Pharmacosexology: the effects of drugs on sexual function a review

Update on cannabis in human sexuality

RATIONALE

Sexuality is a central aspect of being human that encompasses many facets. Cannabis, a widely used psychoactive substance, has been associated with various effects on sexuality. The relationship between cannabis and sexuality is complex and multifaceted, involving physiological, psychological, and social factors.

OBJECTIVES

This review aims to provide an overview of the current literature on the effects of cannabis on several sexual functions, including sexual desire, arousal, orgasm, and sexual satisfaction. It also discusses the potential mechanisms underlying these effects, as well as the impact of dose and frequency of use.

RESULTS

This review has revealed a complex relationship between cannabis dosage and its influence on sexuality. It appears that the frequency of cannabis use in humans has been associated with the frequency of sexual activities. Individuals who use cannabis more frequently tend to report higher levels of sexual activity. Moreover, there is a notable gender difference in how cannabis affects sexuality. In addition, we found lower doses of cannabis to be linked to heightened sexual desire and enjoyment, whereas higher doses may lead to a decrease in sexual desire and performance.

CONCLUSIONS

Overall, the association between cannabis and sexuality is complex and warrants further research to better understand the psychological and neurological mechanisms that underlie the effect of cannabis on these sexuality functions and its implications for sexual health. To advance in this endeavor, a crucial step is establishing a precise measurement of dosage in human studies.

Psychosexual dysfunction in male patients with cannabis dependence and synthetic cannabinoid dependence

OBJECTIVE

There are contradicting reports regarding the relationship between cannabis use and male sexual functions with almost no data about synthetic cannabinoids (SC) and its effect on male sexual functions. This study investigates psychological concerns related to male sexual functions among cannabis and SC users. The research aims to assess different sexual functions and aspects of sexual psychopathology in cannabis and SCs dependent men compared to controls.

METHOD

Thirty male patients with cannabis dependence, thirty male patients with SCs dependence and thirty matched controls from the outpatient clinic of Kasr Al Ainy hospital, Egypt, were assessed using Structured Clinical Interview for DSM-IV TR Axis I Disorders (SCID-I), International Index of Erectile Function (IIEF), and Sexuality scale.

RESULTS

The means of IIEF questionnaire in the cannabis and SC group were significant lower than the means of the control group (P < .001) except the orgasmic function in cannabis group (P = .052). In the SCs group, sexual depression was higher and preoccupation lower than the cannabis (P < .020; P < .003, respectively) and control groups (P < .001; P < .001, respectively). The duration and dose of intake of cannabis and SCs correlated significant with sexual esteem, sexual preoccupation and all domains of IIEF.

CONCLUSION

Cannabis and SC dependence were associated with lower erectile function, sexual desire, intercourse satisfaction and overall satisfaction, and lower orgasmic functions in the SC group than controls. Both groups showed higher sexual depression, lower sexual esteem and sexual preoccupation than controls. SC has a higher negative impact on male sexual functions and psychopathology than cannabis.

Reciprocal effects of single or repeated exposure to methylphenidate or sex in adult male rats

RATIONALE

Exposure to rewards can alter behavioral reactivity to them. For example, stimulants sensitize locomotor activation, whereas sexual experience sensitizes copulatory behaviors. Moreover, rewards can cross-sensitize one another. Although stimulants are known to cross-sensitize locomotor effects, the evidence for cross-sensitization between stimulants and sex is less clear.

OBJECTIVES

This study determined the effects of single and repeated pre-exposure to methylphenidate (MPH) or sex on one another in adult male rats.

METHODS

Cross-sensitization between MPH (5 mg/kg) and sex (30 min with sexually experienced female) was examined. Adult male rats were pre-exposed to 0, 1, or 10 trials of either sex or MPH before being exposed to the other reward. Locomotor chambers were used in MPH trials. Bilevel chambers were used in sexual trials, and sexual behaviors were video scored.

RESULTS

The amount of prior sexual experience differentially influenced the ceiling of MPH-dependent sensitization; in the last drug trial, locomotion was highest in males given 1 previous sexual trial compared with 0 or 10. Compared with MPH-naive males, pre-exposure to MPH (1 and 10 trials) reduced the number of ejaculations without impacting sexual performance (intromission/mount latency and frequency).

CONCLUSIONS

These findings indicate that the degree of pre-exposure to a reward can differentially affect reactivity to novel rewards. The results showed that previous findings of cross-sensitization between amphetamine and sex do not extend to MPH. However, exposure to MPH prior to sexual experience can increase the amount of sexual stimulation needed to achieve ejaculation.

Discrimination and sexual risk among Caribbean Latinx young adults

Objectives: Discrimination, such as being treated unfairly due to race, contributes to stress. Individuals may cope with this by engaging in risky behaviors. Consistent with this premise, prior studies found that discrimination is associated with substance use. Research has also shown that sex while 'high' on alcohol and drugs is associated with increased risk for HIV and other STIs. The present study examines the relationship between discrimination and sexual risk. We investigate whether discrimination is associated with sex while high on alcohol and drugs. Design: Analyses focus on a sample of 356 Caribbean Diasporic young adults, primarily Caribbean Latinx, aged 18 to 25 who participated in the Drug Use and HIV Risk among Youth Survey carried out from 1997 to 2000 in Brooklyn, New York. Logistic regression examined the association between self-reported discrimination and sex while high. Results: More than half (52.3%) of respondents reported moderate discrimination. Sex while high was also reported: 35.7% for alcohol, 43.3% for marijuana, and 32.6% for heroin/cocaine. Discrimination was associated with increased risk of sex while high on (1) marijuana and (2) heroin/cocaine, but was not with alcohol. Conclusions: Discrimination may be a risk factor for engaging in sex while high on drugs, which may put individuals at risk for HIV as well as other STIs. Future research should explore relationships between discrimination and sex while high on alcohol and drugs among various racial/ethnic groups and Diasporas, while also assessing how this relationship may contribute to HIV incidence.

