|Ahead of print publication
Prevalence of sexual dysfunction in women with schizophrenia: A prospective study
Sana Dhamija1, Supriya Davis1, Nishtha Gupta1, Swaleha Mujawar2, Suprakash Chaudhury1, Daniel Saldanha1
1 Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Psychiatry, Regional Mental Hospital, Nagpur, Maharashtra, India
|Date of Submission||26-Nov-2021|
|Date of Decision||19-Dec-2021|
|Date of Acceptance||30-Dec-2021|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Schizophrenia leads to impaired functioning in several domains of life: socioeconomic, personal, and professional. The disorder is complex that impacts thought process, loss of touch with reality, cognitive as well as sexual dysfunction. The taboos around sexual functioning in India are immense and the data pertaining to sexual dysfunction in women in particular are scarce and even lesser for women with schizophrenia. Aim: This study aimed to study the prevalence of sexual dysfunction in women with schizophrenia. Materials and Methods: Seventy women diagnosed with schizophrenia along with age- and sex-matched disorder-free control group were taken as the participants of this study. The participants were assessed with Arizona Sexual Experience Scale (ASEX), and Female Sexual Functioning Index (FSFI) for both the groups and Brief Psychiatric Rating Scale (BPRS) in the index group. Results: A significant difference was found between the ASEX and FSFI scores between the index and control groups, and a significant correlation was found between ASEX and FSFI scores with BPRS scores. Conclusion: Women with schizophrenia have a high prevalence of sexual dysfunction. There was a high association seen between schizophrenia and sexual dysfunction in females with a strong relationship in almost all the areas of sexual functioning (that is desire, arousal, lubrication, orgasm, satisfaction, and pain). More sexual dysfunction was observed in higher severity of schizophrenia, less education, and lower socioeconomic status.
Keywords: Arizona Sexual Experience Scale, Brief Psychiatric Rating Scale, Female Sexual Functioning Index, schizophrenia, sexual dysfunction
|How to cite this URL:|
Dhamija S, Davis S, Gupta N, Mujawar S, Chaudhury S, Saldanha D. Prevalence of sexual dysfunction in women with schizophrenia: A prospective study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339393
| Introduction|| |
Sexual functions are an intricate process that encompasses various domains such as psychological, biological, and social which are also governed by physical systems such as endocrine, neurological, and vascular. The adequate sexual functions in a couple are also based on several other factors, namely personal experience, societal and religious beliefs, health and demographic conditions, their ethnicity and psychological conditions, and individually or together. In many traditional and conservative societies, sex and matters related are not discussed openly in the family but are considered a taboo. The prevalence of sexual dysfunction in women at about 25% is high relative to men.,
Sexual dysfunctions have been reported in 30%–80% of women with schizophrenia patients and they impact the quality of life adversely.,, Previously, sexual dysfunction in schizophrenia was thought to be due to the antipsychotic medication, but lately, it has been found that several other factors contribute to this dysfunction including disease process as well as the severity of the symptoms., Positive and negative symptoms, psychological and social factors, hospitalization, and antipsychotic medication all contribute toward sexual dysfunction in schizophrenia. Patients with psychiatric illness are also less involved in sexual activity as compared to the general population. In addition, the presence of sexual dysfunction in subjects with high-risk potential of schizophrenia and drug-naive patients suggests the presence of sexual dysfunction as an intrinsic factor in the development of the disease.
Very few Indian studies have evaluated sexual dysfunction in women with schizophrenia. One study found the prevalence to be 70%, with impairment of desire and arousal as major problems. Another study compared women with schizophrenia with caregiver controls and found higher sexual dysfunction in the index group. Compared to patients with depression, patients with schizophrenia had less sexual satisfaction, but there was no difference in the prevalence of sexual dysfunction between both the groups. The only study that compared schizophrenia patients and normal control groups found sexual dysfunction to be significantly higher in women with Schizophrenia.
In view of paucity of Indian studies, particularly when it comes to comparing the prevalence of sexual dysfunction in women with schizophrenia with the general population, along with the presence of a wide range of variability in its prevalence, the present study was undertaken to assess the dimension of sexual dysfunction in women with schizophrenia.
| Materials and Methods|| |
This cross-sectional study was carried out in a tertiary care hospital and research center from July 2019 to July 2021. Clearance from the institutional ethics committee was obtained before starting the study (vide DPU/R and R(M)/1124/58/IESC/PGS/2019/59/2019 dated November 8, 2019). The sample included 70 women attending the outpatient department diagnosed with schizophrenia according to the International Classification of Diseases (ICD 10) diagnostic criteria for research (DCR) criteria, and who met the inclusion and exclusion criteria. Equal number of age-matched women who had no past history of psychiatric illness were taken as control.
