Sexual Dysfunction in Schizophrenia: A Systematic Review and Meta-Analysis

Théo Korchia; Vincent Achour; Mélanie Faugere; Ali Albeash; Dong Keon Yon; Laurent Boyer; Guillaume Fond

doi:10.1001/jamapsychiatry.2023.2696

. 2023 Sep 13;80(11):1110–1120. doi: 10.1001/jamapsychiatry.2023.2696

Sexual Dysfunction in Schizophrenia

A Systematic Review and Meta-Analysis

Théo Korchia ¹, Vincent Achour ¹, Mélanie Faugere ^1,², Ali Albeash ¹, Dong Keon Yon ^3,⁴, Laurent Boyer ^1,², Guillaume Fond ^1,^2,^✉

PMCID: PMC10500435 PMID: 37703012

Key Points

Question

What is the prevalence of sexual dysfunction in individuals with schizophrenia and the factors associated with heterogeneity of dysfunction?

Findings

In this systematic review and meta-analysis of 72 studies including 21 076 participants with schizophrenia, prevalence and heterogeneity of global sexual dysfunction were high. Study design, time and location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and the use of antidepressants and anxiolytics were associated with heterogeneity; associations were also found between lower prevalence of sexual dysfunction and use of antidepressant medication.

Meaning

The findings in this study suggest that prevalence of sexual dysfunction remains high in people with schizophrenia with no obvious improvement over time or better tolerance of second-generation antipsychotics; treating depression may be a key point to reduce sexual dysfunction in individuals with schizophrenia.

This systematic review and meta-analysis evaluates the prevalence of and factors associated with sexual dysfunction in individuals with schizophrenia-spectrum disorders.

Abstract

Importance

In individuals with schizophrenia, antipsychotic-induced dysfunctions are frequent but often underexplored in clinical practice.

Objective

To synthetize the data of observational studies exploring the prevalence of sexual dysfunction in individuals with schizophrenia-spectrum disorders as well as associated factors.

Data Sources

A systematic literature search without language or time restrictions was conducted in Google, Google Scholar, PubMed/MEDLINE, Science Direct, and Université Sorbonne Paris Cité for studies published up to June 8, 2022.

Study Selection

All observational studies reporting a prevalence of sexual dysfunction in schizophrenia-spectrum disorder were included.

Data Extraction and Synthesis

The MOOSE guidelines with independent extraction by 2 observers and random-effects models were used.

Main Outcomes and Measures

The prevalence of sexual dysfunction and each specific dysfunction.

Results

A total of 72 of 1119 studies from 33 countries on 6 continents published from inception to June 2022 were included with a total of 21 076 participants with schizophrenia. The pooled global prevalence of sexual dysfunctions was 56.4% (95% CI, 50.5-62.2), with a prevalence of 55.7% (95% CI, 48.1-63.1) for men and 60.0% (95% CI, 48.0-70.8) for women. The most frequent sexual dysfunction was erectile dysfunction in men (44%; 95% CI, 33.5-55.2), followed by loss of libido in men (41%; 95% CI, 30.7-51.4), ejaculation dysfunction in men (39%; 95% CI, 26.8-51.8), orgasm dysfunction in women (28%; 95% CI, 18.4-40.2), and amenorrhea in women (25%; 95% CI, 17.3-35.0). Factors associated with heterogeneity were study design, time and location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and the use of antidepressants and anxiolytics. Sexual dysfunctions were more frequent in schizophrenia vs schizoaffective disorders, and erectile disorders were less frequent in individuals with longer illness duration. Antidepressant and mood stabilizer prescriptions were associated with lower rates of erection disorders (β, −6.30; 95% CI, −10.82 to −1.78); P = .006 and −13.21; 95% CI, −17.59 to −8.83; P < .001, respectively) and ejaculation disorders (β, −6.10; 95% CI, −10.68 to −1.53; P = .009 and β, −11.57; 95% CI, −16.34 to −6.80; P < .001, respectively). No obvious improvements in the rates of sexual dysfunction at other times were found, and there were conflicting results regarding antipsychotic classes.