Sexual Dysfunction in Persons With Substance Use Disorders

Sexual dysfunction is commonly associated with the use of substances, in both men and women. This area requires prominent attention, particularly as the use of substances is often with the expectancy of improving an underlying sexual dysfunction or with a positive expectancy of enhancing sexual function.

The chronic use of substances has a negative impact on sexual function and causes various kinds of sexual dysfunction in both men and women. In this narrative review, we look at the effect of various substances of abuse on sexual functioning and discuss management strategies in such situations.

Assessment of penile erection methods in rhesus macaques to model pharmacokinetics of antiretroviral drugs and penile infection with simian immunodeficiency virus

BACKGROUND

An established macaque model to assess HIV interventions against penile transmission is currently not available. Physiological changes during penile erections may affect susceptibility to infection and drug pharmacokinetics (PK). Here, we identify methods to establish erections in macaques to evaluate penile transmission, PK, and efficacy under physiologic conditions.

METHODS

Penile rigidity and length were evaluated in eight rhesus macaques following rectal electrostimulation (RES), vibratory stimulation (VS), or pharmacological treatment with Sildenafil Citrate (Viagra) or Alprostadil.

RESULTS

Rectal electrostimulation treatment increased penile rigidity (>82%) and length (2.5 ± 0.58 cm), albeit the response was transient. In contrast, VS alone or coupled with Viagra or Alprostadil failed to elicit an erection response.

CONCLUSION

Rectal electrostimulation treatment elicits transient but consistent penile erections in macaques. High rigidity following RES treatment demonstrates increased blood flow and may provide a functional model for penile PK evaluations and possibly simian immunodeficiency virus (SIV) transmission under erect conditions.

Sexual dysfunctions among young men: prevalence and associated factors

PURPOSE

The purposes of this study are to measure the prevalence of premature ejaculation (PE) and erectile dysfunction (ED) among a population of Swiss young men and to assess which factors are associated with these sexual dysfunctions in this age-group.

METHODS

For each condition (PE and ED), we performed separate analyses comparing young men suffering from the condition with those who were not. Groups were compared for substance use (tobacco, alcohol, cannabis, other illegal drugs, and medication without a prescription), self-reported body mass index, sexual orientation, physical activity, professional activity, sexual experience (sexual life length and age at first intercourse), depression status, mental health, and physical health in a bivariate analysis. We then used a log-linear analysis to consider all significant variables simultaneously.

RESULTS

Prevalence rates for PE and ED were 11% and 30%, respectively. Poor mental health was the only variable to have a direct association with both conditions after controlling for potential confounders. In addition, PE was directly associated with tobacco, illegal drugs, professional activity, and physical activity, whereas ED was directly linked with medication without a prescription, length of sexual life, and physical health.

CONCLUSIONS

In Switzerland, one-third of young men suffer from at least one sexual dysfunction. Multiple health-compromising factors are associated with these dysfunctions. These should act as red flags for health professionals to encourage them to take any opportunity to talk about sexuality with their young male patients.

A Qualitative Descriptive Study of Perceived Sexual Effects of Club Drug Use in Gay and Bisexual Men

Club drug use is often associated with unsafe sexual practices and use remains prevalent among gay and bisexual men. Although epidemiological studies commonly report the risk of engaging in unsafe sex due to the effects of particular club drugs, there remain gaps in the literature regarding the specific sexual effects of such substances and the context for their use in this population. We examined secondary data derived from interviews with 198 club drug using gay and bisexual males in New York City and qualitatively describe subjective sexual effects of five drugs: ecstasy, GHB, ketamine, powder cocaine and methamphetamine. Differences and commonalities across the five drugs were examined. Results suggest that each drug tends to provide: 1) unique sexual effects, 2) its own form of disinhibition, and 3) atypical sexual choices, often described as "lower sexual standards." Differences across drugs emerged with regard to social, sensual and sexual enhancement, sexual interest, and impotence. Although some common perceived sexual effects exist across drugs, the wide variation in these effects suggests different levels of risk and may further suggest varying motivations for using each substance. This study seeks to educate public health officials regarding the sexual effects of club drug use in this population.

Mixing pleasures: review of the effects of drugs on sex behavior in humans and animal models

Drugs of abuse act on the brain circuits mediating motivation and reward associated with natural behaviors. There is ample evidence that drugs of abuse impact male and female sexual behavior. First, the current review discusses the effect of drugs of abuse on sexual motivation and performance in male and female humans. In particular, we discuss the effects of commonly abused drugs including psychostimulants, opiates, marijuana/THC, and alcohol. In general, drug use affects sexual motivation, arousal, and performance and is commonly associated with increased sexual risk behaviors. Second, studies on effects of systemic administration of drugs of abuse on sexual behavior in animals are reviewed. These studies analyze the effects on sexual performance and motivation but do not investigate the effects of drugs on risk-taking behavior, creating a disconnect between human and animal studies. For this reason, we discuss two studies that focus on the effects of alcohol and methamphetamine on inhibition of maladaptive sex-seeking behaviors in rodents. Third, this review discusses potential brain areas where drugs of abuse may be exerting their effect on sexual behavior with a focus on the mesolimbic system as the site of action. Finally, we discuss recent studies that have brought to light that sexual experience in turn can affect drug responsiveness, including a sensitized locomotor response to amphetamine in female and male rodents as well as enhanced drug reward in male rats.

