Introduction
It is often expected that among seriously ill patients sexuality is not important. However, satisfaction with sexual functioning is recognized as a component that influences quality of life.
Studies show that patients who are chronically or critically ill are concerned about sexual dysfunction. Sexual function has been studied in some chronic disease states, especially in diabetes, cancer, spinal cord injury, and some cardiac diseases. For example, sexual function in patients after myocardial infarction (MI) or after coronary artery bypass grafting (CABG) has been studied since the 1970s and 1980s.
More recently sexual function in patients with heart transplantation or heart failure has been studied. It is known that there are many important links between sexual activity and heart disease:
• Heart disease can result in both reduced sexual activity and increase sexual dys- function, for example due to fear or symptoms.
• Heart disease and erectile dysfunction share important risk factors such as diabetes and hypertension.
• Sexual activity, like all forms of exertion and/or stress, may trigger cardiac symptoms.
• Medications used to treat heart disease may impair sexual function.
• Drugs that are used to treat sexual dysfunction may have serious interactions with medications used to treat heart disease.
All these complicated relationships can keep healthcare providers from addressing the issue of sexuality in patients with heart disease. Health- care providers may believe that discussing sexual- ity causes anxiety in the patient, that patients do not want to talk about it, or that another health- care provider has discussed it. In this chapter we will discuss problems reported by cardiac patients related to resuming sexual activity, facts and myths related to sexual activity, and give some practical pointers in discussing sexuality with cardiac patients.
Problems
Cardiac patients often are worried about a safe return to sexual activity. They worry about the effect of the condition on sexual activity, the effect of sex on the heart, symptoms that may occur during sexual activity, and possible effects of medication.1–3 Partners of cardiac patients also may be worried and may be overprotective. Some problems in returning to sexual activity are general to (cardiac) patients (Table 40-1), while others might be more disease specific.
Return to sexual activity might be stressful for both for patient and partner, including experi- ences of fear, anxiety, and overprotectiveness.
Cardiac patients also often report erectile difficulties. Vascular disease is a common cause of sexual dysfunction and can be assumed to be present in a proportion of the patients with heart disease. Steinke (2003) found that the areas of greatest concern reported by ICD patients were
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Sexual Counseling of the Cardiac Patient
Tiny Jaarsma and Elaine E. Steinke
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overprotectiveness by the partner (56%) and erec- tile difficulties (57%).4
Myocardial Infarction
Myocardial infarction patients may have all the concerns described in Table 40-1. Specifically patients after an MI might fear a reinfarction and/or sudden death during intercourse.
Coronary Bypass Surgery
Patients recovering from bypass surgery or other cardiac surgery may have specific concerns about pain and support of incisions during sexual activ- ity. In addition, changes in body image due to the operation may play a role in returning to sexual activity.
Heart Failure
From descriptive studies it is known that a con- siderable number of patients report a marked decrease in both sexual interest and the frequency
of sexual relations caused by their heart failure.
Symptoms of dyspnea and fatigue may hinder sexual activity. A relationship between higher levels of daily functioning and fewer sexual prob- lems has been established, and a relationship between the number of co-morbidities and sexual problems.1,5 Patients might fear deterioration as a result of sexual activity and death during intercourse.
Implantable Defibrillators
In addition to the general problems mentioned earlier, ICD patients and their partners often have concerns related to device discharge with sexual activity. Patients are concerned that sexual activ- ity will trigger the device and may avoid sexual encounters. They also fear touching others when the device fires.6
Partners of ICD patients are also known to report a lack of interest in sex after the ICD was implanted. Spouses often describe fear and anxiety about cardiac arrest and ICD firing, often resulting in overprotectiveness towards their partner. Patients and partners may have been in a stressful period before the ICD implantation in which they also had reduced sexual activity.
Myths and Misconceptions
Myth 1:Sex and sexuality are the same.
Truth:The term “sex” is often used to refer to the sex act, whereas sexuality reflects both the psy- chosocial and physical aspects of intimacy. Engag- ing in sex can be fun, passionate, and has been called a “restorative force” that can be both healing and energizing.7
Myth 2:Older adults with cardiac disease are less interested in information on resuming sex.
Truth:Older adults have many of the same ques- tions and sexual concerns as younger individuals.
Studies with cardiac patients have shown that many older adults continue to be sexually active well into the 8th decade of life.2,8
Myth 3: Sex after a heart attack often causes sudden death.
