Archives o f Sexual Behavior, VoL 10, No.

5, 1981

Sexual Behavior of the Male Schizophrenic:

The Impact of Illness and Medications
J. N. Nestoros, M . D . , P h . D . ,
and T. A. Ban, M.D. 2

1'3

H. E. Lehmann,

M.D., 1

The fiterature concerning the impact o f (a) the schizophrenic illness and
(b) the neuroleptic drugs (which are the most commonly employed medications f o r this disorder) on male sexual behavior is critically reviewed in
the light o f what is currently known about the interaction o f both the
schizophrenic illness and the neuroleptic drugs with hormones and neurotransmitters known to play a role in male sexual behavior. The effect o f
the schizophrenic illness on male sexual behavior is unclear, but there are
some indications that chronic, severe schizophrenia may exert detrimental
effects on many aspects of male sexual behavior. As f o r neuroleptic drugs,
a wealth o f evidence suggests that they have many detrimental effects on
male sexual behavior. Nevertheless, since the introduction o f these drugs,
the reproductive rates o f male schizophrenics have increased. The multiplicity o f factors involved in the sexual behavior o f the schizophrenic
patient is emphasized. It is concluded that the sexual behavior o f the
male schizophrenic provides an important forum f o r studying the interaction between psychological, sociological and biochemical-pharmacological
factors which determine sexual behavior.
KEY WORDS: schizophrenia; neuroleptic tirugs; male sexual behavior; hormones; neurotransmitters.

'Departmem of Psychiatry, McGill University, Montr6al, Qu6bec, Canada.

2Department of Psychiatry, Tennessee Neuropsychiatric Institute, Vanderbilt University,
Nashville, Tennessee.
3Address all correspondence to Dr. J. N. Nestoros, Douglas Hospital, 6875 LaSalle Boulevard,
Verdun, Montr6al, Qu6bec, Canada H4H 1R3.
421
0004-0002/81/1000-0421503.00/0 1981 Plenum Publishing Corporation

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Nestoros, Lehmann, and Ban

INTRODUCTION
The literature addressing the sexual behavior of schizophrenic
patients is extremely rich in terms of case reports and theorizing but extremely poor in terms of any findings obtained in controlled studies. The
only well-established facts are the following: (1) schizophrenics have been
consistently found to marry less and to have lower reproductive rates
(child per person), both in comparison to the general population (EssenM~ller, 1935; Kallman, 1938; MacSorley, 1964) and in comparison to
most other psychiatric illnesses (Odegaard, 1946, 1960; Gregory, 1959);
(2) schizophrenics with a history of marriage (Malamud and Render,
1939; Vaillant, 1964; Stephens et al., 1966) or heterosexual involvement
(Wall, 1941; Counts and Devlin, 1954; Bromet et al., 1974) were consistently found to respond more favorably to somatic treatments (insulin
shock, electric shock, pharmacotherapy).
Here, we review the literature for the currently available evidence
concerning the impact of the schizophrenic illness and the neuroleptic
drugs (which are the most commonly employed medications for this
disorder) on male sexual behavior in the light of what is presently known
about their interactions with hormones and neurotransmitters kpown to
play a role in male sexual behavior.

NATURE OF SCHIZOPHRENIC SEXUALITY

Whether sexuality in schizophrenic patients is of the same nature as
in nonschizophrenic individuals has been repeatedly questioned. According
to Rado (1956), there is "little doubt that the sexual differences between
the schizophrenic and other human beings are fundamental (p. 211)," that
"these differences exist throughout the entire life cycle (p. 211)," and that
"sexual concepts derived from the study of healthy and neurotic individuals
cannot be applied indiscriminately to the schizophrenic (p. 211)2' According to him "sex in the schizophrenic must be studied separately, and on
its own terms (p. 211)."
On the other hand, Arieti (1975) expresses the view that the "sexual
life of the schizophrenic and the schizophrenic-to-be [has] nothing specific
in it that could not be repeated for the nonpsychotic (p. 277)." Arieti's
views are supported by Caprio's (1957) detailed case reports, which
illustrate that unusual and peculiar sexual practices are by no means
restricted to psychotic individuals.
Nevertheless, experienced clinicians have expressed the view that
"highly distorted and even bizarre" sexual experiences are more prevalent
among schizophrenics than among the general population (Skopec e t al.,

Sexual Behavior of the Male Schizophrenic

423

1976). Unfortunately, all the aforementioned views were based on uncontrolled clinical observation, and, in the absence of controlled studies,
it therefore remains an open question whether there are really any qualitative differences between the sexual functioning of schizophrenics and nonschizophrenics.

