Sexuality is a quality of life issue for all people and a healthy enjoyment of one’s sexuality is an integral part of the human experience and a basic right of all. Indeed the inclusion of sexuality as part of health care is crucial if the holistic ideology espoused in all health care and mental health literature is to be realised. In order to provide recovery orientated holistic care mental health practitioners need to be confident and competent in assisting young people to address friendship and intimate relationships needs (Pacitti and Thornicroft, 2009).This sub-unit explores some of the issues that surround sexuality, intimacy and relationships, with a view to enabling mental health practitioners to respond to people’s expressions of sexuality in a more informed and sensitive manner.

At the end of this unit you will be able to

  1. Discuss sexual rights of service users in the context of historical views of people experiencing mental health issues and contemporary perspectives on recovery.
  2. Critique various theoretical perspectives on factors influencing intimate relationship development.
  3. Discuss the impact of mental health problems on relationships, intimacy and sexual function.
  4. Respond to the sexuality and intimacy concerns of service users in an informed manner.

Recovery oriented care is predicated on the value of personhood. Central to the concept of personhood is a valuing of the person as a biological, psychological, social, spiritual and sexual being, with rights as sexual citizens (Higgins, 2008) The World Association of Sexual Health (2014) identifies 16 sexual rights including:

  • The right to autonomy and bodily integrity
  • The right to be free from all forms of violence ad coercion
  • The right to privacy
  • The right to information
  • The right to highest attainable standards of health, including sexual health; with the possibility of pleasurable, satisfying and safe sexual experiences
  • The right to education and the right to comprehensive sexuality education

These rights are grounded in universal human rights and in a belief that sexuality is an integral part of being human, as is the need and the desire for contact, intimacy, emotional expression, pleasure, tenderness, and love. They are also grounded in the belief that healthy sexual relationships are consensual, pleasurable, safe and free from coercion, discrimination and violence.

Individuals experiencing mental health problems face complex issues related to their sexual and romantic relationship development. Despite the move towards recovery orientated and socially inclusive mental health care, relatively little is written on the sexuality of people who access mental health services or their support needs in this area.

Patricia Deegan, a consumer of the mental health services and an advocate, (2001:2) states:

“Those of us who have been diagnosed with major mental illness do not cease to be human beings by virtue of that diagnosis. Like all people we experience the need for love, companionship, solitude and intimacy. Like all people we want to feel loved, valued and desired by others. The greatest and most healing service that can be offered to people with psychiatric disabilities is to treat them with respect and honor them as human beings. This means honouring us in our full humanity, including our sexuality and our desire to love and be loved”.


Read the World Health Organisation(2006) definition of sex, sexuality, sexual health and sexual rights.

Read Deegan's (2001) paper on consumer viewpoints on Sexuality, Intimacy and Mental Illness.

Read Higgins (2008) to get a historical perspective on sexuality and people experiencing mental health problems (Chapter 70: Sexuality and Gender page 618-624).

Exploring relationships and sexuality may be considered a sensitive topic and acknowledging one’s own views and discomforts about sexuality is an important first step in learning how to recognise and respond to the people seeking advice and support. Research suggests that practitioners frequently hold particular beliefs that negatively impact on the willingness and confidence to raise a discussion on sexuality and intimacy with service users.

Reflective exercise on own comfort

On a scale of 1-10, where 1 = very comfortable and 10 = very uncomfortable rate yourself on the following:

  • Comfort in opening up a conversation with a service user on intimacy and sexual issues.
  • Comfort in talking to service users about intimacy and sexual concerns if they ask for advice/help.

Indicating your reasons, list the sexuality and relationships issues you would be:

  • Most comfortable talking to a service user about.
  • Least comfortable talking to a service user about.

What factors might impact on you having an open and frank discussion with John about his relationship and sexual desires? Consider cultural, personal, professional, and organizational factors.

Reflective exercise on John's comfort

Engaging in a discussion on sexuality, relationships and intimacy needs can be equally challenging for service users, especially young people.

What factors might inhibit John from engaging in an open and frank discussion about his relationship and sexual desires?

