Sexual functioning is an essential component of life and a significant contributor to quality of life and couple satisfaction (1). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, p. 423), “sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (2). Whereas sexual dysfunctions (SD) in women mostly consist of reduced sexual desire, arousal, and orgasmic disorder, the most common SD in men are erectile dysfunction (ED) and premature ejaculation (3).

A broad range of risk factors for the occurrence of SD has been identified to date, with mental disorders being among the most important (3, 4). Indeed, some literature suggests the impact of poor mental health on sexual functioning is stronger than the impact of physical health problems (5). The link between substance use and SD is of particular interest, as elevated rates of impaired sexual functioning have been observed in individuals who use opioids. The prevalence of SD in opioid-dependent populations have been reported to be as high as 57 and 93% in women and men, respectively (6, 7). Comparable rates have been found in patients suffering from schizophrenia (8), obsessive–compulsive disorder (9), anxiety disorders (4), and depressive disorders (10). Whereas the link between antipsychotic and antidepressant medication and treatment-emergent SD has been well established, the link is less clear for the treatment of opioid use disorder (OUD). There is some evidence for opioid agonist treatment (OAT) improving male sexual functioning with stronger effects being observed in buprenorphine when compared to methadone (11, 12). However, no difference in SD prevalence has been observed in heroin-assisted treatment when compared to other forms of OAT (13).

Among patients with OUD, it remains unclear whether SD are caused by opioid intake itself or result from other substance-use related lifestyle factors (14, 15). Additionally, available literature linking alcohol and nicotine use to SD has been partly inconclusive. Moderate alcohol consumption may have a protective effect on ED (16, 17), whereas alcohol consumption at lower and high doses was reported to be predictive for ED (18, 19). Contradictory findings have also been reported for female SD. Moderate alcohol consumption was found to have a protective effect on hyposexuality in a cohort of Brazilian women (20), although a meta-review reported that in the majority of included studies, alcohol did not influence female sexual functioning at all (21). Regarding the use of nicotine, the available data is equally conflicting. It was demonstrated that under the influence of nicotine, erectile responses to erotic stimuli are substantially diminished, suggesting a dysfunction in the physiological mechanism of sexual arousal (22). Furthermore, the odds ratio for ED is 1.51 (95% CI: 1.34–1.71) for current tobacco smokers (23). Equally, some scholars reported a negative correlation for cumulative smoking dose and female sexual functioning (24), whereas McCool-Myers et al. found smoking to be a protective factor for female hyposexuality (21).

The marked impact that SD exert on the personal well-being is further aggravated by the fact that only a small fraction of affected individuals seek professional help (25). This could be counteracted by consistent sexual history taking by health care providers. However, physicians do not often take sexual history from their patients. One study reported the rate of sexual history taking among general practitioners to be as low as 15.5% (26), whereas the rate of exhaustive explorations in primary care has been found to be 1.1% (27).

In summary, individuals with OUD are at high risk of impaired sexual functioning, similar to other mental disorders. Moreover, SD are likely undertreated in opioid-dependent populations, as there is a lack of help-seeking behavior and sexual health is often not inquired about by treating physicians. Whereas risk factors like cigarette smoking and alcohol consumption on SD have been investigated, far less research has explored SD prevalence, SD risk factors, and SD help-seeking behavior in patients receiving OAT. Moreover, although recent studies have compared sexual desire and sexual dysfunction between men receiving methadone and buprenorphine maintenance treatment (28, 29), no study has directly compared SD between individuals receiving OAT and individuals receiving psychotherapeutic treatment for non-opioid-related mental health problems.

This study investigates SD in patients receiving OAT compared to patients with mental health problems seeking psychotherapeutic treatment. The research question was whether prevalence, contributing factors of SD, and help-seeking behaviors differed between patients with OUD recruited from two OAT centers and patients seeking psychotherapeutic treatment recruited from a psychiatric practice (PP).

All participants were Caucasian and cisgender. Sociodemographic characteristics of the sample are provided in Table 1.

