By Gerene Bauldoff, PhD, RN, MAACVPR

Talking about sex is a learned skill – it isn’t a topic with which healthcare professionals are naturally comfortable. However, as part of a comprehensive assessment and individualized patient educational plan, it is an important component. When talking to patients about sex, it is important to understand that sex and intimacy are not just about a specific activity or outcome. Intimacy is the private nature of a person – social, emotional, sexual, etc.  

Chronic lung disease impacts sexual function. While the GOLD guidelines (2022) recommend evaluation of sexual function as part of a comprehensive assessment, no further information regarding how to evaluate or manage problems is provided. Zysman and colleagues (2020) report that 90% of COPD patients never had sexual dysfunction discussed by their health care providers.

In 2012, Collins and colleagues described the impact of sexual dysfunction on quality of life in men with COPD, reporting that 74% reported at least one sexual dysfunction and that erectile dysfunction (ED) was the most common (in 72% of the subset). While Polland and colleagues (2018) did not report an association between sexual dysfunction and chronic lung disease, they noted that depression and menopause impacted sexual function. As PR patients tend to be older (over 45 years of age) and may present with higher incidence of depression, our population can be impacted. Only one study evaluated the impact of PR on sexual function (Campos-Juanatey, et al., 2020), noting that both men and women reported increased sexual satisfaction following PR. With the increase in patients recovering from COVID-19 presenting to PR, Sansone and colleagues (2021) reported that contracting COVID is a significant risk factor in future ED development.

Developing Skills to Talk About Sex

Developing skills for sexual function assessment and education is a critical competency for the PR professional. Staff training can include professional journals, role modeling and practice to increase professional comfort with the topic while reducing personal embarrassment. PR staff need to self-assess their comfort level with discussing sexual matters. Also, what sexual terms are they comfortable with to describe sexual topics like fantasy, arousal, orgasm and/or behaviors? Self-assessment for personal attitudes and biases around sex and sexuality is also needed. Recognize that age differences between staff and patients can add to discomfort. Consider talking to your program’s psychologist/behavioral medicine specialist for suggestions regarding the subject.

Patient Assessment and Education Regarding Sexual Functioning

Assessment of sexual functioning should be incorporated into the comprehensive clinical assessment. This legitimizes and normalizes the subject for the patient and partner while giving them permission to discuss sexual issues. Remember that timing is essential! As with any sensitive subject, it would not be the first topic you would lead with in your assessment. You want to establish a rapport and gain a level of trust with the patient. While you would not want to treat this assessment as a laundry list of questions, you also want to avoid overt anxiety and trepidation as your tone will impact the patient. Avoid any overreaction to patient revelations. Be sure to ensure both privacy and confidentiality. As the PR professional you can address sexual concerns throughout the PR program. If your patient reports complex problems, refer to behavioral medicine that specializes in sexual dysfunction.

Exemplars of Sexual Function Assessment and Education

So what do you actually say to open the discussion with your PR patients?

Talking to a PR patient and their partner:

• What do you both enjoy?
• Where and how do you both like to be touched?
• Which aspects of sex do you both least like?
• Do you have any particular worries?
• In there anything that particularly embarrasses you at the moment?
• When is the best time of day for you to have sex?
• Which part of your own/partner’s body do you like most?
• What would you both most like to try? (Fantasy)

Considerations for the single patient add a layer to the discussion. For example, these patients can have added concerns related to discussing sex with new and/or potential partners. As PR professionals, you need to offer all sides of conversation such as when to delay discussion to avoid putting off a potential partner. Additionally, you should have the patient ascertain what type of sexual partner they are considering: long-term? More transient? Safe sexual practices should also be encouraged – condoms are not just to prevent pregnancy, but also sexually transmitted diseases.  Remember, older adults are experiencing a dramatic increase in STDs primarily due to unsafe sex practices.  

