Sexuality

Evidence Reviewed as of before: 16-12-2009
Author(s): Andréanne Bégin Morin, BSc OT; Myriam Villeneuve, BSc OT; Audrey Tousignant, BSc OT; Benoit Martin, BSc OT; Louis-Simon Allard, BSc PT; Mylène Larocque, BSc OT; Erica Kader; Nicol Korner-Bitensky, PhD OT;; Elissa Sitcoff, BA BSc
Patient/Family Information Table of contents

Introduction

Sexual issues are among the most important in recovery, but they can be the hardest for stroke survivors and their partners to discuss. However sexuality is a topic that can be addressed by one of the client’s health care providers (e.g. Neurologist, Physical therapist, Occupational therapist, Speech pathologist, Physician, Urologist, or Gynecologist). Given that sex is a private matter, the therapist may feel uncomfortable addressing it with a client, or the client may feel uncomfortable or shy to ask questions. It is important to realize that sexuality can be a serious concern for clients after a stroke, and that there are ways of making sex easier for clients, as long as they are willing to share their concerns and ask questions.

This module addresses common fears and concerns regarding sex and intimacy, timing for resuming sexual activity, special physical challenges, sexual positions, among other topics.

Patient/Family Information

Authors*: Andréanne Bégin Morin, BSc OT; Myriam Villeneuve, BSc OT; Audrey Tousignant, BSc OT; Benoit Martin, BSc OT; Louis-Simon Allard, BSc PT; Mylène Larocque, BSc OT; Erica Kader; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc;

Since my stroke I have difficulties with sexual performance. Is this normal?

Yes. Studies estimate that 65-75% of people who have had a stroke do experience a decrease in sexual activity. Problems with sexual performance can occur for a number of different reasons.

After a stroke, both men and women experience various physical impairments, including:

  • Problems with ejaculation
  • Problems with orgasm
  • Decreased coitus (penetration)
  • Erectile difficulties (problems having an erection)
  • Decrease in frequency and/or duration of foreplay
  • Decrease or absence of vaginal lubrication
  • Urinary incontinence (inability to hold in urine)
  • Difficulty expressing emotion due to speech impairment
  • Difficulty finding comfortable positions for sexual activity (due to physical limitations)
  • Increase in fatigue

People also experience psychological problems, which may include:

  • Insecurity (feeling less attractive)
  • Fear of partner rejection
  • Lack of interest in sex
  • Lack of satisfaction
  • Decreased libido (desire)

After a stroke, who can I ask questions about sexuality?

Sexuality is a topic that can be addressed by one of your health care providers. However, since sex is a private matter, the therapist may feel uncomfortable addressing it with you, or you yourself may feel uncomfortable or shy asking him or her questions. It is important to realize that sexuality can still be a part of your life after your stroke, and there are ways of making it easier for you, as long as you are willing to share your concerns and ask your questions. So, if you need information, do not hesitate to speak to one of your health care providers:

  • Neurologist
  • Physical therapist
  • Occupational therapist
  • Speech pathologist
  • Neurophysiologist
  • Physician
  • Urologist ( specializes in male urinary and reproductive/sexual problems)
  • Gynecologist (specializes in female reproductive and sexual problems)

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How long after a stroke should I wait before becoming sexually active again?

You should try to become sexually active again as soon as you feel comfortable. Resuming a healthy sex life is a part of getting back into a normal routine after a stroke, and can minimize future psychological and physical impacts. Check with your health care provider if you have any questions or concerns. See the helpful hints below under question #4 regarding how to make sexual activity less strenuous.

It is normal and common to feel nervous or hesitant about resuming sexual activity after your stroke, but it is important to be open with your partner so that you can work together to bring sexuality back into your life.

It is often helpful to start off by reintroducing familiar activities into your relationship, such as hugging, kissing and cuddling.

I am afraid that sexual activity can cause another stroke. Is this possible?