TABLE40-1. Problems of cardiac patients and partners related to sexual activity
Psychological problems – General anxiety
– Fear of symptoms (chest pain, dyspnea) – Fear of death
– Worries about the effect of medication on sexual function – Change of self-esteem
Stress for couples – Overprotectiveness – Lack of communication
Symptoms (chest pain, fatigue, dyspnea) Erectile difficulties
Reduced sexual desire
Effect of cardiovascular medications Men:
– Decreased or absent libido – Difficulty in maintaining and erection – Priapism
– Premature retrograde ejaculation Women:
– Decreased vaginal lubrication – Decreased or absent libido – Inability to achieve orgasm
Truth:A number of studies have been conducted in order to clarify whether sexual activity poses any significant risk to cardiac patients. Based on these findings, patients should be reassured that, in most cases, sexual activity carries little risk of causing a cardiac event. Although sexual activity increases the relative risk of MI, the absolute risk remains low for most patients. To communicate this important information to patients, the author of a study on cardiac events triggered by sexual activity suggests that simple analogies can be helpful.9For example, data from the Framingham Heart Study indicate that if a healthy, 50-year-old man exercises regularly, his absolute risk of MI is only 1 chance in a million per hour. If this same person engages in sexual intercourse, his absolute risk doubles to only 2 chances in a million per hour, and only for a 2-hour period. For a post-MI patient who has been in a rehabilitation program, the absolute risk of MI is 10 chances per million per hour. Although sexual activity transiently doubles this risk, the absolute risk is still only 20 per million per hour. A report from the Princeton Consensus Panel10provides guide- lines that health professionals can use to evaluate
the risk of sexual activity and recommended treatment (Table 40-2).
Myth 4:Erectile dysfunction (ED) is always caused by psychological problems.
Truth:Erectile dysfunction is a common problem in the healthy population, with around 10% of adult men being affected, and increasing with age.
The most common cause of ED is so-called vas- culogenic erectile dysfunction, which is associated with the development of atherosclerosis. Accord- ingly diabetes, hypertension, hyperlipidemia, and smoking are all risk factors for the development of ED. Erectile dysfunction is often seen in con- junction with other manifestations of atheroscle- rosis such as cardiovascular, cerebrovascular, and peripheral vascular disease.
Myth 5: Impotence and lack of sex drive always occurs when one has heart disease.
Truth:Both men and women can have a normal sex life after a cardiac event.
Myth 6:If a cardiac patient can walk up two stairs, then they can resume sex.
TABLE40-2. Risks and management of sexual dysfunction10
Risk Categories of CVD Management recommendations
Low – Asymptomatic <3 risk factors CVD – receive treatment for ED as needed
– Controlled HT, – Reassess regularly (6–12 mo)
– Mild stable angina
– Post-successful revascularisation.
– Uncomplicated post MI (>6–8wk) – Mild valvular disease
– LVD (NYHAI)
– other cardiovascula conditions
Intermediate – Asymptomatic ≥ risk factors – Specialised CV testing
– modenater stable angina – Restratification into high or low risk
– recent MI (<2 <6wk) – LVD/CHF class II
– Noncardiac atherosclerotic disease
high – Unstable or refractory angina – Referral specialised CV management
– Uncontrolled HT – Defer treatment for sexual problems
– LVD/CHF class III/IV – Recent MI (<2wk) – High-risk arrhythmias
– Obstructive hypeitrophic cardiomyopathy – Moderate/severe valvular disease
CVD = Cardiovascular disease; MI = Myocardial Infraction; CHF: heart failure; LVD = Left ventricular dysfunction; HT = hypertension; CV = Cardiovascular.
Truth: The energy cost to the cardiovascular system is often measured in metabolic equivalents (METs). The energy cost of sexual intercourse is 5 METs, while the energy expended during the pre- and post-orgasmic phase is estimated at 3.7 METs.11This is equivalent to walking a treadmill at 3 to 4 miles per hour, or 5 to 6 METs. This amount of energy expenditure has also been com- pared to climbing two flights of stairs at a brisk pace, 20 steps in 10 seconds.
Myth 7:Alcohol is a great stimulant for sex.
Truth: The role of alcohol and heart disease in general has been widely discussed. Studies have examined both the preventive or deleterious effect of alcohol for the cardiovascular system.
We know that a small amount of alcohol may help reduce tension or fears; however, one also has to consider that alcohol may impair sexual performance.
Myth 8:It is best for the cardiac patient to be on the bottom during sex.
Truth: It was once believed that certain sexual positions increased cardiac workload; for example, the patient was advised to avoid the on-top posi- tion and to assume a passive position for sexual activity. It was believed that isometric exertion might lead to cardiac stress.12Studies have shown that blood pressure and heart rate do not change significantly when a variety of positions were used.
