First published March 2006, updated May 2021

Psychological consequences of stroke are numerous and often more disabling than motor or cognitive impairments. These can include feelings of fear, frustration and anger, adjustment reactions to new physical and cognitive limitations, depressions and also anxiety1,2.

Sexuality, often a private concern, is not frequently addressed. Sexuality and sexual function encompass an array of meanings that have resulted in a range of measurements of sexual function such as coital frequency, erectile and orgasmic ability, vaginal lubrication, libido and sexual satisfaction3,4.

Epidemiology of sexuality and stroke

Stroke can have an impact on sexual frequency, and post-stroke 33 to 64 per cent of patients have ceased sexual intercourse4,5 and 72 to 83.3 per cent report decreased sexual frequency3,6. Decreased libido also occurs in 57 to 79 per cent of all patients and in up to 79 per cent of males and 66 per cent of females4,5.

Further reading

In male patients, erectile function is diminished or absent in 29 to 75 per cent7. However,, Hawton found that the majority of men regain erectile function post-stroke8. In females, 46 per cent have diminished or absent vaginal lubrication and 55 per cent have diminished or absent orgasmic ability4,9. In regard to sexual satisfaction there is increased dissatisfaction with sexual life frequently observed in up to 49 per cent of patients and 31 per cent of partners1,3,4,10,11.

However, enhanced sexual activity has occurred post–stroke and between 3.2 and 11.1 per cent of patients experience enhanced sexual activity and increased libido3, 4, 5,11. Findings of the key studies on stroke and sexuality are highlighted in Table 1.

Table 1. Summary of key papers

Authors Year Number of patients The main positive findings

Murray CD

Harrison B1

2004 10 patients Highlighted emotional findings post-stroke, particularly social withdrawal and increased pressure in maintaining/forming relationships.

Giaquinto S

Buzzelli S

Di Francesco L

Nolfe G3

2003 68 patients Sexual decline and arousal in the post-stroke period. A negative impact on sexual activity was observed for physical disability. 3.2 per cent experienced enhanced sexual activity.

Korpelainen JT

Nieminen P

Myllyla V

1999 192 patients, 94 partners Patients and partners reported decline in libido, coital frequency, and sexual satisfaction. Sexual dysfunction was related to depression and functional disability. 19 subjects showed increased libido. Psychological factors played an important role in the decline.

Kimura M

Murata Y

Shimoda K

Robinson RG10

2001 100 patients Demonstrated decline in libido and sexual satisfaction post-stroke in males and females. Post-stroke sexual dysfunction was related to the existence and severity of depressive disorder and activities of daily living. Sexual dysfunction in males was related to left hemisphere lesions.

S Buzzelli

L Francesco 

S Giaquinto 

G Nolfe 

1997 86 patients Sexual decline observed post-stroke. Length of marriage had a negative impact on sexual function. Psychological factors influence sexual decline.  

Greenburg E

Treger I

Ring H

2004 120 patients Sexual dysfunction was reported in three per cent.

Sjogren K

Fugl Meyer AR14

1982 110 patients Dependence, causing changes in roles of post-stroke patients is a predictor of sexual activity.
Hawton K 1984 50 male patients Physical disability had been a problem in resuming sexual activity. A man’s sexual response is not usually chronically impaired following stroke. Some partners experienced lack of desire, and fear of another stroke and poor communication added to this.

Factors affecting sexuality after stroke

Many factors have been suggested that may affect the sexual function of a stroke patient and these include demographic, physical and psychosocial factors5,12.

Demographic factors affecting sexuality after stroke

These demographic factors include gender, marital status, age and education. These factors were not found to be significant by many authors in determining sexual function of a patient after a stroke3,4,11,13. However, a study by Buzzelli et al11, found that the length of marriage had a negative impact on the patient’s level of sexual function post-stroke.

Physical factors affecting sexuality after stroke

Site of lesion

Left sided lesions were found to be in a significantly higher frequency among a group of males with sexual dysfunction, in comparison to a group of males with no sexual dysfunction10. This has also been demonstrated by other authors5,15,16. The right hemisphere has also been suggested to be dominant to sexual function17. Coslett et al found that right hemisphere stroke led to found that right hemisphere stroke led to major sexual dysfunction in comparison to left hemisphere stroke in a study of 26 men with unilateral strokes17. In addition, damage to the dominant hemisphere has been implicated in causing sexual decline, with damage to the nondominant hemisphere causing sexual excitation13. These results are conflicting and other studies show no correlation3,4,8.

Physical disability

Physical disability was found to have a negative impact on sexual activity3,6,18. Hawton8 found that of the 50 men included in his study, the majority experienced difficulties due to physical disability. In spite of this, difficulties were overcome by two thirds of the men by trying new sexual positions8. Dependence of a stroke patient on their partner has been implicated in causing changes in sexuality6.

Medication

Whilst the majority of patients are on a wide variety of pharmacological agents, as a whole they have not been implicated in affecting sexual function other than antidepressants and antihypertensives4,11,19.

Psycho-social factors affecting sexuality after stroke

Depression

Post-stroke sexual dysfunction has been shown to be closely related to the degree of depression shown with the Geriatric Depression Scale4,10. Conversely other authors have indicated no relationship between sexual dysfunction and depression3,11.

Psychological fears

Many psychological fears may affect the sexual function of an individual. Salvatore et al3 found that 25 per cent of male partners and 21 per cent of female partners feared relapse in their partners (the patient) that contributed to sexual dysfunction. Korpelainen et al4 discusses other fears that patients have, regarding sexuality, impotence and functional disability. Patients often have reduced self-esteem concerning their desirability to others, in both married and single patients1 . Lack of communication between the patient and their partner also presents a problem4,8.

