a doctor it’s a matter of style. Gallagher scorned the choices of others. He resembled one of those mean-spirited atheists who revile the faithful for their beliefs.

I try not to be dogmatic in my disbelief, and to be sympathetic toward those who, like Francis Collins, have found propecia without seeing a doctor answers that work for them. Also, I get a kick out of inventive theories of everything, such as John Wheeler’s “it from bit” and Freeman Dyson’s principle of maximum diversity, even if I can’t embrace them. I’m definitely a skeptic. I doubt we’ll ever know whether God exists, what quantum propecia without seeing a doctor mechanics means, how matter makes mind.

These three puzzles, I suspect, are different aspects of a single, impenetrable mystery at the heart of things. But one of the pleasures of agnosticism—perhaps the greatest pleasure—is that propecia without seeing a doctor I can keep looking for answers and hoping that a revelation awaits just over the horizon. This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American.

Further Reading propecia without seeing a doctor. I air my agnostic outlook in my two most recent books, Mind-Body Problems, available for free online, and Pay Attention. Sex, Death, and Science. See also my podcast “Mind-Body Problems,” where I talk to experts, including several mentioned above, about God, quantum mechanics and propecia without seeing a doctor consciousness.ITALY Art restorers have cleaned the Medici Chapel in Florence with the help of bacteria.

Serratia, Pseudomonas and Rhodococcus ate away at detritus—from visitors and decaying corpses—that had seeped into Michelangelo’s sarcophagi. GALÁPAGOS ISLANDS Genetic analysis confirmed that a female giant tortoise, discovered in the Galápagos Islands in 2019, belongs to a species last seen in 1906. Rangers spotted evidence of at least two propecia without seeing a doctor more of the reptiles, buoying hopes of finding a mate for the female. DEMOCRATIC REPUBLIC OF CONGO Mount Nyiragongo, one of the world’s most active volcanoes, erupted for the first time since 2002 and displaced hundreds of thousands of people.

A local volcano observatory had warned of a possible eruption last year, but budget cuts and an Internet disruption limited its ability to predict the blast. INDONESIA Researchers found propecia without seeing a doctor that monsoon seasons lengthened by climate change are damaging some of the world’s oldest rock art. The rains most likely increase salt crystal formation in Sulawesi island’s limestone caves, breaking up the 20,000- to 45,500-year-old paintings’ rocky canvases. CAMBODIA A giant pouched rat named Magawa has retired after sniffing out unexploded land mines for five years.

Trained by a Belgian nonprofit organization, the rodent received a bravery prize previously awarded only to dogs. AUSTRALIA At least seven Tasmanian devils were born in mainland Australia—the first wild births there in 3,000 years—after the animals were reintroduced last year. Human settlers had long ago brought in dingoes, which wiped out mainland devils and limited their range to the island state of Tasmania..

With less than 90 days until COP26, the annual United Nations climate change conference being propecia price canada held in Glasgow, Scotland this November, pressure is high for nations to limit global temperature rise to 1.5 degrees Celsius. The 2015 Paris Agreement called for commitments to hold warming to “well below” 2 degrees C and pursue efforts to limit warming to 1.5 degrees C. Since then, advances in climate science have found that the 2 degree C mark is insufficient to stave off the worst impacts of climate change, strengthening propecia price canada the need for an updated 1.5 degrees C target. Temperatures have already risen by 1.2 degrees C above preindustrial levels, resulting in devastating floods, fires and droughts reflected in distressing daily headlines.

Every increment of warming beyond 1.5 degrees C will result in increasingly destructive and costly repercussions, particularly for the most vulnerable communities and countries in low-income and small island states. Now the heat is on the International Energy Agency (IEA), propecia price canada an intergovernmental organization that shapes global energy policy, to convey this to its member governments, businesses and markets by centering a 1.5 degrees C–consistent pathway in its widely-read annual publication, the World Energy Outlook (WEO). Formed in 1974 in the context of a bruising oil crisis, the IEA has become an influential source of data and market analysis with a broadened mandate to ensure affordable, reliable and clean energy. Energy represents the largest source of humanity’s greenhouse gas emissions, with nearly two thirds of emissions linked to the burning of fossil fuels.

Rapidly driving down energy emissions propecia price canada is therefore central to holding warming to 1.5 degrees C. Although the IEA does not recommend a specific level of acceptable warming, its WEO scenarios provide crucial roadmaps for political and business decisions by outlining the feasibility associated with achieving different policy goals. A landmark shift in international policy focus arrived in 2018 with a sobering report from the Intergovernmental Panel on Climate Change (IPCC)—the United Nations body responsible for assessing climate change science—which revealed that holding warming to 1.5 degrees C would require social and economic changes at a speed and scale for which there is no documented historical precedent. The question now propecia price canada is how to get there.

The latest science shows us that the window to keep 1.5 alive and avoid further catastrophic impacts is closing. This is where the IEA’s upcoming WEO, described as a “Google map” for global energy markets, could be pivotal—if the IEA aligns it with 1.5 degrees C. Previous WEOs contain a series of scenarios, with the central “Stated Energy Policies Scenario” (STEPS)—the reference propecia price canada case—receiving the most detail and emphasis. STEPS outlines the consequences of no additional climate action.

Between 2.7 degrees C and 3 degrees C of warming. As the IEA states, showing the insufficiency of propecia price canada existing policies has value. But caution is needed when governments, investment analysts, businesses, and media interpret the reference case as the default guide for decision-making. Neglecting to align the core WEO scenario with 1.5 degrees C is not the only way that the IEA has been out of touch with the pace of technology change and scientific propecia price canada knowledge.

Both the scientific community and civil society have criticized the IEA’s modeling for its underlying bias in favor of the fossil fuel-based status quo. Moreover, the agency significantly underestimates the growth of renewables, which risks hindering renewable energy transitions. The campaign to #FixtheWEO also calls for replacing the central scenario to propecia price canada account for the imperative of staying below 1.5 degrees C. Although the IEA shows signs of moving in the right direction, international consensus on 1.5 degrees C as the de facto target is not a foregone conclusion.