Social context and perceived effects of drugs on sexual behavior among individuals who use both heroin and cocaine

Researchers have identified the association between the use of cocaine and sexual behavior as an important risk factor for HIV infection and have attempted to elucidate the nature of this association. Several lines of research have suggested that facilitation of sexual behavior during intoxication with cocaine may be because of the direct pharmacological effects of the drug (e.g., increase in sexual desire), whereas others have pointed to the importance of factors related to the context of drug use (e.g., opportunities for sexual behavior, expectations about the effects of the drug, social norms). The present study explored the perceived effects of cocaine and heroin on sexual behavior, as well as the social context of drug use as a function of drug type (cocaine vs. heroin), among 46 inner-city drug users who reported a history of regular use of both crack cocaine and heroin. Results indicated that compared to heroin, cocaine had deleterious effects on participants' perceived sexual desire and performance. Despite such deleterious effects on sexual behavior, cocaine was more frequently used with an intimate partner than heroin. Furthermore, participants did not differ in the extent to which they used the two drugs in other social contexts (e.g., with friends, family, or neighbors). These preliminary results suggest that the relationship between cocaine and sexual behavior, especially among long-term cocaine users, may be facilitated by opportunities for sex that exist in the context of cocaine use, rather than by the pharmacological effects of the drug.

Smoking and illicit drug use associations with early versus delayed reproduction: findings in a young adult cohort of Australian twins

OBJECTIVE

This article examines relationships between reproductive onset and lifetime history of smoking, regular smoking, and nicotine dependence, and cannabis and other illicit drug use.

METHOD

Data were drawn from a young adult cohort of 3,386 female and 2,751 male Australian twins born between 1964 and 1971. Survival analyses were conducted using Cox proportional hazards regression models predicting age at first childbirth from history of substance use or disorder separately by substance class. Other substance use or disorder, including alcohol dependence, as well as sociodemographic characteristics, history of psychopathology, and family and childhood risks, were included as control variables in adjusted models.

RESULTS

Regular smoking and nicotine dependence were associated with earlier reproduction, with pronounced effects for women. For women, use of cannabis was associated with early reproduction before age 20, and with delayed reproduction among women who have not reproduced by age 20 or 25. Adjustment for control variables only partially explained these associations.

CONCLUSIONS

Consistent with research linking adolescent use with sexual risk taking predictive of early childbearing, regular smokers and nicotine-dependent individuals show earlier reproductive onset. In contrast, delays in childbearing associated with use of cannabis are consistent with impairments in reproductive ability and/or opportunities for reproduction. Continued research on risks both upstream and downstream of substance-use initiation and onset of substance-use disorder is needed for causal mechanisms to be fully understood.

Cannabis use and sexual health

INTRODUCTION

Cannabis is the most commonly used illicit substance worldwide. Despite this, its impact on sexual health is largely unknown.

AIM

The aim of this article is to examine the association between cannabis use and a range of sexual health outcomes.

MAIN OUTCOME MEASURES

The main outcome measures include the number of sexual partners in the past year, condom use at most recent vaginal or anal intercourse, diagnosis with a sexually transmissible infection in the previous year, and the occurrence of sexual problems.

METHODS

Method used in this article includes a computer-assisted telephone survey of 8,656 Australians aged 16-64 years resident in Australian households with a fixed telephone line.

RESULTS

Of the 8,650 who answered the questions about cannabis use, 754 (8.7%) reported cannabis use in the previous year with 126 (1.5%) reporting daily use, 126 reported (1.5%) weekly use, and 502 (5.8%) reported use less often than weekly. After adjusting for demographic factors, daily cannabis use compared with no use was associated with an increased likelihood of reporting two or more sexual partners in the previous year in both men (adjusted odds ratio 2.08, 95% confidence interval 1.11-3.89; P = 0.02) and women (2.58, 1.08-6.18; P = 0.03). Daily cannabis use was associated with reporting a diagnosis of a sexually transmissible infection in women but not men (7.19, 1.28-40.31; P = 0.02 and 1.45, 0.17-12.42; P = 0.74, respectively). Frequency of cannabis use was unrelated to sexual problems in women but daily use vs. no use was associated with increased reporting among men of an inability to reach orgasm (3.94, 1.71-9.07; P < 0.01), reaching orgasm too quickly (2.68, 1.41-5.08; P < 0.01), and too slowly (2.05, 1.02-4.12; P = 0.04).

CONCLUSIONS

Frequent cannabis use is associated with higher numbers of sexual partners for both men and women, and difficulties in men's ability to orgasm as desired.

ORIGINAL RESEARCH–MEN'S SEXUAL HEALTH: Sexual Dysfunction Prior to First Drug Use Among Former Drug Addicts and Its Possible Causal Meaning on Drug Addiction: Preliminary Results

INTRODUCTION

Adolescence is one of the periods in which the risk of initial use of drugs is high. Among the reasons leading to first drug use (FDU), sexual disorders have so far been poorly investigated.

AIM

To evaluate the prevalence of premature ejaculation, erectile dysfunction, and low sexual desire in former drug addicts in the period prior to FDU; whether or not the former drug addicts claimed that sexual dysfunctions influenced their decision to start illicit drug taking, and whether or not the subjects had sought and used drugs aiming to improve sexual drive.

METHODS

Eighty-six male former drug addicts (18-35 years old) were investigated using a questionnaire.

MAIN OUTCOME MEASURES

Fisher and Armitage tests.

RESULTS

Before FDU, 61 (71%) subjects reported having one or more sexual dysfunctions. Only 25 (29%) had no sexual dysfunction prior to FDU. Among those with normal sexual function, only three (3.49%) stated that sexual dysfunctions had influenced their decision, whereas in the sexual dysfunction group, 27 (31.4%) confirmed this experience. This difference is statistically significant, Fisher test, P = 0.0033. The more severe the sexual dysfunction, the higher the percentage of those who stated that sexual dysfunction influenced their decision to start taking drugs. This trend is statistically significant, P < 0.0025. About 50% of the entire sample admitted they had used drugs to improve sexual performance.

CONCLUSIONS

Users of illicit drugs report a high prevalence of sexual disorders prior to FDU. A large percentage claimed that sexual dysfunction influenced their decision to start taking drugs. The higher the severity of the sexual disorders, the higher the percentage of those claiming that sexual dysfunction had influenced their decision. In our opinion, these data highlight a possible new strategy in the primary prevention of substance abuse in which sexual education and early treatment of sexual disorders, among adolescents, may prevent them from FDU.

