Sexual functioning is a complex process that depends on the neurologic, vascular, and endocrine systems, and is influenced by numerous psychosocial factors, including family and religious background, the sexual partner, and individual factors such as self-concept and self-esteem. Sexuality can be altered by aging, life experiences (e.g., abuse), and various illnesses and their treatments.
Sexuality has received little scholarly attention, and professional training in sexual health is limited. Although the available literature demonstrates the importance of sexuality to patients, (1-6) physicians often do not introduce the subject during clinical encounters (4) or address sexual concerns in patients who have chronic diseases. (7) Because of the complexity of these illnesses and their treatments, as well as time constraints, inquiry about sexual functioning may be neglected. Without physician prompting, patients are reluctant to bring up sexual concerns. (2,8)
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Patients who have chronic illness often have difficulties with sexual functioning. (7,9) With an understanding of the impact that chronic illness can have on sexual functioning and the use of basic management strategies, family physicians can readily screen for and manage sexual dysfunction, thereby enhancing quality of life for their patients.
Chronic Illness and Sexual Health
ISSUES FOR PATIENTS
Although the physical demands of sexual activity are high, (10,11) few, if any, chronic illnesses require restriction of sexual activity. However, couples may have to alter their sexual activity to accommodate physiologic or mechanical limitations.
Patients with chronic illness may become disinterested in sex or may become sexually inactive because of misconceptions about their ability to have sex or the safety of having sexual relations, or because of body-image concerns or grief related to the diagnosis of their disease. (12) Depression, fatigue, pain, stress, and anxiety may further contribute to sexual dysfunction. These problems may affect the willingness of patients or their partners to engage in sexual or other intimate relations. However, touch and physical intimacy are extremely important for severely debilitated or terminally ill patients. (7)
SEXUAL RESPONSE CYCLE AND CHRONIC ILLNESS
A knowledge of the sexual response cycle–desire, arousal, plateau, orgasm, and resolution–is important to understanding the impact that chronic illness can have on sexual functioning (Table 1). (10,11,13)
Desire is influenced by neurotransmitters, androgens, and the sensory system. It is also influenced by psychosocial factors such as self-esteem, body image, and the relationship with the sexual partner. Any illness or treatment that affects these factors can have a negative impact on a patient’s interest in initiating or being receptive to sexual activity.
Arousal and plateau require intact vascular and parasympathetic nervous systems. Orgasm requires an intact sympathetic nervous system, and its intensity is affected by muscle tone.
Chronic medical illnesses tend to disrupt the desire and arousal phases of the sexual response cycle. For example, the diagnosis of diabetes and the subsequent emphasis on lifestyle changes can have a negative effect on a patient’s body image and perception of self as a sexual being. Furthermore, neurologic disorders potentially affect desire, arousal, and orgasm.
Treatments for chronic illnesses also can disrupt the sexual response cycle. Antihypertensive drugs negatively affect arousal. Psychotropic agents interfere with desire and arousal; they can also disrupt orgasm. Surgical treatments such as transurethral prostatectomy can interfere with arousal and orgasm by disrupting delicate sympathetic and parasympathetic pathways.
SEXUAL HISTORY AND COMMUNICATION
Sexual health may have a direct impact on the overall well-being of patients with chronic illness. Therefore, it is important to obtain a sexual history. The physician’s proactive leadership in initiating the discussion lets the patient know that sexuality is an important aspect of health. (14)
Inquiry should be sensitive, but direct enough to clarify the issues. Emphasizing the commonality of concerns about sexual functioning may ease discomfort. In a patient who has arthritis, for example, the physician might begin with the following: “It is common for people with arthritis to notice changes in their sexual lives. Has weakness or pain limited your sexual activity?”
A patient or sexual partner may worry that resuming sexual activity could exacerbate musculoskeletal problems or, in the case of myocardial infarction, precipitate another heart attack. An open-ended question may have a dual function: inquiry about the presence of a sexual problem and exploration of what the patient or couple may have done to try to resolve the problem. If the patient has had a myocardial infarction, the physician might say: “It is common for people who have had a heart attack to worry about resuming sexual activity. How have you and your partner done in this area?” Seeing the patient and partner together also allows the physician to assess the effectiveness of the couple’s general communication and, in particular, their ability to discuss sexual concerns.