Psychosexual Health and Sexual Medicine in Consultation-Liaison Psychiatry.

INTRODUCTION

Sex and sexuality are the primal instincts of civilizations. They form the central core of social bonds, couple dynamics, relationships, intimacy, and reproduction. It is a well-established fact that sexual expressions and manifestations are biopsychosocial constructs and have heavy bearing on cultural and ecological contexts. Classically, three dimensions of sexuality have been defined: desire, attachment, and reproduction. Exploring these complex multidimensional interactions forms the basis of psychosexual health, which is in turn integral to sexual medicine. As defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, sexual medicine is “that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate.” Interestingly, even though psychosexual disorders are predominantly dealt with by psychiatrists, their etiology may be multifaceted including other medical comorbidities and iatrogenic causes. This brings us to the importance of consultation–liaison psychiatry (CLP) while dealing with sexuality and sexual concerns. It is not uncommon in clinical practice to routinely attribute sexual disorders and dysfunctions to a “functional cause,” thereby neglecting the emotional connotations, underlying distress, effect of medications, and concurrent medical conditions. This can lead to misdiagnosis, underdiagnosis of these disorders, and impaired sexuality and quality of life. With this background and with an aim to be a guiding outline for both psychiatrists and other medical specialties, these Clinical Practice Guidelines (CPGs) attempt to synthesize the role, evaluation, principles of assessment, and management of psychosexual disorders in CLP settings.

USING THIS CLINICAL PRACTICE GUIDELINES: ROLE OF PSYCHIATRISTS IN TREATING SEXUAL DISORDERS IN CLP

CLP or liaison psychiatry or consultative psychiatry is the branch of psychiatry that deals with the intersections between general medicine/surgery/pediatrics and psychiatry, usually taking place in a general hospital setting. This relatively developing branch has a significant overlap with psychosomatic medicine (includes psychosexual disorders), pain management, health psychology, and neuropsychiatry. The psychiatrist usually acts as an “advising consultant” in response to specific requests/referrals from the other specialties. Now, when it concerns sexuality and related disorders, the concept of this discipline cannot be more stressed upon, “the interplay of biological and psychosocial factors in the development, course, and outcome of diseases.” An ideal CLP service needs to be a liaison-based model though mostly it is a consultation-based model that lacks interdisciplinary discussion, and further, with significant heterogeneity in training and limited research, CLP is still a naïve field in India. This makes these CPGs assume an increased importance.

The Diagnostic and Statistical Manual (DSM)-5 prevents a sexual disorder to be considered as a psychiatric diagnosis, if the presumed etiology was a medical condition (or several concurrent medical conditions). In clinical reality, however, there are no watertight boundaries; for example, an individual with adjustment issues related to a new diagnosis of malignancy can have resulting erectile dysfunction (ED), which can get further worsened by cancer chemotherapy. Hence, it is a common practice for a physician to encounter a clinical context, in which a precise understanding of the specific cause of a sexual problem remains unidentified. Thus, even when a CLP referral is in place, it is the responsibility of the psychiatrist to recognize and determine the constellation of factors and possible causes that may impact the reported sexual disorders/dysfunctions. In fact, a host of medical conditions and medications can influence sexual functioning and responsiveness, which in turn is dependent on the existing sexual practices, sexual beliefs, and other sociocultural factors. These CPGs are drafted to guide on clinical judgment to understand these complexities and enable the liaison psychiatrist to take a balanced and evidence-based decision on the management of sexual disorders in medical settings. Important to note, this paper does not deal with the general management principles of sexual dysfunction (SD) which are already covered in earlier CPGs.

SEXUAL DISORDERS AND DYSFUNCTIONS ASSOCIATED WITH GENERAL MEDICAL CONDITIONS

Even though the individual disorders are discussed subsequently, in this section, we will outline the ways in which any chronic medical condition can influence sexual functioning and the principles of management. As mentioned before, the traditional duality of psychological and organic factors in sexuality is flawed, and these two are inseparably combined. On the one hand, coping style, personality traits, social support, and external stressors can modulate inflammatory, immune, neurological, and endocrine mechanisms; on the other hand, any medical condition will have psychosocial offshoots that can disrupt physiology of sexuality. SDs can be best understood through a biopsychosocial model [Figure 1], which is also relevant when apparently caused by medical illnesses as correction of the offending disease/medicine is often not enough on its own.

Figure 1

Biopsychosocial model of sexual disorders/dysfunctions

The two most common conditions causing this disruption are vascular ED (due to coronary artery disease [CAD], PVD, CCF, etc.) and dyspareunia due to vulvar vestibulitis syndrome. Based on DSM-5, the different types of SDs can be that of desire, arousal, orgasm, and sexual pain. Broadly, the medical conditions that can lead to any or all of these conditions are enumerated in Table 1.

Table 1

Medical conditions associated with sexual disorders/dysfunctions

Group of disorders	Specific conditions
Cardiovascular	Atherosclerosis
	CAD/angina
	Heart failure
	Hypertension
	Peripheral vascular disease
	Aortic aneurysms
Metabolic and endocrine	Obesity
	Dyslipidemia
	Diabetes mellitus
	Hyperthyroidism/hypothyroidism
	Hyperprolactinemia/hypoprolactinemia
	Hypercalcemia
	Cushing’s syndrome
	Addison disease
	Sex steroid deficiencies
Neurological	CVA
	Dementia
	Head injury/spinal cord injury
	Multiple sclerosis
	Parkinson’s disease
	Epilepsy
Malignancy	Cancers of:
	Prostrate, testis, uterus, breast, ovarian (both direct and indirect)
	All cancers: surgery, chemotherapy, radiation therapy, hormone therapy (indirect)
Others	CKD
	Connective tissue disorders/autoimmune conditions
	Osteoarthritis/related musculoskeletal conditions causing chronic pain
	Amputations
	Urinary tract infections
	STD and HIV
	COPD/ILD
	Cerebral palsy
	Medications (discussed separately)

CAD – Coronary artery disease; CKD – Chronic kidney disease; HIV – Human immunodeficiency virus; COPD – Chronic obstructive pulmonary disease; ILD – Interstitial lung disease; CVA – Cerebrovascular accident; STD – Sexually transmitted diseases

All SDs listed in the international classificatory systems can present to the consultation–liaison psychiatrist (due to the medical condition or medications, and hence not primary in etiology). In order of frequency, they are as follows:

Men:

ED

Premature ejaculation (PME)

Decreased libido and arousal disorders

Anorgasmia

Painful erection and ejaculation

Women

Anorgasmia and arousal disorders

Reduced desire

Reduced vaginal lubrication and vaginismus

Other genital pain disorders.

Epidemiology

Data with regard to SD in medical conditions is complicated by methodological differences, use of heterogeneous questionnaires, and differing designs in population-based studies. Further, the usual dichotomy of “psychiatric” and “medical” etiology of sexual disorders used in many studies makes epidemiological estimation difficult. Data from the National Health and Social Life Survey in the USA showed that SD is more prevalent for women (43%) compared to men (31%). Further, aging, medication use, and presence of at least one comorbid medical condition increased the risk of problems related to arousal (in women) and erection (in men) by 1.5 times, and this was independent of education and ethnicity. Several population-based surveys have shown that while ED, PME, dyspareunia, and hypoactive sexual desire were the most common offshoots of general medical conditions, delayed ejaculation (DE) and frigidity were least prevalent. Besides, diabetic men develop impotence at least 10–15 years earlier than their nondiabetic counterparts. Based on the guidelines, ED is a disorder in which it is fundamental to distinguish medical from psychological causes (or whichever is predominant) for understanding its prognosis and management.

Etiopathogenesis

There are several pathways through which medical disorders can lead to sexual disturbances. The exact manner or cause of a specific sexual disorder can have a plethora of explanations, which is beyond the scope of this CPG. Multifactorial causation is a rule rather than exception, and aging, malnutrition, substance abuse, frailty, and relationships are other influential factors. In general, urinary tract infections lead to arousal and pain problems in women and erectile issues in men. There are several mechanisms involved which are discussed eventually in individual sections.

The various pathways in general medical conditions that can lead to disturbances in different domains of sexual cycle are detailed in Tables 2 and 3.

