Description of the condition
Sexual problems, such as erectile dysfunction among men and pain during intercourse among women, can frequently occur in relation to cardiac disease and its associated risk factors, medications, and psychological sequelae (Jaarsma 2010; Jaarsma 2010a). Such problems are more prevalent among both men (Schumann 2010) and women (Kutmeca 2011) with cardiovascular disease than those without disease; the prevalence rates for men range from 20% (Schumann 2010) to 70% (Mulat 2010) and for women from 43% (Kriston 2010) to 87% (Schwarz 2008).
Reasons for the association between sexual problems and cardiovascular disease include physical vascular causes (Dong 2011), fear of sexual activity provoking cardiac symptoms or a cardiac event (Katz 2007), patient-partner relationship changes following a cardiac event (Dalteg 2011) and associations with psychological problems such as depression (Kriston 2010). Although there is evidence to suggest that some cardiac medications, including beta blockers and lipid lowering medications, may have sexual side effects, more recent analyses have concluded that cardiovascular medications are uncommonly the true cause of sexual problems (Levine 2012).
Sexual dysfunction has been shown to negatively impact quality of life, psychological well-being and marital or partnership satisfaction (Traeen 2007; Gunzler 2009). Social support and strong intimate relationships are important predictors of outcomes for chronic illness patients and poor marital quality has been shown to predict patient mortality (Coyne 2001). Sexual problems also impact cardiac patients’ partners, who rate sexual concerns as one of the most prevalent stressors related to their partner's condition (O' Farrell 2000).
Return to sexual activity after an acute cardiac event, or maintaining a satisfactory sex life when living with chronic cardiovascular disease, can pose challenges for cardiovascular patients and their partners. It has been recommended that sexual problem assessment and counselling should form part of routine care for cardiovascular patients (Steinke 2013). While those with cardiac disease view information about return to sexual activity as an important component of their general rehabilitation (Steinke 1998; Mosack 2009), health professionals have been reluctant to address sexual counselling in practice (Byrne 2010; Djurovic 2010; Ivarsson 2010; Jaarsma 2010b; Goossens 2011; D'eath 2013), including staff in cardiac rehabilitation (Barnason 2011; Doherty 2011). Reasons for provider reluctance include a lack of confidence and education required to address these concerns adequately (Byrne 2010; Doherty 2011; Hoekstra 2012).
Description of the intervention
The aims of sexual counselling (hereafter referred to as counselling) interventions for cardiac patients are to assess existing sexual problems, provide information on concerns and support safe return to sexual activity after a cardiac event or procedure. Counselling interventions address specific psychological or interpersonal factors, sexual performance concerns, and issues related to medication and co-morbid conditions which may affect sexual functioning (Lue 2004). Non-sexual aspects of a relationship may also be addressed in a counselling intervention, such as the need for intimacy in the relationship (Steinke 2004). A range of different types of health professionals or appropriately trained individuals may administer counselling interventions. These interventions may be delivered as separate, stand-alone interventions or as a component of more comprehensive rehabilitation interventions, such as in hospital cardiac rehabilitation following a cardiac event or procedure. Counselling interventions may involve a one-to-one exchange between a health professional and patient (in person or over the telephone) or may be delivered by a health professional to a group of cardiac patients. They may use one or a number of didactic and counselling approaches, including oral information or dialogue, visual information, written materials, audiovisual materials and practical training. Counselling interventions may involve the cardiac patient alone or the cardiac patient with his or her partner or spouse. Interventions can be short-term, for example giving brief information on return to sexual activity (Kushnir 1976; Fridlund 1991), or longer-term, for example providing cognitive behavioural therapy directed towards both psychological and physical aspects of sex and intimate relations (Klein 2007; Song 2011). Interventions may involve a single encounter with a health professional or multiple encounters.
