VOL: 97, ISSUE: 12, PAGE NO: 11
Carol Law, MA, RGN, RCNT, RNT, is senior lecturer, University of HertfordshireThe 'sexual revolution' that has taken place during the later part of the 20th century has seen the media become more tolerant towards private sexual behaviour and public sexual speech, although conservative political forces have demonstrated a considerable opposition which has resulted in jumbled social attitudes towards sexual issues (Maurice, 1999). His view is reflected in the attitudes of many health care professionals towards the sexual health needs of their clients.
The 'sexual revolution' that has taken place during the later part of the 20th century has seen the media become more tolerant towards private sexual behaviour and public sexual speech, although conservative political forces have demonstrated a considerable opposition which has resulted in jumbled social attitudes towards sexual issues (Maurice, 1999). His view is reflected in the attitudes of many health care professionals towards the sexual health needs of their clients.
Maurice cited a study where lay interviewers who were complete strangers to the interviewees conducted a detailed 90-minute interview with adults aged between 18 and 59 regarding their sexual behaviour. They concluded that adults were quite willing to talk about this, provided the interview was conducted in a respectful, confidential and professional manner. If lay people with minimal training are able to discuss such matters with strangers, one could argue that health care professionals should also be able to do so.
Defining sexual health
Sexual health encompasses more than making love or safe sex. Curtis et al (1999) argued that the World Health Organization gives a broader view through its definition which comprises the following:
- A capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic;
- Freedom from fear shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationships;
- Freedom from organic disorders, diseases and deficiencies that interfere with sexual and reproductive functions: sexual health promotion should include any intervention that improves physical or psychological sexual well-being.
Respiratory symptoms and physical/psychological sexual well-being
People with respiratory disease may experience a wide range of symptoms, including shortness of breath, cough, sputum production, wheezing, fatigue, anxiety and depression. Each of these may have an impact on the sexual health of the individual from either a physical or psychological perspective. Someone who is short of breath as a result of chronic obstructive pulmonary disease may not be prepared to exacerbate this by making love, while the copious production of sputum often associated with bronchiectasis may deter potential sexual partners and make the individual feel unattractive. Therapeutic interventions associated with respiratory disorders may themselves influence sexual health - for example, an oxygen mask provides a physical barrier to kissing, and steroids and theophylline may cause loss of libido.
Respiratory disease can impact on individuals' sexual health in a variety of ways at different stages of their life. For example, children with asthma may be small for their age, have decreased exercise tolerance, increased time off school and need to take medication regularly. This may lead to them feeling different from their peers, having low self-esteem and an altered body image.
Teenagers with asthma may be confronted with an acute asthmatic attack as a result of the emotional excitement arising from a first sexual experience which may, in turn, impact on future sexual encounters. Young adults with cystic fibrosis need to consider the risks associated with pregnancy.
Adults with chronic lung disease may have to address changes in role function as well as loss of libido. The use of non-invasive positive pressure ventilation at home may result in the partner sleeping in another room.
The impact on both physical and psychological sexual health needs is evident. From a physical perspective Constain et al (1991) identified four key areas of sexual dysfunction: inhibited sexual desire, inhibited sexual arousal, inhibited orgasm and other problems.
Inhibited sexual desire
Individuals may be fatigued, need to spend energy to perform activities of daily living or be dyspnoeic and hypoxic which can lead to decreased libido. Fear of dyspnoea during sexual activity, altered body image and feeling unattractive may lead to inhibition of sexual desire. Medications such as theophylline may cause nausea, headaches, restlessness, irritability and subsequent loss of libido, while steroid therapy may cause fluid retention, obesity, easy bruising and inhibited sexual desire.
Inhibited sexual arousal
Studies examining impotence in people with respiratory disease have highlighted problems such as erectile dysfunction (Fletcher and Martin, 1982). This may be due to psychogenic problems associated with chronic disease, but it has been argued that this can happen in chronic obstructive pulmonary disease when other known causes of impotence are absent.
