Psychiatry in sexual medicine?

[mistafab]

It seems like psychiatry is particularly poised to deal with sexual issues. Urologists and OBGYNs seem to throw hormones at everything or do surgery. PHDs/MSWs know nothing about the human body. Any experience with psychiatrists carving a niche in sex medicine?

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[birchswing]

There's a book you might like called Love Drugs: The Chemical Future of Relationships.

It's not just about sex but also medications for enhancing relationships, as well.

 

[adiradirim]

What issues would fall under sex medicine?
STDs, OCPs, erectile dysfunction, low sex drive, dyspareunia, vaginismus, hormone replacement?
How would being a psychiatrist help with that?

I suppose I could see it as a multidisciplinary subspecialty fellowship that several specialties could apply to including IM, FM, Uro, Gyn, and Psych.

 

[Stagg737]

What issues would fall under sex medicine?
STDs, OCPs, erectile dysfunction, low sex drive, dyspareunia, vaginismus, hormone replacement?
How would being a psychiatrist help with that?

I suppose I could see it as a multidisciplinary subspecialty fellowship that several specialties could apply to including IM, FM, Uro, Gyn, and Psych.

Plenty of areas of sexual dysfunction have a strongly psychological basis, so I do think one could make a niche here if they wanted to.

Anecdotally, I’ve actually placed urology consults for ED before when bupropion and viagra failed and their recommendation was psychotherapy.


@mistafab I also have an interest in the general area but have not personally met or talked to anyone who specialized in this. Most of the stuff I’ve learned has been through independent research and a few pearls from our more experienced attendings.

 

[PikminOC]

Plenty of areas of sexual dysfunction have a strongly psychological basis, so I do think one could make a niche here if they wanted to.

Anecdotally, I’ve actually placed urology consults for ED before when bupropion and viagra failed and their recommendation was psychotherapy.


@mistafab I also have an interest in the general area but have not personally met or talked to anyone who specialized in this. Most of the stuff I’ve learned has been through independent research and a few pearls from our more experienced attendings.

Share pearls pls

 

[birchswing]

(I am not a doctor.)

I can't give clinical pearls, but I can recall a few things I've learned over the years.

I once read a scientist say that SSRIs are so much more consistent in their effects on sexual function than they are mood (anxiety, depression) that they should be relabeled as sex drugs (that wasn't the exact term, but something similar) with possible side effects including changes in mood, rather than mood drugs with sexual side effects.

And indeed psychiatry is already embedded in the Haredic community with regard to sex in this way. SSRIs are given to stop masturbation and prevent adultery. This niche is already filled however with willing doctors who work with religious officials in these communities. But it certainly is a niche that exists.

MDMA and psilocybin have been studied as part of couples counseling to enhance closeness.

Lamictal is known to sometimes cause hypersexuality, which could theoretically be an off-label use for low libido.

Theoretically it seems anything glutamatergic should increase libido.

I would say from a more bird's eyes point of view, if you were an academician, the change in thinking for psychiatry might be to look at psychiatric drugs from a perspective of how they affect interpersonal relationships rather than how they affect an individual. A focus on sex alone in an individual might miss the point of what psychiatry could offer, as sex inherently involves a relationship. (To that end there is a psychiatrist at Case Western Reserve University who advocates circumcision as a means to promote marriage and reduce adultery as a societal good. I don't want to link to him as his motives are suspect and his science is, well it's published, but it's far from sound.)

 

[splik]

Yes there are psychiatrists who have a special interest in sexual disorders. It's not my main specialty area but it is very much related to some of the work I do so I maintain a special interest. There are three main area 1) sexual dysfunctions (which is probably what you are talking about) 2) LGBTQ+ mental health (which includes transgender health) and 3) paraphilias, which is often part of forensic psychiatry. Some people also specialize in sexual addictions/compulsive sexual behaviors, which can be part of 1 or 3 or can be part of addiction psychiatry.

Benjamin Sadock of Kaplan and Sadock fame is one example of a psychiatrist who specializes in sexual disorders. Richard Balon has written several books about this, as have Robert Taylor Seagreaves, Stephen Levine (now somewhat disgraced as he has sold his sold as an expert witness against transgender care) and Waguih IsHak. I know of several psychiatrists who have additional training in sex therapy.

It is definitely part of psychiatry, but like several other areas (e.g. eating disorders, sleep disorders, somatoform disorders, dissociative disorders, neuropsychiatry) are not well covered in most residency programs and most psychiatrists do not feel very comfortable with them. In the era where psychoanalytic thinking held sway, psychiatrists were much more comfortable managing psychosexual disorders and they fell firmly in the province of psychiatry.

