In this regard, consider the impact of physical impairment as a barrier to intimate relations.
This article is also indebted to input from the members of the Searle Patient Partner program who bared their souls and inner secrets to openly discuss the problems faced by arthritis sufferers, in the bedroom and other intimate, but entirely appropriate situations, to explore and enjoy the wonders of sex and love between partners.

Intimacy has and requires several facets.

• Love – ideally.
• Romance – which brings out the best of us.
• The mood – critical.
• The setting – ideal.
• The act – in all its forms, positions and physical methods.

So often in ordinary relationships these criteria fail, either from ignorance, boredom, or even from neglect, where we take each other for granted. These occur at the best of times. Relationships need work. If they fail we see the consequent outcomes, including failed relationships and a high incidence of divorce.

This is the scenario.

Imagine the difficulties imposed when physical factors are added to the already complex emotional issues. The problems faced by arthritis sufferers are not only physical but in addition are deeply emotional and are shrouded in self-doubt and poor self and body image.

But the problem is not only that of the patient but the impact on the partner as well. Such impact includes physical limitation and variety of technique through consideration for the partner, as well as fulfillment of expectation and personal needs both sexually and emotionally. This of course has short and long term implications.

Physical factors:

Pain.

Pain arises from both inflammation as well as mechanical factors, and is the major inhibitory factor not only from prevention of mobility, but also from inhibition of arousal factors. Arousal occurs with activation of the autonomic spinal reflexes, and is heavily influenced by local spinal pain (nociceptive) reflexes as well as central, i.e. brain pathways. Pain is a major inhibitory factor to these pathways, and severely limits desire as well as physical sexual function, including lubrication and sexual response and orgasm in the female, and ability to sustain an erection and ejaculation in the male.

Physical joint damage.

Joint mobility may be impaired and joint range of movement reduced. This places limitations on the positions adopted during intercourse. The consequence is that accommodation is required be the couple to try several positions. The stress on joints at the extreme range of movement of the joints may result in pain during the more physical part of sexual activity.

Muscle wasting and weakness

The muscles on each side of the affected joints waste within days to weeks of onset of inflammation. Patients often complain of weight loss, and with this comes exposure of the bony prominences, that are less shielded by muscle and fat and they become more exposed to pressure against a hard surface. The wasting of the muscles, results also in weakness and limits duration of muscle activity during isometric exercise. This is especially a problem in sustaining certain positions during sex, as lifting of the body against gravity for a length of time. In addition pain limits exercise, and the overall fitness of the individual becomes lower, in a continuing spiral.

Fatigue

Fatigue is a significant problem in arthritis, especially inflammatory arthritis.
Confusion arises regarding the difference between the activity of the disease versus psychological factors, especially depression. Fatigue or tiredness is a major turn-off. So it is vital to address the cause. If it is physical illness – ensure optimal therapy and disease control. If it is depression, take appropriate therapy, either through counseling or medication as required. How do we differentiate between these two possibilities?
Well, If the fatigue gets worse with exercise, then the disease is likely to be the cause. If fatigue however, gets better with exercise, then the depression or psychological issues are likely to be the cause.

Psychological factors

Body Image.

Body image is the major component to our ego and at the best of times has a huge impact on how we perceive how others see us. The presence of joint disease, with bony thickening and joint prominence, as well as weight and muscle loss, makes the physical appearance potentially less pleasing in the eyes of the mutual partner. It is at this time that the strength of the relationship allows the emotional connection to outweigh the defects of the physical body.

Fear.

Insecurity follows over time, especially if the physical defects are considerable. Self doubt. Fear that the partner will seek gratification in others without disease. The result is a major blow to the libido, and it is essential that the partners communicate the fear but not obsess over the fear.

Persistent inquiry regarding faithfulness may lead to frustration and anger. On the other hand, compensation through attentiveness provides the solution. In addition there is the physical fear of pain. This must be worked through in solutions, either medication to prevent pain, taken at the right time, or adjustment of position. IN either event, communication is essential. Firstly, it is important that no blame is placed on the other partner, and that anger is avoided. Secondly, it must be made clear, that just because it is sore, does not mean that nothing should happen. Pain doesn’t mean the brain isn’t willing, a frequent mistake of the partner. It is vital that the mutual needs of the patient and partner are addressed. Communication here is everything. So often we find that the fear of pain or of hurting the patient ends the sexual relationship and this is the worst outcome.

Anger

Anger and blame are destructive. It is easy to blame the partner for his or her deficiency. Self-blame is also a problem and is a sure remedy for rejection. It is easy to react by pushing the partner away, and in that way avoid the issues.

Love

Love is really the bottom line. It is love and caring that will sustain a relationship through thick and thin. Arthritis sufferers almost always develop the disease in the years after marriage, and it is the foundations of the marriage that cements the relationship thereafter. Rheumatoid arthritis usually develops in the 30’s and 40’s. The 40’s are renowned to be the true trial years of a relationship. It is the midlife crisis times. Loyalty isn’t enough. Attention to the needs of the partners is critical. This applies even more so in the bedroom at this time.

Solutions.

What is remediable and what is not.

1. The relationship.

Love doesn’t grow on trees. It needs nurturing and growth. The partners need to grow together. This applies to all relationships. It is essential that interests are pursued. This means hobbies, pursuit of occupations, and interests. The children in the household, whilst important should not become the only focus for the couple. It is when couples don’t grow, that respect for one of the partners falls away and relationships fail. This translates into communication. The couples must want to be together at home before they can want to be together in bed. The best thing is that couples remain best friends.

