Living a Healthy Life with Chronic Conditions

CHAPTER 10

Sex and Intimacy

LOVING RELATIONSHIPS WITH PHYSICAL INTIMACY and sexual pleasure are basic human needs. However, many individuals and couples with chronic physical or mental health problems are challenged in maintaining this important part of their lives. Emotions, including fear of injury, of being unable to perform, or of causing a health emergency, can dampen desire in one or both partners. Likewise, fear of increasing symptoms can frustrate couples, even if the symptoms occur only during sex itself. Sex, after all, is supposed to be joyful and pleasurable, not scary or uncomfortable!

For humans, sex is more than the act of sexual intercourse or achieving orgasm; it is also the sharing of our physical and emotional selves. There is a special intimacy when we make love. Believe it or not, then, having a chronic health problem may actually offer the opportunity to improve your sex life by encouraging you to experiment with new types of physical and emotional stimulation. This process of exploring sensuality with your partner can open communication and strengthen your relationship. Furthermore, when we have sex, natural “feel-good” hormones, including endorphins, are released into our bloodstream. These help us achieve a deep sense of relaxation and feeling of well-being.

For many people with chronic conditions, intercourse is difficult because of the physical demands. Intercourse increases the heart rate and breathing and can tax someone with limited energy or with breathing or circulatory problems. Therefore, it is helpful to spend more time on sensuality or foreplay and less on actual intercourse. By concentrating on ways to arouse your partner and give pleasure while in a comfortable position, your intimate time together can last longer and be very satisfying. Many people enjoy climax without intercourse; others may wish to climax with intercourse. For some, climax may not be as important as sharing pleasure. There are many ways to enhance sensuality during sexual activity. In sex, as in most things, our minds and bodies are linked. By recognizing this, we can increase the sexual pleasure we experience through both physical and mental stimulation.

Emotional concerns can also be a serious factor for someone with health problems. Someone who has had a heart attack or a stroke is often concerned that sexual activity will bring on another attack. People with breathing difficulties worry that sex is too strenuous and will trigger coughing and wheezing or worse. Their partners may fear that sexual activity might cause these problems or even death and that they would be responsible. Some diseases such as diabetes can make erections difficult or cause vaginal dryness. These worries can certainly hurt the relationship.

Loss of self-esteem and a changed self-image can be subtle and devastating sexual barriers. Many people with chronic conditions believe that they are physically unattractive. This may be because of paralysis, shortness of breath, weight gain from medications, the changing shape of their joints, or the loss of a breast or other body part. Mental health problems also damage people’s sense of self, which causes them to avoid sexual situations; they “try not to think about it.” Ignoring the sexual part of the relationship or physically and emotionally distancing themselves from their partner leads to depression, which in turn leads to lack of interest in sex and more depression—a vicious cycle. Depression can be treated, and you can feel better. For more on depression and how to help yourself overcome it, see Chapter 4. If self-management techniques are not enough, talk to your doctor or therapist.

Even good sex can get better. Thankfully, there are ways you and your partner can explore sensuality and intimacy, as well as some ways to overcome fear during sex.

Overcoming Fear During Sex

Anyone who has experienced a chronic condition has experienced fear that it will get worse or that any worsening could be life-threatening. Health problems can really get in the way of the activities that we want and need to do. When sex is the activity that fear affects, we have a difficult problem: not only are we denying ourselves an important, pleasurable part of life, but we probably also feel guilty about disappointing our partner. On the other hand, our partner may feel more fearful and guilty than we do—afraid that he or she might hurt us during sex and guilty for perhaps feeling resentful. This dynamic can cause serious relationship problems. The resulting stress and depression can produce even more symptoms. We don’t have to allow this to happen!

For successful sexual relationships, the most important thing is communication. The most effective way to address the fears of both partners is to confront them and find ways to alleviate them through good communication and problem solving. Without effective communication, learning new positions and ways to increase sensuality are not going to be enough. This is particularly important for people who may worry about how their health problem may make them look physically to others. Often they find that their partner is far less concerned about their looks than they are.

When you and your partner are comfortable with talking about sex, you can go about finding solutions. Start by sharing what kinds of physical stimulation you prefer and which positions you find most comfortable. Then you can share the fantasies you find most arousing. It’s difficult to dwell on fears when your mind is occupied with a fantasy.

To get this process started, you and your partner may find some help with communication skills in Chapter 9 and problem-solving techniques in Chapter 2. Remember, if these techniques are new, give them time and practice. As with any new skill, it takes patience to learn to do them well.

Sensual Sex

In our society sexual attraction has become almost solely dependent on the visual experience. This leads to an emphasis on our physical image. Sight, however, is only one of our five senses. Therefore, when we think about being sensual, we must also appreciate the seductive qualities of our partner’s voice, scent, taste, and touch. Sensual sex is about connecting with our partner through all the senses, making love not only with the eyes but with our ears, nose, mouth, and hands as well.

