Sharon Pelag Nesher MA, RN
Yael Menor PhD
Tanya Gurevich MD
Movement Disorders Unit and Parkinson's Service
Tel Aviv Medical Center

The development of medicine makes it possible to extend the life expectancy of patients with diseases that were previously considered unrelenting. This development brings with it a broader view of the concept of "treatment of the disease". Therefore, concern for the patient's good quality of life becomes a central goal of the treatment of a disease such as Parkinson's.

When the patient is informed of the diagnosis of Parkinson's disease, a variety of questions are asked: what to do?, how to treat?, what will be the quality of my life? And so on, practical existential questions. As time passes, more questions arise, will I still be a worthy partner? For how long?, will I still be loved?, satisfying?, productive? Therefore, in the chronic stages of the disease, at certain moments, the meaning of quality of life becomes extremely important, perhaps even (the) most important from the practical aspects.

A patient with Parkinson's disease goes through several stages during his illness - from mild signs of the disease and concern for the future that accompanies the diagnosis to the appearance of the clinical disorders that characterize the disease, but the need for warm and loving caressing and touch as part of the intimate and sexual being are proof of the quality of a person's life - healthy and blue, in all stages Parkinson's disease.

Sex and sexuality - what is the role of sex and sexuality in our lives?

Sexuality is a combination of different aspects for each person, including our awareness of our body as a source of pleasure, our perception of ourselves as women and men and as sexual beings. Sexuality is a source of warmth, touch, closeness and love, a basic need that every person wants to feel as long as he lives, regardless of his age or health condition. Human sexuality is influenced by a combination of physiological, emotional, cognitive and spiritual factors. As the research on human sexuality deepened, the dual approach, which holds that sexual dysfunction is caused on an emotional or organic basis, was replaced by the understanding that these two factors are combined Basson, 2001) 2004; (Wschiansky, . Experts in the study of sexual function claim that sex begins in the brain, among other things, because certain parts of the brain control the function of the genitals from a neural point of view and the secretion of substances that mediate sexual activity (Reep, 2007).

Sex can be for reproductive purposes or as a source of pleasure or frustration. There are situations in which low sexual desire, the absence of orgasm and rapid ejaculation will not be perceived as problematic, but there may be situations in which the function will be normal, there is an erection, the ability to experience orgasm exists, but the experience will be of dissatisfaction with sex life or insufficient function. The interpretation that can be functioned many times depends on our self-evaluation, on the spouse's reaction to the new situation and on our ability to adapt to changes. (2012, Georgiadis, Kingelbach & Pfaus).

problems with sexual function

Sexual dysfunction problems are extremely common among the healthy population. Most of the time the subject is not discussed and people usually share it with other people even if they are very close to them. A conversation about the sexual issue is intimate and very difficult for every person, for every couple. We are used to protecting him with the privacy that is sometimes at our expense. It was found that the prevalence of sexual function problems among women from the general population over the age of 18 is about 45% (2008 Shifren et al, ). The most common complaints are decreased libido, vaginal dryness, and difficulty reaching orgasm. In men aged 18-59, about 30% face problems with sexual function (Laumann et al, 1999). The most common complaints are: erectile problems and premature ejaculation. It usually takes years to start addressing the problem, mainly because of the difficulty in deciding who to involve and who to turn to.

Sexuality among Parkinson's patients

The physiological aspect.

As is known, neurological diseases in general and Parkinson's in particular may cause sexual dysfunction. Patients report that this aspect of the disease is one of the most frustrating (Anderson, 2004. A change may appear in the process of sexual stimulation, arousal, and therefore, increase or decrease sexual desire. The difficulty in sexual function due to an autonomic problem in the pelvic nerves among Parkinson's patients is still not completely clear (Reep, 2007). But what is known is that the dopaminergic system has a significant role in building libido and erection (Andersson, 2001; Montorsi, 2003. In the professional literature, there is a report of about 57 percent of men and 22 percent of women with Parkinson's disease, who compete With problems with sexual function as a result of the disease directly (damage to the pelvic muscles, decreased dopamine secretion) or indirectly: urination disorders, constipation, tremors and slowness of movement. The common difficulties with sexual function among Parkinson's patients are: erectile problems and vaginal dryness, difficulty achieving orgasm and changes in character The orgasm, premature ejaculation, decreased sexual desire, decreased sexual satisfaction (Macht, 2005). It is also known that in women, as the disease progressed, the symptoms worsened, and that age, the severity of the disease, and depression have consequences for sexual function in men and women (Jacobs, 2000; Welsh, 1997).

