Journal of Gerontological Nursing

CNE Article 

Sexuality and Chronic Illness

Elaine E. Steinke, PhD, APRN, CNS-BC, FAHA, FAAN

Abstract

How to Obtain Contact Hours by Reading this Article
Instructions

1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564.

To obtain contact hours you must:

1. Read the article, “Sexuality and Chronic Illness” found on pages 18–27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until October 31, 2015.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objectives

1. Identify the sexual concerns and counseling needs of those with a chronic disease diagnosis related to cardiovascular conditions, pulmonary disorders, and cancer.

2. Describe at least four specific sexual counseling strategies and two psychological concerns of patients and/or partners regarding sexuality.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice. [Journal of Gerontological Nursing, 39(11), 18–27.]

Dr. Steinke is Professor of Nursing, School of Nursing, Wichita State University, Wichita, Kansas.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Elaine E. Steinke, PhD, APRN, CNS-BC, FAHA, FAAN, Professor of Nursing, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260-0041; e-mail: Elaine.Steinke@wichita.edu.

Received: June 05, 2013
Accepted: August 15, 2013
Posted Online: September 24, 2013

Do you want to Participate in the CNE activity?

Abstract

How to Obtain Contact Hours by Reading this Article
Instructions

1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at https://villanova.gosignmeup.com/dev_students.asp?action=browse&main=Nursing+Journals&misc=564.

To obtain contact hours you must:

1. Read the article, “Sexuality and Chronic Illness” found on pages 18–27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until October 31, 2015.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Activity Objectives

1. Identify the sexual concerns and counseling needs of those with a chronic disease diagnosis related to cardiovascular conditions, pulmonary disorders, and cancer.

2. Describe at least four specific sexual counseling strategies and two psychological concerns of patients and/or partners regarding sexuality.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice. [Journal of Gerontological Nursing, 39(11), 18–27.]

Dr. Steinke is Professor of Nursing, School of Nursing, Wichita State University, Wichita, Kansas.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Elaine E. Steinke, PhD, APRN, CNS-BC, FAHA, FAAN, Professor of Nursing, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260-0041; e-mail: Elaine.Steinke@wichita.edu.

Received: June 05, 2013
Accepted: August 15, 2013
Posted Online: September 24, 2013

Do you want to Participate in the CNE activity?

Chronic illness presents both physical and psychological challenges to those affected by one or more conditions. Maintaining sexual health and sexual intimacy is important for many individuals with chronic conditions. Physical capacity for sexual activity may be affected by illness, with psychological factors such as anxiety and depression playing a substantial role. Nurses must assume that older adults and those with chronic conditions are sexually active, as many are able to maintain sexual capacity well into old age. One study reported that both men and women believe that sexuality is a lifelong need—88% and 81%, respectively—and sexuality can be beneficial (Penhollow, Young, & Denny, 2009). For women, important predictors of sexual intercourse in this study were sexual self-confidence and social activity, whereas for men, sexual self-confidence, health status, and sexual desire were important. The concerns and sexual counseling needs of partners must be considered as well, as partners often have substantial concerns. This article will focus on sexual concerns and counseling needs of those with chronic conditions in the areas of cardiovascular, pulmonary, and cancer, all commonly occurring conditions and ones for which strategies to guide counseling are available.

Cardiovascular Conditions

General Counseling Strategies

There are several general sexual counseling strategies applicable to patients with cardiovascular conditions. Patients view these suggestions as helpful in considering how to resume sexual activity, going beyond advice on when sexual activity can be safely resumed. This is an important consideration given that patients and their partners often have considerable anxiety and fear in resuming sexual activity. Nurses are ideally suited to address not only the psychological needs of the patient, but to integrate a variety of strategies in patient education and counseling to promote sexual health and successful return to sexual activity. The discussion points in Table 1 are supported with evidence-based cardiac literature that also may be widely applicable to patients with other chronic conditions. It is important to address these general strategies with all patients with cardiovascular disease (CVD) and their partners, and to follow general counseling with more specific strategies that are individualized to the patient’s diagnosis and physical condition.

