Sexual Problems in Cardiac Patients How to Assess, When to Refer

Journal of Cardiovascular Nursing Vol. 25, No. 2, pp 159Y164 x Copyright B 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tiny Jaarsma, PhD, RN; Elaine E. Steinke, PhD, RN, FAAN; Woet L. Gianotten, MD

It is increasingly realized that discussing sexuality is an important issue in the holistic care for cardiac patients. In this review article, the conditions of a good assessment of sexual problems are identified such as creating an appropriate environment, ensuring confidentiality, and using appropriate language. Second, we present different styles and approaches that can be used to start the assessment, differing between settings, persons, or disciplines. The PLISSIT (permission, limited information, specific suggestion, and intensive therapy) model can be helpful to initiate discussion about sexuality with the cardiac patient and his/her partner. This model is a stepwise approach using various levels of discussion or treatment. Open-ended question can facilitate discussion about sexual concerns, and validated questionnaires or diaries can be used to assess sexual problems. Patients with sexual concerns and problems should be counseled and/or treated appropriately, and adequate follow-up is needed. Additional training and research are needed to further improve the quality of sexual assessment and counseling in cardiac patients. KEY WORDS: assessment, sexual function, sexual problems

mong patients with cardiovascular disease, sex- ability of phosphodiesterase 5 inhibitors, the new Aual problems are highly prevalent in both sexes oral treatment for erectile dysfunction, has brought and have been shown to adversely affect the patients’ their own challenges.6 Although safe and effective quality of life and well-being.1,2 Whereas talking about for most stable cardiac patients, these agents are sex seems to be rather normal in daily life and in the absolutely contraindicated in patients taking or- media, in the healthcare setting, assessment of the ef- ganic nitrates.7 fects of disease and treatment on sexual activity is less h The absence of discussion of sexual health issues evident. Within the field of cardiology, healthcare pro- and self-prescribing of increasingly available prod- viders increasingly realize that cardiovascular disease ucts may present a significant health risk to pa- and sexuality are related. The relations are manifold: tients, who may not be aware of the danger of drug interactions. h Erectile dysfunction and heart disease share com- h After a myocardial infarction, the patient and/or mon risk factors such as hypertension or diabetes.3 partner can be scared of sexual expression, fearing h Sexual activity might trigger cardiac symptoms. cardiac death, and with an implantable cardiover- h Cardiac medications can cause sexual problems. ter defibrillator (ICD), they may avoid sex for fear Cardiac medication is cited by part of the patients of a shock. as the reason for sexual problems (eg, "-blockers), which can make patients consider stopping the It is therefore important to address sexual function medications on their own initiative.4,5 as part of the overall medical care of cardiac patients. h Cardiac medications might dangerously interact with Otherwise, patients may worry unnecessarily about the treatment of erectile dysfunction.4,5 The avail- their sexual problems and will not receive optimal treatment. This article is especially aimed at summa- rizing approaches that can be used to discuss sexuality Tiny Jaarsma, PhD, RN, FAAN Associate Professor, Department of Cardiology, Thoraxcenter, in cardiac patients. Many nurses in cardiology are University Hospital Groningen, Groningen, the Netherlands. involved in research, so extra attention is paid to as- Elaine E. Steinke, PhD, RN sessment tools. Professor, School of Nursing, Wichita State University, Kansas. Woet L. Gianotten, MD Psychotherapist, Rehabilitation Centre, De Trappenberg, Huizen, Conditions of a Good Assessment the Netherlands. There are several prerequisites for implementing Corresponding author Tiny Jaarsma, PhD, RN, Department of Cardiology, Thoraxcenter, successful patient education and counseling on issues University Hospital Groningen, PO Box 30.001, 9700 RB Groningen, related to sexual function. A proper assessment is of the Netherlands ([email protected]). vital importance; however, some conditions need to