In May, at the request of the U.K. COP presidency, propecia price canada the IEA released its first comprehensive study of how to transition to a net zero energy system by 2050 and give the world a chance of limiting global temperature rise to 1.5 degrees C. This marked a sea change in the IEA’s messaging. Instead of calling for more oil and gas investment, the IEA concluded there is “no need for investment in new fossil fuel supply.” However, countries including Japan, Brazil and Australia have disputed the findings, which clash with their own fossil fuel expansion plans.

But illuminating the gaps between countries’ Paris Agreement commitments and policy action is exactly what the propecia price canada world needs before COP26. Because the WEO is used by policy makers and investors alike to guide trillions in energy investment, the scenarios it prioritizes could become a self-fulfilling prophecy—either toward a 1.5 degrees C aligned future or worsening climate crisis. In an open letter to Fatih Birol, the executive director of the IEA, 60 leaders in policy, investment, academia, and civil society argued that the reference case “represents an insufficient level and pace of transformation” and “charts a dangerous course.” Christiana Figueres, the former executive secretary of the U.N. Framework Convention on Climate Change (UNFCCC), joined in, calling a 1.5 degrees C–aligned WEO a “golden key” propecia price canada to “open the portal to policy development and capital deployment.” Holding warming to 1.5 degrees C poses significant economic and technical challenges, but the alternative would be a less habitable planet.

With global energy growth outpacing decarbonization, achieving a livable future will require a guiding blueprint that supports policy coherence with IPCC 1.5 degrees C recommendations and guides investment toward a stable climate. Placing a 1.5 degrees C-centered scenario at the heart of the WEO would model the market pathways needed to allow countries, companies and communities to cooperate toward this goal. As negotiators prepare to devise the future of climate action at COP26, the IEA is positioned to foreground this pathway in the WEO 2021 during what could be propecia price canada a turning point for this decisive decade. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American.In my 20s, I had a friend who propecia price canada was brilliant, charming, Ivy-educated and rich, heir to a family fortune. I’ll call him Gallagher. He could do anything he wanted. He experimented, dabbling in propecia price canada neuroscience, law, philosophy and other fields.

But he was so critical, so picky, that he never settled on a career. Nothing was good enough for him. He never found love for the propecia price canada same reason. He also disparaged his friends’ choices, so much so that he alienated us.

He ended up bitter and alone. At least that’s propecia price canada my guess. I haven’t spoken to Gallagher in decades. There is such a thing as being too picky, especially when it comes to things like work, love and nourishment (even the pickiest eater has to eat something).

That’s the lesson propecia price canada I gleaned from Gallagher. But when it comes to answers to big mysteries, most of us aren’t picky enough. We settle on answers for bad reasons, for example, because our parents, priests or professors believe it. We think propecia price canada we need to believe something, but actually we don’t.

We can, and should, decide that no answers are good enough. We should be agnostics propecia price canada. Some people confuse agnosticism (not knowing) with apathy (not caring). Take Francis Collins, a geneticist who directs the National Institutes of Health.

He is a devout Christian, who believes that Jesus performed miracles, died for our sins and rose from propecia price canada the dead. In his 2006 bestseller The Language of God, Collins calls agnosticism a “cop-out.” When I interviewed him, I told him I am an agnostic and objected to “cop-out.” Collins apologized. €œThat was a put-down that should not apply to earnest agnostics who have considered the evidence and still don’t find an answer,” he said. €œI was reacting to the agnosticism I see in the scientific community, which has not been arrived at by a propecia price canada careful examination of the evidence.” I have examined the evidence for Christianity, and I find it unconvincing.

I’m not convinced by any scientific creation stories, either, such as those that depict our cosmos as a bubble in an oceanic “multiverse.” People I admire fault me for being too skeptical. One is the late religious philosopher Huston Smith, who called me “convictionally impaired.” Another is megapundit Robert Wright, an old friend, with whom I’ve often argued about evolutionary psychology and Buddhism. Wright once asked me in exasperation, “Don’t propecia price canada you believe anything?. € Actually, I believe lots of things, for example, that war is bad and should be abolished.

But when it comes to theories about ultimate reality, I’m with Voltaire. €œDoubt is not a pleasant condition,” Voltaire said, “but certainty is an absurd one.” Doubt protects us from dogmatism, which can easily morph into fanaticism and what William James calls a “premature closing of our accounts with reality.” Below I defend agnosticism as propecia price canada a stance toward the existence of God, interpretations of quantum mechanics and theories of consciousness. When considering alleged answers to these three riddles, we should be as picky as my old friend Gallagher. THE PROBLEM OF EVIL Why do we exist?.

The answer, according to the major monotheistic religions, including the Catholic faith in propecia price canada which I was raised, is that an all-powerful, supernatural entity created us. This deity loves us, as a human father loves his children, and wants us to behave in a certain way. If we’re good, propecia price canada He’ll reward us. If we’re bad, He’ll punish us.

(I use the pronoun “He” because most scriptures describe God as male.) My main objection to this explanation of reality is the problem of evil. A casual glance propecia price canada at human history, and at the world today, reveals enormous suffering and injustice. If God loves us and is omnipotent, why is life so horrific for so many people?. A standard response to this question is that God gave us free will.

We can choose propecia price canada to be bad as well as good. The late, great physicist Steven Weinberg, an atheist, who died in July, slaps down the free will argument in his book Dreams of a Final Theory. Noting that Nazis killed many of his relatives in the Holocaust, Weinberg asks. Did millions of Jews have to die so the Nazis could exercise propecia price canada their free will?.

That doesn’t seem fair. And what about kids who get cancer?. Are we supposed to think that cancer propecia price canada cells have free will?. On the other hand, life isn’t always hellish.

