Michał Lew-Starowicz: This kind of message is indeed part of the media’s very negative influence on the image of sex. It fails to take into account the needs of the elderly, those with physical illnesses, or the sexuality of people suffering from mental illnesses, such as depression. This does indeed foster a societal perception that sex is reserved only for the healthy and beautiful. A sick, suffering, or elderly person is usually perceived as asexual, both by society and by healthcare professionals. Doctors often do not realize that they should also talk to the patient about sexual health. And even if they do recognize this need, they are afraid to broach the subject for fear of offending the patient. It’s a bit like talking about suicide with someone suffering from depression. It is well known that this neither creates nor increases the risk of a suicide attempt; on the contrary, simply bringing up the issue often brings relief. The same applies to people with sexual disorders—talking to them about this doesn’t have to be associated with overwhelming sadness; it can be helpful.
Since this is a topic that weighs heavily on them in some way, why don’t patients bring it up themselves?
M.L.S.: Patients expect the doctor to take the initiative in discussing their intimate life; they themselves are too embarrassed to start the conversation. Every day, I see patients who suffer from various issues related to their sexual health. When they come in, they know what topics we’ll be discussing, yet during the first meeting, they experience significant stress and are clearly nervous. It is only after the conversation that they speak of feeling a significant sense of relief. This is even more difficult if we were to have such a conversation with a doctor specializing in a field other than sexology.
What is the reason for this?
M.L.S.: There are many reasons, starting with the obvious ones—sex is rarely discussed in our homes, and schools do not provide sufficient or reliable sex education. The Polish language also does not lend itself well to intimate topics, as it is dominated by extremes—we have at our disposal either scientific terminology or language that veers toward vulgarity or mocking the issues. There is another very significant and multifaceted issue—the problem of shame. Shame affects patients, but also doctors; it is present in their communication, just as it is in relationships between partners or between parents and children when it comes to matters of sexual life. The origins of shame and its impact are a very interesting topic, to which we recently dedicated the book *Shame, Sex, and Medicine: A Guide for Doctors*, which analyzes shame from various perspectives. One could say that this is a problem not yet fully understood even by doctors, let alone patients.
Doctors are becoming increasingly sensitive to their patients’ emotional problems and are more often referring them to a psychologist or psychiatrist. But what about consultations with a sexologist?
M.L.S.: Most patients come to me directly. This is likely due to the nature of living in the capital, but also because we live in the age of the Internet, which makes it easier to search for solutions to one’s problems. Very often, patients come to me with disorders resulting from a range of chronic conditions, such as circulatory and urological problems, diabetes, connective tissue diseases, rheumatoid conditions, oncological conditions, neurological conditions, and finally, mental health conditions. There is also a group of people referred by doctors of other specialties or psychologists. Unfortunately, this remains a minority, even though numerous studies have confirmed links between somatic diseases, mood, the occurrence of mental disorders, and sexual dysfunction. Among patients suffering from various diseases that carry a high risk of sexual problems, usually no more than one in ten is asked about this by a doctor and, if necessary, referred to a sexologist.
It is also important to remember that sexual dysfunction can be a side effect of various medications and can itself be a risk factor for non-adherence to treatment recommendations.
M.L.S.: If a patient begins to experience sexual problems after starting a particular therapy and makes the connection, they will most likely seek treatment irregularly or not at all. In summary, there are many connections between somatic and mental illnesses and sexual dysfunction. Therefore, it would be ideal to address these issues together, viewing the patient holistically, and this would require collaboration among various specialists in the care of a single patient.
You mentioned the impact of medications on sexual function. Could painkillers, which rheumatoid patients take in significant amounts, be a cause of these disorders?
M.L.S.: First and foremost, it is important to realize that pain itself is an experience that severely disrupts sexual responsiveness; among other things, it inhibits arousal responses, so its effective treatment is crucial for the ability to engage in sexual activity. On the other hand, many medications used to treat rheumatoid diseases—steroids, anti-inflammatory drugs, and cytostatics—can indeed cause complications not only in hormonal and metabolic functions, which are often discussed, but also in the sexual sphere.
What then?
M.L.S.: In that case, we need to consider how to adapt the treatment of these disorders to the primary treatment, but also weigh what we can do and at what cost. Most often, the patient must follow the therapy prescribed by a rheumatologist or other treating physician to halt the progression of the disease or alleviate the very bothersome symptoms associated with it. Fortunately, we have medications available that can improve sexual function in people whose sexual function is pharmacologically impaired. Furthermore, addressing sexual problems involves not only discontinuing harmful medications and introducing helpful ones, but also a whole range of other interventions that can prove highly effective.
