Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Chronic alcoholism and male sexual dysfunction Raul C. Schiavi To cite this article: Raul C. Schiavi (1990) Chronic alcoholism and male sexual dysfunction, Journal of Sex & Marital Therapy, 16:1, 23-33, DOI: 10.1080/00926239008405963 To link to this article: http://dx.doi.org/10.1080/00926239008405963
Published online: 14 Jan 2008.
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Date: 06 November 2015, At: 13:34
Chronic Alcoholism and Male Sexual Dysfunction Downloaded by [NUS National University of Singapore] at 13:34 06 November 2015
RAUL C.SCHIAVI
Chronic alcoholism cun profoundly influence marital relationships, but the nature of the effect of alcohol abuse on sexual interactions is not clear. This article critically reviews information on the prevalence of sexual disorders and possible endocrine, neurologac, and psychologic processes that may mediate the effects of chronic alcoholism on male sexual functioning. Emphasis is placed on a conceptual model that integrates biologic and psychologic perspectives, moving away from simplistic unidimensional approaches to the study of the behavioral effects of this serious medical and social problem. Sexual disorders have been frequently reported in chronic alcoholic men, but effective treatment a n d preventive measures have been limited by the paucity of empirical data regarding the nature, prevalence, and pathogenesis of their sexual difficulties. T h e stimulus for the present review stems from the frequent association between alcoholism a n d sexual dysfunction observed over the past 17 years in the Sexual Dysfunction Clinic at the Mount Sinai School of Medicine. It has been prompted by the difficulty in identifying relevant pathogenic mechanisms a n d in developing appropriate therapeutic interventions in patients with various alcoholic histories, concurrent illnesses, and medications. Alcoholic intake may have acute as well as chronic effects in sexual functioning a n d behavior. Acute alcohol studies have demonstrated the important roles that expectation, cognitive processes, a n d social conditions have in interaction with the pharmacologic action of the d r u g on sexual arousability.'-6 'The focus of this selective review is on the chronic effects of alcohol. It summarizes data o n the prevalence a n d nature of sexual difficulties in chronic alcoholic men a n d considers hormonal, neurologic, a n d psychologic factors that may contribute to the development and maintenance of their sexual problems. It is hoped that this overview will identify promising Raul C. Schiavi, MD, is at the Human Sexuality Program, Department of Psychiatry, Mount Sinai School of Medicine. 1 Gustave L. Levy Place, New Y o l k , N Y 10029. This review was conducted with the support of Public Health Service Grants DK 39106 and AG 06895. T h e manuscript was prepared with the valuable assistance of Ms. Natalie Weinstein.
Journal of Sex & Marital Therapy, VoI. 16, No. 1 , Spring 1990, Brunner/MazeI, Inc.
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Chronic Alcoholism and Male Sexual Dys/unclion
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avenues of investigation which may help clarify the impact of alcoholism, one of' the most prevalent diseases of o u r time, on the sexual life of patients.
Knowledge about the chronic effect of alcohol o n sexual functioning is derived f'rom two sources: alcoholic patients a n d patients with sexual disorders. I n 1973, Lemere arid Smith' reported that 8% of 17,000 patients treated for alcoholism suffered froni impotence a n d that in approximatelv half of them the problem persisted after prolonged sobriety. Other investigators8 - l 5 have since confirmed a n d expanded evideiicc o n the deleterious effect of alcohol in sexual functioning. T h e reported prevalence of impotence ranges from 8% to 54% arid lack of sexual desire f'rorn 3 1 % t o ,5876 o f the subjects (see Table 1). Differences in the clinical composition of the samples undoubtedly contribute t o discrepancies i n f'requeiicv. Some studies have been conducted on inpatients at various times aft& admission f'or detoxification, while others have been carried out o r i outpatients still drinking alcohol or under treatment with tlisulfiram (..\NI'ABUS). Additional methodological problems originate f'rom the varied definitions of alcoholism and sexual dysfunction; the confounding effects of aging, physical illness, a n d medications; the retrospectivt. nature of' the reports; a n d the lack of spouse participation i r i the psychosexual assessment. As noted in Table 1, there have been only t w o controlled studies o n the effect of'chronic alcoholism o n sexual function. Whalley"' conipared the sexual behavior of 50 hospitalized alcoholic men with a matched sample from the general population. Erectile impotence was ment.ionetl significantlv more by alcoholics (54470) than controls (28%). A considerable number of' subjects had been taking psychoactive drugs prior to hospitalization, a n d 'they were interviewed on the sixth day after admission while under psychotropic medication. Jensen'? conducted a comparative study of' 30 outpatient married male alcoholics a n d a n age-matched control g r o u p froni a general practitioner's clinic. Sixty-three percent of the alcoholics a n d 1 0 % of the control g r o u p reported sexual dysfunctions, mainly disorders of sexual desire a n d arousal. Half of the alcoholic men claimed that their sexual problems began with the initiation of treatment with disulfir-am. Although all the subjects were married, their wives were not interviewed for validation of their husbands' reports. Studies on the prevalence of alcoholism among sexually dysfunctional patients a r e remarkably few. Masters a n d Johnson16noted that in 35 from a total of 2 13 men with secondary impotence, the erectile disorder occurred as a direct result of acute alcoholic iiitake. N o information was provided o n the effect of chronic alcohol intake in their subject sample. Fagan et. al." studied 145 consecutive patients with sexual problerns at the Sexual Consultation Unit of the Johns Hopkins Hospital. Twentynine percent of these patients scored on the probable a l c o h c h n range in the Michigan Alcohol Screening Test (MAST), a widely-used instru-
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Chsotiic Alcoholism and Male Sexual Dy.function
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ment for identifying alcoholic patients. However, only six of these patients were diagnosed as having alcoholism by routine clinical evaluation procedures. T h e authors conclude that “alcoholism largely goes undetected among patients who present with sexual problems.” In summary, this review supports the hypothesis of an association between alcohol abuse and sexual dysfunction. ‘The data suggest that the chronic effect of alcohol is not limited to erectile impotence, but also t o disorders of sexual desire. Conclusions about the nature, degree and significance of this association are restricted, however, by the heterogeneity of the populations, methodological problems, and unsystematized or incomplete information. NOCTURNAL PENILE TUMESCENCE ASSOCIATED W I T H SLEEP IN ALCOHOLIC MEN
