Psychosexual Health and Sexual Medicine in Consultation-Liaison Psychiatry.

It is clear from the above discussion that psychosexual problems are common in medical settings where a psychiatrist need to be consulted. Although sexual dysfunction inevitably mostly comes under the purview of MHPs, the distinction between medical and psychological causes is often not watertight. The prognosis can have a variable course across patient populations, given significant variability within and between distinct cohorts. With that said, it is recommended that clinicians have an honest and open conversation with patients where the benefits and risk associated with treatment are discussed, as well as the potential complications related to medications or surgical procedures. Throughout this CPG, it has been highlighted how sexual disorders that stem from medical conditions often results in substantial psychological toll on an individual, affecting one’s sense of general well-being and quality of life. Hence, the role of a psychiatrist in such referrals is not limited to a one-time prescription but also an integration of medical and psychosocial management in sync with all the other specialties involved in the care. For example, in an individual with on cancer chemotherapy or renal failure undergoing hemodialysis, management of sexual dysfunction will be incomplete and ineffective without a continued and collaborative dialog between the psychiatrist, patient, families, and other service care providers (oncologist, urologist, nephrologist, dietician, physiotherapist, etc.). Of course, this CPG is not exhaustive. It only covers the most common medical conditions that are capable of having sexual offshoots. Virtually, directly, or indirectly, every other chronic physical illness can lead to psychosexual issues, the details of which are exhaustive and have been suggested in references for further reading. Nevertheless, this CPG provides an anchor for best evidence-based practice, underlying theoretical underpinnings and approach to the diagnosis and management of sexual disorders due to medical conditions. To reiterate, sexual functioning is one of the salient attributes of health and well-being. Thus, in any given clinical context, the appropriate diagnosis and treatment of the underlying cause for sexual dysfunction will increase the chance that a multidisciplinary care with effective psychosocial inputs is able to restore normal sexual functioning and subsequently improve quality of life and a better living for patients and families. Nil. There are no conflicts of interest

Sex and sexuality are the primal instincts of civilizations. They form the central core of social bonds, couple dynamics, relationships, intimacy, and reproduction. It is a well-established fact that sexual expressions and manifestations are biopsychosocial constructs and have heavy bearing on cultural and ecological contexts. Classically, three dimensions of sexuality have been defined: desire, attachment, and reproduction. Exploring these complex multidimensional interactions forms the basis of psychosexual health, which is in turn integral to sexual medicine. As defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, sexual medicine is “that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate.” Interestingly, even though psychosexual disorders are predominantly dealt with by psychiatrists, their etiology may be multifaceted including other medical comorbidities and iatrogenic causes. This brings us to the importance of consultation–liaison psychiatry (CLP) while dealing with sexuality and sexual concerns. It is not uncommon in clinical practice to routinely attribute sexual disorders and dysfunctions to a “functional cause,” thereby neglecting the emotional connotations, underlying distress, effect of medications, and concurrent medical conditions. This can lead to misdiagnosis, underdiagnosis of these disorders, and impaired sexuality and quality of life. With this background and with an aim to be a guiding outline for both psychiatrists and other medical specialties, these Clinical Practice Guidelines (CPGs) attempt to synthesize the role, evaluation, principles of assessment, and management of psychosexual disorders in CLP settings.