Conclusions and Relevance

This systematic review and meta-analysis found a high prevalence of sexual dysfunction among individuals with schizophrenia, with considerable heterogeneity in associated factors. The findings also suggest that some dysfunctions may be explained by schizophrenia. The association between lower rates of dysfunction and antidepressant use suggests that treating comorbid depression could be an effective strategy to improve sexual health. A lack of data on metabolic parameters and physical health in general was also noted, while these issues are frequent in the care of schizophrenia.

Introduction

The attention given to sexual health in schizophrenia has increased since the end of the 20th century.¹ However, schizophrenia has been associated with increased sexual dysfunction only in a small meta-analysis² of 10 observational studies (3 case-control studies and 7 cross-sectional studies) published in 2020. An meta-analysis³ of sexual dysfunction in psychiatric patients taking antipsychotics and limited to studies with sexual dysfunction as the primary objective and using validated scales concluded that antipsychotics were a major source of heterogeneity in the prevalence of sexual dysfunction in schizophrenia, with quetiapine, ziprasidone, perphenazine, aripiprazole, olanzapine, risperidone, haloperidol, clozapine, and thioridazine having an increasing impact on sexual function ranging from 16% (quetiapine) to 60% (thioridazine). One of the major pathophysiological mechanisms is probably the inhibition of dopamine D2 receptors. This inhibition in the tuberoinfundibular pathway is associated with increased serum prolactin levels.⁴ A dose of more than 200 ng/mL of risperidone⁵ induces amenorrhea, breast tenderness, and galactorrhea in women and hypogonadism in men by disrupting the secretion of GnRH by the hypothalamus.^6,7 Antipsychotic-induced sexual dysfunctions may also occur independently of increased prolactinemia due to increased antiparkinsonian adverse effects, including blunted affect and anhedonia.⁴ Anti–α1-adrenergic receptor inhibition may also induce sexual dysfunctions through relaxation of the intracavernosal smooth muscle fibers, inducing erection and ejaculation dysfunctions in men.⁸ Anti–H1 receptor inhibition induces sedation, which may alter satisfactory sexual activity.⁴

Antipsychotic-induced sexual dysfunctions thus appear to be heterogeneous by their type and pathophysiological mechanism. Distinguishing each specific sexual dysfunction may increase the accuracy of interventions. A recent systematic review⁹ found that the most frequent disorders in schizophrenia were loss of libido and erectile dysfunction in men. Decreased libido may be the result of the negative syndrome of the illness associated with anhedonia and social withdrawal.¹⁰ Major depression is a frequent comorbidity of schizophrenia found in approximately one-third of patients.¹¹ It is underscreened and undertreated due to confusion with the negative symptoms of schizophrenia.¹¹ Several potential risk factors for sexual dysfunction in schizophrenia have been identified, including comorbid major depression, unemployment, singlehood, tobacco smoking, and cannabis and alcohol use disorders.⁹ In summary, we need to update the data on sexual dysfunction prevalence, as the only meta-analysis on this topic was published more than 10 years ago, and we need a quantitative analysis of associated factors that may explain the heterogeneity of sexual dysfunctions in schizophrenia with a focus on each sexual dysfunction (in each and both sexes) resulting from different pathophysiological mechanisms. The objectives of the present study were to determine the prevalence of sexual dysfunction in schizophrenia and of each specific dysfunction (sexual dysfunctions in each sex, loss of libido, orgasm dysfunction, genital pain, erectile and ejaculation dysfunctions, amenorrhea, and galactorrhea) and to identify factors associated with heterogeneity.

Methods

Search Strategy and Sources of Information

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.¹² We performed a literature review on 5 digital databases: PubMed/MEDLINE, Science Direct, Google Scholar, Google, and Université Sorbonne Paris Cité from inception to June 8, 2022. The search paradigm is presented in eAppendix 1 in Supplement 1. The protocol was registered in PROSPERO (CRD42022355766). Ethical approval was not sought or required, as the study involved no individual patient data.

