University of Groningen

Sexual dysfunction related to psychiatric disorders

Herder, T.; Spoelstra, S. K.; Peters, A. W.M.; Knegtering, H.

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Journal of Sexual Medicine

DOI:
10.1093/jsxmed/qdad074

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Herder, T., Spoelstra, S. K., Peters, A. W. M., & Knegtering, H. (2023). Sexual dysfunction related to
psychiatric disorders: a systematic review. Journal of Sexual Medicine, 20(7), 965-976.
https://doi.org/10.1093/jsxmed/qdad074

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The Journal of Sexual Medicine, 2023, 20, 965–976
https://doi.org/10.1093/jsxmed/qdad074
Advance access publication date 3 June 2023
Review Article

Sexual dysfunction related to psychiatric disorders:

a systematic review
T. Herder, MD1 ,* , S.K. Spoelstra, MD, PhD2 , A.W.M. Peters, MD3 , H. Knegtering, MD, PhD3 ,4

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1 Department of Psychiatry, Martini Hospital, Groningen, 9728 NT, the Netherlands
2 Addiction Care North Netherlands, Groningen, 9728 NT, the Netherlands
3 Lentis Research, Lentis Mental Health Institute, Groningen, 9728 NT, the Netherlands
4 Department of Psychiatry and Rob Giel Research Center, University Medical Center Groningen, University of Groningen, Groningen, 9728 NT,
the Netherlands
*Corresponding author: Martini Hospital, Department of Psychiatry, Van Swietenlaan 1, 9728 NT Groningen, the Netherlands. Email: [email protected]

Abstract
Background: Sexual dysfunction is thought to be highly prevalent in patients with psychiatric disorders. Factors such as the use of psychotropic
substances (ie, psychopharmaceuticals and drugs), age, or somatic diseases may contribute to sexual problems, but the extent to which
psychopathology itself affects sexual functioning is not well understood.
Aim: The study sought to provide an overview of the literature on the prevalence of sexual dysfunction in psychotropic-free and somatic disease-
free psychiatric patients.
Method: A systematic review (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]) was conducted by 2 authors
(TH and AWMP) independently, with the review process being monitored by a third author. Relevant articles on the relationship between sexual
dysfunctions and psychopathology were searched in PubMed, Web of Science, and PsycINFO from inception until June 16, 2022. The study
methods were entered in the international register of systematic reviews PROSPERO (2021, CRD42021223410).
Outcomes: The main outcome measures were sexual dysfunction and sexual satisfaction.
Results: Twenty-four studies were identified, including a total of 1199 patients. These studies focused on depressive disorders (n = 9 studies),
anxiety disorders (n = 7), obsessive- compulsive disorder (OCD) (n = 5), schizophrenia (n = 4), and posttraumatic stress disorder (n = 2). No
studies on bipolar disorder were found. Reported prevalence rates of sexual dysfunction in psychiatric disorders were 45% to 93% for depressive
disorders, 33% to 75% for anxiety disorders, 25% to 81% for OCD, and 25% for schizophrenia. The most affected phase of the sexual response
cycle was sexual desire, in both men and women with depressive disorders, posttraumatic stress disorder, and schizophrenia. Patients with
OCD and anxiety disorders most frequently reported dysfunction in the orgasm phase, 24% to 44% and 7% to 48%, respectively.
Clinical Implications: The high prevalence of sexual dysfunction requires more clinical attention by means of psychoeducation, clinical guidance,
sexual anamnesis, and additional sexological treatment.
Strengths and Limitations: This is the first systematic review on sexual dysfunction in psychotropic-free and somatic disease–free psychiatric
patients. Limitations include the small number of studies, small sample sizes, the use of multiple questionnaires (some not validated), which
may contribute to bias.
Conclusion: A limited number of studies identified a high prevalence of sexual dysfunction in patients with a psychiatric disorder, with substantial
variation between patient groups in frequency and phase of reported sexual dysfunction.

Keywords: sexual dysfunction; prevalence; psychiatric disorders.

Introduction humanistic burdens.3 Furthermore, it has been clearly demon-

Sexual health plays an important role in most of human’s strated that both psychiatric disorders and sexual dysfunction
lives, as positive and enjoyable sexual expression contributes have an adverse effect on overall quality of life.4-8
significantly to overall well-being.1 According to the World Psychiatric disorder are often accompanied by impaired
Health Organization, sexual health is defined as a state of sexual well-being. Conversely, sexual dysfunction may con-
physical, emotional, mental, and social well-being in rela- tribute to the development of psychiatric problems and/or
tion to sexuality; it is not simply the absence of disease, deterioration of psychiatric symptomatology.9 For example,
dysfunction, or ailments. Sexual health requires a positive a bidirectional association has been demonstrated for depres-
and respectful approach to sexuality and sexual relations, sion and erectile dysfunction.10 Various phases of the sexual
as well as the ability to have pleasurable and safe sexual response cycle (ie, sexual desire, arousal, orgasm, and reso-
experiences, free from coercion, discrimination, and violence.2 lution) may be adversely affected in patients with psychiatric
Although the burden of sexual dysfunction has not yet been disorders.11 It is increasingly recognized that sexual medicine
systematically examined, the recent literature suggests that and psychiatry should converge to understand the presumed
sexual dysfunction is associated with economic, health, and combined pathophysiological mechanisms.12 To date, there