CLP or liaison psychiatry or consultative psychiatry is the branch of psychiatry that deals with the intersections between general medicine/surgery/pediatrics and psychiatry, usually taking place in a general hospital setting. This relatively developing branch has a significant overlap with psychosomatic medicine (includes psychosexual disorders), pain management, health psychology, and neuropsychiatry. The psychiatrist usually acts as an “advising consultant” in response to specific requests/referrals from the other specialties. Now, when it concerns sexuality and related disorders, the concept of this discipline cannot be more stressed upon, “the interplay of biological and psychosocial factors in the development, course, and outcome of diseases.” An ideal CLP service needs to be a liaison-based model though mostly it is a consultation-based model that lacks interdisciplinary discussion, and further, with significant heterogeneity in training and limited research, CLP is still a naïve field in India. This makes these CPGs assume an increased importance. The Diagnostic and Statistical Manual (DSM)-5 prevents a sexual disorder to be considered as a psychiatric diagnosis, if the presumed etiology was a medical condition (or several concurrent medical conditions). In clinical reality, however, there are no watertight boundaries; for example, an individual with adjustment issues related to a new diagnosis of malignancy can have resulting erectile dysfunction (ED), which can get further worsened by cancer chemotherapy. Hence, it is a common practice for a physician to encounter a clinical context, in which a precise understanding of the specific cause of a sexual problem remains unidentified. Thus, even when a CLP referral is in place, it is the responsibility of the psychiatrist to recognize and determine the constellation of factors and possible causes that may impact the reported sexual disorders/dysfunctions. In fact, a host of medical conditions and medications can influence sexual functioning and responsiveness, which in turn is dependent on the existing sexual practices, sexual beliefs, and other sociocultural factors. These CPGs are drafted to guide on clinical judgment to understand these complexities and enable the liaison psychiatrist to take a balanced and evidence-based decision on the management of sexual disorders in medical settings. Important to note, this paper does not deal with the general management principles of sexual dysfunction (SD) which are already covered in earlier CPGs.

ED due to diabetes can be classified as an endocrine system- related problem as well as under vascular causes of ED. Diabetics (type 1 and 2) are at a three times higher risk for ED when compared to nondiabetic individuals as concluded by Massachusetts Male Aging Study. Diabetes-induced ED is of multifactorial origin. Diabetic vasculopathy encompasses microangiopathy, macroangiopathy, and endothelial dysfunction. Macrovascular disease due to atherosclerosis damages the blood vessels limiting flow in the vascular beds. Male SD due to diabetes includes ED, desire/arousal problems, and orgasmic/ejaculatory dysfunction. ED prevalence in diabetic men varies from 35% to 75%. ED as a consequence of diabetes is multifactorial in origin with metabolic, vascular, neurological, hormonal, and psychological components as explained in Figure 6 . Pathophysiology of erectile dysfunction in diabetes mellitus (adapted from Tamás V, Kempler P, 2014, Malaviqe LS, Levy JC, 2009)[ 8 14 44 ] In diabetics, the sensory information from the penis to the spinal and supraspinal centers is impaired. Associated impaired parasympathetic inactivity further worsens erection. In diabetics, strict glycemic control is advised to avoid ED. Reversal of ED even if diabetes is strictly controlled is not very successful. In females, the association of diabetes with SD is not very conclusive. However, the prevalence of SD is much higher in females with diabetes when compared to nondiabetics. Female SD is more related to psychosocial factors associated with diabetes. The human neuroendocrine system includes the hypothalamic–pituitary–adrenal (HPA) axis, hypothalamic–pituitary–gonadal (HPG) axis, hypothalamic–pituitary–thyroid axis, and hypothalamic–neurohypophyseal system. Alteration in any of these four axes can lead to sexual problems. The HPA axis is strongly linked to the reproductive system. The HPA axis and the female reproductive system are intertwined and are responsible for the “hypothalamic” amenorrhea of stress, eating disorders, and the hypogonadism of Cushing’s syndrome. The HPG axis plays a central role in the neuroendocrine