High level of pre-morbid sexual activity

It has been suggested that a high level of premorbid sexual activity is indicative of maintained sexual activity post-stroke in males8, but this has not been supported elsewhere3.

Based on the perceived factors influencing the impact of stroke on sexuality, a variety of assessment tools have been used in considering sexual function in post-stroke patients:

  • Semi-structured interviews1,8
  • Questionnaires – including detail of pre-stroke and post stroke sexual function4
  • Assessment of depression, e.g. using the Geriatric Depression Scale4, Hamilton Rating Scale for Depression10, Beck Scale and Centre for Epidemiologic Studies Depression Scale3
  • Assessment of physical disability, e.g. using the Rankin Scale4 and Functional Independence Measure11.

Inclusion of data from partners of patients has also been reported by some authors (partners completing questionnaires on their sexual activity separately to the patient)3,4. The impact on the partner post-stroke Partners experienced reduced desire, fear of relapse of the patient, and anxiety at having sexual intercourse with an unwell person, as well as experiencing decreased libido (in up to 65 per cent), sexual activity and satisfaction3,4,8. In addition, 27 per cent of spouses are said to have ceased sexual intercourse post-stroke3. Breakdown of marriage due to a reduction in sexual intercourse is an extreme outcome but has been described1.

Management

Management of altered sexuality following stroke is difficult particularly as there is no consensus agreement about the risk factors involved. It is important to screen patients for contributing psychological problems. e.g. depression as well as rehabilitating physically. Most studies suggest that counselling should form part of the ‘routine’ management of patients who have suffered a stroke to facilitate discussion within a couple to address interpersonal problems1,3,4,8,13. In one study approximately half of the patients and spouses displayed an interest in sexual counselling4. In the first instance, there must be a greater awareness and acknowledgement of this problem among physicians and other members of the multidisciplinary team, particularly as patients may be reluctant to discuss symptoms relating to sexuality.

Conclusion

Sexual dysfunction following stroke is a prevalent problem for both patients and their partners but is under recognised by the multidisciplinary stroke team. It has been demonstrated repeatedly that patients have experienced loss of libido, decreased frequency of intercourse, decreased arousal and decreased satisfaction with their sexual health. Factors that may be implicated in this decline are many and at present there are no conclusive answers; it is likely to be combination of the physical and psycho-social factors identified. Counselling of a couple as part of the rehabilitation programme may help to focus on some of their concerns.

References

  1. Murray CD, Harrison B. The meaning and experience of being a stroke survivor: an interpretative phenomenological analysis. Disability and Rehabilitation 2004; 8; 26(13): 808–16
  2. Westcott P. Stroke: Questions and Answers. London: The Stroke Association, 2000
  3. Giaquinto S, Buzzelli S, Di Francesco L, Nolfe G. Evaluation of sexual changes after stroke. J Clin Psychiatry 2003; 64(3): 302–7
  4. Korpelainen JT, Nieminen P, Myllyla VV. Sexual functioning among stroke patients and their spouses. Stroke 1999; 30(4): 715–9
  5. Monga TN, Lawson JS, Inglis J. Sexual Dysfunction in stroke patients. Arch Phys Med Rehabil Arch Phys Med Rehabil 1986;67: 19–22
  6. Sjogren K, Fugl Meyer AR. Adjustment to Life after Stroke with special reference to Sexual Intercourse and Leisure. Journal of Psychosomatic Research 1982; 26(4): 409–17
  7. Aloni R, Ring H, Rozenthul N, et al. Sexual function in male patients after stroke. Sex Disabil Sex Disabil 1993;11: 121–28
  8. Hawton K. Sexual adjustment of men who have had strokes. Journal of Psychosomatic Research 1984; 28(3): 243–49
  9. Aloni R, Schwartz J, Ring H. Sexual function in post-stroke female patients. Sex Disabil Sex Disabil 1994;12: 191–99
  10. Kimura M, Murata Y, Shimoda K, Robinson RG. Sexual dysfunction following stroke. Comprehensive Psychiatry 2001; 42(3): 217–22
  11. Buzzelli S, Di Francesco L, Giaquinto S, Nolfe G. Psychological and Medical Aspects of Sexuality Following Stroke. Sexuality and Disability Disability 1997;15(4): 261–70
  12. Boldrini P, Basaglia N, Calanca MC. Sexual changes in hemiparetic patients. Arch Phys Med Rehabil 1991; 72: 202–7
  13. Greenburg E, Treger J, Ring H. Poststroke Follow- Up in a Rehabilitation Centre Outpatient Clinic. Israel Medical Association Journal Medical Association Journal 2004; 6(10): 603–6
  14. Sjogren K, Damberg JE, Liliequist B. Sexuality after stroke with Hemiplegia, I: aspects of sexual function. Scand J Rehabil Med 1983; 15: 55–610
  15. Goddess ED, Wagner NN, Silverman DR. Poststroke sexual activity of CVA patients. Med Aspects Hum Sex 1979; 13: 16–30
  16. Kalliomaki JL, Markkanen TK, Mustonen VA. Sexual behaviour after cerebral vascular accident. Fertil Steril 1961;12: 156–58
  17. Coslett HB. Heilman KM. Male sexual function. Impairment after right hemisphere stroke. Archives of Neurology Neurology 1986;43(10): 1036–9
  18. Viitanen M, Fugl-Meyer KS, Bernspang B, et al. Life Satisfaction in Long term survivors after stroke. Scand J Rehab Med Scand J Rehab Med 1988;20: 17–24
  19. Monga TN, Ostermann HJ. Sexuality and sexual adjustment in stroke patients. Phys Med Rehabil State Art Rev 1995; 9: 345–59