An important limiting factor in the study of chronic alcoholism and sexual function has been the lack of an objective indicator of erectile capacity. Although recording of noctural penile tumescence during sleep provides a potentially valuable method to assess physiological mechanisms, studies concerning NPT in alcoholic men are very few. Snyder and Karacani8evaluated, during 2 nights in the sleep laboratory, 26 sober chronic alcoholics who w e r e healthy, free from medications, and without sexual dysfunctions. T h e subjects had diminished tumescent latency and decreased number and duration of maximum penile tumescent episodes as compared to age-matched nonalcoholic subjects. T h e authors speculated that the deleterious effect of alcohol on sleep-related erections may be d u e to central as well as peripheral neuropathology. Snyder et al.I9 found that disulfiram significantly decreased the frequency and duration of full erections in abstinent alcoholics evaluated within a double-blind experimental design. This finding is of particular importance because of the possible confounding effect of disulfiram on investigated N P T the reported frequency of sexual disorders. T a n et in 13 abstinent impotent alcoholics; seven men, who had nocturnal erections with a circumference change of more than 16mm, were considered psychologically impotent, while the remaining six men with erections of a lesser degree were diagnosed as “organic patients.” In this latter group, the authors found elevated levels of plasma gonadotrophins in the presence of normal circulating testosterone. Duration of abstinence may be a factor in the differences obtained; patients with “organic impotence” had been sober for a shorter period at the time of the investigation than the subjects categorized as having psychogenic impotence. T w o areas of inquiry that need to be taken into account in the interpretation of NP’T findings are the effect of alcohol on sleep variables and the occurrence of sleep disorders in chronic alcoholics. Acute ethanol intake increases slow wave sleep, decreases REM periodicity and R E M duration, and increases the fragmentation of REM periods.“-*” Chrqnic alcoholism, on the other hand, has inconsistent effects on sleep, possibly because of differences in clinical status, age, addiction, severity, and time
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Jouwial vf Spx i9 Marital Thew&. Vol. 16. N o .
I , Spnng I990
elapsed since alcohol withdrawal. Considerable attention has been paid in recent years to the relation between sleep disorders and medical illnesses.2"-26Sleep disorders may be associated with erectile impotence in physically healthy men, but their prevalence in chronic alcoholics has not been systematically assessed. T h e r e is a high probability, particularly in older subjects, of finding sleep disturbances such as sleep apnea syndrome and periodic leg movement disorders. Unless identified, measured and controlled, alterations in sleep patterns and sleep abnormalities may confound the evaluation of noctural erectile activity. I.'ITL'ITAHY-GONADAI, FUNCTION ABNORMALITIES A N D S E X U A L BEHAVIOR Chronic illcoholism and Pituitar)-C;onciduL Function
Considerable information has accumulated on the deleterious effect o f alcohol in testicular a n d hypothalamic pituitary function. Chronic alcoholic men, independent from evidence of liver disease, frequently show signs of hypogonadism, abnormalities in spermatogenesis, and testicular atrophy.27 Ethanol can have a direct toxic effect o n the testes with a resulting diminution in testosterone secretion." In addition, there is evidence of a dysfuriction at the hypothalamic-pituitary level as shown by the inappropriately low LH secretion in the face of marked hypoandrogenization, and by the defective LH responses to clomiphene or LH-KH administration.2"+3"Hyperprolactinemia is frequently observed in chronic alcoholics with, as well as without, liver disease. T h e sleep-related increase in plasma prolactin secretion is diminished and the responscs to provocative challenge with stimulators a n d inhibitors of prolactin release may also be a b n ~ r r n a l . Disturbances ~' in prolactin secretion could play an important role, not only by facilitating the development of hypogonadism, but also by its direct effect o n sexual behavior. In addition to being hypogonadal, chronic alcoholic men may show signs of hyperoestrogenization a n d have elevated plasma oestrone levels." ?? T h e mechanisms involved have not been fully elucidated yet, but may include increased conversion of weak adrenal androgens to estrogens, alterations in estrogen-binding protein in the liver, and abnormalities in estrogen receptor activity. Liver disease is a common complication in the chronic alcoholic, and it has been assumed that hepatic damage is responsible for the endocrine changes in alcoholism. 'This explanation has been challenged, however, by recent Sleep, as an important synchronizer of endocrine rhythms, provides a means to observe CNS control of pituitary-gonadal activity. Although i t is well known that ethanol alters normal sleep pattcrns, investigations on the effect of alcohol in sleep-hormonal regulation are almost nonexistent. T h e r e is, to o u r knowledge, only one controlled study of this kind on five normal volunteers.'" Ethanol administration reduced the nighttime, sleep-related, growth hormone secretory episodes w'ithout significant alterations in cortisol secretion.
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Pituitary-Gonadal Function and Sexual Behavior
Recent investigations have clarified the important role of gonadal steroids in human sexual b e h a ~ i o r .'The ~ ~ .physiological ~~ processes that subserve sexual desire a r e highly sensitive to androgen deprivation to a greater degree than the mechanisms that mediate erectile capacity. Studies on exogenous hormone administration have documented the deleterious effect of estrogen on male sexual desire and erectile function." An association between elevated prolactin levels, impaired sexual drive, and erectile impotence also has been frequently observed in several clinical groups.38 Low plasma androgens and high estrogen and prolactin levels have been noted repeatedly in sexually dysfunctional alcoholic men, but the relation between the alcohol-induced hormonal alterations and the changes in sexual function has not been systematically examined. One exception is a prospective study by van Thiel et aLs9 on 60 abstinent chronic alcoholic men with sexual desire or erectile problems. Twentyfive percent of them experienced a spontaneous recovery of sexual function which was predicted by lack of testicular atrophy a n d normal gonadotrophic responses to LH-RH or clomiphene. Treatment with high doses of nonaromatizable androgen restored sexual potency in some of the men who had not recovered spontaneously. T h e almost total lack of information on the significance of endocrine abnormalities for the sexual behavior of chronic alcoholics limits the development of possible therapeutic approaches. Without the systematic analysis of hormonal data in relation to information about sexual function and partner variables, inferences about hormonal-behavioral relations in alcoholic men may be unjustified.
