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BackgroundThe ICF core sets for patients with Rheumatoid Arthritis (RA) acknowledge sexual function and intimate relationships as important since the patients' sexual health can be affected by the disease. About 36-70% of all RA-patients experience a reduced sexual health, and their perceived problems are directly or indirectly caused by their disease.
Physiotherapy is often used as non-pharmacological treatment for RA. Mobility treatment, pain reduction, and physical activities are often included in physiotherapy for patients with RA. The aim of the study was to explore sexual health in relation to physiotherapy in women living with RA.
MethodAn explorative qualitative interview study with a phenomenological approach was performed. The study consisted of ten interviews with women with RA. The analysis was performed according to Giorgi. ResultsThe main theme that emerged in the material was that the body and the total life situation affected sexual health.
Three categories were included in the theme: 1) sexual health - physical and psychological dimensions, 2) Impacts of RA, and 3) Possibilities to increase sexual health - does physiotherapy make a difference? ConclusionsSexual health was affected by RA in different ways for the informants. Possibilities to improve sexual health were improved partner communication and physiotherapy. Physiotherapy can play an active role in improving sexual health for patients with RA. According to World Health Organization (WHO), sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality. This means that sexual health has to be seen from a holistic perspective, including physical, psychological, and social aspects of well-being. To receive such a well-being also requires a positive and respectful approach to sexuality and sexual relationships.The International Classification of Functioning, Disability and Health (ICF) includes sexual health in two different areas: sexual functions and intimate relationships.
The ICF core sets for patients with Rheumatoid Arthritis (RA) acknowledge both areas as important since the patients can be affected by the disease. About 36-70% of all RA-patients experience reduced sexual health, and their perceived problems are directly or indirectly caused by their disease –. A majority of the patients with RA are women. However, there are differences concerning sexual health for men and women, especially during sexual activities.
Women report more joint difficulties than men.Sexual health difficulties due to RA can include decreased sexual arousal, decreased sexual desire, and decreased satisfaction. Different problems can cause sexual health difficulties for women with RA.
It can be fatigue, pain, limited physical ability, negative body image, and depression , –. Limited physical ability can affect different areas of sexual activities, for example, restricted hand mobility limits the possibility of caressing the partner , and restricted mobility in larger joints limits possible sexual intercourse positions ,. According to Kraaimaat et al, there is a correlation between decreased mobility, depression, and decreased sexual health. Negative body image can be connected to the amount of morning stiffness.Research concerning women with RA and their sexual health has mainly focused on describing the problems, with few comments on how to improve the women's sexual health.The mentioned solutions include increased and improved communication between health staff and patients and physiotherapy. The recommendations of physiotherapy are based on pain relief treatment and joint mobility treatment with the aim to reduce pain and improve daily functional capacity as a prerequisite for engaging in sexual activities ,.Mobility treatment, pain reduction, and physical activities are often included in physiotherapy for patients with RA. The habits of physical activity can affect sexual health, since increased physical capacity can increase the prevalence of sexual intimacy. Physiotherapy treatment has been shown to increase mobility, self-esteem, and physical daily activities, and to reduce pain for patients with RA ,.
This could indirectly influence sexual health for this group. Concerning direct treatment of sexual health, there has been a study of cognitive-behavioural physiotherapy in order to enhance sexual function for women with chronic pain , which showed positive results. The main theme that emerged in the material was that the body and the total life situation affected sexual health. Three categories were included in the theme: 1) sexual health - physical and psychological dimensions, 2) Impacts of RA and 3) Possibilities to increase sexual health - does physiotherapy make a difference?
Sexual health - physical and psychological dimensionsSexual health was experienced and described by the informants as containing both a physical and a psychological dimension. The physical dimension was experienced as touch, caressing, showing love and tenderness as well as sexual intercourse. The psychological dimension of sexual health was experienced as being there for another person, psychological closeness, feeling loved, and caring for someone. Some of the informants defined limits for their own sexual health, for example, explaining that sexual intercourse no longer was included in their sexual health.