Inclusion criteria for the study group:
- Females diagnosed to have schizophrenia according to ICD 10 DCR
- Eighteen–forty years of age who were sexually active
- Undertreatment with psychotropic medication
- Willing to give consent for the study.
Inclusion criteria for the control group:
- 18–40 years of age who are sexually active
- Willing to participate and give consent for the study
- Not on treatment with psychotropic medications and no past history of psychiatric illness.
Exclusion criteria for the study and control group:
- Who are not sexually active
- Those having any other comorbid medical illness.
Data collection tools
Sociodemographic and clinical pro forma
It is a pro forma to inquire about sociodemographic details, details of psychopathology, presence of sexual dysfunctions, and questions pertaining to aims and objectives of the study.
Arizona Sexual Experience Scale
This Arizona Sexual Experience Scale (ASEX) which is used for assessment of sexual dysfunction in men and women with psychiatric or physical illnesses is a self- or clinician-administered tool. It consists of five questions and each domain has a scoring of 1–6, total scoring is from 5 to 30. The following signifies sexual dysfunction – total scoring of 19 or greater, scoring on any one domain of 5 or greater, and scoring on three individual domains of 4 or higher. This test has an excellent internal consistency and reliability with alpha value 0.9055, which demonstrates strong test–-retest reliability (for patients, r = 0.801, P < 0.01, for controls, r = 0.892, P < 0.01).
Female Sexual Functioning Index
The Female Sexual Functioning Index (FSFI) is a way to administer self-report questionnaire which consists of 19 items rated on a Likert scale of 6 points. The questions assess five domains of sexuality, namely sexual drive, arousal, penile erection/vaginal lubrication, ability to attain orgasm, and satisfaction from orgasm. A final scoring of 26.55 is regarded as the appropriate cutoff scoring for comparison of women with sexual dysfunction from those without it. The internal reliability for the total and six domain scores has Cronbach's alpha >0.9 for the combined sample and above 0.8 for the sexually dysfunctional and nondysfunctional samples, independently.
The Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale (BPRS) is a clinician-rated tool designed to assess the severity of psychopathology. It is most appropriately used as a global measure of response to treatment interventions in patients with moderate to severe psychotic disorders. It is an 18-item scale measuring positive symptoms, general psychopathology, and affective symptoms. The BPRS is primarily intended for patients with major psychiatric disorders, particularly schizophrenia. Each symptom construct is rated on a 7-point scale of severity ranging from not present to extremely severe.
All the patients and control group included in the study were explained about the nature of the study and informed consent was obtained. After that, the sociodemographic data were filled up. Thereafter, all the patients and controls were administered ASEX and FSFI. Patients were also assessed with the BPRS. All the patients with schizophrenia were started on conventional lines of treatment.
Statistical analysis was carried out using SPSS (IBM, Chicago, Illinois, USA) with the help of both descriptive statistics (mean, range, standard deviation [SD] and percentage) and inferential statistics using nonparametric tests, namely Chi-square test and Mann–Whitney U test. The level of significance level was identified at a 95% confidence interval (CI) as P < 0.05.
| Results|| |
The mean (±SD) age of the sample in the index group was 32.97 (±6.27) years and in the control, 32.75 (±5.01) years. There was no significant difference between the two groups (t = 0.223; df = 138; P > 0.824 NS). Schizophrenia patients had significantly lower levels of education and socioeconomic status compared to the control group. There was significantly higher number of arranged marriages 87.14% in the index group compared to 64.29% in the control group [Table 1].
|Table 1: Frequency distribution of demographic data between case and control groups|
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Out of 26 cases on first-generation antipsychotics, 24 had sexual dysfunction and out of the 41 on second-generation antipsychotic drugs, 39 had sexual dysfunction, 3 of those on both medications had sexual dysfunction [Table 2]. There was a significant difference in the ASEX score between index group and control group, with higher scores in the index group signifying more sexual dysfunction in the index group. There was a significant difference observed in the desire, arousal, lubrication, orgasm, satisfaction, pain, and total scores domain of FSFI scores between index and control group [Table 3].
