INVITED CLINICAL COMMENTARY Sexual wellbeing for people with chronic obstructive pulmonary disease: relevance and roles for physiotherapy William MM Levack PhD MHealSc(Rehabilitation) BPthy
Associate Dean Research & Postgraduate Studies; Senior Lecturer in Rehabilitation

Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago Wellington, New Zealand
Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of disability worldwide. The purpose of this article is to provide an overview of current knowledge on sexual wellbeing in people with COPD, with particular attention to the possible role of physiotherapy in helping address problems with sexuality resulting from the condition. People with COPD experience more sexual problems on average than the general population, with these issues arising from hormonal, physiological, psychological, sociological and pharmaceutical factors. Physiotherapists can provide specialist support for people with COPD regarding their sex lives through the provision of exercise therapy, advice on positioning to maximise breathing efficacy and minimise energy expenditure during sexual activity and via patient education on chronic condition management. The PLISSIT model provides a robust framework for helping physiotherapists clarify their scope of practice when engaging with people who have COPD on matters to do with sexuality. Regardless of age or severity of symptoms, people with COPD are capable of leading full and satisfying sex lives should they wish to do so. Physiotherapists can contribute information and solutions to support them in this endeavour.
Levack WMM (2014) Sexual wellbeing for people with chronic obstructive pulmonary disease: relevance and roles for physiotherapy New Zealand Journal of Physiotherapy 42(2): 170-176. Key words: Pulmonary disease, Chronic obstructive; Sexuality; Sexual dysfunction; Dyspnoea; Exercise people (Collins et al 2012, Fletcher and Martin 1982, Kahraman et al 2013, Kaptein et al 2008, Karadag et al 2007, Köseo˘glu et al Sex is an important part of life, self-identity and general 2005, Schönhofer et al 2001, Schouten et al 2007) but as noted wellbeing for the majority of people. It is well established above there appears to be very little experimental research into that many adults maintain sexually active lives well into their strategies to help people with COPD deal with issues related to their older years (Lindau et al 2007, Matthias et al 1997, Nicolosi et sexual wellbeing. al 2004). While sexual activity and sexual interest do tend to decline with age, even very elderly people can enjoy sex and The purpose of this paper, therefore, is to provide an overview include it as part of their intimate relationships. One relatively of current knowledge on sexual dysfunction and sexual health recent US study found that 38.5% of men and 16.7% of in people with COPD, with particular attention to the possible women in the 75-85 year old age group had participated in role of physiotherapy in helping people with COPD maintain or sexual activity with a partner in the previous year, with 54% of regain an active and enjoyable sex life should they choose to those who were sexually active engaging in sexual activity more do so. It is argued within this paper that physiotherapy has the than two or three times a month (Lindau et al 2007). potential to make a unique contribution to this area of clinical practice because of expertise in chronic condition management, At all ages, however, sexual activity and sexual satisfaction is exercise conditioning and use of positioning to enhance the negatively influenced by poorer health status (Lindau et al 2007, efficiency of breathing in people with COPD.
Matthias et al 1997). This has been the subject of a body of research, guidelines and systematic reviews for a number of Definitions and assumptions
conditions including cardiovascular disease (eg Steinke et al 2013), Sexual activity should be considered a broad term referring to a diabetes (eg Pontiroli et al 2013, Vardi and Nini 2007), and cancer wide range of personal interactions and behaviours including, (eg Miles et al 2007). Arguably less research or clinical guidelines but not limited to, sexual intercourse. For the purposes of have been published on the topic of sexual health for people this paper, a modified version of a definition promoted by with chronic obstructive pulmonary disease (COPD). In preparing Lindau et al (2007) will be used: specifically, the term ‘sexual this paper, only one randomised controlled trial (Svartberg et al activity' (to be considered synonymous with ‘sex') will be 2004) and no systematic reviews were identified on the topic of used to refer to ‘any mutually voluntary activity with another management of sexual dysfunction for people with COPD. This person that involves sexual contact, whether or not intercourse is significant because, according the World Health Organizations' or orgasm occurs or any solitary sexual self-stimulation for Global Burden of Disease study, COPD is currently the 5th ranked pleasure'. Neutral terminology has been used throughout cause of years with disability worldwide (Vos et al 2013) – a more this paper regarding sexual orientation, except in situations significant contributor to years with disability in fact than ischaemic describing research studies that specified the gender of people heart disease (ranked 21st), diabetes (ranked 9th) or all cancers in relationships under investigation. Specific issues relating (ranked below 25th). Furthermore, there is growing evidence that to transgender people, however, are outside the scope of this COPD is frequently associated with sexual dysfunction for many paper due to restrictions on article length.