Received: December 13, 2022. Revised: May 3, 2023. Accepted: May 6, 2023
© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions,
please e-mail: [email protected]
966 The Journal of Sexual Medicine, 2023, Vol 20, Issue 7

is an urgent need for a scientifically well-documented foun- Methods

dation for the pathogenesis of combined psychiatric and Search strategy
(associated) sexual problems. We conducted a systematic literature search of the databases
Understanding potential mechanisms of compromised PubMed, Web of Science, and PsycINFO. Included articles
sexual functioning is essential in the assessment and treatment were published from inception until June 16, 2022. To gather
of sexual dysfunction in psychiatric patients.13 Different relevant articles from PubMed, a search string was con-
etiological aspects of sexual dysfunction include psy- structed (Supplementary Appendix A) containing synonyms
chopathology, somatic diseases, (psycho)pharmacological of depressive disorders, bipolar disorders, anxiety disorders,
treatment, substance use, and social factors (eg, intimate obsessive-compulsive disorder (OCD), posttraumatic stress
relationship, trauma, stigma, culture, sexual education).14 disorder (PTSD), schizophrenia, sexual desire disorder, sex-

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Sexual dysfunction and psychiatric symptoms are often the ual arousal disorders, orgasmic disorders, and genitopelvic
sum of various interacting aspects within the biopsychosocial pain/penetration disorders. This search string was converted
domains. Psychiatric disorders and symptoms may directly for PsychINFO. Animal studies were excluded. Articles writ-
and indirectly be causative factors of sexual dysfunction.15–20 ten in English, Dutch, German, and French were included.
The literature suggests that the percentage of psychiatric The included studies were screened for possible cross-
patients reporting undesired sexual effects related to medi- references, and duplicates were removed. An online systematic
cation may range from 25% to 80% for antidepressants and review program (Covidence) was used to perform a structured
16% to 60% for antipsychotics.21–23 In line with studies extraction and inclusion.
showing that spontaneous reporting of sexual problems is The PRISMA (Preferred Reporting Items for Systematic
rare, the prevalence of sexual dysfunction associated with Reviews and Meta-Analyses) guidelines were followed
psychotropic medication is much higher than estimated by (Supplementary Appendix C). The PRISMA guidelines con-
many clinicians.23,24 sist of an internationally accepted standard of rules and
The literature also shows effects of psychiatric disorders regulations in order to reduce sources of bias in reviews.
combined with somatic diseases on sexual dysfunction. A Recommended quality features following the PRISMA
meta-analysis in patients with diabetes mellitus showed an guidelines were incorporated, such as the rationale and
overall prevalence of 52.5% reporting erectile dysfunction in objectives of this study, facilitating full transparency in
heterogeneous populations (ie, not corrected for type of treat- the selection and critical appraisal of articles, providing a
ment, comorbid psychiatric disorders, or use of psychotropic complete overview of the results, and discussing the strengths,
substances).25 In addition, a cross-sectional survey found that limitations, and relevance of this systematic review.37 Prior
clinical depression was most strongly associated with sexual to the start of this review, the study methods were entered in
dysfunction in male patients with diabetes mellitus.26 PROSPERO (2021, CRD42021223410).
Erectile dysfunction is identified as an independent pre-
dictor for cardiovascular disease and is 45% more likely to Inclusion criteria
occur in patients with cardiovascular disease.27 Furthermore,
Participants of the included studies had to be 18 years of
depression and cardiovascular disease share multiple etiologi-
age and experiencing depressive disorders, bipolar disorder,
cal mechanisms, such as biological, behavioral, psychological,
panic disorder, social anxiety disorder, generalized anxiety dis-
and genetic mechanisms.28 Therefore, the triad of erectile dys-
order, OCD, PTSD/trauma- and stressor-related disorders, or
function, depression, and cardiovascular disease is considered
schizophrenia according to the DSM-III, DSM-IV (TR), DSM-
mutually reinforced.29
5, International Classification of Diseases–Ninth Revision,
For patients with inflammatory bowel disease, a meta-
and International Classification of Diseases–Tenth Revision.
analysis reported a prevalence of sexual dysfunction in 53% of
To be included, studies had to report quantitative out-
female patients and 23% in male patients. The prevalence was
comes of sexual (dys)function. Sexual functioning could con-
higher in patients who also reported depressive symptoms.30
sist of increased or decreased sexual desire, increased or
Interacting pathogenetic factors of substance use and
decreased sexual arousal (including erectile dysfunction), pre-
psychiatric symptoms may both influence sexual function-
mature ejaculation, delayed orgasm, anorgasmia, genitopelvic
ing.31,32 The overall prevalence of erectile dysfunction in
pain/penetration disorders (ie, dyspareunia and vaginismus),
cannabis users is 69%, not corrected for possible comorbid
and sexual (dis)satisfaction.
psychiatric disorders.33 Smoking is also associated with
detrimental effects on sexual functioning.34 Chronic alcohol
abuse is associated with both psychiatric symptoms and with Exclusion criteria
impaired sexual functioning.35,36 Studies involving participants known to be diagnosed
Because sexual dysfunction is the result of many, often with comorbid somatic disease and/or patients using of
interacting factors, knowledge of the epidemiology of sexual psychotropic medication and/or patients with substance abuse
dysfunction in psychiatric patients without psychotropic med- (other than nicotine) were excluded.
ication (eg, antidepressants, antipsychotic), comorbid disease
(eg, diabetes mellitus, cardiovascular disease, epilepsy), and Selection of articles
use of substances (eg, cannabis, smoking) may contribute to a Titles and abstracts were independently screened by 2 review-
better understanding of interaction between psychopathology ers (T.H. and A.W.M.P.). After consensus on eligible studies,
and sexual dysfunction. full-text was retrieved and assessed for relevance. In case of
The aim of this study is to provide a comprehensive uncertainty, the inclusion of studies was discussed with a third
systematic review of the prevalence of sexual functioning assessor (S.K.S.). Reasons for exclusion were documented.
in psychotropic-free psychiatric patients, without known Interrater reliability (Cohen’s kappa) between the reviewers
somatic disease and substance use. was documented.
The Journal of Sexual Medicine, 2023, Vol 20, Issue 7 967