NEUROLOGICAL EFFECTS OF ALCOHOL AND SEXUAL DYSFUNCTION Alcohol may impair sexual function by chronic toxic effects o n central as well as peripheral neurological processes. Centrally, chronic alcoholism may be associated with a wide range of brain disturbances, from mild neuropsychological abnormalities4"to severe pathology such as WernicheKorsakoff syndrome and dementia.4' Electroencephalographic a n d cortical evoked potential studies have demonstrated subtle changes in brain function that may continue after prolonged sobriety.42 Neurochemical investigation has revealed complex effects of ethanol in noradrenergic, serotonergic, cholinergic, and GABA central mechanisms a n d on neuIt is tempting, but romodulator receptor-effector coupling would be highly speculative, to relate these neurobiological effects to changes in sexual drive a n d sexual arousability commonly observed in alcoholic individuals. O f more direct relevance is the deleterious action of chronic alcohol intake on peripheral neurological processes that subserve erectile function. Polyneuropathy associated with myelin and axon degeneration is one of the most common neurological complications 'affecting chronic a l c o h o l i ~ s .It~ ~ may impair sexual function by a decrease
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Journal of Sex 3 Muntal Therapy, Vol. 1 6 , No. I , Spring I990
in tactile erotic sensitivity or by painful or unpleasant sensations in response t o genital stimulation. Chronic alcoholism may also impair sexual function by its action o n the autonomic nervous system.4’.’6 Autonomic abnormalities, when they occur, are usually subclinical a n d may be revealed by testing of cardiovascular reflexes such as peak-to-peak variations of heart rate, the Valsalva maneuver, a n d postural pulse a n d blood pressure reactions. Direct evidence o f alcoholic neuropathic impairment of mediating parasympathetic and sympathetic mechanisms of erection and ejaculation is presently lacking. PSYCHOLOGICAL A N D MARITAL FACTORS RELATED T O SEXUAL FUNCTIONING
~I’herelation between psychological factors and chronic alcoholism is complex. With some frequency, the pattern of addiction evolves following efforts to cope, by means of alcohol, with preexisting personality problems, feeling of inadequacy, sexual anxiety, mood disorder, and difficulties with i n t e r p e r s o n a l relationships. C o n c e r n s a b o u t sexual performance, poor self-esteem, depression, and inhibitory emotiorial reactions such as guilt and shame may also be the consequence of alcohol abuse; most frequently, however, the reciprocal interaction between d r u g intake a n d psychological factors is so closely interwoven that it is impossible t o identify the nature of this r e l a t i ~ n . -~5 ’1 A similar difficulty exists in assessing causal links in the association between marital difficulties and alcohol abuse. T h e r e is considerable literature on the “alcoholic marriage,””-54 and several theories have been postulated about the marital dynamics of chronic alcoholics. Empirical research has focused on a wide range of variables, including interpersonal perceptions, affection-hostility, dominance-submissiveness, dependency, and marital cohesiveness, but their role in the development arid maintenance of alcoholism remains to be elucidated. It is of note that, regardless of the role that psychological and marital determinants play in the pathogenesis of alcoholism, efforts at systematically evaluating their impact on the sexual life of alcoholic patients have been almost n o n e x i ~ t e n t . ~This ~ is regrettable in view of the importance that these cognitive, emotional, and relationship factors have on the pathogenesis of sexual dysfunction in nonalcoholic couples. THE INTERACTION AMONG PHYSIOLOGICAL, PSYCHOLOGICAI. A N D RELATIONSHIP DIMENSIONS T h e development of sexual dysfunction invariably causes a n emotional reaction in the individual. T h e nature of this response is influenced by cultural background, personality characteristics, the individual’s prior experiences, and the dynamics of his marital relationship. Thus, dichotomous thinking about causation of sexual disorders is simplistic and f’requently leads to incorrect diagnoses and faulty therapeutic interven-
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Chronic Alcoholism and Malt Sexiuzl Dysfunction
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tions. It seems important to use a multi-factorial model within a conceptual framework that integrates psychosocial variables with biological processes in order to better understand the effect of chronic d r u g use a n d medical illness o n human sexuality. Unfortunately, the sexual functioning of chronic alcoholic men has not yet been assessed experimentally in this manner. Knowledge about the relative contribution of organic and psychological factors is critical for planning predictive studies and for developing adequate treatment strategies for the sexual problems of alcoholic patients. In conclusion, problems of sexual desire and arousal are highly prevalent among chronic alcoholic patients, but the significance of this observation is limited by uncertain clinical categorization and diagnosis of both the disease and the sexual disorder and by the concurrent presence of other medical conditions or pharmacological agents assumed to impair sexual functioning. T h e nature of the organic processes that mediate the chronic effect of alcohol on sexual function are not known but are likely to include hormonal and neurological mechanisms. Evidence for a direct link between pituitary-gonadal abnormalities and sexual dysfunction is almost nonexistent. Organic pathology and psychological factors may interact in the development of sexual disorders in chronic alcoholic men. However, there is n o empirical information that identifies which specific pathophysiologic and psychological factors are involved and defines the nature of their relation. Their association must be explored experimentally within the context of an integrative model using objective biomedical procedures a n d valid psychological measures. REFERENCES I . Rubin HB. Henson DE: Effects of alcohol o n male sexual responding. fsychopharniacol 47:123-124, 1976. 2. Farkas G M , Rosen RC: Effect of alcohol o n elicited male sexual response. J S/udies Alcohol 37~265-272, 1976. 3. Wilson (2-1:Alcohol a n d human sexual behavior. Behau Res Therapy 15:239-2.% 1977. 4. Lang AR, Searles J , Laverman R, Adesso V: Expectancy, alcohol a n d sex guilt 21s determinants o f interest in a n d reaction to sexual stimu1i.j Abnor Psychol89:644-653, 1980. 5 . Lansky D, Wilson GT: Alcohol, expectations a n d sexual arousal in males: An information processing analysis. J Abnor Psycho1 90:3545, 1981. 6. Wilson GT, Niaura RS. Adler JL: Alcohol, selective attention a n d sexual arousal in men. J Studips Alcohol 46: 107-1 15, 1985. 7. Lemere F, Smith JW: Alcohol induced sexual impotence. Am J Psychiat 130:212-213. 1973. 8. Stankvshev T, Yrotic M, Shishkov A: Disturbances of sexual function in alcoholics. Excerpla Medica fsychzatr 1883 (Abstr. Bulgarian), 1976. 9. Akhtar MJ: Sexual disorders in male alcoholics. I n J Madden, I’Walker, LM Kenyon (Eds), Alcoholism and drug dependence. New York: Plenum, 1977. pp. 3-13. 10. Whalley LJ: Sexual adjustment of male alcoholics. Ada Psychiat Scand 58:281-298, 1978.