Prevalence of sexual dysfunction in people with COPD:
with self-esteem influencing sexual activity or problems with The majority of empirical research on sex and COPD to date general sexual satisfaction (Kaptein et al 2008). However, given has focused on the prevalence of sexual dysfunction in COPD the very small sample size, it is highly questionable whether this populations. Sexual dysfunction can include problems with erectile study was sufficiently powered to detect such differences if they dysfunction or premature ejaculation in men; difficulties with vaginal lubrication for women; or lack of interest in sex, inability to achieve One additional study has investigated sex behaviour and sexual orgasm, pain during sex, anxiety about performance or sex not functioning in 383 men and women who used noninvasive being pleasurable for either men or women. mechanical ventilation in the home. This study combined In men with COPD, erectile dysfunction (i.e. difficulty getting findings from people with COPD (45% of the total study or maintaining an erection) has been identified as one of the population; 173/383) with those who had chronic respiratory most common problems with sexual performance. Estimates failure due to other causes (Schönhofer et al 2001). Thirty-four of prevalence of erectile dysfunction in men with moderate to percent of these respondents reported being sexually active very severe COPD have ranged from 72% to 87% (Collins et al and 61% were not (5% did not answer this question). Sexually 2012, Kahraman et al 2013, Karadag et al 2007, Köseo˘glu et active people were more likely have better lung function (higher al 2005). This can be compared to a prevalence of 9-22% for vital capacity, better force vital capacity, and higher partial erectile dysfunction that has been reported in the 50-70 year pressure of oxygen in arterial blood at rest), were more likely old age group in a large, international, population-based study to be married or have a partner and were more often younger. of sexual dysfunction (Laumann et al 2004, Nicolosi et al 2004). However, no statistically significant differences were noted Some of these differences in reported prevalence could be between men and women in this study; both groups were explained by differences in the categorisation and measurement equally likely to be sexually active at all ages. of erectile dysfunction. However, studies which have compared Notably, in this study, while older people were less likely to be men with COPD against age-matched controls (using the sexually active, 20% of those over 70 years on noninvasive same measurement tool for both) have also found significant mechanical ventilation still reported continuing to have an differences in prevalence between these groups. Kahraman active sex life (Schönhofer et al 2001). Furthermore, while et al (2013) found varying degrees of erectile dysfunction in 36% of respondents reported a decrease in their sexual activity 79% of 70 men with COPD in comparison to 56% of 68 age- after initiating home-based mechanical ventilation, 12.6% matched controls, with men who had COPD generally reporting of respondents reported their sexual activity had increased as more severe problems. Similarly, comparing 95 men with stable a result of the introduction of ventilatory support. In other moderate-to-severe COPD to 30 age-matched controls, Karadag words, it is a mistake to assume age or severity of respiratory et al (2007) found 21% of those with COPD to have ‘severe' impairment necessarily limits people's capacity or enthusiasm for erectile dysfunction and 36% to have ‘moderate' erectile sexual activity.
dysfunction versus 10% of the controls for both ‘severe' and ‘moderate' erectile dysfunction. Furthermore, in a population- Returning to the subject of gender differences, it has been based study of erectile dysfunction in the Netherlands involving suggested that COPD presents less of a problem for female 975 men aged 50-75, COPD was found to be one of five sexuality than male sexuality. One view is that male sexual independent determinants for risk of erectile dysfunction activity is generally more dependent on health status than (Schouten et al 2007).