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Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 160 Journal of Cardiovascular Nursing x March/April 2010 be met before starting assessment and education, such discuss. They may wait for the right moment (which as an appropriate environment, ensuring confidentia- never will be there). It is better to take a proactive role lity, and using appropriate language. in bringing up the topic with the patient and address- ing any questions or concerns. h Environment issues. Sexual assessment and coun- The popular approach, ‘‘Sex is fun and we are open seling are preferably conducted in a quiet environ- about it,’’ might also not work. Healthcare providers ment such as a conference room or a private area using this approach may believe that everybody can and without being disturbed by beepers or phones. talk about sex as easy as they do themselves. A pro- h Confidentiality. The healthcare provider should fessional might ask, for example, ‘‘Had good sex after ask permission from the patient prior to beginning your rehabilitation program?’’ In this approach, the sexual assessment and counseling. Patients should language is not adapted to the patients’ needs, and be assured that confidentiality is maintained about patients could feel offended or that their concerns sexual problems or issues that arise. Issues that re- were not taken seriously. quire further intervention should be documented, Approaches that might be more successful include a however. gradual approach, using a matter-of-fact approach, a h Language. The language used in assessment and context approach, the sensitive approach, and a pol- counseling is an important consideration. A lot of icy approach. Using a gradual approach begins by people do not have sufficient language/words to talk asking more general questions about the patient’s sexual about sexuality. In addition, many words used in concerns and then proceed to more sensitive topics.8 subgroups or among friends are not appropriate for In a matter-of-fact approach, the healthcare provider use in a professional conversation. Both healthcare uses experiences of other patients, or evidence from providers and their patients can find it difficult to research is a good opening to discuss sexual function. articulate the right words for such personal health To illustrate, the nurse can state, ‘‘Many people have issues. Imagine, for example, what words to use to concerns about resuming sexual activity after a heart tell your doctor that you have pain in your vagina attack. What concerns do you have?’’ This statement during sexual intercourse? Uneasiness discussing the implies that it is normal to have these concerns and topic of sexuality may be revealed in several com- allows the patient to bring up any concerns. If the pa- munication styles, for example, ‘‘concealing vague tient is not sexually active or does not have concerns, language’’ (eg, using ‘‘it doesn’t work anymore down this usually will become apparent in the patient’s there’’), medical language (eg, coitus), childish lan- answer. In the context approach, the topic of sexual guage, or dirty language. Using the language and concerns and cardiac illness is broached within the terms used by the patient will enhance understand- context of exercise or in a general discussion on con- ing the content of sexual counseling. For example, sequences of the disease or the treatment for daily life. when the patient uses 4-letter words to refer to body After discussing the recommendations for exercise, the parts and the health professional uses medical healthcare provider can introduce the topic of return to language, the message may not be understood. Every sexual activity as a component of exercise. Within the nurse should develop and have a set of words for the context of up-titration of medication (eg, "-blocker), various sexual organs, functions, and behavior. These changes in sexual response can be introduced or the words should feel comfortable for the nurse herself/ fear for impotence can be discussed, for example, by himself. So there should be no misunderstanding of stating, ‘‘Some people report sexual problems as a the meaning of the words for all involved. This result of taking this medication ("-blocker). How is means that verification of understanding is fre- that for you?’’ quently needed. In using the sensitivity approach, the healthcare Approaches for Assessment professional addresses the difficulty of the subject, for example, ‘‘Some people feel that talking about sex- For many professionals, the first step to discuss sexual ually is not easy. However, for a lot of people, this is an concerns might be the most difficult one. Different important subject in their life and your disease might styles and approaches can be used to start the assess- have an effect on sexuality. Is it alright to ask you a few ment, and these approaches might differ between set- questions regarding this subject?’’ tings, persons, or disciplines. Finally, the policy of the team or the organization Some approaches might not work to assess sexual regarding the discussion of sexuality can help profes- concerns. A too direct approach (eg, ‘‘How is your sex sionals to address the subject, for example, ‘‘In our life?’’) might be too confronting for some patients, team, we think it is important to discuss sexuality and whereas others might appreciate this directness. At the effect of treatment with all our patients that we see the same time, some healthcare professionals might at the heart failure clinic. Therefore, I would like to think that sexuality is a too sensitive of a topic to pose a few questions regarding this subject.’’