General Strategies for Sexual Counseling

Table 1:

General Strategies for Sexual Counseling

Sexual Activity Recommendations

The importance of discussing sexual issues with patients diagnosed with CVD and their partners was reinforced by a scientific statement from the American Heart Association on sexual activity and CVD (Levine et al., 2012). Counseling patients regarding when to resume sexual activity as defined in this statement, and strategies for how to resume sexual activity, as discussed in a second scientific statement (Steinke et al., 2013), are key components for nurses and other providers to address. In addition, the safety of sexual activity must be considered based on individual patient diagnoses and cardiac risk factors. Patients and partners often express concerns regarding whether sexual activity will overstress the heart, and they may “give up” sex rather than risk another cardiac event. It is helpful to remind patients that their heart rate and blood pressure normally increase with sexual activity, and these increases are generally mild to moderate, for short durations of time, with a rapid return to baseline post-orgasm. Sexual activity with the usual partner expends 3 to 4 metabolic equivalents (METS), which is similar to climbing two flights of stairs or walking briskly (Levine et al., 2012). In those who are older or less physically fit, mild to moderate physical activity is thought to be equivalent of 3 to 5 METS. This becomes important in assessing risk, as for those who can achieve 3 to 5 METS during exercise testing without ischemia, the risks for ischemia with sexual activity are low. The risk for myocardial infarction (MI) with sexual activity in general is low, accounting for less than 1% of all acute MIs (Muller, Mittleman, Maclure, Sherwood, & Tofler, 1996). Individuals who are physically active are at lower risk for MI with sexual activity as compared to sedentary individuals (Möller et al., 2001). Thus, cardiac rehabilitation and regular exercise provide a gauge to monitor symptoms and evaluate cardiovascular risk related to sexual activity (Levine et al., 2012).

The ability to engage in sexual activity depends on the individual’s physical condition, severity of any symptoms, and evidence-based recommendations for return to sexual activity. Table 2 highlights typical recommendations regarding sexual activity, although variations may exist depending on assessment of the individual, diagnostic testing, and disease staging, such as class of heart failure (HF). Conditions that are most relevant to older adults with CVD are listed. In patients for whom the level of risk is unclear, those with multiple CVD risk factors—and the presence of multiple symptoms—these are indicators that the patient should undergo exercise testing and additional diagnostic tests before safety of sexual activity can be determined. Although these guidelines focus primarily on sexual intercourse, other activities such as kissing, hugging, fondling, and masturbation may be engaged in by the couple, and can help gauge tolerance for sexual intercourse, or used when the patient is unable to engage in sexual intercourse (Steinke & Jaarsma, 2008). Recommendations for stroke are highly dependent on the physical, cognitive, and psychological condition of the patient; thus, a specific recommendation regarding return to sexual activity depends on assessment findings. Stroke patients report the need for sexuality to be addressed before hospital discharge or early in rehabilitation (Schmitz & Finkelstein, 2010).

Recommendations for Returning to Sexual Activity With Cardiovascular Disease

Table 2:

Recommendations for Returning to Sexual Activity With Cardiovascular Disease

Specific Counseling by Cardiac Condition

There are additional considerations for sexual counseling that are specific to each cardiovascular condition (Table 3). For example, in discussing positions for sexual activity to minimize strain on the heart for those post-coronary artery bypass grafting surgery (CABG), it is important to discuss avoiding strain on the incision and the use of a position of comfort. For those with HF, positions that minimize dyspnea and require less effort help decrease symptoms. Thus, tailoring counseling to the individual patient, his or her current level of sexual activity or desire to be sexually active, and the capacity for sexual activity considering cardiovascular risks and the individual cardiac condition are key aspects to address.