female sexual activity, and that for women, ‘the existence of a sexually interested partner and a pleasurable sexual In comparison to age matched norms, significantly more men biography are even more important' (Schönhofer et al 2001, with COPD have also been found to report reduced sexual p.1612). Another view has been that male sexuality is more desire and lower frequency of sexual intimacy; with their vulnerable to dyspnoea and loss of self-esteem resulting from sexuality more often negatively influenced by low self-esteem impaired physical performance (Pietropinto and Arora 1989). and with an overall lower sense of satisfaction with their sex However, it is important to note that all of these viewpoints and lives (Kaptein et al 2008). Collins et al (2012), in a study of 90 perspectives have arisen from expert opinion and anecdote; men with stable moderate-to-severe COPD, found 74% had at detailed studies on the effect of COPD on women's sexuality least one sexual problem. In additional to erectile dysfunction, have yet to be conducted. many of these men also reported lack of sexual interest (37%), inability to achieve orgasm (42%), and difficulty with finding Causes of sexual dysfunction in people with COPD:
sex pleasurable (28%). Furthermore, these issues were most The interaction of variables contributing to sexual dysfunction in often described as ‘very much of a problem' or ‘somewhat of a people with COPD is complex, but broadly speaking problems problem' for these men (Collins et al, 2012).
can arise from a combination of hormonal, physiological, psychological, sociological and pharmaceutical factors. In comparison, sexual dysfunction in women with COPD has yet to be investigated in depth. One exception has been a Hormonal factors study of sexual dysfunction in people with COPD or asthma, With respect to hormonal issues, it has been established that in which ten women with COPD provided information on men with COPD have lower total testosterone levels than men their experiences and feelings regarding sexuality and intimate without COPD. A recent systematic review involving a meta- relationships (Kaptein et al 2008). This study found that, analysis of data from nine case control studies found that men when compared to age-matched controls, women with COPD with COPD have on average 3.21 nmol/L (95% CI 1.23 to 5.18 reported a significantly lower frequency of sexual intimacy, but nmol/L) less total testosterone than age-matched men without no significant differences were reported for other aspect of COPD (Atlantis et al 2013). Testosterone contributes to muscle sexuality, eg physical problems reducing sexual desire, problems mass and the body's response to exercise, but is also directly NEW ZEALAND JOURNAL OF PHYSIOTHERAPY 171
associated with sexual functioning in men. In Collin et al's the position and mechanical efficiency of the diaphragm, the (2012) observational study, adults with COPD who had low free availability and mechanical efficacy of accessory muscles for serum testosterone levels were over three times more likely to breathing, the synchronicity of thoracic and diaphragmatic have erectile dysfunction than adults with COPD who did not movements, the energy (and therefore oxygen) required to have low testosterone levels.
maintain the position, and, particularly significantly, ventilation/perfusion matching (Cavalcanti et al 2014, Dean 1985, Heijdra et al 1994, Jones et al 2003). Ventilation/perfusion matching COPD is also of course associated with reduced exercise capacity refers to the efficiency and adequacy of air in the alveoli secondary to hypoxaemia, dyspnoea and general physical (ventilation) reaching lung tissue that is sufficiently serviced deconditioning. This too can be a reason for problems with by blood from the pulmonary artery (perfusion). Of note, sexual functioning (Karadag et al 2007, Schönhofer et al 2001, the physiological response of individual people with COPD to Steinke 2013). If a person is becomes too breathless or fatigued changes in body position can be very idiosyncratic; influenced during sexual activity, or finds his or her limited exercise capacity by factors such as degree of hyperinflation, asymmetry in worrying, embarrassing or disempowering, then difficulties both lung tissue damage, the presence of sputum in the airways, with sexual arousal and sexual performance can result. Sexual distribution of body mass and state of arousal or relaxation. intercourse is often compared to an exercise workload of 3-4 metabolic equivalents (METS) (Collins et al 2012, Steinke et al As an illustration of this point, the only observational study to 2013). One MET is defined as the amount of oxygen consumed date on the effect of sexual activity on gas exchange in the while sitting at rest: specifically 3.5 ml of oxygen per kg of body context of COPD (albeit based on a single case study) reported weight per minute of activity (Jette et al 1990), with 3-4 METS the unexpected finding that, rather than dropping, oxygen being equivalent to walking on a treadmill at 5-7 kph (i.e. a saturation rose during sex, peaking during the 10 minute period brisk walk). For this reason, in people with heart disease (where after intercourse (Polverino et al 2008). The ‘case' in this study concerns can exist regarding the likelihood of sexual activity was a 63 year old man with severe but stable COPD, engaging causing a myocardial infarct) individuals are usually advised in sex in ‘comfortable' positions. The authors of the study that if they can achieve an energy expenditure of ≥ 3-5 METS speculated that oxygen saturation may have risen during sex for on formal exercise testing without exhibiting symptoms of this man because the positions used (in this case, standing or in ischaemia, then it should be very safe for them to resume their the ‘woman-on-top' position) resulted in improved ventilation/ normal sexual activity (Steinke et al 2013).
