# data[].attributes.attachment_link.readable_text
Am Fam Physician. 2004;69(10):2419-2420

In patients being treated for depression, which antidepressants have a low risk of sexual side effects?

Bupropion (Wellbutrin), nefazodone (Serzone), amitriptyline (Elavil), and moclobemide (Manerix, a reversible inhibitor of monoamine oxidase type A not available in the United States) have been shown to cause less sexual dysfunction than selective serotonin reuptake inhibitors (SSRIs). [Strength of recommendation: B, based on individual randomized controlled trials (RCTs)] Among SSRIs, fluvoxamine (Luvox) may cause less sexual dysfunction than sertraline (Zoloft). [Strength of recommendation: B, single RCT] No other differences between or within classes of antidepressants have been demonstrated in RCTs.

The incidence of sexual side effects between different antidepressants in adults with depressive or anxiety disorders has been reported by 25 RCTs, most of which were included in two recent descriptive systematic reviews. [References 1 and 2-Evidence level 1A] Bupropion led to less sexual dysfunction (or to more sexual satisfaction) than sertraline or fluoxetine in four trials. The number needed to harm (NNH), that is, the number of patients who have to take the drug for one patient to experience sexual dysfunction, ranged from two to 17, depending on the type of dysfunction. Nefazodone led to less sexual dysfunction (or to more sexual satisfaction) than sertraline in two trials (NNH: two to seven). [Reference 3-Evidence level 1B] Moclobemide led to less sexual dysfunction than four SSRIs in one trial (NNH: five) and to greater sexual desire than doxepin (Adapin) in one trial (number needed to treat: eight). [Reference 4-Evidence level 1B] The acompanying table summarizes the different adverse sexual effects and the agents that cause them.

There were no other consistent differences between classes of antidepressants. One trial reported less sexual dysfunction resulting from amitriptyline than from sertraline (NNH: seven), but numerous trials have not shown differences between clomipramine (Anafranil) and other SSRIs. One trial showed less sexual dysfunction resulting from fluvoxamine than from sertraline (NNH: six), but no differences between other SSRIs have been demonstrated. Limitations to many of the published studies include small sample sizes, failure to control for baseline differences in sexual function between groups of patients, and lack of uniform means of inquiring into sexual adverse effects.

Recommendations from Others

Guidelines issued by the American Psychiatric Association5 (APA) and the American College of Physicians-American Society of Internal Medicine6 (ACP-ASIM) do not provide specific recommendations regarding which antidepressant to prescribe to minimize sexual dysfunction. [References 5 and 6-Evidence level 1A] The APA notes that SSRIs can carry a risk of sexual side effects, whereas the ACP-ASIM states that the data are insufficient to estimate incidence rates, thus making quantitative comparisons among antidepressants impossible.

Bupropion appears to be the best antidepressant for use in patients who are concerned about drug-related sexual dysfunction. Amitriptyline may be a less expensive and suitable alternative, but it has other worrisome adverse effects. Nefazodone may have a low incidence of sexual dysfunction, but it has been associated with hepatotoxicity and was withdrawn from the Canadian and European markets. Moclobemide is not available in the United States.

1. Gregorian RS, Golden KA, Bahce A, Goodman C, Kwong WJ, Khan ZM. Antidepressant-induced sexual dysfunction. Ann Pharmacother. 2002;36:1577-89.

2. Montgomery SA, Baldwin DS, Riley A. Antidepressant medications: a review of the evidence for drug-induced sexual dysfunction. J Affect Disord. 2002;69:119-40.

3. Ferguson JM, Shrivastava RK, Stahl SM, Hartford JT, Borian F, Ieni J, et al. Reemergence of sexual dysfunction in patients with major depressive disorder: double-blind comparison of nefazodone and sertraline. J Clin Psychiatry. 2001;62:24-9.

4. Philipp M, Tiller JW, Baier D, Kohnen R. Comparison of moclobemide with selective serotonin reuptake inhibitors (SSRIs) on sexual function in depressed adults. The Australian and German Study Groups. Eur Neuropsychopharmacol. 2000;10:305-14.

5. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry. 2000;157(4 suppl):1-45.

6. Snow V, Lascher S, Mottur-Pilson C. Pharmacologic treatment of acute major depression and dysthymia. American College of Physicians-American Society of Internal Medicine. Ann Intern Med. 2000;132:738-42.

# data[].attributes.attachment_link.title
Which Antidepressant Is Best to Avoid Sexual Dysfunction?

# data[].attributes.attachment_link.description
Bupropion (Wellbutrin), nefazodone (Serzone), amitriptyline (Elavil), and moclobemide (Manerix, a reversible inhibitor of monoamine oxidase type A not available in the United States) have been shown to cause less sexual dysfunction than selective serotonin reuptake inhibitors (SSRIs).

# data[].attributes.headline
APP TO HELP CONNECTING TO YOUR PARTNER AND OVERCOME SEXUAL DIFFICULTIES 

# data[].attributes.subject
APP TO HELP CONNECTING TO YOUR PARTNER AND OVERCOME SEXUAL DIFFICULTIES 

# data[].attributes.attachment_link.title
Antidepressants and Sex Drive: A Guide on How to Manage

# data[].attributes.attachment_link.description
Choosing between antidepressants and sex can feel like choosing between a rock and a hard place. Learn how antidepressants relate to sex drive.

# data[].attributes.attachment_link.title
When an SSRI medication impacts your sex life - Harvard Health

# data[].attributes.attachment_link.description
SSRIs are designed to increase your serotonin levels, but they can have unwanted side effects. Here’s what to know about the sexual side effects of SSRIs.…

# data[].attributes.attachment_link.readable_text
Abstract

Because 1 in 6 women in the United States takes antidepressants and a substantial proportion of patients report some disturbance of sexual function while taking these medications, it is a near certainty that the practicing clinician will need to know how to assess and manage antidepressant-related female sexual dysfunction. Adverse sexual effects can be complex because there are several potentially overlapping etiologies, including sexual dysfunction associated with the underlying mood disorder. As such, careful assessment of sexual function at the premedication visit followed by monitoring at subsequent visits is critical. Treatment of adverse sexual effects can be pharmacological (dose reduction, drug discontinuation or switching, augmentation, or using medications with lower adverse effect profiles), behavioral (exercising before sexual activity, scheduling sexual activity, vibratory stimulation, psychotherapy), complementary and integrative (acupuncture, nutraceuticals), or some combination of these modalities.

Depression is a major risk factor for sexual dysfunction, and vice versa. In one meta-analysis of over 14,000 patients, those with diagnoses of depression had a 50% to 70% risk for development of sexual dysfunction, even after adjusting for common comorbidities.1 Relative to men, women are at increased risk for depression and anxiety, as well as increased risk of sexual dysfunction.2 Depression may impair sexual well-being by reducing motivation for or reward from engaging in pleasurable activities, interfering with intimate relationships,3 or increasing the risk of smoking or substance abuse.4 Depression and its associated behavioral patterns may also contribute to other disease processes, such as metabolic syndrome, that further exacerbate female sexual dysfunction.5

A substantial proportion of patients will experience some disturbance of sexual function while taking antidepressants. Of note, although antidepressants are named for their effect on mood disorders, they are used in the clinical management of many other classes of psychological and physical problems, including (but not limited to) anxiety disorders, chronic pain, excessive weight, smoking, and menopausal hot flashes. On the basis of secondary analyses and observational studies, rates of adverse sexual effects are not thought to differ across subpopulations of antidepressant users; however, more controlled research is needed.

Three recent independent meta-analyses have examined rates of adverse sexual effects, with similar conclusions: although rates of sexual dysfunction attributable to antidepressants were approximately 40%, rates of sexual dysfunction associated with placebo were approximately 14%. 6-8 However, there was wide variability across studies, antidepressant types, and phase of sexual response: for example, only about 2% of patients taking bupropion reported arousal dysfunction compared with about 82% of patients taking citalopram. The high variability in estimates may arise from differences in assessment types and timing; typically, trials that prospectively assess sexual function over more than 6 months with a validated scale report higher rates of adverse sexual effects than trials that rely on spontaneous patient report, brief clinical assessment without a questionnaire,6 or cross-sectional analyses.7 Also, medications with greater effect on serotonin (eg, sertraline, citalopram, venlafaxine) are associated with significantly higher rates of treatment-emergent sexual dysfunction than medications with predominantly noradrenergic, dopaminergic, or nonmonoaminergic effects (eg, mirtazapine, bupropion).6,7 The relative frequency of sexual dysfunction associated with several common antidepressant drugs is presented in Table 1 . Notably, as depression can itself impair sexual function, some women's sexual function improves when taking antidepressants. For example, in a large clinical trial, depressed women who were untreated had a higher odds ratio of experiencing sexually related personal distress than depressed women who received antidepressants.10

TABLE 1.

Drug

Sexual
desire

Sexual
arousal

Orgasm

Nefazodone b

+

+

+

Adverse sexual effects can be categorized according to different aspects of sexual response, such as problems with desire, arousal, orgasm, pain, and general satisfaction. Although patients who present with one of these symptoms often present with others,6,11 there are a few notable differences across phases. The most commonly reported adverse sexual effects in women taking antidepressants are problems with sexual desire (72%) and sexual arousal (83%).6-8,11 About 42% of women taking selective serotonin reuptake inhibitors report problems having an orgasm.6-8,11 Data on the effect of antidepressants on sexual pain are mixed, with some studies suggesting lubrication problems leading to pain with vaginal penetration, some reporting no effect, and still others reporting improvements in vulvodynia (persistent vulvar pain) with antidepressant use.12

Interestingly, although men generally report higher rates of antidepressant-related adverse effects in sexual desire and orgasm, women are more likely to report sexual arousal dysfunction, particularly when taking selective serotonin reuptake inhibitors.6 These higher rates may be due to sex differences in genital arousal processes: recent research suggests that vaginal arousal is facilitated by sympathetic nervous system activity 13 and that serotonergic medications interfere with the autonomic balance necessary to support vaginal arousal.14 Speculatively, this same physiologic difference may partially explain why women appear to be buffered from the very high rates of antidepressant-associated orgasm dysfunction seen in men because the suppression of sympathetically mediated orgasm reflexes may differentially affect female vs male orgasm. Another likely explanation is the higher percentage of women in the general population who report orgasm dysfunction 2-perhaps fewer women report orgasm problems as an adverse sexual effect because they are more likely to have had orgasm problems before treatment.

An unfortunate clinical reality is that the onset of adverse sexual effects (across all phases) occurs within about 1 to 3 weeks of initiating a treatment regimen, whereas the antidepressant effects do not consistently appear until approximately 2 to 4 weeks after starting a medication.15 Thus, many patients will experience detrimental sexual effects before manifestation of positive mood or symptom reduction. Helping patients navigate this critical window can considerably improve long-term treatment adherence and prevent premature discontinuation of medication. Because 1 in 6 women in the United States takes antidepressants and a substantial proportion of patients report some disturbance of sexual function while taking these medications, it is a near certainty that the practicing clinician will need to know how to assess and manage antidepressant-related female sexual dysfunction.

ASSESSMENT

When prescribing an antidepressant, sexual function must be assessed in order to maximize treatment outcomes, particularly medication adherence. One study found that 15% of women stopped taking their psychotropic medication because of adverse sexual effects. Even more striking, half of these patients never discussed their sexual health concerns with their prescriber. 16 Thus, assessment of sexual functioning before and after the prescription of an antidepressant is crucial for patient satisfaction and medication adherence.

Assessment of sexual function is needed both at initial and subsequent visits. Because nearly half of patients experiencing untreated depression also experience sexual dysfunction 17 and patients may be poor historians regarding the onset of sexual dysfunction,18 it may be difficult to determine whether dysfunction is due to depression vs medication adverse effect without prospective assessment. Repeated measures provide important information about either decline in sexual function (due to medication adverse effects) or improvement (due to reduction in depression).

