4.3 Why are intimacy-related side effects often not discussed?
“You don’t have to explain everything right now. I’m here, and I’m not going anywhere.”
Elena:
If sexual well-being is so important, why is it still so rarely discussed in consultations?
Dr. Stein:
There isn’t just one reason. In practice, it’s usually a combination of very human factors.
For many people, sexuality is a sensitive topic. It can feel uncomfortable to bring it up, especially in a psychiatric setting. Some people worry that they will not be taken seriously or fear being judged. Others simply don’t know how to start the conversation, or whether it’s appropriate to bring it up at all.
Elena:
Even when a concern is important, a person may find it difficult to raise.
Dr. Stein:
And sometimes it’s not only about the patient. If the topic isn’t asked about directly, it can easily remain in the background. People may assume it’s not something they’re supposed to talk about here.
Elena:
The concern can remain invisible in the consultation.
Dr. Stein:
And there’s another layer as well. Some people are not sure where the changes are coming from. They may think, “Maybe this is just part of the illness,” and not realize that treatment could also play a role.
When there isn’t a clear explanation, silence can feel like the easier option. Some people think, “Maybe I should just accept it,” even when it affects them more than they expected.
Elena:
But that silence can have consequences.
Dr. Stein:
It can.
In practice, these kinds of side effects are one of the reasons why people sometimes reduce or stop treatment without saying so. Not because they don’t want help, but because something important in their life has changed and hasn’t been addressed. And often, this happens quietly, without discussion, which makes it harder to understand what is really going on.
Elena:
What can make the difference?
Dr. Stein:
Often, it’s something very simple.
When clinicians create space for these topics, even with a gentle question, people feel more able to speak.
A question like:
“How has treatment been affecting your energy, mood, or intimacy?” can open the conversation in a natural way.
Elena:
A simple question may be enough to open the discussion?
Dr. Stein:
Very much so.
When intimacy is recognized as part of overall health, people feel seen. And when they feel seen, they are more likely to stay engaged, to talk openly, and to continue treatment.
Why patients may not talk about intimacy
Common reasons include:
• embarrassment or shame
• fear of being misunderstood
• assumption that nothing can change
• not being asked directly
✔ A simple question can open the conversation
✔ Open dialogue improves adherence
Why might someone hesitate to open up to their partner after diagnosis?
Elena:
Dr. Stein, we’ve talked about why people don’t always report changes in intimacy or side effects.
But sometimes, the difficulty starts even earlier, right after diagnosis.
Some partners notice that their loved one becomes more open with family, but more distant or reserved with them. Why does that happen?
Dr. Stein:
That’s a very important observation.
Receiving a diagnosis like schizophrenia can deeply affect how a person sees themselves, not only medically, but also personally and relationally.
Many people begin to wonder:
• “Will I still be seen as the same partner?”
• “Am I still attractive, still trustworthy, still ‘enough’?” These thoughts are often not shared out loud, but they shape how someone behaves.
Elena:
The hesitation may reflect fear of how disclosure could affect the relationship, rather than a lack of trust.
Dr. Stein:
Exactly.
In clinical practice, we often see that people may feel safer sharing information with parents or family members first. These relationships are usually perceived as more stable, less dependent on intimacy, attraction, or future expectations.
With a partner, the stakes can feel higher. Especially when the relationship is important, the fear of losing it can become very strong.
Elena:
Holding back may function as a form of protection.
Dr. Stein:
Yes, emotional self-protection.
People may internalize fears of rejection, even when there is no actual rejection. This can lead to silence, distance, or partial sharing.
From the outside, it may look like withdrawal.
But internally, it is often:
“I don’t want to lose you.”
Elena:
That must be very confusing for partners.
Dr. Stein:
It is.
One partner may think:
“Why is he shutting me out?”
While the other is thinking:
“I’m afraid to let you see everything.”
Elena:
What can help in that situation?
Dr. Stein:
Creating safety over time.
Not pushing for immediate openness, but showing:
• consistency
• acceptance
• and patience
Simple messages can help:
“You don’t have to explain everything right now.”
“I’m here, and I’m not going anywhere.”
Over time, when fear decreases, openness usually follows.
What happens when desire is present, but circumstances don’t allow expression?
Elena:
Dr. Stein, there is a topic that many people feel, but rarely talk about openly.
What happens when someone has sexual or emotional needs but cannot express them, for example, during hospitalization or when they are not in a relationship?
Dr. Stein:
That’s a very important question, and one that deserves to be addressed with openness and respect.
First, it’s important to say clearly:
Having sexual desire is a normal part of being human, including for people living with schizophrenia.
The illness does not remove the need for closeness, affection, or physical expression.
Elena:
But the situation may not always allow those needs to be fulfilled.
Dr. Stein:
There are periods when circumstances limit expression:
• during hospitalization
• during unstable phases of illness
• or simply when someone is not in a relationship
This can create frustration, loneliness and sometimes also confusion, “What am I supposed to do with these feelings?”
Some people may even feel that these needs are “inappropriate” or something they should suppress, which is not the case.
Elena:
The existence of the need is not itself a problem.
Dr. Stein:
Not at all. The key is how it is understood and managed. Not ignoring it, but also not feeling overwhelmed by it.
From a clinical perspective, we focus on healthy, respectful, and safe ways of coping with these needs.
This may include:
• understanding that desire can exist without immediate action
• finding other forms of connection, such as emotional closeness, conversation, or supportive relationships
• maintaining routines that support overall well-being, including physical activity and social interaction
• and, when appropriate, discussing concerns openly with a clinician
Elena:
So it’s about acknowledging the need, but not feeling overwhelmed by it.
Dr. Stein:
Exactly.
When these needs are recognized as natural, they become easier to manage.
When they are ignored or associated with shame, they can become more distressing.
Elena:
And does this change over time?
Dr. Stein:
Yes.
As stability improves, opportunities for relationships, intimacy, and personal expression often return.
So these phases are usually temporary, even if they feel difficult at the moment.
