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[TRACK 3: INTIMACY AND SEXUALITY]
The following section of this program contains some material that may be considered sensitive or
Intimacy, sexuality, and fertility issues are often neglected topics for cancer survivors. At the time of treatment, the focus is on achieving cure or control of the disease. But, during and after treatment, cancer survivors may experience changes in their desire to be close to other people, their levels of sexual desire and ability to enjoy usual sexual activities, and sometimes in their ability to have children.
In this section we will openly discuss sensitive material about intimacy and sexuality and will offer practical suggestions for people who may be affected by problems commonly reported by cancer survivors. If this section is not of interest please skip to next section – family communication.
Intimacy involves sharing yourself with another person in more ways than through sex. Holding hands, touching, hugging, and caring deeply about another person, as well as sharing feelings, hopes, dreams, fears, emotions, and religious values are all aspects of an intimate relationship. If you were involved in a relationship as you went through treatment, that relationship may have become stronger through the course of your treatment. In some cases, however, a relationship will not last because of the stress of treatment or because of other issues that surface during or after treatment. Your feelings about life may change, and this may affect your intimate relationships.
Whether you were involved in a relationship during treatment or not, you may become involved with someone new in the future. Think about when, and how, you will share the fact that you have had cancer. Talking about your cancer history is personal and can be very important, especially early on in a new relationship. You may want to consider waiting until you and your partner have had a chance to get to know one another and feel comfortable with each other before discussing your cancer experience in depth. Once you have established good communication skills and feel comfortable being with, and talking with, each other, it may be easier to talk about your cancer experience. When you do decide to share this information, don’t assume that your partner will react in any particular way. If you are defensive or confrontational, you might frighten your partner. Television shows and movies have portrayed cancer as a painful, traumatic, and often fatal disease. An unfortunate, but normal, response to hearing the word “cancer” is to be afraid and to believe that the person with cancer will die. Be open to helping your partner understand the effect your cancer history has had on your health and on the way you lead your life now.
Some types of cancer, like cancers of the breast, prostate, urinary tract, uterus, ovary, vagina, cervix, or testicles, are associated with obvious changes in sexuality. However, it’s important to keep in mind that
any type of cancer can affect sexuality. Sexuality is more than just the physical acts involved in intercourse. Human sexuality is a reflection of how we see ourselves both as individuals and in relation to others. It includes how we feel about our bodies, our need for touch, our libido or level of interest in sexual activity, communicating our sexual needs to a partner, and the ability to enjoy sexual activity. Sexuality is complex and involves many factors, including the desire for emotional intimacy. For some people, the ability to have children can affect their sexuality. A cancer diagnosis, and the treatments that follow, can affect sexuality in many ways. As a cancer survivor, you have probably experienced physical, emotional, psychological, and spiritual changes in your life. Any of these can have an impact on your sexuality and your desire for intimate contact with others. Additionally, the use of some medications, fatigue, or emotional stress can lead to a loss of the desire for sexual activity.
Many survivors who experience pain, discomfort, discharge, or bleeding during their first attempts at sexual intercourse after cancer treatment assume that they can no longer enjoy sex.This is not true. Different positions, various types of lubrication, more attention to foreplay, improved communication between partners, and talking with a sex therapist can help survivors deal with problems encountered during sexual activity. Let’s focus on the different challenges that affect women and men who are cancer survivors. Sarah is a sex therapist who works with cancer survivors.
The most common sexual problems that women face after cancer treatment are the lack of interest in sexual intimacy, pain during intercourse, the inability to achieve orgasm, and problems with lubrication. Women need both of the hormones, estrogen and testosterone, to maintain interest in sexual activity. Hormonal treatment for cancer that changes levels of estrogen or testosterone can change libido, which is another word for level of sexual desire. Too little estrogen can cause vaginal dryness, which can interfere with sexual intercourse. If your cancer is not sensitive to levels of estrogen in the bloodstream, your doctor may prescribe estrogen replacement therapy to increase estrogen levels and improve vaginal lubrication. If your cancer is sensitive to estrogen, as some forms of breast and ovarian cancers are, you may be able take estrogen in the form of a cream, vaginal pill, suppository, or through an estradiol ring inserted into the vagina. These forms of estrogen therapy can help with vaginal lubrication without increasing the levels of estrogen in your body’s circulatory system, but be sure to talk with your doctor about your individual situation.
