Sexuality and Physical Disabilities
Brooke Faught and Cheryl A. Glass
A.Physical health problems are one of the most commonly reported reasons for sexual inactivity. With the increasing incidence of physical ailments that occur with aging, most elderly individuals will experience an acute or chronic disability at some point that impacts sexual functioning.
B.When a couple in a sexual relationship encounters independent changes in their physical health, sexual functioning becomes complicated two-fold. Acknowledging and addressing these changes can help alleviate stress surrounding individual and partnered sexual functioning.
C.In many cases, certain sexual positions are not possible to maintain with physical disabilities. At the same time, sexually active individuals may not be familiar with alternative sexual positions and practices. Older men and women may not be comfortable with certain aspects of sexuality. According to the 2009 AARP survey, 20% of men and 12% of women have oral sex at least once a week. Whereas cunnilingus and fellatio may not have been a form of sexual activity included in the practices of older couples prior to the onset of a disability, inclusion of this practice can help to maintain or even resurrect sexual activity in the cases of erectile dysfunction, premature ejaculation, diminished arousal/orgasm, painful intercourse, physical disabilities, and so on.
D.In addition to oral sex, patients can frequently benefit from education on alternative sexual practices, positions, and use of aids and toys. Referral to a certified sex therapist and/or a sexuality educator can benefit patients in this situation.
E.Because neurologic functioning is so critical to the sexual response cycle in both men and women, neurologic conditions can significantly impede sexual functioning. Lower urinary tract symptoms are common in patients with multiple sclerosis, and detrusor overactivity is an independent predictor of erectile dysfunction (ED) and female sexual dysfunction. This same study further supported the connection with depression and sexual dysfunction in both male and female patients.
F.In men with multiple sclerosis, erectile dysfunction is the most common sexual complaint, with prevalence over 50%, followed by decreased sexual desire, then difficulty reaching orgasm and ejaculation. Despite this prevalence and negative impact on sexual quality of life, few men with multiple sclerosis report sexual complaints to their healthcare providers. The length of disease does not seem to play a role in male sexual complaints although it does with women.
G.Parkinson’s disease is another progressive disease of the neurologic system that can impact sexual functioning. Over 60% of both men and women with Parkinson’s report fatigue. Other commonly reported symptoms include changes to bowel and bladder habits, nervousness, feelings of sadness, restless legs, pain, dribbling saliva, and excessive sweating:
1.In men with Parkinson’s disease, sexual dysfunction is a common symptom that also correlates with depression.
2.In women with Parkinson’s, the most influential factors on sexuality are depression as well as anxiety. Women with this disease report more problems with mood and apathy, whereas men report more sexual dysfunction.
Consultation/Referral
A.Despite the prevalence of sexual activity in the older population and the quality of life impact of sexual dysfunction, few medical programs incorporate sexual health training into their curriculum outside of sexually transmitted infections (STIs) and reproduction. Even fewer address specific considerations for the geriatric population. Because of this, it is up to the medical provider to seek the latest information on caring for sexual health issues:
1.Providers should acknowledge sexuality as an important component of overall health when caring for our older patients. It is also necessary for providers to either manage sexual dysfunction or refer out when appropriate.
2.Collaboration with outside healthcare providers fosters a multidisciplinary approach to a complex medical entity. Sexual dysfunction, especially in the elderly population, is nearly nonexistent in medical training.
3.Although few medical programs incorporate sexual health training into their curriculum, especially in relation to the older patient population, there are a variety of organizations available to help foster medical research and clinical practice in the realm of sexual medicine.
4.It is helpful to establish a network of referral sources in the local area with which to collaborate, including pelvic floor physical therapists, sex therapist, sexuality educators, and medical specialists such as urologists, gynecologists, and oncologists.
