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1033
ISSN 1477-9072
© 2009 Expert Reviews Ltd
10.1586/ERC.09.92
www.expert-reviews.com
Editorial
Sexual activity: an exercise to prevent
cardiovascular morbidity and mortality?
Expert Rev. Cardiovasc. Ther. 7(9), 1033–1036 (2009)
“Since, to a certain extent, sexual activity almost always requires
body movements, it can conceptually be considered a quite
specific form of planned and intentional physical activity...”
Sexual activity is an integral and relevant
part of human life. Not only does it func-
tion to preserve the human species but it
also has an impact on the mental, physical
and social health, and on the quality of
life. This editorial, written from a medical
(cardiology and exercise/sports medicine)
and physiological perspective, discusses
the potential role of sexual activity in the
domain of exercise and its relationship
with cardiovascular morbidity and mor-
tality. Benefits and risks of an active sexual
life for both healthy subjects and cardiac
patients, as well as the potential impact of
drugs for treating erectile dysfunction in
this scenario, are also briefly covered.
Presenting terms & expressions
Physical activity, exercise and sports are
terms that describe different concepts.
However, they are often confused with
one another, and the terms are sometimes
used interchangeably. Correctly speaking,
physical activity is defined as any bodily
movement produced by skeletal muscles
that result in energy expenditure and may
be categorized into occupational, condi-
tioning, household or other activities [1].
Exercise is a subset of physical activit y
that is planned, structured and repetitive
and produces, as a final or an intermedi-
ate objective, the improvement or mainte-
nance of physical fitness or health. Sport
is more related to, but not always, par-
ticipating in organized and competition-
oriented forms of physical exercise. Sports
competitors (athletes) are, depending
on modality, often well above average in
some or all components of physical fitness.
Notwithstanding, the physical require-
ments considerably vary among modalities
and some elite Olympic athletes could even
be quite physically unfit (e.g., those com-
peting in archery or shooting) or present
clear adverse clinical characteristics, such
as the morbid obesity pattern typically
seen in sumo wrestlers.
The expression ‘sexual activity’ com-
prises a number of actions, such as kissing,
touching, masturbation and intercourse.
Most sexual activities are performed
either alone (primary masturbation or
other forms of self-stimulation) or with
another person. A sexual encounter can
be divided, for practical purposes, into
four phases: foreplay, penetration, orgasm
and afterplay. Foreplay tends to be the
longest phase, but the duration of phases
is not by all means fixed, even among
long-lasting married couples. Intercourse
includes penetration or stimulation and
orgasm phases. A typical range for the
penile–vagina penetration-phase duration
is somewhere between 2 and 7 min, with
a stroke rate ranging from 10 to 30 penile
thrusts per min. Orgasm is a very brief and
complex physiological phenomena lasting
a few seconds.
Sexual activity as exercise
Since, to a certain extent, sexual activity
almost always requires body movements,
it can conceptually be considered a quite
specific form of planned and intentional
physical activity, that is, exercise. In addi-
tion, sexual activity is probably the most
pleasant and enjoyable type of exercise
available. Considering the health burden
of sedentary life, it is remarkable that a
large recent telephonic survey confirmed
that among individuals aged 40–80 years,
living in the USA, 80 % of the men and
70% of women had engaged in intercourse
during the preceding 12 months and
Claudio Gil Soares
de Araújo, MD,
PhD
Clínica de Medicina do
Exercício, CLINIMEX,
Rio de Janeiro, Brazil
and
Universidade Gama Filho,
Rio de Janeiro, Brazil
Tel.: +55 212 256 7183
Fax: +55 212 549 4295
cgaraujo@iis.com.br
For reprint orders, please contact reprints@expert-reviews.com
Expert Rev. Card iovasc. Ther. 7(9 ), (2009)
1034
Editorial Araújo
approximately a third of all individuals repeated it more than
once a week [2]. With regards to the figures, considering a man or
a woman starting a stable relationship at 30 years of age that lasts
for 40–50 years, it is realistic to suppose that they will copulate
on approximately 4000–5000 occasions, assuming intercourse
performed twice a week on average (45 years × 52 weeks × two
coitus occasions per week). In this sense, if we consider sexual
activity as exercise, it is possible that, for the majority of individu-
als, this represents the most pleasant, relevant and intense activity
regularly performed during their life.
On the other hand, if failure in obtaining a given sport result or
exercise performance may be frustrating for some individuals, a
similar incapacity in a sexual activity brings stronger feelings much
more often and has both relevant health and social implications.
