Sexual dysfunction and schizophrenia: psychiatrists' attitudes and training needs

Sexual dysfunction is a common and distressing symptom in schizophrenia, with rates of up to 86–96% reported in more recent studies (Macdonald et al, 2003), and persisting throughout the course of the illness. Fortier et al (2003) reported a higher incidence of sexual dysfunction among young adults and long-stay patients with schizophrenia. The high rates could be caused by illness variables and treatment. Bitter et al (2005), in a large study of antipsychotic-nai"ve patients with schizophrenia, found high rates of sexual dysfunction at initiation, and at 3 months and 6 months of treatment with antipsychotic medication. Putative mechanisms for sexual dysfunction in schizophrenia include medication-related effects, such as elevation of plasma prolactin levels, sedation owing to antihistaminergic effects, adrenergic effects and serotonergic blockade. Illness variables include negative symptoms mediated by low libido, direct effects of psychosis and abnormalities in the limbic system (Baldwin & Mayers, 2003; Malik, 2007). Sexual dysfunction is implicated as a major factor causing non-compliance (Fakhoury et al, 2001; Perkins, 2002). Patients often find it hard to complain and physicians may find it difficult to enquire about the problem (Clayton, 2001).

However, sexual dysfunction in schizophrenia can be addressed in a number of ways. These may include thorough assessment to exclude physical pathology, medication changes including the use of new atypicals, dose reduction, switching medications and referrals to specialists.

The extent to which staff enquire about sexuality in people with schizophrenia has depended on their general attitude to the importance of sexual issues in schizophrenia which has varied over the years (Kelly & Conley, 2004).

In the past, people with schizophrenia were stopped from procreation, and excessive masturbation was once considered as a possible cause of schizophrenia (Eerlinmayer-Kimmling et al, 1969; Akhtar et al, 1977). Another study (Pinderhughes et al, 1972) showed that professionals believed people with schizophrenia were unable to manage their sexuality and that staff were reluctant to discuss sexual issues with them.

Psychiatrists have an important role in effectively addressing these problems. As patients are often reluctant to talk about difficulties in their sexual life, it has been observed that they are more likely to open up when physicians raise this issue (Montejo-Gonzalez et al, 1997). Smith et al (2002) argued that clinicians should routinely enquire about sexual dysfunction in their patients, but it is unclear what the training experiences and attitudes of psychiatrists are. Identifying these will help improve the care patients receive.

Method

Questionnaire
We drafted a 14-item self-report questionnaire assessing psychiatrists' views on sexual dysfunction and schizophrenia, which was generated after a literature review and focus group discussion (see online data supplement). An initial pilot study was completed among colleagues at Pilgrim Hospital Boston and the community mental health team in Lincolnshire.