New Zealand Rehabilitation Association, Inc.

In 1998, as a physiotherapist working in respiratory medicine with only a couple of years of postgraduate work experience under my belt, I presented a hospital inservice to my colleagues which was entitled: "Bonking and breathlessness - everything you always wanted to know about sex and chronic respiratory disease but were too afraid to ask." My inspiration for the presentation had been a book that had been published a year earlier entitled "Sexual Function in People with Disability and Chronic Illness: A Health Professional's Guide" (see below for full reference). This thick, hardback book introduced theory regarding assessment, evaluation, treatment and management of sexuality and sexual function design for a multidisciplinary audience. There were chapters dedicated to a wide range of specific conditions, including one entirely focused on chronic respiratory conditions. From memory, this chapter included information about the physiology of cardiorespiratory function relevant to sexual function, advice for the management of sputum and the use of supplimentary oxygen during sex, and illustrations of positions that might make achieving pleasure a little easier.

From a physiotherapy perspective, it turned out, sex intercourse for someone with COPD was all about minimising energy expenditure while maximising V/Q matching. For those not in the know, V/Q matching refers to getting the blood from your heart to the areas of your lungs where there is freshly inhaled air. 'V' stands for 'ventilation' (the breathing in and out bit), while 'Q' stands for 'perfusion' (don't ask why) - perfusion being the pumping of blood into the tissue around the aveoli (the tiny air sacks in the lungs). Increase your heart rate and pump more blood to one part of your lungs, but fail to inflate the aveoli in that part with fresh air and you end up with no new oxygen in your blood stream. This is of course the constant battle that people with chronic respiratory conditions face every day. V/Q matching can be affected not only by lung pathology but also by the nature of activities, the position of the body and how the lungs and heart respond to psychological, physiological, physical and environmental conditions. Respiratory physiotherapists specialise in, among other things, utilising physical techniques and modalities to maximise V/Q matching during activity and rest, and hence should be involved in educating patients regarding such matters related to sexual function.

The interesting thing is however, and here is where I finally mention the paper that inspired this column, there is a lot of 'expert opinion' but very little actual research into sexual function and respiratory conditions. Advice regarding sexual function for people with respiratory disease tends to be based on general knowledge of the cardiovascular system and its response during activity. Polverino et al. (2008), to begin to address this gap in the literature, conducted a very simple single observational case study where they asked a 65 year old man on long term oxygen therapy for chronic obstructive pulmonary disease (COPD) to wear a pulse oximeter 10 minutes before, during and 20 minutes after sexual intercourse. They found, interestingly, that while the man himself reported a significant increase in dysnea (shortness of breath) during sex (no surprises there), his blood oxygenation in fact went up during sex and remained elevated for a short period of time after sex and even after his heart rate had returned to normal. Sex was performed without oxygen and this observation (paradoxical elevations in oxygenation during activity) was not reproduced in a 6-minute walk test. The man however had been asked to perform sex in positions that he found 'more comfortable' (e.g. in standing or with his partner on top - which is what is usually recommended in these situations - although sex in side lying, aka. spooning, is also a good position for V/Q matching). The authors speculated that while sexual activity increased heart and lung function, this was achieved without a substantial increase in oxygen demand by the muscles in the arms and legs in comparison to other physical activities such as, say, walking or household chores. Thus better V/Q matching was achieved without loss of oxygenation through energy consumption. The psychological aspects of sexual activity (in terms of elevating heart rate) was also consider another potential contributor to improved V/Q matching in this case.

The author do point out how limited their capacity to analyse this data was, given the very simplistic nature of their method of data collection. Furthermore, it is obviously not possible generalise from this single case study to the whole COPD population. However, what this paper does demonstrate is how little we currently know about the relationship between sex and respiratory function in people with chronic respiratory illness. One would think, given how important sexuality is for personal identity and quality of life, further research in this area ought to be a high priority.

The other reference:

Sipski, M. L., & Alexander, C. J. (Eds.). (1997). Sexual Function in People with Disability and Chronic Illness: A Health Professional's Guide Gaithersburg, MD: Aspen Publishers.

N.B. I recently emailed Sipski to ask if a second edition of this textbook was being planned, noting the need for an update on the research in this area, but unfortunately the answer in this regard was 'no', no such plans in the foreseable future. Sipski however has continued to research sexuality and disability, mainly in populations of people with spinal cord injury.