By Dr. Irina Fiksman & Dr. Schulz-Perez

Sexuality is a life long vital part of human functioning, identity and self-image. More than just genital acts, it encompasses caring, trust, affection and emotional intimacy. Enjoyable sexual activity relieves stress and tension. The act of orgasm releases endorphins and dopamine, resulting in a deep sense of joy and relaxation. Sexual drive may decline some with age, which is based on physiological factors, but sexual expression remains  important for  the overall well-being of persons well into their sixties, seventies and beyond.

There is a wide spectrum of “normal” in human sexuality; and the main criterion of normality is that consenting adult partners find it enjoyable and satisfactory.

The problem arises when people are not satisfied with their sexual functioning, or that of their partners. That condition is called "sexual dysfunction".

Sexual dysfunction may include problems affecting a person’s desire for sex, ability to become and stay sexually aroused, ability to reach orgasm, and problems resulting in discomfort during intercourse.   

Sexual dysfunction can afflict both sexes; it may be caused by physical, emotional factors or a combination of both.  Persons who are sleep deprived, physically or mentally exhausted, in pain or other acute discomfort are not likely to be overly enthusiastic about sexual activity.
Sexual dysfunction occurring only under a particular set of circumstances, or only with certain sexual partners is called "situational" rather than "generalized" (occurring regardless of the circumstances or partner). Sexual dysfunction appearing after normal sexual functioning in the past is considered to be "acquired" rather than "lifelong" difficulty.  

Decreased sexual desire - frequently associated with depression, anxiety, high stress levels, or even simple fatigue - is more common among women.
Decreased sexual desire is often caused by:

• Interpersonal relationship issues, partner performance problems, lack of emotional satisfaction with the relationship, the birth of a child, poor body image, and becoming a caregiver for a loved one.
• Job stress, peer pressure, and media images of sexuality.
• Low testosterone (male hormone) levels. Testosterone affects sexual drive in both men and women.
• Medical problems, such as diabetes, thyroid and other hormone disorders, Multiple Sclerosis, serious injuries, as well as any condition causing pain during intercourse.
• Medications and drugs include, blood pressure lowering drugs, oral contraceptives, pain killers, sedatives, alcohol, and , ironically enough, antidepressants, especially the subgroup called Serotonin Reuptake Inhibitors (SSRIs).

Serotonin Reuptake Inhibitors (Prozac, Zoloft, Paxil, Lexapro, Luvox and Celexa) can cause loss of sexual desire, difficulty getting aroused (in men, erectile flaccidity; in women, lack of lubrication and similar lack of engorgement), duration of time from arousal to orgasm, and intensity and length of orgasm. Both women and men report about 40 % incidence of dysfunction when they take SSRIs.  But the incidence of dysfunction while on SSRIs probably is even greater because physicians and patients either don't talk about the sexual side effects of antidepressants, or recovering persons may accept sexual dysfunction as a price they have to pay to stay well. But they do not necessarily have to contend with a dip in their sex lives.

Strategies that may help:

• Wait and see.  Some people develop tolerance to the sexual side effects and eventually bounce back. It may take a few months.
• Lowering the dose of medication, since sexual side effects are dose related.
• A drug-free holiday. For example, going off SSRI Thursday through Sunday and then attempt sex on Sunday night. This will probably not work with Prozac, which has a longer drug half-life than most other SSRIsi. The drug-free holiday strategy is a gamble. Many users don't want to risk being off their medication, even for a day, many others will develop medication withdrawal symptoms when they attempt to do that.
• Switching antidepressants. Wellbutrin, Remeron,  Serzone, and Desyrel may be less likely to destroy libido.

• There are a host of legal drugs and herbs to counteract sexual side effects caused by antidepressants.  The herb ginkgo biloba taken two 60- to 120-milligram capsules twice a day often causes a substantial improvement in sexual functioning, with no side effects. Ginkgo biloba restores the blood flow to the genitalia often blocked by the serotonin-enhancing drugs. The popular prescription drug, Viagra, does much of the same.

The bottom line is that one does not have to choose between good mental or sexual health.  With proper treatment, one can usually enjoy a considerable improvement in both.