Special circumstances

In this chapter, the effects of major events and illnesses are briefly outlined. In the case of operations, the surgery may affect the functioning of the sex organs and/or be seen as ‘mutilating’. After serious illness, such as a heart attack, the fear that sex could provoke another serious setback can be completely inhibiting. Although more information about particular conditions should be available from the specialists involved, psychologists and psychosexual counsellors would also be able to offer support and treatment in most cases.

SEX DURING PREGNANCY

Many women experience changes in libido during pregnancy. Several surveys have found that the general pattern seems to be a lowering of sexual interest in the first and last three months of pregnancy, with, occasionally, an increase in libido during the middle three months. It is difficult to tell whether the massive hormonal changes that take place during pregnancy, or the social and emotional adjustments that are necessary, are responsible.

It used to be thought that sex and orgasm during pregnancy were possibly harmful to the fetus, and therefore to be avoided. More recent research indicates that this is mostly untrue. Occasionally, wo­men who have had problems at varying stages of their previous pregnancies may be advised to avoid intercourse at that particu­lar time. For instance, if a woman had previously miscarried during the second three months of her pregnancy, due to a relaxed cervix, she may be advised to abstain from sex at this time, the next time round.

The mechanics of having sex during pregnancy, especially in the later stages, calls for some agility and experimentation! It may be difficult to hold each other front to front, never mind try to have sex this way. Possibilities include the woman-on-top position, or entry from the rear, or variations of side-by-side positions. Oral sex and mutual masturbation are also good options.

Men may find the body changes that accompany pregnancy highly arousing or perhaps off-putting. In particular, the vagina feels different, being softer and wetter. There is also a heavier vaginal discharge. Pregnancy is often both a joyful and a stressful time for a couple, and both partners may feel differently about sex at different times. Spen­ding intimate time with each other cuddling and stroking, and offering sexual release, with or without intercourse, can provide the reas­surance that both partners may need.

SEX AFTER CHILDBIRTH

Surveys have found that most women have resumed having sex by 12 weeks after giving birth, with about a third having done so by 6 weeks. The quality of sex after childbirth is influenced by many things. Both partners may be tired and distracted by their new role as parents. The woman may have had stitches in the vagina, which occasionally cause continu­ing problems with painful sex. A traumatic experience of child­birth can also lead to vaginismus (see page 30).

After a vaginal delivery, the vagina may feel more lax, and grip the penis less tightly. Pelvic floor exercises can help the woman regain her vaginal tone.

Breast-feeding can also have an effect on a couple’s sex life.

Full-time breast-feeding is a tiring, time-consuming business, and the woman may be too tired, from interrupted sleep, to enjoy sex. There is some controversy as to whether breast-feeding raises or lowers a woman’s libido. The hormonal levels of a breast-feeding mother may suggest that her libido may be lowered, but some women find breast-feeding an erotic ex­perience. Men have different re­actions to watching their partners breast-feed, and some men find it upsetting.

Generally, most couples find that they have sex less than they did before their child was born.

SEX AFTER SURGERY

Prostate operations

Enlargement of the prostate is a common complaint in middle-aged and elderly men, and it is often assumed that any operation in this area will lead to impotence or problems with erection. The most common method of operating on the prostate is through the urethra – the so-called transurethral re­section of the prostate (TURP) – and in good hands this only results in erection problems in five per cent of cases. Surgery and radiation treatment for prostate cancer, on the other hand, carry higher risks of erectile dysfunction. After a standard prostatectomy, about 80 per cent of men develop erectile difficulties, and recent studies have shown that radiation treatment results in similar rates. However, in a technique known as nerve-sparing prostatectomy, more than 80 per cent of men regained or maintained their erections 18 months after the operation.

Some centres are also per­forming nerve-grafting techniques, which have good results in preserving erections. However, the type of surgery required to treat the cancer varies from case to case and problems with erection may not be avoidable.

Many men will find, however, that, even if their ability to have an erection or to reach orgasm is not disturbed, they do not ejaculate semen as they did before. Instead, the semen is directed into the bladder. This is known as retrograde ejaculation. This does mean that the man is likely to be infertile, although sperm collected from the urine immediately after orgasm has been successfully used to artificially inseminate a partner.

If surgery is for prostatic cancer, other methods of treatment such as oestrogens, drugs that count­eract the male hormone testo­sterone and removal of the testicles may be necessary. This is because the prostate cancer depends on testosterone for growth. The result of these treatments is likely to be a lowering of libido.

