Teach them to fish: Addressing the sexual health needs of patients and practice culture

July 11, 2019

The impact of chronic inflammatory disease on sexual function may seem obvious but it is poorly understood. Pain, morning stiffness, joint swelling and fatigue can lead to a decreased sexual interest and can inhibit actual intercourse. In this article, Dr. Kim Gorgens reviews the current literature on sexual function for patients with chronic conditions, such as arthritis, and makes recommendations for incorporating sexual function complications as part of the discussion in a clinic exam. 

WHAT IS SEXUAL HEALTH?

Sexual health is the broadest category of sex, sexuality, intimacy and sexual activity. The World Health Organization defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” (WHO, 2010). Sexual function is the single facet of the human condition that is equal parts physical, psychological, relational, and cultural. It is somatic, emotional, intellectual, social and sometimes even spiritual. On the other end side of that experience is sexual dysfunction, a disruption of any component of sexual activity. That disruption can include sexual frustration, painful sex, or reduced sexual pleasure, all of which are overrepresented among patients with chronic disease, especially chronic inflammatory diseases. 

People with rheumatic diseases often have pain, restricted joint movement, fatigue and may also experience mood disturbances and a deterioration in self-esteem. Any one of those problems can cause sexual dysfunction. The percentage of arthritic patients who experience sexual dysfunction is reported to range from 31% to 76% (Van Berlo, 2007). A recent study published in Rheumatology International found that 57% of patients with rheumatoid arthritis report difficulty with sexual intercourse (Dorner et al., 2018). Those same high rates of sexual dysfunction are also reported among patients in Mexico (Gonzalez-Lopez et al., 2006) and Brazil (Costa, Silva, Muniz & Da Mota, 2015).

And the shockingly high prevalence rates aren’t limited to western countries with more progressive sexual norms. A recent study in Taiwan reported the prevalence of sexual dysfunction among female arthritis patients to be 67% (Lin et al., 2017). In Persia, 53% of women with arthritic conditions report sexual dysfunction (Mohsen, Gholamzadeh Baeis, & Borzooei, 2016) and in conservative Malay culture, sexual dysfunction including problems with libido, arousal, orgasm and satisfaction are more common among women with rheumatoid arthritis than in healthy controls (Shahar, Hussein, Sidi, Shah & Mohamed Said, 2012). The same is true in Morocco (Khnaba et al., 2016) and Egypt (Gaber, Moghazy, Niazy, & Salem, 2017).  In that latter study with Egyptian patients, problems with orgasm, arousal, and satisfaction were the most common reports (Miedany, El Gaafary & El Aroussy, 2012).

The actual frequency of sexual dysfunction is likely even higher. In research, sexual problems are defined differently from study to study. Some settings query “sexual difficulties” and others assess the frequency of specific types of sexual dysfunction. And, in actual clinical practice, sexual dysfunction is often underdiagnosed because patients decline to report the problem because they are ashamed or frustrated and they also fail to report the problem when they aren’t asked about it. In fact, one study reported that 66% of patients were never asked about the impact of arthritis on their sex lives (Hill, Bird & Thorpe, 2003).

See next page:  WHY IS SEXUAL DYSFUNCTION SO COMMON HERE?

WHY IS SEXUAL DYSFUNCTION SO COMMON HERE?

The impact of chronic inflammatory disease on sexual function may seem obvious but it is poorly understood. Pain, morning stiffness, joint swelling and fatigue can lead to a decreased sexual interest and can inhibit actual intercourse (Tristano, 2014). Drugs used in the treatment of arthritis conditions can also cause sexual dysfunction (e.g., DMARDs, methotrexate, hydroxychloroquine, and sulfasalazine). And common medications that treat mood disorders or whose side effects contribute to depression are also implicated in a loss of libido and loss of sexual satisfaction (e.g., corticosteroids, tricyclic antidepressants, serotonin reuptake inhibitors; Yilmaz, 2012). These psychological contributors to sexual dysfunction are paramount. Depression, altered body image, poor performance in daily physical activities and worries about partner interest are all directly related to sexual dysfunction. Patients who have been exposed to physical or sexual trauma are especially vulnerable to sexual dysfunction.

