The participants’ ages varied from 25–46 years. The time since the participants’ diagnosis with BD varied from 0.5–22 years before the interviews. Three had a diagnosis of BD type 1. One participant was studying, three were working full time, and one was in subsidized part-time employment. One of the women and one of the men were in a relationship, living together with their partner. Four participants were heterosexual, and one homosexual. All patients were treated with lamotrigine (200–250 mg/day), four were additionally treated with low dose quetiapine (100–250 mg/day) and one was also prescribed lithium (24 mmol/day).
Five main themes
The analysis identified five main themes regarding the participants’ perspectives on their BD and sexuality: (1) sexual drive and impulses, (2) sexual behavior, (3) thoughts and feelings in relation to sexual issues, (4) intimate relationships, and (5) the connection between sexuality and identity (Fig. 1). As the participants’ sex drives (lust or urge) did not necessarily lead to actual behavior, these two themes should be distinguished. In addition, sexual behavior (acts) was not necessarily related to pleasure, positive thoughts, or relationships, which made it relevant to distinguish between these themes as well. Finally, the participants’ sexual issues were recurrently linked to self-perceptions, i.e., identity issues.
Theme 1: Sexual drive and impulses
All participants described having always had a high sex drive compared to friends and sexual partners, also before the first episode of hypomania or mania. In general, their sexuality changed depending on the affective phase they were in. When the participants were hypomanic or manic, they tended to have a higher sex drive, to desire more experimental sex, and they were easily sexually bored. Several participants described their higher sex drive not only as a lust but as a need or kind of internal pressure/urge to have sex. One of the women described the following:
Increased sex drive is one of the symptoms I notice, when I am becoming manic. I am not always good at noticing it, and then I suddenly discover it when I am in the middle of a manic phase. I notice it when I am like “Wow, I am thinking a lot about and having sex with myself at the moment.” And then it comes to me: “Well, I might be in a manic phase right now.
During depressed states, the participants typically described having a low sex drive. Yet for the two men, depressed episodes also implied a more self-destructive way of engaging in sexual relations and negative feelings related to sex rather than just a lowered overall sexual impulse.
In the periods with mood shifts, there are also lots of shifts in my sexuality. So, when I am in a manic phase, I want to fuck with everyone. And when I am depressed, I sometimes still feel like having sex with people, but it is in an uglier way, where people must be a little nasty to me. Otherwise, it has to be something I do not have to get emotionally involved in at all.
Theme 2: Sexual behavior
Overall, the participants described a wild youth, characterized by restlessness, difficulties in finding out what they wanted in life, and frequent shifts in interests. With respect to their sexual lives, four participants described chaotic relations, many partners, and a sexually experimental behavior sometimes exceeding one’s own and others’ boundaries. Alcohol was often involved in sex, and relations were affected by infidelity. The three women described that they had been more sexually outgoing than their peers from an early age. They described instances where their sexual behavior had been considered inappropriate, e.g., excessive flirting and acting out sexually in front of friends’ parents or at school reunions. One participant had had three abortions when she was 14–19 years old.
There was this one time when I was dancing with all of my friends’ parents and danced with everybody and I was all over the place. I got a bit ill and tired and then I lay down with one of my breasts showing. My friends were like “it is time to stop now! We will take you home.
The two participants who were in relationships at the time of the interview still tended to flirt with others when they were in hypomanic or manic phases, and the way they had sex with their partner changed with the phases of the BD. The woman described how she might wake her partner up in the middle of the night to have sex and suggested having more experimental sex than the partner wanted. For the participants who were single, there were differences in how their sexual behavior changed during hypomanic and maniac phases. The single male had more sexual partners during his manic episodes, while the two single women masturbated more often, but did not seek sexual partners. Instead, they described having learned to control their high sex drive and using their energy in other ways, e.g., creatively or with projects, which they considered a way to take care of themselves and avoid negative intimate experiences. One of the women explained that with age she had learned that relationships and sexual relations tended to destabilize her disease.
The horniness turns on and off depending on the state I am in. The difference is that I am no longer in a relation to one person or more. The horniness has not diminished. Only, now I am so grown up, that I have chosen not to follow it, because it was too complicated. It was a weird combination of low self-esteem and self-overestimation.
During depressive episodes, the participants’ decreased sex drive mainly affected those who were in a relationship. The woman described that her partner might feel rejected and the lack of intimacy created a distance between them. The other two women who were single were simply not orientated towards sex during these phases. Here, a gender difference was observed since both men described that depression might not be associated with reduced sex drive but rather with a negative sex drive that was self-destructive or that the intimacy became frustrating or saddening due to a lack of sexual and emotional satisfaction.
Theme 3: Thoughts and feelings about sexuality
Across the interviews, the participants speculated whether their sexuality might be related to their BD (i.e., if it was pathologic), whether it was “natural” (a physiological drive and need), “normal” (i.e., in accordance with cultural and societal norms), and/or related to psychological factors (e.g., earlier life experiences) (Fig. 2).
The participants’ distinctions between pathological, natural, socio-cultural, and psychological factors were related to their views on their own sexuality, including feelings of shame, responsibility and the means to control their sexual drive. As such, these perceptions were connected to the participants’ coping strategies and thoughts about sexological treatment. Some participants wanted to know if their sexuality was part of their BD, while others speculated whether their childhood experiences had a negative psychological effect on their intimate issues and adult relationships. The participants’ views on their sexuality could thus be linked to a wider self-perception that was not necessarily related to their BD.