Data extraction While the majority of studies published a DSM classifica-

Table 1 summarizes the study characteristics. The follow- tion, only a minority of them employed formal diagnostic clas-
ing variables were retrieved: name of first author, year of sification tools for psychiatric disorders (Table 1). Assessment
publication, country, type of psychiatric disorder (depressive of dimensional symptomatology for psychiatric symptoms
disorder, anxiety disorders, OCD, PTSD, bipolar disorder, and using validated instruments was published in 20 studies, using
schizophrenia), sample size, age, sex, study design, comparison for example the Hamilton Depression Rating Scale, Beck
group (if any), classification, measures of diagnosis and sever- Depression Inventory, and Maudsley Obsessional Compulsive
ity of disorder, measures used to evaluate sexual function, total Inventory.
score of quality assessment, and funding. Table 2 summarizes In a total of 18 studies, sexual functioning was evaluated
the following variables: questionnaires for assessing sexual using 12 distinct validated questionnaires (eg, International

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function, general sexual functioning, and variables on desire, Index of Erectile Function, Arizona Sexual Experience Scale,
arousal, orgasm, and satisfaction. Golombok-Rust Sexual Satisfaction Inventory, and Female
Sexual Function Index) (see Table 1).

Quality assessment Overall sexual dysfunction

No methodological assessment tool for scoring quality of The prevalence of overall sexual dysfunction per psychiatric
observational studies is thought to be superior.38,39 We used disorder was found to be between 45% and 93% for depres-
the Newcastle–Ottawa Scale to estimate the risk of bias in sive disorder (6 studies), between 33% and 75% for anxiety
individual studies.40 The Newcastle–Ottawa Scale includes disorder (3 studies), between 25% and 81% for OCD (4 stud-
quality criteria on dimensions such as selection bias, com- ies), and 25% for schizophrenia (1 study).16,41,43-51 However,
parability of groups, and outcomes. Risk of bias is rated no specific prevalence was given for PTSD (see Table 2).
in 4 categories: very low risk, low risk, medium risk, and
high risk. Desire
Quality assessment of case-control studies was rated as very Nineteen studies reported outcomes on altered sexual desire.
low risk of bias (8 points), low risk of bias (6-7 points), For depressive disorder, 32% to 68% of the patients reported
medium risk of bias (4-5 points), and high risk of bias (0-3 decreased desire (7 studies) and 14% to 22% reported
points). increased desire (2 studies).16,52 Decreased desire was found
Quality assessment of cross-sectional studies was rated as in patients with anxiety disorder (4 studies).41,43,45,53
very low risk of bias (9-10 points), low risk of bias (7-8 However, 2 studies found no significant difference in
points), medium risk of bias (5-6 points), and high risk of bias desire between patients with anxiety disorder and control
(0-4 points). See Supplementary Appendix B for scoring per subjects.54,55 For OCD, one study found significant more
dimension. decreased desire, another study found no significant differ-
ence, and a third study found decreased sexual desire in 10%
of the male patients and 50% of the female patients.41,43,51
Results Low desire was found for 74% of PTSD patients and
Article selection significantly decreased desire was found in another study.56,57
The electronic search identified 10 986 publications. Deduc- For schizophrenia, 3 studies found significantly decreased
tion of 2519 duplicates resulted in 8467 articles. After screen- desire.50,58,59 In one study, 18% to 24% of patients reported
ing for titles and abstracts, a final 107 articles were eligible increased desire, in contrast to 45% of the male patients and
for the full-text selection. Cohen’s kappa was 0.18, indicating 24% of the female patients reporting decreased desire.60 For
slightly above chance. details, see Table 2.
Full-text screening resulted in a final inclusion of 24 studies.
Cohen’s kappa was 0.31, indicating fairly above chance. Arousal
Results of the selection process are displayed in a flow dia- Fifteen studies reported outcomes on obtaining and sustain-
gram (see Figure 1). ing sexual arousal. In patients with depressive disorders, 3
Characteristics and total quality score of the 24 included studies reported problems regarding sexual arousal, being
studies are shown in Table 1. Eleven of 24 studies were rated reported by 32% to 68% of the patients.41,44,61 In 2 studies
to have a high probability to be biased, 10 studies were rated focused on anxiety disorders, 7% to 22% of male patients
to have a medium-high probability, and 3 studies were rated reported experiencing erectile dysfunction or difficulty sus-
to have a low probability. Details on the rating of the quality taining an erection, while a third study found a significant
assessment of the studies can be found in Supplementary decrease in arousal.41,45,53 One study reported less lubrica-
Appendix B. tion and another study no significant difference in lubrica-
One study included 3 patient populations41 and 2 studies tion between female patients and control subjects.53,55 For
included 2 patient populations.42,43 (see Table 1). These patients with OCD, one study reported no significant differ-
patient populations reflecting diagnostic subgroups were ence in penile erection or vaginal lubrication, while another
separately analyzed in this review. Nine studies were identified study revealed 2 to 3 times more arousal problems for female
on depressive disorders, 7 studies were identified on anxiety patients than for male patients in another study.41,51 For
disorder, 5 were identified on OCD, 2 studies described PTSD, 49% patients reported arousal problems in one study,
sexual dysfunction in patients with PTSD, and 5 studies and a second study found significantly poorer arousal between
described studies with people experiencing schizophre- patients and control subjects.57 For patients fulfilling the
nia. No studies on patients with bipolar disorder were criteria for schizophrenia no significant change in arousal was
identified. found in one study, whereas another study found reduced
 968

