Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners
2013; Lippincott Williams & Wilkins; Volume: 128; Issue: 18 Linguagem: Inglês
10.1161/cir.0b013e31829c2e53
ISSN1524-4539
AutoresElaine E. Steinke, Tiny Jaarsma, Susan Barnason, Molly Byrne, Sally Doherty, Cynthia M. Dougherty, Bengt Fridlund, Donald D. Kautz, Jan Mårtensson, Victoria Mosack, Debra K. Moser,
Tópico(s)Sexuality, Behavior, and Technology
ResumoHomeCirculationVol. 128, No. 18Sexual Counseling for Individuals With Cardiovascular Disease and Their Partners Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBSexual Counseling for Individuals With Cardiovascular Disease and Their PartnersA Consensus Document From the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP) Elaine E. Steinke, PhD, APRN, FAHA, Chair, Tiny Jaarsma, PhD, RN, FAHA, NFESC, Co-Chair, Susan A. Barnason, PhD, RN, APRN-CNS, CEN, CCRN, FAHA, Molly Byrne, BA, MSc, PhD, Sally Doherty, PhD, CPsychol, Cynthia M. Dougherty, PhD, ARNP, FAHA, Bengt Fridlund, PhD, RN, RNT, NFESC, Donald D. Kautz, PhD, RN, CRRN, CNE, Jan Mårtensson, PhD, RN, NFESC, Victoria Mosack, PhD, APRN and Debra K. Moser, DNSc, RN, FAHA Elaine E. SteinkeElaine E. Steinke , Tiny JaarsmaTiny Jaarsma , Susan A. BarnasonSusan A. Barnason , Molly ByrneMolly Byrne , Sally DohertySally Doherty , Cynthia M. DoughertyCynthia M. Dougherty , Bengt FridlundBengt Fridlund , Donald D. KautzDonald D. Kautz , Jan MårtenssonJan Mårtensson , Victoria MosackVictoria Mosack and Debra K. MoserDebra K. Moser and on behalf of the Council on Cardiovascular and Stroke Nursing of the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP) Originally published29 Jul 2013https://doi.org/10.1161/CIR.0b013e31829c2e53Circulation. 2013;128:2075–2096Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 IntroductionAfter a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as "… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences…."1(p4) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.2 Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.3 ED and vaginal dryness may also be presenting signs of heart disease and may appear 1 to 3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care4; therefore, routine assessment of sexual problems and sexual counseling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.Sexual counseling is important for both cardiac patients and their partners. Psychological concerns, including anxiety, fear, and depression, are prevalent among cardiac patients and, to some extent, their partners.5–7 Returning to sexual activity is a common concern, and patients frequently request information on how to resume sexual activity.8,9 Partners have considerable concerns, often more so than patients10,11; therefore, the inclusion of partners in sexual counseling is important.Sexual counseling is an interaction with patients that includes information on sexual concerns and safe return to sexual activity,12 as well as assessment, support, and specific advice related to psychological and sexual problems, also referred to as psychosexual counseling. Sexual counseling takes place during a one-to-one exchange with a trained person, with the aim of solving a problem and offering advice. It offers a psychophysiological approach with the possible integration of pharmacotherapy, which is different from other types of therapy.13,14 Counseling can be short-term, as might occur in the acute care setting, or ongoing counseling in the office setting during repeated patient visits. Patients with both acute and chronic cardiovascular problems can benefit from sexual counseling. Current research clearly articulates the need for healthcare professionals to become more actively involved in sexual counseling.15–17 In general, healthcare professionals, in caring for cardiac patients, recognize the importance of discussing sexual function and activity and also express their responsibility to do so,15,17 although many healthcare professionals do not know what specific advice to give. Therefore, the intent of this consensus statement is to synthesize and summarize current evidence related to sexual counseling in CVD and to provide direction to physicians, nurses, and other healthcare professionals in the practice of sexual counseling.In writing these guidelines, the writing group applied the rules of evidence and the formulation of strength of recommendations used by other writing groups of the American Heart Association (Table 1). A summary of the "top 10 things to know" is presented in Table 2.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceTable 2. Top 10 Things to Know 1. Sexual counseling should be tailored to the individual needs and concerns of patients with CVD and their partners/spouses. 