Perhaps the strongest fear expressed by the ostomate was fear of spillage. Severe humiliation and even suicidal ideation occurred in response to fecal spilling. Ostomates also tended to be phobic concerning the noise or odor from flatus.

The interference with body image often led to social restrictions. The concept of bodily worth and integrity was often severely compromised by a surgical procedure that created a new organ and removed the control of feces, established in early childhood.

The initial sight of a colostomy was usually shocking and frequently precipitated transient to chronic depression in a sample of twenty-nine men and twenty-eight women studied by Sutherland and associates. Several patients described such severe weakness after surgery that occasionally they required periods of prolonged bed rest. Sutherland and colleagues believed that the depression was triggered by the perception of the colostomy as mutilation or disfigurement. The sensation of weakness was attributed to the person's perception of his body as being rendered fragile and vulnerable by the surgery. Marked invalidism was manifest in those who demonstrated both weakness and depression.

Body image has been conceptualized as a mental picture of one's own body-the way in which the body appears to the self. It implies a personal investment in various parts of the body? Body image is a dynamic concept, subject to change in response to influences on the body itself or the person's perceptual apparatus. One develops a total perception of one's body through multiple sensory experiences; this process begins as the infant discovers his body parts. The concepts of one's body are also formed in response to attitudes and emotional overtones that one experiences within the family and from evaluations of one's physique by parents. It is believed that the image of one's body is integrated into the parietotemporal area of the cortex.

The emphasis on the body beautiful is probably nowhere more apparent than in American society. Madison Avenue makes explicit the body type considered most desirable. Advertising is often aimed at generating some need to affiliate oneself with the "beautiful people." It is no surprise, then, that an alteration in one's appearance or even in the perception of one's body may have far-reaching social consequences.

Perhaps the most important intervention designed to promote sexual health in the cardiac patient is the disseminating of information. Patients frequently ask questions such as "Is it safe to resume intercourse? When? How often?" However, previously cited studies indicate that clear-cut, direct advice should be given by the professional adviser.

Assessment of the biologic, psychologic, and sociologic variables previously mentioned is helpful in formulating a diagnosis. Is sexual function adequate and gratifying to both partners? Is a form of sexual dysfunction present? To intervene effectively, the health professional must consider which of the bio-psycho-social variables can be manipulated and which should be maintained.

Intervention: diabetes. Premarital counseling for diabetic patients would perhaps be the most desirable place to begin. At that time the partners could conjointly be informed about the features of the disease, including the following:

Biologic variables. In the process of assessing the biologic variables, the degree of pathology present in the chronically ill patient is determined. For the diabetic one might ask: What is the present level of sexual function? What degree of neuropathy is evident? Of what duration is the disease? To what extent is the disease well controlled? Does a vaginitis coexist with the woman's sexual dysfunction? Is sufficient vaginal lubricant present to facilitate intercourse? Are fertility problems present? Is the patient married to a diabetic?

For the person with cardiac disease one might ask, What is the extent of damage to the heart? The data may be assessed both through a careful history and by electrocardiographic documentation. The "sexercise" test proposed by Hellerstein and Friedman would provide electrocardiographic evidence actually obtained during coitus as well as base-lined data.

Psychologic aspects of adaptation after myocardial infarction may have far reaching consequences for sexual activity. In a study of forty-three male and female postcoronary patients, Weiss and English found that sexual problems existed. Twenty-one of the subjects experienced sexual problems they felt were important, and eighteen of these subjects were men. The most frequent sexual problems included impotence (ten of thirty-one males), frigidity (three), premature ejaculation (one), and decreased libido (two).

Sexual behavior after myocardial infarction has been studied from biologic, psychologic, and sociologic perspectives. A review of these findings is presented to facilitate understanding of the patient's rehabilitation from a holistic perspective.

Perhaps the most comprehensive study of sexual activity after myocardial infarction was reported by Hellerstein and Friedman. These investigators compared sexual activity in normal coronary-prone and postcoronary subjects and evaluated the physiologic changes in heart rate and electrocardiogram during coitus and other activities of daily living. The study subjects were white, middle-aged, middle- to upper-class, and predominantly Jewish businessmen, executives, managers, and professionals.

As early as the 1950s, studies to document cardiovascular change during intercourse were being conducted. Bartlett studied the heart rate and pulmonary ventilation of married men and women (22 to 30 years old) before, during, and after intercourse. During orgasm, the heart rate approached 170 in both sexes, although the heart rate was greater in men. Female responses were more variable than male responses, both among and between subjects. However, the heart rate rapidly returned to normal after orgasm.