Table 1. Summary characteristics of included studies.

Year of Country Subtype Sample Age (y)a,b Sex (% Study design Comparison Classifica- Measures for Measures for Total score Funding
publica- disorder size female) group tion for diagnosis and sexual function quality
tion disorder severity of assessment
disorder
Depressive disorders
Mathew and 1982 Unites States of — 51 29.6 (8.5)b 69 Case-control Healthy control N/A BDI 7-point Likert-type 5c N/A
Weinman52 America subjects scale of symptoms
of sexual
dysfunctions
Angst16 1998 Switzerland Untreated 122 28-35a N/A Longitudinal — N/A Semi-structured Semi-structured 1d N/A
depression interview interview
Kennedy et al61 1999 Canada MDD 134 38.8 (11.5)b 59 Cross-sectional — DSM-IV HAMD-17 SFQ 5d N/A
NEO-PI-R
Frohlich and 2002 United States of — 47 24.55 (5.12)b 100 Case control Nondepressed N/A BDI BISF-W 5c N/A
Meston48 America
Cheng et al63 2007 Hong Kong — 22 69 (10)b 0 Cross-sectional — N/A GDS IIEF-15 6d N/A
Kendurkar et al41 2008 Australia MDD 50 34.3 (9.2)b 38 Case-control Healthy control DSM-IV HAMD-17 ASEX 7c None
subjects
Thakurta et al44 2012 Indian MDD 60 38 (10.5)b 60 Cross-sectional — DSM-IV HAMD-17 ASEX 4d None
Hamzaoui et al47 2016 Tunisia — 30 37.64 (N/A)b 100 Cross-sectional — DSM- IV HAMD FSFI 4d None
Sreelakshmy et al46 2017 India MDD 40 37.7 (N/A)a 100 Cross-sectional — DSM-IV SCID-I FSFI 6d None
HAMD
Anxiety disorders
Van Minnen and 2000 The Netherlands PD with 27 33.7 (10.2)b 100 Case-control Healthy control N/A N/A QSD 4c N/A
Kampman43 agoraphobia subjects MMQ
Figueira et al45 2001 Brasil PD 28 36.46 (11.38)b 50 Cross-sectional - DSM-IV SCID-I DSM-IV criteria 2d N/A
SAD 30 34.39 37 (excluding “C”
34.39 (7.39)b criteria)
Bodinger et al53 2002 Israel Social phobia 41 Men: 41 Case-control Healthy control DSM-IV SCID-P Questionnaire on 4c Grant by Sarah
31.5 (7.5)b subjects LSAS sexual functioning and Moshe
Women: (n = 20) + hospitalized of Schiavi Mayer
31.4 (7.4)b patients for minor foundation
operations (n = 20) (Switzerland)
Mercan et al54 2006 Turkey PD 12 34.7 (8.08)b 100 Case-control Healthy control DSM-IV BDI ASEX 4c none
subjects BAI
PAS
Kendurkar et al41 2008 Australia GAD 50 34.3 (9.2)b 36 Case-control Healthy control DSM-IV HAMA ASEX 8c None
subjects
Aksoy et al42 2012 Croatia PD 40 38.11 (8.64)b N/A Case-control Healthy control DSM-IV SCID-I GRISS 1c N/A
subjects
Dèttore et al55 2013 Italy PD and GAD 30 30.17 (5.96)b 100 Case-control Healthy control DSM-IV STAI FSFI 4c N/A
subjects ASI SES
SIS
Obsessive-compulsive disorder
Freund and 1989 United States of — 44 32 (N/A)b 57 Cross-sectional — DSM-III MOCI 9-point Likert-type 0d Grant by
Steketee49 America CAC scale National
Institute of
Mental Health
No.
R01MH31634

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Table 1. Continued.