Specific Sexual Counseling by Cardiovascular ConditionSpecific Sexual Counseling by Cardiovascular Condition

Table 3:

Specific Sexual Counseling by Cardiovascular Condition

Individuals who experience a stroke often face unique challenges, such as communication difficulties from dysphagia, physical deficits post-stroke, sexual dysfunction, depression, and multiple comorbidities and medications, contributing to decline in sexual frequency and satisfaction, as well as feelings of unattractiveness (Kautz, Van Horn, & Moore, 2009). Couples may compensate for these changes by increased touching and hugging (National Stroke Association, 2006). Similar to patients with other cardiovascular conditions, fear of another stroke during sexual activity has been reported, although unlikely (Schmitz & Finkelstein, 2010; Song, Oh, Kim, & Seo, 2011). Finding a comfortable position for sexual activity can be difficult, particularly if hemiparesis is present. In addition, there may be concerns about the stroke survivor’s ability to consent to sexual activity if cognitive and language impairments are present (Kautz, 2007).

Psychological Concerns

In addition to physical concerns, psychological concerns of cardiac patients are well known and may impact both sexual desire and sexual activity. Anxiety and fear regarding sexual activity are prominent among those with MI and after an implantable cardioverter defibrillator (ICD) (Vasquez, Sears, Shea, & Vasquez, 2010). For those with MI, there is fear of causing another MI (Mosack & Steinke, 2009), although the risk is low, and anxiety has been shown to contribute to lowered sexual satisfaction in those with MI (Steinke & Wright, 2006). Patients with ICD are often fearful about the ICD discharging with sexual activity, and if this does occur, what action should be taken (Steinke, 2003; Steinke, Gill-Hopple, Valdez, & Wooster, 2005; Zayac & Finch, 2009). For MI, ICD, and HF, patients and partners frequently report overprotectiveness by the partner, which contribute to distress of the cardiac patient (Jaarsma, Steinke, & Gianotten, 2010; Medina et al., 2009; Mosack & Steinke, 2009; Steinke, 2003). Stroke patients may describe a sense of loss due to functional changes from the stroke that impact sexuality, leading to frustration, fear, isolation, and lack of confidence (Schmitz & Finkelstein, 2010). In addition, partners often report considerable anxiety and concerns regarding sexual activity (Steinke et al., 2005) and often struggle with the role of caregiver versus sexual partner (Thompson & Walker, 2011).

Depression can affect level of desire, problems with arousal and orgasm, erectile dysfunction (ED) in men, and dyspareunia in women (Levine et al., 2012). In one study, HF patients who were sexually active had lower depression scores, although sexual satisfaction scores were low in those who were depressed (Mosack et al., 2011). The use of antidepressant agents did not negatively affect sexual satisfaction. This is an important point, as antidepressant therapy has been linked with sexual dysfunction, and the authors suggest that the use of brief antidepressant therapy might enhance sexual function.

Chronic Pulmonary Conditions

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) does not directly contribute to sexual dysfunction, but symptoms can indirectly affect sexual function. Symptoms such as exertional dyspnea, activity intolerance, coughing, decreased energy, and stamina often play a role in both sexual interest and the capacity for sexual activity (Steinke, 2005). In addition, anxiety and fear about dyspnea and overexertion may make sexual encounters stressful and diminish both enjoyment and feelings of sexual satisfaction (Hahn, 1989). Open and honest communication between the couple about sexual needs and concerns is critical for a satisfying sexual relationship. This is important, as adaptations are made to deal with patient symptoms or changes in usual patterns of sexual activity.

Patients with COPD and those using long-term oxygen therapy reported significantly lower satisfaction with sexual life when compared to healthy individuals (Sturesson & Bränholm, 2000). In COPD patients with subsequent lung transplantation, patients looked forward to resumption of their sexual life and had sexual desire. However, continued reduction of breathing capacity, as well as partner fears, were limitations to sexual activity (Thomsen & Jensen, 2009). Although sexual interest may be maintained, the ability to be sexually active may be limited by the disease process, medications, partner availability, and other factors. The inclusion of sexual counseling in pulmonary rehabilitation programs is important to not only assess sexual concerns, but to determine fitness and safety of sexual activity.

