Poor sexual function can often be an unexpected side-effect of having arthritis, but it is one that many patients are not comfortable discussing with their partners, let alone their doctors.
Sometimes, in support groups (especially closed, online ones), a brave soul may hesitantly ask a personal question about difficulties with sex and arthritis. When they do, others often speak up and say how relieved they are to know they are not the only ones having problems in the bedroom in that way.
Doctors and patients alike are getting better at discussing lifestyle factors such as exercise, diet, ability to work and so on. Yet, having sex is also an important part of life, so limitations and dysfunctions caused by arthritis also need to be addressed in a professional way.
NOT TONIGHT, BABY, MY JOINTS HAVE LOCKED UP
No doubt, the more common effects of arthritis and related medications, such as pain and joint stiffness, can have a negative influence on sexual performance.
Say, for example, your 25-year-old female patient is looking forward to a great night with a new partner but her whole body is in pain and she can barely dress herself. How would that make her feel?
What about the patient who has recently had a hip replacement and has no idea how soon they can safely resume having sex? They want to have fun, but they don’t want to risk damaging the new joint.
There are many other factors that can influence the outcome (so to speak). These might include vaginal dryness, erectile dysfunction, feeling fragile, inability to orgasm or difficulty getting into positions. All this can generate stress, which, in turn, adds to physical pain and tension.
These aren’t things you would generally discuss at a routine appointment, for sure, but they might be the elephant in the corner waiting to be noticed.
WHAT IF IT HURTS TOO MUCH?
You’ve probably come across many arthritis patients reluctant to move their affected joints due to fear of the pain this could cause. While you understand their fear, you also try to help them overcome it so they can experience the benefits of movement. If they fear having sex for that reason, shouldn’t you be at least acknowledging that in some way? The fear of having sex with arthritis can have other manifestations, too. The fear of a partner not understanding or caring. The fear that they might never be able to get into their favourite positions anymore. The fear that they won’t be able to satisfy their partner’s needs.
Fatigue is another mood-killer when it comes to love life. If your patient is barely managing to get through the day or even showering themselves without needing a nap, how on earth will they have the energy to rock the house at night?
Any one of these issues can lead your patient to experience a hotpot of emotions, such as embarrassment, sadness, grief, anxiety or depression. But what can you, as their rheumatologist, do about it?
Though studies have been done on the nature of these issues, there isn’t much practical information around to help doctors have these conversations.
POINTS TO CONSIDER
If your patients fear the pain of sex, you could mention that some people find sex actually gives them some pain relief due to the endorphins released. Sex can also help strengthen muscles in some cases.
It’s not just heterosexual people with arthritis who are having sex.
Homosexuals or those with other sexual identities may have the same challenges with arthritis and sex as others do.
Nor does your patient have to be in a relationship. They might be too embarrassed to even consider entering a relationship because of their concerns around having sex. Or, they might enjoy a bit of self-love on occasion, but their finger joints are too swollen.
Young people coming of age while under your care might also need some help in this area and have no idea whom to talk to about it.
The topic of sexual positions will probably be an extremely awkward one to discuss with them, but perhaps it could be part of a broader conversation about pregnancy or future family planning.
Your patients should feel comfortable raising these concerns with you if they choose to. Don’t pass the buck and refer them back to their GPs. If you are interested in your patients’ ability to perform regular activities then sex should be under your umbrella of concern, too.
Create conversation-starter opportunities such as pre-appointment questionnaires. These are often full of safe-for-elderly questions, such as a self-assessment of the ability to put on trousers or reach above the head. Your questionnaire doesn’t need to be explicit to open a conversation. For example, you could include a question like, “Rate your difficulty to care for your loved ones”.
Alternatively, you could start the appointment by asking: “Is your arthritis causing you any concern in your daily life?”
These could be interpreted in many ways, and any answer opens up an opportunity for conversation. Of course, tailor your approach to suit the patient.
Have a list of other health professionals handy that you could refer patients to if they want further help. This could include physiotherapists, occupational therapists, family counsellors or sex therapists.
Above all, this subject needs to be treated as part of a holistic approach to your patient’s care. If you are reluctant to include it within your duty of care, you could be contributing to the problem.
Rosemary Ainley was writing on behalf of CreakyJoints Australia. CreakyJoints Australia would like to thank Rheumatology Republic for this opportunity to share the patient voice within the Australian rheumatology community.