Look up: AASECT:: American Association of Sexuality Educators, Counselors and Therapists |

ESSM for Education and Science in Sexual Medicine

The ESSM wants to increase the awareness of policy makers and inform all physicians about the causes and consequences of sexual problems.

www.essm.org

ISSM University | ISSM Professionals

The ISSM University is our official eLearning portal and is freely accessible to all our members. The ISSM University offers instant access to a wide variety of educational materials and eLearning…

professionals.issm.info

Principles and Practice of Sex Therapy
Clinical Manual of Sexual Disorders
The Textbook of Clinical Sexual Medicine

 

[calvnandhobbs68]

What issues would fall under sex medicine?
STDs, OCPs, erectile dysfunction, low sex drive, dyspareunia, vaginismus, hormone replacement?
How would being a psychiatrist help with that?

I suppose I could see it as a multidisciplinary subspecialty fellowship that several specialties could apply to including IM, FM, Uro, Gyn, and Psych.

Sexual disorders were actually thought to be part of psychiatry for a long time. It’s pretty recent that any other specialities even wanted to deal with erectile dysfunction (primarily as a result of viagra coming onto the market and being marketed so heavily). DSM has an entire section of sexual dysfunction disorders which includes erectile dysfunction.

Psychiatry Online | DSM Library

dsm.psychiatryonline.org

 

[Stagg737]

Share pearls pls

I'm sure many of the simpler ones people here are already familiar with, like Sertraline for PE or Viagra for anorgasmia. People may also be familiar with the 'pearls' I was taught as well, so idk how helpful this will be. Some things I've picked up:

- For patients with antidepressant-induced dysfunction who want to stay on the med, I've successfully used cyproheptadine once for ED by recommendation.
- That same attending also talked about occasionally utilizing Melatonin in higher doses which was helpful for some with ED.
- One of my attendings likes Nefazodone quite a bit and has said that he previously used it to alleviate symptoms in quite a few patients.
- There's a study or two that suggest Saffron may be useful for treating this, especially in women
- I never realized until residency that Bupropion may still cause significant sexual dysfunction in some people
- I'd also never heard of augmenting with Abilify for sexual dysfunction, but I've also used this successfully with a patient
- I had also found a couple case studies at one point showing that Reboxetine had actually helped patient who had ED before starting an antidepressant, though I obviously have not and won't try this

If I can think of any other ones I'll share. There's also a couple of decent powerpoint presentations floating around online that are decent starting points for various treatments. Keep in mind, some of the above have pretty limited data and most came from random discussions with attendings.

 

[d2305]

In young males ED is psych related, usually.

 

[mistafab]

As always, great information splik. My primary interest fields are primarily 1 and 3. I will definitely get started with your recommended textbooks (thankfully we have library access) to gain a broader understanding here.

Though my program does an excellent job in many areas of psychiatry, I will admit that sexual medicine, as you eluded to, has fallen by the wayside. It is unfortunate, but in the changing landscape of clinicians it makes sense that the training has also changed. I’ll gain some knowledge from this starting point and then think about where to go from there.

Your time is much appreciated.

Yes there are psychiatrists who have a special interest in sexual disorders. It's not my main specialty area but it is very much related to some of the work I do so I maintain a special interest. There are three main area 1) sexual dysfunctions (which is probably what you are talking about) 2) LGBTQ+ mental health (which includes transgender health) and 3) paraphilias, which is often part of forensic psychiatry. Some people also specialize in sexual addictions/compulsive sexual behaviors, which can be part of 1 or 3 or can be part of addiction psychiatry.

Benjamin Sadock of Kaplan and Sadock fame is one example of a psychiatrist who specializes in sexual disorders. Richard Balon has written several books about this, as have Robert Taylor Seagreaves, Stephen Levine (now somewhat disgraced as he has sold his sold as an expert witness against transgender care) and Waguih IsHak. I know of several psychiatrists who have additional training in sex therapy.

It is definitely part of psychiatry, but like several other areas (e.g. eating disorders, sleep disorders, somatoform disorders, dissociative disorders, neuropsychiatry) are not well covered in most residency programs and most psychiatrists do not feel very comfortable with them. In the era where psychoanalytic thinking held sway, psychiatrists were much more comfortable managing psychosexual disorders and they fell firmly in the province of psychiatry.