SEXUALITY AND SCHIZOPHRENIA: CAUSE-EFFECT

RELATIONSHIP
On the basis of clinical observations and the autobiographical accounts of Dr. jur Daniel Paul Schreber, who had suffered a psychotic
illness with florid delusions of persecutory and sexual content, Freud
(1911) postulated that the main factor involved in the pathogenesis of
schizophrenia is the withdrawal of libido (sexual energy) from relationships with other people. Similarly, Rado (1962), on the basis of his clinical
experience, suggested that one of the main factors in the pathogenesis of
schizophrenia is the schizophrenics' lack of interest in sexual pleasure
because of their generally reduced ability to experience pleasure (anhedonia). Finally, Stein and Wise (1971), who found that chlorpromazine
treatment prevented both the behavioral deficits and the depletion of
brain norepinephrine induced in the rat by 6-hydroxydopamine, suggested
that the fundamental symptoms of chronic, deteriorating schizophrenia
may be the results of progressive deterioration of central noradrenergic
"reward centers."
In this context, it is of interest that Harrow et al. (1977), who gave
blind ratings for anhedonia to tape-recorded interviews of 187 psychiatric
inpatients, found that schizophrenic patients, especially chronic ones,
experience significantly more anhedonia than nonschizophrenics. Of
course, the coincidence of anhedonia and schizophrenia in a significant
number of subjects does not necessarily mean that the two have a causeeffect relationship, and it may be an oversimplification to view sexual
behavior as a strictly pleasure-seeking behavior.
In contrast to Freud's view that schizophrenia may be a result
of reduced sexual interest and activity, it has been suggested that sexual
activity itself may be a contributing factor to the development of schizophrenia. In the Text-Book o f Insanity by Von Krafft-Ebing (1904), who was
the successor of Meynert as Professor of Psychiatry and Nervous Diseases
at the University of Vienna, it is clearly stated that, in the author's experience, sexual excesses and onanism (masturbation) are among the
important factors that lead to insanity (p. 186). More recently, Pinderhughes et al. (1972), who reported on the responses of 18 psychiatrists and
122 psychiatric patients in a questionnaire survey in Boston, found that the

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Nestoros, Lehmann, and Ban

consultant and staff psychiatrists believed that sexual activity might have
been a contributing factor to the development of the illness for two-thirds
of their schizophrenic patients. The same psychiatrists were also concerned
that engagement in sexual activity could retard recovery in one-third to
two-thirds of their schizophrenic patients. In the same study, 47% of the
schizophrenic patients named sexual nctivity as a contributing factor to their
illnesses, and one-third of them believed that their recoveries would be
retarded if they engaged in sexual activity.
A third point of view has been expressed by Kaplan (1974), based
on her experience in treating patients with sexual dysfunctions. She takes
the position that for some patients sexual dysfunction may aggravate their
schizophrenia, whereas in other schizophrenic patients sex therapy may
have removed important psychological "defenses" and lead to psychotic
decompensation. The same author also describes two schizophrenic
patients (cases 4 and 33, pp. 149, 498) who were successfully treated for
sexual dysfunction and who exhibited favorable responses, in terms of
both their sexual symptoms and their overall psychological state. Her
criteria for accepting a schizophrenic patient for treatment of sexual
dysfunction are (a) a stable, compensated psychological state and (b) the
sexual symptom does not seem to "protect" the patient from schizophrenia
(Kaplan, 1974).
Finally, the view has been expressed that the schizophrenic illness
itself may have a detrimental effect on the patient's sexuality. In the study
by Pinderhughes et al. (1972), the consultant and staff psychiatrists were
concerned that the illness might interfere with the sexual functioning of
89-100% of their schizophrenic patients. In the same study, 20o70 of the
schizophrenic patients were concerned that their illness might interfere
with their sexual functioning. In addition, Johnston and Planansky (1968),
who studied the impact of chronic schizophrenia in men on their wives by
means of repeated interviews and ratings of husband-wife interactions,
found that although the wives' responses ranged from acceptance to
rejection, approximately one-half of the wives of patients were rated as
having rejected their husbands by intellectual or physical avoidance
techniques, with divorce or separation being the usual ending of the relationship. In this study, many wives stated openly that the chronic schizophrenic illness had changed their husbands and that they were no longer
sexually attracted to their husbands.

FREQUENCY OF SEXUAL ACTIVITY IN SCHIZOPHRENICS

To our knowledge (assisted by MEDLINE computerized search
of the literature from 1966 to 1980), there are only four clinical studies

