By Rebecca Harrell, BA, Elizabeth Jordan, BA, Rajasekar Nekkanti, MD, and Samuel F. Sears, PhD | East Carolina University
Cardiac events can shake up patients’ home dynamics – including in the bedroom, where some level of dysfunction and/or apprehension related to sexual activity is normal following a scare. Restoring confidence and engagement in exertion remain at the core of cardiac rehabilitation, however, and this pursuit extends to the restoration of intimacy and sexual behavior.
Although the vast majority of patients want to address these issues with their provider, follow-through rates remain low1 2. Barriers that often discourage providers from engaging in conversations around sexual health include topic sensitivity, perception of scope of practice, elevated anxiety symptoms, lack of training, time constraints and cultural and language barriers3. Integration of routine sexual health assessment and intervention following a cardiac event would help support providers in this respect.
Approaching Sexual Health Topics with CR Patients
Set the stage. The majority of patients will not initiate conversations around sexual health concerns. Increasing patient comfort around this topic can help to set the stage for the conversation to occur in an environment that is perceived safe and without judgement. Some questions to spark the conversation include:
- Are there any sexual concerns or questions you would be willing to discuss with me today?
- Have you noticed any changes in sexual intimacy since this event occurred?
- How are these changes affecting you?
- Have you been worried that your cardiac condition will get in the way of sexual intimacy?
- How comfortable have you been with re-engaging with intimacy since your event?
- Do you or your partner have any fears or concerns about re-engaging in sexual activity since experiencing this cardiac event?
Assessment with empathy. Assessment of sexual health concerns involves gauging patient willingness to discuss concerns and determining presence, severity and maintaining factors. Because sexual health concerns often persist, routine assessment and follow-ups across appointments promote thorough evaluation, strengthen patient-provider comfortability with the topic and allow for continued assistance as patients begin to disclose and work toward addressing concerns3 4.
Educate patients and reinforce patient sense of safety and security with evidence. Current American Heart Association guidelines for returning to sexual activities vary slightly across disease state. However, in general, patients with stable cardiovascular disease (e.g., stable symptoms and good functional capacity) can resume sexual activity with minimal risk. For patients with unstable or severe symptoms, proper treatment can facilitate return to sexual activity, and exercise testing and comprehensive physical examination can be administered should further insight into safety of engagement be warranted5. Providing information about safety of sexual activity and impact on QOL is an identified patient need and can address misconceptions around safety of resumption2 6.
Normalize patient experience. Following a cardiac event, many patients may feel misunderstood, isolated, embarrassed, and increasingly hesitant to engage in sensitive topics around sexual health. Because of this, prioritizing comfort of the patient goes beyond first initiating the conversation. Normalizing the patient’s experience in reinitiating sexual behavior throughout the conversation can help decrease feelings of discomfort and embarrassment. Review prevalence of sexual health concerns to let the patient know that they are not alone. Rather, sexual health concerns can be expected for someone in their position, and as such, plans to address concerns can be created.
Tailor conversation and intervention measures to the patient in front of you. Treatment plans for addressing sexual health concerns should be developed collaboratively with the patient. Spend time understanding potential lifestyle factors exacerbating sexual health concerns and incorporate behavioral change where applicable. If possible, involve patient’s partner to join the conversation and weigh in on potential treatment plan. Partners can often provide valuable insight on feasibility and offer support to the patient throughout. Present treatment options that are viable and practical for the patient. These can include medications, sexual aids including devices and products for both men and women, and vaginal moisturizers and lubricants. Advantages and disadvantages of treatment options should be reviewed with the patient and recommended in accordance with the patient’s risk level1 7.
Takeaways for Providers
- Sexual activity is safe for cardiac rehab patients.
- Sexual activity is integral to sense of normality, return-to-life and improved quality of life.
- Most patients following cardiac event will experience sexual health concerns, and many are waiting for you to bring it up.
- Provider-initiated conversations improve patient outcomes.
- Empathy, assessment, education, and planning are key components of approaching and addressing health concerns.
Resources for Patients and Providers
All cardiac patients undergo multiple changes following a cardiac event. Re-initiation of sexual behavior represents an important milestone for many patients toward normalcy and confidence. Although the topic can be considered awkward in layperson conversations, for the cardiac rehab professional, it represents an essential component in patient care. In the end, significant benefit can be achieved with an empathic supportive discussion about sexual behavior to reassure return to this part of quality of life.
- Rosman et al. (2014). Sexual health concerns in patients with cardiovascular disease. Circulation (New York, N.Y.), 129(5), e313-e316. https://doi.org/10.1161/CIRCULATIONAHA.113.004846.
- Schwarz et al. (2008;2007). The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure. International Journal of Impotence Research, 20(1), 85-91. https://doi.org/10.1038/sj.ijir.3901613
- Arora et al. (2015). Guidelines for Sexual Counseling in Patients with Cardiovascular Disease. Osteopathic Family Physician, 7(5).
- Steinke et al. (2013). Sexual counselling for individuals with cardiovascular disease and their partners. European Heart Journal, 34(41), 3217-3235. https://doi.org/10.1093/eurheartj/eht270
- Levine et al. (2012). Sexual activity and cardiovascular disease: A scientific statement from the american heart association. Circulation (New York, N.Y.), 125(8), 1058-1072. https://doi.org/10.1161/CIR.0b013e3182447787
- Abramsohn et al. (2013). “I'm not just a heart, I'm a whole person here”: A qualitative study to improve sexual outcomes in women with myocardial infarction. Journal of the American Heart Association, 2(4), e000199-n/a. https://doi.org/10.1161/JAHA.113.000199
- Kostis et al. (2005). Sexual dysfunction and cardiac risk (the second princeton consensus conference). The American Journal of Cardiology, 96(2), 313-321. https://doi.org/10.1016/j.amjcard.2005.03.065