“Sexual Issues in Rheumatology: Assessment and Intervention” at the American College of Rheumatology Annual Meeting

Although it is often that thing no one talks about, rheumatoid arthritis can have a huge impact on a person’s sex life. From body image to side effects from treatments to physical pain, maintaining something remotely resembling a healthy sex life can be a real challenge with RA. This is an issue I firmly believe our doctors should help us manage, so I was happy to see that the American College of Rheumatology offered a session called Sexual Issues in Rheumatology: Assessment and Intervention at their annual meeting in November. Unfortunately, the session was scheduled for 7:00am – which is honestly a bit early for anyone to be discussing decreased libido and vaginal dryness. But though the session was not particularly well attended, the healthcare professionals who were in the audience were offered some great information.

The session presenters were Doctor Mijal Luria, of The Center for Sexual Health in Israel, and Sharon Peleg-Nehsre, a sexual counselor for chronic patients at the Tel – Aviv Medical Center. Ms. Peleg-Nehsre started off with the reminder that the World Health Organization (WHO) considers sexual health a part of human rights. According to the WHO, sexual health “is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality…as well as the possibility of having pleasurable and safe sexual experiences…For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

It is quite clear that chronic illnesses – like rheumatoid arthritis – can negatively influence a person’s sexual health. Many factors, such as pain, fatigue, mobility, and mood, can impact sexual function. Dr. Luria cited several studies, which found that 31 to 76% of patients with rheumatoid arthritis experience sexual problems. Many struggled with feeling attractive and felt that RA put a strain on their relationship. Single individuals often felt vulnerable and insecure about how to handle a sexual relationship with a new partner. Other issues included diminished sexual desire, vaginal dryness, reduced clitoral sensation, and lower sexual satisfaction. Patients may fear that sex will provoke medical complications or that they will fail or be rejected as a sexual partner. Traumatic medical procedures and fertility issues can also have a negative impact on sexual health.

As someone who has personally struggled with the impact of RA on my sex life, these statistics did not surprise me. However, Ms. Peleg-Nehsre offered a statistic that I did find pretty shocking. In a 2013 study of rheumatology healthcare professionals, 96% considered sexuality a relevant topic in rheumatology care, but 71% seldom or never raised the topic with their patients. Considering the massive impact of RA on sexual health – which the doctors in the study even recognized – I was somewhat appalled to learn that so many doctors are not proactively addressing these issues!

Ms. Peleg-Nehsre offered several explanations for why doctors may not bring up issues of sexual health, even if they think it is relevant. These explanations included issues of time pressure and concerns over embarrassing or offending their patients, particularly in situations where the doctor and patient are opposite genders. However, these explanations should not stop doctors from helping their patients overcome the barriers to discussing this important and intimate topic. Ms. Peleg-Nehsre then proceeded to offer the audience some suggestions as to when, where, and how to address the topic of sexual health with their patients.

Despite the ever-present time constraints on rheumatologists, there are several types of office visits that may provide opportunities for sexual health screening. These include annual exams, appointments to manage chronic illness, appointments to discuss fertility or pregnancy, and appointments where mood and/or depression are discussed. If the patient does not take the initiative to bring up the topic, Ms. Peleg-Nehsre encouraged rheumatologists to provide information about sexual health. Appropriate times to do so include early in the course of the disease, when general information on the disease is provided, upon initiation of new medications, and at regular control intervals. Despite the importance of the topic, Ms. Peleg-Nehsre emphasized that the least suitable time to discuss sexual health is at the time of diagnosis, when patients already have enough on their plates. She also highlighted the importance of waiting until after physical exams when the patient is fully dressed to discuss these issues.

Dr. Luria offered some management strategies healthcare professionals can present to their patients. Something as simple as having brochures about sexual health available in the office can help signal to patients that they have “permission” to talk about their sexual concerns. Doctors can also help their patients develop flexible coping skills. For example, if a patient thinks disease has ruined our sex life, doctors can provide resources so the problem can be re-framed as disease has changed our sexual relationship. We can still have a good sex life, just in different ways than before.

Doctors can also offer their patients various ideas for improving their sex life, including planning ahead for sexual activity, taking pain medications in advance, and experimenting with different positions and forms of sexual stimulation. There are even a few resources available (like information from Arthritis Research UK) that offer suggestions for various positions to overcome different types of joint pain. Dr. Luria also said that at least 65% of women have used lubricant, so recommending the use of lubricants can be another helpful tool.

Overall, the presentation concluded that sexual dysfunction is common among patients with rheumatic diseases. Health care providers may tend to disregard this topic, but they shouldn’t because they can really help. Studies show that 70% of sexual issues can be solved without intensive therapy – if only patients would be given permission to feel comfortable about the topic. Ms. Peleg-Nehsre ended her presentation by reminding the rheumatology professionals in the audience: “if you are not part of the solution, you are part of the problem.” (If your rheumatologist is part of the 71% not bringing up the issue of sexual health, here are some tips for how to talk to your doctor about sex.)

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