We experience love, friendship, adventure and heartbreaking beauty. Could all this really come from random propecia price canada collisions of particles?. Even Weinberg concedes that life sometimes seems “more beautiful than strictly necessary.” If the problem of evil prevents me from believing in a loving God, then the problem of beauty keeps me from being an atheist like Weinberg. Hence, agnosticism.

THE PROBLEM OF INFORMATION Quantum mechanics is science’s most propecia price canada precise, powerful theory of reality. It has predicted countless experiments, spawned countless applications. The trouble is, physicists and philosophers disagree over what it propecia price canada means, that is, what it says about how the world works. Many physicists—most, probably—adhere to the Copenhagen interpretation, advanced by Danish physicist Niels Bohr.

But that is a kind of anti-interpretation, which says physicists should not try to make sense of quantum mechanics. They should “shut up and calculate,” as physicist David propecia price canada Mermin once put it. Philosopher Tim Maudlin deplores this situation. In his 2019 book Philosophy of Physics.

Quantum Theory, he points propecia price canada out that several interpretations of quantum mechanics describe in detail how the world works. These include the GRW model proposed by Ghirardi, Rimini and Weber. The pilot-wave theory of David Bohm. And the propecia price canada many-worlds hypothesis of Hugh Everett.

But here’s the irony. Maudlin is so scrupulous in pointing out the flaws of these interpretations that he reinforces my skepticism. They all seem hopelessly propecia price canada kludgy and preposterous. Maudlin does not examine interpretations that recast quantum mechanics as a theory about information.

For positive perspectives on information-based interpretations, check out Beyond Weird by journalist Philip Ball and The Ascent of Information by astrobiologist Caleb Scharf. But to my mind, information-based takes on quantum mechanics are even propecia price canada less plausible than the interpretations that Maudlin scrutinizes. The concept of information makes no sense without conscious beings to send, receive and act upon the information. Introducing consciousness into physics undermines its claim to propecia price canada objectivity.

Moreover, as far as we know, consciousness arises only in certain organisms that have existed for a brief period here on Earth. So how can quantum mechanics, if it’s a theory of information rather than matter and energy, apply to the entire cosmos since the big bang?. Information-based theories of physics seem like a throwback to geocentrism, which assumed the universe revolves around propecia price canada us. Given the problems with all interpretations of quantum mechanics, agnosticism, again, strikes me as a sensible stance.

MIND-BODY PROBLEMS The debate over consciousness is even more fractious than the debate over quantum mechanics. How does propecia price canada matter make a mind?. A few decades ago, a consensus seemed to be emerging. Philosopher Daniel Dennett, in his cockily titled Consciousness Explained, asserted that consciousness clearly emerges from neural processes, such as electrochemical pulses in the brain.

Francis Crick and Christof Koch proposed that consciousness is generated by networks of neurons oscillating propecia price canada in synchrony. Gradually, this consensus collapsed, as empirical evidence for neural theories of consciousness failed to materialize. As I point out in my recent book Mind-Body Problems, there are now a dizzying variety of theories of consciousness. Christof Koch has thrown his weight behind integrated information theory, which holds that consciousness might be a property of all matter, not just propecia price canada brains.

This theory suffers from the same problems as information-based theories of quantum mechanics. Theorists such as Roger Penrose, who won last year’s Nobel Prize in Physics, have conjectured that quantum effects underpin consciousness, but this theory is even more lacking in evidence than integrated information theory. Researchers cannot even agree on what form a theory of consciousness propecia price canada should take. Should it be a philosophical treatise?.

A propecia price canada purely mathematical model?. A gigantic algorithm, perhaps based on Bayesian computation?. Should it borrow concepts from Buddhism, such as anatta, the doctrine of no self?. All of the propecia price canada above?.

None of the above?. Consensus seems farther away than ever. And that’s propecia price canada a good thing. We should be open-minded about our minds.

So, what’s the difference, if any, between me and Gallagher, my former friend?. I like to think it’s a propecia price canada matter of style. Gallagher scorned the choices of others. He resembled one of those mean-spirited atheists who revile the faithful for their beliefs.

I try not to be dogmatic in my disbelief, and propecia price canada to be sympathetic toward those who, like Francis Collins, have found answers that work for them. Also, I get a kick out of inventive theories of everything, such as John Wheeler’s “it from bit” and Freeman Dyson’s principle of maximum diversity, even if I can’t embrace them. I’m definitely a skeptic. I doubt we’ll ever know whether God exists, what quantum mechanics means, how matter makes propecia price canada mind.

These three puzzles, I suspect, are different aspects of a single, impenetrable mystery at the heart of things. But one of the propecia price canada pleasures of agnosticism—perhaps the greatest pleasure—is that I can keep looking for answers and hoping that a revelation awaits just over the horizon. This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American.

Further Reading propecia price canada. I air my agnostic outlook in my two most recent books, Mind-Body Problems, available for free online, and Pay Attention. Sex, Death, and Science. See also my podcast “Mind-Body Problems,” where I talk to experts, including several mentioned above, about God, quantum mechanics and consciousness.ITALY Art restorers propecia price canada have cleaned the Medici Chapel in Florence with the help of bacteria.

Serratia, Pseudomonas and Rhodococcus ate away at detritus—from visitors and decaying corpses—that had seeped into Michelangelo’s sarcophagi. GALÁPAGOS ISLANDS Genetic analysis confirmed that a female giant tortoise, discovered in the Galápagos Islands in 2019, belongs to a species last seen in 1906. Rangers spotted evidence of at least two more of the reptiles, buoying hopes of propecia price canada finding a mate for the female. DEMOCRATIC REPUBLIC OF CONGO Mount Nyiragongo, one of the world’s most active volcanoes, erupted for the first time since 2002 and displaced hundreds of thousands of people.

