Sexual dysfunction is common among individuals with chronic illnesses and is associated with distress and reduced quality of life. Because of the long-term, often irreversible nature of sexual dysfunction in chronic illness and limitations of pharmacological treatments, there is a need to understand cognitive and behavioral coping processes in this population.
Some of the sexual dysfunctions that can result because of a chronic illness are erectile dysfunction, low desire and arousal, vaginal tightness or dryness, dry orgasms or retrograde ejaculation, and the decrease in orgasmic intensity. Keep in mind, some of these dysfunctions are also a result of medications.
While the issues of sexual function — foreplay, intercourse, and intimacy in general — may not be a priority during the time of diagnosis, or even during one’s initial management of this health issue, there’s a good chance it will eventually become one. It is at this time; the couple comes in for therapy because they feel at a loss. The sick partner is covered in shame (and this is just one of the several emotions!) and the healthy partner feels anxious and, at times, very angry.
To fully examine the physiologic effects of chronic illness on a person’s sexuality, two factors must be considered: (1) the type of chronic illness by which the person is affected and (2) the couple’s strengths and weaknesses on coping with the chronic illness. So, in other words, where are they now?
Issues pertaining to the type of chronic illness include the overall consequences of the specific illness, whether there is an effect on genital function, secondary complications, whether the disorder is static or progressive, iatrogenic concerns, and concomitant medical problems associated with the illness. Static illnesses are those whose symptoms and treatments predominantly remain the same over time and dynamic illnesses are those illnesses that generate cycles of relapse and remission.
Origins of Dysfunction Include Emotional, Physical Elements
The majority of sexual dysfunction originate in reaction to psychologic processes or are compounded by psychologic reaction. Thus, a discussion of sexuality must examine the emotional and physical elements involved.
When evaluating a person’s sexuality, it is critical the clinician also evaluate the factors affecting the couple. Many of the issues will have existed before the onset of the illness and will become exacerbated; however, in some cases, the illness may introduce a new issue.
The clinician must determine the degree of conflict that presently exists between partners and to what extent it is related to the illness. A chronic illness certainly leads to stress, which can lead to increased conflict. Following the diagnosis of an illness, there is the inevitable question, why did this happen to me? Because there usually is not good answer to this question, the sick partner becomes frustrated and angry.
The healthy partner has similar questions and can be left feeling cheated and hostile about his or life situation. The unusual balance of power that exists within any relationship is disrupted by illness, leading to struggles to regain homeostasis with which both partners are comfortable.
The sick partner may feel vulnerable and replete with fears that may be rational or irrational. Furthermore, the sick partner may harbor feelings of inadequacy, both as a person and as a sexual partner. Those increased feelings can lead to an intense fear of disappointing their partner sexually or more broader fear of abandonment- that the healthy partner will leave for a more “adequate,” healthy,” and “worthy” person.
A chronic illness may have changed the couple’s lives significantly to the point that life goals that were once compatible may no longer be compatible.
With the problems and obstacles resulting from a chronic illness, though, comes the opportunity through resolution for an even greater degree of intimacy and satisfaction for a couple. Sexuality can be a sensitive topic that many clinicians feel uncomfortable addressing with patients.
The reasons are twofold. First, few clinicians have received professional training in the area of sexuality. Secondly, the subject of sexuality is replete with the clinician’s own personal values and biases based on his or her upbringing, values and life experiences.
PLISSIT Model Can Be Helpful for Counseling
For many clinicians, it is difficult to separate their own values and attitudes on sexuality to address the issue objectively. In my research and as a psychotherapist who specializes in sexual health, I have found Annon’s PLISSIT model to be extremely helpful. This model is a multilayered framework for sexual counseling that incorporates all health care personnel who are working with clients.
The PLISSIT model is an acronym for permission, limited information, specific suggestions, intensive therapy. According to the model, all personnel should feel comfortable working with clients and should feel comfortable enough with their own sexuality and be knowledgeable enough to engage in the first two levels of the model.
Professionals should feel comfortable raising the issue with the patient to “permit” discussion of the topic. In addition, professionals should possess enough information about sexuality and the specific illness to impart limited information. Therefore, professionals should possess enough information to know their limits or to “know what they do not know.” In that case, they would move up to the next level of the model, that is, referring the client to a more knowledgeable professional for specific suggestions or intensive therapy.
When working with couples who experience sexuality problems because of a chronic illness, the clinician can focus in five areas:
1. A sexual dysfunction that predates the illness.
2. A relationship that is conflicted with the illness.
3. Sexual dysfunction resulting from poor coping.
4. Difficulty coping with severe changes in sexual self-image.
5. Adjustment to medical or surgical procedures.
The clinician can also focus in these areas:
1. Provide sexual education.
2. Help the couple in changing maladaptive and sexual attitudes.
3. Help couples resume sex and this may include sexual adjustment .
4. Decreasing other conflict.
It is critical that couples are educated about the normal sexual response cycle and the impact of their physiologic condition on the sexual response cycle. Couples must be knowledgeable about the impact of medications, lifestyle, and the aging process of their sexuality. Chronic illness often results in maladaptive attitudes (i.e., sex is unhealthy, sex must be spontaneous, and intercourse is the only worthwhile form of sexual expression) that must be challenged and corrected.
Couples will need assistance resuming their sexual activity, which can be accomplished by improving sexual communication, empathy, and learning their sexual styles as a couple. Such education will also help decrease performance anxiety. The couple will learn “ the new normal” of their relationship.
Annon, J. (1976). The behavioral treatment of sexual problems: Brief therapy. New York: Harper & Row.
Burnap, D.W., & Golden, J.S. (1967). Sexual problems in medical practice. Journal of Medical Education, 42, 673-680.
Master, W.H., & Johnson, V.E. (1970). Human sexual inadequacy. Boston: Little, Brown.
Pauly, I.H., & Goldstein, S.G. (1970). Prevalence of sexual dysfunction. Medical Aspects of Human Sexuality, 4, 48-52.
Schover, L.R. (1989). Sexual problems in chronic illness. In S.R. Leiblum & R.C. Rosen (Eds.), Principles and practice of sex therapy: Update for the 1990s (2nd ed., pp. 319-351). New York: Guilford Press.
Dr. Lee Phillips is a licensed clinical social worker (LCSW) in Washington, DC, Maryland, and Virginia. He has worked in several mental health and substance abuse treatment settings including outpatient community mental health, inpatient treatment, and private practice for the past 11 years. An adjunct professor at Western New Mexico University, he holds a Doctor of Education (Ed.D.) degree in organizational leadership with an emphasis in behavioral health from Grand Canyon University and a Master of Social Work (MSW) degree from Norfolk State University. His website is www.drleephillips.com