In addition to hormonal treatment, several good lubricants can be used to overcome vaginal dryness. Generous amounts of a water-based lubricant, such as K-Y jelly, Replens, Astroglide, Hydra-Smooth or other brand should be applied to the labia, vagina, penis, or vibrator to ease penetration, prevent pain, and minimize the risk of injury to the vaginal wall. This can be turned into sexual foreplay, so that it becomes a source of pleasure for both partners.
Women who have experienced painful intercourse after treatment for surgery may have been involuntarily tensing the genital muscles during foreplay. This makes penetration more difficult, causing pain, which, in turn, further increases fear, anxiety, and muscle tensing, and may consequently lead to avoidance of sexual intercourse entirely. Cancer survivors who find that sexual intercourse is no longer comfortable may need to change positions, add lubrication, and practice muscle relaxation exercises.
Additionally, they could use this as an opportunity to learn about other sexual positions and techniques that they might enjoy. A woman who experiences pain during intercourse may want to try positions where she is on top or side by side, so that she can control the angle and depth of penetration. Generous use of lubrication will also help minimize discomfort.
Women who have been treated with certain forms of surgery or radiation need to know that these treatments can cause the vagina to become narrower and less flexible. This is called vaginal stenosis. Women who are at risk for vaginal stenosis need to use vaginal dilators to make sure that the vagina remains open. Even if these women do not plan to be sexually active in the future, it is still important to use vaginal dilators to keep the vagina open and flexible for future vaginal examinations by their health-care providers.
Among men, erectile dysfunction, sometimes referred to as impotence, is a common physical and emotional problem following treatment for prostate cancer. Many affected men become depressed about the loss of sexual function and about not being able to meet the sexual needs of their partners. These men should know that there are many different ways to approach the problem. Let’s hear about Jim’s experience.
After my surgery for prostate cancer, my wife and I wondered about how soon we would be able to start having intercourse again. We spoke with the surgeon who said we could start as soon as I felt physically up to it. He wanted us to be aware, though, that it could take up to a year or more for erections to return to normal or to the firmness they had been prior to surgery. We tried when I thought I was ready, but we were extremely disappointed after our first few attempts. So, we decided to get help from a specialist in erectile dysfunction. He provided me with some medication that might help make the erections more firm while my body was adjusting and recovering. This was very helpful. It took away some of the worry I was having about performance. My wife was also happier with the results. I learned that it’s important not to be afraid to ask for the help you need.
Erectile dysfunction may be related to damage to the nerves or the blood vessels supplying the penis, and it could also relate to the stress and emotions that men with prostate cancer frequently experience. A doctor who specializes in treating erectile dysfunction can determine the cause of the problem and suggest ways to treat it. Most doctors who specialize in erectile dysfunction are urologists, but there are a few general practice doctors who are certified in treating erectile dysfunction. A good resource is www.impotencespecialists.com, where you can get a referral to a specialist in your geographic area.
There are several types of medicines that can be taken to induce an erection. Some, like Viagra, Cialis or Levitra, are taken in pill form. Other medicines are rubbed on the penis to relax blood vessels, or inserted or injected into the penis or urethra to cause an erection. Some men may not be able to take Viagra or
similar medications because these may interfere with other medications these men are already taking or because of some other medical condition unrelated to their cancer. Any doctor who treats a man for erectile dysfunction must know about all the medicines that person is taking, including over-the-counter and herbal medicines, so that potentially harmful chemical interactions between these medications can be avoided.
There are also different types of penile implants and other devices to help men achieve and maintain an erection. If psychological or emotional factors contribute to the problem, talking with a licensed sex therapist can be helpful. The American Association of Sex Educators, Counselors, and Therapists provides a listing of certified sex educators and counselors by state. Men whose maintenance therapy for prostate cancer involves the use of hormones will need to talk with their doctors about options for preserving sexual function.
Treatment of testicular cancer may involve surgical removal of a testicle. This treatment does not make a man sterile as long as he has one functioning testicle. However, some men are bothered by their appearance after this surgery, and this can affect their ability to achieve and maintain an erection. Men who are thinking about having a testicular prosthesis implanted, either at the time of the original surgery or at any time afterward, should know that many experts do not recommend testicular implants for cosmetic reasons. Additionally, surgical fees for this procedure are high, and most public and private insurance plans will not pay for it. After the perceived problems with silicon breast implants among women, testicular implants are not generally offered in the United States. Some companies are making saline-filled implants that could be more readily available.
