title: Sexual activity and counseling in the first month after acute myocardial infarction among younger adults in the United States and Spain: a prospective, observational study.
abstract: BACKGROUND
  United States and European cardiovascular society guidelines recommend physicians counsel patients about resuming sexual activity after acute myocardial infarction (AMI), but little is known about patients' experience with counseling about sexual activity after AMI.
  
  
  RESULTS
  The prospective, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, conducted at 127 hospitals in the United States and Spain, was designed, in part, to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an AMI. This study used baseline and 1-month data collected from the 2:1 sample of women (N=2349) and men (N=1152) ages 18 to 55 years with AMI. Median age was 48 years. Among those who reported discussing sexual activity with a physician in the month after AMI (12% of women, 19% of men), 68% were given restrictions: limit sex (35%), take a more passive role (26%), and/or keep the heart rate down (23%). In risk-adjusted analyses, factors associated with not discussing sexual activity with a physician included female gender (relative risk, 1.07; 95% confidence interval, 1.03-1.11), age (relative risk, 1.05 per 10 years; 95% confidence interval, 1.02-1.08), and sexual inactivity at baseline (relative risk, 1.11; 95% confidence interval, 1.08-1.15). Among patients who received counseling, women in Spain were significantly more likely to be given restrictions than U.S. women (relative risk; 1.36, 95% confidence interval, 1.11-1.66).
  
  
  CONCLUSIONS
  Very few patients reported counseling for sexual activity after AMI. Those who did were commonly given restrictions not supported by evidence or guidelines.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT00597922.
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.). slindau@uchicago.edu.
authors.forename: Stacy Tessler
authors.initials: ST
authors.lastname: Lindau
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Emily M
authors.initials: EM
authors.lastname: Abramsohn
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Héctor
authors.initials: H
authors.lastname: Bueno
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Gail
authors.initials: G
authors.lastname: D'Onofrio
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Judith H
authors.initials: JH
authors.lastname: Lichtman
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Nancy P
authors.initials: NP
authors.lastname: Lorenze
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Rupa
authors.initials: R
authors.lastname: Mehta Sanghani
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Erica S
authors.initials: ES
authors.lastname: Spatz
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Kelly
authors.initials: K
authors.lastname: Strait
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Kristen
authors.initials: K
authors.lastname: Wroblewski
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Shengfan
authors.initials: S
authors.lastname: Zhou
authors.affiliation: From the Department of Obstetrics and Gynecology, Program in Integrative Sexual Medicine (S.T.L., E.M.A.), and the Department of Medicine-Geriatrics, The MacLean Center on Clinical Medical Ethics, Chicago Core on Biomeasures in Population-Based Aging Research at the NORC Chicago Center on Demography and Economics of Aging (S.T.L.), University of Chicago, Chicago, IL; Department of Cardiology, Hospital General Universitario Gregorio Marañón, and Instituto de Investigación Gregorio Marañón, and Universidad Complutense de Madrid, Madrid, Spain (H.B.); Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT (G.D.); Yale School of Public Health, New Haven, CT (J.H.L.); Center for Outcomes Research and Evaluation, Yale University, New Haven, CT (N.P.L., E.S.S., K.S., S.Z., H.M.K.); Department of Medicine, Section of Cardiology, University of Chicago, Chicago, IL (R.M.S.); Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); Yale University/Yale-New Haven Hospital, New Haven, CT (E.S.S., K.S., H.M.K.); Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City, Kansas City, MO (J.A.S.); Department of Health Studies, University of Chicago, Chicago, IL (K.W.); Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.); and Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.).
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D003376:Counseling / Q000379:methods*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000503:physiopathology* / Q000523:psychology; D010817:Physician-Patient Relations; D011446:Prospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D012725:Sexual Behavior / Q000523:psychology*; D012735:Sexual Dysfunction, Physiological / Q000209:etiology / Q000503:physiopathology* / Q000523:psychology; D020018:Sexual Dysfunctions, Psychological / Q000209:etiology / Q000503:physiopathology* / Q000523:psychology; D013030:Spain; D014481:United States; D055815:Young Adult
keywords: acute myocardial infarction; communication; sex differences; sexual activity; sexual dysfunction, physiological; sexual dysfunction, psychological