Sex and Intimacy after Stroke
Sex is a sensitive subject for many stroke survivors and their mates. Stroke can cause big changes in the lives of couples who are sexually active. Stroke-related physiological and psychological changes may affect both sexual desire and performance. The insecurity, fear and doubt that can arise from this can throw even the most open and loving couples into a tangled web of conflicting emotions: Is sex safe? Am I still attractive? Can I be both a caregiver and a lover?
Just talking about these issues may be extremely uncomfortable for some. Still, the experts and survivors we talked with believe these concerns can be overcome.
“The most common concern for survivors and caregivers alike is fear of causing another stroke,” said Florence Denby, a nurse practitioner in the Stroke Rehabilitation Center at the Rehabilitation Institute of Chicago. Denby counsels couples on sex after stroke. “Very often the partner is afraid of hurting the stroke survivor or causing a second stroke. Many couples need reassurance that having sex for most survivors does not put them at risk of having another stroke.”
The experts we talked with agreed that research indicates that it is very unlikely that lovemaking will cause another stroke. The heartbeat accelerates and breathing becomes heavier during intercourse, but that is normal. Making love takes about as much energy as walking up one or two flights of stairs.
Fatigue is another common problem for survivors and their caregivers. Both may require more rest time throughout the day. The best time for sex may be after resting or in the morning. “Perhaps, just to reestablish the relationship, couples should spend time together cuddling and sleeping quietly,” Denby said.
There may also be challenges with affected limbs. To avoid injury, couples may need to work on safe positioning. “I recommend that couples experiment with different positions and use pillows so both people have a comfortable experience,” said Dr. Randie Black-Schaffer, the medical director of the Stroke Rehabilitation Program at Spaulding Rehabilitation Hospital in Boston. “Oral or manual stimulation may be attractive alternatives to intercourse for some couples.”
“Hemiplegia and changes in sensation are common problems,” Denby said. “Learning what positions are the most comfortable can be challenging but also fun. I suggest that couples use pillows or props to protect the weaker side of the body. The more mobile person should assume the top position.
Ask your therapist to recommend different positions. If you’re worried about urinary continence, it is a good idea for the survivor to void prior to having sex.”
Of course, the timing of when to resume sexual activity after a stroke is personal and will vary in each situation. Factors such as medical stability and availability of a partner may be an influence. Privacy may also be an issue because of additional help the spouse or partner may have in the home due to the survivor’s need for assistance with activities of daily living.
Neither partner should force the issue. You will know when you are ready. “For survivors, the personal signs would be first when they feel well enough to have sex and second when they feel the urge or desire,” Denby said. “Stroke survivors are human beings and the first step in all sexual intimacy is desire.”
What happened to desire?
Many survivors find that they don’t have much desire for sex because they are so involved in their recovery. Often there are body image concerns because of hemiplegia, drooling, facial droop or the inability to speak clearly. These concerns often cause survivors, especially younger, single men or women, to feel unattractive and unappealing to others.
For 52-year-old survivor Tracy (not her real name) of California, body image was less an issue than body sensation. “I had and have numbness. I didn’t want to be touched because it didn’t feel like me. Even when the wind blows against my skin, it feels different. And being touched by my husband reminded me of what I had gone through.”
For 51-year-old Walt (not his real name) of New York, medication prevented him from having an erection. This is not uncommon, according to both Ms. Denby and Dr. Black-Schaffer. “A number of antidepressants and blood pressure medicines can reduce libido (sexual desire) and performance,”
Dr. Black-Schaffer said. If you take pills for high blood pressure, plan sexual activity just before taking the pills. This may help you avoid impotence caused by medication.
It is extremely important never to stop taking a medication without consulting your physician first. In consultation with their healthcare providers, survivors may use medications to treat impotence. However, men should avoid erectile dysfunction drugs if they are taking medications for angina. Men should discuss this with their physicians so that treatment can be optimized.
Talk about it first
Walt, who had his stroke at age 43, found it difficult to talk to his wife about sex. “It was a year before we had intercourse,” he said. “I feared that our sex life and intimacy would not return to normal, and that was hard to talk about because I had a lot of anxiety. It takes courage to address this issue. Open communication is key, but very difficult.”
Tracy and her husband were never able to communicate with each other effectively after her stroke, and ultimately decided to end their 21-year marriage. “He was sensitive at first, but after awhile, he wanted business as usual, but my life was changed, and I couldn’t respond to him. He expected me to be my old self and wouldn’t give me room to adjust. He wanted to start where we’d left off, but I wasn’t the same person. It’s an adjustment just to walk or climb stairs, much less make love.”
Returning to sexual activity requires patience and the loving support of your mate. A spouse or partner may not bring up the subject unless the survivor does. And everyone we talked with agreed that it is important not to measure success by past performance. Both partners are faced with major changes, and adjustments will most likely have to be made to accommodate those changes.