As to the different types of sexual dysfunction, there are three principal categories.  Primary sexual dysfunction refers to impaired libido, poor lubrication, and inability to orgasm. Secondary sexual dysfunction refers to physical limitations, such as joint pain or limited mobility, that affect the ability to engage in or enjoy sexual activity. Tertiary sexual dysfunction refers directly the impact of the patient’s psychology (e.g., shame and guilt).

YOU HAVE TO GO THERE

In traditional healthcare settings, all manner of measurements are recorded: clinical parameters, functional classifications/activities of daily living, disease activity, articular index, hand grip, laboratory values, x-rays and objective measures of mental status and depression. 
Sexual functioning (dysfunction or otherwise) isn’t part of traditional intake questionnaires or screening tools used to assess physical function or quality of life but it is imperative that health professionals invite conversations about sexual function.

Still, most healthcare professionals avoid it altogether. A 2013 study of healthcare professional’s reluctance to address sex identified nineteen themes relating to lack of experience,  fear about “opening up a can of worms,” lack of time/resources/training, worry about causing offense, personal discomfort, and a lack of awareness about the frequency of sexual problems (Dyer & Das Nair, 2013). Some areas with particular hesitation included addressing the sexuality of an opposite‐gender patient, of black and ethnic minority groups, of older and non-heterosexual patients, and of patients with cognitive impairments (Dyer, & Das Nair, 2013). And, in an increasingly interdisciplinary practice landscape, it is also easy to assume another provider will address sex. Surprisingly, even ob/gyns often fail to ask about sexual function. In one large study, 60% of ob/gyns failed to routinely ask about sexual problems. Even fewer asked about sexual satisfaction, pleasure with sexual activity, or sexual orientation/identity (Sobecki, Curlin, Rasinski, & Lindau, 2012). On the latter point, a 2008 study reported that only one provider in a sample of 81 physicians routinely asked their lesbian, gay, bisexual, and transgender patients about their sexual function (Dahan, Feldman, & Hermoni, 2008).

See next page:  HOW TO GO THERE

HOW TO GO THERE

One of the best clinical conceptualizations of sexual function is a sex-positive approach which encourages professionals to attend to both dysfunction and the capacity for pleasure (Mona et al., 2011; Syme, Mona, Cameron, & Nicholas, 2013).  There are some hallmark publications to frame this discussion. Panush, Mihailescu, Gornisiewicz and Sutaria (2000) adapted the PLISSIT model (permission, limited information, specific strategies and intensive therapy) for use with arthritis patients. In the general PLISSIT model, the first level is permission, which involves giving your patient permission to broach the topic, to change their lifestyle or to get help. Permission includes questioning the patient about his/her sexual dysfunction and inviting a dialogue with the patient's partner if that applies. The second level is limited information, where patients are provided with limited and specific information. The third level is specific suggestions, where the healthcare professional makes suggestions to address the patient’s specific sexual concern (e.g., recommending specific activities, medications, or making outside referrals). The Panush, Mihailescu, Gornisiewicz and Sutaria (2000) adaptation includes the following:

  • Permission consists in questioning the patient about his/her sexual dysfunction, taking the liberty and showing openness to dialogue. The doctor must show the patient that his/her sexual problems can be mitigated. Furthermore, it is essential that the doctor encourages the dialogue with the patient's partner, due to his/her need to be aware of the difficulties of the couple.

  • The second step is to search and provide information about sexual dysfunction. At this stage, one should establish the cause of the problem – lack of libido, pain, fatigue, vaginal dryness, anxiety, fear of not having a good performance or not satisfying the partner are possible causes.

