Addressing Sexual Wellness: A Psychiatric Perspective

Sexual health, incorporating physical, mental, emotional, and social well-being around sexuality, is declared a basic human right and integral factor in quality of life by the World Health Organization and the US Office of the Surgeon General.^1,2 Yet, sexual dysfunction is prevalent, affecting an estimated one-third of men and over 40% of women in the US,³ with higher rates among transgender and nonbinary individuals.⁴ Among those with psychiatric disorders, rates of sexual dysfunction are higher still compared with the general population, affecting over half of individuals with depression and anxiety.⁵ Depression, anxiety, trauma, and eating disorders can all negatively impact sexual health on their own, and many psychiatric medications prescribed to treat these conditions can compound this by reducing libido or causing anorgasmia. Sexual dysfunction can, in turn, exacerbate comorbid psychiatric disorders and contribute to medication nonadherence. Beyond medication management, histories of shame, trauma, and dysfunction around sexuality are common themes in psychotherapy, and patients may look to their clinicians for healing from these issues.

Matters of sexual health fall under the purview of psychiatry. However, these issues are not routinely addressed in clinical practice. A 2020 Austrian survey of psychiatrists found that fewer than one-third of participants reported asking patients about sexual health regularly, and half of the participants suspected sexual dysfunction in their patients but did not address the topic.⁶ Notably, rates of addressing sexual health were higher among psychiatrists who had received training in this area.

Unfortunately, many physicians do not receive such training, as fewer than half of US and Canadian medical schools incorporate human sexuality into curricula.⁷ Among psychiatry residencies, published didactics on sexuality are limited,⁸ and the Accreditation Council for Graduate Medical Education (ACGME) has not provided specific guidelines for sexual health training beyond recognizing sexual abuse and understanding sexuality in the context of normal development.⁹ It is therefore unsurprising that many psychiatrists graduate from residency ill-equipped to address sexual well-being in clinical practice.

Proposed Solutions

Although other specialties play a critical role in addressing patients’ sexual health, psychiatrists are uniquely positioned to address concerns in this area by leveraging pharmacologic and psychotherapeutic knowledge. However, as noted, training in the assessment and management of sexual dysfunction in psychiatric patients is sporadic at best.^6-8 We propose expanded training for psychiatry residents here.

Implications for Psychopharmacology

Although sexual dysfunction is common among those with psychiatric illness, pharmacotherapy can result in sexual adverse effects. Studies suggest an 80% prevalence of treatment-emergent sexual dysfunction in those taking antidepressants,¹⁰ and a 46% to 52% prevalence in those taking antipsychotics.^11,12 Despite high rates, many clinicians fail to inquire about sexual dysfunction, and patients may hesitate to disclose sexual adverse effects despite significant impacts on quality of life.¹¹

Given the ubiquity of sexual dysfunction in the psychiatric setting, its management should be a key learning objective for all resident trainees. Residents should receive education, through simulated patient cases and/or supervised clinical practice, on taking a sexual history prior to initiation and throughout the course of psychiatric treatment. Programs should also seek to familiarize trainees with common management strategies of medication-associated sexual adverse effects. These include transitioning patients to agents with fewer hyperprolactinemic or serotonergic profiles to mitigate sexual adverse effects, where indicated. In addition, psychiatrists should be knowledgeable in counseling around adjunctive strategies such as recommending PDE5 inhibitors or vaginal lubricants, in addition to engaging patients in risk/benefits discussions around alternative medications with lower sexual adverse effect profiles. In scenarios where patients are unable to tolerate the gold-standard medication due to sexual adverse effects and self-discontinue their pharmacotherapy as a result, psychiatrists should adopt an ethos of harm reduction, encouraging adherence to the most effective medicines that the patient is willing to take and able to tolerate. Where high-quality information is lacking, as is the case among newer psychotropic agents, consensus guidelines for antidepressant and antipsychotic management should be referenced in clinical decision-making.^13-15 See Figure for a summary of assessment and intervention suggestions.