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The PLISSIT Model This step also might indicate the need for referral to someone specialized in sexual counseling or dys- One tool that healthcare providers can use to initiate function. For example, for a patient with erectile prob- discussions about sexuality with their cardiac patients lems after ICD implantation, you would need to and their partners is the PLISSIT model. PLISSIT is an provide sexual counseling or a referral that is specific acronym for permission, limited information, specific to the underlying problem (eg, anxiety, ischemia), suggestion, and intensive therapy. This is a stepwise instead of more general counseling.13,14 Because this model that can be used to initiate discussions about 9 step often includes a more in-depth approach to the sexuality. problem and the related personal factors, a compre- h Step 1: Permission. This step opens the door to a hensive assessment and problem analysis are needed. discussion of sexuality. In a way, discussing sex- h Step 4: Intensive therapy. This final step in the uality is also giving permission for being sexual model usually refers to conditions that require treat- and having sex despite having a disease or health ment by a specialist or a therapist. To optimize ap- condition. propriate referral, specific questions are also used h Step 2: Limited information. This refers to giving to clarify sexual concerns and problems (Table 1). the patients just enough information to help improve Information can be gathered on the nature and de- their sexual functioning.10 For example, a nurse velopment of the sexual difficulty, emotional reactions might explain that the cardiac demands of sex can to the problem, understanding of its development, at- be compared with a range of daily activities such as tempts to resolve the problem, psychiatric history, past walking 1.5 km (or 1 mile) in 20 minutes or walking sexual abuse, illness, therapy, hospitalization, physi- up and down 2 flights of stairs.7,11 This limited and cal health, medical history, medications, drug and 15 general information may help patients and partners alcohol use, and motivation for treatment. to overcome fears or correct misunderstandings. h Step 3: Specific suggestion. The third step in the How to Assess: What Questions PLISSIT model requires greater knowledge and ex- and Questionnaires to Use pertise that is relevant for this specific patient and partner with a specific condition or problem. Advice Questions for cardiac patients might include ‘‘Your problems Open-ended questions tend to facilitate discussion and regarding the lack of energy to have sexual inter- 8 enable the nurse to assess sexual concerns. The re- course might be related to your limited heart function sponse to the question also allows the nurse to deter- and the burden of your daily activities that might mine the order in which sexual counseling topics might consume a lot of your energy. You could consider be discussed. Table 1 summarizes some of the ques- having sex in the morning or taking some extra rest 12 tions that might be used to assess sexual problems. during the day, so you are well rested, and fatigue will be less likely to affect your ability to have sex.’’ Questionnaires Several suggestions for the cardiac population might be general; however, disease-specific advice might be General Questionnaires (for Both Men and Women) needed for the patient with ICD, those who had a Several questionnaires have been developed for self- coronary bypass surgery, or those with heart failure.12 administration in the natural home setting or in a

TABLE 1 Specific Questions

How would you describe your relationship with your partner? What concerns do you have about resuming sexual activity with your cardiac condition (insert appropriate term, eg, heart attack, implantable defibrillator, heart failure, etc) How important are sex and intimacy in your relationship? Are activities like hugging, kissing, and just being close an important part of your relationship? Were you sexually active before you were hospitalized? Is it important to you to be sexually active after you are discharged from the hospital? Did your previous sexual activity include sexual intercourse (vaginal or anal), masturbation, or oral sex? (Note: This helps to gauge the amount of energy expenditure required and to plan sexual counseling strategies.) Changes in sexual performance can occur as part of normal aging. Would you like me to review some of these changes? Have you noticed any changes in your sexual performance such as problems with erections or orgasm, vaginal dryness, or decreased desire for sex? What medications or supplements are you currently taking? (Note: Evaluate for sexual adverse effects.) What concerns has your partner expressed about resuming sex after you are discharged from the hospital? Would you like to include your partner in a discussion of resuming sexual activity after your cardiac condition?

Source: Steinke and Jaarsma.12 Request for reprint submitted to Elsevier.

