Sexual rehabilitation and heart disease.

Sexual Rehabilitation and Heart Disease

Heart disease has reached enormous proportions in the United States, striking more and more at young people. Currently, 14,000,000 Americans have some form of heart or blood ailment (Green, 1979). In spite of this, specific guidelines regarding the sexual adjustment of persons with cardiac problems are scarce in literature.

This article discusses the experimental and empirical data that has been collected on the relationship between the sexual experience and heart disease. The article will propose guidelines for the sexual conduct of the person with cardiac problems. Lastly, implications for the rehabilitation professional who is involved in facilitating sexual rehabilitation will be discussed. The generic term, heart disease, will be used in the text to include the many different ailments, unless otherwise specified.

Why Worry about Sexual Rehabilitation

Traditionally, a person's sexual readjustment following a physical disability has been ignored. Health care professionals have seen persons with disabilities as nonsexual beings and have communicated their attitudes either verbally or nonverbally in the rehabilitation setting (Sidman, 1977). Tuttle, Cook, and Fitch (1964) found that two-thirds of the 20 patients in their study, who were recovering from myocardial infarction, received no advice about secual activity from their physician. One-third received vague and nonspecific advice.

Arguments advanced for this lack of concern are that the average person with cardiac problems is too old to be concerned with sexual activity, or that persons with disabilities can not engage in secual intercourse or are not inclined to do so (Sidman, 1977). However, Peberdy (1967) found that, of individuals practicing secual intercourse, 75% were active at 60 years of age; approximately 50% were active at 70 years; and 12% were still active at 80 years of age. A study of 86 teenage females, with rheumatic heart disease, attacks the second argument by showing a higher rate of pregnancy for this group than for teenage females without rheumatic heart disease (Gordis & Markowitz, 1967).

The most overpowering argument for providing sexual rehabilitation is that, without it, overall recovery may be delayed or extinguished (Frankel, 1967). Most people have unconscious conflicts and anxiety about sex. Devastating disease serves to unearth these conflicts with their attendant anxiety (Frankel, 1967). Literature review supports the idea that there is a relationship between emotional stress and myocardial infarction (Wabrek & Burchell, 1980). Clinical experience suggests that sexual problems are often associated with stress (Wabrek & Burchell, 1980).

The interrelationship between stress, sexuality, and cardiac disease is a complex situation in which any factor may be an antecedent of the other. Pne possible scenario is that the person with cardiac problems experiences stress over his or her possible loss of sexuality and, therefore, the cardiac condition is worsened. McCary (1971) suggests that the tension generated by sexual frustration frequently is more harmful than the tension generated by sedate and relaxed intercourse.

Sexual Activity and Sexual Dysfunction 

in Persons with Cardiac Problems

Many studies correlating sexuality and heart disease report on sexual dysfunctional problems of persons with heart disease. One exception, of interest, is a study by Hellerstein and Freidman (1970) in which 14 white middle-age Jewish men with coronary heart disease were studied to determine heart rate with their wives. The average rate during intercourse was 117 beats per minute with the maximum being 144 beats per minute. This rate compares favorably with healthy heart rates during intercourse, reported by Bartlett (1956) and Masters and Johnson (1966), indicating there is no more demand on the diseased heart during intercourse than on the healthy heart. The conclusion was reached that most middle aged men, who are not in congestive heart failure, can resume sexual activity.

Data indicates that some persons with cardiac problems may be predisposed to sexual dysfunction prior to evidence of heart disease. Weiss, Olin, Rollin, fisher, and Bepler (1967) studied 35 males and eight females with coronary occlusions. They found that sexual problems antedating the occlusion were present in 49% of this group compared to 23% in the control group.

In a more comprehensive study, Wabrek and Burchell (1980) found that, out of 131 males, age 31-86, who suffered myocardial infarctions, 70% reported sexual dysfunctions prior to the event. The majority of the complaints were of impotence. Other complaints were a decrease in sexual drive and premature ejaculation. Although no accurate figure has been reported for the incidence of sexual dysfunction in the general population, no one has suggested that it is as high as 70%. It is impossible to determine a causal relationship between sexual dysfunction and heart disease, but the implication for rehabilitation is clear. A return to the premorbid level of sexual activity may not be enough.