|Table 2: Frequency distribution of the type of antipwsychotic medication in index group|
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|Table 3: Comparison of Arizona Sexual Experience Scale and Female Sexual Functioning Index scores between index and control group|
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There was a positive correlation between socioeconomic status and education, showing that higher the socioeconomic status, higher the education level and a positive correlation between socioeconomic status and domicile, with better socioeconomic status seen in Urban areas. There was a negative correlation between marital type and number of children and family type – lesser children in love marriages and nuclear family type and a positive correlation between marital type and socioeconomic status, more love marriages observed in higher socioeconomic class [Table 4]. There was a negative correlation between ASEX scores and socioeconomic status, with higher scores indicating higher sexual dysfunction in lower socioeconomic status. FSFI scores are positively correlated with education and socioeconomic status, those with higher scores on FSFI (low sexual dysfunction) have better education and socioeconomic status. Lower FSFI scores denote greater sexual dysfunction. Higher ASEX score denotes higher sexual dysfunction. There was a negative correlation between BPRS scores and socioeconomic status showing higher severity of schizophrenia in lower socioeconomic class and a positive correlation between ASEX and BPRS, showing higher sexual dysfunction with higher severity of schizophrenia. There was a negative correlation between FSFI (low score > more sexual dysfunction) and BPRS scores, indicating more sexual dysfunction with higher severity of the disease.
| Discussion|| |
The occurrence of sexual dysfunction in schizophrenia has been reported earlier. Two Indian studies with 63 and 56 participants, respectively,, have reflected on female sexual dysfunction utilizing the ASEX and FSFI scales which were also used in the present study.,
Sociodemographic studies show schizophrenia rises in 10–25 age group in males and age group of 25–35 in females. In women, a peak is observed during middle age, and then, around 23% have the first episode after turning 40. Some studies including the present one have taken the same age group for the evaluation of sexual dysfunction in women and controls., In agreement with the finding of significantly lower levels of education in schizophrenia patients, few studies have reported that early-onset psychiatric illnesses are linked to termination of education in the patients. The finding of a high rate of unemployment in schizophrenia patients in the present study is in agreement with previous studies which showed that the rate of unemployment in schizophrenia is to the tune of 80%–90%.,
Majority of participants from the index group were from lower socioeconomic status, while the participants of control group belonged to lower and middle socioeconomic strata. It is seen that the burden or consequences of many diseases in lower socioeconomic class are skewed when compared with those from higher socioeconomic class. Studies do show that people from lower socioeconomic status have more mental illnesses due to adverse economic stress acting as a trigger; at the same time, drift hypothesis states that illness leads to downward shift and mental health worsens first that results in acquiring lower social class. Family system has a great effect in the outcome/course of illness as caregivers in joint families are valuable assets and responsible for better outcomes of the illness compared to the nuclear family type. The present study found no significant difference between these family types in both index and control groups.
The finding of a significantly higher prevalence of psychiatric disorders in the family of schizophrenia patients compared to controls is in agreement with the observation that people who have first-degree relatives with schizophrenia have a greater risk of acquiring the disorder themselves. Some studies have also reported higher rates of schizophrenia among the relatives of female patients than among the relatives of male patients with schizophrenia.
Most of the participants seen in both groups had two children. This is in accordance with a study done in the US cohort that found no significant difference in fertility among women with schizophrenia and control group; however, they did find reduced fertility in patients with older age or later in life.
There is significantly less number of love marriages in the index group as compared to the control group in the present study. In the West, the rate of marriage is less in patients having schizophrenia as compared to people with other psychiatric illness or those without any disorders. This may be due to the fact that in the West, marriages are not arranged but rather based on finding a partner individually which requires the communication and social adaption lacking in schizophrenia patients. In the Indian context, however, 70% of individuals with schizophrenia eventually get married. This may be due to the belief that marriage cures psychiatric illness and is being arranged by elders of the family. In India, marriage is seen as a social obligation and holds high value, whether or not an individual has a psychiatric disorder.
In our study, we did not find any significant difference in sexual dysfunction upon the usage of either first or second generation. Similar results were found in a study from India and Turkey., There are conflicting reports on first-generation antipsychotics increasing female sexual dysfunction, whereas other reports found no significant difference between using first-generation antipsychotics or second generation., Reports suggest that both risperidone and olanzapine have the greatest possibility of causing sexual dysfunction, 50% of patients treated with olanzapine had experienced sexual dysfunction. Clozapine, as the conventional antipsychotic drug, is associated with least sexual dysfunction and quetiapine with rates of 50%–60% of sexual dysfunction. It was thought that medication that caused hyperprolactinemia caused sexual dysfunction, but recent studies have discounted this assertion.