Although fear that sexual activity will cause another stroke is common, there is no evidence that sexual intercourse can bring about another stroke. In fact, stroke occurs more frequently during sleep or everyday activity than during sexual activity.

The following information comes from research studies and may help you adjust your sexual activities after a stroke.

  • Foreplay

    Studies show that foreplay is very important. Increased foreplay time generates small increases in heart rate. This in turn limits the physical demands of sexual activity so that the cardiac stress experienced during orgasm is decreased.

  • Self-stimulation and partner stimulation

    If you are concerned about an increase in blood pressure, it is interesting to know that self-stimulation or stimulation by your partner is less demanding than sexual intercourse and is less likely to affect heart rate.

  • Positions

    Based on research, the male-on-bottom position is less physically demanding, and does not increase heart rate as much as the male-on-top position. So if you are a man who has had a stroke, you may want to consider this position during sexual intercourse.

  • Time after eating

    It is recommended that you wait a couple of hours after meals before engaging in sexual activity. Your body is using energy to digest your meal and so there will be less demands on your body if you wait.

  • Masturbation

    Research has shown that masturbation has no negative effect and does not increase your risk of having another stroke.

Is it possible that the area of my brain that is damaged by stroke will affect my sexual functioning?

Studies have shown that when the right side of the brain (dominant in perception of emotion and arousal) is damaged, there is a greater chance of having decreased libido (interest in sex) and impaired sexual function than if the left side of the brain is damaged.

Damage to the left side of the brain often results in impaired verbal abilities. This may affect self-esteem and can cause difficulties with intimacy because of a breakdown in communication between you and your partner.

Also, if the part of the brain responsible for memory is affected, the interpretation, identification, and recognition of sexual tension or emotion may be altered, which can make it difficult to initiate sexual activity.

Do physical consequences of stroke affect sexual behavior or ability?

Problems with sexual activities are not always physical. They can also be related to an increase in anxiety, decreased self-esteem, a negative perception of your body, fear of having another stroke during sexual activity and lack of accurate information about sexual activity.

Your health care provider or a specialist such as a psychiatrist, psychologist or sex therapist can help you. Take the time to discuss your concerns and ask questions.

Are there treatments available to regain sexual functions after a stroke?

There has not been much research on specific treatments to improve sexual function after stroke. However, there are things that can be done in order to help create a relaxed atmosphere. For example, plan to engage in sexual activity when you have the most energy. It is also helpful to plan a romantic evening and create an environment conducive to sexual activity. These details of life are often forgotten after a stroke but remain very important to enhancing quality of life and enjoyment.

There are medications available to help with specific sexual impairments and special devices that can be used to help sexual activity (e.g. to help with erection or external lubricants to help with vaginal lubrication). Consult with your health care provider and physician before using any medications prescribed for sexual function.

Also, therapy sessions with a psychologist or sex therapist can be useful for people with psychological concerns about their sexuality after a stroke.

What can I do if I do not feel sexually attractive anymore?

There are a number of minor changes you can make to feel more sexually attractive. It is helpful to increase your level of independence as much as you can so that you feel that you are reestablishing your role as a partner, rather than as a patient or someone needing constant caregiving. Even if you have serious physical limitations you can give emotional support to those who care about you and other important contributions that are not physical in nature.

Also, even though it may take more effort than before your stroke, try to maintain good grooming, wear make-up and have your hair cut and cared for regularly. If you went to the hairdresser before the stroke, continue to do so. If you are man, keep shaving and grooming as you did before the stroke. These small details can make a difference in your self-perception and self esteem and in the perception your partner has of you. And continue to buy new clothes and lingerie – it is important to keep doing the things you would have done before the stroke.

Since my stroke I have difficulty interacting verbally with my sexual partner. What should I do?

For some people, a stroke may lead to difficulty understanding or producing speech, which is referred to as aphasia. This can result in problems having intimate conversations and expressing feelings to your partner.