Strategies for Sexual Counseling with COPD. An important consideration regarding readiness for sexual activity is assessing exercise capacity. Nurses can observe the degree of dyspnea as the patient engages in exertional activities, such as brisk walking or climbing stairs, to help determine exercise tolerance (Hahn, 1989). The nurse might open discussion with, “I’ve noticed that you seem to run out of breath walking up and down the stairs. Because sexual activity takes about the same amount of air, I’m wondering if you’re experiencing changes in your sexual activity that you’d like to talk about, too” (p. 192). The COPD patient may be reluctant to participate in certain sexual activities, for example, providing oral sex to the partner, as it might limit adequate breathing, but the patient may be interested in being the receiver of oral sex (Hahn, 1989). Although these are sensitive topics for the nurse to address, they are important considerations as the couple tries different techniques to maintain a satisfactory sexual relationship. It is critical that patients and partners have open and ongoing communication regarding what sexual activities they find pleasurable and those activities that either cause symptoms or increase anxiety. Trying different adaptations for positioning that are both satisfying and acceptable for both partners is essential to achieve sexual satisfaction. For example, the male COPD patient in the superior position may be too strenuous and may produce dyspnea or bronchospasms (Rabinowitz & Florian, 1992); trying a side-lying or semi-reclining position may be beneficial. The partner should avoid putting pressure on the COPD partner’s chest. In addition, the use of sex aids, such as a vibrator, can reduce energy expenditure (Law, 1987). Optimal management with appropriate therapies such as bronchodilators or other prescribed treatments is an important consideration (Table 4).

Sexual Counseling Strategies for COPD

Table 4:

Sexual Counseling Strategies for COPD

Obstructive Sleep Apnea

The relationship between obstructive sleep apnea (OSA) and sexual dysfunction has recently received attention in the literature. Although less studied, a high prevalence (52%) of female sexual dysfunction in OSA has been noted when compared to controls, particularly for arousal, lubrication, orgasm, satisfaction, and pain (Subramanian et al., 2010). The patho-physiology of sexual dysfunction for women with OSA is multifactorial and has been associated with endothelial dysfunction, abnormal levels of testosterone, low progesterone, altered mood, and lower quality of life. OSA is increasingly recognized as a contributing factor to ED in men, and is thought to be mediated by vascular, hormonal, neural, and psychogenic mechanisms (Zias, Bezwada, Gilman, & Chroneou, 2009). In one study, ED occurred in two thirds of men with OSA, and the severity of OSA was linked with greater risk of ED and overall sexual dysfunction (Budweiser et al., 2009). Treatment with continuous positive airway pressure (CPAP) and phosphodiesterase-5 (PDE5) inhibitors (e.g., sildenafil [Viagra®, Revatio®] and tadalafil [Cialis®]), particularly in combination with CPAP, have shown some success, although PDE5 inhibitors can have both positive and adverse effects on airway function. Thus, the use of PDE5 inhibitors in men with COPD must carefully consider benefits versus risks. Testosterone replacement therapy has also shown negative effects on OSA (Zias et al., 2009). The most important consideration is thorough assessment for both OSA and ED, including physical effects and the impact on quality of life. In addition, both ED and OSA are linked with CVD, putting the individual at increased risk of adverse events. Treatment of ED in the presence of OSA requires careful and individualized evaluation. Nurses can play a key role in identifying these risk factors and advocate for patients through referrals to appropriate health care providers.