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 162 Journal of Cardiovascular Nursing x March/April 2010 clinic setting. They are mostly used in clinical trials, nostic tool of erectile dysfunction. Using the IIEF, and information on their usefulness in clinical prac- erectile dysfunction is classified as severe, moder- tice is limited. Most questionnaires are specifically ate, and normal. A 6-item version (IIEF) and 5-item designed for men or women, with only a few of the version (IIEF-5) are developed and tested,22,23 and more general questionnaires that can be used in both the scale is used in cardiac populations (Table 2). female and male patients. Examples are as follows: h The Male Sexual Health Questionnaire24 is a validated 25-item self-administered questionnaire for as- h The sexual activity subscale of the Psychosocial sessing erection, ejaculation, and satisfaction in older Adjustment to Illness Scale is used in several studies Y men. It was designed to be culturally sensitive and age in cardiac patients.5,16 18 This reliable and valid sub- appropriate. Recently a 4-item version was made avail- scale evaluates shifts in the quality of sexual rela- able,25 which is not widely used in cardiac patients yet. tions due to the current illness or treatment and is composed of 6 multiple-choice questions. A total Questionnaires for Female Patients score ranges from 0 to 18 for the sexual activity In a review, the following questionnaires were recom- subscale. Low scores reflect good adjustment, mended for trials of female sexual dysfunction. Although whereas high scores indicate poor adjustment. they all are reliable and valid measures, no publications h The Multidimensional Sexual Self-concept Inven- using these scales in cardiac patients were found. tory is a reliable and valid questionnaire containing h 26 subscales that measure sexual self-concept: sexual The Brief Sexual Function Index for Women is a satisfaction, sexual anxiety, sexual self-efficacy, and reliable, validated, 22-item, multidimensional self- sexual depression have been specifically tested in report instrument for women that assesses sexual cardiac populations.19,20 Each subscale contains 5 function in 7 dimensions: sexual thoughts/desires, items, and respondents indicate how characteristic arousal, frequency of activity, receptivity/initiation, a statement is of them using a 5-point Likert scale. pleasure/orgasm, relationship satisfaction, and sex- Individual subscale scores range from 5 to 20, with ual problems. The scale also yields an overall com- a higher score representing a greater proportion of posite score. h 27 the specific attribute (eg, more sexual depression, The Female Sexual Function Index is a reliable, val- greater sexual satisfaction). This scale has recently idated, 19-item self-report questionnaire that assesses been used in a heart failure population.20 sexual functioning in women in 6 separate dimensions (desire, arousal, lubrication, orgasm, satisfaction, pain). In addition, a total scale score can be Questionnaires for Male Patients computed according to a simple scoring algorithm. Most questionnaires assessing sexual problems focus on h The Sexual Function Questionnaire28 is a validated, erectile dysfunction. Commonly used are the following: sensitive, 31-item, multidimensional questionnaire de- h The original International Index of Erectile Func- veloped for use in clinical trials in women with sexual tion (IIEF) is a self-report questionnaire with 15 arousal disorders.28 The questionnaire assesses sexual questions and was used in clinical trials.21 Recently, function in 7 dimensions: desire, physical arousal, those 15 questions have been examined for their lubrication, enjoyment, orgasm, pain, and partner usefulness as a simple patient-administered diag- satisfaction.

TABLE 2 The 5-Item Version of the IIEF23 Score Over the Past 6 mo 123 4 5 How do you rate your confidence that Very low Low Moderate High Very high you could get and keep an erection? When you had erections with sexual Almost never Much less than About half Much more than Almost always stimulation, how often were your or never half the time the time half the time or always erections hard enough for penetration? During sexual intercourse, how often were Almost never Much less than About half Much more than Almost always you able to maintain your erection after or never half the time the time half the time or always you had penetrated (entered) your partner? During sexual intercourse, how difficult Extremely Very difficult Difficult Slightly difficult Not difficult was it to maintain your erection to difficult the completion of intercourse? When you attempted sexual intercourse, Almost never Much less than About half Much more than Almost always how often was it satisfactory for you? or never half the time the time half the time or always

Abbreviation: IIEF, International Index of Erectile Function. The IIEF-5 score is the sum of questions 1Y5. The lowest score is 5, and the highest score 25.

