Anita Clayton, MD, on Diagnosing and Discussing Sexual Dysfunction
Key Takeaways
- Normalize sexual health screening within lifestyle and diagnostic reviews, as most patients avoid initiating the topic despite high distress and quality-of-life impact.
- Track anhedonia and antidepressant-associated sexual adverse effects longitudinally, incorporating patient preferences and considering nonpsychiatric contributors before reflexively switching effective psychotropics.
Experts unpack screening for sexual dysfunction in psychiatric care, menopause and meds impacts, and when flibanserin may help restore desire.
BRAIN TRUST: CONVERSATIONS IN PSYCHOPHARMACOLOGY
Series Editor Joseph F. Goldberg, MD
Joseph F. Goldberg, MD, in this installment of
Joseph F. Goldberg, MD: Sexual dysfunction and sexual health, it's an important topic, isn't it—not just because it's your area, but why is this an important and underappreciated topic in psychopharmacology?
Anita H. Clayton, MD: It is. I would say it's because only about 1% of people are asexual, so that means 99% of us care about it—we just don't always talk about it. There's a stigma with talking about it, much like psychiatric conditions. I think people want to know about it and what they can do about something they may not have even known was a problem. It really can enhance people's quality of life for us to be thinking about these issues.
Goldberg: I wonder how many of our viewers and listeners proactively ask patients about their sex lives, in particular how it may change in relation to an episode of depression, anxiety, or medication. When you teach, consult, and supervise, how do you encourage clinicians to bring that into the interview process?
Clayton: The easiest way is to just make it part of your assessment when you start talking about lifestyle—do you eat healthy, do you exercise, do you have sex, are you interested in it—and then, has there been a change, and do you see anything as a problem?
Often patients are thinking about this, but they're hesitant to bring it up. A survey done a number of years ago found that approximately 75% of patients didn't bring up sex because they were afraid it would bother their provider. We're not taught in medical school about talking to patients about sexual functioning, or really about the diagnoses in the DSM. In particular, for perimenopausal women, this has been a topic that hasn't been talked about, but is starting to really explode right now. Your patients may bring it up, or you should follow up and ask about their sexual function, too.
Goldberg: Tell us more about how and why it's exploding now.
Clayton: Probably because there are a lot of women, like me, who are going through—or already through—menopause, and we notice things about our bodies changing that we don't necessarily want, like urinary incontinence. But genitourinary syndrome of menopause, for example, really contributes to vaginal dryness and diminished desire and orgasmic function, either in frequency, intensity, or duration, and women do notice this. They want to know, and they should know.
Goldberg: Mental health clinicians often ask their questions in the context of a chief complaint that coalesces around depression, anxiety, cognitive functioning, or substance use. Any thoughts about couching sexuality differently than a primary care clinician might? For instance, I often link it with anhedonia—when I ask about the ability to derive pleasure from basic things like music and food, sex is always the third thing; maybe it should be second or first. Is that a fair way to get at it, or how would you think of that context?
Clayton: Absolutely. I think we should be asking about that as part of our diagnostic exam, and then following it across time. We know anhedonia is less likely to respond to standard antidepressants, and standard antidepressants—especially SSRIs—can further contribute to sexual dysfunction. When thinking about what to prescribe, I ask about preferences—what adverse effects would they want to avoid? I always hear, “I don't want to gain weight, and I don't want sexual dysfunction.” If somebody doesn't want to talk about sex, they'll say they're not having sex, or they're divorced or widowed—that doesn't necessarily mean they aren't having sex, just maybe not as often. But a light bulb should go off if a clinician picks up on a lack of interest in sex. That's on the Hamilton Depression Rating Scale—asking about interest, desire, or libido.
A problem with sexual desire, or loss of it, is the primary sexual dysfunction in women in this country, affecting about 10% of all women; however, about 40% of that group is probably related to depressive symptoms, so we should really be on top of it. Men are more likely to have performance anxiety related to sexual activity, which can contribute to other things, so that's a question to ask men, too—and men know. I also check testosterone levels in men, especially if depression isn't responding to treatment and they've aged.
Goldberg: Is andropause a real thing?
Clayton: It depends on what you mean, because it's much more gradual. But yes—if you look at the range of testosterone levels in lab studies, you can see that as men get older, and you don't have to be very old to start seeing a decline. By age 45, we really start to see men experiencing sexual dysfunction, and some of that relates to diminished testosterone. It's not like the levels cycle up and down like in women—it's a gradual process. Other medical issues also come on around age 45: weight gain, potentially diabetes, sleep apnea. If sleep is disturbed, that can also impact sexual functioning. It's important to consider that in the whole context of the individual.
Goldberg: This becomes a useful diagnostic assay, beyond just checking a box in the review of systems. If I'm picking up a signal about interest, or the mechanics of sexual response, that may lead me down a particular pathway. I should be sure I've screened for depression—what else?
Clayton: Substance use disorders, hypothyroidism potentially, and hormonal changes. If somebody has depression that isn't responding to treatment, and they're a man over 50, I'll probably check a testosterone level. I had 2 male patients recently where that was the case—I sent one to his primary care provider, who wouldn't prescribe it because urology wasn't going to see him for months, so I did, at a modest dose; when he eventually saw the urologist, the dose was doubled. We need to work in conjunction with other physicians, too.
