During the past 20 years, orthotopic liver transplantation has emerged as the treatment of choice for end-stage liver diseases of various causes. Most transplant centers reported 1-year survival rates for adult transplant recipients of about 80-90% and 9-year survival rates of 55%.1 As the clinical outcomes of orthotopic liver transplantation continue to improve, resulting in fewer postoperative complications and better immunosuppression, other outcomes, such as health-related quality of life, become important targets of evaluation. Although considerable research has been conducted on the morbidity and mortality of orthotopic liver transplantation, less is known about the influence of orthotopic liver transplantation on health-related quality of life of the transplant recipients. In particular, literature on sexual health for this population is limited.
Sexual health encompasses not only sexual function, but also involves the full range of human experience. Sexuality allows communication of emotional feelings, provides a means of physical pleasure and gratification, enhances feelings of self-worth, and strengthens relationships.2 Evaluation of sexual health after transplantation is important for several reasons. First of all, sexual health is a common concern of many transplant recipients,3, 4 even though the medical literature regarding this problem in liver transplant recipients is scant. Many liver transplant recipients from the transplant clinic in our hospital have expressed their concerns about the effect of liver transplantation on their sexual health. Second, assessing the transplant recipients' sexual health can provide a more complete estimate of their overall health status after transplantation. Finally, an understanding of posttransplantation sexual health can assist health care professionals in educating prospective transplant recipients, and it may help them provide posttransplantation counseling and intervention programs that focus on this specific area of the recipients' lives.
The purpose of this study was to describe the frequency and the extent of self-reported sexual dysfunction in orthotopic liver transplant recipients before and after transplantation to determine the degree of satisfaction with life and sexual relationships, to explore the potential factors related to sexual dysfunction, and to determine the need to seek medical attention regarding sexual problems after transplantation.
All 320 adult liver transplant recipients followed at the Solid Organ Clinic of the Vancouver General Hospital were invited to participate in this study.
A self-administered survey was mailed to all liver transplant recipients with a letter of introduction from the transplant clinic staff. Participation in this study was anonymous, and subjects were instructed that the return of the questionnaire indicated consent to participate. During the planning aspect of this study, there was a concern that some transplant recipients could potentially be offended by the subject matter of the survey or some of the questions, and for this reason, only one mailing of the survey was done.
The survey contained 24 questions and was composed of demographic, medical, and sexual health–related information. The demographic and medical data included age, gender, ethnicity, comorbidities, and current medications. The sexual health questions addressed issues such as lack of interest in sex, lack of enjoyment of sex, and difficulty becoming sexually aroused, as well as the quality of life and overall satisfaction with sexual life after transplantation. Patients were encouraged to continue the survey but to leave any questions that were considered offensive or created discomfort unanswered.
This study was reviewed and approved by the Behavioral Research Ethics Board of the University of British Columbia.
A total of 150 completed questionnaires were returned after 2 months, giving an overall response rate of 42%. The characteristics of the study population are outlined in Table 1. The median age of the respondents was 54 years, and 62% were men. Only 7% of the respondents were less than 12 months after transplantation. Thirty-three percent were more than 1 year after transplantation, and 60% were more than 5 years after transplantation. The majority of the respondents were white (79%), and nearly all of them (93%) had more than a high school education. Eighty-three percent of patients reported having an intimate partner.
Table 1. Demographic and Clinical Characteristics of Study Patients (N = 150)
Asian includes Chinese, Korean, Japanese, Vietnamese, and Filipino subjects. Indo-Canadians include subjects from India, Pakistan, and Bangladesh. Middle East includes subjects from Arab nations and Iran.
Acute liver disease secondary to toxin ingestion (mushrooms, DDT, etc.)
Autoimmune liver disease
Metabolic liver disease
Years since transplantation, n (%)
6 months to 1 year
1 year to 5 years
Current immunosuppressive therapy, n (%)
Tacrolimus with other agents
Cyclosporine with other agents
Azathioprine with other agents
Mycophenolate mofetil with other agents
The distribution of underlying liver diseases suffered by the respondents is shown in Table 1. Autoimmune liver disease (28%) and hepatitis C (23%) were the 2 most common causes of liver diseases. In terms of concomitant chronic illness, 70 patients did not answer this question, and among those respondents, 48 (54%) reported experiencing chronic hypertension, and 39 (44%) reported having had diabetes mellitus at some point after transplantation. In terms of immunosuppressive therapy, most were receiving either tacrolimus alone (28%) or in combination with other agents (35%).
