Reproductive Ethics And Antipsychotic Medication
Antipsychotics are the primary medications used to treat Psychotic conditions. These drugs are divided into two classes: Typical and Atypical; or First-Generation and Second-Generation. The primary mechanism of action for Antipsychotics is blocking D2 receptors, which signal Dopamine—though other neurotransmitters may be affected in certain drugs (Bargiota et al, 2013). One side effect of this D2 receptor blockage is the increase in the reproductive hormone Prolactin. Dopamine suppresses Prolactin generation in the pituitary gland, and the loss of Dopamine disinhibits the creation of Prolactin resulting in elevated Prolactin levels, known as Hyperprolactinaemia. (Bargiota et al, 2013). Antipsychotics are not the only medications know to affect Prolactin levels, certain classes of Antidepressants can cause the condition along with some Antihypertensives and Antiemetics (Samperi et al, 2019).
Prolactin is a reproductive hormone, and its elevation can affect reproductive capacity in both natal sexes. In males, elevated Prolactin levels can lead to libido loss and disfunction in spermatogenesis, or the creation of gamete cells (McAllister-Williams et al, 2017). In females, menstrual dysfunction is common, though rates vary by medication. In Typical Antipsychotics, we see 17-91% rate of menstrual changes depending of survey (Bargiota et al, 2013). Atypical Antipsychotic rates vary considerably, with up 48% of patients assigned female reporting Amenorrhea, or loss of the menstrual cycle on Risperidone, to Aripiprazole and Quetiapine being used successfully to regulate a patient’s menstrual cycles. The total incidence on menstrual irregularities and Amenorrhea for patients assigned female taking Antipsychotics in general lies between 15-97% (Bargiota et al, 2013). Not all menstrual difficulties in Psychotic women may be from medication, as disorders like Schizophrenia might have impact on the endocrine system in and of themselves (Bargiota et al, 2013; Yates, 2016).
So, what does all of this mean?
Antipsychotics, while very helpful to some people, are not the panacea that non-Psychotic people often treat them as. The truth is that Psychotic people are often given Antipsychotics under conditions of duress, such as during a forced or coerced hospitalization. Being given medication while held prisoner and then living in fear you will be incarcerated again if you stop taking it is not Informed Consent to treatment. In outpatient, Psychotic people are often pressured by doctors or loved ones to take the medications before they have been fully warned of the risks that come with them. I will not divert into other Antipsychotic side effects here—I have talked and cited plenty on my Instagram—but they are legion and lethal, and we are given little to no education about the facial paralysis and Metabolic Syndrome that might be heading our way. You can’t consent to a treatment if you do not know what the risks are. We are not dogs you need to sneak pills too, we’re adult human beings with body integrity.
If doctors do not discuss Dystonia and Type 2 Diabetes with their patients when prescribing Antipsychotics, they surely do not discuss the loss of fertility. Never did a doctor mention to me that my medication could sterilize me until happened, and suddenly I needed hormone replacements so I wouldn’t develop Endometrial Cancer from lack of Estrogen. It was a very upsetting and disrupting situation, and I had no idea what was happening to my body for a very long time.
Knowing these medications can cause infertility and not discussing it with the patient beforehand is wrong, especially in light of the history of reproductive medicine and Psychotic people in the United States. In the 20th Century, people deemed “Mentally Ill” and “Mentally Deficient” were involuntarily sterilized throughout the United States. In Virginia alone, 7,325 people were sterilized against their will between 1924 and 1979. It should be noted that of particular target were Women of Color, especially after the passage of the Civil Rights Act (Kaelber, 2012). While not equivalent to the forced surgical sterilizations of the 20th Century, some of us do become permanently infertile involuntarily because of these drugs, when we could have been warned and given the choice of another medication/no medication and another treatment. Some people are forced to go through difficult medication switches to get their fertility back. The fact that our reproductive consent is treated so flippantly is what bothers me. I had a functioning organ and now I don’t, and I did not have a say in that.
Treating our fertility as if it doesn’t matter or it is not something we should worry about is incredibly paternalistic. Not all Psychotic people experience severe symptoms forever and with the right support, can be a good parent. Wanting to experience something so basic is perfectly normal. Psychosis is not a terminal illness, it not a family curse that if passed down destroys the child’s life. We are people with our way of viewing the world and interacting with it and our lives are not lesser. If a Psychotic person does pass down their condition, they are in the perfect position to get their child support. Deciding your patient’s life path for them isn’t ethical and isn’t professional, and we need Psychiatrists to treat us as active agents in our own lives.
Psychotic people are people. People sometimes laugh when I say that, but they’re missing the point. Being a person comes with an implied set of rights and privileges, and so often Psychotic people are denied these on account of our Psychosis, and that needs to change. We need reproductive autonomy, and we need it now.
Citations
Bargiota, S. I., Bonotis, K. S., Messinis, I. E., & Angelopoulos, N. V. (2013). The Effects of Antipsychotics on Prolactin Levels and Women's Menstruation. Schizophrenia research and treatment, 2013, 502697. https://doi.org/10.1155/2013/502697
Kaelber, L. (2012). Eugenics: Compulsory Sterilization in 50 American States. Retrieved October 29, 2021, from https://www.uvm.edu/~lkaelber/eugenics/.
McAllister-Williams, R. H., Baldwin, D. S., Cantwell, R., Easter, A., Gilvarry, E., Glover, V., Green, L., Gregoire, A., Howard, L. M., Jones, I., Khalifeh, H., Lingford-Hughes, A., McDonald, E., Micali, N., Pariante, C. M., Peters, L., Roberts, A., Smith, N. C., Taylor, D., Wieck, A., … endorsed by the British Association for Psychopharmacology (2017). British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of psychopharmacology (Oxford, England), 31(5), 519–552. https://doi.org/10.1177/0269881117699361
Samperi, I., Lithgow, K., & Karavitaki, N. (2019). Hyperprolactinaemia. Journal of clinical medicine, 8(12), 2203. https://doi.org/10.3390/jcm8122203
Yates N. J. (2016). Schizophrenia: the role of sleep and circadian rhythms in regulating dopamine and psychosis. Reviews in the neurosciences, 27(7), 669–687. https://doi.org/10.1515/revneuro-2016-0030