Studies examining sexual arousal in women with respiratory disease are extremely rare. However, there is anecdotal evidence to suggest that the psychogenic problems described in male studies also affect women and their potential sexual arousal. Atropine-based compounds can have a drying effect on vaginal secretions, which can affect the sexual experience.
This is not necessarily specifically due to respiratory disease but may be caused by concomitant disorders and associated treatment along with psychological issues. A study focusing on cystic fibrosis concluded that the severity of the disease did not correlate with the presence of sexual difficulties (Levine and Stern, 1982). This can be compared with work suggesting that in chronic lung disease there is not a direct correlation between the degree of disability (demonstrated by respiratory function tests) and the individual's perception of breathlessness, which may subsequently impact on sexual activity.
In general respiratory disease itself does not cause physical changes in sexual responsiveness, but concomitant medical conditions and medications can do so and need to be addressed.
Gift (1993) discussed a multidimensional approach to the management of breathlessness, namely physiological, psychological, social and cognitive. This approach reflects the broader definition of sexual health proposed by Curtis et al (1999).
When considering sexual health from a physiological perspective, the aim is to reduce (minimise) energy expenditure while maximising pleasure. Strategies that reduce the amount of oxygen or mets (the amount of oxygen consumed per kilogram of body weight per minute) needed by the body need to be assessed. It is estimated that penis-to-vagina intercourse utilises three to four mets, which is approximately the equivalent of walking three miles.
There are a variety of positions for sexual intercourse which limit energy expenditure for the breathless patient. This, in conjunction with timing of sexual activity to coincide when energy levels are optimal, can help reduce the impact of breathlessness on performance. Having sex after using inhalers or physiotherapy and the use of supplemental oxygen during sex may also help reduce breathlessness.
The partner should also be advised to avoid putting pressure on the affected individual's chest wall. The use of sex aids, such as a vibrator, will avoid the need for high levels of energy expenditure. Mutual masturbation and oral sex are also strategies that require low levels of energy expenditure, while the use of a waterbed may facilitate movement.
The aim of this aspect of care could be said to be to enhance self-esteem and address anxiety and depression with regard to their impact on sexual health. It is not the intention of this article to explore strategies that may be helpful when addressing an individual's adaptation to an altered body image or to consider the management of anxiety and depression. However, it is important for nurses to recognise that they can form an integral part of the management of sexual health needs in respiratory patients. Nurses can contribute to this process by giving advice and support regarding patients' experiences of breathlessness while making love.
Increased breathlessness is normal during sexual intercourse and is usually harmless. Indeed, Currigan and Gronkiewicz (1988) argued that the energy expenditure during sexual intercourse can be equated to climbing two flights of stairs. If this is tolerated then reassurance can be given that the dyspnoea provoked should be of no more danger than climbing stairs.
From a social perspective the aim of care is to promote social interaction and address the potential impact on interpersonal relationships. This is closely related to the psychological component. For example, someone who has failed to come to terms with an altered body image may withdraw from company. It is also linked with the physical management of breathlessness. Poorly controlled symptoms may lead to depression, withdrawal and an increasing spiral of debilitation.
From a sexual health perspective the nurse may wish to consider encouraging communication between partners with regard to their sexual likes and dislikes and to discuss how one can express oneself in other ways such as hugging, stroking and caressing. Asking how the illness has affected their relationship with their partner provides an opening for patients to discuss any problems they may have.
Indeed, the effect of respiratory disease on sexual health may depend on the way in which the patient's partner responds. Facilitating discussion does require the nurse to feel confident and skilled enough to deal with the responses received. Maurice (1999) identified that nurses did not routinely take a sexual history.
Identifying coping strategies and ways of adapting to the disease promotes a sense of control. Nurses need to be self-aware and have the confidence to raise these issues in a professional manner if they are going to recognise sexual health problems. Patients may or may not wish to discuss their sexuality, but it is an area of care nurses should not overlook.
If nurses are to deliver truly holistic care then the development of appropriate interpersonal and communication skills will go some way to facilitating this. Nurses must recognise that they often need to take the first steps in initiating this avenue of discussion and give the patient permission to raise areas of concern. This is not always easy in busy wards or clinics.