Year of Country Subtype Sample Age (y)a,b Sex (% Study design Comparison Classifica- Measures for Measures for Total score Funding
publica- disorder size female) group tion for diagnosis and sexual function quality
tion disorder severity of assessment
disorder
Van Minnen and 2000 The Netherlands — 17 31.6(6.9)b 100 Case-control Healthy control N/A N/A QSD 4c N/A
Kampman43 subjects MMQ
Kendurkar et al41 2008 Australia — 50 34.3 (9.2)b 44 Case-control Healthy control DSM-IV YBOCS ASEX 8c None
subjects
Aksoy et al42 2012 Croatia — 40 34.17 (7.62)b N/A Case-control Healthy control DSM-IV SCID-I GRISS 1c None
subjects
Ghassemzadeh 2017 Iran — 56 Men 64 Cross-sectional — DSM-IV MOCI FSFI (in Persian, not 3d None
et al51 35.2 (5)b OCI-R validated)
Women IIEF (in Persian, not
33.19 (7.71)b validated)
Posttraumatic stress disorder
Kotler et al56 2000 Israel — 15 39.8 (7.4)b 0 Case-control Healthy control N/A SCL-90 Questionnaire on 3c N/A
subjects IES sexual functioning
of Schiavi
Hirsch57 2009 United States of — 53 35 (N/A)b 0 Cross-sectional — N/A PCL (military Self-designed 1d None
America version) questionnaire on
sexual functioning
The Journal of Sexual Medicine, 2023, Vol 20, Issue 7

Psychotic disorders
Aizenberg et al58 1995 Israel Schizophrenia 20 35.26 (6.61)b 0 Case-control Healthy control DSM-III-R N/A Questionnaire on 3c Supported by
subjects sexual functioning Emouna
of Schiavi Foundation
(Germany)
Kockott and 1996 Germany Schizophrenia 12 18-65a N/A Case-control Dermatological DSM-III-R BPRS Semi-structured 1c Supported by
Pfeiffer50 patients ICD-9 interview Wilhelm-
Sander-Stiftung
(Germany)
Dembler-Stamm 2017 Germany Schizophrenia 19 25.4 (4.0)b 11 Case-control Healthy control DSM-IV SCID-I DISF-SR 7c Supported by
et al62 subjects ICD-10 Charité
University
Hospital Berlin
(Germany)
Düring et al60 2019 Denmark Schizophrenia 59 24.7 (6.1)b 36 Cross-sectional — ICD-10 PANSS UKU 7d Grant by
CDSS Sexual anamnesis Mental Health
Services
(Denmark) and
by grant
R25-A2701
from the
Lundbeck
Foundation
Del Cacho et al59 2020 Spain First-episode 68 24.4 (9.22)b 35 Case-control Healthy control N/A PANSS CSFQ 5c Supported by
psychosis subjects Parc Sanitari
Sant Joan de
Déu (PSSJD)
(Spain)

Abbreviations: ASEX, Arizona Sexual Experience Scale; ASI, Anxiety Sensitivity Index; BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; BISF-W, Brief Index of Sexual Functioning for Women; BPRS,
Brief Psychiatric Rating Scale; CAC, compulsive activity checklist; CDSS, Calgary Depression Scale in Schizophrenia; CSFQ, Change in Sexual Functioning Questionnaire; ED, erectile dysfunction; DISF-SR, Derogatis
Inventory in Sexual Function Self Report; FSFI, Female Sexual Function Index; GAD, generalized anxiety disorder; GDS, Geriatric Depression Scale; GRISS, Golombok-Rust Sexual Satisfaction Inventory; HAMA,
Hamilton Anxiety Rating Scale; HAMD, Hamilton Depression Rating Scale; IES, Impact of Event Scale; IIEF, International Index of Erectile Function; LSAS, Liebowitz Social Anxiety Scale; MDD, major depressive
disorder; MMQ, Maudsley Marital Questionnaire; MOCI, Maudsley Obsessional Compulsive Inventory; N/A, •••; NEO-PI-R, Revised NEO Personality Inventory; OCI-R, Obsessive Compulsive Inventory–Revised;
PANSS, Positive and Negative Syndrome Scale; PAS, Panic and Agoraphobia Scale; PCL, PTSD Checklist; PD, panic disorder; QSD, Questionnaire for Screening Sexual Dysfunctions; SAD, social anxiety disorder;
SCID-I, Structured Clinical Interview for DSM-IV Axis I Disorders; SCID-P, Structured Clinical Interview for DSM-IV Axis I Disorders–Patient Version; SCL-90, Symptom Check List-90; SFQ, Sexual Functioning
969

Questionnaire; STAI, State–Trait Anxiety Inventory version Y; UKU, Udvalg for Kliniske Undersøgelse; Y-BOCS, Yale-Brown Obsessive Compulsive Scale; N/A, not applicable. a Range. b Mean (SD). c Quality
assessment case-control studies: very low risk of bias = 8 points, low risk of bias = 6-7 points, medium risk of bias = 4-5 points, high risk of bias = 0-3 points. d Quality assessment cross-sectional studies: very low
risk of bias = 9-10 points, low risk of bias = 7-8 points, medium risk of bias = 5-6 points, high risk of bias = 0-4 points.
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 970

Table 2. Outcome of included studies.