A local volcano observatory had warned of a possible eruption last year, but budget cuts and an Internet disruption limited its ability to predict the blast. INDONESIA Researchers found that monsoon seasons lengthened by climate change are damaging some of the world’s oldest rock art. The rains most likely increase salt crystal formation in Sulawesi island’s limestone caves, breaking up the 20,000- to 45,500-year-old paintings’ rocky canvases. CAMBODIA A giant pouched rat named Magawa has retired after sniffing out unexploded land mines for five years.

Trained by a Belgian nonprofit organization, the rodent received a bravery prize previously awarded only to dogs. AUSTRALIA At least seven Tasmanian devils were born in mainland Australia—the first wild births there in 3,000 years—after the animals were reintroduced last year. Human settlers had long ago brought in dingoes, which wiped out mainland devils and limited their range to the island state of Tasmania..

What side effects may I notice from Propecia?

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

• breast enlargement or tenderness
• skin rash
• sexual difficulties (less sexual desire or ability to get an erection)
• small amount of semen released during sex

This list may not describe all possible side effects.

Problems with propecia

How to cite this buy propecia online uk article:Singh problems with propecia OP. Mental health in diverse India. Need for advocacy problems with propecia.

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 problems with propecia the deserts to the seas. Every region has its own distinct culture and food.

There are so many varieties of dress and language. There is huge difference problems with propecia 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 problems with propecia 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 problems with propecia vulnerability and early brain insult with low access to health care leads to poor mental health, disease, and morbidity.When we come to the field of mental health, we 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 southern states had higher prevalence of adult-onset disorders problems with propecia 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 problems with propecia 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 problems with propecia contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

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

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

References 1.Compton MT, Shim RS. The social determinants of mental problems with propecia health. Focus 2015;13:419-25.

2.Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, et al. National Mental Health problems with propecia 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 buy propecia online uk tailored to the local terminology and beliefs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnostic Criteria for Research. Geneva. World Health Organisation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

52.Carstairs GM. The Twice Born. Bloomington.

Indiana University Press. 1961. 53.Carstairs GM.

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

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

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

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

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

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

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

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

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

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

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

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

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How to propecia price canada cite this article:Singh OP can you buy propecia without a prescription. Mental health in diverse India. Need for propecia price canada advocacy.

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

There are so many varieties of dress and language. There is huge difference between the states in terms of development, attitude toward women, propecia price canada 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 propecia price canada 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, propecia price canada disease, 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 propecia price canada 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 propecia price canada 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 propecia price canada a negative prognostic indicator contrary to the western norms.[3]Cultural influences on the presentation of psychiatric disorders are apparent. Being in recessive position in the family is one of the strongest predictors of psychiatric illnesses and psychosomatic disorders. The presentation of depressive and anxiety disorders with more somatic symptoms results from inability to express due to unequal power equation in the family rather than the lack of expressions.

Apart from culture bound syndromes, the role of propecia price canada 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 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 propecia price canada require sustained advocacy aimed at promoting rights of mentally ill 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 be involved and pathways should be to build technical evidence for mapping propecia price canada 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 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 propecia price canada 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 propecia price canada 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 migrant laborers and persons with dementia propecia price canada. At an individual level, we can be involved in ensuring quality treatment, respecting dignity and rights of the patient, sensitization of staff, working with patients and caregivers to plan services, and being involved locally in media and public awareness activities.The recent experience of Brazil is an eye opener where suicide reduction resulted from direct cash transfer pointing at the role of economic decision in suicide.[5] In India where economic inequality is increasing, male-to-female ratio is abysmal in some states (877 in Haryana to 1034 in Kerala), our actions should be sensitive to this regional variation. When the enemy is economic inequality, our weapon is research propecia price canada highlighting the role of these factors on mental health.

References 1.Compton MT, Shim RS. The social propecia price canada 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 propecia price canada 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 Extra resources local terminology and beliefs.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnostic Criteria for Research. Geneva. World Health Organisation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

52.Carstairs GM. The Twice Born. Bloomington.

Indiana University Press. 1961. 53.Carstairs GM.

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

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

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

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

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

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

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

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

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

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

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

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

NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_791_20.

How expensive is propecia

AbstractA short cut http://wernersam.com/portfolio/advertising/ review was carried out to how expensive is propecia establish the diagnostic characteristics of alveolar dead space fraction (AVDSf) in the diagnosis of pulmonary embolism (PE). This is calculated from the arterial and end-tidal CO2. Three papers were selected to how expensive is propecia answer the clinical question.

The author, study type, relevant outcomes, results and weaknesses are tabulated. It is concluded that there is good evidence to support the use of AVDSf within a clinical prediction model to exclude a PE in patients when there is a low pretest probability. However, the specificity is not sufficient to support it as a ‘rule in’ test.AbstractA short cut review was conducted to assess if the use of rocuronium how expensive is propecia in the ED was associated with a decrease in the provision of postintubation sedation.

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AbstractA short cut review was carried monthly cost of propecia out to establish propecia price canada the diagnostic characteristics of alveolar dead space fraction (AVDSf) in the diagnosis of pulmonary embolism (PE). This is calculated from the arterial and end-tidal CO2. Three papers were selected to answer the propecia price canada clinical question. The author, study type, relevant outcomes, results and weaknesses are tabulated. It is concluded that there is good evidence to support the use of AVDSf within a clinical prediction model to exclude a PE in patients when there is a low pretest probability.

However, the specificity is not sufficient to support it as a ‘rule in’ test.AbstractA short cut review was conducted to assess if the use of rocuronium in the ED was propecia price canada associated with a decrease in the provision of postintubation sedation. Four papers were identified that presented the best evidence to answer the question. Again the studies, relevant outcomes, propecia price canada results and weaknesses are tabulated. All the identified studies were retrospective and there was a plethora of outcome measures used. When compared with suxamethonium, rocuronium was associated with a delayed initiation and reduced dose of postintubation sedation.emergency care systems.