Eligibility Criteria

All observational studies reporting a prevalence of sexual dysfunction (by any tool of measure, which includes nonvalidated tools, such as binary questions and unstructured clinical interviews) in patients with schizophrenia or schizoaffective disorder were included in the present work. In the case of longitudinal studies, cross-sectional baseline data were included. While English search words were used for PubMed/MEDLINE, Science Direct, Google Scholar, Google and French words for Université Sorbonne Paris Cité, there was no language limitation to ensure the comprehensiveness of the data, and the articles were translated as needed to extract relevant data.

All interventional studies were excluded to eliminate a participation bias and because randomized clinical trials overselect participants.¹³ Studies including inpatients were excluded, assuming that the stress of the hospitalization and the short-term phase of the disease would have a major impact on sexual dysfunction. Studies assessing only treatment-resistant patients were not included, as we hypothesized an overestimation bias in these patients, who usually receive high doses of treatments with persistent psychotic symptomatology. In summary, the aim of the present work was to assess sexual dysfunction in the daily life of treated patients, not in resistant or hospitalized patients.

Data Extraction

Two investigators (M.F. and V.A.) independently performed the literature review and extracted data. Controversial articles were discussed in a meeting between the 2 investigators, and in case of persistent disagreement, a third investigator (G.F.) was consulted and made the final decision. The extracted data are presented in eAppendix 2 in Supplement 1.

Assessment of Methodological Quality

The study quality assessment was carried out independently by 2 investigators (M.F. and V.A.) using the modified version of the Newcastle-Ottawa Scale (NOS).¹⁴ Studies were scored from 0 (poor quality) to 10 points (excellent quality). Studies scoring 7 or more points were considered good quality studies.

Statistical Analysis

A random logistic regression model was used to calculate the pooled prevalence estimates of sexual dysfunction and its 95% CI.¹⁵ A sensitivity analysis was performed with the inverse-variance random-effects model, confirming the robustness of the findings. Heterogeneity between studies was quantified using the I² statistic.¹⁶ Sensitivity analyses were performed using the leave-one-out method. Publication bias was assessed graphically with a funnel plot and statistically with the Thompson-Sharp test when the number of studies exceeded 10.¹⁷ Subgroup analyses for binary variables and univariate meta-regressions for quantitative variables were used to assess factors moderating the pooled prevalence estimate of sexual dysfunction from individual studies. All analyses were performed using the meta package in R version 4.1.3 (R Foundation).¹⁸

Results

Study Characteristics

Seventy-two studies published between 1979 and 2021 were included in the random-effects model.^{6,7,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88} The flow diagram is presented in Figure 1. Among those, 35 studies included data on the prevalence of orgasm dysfunction, 34 on loss of libido, 10 on genital pain, 33 on erectile dysfunction, 19 on ejaculation dysfunction, 6 on amenorrhea, and 5 on galactorrhea. The 63 excluded studies and the reason for exclusion are presented in eAppendix 3 in Supplement 1.

Figure 1. — Flow diagram for new systematic reviews, which included searches of databases and registers only.

The selected articles included 21 076 patients from 33 countries on 6 continents. The study characteristics are reported in eAppendices 4-6 in Supplement 1. The study quality assessment is presented in eAppendix 7 in Supplement 1. Overall, 30 studies (41.7%) were classified in the good quality group. A total of 59 studies (81.9%) used a standardized questionnaire to assess sexual dysfunctions (eAppendices 4-6 in Supplement 1). The most frequent sexual dysfunction scales were the Arizona Sexual Experience scale⁸⁹ (N = 19), Changes in Sexual Functioning Questionnaire⁹⁰ (N = 7), Sexual Functioning Questionnaire⁹¹ (N = 6), Female Sexual Function Index⁹² (N = 6), Udvalg for Kliniske Undersogelser⁹³ (N = 4), and Psychotropic-Related Sexual Dysfunction Questionnaire⁹⁴ (N = 4). Thirteen studies (18.1%) used a clinical semistructured interview, 6 (8.3%) used an original questionnaire, and 1 (1.4%) used medical records.