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1 1 . Jensen SB: Sexual function a n d dysfunction in alcoholics. Br J Sex Med 10:29-31, 1979. 12. Vijayasenan ME: Alcohol a n d sex. N Z Med J 7Y: 18420, 1981. 13. Mandell W. Miller CM: Male sexual dysfunction is related to alcohol consumption: A pilot study. Alcoholism: Clin Exprr Res 7:65-67, 1983. 14. Jensen SB: Sexual function arid dysfunction in younger married alcoholics. Acla Psychnatr Scand 69:543-549. 1984. 15. Fahrner EM: Sexual dysfunction in male alcohol addicts: Prevalence a n d treatment. Arch Sex Behuv 16:247-257, 1987. 16. Masters W. Johnson VE: Human sexuality inadequacy. Little. Brown, 1970, p. 164. 17. Fagan PJ, Schmidt CW. Wise T, Derogatis LK: Alcoholism in patients with sexual disorders.J Sex Marital Ther 14:245-252, 1988. 18. Snyder S , Karacan 1: Effects of chronic alcoholism o n nocturnal penile tumescence. Psychosomatic Med 43:423429, 1981. 1 9 Snyder S, Karacan I. Salk PJ: Disulfiram a n d nocturnal penile tumescence in the chronic alcoholic. Biological Pcychiaf 16:399-406. I98 1. 110. T a n E T H , J o h n s o n KA, Lambie DG, Vi,jayasenah ME. Whiteside EA: Erectile impotence in chronic alcoholics. Alroholrrm: Clin Exper Res 8:297-301, 1984. 2 I . Zarcone VP: Sleep a n d alcoholism. I n M H Chase. ED Weitzman (eds), Sleep disorders: Buric and clinical research. New York, Spectrum, 1983. pp. 3 19-325. 22. Williams HL, Salamy A: Alcohol a n d sleep in the biology of alcoholism. I n H Kissin. H Begleiter (Eds), Physiology nnd behavior. vol 2 . New York, Plenum, 1974. pp. 43~84. 23. Gross M M , Hastey JM: Sleepdisturbances in alcoholism. In RF l’arter. A A Sugarman (Eds), Alcoholism: Inlerdisciplinary approaches lo a n enduring problem. Reading. M A , Addison-Wesley. 1976, pp. 257-307. 24. Dement WC, Miles LE, Carskadon D: “White paper” o n sleep a n d agir1g.J Am Ger Soc 30:25-.50. 1982. 25. Guilleniinault C: Obstructive sleep apnea syndrome: A review. Psychkt Clin A’ Am 10:607-621. 1987. 26. Berry IITR, Phillips BA, Cook YR, Schmitt FA, Honeycutt N A , Edwards CL, I a n b DG, Magan LK, Allen RS:Sleep-disordered breathing in healthy aged persons: O n e year follow-up of daytime sequelae. Slrep 12:211-215, 1989. 27. Bannister P, Lowosky MS: Ethanol a n d hypogonadism. Alcohol Alcoholism 22:3 13-2 17, 1987. 28. Goi-don C X , Altman K, Southren L. Rubin E, Lieber C: Effect of alcohol administration o n sex-hormone metabolism in normal m e n . Nrw E n g J Med 295:793-797. 1976. 29. van Thiel D H , Lester R, VaitukaitisJ: Evidence for a defect in pituitary secretion of luteinizing hormone in chronic alcoholic m e n . J Clin Endocrinol Mefa6 473499-304, 1978. 30. van Thiel D H , Gavaler JS. Eagon PK, Chiao Y-B. Cobb CF, Lester K: Alcohol a n d sexual function. Phamacol Biocheni Llehuv 13 Suppl. I , 125-129. 1980. 31. van Thiel, DH, Lester R: T h e effect of chronic alcohol abuse o n sexual function. Clin Endocnnol Metab 8:499-5 10. 1979. 32. Valiniaki M, Ylikahri K: T h e effect of alcohol in niale a n d female sexual function. Alcohol Alcoholism lX:3 13-320. 1983. 33. van l‘hiel D H , Gavaler JS, Schade KR: Liver disease a n d the hypothalamic pituitarygonadal axis. Sem Liver Dir 5:35-45. 1985. 3.1. Prinz, PN. Koehrs T A , Vitaliano PP, Linrioila M , Weitzrnari ED: Effect of alcohol o n sleep a n d nighttime plasma growth h o r m o n e a n d cortisol concentrations. J Clrn Endornnol ,l.letab 51 :757-764, 1980.
