Adaptation to Sexual Dysfunction in Patients with Chronic Renal Failure

The prevalence of chronic renal failure in Indonesia tends to increase in the lower age group (45–54 years). Chronic renal failure may lead to impaired sexual function. A descriptive phenomenology study with in-depth interviews was carried out with 12 participants, and thematic content analysis was applied. Six themes were revealed, as follows: 1) adaptation process to sexual dysfunction experienced, 2) sexual dysfunction experience, 3) importance of fulfilling sexuality needs, 4) behavior in dealing with sexual dysfunction, 5) perception of the cause of sexual dysfunction, and 6) participants’ expectation of health service related to sexual function. The experience of adapting to sexual dysfunction became a meaningful process through partner involvement. Similar research involving more heterogeneous samples would benefit further discourse. Abstrak Adaptasi Terhadap Disfungsi Seksual Pada Pasien Gagal Ginjal Kronis. Prevalensi gagal ginjal kronis di Indonesia cenderung meningkat pada kelompok usia lebih muda (45-54 tahun). Gagal ginjal kronis sering menyebabkan gangguan fungsi seksualitas (disfungsi seksual). Penelitian ini bertujuan mendapatkan gambaran mendalam tentang pengalaman proses adaptasi pasien gagal ginjal kronis yang mengalami disfungsi seksual. Desain penelitian menggunakan deskriptif fenomenologi dengan wawancara mendalam. Dua belas partisipan diperoleh dengan teknik purposive sampling. Hasil penelitian ini teridentifikasi enam tema yaitu 1) proses adaptasi terhadap disfungsi seksual yang dialami partisipan, 2) disfungsi seksual yang dialami, 3) makna pentingnya pemenuhan kebutuhan seksualitas, 4) perilaku dalam menghadapi disfungsi seksual, 5) persepsi tentang penyebab disfungsi seksual, dan 6) harapan partisipan terhadap pelayanan kesehatan terkait fungsi seksualitas. Proses adaptasi yang dialami partisipan merupakan pengalaman yang sangat bermakna karena melibatkan dirinya sendiri dan hubungan interpersonal dengan pasangannya. Penelitian sejenis dengan sampel lebih heterogen diperlukan untuk memperkaya keilmuan. Kata Kunci : disfungsi seksual, gagal ginjal kronis, pengalaman proses adaptasi pasien


Introduction
The global prevalence of chronic renal failure was 13.4% (Hill et al., 2016), while it was 0.2% in Indonesia, with an increasing tendency in the lower age group (45-54 years) compared with the results in the previous period (Ministry of Health Republic of Indonesia, 2013). Chronic kidney failure disrupts sexual function/sexual dysfunction (Sunanto, Rompas, & Pondang, 2015). Sabanciogullari, Taskin Yilmaz, Güngör, Söylemez, and Benli (2015) reported that 85.6% of patients with chronic renal failure have sexual dysfunction. Factors that influence sexual function in both men and women include hormonal problems, nerve disorders, decreased energy, and side effects of drugs (Lessan-pezeshki & Ghazizadeh, 2008). Other factors are emotional feelings, such as worry, anxiety, or depression, which are considered to endanger dialysis (Basok et al., 2009;Tannor, Archer, Kapembwa, van Schalkwyk, & Davids, 2017;Tobing, 2006). Changes in sexual function can cause complex problems, including physical and psychological issues that are influenced by internal and external factors (Sunanto et al., 2015). The response of each person will vary depending on the individual's perception of the stimulus of sexual dysfunction. Stimulus that takes place continuously to produce a sustainable response will result in individual adaptation patterns. The view of the importance of sexual function significantly affects intimacy and individual's relationship with his or her partner and, thus, his or her happiness in life (Hjelm, Bard, Nyberg, & Apelqvist, 2004).
Sexual dysfunction causes a feeling of unhappiness because sexual satisfaction is not fulfilled (Elvira, 2006). Sexual needs are important basic needs to be met, including physiological (i.e., biological sexual aspects) and psychological needs (i.e., the need to love and be loved). Fulfillment of sexual needs varies and depends on individual sexual desires (Hendranata, 2011).
In sexual needs are not met, individuals will respond by adapting to the problem. The response can be an adaptive sexual shift or ineffective response, depending on the individual (Alligood, 2015;Roy, 2009). However, little evidence is available on sexual dysfunction in patients with chronic renal failure, especially in Indonesia (Sunanto et al., 2015). Thus, it is necessary to explore how chronic renal failure patients in Indonesia adapt to conditions that represent adverse effects of the disease, especially sexual aspects.