2. Healthcare professionals working with patients with CVD may need education and training in sexual assessment, communication techniques, and sexual counseling (Class I; LOE C). 3. Structured strategies, such as the use of the PLISSIT model and assessment tools, can be useful in assessing psychosexual concerns of patients with CVD (Class IIa; LOE C). 4. Patients with CVD and their partners may want to discuss sexual issues and their associated psychological concerns (Class I; LOE C). 5. Psychological factors including fear, anxiety, and depression can adversely influence participation in sexual activities in patients with CVD (Class I; LOE B). 6. Sexual counseling interventions with patients with CVD can improve the frequency of sexual intimacy and the quality of sexual functioning and should be offered regardless of age, gender, culture, or sexual orientation, using a team approach when possible (Class I–IIa; LOE B). 7. Cognitive-behavioral techniques, patient education, and therapeutic communication strategies have been used successfully in sexual counseling with cardiac patients (Class IIa; LOE B). 8. Sexual counseling content appropriate for all patients with CVD includes a review of medications and potential effects on sexual function, any risk related to sexual activity, the role of regular exercise in supporting intimacy, use of a comfortable familiar setting to minimize any stress with sexual activity, use of sexual activities that require less energy expenditure as a bridge to sexual intercourse, avoidance of anal sex, and the reporting of warning signs experienced with sexual activity (Class IIa; LOE B–C). 9. Specific recommendations by cardiovascular diagnosis should be incorporated in sexual counseling, for example, fear of ICD discharge with sexual activity or appropriate sexual activities in patients with heart failure with reduced exercise capacity (Class IIa-IIb; LOE B–C).10. RCTs using a specific sexual counseling intervention with patients with CVD and their partners would be useful in determining efficaciousness in reducing the incidence or severity of specific physical and psychological variables.CVD indicates cardiovascular disease; ICD, implantable cardioverter-defibrillator; LOE, level of evidence; PLISSIT, permission, limited information, specific suggestions, and intensive therapy; and RCTs, randomized controlled trials.Recommendations for Sexual Counseling by Healthcare ProfessionalsPatient and spouse/partner counseling by healthcare professionals is useful to assist in resumption of sexual activity after an acute cardiac event, new CVD diagnosis, stroke, changes in chronic cardiac disease function or status, or implantable cardioverter-defibrillator (ICD) implantation, and may include the use of educational materials, such as written materials or a video provided to both patients and partners (Class I; Level of Evidence B).2,17,18Training should be provided for staff working with patients with CVD in relation to taking a sexual history; counseling and communication techniques for use within a sexual counseling consultation; delivery of accurate information to patients; follow-up education or counseling; referrals to other healthcare professionals; and discussion of sexual concerns in various populations and situations (Class I; Level of Evidence C).It is reasonable to tailor sexual counseling to the individual needs of the patient, regardless of age and sex, and offer it to patients as well as partners (Class IIa; Level of Evidence B).8,17,19,20Evidence suggests that information and support regarding sexual issues are not readily available to patients,21,22 and this lack of support may be attributable to both healthcare provider and patient misperceptions relating to sexual counseling after a coronary event.15,20,23,24 Findings from descriptive qualitative studies reveal that cardiac patients want and need to receive information about sexual functioning and a safe return to sexual activity related to myocardial infarction (MI),9,25–27 coronary artery bypass graft (CABG) surgery,28 stroke,4 and heart failure (HF).29 Patients who have experienced a coronary event may report issues related to resuming sexual activity that are both physiological and psychological, such as general anxiety, fear of having another MI, feeling unwanted by their partner or not good enough, changes in self-perceptions, inadequate knowledge regarding the impact of heart medications, and finally, partner concerns.9,25,30 Patients generally report a desire to receive information regarding the resumption of sexual activity and to have sexual counseling services available when sexual problems arise.31 Discussion of sexual concerns is not limited to those with acute conditions, because those with chronic CVD may require ongoing