The informants experienced the importance of sexual intercourse differently. Sexual health was not experienced to be limited to sexual intercourse.' Sexual health for me is not sexual intercourse.
It's more like physical closeness.' Some informants had no sexual desire and were negative to sexual activities. A negative attitude towards sexual activities and loss of sexual desire affected their relationships in a negative way. The informants that described an acceptance of this by their partners or an increased acceptance over time also described less strain on their relationship. Others experienced sexual health as very important, and considered sexual intercourse as a joyful experience. All mentioned closeness and caring as important aspects of a relationship. 'Attraction, yes.
That you are. That tenderness is mutual and that you.That you're now together with each other.' The informants mentioned different emotional experiences related to their definitions of sexual health.
Pleasure, happiness, joy and the opportunity to release emotions were experienced, but also increased pain and psychological pressure. Feeling attractive and being attracted to the opposite sex were also included in sexual health, as well as feelings of unattractiveness.' You're happier simply because you've got someone.'
Sexual health was also experienced as a close sexual companionship, doing things that felt good for each other, and having pleasurable sexual experiences with the partner. To achieve sexual health, understanding and communication between the partners were vital, as well as honesty with each other, and willingness to participate in the sexual relationship. Sexual health and the importance of sexual health were experienced to have changed in different phases of life.' I don't put too much weight in it. It was more important when I was younger. One does revalue things. I wouldn't have responded like this 10 years ago.'
Impacts of RAThe informants experienced that RA could have physical, psychological, emotional, and relational impacts on them. Most informants experienced negative impacts of RA, both directly and indirectly, on their sexual health.Physical impacts of RA were experienced to be similar for the informants such as pain, fatigue, stiffness, and swollen joints, with varying severity. Some of the informants also experienced decreased physical ability, deformed joints, and reduced muscle strength, which could lead to decreased ability to walk and to perform daily activities.
There was a large variety of direct negative impact on sexual health: deformed hip joints which made sexual intercourse impossible, pain (before, during and after sexual activities), hip mobility problems during intercourse, decreased mobility in sexual activities in caresses, decreased sexual arousal and desire, pain when being touched, pain when caressing the partner, decreased sexual satisfaction, and fewer possible positions for sexual intercourse. Caresses could lead to increased pain, and in those cases further sexual activities were often avoided.' And then, it hurts so much when someone touches me that I feel, no, you mustn't touch me.' 'I've lost my sexual desire.'
'Sex simply doesn't work. I can barely walk sometimes.' Some of the informants had gone through or planned to go through joint surgery.Body image was experienced to be affected for some of the informants, and the most common negative impact was increased weight due to medication and inability to be physically active. RA was experienced to influence the whole life situation.Psychological impacts of RA were experienced but differed within the group. A positive impact was increased psychological strength, which was achieved by having to handle the physical impacts of RA. Negative impacts were problems due to sleeping difficulties, anxiety, worry, frustration, fear of being abandoned by their partner, feeling old, and being angry. The negative emotions affected the sexual life of the informants, for example, worrying about increased pain during sexual activities led to avoidance of sexual activities, and feeling old was connected to feelings of being unattractive.'
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.but I get so damned mad for I can't manage anything without feeling pain as a result of it.' 'For I have felt I'm not good enough.
In different ways, not just sexually.' The relational impacts of RA were experienced within the field of sexuality, as for example different sexual needs.
Other relational impacts of RA concerned reduced capacity to perform daily activities. The informants described experiences both from present and earlier relationships. One informant experienced an improved relationship with her partner after the RA diagnosis.' Well, it's a little like this - what I can do and what I can't do. The discussion pops up now and then on what we want to do.
He wants to do it, but I can't and that's a pity, I think.' 'I couldn't manage anything. I couldn't even manage intimacy because I couldn't bear being touched.'
