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Clinical Interventions in Aging Dove Press

The correlation between emotional distress and aging males symptoms at a psychiatric outpatient clinic: sexual dysfunction as a distinguishing characteristic between andropause and anxiety/depression in aging men
Ching-Yen Chen, Chin-Pang Lee, [...], and Chun-Liang Chen Additional article information

Abstract
Background
Andropause and ps chiatric disorders are associated !ith various s mptoms in aging males and are part of the differential diagnosis of depression and an"iet . #his stud !as designed to investigate the relationship $et!een s mptoms of aging, an"iet , and depression, and to determine if se"ual d sfunction could $e a differentiating characteristic in the ps chiatric outpatient clinic.

Methods
%ne hundred sevent -si" male ps chiatric outpatients participated in the stud and completed self-reported measures assessing s mptoms of aging, depression, and an"iet . & mptoms of aging !ere assessed $ the Aging 'ales( & mptoms scale. An"iet and depression !ere measured $ the )ospital An"iet and Depression &cale. *rectile d sfunction !as considered if a response to item +, on the Aging 'ales( & mptoms scale -impaired se"ual potenc . !as rated !ith / or , points. Affective distur$ance !as assessed $ the total scores of the )ospital An"iet and Depression &cale.

Results
Age !as correlated !ith less an"iet and more se"ual s mptoms. An"iet and depression !ere associated !ith more severe s mptoms of aging, and depression !as associated

!ith more se"ual s mptoms than !as an"iet . Impaired se"ual potenc !as the onl se"ual s mptom not significantl associated !ith depression and an"iet . Depression !as associated !ith an interspousal age gap of 01 ears. #he point prevalence of erectile d sfunction !as 23./4, and age and affective distur$ance !ere associated !ith the ris5 of erectile d sfunction.

onclusion
Impaired se"ual potenc should raise the suspicion of androgen deficienc rather than depression and an"iet among middle-aged or older male ps chiatric outpatients. !eywords: androgen deficienc , depression, an"iet , erectile d sfunction

"ntroduction
#he term 6andropause7 has $een used to descri$e s ndromes in aging males including various clinical s mptoms encompassing somatic, ps chological, and se"ual dimensions, as !ell as endocrine d sfunction, partl related to an age-related decline in androgen and even androgen deficienc .+89 It is also associated !ith d sth mia/ and an increase in depressive s mptoms.,,1 *"ogenous testosterone replacement ma $e $eneficial for treatment-resistant depression associated !ith androgen deficienc .1,: Androgen deficienc is associated !ith premature death, erectile d sfunction -*D., meta$olic s ndrome, and cardiovascular disease.2 & mptoms of andropause and androgen deficienc overlap !ith common ps chiatric disorders such as ma;or depressive disorder -'DD..3 In one stud conducted in a male climacteric clinic in <apan, patients !ith 'DD had significantl more severe s mptoms of aging as assessed $ the Aging 'ales( & mptoms -A'&. scale than did patients !ithout 'DD= the estimated prevalence of 'DD approached ,>4.? &ato et al, in 2>>:, reported that the prevalence of 'DD !as /24 in an androlog clinic and recommended routine screening for 'DD.+> Although the gold standard for the diagnosis of androgen deficienc is the measurement of serum free or $ioavaila$le testosterone, such data are not availa$le for ever male suspected of suffering from decreased testicular function.++ In order to assess aging males( s mptoms, a valua$le and easil applica$le screening tool should $e considered. In the present stud , the A'& scale !as selected as the screening @uestionnaire for several reasons. Airst, the validit and relia$ilit of the A'& scale had $een esta$lished in #ai!an.+2 &econd, the internal structure of the A'& scale across other countries has $een sufficientl similar to conclude that the scale measures the same phenomenon in var ing conte"ts.+9 #hird, the A'& scale !as developed in response to the lac5 of a standardiBed scale+/ such as the androgen deficienc in aging males @uestionnaire. Aourth, it can measure the severit of s mptoms of aging over time in different dimensions as !ell as their impact on health-related @ualit of life -CoL..+,

Due to the comple" nature of the phenomenon and the limited num$er of studies in the male ps chiatric population, !e investigated the relationship $et!een aging males( s mptoms and emotional distress $ using the A'& scale and the )ospital An"iet and Depression &cale -)AD&., and e"amined !hether se"ual d sfunction could $e a differentiating characteristic for s mptoms of aging among middle-aged or older male ps chiatric outpatients.

Methods
#opulation
#he sample !as previousl recruited for validation of the Chinese version of the A'& scale, and a more detailed description has $een pu$lished else!here.+2 %ne hundred sevent -si" #ai!anese men, />83> ears of age, attending the ps chiatric outpatient service of Chang Dung 'emorial )ospital at Lin5ou -a convenience sample. participated in the stud . All participants reported neurotic s mptoms such as an"iet , depression, insomnia, or somatic complaints. #he participants had received general ps chiatric evaluations during their initial visits and had no ps chotic, $ipolar, or cognitive disorders and no histor of ps choactive su$stance a$use. #he demographic data !ere o$tained through clinical intervie!s -#a$le +.. #he age groups !ere defined as middle-aged -/>8 /? ears., pre-elderl -,>81/ ears., and elderl -01, ears.. #he interspousal age gap -IAD. !as defined as the a$solute age difference $et!een the participants and their spouses. #hree IAD groups !ere definedE age-matched -IAD F >82 ears., moderate age gap -IAD F 98, ears., and large age gap -IAD 0 1 ears.. God mass inde" -G'I. groups !ere defined as normal -G'I H 2/.> 5gIm2., over!eight -G'I F 2/.>821.? 5gIm2., and o$ese -G'I J 2:.> 5gIm2.. *ducation groups !ere defined $ ears of educationE primar school and under ->81 ears., high school -:8+2 ears., and college or universit and a$ove -J+2 ears..

#a$le + Demographic data and characteristics of the initial participant sample -n F +:1.

Main outcome measures

Aging males symptoms scale #his +:-item self-administered @uestionnaire is the $est studied and validated @uestionnaire to help assess the severit of s mptoms of aging males and the CoL in men

J/> ears of age.+9,+1 #he scale has $een validated internationall !ith a standard translation of the Chinese version.+2 *ach item is rated on a five-point Li5ert scale, !ith a response of 6,7 representing 6e"tremel severe7 and 6+7 representing 6none.7 #he total score -A'&-#. measures the overall severit of s mptoms of aging and the CoL. #he ps chological score -A'&-P&Y., the sum of items 183, ++, and +9, assesses the ps chological dimension. #he somatovegetative score -A'&-&%'., the sum of items +8 ,, ?, and +>, assesses the somatic dimension. #he se"ual score -A'&-&*K., the sum of the remaining five items, assesses the se"ual dimension. #he A'& scale is moderatel correlated !ith the Gec5 Depression Inventor ?,+: and the )AD&.+2 Lith a cut-off value of 2:,+3 the A'&-# has a sensitivit of 2?4 and a specificit of ?:4 in predicting androgen deficienc .+? *rectile d sfunction -*D. is considered if a response to item +, of the A'& scale -impaired se"ual potenc . is rated at / or ,.2>

$ospital anxiety and depression scale

#he )AD&, a +/-item self-administered @uestionnaire comprised of a seven-item an"iet scale -)AD&-A. and a seven-item depression scale -)AD&-D. scored on a four-point Li5ert scale ->89., is designed to provide a simple et relia$le screening tool for depression and an"iet in various clinical settings, !ith good internall consistent relia$ilit for an"iet and depression -Cron$ach(s M F >.3> and >.:1, respectivel .,2+829 and !ith good sensitivit and specificit -appro"imatel >.3. for identif ing ps chiatric cases.2/,2, #he total score -)AD&-#. measures affective distur$ance= an"iet is defined as a )AD&-A 0 ++= depression is defined as a )AD&-D 0 ++.29 Aour severit grades of ps chological distress are distinguished as follo!sE none -)AD&-# H 3., little -)AD&-# F 38+>., moderate -)AD&-# F ++8+,., and severe -)AD&-# 0 +1..22 #o determine the effect of an"iet and depression, control !as defined as a )AD&-A H ++ and a )AD&-D H ++, an"iet as a )AD&-A 0 ++ and a )AD&-D H ++, depression as a )AD&-A H ++ and a )AD&-D 0 ++, and mi"ed an"iet and depression as $oth )AD&-A 0 ++ and )AD&-D 0 ++.

%tatistical analysis
&tatistical anal ses !ere performed using N version 2.+/.+ for Lindo!s -N Aoundation for &tatistical Computing, Oienna, Austria..21 &tudent(s t-test !as used to test for continuous varia$les $ t!o groups. A one-!a anal sis of variance !as used to test for differences among groups. A post hoc #u5e )&D test !as used to discern su$group differences. Aisher(s e"act test !as used to test for an association $et!een t!o categorical varia$les. Pendall(s correlation coefficients !ere derived !ith significance and multiplicit ad;usted $ )olm(s method. A step!ise multiple logistic regression anal sis !as used for *D. #he independent varia$les !ere the )AD&-#, age, the IAD, G'I, marriage, emplo ment, and education. #he P value !as set at >.>, for all statistical tests.

Results
#he mean age of su$;ects !as ,/.9 ears -standard deviation [&D] F +>.:.. #a$le + sho!s the demographic characteristics of all +:1 participants.

orrelation between age& BM"& $A'%& and AM%

Age !as negativel correlated !ith the )AD&-A -Q F R>.+1., and positivel correlated !ith the A'&-&*K -Q F >.22.. G'I !as not correlated !ith )AD& or A'&. #here !ere mostl !ea5-to-moderatel positive correlations -Q F >.2+8>.,,. among responses to the )AD& and A'& scales -#a$le 2..

#a$le 2 Pendall correlations $et!een age, G'I, )AD&, and A'& scale

(roups of depression and anxiety

#a$le 9 sho!s the results of the one-!a anal sis of variance among groups in terms of depression and an"iet . #here !ere +>9 -,3.,4. controls, +3 -+>.24. su$;ects !ith depression, 21 -+/.34. !ith an"iet , and 2? -+1.,4. !ith mi"ed an"iet and depression. #here !ere significant differences in the IAD, A'&-&*K, and all se"ual s mptoms e"cept impaired se"ual potenc among groups !ith depression and an"iet . A post hoc #u5e )&D test sho!ed that the depression group had a significantl higher IAD than the control and an"iet groups. #he group !ith an"iet onl had a significantl higher score on item +2 -past pea5. than did the control group, !hile the groups !ith depression and mi"ed an"iet and depression had significantl higher scores on items +2, +1 -fe!er morning erections., and +: -distur$ed li$ido. than did the control group. #he group !ith depression had a significantl higher score on item +/ -decrease in $eard gro!th. than did the other 9 groups.

#a$le 9 Anal sis of variance among groups !ith depression and an"iet

)rectile dysfunction

Aift -23./4. of the +:1 participants had *D. #here !as significant positive association $et!een age and *D -for ever &D [+>.: ears], the odds ratio for *D !as 2.,+ [?,4 confidence interval +.,38/.>>].. &u$;ects !ith *D !ere significantl older -1+.> S ++.> ears versus ,+.: S ?./ ears, t[+:/] F ,.19,, P H >.>>>+.= had higher spousal ages -,:.> S ?.? ears versus /3./ S ?.2 ears, t[+,,] F ,.221, P H >.>>>+.= !ere less emplo ed -/>4 versus 11.:4, P F >.>>2>.= and scored higher on the A'&-# -/:.: S ++.+ versus 91.3 S ?.:, t[+:/] F 1./+?, P H >.>>>+., A'&-P&Y -+9./ S /.3 versus ++.2 S /.9, t[+:/] F 2.?,3, P F >.>>91., A'&-&%' -+3.9 S ,.> versus +,.: S /.,, t[+:/] F 9.999, P F >.>>++., and A'&-&*K -+1.> S 2.3 versus ?.? S 9.>, t[+:/] F +2.,29, P H >.>>>+. compared !ith the +21 participants !ithout *D. &u$;ects !ith *D had a trend to!ards a higher )AD&-D than those !ithout *D -3.3 S ,./ versus :.9 S /./, t[+:/] F +.?22, P F >.>,19.. &u$;ects !ith *D !ere not significantl different from those !ithout *D in terms of IAD, )AD& scores, marital status, G'I, and education -#a$le /.. After ad;usting for demographic factors including age, G'I, )AD&-D, and emplo ment, the results of multiple logistic regression anal ses for *D are sho!n in #a$le ,.

#a$le / Comparisons $et!een su$;ects !ith and !ithout erectile d sfunction

#a$le , Logistic regression of erectile d sfunction

'iscussion
In the present stud , an"iet and depression !ere associated !ith more severe s mptoms of aging and a poorer CoL, et the e"erted different effects on se"ual s mptoms. It is note!orth that impaired se"ual potenc !as the onl se"ual s mptom not significantl associated !ith an"iet and depression. An"iet !as associated onl !ith past pea5, !hile depression !as associated !ith all se"ual s mptoms e"cept impaired se"ual potenc . #he severit of $oth an"iet and depression !as moderatel correlated !ith past pea5, !hile age !as not, suggesting that this s mptom !as related more to ps chological health than to aging. #he other four se"ual s mptoms !ere !ea5l correlated !ith severit of depression $ut not !ith an"iet , suggesting that depression ma pla a more

important role in se"ual d sfunction than does an"iet . #here !as a !ea5 negative correlation $et!een age and severit of an"iet , and no correlation $et!een age and severit of depression, !hich is in contrast to a previous report of a !ea5 negative correlation $et!een age and an"iet , and a curvilinear relationship $et!een age and depression.2: Age !as positivel correlated !ith the severit of se"ual s mptoms, impaired se"ual potenc , and fe!er morning erections, $ut !as not correlated !ith past pea5 and distur$ed li$ido, paralleling the findings associated !ith age-related se"ual d sfunction. A large interspousal age gap !as associated !ith depression and its severit , $ut not !ith an"iet . &uch an age gap ma place more of a ps chological $urden on men $ased on differences in se"ual function, age identit ,23 health status, and social life. In one stud of men !ith s mptomatic $enign prostatic h perplasia, IAD !as associated !ith increased s mptoms and $urden on the partner.2? *rectile d sfunction has a multifaceted relationship !ith ps chological, neurologic, hormonal, and vascular pro$lems,2 and is lin5ed to meta$olic s ndrome and cardiovascular diseases.9> #he prevalence of *D in Asian countries is estimated to $e :48+,4 -/>8/? ears of age. and 9?48/?4 -1>8:> ears of age..9+ &everal studies have sho!n a high prevalence of *D among ps chiatric patients.92,99 Age is one of the important ris5 factors for *D. %ther ris5 factors include less than good overall health, dia$etes mellitus, cardiovascular disease, genitourinar disease, ps chiatric disorders, other chronic conditions, smo5ing, and hormonal factors.9> &chneider et al reported that significantl more individuals in clinical samples had *D than did a general population sample -23.?489>.34 versus +,4., and su$;ects !ith *D !ere older, had lo!er testosterone levels, and more an"iet than those !ithout *D.2> #he point prevalence of *D in our sample !as 23./4, and su$;ects !ith *D !ere significantl older, more li5el to $e unemplo ed, and had significantl higher A'& scores than did those !ithout *D. #he response to the )AD& !as not significantl different $et!een su$;ects !ith and !ithout *D. As sho!n in our logistic regression model, there !as onl a trend to!ards an association $et!een *D and depression $ut not for an"iet . #he present cross-sectional stud is one of the fe! papers to investigate relationships $et!een s mptoms of aging and emotional distress among male ps chiatric outpatients !ith neurotic complaints, $ut it does have several methodological limitations. Airst, !e did not have detailed medical and lifest le assessments of the participants, and not all participants under!ent $lood tests for testosterone levels due to some economic and technical constraints. &econd, !e did not record potential confounding factors such as income, marriage duration, partner relationship, and ps chosocial stressors, all of !hich ma contri$ute to depression and an"iet . #hird, self-administered @uestionnaires do not necessaril infer an specific diagnosis, and the are confounded $ the current state of mind and personalit traits. Tevertheless, the are efficient tools and provide some insight in phenomenological investigation. In addition, the A'& scale !as not specific for the diagnosis of androgen deficienc , and !e did not use a validated assessment of *D. Aurthermore, the results ma not $e applied to the communit at large due to the small sample siBe and hospital-$ased population.

onclusion
An"iet , depression, and *D !ere associated !ith more severe s mptoms of aging and a poorer CoL in males. Impaired se"ual potenc !as related more to aging than to emotional pro$lems. A high prevalence of *D highlighted the importance of routine screening in male ps chiatric outpatients !ho present !ith s mptoms of aging. 'ental health clinicians should $e a!are of the relationship $et!een s mptoms of aging and ps chological health, and re@uest further investigation !hen !arranted.

Acknowledgments
All of the participants are ac5no!ledged !ith appreciation.

*ootnotes
'isclosure #he authors report no conflicts of interest in this !or5.

Article information
Clin Interv Aging. 2>+9= 3E 19,81/>. Pu$lished online 2>+9 <une /. doiE +>.2+/:ICIA.&/,+?> P'CIDE P'C91::3>: Ching-Yen Chen,+,/,, Chin-Pang Lee,+,/ Yu Chen,2,/,, <un-Nan <iang,9,/,, Chun-Lin Chu,+,/,, and Chun-Liang Chen9,/,, + Department of Ps chiatr , Chang Dung 'emorial )ospital at Lin5ou, #ai!an 2 Department of Urolog , Chang Dung 'emorial )ospital at Lin5ou, #ai!an 9 Department of #raditional Chinese 'edicine, Chang Dung 'emorial )ospital at Lin5ou, #ai!an / 'en(s )ealth Center, Chang Dung 'emorial )ospital at Lin5ou, #ai!an , &chool of 'edicine, Chang Dung Universit , #ao uan, #ai!an CorrespondenceE Ching-Yen Chen, Department of Ps chiatr , Chang Dung 'emorial )ospital at Lin5ou, To ,, Ausing &t, Dueishan, #ao uan 999, #ai!an, #el V331 9923+2>> e"t 2/9?, Aa" V331 9923>21:, *mail ps c chenIatI ahoo.com.t! Cop right W 2>+9 Chen et al, pu$lisher and licensee Dove 'edical Press Ltd #his is an %pen Access article !hich permits unrestricted noncommercial use, provided the original !or5 is properl cited. Articles from Clinical Interventions in Aging are provided here courtes of 'o+e #ress

References
+. 'orales A, #enover <L. Androgen deficienc in the aging maleE !hen, !ho, and ho! to investigate and treat. Urol Clin Torth Am. 2>>2=2?-/.E?:,8?32. [Pu$'ed]

2. &helton <G, Na;fer <. Androgen deficienc in aging and meta$olicall challenged men. Urol Clin Torth Am. 2>+2=9?-+.E198:,. [Pu$'ed] 9. &urampudi PT, Lang C, &!erdloff N. ) pogonadism in the aging male diagnosis, potential $enefits, and ris5s of testosterone replacement therap . Int < *ndocrinol. 2>+2 'ar +/= *pu$. [P'C free article] [Pu$'ed] /. &eidman &T, Arau;o AG, Noose &P, et al. Lo! testosterone levels in elderl men !ith d sth mic disorder. Am < Ps chiatr . 2>>2=+,?-9.E/,18/,?. [Pu$'ed] ,. &eidman &T. Tormative h pogonadism and depressionE does Xandropause( e"istY Int < Impot Nes. 2>>1=+3-,.E/+,8/22. [Pu$'ed] 1. &eidman &T. Androgens and the aging male. Ps chopharmacol Gull. 2>>:=/>-/.E2>,8 2+3. [Pu$'ed] :. Gassil T. Late-onset h pogonadism. 'ed Clin Torth Am. 2>++=?,-9.E,>:8,29. [Pu$'ed] 3. Amore '. Partial androgen deficienc and neurops chiatric s mptoms in aging men. < *ndocrinol Invest. 2>>,=23-++ &uppl Proceedings.E/?8,/. [Pu$'ed] ?. Yoshida T', Pumano ), Pu$o5i #. Does the Aging 'ales( & mptoms scale assess ma;or depressive disorderYE a pilot stud . 'aturitas. 2>>1=,9-2.E+:+8+:,. [Pu$'ed] +>. &ato Y, #anda ), Pato &, et al. Prevalence of ma;or depressive disorder in selfreferred patients in a late onset h pogonadism clinic. Int < Impot Nes. 2>>:=+?-/.E/>:8 /+>. [Pu$'ed] ++. #ancredi A, Neginster <Y, &chleich A, et al. Interest of the androgen deficienc in aging males -ADA'. @uestionnaire for the identification of h pogonadism in elderl communit -d!elling male volunteers. *ur < *ndocrinol. 2>>/=+,+-9.E9,,891>. [Pu$'ed] +2. Chen CY, Lang L&, Liu CY, Lee &). Nelia$ilit and validation of a Chinese version of the Aging 'ales( & mptoms scale. Ps chol Nep. 2>>:=+>+-+.E2:893. [Pu$'ed] +9. Daig I, )einemann LA, Pim &, et al. #he Aging 'ales( & mptoms -A'&. scaleE revie! of its methodological characteristics. )ealth Cual Life %utcomes. 2>>9=+E::. [P'C free article] [Pu$'ed] +/. )einemann LA<, &aad A, #hiele P, Lood-Dauphinee &. #he Aging 'ales( & mptoms rating scaleE cultural and linguistic validation into *nglish. Aging 'ale. 2>>+=/-+.E+/822. +,. )einemann LA, &aad A, PZll[nen P. &chneider )PD. )ormone Neplacement #herap and Cualit of Life. Te! Yor5, TYE Parthenon Pu$lishing Droup= 2>>2. 'easurement of @ualit of life specific for aging males= pp. 19839. +1. )einemann LA, &aad A, \immermann #, et al. #he Aging 'ales( & mptoms -A'&. scaleE update and compilation of international versions. )ealth Cual Life %utcomes. 2>>9=+E+,. [P'C free article] [Pu$'ed] +:. Chiu YL, Chu CL, Chen Y, et al. Complaint of insomnia as a predictor of aging s mptoms in males at a men(s health clinic. Aging 'ale. 2>+2=+,-+.E:8+9. [Pu$'ed] +3. 'orle <*, Charlton *, Patric5 P, et al. Oalidation of a screening @uestionnaire for androgen deficienc in aging males. 'eta$olism. 2>>>=/?-?.E+29?8+2/2. [Pu$'ed] +?. )einemann LA, &aad A, )einemann P, #hai D'. Can results of the Aging 'ales( & mptoms -A'&. scale predict those of screening scales for androgen deficienc Y Aging 'ale. 2>>/=:-9.E2++82+3. [Pu$'ed]

2>. &chneider D, Tienhaus P, Dromoll <, )euft D, Tieschlag *, \itBmann '. &e" hormone levels, genetic androgen receptor pol morphism, and an"iet in 0,>- ear-old males. < &e" 'ed. 2>++=3-+2.E9/,289/1/. [Pu$'ed] 2+. ' 5letun A, &tordal *, Dahl AA. )ospital An"iet and Depression -)AD. scaleE factor structure, item anal ses and internal consistenc in a large population. Gr < Ps chiatr . 2>>+=+:?-1.E,/>8,//. [Pu$'ed] 22. &naith NP. #he )ospital An"iet and Depression &cale. )ealth Cual Life %utcomes. 2>>9=+E2?. [P'C free article] [Pu$'ed] 29. \igmond A&, &naith NP. #he )ospital An"iet and Depression &cale. Acta Ps chiatr &cand. +?39=1:-1.E91+89:>. [Pu$'ed] 2/. G;elland I, Dahl AA, )aug ##, Tec5elmann D. #he validit of the )ospital An"iet and Depression &cale. an updated literature revie!. < Ps chosom Nes. 2>>2=,2-2.E1?8::. [Pu$'ed] 2,. )errmann C. International e"periences !ith the )ospital An"iet and Depression &cale 8 a revie! of validation data and clinical results. < Ps chosom Nes. +??:=/2-+.E+:8 /+. [Pu$'ed] 21. N Development Core #eam NE A language and environment for statistical computing. N Aoundation for &tatistical Computing= Oienna, AustriaE 2>+2. I&GT 9-?>>>,+->:->, UNL httpEI!!!.N-pro;ect.org. 2:. DelheB ', )ansenne ', Legros <<. Andropause and ps chopatholog E minor s mptoms rather than pathological ones. Ps choneuroendocrinolog . 2>>9=23-:.E3198 3:/. [Pu$'ed] 23. Garrett A*. Dendered e"periences in midlifeE Implications for age identit . < Aging &tud. 2>>,=+?-2.E+198+39. 2?. 'itropoulos D, Anastasiou I, Diannopoulou C, et al. & mptomatic $enign prostate h perplasiaE impact on partners( @ualit of life. *ur Urol. 2>>2=/+-9.E2/>82//. [Pu$'ed] 9>. Le!is NL, Augl-'e er P&, Corona D, et al. DefinitionsIepidemiolog Iris5 factors for se"ual d sfunction. < &e" 'ed. 2>+>=:-/ Pt 2.E+,?38+1>:. [Pu$'ed] 9+. Le!is NL. *pidemiolog of se"ual d sfunction in Asia compared to the rest of the !orld. Asian < Androl. 2>++=+9-+.E+,28+,3. [P'C free article] [Pu$'ed] 92. )ariri AD, Paradag A, Durol D#, A5so U', #eBcan A*. &e"ual pro$lems in a sample of the #ur5ish ps chiatric population. Compr Ps chiatr . 2>>?=,>-/.E9,9891>. [Pu$'ed] 99. 'osa5u P&, U5pong DI. *rectile d sfunction in a sample of patients attending a ps chiatric outpatient department. Int < Impot Nes. 2>>?=2+-/.E29,829?. [Pu$'ed]

G'C Nesearch Totes Gio'ed Central

'emographic and clinical correlates of sexual dysfunction among ,igerian male

outpatients on con+entional antipsychotic medications

Aina Pi5elomo % e5anmi, Adego5e %lorunto$a Adelufosi, [...], and #imoth %laolu Ade$o!ale Additional article information

Abstract
Background
In ps chotic disorders, earl intervention !ith antips chotic medications increases the li5elihood of favoura$le long-term course. )o!ever, the pharmacologic management especiall !ith conventional antips chotic medications is complicated $ a high rate of adverse effects including se"ual d sfunction. #his stud aims to determine the demographic and clinical factors associated !ith se"ual d sfunction among male ps chiatric outpatients on conventional antips chotic medications in &outh-!estern Tigeria.

Methods
#!o hundred and sevent five consecutive male outpatients !ith ps chotic disorders on conventional antips chotic medications !ere intervie!ed. Data !as collected on demographic characteristics, illness-related and medication-related varia$les. Illness severit !as assessed !ith the Grief ps chiatric rating scale. #he International Inde" of *rectile Aunction @uestionnaire !as used to assess for se"ual d sfunctions.

Results
A total of +++ -/>./4. respondents had one or more forms of se"ual d sfunction. &e"ual desire d sfunction !as present in /: -+:.+4. of respondents, erectile d sfunction in ?, -9/.,4., orgasmic d sfunctions in ,+ -+3.,4., intercourse dissatisfaction in :2 -21.24. and overall dissatisfaction in 1/ -29.94.. &e"ual d sfunction !as significantl associated !ith emplo ment status, age, marital status, haloperidol use, medication dosage, and presence of ps chopatholog . Unemplo ment !as the onl significant independent correlate of se"ual d sfunction, !ith unemplo ed respondents t!ice more li5el to have se"ual d sfunction compared !ith those emplo ed -Lald F 9.31,, %dds Natio F 2.>99, ?,4 confidence interval F +.>>2 - /.+2/, p F >.>/?..

onclusions

#he high prevalence of se"ual d sfunction found in this stud suggests a need among clinicians for increased a!areness and recognition of the se"ual side effects in patients ta5ing conventional antips chotic medications. #his 5no!ledge should guide conventional antips chotic medication prescription in the at-ris5 population to improve treatment adherence. !eywords: &e"ual d sfunction, Conventional antips chotics, &chiBophrenia

Background
&e"ual d sfunction is commonl associated !ith the pharmacologic management of ps chotic illnesses especiall conventional antips chotic medications [+-9]. #his is further complicated $ the effects of ma;or ps chotic illness itself on se"ual functioning, among !hich are reduced li$ido, decreased se"ual performance and satisfaction [/]. Previous studies sho!ed that se"ual d sfunction occurred in as man as 1>4 of outpatients !ith schiBophrenia [,-:]. &e"ual adverse effects have $een reported in up to /,8,>4 of patients ta5ing conventional antips chotics and are more li5el to $e distur$ing to men than !omen [3-+>]. %ther authors reported that more than ,>4 of males on conventional antips chotics e"perienced se"ual d sfunction [++]. Commonl e"perienced se"ual side effects in males are poor penile erection, e;aculator and orgasmic distur$ance [+2,+9]. Despite this high rate, complaints a$out se"ual d sfunction are largel une"plored or ignored $ clinicians, or attracted onl vague reassurances resulting in poor medication adherence and @ualit of life [2,+/,+,]. #here is a paucit of studies on se"ual d sfunction in Tigeria [+1]. 'an of the availa$le studies !ere conducted among medical outpatient clinic attendees and communit samples, !ith findings !hich cannot $e generaliBed to patients in specific diagnostic groups li5e schiBophrenia and other ps chotic disorders [+:,+3]. A recent stud $ 'osa5u ] U5pong [+?] conducted among outpatients attending a ps chiatric clinic in &outh!est Tigeria reported a prevalence of 31.,4 for erectile d sfunction, !ith var ing prevalences reported for other forms of se"ual d sfunctions. )o!ever, aside patients !ith schiBophrenia, the stud included patients diagnosed !ith other mental illnesses such as depression, $ipolar affective disorder, and ps choactive su$stance dependence, !ho ma actuall have differing patterns and prevalences of se"ual d sfunction. #o the $est 5no!ledge of the authors, no Tigerian studies have reported the prevalence and correlates of se"ual d sfunction among patients in a specific diagnostic group li5e those !ith schiBophrenia and delusional disorders. #he aim of this stud !as to determine the prevalence of se"ual d sfunction, associated socio-demographic and clinical factors among male patients !ith ps chotic disorders on conventional antips chotic, in &outh!estern Tigeria.

Methods

%tudy design and setting

#his !as a descriptive cross sectional surve of se"ual d sfunction among male outpatients !ith schiBophrenia on conventional antips chotic medications for at least si" months. #he stud !as carried out at the out-patient clinic of the Teurops chiatric )ospital Aro, A$eo5uta, Tigeria $et!een August 2>>, and Ae$ruar 2>>1. #he annual report of the medical records department of the hospital sho!ed that 9,2:> patients !ith a diagnosis of schiBophrenia attended the outpatient clinic in 2>>/ -Unpu$lished data, medical records department.. #he hospital has a total capacit of ,21 $eds and attends to all patients that come to the hospital through referrals and those $rought $ relatives. It has an *mergenc IAssessment Unit that provides a 2/-hour first-contact and *mergenc services, : da s of the !ee5 !hile outpatient clinics are run for follo!-up consultations on 'onda s, #uesda s, #hursda s and Arida s after the first contact or follo!ing discharge from the in-patient care.

#articipants
Participants !ere consecutive male outpatient $et!een the ages of +381> ears. %nl su$;ects meeting the ICD-+> criteria for schiBophrenia and delusional disorders -A2> 8 A2?. $ased on information from patients^ case notes( !ere included in the stud . Patients !ith clinical histor Irecord of conditions and medications that ma contri$ute to se"ual d sfunctions viB Dia$etes, h pertension, cere$rovascular disorder e.g. stro5e, gonadal in;ur , endocrine disorderImedications, alcohol dependence, antidepressant medication !ere e"cluded from the stud -all patients undergo routine la$orator screening including fastingIrandom $lood sugar and full ph sical e"amination at presentation and regular intervals for an concomitant ph sical illness at the stud center= $od !eight and GP chec5s are also carried out at ever visit..

"nstruments
#he follo!ing instruments !ere administeredE +. A @uestionnaire dra!n up $ the researchers -AP% and #%A. to elicit information on socio-demographic characteristics of respondents and their clinical characteristics, such as illness and medication histor . 2. Grief Ps chiatric Nating &cale -GPN&. - #he GPN& is a !idel used instrument developed $ %verall ] Dorham to measure ps chotic s mptoms and ps chopatholog profiles [2>]. It is a semi-structured intervie! schedule originall comprising +1 items. *ach item is scored on a :-point scale and produces su$ scores -profiles. for affective, ps chotic and negative s mptoms. #he +1 items of the original scale !as used in this stud to measure current ps chopathological profile of the su$;ects. #he GPN& has $een used $ previous researchers in Tigeria [2+] 9. #he International Inde" of *rectile Aunction -II*A. @uestionnaire - #his is a self administered @uestionnaire that evaluates male se"ual functions. #he II*A !as developed

$ an International panel of e"perts through an e"tensive revie! of the literature and e"isting @uestionnaires in addition to detailed intervie! of men !ith se"ual d sfunction and their partners [22]. #he II*A instrument consists of +, @uestions -C., rated on a scale of +8,, !ith > indicating no se"ual activit or no attempt. It has , domainsE *rectile d sfunction -C+ 8 ,, +,., %rgasmic Aunction -C?, +>., &e"ual Desire -C++, +2., Intercourse &atisfaction -C1 8 3., and %verall &atisfaction -C+9, +/., each addressing a uni@ue dimension of se"ual function. #otal II*A @uestionnaire score ranged from >89>, !ith higher scores indicating $etter se"ual functioning. Nesponses to each @uestion are $ased on a man(s e"perience over the past / !ee5s. #he II*A has $een used $ previous authors in Tigeria [+?] and in their stud , a relia$ilit coefficient -cron$ach(s alpha. of >.?2+ !as o$tained. All the @uestionnaires !ere translated to Yoru$a -the predominant language in the localit of the stud . through the process of $ac5 translation.

#rocedure
Consecutive male outpatient clinic attenders $et!een the ages of +381> !ho !ere married andIor !ho had a regular se"ual partner and !ho had fulfilled the ICD-+> criteria for schiBophrenia, and delusional disorders -A2> 8 A2?. at one time or the other $ased on information from patients^ case notes(, and !ere currentl on conventional antips chotic medications for at least si" months -including those that still had active or residual s mptoms $ut not acutel distur$ed !ith gross e"citement or disorientation. !ere included. #he intervie!s !ere conducted $ AP% and t!o trained research assistants -resident doctors in ps chiatr . in the outpatient clinic consultation rooms after routine consultation, to ensure confidentialit . Assistance in completing the @uestionnaires !as provided for the respondents !here necessar .

)thical considerations
Approval of the Nesearch *thical Committee of the Teurops chiatric )ospital, Aro, A$eo5uta, %gun &tate, Tigeria !as o$tained to carr out the stud . #his stud complied !ith the Declaration of )elsin5i protocol and informed ver$al consent !as o$tained from the participants after a detailed e"planation of the stud .

'ata analysis
&tatistical Pac5age for &ocial &ciences -&P&&. version ++.> for Lindo!s_ !as used for data anal sis. 'ost of the varia$les !ere grouped for ease of statistical anal sis. Nesults !ere calculated as fre@uenc -4. and mean. Droup differences !ere determined using Chi-s@uare -2. test for categorical varia$les and student t-test for continuous varia$les. Oaria$les that !ere found to $e significantl associated !ith an form of se"ual d sfunction -independent varia$les. !ere then included in a logistic regression model !ith presence or a$sence of se"ual d sfunction as the outcome -dependent varia$le.. Level of significance !as set at p H >.>,.

Results
%ociodemographic characteristics
#!o hundred and sevent nine male outpatients !ho met the inclusion criteria !ere invited to participate in the stud . #here !ere , outright refusals, giving a response rate of ?3.14. #he data of 2:, male outpatients meeting the inclusion criteria for the stud !ere anal sed. 'ean age !as 9?., S ?./ ears, and the !ere mainl $et!een 9> and 9? ears old -91./4.. Nespondents !ere predominantl married -1>.:4. and the ma;orit of patients -31.?4. !ere emplo ed. #he patients !ere predominantl Christians -12.?4. #a$le #a$le++.

#a$le + Demographic, Clinical and 'edication Nelated Characteristics of Nespondents

linical characteristics and medication related +ariables

#he ma;orit of patients -3:.14. had a diagnosis of schiBophrenia. #he mean age at onset of illness !as 2:./ S :./ ears. #he ma;orit of respondents -/2.,4. had their onset of illness $et!een +, and 2, ears. #he mean -&D. GPN& score !as >./> -+.2.. #he mean duration of conventional antips chotic medication use !as 3./ S 2.+ ears. %ne hundred and thirt one patients -/:.14. had $een using medications for more than 9, ears. 'a;orit of the patients -,,.94. !ere ta5ing more than t!o conventional antips chotic at the time of the stud . #he mean chlorpromaBine e@uivalent dail medication dose ta5en $ the patients !as /12 mg, !ith the ma;orit -1+.34. $eing maintained on less than ,>> mg chlorpromaBine e@uivalent dail dose -#a$le -#a$le++..

#re+alence of sexual dysfunction

%ne or more forms of se"ual d sfunction e"isted among +++ -/>./4. of the respondents. &e"ual desire d sfunction !as present in /: -+:.+4. of su$;ects, *rectile d sfunction in ?, -9/.,4., %rgasmic D sfunctions ,+ -+3.,4., Intercourse Dissatisfaction :2 -21.24. and %verall Dissatisfaction 1/ -29.94..

orrelates of sexual dysfunction

#he demographic, medication and illness related varia$les associated !ith one or more forms of se"ual d sfunction !ereE *mplo ment status -se"ual desire d sfunction, orgasmic d sfunction, intercourse dissatisfaction and overall dissatisfaction., age group -orgasmic d sfunction., marital status -overall dissatisfaction., haloperidol use -erectile d sfunction, orgasmic d sfunction., medication dose -erectile d sfunction, orgasmic d sfunction, overall dissatisfaction., an ps chopatholog on the GPN& -overall dissatisfaction. #a$le #a$le22.

#a$le 2 Association $et!een &pecific &e"ual d sfunctions and &ociodemographic, Illness-related and 'edication-related Oaria$les

"ndependent correlates of sexual dysfunction

Nesult of the logistic regression anal sis sho!ed unemplo ment as the onl independent correlate of se"ual d sfunction, !ith unemplo ed respondents t!ice as li5el to have se"ual d sfunction as those emplo ed -Lald F 9.31,, %dds ratio F 2.>99, ?,4 confidence interval F +.>>2 - /.+2/, p F >.>/?..

