「愉悅衛生」案例：慢性病患者的性健康

Pebble Kranz，醫學博士 / 2023 年 9 月 15 日 / Medscape

最近的一項研究發現，年輕和中年高血壓患者的性生活頻率較低與全因死亡率較高之間有顯著關聯。 初級保健醫生是否應該為十分之六的患有慢性病的美國人提供快樂處方？ 我們如何幫助這些患者獲得性快感的能力，這是人類經驗中至關重要且肯定生命的組成部分？

醫學博士 Pebble Kranz

先詢問，而非立即告訴

首先，我們需要定期詢問性福祉和性愉悅。 如果不詢問患者的看法，我們就不知道性與他們的生活品質的相關性。 除非我們詢問，否則我們不知道哪些特定類型的性遊戲對於一個人的快樂很重要，我們也無法假設他們在醫療保健的背景下如何優先考慮性功能。 當我開始向我的初級保健患者詢問有關性健康的問題時，比我預想更多的人都在默默地堅持著令人痛苦的問題。 現在，身為性醫學專家，在每次性功能評估中，我都會問三個關鍵問題：您的目標是什麼？性對你來說意味著什麼？ 什麼樣的性遊戲對於您（和您的伴侶）的快樂很重要？

慢性疾病——具有身體症狀以及心理、關係和文化成分——影響一般生理和生殖生理。 任何改變血管、神經內分泌或肌肉骨骼功能的疾病過程都可能直接透過疾病的過程或透過併發症或對身分和健康的影響而間接地影響性功能。 此外，治療效果可能伴隨著性功能的一系列醫源性變化。

管理慢性疾病對性的影響需要韌性和靈活性。 嚴重的傷害可能需要對性行為進行大規模調整，但進行性的疾病可能需要不斷去適應性的變化。 疾病發生的生命階段也很重要。 生命早期面臨疾病的人們會遇到挑戰（尋找願意的性伴侶和有限的有關其性功能之醫療指導）以及好處（他們可能將疾病納入性生活的一部分）。 那些在晚年經歷與疾病相關的性變化的人可能會面臨「正常」的性功能和健康的喪失。

同時，沒有生病的伴侶可能有自己的性需求、恐懼和擔憂。 病人和伴侶都可能經歷被剝奪權利的悲傷—— 一種文化上不允許哀悼的事情之失落感（「我的伴侶在面對這種可怕的疾病時還活著；我卻是擔心我們/我的性快感？ 」）。

積極的婚姻關係透過提高生存率、提高醫療順從性、改善患者的生活品質和提高生活滿意度來影響健康。 性滿意度是關係滿意度的重要因素。 因此，幫助我們的患者進行這些改變不僅可以改善性健康，還可以改善整體健康。

那麼，我們該如何解決慢性病照護中的性愉悅問題呢？ 以下是一些提示：

專注於快樂。 當談到性時，「表演」是粗俗的語言。 完全專注於感覺和享受，這是任何人唯一需要的性「技巧」，在嘗試要去表演時是不可能的。

鼓勵靈活性並認識到性包含了一生中不斷變化的廣泛而多樣的經驗。 性可以是一切，從接吻、擁抱到人們所能想像的最瘋狂的事。 我們可以幫助患者和伴侶考慮滿足性需求的多種方法。 平衡對性變化的接受與改善的動力也是我們職責的一部分。

解決疾病對患者與身體關係的影響。 疾病不僅會改變身體機能，還會改變自尊和身體形象。 自我概念的重組可能會發生（ 「我不再是一個有性慾的人；我是一個性功能障礙的氣喘患者/糖尿病患者等，應該避免親密的性行為」 ）。 檢視這些自我建構可以改變思想和行為，從而改善心理和性健康。 鼓勵患者探索現在身體感覺良好的部位。 如果可能，我們可以幫助轉診矯正手術或提供造口蓋、假髮、圍巾和刺青等資源指導。

