Secondary Logo

Journal Logo

CLINICAL PRACTICE GUIDELINES

Psychosexual Health and Sexual Medicine in Consultation–Liaison Psychiatry

Rao, T. S. Sathyanarayana; Banerjee, Debanjan1; Tandon, Abhinav2; Sawant, Neena S.3; Jha, Aishwariya4; Manohar, Shivanand; Rao, Suman S.5

Author Information
doi: 10.4103/indianjpsychiatry.indianjpsychiatry_13_22
  • Open

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.

F1
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.

T1
Table 1:
Medical conditions associated with sexual disorders/dysfunctions

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.

T2
Table 2:
Sexual dysfunction associated with chronic diseases: The mechanisms involved (adapted from Basson et al., 2010)
T3
Table 3:
Pathophysiology and types of sexual dysfunction in different medical conditions with their basic management principles

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.

T4
Table 4:
General areas of assessment/evaluation in sexual dysfunctions induced by medical conditions

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.

F2
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.

T5
Table 5:
Factors involved in psychosocial management

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.

T6
Table 6:
Sexual difficulties in neurological diseases

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.

T7
Table 7:
Classes of nonpsychotropic medication and their sexual side effects

Management of drug-induced sexual dysfunction

  1. 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
  2. Providing proper information can dispel fears and misconceptions about sexual problems
  3. Considering medication with a lower probability of associated SD, especially in sexually active individuals. During treatment, active monitoring of sexual functioning is important
  4. Reducing the dose of medication to the lowest effective dose
  5. Advising to schedule sexual activity around the dose of medication
  6. 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
  7. Employing drug holidays
  8. Administering specific antidotes, if available
  9. Administering PDE inhibitors such as sildenafil when indicated
  10. Adjunctive or alternative treatment with cognitive behavioral therapy, supportive therapy, or sex therapy
  11. Advising exercise in daily lifestyle and before sexual activity
  12. Use of mechanical interventions such as vacuum pumps and vibrators
  13. 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.

F3
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.

T8
Table 8:
Coronary artery disease and sexual functioning of males and females over a period of 6 months (Schwarz ER, Kapur V, 2008)

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.

F4
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.

F5
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

  1. Surgery related sexual concerns are enumerated in Table 9
  2. Chemotherapy
  3. 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
  4. Radiation therapy
  5. 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.
  6. Hormone therapy
  7. 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.

T9
Table 9:
Surgery related sexual dysfunctions in males and females

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.

F6
Figure 6:
Pathophysiology of erectile dysfunction in diabetes mellitus (adapted from Tamás V, Kempler P, 2014, Malaviqe LS, Levy JC, 2009)[8 14 44]

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.

T10
Table 10:
The prevalence and type of sexual dysfunction associated with thyroid disorders

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.

F7
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).

T11
Table 11:
Comorbid medical conditions associated with hypersexuality

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.

T12
Table 12:
Proposed criteria for Diagnostic and Statistical Manual-5 hypersexual disorder

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

T13
Table 13:
Subtypes of hypersexual disorder

Treatment algorithm to HSD is mentioned in Figure 8.

F8
Figure 8:
Treatment Algorithm for hypersexual disorders (Reid RC, Garos S 2011; Khan O, Ferriter M, Huband N 2015, Tierens E, Vansintejan J 2014).[36 51 57] 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.

T14
Table 14:
Sexual disorders and other chronic illnesses

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.

F9
Figure 9:
Treatment options for gender dysphoria. (Reid RC, Garos S, 2011; Khan O, Ferriter M, Huband N, 2015, Tierens E, Vansintejan J, 2014).[36 51 57] 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.