'iscussion
#his stud e"amined the prevalence and correlates of se"ual d sfunction among Tigerian men !ith ps chotic illness attending a ps chiatric outpatient clinic. %verall, a$out />4 of the respondents had at least one form of se"ual d sfunction. #his rate of se"ual d sfunction is similar to that reported in other previous studies [3,+>,+3]. Considering the finding that the mean age -9?., ears. of the respondents fell !ithin the reproductive age group, pro$lems !ith their se"ual functioning ma $e a significant source of concern for them !ith far reaching conse@uences if left untreated. 'ost of the patients -1/.:4. in this stud !ere ta5ing more than one conventional antips chotics, an o$servation also made in a stud e"amining the prescri$ing ha$its for ps chiatric in-patient admissions [29]. %ther authors have found that despite e"tensive research and recommendations regarding the rational prescription of antips chotic drugs, pol pharmac e"ists even among clinicall sta$le patients [2/]. #his stud reports an association $et!een pol -pharmac and se"ual d sfunction !hich can $e e"plained $ the fact that increasing the num$er of medications result in increased

ris5 of adverse effects e"perienced $ patients. %ur finding is similar to !hat previous authors reported that com$ination of antips chotics adds to the ris5s of developing medication side effects [2,]. In addition, !e found a significant relationship $et!een medication dosages -chlorpromaBine e@uivalents. and some forms of se"ual d sfunction, similar to that reported $ some authors [:]. )igher dosages of conventional antips chotics are therefore associated !ith higher prevalence of se"ual d sfunction since there !ill $e more drugs to act at the various path!a s leading to se"ual d sfunction [3]. Among the conventional antips chotics medications prescri$ed, onl haloperidol sho!ed a significant relationship !ith se"ual d sfunction -erectile and orgasmic d sfunctions.. #his ma $e attri$uted to the high affinit of haloperidol for dopamine D2 receptor and inhi$ition of dopamine release, resulting in impaired li$ido and erection [21]. %n the other hand, the se"ual d sfunction o$served ma $e a result of severe ps chopathologies e"perienced $ the patients [/], !hich then necessitated the use of a highl potent t pical antips chotic medication li5e haloperidol. *rectile d sfunction !as the commonest t pe of se"ual d sfunction reported $ the respondents, a finding also reported in previous studies [+?,2:,23]. Poor penile erection interferes !ith su$;ective en;o ment of other stages of se"ual intercourse and $ecause it !as the commonest se"ual d sfunction reported $ respondents, it ma account for the high prevalence of intercourse dissatisfaction and overall dissatisfaction !ith se" o$served in this sample. Ina$ilit to achieve good penile erection for optimal se"ual satisfaction ma $e associated !ith feelings of inade@uac in the sufferer. In man societies, including Tigeria, individuals !ith poor or a$sent penile erection are often stigmatiBed, su$;ected to pu$lic ridicule and ma $e deserted $ their spouse. *rectile d sfunction ma result in poor treatment adherence and negativel impacts on patients( @ualit of life [+,]. %ur stud revealed a significant relationship $et!een marital status and se"ual d sfunction, specificall !ith overall dissatisfaction !ith se". It ma $e that patients !ith medication induced se"ual d sfunction !ere li5el to $e dissatisfied !ith their overall se"ual functioning. Aor married men, the marriage setting provides an opportunit for a Xfeed$ac5( from the spouse a$out se"ual performance, !hich ma result in su$;ective a!areness of an e"isting se"ual inade@uac , other!ise unnoticed $ the patient. #his raises a possi$ilit that the relationship $et!een marital status and se"ual d sfunction seen in these patients ma $e ps chogenic in origin, rather than organic. Unfortunatel , the I*AA could not distinguish $et!een organic and ps chogenic se"ual d sfunction, an important limitation of this stud . )o!ever, other authors have also reported a significant association $et!een marital status and se"ual d sfunction among patients ta5ing conventional antips chotics in Tigeria [+?] In this stud , unemplo ed respondents !ere more li5el to have se"ual d sfunction than those !ho are emplo ed. Previous studies have found an association $et!een se"ual d sfunction, depression and socioeconomic disadvantages li5e unemplo ment [3,2?]. Unemplo ment ma result in role reversal !ithin a relationship, engendering feelings of shame and inade@uac in the male partner. Previous authors have reported that

unemplo ment in a person !ith mental illness is associated !ith pu$lic and selfstigmatiBation, a 6dou$le ;eopard 7, !hich ma negativel impact on self-!orth and se"ual performance or satisfaction [2+]. #his stud has a num$er of limitations. Airst, it !as cross-sectional in nature, so the direction of causalit $et!een se"ual d sfunction and the sociodemographic and clinical varia$les could not $e inferred from the findings. &econd, there is a limitation regarding the generaliBa$ilit of the result to other patients on conventional antips chotics in Tigeria, as the stud !as conducted in ;ust one centre. #hird, the a$sence of a control group is also an important limitation to the generaliBa$ilit of our results. )o!ever, to the $est of our 5no!ledge, it is the first to e"amine se"ual d sfunction among specific group of ps chiatric outpatients on conventional antips chotics in Tigeria. It is also one of the fe! availa$le studies on se"ual d sfunction in a developing countr setting !here conventional antips chotic medications are commonl prescri$ed for the treatment of ps chotic illnesses [9>].

onclusions
&e"ual d sfunction is common among outpatients !ith ps chotic disorders on conventional antips chotics. It is associated !ith demographic, illness and medication related varia$les. Unemplo ment !as found to $e the most important independent correlate of se"ual d sfunction. #herefore, there is a need among clinicians for increased a!areness and recognition of the se"ual side effects of conventional medications on patients, especiall those sociall disadvantaged. #his should guide antips chotic medication prescription resulting possi$le improvement in treatment adherence and outcome.

ompeting interests
#he authors declare that the have no competing interests.

Authors contribution
%AP conceived the stud and together !ith A#% designed the stud . %AP e"ecuted the data collection. A%A and %A did the statistical anal sis and drafted the first version of the manuscript. %AP and A#% participated in the interpretation of data. All authors read and approved the final manuscript.

%ource of financial support

Tone.

Article information

G'C Nes Totes. 2>+2= ,E 21:. Pu$lished online 2>+2 <une :. doiE +>.++31I+:,1->,>>-,-21: P'CIDE P'C9/21/:/ Aina Pi5elomo % e5anmi,+ Adego5e %lorunto$a Adelufosi, 2 %lu5a ode A$a omi,2 and #imoth %laolu Ade$o!ale+ + Teurops chiatric )ospital, Aro, P.% Go" 22+>, &apon, A$eo5uta, %gun &tate, Tigeria 2 Lado5e A5intola Universit #eaching )ospital, %g$omoso, % o &tate, Tigeria Corresponding author. Aina Pi5elomo % e5anmiE a5o e5anmiIatIgmail.com= Adego5e %lorunto$a AdelufosiE oBoteeIatIgmail.com= %lu5a ode A$a omiE a$a omi5a IatIgmail.com= #imoth %laolu Ade$o!aleE toade$oIatI ahoo.com Neceived 'arch 23, 2>+2= Accepted 'a 23, 2>+2. Cop right W2>+2 % e5anmi et al.= licensee Gio'ed Central Ltd. #his is an %pen Access article distri$uted under the terms of the Creative Commons Attri$ution License -httpEIIcreativecommons.orgIlicensesI$ I2.>., !hich permits unrestricted use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from G'C Nesearch Totes are provided here courtes of BioMed entral

References
1. AiBen$erg D, 'odai I, Landa A. et al. Comparison of se"ual d sfunction in male

2. 3.

/.
5. 6.

7.

8.

schiBophrenic patients maintained on treatment !ith classical antips chotics versus cloBapine. < Clin Ps chiatr . 2>>+=12-:.E,/+8,//. doiE +>./>33I<CP.v12n>:a>:. [Pu$'ed] [Cross Nef] Cutler A<. &e"ual d sfunction and antips chotic treatment. Ps choneuroendocrinolog . 2>>9=23-&uppl +.E1?832. [Pu$'ed] Les$ N, Gullimore *, *arle <, )eave A. A surve of ps chose"ual arousa$ilit in male patients on depot neuroleptic medication. *ur Ps chiatr . +??1=++E3+831. doiE +>.+>+1I>?2/-?993-?1.3/:3/-,. [Pu$'ed] [Cross Nef] 'ilner P, #andon N, #omori %, Alorence #. InE &e"ualit and &erious 'ental Illness. Guc5le PA, editor. )ar!ood Academic Pu$lishers, Amsterdam= +???. Ps chotropic medications and se"ual d sfunction. 'enon A, Lilliams N), Latson &. Increased li$ido associated !ith @uetiapine. < Ps chopharm. 2>>1=2>-+.E+2,8+2:. [Pu$'ed] Uco5 A, Incesu C, A5er #, *r5oc &. &e"ual d sfunction in patients !ith schiBophrenia on antips chotic medication. *ur Ps chiatr . 2>>:=22E9238999. doiE +>.+>+1I;.eurps .2>>:.>+.>>+. [Pu$'ed] [Cross Nef] Au;ii A, Yasui-Auru5ori T, &uga!ara T, &ato Y, Ta5agami #, &aito ', Pane5o &. &e"ual d sfunction in <apanese patients !ith schiBophrenia treated !ith antips chotics. Prog Teurops chopharmacol Giol Ps chiatr . 2>+>=9/E23382?9. doiE +>.+>+1I;.pnp$p.2>>?.++.>22. [Pu$'ed] [Cross Nef] &mith &', %(Peane O, 'urra N. &e"ual d sfunction in patients ta5ing conventional antips chotics. Gr < Ps chiatr . 2>>2=+3+E/?8,,. doiE +>.++?2I$;p.+3+.+./?. [Pu$'ed] [Cross Nef]

9. Aa5hour LP, Lright D, Lallace '. Prevalence and e"tent of distress of adverse

effects of antips chotics among callers to a United Pingdom Tational 'ental )ealth )elpline. Int Clin Ps chopharmacol. 2>>+=+1-9.E+,98+12. doiE +>.+>?:I>>>>/3,>-2>>+>,>>>->>>>/. [Pu$'ed] [Cross Nef] 10. Pnegtering ), Go5s ', Gli;d C, Castelein &, Oan den Gosch N<, Liersma DA. NandomiBed open-la$el comparison of the impact of olanBapine versus risperidone on se"ual functioning. < &e" 'arital #her. 2>>1=92E9+,8921. doiE +>.+>3>I>>?2129>1>>1119:3. [Pu$'ed] [Cross Nef] 11. Dhadirian A', Chouinard D, Anna$le L. &e"ual d sfunction and plasma proclatinlevels in neuroleptic-treated schiBophrenic outpatients. < Terv 'ental Disease. +?32=+:>E/198/1:. doiE +>.+>?:I>>>>,>,9-+?32>3>>>->>>>/. [Pu$'ed] [Cross Nef] 12. &egraves N#. *ffects of ps chotropic drugs on human erection and e;aculation. Arch Den Ps chiatr . +?3?=/1-9.E2:,823/. doiE +>.+>>+Iarchps c.+?3?.>+3+>>9>>3+>++. [Pu$'ed] [Cross Nef] 13. Ditlin '<. Ps chotropic medications and their effects on se"ual functionE diagnosis, $iolog , and treatment approaches. < Clin Ps chiatr . +??/=,,E/>18 /+9. [Pu$'ed] 14. Aviv A, &helef A, LeiBman A. An open-la$el trial of sildenafil addition in risperidone8 treated male schiBophrenia patients !ith erectile d sfunction. < Clin Ps chiatr . 2>>/=1,-+.E?:8+>9. doiE +>./>33I<CP.v1,n>++:. [Pu$'ed] [Cross Nef] 15. Dopala5rishnan N, <aco$ P&, Puruvilla A, Oasanthara; G, <ohn <P. &ildenafil in the treatment of antips chotic induced erectile d sfunctionE a randomiBed, dou$le$lind, place$o-controlled, fle"i$le-dose, t!o-!a crossover trial. Am < Ps chiatr . 2>>1=+19-9.E/?/8/??. doiE +>.++:1Iappi.a;p.+19.9./?/. [Pu$'ed] [Cross Nef] 16. 'ode$e %. *rectile failure among medical clinic patients. Afr < 'ed &cience. +??>=+?E2,?821/. [Pu$'ed] 17. %5ulate D, %lado5un %, Dogunro A&. *rectile d sfunctionE Prevalence and relationship !ith depression, alcohol a$use and Panic disorder. Den )osp Ps chiatr . 2>>9=2,-9.E2>?82+9. doiE +>.+>+1I&>+19-39/9->9.>>>+,-K. [Pu$'ed] [Cross Nef] 18. Adegunlo e %A, 'a5an;uola AG, Adele5an 'L. &e"ual d sfunction among secondar school teachers in Ilorin, Tigeria. < &e" 'ed. 2>+>=:E939,893//. doiE +>.++++I;.+:/9-1+>?.2>+>.>+:1/.". [Pu$'ed] [Cross Nef] 19. 'osa5u P&, U5pong DI. *rectile d sfunction in a sample of patients attending a ps chiatric outpatient department. Int < Impotence Nes. 2>>?=2+E29,829?. doiE +>.+>93Ii;ir.2>>?.+1. [Pu$'ed] [Cross Nef] 20. %verall <*, Dorham DN. #he Grief Ps chiatric Nating &cale. Ps chol Neports. +?12=+>E:??83+2. doiE +>.2/11Ipr>.+?12.+>.9.:??. [Cross Nef] 21. Ade!u a A%, %!oe e A%, *rinfolami A%, %la GA. Correlates of self-stigma among outpatients !ith mental illness in Lagos, Tigeria. Int < &oc Ps chiatr . 2>++=,:-/.E/+38/2:. doiE +>.++::I>>2>:1/>+>919,22. [Pu$'ed] [Cross Nef] 22. Nosen NC, Nile A, Lagner D. et al. #he international inde" of erectile function -II*A.E a multidimensional scale for assessment of erectile d sfunction. Urolog .

+??:=/?-1.E322839>. doiE +>.+>+1I&>>?>-/2?,-?:.>>293->. [Pu$'ed] [Cross Nef] 23. Adamson #A. Prescri$ing ha$its for ps chiatric in-patient admissions in a Tigerian ps chiatric hospital. Afr < 'ed &ci. +??,=2/E21+821,. ref for pg :/. [Pu$'ed] 2/. )iroto I, Asu5a P, #eruhi5o ). Pol pharmac and e"cessive dosingE ps chiatrists` perceptions of antips chotic drug prescription. Gr < Ps chiatr . 2>>,=+3:E2/982/:. doiE +>.++?2I$;p.+3:.9.2/9. [Pu$'ed] [Cross Nef] 25. )arrington ', Lelliott P, Paton C. et al. #he result of a multicentre audit of the prescri$ing of antips chotic drugs for in-patient in the U.P. Ps chiatr Gull. 2>>2=21E/+/8/+3. doiE +>.++?2Ip$.21.++./+/. [Cross Nef] 21. Collins AC, Pellner N. Teuroleptics and se"ual functioning. Integr Ps chiatr . +?31=/E?18+>3. 27. #eusch L, &cher$aum T, Gohme ). et al. Different patterns of se"ual d sfunctions associated !ith ps chiatric disorders and ps chopharmacological treatment. Nesults of an investigation $ semi structured intervie! of schiBophrenic and neurotic patients and methadone-su$stituted opiate addicts. Pharmacops chiatr . +??,=23-9.E3/8?2. [Pu$'ed] 28. Pha!a;a 'Y. &e"ual d sfunction in male patients ta5ing antips chotics. < A u$ 'ed Coll. 2>>,=+:-9.E . [Pu$'ed] 2?. A$do C)T, %liveira <anior L', <anior *', A$do <A, Aittipaldi <A&. #he impact of ps chosocial factors on the ris5 of erectile d sfunction and inhi$ition of se"ual desire in a sample of the GraBilian population. &ao Paulo 'ed <. 2>>,=+29-+.E++8+/. [Pu$'ed] 30. Adelufosi A%, Ade$o!ale #%, A$a omi %, 'osan a <#. 'edication adherence and @ualit of life among Tigerian outpatients !ith &chiBophrenia. Den )osp Ps chiatr . 2>+2=9/E:28:?. doiE +>.+>+1I;.genhospps ch.2>++.>?.>>+. [Pu$'ed] [Cross Nef]

Advances in Urolog )inda!i Pu$lishing Corporation

%exual 'ysfunction and $yperprolactinemia in Male #sychotic "npatients: A ross-%ectional %tudy

*ri5 <ohnsen, Nune Pro5en, [...], and )ugo A. <brgensen Additional article information

Abstract
Introduction. &e"ual d sfunction -&D. and h perprolactinemia are fre@uentl reported in patients !ith ps chotic disorders and have the potential for severe complications $ut investigations in males are particularl scarce. #he primar aims !ere to determine the prevalence of &D and h perprolactinemia in male patients and to investigate !hether associations e"ist $et!een &D and prolactin levels. Methods. Cross-sectional data !ere o$tained at discharge from the hospital or 1 !ee5s after admittance for patients acutel admitted for ps chosis and treated !ith a second-generation antips chotic drug. Results. )alf the patients reported diminished se"ual desire and more than a third reported erectile and e;aculator d sfunctions !ith no differences among the drugs. 'ore than half the sample !as h perprolactinemic. To association !as found $et!een prolactin levels and &D. Conclusion. )igh rates of &D and h perprolactinemia !ere found in male patients and should $e a treatment target. &D and h perprolactinemia !ere not correlated.

./ "ntroduction
Active ps chosis affects most aspects of normal functioning and has $een ran5ed the third most disa$ling disorder in the general population, and more disa$ling than paraplegia, $lindness, or )IO infection [+]. #he life-time prevalence of an ps chotic disorder is a$out 9 in +>> persons [2]. In a su$stantial proportion of cases, the disorders are chronic and life long. #he presence of ps chosis !ill in most instances indicate the use of antips chotic drugs. Goth the nature of the disorders and antips chotic drug treatment can profoundl affect se"ual functioning. 'ain tolera$ilit issues related to antips chotic drug use have traditionall $een the e"trap ramidal s ndrome -*P&. associated !ith the first-generation -t pical. antips chotics, and meta$olic adverse effects associated mainl !ith the secondgeneration -at pical. agents [9, /]. &e"ual d sfunction -&D. has received far less attention, although these side effects have $een reported among the most discomforting ones $ patients !ith schiBophrenia [,, 1]. &D is important also as it has negative impact on medication adherence. Antips chotic-induced h perprolactinemia is commonl regarded as a fre@uent cause of &D. As demonstrated in a revie! $ G erl et al. [:], the findings of different studies are conflicting, ho!ever, !ith regards to associations $et!een h perprolactinemia and se"ual side effects. Lhile differential propensities among second-generation antips chotics -&DAs. in causing h perprolactinemia are !ell documented [3], differences among the &DAs in causing &D are less investigated. &tudies addressing male &D specificall in ps chosis are particularl scarce. In one stud , &D has $een reported to affect almost half the sample of outpatients !ith schiBophrenia and to adversel affect their @ualit of life [?]. &everal research @uestions of clinical relevance thus remain unresolved, and studies in clinicall relevant samples are called for.

#he primar aims of the present stud !ere to determine the prevalence of &D and h perprolactinemia, and to investigate !hether associations e"ist $et!een &D and prolactin levels in male patients !ith ps chosis. &econdar aims !ere to disclose !hether differences e"ist among second-generation antips chotics -&DA. !ith regards to &D.

0/ Materials and Methods

#he materials and methods used have $een descri$ed in more detail in a previous pu$lication [+>]. #he Gergen ps chosis pro;ect -GPP. is a pragmatic, randomiBed trial comparing &DAs in the treatment of ps chosis. #he present stud reports results from the GPP from the time of discharge or 1 !ee5s after admission if not discharged from hospital. #o ensure a clinicall relevant sample, the patient recruitment focused on all patients !ith ps chosis acutel admitted to the emergenc !ard. Patients !ere recruited from 'arch 2>>/ until Ae$ruar 2>>?. All patients !ere recruited from )au5eland Universit )ospital, Division of Ps chiatr , !ith a catchment population of a$out />>,>>>. #he GPP !as approved $ the Negional Committee for 'edical Nesearch *thics, and the Tor!egian &ocial &cience Data &ervices. #he GPP !as pu$licl funded and has not received an financial or other support from the pharmaceutical industr . #he Negional Committee for 'edical Nesearch *thics allo!ed eligi$le patients to $e included $efore informed consent !as provided, thus entailing a clinicall relevant representation in the stud . Patients from +3 to 1, ears of age !ere eligi$le for the stud if the !ere acutel admitted to the emergenc !ard for s mptoms of ps chosis as determined $ a score of 0/ on one or more of the items delusions, hallucinator $ehavior, grandiosit , suspiciousnessIpersecution, or unusual thought content from the Positive and Tegative & ndrome &cale -PAT&&. [++]. *ligi$le patients met the ICD-+> [+2] diagnostic criteria for schiBophrenia, schiBoaffective disorder, acute and transient ps chotic disorder, delusional disorder, drug-induced ps chosis, $ipolar disorder e"cept manic ps chosis, and ma;or depressive disorder !ith ps chotic features. #he diagnoses !ere determined $ the hospital`s ps chiatrists or specialists in clinical ps cholog . Patients !ere e"cluded from the stud if the !ere una$le to use oral antips chotics $ecause a depot formulation !as indicated, !ere suffering from manic ps chosis or for other $ehavioral or mental reasons related to the state of illness !ere una$le to cooperate !ith assessments, did not understand spo5en Tor!egian, !ere candidates for electroconvulsive therap as determined $ the attending ps chiatrists, or !ere medicated !ith cloBapine, usuall regarded as a final resort, on admittance. Patients !ith druginduced ps choses !ere included onl !hen the condition did not resolve !ithin a fe! da s and !hen antips chotic drug therap !as indicated. #he patients !ere rated using the PAT&&, the Calgar Depression &cale for &chiBophrenia -CD&&. [+9], the Clinical Drug and Alcohol Use &cales -CDU&ICAU&. [+/], the Clinical Dlo$al Impressionc&everit of Illness scale -CDI-&. [+,], the Dlo$al Assessment of Aunctioningc&plit Oersion, Aunctions scale -DAA-A. [+1], and a neurocognitive screening test -Nepeata$le Gatter for the Assessment of Teurops chological &tatus -NGAT&.. [+:]. Patients !ere as5ed also to complete the patient-administered version of the UPU &ide *ffect Nating &cale -UPU-&*N& Pat. [+3].

#he items reported here include diminished se"ual desire= erectile d sfunction= and e;aculator d sfunction. #he patient-administered version of the intervie! !as chosen to o$tain more valid results as clinicians often underestimate &D [+?]. #he @uestions as5ed !ere 6have ou e"perienced decreased se"ual interest or decreased se"ual desireY7= 6have ou e"perienced difficult in reaching erectionY7= 6have ou e"perienced difficulties in e;aculationY7 #he patients !ere instructed to report s mptoms that the attri$uted to their prescri$ed medications and use the last !ee5 as the time frame of reference. *ach item !as rated from > -not at all. to 9 !ith increasing severit of the &D s mptom reported. A composite mean &D score !as calculated $ased on the three UPU&*N& Pat items, accepting up to t!o missing values. A $lood sample !as collected from the patients $et!een >3 and +> am, and serum level measurements of prolactin and antips chotics !ere conducted. Drug doses !ere converted to mean Defined Dail Doses -DDDs. as developed $ the Lorld )ealth %rganiBation Colla$orating Centre for Drug &tatistics 'ethodolog [2>]. #he $asic definition of the DDD unit is the assumed average maintenance dose per da for a drug used for its main indication in adults. Aifteen -29.+4. of the prolactin $lood samples !ere anal sed at La$orator A $ means of a noncompetitive immunofluorometric assa -D*LAIA 5it $ Lallac % , #ur5u, Ainland.. Aift -:1.?4. of the samples !ere anal Bed at La$orator G using another immunoassa 5it -Immulite 2>>> $ &iemens 'edical &olutions Diagnostics, Gerlin and 'unich, Derman .. #he cutoff for h perprolactinemia !as set at 91> mIUIL. &creening for macroprolactinemia $ pol eth lengl col -P*D. precipitation !as performed if prolactin levels !ere a$ove +>>> mIUIL at $oth la$oratories to identif cases !ith pseudoh perprolactinemia caused $ the $iologicall inert macroprolactin fraction. &P&& version +3.> !as used for statistical anal ses. 'ean serum prolactin levels at la$oratories A and G !ere compared using an independent samples t-test. Chi s@uare e"act test !as used for categorical data. #o investigate the association $et!een prolactin levels and s mptoms registered on the rating scale, a $ivariate anal sis of correlation !as performed using the &pearman correlation coefficient as normal distri$ution could not $e assumed. &ignificance level !as set at F >.>,.

1/ Results and 'iscussion

1/./ Results
A total of :2 men !ere assessed. A total of 2> patients used risperidone, the corresponding figures !ere for olanBapine 21, @uetiapine ?, Biprasidone +9, and aripipraBole +. #hree patients !ere not prescri$ed antips chotics. #he mean serum levels !ith standard deviations -sd. and reference levels in nanomoles per litre !ere for risperidone :?., -,3.,. -9>8+2>., for olanBapine +>:.9 -:,.3. -9>82>>., for @uetiapine ,22.3 -11>.?. -+>>83>>., for Biprasidone +2?.+ -+>:.2. -9>82>>., and for aripipraBole +/+ --. -2>>8+9>>.. #he mean doses in milligrams !ith sd !ere for risperidone 9.: -+.9., for olanBapine +:.9 -1./., for @uetiapine /::.3 -2>/.3., for Biprasidone ?3.9 -/1.9.= and

for aripipraBole , --.. #here !ere no differences among the groups !ith regards to the use of concomitant medication. #he clinical characteristics and demographics are displa ed in #a$le +. #he ma;orit had a diagnosis of schiBophrenia -,,.14.. A total of 99 -/,.34. patients had not used antips chotic drugs $efore this admittance to hospital. Lith the e"ception of a higher CD&& sum score -1.?., in the risperidone group versus 2.3= 9.?= 9.1= +.>= 9.,, in the olanBapine, @uetiapine, Biprasidone, aripipraBole, and unmedicated groups, respectivel -one-!a anova, P F >.>99., there !ere no statisticall significant differences among the drug groups. A total of /,.?4 of the patients reported diminished se"ual desire, !hereas 9,.?4 and 91.+4 reported erectile and e;aculator d sfunction, respectivel -Aigure +.. #here !ere no differences among the groups, or $et!een the antips chotic nadve patients and those !ith prior antips chotic drug use in this regard. #he mean prolactin level !as 12:.? mIUIL, range ,?.>89>+?.>. #here !as no significant difference among the la$oratories !ith regards to mean prolactin levels -t-testE P F >.2,= mean difference 13.9= ?,4 CI R231.>8/22.1.. #he risperidone group had the highest mean prolactin level -+2,>.3 mIUIL. follo!ed $ olanBapine -/39.> mIUIL., Biprasidone -9:?.1 mIUIL., @uetiapine -291.2 mIUIL., the unmedicated group -+3/.: mIUIL., and aripipraBole -:>.> mIUIL, one-!a anovaE P H >.>>+.. A total of ,1.94 of the patients had h perprolactinemia, and there !ere significant differences among the groups follo!ing the same pattern as for the mean prolactin levels -chis@uareE P H >.>>+.. A total of +3.,4 had prolactin levels a$ove +>3> mIUIL, the proportion $eing ,:.?4 in the risperidone group !ith significant differences among the groups -chis@uareE P H >.>>+.. #here !as no association $et!een prolactin level and the composite &D score -&pearman`s correlation coefficient r F >.+/+= P F >.2?, Aigure 2.. Also, there !as no association $et!een &D and the PAT&& total and su$scale scores= the CD&&, the CDI, the DAA-A, neurocognitive test score, or DDDs of the different drugs. Aor risperidone $ut not the other antips chotics, there !as a significant correlation $et!een serum prolactin level and drug doses of risperidone in DDD e@uivalents -&pearman`s correlation coefficient r F >.,?3= P F >.>++..

Aigure + Distri$ution of se"ual d sfunction.

Aigure 2 &e"ual d sfunction and serum prolactin levels. Totes. 'ean se"ual d sfunction score F Composite mean se"ual d sfunction score calculated $ased on the UPU-&*N& Pat items Diminished se"ual desire= *rectile d sfunction= and *;aculator d sfunction.

#a$le + Clinical and demographic characteristics.

1/0/ 'iscussion
#he sample !as heterogeneous $oth !ith regards to diagnoses and stage of illness and a$out half the sample !as antips chotic drug nadve at admittance !hich most li5el represents patients !ith first-episode ps chosis. #he sample should accordingl $e clinicall relevant. #he main findings of the present stud !ere the ver high rates of &D and h perprolactinemia in patients treated !ith &DAs, and the lac5 of association $et!een the t!o. A$out half the patients reported diminished se"ual desire and more than a third reported erectile and e;aculator d sfunction. #he rate of &D is in correspondence !ith the findings of %lfson et al. [?] in their sample of male outpatients !ith schiBophrenia. #he mean age of the sample !as more than +> ears older than in the GPP sample and seemed to $e selected for the assessment of &D specificall , ma5ing the results of the more diagnosticall and clinicall heterogeneous GPP sample even more startling. &D is perceived $ patients as among the more severe side effects of antips chotics and is associated !ith poor drug adherence [,, 1]. Toncompliance is one leading cause of relapse and rehospitalisation in patients !ith schiBophrenia, the latter representing the largest part of the schiBophrenia treatment costs [2+]. #he proportions !ith &D are accordingl alarmingl high $oth in terms of individual suffering and economic $urden to societ . Lith regards to the secondar aim, no differences among the drug groups !ere found. Go$es et al. [22] found in their sample of 191 schiBophrenia outpatients a lo!er ris5 of &D in @uetiapine, treated patients compared to those treated !ith haloperidol, risperidone, or olanBapine. #he different findings across the studies ma $e related to different samples, treatment settings, or an insufficient sample siBe in the GPP to detect actual differences among the drug groups.

'ore than half the sample !as h perprolactinemic, and a$out one fifth had prolactin levels more than 9 times the upper threshold, none of !hich !ere caused $ the $iologicall inert macroprolactin fraction. #here !ere differences among the drug groups, !ith risperidone-treated patients having the highest prolactin levels and the highest proportions !ith h perprolactinemia. ) perprolactinemia has received ne! attention latel as potential long-term complications have $een pointed to, including osteoporosis and carcinogenic effects [:, 3]. To association !as found in the present stud $et!een prolactin levels and &D. #his is in line !ith previous findings from our research group [29]. In a recent stud in schiBophrenia patients s!itched to a second-generation antips chotic drug, positive correlation $et!een prolactin levels and diminished se"ual desire !as found for men [2/]. Ta5oneBn et al. [2,] found an association $et!een serum prolactin level and &D for prolactin $ut not @uetiapine in their 1-!ee5 randomiBed trial. G erl et al. [:] report differing results among different studies regarding relationship $et!een prolactin levels and &D in men, as onl a$out half the studies revie!ed found support for such a relationship. Data on &D in first-episode ps chosis has $een pu$lished from the *UA*&# stud , indicating influence from the ps chotic disorder itself as !ell as from prolactin on at least some aspects of &D [21]. #he primar strengths of the present stud are the clinicall relevant sample of consecutivel recruited male ps chotic patients, and the ver comprehensive characterisation of the sample. #he measurement of serum levels of the antips chotics used adds special value to the stud too. &ome limitations should $e mentioned, ho!ever. #he cross-sectional design does not allo! for anal ses of causalit . #he sample siBe ma have $een too small to detect actual associations. Le do not $elieve this to $e the case, ho!ever, as significant correlations $et!een h perprolactinemia and &D !ere disclosed in even smaller samples of schiBophrenia patients in the revie! $ G erl et al. [:]. Le h pothesise that in a heterogeneous sample such as the GPP sample, the prolactin contri$ution is $lurred among several other causes of &D.

2/ onclusions
Goth &D and h perprolactinemia !ere ver prevalent in this sample of male ps chotic patients. Gased on our findings, the phenomena should $e regarded as relativel independent entities !ith regards to planning appropriate actions. In some instances, reduction of the prolactin level ma also resolve &D, !hereas in other cases this ma not suffice. Ainall , prolactin levels should $e measured irrespective of !hether s mptoms of &D are present or not to avoid potential long-term complications of 6silent7 h perprolactinemia.

Acknowledgments
Aunding of the pro;ect !as initiated $ the Nesearch Council of Tor!a , follo!ed $ the Lestern Tor!a Negional )ealth Authorit , and )au5eland Universit )ospital,

)au5eland Universit )ospital, Division of Ps chiatr . #he supporters had no role in the design and conduct of the stud = collection, management, anal sis, and interpretation of the data= or preparation, revie!, or approval of the manuscript. *. <ohnsen has received honoraria for lectures given in meetings arranged $ Gristol-' ers &@ui$$, *li Lill , and Astra\eneca, and for a contri$ution to an information $rochure $ *li Lill . *. <ohnsen has $een reim$ursed $ the *li Lill Compan and the <anssen Cilag Compan for attending conferences. N. Pro5en has $een reim$ursed $ the *li Lill Compan , <anssen Cilag Compan , Gristol-' ers &@ui$$, and Astra\eneca for attending conferences. *. '. Lb$erg has no competing interests to declare. *. P;el$ has $een reim$ursed $ Gristol' ers &@ui$$, Tovartis, Lund$ec5, *li Lill , and Astra\eneca pharmaceutical companies for attending conferences. ). A. <brgensen has received honoraria for lectures given in meetings arranged $ Astra\eneca and *li Lill .

Article information
Adv Urol. 2>++= 2>++E 131?2/. Pu$lished online 2>++ Tovem$er 9>. doiE +>.++,,I2>++I131?2/ P'CIDE P'C929,/?9 *ri5 <ohnsen, +, 2 e Nune Pro5en, + *lse-'arie Lb$erg, +, 9 *iri5 P;el$ , + and )ugo A. <brgensen 2 + Division of Ps chiatr , )au5eland Universit )ospital, &andvi5sleitet +, ,>9, Gergen, Tor!a 2 Department of Clinical 'edicine, Ps chiatr , Universit of Gergen, &andvi5sleitet +, ,>9, Gergen, Tor!a 9 Institute Giological and 'edical Ps cholog , Universit of Gergen, &andvi5sleitet +, ,>9, Gergen, Tor!a e*ri5 <ohnsenE *mailE eri;IatIhelse-$ergen.no Academic *ditorE )ussein Dhanem Neceived <une 2,, 2>++= Accepted &eptem$er +/, 2>++. Cop right W 2>++ *ri5 <ohnsen et al. #his is an open access article distri$uted under the Creative Commons Attri$ution License, !hich permits unrestricted use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from Advances in Urolog are provided here courtes of $indawi #ublishing orporation

References
+. fstgn #G, Nehm <, Chatter;i &, et al. 'ultiple-informant ran5ing of the disa$ling effects of different health conditions in +/ countries. The Lancet. +???=9,/E+++8++,. [Pu$'ed] 2. Per[l[ <, &uvisaari <, &aarni &I, et al. Lifetime prevalence of ps chotic and $ipolar I disorders in a general population. Archives of General Psychiatry. 2>>:=1/E+?823. [Pu$'ed]

9. Leucht &, Corves C, Ar$ter D, *ngel NN, Li C, Davis <'. &econd-generation versus first-generation antips chotic drugs for schiBophreniaE a meta-anal sis. The Lancet. 2>>?=9:9-?1,:.E9+8/+. [Pu$'ed] /. Crossle TA, Constante ', 'cDuire P, Po!er P. *fficac of at pical v. t pical antips chotics in the treatment of earl ps chosisE meta-anal sis. The British ournal of Psychiatry. 2>+>=+?1-1.E/9/8/9?. [P'C free article] [Pu$'ed] ,. Per5ins D%. Predictors of noncompliance in patients !ith schiBophrenia. ournal of Clinical Psychiatry. 2>>2=19-+2.E++2+8++23. [Pu$'ed] 1. Lam$ert ', Conus P, *ide P, et al. Impact of present and past antips chotic side effects on attitude to!ard t pical antips chotic treatment and adherence. !uropean Psychiatry. 2>>/=+?-:.E/+,8/22. [Pu$'ed] :. G erl ', &uppes #, #ran CO, Ga5er NA. Clinical implications of antips choticinduced h perprolactinemia in patients !ith schiBophrenia spectrum or $ipolar spectrum disordersE recent developments and current perspectives. ournal of Clinical Psychophar"acolo#y. 2>>:=2:-1.E19?811+. [Pu$'ed] 3. )addad P', Liec5 A. Antips chotic-induced h perprolactinaemia. 'echanisms, clinical features and management. $ru#s. 2>>/=1/-2>.E22?+829+/. [Pu$'ed] ?. %lfson ', Uttaro #, Carson L), #afesse *. 'ale se"ual d sfunction and @ualit of life in schiBophrenia. ournal of Clinical Psychiatry. 2>>,=11-9.E,9+8,93. [Pu$'ed] +>. <ohnsen *, Pro5en NA, LentBel-Larsen #, <brgensen )A. *ffectiveness of secondgeneration antips choticsE a naturalistic, randomiBed comparison of olanBapine, @uetiapine, risperidone, and Biprasidone. BMC Psychiatry. 2>+>=+>, article 21 [P'C free article] [Pu$'ed] ++. Pa &N, AisB$ein A, %pler LA. #he positive and negative s ndrome scale -PAT&&. for schiBophrenia. %chi&ophrenia Bulletin. +?3:=+9-2.E21+82:1. [Pu$'ed] +2. Lorld )ealth %rganiBation. International statistical classification of diseases and related health pro$lems. +>th Nevision, version for 2>>:. Lorld )ealth %rganiBationIDerman Institute of 'edical Documentation and Information, +??/82>>1 httpEII!!!.!ho.intIclassificationsIappsIicdIicd+>onlineI +9. Addington D, Addington <, &chissel G. A depression rating scale for schiBophrenics. %chi&ophrenia Research. +??>=9-/.E2/:82,+. [Pu$'ed] +/. Dra5e N*, Nosen$erg &D, 'ueser P#. Assessing su$stance use disorder in persons !ith severe mental illness. 'e( $irections for Mental )ealth %ervices. +??1=-:>.E98+:. [Pu$'ed] +,. Du L. !$$!* Assess"ent Manual for Psychophar"acolo#y + Revisited ,$))% pu-l '. A$M /0+1123 Noc5ville, 'd, U&AE U& Department of )ealth and )uman &ervices= +?:1. +1. Parterud &, Pedersen D, Loevdahl ), Ariis &. Glo-al Assess"ent of 4unctionin#5 %plit 6ersion ,%7GA438 Bac9#round and %corin# Manual. %slo, Tor!a E Ullevaal Universit )ospital, Department of Ps chiatr = +??3. +:. Nandolph C, #ierne 'C, 'ohr *, Chase #T. #he Nepeata$le Gatter for the Assessment of Teurops chological &tatus -NGAT&.E preliminar clinical validit . ournal of Clinical and !:peri"ental 'europsycholo#y. +??3=2>-9.E9+>89+?. [Pu$'ed] +3. LindstrZm *, Le!ander #, 'alm U, 'alt UA, Lu$lin ), Ahlfors UD. Patient-rated versus clinician-rated side effects of drug treatment in schiBophrenia. Clinical validation

of a self-rating version of the UPU &ide *ffect Nating &cale -UPU-&*N&-Pat. 'ordic ournal of Psychiatry; %upple"ent. 2>>+=,,-supplement //.E,81?. [Pu$'ed] +?. Dossen$ach ', )odge A, Anders ', et al. Prevalence of se"ual d sfunction in patients !ith schiBophreniaE international variation and underestimation. International ournal of 'europsychophar"acolo#y. 2>>,=3-2.E+?,82>+. [Pu$'ed] 2>. Nonning '. #he L)% colla$orating centre for drug statistics methodolog . *sta$lished +?32 httpEII!!!.!hocc.noIatcdddI 2+. %$radovic ', 'rhar A, Pos '. Cost-effectiveness of antips chotics for outpatients !ith chronic schiBophrenia. International ournal of Clinical Practice. 2>>:=1+-+2.E+?:?8+?33. [Pu$'ed] 22. Go$es <, Darcha-Portilla 'P, Ne;as <, et al. Are@uenc of se"ual d sfunction and other reproductive side-effects in patients !ith schiBophrenia treated !ith risperidone, olanBapine, @uetiapine, or haloperidolE the results of the *IN* stud . ournal of %e: and Marital Therapy. 2>>9=2?-2.E+2,8+/:. [Pu$'ed] 29. <ohnsen *, Pro5en NA, A$aBa ', %l$erg ), <brgensen )A. Antips chotic-induced h perprolactinemiaE a cross-sectional surve . ournal of Clinical Psychophar"acolo#y. 2>>3=23-1.E13181?>. [Pu$'ed] 2/. Netten$acher 'A, )ofer A, *$en$ichler C, et al. Prolactin levels and se"ual adverse effects in patients !ith schiBophrenia during antips chotic treatment. ournal of Clinical Psychophar"acolo#y. 2>+>=9>-1.E:++8:+,. [Pu$'ed] 2,. Ta5oneBn PA, G erl '<, Nush A<. #he relationship $et!een serum prolactin level and se"ual functioning among male outpatients !ith schiBophrenia or schiBoaffective disorderE a randomiBed dou$le-$lind trial of risperidone vs. @uetiapine. ournal of %e: and Marital Therapy. 2>>:=99-9.E2>982+1. [Pu$'ed] 21. 'ali5 P, Pemmler D, )ummer ', Niecher-Noessler A, Pahn N&, Aleischhac5er LL. &D in first-episode schiBophrenia patients. Nesults from *uropeand Airst *pisode &chiBophrenia #rial. ournal of Clinical Psychophar"acolo#y. 2>++=9+E2:/823>. [Pu$'ed]

<ournal of Ps chiatr ] Teuroscience E <PT Canadian 'edical Association

#sychopharmacology for the linician

&a5ina <. NiBvi, PhD -candidate. and &idne ). Penned , 'D Additional article information

Management strategies for %%R"-induced sexual dysfunction

A /,- ear old !oman !ith ma;or depressive disorder -'DD. and comor$id generaliBed an"iet disorder -DAD. reported a decrease in li$ido since her last depressive episode a$out 9 ears ago. Despite $eing in remission for the last ear and ta5ing a 1> mg dose of paro"etine, she reported an overall decrease in se"ual interest and activit . &e"ual d sfunction occurs through several $rain path!a s involving increases in serotonin -,-)#., decreases in dopamine -DA. and inhi$ition of nitric o"ide s nthase.+ Increases in cortico-lim$ic ,-)# result in decreased se"ual desire, e;aculation and orgasm.2 Conse@uentl , it is not surprising that selective serotonin reupta5e inhi$itor -&&NI.-induced se"ual d sfunction occurs in 9>483>4 of patients9,/ and is a main cause of treatment discontinuation.,,1 #herefore, it is important to use strategies to alleviate treatment-emergent se"ual d sfunction. #he 5e to addressing se"ual impairment is to s stematicall assess the domains of se"ual function. #here are several validated se"ual side effect scales availa$le to clinicians.:8? #he patient !e descri$e received a score of , of // on the &e" *ffects &cale? -&e"AK= a high score is good., as paro"etine is 5no!n for its adverse effects on se"ual function -Go" +.. Pharmacologic methods to reduce se"ual d sfunction involve dose reduction, augmentation, or s!itching medication. &ince dose reduction is the least disruptive strateg it should $e considered first, particularl in a responder. Lhen our patient(s dose !as reduced to /> mg, she remained in remission !ith reduced $ut persisting se"ual d sfunction, particularl anorgasmia.

