A Reading on Sexual Dysfunctions

____________________

Presented to
The Faculty of Nursing Department
Mrs. Melinda Tantoy, RN, MAN

____________________

In Partial Fulfillment of
the Requirements in NCM – 217 RLE
MALADAPTIVE NURSING TFS

By:

Geozil Anne A. Mosqueda, St. N.

BSN 3H

January 28, 2021

Title: Women’s Sexual Dysfunction Associated with Psychiatric Disorders and
their Treatment

Reference: Written by Rosemary Basson, and Thea Gilks. First Published April
12, 2018 https://journals.sagepub.com/doi/full/10.1177/1745506518762664

Summary:

Sexual problems are highly prevalent among patients with psychiatric

disorders. They may be caused by the psychopathology of the psychiatric
disorder but also by its pharmacotherapy. With the exception of bupropion,
agomelatine, mirtazapine, vortioxetine, amineptine, and moclobemide, all
antidepressants cause sexual side-effects. Both positive symptoms like
psychosis, hallucinations as well as negative symptoms like anhedonia of
schizophrenia may negatively interfere with interpersonal and sexual
relationships. Selective serotonin reuptake inhibitors may particularly delay
ejaculation and female orgasm, but also can cause decreased libido and erectile
difficulties. Some personality characteristics are a risk factor for sexual
dysfunction. Also patients with eating disorders may suffer from sexual
difficulties. So far, research into psychotropic-induced sexual side-effects suffers
from substantial methodologic limitations. Sexual dysfunction is prevalent among
psychiatric patients and may be related to both the psychopathology and the
pharmacotherapy. Due to their weak antagonistic activity at D2 receptors,
second-generation antipsychotics are associated with fewer sexual side effects,
and thus may provide an option for schizophrenia patients with sexual
dysfunction. Eating disorders and personality disorders, mainly borderline
personality disorder, are also associated with sexual dysfunction. Sexual
dysfunction in these cases stems from impaired interpersonal relationships and
may respond to adequate psychosexual therapy. Studies confirm anxiety
disorders to be risk factors for low sexual desire and arousal with more recent
research strongly linking aspects of anxiety with orgasmic difficulties and with
sexual pain. The increased sympathetic nervous system activity of sexual
arousal, while increasing women’s genital congestion, involves non-genital
sensations which could be misinterpreted as threatening by an anxious woman,
thereby negating any potential sexual pleasure. Laboratory studies confirm that
women’s subjective arousal from an erotic film decreases if there is a preceding
anxiety-evoking film, while genital congestion may increase. This is in keeping
with the generally poor correlation between women’s genital sexual
arousal/congestion and subjective arousal.

Reaction:

Upon reading the article I would strongly agree with the contents that was
written on it. Sexual dysfunction is also very common in patients with depressive
illness. Like in patients with psychotic illness the sexual dysfunction can affect
libido, arousal, orgasm and satisfaction with sex. Often more than one of these
domains is affected. Like in psychotic illness, sexual dysfunction can be blamed
on the condition and on the medication. That is why it is not easy for the patient
who have this type of health problem.

It is also associated to psychiatric disorders, either as part of the

psychopathology, or as adverse effect of psychotropic medication. When sexual
complains are secondary to the clinical condition, it is expected to remit with
treatment. Substance-induced sexual dysfunctions, on the other hand, tend to
persist, even after pharmacotherapy is over, with deleterious impact in sexual
function. Therefore, it is plausible to affirm that a significant number of patients in
psychiatric settings, and even a relevant percentage of the general population,
will be exposed to the deleterious effects of psychotropic medication in sexual
function. These problems deeply affect patients’ and partners’ sexual
satisfaction, threatening relationship stability and partnership-related quality of
life aspects. It also negatively impacts pharmacotherapy adherence, thus
affecting therapeutic outcomes.

The patient should undergone some test, female sexual complaints are
common, occurring in approximately 40 percent of women. Decreased desire is
the most common complaint. Normal versus abnormal sexual functioning in
women is poorly understood, although the concept of normal female sexual
function continues to develop. A complete history combined with a physical
examination is warranted for the evaluation of women with sexual complaints or
concerns. Although laboratory evaluation is rarely helpful in guiding diagnosis or
treatment, it may be indicated in women with abnormal physical examination
findings or suspected comorbidities . The PLISSIT (Permission, Limited
Information, Specific Suggestions, Intensive Therapy) or ALLOW (Ask,
Legitimize, Limitations, Open up, Work together) method can be used to facilitate
discussions about sexual concerns and initiation of treatment. Developments in
the treatment of male erectile dysfunction have led to investigation of
pharmacotherapy for the treatment of female sexual dysfunction. Treating patient
with sexual dysfunctions is never easy. You’ll have to go through multiple
doctor’s visits, tests, and therapies. This could last for years. But if you stick with
your treatment for the long-term, your odds of controlling or even beating your
sexual dysfunction associated with personal distress are better than they’ve ever
been.

As a student nurse this article help us to know and give us heads up about
treating this sexual problems that are highly prevalent among patients with
psychiatric disorders. Because having sexual dysfunction and dealing with
treatment can be hard, but it can also be a time to look at our life in new ways
and improve our health. Thus, we need someone to give you positive look in life
or might talk to the doctor to find out what you can do to feel better. The
treatment often will not cure sexual dysfunction, but it might make it go away for
a time. If you have sexual dysfunction, there might be times when you are not
being treated. Or you might continue to get regular treatments or with any other
drugs, to try to help keep yourself in check.