Table 2

Sexual dysfunction associated with chronic diseases: The mechanisms involved (adapted from Basson et al., 2010)

Type	Mechanisms	Examples
Indirect	Low mood	Associated with recent diagnosis of debilitating or terminal medical condition (strong link with ED and anorgasmia)
	Low-energy levels	Fatigue can reduce sexual desire and motivation (in chemotherapy, infections, CCF, renal failure, etc.)
	Restricted mobility	Limited ability for physical intimacy, social touch, sexually stimulate partner/self, problems in sexual positioning and experimentation (Parkinson’s and other motor disorders, ALS, CVA, brain and spinal cord injuries, postamputation)
	Relationship dynamics	Couple discord, reduced social support, inability in finding a partner due to caregiver burnout, stress, perceived burdensomeness, lack of autonomy
		“Medicalized lives” (recurrent dialysis, CKD, post-CABG, chemotherapy)
	Self-image disturbances	Disfiguring surgeries, scars, stomas, incontinence, muscle wasting, altered face and body movements in motor disorders (perceived lack of attraction)
	Infertility leading to perceived loss of sexuality	From surgical removal of uterus/gonads or chemotherapy or radiation therapy, leading to gonadal failure
	Fear of sex	Fear of precipitating stress-induced medical event (CAD, CVA, genital pain in STD and surgeries, etc.)
Direct	Change in sexual desire	Due to hyperprolactinemia or anemia in CRF
		Due to testicular or ovarian failure after chemotherapy/hormonal therapy
		Narcotics causing gonadotrophin suppression
	Impaired genital response	Effect of disease: ED (multiple sclerosis, IPD, hypertension, CCF); orgasmic disorder (neurological conditions)
		Effect of surgery (radical prostatectomy, radical vulvectomy, etc.)
		Effect of radiation (vascular damage, vaginal stenosis, etc.)
		Effect of medications (e.g., aromatase inhibitors, GnRH analogs, leading to decreased genital sensitivity)
	Pain	Surgery/medication/radiotherapy leading to structural and chemical changes (e.g., vaginal stenosis, reduced genital lubrication)
		Chronic pain from any condition, leading to restriction of mobility and reduced sexual pleasure/altered orgasm

ED – Erectile dysfunction; CKD – Chronic kidney disease; CAD – Coronary artery disease; CCF – Congestive cardiac failure; ALS – Amyotrophic lateral sclerosis; CVA – Cerebrovascular accident; STD – Sexually transmitted diseases; CRF – Chronic renal failure; IPD – Idiopathic Parkinson’s disease; CABG – Coronary artery bypass graft

Table 3

Pathophysiology and types of sexual dysfunction in different medical conditions with their basic management principles

Disorder	Pathogenesis of sexual dysfunction	Management	Prevalence (%)*
Reduced sexual desire and arousal
CAD/AMI	Low motivation for desire Fear of a subsequent attack Concern about using PDE-5 inhibitors among those on nitrates Comorbid depression (almost in half of the cases)	Reassurance (risk is low and short-lived; regular testing) Need for regular exercise Use alternatives (trimetazidine) of nitrates Screen and treat depression/anxiety	15-20
CRF	Low testosterone in men (LH response blunted, GnRH pulsation reduced) Anovulation Hyperprolactinemia Anemia Uremic menorrhagia/amenorrhea Estrogen deficiency leading to dyspareunia	Limited benefit of testosterone supplementation (in men) Bromocriptine to reduce prolactin Vitamin D and zinc therapy Erythropoietin for anemia Cyclical progesterone for uremic menstrual irregularities Topical estrogen for genital pain	5-10
UTI and urinary incontinence	Reduced sexual motivation and orgasm	Postmenopausal estrogen therapy (limited benefit in those with infections) Surgical interventions for incontinence can worsen sexual dysfunction	5-15
Diabetes mellitus	Some correlation between high blood glucose and low desire Reduced serum testosterone and low GnRH pulses (in men) Reduced arousal, orgasm, and genital pain (in women)	Adequate glycemic control and screen for sexual problems	30-40 (more in older people)
Neurological conditions	Low desire with dopaminergic medications and in IPD, MS, etc. Hypothalamic lesions (CVA, head injury)	Correct the specific cause Nonpharmacological measures	15-70 (depends on the condition)
Adrenal diseases	Lack of sex androgens (DHEA)	Mild benefit of DHEA supplementation	No data
Primary and secondary hypogonadism in men, bilateral oophorectomy in women	Loss of sex hormones and sex hormone precursors affect processing and perpetuation of sexual stimuli Reduced availability of NO, leading to ED	Treat causes of secondary hypogonadism Replace testosterone (prostrate or breast CA is a contraindication) Transdermal patch testosterone supplementation is of some benefit in surgical menopause	10-20
Erectile dysfunction			Prevalence (%)*
CAD	Endothelial dysfunction Structural atheromatous change Smooth muscle ischemic changes Venous occlusion	PDE-5 inhibitors (when not on nitrates) Vardenafil to be avoided in patients on class-IA anti-arrhythmics Apomorphine (D1/D2 agonist) can be tried when on nitrates Lifestyle modifications	35-50
CRF	Endothelial and cavernosal smooth muscle dysfunction Reduced NO production and NOS expression ANS dysfunction due to uremia	PDE-5 inhibitors RAS antagonists and CCBs have an experimental role (not tested clinically)	20-25
UTI/BHP	Increased SNS, increased smooth muscle tone Reduced NOS activity in bladder outlet nerves Ischemic smooth muscle fibrosis	Alfuzonsin is associated with least ED PDE-5 inhibitors+alpha-blockers have been tried (no RCTs)	15-20
CCF	Highest prevalence of ED (80–90%) Associated vascular risk factors and depression	PDE-5 inhibitors are useful and improve exercise tolerance Risk for hypotension	20-30
Diabetes mellitus	Reduced NOS activity (lack of NADPH, increased arginase) Increased smooth muscle contraction Age products and ROS impair NO-induced vasodilation	PDE-5 inhibitors useful in 50% Intracavernosal PGE-1 in resistant cases	40-70
Hypertension	Endothelial dysfunction Vascular smooth muscle changes	CCBs and ARB improve endothelial functioning PDE-5 inhibitors are effective (vardenafil should not be used with alpha-blockers)	15-25
Primary and secondary hypogonadism	Low testosterone: reduced NO, low desire	Supplement testosterone if no contraindications Correct the secondary causes	60-80
OSA	ANS and endothelial dysfunction (nocturnal hypoxia and nocturnal SNS overactivity)	Sildenafil+CPAP improves ED in clinical trials	60-70
Neurological conditions	CNS, PNS, ANS dysfunction	PDE-5 inhibitors offer modest benefit (also in postsurgical cases) Intracavernosal PGE-1 to be used in least possible doses	40-70 (depends on the condition)
Dysfunction of orgasm and ejaculation			Prevalence (%)*
Infections (prostatitis, urethritis, epididymitis), PID	PME due to the local trigger Urethral strictures and ejaculatory duct obstruction Painful and low-volume ejaculation Painful female orgasm	SSRIs (paroxetine has an advantage) CBT techniques Pubococcygeal muscle training Tamsulosin may benefit painful ejaculation Surgical treatment of strictures Postmenopausal estrogen and progesterone	20-30
Diabetes mellitus	Retrograde ejaculation Delayed/absent ejaculation/orgasm	Vibrostimulation Yohimbine, bupropion, buspirone, cyproheptadine can be tried Sympathomimetics can be used for fertility	30-40
Pelvic floor or local genital surgeries, spinal cord injuries	Absent/retrograde ejaculation (pelvic sympathetic nerve damage) Ejaculatory duct strictures Delayed orgasm Painful female orgasm	Mechanical stimulation Pelvic floor exercises Sympathomimetics for fertility Surgical correction may be necessary for incontinence Postmenopausal estrogen (for female orgasmic disorders)	50-70
Endometriosis	Delayed/painful female orgasm	Bupropion/yohimbine has been tried Mechanical stimulation (vibrators) Treat underlying disorder	30-40
Pain disorders			Prevalence (%)*
Peyronie’s disease, phimosis, priapism	Pain on erection Difficulty in penetration Altered urinary frequency Unwanted painful erections	Mostly corrected surgically (rarely referred to a psychiatrist) Priapism can be a potential medical emergency Treat secondary causes	70-80
Dermatological disorders (in men)	Pain on sexual touch and penetration	Exclude STD Treat underlying disorder Couple counseling about nonpenetrative and safe sex Psychosexual support (inability to contact a partner, disrupted self-image, lack of confidence, etc.)	No reliable data
Vulvovaginal atrophy	Introital pain during intercourse Postcoital burning Deep dyspareunia	Local estrogen therapy Tibolone is of benefit Dopaminergic drugs to reduce prolactin in pituitary disease Nonpenetrative sex Surgery/radiation (for cancers)	20-30
Chronic abdominal pain conditions	Endometriosis, IBD, chronic PID, ovarian tumor, adhesions (deep dyspareunia and introital pain)	Pelvic floor exercises Treat specific conditions Address negative sexual experiences	30-40
LUTS and incontinence	Deep dyspareunia Postcoital burning (vulvar inflammation) Also associated with hypoactive sexual disorders	Treat infections with antibiotics Surgical management of prolapse	No reliable data
Pelvic radiation	Coital pain	Preventive measures (to be discussed with liaison) Couple counseling Topical estrogen, lubricants, vaginal inserts	40-50
Dysesthetic vulvodynia	Introital dyspareunia	Topical estrogen/xylocaine EMG biofeedback CBT TCAs or AEDs for pain management Sexual counseling	No reliable data
STD	Superficial or deep dyspareunia	Follow STD management guidelines Protective measures for safe sex Deal with performance anxiety	Prevalence varies with the infection
Genital mutilation	Wide range of pain symptoms (type I–III)	Sexual counseling, psychotherapy and support groups Involve sexual partner in decision-making Clarify legal/ethical responsibility Specific management of sexual dysfunction