Psychiatric disorder Study General Desire Arousal Orgasm Satisfaction

Depressive disorders Mathew and Weinman52 — Compared with control No significant difference was No significant difference was —
subjects, a significant found for impotence. found for PE, delayed
difference was shown in loss ejaculation, and lack of
of libido (31%) and excessive orgasm.
libido (22%).
Angst16 45.1% reported any sexual 14.6% increased desire — — —
problem. 32% decreased desire
Kennedy et al61 — Men: Men: Men: —
42% decreased desire and 34% less vigorous erections 12% PE
reduced sexual fantasies 46% unable to sustain an 22% delayed ejaculation
Women: erection Women:
50% decreased desire, Women: 15% orgasmic problems
35% reduced sexual fantasies 40% difficulty obtaining
vaginal lubrication
Frohlich and Meston48 Significantly more sexual Significantly more desire for Significantly more inhibited Significantly more inhibited Significantly less sexual
problems. sexual activity. sexual arousal. orgasm. satisfaction.
Cheng et al63 — — Depressive symptomatology is Depressive symptomatology Depressive symptomatology
negatively associated with ED. is negatively associated with is negatively associated with
orgasmic function. intercourse and overall
satisfaction.
Kendurkar et al63 76% reported sexual Men: Men: — —
dysfunction (OR, 2.8). 45% low desire 36% difficulty sustaining
Women: penile erection
68% low desire Women
58% low sexual arousal
Thakurta et al44 72% displayed sexual Men: Men: Men: —
dysfunction. 33% low desire 22% sustaining penile 17% difficulty achieving an
Women: erection orgasm
42% low desire Women: Women:
22% arousal problems 11% difficulty achieving an
orgasm
Hamzaoui et al47 93,33% reported sexual 33,33% reported low desire — — —
dysfunction.
Sreelakshmy et al46 90% reported sexual — — — —
dysfunction.
Anxiety disorders Van Minnen and Kampman43 44% had 1 or more sexual Significantly less sexual — — —
dysfunction, compared with desire.
18% of the control subjects.
Figueira et al45 Panic disorder: Men: Men: Men: —
75% sexual dysfunction 14% HSDD 7% ED 21% PE
Social phobia: Women: Women:
33% sexual dysfunction 21% HSDD 7% orgasmic disorder
Men:
48% PE,
5% orgasmic disorder
Women:
18% orgasmic disorder
Bodinger et al53 — Women: Men: Men: Men:
Less frequency of sexual Less arousal 33% PE Less satisfaction
thoughts, desire, and more Women: Less frequency of orgasm. Women:
loss of desire during Less lubrication/arousal Less satisfaction
intercourse.

(Continued)
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Table 2. Continued.

Psychiatric disorder Study General Desire Arousal Orgasm Satisfaction

Mercan et al54 — No significant difference — — —
between patients with panic
disorder and healthy control
subjects on sexual desire.
Kendurkar et al41 64% reported sexual Low desire was the most Men: Women: —
dysfunction (OR, 2.0). prevalent complaint for both 28% difficulty sustaining 44% orgasmic dysfunction
genders. penile erection
Aksoy et al42 — — — — Higher prevalence of
dissatisfaction.
Dètorre et al55 — No significant differences Significantly more arousal Significantly more orgasmic —
were reported in desire. problems. problems.
No significant differences
were reported in lubrication.
OCD Freund and Steketee49 39% of the patients were — — — 73% was not satisfied with
indicated as sexually their sex lives.
dysfunctional.
Van Minnen and Kampman43 76% had 1 or more sexual OCD patients showed — — —
dysfunction compared with significantly less desire.
18% of the control subjects.
Kendurkar et al41 50% reported sexual No significant difference in No significant difference in Orgasmic dysfunction was No significant difference in
dysfunction (OR, 1.5). desire. penile erection/vaginal the most frequent complaint. orgasmic satisfaction.
The Journal of Sexual Medicine, 2023, Vol 20, Issue 7

lubrication.
Aksoy et al42 — — — Women: Higher prevalence of
24% anorgasmia dissatisfaction.
Ghassemzadeh et al51 Men: Men: Men: Men: Men:
25% sexual dysfunction 10% low desire 20% ED 25% orgasmic dysfunction 40% less intercourse
Women: Women: Women: Women satisfaction
81% sexual dysfunction 50% low desire 58% problems regarding 44% orgasmic dysfunction Women:
arousal, 42% less satisfaction
36% less lubrication
Posttraumatic stressdisorder Kotler et al56 — Significantly poorer sexual Significantly poorer sexual Significantly poorer sexual Significantly poorer sexual
function in desire function arousal and orgasmic function function satisfaction)
compared with the control compared with the control
group. group.
Hirsch57 — 74% diminished desire 49% ED 15% reported ejaculatory —
delay or incompetence
Schizophrenia Aizenberg et al58 — Reduced frequency of sexual Reduced degree of coital More PE. —
fantasies, lower frequency of erections and more erectile
desire, and more lack of problem during intercourse.
desire.
Kockott and Pfeiffer50 25% patients and 13% of the — — — —
control group reported sexual
problems.
Dembler-Stamm et al62 — Significantly more problems No significant difference on Significant more problems —
regarding sexual cognitions sexual arousal compared with regarding orgasm compared
and fantasies compared with control subjects. with control subjects.
control subjects.
Düring et al60 — Men: Men: Men: —
18% increased desire, 7% ED 15% ejaculatory dysfunction
45% decreased desire Women: Women:
Women: 14% decreased lubrication 26% orgasmic dysfunction
24% increased desire,
19% decreased desire
Del Cacho et al59 Significantly poorer overall Significantly poorer sexual — — —
sexual functioning in patients desire in patients than healthy
than healthy control subjects. control subjects.
971