Prevalences of different types of sexual dysfunctions vary according
to age, gender and culture [3–5]; notwithstanding, the figures are
typically quite high, starting from approximately 10% in young
males and increasing to over 50% for those 60–70 years of age [6].
There is a substantial body of literature covering sexual activity;
however, owing to equipment and observation interferences mini-
mizing the chances to re-enact the normal intimacy observed in
real-life conditions in the laboratory setting, the amount of in vivo
scientific data taken during actual intercourse is very limited [7–10].
“...if failure in obtaining a given sport result or
exercise performance may be frustrating for some
individuals, a similar incapacity in a sexual activity
brings stronger feelings much more often and has
both relevant health and social implications.”
Physiologically speaking, intercourse is the most demanding
phase, especially per orgasm [11]. However, intercourse, per se, is a
nonstandardized procedure, varying in body positions, rhythm of
thrusts, depth of penetrations, and therefore, the energy expenditure
of both partners vary. In this context, it is worthwhile to men-
tion that the large majority of data come from male subjects [12].
Some studies with small samples of couples have proposed that
energy requirements during coitus would range from two to four
metabolic equivalents (one metabolic equivalent = resting energy
expenditure or an oxygen uptake of 3.5 ml/kg·min), which are
somewhat lower for women and equivalent to a brisk walk [13]. Peak
values of heart rate and systolic blood pressure during sexual activ-
ity tend to be much lower than during maximal treadmill exercise
testing [8]. Nevertheless, most of these physiological studies based
on hemodynamic responses have missed the concept that inter-
course is a non-steady-state exercise, so that the heart rate–oxygen
uptake relationship would not remain linear. As an example of this
non linearity, we have recently shown that arm or leg fast cycling
under no resistance for just 4 s – a non-steady-state, sudden and
brief exercise with minimal metabolic requirements – is sufficient
to increase the heart rate for approximately 20–50 beats/min in
healthy individuals [14], mainly by vagal withdrawal, similar to the
cardiac acceleration seen during coitus. Therefore, it is truly possible
that the energy requirements during a sexual relation have been
overestimated by previous studies using heart rate data. Most likely,
the actual oxygen uptake during intercourse is much lower than
previously thought and resembles a relaxed walk for a few blocks,
interspaced by ascending one or two flights of stairs at moderate
and, most importantly, at a very much individual pace.
Sexual activity & risk of unfavorable cardiovascular
& pulmonary events
Unfavorable clinical manifestations can be triggered by physical
activity or exercise, including sexual activity [5,15,16]. Searching the
medical literature, it is possible to find reports of hemoptysis [17],
pulmonary embolism [18,19], stroke [20,21], myocardial ischemia [22]
or infarction [23, 24] , Takotsubo syndrome [25], severe ventricular
tachyarrythmias [26] and sudden death [27], occurring, in the large
majority of cases, in previously sick individuals. Comprehensive
reviews of autopsy data were recently updated by authors from
Germany [28] and showed that in over 32,000 forensic autopsies,
only 68 cases (0.22% or 1.9 out of 1000) of natural deaths have
occurred during sexual activity. It is worthwhile to comment that
in this very large sample, except for five cases (7.4%), all subjects
were men. Interestingly, an International Olympic Committee
review paper on the sudden deaths of athletes has found an almost
identical female:male ratio of 1:9 [29]. As also seen in similar
reports from Asia [16], considering the statistical and methodo-
logical constrains to obtain reliable data, it seems that sudden
deaths or major complications tend to be more common in those
engaged in extramarital sex, especially when involving prostitutes.
Based on these reports, it has been pointed out that clinicians
and other health professionals are quite often prone to overprotect
their cardiac patients, especially female patients, by restricting
sexual activity [30–33]. Looking more carefully at the available data
– both prevalence and frequency of sexual relations among mature
adults and the incidence of unfavorable events – it becomes clear
that the absolute risk is still remarkably low, even for most chroni-
cally ill patients (<0.1%/year), despite a probable minor increase
in relative risk (2–2.5) compared with resting conditions.
Since the energy requirements of sexual intercourse are quite low
and are in the range of many daily activities, even for older individu-
als, the minor increase in relative risk cannot be fully explained by
exercise intensity, but rather, other mechanisms may be involved.