*Data is based on major epidemiological studies (National Health and Social Life Survey; US; American Diabetes Association; the National Cancer Institute; The American Cancer Society; Bureau of Health Statistics; MMAS; Framingham Heart Study); The prevalence percentages are only tentative; can vary widely and should not be considered as strict cutoffs. MMAS – Massachusetts Male Aging Study; PDE-5 – Phosphodiesterase 5; ED – Erectile dysfunction; PME – Premature ejaculation; CAD – Coronary artery disease; LH – Luteinizing Hormone; IPD – Idiopathic Parkinson’s Disease; MS – Multiple Sclerosis; DHEA – dehydroepiandrosterone; ANS – Autonomic nervous system; SNS – Sympathetic nervous system; CNS – Central nervous system; PNS – Parasympathetic nervous system; NOS – Nitric Oxide Synthase; NADPH – nicotinamide adenine dinucleotide phosphate; ROS – Reactive Oxygen Species; IBD – Inflammatory Bowel Disease; PID – Pelvic Inflammatory Disease; CA – Carcinoma; CCB – Calcium Channel Blocker; RCT – Randomized Controlled Trial; PGE – Prostraglandin; ARB – Angiotensin Receptor Blocker; CPAP – Continous Positive Airway Pressure; CBT – Cognitive Behaviour Therapy; EMG – Electromyogram; TCA – Tricyclic antidepressants; AED – Anti-epileptic drugs; STD – Sexually transmitted diseases; NO – Nitric Oxide; AMI – Acute Myocardial Infarction; CRF – Chronic Renal Failure; UTI – Urinary tract infections; BHP – Beningn Hyperplasia of Prostrate; CCF – Congestive Cardiac Failure; OSA – Obstructive Sleep Apnoea; LUTS – Lower urinary tract symptoms

Evaluation and management

As mentioned before, when SD is better explained by a medical condition, the individual cannot receive a psychiatric diagnosis as per the DSM-5. In fact, an SD diagnosis requires the treating clinician to rule out a multitude of problems that could be better explained by a nonsexual psychiatric disorder, by the direct and indirect effects of a specific substance, by a medical condition, or by marked interpersonal and psychosocial stress. The usual protocol and outline of evaluation and management of SDs in both men and women have already been detailed in earlier CPGs and will not be discussed any further. Here, we only consider the issues caused directly or indirectly by any medical conditions.

It is imperative that physicians are required to conduct a thorough evaluation of possible medical conditions that can lead to these symptoms, as many of these medical conditions are readily treated and can result in a reversal of symptomatology. Further, management in any such case starts with a detailed and comprehensive review of a patient’s sexual, psychiatric, and medical history including sexual practices, beliefs, myths, and couple relationship dynamics. This needs to be supplemented with corroborative information from the partner, psychosocial assessment, and comprehensive yet focused physical (and genitopelvic) examination. Additional laboratory investigations are required as deemed necessary. Few salient principles are listed in Table 4. The key is often to have a multidisciplinary bidirectional liaison with the respective specialty dealing with the medical condition and longitudinal follow-up.

Table 4

General areas of assessment/evaluation in sexual dysfunctions induced by medical conditions

Past psychiatric and medical history

Premorbid personality

Sexual attitudes and beliefs

Current medical state (cardiac, respiratory, genitourinary, metabolic, neurological)

Mobility, pain and continence status (for sexual activities)

Preillness sexual behavior (preferences, frequency, fetishes)

Detailed review of current medications and their impact on sexual cycle (whether change of medicines had an influence on sexuality)

Duration, type and context of the sexual dysfunctions; treatment received (pharmacological and psychosocial)

Specifics needed for the dysfunctions

Motivation/fear/apprehension about sex

Perceived sexual satisfaction/pleasure

Morning erections

Masturbatory practices

Distracting/anxiety-provoking thoughts during sex

Experiences of orgasm/intercourse

Ask about vaginal lubrication, coital pain and postcoital dysuria

Ask about male dyspareunia

Couple relationship status, quality and communication

Independence and autonomy for sex in daily living

Effect of medical illness on sexual self-image and body satisfaction

Detailed physical examination (including local genital evaluation): especially in cases of ED, pain disorders, problems with arousal, neurological conditions

Mental status examination (depression, performance anxiety, stressors)

Blood investigations (to rule out anemia, dyslipidemia, hypo/hyperthyroidism, hypogonadism, hyperprolactinemia, sex steroids/androgens)

ECG and ECHO for cardiac status

Penile Doppler/plethysmography (rarely needed)

Investigations

Basic

CBC

Fasting lipid profile

Metabolic panel and blood sugars

RFT, TFT, LFT

Urine analysis (routine and culture), drug screen

Hormonal assaysa

Specific disordersb

ED: Blood (total and free testosterone, LH, serum prolactin), vascular testing (duplex ultrasound, cavernosometry, nocturnal penile tumescence)

Female sexual arousal disorder: Vaginal photoplethysmography (to test blood flow and temperature, biomechanical function of female genital tract, testing vaginal pH)

PME: Ejaculatory latency testing (rarely used in real-world setting)

Certain hormonal levels (standard)c

LH: 5-15 mIU/mL

FSH: 5-15 mIU/mL

Prolactin: <15 mIU/mL

Total testosteroned: 300-1000 ng/dL (adult males), 30-120 ng/dL (adult females)

Free testosteroned: 5-21 ng/dL (adult males), 0.3-0.85 ng/dL (adult females)

SHBG: 0.6-3.5 mg/L (adult males), 2.5-5.4 mg/L (adult nonpregnant females)

aNormal ranges and standardization vary; bFor PME (males) and orgasmic disorder (females); self-report is always the best diagnostic marker; cHormonal levels can highly fluctuate based on medical conditions; psychological factors; diet; sexual activity; etc.; dBlood for serum testosterone assessment need to be drawn from 8–10 am and not during early follicular phase in pre-menopausal women. ED – Erectile dysfunction; PME – Premature ejaculation; ECG – Electrocardiogram; ECHO – Echocardiogram; CBC – Complete blood count; RFT – Renal function test; TFT – Thyroid profile test; LFT – Liver function test; LH – Luteinizing hormone; FSH – Follicle stimulating hormone; SHBG – Sex hormone binding globulin

Psychiatric disorders are often comorbid with medical conditions in the CLP setting. Depression, bipolar disorder, anxiety spectrum disorders, schizophrenia, personality disorders, neurocognitive disorders, and psychotropic medications (antipsychotics, antidepressants, mood stabilizers, and benzodiazepines) are responsible for causing various SDs. ED, anorgasmia, and PME are the most common sexual dysfunctions comorbid with mental health conditions. The primary psychiatric disorder needs to be treated, and offending medication is to be changed along with psychotherapeutic interventions as needed. These aspects have been covered in earlier CPGs and hence not detailed here.

An evidence-based management strategy for a CLP psychiatrist while evaluating a case of SD will be to have a holistic biopsychosocial plan incorporating the precipitating and perpetuating factors. This plan needs to be documented, backed up by relevant investigations, and discussed with other clinicians involved in the care. A direct and constructive communication between all stakeholders is the key. It is essential to treat endocrinal abnormalities such as hypothyroidism and correct hormonal deficiencies such as low testosterone and manage physically-limiting disorders such as arthritis. To better differentiate between drug-induced SD and SD due to other causes, a baseline evaluation of sexual functioning is of utmost importance. Often, it may be difficult to decipher the relationship between illness, medication, and SD since the underlying illness, for example, cardiovascular disease (CVD), may itself be associated with SD.

At times, the burden of chronic illness, adjustment issues, and self-perceptions related to it may impair sexual relationships which need to be addressed. The offending medicine leading to SD needs to be halted and is the most definitive treatment in some cases. While it is important to consider that there is no threshold or optimum level of sexuality, the perceptions and needs of the individual/couple in question are vital and will guide treatment decisions. Sexuality also involves closeness, intimacy, emotional bonds, and social touch, and equating it with intercourse is reductionistic. Keeping the individualized sexual needs and changing descriptions of intimacy with aging are necessary for the treating psychiatrist.