perfusion matching in comparison to breathing at rest, without significant additional energy expenditure for muscle activity. One of the original studies that is often cited to justify this figure However, as noted above, cardiorespiratory responses to body of 3-4 MET is an observational study involving ten healthy, position can differ for individual people with COPD, which married couples, aged 25-43, in which heart rate and oxygen means that sex positions that work for one couple may not consumption were measured during sexual intercourse (Bohlen be suitable for another. Individual assessment of physiological et al 1984). In fact, in this study, physiological responses were response to different body positions may be warranted.
recorded only for the male partner, and the figure of 3-4 METs was only achieved during the penetration and orgasm stages Psychological and sociological factors of sex if using the ‘man-on-top' position for intercourse. Other In addition to physiological consequences of lung disease, COPD types of sexual activities, however, were associated with lower is also associated with psychological and sociological responses maximum energy expenditure: an average of 1.4 METs (95% which can negatively influence sexual interest, arousal and CI 1.2 to 1.6 METs) during foreplay; 1.7 METs (95% CI 1.3 to behaviour. Collins et al (2012), for instance, suggested that 2.1 METs) during orgasm when the woman was stimulating the physical limitations arising from COPD may make men take a man without intercourse; 1.8 METs (95% CI 1.5 to 2.1 METs) much more passive approach to sexuality or to avoid sexual during orgasm when the man was stimulating himself without activity altogether. They also reported that, despite continuing intercourse, and 2.5 METs (95% CI 1.8 to 3.1 METs) when to desire an active sex life, the most commonly perceived having intercourse in the ‘woman-on-top' position (Bohlen et al reasons for decreased sexual activity among the 90 men with 1984) 1. The figure of 3-4 METs therefore is conservatively high, COPD in their study was the participants' belief that they were appropriate to use perhaps when advising people about risk of ‘too old' or ‘too sick'. For both men and women, symptoms myocardial infarct, during sex, but potentially misrepresentative of COPD such as breathlessness, coughing and sputum can of the level of exercise capacity that is necessarily required for contribute to feeling unattractive and to loss of self-esteem, an enjoyable sexual encounter. For this reason, de Araújo (2009) which can affect both attitudes towards sex and physical has suggested that instead of using the analogue of a ‘brisk responses during it (Steinke 2013). Fear and anxiety about walk', sexual activity could be more usefully compared to ‘a dyspnoea can result in stress associated with sexual activity, relaxed walk for a few blocks, interspaced by ascending one or reducing enjoyment and willingness to participate in it (Steinke two flights of stairs at moderate and, most importantly, at a very 2013). Mood disorders such as depression, which are known much individual pace' (p.1034).
to be significantly more of a problem for people with COPD than the general population (Di Marco et al 2006, Schneider Along with exercise deconditioning, people with COPD are et al 2010), can also negative impact on sexual desire and also more vulnerable to changes in oxygenation as a result of changes in body position. In COPD, the position of the body (eg supine lying, prone lying, sitting or standing) can influence Furthermore, changes in a person's physical body and sexual performance often require couples to develop a renewed 1 Average METs and 95% CI were calculated from the means and standard understanding of their sexual roles and relationship. This deviations for oxygen consumption (VO ) for sexual activity reported in Bohlen et al requires open, honest and caring communication. If either (1984), using the conversion value of 1 MET to 3.5mL/min/kg VO .