T15
Table 15:
Role of mental health professional as per World Professional Association for Transgender Health Standards of Care version 7 and Endocrine Society guidelines

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest

KEY REFERENCES

1. Montorsi F, Adaikan G, Becher E, Giuliano F, Khoury S, Lue TF, et al. Summary of the recommendations on sexual dysfunctions in men J Sexual Med 2010 7 3572 88
2. Addis IB, Ireland CC, Vittinghoff E, Lin F, Stuenkel CA, Hulley S Sexual activity and function in postmenopausal women with heart disease Obstet Gynecol 2005 106 121 7
3. Asiff M, Sidi H, Masiran R, Kumar J, Das S, Hatta NH, et al. Hypersexuality as a neuropsychiatric disorder:The neurobiology and treatment options Curr Drug Targets 2018 19 1391 401
4. Avasthi A, Grover S, Sathyanarayana Rao TS Clinical practice guidelines for management of sexual dysfunction Indian J Psychiatry 2017 59 S91 115
5. Bartula I, Sherman KA Screening for sexual dysfunction in women diagnosed with breast cancer:Systematic review and recommendations Breast Cancer Res Treat 2013 141 173 85
6. Basson R, Schultz WW Sexual sequelae of general medical disorders Lancet 2007 369 409 24
7. Nehra A, Jackson G, Miner M, Billups KL, Burnett AL, Buvat J, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease Mayo Clin Proc 2012 87 766 78
8. Cakar B, Karaca B, Uslu R Sexual dysfunction in cancer patients:A review J BUON 2013 18 818 23
9. Cellek S, Cameron NE, Cotter MA, Muneer A Pathophysiology of diabetic erectile dysfunction:Potential contribution of vasa nervorum and advanced glycation endproducts Int J Impot Res 2013 25 1 6
10. Chandra A, Borjoev A, Schwarz ER Sex and the heart Ishak WW The Textbook of Clinical Sexual Medicine. Ch. 29 New York Springer International Publishing AG 2017 447 54
    11. Conaglen HM, Conaglen JV Drug-induced sexual dysfunction in men and women Aust Prescriber 2013 36 42 5
    12. Cook SC, Arnott LM, Nicholson LM, Cook LR, Sparks EA, Daniels CJ Erectile dysfunction in men with congenital heart disease Am J Cardiol 2008 102 1728 30
    13. Corona G, Jannini EA, Vignozzi L, Rastrelli G, Maggi M The hormonal control of ejaculation Nat Rev Urol 2012 9 508 19
    14. Tamás V, Kempler P Sexual dysfunction in diabetes Handb Clin Neurol 2014 126 223 32
    15. Doumas M, Tsakiris A, Douma S, Grigorakis A, Papadopoulos A, Hounta A, et al. Factors affecting the increased prevalence of erectile dysfunction in Greek hypertensive compared with normotensive subjects J Androl 2006 27 469 77
    16. Drescher J, Byne WM Gender identity, gender variance, and gender dysphoria Sadock BJ, Sadock VA, Gregory MS, Ruiz P Kaplan &Sadock's Comprehensive Textbook of Psychiatry 10th ed China Wolters Kluwer 2018 5175 218
      17. Drescher J, Byne WM Homosexuality, gay and lesbian identities, and homosexual behavior Sadock BJ, Sadock VA, Gregory MS, Ruiz P Kaplan &Sadock's Comprehensive Textbook of Psychiatry 10th ed China Wolters Kluwer 2018 5068 149
        18. Esposito K, Giugliano F, Martedì E, Feola G, Marfella R, D'Armiento M, et al. High proportions of erectile dysfunction in men with the metabolic syndrome Diabetes Care 2005 28 1201 3
        19. Feldman HA, Johannes CB, Derby CA, Kleinman KP, Mohr BA, Araujo AB, et al. Erectile dysfunction and coronary risk factors:Prospective results from the Massachusetts male aging study Prev Med 2000 30 328 38
        20. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB Impotence and its medical and psychosocial correlates:Results of the Massachusetts Male Aging Study J Urol 1994 151 54 61
        21. Fitzgerald P, Dinan TG Prolactin and dopamine:What is the connection?A review article J Psychopharmacol 2008 22 12 9