Sexual dysfunction following onset of heart disease is common. Often concern over sexual dysfunction occurs very early in the course of the disease. Cassem and Hackett (1971) report that several males, in the cardiac care unit of the hospital in which they conducted their study, were concerned with impotence. Group therapy with male patients with cardiac problems has revealed feelings of diminished libido, fear of death during intercourse, and anxiety at a preconscious level (Green, 1975).

Farber (1978) reports that the two most common patient problems in the cardiac care unit are depression and anxiety. Sexual excitement is the quickest and easiest way to deal with these feelings. The aim is to flood oneself with good feelings. Therefore, it is not unusual for males on the unit to make passes at the nurses. When this action fails to excite the patient and ward off depression, he may either: regress to a childlike state and seek protection and care; become angry; or keep trying to establish his sexuality. Farber (1978) recommends tolerance on the part of the nursing staff because, with time, the depression lessens, and the overt behavior decreases.

After stabilization and release from the hospital, many patients continue to show sexual dysfunction. A study in Switzerland of 88 men and 12 women was conducted 11 months post myocardial infarction (Bloch, Maeder, & Haissly, 1975). The mean frequency of premorbid sexual intercourse was 5.2 times per month. At the time of the study, the rate was 2.7 times per month. Of those who engaged in preinfarction sexual activity, 73% experienced a diminished frequency of intercourse. The reasons given were: decreased desire, depression, anxiety, partner's decision, fear of sudden death, angina, and impotence. The conclusion reached was that the most prevalent reasons for the decreased frequency of the sex act were psychological aspects rather than physical.

The type of heart disease can also affect sexual dysfunction. Kushnir (1975) studied ten men with myocardial infarction and ventricular fibrillation compared to 70 men with myocardial infarction and no ventricular fibrillation. He found that, after four months, a significantly lower percentage of men had resumed sexual activity in the group with ventricular fibrillation. At ten months, this difference had disappeared. The indication is that complications delay the return to sexual activity.

Two studies to date have been done exclusivly with post coronary females. In the first, one-hundred women hospitalized for myocardial infarction were interviewed, with 100 women without heart trouble as a control group. The results showed 65% of the hospitalized patients reported sexual dysfunction as compared to 24% in the control group (Abramov, 1976). Unfortunately, a very broad definition of sexual dysfunction, to the point of using the meaningless term, "frigid" (Woods, 1979), was used to describe the women in this study.

The second study interviewed 130 female patients, who had recovered from their first myocardial infarction, in the privacy of their homes. Of the previously sexually active patients (84), almost one-third (25) developed sexual concerns while still in the hospital. Of the 84 patients, 61 (72.6%) resumed sexual activity. A significant finding of this study was that receiving sexual instructions, before and/or after discharge, was a significant factor related to resumption of sexual activity (Papadopoulos, Beaumont, Shelley, & Larrimore, 1983).

Findings vary as to sexual dysfunction problems. A study of 17 males, three to four months after myocardial infarction, found that questions and concerns regarding sexual activity had resolved themselves either because couples sought advice or because they arrived at an unspoken agreement (Cohen, Wallston, & Wallston, 1976). More representative of the studies conducted, however, is the work evaluation clinic review that reported only one-third of the patients who were post-infarction returned to normal sexual activity, and two-thirds had a marked and lasting decrease in frequency of intercourse to below 50% of their premorbid state (Tuttle et al., 1964).