Sexual function assessment includes both a direct query of the patient and use of a validated questionnaire.19 At most, 35% of patients spontaneously report sexual health concerns, whereas direct assessment may reveal sexual health concerns in up to 69% of patients.1 Direct inquiry can be accomplished at baseline by simply asking during the review of systems, "Do you have any sexual health concerns?" At subsequent visits, the patient can be asked, "Have you noticed any bothersome changes in your sexual function?" It is important that the health care professional determines whether the sexual health issue is distressing or bothersome. Many women report sexual health concerns, but far fewer of these concerns actually cause personal distress. For example, 43% of women report sexual health concerns, yet only 12% report associated distress.4 A sexual health concern warrants intervention only if it causes distress.

If the patient reports a distressing sexual health issue, the assessment should address each domain of sexual function (ie, desire, arousal, orgasm, pain). This process may be most efficiently completed with a validated screening tool. One of the most commonly utilized questionnaires is the Arizona Sexual Experience Scale, a 5-item measure designed specifically to evaluate sexual dysfunction due to psychotropic medication. It has good reliability and validity and requires approximately 5 minutes to complete.20 However, it does not impart information about sexual pain or sexual distress.

Finally, to optimize treatment outcomes, collaboration with the patient and shared decision making is necessary. Educating patients about the potential for and prevalence of adverse sexual effects is important, as is assessing how this problem may impact their willingness to take the medication.21 This information will inform medication choice. Patients should be advised to report any adverse sexual effects at future visits and be assured that treatment is available.

MANAGEMENT

The best clinical evidence supports starting treatment with an antidepressant that has a better adverse sexual effect profile, such as bupropion or mirtazapine, particularly in patients concerned about their sexual functioning and in those with sexual dysfunction at baseline.17 However, this option may not be feasible in some circumstances (eg, bupropion is contraindicated in women with eating disorders 22). Moreover, given the ubiquity of these medications, many health care professionals find themselves treating patients whose depression has already stabilized with use of an antidepressant from another prescriber.

Only 20% of prescribers discuss with their patients the management strategies for adverse sexual effects related to antidepressants.23 Yet, there are a number of effective pharmacological and nonpharmacological treatment options for antidepressant-induced sexual dysfunction. Before discussing these options with the patient, prescribers should first ask what strategies they have already tried because the patient may already have identified a potentially effective strategy and merely needs reassurance to continue.21 For those who have not found an effective remedy, there are a variety of management strategies available ( Table 2 ).

TABLE 2.

Treatment type

Specific therapy

References

Behavioral

Exercise

14, 24

Scheduling sexual activity

24, 25

Vibratory stimulation
26

Psychotherapy
21

Complementary and integrative

Acupuncture
27

Maca root (Lepidium meyenii)
28

Saffron (Crocus sativus L)
29

Rosa damascena oil
30

Pharmacological

Dose reduction or discontinuation of antidepressant

31, 32

Watchful waiting
15

Drug holiday
32

Switching antidepressants

33, 34

Adjunctive treatment (eg, phosphodiesterase type 5 inhibitor, bupropion, testosterone)

35- 37

Desire Dysfunction

Pharmacological Strategies.

Augmentation strategies consist of adding another drug to counteract the adverse sexual effects related to the initial antidepressant treatment. In a randomized, double-blind, placebo-controlled trial involving 42 patients (37 women and 5 men) with antidepressant-induced sexual dysfunction, sustained-release bupropion at 150 mg twice daily resulted in a statistically significant increase in self-reported desire and frequency of sexual activity at 4 weeks compared with placebo.35 A recent Cochrane review concluded that bupropion in higher doses may be an effective augmentation strategy for women.33 A 12-week course of transdermal testosterone (300-μg patch) has been found to significantly increase the number of sexually satisfying events over placebo in a double-blind, randomized, placebo-controlled trial involving 34 premenopausal and 10 postmenopausal women.36 Currently, however, no testosterone products have been approved by the US Food and Drug Administration for use in women.

Arousal Dysfunction

Pharmacological Strategies.

Although there is some evidence of effectiveness of phosphodiesterase type 5 inhibitors in managing adverse arousal effects in men,33 they have not proven effective in improving arousal in women37.

Behavioral Strategies.

There is ample evidence that exercise reduces symptoms of depression and can improve sexual wellbeing in unmedicated depressed patients.38 Thus, it is not surprising that exercise may ameliorate antidepressant adverse sexual effects. Moreover, female sexual arousal may be disrupted by antidepressants via interference with sympathetic contributions to vaginal arousal. As such, exercise, which is a potent stimulator of the sympathetic nervous system, may improve genital arousal in women if conducted immediately before sexual activity.14 A small but well-controlled randomized clinical trial found that 30 minutes of cardiovascular and strength-training exercise before sexual activity significantly improved sexual functioning in women taking serotonergic antidepressants, above and beyond the effects of exercise at other times.24 The authors recommended a prescription of 30 minutes of moderately intense exercise 3 times a week, scheduled immediately before sexual activity for maximal benefit, to reduce adverse sexual effects.

Other Strategies.

In one randomized, doubleblind, placebo-controlled study, saffron ( Crocus sativus L), 30 mg daily, was used to treat sexual dysfunction induced by fluoxetine. It improved women's sexual arousal and vaginal lubrication compared with the placebo group after 4 weeks.29

Orgasm Dysfunction

Behavioral Strategies.

For women experiencing arousal and orgasm adverse effects, more intense stimulation with the use of a vibrator may help counter decreased tactile sensitivity related to an antidepressant.26

It is worth considering whether other factors may have changed concurrent with antidepressant treatment that may also contribute to orgasm dysfunction. For example, women with a history of depression more often prefer solitary sexual activity over partnered sexual activity, particularly while depressed.39 As women recover from depression, they may transition from one form of sexual stimulation that is likely to lead to orgasm (self-stimulation) to another less likely to be orgasmic (ie, partnered sexual activity).40 In the absence of careful assessment, these changes may be misinterpreted as antidepressant-associated orgasm dysfunction.

Other Strategies.

Maca root ( Lepidium meyenii) has been found to improve orgasmic function for women with antidepressant-induced arousal and orgasm dysfunction. In a double-blind, placebo-controlled trial,28 postmenopausal women taking 3.0 g/d of maca root for 12 weeks reported significant improvement in sexual function compared with the placebo group, particularly in orgasmic function.

Improvement Across Domains of Sexual Function

Pharmacological Strategies.

Switching to an antidepressant with fewer adverse sexual effects is a therapeutic option, although there is a lack of randomized, controlled clinical trial data to support this theory.33 In one study, switching to vortioxetine, an antidepressant with a multimodal mechanism of action, was associated with significant improvements in sexual function scores compared with switching to escitalopram, while maintaining antidepressant efficacy.34

Simply waiting for sexual symptoms to improve can be an effective strategy. One study suggested that adverse effects will remit in 6 months in approximately 80% of patients,15 but others note that adverse effects remit in 6 months for only about 10% of patients.41 A small subset of patients (3%-5%) may continue to experience these effects even after discontinuing the medication. The strongest predictors of postdiscontinuation adverse sexual effects are female sex, depressive symptoms (suggesting incomplete remission), and decreased genital sensitivity.42 Because it may take several months for symptoms related to sexual dysfunction to improve with watchful waiting, this may not be a practical solution for some, and medication nonadherence is a potential concern.

Reducing the dose or discontinuing the antidepressant is feasible only if the mood disorder is well controlled because this action may lead to recurrence of symptoms.31 A drug holiday (eg, temporarily discontinuing the drug on weekends) is not recommended because it may induce withdrawal symptoms related to discontinuation, particularly with shorter-acting antidepressants. Additionally, this practice may lead to medication nonadherence and relapse in patients who fail to restart the medication.32

Other Strategies.

A double-blind, placebo-controlled study of citronellol of Rosa damascena oil 30 reported significant improvements in overall sexual function and reduced sexual pain compared with placebo.

Certain genetic polymorphisms related to inefficient serotonin transport (eg, 5-HTTLPR) are associated with significantly higher risk of adverse sexual effects.43Women with vulnerable polymorphisms are at significantly increased risk of adverse sexual effects if they take hormonal contraceptives,44 suggesting that switching to a low-dose or nonhormonal contraceptive method may improve sexual function in a subset of female antidepressant users. However, this recommendation is speculative and further research is needed to examine the efficacy of this strategy.

Finally, for women receiving long-term antidepressant therapy in whom other treatment strategies have not been helpful, acceptance of current sexual function may be a useful therapeutic option. Women who have accepted their sexual function "as is" have utilized the following coping strategies: (1) emphasizing the benefits of the antidepressant over the consequences, (2) attending to the positives in their relationship with their partner and to emotional vs physical satisfaction, and (3) changing sexual expectations.21

CONCLUSION

Treatment with antidepressant medications can cause difficulty with sexual function in the domains of sexual desire, arousal, and orgasm. Rates of sexual dysfunction with antidepressant use are very high, particularly during the adjustment phase. Medications with the greatest serotonin effect are associated with the highest rates of sexual dysfunction. Determining the cause of the sexual dysfunction (underlying mood disorder vs medication-induced vs other contributing factors, eg, relationship concerns, chronic medical conditions) can be challenging for the clinician. Assessment of sexual functioning is important, not only at the initial visit but also at subsequent visits and can be accomplished with direct inquiry. Treatment options for antidepressant-associated sexual dysfunction include pharmacological strategies such as drug discontinuation or dose reduction but may not be feasible; drug holidays may cause discontinuation symptoms and may lead to nonadherence and relapse. Augmentation, switching to medications with fewer adverse sexual effects, or starting a medication with a better adverse effect profile a priori may be preferable strategies. Behavioral strategies include exercise, scheduling sexual activity, vibratory stimulation, and psychotherapy. Complementary and integrative treatments require additional study but include acupuncture, maca root, saffron, or R demascena oil.

​

Target Audience: The target audience for Mayo Clinic Proceedings is primarily internal medicine physicians and other clinicians who wish to advance their current knowledge of clinical medicine and who wish to stay abreast of advances in medical research.

Statement of Need: General internists and primary care physiciansmustmaintain an extensive knowledge base on a wide variety of topics covering allbody systems as well ascommon anduncommon disorders. Mayo Clinic Proceedings aims to leverage the expertise of its authors to help physicians understand best practices in diagnosis and management of conditions encountered in the clinical setting.

Accreditation: Mayo Clinic College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Statement: Mayo Clinic College of Medicine designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

MOC Credit Statement: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Learning Objectives: On completion of this article, you should be able to (1) list the antidepressants most likely to cause sexual dysfunction; (2) describe how and when to assess for antidepressant-induced sexual dysfunction; and (3) evaluate the interventions available for antidepressant-induced sexual dysfunction.

Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Medicine (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation.

Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation.

In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry. The authors report no competing interests.

Method of Participation: In order to claim credit, participants must complete the following:

Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed.

Visit www.mayoclinicproceedings.org, select CME, and then select CME articles to locate this article online to access the online process. On successful completion of the online test and evaluation, you can instantly download and print your certificate of credit.

Estimated Time: The estimated time to complete each article is approximately 1 hour.

Hardware/Software: PC or MAC with Internet access.

Date of Release: 9/1//2016

Expiration Date: 8/31/2018 (Credit can no longer be offered after it has passed the expiration date.)

Privacy Policy: http://www.mayoclinic.org/global/privacy.html.

Questions? Contact ude.oyam@troppuscteld.

Contributor Information

Tierney Lorenz, Kinsey Institute and Center for the Integrative Study of Animal Behavior, Indiana University, Bloomington; Mayo Clinic, Rochester, MN. Dr Lorenz is now with the Department of Psychology, University of North Carolina at Charlotte.

Jordan Rullo, Women's Health Clinic, Division of General Internal Medicine, Department of Medicine, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Stephanie Faubion, Women's Health Clinic, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.