But whether or not you are being treated, ongoing follow-up is very
important. You can’t change the fact that you have sexual dysfunction because it
is an impairment of mental health. What you can change is how you live the rest
of your life making healthy choices and feeling as good as you can.
Women’s sexual dysfunction associated with psychiatric
disorders and their treatment
Rosemary Basson, Thea Gilks

Abstract

Impairment of mental health is the most important risk factor for female sexual
dysfunction. Women living with psychiatric illness, despite their frequent
sexual difficulties, consider sexuality to be an important aspect of their quality
of life. Antidepressant and antipsychotic medication, the neurobiology and
symptoms of the illness, past trauma, difficulties in establishing relationships
and stigmatization can all contribute to sexual dysfunction. Low sexual desire
is strongly linked to depression. Lack of subjective arousal and pleasure are
linked to trait anxiety: the sensations of physical sexual arousal may lead to
fear rather than to pleasure. The most common type of sexual pain is 10 times
more common in women with previous diagnoses of anxiety disorder.
Clinicians often do not routinely inquire about their patients’ sexual concerns,
particularly in the context of psychotic illness but careful assessment,
diagnosis and explanation of their situation is necessary and in keeping with
patients’ wishes. Evidence-based pharmacological and non-pharmacological
interventions are available but poorly researched in the context of psychotic
illness.

Keywords antidepressant/ antipsychotic induced sexual dysfunction , female

sexual dysfunction, psychiatric illness

Introduction

Psychiatric disease is the most important risk factor for women’s sexual
dysfunction.1–4 This remains true in the context of chronic diseases known to
interrupt the neurovascular basis of sexual physiology. Thus, depression,
rather than the burden of physical disease or severity of complications, is the
independent factor determining presence or absence of sexual dysfunction in
women living with diabetes,5 multiple sclerosis,6 renal failure7 or rheumatic
disease8 as well as those with a history of past childhood sexual abuse. 9 A
recent study of older women aged 50–99 years of age suggested that sexual
health is linked more strongly to mental health than to physical function, stress
or age itself.10 Nonetheless, poor mental health does not necessarily reduce
the importance of sexual experience: a recent survey found that 43% of 1200
American women, including those with poor mental health, confirmed sexual
health to be an important component of their quality of life, rating it as 4 or 5
on a 5-point Likert-type scale.11

The literature confirms that depression, anxiety and sexual dysfunction in

women are related; however, the causal pathway is debated. Do depression
and anxiety precipitate sexual dysfunction or is sexual dysfunction a frequent
cause of mood disorder? The third possibility is that sexual dysfunctions,
depression and anxiety disorders all result from an underlying vulnerability to
both psychiatric disease and sexual dysfunction. Recent research studying
this comorbidity over time showed results consistent with the last possibility,
namely a shared underlying latent psychological vulnerability. 12 This suggests
that the presence of any one of the three risk factors will increase the odds of
current or future symptoms of one or both of the other two, thus screening for
all comorbidities needs to become routine.

The relationship between sexual dysfunction and psychotic disease in women

is poorly understood. As with women experiencing depression and anxiety,
women with schizophrenia and schizophrenia spectrum disorders have a very
high burden of sexual dysfunction, with 60%–80% of women being affected. 13–
18
 Antipsychotic medications, the symptoms of psychosis, institutionalization
and societal stigma are all likely contributory factors. In comparison with
women suffering from depression and anxiety, women with psychosis tend to
have less social integration, more difficulty finding intimate partners and an
overall lower level of functioning. This greater level of impairment has
implications for both diagnosis and treatment of sexual dysfunction.
 An additional challenge in addressing the sexual function of women with
psychotic illness is that many clinicians may not feel comfortable speaking
about sexuality with this patient population. Studies have shown that clinicians
tend to underestimate the importance of the sexual aspects of their psychiatric
patients’ lives and often do not inquire directly about sexual matters. 18,19 A
survey of British psychiatrists found that two-thirds do not inquire regularly
about sexual function and only 17% of respondents felt competent assessing
sexual concerns in their schizophrenic patients.19 Patients with psychotic
illness feel this is an unmet treatment need and a cause for decreased quality
of life.17,20–23

This review will identify the common sexual dysfunctions associated with
depression, anxiety and psychosis as well as dysfunctions linked to their
pharmacological treatment. We will outline evidence-based treatments of
women’s Sexual Disorders including the management of medication-
associated dysfunction. We will then discuss directions for future research.

Sexual response cycle

Research confirms women (and men) have many reasons to engage (or
decline) partnered sex:24 the current model is often labeled an incentive-based
sex response cycle.25 The two largest groups of reasons to be sexual are
found to be those associated with a couple’s emotional intimacy and second,
those to do with the expected pleasurable reward from the sexual event such
that there need not necessarily be an initial sense of sexual urging/drive/innate
desire.24 Instead, desire for sex itself can be experienced once arousal has
occurred. This has been termed “responsive” or “triggered” desire. But to
become aroused and desirous, there is need for appropriate sexual stimuli
and context and the ability to pay attention to the stimuli and the sensations
that follow.26 There is also a need to find the physical sensations and mental
sexual excitement/arousal pleasurable. This will allow the intensity of sexual
arousal to increase and ultimately lead to orgasm(s) on some or many
occasions. Figure 1 shows the sexual response cycle in a diagrammatic form.
Figure 1. Incentive-based model of sexual response.

Human sexual response is depicted as a motivation-/incentive-based cycle of overlapping phases

of variable order. A sense of desire may or may not be present initially: it can be triggered
alongside the sexual arousal resulting from attending to sexual stimuli. Sexual arousal comprises
subjective (pleasure/excitement/wanting more of the same), and physical (genital and non-genital
responses) components. Psychological and biological factors influence the brain’s appraisal of
the sexual stimuli. The sexual and non-sexual outcomes influence present and future sexual
motivation.

