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As new competitors to sildenafil come to market, it is timely for psychiatrists to review their opportunities and obligations regarding the sexual concerns of their patients. Sexual medicine is a multidisciplinary and increasingly subspecialized field that reflects the complex biopsychosocial interplay among the elements comprising human sexual response. Historically, the conceptualization of sex behaviour, the nature of the available treatments for sexual problems, and the dearth of knowledge concerning the biochemical mechanisms’ underlying function and dysfunction meant that sexual medicine fell mainly within the purview of psychiatry, where diverse sexual abnormalities are still formalized in the DSM-IV category “Sexual and Gender Identity Disorders.” Psychiatrists are well-positioned to take the lead in assessing and treating these problems. As physicians, psychiatrists’ basic training is in the biological understanding of health and illness, but as specialists, their postgraduate focus is on the mechanisms and disturbances of human thought, emotion, behaviour, and relationships. Further, psychiatrists treat patients as whole people rather than as separate body parts or systems—a perspective that permits the most comprehensive understanding of sexual problems within the broadest personal and interpersonal context. In addition, psychiatrists can take the time necessary to sensitively and nonjudgementally explore issues that patients find difficult to articulate. They can confront issues that are inaccessible to medical instrumentation or psychological tests and that can only be elucidated through skilled history-taking—the forte of a psychiatrist. Paraphilias and gender identity disorders are among the DSM-IV categories. These disorders are self-evidently psychiatric in nature because of their psychodynamic complexities and potential for harm to the patient or others. However, the vastly more prevalent sexual dysfunctions, arguably as disabling in their psychological pain as many chronic physical conditions, are an equally important part of the mental health professional’s domain. There are recent indications that knowledge of psychosexual development and competency in the assessment and treatment of psychosexual disorders should be core components of a psychiatry residency curriculum (1). However, there are few experts and even fewer organized training programs anywhere in North America to provide the current generation of residents with the knowledge and skills needed to treat common sexual problems. Clinicians already in practice are at an even greater disadvantage, since virtually no training will have been available to most of them. Consequently, inquiry into sexual function or problems is unlikely to be included as a routine part of the psychiatric history or therapeutic regimen for many patients. Within the last 5 years, advances in the understanding of genital neurophysiology have led to a remarkably simple, safe, and highly efficacious treatment for male erectile dysfunction (ED) with phosphodiesterase type-5 (PDE5) inhibitors. The availability of sildenafil and now tadalafil and vardenafil, has prompted greater recognition of sexual problems as a fundamental quality-of-life issue. Millions of men and their partners are benefiting from the availability of this new class of drug and the medical legitimacy it has brought to patients’ experience of sexual problems. The caveat in this otherwise positive trend is that treatment may still fail if both doctors and patients approach a potentially complicated sexual dysfunction in a unidimensional manner by limiting consideration of sexuality to a genitally focused, medication-reliant experience. Despite its impressive broad-spectrum efficacy, renewals for sildenafil drop by over 30% (2), and possbily by as much as 50% (3), of the original prescription rate. This fall-off may be interpreted to mean that at least some patients deserve and require more time and attention to the multiple personal and interpersonal themes (that is, the context) that can affect their compliance and success with this medication. Psychiatrists should be one resource that patients can confidently and reliably turn to for a more detailed exploration of sexual problems. Yet available data indicate that psychiatrists write less than 3% of prescriptions for sildenafil (4), suggesting that sex is not an issue that our profession routinely addresses. Physicians cite several reasons for their reluctance to broach this topic: 1) sexual problems take too much time to unravel; 2) sexual problems are too biopsychosocially complex (that is, too much biology for a psychotherapist and too much psychology for a neuropsychiatrist or a psychopharmacologist); 3) it is difficult to find the appropriate moment in the interview to introduce sexual topics (questions may be misinterpreted or deemed offensive if not properly introduced or context- ualized); 4) sex is not identified as a priority or as relevant to the patient’s presenting problem; 5) the professional may have personal discomfort with the topic or with the nature of a patient’s sexual proclivities; and 6) the physician lacks knowledge or skills concerning what to ask, how to treat, or when to refer the patient. Why Talk About Sex?For most people, some form of sexual expression is an important part of a full and healthy life. The World Health Organization (5) and the office of the Surgeon General of the United States (6) have declared that sex is a basic human right and an integral part of life. The value and importance of sex may seem obvious, but there is also a modicum of evidence-based data from the Global Study of Sexual Attitudes and Behaviours to support the assumption that sex is valuable and important to patients (7). The survey involved over 26 000 persons in 28 countries and found that, at least in the group aged 40 to 80 years, approximately 83% of men and 63% of women describe sex as “extremely,” “very,” or “moderately” important. It is a safe assumption that