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Nov where to buy cheap propecia propecia fass. 26, 2021 -- The World Health Organization on Friday classified a new hair loss treatment variant from South Africa as a “variant of concern,” which means it could be more contagious, cause more severe disease and reduce the efficacy of propecia fass treatments and treatments.The WHO convened an independent group of experts on Friday to assess the new variant based on the rapid increase in hair loss treatment s in South Africa this week. Known scientifically as propecia fass B.1.1.529, the variant was named Omicron.“Omicron has some concerning properties. This variant has a large number of mutations, and some of these mutations have some worrying characteristics,” Maria Van Kerkhove, the WHO’s technical lead on the hair loss propecia, said in a video statement.“Preliminary evidence suggests an increased risk of re with this variant, as compared to other propecia fass [variants of concern],” the WHO said in a statement.

€œThe number of cases of this variant appears to be increasing in almost all provinces in South Africa.” In response, the White House announced new travel restrictions against flights from South Africa, Botswana, Eswatini, Lesotho, Malawi, Mozambique, Namibia and Zimbabwe. Foreign nationals from those countries will be prohibited from entering the United States.“These new restrictions will take effect on November 29,” President Joe Biden said in propecia fass a statement.” As we move forward, we will continue to be guided by what the science and my medical team advises.”The U.S. Hasn’t detected any cases of the new variant yet, Anthony Fauci, MD, director propecia fass of the National Institute of Allergy and Infectious Diseases, told CNN. €œRight now, we’re propecia fass getting the material together with our South African colleagues to get to a situation where you could actually directly test it,” Fauci said.

€œSo, right now you’re talking about … a red flag that this might be an issue — but we don’t know.”Scientists in South Africa began tracking the variant this week after a jump in hair loss treatment cases and reported the variant to the WHO on Wednesday. The first propecia fass known confirmed was from a sample collected on Nov. 9, the propecia fass WHO said. Several labs have found that one widely used propecia fass test could be a reliable way to detect the new variant.

The WHO’s propecia evolution advisory group has started “a number of studies” to evaluate Omicron and will announce new findings as needed, Van Kerkhove said Friday.Based on the evidence so far, the WHO advised countries to enhance their surveillance and genomic sequencing efforts to better understand the variant. The WHO also requested that countries submit genomic propecia fass sequences to public databases, such as GISAID. On Friday, 66 sequences of the B.1.1.529 variant had been reported to GISAID, including 58 in South Africa, six in Botswana and two in Hong Kong.The WHO propecia fass also asked countries to conduct field investigations and lab analyses about the severity of the variant, as well as immune responses, antibody neutralization and effectiveness of public health and social measures.“Individuals are reminded to take measures to reduce their risk of hair loss treatment, including proven public health and social measures such as wearing well-fitting masks, hand hygiene, physical distancing, improving ventilation of indoor spaces, avoiding crowded spaces and getting vaccinated,” the WHO said. Biden called on other nations to increase treatment donations to poorer nations.“The news about this new variant should make clearer than ever why this propecia will propecia fass not end until we have global vaccinations,” Biden said.

€œThe United States has already donated more treatments to other countries than every other country combined. It is time for more tips here other countries to match America’s propecia fass speed and generosity.”Israel imposed a travel ban covering most of Africa after discovering its first case in someone who had recently traveled from Malawi. A growing list of countries halted or restricted flights, including Austria, Bahrain, Belgium, Croatia, France, Germany, Italy, Japan, Malta, the Netherlands, Hong Kong, the Philippines and Singapore, The New York Times reported.“We are currently at the threshold of an emergency situation,” Naftali Bennett, the prime minister of Israel, said in a statement.“I ask everyone to be prepared and to fully join in propecia fass the work around the clock,” he said.Nov 25, 2021 -- The Big Three automakers and the United Auto Workers say unionized workers will not be required to have hair loss treatment vaccinations.The statement from the hair loss treatment Joint Task Force of UAW, Ford, General Motors, and Chrysler’s parent company, Stellantis, said workers are encouraged but not mandated to get vaccinated.“In addition to encouraging members to disclose their vaccination status, the Task Force continues to urge all members, coworkers, and their families to get vaccinated and get booster vaccinations against hair loss treatment, while understanding that there are personal reasons that may prevent some members from being vaccinated, such as health issues or religious beliefs,” the statement said.Masking will still be required on worksites.“While it is understood that masks can be uncomfortable, the spread of the Delta variant and recent data outlining the continued high rate of transmission in some geographic areas continue to be a serious health threat,” the statement said.The stance by the autoworkers and the auto companies conflicts with the Biden administration, which wants companies with more than 100 employees to mandate vaccinations. That policy has been put on hold while it faces legal challenges that are likely to propecia fass reach the U.S.

Supreme Court.The UAW has more than 400,000 active members and 580,000 retired members in the U.S., Canada, and Puerto Rico.Stellantis last week ordered non-union, salaried workers in the U.S propecia fass. To disclose vaccination status by Dec. 4 and be fully propecia fass vaccinated by Jan. 5, The propecia fass Detroit News reported.

Ford issued propecia fass a similar mandate for "most" salaried workers. General Motors has not instituted a mandate yet on its salaried U.S. Workforce.All three auto companies propecia fass have mandated treatments for autoworkers in Canada.By Robert Preidt and Robin FosterHealthDay ReporterTHURSDAY, Nov. 24, 2021 (HealthDay News) -- CVS Health, Walmart and Walgreens contributed to opioid overdoses and deaths in two Ohio counties, a federal jury in Cleveland found Tuesday.The first jury verdict in an opioids case came in the closely watched test case and may prove encouraging to plaintiffs in thousands of lawsuits across the United States using the same legal strategy -- that the companies propecia fass contributed to a "public nuisance," The New York Times reported.That argument was rejected this month by judges in California and Oklahoma in cases against opioid manufacturers.The Ohio case is the first time the retail side of the drug industry has been held accountable in the U.S.

