Rheumatoid arthritis (RA) has been associated with an increased risk of sexual dysfunction (SD), especially during periods of high disease activity. In addition to the associated pain, chronic inflammation in RA might lead to fatigue and stiffness, which can lower sexual desire.1–6 Moreover, the deformities generated by the natural course of the disease can deteriorate one's perceived body image, resulting in low self-esteem and decreased sexual pleasure, as well as in irreversible joint damage which leads to limited mobility. In addition to the joint symptomatology, it is frequent the coexistence of sicca syndrome, due to the disease and as a pharmacological adverse effect. This combination of factors can result in dyspareunia, erectile dysfunction, loss of interest in sexual activities, and finally, less frequent relations.1–6

Psoriatic arthritis (PsA) is a chronic inflammatory joint disease complicated by skin psoriasis in a large percentage of patients. These patients are therefore not only inhibited in their everyday lives by joint and axial inflammation, but also by their cutaneous condition.7 Although most published studies on the association of SD with musculoskeletal diseases have focused on RA, patients with PsA and skin involvement seem to have a higher prevalence of SD and erectile dysfunction. These findings were independent from other physical and psychological comorbidities.7–11

In some instances, the patient's partner might not fully comprehend the disease. Indeed, to prevent discomfort, they might become too cautious, and satisfying sexual intercourse can become a challenge.6

There are a limited number of studies on joint diseases and sexuality, many of which lack a control group and do not explore the different areas of sexual response. Sexual response is defined as the sequence of physical and emotional changes that arise as an individual is sexually excited and participates in stimulating sexual activities like intercourse or masturbation. The 4 described stages of sexual response are desire, arousal, orgasm, and its resolution.12 The prevalence of SD is known to differ between men and women: it is more common in women, many of whom experience less sexual response in multiple domains. In men, erectile dysfunction and premature ejaculation were listed as the most frequent type of SD, whereas in women, the lack of sexual interest, inability to reach orgasm, and insufficient lubrication were the most commonly reported events.12,13

In everyday rheumatology practice, numerous scales have been devised to quantify the disease activity of chronic inflammatory joint disorders, and questionnaires have been developed to evaluate the repercussions of disease on quality of life. The questionnaire Qualisex, and its homonym, Qualipsosex, have been validated for the addressing of the sexual sphere in RA and PsA respectively. In this study, our objectives were to describe the prevalence of SD in patients with RA and PsA, to compare the results obtained in the 2 groups and a healthy population, and to analyze the factors associated with SD in these 3 groups.

According to our analyses, patients with RA or PsA have a poorer sexual life than a healthy population. We could have hypothesized, that PsA would have a greater effect on sexual life due to the skin component of the disease and its aforementioned effect on body image.8,11 However, this was not the case, as RA patients showed a higher proportion of SD than PsA patients (48.15% vs 30.43% respectively). The risk of developing SD was higher in RA as calculated by the odds ratio in the multivariate analysis. In previous publications examining the effects of RA on SD, pain was a direct predictive factor.19 Furthermore, a study by Saad et al. (2021) linked the number of tender joints and pain with SD.20 Although we did not quantify disease activity or accumulated damage in our study, this further highlights the deleterious effect of joint pain and chronic inflammation on sexual function. From currently available data, it can be interpreted that the articular component of RA has a more detrimental influence on the development of SD, although further investigation is required to validate this statement.

Previous studies have demonstrated the multifactorial origin of SD.12,13,19,20 In the overall population, SD is more prevalent in women and the incidence also increases with age, personal history of depression, poor health, low economic status, and education level.12,19,20 Age is known to be related to SD in the healthy population and in patients with RA: Saad et al. found age to be a predictive factor for SD in RA patients.12,20 In our study, older patients, women, unemployed individuals, and individuals with low annual income had an increased risk of SD. Moreover, poorer self-perceived health was reported by the groups of patients with RA and PsA who reported an impoverished sexual life, although our multivariate model did not confirm that this was a determinant risk factor of SD. We did not directly investigate quality of life in our study, but Tanski et al. found that poor quality of life was associated with SD. Nevertheless, the same authors reported that the absence of comorbidities had a direct correlation with SD, which could explain the relationship between the physiological burden of the disease and sexual health.

Interestingly, our data showed that, contrary to prior research on general population as well as focused specifically on patients with RA,12,19,20 a personal history of depression and active treatment, whether psychological or pharmacological, were not associated with SD. This discrepancy between our study and the existing literature helps to further define the subsequent impact of chronic joint diseases in sexual health, as it might be interpreted that the effect of PsA and RA on SD are more related to the physical aspect than to the psychological component.