Adapted from Basson.27

Female Sexual Disorders

Long standing concern and criticism of definitions of female Sexual Disorders

as identified in the American Psychiatric Association’s Diagnostic and
Statistical Manual Fourth Edition (DSM-IV) led to revised definitions published
in 2013.28 Whereas previously sexual desire was deemed necessary prior to
healthy sexual response in both men and women there is now acceptance of
research confirming desire may follow and accompany a healthy sexual
response of arousal from sexual stimuli.29 As well, arousal is now appreciated
as a subjective excitement/pleasure—not only as a physical genital
phenomenon. Thus, the definition of disordered female desire/interest and
arousal has changed considerably: see Table 1. Due to lack of clear
distinction between “vaginismus” and other causes of sexual pain on
attempted or completed vaginal penetration, Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5) uses the umbrella term of genito-
pelvic penetration pain disorder. These other causes include not only
provoked vestibulodynia (PVD) which typically overlaps with
“vaginismus”30 but other “more gynecological” entities, for example, lack of
lubrication associated with estrogen lack, which often invoke the reflex pelvic
muscle tightening response. There are now three criteria for diagnosing a
Sexual Disorders: symptoms need to have persisted for a minimum of 6
months, be experienced in all or almost all (75%–100%) sexual encounters or
have been persistent/ recurrent, and to have caused clinically significant
distress. Unfortunately, validated questionnaires for diagnosing Sexual
Disorders as per Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) are not yet available and so the prevalence of Sexual
Disorders as currently understood is as yet unknown. A recent large British
survey study, using proxy measures of DSM-5 Sexual Disorders found that
while 22.8% of women reported one or more sexual difficulty including
problematic orgasm, low sexual interest and arousal or painful sex, 3.6% of
women met all three criteria for disorder.31

Table 1. Definitions of Sexual Disorders in women,

American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5).28

Table 1. Definitions of Sexual Disorders in women, American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).28
 View larger version

Notwithstanding the limitations of previous research into the epidemiology of

female sexual dysfunction in light of the new definitions, its brief summary may
still be helpful. The larger surveys conducted during the last 10 years found
approximately 10% of women reported ongoing sexual dysfunction that
caused them distress, while a further 20% reported less disturbing sexual
problems.1,4,32 A general muting of response—low desire, low subjective
arousal along with infrequent or absent orgasm was the most common
presentation in many surveys.33 Seven year longitudinal study of Australian
women showed desire to decrease with age and with menopause. 34 Studies of
sexual function after natural and surgical menopause suggest desire is
similar32,35 but distress about lowered desire is greater after surgical
menopause.32 Although desire was seen to lessen with older age, women’s
associated distress decreased such that the prevalence of DSM-IV
“hypoactive sexual desire disorder” was thought to vary little with age. 36

Postmenopausal vaginal dryness and associated dyspareunia was found to

affect some 15% to 30% of women with marked cultural differences to the
extent that this lead to bothersome sexual difficulties. 37 Lack of lubrication and
associated dyspareunia was reported by 5%–25% of younger women again
with marked cultural differences leading to resulting sexual distress Leiblum et
 al.37 Dyspareunia from PVD, the most common cause of dyspareunia in
premenopausal women, is thought to affect some 15%–18% of
women.30 Isolated lack of orgasm despite high arousal is of uncertain
prevalence because studies generally include women with low arousal
alongside their lack of orgasm.

Recent reviews conclude that the lessening of sexual activities during

pregnancy,38 especially during the third trimester, and postpartum 39 are due to
many psychological and physiological factors, are logical and not indicative of
ongoing Sexual Disorders.

Critique of the various survey instruments used in clinical sexual research is

beyond the scope of this review. However, the most widely used survey
instrument, the Female Sexual Function Index (FSFI) 40 which asks about
sexual experience in the previous 4 weeks has some limitations. Although the
FSFI’s internal consistency is good with a Cronbach’s alpha coefficient 0.82,
and a test–retest reliability of 0.79–0.86, the questionnaire does focus on initial
sexual desire and thus penalizes women with mostly responsive desire
triggered along with arousal.29 Moreover the appropriateness of relying only on
the past 4 weeks which for many reasons, including partner absence, may not
represent a woman’s usual experiences, has been highly criticized. 41

Depression

In addition to consistently identifying the strong link between depression and

women’s reduced interest or desire for partnered sex, epidemiological studies
confirm depression’s negative effects upon orgasmic experience, 42 and its
strong association with increased sexual risk behaviors. 43

A recent British survey of 6669 women using proxy measures of DSM-5 items
found current depression to increase the risk of sexual dysfunction with an
odds ratio of 3.12.4 The anhedonia of depression has been shown to be
particularly linked to muting of desire and response as well as to the risk of
sexual pain.44 The most common form of chronic dyspareunia, (chronic
 dyspareunia now being subsumed under the more broad DSM-5
nomenclature of “Genital Penetration Pain Disorder”), namely PVD, is three
times more common in women with a premorbid diagnosis of
depression.45 Even in the absence of a clinical depression, negative mood has
been found to impair sexual function, 33 while positive or negative sexual
experiences were found to modulate mood the day after the sexual
engagement.46,47 Studies which control for current mood (as well as for
medications, marital state and substance abuse), such as the Study of
Women’s Health Across the Nation (SWAN), confirm a history of recurrent
depression to be associated with reduced sexual arousal and reduced sexual
pleasure.48

Review of the currently accepted model of human sexual response cycle

clarifies its potential major disruption in the presence of depression,
see Figure 2.

Figure 2. Sexual response cycle is potentially weakened by depression at all points in an

incentive-based model of sexual response.
Depression diminishes sexual incentives: anhedonia lessens the wanting of physical pleasure;
depression reduces emotional intimacy—a major sexual incentive for women. There is little effort
to secure needed sexual stimuli and sexual context. Sexual information processing in the brain is
severely compromised by poor concentration and non-erotic thoughts and emotions leading to
minimal arousal and no triggered desire. Neurotransmitters modulating sexual arousal are altered
in depression. Outcome is unsatisfactory physically and emotionally and does not motivate further
sexual interaction.