Cancer

Cancer and its treatment are commonly associated with changes in sexual function. In a study of men and women with various cancers, 37.5% no longer engaged in sexual activity after their diagnosis, and changes in sexual desire, sexual satisfaction, and frequency of sexual activity occurred for the majority of patients (82% to 85%) (Eker & Acikgoz, 2011). Most cancer patients report not receiving information from health care providers on potential sexual problems, although rated by patients as important (Eker & Acikgoz, 2011; Flynn et al., 2012). Sexual problems experienced by breast cancer survivors include decreased sexual frequency, response, and satisfaction (Jun et al., 2011; Ussher, Perz, & Gilbert, 2012). Reasons for these changes were fatigue, pain, changes in body image, emotional distress, and medically induced menopausal changes such as hot flashes, vaginal dryness, and weight gain (Ussher et al., 2012). In sexually active women, decreased sexual frequency and sexual pleasure and higher sexual discomfort were associated with feelings of emotional separation from the partner, partner fear of intercourse, decreased emotional functioning, age older than 50, and symptoms of nausea or insomnia (Bredart et al., 2011).

Gynecological cancer significantly impacts body image, sexual esteem, views of womanhood, and sexual functioning, changes in sexual desire, arousal, orgasm, and frequency of sexual intercourse (Bal, Yilmaz, & Beji, 2013; Cleary, Hegarty, & McCarthy, 2011; Oskay, Beji, Bal, & Yilmaz, 2011). Treatments such as surgery, chemotherapy, and radiation affect self-image (e.g., views of no longer being a woman, hair loss, scarring from surgery). The loss of sexual desire is often distressing to both the woman and her partner. Surgical intervention can cause damage to nerves that impair orgasmic ability, and women frequently describe vaginal dryness and painful intercourse as changes in sexual function (Bal et al., 2013; Cleary et al., 2011). The frequency of sexual intercourse, overall sexual functioning, and both the frequency of the woman and her partner initiating sexual activity have been reported to decline in one study, whereas the need for intimacy such as desire to be held, touched, or stroked increased for some women (Cleary et al., 2011). In contrast, survivors of cervical cancer (mean age = 52) report being sexually active, with stronger desire, sexual enjoyment, and less negative effects on the sexual relationship that persisted over time (Greenwald & McCorkle, 2008).

For men, prostate cancer is viewed as a devastating diagnosis and treatment for localized prostate cancer often includes surgery and radiotherapy, contributing to ED, changes in sexual frequency, decreased sexual desire, orgasmic problems, and low sexual satisfaction (Bober & Varela, 2012; Letts, Tamlyn, & Byers, 2010). Men may be unable to have a full erection without assistive devices, and erectile ability is often insufficient for sexual intercourse, although orgasmic ability may be present for some. Of note, men may hold the view that they do not need to discuss sexual concerns or abilities with their partner, believing that sexual problems relate to them alone, reluctance to share their feelings, and feeling isolated regarding the sexual difficulties with prostate cancer (Letts et al., 2010). In addition, lack of communication and information by physicians add to men’s distress.

The concept of coping flexibility has emerged recently as a framework for challenging the impact of cancer on one’s beliefs about sexuality, specifically in regard to sexual intercourse as the only acceptable sexual activity. Broadening ideas and behaviors related to sexual activity, including the overlapping areas of sexual intercourse, non-intercourse sexual activities, and non-sexually intimate activities, can improve sexual satisfaction and the couple’s sexual relationship (Reese, 2011). Key elements for discussing sexual concerns for men and women are shown in Table 5. Although this brief overview of cancer focused primarily on gynecological and prostate cancer, many of these strategies are applicable to other cancers.

Sexual Counseling Strategies for Cancer

Table 5:

Sexual Counseling Strategies for Cancer

Implications and Conclusion

Nurses have tremendous opportunities to positively affect the sexual health of individuals with chronic illness. Not only are nurses a trusted source of information, their holistic view of meeting both psychological and physical needs of patients is well suited to be inclusive of sexuality. This article provides practical approaches to facilitate these interactions between nurses, patients, and partners. Using clear, open, and honest communication is essential to meet the sexual quality of life needs for those with chronic illness. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice.