In fact, elevations in these vital signs may occur when assuming an unfamiliar position. Patients can usually be advised to assume their usual posi- tion or one that is most comfortable for them.
Myth 9: The heart needs to recover at least 6 months after an MI, before resuming sex.
Truth:The rate of return to sexual activity is quite variable, with some patients returning as soon as a few weeks and others more than 6 months post- MI. Guidelines from the American College of Cardiology and American Heart Association suggest that patients with an uncomplicated MI can resume sexual activity in a week to 10 days,13 and in the Second Princeton Consensus this is advised at 3 to 4 weeks.10Return to sexual activity is often gradual, sometimes at reduced frequency and some do not resume sexual activity at all.
Most patients return to sexual activity in the first
month post-MI, although some may take more than 6 months to return to prior levels of activ- ity.2,8,14
Myth 10:If a doctor or nurse does not talk about it, then sex is prohibited.
Truth: Health professionals have historically been reluctant to discuss sexual issues. However, studies have shown that cardiac patients want this information.2 Sex is generally not prohibited unless cardiac function is seriously compromised.
Health professionals must take the initiative in assessing sexual concerns of patients and partners and provide teaching that is individualized to the cardiac condition and the needs of the patient.
Sexual Counseling
Health professionals must take the initiative to bring up the topic of sex with the cardiac patient.
Often, the patient may feel too embarrassed to ask questions about such a private area. By bringing up the topic, health professionals are acknowledg- ing that sexual concerns are both normal and common for cardiac patients. Health professionals must be aware of their own biases in regard to sexuality, and be careful to approach sexual counseling in a non-judgmental way. Drench and Losee15 provide a helpful guide for self- assessment of feelings and attitudes, particularly toward sexuality in older adults (Table 40-3).
TABLE 40-3. Self-assessment of sexual attitudes by health professionals
• When I think about people in their 60s and 70s, do I assume that intercourse ceases and they are no longer interested in sex?
• Do I think that sex among older adults is normal? Is it repulsive or immoral?
• When I think about sex, do I think it is limited to sexual intercourse?
Does sex also include touching, stroking, and fondling?
• Do I think orgasm has to occur with sex?
• What do I think of my own parents engaging in sex? What about my grandparents?
• What would I think if my widowed parent engaged in sex without being married?
• How do I feel about masturbation, oral sex, and anal sex?
• How comfortable am I in discussing these issues with any of my patients, irregardless of age, young or old?
• Do I feel comfortable talking about sex to adults of both genders?
Source: Adapted from Froelicher et al.14
These can be used by health professionals to evaluate their own readiness to initiate sexual counseling.
There are several prerequisites to implementing successful sexual counseling. Environmental issues include providing a quiet environment in a private setting. Sexual counseling might be con- ducted in a conference room or other private area. Ask permission from the patient prior to beginning sexual counseling. Begin by asking more general questions about the patient’s sexual concerns and then proceed to more sensitive topics.16Patients should be assured that confiden- tiality is maintained about sexual problems or issues that arise. Issues that require further intervention should be documented, however. The language used in sexual counseling is an impor- tant consideration. Using the language and terms used by the patient will enhance understanding of the content of sexual counseling. For example, some patients use slang terms to refer to body parts; if the health professional uses medical lan- guage, the message may not be understood by the patient.
Formulating Questions for Sexual Counseling
When beginning sexual counseling, start with a statement that stresses that concerns about sex and sexuality are normal after a cardiac illness.
Often, open-ended questions are used to facilitate discussion and to assess patient concerns.
For example, the health professional might use this statement: “Many people have concerns about sexual activity as part of living with heart failure. What concerns do you have?” This statement stresses that it is normal to have concerns, and it allows the individual to state any concerns to be addressed. This question can be used with any cardiac condition by inserting the appropriate health issue, for example heart attack or implantable defibrillator. In addition, specific questions are asked during this discus- sion, moving from general questions to more specific issues or problems as the counseling session continues (Table 40-4). This gives the health professional a better perspective of the issues and concerns. Evaluating usual sexual activities, current medications and supplements,
sexual dysfunction, and specific sexual concerns assists in tailoring sexual counseling to each individual.
Specific Strategies for Sexual Counseling for Selected Cardiac Conditions
As there are some similarities in problems experienced by cardiac patients there are also some similarities in content in providing sexual counseling of cardiac conditions, although there are some distinct concerns described by patients.