Box .
*re3uency of sexual dysfunction with antidepressant treatment 4 5 .67 Agomelatine Gupropion 'irtaBapine 'oclo$emide Ne$o"etine
e

.678167 9 167 Citalopram Aluo"etine Dulo"etine Aluvo"amine *scitalopram Paro"etine Oenlafa"ine &ertraline 'ilnacipran

'odified !ith permission.+>

Altering ,-)# receptor antagonism and agonism can have favoura$le se"ual effects, $ut ma cause other adverse events. 'irtaBapine antagoniBes ,-)#2 and ,-)#9 receptors and it has $een successfull used as an add-on therap for antidepressant-induced se"ual d sfunction, al$eit !ith a relativel high rate of !eight gain.++,+2 In addition, c proheptidine, a ,-)#2A antagonist, has $een found to relieve &&NI-induced anorgasmia,+9,+/ $ut its use is limited $ sedation. Guspirone, a ,-)#+A agonist, ma also alleviate &&NI-induced se"ual d sfunction.+, %ur patient !as started on a +, mg dose of mirtaBapine, $ut it !as discontinued o!ing to da time sedation.

&ildenafil and tadalafil are phospho-diesterase inhi$itors that increase nitric o"ide, !hich in turn, helps to increase $lood flo! to genetalia. #he have $oth demonstrated evidence for the reversal of &&NI-induced se"ual side effects in men.+18+? #here is onl preliminar evidence that these drugs improve se"ual adverse events in !omen,2>,2+ and neither !as prescri$ed to our patient. *vidence also suggests that DA release enhances se"ual function.+ #he strongest evidence supports +,>89>> mg of ad;unctive $upropion KL for reversing &&NI-induced se"ual d sfunction in men and !omen across the domains of desire, arousal and orgasm.22,29 #hese $enefits occur irrespective of the &&NI used or duration of se"ual d sfunction.2/ #here is also evidence to support drugs that have more pronounced effects on DA, including meth lphenidate, de"troamphetamine, pramipe"ole or ropinerole.2,82: )o!ever, caution should $e e"ercised !hen using DA agonists, given reports of h perse"ualit associated !ith pramipe"ole.23 %ur patient(s regimen !as augmented !ith +,> mgIda of $upropion KL, ta5en in the morning. &he reported improved arousal and lu$rication after 1 !ee5s, and her overall &e"AK score improved to +9 -moderate impairment.. &everal antidepressants, including $upropion, moclo$emide, mirtaBapine, agomelatine and vilaBodone,9,2? have little to no effect on se"ual function compared !ith place$o !hen used as a monotherap . %ur patient(s paro"etine !as discontinued and the $upropion !as increased to +,> mg t!ice dail . #his s!itch resulted in a return to normal se"ual function -&e"AK 2?. over the course of / !ee5s. At 9 months, she !as still in remission. Aor patients reluctant to add another medication to their regimen, nonpharmacotherapeutic options ma $e useful. *vidence suggests e"ercise can improve se"ual function. A trial involving !omen treated !ith &&NIs found that e"ercise $efore vie!ing se"ual stimuli significantl increased arousal.9> %pen-la$el trials have suggested oga improves se"ual function.9+,92 #here is little support for neutraceuticals alleviating &&NI-induced se"ual d sfunction.9989, In summar , pharmacologic methods have the strongest support in alleviating &&NIinduced se"ual d sfunction. %f the augmentation strategies, $upropion has the most support in terms of efficac and tolera$ilit . #here are several possi$le treatment strategiesE reduce antidepressant dose, augment !ith an antidote, or s!itch medication. )o!ever, it is $etter to ta5e the importance of se"ual side effects into consideration !hen prescri$ing an initial antidepressant. It is also important to @uer se"ual adverse events specificall to ensure that side effects are mitigated and to avoid treatment discontinuation.

*ootnotes
#he information in this column is not intended as a definitive treatment strateg $ut as a suggested approach for clinicians treating patients !ith similar histories. Individual cases ma var and should $e evaluated carefull $efore treatment is provided. #he patient descri$ed in this column is a composite !ith characteristics of several real patients.

Ps chopharmacolog for the Clinician columns are usuall $ased on a case report that illustrates a point of interest in clinical ps chopharmacolog . #he are a$out 1,> !ords long. ompeting interests: &.<. NiBvi has received pa ment for travel e"penses and course registration from &t. <ude 'edical and *li Lill . &.). Penned is on the $oards of Lund$ec5, PfiBer, &ervier, and &t. <ude 'edical and has consulted for Astra \eneca, *li Lill , <anssen, Lund$ec5, PfiBer, &ervier and &t. <ude 'edical.

Article information
< Ps chiatr Teurosci. 2>+9 &eptem$er= 93-,.E *2:8*23. doiE +>.+,>9I;pn.+9>>:1 P'CIDE P'C9:,1+2> &a5ina <. NiBvi, PhD -candidate. Departments of Pharmaceutical &ciences and Teuroscience, Universit of #oronto, Department of Ps chiatr , Universit )ealth Tet!or5, #oronto, %nt., Canada &idne ). Penned , 'D Department of Ps chiatr , Universit )ealth Tet!or5, Department of Ps chiatr , Universit of #oronto, #oronto, %nt., Canada Cop right W 2>+9 Canadian 'edical Association Articles from <ournal of Ps chiatr ] Teuroscience E <PT are provided here courtes of anadian Medical Association

References
+. Peltner TL, 'cAfee P', #a lor CL. 'echanisms and treatments of &&NI-induced se"ual d sfunction. Perspect Ps chiatr Care. 2>>2=93E+++81. [Pu$'ed] 2. 'onte;o AL, Llorca D, IB@uierdo <, et al. Incidence of se"ual d sfunction associated !ith antidepressant agentsE a prospective multicenter stud of +>22 outpatients. < Clin Ps chiatr . 2>>+=12E+>82+. [Pu$'ed] 9. &erretti A, Chiesa A. #reatment-emergent se"ual d sfunction related to antidepressantsE a meta-anal sis. < Clin Ps chopharmacol. 2>>?=2?E2,?811. [Pu$'ed] /. Penned &), NiBvi &. &e"ual d sfunction, depression, and the impact of antidepressants. < Clin Ps chopharmacol. 2>>?=2?E+,:81/. [Pu$'ed] ,. Gull &A, )un5eler *', Lee <Y. Discontinuing or s!itching serotonin reupta5e inhi$itors. Ann Pharmacother. 2>>2=91E,:383/. [Pu$'ed] 1. )u K), Gull &A, )un5eler *'. Incidence and duration of side effects and those rated as $othersome !ith selective serotonin reupta5e inhi$itor treatment for depressionE patient report versus ph sician estimate. < Clin Ps chiatr . 2>>/=1,E?,?81,. [Pu$'ed] :. 'cDahue CA, Delen$erg A<, Lau5es CA, et al. #he AriBona &e"ual *"perience &caleE relia$ilit and validit . < &e" 'arital #her. 2>>>=21E2,8/>. [Pu$'ed] 3. Cla ton A), 'cDarve *L, Clavet D<. #he Changes in &e"ual Aunctioning Cuestionnaire -C&AC.E development, relia$ilit , and validit . Ps chopharmacol Gull. +??:=99E:9+8/,. [Pu$'ed]

?. Penned &), NiBvi &<, Aulton P. #he se" effects scaleE pilot validation in a health population. Ps chopharmacol Gull. 2>+>=/9E+,82,. [Pu$'ed] +>. Penned &), Lam NL, Tutt D<, et al. #reating depression effectivel . Oalle &tream, TYE 'artin DunitB= 2>>:. ++. Atmaca ', Por5maB &, #opuB ', et al. 'irtaBapine augmentation for selective serotonin reupta5e inhi$itor-induced se"ual d sfunctionE a retropective investigation. Ps chiatr Investig. 2>++=3E,,8:. [P'C free article] [Pu$'ed] +2. Navindran LT, *isfeld G&, Penned &). Com$ining mirtaBapine and dulo"etine in treatment-resistant depression improves outcomes and se"ual function. < Clin Ps chopharmacol. 2>>3$=23E+>:83. [Pu$'ed] +9. AiBen$erg D, \emishlan \, LeiBman A. C proheptadine treatment of se"ual d sfunction induced serotonin reupta5e inhi$itors. Clin Teuropharmacol. +??,=/E92>8/. [Pu$'ed] +/. Lauerma ). &uccessful treatment of citalopram-induced anorgasmia $ c proheptadine. Acta Ps chiatr &cand. +??1=?9E1?8:>. [Pu$'ed] +,. Landin ', *ri5sson *, Agren ), et al. *ffect of $uspirone on se"ual d sfunction in depressed patients treated !ith selective serotonin reupta5e inhi$itors. < Clin Ps chopharmacol. +???=+?E2138:+. [Pu$'ed] +1. Aava ', Turn$erg )D, &eidman &T, et al. *fficac and safet of sildenafil in men !ith serotonergic antidepressant-associated erectile d sfunctionE results from a randomiBed, dou$le-$lind, place$o-controlled trial. < Clin Ps chiatr . 2>>1=1:E2/>81. [Pu$'ed] +:. Turn$erg )D, )ensle PL. &ildenafil citrate for the management of antidepressantassociated erectile d sfunction. < Clin Ps chiatr . 2>>9=1/-&uppl +>.E2>8,. [Pu$'ed] +3. *vli aoglu Y, Yelsel P, Po$aner ', et al. *fficac and tolera$ilit of tadalafil for treatment of erectile d sfunction in men ta5ing serotonin reupta5e inhi$itors. Urolog . 2>++=::E++9:8/+. [Pu$'ed] +?. &egraves N#, Lee <, &tevenson N, et al. #adalafil for treatment of erectile d sfunction in men on antidepressants. < Clin Ps chopharmacol. 2>>:=2:E1281. [Pu$'ed] 2>. Turn$erg )D, )ensle PL, )eiman <N, et al. &ildenafil treatment of !omen !ith antidepressant-associated se"ual d sfunctionE a randomiBed controlled trial. <A'A. 2>>3=9>>E9?,8/>/. [Pu$'ed] 2+. Ashton AP, Leinstein L. #adalafil reversal of se"ual d sfunction caused $ serotonin enhancing medications in !omen. < &e" 'arital #her. 2>>1=92E+89. [Pu$'ed] 22. \isoo5 &, Nush A<, )aight GN, et al. Use of $upropion in com$ination !ith serotonin reupta5e inhi$itors. Giol Ps chiatr . 2>>1=,?E2>98+>. [Pu$'ed] 29. Cla ton A), Larnoc5 <P, Pornstein &D, et al. A place$o-controlled trial of $upropion &N as an antidote for selective serotonin reupta5e inhi$itor-induced se"ual d sfunction. < Clin Ps chiatr . 2>>/=1,E128:. [Pu$'ed] 2/. &afarine;ad 'N. #he effects of the ad;unctive $upropion on male se"ual d sfunction induced $ a selective serotonin reupta5e inhi$itorE a dou$le-$lind place$o-controlled and randomiBed stud . G<U Int. 2>+>=+>1E3/>8:. [Pu$'ed] 2,. Navindran AO, Penned &), %(Donovan 'C, et al. %smotic-release oral s stem meth lphenidate augmentation of antidepressant monotherap in ma;or depressive disorderE results of a dou$le-$lind, randomiBed, place$o-controlled trial. < Clin Ps chiatr . 2>>3a=1?E3:8?/. [Pu$'ed]

21. Galon N, &egraves N#. &urve of treatment practices for se"ual d sfunction-s. associated !ith anti-depressants. < &e" 'arital #her. 2>>3=9/E9,981,. [Pu$'ed] 2:. Lorthington <<, III, &imon T', Por$l TG, et al. An"iet Disorders Nesearch Program. Nopinirole for antidepressant-induced se"ual d sfunction. Int Clin Ps chopharmacol. 2>>2=+:E9>:8+>. [Pu$'ed] 23. Ai5en CG. Pramipe"ole in ps chiatr E a s stematic revie! of the literature. < Clin Ps chiatr . 2>>:=13E+29>81. [Pu$'ed] 2?. Neinhold <A, 'andos LA, Lohoff AL, et al. *vidence for the use of vilaBodone in the treatment of ma;or depressive disorder. *"pert %pin Pharmacother. 2>+2=+9E22+,82/. [Pu$'ed] 9>. LorenB #A, 'eston C'. Acute e"ercise improves ph sical se"ual arousal in !omen ta5ing antidepressants. Ann Gehav 'ed. 2>+2=/9E9,281+. [P'C free article] [Pu$'ed] 9+. Dhi5av O, Parmar5ar D, Dupta N, et al. Yoga in female se"ual functions. < &e" 'ed. 2>+>a=:E?1/8:>. [Pu$'ed] 92. Dhi5av O, Parmar5ar D, Oerma ', et al. Yoga in male se"ual functioningE a noncompararive pilot stud . < &e" 'ed. 2>+>$=:E9/1>81. [Pu$'ed] 99. <aco$sen A'. Aluo"etine-induced se"ual d sfunction and an open trial of ohim$ine. < Clin Ps chiatr . +??2=,9E++?822. [Pu$'ed] 9/. 'ichelson D, Poci$an P, #amura N, et al. 'irtaBapine, ohim$ine or olanBapine augmentation therap for serotonin reupta5e-associated female se"ual d sfunctionE a randomiBed, place$o controlled trial. < Ps chiatr Nes. 2>>2=91E+/:8,2. [Pu$'ed] 9,. Dording C', Aisher L, Papa5ostas D, et al. A dou$le-$lind, randomiBed, pilot dosefinding stud of maca root -L. me enii. for the management of &&NI-induced se"ual d sfunction. CT& Teurosci #her. 2>>3=+/E+328?+. [Pu$'ed]

Indian <ournal of Ps chological 'edicine 'ed5no! Pu$lications

,ature of %exual 'ysfunctions in Ma:or 'epressi+e 'isorder and its "mpact on ;uality of <ife
Na;arshi Duha #ha5urta, %m Pra5ash &ingh, [...], and Nan;an Das Additional article information

Abstract
Background:

Ade@uate se"ual e"pression is an essential part of man human relationships, and ma enhance @ualit of life and provide a sense of ph sical, ps chological, and social !ell$eing. *pidemiological and clinical studies sho! that depression is associated !ith impairments of se"ual function and satisfaction, even in untreated patients. 'ost antidepressant drugs have adverse effects on se"ual function, $ut accurate identification of the incidence of treatment-emergent d sfunction has proved trou$lesome. )o!ever, fe! investigators have reported the $ase rate for distur$ances in se"ual desire, arousal, and orgasm or e;aculation in patients !ith ma;or depressive disorder -'DD. prior to antidepressant treatment. #he purpose of this stud is to define the fre@uenc of se"ual d sfunction -&D. in 1> patients !ith 'DD and e"amine the relationship $et!een &D and @ualit of life en;o ment and satisfaction varia$les.

Materials and Methods:

A consecutive series of 2/ male and 91 female 'DD patients diagnosed $ &CID-D&' IO assessment completed a series of ps chometric measures including a &e"ual Aunction CuestionnairecAriBona &e"ual *"perience &cale -A&*K. !hich as5ed a$out change in se"ual interest and function as !ell as @ualit of life of life en;o ment using CL*&C-&A.

Results:
%ver 99.994 of men and /24 of !omen reported decreased se"ual interest. Neduced levels of arousal !ere more common in $oth men and !omen -3-224. than e;aculator or orgasm difficulties -++8+14.. In !omen, &Ds !ere more than males. Cualit of life !as more impaired in sample !ith &Ds than those !ithout d sfunction sho!ing significant impact of &D on @ualit of life.

<imitation and onclusion:

Although limited $ a relativel small sample of drug-free patients !ith 'DD, and $ the a$sence of a non-depressed comparison sample, these results emphasiBe the importance of factors $e ond specific drug effects in the assessment of &D in drug naivedepressed patients. !eywords: I"pair"ent, "a<or depressive disorder, =uality of life, se:ual dysfunctions

",TR='> T"=,
&e"ual functioning is influenced $ a num$er of factors, mental illness $eing one of them. &e"ual d sfunctions -&Ds. are characteriBed $ distur$ances in se"ual desire and in the ps choph siological changes associated !ith the se"ual response c cle in men and !omen.[+] Using the measure of disa$ilit -ad;usted life ears, it !as determined that unipolar ma;or depression !as the fourth leading cause of disease $urden in the !orld. It !as also

pro;ected that, in the ear 2>2>, unipolar ma;or depression !ould $e the second leading cause of disease $urden in the !orld.[2] 'a;or depressive disorder -'DD. is characteriBed $ loss of interest, reduction in energ , lo!ered self-esteem, ina$ilit to e"perience pleasure, this constellation of s mptoms ma $e e"pected to produce difficult in se"ual relationship. Depressed patients have sho!n &D t!o to three times more than non-depressed individuals.[9] Cualit of Life -C%L. is a multidimensional construct to include su$;ective !ell-$eing and life satisfaction. &u$;ects !ith affective disorders have significant C%L impairment although the degree of d sfunction varies.[/] &D in patients !ith 'DD has mostl $een studied independentl or in gender-specific studies. #hese studies have reported significant d sfunction in different areas of se"ual functioning. )o!ever, a ma;orit of these studies are uncontrolled and provide limited evidence a$out the $aseline rates of d sfunction across 'DD. Aurthermore, patients in affective disorders are usuall prescri$ed antidepressant medications, !hich are 5no!n to cause su$stantial &D. &impl e"emplif ing the d sfunction caused $ medications is imperfect unless the d sfunction caused $ the disease is clearl demarcated. &D and C%L in 'DD have mostl $een studied independentl or in gender-specific studies. 'ost studies have highlighted the role of drugs used in the class of affective disorders !hich cause su$stantial &Ds.[,] In India, most of the studies have focused on male &D, ver fe! have voiced the female &D.[1] #hus, limited data e"ist on &D and C%L in 'DD in Indian Literature in rural or ur$an settings. #he aim of the present stud !as to assess the se"ual functioning in drug-free 'DD su$;ects and to investigate the association !ith C%L domains.

MAT)R"A<% A,' M)T$='%

#he present stud !as a single center, cross-sectional, single intervie! stud that !as approved $ the institutional ethics $oard. All the first-time registered patients !ere screened !ith the Ps chiatric Diagnostic &creening Cuestionnaire -PD&C..[:] &u$;ects of either se" aged $et!een +3 and 1, ears fulfilling the criteria for 'DD !ere included. All su$;ects !ere intervie!ed $ using the &tructured Clinical Intervie! for D&'-IO-#N A"is I Disorders, Ne-search Oersion, Patient *dition -&CID-IIP. and &tructured Clinical Intervie! for D&'-IO A"is II Personalit Disorders -&CID-II..[3] A detailed histor !as o$tained and a ph sical e"amination, consultation liaison -!hen re@uired., and la$orator investigations -!here indicated. !ere performed to rule out an ph sical comor$idit .

#he selected cases fulfilling the selection criteria for 'DD !ere rated for severit of illness !ith the +:-item )amilton Nating &cale for Depression -)A'-D..[?] &e"ual e"perience of su$;ects !as assessed $ using the AriBona &e"ual *"perience &cale -A&*K.,[+>] a self-rated instrument for $oth genders. #he A&*K rates se"ual e"perience in the areas of desire, e"citement, penile erectionIvaginal lu$rication, orgasm, and satisfaction from orgasm on a scale of + to 1. &D is defined as having either a score of , or more on an item or a total score of +? or more. #he patients !ere then evaluated for impairment in C%L using C%L *n;o ment and &atisfaction Cuestionnaire-&hort Aorm -CL*&-C-&A..[++] )igher scores on the CL*&-C are indicative of greater en;o ment or satisfaction. &coring on all scales !ere administered $ a ps chiatrist and recorded. After screening +>/ su$;ects, 1> su$;ects !ere included on giving !ritten consent. #he e"clusion criteria for all su$;ects included having comor$id A"is I and A"is II disorders -e"cluding to$acco dependence. on &CID-IIP and &CID-II= ps chotic s mptoms= histor of &D prior to present episode of illness= endocrinal disorders -th roid d sfunctions, dia$etes.= local genital pro$lems -vaginitis, pelvic infections.= h pogonadism= cardiovascular disorders -angina, m ocardial infarction.= renal d sfunctions= neurologic disorders -stro5e, spinal cord lesions, pelvic autonomic neuropath .= inta5e of an ps chiatric medication in last + month= and pelvic and a$dominal surgeries in past, 5no!n to $e causing &Ds -oophorectom , operations for prolapse.. #he su$;ects !ere e"cluded if an of the a$ove-mentioned ph sical disorders !ere present in last 9 months. #he data !as pooled and statistical anal sis !as done using &P&& version 2> -&P&& Inc., Chicago, ILL.. Chi s@uare tests, t!o sample t-tests, and correlation anal sis using Pearson`s correlation !ere performed !here necessar . In all these anal ses, t!o-tailed level of significance !as set at PH>.>, and confidence interval -CI. at ?,4.

R)%><T%
#a$le + descri$es the demographic and clinical characteristics of the su$;ects participating in the stud . #he overall sample -nF1>. had a meanS&D age of 93.>S+>.,9 ears. 1>4 of the su$;ects !ere female -nF91.. 'ost of the su$;ects !ere from a rural $ac5ground -nF/3., !hile 2>4 !ere from ur$an areas. 33.94 of the su$;ects !ere married. #he meanS&D of duration of illness !as +/.21S3.2, months.

#a$le + &ocio-demographic characteristics of the sample %n rating for severit of depression, the overall sample had )A'-D meanS&D +?.9,S9.?1, !ith higher mean scores on )A'-D for females +?.?:S/.+>. Aigure + depicts the distri$ution of severit across either gender, 2?., 4 of male su$;ects -nF:. had moderate depression !hile 9:.,4 of them had severe depression. )o!ever, in female su$;ects, severe and ver severe depression !as rated in 99.94 of su$;ects -nF+2. in each categor .

Aigure + Depicts the gender-!ise distri$ution of severit of )am-D scores &D !as reported in :+.114 of the su$;ects -nF/9.. #a$le 2 depicts the gender !ise distri$ution of &D across all the domains. In males, total d sfunction !as present in 11.1:4 of the su$;ects, lo! desire 99.994 -nF3. !as most fre@uentl reported follo!ed $ difficult in sustaining penile erection -nF:, 22.294.. Arousal and e"citement pro$lems !ere less reported. #he meanS&D A&*K scores in males !as +3.:+S9.1:.

#a$le 2 Depicts distri$ution of A&*K severit scores among su$;ects Aemales reported higher rates of d sfunction spanning all domains !ith total d sfunction in :,4 -nF2:. of su$;ects. Aigure 2 depicts the gender !ise and domain !ise distri$ution of &D. In female su$;ects, lo! desire /+.1:4 -nF+,. !as the most common reported

a$normalit follo!ed $ arousal and e"citement pro$lems 22.24 -nF3.. #he meanS&D A&*K scores in females !as +3.:3S9.+2.

Aigure 2 Depicts the gender-!ise distri$ution of se"ual d sfunction on A&*K items #he overall sample had d sfunctions in the domains of desire 93.994 follo!ed $ d sfunctions in penile erectionIvaginal lu$rication 29.94. #o stud the impact of depression on &D, a t!o sample t-test !as done -tF+/.+2, PF>.>>>. sho!ing that mean )A'-D scores !ere significantl higher in the &D group. Aigure 9 sho!s the relationship $et!een mean )A'-D and A&*K scores. %n correlation anal sis, )A'-D scores correlated significantl !ith all A&*K items e"cept erectionIlu$rication -rF>.+,, PF>.2,:.. #otal )A'-D scores correlated positivel !ith total A&*K scores significantl -rF>.3+:, PH>.>>>..

Aigure 9 Nepresents the relationship $et!een mean )A'-D and A&*K -total. scores #o stud the relationship of &D on C%L ra! scores on CL*&-C-&A !ere converted to 4 ma"imum scores. &u$;ects !ithout d sfunction had meanS&D -1,.2/S?.?>. compared to su$;ects !ith &D -9>.19S1.13. the difference $eing statisticall significant -t F -+9.21,, dfF22.>, PH>.>>+.. #he mean differences on all items of CL*&C-&A !ere significant statisticall in $et!een the groups, helping in assessing the impact of &D on all domains of C%L. A correlation matri" $et!een )A'-D, A&*K -#%#AL., all items of CL*&-C, and total CL*&-C-&A revealed total score on )A'-D correlated positivel and significantl !ith duration of illness -rF>.,:?, PH>.>>+., total A&*K scores -rF>.3+:, PH>.>>>., negativel !ith all domains of C%L scale and total scores -rFR>.3/?, PH>.>>+.. &imilarl as depicted in #a$le 9, total A&*K scores correlated negativel !ith all items on CL*&-C-&A and total score -rFR>.:,2, PH>.>>+..

#a$le 9 &ho!s the correlation matri" $et!een the varia$les #he scatter plot in Aigure / sho!s the association $et!een A&*K scores and CL*&-C-&A -4ma"imum..

Aigure / &ho!s the scatter plot $et!een A&*K and 4 ma"imum score CL*&-C

'"% >%%"=,
#he present stud aimed to assess the prevalence of &Ds in drug-free depressed patients and to evaluate its impact on C%L. #he results from the present stud indicate high rates of &D in 'DD patients, :+.114 !hich is compara$le to the results of Casper et al.[+2] !ho found in +92 patients !ith depressive disorders, loss of se"ual interest, characteriBed $ loss of li$ido, or decrease of se"ual desire or potenc , !as reported $ :24 of patients !ith unipolar depression.[+2] %ur findings are compara$le to Pendur5ar and Paur[+9] !ho in ,> drug naive-depressed patients from India reported :14 $aseline rates of &D. #he prospective \urich cohort stud sho!s that the prevalence of se"ual pro$lems in depressed su$;ects -including those !ith ma;or depression, d sth mia, and recurrent $rief depression. is appro"imatel t!ice that in controls -,>4 versus 2/4.. #his difference encompassed emotional pro$lems, &D, and $oth decreased and increased li$ido. #he data in this stud are from a group of oung people -23-9, ears. and ma not $e applica$le to older age groups.[+/] Lo! se"ual desire has fre@uentl $een reported !ith 'DD as it !as reported !ith the highest mean score in this stud !ith 99.94 males and /+.1:4 females reporting d sfunctions in the area of desire !hich is compara$le !ith the findings of Penned et al. [+,] !ho assessed &D in a depressed sample of 1: men and +>2 !omen !ho either had never ta5en antidepressant medication or had $een antidepressant free for at least 2 !ee5s -, !ee5s if the had $een ta5ing fluo"etine.. #he found that /24 of men and ,>4 of !omen reported a decrease in se"ual drive, 914 of men and 934 of !omen had a

decreased interest in se"uall e"plicit material, and /24 of men and 9,4 of !omen had a reduction in fantasiBing a$out se". In female su$;ects, 22.24 reported d sfunction in arousal !hich !as compara$le to previous self-reported measures in arousal in ?+/ !omen and found that arousal !as significantl lo!er in !omen !ith recurrent 'DD compared to !omen !ith no histor of depressive disorder, even !hen controlling for current depression scores, ps chotropic medication use, and comor$id an"iet or su$stance a$use.[+1] Difficult in erection !as the second most common d sfunction in males. 2?.+14 preceeded $ desire pro$lems in this stud !hich is compara$le to the findings of Pendur5ar[+9] !ho reported 924 d sfunction in the domains of erection using the same rating instrument in Indian population. A stud $ Penned and co-!or5ers sho!ed similar rates of d sfunction !ith erection difficulties in 9/4 of male su$;ects.[+1] %rgasmic d sfunctions !ere comparativel lo!er in this stud population $ut corro$orated !ith the findings of Penned and co!or5ers !ho found that 224 of depressed men reported dela ed e;aculation and +24 had difficult !ith premature e;aculation !hile +,4 of depressed !omen reported difficult in attaining orgasm. Comparing our results !ith that of Pendur5ar et al.[+9] !e reported lo!er rates of d sfunction in males -:/4 vs 11.:4. and compara$le rates in female su$;ects -:34 vs :,4., !hich could $e due to the higher male representation in the previous studies. #he most important finding of this cross-sectional stud is the strong correlation $et!een )A'-D scores and all individual items of A&*K scale !hich is not compara$le to results previousl documented.[+:] #his stud found a significant correlation $et!een A&*K and CL*&C-&A in all domains !hich !ere negativel correlated, @uantif ing the strength of impairment in all domains of C%L, en;o ment, and satisfaction. #he strong negative association $et!een severit of depression and C%L domains are consistent !ith previous !or5 demonstrating a monotonic gradient $et!een 'DD and C%L.[+3] #he finding that su$;ects !ith &D have statisticall significant impairment in all domains of C%L compared to su$;ects !ithout se"ual complaints suggests it is li5el that depressive s mptoms and se"ual pro$lems are lin5ed in a c clic fashion !ith one contri$uting to the other. Concerning &D alone, there is little agreement a$out its causes, e"cept that it is multipl determined, and that the relationships $et!een &D and mood are 6comple" and multidirectional.7[+?82+] #here are certain inherent limitations !ith this stud , firstl the a$sence of a control health group, secondl the small sample siBe, and thirdl the cross-sectional nature of this stud limits the possi$ilit to e"plore the cause and effect relationship $et!een &D

and ps chiatric diagnosis. Lastl , since the data !ere collected from a specific population, the degree to !hich the represent the general population cannot $e commented upon. #he ro$ust nature of this stud lies in documenting the $aseline prevalence and t pes of &Ds in $oth genders in 'DD !ithout highlighting the role of medication-induced d sfunctions. Also $ e"cluding su$;ects !ith onset of &D prior to current episode and those !ith 5no!n ph sical conditions 5no!n to cause &Ds an attempt !as made to o$tain more unam$iguous data.

=, <>%"=,
#his stud highlights the high rates of se"ual d sfunctions in drug-free outpatients of 'DD, involving all phases of se"ual c cle !ith females having greater d sfunction rates. #he greater impairment in @ualit of life in su$;ects !ith se"ual d sfunction suggests that although various factors contri$ute to se"ual d sfunctions, earl recognition of se"ual d sfunctions and appropriate treatment of depressed patients !ith se"ual complaints !ill prevent progression from milder to more severe disorders. 'oreover, earl recognition of &D !ill lead to $etter choice of antidepressant medication and treatment plan !ith a favora$le side effect profile and use of pharmacologic antidotes !herever necessar to improve the overall @ualit of life in 'DD.

*ootnotes
%ource of %upport: Til onflict of "nterest: Tone.

Article information
Indian < Ps chol 'ed. 2>+2 %ct-Dec= 9/-/.E 91,89:>. doiE +>./+>9I>2,9-:+:1.+>3222 P'CIDE P'C9112+9, Na;arshi Duha #ha5urta, %m Pra5ash &ingh,+ Amit Ghattachar a, Asim Pumar 'allic5, Paramita Na , &re ashi &en,2 and Nan;an Das Department of Ps chiatr , G'C), Pol5ata, Lest Gengal, India + Department of Ps chiatr , TN& 'edical College and )ospital, Pol5ata, Lest Gengal, India 2 Department of Ps chiatr , Anaesthesiolog , IPD'*N )ospital, Pol5ata, Lest Gengal, India Address for correspondence: Dr. %m Pra5ash &ingh, Department of Ps chiatr , TN& 'edical College, Pol5ata - :>> >+/, Lest Gengal, India. *-mailE hodps $mcIatIgmail.com Cop right E W Indian <ournal of Ps chological 'edicine

#his is an open-access article distri$uted under the terms of the Creative Commons Attri$ution-Toncommercial-&hare Ali5e 9.> Unported, !hich permits unrestricted use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from Indian <ournal of Ps chological 'edicine are provided here courtes of Medknow #ublications

R)*)R), )%
+. Laumann *%, Par5 A, Nosen NC. &e"ual d sfunction in the United &tatesE Prevalence and predictors. <A'A. +???=23+E,9:8//. [Pu$'ed] 2. 'urra C<, LopeB AD. Goston, 'AE )arvard Universit Press= +??1. #he glo$al $urden of disease and glo$al health statistics. 9. Gald!in D&. Depression and se"ual function. < Ps chopharmacol. +??1=+>-&uppl +.E&9>8/. /. Napaport '), Clar C, Aa ad N, *ndicott <. Cualit -of-life impairment in depressive and an"iet disorders. Am < Ps chiatr . 2>>,=+12E++:+83. [Pu$'ed] ,. Galon N. 'ood, an"iet , and ph sical illnessE God and mind, or mind and $od Y Depress An"iet . 2>>1=29E9::83:. [Pu$'ed] 1. Pra5ash %, Nao #&. &e"ualit research in India. Indian < Ps chiatr . 2>+>=,2-&uppl +.E&21>89. [P'C free article] [Pu$'ed] :. \immerman ', 'attia <I. A self-report scale to help ma5e ps chiatric diagnosesE #he ps chiatric diagnostic screening @uestionnaire. Arch Den Ps chiatr . 2>>+=,3E:3:8?/. [Pu$'ed] 3. /th ed. Lashington, DCE American Ps chiatric Association= +??/. American Ps chiatric Association. Diagnostic and &tatistical 'anual of 'ental Disorders= pp. /?98 ,22. ?. )amilton '. A Nating scale for Depression. < Teurol Teurosug. +?1>=29E,181+. [P'C free article] [Pu$'ed] +>. 'cDahue CA, Delem$erg A<, Lau5es CA, 'oreno AA, Delgado PI, 'cPnight P', et al. #he AriBona &e"ual *"perience &cale -A&*K.E Nelia$ilit and validit . < &e" 'arital #her. 2>>>=21E2,8/>. [Pu$'ed] ++. *ndicott <, Tee <, )arrison L, Glumenthal N. Cualit of Life *n;o ment and &atisfaction CuestionnaireE A ne! measure. Ps chopharmacol Gull. +??9=2?E92+81. [Pu$'ed] +2. Casper NC, Nedmond *, PatB '', &chaffer CG, Davis <', Poslo! &). &omatic s mptoms in primar affective disordersE Presence and relationship to the classification of depression. Arch Den Ps chiatr . +?3,=/2E+>?38+>/. [Pu$'ed] +9. Pendur5ar A, Paur G. 'a;or depressive disorder, o$sessive-compulsive disorder, and generaliBed an"iet disorderE Do the se"ual d sfunctions differY Prim Care Companion < Clin Ps chiatr . 2>>3=+?E2??89>,. [P'C free article] [Pu$'ed] +/. Angst <. &e"ual pro$lems in health and depressed patients. Int Clin Ps chopharmacol. +??3=+9-&uppl 1.E&+89. [Pu$'ed] +,. Penned &), Dic5ens &*, *isfeld G&, Gag$ N'. &e"ual d sfunction $efore antidepressant therap in ma;or depression. < Affect Disord. +???=,1E2>+83. [Pu$'ed]

+1. C rano!s5i <', Grom$erger <, You5 A, 'atthe!s P, PravitB D%, Po!ell L). Lifetime depression histor and se"ual function in !omen at midlife. Arch &e" Gehav. 2>>/=99E,9?8/3. [Pu$'ed] +:. Ticolosi A, 'oreira <r *D, Oilla ', Dlasser D. A population stud of the association $et!een se"ual function, se"ual satisfaction and depressive s mptoms in men. < Affect Disord. 2>>/=32E29,8/9. [Pu$'ed] +3. Pessler NC, \hao &, GlaBer DD, &!artB '. Prevalence, correlates, and course of minor depression and ma;or depression in the Tational Comor$idit &urve . < Affect Disord. +??:=/,E+?89>. [Pu$'ed] +?. LincBe <P, Care 'P. Te! Yor5E #he Duilford Press= 2>>+. &e"ual d sfunctionE A guide for assessment and treatment. 2nd ed. 2>. Leiner DT, Nosen NC. &e"ual d sfunctions and disorders. InE 'illon #, Glane P), Davis ND, editors. %"ford #e"t$oo5 of Ps chopatholog . Te! Yor5E %"ford Universit Press= +???. pp. /+>8/9. 2+. Lerne5e U, Torthe &, Ghugra D. Antidepressants and se"ual d sfunction. Acta Ps chiatr &cand. 2>>1=++/E93/8?:. [Pu$'ed]

Clinics )ospital das Clinicas da Aaculdade de 'edicina da Universidade de &ao Paulo

*emale sexual dysfunction in patients with substance-related disorders

Alessandra Diehl, Nosiane Lopes da &ilva, and Nonaldo Laran;eira Additional article information

Abstract
=B?) T"@):
#o estimate the prevalence of female se"ual d sfunction s mptoms and the associated ris5 factors in a sample of patients !ith su$stance-related disorders admitted to a specialiBed in-patient care unit.

M)T$='%:
#his stud used a cross-section design, !ith eight months of data collection, conducted !ith su$stance-dependent !omen using structured @uestionnaires to collect sociodemographic data and identif their drug of choice. #he Drug A$use &creening #est,

&hort Alcohol Dependence Data @uestionnaire, AagerstrZm #est for Ticotine Dependence, and AriBona &e"ual *"perience &cale !ere also administered.

R)%><T%:
#he sample consisted of +>, !omen !ho had a mean age of 9/.3 ears -&D F +2.+, range F +3-1,. and !ere predominantl heterose"ual -:/.94., single -/:.14., Caucasian -,>.,4., catholic -91.24., and educated onl to the level of primar education -/>4., !ith a monthl famil income of up to one minimum salar -9:.,4.. In /2.?4 of the patients, crac5 !as the drug of choice= /:.14 of the sample @ualified for the Drug A$use &creening #est -su$stantial pro$lems related to drugs., /9.34 e"hi$ited &hort Alcohol Dependence Data -moderate or severe dependenc ., /:.14 e"hi$ited AagerstrZm #est for Ticotine Dependence -high or ver high nicotine dependence.. #he prevalence of se"ual d sfunction s mptoms !as 9/.24 -?,4 CI F [2,.9, //.+]., and a high level of nicotine dependence and lo! income increased the chances of having se"ual d sfunction $ 2.:2fold and 2.,/ fold, respectivel . An association !as also o$served $et!een female se"ual d sfunction s mptoms and schooling and levels of drug dependence.

=, <>%"=,%:
Aemale se"ual d sfunction s mptoms !ere common among this sample and primaril associated !ith high levels of nicotine use. !eywords: &e"ual D sfunction, &u$stance-Nelated Disorders, Lomen, Crac5ICocaine, #o$acco Use Disorder

",TR='> T"=,
Aemale se"ual d sfunction -A&D. is a common disorder in societies !orld!ide, $ut it is also a comple" multifactor phenomenon that encompasses emotional intimac and relationship satisfaction, along !ith other ps chosocial factors across all cultures, all se"ual orientations and various socio-economic statuses, !ith a great potential to affect relationships negativel and impair @ualit of life -+-9.. *pidemiological studies in the United &tates have estimated that A&D affected /94 of !omen in the general population over the past +2 months -/.. In the United Pingdom, ,.34 of !omen have reported recent se"ual d sfunction, and +,.,4 have reported lifelong se"ual d sfunction -+., !hereas in Latin America, the rate of A&D for middle aged !omen it is appro"imatel ,34 -,.. &ome studies on this issue have indicated that among !omen !ith an se"ual difficult , an average of 1/4 -range F +1-:,4. e"perienced difficult !ith desire, 9,4 -range F +1-/34. e"perienced difficult achieving orgasm, 9+4 -range F +2-1/4. e"perienced difficult $ecoming aroused, and 214 -range F :-,34. e"perienced se"ual pain -+,/,1.. Unfortunatel , this condition remains a largel under-e"plored field in medicine, despite -a. se"ual d sfunction $eing more prevalent in !omen than in men and -$. the evolution

of nonlinear models due to understanding the intricac of female se"ual function that recogniBe the importance of $oth non$iological and $iological factors -+.,. &ome of the ps chological factors associated !ith A&D include the unconscious avoidance of se" and pleasure, fear, structured rigid families, the demands of a relationship, and an e"cessive need to satisf the partner. In addition, the guilt that comes from e"periencing pleasure can $e internaliBed as a potential ris5 and danger, !hich in turn leads to $oth insecurit and a repression of the $od and possi$le pleasure that it can e"perience -/,:.. Alcohol consumption, to$acco smo5ing, and illicit drug a$useIdependence have long $een associated !ith se"ual d sfunction -+>-+2.. Among chronic heroin and morphine users, for e"ample, a revie! stud noted decreases in se"ual intercourse fre@uenc , mastur$ation, and the @ualit and fre@uenc of orgasm -+9.. #hese effects occur $ecause opioids inhi$it the h pothalamic-pituitar -gonadal a"is and increase prolactin levels, !hich affect $oth the male and female se"ual response -+9.. Animal and in vitro studies e"amining the effects of canna$is a$use on se"ual function have identified potential lin5s $et!een chronic canna$is smo5ing and inhi$ited orgasms -+9-+,.. Chronic cocaine a$use is also associated !ith h perprolactinemia and se"ual d sfunction s mptoms, such as diminished li$ido and difficult reaching orgasm -++,+2.. In alcohol-dependent !omen, the most common forms of se"ual d sfunction o$served include d spareunia, high rates of genitourinar health pro$lems, and lo! vaginal lu$rication, revealing pro$lems !ith se"ual arousal -+9,+1.. %ther factors that ma predict s mptoms of se"ual d sfunction in this population include a histor of se"ual a$use, ps chiatric comor$idities -such as depression, an"iet , and eating disorders. that commonl co-occur !ith dependence to alcohol and other drugs in !omen, various specific s mptoms associated !ith the a$use of ps choactive su$stances -such as jcrashingj after cocaine use., and insomnia pro$lems -9,+>,+1.. Aurthermore, research on the relationship $et!een A&D s mptoms and drug a$use -especiall for other drugs, such as crac5. has $een neglected to an even greater e"tent -++,+9.. Tevertheless, identif ing the magnitude of this pro$lem and managing the se"ual health issues among this population ma have a significant impact on the prevention of relapse. 'anaging this pro$lem is especiall important $ecause the use of ps choactive su$stances ma $e involved in the relief of s mptoms related to se"ual d sfunction or result from a search for 6anesthesia feelings7 in response to the frustration of not achieving se"ual pleasure -+:.. #he scarcit of data on the prevalence of se"ual d sfunction s mptoms in !omen, especiall among crac5 users, ;ustifies the e"pansion of scientific evidence in this area -1,+9.. %ur h pothesis is that A&D occurs more fre@uentl in addict patients than the general population and is largel associated !ith alcohol, crac5, and pol drug a$use.

