Co-authored by Jonathan Gallagher.
In Part 1 of this post, we discussed the degree of sexual activity and dysfunction in people with chronic disease and why it is important to address it where desired. Unfortunately, while sex is a private matter, due to taboos and cultural mores, most patients do not feel comfortable raising their sexual concerns with their clinicians.
Moreover, and disconcertingly, healthcare providers generally do not raise the issue with patients, except in the case of potential interaction of sexual function medication with chronic disease medication (eg, phosphodiesterase (PDE)-5 inhibitors and nitrates for chest pain should be taken at different times). Often, clinicians are waiting for patients to raise the issue, and vice versa. Doctors truly have heard it all, so given that most patients want to discuss their sexuality, please raise it so they can help.
Back to Sex Ed
Older couple on a bench overlooking water.
Source: Mark A Sporys / Unsplash
It is hoped that patients access a chronic disease management program, where they undergo an assessment of sexual well-being so that any issues can be identified and treatment provided where patients are interested. In these programs, patients need to learn about the benefits of sex for quality of life and physical wellness and the potential effects of their chronic disease on their sexual functioning.
Psychoeducation is defined as providing those seeking or receiving mental health services with information or education.
Psychoeducation regarding anatomy, as well as average sexual response and how it changes with age and in the context of chronic disease risk factors, should be shared with patients, such as is available here (see also videos).
This is important to dispel myths portrayed in movies or in pornography where that is accessed. For example, many women do not experience spontaneous but “responsive” desire, nor do most attain orgasm from vaginal penetration alone, which is not abnormal. All this knowledge can reduce sexual anxiety.
Treatment Options: Lifestyle Modification and Sexual Counseling
Remember us raising “sexercise” in the previous post? Physical activity interventions are effective for treating erectile dysfunction and can improve sexual functioning and frequency. And it is a form of exercise we are confident many patients will maintain! Moreover, tobacco cessation, weight loss, and blood pressure control improve sex too. Again, accessing a chronic disease management program is a great place to get support to control these risk factors and support for any sexual concerns. You can develop comfortable relationships with your care team over time to get to where you want to be sexual.
Sexual counseling includes assessment, treatment plan formulation based on patient choice, information on sexual concerns, behavioral strategies to assist with return to sexual activity, teaching relaxation techniques such as diaphragmatic breathing, and psychological support. It is psychophysiological in approach, so pharmacotherapy may also be integrated (see medication section below). This can be short-term or require ongoing visits, depending upon the needs of the patient.
Depending on the degree of need and whether a partner needs to be involved, this could be provided by a primary care clinician, couples, or sex therapist. As outlined in this post, be sure to find regulated mental healthcare professional. Pharmacists can also be helpful, as some medications for chronic conditions can impact sexual response, and some others may enhance it (eg, statins).
Where issues involve mismatch in desired sexual frequency or relationship issues, couples therapy would be indicated. Emotion-focused therapy has good evidence behind it for couples, and often when relational issues are addressed, things improve in the bedroom.
In instances of lower desire in one partner than the other, mindfulness or relaxation therapy may help a patient to better attune to sexual sensation. The couple should also work towards having sex that is desirable for all parties, This requires communication about their sexual life, what feels good, and what they like. Several science-informed books that are also relevant to patients with chronic disease are listed in the references.
Medications for Sexual Function
Unfortunately, proven pharmacotherapy for sexual difficulties is only available for men. PDE5i are available in short and longer-acting formulations, and the latter may be available over-the-counter in the future. These medications are safe for chronic disease patients when supervised by a physician, but non-prescription PDE5i use, such as through online pharmacies, can be dangerous. There is some evidence that treatment of erectile dysfunction is associated with reduced death rates and hospitalizations, so addressing sexual issues is important for reasons beyond the bedroom.
PDE5i does not work for everyone, and thus follow-up appointments should be made. Adjunctive sexual psychotherapy may be needed. Sometimes initiation of these medications can exacerbate a mismatch in the desired frequency between a couple. Here again, some couples or sex therapy can help.
Research is ongoing to find a medication to address sexual dysfunction in women. Some sexual changes can accompany menopause, as discussed here. Lubricants can help women with vaginal dryness.
In their recent book, Kleinplatz and Menard found most extraordinary sex came with age. Moreover, people with chronic diseases that engage in the lifestyle behaviors needed to manage their condition also derive many benefits for their sex lives: increased vigor, reduced anxiety, improved body image, as well as decreased time to resume sexual activity, and improved sexual function , frequency, and satisfaction. So while sex may look a bit different over time, it is a universal aspect of well-being and should not be neglected.
Jonathan Gallagher, BA, MPsychSc, PG Dip CBT, CRFC, is a senior psychologist in the Department of Cardiology (Cardiac Rehabilitation) at Beaumont Hospital, Dublin, Ireland.
To find a therapist near you, visit the Psychology Today Therapy Directory.