In all cases, sexual assessment questions should be used first, and followed with specific counseling strategies for the particular cardiac condition.
It is often helpful to briefly discuss myths about sexual activity and cardiac disease to help frame the discussion. Open communication about sexu- ality between patient and partner is particularly important. Health professionals can model appro- priate communication by including partners in sexual counseling, framing the questions and dis- cussion with sensitivity to the personal nature of the topic, and involving the partner in care TABLE40-4. Questions for sexual assessment16
• How would you describe your relationship with your partner?
• What concerns do you have about resuming sexual activity with your cardiac condition (insert appropriate term, e.g. heart attack, implantable defibrillator, heart failure, etc.)
• How important is sex and intimacy in your relationship? Are activities like hugging, kissing, and just being close an important part of your relationship?
• Were you sexually active before you were hospitalized? Is it important to you to be sexually active after you are discharged from the hospital?
• Did your previous sexual activity include sexual intercourse (vaginal or anal), masturbation, or oral sex? Note: this helps to gauge the amount of energy expenditure required and to plan sexual counseling strategies.
• Changes in sexual performance can occur as part of normal aging.
Would you like me to review some of these changes?
• Have you noticed any changes in your sexual performance such as problems with erections or orgasm, vaginal dryness, or decreased desire for sex?
• What medications or supplements are you currently taking? (Note:
evaluate for sexual side-effects.)
• What concerns has your partner expressed about resuming sex after you are discharged from the hospital? Would you like to include your partner in a discussion of resuming sexual activity after your cardiac condition?
activities that involve touch. Recommending that the couple take daily walks together is one way to encourage couple communication and to promote intimacy.
Myocardial Infarction
The importance of including information about return to sexual activity post-MI has been demonstrated in several studies and a few studies have specifically addressed sexual learning needs post-MI, although limited to one or two questionnaire items. In one study of the specific sexual counseling needs of MI patients, the impor- tance and timing of 14 specific sexual teaching items were rated by patients as important to learn.2
Few studies have explored interventions for sexual counseling post-MI. Varvaro17 found that patients who received a nursing instructional program had fewer concerns about sexual activ- ity, and better adaptation to family role and work.
The treatment group showed a trend for increased self-confidence (P = 0.059) in resuming sexual activity over time and the largest decrease in adjusting to sexual intercourse over time, reflecting the positive effect of the intervention.
Froelicher and colleagues14 used a teaching- counseling program on exercise to assess return to usual activities; participants completed eight sessions on risk factor modification and post-MI adjustment. The rate of return to physical acti- vities was not significantly different between groups, and most patients returned to sexual activity, driving, and outdoor activities by 3 weeks post-MI. Steinke and Swan8tested a videotape for sexual counseling post-MI which demonstrated improved knowledge in the experimental group at 1 month. While these studies have added to the body of knowledge on sexual counseling post-MI, interventions and strategies for sexual counseling must be implemented in practice. Table 40-5 illus- trates key points to be included in sexual counsel- ing post-MI.
Coronary Bypass Surgery
For those patients having coronary artery bypass grafts (CABG), the topics discussed for MI should be followed. However, return to sexual activity occurs over a longer period of time, generally 3 to
6 weeks post-CABG or at the direction of the physician. Once the incisions have had time to heal, sexual activity can generally be successfully resumed.
Heart Failure
There are a few guidelines for heart failure patients and sexual activity in the literature (Table 40-6). Patients can be advised that a semi- reclining or on-bottom position may decrease the amount of physical effort needed for sexual activity. The suggestions for MI patients related to the setting and timing of sexual activity also apply to the heart failure patient. In addition, patients should be encouraged to stop and rest if shortness of breath occurs with sexual activity.
Sexual foreplay can be beneficial in allowing the patient and the partner to determine tolerance to sexual activity. Patients should be encouraged to express their affection through hugging, kissing, and sexual foreplay. Activities such as mutual masturbation, oral sex, or intercourse TABLE40-5. Sexual counseling topics post-MI11,16
• Ask the sexual assessment questions (Table 40-4).
• Effect of the MI on sexual function, such as energy requirements.
• Partner concerns such as anxiety, overprotectiveness, communication.
• Sexual activity can be resumed in an uncomplicated MI. Those with a complicated MI (e.g. cardiac arrest, arrhythmias) will need to resume sexual activity more slowly and will need to seek advice from their physician about this.
• The setting for sexual activity should be comfortable and the cardiac patient should be well rested.
• Avoid alcohol or a heavy meal for 2 to 3 hours before having sex.