counseling and support.Barriers to sexual counseling by healthcare professionals include an expectation that the patient does not want this information, provider inexperience, a lack of training, and time constraints. Cultural and language barriers may also inhibit sensitive discussions.15,17,22,32–39Although healthcare professionals indicate some knowledge about sexual activity in cardiac populations and are willing to engage in sexual counseling,22 evidence suggests limited follow-through in providing such interventions to patients40,41 because of lack of confidence and specialized training,15,32,42 as well as perceived restrictions in the practice setting43 and cultural background of the healthcare provider.33Specific areas of knowledge to be addressed in staff training are the role of intimacy without sex to gain confidence, positions for sexual activity, use of foreplay before sexual activity, and avoidance of unfamiliar partners and surroundings,17,36,44 as well as knowledge regarding the use of medications to enhance sexual performance and whether or not these are safe for patients to use with specific types of CVD. Embarrassment and fear of upsetting the patient are often cited as barriers by providers, and patients themselves cite embarrassment as their greatest barrier to discussing sexual health issues.45–49 Assumptions, stereotypical views, and overprotective judgments on the part of the healthcare professional may unnecessarily deter sexual counseling.Patient CounselingThe practice of delivering sexual counseling to patients varies both across and within countries and services.33,44,50 Only a few studies have focused on the number of patients receiving sexual counseling,2,51 and even fewer have examined the quality and efficacy of sexual counseling after a cardiac event or stroke.19,52–54Healthcare professionals must balance the sensitivity of the topic, their own knowledge and comfort, and the need for education and support on the part of the patient when discussing resumption of sexual activity. Patients who have had no sexual activity before CVD may have no interest in initiating sexual activity or indeed in discussing sexual activity, so careful history taking is imperative to ascertain the need for sexual counseling.55 Conversely, those patients whose cardiac symptoms have previously precluded sexual activity may now be interested in a return to sexual activity.Patients who have concerns about resuming sexual activity after a cardiac event or stroke25 report wanting healthcare professionals, especially their cardiologists,31 to discuss sexual issues, with a preference for individual counseling tailored to meet their individual needs. Timing the provision of information is difficult to ascertain, because some patients would prefer information while hospitalized, whereas others prefer the information later, after settling back into their usual routine.8 The level of specific information and detail required varies with individual needs and preferences.16Patient reluctance to discuss intimate details of their relationships and sex life may be related to gender, age, gender of the healthcare professional, and personal issues such as embarrassment or regarding sex as a taboo topic. In some cultures, sex is regarded as more private than in others and is not openly discussed. In 1 study, 69% of MI patients stated that because sex was regarded as private, it could not be discussed with friends, spouse, sisters or brothers, or children. In addition, participants stated that people could not talk about sex because of cultural taboos.25 The patient's perception of the provider's knowledge, maturity, and willingness to discuss sexual issues also plays a role in facilitating discussion.46,56–58Gender and Sexual CounselingSexual problems are highly prevalent in both sexes and across all age groups among people with CVD.59–61 What is not known is whether men and women have different needs and experiences related to CVD and sexual counseling. It has been suggested that men and women may have different physiological and psychological responses to sexual activity.62–64 Sexual dissatisfaction differs in men and women who have experienced a cardiac event or stroke; women often relate sexual dissatisfaction to conflict within the relationship, fear of intercourse, and lack of orgasm, whereas men report dissatisfaction relating to rejection of sexual advances, problems with arousal, fear of ED, and low self-esteem. Both men and women report that the perceived importance of sex within the relationship was related to the level of sexual dissatisfaction and satisfaction with life.60 In general, research exploring female sexual dysfunction after a cardiac event or stroke has received considerably less attention than