or both partners within a couple are unable or unwilling to discussing sexual matters with the type and extent of involvement in discuss such matters, sexual wellbeing can suffer. In one unique interventions for addressing sexual health needs. study of COPD and intimate relationships, Ibáñez et al (2001) Within this model, ‘permission' refers simply to letting patients interviewed 49 men with severe COPD and their partners (all and their partners be aware that it is perfectly acceptable and female) separately but concurrently. Sixty-seven percent of the appropriate to raise questions or express concerns regarding men reported some type of sexual dysfunction, mostly involving issues to do with sexuality. This can be done overtly or less-than-preferred sexual desire or erectile dysfunction; while covertly. Indirect methods for giving permission might include 94% of their female partners reported noticing changes in the having information brochures on sexual health and COPD men's sexual behaviour. Thirty-three percent of the women visible and accessible in waiting rooms or clinic areas. Direct also reported that they had noticed negative changes in their methods might include validating sexuality as a legitimate partners' communication levels since the onset of COPD and/ topic for discussion if it should arise during clinical interaction, or home oxygen use, with the women who reported such or by specifically inviting people to raise it for discussion. For communication problems being significantly more likely to be example, if a patient were to make a half-joking reference dissatisfied in their partners in general than those who did not. to ‘problems in the bedroom' when discussing respiratory Of note, fear of causing an exacerbation in their husband's symptoms, the physiotherapist could respond by saying: ‘yes, condition appeared to have resulted in over a third of the sexual function is something that can be affected by COPD, and women reducing their willingness to engage in sexual activity in this might be something you would like to discuss further with this study population. me or your general practitioner (GP)'. Giving a person permission to raise issues to do with sexual Outside the scope of physiotherapy, but still important to know function does not mean that physiotherapists are then required about, is the influence of pharmaceuticals on sexual functioning. to address those issues in full by themselves. If the subsequent A number of drugs can contribute to sexual dysfunction in both issues raised are more specific than the physiotherapist is able men and women. Medications commonly known to reduce to deal with, a suitable response would be to say: ‘Yes, that is a sexual desire or sexual performance include diuretics and beta- valid concern. However, what you are discussing is outside of my blockers for high blood pressure; anti-depressant, anti-anxiety, particular training. Would you like me to raise this in a referral and anti-psychotic medication for mental health conditions; letter to your GP or respiratory consultant?' The potential benefit anti-epileptic drugs; steroidal medications such as prednisone; of simply normalising sexuality as a valid topic for discussion in and some medications for Parkinson's disease and cancer the health context should not be underestimated.
treatments (Collins et al 2012, Conaglen and Conaglen 2013, Schouten et al 2007). As COPD is frequently associated with ‘Limited information' is the next level of engagement with co-morbidities, the possibility that people with COPD may be on patients on matters to do with sexuality. It involves giving general medications such as these needs to be taken into consideration.
information about sexuality and sexual function, tailoring this Incorporating sexual wellbeing in physiotherapy for COPD
information to specific health conditions where appropriate. This includes, for instance, providing education on sexuality to groups Even when physiotherapists agree that sexual function is an of people as part of a pulmonary rehabilitation programme or important area of health and wellbeing, making decisions about providing general information to individuals in a clinical session, how to include it (if at all) as a subject for clinical intervention or drawing on standard information brochures or letting people patient education can be difficult. Like all health professionals, know about other clinical or information services relevant to physiotherapists can feel poorly equipped to address sexuality in sexuality that are available to them.
clinical practice, can have concerns about making their clients uncomfortable or feel uncertain about the ethical implications Providing limited information stops short of discussing individual associated with broaching the topic of sex in the clinic or hospital.
people's actual sex life and instead couches sex interventions within the context of general information that has been helpful One useful framework for guiding health professionals when for many people in similar kinds of situations. Within the context integrating interventions for sexual wellbeing into regular practice of an interprofessional team it is usually ideal that all team is the PLISSIT model. Originally proposed as a guide for sex members are sufficiently comfortable with the topic of sexual therapists in the 1970's (Annon 1976), the PLISSIT model has health, and with their own sexuality, to work with any patients subsequently been applied in a range of different health contexts at the ‘permission' and ‘limited information' level of the PLISSIT (Jaarsma et al 2010, Marsden and Botell 2010, McBride and model (Sipski and Alexander 1997).