Abbreviations: ED, erectile dysfunction; HSDD, hypoactive sexual desire disorder; OCD, obsessive-compulsive disorder; OR, odds ratio; PE, premature ejaculation.
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972 The Journal of Sexual Medicine, 2023, Vol 20, Issue 7

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Figure 1. Flow chart of search, selection, exclusion, and inclusion.

arousal.58,62 The third study found that female patients expe- Discussion
riencing schizophrenia showed a more decreased arousal in The research on sexual dysfunction in psychiatric patients
comparison with male patients.60 For details, see Table 2. without the use of psychotropic medication, drugs, and
somatic comorbidity is limited. When categorized in diag-
nostic subgroups, a prevalence of sexual dysfunction was
Orgasm found in 45% to 93% for patients with depressive disorder,
Sixteen studies reported on orgasmic dysfunction. In order in 33% to 75% for patients with anxiety disorders, in 25% to
of declining prevalence per psychiatric disorder, overall 81% for OCD, and in 25% for schizophrenia. The prevalence
orgasmic dysfunction was found in 24% to 44% of patients of overall sexual dysfunction for PTSD was not reported in
with OCD (2 studies), in 7% to 48% of patients with the identified studies. The most commonly reported sexual
anxiety disorders (3 studies), in 15% to 26% of patients problem among both men and women was decreased sexual
with schizophrenia (1 study), in 11% to 22% of patients desire. Orgasm difficulties were most frequently reported
with a depressive disorder (2 studies), and in 15% of in patients with OCD, and to a lesser extent in patients
patients with PTSD.41,42,44,45,51,53,57,60,61 For details, with anxiety disorders (eg, a decreased ability to achieve an
see Table 2). orgasm and/or a decreased quality of their orgasm). Lower
sexual satisfaction was reported in patients with a depressive
disorder, anxiety disorder, OCD, and PTSD, whereas this
Satisfaction outcome was not available for patients with schizophrenia. It
Eight studies reported on sexual satisfaction. Seven studies is striking that no articles were found on patients with bipolar
reported reduced sexual satisfaction (in 2 studies in depressive disorder, while lifetime impairment of sexual function and
disorders, 2 studies on anxiety disorders, and 1 study on promiscuity is significantly more common in patients with
patients with PTSD).48,51,53,56,63 For OCD patients, 40% bipolar disorder than in control subjects.64 The findings of
to 73% of the patients reported less sexual satisfaction (2 our study are in accordance with previous articles suggesting
studies) and higher prevalence of dissatisfaction (1 study), that psychiatric disorders are often associated with decreased
in contrast to 1 study that found no significant difference sexual functioning.14,18,20
between patients with OCD and control subjects.41,42,49,51 Variations in reported sexual dysfunction both within and
For details, see Table 2). between psychiatric disorders may have been influenced by
The Journal of Sexual Medicine, 2023, Vol 20, Issue 7 973

lack of a standardized assessment tool, differences in assess- A significant number of reviewed studies had small sample
ment tools, diagnostic criteria, differences in demographic sizes and were of a heterogeneous nature.74 Based on the
characteristics, and sample sizes used in the studies. Also, lack quality assessment of the included studies, most were classified
of knowledge on the prediagnosis sexual dysfunction prior as poor quality, which restricts the ability to draw definitive
to developing a psychiatric disorder could be a confounding conclusions from these studies (Table 2). Furthermore, 11 of
factor.49 Furthermore, the severity of the psychiatric disorder 24 studies that were included had no control group.
and the impact of comorbid psychiatric disorders may have Third, many different scales measuring sexual function
also contributed to the observed variability in sexual dysfunc- were used, making it difficult to compare study results. Studies
tion.43,44,63 used semi-structured interviews, self-designed questionnaires,
The literature hypothesizes on possible common pathways and clinical impressions to quantify sexual function, some-