#he o$;ective of this stud !as to evaluate the prevalence of se"ual d sfunction and the associated ris5 factors among a sample of su$stance-dependent !omen admitted to an inpatient care service.

M)T$='%
#his stud !as approved $ the Aederal Universit of &ko Paulo *thics Committees -protocol num$er ++?9I>?., and all of the su$;ects signed an informed consent form. #he patients did not receive an financial re!ard or compensation for participating in this stud . #he stud used a cross-sectional design and !as conducted at the pu$lic inpatient care center of the Alcohol and Drugs Nesearch Unit of the Aederal Universit of &ko Paulo, !hich specialiBes in the treatment of disorders related to su$stance use, is dedicated e"clusivel to !omen, and is located !ithin a tertiar ps chiatric hospital near &ao Paulo, GraBil. #his unit has 23 $eds for !omen over the age of +3 ears, !ith an average occupanc of +, $eds per month. #he average duration of treatment for each patient is appro"imatel /, da s and includes individual and group activities !ith a multidisciplinar staff that emplo s a com$ination of pharmacological treatment and several ps chosocial approaches, such as relapse prevention, +2-step program facilitation, motivational intervie!ing, cognitive $ehavioral therap , harm reduction, and complementar therapies, such as ph sical activit and dance -+3..

#rocedures
During the eight months of data collection $et!een Ae$ruar 2>++ and %cto$er 2>++, a ps chologist and a nurse, $oth !ith e"pertise in addiction and previous training, administered a @uestionnaire developed $ the authors to +>, !omen !ho had $een diagnosed !ith su$stance-related disorder and !ho !ere older than +3 ears of age. All of the patients had a confirmed clinical diagnosis of dependence according to the diagnosis criteria of the Diagnostic and &tatistical 'anual of 'ental Disorders, Aourth *dition, #e"t Nevision, -+?. up to the first !ee5 of admission to this setting. #he intervie! duration !as /> minutes on average. To refusals !ere recorded.

Main outcomes measures

&ocio-demographic dataE #he follo!ing socio-demographic data !ere collectedE age, se"ual orientation, educational level, ethnicit , marital status, monthl income, emplo ment status, and religious affiliation. Drug of choiceE #he term jdrug of choicej refers to the preferred drug of the su$stance a$user, and this information is often important to the clinical status of the patient $ecause su$stance users often meet diagnostic criteria for dependence on multiple drugs. Certain characteristics, such as age, race, and marital status, have $een sho!n to var $et!een individuals according to their drug of choice preferences. #hese data are not collected on a scale, $ut each patient is as5ed a simple @uestionE 6Lhat is our drug of choiceY7 -2>..

&hort Alcohol Dependence Data -&ADD. @uestionnaireE #his instrument is a +,-item self-report @uestionnaire used to provide a measure of the severit of alcohol dependence !ithin a continuum ranging from a mild drin5ing pro$lem to severe alcohol dependence= it evaluates the $ehavioral and su$;ective aspects of alcohol dependence, !ith an ade@uate construct validit and high correlation !ith other instruments. #he GraBilian version of the &ADD and original *nglish version !ere highl correlated. #he coefficient of internal consistenc !as >.:? -2+.. Drug A$use &creening #est -DA&#-2>.E #his surve comprises 2> @uestions relating to drug use during the last ear. #he @uestions pertain specificall to a$use, dependence, !ithdra!al -signs and s mptoms., social impairment, familial relationships, legal implications, medical pro$lems, and previous treatment. #he pro$lem severit !as classified on a scale from > to 2> and scored as follo!sE > F no pro$lem= from + to , F mild= 1 to +> F moderate= ++ to +, F su$stantial= and +1 to 2> F severe. #his scale has $een used in several studies and validated in other countries !ith good results in concurrent and discriminate validit , $ut it has et to $e validated in GraBil -22.. 4a#erstr>" Test for 'icotine $ependence ,4T'$3E #his @uestionnaire is a screening instrument that has $een e"tensivel translated and used in man countries, including GraBil, to assess ph sical nicotine dependence. #he instrument consists of si" items that are easil understood and can $e rapidl applied. #he scores o$tained on the test permit the classification of nicotine dependence into five levelsE ver lo! -> to 2 points.= lo! -9 to / points.= moderate -, points.= high -1 to : points.= and ver high -3 to +> points.. #he relia$ilit inde" of this instrument is e"cellent ->.3:., and Cron$ach`s alpha coefficient ranged from >.,, to >.:/, indicating that the A#TD has moderate internal consistenc . #he A#TD sho!ed satisfactor sensitivit ->.:,. and specificit ->.3>. -29.. AriBona &e"ual *"perience &cale -A&*K.E #his instrument is a scale designed to measure five specific items as the core elements of se"ual functionE se"ual drive, arousal, penile erectionIvaginal lu$rication, a$ilit to reach orgasm, and satisfaction from orgasm. #he instrument measures these items !ith five @uestions in a relativel nonintrusive $imodal fashion using a si"-point Li5ert scale that ranges from h perfunction -+. to h pofunction -1.. #he scores range from , to 9>, and scores higher than or e@ual to +? indicate se"ual d sfunction. #he A&*K !as designed to $e either self- or clinicall administered and can $e used in either heterose"ual or homose"ual populations, regardless of !hether the su$;ect has a se"ual partner. Cuestions addressing the fre@uenc Ipreference of se"ual activit !ere considered unrelated to se"ual d sfunction. Cron$ach`s alpha anal sis indicated that the A&*K demonstrated e"cellent internal consistenc and scale relia$ilit -alpha F >.?>,,.. #he A&*K also demonstrated strong test-retest relia$ilit -for patients, r F >.3>+, pH>.>+= for controls, r F >.3?2, pH>.>+.. #he sensitivit and specificit of the A&*K in terms of the identification of se"ual d sfunction !ere 324 and ?>4, respectivel -2/.. #he main rationale for using the A&*K scale instead of !ellesta$lished measures for se"ual d sfunction in !omen, such as the Aemale &e"ual Aunction Inde" or Aemale &e"ual Distress &cale, !as that the A&*K scale is shorter than those mentioned and more easil incorporated into the protocols of our service, !hich alread includes man other instruments and also provides inpatient care for men !ith su$stance-related disorders -1,:,+3..

'ata analyses
Aor the descriptive anal sis, !e evaluated the a$solute and relative fre@uencies of the categorical varia$les and summar measuresE means, @uartiles, minimums, ma"imums and standard deviations of the numeric varia$les. #o investigate the association $et!een the characteristics of the categorical varia$les of the sample !ith se"ual d sfunction s mptoms, !e used the l2 test or Aisher e"act test if the sample !as insufficient -2,.. #he use of categorical varia$les in the &ADD, DA&#-2>, A#TD, and A&*K scales !as adopted o!ing to their nonlinear functional relationship !ith the varia$le of interest and $ecause the cut-off points are alread !ell accepted in the literature -+3,2,.. #o compare the means of the numerical varia$les $et!een the t!o groups, !e used the &tudent t test for independent samples. #o ma5e comparisons $et!een the averages of more than t!o groups, !e used an anal sis of variance -AT%OA. after confirming the assumption of o$served data normalit using the Polmogorov-&mirnov test -2,.. Initiall , all of the varia$les !ere included in the model. #hen, the varia$les that !ere not significant at the ,4 level !ere e"cluded one $ one in order of significance -reverse method.. Aurthermore, the )osmer-Lemesho! test !as used to evaluate the suita$ilit of model ad;ustment means in the final model. #he sensitivit and specificit !ere calculated from the odds of se"ual d sfunction final model, !hich !as estimated using the N%C curve -2,.. In this stud , t!o pseudo R? -coefficient of determination. values !ere o$tained. #he first !as Co"-&nell, and the second !as Tagel5er5e. Logistic regression does not have an R? value that allo!s a linear regression to e"plain the variation of the model. #herefore, an attempt must $e made to o$tain a statisticall similar value= various pseudo R? values have $een proposed. It is important to note that the R? assumes nonnegative values -greater than or e@ual to Bero. $ut never reaches a value of one -in a linear regression, the R? ta5es values $et!een Bero and one, and one indicates a perfect fit of the model.. #herefore, $ecause the pseudo R? shares the same interpretation as the R? -part of the varia$ilit of the dependent varia$le R the outcome e"plained $ the regressors R e"planator varia$les., its value must $e assessed !ith caution -2,.. Ainall , for the ;oint assessment of the effects of characteristics on se"ual d sfunction s mptoms, logistic regression !as used. Aor all of the statistical tests, a significance level of ,4 !as used -2,..

R)%><T%
%ocio-demographic data
#he sample consisted of +>, !omen, !ith a mean age of 9/.3 ears -&D F +2.+., an age range of +3-1, ears -t F -+./+, p F >.+1. and a median age of 9+ ears -second @uartile.. #he !omen !ere predominantl heterose"ual -:/.94, n F :3., single -/:.14, n F ,>.,

Caucasian -,>.,4, n F ,9., and catholic -91.24, n F 93.. #he also had a monthl income of up to one minimum !age, and 9:.,4 -n F 9?. had an elementar education, !hich e@uates to an average of appro"imatel si" to seven ears of stud . According to #a$le +, the onl association o$served !as $et!een education and se"ual d sfunction s mptoms 1+.+4 -n F 22. of the !omen !ith se"ual d sfunction s mptoms had not completed elementar school, !hereas 2?4 -n F 2>. of the !omen !ith no se"ual d sfunction s mptoms had not completed elementar school.

#a$le + &ociodemographic data and se"ual d sfunction s mptoms -T F +>,.. #he average age of the !omen !ith se"ual d sfunction s mptoms -n F 91. !as 9:.+ ears -&D F +2.>., and the average age of those !ithout se"ual d sfunction s mptoms -n F 1?. !as 99.1 ears -&D F +2.+.. #here !ere no detecta$le differences $et!een the mean ages for se"ual d sfunction s mptoms -t F -+./+, p F >.+1..

#re+alence of sexual dysfunction symptoms

In this sample, the prevalence of se"ual d sfunction s mptoms !as 9/.24 -?,4 CI F [2,.9, //.+]. according to the A&*K.

Affecti+e sex orientation

#he su$;ects !ere predominantl heterose"ual -:/.94, n F :3., follo!ed $ $ise"ual -+:.+4, n F +3., and homose"ual -3.14, n F ?.. #he proportion of e"clusivel homose"ual !omen !as too small in our sample to conduct an meaningful comparative anal sis in terms of the prevalence of A&D s mptoms in homose"ual versus heterose"ual !omen.

haracteristics related to substance abuse/dependence

In /2.?4 -n F /,. of the su$;ects, crac5 !as the drug of choice, follo!ed $ alcohol in 9>4 -n F 92. of su$;ects. In addition, /:.14 of this sample presents a su$stantial level of pro$lems related to drugs according to the DA&#-2>= /9.34 -n F /1. have a moderate or severe dependence on alcohol according to &ADD, and /:.14 -n F 1>. have a high or ver high level of nicotine dependence according to A#TD -#a$le 2.. #here !ere no

differences in the mean levels $et!een the A&*K, &ADD -p F >.,>., DA&#-2> -p F >.1:., and A#TD -p F >.2:..

#a$le 2 Dependence level and se"ual d sfunction s mptoms -T F +>,A

Risk factors
#a$le 9 presents the final logistic regression model. #he coefficients associated !ith the incomplete high school and high school levels of education !ere similar -p F >.:3.= therefore, these t!o categories !ere com$ined to increase the regression model degrees of freedom due to sample siBe. #he same occurred !ith the levels of DA&#-2>= the coefficients associated !ith the lo!, moderate, su$stantial and severe levels !ere similar -p F >.:+..

#a$le 9 Nis5 factors associated !ith female se"ual d sfunction. #he varia$le salar and DA&#-2>, although not significant at the ,4 level, !ere maintained in the sample $ecause the !ere marginall significant. It can $e o$served in this ta$le that !omen !ho have had secondar education -complete or incomplete. have an 3>4 reduced chance of presenting d sfunction s mptoms compared !ith !omen !ith lo!er levels of education. )o!ever, !omen !ith a high level of nicotine dependence increased their chance of presenting se"ual d sfunction s mptoms $ 2.:2 compared !ith !omen of other levels of drug dependence. #he )osmer-Lemesho! test -p F >./3. indicated a good ade@uac of fit to the model. Arom the final model, it is possi$le to use the characteristics of !omen in terms of education, A#TD, DA&#-2>, and salar to estimate the pro$a$ilit of having A&D s mptoms.

Using the N%C curve, !e o$tained a cut-off of >.9+ in pro$a$ilit , !hich !as associated !ith a sensitivit of 32.?4 and specificit of 13.+4. )ence, if all of the !omen !ith a pro$a$ilit greater than >.9+ are classified as having se"ual d sfunction s mptoms, the model classifies 32.?4 of !omen !ho trul have positive se"ual d sfunction s mptoms. In addition, among the !omen !ho do not have se"ual d sfunction s mptoms, 13.+4 are properl classified as not having se"ual d sfunction s mptoms. In this stud , t!o pseudo R? !ere o$tained. #he first !as Co"-&nell and had a value of >.2+, and the second !as Tagel5er5e and had a value of >.2?.

'"% >%%"=,
&ocio-demographic factors, such as age, marital status, income, and education, have $een strongl predictive of se"ual d sfunction s mptoms in !omen -9,/.. In this sample, a significant association $et!een se"ual d sfunction s mptoms and socio-demographic characteristics !as o$served onl for schooling, !hich is in agreement !ith other international studies sho!ing that levels of se"ual d sfunction are higher in !omen !ith lo! levels of education -9,/.. In addition to education, another finding that stands out and concurs !ith other international studies refers to the 2.,/ fold increased chance of se"ual d sfunction s mptoms in !omen !ith lo! income. Lomen !ho su$sist on a lo! income comprise a high-ris5 vulnera$le population !ith limited access to social and health services. In general, this population is also more vulnera$le to povert and higher levels of se"ual crime and violence than most other populations investigated in se"ual function studies -9.. Aor !omen addicted to alcohol and drugs, these vulnera$ilities ma $e heightened $ecause the consumption of drugs, especiall crac5, has $een associated !ith various t pes of violence and the e"change of se" for drugs in !omen -+3.. #he prevalence of 9/.24 A&D s mptoms in this sample of !omen !ith su$stance-related disorder !as common and compara$le to other studies reported !orld!ide, !hich have reported prevalence rates of A&D s mptoms of +2-194 -9,1,+>., even in a sample of !omen !ith severe ps choactive su$stance dependence, as determined $ the DA&#-2>, &ADD, and A#TD scales. Conse@uentl , !e e"pected to find higher se"ual d sfunction s mptom prevalence rates than in the general population. Another finding that is in accordance !ith the current scientific evidence is the association $et!een severe nicotine dependence and se"ual d sfunction s mptoms, !hich !as almost threefold the odds ratio compared !ith !omen of other nicotine dependence levels in our sample -+>.. &cientific evidence has suggested that long-term cigarette smo5ing is an independent ris5 factor for se"ual d sfunction in men -21,2:.. )o!ever, the results of the limited data investigating this relationship in !omen are diverse, and some of the evidence supports the suggestion that nicotine ma $e the primar pharmacological agent responsi$le for genital hemod namic distur$ance, there$ facilitating a cascade of vascular and $iochemical events that ma o$struct normal se"ual arousal responses in !omen.

Controlled e"perimental studies e"amining the acute and chronic effects of isolated nicotine inta5e on female ph siological se"ual responses are necessar to help clarif the potential role of to$acco in the development andIor maintenance of se"ual d sfunction in !omen -21,2:.. Although A&D has $een investigated in groups of !omen !ith various health pro$lems, such as pol c stic ovar s ndrome, dia$etes, )IO, and $reast cancer -23-9>., !omen !ith su$stance-related disorder represent a uni@ue underserved and vulnera$le population that continues to suffer from lo! detection rates and limited access to treatment -+3.. #he strong point of this stud is on the recruitment of this special group of !omen $ecause little focus has $een given to the lin5 $et!een these t!o issuescse"ual d sfunction s mptoms and alcohol and drug dependencecusing validated @uestionnaires as the assessment measures, especiall in GraBil and other Latin American countries, !here ver fe! studies have $een conducted on this association at alcohol and drug dependence services -9+.. #his stud is limited $ its cross-sectional design and the relativel small sample siBe. %nl associations, not causal relationships, can $e inferred from cross-sectional studies. A longitudinal stud design !ould allo! causalit related to the onset of su$stance use and reported se"ual d sfunction s mptoms. Ge ond that issue, $ecause the recruitment too5 place at a tertiar service, this sample of !omen ma not $e representative of the communit $ecause it can $e assumed that onl the most serious patients receive this t pe of treatment -+3.. #his sample $ias ma therefore limit the e"ternal validit of these findings. Another limitation is that ps chiatric comor$idities, deto" periods, the use of medication, and other medical conditions that might cause se"ual d sfunction s mptoms !ere not investigated or controlled= therefore, the might $e potential confounding factors -9-,.. Another limitation that should $e noted is that the authors have chosen not to e"amine the individual se"ual functions affected and the various e"planator varia$les, as there are 5no!n differences in the etiolog of various s mptoms of se"ual d sfunction, such as those affecting the phases of desire and arousal -9,:.. )o!ever, future studies ma focus on this topic, e"panding the scientific evidence on this theme. #he clinical implications of the findings of this stud indicate that addressing se"ual d sfunction should $e part of the recover process of the recovering addict and should not $e marginaliBed or made invisi$le in most reha$ilitation centers -92.. Lhen se"ual health and se"ual d sfunction are not directl addressed in alcohol and drug treatment centers, the ma contri$ute to treatment failure !ith relapses and conse@uentl , su$stantial losses in the life @ualit of the addict -92.. 'an patients come to treatment !ith feelings of guilt and shame related to their se"ual $ehavior !hen using, !hich can contri$ute to relapse and noncompliance if the issue is not addressed -92..

Aor e"ample, alcohol-dependent !omen !ith vaginismus can relapse and use alcohol to cope !ith their se"ual d sfunction, as ma other !omen !ho use alcohol to achieve se"ual e"citement or rela"ation during se" -92.. #herefore, recover offers an e"cellent opportunit to identif , prevent, and manage se"ual d sfunction s mptoms in !omen !ith pro$lems related to alcohol and other drugs -9+,92.. Auture su$stance a$use population-$ased and longitudinal studies should $e conducted to e"tend the scientific evidence, including the research on se"ual d sfunction and se"ual health. It is especiall important to stud crac5 smo5ers $ecause this drug has $ecome a pu$lic health pro$lem in man lo! to middle income countries -99.. In conclusion, A&D s mptoms in this sample !ere common and primaril associated !ith high levels of nicotine dependence.

A !,=B<)'(M),T%
Aor their attention and cooperation in the performance of this pro;ect, the inpatient care staff of the Alcohol and Drugs Nesearch Unit of Aederal Universit of &ko Paulo has our sincere gratitude and appreciation.

*ootnotes
To potential conflict of interest !as reported.

Article information
Clinics -&ao Paulo.. 2>+9 Ae$ruar = 13-2.E 2>,82++. doiE +>.1>1+IclinicsI2>+9->2.%A+/ P'CIDE P'C9,3/21+ Alessandra Diehl, Nosiane Lopes da &ilva, and Nonaldo Laran;eira Aederal Universit of &ko Paulo -UTIA*&P.IPs chiatr DepartmentIAlcohol and Drug Nesearch Unit -UTIAD.ITational Institute of Alcohol and Drugs Polic -ITPAD., &ko PauloI&P, GraBil. Contri$uted $ &ilva NL contri$uted to the data collection and preparation of the data$ase. Diehl A contri$uted data anal sis and preparation of the article $ !riting the same. Laran;eira N contri$uted overseeing the stud , selecting papers on the topic and revie! the article after it has $een finaliBed. *-mailE alediehlIatIterra.com.$r #el.E PhoneE ,, ++ ,,:?-,1/9 Neceived &eptem$er 9>, 2>+2= Nevised %cto$er 3, 2>+2= Accepted %cto$er 21, 2>+2. Cop right W 2>+9 )ospital das Clhnicas da A'U&P #his is an %pen Access article distri$uted under the terms of the Creative Commons Attri$ution Ton-Commercial License -httpEIIcreativecommons.orgIlicensesI$ -ncI9.>I.

!hich permits unrestricted non-commercial use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from Clinics are provided here courtes of $ospital das linicas da *aculdade de Medicina da >ni+ersidade de %ao #aulo

R)*)R), )%
+. Gurri A, &pector #. Necent and lifelong se"ual d sfunction in a female UP population sampleE prevalence and ris5 factors. < &e" 'ed. 2>++=3-?.E2/2>89>. [Pu$'ed] 2. Le!is NL. *pidemiolog of se"ual d sfunction in Asia compared to the rest of the !orld. Asian < Androl. 2>++=+9-+.E+,283. [P'C free article] [Pu$'ed] 9. Lorl G, Dopal ', Ar a L. &e"ual d sfunction among !omen of lo!-income status in an ur$an setting. Int < D naecol %$stet. 2>+>=+++-9.E2/+8/. [Pu$'ed] /. Laumann *%, Pai5 A, Nosen NC. &e"ual d sfunction in the United &tatesE prevalence and predictors. <A'A. +???=23+-1.E,9:8//. [Pu$'ed] ,. Glgmel <*, Chedraui P, Garon D, GelBares *, Gencosme A, Calle A, et al. &e"ual d sfunction in middle-aged !omenE a multicenter Latin American stud using the Aemale &e"ual Aunction Inde". 'enopause. 2>>?=+1-1.E++9?8/3. [Pu$'ed] 1. )a es ND, Gennett C', Aairle CP, Dennerstein L. Lhat can prevalence studies tell us a$out female se"ual difficult and d sfunction. < &e" 'ed. 2>>1=9-/.E,3?8?,. [Pu$'ed] :. Gasson N. Using a different model for female se"ual response to address !omen`s pro$lematic lo! se"ual desire. < &e" 'arital #her. 2>>+=2:-,.E9?,8/>9. [Pu$'ed] 3. ABadBoi P', &iro5 'G. Teurologic factors in female se"ual function and d sfunction. Porean < Urol. 2>+>=,+-:.E//98?. [P'C free article] [Pu$'ed] ?. Gurri AO, Cher5as L', &pector #D. #he genetics and epidemiolog of female se"ual d sfunctionE a revie!. < &e" 'ed. 2>>?=1-9.E1/18,:. [Pu$'ed] +>. Lau <#, Pim <), #sui )Y. Prevalence, health outcomes, and patterns of ps chotropic su$stance use in a Chinese population in )ong PongE a population-$ased stud . &u$st Use 'isuse. 2>>,=/>-2.E+3:82>?. [Pu$'ed] ++. Gang-Ping <. &e"ual d sfunction in men !ho a$use illicit drugsE a preliminar report. < &e" 'ed. 2>>?=1-/.E+>:283>. [Pu$'ed] +2. PopetB C*, Ne nolds *P, )art CL, Pruglans5i AL, Le;ueB CL. &ocial conte"t and perceived effects of drugs on se"ual $ehavior among individuals !ho use $oth heroin and cocaine. *"p Clin Ps chopharmacol. 2>+>=+3-9.E2+/82>. [P'C free article] [Pu$'ed] +9. &aso L. *ffects of drug a$use on se"ual response. Ann Ist &uper &anita. 2>>2=93-9.E23?8?1. [Pu$'ed] +/. &hamloul N, Gella A<. Impact of canna$is use on male se"ual health. < &e" 'ed. 2>++=3-/.E?:+8,. [Pu$'ed] +,. Aversa A, Nossi A, Arancomano D, GruBBiches N, Gertone C, &antiemma O, et al. *arl endothelial d sfunction as a mar5er of vasculogenic erectile d sfunction in oung ha$itual canna$is users. Int < Impot Nes. 2>>3=2>-1.E,118:9. [Pu$'ed] +1. DimsiB ', %s5a UY, Ge;i TP. Use of alcoholic $everages and other ps choactive su$stances among !omen in #ur5e E medical, $iological, and social conse@uences. A pilot stud . &u$st Use 'isuse. 2>+>=/,-:-3.E+>1>8:1. [Pu$'ed]

+:. Palha AP, *steves '. Drugs of a$use and se"ual functioning. Adv Ps chosom 'ed. 2>>3=2?E+9+8/?. [Pu$'ed] +3. Diehl A, Cordeiro DC, Laran;eira N. Dependnncia CuhmicaE prevenoko, tratamento e polhticas pa$licas. Porto AlegreE *ditora AN#'*D= 2>++. +?. American Ps chiatric Association -APA. Diagnostic and statistical manual of mental disorders -D&'-IO. Lashington, DCE American Ps chiatric Association= 2>>>. 2>. Clar5 GC, Per5ins A, 'cCullumsmith CG, Islam A', &ung <, Cropse PL. Lhat does self-identified drug of choice tell us a$out individuals under communit corrections supervision. < Addict 'ed. 2>+2=1-+.E,:81:. [Pu$'ed] 2+. Nosa-%liveira LC, Presti Pde A, Antunes IN, Car$onari DC, Imada AC, 'aeda 'Y, et al. Nelia$ilit and dimensionalit of the &hort Alcohol Dependence Data -&ADD. @uestionnaire in a clinical sample of hospitaliBed patientsE using the &ADD in a general hospital setting. Nev Gras Psi@uiatr. 2>++=99-+.E138:+. [Pu$'ed] 22. Yud5o *, LoBh5ina %, Aouts A. A comprehensive revie! of the ps chometric properties of the Drug A$use &creening #est. < &u$st A$use #reat. 2>>:=92-2.E+3?8?3. [Pu$'ed] 29. 'eneses-Da a IC, \uardi AL, Loureiro &N, Crippa <A. Ps chometric properties of the AagerstrZm #est for Ticotine Dependence. < Gras Pneumol. 2>>?=9,-+.E:9832. [Pu$'ed] 2/. 'cDahue CA, Delen$erg A<, Lau5es CA, 'oreno AA, Delgado PL, 'cPnight P', et al. #he AriBona &e"ual *"perience &cale -A&*K.E relia$ilit and validit . < &e" 'arital #her. 2>++=21-+.E2,8/>. [Pu$'ed] 2,. Neis *. *stathstica multivariada aplicada. Lis$oaE *diopes &hla$o= +??:. 21. )arte CG, 'eston C'. Association $et!een smo5ing cessation and se"ual health in men. G<U Int. 2>+2=+>?-1.E3338?1. [P'C free article] [Pu$'ed] 2:. )arte CG, 'eston C'. #he inhi$itor effects of nicotine on ph siological se"ual arousal in nonsmo5ing !omenE results from a randomiBed, dou$le-$lind, place$ocontrolled, cross-over trial. < &e" 'ed. 2>>3=,-,.E++3/8?:. [P'C free article] [Pu$'ed] 23. Oeras AG, Gruno NO, de Avila 'A, Tardi A*. &e"ual d sfunction in patients !ith pol c stic ovar s ndromeE clinical and hormonal correlations. Compr Ps chiatr . 2>++=,2-,.E/318?. [Pu$'ed] 2?. &$itti Y, Padiri ), *ssaidi I, Aadou5hair \, Pharmoun &, &limani P, et al. Greast cancer treatment and se"ual d sfunctionE 'oroccan !omen`s perception. G'C Lomens )ealth. 2>++=++E2?. [P'C free article] [Pu$'ed] 9>. Diraldi A, Pristensen *. &e"ual d sfunction in !omen !ith dia$etes mellitus. < &e" Nes. 2>+>=/:-2.E+??82++. [Pu$'ed] 9+. Tiv T, )ser YI. Lomen-onl and mi"ed-gender drug a$use treatment programsE service needs, utiliBation and outcomes. Drug Alcohol Depend. 2>>:=3:-2-9.E+?/82>+. [Pu$'ed] 92. )arve DG. &e"ual health in drug and alcohol treatmentE group facilitator`s manual. Te! Yor5E &pringer Pu$lishing Compan = 2>>?. 99. Gastos AI, 'endes A, Duarte Pdo C, Gertoni T. &mo5ed crac5 cocaine in contemporar GraBilE the emergence and spread of 6o"i.7 Addiction. 2>++=+>1-1.E++?+8 2. [Pu$'ed]

Depression Nesearch and #reatment )inda!i Pu$lishing Corporation

Reduced Treatment-)mergent %exual 'ysfunction as a #otential Target in the 'e+elopment of ,ew Antidepressants
David &. Gald!in, '. Carlotta PalaBBo, and Oasilios D. 'asdra5is Additional article information

Abstract
Pleasura$le se"ual activit is an essential component of man human relationships, providing a sense of ph sical, ps chological, and social !ell-$eing. *pidemiological and clinical studies sho! that depressive s mptoms and depressive illness are associated !ith impairments in se"ual function and satisfaction, $oth in untreated and treated patients. #he findings of randomiBed place$o-controlled trials demonstrate that most of the currentl availa$le antidepressant drugs are associated !ith the development or !orsening of se"ual d sfunction, in a su$stantial proportion of patients. &e"ual difficulties during antidepressant treatment often resolve as depression lifts $ut can endure over long periods and ma reduce self-esteem and affect mood and relationships adversel . &e"ual d sfunction during antidepressant treatment is t picall associated !ith man possi$le causes, $ut the ris5 and t pe of d sfunction var !ith differing compounds and should $e considered !hen ma5ing decisions a$out the relative merits and dra!$ac5s of differing antidepressants. A range of interventions can $e considered !hen managing patients !ith se"ual d sfunction associated !ith antidepressants, including the prescription of phosphodiesterase-, inhi$itors, $ut none of these approaches can $e considered 6ideal.7 As treatment-emergent se"ual d sfunction is less fre@uent !ith certain drugs, presuma$l related to differences in their pharmacological properties, and $ecause current management approaches are less than ideal, a reduced $urden of treatment-emergent se"ual d sfunction represents a tolera$ilit target in the development of novel antidepressants.

./ "ntroduction
& stematic revie!s of the epidemiolog of se"ual difficulties, d sfunction, and dissatisfaction indicate that se"ual pro$lems are common in men and !omen in all societies and more fre@uent in older individuals and among those !ith chronic medical conditions, including depression [+, 2]. Aor e"ample, the Dlo$al &urve of &e"ual Attitudes and Gehavior, of over 2:,>>> men and !omen aged />83> ears, found 6earl

e;aculation7 -i.e., rapid or premature e;aculation. to $e the most common se"ual d sfunction, affecting +/4 of men, !ith 6erectile difficulties7 having a prevalence of +>4 all se"ual d sfunctions in men $eing more prevalent in older groups [9]. #he 'en`s Attitudes to Life *vents and &e"ualit &tud , of similar siBe $ut among men aged 2>8:, ears, found the prevalence of 6erectile d sfunction7 to $e +14, the proportion $eing higher in older men and individuals !ith cardiovascular disease, h pertension, or depression [/]. #he Lomen`s International &tud of )ealth and &e"ualit , in over /,,>> !omen aged 2>8:> ears, found 6h poactive se"ual desire disorder7 to have a prevalence range of +18/14, in pre-menopausal to surgicall postmenopausal !omen [,]. #here is a close and t!o-!a relationship $et!een the presence of depressive s mptoms and reports of se"ual difficulties and dissatisfaction. NecogniBing the nature and strength of this association, a recent international consensus statement on se"ual d sfunction in patients !ith chronic illness recommends screening for depression [1]. #he longitudinal epidemiological \urich &tud found the prevalence of se"ual pro$lems in depressed individuals -including those !ith ma;or depression, d sth mia, and recurrent $rief depression. to $e appro"imatel t!ice that in controls -,>4 versus 2/4. [:]. &e"ual pro$lems ma $e more fre@uent in those !ith recurrent depression, as the United &tates &tud of Lomen`s )ealth Across the Tation found that onl those !ith recurrent episodes !ere significantl more li5el to report pro$lems in se"ual arousal, ph sical pleasure, and emotional satisfaction, !hen compared to controls [3]. Diven its effects on mood, energ , capacit for pleasure, self-confidence, and selfesteem, it should $e anticipated that depression !ould lo!er se"ual interest and satisfaction= and this is the case, more mar5edl so in ounger patients [?]. Depressive s mptoms commonl coe"ist !ith an"iet s mptoms, !hich are also associated !ith reports of se"ual difficulties [+>, ++] and often !ith o$sessive-compulsive s mptoms, 5no!n to $e associated !ith loss of se"ual pleasure and se"ual dissatisfaction [+2, +9]. Gut depression e"erts adverse effects on the full range of the se"ual response, including the a$ilit to achieve and maintain penile erection or attain ade@uate vaginal moistening and to achieve e;aculation or orgasm [+/]. 'ost antidepressant drugs can e"ert unto!ard effects on se"ual function and satisfaction, $ut !hen considering the relative ris5s for and management of se"ual d sfunction associated !ith antidepressant treatment, the adverse effects of depression itselfcand of an coe"isting ph sical illness or concomitant medicationccan $e eas to overloo5.

0/ Relati+e "ncidence of %exual 'ysfunction during Antidepressant Treatment

Accurate identification of the incidence of 6treatment-emergent7 se"ual d sfunction -including $oth the !orsening of pree"isting pro$lems and the development of ne! se"ual difficulties in previousl untrou$led patients. during antidepressant treatment has proved trou$lesome. #!o international studies of the prevalence of se"ual d sfunction in depressed patients prescri$ed either a selective serotonin reupta5e inhi$itor or serotoninnoradrenaline reupta5e inhi$itor, !hich ta5e account of the presence of self-reported

se"ual pro$lems prior to starting antidepressant and of the presence of concomitant medication sometimes implicated in causing se"ual difficulties, suggest that 2:81,4 of female and 218,:4 of male patients e"perience either a !orsening of pree"isting difficulties or the emergence of ne! se"ual difficulties in the earl stages of treatment, the differences in prevalence partl reflecting variations in case ascertainment and local clinical practice [+,, +1]. *lucidation of the relative incidence of treatment-emergent se"ual d sfunction !ith differing antidepressants has also proved difficult. Ideall , studies should $e prospective, randomiBed, dou$le-$lind, and place$o-controlled in a defined diagnostic group, !ith an assessment of se"ual function at $aseline, and direct comparisons $et!een drugs, prescri$ed at doses of e@uivalent efficac . In addition, se"ual d sfunction should $e assessed !ith a relia$le, valid and sensitive rating scale, rather than rel ing on reports or open @uestions !hich could $e interpreted varia$l $ different patients. %nl a small proportion of investigations of treatment-emergent se"ual d sfunction have met these rigorous criteria, $ut a series of meta-anal ses together provide reasona$le evidence that antidepressants differ in their propensit for !orsening se"ual function. An earl meta-anal sis of studies !ith differing methodologies -including open-la$el, dou$le-$lind, cross-sectional, and retrospective investigations. indicates that 6treatmentemergent se"ual d sfunction7 is no more common !ith agomelatine, amineptine, $upropion, moclo$emide, mirtaBapine, or nefaBodone than it is !ith place$o, in contrast to the situation !ith other antidepressants [+:] -#a$le +.E all other antidepressants !ere significantl more li5el than place$o to $e associated !ith se"ual d sfunction, as a unitar categor , and nearl all of these !ere significantl more li5el to $e associated !ith d sfunction in each stage of the normal se"ual response. A meta-anal sis of randomiBed controlled trials of the efficac and tolera$ilit of acute treatment of ma;or depressive episodes !ith 6second-generation7 antidepressants indicates that $upropion is associated !ith a significantl lo!er rate of treatment-emergent se"ual d sfunction than is seen !ith escitalopram, fluo"etine, paro"etine, or sertraline [+3]E this is pro$a$l due to the nonserotonergic $ut predominantl noradrenergic-dopaminergic mechanism of action of $upropion [+?]. A s stematic revie! of the relative efficac and tolera$ilit of mirtaBapine and comparator antidepressants in the acute treatment of ma;or depression suggests that mirtaBapine is significantl less li5el than other antidepressants to cause adverse se"ual effects [2>], !hich is pro$a$l related to its antagonist effects at $oth the alpha-2 adrenergic receptor and the ,-)#2C receptor [2+]. NandomiBed controlled trials !ith agomelatine suggest it has fe!er adverse effects on se"ual functioning than some other antidepressants, !hich is more pro$a$l due to its antagonist effects on the ,-)#2C receptor, rather than the agonist effects at melatonin receptors [2282/].

#a$le + *stimated proportion and relative li5elihood of treatment-emergent se"ual d sfunction -derived from &erretti and Chiesa [+:]..

1/ Assessing %exual *unctioning in 'epressed #atients

#here are man ris5 factors for developing se"ual d sfunction during antidepressant treatment -including male gender, older age, lo!er academic achievement, lac5 of fulltime emplo ment, ph sical ill-health, multiple drug treatment, and trou$led interpersonal relationships., $ut onl some of these are amena$le to intervention. Interindividual variations in pharmaco5inetics ma $e important, as the 6poor meta$oliBer7 status for c tochrome P/,> 2D1 contri$utes to se"ual d sfunction !ith paro"etine [2,, 21], as does genetic variation in P-gl coprotein !hich affects its $lood-$rain $arrier transfer [2:]. Goth patients and health professionals ma find it em$arrassing to mention and discuss se"ual s mptoms, consultation [23] and recognition rates in primar care are lo! [2?], and recent revie!s demonstrate that rel ing on the spontaneous reporting of adverse events can lead to a su$stantial underestimation of the prevalence of se"ual pro$lems [9>, 9+]. Comprehensive assessment of a depressed patient reporting se"ual difficulties !hilst undergoing antidepressant treatment can $e a protracted processE although use of scales cannot full su$stitute for a sensitive $ut comprehensive intervie!, the assessment can $e facilitated $ emplo ing screening or severit @uestionnaires [92]. An earl revie! suggested that fe! se"ual functioning scales and @uestionnaires had sufficientl ro$ust ps chometric properties, $ut the AriBona &e"ual *"periences &cale, the Changes in &e"ual Aunctioning Cuestionnaire, the Ps chotropic-Nelated &e"ual D sfunction Cuestionnaire, and the &e" *ffects &cale all have ade@uate properties -including validit , relia$ilit , and sensitivit to change. and so can $e used to monitor se"ual function and satisfaction prior to and during antidepressant treatment [92].

2/ "mpro+ement in %exual *unction during Antidepressant Treatment

Tot all the se"ual effects of antidepressants are un!anted in all patients. Aor e"ample, man men trou$led $ persistent premature e;aculation can derive $enefits from treatment !ith either clomipramine or selective serotonin reupta5e inhi$itors, on either a dail or 6as re@uired7 $asis [99], and a s stematic revie! of randomiBed place$ocontrolled trials !ith traBodone indicates that !hen prescri$ed at a higher dosage -+,>8 2>> mg per da ., it is efficacious in reducing the 6ps chogenic7 erectile d sfunction [9/].

Lhilst a su$stantial proportion of patients e"perience treatment-emergent se"ual d sfunction !hilst ta5ing antidepressants [+,, +1], the reduction of depressive s mptoms through successful antidepressant treatment can also $e accompanied $ reported improvements in se"ual desire and satisfaction [9,, 91]. Lhilst it is thought that treatment-emergent se"ual d sfunction is a cause of nonadherence to antidepressants, the proportion of patients that stop treatment $ecause of se"ual pro$lems is not esta$lished [9:], and neither is the time-course of se"ual d sfunction in patients !ho persist !ith antidepressant treatment [93].