If you are having difficulty expressing yourself verbally, find new ways to communicate. Body language can be just as meaningful as spoken words. Gestures, body movement, facial expression, pictures, and writing notes (if you are able to write) are all ways of expressing feelings, desires, and needs to your partner. For example, pointing to your heart with your hand can be your way of saying “I love you” to your partner.

You and your partner can also develop nonverbal codes to help initiate intimacy. For example, you can light candles, place flowers in the room, make subtle gestures, or wear your favorite cologne or perfume. Be creative even if it is hard to find the energy to do so. It will be worth the effort.

Since my stroke I find that I have less interest in sex. Is this normal?

Studies have shown that it takes, on average, about 7 weeks for people to regain their interest in sexual activity after a stroke. For some people it may take more or less time, but it is important to realize that it is normal to feel differently after a stroke and that in time your interest in sex will come back.

Some factors post-stroke may affect your interest in sex:

  • decreased level of energy
  • depression
  • injury to the brain caused by the stroke
  • decreased or absent emotional expression (flattening effect).

I am taking new medications since my stroke. Can medications have an impact on my sexual functioning?

It is possible that the new medications will have an impact on sexual activity. Some medications that control blood pressure are known to be a potential cause of erectile dysfunction. If this is the case, you can ask your physician if there is an alternative medication that he or she can recommend. However, it is very important that you do not stop your medication. Always consult with your physician if you have concerns.

My stroke has caused me to have some physical limitations. Can I still enjoy sexual activities?

There are different factors associated with a decrease in sexual activity:

  1. Level of dependence in daily activities: Studies have shown that a higher level of dependence on others for activities of daily living is associated with a decrease in frequency of sexual activity.
  2. Sensation integrity (problems with sense of touch): People who have an impaired sense of touch have reported a decrease in sexual activity. In this case, sexual pleasure can be improved if your partner engages in kissing and caressing in parts of your body where sensation is still intact.
  3. Motor impairment (problems moving): This is another important factor influencing sexual activity, since sexual positions become difficult to assume. You should try to explore new positions with your partner and then select the ones where you are the most comfortable and where sexual activity is the most enjoyable.

I have lost some strength and function in my arm and leg. How can I position myself during sexual activity?

Here are some tips for selecting adequate and successful positions:

  • Choose positions where the partner who has not had the stroke is on top. You may find it easier to be side by side with your partner.
  • If you are in a side by side position, lie on your affected side in order to use your non-affected hand and arm to touch your partner
  • Assistive devices can be used, such as a handle on the headboard to help you move from side to side or a pillow to support your body.

What can I do if I do not find my partner sexually attractive since the stroke?

Some people do lose desire in their partners after a stroke. To try and gain back the attraction you felt before, focus on physical traits that haven’t changed, such as hair, eyes, and skin. Also, concentrate on characteristics in your partner that you find attractive, like their sense of humour or their knowledge about certain things. Make an effort to spend time together, doing activities that you both enjoy.

FOR THE SPOUSE/PARTNER

I find that my spouse has different sexual behaviors that he/she did not have before the stroke. Is this caused by the stroke? It is not uncommon to find that your partner’s sexual behaviour has changed after the stroke. Some of these changes may include:

  • significant increase in libido
  • increase in frequency of sexual acts
  • inappropriately removing clothes
  • inappropriately physically touching others
  • masturbating at inappropriate times or places

The exact cause of these behaviours is unknown, but may be related to damage to specific regions of the brain. If your spouse has any of these behaviors, talk to the healthcare team for suggestions on how to handle the behaviors.

Is it possible to assume the caretaking role and sexual partner role at the same time?

As much as possible, the role of caretaker should be separated from the role of sexual partner. To achieve this balance, try maximizing your partner’s level of independence wherever possible. Also try to give your partner the role of initiating sexual activity in the relationship, at least some of the time.

Remember that it is very important for you to participate in activities that you enjoy and to spend some time alone without feeling guilty. Although it is important to care for your partner, you also need to have time to care for yourself. Research has shown that in taking care of yourself, you will be better able to care for your partner.

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