If sexual dysfunction occurs, one source that should be considered is the patient's medication. A study of 14 males, between 25 and 40 years of age, with rheumatic heart disease, who had taken digoxin on a long term basis, reported a significant decrease in desire and frequency of intercourse and an increase in the incidence of impotence when compared to a control group (Neri, Aygen, Zukerman, & Bahary, 1980). If a patient is taking medication for hypertension, which is often a correlate of heart disease, some of these drugs can cause impotence, and some can cause an inability to ejaculate (Scheingold & Wagner, 1974). It is important for the person taking such drugs to discuss the question of sexual functioning with the physician.

Demise during Sexual Activity

It has been picturesquely called La mort d'amour (Heggtveit, 1965). From Massie, Rose, Rupp, and Whelton (1969), comes a more pedestrian term, often heard in coroner's offices around the country, I.E., D.I.S. (Death in the Saddle). Reports of coital death have been recorded as far back as the 1500s (Trimble, 1970). Patients with cardiac problems often express this fear (Green, 1975; Tuttle et al., 1964), but how real is it?

The first published study on the subject comes from a Japanese pathologist who performed autopsies on 28 males and six females who died suddenly during coitus. Eighteen males and two females were determined to have died of cardiac origins. These deaths comprised 0.3% of 5,559 cases of sudden death observed over a four and one-half year span. Of the 20 deaths, 70% (14) occurred during extramarital intercourse (Ueno, 1963).

Hellerstein and Freidman (1970) estimate, from communication with coroners, that acute coronary insufficiency resulting from coitus is a fact, but the incidence rate is no more than three out of every 500 subjects with heart disease. Reference is made by several writers to the dangers of extramarital intercourse (Heggtveit, 1965;Hellerstein & Freidman, 1970: Scheingold & Wagner, 1970; Trimble, 1970; Ueno, 1963). The inference is that non-marital sexual activities, by married patients, may lead to much more profound physiological changes, including severe elevation in both heart rate and blood pressure. Sexual activity with new partners is viewed as more stressful because of the anxiety factor (Hellerstein & Freidman, 1970).

Massie et al. (1969) offered another viewpoint. They noted that, often, extramarital coital death has followed an evening out with heavy imbibing of alcohol and a heavy meal. They also hypothesized that just as many married men may die at home during intercourse, but private physicians, out of lack of knowledge or acquiescence to the spouse's desire, sign the death certificate without entering the exact circumstances of the event. No matter which philosophy one follows, it is obvious that coital death is a rare occurrence, and that reports of coital death of a middle aged, middle-class, male patient with heart disease who engages in sexual activity with his wife. of 20 or more years in their own bedroom is even rarer. This description, coincidentally, is the profile of the average person with cardiac problems (Scheingold & Wagner, 1974).

Reimplementing Sexual Activity

For many patients, after leaving the acute phase of an illness, the return of sexual arousal is a welcome sign of rehabilitation and the potential for a normal life. Interviews indicate that it is not uncommon for the male patient with cardiac problems to masturbate while still in the hospital (Green, 1979). This subject, rarely studied or discussed, is becoming more acceptable to many authorities who acknowledge the reality of studies that show 90% of all males and 60% of all females masturbate with some regularity (Scheingold & Wagner, 1974).

An unpublished study of 10 healthy males at the University of Washington indicates a maximum heart rate of 130 beats per minute while masturbating (Green, 1979). This compares well against the 150 beats per minute recorded by Bartlett (1956); the 180 beats per minute reported by Masters and Johnson (1966); and the 144 maximum rate per minute stated by Hellerstein and Freidman (1970) during intercourse.

Masturbation is a way of resuming sexual activity with lessened cardiac cost and without the additional anxiety of interpersonal reaction with one's partner (Scheingold & Wagner, 1974). Naughton (1976) suggests that feeling of guilt or anxiety may increase the energy cost of masturbation, but, if the patient does not find the concept wrong from an ethical or moral point of view and if a heart rate of 130 beats per minute can be tolerated, there is no contraindication to masturbating as a way of renewing sexual activity. Masturbation can also be a viable sexual outlet for the widowed, divorced, or single person with cardiac problems (Scheingold & Wagner, 1974).

