I recently completed some research on sexual dysfunction concerning hypertension and antihypertensive medication. More research is needed to definitively pinpoint the prevalence of sexual dysfunction in relation to the black experience and living with hypertension.

Hypertension

Blood pressure (BP) is commonly described as the ratio of systolic BP (the pressure that the blood exerts on the arterial walls when the heart contracts) and diastolic BP (the pressure when the heart relaxes). Hypertension, also known as high blood pressure, affects about 25% of the world’s population. High blood pressure can lead to many symptoms, including death, by damaging critical organs like the heart, brain, kidney, and blood vessels. Chronic kidney failure is often the result of hypertension, as is hypertensive nephropathy. (Constantino et al., 3146 ). 

The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) updated the hypertension guidelines in 2017 to a healthy systolic blood pressure (SBP) = 130 mm and diastolic blood pressure (DBP) of 80 mm Hg. The previous goals were 140/90 mm Hg. These changes tighten the parameters around a disease that is still out of control globally. 

It is estimated that 1.5 billion people globally will develop hypertension by 2025.(Chockalingam et al., 517) With numbers that large, our country has a crisis that we are nowhere near controlling. 

There haven’t been any large-scale inclusive studies on the effects of sexual function in African Americans while living with this illness. Most of the studies found were small-scale, exclusively white, and not enough perimeters were met to be conclusive. There were zero studies found on hypertension and sexual function that studied the African American experience, even though we are the most affected demographic in this area. 

Even with hypertension being a worldwide issue, African Americans still exhibit a significantly higher chance of developing and, in time, dying from hypertension and hypertension-related complications. The evidence is not clear why we have exceptionally high rates of hypertension, but it likely includes more than just health implications. The risk factors can consist of socioeconomic status, clinical factors, lifestyle choices, environmental factors, and a possible biological predisposition. 

Very little has been devoted to the study of sexual dysfunction in those with vulvas who live with hypertension vs. erectile dysfunction, which tracks with the history of most medical research. There was still some exciting information found in the studies that were conducted. 

African Americans

African Americans in the United States develop hypertension at an earlier age than their white counterparts. They also have a greater likelihood of refractory hypertension, higher average blood pressure readings, and greater rates of premature hypertensive complications such as CKD, stroke, and heart disease. (Williams, 879)  

Many factors build the framework of these statistics, but a genuine distrust of the medical community cannot be downplayed. African Americans were legally used as medical subjects at one point in history under the premise that black patients would not feel pain in the same ways as nonblack patients. This false narrative still plagues the medical system in most established countries, even in 2022. Medical policies and procedures are still being dictated by incorrect and antiquated medical falsehoods all around the globe. 

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These “medical facts” built the healthcare framework, and it continues to paint black people as this superhuman mongrel that doesn’t feel pain, therefore, doesn’t require the same quality care as other nonblack patients. In an exploratory study on trust in healthcare institutions, they found black people were most worried about 1. discriminatory practices based on race or socioeconomic status and 2. government experimentation. (Jacobs et al.,92) in contrast to their non-black counterparts, who could not relate. 

One of the continued medical conundrums surrounding hypertension is the high prevalence of salt sensitivity among African Americans. One study in 1991 came up with an interesting explanation. The study hypothesized; 

“The published historical evidence on the transatlantic slave trade and New World slavery (from the 16th century to the 19th century) reveals that conditions existed for “natural selection,” and therefore, genetic changes were virtually inevitable in the slave populations. During this period of history, mortality was extremely high, and fertility (or reproductive success) was so low among the survivors that most plantation societies in the western hemisphere depended on a constant importation of captives (over 12 million) from Africa for the viability of the plantation communities. Because the major causes of death were salt-depletive diseases such as diarrhea, fevers, and vomiting, it is argued that individuals with an enhanced genetic-based ability to conserve salt had a distinct survival advantage over others and were, therefore, more likely to bequeath their genotype to subsequent generations of Western hemisphere blacks. Thus, it is predicted that blacks in the Americas have a greater frequency of individuals with an enhanced genetic-based ability to conserve salt than African blacks.” (Wilson et al.,122-128)

Another study on 300 city-dwelling South Africans did not render the same high levels of salt sensitivity as African Americans (Maseko et al.,186), theorizing that biology may be a possible factor in the higher rates of hypertension in our communities. The theory here is that the slave trade caused an accelerated mutation in gene selection among the descendants of enslaved people. Unfortunately, this was not the purpose of the Maseko study, so more research is needed to support this theory.

Sexual Function

Sexual dysfunction is commonly observed in hypertensive patients. The effect of hypertension on the vascular system and neural component of the genitalia may cause a reduction in blood flow (in the penis or clitoris) and mucus secretions of the vagina, subsequently leading to sexual dysfunction. (Latif et al., S7)  

The data for sexual function all comes from very small-scale studies. The people frequently left out/not specified in the studies were post-menopausal, Black American women and Black American men. No studies included non-binary or gender-neutral participants as a study group. Class was not a factor in any of the studies researched, but the access to partake in a healthcare study indicates some form of privilege. More overall research is needed to assess sexual dysfunction in hypertensive patients. 