C/ Management of %exual 'ysfunction in 'epression

#he international studies demonstrate that the presence of se"ual d sfunction associated !ith antidepressant treatment can significantl reduce self-esteem and @ualit of life, and also impose $urdens on interpersonal relationships over and a$ove those associated !ith depression [+,, +1, 9?]. 'an approaches for managing patients trou$led $ se"ual d sfunction associated !ith antidepressant drugs have $een proposed, $ut the num$er of randomised place$o-controlled trials is limited, there is an a$sence of randomised controlled data evaluating the effect of ps chological interventions [/>], and none of the current approaches can $e considered 6ideal.7 If patients are concerned to preserve se"ual functioning, choosing an antidepressant from the list of those regarded as having fe!er adverse effects on se"ual functioning -#a$le +. is reasona$le, !hen other considerations allo!= ho!ever some of these antidepressants have other side effects, onl limited availa$ilit , or @uestiona$le efficac . &e"ual side effects of at least some antidepressants ma $e dose-related, and a reduction in dail dosage is a commonl adopted first-line approach to management [/+] -#a$le 2., $ut this approach ma contri$ute to a relapse of s mptoms and should $e contemplated onl for patients !ho have achieved a full s mptomatic remission and !ho have successfull completed the continuation treatment. Negular $rief interruptions of treatment -drug holida s. have previousl $een proposed as potentiall useful for some antidepressants [/2], $ut onl a proportion of patients descri$e improvements in se"ual function -and onl !ith some antidepressants., depressive s mptoms tend to !orsen, and discontinuation s mptoms can $e trou$lesome [/9], together ma5ing this approach to management potentiall haBardous and conse@uentl rather uncommon [/+].

#a$le 2 Commonl adopted strategies for managing se"ual d sfunction associated !ith antidepressant drugs. Cuestionnaire surve , U& ps chiatrists, e"pertise in managing

se"ual d sfunction [/+]. Percentages indicate the proportion of ph sicians using that strateg /// 'an ad;uvant compounds have $een advocated for relieving se"ual d sfunction associated !ith antidepressant drug treatment, though relativel fe! compounds have $een su$;ected to rigorous evaluation. Nandomised place$o-controlled trials indicate pro$a$le efficac for $upropion [/>], olanBapine [/>], testosterone gel [//], and the phosphodiesterase-, inhi$itors sildenafil -$oth in male and female patients [/,, /1]. and tadalafil [/:]. Comparative studies are rare, though a place$o-controlled stud found no evidence of efficac for augmentation !ith mirtaBapine, olanBapine, or ohim$ine in female patients [/3]. Augmentation of antidepressant treatment !ith aripipraBole is associated !ith improvements in se"ual interest and satisfaction in female depressed patients, independent of the improvement in depressive s mptoms [/?]. #hough s!itching from one antidepressant drug to another seems reasona$le and is a commonl adopted practice [/+]= place$o-controlled evidence of efficac for this approach rests on a stud of s!itching from sertraline to nefaBodone [/>]E furthermore s!itching a!a from one drug to another ma lead to discontinuation s mptoms, and the replacement drug ma prove less effective in controlling depressive s mptoms.

D/ The Role of #hosphodiesterase-C "nhibitors

Titric o"ide is involved in the ph siolog of the se"ual response, in $oth men and !omen. In men, nitric o"ide in the corpus cavernosum of the penis $inds to guan late c clase receptors, !hich results in increased levels of c clic guanosine monophosphate -cD'P., leading to smooth muscle rela"ation -vasodilation. of the intimal cushions of the helicine arteries, !hich in turn leads to vasodilation, increased flo! of $lood into the spong tissue of the penis, and resulting in erection. &ildenafil, tadalafil and vardenafil are potent and selective inhi$itors of cD'P-specific phosphodiesterase t pe , -PD*,., !hich is responsi$le for degradation of cD'P in the corpus cavernosum. #he molecular structure of sildenafil is similar to that of cD'P and acts as a competitive $inding agent of PD*, in the corpus cavernosum, resulting in more cD'P and facilitation of erection [,>]. In !omen, the role of nitric o"ide and its interpla !ith estrogen are less !ell understood, $ut phosphodiesterase t pe , inhi$itor enhancement of nitric o"ide-cD'P in nonadrenergic-noncholinergic signaling for !omen seems similar to men, and the release of nitric o"ide results in vasodilatation in clitoral and vaginal tissues [,+]. As noted a$ove, a series of randomised place$o-controlled trials have demonstrated that PD*-, inhi$itors are efficacious in resolving se"ual d sfunction associated !ith antidepressants [/,8/:]. In addition, studies of men !ith erectile d sfunction and depressive s mptoms -$ut not undergoing antidepressant treatment. indicate that prescription of PD*-, inhi$itors is often accompanied $ a reduction in depressive s mptom severit , an enhancement of @ualit of life, and an improvement in interpersonal relationships [,2, ,9]. Aurthermore, investigations in animal models indicate that nitric o"ide activit is an important vulnera$ilit factor in the Alinders rat depressive phenot pe [,/], that passage of PD*-, inhi$itors across the 6$lood-$rain $arrier7 is possi$le [,,], that sildenafil has antidepressant-li5e effects after central

muscarinic receptor $loc5ade [,1], and that administration of sildenafil can lead to a reversal of reduced social interactive $ehavior [,,]. Diven these o$servations, it could $e argued that the advent of treatment !ith PD*-, inhi$itors is a 6game-changer7 in the management of patients !ith se"ual d sfunction associated !ith antidepressants. )o!ever li5e other potential treatment approaches, PD*-, inhi$itors are not 6ideal,7 having side effects such as headache, d spepsia, and visual distur$ances and needing to $e used cautiousl in patients !ith cardiovascular disease, !hich is a common comor$idit !ith depression.

E/ Refined Approaches to #harmacotherapy

It seems possi$le that a gro!ing understanding of the influence of genetic pol morphisms ma see the adoption of la$orator approaches to identif ing patient su$groups at increased ris5 of developing se"ual side effects of antidepressant treatment. #he genome!ide association stud associated !ith the &#ANeD programme in the United &tates sho!s that ten single nucleotide pol morphisms -&TPs. ma mediate the effects of $upropion on se"ual side effects [,:], and another genome-!ide association stud in <apan indicates that ++ &TPs are associated !ith se"ual d sfunction associated !ith the antidepressants fluvo"amine, milnacipran, and paro"etine [,3]. &maller studies suggest that se"ual d sfunction associated !ith selective serotonin reupta5e inhi$itors ma $e influenced $ $oth the DD [,?] and the AA [1>] genot pe of the ,-)#2A receptor +/93 DIA pol morphism. Auture management options ma $e e"tended through the development of ne! antidepressant treatments !ith a lo!er ris5 of causing se"ual pro$lems. #hese could include compounds !ith effects on the ,-)#+A receptor, or !ith noradrenaline reupta5e inhi$itor properties or even complementar approaches, such as the use of &-adenos l-lmethionine -&A'e. [1+], 'aca root -Peruvian Dinseng. [12], or saffron [19]. At present, the evidence relating to the effects of drugs acting on the ,-)#+A receptor is intriguingE the partial agonist $uspirone has $een used to reduce se"ual d sfunction associated !ith selective serotonin reupta5e inhi$itors [1/, 1,], and the partial agonist gepirone improves se"ual functioning in depressed men, independent of antidepressant or an"iol tic effects [11]. #he novel antidepressant drug vilaBodone, !hich has $oth selective serotonin reupta5e inhi$itor and ,-)#+A partial agonist properties, appears to have a lo! incidence of adverse effects on se"ual functioning [1:, 13], as does the 6multimodal7 compound LuAA2+>>/ -vortio"etine., !hose pharmacological properties include full agonism at the ,-)#+A receptor [1?]. )o!ever, the e"perimental ,-)#+A full agonist O'L-1:> !as not efficacious in reversing se"ual d sfunction associated !ith fluo"etine or paro"etine [:>], and preclinical studies suggest that selective ,-)#+A antagonists can $oth prevent and reverse fluo"etine-induced se"ual d sfunction in rats [:+]. Although the antidepressant efficac of the selective noradrenaline reupta5e inhi$itor is limited [:2], randomised controlled trials indicate that it pro$a$l has fe!er adverse effects on se"ual function than selective serotonin reupta5e inhi$itors [9,, :9, :/]. #hese findings could encourage the further development of compounds !ith noradrenaline reupta5e inhi$itor properties as part of their mechanism of actionE a proof-of-concept

place$o-controlled stud !ith the novel 6triple reupta5e inhi$itor7 amitifadine suggests that it has a lo! propensit to !orsen se"ual function in depressed patients [:,], though the novel noradrenaline reupta5e inhi$itor LY22+1133/ !as associated !ith significantl more se"ual adverse events than place$o in a recent large place$o-controlled trial [:]. Lhilst these findings suggest a prospect for novel antidepressant treatments, less li5el to $e associated !ith se"ual adverse effects than man of the current medications, patient management currentl rests on ma5ing the $est use of the availa$le treatments. #his involves careful $ut sensitive en@uiries to esta$lish !hether se"ual difficulties are present, on choosing antidepressants !ith a lo!er li5elihood of !orsening se"ual d sfunction, !hen other considerations allo!= on ;udiciousl reducing antidepressant dosage, !hen this is feasi$le= and on gaining greater familiarit !ith the potential $enefits and dra!$ac5s of phosphodiesterase-, inhi$itors and other ad;uvant treatments.

onflict of "nterests
D. &. Gald!in has received research grants -funding to the Universit of &outhampton. from Gristol-' ers &@ui$$, Cephalon, *li Lill Ltd, Dla"o&mithPline, ). Lund$ec5 AI&, Pierre Aa$re, PfiBer Ltd, Noche, and Oernalis Ltd. )e has served on advisor $oards hosted $ Astra-\eneca, Gristol-' ers &@ui$$, *li Lill Ltd, Dla"o&mithPline, Drgnenthal, ). Lund$ec5 AI&, Pierre Aa$re, and PfiBer Ltd. )e is a past President of Depression Alliance and a current 'edical Patron of An"iet UP. '. C. PalaBBo and O. D. 'asdra5is report no conflict of interest.

Acknowledgments
#his paper is $ased upon a tal5 given $ D. &. Gald!in in the Tational Institute of 'ental )ealth in Angoda, &ri Lan5a, in 'a 2>+2.

Article information
Depress Nes #reat. 2>+9= 2>+9E 2,13/+. Pu$lished online 2>+9 Ae$ruar /. doiE +>.++,,I2>+9I2,13/+ P'CIDE P'C9,:,112 David &. Gald!in, + , 2 ,e '. Carlotta PalaBBo, 9 and Oasilios D. 'asdra5is / + Clinical and *"perimental &ciences Academic Unit, Aacult of 'edicine, Universit of &outhampton, &outhampton &%+/ 9D#, UP 2 Department of Ps chiatr , Universit of Cape #o!n, Cape #o!n, &outh Africa 9 Department of Pathoph siolog and #ransplantation, Universit of 'ilan and AondaBione INCC& Ca` Dranda, %spedale 'aggiore Policlinico, 2>+22 'ilan, Ital / Airst Department of Ps chiatr , *ginition )ospital, Athens Universit 'edical &chool, ++,23 Athens, Dreece eDavid &. Gald!inE *mailE ds$+IatIsoton.ac.u5 Academic *ditorE Charles G. Temeroff Neceived %cto$er +, 2>+2= Nevised Decem$er +3, 2>+2= Accepted <anuar 9, 2>+9.

Cop right W 2>+9 David &. Gald!in et al. #his is an open access article distri$uted under the Creative Commons Attri$ution License, !hich permits unrestricted use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from Depression Nesearch and #reatment are provided here courtes of $indawi #ublishing orporation

References
+. DeNogatis LN, Gurnett AL. #he epidemiolog of se"ual d sfunctions. ournal of %e:ual Medicine. 2>>3=,-2.E23?89>>. [Pu$'ed] 2. Le!is NL, Augl-'e er P&, Corona D, et al. DefinitionsIepidemiolog Iris5 factors for se"ual d sfunction. ournal of %e:ual Medicine. 2>+>=:-/.E+,?38+1>:. [Pu$'ed] 9. Ticolosi A, Laumann *%, Dlasser DG, 'oreira *D, Pai5 A, Dingell C. &e"ual $ehavior and se"ual d sfunctions after age />E the glo$al stud of se"ual attitudes and $ehaviors. *rolo#y. 2>>/=1/-,.E??+8??:. [Pu$'ed] /. Nosen N%, Aisher LA, *ardle I, Tieder$erger C, Tadel A, &and '. #he multinational 'en(s Attitudes to Life *vents and &e"ualit -'AL*&. stud E I. Prevalence of erectile d sfunction and related health concerns in the general population. Current Medical Research and .pinion. 2>>/=2>-,.E1>:81+:. [Pu$'ed] ,. Dennerstein L, Poocha5i P, Garton I, DraBiottin A. ) poactive se"ual desire disorder in menopausal !omenE a surve of Lestern *uropean !omen. ournal of %e:ual Medicine. 2>>1=9-2.E2+28222. [Pu$'ed] 1. Gasson N, Nees P, Lang N, 'onte;o AL, Incrocci L. &e"ual function in chronic illness. ournal of %e:ual Medicine. 2>+>=:-+.E9:/8933. [Pu$'ed] :. Angst <. &e"ual pro$lems in health and depressed persons. International Clinical Psychophar"acolo#y. +??3=+9-supplement 1.E&+8&9. [Pu$'ed] 3. C rano!s5i <', Grom$erger <, You5 A, 'atthe!s P, PravitB )', Po!ell L). Lifetime depression histor and se"ual function in !omen at midlife. Archives of %e:ual Behavior. 2>>/=99-1.E,9?8,/3. [Pu$'ed] ?. )egeman <', Po5 N', van der 'ast NC, Dilta *<. Phenomenolog of depression in older compared !ith ounger adultsE meta-anal sis. British ournal of Psychiatry. 2>+2=2>>E2:,823+. [Pu$'ed] +>. Lin CA, <uang YY, Len <P, Liu CY, )ung CI. Correlations $et!een se"ual d sfunction, depression, an"iet , and somatic s mptoms among patients !ith ma;or depressive disorder. Chan# Gun# Medical ournal. 2>+2=9,-/.E929899+. [Pu$'ed] ++. Laurent &', &imons AD. &e"ual d sfunction in depression and an"iet E conceptualiBing se"ual d sfunction as part of an internaliBing dimension. Clinical Psycholo#y Revie(. 2>>?=2?-:.E,:98,3,. [Pu$'ed] +2. Oulin5 TCC, Den s D, Gus L, Lesten$erg )D'. &e"ual pleasure in !omen !ith o$sessive-compulsive disorderY ournal of Affective $isorders. 2>>1=?+-+.E+?82,. [Pu$'ed] +9. A5sara D, Yel5en G, Paptanoqlu C, %flu &, rBaltin '. &e"ualit in !omen !ith o$sessive compulsive disorder. ournal of %e: and Marital Therapy. 2>>+=2:-9.E2:98 2::. [Pu$'ed]

+/. Lilliams P, Ne nolds 'A. &e"ual d sfunction in ma;or depression. C'% %pectru"s. 2>>1=++-supplement ?.E+?829. [Pu$'ed] +,. Lilliams O&L, Gald!in D&, )ogue &L, Aehnel &*, )ollis PA, *din )'. *stimating the prevalence and impact of antidepressant-induced se"ual d sfunction in 2 *uropean countriesE a cross-sectional patient surve . ournal of Clinical Psychiatry. 2>>1=1:-2.E2>/82+>. [Pu$'ed] +1. Lilliams O&L, *din )', )ogue &L, Aehnel &*, Gald!in D&. Prevalence and impact of antidepressant-associated se"ual d sfunction in three *uropean countriesE replication in a cross-sectional patient surve . ournal of Psychophar"acolo#y. 2>+>=2/-/.E/3?8 /?1. [Pu$'ed] +:. &erretti A, Chiesa A. #reatment-emergent se"ual d sfunction related to antidepressantsE a meta-anal sis. ournal of Clinical Psychophar"acolo#y. 2>>?=2?-9.E2,?8211. [Pu$'ed] +3. Dartlehner ), )ansen NA, 'organ LC, et al. Comparative $enefits and harms of second-generation antidepressants for treating ma;or depressive disorder. An updated meta-anal sis. Annals of Internal Medicine. 2>++=+,,-++.E::28:3,. [Pu$'ed] +?. Dem ttenaere P, <aspers L. Nevie!E $upropion and &&NI-induced side effects. ournal of Psychophar"acolo#y. 2>>3=22-:.E:?283>/. [Pu$'ed] 2>. Latana$e T, %mori I', Ta5aga!a A, et al. 'irtaBapine versus other anti-depressive agents for depression. Cochrane $ata-ase of %yste"atic Revie(s. 2>>:=+2-2.CD>>1,23 2+. Genelli A, Arigeri C, Gertolini A, Denedani &. Influence of mirtaBapine on the se"ual $ehavior of male rats. Psychophar"acolo#y. 2>>/=+:+-9.E2,>82,3. [Pu$'ed] 22. 'onte;o AL, Prieto T, #erleira A, et al. Getter se"ual accepta$ilit of agomelatine -2, and ,> mg. compared !ith paro"etine -2> mg. in health male volunteers. An 3!ee5, place$o-controlled stud using the PN&*KDC-&AL&*K scale. ournal of Psychophar"acolo#y. 2>+>=2/-+.E+++8+2>. [Pu$'ed] 29. Penned &), NiBvi &, Aulton P, Nasmussen <. A dou$le-$lind comparison of se"ual functioning, antidepressant efficac , and tolera$ilit $et!een agomelatine and venlafa"ine KN. ournal of Clinical Psychophar"acolo#y. 2>>3=23-9.E92?8999. [Pu$'ed] 2/. )ic5ie IG, Nogers TL. Tovel melatonin-$ased therapiesE potential advances in the treatment of ma;or depression. The Lancet. 2>++=9:3-?:?+.E12+819+. [Pu$'ed] 2,. \our5ova A, )adasova *. Paro"etine-induced conversion of c tochrome P/,> 2D1 phenot pe and occurence of adverse effects. General Physiolo#y and Biophysics. 2>>9=22-+.E+>98++9. [Pu$'ed] 21. \our5ova A, Ces5ova *, )adasovt *, Navuu5ovt G. Lin5s among paro"etineinduced se"ual d sfunctions, gender, and CYP2D1 activit . ournal of %e: and Marital Therapy. 2>>:=99-/.E9/989,,. [Pu$'ed] 2:. \our5ova A, &lanar %, <ar5ovs5 <, Palci5ova I, Pindurova *, Cvanova '. 'DN+ in paro"etine-induced se"ual d sfunction. ournal of %e: @ Marital Therapy . 2>+9=9?-+.E:+8:3. [Pu$'ed] 23. TaBareth I, Go nton P, Ping '. Pro$lems !ith se"ual function in people attending London general practitionersE cross sectional stud . British Medical ournal. 2>>9=92:-:/+2.E/298/21. [P'C free article] [Pu$'ed]

2?. Nead &, Ping ', Latson <. &e"ual d sfunction in primar medical careE prevalence, characteristics and detection $ the general practitioner. ournal of Pu-lic )ealth Medicine. +??:=+?-/.E93:89?+. [Pu$'ed] 9>. Nief L, Testoriuc Y, Oon Lilienfeld-#oal A, et al. Differences in adverse effect reporting in place$o groups in &&NI and tric clic antidepressant trialsE a s stematic revie! and meta-anal sis. $ru# %afety. 2>>?=92-++.E+>/+8+>,1. [Pu$'ed] 9+. )a$erfellner *'. A revie! of the assessment of antidepressant-induced se"ual d sfunction used in randomiBed, controlled clinical trials. Phar"acopsychiatry. 2>>:=/>-,.E+:98+32. [Pu$'ed] 92. NiBvi &<, Yeung TL, Penned &). Instruments to measure se"ual d sfunction in communit and ps chiatric populations. ournal of Psychoso"atic Research. 2>++=:>-+.E??8+>?. [Pu$'ed] 99. Diuliano A, )ellstrom L<D. #he pharmacological treatment of premature e;aculation. B * International. 2>>3=+>2-1.E11381:,. [Pu$'ed] 9/. Ain5 )A, 'acDonald N, Nut5s IN, Lilt #<. #raBodone for erectile d sfunctionE a s stematic revie! and meta-anal sis. B * International. 2>>9=?2-/.E//+8//1. [Pu$'ed] 9,. Gald!in D, Gridgman P, Guis C. Nesolution of se"ual d sfunction during dou$le$lind treatment of ma;or depression !ith re$o"etine or paro"etine. ournal of Psychophar"acolo#y. 2>>1=2>-+.E?+8?1. [Pu$'ed] 91. Gald!in D, 'oreno NA, Grile '. Nesolution of se"ual d sfunction during acute treatment of ma;or depression !ith milnacipran. )u"an Psychophar"acolo#y. 2>>3=29-1.E,2:8,92. [Pu$'ed] 9:. Lerne5e U, Torthe &, Ghugra D. Antidepressants and se"ual d sfunction. Acta Psychiatrica %candinavica. 2>>1=++/-1.E93/89?:. [Pu$'ed] 93. )u K), Gull &A, )un5eler *', et al. Incidence and duration of side effects and those rated as $othersome !ith selective serotonin reupta5e inhi$itor treatment for depressionE patient report versus ph sician estimate. ournal of Clinical Psychiatry. 2>>/=1,-:.E?,?8 ?1,. [Pu$'ed] 9?. Duevas ), Lee A, Grna$ic A<', et al. Are@uenc of treatment-emergent se"ual d sfunction and treatment effectiveness during &&NI or dulo"etine therap E 3-!ee5 data from a 1-month o$servational stud . International ournal of Psychiatry in Clinical Practice. 2>++=+,-2.E3>8?>. [Pu$'ed] />. #a lor '<, Nud5in L, )a!ton P. &trategies for managing antidepressant-induced se"ual d sfunctionE s stematic revie! of randomised controlled trials. ournal of Affective $isorders. 2>>,=33-9.E2/+82,/. [Pu$'ed] /+. Galon N, &egraves N#. &urve of treatment practices for se"ual d sfunction-s. associated !ith anti-depressants. ournal of %e: and Marital Therapy. 2>>3=9/-/.E9,98 91,. [Pu$'ed] /2. Nothschild A<. &elective serotonin reupta5e inhi$itor-induced se"ual d sfunctionE efficac of a drug holida . A"erican ournal of Psychiatry. +??,=+,2-+>.E+,+/8+,+1. [Pu$'ed] /9. Gald!in D&. &e"ual d sfunction associated !ith antidepressant drugs. !:pert .pinion on $ru# %afety. 2>>/=9-,.E/,:8/:>. [Pu$'ed] //. AmiaB N, Pope )D, 'ahne #, et al. #estosterone gel replacement improves se"ual function in depressed men ta5ing serotonergic antidepressantsE a randomiBed, place$o-

controlled clinical trial. ournal of %e: and Marital Therapy. 2>++=9:-/.E2/982,/. [Pu$'ed] /,. Turn$erg )D, )ensle PL, Delen$erg A<, Aava ', Lauriello <, Paine &. #reatment of antidepressant-associated se"ual d sfunction !ith sildenafilE a randomiBed controlled trial. ournal of the A"erican Medical Association. 2>>9=23?-+.E,181/. [Pu$'ed] /1. Turn$erg )D, )ensle PL, )eiman <N, Croft )A, De$attista C, Paine &. &ildenafil treatment of !omen !ith antidepressant-associated se"ual d sfunctionE a randomiBed controlled trial. ournal of the A"erican Medical Association. 2>>3=9>>-/.E9?,8/>/. [Pu$'ed] /:. &egraves N#, Lee <, &tevenson N, Lal5er D<, Lang LC, Dic5son NA. #adalafil for treatment of erectile d sfunction in men on antidepressants. ournal of Clinical Psychophar"acolo#y. 2>>:=2:-+.E12811. [Pu$'ed] /3. 'ichelson D, Poci$an P, #amura N, 'orrison 'A. 'irtaBapine, ohim$ine or olanBapine augmentation therap for serotonin reupta5e-associated female se"ual d sfunctionE a randomiBed, place$o controlled trial. ournal of Psychiatric Research. 2>>2=91-9.E+/:8+,2. [Pu$'ed] /?. Aava ', Dording C', Ga5er NA, et al. *ffects of ad;unctive aripipraBole on se"ual functioning in patients !ith ma;or depressive disorder and an inade@uate response to standard antidepressant monotherap E a post hoc anal sis of 9 randomiBed, dou$le-$lind, place$o-controlled studies. Pri"ary Care Co"panion to the ournal of Clinical Psychiatry. 2>++=+9-+.Ee+8e+>. [P'C free article] [Pu$'ed] ,>. Andersson P-*. 'echanisms of penile erection and $asis for pharmacological treatment of erectile d sfunction. Phar"acolo#ical Revie(s. 2>++=19-/.E3++83,?. [Pu$'ed] ,+. 'usic5i G, Liu #, Lagoda DA, Givalac@ua #<, &trong #D, Gurnett AL. *ndothelial nitric o"ide s nthase regulation in female genital tract structures. ournal of %e:ual Medicine. 2>>?=1-supplement 9.E2/:82,9. [P'C free article] [Pu$'ed] ,2. Turn$erg )D, &eidman &T, Delen$erg A<, Aava ', Nosen N, &ha$sigh N. Depression, antidepressant therapies, and erectile d sfunctionE clinical trials of sildenafil citrate -Oiagra. in treated and untreated patients !ith depression. *rolo#y B. 2>>2=1>-supplement 2.E,3811. [Pu$'ed] ,9. Nosen NC, &eidman &T, 'enBa 'A, et al. Cualit of life, mood, and se"ual functionE a path anal tic model of treatment effects in men !ith erectile d sfunction and depressive s mptoms. International ournal of I"potence Research. 2>>/=+1-/.E99/89/>. [Pu$'ed] ,/. Legener D, )arve G), Gonefeld G, et al. Increased stress-evo5ed nitric o"ide signalling in the Alinders sensitive line -A&L. ratE a genetic animal model of depression. International ournal of 'europsychophar"acolo#y. 2>+>=+9-/.E/1+8/:9. [Pu$'ed] ,,. Lie$en$erg T, )arve G), Grand L, Legener D, Grin5 CG. Chronic treatment !ith the phosphodiesterase t pe , inhi$itors sildenafil and tadalafil displa an"iol tic effects in Alinders &ensitive Line rats. Meta-olic Brain $isease. 2>+2=2:-9.E99:89/>. [Pu$'ed] ,1. Grin5 CG, Clapton <D, *agar G*, )arve G). Appearance of antidepressant-li5e effect $ sildenafil in rats after central muscarinic receptor $loc5adeE evidence from $ehavioural and neuro-receptor studies. ournal of 'eural Trans"ission. 2>>3=++,-+.E++:8+2,. [Pu$'ed]

,:. Clar5 &L, Ad5ins D*, A$erg P, et al. Pharmacogenomic stud of side-effects for antidepressant treatment options in &#AN D. Psycholo#ical Medicine. 2>+2=/2-1.E++,+8 ++12. [P'C free article] [Pu$'ed] ,3. Purose P, )iratsu5a P, Ishi!ata P, et al. Denome-!ide association stud of &&NII&TNI-induced se"ual d sfunction in a <apanese cohort !ith ma;or depression. Psychiatry Research. 2>+2=+?3-9.E/2/8/2?. [Pu$'ed] ,?. Gishop <N, 'oline <, *llingrod OL, &chultB &P, Cla ton A). &erotonin 2A -+/93 DIA and D-protein $eta9 su$unit C32,# pol morphisms in patients !ith depression and &&NI-associated se"ual side-effects. 'europsychophar"acolo#y. 2>>1=9+-+>.E223+8 2233. [Pu$'ed] 1>. Liang C&, )o P&, Chiang P#. &u )C. ,-)#-2A. receptor -+/93 DIA pol morphism and serotonergic antidepressant-induced se"ual d sfunction in male patients !ith ma;or depressive disorderE a prospective e"plorator stud . ournal of %e:ual Medicine. In press. 1+. Dording C', 'ischoulon D, &h u I, Alpert <*, Papa5ostas DI. &A'e and se"ual functioning. !uropean Psychiatry. 2>+2=2:l-1.E/,+8/,/. [Pu$'ed] 12. Dording C', Aisher L, Papa5ostas D, et al. A dou$le-$lind, randomiBed, pilot dosefinding stud of maca root -L. 'e enii. for the management of &&NI-induced se"ual d sfunction. C'% 'euroscience and Therapeutics. 2>>3=+/-9.E+328+?+. [Pu$'ed] 19. 'oda$$ernia A, &ohra$i ), Tasehi AA, et al. *ffect of saffron on fluo"etine-induced se"ual impairment in menE randomiBed dou$le-$lind place$o-controlled trial. Psychophar"acolo#y. 2>+2=229-/.E93+8933. [Pu$'ed] 1/. Torden '<. Guspirone treatment of se"ual d sfunction associated !ith selective serotonin re-upta5e inhi$itors. $epression. +??/=2-2.E+>?8++2. 1,. Landen ', *ri55son *, Agren ), Aahlen #. *ffects of $uspirone on se"ual function in depressed patients treated !ith selective serotonin reupta5e inhi$itors. ournal of Clinical Psychophar"acolo#y. +???=+?-9.E21382:+. [Pu$'ed] 11. Aa$re LA, Cla ton A), &mith LC, Doldstein I, Derogatis LN. #he effect of gepirone*N in the treatment of se"ual d sfunction in depressed men. ournal of %e:ual Medicine. 2>+2=?-9.E32+832?. [Pu$'ed] 1:. Citrome L. OilaBodone for ma;or depressive disorderE a s stematic revie! of the efficac and safet profile for this ne!l approved antidepressant-!hat is the num$er needed to treat, num$er needed to harm and li5elihood to $e helped or harmedY International ournal of Clinical Practice. 2>+2=11-/.E9,18913. [Pu$'ed] 13. Cla ton A), Penned &), *d!ards <G, Dallipoli &, Need CN. #he effect of vilaBodone on se"ual function during the treatment of ma;or depressive disorder. ournal of %e:ual Medicine. In press. 1?. Gald!in D&, Loft ), Dragheim '. A randomised, dou$le-$lind, place$o controlled, dulo"etine-referenced, fi"ed-dose stud of three dosages of LuAA2+>>/ in acute treatment of ma;or depressive disorder -'DD. !uropean 'europsychophar"acolo#y. 2>+2=22-:.E/328/?+. [Pu$'ed] :>. Gald!in D, )utchison <, Donaldson P, &ha! G, &mithers A. &elective serotonin reupta5e inhi$itor treatment-emergent se"ual d sfunctionE randomiBed dou$le-$lind place$o-controlled parallel-group fi"ed-dose stud of a potential ad;uvant compound, O'L-1:>. ournal of Psychophar"acolo#y. 2>>3=22-+.E,,819. [Pu$'ed]

:+. &u5off NiBBo &<, Pulicicchio C, 'al$erg <*, et al. ,-)#+A receptor antagonism reverses and prevents fluo"etine-induced se"ual d sfunction in rats. International ournal of 'europsychophar"acolo#y. 2>>?=+2-3.E+>/,8+>,9. [Pu$'ed] :2. Cipriani A, Auru5a!a #A, &alanti D, et al. Comparative efficac and accepta$ilit of +2 ne!-generation antidepressantsE a multiple-treatments meta-anal sis. The Lancet. 2>>?=9:9-?11,.E:/18:,3. [Pu$'ed] :9. Cla ton A), \a;ec5a <, Aerguson <', Ailipia5-Neisner <P, Gro!n '#, &ch!artB D*. Lac5 of se"ual d sfunction !ith the selective noradrenaline reupta5e inhi$itor re$o"etine during treatment for ma;or depressive disorder. International Clinical Psychophar"acolo#y. 2>>9=+3-9.E+,+8+,1. [Pu$'ed] :/. Lang!orth &, Godlund %, wgren ). *fficac and tolera$ilit of re$o"etine compared !ith citalopramE a dou$le-$lind stud in patients !ith ma;or depressive disorder. ournal of Clinical Psychophar"acolo#y. 2>>1=21-2.E+2+8+2:. [Pu$'ed] :,. #ran P, &5olnic5 P, CBo$or P, et al. *fficac and tolera$ilit of the novel triple reupta5e inhi$itor amitifadine in the treatment of patients !ith ma;or depressive disorderE a randomiBed, dou$le-$lind, place$o-controlled trial. ournal of Psychiatric Research. 2>+2=/1-+.E1/8:+. [Pu$'ed]

)istor of the )uman &ciences &AD* Pu$lications

ontested psychiatric ontology and feminist criti3ue

XAemale &e"ual D sfunction( and the $ia#nostic and %tatistical Manual Patherine Angel Additional article information

Abstract
In this article I discuss the emergence of Aemale &e"ual D sfunction -A&D. !ithin American ps chiatr and $e ond in the post!ar period, setting out !hat I $elieve to $e important and suggestive @uestions neglected in e"isting scholarship. #racing the nomenclature !ithin successive editions of the American Ps chiatric Association(s $ia#nostic and %tatistical Manual -$%M., I consider the reification of the term XA&D(, and the activism and scholarship that the rise of the categor has occasioned. I suggest that anal sis of A&D $enefits from scrutin of a !ider range of sources -especiall since the popular and scientific cross-pollinate.. I e"plore the multiplicit of A&D that emerges !hen one e"amines this !ider range, $ut I also underscore a reinscri$ing of an"ieties

a$out ps chogenic aetiologies. I then argue that !hat ma5es the A&D case additionall interesting, over and a$ove other conditions !ith a contested status, is the historicall comple" relationship $et!een ps chiatr and feminism that is at !or5 in contemporar de$ates. I suggest that e"isting literature on A&D has not et posed some of the most important and salient @uestions at sta5e in !riting a$out !omen(s se"ual pro$lems in this period, and can onl do this !hen the relationship $et!een Xsecond-!ave( feminism, Xpost-feminism(, ps chiatr and ps choanal sis $ecomes part of the terrain to $e anal sed, rather than the medium through !hich anal sis is conducted. !eywords: American Ps chiatric Association, $ia#nostic and %tatistical Manual, Aemale &e"ual D sfunction, feminism and post-feminism, ps chiatric ontologies

"ntroduction
XAemale &e"ual D sfunction( -A&D. is a term that has gained in medical, ps chiatric and media prominence in recent decades, especiall in the last +, ears. It is not in itself a diagnostic categor , $ut has gained a currenc that can sometimes suggest other!ise. Aemale se"ual pro$lems are currentl classified in the American Ps chiatric Association(s /th edition of the $ia#nostic and %tatistical Manual -$%M. -American Ps chiatric Association, 2>>>., in a section on &e"ual D sfunctions -separate $oth from the paraphilias and from gender identit disorders., and assem$ling diagnoses relating to desire, arousal, orgasm and pain -see ta$le +.. #he $%M(s rise has $een much criticiBed, and !hile the gro!ing discussions of A&D are praised $ researchers and scientists as an inde" of a long-overdue attention to !omen(s se"ualit 8 a triumph of feminism -Gasson et al., 2>>+= German and German, 2>>+. 8 critics have underscored the lin5 $et!een this rene!ed medical attention and pharmaceutical interests in launching a compound compara$le to Oiagra for X*rectile D sfunction( -#iefer, 2>>3= Pascha5 and #iefer, 2>>+= Loe, 2>>/..

#a$le +. $%M-IO, +??/. #he A&D de$ate pla s itself out in the pu$lic and popular domains as !ell as in the medical, ps chiatric and se"ological realms. *"isting historical scholarship on female se"ualit in the post!ar period focuses primaril on se"olog -e.g. Derhard, 2>>+= Irvine, +??>.. In this article, I suggest that anal sis of A&D $enefits $oth from scrutin of a !ider range of sources -especiall since the popular and scientific cross-pollinate., and from an approach from the histor of ps chiatr , in particular one that pro$es de$ates a$out the

ontolog and aetiolog of se"ual disorders, and the relationship $et!een feminism and ps chiatr in the post!ar period. I suggest that e"isting literature on A&D has not et posed some of the most important and salient @uestions at sta5e in !riting a$out !omen(s se"ual pro$lems in this period, and can onl do this !hen the relationship $et!een `second-!ave` feminism, `post-feminism`, ps chiatr and ps choanal sis $ecomes part of the terrain to $e anal sed, rather than the medium through !hich anal sis is conducted. I $egin $ outlining a $rief s5etch of female se"ual pro$lems in the 2>th centur , and their rendering in the first t!o post!ar $%Ms. I then give an account of the emergence of $%M-III in +?3>, and the classifications of se"ual disorders in this manual. I then discuss $oth the reification of XA&D( as a term, in relation to Oiagra(s emergence in the late +??>s, and the recent activism and scholarship around A&D. I e"plore the multiplicit of A&D that emerges !hen one e"amines a !ider range of sources, $ut also underscore a reinscri$ing of an"ieties a$out ps chogenic aetiologies. I then argue that !hat ma5es the A&D case additionall interesting, over and a$ove other conditions !ith a contested status, is the historicall comple" relationship $et!een ps chiatr and feminism that is at !or5 in contemporar de$ates. I conclude !ith some thoughts a$out Xpost-feminism( and the historiographical challenges raised $ A&D.

%exual problems and the DSM

Lomen(s se"ual pro$lems have $een !ritten a$out prolificall during the 2>th centur , in se"ological, g necological, ps chiatric and ps choanal tic literature, as !ell as marital advice material -e.g. *llis, +3?:8+?23= Prafft-*$ing, +3??= )itschmann and Gergler, +?91= &te5el, +?91= &topes, +?+3= Lright, +?,,[+?9>]= Oan de Oelde, +?23[+?21]= Dra , +?29= see Lun$ec5, +??/= Do!ning, 2>>/= Irvine, +??>= 'aines, +???= Coo5, 2>>/= Cr le, 2>>?= Angel, 2>+>.. Ps chiatr has $een salient in these discussions due to the mutuall entangled development of ps chiatr , se"olog and criminolog in the last @uarter of the +?th centur -Aoucault, +?:?= Gland and Doan, +??3= Davidson, 2>>+.. A forensic rationale fostered a focus in late +?th- and earl 2>th-centur se"olog on se"ual $ehaviours and identities, !ith the reification of classifications such as homose"ualit , sadism, masochism and fetishism. Arigidit 8 and its flip-side, n mphomania 8 !ere much invo5ed preoccupations in the first half of the 2>th centur , enduring until the +?1>s at least= other concepts throughout the centur have included se"ual anaesthesia, se"ual inhi$ition, anorgasmia, or preorgasmia, and, from the +?:>s, se"ual d sfunction. Arigidit especiall has $een a semanticall shifting term variousl meaning !omen(s natural lac5 of desire, their unnatural failure to e"perience a normal desire, their failure to $ecome aroused, failure to reach orgasm, or failure to reach va#inal orgasm -Loe!enfeld, +3??= Acton, +312, @uoted in *llis, +?>3E +,:83= )itschmann and Gergler, +?91= &te5el, +?91= )uhner, +?9:.. A vast literature has documented the neo-Areudian lin5ing of a range of social and ps chological ills to a clitoral, rather than a vaginal, se"ualit , !here the outlining of norms for female se"ualit has functioned as a !a of defining norms of femininit and heterose"ualit -e.g. in A$raham, +?2>= Gonaparte, +?,9= Deutsch, +?//8 ,= see Guhle, +??3= Lun$ec5, +??/= Irvine, +??>= 'aines, +???= Do!ning, 2>>/..

In the post!ar period, the American Ps chiatric Association -APA. and its $%M loom increasingl large in ps chiatr and in matters se"ual. In its +st edition in +?,2 -an attempt to consolidate the man local variations to the American 'edico-Ps chological Association(s e"isting nomenclature and a proliferation of militar nomenclatures., pro$lems such as impotence and frigidit are an instance of XPs choph siological autonomic and visceral disorders( -under a larger group of XDisorders of ps chogenic origin or !ithout clearl defined ph sical cause or structural change in the $rain(., of !hich a Xps choph siological genito-urinar reaction( is an instance. Le are told that these include Xsome t pes of menstrual distur$ance, d suria, and so forth, in !hich emotional factors pla a causative role( -American Ps chiatric Association, +?,2E 9>.. -&ee ta$le 2..

#a$le 2. $%M-I, +?,2. #hese disorders represent the visceral e"pression of affect that is often Xprevented from $eing conscious(. & mptoms are due to a Xchronic and e"aggerated state of the normal ph siological e"pression of emotion, !ith the feeling, or su$;ective part, repressed. &uch long continued visceral states ma eventuall lead to structural change( -American Ps chiatric Association, +?,2E 2?.. In the +?13 $%M-II -see ta$le 9., !e see a slight variation of this= Xps choph siological disorders( include Xgenito-urinar disorders such as distur$ances in menstruation and micturition, d spareunia, and impotence in !hich emotional factors pla a causative role( -American Ps chiatric Association, +?13E /:.. #hese Xps choph siological disorders( are characteriBed $ x ph sical s mptoms that are caused $ emotional factors and involve a single organ s stem, usuall under autonomic nervous s stem innervation. #he ph siological changes involved are those that normall accompan certain emotional states, $ut in these disorders the changes are more intense and sustained. #he individual ma not $e consciousl a!are of his emotional state. -American Ps chiatric Association, +?13E /1.

#a$le 9. $%M-II, +?13.