What strategies might help you and John overcome these barriers and how might you implement each of the strategies identified?

Having completed this activity you may wish to look at some frameworks, questions and strategies suggested by others.

Quinn, C. and Happell, B. (2012) Getting BETTER: Breaking the ice and warming to the inclusion of sexuality in mental health nursing care. International Journal of Mental Health Nursing 12(2), pp.154–162.

Higgins, A. et al. (2006) Sexuality the challenge to espoused holistic care. International Journal of Nursing Practice 12(6), pp.345- 351.

ANNON (1976) The PLISSIT model: a proposed conceptual scheme for the behavioural treatment of sexual problems. Journal of Sex Education Therapists 2: pp.1-15.

Mental health practitioners are in a unique position to support people experiencing mental health problems, develop and maintain positive intimate and sexual relationships, and provide sexual health care and advice. However, research involving mental health practitioners suggests that there are a number of reasons for their reluctance to include sexuality and intimacy issues as a dimension of practice; including lack of knowledge on sexual health; lack of skill in opening a discussion on sexual issues; belief that discussion would cause offence to the person; belief that service users would not want to talk about sexual issues, and fear of being thought of as intrusive or prying.


You may wish to read more on this topic in relation to nursing and consider if the issues are the same for all disciplines: (Higgins et al. 2008; Quinn et al. 2011).

Staff working in mental health settings also struggle with balancing their duty of care to protect vulnerable service users with the rights of service users to live a full and meaningful life, including the right and need to explore their sexuality and forge intimate and sexual relationships (Tennille and Wright, 2013; Pacitti and Thornicroft, 2009). Consequently, service users often learn not to expect support in this area of life and therefore struggle with the challenges of developing satisfying intimate relationships without support (Tennille and Wright, 2013).

In addition, poor mental health literacy, fear of stigma and peer isolation have the potential to reduce help-seeking behaviour. Consequently young people may struggle alone for long periods without any help or support for their mental distress, risking significant negative impact on their psychosocial development. Read the McEvoy, (2009) report to review what some adolescents think about what helps and what hinders their mental health.

Rate your beliefs

On a scale of 1-5 where 1 is 'strongly disagree' and 5 is 'strongly agree' rate your beliefs:

  • Sexual issues are too private and personal to discuss.
  • Sexual concerns are minor problems for people with mental health issues
  • Sexual issues are unimportant compared to people’s struggle with their mental distress.
  • People are too ill to discuss sexual concerns.
  • If a person has a concern or problem they will ask for help.
  • Discussing sexual issues will cause the person anxiety or embarrassment.
  • People don’t want to talk about sexuality issues with health care practitioners.
  • People want solutions to their problems and concerns, so if there isn’t any treatment, it’s cruel to bring it up.
  • People might misinterpret my exploration or questions as a sexual advance.
  • If I discuss sexuality issues with people, members of the team may think I am being voyeuristic and nosey.
  • Talking about sexual issues could make the situation worse as they may reveal past traumas that they had forgotten.
  • Sex is only for healthy young people and this person is too old.
  • People with mental health problems are not interested in sexual expression.

(Adapted from Higgins (2012) All of me: embracing sexuality as a dimension of care. In: Cooper, J and Cooper, D (Eds) Palliative Care-Mental Health London: Radcliffe Publishing, pp.126-146.)

The establishment of romantic relationships is a key feature of adolescent development. Different developmental theorists provide different frameworks for understanding development across the life course. Known in popular culture as “the identity crisis”, one of the key developmental tasks of adolescence is identity formation (Erikson, 1968). During this time, adolescents and young people like John are not only confronted with physical and hormonal changes in themselves and their peers, but they are learning to integrate numerous roles - at home, at school and with friends. In addition, they are confronting the developmental task of forming and experimenting with opposite sex or same sex intimate relationships.

Read more on Eric Erickson (1968) psychosocial developmental theory.

Read more by Collins and Sroufe (1999) on the development of romantic relationships in adolescents.

There are a number of factors that influence and impact on young peoples' intimate relationship development, including: family, peers, sexual orientation, internet and cultural context.

