Sexual dysfunction in women post stroke: The hidden morbidity

Santosh K Chaturvedi¹, Poornima Bhola²,  
¹ Department of Psychiatry and Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences, Bangalore, India
² Department of Clinical Psychology and Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences, Bangalore, India

Correspondence Address:
Dr. Santosh K Chaturvedi
Department of Psychiatry and Psychiatric Rehabilitation Services, National Institute of Mental Health & Neurosciences, Bangalore
India

Full Text

Neurologists, neurological rehabilitation and physical medicine therapists mainly focus on motor and sensory functions and their recovery after stroke. Quality of life is considered to be related to the resumption of motor functions and the person's ability to be independent. The rehabilitation goals of post-stroke patients include improving quality of life and returning to functional activities, but the extent to which sexual activity is addressed as part of the standard rehabilitation process is limited, both in clinical practice and research.

Yilmaz et al., in their study on the evaluation of sexual function in women with stroke have documented lower scores on sexual functioning in women who had stroke as compared to the control group.[1] The current study by Yilmaz et al., had women in their fifth decade, which being the pre- and peri- menopausal age, has its own effects on sexual health and functioning.

Depression is a common consequence following stroke, and one may expect that sexual dysfunction and loss of libido may be related to depression following stroke. However, the authors have noted sexual dysfunction in women post-stroke, independent of the effect of depression. The authors report that 60.8% of the women post-stroke had significant levels of depression but this seems to have been underrecognised and untreated.[1] The interplay of depression and sexual functioning has also been examined closely in other studies [2],[3] and this points to the need to assess and address symptoms of depression during follow-up visits. Treatment of depresssion could have a beneficial effect on patients with stroke who are experiencing sexual dysfunction.[2] Clinicians would need to be cognisant of the potential sexual side-effects of antidepressants and consider making a choice of medication with the least sexual side-effects, and make appropriate referrals for nonpharmacological interventions.[4]

This study confirms that sexual dysfunction and decreased sexual satisfaction are common in the post-stroke population and are related to a range of sociodemographic (e.g., age, duration of marriage), physical (e.g., stroke severity, level of independence) and psychological (e.g., depression) factors. Related research in post-stroke sexual dysfunction has identified other psychosocial and relationship domains that emerged as contributors to the sexual difficulties experienced by women.[5],[6] Both research and practice in this area needs an expanded lens; one that looks beyond the domains and degree of sexual 'dysfunction', and encompasses the concept of sexual health. The World Health Organisation definition describes sexual health as “a state of physical, emotional, mental and social well-being in relationship to sexuality.”[7] Understanding sexual functioning within a biopsychosocial paradigm can provide a more comprehensive framework for assessment and intervention. A recommendation for future exploratory research in post-stroke sexual difficulties would be to adopt a qualitative or mixed method research design.

Specific sexual concerns of stroke patients, including the effect of stroke on intimate relationships and sexuality of the partner, the ability to physically engage in sex, and the effect of psychological components such as role identity, depression, and anxiety on sexuality, all warrant examination by rehabilitation professionals.[8] Assessment of sexual dysfunction is not an easy or a comfortable task, though. A popular stroke specific quality of life scale [8] has just two items related to sexuality, 'I had sex less often than I would like' under social roles and 'My physical condition interfered with my personal life,' under family roles. It can be noted that these items only skirt around the issue of sexuality in women. Sexual concerns are not likely to be voluntarily expressed by women, and even on questioning, these may be mentioned with some reluctance. An interesting observation in the current study by Yilmaz et al., was that fourteen women from the study group refused to respond to the questions because of their reluctance or limited time.[1] Various researchers have remarked on the societal taboos concerning discussions of sexual issues [6] and the reticence of both patients and health care providers.[4] Attitudinal barriers among health care providers have been documented, where discussion of post-stroke sexual issues was seen as being unimportant to women.[9],[10] Studies have also indicated that stroke survivors are concerned about these issues and do want information and sexual counselling from health care providers.[5],[11] A sensitive and facilitatory approach to addressing sexual dysfunction and decreased sexual satisfaction needs to be integrated into the post-stroke rehabilitation process.

The development of post-stroke sexual adjustment assessment tools and interventions would be useful for clinicians and rehabilitation professionals. The Female Sexual Function Index (FSFI)[12] used in the current study focuses on specific domains; desire, arousal, lubrication, orgasm, satisfaction and pain, with little scope to understand the complex array of psychosocial and relationship contributors. In fact, the authors of the instrument caution against using it as a substitute for a detailed clinical evaluation. Clinicians could consider using a 5 item short form of the FSFI [13] as a quick screening assessment in often busy clinical settings. This would allow for some privacy in disclosing intimate sexual concerns and demonstrate the willingness of the clinician to address issues concerning post-stroke sexual functioning. An examination of the FFSI items would help in identifying the specific domains of enquiry and in planning individualised interventions. This could be followed up with a detailed interview, if required. Research on sexual health and dysfunction, and specifically on post-stroke sexual difficulties, has identified a range of associated physical, psychosocial, and relational factors. These collective findings need to be translated into a brief and clinically relevant interview guide to enable a comprehensive assessment.

Sexual function is a significant aspect of quality of life and professionals involved in the care of stroke patients should receive training in addressing sexuality in the treatment of post-stroke patients.[8] Rehabilitation programs need to evaluate the level of training and services provided to address post-stroke sexual issues. Ideally, sexologists and sex therapists should be an integral part of the rehabilitation team; however, this may not be always possible due to paucity of these specialists. Psychologists, marital and couple therapists and behaviour therapists can provide necessary guidance and counselling to manage sexual dysfunction. The value of sexual health and functions should be emphasized to the women recovering from the effects of stroke, to encourage them to discuss these without embarrassment or hesitation. Simple guidance and counselling to improve sexual functioning should be routinely provided, irrespective of the age and gender of the patient. Many myths abound about sexual activity following stroke, which also need to be clarified. The American Stroke Association provides online information to address a range of possible misconceptions. These include fears about the possibility of recurrence of stroke during or post sexual activity, potential concerns about partner's reactions, and also provides information about suitable sexual positions. Neurologists and other involved health care providers could display educational material about post-stroke sexual intimacy in their clinics. This proactive approach could make patients feel that others share this experience and that this is a legitimate space to discuss these sensitive issues. Different strokes in the management of sexual concerns and functions in women post stroke would perhaps work together to enhance their wellbeing and satisfaction.

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