• Avoid unfamiliar settings or partners.
• Use foreplay prior to sexual activity (decreases anxiety, less strain on heart, allows vital signs to rise gradually).
• Use a position for sex that is comfortable and relaxing.
• Report any warning signs that occur with sex such as unrelieved chest pain, shortness of breath, irregular heart rate, extreme fatigue the next day.
• Avoid anal sex unless approved by your physician; this puts added strain on the heart.
• Nitroglycerine, if prescribed, can be used for angina with sexual activity; stop and rest if chest pain is experienced.
• Discuss any medication with the physician that you think may be causing a sexual problem. Do not discontinue use of a medication without consulting the physician.
• Avoid drugs such as amphetamines, amyl nitrate (both are stimulants), marijuana (increases heart rate and oxygen consumption), and cocaine (chest pain, fatal MI).
may not be possible if exercise capacity is diminished. There is a correlation between the 6-minute walk test and improved patient levels of sexual function. The 6-minute walk test can be easily administered in the clinical setting and serve as a guide for overall physical function and sexual activity. Patients who are not able to manage the 6-minute walk or expend approxi- mately 5 METs may not be able to handle the exer- tion required for sexual activity. Patients with symptoms at rest should be advised to be careful in engaging in coital activity. Although heart failure patients may experience sexual difficul- ties, they still may have a satisfying sexual relationship.1
Implantable Defibrillators
Specific guidelines for resuming sexual activity after ICD are largely unavailable. Some sugges- tions for teaching include normalizing fears and concerns about resuming sex; providing educa- tion on safe levels of activity, although not well defined; and the role of regular exercise in increas- ing confidence for sexual activity (see also Table 40-7). Patients frequently want to know when they can resume sexual activity. There are usually no restrictions as long as strain on the incision site is avoided in the immediate postoperative period.6 The possibility of ICD discharge should be dis- cussed with the patient and partner. The relative risk of arrhythmia with sexual activity is reported
to be low, although it is possible for the ICD to sense increased heart rates with sexual activity and fire. The ICD settings may need to be adjusted. Other items to discuss include medica- tions, vascular disease, and alternative causes of sexual difficulties or impotence.4 The patient should be advised to report any dyspnea, chest discomfort, or dizziness with sexual activity. If patient anxieties persist, additional concerns of patients and partners must be identified and discussed.
Summary
Increased attention to the sexual counseling needs of cardiac patients is warranted. Health professionals are in key positions to provide this teaching and facilitate successful return to sexual activity after a cardiac event. Return to sexual activity is part of the recovery process and can lead to improved satisfaction and quality of life.
References
1. Jaarsma T, Dracup K, Walden J, et al. Sexual func- tion in patients with advanced heart failure. Heart Lung 1996;25:262–270.
2. Steinke E, Patterson-Midgley P. Importance and timing of sexual counseling after myocardial infarc- tion. J Cardiopulmon Rehabil 1998;18:401–407.
TABLE40-6. Sexual counseling topics for heart failure
• Ask the sexual assessment questions (Table 40-4).
• Explore alternative means of sexual expression, e.g. hugging, kissing, fondling, sexual foreplay.
• Encourage the use of a semi-reclining or on-bottom position for the patient to minimize energy expenditure and strain on the heart.
• Sexual activity should be in a comfortable setting, including no extremes of room temperature, and when the patient is well rested and less short of breath.
• The patient should stop and rest if shortness of breath is experienced.
• Take nitroglycerine if needed for chest discomfort.
• Adjust diuretic use if needed.
• Some activities may not be possible with decreased exercise capacity.
• Use the 6-minute walk test as a guide to whether the patient can resume sexual activity.
• Patients with symptoms at rest should be careful in engaging in sexual activity.
TABLE40-7. Sexual counseling topics for implantable cardioverter defibrillators
• Ask the sexual assessment questions (Table 40-4).
• Sexual activity can be normally resumed after hospital discharge; avoid strain on the incision.
• Report problems such as dyspnea, chest discomfort, or dizziness with sexual activity.
• Discuss the likelihood of ICD discharge with sexual activity. Discuss what to do if a shock occurs with sexual activity, and that the partner will not be injured.
• Discuss feelings of overprotectiveness by partner.
• Reinforce positive aspects of living with the ICD.
• Have a resource person, someone who has an ICD and is sexually active, discuss living with the ICD with the patient and partner.
• Advise patients regarding organic causes of sexual problems and also medications. Further sexual assessment may be needed if problems are detected, e.g. erectile dysfunction.
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