that in men,65,66 and the need for specialists to provide sexual advice and counseling for a woman is less well recognized.34,67Age and Sexual CounselingMany individuals enjoy a sex life into older age,68 but later life is typically viewed as a time of being asexual by society, and resuming or continuing sex with an illness is rarely discussed.68 Healthcare professionals may hold stereotypical views on aging and sexuality, so to provide sexual counseling, a thorough understanding of the myths and realities of sex in older age is needed.69 In a review of 25 articles from 1999 to 2010, patients were more likely to seek help if the provider used a proactive approach and inquired about sexual concerns during routine visits with adults of any age, which highlights the need for providers to avoid making the assumption that sexual issues are of lesser concern to older adults.70Partner CounselingThe focus of education and counseling is often on the person with cardiac disease, and partners may feel their needs are pushed aside.71–73 Among partners of patients undergoing cardiac rehabilitation, sexual concerns were among the most prevalent stressors reported. Distressed spouses also reported significantly less intimacy in their marriages.73 If a couple believes that their sex life is over because of illness, they will need help in redefining their sexual relationship. The severity of the disease often requires the patient and partner to redefine their sexual roles and to explore other sexual behaviors besides intercourse. Couples who have been together for many years often have established routines related to their sexual behavior and will need help in negotiating new roles.74 Couples may have had sexual problems for many years and have not sought treatment; therefore, sexual problems may now need to be addressed.Both sexes report fear of intercourse or orgasm after a cardiac event, and often this information is not communicated by the patient to the partner or provider, which leads to stress and possible deterioration of the relationship.57,75 Men as partners reported challenges to masculine self-image as a sexual being and hesitancy in approaching their female partners, viewing them as more fragile after MI.76 Women as partners reported a great sense of loss and uncertainty, both emotional and sexual, related to their male partner with MI.77The experience of being in a caregiver role affects not only the intimate relationship but also the physical health of the partner. Overprotection by family members is cited as a source of frustration and aggravation for cardiac patients and can create conflict for the couple,78 particularly for those who have experienced an MI or have had an ICD implanted.10,79 It is important to provide interventions for patients and partners in coping and management specific to sexuality and psychological health10,72,80; such an intervention may include telephone follow-up with the couple.81 During sexual counseling with the couple, health professionals should acknowledge the impact CVD may have on the partner in relation to anxiety, fear, and overprotectiveness and offer interventions in coping and stress-relieving strategies.Sexual Counseling for Same-Sex CouplesVery little literature exists in relation to sexual counseling for same-sex couples,82 and even less in the context of CVD. Gender stereotyping about same-sex couples by healthcare professionals may be a barrier for sexual counseling. Assumptions about sexual orientation need to be addressed and explored in provider training.83 Patients may be prevented from discussing sexual issues because of fear of healthcare providers' attitudes toward homosexuality or bisexuality.39Recommendation for Psychological Impact of CVD and Implications for Sexual CounselingTo reduce the psychological sequelae associated with CVD, sexual counseling can be useful for most patients and their partners (Class IIa; Level of Evidence C).The association between CVD and psychological issues such as fear,25,84,85 anxiety,79,86,87 and depression86,88,89 has been well documented. There is limited evidence, however, specifically related to sexual counseling and psychological concerns, yet depression and anxiety can have detrimental effects on sexual activity when comorbid CVD is present and should be assessed in patients before they engage in sexual activity.2 There is a strong association between sexual disorders and comorbid conditions, especially ED, CVD, and depression.90–92 Depression may be an important contributing cause of ED, including decreased libido, difficulty with arousal and orgasm, and dyspareunia.3,93,94 Changes in sexual activity after a cardiac event may impair the patient's quality of life, negatively affect psychological health, and strain