What is sexual health? One definition includes the phrase “a capacity to enjoy and control sexual behavior without fear, shame or guilt” (Mosby’s Medical Dictionary 2009). The World Health Organization (WHO) defines the term in part as “a state of physical, mental and social well-being in relation to sexuality” (WHO 2011). Sexual dysfunction is broadly defined as “disorders that interfere with a full sexual response cycle. These disorders make it difficult for a person to enjoy or to have sexual intercourse” (Gale Encyclopedia of Medicine 2008).
Many people accept as common knowledge that sexual activity itself is exercise, but is there an established link between exercise and sexual health or sexual functioning? Is it possible to increase one’s sexual health through standard exercise protocols? Assuming the holistic (whole, complete-system) nature of the body, also known as the mind-body-spirit connection, it is logical to presume a relationship. The following research roundup offers evidence the fitness professional can use when working with clients.
Positive Associations for Healthy Populations
Exercise may increase sexual drive, functioning, activity and satisfaction (Stanten & Yeager 2003), in part because of improvements in physical endurance, muscle tone and body composition (Krucoff & Krucoff 2000). According to Stanten and Yeager (2003), exercise activates the sympathetic nervous system, which encourages blood flow to the genital region. In addition, Stanten and Yeager discovered that even low levels of physical activity tend to elevate mood and help keep sex organs and muscles in better working condition. The authors further reported that women became more sexually responsive following 20 minutes of vigorous exercise. Krucoff & Krucoff 2000 found that men had higher testosterone levels after short, intense bouts of exercise.
Age does not appear to be a determining factor in sexual functioning. In a study of college undergraduates, Frauman (1982) found that subjects who spent more time in physical activity reported a higher frequency of sexual behavior as well as a higher frequency of desire. A Harvard study of 160 female and male swimmers in their 40s and 60s showed similar results—a positive relationship between regular exercise and sexual enjoyment (Krucoff & Krucoff 2000). Similarly, Bortz and Wallace (1999) reported a correlation between physical fitness and a high level of sexual activity and satisfaction in older men and women. In a study of college-age students, Penhollow and Young (2004) found strong correlations among fitness levels, self-perception, body image, social meaning, outward appearance and sexual performance and desire.
In an intriguing comparison of exercise and sexual activity, Palmeri et al. (2007) looked at heart rate (HR) and blood pressure (BP) in adult men and women during the two activities, using a treadmill as the exercise mode. One rather unsurprising discovery was that participants spent more time in sexual activity than they did on the treadmill. It turned out that treadmill exercise duration predicted sexual activity duration (a 2.3-minute increase in sexual activity duration for each 1 minute of treadmill time), with age inversely correlated to treadmill and sexual activity duration (the older the person, the less time spent in either activity). For both genders, it turned out that HR and BP were higher during treadmill exercise than during sexual activity. In other words, sexual activity provided modest physical stress compared with treadmill exercise.
In a 2008 study that looked at the roles of testosterone and alpha-amylase (a marker of sympathetic nervous system activity) in exercise-induced sexual arousal in women, Hamilton, Rellini and Meston found a significant correlation between sexual arousal and exercise. Using saliva samples, the researchers measured an increase in alpha-amylase in women who exercised, but not in the no-exercise control group. Interestingly, there were no differences in testosterone levels between the exercise and no-exercise groups.
A study of over 4,000 women in Sweden (Stadberg, Mattisson & Milsom 2000) showed that those who had a higher level of education, pursued spare-time activities and exercised regularly were more often free of climacteric symptoms (endocrine, somatic and psychological changes that can occur at menopause). In a similar study of over 5,500 Finnish women in their 40s and 50s (Ojanlatva et al. 2006), statistically significant positive associations were observed between strenuous exercise and orgasm experiences, but only for women in their 40s, not for those in their 50s.
On the other side of the globe, in Australia, researchers looked at the relationship between exercise, body mass index (BMI) and menopausal symptoms to see if the first two had an effect on the latter (Mirzaiinjmabadi, Anderson & Barnes 2006). The findings should be welcome news to women wishing to relieve symptoms of menopause using nonpharmacological interventions, as exercise was shown to be an effective intervention for both somatic and psychological symptoms.
At the 2010 meeting of the Urological Association, Erin McNamara, MD, of Duke University Medical Center in Durham, North Carolina, presented preliminary findings that showed a correlation between exercise and sexual functioning in healthy men. “Men who were moderately active—walking briskly just 30 minutes a day, 4 days a week, or the equivalent—were about two-thirds less likely to have sexual dysfunction than their sedentary counterparts,” stated McNamara. On a 100-point sexual function scale, men who were sedentary scored 43 points; moderately active men scored 72; highly active men scored 70; and the average score was 53 points. Further studies can verify or disprove a cause-and-effect relationship, but for now McNamara muses, “If men won’t exercise for their cardiovascular health, maybe they will for their sexual function.”
McNamara plans to conduct further research on the topic, especially as a way to help patients after prostate cancer surgery. “What we have right now is pharmacotherapy. It would be nice to do something that’s more holistic.”
