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Over the past decade, clinicians and researchers have paid growing
attention to women’s health issues, including sexual and reproductive
health concerns throughout the female life cycle. Articles in this
issue by Dr Robert Segraves and Dr Adele Viguera reflect this interest
by capturing 2 important topics: sexual dysfunction in women (1)
and the treatment of mood disorders during pregnancy (2).
Few topics seem to generate such a spectrum of emotional responses—often
very mixed—from psychiatrists as do sexual and reproductive
issues in persons with serious mental illnesses. Clinicians often
experience very mixed emotions (3,4). While we want to help both
male and female patients to participate fully in life to the extent
of their abilities, it may be challenging to include optimal sexual
and reproductive functioning in the treatment plan. At an intellectual
level, we accept that sexuality is an important subject to explore
with our patients, but on a daily basis we often fail to take a
sexual history (5). In my clinical experience, this is especially
true in the case of women with psychotic disorders, where there
is often great reluctance to inquire about sexual and reproductive
functioning. By understanding the multiple factors that affect fertility
and sexuality, clinicians can more effectively collaborate with
patients to improve their quality of life.
The ability to function sexually is an important but historically
neglected psychiatric outcome. Persons with psychiatric disorders
often suffer chronically and may require lifelong treatment with
psychotropic medications that affect their sexual health. Those
working in this field need to know the consequences of sexual and
reproductive dysfunction occurring during adolescence and young
adulthood—the time of onset of many major psychiatric conditions.
How does drug-induced sexual dysfunction affect compliance? What
are the relations among the underlying illness, the drugs used to
treat it, the individual’s medical health and psychosocial
condition, and sexual functioning and the ability to engage in fulfilling,
intimate relationships? There are many unanswered questions. While
this issue’s “In Review” section focuses on women’s
mental health, sexual dysfunction is not only a women’s issue.
Nevertheless, as Dr Segraves points out, “Information concerning
female sexuality has consistently lagged behind our knowledge of
male sexuality” (1). His article provides a welcome update.
As this quote (6) suggests, the desire (or lack thereof) for children
is a human issue that does not disappear with the diagnosis of a
psychiatric disorder. When confronted with a pregnant woman who
has a serious mental illness such as schizophrenia or bipolar disorder,
clinicians understandably often feel overwhelmed by the complexity
of the situation. Over the past decade, there has been increased
recognition of the risks for the mother and fetus of not treating
the underlying psychiatric disorder.
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Dr Viguera’s article supports what has become increasingly
clear: no decision—whether to discontinue, change, or continue
psychotropic medication—is risk-free. Clinicians in these situations
face the following questions: What are the benefits and risks of
the medications? Should the medications be stopped or changed? If
I do that, what is the risk to the mother? What is the risk to the
fetus? What genetic counselling should be offered and when? Does
the woman have the support system she requires to optimize outcomes,
not only during the pregnancy but also during the years of parenthood
that will follow? As psychiatrists, we have much-needed expertise
that we can share with our colleagues to improve the care of pregnant
women with psychiatric disorders.
Sexuality and reproductive functioning are obvious topics to discuss
from the perspective of gender roles and sex differences. However,
there is also a need to expand on the work done during the 1990s
on gender roles and psychopathology, on neurobiological differences
between the sexes, on sex differences in psychopharmacology, and
on policies that encourage the inclusion of women in clinical trials
of new treatments. Becoming more gender-sensitive in our clinical
practices, program planning, and research endeavours does not mean
becoming a “male” or “female” specialist. Ultimately,
sensitivity to and acknowledgement of sex and gender role differences
can improve psychiatric care for both men and women. I hope that
the contributions from Dr Viguera and Dr Segraves will help clinicians
develop this sensitivity in their evolving practices and encourage
researchers to consider these issues in their psychiatric research.
Gender issues are not synonymous with women’s issues; I hope,
too, that we can look forward to a future Journal “In Review”
section on men’s mental health issues.
References
1. Segraves RT. Female sexual disorders: psychiatric
aspects. Can J Psychiatry 2002;47:419–25.
2. Viguera A. Clinical issues in the management of
bipolar disorder during pregnancy: weighing the risks and benefits.Can
J Psychiatry 2002;47:426–34.
3. Dickson RA, Hogg L. Pregnancy of a patient treated
with clozapine. Psychiatr Serv 1998;49:1081–3.
4. Coverdale JH, Bayer TL, McCullough LB, Chervenak
FA. Respecting the autonomy of chronic mentally ill women in decisions
about contraception. Hospital and Community Psychiatry 1993;44:671–4.
5. Singh SP, Beck AJ, No sex please, we’re British.
Psychiatric Bull 1997;21:99–101
6. Ian Brockington. Motherhood and mental health. Oxford
University Press; New York 1996.
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Address for correspondence: rul353@aol.com
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