Individual Psychosexual Counseling Is One of the Educational Necessities for Cardiac Rehabilitation of Patients in Iran

Cardiovascular diseases (CVDs) are debilitating conditions with long-term physical and psycho-logical consequences (1). After a cardiac event or procedure, the patient encounters several problems, two of the most important of which are psychosexual dysfunction and difficulty in resuming sexual activity (2-4). The World Health Organization (WHO) defines sexual health as a state of physical, emotional, psychological, and social well-being related to sexual interaction and sexuality (2). Resuming sexual activity is a common concern among patients, such that in nearly half of patients resuming sexual activity is associated with fear (5). In the developed countries, despite cultural constraints and shame, numerous cardiac patients frequently request information on how to resume sexual activity (2). However, the evidence suggests that information on sexual issues is not easily available to patients, which can lead to misper-ceptions among patients on how to resume sexual activity (2, 6). According to the available evidence, 37-76% of cardiac patients experience changes in their sexual activity, only in 42% of whom these issues are raised with the treating physician (7, 8). However, in the developing countries, only 11% of patients receive information about sexual life after a cardiac event (7) and Iran is no exception in this regard. Barriers to sexual activity include lack of need for patients by health professionals, lack of experience of care providers, time constraints, linguistic and cultural barriers, as well as fear and shame (6). After cardiac event or procedures, doubt about resuming sexual activity, fear of sudden death during sexual intercourse, inadequate knowledge about when and how to resume sexual activity, as well as sexual anxiety and depression are the main obstacles cardiac patients face (9, 10). Based on the repeated recommendations of professionals and researchers on this issue, psychosexual counseling and rehabilitation is one of the educational needs of this group of patients (2, 3, 6, 8, 11), and the focus of sexual counseling strategies should be on assuaging patients' anxiety and the healthy resumption of sexual activity (3). Counseling and psychosexual education can be presented to patients in the form of verbal (face to face counseling), written (books and pamphlets), and visual (photos and videos) information (2, 6). The content of sexual education and psych-osexual counseling with a focus on psychosocial homework, including cognitive behavioral therapy and social support, can be effective in reducing patient anxiety and problems (6). In addition, in relation to delivery format of psychosexual counseling to cardiac patients, various approaches were proposed and it seems that culture plays an important role in choosing the appropriate format. Based on pair, group, or one-on-one teaching methods and seminars despite being used in different parts of the world (2, 6), it seems that one-on-one approach is more appropriate for the Iranian culture. Our experience in Kermanshah center of cardiac rehabilitation showed that patients do not welcome pair and group meetings and they generally refuse to participate in meetings and ask their questions. However, creating a private and safe environment with a same-sex counselor can facilitate participation of patients. Given that the sexual problems of men and women, and consequently, their needs are different (4), content of interventions should be defined according to the needs of each sex. Therefore, we recommend providing one-on-one psychosexual counseling, as one of the educational requirements of patients, in cardiac rehabilitation centers of Iran.