Many of the factors involved in partnered sex, including the relationship itself,
the need to communicate sexual needs, the need to take care of the partner’s
sexual satisfaction, concern about outcome and dealing with feelings of
inadequacy, do not apply to sex alone. Self-stimulation/masturbation may
continue in the presence of depression.48

Patients with bipolar disorder may have a different profile of sexual

dysfunction than patients with unipolar depression. Research has found that
patients with bipolar disorder experience difficulties with desire, arousal and
achieving orgasm, but they also have increased risky sexual behaviors and
more frequently changing partners as compared to patients with unipolar
depression.49 This same study also found that all types of sexual dysfunction
in bipolar men and women were associated with suicide plans, attempts and
thoughts of death.49 The link between sexual dysfunction and suicidality was
more subtle in patients with unipolar disease: impaired desire was related to
thoughts of death.

Anxiety disorders

Epidemiological studies confirm anxiety disorders to be risk factors for low

sexual desire and arousal50–54 with more recent research strongly linking
aspects of anxiety with orgasmic difficulties42 and with sexual pain.45 The
increased sympathetic nervous system activity of sexual arousal, while
increasing women’s genital congestion, involves non-genital sensations which
could be misinterpreted as threatening by an anxious woman, thereby
negating any potential sexual pleasure.50 Laboratory studies confirm that
women’s subjective arousal from an erotic film decreases if there is a
preceding anxiety-evoking film, while genital congestion may increase. 55 This
is in keeping with the generally poor correlation between women’s genital
sexual arousal/congestion and subjective arousal. 56 These physical sensations
from increased sympathetic drive, including shortness of breath, increased
temperature, muscle tension and palpitations, have been termed “anxious
arousal.” Trait anxiety is linked to anxiety sensitivity, that is, fear of the anxiety
response itself and misinterpretation of these sensations: thus, it is postulated
that a highly anxious woman is unlikely to experience pleasure from the
physical sensations of sexual arousal.50

Keeping in mind the sexual response cycle, it is understandable that both

sexual and nonsexual worries can be potent distractors when women with
anxiety disorders are attempting to be sexual, limiting their arousal 57 (and
therefore frequency of orgasm) and likelihood of triggering desire. Brain
imaging, albeit mainly focused on men, confirms marked deactivation to
remove tonic sexual disinhibition, that is, necessary for orgasm to take
place.58 Thoughts of potential harm from letting go of control and becoming
vulnerable would logically preclude orgasm as would compulsive thoughts of
orderliness and tidiness. Research confirms the inhibitory effect of trait anxiety
on women’s subjective arousal in a laboratory setting but more strongly with
partnered sexual experiences.50 Longitudinal study of women from age 21 to
50 years showed orgasmic difficulties to be associated with obsessive-
compulsive features.42 Also noted was a detrimental effect on desire and
orgasm from phobic anxiety, somatization and panic disorder. 42 Obsessive
compulsive disorder has been shown to be likely more detrimental than social
anxiety or generalized anxiety disorder.52,59

Importantly, the experience of “anxious arousal” has been shown to be linked

to women’s sexual pain, reduced subjective arousal and impaired
lubrication.46 PVD is some 10 times more common in women with a premorbid
history of anxiety disorder.45 A recent twin study confirmed a strong
association between women’s sexual pain and anxiety sensitivity. 60 PVD is a
chronic pain syndrome associated with both peripheral and central
sensitization of the nervous system and typically co-morbid with other chronic
 pain conditions including temporomandibular joint pain, irritable bowel
syndrome, fibromyalgia and interstitial cystitis. As well as clinically diagnosed
anxiety disorders, certain personality traits also appear to be risk factors.
These include overly conscientiousness, hypervigilance to pain, fear of
negative evaluation by others, and pain catastrophizing, the latter being
significantly correlated with pain intensity during intercourse. 61 It is thought that
these internal stressors may modulate pain circuitry and be involved in central
sensitization of the nervous system.62 The resulting damage to self-image and
sexual self-confidence and the increased burden of guilt and responsibility for
deterioration of relationships63 from the inability to have penetrative sex only
add to the woman’s stress, and maintain the vicious cycle. 60,64

Antidepressant induced sexual dysfunction

The frequency of sexual dysfunction due to antidepressant medications is

difficult to assess, given that the adverse sexual effects of anxiety and
depression are comparable to the side effects of antidepressant medications.
Patient surveys may not be able to differentiate between these two
etiologies.65 Many studies also rely on spontaneous patient report, and
research has shown that incidence of sexual side effects is higher when
patients are directly asked and a validated scale is used. 66 Another
methodological problem is that many studies record the responses of patients
who have no sexual life as indicating that they have no sexual disturbances
from their medications.67 With these limitations in mind, it is worth noting that
self-reported sexual dysfunction among patients using antidepressants is
extremely common. One recent study of long-term users of antidepressants
found that 71.8% of respondents reported adverse sexual effects. 68 A meta-
analysis from 2013 reported prevalence rates ranging from 50% to 70%. 69

Medication-associated sexual dysfunction is a serious concern in both the

initial treatment of depression and anxiety and in longer term maintenance
therapy.69 Unfortunately, the sexual side effects tend to occur within the first 3
weeks of treatment before benefit on mood is obtained, thereby risking early
discontinuance. In the longer term, women whose mood disorder is in
 remission may find they are balancing continuing the medication to sustain
their mood with discontinuing medication so as to improve their sexual lives.
Fortunately, there are now choices and therapeutic interventions to limit the
muting of women’s sexual response from antidepressants.

Studies suggest that sexual dysfunction is most likely when the mechanism of
drug action is focused on the blockade of the reuptake of serotonin at 5-HT
receptors—especially 5HT2 subtypes, whereas 5-HT1A receptor activity
appears to be is pro-sexual.69,70 Medications that focus on increasing the
uptake of norepinephrine or dopamine or blocking 5-HT 2 receptors tend to
have minimal negative sexual side effects.71 Suppression of sexual desire and
arousal is commonly reported as is delay or absence of orgasm. 69 Impaired
lubrication and subsequent pain and discomfort are less frequent complaints.

Mechanisms of action and risk of antidepressant induced sexual

dysfunction

Table 2 indicates presumed mechanism of interference with sexual response

with different classes of antidepressants as well as approximate risk of
medication-associated dysfunction.72–83

Table 2. Mechanisms of action and risk of

antidepressant induced sexual dysfunction.