younger men and women find sex to be equally or even more important than do their senior counterparts. Sex is not a lifestyle issue, it is a quality-of-life issue, and there is a profound difference between the two. Insofar as sex is a significant aspect of life and health, and insofar as the psychiatrist’s goal is to restore quality of life where it is impaired, sexuality is part of that clinical service mandate. Sexual dysfunction is common and distressing. The Laumann study indicates that, in the group aged between 18 and 59 years, 31% of men and 43% of women have significant sexual concerns or problems (8). Even if just a portion of these represent clinically important dysfunctions, tens of millions of people are affected. The Massachusetts Male Aging Study found that, when the focus is narrowed to a community sample of men aged 40 to 70 years, the prevalence of ED essentially matches the age at each decade. For example, the prevalence of ED is 40% among persons aged 40 years and 70% among those aged 70 years (9). Indeed, 52% of men in this age group (that is, aged 40 to 70 years) experience some degree of ED, and in about two-thirds of that group, the ED is of moderate-to-complete severity. The impact of sexual problems for patient or partner can vary from unhappiness, frustration, or a sense of sexual inadequacy in intimate relationships to a more pervasive loss of self-esteem, affecting general happiness and function within a couple and even within social and occupational spheres. Sexual dysfunction is frequently comorbid with, and may be a harbinger of, other illnesses. ED can be the presenting symptom for diabetes or cardiovascular disease. Sexual problems are also associated with various psychiatric disorders. In depression, there is usually a loss of sexual response or interest. Kennedy determined that, among untreated patients with depression, problems with sexual interest or arousal were present in 50% of women and 40% of men (10). In older men with more severe degrees of depression, the prevalence of ED approaches 100% (9). In anxiety syndromes, there may be heightened sexual performance distractions, avoidance of intimacy, or in extreme cases with deeper psychodynamic roots, florid sexual aversion. Similarly, sexual trauma can be a source of depression, anxiety, or even posttraumatic stress disorder. In bipolar disease, interest and activity may escalate to inappropriate or harmful levels during hypomanic episodes. In psychosis, sexual themes are a common component of delusional systems. Substance abuse may represent self-medication for the distress caused by sexual difficulties; alternatively, sexual dysfunction may be a consequence of substance use. As a final example, personality disorders may manifest with varying kinds of sexual difficulties ranging from promiscuity to avoidance. This high degree of comorbidity suggests that evaluating sexual complaints can have multisystem diagnostic significance, sometimes providing an index clue to other serious physical or emotional issues. Sexual dysfunction can influence the course of other illnesses and can exacerbate the severity of other psychiatric problems or the psychological response or adjustment to a physical problem. Alternatively, resolution of a sexual problem can ameliorate the intensity or distress of other illnesses. There is evidence that a significant number of men with ED report mild-to-moderate symptoms of depression (11). Interestingly, these symptoms normalize with successful treatment of ED, whereas depression scale scores remain elevated when ED is unresponsive to treatment. This suggests that the experience of a sexual dysfunction may aggravate or, in some individuals, even precipitate depression. Other recent evidence suggests that humiliation, “most typically, being abandoned by a romantic partner” (12), is one of the major events that provoke depression. Such encounters may encompass sexual incompatibilities or difficulties that should be explored. New treatments for ED have contraindications that may affect psychiatric patients. PDE5 inhibitors are extremely simple, safe, and effective for most men with ED. However, nitrates in any form (for example, nitroglycerine-containing antianginal drugs) are an absolute contraindication to PDE5 inhibitors. In the absence of nitrates, most patients with cardiovascular disease may safely take PDE5 inhibitors, but combining the 2 can cause serious hypotension. Since there is a correlation between depression and cardiovascular morbidity, a psychiatric patient may have angina and be taking nitrates. If that patient experiences ED, either as a symptom of depression or peripheral vasculopathy, he cannot be prescribed a PDE5 inhibitor. If the patient is reluctant to broach the subject of sex with his physician or psychiatrist, he may obtain medication illegitimately (for example, from friends or via the Internet), unintentionally placing himself at risk. Other patients may intermittently use nitrates in some nonclinical form (such as amyl nitrate or “poppers”). Accordingly, it is imperative that psychiatrists be aware of and be able to thoroughly discuss their patients’ overall health, including sexuality and concurrent medications. Sexual activity may be unsafe for a small number of patients. Although sexual activity requires only modest energy expenditure (about the same as climbing 2 flights of stairs), there is a slight risk (about 0.6%) of a fatal myocardial infarction during sex (13). For the seriously compromised cardiac patient, it may be temporarily inappropriate to promote or enable potentially unsafe sexual activities. This is especially the case in unwell older patients who may not have been sexually active for some years but who now want to try a PDE5 inhibitor. Some patients who are quite ill may still want to continue (or prematurely resume) sexual activity. Again, whether the presentation is medical or psychiatric, a thorough sexual history will enable the professional to safely and appropriately facilitate patients’ sexual activity or the treatment of any sexual problems. Sexual dysfunction is a common treatment side effect of many psychotropic drugs. This not only adds to the patient’s distress but may also induce noncompliance with medication. It is therefore necessary for psychiatrists to routinely inquire about sexual behaviour and response before starting medications so that the role of any drug in causing dysfunction can be clearly delineated. It is possible to deduce the likelihood of medication sexual side effects by knowing the following 4 key neurotransmitters involved with sexual response:
Effective treatment is available for many sexual problems. However, the efficacy of psychological or pharmacologic therapies depends on a thorough sex history of the patient. It is not necessary to be a subspecialty expert in sexual medicine to provide meaningful care. The PLISSIT (permission, limited information, specific suggestions, and intensive therapy) model developed by Jack Annon decades ago is still useful. Given the prevalence of sexual problems, the potential distress caused by dysfunction, the potential harm to self and others consequent to sexual behaviours or disorders, the comorbidity with other illnesses, the sexual side effects caused by psychotropic drugs, the availability of an effective medical treatment to counteract a side effect of ED, and the possible interactions between PDE5 inhibitors and nitrates (which may be relevant in some psychiatric patients), it may be argued that it is indefensible not to take a good screening sexual history from each patient. For an area of life and health that is so fundamental and pervasive, professional ignorance or inattention to possible sexual problems does not meet current standards of psychiatric practice. The PLISSIT ModelPermission (P): Legitimize the topic of sex, validate the patient’s problem, and empower the patient to make choices and changes. Limited Information (LI): Discuss the prevalent concerns and norms of behaviour. Emphasize the importance of communication and trust within a relationship. Review the need for physical health, comfort, and emotional safety, and discuss medication side effects. Specific Suggestion (SS): Provide psychiatric medication options, eliminate modifiable risks, and stimulate patients’ interest (using books or videos). Suggest dating sessions with a partner, including noncoital sex options. Consider PDE5 inhibitors for depression or other illness-related ED and for SSRI-induced or other medication-induced ED (14). Intensive Therapy (IT): Therapy includes marital or couples counselling, a possible referral for sex therapy, and (or) more in-depth psychotherapy. Psychiatrists and other mental health professionals are qualified to provide at least the first 3 levels of the PLISSIT model and probably many components of the fourth. Most patients with sexual concerns will respond to the first 3 stages. ConclusionSex is a fundamental quality-of-life issue. Sexual problems are extremely prevalent among the general population and even more so among persons with psychiatric or medical illness. There are at least 9 reasons why all physicians, perhaps psychiatrists especially, should make inquiry into sexual behaviours and response a routine part of caring for every patient. References1. Scheiber SC, Kramer TAM, Adamowski SE. The implications of core competencies for psychiatric education and practice in the US. Can J Psychiatry 2003;48:215–21. 2. Son H, Park K, Kim S-W Kim, Paick J-S. Reasons for discontinuation of sildenafil citrate after successful restoration of erectile function. Asian J Androl 2004;6:117–20. 3. The Wall Street Journal On Line. 2002 Nov 11. Available: http://www.usrf.org/breakingnews/bn_111202_viagra/bn_111202_viagra.html. Accessed 2004 July 6. 4. Carson CC. Advances in the treatment of patients with erectile dysfunction. Business Briefing: North American Pharmacotherapy 2004; p 56–9. Available: http://www.bbriefings.com/pdf/790/carson.pdf. Accessed 2004 July 21. 5. World Health Organization draft working definition, October 2002. Available: www.who.int/reproductive-health/gender/glossary.html. Accessed 2004 June 24. 6. The Surgeon General’s call to action to promote sexual health and responsible sexual behaviour. 2001 June. Available: www.surgeongeneral.gov/library/sexualhealth/call.pdf. Accessed 2004 June 24. 7. Nicolosi A, Hartmann U, Glasser DB, Gingell C, Buvat J, Moreira E, and others. Sexual attitudes and beliefs in mature men and women: results of an international survey. Presented at the European Public Health Association Meeting; 2002 Nov 28–30; Hamburg, Germany. 8. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537–44. 9. Feldman HA, Goldstein L, Hatzichristou DG. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54–61. 10. Kennedy SH, Dickens SE, Eisfeld BS, Bagby RM. Sexual Dysfunction before antidepressant therapy in major depression. J Affect Disord 1999;56:201–8. 11. Seidman SN, Roose SP, Menza MA, Shabsigh R, Rosen RC. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate. Am J Psychiatry 2001;158:1623–30. 12. Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA. Life event dimensions of loss, humiliation, entrapment, and danger in prediction of onsets of major depression and generalized anxiety. Arch Gen Psychiatry 2003;60:789–96. 13. Muller JE, Mittleman A, Maclure M, Sherwood JB, Tofler GH. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. JAMA 1996;275:1405–9. 14. Nurnberg HG, Hensley PL, Gelenberg AJ, Fava M, Lauriello J, Paine S. Treatment of antidepressant-associated sexual dysfunction with sildenafil: a randomized controlled trial. JAMA 2003;289:56–64. Author(s)Manuscript received September 2003, revised, and accepted February 2003. 1. Associate Clinical Professor, UBC Department of Psychiatry; Former Clinical Director, The BC Centre for Sexual Medicine, Vancouver General Hospital, Vancouver, British Columbia. Address for correspondence: Dr R Stevenson, Vancouver General Hospital, Suite 500, 575 West 8th Avenue, Vancouver, BC V5Z 1C6 e-mail: rwds@interchange.ubc.ca
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