system, linking the brain with the gonads. The HPG axis controls the various aspects of sexual function; excess or deficiency of pituitary hormones; or metabolic alteration associated with pituitary diseases (Cushing’s disease) that can lead to ED. Endocrinopathies associated with ED include thyroid dysfunction, hypogonadism, and hyperprolactinemia. Androgen deficiency has been noted in 2%–33% of men with ED. The most common endocrinopathy in ED patients is low testosterone levels (15%) followed by hyperprolactinemia (13.7%) and hypothyroidism (3.1%). The diagnosis of endocrinopathies is based on blood hormone levels. Both hypothyroidism and hyperthyroidism are associated with SD in both the sexes. The prevalence and type of SD are mentioned in Table 10 . Thyroid hormone may have a direct effect on ejaculatory process or a secondary effect of testosterone. Both hypothyroid and hyperthyroid state can alter circulating sex hormone levels through peripheral and central pathways which lead to sexual problems. In hypothyroidism, the disruption of HPA axis leads to decrease in sex hormones, both free and total testosterone levels, leading to sexual problems. The prevalence and type of sexual dysfunction associated with thyroid disorders SD – Sexual dysfunction Hypogonadism can occur due to any insult to the HPG axis. Thus, hypogonadism can be primary (Klinefelter’s syndrome and cryptorchidism) or secondary (i.e., central dysfunction which includes head trauma, prolactinoma, pituitary surgery, and drug abuse). Hypogonadism can be effectively treated with testosterone replacement therapy which improves sex drive and enhances PDE-5 inhibitor effectiveness. The hormonal conditions required for ejaculation are complex. Androgen receptors are present throughout the body including the areas of the brain associated with arousal and orgasm. Low testosterone levels are associated with DE, and higher levels of the same are linked to PME. Prolactin can be considered as a surrogate marker of serotonin activity. High levels of prolactin suppress ejaculation. During ejaculation, dopamine peaks (during orgasm and climax) and prolactin are suppressed. Once orgasm is over, prolactin spikes and dopamine decrease. Prolactin is partially responsible for the refractory period in men. Hence, both prolactin and dopamine levels are inversely related. Hyperprolactinemia occurs in 1%–5% of men with ED. Around 50% of men with microprolactinomas and 75% of men with macroprolactinomas report either reduced sexual desire or ED. Hyperprolactinemia in women can be associated with reduced sexual arousal, lubrication, orgasm, and satisfaction. The relationship between dopamine, prolactin, and testosterone is shown in Figure 7 . The relationship between dopamine, prolactin, and testosterone Prolactin is involved in control of sexual behavior by modulating the effects of dopaminergic and serotoninergic systems on sexual function. A short-term or long-term increase in prolactin can control central nervous system sexual function by acting directly on receptors in the brain and possibly affect erection in men and response of genitalia in women. A chronic increase in prolactin levels is associated with hypogonadotropic hypogonadism and SD in both sexes. Growth hormone (GH) is an important regulator of HPG axis and possibly regulates sexual response of genitalia in both men and women. Both in GH deficiency and excess, a decrease in desire and arousability is present (in both the sexes) with impaired erection in men. Hypersexual disorder (HSD) (not included in DSM-5) is a diagnostic label given to a range of behaviors, which are a result of intense sexual urges or fantasies and cause significant distress or socio-occupational dysfunctioning. Clinical presentation may include excessive sexual activity or intercourse, masturbation, pornography, or computer-assisted sexual activity. HSD can be considered as a type of compulsion, addiction, or impulse control disorder. Other names for HSD include hypersexuality, erotomania, compulsive masturbation, and sexual compulsivity. Common medical conditions that may be associated with hypersexual behavior are listed in Table 11 . HSD neurobiology involves the thalamus, mammillary body, amygdala, prefrontal region, cingulate gyrus, hippocampus, nucleus accumbens, caudate nucleus, and brainstem (ventral tegmental area, raphe nuclei, and substantia nigra). Comorbid medical conditions associated with hypersexuality It is important to note the following points of HSD: (1) whether it is a distinct disorder (as yet unrecognized) (or problematic psychosexual behavior), (2) a symptom of an existing disorder or medical condition, (3) normophilic activity at the high end of sexual functioning. The sexual behavior cycle of HSD includes sexual incongruence and cognitive abeyance. A sexual urge leads to sexual behavior and sexual and postsexual satiation. This is again followed by sexual urge when the cycle repeats. Although HSD could not make it to DSM-5, criteria proposed for the same by Reid et al .