The basic steps for assessing and treating SD (International Consultation on Sexual Medicine-5) which also need to be followed in the CLP setting are depicted in Figure 2.

Figure 2

International Consultation on Sexual Medicine-5 guidelines for evaluating sexual dysfunctions (adapted from Montorsi et al., 2010)[1]

Besides treating the medical cause of SD, it might necessitate biological treatments such as oral medications (phosphodiesterase-5 [PDE-5] inhibitors, non-PDE-5 agents, antidepressants, and hormones), injections, devices, and implants as well as psychosocial interventions (individual psychotherapy, couple therapy, and sex therapy). The nonpharmacological techniques are extremely important but often neglected. They do not exist in vacuum and are usually coupled with sex education, clarifying the myths related to sexuality, as well as anxiety related to the concurrent medical illness [Table 5]. The guidelines for these treatments are not much different from SD without a medical cause and hence will not be discussed in detail. While some strategies are mentioned in Table 4, and other relevant management techniques will be detailed in subsequent sections under specific disorders.

Table 5

Factors involved in psychosocial management

Reassurance and sex education

Address barriers in seeking treatment (misinformation, stigma, fear of judgment and embarrassment)

Lifestyle measures (exercise, Yoga, optimum control of vascular risk factors, nutrition, weight management, tobacco cessation, alcohol restriction)

Treat the apprehensive anxiety of recurrence following AMI/CVA

Encourage self-stimulatory activities for single individuals

Link sexuality with intimacy and emotional closeness

Address associated somatic complaints and depression/performance anxiety

Positive self-talk and positive attitudes toward sex/genitals

Specific interventions

Pelvic floor exercises, vaginal containment, suitable intercourse positions, and progressive muscle relaxation (for dyspareunia)

Sensate focus, stop and start technique, squeeze technique (for PME)

Couple and sex therapy (with homework assignments)

Mindfulness-based group therapy

CBT

Tailored psychosocial interventions that target coping style and illness perception modification (in cancers, genital surgeries, etc.)

Cognitive/behavioral interventions for sexual minorities (especially those on HRT)

PME – Premature ejaculation; AMI – Acute myocardial infarction; CVA – Cerebrovascular accident; CBT – Cognitive behaviour therapy; HRT – Hormone replacement therapy

Sexual problems in neurological disorders

Table 6 provides an overview of the etiologies, management, and prevalence of sexual difficulties for pertinent neurological illnesses. General measures for all illnesses include proper education, addressing partner concerns, evaluating beliefs about sexuality and sexual health, dispelling myths and misconceptions, symptomatic management of associated complaints, and removal or modification of any offending pharmacological agent with a propensity to cause SD.

Table 6

Sexual difficulties in neurological diseases

Neurological condition	Etiology of sexual difficulties	Management of sexual difficulties	Prevalence
Neurocognitive disorders	Loss of roles, loss of employment, financial constraints, increasing dependence, fatigue, caregiver burden, social isolation, and the knowledge that the person may soon lose the ability to connect with their loved ones Impact of the disease, the loss of self-concept, and feelings of anger and disappointment aimed toward themselves and their partners Deficits in executive functions Obstruction by physical symptoms such as problems with vision, hearing, or fine motor skills, physiological difficulties with arousal mechanisms, and psychological lack of desire or sexual awkwardness	Hormone replacement Phosphodiesterase inhibitors, and vaginal creams or lubricants Sexual-assistive devices Provision of physical intimacy and privacy in long-term residential facilities Management of inappropriate sexual behavior Environmental  Combating understimulation, involvement in daily activities  Comfortable clothing that cannot be easily shed  Providing soft toys and aids  Separating the patient from the individual toward whom the sexual behavior is directed Pharmacological  Antidepressants - paroxetine, citalopram, mirtazapine, and trazodone  Antipsychotics - haloperidol, risperidone, and quetiapine to reduce the frequency of acting out behavior  Anticonvulsants such as benzodiazepines, carbamazepine, valproate, gabapentin, and topiramate  Antidementia treatments such as donepezil and memantine  Antiandrogens - medroxyprogesterone acetate, ethinylestradiol, finasteride, ketoconazole, spironolactone, and cimetidine	Men: ED (40-60) Women: Reduced libido (40-50)  More than half of individuals living with AD have comorbid ED due to vascular pathology  30%-40% inappropriate sexual behaviors in FTD
Idiopathic Parkinson’s disease	Motor symptoms: Bradykinesia, rigidity, resting tremors, akinesia, and loss of fine motor skills may hamper one’s ability to participate in sexual activity Muscle rigidity and akinesia may also worsen at night due to dose scheduling Nonmotor symptoms: Anxiety, depression, cognitive impairment as well as autonomic disturbances affecting the bowel and bladder Decreased dopamine levels in the brains and reward circuitries of these patients (reduced “hedonic” pleasure)	Adequate control of tremors, akinesia Anticholinergic agents for sialorrhea Ephedrine, midodrine for orthostatic hypotension Sexual difficulties - Sildenafil, apomorphine, and PGE-1 for ED Vaginal lubricants, topical creams DBS of the subthalamic nucleus for ED Treatment of hypersexual behavior -antipsychotic agents such as quetiapine	Men: ED, PME, decreased libido (50-80) Women: Arousal disorders, vaginal tightness, reduced libido (30–50)
Stroke	Sexual activity may be impacted by muscular weakness, stiffness, fatigue, pain, altered sensations, impaired mobility, and incontinence Depression and anxiety after stroke Patients and partners may also avoid sexual intercourse for fear of precipitating another stroke	Physiotherapy Rehabilitative aids Speech therapy Management of incontinence Management of uncontrolled diabetes Sildenafil for ED Baclofen, tizanidine for spasticity Measures as enlisted above for hypersexual behavior	Men (50-70) Women (20-35) (one-third within 6 months of stroke)
Epilepsy	Epileptiform discharges may disrupt pathways in the limbic system which play an important role in human sexual behaviors Poor self-esteem and fears of rejection may lead to avoidance of sexual contact Hyperventilation is known to provoke epileptic seizures and commonly accompanies sexual activity TLE is associated with sexual auras, ictal orgasms, and sexual automatisms and thus this subtype may have a larger impact on sexual functioning	Choosing antiepileptic agents that are neutral to the P450 enzyme system and that have a lesser propensity to alter SHBG Hormone replacement in both sexes Evaluation and management of endocrinological disturbances such as hypogonadotropic hypogonadism, hypothalamic dysfunction, and PCOS	Men: ED (40-50) Women: diminished libido, arousal, and orgasmic ability (10-20)
Multiple sclerosis	Direct compromise of the spinal cord Involvement of the bowel, bladder, and lower limbs Spasticity and ambulation difficulties Insults to self-esteem and sexual expressivity, depression	Sildenafil and PGE-1 for ED Sildenafil for vaginal lubrication Baclofen, tizanidine, botulinum toxin for spasticity Address comorbid depression, anxiety, and bowel and bladder difficulties	Men: ED (50-60) Ejaculatory and arousal disorders (30-40) Women: Arousal disorders (20-30)
Head injury	TBI can lead to physical disability, cognitive impairment, and personality changes Hypersexual behavior may be associated with lesions in basal frontal and limbic areas Pituitary damage and medication may also compound the sexual difficulties after TBI Depression	Baclofen, tizanidine, botulinum toxin for spasticity Dopamine agonists such as Bromocriptine to improve motivation, apathy Atypical antipsychotic medication, MDPA, SSRIs for sexually disinhibited behavior Sex therapy and behavioral approaches such as time out, social skills training, self-monitoring for sexual urges, and feedback may be employed for inappropriate sexual behavior Addressing physical limitations and bowel or bladder incontinence and provision of suitable aids Pituitary damage should be screened for at 3 and 12 months after head injury	40-60 (both genders)
Spinal cord injury	Chronic pain occurs in about one-third of cases Bladder and bowel urgency and incontinence Limitation in movement, motor control, and sensory abilities Decreased vaginal lubrication and pain during intercourse related to the level and completeness of the lesion Injuries to the sacral segments and the cauda equine impair reflex activity and reflex erections. Lesions above T10 substantially impair the capacity for psychogenic erections Women with S2–S5 spinal segment injuries are less likely to experience orgasms	Sildenafil, PGE-1 for ED Tadalafil, vardenafil, midodrine for ejaculatory dysfunction as adjuncts to PVS Sildenafil for lubrication Baclofen, tizanidine, botox for spasticity Audiovisual stimulation leads to subjective and autonomic responses similar to healthy controls in women Methods focused on partner satisfaction, nonsexual forms of intimacy, and manual stimulation	Men: 40-50 Women: 5-15

DBS – Deep Brain Stimulation; ED – Erectile dysfunction; AD – Alzheimer’s disease; PGE-1- Prostaglandin E1; TLE – Temporal lobe epilepsy; SHBG – Sex hormone-binding globulin; PVS – Penile vibrostimulation; MDPA – Medroxyprogesterone acetate; SSRI – Selective serotonin reuptake inhibitors; PME – Premature ejaculation; FTD – Frontotemporal dementia; PCOS – Polycystic Ovarian Syndrome; TBI – Traumatic Brain Injury

Nonpsychotropic medication-induced sexual dysfunction

SD may be caused by a variety of medical conditions and their treatments. The commonly implicated agents are psychotropic medications such as antidepressants and antipsychotics. However, antihypertensives, antacids, and contraceptives, among others, may also be linked with sexual difficulties. Understanding the potential for drug-induced sexual problems and their negative impact on treatment adherence can better enable clinicians to tailor treatment strategies for the patient and their partner.