Little detail is given, then, of the specific 5inds of disorders included in these categories -in $%M-I, readers are told that each diagnosis of Xps choph siologic autonomic and visceral disorders( !ill $e Xamplified !ith the specific s mptomatic manifestations, e.g. anore"ia, loss of !eight, d smenorrhea, h pertensions, and so forth( -American Ps chiatric Association, +?,2E 2?., and the 5inds of disorders enumerated are not meant to $e comprehensive. An aetiological process is posited, and it is the process 8 rather than its specific manifestations 8 that is salient. In their focus on unconscious, repressed emotions, the manuals( terminolog reflects the importance !ithin American ps chiatr , $et!een the +?9>s and +?1>s, of an American-inflected ps choanal sis -)ale, +??,.= in their emphasis on ph siological changes that accompan certain emotions, and eventuall , if sustained for long enough, lead to structural damage, the reflect the influence of a ps chosomatic medicine much shaped $ AranB Ale"ander -Ale"ander, +?92, +?,>= Gro!n, 2>>>= Dreco, +??3.. 'oreover, the manuals, in their emphasis on mental illness as on a continuum !ith health, also voice the influence of Adolf 'e er(s ps cho$iolog , in !hich environmental factors interacted !ith certain predisposing factors in an individual to determine his or her capacit to adapt to that environment -'e er, +?,2.. #he $%M-III of +?3>, ho!ever, ushers in significant changes in classification, mar5ing an important shift in ps chiatr (s 2>th-centur histor .

DSM-"""
#he $%M-III of +?3> emerged out of a period of intense controvers and @uestioning in the ps chiatric profession and $e ond. Ps choanal sis !as at the core of American ps chiatr $ the +?,>s, $ut increasingl competing !ith other emerging forms of ps chotherap , and increasingl challenged $ a criti@ue of its scientific validit made $ academic ps chologists, $ehaviourists and philosophers !ho @uestioned the ver possi$ilit of its generating verifia$le predictions and testa$le theories -see * senc5, +?,?= * senc5, +?1,-a., +?1,-$.= Popper, +?19= )oo5, +?,?= Aisher and Dreen$erg, +?::= Areedheim, +??2= Lu$ors5 , +?:,= Lallerstein, +?11= see )ale, +??,E ch. +:.. In addition, insurers !ere $ecoming un!illing to fund long ps choanal tic treatments !hose efficac !as under @uestion -'a es and )or!itB, 2>>,.. And the criti@ue of ps choanal sis overlapped !ith some strands of the Xanti-ps chiatr ( movement, !hich challenged !hat it sa! as diagnostic promiscuit and a$usive and authoritarian relationships to the patient 8 !ith some criti@ues focusing particularl on the gender $iases at !or5 in ps choanal sis+ -&BasB, +?12= Laing, +?1>, +?1/= &cheff, +?11= Doffman, +?1+= Gec5er, +?19= &ullo!a , +?:?= NoaBen, +?:1= Grome, +?1:= 'eda!ar, +?:,= Delfman, +?1?= Aliegel, +?:9= Dilman, +?:+, +?::= Ariedan, +?19= Chesler, +?:2= 'illett, +?:>= see Dro$, +??+= )ale, +??,= &horter, +??:= )eal , 2>>2, +??:= Dain, +?3?= T e, 2>>9= %s$orne, +??2= Appignanesi and Aorrester, 2>>>= #omes, +??/.. #his scientific and cultural dissatisfaction !as reflected in professional concern over diagnostic confusion and classificator unrelia$ilit , !ith star5 disparities in diagnostic trends causing em$arrassment -see &tengel, +?,?= Pramer, +?1?= Pendell et al., +?:+= L)%, +?:9.. In the late +?:>s at the APA, No$ert &pitBer, trained in $oth medicine and ps choanal sis, !as appointed to the ne! tas5 force to revise the $%M. )e and his colla$orators !ere committed to several a"ioms a$out ps chiatr and mental illness that

overturned the 5e assumptions of previous $%Ms= namel , that there is a $oundar $et!een the normal and the sic5= that there are discrete mental illnesses= and that the focus Xof ps chiatric ph sicians should $e particularl on the $iological aspects of mental illness( -Plerman, +?:3E +>/, see Ga er and &pitBer, +?3,.. #he $%M-III sought to remove aetiological assumptions -of a ps choanal tic 5ind, emphasiBing neurosis and defences. that it argued !ere unsupported. Disorders !ere discrete, and operationaliBed relia$l $ sets of s mptom criteria -Nogler, +??:.= an effect, argues )eal , of the rise of the randomiBed, place$o-controlled trial to test ne! medications re@uired $ the ADA prova$l to target clearl defina$le illness -see )eal , +??:, 2>>2= Pignarre, 2>>/.. )ighl controversial at the time for its e"cision of ps choanal tic conceptions, the $%MIII has consistentl provo5ed controvers since, though latterl focused on the $%M(s e"pansion and its role in providing a rationale for pharmaceutical products -'a es and )or!itB, 2>>,= )or!itB and La5efield, 2>>:= Pir5 and Putchins, +??2= Putchins and Pir5, +??:= Angell, 2>++= Latters, 2>+>= Lane, 2>>:= La5off, 2>>,= 'o nihan and 'intBes, 2>+>.. Aor good or for ill, the $%M is no! Xconnective tissue for $iomedical ps chiatr (, $inding together measurement tools, diagnosis, treatment, research, drug assessment, epidemiolog , insurance, and the la! -La5off, 2>>,E +9..

The DSM-""" and sexual dysfunctions

$%M-III ielded an increasingl detailed and differentiated classification of disorders, su$sumed under a ne! splitting of diagnostic areas -e.g. XTeurotic Disorders( !ere dispensed !ith, $ut s mptomatic remnants !ere distri$uted into the affective, an"iet , somatoform and dissociative disorders. -see Nogler, +??:.. #he manual reorganiBes the t!o categories of se"ual pro$lems that e"isted in $%M-I and $%M-II= instead of entirel separate categories and chapters for X&e"ual Deviations( and XPs choph siological Denito-urinar Disorders(, in $%M-III !e have an overarching chapter on XPs chose"ual Disorders(. -&ee ta$le /..

#a$le /. $%M-III, +?3>. #his is $ro5en do!n into gender identit disorders, paraphilias and ps chose"ual d sfunctions -!ith the latter using gender as a defining principle.. #he revised $%M-III-N of +?3: changed XPs chose"ual D sfunctions( to X&e"ual D sfunctions(, and lists the various disorders under the overarching categories of X&e"ual Desire Disorders(, X&e"ual Arousal Disorders(, X%rgasm Disorders( and X&e"ual Pain Disorders(, among other changes -see ta$le ,.. $%M7IO -+??/. remains much the same, e"cept that XInhi$ited female orgasm( $ecomes XAemale orgasmic disorder(. -&ee ta$le +..2

#a$le ,. $%M-III-N, +?3:. #he classification, since $%M-III, is much inde$ted to the !or5 of 'asters and <ohnson, !hose )u"an %e:ual Response and )u"an %e:ual Inade=uacy !ere pu$lished in +?11 and +?:> respectivel . 'asters and <ohnson !ere not the first to approach se"ual pro$lems !ith a form of $ehavioural conditioning, or to emphasiBe the clitoris in female se"ual pleasure -Nachman, +?1+= LaBarus, +?19= Pinse et al., +?,9= see also Do!ning, 2>>/.. Gut their detailed ph siological studies heralded the professionaliBation of a $ehaviouristicall inflected se" therap . Concerned to dra! a near-total e@uivalence $et!een male and female se"ual function,9 the outlined a four-stage X)uman &e"ual Nesponse C cle( -e"citement, plateau, orgasm, resolution., and three female se"ual disordersE d spareunia, vaginismus and orgasmic d sfunction -primar and secondar . -'asters and <ohnson, +?11, +?:>.. -#he pro$lems for men !ere premature e;aculation, e;aculator incompetence and primar and secondar impotence.. 'asters and <ohnson(s ideas and nomenclature !ere mediated through )elen &inger Paplan, !ho !as a mem$er of the &e"ual Disorders Committee for $%M-III, and a se" therapist and ps choanal st !ho sought to com$ine $ehaviourist and ps choanal tic models in her !or5. &he modified their nomenclature into a three-stage model of desire, e"citement and orgasm, incorporated into the document -American Ps chiatric Association, +?3>= #iefer, 2>>/E ,+82.. #ogether !ith ps choanal st )arold Lief, !ho also served on the $%M-III &e"ual Disorders Committee, she ensured that pro$lems of desire, as !ell as those of arousal and orgasm, !ere foregrounded -see Paplan, +?:: and +?:?= Lief, +?::.. APA archival material, ho!ever, also reveals that ps choanal st No$ert &toller, !ith !hom &pitBer 5ept up a detailed correspondence, similarl -and earlier. suggested a$andoning 'asters and <ohnson(s distinction $et!een the e"citement and plateau phasesE #here is one issue !ith !hich I am out of step as compared to other colleagues in se" research. I am not sure there is good reason to separate out an e"citement phase from a plateau phase. I do not $elieve that !hat is called Xplateau( is an thing other than e"citement. It is as if !e !ere to divide e"citement into a num$er of non-distinguisha$le episodes= such distinctions have no real function. -&toller, +?::. #his rene!ed emphasis on desire 8 pro$lems of !hich had $een a significant component of the neo-Areudian !ritings on frigidit 8 undid an emphasis on the mechanics of arousal and orgasm in 'asters and <ohnson. Paplan(s categories of Xinhi$ited( desire, e"citement and orgasm reinscri$ed a ps choanal tic affinit , !ith the concept of

inhi$ition containing !ithin it the ps choanal tic connotations of s mptoms resulting from the defences mounted against an"iet . &o !hile criticisms of the $%M(s A&D nomenclature have tended to focus on their allegedl uncritical adoption of a fla!ed and mechanistic 'asters and <ohnson model -#iefer, 2>>/., and criticisms of the methods and rationale of the $%M-III Xrevolution( have underlined &pitBer(s ruthless eviction of ps choanal sis from the manual -and the profession. -Putchins and Pir5, +??:., it appears that, at least for the &e"ual Disorders, this narrative of eviction does not hold up so !ell, suggesting that a vision of the move to $%M-III as involving a star5 and !holesale shift a!a from ps choanal tic concepts is in need of some refinement.

F*emale %exual 'ysfunction and F)rectile 'ysfunction

In 'asters and <ohnson(s $oo5s, the term Xfemale se"ual d sfunction( operated simpl as a generic description rather than as a specific diagnosis= it signified an pro$lem !ith se"ual function as identified in the human se"ual response c cle. Gut the term XAemale &e"ual D sfunction( $ecomes more prominent after their pu$lications, ho!ever. It $egins to appear in medical and scientific ;ournals as a phrase onl from +?:: on!ards= half a doBen results appear in the +?:>s, and the same num$er in the +?3>s 8 a period !hen the term Xfrigidit ( is !aning in fre@uenc . %ccurrences of XA&D( from the +??>s on!ards ;ump to $eing in the ,>>s. And et there is in fact no such term XA&D( in the $%Ms= the chapter headings are XPs chose"ual Disorders( -$%M-III. or X&e"ual Disorders( -$%MIII-N., under !hich the various su$t pes appear. #his ;ump in A&D discourse occurs around the time of Oiagra(s licensing for *rectile D sfunction -*D. in +??3. Oiagra(s apparentl phenomenal success, and its astounding sales, put a premium on finding a similar drug for !omen. Pharmaceutical companies rushed to test Oiagra in !omen and sought to develop other compounds -Loe, 2>>/= )artle , 2>>9, 2>>1.. Lhat !e see, from the +??>s on!ards, is a significant slippage $et!een XA&D( as a generic um$rella term 8 !here the general t pe of d sfunctions is se"ual, and the Xfemale( !or5s as a @ualifier 8 to XA&D( figuring as a condition in itself, a slippage ena$led $ the use of the singular term Xd sfunction(. An e"ample is a +??? article $ <ennifer and Laura German and Ir!in Doldstein -prominent and prolific authors 8 the former in scientific and popular te"ts 8 on *D and A&D., !hich opens thusE XAemale se"ual d sfunction is age-related, progressive, and highl prevalent, affecting 9>4 to ,>4 of !omen( -German et al., +???aE 93,.. Lhile the go on to specif particular areas of diagnosis such as Xvaginal lu$rication, pain and discomfort !ith intercourse, decreased arousal, and difficult achieving orgasm(, the also state that Xour 5no!ledge and understanding of the anatom and ph siolog of the female se"ual response and the pathoph siolog of female se"ual d sfunction is limited(. And et, some of the diversit of se"ual pro$lems having $een roll-called, the slippage to the phrase Xpathoph siolog of female se"ual d sfunction( assumes that the path!a to these diverse phenomena is one and the same, though it remains to $e clearl elucidated. In other !ords, it casts Xfemale se"ual d sfunction( as a condition in itself. #his pattern is much repeated else!here, and articles fre@uentl use the term XA&D( in the title, $ut @uic5l move in the te"t to specif ing disorders under

consideration -%(Donohue et al., +??:= &ar!er and Durla5, +??1.. A recent e"ample is Aigueroa-)aas -2>+2., !ho uses XAemale &e"ual D sfunction( in the title, and !rites the follo!ingE Aemale se"ual d sfunction -A&D. occurs !hen a !oman is una$le to full e"perience pleasure during se"ual activit . #his d sfunction can affect a !oman(s @ualit of life and lead to personal distress and interpersonal impairments. It is defined as disorders of se"ual desire, arousal, orgasm, and se"ual pain. An estimated />4 of !omen are affected $ se"ual d sfunction and + in / is una$le to achieve orgasm. -Aigueroa-)aas, 2>+2E +,1. In this particularl confused e"ample, A&D is cast as a disorder in itself, offering a definition of XA&D( as Xdisorders of desire, arousal( and so on 8 !hereas these categories are not definitions of a disorder, $ut the diagnostic categories su$sumed under a generic term for them. 'oreover, it emphasiBes pleasure, !hich potentiall $rac5ets out desire pro$lems. Lhat !e are seeing here is A&D $eing used as an analogue 8 a counterpart 8 to *D, as in an article entitled XLifest leIDietar Necommendations for *rectile D sfunction and Aemale &e"ual D sfunction( -*sposito and Diugliano, 2>++.. Gut *D is one diagnostic categor applica$le to men in the X&e"ual Disorders( section of the $%M, !hile A&D is not its e@uivalent 8 it is a generic um$rella term for diagnoses that var significantl . #his reification of XA&D( $oth reflects and $olsters the desire to see XA&D( as a discrete, $ounded diagnostic categor amena$le to a technolog that !ould target it in the allegedl specific !a Oiagra did for *D 8 a desire that nonetheless has ielded little in the !a of concrete results./

Acti+ism and scholarship

#he rise of XA&D( and pharmaceutical efforts around it has provo5ed considera$le controvers as !ell as activism. Te! Yor5 se"ologist Leonore #iefer founded the Te! Oie! Campaign, Xchallenging the medicalisation of se"( -see Pascha5 and #iefer, 2>>+., after the increase, post-Oiagra, in the Xmar5eting( of A&D, having previousl !ritten a$out *D -#iefer, +??/, 2>>/.. #he campaign sees Oiagra as reinforcing a mechanical vie! of se"ualit , rendering penetration and orgasm the pinnacle of se"ual activit , and e"pressing hetero-normative ideals of se"ual $ehaviour. It argues that A&D discourse reduces se"ualit to the purel $iological as malfunctions of vascular, hormonal, or cere$ral s stems to $e fi"ed $ pharmacological intervention, suggesting instead that female se"ual pro$lems especiall are highl conte"tual 8 the result of social, cultural and political factors -lac5 of communication $et!een partners= e"haustion due to ine@ualities in child-rearing and house!or5= an"ieties a$out $od image= violence from se"ual partners= and misunderstandings of female anatom = [see httpEII!!!.ne!vie!campaign.orgImanifesto.asp].. #he campaign has received gro!ing press coverage in the last fe! ears -Oernon, 2>+>= &ample, 2>>?= Independent, 2>+>a= Laurence, 2>+>= Independent, 2>+>$..

#he campaign is also interlin5ed !ith a gro!ing scholarship on A&D, the $%M and pharmaceutical developments for se"ual pro$lems -much coming from social science, @ualitative research and science studies., part of a larger movement challenging the XmedicaliBation( of pro$lems seen as social, political, conte"tual and relational in nature -Cacchioni, 2>>:= see Potts, 2>>>= Potts et al., 2>>/= Potts et al., 2>>9 for material on masculinit and Oiagra= Namage, 2>>1a, 2>>1$= Aishman, 2>>/= Ticolson and Gurr, 2>>9= Pascha5 and #iefer, 2>>+= Potts, 2>>3.. Polemical and general audience !or5s are also interlin5ed !ith the campaign -Dre!, 2>>9= 'o nihan and Cassels, 2>>,= 'o nihan and 'intBes, 2>+>.. 'an of these !or5s o!e much in spirit to the discourses of Xanti-medicaliBation( that have $een such a prominent part of de$ates a$out medicine and ps chiatr since the +?1>s. And the o!e much to a component of second-!ave feminism, suspicious of ps chiatric e"pertise and professional e"pansion of authorit over !omen(s health, $odies and minds -e.g. X#o!ards a Aeminist &e" #herap (, in #iefer, 2>>/.. #hat the e"isting scholarship ta5es its impetus largel from activist concerns has some important methodological conse@uences. It necessitates and e"plains a focus on the $%M and on pharmaceutical developments. Gut in conse@uence, it narro!l construes the A&D landscape, glossing over resources such as !omen(s magaBines and self-help $oo5s, for instance, !hich spea5 in an emotional, ps chological and $ehavioural register. 'oreover, it also glosses over the multiplicit at !or5 in medical te"ts themselves.

Multiplicity
#a5e, for e"ample, the pages of Cos"opolitan. %e" ps chotherapist Nachel 'orris responds to a letter a$out li$ido pro$lemsE XA lac5 of desire can $e due to man things(, hormone im$alance included, x $ut usuall it(s do!n to a ps chological or emotional $loc5. #here are so man reasons to frea5 out a$out se" 8 !hat if I(m no goodY Lhat if I don(t orgasmY It could $e that ou let negative thoughts freeBe desire $efore it starts. x Adding pressure !ill onl ma5e it !orse, and stress, depression and an"iet are li$ido 5illers. &e"ualit can(t $e forced 8 it has a life of its o!n. #al5 to our DP and as5 for ps chose"ual counselling. -Cos"opolitan, 'a 2>>+E 91. &imilarl , <ennifer and Laura German, authors of the $est-selling 4or Ao"en .nly8 A Revolutionary Guide to .verco"in# %e:ual $ysfunction and Reclai"in# Bour %e: Life -German is also the author of The Passion Prescription8 Ten Aee9s to Bour Best %e: + !verC., and prolific in medical ;ournals also, advocate a significantl medical and pharmacological frame!or5 for se"ual pro$lems, especiall the virtues of Oiagra and testosterone= $ut the too see fantas , imagination and thoughts as 5e to Xhelping ourself( !ith our se"ual pro$lems. In these te"ts, emotional, $ehavioural and cognitive ha$its are on a par !ith medical drugs, pornograph and se" to s= factors 5e to enhancing pleasure and overcoming se"ual pro$lems. Li5e!ise, health information !e$sites such as Tetdoctor identif a range of factors in se"ual pro$lems -Le$$er and

Delvin, 2>++., and a representative article in the A"erican 4a"ily Physician lists, as possi$le causes of se"ual pro$lemsE medicines= dia$etes= high $lood pressure= alcohol= vaginal infections= menopause= depression, Xan unhapp relationship or a$use -no! or in the past.(= the stresses of ever da life, or $eing X$ored $ a long-standing se"ual routine( - A"erican 4a"ily Physician, 2>>>E +/+82.. #he ontolog of se"ual pro$lems !e see in a range of resources is, I thin5, more cacophonous and multiple than a focus on pharmacological reductionism suggests. It is perhaps an inde" of a late 2>th- and earl 2+st-centur Xsurveillance( medicine in !hich multiple s mptoms and signs $ecome ris5 factors for future outcomes -Armstrong, +??,= Nose, 2>>:.. And et, !hile a great man things 8 hormones and emotional $loc5s, as Cos"opolitan tells us 8 are relevant to se"ual pro$lems, the are not all e@ual. A 5ind of ontological hierarch is asserted in a range of te"ts, !ith those construed as ps chosomatic, ps chological, or ps chod namic 8 as parta5ing of the Xunscientific( ps chiatr !hich $%M-III overturned 8 figuring as morall and scientificall fraught. A 2>>+ Consensus Neport !ritten $ prominent urologists and ps chiatrists, for e"ample, proposes a nomenclature that !ould cover $oth Xps chogenic and organicall $ased disorders( -unli5e the $%M, !hich it descri$es as narro!l ps chiatric, Xnot intended to $e used for classification of organic causes of female se"ual d sfunctions(= Gasson et al., 2>>+E ?2.. #his is a curious reading of the $%M, given the latter(s insistence on its o!n nature as providing a medical nomenclature, and as aetiologicall neutral -American Ps chiatric Association, +??/E "vii8"viii.. Gut it reveals there$ the am$ivalence !ith !hich the past of ps chiatr 8 !ith its aetiologies that so prioritiBed ps chogenic factors in causing s mptoms 8 is e"perienced. Location in the $%M is pro$lematic, signalling a discomfort !ith ps chiatric theoriBing that also sustains the claim that female se"ualit , unli5e male se"ualit , has not, historicall , $een the su$;ect of medical scrutin -Gasson et al., 2>>+E 398/. 8 a claim that overloo5s the location of female se"ual pro$lems !ithin se"ological, ps chiatric and ps choanal tic !or5 in the 2>th centur . As such, it reflects a contemporar discomfort !ith the ps chod namic past of ps chiatr that necessitates defining it, retrospectivel , as non-medical. Ps chiatr , its o!n medical protestations not!ithstanding, is e"perienced as a trou$ling fringe discipline !ith a trou$ling pastE female se"ual pro$lems should $e removed Xfrom the realm of primaril ps chiatric disorders x into the "ainstrea" of research and treatment( -Nosenthal, 2>>+E 2>9= emphasis added.. #he fraught status of the ps chogenic aetiologies associated !ith a ps chiatr that has $een left $ehind is also evident in responses to a British Medical ournal article in 2>>9 !ritten $ Na 'o nihan that descri$ed the Xma5ing of( A&D $ researchers !ith close ties to drug companies -'o nihan, 2>>9E /,.. %utraged responses ensued. A nurse therapist !rote that A&D is not a Xne!, pharmaceuticall manufactured condition( and that it is Xignorant in the e"treme( to thin5 that she is Xonl treating 6social disorders7( -Ast$ur -Lard, 2>>9.. &e"ual d sfunction is not, a patient !rote, a Xfa$rication( of !omen(s imagination or of Xcorporate America(s financial imagination( -Dionne, 2>>9.. Another patient !rote that a !oman is Xeffectivel silenced $ the constant response that it is ps chological -i.e. that she is imagining it.( -Le!is, 2>>9.. &imilarl , <ennifer and

Laura German 8 a urologist and ps chiatrist team 8 !rite that the are Xshoc5ed( to hear of doctors telling patients that their se"ual pro$lems are Xemotional, relational, or due to fatigue from child rearing or their $us ;o$s(E Le hope that this $oo5 !ill serve as an antidote to !hat !omen have heard for decades. #he pro$lem is not ;ust in our head. You are not craB . xLe are $eginning to recogniBe female se"ual d sfunction as a medical pro$lem. -German and German, 2>>+E "8"i. In the !a5e of Oiagra, much-cited articles state that the conte"t of female se"ualit is highl important, $ut their priorit remains to frame A&D as medical rather than ps chiatric or ps chological, as in German et al. -+???aE 93?., !hich states that Xnot all fe"ale se:ual co"plaints are psycholo#ical; and that there are possi-le therapeutic options(. #his article, and others, frames the ps chological as secondar matter, !hich rhetoricall functions as a concession in the article= the also echo an aspect of the OiagraI*D de$ate, in !hich Oiagra(s apparent success !as invo5ed -though this is not logicall compelling. as proof that *D is Xph sical(, not ps chological -German et al., 2>>>= Par5 et al., +??:= Porenman, +??3= Dolden$erg, +??3= German et al., +???a= German et al., +???$= see Loe, 2>>/= )artle , 2>>9.. Le are seeing here the slipper po!er of terms !ith deep ontological and moral rever$erations. Claims a$out !hat influences diagnostic categories, aetiological narratives and s mptoms themselves are repeatedl interpreted as claims a$out the reality of s mptoms. Descri$ing a condition as ps chological is interpreted as meaning that it is non-ph sical= !hat is not ph sical is thought to $e not real. &o sa ing that something is ps chological is e@uated !ith sa ing it is unreal, imaginar , or fa5e. XPs chosomatic illness(, in popular usage, tends to connote deception, if not of others then at least of oneself, raising sensitive @uestions a$out !ilful motivation and individual culpa$ilit -La!rie, 2>>>= &tone et al., 2>>/..

#sychiatry and feminism

#he fraught ontologies in the A&D landscape are, to $e sure, not dissimilar from controversies regarding other conditions, Chronic Aatigue & ndrome most nota$l , !here $itter and tail-chasing de$ates ensue a$out the Xrealit ( of conditions -Prins et al., 2>>1.. #he ontological discomforts I outline here, ho!ever, are overlain !ith something else 8 the historicall uncomforta$le relationship $et!een feminism, ps chiatr and ps choanal sis, !hich adds a comple" dimension to this landscape. #he fact that A&D scholarship tends to $e activist-related e"plains another phenomenon in the e"isting literatureE a failure to scrutiniBe, as an o$;ect in landscape, the feminism that sustains the criti@ue of it. Aeminist critics !ere vocal in the criticisms of ps chiatr , and especiall of ps choanal sis, from the +?1>s, underscoring gender $iases and the violences these !ere seen to ena$le -e.g. Ariedan, +?19= Chesler, +?:2= 'illett, +?:>= also, in the +?3>s, 'asson, +?3,, +?3?.. #he figure of Areud looms large in these !or5s= 'illett descri$ed him as X$e ond @uestion the strongest individual counterrevolutionar force in the ideolog of se"ual politics(= and Anne Poedt framed the Xm th of vaginal

orgasms( -+?:9. as his most pernicious legac -a legac repeatedl invo5ed else!here= see 'aines, +???, and a criticism $ Lun$ec5, 2>>2.. *"isting scholarship on female se"ualit , ps chiatr , medicine and se"olog is emphatic in its recognition of the feminist sta5es in understandings of female se"ual pro$lems -Coo5, 2>>/= Irvine, +??>= Derhard, 2>>+.. #o Irvine, for e"ample, the measure of se"olog , and its histor , is the e"tent to !hich it is compati$le !ith Xfeminism( -even if the nature of that feminism is not e"plicitl articulated or spelt out in the $oo5.. Indeed, the fields of !omen(s histor , feminist criti@ue and the histor of medicine themselves have a thoroughl intert!ined, and immensel fruitful, histor -#omes, +??/.. Lhile feminist criti@ues of A&D emphasiBe the social, ps chological and conte"tual factors involved in se"ual pro$lems, the sidestep the thorn @uestion of ps chod namic understandings of s mptoms, or of an potential role of the unconscious in forming s mptoms. #he articulate a comple" position via the nature and causes of se"ual pro$lems, $ut do so under the shado! of the sins of the fathers 8 the a$uses perpetrated in the name of ps chiatric and especiall ps choanal tic conceptions of se"ualit ., As such, it reveals its o!n historicall contingent identit as part of a particular strand of AngloAmerican second-!ave feminism, evincing an antipath to!ards the ps chological discourses of se"ualit associated !ith Areud 8 rather than as part of feminisms that have !rought s mpathetic if critical engagement !ith ps choanal sis -'itchell, +?:/= Chodoro!, +?3?= Ci"ous, +?:1[+?:,]= Irigara , +?::.. And !hile feminist criti@ue of ps choanal sis emerged !ith good reason, it cannot simpl $e assumed, theoreticall and methodologicall , $ scholarship that attempts to illuminate the post!ar tra;ector of female se"ual pro$lems !ithin ps chiatr and culture 8 given that the re;ection of ps choanal sis $ $oth feminist and ps chiatric discourses is such a pivotal phenomenon in that landscape.1 In see5ing to understand the A&D landscape, I suggest, it is helpful to !iden the lens of criticism from discerning the norms of se"ualit and gender e"pressed in e"plicitl medico-pharmaceutical discourse 8 vital though that is 8 to also scrutiniBing feminism itself as a categor that is discursivel managed across a range of realmsE medical te"ts, popular te"ts, and indeed feminist te"ts themselves. De$ates a$out female se"ual pro$lems in the post!ar period are characteriBed $ am$ivalences to!ards the past, and indeed to!ards the ver act of loo5ing $ac5 at the past. 'edical, feminist and popular te"ts evince discomfort !ith har5ing $ac5 to the past of ps chiatric theoriBing 8 !hich, in ps chod namic ps chiatr , involved precisel a commitment to the importance of the past in creating s mptoms. 'oreover, scholarship on these matters em$odies a reluctance to loo5 $ac5, inclusivel , at the histor of feminism itselfE at its comple" relationship to ps chiatr and its past, and ho! that shapes the modes in !hich criti@ue is articulated. Angela 'cNo$$ie has descri$ed a post-feminist se"ual contract, in !hich, under the guise of an e@ualit assumed to have $een achieved, oung !omen are attri$uted !ith political, economic and se"ual capacit . XYoung !omen are a$le to come for!ard( 8 as high-achieving, economicall po!erful figures 8 Xon condition that feminism fades

a!a (, and that the a$andon the criti@ue of hegemonic masculinit and se"ism associated !ith feminism -'cNo$$ie, 2>>:E :2>, :2?.. &he implies that the re;ecting and the historiciBing of feminism are essentiall inter!oven -'cNo$$ie, 2>>?E +1.. Le are re@uired to loo5 $ac5 at feminism as something unnecessar , old and !orn, and the dismantling of feminist politics is, she argues, ine"trica$l lin5ed to the contemporaneous dismantling of feminism !ithin the academ -i$id.E +9.. Lhat relationship, then, does this historical activit 8 of including feminism as a component in the landscape to $e anal sed 8 $ear to a Xpost-feminist( stance that has $een diagnosed as a s mptom of a contemporar re;ection of feminismY )o! should one loo5 $ac5, historicall and criticall , at the feminisms of the post!ar periodY It is m vie! that an ade@uate anal sis of the landscape re@uires, in addition to a critical relationship to re;ections of feminism, a critical relationship to modes of re<ectin# the activit of loo5ing $ac5 at the past. A&D scholarship provides us, I thin5, !ith an opportunit 8 as et not ta5en up 8 to rethin5 the relationships $et!een Xsecond-!ave( feminism, Xpostfeminism(, ps choanal sis, medicine and ps chiatr . It provides an opportunit not onl to thin5 a$out the intert!ined legacies of ps chiatr and feminism, $ut also to listen to comple" discourses a$out histor itself= a$out !hat is past, and !hat is present. It is, in other !ords, an opportunit to as5, and to find out, !hat 5ind of scholarship this particular moment 8 in ps chiatr , feminism and their historiograph 8 is challenging us to !rite.

Biographical note
!atherine Angel is a Postdoctoral Aello! in the )istor of 'edicine at Lar!ic5 Universit . &he holds a PhD from the )istor and Philosoph of &cience Department at Cam$ridge, and has held research posts there, at UCL and at Pings College London. &he has pu$lished on A&D, clinical !aste and inter!ar ps chiatr .

,otes
+.

#he catch-all term Xantips chiatr ( needs to $e used !ith caution= as Colin <ones has underlined, it encompasses a ver varied phenomenon made up of sometimes conflicting positions, among !hich are a content-$ased criti@ue of ps chiatr , a Xgestural politics of carnivales@ue inversion and s m$olic performance( and the e"ploration of ne! paradigms of 5no!ledge a$out !hat it is to $e human= see <ones -+??3..
2.

$%M-O is, at the time of !riting, $eing prepared, due to $e pu$lished in 2>+9= it appears to $e significantl reordering the se"ual classifications, in particular collapsing desire and arousal pro$lems into a categor of &e"ual InterestIArousal Disorder in !omen, and com$ining Ds pareunia and Oaginismus into Denito-Pelvic PainIPenetration Disorder= accessed 2+ <ul 2>++ yE httpEII!!!.dsm,.orgIPagesIDefault.asp"
9.

A commitment to e@uivalence has persisted into later $%Ms, and has $een the target of criti@ue -#iefer, 2>>/.. It is also $eing rethought in current revisions for $%M-O, through

the !or5 of Nosemar Gasson, and Lori Grotto, !ho $oth suggest that female se"ual response is more responsive and receptive, and less spontaneous, than male desire -Gasson, 2>>2= Grotto, 2>+>..
/.

Initial attempts to develop vasocongestive targeting arousal pro$lems proved disappointing= efforts have since focused on Xcentral path!a s( and the Xdesire centres( of the $rain, !ith testosterone and serotonin receptor antagonists candidates -e.g. fli$anserin.. #he latter garnered much media attention, $ut !as re;ected $ the ADA, !hich has not et approved a pharmacological agent for A&D, though the *uropean 'edicines Agenc has licensed Intrinsa, a testosterone patch for post-menopausal !omen !ith ) poactive &e"ual Desire Disorder -)&DD..
,.

#he criti@ue features prominentl in 'o nihan and 'intBes(s recent popular $oo5, ma5ing use of the tremendousl fruitful language of Xconstruction(, $ut in !a s that slip $et!een @uestioning the validit of the A&D categor , and indeed of the ver tas5 of classification 8 an episte"olo#ical point 8 and @uestioning !hether someone has s mptoms that the diagnosis claims to descri$e 8 @uestioning !hether there is an thing there to -mis.descri$e 8 an ontolo#ical point. #his o$fuscation in the use of the term is !here interested parties 8 pharmaceutical companies, practitioners invested in the dissemination of A&D and treatments for it 8 have immense lee!a to accuse A&D critics of disregard for !omen. &ee Angel -2>+2..
1.

Do!ning -2>>/. stands out some!hat in that it uses critical and @ueer theor to approach A&D.

Article information
)ist )uman &ci. 2>+2 %cto$er= 2,-/.E 982/. doiE +>.++::I>?,21?,++2/,1?/? P'CIDE P'C9,/?,:/ Patherine Angel Universit of Lar!ic5, UP Patherine Angel, Centre for the )istor of 'edicine, Universit of Lar!ic5, )umanities Guilding, //3 Di$$et )ill Noad, Coventr CO/ :AL, UP *mailE 5.angelIatI!ar!ic5.ac.u5 Cop right W #he Author-s. 2>+2 #his is an open-access article distri$uted under the terms of the Creative Commons Attri$ution License, !hich permits unrestricted use, distri$ution, and reproduction in an medium, provided the original !or5 is properl cited. Articles from &AD* Choice are provided here courtes of %A() #ublications

References
A$raham P. -+?2>. X'anifestations of the Aemale Castration Comple"(, in &elected Papers on Ps cho-Anal sis. LondonE )ogarth, pp. 99,81?.

Acton L. -+312. #he Aunctions and Disorders of the Neproductive %rgans in Childhood, Youth, Adult Age, and Advanced LifeE Considered in their Ph siological, &ocial, and 'oral Nelations. LondonE <. Churchill. Ale"ander A. -+?92. #he 'edical Oalue of Ps choanal sis. LondonE Allen ] Un!in. Ale"ander A. -+?,>. Ps chosomatic 'edicineE Its Principles and Applications. Te! Yor5E Torton. A"erican 4a"ily Physician -2>>>. X&e" isn(t !or5ing for 'e. Lhat can I doY( -+ <ul .E +/+82. American Ps chiatric Association -+?,2. #he Diagnostic and &tatistical 'anual of 'ental Disorders. Lashington, DCE American Ps chiatric Association. American Ps chiatric Association -+?13. D&'-IIE Diagnostic and &tatistical 'anual of 'ental Disorders, 2nd edn Lashington, DCE American Ps chiatric Association. American Ps chiatric Association -+?3>. D&'-IIIE Diagnostic and &tatistical 'anual of 'ental Disorders, 9rd edn Lashington, DCE American Ps chiatric Association. American Ps chiatric Association -+?3:. D&'-III-NE Diagnostic and &tatistical 'anual of 'ental Disorders, 9rd edn, revised Lashington, DCE American Ps chiatric Association. American Ps chiatric Association -+??/. D&'-IOE Diagnostic and &tatistical 'anual of 'ental Disorders, /th edn Lashington, DCE American Ps chiatric Association. American Ps chiatric Association -2>>>. D&'-IO-#NE Diagnostic and &tatistical 'anual of 'ental Disorders, /th edn, te"t revision Lashington, DCE American Ps chiatric Association. Angel P. -2>+>. X#he )istor of 6Aemale &e"ual D sfunction7 as a 'ental Disorder in the #!entieth Centur (, Current %pinion in Ps chiatr 29-1.E ,918/+. [P'C free article] [Pu$'ed] Angel P. -2>+2, forthcoming. revie! of N. 'o nihan and G. 'intBes, &e", Lies and PharmaceuticalsE )o! Drug Companies Plan to Profit from Aemale &e"ual D sfunction, Ps cholog and &e"ualit . Angell '. -2>++. X#he Illusions of Ps chiatr (, Te! Yor5 Nevie! of Goo5s, accessed +> <ul 2>++ yE httpEII!!!.n $oo5s.comIarticlesIarchivesI2>++I;ulI+/Iillusions-ofps chiatr IYpaginationFfalse. Appignanesi L., Aorrester <. -2>>>. Areud(s LomenE Aamil , Patients, Aollo!ers. Te! Yor5E %ther Press. Armstrong D. -+??,. X#he Nise of &urveillance 'edicine(, &ociolog , )ealth and Illness +:E 9?98/>/. Ast$ur -Lard *. '. -2>>9. X*nhancing Nelationships is a <o5e(, Gritish 'edical <ournal Napid Nesponses -/ <anuar ., yE $m;.com. Gasson N., et al. -2>>+. XNeport of the International Consensus Development Conference on Aemale &e"ual D sfunctionE Definitions and Classifications(, ournal of *rolo#y +19E 3338?9= reprinted in <ournal of &e" and 'arital #herap 2:-2>>+.E 398?/. Gasson N. -2>>2. XNethin5ing Lo! &e"ual Desire in Lomen(, G<%DE An International <ournal of %$stetrics and D naecolog +>?-/.E 9,:819. [Pu$'ed] Ga er N., &pitBer N. L. -+?3,. XTeurosis, Ps chod namics, and D&'-IIIE a )istor of the Controvers (, Archives of Deneral Ps chiatr /2E +3:8?,. [Pu$'ed] Gec5er ). &. -+?19. %utsidersE &tudies in the &ociolog of Deviance. Dlencoe, ILE Aree Press.

German <. N., Adhi5ari &. P., Doldstein I. -2>>>. XAnatom and Ph siolog of Aemale &e"ual Aunction and D sfunction(, *uropean Urolog 93E 2>8?. [Pu$'ed] German <. N., German L. -2>>+. Aor Lomen %nl E A Nevolutionar Duide to %vercoming &e"ual D sfunction and Neclaiming Your &e" Life. LondonE Oirago. German <. N., German L., Doldstein I. -+???a. XAemale &e"ual D sfunctionE Incidence, Pathoph siolog , *valuation, and #reatment %ptions(, Urolog ,/E 93,8?+. [Pu$'ed] German <. N., German L., Ler$in #. <., Alahert *. *., Leah T. '., Doldstein I. -+???$. XClinical *valuation of Aemale &e"ual AunctionE *ffects of Age and *strogen &tatus on &u$;ective and Ph siologic &e"ual Nesponses(, International <ournal of Impotence Nesearch ++ -supplement +.E &9+8&93. [Pu$'ed] German L. -2>>:. #he Passion PrescriptionE #en Lee5s to Your Gest &e" 8 *verz. Te! Yor5E ) perion. Gland L., Doan L., eds -+??3. &e"olog in CultureE La$elling Godies and Desires. Cam$ridgeE Polit Press. Gonaparte '. -+?,9. Aemale &e"ualit . Te! Yor5E Drove. Grome O. -+?1:. Areud and his *arl CircleE #he &truggle of Ps cho-Anal sis. LondonE )einemann. Grotto L. -2>+>. X#he D&' Diagnostic Criteria for ) poactive &e"ual Desire Disorder in Lomen(, Archives of &e"ual Gehavior 9?-2.E 22+89?. [Pu$'ed] Gro!n #. '. -2>>>. X#he Nise and Aall of American Ps chosomatic 'edicine(, te"t of a lecture presented at the Te! Yor5 Academ of 'edicine on 2? Tovem$er, accessed 23 <anuar 2>>3 yE httpEII!!!.human-nature.comIfree-associationsIriseandfall.html. Guhle '. <. -+??3. Aeminism and Its DiscontentsE A Centur of &truggle !ith Ps choanal sis. Cam$ridge, 'AE )arvard Universit Press. Cacchioni #. -2>>:. X)eterose"ualit and the 6La$our of Love7E a Contri$ution to Necent De$ates a$out Aemale &e"ual D sfunction(, &e"ualities +>E 2??892>. Chesler P. -+?:2. Lomen and 'adness. Te! Yor5E Palgrave 'acmillan. Chodoro! T. -+?3?. Aeminism and Ps choanal tic #heor . Cam$ridgeE Polit . Ci"ous ). -+?:1[+?:,]. Le Nire de la 'eduse. ParisE L(Arc= pu$lished in *nglish as X#he Laugh of the 'edusa(, trans. P. and P. Cohen, %i#ns +-/.E 3:,8?9. Coo5 ). -2>>/. #he Long &e"ual NevolutionE *nglish Lomen, &e", and Contraception, +3>>8+?:,. %"fordE %"ford Universit Press. Cr le P. -2>>?. X6A #erri$le %rdeal from *ver Point of Oie!7E -Tot. 'anaging Aemale &e"ualit on the Ledding Tight(, <ournal of the )istor of &e"ualit +3-+.E //81/. [Pu$'ed] Dain T. -+?3?. XCritics and DissentersE Neflections on 6Anti-Ps chiatr 7 in the United &tates(, <ournal of the )istor of the Gehavioral &ciences 2,E 982,. [Pu$'ed] Davidson A. I. -2>>+. #he *mergence of &e"ualit E )istorical *pistemolog and the Aormation of Concepts. Cam$ridge, 'AE )arvard Universit Press. Deutsch ). -+?//8,. #he Ps cholog of LomenE A Ps choanal tic Interpretation, vols I and II Te! Yor5E Drune ] &tratton. Dionne C. D. -2>>9. XAll in #heir Prett Little )eads(, Gritish 'edical <ournal Napid Nesponses -/ <anuar ., yE $m;.com. Do!ning L. -2>>/. X#he 'easure of 6&e"ual D sfunction7E a Plea for #heoretical Limitlessness(, #ransformations 3, yE httpEII!!!.transformations;ournal.orgI;ournalIissue{>3Iarticle{>2.shtml.