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that may lead to the development of psychiatric symptoms times using nonvalidated measurements that did not evaluate
and sexual dysfunction. However, due to the limited available different phases of the sexual response cycle or sexual satisfac-
data, it is not possible to prove these hypotheses. Various tion. These methodologic differences, along with variations
authors have proposed, for example, a complex relationship in diagnostic categories and the limited number of studies,
between sexual dysfunction, depression, and anxiety, high- hinder drawing firm conclusions and may potentially explain
lighting the multifactorial and bidirectional nature of this con- the wide range of reported prevalence range.
nection.10,12,65 Baranowski et al66 suggested that depressive Fourth, interrater reliability (Cohen’s Kappa) between the
female patients may not pay less attention to sexual stimuli, reviewers was just above chance. Differences in ratings by
but rather explicitly evaluate them differently. This seems to 2 reviewers were related to different interpretations of the
be mediated by automatic negative thoughts (dysfunctional intended quantitative outcome (eg, primary outcome or not)
beliefs) as a part of the depressive disorder and also reduces and population (eg, well recruited or homogeneous). How-
sexual arousal. ever, all ambiguous publications were discussed together and
Patients with PTSD may experience emotional numbing or with a third accessor until finally reaching consensus.
interpersonal disconnection, which may lead to low sexual Fifth, psychiatric disorders often coexist with other psychi-
desire. Hypervigilance in patients with PTSD may also con- atric disorders, which may have a role in the prevalence of sex-
tribute to sexual dysfunction, including difficulties in achiev- ual problems.75 For example, Ghassemzadeh et al51 reported
ing orgasm.20,67,68 low desire and low sexual arousal in OCD patients, with 82%
Patients with anxiety disorders may tend to avoid arousing of the participants showing symptoms of depression. Thus,
activities to avoid anxiety or a panic attack. Constant vigilance comorbid depressive symptoms could be a contributing factor
to physical symptoms may predominate and could contribute to the rates of sexual problems reported in OCD patients.
to erectile dysfunction.42,69 In addition, patients with social However, it should be noted that most of the included studies
phobia may avoid social contacts with others unknown to did not report on comorbid psychiatric disorders or their
them, leading to fewer dates. They may be anxious about potential influence on sexual dysfunction beyond the primary
being unattractive or uninteresting and avoid sexual con- psychiatric disorder.
tacts.70 In patients with panic disorder, misinterpretations of Sixth, the majority of studies included in our analysis
bodily sensations of autonomic arousal resulting from sexual reported subjective outcomes on sexual dysfunction using
arousal are perceived as interoceptive cues. These interocep- questionnaires, semi-structured interviews, and sexual history
tive cues can be misinterpreted as threats and can lead to panic taking, whereas no objective outcomes such as vital signs (eg,
attacks.71 Therefore, patients with panic disorder may avoid heartrate, blood pressure) or sonographic vaginal or penile
sexual activities.43 flow measurements were collected. Collecting both subjective
Sexual dysfunction in patients with schizophrenia may and objective outcomes on sexual dysfunction may provide
be related to the symptoms of the illness, such as posi- a more comprehensive understanding of the influence of
tive, cognitive, and negative symptoms. Negative symptoms, psychiatric disorders on sexual dysfunction.76
such as apathy, may play a particular role in sexual dys- Seventh, sexual distress and sexual satisfaction may be
function. Hypodopaminergic activity in the frontal cortex, more prevalent in patients with a psychiatric disorder than
often thought to contribute to negative symptoms, may also sexual dysfunction, and this may lead to a diminished quality
decrease sexual motivation and pleasure.13 The development of life.15 Although only one-third of the included studies
of the emotional basis for sexuality during adolescence of reported on sexual satisfaction, none of them reported on
schizophrenia patients may be altered, due to their premor- sexual distress. Thus, our findings may underestimate the
bid personality such as schizoid or schizotypical personality clinically significant sexual burden experienced by patients.
disorder.13 They begin their journey of sexuality with a lack Last, most of the included studies in the review reported
of interpersonal contacts and sexual experience and are there- outcomes in patients between 20 and 40 years of age, while
fore at higher risk of compulsive masturbation with deviant only one study reported outcomes in patients with a mean
fantasies and genital dysmorphia.72 age of 69 years.63 As a result, caution should be exercised
Our study has a number of limitations. First, we have found when interpreting the conclusions of this systematic review
a very limited number of eligible studies per psychiatric disor- with regard to the generalizability of findings for younger or
der. For example, very few studies were available on patients older patients.
with schizophrenia, PTSD, and OCD, and no studies were Our study has several strengths. First, to our knowledge,
identified on patients with bipolar disorder, despite evidence this is the first study to systematically review sexual dysfunc-
between bipolar disorder and sexual dissatisfaction in the tion in patients with psychiatric disorders who are not using
general Dutch population.73 psychotropic drugs, do not have known comorbid somatic
The second limitation of this study was that the major- diseases, and have no known use of substances. Second,
ity of the studies included had methodology limitations. the outcome of this study is of importance to clinicians for
974 The Journal of Sexual Medicine, 2023, Vol 20, Issue 7

counseling their patients on the role of psychiatric disorders Supplementary material

and their effect on sexual dysfunction. Supplementary material is available at The Journal of Sexual Medicine
Due to the limited number of studies available for each psy- online.
chiatric disorder and the presumed prevalence of sexual dys-
function caused by psychotropic drugs (eg, antipsychotics and
antidepressants), it is methodologically incorrect to compare Funding
psychiatric patients using and not using these psychotropic The authors received no funding for this work.
drugs. However, this review suggests that when comparing
the prevalence of sexual dysfunction in psychiatric patients Conflicts of interest: None declared.
not using psychotropic drugs with that of healthy individuals,

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there is a higher prevalence of sexual dysfunction in the
former group. The range of sexual dysfunction found in psy- Data availability
chiatric patients not using psychotropic drugs in this review The authors confirm that the data supporting that the findings of this
is 25% to 93%. In comparison, a meta-analysis of treatment- study are available within the article and its supplementary materials.
emergent sexual dysfunction related to antidepressants found
a range of 26% to 80%,22 while another meta-analysis on
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