A comparative study of HIV/AIDS: the knowledge, attitudes, and risk behaviors of schizophrenic and diabetic patients in regard to HIV/AIDS in Nigeria

Context

Studies on knowledge and risk behaviors related to HIV/AIDS reported from developed countries have shown that people with psychiatric disorders constitute a special risk group. In Nigeria, although similar studies have been conducted on various population groups, there has, so far, been no reported study on people suffering from psychiatric disorders.

Objective

The present study set out to compare knowledge, attitudes, and risk behaviors related to HIV/AIDS among schizophrenic patients and diabetic patients.

Methods

Ninety-eight consecutive schizophrenic patients attending the outpatient clinics of a psychiatric hospital over a period of 8 weeks completed an interviewer's administered questionnaire. The interview covered demographics, risk behaviors, knowledge related to HIV/AIDS, and patients' attitudes toward people infected with HIV/AIDS. Their responses were compared with those of 56 diabetic patients who were similarly interviewed in a teaching hospital.

Results

Compared with the diabetic patients, the schizophrenic patients were significantly less sexually active in the previous 12 months (P < .05). They had more misconceptions about HIV/AIDS and were less tolerant towards people living with HIV/AIDS compared with the diabetic patients. They were also more likely to engage in high-risk behaviors.

Conclusion

Mental health providers rarely educate psychiatric patients about HIV/AIDS and should be more involved in doing so. Despite being less sexually active, patients with schizophrenia engaged in risk behaviors as did the diabetic patients.

Management of the cardinal features of andropause

There are several problems facing aging men, especially sexual dysfunction, hypogonadism, and psychologic changes. This constellation of changes is sometimes referred to as "manopause" or "andropause." Unlike the dramatic changes in the hormonal milieu occurring during menopause in women, the age-related changes in reproductive hormones of men are subtle and occur gradually throughout the years of mature life. It has been estimated that circulating testosterone (T) declines longitudinally from age 19 at an average rate of 1% per year. The free or dialyzable fraction of serum T and the bioavailable (the sum of free fraction and loosely bound to albumin fraction) T decline more rapidly with age. Although the essential role of androgens in reproductive tissue development and emergence of secondary sex characteristics is well known, their role in adult sexual function seems to be primarily facultative. The effect of T on the central nervous system extends beyond sexual behavior. T has been shown to alter mood, memory, ability to concentrate, and the overall sense of vigor and well being that may interact with a host of other psychologic changes associated with aging. Disordered erectile function is not generally an endocrine problem but rather vascular, neurologic, and psychogenic in origin. It also may be the first sign of systemic vascular disease. The clinical management of andropause requires an individualized approach. In some men, the main problem may be psychologic, whereas in others, hypogonadism may play an important role. Many with erectile failure, suffer silently regardless of its etiology. In this review, we suggest some practical guidelines for the management of these conditions.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Ejaculatory disorders: epidemiology and current approaches to definition, classification and subtyping

Ejaculatory disorders (disorders of emission, ejaculation and orgasm) are the most frequent sexual complaint. Conventional algorithms on ejaculatory disorders are based on an organic or psychogenic dichotomy, with the latter being traditionally considered the main etiological cause. The scope of this review is to propose a new classification of ejaculatory disorders, with special emphasis on epidemiology and subtyping of the most frequent: premature ejaculation (PE). There is growing agreement on definition, diagnosis, and treatment options. In many cases, ejaculatory disorders can be classified by psycho-neuro-uro-endocrine symptoms. Epidemiological data, new classifications and subtyping, together with new diagnostic procedures and the availability of pharmacological aids, place this topic in the mainframe of sexual medicine. This will soon demolish the barriers to seeking help perceived by patients suffering ejaculatory disorders.

Structural Effects and Neurofunctional Sequelae of Developmental Exposure to Psychotherapeutic Drugs: Experimental and Clinical Aspects

The advent of psychotherapeutic drugs has enabled management of mental illness and other neurological problems such as epilepsy in the general population, without requiring hospitalization. The success of these drugs in controlling symptoms has led to their widespread use in the vulnerable population of pregnant women as well, where the potential embryotoxicity of the drugs has to be weighed against the potential problems of the maternal neurological state. This review focuses on the developmental toxicity and neurotoxicity of five broad categories of widely available psychotherapeutic drugs: the neuroleptics, the antiepileptics, the antidepressants, the anxiolytics and mood stabilizers, and a newly emerging class of nonprescription drugs, the herbal remedies. A brief review of nervous system development during gestation and following parturition in mammals is provided, with a description of the development of neurochemical pathways that may be involved in the action of the psychotherapeutic agents. A thorough discussion of animal research and human clinical studies is used to determine the risk associated with the use of each drug category. The potential risks to the fetus, as demonstrated in well described neurotoxicity studies in animals, are contrasted with the often negative findings in the still limited human studies. The potential risk fo the human fetus in the continued use of these chemicals without more adequate research is also addressed. The direction of future research using psychotherapeutic drugs should more closely parallel the methodology developed in the animal laboratories, especially since these models have already been used extremely successfully in specific instances in the investigation of neurotoxic agents.

Effects of medical therapy, alcohol, smoking, and endocrine disruptors on male infertility

Infertility affects up to 15% of the sexually active population, and in 50% of cases, a male factor is involved, either as a primary problem or in combination with a problem in the female partner. Because many commonly encountered drugs and medications can have a detrimental effect on male fertility, the medical evaluation should include a discussion regarding the use of recreational and illicit drugs, medications, and other substances that may impair fertility. With the knowledge of which drugs and medications may be detrimental to fertility, it may be possible to modify medication regimens or convince a patient to modify habits to decrease adverse effects on fertility and improve the chances of achieving a successful pregnancy. Concern is growing that male sexual development and reproduction have changed for the worse over the past 30 to 50 years. Although some reports find no changes, others suggest that sperm counts appear to be decreasing and that the incidence of developmental abnormalities such as hypospadias and cryptorchidism appears to be increasing, as is the incidence of testicular cancer. These concerns center around the possibility that our environment is contaminated with chemicals - both natural and synthetic - that can interact with the endocrine system.

