And there they were, the stroke patient and his wife – she laughing nervously and he avoiding eye contact – both clearly uncomfortable talking about their sex life, although they assured me that nothing in their relationship had changed since Mahmud (not his real name) suffered a stroke six months ago.

Perhaps I had indeed overstepped some boundaries in raising this issue with husband and wife. Nonetheless, sexuality and relationship issues are neither trivial nor irrelevant for stroke patients and their partners.

Quality of life refers to all day-to-day functions and emotions, including sexuality. Sex plays such an important role in our lives that if it is neglected, or worse, deliberately ignored, it can make us feel less of a person.

“Some studies show that almost 80-90% of stroke patients report a decrease in sexual function, frequency, intimacy and satisfaction,” says Dr George.

“The whole aspect of sexual function is affected ? not just sexual intercourse,” says Assoc Prof Nathan Vytialingam, a consultant occupational therapist.

Most of the patients attributed these changes to their general attitude towards sexuality, a fear of impotence, an inability to discuss sexuality, unwillingness to participate in sex and the degree of their functional disability.

“There are two extremes – you have people who abstain totally from sex and (at the other extreme), those who think they can have normal sexual function like they used to have before,” says Dr George.

For Assoc Prof Nathan, however, whether the actual act of intercourse takes place successfully is secondary to whether both patient and partner still feel loved and wanted by each other.

“The definition of sexual satisfaction depends on what both parties want,” he says. Perhaps a stroke patient and his wife are perfectly content just to hold each other close.

“When you hug somebody, at least the person will know that he/she is still wanted and loved. That, in some ways, will motivate patients to want to improve their quality of life,” he notes.

Interestingly, Dr Abdias Aquino, a neurologist at St Luke's Medical Center in Manila, has said that stroke victims can regain physical and psychological strength by rekindling their sex lives with their marital partners.

But their lives certainly have: Stroke patients find that they can no longer perform simple tasks effortlessly, they have to succumb to letting a person clean and change them, and they are not who they used to be.

It is very hard for someone with a disabling disease to feel sensual, lovable or sexually adequate. Often, a reduced sex drive is due to the patient spiralling into depression, a common occurrence in almost half of all stroke patients.

Perhaps they should just try holding hands, not to help Mahmud walk or do his exercises, but for sheer comfort. Still, there will come a time when one or both of them will desire more intimacy and at this juncture, both the patient and spouse will have to find a way to rekindle the flame without anxiety or fear of rejection.

The spouse will have to adjust to his/her role as the carer who handles duties like bathing, cleaning, feeding and assisting the stroke patient with toileting. It would be very difficult for him/her to go into the bedroom and suddenly become aroused.

Other conflicts come into play as well. Take, for instance, the spouse who still wants intimacy, but feels guilty for wanting to seek sexual satisfaction from a person who has a stroke and disability. Or perhaps both patient and partner want sex, but are afraid that any bedroom activities will make the stroke worse.

Aside from the fact that nobody would want to face a crisis in flagrante delicto, it is a medically valid concern that should be addressed by the health team managing the patient.

“Most often, after the acute phase (of the stroke), there is no real issue about having sexual relationships, with precautions like changing the style, position or technique,” Dr George assures.

Stroke patients with a disability may have muscle spasticity, contractures or limb paralysis. They may tire easily, not be able to get into certain positions or may need stimulation with sexual aids. They need to think about hygiene, especially those with an in-dwelling catheter, or those with bowel or bladder incontinence (see ‘Adjusting to changes').

Doctors also need to consider whether the patient is on medication that can affect sexual function. For instance, many stroke patients have hypertension, and some anti-hypertensives can cause sexual side effects.

“Some of these side effects wear off with time, so the patients just need reassurance. Sometimes we need to change medications to those with fewer side effects,” Dr George recommends.

Mahmud and his wife celebrated their 23rd wedding anniversary on Valentine's Day. She is glad that he is now able to walk by himself and encourages him to continue improving his right hand function.

As for Mahmud? “When I want to cross the road, you have to hold my hand. So I need you,” he says, his soft-spoken manner and slightly slurred speech making his words barely discernible.

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