Sex


Should I worry about foreplay?

Kissing and oral sex can seem like a less risky option than penetrative sex, in terms of unwanted pregnancies, but you do still need to be responsible and aware of the potential for problems.

  • Anything that involves deliberately drawing blood to the surface of the skin e.g. a 'love-bite', can cause more of a problem for you than for someone without haemophilia; breaking the skin means that you could bleed for a long time
  • A penile injury, though unlikely, may cause external bleeding, discoloration of urine, swelling or pain. If you have any of these symptoms, talk to your Haemophilia Centre or A&E department at your local hospital (depending on the urgency)

Is it safe for me to have sex?

Yes, although like anyone else you need to be responsible. Living with haemophilia means that there are three things you need to be thinking about when you have sex:

  • be aware of the potential for bleeds, how to minimise the risks, and what to look out for after you've had sex
  • consider prophylactic use of clotting factor to reduce the number of bleeds you experience
  • use a condom whenever you have vaginal, anal or oral sex, to protect you against sexually transmitted infections (STIs) and, of course, prevent unwanted pregnancies via vaginal sex

STIs are easy to catch and can be symptomless, which means you won't necessarily know you've got them. It's really important that you take precautions to protect yourself and your partner from STIs as they can result in serious health problems for you both later on. There are many different types of STI and it's a good idea to be aware of them, so check out this website for further information on how to spot them, treat them, and prevent them.

The iliopsoas? What's that?

The iliopsoas refers to two muscles that work closely together to help your hips move freely and keep you standing upright. They're called the psoas and the iliacus, and they connect the lower portion of your spine to the top of your thigh at the front of your leg. Together with the abdominal muscles, the iliopsoas is very active during the thrusting motions of the hips and pelvis during sex. Unfortunately, because this is not what your iliopsoas is usually used for it can increase the risk of injury, so you should be aware of the potential for experiencing an internal bleed in your psoas muscle. As you might expect, these are known as psoas bleeds.

What happens if I get a bleed from having sex?

Psoas bleeds may not be immediately apparent after sex, but if you find it difficult to straighten your legs whilst lying down, or find it difficult to get out of bed without using your hands to support yourself, you should contact your Haemophilia Centre straight away.

You should also watch for signs of other types of bleed after sex, such as:

  • Bruising on the surface of the skin
  • Bleeding into muscles like the calf, forearm or hip, which can lead to stiffness, tingling, swelling, pain and restriction of movement
  • Bleeding into joints like the knees, elbows and ankles after twisting or putting weight on them, which can lead to stiffness, pain and restriction of motion
  • Veins looking larger than normal

If you notice blood in the semen after sex, don't panic. This condition is called haemospermia, and can happen to people with haemophilia from time-to-time. If this happens to you, make sure you tell your haemophilia healthcare professionals, who will be able to advise you further.

In addition to your normal factor replacement, you will need to rest the injured tissues to help with healing and recovery.

Will I have to wait before I can have sex again?

The amount of time you need to rest and restrict your activity in order to properly recover can be very lengthy, especially after large joint bleeds and muscle bleeds, as these have a greater chance of happening again. You may need to avoid having intercourse during this time to reduce the chance of you experiencing another bleed in the same tissue. This period will vary from person to person, so follow the advice given to you by your doctor or nurse. The most important thing to remember is that you need to allow time for the muscle or joint to fully recover in order to avoid causing a more serious injury in the future. Remember, intercourse is not the only form of sexual expression, and there are other ways to be intimate with each other.

Are there things I can do to minimise the risks?

Repeated episodes of bleeding can cause permanent loss of joint and muscle function, so it's important that you find ways to enjoy being intimate with your girlfriend or boyfriend that do not put you at excessive risk of experiencing a bleed. The following positions have been given as alternatives to what you may have tried previously and will help to reduce the pressure you put on various parts of your body during sex. If you have limited movement in your joints, or suffer from joint pain, you will find that some positions are easier than others. Try a few and see which one's comfortable for you. Adding pillows or other supports can play a role in helping relieve pressure on your joints and allow for continuation of a healthy sex life.