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General Strategies for Sexual Counseling

• Conduct a brief sexual assessment addressing concerns about resuming sexual activity by the patient and partner, current level of sexual activity or desire to be sexually active, the importance of sex in the relationship, and health problems and medications that might affect sexual activity. This can be followed with a more detailed assessment if needed.
• Encourage open and honest communication between the patient and partner regarding sexual needs and concerns, while emphasizing it is normal to have concerns.
• Suggest that the couple engage in physical activity together (e.g., a daily walk to enhance physical endurance and promote intimacy).
• Discuss sexual activity in the context of exercise. It is helpful for the couple to know that the effort required for sexual activity is similar to that of moderate physical activity.
• Discuss being well rested and relaxed at the time of sexual activity, avoiding unfamiliar surroundings or partners to decrease any stress with sexual activity.
• Suggest avoiding heavy meals or alcohol for at least 1 hour prior to sexual activity to avoid symptoms such as chest pain, as blood is diverted for digestion.
• Encourage the patient to report warning signs with sexual activity, such as shortness of breath, chest pain, rapid or irregular heart rate, dizziness, extreme fatigue the day after sexual activity, insomnia, or dizziness.
• Discuss patient medications and evaluate any sexual side effects experienced, while encouraging the patient to not stop medications suddenly and to contact his or her health care provider. A dosage or change of medication may be all that is required.

Recommendations for Returning to Sexual Activity With Cardiovascular Disease

Condition Recommended Return to Sexual Activity Considerations
Angina Depends on stability Mild, stable angina—low risk; unstable, refractory angina—high risk, exercise testing recommended
Previous MI 1 to 4 weeks Asymptomatic with mild to moderate physical activity; no ischemia with exercise testing; successful coronary revascularization
Percutaneous coronary intervention (PCI) Several days post-PCI Those with PCI using radial access may be able to resume sexual activity more quickly than those with femoral access. If a vascular complication is suspected, further evaluation is needed before resuming sexual activity.
Post-CABG or non-coronary open heart procedures 6 to 8 weeks post-CABG; in cases of minimally invasive procedures, may resume sex sooner Avoid undue pressure or stress on sternal incision.
Heart failure Depends on NYHA Class and decompensation NYHA Class I or II can generally engage in sexual activity; in cases of decompensated HF or NYHA Class III or IV, sexual activity is not advised until stabilized with effective medical management.
Valvular heart disease Surgical repair—6 to 8 weeks; minimally invasive procedures— may resume sooner Sexual activity can be resumed for those with mild to moderate valvular disease with no or mild symptoms, and for repaired valves or valvular replacement. Those with severe valvular disease and significant symptoms should avoid sexual activity until optimally managed. Exercise testing may be required.
Pacemaker, ICDs Generally safe post-procedure for pacemakers and ICDs implanted for primary prevention Avoid strain or direct pressure on implanted device/incision; patients with ICDs for secondary prevention should be able to engage in moderate physical activity (3 to 5 METS) without ventricular tachycardia or fibrillation, and frequent inappropriate shocks. Those with poorly controlled arrhythmias should not engage in sexual activity until the condition is well managed.