Her findings parallel those of Holden et al. (2010). In summing up their own research they concluded, “The present observational study suggests that maintaining general health with beneficial lifestyle behaviours . . . such as physical activity may confer benefits for reproductive health of middle-aged and older men, a concept that warrants further direct study.” Holden et al. emphasized that men’s reproductive health should not be considered in isolation from their general health, which would definitely include exercise.
Sexual Dysfunction and Medical Issues
Until recently, most research into the effects of exercise on people with diabetes looked at glycemic control rather than sexual dysfunction. In 2010, Adeniyi, Adeleye and Adeniyi published a 20-year research review aimed at determining whether therapeutic exercise was a viable intervention for addressing sexual dysfunction in people with diabetes. On the basis of the review, the authors did find some effectiveness. Although the research was fairly scanty, pelvic-floor exercises in particular were shown to help with sexual dysfunction in both diabetic and nondiabetic populations.
At about the same time, researchers in Italy turned up a protective role for exercise when assessing determinants of female sexual dysfunction in type 2 diabetes (Esposito et al. 2010). The researchers recommended that sexual function be routinely evaluated in women with type 2 diabetes.
In the Look AHEAD trial (Action for Health in Diabetes), Rosen et al. (2009) studied the correlates and prevalence of erectile dysfunction (ED) in overweight men with type 2 diabetes. There were 373 men, aged 45–75, of whom 263 were sexually active at the time of the study. The numbers were fairly alarming: 49.8% reported mild to moderate ED, and another 24.8% had complete ED. Of the 263 sexually active men, 42.6% had sought medical help and 39.7% were using ED medications. In line with all the other research done on exercise and diabetes, cardiorespiratory fitness was found to be protective. With nearly 75% of the men experiencing some level of ED, it is highly likely that any fitness professional working with overweight men with type 2 diabetes will—either overtly or otherwise—be addressing the concomitant ED through exercise protocols.
In a 12-month program of supervised pelvic-floor muscle training (PFMT), Zahariou, Karamouti & Papaioannou (2008) assessed the training’s impact on women with stress urinary incontinence (SUI). In results that will probably come as no surprise to the many women who suffer from SUI, the frequency and degree of incontinence decreased after the training. Additionally, the 70 women who finished the full 12 months reported (via the Female Sexual Function Index) that their sexual functioning had improved. Again, PFMT appears to be an excellent exercise choice.
In a related study that looked at restoring pelvic-floor function in men (Dorey 2005), strengthening the pelvic-floor muscles considerably decreased the incidences of urinary and fecal incontinence and improved erectile function. With these results in mind, fitness professionals would be well advised to offer PFMT for men as well as for women.
Postpartum Sexual Functioning
It is probably obvious by now that PFMT is important exercise for sexual health. Furthering this idea are the beneficial effects of PFMT on primiparous (giving birth only once) women who have vaginal deliveries. After PFMT training, index scores rose for all measured elements of sexual functioning (e.g., desire, satisfaction), while pain scores decreased (Citak et al. 2010).
With the prevalence and increased awareness of breast cancer, it makes sense to consider whether breast cancer survivors can improve their quality of life by participating in physical activity. In a prospective analysis that investigated physical activity, occurrence of physical cancer symptoms and health-related quality of life (HRQOL), Alfano et al. (2007) found that physical activity was consistently related to “better physical functioning and to reduced fatigue and bodily pain, underscoring the need for physical activity promotion among survivors.” The analysis focused on reported hormone symptoms, pain, sexual interest/dysfunction, physical subscales of HRQOL and fatigue. Although no specific types of physical activity were addressed, it would behoove fitness professionals to discuss the advantages of exercise with clients who have survived breast cancer.
To asses the impact of lifestyle on HRQOL, perceived stress and self-reported sexual function in men with early-stage prostate cancer, Daubenmier et al. (2006) enrolled just under 100 men in a 12-month trial that consisted of exercise, stress management and a low-fat, vegan diet. By the end of the trial, men in the intervention group had significantly improved their lifestyles in all categories compared with the control group, although the study authors took care to note that participants who scored higher at baseline also scored higher after the intervention.
By 2007, exercise had already been shown to improve quality of life in some cancer survivor groups, but that year Karvinen et al. (2007) published the first study to look at the associations between exercise and quality of life in bladder cancer survivors. Even though very few of the study participants met the public health guidelines for exercise, the researchers were still able to find a positive association between quality of life and exercise, using functional well-being, sexual functioning, erectile function, body image and various fatigue indicators as determinants for quality of life.