Family: Attachment theory

While families, family composition or family structures are diverse and constantly changing, the nature and quality of family relationships has a strong influence on the offspring’s interactional or communication patterns in romantic relationships (Laursen and Collins, 2012, Seiffge-Krenke & Shulman, 2012, Dadds et al. 1999, Rodriques and Kitzmann, 2007,Conger et al. 2000, Fosco et al. 2007).

Family systems theory thinks about the family as a system that operates in predictable and repetitive patterns over time, which are designed to maintain stability, be it adaptive or maladaptive. A healthy family is not a problem free family, as all families experience stress. Dealing successfully with a stressful situation or crisis promotes family strength or resilience and has a positive impact on children (Seligman & Rider, 2012; Collins, Jordan and Coleman, 2010, Kaakinen et al. 2010).

Attachment theorists, such as Bowlby (1979) and Ainsworth (1989) postulate that the emotional bonds established in early childhood may be carried into relationships later in life. They suggest that caregivers who are available and responsive to their infant's needs establish a sense of security in their children. The infant knows that the caregiver is dependable, which creates a secure base for the child to then explore the world. If, however, the caregiver is unavailable or unresponsive to the infant they will have insecure attachment, which may impact on later relationship development (Sigelman and Rider, 2012; Weiten, 2011).

Reading on Attachment

Read Bretherton (1992) article (subject to the access rights of your institution) on 'The origins of attachment theory: John Bowlby and Mary Ainsworth'. Developmental Psychology, 28, 759-775.

YouTube: Attachment

Click on this video link for a 5-minute summary of the role of parenting and attachment in the health outcomes of children.

Make notes on key concepts associated with secure attachment development and on the health outcomes associated with insecure attachment.

Family: Parenting styles

Parenting styles are also implicated in outcomes (Sigelman and Rider, 2012). The couple's relationship influences the relationship parents have with their children – those in harmonious and supportive relationships tend to be more engaged, patient and sensitive with their children. Children feel safe and secure if parents are cooperative and consistently implement or reinforce expectations. Inconsistent parenting occurs when parents do not communicate, undermine one another or attempt to compete for their child's affection. Thus, problems arise in family functioning if parents cannot form a coalition and work together. Families where communication is poor function less effectively and have difficulty in responding appropriately to each other’s feelings (McCubbin and McCubbin, 1993, as cited in Rungreangkulkij and Gilliss, 2000)(Conceptual approaches to studying family caregiving for persons with severe mental illness).

Some suggest that conflictual patterns of interaction and family discord increases the likelihood of high levels of hostility in the offspring’s romantic relationships (Scharf and Mayseless, 2001 in Laursen and Collins, 2012:170). Whereas positive communication processes within families not only promotes resilience, but also provides a model of effective expression of emotion- warmth, love, and affection towards each other, including effective conflict resolution (Collins, Jordan and Coleman, 2010).

YouTube: Parenting styles

Click on this video link and take notes on the different styles of parenting and the implications for child development.

Parenting styles

Read the following Seiffge-Krenke et al. (2010) Parent–child relationship trajectories during adolescence: Longitudinal associations with romantic outcomes in emerging adulthood. Journal of Adolescence, 33, (1), 159-171.

In Western societies adolescent peer friendships play an influential role in socialisation and in the development of romantic relationships Seiffge-Krenke and Shulman, 2012, pp. 170-171. Brown (1999) in Laursen & Collins (2012, p. 165) proposes that there are four distinct phases of romantic activity in adolescence and identifies the central role of peer relationships in the development of romantic intimacy.

Peer influences

Read the following (subject to the access rights of your institution) to review the influences of peers on relationship development and make notes on the factors associated with atypical relationship development.

Connolly, J. et al. (2014) Development of Romantic Relationships in Adolescence and Emerging Adulthood: Implications for Community Mental Health. Canadian Journal Of Community Mental Health 33(1), pp. 7-19.

Scharf, M. and Mayseless, O. (2001)The capacity for romantic intimacy. Exploring the contribution of best friend and marital and parental relationships. Journal of Adolescence 24, pp.379-399.

