Stroke

Addressing Sexuality

  • Healthcare providers should be the first to broach the topic of sexuality (Grenier-Genest, Gerard, & Courtois, 2017). The onus should not be put on the client.
  • There is no conensus on when the appropriate time to introduce the topic is. Some clients would prefer sexuality be addressed early in rehabilitation, while others would prefer later (Grenier-Genest et al., 2017). On the other hand, a panel of experts suggested that sexual activity would most appropriately be addressed during the subacute and chronic phases of stroke rehabilitation (McGrath, Lever, McCluskey, & Power, E., 2019).
  • Sex can first be mentioned during the acute hospitalization phase (Mioduszewski, 2012). Therapists should use the PLISSIT Model and provide clients with the opportunity to discuss sexual activity if it is a concern. When completing discharge education, the therapist should include some information regarding sexuality following a stroke.
  • During the inpatient rehabilitation phase, the occupational therapist may address sexuality more specifically if the client is interested. At this stage, the therapist may assist the client in finding positions that inhibit tone and encourage practice during home visitations.
  • Once the client is living at home again, the therapist has much more freedom in addressing sexuality, as the client is more realistically going to be able to engage in sex once again.
  • If the client is admitted to a long-term care facility, addressing sexuality may become difficult due to environmental barriers or medical instability. In this setting, the therapist must consider the facility's policies as well as the client's desires. Depending on the situation, there may be a potential to arrange for the client to have private time for intimacy with a partner in the facility or during a home visitation.
  • Regardless of the setting, the therapist should always follow the client's lead. If the client is uncomfortable discussing sexuality, then the therapist should respect this.
  • In general, individuals with stroke would prefer information sessions covering the affects of stroke on sexual function, including positioning ideas, medication side-effects, and effects of comorbidities (Grenier-Genest et al., 2017)
  • A survey of stroke patients found that the preferred method of instruction was in a private discussion supplemented with written information (Prior, Reeves, Peterson, Jaffray, & Campbell, 2019).
  • Another study found that written information is just as effective as individualized sexual rehabilitation programmes (Ng, Sansom, Zhang, Amatya, & Khan, 2017).

Barriers

  • May experience erectile dysfunction (Tamam, Tamam, Akil, Yasan, and Tamam, 2008)
  • May experience decreased libido
  • May experience vaginal dryness
  • May have hemiparesis or hemiplegia that impacts client's ability to engage in sexual activity (Boller, Agrawal, & Romano, 2015)
  • Medications prescribed post-stroke, such as anti-depressants and antihypertensives, may cause sexual dysfunction
  • May have limited range of motion (See Limited ROM) (Rosenbaum, Dor Vadas, & Kalichman, 2014)
  • May have spasticity which impacts positioning and engagement in sex (See Spasticity )
  • May have hypersensitivity and avoid touch (See Sensation and Pain) (Mioduszewski, 2012)
  • May have decreased sensation that reduces client's safety during positioning (See Sensation and Pain)
  • May have decreased fine motor control
  • May present with aphasia or dysarthria, which impacts their ability to communicate with potential partners
  • May have poor motor planning, which could impact ability to successfully engage in sexual activities
  • May have personality changes that impair bonding and intimacy with partners (Gillen, 2006)
  • May have cognitive impairments (Miodeszewski, 2012)
  • May have visual impairment
  • May have bladder and bowel dysfunction that could impact ability or comfort with engaging in sexual activity
  • May have paralysis of oral muscles and dysphagia which can compliacte kissing and oral sex
  • Decreased frequency of orgasm in females (Grenier-Genest et al., 2017)
  • May have pain that prevents engagement in sexual activity (See Sensation and Pain) (Kautz & Van Horn, 2017)
  • May have fatigue that decreases arousal or interest in engaging in sexual activities (See Fatigue)

Strategies

  • Pillows or bolsters may be helpful in supporting the hemiparetic side (Miodeszewski, 2012)
  • Avoid positions where hemiparetic limbs are in positions where they may be injured, such as sidelying on top of the weaker limb
  • Maintaining a prone or quadruped position during sexual activity may be difficult. Instead, the client may benefit from remaining in the supine position.
  • Taking a warm bath before engaging in sexual activity may reduce spasticity and could increase intimacy if performed with a partner
  • Use of body mapping techniques may help the client and partner understand what types of touch are pleasurable in different areas of the body
  • Clients may benefit from desensitization techniques (See Sensation and Pain)
  • Educate on the incorporation of energy conservation techniques into sexual activity
  • While kissing, the client should assume a superior position to reduce the risk of aspiration
  • May recommend referral to speech language pathologist to intervene in dysphagia and oral motor skills
  • Encourage client to develop simple non-verbal cues to communicate discomfort during sex, especially if communication skills are impaired
  • If a cognitive impairment is present, encourage client to plan for sexual activity and keep a checklist of actions that should occur before engaging in sexual activity
  • Compensatory strategies to maintain safety of neglected body parts. For example, visually checking on the affected limbs and positioning them during sex.
  • External lubrication to combat vaginal dryness
  • Encourage male clients to seek medical advice in reference to erectile dysfunction
  • Inform client of strategies to reduce bladder and bowel accidents during sexual activity, such as emptying the bladder and bowel prior to the activity

References

Boller, F., Agrawal, K., & Romano, A. (2015). Sexual function after strokes. Handbook of Clinical Neurology, 130, 289-295. Retrieved from https://doi.org/10.1016/B978-0-444-63247-0.00016-X

Gillen, G. (2006). Coping during inpatient stroke rehabilitation: An exploratory study. American Journal of Occupational Therapy, 60, 136-145. doi: 10.5014/ajot.60.2.136

Grenier-Genest, A., Gerard, M., & Courtois, F. (2017). Stroke and sexual functioning: A literature review. NeuroRehabilitation, 41, 293-315. doi: 10.3233/NRE-001481

Kautz, D. D., & Van Horn, E. R. (2017). Sex and intimacy after stroke. Rehabilitation Nursing, 42(6), 333-340. doi: 10.1002/rnj.296

McGrath, M., Lever, S., McCluskey, A., & Power, E. (2019). Developing interventions to address sexuality after stroke: Findings from a four-panel modified Delphi study. Journal of Rehabilitation Medicine, 51(5), 352-360. doi: 10.2340/16501977-2548

Mioduszewski, M. (2012). Stroke and spasticity. In B. Hattjar (Ed.), Sexuality and occupational therapy. Bethesda, MA: American Occupational Therapy Association.

Ng, L., Sansom, J., Zhang, N., Amatya, B., & Khan, F. (2017). Effectiveness of a structured sexual rehabilitation programme following stroke: A randomized controlled trial. Journal of Rehabilitation Medicine, 49(4), 333-340. doi: 10.2340/16501977-2219

Prior, S., Reeves, N., Peterson, G., Jaffray, L., & Campbell, S. (2019). Addressing the gaps in post-stroke sexual activity rehabilitation: Patient perspectives. Healthcare, 7(1), 25. doi: 10.3390/healthcare7010025

Rosenbaum, T., Dor Vadas, B. P. T., & Kalichman, L. (2014). Sexual function in post-stroke patients: Considerations for rehabilitation. Journal of Sexual Medicine, 11(1), 15-21. Retrieved from https://doi.org/10.1111/jsm.12343

Tamam, Y., Tamam, L., Akil, E., Yasan, A., & Tamam, B. (2008). Post-stroke sexual functioning in first stroke patients. European Journal of Neurology, 15(7), 660-666. doi: 10.1111/j.1468-1331.2008.02184.x