Human Sexuality: An Intimate Connection of Psyche and Soma – Neglected Area of Psychosomatics?
Authors: Richard Balon
Journal: Psychotherapy and Psychosomatics (2009)

This editorial review of the latest pertinent literature presents an argument that the area of human sexuality is also an important part of psychosomatic medicine. In his classic article Lipowski [1] defined 'psychosomatic' as a term 'referring or related to the inseparability and interdependence of psychosocial and biologic (physiologic, somatic) aspects of human kind'. He [1] also defined 'psychosomatic medicine' (psychosomatics) as a discipline 'concerned with (a) the study of the correlations of psychologic and social phenomena with physiologic functions, normal or pathologic, and of the interplay of biologic and psychosocial factors in the development, course, and outcome of diseases; and (b) advocacy of a holistic (or biopsychosocial) approach to patient care and application of methods derived from behavioral sciences to the prevention and treatment of human morbidity'.One would, maybe mistakenly, assume that study of one of the basic drives, sex, and its impairment, dysfunction(s) and management would be a prime target of psychosomatic medicine. Sexual dysfunction, with its complex regulation, involving the central nervous system, peripheral nervous system, various hormones, as well as psychological factors including relationship, the stage of a person's development and life circumstances, seems to be a prime example of the interdependence of psychosocial and biologic/physiologic factors. The impact of mental [2] and physical illness [3] on sexual functioning is becoming well known.Zemishlany and Weizman [2] pointed out that the rates of various sexual dysfunctions are fairly high in patients suffering from schizophrenia, depression, various anxiety disorders (e.g. social phobia, posttraumatic stress disorder), eating disorders and some personality disorders. A recent study by Corona et al. [4] demonstrated an association of erectile dysfunction and a wide array of psychiatric symptoms, such as depression, phobic anxiety and somatization. Subjects with somatization symptoms actually showed the worst erectile functioning. While the nature of this trial did not allow determining any causal relationship, the results suggest that patients with erectile dysfunction may suffer from various, even sublinical, symptoms and distresses that may exacerbate sexual functioning. The association of obstructive sleep apnea with erectile dysfunction remains unresolved. However, another recent study of a fairly large sample of snoring men provided evidence of a link between snoring severity and reduced sexual satisfaction in elderly males [5].The association of somatic illness and sexual dysfunction and rates of sexual dysfunction(s) in various physical illnesses have been investigated much more extensively than the connection between sexual dysfunction and mental disorders. Clayton and Ramamurthy [3] summarized the numerous physical illnesses and trauma that impact sexual functioning. The association between cardiovascular diseases and sexual functioning, namely erectile dysfunction, has probably received most attention. For instance, the results of a study by Chew et al. [6] support the 'postulated intimate nexus between cardiovascular disease and erectile dysfunction'. The authors [6] point out that erectile dysfunction has evolved 'from being regarded as a trivial and presumably psychologic impediment with varying nuisance values to its current eminence as a marker and predictor of cardiovascular disease'. Erectile dysfunction and cardiovascular disease are associated with similar risk factors, for instance smoking and pure hypertriglyceridemia [7] or other dyslipidemias [8]. These factors may be modifiable by medications (statins) or lifestyle changes (diet, exercise) or a combination of both.The studies of interaction between sexual dysfunction and physical illnesses have not been limited only to cardiovascular disease, males and erectile disorder. A recent trial from Turkey [9] reported that sexual dysfunction and accompanying depression were more common in patients with neurodermatitis or psoriasis than in a control group and that patients with neurodermatitis had more sexual problems than those with psoriasis. The results of a study from Nigeria [10] demonstrated that diabetes mellitus impaired all domains of sexual functioning in Nigerian women. In an analysis by Kettas et al. [11], women with end-stage renal disease had a higher risk of sexual dysfunction than healthy women. The association of sexual dysfunction with various surgical procedures, namely radical prostatectomy or even intestinal ostomy [12], is also well known. Interestingly, urologists tend to underestimate the patients' distress and desire for early treatment of sexual dysfunction after radical prostatectomy [13]. The area of recovery of sexual function after radical prostatectomy has been rapidly developing and the role of psychiatrists and other mental health professionals in this process may be very important. For instance, a multidisciplinary group of researchers [14] found that group-based cognitive-behavioral stress management was effective in improving sexual function after radical prostatectomy. Interestingly, individuals with higher levels of interpersonal sensitivity were more likely to perceive sexual dysfunction as a threat to their masculine identity. Thus in addition to phosphodiesterase-5 inhibitors, various psychological interventions may be useful, either alone, or in combination with phosphodiesterase-5 inhibitors, in rehabilitation after this invasive surgery. These few examples illustrate the