Methods
This descriptive phenomenological study aimed to elucidate the experience of adaptation to sexual dysfunction in patients with chronic renal failure. Data were collected through in-depth interviews using semi-structured questions. This research was conducted by applying research ethics, that is, protecting participants, building trust, being honest during the research process, and preventing negligence that could negatively affect the institution's reputation. This study was approved by the Research Ethics Committee of the Faculty of Nursing, Universitas Indonesia with number 151/UN2.F12.D/HKP.02.04/2017. The participants were selected by purposive sampling. The inclusion criteria were as follows: 1) chronic renal failure, 2) sexual dysfunction problems since diagnosis of chronic renal failure, 3) ability to communicate well using the Indonesian and/or Javanese language such that the researchers could understand them, and 4) willingness to participate in the research, as signified by signing informed consent form. An open-question interview was conducted at the participants' homes, which lasted 45-60 min.

Results
The study participants were seven men (45-67 years) and five women (33-47 years). The themes identified from the analysis process are described below: Theme 1: Adaptation process to sexual dysfunction experienced by participants. The process of adaptation experienced in living life with sexual dysfunction was divided into two categories, namely, positive adaptation and negative adaptation. Positive adaptation was an individual's self-adjustment mechanism toward stimuli by using positive approaches, supporting their life goals, and not creating new problems. Most of the participants were found to have positively adapted, for example, by hugging their partner, accepting the situation, and dhikr or praying, as two participants stated: "Yes, it doesn't have to be like that (sexual intercourse). Communication from conversation, giving love, then a physical method such as kissing, hugging, and others." (P3) "Well sometimes, sometimes once a month. For refreshing. Hehehe (laugh).

" (P11)
A negative adaptation is defined as an adaptation that was not in line with the human life purpose, where the response damaged the integrity of the individual and created new problems. The participants felt their partners still expected sexual fulfillment, as they did before -the state of sexual dysfunction experienced by participants conflicted with the couple's desire to continue their sexual intimacy, so that the participants adapted negatively, such as via compulsion in relationships and leaving their partners to marry someone else. Other participants expressed that they still had sexual feelings, but they do not have the physical ability to act on them, so they only imagined sexual encounters. One participant stated,

"Sometimes I still serve my partner, sometimes I'm lazy. If I don't want to serve, the partner's response becomes less harmonious." (P9)
Theme 2: Sexual dysfunction experience. Male and female participants experienced sexual dysfunction. A male participant with erectile function problems stated,

"Yes, difficulty waking up (erection) is the point." (P3)
Another sexuality problem was about desire, as one male participant mentioned,

"[I] don't think about lust. Really. No. Now there is no lust at all." (P12)
Theme 3: Importance of fulfilling sexuality needs. Participants interpreted the fulfillment of sexuality needs as crucial for both men and women. Through sexual activity, humans can give their partners a feeling of mutual affection, as in the following participant's expression: "Yes, those sexual needs are significant. Life is like that, especially those who are husband and wife (married). If people are married, it is a form of expression of affection, love for his partner. Yes, it is a natural process; it is also important because of needs." (P12) Some other participants expressed a different interpretation. One thought more about the economic needs of the family and prepared for the future of his children. For other participants, sexual needs were only peripheral, and they prioritized the treatment for kidney failure that was being experienced, as one participant stated: Other participants choose non-medical treatment, but there were no results, as one participant revealed, "Alternative medicine has also been done, in the Karanganyar district which was promoted massively on the radio, until I finished the treatment, I did not get results. Ha ha ha (laugh)." (P5) Half of the participants said they were resigned to and accepted having sexual dysfunction, as expressed in the following statement, "Yes, 'Yes, now let go of me.' Thank God, my husband knows, he is not selfish." (P8)

