FACTORS AFFECTING SEXUALITY AND SEXUAL EXPRESSION IN AGING

Alex Comfort noted author of “The Joy of Sex” and “More Joy of Sex,” stated in 1976 that there were three primary reasons people stopped having sex as they grew older:

1. Societal messages often imply that older people are not supposed to be sexual. Messages about sexuality and aging that we receive over the years can have a major impact on our sexuality and sexual expression as we mature. We hear stories and derisive comments about “dirty old men” and nowadays even about older women who enjoy sex. Older adults frequently get the message that they look and act ridiculous being sexual.

2. Lack of a partner

3. Illness and disability The loss of a partner and some type of illness and/or disability are frequently a part of the aging process. Medical, surgical, and disabling conditions that may occur with aging, including diabetes, hypertension, heart disease, stroke, and prostatectomy, along with the impact of medications taken for various conditions, can have a profound impact on sexuality and sexual expression.

In addition to the three factors noted by Comfort (1976), a fourth factor affecting sexuality is:
4. Natural changes of aging. While many of these changes are viewed as negative, some are actually considered positive. For example, the ability to delay ejaculation may be increased, and for the man who has experienced rapid ejaculation as a younger man, this change can be a benefit.

Another effect of aging is that there may not be an ejaculation or orgasm with every act of intercourse, a prospect that younger men may consider disconcerting. Many men, however, say that as they age they make much better lovers because they are more concerned and focused on their partner’s enjoyment.

Several years ago a story was told about Helen Gurley Brown’s husband and some of his friends making a nude male calendar—in order to be featured on the calendar, men had to be over the age of 60. At the time, the statement was made by these older men that, “Women are more interested in our 20 minutes than in our 20 millions, because we are now much better lovers.”

AGING--PHYSICAL CHANGES ON SEXUAL EXPRESSION

MALE

1. More time and more direct physical stimulation are necessary to get an erection.
2. An erection may be less firm.
3. The ability to delay ejaculation is increased.
4. There may not be an ejaculation or orgasm with every act of intercourse.
5. Semen release may be less forceful and the volume may be decreased.
6. The refractory period is longer, perhaps days.
7. There is typically a marked decrease in fertility. (WebMD, 2007a)

FEMALE

1. There is some loss of lubrication and some thinning of the vaginal walls with loss of elasticity.
2. Honeymoon cystitis may occur, because as the vaginal walls become thinner, the bladder and urethra are less protected.
3. There is some narrowing and shortening of the vagina.
4. The size of the clitoris may be reduced, and the covering may lose some fatty tissue, resulting in irritation.
5. There is some increase in susceptibility to vaginal infections due to decreased acidity of secretions.
6. A longer time is needed to become excited.
7. Orgasmic contractions may sometimes become uncomfortable, or orgasms may be shorter and less intense. The capacity for multiple orgasms remains. (WebMD, 2007b).

15. Relationship issues

a. Lack of attraction to the partner may contribute to lessening of sexual desire. Weight gain in either partner, body changes that happen with aging, disfiguring injuries or surgeries, pregnancy, communication problems, and boredom are common examples of factors that can impact attraction
b. Poor social and relationship skills as well as poor lovemaking techniques can, particularly over time, lead to diminished sexual interest. In general, women tend to be more sexually interested and attuned when the overall relationship is going well and they feel cared for and loved. On the other hand, many men view having sex as the way they express love for their partner.
c. Fear of closeness and vulnerability may impact sexual desire. Many people believe that the most fulfilling expressions of sexuality occur in relationships where individuals feel free to express themselves in a loving atmosphere without fear of condemnation or criticism.
d. Passive-aggressive issues can result in sexual interactions becoming a silent battleground. With passive aggressive behaviors, individuals may appear to be agreeable and compliant, but then will exhibit behaviors that are contrary to expectations. A woman may voice interest in pursuing sexual activity, but then the evening will be filled with other activities or she may complain of a headache. Or one spouse may use silence to exert control in certain areas. The partner may not know how to respond. These behaviors repeated over time can turn into a vicious cycle of anger, blame, resentment, and distancing. The therapist’s task in these situations is to help create a climate of safety and enhance communication effectiveness so that couples can relate honestly and openly.
e. Marital conflict, unresolved anger, and other relationship issues can also have adverse effects on sexuality and sexual expression. Obligatory sex and sex that has become mechanical, scripted, and impersonal can exact a toll on sexual desire. It seems that sex often has to be all about intercourse, and a person’s body or mind or spirit is too fragile to handle intensity.
f. The madonna-prostitute (aka madonna-whore) syndrome occurs when a man is sexually attracted to other women, but not to his wife. In this syndrome, the male psyche divides women into two mutually exclusive categories: the good girl and the bad girl, the madonna and the prostitute. The good girl is the idealized, asexual woman, the virgin/wife/mother who bakes chocolate chip cookies, puts Band-Aids on cuts, and gives hugs to make hurts go away. The bad girl, on the other hand, is the eroticized woman, the hussy or whore who represents sexual lust and satisfaction. For some men this problem surfaces after their wives have given birth for the first time. This is often a very difficult issue to work with therapeutically.