REFERENCES

18. Segraves RT, Balon R. Antidepressant-induced sexual dysfunction in men. Pharmacol Biochem Behav. 2014;121:132-137. [[ PubMed] Google Scholar]

21. O'Mullan C, Doherty M, Coates R, Matt Tilley PJ. 'Accepting what is': an approach for managing the long-term sexual side effects of selective serotonin reuptake inhibitors (SSRIs) in women. Sex Relation Ther. 2015;30(3):325-337. [ Google Scholar]

23. Chong WW, Aslani P, Chen TF. Adherence to antidepressant medications: an evaluation of community pharmacists' counseling practices. Patient Prefer Adherence. 2013;7:813-825. [[ PubMed] PMC free article] [ Google Scholar]

28. Dording CM, Schettler PJ, Dalton ED, et al. A double-blind placebo-controlled trial of maca root as treatment for antidepressant-induced sexual dysfunction in women. Evid Based Complement Alternat Med. 2015;2015:949036. [[ PubMed] PMC free article] [ Google Scholar]

33. Taylor MJ, Rudkin L, Bullemor-Day P, Lubin J, Chukwujekwu C, Hawton K. Strategies for managing sexual dysfunction induced by antidepressant medication. Cochrane Database Syst Rev. 2013;(5):CD003382. [[ PubMed] Google Scholar]

34. Jacobsen PL, Mahableshwarkar AR, Chen Y, Chrones L, Clayton AH. Effect of vortioxetine vs. escitalopram on sexual functioning in adults with well-treated major depressive disorder experiencing SSRI-induced sexual dysfunction. J Sex Med. 2015;12:2036-2048. [[ PubMed] Google Scholar]

# data[].attributes.attachment_link.description
Because 1 in 6 women in the United States takes antidepressants and a substantial proportion of patients report some disturbance of sexual function while taking these medications, it is a near certainty that the practicing clinician will need to know ...

# data[].attributes.attachment_link.readable_text
Depression and Sexual Health

Despite social stigma, depression is a very common illness. According to the Centers for Disease Control and Prevention (CDC), about one in 20 Americans over the age of 12 has some form of depression. While the National Institute of Mental Health (NIMH) reports a higher prevalence in women, the fact is that depression can develop in anyone, and at any age. The types of depression include:

persistent depressive disorder (symptoms last for two years)

psychotic depression

major depression

bipolar disorder

postpartum depression (occurs in women after having a baby)

seasonal affective disorder (occurs during the winter months)

depression coupled with anxiety disorders

For those affected, having depression means more than just feeling blue - it can cause a range of symptoms, including sexual health problems. Learn more about the link between depression and sexual dysfunction, and what you can do about it.

Both men and women can experience difficulties with initiating and enjoying sex because of depression. Still, there are some differences in the ways depression affects women and men.

Women

According to the , a higher rate of depression in women is connected to hormonal changes. This is why a woman's risk of depression may increase:

before and during menstruation

after childbirth

when juggling work, home, and family life

during perimenopause and menopause

Women are the most likely to experience persistent "bluesy" feelings that can make them feel less confident and less worthy. These feelings can drastically change your overall sex life.

As women age, physical factors can make sex less enjoyable (and sometimes even painful). Changes in the vaginal wall can make sexual activity unpleasant. Also, lower levels of estrogen can disrupt natural lubrication. Such factors can be depressing for women if they do not seek help to find relief.

Men

Anxiety, low self-esteem, and guilt are common causes of erectile dysfunction. These are all symptoms of depression, but such issues can also occur naturally with stress and age. The explains that men are also more likely to lose interest in activities during depression. This could also mean that men might not find sex as appealing.

In men, antidepressants are directly related to impotence. Delayed orgasm or premature ejaculation may occur, too.

In both men and women, having troubles with sexual health can worsen feelings of worthlessness and other depression symptoms. This in turn can cause a vicious cycle of both worsening depression andsexual dysfunction.

Chemical imbalances in the brain cause depression These can occur on their own as a result of genetics and hormonal issues. Depression can also coexist with other illnesses. No matter the exact cause of depression, it can result in numerous physical and emotional symptoms. Some of the most common symptoms of depression include:

persistent sadness

lack of interest in activities you once loved

guilt and hopelessness

insomnia and fatigue

irritability and anxiety

weakness, aches, and pains

sexual dysfunction

concentration difficulties

weight loss or gain (usually from changes in eating habits)

suicidal disposition

The symptoms of depression vary in frequency and severity for each person. Generally, the more severe of depression you have, the more problems you're likely to have with sexual health.

Sexual desire is cultivated in the brain, and sex organs rely on chemicals in the brain to promote libido as well as the changes in blood flow needed for the sexual act. When depression disrupts these brain chemicals, it can make sexual activity more difficult. This may be worse in older adults who already have occasional problems with sexual dysfunction.

It is also not just the depression itself that may interfere with sexual health. In fact, antidepressants - the most common forms of medical treatment for depression - can often have unwanted sexual side effects. The most common culprits are:

monoamine oxidase inhibitors (MAOIs)

serotonin and norepinephrine reuptake inhibitors (SNRIs)

selective serotonin reuptake inhibitors (SSRIs)

tetracyclic and tricyclic medications

Treating depression is just one way you can overcome sexual dysfunction. In fact, according to a study published in American Family Physician, 70 percent of adults facing depression without treatment had problems with libido. Feeling good again may help you get back to a normal sex life.

Still, the problem may not always resolve in adults who do seek depression treatment. If your primary care provider determines that sexual dysfunction is a side effect of an antidepressant you take, they might switch you to a different medication. Mirtazapine (Remeron), nefazodone (Serzone), and bupropion (Wellbutrin) do not typically cause sexual side effects.

Aside from additions and adjustments within conventional depression treatment, there are other steps you can take which may improve overall sexual health:

Take antidepressant dose after engaging in sex.

Ask your provider about adding a medication for sexual function (such as Viagra for men).

Exercise regularly to improve mood and physical well-being.

Talk to your partner about how your depression is affecting your sexual health. Open communication may not automatically resolve the issue, but it can help alleviate feelings of guilt and worthlessness.

Depression and its related treatment can sometimes cause issues with sexual health, but there is hope in resolving both issues. Treating one can often help the other. However, finding the right balance can take time and patience. In the meantime, you should not alter any medications on your own without checking with your healthcare professional. Tell your provider if sexual dysfunction worsens despite any alterations in treatment.

It's also important to remember that, while depression and sexual dysfunction can go hand in hand, there are also a variety of factors that can cause problems with sexual health.

# data[].attributes.attachment_link.title
Depression & Sex: How Depression Can Affect Sexual Health

# data[].attributes.attachment_link.description
For those affected, having depression means more than just feeling blue - it can cause a range of symptoms, including sexual health problems.

# data[].attributes.attachment_link.readable_text
Abstract

Adequate sexual expression is an essential part of many human relationships, and may enhance quality of life and provide a sense of physical, psychological and social well-being. Epidemiological and clinical studies show that depression is associated with impairments of sexual function and satisfaction, even in untreated patients. Most antidepressant drugs have adverse effects on sexual function, but accurate identification of the incidence of treatment-emergent dysfunction has proved troublesome, as disturbances of the sexual response can only be detected in a reliable fashion when systematic enquiries are made before and during the course of treatment. Growing awareness of the adverse effects of many antidepressants on sexual function has led to attempts to resolve dysfunction though adjuvant or substitution treatment approaches. There is a need for further studies of the effects of antidepressants on sexual function.

Sexual dysfunction can arise from physical conditions ( e.g. circulatory disorders may cause erectile dysfunction in men) and from psychological factors ( e.g. unsatisfactory interpersonal relationships, psychiatric illness). Many drugs can cause sexual dysfunction, including antihypertensives, antipsychotics, and antidepressants. However, it can be difficult to separate drug-induced adverse effects from consequences of illness, particularly in psychiatric disorders with major effects on interpersonal relationships. There is relatively little scientific information on the incidence of antidepressant-induced sexual dysfunction, even though this may be important to the patient and contribute to non-compliance with treatment.

The human sexual response and sexual dysfunctions

The normal human sexual response cycle is conventionally divided into four phases. Disorders of the sexual response can occur at one or more of these phases.

1. Desire: typically this consists of fantasies about, and the desire to have, sexual activity.

2. Excitement: the subjective sense of sexual pleasure and accompanying physiological changes, namely penile tumescence and erection in men, and pelvic vasocongestion, swelling of the external genitalia, and vaginal lubrication and expansion in women.

3. Orgasm: sexual pleasure peaks, with release of sexual tension and rhythmic contraction of the perineal muscles and reproductive organs. In men, the sensation of ejaculatory inevitability is followed by ejaculation of semen. In women, contractions of the outer third of the vaginal wall occur.

4. Resolution: the sense of muscular relaxation and general well-being. Men are physiologically refractory to erection and orgasm for a variable period, whereas women may be able to respond to further stimulation.

The tenth edition of the International Classification of Mental and Behavioural Disorders (ICD-10) uses the term 'sexual dysfunction' to cover the ways in which an individual is unable to participate in a sexual relationship as he or she would wish. The ICD-10 classification of sexual dysfunction, not caused by organic disorder or disease is as shown below. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) uses a broadly similar classificatory scheme.

F52.0 Lack or loss of sexual desire

F52.1 Sexual aversion and lack of sexual enjoyment

F52.2 Failure of genital response

F52.3 Orgasmic dysfunction

F52.4 Premature ejaculation

F52.5 Non-organic vaginismus

F52.6 Non-organic dyspareunia

F52.7 Excessive sexual drive

F52.8 Other sexual dysfunction, not caused by organic disorder or disease

F52.9 Unspecified sexual dysfunction, not caused by organic disorder or disease

Some types of dysfunction occur in both men and women, although women tend to present with complaints about the subjective quality of sexual experience ( e.g. lack of interest or enjoyment) whereas men often describe the failure of a specific response such as erection, whilst reporting a continuing sexual appetite. It has been argued that the categorical approach to sexual dysfunction adopted by the ICD-10 and DSM-IV simply serves 'to obscure the varied and often unique ways in which individuals and couples present with sexual problems'. When one aspect of the sexual response is affected, other aspects are also likely to be impaired, and it is important to 'look beyond' any presenting complaint, to find the most appropriate diagnosis.

Epidemiology of sexual dysfunction

This area has not been studied extensively ( Table 1). In an attempt to derive prevalence data for sexual dysfunctions as defined in DSM-III, Nathan surveyed 22 studies of sexual behaviour in the general population, but concluded that methodological problems in the surveys meant that only broad estimates could be made. The prevalence of inhibited sexual desire was 16% for men, 35% for women; erectile dysfunction and premature ejaculation, 10-20% and 35% of men, respectively; and female orgasmic difficulties had a prevalence of 5-15%.

Many factors influence the reported incidence of sexual dysfunction. First, the method of enquiry; for example, in a prospective study of depressed out-patients, the incidence of sexual dysfunction was 14% when relying on spontaneous reporting, but 58% when patients were questioned directly by doctors. Second, the expectations people have of their sexual performance and their willingness to discuss problems varies widely between different cultures. Third, many terms used to define sexual dysfunction are subjective and dependent on ideas of what is normal. Finally, temporal trends can occur as increased awareness of sexual matters and availability of medical treatments increase the number who perceive themselves as suffering from sexual dysfunction.

Sexual dysfunction in depressed patients

Comparative studies reveal higher levels of sexual dysfunction in depressed patients than in non-depressed controls ( Table 2). The specific type of sexual dysfunctions vary in incidence, but loss of sexual desire may be more common than disorders of arousal and orgasm: in a comparative study, changes in libido were significantly more common in depressed patients than controls, but differences in the prevalence of impotence, orgasmic or ejaculatory problems were not. The prospective Zurich cohort study shows that the prevalence of sexual problems in depressed subjects (including those with major depression, dysthymia and recurrent brief depression) is approximately twice that in controls (50% versus 24%). This difference encompassed emotional problems, sexual dysfunction, and both decreased and increased libido. The data in this study are from a group of young people (28-35 years) and may not be applicable to older age groups.

Sexual dysfunction associated with antidepressants

Papers for this review were identified by searching the Medline, Toxline, Embase, Biosis, DDFU, Scisearch, PsychLit and ADIS Newsletter databases. Sexual dysfunction was used as an index term, and combined with names of antidepressant drugs. Further papers were obtained from Current Contents 1995-1999. These were supplemented by papers identified from reference lists, abstracts presented at congresses, and through scanning library copies of relevant journals. Studies were included if they were published in English, reported an incidence of sexual dysfunction in patients receiving antidepressant medication and if there were 10 or more subjects. All studies reporting data on drug-associated sexual dysfunction were assessed on the following criteria: design (randomised, prospective, double-blind); comparative; type of control (placebo-controlled and/or baseline-controlled); use of defined diagnostic criteria; use of validated rating scale for assessing sexual dysfunction.

