Sexual Health

The relationship between sexuality and quality of life in bipolar disorder is complex, and there are many important factors to consider. Both the symptoms of bipolar disorder, and the medications used to treat it, can have a significant impact on a person’s sexual health and quality of life. Issues related to intimate partner relationships can also impact quality of life: a mutually enjoyable sex life can contribute to the health of a relationship, which can enhance overall wellbeing. People who identify as lesbian, gay, bisexual, transgender, intersex, queer, two-spirit, non-binary, or other marginalised gender identity/sexual orientations (LGBTIQ2S+) may experience discrimination or minority stress that negatively impacts their quality of life, or barriers to accessing safe and inclusive healthcare.

Key Messages

What to know about sexual health and bipolar disorder:

  • Increased sexual desire may be an early warning sign of a hypo/manic mood episode
  • Both depression and anti-depressant medications can reduce sexual desire
  • High risk sexual activities may be increased during hypo/mania

Why sexual health is important to your quality of life

When people with bipolar disorder experience hypomanic or manic episodes, they can be less inhibited and more impulsive, and increased sexual interest and behaviour (known as “hypersexuality” may result. For example, one Australian study of people with a bipolar II diagnosis found that becoming sexually disinhibited was one of the most common behaviours people engaged in while hypomanic1. Increased sexual interest and activity can be experienced as positive if encounters are consensual and consistent with your personal values, as well as any boundaries you have agreed on in your relationships. However, the disinhibition associated with hypomania or mania may cause individuals to engage in out-of-character risky sexual behaviours (such as unprotected sex, multiple partners, or sex while substance-affected2.) that can raise the risk of consequences like sexually transmitted infections3, unwanted pregnancy4, and damages to their relationships or self-image5.

Of course, there is another side to bipolar disorder that can impact sexuality: when you’re in the depressive part of the cycle, you’re not likely to have much sexual desire at all. Reduced sexual drive (libido) or problems with sexual response (e.g., difficulty becoming aroused, maintaining an erection, becoming adequately lubricated, or achieving orgasm or ejaculation) are a common feature of depression and can certainly reduce your quality of life. Loss of interest in sex may be a direct result of the low mood, lack of interest in pleasurable activities, and fatigue people with depression often experience. Low self-esteem or feelings of worthlessness when depressed may contribute to unhelpful thought patterns (e.g., “I’m not attractive”) that make it difficult to initiate or respond to intimacy with a partner. Additionally, some antidepressant and mood-stabilising medications have reduced libido or problems with sexual function as a side-effect6,7.

A middle-aged white couple embracing in what looks to be a greenhouse.

Intimate relationships and bipolar disorder

Often, people are concerned not only about how bipolar disorder impacts their own sexual quality of life, but also how it may impact their intimate partner relationship(s). A review of the literature on mania-related hypersexuality and the impact of mood cycling on couple relationships has been conducted8. The review found 27 studies in these two areas. The most important take home message from the review is that the quality of the science looking at sexuality in bipolar disorder is still poor. The results of the review, therefore, needed to be treated with caution. This being said, the review found that people with bipolar disorder do not have marked problems in establishing and maintaining couple relationships. However, the studies identified in the review did describe lower levels of sexual satisfaction linked to having a diagnosis of bipolar disorder, varying levels of sexual interest across mood states (i.e. depression and mania), frequent problems with sexual wellbeing during depression and uneven levels of sexual satisfaction between patients and their partners.

When considering research on sexual quality of life in mood disorders, it is important to remember that these studies have typically focused on the physiology of sexual function and risky sexual behaviour. Much less is known about sexual satisfaction and healthy expressions of sexuality for people with bipolar disorder. For example, one study has reported how some people with bipolar disorder perceive increased sexual intensity during their manic or hypomanic episodes as a positive change9.

A middle eastern man has his arm around a white man. They look joyful and are sitting in the sun.

How you can take action

Protect your sexual safety. There is limited research about the most helpful ways to increase the safety of sexual behaviour during a manic phase. Some research studies have shown that educational and psychological treatments can increase the sexual safety of individuals with bipolar disorder10. These treatments increased knowledge of sexual risks, encouraged the use of condoms, increased the ability to stand firm when refusing risky sexual contact and helped in planning to keep oneself safe in risky situations.

When it comes to protecting sexual safety, for yourself and your partner(s), research suggests that the key is to make sure that you seriously look at the risks of disinhibited sexual behaviour (remember, that’s sexual behavior that you wouldn’t normally take part in), speak openly with a therapist or trusted friend about your own history of risky sexuality when you are feeling manic or hypomanic, and plan ahead to keep yourself safe in risky situations (for example, notify a friend of where you are going and when you plan to return, carry and use condoms to keep sexual encounters safer). If you do not regularly use condoms with sexual partners whose HIV status is unknown, consider asking your healthcare provider whether pre-exposure prophylaxis (PrEP) is appropriate for you.

Two young white women with long red hair are holding hands in a public space. The woman on the right is running her hands through her hair and smiling bashfully while the woman on the left looks at her with amusement.

It is important to set boundaries in your intimate partner relationships to protect your sexual safety. When well, think seriously about the five basic conditions of healthy sexuality (known by the acronym CERTS), and talk about them with your partner(s). And remember that, of these five conditions, consent is number one.