Exaggerated sympathetic [5, 27] and uncommon sympathovagal
interactions [34] have been proposed as contributing factors to poten-
tially lethal cardiac arrhythmias induced by intercourse. While it
is true that sympathetic stimulation unrelated to physical activity
or exercise, as occurs during intense emotional situations [35], may
induce complex arrhythmias, it does not seem to be a rule. Israeli
researchers found that arrhythmias were slightly more frequent and
common during coitus than in near-maximal cycling testing in
coronary patients [36]; however, most of the sex-related ectopic beats
were often simple and essentially similar to disturbances experi-
enced in daily activities. Using another type of sudden and very brief
exercise – the spirometry maneuver – in comparison with maximal
exercise testing, we have also found similar results for arrhythmias
in cardiac patients [37]. This suggests that, although sexual activity
can often induce cardiac arrhythmias, for most individuals, they
would be clinically irrelevant. On the other hand, coitus can induce
www.expert-reviews.com 1035
Editorial
Sexual activity: an exercise to prevent cardiovascular morbidity & mortality?
beneficial cardiovascular effects. Using an interesting approach,
Brody found lower blood pressure reactivity to stress in adults who
had recently performed a penile–vaginal intercourse [38].
Currently, there are good sources of advice regarding safe sexual
activity [30,33,39–41], which will promote a healthier sex life for both
healthy subjects and cardiac patients.
Regular exercise promoting sexual activity
Being regularly active and/or having an above-average exercise
capacity has been shown to substantially reduce cardiovascular
and all-cause mortality [42] and, according to recent research, to
favorably influence sex lifestyles [38, 43–45]. Esposito et al. carried
out a randomized, clinical trial and identified a favorable influence
of intensive lifestyle changes (including exercise) in a large sample
of men followed-up for 2 years [46 ]. Belardinelli et al. submitted
30 male patients with heart failure to 24 cycling exercise sessions
in 8 weeks and found a significant beneficial effect in brachial
artery endothelial dysfunction [45]. This finding was positively
related to more favorable responses to a sexual-activity profile-
assessment questionnaire. Kratzik et al., in an observational study,
showed an inverse relationship between exercise energy expendi-
ture – between 1000 and 4000 kcal/week – and the prevalence
of erectile dysfunction in a large sample of Viennese men [44].
Currently, partially based in preliminary evidences, it is reason-
able to suggest that regular exercise and high exercise capacity
are associated with less sexual dysfunctions in both apparently
healthy and sick adults. Notwithstanding, it remains to be deter-
mined if any specific exercise intervention or program (i.e., aerobic
or combined aerobic–strength–flexibility) will be more beneficial
than other forms of activity in this regard.
Conclusion
Nowadays, with the increasing life expectancy (and correspond-
ing median population age), simultaneously accompanied by a
higher prevalence of cardiovascular and metabolic diseases, to
be able to maintain an active sexual life is becoming a challenge.
Available evidence strongly corroborates a positive role for sexual
activity in health. With the recent interest in drugs for treating
erectile dysfunctions, clinicians will often be requested to advise,
for example, a post-myocardial infarction, 80-year-old male
patient regarding sexual activity and use of erectile dysfunction
drugs. Furthermore, recognizing the recently discovered benefi-
cial effects of these drugs on hemo dynamic aspects and exercise
capacity [47,48], it is likely that the number of clinicians prescribing
them will soon increase.
In addition, adult individuals will probably be motivated to par-
ticipate and to adhere to regular exercise programs if they feel an
improvement in their sexual performance as a positive side effect
or bonus. While regular sexual activity itself will not be of suf-
ficient intensity and duration to fully induce and optimize cardio-
vascular exercise-training adaptations and benefits, it should be
incorporated as part of an exercise program or prescription aimed
to improve and maintain physical and mental health. It is also
possible that physically active and fit male and female individuals
would appear more sexually attractive, which will encourage them
to be sexually active. These facts and the possibility that higher
levels of physical fitness – aerobic condition, joint flexibility, mus-
cular strength/power, balance and low-fat body composition – are
useful components for better sexual performances, will work as
potent stimuli for engagement in regular physical exercise.
Physicians and other allied health professionals should inform
patients that the health risks involved in sexual activity are very
low, especially for women and when performed with partners in
stable relationships, and should recommend regular sexual activity
for most, if not all, of his/her patients as part of a healthy lifestyle.
An active sexual life as part of a pro-exercise and healthy lifestyle
could potentially contribute, mainly by indirect means (exercis-
ing regularly in order to have a better sexual performance), to
reduce cardio vascular morbidity and mortality. The enormous
health and social benefits of an active sexual activity will certainly
outweigh the very minor risks of unfavorable events during this
activity that could also be minimized and individually tailored
by adequate professional advice, including use of specific drugs
and prescription of regular exercise.
Financial & competing interests disclosure
Claudio Gil Soares de Araújo is a recipient of a CNPq research scholarship.
The author has no other relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial conflict
with the subject matter or materials discussed in the manuscript apart from
those disclosed.
No writing assistance was utilized in the production of this manuscript.
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