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Sexual Problems in Cardiac Patients 163 h The Female Sexual Distress Scale is a reliable and valid 12-item instrument for assessing subjective distress associated with sexual dysfunction in women.29

Daily Diaries and Event Logs Diaries or sexual event logs are brief, self-report in- struments that are often used to obtain frequency data in clinical trials. Diaries typically require the subject to record sexual activity on a daily basis, whereas event logs are completed only on days that sexual activity occurs. For example, the Sexual Encounter Profile is a 6-item event log that has been used in several multi- center, clinical trials of erectile dysfunction.30 Patients are asked to report on specific aspects of sexual activity, for example, SEP2 Patient Diary: ‘‘Were you able to insert your penis into your partner’s vagina?’’ And in SEP3 Patient Diary: ‘‘Did your erection last long enough to satisfactorily complete the sexual intercourse?’’ A corresponding version for women (Sexual Encoun- ter Profile for Women) has been developed for use in clinical trials of female sexual dysfunction, with questions such as ‘‘Were you satisfied with your arousal during intercourse?’’ FIGURE 1. A treatment algorithm11 for the treatment of sexual problems of cardiac patients. Follow-up and Referral Israel, and China. The organization has information for Follow-up needs to be planned to evaluate the effec- both the public and healthcare professionals. tiveness of the treatment working, if the treatment was used properly, if the couple was happy with the treat- Concluding Remarks ment, and if the couple had any problems.11 Structured questionnaires can help to assess the treatment effec- Sexual problems are common in cardiac patients, and tiveness. An assessment algorithm might help to deter- their lives and those of their partners might be ad- mine which steps need to be taken before appropriate versely affected. Assessment of sexual function after a treatment can be initiated. Following the Second cardiac event is an important part of holistic patient Princeton Consensus guidelines, a patient’s cardiovas- care. In addition, healthcare providers need to con- cular risk is graded low, intermediate, or high (Figure 1). sider the feelings, needs, and fears of the spouse/ Treatment can be initiated according to the risk score, partner of the cardiac patient. In some situations, the and patients with low or intermediate risk can be patients may not be experiencing physical issues of treated in the outpatient or primary care setting.7,11 their own, but issues related to the worries or fears of Some professionals might not be comfortable in dis- the spouse may indeed affect performance. The spouse cussing the consequences of the disease or treatment for may also have problems expressing feelings to the sexual activities or to provide advice on resuming sex- partner because he/she may have not even come to ual activities. Others might not want to treat erectile terms with his/her own concerns. dysfunction within their daily cardiology practice. It is Healthcare professionals involved in the manage- important to establish a policy within the team and ment of these patients need to address this issue but determine which healthcare professional will be involved sometimes may be reluctant to do so. By integrating and responsible for the assessment of sexual issues. If the topic into daily care, applying different approaches, specialist help is required, referral should be made to and using open-ended questions that suit a specific an internist, diabetologist, cardiologist, primary care patientYhealthcare provider interaction, assessment practitioner, or sexologist. Some centers have urology of sexual function can be integrated into the various or sexology specialists with a special interest and ex- practices of healthcare providers, in clinical, rehabil- pertise in the field of treating erectile and other sexual itation, or home care settings. disturbances. The American Association of Sexuality Healthcare providers might benefit from specific Educators, Counselors and Therapists (www.aasect.org) training courses to assist in developing the knowledge provides a list of healthcare providers by state or region and skills to discuss sexual issues in practice. In addi- in the United States, Canada, Mexico, United Kingdom, tion, it is helpful if such programs incorporate the role

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 164 Journal of Cardiovascular Nursing x March/April 2010

concerns and educational needs after an implantable Clinical Pearl cardioverter defibrillator. Heart Lung. 2005;34:299Y308. 14. Steinke EE. Sexual concerns of patients and partners after h Various approaches are available that can help an implantable cardioverter defibrillator. Dimens Crit Care providers to begin the discussion of sexual concerns Nurs. 2003;22:89Y96. with cardiac patients and their partners. 15. Charlton RS. Treating Sexual Disorders. San Francisco, h Validated and reliable questionnaires can help to CA: Jossey-Bass; 1997. identify sexual problems in cardiac patients. 16. Derogatis LR, Lopez MC. Psychosocial Adjustment to Illness Scale Administration. Scoring and Procedures Manual. of team members in discussing sexuality. Taking ad- Baltimore, MD: Clinical Psychometric Research; 1983. 17. Jaarsma T, Dracup K, Walden J, Stevenson LW. Sexual vantage of these educational courses might improve function in patients with advanced heart failure. 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