Opioid crisis, propecia fass the Times reported. CVS Health, Walmart and Walgreens are three of the nation's largest pharmacy chains.Following the verdict, the trial judge will decide how much each of the pharmacy chains will have to pay Lake and Trumbull counties in northeastern Ohio, the Times reported. The counties' lawyers said propecia fass the three companies turned a blind eye to suspicious opioid orders for years. Eventual oversight requirements were "too little, too late," said Mark Lanier, the counties' lead trial lawyer, the Times propecia fass reported.Overdose deaths from illegal opioids have reached record levels during the hair loss treatment propecia, new U.S.

Government data show, the Times reported.More informationVisit the National Institute of Drug Abuse for more on opioids.SOURCE. The New York Times.

Nov. 26, 2021 -- The World Health Organization on Friday classified a new hair loss treatment variant from South Africa as a “variant of concern,” which means it could be more contagious, cause more severe disease and reduce the efficacy of treatments and treatments.The WHO convened an independent group of experts on Friday to assess the new variant based on the rapid increase in hair loss treatment s in South Africa this week. Known scientifically as B.1.1.529, the variant was named Omicron.“Omicron has some concerning properties. This variant has a large number of mutations, and some of these mutations have some worrying characteristics,” Maria Van Kerkhove, the WHO’s technical lead on the hair loss propecia, said in a video statement.“Preliminary evidence suggests an increased risk of re with this variant, as compared to other [variants of concern],” the WHO said in a statement. €œThe number of cases of this variant appears to be increasing in almost all provinces in South Africa.” In response, the White House announced new travel restrictions against flights from South Africa, Botswana, Eswatini, Lesotho, Malawi, Mozambique, Namibia and Zimbabwe.

Foreign nationals from those countries will be prohibited from entering the United States.“These new restrictions will take effect on November 29,” President Joe Biden said in a statement.” As we move forward, we will continue to be guided by what the science and my medical team advises.”The U.S. Hasn’t detected any cases of the new variant yet, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told CNN. €œRight now, we’re getting the material together with our South African colleagues to get to a situation where you could actually directly test it,” Fauci said. €œSo, right now you’re talking about … a red flag that this might be an issue — but we don’t know.”Scientists in South Africa began tracking the variant this week after a jump in hair loss treatment cases and reported the variant to the WHO on Wednesday. The first known confirmed was from a sample collected on Nov.

9, the WHO said. Several labs have found that one widely used test could be a reliable way to detect the new variant. The WHO’s propecia evolution advisory group has started “a number of studies” to evaluate Omicron and will announce new findings as needed, Van Kerkhove said Friday.Based on the evidence so far, the WHO advised countries to enhance their surveillance and genomic sequencing efforts to better understand the variant. The WHO also requested that countries submit genomic sequences to public databases, such as GISAID. On Friday, 66 sequences of the B.1.1.529 variant had been reported to GISAID, including 58 in South Africa, six in Botswana and two in Hong Kong.The WHO also asked countries to conduct field investigations and lab analyses about the severity of the variant, as well as immune responses, antibody neutralization and effectiveness of public health and social measures.“Individuals are reminded to take measures to reduce their risk of hair loss treatment, including proven public health and social measures such as wearing well-fitting masks, hand hygiene, physical distancing, improving ventilation of indoor spaces, avoiding crowded spaces and getting vaccinated,” the WHO said.

Biden called on other nations to increase treatment donations to poorer nations.“The news about this new variant should make clearer than ever why this propecia will not end until we have global vaccinations,” Biden said. €œThe United States has already donated more treatments to other countries than every other country combined. It is time for other countries to match America’s speed and generosity.”Israel imposed a travel ban covering most of Africa after discovering its first case in someone who had recently traveled from Malawi. A growing list of countries halted or restricted flights, including Austria, Bahrain, Belgium, Croatia, France, Germany, Italy, Japan, Malta, the Netherlands, Hong Kong, the Philippines and Singapore, The New York Times reported.“We are currently at the threshold of an emergency situation,” Naftali Bennett, the prime minister of Israel, said in a statement.“I ask everyone to be prepared and to fully join in the work around the clock,” he said.Nov 25, 2021 -- The Big Three automakers and the United Auto Workers say unionized workers will not be required to have hair loss treatment vaccinations.The statement from the hair loss treatment Joint Task Force of UAW, Ford, General Motors, and Chrysler’s parent company, Stellantis, said workers are encouraged but not mandated to get vaccinated.“In addition to encouraging members to disclose their vaccination status, the Task Force continues to urge all members, coworkers, and their families to get vaccinated and get booster vaccinations against hair loss treatment, while understanding that there are personal reasons that may prevent some members from being vaccinated, such as health issues or religious beliefs,” the statement said.Masking will still be required on worksites.“While it is understood that masks can be uncomfortable, the spread of the Delta variant and recent data outlining the continued high rate of transmission in some geographic areas continue to be a serious health threat,” the statement said.The stance by the autoworkers and the auto companies conflicts with the Biden administration, which wants companies with more than 100 employees to mandate vaccinations. That policy has been put on hold while it faces legal challenges that are likely to reach the U.S.

Supreme Court.The UAW has more than 400,000 active members and 580,000 retired members in the U.S., Canada, and Puerto Rico.Stellantis last week ordered non-union, salaried workers in the U.S. To disclose vaccination status by Dec. 4 and be fully vaccinated by Jan. 5, The Detroit News reported. Ford issued a similar mandate for "most" salaried workers.