Implications for Psychotherapy

Within psychotherapy, insufficient training in sexual health and wellness carries risks for patients, as clinicians may unwittingly do harm by perpetuating misinformation, allowing their personal biases to infiltrate the discourse, or avoiding these topics altogether due to their own discomfort or misgivings.¹⁶ A recent survey of over 100 US clinicians who publicly marketed themselves as specialists in sex therapy found that almost one-third of participants had never completed graduate-level coursework in this field, and only 1 in 4 were certified in sex therapy.¹⁷ Rectifying this gap in education poses significant challenges due to the minimal regulation of sex therapists in the US. Florida is the only state that statutorily requires clinicians to meet specific training and supervision standards before using this title.¹⁷ 

One potential solution would be to implement more stringent accreditation requirements and regulatory oversight to promote the dissemination of best practices in the field. The most well-recognized accrediting organization in the US is the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). However, completing AASECT certification requires several hundred hours of training and can cost thousands of dollars, limiting its accessibility to psychiatry residents and early-career attendings. Increased specialization also risks perpetuating the stereotype of sexual health and wellness as a niche concern rather than an essential aspect of whole-person health, generating barriers to treatment and potentially increasing stigma around seeking care.¹⁸ 

Binik and Meana argue that, in the absence of a unified theoretical framework and empirically validated treatment outcomes, sex therapy as a distinct specialty should be dismantled altogether.¹⁹ Instead, they propose that topics of sexual health and wellness remain under the purview of general psychotherapy without requiring professional certification. The appeal of this approach includes the integration and expectation of sexual health concerns into psychiatric practice, as well as greater access to treatment without the need for additional specialty referrals. However, as outlined, there remain significant risks associated with the provision of sex therapy by unqualified individuals, especially given the dearth of evidence-based sex education in general medical and psychotherapy education.²⁰ 

To avoid these pitfalls, we argue that sexual medicine should be included in the ACGME requirements for psychiatry residency programs. The goal is not to turn every psychiatry resident into a budding sex therapist but rather to promote the dissemination of best practices across a general psychiatry audience. Trainees could develop their clinical skills and critically examine their own attitudes and biases around human sexuality while remaining under the supervision of more experienced clinicians. Prior authors have proposed frameworks for such a curriculum.⁸ We advocate for training that broadens our conception of sexual health beyond dysfunction alone, one that prioritizes wellness as much as pathology, in the same way that we no longer conceive of mental health as simply the absence of mental illness. In learning about the basic principles of sex therapy, we hope psychiatry residents will appreciate the relevance of human sexuality to general psychiatric practice.

Clinical Pearls

The Ex-PLISSIT model (Extended Permission-giving, Limited Information, Specific Suggestions, and Intensive Therapy)²¹ provides a stepwise framework for psychiatrists to inquire about general sexual health and provide recommendations according to the patient’s needs. This approach emphasizes the crucial first step of intentionally asking patients about their sexual health concerns. Psychiatrists can also employ the Five Ps (Partners, Practices, Past history of/protection from sexually transmitted infections, Pregnancy plans, and Pleasure) to obtain a detailed assessment of sexual health risk factors and current functioning.²² After psychotropic initiation, psychiatrists should screen for adverse sexual effects. Multiple validated measures have been developed for this purpose, including the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ) and the Changes in Sexual Function Questionnaire (CSFQ).²³ See Table for a list of recommended questions to ask during the initial interview and after medication initiation or dose changes.

Concluding Thoughts

The future of psychiatry emphasizes destigmatizing mental health and promoting preventive care through a holistic approach, which includes human sexuality. From Freud’s early theories on the unconscious sexual desires in mental health to contemporary issues on the intersection of mental health and sexuality across diverse populations, psychiatry’s perspective has been foundational and inspirational. Advancements in the understanding of human sexuality from a medical model require psychiatric expertise. Our patients deserve physicians who consider sexual health when promoting wellness. Our patients seek physicians who are competent and nonjudgmental about sexuality. It is time we, as psychiatrists, address our own biases and stigma to assume our rightful role as holistic mental health treaters, which includes sexual healing.

Dr Johnson is a psychiatry resident at Brigham and Women's Hospital in Boston, Massachusetts.

Dr Rains is a psychiatry resident at Brigham and Women's Hospital.

Dr Sorrentino is a clinical assistant professor at Harvard Medical School in Boston.