Adolescent sexual and romantic relationship development is a normative process embedded in the values of Western culture which enables young people to communicate, anticipate and interpret each other’s romantic behaviours and motives. Autonomy from parents and freedom to choose sexual or romantic partners is characteristic of individualistic Western culture in adolescence. This cultural norm cannot be generalised to all cultures. Romantic relationship development in collectivist countries may occur within the context of family and group interdependence, with higher levels of parental involvement, supervision and gender stereotypes (Seiffge-Krenke and Shulman, 2012).

The term ‘gender’ refers to the socially-constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women and, as an extension, denotes the social ordering of relations between men and women Jackson and Scott, 2002. Whilst biological processes play a role in gender development, cultural gender-based ideology and gender socialisation are linked to the construction of masculinity and femininity. For young mens’ relationship development, codes of conduct associated with masculinity in a cultural context inform their early romantic and sexual relationships (Ott, 2010).

Gender socialisation

Choose two popular magazines or two Internet sites popular with young people of John’s age in your country.

  • Write down what you think are the dominant stereotypical images associated with masculinity and femininity as depicted in these websites?

  • How might dominant masculine and feminine ideologies depicted in media influence John’s relationship development?

  • How might your answers to the above questions influence your potential conversation with John?

Resources for task:

Click on the links to the articles below (subject to the access rights of your institution) to assist you with the task identified.

Wade, J.C. and Donis, E. (2007) Masculinity ideology, male identity, and romantic relationship quality among heterosexual and gay men. Sex Roles 57, pp.775–786. doi:10.1007/s11199-007-9303-4.

Moradi, B., Velez, B.L. and Parent, M.C. (2013) The Theory of Male Reference Group Identity Dependence: Roles of Social Desirability, Masculinity Ideology and Collective Identity. Sex Roles, 68, 415-426. doi: 10.1007/s11199-013-0258-3

For the vast majority of people, their sexuality, sexual identity and sexual orientation are an integral part of their identity that can be celebrated, demonstrated and spoken about in an open manner. The literature on intimacy in adolescence has primarily focused on heterosexual relationship development, however, in a world where heteronormativity prevails, the sexual identity of people with an LGB (lesbian, gay and bisexual) identity continues to be constructed as ‘other’ (Higgins, 2008). Research indicates that the most common age for LGB people knowing their sexual orientation is 12 years of age (Mayock et al. 2009). Despite the increased acceptance and visibility of same-sex relationships there is still a degree of stigma and homophobic attitudes that impact on young people in their relationship development (Russell, Watson and Muraco, 2012, p.217).

Sexual orientation

What do you think are the challenges for young people navigating same-sex attraction and romantic relationships in adolescence?

Click on the link to the article below (subject to the access rights of your institution) to read about some of the challenges associated with adolescent same-sex relationship development.

Bauermeister et al. (2010) Relationship trajectories and psychological well-being among sexual minority youth. Journal of Youth and Adolescence 39(10), pp.1148-1163. doi:10.1007/s10964-010-9557-y

How does your list of issues compare with this list:

  • Difficulty accepting LGB identity
  • Not knowing how to disclose their sexual orientation to others
  • Fear of ‘coming out’ or telling for fear of rejection from family, friends, and others
  • Being told they are confused and that their sexual orientation is a phase that they will grow out of
  • Being rejected by family and friends when LGB identity is revealed
  • Experiencing homophobic bullying, harassment or violence in school, work or other environments
  • Being exposed to negative messages about being LGB
  • Hiding and concealment of sexual orientation e.g. an LGB person who enters a heterosexual relationship

There is a variety of sexual material, resources and services available on the Internet that ranges from sex education, online dating services, sex shops and pornography. Online sexuality has changed the landscape of sexual socialisation and may influence sexual attitudes and behaviors of young people (Doring, 2009). The Internet may have positive or negative effects depending on how it is used for sexual related activities. The Internet can provide users with information and opportunity to explore their sexuality and satisfy their sexual needs in a constructive way, however, there are also risks associated, including risk of sexual harassment, sexual exploitation, being exposed to unwanted sexual content or contact, and/or addictive or compulsive usage patterns (Doring, 2009, p.1091) . Exposure to and participation in Internet sexuality may have different consequences for different individuals or for the same individual at different stages of development. In addition, people who experience mental health problems may at times have their decision making capacity impaired (Kennedy et al. 2009), thus may be more vulnerable to online exploitation.