Examples of Therapeutic Considerations in Addressing Sexual Desire in Women

Therapist #1: “Some women feel that they should desire sex every time they have it. They say they would feel fake if they have sex and they don’t feel desire. So, if they don’t feel desire, then they don’t have sex. It’s okay to have sex even though we don’t feel desire. As long as you care for your partner, there is no coercion, abuse, or pain, and you find sexual activity enjoyable, then sometimes it is okay to decide to have sex – without desire. Many women say, ‘Even though I may not be sexually interested at the time, I find once we get going it is very enjoyable and I like the closeness and the benefits to our relationship.’”

Therapist #2: Another therapist in addressing one client’s depression and accompanying lack of sexual desire who is continuing to have sex, states, “The sex she is having for the sake of her husband suggests a pattern of fusion and co-dependence in their relationship and a need for an increased level of differentiation. It has been my observation that when women engage in ‘duty’ or ‘mercy’ sex and do not hold on to themselves and their integrity, they eventually come to hate sex, hate their partners, and hate themselves. This could well be a significant part of both the depression and the sexual shutdown. 

That's not a problem that chemicals are going to fix. I don't get that drug therapy is the solution and it may well be part of the problem. Since desire in women is so linked to emotional intimacy and meaning, if she is not responding to meaningless ‘duty sex’, that's a sign of health, not pathology. As part of my evaluation, I would want to know about thyroid function, testosterone levels, diet, nutrition, exercise, use of substances (nicotine, alcohol, pot, caffeine). I am admittedly a minority voice in a pharmaceutically dominated industry, but I would much prefer to look to a comprehensive holistic treatment paradigm including nutrition, extra B vitamins, omega 3 oils, eliminating toxic substances, exercise, and intensive Integrated Marital and Sexual Therapy.

If a mood enhancer is indicated, my preference is to begin with less toxic agents such as SJW, 5HPT, Tryptophan, SAMe and only turn to pharmaceuticals when absolutely necessary and less toxic agents and approaches have failed. If you are not familiar with these approaches, a naturopathic physician could be of help. The situation becomes more clinically and professionally complicated when she is already under psychiatric care in the pharmaceutical paradigm. There are also significant difficulties in getting people off of drugs like Effexor, and abrupt discontinuation is highly inadvisable. I have to reluctantly admit that for some patients SSRIs are extremely helpful and even lifesaving” (Personal communication, AASECT Listserve)

16. Medical, Surgical, and Disabling Conditions

This section of the module includes a brief overview of the sexual implications of medical, surgical, and disabling conditions. A large number of these conditions exist and many, if not most, are believed to have sexual difficulties of one sort or another associated with them.

The large number of conditions precludes a discussion of the impact of each of these on sexuality. Representative groups are presented here. These include diseases (diabetes, heart disease, and hypertension), surgeries (hysterectomy, mastectomy, and prostatectomy), and disabling conditions (arthritis, stroke, and spinal cord injury).

Information on these commonly occurring conditions will enable you to understand and address issues that apply generally (to many conditions) and specifically (to similar conditions as those presented).