Sexual Behavior of the Male Schizophrenic

425

that provide information about the frequency of sexual activity in schizophrenic patients. Obviously, the neglect of this area of research is phenomenal, especially if one takes into account that in one year alone (the
year 1979) 1129 articles on various aspects of schizophrenia were published
(again as revealed by the MEDLINE computerized search). In the first
of the four studies that deal with frequency, Lukianowicz (1963) investigated the "direction of sexual drive" (heterosexual vs. homosexual) and
the frequency of sexual activity in a group of 100 male inpatients treated
for schizophrenia of less than two years' duration and compared them
with a control group of 100 normal males and a second control group of
100 patients suffering from depression. He found not only that the schizophrenic subjects retained their premorbid sexual drive, and its particular
direction, during the first two years of their illness but that there was a
marked increase in both sexual desire and actual sexual activity. The
frequency of autoerotic activity in schizophrenic men was two,to three
times higher than in normal control men. In addition, the frequency of
heterosexual coitus in schizophrenic men was found to be higher, both
in comparison with their own premorbid level and in comparison with
the normal control men.
At variance with Lukianowicz, Rozan et al. (1971), who evaluated
pre- and postmorbid levels of sexual activity in a group of 130 newly admitted psychiatric patients (58 male, 72 female), 63.97o of whom were
schizophrenics, found that the onset of psychiatric illness was associated
with a very significant lowering of the level of reported sexual activity.
Akhtar et al. (1977) found that, out of a total of 34 inpatients of a general
hospital psychiatric unit who were identified as having displayed overt
sexual activity during a 2-year period, patients with a diagnosis of schizophrenia were underrepresented among the overtly sexually active in terms
of their percentage representation among the patient population. Patients
with character disorders and mental subnormalities engaged in sexual
acts significantly more often (p = 0.001) than schizophrenics, manicdepressives, or patients with organic brain syndromes.
Finally, in a recent study (Nestoros et al., 1980), it was found that
the sexual functioning of drug-treated, severely ill, hospitalized, chronic
schizophrenic men is different from normal controls in most aspects of
human sexuality. The differences existed even in the patient's premorbid
state, became magnified with the onset of mental illness and neuroleptic
treatment, and tended to become progressively worse with increasing age.
In this study, the ratings on a Sexual Dysfunction Inventory (a 12-item
questionnaire) of 50 male schizophrenic patients were compared with
those of 36 male normal control subjects for two time periods: (1) the
present (within the past year) and (2) the past (premorbid state for the
patients; late adolescence--early adulthood for the controls). In summary,

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Nestoros, Lehmann, and Ban

the results are the following: Of the normal subjects, 97% reported frequent
(once a day or more to once every several days) sexual urges in the past,
and 92% reported this at present, compared to only 68% of schizophrenic
patients in the premorbid state and 427o of them at present. Of the normal
subjects, 92% reported frequent (once a day or more to once every several
days) erections in the past and 86% reported them at present; this was
the case for 70% of the schizophrenics in the premorbid state and for
only 34% of them at present. None of the normal subjects, either in the
past or at present, reported that they had erections only rarely (once a
year or less often), but this was the case for 12% of schizophrenic patients
in the premorbid state and 427o of them at present. Within the previous
year, 22% of schizophrenic patients reported frequent (dysfunction more
often present than absent) masturbatory impotence, 10% of them frequent
(dysfunction more often present than absent) retardation of ejaculation,
and 32O7o frequent (dysfunction more often present than absent) complete
inability to ejaculate; none of the normal subjects, either in the past or at
present, reported this, and none of the schizophrenic patients reported
it for the premorbid state.
The predominant type of sexual activity was heterosexual for 58%
of the normal subjects in late adolescencehearly adulthood and for 86%
of them within the previous year, but heterosexual activity was reported by
only 8% of the schizophrenic patients for the time prior to the onset of
mental illness and by only 270 of them within the previous year. Instead,
for 76o70 of the schizophrenic patients prior to the onset of mental illness
and for 3470 of them within the previous year, the predominant type
of sexual activity was autoerotic, in contrast to only 19% of normal subjects
in late adolescence--early adulthood and 6% of them within the previous
year. A striking finding was that 34% of schizophrenic patients within
the previous year--and 14% of them in the premorbid state--reported
that they did not engage in any kind of sexual activity or ideation. Typical
responses of these patients were as follows: " M y sex life is zero." "I've
lost all interest in sex." "Sex feelings for me have been nonexistent for a
long time." None of the normal subjects gave this kind of response for
either the past or the present.
Nestoros et al. (1980) have also explored the possible correlations
between dosage and chemical class of neuroleptic medications and the
frequencies of sexual activity and sexual dysflanction reported by the
schizophrenic patients. Their findings are reported later in the following
section of this review.
It must be stressed that the aforementioned clinical studies addressing the frequency of sexual behavior in schizophrenic patients suffer
from three serious limitations: (1) none of these studies has employed a
reliable and valid method to measure the aspects of sexual behavior that

Sexual Behavior of the Male Schizophrenic

427

were addressed; (2) with the exception of the study by Nestoros et al. (1980),
who studied severely ill, chronic schizophrenic patients with poor prognosis, no attempt was made to examine a homogeneous subgroup of
schizophrenic patients in terms of diagnosis; (3) none of these studies has
employed measurements addressing the effects of hospitalization per se on
the sexual behavior of these patients.
The consistent finding that schizophrenic patients with a history
of marriage (Malamud and Render, 1939; Vaillant, 1964; Stephens et al.,
1966) or heterosexual involvement (Wall, 1941; Counts and Devlin, 1954;
Bromet et al., 1974) respond more favorably to somatic treatments (insulin
shock, electric shock, pharmacotherapy) suggests the possibility that
certain subgroups of schizophrenic patients with good prognosis may
exhibit differences in sexual behavior from other, poor-prognosis subgroups. In conclusion, although there are strong indications that the sexual
behavior or schizophrenic patients is quantitatively different from that
of normal controls and patients with other psychiatric disorders, this
issue remains a matter of controversy and awaits clarification by future
research.

