“At a different APA forum, "Sex, Sexuality, and Serotonin," Dr Fisher warned that antidepressants may jeopardize romantic love. As well as high dopamine and norepinephrine, she said, romantic love is characterized by low serotonin. Low serotonin would explain the obsessive thinking attached to romantic love. In her MRI study, her subjects reported that they thought about their loved one 95 percent of the day and couldn’t stop thinking about them. This kind of obsessive thinking is comparable to OCD, she said, also characterized by low serotonin.

Serotonin-enhancing antidepressants, she said, blunt the emotions, including the elation of romance, and suppress obsessive thinking, a critical component of romance. "When you inhibit this brain system," she warned, "you can inhibit your patient’s well-being and possibly their genetic future."

These antidepressants also inhibit orgasm, clitoral stimulation, penile erection ("the entertainment system, in my business"), and deposit of seminal fluid. From an anthropological perspective, a woman who can’t get an orgasm may fail to distinguish Mr Right from Mr Wrong. As one woman on an SSRI confided to her: "I thought I no longer loved my husband." In a study in press, women on SSRIs rated male faces as more unattractive, a process she calls "courtship blunting."

Seminal fluid contains dopamine and norepinephrine, oxytocin and vasopressin, testosterone and estrogen, and FSH and LH. Without an orgasm, said Dr Fisher, men lose the ability to send courtship signals. Said one man, who lost his motivation and self esteem as a result, "I just stopped dating."

Ironically, because antidepressants inhibit depression, patients may lose their ability to send an honest clear signal for social support and (for those with mild depression) lose the necessary insight to make hard decisions (the failure of denial factor).

Dr Fisher said she didn’t want psychiatrists to stop prescribing serotonin-enhancing antidepressants for their patients, but did stress the need to take the love-relationship picture into account.

When Sex Goes Right

At the same symposium, Anita Clayton MD of the University of Virginia related what goes on molecularly during arousal and orgasm: Testosterone drives sexual activity in men. Testosterone also affects women, plus estrogen and progesterone, associated with permissivity and receptivity, respectively. These three hormones help maintain genital structure and function. Dopamine is tied into sexual desire while norepinephrine is related to subjective excitement. During orgasm, oxytocin levels rise.

When Sex Goes Wrong

At the same symposium, Dr Clayton mentioned that serotonin can dampen sexual desire and excitement. It can also deaden sensation, leading to vasocongestion ("blue balls"). Prolactin can have a negative impact on sexual excitement.

Philip Muskin MD of Columbia University cited these statistics:

Married couples report having sex 68.5 times a year (1.3 times a week) according to a 2002 University of Chicago National Opinion Research Center Report. According to a 2003 cover story in Newsweek, 15 to 20 percent of couples have sex less than 10 times a year, regarded as a sexless marriage.

Various studies give the following breakdown for incidence of sexual disorders: Hypoactive sexual desire (27-34 percent women, 13-17 percent men); Sexual arousal disorder (11-27 percent women); Erectile disorders (eight-38 percent men); Orgasmic disorders (15-28 percent women); Premature ejaculation (25-32 percent men); Pain during intercourse (eight-23 percent women).

Dr Clayton cited her 2001 study that found that 37 percent of men taking antidepressants experienced sexual dysfunction. Paxil was the highest at more than 40 percent and Wellbutrin the lowest at about 20 percent. Remeron was surprisingly at the high end of the scale.

Only 14.2 percent of patients spontaneously report antidepressant induced sexual dysfunction to their physicians, according to a 1997 study vs 58.1 percent responding to a questionnaire.

Antipsychotics pose their own set of problems. A 2003 study by Knegtering et al reports that 60 percent of Risperdal patients reported sexual side effects vs about 27 percent for Zyprexa and about 44 percent for old generation antipsychotics.

Risk factors for sexual dysfunction include being at least 50 years old, married, less than college education, not employed full time, tobacco use, higher doses of antidepressants, concomitant meds, co-occurring ills known to cause sexual dysfunction, prior history of antidepressant-induced sexual dysfunction, history of little or no sexual enjoyment, and regarding sexual functioning as not or somewhat important.

According to data from the 1992 National Health and Social Life Survey, 43 percent of women and 30 percent of men have a sexual complaint (a sexual complaint is not of the same magnitude as sexual dysfunction or sexual disorder). In patients with depression, that figure is 70 to 80 percent. Depression itself rarely causes sexual dysfunction, Dr Muskin explained. Untreated depression, however, often causes a lack of interest in sex, and disrupts intimacy.