Dre! <. -2>>9. X#he ' th of Aemale &e"ual D sfunction and Its 'edicaliBation(, &e"ualities, *volution and Dender ,E 3?8?1. *llis ). -+3?:8+?23. &tudies in the Ps cholog of &e", vols I8OII Philadelphia, PAE A. A. Davis. *llis ). -+?>3. &tudies in the Ps cholog of &e"E Anal sis of the &e"ual Impulse= Love and Pain= #he &e"ual Impulse in Lomen. Philadelphia, PAE A. A. Davis. *sposito P., Diugliano D. -2>++. XLifest leIDietar Necommendations for *rectile D sfunction and Aemale &e"ual D sfunction(, Urologic Clinics of Torth America 93 -9. -August.E 2?989>+. [Pu$'ed] * senc5 ). -+?,?. #he Uses and A$uses of Ps cholog . )armonds!orth, '"E Penguin. * senc5 ). -+?1,a. X#he *ffects of Ps chotherap (, International <ournal of Ps chiatr +-+.E ?:8+:3. * senc5 ). -+?1,$. X#he *ffects of Ps chotherap -Continued.(, International <ournal of Ps chiatr +-2.E 9+:89,. [Pu$'ed] Aigueroa-)aas C. -2>+2. X&creening for Aemale &e"ual D sfunction in Primar Care &ettings(, #he <ournal for Turse Practitioners 3-2.E +,18:. Aisher &., Dreen$erg N. P. -+?::. #he &cientific Credi$ilit of Areud(s #heories and #herap . )assoc5s, &"E )arvester Press. Aishman <. N. -2>>/. X'anufacturing DesireE #he Commodification of Aemale &e"ual D sfunction(, &ocial &tudies of &cience 9/E +3:82+3. [Pu$'ed] Aliegel \. %. -+?:9. XAeminine Ps chose"ual Development in Areudian #heor (, Ps choanal tic Cuarterl /2E 93,8/>?. [Pu$'ed] Aoucault '. -+?:?. #he )istor of &e"ualit , vol. +, An Introduction Te! Yor5E Pantheon Goo5s. Areedheim D. P., ed. -+??2. )istor of Ps chotherap E A Centur of Change. Lashington, DCE American Ps chological Association. Ariedan G. -+?19. #he Aeminine ' sti@ue. LondonE Oictor DollancB. Delfman '. -+?1?. XA Post-Areudian Comment on &e"ualit (, American <ournal of Ps chiatr +21 -Tovem$er.E 1,+8:. [Pu$'ed] Derhard <. -2>>+. Desiring NevolutionE &econd-Lave Aeminism and the Ne!riting of American &e"ual #hought, +?2> to +?32. Te! Yor5E Colum$ia Universit Press. Dilman N. -+?:+. X#he AemLi$ Case Against &igmund Areud(, Te! Yor5 #imes 'agaBine -9+ <anuar .E +>8++. Dilman N. -+?::. XLi$erating Lomen from Areud(, #ime +>? -+: <anuar .E /?. Doffman *. -+?1+. As lumsE *ssa s on the &ocial &ituation of 'ental Patients and %ther Inmates. Te! Yor5E Dou$leda . Dolden$erg '. '. -+??3. X&afet and *fficac of &ildenafil Citrate in the #reatment of 'ale *rectile D sfunction(, Clinical #herapeutics 2>-1.E +>998/3. [Pu$'ed] Dra A. ). -+?29. 'en, Lomen and DodE A Discussion of &e" Cuestions from the Christian Point of Oie!. LondonE &tudent Christian 'ovement. Dreco '. -+??3. Illness as a Lor5 of #houghtE A Aoucauldian Perspective on Ps chosomatics. LondonE Noutledge. Dro$ D. T. -+??+. Arom As lum to Communit E 'ental )ealth Polic in 'odern America. Princeton, T<E Princeton Universit Press. )ale T. D. -+??,. #he Nise and Crisis of Ps choanal sis in the United &tatesE Areud and the Americans, +?+:8+?3,. Te! Yor5E %"ford Universit Press.

)artle ). -2>>9. X6Gig Pharma7 in our GedroomsE an Anal sis of the 'edicalisation of Lomen(s &e"ual Pro$lems(, Advances in Dender NesearchE Dender Perspectives on )ealth and 'edicine, Pe #hemes :E 3?8+2?. )artle ). -2>>1. X#he 6Pin5ing7 of Oiagra CultureE Drug Industr *fforts to create and repac5age &e" Drugs for Lomen(, &e"ualities ?E 9198:3. )eal D. -+??:. #he Anti-Depressant *ra. Cam$ridge, 'AE )arvard Universit Press. )eal D. -2>>2. #he Creation of Ps chopharmacolog . Cam$ridge, 'AE )arvard Universit Press. )itschmann *., Gergler *. -+?91. Arigidit in LomenE Its Characteristics and #reatment, trans. Leil P. L., editor. Lashington, DCE Tervous and 'ental Disease Pu$lications. )oo5 &. ed. -+?,?. Ps choanal sis, &cientific 'ethod and Philosoph . Te! Yor5E Drove Press. )or!itB A. O., La5efield <. C. -2>>:. #he Loss of &adnessE )o! Ps chiatr #ransformed Tormal &orro! into Depressive Disorder. %"fordE %"ford Universit Press. )uhner '. -+?9:. #he Diagnosis and #reatment of &e"ual Disorders in the 'ale and Aemale, Including &terilit and Impotence. Philadelphia, PAE A. A. Davis. Independent -2>+>a. XOiagra for )erE Neal or Pla ing on a Te! Insecurit ( -+9 <une., yE httpEII!!!.independent.co.u5Ilife-st leIhealth-and-familiesIviagra-for-her-real-orpla ing-on-a-ne!-insecurit -+???2/2.html. Independent -2>+>$. X&e" Pill for Lomen(s Auture Dim, for To!( -22 <une., yE httpEII!!!.independent.co.u5Ilife-st leIhealth-and-familiesIse"-pill-for-!omens-futuredim-for-no!-2>>:++>.html. Irigara L. -+?::. Ce se"e @ui n(en est pas un [#his &e" !hich is Tot %ne] ParisE *ditions de 'inuit. Irvine <. '. -+??>. Disorders of DesireE &e"ualit and Dender in 'odern American &e"olog . Philadelphia, PAE #emple Universit Press. <ones C. -+??3. XNaising the AntiE <an Aoudraine, Nonald Laing and Anti-Ps chiatr (, in Di;s!i;it-)ofstra '., Porter N., editors. -eds. Cultures of Ps chiatr and 'ental )ealth Care in Post!ar Gritain and the Tetherlands. AmsterdamE Nodopi. Paplan ). &. -+?::. X) poactive &e"ual Desire(, <ournal of &e" and 'arital #herap 9E 98?. [Pu$'ed] Paplan ). &. -+?:?. Disorders of &e"ual Desire. Te! Yor5E GrunnerI'aBel. Pascha5 *., #iefer L., eds -2>>+. A Te! Oie! of Lomen(s &e"ual Pro$lems. Te! Yor5E )a!orth Press. Pendell N., et al. -+?:+. XDiagnostic Criteria of American and Gritish Ps chiatr (, Archives of Deneral Ps chiatr 2,E +2989>. [Pu$'ed] Pinse A. C., et al. -+?,9. &e"ual Gehavior in the )uman Aemale. Philadelphia, PAE L. G. &aunders. Pir5 &. A., Putchins ). -+??2. #he &elling of D&'E #he Nhetoric of &cience in Ps chiatr . Te! Yor5E Lalter de Dru ter. Plerman D. L. -+?:3. X#he *volution of a &cientific Tosolog (, in &hersho! <. C., editor. -ed.. &chiBophreniaE &cience and Practice. Cam$ridge, 'AE )arvard Universit Press, pp. ??8+2+. Poedt A. -+?:9. X#he ' th of the Oaginal %rgasm(, in Poedt A., Levine *., Napone A., editors. -eds. Nadical Aeminism. Te! Yor5E Cuadrangle, pp. +?382>:.

Porenman &. D. -+??3. XTe! Insights into *rectile D sfunctionE a Practical Approach(, American <ournal of 'edicine +>,E +9,8//. [Pu$'ed] Prafft-*$ing N. von. -+3??. Ps chopathia &e"ualisE Lith *special Neference to the Antipathic &e"ual Instinct. A 'edico-Aorensic &tud . Philadelphia, PAE A. A. Davis. Pramer '. -+?1?. XCross-Tational &tud of Diagnosis of the 'ental DisordersE %rigin of the Pro$lem(, American <ournal of Ps chiatr +2, -+>. -supplement.E +8++. [Pu$'ed] Putchins )., Pir5 &. A. -+??:. 'a5ing Us CraB E D&' 8 #he Ps chiatric Gi$le and the Creation of 'ental Disorders. LondonE Consta$le. Laing N. D. -+?1>. #he Divided &elfE An *"istential &tud of &anit and 'adness. LondonE #avistoc5. Laing N. D. -+?1/. &anit , 'adness and the Aamil . LondonE #avistoc5. La5off A. -2>>,. Pharmaceutical NeasonE Pno!ledge and Oalue in Dlo$al Ps chiatr . Cam$ridgeE Cam$ridge Universit Press. Lane C. -2>>:.. &h nessE )o! Tormal Gehaviour Gecame a &ic5ness. Te! )aven, C#E Yale Universit Press. Laurence <. -2>+>. XAemale &e"ual D sfunction 6!as invented $ Drugs Industr 7(, Independent -+ %cto$er.. La!rie &. '. -2>>>. XTe!spaper Coverage of Ps chiatric and Ph sical Illness(, Ps chiatric Gulletin 2/E +>/81. LaBarus A. A. -+?19. X#he #reatment of Chronic Arigidit $ & stematic DesensitiBation(, <ournal of Tervous and 'ental Disease +91E 2:283. Le!is P. -2>>9. XConspirac of &ilence hinders Understanding(, Gritish 'edical <ournal Napid Nesponses -/ <anuar ., yE $m;.com. Lief ). I. -+?::. XInhi$ited &e"ual Desire(, 'edical Aspects of )uman &e"ualit :E ?/8 ,. Loe '. -2>>/. #he Nise of OiagraE )o! the Little Glue Pill Changed &e" in America. Te! Yor5E Te! Yor5 Universit Press. Loe!enfeld L. -+3??. &e"uelle$en und Tervenleiden [ &e"ual Lives and Tervous Disorders], 2nd edn Lies$adenE <. A. Gergmann. Lu$ors5 L. -+?:,. XComparative &tudies of Ps chotherapies(, Archives of Deneral Ps chiatr 92-August.E 3. [Pu$'ed] Lun$ec5 *. -+??/. #he Ps chiatric PersuasionE Pno!ledge, Dender and Po!er in 'odern America. Princeton, T<E Princeton Universit Press. Lun$ec5 *. -2>>2. X#itillation of the #issues(, revie! of Nachel 'aines( #he #echnolog of %rgasmE X) steria(, the Oi$rator, and Lomen(s &e"ual &atisfaction, )istor Lor5shop <ournal ,9 -&pring.E 2,381/. 'aines N. -+???. #he #echnolog of %rgasmE X) steria(, the Oi$rator, and Lomen`s &e"ual &atisfaction. Galtimore, 'DE <ohns )op5ins Universit Press. 'asson <. '. -+?3,. Assault on #ruthE Areud(s &uppression of the &eduction #heor . )armonds!orth, '"E Penguin. 'asson <. '. -+?3?. Against #herap . LondonE Collins. 'asters L. )., <ohnson O. *. -+?11. )uman &e"ual Nesponse. Goston, 'AE Little, Gro!n. 'asters L. )., <ohnson O. *. -+?:>. )uman &e"ual Inade@uac . Goston, 'AE Little, Gro!n.

'a es N., )or!itB A. O. -2>>,. XD&'-III and the Nevolution in the Classification of 'ental Illness(, <ournal of the )istor of the Gehavioral &ciences /+-9.E 2/?81:. [Pu$'ed] 'cNo$$ie A. -2>>:. X#op DirlsYYoung Lomen and the Post-Aeminist &e"ual Contract(, Cultural &tudies 2+E :+389:. 'cNo$$ie A. -2>>?. #he Aftermath of AeminismE Dender, Culture, and &ocial Change. LondonE &age. 'eda!ar P. G. -+?:,. revie! of I. &. Cooper(s #he Oictim Is Al!a s the &ame, Te! Yor5 Nevie! of Goo5s -29 <anuar .E +18+?. 'e er A. -+?,2. #he Collected Papers of Adolf 'e er, vol. 9, ed. Linters *., editor. Galtimore, 'DE <ohns )op5ins Universit Press. 'illett P. -+?:>. &e"ual Politics. Te! Yor5E Dou$leda . 'itchell <. -+?:/. Ps choanal sis and Aeminism. LondonE Allen Lane. 'o nihan N. -2>>9. X#he 'a5ing of a DiseaseE Aemale &e"ual D sfunction(, Gritish 'edical <ournal 921E /,8:. [P'C free article] [Pu$'ed] 'o nihan N., Cassels A. -2>>,. &elling &ic5nessE )o! the Lorld(s Giggest Pharmaceutical Companies Are #urning Us All into Patients. Te! Yor5E Tation Goo5s. 'o nihan N., 'intBes G. -2>+>. &e", Lies and PharmaceuticalsE )o! Drug Companies Plan to Profit from Aemale &e"ual D sfunction. OancouverE Dre stone Press. Ticolson P., Gurr <. A. -2>>9. XLhat is 6Tormal7 a$out Lomen(s -)etero.&e"ual Desire and %rgasmYA Neport of an In-Depth Intervie! &tud (, &ocial &cience and 'edicine ,:-?.E +:9,8/,. [Pu$'ed] T)&Direct, XA )ealth &e" Life(, T)& Direct.co.u5, yE httpEII!!!.nhs.u5ILive!ellIDoodse"IPagesI#al5a$outse".asp"|old. T e N. -2>>9. X#he *volution of the Concept of 'edicaliBation in the Late #!entieth Centur (, <ournal of the )istor of the Gehavioral &ciences 9?-2.E ++,82?. [Pu$'ed] %(Donohue L., Dop5e C. A., &!ingen D. T. -+??:. XPs chotherap for Aemale &e"ual D sfunctionE a Nevie!(, Clinical Ps cholog Nevie! +:-,.E ,9:811. [Pu$'ed] %s$orne #. -+??2. X'edicine and *pistemolog E 'ichel Aoucault and the Li$eralit of Clinical Neason(, )istor of the )uman &ciences ,-2.E 198?9. Par5 P., et al. -+??:. XOasculogenic Aemale &e"ual D sfunctionE #he )emod namic Gasis for Oaginal *ngorgement Insufficienc and Clitoral *rectile *fficienc (, International <ournal of Impotence Nesearch ?E 2:8/:. [Pu$'ed] Pignarre P. -2>>/. Le grand secret de l(industrie pharmaceuti@ue [#he Pharmaceutical Industr (s Gig &ecret] ParisE La Dicouverte. Popper P. -+?19. Con;ectures and Nefutations. LondonE Noutledge ] Pegan Paul. Potts A. -2>>>. X6#he *ssence of the )ard %n7E )egemonic 'asculinit and the Cultural Construction of 6*rectile D sfunction7(, 'en and 'asculinities 9-+.E 3,8+>9. Potts A. -2>>9. X#he Do!nside of OiagraE Lomen(s *"periences and Perspectives(, &ociolog of )ealth and Illness 2,-:.E 1?:8:+?. [Pu$'ed] Potts A., et al. -2>>/. XOiagra &toriesE Challenging 6*rectile D sfunction7(, &ocial &cience and 'edicine ,?E /3?8??. [Pu$'ed] Potts A. -2>>3. X#he Aemale &e"ual D sfunction De$ateE Different 6Pro$lems7, Te! Drugs 8 'ore PressuresY(, in 'oss P., #eghtsoonian P., editors. -eds. Contesting IllnessE Processes and Practices. #orontoE Universit of #oronto Press, pp. 2,?83>.

Prins <. G., van der 'eer <. L. '., Glei;en$erg D. -2>>1. XChronic Aatigue & ndrome(, Lancet 91:E 9/18,,. [Pu$'ed] Nachman &. -+?1+. X&e"ual Disorders and Gehavior #herap (, American <ournal of Ps chiatr ++3E 29,8/>. [Pu$'ed] Namage '. -2>>1a. XAemale &e"ual D sfunction(, Ps chiatr 1-9.E +>,8+>. Namage '. -2>>1$. XAemale &e"ual D sfunction(, Lomen(s )ealth 'edicine 9-2.E 3/8 3. NoaBen P. -+?:1. Areud and his Aollo!ers. LondonE Allen Lane. Nogler L. ). -+??:. X'a5ing &ense of )istorical Changes in the $ia#nostic and %tatistical Manual of Mental $isordersE Aive Propositions(, <ournal of )ealth and &ocial Gehavior 93-+.E ?82>. [Pu$'ed] Nose T. -2>>:. #he Politics of Life ItselfE Giomedicine, Po!er, and &u$;ectivit in the #!ent -Airst Centur . Princeton, T<E Princeton Universit Press. Nosenthal N. -2>>+. XAemale &e"ualit comes out of the Ps chiatric Closet,( <ournal of &e" and 'arital #herap 2:E 2>98/. [Pu$'ed] &ample I. -2>>?. X6Aemale Oiagra7 $oosts &e"ual Desire in Lomen !ith Alagging Li$ido(, Duardian -+1 Tovem$er., yE httpEII!!!.guardian.co.u5IscienceI2>>?InovI+1Ifemale-viagra-se"ual-desire-li$ido. &ar!er D. G., Durla5 <. A. -+??1. XChildhood &e"ual A$use a Predictor of Adult Aemale &e"ual D sfunctionE a &tud of Couples &ee5ing &e" #herap (, Child A$use and Teglect 2>-+>.E ?198:2. [Pu$'ed] &cheff #. <. -+?11. Geing 'entall IllE A &ociological #heor . LondonE Leidenfeld ] Ticolson. &horter *. -+??:. A )istor of Ps chiatr E Arom the *ra of the As lum to the Age of ProBac. Te! Yor5E Lile . &te5el L. -+?91. Arigidit in LomanE In Nelation to her Love Life, vols + and 2, trans. Oan #eslaar <. &., editor. LondonE Oision Press. &tengel I. -+?,?. XClassification of 'ental Disorders(, Gulletin of the Lorld )ealth %rganiBation 2+E 1>+819. [P'C free article] [Pu$'ed] &toller N. -+?::. XLetter to No$ert L. &pitBer, %cto$er 1, +?::(, American Ps chiatric Association archival materials, $o" +>>?>/. &tone <., et al. -2>>/. X6Ps chosomatic7E a & stematic Nevie! of Its 'eaning in Te!spaper Articles(, Ps chosomatics /,-/.E 23:8?>. [Pu$'ed] &topes '. -+?+3. 'arried LoveE A Te! Contri$ution to the &olution of &e" Difficulties. LondonE A. C. Aifield. &ullo!a A. -+?:?. Areud, Giologist of the 'indE Ge ond the Ps choanal tic Legend. LondonE Gurnett Goo5s. &BasB #. -+?12. #he ' th of 'ental IllnessE Aoundations of a #heor of Personal Conduct. LondonE &ec5er ] Lar$urg. #iefer L. -+??/. X#he 'edicaliBation of ImpotenceE TormaliBing Phallocentrism(, Dender and &ociet 3E 9198::. #iefer L. -2>>/. &e" Is Tot a Tatural Act and %ther *ssa s, 2nd edn Goulder, C%E Lestvie! Press. #iefer L., ed. -2>>3. X&pecial Issue on the Te! Oie! Campaign against the 'edicaliBation of &e"E Academics, Activism, Applications(, Aeminism and Ps cholog +3 -/. -Tovem$er.E /,+81.

#omes T. -+??/. XAeminist )istories of Ps chiatr (, in 'icale '. &., Porter N., editors. -eds. Discovering the )istor of Ps chiatr . Te! Yor5E %"ford Universit Press, pp. 9/3839. Oan de Oelde #. ). -+?23[+?21]. Ideal 'arriageE Its Ph siolog and #echni@ue, trans. Gro!ne &., editor. LondonE )einemann. Oernon P. -2>+>. X#he Nace to Discover Oiagra for Lomen(, %$server -2, April.. Lallerstein N. -+?11. X#he Current &tate of Ps chotherap (, <ournal of the American Ps choanal tic Association +/E +39822,. [Pu$'ed] Latters *. -2>+>. CraB Li5e UsE #he Dlo$aliBation of the American Ps che. Te! Yor5E Aree Press. Le$$er C., Delvin D. -2>++. XAre ou having #rou$le reaching %rgasmYA Duide for Lomen(, Tetdoctor.co.u5, -22 'a . yE httpEII!!!.netdoctor.co.u5Ise"{relationshipsIfactsIorgasmtrou$le.htm|. L)% -+?:9. Neport of the International Pilot &tud of &chiBophrenia. DenevaE Lorld )ealth %rganiBation. Lright ). -+?,,[+?9>]. #he &e" Aactor in 'arriage. LondonE Lilliams ] Torgate.

Aging and Disease <PL International LLC

An >pdate on *emale %exual *unction and 'ysfunction in =ld Age and "ts Rele+ance to =ld Age #sychiatry
Alison Lood, Noss Nunciman, [...], and Noss 'c'anus Additional article information

Abstract
Tumerous studies have no! demonstrated that man older !omen retain an interest in their se"ual lives. Yet, ho! man old age ps chiatrists commonl chec5 !ith older !omen a$out !hether the depression the are treating, or the &&NIs -&elective &erotonin Ne-upta5e Inhi$itors. the have prescri$ed, have adversel affected their patient(s se"ual livesY Le consider the latest evidence regarding cultural, social and medical influences on older !omen(s se"ual lives and some specific issues !hich affect les$ian and transse"ual people. Le e"amine ho! mental illness and ps chotropic medication in particular can adversel affect older !omen(s se"ual functioning and at ho! difficult it often proves to $e for !omen to see5 help. Le also focus on !h doctors and in particular ps chiatrists ma not ta5e a se"ual histor , loo5 for se"ual side effects or refer

for appropriate treatment, especiall !hen intervie!ing older !omen patients. 'ost pu$lished information a$out ps chiatric training and se"ual issues focuses on the ounger male patient. Le therefore aimed to provide a $road-ranging revie! of the literature regarding female se"ual functioning in old age, the difficulties that can arise and the role that old age ps chiatrists have an opportunit to fulfil, in this often neglected aspect of their patients( treatment. Arom our revie! it !as clear that, in the light of the increasing cultural accepta$ilit of discussions regarding se"ualit and older !omen, the training of student doctors and trainee ps chiatrists needs to reflect this change so that old age ps chiatrists can enhance the @ualit of their patient care. !eywords: Aemale, old age, se"ualit , chronic disease, help-see5ing, ps chiatr 6&e"ualit in our later ears is no! positioned as a 5e element of successful aging.7 )inchliff et al [+]. Increasingl organiBations such as the AANP -American Association of Netired Persons. are pu$liciBing the cultural accepta$ilit of ongoing ph sical closeness and contri$uting to gathering data reflective of this trend [2]. Aor e"ample, on their !e$site articles such as 6Are You &avv A$out &e" After ,>Y #a5e our @uiB and then compare scores !ith our partner to see !ho comes out on top7 are eas to find. Tumerous studies have no! demonstrated that man older !omen retain an interest in their se"ual lives. #he are li5el to feel $etter ph sicall and mentall for doing so Grod and Costa [9]. Yet, ho! man old age ps chiatrists commonl chec5 !ith older !omen a$out !hether the depression the are treating or the &&NIs -&elective &erotonin Ne-upta5e Inhi$itors. the have prescri$ed have adversel affected their patient(s se"ual livesY 'ost pu$lished information a$out ps chiatric training and se"ual issues focuses on the ounger male patient as, in *ngland, have the practical e"aminations of ps chiatric competence !ith regard to se"ual side effects of medication. Le aim to e"amine the latest data on female se"ual functioning in old age, the difficulties that can arise and the role that old age ps chiatrists have an opportunit to fulfil in this often neglected aspect of their patients( care. Le !ill e"amine the latest evidence regarding cultural, medical and social influences on older !omen(s se"ual lives including some !hich specificall affect les$ian and transse"ual people. Le !ill loo5 at ho! mental illness and ps chotropic medication in particular can adversel affect older !omen(s se"ual functioning and at ho! difficult it often proves to $e for !omen to see5 help. Le @uestion !h doctors and in particular ps chiatrists ma not ta5e a se"ual histor , loo5 for side effects or refer for appropriate treatment, especiall !hen intervie!ing older !omen patients.

Method
Le made this a selective revie!, due to the $readth of aspects covered. 'ultiple searches !ere conducted, mainl via Athens Login to the Tational Li$rar for health in the UP.

#he follo!ing data$ases !ere accessed 8 GTI, CITA)IL, *'GA&*, '*DLIT*, PUG'*D, P&YC)ITA%. &earch terms included female, !omen, old age, elderl and geriatric, se", se"ualit and se"ual, les$ian and transse"ual, ps chiatr and nursing home. Nelevant additional studies and !e$sites 5no!n to the authors !ere included. 'ost research cited has $een pu$lished since the ear 2>>> and much of it in the last t!o ears. &ome smaller studies have $een included in areas !here there is a dearth of larger studies to dra! upon.

Are older women bothered about sexG

Ticolosi et al [/] as part of the Dlo$al &tud of &e"ual Attitudes and Gehaviors -D&&AG., aimed to stud 6the se"ual activit and the prevalence of se"ual d sfunctions and related help see5ing $ehaviour, among people in *urope aged />83> ears.7 #his !as a large scale stud 8 $oth men and !omen !ere intervie!ed $ telephone in 2>>+ and 2>>2. #he came from &!eden, the United Pingdom, Gelgium, Derman , Austria, Arance, &pain and Ital . Altogether ,>29 !omen too5 part. %verall 2+4 of the !omen aged :>83> had had se"ual intercourse !ithin the preceding +2 months and 2,4 of those se"uall active !omen aged :>83> had se"ual intercourse more than once a !ee5. Lomen aged />83> !ere as5ed, as part of the same stud , !hether satisfactor se" !as essential to the maintenance of a relationship. ::4 agreed that it !as. %nl +34 agreed that 6%lder people no longer !ant se".7 #here have $een t!o recent large-scale studies in the United &tates !hich investigated the prevalence of se"ual activit in the over-:>s. According to the American Association of Netired Persons surve in 2>>?[,]-!!!.aarp.orgIhome-famil Ise"-intimac ., the percentage of !omen over sevent having vaginal intercourse even once !ithin the previous si" months !as +9.94. Lhereas the Tational &urve of &e"ual )ealth and Gehaviour, also conducted in 2>>? and pu$lished $ )ern$enic5 et al [1] 2+.14 of !omen over sevent reported having vaginal intercourse !ithin the previous ear. #hese studies also indicated that mastur$ation !as underta5en $ 998/>4 of !omen over sevent , sho!ing ongoing se"ual interest in this age-group. In &!eden Gec5man et al [:] found that &!edes over sevent appeared to $e more se"uall active and more se"uall satisfied than the had $een 9> ears previousl and that ,14 of married !omen over sevent remained se"uall active. It is also !orth pointing out that !hat counts as se"ual activit can change, as !omen get older. %lder people often redefine their se"ualit . )inchliff [+] noted 6other activities engaged in as a couple ma $e vie!ed as se"ual. Penetrative se" ma $e less of a focus for men and !omen7. )aving a positive attitude to se" appears to $e an important factor !hen it comes to older people engaging in se"ual activit DeLamater -2>+2. [3]. #his point is emphasised $ some studies loo5ing into ph sical difficulties of various 5inds, !hich have sho!n that having a ph sical disa$ilit !hich affects a !oman(s( se"ual life does not necessaril have as much impact as ho! the !oman feels a$out that ph sical disa$ilit . Lo!enstein

et al [?] !ho studied 93> !omen !ith Pelvic %rgan Prolapse -P%P. and concluded that 6&e"ual function is related to a !oman(s self-perceived $od image and degree of $other from P%P regardless of vaginal topograph . &e"ual function ma $e more related to a !oman(s perception of her $od image than to actual topographical changes from P%P.7 &imilarl )inchliff et al, 2>++[+] noted the discrepanc in some studies $et!een the levels of !omen !ith clinicall significant se"ual d sfunction and the lo!er proportions of !omen !ithin the same studies, !ho identified themselves as having a se"ual pro$lem.

The impact of aging on female sexuality

#he foremost change in discussing the medical effects of aging in !omen !ith regards to se"ualit is perhaps that of the menopause as DeLamater -2>+2. [3] indicates. #his period of transition as Avis et al [+>] discuss, rather than $eing a singular event, lasts on average 9.3 ears and is preceded $ the climacteric or peri-menopause !hich $egins at the mean age of /:., ears. It is during this climacteric period, !hen there is a gradual decline in the functioning of the ovaries, that s mptoms $egin to appear, consisting mainl of vaginal dr ness and vaginal atroph as )o!ard et al [++] discovered in their research of !omen aged /> to :?. )o!ever, in their stud of middle aged and older !omen in Australia, vaginal dr ness !as reported as completel a$sent in 9,.34 of !omen and al!a s present in onl ++.,4. Aurthermore, onl +/.14 of !omen e"perience d spareunia ,>4 or more of the time. Interestingl , the also found that the overall incidence of $oth d spareunia and of dr ness did not var significantl in their age group of /> to :?. )o!ever Lei$lum et al [+2] in their international stud of 1,:2, !omen from ++ countries including the UP, Derman , <apan, Canada, &pain, and GraBil found that the incidence of vaginal dr ness varied significantl $et!een different countries. In Ital vaginal dr ness !as reported $ ,.34 of !omen, $ contrast in GraBil +?.:4 of !omen complained of the same pro$lem. A similar picture emerged !ith reports of d spareunia, !hich !as e"perienced $ 9.14 of !omen in Australia $ut +3.14 of !omen in GraBil= this contrast also casts some dou$t over the value of e"trapolating the results of )o!ard et al(s [+>] stud internationall . In addition, this detailed research found that there !as significantl more vaginal dr ness in the UP, Australia, Canada, Ital , &pain, Argentina, and #hailand in the ,>81, ear old age group compared !ith the +38/9 ear age group. Lastl , the researchers highlighted an important contrast in health $eliefs in these t!o age groups= internationall , the ma;orit of !omen under ,> attri$uted vaginal dr ness to inade@uate se"ual arousal !hereas the over ,> age group $lamed this on their age or the menopause. Cruciall , this also illustrates the importance of ho! the individual !oman perceives $iological aging and ma e"plain, to a certain e"tent, the varied vie!s of attitudes to!ards se" post-menopausall as discussed $ DeLamater -2>+2. [3]. Also there is little evidence that se"ual desire declines directl as a result of the menopause as )inchliff et al [+] discovered in their @ualitative stud of the se"ual e"periences of !omen over the age ,>. It is also !orth noting that there is little consistent evidence to sho! that the menopause causes depression as *den et al [+9] discuss in their revie! article= furthermore Avis et al(s [+>] stud of 2,1, !omen aged /,8,, ears in 'assachusetts

highlighted that previous depression is the most li5el factor to predict depression at menopause, supported also $ Duthrie et al(s [+/] stud of /93 'el$ourne !omen. Clearl a comple" $iops chosocial model is necessar to e"plain ho! the menopause effects female se"ual functioning. Although o$viousl not universal li5e the menopause, dia$etes mellitus t pe II in the older !oman is increasingl common internationall and the incidence increases !ith age as Lhitehouse [+,] indicates. In her literature revie! she highlighted t!o main conse@uences of dia$etes= firstl , the direct effect of the disease on the ph siolog of the $od and secondl , the ps chological effects of dia$etes. Airstl , h pergl caemia !hich can commonl occur in poorl controlled dia$etes and indeed $efore it is diagnosed is thought to reduce the h dration of the mucus mem$ranes !hich include vaginal tissues therefore resulting in vaginal dr ness and associated d spareunia. In addition the increased incidence of urinar tract infections in !omen !ith dia$etes can cause further vaginal discomfort. Additionall , dia$etes causes significant pathological changes to vascular structures leading to potential damage to the $lood suppl to the vagina. #his can result in reduced lu$rication and diminished circulation to the clitoris, inhi$iting engorgement during se"ual arousal. &econdl , the ps chological effects of dia$etes such as increased perceived tiredness, em$arrassment a$out the disease as !ell as reported loss of desire all serve to indirectl reduce se"ual function. #here is a disagreement in the literature a$out !hether t pe I or t pe II dia$etes effects se"ual functioning the most, !ith no conclusive ans!er. #his lac5 of clarit could $e accounted for $ the lac5 of research. *nBlin et al [+1] are scathing $oth a$out the scarcit and @ualit of research a$out dia$etes and its effect on the dia$etic !omen, !hilst the corro$orate Lhitehouse [+,] citing the com$ination of decreased or slo! vaginal lu$rication !ith reduced se"ual arousal. )o!ever the suggest that pro$lems !ith achieving orgasm are not more common in dia$etic !omen. Urinar incontinence and pelvic organ prolapse are also more common in the older !oman. Unsurprisingl urinar incontinence results in significant ps chological distress in man !omen, !ith the fear of urine lea5age during intercourse uppermost in their minds, accompanied !ith increased feelings of guilt and disgust a$out se" as 'elin et al [+:] e"plored. #he also found that the fear of incontinence led to !omen avoiding se"ual contact. Interestingl in #anne$aum et al(s [+3] stud 291+ !omen !ith a mean age of :+ in Canada found that the !omen !ith urinar incontinence !eren(t less li5el to $e se"uall active, ho!ever the severe incontinence did correlate !ith less intercourse. )ere, overall, the found age - ounger. and marital -married. status to $e $etter predictors of regular se"ual activit . Closel related to urinar incontinence in effect is pelvic organ prolapse on !omen(s perception of their se"ualit = a su$;ect !hich &u$lett [+?] highlights is often unvisited $ health care professionals and et despite the scarcit of research on this su$;ect, there ma $e a considera$le impact on se"ual function. A common ris5 factor for dia$etes mellitus t pe II, urinar incontinence and pelvic organ prolapse is o$esit , a commonl 5no!n gro!ing epidemic. Ge ond the direct pathological lin5s $et!een these conditions and o$esit it is important to consider the

relationship $et!een o$esit and se"ual function directl , on !hich there is little research as \a$elina et al [2>] discuss. In their stud of ???+ over!eight and o$ese men and !omen the used the Impact of Leight on Cualit of Life-Lite -ILC%L-Lite., a measure of !eight-related @ualit of life tool, to e"plore se"ual function. Interestingl the results sho!ed that at all age groups, the over!eight and o$ese !omen had less self-esteem, encountered more pu$lic distress at their perceived image and had a less active se" life than the men. #he found that the fre@uenc of se"ual activit in the !omen too5 a sharp dive after the age of 2, and then levelled out, in contrast to the more gradual decline for the men. )o!ever, self-esteem increased ever decade in !omen pea5ing aged :> along !ith a consistent decline in pu$lic distress as the got older. #his research did not compare o$ese or over!eight individuals !ith those of a more health !eight $ut the aforementioned stud $ 'elin et al [+:] usefull contrasts o$ese and non-o$ese !omen, finding the former group e"periencing less se"ual e"citement, lo!er se"ual activit and less satisfaction !ith their se"ual lives. Yet d spareunia and a$ilit to achieve orgasm !ere not significantl different !hen o$ese !omen !ere compared !ith non-o$ese !omen. %$esit therefore clearl impacts on se"ual function in !omen of all ages. #here has, thus far, $een ver little research into the impact of o$esit on the se"ual functioning specificall of older !omen. Although certain chronic illnesses have $een discussed, the older !oman ma encounter a variet of de$ilitating conditions. *ncouragingl ho!ever, )o!ard et al(s [++] Australian stud !hich compared !omen !ith $reast cancer, osteoarthritis and h pertension to health !omen of the same age, found little difference in their se"ual function and satisfaction. Despite these findings the authors suggest that advances in medical care for the older !omen, !ould ver pro$a$l lead to increases in se"ual functioning in the future. #heir findings !ere supported $ Lindau et al(s [2+] stud of 1>9: U& American !omen !here the found that men tended to have their se"ual functioning impaired much more $ chronic illness than their female counterparts at all ages. Dood health !as associated strongl !ith a good @ualit fre@uent se" in their stud , ho!ever the e"act causalit and nature of this relationship is un5no!n.

ultural and social influences on aging female sexuality

)inchliff et al [+] highlighted some of the $arriers to older people e"pressing their se"ualit = 6old $odies sit in star5 contrast to contemporar images of se"ualit , !hich portra a outhful ph sical appearance7 and noting that $ecause 6se" has traditionall $een lin5ed to the natural order -reproduction., later-life se"ualit has $een vie!ed as a perversion7. )o!ever attitudes are changing. )inchliff et al [+] noted that 6&e"ualit in our later ears is no! positioned as a 5e element of successful aging.7 #he apparent health $enefits of continuing se"ual activities into old age are also $ecoming more noticed 6Gased upon a $road range of methods, samples, and measures, the research findings are remar5a$l consistent in demonstrating that one se"ual activit -POI }penile-vaginal intercourse~ and the orgasmic response to it. is associated !ith, and in some cases, causes processes associated !ith $etter ps chological and ph sical functioning.7 Grod [22] concluded

after his 2>+> revie! of the literature on health and se"ual activit . Ps chiatrists !ill $e particularl interested in the stud , previousl conducted $ Grod and Costa [9] of a large representative sample of the &!edish population. #he found that POI fre@uenc !as a significant predictor of $oth men(s and !omen(s greater satisfaction !ith their mental health. Age did not confound these results. Lomen tend to live longer than men. #hus one clear factor limiting the se"ual lives of heterose"ual older !omen is lac5 of a partner. #his !as highlighted in an unusual stud in Derman !here Geutel et al [29] e"amined se"ual desire and se"ual activit , $ut included all ages. #heir overall sample included 2>+ !omen and +>+ men over sevent and even some people in their nineties. In the over-seventies the ma;or factor determining se"ual activit levels !as !hether someone had a partner. DeLamater et al [3] also noted after his revie! that 6relationship or marital status is perhaps the ma;or influence on the fre@uenc of heterose"ual se"ual activit in later life.7 Additionall he highlighted the fre@uent presence of 6cultural norms limiting se"ual activit to persons in committed relationships7. #he se"ual and general health of a !oman(s partner also naturall affects their se"ual lives. A male partner ma also $e e"periencing the effects of aging, #he effects of social, cultural, medical and pharmaceutical factors on the se"ual functioning of men is ho!ever $e ond the scope of this article. As !omen get older the or their partners ma not $e a$le to continue !ithout residential or nursing home care. Unfortunatel this ma ma5e continuation of their se"ual life ver difficult due to staff attitudes and lac5 of privac . 6#heir onl privac is $et!een the sheets7 $ Gauer et al [2/] in Australia demonstrated a lac5 of individual rooms and ho! difficult it !as for residents to have privac from other residents or from staff. &taff felt that their need for access !as more important than residents( privac . 6&taff and nursing home managers need to !or5 to!ard developing a home environment that is supportive of residents( se"ualit rights, that permits se"ualit e"pression and promotes a culture !here all people concerned are comforta$le !ith se"ualit issues7, Noach [2,] in 2>>/ concluded after loo5ing @ualitativel at staff attitudes in Lestern Australia.

