Sex and chronic illness

Surveys of people living with long-term conditions consistently find sexual function among their significant concerns and among the least likely topics to have been discussed with any clinician.

The routes by which illness affects sex

Several at once, and distinguishing them helps.

Directly physiological: vascular disease affecting blood flow, neuropathy affecting sensation, hormonal effects, and conditions affecting the pelvic organs directly.

Diabetes affects sexual function through both vascular and nerve mechanisms in men and women.

Symptomatic: pain, fatigue, breathlessness, stiffness, nausea, incontinence — which limit what is possible rather than what is wanted.

Medication, which is discussed elsewhere on this site and which is frequently the largest single contributor.

Psychological: altered body image, particularly after surgery, stoma formation, mastectomy or amputation; depression, which is more common in chronic illness; and anxiety about causing harm.

Relational: the shift when a partner becomes a carer, which is one of the most consistently reported difficulties and one of the least addressed.

The fear of harm

Frequently unspoken and frequently unfounded.

After a heart attack, patients and partners commonly avoid sex from fear of triggering another event; the actual risk is low, and cardiac rehabilitation guidance addresses sexual activity explicitly, generally permitting resumption once a person can manage moderate exertion without symptoms.

The relevant caution is the interaction between nitrates and PDE5 inhibitors, which is genuinely dangerous and needs stating.

Similar unfounded fears exist after stroke, joint replacement and cancer treatment, and in almost every case the clinical answer is more permissive than the assumption.

Which is an argument for asking rather than deciding privately.

Adapting rather than abandoning

The practical work.

Timing around symptoms and medication: after pain relief has taken effect, at the time of day when energy is highest, which for many conditions is not the evening.

Positions that reduce load on affected joints, that reduce breathlessness, or that permit support with pillows and props.

Shorter, more frequent, less demanding encounters rather than the previous pattern.

Lubricant, which addresses a large proportion of medication-related and hormonal dryness.

Warmth and gentle movement beforehand for stiffness and pain.

Planning around a stoma or catheter, which stoma and continence nurses advise on routinely and which is a normal part of their work.

And redefining what the encounter consists of, since a great deal of what gets abandoned is abandoned because one specific act became difficult.

Cancer specifically

Where the effects are frequently long-term and frequently unmentioned.

Surgery, radiotherapy, chemotherapy and hormonal treatments all affect sexual function, and hormonal treatments for breast and prostate cancer do so substantially and for years.

Vaginal dryness, stenosis and pain after pelvic radiotherapy are common and are managed with moisturisers, dilators and specialist input.

Erectile dysfunction after prostate treatment is common and has effective management, with early rehabilitation improving outcomes.

Fertility preservation should be discussed before treatment begins, and frequently is not.

Specialist psychosexual services within cancer care exist in many places, and asking for a referral is reasonable rather than trivial.

The carer question

The most difficult part for many couples.

When one partner provides intimate personal care, the shift in role can make sexual intimacy feel impossible for either person.

What helps, where it is available: outside help with the most intimate care tasks, so the partner is not the only person performing them; deliberate separation of caring interactions from intimate ones; and naming the difficulty rather than each privately concluding the other has lost interest.

Carer exhaustion is a substantial and legitimate factor, and support for the carer is part of the sexual health picture rather than separate from it.

Disability more broadly

Worth distinguishing from illness.

Assumptions of asexuality remain common and are the source of a great deal of poor healthcare, including inadequate sexual health provision and screening.

Practical adaptations, equipment and specialist advice exist, and organisations run by disabled people are frequently a better source than clinical services.

And the barriers reported are more often social, structural and attitudinal than physical.

Raising it

Since it will usually not be raised for you.

A direct opening — "I want to ask about the effect of this on sex" — is sufficient and is a normal clinical question.

Specialist nurses in cardiac, stoma, continence, diabetes and cancer care frequently have more time and more relevant knowledge than the consultant.

And if a clinician is dismissive, that is a reason to ask someone else rather than to conclude the subject is closed.

General information only, not medical advice. Consult a qualified clinician about your own condition, particularly before resuming activity after a cardiac event.