Most literature discusses when sexual intercourse should be resumed, rather than when sexual activity should be resumed. It is generally agreed that no sexual intercourse should be attempted while the patient is still in the acute, decompensated cardiac stage (Heslinga, 1974). Male patients will usually acknowledge this fact, but, occasionally, a husband may insist on relations with wife at the decompensated cardiac stage on the assumption that the passive part women play in coitus will not constitute undue exercise (Massie et al., 1969). This fallacy ignores Masters and Johnson's (1966) work that showed heart function to be basically the same in both sexes during intercourse. Fisher and Orofsky's (1968) study of four healthy females also disputes this fallacy. They concluded that the subjective feelings a woman experiences during and after sexual intercourse, rather than her apparent performance level, are most meaningfully related to her autonomic responses, including heart rate.

Once the patient has recovered from the acute stage of heart disease, there is no reason not to engage in intercourse. The average recovery time varies from eight to 16 weeks, but both extremes have been violated (Labby, 1975). Possible factors in delaying sexual intercourse are pain, spouse decision, medication, aging, loss of self-esteem, and interpersonal dynamics (Neri et al., 1980).

Although the physician's permission should always be sought before resuming sexual intercourse, the standard measure of sufficient stamina has long been the ability to climb a flight of stairs (Green, 1975; Heslinga, 1974; Labby, 1975; Massie, et al., 1969; Soloff, 1977). Until 1977, however, no one knew exactly what a flight of stairs was. Siewicki and Mansfield (1977) conducted a study with 30 healthy males, between 20 and 39 years of age, which established a flight of stairs as 20 steps in ten seconds or two steps per second with a landing in the middle, The mean maximum heart rate reported for this study was 127 beats per minute which corresponds roughly to the rates for intercourse previously cited. Soloff (1977) also added the measure of walking briskly for a city block without discomfort for those persons with cardiac problems without access to a flight of stairs.

Often a major cause of problems is not sexual intercourse itself, but a futile attempt to perform the act (Soloff, 1977). Rather than attempting to perform prodigious coital athletics, the patient may prefer a more passive reentry to sexual activity. Cuddling, petting, a lingering caress, or a whispered word of love are erotic adventures in their own right. The male patient may practice coitus reservatus in early stages of resumption of sexual activity if he wishes to avoid undue exertion (Heslinga, 1974). Five milligrams of glycerine trinitrate or nitroglycerine placed under the tongue can act both as a prophylactic and as a therapeutic treatment for the pain of angina pectoris during intercourse (Heslinga, 1974; Massie et al., 1969).

Choosing the position for sexual intercourse that is the least taxing for the person with cardiac problems is a subject for debate. Traditionally, for the male patient, either female astride or side-by-side has been recommended (Green, 1979; Heslinga, 1974; Scheingold & Wagner, 1974). For the female patient, the male-on-top position has been recommended (Scheingold & Wagner, 1974).

Two studies have questioned this advice. Stein (1975) tested coital positions with six male patients with myocardial infarction. No significant difference was found in the mean maximal heart rate between the female and male astride positions. Eight healthy males were tested by Nemec, Mansfield, and Kennedy (1976) in both positions. The mean maximal heart rate with the male-on-top position was 114 beats per minute and with the female-on-top position was 117 beats per minute. Comparing this to Hellerstein and Freidman's (1970) patients with ischemic heart disease, who had a mean maximal heart rate of 117 beats per minute, suggests that the restriction of coital positions is not necessary and further confirms the modest energy cost of sexual intercourse.

Woods (1979) recommends anal intercourse as a viable alternative form of intercourse. Although there is no data in cardiac function and anal intercourse, rectal stimulation may innervate the vagus nerve. This nerve has parasympathetic effects on cardiac function. The end result would be a reduced heart rate during intercourse.