complicated and multiple associations between sexual dysfunctions and numerous physical illnesses, as well as the possible role of psychiatrists, psychologists and sex therapists in the rehabilitation of sexual dysfunction due to physical illness.The complex interplay of drugs of abuse and sexual functioning is also becoming more evident. Palha and Esteves [15] discussed the growing literature on association of sexual dysfunction with the use of tobacco, opioids, cocaine (2 opposite effects) and other substances of abuse but also the perceived beneficial effects on sexual functioning of substances such as cannabis and ecstasy. The relationship between substances of abuse and sexual functioning seems very complex. For instance, men on methadone maintenance treatment but not on buprenorphine maintenance treatment had a higher prevalence of erectile dysfunction related to hypogonadism and depression in a small Australian study [16]. An interesting suggestion in regards to sexual dysfunction and substance abuse came out of a small trial by La Pera et al. [17]. They found that users of illicit drugs reported a high prevalence of sexual disorders prior to 'first drug use'. The authors suggest that their data highlight a possible new strategy in the primary prevention of substance abuse – sexual education and early treatment of sexual disorders/dysfunctions in some adolescents. Psychotropic (antidepressants, antipsychotics, mood stabilizers [18]) and other medications (antihypertensives, hormones and others [19]) may impair sexual functioning. However, they have also been used in the treatment of sexual dysfunctions [19], e.g. premature ejaculation. It seems that an entire new field of sexual pharmacology may be developing.Last but not least, the negative impact of sexual dysfunction (e.g. male erectile dysfunction [20]) on relationships, marital satisfaction and overall well-being is well known.Thus it seems that the evidence for designating the study of human sexuality and its impairments as a target of psychosomatic medicine is there. Human sexuality truly represents an intimate connection of psyche and soma. Yet, the psychosomatic medicine literature is almost devoid of publications addressing human sexuality and sexual dysfunction. Psychotherapy and Psychosomatics rarely publishes articles on human sexuality or sexual dysfunction – there were just 2 reports on issues related to human sexuality during the past 2 years [21, 22]. In all fairness, the journal would probably publish solid articles addressing this area, if there were any submitted. Also, the lack of attention to human sexuality is not unique to the area of psychosomatics but applies to the entire psychiatry. Sadly, this is all happening at the time of increased interest in human sexuality by other disciplines, such as urology, obstetrics and gynecology and basic sciences. New research strategies (e.g. see progress in imaging methods used in sex research [23]) and new medications for sexual dysfunctions are being developed [24,25,26,27], and we even see attempts to define new diagnostic entities [28].Why is this happening, why the lack of interest? As Levine [29] noted: 'For most of the 20th century, sexuality was seen as a vital component of personality health, mental health and mental distress. During the past 25 years, the extent of sexual problems has been even better defined, and their negative consequences have been better appreciated. Mental health professionals' interest in these matters has been thwarted by new biological paradigms for understanding the causes and treatment of mental conditions, the emphasis on short-term psychotherapy, the constriction of insurance support for nonpharmacological interventions, the political conservatism of government funding sources, and the policy to consider sexual problems inconsequential.' Pfaus [30] also suggested that 'all too often our questions [about sexual functioning] are obscured by scientific status quo, constrained by research review committees, and have ethical limitations imposed by institutional review boards or government agencies pressured to enforce ''community standards'' or that are downright hostile to the concept of ''lifestyle'' improvement where sexuality is concerned.' Finally, our progress may have been hindered by the problematic diagnostic criteria of sexual dysfunction [31]. As I [31] pointed out, the revision of sexual dysfunction diagnostic criteria needs to address various issues such as the duration, intensity, frequency, associated distress and validity of some diagnostic entities and a discussion of 'normalcy' of sexual functioning.We may disagree with some of the points made by Levine [29], Pfaus [30], and Balon [31], but most would agree that they are right at least in some respects. Nevertheless, these obstacles should not stop or slow us in our quest for better understanding of sexual functioning and management of sexual dysfunction(s), as none of them is insurmountable. In addition, as Pfaus [30] and many others have observed, we have made real progress in the past decade in our understanding of human sexuality, in spite of all these roadblocks. Psychosomatics and psychiatry should return to their roots and deal with all basic drives, dysfunctions and disorders, including sexual functioning and dysfunctions. Otherwise, other disciplines will gradually take over. That, in addition to the unspoken guild interest issues, may not be in the best interest of our patients. I believe that psychiatry and psychosomatic medicine are still best qualified to address the inseparable and interdependent psychosocial and biological aspects of human kind discussed by Lipowski [1] – even in the area of human sexuality.