Positions

Position 1 [Missionary / hips flexed]

Things to be aware of

High risk

With powerful thrusting the iliopsoas muscle could be injured, leading to a psoas bleed. This is most likely if you have had multiple bleeds into this muscle, or a single bleed into this muscle in the last six months. Forceful straightening of the elbow creates a high risk for causing a joint bleed.

Moderate risk

In this position the triceps muscles on the back of the upper arms work constantly to prop up your body above your partner. These muscles may tire out after a longer time, and be more at risk of injury. The knee joints may also be at risk from direct pressure and body weight resting on them in this position. The risk will increase on hard surfaces like a floor or carpet, and be decreased if you are on a bed.

Position 2 [Missionary / hips extended]

Things to be aware of

High risk

In the upper body, the increased demand of taking most of the body weight places the triceps and elbow joint at a high level of risk. In the lower body, the extended position of the hips requires full flexibility of the iliopsoas. This position should be avoided if you have had a recent psoas bleed or have lost flexibility in this muscle.

Moderate risk

With the lower body extended, a greater amount of body weight is being supported by the arms. If you have a history of shoulder joint bleeds you should exercise caution in this position.

Position 3 [Cowboy / man with bent legs]

Things to be aware of

High risk

None of the joints and muscles are at a high risk of injury in this position.

Moderate risk

This position requires a deep bend in the knees. If you have limited motion in the knee joints exercise caution, or straighten the affected joint to decrease the stress. You could also support the knees with some cushions or pillows underneath to make yourself more comfortable.

Position 4 [Cowboy / man with legs extended]

Things to be aware of

High risk

None of the joints and muscles are at a high risk of injury in this position. The exception would be in the case of a recent psoas bleed or hip joint bleed. Until fully recovered this position should be avoided.

Moderate risk

With the hips extended, and your partner's body weight on top of you, the iliopsoas muscle and the hip joints could be injured. Exercise caution if you do not have full mobility of both.

Position 5 [Reverse Cowboy / man with bent legs]

Things to be aware of

High risk

None of the joints and muscles have a high risk of injury in this position.

Moderate risk

This position requires deeply bent knees. If you have limited motion in the knee joints exercise caution, or straighten the affected joint to decrease the stress. You could also support the knees with some cushions or pillows underneath to make yourself more comfortable.

Position 6 [Reverse Cowboy / man with legs extended]

Things to be aware of

High risk

None of the joints and muscles are at a high risk of injury in this position. The exception would be in the case of a recent psoas bleed or hip joint bleed. Until fully recovered this position should be avoided.

Moderate risk

With the hips extended, and your partner's body weight on top of you, the iliopsoas muscle and the hip joints could be injured. Exercise caution if you do not have full mobility of both.

Position 7 [Rear entry / kneeling]

Things to be aware of

High risk

Especially on harder surfaces, the direct pressure on the knee joints may cause a bleed. If you have trouble with only one of your knees, bending the leg at the hip and knee on that side so that your foot is flat on the floor or bed may decrease the risk of injury in this position. Be aware that this will increase the physical demand on your other knee.

Moderate risk

The quadriceps and iliopsoas muscles are maintained in a stretched or lengthened posture in this position. Both will be generating force to control the movement of the body and thrust the pelvis. If you have had recent bleeds into these muscles, or a tendency to bleed here, exercise caution.

Position 8 [Rear entry / standing]

Things to be aware of

High risk

If you have permanent joint damage making it impossible for you to fully straighten your knees, or place your feet flat on the floor when standing straight, you should avoid this position. If you have trouble with only one of your knees, bending the leg at the hip and knee on that side so that your foot is flat on the floor or bed may decrease the risk of injury in this position. Be aware that this will increase the physical demand on your other knee.