  • The third phase is to develop specific strategies for each problem. Low sexual desire can be circumvented by replacing medications, psychotherapy and stress reduction. Transdermal testosterone may be used in women with low levels of this hormone or in those undergoing surgical menopause. As to vaginal dryness, lubricating oils or intravaginal estrogen creams may be used.  With regard to pain and fatigue, the practice of different sexual positions, resting before intercourse and the use of muscle relaxants or painkillers are recommended.  The use of supports in the joints helps in maintaining the sexual positions; on the other hand, heat in the form of compresses takes effect reducing joint stiffness. It is recommended, though, to take a warm bath before intercourse, to achieve muscular relaxation. (p. 1-6; Panush, Mihailescu, Gornisiewicz, & Sutaria, 2000)

As to the management of sexual dysfunction, there are a few cotemporary models to guide physicians and medical teams. A 2014 review by Tristano provides specific treatment recommendations for the causes primary sexual dysfunction and an English-language translation of a review by De Almeida, Ferreira, Kurizky, Muniz, and Da Mota (2015) features a multidisciplinary perspective for assessment and treatment and a useful series of visual guides/handouts for sexual positioning.

See next page:  HOMEWORK

YOUR HOMEWORK

With these guides, handouts, and mnemonics, professionals should feel equipped to ‘go there’ and invite conversations with their patients about sexual function and that alone will contribute to a vast improvement in patient experience and well-being. That conversation though, is a single step towards changing a healthcare culture that fails to encourage professionals to have this conversation and may even suppress the initiative.

Your responsibility for culture change includes a few imperatives. The first is a self-reflective assessment of your own beliefs, taking careful stock of your hesitations, assumptions and bias. Review and challenge those constructs with colleagues and mentors and seek out professional (and/or personal) consultation from experts in sexual health and dysfunction. Your second responsibility is to create the kind of practice and healthcare culture where sex is spoken. Some settings hang a “SEX IS SPOKEN HERE” sign but it is otherwise more subtle but no less powerful.

Add sexual health questions to your patient self-report forms (alongside symptom inventories or HIPAA forms), add that query to your intake assessment and to your routine re-evaluations. The aim isn’t to have an in-depth conversation with *every single* patient but to send a message that you are willing to field these questions or concerns.

Planned Parenthood, arguably the experts in sex education, calls this making yourself "askable." And perhaps your most important responsibility is to be OK with not knowing the answers but to make the investigation and your commitment to it, plain to the patient. Show your patients how and where you find those answers and that you are willing to do so. The value is more often in seeing you puzzle it out (an alternate version of the adage about “teach a man to fish” comes to mind). All told, the cost of desexualizing patients is counted in patient satisfaction but also in health outcomes.

* See related slideshow:  Sexual Health and Your Patients

 

ABOUT THE AUTHOR:  Dr. Gorgens is Clinical Professor and Director of Continuing Education, Graduate School of Professional Psychology, University of Denver. For more articles from Dr. Gorgens, visit her blog "Brains Matter."

 

REFERENCES

Costa, T.F., Silva, R.S., Muniz, L.F., & Da Mota, L.M. (2015). Prevalence of sexual dysfunction
among female patients followed in a Brasília Cohort of early rheumatoid arthritis. Revista Brasileira De Reumatologia (English Edition), 55(2), p. 123-132.

Dahan, R., Feldman, R., & Hermoni, D. (2008). Is Patients' Sexual Orientation a Blind Spot of
Family Physicians? Journal of Homosexuality, 55(3), p. 524-532.

De Almeida, P.H., Castro Ferreira, C., Kurizky, P.S., Muniz, L.F., & Da Mota, L.M. (2015).
How the rheumatologist can guide the patient with rheumatoid arthritis on sexual function. Revista Brasileira De Reumatologia (English Edition),55(5), p. 458-463.

Dorner, T., Berner, E., Haider, C., Grabovac, S., Lamprecht, I., Fenzl, K., & Erlacher, H. (2018).
Sexual health in patients with rheumatoid arthritis and the association between physical fitness and sexual function: A cross-sectional study. Rheumatology International, 38(6), p. 1103-1114.

Dyer, K., & Das Nair, R. (2013). Why Don't Healthcare Professionals Talk About Sex? A
Systematic Review of Recent Qualitative Studies Conducted in the United Kingdom. Journal of Sexual Medicine, 10(11), p. 2658-2670.