Specific Sexual Counseling by Cardiovascular Condition

Condition Discussion Points Rationale
MI Those able to engage in mild to moderate physical activity (3 to 5 METS) without symptoms can generally resume sexual activity. Building overall physical endurance is similar in effort required for sexual activity.
Those with a complicated MI may need to resume sexual activity gradually over a longer period of time. A complicated MI includes those requiring CPR, hypotension, serious arrhythmias, or heart failure.
Use a position that allows unrestricted breathing. To minimize shortness of breath, chest pain, or other symptoms.
Stop and rest if chest pain is experienced, take nitroglycerine (if prescribed), and seek emergency treatment for sustained chest pain. Angina symptoms may occur and may subside with rest or nitroglycerine, but sustained symptoms should be considered an emergent condition.
Avoid anal sex and illicit drug use such as stimulants or cocaine. Anal sex can induce chest pain from pressure on the vagal nerve; illicit drug use has been linked to chest pain and fatal MIs.
CABG Avoid positions that put strain on the sternal incision or cause discomfort. Reassure patients/partners that it is unlikely they would harm the sternum. Strain on the incision may compromise wound healing.
A mild pain reliever before sexual activity may minimize discomfort. Incisional pain is usually described as a dull ache, different from angina pain.
The use of pillows to support the chest may be useful. Avoid strain on incisions.
Some women have described breast discomfort; try position of comfort, pillows for support, pain reliever if needed. Breast sensations reported include shooting pain to breasts, numbness, tingling, and heaviness.
HF Use positions that allow easier breathing, such as semi-reclining or those requiring less effort such as on-bottom positions. Positioning can help minimize symptoms and decrease physical effort required for sexual activity.
If shortness of breath occurs, stop and rest. Allows time for the episode to subside and the patient to determine if he or she wants to proceed with sexual activity.
Take prescribed diuretic agents at time that will not interfere with sexual activity. Frequent urination from a diuretic agent may interfere with sexual intimacy.
Use of sexual foreplay to help determine tolerance for sexual activity. Foreplay with hugging, kissing, fondling, masturbation requires less exertion and is useful to determine tolerance for sexual intercourse.
Sexual intercourse may not be possible with HF exacerbations or those with NYHA Class III or IV HF The safety of sexual intercourse with HF exacerbations must be assessed.
ICD Avoid pressure or strain on the ICD implantation site. There are few limitations on sexual activity, particularly when the incision is well healed.
Discuss patient/partner fears related to the ICD firing during sexual activity; the partner will not be injured if ICD fires. Patients and partners need to be informed that the ICD could fire with sex, although uncommon.
If the ICD fires with sexual activity, report it to health care provider. A change in device settings may be needed.
Stroke Begin with activities such as kissing, touching, and hugging. Familiar activities are less stressful and can increase confidence in resuming sex.
For problems controlling the bladder or bowel, go to the bathroom prior to sexual activity; avoid positions that put pressure on the bladder. Minimize discomfort and embarrassment from incontinence.
Explore body for areas of greater sensitivity or pain, and gentle touch on the side of the body that lacks feeling. Changes post-stroke may necessitate determining what feels pleasurable versus uncomfortable.
Use pillows to provide support, for example in a side-lying position. The patient may need to try several positions to find what works best. Pillows provide support and can assist with adaptations in positioning.
If sexual intercourse is too difficult, try other activities such as hugging, massage, oral sex, or masturbation. Couples may find some activities less stressful or helpful to build confidence in engaging in sexual intercourse, when possible.

Sexual Counseling Strategies for COPD

Discussion Points Rationale
Plan sexual activity when energy level is highest and when well rested. Use soothing music, lighting, and relaxation exercises to promote relaxation and set the mood for sexual activity. Minimizes fatigue and enhances ability to successfully engage in sexual activity.
Use of controlled breathing techniques and low-level physical exercises. Avoid physical exertion prior to sexual activity. It may be important for the couple to remember that increased breathlessness is normal during sex, so unless this is bothersome or other symptoms are experienced, this is normal. Help build breathing capacity and tolerance for breathing with exercise and sexual activity. Increased physical fitness tends to improve sexual desire.
Plan sexual activity when medications are at peak effectiveness. When medications are at their peak effectiveness, difficulties with breathing may be minimized.
Use other intimate activities to build tolerance for sexual activity, such as hugging, touching, fondling, or masturbation, before engaging in sexual intercourse. Activities such as prolonged kissing or oral sex may cause dyspnea and panic. Build exercise tolerance for sexual activity and avoid sexual activities that exacerbate symptoms.
Use sexual positions that prevent shortness of breath, using ample pillows for support and to elevate the upper body, or use a sitting, upright position. Try different positions to find ones most comfortable for the couple. Instruct the partner to avoid any pressure on the COPD partner’s chest. Allow unrestricted breathing without pressure on the chest.
Use an oxygen cannula (if prescribed and needed) before, during, and/or after sex, whenever it seems to be most beneficial. Maximize breathing capacity
Include the partner in all discussions when possible. Teach the partner how to observe for breathing difficulty, and allow time for the COPD partner to change positions and catch breath when needed during sexual activity. Including the partner in sexual counseling is important for his or her understanding of how COPD might affect the sexual relationship and provide ways to approach sexual activity, thus promoting sexual confidence for both the patient and partner.