Pooled Prevalence Estimate of Global Sexual Dysfunctions

The pooled prevalence estimates of global sexual dysfunctions and sexual dysfunctions in men and women with schizophrenia are presented in Figure 2. The pooled estimates and their 95% CIs were as follows: global prevalence of sexual dysfunctions, 56.4% (95% CI, 50.5-62.2), with values ranging from 3% to 98%; loss of libido, 40.6% (95% CI, 30.7-51.4); orgasm dysfunction, 28.0% (95% CI, 18.4-40.2); and genital pain, 6.1% (95% CI, 2.8-12.7). There was significant heterogeneity within the results for global dysfunction and sexual dysfunctions (I² for men, 98% [P < .001]; I² for women, 96% [P < .01]). The forest plots are presented in Figure 3 and eAppendices 8-10 in Supplement 1.

Pooled Prevalence Estimates of Sexual Dysfunctions in Men With Schizophrenia

The pooled estimates and their 95% CIs were as follows: male sexual dysfunction, 55.7% (95% CI, 48.1-63.1); erectile dysfunction, 44.0% (95% CI, 33.5-55.2); and ejaculation dysfunction, 38.6% (95% CI, 26.8-51.8). The forest plots are presented in Figure 3, Figure 4, and eAppendices 11-12 in Supplement 1.

Pooled Prevalence Estimates of Sexual Dysfunctions in Women With Schizophrenia

The pooled estimates and their 95% CIs were as follows: female sexual dysfunction, 60.0% (95% CI, 48.0-70.8); amenorrhea, 25.1% (95% CI, 17.3-35.0); and galactorrhea, 7.7% (95% CI, 3.7-15.3). The forest plots are presented in Figure 3, Figure 5, and eAppendices 13-14 in Supplement 1.

Leave-One-Out Analyses and Publication Bias

The leave-one-out analyses are presented in eAppendices 15-17 in Supplement 1. No study had a disproportionate effect on the pooled prevalence estimate of sexual dysfunction or on heterogeneity. The funnel plots are presented in eAppendices 18-20 in Supplement 1. Visual inspection of the forest plots did not identify substantial asymmetrical shape. The Thompson-Sharp test P values were significant for global sexual dysfunctions (t, 5.63; P < .001), sexual dysfunctions among men (t, 4.58; P < .001), sexual dysfunctions among women (t, 2.25; P = .03), orgasm dysfunction (t, −3.85; P < .001), and ejaculation disorder (t, −2.33; P = .03). The results were not significant for libido dysfunction or erection disorder.

Subgroup and Meta-Regression Analyses

Subgroup and meta-regression analyses are presented in eAppendices 21-23 (global dysfunctions) and 27-29 (specific dysfunctions) in Supplement 1, and meta-regression analyses are in eAppendices 24-26 (global dysfunctions) and 30-32 (specific dysfunctions) in Supplement 1. The significant associations are summarized as follows:

Study Design, Time, and Location

Compared to cohort studies, cross-sectional studies reported significantly higher rates of sexual, orgasm, and male sexual dysfunctions. Studies including consecutive participants reported significantly lower rates of loss of libido, male sexual dysfunction, and erectile dysfunction. Studies including sexual dysfunctions in their primary objective reported significantly higher rates of sexual dysfunctions. Studies including a validated tool for diagnosis reported higher rates of loss of libido. Studies including patient-reported diagnoses reported significantly higher rates of genital pain. Studies including clinical interview diagnosis reported lower rates of loss of libido and orgasm dysfunction. Studies including a clinician-rated tool diagnosis reported significantly higher rates of loss of libido. No significant association was found with study quality. We found that time and location were associated with higher rates of sexual dysfunction in more recent studies and lower rates in North America and Europe compared to the rest of the world.

