is without doubt a taboo in society to talk of sexual issues
openly. People at the best of times, find it most difficult to
allow others in their “space” to disclose intimate details of
life behind closed doors. Even couples with the most wonderful
relationships, tend to hide inner feelings and avoid the subject
which is probably the most important in sustaining a healthy
In this regard, consider the impact of physical impairment as a
barrier to intimate relations.
This article is also indebted to input from the members of the
Searle Patient Partner program who bared their souls
and inner secrets to openly discuss the problems faced by
arthritis sufferers, in the bedroom and other intimate, but
entirely appropriate situations, to explore and enjoy the wonders
of sex and love between partners.
has and requires several facets.
q Love – ideally.
Romance – which brings out the best of us.
The mood – critical.
The setting – ideal.
The act – in all its forms, positions and physical
often in ordinary relationships these criteria fail, either from
ignorance, boredom, or even from neglect, where we take each other
for granted. These
occur at the best of times. Relationships need work.
If they fail we see the consequent outcomes, including
failed relationships and a high incidence of divorce.
is the scenario.
the difficulties imposed when physical factors are added to the
already complex emotional issues. The problems faced by arthritis
sufferers are not only physical but in addition are deeply
emotional and are shrouded in self-doubt and poor self and body
the problem is not only that of the patient but the impact on the
partner as well. Such impact includes physical limitation and
variety of technique through consideration for the partner, as
well as fulfillment of expectation and personal needs both
sexually and emotionally. This of course has short and long term
arises from both inflammation as well as mechanical factors, and
is the major inhibitory factor not only from prevention of
mobility, but also from inhibition of arousal factors. Arousal
occurs with activation of the autonomic spinal reflexes, and is
heavily influenced by local spinal pain (nociceptive) reflexes as
well as central, i.e. brain pathways. Pain is a major inhibitory
factor to these pathways, and severely limits desire as well as
physical sexual function, including lubrication and sexual
response and orgasm in the female, and ability to sustain an
erection and ejaculation in the male.
mobility may be impaired and joint range of movement reduced. This
places limitations on the positions adopted during intercourse.
The consequence is that accommodation is required be the couple to
try several positions. The stress on joints at the extreme range
of movement of the joints may result in pain during the more
physical part of sexual activity.
wasting and weakness
muscles on each side of the affected joints waste within days to
weeks of onset of inflammation.
Patients often complain of weight loss, and with this comes
exposure of the bony prominences, that are less shielded by muscle
and fat and they become more exposed to pressure against a hard
surface. The wasting of the muscles, results also in weakness and
limits duration of muscle activity during isometric exercise. This
is especially a problem in sustaining certain positions during
sex, as lifting of the body against gravity for a length of time.
In addition pain limits exercise, and the overall fitness of the
individual becomes lower, in a continuing spiral.
is a significant problem in arthritis, especially inflammatory
Confusion arises regarding the difference between the activity of
the disease versus psychological factors, especially depression.
Fatigue or tiredness is a major turn-off. So it is vital to
address the cause. If it is physical illness – ensure optimal
therapy and disease control. If it is depression, take appropriate
therapy, either through counseling or medication as required. How
do we differentiate between these two possibilities?
Well, If the fatigue gets worse with exercise, then the disease is
likely to be the cause. If fatigue however, gets better with
exercise, then the depression or psychological issues are likely
to be the cause.
image is the major component to our ego and at the best of times
has a huge impact on how we perceive how others see us. The
presence of joint disease, with bony thickening and joint
prominence, as well as weight and muscle loss, makes the physical
appearance potentially less pleasing in the eyes of the mutual
partner. It is at this time that the strength of the relationship
allows the emotional connection to outweigh the defects of the
follows over time, especially if the physical defects are
considerable. Self doubt. Fear that the partner will seek
gratification in others without disease. The result is a major
blow to the libido, and it is essential that the partners
communicate the fear but not obsess over the fear.
inquiry regarding faithfulness may lead to frustration and anger.
On the other hand, compensation through attentiveness provides the
solution. In addition there is the physical fear of pain. This
must be worked through in solutions, either medication to prevent
pain, taken at the right time, or adjustment of position. IN
either event, communication is essential. Firstly, it is important
that no blame is placed on the other partner, and that anger is
avoided. Secondly, it must be made clear, that just because it is
sore, does not mean that nothing should happen. Pain doesn’t
mean the brain isn’t willing, a frequent mistake of the partner.
It is vital that the mutual needs of the patient and partner are
addressed. Communication here is everything. So often we find that
the fear of pain or of hurting the patient ends the sexual
relationship and this is the worst outcome.
and blame are destructive. It is easy to blame the partner for his
or her deficiency. Self-blame is also a problem and is a sure
remedy for rejection. It is easy to react by pushing the partner
away, and in that way avoid the issues.
is really the bottom line. It is love and caring that will sustain
a relationship through thick and thin. Arthritis sufferers almost
always develop the disease in the years after marriage, and it is
the foundations of the marriage that cements the relationship
thereafter. Rheumatoid arthritis usually develops in the 30’s
and 40’s. The 40’s are renowned to be the true trial years of
a relationship. It is the midlife crisis times. Loyalty isn’t
enough. Attention to the needs of the partners is critical. This
applies even more so in the bedroom at this time.
is remediable and what is not.
doesn’t grow on trees. It needs nurturing and growth. The
partners need to grow together. This applies to all relationships.