Although the high prevalence of sexual dysfunction in the general population and in depressed patients can make evaluation difficult, treatment-emergent sexual dysfunction can occur with tricyclic antidepressants (TCAs), selective serotonin re-uptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). Some antidepressants (bupropion, mirtazapine, moclobemide, reboxetine, nefazodone) may be associated with a relatively lower incidence of sexual dysfunction, but most data for these newer drugs come from reviews of clinical trial adverse event databases or work with healthy volunteers.

Studies which made no direct comparison between antidepressants

Table 3 lists studies conducted in mixed populations of patients receiving antidepressants for depressive or anxiety disorders. The prevalence of sexual dysfunction may not differ according to diagnosis. One study found no significant difference between patients undergoing drug or non-drug therapy, across a range of sexual function variables assessed using the Social Adjustment Scale (SAS) and Hamilton Rating Scale for Depression (HRSD). Few data have been published on sexual dysfunction occurring with TCAs, although anorgasmia was common in a study of clomipramine in patients with obsessive-compulsive disorder.

The majority of the studies assess sexual dysfunction with SSRIs. It is difficult to interpret these findings, as the study populations include patients with varying degrees of depression and/or anxiety, and no two studies used the same method of assessing sexual dysfunction. Few studies assessed sexual function at baseline (4 studies), and 8 of the studies involved fewer than 100 subjects. Large patient populations and placebo control were mainly confined to controlled clinical trials, which invariably failed to include a baseline control. Fluoxetine had both the highest (75%) and the lowest (8%) reported prevalence of treatment-emergent sexual dysfunction, one figure derived from specific questioning about abnormal ejaculation, the other derived from spontaneous reports of orgasmic problems.

Studies which made direct comparisons between antidepressants

Table 4 summarises studies which directly compared two or more active agents. As with the non-comparative studies, the methodology varies considerably. Several are not true comparisons, but report differences between drugs in manufacturers' databases, adverse events spontaneously reported to a national body or hospital monitoring scheme. These evaluations are troublesome to interpret, through differences in coding of adverse events, possible bias in reporting, and inadequate data on dosage and number of exposed patients.

Comparative studies of SSRIs have generally found no significant differences between drugs, but one study reported more sexual dysfunction with sertraline than fluvoxamine. Bupropion may be associated with a low incidence of sexual adverse effects, being significantly superior to sertraline in one study and to SSRIs in another. A comparative study with nefazodone found it to be significantly superior to sertraline on some measures of sexual function. All the studies had some methodological flaw. Only two used a recognised rating scale for sexual dysfunction (the Sexual Function Questionnaire), the others relying on patients reporting adverse events. Only two used a baseline assessment and placebo control.

Augmentation or switching studies

The largest body of data is for bupropion. Adjunctive treatment improved sexual dysfunction in 31 of 47 (66%) patients previously treated with SSRIs, but 7 (15%) discontinued bupropion because of anxiety and tremor. In another study, switching to bupropion improved sexual function in 24 of 28 men who had experienced sexual dysfunction during treatment with TCAs or MAOIs. Similar effects have been reported in 31 patients (men and women) who developed anorgasmia or delayed orgasm while taking fluoxetine: after switching to bupropion for 8 weeks, orgasm dysfunction completely or partially resolved in 29 patients (94%), and libido was much or very much increased in 25 (81%). However, not all data with bupropion are consistent: a retrospective review in 27 patients found that sexual dysfunction occurred in 11 patients (41%) when they were receiving combination bupropion-SSRI treatment, not significantly different to the rate (52%) when they were taking either agent alone.

Method for assessing sexual dysfunction

Studies investigating antidepressant drug-induced sexual dysfunction must be especially stringent, in order to differentiate between normal variations in sexual function, sexual problems related to depression or anxiety, and sexual dysfunction associated with antidepressant treatment. Ideally, these studies should be prospective, randomised, double-blind, placebo-controlled and conducted in a defined diagnostic population. The studies should make direct comparisons between different drugs, and the dose ranges should be of equivalent efficacy.

Sexual dysfunction should be assessed using a rating scale administered to all patients, rather than relying on spontaneous reporting or open questions which may be interpreted differently by different patients. The rating scale chosen should be valid and reliable, able to discriminate between normal variations in sexual behaviour and sexual dysfunction, and sensitive to change. A baseline measure of sexual dysfunction is needed to identify treatment-emergent changes, and in comparative studies groups should be balanced according to degree of sexual function at baseline. Many sexual functioning questionnaires exist, but most have not been thoroughly tested and remain unvalidated. Some of the most well-known scales are the Sexual Function Questionnaire, the Sexual Functioning Questionnaire, and the Arizona Sexual Experience Scale (ASEX). The latter has been validated for multiple comparisons, but is not yet used widely.

Treatment of sexual dysfunction

behavioural strategies to improve sexual technique

waiting for the development of tolerance

reduction in dosage

delaying drug intake until after sexual activity

'drug holidays'

adjuvant treatments

changing to a different antidepressant

Drug holidays, involving brief interruptions of treatment, have been advocated as an approach to SSRI-induced sexual dysfunction. However, this approach can put the patient at risk of discontinuation symptoms and possible relapse of depression: furthermore, a drug holiday is only possible with drugs with a short half-life and not with fluoxetine, where sexual side effects may not resolve until a few weeks after stopping treatment. Many adjuvant compounds have been advocated for the treatment of psychotropic drug-induced sexual dysfunction, including buspirone, cyproheptadine, mianserin, yohimbine, neostigmine, amantadine and dexamphetamine. However, there have been very few double-blind placebo-controlled studies of these drugs, and it is wise to be cautious when using unfamiliar treatments. Finally, it seems likely that sildenafil may come to have a role in relieving sexual dysfunction in depression. In a sub-group of 136 depressed patients included within the placebo-controlled clinical trial database, 76% described improvements with sildenafil, compared to 18% of the group receiving placebo: in a second report, sildenafil was effective in 10 of 14 patients with antidepressant drug-induced sexual dysfunction.

Conclusions

Accurate assessment of sexual function in depression is subject to many difficulties, including the little data on prevalence of sexual dysfunction in the general population, and the effects of antidepressant drugs. Obtaining accurate data on an intimate subject is potentially prone to under-reporting unless careful attention is paid to the method of data collection. Until data from rigorous, controlled, comparative studies are available, the perceived likelihood of sexual side effects should not unduly influence the choice of antidepressant drug, and prescribing decisions should be made on an assessment of the overall balance of the benefits and risks of treatment.

Thanks are due to Jon Birtwistle for his help with the literature search, and to Stuart Montgomery and Alan Riley for shared discussions regarding the assessment of sexual dysfunction in depression.

References

# data[].attributes.attachment_link.description
Abstract. Adequate sexual expression is an essential part of many human relationships, and may enhance quality of life and provide a sense of physical, psycholo

# data[].attributes.attachment_link.readable_text
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

doi: 10.1097/JCP.0b013e31819c76e9.

Affiliation

¹ Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario, Canada. sidney.kennedy@uhn.on.ca

Abstract

Sexual dysfunction is a common symptom of depression. Although decreased libido is most often reported, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse effect of treatment with most antidepressants and is one of the predominant reasons for premature drug discontinuation. Selective serotonin reuptake inhibitors are the most widely prescribed antidepressants and have significant effects on arousal and orgasm compared with antidepressants that target norepinephrine, dopamine, and melatonin systems. The availability of an antidepressant that does not cause or exacerbate sexual dysfunction represents an advance in pharmacotherapy for mood disorders and should reduce treatment noncompliance and decrease the need for switching antidepressants or adding antidotes. The purpose of this review was to provide an update on the prevalence, psychobiology, and relative adverse effect burden of sexual dysfunction associated with different antidepressants.

PubMed Disclaimer

Similar articles

Antidepressant-induced sexual dysfunction during treatment with moclobemide, paroxetine, sertraline, and venlafaxine.

Kennedy SH, Eisfeld BS, Dickens SE, Bacchiochi JR, Bagby RM. Kennedy SH, et al. J Clin Psychiatry. 2000 Apr;61(4):276-81. doi: 10.4088/jcp.v61n0406. J Clin Psychiatry. 2000. PMID: 10830148

Male sexual side effects associated with antidepressants: a descriptive clinical study of 32 patients.

Hsu JH, Shen WW. Hsu JH, et al. Int J Psychiatry Med. 1995;25(2):191-201. doi: 10.2190/1DHU-Y7L7-9GKG-V7WV. Int J Psychiatry Med. 1995. PMID: 7591493

[Major depressive disorder, antidepressants and sexual dysfunction].

# data[].attributes.attachment_link.keywords[]
antidepressive agents / adverse effects*

# data[].attributes.attachment_link.keywords[]
erectile dysfunction / chemically induced

# data[].attributes.attachment_link.keywords[]
selective serotonin reuptake inhibitors / adverse effects

# data[].attributes.attachment_link.keywords[]
selective serotonin reuptake inhibitors / therapeutic use

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Sexual dysfunction, depression, and the impact of antidepressants - PubMed

# data[].attributes.attachment_link.description
Sexual dysfunction is a common symptom of depression. Although decreased libido is most often reported, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse eff ...

# data[].attributes.attachment_link.readable_text
Reviews provided by Syndetics

Library Journal Review

At a youthfully dissipated summer house party, Fred is smitten by Cati and her joie de vivre, though they barely speak. Several years later, they connect again, and love sparks. But Cati brings with her two surprises: a young son and their mutual HIV-positive status--the blue pills keep them alive and relatively healthy. The couple's deepening intimacy despite the hovering viral ghost carries the plot, as a sympathetic doctor counsels them with skill and frankness. Toward the end, a fantasy Socratic dialog with a mammoth helps Fred get his priorities together to appreciate the gift of love in all its wrappings. Peeters is an award-winning artist living in Switzerland, and his muscular, black-and-white art suits his story perfectly. Realistic and touching, by turns amusing and yet romantic, this memoir is strongly recommended for ages 18+ because of some well-contextualized nudity and explicitness. Needs appropriate HIV-related nonfiction catalog headings.--M.C. (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.

Publishers Weekly Review

Originally published in Switzerland, Peeters's comics memoir of his romance with an HIV-positive woman named Cati (whose young son is also seropositive) is a new and sweeter kind of AIDS narrative-set in the era when HIV has become a chronic condition rather than a death sentence. There's not much of a plot here (the unnamed boy gets sick, then better; Peeters and Cati panic after a condom breaks, and are reassured by their doctor), but the book is much more about Peeters's fluid, slashing, unfailingly evocative ink brushwork documenting the psychological changes he's gone through. Sure-handedly caricatured facial expressions and body language tell a lot of the story, and almost every page is punctuated with a silent panel or two that suggests the way Peeters's newly expanded awareness of his mortality has made him more aware of the world he lives in, too. The final chapters feature an ingenious visual metaphor: after a doctor tells Peeters that he has "as much chance of catching AIDS as you have of running into a white rhinoceros on your way out," he imagines himself stalked everywhere by the rhino. It's a small gem of a book, whose only real flaw is an ungainly English translation, larded with unfiltered Gallicisms. (Jan.) Copyright 2008 Reed Business Information.

