Sex and Intimacy after Stroke: Recommendations from the 2013 AHA Consensus Document

This paper summarizes the key points of an AHA consensus document and other recent research for multidisciplinary members of stroke rehabilitation teams to use in alleviating concerns about sex and intimacy for stroke survivors and their partners. Evidence-based recommendations include asking about intimacy and sexual concerns, discussing the safety of resuming sexual activity, coping with the stroke sequelae of paraparesis, aphasia, concrete thinking, emotional liability, and loss of emotional awareness.


Introduction
The American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions published a state of the science consensus document in 2013 on the impact of cardiovascular disease on sex and intimacy in those with the disease and their partners [1]. This paper reviews the major points of the consensus document concerning sex after stroke and the implications for multidisciplinary practice, which have also been supported by recent research on stroke survivors and their partners [2][3][4][5].

American Heart Association Recommendations for Intimacy after Stroke
The AHA consensus document provides over 20 evidence-based recommendations for intimacy after stroke, including the following three: All stroke survivors and their partners should be asked about intimacy and sexual function at the time of the stroke, and then at regular intervals during follow-up after stroke [ Patient and partner counseling by healthcare providers has been determined to be helpful in the resumption of sexual activity after stroke, and this counseling can be tailored for the individual needs based on their age and sex, diagnosis, and severity of the stroke sequelae [1,3,[5][6][7]. While some patients and their partners may not want to discuss sexual issues, for others sexual concerns may be a priority during the rehabilitation and reintegration phase in the weeks and months following the stroke. Patients and their partners may not understand that it is safe to resume sex after a stroke, or recognize how their medications may affect intimacy, and how regular exercise, physical, occupational, and speech and language therapy support intimacy. Recent research confirms that in spite of decades of research indicating it is safe to resume sex, patients and their partners need to be told it is safe [1,3,4,8]. Some patients and their partners may also benefit from counseling to address fears, anxiety and depression following the stroke.
Although it is clear that sexual and personal counseling after stroke is needed to address a variety of issues that occur as a result of stroke sequelae, recent research continues to support that health care providers lack the motivation to address these concerns, do not think it is part of their practice, or lack the confidence or sufficient education and training to provide sexual counseling [3,9,10]. One recent study found 81% of stroke survivors received insufficient information about sexuality post stroke5. Sexual counseling education should be readily available and required continuing education for all members of the stroke rehabilitation team. Because team members report that they are not prepared to discuss intimate matters, one of the purposes of this article is to provide practical advice on sex after stroke based on AHA recommendations. The goal is to normalize and integrate discussions of sensitive, yet important sexual topics into their current practice, supporting the call to action by Mellor and colleagues, along with preceding authors that these changes are needed now [3,[5][6][7]10].
The consensus document provides evidence for sexual counseling based on cognitive behavioral therapy and social support, and the value of sexual counseling over several meetings, using a multidisciplinary team approach. With appropriate training, the entire rehabilitation team can play a role in helping couples adapt to changes after the stroke and maintain and improve sexual function and intimacy. However, even if only a few members of the team without special training are able and willing to provide basic education, patients and their partners may benefit. At a minimum, patients and their partners can be given educational resources, which is supported by the AHA document1, and current research [3,5,8]. Some current materials are listed in Table 1.  The AHA 20131 consensus document information is based on a review of 17 studies examining issues affecting sex and intimacy after stroke [7], which led to the following general conclusions. The sequelae of stroke and medications the stroke survivor is taking can negatively affect the gestalt of the sexual act through effects on physical functioning, cognitive processing, emotional expression, and depression [2][3][4][6][7][8]10]. Also, individuals affected by stroke commonly have other vascular comorbidities, including diabetes, heart disease, and hypertension, or arthritis or chronic pain, all of which may also interfere with or preclude sexual activity [1][2][3].
The physical and cognitive deficits following a stroke can be overwhelming for stroke survivors and their partners, with profound effects on intimacy and sexuality. To date, research exploring the problems associated with sex after stroke has been limited to descriptive and qualitative studies, and few studies have tested the effectiveness of interventions designed to aid couples in overcoming physical, cognitive, or emotional difficulties encountered during sex after stroke. However, investigators have found that individuals and their partners are open to discussion of sexual concerns after stroke [3,5,8]. Thus, is it time to move the science forward to test interventions to help stroke survivors and their partners maximize their sexual abilities after stroke.
The findings of a study8 of a sexual rehabilitation intervention program for stroke patients and their spouses demonstrated that a program of educational content, emotional counseling, and specific strategies to minimize or overcome post-stroke sexual problems increased sexual satisfaction and frequency of sexual activity in a sample of 12 couples, compared to 11 couples in a control group. The authors concluded that a similar intervention program can be useful as a practical guideline for post-stroke sexual rehabilitation, and that informational components of the program can be administered prior to hospital discharge in a booklet format. (Table 1 for a list of educational resources for stroke survivors and their partners). Taking a proactive approach to addressing sexual concerns may prevent problems from becoming more serious. These findings are supported by those of Akinpelu and colleagues4, who found that untreated psychological problems after a stroke can have a negative influence on sexual function.

Recommendations for Stroke Survivors and their Partners
The following specific recommendations can be made based on the AHA consensus document1, recent research [2,4,5,8] and reviews of research [3,7] to aid couples to overcome specific impairments after a stroke. These recommendations are primarily based on anecdotal reports and a clinical article of practical advice for stroke survivors and their partners [10]; however, there is no reason to suspect that any of these recommendations are harmful.

Paraparesis
Couples may need to adopt new positions for intercourse [1,7,8] ( Figure 1). In addition to the paraparesis, older couples may have limitations caused by breathing difficulties or arthritis, and the positions in Figure 1 will assist them to overcome these limitations. Suggest experimenting with new sexual activities, including new ways or areas of touching [3,7,8]. It may be that the stroke increases touch sensitivity in areas of the body other than the genitals, and these become erogenous zones, for example, specific places on the head and neck, or areas of the skin in the zone between where touch sensation is lost and touch sensation is maintained. When couples explore these erogenous zones, they may find additional pleasure and arousal.

Concrete thinking
Teach partners to be direct with sexual communication so that the stroke survivor does not miss the subtle cues of intimate communication. The ability of a stroke survivor to use humor as a part of intimacy may be lost due to concrete thinking. Humor can still be used as a part of intimacy, as long as both parties understand the meaning of the humor. Use of established expressions of humor (such as jokes or humorous words or phrases) to express feelings or discuss events may add to a couple's intimacy, as long as the meaning is clear.

Emotional Lability and Loss of Ability to Express and Interpret Emotions
A stroke survivor may spontaneously laugh or cry. Others may not "feel" the emotions of love and belonging after a stroke, or may lose the ability to notice or interpret the emotions of love and joy. Encourage couples to develop routines for expressing emotions and sharing joy with each other every day.

Conclusion
Sexual counseling for cardiovascular disease patients, including stroke, is an area that needs more attention and action by multidisciplinary health care providers. Education is also needed for health care providers, so that they can be comfortable and knowledgeable in providing guidance to their patients on addressing sexual issues. As Mellor et al [9] note, this is not new information, the time for change is now.