Predictors of change in sexual activity after cardiac diagnosis: Elements to inform sexual counseling

Abstract

Safely returning to sexual activity after being diagnosed with a cardiac condition is at the core of sexual counseling strategies. To further inform sexual counseling, this study examined changes in sexual activity before and after a cardiac diagnosis. Logistic analysis was used to suggest factors that can contribute to a change in sexual activity among cardiac patients. Reduced frequency in sexual activity after a cardiac diagnosis was influenced by greater sexual concerns and a history of smoking, as well as by education and employment status. These findings suggest that cardiac patients experiencing significant concerns about resuming sexual activity need added support through the mental health system.

Keywords

coronary heart disease heart sexual counseling sexual health strategies

Introduction

Humans are sexual beings regardless of age, gender, race, or status; and human sexual health extends beyond the absence of disease, dysfunction, or infirmity. Sexual health involves human sexuality, in terms of relational harmony between the physiological, psychological, and social aspects of life (World Health Organization (WHO), 2006). Within the scientific literature, there are reports about the consequences of acute and chronic health conditions on sexual health. Yet, little is known about how sexual health is influenced by the characteristics of individuals who are living with acute and chronic health conditions.

For many years, disorders of sexual function have been addressed in the Diagnostic and Statistical Manual of Mental Disorders, yet when symptoms can be attributed to medical condition, a psychiatric diagnosis is not made (American Psychiatric Association, 2013). The lack of a psychiatric diagnosis does not preclude the experience of angst for the individual and their sexual partner, however. Scarring, pain, positioning issues, and fear related to sexual performance can accompany medical conditions; such issues can have a profound effect on the sexual relationship between the individual and their intimate partner.

Heart and cardiovascular diseases are among the leading causes of infirmity and death worldwide (WHO, 2013). Although experienced differently by men and women, coronary heart disease is a universal determinate in decreased health quality of life (Duenas et al., 2011). Sexual health issues, associated with cardiovascular disease, were recently documented in scientific statements issued by the American Heart Association (AHA) and European Society of Cardiology (Levine et al., 2012; Steinke et al., 2013a). While both statements include information about resuming sexual activity following a cardiac event, there is little known about what influences such return to sexual activity. In addition, ample evidence suggests that sexual counseling of cardiac patients is overlooked by health care professionals (Barnason et al., 2013; Byrne et al., 2013), but is an area that should be addressed by interprofessional teams to be most effective in providing ongoing education and support to these patients and their partners (Steinke et al., 2013a). This is important not only to physical health, but in supporting of psychological health and sexual quality of life (Lai et al., 2011; Steinke et al., 2013a).

Patients and their partners are frequently concerned about how the activities involved with sexual intimacy might affect or exacerbate the cardiac patient’s heart condition (Lange and Levine, 2014). Concerns about resuming sexual activity can lead to avoidance behavior with negative consequences for quality of life among cardiac patients and their sexual partner (Steinke et al., 2013b). Concerns about returning to sexual activity have been reported among cardiac patients with specific cardiac conditions such as myocardial ischemia (Lopez-Medina et al., 2014), myocardial infarction (MI; Bispo et al., 2013), and heart failure (HF; Medina et al., 2009; Steinke, 2013). Limited information is available about how sexual concerns are experienced among cardiac patients overall.

Study objectives

One objective of this study was to examine the changes in sexual activity after diagnosis with a cardiac condition. A second objective was to identify factors that predict a change in sexual activity after a cardiac diagnosis. This study is unique in that it examined the patient’s sexual activity before and after the diagnosis of a cardiac condition and seeks to identify elements that influence any associated change in sexual activity.

