Patient and Family Issues

When people develop a serious, life-limiting illness, they may appear to lose interest in sex as they adjust to dealing with the illness and its treatment. Many patients have a poor understanding of their own sexual needs and ways of expressing those needs in the setting of illness. They may be very reluctant to raise the issue of sexual function or to discuss issues of sexuality with their physicians because many patients expect their physician to initiate the discussion. Some cultures may not allow patients to discuss sexual concerns, even with professional health care providers.

A patient’s physical disabilities, symptoms, medications, surgery, treatment regimens, and associated psychological issues (e.g., anxiety and depression) may affect the desire for sexual expression and the physical ability to have such contact. Patients may worry that their partner may no longer be sexually attracted to them because of the changes in their body and the fact that they have cancer or another serious illness. Serious illness puts a great strain on partner and family relationships. This stress may cause problems in the relationship between partners and may disturb usual sexual function. The partner may feel guilty for having sexual feelings at a time when the patient is coping with the illness and associated problems. Similarly, the sexual partner may also be affected by the illness and may feel that sexual expression is not possible or even appropriate or may even be less attracted to his or her partner because of changes in appearance. This may be manifested by sexual dysfunction in the partner, such as erectile dysfunction or lack of arousal in either partner.

Aging Patients

Many patients who need palliative care are elderly. The Masters and Johnson’s four stages of human sexual response (excitement/arousal, plateau, orgasm, and resolution) are all affected by the aging process. Nonetheless, elderly men and women can continue to enjoy fulfilling sexual experiences. Therefore, elderly patients should also have sexual assessments as part of their comprehensive assessment. The clinician should also be cognizant of the possibility of preexisting sexual dysfunction that often has never been addressed.

Physiologic changes that should be taken into account include the following:

• •
  

  More and longer direct stimulation of the penis may be required to achieve erection in older men.

  
  
• •
  

  Erections are usually not as full and may occur less frequently.

  
  
• •
  

  The plateau phase is prolonged, resulting in better control of ejaculation compared with that of younger men.

  
  
• •
  

  During orgasm, both the force of ejaculation and the number of contractions with each ejaculation are reduced, but the subjective feeling of pleasure is not diminished.

  
  
• •
  

  Older men who lose an erection before orgasm may not be able to achieve another because they experience a longer refractory period before another erection can begin.

Women also experience changes in sexual functioning with age. Most of these changes probably result from the decline in estrogen production that occurs with the onset of menopause. The reduced estrogen stimulation causes many changes in anatomy, including thinning of the vaginal mucosa, shrinking of the uterus, and replacement of breast glandular tissue by fat. Sexual arousal in older women requires more and longer direct stimulation. Vaginal lubrication is reduced, and the vaginal opening expands less fully. During the succeeding plateau phase, older women experience less vasocongestion and tenting of the vagina. With orgasm, fewer uterine contractions occur and, during resolution, clitoral tumescence is lost more rapidly than in younger women.

Dying individuals often are elderly, and their sexual needs may not include intercourse. They may have found that their sensuality can be expressed by hugging and cuddling.

Health Care Provider Issues

Poor knowledge and attitudes about sexual function and dysfunction are still issues with many health care providers. Curricula in this area and clinical teaching experience in assessing and managing sexuality may be lacking. This means that skills in assessing and managing issues of sexuality are likely to be suboptimal among most clinicians.

The health care provider’s reluctance to assess a patient’s sexuality and to deal with related issues often stems from the provider’s own sensitivity to discussing this very intimate function. This reticence can occur even if the patient wishes to discuss the issue of sexuality. Health care providers may be reluctant to ask questions about their patients’ sexual functioning because they themselves are embarrassed and not comfortable with their own sexuality, they may not believe that sexuality is part of the presenting problem, or they may feel that they are not trained adequately to deal with sexual concerns.

In considering all the issues for patients at the end of life, health care providers may feel that sexuality must have a low priority. Health care providers often wait for the patient to initiate discussion, yet most patients want and expect the physician to initiate the conversation. The cultural and religious background of the health care provider may also inhibit such discussion of sexuality, especially if there is a significant difference between the health care provider’s beliefs and those of the patient. Some health care providers have significant difficulties dealing with patients whose sexual orientation and practices may be very different from their own, and these difficulties provide yet another barrier for effective patient care and evaluation. In such cases, clinicians must recognize and acknowledge their own beliefs and be willing to refer their patients to others who are better equipped to help.

System Issues

The structure of health care institutions presents another barrier to sexuality for those patients who reside in the facility. Simple items, such as the use of single beds, inhibit the ability of partners to experience sexual relations. Privacy is in short supply in most health care settings. Multipatient rooms are not conducive to intimate exchanges between a patient and his or her partner. Even private rooms may not have doors or locks, so anyone can enter without notice, and this creates an environment that is not conducive to sexual intimacy. In addition, patient’s lives are often discussed freely among the staff, a situation that leaves no sense of privacy. Many institutions still are reluctant to endorse a policy in which sexual contact or activity is allowed on site. Patients may be confined to the facility and may not have access to items such as condoms that would allow for safe sex practices. Institutions must develop policies that will allow patients access to such items and must develop systems that allow for the private and safe conduct of sexual activity for its residents.