Table 2. Mechanisms of action and risk of antidepressant induced sexual dysfunction.

 View larger version

Psychotic illness

Women with psychotic illness experience a variety of dysfunctions, including

impaired arousal, delayed or absent orgasm, low frequency of sexual activity
and decreased sexual satisfaction.13,17,22,84,85 In contrast to previous
assumptions, recent research suggests that both partnered and individual
desire may be similar in women with psychotic illness and age-matched
healthy women.86

The pathophysiology of sexual dysfunction in psychotic illness remains poorly

understood, particularly with regards to psychosocial factors. Potential
etiologies of sexual dysfunction include antipsychotic medications, positive
and negative symptoms of psychosis, interpersonal difficulties, stigmatization,
institutionalization, sexual trauma and somatic concerns. Most studies
examining sexual function in psychosis have limited their focus to the effects
of anti-psychotic medications. Studies have also largely been conducted using
male patients, despite evidence that women with psychosis experience a
higher prevalence of sexual dysfunction than men. 14,16 Given the differences
between male and female sexuality, these under-studied psychosocial factors
likely play an even greater role in women’s dysfunctions than in men’s.

A number of investigators have found higher than average levels of sexual

dysfunction in un-medicated psychotic patients,21,87 signifying that the causes
of sexual dysfunction extend beyond those related to medication. Marques et
al.88 found a high prevalence of sexual dysfunction among prodromal, un-
medicated psychotic patients, as well as a correlation between symptom
severity and the degree of sexual dysfunction. Several studies have
corroborated this association between higher scores on the Positive and
Negative Symptoms Scale (PANSS) and decreased interest in and enjoyment
of sex.85,89 These studies provide further evidence that the symptoms of
psychotic illness itself may play a role in the pathophysiology of sexual
dysfunction: low motivation, cognitive impairment, poor judgment and
hallucinations and delusions, may all play a role in preventing women from
forming intimate relationships. Multiple studies have found that women with
psychotic illness site “lack of a partner” as a cause for low sexual
satisfaction.18,23 Rates of marriage are lower among women with schizophrenia
than the general population.15

Societal stigmatization and hospitalization may also play roles in preventing

women with psychosis from forming intimate relationships and attaining sexual
satisfaction. Stigmatization can be a major source of poor self-esteem and
negative self-concept. Research by Segalovitch et al. 90 found a correlation
between internalized stigma and decreased capacity to form intimate
relationships among outpatients with schizophrenia. Several small studies
have also shown the impact that stigmatization can have on sexual self-
concept and perceptions of sexual competence.23,91,92 In their study of women
with psychotic illness, Huguelet et al.86 found that 65% of women had impaired
sexual self-esteem (vs 29% of healthy controls). This same study found that
desire for solitary sexual activity was intact for women with psychosis.
 Research also suggests that rates of masturbation are higher among women
with schizophrenia than controls, indicating that solitary sexual activity may
have modest potential to offset the difficulties posed by having multiple
barriers to intimacy.93,94

Women with psychotic illness are more likely than members of the general
population to have experienced childhood sexual abuse and intimate partner
violence.95–97 Childhood sexual abuse is a well-recognized risk factor for later
re-victimization. Due to social and cognitive impairments, psychotic patients
may also be more likely to engage in high-risk sexual behaviors. The potential
link between sexual trauma and sexual dysfunction in patients with psychotic
illness has not been well studied.

Somatic concerns associated with both antipsychotic medications and

psychotic illness, such as metabolic syndrome, acne, extrapyramidal
symptoms (e.g. abnormal movements, muscle stiffness, restlessness),
excessive salivation and abnormal leakage of breast milk almost certainly
contribute to impaired sexual function. This topic has not been well
documented in the literature, although an association has been found between
certain extrapyramidal symptoms and decreased sexual desire and
arousal.98,99 In women without psychotic illness, metabolic syndrome is a well-
recognized risk factor for sexual dysfunction.100

Antipsychotic induced sexual dysfunction

As is the case with antidepressant medications, it is difficult to evaluate the

prevalence of antipsychotic induced sexual dysfunction due to the high rates
of sexual dysfunction seen in non-medicated patients with psychotic illness.
Sexual dysfunctions associated with antipsychotic medications include
impairment of libido, arousal and orgasm. These side effects do not appear to
subside over time.89,101

The pathophysiology of antipsychotic induced sexual dysfunction is poorly

understood, but appears to be mediated by a combination of the effects of
dopamine, prolactin, serotonin, acetylcholine, histamine and the action of
noradrenaline at the alpha-1 adrenergic receptor. Dopamine blockade likely
affects sexual function by modifying the reward circuitry, thereby negatively
impacting sexual motivation and desire. Dopamine (D2) blockade may also
have an indirect effect by causing a sustained elevation of serum prolactin.
Hyperprolactinemia has been well-documented to cause menstrual
irregularities and galactorrhea. Some authors classify these iatrogenic
reproductive disturbances as sexual dysfunctions, which has led to
confounded results.102,103 With regard to the effects of hyperprolactinemia on
female libido, arousal and orgasm, there have been conflicting results, with
several studies suggesting an association89,104,105 and others finding no
link.16,98,106 Antipsychotics variably cause alpha-1 blockade, which has been
associated with impairment of erection and ejaculation in men, as well as
potential impairment of lubrication in women.84 Agonism at the 5-HT2 serotonin
receptors causes delay of orgasm. The anticholinergic effects of antipsychotic
medications may cause decreased lubrication and the antihistaminic effects
are theorized to indirectly impact sexual function through sedation. The extent
to which each of these neurotransmitters is implicated in sexual dysfunction is
not clear.107