Bhy do older women commonly not seek help for sexual difficultiesG
Lomen often do not see5 help for se"ual pro$lems Ticolosi et al [/] -D&&AG. found that 924 of their sample of ,>29 !omen in *urope reported a se"ual d sfunction. ++4 had lu$rication difficulties, +94 had an ina$ilit to reach orgasm and +34 had lac5 of se"ual interest. #his stud found that of men and !omen !ho reported a se"ual d sfunction, overall, :/4 had not sought medical help. #he authors did not report these results $ gender $ecause 6the results !ere almost identical for men and !omen.7 #his stud also as5ed respondents, !ho had not sought help for their se"ual d sfunction !h the had not done so. #heir results highlighted four main reasons. A$out :14 of respondents said that the did not feel that the had a pro$lem, :+4 felt that it !as not a medical issue,

9?4 felt em$arrassed and 214 had concerns a$out afforda$ilit or access to medical care. Interestingl though, ,?4 of !omen agreed !ith the statement 6I am in favour of the use of medical treatments to help older people en;o se"ual activit 7. )inchliff et al, 2>++[+] e"tensivel revie!ed the help-see5ing $ehaviour of people over ,>, !ith respect to their se"ual functioning. Cualitative studies highlighted common $eliefs that se"ual difficulties !ere a normal part of old age and that the se"ual difficulties !ere not causing much distress= people !ere 6comforta$le the !a the !ere7. Difficulties !ere left to see !hether the !ould resolve $ themselves and !ere often not considered to $e serious. It !as common to feel that se"ual functioning !as recreational and as so, not so much a medical issue to discuss !ith a doctor. &ome patients felt that the doctor might $e uncomforta$le !ith the su$;ect of se" themselves and some older people even feared that a ounger doctor ma appear to disapprove of se"ual activit in an older person. 'an older !omen suffer !ith chronic diseases !hich ma impact upon their se"ual functioning. Pedde et al [21] in the Tetherlands sought to 6investigate help-see5ing $ehavior concerning se"ual pro$lems among people !ith a disease or an impairment7 and to 6determine factors and reasons that deter people from see5ing professional se"ological help7. &hame sh ness and an"iet prohi$ited people and man !ere unsure !hich health professional to approach and dou$tful that the !ould receive useful help. Unfortunatel , !hen Pedde et al [21] en@uired, it turned out that t!o thirds of those !ho had sought help ;udged the consultation the received negativel so people(s dou$ts appeared to $e !ell-founded. #here is some research availa$le regarding attitudes of doctors !hich illustrates that doctors themselves often su$liminall or overtl discourage their patients from consulting them a$out se"ual functioning. )inchliff et al [+] found that doctors !ere more li5el to $roach the su$;ect of se"ual functioning !ith ounger patients than older patients in their revie!. #he also found that cultural factors can influence attitudes of $oth doctors and patients, creating $arriers to open communication, noting that there are noticea$l $ehaviours in different countries. It !as esta$lished in 2>>+ that Ps chiatrists, even %ld Age Ps chiatrists, are not immune from this as Gouman et al [2:] illustrated in their stud entitled 6Are Ps chiatrists Duilt of Ageism !hen it comes to ta5ing a &e"ual )istor Y7 #he aimed to e"amine the attitudes and perceived clinical practice of ps chiatrists !ith regard to ta5ing a se"ual histor and management of se"ual d sfunction in their patients $ comparing responses of old age and general ps chiatrists. #he sent their @uestionnaire to +// consultants in old age ps chiatr and general adult ps chiatr . #he @uestionnaire contained one out of t!o possi$le t!o case vignettes. %ne descri$ed an 39 ear old man !ith no previous ps chiatric histor and !ithout an cognitive impairment, complaining of lo! mood for t!o months and the other descri$ed a /> ear old man !ith the same complaint. Cuestions then covered !hether the consultant !ould ta5e the various elements of a se"ual histor and if not, !h not. #he !ere then as5ed !hat their management !ould

$e if a se"ual difficult !as identified. #heir results sho!ed, from 1+4 replies, that $oth groups of consultants !ere more li5el to as5 the ounger man a$out se"ual function and to refer the ounger man for appropriate treatment. #hese authors postulated that factors !hich ma have influenced the lac5 of histor ta5ing !ere that patients don(t tend to raise the su$;ect themselves, Ps chiatrists ma 6have difficulties disconnecting from their o!n personal $elief s stem regarding aged se"ualit 7 or the ma ;ust 6lac5 a!areness of ph siological, pharmacological and ps chosocial $ases of se"ual pro$lems as !ell as of aged se"ualit 7. &imilarl , !ith respect to treatment referral, their results sho!ed that a Ps chiatrist !ould t picall refer a middle-aged patient !ith se"ual d sfunction for se"ual therap $ut that an elderl man !ith the same pro$lems !ould $e referred to a communit ps chiatric nurse, !ho is not trained in se"ual therap . #he authors concluded that ta5ing a se"ual histor is often omitted in the ps chiatric assessment of elderl men and that elderl men !ith se"ual d sfunction do not receive appropriate referral and treatment. Gouman et al [2:] reached the conclusion that 6)uman se"ualit and particularl aged se"ualit is an area that re@uires more attention in ps chiatric training.7 #his stud also $egs the @uestion= !hat !ould the respondents have ans!ered, had the patient $een femaleY Nele and L lie in 2>>: [23] loo5ed at the 6'anagement of ps chose"ual and relationship pro$lems in general mental health services $ ps chiatr trainees7. #he sent a completel anon mous @uestionnaire to all ps chiatr trainees in one region of the United Pingdom, regarding their perception of their competenc in dealing !ith se"ual d sfunction and relationship pro$lems= the need to discuss potential se"ual side-effects $efore and after starting ps chotropic medication and the importance of a readil availa$le ps chose"ual disorder clinic. #he @uestionnaire also tried to esta$lish the e"tent of their training on ps chose"ual issues and se"ual medicine. 3+4 of trainees reported feeling inade@uac !hilst dealing !ith ps chose"ual disorders during their training in ps chiatr . %nl 9>4 reported as5ing patients a$out potential se"ual side-effects !hen on ps chotropic medication. #he authors concluded that training for undergraduates needed to focus on se"ual health more full and that trainees should $e supervised and assessed so that the could demonstrate competence in this area of the curriculum. &chindel et al [2?] recentl completed a larger scale stud of U& and Canadian 'edical students. #he received over 2>>> self-selected replies to a !ide-ranging surve !hich e"amined not onl their attitudes to!ards discussing se"ualit !ith their patients $ut also the students o!n se"ual preferences and levels of se"ual activit . #he found that 6the most po!erful association of lac5 of comfort in dealing !ith patients( se"ualit !as a perception of inade@uate human se"ualit training in medical school.7 #his !as the case 6irrespective of their personal se"ual choices and e"periences7 #hese authors therefore highlighted 6the importance of ensuring a @ualit human se"ualit curriculum at medical schools throughout the United &tates and Canada.7

"ssues specifically affecting older lesbian women

Although there is limited research availa$le in this area, studies indicate that Les$ian !omen have specific concerns as the enter old age.

In their small-scale @ualitative stud of les$ians in Te! Yor5, )o!ell and Geth [9>] found that 6'iddle-aged les$ians e"pressed concern regarding !ho !ould care for them !hen the !ere old. Lhat !ould the do !hen the could no longer use coping s5ills that the learned as oung people facing homopho$iaY &ome e"pressed hope that homose"ual communities that supported them through their coming out processes !ould also meet this need. )o!ever, the !ere concerned that les$ian-friendl services !ere alread difficult to find, even in Te! Yor5 Cit !here man ga and les$ian service organiBations e"ist.7 &imilarl , &mith et al [9+], !ho e"amined the vie!s of Da , Les$ian, Gise"ual and #ransse"ual -DLG#. people in California noted that 6Tot a single participant thought that nursing homes !ere 6ver 7 DLG#-friendl and over half -,2.14. thought nursing homes !ere not DLG#-friendl . Almost as man -/:./4. thought that assisted living services !ere not DLG#-friendl . *@ual percentages -91.34. thought that senior centers and accessi$le transportation !ere not DLG#-friendl . A$out a @uarter thought that in-home care personnel !ould not $e DLG#-friendl .7 Teville et al [92], did a larger-scale surve , underta5en in Te! \ealand, entitled XLavender retirement(E a @uestionnaire surve of les$ian, ga and $ise"ual people(s accommodation plans for old age7 %f !omen -nF+>>+., /:1 -/:.14. chose living !ith famil Ipartner, 9?, -9?.,4. chose living in their o!n house, flat or apartment, :3 -:.34. chose Xother( and onl ,2 -,.24. chose a general retirement facilit .7 #he also found that, !hen !omen !ere as5ed !hat the !ould prefer if the !ere una$le to live on their o!n,7+>>: !omen respondents to this @uestion, ,?9-,3.?4. preferred an LDG-friendl retirement facilit , 2>+ -2>.>4. preferred to $e cared for in her o!n home $ pu$lic services, +22 -+2.+4. preferred a general retirement facilit , and ?+ -?.>4. preferred some other accommodation option.7 #he advocated 6ensuring nursing curricula covers topics such as se"ualit , gender, discrimination, as !ell as relationships, friendships and lifest le patterns of Les$ian, Da and Gise"ual people.7

=ld age in the transsexual community

People have usuall $een part of the transse"ual communit for man ears $efore entering old age $ut some people re@uest gender reassignment !hen older as descri$ed $ Docter [99] and previousl $ Lothstein [9/]. Ps chiatrists in old age therefore need to $e a!are that a strong desire to change gender can present in old age and 5no! the appropriate referral procedure in their area. Aor people !ithin the transse"ual communit , aging can $e a daunting prospect. &mith et al [9+] in California collected some @ualitative data from the LDG# communit , !hich illustrates some perceived unmet needs. #heir respondents( suggestions included= 6)ave more ga friendl people that provide services,7 6Gegin to educate the organiBations that cater to senior citiBens a$out the need to $e accepting of DLG# persons,7 6'ore training for people involved in social services, non$iased.7 #hese comments appear to indicate a !orr that as an elderl LDG# person, one might find oneself vulnera$le to pre;udice from professionals. &everal people also e"pressed a preference for specialised services=

6%pen DLG# specific centers geared for senior DLG# persons to congregate7 6'ore communit activities for older ga sIhomose"ual people and their partners7 6&tart an LDG#C [les$ian, ga , $ise"ual, transgender, or @ueer] housing pro;ect, li5e the have in other cities.7 <onson et al [9,] in their 2>+2 &!edish stud deftl illustrated ho! se"ualit can adapt during aging for the LDG# communit . 6#urning vinegar into !ineE )umorous selfpresentations among older7 LDG#C, loo5ed at self advertising in t!o Internet dating forums. &elf depreciating humour a$out 6old age, $eing over!eight, impotence and other age-related changes !ere in fact part of a repertoire that displa ed mar5eta$le characteristics such as humor, self-distance and honest among advertisers.7

'irect effects of mental illness on female sexual functioning

Depression and an"iet are more common in older !omen and the are directl associated !ith increased anorgasmia and lac5 of pleasure according to 'oreira et al [91]. Ching et al [9:] in their unusual stud of :9 unmedicated patients !ith depression alongside ++1 health volunteers revealed that depressed !omen in all age groups had poorer se"ual functioning than the control group. #he also found that increased age !as associated !ith poorer se"ual functioning in the depressed group, !hereas in the control group, se"ual satisfaction continued to increase to the age />, $efore starting to decline. Aa$re et al [93] studied ++3/ !omen, using the )amiliton Depression Nating &cale and the Derogatis Inventor of &e"ual Aunction tool. )ere the found that a higher the depression score correlated !ith a lo!er the level of se"ual functioning. )o!ever, this relationship $et!een depression and se"ual d sfunction is highl comple". Indeed there is evidence that penile-vaginal intercourse, cruciall including e;aculation, leads to stimulation of hormones in !omen that can $e ps cho-protective, such as seminal prostaglandins, as Grod [9?] discusses. #he length of e"posure to seminal fluid is also 5e , !ith !omen !ho void urine shortl after se" having a higher incidence !ith depression than those that don(t. #his potentiall leads to vicious circle in depressed !omen, !here$ reduced li$ido from their mental illness engenders less se"ual activit , !hich in turn reduces e"posure to seminal fluid via penile-vaginal intercourse. #his research does not directl discuss older !omen= ho!ever their increased incidence of depression together !ith the tendenc for older !omen to engage in less fre@uent penilevaginal intercourse ma5es these findings !orth of note. #here is again a great paucit of contemporar research on the effect on female se"ual functioning of other mental illness across an age groups, let alone in older !omen. )o!ever, over 2, ears ago, some interesting research !as conducted $ Na$och [/>] on CBechoslova5ian !omen !hich found there to $e no difference in orgasmic response in $ipolar patients, compared !ith a control group. )o!ever, he found those !omen !ith schiBophrenia and 6neurotic7 disorders had much lo!er rates of coital orgasm than the controls !ith no mental illness. #here is clearl an on-going need for research into the

relationship $et!een mental illness, especiall those other than depression and se"ual d sfunction in the older !oman.

The dilemmas faced by dementia sufferers and their carers

Dementia is a pervasive disease of increasing prevalence, especiall in Lestern societies, as people(s life e"pectanc has increased. Although @ualit of life maintaining treatments are increasingl availa$le there is a stead progression to!ards !idespread loss of mental faculties. #his is often devastating for sufferers and partners, !ho are often redesignated as 6carers7. Lhen ver$al communication is impaired, sometimes non-ver$al communication and ph sical closeness can provide an intermittent !indo! of comfort. )o!ever as the sufferer(s capacit to consent declines, couples can find themselves in a minefield, surrounded $ !ell-meaning professionals. #he AlBheimer(s &ociet E &e" and Dementia leaflet [/+] -!!!.alBheimers.org.u5IsiteIscriptsIdocuments{info.phpY documentIDF+2?. outlines common changes that can occur in the conte"t of dementia. #hese are a greater or lesser interest in se", an increase or decrease in se"ual performance, changes in se"ual Xmanners( R for e"ample, appearing less sensitive to the other(s person needs or appearing se"uall aggressive and changes in levels of inhi$itions. #his pu$lication also provides some practical guidance for couples negotiating through these sometimes ethicall challenging areas. #he *nglish Tational Institute for Clinical *"cellence -TIC*. recommends 6At the time of diagnosis and !hen indicated su$se@uentl , the impact of dementia on relationships, including se"ual relationships, should $e assessed in a sensitive manner7 #here is even hope after dementia leads to care outside one(s o!n home. 6Intimac , &e"ualit and &e"ual Gehaviour in DementiaE )o! to Develop Practice Duidelines and Polic for Long #erm Care Aacilities7 [/2] has $een developed in Canada. #his pragmatic approach aims to challenge the 6pervasive7 $elief in societ that 6se" is for the cognitivel intact7.

The effects of prescription medications on sexuality in the elderly

As the population ages the need for multiple drug therapies gro!s. Lhilst man !omen in older age !ish to continue their se"ual relationships, the medicines the are prescri$ed can ma5e this difficult and sometimes impossi$le. Additionall the medicines prescri$ed for their se"ual partner can impair their se"ual performance and as a result damage their relationship. #he potential for ne!l prescri$ed drugs to cause se"ual impairment is easil overloo5ed at the counselling phase. 'an prescri$ers ma $e una!are of their patients( difficulties as a conse@uence of reluctance $ the patient to tal5 a$out them. Direct @uestioning from the prescri$er is usuall re@uired to open this dialogue. It is important that the are a!are

!hich medicines have the potential to impair se"ualit in order to as5 appropriate @uestions of those patients recentl started on such drugs. In order to predict the potential for a medicine to impair se"ual function an appreciation of the normal mechanisms involved in se"ual function is re@uired. #he central nervous s stem -CT&., paras mpathetic s stem and the s mpathetic s stem are all involved in normal se"ual function.

&e"ual interest or li$ido8mediated primaril $ CT& Arousal 8 mediated $ CT& and paras mpathetic s stem Plateau %rgasmIe;aculation 8 mediated $ CT& and s mpathetic s stem Nesolution

'an neurotransmitters, neuropeptides and hormones are involved in normal se"ual reactions.

#sychotropic medication which may affect sexual functioning of women and men:
Antidepressants
'i"ed an"iet ] depression is a common mental disorder. Aor e"ample, appro"imatel 38+24 of the Gritish population e"perience depression in an ear according to the #he %ffice for Tational &tatistics Ps chiatric 'or$idit report [/9]. %f these, half onl e"perience s mptoms for +3 months. )o!ever the poor, the long-term sic5 and the unemplo ed, three states often attri$uta$le to the elderl , are li5el to $e affected for a longer duration than the general population. &e"ual d sfunction is a 5no!n cause of depression $ut the relationship is comple". Unfortunatel it is also a s mptom of depression and can $e an adverse effect of treatment !ith antidepressant medicines &eidman [//]. #hese confounding issues impl that there is a re@uirement to esta$lish an understanding of the patients $aseline se"ual functioning $efore the !ere depressed and $efore the su$se@uentl commence treatment !ith antidepressants. &e"ual d sfunction in men and !omen has $een reported !ith nearl all antidepressant medication !ith reported incidence var ing from />4 according to the Getter %r LorseE A Longitudinal &tud %f #he 'ental )ealth %f Adults In Dreat Gritain report [/,] to ,?.+4 according to Nothschild [/1]. Dela ed orgasm can $e attri$uted to the anticholinergic effects of tric clic antidepressants !hile decreased li$ido is a result of their dopamine antagonist properties. Aemales not re@uiring antidepressants ma still e"perience the results of tric clic antidepressant se"ual adverse effects such as erectile d sfunction and impaired

e;aculation in their male partner. Geaumont [/:] highlights that elderl patients are especiall vulnera$le to man of the side-effects of tric clic antidepressants. #he selective serotonin reupta5e inhi$itors -&&NIs. are increasingl common drugs prescri$ed for depression, et the also carr a ris5 of !orsening se"ual function. 'onte;o et al [/3] o$served that dela ed orgasm is seen !ith the &&NIs along !ith decreased li$ido, anorgasmia, and decreased vaginal lu$rication. Citalopram and paro"etine !ere sho!n to $e relativel li5el to have had an effect in the 'onte;o et al stud [/3]. #he se"ual adverse effects of &&NIs are thought to $e caused $ increasing s naptic concentrations of serotonin stimulating ,)#2 and ,)#9 receptors resulting in decreased levels of dopamine activit , according to 'ichael et al [/?]. &pecific resources should therefore $e directed to!ards the education of prescri$ers to help identif those patients most at ris5 and monitor for treatment emergent se"ual side effects. As !ith the tric clic antidepressants, females !hose male partners are ta5ing an &&NI ma still e"perience se"ual adverse effects as a result of erectile d sfunction. Oenlafa"ine, a serotonin and noradrenaline reupta5e inhi$itor, !as identified in one stud $ 'onte;o et al [/3], !hich compared several antidepressants, as having a relativel high incidence of se"ual d sfunction -1:.94.. *ffects ma include decreased li$ido, dela ed orgasm, anorgasmia, decreased vaginal lu$rication and in men, erectile d sfunction. 'irtaBapine is a selective ,)#2 and ,)#9 antagonist, !hich ma e"plain the relativel lo! fre@uenc and intensit of se"ual d sfunction -2/./4.[/3] as compared to some &&NIs. As a conse@uence of its lo! fre@uenc and intensit of se"ual d sfunction, mirtaBapine ma $e considered a via$le choice as an alternative antidepressant for !omen e"periencing se"ual d sfunction. It remains unclear !hat effects traBadone has on se"ual function= Natt a et al [,>] reported increased li$ido. Dulo"etine(s effect on se"ual function !as assessed in / randomised dou$le $lind place$o and paro"etine controlled trials in patients !ith ma;or depression in a stud $ Delgarno et al [,+]. It !as found to have a higher rate of treatment-emergent se"ual d sfunction -/1./4. than place$o -23.34. $ut significantl lo!er rate than paro"etine -1/.+4.. Li5e the tric clic and &&NI antidepressants the non-reversi$le 'A%Is ma produce se"ual d sfunction, !hich is suggested to $e as a result of their serotonergic stimulating action. Ph siological effects are similar to those of the tric clic antidepressants. Nothschild [/1] suggests the alternative of moclo$emide, a reversi$le 'A%I !ith a lo!er reported incidence of se"ual d sfunction and !hich ma even have a stimulating effect on se"ual function.

Anti-epileptics

*pileps can affect reproductive function and se"ualit . #his is li5el to $e $ecause man patients report lo! satisfaction !ith se"ual relationships in the conte"t of feeling stigmatiBed $ having the condition according to )arden [,2]. Changes in se" hormone levels in patients !ith epileps ma $e attri$uta$le to the condition, the antiepileptic drugs or to $oth. Aindings in !omen !ith epileps include a$normal levels of prolactin, luteiniBing hormone, estradiol, se" hormone $inding glo$ulin, and deh droepiandrosterone. #he hepatic enB me-inducing anti-epileptic drugs= pheno$ar$ital, phen toin, car$amaBepine, and o"car$aBepine increase hepatic s nthesis of se" hormone $inding glo$ulin and the meta$olism of se" hormones. Lam$ert [,9] reports that lamotrigine, !hich does not induce hepatic enB mes, appears not to affect se"ual function.

Anti-parkinsons drugs
#he ph sical manifestations of Par5inson(s disease -PD. impair the a$ilit to perform se"ual activit successfull . In addition, the effects of PD also produce a range of s mptoms that can impair se"ualit . In $oth genders loss of li$ido is common !hile in men erectile d sfunction and dela ed e;aculation is seen also. In !omen vaginal tightness and dissatisfaction in se"ual intercourse has $een noted. &a5a5i$ara et al [,/] discuss that treatment of PD using dopaminergic drugs improves se"ual functioning to some e"tent ho!ever pathological h perse"ualit ma occur !hich the attri$ute to the dopamine d sregulation s ndrome in this disorder.

Antipsychotics
&timmel et al [,,] highlight that se"ual d sfunction can occur in patients !ith schiBophrenia $ut that it is more li5el still to affect individuals !ho are ta5ing antips chotics. Advanced age is one of the factors influencing the degree of se"ual d sfunction. Also relevant are the class of antips chotic, higher levels of depression and concomitant diseaseIdrug therap according to &timmel et al [,,]. #he most common se"ual side effect of antips chotics is reduced li$ido affecting 9>4 to 1>4 of those ta5ing older antips chotics affected and up to /94 of those ta5ing ne!er at pical antips chotics in the &timmel et al revie! [,,]. #his is apparentl related to dopamine antagonism and the increased prolactin levels caused $ dopamine $loc5ade. Nisperidone has $een found to cause elevations in prolactin levels relativel fre@uentl . %lanBapine and cloBapine are respectivel less li5el to cause this and @uetiepine less li5el still [,,]. #he older conventional antips chotic drugs such as chlorpromaBine, haloperidol and fluphenaBine are potent dopamine $loc5ers. #hese ma cause up to 1>4 of patients to e"perience se"ual adverse effects [,,]. )anssens et al [,1], in their trial comparing aripipraBole !ith standard care -olanBapine, @uetiapine or risperidone., found that $oth groups e"perienced improvements in se"ual function !hen compared !ith $aseline assessments. )o!ever at 3 !ee5s the aripipraBole group reported significantl greater improvement compared !ith the standard care group.

Although $aseline mean serum prolactin levels !ere similar in the t!o treatment groups, at Lee5 21, mean decreases in serum prolactin !ere 9/.2 mgIdL in the aripipraBole group, compared !ith +9.9 mgIdL in the standard care group. #he stud concluded that 6aripipraBole has the potential to reduce se"ual d sfunction, !hich in turn might improve patient compliance.7

BenHodiaHepines
GenBodiaBepines such as diaBepam and temaBepam are often used at relativel high doses for the treatment of an"iet and panic disorders. #ogether !ith the dro!siness ou !ould e"pect the have $een found to cause reduced li$ido and e;aculator difficult in the )anssens et al trial [,1].

=ld Age #sychiatry and sexual functioning

&o, !hat has se"ual functioning got to do !ith ps chiatr , an !a Y #he effects of mental illness on female se"ualit and se"ual functioning have alread $een addressed. Also !e have e"amined the role of ps chotropic medication on se"ual functioning. #herefore surel , se"ual functioning and an changes to it are the $usiness of the ps chiatrist. In addition, !e have esta$lished that training in this area at the undergraduate and postgraduate level in Ps chiatr appears to $e insufficient !hich impairs communication !ith patients. Tna;i et al [,:] loo5ed specificall at se"ual d sfunction in schiBophrenia and found 6As regards training in the management of se"ual d sfunction in schiBophrenia, 12 ps chiatrists -3+.14. had not had an = 1> respondents -:3.?4. agreed the !ould !ant training, !ith +? -21.94. agreeing strongl that this !as re@uired.7 Although a!areness of se"ual d sfunction has $een rising over recent ears amongst ps chiatrists, this a!areness still tends to $e focused on the needs of ounger men, ;ust as it !as for Gouman [2:]. Yet !e have a responsi$ilit . &tevenson [,3] in Canada in 2>>/ asserted 6Aor an area of life and health that is so fundamental and pervasive, professional ignorance or inattention to possi$le se"ual pro$lems does not meet current standards of ps chiatric practice.7 and 6it ma $e argued that it is indefensi$le not to ta5e a good screening se"ual histor from each patient.7

onclusions
#he prospect of a good se"ual life for older !omen appears to $e improving. #he internet is providing more resources for older !omen to see5 and find information and se"ual aids. Information can $e found via the AANP [,] !e$site and the &e"ual Advice Association -!!!.sda.u5.net., !hich also provides a helpline in the United Pingdom. It additionall provides specific information a$out ho! to approach our Deneral Practitioner a$out a se"ual difficult . As pointed out $ )inchliff et al [+] the internet also ena$les people !ho are not a$le to travel easil , to o$tain items to assist their se"ual

functioning $ post and anon mousl . Ainding partners can $e facilitated $ !e$sites as highlighted $ <onson et al [9,]. #he authors !ere una$le to find an specific research investigating the attitudes or practice of Ps chiatrists regarding the se"ual health of their older !omen patients despite the 5no!n effects of mental illness and ps chotropic medication on female se"ual functioning and the increasing a!areness that man older !omen treasure their se"ual lives. Ps chiatrists have a uni@ue opportunit to address this topic !ith their patients. Usuall the ps chiatrist has more time !ith their patient than, for e"ample, their general practitioner. #he ps chiatrist is also routinel overcoming ps chological $arriers to as5 6difficult7 @uestions. If ps chiatrists can address the m riad of ps chotic s mptoms and suicidal ideation !ith their older female patients, is it reall so difficult to en@uire a$out and appropriatel address changes in se"ual functioningY #raining in $oth medical school and for ps chiatric trainees appears to $e fundamental to overcoming the identified $arriers to this aspect of patient care.

Article information
Aging Dis. 2>+2 %cto$er= 9-,.E 9:9893/. Pu$lished online 2>+2 August 2,. P'CIDE P'C9,>+9?9 Alison Lood,+,e Noss Nunciman,2 Pevan N. L lie,9 and Noss 'c'anus/ + %ld Age Ps chiatr , &heffield )ealth and &ocial Care #rust, *astglade Centre, &heffield, UP 2 Notherham )ospital, Notherham, UP 9 Porter$roo5 Clinic, &heffield, UP / Pharmac Department, No al )allamshire )ospital, &heffield, UP e Correspondence should $e addressed toE Alison Lood. %ld Age Ps chiatr , &heffield )ealth and &ocial Care #rust, *astglade Centre, &heffield, UP. *-mailE alison.!oodIatIshsc.nhs.u5 Neceived <ul 2>, 2>+2= Nevised August +>, 2>+2= Accepted August +>, 2>+2. Cop right notice Articles from Aging and Disease are provided here courtes of ?!< "nternational <<

References
[+] )inchliff &, Dott '. &ee5ing 'edical )elp for &e"ual Concerns in 'id- and Later LifeE A Nevie! of the Literature. <ournal of &e" Nesearch. 2>++=/3E+>18++:. [Pu$'ed] [2] American Association of Netired Persons &e", romance, and relationshipsE AANP surve of midlife and older adults -Pu$ To D+?29/. Lashington, DCE Author= 2>+>. [9] Grod &, Costa N'. &atisfaction -se"ual, life, relationship, and mental health. is associated directl !ith penile-vaginal intercourse $ut inversel !ith other se"ual $ehavior fre@uencies. <ournal of &e"ual 'edicine. 2>>?=1E+?/:8,/. [Pu$'ed] [/] Ticolosi A, Guvat <, Dale G, Dlasser DG, )artmann U, Laumann *%, Dingell C. &e"ual $ehaviour, se"ual d sfunctions and related help see5ing patterns in middle-aged

and elderl *uropeansE the glo$al stud of se"ual attitudes and $ehaviors. Lorld <ournal of Urolog . 2>>1=2/E/298/23. [Pu$'ed] [,] Association of Netired PersonsE se" and intimac !e$site. [1] )er$enic5 D, Neece ', &chic5 O, &anders &, Dodge G, Aorten$err <D. &e"ual $ehavior in the United &tatesE Nesults from a national pro$a$ilit sample of men and !omen ages +/ to ?/. <ournal of &e"ual 'edicine. 2>+>=:E2,,821. [Pu$'ed] [:] Gec5man T, Laern ', Dustafson D, &5oog I. &ecular trends in self-reported se"ual activit and satisfaction in &!edish :> ear oldsE a cross sectional surve of four populations, +?:+82>>+. Gritish 'edical <ournal. 2>>3=99:E+,+8+,/. [P'C free article] [Pu$'ed] [3] DeLamater <. &e"ual *"pression in Later LifeE A Nevie! and & nthesis. <ournal of &e" Nesearch. 2>+2=/?E+2,8+/+. [Pu$'ed] [?] Lo!estein L, Dam$le #, Denisei5o &. &e"ual Aunction is Nelated to God Image Perception in Lomen !ith Pelvic %rgan Prolapse. <ournal of &e"ual 'edicine. 2>>?=1E2231822?+. [Pu$'ed] [+>] Avis T*, 'cPinla &'. #he 'assachusetts Lomen(s )ealth &tud E an epidemiologic investigation of the menopause. <ournal of the American 'edical Lomen(s Association. +??,=,>E/,8?. [Pu$'ed] [++] )o!ard <N, %(Teill &, #ravers C. Aactors affecting se"ualit in older Australian !omenE &e"ual interest, se"ual arousal, relationships, and se"ual distress in older Australian !omen. Climacteric. 2>>1=?E9,,891:. [Pu$'ed] [+2] Lei$lum &N, )a es ND, Lanser NA, Telson <&. Oaginal Dr nessE A Comparison of Prevalence and Interventions in ++ Countries. <ournal of &e"ual 'edicine. 2>>?=1E2/2,8 2/99. [Pu$'ed] [+9] *den P, L lie P. Cualit of se"ual life and menopause. Lomen(s )ealth. 2>>?=,E93,89?1. [Pu$'ed] [+/] Duthrie <N, Dennerstein L, #affe <N, Lehert P, Gurger )D. #he menopausal transitionE a ?- ear prospective population-$ased stud . #he 'el$ourne Lomen(s 'idlife )ealth Pro;ect. Climacteric. 2>>/=:E9:,83?. [Pu$'ed] [+,] Lhitehouse CN. &e"ualit in the %lder Aemale Lith Dia$etes 'ellitus 8 A Nevie! %f the Literature. Urological Tursing. 2>>?=2?E++82?. [Pu$'ed] [+1] *nBlin P, 'athieu C, Gruel A, Gosteels <, Oanderschueren D, Dem ttenaere P. &e"ual d sfunction in !omen !ith t pe + dia$etesE a controlled stud . Dia$etes Care. 2>>2=2,E1:281::. [Pu$'ed] [+:] 'elin I, Aalconer C, Nossner &, Altman D. &e"ual function in o$ese !omenE impact of lo!er urinar tract d sfunction. International <ournal of %$esit . 2>>3=92E+9+28+9+3. [Pu$'ed] [+3] #annen$aum C, Corcos <, Assalian P. #he Nelationship Get!een &e"ual Activit and Urinar Incontinence in %lder Lomen. <ournal of the American Deriatric &ociet . 2>>1=,/E+22>8+22/. [Pu$'ed] [+?] &u$lett C. Adding to the *vidence GaseE God Image and &e"ualit in Lomen Lith Pelvic %rgan Prolapse. Urologic Tursing. 2>>?=2?E2/:8211. [Pu$'ed] [2>] \a$elina DL, *ric5son AL, Polot5in NL, Cros$ ND. #he *ffect of Age on LeightNelated Cualit of Life in %ver!eight and %$ese Individuals. %$esit <ournal. 2>>?=:E+/+>8+/+9. [Pu$'ed]

[2+] Lindau &#, Davrilova T. &e", health, and ears of se"uall active life gained due to good healthE evidence from t!o U& population $ased cross sectional surve s of ageing. Gritish 'edical <ournal. 2>+>=9/>E3+>. [P'C free article] [Pu$'ed] [22] Grod &. #he relative health $enefits of different se"ual activities. <ournal of &e"ual 'edicine. 2>+>=:E+9918+91+. [Pu$'ed] [29] Geutel '*, &tZ$el-Nichter Y, Gr[hler *. &e"ual desire and se"ual activit of men and !omen across their lifespansE results from a representative Derman communit surve . Gritish <ournal of Urolog International. 2>>:=+>+E:1832. [Pu$'ed] [2/] Gauer '. #heir onl privac is $et!een their sheets. <ournal of Derontological Tursing. +???E2,. [Pu$'ed] [2,] Noach &. &e"ual $ehaviour of nursing home residentsE staff perceptions and responses. <ournal of Advanced Tursing. 2>>/=/3E9:+89:?. [Pu$'ed] [21] Pedde ), Oan de Liel ), &chultB LL, Oan!esen$eec5 I, Gender <. &e"ual )ealth Pro$lems and Associated )elp-&ee5ing Gehavior of People Lith Ph sical Disa$ilities and Chronic Diseases. <ournal of &e" ] 'arital #herap . 2>+2=93E198:3. [Pu$'ed] [2:] Gouman LP, Arcelus <. Are Ps chiatrists Duilt of Ageism !hen it comes to ta5ing a &e"ual )istor Y International <ournal of Deriatric Ps chiatr . 2>>+=+1E2:89+. [Pu$'ed] [23] Nele P, L lie PN. 'anagement of ps chose"ual and relationship pro$lems in general mental health services $ ps chiatr trainees. International <ournal of Clinical Practice. 2>>:=1+E+:>+8+:>/. [Pu$'ed] [2?] &chindel AL, Ando PA, Telson C<, Gre er GT, Lue #A, &mith <A. 'edical student se"ualit E )o! se"ual e"perience and se"ualit training impact U.&. and Canadian medical students( comfort in dealing !ith patients( se"ualit in clinical practice. Academic 'edicine. 2>+>=3,E+92+8+99>. [P'C free article] [Pu$'ed] [9>] )o!ell LC, Geth A. Pioneers in %ur %!n LivesE Drounded #heor of Les$ians( 'idlife Development. <ournal of Lomen ] Aging. 2>>/E+1. [Pu$'ed] [9+] &mith LA, 'cCaslin N, Chang <, 'artineB P, 'cDre! P. Assessing the needs of older ga , les$ian, $ise"ual, and transgender peopleE a service-learning and agenc partnership. <ournal of Derontological &ocial Lor5. 2>+>=,9E93:8/>+. [Pu$'ed] [92] Teville &, )enric5son '. XLavender retirement(E a @uestionnaire surve of les$ian, ga and $ise"ual people(s accommodation plans for old age. International <ournal of Tursing Practice. 2>+>=+1E,318?/. [Pu$'ed] [99] Docter NA. #ransse"ual surger at :/E A case report. Archives of &e"ual Gehavior. +?3,=+/E2:+82::. [Pu$'ed] [9/] Lothstein L'. #he aging gender d sphoria -transse"ual. patient. Archives of &e"ual Gehavior. +?:?=3E/9+8///. [Pu$'ed] [9,] )o5an <, &ivers5og A. #urning vinegar into !ineE )umorous self-presentations among older DLG#C. <ournal of Aging &tudies. 2>+2=21E,,. [91] 'oreira *D, Dlasser DG, Ping N, Duarte A, Dingell C. #he Dlo$al &tud of &e"ual Attitudes, and Gehaviors Investigators Droup= &e"ual difficulties and help-see5ing among mature adults in AustraliaE Nesults from the Dlo$al &tud of &e"ual Attitudes and Gehaviours. &e"ual )ealth. 2>>3=,E22:829/. [Pu$'ed] [9:] Ching CP, Lieh Y#, )ui L, &ee CP, )ui-Chun ), Puang ), Linston L, Nu-Gand L. Age, Dender, Depression, and &e"ual D sfunction in #ai!an. <ournal of &e"ual 'edicine. 2>>?=1E9>,189>12. [Pu$'ed]

[93] Aa$re LA, &mith LC. #he *ffect of 'a;or Depression on &e"ual Aunction in Lomen. <ournal of &e"ual 'edicine. 2>+2=?E29+829?. [Pu$'ed] [9?] Grod &. #he relative health $enefits of different se"ual activities. <ournal of &e"ual 'edicine. 2>+>=:E+9918+91+. [Pu$'ed] [/>] Na$och <. &e"ual development and life of ps chiatric female patients. Archive &e"ual Gehaviour. +?31=+,E9/+8,9. [Pu$'ed] [/+] AlBheimers &ociet E &e" and Dementia Le$site. [/2] Continuing Derontological *ducation Cooperative %ffice, 'c'aster Universit Intimac , &e"ualit and &e"ual Gehaviour in DementiaE )o! to Develop Practice Duidelines and Polic for Long #erm Care Aacilities. )amilton, %ntarioE Author= 2>+2. [/9] #he %ffice for Tational &tatistics #he %ffice for Tational &tatistics Ps chiatric 'or$idit Neport 2>>+. Te!port, LalesE Author= 2>>+. [//] &eidman &T. *"ploring the relationship $et!een depression and erectile d sfunction in aging men. <ournal of Clinical Ps chiatr . 2>>2=19E,8+2. [Pu$'ed] [/,] #he %ffice for Tational &tatistics Getter %r LorseE A Longitudinal &tud %f #he 'ental )ealth %f Adults In Dreat Gritain, Tational &tatistics, 2>>9. Te!port, LalesE Author= 2>>9. [/1] Nothschild A. &e"ual side effects of antidepressants. <ournal of Clinical Ps chiatr . 2>>>=1+E23891. [Pu$'ed] [/:] Geaumont D. &e"ual side effects of clomipramine. <ournal International 'edical Nesearch. +??:=,+E9:8//. [Pu$'ed] [/3] 'onte;o A, Llorca D, IB@uierdo <, Nico-Oillademoros A. Incidence of se"ual d sfunction associated !ith antidepressant agentsE a prospective multicenter stud of +>22 outpatients= &panish Lor5ing Droup for the &tud of Ps chotropic-Nelated &e"ual D sfunction. <ournal of Clinical Ps chiatr . 2>>+=12E+>82+. [Pu$'ed] [/?] 'ichael A, %(Peane O. &e"ual d sfunction and depression. )uman Ps chopharmacolog Clinical and *"perimental. 2>>>=+,E99:89/,. [Pu$'ed] [,>] Natt a <, #ur55a <, Pa5arinen A<. Neproductive effects of valproate, car$amaBepine, and o"car$aBepine in men !ith epileps . <ournal of Teurolog . 2>>+=,1E9+891. [Pu$'ed] [,+] Delgarno PL, Grannan &P, 'allinc5rodt C). &e"ual functioning assessed in / dou$le $lind place$o and paro"etine controlled trials of dulo"etine for ma;or depressive disorder. <ournal of Clinical Ps chiatr . 2>>,=11E13181?2. [Pu$'ed] [,2] )arden CL. &e"ualit in 'en and Lomen !ith *pileps . CT& &pectrums. 2>>1=++E+98+3. [Pu$'ed] [,9] Lam$ert 'O. &eiBures, hormones and se"ualit . &eiBure. 2>>+=+>E9+?8/>. [Pu$'ed] [,/] &a5a5i$ara N, Pishi ', %ga!a *, #ateno A. Gladder, Go!el, and &e"ual D sfunction in Par5inson(s Disease. Par5inson(s Disease. 2>++=2>++E?2/1>,. [P'C free article] [Pu$'ed] [,,] &timmel DL, DutierreB 'A. &e"ual D sfunction and Ps chotropic 'edications. CT& &pectrum. 2>>1=++E2/89>. [Pu$'ed] [,1] )anssens L, L(Italien D, LoBe <, 'arcus NT, Pans ', Perselaers L. #he effect of antips chotic medication on se"ual function and serum prolactin levels in communit treated schiBophrenic patientsE results from the &chiBophrenia #rial of AripipraBole -&#AN. stud -TC#>>29:?+9. G'C Ps chiatr . 2>>3=3 [P'C free article] [Pu$'ed]

[,:] Tna;i NT, Ariedman #. &e"ual d sfunction and schiBophreniaE ps chiatrists( attitudes and training needs. Ps chiatric Gulletin. 2>>3=92E2>382+>. [,3] &tevenson N. &e"ual 'edicineE !h ps chiatrists must tal5 to their patients a$out se". Canadian <ournal of Ps chiatr . 2>>/=/?E1:981. [Pu$'ed]

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