Sociodemographic Variables

Lower rates of loss of libido were reported in studies including a higher proportion of men. Higher rates of genital pain were reported in studies including more male and single participants, and higher rates of loss of libido were reported in studies including more unemployed participants.

Physical Health and Addictions

There was a significant association between the percentage of patients with alcohol use disorders and lower rates of male sexual dysfunction. No other significant associations were found.

Psychiatric Diagnosis and Illness Severity

Globally, we found that higher loss of libido, orgasm dysfunction, and erection disorder were reported in studies including more patients with schizophrenia vs schizoaffective disorder. The rate of erectile dysfunction decreased with the mean duration of illness. Higher rates of female sexual dysfunction were significantly associated with positive scores on the Positive and Negative Syndrome Scale.

Antipsychotic Classes and Daily Dose (Chlorpromazine Equivalents)

We found contradictory results concerning antipsychotic classes (first generation vs second generation) and sexual dysfunctions, and it was not possible to identify a class or specific antipsychotic associated with a higher or lower prevalence of sexual dysfunction. Sexual dysfunction prevalence was mostly not reported according to the administered antipsychotic, and there were not enough studies to determine the sexual dysfunction prevalence in samples treated with homogenous antipsychotic treatment.

Other Psychotropic Drugs

Given that these were observational studies, patients were often administered multiple treatments other than antipsychotics. Compared to other studies, erectile and ejaculation dysfunctions and loss of libido were significantly lower in studies including participants treated with antidepressants, and erectile and ejaculation dysfunctions decreased with the percentage of patients treated with antidepressants and mood stabilizers. Sexual dysfunctions in general among men and erectile and ejaculation dysfunctions were significantly lower in studies including patients with anxiolytics. Antidepressant and mood stabilizer prescriptions were associated with lower rates of erection disorders (β, −6.30; 95% CI, −10.82 to −1.78); P = .006 and −13.21; 95% CI, −17.59 to −8.83; P < .001, respectively) and ejaculation disorders (β, −6.10; 95% CI, −10.68 to −1.53; P = .009 and β, −11.57; 95% CI, −16.34 to −6.80; P < .001, respectively).

Comparative Pooled Prevalence Estimates of Sexual Dysfunction of the Inverse Variance Method vs Random Intercept Logistic Regression Model

The comparative pooled prevalence estimates of sexual dysfunction and 95% CIs for the inverse variance method vs random intercept logistic regression model are presented in eAppendix 33 in Supplement 1.

Discussion

This systematic review and meta-analysis synthesized a high number of observational studies including quantitative data on the prevalence of sexual dysfunctions in schizophrenia published over 4 decades and 6 continents. The prevalence of sexual dysfunction in schizophrenia was found to be high and heterogeneous. Our results provided important data on the prevalence of each sexual dysfunction. The most frequent sexual dysfunction was erectile dysfunction (44% of men), followed by loss of libido (41%), ejaculation dysfunction (39% of men), orgasm dysfunction (28%), and amenorrhea (25% of women). Galactorrhea and genital pain were less explored and less frequent.

These rates are extremely high. For comparison, erectile dysfunction affects an estimated 30 million men in the US according to the National Institute of Diabetes and Digestive and Kidney Diseases.⁹⁵ The prevalence of erectile dysfunction increases with age, with approximately 12% of men younger than 60 years experiencing erectile dysfunction compared to 30% of men aged 70 years and older.⁹⁵ The prevalence of loss of libido, also known as hypoactive sexual desire disorder, is estimated to be approximately 10% in women and 5% in men in the US according to the American Psychiatric Association’s DSM-5.¹⁰

