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Let's talk about sex!
Doctors need to start the conversation with their cardiac patients

Keywords: New guidelines urge doctors to talk about sexual activity with cardiac patients


by Paula S. Katz



Published in the December 2013 issue of Today's Hospitalist

IF YOU AREN'T HAVING "THE TALK" with your cardiac patients about sexual activity, new guidelines might help you find the words.

Previous guidelines from the American Heart Association addressed the timing and safety of resuming sexual activity after a cardiac event. New guidelines published online in July by Circulation go into the details of sex counseling.

Most cardiac patients without ongoing acute chest pain can resume sexual activity within a week or so after discharge, says Elaine E. Steinke, PhD, APRN, lead author of the article.

These patients—and their significant others—may not have
"Assume the patient is sexually active and bring up the subject."

–Elaine E. Steinke, PhD, APRN
Wichita State University

been sexually active for a while because of health issues, and they may be anxious about everything from chest pain to positions. Thus, an explicit conversation should start in the hospital to allay concerns and prepare patients for their sex life after hospitalization, says Dr. Steinke, a professor in the school of nursing at Wichita State University in Wichita.

Unfortunately, she adds, studies show that only some nurses take the lead on such counseling. That represents a lost opportunity for hospitalists.

"They see patients on a continual basis, so that's a good time to bring up the topic or reinforce what someone else has said," she says.

Dr. Steinke talked with Today's Hospitalist about what hospitalists should say to help cardiac patients with this key part of their recovery.

What's holding physicians back?
Physicians assume patients don't want to talk about sex, but research shows that patients and their partners want us to address this.

Physicians also assume that older people gave up on sex a long time ago, but people are sexually active across a wide range of ages. And although physicians sometimes think women are not as interested, that's not true.

Instead, assume the patient is sexually active and bring up the subject. Those not sexually active will usually tell you that. And people who may not have been sexually active due to cardiac symptoms may now want information if their symptoms or condition have improved.

Should hospitalists start the conversation?
Some patients bring up the topic while still in the ICU, but most don't, and patients are often embarrassed to. Research with patients with cardiovascular diseases shows they want physicians to start the conversation and provide information.

How should the topic be broached?
Bring it up in the context of post-hospitalization exercise: Another form of physical activity is resuming sexual activity. Normalize the topic. Say, "It's normal for patients after a heart attack to be concerned about this. Tell me the concerns you have." Use general, open-ended statements. That gives patients permission to talk about this further. They may not be as reticent to talk about sex as you think.

How detailed should physicians get?
Be very specific. Talk about when to resume sexual activity, how to resume it and the sexual side effects of their medications. Review some simple, common-sense guidelines: No eating or drinking prior to sexual activity, stay well-rested, recognize warning signs to report, and know what to do if problems are experienced. Tailor other suggestions to the patient's cardiac condition, as noted in the guidelines.

And talk about the role of intimacy without intercourse. The guidelines define intimacy as a range of sexual activities. That's important because patients with cardiac symptoms may not be able to resume sexual intercourse.

What other adaptations can help?
Stroke patients with weakness on one side have to change positions or use extra pillows for support. With numbness or weakness, they're challenged to find more sensitive areas that they weren't aware of. Also, they should face their partner directly during sexual activity, so the partner can read lips or facial expressions. Patients with aphasia need to find nonverbal ways to communicate about what is and isn't pleasurable.

Patients with heart failure may have difficulty lying flat, so using pillows to support a more upright position can help as well. Those who have had coronary bypass surgery may need extra pillows to support the incision.

What about talking to same-sex couples?
Physicians may say they don't have the capacity to address that. Well, they do. The new guidance recommends asking careful questions to find out what kind of sexual activity patients engage in and then determine if it will be possible or dangerous. We know at some point that same-sex couples—and some heterosexual couples—will resume anal sex, so we should give direct guidance as to when it's safe. This may require exercise testing to determine.

What if the patient considers any discussion taboo?
People of different cultures have varying beliefs about sexuality. You should say, "I know sexual activity is an important part of the quality of life for many, and I want to make sure you have information you need when you go home." If the patient is still uncomfortable, say, "I can come back later and maybe we can resume this conversation." Bringing it up at least gives them an opportunity to say, "I'm not sure I can talk about this right now."

What are patients' fears?
Heart attack patients' greatest concern is that sexual activity will cause another heart attack, although the chance of that happening is less than 1%. It typically happens only when patients overindulge with alcohol or a heavy meal or because of stress related to being with an unfamiliar partner. Just telling patients that the risk of another heart attack during sex is quite low relieves some anxiety.

Reassure them that blood pressure and heart rate rise for us all—and unless it's sustained, it's not of concern. Patients with chronic angina might take nitroglycerin prior to sexual activity. But if they have cardiac symptoms during sexual activity, tell them to talk to their health care provider to decide if it's normal or if further testing is needed.

Patients are also concerned about pain. Patients with a split sternum during surgery, even after six weeks of recovery, may need a mild pain reliever prior to sexual activity if there's discomfort. Patients with bypass surgery or surgery for congenital heart disease may have some change in body image—an ugly scar or leg incision. Health care providers need to address that.

Should patients with a defibrillator be extra cautious? Defibrillators may fire with sexual activity, though that occurs less often—10% or less—with newer devices. It can be frightening, so tell patients, "It won't harm your partner. If it happens, stop, rest and report it to your health care provider at the next opportunity. If it continues to go off, get emergency treatment."

Should partners be included in the conversation?
Research shows partners may have more anxiety and concern than patients themselves, so include them whenever possible.

What other providers should be talking to patients about this? It's not just the hospitalist. It's also the cardiologist, primary care physician, nurse practitioner, physician assistant, nurse and physical therapist. Put in the discharge plan, "Ms. Jones says she's sexually active. We briefly discussed this. I'd appreciate it if you could continue this conversation with her."

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
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