CLINICAL HANDBOOK OF SCHIZOPHRENIA

606 VIII. SPECIAL TOPICSmay result in sexual problems. Given their anhedonia, limited social initiative, social anxiety,and deficits in social perception, sexual dysfunctions can be the source of their demoralizationand discouragement in seeking sex with appropriate partners. Because ofthese barriers, many individuals with schizophrenia seek hazardous sex from prostitutesor workers in massage parlors.Perhaps most importantly, the antipsychotic and antidepressant medications commonlyprescribed and used to treat symptoms of the disorder effectively may actuallycause or contribute to the sexual dysfunctions experienced by persons with schizophrenia.Rates of sexual dysfunction associated with the use of these medications range from50 to 90% for the older, conventional antipsychotics and 10 to 30% for the newer, atypicalantipsychotics. Sedation and weight gain may lead to diminished interest in sex. Alternatively,extrapyramidal side effects and tardive dyskinesia may reduce mobility, which inturn adversely affects sexual functioning. Finally, the neural systems and neurotransmittersaffected by the drugs themselves may have a direct impact on sexual functioning. Serotonin,cholinergic antagonism, alpha-adrenergic blockade, calcium channel blockade,and dopamine blockade at the pituitary level (resulting in increased prolactin levels) cancause sexual dysfunctions, including loss of libido, orgasmic dysfunction, ejaculatorydifficulty, and menstrual disturbances. Most importantly, sexual dysfunction has been implicatedas one of the major factors contributing to noncompliance with antipsychoticmedication regimens.VULNERABILITY TO SEXUAL VICTIMIZATIONAND SEXUALLY TRANSMITTED DISEASESCompared to normal controls, people with schizophrenia have significantly less knowledgeabout reproduction and contraception. Moreover, deficits in social cue perceptionand social judgment put individuals with schizophrenia at heightened risk of being sexuallyvictimized. Compared to non-mentally-ill women, women with schizophrenia reportbeing more likely to have been pressured into unwanted sexual intercourse and less likelyto use contraception, resulting in higher rates of sexually transmitted diseases and unwantedpregnancies.Men with schizophrenia are also at high risk. In one study, sexual activity of menwith schizophrenia often occurred with homosexual or bisexual individuals known to beinfected with human immunodeficiency virus (HIV). Half of the men with schizophreniawere involved in sex exchange behavior; that is, sex bought or sold for money, drugs, orgoods. In addition, condom use was low, with fewer than 10% utilizing protective measures.Other investigators have reported that the risk for HIV is much higher in theschizophrenia population, and rates of infection have increased substantially in recentyears.PSYCHOEDUCATIONAL PROGRAMS FOR TEACHING SAFE SEXDuring the past two decades, a relatively small number of sexual education programsdesigned for mentally disabled persons have been described in the literature. They havealmost exclusively focused on safe sex, not on helping patients to learn about the processof considering and deciding whether or not to have sexual relations. Nor have these programstaught patients how to go about having mutually satisfying sex with a partner. Extanteducational programs primarily have been discussion groups. Typically the discus-