I had just finished going over the prognosis and treatment plan with my newly diagnosed rheumatoid arthritis patient. I asked if she had any questions for me. She meekly asked if using her hand to please her husband would cause more joint damage (admittedly, her question was more pointed, but you get the idea).
She seemed worried about the answer I was going to give her. In my mind, I debated what she wanted to hear—yes, the action can cause severe and irreversible radiocarpal subluxation and therefore, you are off the hook, or don’t worry about it and go for it if you are so inclined. I decided to go with the latter answer. She seemed relieved and later explained that because of the arthritis, her hip joints hurt so much she could not have regular sex, and she wanted to make her husband happy.
This case encouraged me explore the area of sex and the rheumatic disease patient. I ran a PubMed search for joint damage associated with manual genital stimulation in RA—this yielded no publications. I changed the search to sexual function and RA: 104 articles resulted (compared to a search of RA where there are 122,935 articles published).
Sexual life and sexual dysfunction are rarely discussed due to patients’ and physicians’ reluctance to introduce the subject. As rheumatologists, we are comfortable talking about depression, ability to perform activities of daily living, and quality of life. Sexuality is rarely addressed. A survey of rheumatologists noted 12% of patients seen in their practice were screened for sexual activity (1). It’s just not polite conversation!
Factors affecting sexual function in RA patients can be divided into physical and psychological variables. In a study of 246 adult patients with longstanding JIA, Packham et al. noted 58.3% had disease-related sexual problems (2). Patients may have difficulties with positioning due to pain and/or deformities; additionally, vaginal dryness secondary to Sjogren's syndrome may cause dyspareunia. The study additionally found that 50% of patients felt detrimental effects of arthritis on the psyche and body image. Fatigue, depression, medications, and hormonal dysregulation contribute frequently to sexual dysfunction. Not surprisingly, sexual disability correlated with parameters of disease activity (p<0.001), Health Assessment Questionnaire (HAQ)-disability (p<0.001), hip (p<0.001) but not knee joint disease, and seropositivity (p<0.05).
So, sex is important. Beyond reproductive purposes, it impacts our patients’ quality of life. French researchers developed the Qualisex questionnaire, which is a sexual function survey to evaluate the impact of RA on sexuality. While I doubt that many of us will adopt another survey form in our busy schedule, I think it is important to take a moment with our patients and address how the disease is affecting their sex life.
Let’s break the ice on this taboo subject.
Britto MT, Rosenthal SL, Taylor J, Passo MH. Improving rheumatologists’ screening for alcohol use and sexual activity. Arch Pediatr Adolesc Med. 2000;154:478–483
Packham JC, Hall MA, Pimm TJ. Long-term follow-up of 246 adults with juvenile idiopathic arthritis: predictive factors for mood and pain. Rheumatology (Oxford) 2002;41:1444–1449
Gordon D, Beastall GH, Thomson JA, Sturrock RD. Androgenic status and sexual function in males with rheumatoid arthritis and ankylosing spondylitis. Q J Med. 1986;60:671–679
Clin Rheumatol. 2006 Nov;25(6):822-30. Epub 2006 Mar 7.