Moderate risk

The iliopsoas muscle is in a lengthened posture, and being used to thrust the pelvis. The gluteal muscles in the buttocks are also active by forcefully extending the hips. If you have synovitis in your ankles or knees, the forceful straightening of your knees or the movement of your body weight forward over the top of your feet may cause it to be pinched, increasing the risk of a bleed.

Position 9 [Both standing]

Things to be aware of

High risk

If you have had a recent bleed in your calf avoid this position. Also, if you have permanent joint damage making it impossible for you to fully straighten your knees, or place your feet flat on the floor when standing straight, you should avoid this position.

Moderate risk

The iliopsoas muscle is in a lengthened position, and may be at risk if you have lost flexibility from previous bleeds. If you have difficulties with this muscle on only one side, you could ease the stress on it by placing the foot of that leg up on a stool or chair. Be advised that this would increase the weight load being taken by the opposite leg. Also, if you have synovitis in your ankles or knees, the forceful straightening of your knees or the movement of your body weight forward over the top of your feet may cause it to be pinched, increasing the risk of a bleed.

Position 10 [Laying on your side]

Things to be aware of

High risk

None of the joints and muscles are at a high risk of injury in this position.

Moderate risk

If you have lost flexibility in the iliopsoas muscle, or if the muscle has had a recent bleed, exercise caution. If you only have trouble with the muscle on one side of your body, in this position that side should be uppermost, and you should have that hip and knee bent to reduce the stretch on the muscle.

Position 11 [Seated in a chair]

Things to be aware of

High risk

The only time this position should be avoided is if you have had recent elbow joint or bicep muscle bleeds, or a significant tendency to bleed in these locations.

Moderate risk

More vigorous sex in this position will place more stress on the biceps muscles and the elbow joints as you help to control the weight of your partner as their body moves away from you.

How can regular Clotting Factor treatment (i.e. prophylaxis) help?

Prophylaxis will keep the level of Clotting Factor in your blood topped up, to reduce the number of bleeds that you may experience. This will help protect you from joint bleeds, which might be beneficial for the sexual aspect of your life. Speak to your Haemophilia Centre about tailoring your treatment to suit your needs.

What about contraception?

There are many different types of contraception for males and females that protect against unwanted pregnancies. However, to protect against STIs as well, you'll have to use a condom.

What are condoms exactly?

Though female condoms are available, we'll focus on male condoms here. They're worn on the penis to stop sperm from entering your partner's vagina, mouth or anus, and are made of very thin latex. (They're also available in polyurethane or polyisoprene for people who have a latex allergy.) Condoms come in many different sizes, shapes, colours, textures and flavours, so you can experiment and find the ones that suit you. You can even use stronger condoms (with thicker latex) for anal intercourse, as this normally places more strain on the condom. Standard condoms, however, are just as effective as long as they are used correctly with plenty of lubricant. However, please bare in mind that the chance of a latex condom splitting is much higher when mineral oil based lubricants are used rather than water-based lubricants.

You can find out more about the different types of condoms available here: avert.org/condom.htm

How do I use condoms?

It's important to use condoms properly as, if handled the wrong way, they can slip off or split. If you're using condoms for the first time, it's a good idea to practise putting them on properly before attempting to use them for sex. Also, make sure you put a condom on your penis when it's erect, before it comes into contact with the vagina, mouth or anus. Below are a few steps to help you wear condoms correctly:

  • Remove the condom from its packet
  • Place the condom over the tip of the erect penis
  • Use your thumb and forefinger to squeeze the air out of the teat (on the end of the condom)
  • Gently roll the condom down to the base of the penis (If the condom won't roll down, you're probably holding it the wrong way round. If this happens, throw the condom away, as it may have semen on it, and try again with a new one)
  • After sex withdraw the erect penis, being careful to hold the condom on to the base of the penis
  • Remove the condom from the penis, being careful not to spill any semen. Dispose of the condom in a bin, don't throw it down the toilet

How effective are condoms?

If used correctly and consistently, condoms are 98% effective; there's a two percent chance of you making your partner, if female, pregnant.