Emotional consequences of the disease and its treatment on sexuality

The fact that Parkinson's patients face depression and are treated for it is of great importance, since both depression and its treatment have an effect on sexual function (Basson, 2010).. A decrease in self-image, fatigue, loss of independence, and changes in the marital system also need to be taken into account when referring to sexual function Among patients with Parkinson's disease, since they have an impact no less than the neurological damage itself (Reep, 2007).

There are studies that found a decrease in sexual function only as a response to receiving the diagnosis of the disease. It was also found in the study, that the concern about changes in sexual function among Parkinson's patients were found without differences in marital status, gender, and type of residence (sheltered housing or independent residence) (Hand, 2010).

The consequences of the treatment on sexuality

The medication for Parkinson's disease has a significant effect on sexual function. Some medications may cause a decrease in desire and erection, difficulty reaching orgasm, rapid or delayed ejaculation (Giladi, 2013).

On the other hand, dopamine treatment has consequences for behavior in general and sexual behavior in particular. It is known that dopaminergic treatment can cause parasexuality. This phenomenon is rare, more common in men than women and the main source of the complaint is the partners who report great difficulties in intimacy and sex life as a result of their partner's increased sexual desire. At this point it is important to note that one must distinguish between the presexuality as a result of drug treatment and a constant search for a solution to the problems of sexual function caused by the disease itself.

Sexual counseling for Parkinson's patients.

When there is a medical problem, one usually turns to a professional expert in the field. Since Parkinson's disease causes disorders in several systems - interdisciplinary treatment is an effective and accepted treatment in the modern era. An interdisciplinary team that treats Parkinson's disease includes several professions, including sexology - dealing with changes in sexual function.

We are aware of the fact that a referral to a clinic that deals in the sexual field may cause some discomfort among patients and caregivers. Still not all the therapeutic staff show openness in the discourse on the sexual issue, this is a clear and understandable feeling, but it is not legitimate. A medical team is supposed to respond to all aspects of the patient's life, therefore, today, with the development of the field, the awareness of the need for sexual counseling is increasing, and in fact counseling at a sexual counseling clinic is an integral part of interdisciplinary treatment for Parkinson's disease.

In light of the understanding and recognition of the need, and based on the findings of studies that indicate that there is a clear preference to receive the sexual counseling service from the staff that treats the disease itself, today a sexual counseling service is provided to Parkinson's patients within the framework of dedicated clinics that treat Parkinson's disease and parkinsonism. Counseling at the sexual function clinic is intended for women and men, Parkinson's patients and their spouses.

What does the consultation include?

The consultation includes an assessment conversation with an expert in the sexual field who deals with sexual counseling for people with chronic diseases and their partners.

The consultation may include a functional assessment in the present compared to the past, providing information on the causes of the difficulties you are facing, specific suggestions according to the difficulties and, if necessary, the integration of additional professionals.

You may well find that a short intervention is enough since in the past you functioned, loved, provided and provided. A little assistance can get you back to functioning just as satisfactorily today. It is true that sometimes you will need to adapt to other positions, say goodbye to spontaneity, use lubricants that will facilitate penetration, as well as try medication that will help with erectile problems. However, this does not require that intimacy be harmed.

In conclusion, sexuality is a source of warmth, touch, closeness and love, a basic need that every person wants to feel as long as he lives regardless of his age or health condition. Sometimes the patients tend to pay too heavy a price for dealing with the disease and its treatment because of barriers in raising the sexual issue with the treating staff. Today there are intervention methods that include strengthening the relationship and intimacy alongside medicinal solutions. The sooner you address the issue, the less likely it is that precipitation, frustration and the feeling of helplessness will develop.

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