Gaber, W., Moghazy, M., Niazy, A., & Salem, H. (2017). Risk factors for sexual dysfunction in
Egyptian patients with rheumatoid arthritis and its relation to disease activity. The Egyptian Rheumatologist, 39(3), p. 135-138.

Gonzalez-Lopez, L., Rojo-Contreras, E., Ayala Lopez, K., Vazquez-Salcedo, J., Castillo-
Gonzalez, B., Trujillo-Hernandez, E., . . . Gamez-Nava, L. (2006). Sexual dysfunction in Mexican women with rheumatoid arthritis. Annals of The Rheumatic Diseases, 65(S2), p. 170-171.

Hill, J., Bird, H., & Thorpe, R. (2003) Effects of rheumatoid arthritis on sexual activity and
relationships. Rheumatology, 42, p. 280–286.

Lin, M., Lu, M., Livneh, H., Lai, N., Guo, H., & Tsai, T. (2017). Factors associated with sexual
dysfunction in Taiwanese females with rheumatoid arthritis. BMC Women's Health, 17(1), p. 12.

Khnaba, D., Rostom, S., Lahlou, R., Bahiri, R., Abouqal, R., & Hajjaj-Hassouni, N. (2016).
Sexual dysfunction and its determinants in Moroccan women with rheumatoid arthritis. The Pan African Medical Journal, 24, p. 16.

Miedany, Y., Gaafary, M., Aroussy, N., Youssef, S., & Ahmed, I. (2012). Sexual dysfunction in
rheumatoid arthritis patients: Arthritis and beyond. Clinical Rheumatology, 31(4), p. 601-606.

Mona, L., Syme, M., Goldwaser, G., Cameron, R., Chen, S., Clemency, C. ... Lemos, L. (2011).
Sexual health in older adults: Conceptualization and treatment.  In K. Sorocco & S. Lauderdale (Eds.), Implementing CBT for older adults: Innovations across care settings (pp. 263-287). New York: Springer.

Mohsen, M., Gholamzadeh Baeis, M., & Borzooei, S. (2016). Evaluation of Sexual Dysfunction
in Patients with Rheumatoid Arthritis. Majallah-i Dānishgāh-i ̒Ulūm-i Pizishkī-i Qum,10(8), p. 62-70.

Panush, S.R., Mihailescu, G.D., Gornisiewicz, M.T., Sutaria, H.S. (2000). Sex and arthritis.
Bulletin of Rheumatic Disease, 49, p. 1-6

Shahar, M., Hussein, H., Sidi, H., Shah, S., & Mohamed Said, M. (2012). Sexual dysfunction
and its determinants in Malaysian women with rheumatoid arthritis. International Journal of Rheumatic Diseases, 15(5), p. 468-477.

Sobecki, J., Curlin, F., Rasinski, K., & Lindau, S. (2012). What we don't talk about when we
don't talk about sex: Results of a national survey of U.S. obstetrician/gynecologists. The Journal of Sexual Medicine, 9(5), p. 1285-1294.

Syme, M., Mona, L., Cameron, R., & Nicholas, D. (2013). Sexual Health and Well-Being After
Cancer: Applying the Sexual Health Model. The Counseling Psychologist, 41(2), 268-285.

Tristano, A. (2014). Impact of rheumatoid arthritis on sexual function. World Journal of
Orthopedics, 5(2), p. 107-11.

Van Berlo, W.T., van de Wiel, H.B., Taal, E., Rasker, J., Schultz, W.C., & van Rijswijk, M.
(2007). Sexual functioning of people with rheumatoid arthritis: a multicenter study. Clinical Rheumatology, 26, p. 30–38.

Yilmaz, H., Polat, H.A.D., Yilmaz, S.D., Erkin, G., Kucuksen, S., Salli, A. et al. (2012).
Evaluation of sexual dysfunction in women with rheumatoid arthritis: a controlled study
Journal of Sexual Medicine, 9, p. 2664-2670

World Health Organization.  Gender and human rights.
http://www.who.int/reproductivehealth/topics/gender_rights/sexual_health/en/index.html.

download issueDownload Issue : Vol 64 No 08