The relationship between drug abuse and sexual performance among women on methadone

PURPOSE

Through in-depth interviews with 38 women recruited from methadone maintenance treatment programs (MMTPs), this paper examines subjective experiences regarding the effects of illicit drugs on the women's sexual behavior and that of their male sexual partners, mainly changes in libido, performance, and pleasure.

METHODS

This paper addresses several questions: (1) How does drug use affect women's sexual performance? (2) How does drug use affect their partners' sexual performance and the sexual dynamics in their relationship? (3) How does drug use affect these women and their partners differently? (4) How are sexual disparities between women and their partners, heightened by drug use, linked with sexual and physical violence and risk of HIV?

RESULTS

Three major themes are discussed: some women believe that drugs, particularly heroin, increase their sexual performance, libido, and pleasure, but for others, drugs, particularly crack cocaine, inhibit their sexual performance and desire. Many of the women believe that crack cocaine and heroin enhance a man's sexual desire, performance, and pleasure. However, other women deem that these drugs are responsible for their partners' abusive and coercive behavior. The data further indicate that gender disparities, in how crack cocaine and heroin affect the sexual dynamics between drug-involved couples, often lead to sexual coercion and physical abuse.

CONCLUSION

This in-depth narrative study of abused women in MMTPs draws implications from their subjective experiences for understanding the contextual mechanisms linking drug use, intimate sexual abuse, and HIV risk. It also suggests implications for designing HIV prevention programs that take into account the differential effects of drugs on sexual intimate violence and HIV risk. Education about the effects of drugs on sexuality and on the risks of sexual violence and HIV transmission is crucial for drug-involved women.

Disorders of ejaculation

The physiology of ejaculation includes emission of sperm with the accessory gland fluid into the urethra, simultaneous closure of the urethral sphincters, and forceful ejaculation of semen through the urethra. Emission and closure of the bladder neck are primarily alpha-adrenergically mediated thoracolumbar sympathetic reflex events with supraspinal modulation. Ejaculation is a sacralspinal reflex mediated by the pudendal nerve. The most common ejaculation disorder is premature ejaculation, but there is little agreement regarding the definition of this disorder or its etiology, diagnosis, and treatment options. Premature ejaculation is in fact classically considered psychogenic in nature. However, recent data have demonstrated that prostatic inflammation/infection has been found with high frequency in premature ejaculation, suggesting a role of prostatic pathologies in the pathogenesis of some cases of failure of ejaculatory control. Rarer disorders are emission and ejaculation failure and urine contamination of semen. The new use of diagnostic procedures and the availability of pharmacological aids place this topic in the mainframe of medical sexology.

Common medications and drugs: how they affect male fertility

Numerous drugs and medications have been shown to have adverse effects on male fertility, acting through diverse mechanisms. These drugs are summarized in Table 2. Mechanisms of impaired fertility include direct effects on germ cells or their supporting cells, effects on the delicately balanced HPG axis, effects on erectile or ejaculatory function, and effects on libido. In a thorough fertility evaluation of the male partner, the physician should determine what medication the patient is taking and his social habits involving alcohol consumption, tobacco, and recreational drug use. Most adverse effects from drugs and medications can be reversed by simply discontinuing the offending agents; however, in some instances, such as chemotherapeutic regimens, the medications cannot be discontinued, and pretreatment sperm cryopreservation remains critical. It is essential for urologists treating infertile men to be familiar with the more commonly encountered drugs and medications that may affect the potential for fertility.

Longitudinal study of menopause and sexuality

Longitudinal study of the menopause and sexuality involves many problems that may account for the small number of such studies. In seeking subjects, the mention of sexuality is best delayed until the initial interview when subjects can be informed of the strict confidentiality of the data and be assured that having a sex partner is not a requirement for participation. It is best if subjects are required to be early perimenopausal with regular menstrual cycles but with a change in cycle length and/or flow. Important demographic variables of interest are ethnicity, education, socioeconomic status, health, and partner status. Subjects who have had reproductive surgery or use medications likely to affect sexuality are properly excluded from study or studied as a separate group. Measures include daily calendars for prospective recording of menstruation and sexual behavior as well as repeated questionnaires assessing menopausal symptoms and sexuality; questionnaires should be designed to obtain data concerning sexual interest, sexual attractiveness, and sexual response. It is desirable to measure sex hormone levels at regular intervals if possible. Technological advances have added new and better methods of data collection and have increased the chance of getting accurate prospective data. Nonetheless a good relationship with the investigator is important in obtaining subject co-operation and avoiding attrition. Future studies need to attempt to collect data from sex partners of subjects as well as explore the effects of different sex hormone products and regimens on sexual attractiveness, sexual interest, and sexual response.

Drugs and sexual effects: role of drug type and gender

This study investigated gender differences in the relationship between psychoactive substance use and sexual thoughts, feelings, and behaviors. Participants (N = 464) were male and female alcohol, opiate, cocaine, and methamphetamine users enrolled in an outpatient treatment program at any of 8 sites. A self-report survey that inquired about the specific sexual thoughts, feelings, and behaviors of the participant during previous instances of being under the influence of their primary drug of dependence served as the data source. The results indicate that different categories of psychoactive agents were associated with different effects on sexual behavior, and that those effects vary by gender. Development of a valid measure assessing the type and strength of these relationships may be beneficial for use by treatment programs in promoting abstinence from drug and alcohol use and preventing relapse.