Sexual Function Before and After Transplantation
The response rate varied for each question. Ten patients (7%) did not complete the questions regarding sexual problems before and after liver transplantation. Thirty-six patients (24%; 21 men, 15 women) experienced sexual problems before transplantation, which persisted in 22 patients (15%; 14 men, 8 women) after transplantation. However, 48 patients (32%; 30 men, 18 women) felt their sexual function was newly affected after transplantation. Overall, 70 patients (47%; 45 men, 25 women) reported posttransplantation sexual problems (Fig. 1). In other words, the incidence of sexual problems in men and women before liver transplantation were 23.8% and 24.1%, which had increased to 51.1% and 40.3% in men and women after transplantation, respectively.
Male Sex–Related Issues After Transplantation
The following specific sex-related issues were addressed in this survey: decreased libido; premature ejaculation; erectile dysfunction; and inability to experience climax with intercourse. Of the 88 male respondents, 77 (88%) completed these questions. The results of the different male sex–related issues are summarized in Table 2.
Table 2. Male Sex–Related Problems After Transplantation (N = 77)
A few times
Total, 16 (20%)
A few times
Total, 14 (18%)
A few times
Total, 23 (30%)
Inability to reach orgasm with intercourse
A few times
Total, 25 (33%)
In this study, 16 patients (20%), who did not experience libido problems before transplantation felt that their libido had decreased after transplantation. Patient self-reports of decreased libido varied: 1 patient (1%) reported that decreased libido was always present after transplantation. On the other hand, another patient (1%) reported decreased libido only “a few times.” The rest of the group reported decreased libido “sometimes” (7 patients, 9%) or “most of the time” (7 patients, 9%) after transplantation.
Fourteen patients (18%) reported having problems with premature ejaculation after transplantation. Six of them (8%) experienced this problem “a few times,” 5 (6%) “sometimes,” and 3 (4%) “most of the time.”
Twenty-three male respondents (30%) experienced some degree of erectile dysfunction after liver transplantation. Impotence occurred “a few times” in 3 patients (4%), “sometimes” in 9 patients (12%), “most times” in 6 patients (8%), and “always” in 5 patients (6%).
Inability to Reach Orgasm With Intercourse
Twenty-five respondents (33%) who reported not experiencing problems reaching orgasm before transplantation reported having difficulty afterward. Twelve of them (16%) reported inability to experience climax with intercourse “a few times”; 7 patients (9%) had problems “sometimes,” and the rest (8%) reported inability to achieve orgasm “most of the time.”
Female Sex–Related Issues After Transplantation
Similar sex-related issues were addressed in the female populations: decreased libido; difficulty maintaining lubrication; painful intercourse; and inability to reach orgasm. Of the 62 female respondents, 51 (82%) completed these questions. The results of the different female sex–related issues are summarized in Table 3.
Table 3. Female sex–Related Problems After Transplantation (N = 51)
A few times
Total, 13 (26%)
Difficulty maintaining lubrication
A few times
Total, 17 (34%)
A few times
Total, 20 (40%)
Inability to reach orgasm with intercourse
A few times
Total, 13 (26%)
In this study, 13 patients (26%) did not recall experiencing libido problems before, but experienced some degree of libido loss after transplantation. Decreased libido happened “a few times” in 4 patients (8%), “sometimes” in 4 (8%), “most times” in 3 (6%), and “always” in 2 patients (4%).
Difficulty Maintaining Lubrication
Seventeen patients (34%) had difficulty maintaining lubrication after transplantation. Two patients (4%) “always” had this problem, whereas the rest of them—15 patients—had difficulty maintaining lubrication “a few times” (5 patients, 10%), “sometimes” (10%), and “most of the time” (10%).
Similar to above, 20 women (40%) reported experiencing pain during intercourse only after transplantation. Dysparenuia occurred “a few times” in 4 patients (8%), “sometimes” in 8 (16%), “most times” in 3 (6%), and “always” in 5 patients (10%).
Inability to Reach Orgasm With Intercourse
In this study, 13 women (26%) did not recall experiencing problems reaching orgasm before but reported having difficulty after transplantation, with 3 of them (6%) reporting inability to reach orgasm “all the time.” Two patients (4%) had this problem “a few times,” 7 (14%) experienced it “sometimes,” and 1 patient (2%) had difficulty “most of the time.”
Potential Factors Contributing to Sexual Dysfunction
The patient's perception of the main contributing factors to his or her sexual dysfunction is illustrated in Figure 2. Thirty-six percent of the respondents believed that medications were the main contributing factor to their sexual dysfunction after liver transplantation, followed by liver disease (33%), other causes (18%), and depression (10%).
With regard to immunosuppressive medications among the 150 respondents, 94 (63%) were receiving tacrolimus alone (42 patients) or in combination with other immunosuppressive agents (52 patients), including azathioprine, mycophenolate mofetil, or prednisone. In the tacrolimus monotherapy group, 14 patients (33%) reported experiencing sexually related problems only after transplantation.