  • Consent: You and your partner are conscious and able to stop the activity at any time.
  • Equality: You and your partner are on equal levels with each other.
  • Respect: You and your partner have positive regard for yourselves and each other.
  • Trust: You and your partner trust each other physically and emotionally and can communicate about sexuality.
  • Safety: You and your partner feel secure in your physical setting, without the possibility of negative consequences, for example, injury, unintended pregnancy, or sexually transmitted infection.

Find positive ways to express your sexuality. If low libido or sexual response is a problem for you, open communication with your partner(s) can help identify ways to make your sex life more satisfying and reduce any tension surrounding sex. It may be helpful to discuss what a positive sex life means to you, and to consider alternative forms of intimacy to find one that is rewarding for both of you. It is also important to remember that sexual interest and function ebbs and flows for all people, not just people with bipolar disorder.

Find a healthcare provider you trust. While mood stabilizing medications that balance your mood can reduce the manic or hypomanic disinhibition that adds to risky sexual behavior, other medications can lead to reduced libido or other sexual issues. If this happens for you, it’s worth discussing the problem with your healthcare provider in order to try to find a medication with less effect on your sexuality.

Unfortunately, research shows that healthcare providers often don’t ask about sexual side effects of medications11. If you have concerns about such side effects, you may need to become an advocate for your own health and quality of life. If you find it embarrassing or awkward to bring up these issues, it can help to email your healthcare provider or write a list of concerns to show them in session.

If you identify as LGBTIQ2S+, it can be particularly important to be able to attend a healthcare practice which is safe, inclusive, and welcoming for people with diverse gender identities and sexual orientations. Healthcare providers also need to be knowledgeable about specific health risks and concerns facing the LGBTIQ2S+ community; for example, offering trans men appropriate pelvic care and pap smears. Fortunately, there are many online resources for finding LGBTIQ2S+ safe and competent care – googling “LGBTIQ2S+ healthcare near me” or similar terms can be useful for finding inclusive clinics or community organisations that can help direct you to queer-friendly healthcare.

Take Action

How you can take action:

  • When well, explore risks of disinhibited sexual behaviour and plan for risky situations
  • Discuss side-effects of medications that are impacting your sexual life with your healthcare provider
  • Talk openly with intimate partner(s) about sexual concerns/problems

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References

  1. Fletcher, K., Parker, G., Paterson, A., & Synnott, H. (2013). High-risk behaviour in hypomanic states. Journal of Affective Disorders, 150(1), 50–56. https://doi.org/10.1016/j.jad.2013.02.018 
  2. Meade, C. S., Fitzmaurice, G. M., Sanchez, A. K., Griffin, M. L., McDonald, L. J., & Weiss, R. D. (2011). The relationship of manic episodes and drug abuse to sexual risk behavior in patients with co-occurring bipolar and substance use disorders: a 15-month prospective analysis. AIDS and Behaviour, 15(8), 1829–1833. doi: 10.1007/s10461-010-9814-9
  3. Chen, S. F., Wang, L. Y., Chiang, J. H., & Shen, Y. C. (2018). Bipolar disorder is associated with an increased risk of sexually transmitted infections: A nationwide population-based cohort study. Sexually Transmitted Diseases, 45(11), 735-740. doi: 10.1097/OLQ.0000000000000863
  4. Marengo, E., Martino, D. J., Igoa, A., Scapola, M., Fassi, G., Baamonde, M. U., & Strejilevich, S. A. (2015). Unplanned pregnancies and reproductive health among women with bipolar disorder. Journal of Affective Disorders, 178, 201-205. https://doi.org/10.1016/j.jad.2015.02.033 
  5. McCandless, F., & Sladen, C. (2003). Sexual health and women with bipolar disorder. Journal of Advanced Nursing, 44, 42–48. https://doi.org/10.1046/j.1365-2648.2003.02766.x 
  6. Clayton, A. H., Croft, H. A., & Handiwala, L. (2014). Antidepressants and sexual dysfunction: Mechanisms and clinical implications. Postgraduate Medicine, 126(2), 91-99. https://doi.org/10.3810/pgm.2014.03.2744 
  7. Montejo, A. L., Montejo, L., & Navarro-Cremades, F. (2015). Sexual side-effects of antidepressant and antipsychotic drugs. Current Opinion in Psychiatry, 28(6), 418-423.
    doi: 10.1097/YCO.0000000000000198
  8. Kopeykina, I., Kim, H.-J., Khatun, T., Boland, J., Haeri, S., Cohen, L. J., & Galynker, I. I. (2016). Hypersexuality and couple relationships in bipolar disorder: A review. Journal of Affective Disorders, 195, 1–14.  https://doi.org/10.1016/j.jad.2016.01.035 
  9. Jamison, K. R., Gerner, R. H., Hammen, C., & Padesky, C. (1980). Clouds and silver linings: Positive experiences associated with primary affective disorders. The American Journal of Psychiatry, 137(2), 198–202. https://doi.org/10.1176/ajp.137.2.198 
  10. Kaltenthaler, E., Pandor, A., & Wong, R. (2014). The effectiveness of sexual health interventions for people with severe mental illness: A systematic review. Health Technology Assessment, 18(1), 1-74. http://dx.doi.org/10.3310/hta18010
  11. Higgins, A., Barker, P., & Begley, C. M. (2005). Neuroleptic medication and sexuality: the forgotten aspect of education and care. Journal of Psychiatric and Mental Health Nursing, 12(4), 439-446. https://doi.org/10.1111/j.1365-2850.2005.00862.x