We found multiple factors associated with this heterogeneity beyond the expected association with antipsychotics. Among these factors, study design (recruitment and tools but not quality) are classical factors inducing heterogeneity in prevalence studies. As expected, studies including sexual dysfunction in their primary objective reported a higher prevalence of sexual dysfunction. This may be explained by a selection bias.^96,97 Our results suggest that studies including nonconsecutive participants may have included a selection bias overestimating the findings. Cross-sectional studies reported higher rates than cohort studies. Except for population-based studies (which were not available for sexual dysfunctions), cohort studies may induce a selection bias at inclusion. For clinical trials, patients to be included in a follow-up cohort may not be representative of all real-life patients, with better compliance, lower addictions, and other clinical setting–related factors explaining lower sexual dysfunctions in cohort studies. Similar to other comorbidities of schizophrenia,¹¹ we found that some sexual dysfunctions were more frequently reported when a validated tool and a self-reported tool were used (compared to clinical interviews or nonvalidated tools). This may be particularly true if some patients are reluctant to answer or ashamed of answering questions about intimate areas during a clinical interview, which may also be modulated by age, sex of the patient, sex of the clinician, and cultural factors. The use of a self-reported validated tool could be actively promoted to improve screening in daily practice. This could be automated with online Patient-Reported Outcomes Measures (PROMs).⁹⁸ We found that the Arizona Sexual Experience scale was the most frequently used questionnaire in the studies included in this work that could be used as a PROM in clinical practice. Importantly, we found that limiting the results to high-quality studies did not change our results, which reinforces their robustness and the confidence we can have in them.

We found significant associations between the prevalence of sexual dysfunctions and time and location. We found that most sexual dysfunctions had a higher prevalence in recent studies than in ancient studies and no evidence of an improvement in sexual dysfunction prevalence with the release of second-generation antipsychotics. Time and location may also intersect with other factors, such as study design, as discussed above. Geographical discrepancies could also be explained by differences in prescription habits and general social and health factors (including prevention, lifestyle and health care systems). Of note, we found no significant difference in sexual dysfunction prevalence in schizophrenia between high-income countries and low- to middle-income countries, but data in Africa and Polynesia were limited.

Our purpose was to provide a picture of observational studies of real-world stabilized outpatients with schizophrenia. Stabilization does not mean remission, and we found that 3 studies including patients with higher psychotic symptomatology and higher positive and negative symptoms also reported more frequent orgasm dysfunction and loss of libido. However, these few data call for additional studies including participants with high positive or negative symptom levels to confirm these associations. It is probably impossible to discriminate the part of the mental illness itself in the onset of sexual dysfunctions. For example, we found that a lower prevalence of sexual dysfunction was reported in studies including more patients with schizoaffective disorders. We do not know if the results found for antidepressants are explained by an indication bias. A strikingly missing clinical factor is comorbid major depressive disorder. The association of major depressive disorder with sexual dysfunction has been robustly demonstrated in other psychiatric populations and in the general population.^99,100 A meta-analysis¹¹ of observational studies recently concluded that approximately one-third of individuals with stabilized schizophrenia are identified with comorbid major depressive disorder, that is, 3 to 4 times the prevalence of the general population. We found that the studies with the highest proportion of antidepressant, mood stabilizer, and anxiolytic prescriptions also reported lower rates of sexual dysfunctions compared to other studies, which is a compelling reason to investigate the role of major depression in the high prevalence of sexual dysfunctions in schizophrenia and their treatment. Thus, the systematic coscreening of sexual dysfunctions combined with major depression may be an effective strategy to improve the care of schizophrenia.

Limitations

This study has limitations. More than 80% of the included studies used validated tools, and their absence was only associated with a higher prevalence of loss of libido. Most factors known to increase sexual dysfunction in the general population (eg, hypertension, diabetes, overweight and obesity, tobacco smoking, and sleep disorders) were not identified as risk factors in our results; however, they were poorly explored in the included studies. Tobacco smoking and overweight or obesity are 2 major sources of sexual dysfunctions that are frequently present in people with schizophrenia, and their role should be better delimited. It is currently impossible to capture diet parameters, as no questionnaire has been specifically designed for this purpose. This issue will probably be addressed in the coming years.¹⁰¹ These results may not be extrapolated to some continents, such as Africa and Polynesia, which were underrepresented. Additionally, the presence of publication bias in our meta-analysis cannot be entirely ruled out, as indicated by the statistical significance of the Thompson-Sharp test. However, the absence of a clear asymmetrical pattern in the funnel plots suggests that the likelihood of publication bias is relatively low. Heterogeneity or methodological differences may also contribute to the observed results.¹⁷