NEUROLEPTIC DRUGS AND SEXUAL FUNCTION:

THE CLINICAL STUDIES
The introduction of neuroleptics in the early 1950s has added one
more dimension to the already complex and little known domain of
sexuality of schizophrenic patients, since it was soon discovered that these
drugs produce significant alterations in many parameters of sexual function. The initial observations consisted of case reports that thioridazine
may cause inhibition of ejaculation (Freyhan, 1961; Heller, 1961; Singh,
1962; Taubel, 1962; Witton, 1962; Shader, 1964; Greenberg and Carrillo,
1968). Consequently, other neuroleptics, such as chlorpromazine (Bolelouck, 1965; Greenberg, 1971) and mesoridazine (Shader, 1972) were
reported to have the same side effect.
Blair and Simpson (1966) investigated systematically the effects of
a variety of neuroleptics (perphenazine, trifluoperazine, butaperazine,
reserpine, and two butyrophenones at an experimental stage - WY 6123
and WY 3457) on the ejaculations produced in 35 chronic schizophrenic
patients by means of a mechanical vibrator described by Sobrero et al.
(1965). The ejaculation reflex was tested prior to, during, and after neuroleptic treatment. Prior to neuroleptic treatment (the drug-free period lasted
for at least 6 months), there was only rare inability to ejaculate (less than
2% of trials). During the neurolpetic treatment, there was partial or total
interference with ejaculation 64.2-100% of trials, depending on the par-

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Nestoros, Lehmann, and Ban

ticular neuroleptic used. Ejaculation returned to pretreatment levels between 1 and 8 weeks after cessation of neuroleptics.
Finally, case reports appeared that neuroleptics may cause not only
inhibition of ejaculation, without any other dysfunction, but also decreased
libido, erectile impotence, and interference with orgasm (Haider, 1966;
Greenberg, 1971). Kotin et al. (1976) interviewed 87 male psychiatric
patients (75 were schizophrenic) who engaged in sexual activity while on
neuroleptics and found that 44% of patients receiving thioridazine and
1970 of patients on other neuroleptics reported difficulties in achieving
erection; 35% of patients on thioridazine and 11% of patients on other
neuroleptics reported difficulties in maintaining erection; and 4 patients
on thioridazine and 2 patients on other neuroleptics reported changes in
the quality of orgasm. Furthermore, it has been established that the semen
of drug-free schizophrenics is morphologically essentially normal (Blair
et al., 1969) but that neuroleptics produce a variety of abnormalities in
spermatogenesis (Simpson et al., 1964, 1966; Kline er al., 1968).
It is of interest that low doses of benperidol, a butyrophenone,
have been reported to "inhibit impulsive sexual behavior, whether neurotic
or delinquent, without interfering with normal sexual activity" in 52 out
of 54 nonpsychotic sexual offenders who committed exhibitionism or
indecent assault (Deberdt, 1971) (p. 396).
Only one study (Nestoros et aL, 1980) has thus far attempted to
evaluate systematically the influence of either the chemical class or the
dosage of neuroleptic medications on the frequency of sexual activity
and the frequency of sexual dysfunction among schizophrenic patients.
It is of interest that this study failed to find any clear, statistically significant
and consistent influences of either the chemical class or the dosage of
neuroleptic medications on the frequency of sexual activity or the
frequency of sexual dysfunction among the chronic schizophrenic patients
studied. Actually, the percentage of patients reporting frequent or occasional sexual urges, erections, intercourse, or masturbation was highest
in the high-dosage group and in those patients who received aliphatic
together with piperazine phenothiazines as well as antiparkinson drugs.
This suggests that the dosage and class of neuroleptic drugs is only one
of many factors involved in the sexual behavior of the schizophrenic
patient. The extent to which the neuroleptic treatment contributed to the
exaggeration of the distinct differences reported by these investigators
between the schizophrenic patients and the normal control subjects within
the previous year as compared to the period prior to the onset of mental
illness cannot be ascertained, since Nestoros er al. (1980) were not able
to study the same group of patients in the drug-free state. Furthermore,

Sexual Behavior of the Male Schizophrenic

429

they could not compare the information on the sexual behavior of their
group to that of a similar group of schizophrenic patients studied in the
preneuroleptic era because this information is not available. However,
although the classical textbooks (Kraepelin, 1913; Bleuler, 1950) refer to
it only fleetingly, frequent and openmasturbation by chronically psychotic,
hospitalized patients was considered to be a common clinical "problem."
Although nobody has reported whether these patients could achieve normal
erection, ejaculation, and orgasm, this is hardly the picture that is presented
by the group of schizophrenic patients studied by these investigators.

