In the last two decades, much gain in knowledge concerning human sexuality has been incorporated into the practices of urologists, family physicians, and obstetricians and gynecologists. Unfortunately, this information has not been incorporated into the practices of most psychiatrists. This article will briefly examine the history of psychiatry’s involvement in sexual medicine, why psychiatry has minimal involvement in this area at present, and why psychiatry may have a unique contribution to make in sexual medicine.

Psychiatry as a discipline appears to have an ambivalent relationship to the study and treatment of human sexual problems. Although only a few psychiatrists have shown interest in treating sexual disorders, they have made major contributions to our understanding of human sexuality. For example, Richard Kraft-Ebbing (1) detailed cases of sexual perversity in his famous text Psychopathia Sexualis, published in 1886. Sigmund Freud (2) established a school of psychoanalytic thought that emphasized the hypothetical role of unconscious sexual desires on the development of adult neuroses.

In the 1960s, isolated behavior therapists such as Joseph Wolpe (3) and John Paul Brady (4) used targeted behavioral interventions to treat sexual disorders. Their reported approaches were remarkably similar to methods subsequently popularized by Masters and Johnson (5). Although broader interest in the treatment of sexual disorders began after the publication of Human Sexual Inadequacy by Masters and Johnson in 1970, the number of psychiatrists interested in sexual medicine was still limited. Giles Brindley (6), a British psychiatrist, was the first to demonstrate that intracavernousal injection of vasoactive substances could induce penile erections in the human, and Thavundayil S. Lal (7), a Canadian psychiatrist, was the first to report the erectogenic effect of apomorphine.

Before the advent of sildenafil and other PDE-5 inhibitors, intracavernosal injection was a common treatment modality for erectile dysfunction (8). Apomorphine was subsequently approved in the European Union for the treatment of erectile problems (9).

When monoamine oxidase inhibitors and tricyclic antidepressants were the predominant pharmacological interventions for depressive disorders, very few psychiatrists realized that these drugs were associated with delayed orgasm. It similarly took many years before most psychiatrists were aware that selective serotonin reuptake inhibitors (SSRIs) were associated with sexual dysfunction (10). Subsequently, psychiatrists methodically studied the efficacy of serotonergic drugs in delaying ejaculation in men with rapid ejaculation (11). Recently, a short-acting SSRI was approved in some European countries for the treatment of premature ejaculation. Psychiatrists have largely ignored the sexual side effects of antipsychotic medications and their effect on adherence to these medications. An even smaller number of biological psychiatrists have shown an interest in the neurobiological basis for sexual dysfunction (12).

In the 1960s, it was assumed that most cases of erectile dysfunction were psychogenic in etiology. Considerable effort was used to differentiate psychogenic from organogenic erectile dysfunction because the major urological treatment involved surgery. There also was interest in the interplay of organic and psychogenic components of sexual disorders (13). This changed dramatically with the introduction of the phosphodiesterase inhibitors (14). Suddenly it was assumed that most cases of erectile dysfunction were biogenic. In spite of the introduction of oral therapies for the treatment of both psychogenic and biogenic erectile problems, only a few psychiatrists studied or prescribed phosphodiesterase inhibitors (15). Many men began to go to urologists and primary care physicians for the treatment of erectile dysfunction. After the introduction of the phosphodiesterase inhibitors, most research turned toward augmenting pharmacotherapy with psychotherapy. Very little was published concerning the use of psychotherapy alone in men with psychogenic erectile problems (16, 17). The incredible success of sildenafil served as an impetus to study sexual dysfunction in women, particularly hypoactive sexual desire disorder. Urologists mostly outnumber psychiatrists in the study of these agents (18). Many psychiatric residency programs do not offer training in the treatment of sexual disorders (19).

Negative Influences

In the past two to three decades, very few psychiatrists in the United States have had a primary interest in the treatment of sexual disorders. One factor is that many insurance companies did not reimburse treatment of sexual disorders (20). Managed care often reimbursed psychiatrists much better for providing psychopharmacological services and relegated psychotherapeutic interventions to other mental health providers. With the advent of medical therapies for sexual disorders, many patients preferred to seek care from nonpsychiatric physicians to avoid the stigma of a psychiatric referral.

Another factor is that psychiatry as a whole began to drift away from treating “problems in living” to treating major psychiatric syndromes with a presumably strong biological basis. Thus, many young psychiatrists are unprepared to address sexual or interpersonal issues. This situation may worsen as neuroscience gains greater emphasis in psychiatry.

Unless psychiatry as a field continues to firmly embrace the biopsychosocial model and includes more training in diagnosing and treating sexual problems, it may be logical for the predominant treatment model to be a psychologist working with a urologist or primary care physician.

Psychiatry and Sexual Dysfunction

The lack of interest in sexual medicine is puzzling. Adequate sexual function is not a trivial or infrequent concern. It also is highly prevalent in many psychiatric syndromes and is a frequent side effect of many psychopharmacological interventions. Sexual activity serves as a vehicle for interpersonal connectedness and can help to reinforce one’s sense of competence and masculinity or femininity. Failure of sexual function can have devastating effects on an individual’s sense of self-worth and competence. Numerous studies have shown an increase in self-confidence and relationship satisfaction after the resolution of sexual problems (21).

International surveys indicate that sexual concerns are highly prevalent (22). The largest multinational cross-sectional study of sexual behavior, the Global Study of Sexual Attitudes and Behavior, studied more than 27,000 men and women in 29 countries (23). Twenty-three percent of men complained of problems with premature ejaculation, and 17% reported erectile dysfunction for at least 2 months during the preceding year. Thirty-one percent of women complained of lack of interest in sex, and 24% complained of inability to reach orgasm. Other studies have found similar rates of sexual problems (24, 25).