Rines 1999, McLeod and Hamilton 2012). It has been promoted as a model appropriate for interprofessional teams (Dunn 1997), At the ‘specific suggestion' stage of the PLISSIT model, and already been used in at least one New Zealand rehabilitation assessment of issues and provision of interventions occurs at service for this purpose (Simpson et al 2006).
the individual patient level. In terms of physiotherapy, this might including making recommendations regarding positioning PLISSIT is a mnemonic which stands for permission (P), limited to minimise dyspnoea and maximise body movements with information (LI), specific suggestions (SS), and intensive therapy minimum energy expenditure during sex. It might also involve (IT). These four terms relate to four levels of engagement that a advice regarding management of home oxygen and ventilators health professional can take with any client when considering the to support sexual activity. Generally speaking, this level topic of sexual functioning and wellbeing. They also correspond of engagement with patients and their partners is likely to to increasing levels of intimacy when discussing sexuality in the require some degree of postgraduate training and should be clinical setting and so can be used to align a health professional's accompanied by close professional supervision.
level of training, scope of practice and degree of comfort in NEW ZEALAND JOURNAL OF PHYSIOTHERAPY 173
The ‘intensive therapy' level of the PLISSIT model refers to chest, or prolonged activities involving the mouth (eg prolonged the type of professional input that is usually only provided by kissing or giving oral sex). Figure 1 provides examples of some trained relationship counsellors, sex therapists, or physicians. It sexual positions that have been reported to be effective for might include ‘psychotherapy; intensive or prolonged marital people with COPD (Polverino et al 2008, Stitik and Benevento relationship counselling; counselling and therapy for battering, sexual abuse, or rape; surgical or invasive procedures… or People with COPD and their partners can be encouraged to medical management of infertility; childbirth; hormonal make use of aids to reduce the physical demand of sexual imbalances; or severe behavioural or psychiatric problems' (Dunn activity. This includes making use of sex toys such as vibrators 1997, p. 398). As such, this level of engagement with patients (which can be privately purchased online) as well as medical and their partners is useful to know about, but is generally devices to reduce the work of breathing. If using supplementary outside the scope of practice of physiotherapists, except for a oxygen or ventilators at home, people with COPD should be few specific topics within specialist areas (eg perhaps within encourage to use these during sex too, adjusting ventilators women's health physiotherapy).
settings to compensate for increased breath frequency and tidal Interventions for sexual dysfunction for people with COPD:
volumes within comfortable limits (Schönhofer et al 2001). For the purpose of this paper, interventions for sexual Outside the scope of physiotherapy are medical interventions to dysfunction can be divided into those that can be provided compensate for sexual dysfunction. These include, for instance, by physiotherapists and those which need input from other the use of phosphodiesterase inhibitors (eg Sildenafil citrate; specialist health professionals. In terms of physiotherapy, sold as Viagra), hormonal therapy in the case of hypogonadism interventions for improving sexual satisfaction for people with (Svartberg et al 2004), or vacuum pumps and penile implants COPD might include: to treat erectile dysfunction (Hackett et al 2008). Psychosexual Advice on cardiorespiratory training to improve general counselling, relationship counselling and cognitive behaviour exercise capacity (with exercise also potentially resulting in therapy interventions may also be helpful for dealing with improved mood and self-esteem); psychological and social issues related to sexual functioning (Steinke 2013), although access to these type of therapies may Training of people with COPD in sputum clearance techniques be restricted by cost. While not directly involved in the provision (eg postural drainage and active cycle of breathing), with of these interventions, physiotherapists can play a role in raising advice to use these techniques prior to engaging in sexual the possibility of them to people with COPD.