Specific Discussion Topics

Medications impact sexual function. For those patients with ED, the use of phosphodiesterase inhibitors can be considered, dependent on patient history. Short-acting bronchodilators may be used to avoid activity-induced bronchoconstriction. Remember, oxygen is a drug! For patients who require oxygen during activity, it should be used during sex.

Pre-sex preparations discussions should include bronchial and personal hygiene. Consider assigning “homework” such as candlelight dinners, flirtations, love notes, picnics and novel locations. Be sure to reinforce that intimacy is more than just the physical act. Discussion points during sex should include energy conservation and activity pacing.

For patients who report fatigue and/or dyspnea during sex:

• Explore alternate methods of expression
• Penetrative intercourse is not the only option! (Yes, you must get comfortable talking about oral sex).

Suggestions for sexual positions:

• Side- and bottom lying may be more comfortable by reducing work
• Top position allows patient to move into “tripod” position to improve breathing
• More comfort for the COPD patient enhances unaffected partner’s enjoyment

The Handbook of Adult and Pediatric Respiratory Home Care (1994) has an excellent chapter on Sexuality by Sally Crim-Tibbals that includes detailed illustrations of suggested positions. While the book is out of print, it is available on Amazon. The illustrations could not be included here due to copyright, but email me for further information (Bauldoff.1@osu.edu).

Finally, reinforce that intimacy is more than just a physical act. The biggest part of sex doesn’t occur in the genitalia, but in the brain. Sexual intimacy starts with emotional intimacy long before physical arousal occurs.

In conclusion, you need to start the conversation! Don’t wait for patient to broach the subject. Be aware of your values and biases and cognizant with your patient’s comfort with the discussion. You need to practice these discussions to become comfortable yourself. 

Be sure to create a welcoming environment. This includes use of posters with both heterosexual and same-sex couples. Make sure your forms are inclusive. All PR professionals need to develop this competency. Be cognizant how significant others/partners are treated in every couple your encounter!

References:

Campos-Juanatey F, Amado Diago CA, Varea Malo R, Agüero Calvo J, Correas Gómez MÁ, Portillo Martín JA. (2020). Assessment of the impact of pulmonary rehabilitation on sexual activity in patients with chronic obstructive pulmonary disease (article in spanish). Reviews in International Andrology 18 (4):144-150. doi:10.1016/j.androl.2019.04.006. Epub 2019 Sep 24.

Collins EG, Halabi S, Langston M, Schnell T, Tobin MJ, Laghi F. (2012). Sexual dysfunction in men with COPD: impact on quality of life and survival. Lung 190: 545-56. doi: 10.1007/s00408-012-9398-4

Crim-Tibbals S. (1993). Sexuality. In Handbook of Adult and Pediatric Respiratory Home Care (Eds. Joan Turner, Gwendolyn McDonald, Nancy Larter). St. Louis: Mosby.

Global Obstructive Lung Disease Initiative. (2022). GOLD Guidelines. Available at: www.goldcopd.org

Polland A, Davis M, Zeymo A, et al. (2018). Comparison of Correlated Comorbidities in Male and Female Sexual Dysfunction: Findings From the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Journal of Sexual Medicine 15: 678-86. doi:10.1016/j.jsxm.2018.02.023.

Sansone A, Mollaioli D, Ciocca G, Colonnello E, Limoncin E, Balercia G, Jannini EA. (2021). “Mask up to keep it up”: Preliminary evidence of the association between erectile dysfunction and COVID-19. Andrology 9: 1053-59.  doi: 10.1111/andr.13003

Zysman M, Rubenstein J, LeGuillou F, Colson RMH, Pochulu C, Grassion L, Escamilla R, Piperno D Pon J, Kahn S, Raherison-Serrijen C. (2020). COPD burden on sexual well-being. Respiratory Research 21:311 doi: 10.1186/s12931-020-01572-0

Gerene Bauldoff is a Professor of Clinical Nursing at the Ohio State University and a member of the AACVPR Board of Directors.