我們提供「睡眠健康」之建議；而愉悅健康又如何呢？

• 鼓勵與合作夥伴進行開放式溝通，並提供資源以培養溝通技巧。

• 考慮性行為所需的身體和情緒準備：充足的休息、為體液準備環境、舒適的枕頭或協助定位之輔具以及手頭上有充足的潤滑劑。

• 留出足夠的時間進行性遊戲，並鼓勵調整或停止性行為的能力。帶著幽默和自我同情重新開始。

• 使用性輔助來增強快感。

當事情變得棘手時，請尋求性醫學和性治療的同事。

所有的身體，無論其健康狀況或疾病狀況，都有能力獲得愉悅。 嘿，快樂甚至可以拯救生命！

The Case for ‘Pleasure Hygiene’: Sexual Health in Patients With Chronic Illness

Pebble Kranz, MD / September 15, 2023 / Medscape

A recent study found a significant association between lower sexual frequency and greater all-cause mortality in young and middle-aged people with hypertension. Should primary care physicians be offering a pleasure prescription to the 6 in 10 Americans living with chronic illness? How can we help these patients access their capacity for sexual pleasure, a critical and life-affirming component of the human experience?

Pebble Kranz, MD

Ask, Don’t Tell

First, we need to ask routinely about sexual well-being and pleasure. Without asking patients their views, we do not know the relevance of sex for their quality of life. Unless we ask, we do not know what specific kinds of sexual play are important for a person’s pleasure, nor can we assume how they prioritize their sexual functioning in the context of their medical care. When I began asking my primary care patients about sexual well-being, many more than I expected were quietly holding on to distressing issues. Now, as a sexual medicine specialist, in each sexual function evaluation, I ask three key questions: What are your goals? What does sex mean to you? What kinds of sexual play are important for your (and your partner’s) pleasure?

Chronic disease — with physical symptoms as well as psychological, relational, and cultural components — affects both general and genital physiology. Any disease process that alters vascular, neuroendocrine, or musculoskeletal function is likely to influence sexual function, either directly through the disease process or indirectly through complications or the effect on identity and well-being. In addition, a host of iatrogenic changes to sexual function may accompany effects of treatments.

Managing the effects of chronic illness on sexuality requires resilience and flexibility. A serious injury may require a massive adjustment to sexuality, but progressive disease may require continuous accommodations to sexual changes. The life stage at which the disease occurs also matters. People facing disease early in life encounter challenges (finding willing sexual partners and limited medical guidance regarding their sexual functioning) as well as benefits (they may integrate their disease as part of their sexual life). Those who experience sexual changes related to their illness later in life may face a loss of “normal” sexual function and well-being.

Meanwhile, the partner who is not ill may have their own sexual needs, fears, and worries. Both patients and partners may experience disenfranchised grief — a sense of loss about something one is not culturally permitted to mourn (“I my partner is alive in the face of this terrible illness; who am I to worry about our/my sexual pleasure?“).

Positive marital relationships influence health through improved survival, improved medical adherence, better quality of life for the patient, and improved life satisfaction. Sexual satisfaction is an important factor in relational satisfaction. Helping our patients with these changes therefore may improve not only sexual health but overall health.

How, then, should we address sexual pleasure in chronic illness care? Here are a few tips:

Focus on pleasure. “Performance” is foul language when it comes to sex. Full attention to sensation and enjoyment, the only sexual “skill” anyone needs, is impossible while trying to perform.

Encourage flexibility and recognize that sex encompasses a wide and varied menu of experiences that change over a lifetime. Sex is everything from kissing and cuddling to the wildest things a mind can imagine. We can help both patients and partners think about the wide variety of ways to meet sexual needs. Balancing acceptance of sexual changes with motivation for improvement also is part of our role.

Address the effects of illness on the patient’s relationship with their body. Illness may alter not only bodily function but also self-esteem and body image. A reorganization of self-concept may occur (“I am no longer a sexual person; I’m a sexually dysfunctional asthmatic/diabetic/etc. and should avoid sexual intimacy“). Examining these self-constructs allows shifts in thoughts and behaviours, leading to improved psychological and sexual well-being. Encourage patients to explore what feels good in this body now. When possible, we can help with referral for corrective surgeries or direction to resources like stoma covers, wigs, scarves, and tattoos.

We offer suggestions for “sleep hygiene”; how about pleasure hygiene?

• Encourage open communication with partner(s) and offer resources to develop communication skills.
• Consider needs for physical and emotional preparation for sexual play: adequate rest, preparing the environment for body fluids, pillows for comfort or aides for positioning, and plenty of lubricant at hand.
• Allow adequate time for sexual play and encourage the ability to adjust or stop and start over — with humor and self-compassion.
• Use sexual aides to enhance pleasure.

Seek out sexual medicine and sex therapy colleagues when things become tricky.

All bodies, no matter their health or illness state, are capable of pleasure. Hey, pleasure might even save lives!