Look up: AASECT:: American Association of Sexuality Educators, Counselors and Therapists |

ESSM for Education and Science in Sexual Medicine

The ESSM wants to increase the awareness of policy makers and inform all physicians about the causes and consequences of sexual problems.

www.essm.org

ISSM University | ISSM Professionals

The ISSM University is our official eLearning portal and is freely accessible to all our members. The ISSM University offers instant access to a wide variety of educational materials and eLearning…

professionals.issm.info

Principles and Practice of Sex Therapy
Clinical Manual of Sexual Disorders
The Textbook of Clinical Sexual Medicine

 

[mistafab]

Hey stagg,

Great info here. The vast majority of these pearls I have never heard about or seen before. I remember a particular patient who’s primary driver for medication noncompliance that kept putting him back in the hospital was his loss of sex drive.

My attending and I wrote it off, but looking back on it now I feel we did this patient a disservice by not addressing or at least exploring their primary concern. It is rare that patients ever tell you why they stop taking medication, we should have taken it seriously. The patient has not returned to the hospital though, and this was early intern year. I hope that means that they got better.

 

[calvnandhobbs68]

Hey stagg,

Great info here. The vast majority of these pearls I have never heard about or seen before. I remember a particular patient who’s primary driver for medication noncompliance that kept putting him back in the hospital was his loss of sex drive.

My attending and I wrote it off, but looking back on it now I feel we did this patient a disservice by not addressing or at least exploring their primary concern. It is rare that patients ever tell you why they stop taking medication, we should have taken it seriously. The patient has not returned to the hospital though, and this was early intern year. I hope that means that they got better.

Yeah this is definitely something to ask in particular about to all patients who are taking SSRIs/SNRIs and especially patients who aren't compliant with SSRIs/SNRIs. For many many people, the sexual side effects in particular are the reason for noncompliance and there are a variety of different things we can do to help out with that. Lots of people are embarrassed to bring it up or will make up some other side effect, so asking about it specifically is key. At the very least, they feel like you actually give a crap about the problems they're having with the medication.

 

[Stagg737]

Yeah this is definitely something to ask in particular about to all patients who are taking SSRIs/SNRIs and especially patients who aren't compliant with SSRIs/SNRIs. For many many people, the sexual side effects in particular are the reason for noncompliance and there are a variety of different things we can do to help out with that. Lots of people are embarrassed to bring it up or will make up some other side effect, so asking about it specifically is key. At the very least, they feel like you actually give a crap about the problems they're having with the medication.

100% this. @mistafab, any time I start a patient on an SSRI or SNRI I tell them that about 1/4 to 1/3 of patients experience some form of sexual side effect to normalize it a bit. I say that most of the time they're mild, but if it is bothering them or causing problems to please let me know because there are so many ways it can be addressed. I also reassure them that it will go away after the med is discontinued, to discourage them from stopping the med d/t fear that the sexual dysfunction may be permanent. I've been surprised how many patients stopped their meds because they were afraid of this.

It's one of the few times I give an actual stat to patients as I think it helps alleviate concerns or embarrassment they may feel if experiencing it. Anecdotally, I've had a significant number of patients open up to me about SD with past meds after discussing how common it is and I like to think that most of my patients who are concerned about it bring it up with me. I've also been surprised by how many patients brought it up or stopped taking the med because their SO was distressed. So it's an educational point worth mentioning to SO's if they're involved with the appointments at all.

 

[Merovinge]

In young males ED is psych related, usually.

It is, but this type of psychogenic ED can still often be treated pharmacologically with Viagra and the ilk. Not to say I wouldn't highly recommend a sexual med informed therapist as well but these people can and do get treatment in this domain from PCPs or Urologists regularly. No reason a psychiatrist couldn't do this type of work but it's far from a unique niche. I happen to have had some good training in this area and feel comfortable Rxing low dosages of Viagra, currently 1/1 in treating SSRI induced ED with it this year (I'm CAP but see some transitional age patients so very low sample size in my practice).

 

[clausewitz2]

Yeah this is definitely something to ask in particular about to all patients who are taking SSRIs/SNRIs and especially patients who aren't compliant with SSRIs/SNRIs. For many many people, the sexual side effects in particular are the reason for noncompliance and there are a variety of different things we can do to help out with that. Lots of people are embarrassed to bring it up or will make up some other side effect, so asking about it specifically is key. At the very least, they feel like you actually give a crap about the problems they're having with the medication.

Agreed. I ask everyone on those medications about sexual side effects and if they do endorse them, we definitely talk about the treatment options and they get regular Arizona Sexual Experience Scales at whatever interval I repeat other scales/questionnaires.

 

[splik]

100% this. @mistafab, any time I start a patient on an SSRI or SNRI I tell them that about 1/4 to 1/3 of patients experience some form of sexual side effect to normalize it a bit.

closer to 70%+