Booklist Review

Peeters' graphic-novel memoir traces his circumspect courtship of Cati, the HIV-positive mother of an HIV-positive toddler. As is often the case when such a young child is involved, the courtship must be almost as much about the child's sensibilities as the mother's. At first, Peeters is a chump, but after he realizes his true affection for Cati, he becomes cautious, both in matters of sexual intimacy and also in relating to the little one, as Cati's son is called throughout. As the story unfolds and despite a dramatic scare from a broken condom, Peeters and Cati decide, with medical guidance, to have a child of their own. Peeters' quiet, nuanced narrative is joined to scratchy and energetic black-and-white images that show his stubble, her wide-eyed honesty, and the toddler's shifting allegiances. Occasional passages include symbolic presences a geisha in one, a woolly mammoth in another but in the unvarnished humanity of the story lies the book's strength and attraction. Excellent as both realistic romance and a case report on living with HIV.--Goldsmith, Francisca Copyright 2007 Booklist

Kirkus Book Review

A compelling graphic memoir about desire and illness, and the depth of love that often results. Published in the artist's native Switzerland in 2001 but not translated from the French until now, this prize-winning work details the romance of a Geneva couple, Fred and Cati. They meet at a party, where her attractiveness and abandon strike a spark in him. "What kind of girl is this who allows herself to drink Champagne in a swimming pool with a wet t-shirt, while managing to remain classy and in good taste?" he asks. In the years that follow, they run into each other occasionally, while their lives otherwise take different paths. The next time they truly connect is on the cusp of the millennium, at yet another party, where Cati looks "frail and pale. . .more beautiful than ever." Not only does she have a failed marriage and a young son, but both she and her son have HIV. Much of the memoir concerns the complicated relationship that Fred, who hates hospitals, develops with Cati's son; much of the rest concerns the equally complicated but rapturously sensual relationship he enjoys with Cati, whose illness arouses dread as well as desire within him. Even after a doctor assures him that he has as much chance of contracting the virus from her--particularly if they're careful--as he has of being chased by a rhino through the streets of the city, he ultimately confronts even bigger fears that lurk inside himself. This material would be sufficiently riveting if it were all prose, but the drawings of Peeters are what elevate the book to another level, as he evocatively captures not only physical settings (Geneva, the hospital) but the attraction between Fred and Cati and the darkest musings of his psyche. Better late than never--American graphic-narrative fans will embrace a memoir that ranks with the best. Copyright ©Kirkus Reviews, used with permission.

# data[].attributes.attachment_link.title
Details for: Blue pills / › UAL homepage catalogue

# data[].attributes.attachment_link.description
At a youthfully dissipated summer house party, Fred is smitten by Cati and her joie de vivre, though they barely speak. Several years later, they connect again, and love sparks. But Cati brings with her two surprises: a young son and their mutual HIV-positive status--the blue pills keep them alive and relatively healthy.

# data[].attributes.attachment_link.readable_text
Relationships are the oldest points of connection that allow us to see and understand ourselves. They are mirrors that reflect who we are - the best and not-so-best parts - and grow us into new ways of living. They are bridges to becoming better.

Finding love used to be a predictable process resting on ancient tectonic plates of behavior, until 1995, when a rush of new energy moved those plates, permanently shifting the landscape.
Challenge
Since its founding, Match has pioneered a land of online dating. Their vision was a seed planted in the vast new expanse of the internet, germinating an entirely new category, opening up a world that ushered in an assortment of platforms and, in turn, cultures.

It's no wonder that dating has become a panic-induced, anxiety-ridden journey. We now act as if the last train is leaving the station. We're either too cynical to get on or we take the wrong one and never get off.

The challenge for leaders is to show what's possible while also learning from history. Every now and then, a brand has to empty out its bag and reorder it for their next adventure. Match was sitting on a treasure trove of experience and knowledge gained over 25 years, ready to be reassembled and reorganized for a new future.

Evolving Match has been about taking the most powerful, meaningful qualities of their brand and delivering them in a new way; to expand the story, the language and the capabilities to be of better service to people who are confident and eager to live in more intentional ways.
Solution
Leveraging their long track record of success and industry mastery, we zoomed in on where Match is unmatched.

If apps today are a means to an end for dating, what is the opposite edge of this? How can a product feel more like a beloved service rather than a convenient game?

Enter: hospitality and concierge. Where other apps forcibly push you to "engage" and maximize your limits - to then pay for more maximum engagement - Match strives for the effortlessness of a concierge's wave, showing you to your table; almost invisible but deeply appreciated.

A logo implies something more than its obvious meaning. The heart moved from the top to the bottom-full stop- indicates the confidence in service that Match represents. Match becomes a simple statement and a clear ambition. The original helped Match light the way; this new logo shows they have arrived.

The color palette has evolved to fit the context in which Match is readily used. No glaring, bright colors, but tonal and inviting.

For decades, people have looked to Match with high expectations: They knew what they were looking for, and they wouldn't settle for less. At every touchpoint, from creating a profile to being onboarded into their world, people knew that if you were on Match, you were ready to connect. We brought that trust and experience back to the forefront.

It doesn't take minutes to create a profile; it takes time and intention. Dating, then, is not an end. It's the means.

By working cross-functionally with Match's executive, product, design, and marketing teams, the new brand strategy enabled us to amplify the experience of Match while also paving new roads for a more inclusive, ever-changing environment of dating. To feel elegant, playful, intimate, and inviting. The technology works so the conversation can flow effortlessly forward.

Match's new features, finely honed expertise built over time, and standard of service, allows them to re-emerge in the universe that they created. From hiring dating experts to new iconography and language that encourages you to be more open to the myriad of possibilities, Match supports you to focus on the good stuff: getting to know someone. They craft anticipation into the experience. Now, smiling down at your phone will be the work of design.

This is not about pressing buttons or acing an algorithm. This is about the long-haul. It's about the bedrock of conversations that sprout serendipity and connection. Rather than a slip into cynicism, you might fall hard for the right person.

A few months before the official launch, Match tested the new identity to see how it resonated with their customers. A 13% increase across all key metrics on Match's platform revealed that the new identity and language was, well ... loved.

Evolution is not about discarding the old you. It's about reamplifying the traits that are most unique to you. It's about using design to craft symbols, stories, and opportunities that shape hearts and minds for a new future.

# data[].attributes.attachment_link.description
Re-emerging in the universe they created.

# data[].attributes.attachment_link.readable_text
Jacob, 29

One of our favourite things to do is 'outercourse'

I was raised in a really conservative religious household and went to a Catholic school. I'm bisexual, or maybe the more correct term is pansexual - I don't really see gender as a dividing line for who I'm attracted to. Growing up, I was ostracised for it, so I always masked my behaviour, and it wasn't until my mid-20s that I started to think: hold on, I can't just keep faking who I am.

By the time I met Kasey four years ago, I had been through enough to feel comfortable in myself. But sometimes I still have intrusive thoughts, like this school tutor in my head saying: "What you're doing is wrong." Kasey is also bisexual - being able to have someone that you love and trust in your corner helps you figure these things out.

We will usually start with cuddling on the couch, kissing and we'll move to oral and grinding

I now see that many things that I hadn't thought of before can constitute sex. One of our favourite things to do is outercourse. We will usually start with cuddling on the couch, kissing and then move to oral and grinding.

For us, sex means starting from a place of intimacy and touch and, depending on how we're both feeling, we'll decide whether we want to have penetrative sex, or if we just want to edge and stop just before we orgasm, and be close to each other for 40 minutes. Kasey is on antidepressants, so it is hard for her to get off, and there are times when we'll be having sex and we know it's not going to happen. So, we'll go to bed and lie in each other's arms. It's frustrating sometimes for her, but it's normal if it doesn't happen.

Over time, I have started to want to cross-dress and present as more feminine. I was really self-conscious about it - I'm a fairly burly guy. But Kasey pointed out how great my legs looked in tights and other such nice things, so I now feel much better about it. In the same way, she has cut her hair and is presenting a lot more masculine, and she is still so attractive to me.

I want to continue exploring this part of ourselves. Sometimes I still get these nagging thoughts as a hangover from my childhood that there's something wrong with what I'm doing. But it just takes time.

Kasey, 27

We don't go through the motions assuming that we're going to have heterosexual penetrative sex

Since we've been together, we have always been open with each other about not wanting to play the normal gender game. Jacob sometimes wants to be able to be more feminine. I have historically identified as agender but I'm moving toward identifying as trans masculine. I remember going to Pride during the first year of our relationship. Jacob wore my clothes and I wore some of his.

Still, when we first started dating, sex felt very performative. I think a big reason for that is that we were having the kind of sex they tell you about in school, where you have foreplay, then you have penetrative sex, and then the guy comes. We'd both internalised the cis attitude that sex means penetration.

Jacob can usually come pretty fast, which I'm very jealous of

As we've been more open about gender, we've had less penetrative sex and are less guided by the fact that he has a penis and I have a vagina. We don't go through the motions assuming that we're going to have heterosexual penetrative sex, and talking about our feelings of gender has helped us to not feel guilty about what kind of sex we "should" be having. Though we both had radically different backgrounds in terms of how we were told about sex as teenagers (I went to more of a hippy school), we'd both internalised societal norms.

I'm now on medication for my mental health, which makes it really tricky for me to orgasm, and penetrative sex can be uncomfortable. Jacob usually comes pretty fast, which I'm very jealous of. It's frustrating to not be able to enjoy sex like I used to before I started this medication. But now we do a lot more foreplay like grinding and just lying together naked and touching each other.

We have sex one to three times a week. It's more just a time for us to be together, to talk, to cuddle. We both want to explore more gender play, and I feel as though we have a foundation to do that.

# data[].attributes.attachment_link.title
This is how we do it: 'We don't play the normal gender game, and enjoy exploring that'

# data[].attributes.attachment_link.description
Jacob and Kasey like to experiment, and reject the notion that sex has to mean penetration

# data[].attributes.attachment_link.readable_text
Tristan, 43

She asked me to touch her using only my hands ... I felt a weight of expectation had been lifted

Ever since puberty, I have had trouble maintaining an erection. I've never had a one-night stand because I dread telling people this secret. When I've had anything approaching "casual sex", I have scrupulously avoided full intercourse, and done a lot of tactical re-positioning in the dark to try to hide my lack of erection.

Nell is a wonderfully gentle, open person but I spent the first few weeks of our relationship in a state of panic. My mind was whirling through various worst-case scenarios: that she would run a mile or, worse, laugh. When I finally told her about my erectile dysfunction, she was so loving and patient. She began to kiss and stroke me, and just at the moment when I was starting to spiral again because I couldn't get hard, she asked me very simply and directly to touch her using only my hands. I felt a weight of expectation had been lifted.

I can have an orgasm even if I don't have an erection

Over the course of our two-year relationship, Nell has helped me reimagine what counts as sex. We don't place emphasis on penetration, but Nell still focuses a lot of attention on my body. When I told previous girlfriends about my dysfunction, they stopped touching me altogether, which made me feel - in a horrible way - like I didn't have a body. For a long time, my only sexual interaction with one ex-partner was her masturbating next to me and then going to sleep.

I can have an orgasm even if I don't have an erection, so that is something we are exploring. Nell gave me my first ever blowjob - something I've never felt confident enough to ask for. Even something as simple as taking a shower together is new to me because I have grown so used to hiding my body.

I've often felt my anxiety around sex permeates every aspect of my life. I've sat in the pub with friends who are laughing about so-and-so who can't get it up and felt paralysed: what if they find out about me? I still feel that way to a certain extent, but much less so. My sexual relationship doesn't look like the movie version - but that just makes what Nell and I do together feel more intimate and precious.

Nell, 40

Working through his anxieties has required some patience, but the payoff is massive

I have been pressured by partners for sex in the past, so the fact that Tristan wasn't immediately all over me actually piqued my interest. Tristan is a quiet and perceptive person. The first night we spent together we didn't try anything sexual. There was a storm, so we lay and listened to the thunder and just kissed. I felt that for once I'd be able to set the sexual pace.

Penetrative intercourse is often an overhyped aspect of sex, so when Tristan told me about his performance anxiety, I was happy to explore other avenues. He is wonderful with his tongue. I can tell he genuinely enjoys giving me oral sex, and that makes me feel able to let go and really concentrate on my own pleasure.

This is the most connected sex I've ever had, but also the most physically pleasurable

In the early stages of our relationship, Tristan shied away from allowing me to touch him back. I think his instinct to stifle his own needs - and perhaps the performance anxiety itself - is rooted in the conviction that he isn't good enough. We maintain eye contact during sex, and I tell him how much I love and want him. I try to normalise talking about sex, asking him what he likes and dislikes, so he knows I want to give him pleasure.