Cyber sexuality

Click on the link to the article below (subject to the access rights of your institution) and make notes on the positive and negative effects of online sexual related activity.

Doring (2009) The Internet’s impact on sexuality: A critical review of 15 years of research. Computers in Human Behaviour 25(5), pp.1089-1101.

  • How would you open a discussion with John on the positive benefits of the Internet?

  • How would you work with John to promote the safe use of the Internet and minimize any possible negative consequences?

The onset of mental health problems frequently occurs in adolescence and can cause disruptions to achieving the associated milestones of identity formation, establishment of independence and relationships, and academic or vocational goals.

Reading and task

Read Gowan (2011) on how mental health challenges impact the sexual and relational health of youth.

Read Redmond et al.'s (2010) paper on: 'The personal meaning of romantic relationships for young people with psychosis' and identify the challenges young people with psychosis face in initiating or developing intimate relationships.

Read Eglington et al.'s (2013) paper and identify how stigma associated with mental illness impacts on sexual and romantic relationships of young people.

Read Tennille and Wrights' (2013) Monograph on Intimacy interests of people with mental health problems where she discusses the challenges people encounter in relation to intimacy and relationships and highlights the importance of service providers addressing deficits within policy and practice in this area.

YouTube Video

In this video Dr. Tennille (2015) briefly introduces sexuality and intimacy as it applies to persons experiencing mental health problems and stresses the importance of provider support for service users.

From your reading you will know mental health problems can seriously impact on a young person’s ability to make or maintain friendships and romantic relationships, and can affect their self-esteem and confidence, a key requirement in relationship development. Young people like John may have had interruptions to the usual relationship and sexuality education due to onset of mental illness, and consequently may have limited knowledge regarding relationships, appropriate sexual behaviour, and may also lack key information on sexual health, including information on safer sexual practices (Gowan, 2011). Like many young people, they may also be concerned about their ability to communicate with a person of the opposite sex, and use skills such as flirting. In addition, the stigma associated with mental illness provides additional challenges for the young person in their friendships and relationships (Pacitti and Thornicroft, 2009), as they worry about disclosing their mental health history to partners.

John's story

Return to John's story and complete the following tasks.

  1. What sense do you make of John’s relationship development to date?
  2. Identify the key areas of disruption that has occurred in John’s development.
  3. What do you think are the potential consequences for John for each of the developmental areas you identified if they remain disrupted?
  4. Identify specific barriers that may prevent John in achieving these developmental milestones.
  5. Identify specific strengths that may assist John in achieving these developmental milestones
  6. Make a list of questions you would ask John about his relationship history, stating the rationale for asking each of the questions you identified.
  7. Identify the strategies you would use to work with John to address his concerns about having no friends and his desire to have a girlfriend. Consider strategies to i) increase John's connection with friends and community ii) increase his skills in locating social activities for people of his age within the community where he lives iii) increase his skills in communicating with members of the opposite sex iv) address his concern about disclosing his mental health history.

While legally consensual sexual relationships between adults are a right in our society, people experiencing mental health problems also have a right to sexual safety. There are a number of evidence based reasons why the identification of sexual vulnerabilities and the promotion of sexual safety should be included as part of an overall approach to recovery care planning.

  • Sexual disinhibition is sometimes associated with experiences of mania and psychosis.
  • Research indicated that people who have experienced sexual trauma are more at risk to re-victimisation and sexual exploitation.
  • Co-morbid substance abuse is also associated with increased sexual vulnerability and increased risk of engaging in sexual risk behaviour, such as engaging in sex with high risk groups, trading sex for some material gain, having multiple partners and using condoms infrequently.
  • People in times of mental health crisis may have impaired decision making in relation to social media and are at an increased risk of sexual victimization and exploitation through posting inappropriate sexual images or comments online, or accessing website/chat rooms that is outside their norm.
  • People may lack the knowledge and skills to negotiate safe sexual practices.