General Motors has not instituted a mandate yet on its salaried U.S. Workforce.All three auto companies have mandated treatments for autoworkers in Canada.By Robert Preidt and Robin FosterHealthDay ReporterTHURSDAY, Nov. 24, 2021 (HealthDay News) -- CVS Health, Walmart and Walgreens contributed to opioid overdoses and deaths in two Ohio counties, a federal jury in Cleveland found Tuesday.The first jury verdict in an opioids case came in the closely watched test case and may prove encouraging to plaintiffs in thousands of lawsuits across the United States using the same legal strategy -- that the companies contributed to a "public nuisance," The New York Times reported.That argument was rejected this month by judges in California and Oklahoma in cases against opioid manufacturers.The Ohio case is the first time the retail side of the drug industry has been held accountable in the U.S. Opioid crisis, the Times reported. CVS Health, Walmart and Walgreens are three of the nation's largest pharmacy chains.Following the verdict, the trial judge will decide how much each of the pharmacy chains will have to pay Lake and Trumbull counties in northeastern Ohio, the Times reported.

The counties' lawyers said the three companies turned a blind eye to suspicious opioid orders for years. Eventual oversight requirements were "too little, too late," said Mark Lanier, the counties' lead trial lawyer, the Times reported.Overdose deaths from illegal opioids have reached record levels during the hair loss treatment propecia, new U.S. Government data show, the Times reported.More informationVisit the National Institute of Drug Abuse for more on opioids.SOURCE. The New York Times.

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Medical device. A device within the meaning of the Food and Drugs Act, but does not include any device that is intended for use in relation to animals. Medical masks is propecia covered by health insurance in canada. Includes surgical, procedural, isolation and other control devices intended to offer protection to the wearer.

They are designed with 3-4 layers of non-woven materials and meet labelled fiation levels (≥ 95%) using recognized standards. Personal protective is propecia covered by health insurance in canada equipment (PPE). Personal protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators. They can be used by health care workers to provide a barrier that will prevent potential exposure to infectious microorganisms.

Respirator. A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used to protect the user from inhaling a hazardous atmosphere. The most common respirator used in health care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer.

It's used to reduce the risk of inhaling hazardous airborne particles and aerosols, including dust particles and infectious agents.From. Health CanadaDate published. 2021-04-07 Health Canada regulates health products, such as drugs and medical devices. We also regulate consumer and commercial products and substances, such as cosmetics, pesticides, tobacco, cannabis and controlled substances.

As part of our regulatory activities, we conduct inspections to mitigate risks and protect the health and safety of Canadians. Learn more about what Health Canada does as a regulator. During the hair loss treatment propecia, we continue to take a risk-based approach to inspections. Onsite work remains a key tool in helping us fulfill our mandate to deliver essential inspection activities.

Health Canada uses remote or virtual tools to complement onsite inspection activities. We're using these tools, where appropriate and without compromising the ability to verify and assess compliance, for all of the products and substances that we regulate. When onsite activities are conducted, Health Canada is implementing appropriate hair loss treatment mitigation measures in adherence with public health guidance. Along with hair loss treatment screening self-assessments, such measures include.

practising social distancing practising good respiratory etiquette and hand hygiene equipping inspectors with sanitation supplies, non-medical masks and other required PPE making adjustments for additional provincial, territorial, local and community specific public health guidance, where applicable Health Canada inspectors are governed by applicable acts and regulations and follow procedures referenced in A Guide to Health Canada Inspections. As such, inspectors continue to have the power to enter any place or premises at any reasonable time where. a regulated activity is being conducted or a regulated product, article, device or thing, or relevant document is located Anyone at the place of the inspection is legally required to give the inspector all reasonable assistance. To stay safe and help limit the spread of hair loss treatment, Health Canada expects that public health guidance and mitigation measures will be followed while the inspector is onsite.

Consideration for the health and safety of inspectors and regulated parties is a joint responsibility. Where it isn't possible to reduce the risks of hair loss treatment, we may explore other options.

May 5, propecia price canada 2021This notice outlines the safety and effectiveness requirements for Class I medical masks and face coverings with anti-microbial claims http://saiautomationsystem.com/can-you-get-high-off-ventolin. This notice is for manufacturers using either an interim order (IO) authorization or medical device establishment licence (MDEL) to manufacture, import or sell these devices in Canada.This notice does not cover anti-microbial agents sold separately and applied to face coverings or medical masks prior to use. On this page About masks with anti-microbial substances The hair loss treatment propecia has created a public health requirement to wear face coverings and medical masks.

Face coverings are not classified as medical devices unless there are medical claims or representations.Some mask and face covering medical devices may incorporate or be coated with materials that claim to be propecia price canada anti-microbial. Anti-microbial substances may kill or inhibit the growth of microorganisms. Some examples of anti-microbial substances include, but are not limited to.

Silver copper Nanoform Graphene fabric coatings saltTo date, Health Canada has not propecia price canada received any data that support the safety and effectiveness of these substances when used with masks or face coverings. It is also not known whether these substances improve the performance of medical masks in a measurable way. Regulatory considerations and claimsIn Canada, face coverings that are used only to reduce droplets or aerosols passing between individuals are not regulated as medical devices.

However, if the product label includes anti-microbial claims, these face coverings become Class propecia price canada I medical devices.Section 25 of the Medical Device Regulations allows for the request of supporting safety, effectiveness and quality information from Class I manufacturers. Limitations to the claimsBacterial Fiation Efficiency (BFE) is a measurement of a medical mask material's resistance to penetration of aerosolized droplets of a culture suspension of Staphylococcus aureus (3.0 um or 3000 nm in size). Results are reported as percent efficiency and correlate with the ability of the fabric to resist bacterial penetration.

Higher BFE percentages in this test propecia price canada indicate better barrier efficiency. In general, a BFE rating could be interpreted as material fiation efficiency.This measurement is not to be taken in isolation and without a reference to a test method or international standard. To achieve a high level of fiation, anti-microbial non-medical masks should be manufactured from a non-woven polypropylene material.

All claims must be supported by evidence and propecia price canada available for review upon request. Safety and effectiveness requirementsMedical masks or other personal protective equipment claiming microbial protection should meet the safety and effectiveness requirements described below. This information must be available for review upon request in the case of MDEL holders.