Discussion
Adaptation process to sexual dysfunction experienced by participants. Adaptation is a process of change accompanying individuals' response to changes in the environment, and it can have physiological and psychological effects that will produce behavior (Chatrung, Sorajjakool, & Amnatsatsue, 2015;Roy, 2009). In this study, most of the participants (75%) went through a positive adaptation process. Some need their partners to be able to adapt as well, engaging in activities like sleeping together, kissing, and hugging. Spiritual activity was part of the positive adaptation process in dealing with sexual stressors due to chronic kidney failure (Krägeloh, 2011). The participants performed spiritual activities, such as remembering God, dhikr, and surrendering their living conditions to God. Through his grounded theory, Walton (2002) found that participants sought dialog with God and reflected on the meaning and purpose of life to alleviate stress.
In their phenomenological study in Turkey, Yılmaz and Özaltın (2011) found that six participants considered their sexual dysfunction as destiny and God's will, so they resigned themselves to being grateful so that they could avoid despair and depression. In this study, 48.5% of the dialysis patients who experienced sexual dysfunction accepted their decreasing sexual function. They thought that old age also influenced the decline in sexual function.
The negative adaptation processes found in this study were the participants' self-sacrifice for their partners. Sexual problems are the primary cause of disappointment in marriage, and they can lead to divorce, which occurred in 17% of the cases (Syarifuddin, 2014). In contrast, in another study, a woman in Turkey experiencing sexual dysfunction since diagnosis of chronic kidney failure did not feel the slightest concern when left by her partner due to sexual dysfunction. Yılmaz and Ozaltın (2011) mentions that this is a family relationship factor in marriage, as the woman's husband was his cousin.

Sexual dysfunction experience.
In this study, sexual dysfunction was reported in both men and women. This is consistent with the research of Finkelstein, Shirani, Wuerth, and Finkelstein (2007), who found that the incidence rates of sexual dysfunction in cases of kidney failure were almost the same in men and women. In men, sexual dysfunction mostly presents as erectile dysfunction and decreased sexual desire, whereas in women, only sexual desire problems are found. According to Finkelstein et al. (2007), approximately 65% of male dialysis patients have difficulty getting and maintaining an erection. According to Drüeke and Massy (2010), erectile dysfunction in patients with renal failure can be caused by arterial atherosclerosis of the genital area, which inhibits dilation of the cavernous artery during the erection process.
Another sexual dysfunction is the lack of sexual desire, which was experienced by nine participants (four men and five women). Most of them (67%) stated that the desire to have sexual intercourse had dissipated entirely. Others said it had decreased, but sometimes, sexual desire would still arise. This is in line with the results of Basok et al. (2009), who reported that 50% of women with chronic kidney failure experienced decreased libido, decreased orgasm, and decreased coitus frequency. Uremia due to chronic renal failure can also reduce sexual desire, lower fertility, and cause vaginal dryness (Arslan & Ege, 2009). Importance of fulfilling sexuality needs. Sexuality needs are natural needs that usually must be fulfilled. According to the participants, sexual relations are important because they are a means of expressing their affection to their partners and producing offspring. Fesharah (2006) described sexual needs as expressions of the feelings of two individuals who respect, pay attention to, and love each other, so that there is a reciprocal relationship between them. The aspect of sexuality has a vital role in maintaining intimacy with a partner. Some participants thought that the sexuality needs of adults until old age were no longer oriented to sexual intercourse alone, but on how to live life with their partners as loyal friends. The feeling of mutual love and support for each other was more important than sexual biological needs. The larger view of sexuality needs is more on attention and a supportive attitude, mutual love, helping each other when in need, being happy together, and becoming lifelong loyal friends (Santos et al., 2012).

