CHRONIC PAIN AND SEXUALITY

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1 CHRONIC PAIN AND SEXUALITY The Sexual Response Cycle The sexual response cycle is the process of sexual desire that leads to arousal, builds to orgasm, and ends with resolution. A person will have sexual thoughts. These thoughts may, or may not, be acted upon. When these feelings are followed up on, it should increase the person s perception of arousal. If enough stimulation and excitement occur (physiological, emotional, and/or psychological) this will lead to a climax (orgasm). Stereotypically, men build their level of excitement faster than women. It takes them on average two to seven minutes to reach orgasm. Women, on the other hand, can take more than 30 minutes to climax. Desire, arousal, and orgasm can be person and/or situation dependent. Pain can disrupt the sexual response cycle in any place, often in more than one spot, i.e., pain may affect desire, arousal, and/or the ability to orgasm. Common Sexual Concerns Physical Limitations Worry or concern a sexual encounter may be too painful and/or worsen the condition Worry about performance/failure Difficulty communicating worries and sexual feelings (both for individual living with pain and partner s ability to openly express feelings and feel heard) Overall changes in desire, interest, and function 1

2 Emotional Changes living with symptoms of depression and/or anxiety can impact feelings of self-worth, attractiveness, energy level, desire, and outlook Medication effects consult with family doctor or specialist about the impact of pain meds on desire, performance etc consider alternatives Relationship/Role Changes - changes in partnership roles due to pain experience can transcend into sexual relationship and/or sexual feelings toward partner Communication and Planning It is especially important for patients to talk openly to their partner(s) about their pain and sexual feelings. Although many people are resistant to the idea of planning, it is a good idea to plan around the pain. Have patients notice if there are times during the day that they are feeling more energetic, and less sore. If these times can be predicted, it would be smart to schedule some kind of sexual play during that time. If these windows are less predictable, they might wish to capitalize on opportunities when they do notice less fatigue and discomfort. If, they have started to engage in a sexual encounter, and it becomes painful, give patients permission to tell their partner(s). Do not suggest participating in a painful sexual liaison. This only sets up a negative feedback loop whereby people tend to become more avoidant of sexual intimacy. Negative Feedback Loop Pain during intercourse leads to avoidance and that avoidance increases the fear of pain. Because no pain is caused when avoiding intercourse, or other sexual activities, people are reinforced to avoid sex with their partners. Unfortunately, this usually generalizes to include all forms of intimacy, whether or not it is painful, for fear it will lead to painful sex. Pain during intercourse Intercourse without desire Worry pain will be felt during intercourse Little interest to set up sexual contexts 2

3 Redefining Sex And Intimacy Sex may include intercourse, but intercourse does not equal sex. It is possible to have a satisfying sexual relationship that does not include erections, intercourse, or even orgasms. Sex can also be asynchronous rather than synchronous. I talk about outercourse as anything that happens outside of the body (typically referred to as foreplay), intercourse as penetration (either vaginal or anal), and foreplay as the stuff that happens after sex until the next time. Foreplay is the relationship maintenance that makes us want to have sex with a partner in the first place. Other Diagnoses and Medication Side Effects Twenty-five percent of sexual dysfunction is caused by medications (The Medical Letter). Many drugs have negative sexual side effects including non prescription medication like antihistamines. Especially drugs used to treat depression and anxiety which can go hand in hand with a chronic pain diagnosis including; opiates, SSRIs, sedatives, anxiolytics, and recreational drugs. Do not be afraid to talk to your patients about the sexual side effects of medications they are taking. Antidepressants, cause sexual sideeffects in 30 to 70 per cent of people who take them including erectile dysfunction and delayed orgasm in male identified patients, and vaginal dryness, lowered sensitivity and difficulty reaching orgasm for female identified patients. A decrease in interest is not uncommon for all genders. Body Image and Self Esteem Even when there is no pain diagnosis, people worry about; being a good enough sexual partner, the way our bodies look, the uncooperativeness of our body, and various other sexual insecurities. Being kind to patients, helping them practice self compassion, and encouraging discourse with their partners can be invaluable tools. Strategies For Ameliorating Sex with Chronic Pain Plan and experiment when do patients have the least amount of pain and the most amount of energy, if they don t know, have them start to notice (suggest they keep a desire diary). It is important to point out at this time, that sex was never spontaneous. Spontaneous sex is a myth many people buy into. For example, when people first start dating, they shower, fix themselves up so they look nice, shave (legs, face, whatever), etc. Why? Just in case sex would magically happen. Positioning suggest patients use pillows (Liberator), lie on their side, back, front what ever is most comfortable for them. Encourage discourse have patients talk to their partners about expectations and try to find ways to meet everyone s needs. Ramp up desire suggest sexual simmering, use sexual fantasy, watch, read, or look at things that they find titillating. Use synthetic water based lubrication, e.g., Pjur Eros, Very Private, Liquid Silk, Sliquid, etc. Vibrators can be used for either men or women. Often times, as we age, or if we have experienced physiological changes, we need extra stimulation. A vibrator can do the trick. Asynchronous versus Synchronous sex 3