This study examined the prevalence of SD in a sample of patients receiving OAT and a sample of patients seeking psychotherapy from a general psychiatric practice. We found a higher prevalence of SD in the OAT sample (66.0%) when compared to the PP sample (53.8%), with the difference not being statistically significant. This result is likely masked due to the unequal sex distribution in our sample. Only 36.1% of OAT patients were female compared to 43.1% of PP patients, with the latter showing worse sexual health and scoring significantly worse on the Pain domain of the FSFI. Furthermore, female sex remained a significant predictor of SD in PP patients, which was not the case for OAT patients. This observation could explain why, when controlling for sex in the logistic regression model of the total sample, presence of OUD predicted the occurrence of SD. Therefore, even though no significant differences in prevalence were found, the regression model demonstrates that OUD poses a risk for developing SD when compared to milder psychiatric disorders. In line with this, patients with mild transient physically-related illnesses have been found to have a significantly lower prevalence of SDs when compared to patients with OUD receiving OAT (13). A study comparing psychiatric patients to physically ill patients found significantly higher rates of SD in the psychiatric sample, adding to the existing evidence for the impact of mental health on sexual functioning (43).

When specific sexual functioning domains were compared in our study, men in the OAT sample scored significantly lower in the Erectile Function domain of the IIEF whereas women in the PP sample scored significantly lower in the Pain domain of the FSFI, both indicative of worse overall sexual functioning. This highlights the need for more research on specific sexual dysfunctions within different psychiatric subpopulations (e.g., pain in women), in order to provide better individualized and targeted treatment strategies to patients suffering from SD. Other differences were identified between the samples, such as significantly higher FTND and ADS-L scores (assessments for nicotine use and depressive symptoms respectively) among those receiving OAT when compared to the PP sample, which may have influenced the presence or absence of specific sexual dysfunctions in the unique samples. However, in our sample, both nicotine use and depressive state did not significantly predict SD in isolation.

Presence of OUD, higher age, and being female predicted the occurrence of SD in the total sample. In the logistic regression analysis, higher age was a predictor of SD among individuals receiving OAT but not in the general PP sample. This might be related to the hormonal effects of prolonged opioid use, continued use of other substances (e.g., cocaine), as well as prolonged presence of substance use-related lifestyle factors (e.g., poor nutrition, impaired physical health, reduced fitness) (44). However, this is speculative, as this study did not control for these variables. Nonetheless, the influence of higher age is an important finding. As the opioid-dependent population is ageing in Switzerland and European countries, individuals receiving OAT are likely to be at even greater risk of developing SD in the future (45). Surprisingly, depressive state was not a predictor of SD in neither of the samples, despite recent literature demonstrating high rates of SD in populations suffering from depressive disorders (10). As for the impact of alcohol and nicotine use on SD, the available literature has been partly inconclusive (16, 17, 21, 24), and our results unfortunately do not provide more clarity. In our study, neither nicotine use nor alcohol use predicted the occurrence of SD in the logistic regression models, despite a significant difference in FTND scores being observed between the PP and OAT sample.

Regarding help-seeking behavior, no significant differences were found between the PP and the OAT sample. Although we observed a high prevalence of SD in both samples, only 31% of OAT patients and 35% of PP patients had ever talked about sexual health issues with their treating physician. Interestingly, both patient populations seemed to not want to receive counselling regarding their sexual health from their treating physician. This is an important finding, as SD appear to be particularly common in psychiatric patients (4). When compared by SD status, patients suffering from SD w. This is problematic, as help-seeking behavior seems to be lowest in patients who would likely benefit the most from counselling. Future studies should explore the underlying reasons behind these observations in order to best address possible stigma and perceived barriers as it relates to sexual function/dysfunction. For instance, patients may feel generally uncomfortable talking about their sexual health with their treating physician or may believe their treating physician would not be able to help them and may prefer talking to a sexual health specialist instead.

SD are common among psychiatric patients receiving OAT and general psychiatric patients seeking psychotherapy, with higher age, female sex, and presence of OUD predicting SD. Future research should focus on specific sexual dysfunctions (e.g., pain in women), within different psychiatric subpopulations, in order to provide better individualized and targeted treatment strategies to patients suffering from SD. Despite low rates of help-seeking and surprisingly low rates of perceived need for sexual functioning healthcare, professionals providing mental healthcare to patients must emphasize prevention and routine assessments of sexual functioning needs.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Ethikkommission beider Basel. The patients/participants provided their written informed consent to participate in this study.

MM was involved in data curation and formal analysis. MM and JW wrote the original draft. PB and MG were involved in investigation. GW and UL contributed to writing: review and editing, and resources. MV and KD supervised the project. KD was involved in conceptualization, methodology, and writing: review and editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.