Hysterectomy

It is still unclear whether the uterus is important for orgasm. Some studies have found that women’s sexual satisfaction increased after hysterectomy, others that it deteri­orated. Many women report no change.

If removal of the uterus is ac­companied by the removal of both ovaries, then there may be hor­monal reasons why libido may decrease. Otherwise many women feel released from the problems that they were suffering before the operation (for instance heavy, prolonged and painful bleeding) and embark on a new, enthusiastic phase in their sexual lives.

Mastectomy

About a third of women who have undergone a mastectomy find that, temporarily at least, their enjoy­ment of sex is reduced. Mastec­tomy brings a massive alteration to body image, and some women imagine that they are sexually deformed, and no longer attractive. Women may receive advice after the operation on breast recon­struction and breast prostheses, and it is important that the sexual repercussions of the operation are not forgotten by partners or counsellors.

Bowel surgery

Major bowel surgery sometimes involves the bringing of one bit of bowel out to the exterior – this is called an ileostomy if the small bowel is involved, or a colostomy if the large bowel is involved. A bag is placed over the bowel opening to hold the bowel contents. Under­standably this kind of operation can have a large psychological ef­fect and interfere with a person’s sexual functioning.

On top of this, some surgery can also damage the nerve supply to the genitals, and cause sexual problems in this way. This is much more common if the rectum (the back passage) has been removed. In such cases, about a third of men suffer erectile problems, and a third of women find sex painful because of scarring in the area. It has been known, however, for sexual function to improve over several years after the operation.

People who have an ileostomy or colostomy may be haunted by anxieties that new partners may find their bodies off-putting, that their regular partners may reject them sexually, that the bag will burst during lovemaking, or release unpleasant sounds and smells. Clearly, time to adjust and sensitive handling on the part of new or es­tablished partners, or counsellors, will help. Many people get married and have children after such op­erations. The couple may have to find new ways of lovemaking that they both find acceptable and pleasurable.

SEX AFTER A HEART ATTACK

Sex should be seen as part of ‘getting back to normal’ after a heart attack. Unless there are major complications following the attack (in which case the person is likely to be too unwell to think about sex), there are no special reasons not to have sex. The exertion involved in sex is said to be similar to that of climbing two flights of stairs – and if this is possible, then so is relaxed, non-athletic intercourse.

Occasionally sex provokes angina. A glyceryl trinitrate (GTN) tablet or spray can be taken before­hand. Sometimes treatment for high blood pressure is started after a heart attack. Certain blood pres­sure medication, such as diuretics and beta blockers, can occasionally cause erectile problems or loss of libido. If this happens, consult the doctor for a change of dose or medication.

SEX AFTER A STROKE

One survey of male stroke pa­tients found that, for most of them, sexual interest and erections reappeared within seven weeks of the stroke. A person may be left partially paralysed or weak on one side after a stroke, and so sex has to be modified to take this into account. As with heart attacks, new medication may sometimes affect sexual functioning, and it would be wise to check this out with the doctor.

SEX AFTER SPINAL INJURY

The actor Christopher Reeve may have caused some surprise when he announced, only months after the injury that left him paralysed from the neck downwards, that his libido was very much intact, and that he hoped one day to father another child.

Although individual cases need to be considered separately, the evidence seems to be that many men and women who have spinal injuries and are paralysed have normal sexual appetites. Some men become impotent after the injury, but many do not. Ejaculation is affected more than erection. Even if there is no feeling in the genitals, many paraplegic individuals describe the ability to have orgasms, which are different from the orgasms they had before their injury.

Women seem to be less af­fected than men, and many adjust to a new and pleasurable sex life. Fertility in women is often unaf­fected, and women continue to menstruate as before. Men may become infertile, depending on whether they are able to ejaculate, but artificial insemination is some­times an option.

For more information, contact SPOD (Sexual Problems of the Dis­abled), 286 Camden Road, London N7 0BJ. Tel.: 020 7607 8851.

KEY POINTS

• Pregnancy may affect libido either way

• For a variety of reasons, a couple’s sex life may be different after a child is born

• The impact of major surgery on the sexual functioning of the patient should never be forgotten

• Sex is part of getting better after a stroke or heart attack

• People with spinal injuries may continue to enjoy rewarding sex lives