Index group showed higher ASEX scores as compared to the control group signifying more sexual dysfunction. Several studies have reported more impairment in sexual functioning in index groups as compared to the control groups.,, One study from Turkey observed comparative prevalence of sexual impairment in females of index and control group, denoting that factors such as ethnic and cultural differences and hesitant communication were the reasons for sexual dysfunction. Such factors can also be applicable to a country like India. Several ASEX studies have been found for sexual dysfunction in schizophrenia; however, such studies related to female sexual dysfunction are few.
A significant difference was observed in the index and control group regarding the domains of desire, arousal, lubrication, orgasm, satisfaction, pain, and total FSFI score. More sexual dysfunction was observed in the index group.
One major finding in our study was that the sexual dysfunction in women with schizophrenia came out to be 94.2%. Akin to our study, other studies have also found sexual dysfunction in participants having a diagnosis of schizophrenia compared to the control group. Simiyon et al. found 70% sexual dysfunction in women with schizophrenia on FSFI. Studies including systematic reviews show similar results regarding sexual dysfunction in schizophrenia, ranging from 30% to 90% – one of which shows 30%–80%.,, The most consistent with our findings is another Indian study which identified sexual dysfunction in 90% of cases of women with schizophrenia.
The most common domains for sexual dysfunction seen across the studies were desire and arousal.,, There are also reports of impairment in lubrication, orgasm as well as presence of pain. One Indian study of Simiyon et al. has shown the prevalence of these around 30%–50% in women. One meta-analysis showed a reduction in sexual desire in about 12%–38% of patients evaluated under it. Patients with schizophrenia have reported reduced sexual arousal lubrication, vaginal dryness, and dysfunction in orgasm reported as 40%–49%., Studying sexual dysfunction in women is in the eastern world comes with challenges, especially in a country like India, where cultural and social taboos regarding sexual experiences are prevalent. Mental health issues carry their own stigma. When both are combined, they pose more difficulties regarding open discussion or communication.
More sexual dysfunction is seen in less education and lower socioeconomic status and higher severity of schizophrenia. There are several studies which are consistent in findings with our correlation between sexual dysfunction and education level which show that lower education level has been observed with higher sexual dysfunction., Studies have linked low education to sexual dysfunction to less awareness regarding genital anatomy and function., One study found lower sexual dysfunction among those who had a higher level of education, which is similar to our finding. Age, education level, socioeconomic status, and marital duration contributed to female sexual dysfunction, whereas menopause, and family type – being joint or nuclear – did not.
Regarding the associations between sexual dysfunction and severity of symptoms of schizophrenia, studies have suggested that sexual dysfunction can be a consequence of the disease itself and it may also be rated to the severity of symptoms of the disorder., Other studies have also found a positive association between severity of illness and severity of sexual dysfunction in schizophrenia., This association of severity of disease with sexual function can be explained by several theories, one of them being dopaminergic dysfunction. This may cause a disturbance in the processing of motivation and arousal pathways that are needed for appropriate sexual function. A study from South London has concluded with similar results that the severity of sexual function impairment is correlated with that of the psychotic symptoms. Severity of psychotic features is well correlated with impaired sexual functioning in females. Greater rates of sexual dysfunction impairment in lower socioeconomic strata and lack of employment can be indirectly related to the severity of the disease process. It is seen that sexual dysfunction has been associated with greater scores on the negative domain subscale, the general symptom subscale, and even total score in PANSS. The disturbances found in sexual functioning in schizophrenia can be due to multiple factors such as the disease process itself, negative features of apathy or avolition, symptoms of depression, and side effects of antipsychotic medication. Patients who get diagnosed with psychosis can also have needs of sexuality that have remained unmet and can impact the recovery in a negative manner. These can become a barrier to the expression of intimacy.
The cases of the sample belonged to a tertiary care center and did not reflect the prevalence in the general population. The sample size was modest. A larger sample would throw more light on the extent of problem in the general population. The sample was matched for age but not for other parameters such as education and occupation which could have affected understanding and reporting sexual problems.
| Conclusion|| |
Women with schizophrenia have a high prevalence of sexual dysfunction. There was a high association seen between schizophrenia and sexual dysfunction in females with a strong relationship in almost all the areas of sexual functioning (i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain). The effect of sociodemographic factors too contributed toward sexual dysfunction with high severity of schizophrenia, less education, and lower socioeconomic status.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]