Now we are at a point where Tristan will have an orgasm almost every time we have sex. He won't necessarily be hard when I touch him but it is understood between us that his loss of erection has very little to do with the level of his desire.

Working through Tristan's anxieties has required some patience, but the payoff is massive. This is certainly the most connected sex I have ever had, but it is also the most physically pleasurable. If I had been at another stage of my life - younger and less jaded by past loves - I might have thrown in the towel with Tristan early on, thinking some "perfect" relationship was round the corner. I would have lost so much.
Would you and your partner like to share the story, anonymously, of your sex life?

# data[].attributes.attachment_link.title
This is how we do it: 'His loss of erection has very little to do with the level of his desire'

# data[].attributes.attachment_link.description
When Tristan told Nell about his performance anxiety, she was happy to explore other avenues

# data[].attributes.attachment_link.readable_text
Intimacy gives me the ability to remind myself I am loved and needed, in the face of this constant string of stress

Lucas and I met at work four years ago. He came in to do some contract work and by the next year we were dating.

Most of the time sex for us is just an opportunity to be close to each other. We both have kids from previous relationships, but his are all over 18 and don't live with us. My elder son has severe autism, is non-verbal and has to be watched constantly. So I have to juggle all these things - housework, work - while taking care of him.

Lucas and I can get so bogged down with the day-to-day that we lose focus on each other. It does affect our sex life, so we prioritise ourselves and our relationship on Fridays. It may sound sad, having to book in time with the person you share a home with, but that's the only way we can do it.

I'm not someone who can just come on a whim - and I didn't figure out what I needed until I met Lucas

We had more sex at the beginning than now. There's a level of excitement with a new partner that fades as your relationship grows, but that doesn't take away from the intimacy of it. We might have sex twice a week, but that's bunched into the weekend.

I'm not someone who can orgasm on a whim - and I hadn't figured out what I needed until I met Lucas. It took me a while to realise what I liked and not feel ashamed about asking for it - like more time with foreplay. That's another reason why we don't always have sex during the week, as I know that I need extra time and we just don't have that on weekdays.

For the most part, our sex is pretty standard, like missionary, or I might be on top. But we don't want it to become stale. So we've bought toys which I use for clitoral stimulation, and an Adventure Challenge pack, which are scratchcards giving ideas on new positions and challenges to try, like trying five different sex positions in 20 minutes without climaxing.

That intimacy gives me the ability to remind myself that I am loved and I am needed, in the face of this constant string of stress. When we have sex, even if it's just a quickie, it's a reminder that it's OK for me to have these personal moments with somebody I love. It really helps improve my mood.

Share your experiences

If you're keen to talk to us about your sex lives you can get in touch by filling in the form below. It is very important that both sexual partners are happy to participate.

Your responses, which can be anonymous, are secure as the form is encrypted and only the Guardian has access to your contributions. We will only use the data you provide us for the purpose of the feature and we will delete any personal data when we no longer require it for this purpose. For true anonymity please use our SecureDrop service instead.

Lucas, 44

Having sex can be a vent for stress, which is why I can get angsty if we haven't done it in a while

Ava and I typically devote Friday nights to each other. Our biggest challenge is exhaustion and our mental state, of feeling beaten down. Often, we just want to go to bed.

Putting aside time really helps because we both look forward to it, and tend to be affectionate in the days leading up to it. Over four years together, we've maintained a healthy level of romance - it just might be a nice kiss while we're cooking dinner.

Our sex is really good when we get time, but it's not as often as I'd like. I have multiple jobs and often work nights, while Ava works from home while caring for her son during the day. He has to take medication, and when it's the right balance he's very sweet and happy and social. But he has a lot of needs and that can be very taxing, especially for Ava. Being mentally exhausted is not conducive to looking forward to having fun together. By the time the weekend rolls around, I feel a little frustrated and a little disconnected.

Sometimes I come home and I find her vibrator next to the bed. It means she's taken a break during the day

We both masturbate during the week, but we never mention it to each other. Sometimes I come home and find her vibrator next to the bed. It means she's taken a break during the day, which is nice to know.

We try different things to keep the intimacy, like sex toys - there's one she really likes that uses pulses of air to stimulate her clitoris.It takes Ava a while to climax, so when we have more time I focus on giving her oral sex; she'll orgasm at least once, then we move on to intercourse.

Having sex can be a vent for stress, which is why I can get angsty if we haven't done it in a while. But remaining patient through those times, knowing that it isn't for ever, has got us through. Sex is an important part of our relationship, but it's not the only part.

How do you do it? Share the story of your sex life, anonymously

# data[].attributes.attachment_link.title
This is how we do it: 'Keeping Fridays free for sex helps us get through our stressful weeks'

# data[].attributes.attachment_link.description
Ava and Lucas's stressful lives mean they have to carve out time for intimacy - even if it's just for a quickie

# data[].attributes.attachment_link.readable_text
Diego, 66

People say sex should be intuitive, but I think to be a good lover you have to put the work in

Chloe and I have been married for nearly three years, but we have separate houses. We are forced to live hundreds of miles away from each another because of our jobs, and I miss her a lot - but the distance is good for our sex life. When you're together every day, you forget to actually woo your partner. Living separately means we both make a conscious effort to plan romantic gestures.

If Chloe is travelling to see me, I will beautify the whole house for her and lay out candles and massage oils in the bedroom. I try to beautify myself, too: it is not unusual for me to have three showers on the day of Chloe's arrival.

I also try to make an effort when Chloe and I are in bed together. People say that sex should be intuitive, but I think you can only be a good lover if you put the work in, so I study her reactions very closely. I also regularly ask her whether there's anything I could be doing differently.

When I told her that since the surgery I am able to orgasm but not ejaculate, she just said: 'Well aren't I a lucky girl?'

The other day Chloe told me that she would prefer a softer mouth when I go down on her, so I've modified my technique. I value that kind of constructive criticism, because in my previous marriage sex happened rarely and was never discussed. I underwent prostate surgery toward the end of that relationship which has left me with occasional dysfunction, but talking about that with my ex was unthinkable.

With Chloe, I was determined that I would talk openly about sex, no matter how vulnerable it made me feel. So I called her before our first proper date to talk to her about my operation. Luckily, she is very loving and affirming: when I told her that while I still orgasm, since the surgery I am no longer able to ejaculate, she just said: "Well, aren't I a lucky girl?!"

Recently I bought a massage table, so I like to give Chloe a full body rub, then perform cunnilingus before we finish in missionary - by which point we are both on the table. We both have neck problems, so I did originally buy the table for legitimate massages - but that's not really the way it has panned out.

Chloe, 53

He reassured me that he loved the way I looked and tasted, but it took months before I really believed him

I never enjoyed receiving oral sex before I met Diego. I was married for 32 years and my ex-husband was very clear that he would prefer not to go down on me, which made me feel like there was something wrong with my vulva. On our first night together, Diego reassured me that he loved the way I looked and tasted, but it took months before I really believed him. I thought he was just trying to be nice.

I still struggle a bit with feeling relaxed when he's kissing me there, so we've started experimenting with a new technique. Diego puts on music, and my job is to just lie back and concentrate on the sensations, for at least three songs, without touching him back. It's helpful knowing there is a finite amount of time, because it makes it easier for me to give myself permission to really experience the pleasure, without feeling pressure to reciprocate immediately.

skip past newsletter promotion

Sign up to Inside Saturday

The only way to get a look behind the scenes of the Saturday magazine. Sign up to get the inside story from our top writers as well as all the must-read articles and columns, delivered to your inbox every weekend.
Privacy Notice: Newsletters may contain info about charities, online ads, and content funded by outside parties. For more information see our Privacy Policy. We use Google reCaptcha to protect our website and the Google Privacy Policy and Terms of Service apply.
after newsletter promotion

Our sex life involves a lot of massage and soft touching - we spend hours curled up in bed enjoying skin-on-skin contact

Recently Diego asked me whether he could improve anything, and I felt comfortable enough to ask him to use less pressure with his tongue. A different man might have taken that as criticism, but Diego seemed genuinely happy to hear what I truly liked.

From the very beginning of our relationship, he has spoken honestly about his own body and insecurities, and that is probably why we are so open with each other. Before we had even officially started dating, he explained to me that an operation on his prostate had left him with occasional problems getting an erection. It happens very rarely and has never fazed me.

Our sex life involves a lot of massage and soft touching - it's not limited to penetration. We spend hours curled up in bed together, not technically having sex but enjoying skin-on-skin contact.

I sometimes catch myself thinking: is the intensity of our relationship partly down to the fact that we're not together all the time? It's easy to get into a "comfortable" rut and put sex off, but that's not an option for us, because our couple-time is limited. Being married without cohabiting is a little unconventional - but it works for us.
Would you and your partner like to share the story, anonymously, of your sex life?

If you're keen to talk to us about your sex lives you can get in touch by filling in the form below. It is very important that both sexual partners are happy to participate.

Your responses, which can be anonymous, are secure as the form is encrypted and only the Guardian has access to your contributions. We will only use the data you provide us for the purpose of the feature and we will delete any personal data when we no longer require it for this purpose. For true anonymity please use our SecureDrop service instead.

# data[].attributes.attachment_link.title
This is how we do it: 'I told her I no longer ejaculate. She said: "Well, aren't I lucky?"'

# data[].attributes.attachment_link.description
Body rubs followed by extended foreplay and full sex - all on the massage table - keeps the passion flowing for Diego and Chloe

# data[].attributes.attachment_link.readable_text
We can lay naked together without having sex, or we can have sex, and I never have to worry about feeling vulnerable

I often lose the desire to have sex a few months after meeting a partner. In my last relationship, we didn't have sex for about two years - I found myself just wanting the romantic things, not the sexual things. At the time I didn't have the words to explain that feeling, but I now consider this part of my asexuality. But I do believe our sex lives changes as we grow and meet different partners.

Syd and I met five months ago, and currently have sex about three times a week. We have a lot of non-sexual intimacy, which is extremely important. We can lie naked together without having sex, or we can have sex, or we can do any of a variety of things together, and I never have to worry about feeling vulnerable. That's been the most important component in maintaining a sex drive with him.

The sex we have makes me feel good. But even more than the physical pleasure of sex, I'm enjoying the emotional pleasure of feeling really connected with my partner.

We joke about how it's assumed people with disabilities can't have sex, because Syd is the more active player in our bedroom

We tend to keep it pretty vanilla. I like to call it missionary-plus type positions, sometimes the more passive partner lying on their back, or doggy style, or oral. We always kiss and cuddle first, and we're big fans of skin-to-skin contact. We tend not to have sex for very long, which I find really nice - 20 minutes max from start to finish. More than that and I start to get sore. It's the right amount of time for me to feel connected with him.

Syd has motor neurone disease and he walks with crutches. We joke about how often people think that people with disabilities can't have sex, because he's actually the more active player in our bedroom. One of the challenges is that occasionally he will overheat, so sometimes we have to take little breaks in the middle, which is actually nice - you get to catch your breath. He can also get big knots in his shoulders, so one of our lead-ups to intimacy is just massaging each other.

He will continue to lose the ability to do certain things. The disease will never affect his ability to get hard, but it might change the sex that we have. It is going to mean that I need to get better about being on top. Syd doesn't know what his future will look like. He figures he'll make it work, and I think he's right. We will just adapt to his changing needs, in the same way that he adapts to mine.

Syd, 28

I don't fit the normative idea of masculinity - and that attracts people who are looking for something different

When we first started seeing each other, Jayda warned me that her sexual drive would go down, but that hasn't happened. I was concerned that she would want something that physically I can't provide, which was the biggest mental hurdle for me. But with time and open communication, I'm not worried any more. We receive and give love and affection in compatible ways.

Jayda has used the term "vanilla-plus", which is accurate. I enjoy penetrative sex, and I do try to focus more on my partner. It's not super long sex, and as the relationship goes on, we're becoming less spontaneous as we navigate our schedules. But we have sex three or four times a week, which is a good, healthy amount for me.