Figure 2 Perceived domains of sexuality based on the qualitative interviews with individuals with BD
When it came to changes in sex drive following mood phases, the participants described that a high sex drive/urge was not necessarily connected to a pleasurable feeling, nor was having intercourse. One of the women explained that it was not always lust that made her have sex, despite having had several sexual affairs and flirting and being sexually curious. Her satisfaction mainly relied on getting men to long for her. One of the men also described never actually reaching sexual satisfaction, even during intercourse, no matter for how long or how he had sex. He always longed for more, which might lead to a sense of desperate insatiability.
In general, the participants did not consider the number of their sex partners and extent of sexual experiences to be problematic. They did not feel ashamed, although they were aware that others might look down upon their behavior.
“I have not felt ashamed, when I was depressed, or turned into ponderings about the things I have done. But I sometimes shortly felt ashamed, because when I was most manic, I might have been too wild for them and have overheard their signals about it hurting their knees or so. I may have been a bit abusive. Then it is very embarrassing if I should meet them again. But it has not haunted me in a way where I felt that my sexuality is too much. And over time I have taken it to heart and become more considerate (….) In fact, I don’t think my sexuality is problematic at all. It is the emotional things that are hard. “
Theme 4: Intimate relationships
Several participants mentioned having a history of intense love affairs, short-lived, chaotic relations, and confusion about the connection between love and sex. Some reflected on their search for love and attention through sex, about uneven relations, or people who only wanted them for sex.
The participants were especially concerned with how changes in their sex drive affected their love life. One of the men described problems with engaging in close relations and a self-destructive sexual behavior that prevented him from having healthy romantic relationships. The other man’s insatiable need for sex and desire was a constant conflict in his marriage and the reason why the couple could “never meet or be in the same place.” One woman described that the changes in her sexual desire affected her relationship, making her worry about whether her boyfriend would leave her and whether they would be able to have kids. The two single women felt that rather than having sexual problems, more importantly, they had difficulties with emotions and entering and maintaining romantic relationships, and one woman described how heartaches affected her BD.
My psychiatrist knows that I have had these heartaches and how they affect my mood swings. When it happens, I often becomes manic because I have, yes maybe a short-lived depression in three days where I am not able to concentrate on anything or do anything. But then I pull myself back up, and then it becomes like a manic phase where I do anything to forget it and keep myself going. And then I keep going further, and I stop sleeping and run around.
Theme 5: The connection between sexuality and identity
For all participants, their sexuality was closely related to their identity. For two of the women, it had been a positive part of their self-perception to be sexually experienced and adventurous. One described that her sexuality had overruled negative thoughts and low self-esteem and that her teenage friends had had more complicated body images. When the women were young, being the sexually outgoing and experienced girl among their peers was part of their identity and role. One of the men said he had always attracted people, also without being aware of it, which he linked to a certain enticing energy that comes with being bipolar.
“There were also quite a lot of feelings about feeling less worth because I thought something about my body and I was fat, but somehow my sexuality overruled these thoughts. I wasn’t thinking about my stomach being too fat when we were in the act…” (woman)
Participants’ thoughts about sexual counseling
In the final part of the interview the participants were asked if they felt sexual issues should be part of their treatment and conversations with their psychiatrist or other health care professionals. The participants’ wishes for sexological treatment were especially linked to three different aspects: (1) whether they considered their sexuality to be problematic, (2) whether they thought the issues with their sexuality could be treated, and (3) whether they were already talking with their health care provider about sexual issues or felt they could do so. In general, these participants did not call for specific sexological counseling, either because they did not see their sexuality as problematic or because they already felt they could talk with their psychiatrist about it. One participant was depressed at the time of the interview and stated that she could not see herself talking about sexual issues when she was in this state.
Main factors affecting sexuality issues
Across the major themes described above, the analysis of the interviews pointed to several factors influencing the participants’ experiences with their sexuality, including (a) their gender, (b) their relationship status, (c) their age and time of diagnosis, and (d) coping strategies and insight (Fig. 3).
The interviews suggested that there may be gender differences (Fig. 3) (a) in the way the participants viewed their own sexuality. The men described a negative sex drive in depressed episodes, rather than merely a lower sexual drive, which was more common in the women. Among the participants who were single, there also seemed to be a gender difference. The single man sought more sexual partners during hypomanic or manic episodes; the two women masturbated more than usual but otherwise channeled their energy towards other activities.
Being in a relationship or not (b) was important to the consequences of the participants’ sexual drive and behavior. Those in a relationship had difficulties being on the same level as their partner, which created dissatisfaction to both, even in euthymic phases. Those who were single longed for serious romantic relationships, rather than just sex. One of the single women said that she never engaged in one-night stands because they made her feel empty and hollow. The single male considered his high sexual activity level as really being a quest for love, but instead this brought him to self-loathing and humiliation.
With age and time since the BD diagnosis (c), the participants appeared to have gained more self- and disease insight and improved coping strategies (d) to handle the challenges coming with the disease, including sexual challenges. For instance, one of the women described that she paid much attention to generally structuring her life after her diagnosis with BD, including her work life and social life and not engaging in random sexual relations that would destabilize her.