Despite a healthy interest in sex, many people with schizophrenia report a progressive deterioration of their sexual and sociosexual function beginning in young adulthood, closely paralleling the age of onset of their illness.  Indeed, there appears to be a complex yet definite relationship between sexuality and schizophrenia. For example, estrogen, a key hormone for sexual functioning, is lower than normal in females with schizophrenia at the onset of illness. Similarly, lower levels of gonadotropins and testosterone have been observed in unmedicated males with schizophrenia. Together these findings suggest that these hormonal disturbances contribute to the sexual dysfunction associated with the disorder.

Sexual dysfunctions may also result directly or indirectly from symptoms of the disorder and their functional consequences. For example, individuals with schizophrenia may have low self-confidence, few personal relationships, loss of impulse control, and negative or deficit symptoms, such as lack of interest and loss of pleasure, all of which may result in sexual problems. Given their anhedonia, limited social initiative, social anxiety, and deficits in social perception, sexual dysfunctions can be the source of their demoralization and discouragement in seeking sex with appropriate partners. Because of these barriers, many individuals with schizophrenia seek hazardous sex from prostitutes or workers in massage parlors.

Perhaps most importantly, the antipsychotic and antidepressant medications commonly prescribed and used to treat symptoms of the disorder effectively may actually cause or contribute to the sexual dysfunctions experienced by persons with schizophrenia.

Rates of sexual dysfunction associated with the use of these medications range from 50 to 90% for the older, conventional antipsychotics and 10 to 30% for the newer, atypical antipsychotics. Sedation and weight gain may lead to diminished interest in sex. Alternatively, extrapyramidal side effects and tardive dyskinesia may reduce mobility, which in turn adversely affects sexual functioning. Finally, the neural systems and neurotransmitters affected by the drugs themselves may have a direct impact on sexual functioning. Serotonin, cholinergic antagonism, alpha-adrenergic blockade, calcium channel blockade, and dopamine blockade at the pituitary level (resulting in increased prolactin levels) can cause sexual dysfunctions, including loss of libido, orgasmic dysfunction, ejaculatory difficulty, and menstrual disturbances. Most importantly, sexual dysfunction has been implicated as one of the major factors contributing to noncompliance with antipsychotic medication regimens.

Vulnerability to sexual victimization and sexually transmitted diseases
Compared to normal controls, people with schizophrenia have significantly less knowledge about reproduction and contraception. Moreover, deficits in social cue perception and social judgment put individuals with schizophrenia at heightened risk of being sexually victimized. Compared to non-mentally-ill women, women with schizophrenia report being more likely to have been pressured into unwanted sexual intercourse and less likely to use contraception, resulting in higher rates of sexually transmitted diseases and unwanted pregnancies.

Men with schizophrenia are also at high risk. In one study, sexual activity of men with schizophrenia often occurred with homosexual or bisexual individuals known to be infected with human immunodeficiency virus (HIV). Half of the men with schizophrenia were involved in sex exchange behavior; that is, sex bought or sold for money, drugs, or goods. In addition, condom use was low, with fewer than 10% utilizing protective measures. Other investigators have reported that the risk for HIV is much higher in the schizophrenia population, and rates of infection have increased substantially in recent years.

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Alex Kopelowicz, M.D.^a
Robert Paul Liberman^b
Donald Stolar, PhD^c

^a Associate Professor of Psychiatry, David Geffen School of Medicine at UCLA
^bProfessor of psychiatry at the University of California at Los Angeles
^cDepartment of Psychiatry, University of California, Los Angeles,. Los Angeles, California

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REFERENCES

1. Assalian, P., Fraser, R. R., Tempier, R., & Cohen, D. (2000). Sexuality and quality of life of patients with schizophrenia. International Journal of Psychiatry in Clinical Practice, 4, 29–33.
2. Coverdale, J. H., & Turbott, S. H. (2000). Risk behaviors for sexually transmitted infections among men with mental disorders. Psychiatric Services, 51, 234–238.
3. Crenshaw, T. L., & Goldberg, J. P. (1996). Sexual pharmacology: Drugs that affect sexual functioning. New York: Norton.
4. Friedman, S., & Harrison, G. (1984). Sexual histories, attitudes and behavior of schizophrenic and “normal” women. Archives of Sexual Behavior, 13, 555–567.
5. Goisman, R. (2001). Choices: An educational program for AIDS prevention. Boston: MMH Reseach Corporation.

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