Classes of nonpsychotropic medicines linked with SD are enlisted in Table 7.

Table 7

Classes of nonpsychotropic medication and their sexual side effects

Class of drugs	Drug names/subsections	Sexual side effects
Antihypertensives	Beta blockers: Atenolol, Acebutolol Calcium channel blockers Amlodipine, nifedipine Diltiazem Verapamil Diuretics Spironolactone Thiazide diuretics (Chlorthalidone) ACE inhibitors: Enalapril, lisinopril, perindopril, benazepril, trandolapril Angiotensin receptor blockers: Irbesartan (note: valsartan and losartan may improve sexual functioning in hypertensive males)	Decreased sexual desire Decreased libido, ED, decreased subjective and physiological arousal Decreased libido ED Decreased libido Gynecomastia, ED ED, decreased libido Vaginitis, decreased libido, nonspecific sexual difficulties Decreased libido, ED
Alpha adrenergic blockers	Clonidine Prazosin, tamsulosin, doxazosin, alfuzosin, terazosin	Decreased libido, orgasmic dysfunction Ejaculatory dysfunction
Lipid lowering agents	Statins and fibrates	Decreased libido
Antiarrhythmic agent	Digoxin	Decreased desire, arousal and orgasmic dysfunction
Gonadotropins	GnRH agonists - goserelin, leuprolide acetate and LHRH agonists - histrelin	Vaginal atrophy, dyspareunia, decreased libido, hot flashes
Antiandrogens	Cyproterone acetate, finasteride, dutasteride, ketoconazole	Decreased desire, arousal, orgasmic dysfunction and nonspecific sexual difficulties
Contraceptive drugs	Injectable progestins and MDPA	Atrophic vaginitis, dyspareunia, weight gain, depression
	Oral contraceptives	Decreased libido, hirsutism, acne and weight gain, depression
Alpha interferon		Nonspecific sexual dysfunction: Prevalence of 1%-3%. Amenorrhea, pelvic pain, decreased libido
5HT3 receptor antagonists	Alosetron	Nonspecific sexual dysfunction
Antacids	Ranitidine, Cimetidine, Famotidine	Decreased levels of circulating testosterone - decreased sexual desire and arousal
Steroids	Prednisolone	Weight gain, depression, decreased testosterone levels, decreased desire, ED
mTOR inhibitors	Sirolimus, everolimus	ED, nonspecific sexual side effects
Protease inhibitors	In HAART	ED

ED – Erectile dysfunction; ACE – Angiotensin converting enzyme; MDPA – Medroxyprogesterone acetate; HAART – Highly active antiretroviral therapy; LHRH – Luteinizing hormone-releasing hormone; GnRH – Gonadotropin hormone-releasing hormone; mTOR – Mammalian target of rapamycin

Management of drug-induced sexual dysfunction

Addressing sexual functioning, patient’s expectations, fantasies, lifestyle, and partner-related factors. Patients should be encouraged to lead a healthy lifestyle, exercise, and adhere to treatment of physical illnesses. This may enhance their overall physical and mental health, overall well-being, and self-image

Providing proper information can dispel fears and misconceptions about sexual problems

Considering medication with a lower probability of associated SD, especially in sexually active individuals. During treatment, active monitoring of sexual functioning is important

Reducing the dose of medication to the lowest effective dose

Advising to schedule sexual activity around the dose of medication

Switching to another medication from the same class with a lower propensity to cause SD. For example, if beta-blockers are being used as antihypertensives, switching to a cardioselective agent such as nebivolol may help reduce SD

Employing drug holidays

Administering specific antidotes, if available

Administering PDE inhibitors such as sildenafil when indicated

Adjunctive or alternative treatment with cognitive behavioral therapy, supportive therapy, or sex therapy

Advising exercise in daily lifestyle and before sexual activity

Use of mechanical interventions such as vacuum pumps and vibrators

The guidelines for the management of SD associated with cardiovascular medication and antihypertensives are not very clear. However, the main recommendations seem to either switch to another drug with a better safety profile such as calcium channel blockers or angiotensin-converting enzyme inhibitors/captopril or add a PDE inhibitor. The addition of PDE-5 inhibitors to usual common antihypertensive medicines (diuretics, beta-blockers, calcium blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers) results in either no or small additive reductions in blood pressure (BP) and no increase in serious clinical adverse events. However, the combination of organic nitrates and PDE-5 inhibitors should be avoided entirely because of synergistic and symptomatic reductions in BP.

To conclude, a risk–benefit analysis should be done for any pharmacological agent associated with SD, and wherever possible, the offending agent should be stopped or switched to an agent with a better tolerability profile.

SEXUAL DISORDERS AND CARDIOVASCULAR CONDITIONS

Vascular causes of erectile dysfunction

The most common link between CVDs and ED is endothelial injury. The artery size hypothesis explains that endothelial injury and stenosis of all vascular beds due to atherosclerosis limit the flow of blood. Smaller vessels (penile arteries; 1–2 mm diameter) are unable to adapt to the same extent when compared to larger vessels (coronary arteries; 3–4 mm diameter). A vascular compromise in the penile arteries due to atherosclerosis leads to ED.

The etiopathogenesis of ED of CVD and ED is explained in Figure 3.

Figure 3

Common etiopathogenesis of cardiovascular disorders and erectile dysfunction

CAD affects sexual functioning of both men and women conspicuously over a period of 6 months as briefed in Table 8.

Table 8

Coronary artery disease and sexual functioning of males and females over a period of 6 months (Schwarz ER, Kapur V, 2008)

Males	Females
Difficulty maintaining an erection after penetration (~84%)	Arousal disorder (~87%)
Reduced sexual desire and excitement (~76%)	Decreased vaginal lubrication (~84%)
Difficulty reaching orgasm (~62%)	Difficulty reaching orgasm (~62%)
Difficulty having an erection for penetration (~84%)	Sexual pain (~50%)
	Reduced sexual activity (~29%)

Hypertension

Arterial hypertension is strongly associated with ED and is a major risk factor for CVD. The prevalence of ED in hypertensive individuals is approximately double than that in normotensive population.

The comorbidity of ED and hypertension increases with age, severity, and duration of hypertension and presence of other CVD risk factors as shown in Figure 4.

Figure 4

Comorbidity of hypertension and erectile dysfunction: Risk factors

ED prevalence is double in men with systolic blood pressure (SBP) >140 mmHg when compared men with SBP <140 mmHg. Pelvic arterial insufficiency is the major cause of ED in elderly aged over 50 years. Narrowing of any part of erection-related arterial axis (iliac–pudendal–penile arterial system) could lead to ED. ED is a marker of asymptomatic CAD and may precede the development of CAD by 3–5 years.

Heart failure

Figure 5 depicts how heart failure can be linked to sexual dysfunction.

Figure 5

Pathophysiology of sexual dysfunction in heart failure

Myocardial infarction

Post-myocardial infarction (MI), a significant number of individuals develop sexual dysfunction. A number of researchers have studied sexual functioning post-MI. However, during this period, they remain under informed about their sexual concerns. Even at 1-year follow-up, only 41% of patients and 31% of their partners had received information about their relationships, sexual health, and how to resume sexual activity, during the cardiac rehabilitation process. Sexual education plays a vital role for individuals, in resuming their sexual activity. Sexual performance-related anxiety and difficulty getting aroused due to vaginal dryness may be present post-MI.