        22. Furlow B Sexual dysfunction in patients with lung disease Lancet Respir Med 2014 2 439
        23. Gabrielson AT, Sartor RA, Hellstrom WJ The impact of thyroid disease on sexual dysfunction in men and women Sex Med Rev 2019 7 57 70
        24. Galdiero M, Pivonello R, Grasso LF, Cozzolino A, Colao A Growth hormone prolactin, and sexuality J Endocrinol Invest 2012 35 782 94
        25. Giugliano F, Maiorino M, Bellastella G, Gicchino M, Giugliano D, Esposito K Determinants of erectile dysfunction in type 2 diabetes Int J Impot Res 2010 22 204 9
        26. Grover S, Avasthi A Consultation-liaison psychiatry in India:Where to go from here? Indian J Psychiatry 2019 61 117 24
        27. Hadj-Moussa M, Agarwal S, Ohl DA, Kuzon WM Jr Masculinizing genital gender confirmation surgery Sex Med Rev 2019 7 141 55
        28. Hadj-Moussa M, Ohl DA, Kuzon WM Jr Evaluation and treatment of gender dysphoria to prepare for gender confirmation surgery Sex Med Rev 2018 6 607 17
        29. Hadj-Moussa M, Ohl DA, Kuzon WM Jr Feminizing genital gender-confirmation surgery Sex Med Rev 2018 6 457 68 e2
        30. Ishak WW The Textbook of Clinical Sexual Medicine Nature, Switzerland Springer 2017
          31. Jaarsma T, Dracup K, Walden J, Stevenson LW Sexual function in patients with advanced heart failure Heart Lung 1996 25 262 70
          32. Johnston BL, Fletcher GF Dynamic electrocardiographic recording during sexual activity in recent post-myocardial infarction and revascularization patients Am Heart J 1979 98 736 41
          33. Kafka MP Hypersexual desire in males:An operational definition and clinical implications for males with paraphilias and paraphilia-related disorders Arch Sex Behav 1997 26 505 26
          34. Kaplan MS, Krueger RB Diagnosis, assessment, and treatment of hypersexuality J Sex Res 2010 47 181 98
          35. Keller J, Chen YK, Lin HC Hyperthyroidism and erectile dysfunction:A population-based case-control study Int J Impot Res 2012 24 242 6
          36. Khan O, Ferriter M, Huband N, Powney MJ, Dennis JA, Duggan C Pharmacological interventions for those who have sexually offended or are at risk of offending Cochrane Database Syst Rev 2015 CD007989
          37. Krassas GE, Tziomalos K, Papadopoulou F, Pontikides N, Perros P Erectile dysfunction in patients with hyper- and hypothyroidism:How common and should we treat? J Clin Endocrinol Metab 2008 93 1815 9
          38. Kutty ON Consultation liaison psychiatry Indian J Psychol Med 2005 26 7 12
          39. Långström N, Hanson RK High rates of sexual behavior in the general population:Correlates and predictors Arch Sex Behav 2006 35 37 52
          40. Leifke E, Gorenoi V, Wichers C, Von Zur Mühlen A, Von Büren E, Brabant G Age-related changes of serum sex hormones, insulin-like growth factor-1 and sex-hormone binding globulin levels in men:Cross-sectional data from a healthy male cohort Clin Endocrinol (Oxf) 2000 53 689 95
          41. Lindau ST, Abramsohn E, Gosch K, Wroblewski K, Spatz ES, Chan PS, et al. Patterns and loss of sexual activity in the year following hospitalization for acute myocardial infarction (a United States National Multisite Observational Study) Am J Cardiol 2012 109 1439 44
          42. Llisterri JL, Lozano Vidal JV, Aznar Vicente J, Argaya Roca M, Pol Bravo C, Sanchez Zamorano MA, et al. Sexual dysfunction in hypertensive patients treated with losartan Am J Med Sci 2001 321 336 41
          43. Maiorino MI, Bellastella G, Esposito K Diabetes and sexual dysfunction:Current perspectives Diabetes Metab Syndr Obes 2014 7 95 105
          44. Malavige LS, Levy JC Erectile dysfunction in diabetes mellitus J Sex Med 2009 6 1232 47
          45. Mobley D, Baum N Smoking:Its impact on urologic health Rev Urol 2015 17 220 5