The research comparing the adverse sexual effects of different antipsychotic

medications has been plagued by conflicting results and methodological
problems. Many studies use different surveys to assess sexual function,
making it difficult to compare data. Taking into account this paucity of robust
evidence, it appears that all antipsychotics cause some degree of sexual
dysfunction, with the worst offenders being first generation antipsychotics and
risperidone, followed by olanzapine and clozapine. The superior
antipsychotics are ziprasidone, quetiapine and aripiprazole. 101,107,108 The largest
study to date on this topic, which surveyed 3838 schizophrenic patients from
27 countries, found lower rates of self-reported sexual dysfunction for
olanzapine (56%) and quetiapine (60%), as compared to risperidone (68%)
and haloperidol (71%), although these results were not statistically
significant.102 A Japanese study of 352 patients also found no significant
 difference between haloperidol, risperidone, olanzapine and
aripiprazole.109 The EUFEST study, which followed 498 patients with first
episode psychosis for one year of treatment found no significant difference in
sexual side effects between haloperidol, amisulpride, olanzapine, quetiapine
and ziprasidone.89 The most consistently replicated finding in this literature is
that aripiprazole, a partial dopamine agonist with agonism at 5-HT 1A, is the
most sexually neutral antipsychotic.110 The conflicting results in this area of
research are due in part to variations in methodology, although they also
highlight the important role of psychosis itself in the pathogenesis of sexual
dysfunction.

Management of sexual dysfunction associated with

psychiatric illness

Given that disturbed mental health is the major risk factor for women’s sexual
dysfunction, the initial essential step is to ensure remission of the psychiatric
condition. This is applicable to women with depression, anxiety and psychosis.
If pharmacotherapy is required to achieve remission, then every effort should
be made to use the lowest possible dose and to choose sexually neutral
drugs. Once medications have been optimized, psychological therapies can
address the distracting thoughts, low self-image and the fear of the physical
sensations of increased sympathetic nervous activity found in patients with
depression and anxiety. Both cognitive behavioral therapy (CBT) and
mindfulness-based cognitive therapy (MBCT) have proven benefit on
depression and anxiety disorders and are basic to the treatment for women’s
sexual dysfunctions of arousal and desire. As well, cognitive therapy,
especially MBCT, has recently been shown to benefit many types of chronic
pain111 including sexual pain.112 Patients with psychotic illness, who are more
likely to have cognitive impairment, may not be able to participate in CBT or
sex therapy for their sexual dysfunction, requiring instead a more supportive
therapeutic approach. Recent qualitative research in sexually active mid-life
women who mostly reported sexual problems, found that the participants
considered behavioral and psychological treatments more likely than
 medication to be of benefit for both their physical and emotional sexual
concerns.113

Psychological therapies

CBT

CBT has been the mainstay of treatment for women’s concerns with low
sexual desire/arousal and was recommended by the 2015 International
Consultation on Sexual Medicine: the evidence of benefit was graded as
moderate—there being a number of small studies but further research
needed.114 CBT can target women’s biased thoughts both during and outside
of sexual activity including inaccurate negative self-critical thoughts about their
sexuality, teach relaxation skills, address avoidance behavior and to then
improve or restore sexual functioning. Recent meta-analyses have reviewed
the benefit of CBT for women with low sexual desire/arousal: findings included
a large effect size on sexual desire and also a moderate effect on improving
sexual satisfaction. Including the male partner in CBT treatment for low desire
led to better outcome.115,116

There is evidence of benefit from CBT for sexual pain. PVD is likely the end
result of a number of different pathophysiological mechanisms, and there are
no official guidelines for optimal therapy. As with other chronic pain conditions,
cognitive therapy can be recommended.117,118 When women hear about the
complex brain activity during pain, the ability of thoughts and emotions to
modulate the physical sensation of pain becomes understandable. Brain areas
activated during a painful stimulus include areas involved in regulating
emotions (prefrontal cortex-PFC), motivation (anterior cingulate cortex),
thoughts (dorso lateral and ventro lateral PFC) and areas processing the
sensory aspects of pain (posterior insula). 119 With cognitive therapies,
catastrophic thinking, so common in women with PVD, can be usefully
targeted. Reduction of allodynia as detected by using a non-noxious touch
stimulus from a cotton swab, and increased frequency of intercourse has been
documented for up to 2.5 years after 10 weeks of CBT. 120
MBCT

Mindfulness-based therapies are now increasingly included in Western

medicine, notably for depression, anxiety disorders, chronic pain, attention
deficit disorder and cognitive decline. In addition to improved attention and
focus and ability not to follow distracting thoughts, mindfulness skills include
acceptance, non-criticism and non-reaction to the sensations (and thoughts
and emotions), of the present moment. Thus, as mindfulness skills increase,
the cognitive distractions have less effect, women’s awareness and
acceptance of their physical sensations increases and the negative judgments
that they harbor, are no longer believed and ruminated upon. Benefit against a
waitlist control and against pre-treatment levels of sexual function has been
recently shown for women with low desire and arousal. 121 Reduced avoidance
of sexual interaction and a new focus on the sexual sensory experience rather
than on any goal has been observed in a number of sexual dysfunctions
including reduced sexual interest and arousal. 122

Sexual pain has recently been shown to benefit from MBCT. Mindfulness has
been described as “uncoupling” the physical sensation from the emotional and
cognitive experience of pain,123 leading to a reduction in catastrophizing.124 To
investigate meditation’s means of diminishing pain intensity and its associated
unpleasantness, research is beginning to clarify the multiple brain networks
involved when interactions between meditation and pain-related brain
activation are studied.111 Studies are also suggesting that meditation may alter
brain morphology in meditation practitioners. 125 In a study comparing MBCT to
a wait-list control group in 85 women, researchers found significant reductions
in genital pain intensity, rumination, helplessness, magnification,
hypervigilance, sexual distress and negative mood, and an increase in
feelings of self-efficacy for managing pain. 112 Qualitative study identified
acceptance to be a major means of benefit to mood and anxiety. Women
spoke of feeling less abnormal, developed a stronger sense of self-efficacy
and expressed appreciation for their newly acquired mindful skills. 126 Recently
 submitted for publication is an 8-week program to compare 8 weeks CBT
versus 8 weeks of MBCT with follow-up for a year.