General causes of problems related to sexuality and medical, surgical, and disabling conditions include:

1. Impact of the diagnosis
2. Effects of the illness, surgery, injury
3. Effects of treatments (medications, etc.)
4. Threats to self concept and body image (e.g., decreased feelings of attractiveness)
5. Changes in societal role expectations
6. Lack of information and knowledge about what to expect or of sexuality resources
7. Myths and misconceptions
a. Sex no longer a part of one’s life
b. Illness as a punishment for sin
c. Others (e.g. sexual activity will lead to another heart attack)
8. Unrealistic sexual expectations that make sex a task rather than a pleasure
9. Stress, anxiety, fear, or anger
10. Fear of rejection and of losing partner
11. Partner’s attitude
a. Fears of injuring the other person
b. Guilt about wanting sexual contact
c. Lack of attraction to other person
12. Poor communication with a partner
13. A "vicious cycle" of doubt, failure, or negative communication that reinforces the problems
14. Attitudes of family and friends
15. Attitudes of healthcare providers

Unfortunately one of the frequent occurrences with any health changes and concerns is that sexuality is not addressed by the healthcare community, and patients are often “on their own” to discover solutions. If the topic is mentioned at all, information may be so vague as to be largely unhelpful.

For example, following a heart attack, a patient was told, “When you have sex, take it easy.” Whatever this means in terms of practical application is left up to the individual’s interpretation. Another patient reported that a therapist told her, “Just go to Victoria’s Secret and get something sexy, and things should work out.”
The importance of having someone open and knowledgeable to talk with can not be underestimated in terms of patients’ healing and adaptation to the life changes brought about by an illness, injury, or disability. Recognition of sexuality as an integral aspect of recovery has given rise to articles, journals, books, and many internet resources to address these issues.

In addition to the problems related to sexuality and physical conditions, there are several variables that affect intimacy in disease or disability:

1. Viewing the disease/disability as an issue affecting both partners
2. Establishing healthy boundaries - remembering that the relationship is about more than the disease/disability
3. Communicating perceptions and feelings about what has happened
4. Addressing the changes in living & lovemaking
5. Identifying and renegotiating gender-defined roles
6. Establishing a balance between time-together and time spent apart—partners being considerate of each other’s needs
7. Sensitive and open communicating about intimacy and nurturance issues
8. Exploring varied forms of sexual expression

Life changing events that impact sexuality and sexual expression can provide an opportunity to alter the focus on sexual intercourse as the “ultimate” form of sex (i.e., the American idea of sex). There are many ways of being sexual (the concept of non-goal-directed sex) that provide sexual satisfaction and physical and emotional intimacy.

Once again, healthcare practitioners who provide patients an opportunity to talk openly and explore sensitive issues are in all likelihood having a significant impact on the future sexual health and quality of life of patients and their significant others.

Medical, Surgical, and Disabling Conditions that Affect Sexuality

Diabetes

Diabetes is a condition in which sugar (glucose) remains in the blood rather than entering the body's cells to be used for energy. This results in persistently high blood sugar which, over time, can damage many body systems. In Type 1 diabetes, usually diagnosed in children, teens, or young adults, the cells of the pancreas do not make insulin, and in Type 2 diabetes (the most common type), which can develop at any age, the cells of the pancreas do not make enough insulin.

Over time diabetes can interfere with sexual function because of a reduction in blood flow, hormonal changes, increased frequency of urinary tract and yeast infections, development of neuropathy (nerve damage), and psychological factors (Silverberg, 2005).
Although not all men with diabetes will have erectile dysfunction (ED), diabetes ranks as the number two cause of erectile dysfunction (running a close second to vascular insufficiency), and some studies suggest that at least 50% of diabetic men will develop this condition, some at young ages. Monitoring and maintaining appropriate blood sugar levels can delay or possibly prevent erection problems, but ED that occurs in men with well controlled diabetes is likely to be permanent (Vinik and Richardson, 1996).

Interestingly, an erection problem might be the first sign of an undiagnosed diabetic disorder and may precede the diagnosis of the disorder for up to a year. This is a primary reason for having a patient who presents in your office with an erection problem evaluated by an internist or urologist. Prostate problems related to diabetes can also impact erections and result in pain with sexual arousal and orgasm.

Retrograde ejaculation is common in males with diabetes who suffer from diabetic neuropathy (nerve damage). This is due to problems with the nerves in the bladder and the bladder neck that allow the ejaculate to flow backward into the bladder.

In the past, research on the sexual effects of diabetes has focused largely on men, but this is beginning to change. Men and women with diabetes can develop urinary tract and yeast infections that can cause discomfort for women during intercourse and for men during urination and ejaculation.

In women, diabetes can result in decreased vaginal lubrication, also causing discomfort during intercourse, and some studies have found a decrease in orgasmic capability. The use of a good-quality water based or silicone based lubricant can help to alleviate the problem of decreased lubrication (Silverberg, 2005).