Assigned Female at Birth studies

A study of 54 hypertensives and 54 normotensive patients found that 63% of hypertensive patients reported sexual dysfunction, as opposed to 39% of normotensive patients. Hypertensive patients had 1.67 more chances of sexual dysfunction than those with normal blood pressure. (Lunelli et al., 2477)

Sexual dysfunction in hypertensive not only effects the vaginal mucosa and lubrication, but also affects the sexual response cycle. 

A study of 150 women using a (very binary) female sexual function index (FSFI) found that:

• 68.2% reported a desire disorder
• 68.2% reported an excitement disorder
• 41.1% reported a lubrication disorder
• 66.4% reported a satisfaction disorder
• 56.1% reported pain during sex
• 55.4% reported an orgasm disorder

(Nascimento et al., 96)

Hypertensive patients showed lower vaginal lubrication, less frequent orgasms, and more frequent pain during sex than normotensive patients. (Duncan et al., 640)

None of these tests specifically center on the study of Black American vulva owners and the effect of hypertension on sexual function.

Assigned Male at Birth studies

It is estimated that some degree of erectile dysfunction affects 150 million patients worldwide. The prevalence of erectile dysfunction is two-fold higher in hypertensive patients assigned male at birth compared to normotensive patients. (Viigimaa et al., 908) 

Even when you account for age, hypertension still increases the chances of experiencing erectile dysfunction (Bansel., 1.) Many of the studies surrounding sexual function in those assigned male at birth expressly focus on the antihypertensive drugs prescribed. Very little is studied on how or why the dysfunction occurs or the effects on the body. It turns out the pharmacotherapy chapter of this tale has a secret of its own.

Antihypertensive drugs

Research showed hypertensive medications had a negative effect on sexual function in both men and women. Increased sexual dysfunction was reported in those undergoing treatment for hypertension, as opposed to those with uncontrolled and untreated hypertension. This phenomenon is repeated with studies of both binary sexes.

African Americans usually require two or more medications to control hypertension (Williams et al., 878), which leaves much more room for adverse effects. 

Older drugs seem to have worse sexual functioning side effects. Antihypertensive medications, particularly beta-blockers and diuretics, are associated with an increased risk of sexual dysfunction. (Latif et al., S11)

In a study of 14, 897 people with hypertension, 21.6% of patients reported sexual dysfunction in the beta-blocker group and only 17.4% in the placebo group. (Ko., 1012)

Beta-blockers interact directly with the hormones, which may confuse the brain during the sexual response cycle.

Diuretics, mainly those in the thiazide family, are most commonly prescribed to treat hypertension. They are cost-effective drugs, but diuretics present unwanted sexual side effects, notably reduced libido and vaginal lubrication. (Latif et al., S11)

It has been proposed that diuretics interfere with the smooth muscle relaxation and provoke a decreased response to certain chemicals, which may reduce sexual arousal and desire. The medication also has an adverse effect on lubrication. 

Fugari found that those prescribed calcium-channel blockers, angiotensin-converting enzyme inhibitors (ACEI), and angiotensin receptor blockers (ARB) have less interaction with the hormones, and patients experience fewer problems with sexual dysfunction. (Fugari et al., 177) Some medicines even support a positive effect over baseline studies, showing that some hypertensive medications could increase sexual function.

American-based studies are primarily centered around white, pre-menopausal women, as with many medical studies.

One study of 159 male Nigerian patients showed a different outcome to their research. In this study of men aged 39-98 years old, they found:

• 21.1% reported sexual dysfunction on calcium channel blockers 
• 17.0% reported sexual dysfunction on diuretics
• 12.6% reported sexual dysfunction on ACEI

In this case study, calcium blockers had the most instances of reported sexual dysfunction. (Akinyede et al., 6)

Conclusion

The data collected on sexual dysfunction needs more dedicated research to understand hypertension in African Americans and treatment options that do not impair sexual function. Sexual dysfunction is one of the leading causes of medical non·​adherence, even if patients are too scared to discuss it with their doctor. Decreased trust in the medical field and other socioeconomic factors could contribute to the lack of research within the African American population surrounding this subject. Hypertension disproportionately affects black folk, so it only stands to reason that we may be experiencing sexual dysfunction at rates higher than other Americans. Additional steps must be taken to improve the quality of life for those at the highest risk of experiencing sexual dysfunction due to this illness. 

