One of the great therapeutic accomplishments of the second half of the 20th century was the establishment of legitimacy and efficacy in interventions exclusively targeting sexual difficulties. Despite the availability of empirically validated techniques for helping patients with sexuality, there remains a significant training challenge, namely, convincing mental health professionals that such treatment is appropriate, safe, and necessary for this population. Some clinicians fear that people with schizophrenia, by definition, cannot “tolerate” such explicit discussion and graphic illustration of sex, and assume that such exposure will cause patients to regress psychotically and/or engage in inappropriate sexual behavior.

To overcome this limitation in clinicians’ knowledge base and comfort level, clinical training workshops in sexuality have been developed. At UCLA, such workshops have been conducted for over 20 years. These workshops are taught in two intensive training weekends by clinicians trained and experienced in human sexuality and sex therapy.

Some elements of these training workshops include the following:

1. Education in the anatomy and physiology of sex.
2. Learning the effects of illness and certain medications on sexuality.
3. Dispelling sexual myths and misinformation.
4. Exploration of the concepts of “normal” and “abnormal” sex.
5. Becoming fully knowledgeable about safe and unsafe sexual practices.
6. Learning specific behavioral programs for treating both genders’ sexual difficulties (e.g., knowing how and when to initiate appropriate sexual activity, and how to deal with problems of desire, arousal, and orgasm).
7. Learning to individualize these programs to a patient’s specific behavioral, cognitive, affective, and cultural profile.
8. Creating an environment in which discussing sexual feelings, behaviors, fantasies, and experiences feels emotionally safe.

The weekend workshops are followed by ongoing weekly seminars that include (1) didactic teaching, (2) viewing sexually explicit training media, (3) exercises in verbal sexual self-disclosure, (4) role playing by patient and therapist, and (5) case presentations. Ideally, once trainees begin seeing patients specifically for sex education training, concurrent weekly supervision is provided.  The great majority of participants in the workshops and seminars report feeling more comfortable openly discussing their own sexual feelings, fantasies, and experiences, which in turn leads them to experience greater willingness and facility when teaching sexually explicit material to their patients.

KEY POINTS

•   Despite stereotypes to the contrary, people with schizophrenia are as likely as individuals without a serious mental disorder to engage in sexual activity.
•   However, people with schizophrenia are susceptible to sexual dysfunction, because of both the symptoms of their disorder and the side effects of their medications.
•   Cognitive deficits and lack of social support lead individuals with schizophrenia to be particularly vulnerable to sexually transmitted diseases (including HIV/AIDS) and unwanted pregnancies.
•   Psychoeducational programs that provide information on sexuality to people with schizophrenia can increase their knowledge and encourage behavior that is consistent with safe and satisfying sex.
•   Mental health practitioners require special training to undertake the task of teaching people with schizophrenia how to make informed decisions about sexual relations.

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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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