Do an internet search of health promotion services in your country and locate information that would assist you to devise a plan with John to address issues of sexual safety. Consider issues such as knowledge of sexual health, skills in negotiating safer sexual practices, assertive communication skills and skills in acquiring and using contraception and/or condoms.

Some resources to begin the task:

Pandor, A., Kaltenthaler, E., Wong, R., Higgins, A., Lorimer, K., Smith, S. & Wylie, K. (2015) Sexual health risk reduction interventions for people with severe mental illness: a systematic review. BMC Public Health journal 15(1), p.138.

Sense and Sexuality (2004) Resource – a support pack for youth workers addressing the issue of sexual health with young people. National Youth Council of Ireland

Higgins, A., Barker, P. and Begley, C. (2006) Sexual health education for people with mental health problems: what can we learn from the literature?. Journal of Psychiatric and Mental Health Nursing 13(6), pp.687-697.

Ministry of Health (New South Wales) (2013) Sexual Safety of Mental Health Consumers Guidelines. Sydney: NSW Government.

Department of Health (Victoria Australia) (2012) Promoting sexual safety, responding to sexual activity, and managing allegations of sexual assault in adult acute inpatient units: Chief Psychiatrist’s guideline. Melbourne: Victorian Government.

Irrespective of people’s views for and against medication, psychotropic medication continues to be a central element in the care and treatment of people experiencing mental health problems. While sexual health is defined as including a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free from coercion, discrimination and violence, and not merely the absence of disease or dysfunction; psychotropic medication can have a significant negative impact on peoples' sexual function, leading to sexual dysfunction.

The ability to engage in a physical sexual relationship is dependent on both physical and psychological integrity. Masters and Johnson (1966) were the pioneers in exploring and explaining the physiology of human sexual response. In so doing not only did they provide a model of the sexual response cycle they revolutionized treatment methods for impotency, premature ejaculation, and other "dysfunctions"—a term they coined.

Youtube and task

Click on the link to video on Science of Masters & Johnson (1966) and take notes on the questions identified below.

  • What does Maier mean by the medicalisation of sex?

  • How did Masters and Johnson's work change the way we think about, talk about, and engage in sex?

Read some discussion on Masters and Johnson sexual response cycle.

From a psychological point of view stress, worry, anxiety and low self-esteem can impact negatively on sexual function; equally from a physical point of view changes in energy levels and fatigue can also impact on desire and the physical ability to engage in sexual activity. Equally antipsychotic and antidepressant drugs can have many adverse side-effects, which impact directly and indirectly on sexual function. The reported rates of sexual dysfunction in people treated with conventional neuroleptics (Phenothiazines, Butrophenones, Thioxantines) range from 45-60% in men and 30-93% in women. The so-called atypical antipsychotics (olanzapine, risperidone and clozapine) are considered to be more effective in the treatment of ‘positive symptoms’ when compared to the older antipsychotics. As a consequence they are deemed to have favourable effects on interpersonal relationships. However, in the past few years there are an increasing number of case reports of sexual dysfunction with these drugs. Sexual dysfunction has also been reported with virtually all antidepressant medication, with reported rates of sexual problems with antidepressant medication ranging from 40-62% (Higgins et al. 2005; Baldwin and Mayers, 2003). The variation in rates between studies is possibly due to different assessment methodologies, study populations, differences in duration of studies and under or over-reporting.

Reading and task

There are numerous articles, which highlight the effects that antipsychotic medication and anti-depressant medication can have on sexuality and sexual functioning.

  1. Type “sexual side effects of psychotropic medication” into Google Scholar and find some journal articles on this topic.
  2. Make a list of the impact of antipsychotics, antidepressants, and anticholinergic medications on sexual function.
  3. Differentiate between the sexual side effects that impact on men and women.
  4. Map the side effects onto the phases of Masters and Johnson's (1966) sexual response cycle.