Alcohol, drugs and sexual function: a review

The use of psychoactive substances is popularly believed to loosen sexual inhibitions and contribute to increased sexual activity. However, the actual direct and indirect effects of alcohol and drugs on sexual function are still not fully understood. This article provides a new critical review of the research on the impact on male and female sexual function of psychoactive drugs including alcohol, nicotine, and illicit drugs. The authors consider the effects of both acute and chronic use and review findings from controlled laboratory studies as well as survey and interview research. Research on the impact of substance use and abuse on human sexual function has some limitations due to small and nongeneralizable samples, lack of controlled research design or comparison groups, reliance on self-reported data, or failure to specify or control for dosage effects, expectancies, social effects, and multiple substance use. The lack of controls on physiological, psychological, environmental and cultural factors that could alter the relationship between substance use and sexual function also make it difficult to draw conclusions about direct causal mechanisms. Despite these limitations, this review suggests that chronic alcohol and drug abuse have clear deleterious affects on sexual functioning for many individuals.

Increased libido in a woman treated with fluvoxamine: a case report

OBJECTIVE

The aim of this paper is to describe a case of increased libido during fluvoxamine therapy.

METHOD

Single case report.

RESULTS

The patient, a 27-year-old married Japanese woman with borderline personality disorder, developed an increased libido with the administration of fluvoxamine. The increased libido disappeared after fluvoxamine was discontinued.

CONCLUSION

The present findings suggest that fluvoxamine can cause increased libido in some patients.

Premature ejaculation: a psychophysiological approach for assessment and management

This article distinguishes several subtypes of biogenic and psychogenic premature ejaculation (PE) according to their etiologic features: the physiological PE types of (a) neurologic constitution, (b) acute physical illness, (c) physical injury, and (d) pharmacologic side effect; and the psychological PE types of (a) psychological constitution, (b) acute psychological distress, (c) relationship distress, and (d) psychosexual skills deficit. Attention is given to assessment and differential diagnosis, and to specific treatment of the types of PE, such as the pharmacologic management of difficult neurologic cases. Effective psychosexual treatment combines multiple strategies such as physiological relaxation, pubococcygeal muscle training, cognitive and behavioral pacing strategies, and the involvement of the partner in the therapy. Treatment should determine the specific type of PE and comprehensively address its particular features in order to improve long-term treatment effectiveness.

Sexual functioning among stroke patients and their spouses

BACKGROUND AND PURPOSE

The aim of this study was to assess effects of stroke on sexual functioning of stroke patients and their spouses and to study the associations of clinical and psychosocial factors with poststroke changes in sexual functions.

METHODS

One hundred ninety-two stroke patients and 94 spouses participating in stroke adjustment courses sponsored by the Finnish Stroke and Aphasia Federation completed a self-administered questionnaire concerning their prestroke and poststroke sexual functions and habits. The main outcome measures were (1) libido, (2) coital frequency, (3) sexual arousal, including erectile and orgastic ability and vaginal lubrication, and (4) sexual satisfaction.

RESULTS

A majority of the stroke patients reported a marked decline in all the measured sexual functions, ie, libido, coital frequency, erectile and orgastic ability, and vaginal lubrication, as well as in their sexual satisfaction. The most important explanatory factors for these changes were the general attitude toward sexuality (odds ratio [OR] range, 7.4 to 21.9; logistic regression analysis), fear of impotence (OR, 6.1), inability to discuss sexuality (OR range, 6.8 to 18.5), unwillingness to participate in sexual activity (OR range, 3.1 to 5. 4), and the degree of functional disability (OR range, 3.2 to 5.0). The spouses also reported a significant decline in their libido, sexual activity, and sexual satisfaction as a consequence of stroke.

CONCLUSIONS

Sexual dysfunction and dissatisfaction with sexual life are common in both male and female stroke patients and in their spouses. Psychological and social factors seem to exert a strong impact on sexual functioning and the quality of sexual life after stroke.

Sexual dysfunction in stroke patients

OBJECTIVES

A marked decline in sexual activity has been reported in stroke patients. Little information, however, is available on clinical correlates of sexual dysfunction, changes in the sexual life of spouses of stroke patients, and abnormalities of nocturnal penile erections.

MATERIAL AND METHODS

In this prospective 6-month follow-up study, we assessed the impact of stroke on libido, sexual arousal, coital frequency and satisfaction with sexual life in 50 stroke patients (38 men, 12 women, aged 32 to 65 years) and in their spouses. We also measured nocturnal penile erections of the male patients using a strain gauge attached around the penis.

RESULTS

All the analyzed aspects of sexuality, i.e., libido, coital frequency, erection, ejaculation, vaginal lubrication, orgasm and satisfaction with sexual life, were commonly decreased as a consequence of stroke both in the patients and in their spouses. Fourteen (28%) patients at 2 months post-stroke and 6 (14%) patients at 6 months had ceased having sexual intercourse. Nocturnal erections at 2 months post-stroke were normal in 17 (45%) of the 38 male patients and impaired in 21 (55%) patients, but all of the patients had some nocturnal erections. Sexual dysfunction correlated significantly (P<0.05) with the presence of the sensory hemisyndrome.

CONCLUSIONS

Sexual dysfunction and dissatisfaction with sexual life seems to be common both in male and female stroke patients and in their spouses. Decreased libido, sexual arousal and satisfaction are related particularly to the presence of the hemisensory syndrome. The etiology for sexual dysfunction after stroke is multifactorial including both organic and psychosocial factors.

New insights into erectile dysfunction: a practical approach

Erectile dysfunction (ED) is the most common sexual problem in men, after premature ejaculation, affecting up to 30 million in the United States. In a society in which sexuality is widely promoted, ED impacts on feelings of self-worth and self-confidence and may impair the quality of life of affected men and their partners. Damage to personal relationships can ensue; and the anger, depression, and anxiety engendered spill over into all aspects of life. Patients are often embarrassed or reluctant to discuss the matter with their primary care practitioners. Unfortunately, many physicians fail to take the opportunity to promote open discussion of sexual dysfunction. They too, may avoid the topic through personal embarrassment. Since the National Institutes of Health (NIH) Consensus Conference on Impotence in 1992, the inadequate level of public and professional understanding of ED has begun to be addressed. As a first step in breaking down the communication barriers between patients and practitioners, it is important that physicians have a thorough understanding of the wide variety of conditions associated with ED and how the different risk factors for ED may be readily identified. This review addresses the diagnosis of ED and identifies diagnostic tests that can be used by primary care physicians to determine the patients most at risk and the treatments most suited to meet the patients' and their partners' goal for therapy.