In the translated abstract from a German-language article on cardiovascular disease (CVD) and sexuality, Pfister (2010), of the Clinic for Cardiology in Basel, Switzerland, stated that “sexual activity corresponds to light to moderate physical exercise and entails no significant risk to the majority of patients with CVD. In patients suffering from severe angina or chronic heart failure, however, sexual activity might trigger coital angina or cardiac decompensation necessitating hospitalization. Nevertheless, even for patients with coronary artery disease the absolute risk of having a heart attack or fatal event during sexual activity is extremely low.” Pfister went on to note that patients with CVD have a higher prevalence of sexual dysfunction compared with the general population. He also emphasized the importance of obtaining information from clients and participants about prescribed drugs, as some drugs used by those who suffer from both CVD and sexual dysfunction can be fatal if mixed with nitrates. Fitness professionals who work with clients with CVD should be aware of both the good news about exercise and sexual activity as well as the possible medication contraindications. Obtaining a thorough history and doctor’s release is essential.
Quite a lot of research has been done on the relationship between ED and exercise. A multifaceted disease affecting more than 100 million men worldwide, ED has cardiovascular, metabolic and hormonal risk factors as well as common risk factors such as hypertension, aging, obesity and smoking. It is important for fitness professionals to be aware of the strong links between CVD, metabolic syndrome and ED.
Luckily, exercise has been shown to mitigate all three of these conditions. In a 2007 study (originally in German), Sommer and Mathers stated very clearly that while men might initially visit the doctor for treatment of urological symptoms, it is then incumbent upon the medical community to recommend modification of lifestyle factors such as obesity, lack of exercise and smoking. Sommer and Mathers emphasized the preventive aspect of exercise and specifically recommended altering behavior (i.e., exercising more) before trying testosterone replacement or other more invasive techniques.
In a 2009 literature review that looked at common risk factors for ED and CVD, paying specific attention to obesity, Hannan et al. came to a conclusion that, in one sentence, should be enough to convince men—especially those who are older and obese—to exercise: “Lifestyle modifications provide significant benefits to vascular health and erectile function.” These researchers included diet as a lifestyle modification, too: “Mediterranean-style diets and a reduction in caloric intake have been found to improve erectile function in men. In addition, combining the two interventions [exercise and diet] provides additional benefit to erectile function.”
Bacon et al., from the department of nutrition at the Harvard School of Public Health, reached a very similar conclusion in a large 2003 study that looked at data from over 31,000 men aged 53–90. After ruling out prostate cancer, the researchers found that physical activity and leanness, as they termed it, were the two lifestyle factors most strongly associated with maintenance of “good erectile function.” They defined physical activity as >32.6 metabolic equivalent hours of exercise per week, and obesity as body mass index >28.7 kilograms of body weight per meter of height squared. Three other behaviors associated with a higher prevalence of ED were quite interesting and are worth sharing with clients and students: smoking, alcohol consumption and television viewing time.
Ridwan Shabsigh, MD, director of the division of urology at the Maimonides Medical Center in Brooklyn, New York, and professor of clinical urology at the College of Physicians and Surgeons of Columbia University, has focused his research on men’s health and the treatment of sexual dysfunction. Believing strongly that sexual functioning is something everyone should be able to enjoy at any age, Shabsigh looks at lifestyle approaches prior to offering medical options. “My recommendation for middle-aged and older men is to do a combination of cardio, strength, balance and stretching exercises, with the cardio component being 150 minutes per week, bringing the total [exercise] to about 200–210 minutes per week.”
In a further comment that has a “canary in a coal mine” aspect to it, Shabsigh cautions, “ED in a middle-aged man could be a predictor of either a future heart attack or stroke or a predictor of existing cardiovascular disease that is otherwise asymptomatic. Such a man should seek a complete health evaluation by a doctor. In addition, he should modify his lifestyle by quitting smoking, reducing alcohol, exercising and controlling weight as appropriate.”
Considering Shabsigh’s use of the words asymptomatic and predictor, it might be a good idea to include an ED section in health histories gathered from male exercise clients. Although the topic has the potential to be somewhat embarrassing, fitness professionals who can present the information tactfully and in a straightforward manner will be in a strong position to prevent at-risk clients from having a heart attack or stroke.
Obesity, Social Stigma and Risky Behaviors
In what is a sad commentary on just a few of the issues facing obese men and women, researchers in Paris (Bajos et al. 2010) found that obesity has a strong influence on people’s sexual lives. Although it may seem logical to some that frequency of activity would be an issue, the research also turned up a number of alarming behaviors—suggesting that obesity can sometimes lead to riskier sexual health practices. In one finding, obese women were five times more likely than normal-weight women to find their sexual partners via the Internet. In addition, the women were less likely to access contraceptive healthcare services and had unplanned pregnancies four times more often than women with normal BMI. Another discovery was that obese men, particularly those under age 30, were at a 10 times greater risk of contracting a sexually transmitted disease. One conclusion is that exercise might help obese people with more than their medical issues; it could also decrease risky sexual behaviors and increase social standing.
With sexual health and functioning, as well as general life satisfaction, linked so strongly to exercise in so many areas, this is clearly a topic that should be considered in clients’ health histories and exercise programs. It is a relevant subject in any discussion about the many advantages of exercise and healthy living. Or, as Marvin Gaye put it, “When I get this feeling, I need sexual healing!”
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