The negative effect of PsA and RA on the four domains (pleasure, desire, arousal, and orgasm) observed in both patient groups, including men and women, was consistent with reports from prior studies in RA using the CSFQ-14 questionnaire or other tools for the evaluation of sexual health.19–23 Remarkably, Bay et al. observed lower CSFQ-14 scores, and therefore, a higher percentage of SD in patients affected by RA fatigue.21 In our study, we did not measure fatigue as an individual item either in RA or in PsA, but fatigue associated with chronic joint diseases may also be a factor to take into account when evaluating SD in our patients.

The impact that rheumatoid diseases may have on the sexual aspect of our patients’ health is often overlooked in the rheumatology clinic. Several publications state that a large percentage of patients (65%) affected by chronic joint diseases wished to discuss their sexual related problems with their rheumatologist but never had the chance.5,21 As our study shows, the CSFQ-14 questionnaire is a comprehensive method of assessing sexual health and can be a valuable evaluation tool in the integral management of patients with chronic joint diseases.14–17 Given the limited time that rheumatologists can dedicate to each patient in the outpatients’ clinic,21 this questionnaire could be used to assess the patient's sexual sphere rapidly and thoroughly during consultations. Some studies have shown that a proportion of patients may be reluctant to reveal details about their sexual life, but in our opinion, the availability of tools that evaluate underevaluated aspects of rheumatoid patients’ health are of particular interest in today's medicine, which aims for the holistic management of diseases.

Our study has strengths and limitations. In comparison with other tools used in previous published data to evaluate sexual life in chronic joint diseases, like Qualisex for RA and Qualipsosex for PsA, the CSFQ-14 questionnaire distinguishes itself in two remarkable ways. First, it has two different versions according to the participant's sex, whereas Qualisex and Qualipsosex are applied indifferently, failing to take into account the differences in sexual health between the male and female sex. Second, the CSFQ-14 questionnaire divides SD into specific areas, whereas Qualisex and Qualipsosex do not present such intricacies, which definitely offers a more “in depth” analyses in the diagnoses of SD. A possible advantage of Qualisex and Qualipsosex against the CSFQ-14 questionnaire is that the latter lacks questions designed to be answered by the participant's sexual partner, therefore, missing data to complete the holistic approach to SD.24,25

One of the main interests of our study is the inclusion of patients with PsA, a chronic joint disease for which the data on sexual activity is scarce. Nevertheless, an important limitation is the imbalance in the number of participants between the PsA and RA groups, with a higher proportion of PsA patients despite RA being more prevalent in the general population. This discrepancy reflects the recruitment process and voluntary participation rather than actual disease prevalence, and it may affect the generalizability of our findings.

Additional limitations relate to the nature of the CSFQ-14 questionnaire, which explores intimate aspects such as sexual thoughts and activity. Although the majority of participants completed it without expressing discomfort, it is important to note that all subjects voluntarily agreed to participate with full awareness of the study's focus. As previously mentioned, potential selection bias inherent to voluntary participation, as well as recall bias associated with self-reported data, should be taken into account when interpreting the results.

Another main limitation is that disease activity was not evaluated at the moment of questionnaire completion. It will certainly be of interest and leaves room for further investigation of the relationship between active inflammatory burden of the disease and the quality of sexual life. Since this was a cross-sectional study, we could establish associations between the study variables, but not a temporal sequence of events. Our data and the conclusions we extract from it are adjusted by age and sex, however, it is true that the control group was significantly younger, which could still represent a potential bias for the crude comparison. Finally, even though pharmacological treatment for mental health was recorded, we did not analyze the effect of specific therapies for PsA and RA. It certainly is uncommon for DMARDs, glucocorticoids and biologics to alter sexual function, yet decreased libido in both sexes and impotence in men have been described, which could perhaps influence sexual activity.18

Rheumatoid arthritis and psoriatic arthritis have a negative impact in the sexual sphere of patients when compared to a healthy population. In our study, we examine not only sexual life as a whole, but also its separate domains, determining how pleasure, desire, arousal and orgasm are affected by disease. Other factors to consider when evaluating patients’ sexuality are age, gender, perceived health, employment situation and economic status, as they increase the chances of developing SD. The CSFQ-14 questionnaire is a fast and comprehensive test for appraising this health area that may be utilized for the integral evaluation of patients with chronic joint diseases.

The authors declare that they have no conflict of interest.