HORMONES AND MALE SEXUAL BEHAVIOR

There is now abundant evidence that hormones, especially the
androgens, the gonadotrophins (luteinizing hormone, LH; follicle-stimulating hormone, FSH), and prolactin affect male sexual behavior (see
reviews by Young, 1961; Manning, 1971; Davidson and Levine, 1972).
Furthermore, there is abundant evidence that steroid hormones exert
some of their influence on sexual behavior by direct action on specialized
neurons in the central nervous system (see overview by Davidson, 1971).
The role of androgens in male sexual behavior has recently been
reviewed by Davidson (1977). As for the gonadotrophins, LH stimulates
the interstitial cells of the testis to excrete androgens, and both LH and
FSH are necessary for the full development of mature sperm (Odell and
Moyer, 1971; Hafez and Evans, 1973). Until recently, the function of
prolactin was poorly understood, but progress is being made in the
clarification of its effects (Horrobin, 1973, 1975). Hyperprolactinemia has
been associated with decreased fertility and hypogonadism in man (Friesen
and Hwang, 1973; Boyar et al., 1974; Franks et al., 1976), and it has been
reported that sulpiridine-induced elevation of prolactin interferes with the
conversion of testosterone into its active metabolite dihydrotestosterone
(Margrini et al., 1977).

NEUROLEPTIC DRUGS AND SEX HORMONES

Since it is known that phenothiazine and butyrophenone neuroleptics both suppress LH and FSH and stimulate prolactin (see reviews
by Givant and Sulman, 1976; Clemens, 1976), one would expect a detrimental effect of these psychopharmaceuticals on sexual behavior.

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Nestoros, Lehmann, and Ban

SCHIZOPHRENIC ILLNESS AND SEX HORMONES

Gonadotrophins
Suwa et al. (1966) found that the levels of total urinary gonadotrophins were different in a group of "considerably emotionally disturbed"
patients than in groups of normal controls and psychiatric patients with
"stabilized clinical condition." The total urinary gonadotrophins were
suppressed in the emotionally disturbed patients, regardless of diagnosis,
with one-third of them showing a transient increase in total gonadotrophins
"at the height of the psychic aggravation." Unfortunately, the patients in
this study were receiving neuroleptic drugs and no provisions were made
to differentiate the drug effect from the effect of the psychosis on the
gonadotrophin levels. In another study, Brambilla and Penati (1970)
found that significant percentages of drug-free, acute and chronic schizophrenic patients showed reduced total urinary gonadotrophin levels (637o
of acute hebephrenics, 70070 of acute paranoids, 78% of chronic hebephrenics, and 30070 of chronic paranoids). The same authors reported that,
in a group of 22 male, chronic schizophrenic patients treated with haloperidol, the total urinary gonadotrophin secretion was increased within
15 days of therapy from low to normal values and returned to the pretreatment low values after withdrawal of the drug. However, total gonadotrophin levels do not clearly reflect individual gonadotrophin levels. In
conclusion, although the effect on individual gonadotrophins remains
unknown, there are some indications that schizophrenic illness can decrease
total gonadotrophin levels and thus have an effect of its own on sexual
behavior.

Androgens
Brambilla and Penati (1970) reported that a significant percentage
of drug-free acute and chronic schizophrenic patients have low androgen
secretion, as judged by the measured low levels of 17-ketosteroids. However, 17-ketosteroid excretion rates are a poor index of androgen production because they derive not only from the metabolism of androgens but
also from the metabolism of cortisol and cortisone. Tourney and Hatfield
(1973) studied the androgen metabolism of drug-free schizophrenics (acute,
chronic institutionalized and chronic noninstitutionalized) by measuring
plasma testosterone, dehydroepiandrosterone, and androstenedione and
urine 17-ketosteroids, androsterone, and etiocholanolone. They found a
significant reduction of plasma dehydroepiandrosterone in chronic schizophrenics that was independent of age and institutionalization. The other

Sexual Behavior of the Male Schizophrenic

431

indices measured were within the range of t h e normal control group.

Since 93% of dehydroepiandrosterone is produced by the adrenal cortex
and only the remaining 7% by the testis (Hudson et al., 1967), the findings
of this study might indicate some failure in adrenal cortical rather than
testicular function (Tourney and Hatfield, 1973). Finally, at variance with
Brambilla and Penati (1970), who foun:d low levels of 17-ketosteroids in
drug-flee schizophrenics, and Tourney and Hatfield (1973), who found
normal levels of 17-ketosteroids, Matsumoto et al. (1966) found that the
urinary excretion of 17-ketosteroids in drug-free schizophrenic patients
was consistently higher than that of normal controls. Therefore, the
effect of schizophrenic illness on androgen secretion and metabolism
remains controversial. However, the possibility that the psychosis by itself
can influence sexual behavior by changing the levels of circulating androgens is an interesting one that can be tested in controlled experiments.