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35. Bancroft J: Endocrinology of sexual function. Clin ObsfefGynaecol 7:253-28 I , 1080. 36. Schiavi RC: 'Treatment of psychosexual dysfunctions; basic research. In 'I'B Karasu (Ed), The freafmenfof psychosexual dysfuncfiom. Washington, DC, APA, 1989. 37. Mcyer-Bahlburg, HFL: Behavior effects of estrogen treatment in human males. Pediatrics62:1171-1177, 1978. 38. Drago F : Prolactin and sexual behavior: A review. Neurosci Behav Rev 8:433-439, 1984. 39. van Thiel DH, Gavaler JS, Sanghui A: Recovery of sexual function in abstinent alcoholic men. Casfroenferology84:677-682, 1982. 40. Tarter RE, Edwards KL: Neuropsychology of alcoholism. In RE Tarter, DH van Thiel (Eds), Alcohol and the brain: Chronic eflecfs. New York, Plenum, 1985, pp. 217-244. 41. Nakada T, Knight K T : Alcohol and the central nervous system. Med clzn NA 68:I2 1-1 3 1, 1984. 42. Porjesz B. Begleiter H: Human brain electrophysiology and alcoholism. In RE Tarter. DH van Thiel (Eds), Alcohol and the brain: Chronic eflecfs. N e w York, Plenum, 1985, pp. 13%182. 43. Hoffman PL, Tabakoff B: Ethanol's action on brain biochemistry. In RE Tarter. DH van Thiel (Eds), Alcohol and the bruin: Chronic effecls. New York, Plenum, 1985, pp. 19-68. 44. Victor M : Polyneuropathy d u e to nutritional deficiency and alcoholism. In PJ Dyke, PK Thomas, EH Lambert (Eds), Peripheral neuropafhy.Philadelphia, Saunders. 1975, pp. 1030- 1066. 45. Duncan G, Lambie DG, Johnson R H , Whiteside E: Evidence of vagal neriropathy in rhronic alcoholics. Lancet 2:1053-1057, 1980. 46. Matikainen E , Juntunen J , Salmi T: Autonomic dysfunction in long-standing alcoholism. Alcohol Alcoholism 21 369-73. 1986. 47. Ross HE, Glasser FB, Germanson T: T h e prevalence of psychiatric disorders in patients with alcohol and other d r u g problems. Arch Gen Psych 45:1023-1031, 1988. 48. Konovsky M, Wilsnack SC: Social drinking and self-esteem in married couples.,] Stud Alcohol 4 3 1 3 1 9 4 3 5 ,1982. 49. Bedi AR, Halikas JA: Alcoholism and affective disorders. Alcoholkm 9: 133-1 34, 1985. 50. Weissman MM: Clinical depression in alcoholism. Am J Psychiat. 137:372-373, 1980. 5 1. Bowen RC, Cipywnyk D, D'Arcy C, Keegan DL: Alcoholism, anxiety disorders and agoraphobia. Alcoholism 8:48-50, 1984. 52. Orford J. Oppenheimer E, Egert S, Hensman C, Guthrie S: T h e cohesiveness of alcoholism in complicated marriages and its influence on treatment outcome. Bri! J Psychiuf 128.318-339, 1976. 53. Rae, JB: T h e influence of the wives on the treatment outcome of alcoholics. Rrif J Psychiaf 120:601-613, 1972. 54. Kogan KL, Jackson JK: Patterns of atypical perceptions of self and spouse in wives of alcoholics. QJ Sfud Alcohol 253.555-557. 1964. 55. Burton G, Kaplaii HM: Sexual behavior and adjustment of married alcoholics. Q J S f u d Alcohol 29:603-609, 1968. 56. Wiseman JP: Alcohol, eroticism and sexual performance: A social interactionist perspective.J Drug Issues 15:291-308, 1988.
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Chronic alcoholism and male sexual dysfunction Raul C. Schiavi To cite this article: Raul C. Schiavi (1990) Chronic alcoholism and male sexual dysfunction, Journal of Sex & Marital Therapy, 16:1, 23-33, DOI: 10.1080/00926239008405963 To link to this article: http://dx.doi.org/10.1080/00926239008405963
Published online: 14 Jan 2008.
Submit your article to this journal
Article views: 32
View related articles
Citing articles: 14 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=usmt20 Download by: [NUS National University of Singapore]
Date: 06 November 2015, At: 13:34
Chronic Alcoholism and Male Sexual Dysfunction Downloaded by [NUS National University of Singapore] at 13:34 06 November 2015
RAUL C.SCHIAVI
Chronic alcoholism cun profoundly influence marital relationships, but the nature of the effect of alcohol abuse on sexual interactions is not clear. This article critically reviews information on the prevalence of sexual disorders and possible endocrine, neurologac, and psychologic processes that may mediate the effects of chronic alcoholism on male sexual functioning. Emphasis is placed on a conceptual model that integrates biologic and psychologic perspectives, moving away from simplistic unidimensional approaches to the study of the behavioral effects of this serious medical and social problem. Sexual disorders have been frequently reported in chronic alcoholic men, but effective treatment a n d preventive measures have been limited by the paucity of empirical data regarding the nature, prevalence, and pathogenesis of their sexual difficulties. T h e stimulus for the present review stems from the frequent association between alcoholism a n d sexual dysfunction observed over the past 17 years in the Sexual Dysfunction Clinic at the Mount Sinai School of Medicine. It has been prompted by the difficulty in identifying relevant pathogenic mechanisms a n d in developing appropriate therapeutic interventions in patients with various alcoholic histories, concurrent illnesses, and medications. Alcoholic intake may have acute as well as chronic effects in sexual functioning a n d behavior. Acute alcohol studies have demonstrated the important roles that expectation, cognitive processes, a n d social conditions have in interaction with the pharmacologic action of the d r u g on sexual arousability.'-6 'The focus of this selective review is on the chronic effects of alcohol. It summarizes data o n the prevalence a n d nature of sexual difficulties in chronic alcoholic men a n d considers hormonal, neurologic, a n d psychologic factors that may contribute to the development and maintenance of their sexual problems. It is hoped that this overview will identify promising Raul C. Schiavi, MD, is at the Human Sexuality Program, Department of Psychiatry, Mount Sinai School of Medicine. 1 Gustave L. Levy Place, New Y o l k , N Y 10029. This review was conducted with the support of Public Health Service Grants DK 39106 and AG 06895. T h e manuscript was prepared with the valuable assistance of Ms. Natalie Weinstein.