Sexual Counseling Strategies for Cancer

Strategies for Men and Women
• Assess sexual concerns at every visit and stress that having concerns is normal. To open discussion, use a statement such as “Many cancer survivors who have had this type of cancer (or treatment) have concerns about sex. Please help me understand what concerns you about sexuality or intimacy.”
• Discuss the potential side effects of cancer diagnosis and treatment.
• Specifically ask about loss of interest in sex, problems with arousal, difficulty with orgasm.
• Standardized instruments can be used to determine the extent of sexual problems.
• Encourage the couple to openly discuss sexual concerns with each other to promote intimacy and to work at solutions together.
• Focusing on pleasure, rather than sex, to begin with can help the couple explore the changes in their body, non-sexual touch or massage that may be pleasurable, and later progressing to sexual touch.
• Encourage the couple to try fantasy, relaxation exercises, or using longer times in foreplay to build intimacy.
• Discuss flexible coping and that it requires the couple to think beyond sexual intercourse and erection as the only sexual activity, and an exploration of alternative sexual activities that supports the sexual role. By touching each other, they may find new erotic areas. New sexual positions may be helpful. This may help redefine sexuality for the couple.
• Promote intimacy with good hygiene, the use of candlelight, massage, or bathing together.
• Provide complete and accurate information, and written resources, when possible.
• Refer to support groups, sex therapists, counselors, and urologists, if needed. There are a number of medical treatments that may be helpful for the couple.
• Remember the partner also needs support to adapt to changes in sexual functioning.
• Refer the patient for treatment of anxiety and depression, if necessary, to help minimize distress.
Strategies for Women Strategies for Men
• The Female Sexual Function Index (Rosen et al., 2000) or other tools can be used for sexual assessment. • The International Index of Erectile Function 5 (Rosen, Cappelleri, Smith, Lipsky, & Peña, 1999; Rosen et al., 1997) is a widely used assessment tool.
• Discuss any pain experienced with sexual activity or problems with vaginal lubrication. • The use of sexual aids, such as vacuum devices or other treatments, as part of a penile rehabilitation can help promote erectile function.
• For treatment-related sexual side effects, vaginal dilator therapy, low-dose hormone replacement therapy, vaginal lubricants, and selective serotonin reuptake inhibitors have been useful approaches to discuss with health care providers.

Keypoints

Steinke, E.E. (2013). Sexuality and Chronic Illness. Journal of Gerontological Nursing, 39 (11), 18–27.

  1. Maintaining sexual health and intimacy is important for many individuals with chronic illness.

  2. Addressing psychological reactions such as anxiety, fear, changes in body image, and depression of both the patient and his or her partner is an essential aspect of sexual assessment and counseling.

  3. Sexual counseling can be easily tailored to the patient’s specific chronic condition, based on exercise capacity, any risks with sexual activity, and specific concerns of the patient and partner.

  4. The concept of flexible coping is a useful strategy in helping those with chronic illness examine beliefs about sexual activity and alternatives to sexual intercourse.

10.3928/00989134-20130916-01

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