Method

A subsample analysis of self-reported data measuring sexual activity and sexual concerns was performed. The original sample consisted of a cross-section of 205 cardiac patients from two medical centers in the Midwestern United States (Mosack et al., 2013). Before data collection was initiated, the researchers for the parent study obtained permission from the institutional review boards of the university and both medical centers to proceed with the study. The study conformed to the principles outlined in the Declaration of Helsinki. The data were collected from previously hospitalized patients receiving a cardiac diagnosis within the past year. Cardiac diagnoses included acute coronary syndrome, angina pectoris, coronary artery bypass grafting (CABG), coronary artery disease (CAD), HF, MI, and implanted devices such as a pacemaker or implantable cardioverter defibrillator (ICD). Patients selected for the parent study were discharged from the hospital within the past 12 months, at least 25 years of age, fluent in spoken and written English, and in a stable sexual relationship of 6 months or more.

The sample for this subsample analysis consisted of 192 cardiac patients reporting the frequency of sexual activity before their cardiac problem and in the past 2 months. The participants were categorized into three groups: (1) sexual activity as frequently as before diagnosis (n = 68), (2) sexual activity less often (n = 93), and (3) no sexual activity prior to diagnosis nor presently (n = 31, control group). A subgroup of 161 participants responded to demographic questions, as well as completed all items on a sexual activity questionnaire and sexual concerns inventory (12 items rated “never” to “frequently”).

Procedure

Data were collected using a modified Dillman survey method (Dillman et al., 2008) with questionnaires mailed through the US postal service. Over a 1-month period, two separate mailings of a cover letter, informed consent form, and study questionnaires were sent to prospective study participants, as well as a reminder postcard 1 week after the first mailing. All documents were assigned a unique identity code and no personally identifying information was available on the self-report instruments. The full procedure is reported in detail in a previous report (Mosack et al., 2013).

Instruments

Social and demographic data collected included age, gender, partner status, ethnicity, level of education, employment status, and history of cigarette smoking. Partner status was a dichotomous variable where partnered was defined as married or cohabiting, while not partnered meant widowed, divorced, or never married. The data collection instruments included 16 self-report questions to assess the presence or absence of cardiac and non-cardiac conditions that can influence a person’s participation in sexual activity. Cardiac conditions that can affect sexual functioning included HF, MI, CAD, whereas non-cardiac conditions affecting sexual activity included diabetes, kidney disease, anxiety, depression, and male erectile dysfunction.

Sexual concerns measure

The Steinke Sexual Concerns Inventory–General Cardiac Version (SSCI-GCV) was used as a self-report measure of sexual concerns. The SSCI-GCV is a 12-item instrument with an additional open-ended question asking respondents about overall sexual concerns. The instrument was developed and tested in English with a sample of cardiac patients diagnosed with various cardiac conditions. The readability of the instrument was established at a Flesch Reading Ease of 78.3 and a Flesch–Kincaid Grade Level of 5.1. Response options for the items of the instrument ranged from “never” (0) to “frequently” (3), with a possible range of scores from 0 to 33; a higher score indicates greater sexual concerns. Content validity of the instrument was assessed by a cardiologist and two internationally recognized nurse researchers. Internal consistency of the SSCI-GCV yielded a Cronbach’s alpha of 0.86 (Mosack et al., 2013).

Measure of sexual activity

The Sexual Activity and Heart Disease Questionnaire (SAHDQ) was used to measure sexual activity. The SAHDQ is a seven-item self-report instrument that measures the frequency of sexual activity, change in sexual activity since diagnosis with a cardiac condition, and specific sexual activities in which sexual partners engage. Within the instrument, sexual inter was defined as including vaginal, finger or anal penetration, or oral sex. For the purposes of this subsample analysis, a discrete variable was created to indicate the frequency of sexual activity by the cardiac patient. The variable consisted of three levels: (1) sexual activity as frequently as before receiving a cardiac diagnosis, (2) sexual activity less often since diagnosis, and (3) no sexual activity before or after diagnosis.

Data analysis

Data analyses were conducted using PASW Statistics 18, release 18.0.2 (2 April 2010) SPSS software. Social and demographic data were analyzed using descriptive statistics. Other statistical analyses included chi-square and logistic regression.