Sex therapy

Sex therapy typically involves sensate focus exercises 127,128 —a series of

planned progressive non-demand pleasuring exercises whereby each partner
takes turns giving and receiving sensual and later on, sexual touches,
caresses, and kisses. Guiding verbally and non-verbally as to what feels most
pleasurable is encouraged. Women learn to slow down instead of rushing
through a sexual experience sometimes “to get it over with.” Initially, genital
areas and breasts are off-limits. The idea of any goal or expectation of arousal
or orgasm is discouraged. Usually, each session lasts 15–20 min and two or
preferably three sessions occur each week for 3–6 weeks. The clinician and
the couple decide when to include breasts and genital areas. As sessions are
planned, touches may often be sensual rather than specifically sexual.
However, when sexual touches are wanted, oral and manual genital
stimulation or the use of a vibrator can be considered. Ultimately, the act of
intercourse (or vaginal penetration with dildo) may be included but not be the
major focus. Focusing away from intercourse can alleviate anxiety, decrease
self-monitoring and cognitive distractions considered to promote women’s
sexual dysfunction.129 More low-key sensual pleasuring may be more
acceptable to women with poor mental health. Encouragement of exploration
of erotica is often a component of sex therapy as are skills to improve couple
communication.128

Medical therapies

Vaginal dehydroepiandrosterone (DHEA): initially trialed to confirm benefit for

dryness and discomfort post menopause, research in mentally healthy women
confirms generalized sexual benefit in terms of easier orgasm and increased
sexual desire without any increase in mass spectrometry measured serum
levels of either testosterone or estrogen. 130 Serum DHEA levels increase
modestly, staying in the normal range for age-matched women. Recently Food
 and Drug Administration (FDA)-approved, 6.5 mg DHEA vaginally is an
alternative to local estrogen for menopausal vaginal dryness and pain and has
the advantage of more general sexual benefit—at least in women recruited
primarily for their vaginal symptoms. Thus, menopausal women reporting
antidepressant-associated muting of sexual response who also require local
vaginal estrogen may benefit more from using estrogen’s precursor i.e. vaginal
DHEA.

Medications for sexual pain

 PVD. The medications used for chronic pain including tricyclic

antidepressants and anti-seizure drugs have not shown benefit in the few
small randomized controlled trials conducted for PVD. However, individual
women may nevertheless benefit particularly from the TCA’s or the
serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine.
 Genitourinary syndrome of menopause (GSM). A woman whose
depression is associated with menopause may also be dealing with GSM.
Often the symptoms require local estrogen in pill, cream or sialastic ring
formulation to restore vaginal cell health, decreasing pH, and increasing
vulvar and vaginal blood flow. When systemic estrogen is used for
nonsexual reasons, additional topical vaginal estrogen may still be
required.131 Vaginal hyaluronic acid has been shown to be non-inferior to
0.5 mg estriol twice weekly with both treatments showing benefit within 2 
weeks.132 For women with both depression and GSM associated with past
breast cancer treatment, topical lidocaine applied to the vestibule for 10 
min before penetration is another non-estrogen product and has been
shown to significantly lessen dyspareunia.133

Physical therapy

Pelvic muscle physiotherapy is often helpful to lessen sexual pain both by

means of addressing concomitant hypertonicity of pelvic muscles which in
itself can be painful134 and also as a form of desensitization135 as
physiotherapy-associated pain becomes more familiar and non-threatening.
 Incorporating a mindfulness approach to the physical therapy has recently
been encouraged.136

Management of antidepressant induced sexual dysfunction

Although sometimes dose reduction can continue to benefit mood and lessen
sexual side effects, and for some 10% sexual side effects may lessen with
time,76 other interventions are often necessary to address antidepressant–
associated sexual dysfunction. A number of specific strategies will be outlined,
but the overall stance is often to accept the sexual side effects and use
evidence-based psychotherapy. Both CBT- and MBCT-based therapies are
effective for women with sexual dysfunction caused at least in part by
antidepressants.115,116,121 Unlike most trials of pharmacological agents, studies
of psychological treatments tend not to exclude women with mood and anxiety
disorders currently in remission, and thus a number of women in those studies
of cognitive therapy–based programs would have been taking
antidepressants. Outlining the sexual response cycle and explaining to women
that because of the drug’s effects, more attention is needed on the sexual
circumstances (not unduly fatigued, surroundings private, conducive to
sensual feelings, positive feelings for the partner in that moment), the sexual
stimuli- that they are optimal for her (e.g. that there is sufficient non-genital
and non-breast caressing, sufficient non-penetrative genital sex and time to
enjoy subsequent emotional closeness) and to focus on pleasure not
performance can be helpful.137

In addition one or more of the following interventions can be chosen:

1. Switching antidepressants. With the choice of some medications with

fewer sexual side effects, switching medication is an option. Thus,
switching to vortioxetine, vilazodone, moclobemide, bupropion or
desvenlafaxine can all be considered see Table 1
2. Additional psychotropic agent. A number of “antidotes” have been
suggested, but only three have evidence in the form of randomized control
trials using approved medications: adding bupropion can reverse SSRI
 induced dysfunction,138 as can the addition of aripiprazole.139 Recently,
vortioxetine has been shown to improve sexual dysfunction from SSRIs in
patients in remission from depression, to a greater degree than did
escitalopram.140
3. One study suggests the use of transdermal testosterone for treating
SSRI-/SNRI-induced loss of sexual desire in women showed some
benefit.141 However, testosterone supplementation in women is
controversial given the need for supplementing estrogen also, the lack of
benefit in premenopausal women, of long-term safety data, of FDA
approval and of any formulation for women.
4. There is also some evidence of improved lubrication and desire in women
with the use of acupuncture.142
5. Two small recent placebo-controlled trials have shown improvement in
antidepressant-associated dysfunction in women first from saffron 143 and
second from maca root.144
6. In contrast to clinical experience with investigational use of sildenafil in
women, one study with strict recruitment criteria and extended recruitment
period, reported benefit to orgasm dysfunction from the addition of
sildenafil to treat antidepressant-associated dysfunction. 145
7. Acute exercise. There is some evidence that exercise, by increasing
sympathetic nervous system drive might combat the sexual side effects of
serotonergic antidepressants given serotonin has an inhibitory effect on
noradrenaline and women’s genital sexual arousal is sympathetically-
driven. Laboratory studies of women reporting SSRI or SNRI-induced
sexual dysfunction have been conducted.146 Women watched an erotic film
while their genital congestion was measured, their subjective sexual
arousal recorded and their sympathetic nervous system activity recorded
by means of heart rate variation. Women using SSRIs were found to have
increased genital arousal when they exercised for 20 min either 5 or 15 
min prior to the films. However, there was no increase in their subjective
arousal and thus the usefulness of this intervention (in addition to its
relative impracticality), limits its use.
Management of antipsychotic induced sexual dysfunction

Options for the pharmacologic management of antipsychotic induced sexual

dysfunction in women are limited. Recommended treatment approaches
include reducing the dose of medication or changing to a more sexually
neutral antipsychotic, such as quetiapine or aripiprazole. 101,107 In a study of 27
patients with psychosis, Mir et al.147 found that libido was significantly
improved after switching to aripiprazole or adding on aripiprazole. There is
little evidence to support waiting for spontaneous remission of sexual
symptoms or taking a drug holiday.148 In addition to optimizing the
antipsychotic regimen, it is important to target modifiable risk factors that may
be impacting sexual function, such as metabolic syndrome,
hyperprolactinemia and substance use.

Many women with psychosis will be on antipsychotic medications lifelong and

even patients on optimal medical management experience significant sexual
dysfunction, thus it is important to incorporate non-pharmacologic strategies to
alleviate this distressing persistent side effect. Regular, non-judgmental inquiry
into patient’s sexual function in order to reduce stigma and understand the
particular circumstances of each woman’s difficulties is advocated. Multiple
studies have demonstrated that patients wish to speak more openly about
sexuality and intimate relationships with their psychiatrists. 22,84,92 Based on the
barrier(s) present and the level of functioning of the patient, clinicians may
then find it helpful to pursue an individualized approach, providing either
psychoeducation, relationship counseling or more cognitively challenging
therapies such as MBCT or sex therapy. A small qualitative study by Östman
and Bjorkman149 found that patients with psychotic illness who are in
relationships would like to have their partners participate more actively in
clinical discussions of sexual function. Given that many women with psychosis
cite lack of intimate relationships as a source of sexual impairment, this
population would also likely benefit from interventions aimed at reducing
hospitalization, improving social skills, decreasing stigma and enhancing
integration into society.
Directions for future research

The prevalence of DSM-5 defined Sexual Disorders in psychiatric conditions

using validated assessment tools needs to be identified. When researching
the sexual effects of antidepressant and antipsychotic medications, greater
care needs to be taken to compare pre-treatment sexual dysfunction with
treatment-emergent sexual dysfunction, as the problem of causal attribution of
sexual dysfunction among patients taking psychotropic medications is a major
problem within the literature.

Second, when new treatments, including pharmacological choices, are trialed,

women with psychiatric conditions (in remission) need to be included since
they are the main cohort requiring treatment. To date, pharmacological studies
in particular have excluded women with treated psychiatric conditions. This is
true for recent studies of controversial medications:

1. Transdermal testosterone. Neither accurately measured (by mass

spectrometry) serum levels of testosterone nor total androgen metabolites
to reflect ovarian and adrenal sources of androgens are linked to women’s
sexual desire disorder.150 Nevertheless, there is a long history of using off-
label often supra-physiological testosterone supplementation. Using lower
hormonal dosage via a transdermal patch releasing 300 μg testosterone
daily, a series of studies beginning in 2005 showed modest benefit,
whereas a second series using an equivalent gel, failed to show benefit.
The latter has only been published in abstract form. 151 Prior to the failed
gel studies, the “patch” was approved in Europe but due to low sales is no
longer available. It was not approved in the United States. Importantly
neither series recruited women with Sexual Disorders as currently defined.
Recruited women reported 2–3 sexually satisfactory experiences at
baseline, that is, the participants did not have sexual interest arousal
disorder since absence of arousal and pleasure are two key criteria for the
diagnosis.28 The long-term safety of testosterone supplementation is
unknown.152
2. Flibanserin. Women with treated psychiatric conditions were again
excluded in trials of flibanserin—an agent initially studied as an
antidepressant and inconsistently found to have very mild benefit to
desire, albeit with major risk factors. Two meta-analyses based on both
published and unpublished randomized controlled trials showed that
flibanserin led to a mean increase of 0.49 satisfying sexual events per
month.153 There was an increase of 0.3 (range 1.2—6.0) on the desire
subscale of the validated questionnaire: the analysis concluded that the
magnitude of that increase did not differ from placebo. 154 As with the
testosterone studies, the women in the trials reported 2–3 rewarding
sexual experiences each month at baseline. Although approved for limited
prescription in the United States sales are extremely low given the serious
risks, doubtful benefit, daily dosage and contraindications, including
alcohol and hormonal contraceptives.

Finally, more research needs to be conducted to understand the complex

pathophysiology of the sexual dysfunction seen among women with
psychosis. It is likely multifactorial, with contribution from medications, the
symptoms of psychosis, somatic illness and the sociocultural effects of severe
mental illness; however, until we understand the etiology of the dysfunction,
we will be limited in our ability to develop effective treatment strategies. Were
this knowledge more readily available, clinicians would also feel more
comfortable making the needed inquiries and treatment recommendations:
currently, this remains a documented but unmet need.