Do you mean psychotherapy or working with the couple on their relationship?
M.L.S.: If possible, it’s always worth working at the level of the relationship. Let’s remember that sexual problems in a patient suffering from a serious somatic illness may or may not be related to that illness. In sex, relational factors are of enormous importance. Illness strongly affects identity and the sense of sexual attractiveness. It determines how a sick person enters into a relationship with a partner. Illness can also change the patient’s behavior and their experience of sexuality.
For people with rheumatoid arthritis, typical problems limiting sexual activity include pain, joint stiffness, and changes in body image resulting from frequent deformities. Pain not only inhibits sexual response but also makes it difficult to engage in intercourse in the way the couple is accustomed to, limiting the possibility of certain sexual positions. For couples accustomed to physically intense intercourse and vigorous movements, pain can be a factor that severely limits these possibilities. Therefore, readjustment and a change in the way sexual interaction is initiated are often necessary. Thus, it is not only medications but also how the disease affects body image, relationships, mood, and bedroom capabilities—these are factors that interact with one another and can cause and exacerbate sexual problems. All of this must be taken into account when prescribing medications or therapy.
Do women and men experience the disease similarly?
M.L.S.: Men affected by chronic illness often experience an identity crisis; they feel inadequate, helpless, are prone to depression, fall into addictions, and have an intense need to prove their capabilities to themselves and others. They also struggle with their partner’s illness and the sense of helplessness it causes. By nature, men are more action-oriented and focused on problem-solving; they are less suited to a caregiving role. Meanwhile, a partner’s chronic illness requires warmth, understanding, and being a patient companion; it cannot be treated as a problem to be solved, which is why it is so difficult to accept. Women, on the other hand, primarily struggle with the changes occurring in their bodies; they often feel less valuable and are prone to mood swings. Especially in their case, an approach focused on sexual physiology, without taking into account what is happening in the psyche and in the relationship between partners, may not be sufficient—or effective.
From what you’re saying, a picture of very complex problems emerges. They surely pose a significant challenge for the doctor as well, who must view the patient from a very broad perspective.
M.L.S.: When a patient comes to the doctor, they are not just their illness. They are an individual and require a broader perspective. This is very well understood in psychiatry and sexology. When dealing with a chronically ill patient, several tasks arise for the doctor. One must try to adjust the treatment of the underlying disease so that it negatively impacts sexual life as little as possible, the doctor must advise the patient on how to adapt their sexual activity to the physical limitations resulting from the illness, and finally, they must address any mood disorders or other coexisting issues that affect sexual function. This often involves working with the couple on their individual experience of sexuality and attempting to adapt it to the changing conditions dictated by the illness.
It follows that people with chronic illnesses sometimes have to learn about sex all over again. How can this be done, and what is the availability of sexologists?
M.L.S.: The availability of specialists is limited, and treatment by a sexologist is not covered by insurance in Poland. One could say that sexual problems are neglected by the system. But it should be noted that this applies to the healthcare systems of most countries, with few exceptions. Still, we are fortunate that sexology is a medical specialty here and that specialists in sexual health are being trained.
As for the need for sexual re-education, it is true that people develop certain habits or sexual scripts, often formed intuitively, and they rarely talk to each other about sex. As long as no difficulties or health issues arise, this model often functions reasonably well. However, when they encounter an obvious obstacle or limitation in sex—such as reduced joint mobility, pain, other physical difficulties, this can completely halt the couple’s sexual activity if they are unable to discuss the issue. Illness forces changes and adaptation to new conditions, and this requires new agreements between partners and readjusting in bed. Of course, there are couples who get along very well and are able to modify their habits on their own and derive satisfaction from their “new” sex life. However, in many cases, the help of a specialist is needed for this.
It is interesting to note experiences in working with patients with serious physical problems who, paradoxically, discover that sex with certain limitations can become more attractive. One could say that in a situation of forced adaptation, one can discover something completely new, something that brings a very positive new quality to the relationship. A crisis situation, on the one hand, places a burden on the psyche and poses a challenge to the relationship, but on the other, it can be an opportunity for growth.
People always say that...
M.L.S.: But that’s not a euphemism. Of course, it’s better to have a fully healthy body, to be young, fit, and without limitations. However, a state of relative well-being often limits our drive for growth. The emergence of limitations stimulates the desire to overcome them, and a “side effect” may be discovering a new quality in experiencing intimacy and pleasure. Let’s remember that the center of our sexuality is not the genitals, but the brain.
