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The brain is the most important sexual organ. The interplay of the different structures of the brain involved in human sexuality is very complex, comprising of neural structures, neurotransmitters and hormones. Sexuality is a bio–psycho–social phenomenon, a fragile system that is easily disturbed by all kinds of physical or mental illnesses, drugs, moods, situations, and, for that matter: other people. It therefore comes as no surprise that sexual dysfunction in the general population is rather the rule than the exception. In their review “Psychotropics and sexual dysfunction”, Bella and Shamloul report from the literature a proportion as high as 40 per cent in women and 30 per cent in men in the US with sexual dysfunction.  Psychotropic drugs pose a major threat to sexual function. The numbers presented by Bella and Shamloul are impressive: SSRI use is associated with sexual dysfunction ranging from 26 per cent (Fluvoxamine) to 80 per cent (Setraline, Venlafaxine) [1]. With most antipsychotics, at least every other patient suffers from some kind of sexual dysfunction.  Other psychotropic medication has also been reported to cause negative side effects on sexuality. The underlying mechanisms responsible are numerous and have not yet been clarified in detail. Regarding the dopaminergic and serotonergic pathways in the brain, it is known that they are delicately intertwined [2]. Any interference may have a major impact on sexual function, not only inhibitory but also excitatory. In 2011, 51–year–old family father Didier Jambart, suffering from Parkinson's disease, made the headlines of the world's media by suing GlaxoSmithKline for turning him into a compulsive gay sex addict after having been on their dopamine–agonist Requip.  One can ask whether all sexual side effects are attributable to the medication alone. Depression in itself has a substantial impact on all aspects of the sexual response in both men and women [3]. Furthermore, psychotropic medication often results in weight gain, thus altering body image. Antipsychotics have been observed to have the most profound body– altering effects, with olanzapine causing an average weight gain of 2.3 kg per month (!) [4]. The authors point out that Bupropion appears to be the only modern agent that actually causes weight loss. The relationship between obesity and sexuality has been addressed in several publications. A French national survey of 12,364 randomly chosen participants aged 18–69 revealed links between obesity, sexual behavior and adverse sexual health. Obese men and women had fewer sexual partners during the past 12 months and were more likely to engage in unsafe sex, resulting in an increase in sexually transmitted diseases in men and unwanted pregnancies in women. Obese women were twice as likely to downgrade sexuality as unimportant in their personal life balance, presumably rationalizing the lack of a sexual partner. Once with a partner, no difference could be seen in terms of frequency of sexual intercourse and in sexual practices in overweight and obese men and women as compared to those with normal weight [5]. In their study about the relationship between body image and sexual function, Davison and McCabe found that self–esteem seems to be the crucial factor to explain negative sexual functioning. A negative self–concept may represent the missing link between body image and the otherwise unrelated psychological, social and sexual functioning observed by other researchers [6].  Talking about sexuality is still taboo in many doctors’ offices. Not only do patients often feel uneasy addressing these issues with their doctors, the physicians themselves tend to avoid conversations about sexual problems. Lack of proper training, lack of time and reimbursement issues are among the main reasons doctors give when asked why they avoid the topic. Of 110 General Practitioners from the area of Kiel and Rendsburg–Eckernforde in Germany, two thirds indicated that they felt insecure to speak to their patients about sexuality [7]. However, 81 per cent indicated that they would like to receive proper training. This finding supports the statement of Bella and Shamloul that fortunately, the trend to ignore sexual issues by the medical community is changing.

Letter to the Editor Sex and psychotropic drugs and relationship blues