Journal of Sex & Marital Therapy, VoI. 16, No. 1 , Spring 1990, Brunner/MazeI, Inc.
23
24
journal of Sex i9 ~Clnritul7hernpv. Vol. 16, No. I , Sprrng 1990
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Chronic Alcoholism and Male Sexual Dys/unclion
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avenues of investigation which may help clarify the impact of alcoholism, one of' the most prevalent diseases of o u r time, on the sexual life of patients.
Knowledge about the chronic effect of alcohol o n sexual functioning is derived f'rom two sources: alcoholic patients a n d patients with sexual disorders. I n 1973, Lemere arid Smith' reported that 8% of 17,000 patients treated for alcoholism suffered froni impotence a n d that in approximatelv half of them the problem persisted after prolonged sobriety. Other investigators8 - l 5 have since confirmed a n d expanded evideiicc o n the deleterious effect of alcohol in sexual functioning. T h e reported prevalence of impotence ranges from 8% to 54% arid lack of sexual desire f'rorn 3 1 % t o ,5876 o f the subjects (see Table 1). Differences in the clinical composition of the samples undoubtedly contribute t o discrepancies i n f'requeiicv. Some studies have been conducted on inpatients at various times aft& admission f'or detoxification, while others have been carried out o r i outpatients still drinking alcohol or under treatment with tlisulfiram (..\NI'ABUS). Additional methodological problems originate f'rom the varied definitions of alcoholism and sexual dysfunction; the confounding effects of aging, physical illness, a n d medications; the retrospectivt. nature of' the reports; a n d the lack of spouse participation i r i the psychosexual assessment. As noted in Table 1, there have been only t w o controlled studies o n the effect of'chronic alcoholism o n sexual function. Whalley"' conipared the sexual behavior of 50 hospitalized alcoholic men with a matched sample from the general population. Erectile impotence was ment.ionetl significantlv more by alcoholics (54470) than controls (28%). A considerable number of' subjects had been taking psychoactive drugs prior to hospitalization, a n d 'they were interviewed on the sixth day after admission while under psychotropic medication. Jensen'? conducted a comparative study of' 30 outpatient married male alcoholics a n d a n age-matched control g r o u p froni a general practitioner's clinic. Sixty-three percent of the alcoholics a n d 1 0 % of the control g r o u p reported sexual dysfunctions, mainly disorders of sexual desire a n d arousal. Half of the alcoholic men claimed that their sexual problems began with the initiation of treatment with disulfir-am. Although all the subjects were married, their wives were not interviewed for validation of their husbands' reports. Studies on the prevalence of alcoholism among sexually dysfunctional patients a r e remarkably few. Masters a n d Johnson16noted that in 35 from a total of 2 13 men with secondary impotence, the erectile disorder occurred as a direct result of acute alcoholic iiitake. N o information was provided o n the effect of chronic alcohol intake in their subject sample. Fagan et. al." studied 145 consecutive patients with sexual problerns at the Sexual Consultation Unit of the Johns Hopkins Hospital. Twentynine percent of these patients scored on the probable a l c o h c h n range in the Michigan Alcohol Screening Test (MAST), a widely-used instru-
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Chsotiic Alcoholism and Male Sexual Dy.function
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ment for identifying alcoholic patients. However, only six of these patients were diagnosed as having alcoholism by routine clinical evaluation procedures. T h e authors conclude that “alcoholism largely goes undetected among patients who present with sexual problems.” In summary, this review supports the hypothesis of an association between alcohol abuse and sexual dysfunction. ‘The data suggest that the chronic effect of alcohol is not limited to erectile impotence, but also t o disorders of sexual desire. Conclusions about the nature, degree and significance of this association are restricted, however, by the heterogeneity of the populations, methodological problems, and unsystematized or incomplete information. NOCTURNAL PENILE TUMESCENCE ASSOCIATED W I T H SLEEP IN ALCOHOLIC MEN
An important limiting factor in the study of chronic alcoholism and sexual function has been the lack of an objective indicator of erectile capacity. Although recording of noctural penile tumescence during sleep provides a potentially valuable method to assess physiological mechanisms, studies concerning NPT in alcoholic men are very few. Snyder and Karacani8evaluated, during 2 nights in the sleep laboratory, 26 sober chronic alcoholics who w e r e healthy, free from medications, and without sexual dysfunctions. T h e subjects had diminished tumescent latency and decreased number and duration of maximum penile tumescent episodes as compared to age-matched nonalcoholic subjects. T h e authors speculated that the deleterious effect of alcohol on sleep-related erections may be d u e to central as well as peripheral neuropathology. Snyder et al.I9 found that disulfiram significantly decreased the frequency and duration of full erections in abstinent alcoholics evaluated within a double-blind experimental design. This finding is of particular importance because of the possible confounding effect of disulfiram on investigated N P T the reported frequency of sexual disorders. T a n et in 13 abstinent impotent alcoholics; seven men, who had nocturnal erections with a circumference change of more than 16mm, were considered psychologically impotent, while the remaining six men with erections of a lesser degree were diagnosed as “organic patients.” In this latter group, the authors found elevated levels of plasma gonadotrophins in the presence of normal circulating testosterone. Duration of abstinence may be a factor in the differences obtained; patients with “organic impotence” had been sober for a shorter period at the time of the investigation than the subjects categorized as having psychogenic impotence. T w o areas of inquiry that need to be taken into account in the interpretation of NP’T findings are the effect of alcohol on sleep variables and the occurrence of sleep disorders in chronic alcoholics. Acute ethanol intake increases slow wave sleep, decreases REM periodicity and R E M duration, and increases the fragmentation of REM periods.“-*” Chrqnic alcoholism, on the other hand, has inconsistent effects on sleep, possibly because of differences in clinical status, age, addiction, severity, and time
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Jouwial vf Spx i9 Marital Thew&. Vol. 16. N o .