Sensual touch is particularly important because the largest sensual organ of our bodies is the skin; it is rich with sensory nerves. The right touch on almost any area of our skin can be very erotic. Fortunately, sexual stimulation through touch can be done in just about any position and can be enhanced with the use of oils, flavored lotions, scents, feathers, fur gloves—whatever the imagination desires. Just about any part of the body is an erogenous zone. The most popular are the mouth, ear lobes, neck, breasts and nipples (for both genders), navel area, hands (fingertips if you are giving pleasure, palms if you are receiving pleasure), wrists, small of the back, buttocks, toes, and insides of the thighs and arms. Experiment with the type of touch—some people find a light touch arousing; others prefer a firm touch. Many people also become very aroused when touched with the nose, lips, and tongue or even sex toys.

Sensuality with Fantasy

What goes on in our mind can be extremely arousing. If it weren’t, there would be no strip clubs, pornography, or romance novels. Most people engage in sexual fantasy at some time or another. There are probably as many sexual fantasies as there are people. It is OK to mentally indulge in fantasy. If you discover a fantasy that you and your partner share, you can play it out in bed, even if it is as simple as a particular saying you or your partner like to hear during sex.

Engaging the mind during sexual activity can be every bit as arousing as the physical stimulation. It is also useful when symptoms during sex interfere with your enjoyment. But you also want to be careful—sometimes fantasy leads to unrealistic expectations. Your real partner might not compare favorably to your dream lover. You may find decreased sexual satisfaction if you regularly fire up your imagination with explicit photos or videos of young, hard bodies.

Overcoming Symptoms During Sex

Some people are unable to find a sexual position that is completely comfortable. Others find that pain, shortness of breath, fatigue, or even negative thoughts (self-talk) during sex are so distracting that they interfere with the enjoyment of sex or the ability to have an orgasm. This can pose some special problems. If you are unable to climax, you may feel resentful of your partner. If he or she is unable to climax, you may feel guilty about it. If you avoid sex because you are frustrated, your partner may become resentful and you may feel guilty. Your self-esteem may suffer. Your relationship with your partner may suffer. Everything suffers.

One thing you can do to help deal with this situation is to time the taking of medication so that it is at peak effectiveness when you are ready to have sex. Of course, this involves planning ahead. The type of medication may be important too. If you take a narcotic-type pain reliever, for example, or one containing muscle relaxants or tranquilizers, you may find that your sensory nerves are dulled along with your pain. Obviously, it would be counterproductive to dull the nerves that will give you pleasure. Your thinking may also be muddled due to the medication, making it more difficult to focus. Some medications can make it difficult for a man to achieve an erection; others can help with an erection. Ask your doctor or pharmacist about possible timing or alternatives if this is a problem for you.

Another way to deal with uncomfortable symptoms is to become an expert at fantasy. To be really good at something, you have to train for it, and this is no exception. The idea here is to develop one or more sexual fantasies that you can indulge in when needed, making it vivid in your mind. Then, during sex, you can call up your fantasy and concentrate on it. By concentrating on the fantasy or on picturing you and your partner making love while you actually are, you are keeping your mind consumed with erotic thoughts rather than your symptoms or negative thoughts. However, if you have not had experience in visualization and imagery techniques, generally used for relaxation exercises such as those in Chapter 5, you will need to practice several times a week to learn them well. All of this practice need not be devoted to your chosen sexual fantasy, however. You can start with any guided imagery tape or script such as the ones in Chapter 5, working to make it more vivid each time you practice. Start with just picturing the images. When you get good at that, add and dwell on colors; then, in your mind, look down to your feet as you walk; then listen to the sounds around you; then concentrate on the smells and tastes in the image and feel your skin being touched by a breeze or mist; finally, feel yourself touch things in the image. Work on one of the senses at a time. Become good at one before going on to another. Once you are proficient at imagery, you can invent your own sexual fantasy and picture it, hear it, smell it, and feel it. You can even begin your fantasy by picturing yourself setting your symptoms aside. The possibilities are limited only by your imagination.

Learning to call on this level of concentration can also help you focus on the moment. Really focusing on your physical and emotional sensations during sex can be powerfully erotic. If your mind wanders (which is normal), gently bring it back to the here and now. IMPORTANT: Do not try to overcome chest pain or sudden weakness on one side of the body in this way. These symptoms should not be ignored, and a physician should be consulted right away.

If you decide that you wish to abstain from sexual activity because of your chronic health problem or if it is not an important part of your life, that’s OK—but it is important that your partner be in agreement with your decision. Good communication skills are essential in this situation, and you may even benefit from discussing the situation with a professional therapist present. Someone trained to deal with important interpersonal situations can help facilitate the discussion.

Sexual Positions

Finding a comfortable sexual position can minimize symptoms during sex. They can also minimize fear of pain or injury for both partners. Experimentation may be the best way of finding the right positions for you and your partner. Everybody is different; no one position is good for everyone. We encourage you to experiment with different positions, possibly before you and your partner are too aroused. Experiment with placement of pillows or with using a sitting position on a chair. Experimentation itself can be erotic.