SEXUAL DISORDERS AND CANCER

The prevalence of cancer has been increasing with approximately 10 million deaths occurring worldwide in 2020. The most common cancers in men include lung, prostate, colorectal, stomach, and liver cancers, whereas women are more prone to breast, colorectal, lung, cervical, and thyroid cancers. There is an increase in cancer burden which affects not only the individual and the family but also the health-care system. Improvement in facilities and early detection have helped in cancer survival, though many survivors still face the challenges of navigating lives in various domains. The impact on interpersonal relationships, intimacy, and sexual concerns would not be of primary importance to the cancer survivor, and hence, that domain of life would remain impaired. This would be most affected in patients with breast, cervical, and prostate cancers but as is commonly seen in other patients of sexual dysfunctions; most patients and relatives would be hesitant to broach the problems associated with sexual functioning.

Most oncologists may not be aware of asking about sexual functioning though sexual satisfaction is important for a better quality of life. Hence, psychiatrists or counselors should therefore address these issues when seeing patients of cancer or cancer survivors.

How does cancer affect sexuality?

Cancer as an illness has severe burden and clinical outcomes which affects the patients physically, biologically, and emotionally. A patient afflicted with cancer and undergoing cancer treatment would show different responses to sexuality depending on the phase of detection or treatment of cancer. Hence, the sexual dysfunctions could be related to any phase, and hence, it becomes vital to assess the same. Cancer treatment is also very rigorous involving surgery, chemotherapy, and radiotherapy, which results in anatomical changes, body image issues, and emotional changes, all of which affect the patient’s perception to self, partner, relationship, and quality of life. Many oncologists are focused on the treatments for life-threatening cancer and may underestimate the psychological effects on the cancer survivors. With improved cancer care and aging population, there are many cancer survivors. Hence, it becomes important to improve their sexual health which is an integral part of quality of life.

Sexual dysfunctions occurring due to the various treatment options

Surgery related sexual concerns are enumerated in Table 9

Table 9

Surgery related sexual dysfunctions in males and females

Treatment options	Male	Female
Surgery: Genitourinary cancers
Cervical cancers: Radical hysterectomy		Dyspareunia
		Innervation problems
Vulval/vaginal cancers: Large excisions		Difficulty in penile–vaginal intercourse
		Nerve injuries due to excisions can cause reduced sexual arousal and orgasm
Oopherectomy		Iatrogenic menopause in premenopausal women leading to arousal disorders
		Low desire
Surgery: Breast cancer (mastectomy/breast conserving surgery)		Reduced breast stimulation leading to desire, arousal difficulties
		Body image problems, appearance-related concerns, being feminine
Surgery: Head/neck cancers/breast cancers	Anatomical changes, disfigurement, lack of attractiveness, body image problems, embarrassment, desire, and arousal problems
Prostate Cancer: Prostatectomy (nerve sparing) TURP	Erectile dysfunction anejaculation, delayed, orgasm, less intense orgasm, anorgasmia
	Retrograde ejaculation
Low resection of rectal tumors	Erectile dysfunction
Bladder surgery	Erectile dysfunction, anejaculation
Retroperitoneal lymphadenectomy in testicular cancer	Anejaculation
Abdominoperitoneal resection/sigmoidectomy in colorectal cancers	Anejaculation
Surgical complications: enervation/ischemia	Fibrosis and erectile dysfunction

TURP – Transurethral resection of the prostate

Chemotherapy

Chemotherapy is known to have severe side effects as it also affects normal cells. All patients of cancers do undergo a course of chemotherapy which results in hair loss, mucositis, weakness, tiredness, fatigue, and gastrointestinal symptoms. These side effects have an impact on the emotional status of the individual and therefore may lead to an overall decreased interest or desire in sexual activity. Due to hair loss, changes in hair, and skin texture, body image concerns arise along with reduced self-esteem and feelings of embarrassment, especially in breast cancer survivors. This therefore affects the sexuality of the individuals. Some chemotherapeutic drugs are also known to affect infertility due to their effects on the gonadal tissue. Premature menopause is also seen in women and girls exposed to treatments which results in reduced desire

Radiation therapy

Radiation therapy is known to result in scarring of the affected tissue along with vascular damage. Radiation to normal tissues also results in this damage. Very often, SD results due to radiation therapy given to gonadal or genitourinary cancers. Radiation therapy to prostate cancers may result in ED mostly 1 year later and is often seen 3–5 years of treatment. This is because radiation causes damage to the blood vessel lining and nerves and sometimes the erectile tissue, due to which they cannot hold the blood during erection, resulting in venous leaks. Pelvic radiation also results in premature ovarian failure causing low desire in women cancer survivors.

Hormone therapy

Hormonal treatments that are given to reduce the growth of hormone-sensitive tumors result in disruption of the hormonal axis. Hence, hormonal treatments of breast and prostate cancers may result in reduced sexual desire, arousal, and impairment in sexual functioning.

Impact on sexual functioning

Cancer and its treatment have been known to affect all areas of sexual functioning.

Table 9 mentions the various SDs seen in different cancers

Self-image is an important aspect which is affected in patients with cancer. Appearance-related concerns due to scarring and disfigurement in breast cancers are commonly seen in breast cancer survivors. Several researchers have noted that women feel “less sexually attractive’ and less feminine after cancer treatments. Further, several breast and gynecologic cancer survivors had a negative “sexual self-schema,” which would be the cognitive representation of one’s sexual beliefs, attributes, and sexuality. This often resulted in poorer sexual outcomes as the negative schema is known to impact sexual functioning and behavior

Low sex drive has been seen in breast cancer survivors, and some studies have reported a fear/aversion to sexual activity posttreatment

Mood disturbances such as depressed mood, fatigue, and reduced interest are seen in patients of cancer and those undergoing treatment, which may further cause a loss of libido. Treatment with antidepressants is also known to worsen the sexual functioning

Fear about resuming sexual activity is often seen in patients and their partners due to concerns regarding sex causing tissue damage or interfering with the healing process

Lack of awareness/knowledge/incomplete information about the procedure, its impact on organ functioning, or anatomical correlates may often result in misconceptions in patients and their partners

Poor communication between partners before the illness may further worsen the communication process posttreatment, and the partners’ fears or concerns could be mistaken for lack of interest or attraction

Survivors of human papillomavirus cancers often experience shame, guilt, and stigma as they know it is sexually transmitted. They have anxiety about sexual activity and hence also refrain from sexual activity as they fear recurrence.

SD in cancer and postcancer survivors is an important aspect that needs to be looked into by the oncologist in liaison with the psychiatrist. Importance needs to be given to sexual health which helps to improve the overall quality of life. Creating awareness among the oncology colleagues, timely assessment of cancer patients, and treatment of the sexual dysfunctions would help in improving health-related outcomes in the postcancer survivors.

SEXUAL DISORDERS AND ENDOCRINE DISORDERS

Diabetes mellitus

ED due to diabetes can be classified as an endocrine system- related problem as well as under vascular causes of ED. Diabetics (type 1 and 2) are at a three times higher risk for ED when compared to nondiabetic individuals as concluded by Massachusetts Male Aging Study. Diabetes-induced ED is of multifactorial origin.

Diabetic vasculopathy encompasses microangiopathy, macroangiopathy, and endothelial dysfunction. Macrovascular disease due to atherosclerosis damages the blood vessels limiting flow in the vascular beds.

Male SD due to diabetes includes ED, desire/arousal problems, and orgasmic/ejaculatory dysfunction. ED prevalence in diabetic men varies from 35% to 75%. ED as a consequence of diabetes is multifactorial in origin with metabolic, vascular, neurological, hormonal, and psychological components as explained in Figure 6.

Figure 6

Pathophysiology of erectile dysfunction in diabetes mellitus (adapted from Tamás V, Kempler P, 2014, Malaviqe LS, Levy JC, 2009)[81444]

In diabetics, the sensory information from the penis to the spinal and supraspinal centers is impaired. Associated impaired parasympathetic inactivity further worsens erection. In diabetics, strict glycemic control is advised to avoid ED. Reversal of ED even if diabetes is strictly controlled is not very successful. In females, the association of diabetes with SD is not very conclusive. However, the prevalence of SD is much higher in females with diabetes when compared to nondiabetics. Female SD is more related to psychosocial factors associated with diabetes.

Neuroendocrine system and sexual dysfunction

The human neuroendocrine system includes the hypothalamic–pituitary–adrenal (HPA) axis, hypothalamic–pituitary–gonadal (HPG) axis, hypothalamic–pituitary–thyroid axis, and hypothalamic–neurohypophyseal system. Alteration in any of these four axes can lead to sexual problems. The HPA axis is strongly linked to the reproductive system. The HPA axis and the female reproductive system are intertwined and are responsible for the “hypothalamic” amenorrhea of stress, eating disorders, and the hypogonadism of Cushing’s syndrome. The HPG axis plays a central role in the neuroendocrine system, linking the brain with the gonads. The HPG axis controls the various aspects of sexual function; excess or deficiency of pituitary hormones; or metabolic alteration associated with pituitary diseases (Cushing’s disease) that can lead to ED.