Fifty-two patients (32%) were receiving cyclosporine alone (20 patients) or in combination with other immunosuppressive agents (32 patients). In the cyclosporine monotherapy group, 7 patients (35%) experienced sexual dysfunction only after transplantation.
Satisfaction With Sexual Relationship
Despite the sex-related problems experienced after transplantation, 86 patients (59%) reported that they were satisfied with their sex life after transplantation: 51 patients (35%) stated that they were “moderately satisfied,” and 35 (24%) reported being “very satisfied.” In contrast, only 33 (23%) reported that they were dissatisfied with their sex life: 19 (13%) reported being “very dissatisfied” and 14 (10%) were “moderately dissatisfied.” A total of 27 patients (18%) were neither satisfied nor dissatisfied with their sex life. These results suggest that the majority of the transplant recipients experienced satisfaction with their sexual relationship after transplantation.
Respondents' Partners' Satisfaction With Their Sexual Relationship
A total of 138 survey respondents answered this question, and only 23% (32 patients: 16 men, 16 women) reported that their partners had expressed their dissatisfaction with their sexual relationship. This proportion was similar to the proportion survey respondents who reported sexual relationship dissatisfaction.
Seeking Medical Advice for Sexual Dysfunction
When asked whether they would consider seeking medical advice or treatment for sexual dysfunction, 106 survey respondents (64 men, 42 women) answered, for a response rate of 71%. Among the 64 male respondents, 51 (80%) indicated that they would seek medical help for sexual dysfunction. Similarly, 32 (76%) of 42 female respondents indicated that they would seek medical advice for the same problem.
In terms of medication use for sexual dysfunction, 73% (110 patients) responded to the question, and 19% of respondents (21 patients: 20 men, 1 woman) reported having tried sildenafil citrate (Viagra; Pfizer Canada Inc., Kirkland, Quebec, Canada). Thirteen of the male patients receiving sildenafil (65%) found this medication beneficial.
Research related to sexual health after transplantation has always been limited. Most studies had small sample size, and most of them were of lung or renal transplant recipients. There are few, if any, studies of sexual health in the liver transplant literature worldwide, and we are unaware of any specific studies of this subject matter conducted in North America. A recent study5 emphasizes the need for specific socioculturally generalizable studies. This study, conducted in Barcelona, included sexual health, but only as a domain within a larger psychosocial study using the Psychosocial Adjustments to Illness Scale. Although this Spanish study reported that women and older patients were more likely to experience sexual dysfunction, the specific components of sexual dysfunction after liver transplantation remain unexplored. Moreover, this study used professional interviewers, which may lead to response bias because patients who may not be comfortable with the subject matter may not disclose their true feelings. Sexual health after liver transplantation is an important aspect, given that factors related to sexuality and sexual satisfaction may, to some degree, be reflective of the patients' societal and cultural milieu. Our single-center study attempted to explore the influence of liver transplantation on the recipients' perception of their sexual health. The cross-sectional study nature of our study allowed us only to determine the influence of liver transplantation on our recipients' sexual health at a particular point in time only. The cross-sectional survey design of study was appropriate given that, a priori, we did not have a clear idea as to the general sexual health of our transplant recipients and that the returned questionnaires were intentionally anonymous and free of identifying markers of the recipients. The motivation to conduct this study came from some of our liver transplant recipients who felt that this posttransplantation issue needed exploration.
The response rate of 42% is reasonable given the similar response rate of previous study of sexuality after transplantation (39%).2 We acknowledge, however, that a possible limitation of our study is that the responses of those who returned questionnaires may not be reflective of the entire population of liver transplant recipients in our province. We think that it is important to appreciate that although we implemented this study at the encouragement of some of our liver transplant recipients, we understand that other patients could be uncomfortable or offended by a study of this nature. A cover letter accompanying the study survey emphasized that participation was entirely voluntary, and outside of the initial mailing, we did not actively attempt to increase the response rate.
Whether or not a sexual problem exists is based on the subjective experience and evaluation of sexual functioning by the individual.6 Thus, the perception of the individual determines whether a problem exists in a particular dimension of sexual functioning.7 Twenty-four percent of the patients in this study perceived that they suffered from sexual problems before transplantation, and this perception persisted in 15% after transplantation. It is unclear whether sexual problems that persist after transplantation result from organic pathology, side effects of therapy, psychological reactions, or anxiety about sexual performance. However, 32% of respondents who reported not having sexual problems before transplantation perceived their sexual function to be affected after transplantation. This result contrasts with the findings from studies involving other solid organ transplants. Schover et al.8 found that the prevalence of sexual dysfunction was reduced from 50% to 25% after renal transplantation. However, Hart et al.2 did not find any changes regarding sexual frequency, satisfaction, or desire in the group of kidney, pancreas-kidney, and liver transplant recipients.