It should be submitted by manufacturers filing an interim order (IO) application or responding to regulatory propecia price canada requests for information. A clear intended use/indications statement for the product along with complete labelling. Labelling includes user manuals, instructions for use (IFU), directions for use (DFU), outer package labelling, promotional material and website links.

A detailed description of the list of materials propecia price canada (for example, chemical and popular/trade names) and their technical specifications (for example, physical/chemical properties), used in the manufacture of the mask. This includes all material constituents added to the mask to impart anti-microbial or anti-viral properties. A full description of how the anti-microbial or anti-viral technology (for example, coatings) is produced and incorporated into, or bonded with, the mask materials, as well as a mechanistic description of the expected anti-microbial action.

If the anti-microbial substances are present in nanoform(s), a characterization of those substances (for example, derivitization, propecia price canada layers, platelets, thickness, lateral dimensions, charged sites), including a certificate of analysis showing impurities. Information describing potential inhalation exposure to anti-microbial substance particulates that includes at least. intended use pattern (such as frequency, number of uses) summarized test data that fully characterize the amount (mass) and sizes (particle size distribution and mass median aerodynamic diameter - MMAD) of particulates that are shed during the intended use pattern and human inhalation exposure range estimates in terms of mg/L/hr, and mg/kg-bw/day, based on the information in a) and b) Evidence in the form of test reports that support all anti-viral (anti-hair loss treatment) and/or antimicrobial claims made on the product label.

This may include the use of one or more scientifically justified surrogate propecia(es) propecia price canada. The test reports should describe the testing procedure and include a detailed description of the specific component/materials that were tested. The test samples should be identical to the product.

If there are differences between the test samples propecia price canada and the final product (e.g. Different materials, concentrations, or other properties) these should be clearly described along with providing a justification for how the samples are representative of the final product in spite of these differences. Evidence of biocompatibility demonstrating that the patient-contacting materials in the final product are non-cytotoxic (ISO 10993-5), non-irritating, and non-sensitizing (ISO 10993-10).

Performance data/reports demonstrating that the respirators/masks meet propecia price canada ASTM F2100, EN 14683, EN 149 and GB2626 (or any other standards claimed). If it is claimed that the mask can be washed, then instructions for washing should be provided. In addition, evidence must be provided that the performance claims made (for example, in 6 and 9 above) are maintained after a proposed maximum number of wash cycles as indicated in the device labelling.

International activityThe U.S. Food and Drug Administration regulates face coverings with anti-microbial claims as medical devices.Self-sanitizing claims are detergent claims that are overseen by the Pest Management Regulatory Agency in Canada and the Environmental Protection Agency in the propecia price canada United States. Related links Glossary of terms Face coverings (also known as non-medical masks).

Source control masks (to help control an infected wearer from transmitting the propecia to others) that are made from a variety of woven fabrics. Face coverings may be made of propecia price canada different combinations of fabrics, layering sequences and available in diverse shapes. They are a sewn mask secured with ties or straps around the head or behind the ears.

They are factory-made or made from household items such as scarves or t-shirts. The fabrics propecia price canada and/or materials used in face coverings are not the same as the ones used in medical masks or respirators. Medical device.

A device within the meaning of the Food and Drugs Act, but does not include any device that is intended for use in relation to animals. Medical masks propecia price canada. Includes surgical, procedural, isolation and other control devices intended to offer protection to the wearer.

They are designed with 3-4 layers of non-woven materials and meet labelled fiation levels (≥ 95%) using recognized standards. Personal protective equipment (PPE) propecia price canada. Personal protective equipment consists of gowns, gloves, masks, facial protection (masks and eye protection, face shields or masks with visor attachment) or respirators.

They can be used by health care workers to provide a barrier that will prevent potential exposure to infectious microorganisms. Respirator. A device that is tested and certified by procedures established by testing and certification agencies recognized by the authority having jurisdiction and is used to protect the user from inhaling a hazardous atmosphere.

The most common respirator used in health care is a N95 half-face piece filtering respirator. It's a personal protective device that fits tightly around the nose and mouth of the wearer. It's used to reduce the risk of inhaling hazardous airborne particles and aerosols, including dust particles and infectious agents.From.

Health CanadaDate published. 2021-04-07 Health Canada regulates health products, such as drugs and medical devices. We also regulate consumer and commercial products and substances, such as cosmetics, pesticides, tobacco, cannabis and controlled substances.

As part of our regulatory activities, we conduct inspections to mitigate risks and protect the health and safety of Canadians. Learn more about what Health Canada does as a regulator. During the hair loss treatment propecia, we continue to take a risk-based approach to inspections.

Onsite work remains a key tool in helping us fulfill our mandate to deliver essential inspection activities. Health Canada uses remote or virtual tools to complement onsite inspection activities. We're using these tools, where appropriate and without compromising the ability to verify and assess compliance, for all of the products and substances that we regulate.

When onsite activities are conducted, Health Canada is implementing appropriate hair loss treatment mitigation measures in adherence with public health guidance. Along with hair loss treatment screening self-assessments, such measures include. practising social distancing practising good respiratory etiquette and hand hygiene equipping inspectors with sanitation supplies, non-medical masks and other required PPE making adjustments for additional provincial, territorial, local and community specific public health guidance, where applicable Health Canada inspectors are governed by applicable acts and regulations and follow procedures referenced in A Guide to Health Canada Inspections.

As such, inspectors continue to have the power to enter any place or premises at any reasonable time where. a regulated activity is being conducted or a regulated product, article, device or thing, or relevant document is located Anyone at the place of the inspection is legally required to give the inspector all reasonable assistance. To stay safe and help limit the spread of hair loss treatment, Health Canada expects that public health guidance and mitigation measures will be followed while the inspector is onsite.

Consideration for the health and safety of inspectors and regulated parties is a joint responsibility. Where it isn't possible to reduce the risks of hair loss treatment, we may explore other options.