Many issues relating to both the health professional and the patient and their partner influence the delivery and effectiveness of counselling interventions. These can include gender and age differences of the health professional and the recipient, cultural and religious issues, and sexuality of the couple (Klein 2007; O'Donovan 2007; Hoga 2010; Goossens 2011). The nature and extent of the cardiac event itself may vary in complexity (Jaarsma 2010b), with more complex conditions requiring a more focused and specialised sexual counselling intervention (Ivarsson 2009; Ivarsson 2010). Health professionals’ own beliefs about sexuality may influence the delivery of counselling interventions, for example health professionals may adhere to myths and biases regarding the need for counselling based on the age of the patient experiencing the cardiac event and their gender (Kazemi-Saleh 2008; Taylor 2011; Hoekstra 2012; Hoekstra 2012a). Apart from the individual health professional, organisational structures relating to financial resources, availability of staff, time restrictions and availability of private spaces can dictate the delivery and organisation of counselling interventions (Song 2011; Steinke 2012).
How the intervention might work
Counselling interventions are likely to work by providing useful information, which may reduce anxiety related to sexual problems and fears about resuming sexual activity after a cardiac event. They may also increase confidence in sexual abilities and potential, improve patient-partner communication around changes to sexual activity required following a cardiac event, provide practical guidance and teach skills to support couples in returning to sex. In such interventions, health professionals may assess any risk associated with sexual activity and develop an individualised plan to guide safe resumption of sexual activity following a cardiac event or procedure (Gamel 1993; Levine 2012). Such information is likely to alleviate fears associated with return to sexual activity and provide patients and partners with greater confidence in their ability to assess if, and when, it is right for them to return to sexual activity. Counselling interventions aim to provide correct information and dispel myths about how cardiac disease impacts on sexual activity. By giving cardiac patients the opportunity to express their sexual concerns, interventions in this area are likely to ‘normalise’ these concerns and reassure patients and their partners that sexual problems are common after a cardiac event and can be addressed. In addition, counselling interventions may support patients in dealing with specific psychological or interpersonal factors and sexual performance concerns (Lue 2004). Non-sexual aspects of a relationship may be addressed in a counselling intervention, such as acknowledging the need for emotional intimacy and being close in a relationship (Steinke 2004). Counselling interventions may also provide practical guidance to patients about how to return to sexual activity (Mosack 2009). Such guidance may include aspects such as ideal timing (when the patient is not tired) and setting (comfortable and familiar), and warning against things that may increase risks associated with sexual activity, for example sex should generally be avoided following a heavy meal (Levine 2012).
The effectiveness of interventions can be evaluated by assessing outcomes that reflect the ways in which the intervention is likely to work. These include changes in sexual activity levels and resumption of sexual activity following a cardiac event or procedure, sexual knowledge, sexual function and satisfaction, and quality of life (Bertie 1992; Klein 2007; Song 2011; Steinke 2012).
Why it is important to do this review
Worldwide, cardiovascular disease is a leading cause of morbidity and mortality but with an improving survival rate, resulting in an increasing number of people living in the community with some form of cardiovascular disease (World Health Organisation 2012). Counselling for patients and their partners or spouses has been recommended as an important component of cardiac rehabilitation (Levine 2012; Steinke 2013). There is ample literature to indicate that counselling of cardiac patients is infrequently provided in practice (Steinke 1998; Goossens 2011; Steinke 2011) yet, when asked, cardiac patients (Byrne 2013) and their partners (O' Farrell 2000; Fisher 2005; Agren 2009) generally report that this is something they would appreciate. While health professionals report responsibility for, and some knowledge of, providing counselling (Steinke 2011a), there is a lack of follow through in implementing counselling interventions in daily practice (Pouraboli 2010; Yıldız 2012). There are published trials examining the effectiveness of counselling interventions, yet there is currently no systematic review of these studies. A well-conducted systematic review is needed to inform health professionals, patients and their partners, and policy makers about the effectiveness of such interventions. In addition, an evaluation of interventions may provide insight into which strategies might be most or least effective for cardiac patients, as well as which interventions may be most amenable to use in busy practice settings by health professionals.