To get started read the following three articles:

Chiesa et al. (2013) Antipsychotics and sexual dysfuction: Epidemiology, Mechanisms, and Management. Clinical Neuropsychiatry 10, pp. 31-36.

Higgins et al.(2010) Antidepressants-associated sexual dysfunction: impact, effects and treatment. Drug, Health care and Patient Safety 2, pp. 141-152.

Post, L (undated) Sexual Side Effects of Psychiatric Medications in Women: A Clinical Review.. Jefferson Journal of Psychiatry, pp 5-81.

Mersey Care Clinical Guideline / Formulary Document (2014) Side effects of psychotropic medications Page 4.

Why does prescribed medication impact on sexual function: mode of action?

Points of information

  • The biological view of sexuality suggests that sexual function involves a complex interplay of neurotransmitters, hormones and peptides that act both centrally and peripherally. The current scientific knowledge regarding sexuality cannot fully explain the neurophysiology, neuroendocrinology and psychological mechanisms induced by drugs. Side effects of antipsychotic and antidepressants that impact on sexual function are idiosyncratic and unpredictable, with no apparent relationship between the type of drug used, dose and the incidence of a specific sexual dysfunction.

  • Many drugs act both on the peripheral and central nervous systems and it is sometimes not possible to know which action is responsible for the sexual side effects. The exact mode of action is unclear; however, it is thought that drugs that enhance serotonin or decrease dopamine tend to diminish sexual function and desire.

  • Selective serotonin reuptake inhibitors block the reuptake of serotonin, increasing the amount of serotonin in the synaptic area which is thought to inhibit the mechanistic aspects of the nervous system responsible for erection, vaginal lubrication, ejaculation and orgasm (Keltner et al. 2002).

  • Anticholinergic drugs work by inhibiting acetylcholine (ACh), thus preventing its stimulation of the cholinergic pathways. In a study of people taking neuroleptic medications, Smith et al. (2002) found that anticholinergic side effects were particularly associated with erectile dysfunction and anti-adrenergic side effects were associated with abnormal ejaculation. Neuroleptics (antipsychotics) inhibit dopamine activity by blocking the dopamine D2 receptors in the hypothalamus, thus, the dopamine inhibiting effect on prolactin is reduced or abolished, and plasma levels of prolactin are increased (Melkersson et al. 2001).

  • Baldwin and Mayers (2003) found that elevated prolactin levels resulted in amenorrhoea and decreased levels of arousal and desire in women, plus gynecomastica and galactorrhea in both men and women. However, when men had hyperprolactinaemia, these relationships ceased to exist, suggesting that when men became hyperprolactinaemic (elevated prolactin), it was the hyperprolactemia that was the likely cause of their sexual dysfunction.

John's story

Now put yourself in John’s position and think about:

  • How you would feel if you experienced the sexual side-effects you have just listed.

  • What questions would you like to ask a health care practitioner about the side-effects you listed in the table?

  • What help or advice would you like them to offer you?

  • What member of the team would you like to talk to about your experiences, and why?

Understanding the person’s experience and its impact on identity, self esteem and relationships

Review the following YouTube videos where a young man speaks of the impact of medication on his sexual function and his search for solutions and treatments.

YouTube video 1 Romantically Involved with Psychiatric Medication Induced Sexual Dysfunction

YouTube video 2 Psychiatric Medication and Sexual Side Effects - Part 1

YouTube video 3 Psychiatric Medication and Sexual Side Effects - Part 2

Take notes on:

  1. The impact sexual side-effects that are mentioned in the video have on his sense of masculinity and possible future relationships.
  2. The role of prolactin in the body and how psychotropic medication impacts on prolactin, including how changes in prolactin in men and women may differ.
  3. The strategies that he suggests might help with drug induced sexual dysfunction.