Female sexual dysfunction has been found to correlate with depression, anxiety, and relationship satisfaction (26), and sexual dysfunction has also been connected to a history of sexual abuse or assault (27). Epidemiological studies have found that erectile dysfunction and depression are highly related (27). An association between depression and loss of libido has been found in both men and women up to the age of 70 (28). In a study of individuals diagnosed with sexual disorders, high rates of anxiety disorders, substance abuse, and affective disorders were reported (29).

Studies in groups of psychiatric patients have likewise found high rates of sexual problems. Several studies have found increased rates of diminished libido and decreased sexual activity in patients diagnosed with depression (30–33). In contrast, higher rates of sexual activity during manic episodes have been reported (34). Studies in patients with anxiety disorders indicate a higher frequency of sexual disorders (35–39). Studies in other psychiatric populations, including patients with anorexia nervosa and psychotic disorders, have also found high rates of sexual problems (40–44).

Among drugs that cause sexual dysfunction, psychiatric medications are often the worst. Controlled studies have shown that all classes of psychotropic medications, including monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors (45), benzodiazepines, and typical antipsychotics, can cause sexual dysfunction. Clinical series and case reports have also implicated atypical antipsychotics, lithium, and some mood stabilizers (46). Similarly, sexual dysfunction has been associated with multiple drugs of abuse (47).

The Biopsychosocial Model

The diagnosis and treatment of sexual disorders can be extremely complicated. Diverse and interactive biological, psychological, and interpersonal factors can influence the genesis and maintenance of sexual problems. The specific contribution of the psychiatrist is to broaden the diagnostic and treatment options. In particular, the psychiatrist can consider biological, psychological, interpersonal, and cultural influences in the classic biopsychosocial model originally proposed by George Engel (48). He or she can diagnose sexual disorders secondary to other psychiatric syndromes, side effects of pharmacological agents, couple dynamics, and individual psychopathology. In addition, the psychiatrist can offer interventions on multiple levels, including treatment of the underlying syndrome, switching psychiatric drugs, couples psychotherapy, individual psychotherapy, or targeted behavioral therapy. The psychiatrist can distinguish transient disturbances in sexual function from the more serious problems that require intervention. The psychiatrist can also distinguish between deep-seated problems, such as difficulties with trust and intimacy, and problems that may respond to simpler, targeted interventions (49).

Fagan (50) outlines an excellent model for evaluating sexual problems from various perspectives. He suggests that sexual problems should be evaluated from multiple perspectives: disease, dimensional, behavioral, and life story. Mezzich and Hernandez-Serrano (51) propose an integrative approach to human sexual difficulties.

Although the surgical specialties of urology and obstetrics-gynecology are in an obvious position for a solid biological evaluation of sexual problems, these physicians are not trained to appreciate or handle psychological or interpersonal issues involved in sexual disorders. Some surgical specialists attempt to accommodate this training gap by either employing psychologists in multidisciplinary treatment teams or referring to outside resources. This approach has advantages but is often complicated by the disjointed health insurance reimbursement system. Another complicating issue is the small number of patients who follow up with a referral to a mental health professional. The cost of two separate professionals treating the same patient for the same complaint can be financially burdensome or cumbersome. Some psychologists have attempted to train urologists and primary care physicians to be “mini-psychologists” (52). There are no data to support the efficacy of this approach.

In erectile dysfunction, there is some evidence that combining counseling with biological therapies can augment the benefits obtained from biological therapies alone. As psychological factors may contribute to or result from erectile dysfunction, an integrated approach has been advocated (53). Relationship factors also influence treatment outcome with sildenafil (54). Four separate studies have reported greater treatment adherence, treatment satisfaction, or efficacy combining a cognitive behavior therapy with pharmacotherapy of erectile problems (55–58). It is unfortunate that these studies of “split” or combined treatment have primarily involved urologists working with psychologists. With the advent of managed care, psychiatrists have accumulated considerable clinical experience in the use of split therapies and have an innate appreciation of the importance of relationship issues in pharmacological therapies (59). The available evidence suggests that premature ejaculation, similar to erectile dysfunction, interacts with quality of life and sexual relationship issues (60). Unhappy relationships, depression, and anxiety have all been associated with female sexual problems. One would expect a combination of psychotherapy and pharmacotherapy to be the most effective approach to treating female sexual difficulties. Many clinicians have commented that the male model of sexual dysfunction may not be appropriate for female patients. Many sexually functional women may not report spontaneous sexual desire but instead report responsive desire. Women may also experience a more rapid decline in sexual desire in long-term relationships than men do (61). These factors indicate the need for clinicians capable of providing an integrated approach to diagnosis and therapy.

Sexual dysfunction is highly prevalent in many psychiatric patient populations, and some psychopharmacological interventions negatively influence sexual function. These side effects, in turn, may influence treatment adherence. Sexuality often has a large influence on patients’ sense of personal competence and is a conduit for intimacy in intimate relationships. In addition, psychiatry, with its emphasis on the biopsychosocial model, has much to offer the evolving field of sexual medicine, which is beginning to understand the neurobiological factors involved in sexual behavior. Advances in our understanding of the biological contributions to sexual behavior need to be put into a cultural and psychosocial context. In this arena psychiatry can make an invaluable contribution.

Dr. Segraves is currently conducting research for Boehringer Ingelheim, Otsuka, Takeda, and Pfizer. He is a consultant for TransTech Pharma and for Boehringer Ingelheim.