Note: Use of the birth control pill may raise blood glucose levels and over time may increase the risk for diabetes complications.

Heart Disease

Cardiovascular disease is the number one killer in America today. More than one in five Americans suffer from some form of the disease, and two of every five Americans die of the disease. Depression, another common condition in America, is recognized as an independent risk factor for myocardial infarction (MI) and the presence of depression increases the likelihood of death from MI (Pozuelo, 2008).

Having had a heart attack (myocardial infarction—MI) often leads to fears of having another heart attack during sex. Research has shown that the absolute risk for death or MI during sexual activity is very low even in patients with known coronary artery disease (CAD). Also, heart attacks differ widely in severity and many men and women recover with little damage.

Today people with heart attacks once considered damaging can be treated with surgery and medications and then return to reasonably normal lives, including their careers. Fears of physical activity after a heart attack persist, however, and as a result many couples mistakenly believe intercourse is risky and abstain from it.

Couples may also avoid holding, caressing, or pleasuring because they think these activities may lead to intercourse. Unfortunately, these fears may place a strain on their lives and their relationships, and they may become depressed and adopt a lifelong defeatist attitude.

Note: While sexual dysfunction may be a consequence of heart disease, it may also be a risk indicator for arteriosclerosis and for heart disease, and as with diabetes, sexual problems may precede a diagnosis of underlying heart disease. Once again, physical assessment is essential before or in conjunction with sex therapy.

The following is a printable page to help clients assessed to be dealing with sexual concerns post-MI.

Specific Suggestions (PLISSIT Model) for Dealing with
Sexuality Issues Following a Myocardial Infarction (MI)

To help overcome fear and anxiety related to intercourse after a heart attack:
1. Preparations
a. Attempt intercourse only when you feel rested.
b. Have no time constraints or possibility of interruption.
c. Play soft, relaxing music.
d. Have a comfortable room temperature.
e. Take an angina preventive medication if indicated and prescribed (NOT with Viagra, Cialis, or Levitra—see precautions below).
f. Take the emphasis off having intercourse and focus on touch, sharing, and closeness by using sex play, mutual pleasuring, including mutual masturbation, and self-pleasuring (masturbation) to orgasm.
2. Positions - Use the positions during intercourse that feel most comfortable and relaxing. The stress on your heart differs little whether you are on top or on bottom.
a. If the male is on top it may require less muscle activity if he is prone on his elbows, rather than extending his arms to support his upper body.
b. A side-by-side position may be used.
c. A wide chair may be comfortable.
Some of these positions are well illustrated in the following book:
Sipski, M. L. & Alexander, C. J. (1997). Sexual Function in People with Disability and Chronic Illness. Aspen Publishers, Inc.
3. Precautions
a. Avoid sex after heavy meals or alcohol intake.
b. Avoid sex when under emotional stress.
c. DO NOT take Viagra, Cialis, or Levitra if you are taking nitrate drugs (ex. Nitroglycerin), as this combination could lead to a large, sudden and dangerous drop in blood pressure.

Patients Should Report the Following Symptoms to Their Health Care Provider:

1. Persistent angina during intercourse
2. Rapid heart rate or difficulty breathing that persists for 7 to 10 minutes after orgasm
3. Feelings of extreme fatigue after orgasm
4. Development or persistence of other sexual difficulties (Owens, 2004).

Note: Regular exercise reduces the risk of MI during sexual activity.

A study done in Japan several years ago looked at cases of sudden death during sexual activity. The number of such cases was found to be low, and times when it did occur appeared to be during periods of extramarital activity. The message to healthcare practitioners was to caution heart patients against having extramarital affairs (Lowen, 2004). This is a resource that is often cited and seems important.

Hypertension

As many as 50 million Americans have high blood pressure, the leading contributor to heart disease. Of those people, 35% do not know that they have it. There are often no presenting symptoms, especially in the initial stages of the disease. High blood pressure is easily detectable by mechanical monitoring devices and is usually controllable.

Persons with hypertension generally do not need to restrict sexual activity. However, the disease itself can cause clogging of blood vessels with fat deposits, resulting in the inability to achieve erection as blood flow is diminished. Also, drugs to control hypertension can cause erectile dysfunction (ED).

The effects of hypertension and antihypertensive medications on sexuality in women are not as well studied as those in men (The Merck Manual of Geriatrics, 2008).

