• dont assume patient is monogamous
• dont assume all marriages are alike
• dont assume that older people are not interested in sex and sexuality
• dont bring your own assumptions about morality into the clinical encounter
• dont assume heterosexuality
• dont assume that gay patient is not bisexual
• if you treat more than one family member, be prepared to maintain confidence and neutrality
• dont assume that elderly patients are monogamous

• heart disease
• DM
• HTN
• atherosclerosis
• stroke
• cancer
• MS
• arthritis
• Sjogren's syndrome
• spinal cord injuries
• MDD
• HIV
  skin disorders
• urinary incontinence

• increased physical demands
• fear of overexertion

• impotence
• decreased libido

• HTN men have higher rates of ED than normal bp patients
• can be due to HTN or drug effects

• impotence (contributes to ED)

• decreased libido
• less frequent orgasm

• breast cancer- disfigurement, fear of loss of physical attractiveness
• prostate cancer- impotence, incontinence
• fear of death, infertility
• ostomies
• gyn cancers- hysterectomy may lead to vaginal scarring and dyspareunia

fear of death/infertility

• decreased physical capacity
• difficulty with orgasm
• incontinence

• physical pain
• joint stiffness
• limited ROM
• decreased ability to masturbate

• impotence
• decreased ability to achieve orgasm

• vascular disease (most common)
• neurologic disease is second most common
• surgical procedures
• medications
• psychogenic problems
• hormonal abnormalities

• any d/o that:
  • impair parasymp. sacral spinal cord or peripheral efferent autonomic fibers to the penis
  • impair penile smooth muscle relaxation
  • prevent vasodilation necessary for erection
• spinal cord injury- level and degree determine extent of erectile function
• diseases that cause autonomic dysfunction
  • DM
  • stroke
  • Parkinson's

• beta blockers
• clonidine
• thiazide diuretics

Because mechanism to lower blood pressure is critical to maintain blood flow for penile erection

• body image issues
• disfigurement (w/mastectomy)
• issues around incontinency (colostomy patients, for men with prostatectomy) can impede sexual function
• fertility issues also problem after chemotherapy

• lower rates of surgery for prostate cancer in Europe due to premium placed on preservation of sexual function
• informed consent requires discussion of frank effect of different therapies on sexual function

• possible causes of sexual dysfunction
  • disruption of body image
  • family or marital problems
  • spousal reaction
  • adjuvant therapy
  • psychological impact of cancer diagnosis

• illicit sex is not safe
• very few MI's associated with sexuality (0.9%)
• sex with regular legitimate partner is fine, provided that normal physical activity has been resumed
  • regular exercise reduce risk of sexual activity
• exercise stress testing to establish restoration of normal exercise tolerance
• heart rate and energy expenditure of 5 mets is comparable to intercouse and orgasm
• ED common in  men with heart disease
• risk of ED are lower education, DM, heart disease, HTN, cigarette smoking, obesity
• depression increase risk of CAD and impaired sexual dysfunction

• avoid positions involving weight bearing for arthritic partner
• use pillows to support and protect joints
• find positions that are comfortable
• lubricants for dryness

• both men and women with DM experience sexual dysfunction
• peripheral neuropathy may impede women's lubrication and ability to achieve orgasm
• men with DM experience ED

• major sign of depression is loss of libido and anhedonia
• antidepression medication can cause loss of desire or alter performance

• many have experienced sexual trauma including:
  • childhood abuse
  • rape, domestic abuse
  • refugees may experience sexual violence in their home countries or on the journey
  • female genital mutilation may affect gynecological and sexual function

• lesbian health issues
  • when lesbians out to their doctors, more likely to get pap smears and mamograms
• special vulnerabilities of gay men
• need to understand appropriate medical evaluations, for example when to do anal pap smears and anoscopy exams

• individuals with sexual identity issues and transgender patients need a sensitive clinician who can be trusted to keep secrets and respect their individuality

• oral contraceptives may diminsh desire and decrease lubrication
• tamoxifen can cause atrophy and decrease lubrication
• menopause may cause vaginal atrophy, which results in pain with intercourse
• hysterectomy may cause vaginal scarring and dyspareunia

• desire and activity of sex does not disappear with advancing age
• often the elderly are frusterated because of lack of partner or lack of privacy
• older women who remain sexually active are more likely to find their partners attractive and romantic

• older patients more likely to have chronic medical conditions
• older patients are more likely to have had surgical procedures that affect sexuality
• among women who have had MI, almost half report decreased frequency of intercourse and 27% reported total abstinence

• level of sexual activity, interest, and enjoyment in younger years determines sexual behavior with aging
• decrease sexual activity associated with:
  • poor health
  • social issues
  • partner availability
  • decreased libido
  • ED
• ED is prevalent, but not part of healthy aging

• menopause is associated with decreased sexual function
  • decrease sexual interest
  • decrease responsiveness
  • decrease coital frequency
  • increase UG symptoms, often not discussed with physician

• vaginal lubricants (astroglide, KJ jelly)
• hormone replacement therapy
• topical estrogens for those who dont like HRT
• testosterone may be more important in improving function

• can be liberated for women because of cessation of menses and loss of fertility
• loss of fertility and physical signs of aging can make a woman feel unattractive
• sexual issues should be part of any conversation about HRT

• DM- decrease libido and lubrication and longer time to reach orgasm
• rheumatic diseases decrease functional ability and therefore sexuality

• caregiver stress may be sometimes aggrevated by sexual demands of demented partner
  • dementia may bring with it loss of inhibition
• when is sex consensual?

• antihistamines
• barbituates
• BZ's
• H2 blockers
• clofibrate
• progesterone
• prazosine
• propanolol
• TCA
• spironolactone

• anticholinergics
• clonidine
• methyldopa
• MAOI
• SSRI
• TCA