Possibilities to increase sexual health - does physiotherapy make a difference?Reflections about possibilities to improve sexual health were a new field for the informants. Most of them had not reflected on their sexual health or thought it possible to improve it. Some informants were satisfied with their sexual life. However, in the interview situations, possibilities to increase sexual health were explored.
The informants described that if their pain and fatigue could be decreased, and if their sexual desire could be increased, they believed that their sexual health would be improved.' If I hadn't had pain, it would have worked better. Take away tiredness.' Some of the informants had experienced direct positive effect of physiotherapy on their sexual health, and some had not reflected on this topic before the interviews.
Several of the informants described perceived effects of physiotherapy for rheumatic patients in general, and not only from their personal experiences.Direct experienced effects of physiotherapy concerning sexual health included increased physical activity levels, knowledge of their own physical capacities, and increased fantasy. Increased knowledge of physical abilities and increased physical capacity could make sexual activities easier since the informants felt that they had enough physical strength to manage specific intercourse positions. Physical activities during physiotherapy were described as a way to get a widened range of positions that could be used in sexual activities. Touch and increased ability to accept being touched were mentioned by some informants as important for sexual health. Several physiotherapy interventions include touching and passive joint mobility stretching.
Increased joint movement was given as a suggestion for more possible positions for sexual intercourse. Increased relaxation was mentioned as an effect of physiotherapy that improved sexual health.' I think it has helped me to be more agile.' 'Because you get softer in your body. You get energy as well. You get a burst of energy.' The positive emotions following a physiotherapy session were experienced to have given an increased attention for the partner and more energy to the relationship.
Increased self-esteem and a positive body image were experienced to have improved the feeling of sexual attractiveness.' Yes, I think so. In any case, to maintain agility and strength and to feel satisfied. You're in fact exercising and you feel satisfied with your body.'
Some of the informants believed physiotherapy to be more important concerning sexual health for patients with severely decreased mobility and low range of joint movement. Exercise programs that decreased pain were also believed to improve sexual health, since several of the informants mentioned pain as an important factor that could decrease sexual health.Informants experienced both positive and negative effects of physiotherapy, and all of the informants still had a positive opinion of physiotherapy, and had experienced emotions of contentment and joy regarding treatment sessions.
All informants expressed a flow of positive emotions during and after physiotherapy, such as joy, feeling appreciated and cared for. These emotions increased the experienced positive effects of physiotherapy.The informants described their physiotherapists as a coach, a provider of information concerning the body and the disease, someone who gave them feedback and back-up in their daily activities.
The physiotherapist was considered by the informants to have an important role in rheumatological care.' It's also that you get. How you should do and feedback and I ask like this: 'What should I do if I want to have muscles there?
If I want help with the right exercises.' According to the informants, sexual health could also be improved by imagination, fantasies, and planning of sexual activities that consisted of: spending time together on holidays, creating a more intimate atmosphere with your partner, finding time for more foreplay and using stimuli for love, such as music.An important aspect to achieving sexual health was an increased communication between partners and knowledge about the impacts of RA concerning sexual health. Written information, shared with the partner, could be used as a basis to discuss their own mutual sexual life. Long-lasting relationships were experienced to increase the possibilities of having an open communication concerning sexual health between partners. Elko speedway drive in theater. The partner's own health also affected the sexual health for the informants, and a healthy spouse increased the possibilities of having good sexual health. As this is an explorative first study of experiences of sexual health in relation to physiotherapy, we used a qualitative design with a phenomenological approach to cover the lived experiences of sexual health when living with RA.
Phenomenological approach with analysis according to Giorgi, has been used in earlier physiotherapy research concerning musculoskeletal disorders and in other studies in rheumatology. One of the interviews was short time-wise, which could indicate that the researched phenomena were not fully explored , and it is possible that the informant was not willing to share her views of the researched phenomena due to the sensitivity of the topic. A follow-up interview with this infor.