[ 49 ] are briefed in Table 12 . Proposed criteria for Diagnostic and Statistical Manual-5 hypersexual disorder Kaplan and Krueger[ 34 ] have explained subtypes of HSD as mentioned in Table 13 . Subtypes of hypersexual disorder HSD – Hypersexual disorder Treatment algorithm to HSD is mentioned in Figure 8 . Treatment Algorithm for hypersexual disorders (Reid RC, Garos S 2011; Khan O, Ferriter M, Huband N 2015, Tierens E, Vansintejan J 2014).[ 36 51 57 ] SSRIs: Selective Serotonin Reuptake Inhibitors; TCAs: Tricyclic antidepressants; LHRH: Luteinizing hormone- releasing hormone; GnRH: Gonadotropin-releasing hormone); im: Intramuscular Apart from the various medical conditions discussed earlier, few other chronic illnesses and their intersections with sexual dysfunctions relevant to CLP are highlighted in Table 14 . Sexual disorders and other chronic illnesses HIV – Human immunodeficiency virus; COPD – Chronic obstructive pulmonary disease

Gender dysphoria has replaced gender identity disorder in DSM-5, and it is signifying a marked sense of unease that a person experiences with the biological sex and ones’ gender identity. The distress may be so severe that it can impair social and occupational functioning and may also cause anxiety/depression in the person. Gender nonconformity is not a mental disorder by itself; however, if there is distress arising from it, then it needs to be evaluated. Many patients of gender dysphoria want to change their biological sex to conform to their sexual orientation. Gender dysphoria has also been seen in adolescents and children and also includes disorders of sex development where children are assigned genders by parents or physicians. Although the number of people coming out in the open about their gender dysphoria has risen, there is still social stigma associated with gender nonconformity and cultural differences due to which the gender dysphoric individual faces a lot of mental health issues. Further, due to the lack of teaching about the same in medical schools along with reduced importance, several medical professional bodies have to depend on the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) and the Endocrine Society (ES) guidelines for the treatment of gender dysphoria. The goals of treatment include to resolve the distress experienced by the patient and to affirm his/her gender identity. This approach therefore requires a multidisciplinary team which includes a mental health professional (MHP) psychiatrist and psychologist/counselor, plastic surgeon, endocrinologist, urologist, and gynecologist in adult patients and also a pediatrician and pediatric endocrinologist for children and adolescents with gender dysphoria. Treatment parameters are included in Figure 9 . Treatment options for gender dysphoria. (Reid RC, Garos S, 2011; Khan O, Ferriter M, Huband N, 2015, Tierens E, Vansintejan J, 2014).[ 36 51 57 ] SSRIs – Selective Serotonin Reuptake Inhibitors; TCAs – Tricyclic antidepressants; LHRH – Luteinizing hormone-releasing hormone; GnRH – Gonadotropin-releasing hormone; im – Intramuscular Table 15 describes the role of an MHP as per the WPATH SOC version 7 and ES guidelines. Role of mental health professional as per World Professional Association for Transgender Health Standards of Care version 7 and Endocrine Society guidelines MHP – Mental health professional; WPATH: World Professional Association for Transgender Health; DSM – Diagnostic and Statistical Manual; SOC – Standards of care; ICD – International Classification of Diseases The current laws in India as per The Transgender Persons (Protection of rights) Act, 2019 allow the procedure for gender affirming/confirming surgeries and change in name after following the proper procedure laid down in the Act. However, it still remains a continued need to establish teams that would work together to help patients of gender dysphoria. The medical curriculum also needs to be aligned to the changes and reforms taking place in different cultures and societies so as to offer teaching and learning opportunities to the medical fraternity. Creating awareness among MHPs and medical practitioners about the needs of the transgender community would definitely improve the quality of care given to this minority section.