Endocrinopathies associated with ED include thyroid dysfunction, hypogonadism, and hyperprolactinemia. Androgen deficiency has been noted in 2%–33% of men with ED. The most common endocrinopathy in ED patients is low testosterone levels (15%) followed by hyperprolactinemia (13.7%) and hypothyroidism (3.1%). The diagnosis of endocrinopathies is based on blood hormone levels.

Both hypothyroidism and hyperthyroidism are associated with SD in both the sexes. The prevalence and type of SD are mentioned in Table 10. Thyroid hormone may have a direct effect on ejaculatory process or a secondary effect of testosterone. Both hypothyroid and hyperthyroid state can alter circulating sex hormone levels through peripheral and central pathways which lead to sexual problems. In hypothyroidism, the disruption of HPA axis leads to decrease in sex hormones, both free and total testosterone levels, leading to sexual problems.

Table 10

The prevalence and type of sexual dysfunction associated with thyroid disorders

Thyroid disorder	Males	Females
Hypothyroidism
Prevalence	59-63%	22-46%
Type of SD	Erectile and ejaculatory dysfunction (delayed ejaculation)	Impaired libido
	Impaired libido	Impaired desire, arousal/lubrication, orgasm, satisfaction, and pain during intercourse
Hyperthyroidism
Prevalence	48%-77%	44%-60%
Type of SD	Erectile and ejaculatory dysfunction (premature ejaculation)	Impaired libido
	Impaired libido	Impaired desire, arousal/lubrication, orgasm, satisfaction, and pain during intercourse

SD – Sexual dysfunction

Hypogonadism can occur due to any insult to the HPG axis. Thus, hypogonadism can be primary (Klinefelter’s syndrome and cryptorchidism) or secondary (i.e., central dysfunction which includes head trauma, prolactinoma, pituitary surgery, and drug abuse). Hypogonadism can be effectively treated with testosterone replacement therapy which improves sex drive and enhances PDE-5 inhibitor effectiveness.

The hormonal conditions required for ejaculation are complex. Androgen receptors are present throughout the body including the areas of the brain associated with arousal and orgasm. Low testosterone levels are associated with DE, and higher levels of the same are linked to PME. Prolactin can be considered as a surrogate marker of serotonin activity. High levels of prolactin suppress ejaculation. During ejaculation, dopamine peaks (during orgasm and climax) and prolactin are suppressed. Once orgasm is over, prolactin spikes and dopamine decrease. Prolactin is partially responsible for the refractory period in men. Hence, both prolactin and dopamine levels are inversely related. Hyperprolactinemia occurs in 1%–5% of men with ED. Around 50% of men with microprolactinomas and 75% of men with macroprolactinomas report either reduced sexual desire or ED. Hyperprolactinemia in women can be associated with reduced sexual arousal, lubrication, orgasm, and satisfaction. The relationship between dopamine, prolactin, and testosterone is shown in Figure 7.

Figure 7

The relationship between dopamine, prolactin, and testosterone

Prolactin is involved in control of sexual behavior by modulating the effects of dopaminergic and serotoninergic systems on sexual function. A short-term or long-term increase in prolactin can control central nervous system sexual function by acting directly on receptors in the brain and possibly affect erection in men and response of genitalia in women. A chronic increase in prolactin levels is associated with hypogonadotropic hypogonadism and SD in both sexes. Growth hormone (GH) is an important regulator of HPG axis and possibly regulates sexual response of genitalia in both men and women. Both in GH deficiency and excess, a decrease in desire and arousability is present (in both the sexes) with impaired erection in men.

Hypersexuality and hormonal imbalance

Hypersexual disorder (HSD) (not included in DSM-5) is a diagnostic label given to a range of behaviors, which are a result of intense sexual urges or fantasies and cause significant distress or socio-occupational dysfunctioning. Clinical presentation may include excessive sexual activity or intercourse, masturbation, pornography, or computer-assisted sexual activity. HSD can be considered as a type of compulsion, addiction, or impulse control disorder. Other names for HSD include hypersexuality, erotomania, compulsive masturbation, and sexual compulsivity. Common medical conditions that may be associated with hypersexual behavior are listed in Table 11. HSD neurobiology involves the thalamus, mammillary body, amygdala, prefrontal region, cingulate gyrus, hippocampus, nucleus accumbens, caudate nucleus, and brainstem (ventral tegmental area, raphe nuclei, and substantia nigra).

Table 11

Comorbid medical conditions associated with hypersexuality

Group of illness	Specific disorders/drugs
Neurological disorders	Kluver–Bucy syndrome, partial complex seizures, frontal lobe lesions, traumatic brain injury
Neuropsychiatric conditions	Sexual disinhibition in dementia and delirium
Psychiatric disorders	Bipolar mood disorder, schizoaffective disorder, attention deficit hyperactivity disorder, borderline personality disorder
Substance abuse	Methamphetamine, alcohol
Drugs	Dopaminergic agonists
Psychological	Stress: Altered hypothalamic–pituitary axis
	Childhood and adolescence psychological abuse

It is important to note the following points of HSD: (1) whether it is a distinct disorder (as yet unrecognized) (or problematic psychosexual behavior), (2) a symptom of an existing disorder or medical condition, (3) normophilic activity at the high end of sexual functioning. The sexual behavior cycle of HSD includes sexual incongruence and cognitive abeyance. A sexual urge leads to sexual behavior and sexual and postsexual satiation. This is again followed by sexual urge when the cycle repeats.

Although HSD could not make it to DSM-5, criteria proposed for the same by Reid et al.[49] are briefed in Table 12.

Table 12

Proposed criteria for Diagnostic and Statistical Manual-5 hypersexual disorder

Over a period of at least 6 months, “Recurrent and intense sexual fantasies, over a period of 6 months with ≥4 of the following five criteria”

“Excessive time is spent on sexual fantasies, planning, and performing the act”

“Repeatedly engaging in sexual fantasies or behavior in response to either dysphoric mood state or stressful life events”

“Repeated efforts to control urges or behavior are not successful”

“Repetitively engaging in sexual behavior, irrespective of the physical or emotional risk involved”

“There is associated significant distress or socio-occupational impairment”

“These behaviors are not substance induced and not due to a general medical condition”

“The person should be 18 years of age”

Specify: Type of hypersexual disorder

Kaplan and Krueger[34] have explained subtypes of HSD as mentioned in Table 13.

Table 13

Subtypes of hypersexual disorder

Excessive masturbation: in ranges from 50% to 75%

Pornography: 50%-60% of patients with HSD are dependent on pornography[51]

Sexual behavior with (consenting) adults: Reid et al.,[51] in 2009, concluded that 7% (of males seeking treatment) solicited sex workers regularly, 12% had unprotected (multiple innominate) sex, and 21% had extramarital affairs[51]

Cybersex: Includes online “sexual conversations” in chat rooms or “text-messaging applications: Sexting”

Telephone sex: Studies done two and a half decades back concluded that around 37% of males struggling with HSD had excessive telephone sex

Strip clubs: Many individuals with HSD are dependent on strip clubs with excessive alcohol use and guilt

HSD – Hypersexual disorder

Treatment algorithm to HSD is mentioned in Figure 8.

Figure 8

Treatment Algorithm for hypersexual disorders (Reid RC, Garos S 2011; Khan O, Ferriter M, Huband N 2015, Tierens E, Vansintejan J 2014).[365157] SSRIs: Selective Serotonin Reuptake Inhibitors; TCAs: Tricyclic antidepressants; LHRH: Luteinizing hormone- releasing hormone; GnRH: Gonadotropin-releasing hormone); im: Intramuscular

SEXUAL DISORDERS AND OTHER CHRONIC PHYSICAL ILLNESSES

Apart from the various medical conditions discussed earlier, few other chronic illnesses and their intersections with sexual dysfunctions relevant to CLP are highlighted in Table 14.