activity so as to minimise coughing and maximise lung capacity during sex; Advice regarding use of bronchodilators, where these have A pleasurable and satisfying sex life is important to many people been prescribed, prior to engaging in sexual activity; with COPD regardless of age or severity of impairments. Factors Advice regarding fatigue management, including preparing contributing to problems with sexual functioning are complex for sexual activity through use of relaxation techniques and by and interrelated, but in the presence of COPD sexuality can picking times when feeling well rested; be affected by hormonal dysfunction, exercise deconditioning, exertional dyspnoea, the psychological and sociological Assessment and training of people with COPD in the use consequences of having a chronic condition and by the side- of positioning to maximise ventilation/perfusion matching, effects of common medications. Physiotherapy has a role to maximise capacity for movement with minimum energy play in the management of problems with sexual function in expenditure and minimum dyspnoea during sexual activity; COPD, providing guidance in the restoration of exercise capacity, Encouraging people with COPD and their partners to talk to the use of positioning to maximise efficiency of breathing and one another about their changing bodies, what they find easy movement and in the everyday management of respiratory or difficult to do, what they still find pleasurable and enjoyable and to explore new ways of physically interacting with one another for pleasure; KEY POINTS
Reminding people the full range of sexual activities that are • A pleasurable and satisfying sex life is important to open to them, reinforcing the notion that sexual activity is not many people with COPD regardless of age or severity of just limited to intercourse, but can involve other activities too, such as kissing, cuddling and touching (activities which are not • COPD can have a negative influence on sexuality due only enjoyable in themselves, but which can also be a good to hormonal, physiological, psychological and social way of building up tolerance for other activities in the future).
consequences of the disease. In terms of positioning for sexual intercourse, there are a • Physiotherapy can play an important role in helping people number of factors likely to contribute to increased dyspnoea with COPD and their partners deal with issues to do with for people with COPD and so should be avoided, particularly if respiratory symptoms are severe. These include lying completely • The PLISSIT model provides a framework to help flat in supine, being in a position that requires high levels of physiotherapists decide what level of involvement they energy expenditure to maintain (eg sustaining a prone lying should have regarding interventions for improving a person's position, propped up on arms, such as when lying on top of sexual wellbeing.
one's partner), having a weight (eg one's partner) on one's 174 NEW ZEALAND JOURNAL OF PHYSIOTHERAPY

Figure 1: Sex positions for people with COPD and their partners
Figures 1a-1d provide examples of sex positions reported to be effective for people with COPD. While only one of the partners in these illustrations is presented as having COPD, these positions are suitable if either partner has COPD. People with COPD should be encouraged to make use of pillows during sex for comfort, to elevate parts of the body and to support limbs.
Figure 1a: Side lying
Figure 1b: Recline lying
Figure 1c: Standing
Figure 1d: Seated
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Geophysical Journal International Geophys. J. Int. (2002) 148, 256–277 Morphological dating of cumulative reverse fault scarps: examplesfrom the Gurvan Bogd fault system, Mongolia S. Carretier,1,∗ J-F Ritz,1 J. Jackson2 and A. Bayasgalan21Laboratoire de G´eophysique Tectonique et S´edimentologie, CNRS-UMR, Universit´e Montpellier II, 4, Place Eug ene Bataillon, 34000 Montpellier, France.E-mail: scarret@dstu.univ-montp2.fr2Bullard Laboratories, Madingley Road, Cambridge, CB3 OEZ England

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Journal of Pharmacognosy and Phytochemistry 2013; 2 (3): 55-60 ISSN 2278-4136 Natural Bioenhancers: An overview ISSN 2349-8234 JPP 2013; 2 (3): 55-60 Deepthi V. Tatiraju,* Varsha B. Bagade, Priya J. Karambelkar, Varsha M. Jadhav, © 2013 AkiNik Publications Vilasrao Kadam Received: 19-7-2013 Accepted: 09-8-2013

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