D O P A M I N E A N D MALE SEXUAL BEHAVIOR

A wealth of experimental evidence suggests that dopamine plays

an excitatory role in the modulation of many parameters in the sexual
behavior of the male rat. Thus, dopamine agonists, such as apomorphine,
and treatments that elevate brain dopamine, such as L-dopa administration,
stimulate sexual behavior, whereas dopamine antagonists suppress sexual
behavior, in the male rat (see review by Gessa and Tagliamonte, 1975).
In agreement with the findings of experiments with animals it was
observed that the sexual functioning of some parkinsonian patients
improved during L-dopa therapy, with a few becoming hypersexual (for
reviews o f the L-dopa studies, see Brogden et al., 1971; Goodwin et al., 1971).
For example, O'Brien et al. (1971) found that six of nine male parkinsonian
patients treated with high dosages (4-6 gm/day) of L-dopa reported
spontaneous penile erections, and one resumed successful intercourse
after 3 years of impotence.
Three studies were specifically designed to evaluate the effects of
L-dopa on human sexual functioning. Benkert (1972) administered up to
5 gm of L-dopa daily for up to 12 weeks to ten male patients with primarily
organic impotence, six of whom had undergone unsuccessful testosterone
treatment. He found that in 6 patients there was a temporary small increase
of penile erection after 2 to 4 weeks of therapy and that in one patient this
increase in penile erection was permanent. However, in none of Benkert's
patients were libido and penile erection increased enough to achieve
satisfactory intercourse. In the second study, carried out by Hyypp~ et al.
(1975b), parkinsonian patients undergoing L-dopa therapy were systematically evaluated for their subjective ratings of guilty attitudes toward

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Nestoros, Lehmann, and Ban

sex, their sexual responses to Thematic Apperception Test pictures, and

their subjective emotions during an erotic color film. None of the ratings
changed for any of the four male patients after a 3-month period of L-dopa
treatment. The authors concluded that socioeconomic and psychological
factors determine sexual motivation in human beings to such an extent
that it is very difficult, even with a very potent neuropharmacological
drug, such as L-dopa, to influence their sexual motivation. The most
striking effects of L-dopa on male human sexual behavior have been
reported in the last of the three studies, carried out by Angrist and Gershon
(1976). They found that 2 of 6 schizophrenic patients who were administered L-dopa expressed increased somatic delusions of sexual content,
and 1 of 6 exhibited marked "bizarre," overt sexual behavior. Furthermore, these investigators found that 3 of 6 nonschizophrenic subjects
became hypersexual during L-dopa administration. One of them experienced frequent erections with minimal stimulation, the second had a
return of erections after several years of absence, and the third exhibited
marked hypersexuality with compulsive masturbation (4 to 5 times per
day).

DOPAMINE, SCHIZOPHRENIA, AND NEUROLEPTIC DRUGS

All recent reviews of the available evidence (Meltzer and Stah!,

1976; Carlsson, 1978; Volavka et al., 1979; Stefanis and Issidorides,
1979) conclude that dopaminergic mechanisms occupy a strategic position
in the functions that are disturbed in schizophrenia and that inhibition of
central dopamine functions appears to be a common basic property of
all neuroleptic drugs. In fact, there is evidence suggesting that there is a
good correlation between the clinical antipsychotic potenty of neuroleptics
and their potency to bind stereospecifically with the postsynaptic dopamine
receptor (Creese et al., 1976; Seeman et al., 1976). In view of the above,
one would theoretically expect that schizophrenic episodes will be associated with increased sexual activity and that neuroleptic drugs will suppress male sexual behavior.

SEROTONIN AND MALE SEXUAL BEHAVIOR

A wealth of ~experimental data suggests that serotonin plays an
inhibitory role in the modulation of many parameters in sexual behavior
of the male rat. First, parachlorophenylalanine (PCPA), a potent inhibitor
of tryptophan hydroxylase which leads to depletion of brain serotonin
(5-hydroxytryptamine), has been found to have an aphrodisiac effect on

Sexual Behavior of the Male Schizophrenic

433

male rats (see reviews by Gessa and Tagliamonte, 1973, 1974, 1975).
Similarly, aphrodisiac effects on male rats were found after marked
depletion of brain serotonin following a tryptophan-free diet (Fratta et al.,
1977) and after selective destruction of the serotonin neurons of the raphe
nuclei by injecting 5,6-dihydroxytryptamine (5,6-DHT) (Gessa and Tagliamonte, 1975). Furthermore, Quibazine, 2-(1-piperazinyl)quinoline maleate,
a drug which stimulates both peripheral and central serotoninergic receptors (serotoninergic agonist), was found to inhibit mounting behavior
of male rats (Grabowska, 1975). Finally, administration of 5-hydroxytryptophan, which is the precursor of serotonin, produced inhibition of
sexual behavior of male rats (Tagliamonte et aL, 1969; Gessa et aL, 1970).
In contrast to the results with rats, all experiments with monkeys
have consistently failed to show any increase in sexual mounting, copulation, or masturbation during PCPA treatment (Redmond et al., 1971;
Maas et al., 1973; Boelkins, 1973; Zitrin, 1973). In addition, all attempts
so far to influence male sexual behavior in humans with serotonin depletors
and serotonin precursors have been unsuccessful.
In an uncontrolled clinical trial with six normal prison volunteers,
3000 mg of PCPA produced tiredness, dizziness, fullness in the head,
paresthesia, headache, and constipation, but no changes in sexual function
(Cremata and Koe, 1966). Similarly, Cremata and Koe (1968), in a second
uncontrolled study with nine normal prison volunteers, found that doses
of PCPA that produced a decline in blood serotonin to 60-707o of pretreatment levels and urinary 5-hydroxyindoleacetic acid (5-HIAA) to
10-5070 of pretreatment levels induced all the aforementioned side-effects,
but no effects on sexual behavior. In a third study, Sjoerdsma et al. (1970)
administered PCPA to seven patients (four male and three female) with
carcinoid syndrome in a placebo-controlled double-blind study and found
no changes in sexual behavior, sexual thought content, or self-rated
interest in sex, in spite of the documented inhibition of serotonin synthesis
as measured by the decrease in urinary 5-HIAA. In a fourth study, Benkert
(1975) administered L-5-hydroxytryptophan (L-5-HTP), a precursor of
serotonin, in combination with a decarboxylase inhibitor (Ro4-4602) in
a placebo-controlled study to five male human subjects suffering from
exhibitionism or increased sexual behavior and to four male human subjects with normal sexual behavior; again, no changes in sexual behavior
were found. Finally, Hyyppa et aL (1975a) administered L-tryptophan,
a precursor of serotonin, to three male human subjects suffering from
multiple sclerosis and found no alterations in the sexual parameters tested
(including response to a pornographic film).
In contrast to these studies with male subjects, Lovett Doust and
Huszka (1972) administered L-tryptophan in combination with phenelzine,
a monoamine oxidase inhibitor that prevents the degradation of serotonin,