I've had sexual partners who said, 'Oh, wow, I'm surprised you were able to have sex'

I'm a physically disabled man, which makes me unconventional in a lot of ways, so I don't fit the normative, hegemonic idea of masculinity. I think that attracts people who are looking for something different. My disease hasn't affected the way I have sex, more the way I date. I've had sexual partners who basically said, "Oh, wow, I'm so surprised you were able to have sex." That definitely hits your confidence.

Like a lot of muscular diseases, mineis ascending - starting at the feet and working its way up. Most of my impairment is still in my lower body which isn't super important if you have penetrative sex and you're male. It's when my core and abdomen get affected that things will be forced to change. But I think if you're in a relationship with someone, and they love you and want to have sex with you, you will try to make it work. Though Jayda is more concerned than I am, in part because she's only dated me for five months and I've been living with this muscular diagnosis for half of my life, so I've made peace with it in a certain way.

I don't like to try to predict how things might turn out, because no one knows how fast it will progress. I just have to adapt to things when they happen. It's more how people treat you out in the world. There's a lot of prejudice against people with disabilities; if I become impaired to a more severe degree, will that get worse? If I was single, would I even be able to find a partner? I will always have to deal with these considerations, and of course it affects your self-esteem. But Jayda's been a breath of fresh air.

# data[].attributes.attachment_link.title
This is how we do it: 'His disability might change the sex we have, but we'll adapt'

# data[].attributes.attachment_link.description
Jayda has lost desire in the past, but is loving the "vanilla-plus" sex she has with Syd - who has motor neurone disease

# data[].attributes.attachment_link.readable_text
Olivia, 28

My libido is surging and I suddenly want it all the time, which is thrilling'

Finlay and I became parents in our early 20s, so while all our friends were shagging around we were virtually sexless. Breastfeeding is such an intimate thing, and for the 22 months I did it that was the only closeness I felt open to. I had this strong feeling that there were only so many people I could service with my body. Kitchen closed.

It's only now, four years later, that we've started having really indulgent sex again. We're expecting another baby and, surprisingly, it's my pregnancy that has turbo-charged our sex life. I'm in the second trimester, which is meant to be the horniest time, and I feel curvy but not whale-like. My libido is surging and I suddenly want it all the time, which is thrilling.

Of course, sex while pregnant requires adaptations. I have to be on top, so my bump doesn't get squished. If I suffer a little pain or feel the baby kick, I can suddenly lose the sexual feeling. Often, we will avoid penetration altogether, so I'm more comfortable, and use our hands instead.

Finlay and I got together so young that our blueprint for sex in the early years was almost teenlike. The sex was exclusively penetrative and I don't think I even expected to climax. These days, the focus of a session will be that I orgasm, too.

For a brief moment, we feel like two wild, spontaneous lovers, who just can't help but succumb to the pull of the moment

Sex usually happens at odd moments because we have a four-year-old in the house and we are slaves to her schedule. Now she's at nursery, we have a little window in the middle of the day that we like to take advantage of. We both work from home so we tend to do it during our lunch break. Sometimes, it feels naughty doing it in broad daylight. For a brief moment, we feel like two wild, spontaneous lovers, who just can't help but succumb. Then I remember that we're two sensible parents, and practically speaking, it's now or never.

I have this worry in the back of my mind that I will go off sex all over again after I give birth. I'm resigned to that possibility, as I can't change the fact that being in my body will feel different. So, while I still feel rambunctious, I intend to make the most of it.

Finlay, 28

As a parent, sex becomes like sleep: you get it when you can

Olivia is fuller and more curvaceous these days and we're having a lot of joyful sex. She can't do certain positions, but we're developing work-arounds. We're doing more foreplay and oral sex and fingering, but not the 14-year-olds' version - there's a lot of clitoral stimulation.

Sex is no longer a night-time activity, but something done in the day when our daughter is at nursery, or more hastily when she is having a nap. Sometimes, we put on the TV for her, so we can sneak off. As a parent, sex becomes like sleep: you get it when you can. If I want two hours with Olivia, I catch myself thinking: that's a film our daughter needs to watch. Or, if it's at night, I think: can I afford to sacrifice that much sleep? I need a minimum of half an hour to properly provide for Olivia, because there is less guarantee that she will have an easy orgasm.

I don't worry about the frequency of our sex dipping back down after Olivia gives birth because I know it will pick up again

I know after Olivia had our daughter she felt less confident in her body for a while, but it didn't affect how attractive I found her. Although I couldn't enjoy her breasts in the same way, as they served a more functional purpose. Of course, I know I don't have ownership over Olivia's body, but there is a strange physical aspect to lactating breasts that removes any sense that they're yours.

I don't worry that we'll have less sex after the birth because I know it will pick up again. We've been together for nine years and experienced many different phases of life. I imagine that once the baby is born, sex will be more difficult as there will be less privacy and even more interruptions. The old tactics of putting the television on might not even work for two children, four years apart. Will they even want to watch the same thing?

Until Olivia has the second baby, our daughter is going to be watching a lot of films. We need to make proper use of that strategy, while it still works.
As told to Elena Angelides Would you and your partner like to share the story, anonymously, of your sex life? Email sexlives@theguardian.com with a few words about what you get up to in the bedroom

# data[].attributes.attachment_link.title
This is how we do it: 'We're expecting another baby, and it's turbocharged our sex life'

# data[].attributes.attachment_link.description
Sex was off the menu for a time after Olivia and Finlay had their first child, but their second pregnancy is making them horny - and creative

# data[].attributes.attachment_link.readable_text
I remember marvelling at his big hands on my waist and how focused he was on my stockings

I was living with my elderly mum and neither of us could get the lid off a huge jar of gherkins. I took it to the garage next door and one of the electricians said: "I'll open your gherkins for you." I'd had my eye on him for a while. His van was parked outside my house, with his name and telephone number branded across the side. I plucked up the courage and texted: "Isn't it about time we went on a date and stopped all this messing about?"

When it came to our first time, Liam booked a Travelodge. I was my mum's carer so I couldn't take him back to mine, and we thought a night away would be romantic. I was 45 and eight years out of a divorce. I wanted to feel attractive, so I bought high-waisted lingerie. I remember marvelling at his big hands on my waist and how focused he was on my stockings.

He survived, but suffered a brain injury and lost most of his eyesight. We tried to make love, but it was challenging

But I got a bit annoyed that night, because every time we paused, Liam would go and have a shower. I thought,"What's wrong with me?" Now we've been together a decade I realise it's because he's a clean freak. I'd rather just keep going, but if we have sex a few times on the trot, Liam likes to wash in between.

Six months later, Liam moved in with me and my mum. We had to turn the volume down on our sex, but not the frequency. Mum didn't have any mobility and couldn't get up the stairs, and she was pretty deaf. We'd give her a Turkish delight and scurry upstairs.

We'd been together three years when our lives changed. Liam had a motorbike accident that left him on life support for 11 days. He survived but suffered a brain injury and lost most of his eyesight. We tried to make love, but it was challenging. The doctors prescribed him Viagra. We spent a lot of time being close to each other, lying in bed, just touching.

Our sex is more sporadic now. In hot weather I'm on top or on all fours, and it's not too steamy. When it's cold, it's the "winter position", under the covers. And we've discovered new tricks ... On a trip to Crete, we bought a penis-shaped bottle opener, but we don't use it to open bottles.

Liam, 57

I pulled her towards me for a kiss. After that, it was all a blur of clothes falling off

I was an auto electrician at a garage and Helen lived next door. When I was working on a car, she came over with this big jar of gherkins. She wanted a strong man to undo it. It's possible she knew I was working, because she would have seen my parked van, but I'm not certain. She had blond hair. Nowadays it's red. Total knockout. I unscrewed the lid like a big macho man.

Since my accident, it's hard to recall every detail, but it's impossible to forget the image of her the first time we had sex. She was wearing 1950s-style lingerie. I placed my hand on the nape of her neck and pulled her towards me for a kiss. After that, it was all a blur of clothes falling off. I prefer to wash in between sessions, but she thought I was shy and hiding in the bathroom.

I didn't want her to think I didn't find her attractive. In the shops, I spotted penis-shaped bottle openers

Right up until my crash, we made love every day. The accident totally changed our sex life. I suffered brain damage, but I think a large part of it was losing most of my eyesight. I am a very visual person: I liked to see Helen in stockings, high heels, sexy lingerie, nice skirts. For a while I couldn't get aroused. My neurologist even put us in touch with someone to get marriage counselling, but the issue wasn't between us. I'd lost that sexual feeling altogether. I felt completely disconnected from my own body.

Seven years on, I get aroused and can perform again. On holiday in Crete, she wanted to do it all the time. I was worried that I couldn't perform as frequently as she desired, and I didn't want to upset her or to think that I no longer found her attractive. In the shops I spotted these penis-shaped bottle openers. I asked: "Do you fancy one?" It was a bit of a joke, but there's a lot of truth spoken in jest.
Would you and your partner like to share the story, anonymously, of your sex life? Email sexlives@theguardian.com with a brief outline of what you get up to in the bedroom

# data[].attributes.attachment_link.title
This is how we do it: 'Sex is less frequent since my accident, but we've discovered new tricks'

# data[].attributes.attachment_link.description
Before Liam's motorbike crash, they were making love every day; now he's discovered different ways to get aroused

# data[].attributes.attachment_link.title
This is how we do it: ‘She sets a timer for sex and my job is just to enjoy what she’s doing to me’

# data[].attributes.attachment_link.description
Stella loves her new-found desire, while Satya is learning how to worry less. And they’re saving their long sessions for the weekend

# data[].attributes.attachment_link.description
You don’t have authorization to view this page.

# data[].attributes.attachment_link.description
You don’t have authorization to view this page.

# data[].attributes.attachment_link.readable_text
Ashima é uma empresa de marketing multinível, direcionada em oferecer produtos de sexshop, serviços de gestão organizacional e capacitação de operadores e líderes através de cursos de capacitação. A marca tem como objetivo principal trazer a libertação sexual, quebrar tabus e crenças limitantes e consequentemente elevar o empoderamento feminina, permitindo o prazer e independência através do empreendedorismo individual.

# data[].attributes.attachment_link.description
You don’t have authorization to view this page.

# data[].attributes.attachment_link.title
ONE HOUR of Vintage Commercials from the 70s IN 4K  | Part 1

# data[].attributes.attachment_link.provider_name
designboom | architecture & design magazine

# data[].attributes.attachment_link.readable_text
'type trumps' is a typographic version of the popular card game top trumps - different typefaces have been subjectively designated values by designer rick banks (AKA face 37).

face 37: http://www.face37.com -

' world disaster top trumps' by martin robitsch ' designer trading card game ' by designtutor

bloomberg connects app enriches refik anadol's serpentine exhibition with exclusive content

# data[].attributes.attachment_link.description
'type trumps' is a typographic version of the popular card game top trumps - different typefaces have been subjectively designated values by designer rick

# data[].attributes.attachment_link.readable_text
Real Questions. Real conversations.

199 Questions

Discover real conversations and deeper connections than ever before. Each unique edition of &lcub;THE AND&rcub; includes 199 questions based on thousands of real conversations filmed around the world - something no other game has!

EXPERIENCE THE VIRAL SENSATION

With thousands of videos and clips seen millions of times, not only can you watch &lcub;THE AND&rcub;, you can experience it for yourself! Just like the wildly popular videos, you too can have amazing conversations and experiences with &lcub;THE AND&rcub; card games.

# data[].attributes.attachment_link.description
Are you feeling like the spark has fizzled out in your long-term relationship? It's time to reignite the flame and discover a whole new level of connection with your partner through {THE AND} Long-Term Couples Edition card game!

# data[].attributes.attachment_link.readable_text
How it works

→ Get Closer Couples Edition features love and intimacy topics--love languages, values, pleasures, and sorrows.

→ Intimately curated questions-based on the principles of positive psychology and positive language-spark meaningful and honest conversations around relationships, closeness, and love.

→ Questions are curated in a way to help you share personal and intimate experiences, strengthen your bond, and connect on a deeper, more passionate level with your partner.

→ Gain a more positive perspective on your life and relationships. Reflect on what truly matters to you as a couple. Define your love.

Features

→ The couples game is separated into three levels: Close, Closer, and Closest.