Opportunities for the treatment of erectile dysfunction by modulation of the NO axis--alternatives to sildenafil citrate

Erectile function in man depends upon a complex interaction of psychogenic, neurologic, hormonal and vascular factors, and therefore the management of erectile dysfunction (ED) reflects this complexity of control. Therapeutic options include psychological and non-pharmacological approaches as well as drug treatments. The effectiveness of the type-5 cGMP phosphodiesterase inhibitor sildenafil citrate (Viagra) confirms the pivotal role of the NO-cGMP axis in promoting and maintaining erection. Although widely acclaimed, sildenafil leaves many questions unanswered, especially regarding its susceptibility to pharmacokinetic drug interactions, and its safety in patients with ischaemic heart disease and those taking nitrates. In view of the epidemiological link between erectile dysfunction and cardiovascular disease in the elderly, this limitation might have much broader implications. The presently available scientific documentation, although less extensive, indicates that NO donors, such as topically applied nitroglycerin (GTN; for example, 1-2 puffs of an ordinary GTN spray applied to the shaft of the penis), might be a reasonable alternative. Further larger-scale research on the efficacy and tolerability of topical GTN is needed to establish its full therapeutic potential in the treatment of erectile dysfunction.

Inhibition of penile erection in rats by a long-acting somatostatin analogue, octreotide (SMS 201-995)

OBJECTIVE

To assess the effect of a new somatostatin analogue (SMS 201-995, octreotide) on erectile function in rats.

MATERIALS AND METHODS

Animals were fasted and anaesthetized intraperitoneally with pentobarbital. A cannula was placed in the trachea and the femoral vein cannulated for intravenous infusion. The hypogastric and pelvic nerve, major pelvic ganglion, and the nerve fibres to the lower genitourinary tract were identified. In 20 animals, these nerves were stimulated unilaterally using bipolar silver-wire electrodes; the stimulation was repeated every 15 min for 1 h. Twenty animals were divided into two equal groups; after measuring penile erection to obtain basal values, the animals received either saline or 50 micrograms SMS 201-995 over 1 h and 30 min later, the stimulation was repeated.

RESULTS

After administering SMS 201-995 or saline, the levels of penile erection reduced linearly in both groups, but SMS 201-995 caused a greater decrease than in the control group (P < 0.05) and from baseline (P < 0.01) at all times.

CONCLUSION

SMS 201-995 inhibits penile erection in rats and the systems may serve as an in vivo animal model for further investigation.

A Qualitative Study of the Social Contextual Use of Alkyl Nitrites (Poppers) among Targeted Groups

This paper uses qualitative methods to examine the social contextual use of alkyl nitrites among targeted groups: young recreational drug users (students), polysubstance users receiving treatment in a methadone program, homosexual men, and homeless people. Nitrites were a popular recreational and social drug, most commonly taken in nightclubs to enhance both music and the effects of other recreational drugs or taken to enhance sexual experience. Its legal status, low cost, and easy availability added to its popularity, particularly among younger people.

Nitrites appeared to be commonplace in mainstream night clubs, having previously been confined to night clubs catering to a more homosexual clientele. Despite this fact, nitrites were still associated with gay culture. There was no evidence that nitrite use led directly to use of illicit drugs.

Factors associated with waning sexual function among elderly men and prostate cancer patients

PURPOSE

We identified factors that affect sexual function in men 50 to 80 years old and, therefore, may confound the comparison among groups of elderly men. In particular, we identified factors that may influence a comparison between prostate cancer patients and the general population, or confound the relationship when comparing subgroups of patients in nonrandomized studies.

MATERIALS AND METHODS

A questionnaire, including the Radiumhemmet Scale of Sexual Function and modules assessing potential risk factors for waning sexual function, was sent to 431 patients 50 to 80 years old with prostate cancer diagnosed 1.5 to 2 years previously in the Stockholm area (Sweden) and a reference group of 435 age matched randomly selected men.

RESULTS

Factors associated with physiological impotence included prostate cancer (relative risk 1.9), diabetes mellitus (relative risk 2.3), myocardial infarction (relative risk 1.5), medication with diuretics (relative risk 1.5), hydrogen blockers (relative risk 2.3) and warfarin type anticoagulants (relative risk 1.7). Patients treated for prostate cancer were more likely to be physiologically impotent compared to those with no initial treatment, and this was true for all treatment protocols after adjustment for confounding factors. Men treated with radical prostatectomy were more likely to be physiologically impotent than men treated with external beam radiation therapy (relative risk 1.5).

CONCLUSIONS

Waning sexual function in the prostate cancer patients was largely due to side effects of the treatment and this could not be explained by confounding factors. In particular, confounding could not explain the greater risk of impotence after radical prostatectomy compared to external beam radiation therapy.

Premature ejaculation: a psychophysiological review

This review examines the most common male sexual dysfunction, premature ejaculation (PE). The prevalence, classification, neurophysiology, neuropharmacology, and psychological studies that offer evidence useful for understanding and clinically evaluating PE are reviewed. It is proposed that there are two basic kinds of PE: biogenic and psychogenic. Studies reporting pharmacological aspects of ejaculation offer some suggestions regarding the mechanisms of ejaculation as well as possible pharmacologic aid for some premature ejaculators. The traditional assumption among sex therapists that PE is almost universally caused by psychological features, and easily treated with sex therapy behavioral techniques, is drawn into question. Based on the limited available results from systematic investigations, behavioral treatments for PE remain beneficial to only a minority of men three years after treatment ends, suggesting that this male dysfunction is difficult to treat effectively. The mediocre results reported in treatment outcome studies may be due, in part, to reports on heterogeneous groups of premature ejaculators, for whom treatment has been generalized rather than targeted to the specific type of PE. We propose a biological and psychological etiology. With more discriminating assessment and more specific diagnosis of PE, and with treatment designed to address the particular type of PE, long-term outcome should improve for this common sexual dysfunction.