marital or other important intimate relationships, which in turn may lead to depression and anxiety.3,9,93 These psychological effects can occur after an acute cardiac event but may persist for those with chronic CVD. Fear of a cardiac event during sexual intercourse can interfere with patients' ability to perform and enjoy sex95; therefore, providers should discuss this issue as soon as possible, including offering reassurance to patients and partners that the risk of MI with sexual activity is low.96 Anxiety itself has been found to be a contributor for increased likelihood of cardiac events; therefore, the assessment of anxiety and a discussion of sexual concerns are important areas to be addressed by healthcare professionals.97 For those with an ICD, shocks contributed to anxiety, fear, and overall distress for the patient and his or her partner,10 with psychological adjustment to the device similar for both patient and partner.80A small number of well-designed nonrandomized studies have examined sexual counseling and related psychological issues in a cardiac patient population. One study comparing healthy older adults (n=59) and patients with HF (n=85) found that higher sexual self-efficacy, lower sexual anxiety, and being married and of younger age independently predicted sexual activity, whereas sexual depression (a specific measure reflecting sadness or unhappiness within the sexual relationship)11 had no effect on sexual activity.98 Randomized controlled trials measuring the effects of psychological issues on sexual functioning among patients with cardiac conditions are lacking, and intervention studies using sexual counseling have received even less attention in this population. The only randomized controlled trial measuring the effectiveness of sexual therapy (patient education and cognitive-behavioral techniques) involved men (n=92) admitted to a cardiac rehabilitation program and then randomized to treatment/sexual therapy or to a control group.54 After patients and partners participated in 3 sessions conducted by cotherapists who specialized in sexual counseling, patients receiving sexual therapy reported improvement in the frequency of sexual intimacy and quality of sexual functioning compared with reports of control subjects.54 In addition to using cognitive-behavioral techniques54,99 in counseling cardiac patients, there is evidence to suggest the value of patient education19,25 and therapeutic communication strategies in sexual counseling.35,97,100Recommendations for Sexual Assessment and CounselingStructured counseling strategies to address the psychosexual needs of cardiac and stroke patients can be useful (Class IIa; Level of Evidence C).The use of instruments to assess cardiac and stroke patients' sexual concerns can be beneficial (Class IIa; Level of Evidence C).A variety of factors should be assessed related to sexual function, including response to treatment, previous medical history, and the couple's concerns about resuming sexual activity. Coexisting conditions, such as hypertension, diabetes mellitus, and HF, may also influence the ability to return to sexual activity. Vascular changes and reduced exercise endurance may affect sexual performance.97Annon101 published the PLISSIT model to assist healthcare professionals in addressing sexual concerns, and it has been used for 35 years to help practitioners better conceptualize their roles in helping patients and their sexual partners.100,102,103 PLISSIT is an acronym for the strategies or stages of giving Permission, Limited Information, Specific Suggestions, and Intensive Therapy, a model that may be useful to practitioners in addressing sexual concerns. Although it is helpful to conceptualize each of these stages or strategies as being separate, there is a great deal of overlap among the stages. Giving the patient or partner permission to bring up sexual issues is considered the first stage in addressing sexual concerns and is considered within the realm of all practitioners in all settings. Giving permission is as simple as saying, "After a heart attack, patients and their partners may have concerns about whether it is safe to engage in sex. What concerns do you have?" After giving permission, the next step is giving the patient limited information, providing a few instructions to assist with sexual functioning.100 The suggestions of waiting 2 hours after a meal before engaging in sex, having sex in a cool room, and having sex with a familiar partner are examples of limited information. Giving patients and their partners copies of educational pamphlets is also an example of limited information (Table 3). Specific suggestions involve tailoring information for a specific individual who has a specific concern. For example, a