Regular questioning of people about their experiences of medication has the potential to reduce the side-effect burden as medication can be changed or reduced. The introduction of standardized side-effect assessment tools increases the number of problems detected and actioned including long-standing problems that had previously gone unnoticed (Jordan et al. 2002; Higgins, 2007). They also help practitioners legitimize the inclusion of a discussion on sexual function and may help with a discussion of side effects that may be considered embarrassing. Although a number of side-effects rating scales exist, such as Simpson-Angus Scale (Simpson and Angus, 1970); The Abnormal Involuntary Movement Scale (Guy, 1976); The Udvalg for Kliniske Undersogelse Scale (Lingjaerde et al. 1987); Liverpool University Neuroleptic Side Effect Rating Scale (Day et al. 1995); and the Extrapyramidal Symptom Rating Scale (ESRS) (Chouinard and Margolese, 2005); they tend to focus on the side effects of neuroleptic medications, as opposed to antidepressants and anticholinergic drugs. It is also important that practitioners eliminate other confounding factors for sexual dysfunction, such as physical illness: diabetes, atherosclerosis, cardiac disease, central and peripheral nervous system disease; substance misuse: alcohol, smoking, illicit drugs and side effects of other drugs used such as antihypertensives.

Plan your response to John

  1. Devise an aide memoire that you would use to assist you in screening for sexual side effects of medication.

  2. During the discussion with John he tells you that he read a number of articles on the internet and is aware of the sexual side-effects induced by his antipsychotic medication but he has a number of questions that he would like to discuss. He would like to know:
    • If everybody on antipsychotics get all the sexual side-effects listed on the internet.
  • Why gynaecomastia occurs and he would like an explanation from a physiology perspective on why this happens.

  • If his retrograde ejaculation and erectile difficulties are reversible as another service user told him that if he was taking antipsychotic medication for over six months his erectile dysfunction and difficulties were irreversible.

A wide range of strategies are identified for the management of drug induced sexual dysfunction, including behavioural, psychological and pharmacological approaches however, the search for a treatment is in its infancy. The Cochrane Database of Systematic Reviews (CDSR) is the leading resource for systematic reviews in health care. The CDSR includes Cochrane Reviews (systematic reviews) and protocols for Cochrane Reviews as well as editorials.

Accessing some evidence for the effectiveness of interventions

  1. Log on to the Cochrane Library and locate systematic reviews on evidence for the strategies to manage sexual dysfunction due to antipsychotic drug therapy and antidepressant medication. Look for evidence on the following approaches: Wait-and-see approach; Dose reduction; Drug holidays; Change to another medication such as Sildanefil (viagra) and Herbal medication for e.g. Gingo biloba.

  2. Devise a table to indicate what the evidence states about each strategy. The table should be suitable to be published as an information leaflet for people experiencing drug induced sexual dysfunction.

Sexuality is a complex and elusive phenomenon having multiple interlinkages with all aspect of our lives and is an integral part of their being human, being alive and being real. It is a symbol for an attribute that goes beyond the confines of copulation and gender designation. Sexuality is about who we are, our identity, our relationships and bound up with our self-concept, self-esteem, body image and total self-image. Sexuality is a force that has the potential to promote intimacy, pleasure, self-esteem and support the deepest longing for human connection, while paradoxically being a force that can diminish, hurt and exploit the vulnerabilities of others.

Mental health practitioners working within a recovery ethos recognise the importance of creating a space that acknowledges the centrality of the person’s sexuality, intimacy and relationships needs.

This unit addressed concept of sex rights, factors influencing relationship development, impact of mental health issues on relationship and intimacy development, as well as issues around sexual diversity, prescribed drugs and sexuality and sexual vulnerability with a view to improving practitioners’ responses to people’s expressions of sexuality in a more informed and sensitive manner.

What is evident is the growing body of evidence that suggests people experiencing mental health problems have needs and concerns in relation to sexuality and relationships. Therefore, the main messages of this unit is that: recovery-oriented care is predicated on the value of personhood and the uniqueness of each individual. Central to this is the need to acknowledge the sexual dimension of the person and develop strategies to supports the rights of each man or woman as a sexual citizen.

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Sexuality, Intimacy and Relationships BCM's Mental Health Journal.

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