Start slowly, perhaps just by being close and cuddling. Explore what feels good to you now that sensation on one side of your body may be different. Tell your mate what pleases you – he or she cannot read your mind. Intercourse may not happen at first, so just relax and focus on the intimacy that you are building together. Add intercourse only if and when you both feel ready.
Where the stroke happens in the brain determines how the survivor is affected. “If a stroke occurs in the frontal lobe, the survivor may be less aware of socially appropriate behavior and feel less inhibited,” Denby said. “Or if it occurs in the temporal lobe, the survivor may have decreased sexual arousal, genital arousal and libido. If the stroke occurs in the left brain, the survivor may be more depressed, which can also affect desire.”
It is even possible, though rare, that a stroke may result in an increased sex drive. “If a stroke occurs in the bilateral temporal lobes, the survivor may become more hypersexual and be inappropriate in their approach to sex,” Denby said. “Like in any act of inappropriate behavior, caregivers should remember that this is a result of the stroke. The spouse or partner needs to redirect the survivor into more positive behavior. You have to set boundaries. It takes a lot of patience and a lot of love.”
What about depression?
As in so many other areas of recovery from stroke, depression has an impact. “Depression often reduces libido, and drugs for depression may also reduce libido,” Dr. Black-Schaffer said. “There may also be cognitive changes – reduced ability to pay attention or short-term memory loss that may adversely affect the performance of many focused activities, including lovemaking.”
Those problems can be extremely frustrating for your mate and may alter your sexual relationship more than paralysis does. If you have problems with memory, depression or focus, ask your doctor to recommend someone who can help in behavior management and rebuilding your relationship.
Careful grooming and attractive clothes can help you feel good about yourself. While this may take extra effort at first, you’ll feel more attractive. A satisfying and intimate relationship also helps you accept your new self and regain confidence.
What about aphasia?
Communication is a key ingredient in a satisfying sex life, and both our experts agreed that survivors with aphasia can still enjoy sex. “The survivor with aphasia and their partner may need to learn other ways to communicate their sexuality and their sexual needs,” Denby said. “Touching and caressing are wonderful ways to show your love for another person and can aid in healing.”
“Verbalization is often not necessary for satisfactory sexual intimacy. Touch, gesture, tone of voice — which are frequently preserved in patients with aphasia — may be entirely sufficient,” Dr. Black-Schaffer said.
Both experts and the married survivors pointed out the difficult position the caregiver spouse is in. “The couple’s life has suddenly changed, and this is not an easy adjustment,” Denby said. “It’s not easy to change roles, to be a caregiver one minute and then be a lover. But many couples report that they have been able to adjust, adapt to the changes caused by stroke and their relationships have gotten even stronger.”
If switching roles is difficult, it may help to hire someone to help provide some of the day-to-day physical care. Also, it is important for the caregiver spouse to have breaks from her or his responsibilities without feeling guilty. Both partners need time to themselves.
Sexual attractiveness and intimacy are augmented by simply having fun together. Playfulness in your leisure time goes a long way in maintaining an adult-to-adult relationship. “If you’re interested in restoring your sexual relationship, you don’t want your mate to become like your parent!” Denby said.
“My wife and I found that improving our non-sexual intimacy – hugging, laughing, having fun – really improved our sexual intimacy,” Walt said. “It’s important to focus on what you have, not what you have lost.”
Women of childbearing age should talk to their physicians about family planning. Generally birth control pills are not recommended for stroke survivors because they increase the possibility of blood clots. However, other forms of contraception may be appropriate – discuss them with your healthcare provider.
“If a stroke survivor does get pregnant, it will most likely be considered a high-risk pregnancy,” Denby said. “You will need to be followed closely by your obstetrician.”
Sex after stroke can be complicated, but for many couples sex was complicated before a stroke. Both of you are likely to be nervous, so give yourselves time. And don’t dive into disappointment because it’s not like it used to be. A learning curve is likely.
“Just as you may have to relearn other functions such as mobility and self care after a stroke, you may have to relearn how to have sex,” Denby said. “Reviewing photo albums and happy memories may help to remind you of the love you share. As a couple you need to be patient, loving and keep humor in the relationship. It is good to set aside a special time for intimacy and sex. Do things that make both of you feel sexy and attractive. Create a loving atmosphere with music, soft lights, candles and by giving compliments to each other. Having sex is not just about vaginal penetration as much as touching, caressing, kissing and just showing appreciation for your mate. These things help solidify your relationship.”
If you are interested in seeking professional help, the American Association of Sexuality Educators, Counselors and Therapists may be able to help you identify a therapist specially trained to help persons with disabilities. Send an e-mail with the subject “Referred by Stroke Connection Magazine” to firstname.lastname@example.org, and ask if they can help find a specialized therapist or counselor in your area. For general information, visit www.aasect.org.
This information is provided as a resource to our readers. The tips, products or resources listed have not been reviewed or endorsed by the American Stroke Association.