Dr Muskin says doctors must encourage their patients to accept the reality that getting well is more important than sexual dysfunction. Patients and their partners, he said, may need to reconfigure how they have sex. Arousal may need to be at a higher pitch before intercourse, and orgasm need not be linked to the act.

But patients may want to try these antidotes first, cited by Dr Clayton: Wellbutrin, Viagra (for men), and Buspar (for women), all supported by studies. Other possibilities include hormones (testosterone, estrogen), yohimbine, amantadine, and low dose psychostimulants.

At another APA forum, WebMD reported on a presentation by Richard Brown MD of Columbia University, who noted that although Viagra may improve erection, it doesn't help much with libido and orgasm. The following natural treatments, he said, show promise: Rhodiola (an arctic plant that works for both men and women, may work on dopamine, helps libido and boosts energy); Ginko biloba (for impotence in men and maintains erection); Gingseng (appears to work on dopamine, so woman can benefit too); Maca (a Peruvian root that "can have powerful effects on desire, erections, and orgasms"); Horny goat weed (forgive the term, little data).

Gay and Lesbian Sex

At the same symposium, Serena Volpp MD, MPH of New York University discussed gay and lesbian sex. According to 1994 NHSL Survey figures, nine percent of women and 10 percent of men reported homosexual behavior, desire, or identity. One-third of those who had same sex partners in the past year did not consider themselves homosexual. Fifty percent of gay men and 75 percent of lesbians have had intercourse with the opposite sex. According to figures from a 1983 book by Blumstein and Schwartz, 67 percent of gay male couples have sex at least three times a week in the first two years of marriage compared to 61 percent of sexual couples and 33 percent lesbian couples. Various authorities estimate that gay men have had somewhat less than 50 sexual partners while the figure was less than 10 for lesbians. NHSL Survey data indicates that men have six long-term sexual partners while women have two.

Dr Volpp stressed that gay and lesbian sexual practices are essentially the same as for heterosexuals, with the same body parts in play and the goals of achieving a high degree of intimacy and sexual release or orgasm. A 1991 study by Roesser found that gay males had anal intercourse in one-third of their encounters. Oral sex and mutual masturbation made up the other two-thirds. Lesbians engaged in kissing, petting, mutual genital contact, oral-genital contact, body contact, and object-genital insertion.

Unfortunately, owing to the effectiveness of new medications, the younger generation is more complacent about safe sex. New HIV infections among gay men went up 17 percent between 1999 and 2002.

Better Than Cheesecake

"For many of us, sexual orgasm, accomplished within a love relationship, is one of the all-time highs. And sex, like love, can be accompanied by a sense of merger and transcendence." Ethel Peterson MD of Columbia University, at the same APA symposium.

Love Potion Number 32

A Rockefeller University press release dated Feb 15, 2000 began:

"Valentine's Day cards usually depict Cupid's dart as the messenger of love. New scientific research, however, shows that a key messenger molecule, rather than Cupid's dart, is responsible for female sexual receptivity - at least in rats and mice.

"Scientists at New York's Rockefeller University and Houston's Baylor College of Medicine have found that a protein called DARPP-32 is the essential ingredient in the brain pathway that makes female mice and rats sexually receptive. The study is reported in the Feb. 11 issue of Science."

The title for the Science article was a far less suggestive: "Requirement for DARPP-32 in Progesterone-Facilitated Sexual Receptivity in Female Rats and Mice."

When 2000 Nobel Laureate Paul Greengard PhD brought this up at a lecture at the APA’s 2004 annual meeting, the audience burst out into appreciative laughter. Up until this time, Dr Greengard had been giving the equivalent of a master’s class on the fine points of brain science, with a focus on how DARPP-32 acts as a virtual Grand Central Station for routing and rerouting chemical impulses along an interlocking network of molecular signaling pathways inside the neuron.

Dr Greengard’s pioneering work into DARPP-32 has provided new insights into schizophrenia and drug use. Mice with no DARPP-32, for example no longer respond to recreational drugs. This research may have helped Dr Greengard win a Nobel Prize, but it was his findings into female sexual receptivity that got him in the papers. Without DARPP-32, signals that would normally get sent to dopamine and estrogen and progesterone don’t get sent.

Dr Greengard amused his audience with this reading from one media account: "But researchers say the protein will not be available in drug form for five years."