Stuart A. Schneck, M.D., has earned the respect and admiration of colleagues, students and patients alike during his 43-year career in academic medicine. His contributions as a clinician, researcher and teacher have significantly advanced our understanding of the causes of stroke and enhanced the lives of survivors. He is nationally known and recognized for his numerous achievements.

Little has been written about this subject, despite the importance of sexual activity in our lives. In my neurological practice spanning almost four decades, this topic rarely was raised. The medical literature confirms a similar paucity of questions to physicians and rehabilitation caregivers. Despite data indicating that almost half of disabled patients desired professional help about sexuality, preferably from same-sex physicians, many doctors and other professionals avoid discussion about sexual behavior among the chronically ill.

Possible reasons for this lack of communication are:

1.	Stroke victims are usually in their 50s or older. The cultures in which they grew up and which shaped attitudes often did not recognize that older people, as well as the disabled, commonly had a sexual life.
2.	Current cultural attitudes glamorize sexual activity among the young, while often neglecting recognition, or even voicing denigration (“dirty old man”) of the desire for such activity in older people
3.	Patients significantly impaired by a stroke may lose partial or complete independence in many activities of daily living. This may lead to the erroneous assumption that loss of independence extends also to sexual functioning.
4.	Fear by the patient or partner that sexual activity might precipitate another stroke.
5.	Unsatisfactory sexual activity prior to the stroke.
6.	Embarrassment. Older people seem less comfortable than younger individuals in discussing issues of personal sexuality.

Sexual Activity in Older (over age 50) Adults
Regular sexual activity continues in a number of people in the ninth decade. In healthy women, age alone does not necessarily diminish libido or the capacity to achieve orgasm. Vaginal lubrication and expansibility do diminish with age, especially if sexual activity is infrequent. In healthy older men, it takes more time and more direct genital stimulation to
obtain an erection, intensity of ejaculation is decreased, and increased time must pass before another ejaculation is possible.

For both sexes, the overall quantity of sexual activity during ages 20 to 40 correlates significantly with the frequency of sexual activity during normal aging. Prolonged abstention from sexual activity in older individuals makes it harder physiologically to resume satisfactory sexual activity than in younger people. Older persons taking medications, such as antihypertensives, antidepressants or sedatives may note a decrease of libido, lubrication and orgasm in women, and libido, erection, ejaculation and orgasm in men.

Sexual Activity Following Stroke
Stroke patients are more likely to experience decreases in libido, intercourse frequency, erections, ejaculations, vaginal lubrication, orgasms and overall sexual satisfaction. Some do resume a degree of sexual activity similar to their previous level, while a few develop increased sexual behavior. The side involved with a paralysis does not seem related to whether libido and intercourse frequency will decrease. Individuals with paralysis, language difficulty (aphasia) or confusion are less likely to resume their pre-stroke level of sexual activity than those with no motor or speech difficulty.

A stroke usually causes less extensive organic loss of sexual function than is commonly assumed. Most post-stroke sexual problems in men and women are related more to emotional and psychological factors, particularly frustration and depression, than to organic brain damage. How couples adjust sexually after a stroke depends mainly on their previous sexual relationship. The risk of a second stroke as a result of sexual activity appears to be quite small.

It may be harder for men to resume sexual activity after stroke for both physical and emotional reasons. Their previous sexual role has often been that of the more active partner, and any physical handicap may cause fatigue and make customary positions difficult or impossible. Women after a stroke may not have as much physical difficulty if their usual role has been more passive, but they may harbor feelings of unattractiveness. Any sensory loss as a result of the stroke may make sexual arousal more difficult. A few stroke patients may use increased sexual activity as a way to deny their disability. A more common defense is complete withdrawal from sexual activity.

Rehabilitation
To improve post-stroke functioning, patients and partners must be able to ask for information and help, while physicians and rehabilitation professionals should offer the couple an opportunity to talk about their feelings and desires. It may be useful to refer them to sex therapists. How couples adjust depends greatly on their previous sexual relationship. Stroke patients and partners should realize that sexual activity does not always equate to intercourse. They often can still give and receive pleasure by holding each other, caressing and expressing feelings. Sexual activity of any kind, even if considerably different from that before the stroke, gives a sense of self-esteem and independence. For men, this may mean a return to a sense of masculinity; for women it may mean that she is still desirable. Customary sexual positions may have to be changed, which initially might be awkward or embarrassing. Support and participation from the unaffected partner in openly discussing feelings is extremely important. Physicians, therapists and patients should recognize that the form of sexual activity best suited to a couple may differ significantly from pre-stroke sexual behavior. Regarding medications, there is no controlled clinical data on the safety or effectiveness of Viagra® in stroke patients.

If the sexual functioning of an individual with a stroke is given the same care and attention as other problems in rehabilitation, it is likely that recovery will be even more satisfactory for many patients.