patient may ask whether it is safe to take sildenafil citrate after MI; the healthcare provider would evaluate the patient's medications, conduct a short health history for contraindications for that specific patient, and explain the serious adverse effects of phosphodiesterase-5 (PDE5) inhibitors and nitrates when taken together, if appropriate for that patient. Intensive therapy is conceptualized as being provided by a sex therapist or counselor unless a healthcare provider has had specific training, as would be indicated in dealing with longstanding or complex sexual problems.101Table 3. Patient Education Resources for Cardiovascular Sexual CounselingTable 3. Patient Education Resources for Cardiovascular Sexual CounselingThe PLISSIT model has been advocated to use or adapt for clinical practice or research, although some believe it is outdated104 and that it might be more helpful to focus on reflective, patient-centered, and negotiated forms of communication about sexuality and intimacy issues to truly help patients and their partners adapt their sexual experiences when confronted with an acute or chronic illness. A practical approach that can be used by clinicians is reflected in the BETTER acronym.105 As a clinician, (1) Bring up the topic of sexuality, (2) Explain concerns you have about the patient's quality of life that may be impacted by their cardiac disease/event, (3) Tell patients you can help guide them to resources that can address their concerns, (4) consider the Timing (although the patient may not want to discuss the subject at this time, reassure the patient that issues he or she might have can be discussed in the future), (5) Educate patients about the potential effects of their cardiac disease/event/treatments on their sexual functioning, and (6) Record or document the assessment and interventions provided. Although this approach can be used with many clinical situations, it may be quite useful in discussing sexual concerns.Specific assessment of sexual dysfunction can help the provider differentiate cardiac disease–specific causes, other underlying conditions that contribute to sexual dysfunction, and adverse effects of cardiovascular medications. Assessment instruments and other tools can provide a basis for providing psychosocial support and for addressing a patient's particular concerns or problems (Table 4). These instruments can be used easily in the practice setting and may provide a starting point for sexual counseling, education, and provision of resources and referrals to address sexual issues.Table 4. Assessment Instruments for Sexual FunctionInstrumentAreas AssessedAttributesFemale Sexual Function Index (FSFI)106Women's sexual functioning: Desire, arousal, lubrication, orgasm, satisfaction19 ItemsDiscriminates between clinical and nonclinical populations106,107Established reliability (test-retest: 0.79–0.86; Cronbach α=0.82), with reported construct and divergent validityResponse time 15 minBrief Index of Sexual Functioning for Women (BISF-W)108Dimensions of sexual functioning: Thoughts/desires, arousal, frequency of sexual activity, receptivity/initiation, pleasure/orgasm, relationship satisfaction, problems affecting sexual function10922 Items; self-reportSubscale and composite score, with major factors of sexual desire, sexual activity, and sexual satisfactionMost items rated on Likert scaleReliability (test-retest, 0.68–0.78; 0.39 [factor 1] to 0.83 [factor 2]) and validity demonstrated109,110Response time 15–20 minChanges in Sexual Functioning Questionnaire (CSFQ) and Changes in Sexual Functioning-Short Form (CSFQ-SF)111,112Male and female sexual function in all domains of the sexual response cycleSubscales: Dimensions of pleasure, desire/frequency, desire/interest, arousal/excitement, orgasm/completion, and phases of sexual functioning (desire, arousal, orgasm)CSFQ: females, 35 items; males, 36 itemsCSFQ-SF: 14 items for each of the female and male versions5-Point Likert scale, from "never or no enjoyment" to "every day or always"May be scored on the 3 phases of sexual response: Desire, arousal, orgasm/completion112Reliability (0.89–0.90, CSFQ-SF) and construct validity established112Response time for CSFQ, 15–20 min; CSFQ-SF appropriate for clinical setting, with response time of 4–5 minDerogatis Interview for Sexual Functioning (DISF) and Derogatis Interview for Sexual Functioning – Self-Report (DISF-SR)113Patient's perception of overall current sexual functioning5 Domains: Sexual cognition/fantasy, sexual arousal, sexual behavior/experience, orgasm, sexual drive/relationship26 ItemsRated on 4-point Likert scaleComposite scoreGender-specific versionsReliability (0.74–0.80) and validity establishedResponse tim
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