Behavior in dealing with sexual dysfunction.
Approximately 25% of the participants only relied on medical treatment to cure their sexual dysfunction. This is line with the work of Thompson and Barnes (2013), who revealed that 52.4% of the patients with sexual dysfunction in the United States use medication to treat erectile dysfunction. Ho, Singam, Hong, and Zainuddin (2011) described the behavior of men in Asia in facing sexuality problems, where they expect more concrete medical solutions that will have positive effects that can be directly perceived, in contrast to the indirect effects of lifestyle changes, weight loss, and smoking cessation. However, women are more likely to accept the doctor's advice through counseling, and 80% of women in China check their health related to sexual and reproductive functions via health services. The likelihood of men in China to consulting with doctors about their sexual health problems is lower than that of women.
Moreoer, 25% of the participants used nonhealthcare treatments, such as traditional medicine, Javanese medicine, and massage. Their attempts at treatment were not successful. According to Ho et al. (2011), many people resort to exploring various types of traditional, alternative, and spiritual healing practices after being frustrated with the results of modern medicine. Non-healthcare methods combine body, mind, and spirit, and healing is achieved through the concept of energy and not matter, unlike modern medicine. Dwiyanto (2008) argues that the Javanese cultural community still holds a strong custom regarding the issue of sexuality by refering to a book entitled Serat Centhini by King Pakubuwono V in 1814 AD which contains problems of marriage and sexuality. Some of the ingredients that are often used in treating sexual dysfunction are ginseng, peg earth plants, turmeric, salt, Java chili, and chicken eggs.
Perceptions of the causes of sexual dysfunction. Among the participants, the causes of sexual dysfunction are related to nutritional intake, blood laboratory results, kidney disease, diabetes, hypertension, and physical conditions. Two participants felt that there were food restrictions in chronic renal failure that caused sex-ual dysfunction. According to Zhou, Liu, and Zhai (2007) and Guan et al. (2015), the adequacy of nutrition dramatically affects the quality of sperm, whereas a low intake of nutrients can reduce sperm quality and quantity. Foods that are needed to improve sperm quality are those that contain folic acid, magnesium, antioxidants, zinc, and selenium.
This study found that 25% of the participants thought that sexual dysfunction was caused by hormonal factors, hemoglobin, and blood creatinine levels. Ali et al. (2005) found that blood urea and creatinine levels were risk factors and had a significant negative correlation with the incidence of sexual dysfunction (p= 0.001), while hemoglobin levels had a significant positive relationship (p< 0.001). Men will have normal sexual function if the concentration of testosterone in the blood remains in the normal range of 2.8-11 ng/ml.
In this study, kidney problems were the most common causes of sexual dysfunction, affecting two men and two women. This is in line with the results of other studies, for example, Sabanciogullari et al. (2015) found that sexual dysfunction occurs in 40%-80% of patients with chronic kidney failure. Chronic kidney failure causes significant changes in the body's metabolic system, and one of the effects is anemia due to the disruption of erythropoietin production (Cibulka & Racek, 2007;Kim et al., 2014). Saglimbene et al. (2017) showed that fatigue due to anemia can also reduce sexual ability by 41%.
Participants' expectation of health service related to sexuality function. Most of the participants (67%) wanted attention from health services to address sexual dysfunction problems, which could be a polyclinic or consultation measure because it is an important part of health care. Participants thought that nurses should be proactive in communicating with patients about sexuality issues so that patients felt they received attention. According to Yee (2010), different perspectives on sexuality is-sues between health workers and patients are one of the reasons for not discussing sexuality issues. A positive perspective can be built from a comprehensive understanding and knowledge (Fesharah, 2006). This shows that nurses have not made an extensive contribution in helping patients overcome sexuality problems. Ho and Fernández's (2006) findings supported the hypothesis that health workers do not provide adequate care for patients' sexual health. Up to 92% of health workers never broached this topic with their clients, and 86% admitted that they did not provide adequate care. Several influencing factors included lack of knowledge about sexuality, shame, culture, lack of experience in caring for patients, lack of understanding of religious belief regarding sexuality, and nurses feeling embarrassed in dealing with patients' sexual issues (Clarkson & Robinson, 2010).
Limitation of this study were the majority of participants from the Javanese tribe. Ethnic and cultural differences will influence attitudes, perspectives, and adaptations in dealing the problems.

Conclusions
In describing the process of adaptation to sexual dysfunction in patients with chronic kidney failure, the experiences of the participants can be considered varied, and they were classified as positive and negative. The process is significant because it involves both the patients and their interpersonal relationships with their partners. The participants hoped that health services would be able to provide the best service in attending to the problem of sexual dysfunction in patients with chronic renal failure. Subsequent research may focus on analyzing appropriate interventions in addressing sexual dysfunction in patients with chronic renal failure.
search, Technology and Higher Education of the Republic of Indonesia, which supported this study financially, and all the study participants.