I , Spnng I990
elapsed since alcohol withdrawal. Considerable attention has been paid in recent years to the relation between sleep disorders and medical illnesses.2"-26Sleep disorders may be associated with erectile impotence in physically healthy men, but their prevalence in chronic alcoholics has not been systematically assessed. T h e r e is a high probability, particularly in older subjects, of finding sleep disturbances such as sleep apnea syndrome and periodic leg movement disorders. Unless identified, measured and controlled, alterations in sleep patterns and sleep abnormalities may confound the evaluation of noctural erectile activity. I.'ITL'ITAHY-GONADAI, FUNCTION ABNORMALITIES A N D S E X U A L BEHAVIOR Chronic illcoholism and Pituitar)-C;onciduL Function
Considerable information has accumulated on the deleterious effect o f alcohol in testicular a n d hypothalamic pituitary function. Chronic alcoholic men, independent from evidence of liver disease, frequently show signs of hypogonadism, abnormalities in spermatogenesis, and testicular atrophy.27 Ethanol can have a direct toxic effect o n the testes with a resulting diminution in testosterone secretion." In addition, there is evidence of a dysfuriction at the hypothalamic-pituitary level as shown by the inappropriately low LH secretion in the face of marked hypoandrogenization, and by the defective LH responses to clomiphene or LH-KH administration.2"+3"Hyperprolactinemia is frequently observed in chronic alcoholics with, as well as without, liver disease. T h e sleep-related increase in plasma prolactin secretion is diminished and the responscs to provocative challenge with stimulators a n d inhibitors of prolactin release may also be a b n ~ r r n a l . Disturbances ~' in prolactin secretion could play an important role, not only by facilitating the development of hypogonadism, but also by its direct effect o n sexual behavior. In addition to being hypogonadal, chronic alcoholic men may show signs of hyperoestrogenization a n d have elevated plasma oestrone levels." ?? T h e mechanisms involved have not been fully elucidated yet, but may include increased conversion of weak adrenal androgens to estrogens, alterations in estrogen-binding protein in the liver, and abnormalities in estrogen receptor activity. Liver disease is a common complication in the chronic alcoholic, and it has been assumed that hepatic damage is responsible for the endocrine changes in alcoholism. 'This explanation has been challenged, however, by recent Sleep, as an important synchronizer of endocrine rhythms, provides a means to observe CNS control of pituitary-gonadal activity. Although i t is well known that ethanol alters normal sleep pattcrns, investigations on the effect of alcohol in sleep-hormonal regulation are almost nonexistent. T h e r e is, to o u r knowledge, only one controlled study of this kind on five normal volunteers.'" Ethanol administration reduced the nighttime, sleep-related, growth hormone secretory episodes w'ithout significant alterations in cortisol secretion.
Chronic Alcoholism and Male Sexual Dyqunction
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Pituitary-Gonadal Function and Sexual Behavior
Recent investigations have clarified the important role of gonadal steroids in human sexual b e h a ~ i o r .'The ~ ~ .physiological ~~ processes that subserve sexual desire a r e highly sensitive to androgen deprivation to a greater degree than the mechanisms that mediate erectile capacity. Studies on exogenous hormone administration have documented the deleterious effect of estrogen on male sexual desire and erectile function." An association between elevated prolactin levels, impaired sexual drive, and erectile impotence also has been frequently observed in several clinical groups.38 Low plasma androgens and high estrogen and prolactin levels have been noted repeatedly in sexually dysfunctional alcoholic men, but the relation between the alcohol-induced hormonal alterations and the changes in sexual function has not been systematically examined. One exception is a prospective study by van Thiel et aLs9 on 60 abstinent chronic alcoholic men with sexual desire or erectile problems. Twentyfive percent of them experienced a spontaneous recovery of sexual function which was predicted by lack of testicular atrophy a n d normal gonadotrophic responses to LH-RH or clomiphene. Treatment with high doses of nonaromatizable androgen restored sexual potency in some of the men who had not recovered spontaneously. T h e almost total lack of information on the significance of endocrine abnormalities for the sexual behavior of chronic alcoholics limits the development of possible therapeutic approaches. Without the systematic analysis of hormonal data in relation to information about sexual function and partner variables, inferences about hormonal-behavioral relations in alcoholic men may be unjustified.