434

Nestoros, Lehmann~ and Ban

and found that 5 of 7 female chronic schizophrenic patients, who were

also receiving neuroleptic drugs, exhibited compulsive pathological sexual
activation.
Whereas serotonin depletors and serotonin precursors alone were
not found to affect male sexual behavior in man, Sicuteri et al. (1975) have
reported that, in an open controlled study with 16 sexually deficient men,
the combination of PCPA with testosterone had a much stronger aphrodisiac effect than testosterone alone. Testosterone has been implicated
previously as playing an essential role in the sexual stimulation induced by
PCPA in male animals by Gessa et al. (1970), who found that none of the
castrated male rats treated with PCPA alone showed any sexual behavior,
whereas castrated rats treated with PCPA and testosterone showed far
more sexual excitation than intact rats treated with PCPA alone~

SEROTONIN AND NEUROLEPTIC DRUGS

At present, very little is known about the interaction of neuroleptics with serotonin, but the available evidence suggests that different
neuroleptics exert different effects on serotonin functions that may vary
from synergism to antagonism. Green (1977) found that repeated chlorpromazine administration increased a behavioral response in rats that
he believed to be the result of serotonin receptor stimulation, Fuller and
Wong (1977) found that chlorpromazine inhibits the reuptake of serotonin
by nerve terminals, and Bender (1976) observed that the brain serotonin
pool in the rat was increased following single and repeated chlorpromazine
administration. Furthermore, Ruch et al. (1976) found that clozapine
increased the levels of tryptophan, serotonin, and 5-hydroxyindoleacetic
acid in the brain of the rat. All the above suggests that at least some neuroleptics may facilitate serotonin functions. Also, it is of interest that serotonin was found to facilitate the catalepsy induced by some neuroleptics
(Kostowski et al., 1972; Costall et al., 1975). However, Ruch et al. (1976)
found that haloperidol, thioridazine, and loxapine, in contrast to clozapine,
did not increase the concentrations of tryptophan, serotonin, and 5-hydroxyindoleacetic acid in the brain of the rat. Dray et al. (1976) showed that
a-flupenthixol, applied by microiontophoresis, antagonized the effects of
serotonin on substantia nigra neurons, and Gallager and Aghajanian
(1976) found that the activity of serotonergic neurons in the dorsal raphe
nucleus was inhibited by the intravenous administration of certain neuroleptics (methiothepin, clozapine, and thioridazine), whereas other neuroleptics (chlorpromazine, haloperidol, and pimozine) had no effect.

Sexual Behavior of the Male Schizophrenic

435

In conclusion, the available data suggest that some neuroleptics may

facilitate, and other neuroleptics may antagonize, the serotonin-mediated
inhibition of sexual behavior in the male rat. Whether this also applies to
human males remains an open question.

ACETYLCHOLINE AND MALE SEXUAL BEHAVIOR

In a series of experiments with male rats, it has been found that
nicotine, a cholinergic agonist, facilitates all components of sexual behavior, whereas atropine, a cholinergic antagonist, produces extinction of
sexual behavior (Bignami, 1966; Soulairac and Soulairac, 1975). Furthermore, Heath (1972) has reported that in human subjects the intraseptal
administration of acetylcholine produced orgastic behavior indistinguishable, by EEG and subjectively by the patients, from spontaneous
coitus.

ACETYLCHOLINE AND NEUROLEPTIC DRUGS

Many neuroleptic drugs have anticholinergic properties, and Snyder
et al. (1974) have provided evidence that the relative affinities of neuro-

leptic drugs for muscarinic cholinergic receptor binding in the brain correlate inversely with their extrapyramidal side-effects.
On the basis of the above, one would theoretically expect that
neuroleptics, with strong anticholinergic properties will produce less extrapyramidal side-effects and more sexual dysfunction. The findings that
thioridazine, which as compared to chlorpromazine, produces less extrapyramidal but more sexual side-effects (Lehmann, 1975) is consistent with
this hypothesis. However, in the absence of more data, no definite conclusion is warranted.