Antihypertensive medications should be selected to avoid impairing sexual function whenever possible, and this issue should be addressed by the prescribing healthcare provider. It seems that there may be a general awareness about the sexual side effects of these medications.

However, if men do not know that they can report these changes to a healthcare provider and be offered different medications, they may stop taking the antihypertensive medications without reporting this to the provider.

Hysterectomy

The impact of hysterectomy is not the same for all women, emotionally or physically. Some women view the loss of their uterus as a grievous occurrence with serious emotional sequelae. Others are pleased that they no longer have to worry about what may have become a troublesome physical encumbrance, particularly if they had experienced pain or excessive bleeding prior to surgery. Whichever is the case, a hysterectomy will most likely exert some type of impact on sexuality and sexual expression.

For women who have had an abdominal hysterectomy, there is the possibility of nerve damage that may impact sexual functioning. In addition, the effects of hysterectomy may be more dramatic if the ovaries are also removed (oophorectomy).

Testosterone, one of the hormones of sexual desire in both men and women, is produced in the ovaries and adrenal glands, and removal of the ovaries will eliminate this source. As a result, the sexual response cycle may change, beginning with a decrease in sexual desire.

Some women report decreased desire, while others report little change. Lubrication may decrease due to a decrease of estrogen, and the experience of orgasm may also change to varying degrees.

One therapist reports anecdotally that the women she sees who note the biggest negative changes in orgasm are those who incorporate much vaginal/G-spot stimulation in their sexual encounters, while those who use primarily clitoral stimulation do not report major differences following hysterectomy. Also, for those women who enjoyed the experience of uterine contractions during orgasm, the loss of orgasmic intensity may be a concern to them.

Adjusting to physical and hormonal changes post-hysterectomy may take three to five months, perhaps longer. For many women, hysterectomy may be a very emotionally loaded surgery, despite how ‘routine’ it is. In approaching the sexual assessment with a post-hysterectomy woman, it may be helpful to explore with her the circumstances of the hysterectomy, what it means to her, her partner’s responses, and other considerations.

Suggesting Sensate Focus exercises can be a valuable way of aiding her in re-sexualizing and learning what feels best given the changes in her body. She may need a different or increased method of stimulation. Adjunctive therapies that might be helpful include physical therapy (by a therapist who specialize in pelvic floor therapy) and massage therapy (including abdominal massage).

Clinical studies have shown that post-hysterectomy sexual functioning and depression are strongly influenced by PRE-hysterectomy sexual functioning and by PRE-hysterectomy psychosocial state. It is noted that only a small number of women are reported to develop post-hysterectomy sexual dysfunction, and the literature is not conclusive (Maas, Weijenborg, & ter Juile, 2003).
Note: For uterine fibroids, an experimental surgery, Uterine Artery Embolization (UAE), also called Uterine Fibroid Embolization (UFE) is currently being promoted as an alternative to hysterectomy or myomectomy (removal of just the fibroids, leaving the uterus intact). In UAE, a substance of gelatin or polyvinyl alcohol is injected into the uterine arteries to block the flow of blood into these vessels. Cutting off the blood supply is supposed to result in shrinkage and death of the fibroids. There are reported adverse effects of the surgery, and UAE is too new to know what the long-term effects will be. In addition, even though UAE is a less invasive procedure than hysterectomy, it does not guarantee an absence of sexual side effects (Lai et al., 2000).

Note: Some women also report lowered sensation following C-sections and other abdominal surgeries.

Mastectomy

Mastectomy is the surgical removal of the breast and varying amounts of surrounding tissue, which can include chest muscles and lymph nodes under the arm. Following surgery, there may be skin numbness, scarring, and swelling of the arm and hand if lymph nodes have been removed.

Many women have sexual difficulties following mastectomy due to physical changes and also to an altered body image. Chemotherapy and radiation can magnify these difficulties, as the side effects of these treatments can cause loss of desire, diminished arousal, and lowered intensity of orgasm, in addition to the self esteem issues of hair loss, weight gain or loss, and changes in skin texture.

The reaction of a partner to a woman’s mastectomy is important in her overall recovery and in their future sexual relationship, and the partner should be included as much as possible in the experience. A man may be fearful of approaching his partner for intimate contact, while she may be concerned about not being desired.

As in almost all areas of sexual interaction, communication is the key. Healthcare professionals can help to facilitate open and honest communication between partners.