Conclusions

Four decades of studies have reported sexual dysfunction as extremely frequent in schizophrenia. Beyond methodological discrepancies partially explaining heterogeneity, we found important evidence in observational studies suggesting that improving the screening and treatment of depression may be an effective strategy to improve sexual health in patients with schizophrenia. Promoting systematic health assessment in sexual dysfunction studies could also help better understand associations between sexual dysfunction and metabolic parameters.

Supplement 1.

eAppendix 1. Search paradigm

eAppendix 2. Extracted data

eAppendix 3. Excluded studies and reason for exclusion

eAppendix 4. Characteristics of the included studies reporting a prevalence of global sexual dysfunction in schizophrenia

eAppendix 5. Characteristics of the included studies reporting a prevalence of sexual dysfunction in men with schizophrenia

eAppendix 6. Characteristics of the included studies reporting a prevalence of sexual dysfunction in women with schizophrenia

eAppendix 7. Study quality

eAppendix 8. Forest plot of studies exploring the prevalence of loss of libido in schizophrenia

eAppendix 9. Forest plot of studies exploring the prevalence of orgasm dysfunction in schizophrenia

eAppendix 10. Forest plot of studies exploring the prevalence of genital pain in schizophrenia

eAppendix 11. Forest plot of studies exploring the prevalence of erection disorder in schizophrenia

eAppendix 12. Forest plot of studies exploring the prevalence of ejaculation disorder in schizophrenia

eAppendix 13. Forest plot of studies exploring the prevalence of amenorrhea in schizophrenia

eAppendix 14. Forest plot of studies exploring the prevalence of galactorrhea in schizophrenia

eAppendix 15. Leave-one-out analyses

eAppendix 16. Leave-one-out analyses, men

eAppendix 17. Leave-one-out analyses, women

eAppendix 18. Funnel plot

eAppendix 19. Funnel plot, men

eAppendix 20. Funnel plot, women

eAppendix 21. Factors associated with the global prevalence of sexual dysfunctions in schizophrenia: subgroup analyses

eAppendix 22. Factors associated with the prevalence of sexual dysfunctions in men with schizophrenia: subgroup analyses

eAppendix 23. Factors associated with the prevalence of sexual dysfunctions in women with schizophrenia: subgroup analyses

eAppendix 24. Factors associated with the global prevalence of sexual dysfunctions in schizophrenia: metaregression analyses

eAppendix 25. Factors associated with the prevalence of sexual dysfunctions in men with schizophrenia: metaregression analyses

eAppendix 26. Factors associated with the prevalence of sexual dysfunctions in women with schizophrenia: metaregression analyses

eAppendix 27. Factors associated with the prevalence of loss of libido, orgasm dysfunction, genital pain and sex specific dysfunctions in schizophrenia: subgroup analyses

eAppendix 28. Factors associated with the prevalence of specific dysfunctions in men with schizophrenia: subgroup analyses

eAppendix 29. Factors associated with the prevalence of specific dysfunctions in women with schizophrenia: subgroup analyses

eAppendix 30. Factors associated with the prevalence of loss of libido, orgasm dysfunction and genital pain in schizophrenia: meta-regression analyses

eAppendix 31. Factors associated with the prevalence of sex specific dysfunctions in men with schizophrenia: meta-regression analyses

eAppendix 32. Factors associated with the prevalence of sex specific dysfunctions in women with schizophrenia: meta-regression analyses

eAppendix 33. Comparative pooled prevalence estimates of sexual dysfunction and its 95% confidence interval of the Inverse variance method vs. Random intercept logistic regression model

Click here for additional data file.^{(4.2MB, pdf)}

Supplement 2.

Data sharing statement

Click here for additional data file.^{(16KB, pdf)}

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