THE PARADOX
Most of what has been mentioned so far points to the conclusion
that neuroleptic drugs have a variety of detrimental effects on male sexual
functioning and fertility. Therefore, one would expect that the introduction of neuroleptics in the early 1950s would have decreased even further
the low reproductive rates of schizophrenics. In fact, the opposite was
found to be true, for both male and female schizophrenics. Erlenmeyer-

436

Nestoros, Lehmann, and Ban

Kimling et aL (1969), who studied two cohorts of schizophrenic patients

admitted in 1934-1936 (preneuroleptic era) and 1954-1956 (postneuroleptic
era), found that patients of both sexes, and all age groups in the later
cohort, showed increases both in the rate of marriage and in reproductive
rate in comparison with those of the earlier cohort. Furthermore, Slater
et al. (1971) found that the marital fertility of schizophrenic men and
women was 73.7 and 73.0%, respectively, of comparable census values,
which is much higher than the fertility rates found by Essen-Mbller
(1935) in the preneuroleptic era; Essen-Mbller's rates were less than 50%
of normal for schizophrenic men and about 25% of normal for schizophrenic women. Thus, the introduction of neuroleptic drugs has been
associated with an increase in the reproductive rates of schizophrenics.
This increase in the postneuroleptic era can be attributed to various
factors. In the first place, it has been suggested that the introduction of
neuroleptics initiated a therapeutic revolution which went far beyond the
direct pharmacological effects of the drugs on patients (Davis and Cole,
1975). The length of hospital stay was decreased, many patients were
treated effectively without hospitalization, and, for those remaining in the
mental hospital, at least some of the disruptive and destructive aspects
of their illness were controlled. All these effects led to a series of profound
changes in the attitudes of both hospital personnel and society in general
(Davis and Cole, 1975), resulting in schizophrenics having available to
them more years of community life as well as more opportunities for
marriage and reproduction (Erlenmeyer-Kimling et al., 1969).
Furthermore, the possibility that certain schizophrenic patients may
function sexually better while taking neuroleptics than when they are drugfree cannot be ignored. In these patients, the facilitation of sexual functioning produced by the alleviation of psychotic anxiety, thought disorganization, fear of physical intimacy with potential sexual partners,
and other symptoms that can be expected to interfere with the patient's
sexual functioning may be more significant and outweigh the detrimental
effects of the drugs on sexual functioning. The antipsychotic effects of
these drugs are presumably mediated by certain brain structures which
are responsible for the so-called higher-mental or psychological functions.
The evidence that extrahypothalamic areas, including some of those that
have been associated with "psychological functions," such as the amygdala
and the hippocampus, can influence the mediobasal hypothalamus and the
anterior pituitary-gonadal function has been reviewed recently by
Ellendorff (1976). This evidence provides the link between the various
brain areas which are candidates for being the location where the antipsychotic effects of neuroleptic drugs are exerted and the brain areas which
have been associated with the expression of sexual behavior. Since our
knowledge of brain-mind relationships is still very limited and the topic is

Sexual Behavior of the Male Schizophrenic

437

highly controversial (Penfield, 1975; Brown, 1976; Popper and Eccles,

1977; Bunge, 1977), this hypothesis cannot be expressed in more specific
terms.
Finally, one of the possible ways in which neuroleptics may have
increased the reproductive rates of schizophrenic patients is through
changing the ratio between the various subtypes of schizophrenia. It has
been found by Larson and Nyman (1973) that hebephrenic and catatonic
schizophrenics have lower reproductive rates than paranoid schizophrenics.
Concurrenly, Morrison (1974) has found that, in the postneuroleptic era,
the incidence of hebephrenic and catatonic schizophrenia has markedly
decreased. It has been suggested that the introduction of neuroleptic drug
therapy may have been one of the causes of these changes in the ratio between the subtypes of schizophrenia (Morrison, 1974).

CONCLUSION
A multiplicity of factors are involved in the sexual behavior of the
male schizophrenic patient. These factors include the following: (a) the
type and severity of the schizophrenic symptoms that he is experiencing;
(b) the attitudes of the society in which he lives toward his illness and
toward sexual behavior; (c) the state of his dopaminergic, serotoninergic,
and cholinergic neurotransmission; and (d) hormonal factors. Obviously,
any treatment that he receives will exert effects on his sexual behavior that
will reflect the effects of the treatment on one or more of the above factors.
Since dopamine plays an excitatory role in male sexual behavior, according to the dopamine hypothesis of schizophrenia one would expect
schizophrenic patients to be hypersexual. Furthermore, since neuroleptics
block dopamine receptors, one would expect that these drugs will simply
suppress male sexual behavior. However, many schizophrenic symptoms
exert deleterious effects on sexual behavior. In addition, it appears that
the beneficial effects of neuroleptic drugs on the patient's schizophrenic
symptoms and on the attitudes of society toward him outweigh the suppression of sexual behavior produced by the blocking of dopaminergic
neurotransmission. In conclusion, the sexual behavior of the male schizophrenic provides an important forum for the study of the interaction and
relative importance of the various psychological, sociological, and biochemical-pharmacological factors which determine sexual behavior.

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