For individuals who are not in current intimate relationships, entry into new relationships can be difficult. People whose disabilities are visible may be viewed as asexual, and those with conditions that are not readily visible are often confronted with the dilemma of whether or not (and also when) to disclose their disability to a prospective lover.

Prostatectomy

Prostatectomy involves the surgical excision of part or all of the prostate gland. This procedure may result in permanent erection problems, particularly if the incision is in the perineum. For men with prostate cancer, erectile dysfunction (ED) has been the primary form of sexual dysfunction investigated.

Prevalence rates of ED have varied. In general, high rates of sexual difficulty have been reported in radical prostatectomy, radiation therapy, including external-beam radiation therapy (a high-energy x-ray directed to the prostate tumor), brachytherapy (implanted radioactive seeds or a series of radiation treatments through very small plastic catheters placed in the prostate gland), and cryotherapy (a controlled freezing process).

ED appears to be least prevalent with brachytherapy and most prevalent when cryotherapy is used (to treat localized prostate cancer (UPMC Cancer Centers, 2008a).

The study of the specific anatomy of the pelvic nerves in the male enabled surgeons to develop nerve-sparing techniques for radical prostatectomy in 1982, and subsequent refinements have facilitated the preservation of sexual functioning in many patients undergoing this procedure.

If the nerves are not damaged during surgery, erections may return within 2 to 18 months. For some cancers, however, nerve damage can not be avoided if all the cancer is to be removed, and erection problems associated with these surgeries are permanent (UPMC Cancer Centers, 2008b).

A new practice that has developed in the recent years is the practice of penile rehabilitation. Following nerve-sparing radical prostatectomies, patients will have some degree of damage to the neural pathway and will likely lose natural nocturnal erections, resulting in less blood flow to the penis and eventually fibrosis of the penile tissue.

Oral ED medications will not work during this time because the neural pathway needs time to regenerate. The purpose of early penile rehabilitation is to increase blood flow to the penis so that the penile tissue is maintained while the neural pathway regenerates, allowing for a much higher likelihood that oral medications will be effective.

A study reported to the annual meeting of the American Society of Reproductive Medicine found that the post-surgery use of intraurethral alprostadil (MUSE), a vacuum erection device (VED), or intracavernosal injections, (refer to the section on male sexuality) were all effective in improving patients' ability to have an erection up to a year after surgery, with the MUSE offering the best outcomes. The study also found that with early penile rehabilitation, patients could have sexual activity two or three months after surgery, whereas in the past they had to wait at least 12 to 18 months (Palkhivala, 2005)

Early penile rehabilitation through one of these three methods may represent the best first-line treatment option for the first few months following nerve-sparing radical prostatectomies, as their mechanism of action does not require intact neural tissue for erection. After this time period, oral phosphodiesterase 5 (PDE5) inhibitor therapy (i.e., Viagra, Cialis, Levitra) may be a reasonable choice for those patients who can achieve at least a partial erection. A PDE5 inhibitor may not be effective when spontaneous erections are absent (Palkhivala, 2005).

A prostatectomy also causes ejaculation changes which include a decrease in the amount of ejaculate, as a portion of the ejaculate is made in the prostate gland. Retrograde ejaculation may also occur—in this condition, semen is propelled backward into the bladder instead of into the urethra and out of the body.

These changes may result in an orgasm without semen—a dry orgasm. Some men say that a dry ejaculation feels no different and often their partners do not notice or do not mind the difference. Other men, however, find that dry orgasms are weaker or feel less pleasurable than their orgasms before surgery. Urinary incontinence may be problematic to varying degrees with the surgical procedures but is reported in many instances to improve over time. (MayoClinic.com, 2007).

The New View Campaign (Tiefer, 2006) reported a study of 18 men ages 57-75 following their treatment for prostate cancer. The men were ethnically diverse, and four were gay. Researchers found that one of the men’s greatest struggles involved the realization of the symbolic importance of sexual capacity.

Rather than being an isolated function, sexuality emerged as an integral component of the men’s identities and lifestyles. Challenges to their sexuality and masculinity including incontinence, loss of the ability to work, fatigue and body changes resulting from anti-androgen hormones treatments had a greater impact than impotence.

The New View Campaign for Men (Tiefer, 2006) stresses the importance of addressing the domains of sexual concern described by prostate cancer patients.