2. The mood.

Having established the most optimal relationship in the home, the setting is right for a good sexual relationship. This doesn’t mean that the physical act of sex is everything. The mood must be right. A dinner, music, candles, whatever makes the partner comfortable. Turn off the television. Throw away the remote control. Have a warm bath or shower. Preferably together!

A soothing heat will usually make the physical pain more tolerable. This amplifies the mood at the same time. A bubble bath with addition of bath gel and fragrances, and a light perfume are winners. Who can resist the sensual seductive mood of a touch, and there is no harm in asking where to touch. There are countless differences between different people. Don’t zero in on the genitals. Kisses are king. Kisses mean caring and love. A light kiss may be better than anything else. Thereafter, touching in sensitive places sets the mood. Light kissing of the painful joints may lead to a confidence that the love is still there, beyond the physical!

Pain medication or anti-inflammatory taken 30-60 minutes before may assist in prevention of discomfort. With the recent release of the COXIB drugs, such as Celecoxib / Celebrex, safer ongoing anti-inflammatory therapy is now possible.

3. The Deed.

It is at this point where awareness of physical limitation become most important. It is said that there are hundreds of positions for humans to make love. Most couples never try more than four and alternate these depending on mood. Shyness prevents experimentation in even the most seasoned of couples. The taboo that the past has left on sex is a legacy of shame and sorrow. There is no shame to masturbation, oral sex or changing positions. Of course society sets its limits. But more important, the couple itself must set the boundaries. However, both parties’ needs require addressing. What is depravity to one may be the fetish of the other. Communication and understanding is required. Leeway is essential for both. And this is even greater in the arthritis sufferer and the partner. Limitation by physical factors may leave one of the partners unsatiated. The other partner must compensate. This may mean mutual masturbation or oral sex, or other. But it is critical. It is the yin and yang, equal and opposite. Satisfaction for both. So that when the act is done a quiet snuggle in each others arms with feelings of love and security make the happiness follow.

4. Positions.

The most comfortable position depends mainly on the joints involved and on individual factors. No-one can prescribe to the couple, and experimentation is the real solution.

The wrists, elbows and upper limbs:

Painful wrists make lying on the back or side more easy, as pressure with the wrists extended upwards, are a nightmare for the patient with inflammation. However making a fist and keeping the wrists neutral may be the way out if wrist pressure is applied. A light splint across the wrist made of a soft material with a Velcro support are useful. The elbows may be supported from pressure with appropriate placement of pillows.

The neck

It is always a fear in erosive rheumatoid arthritis, that neck flexion may aggravate spinal cord problems, so advice and assessment from your doctor regarding the seriousness of neck involvement is important. The few individuals with an unstable neck, at the base of the skull should avoid placing pillows behind the neck, bending the neck forward especially when having sex on their back. This is a problem seen in some rheumatoid arthritis patients. If the neck is not unstable, then such advice becomes less important.

The lower back

Low back pain is not a feature of rheumatoid, but more that of osteoarthritis. In this event, a supportive pillow placed between the shoulder blades may help for the patient lying on the back. A side-ways position is also less irritating with the knees flexed or bent up. If stiffness in the spine is a problem, a warm shower is most helpful before retiring to bed.

The hips

Arthritis of the hips is common to many types of disease, including both RA and OA and the spondyloarthropathy group of diseases. In this instance, moving the hips sideways and outwards, (a movement called abduction) may be painful, and restricted. A posterior approach with the patient bending forward, and approached from behind, or a sideways posterior approach is most comfortable.

An additional factor comes in with hip replacement surgery, where certain hip movements are to be avoided to minimize dislocation of the prosthesis. Surgeons do not like the patient to swing the leg inwards and over the other leg, (a movement known as adduction and internal rotation). They therefore suggest the missionary position as safest for the replaced hip joint. Lying on top with the body straight and the hips straight (extended) is also easier.

The knees

Pressure on the knees is to be avoided, i.e. kneeling where there is swelling locally present.
Maintaining the knees in a straight position, helps distribute the weight, i.e. leaning forward over a bed or surface for a posterior approach. A sideways, or passive position with partner on top is probably best.

Man on top: modified missionary position with legs clasped behind the man’s back	Man on top with posterior approach with cushions beneath partners elbows
Sideways position – posterior approach: Removes pressure from the lower limbs. Frees hands to stimulate the body.	Woman on top: with legs extended and avoiding hip movement and knee discomfort
Man on top with woman at edge of bed. Relieves pressure off the knees and upper limbs. Allows maximal clitoral stimulation.	Sitting position – posterior approach: Woman on top. Relieves pressure from most joints. Allows hands to stimulate body for both partners

In Summary

It remains essential to stick to general principles, with view to both getting the emotions right – by optimizing the mind, and to get the body right – by treating the disease appropriately.
Patients need to talk to each other freely and without inhibitions. They need to penetrate the barrier of silence and shyness. They need to communicate for advice. Ideally that means the partner, but also the patient should feel free to ask questions of their doctor or specialist, or even best friend.

Arthritis does not mean the end of sexual relationships, but it does require adjustment and a new focus on caring – for each other.

With very special thanks to my South African colleague, Dr. David Gotlieb, “Dr Doc”! He can be visited at www.arthritis.co.za