Implications for Rehabilitation Professionals

This brief article can not possibly explore all the sexuality issues and sexuality concerns of persons with cardiac problems, but even this limited discussion illustrates the complexity of the subject. The paradox is that, even though such a labyrinthine matter would be best addressed by providing as much information and assistance as possible to the person, only rarely is that the case. Too often, persons with cardiac problems act according to their limited knowledge, fears, opinions, or superstitions about their own sexuality. Many take unwarranted reductions in sexual activity, even to abstinence. This cycle of behavior can hamper full rehabilitation, i.e., reduced sexual activity can lead to frustration and marital conflicts (Green, 1979). Sexual counseling needs to be incorporated as a part of cardiac rehabilitation beginning at the hospital phase (Cohen, Wallston, & Wallston, 1976).

Rehabilitation professionals who are confronted by a patient's sexual problems may feel uneasy and unqualified to discuss sex with the patient. However, the patient's problems exist and must be handled. The professional often feels concern, fear, and a vague distress when patients talk about sex. The personal feelings of the professional, inadequate academic preparation, agency restrictions, and the fact that it is an emotionally loaded topic contribute to the uneasiness (Frankel, 1967).

If the professional is in a medical rehabilitation setting, or has access, the first person with whom to discuss the patient's problem should be the physician. Often the most therapeutic approach for the professional is to listen. The professional should use his or her sensitivity, experience, and sophistication to understand the problem (Frankel, 1967).

Some general factors to consider in determining when and to what extent sexual activity can be resumed are: the patient's general health; the extent of recovery from the coronary episode; the patient's physical activity level; the patient's fatigability; the physiological cost of sexual activity; the patient's emotional characteristics; and, most importantly, the extent of precoronary sexual activity (Green, 1979). In general, sexual rehabilitation has as its goal a return to the pre-illness level of sexual functioning, but, as discussed earlier in this article, that is not always an acceptable or optimum level (Soloff, 1977; Wabrek & Burchell, 1980). What is best for the individual is usually that with which he or she is most comfortable.

One approach to sexual rehabilitation, of the person with cardiac problems, is to make the spouse a valuable ally. Counseling of the spouse should focus on developing realistic expectations, allaying the spouse's fears, and avoiding over-protectiveness by the spouse. Clearly delineating the spouse's role can create a remarkable asset to the patient's recovery.

The relationship between self-esteem and work is comparable to the relationship between self-esteem and sexuality. Patients who engage in activities that increase their self-esteem (e.g., work and sex) have fewer medical complaints and feel less need for medical or social support (Anderson & Cole, 1975). Counseling persons with cardiac problems to accept the reality of their sexuality may also enable them to accept and adapt to their disability in general (Sidman, 1977).

Conclusion

Only in the latter half of the twentieth century has technology and sexual mores allowed the study of human sexuality from a physiological standpoint. The earliest published work on physiologic functioning during sexual intercourse is Bartlett's (1956) examination of coital responses in healthy subjects. The study of sexual rehabilitation is even in a more infant state. Hellerstein and Freidman's (1970) ground breaking study of sexual activity and the patient at the post-coronary stage was performed just 18 years ago.

Because of the newness of the field, much work is yet to be done. Many studies drew their conclusions from small and/or biased groups of subjects. Other studies relied on suspect measuring devices, such as the patient's self-report to gather their data. Therefore, there is a need for systematic replications of many experiments, as well as new research. Women have been underrepresented in all aspects of cardiac rehabilitation literature for many possible reasons: most researchers are male; the majority of persons with cardiac problems are male; and/or the genitals and sexual responsiveness of women are more difficult to evaluate. A challenge is presented to future researchers to produce more specific information about the sexual rehabilitation of women rather than vague generalities.

With the increased knowledge of both male and female sexual functioning and needs, may come an increased awareness and acceptance by society of the special sexual needs of persons with cardiac problems and other people with disabilities. This awareness, in turn, expedites the adaptation of the individual into society by providing a facilitative, rather than restrictive, atmosphere in which to deal with his or her personal problems. Given time and nurturing, this symbiotic model can help facilitate the person's total rehabilitation, of which sexual rehabilitation is an important part.