5.Some key organizations to consider becoming involved in include the International Society for Sexual Medicine (ISSM), International Society for the Study of Women’s Sexual Health (ISSWSH), Sexual Medicine Society of North America (SMSNA), American Association of Sexuality Educators, Counselors and Therapists (AASECT), and the Society for Sex Therapy and Research (STAR).
Individual Considerations
A.Divorcees/widows/widowers:
1.The United States has the highest rate of divorce in the world, with approximately 45% of marriages expected to end in divorce. According to the U.S. Census Bureau, 17.5% of people age 50 and older were either divorced or separated as of 2011. This age group is the only population where divorce rates are rising, which further supports the need for sexuality education with older patients.
2.Infidelity is a fairly common occurrence in U.S. marriages, from which older couples most certainly are not immune. From the AARP Sex, Romance, and Relationships survey, 21% of male respondents and 11% of female respondents admitted that they cheated during a current or recent long-term relationship, yet only 12% of both sexes say that their partner cheated on them. This identifies a discrepancy between true infidelity in this population and partner awareness:
a.Social media allows individuals to connect who previously may not have had contact. Interactions via technology allow for private communication that facilitates loss of inhibitions that may play more of a role in face-to-face encounters. As younger generations age, social media will likely become even more commonplace with advancing technology.
b.Younger couples are adhering less to some of the strict beliefs, values, and morals that prevented many older couples from having premarital sexual activity. As this younger population ages, men and women are more likely to have had multiple sexual partners prior to their marriage, potentially leading to difficulty with long-term monogamy.
c.Physical changes including disabilities, chronic health conditions, and aesthetic transitions can impact sexual attraction, leading partners to possibly seek out something better.
d.Despite the potential increase in infidelity in coming years within the older population, only about 6% of respondents from the AARP survey reported that infidelity was the cause of their breakup. Some respondents actually reported that infidelity enhanced their relationship; 25% of cheaters reported that their infidelity improved their sex lives and 11% of the partners agreed.
e.Marital status does not seem to play a role in the prevalence of male ED, although having never been married and widowhood are predictors of low sexual desire in men.
f.Older widowers are more likely to remarry than older widowed women. Younger age correlates with increased likelihood of becoming involved in a new relationship for women, although higher monthly income and level of education were better predictors for men.
3.There is minimal research in the realm of sexuality after spousal loss. Widows report a lower incidence of sexual intercourse than widowers and they are more likely to report lack of sexual desire:
a.Recent partner loss has been shown to be a significant risk factor for depression in the elderly, which is a known correlating factor for sexual dysfunction in both men and women.
b.For sexually active widows and widowers, four key needs reported to maintain sexual desire are the following:
i.Good health.
ii.Good sexual functioning.
iii.Positive sexual self-esteem.
iv.Sexually skillful partner.
B.Survivors:
1.The emotional burden of losing a spouse or partner is frequently compounded by survivor’s guilt. It is not uncommon for the surviving partner to feel uncomfortable or uneasy about developing feelings toward new partner(s). There is the guilt of disrespecting the memory of the deceased, the social stigma of being perceived as moving on too fast,
and the fear of the unknown.
2.Many older widows and widowers have been in a monogamous relationship for an extended period of time and are unfamiliar with modern-day dating practices. In addition, it is completely normal for a widow/widower to inadvertently compare new intimate and sexual partners with the deceased spouse. This makes for potential interpersonal conflict as well as partner discomfort.
3.Many spouses take on the role of caregiver in the situation of a chronic illness. Caretaker guilt can develop during this period of time, which hinders the caregiver’s psychosocial and somatic adjustment of this role. The abrupt change in role from caregiver to grieving widow following spousal death has the potential to be extremely psychologically taxing and should be acknowledged by the medical provider. Referral to a grief counselor familiar with such situations can be very helpful in this circumstance.
4.For spousal loss related to suicide, there is added sensitivity. Bereavement group postvention (BGP) therapy has been shown to reduce anger, guilt, and despair. Because of the stigma attached to suicide, surviving partners may find it difficult to bring up their experience with future partners.