Goldberg: How strong is the connection between interest and logistics? If someone—man or woman—is complaining of issues around satisfaction or orgasmic delay, as opposed to interest, is that diagnostically helpful? Interest is there, but the mechanics are down.
Clayton: Yes—we should be looking for more biological problems if you see those functional impairments. One thing I ask about later in the conversation is pornography use, because algorithms tend to escalate content toward more aggressive or deviant material, and once that's what someone uses to reach orgasm, regular sex with a partner can become difficult. It's insidious—people don't always realize it's affecting function. Desire is influenced by all kinds of things: the relationship, a partner's technique, and when things aren't good, people may not want sex as often. But when low desire is truly distressing and bothersome, there are often biological factors, and some are modifiable—for example, if someone is perimenopausal, should they have estrogen, or testosterone? We give testosterone to women, too, though for reproductive-age women it's a bigger issue because of pregnancy risk. Even birth control pills can cause sexual dysfunction—I've had young women on birth control and an SSRI develop sexual dysfunction, and switching the birth control method, rather than the SSRI, often resolves it while keeping the antidepressant that was working.
We have to think about other medicines, too: antihypertensives, and interestingly, chronic opioid use and chronic NSAID use, both of which can contribute to sexual dysfunction because prostaglandins are involved, especially in genital sexual function. Uncontrolled diabetes will cause sexual dysfunction as well—for men in their 40s presenting with erectile dysfunction, the advice is to test for diabetes right away, with a hemoglobin A1c or glucose as part of a comprehensive metabolic panel. The clinician has to be on their toes, thinking about the entirety of the patient medically, psychologically, and pharmacologically.
Goldberg: Is hypoactive sexual desire disorder a real, established diagnosis? Can you speak to that?
Clayton: Yes, it has been for a long time, though it used to be called other, more derogatory, terms. It affects about 10% of the population and has been in every DSM up to DSM-5. DSM-5 combined hypoactive sexual desire disorder and sexual arousal disorder into a single diagnosis, sexual interest and arousal disorder (SIAD), in part because psychiatrists who were actively involved in caring for and researching sexual dysfunction couldn't serve on the committee if they had earned more than $10,000 total related to industry, so the committee was largely psychologists without a medical model in their training. We actually studied this: about half the people who have hypoactive sexual desire disorder wouldn't meet SIAD criteria, because it requires some arousal problems, too, and what's happening in the genitals isn't necessarily what's happening in the brain. There's such a thing as cognitive desire, or cognitive arousal—desire that continues as you get more involved and excited. There are also women who are interested in sex, start having sex, and then lose interest because they're distracted by other things, like whether they turned off the oven. On the flip side, there are young women with hypoactive sexual desire disorder who are perfectly able to get aroused and have an orgasm but don't really want to have sex—nothing is driving them to it—and their partners assume they've lost interest in them, or are cheating, when in fact they're clearly aroused and orgasmic during activity.
Goldberg: So when does a drug like flibanserin come into the picture?
Clayton: The situation I just described is often where flibanserin comes in. It's also known by the brand name Addyi, available through pharmacies or a dedicated website. Flibanserin is a 5-HT1A agonist and a 5-HT2A antagonist, so it's somewhat like a combination of buspirone and trazodone.
Goldberg: Could I make my own that way, or should I think about that?
Clayton: I wouldn't advise that, but you could think about it in the context of a patient being treated for an anxiety disorder, or who needs an augmenting strategy, or isn't sleeping. We have plenty of people on that combination, and there are data with both buspirone and trazodone, and other 5-HT2A antagonists, as antidote strategies.
Goldberg: So who is a candidate for Addyi?
Clayton: The FDA only approved it after a huge fight—there's actually a documentary about that whole process, “The Pink Pill,” on Paramount Plus, worth watching to understand that the FDA didn't really understand sexual functioning, since the drug fell under the division of urologic, obstetric, and gynecologic products. Now the CNS group has been brought in for sexual function issues. It was recently approved for premenopausal women, who had to be studied separately, as though the mechanisms had something to do with hormones, which they don't, really. I wasn't supposed to prescribe it in postmenopausal women—of course we prescribe off-label all the time as psychiatrists, but the data were already there; there just hadn't been a formal application, and there was no reason to limit it. Similarly, they recently confirmed that vaginal estrogen doesn't cause breast cancer and doesn't become systemic—there had been a black-box warning about it that colleagues in gynecology have been fighting for 20 years. This medication is helpful in about 50% of patients, much like our other monoamine-active drugs, and for some people it's really impressive—they feel like they have their youth back, their interest is back, and their relationship is better.
Continue reading this discussion in part 2 here.
Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.
Dr Clayton is chair of psychiatry and neurobehavioral sciences and professor of clinical obstetrics and gynecology at the University of Virginia. She is also current president of the American Society for Clinical Psychopharmacology.
References
1. Johannes CB, Clayton AH, Odom DM, et al.
2. Simon JA, Derogatis L, Portman D, et al.
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