4 Transition from caregiver or patient to lover via ritual (tea, eye gazing, bathing together, etc.) Experimenting with the timing of taking pain medication perhaps 30 minutes before sexual activity or at a time that works best for the patient Maintain physical conditioning to the best of their ability yoga and tai chi are excellent Maximize use of non sexual intimate touching and other gears of touch (affectionate, sensual, playful, erotic, intercourse) Solo sex to help with sleep, energy, decrease anxiety, and experiences of pleasure Physiotherapy (including pelvic floor physiotherapy) Rubber sheets or towels Opening up the relationship for certain sexual needs to be met Orgasms for pain relief (endorphin release) Add afterplay/aftercare/afterconnection to sexual experiences Consult with other experts Communication!!! If it hurts, readjust or stop 4

5 A brief guide for physicians: How to talk to your patients about sex It has been my experience that most physicians are not comfortable broaching the topic of sex and relationships with their patients. In addition to a general discomfort with the topic, it is my understanding, that there is very little education in medical school on treating sexual dysfunction. Since many prescription medications and health conditions have sexual side effects, it is important for doctors to talk to their patients to monitor for sexual side effects. These side effects may negatively affect people s quality of life, mood, and romantic relationships. Listed below are some guidelines and questions you can ask to better ascertain the sexual health of your patients and incorporate into your practice straightaway. 1. When discussing sexual health it is important to be direct. Do not use euphemisms, waffle, or be equivocal. The more embarrassed you are, the less information you will get from your patient. Ask questions like, Is the prescribed medication having an impact on your sex life? Or, Have you noticed a difference in the quality of the sex you are having as a result of the pain, medication, diagnosis, et cetera? 2. Before prescribing a medication, familiarize yourself with any potential sexual side effects and share them with your patient. If there are possible sexual side effects, tell your patient what they are. For example, You may notice a decrease in your interest in sex., or, Some people find it more difficult to reach orgasm while on this drug. 3. Offer to work with the patient to find a solution if the medication does impact negatively on their sexuality. Tell your patient, If you notice that your sex life is negatively affected by this medication, please let me know so we can try a different drug, modify the dose, or add another prescription. 4. Have resources to share with your patients if their complaints are out of the scope of your practice. Validate your patients concerns and offer to assist them to find the necessary help. You can say something like, Unfortunately, these are common concerns. I cannot address those issues; however, if you would like to consult a specialist like a gynecologist, urologist, physiotherapist, registered sex therapist, et cetera, I would be happy to make the referral. Resources you may like to use yourself or share with your patients could include: The Board of Examiners in Sex Therapy and Counselling in Ontario (BESTCO): Planned Parenthood Toronto: The Sex Information and Education Council of Canada (SIECCAN): The Ultimate Guide to Sex and Disability: For all of us who live with disabilities, chronic pain, and illness by Kaufman, Silverberg, and Odette Pelvic Health Solutions: pelvichealthsolutions.ca 5

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