Sexual performance
a. Anxiety about satisfying a partner and oneself
b. Hesitation in initiating physical intimacy
c. Feeling that sex is awkward and unnatural

Relationships with women
a. Awareness of loss of potential for sexual intimacy
b. Disquieting absence of a sexual element in everyday interaction

Sexual imaginings
a. Distressing lack of physical or emotional response to attractive women
b. Loss of pleasant pastime: fantasizing about sexual intimacy

Masculinity
a. Sense of oneself as a man diminished
b. Loss of defining feature of manhood

Arthritis

Arthritis and the debilitating effect of chronic body pain on the person’s sense of well-being can affect sexual function in either subtle or significant ways. Certain sexual positions can result in pain. Experimenting with positions that do not aggravate joint pain can be helpful, as can a program of exercise, rest, and warm baths.

Planning for times of day when arthritis pain and stiffness are less severe can also be helpful. For some rheumatoid arthritis patients, regular sexual activity relieves their pain for 4 to 8 hours, possibly because of hormone production, release of endorphins, or the physical activity involved (The Merck Manual of Geriatrics, 2008).

Stroke

Stroke can impact life and sexuality in a large number of ways, and the recovery process involves dealing with all the changes that can result from a stroke. Physical and emotional consequences that can negatively affect desire or the ability to act on desire include:

1. Hemiplegia (the vertical half of a person’s body is weak or paralyzed)
2. Muscle spasms or stiffness, bowel or bladder incontinence, fatigue, vision problems, and lack of balance.
3. Problems with memory and learning new things
4. Personality change
5. Poor ability to communicate
6. Depression in either partner
7. Fears (of having another stroke, of sexual failure, of being rejected or not being loved, etc.)
8. Adjusting to a self-image which has been dramatically altered
9. Disappointment in terms of performance in many life areas
10. Self-doubts about one's capability of dealing with these changes

Other factors that directly impact sexuality and sexual expression include:

1. After the initial disruption of a stroke, couples may lose the habit of making love.
2. The side effects of medications, particularly those for high blood pressure, may affect sex drive and performance. (It is very important that this be discussed with the patient and his/her partner).
3. Right brain damage may alter attention span, judgment and planning, making previous patterns of sexual activity difficult or impossible.
4. The non-disabled partner may lose sexual interest because of the spouse's altered appearance and manner.
5. It may be hard for the caregiver to shift from giving physical care to being a lover.

In the initial stages of recovery from a stroke, sex is less important than issues of possible mortality and, then, of mobility or speech. However, as recovery progresses and survivors and their spouses begin again to have sexual feelings, an informed and positive approach to the effects of stroke on sexuality can enhance recovery and strengthen self-esteem.

A stroke does not have to mean the end of one's sex life. Although there is often fear involved in resuming sexual activity, this activity has not been shown to cause stroke or to increase neurologic deficit after stroke.

Unless brain damage is severe, sexual desire is not generally impacted by a stroke. Sexual functioning, however, is likely to be affected to some degree. In the area of erectile capability, some male stroke patients experience dysfunction; male partners of stroke patients may also experience erectile dysfunction and/or loss of desire because they are fearful of causing injury during sexual activity.

Patients may have compromised sensory and motor activity that requires different types of sexual positioning and/or forms of expression. The unaffected side of the body should be the focus of physical stimulation during sexual activity. If motor activity is affected, pillows, headboards, or overhead chain grips for support during sexual activity can be useful. (Merck Manual of Geriatrics, 2008).

Traditional sex roles can also work to the disadvantage of individuals and couples adjusting to a stroke. There are those, men in particular, who feel that without intercourse, their sexual lives are over. Reducing the emphasis on sexual intercourse as the only way to enjoy sex can make other types of sexual expression, such as tenderness, touching, self-pleasuring, and other types of sex more acceptable, and allow stroke survivors a more positive outcome when contemplating sex after a stroke.

The New View Campaign notes the importance of general attitude toward sexuality (important versus not important) and patients’ ability to discuss sexuality with their spouses as more important components of continuing satisfaction with sexual life than libido, coital frequency, or functional abilities (Tiefer, 2006).

Adjusting to life and sexual changes after a stroke can definitely be a challenge, and counselors, therapists, and support groups can be allies in helping survivors and their partners integrate changes in positive ways.