Table 14

Sexual disorders and other chronic illnesses

Category	Mechanisms	Manifestations
Chronic pain
Psychological factors	Decreased sense of self-esteem, sexual desire and feelings of desirability. Comorbid depression and anxiety	Decreased libido
Physiological factors	Direct injury to nerves and adnexa due to surgery and physical trauma	Decreased arousal, erectile dysfunction, dyspareunia
	Radiation therapy, nerve blocks, and other surgical procedures may cause difficulties with sexual intercourse
Pharmacological factors	Analgesic medication may have sexual side effects. Opioid preparations, sedatives, antispasmodics, and antidepressants may also compound the sexual distress due to the pain	Decreased libido
Chronic inflammatory conditions	Inflammatory bowel disease, rheumatoid arthritis, and fibromyalgia among other chronic inflammatory conditions have been associated with an increase in the levels of C-reactive protein which may interfere with arousal via direct (neuronal) and indirect (endocrine, vascular) mechanisms	Decreased libido, reduced mobility, erectile dysfunction and difficulties with arousal
	There may also be associated pain, restriction of movement, and fatigue
Sexually transmitted diseases	Chlamydia associated chronic prostatitis	Premature ejaculation and erectile dysfunction in men
	Chlamydia and gonorrhea-associated pelvic inflammatory disease	Dyspareunia, infertility in women
	HIV therapy	Decreased libido
	Genital herpes	Comorbid psychiatric illnesses, nonspecific sexual dysfunction
Chronic respiratory illnesses	COPD, interstitial lung disease, lung cancer - decreased exercise tolerance, fear of dyspnea, decreased testosterone levels and increased cardiopulmonary load	Decreased sexual desire, erectile dysfunction in men
		Decreased sexual desire, anorgasmia, and painful intercourse in women

HIV – Human immunodeficiency virus; COPD – Chronic obstructive pulmonary disease

SPECIAL CONSIDERATIONS

Gender dysphoria and gender-affirming/confirming surgery

Gender dysphoria has replaced gender identity disorder in DSM-5, and it is signifying a marked sense of unease that a person experiences with the biological sex and ones’ gender identity. The distress may be so severe that it can impair social and occupational functioning and may also cause anxiety/depression in the person. Gender nonconformity is not a mental disorder by itself; however, if there is distress arising from it, then it needs to be evaluated. Many patients of gender dysphoria want to change their biological sex to conform to their sexual orientation. Gender dysphoria has also been seen in adolescents and children and also includes disorders of sex development where children are assigned genders by parents or physicians.

Although the number of people coming out in the open about their gender dysphoria has risen, there is still social stigma associated with gender nonconformity and cultural differences due to which the gender dysphoric individual faces a lot of mental health issues. Further, due to the lack of teaching about the same in medical schools along with reduced importance, several medical professional bodies have to depend on the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) and the Endocrine Society (ES) guidelines for the treatment of gender dysphoria. The goals of treatment include to resolve the distress experienced by the patient and to affirm his/her gender identity. This approach therefore requires a multidisciplinary team which includes a mental health professional (MHP) psychiatrist and psychologist/counselor, plastic surgeon, endocrinologist, urologist, and gynecologist in adult patients and also a pediatrician and pediatric endocrinologist for children and adolescents with gender dysphoria. Treatment parameters are included in Figure 9.

Figure 9

Treatment options for gender dysphoria. (Reid RC, Garos S, 2011; Khan O, Ferriter M, Huband N, 2015, Tierens E, Vansintejan J, 2014).[365157] SSRIs – Selective Serotonin Reuptake Inhibitors; TCAs – Tricyclic antidepressants; LHRH – Luteinizing hormone-releasing hormone; GnRH – Gonadotropin-releasing hormone; im – Intramuscular

Table 15 describes the role of an MHP as per the WPATH SOC version 7 and ES guidelines.

Table 15

Role of mental health professional as per World Professional Association for Transgender Health Standards of Care version 7 and Endocrine Society guidelines

Only a qualified MHP should diagnose gender dysphoria
• A detailed psychological evaluation with screening tools or psychological tests to be done for gender dysphoria
• MHP should be trained in assessment and treatment of transgender or gender nonconforming patients
• If MHP is not available, then other medical professionals can also diagnose if they had training in gender and mental health issues
• Diagnosis is as per DSM-5 or ICD-11 criteria; psychosocial functioning should also be examined
• MHP discusses treatment options for gender dysphoria and concomitant mental disorders
• To psychoeducate patients about gender identity and gender expression and evaluate their comfort in gender expression and assess social support systems
• As per WPATH SOC v7 MHP can ask the patient to do social transition or have real-life experience of living full-time as his/her preferred gender identity in all aspects of his/her life at least for a year. Social transition is important as the patient knows what to expect in his/her personal life, from families, workplace, and community. This phase is reversible and hence important before he/she takes the step for surgery
• MHP should document these aspects of social transition in a regular follow-up detailing the timeline, coping, and patient’s commitment. This information can be used to provide counseling to the patient or strengthening his support systems. Family education and counseling also helps. Patient can then be referred for hormonal therapy
• Provide appropriate referrals for hormone therapy if patient meets WPATH SOC readiness and eligibility criteria; liaison with the endocrinologist/specialist to assess patient’s expectations from hormonal therapy
• Cross-sex hormone therapy is initiated as a treatment modality for gender dysphoria to induce secondary sexual characteristics as per patient’s desired gender and minimizing those of their biological gender for at least 12 months. This also helps in improving the quality of life, sexual functioning, reducing psychopathology, easing social transition, and giving some relief from gender dysphoria. MHP also need to continue ongoing psychotherapy for 12 months
• A record of the hormone therapy needs to be maintained and is a requisite for some gender affirming surgeries
• If patient wants to consider gender affirming/confirming surgical procedures, then patient should be referred to appropriate surgeons if patient meets WPATH SOC readiness and eligibility criteria
• WPATH SOC requires 2 referral letters from MHP for surgery which document persistent gender dysphoria, capacity to make a fully informed decision and give consent for treatment with patient achieving legal age of maturity in a given country. Any associated medical or psychiatric co-morbidity should also be adequately controlled
• WPATH SOC encourages individualized treatment and hence surgeons and patients should discuss options as per patient’s goals for gender expression, realistic expectations from surgery, cost, esthetics, postoperative care, recovery, complications, etc.
• WPATH SOC does not require referral letters if the patient wants facial feminization or masculinization procedures or thyroid laryngoplasty
• WPATH SOC requires 1 letter of referral from MHP for breast/chest gender-affirming surgeries
• It is important to educate patients and families about regulations for change of gender on legal documents as per the country’s policies and laws
• Information and referral for peer support should also be provided

MHP – Mental health professional; WPATH: World Professional Association for Transgender Health; DSM – Diagnostic and Statistical Manual; SOC – Standards of care; ICD – International Classification of Diseases

The current laws in India as per The Transgender Persons (Protection of rights) Act, 2019 allow the procedure for gender affirming/confirming surgeries and change in name after following the proper procedure laid down in the Act. However, it still remains a continued need to establish teams that would work together to help patients of gender dysphoria. The medical curriculum also needs to be aligned to the changes and reforms taking place in different cultures and societies so as to offer teaching and learning opportunities to the medical fraternity. Creating awareness among MHPs and medical practitioners about the needs of the transgender community would definitely improve the quality of care given to this minority section.

THE WAY FORWARD IN MANAGEMENT: MULTIDISCIPLINARY INTEGRATION OF CARE

It is clear from the above discussion that psychosexual problems are common in medical settings where a psychiatrist need to be consulted. Although sexual dysfunction inevitably mostly comes under the purview of MHPs, the distinction between medical and psychological causes is often not watertight. The prognosis can have a variable course across patient populations, given significant variability within and between distinct cohorts. With that said, it is recommended that clinicians have an honest and open conversation with patients where the benefits and risk associated with treatment are discussed, as well as the potential complications related to medications or surgical procedures. Throughout this CPG, it has been highlighted how sexual disorders that stem from medical conditions often results in substantial psychological toll on an individual, affecting one’s sense of general well-being and quality of life. Hence, the role of a psychiatrist in such referrals is not limited to a one-time prescription but also an integration of medical and psychosocial management in sync with all the other specialties involved in the care. For example, in an individual with on cancer chemotherapy or renal failure undergoing hemodialysis, management of sexual dysfunction will be incomplete and ineffective without a continued and collaborative dialog between the psychiatrist, patient, families, and other service care providers (oncologist, urologist, nephrologist, dietician, physiotherapist, etc.).

Of course, this CPG is not exhaustive. It only covers the most common medical conditions that are capable of having sexual offshoots. Virtually, directly, or indirectly, every other chronic physical illness can lead to psychosexual issues, the details of which are exhaustive and have been suggested in references for further reading. Nevertheless, this CPG provides an anchor for best evidence-based practice, underlying theoretical underpinnings and approach to the diagnosis and management of sexual disorders due to medical conditions. To reiterate, sexual functioning is one of the salient attributes of health and well-being. Thus, in any given clinical context, the appropriate diagnosis and treatment of the underlying cause for sexual dysfunction will increase the chance that a multidisciplinary care with effective psychosocial inputs is able to restore normal sexual functioning and subsequently improve quality of life and a better living for patients and families.

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Conflicts of interest

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