          46. Nicolai MP, Liem SS, Both S, Pelger RC, Putter H, Schalij MJ, et al. Areview of the positive and negative effects of cardiovascular drugs on sexual function:A proposed table for use in clinical practice Neth Heart J 2014 22 11 9
          47. Parsons JT, Rendina HJ, Ventuneac A, Moody RL, Grov C Hypersexual, sexually compulsive, or just highly sexually active?Investigating three distinct groups of gay and bisexual men and their profiles of HIV-related sexual risk AIDS Behav 2016 20 262 72
          48. Perez-Pouchoulen M, Toledo R, Garcia LI, Perez-Estudillo CA, Coria-Avila GA, Hernandez ME, et al. Androgen receptors in Purkinje neurons are modulated by systemic testosterone and sexual training in a region-specific manner in the male rat Physiol Behav 2016 156 191 8
          49. Reid RC, Carpenter BN, Hook JN, Garos S, Manning JC, Gilliland R, et al. Report of findings in a DSM-5 field trial for hypersexual disorder J Sex Med 2012 9 2868 77
          50. Reid RC, Carpenter BN, Lloyd TQ Assessing psychological symptom patterns of patients seeking help for hypersexual behavior Sex Relation Ther 2009 24 47 63
          51. Reid RC, Garos S, Carpenter BN Reliability, validity, and psychometric development of the hypersexual behavior inventory in an outpatient sample of men J Sex Addict Compulsivity 2011 18 30 51
          52. Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics –2008 update:A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation 2008 117 e25 146
          53. Sai Ravi Shanker A, Phanikrishna B, Bhaktha Vatsala Reddy C Association between erectile dysfunction and coronary artery disease and its severity Indian Heart J 2013 65 180 6
          54. Salvio G, Martino M, Giancola G, Arnaldi G, Balercia G Hypothalamic-pituitary diseases and erectile dysfunction J Clin Med 2021 10 2551
          55. Schwarz ER, Kapur V, Bionat S, Rastogi S, Gupta R, Rosanio S The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure Int J Impot Res 2008 20 85 91
          56. Shi H, Zhang FR, Zhu CX, Wang S, Li S, Chen SW Incidence of changes and predictive factors for sexual function after coronary stenting Andrologia 2007 39 16 21
          57. Tierens E, Vansintejan J, Vandevoorde J, Devroey D Diagnosis and treatment of participants of support groups for hypersexual disorder Arch Ital Urol Androl 2014 86 175 82
          58. Turek SJ, Hastings SM, Sun JK, King GL, Keenan HA Sexual dysfunction as a marker of cardiovascular disease in males with 50 or more years of type 1 diabetes Diabetes Care 2013 36 3222 6
          59. Turner D, Schöttle D, Bradford J, Briken P Assessment methods and management of hypersexuality and paraphilic disorders Curr Opin Psychiatry 2014 27 413 22
          60. Vlachopoulos C, Ioakeimidis N, Terentes-Printzios D, Stefanadis C The triad:Erectile dysfunction –Endothelial dysfunction –Cardiovascular disease Curr Pharm Des 2008 14 3700 14
          61. Wabrek AJ, Burchell RC Male sexual dysfunction associated with coronary heart disease Arch Sex Behav 1980 9 69 75
          62. Walton MT, Cantor JM, Bhullar N, Lykins AD Response to commentaries:Recognizing hypersexuality as a psychosexual behavioral problem and advancing the sexhavior cycle of hypersexuality Arch Sex Behav 2017 46 2279 87
          63. Wang TD, Lee CK, Chia YC, Tsoi K, Buranakitjaroen P, Chen CH, et al. Hypertension and erectile dysfunction:The role of endovascular therapy in Asia J Clin Hypertens (Greenwich) 2021 23 481 8
          64. Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul S, Baral S Serving transgender people:Clinical care considerations and service delivery models in transgender health Lancet 2016 388 401 11
          Copyright: © 2022 Indian Journal of Psychiatry