These include:

1. Talking candidly and realistically about desires and ways to achieve them.
2. Experimenting with new ways of touching and positions for sex.
3. Attending to personal hygiene and appearance.
4. Realizing it will take time to rediscover what works best for people as individuals and as a couple.
5. Recognizing there are many ways to enjoy sexual activities and interaction.
6. Maintaining HUMOR and not taking setbacks too seriously.

Example: A good example of the success of humor was a couple in which the husband was the stroke survivor. One of the results of his particular stroke was that he wanted to have sex frequently—much more frequently than before his stroke. His memory was also impacted and he would not remember having sex even if it had happened only a short time before. His wife would have to remind him. This became problematic for her, because she did not want sex nearly as often as he did. Over time when he would ask for sex and she did not want to participate, she would tell him they had just had sex even if they had not. From her perspective, his memory loss was a benefit in this situation. The couple together told this story in a sexuality class and both of them were laughing and looking lovingly at one another.

Spinal Cord Injuries

Spinal cord injuries can exert a major impact on sexuality and sexual functioning. Today we sometimes use the example of a sexually active spinal cord injured person to illustrate that there is virtually no illness or injury that precludes some type of sexual functioning.

A spinal cord injury can be a devastating event at any time in life. However, many of the people who become spinal cord injured are young people (accidents) who are in the process of exploring their sexuality and relationships. For them, as well as others, the sexual repercussions of their loss can feel overwhelming. Fortunately today there are excellent sexuality resources available for spinal cord injured patients and their partners.

A spinal cord injury (SCI) affects a person’s sexuality physically and emotionally. The type (incomplete or complete) and level (high or low) of injury both exert an impact on a person’s sexuality and sexual expression. Men may not be able to experience psychogenic erections (arising from sexual thoughts, visual images, smells, sounds) or reflex erections (arising from direct physical contact to the penis or other erotic areas such as the ears, nipples or neck), although most men with spinal cord injury are able to have a reflex erection if the S2-S4 pathway is not damaged (Klebine and Lindsey, 2007).

While a number of men with SCI are capable of having an erection, the erection may not be hard enough or last long enough for sexual intercourse. There are various treatments and products available for treating erectile dysfunction (see ED section of this module), but men with SCI may have special concerns or problems with their use, and it is important to see a doctor or urologist for accurate information on the use of these products.

With all treatments, men with SCI must be watchful for signs of Autonomic Dysreflexia (AD), is a life-threatening condition that can occur when an irritation, pain, or stimulus to the nervous system sends a message to the brain and the message is unable to reach the brain due to an injury at or above the T6 level.

A reflex action takes place that tightens the blood vessels and causes the blood pressure to rise, sometimes to dangerous levels. Signs of AD include flushing in the face, headaches, nasal congestion, and/or changes in vision. (University of Alabama at Birmingham Spinal Cord Injury Model System, 2001).

For men, the ability to biologically father children will likely be impacted due to anejaculation (inability to ejaculate) or retrograde ejaculation (semen is propelled backward into the bladder). Options are available to assist men with spinal cord injury improve their ability to father children, including Penile Vibratory Stimulation (PVS) to produce an ejaculate or Rectal Probe Electroejaculation (RPE).

If these methods are unsuccessful, minor surgery can be performed to remove sperm from the testicle. Once sperm are collected they can be used in artificial insemination.

In the past, research on the sexual effects of spinal cord injuries has focused to a large extent on men. Women were told that they would no longer be able to feel sexual stimulation, but they would still be able to become pregnant and give birth. However, research by Komisaruk et. al (2004) has demonstrated that spinal cord injured women are indeed able to achieve orgasms.

These researchers discovered that although the majority of messages from the genital area are delivered to the brain via the spinal cord, the vagus nerve bypasses the spinal cord, allowing these women to orgasm.

Because every spinal cord injury is different, each person’s physical response is different, and individuals should be encouraged to explore their unique experiences and responses. Both men and women with SCI need to rely on their own observations and experiences to fully understand the changes in their sexual functioning.

Couples should be encouraged (and assisted in doing this if necessary) to have open and honest communication with one another and to explore and experiment with different ways to be romantic and intimate. Together, they can then discover what is sexually stimulating and enjoyable.

In assessing, teaching, counseling, and conducting therapy with SCI persons who have partners, including both partners in the process is important as a part of the overall recovery from the injury. Single individuals with spinal cord injuries often worry about future relationships and how they will meet and attract potential partners. Counseling with these persons will involve exploration of these issues and working through feelings of anxiety over establishing or continuing a healthy relationship.

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