It is essential that interests are pursued. This means hobbies,
pursuit of occupations, and interests. The children in the
household, whilst important should not become the only focus for
the couple. It is when couples don’t grow, that respect for one
of the partners falls away and relationships fail. This translates
into communication. The couples must want to be together at home
before they can want to be together in bed. The best thing is that
couples remain best friends.
established the most optimal relationship in the home, the setting
is right for a good sexual relationship. This doesn’t mean that
the physical act of sex is everything. The mood must be right. A
dinner, music, candles, whatever makes the partner comfortable.
Turn off the television. Throw away the remote control. Have a
warm bath or shower. Preferably together!
soothing heat will usually make the physical pain more tolerable.
This amplifies the mood at the same time. A bubble bath with
addition of bath gel and fragrances, and a light perfume are
winners. Who can
resist the sensual seductive mood of a touch, and there is no harm
in asking where to touch. There are countless differences between
different people. Don’t zero in on the genitals. Kisses are
king. Kisses mean caring and love. A light kiss may be better than
anything else. Thereafter, touching in sensitive places sets the
mood. Light kissing of the painful joints may lead to a confidence
that the love is still there, beyond the physical!
medication or anti-inflammatory taken 30-60 minutes before may
assist in prevention of discomfort. With the recent release of the
COXIB drugs, such as Celecoxib / Celebrex, safer ongoing
anti-inflammatory therapy is now possible.
is at this point where awareness of physical limitation become
most important. It is said that there are hundreds of positions
for humans to make love. Most couples never try more than four and
alternate these depending on mood. Shyness prevents
experimentation in even the most seasoned of couples. The taboo
that the past has left on sex is a legacy of shame and sorrow.
There is no shame to masturbation, oral sex or changing positions.
Of course society sets its limits. But more important, the couple
itself must set the boundaries. However, both parties’ needs
require addressing. What is depravity to one may be the fetish of
the other. Communication and understanding is required. Leeway is
essential for both. And this is even greater in the arthritis
sufferer and the partner. Limitation by physical factors may leave
one of the partners unsatiated. The other partner must compensate.
This may mean mutual masturbation or oral sex, or other. But it is
critical. It is the yin and yang, equal and opposite. Satisfaction
for both. So that when the act is done a quiet snuggle in each
others arms with feelings of love and security make the happiness
most comfortable position depends mainly on the joints involved
and on individual factors. No-one can prescribe to the couple, and
experimentation is the real solution.
wrists, elbows and upper limbs:
wrists make lying on the back or side more easy, as pressure with
the wrists extended upwards, are a nightmare for the patient with
inflammation. However making a fist and keeping the wrists neutral
may be the way out if wrist pressure is applied. A light splint
across the wrist made of a soft material with a Velcro support are
useful. The elbows may be supported from pressure with appropriate
placement of pillows.
is always a fear in erosive rheumatoid arthritis, that neck
flexion may aggravate spinal cord problems, so advice and
assessment from your doctor regarding the seriousness of neck
involvement is important. The few individuals with an unstable
neck, at the base of
the skull should avoid placing pillows behind the neck, bending
the neck forward especially when having sex on their back. This is
a problem seen in some rheumatoid arthritis patients. If the neck
is not unstable, then such advice becomes less important.
back pain is not a feature of rheumatoid, but more that of
osteoarthritis. In this event, a supportive pillow placed between
the shoulder blades may help for the patient lying on the back. A
side-ways position is also less irritating with the knees flexed
or bent up. If stiffness in the spine is a problem, a warm shower
is most helpful before retiring to bed.
of the hips is common to many types of disease, including both RA
and OA and the spondyloarthropathy group of diseases. In this
instance, moving the hips sideways and outwards, (a movement
called abduction) may be painful, and restricted. A posterior
approach with the patient bending forward, and approached from
behind, or a sideways posterior approach is most comfortable.
additional factor comes in with hip replacement surgery, where
certain hip movements are to be avoided to minimize dislocation of
the prosthesis. Surgeons do not like the patient to swing the leg
inwards and over the other leg, (a movement known as adduction and
internal rotation). They therefore suggest the missionary position
as safest for the replaced hip joint. Lying on top with the body
straight and the hips straight (extended) is also easier.
on the knees is to be avoided, i.e. kneeling where there is
swelling locally present.
Maintaining the knees in a straight position, helps distribute the
weight, i.e. leaning forward over a bed or surface for a posterior
approach. A sideways, or passive position with partner on top is