NEUROLOGICAL EFFECTS OF ALCOHOL AND SEXUAL DYSFUNCTION Alcohol may impair sexual function by chronic toxic effects o n central as well as peripheral neurological processes. Centrally, chronic alcoholism may be associated with a wide range of brain disturbances, from mild neuropsychological abnormalities4"to severe pathology such as WernicheKorsakoff syndrome and dementia.4' Electroencephalographic a n d cortical evoked potential studies have demonstrated subtle changes in brain function that may continue after prolonged sobriety.42 Neurochemical investigation has revealed complex effects of ethanol in noradrenergic, serotonergic, cholinergic, and GABA central mechanisms a n d on neuIt is tempting, but romodulator receptor-effector coupling would be highly speculative, to relate these neurobiological effects to changes in sexual drive a n d sexual arousability commonly observed in alcoholic individuals. O f more direct relevance is the deleterious action of chronic alcohol intake on peripheral neurological processes that subserve erectile function. Polyneuropathy associated with myelin and axon degeneration is one of the most common neurological complications 'affecting chronic a l c o h o l i ~ s .It~ ~ may impair sexual function by a decrease
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Journal of Sex 3 Muntal Therapy, Vol. 1 6 , No. I , Spring I990
in tactile erotic sensitivity or by painful or unpleasant sensations in response t o genital stimulation. Chronic alcoholism may also impair sexual function by its action o n the autonomic nervous system.4’.’6 Autonomic abnormalities, when they occur, are usually subclinical a n d may be revealed by testing of cardiovascular reflexes such as peak-to-peak variations of heart rate, the Valsalva maneuver, a n d postural pulse a n d blood pressure reactions. Direct evidence o f alcoholic neuropathic impairment of mediating parasympathetic and sympathetic mechanisms of erection and ejaculation is presently lacking. PSYCHOLOGICAL A N D MARITAL FACTORS RELATED T O SEXUAL FUNCTIONING
~I’herelation between psychological factors and chronic alcoholism is complex. With some frequency, the pattern of addiction evolves following efforts to cope, by means of alcohol, with preexisting personality problems, feeling of inadequacy, sexual anxiety, mood disorder, and difficulties with i n t e r p e r s o n a l relationships. C o n c e r n s a b o u t sexual performance, poor self-esteem, depression, and inhibitory emotiorial reactions such as guilt and shame may also be the consequence of alcohol abuse; most frequently, however, the reciprocal interaction between d r u g intake a n d psychological factors is so closely interwoven that it is impossible t o identify the nature of this r e l a t i ~ n . -~5 ’1 A similar difficulty exists in assessing causal links in the association between marital difficulties and alcohol abuse. T h e r e is considerable literature on the “alcoholic marriage,””-54 and several theories have been postulated about the marital dynamics of chronic alcoholics. Empirical research has focused on a wide range of variables, including interpersonal perceptions, affection-hostility, dominance-submissiveness, dependency, and marital cohesiveness, but their role in the development arid maintenance of alcoholism remains to be elucidated. It is of note that, regardless of the role that psychological and marital determinants play in the pathogenesis of alcoholism, efforts at systematically evaluating their impact on the sexual life of alcoholic patients have been almost n o n e x i ~ t e n t . ~This ~ is regrettable in view of the importance that these cognitive, emotional, and relationship factors have on the pathogenesis of sexual dysfunction in nonalcoholic couples. THE INTERACTION AMONG PHYSIOLOGICAL, PSYCHOLOGICAI. A N D RELATIONSHIP DIMENSIONS T h e development of sexual dysfunction invariably causes a n emotional reaction in the individual. T h e nature of this response is influenced by cultural background, personality characteristics, the individual’s prior experiences, and the dynamics of his marital relationship. Thus, dichotomous thinking about causation of sexual disorders is simplistic and f’requently leads to incorrect diagnoses and faulty therapeutic interven-
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tions. It seems important to use a multi-factorial model within a conceptual framework that integrates psychosocial variables with biological processes in order to better understand the effect of chronic d r u g use a n d medical illness o n human sexuality. Unfortunately, the sexual functioning of chronic alcoholic men has not yet been assessed experimentally in this manner. Knowledge about the relative contribution of organic and psychological factors is critical for planning predictive studies and for developing adequate treatment strategies for the sexual problems of alcoholic patients. In conclusion, problems of sexual desire and arousal are highly prevalent among chronic alcoholic patients, but the significance of this observation is limited by uncertain clinical categorization and diagnosis of both the disease and the sexual disorder and by the concurrent presence of other medical conditions or pharmacological agents assumed to impair sexual functioning. T h e nature of the organic processes that mediate the chronic effect of alcohol on sexual function are not known but are likely to include hormonal and neurological mechanisms. Evidence for a direct link between pituitary-gonadal abnormalities and sexual dysfunction is almost nonexistent. Organic pathology and psychological factors may interact in the development of sexual disorders in chronic alcoholic men. However, there is n o empirical information that identifies which specific pathophysiologic and psychological factors are involved and defines the nature of their relation. Their association must be explored experimentally within the context of an integrative model using objective biomedical procedures a n d valid psychological measures. REFERENCES I . Rubin HB. Henson DE: Effects of alcohol o n male sexual responding. fsychopharniacol 47:123-124, 1976. 2. Farkas G M , Rosen RC: Effect of alcohol o n elicited male sexual response. J S/udies Alcohol 37~265-272, 1976. 3. Wilson (2-1:Alcohol a n d human sexual behavior. Behau Res Therapy 15:239-2.% 1977. 4. Lang AR, Searles J , Laverman R, Adesso V: Expectancy, alcohol a n d sex guilt 21s determinants o f interest in a n d reaction to sexual stimu1i.j Abnor Psychol89:644-653, 1980. 5 . Lansky D, Wilson GT: Alcohol, expectations a n d sexual arousal in males: An information processing analysis. J Abnor Psycho1 90:3545, 1981. 6. Wilson GT, Niaura RS. Adler JL: Alcohol, selective attention a n d sexual arousal in men. J Studips Alcohol 46: 107-1 15, 1985. 7. Lemere F, Smith JW: Alcohol induced sexual impotence. Am J Psychiat 130:212-213. 1973. 8. Stankvshev T, Yrotic M, Shishkov A: Disturbances of sexual function in alcoholics. Excerpla Medica fsychzatr 1883 (Abstr. Bulgarian), 1976. 9. Akhtar MJ: Sexual disorders in male alcoholics. I n J Madden, I’Walker, LM Kenyon (Eds), Alcoholism and drug dependence. New York: Plenum, 1977. pp. 3-13. 10. Whalley LJ: Sexual adjustment of male alcoholics. Ada Psychiat Scand 58:281-298, 1978.
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