  • If the condom splits or comes off, you should contact a pharmacist or doctor for emergency contraception
  • Also, if you have been at risk of pregnancy, you've been at risk of STIs, so it's a good idea to have an STI-check at a GP surgery, contraceptive clinic, sexual health clinic, genitourinary medicine (GUM) clinic or young person's clinic

Where can I get condoms?

You can buy condoms from most places: chemists, corner shops and supermarkets. Just make sure you buy brands that have 'CE' on the packet, as this means they've been tested to European safety standards.

As well as buying condoms, you can also collect them for free from: community contraceptive clinics, sexual health and GUM clinics, as well as some GP surgeries.

If you'd like any more information about contraception, talk to the healthcare professionals at your Haemophilia Centre, or find your nearest contraceptive service from the NHS. These can sometimes be found in GP centres, and offer free and confidential advice.

What would you do?

So you've read all the adviceā€¦ but how would you handle these situations when things start to get steamy?

You're practicing your kissing technique with your girlfriend when she tells you she wants to give you a 'love bite'.
Should you (pick one):

  • a) Tell her to go ahead and hope she doesn't suck too hard, you can deal with any bleeds later
  • b) Take a moment to explain to her about your haemophilia and why that would not be a good idea
  • c) Suggest she does it on your arm because you're less likely to have a bleed there

Answer: B. It's important that you trust your partner enough to be able to tell them about your haemophilia and that this means you need to be more careful than usual when it comes to certain activities. There aren't any 'safe' areas, you can suffer a bleed anywhere. If you're going in for something more adventurous, don't forget protection.

Tonight will be the first time you've been intimate with your partner. Should you (pick two):

  • a) Top yourself up with your clotting factor to help prevent any bleeds in case you have sex
  • b) Pack a condom just in case, you don't want an STI or an unwanted pregnancy
  • c) Perform some gentle stretches to try and loosen yourself up
  • d) Have a shave to get rid of all that stubble

Answer: A & B. You can shave if you want, some girls like stubble some don't, it's more important that you remember to take a condom and top up your levels of clotting factor to help prevent bleeds, STIs and unwanted pregnancies.

You had sex last night and found that you couldn't straighten your leg properly this morning. Should you (pick one):

  • a) Do some gentle stretching to try and loosen it up
  • b) Take yourself to the haemophilia centre or doctor straight away in case it's a psoas bleed
  • c) Assume you just overdid it in your football game the other day and take it easy for a while
  • d) Give it a day or two and see if it gets better before going to the doctor

Answer: B. If you notice any bruising, stiffness, tingling, swelling or pain, you should assume you have suffered a bleed and get yourself seen by a healthcare professional as soon as possible to prevent it becoming more serious.

You want to have sex with your partner but are worried because you suffered a bleed last time. Should you (pick four):

  • a) Have sex like you usually do, it's been a month since your bleed so it's unlikely to be a problem if you're careful
  • b) Adopt a different position that's less likely to result in another bleed in the same part of your body
  • c) Try having oral sex or exploring other ways to be intimate instead of intercourse
  • d) Talk to your healthcare professional about other options that can help reduce your risk
  • e) Top yourself up with your clotting factor and go ahead as usual

Answer: B, C D & E. The best thing to do is have a chat with your doctor or nurse about your options. Sometimes adopting a different position can relieve the pressure on your joints and reduce the risk of injury. If your previous bleed still hasn't healed completely, you may have to abstain from intercourse entirely, so try exploring some other ways of being intimate, like oral sex.

What are the classic telltale signs of a psoas bleed? (Pick all that apply):

  • a) Unable to straighten your leg
  • b) Pain in the hip, groin, stomach area, buttocks, or lower back
  • c) Stiffness in your leg
  • d) Unable to walk
  • e) Numbness down the outer thigh

Answer: all of the above. Psoas bleeds can be very serious, so contact your doctor straightaway if you notice any of these symptoms, and keep a close eye out for symptoms if you've been hit on the hip, groin, stomach area, buttocks, or lower back.

All information on this page has been taken from the following sources