References

1. Sexual and reproductive health and rights. World Health Organization. Accessed March 25, 2026. https://www.who.int/health-topics/sexual-and-reproductive-health-and-rights

2. US Office of the Surgeon General; US Office of Population Affairs. The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior. Office of the Surgeon General; 2001. Accessed March 25, 2026. http://www.ncbi.nlm.nih.gov/books/NBK44216/

3. Rosen RC. Prevalence and risk factors of sexual dysfunction in men and women. Curr Psychiatry Rep. 2000;2(3):189-195.

4. Rutherford L, Stark A, Ablona A, et al. Health and well-being of trans and non-binary participants in a community-based survey of gay, bisexual, and queer men, and non-binary and Two-Spirit people across Canada. PLoS One. 2021;16(2):e0246525.

5. Herder T, Spoelstra SK, Peters AWM, Knegtering H. Sexual dysfunction related to psychiatric disorders: a systematic review. J Sex Med. 2023;20(7):965-976.

6. Seitz T, Ucsnik L, Kottmel A, et al. Let us integrate sexual health-do psychiatrists integrate sexual health in patient management? Arch Womens Ment Health. 2020;23(4):527-534.

7. Derenne J, Roberts L. Psychiatry’s role in teaching medical students, psychiatric residents, and colleague physicians about human sexuality. Acad Psychiatry. 2010;34(5):321-324.

8. Seritan A, Aminololama-Shakeri S. A gender and sexuality curriculum for psychiatry residents. Med Sci Educ. 2016;26:525-528.

9. ACGME program requirements for graduate medical education in psychiatry. Accreditation Council for Graduate Medical Education. Updated September 3, 2025. Accessed March 25, 2026. https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformatted-requirements/400_psychiatry_2025_reformatted.pdf

10. Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. J Clin Psychopharmacol. 2009;29(3):259-266.

11. Montejo AL, Majadas S, Rico-Villademoros F, et al; Spanish Working Group for the Study of Psychotropic-Related Sexual Dysfunction. Frequency of sexual dysfunction in patients with a psychotic disorder receiving antipsychotics. J Sex Med. 2010;7(10):3404-3413.

12. Üçok A, İncesu C, Aker T, Erkoç Ş. Sexual dysfunction in patients with schizophrenia on antipsychotic medication. Eur Psychiatry. 2007;22(5):328-333.

13. Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry. 2016;50(5):410-472.

14. Montejo AL, Prieto N, de Alarcón R, et al. Management strategies for antidepressant-related sexual dysfunction: a clinical approach. J Clin Med. 2019;8(10):1640.

15. Montejo AL, de Alarcón R, Prieto N, et al. Management strategies for antipsychotic-related sexual dysfunction: a clinical approach. J Clin Med. 2021;10(2):308.

16. Reissing ED, Giulio GD. Practicing clinical psychologists’ provision of sexual health care services. Prof Psychol Res Pr. 2010;41(1):57-63.

17. Zeglin RJ, Goldberg S, Stalnaker-Shofner DM, et al. Sex therapy credentials: a descriptive analysis of the training of clinicians who do sex therapy. Sex Relatsh Ther. 2024;39(1):4-19.

18. Martinez-Gilliard E. Sex, Social Justice, and Intimacy in Mental Health Practice: Incorporating Sexual Health in Approaches to Wellness. Routledge; 2023.

19. Binik YM, Meana M. The future of sex therapy: specialization or marginalization? Arch Sex Behav. 2009;38(6):1016-1027.

20. Nasserzadeh S. “Sex therapy”: a marginalized specialization. Arch Sex Behav. 2009;38(6):1037-1038.

21. Davis S, Taylor B. Chapter 6 - From PLISSIT to Ex-PLISSIT. In: Davis S, ed. Rehabilitation: The Use of Theories and Models in Practice. Elsevier; 2005:101-129.

22. Savoy M, O’Gurek D, Brown-James A. Sexual health history: techniques and tips. Am Fam Physician. 2020;101(5):286-293.

23. de Boer MK, Castelein S, Wiersma D, et al. A systematic review of instruments to measure sexual functioning in patients using antipsychotics. J Sex Res. 2014;51(4):383-389.