→ Each progressive level challenges players to open up more, speak their truth, and engage in honest and open conversations.

→ Wildcards in each level pose intimate activities and fun challenges to go deep and connect on a new level.

Made sustainable

→ Get Closer Couples Edition has been designed with the environment in mind.

→ 100% recycled, biodegradable, and FSC™ certified paper cards and box packaging.

→ 100% plastic-free, fully recyclable, and compostable.

How to play

Select your question cards.

Create a calm, inviting atmosphere. Light some candles, play your favorite background music, have your chosen drinks ready.

Choose which level of closeness you're comfortable with based on how deep your relationship is right now.

Get closer with deep conversation

Take turns reading and answering the questions. Listen mindfully and engage in discussions.

Try more questions from the same level. Go up a level. Even go down a level.There's no wrong way to play, as long as you're getting closer.

Reflect on your discoveries

Once you have finished, take some time together and reflect on the answers. What did you discover about each other and your relationship?

Dating Edition is ideal for individuals in the dating stage of a relationship-though certainly can be enjoyed by long-term coupels, too. It's a fun conversation game to be able to learn new things about each other and explore your compatibility, which is ideal for building a strong relationship foundation. This edition does not contain sexually charged questions or assumption of physical intimacy.

Couples Edition is designed for those who are already in a commited relationship with an established level of intimacy. The questions explore your love, dreams and life experiences. Some questions are sexual in nature.

All of the questions in each edition are unique, so you can use both if desired!

Get Closer games are conversational card games, based on principles of positive psychology, designed to strengthen relationships with friends, relatives, loved ones, colleagues, and even strangers.

We currently have 5 editions of the Get Closer game. Here's how they are different:
Get Closer Original
→ 100 question prompts
→ 3 levels: Close, Closer, Closest
→ Wide range of topics
→ Created for all relationships
Get Closer Family Edition
→ 100 question prompts
→ 3 levels: Close, Closer, Closest
→ Family bonding topics
→ Created for all generations
Get Closer Couples Edition
→ 100 question prompts
→ 3 levels: Close, Closer, Closest
→ Love and intimacy topics
→ Created for all couples

Get Closer Dating Edition
→ 100 question prompts
→ 3 levels: Close, Closer, Closest
→ Topics of life experiences, core values, life goals, and relationships
→ Created for all couples including those newly dating
Get Closer Table Talk
→ 52 question prompts
→ Small portable design
→ Wide range of topics
→ Created for dinnertime guests
Get Closer Team Edition
→ 52 question prompts
→ Small portable design
→ Culture and values topics
→ Created for all teams

We created this game to represent all couples. This means the game's questions are suitable for same sex couples.

We ship worldwide!

We are excited to share that Intelligent Change ships worldwide*. We ship from three different warehouses in the USA, the United Kingdom, and the Netherlands. We offer FREE Shipping to U.S. on orders $75-$500.

Processing Time

Orders are processed and shipped in 1-2 business days, likely sooner.

Once your order has shipped, you will receive a confirmation email containing your tracking information. Please allow 24-48 hours for the tracking details to update. If you have not received this email, kindly check your spam/trash folders, or email us at hello@intelligentchange.com for further support . Please note that we cannot be held accountable for any shipping delays caused by the carrier.

Should inaccurate or incomplete address information be provided, it may delay processing time by 1-2 business days. All customers are encouraged to thoroughly review their shipping and billing information prior to checking out to ensure any possible delays are avoided.

Shipping Time
United States
Express (1-2 Business Days) Standard (2-4 Business Days)

Economy (5-7 Business Days)

United Kingdom

Express (1-2 Business Days)
Standard (2-4 Business Days)
Europe
Express (2-3 Business Days)
Standard (3-7 Business Days)
International
International Express (3-5 Business Days to Cities)
International Standard (5-10 Business Days)

**Please note that specific carriers cannot be selected.

Taxes & Duties
United States
Intelligent Change charges a sales tax for all US orders. These collected taxes are mandated by the local state governments. Intelligent Change in no way benefits from this and directly pays this amount collected to the state.
United Kingdom
Orders being shipped to the UK (from our UK warehouse) will have a 20% VAT included in the price. These collected taxes are mandated by UK government. Intelligent Change in no way benefits from this and directly pays this amount collected by the UK government.
Europe
With our newest warehouse in the Netherlands, any orders being shipped to a country in the European Union should not incur any added fees for customs and duties at the time of delivery.
Canada, Mexico, Asia & Other International Countries
As your order is shipped DDU (Delivered Duty Unpaid), orders being shipped internationally may incur duties, fees and import taxes upon delivery. This charge is determined by your local customs authority and must be paid to your local carrier or government in order to receive your order. These fees are not collected by Intelligent Change.

*COUNTRIES WE DO NOT SHIP TO: Afghanistan, Albania, Algeria, Angola, Azerbaijan, Bahrain, Bangladesh, Belarus, Benin, Bermuda, Brazil, Botswana, Cameroon, Cayman Islands, Central African Republic, Chad, Chile, China, Colombia, Comoros, Cook Islands, Cyprus, Democratic Republic of the Congo, Republic of the Congo, Cote d'Ivoire, Cuba, Djibouti, Dominica, Dominican Republic, Egypt, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Guatemala, Guyana, Haiti, Hungary, India, Indonesia, Iran, Iraq, Kazakhstan, Kenya, Kiribati, Kosovo, Kuwait, Kyrgyzstan, Laos, Lebanon, Liberia, Libya, Macedonia, Madagascar, Malawi, Maldives, Mali, Marshall Islands, Mauritania, Micronesia, Moldova, Mongolia, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua, Niger, Nigeria, North Korea, Oman, Pakistan, Papua New Guinea, Palau, Paraguay, Palestine, Peru, Philippines, Qatar, Russia, Rwanda, Saint Lucia, Saint Vincent and the Grenadines, Saudi Arabia, Senegal, Serbia, Seychelles, Sierra Leone, Somalia, South Africa, South Korea, South Sudan, Solomon Islands, Sri Lanka, Sudan, Suriname, Swaziland, Syria, Taiwan, Tajikistan, Tanzania, Timor-Leste, Togo, Tonga, Trinidad and Tobago, Tunisia, Turkmenistan, Tuvalu, Uganda, Ukraine, Uzbekistan, Vatican City, Vanuatu, Vietnam, Venezuela, Yemen, Zambia, Zimbabwe.

Yes! We are happy to offer Shop Pay Installments to US residents at this time (for orders between $50 USD and $3,000 USD).

How does Shop Pay Installments work?

Shop Pay gives you the option to pay in full at checkout, or to split your purchase into four equal, bi-weekly, interest-free installment payments. When available, Shop Pay Installments is an option for orders between 50 USD and 3,000 USD.

There are no additional charges, interest rates, or late fees, and your credit score isn't affected. Shop Pay Installments is powered and serviced by Affirm and is only available in some stores.

Am I eligible to use Shop Pay Installments?

To use Shop Pay Installments, you need to live in the United States and register for Shop Pay. When choosing Shop Pay Installments, the following limitations apply:

You cannot pay for an order if the order includes currency in any form, including virtual and digital currency, like gift cards.

Orders need to be between 50 USD and 3,000 USD, including shipping and taxes.

If you change your Shop Pay phone number, then you also need to update this with Affirm before you can pay for another purchase using Shop Pay Installments.

Shop Pay Installments does not accept Capital One cards, prepaid debit cards, or prepaid credit cards.

How do I manage my Shop Pay Installments payments?

Your Shop Pay Installments orders appear in the Hometab of the app. You can tap on an order for a summary of your repayment status. Tap View installments for more detailed info about past and upcoming payments.

Make a manual payment on a Shop Pay Installments order:

You can make a manual payment on a Shop Pay Installments order in the Shop app.

1. From the Home tab, tap the order you want to make a payment for.

2. Tap View Installments, and then tap Make a payment.

3. Select an option in the Amount to pay section.

4. In the Card section, select the card you want to pay with.

5. Tap Pay now, and then tap Continue.

Change your payment method for an existing Shop Pay Installments order:

You can change your payment method on a Shop Pay Installments order while it's in repayment. Going forward, the new payment method will be used for payments on this order. If you want to update your payment method for multiple Shop Pay Installments orders, then you need to complete the steps below for each order.

1. From the Home tab, tap the order that you want to change the payment method for.

2. Tap View Installments, and then tap Payment options.

3. Select the new payment method that you want to use. If you need to add a new payment method, then tap Use a different card, and complete the required fields.

Where can I find more information about Shop Pay Installments?

We believe in a better tomorrow, a more productive and happier you. We create tools for the lifelong learners and doers because you are changing the world every day. We designed these tools with proven principles of positive psychology and daily accountability.

This is why we are offering a 6 Month Money Back Guarantee:if you do not feel Intelligent Change products have shaped a better attitude towards productivity and happiness, simply email us at hello@intelligentchange.com so we can organize the return of your full journal or planner and issue a refund.

Kindly include your order number, which complete product(s) you are looking to return and the reason. Prepaid return shipping labels for your full journal and/or planner are provided for US orders only by our customer support team which will expedite the return shipping and refund process.

If you returned any products prior to contacting us, please contact our support to make us aware of the returned items so that we can proceed further with the return or exchange.

How do I return my order?

1. Email us at hello@intelligentchange.com

2. Include your name and order number

3. Tell us which product(s) you want to return and the reason

We are pleased to extend a 20% discount on orders over 10 units, and a 30% discount on orders over 40 units. The discounts are automatically applied at checkout.

***Please note that bulk discount offer cannot be combined with sitewide sales or other coupons and discounts.***

If you are interested in a custom request, please see more about customization options here to learn more and apply.

EUROPE

24paper shop
Agora Hotel Ibiza
Bodyism
Brown Thomas
De L'Europe
DutchMills
Gleneagles
Grab coffee shop
Healf
IKONA
Le Bonne Marche
Liberty
Liv Concept
Mount Street Printers
Musea Brugge
My lovely notebook
Natural Edge
Niche Beauty
Orell Füssli Thalia AG
Papersmiths
Planetopija
Sissy Boy
The Feelgood Shop
The ICA Bookshop
Waterstones
Wolf & Badger
Zapp

NORTH AMERICA

Barnes & Noble
Canyon Ranch
Crystal Magic
Ellenshop
Ellenshop
Flip shop
Foxblossom Co.
Haven Well Within
Hot Pilates
Indigo
Little Words Project
Magnolia
New Lane Road
Nordstrom
Othership
Papersource
PeachBox Co.
Poosh
Revolve
Target
Terrain
The Four Seasons NY
The Paperstore
Thriftknd
Urban Outfitters
Wolf & Badger - NY & LA

UAE

Arts of Guitar
Joi Gifts
Kinokuniya
L'couture
Mumzworld
Namshi
Noon
Prickly Pear
Samadhi
UAE Flowers
Virgin UAE
Zoga Yoga Centre

AUSTRALIA

Deadly Ponies
Simple Beautiful Things
The Keep Collective
KUWAIT
Nine Co
Waha Kuwait
SOUTH AMERICA
Mercado MöM
QATAR
Darwish

Free Shipping

Enjoy FREE Shipping on U.S. orders over $75*. Intelligent Change also ships worldwide.

100% Secure Checkout

Shop with confidence that your purchase is safe and secure throughout the checkout process.

6 Month Money-Back Guarantee

Because we're confident you'll experience transformative change.

About Intelligent Change

We create elevated, thoughtfully designed products to help you cultivate gratitude, build positive habits, and foster mindfulness to help you live a happier, more fulfilled life. We believe in the power of simple rituals. Our products help you live more intentionally, so you can actualize your dreams effortlessly. From cultivating a daily gratitude practice with The Five Minute Journal to improving your workflow with The Productivity Planner, we leverage research-supported frameworks that enable you to seamlessly integrate positive habits into your everyday life.

Read more

# data[].attributes.attachment_link.title
Get Closer Conversation Game: Couples - Couples

# data[].attributes.attachment_link.description
Let's Get Closer is an easy-to-play prompt card game that cultivates relationships by engaging friends, family members, couples, or even those who have just met in deep and meaningful conversations.