Results

Change in sexual activity

Responses on the SAHDQ (n = 192) showed that 16 percent of respondents remained abstinent, while 36 percent reported no change in sexual activity, and 48 percent indicated having sex less frequently after being diagnosed with a cardiac condition. To explore differences in frequency of sexual activity across demographic and clinical variables, Chi-square analyses were completed (Table 1). There were differences in the frequency of sexual activity for the following variables: partner status, education, employment, smoking history, and financial security.

Table 1.

Differences in frequency of sexual activity after cardiac diagnosis (N = 192).

Variable	No sexual activity	Sexual activity less often than previous	Sexual activity the same as previous	Total (n)	χ ²	p value
Race/ethnicity					1.78	0.411
White	28	81	63	172
Non-White	2	12	5	19
Partner status					10.89	0.004
Partnered	22	59	59	140
Not partnered/single	9	34	9	52
Education					22.76	0.012
Grade school or less	1	2	0	3
Some high school	0	9	2	11
High school graduate	11	31	10	52
Some college	7	30	33	70
Baccalaureate degree	9	11	13	33
Graduate school	3	10	10	23
Employment					15.10	0.001
Employed	5	24	34	63
Not employed	26	69	34	129
Smoking history					14.52	0.001
Never smoked	16	23	35	74
History of or current use	15	70	33	118
Financial security					1.55	0.021
More than enough	7	19	28	54
Enough	20	50	30	100
Not enough	4	24	10	38
Alcohol use					5.73	0.678
Never used	16	41	29	86
1 or fewer drinks/week	12	36	25	73
2–7 drinks/week	3	11	6	20
7 or more drinks per week	0	4	6	10
5 or more drinks on occasion	0	1	2	3
Exercise (per week)					7.39	0.495
None	4	12	7	23
Less than 30 minutes	5	16	6	27
30–60 minutes	4	18	11	33
1–3 hours	10	24	17	51
More than 3 hours	7	22	27	56

Bivariate testing showed that those of younger age had sex as frequently as before (M = 63 years, standard deviation (SD) = 12.4 years), compared to controls (M = 70 years, SD = 12.5 years). Most were well educated, but those having sex as frequently as before had more education. Those who were single, not working, and with ‘enough’ or ‘not enough’ finances were less likely to have sex as frequently as before being diagnosed with a cardiac problem. Those who were current or former smokers had sex less often than those who had never smoked (75% vs 25%).

Sexual concerns

Sexual activity was compared to scores on the SSCI-GCV. The control group and those having sex as frequently as before had a similar mean score (6 and 6.6, respectively), while those having sex less often have a mean score of 10.8 (SD = 7.28), indicating greater sexual concerns.

Logistic regression was used for multivariate analysis (Table 2). The outcome variable was coded as having sex less often (0) and as frequently as before (1). The control group was removed to more clearly determine the prediction of having sex less frequently after a cardiac diagnosis. Statistically significant predictor variables in the logistic regression were SSCI-GCV score, education, employment status, and whether or not the respondent had ever smoked. Those respondents with higher sexual concerns scores and having ever smoked were more likely to have experienced a reduction in the frequency of sexual activity after being diagnosed with a cardiac condition, whereas those with higher education levels, and those still working tended to experience little, if any, change in the frequency of sexual activity after being diagnosed.

Table 2.

Predictors of change in sexual activity (n = 161).

Predictors	B	SE	Wald	Sig.	Exp(B)
Sexual concerns score	−0.092	0.030	9.338	0.002	0.912
Education	0.409	0.166	6.032	0.014	1.505
Employment status	1.073	0.381	7.920	0.005	2.925
History of smoking	−0.974	0.385	6.393	0.011	0.378
Constant	−0.957	0.787	1.481	0.224	0.384

Nagelkerke R² = 0.292; p < 0.001.