We also discovered that 20% of the male and 26% of the female respondents reported that their libido had decreased since transplantation. As well, we found that 33% of male and 26% of female respondents reported having difficulty reaching orgasm with intercourse after transplantation. This is in contrast to the general population, where only 3% of men and 10% of women are reported to experience problems with libido, and 4% of men and 7% of women, respectively, are reported to experience problems with orgasm.9 In terms of specific gender-associated perceived sexual problems, inability to reach orgasm (33%) and erectile dysfunction (30%) were the most common complaints by men, whereas dyspareunia (40%) was the most common problem reported by women.
In terms of perceived causation of their sexual problems, more than one-third of the survey respondents believed that medication was the major contributing factor to their sexual dysfunction after transplantation. Although we are aware of no study that specifically establishes a causal relationship between immunosuppressants and sexual dysfunction, we note that 33% and 35% of respondents receiving tacrolimus monotherapy or cyclosporine monotherapy, respectively, experienced some degree of sexual problems after transplantation. There are many factors that could contribute to the respondents' sexual problems, including medical, physiological, or psychological factors. Some of these factors, such as diabetes mellitus, hypertension, and cardiovascular diseases, are known to be associated with immunosuppressant use. It is interesting that in this study, 44% of respondents reported having had posttransplantation diabetes mellitus (although this may have been transient) and 36% had hypertension, suggesting that attributing sexual dysfunction to immunosuppression is reasonable. Unfortunately, the confounding variables (e.g., diabetes, hypertension) contributing to sexual problems cannot be controlled for in a preliminary exploratory questionnaire study. We note that an exploration of the exact cause of sexual dysfunction after liver transplantation was beyond the scope of our study because we were attempting to discover whether problems in sexual health existed and the magnitude and components of those problems. Therefore, we could not tease out the specific influence of immunosuppression agents themselves on sexual function after transplantation, although this is clearly an area of potential future studies.
It must be emphasized, however, that sexual dysfunction by no means inevitable after liver transplantation, and that our sexual health survey respondents also reported positive experiences. Despite the reported sex-related problems, 59% of patients were moderately to very satisfied with their sex life since transplantation, and only 23% found their sexual relationship very to moderately dissatisfactory. Interestingly, the same number of respondents reported that their partners had expressed their sexual relationship dissatisfaction, suggesting that the effects of posttransplantation sexual dysfunction affects more than just the liver transplant recipient. Another interesting aspect of this survey was the fact that a minority (19%) reported taking sildenafil to improve their sexual function. This was a surprise to us because our liver transplant recipients have, for the most part, not disclosed this medication use to either the transplant physicians or to the transplant clinic nursing staff. The majority (65%) reported that sildenafil was of value, suggesting that the use of this medication, as well as other similar medications, should be studied in the posttransplantation setting in terms of risks and benefits.
This study has a few limitations. First, as mentioned previously, there may be a response bias. Respondents might find this a good opportunity to express their dissatisfaction of sexual function after transplantation, which could potentially lead to an overestimation of the number of patients with sexual dysfunction after transplantation. Second, there might be a component of race- and socioeconomic status–associated bias because the majority of respondents were white, and most of them had more than a high school education. However, this is not unexpected because this study was conducted in a setting where the majority of the population was white, and achieving a high school education level is not uncommon among our patients. Last, the pretransplantation sexual health reported by the patients may reflect recall bias because they may have had encephalopathy, or they may even have been recalling a time before they had overt liver disease.
A limitation of our study is our failure to use a validated sexual health survey instrument, and in addition, we did not include a nontransplant control group (e.g., we did not compare liver transplant recipients with patients who had undergone major surgeries). However, we noted during the planning stage of this study that there were no similar North American studies specific to liver transplantation that we were aware of. The magnitude of sexual health problems that our liver transplant recipients may have been experiencing was thus unknown. Likewise, the specific aspects of posttransplantation sexual health that were of concern to our transplant recipients was also unknown. Therefore, we decided that a baseline assessment of sexual health after liver transplantation was needed. We hope that this preliminary work will lead to further study in the area.
In conclusion, it is evident that patients perceive that sexual problems exist after liver transplantation and that that the liver transplant recipients feel that it is of importance. This area of the liver transplant experience has not been well studied, especially in North America, and is an area that needs to be further explored. Although our study has shed some light on the relationship between liver transplantation and sexual health, further prospective studies, including confirmatory studies using validated instruments and clinical trials with agents that improve posttransplantation sexual function, are needed.