Sexual and Reproductive Health

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Establishing a sexual identity is a key task of adolescent development, and addressing sexual and reproductive health issues during adolescence and adulthood are important aspects of management.

Women with JIA have similar levels of sexual activity and relationships when compared to healthy controls. However, this group has a higher rate of gynecological problems than controls; these include increased incidence of menorrhagia, pelvic inflammatory disease, difficulty in conceiving, and a higher-than-normal rate of miscarriage. These may all reflect hormonal imbalances including luteinizing hormone hypersecretion (52).

There is an increased risk (at least 3.4%) of premature ovarian failure in women with JIA compared to the general population (53). There are significant implications for women with JIA in terms of when they should consider starting a family, as delay may put them at risk of infertility. Early loss of ovarian function has both significant physical sequelae (amenor-rhoea, breast atrophy, mucosal dryness, fatigue, and loss of libido) and psychosocial sequelae (exclusion from "motherhood," loss of self-esteem, and poor body image). It also has major health implications, with a nearly two-fold, age-specific increase in mortality rate (54).

Sexuality includes the adoption of certain gender roles (55). Society's definition of masculinity traditionally identifies the male as strong, practical, and the main "bread winner" in a family. The corresponding role for a woman traditionally identifies her as a wife, homemaker, attentive mother, and, more recently, an income provider. Arthritis may interfere with an individual's capacity to meet these expectations. Men with JIA are less sexually active and have greater difficulty establishing a permanent partnership than both healthy males and women with JIA (52). Poor body image, low self-esteem, social isolation, and fears of being unable to support a family or to fill the social role expected from a male in a relationship may all have contributed to this finding.

Despite high levels of disability, most patients are sexually active. A significant minority (37%) of adolescents become sexually active while still under the care of a pediatric rheumatologist (44). As potentially teratogenic drugs are increasingly used in the pediatric population, the need to address sex education and contraception in adolescent clinics becomes essential. Delay in the onset of sexual activity tends to be related to poor body image and decreased mobility that limits social activities (56-59).

Sexual activity can be adversely affected by arthritis, with pain, the fear of pain, fatigue, depression, and anxiety all potentially reducing libido (60,61). Many patients who are sexually active experience difficulties related to their disease. Although the majority of adverse effects are related to the physical effects of arthritis (pain and physical restriction), a significant minority of patients experience body image or self-confidence problems (44).

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