Bibliography

1. Chockalingam A. (2007). Impact of World Hypertension Day. The Canadian journal of cardiology, 23(7), 517–519. https://doi.org/10.1016/s0828-282x(07)70795-x
2. Costantino,V.V.;Gil Lorenzo, A.F.; Bocanegra, V.; Vallés, P.G. Molecular Mechanisms of Hypertensive Nephropathy: Renoprotective Effect of Losartan through Hsp70. Cells 2021, 10, 3146. https://doi.org/10.3390/ cells10113146
3. Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature reviews. Disease primers, 4, 18014. https://doi.org/10.1038/nrdp.2018.14
4. Sandberg, K., & Ji, H. (2012). Sex differences in primary hypertension. Biology of sex differences, 3(1), 7. https://doi.org/10.1186/2042-6410-3-7
5. Wilson, T. W., & Grim, C. E. (1991). Biohistory of slavery and blood pressure differences in blacks today. A hypothesis. Hypertension (Dallas, Tex. : 1979), 17(1 Suppl), I122–I128. https://doi.org/10.1161/01.hyp.17.1_suppl.i122
6. Maseko, M. J., Majane, H. O., Milne, J., Norton, G. R., & Woodiwiss, A. J. (2006). Salt intake in an urban, developing South African community. Cardiovascular journal of South Africa : official journal for Southern Africa Cardiac Society [and] South African Society of Cardiac Practitioners, 17(4), 186–191.
7. Alidu, H., Owiredu, W. K. B. A., Amidu, N., Gyasi-Sarpong, C. K., Dapare, P. P. M., Bawah, A. T., Obirikorang, C., & Luuse, A. T. (2018). Hypertension and obesity comorbidities increases coronary risk, affects domains of sexual function and sexual quality of life. International journal of impotence research, 30(1), 8–13. https://doi.org/10.1038/s41443-017-0003-5
8. Latif, R. A., Muhamad, R., Ann, A. Y., Sidi, H., Nik Jaafar, N. R., Midin, M., Das, S., Seng, L. H., & Guan, N. C. (2014). Duration of hypertension and antihypertensive agents in correlation with the phases of female sexual response cycle. Comprehensive psychiatry, 55 Suppl 1, S7–S12. https://doi.org/10.1016/j.comppsych.2012.10.008
9. Manolis, A., & Doumas, M. (2012). Antihypertensive treatment and sexual dysfunction. Current hypertension reports, 14(4), 285–292. https://doi.org/10.1007/s11906-012-0276-5
10. Lunelli, R. P., Irigoyen, M. C., & Goldmeier, S. (2018). Hypertension as a risk factor for female sexual dysfunction: cross-sectional study. Revista brasileira de enfermagem, 71(5), 2477–2482. https://doi.org/10.1590/0034-7167-2017-0259
11. Doumas, M., Tsiodras, S., Tsakiris, A., Douma, S., Chounta, A., Papadopoulos, A., Kanellakopoulou, K., & Giamarellou, H. (2006). Female sexual dysfunction in essential hypertension: a common problem being uncovered. Journal of hypertension, 24(12), 2387–2392. https://doi.org/10.1097/01.hjh.0000251898.40002.5b
12. Duncan, L. E., Lewis, C., Jenkins, P., & Pearson, T. A. (2000). Does hypertension and its pharmacotherapy affect the quality of sexual function in women?. American journal of hypertension, 13(6 Pt 1), 640–647. https://doi.org/10.1016/s0895-7061(99)00288-5
13. Zhong, Q., & Anderson, Y. (2022). Management of Hypertension with Female Sexual Dysfunction. Medicina (Kaunas, Lithuania), 58(5), 637. https://doi.org/10.3390/medicina58050637
14. Viigimaa, M., Vlachopoulos, C., Lazaridis, A., & Doumas, M. (2014). Management of erectile dysfunction in hypertension: Tips and tricks. World journal of cardiology, 6(9), 908–915. https://doi.org/10.4330/wjc.v6.i9.908
15. Bansal, S. (1988). Sexual Dysfunction in Hypertensive Men A Critical Review of the Literature. Hypertension, 12, 1–10.
16. Williams, S. F., Nicholas, S. B., Vaziri, N. D., & Norris, K. C. (2014). African Americans, hypertension and the renin angiotensin system. World journal of cardiology, 6(9), 878–889. https://doi.org/10.4330/wjc.v6.i9.878
17. Ko, D. T., Hebert, P. R., Coffey, C. S., Sedrakyan, A., Curtis, J. P., & Krumholz, H. M. (2002). Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction. JAMA, 288(3), 351–357. https://doi.org/10.1001/jama.288.3.351
18. Fogari, R., Preti, P., Derosa, G., Marasi, G., Zoppi, A., Rinaldi, A., & Mugellini, A. (2002). Effect of antihypertensive treatment with valsartan or atenolol on sexual activity and plasma testosterone in hypertensive men. European journal of clinical pharmacology, 58(3), 177–180. https://doi.org/10.1007/s00228-002-0456-3
19. Akinyede, A. A., Nwaiwu, O., Fasipe, O. J., Olusanya, A., Olayemi, S. O., & Akande, B. (2020). A prospective   study of the effect of antihypertensive medications on the sexual functions of hypertensive adult male patients. Future science OA, 6(6), FSO479. https://doi.org/10.2144/fsoa-2020-0030