No matter which position you try, it is often helpful to do some warm-up exercises before sex. Look at some of the stretching exercises in Chapter 7. Exercise can help your sex life in other ways as well. Becoming more fit is an excellent way to increase comfort and endurance during sex. Walking, swimming, bicycling, and other activities can benefit you in bed as well as elsewhere by reducing shortness of breath, fatigue, and pain. They also help you learn your limits and how to pace yourself, just as in any other physical activity.

During sexual activity, it may be advisable to change positions once in a while. This is especially true if your symptoms come on or increase when you stay in one position too long. This can be done in a playful fashion, whereby it becomes fun for both of you. As with any exercise, stopping to rest is OK.

Special Considerations

People with certain health problems have specific concerns about sex and intimacy. For example, people who are recovering from a heart attack or stroke are often afraid to resume sexual relations for fear of not being able to perform or of bringing on another attack or even death. This fear is even more common for their partners. Fortunately, there is no basis for this fear, and sexual relations can be resumed as soon as you feel ready to do so. Studies show that the risk of sexual activity contributing to a heart attack is less than 1%. And this risk is even lower in individuals who do regular physical exercise. After a stroke, in particular, any remaining paralysis or weakness may require a little more attention to finding the best positions for support and comfort and the most sensitive areas of the body to caress. There may also be concerns about bowel and bladder control. The American Heart Association (http://www.heart.org) has some excellent guides about sex after a heart attack or stroke.

People with diabetes sometimes report problems with sexual function. Men may have difficulty achieving or maintaining an erection, which can be caused by medication side effects or other medical conditions associated with diabetes. Women and men can have reduced feeling (neuropathy) in the genital area. Women’s most common complaint is not enough vaginal lubrication. For people with diabetes, the most effective ways to prevent or lessen these problems is to maintain tight management of blood sugar, exercise, keep a positive outlook, and generally take care of themselves. Lubricants can help with sensitivity for both men and women. If you are using condoms, be sure to use a water-based lubricant; petroleum-based lubricants destroy latex. The use of a vibrator can be very helpful for individuals with neuropathy, and concentrating on the most sensual parts of the body for stimulation can help make sex pleasurable. There are new therapies for men with erectile problems. The American Diabetes Association (http://www.diabetes.org) has more detailed information about sex and diabetes.

Chronic or recurring pain can put a big damper on sexual interest. It can be difficult to feel sexy when you are hurting or are afraid that sex will make you hurt. Pain is often the main symptom of arthritis, migraine headaches, bowel disease, and many other disorders. People with these conditions have the challenge of overcoming pain in order to become sexually aroused or to have an orgasm. This is one area where concentration and focus, as discussed earlier in this chapter, are helpful skills. Learning to focus on the moment or on sexual fantasy can distract you from the pain and allow you to concentrate on sex and your partner. Time your pain medication to have maximum effect during sex, find a comfortable position, take it slow and easy, relax, and enjoy extended foreplay.

People who are missing a breast, testicle, or another body part as a result of their treatment for cancer or some other medical condition, or people with surgical scars or swollen or disfigured joints from arthritis, may also have fears about sex and intimacy. In these cases, people may worry about what their partner will think. Will their partner or potential partner find them undesirable? Although this may happen sometimes, it actually occurs less often than you think. Usually when we fall in love with someone, we fall in love with who the person is, not that person’s breast, testicle, or other body part. Here again, good communication and the sharing of your concerns and fears with your partner can help. If this is difficult to do alone, perhaps talking with a couples counselor may help you. Often what you think will be a problem really is not.

Fatigue is another symptom that can kill sexual desire. In Chapter 4 we talked a lot about how to deal with fatigue. Here we will add one more hint: plan your sexual activities around your fatigue; that is, try to engage in sex during the times you are less tired. This might mean that mornings are better than evenings.

Many mental health conditions and the medications used to treat their symptoms can also interfere with sexual function and desire. Therefore, it is important to talk with your doctor about these side effects so that together you can find alternatives. Sometimes the doctor may find another medication, change the dosage and timing of the medication, or refer you to a therapist who may help you and your partner learn other coping strategies to decrease or eliminate symptoms. Individual or couples therapy can also help in dealing with other non-medication-related personal relationship, intimacy, and sexual problems.

No matter what your chronic health problem, your doctor should be your first consultant on chronic-condition-related sexual problems. It’s unlikely that your problem is unique; your doctor has probably heard about it many times before and may have some solutions. Remember, this is just another problem associated with your chronic condition, just like fatigue, pain, and physical limitations, and it is a problem that can be addressed. Chronic health problems need not end sex. Through good communication and planning, satisfying sex can prevail. By being creative and willing to experiment, both the sex and the relationship can actually be better.

Other Resources

American Diabetes Association: http://www.diabetes.org/

American Heart Association: http://www.heart.org/

Arthritis Foundation: http://www.arthritis.org/

CHAPTER 10Sex and Intimacy