Fluvoxamine-associated sexual dysfunction

OBJECTIVE

To report two cases of sexual dysfunction induced by fluvoxamine, a selective serotonin reuptake inhibitor (SSRI).

SETTING

University teaching hospital.

PATIENTS

Two depressed patients who developed ejaculation and orgasmic difficulties after initiation of fluvoxamine therapy.

DISCUSSION

The literature concerning sexual dysfunction with serotonergic antidepressants is reviewed, and speculated mechanisms for this untoward effect are discussed.

CONCLUSIONS

Sexual dysfunction associated with antidepressant drugs, including SSRIs, may be underreported. This troublesome adverse effect may significantly affect patient comfort and compliance. Careful evaluation of sexual function is warranted, prior to and during drug treatment, especially as more serotonergic antidepressant agents become available.

Prosexual drugs: empirical status of the "new aphrodisiacs"

The search for an effective aphrodisiac has been a perennial pursuit of most societies throughout history. In the past decade, attention has focused increasingly on the prosexual effects of oral pharmacological agents with central neurotransmitter actions. The role of various dopaminergic, adrenergic, and serotonergic agents, in particular, has been intensively investigated in both human and animal studies. Some of these drugs have been considered for their potential role in the treatment of sexual dysfunction, while others have contributed to our understanding of basic neurophysiological processes in sexual arousal. This review provides a critical evaluation of current laboratory and clinical research on the "new aphrodisiacs," including studies in both patient populations and normal volunteers. Several conceptual and methodological problems are addressed, such as the definition and measurement of sexual response, the need to separate specific and nonspecific drug effects on sexual response, and the lack of studies in women. Although no single drug has proven to be clinically safe and reliably effective for human use, several promising candidates have been identified. Overall, research on prosexual drugs has contributed significantly to our understanding of basic mechanisms in sexual response, as well as providing new treatment options for common sexual disorders.

Drug-induced male sexual dysfunction. An update

Impotence, defined as the consistent inability to maintain an erect penis of sufficient rigidity for sexual intercourse, has been estimated to affect 10 million American men. An age dependence has been shown to exist, with 25% of men over age 65 affected. A large body of clinical experience and published reports in the literature link many commonly prescribed drugs with sexual dysfunction. Drugs can affect sexual function at a variety of points such as inhibition of ejaculation or sedation/depression leading to reduced libido. Antihypertensive drugs have been most commonly associated with impotence. There have been reports of sexual dysfunction with almost all classes of antipsychotics, but little clinical investigation has been performed. Other drugs associated with sexual dysfunction include digoxin, clofibrate, cimetidine and various hormonal agents and antineoplastics. An important first step in approaching all impotent patients is the taking of a detailed medical, surgical, sexual and drug/substance abuse history. The least invasive form of therapy should be employed. Recent studies have shown intracavernous injections of alprostadil (prostaglandin E1) to be safe and effective for long term use. Vacuum constriction devices may also be of help. Better and more durable prostheses are now available should other treatment be unsuccessful.

Effects of antihypertensive drugs atenolol and nifedipine on sexual function in older men: a placebo-controlled, crossover study

Investigated the adverse sexual effects of two antihypertensive drugs, atenolol and slow-release nifedipine, in a placebo-controlled, randomized, crossover study. Subjects were 16 older men (mean age = 66.6 years, SEM = 1.4) with mild to moderate hypertension. Subjects completed daily self-reports on 13 measures of sexuality: frequency of desire, coitus, noncoital partner sex, masturbation, morning erections, spontaneous erections, orgasms in coitus and masturbation, firmness of morning, masturbatory and coital erections, and subjective pleasure in coitus and masturbation. Except for a significant decrease in masturbatory erectile firmness with nifedipine therapy, variables did not differ between the two drug treatments or between either drug and placebo. Although the sample was relatively small, small differences between treatment means suggest that these antihypertensive agents are fairly benign relative to sexual function in men.

Genitourinary and sexual adverse effects of psychotropic medication

OBJECTIVE

We review the adverse effects on genitourinary and sexual function associated with antidepressants, neuroleptics, lithium, and benzodiazepines, and suggest treatment strategies that may be used for their management.

METHOD

This article is based on systematic review of the existing literature, including more than 130 relevant articles on genitourinary and sexual effects of psychotropic medications.

RESULTS

We find that genitourinary function, including effects on continence and flow, and sexual function, including libido, erection, ejaculation and orgasm, may be altered by psychotropic administration. Many of these effects may be consequent to the impact of these medications on neurophysiologic systems.

CONCLUSIONS

Genitourinary and sexual adverse effects associated with psychotropic therapy are important areas of study and clinical concern that may affect patient comfort and compliance with treatment.

Evaluation and treatment of premature ejaculation: a critical review

OBJECTIVE

Premature ejaculation is the most prevalent male sexual dysfunction. The present article is a comprehensive review of the literature on premature ejaculation.

METHOD

This critical discussion of the literature evaluates the definitional issues, theoretical conceptualizations, assessment strategies, and treatment alternatives for premature ejaculation.

RESULTS

The review integrates the most recent findings on the diagnosis and treatment of premature ejaculation updating an earlier review with the addition of more than fifty recent articles and adding sections on treatment generalization and maintenance, medical evaluation, pharmacological intervention, and a discussion of methodological issues in the literature.

CONCLUSIONS

The pause-squeeze technique remains the current treatment of choice for the disorder. However, this unitary treatment recommendation disguises a multidimensional disorder which has yet to evolve an operational definition, psychometrically sound assessment procedures, or clearly articulated etiology.