Discussion

Cardiac patients with greater sexual concerns are less likely to resume sexual activity at the same frequency as before a cardiac diagnosis, and may need additional counseling and support. Both sociodemographic factors and greater sexual concerns significantly contributed to change in sexual activity. Similar to prior research, it is not uncommon for patients to experience a decline in sexual activity after a cardiac illness (Steinke et al., 2013a), with nearly one-quarter of cardiac patients in one study experiencing a change in sexual activity, and with 53 percent of these indicating this was a serious problem (Byrne et al., 2013). For some patients, this may be a short-term decline in sexual activity, while others the change may be permanent, and negatively affecting the couple’s relationship. In this study, several sociodemographic factors significantly contributed to a change in sexual function, primarily for those reporting sexual activity less than before the cardiac event. These included a lack of a sexual partner, unemployed, having enough or not enough income (compared to those with more than enough), and history of or current use of tobacco. Partner availability may be a concern, particularly for older individuals. Additional stress on the sexual relationship may occur for those who do not have employment or sufficient income, making sexual activity a lesser priority. Tobacco use and related vascular changes has been significantly associated with sexual problems or sexual concerns in cardiac patients, including those with HF (Steinke et al., 2009), and cardiac patients in general (Mosack et al., 2013).

In this study, a history of current or past smoking was a predictor of change in sexual activity. In addition to smoking, other variables that significantly contributed to the prediction of a change in sexual activity included sexual concerns score, education, and employment status. Few studies have specifically examined sexual concerns of cardiac patients (Medina et al., 2009; Mosack et al., 2014; Steinke, 2003).

One study suggested that the presence of sexual concerns may vary by type of sexual activity, with some requiring more exertion than others (Mosack et al., 2013). For cardiac patients who are symptomatic, this may be an important consideration regarding return to sexual activity. In addition, cardiac and non-cardiac comorbidities may affect the ability to be sexually active, including the number of comorbidities (Steinke et al., 2014), and types of comorbidities such as stroke, emphysema, kidney disease (Mosack et al., 2014). These studies suggest that both sexual assessment counseling by health care professionals are important strategies.

Implications for sexual counseling

Sexual counseling of cardiac patients is not limited to those working in cardiac settings, and health care professionals in mental health settings are perfectly positioned to address sexual concerns. While perhaps not needing psychotherapy, cardiac patients can benefit from a variety of sexual counseling strategies. Research demonstrates that effective strategies include cognitive-behavioral therapy, social-cognitive theory-based interventions, social and psychological support, specific and deliberate sexual counseling, sexual counseling over several sessions, inclusion of both patients and partners, and using a team-based approach to counseling (Klein et al., 2007; Steinke, 2013; Steinke et al., 2013a, 2013b). In addition to traditional talk therapy, strategies related to the actual physical condition needs to be incorporated into the sexual counseling intervention. Guidance by cardiac condition is well addressed in two scientific statements that provide specific cardiac-related content to be addressed, as well as psychological issues such as fear, anxiety, and depression (Levine et al., 2012; Steinke et al., 2013a). An online supplement illustrates potential changes in sexual positioning if needed (Steinke et al., 2013a). Printed patient education resources includes the AHA’s Sex and Heart Disease brochure (AHA, 2014), and patient pages on cardiovascular disease (Rosman et al., 2014) and ICD (Vazquez et al., 2010).

Study limitations

The limitations for this study include the use of cross-sectional data where changes in measures of sexual activity and sexual concerns over time were not collected and causal relationships between variables cannot be made. Additionally, the data for this subsample analysis were collected using self-report measures with a potential of reporting bias such as social desirability.

Conclusion

It is imperative that health care providers addressing physical and psychological issues work in concert with one another to address the sexual counseling needs of cardiac patients and their partners. Thorough sexual assessment by health care providers is critical in understanding individual concerns and situational factors, and to tailor sexual counseling based on this assessment. Ample resources are available to guide health care professionals in addressing safe return to sexual activity. Psychological and mental health support can be addressed by a variety of care providers, along with more intensive psychotherapy by mental health professionals when needed.

Footnotes

Acknowledgements

The authors gratefully acknowledge the assistance of medical center personnel for their help in identifying potential study participants.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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