Men who have had lymph nodes removed from their pelvic area or groin may have had damage to the nerves that control ejaculation. If so, they may still experience the sensations of sexual activity and ejaculation, but without the release of fluid during ejaculation. Men who have had their prostate gland or seminal vesicles removed, or who have had radiation therapy after prostate cancer, may also experience orgasm with little or no fluid being released. The absence of fluid will not affect their ability to have an orgasm. In some cases, the semen is produced but flows into the bladder rather than moving into the penis. This is called retrograde ejaculation. The feelings of ejaculation are not affected, but no fluid is released. The semen and sperm will eventually be carried out of the bladder with the urine, which might look cloudy. For men considering sperm banking, sperm can be harvested using methods other than ejaculation.
All cancer survivors whose sexuality, and specifically sexual organs, have been affected by cancer or cancer treatment can benefit from taking time to explore sensations in other areas of the body. The areas
of the nipples, inner thigh, ears, neck, and face are all very sensitive to stimulation. Try different types of touch, from a light touch using the fingers, a piece of silk, or a feather, to a deeper, massaging type of touch, until you discover techniques that work for you and your partner.
It’s also possible that sexual function may be affected in ways that are not directly related to the sexual organs. For example, survivors who get short of breath during physical activity need to plan ahead for sexual activity. Survivors who use supplemental oxygen should make sure that they have enough oxygen in the tank and that the tubing is long enough to allow them to move around freely during sexual activity. These people may find breathing easier if they lie flat on their backs. Positions that involve either sitting upright or standing may be more comfortable, since they allow the lungs to fully expand and take in more oxygen with each breath. These people should be sure to tell their partners if they are getting short of breath. If so, they should take a rest or slow the pace of their activity until they no longer feel short of breath.
Survivors who have conditions that make their bones fragile, like multiple myeloma or bone metastases, may be concerned about the possible impact of sexual activity on their bones. Careful positioning may make sexual activity possible, comfortable, and safe even for these people. Generous use of pillows, rolled towels, and blankets can provide for comfort and support. Any survivor who experiences pain at any time during sexual activity should tell his or her partner immediately, and check if the affected part of the body can be moved without pain. They should contact their doctor right away if there is redness or swelling at the site of the pain, or if the pain does not go away in a reasonable time.
Finally, anyone who is sexually active, whether they have cancer or not, should take precautions against
sexually transmitted diseases. Any exchange of body fluids between people creates a risk of transmitting
an infectious disease. The best protection against sexually transmitted diseases is to always
use a latex
condom, which can be used with water-based lubricants, such as K-Y jelly. These should be used for
oral sex, vaginal intercourse, or anal intercourse. Before performing oral sex on a woman, a dental dam
or plastic wrap should be placed over the woman’s vulva to prevent possible transmission of infection.
When performing oral sex on a man, the use of flavored condoms or topping a regular condom with
flavored, water-based lubricant can diminish the taste of the barrier.
Your doctor, oncology nurse, or social worker may have talked to you about fertility issues before you started treatment. Survivors who do not want to have children should practice an effective method of birth control. Survivors who knew before their cancer treatment that they would want to keep their options open were probably offered the chance to bank sperm, or to freeze embryos, ovarian tissue, or eggs. If you did not do any of these things before treatment, and you later decide that you do want to have children, there are things you should consider. First, you may want to talk with a reproductive endocrinologist or a fertility specialist. New techniques are constantly being developed to treat infertility. [Narrator]
A growing number of doctors, nurses, social workers, and other providers are not only comfortable talking about sexuality and intimacy, but they have developed a great deal of expertise in it. Sometimes, all that’s needed for a survivor to make his or her concern known is to simply bring up the question. If you don’t feel comfortable with the provider you have, ask for a referral to another provider with the expertise you need. [Narrator]
In summary, the desire for intimacy is a basic human trait. It brings joy to our lives and allows us to give joy to others in a variety of ways. Survivors may find that using survival skills, such as finding information, communicating, negotiating, solving problems, and making decisions, which are found in earlier Toolbox
programs, helpful as they explore new ways of expressing intimacy and sexuality in current and new relationships.
THE NEWSLETTER Datchet Health Centre JUNE 2012 Patient Participation Group Editor’s note Last March, in my first newsletter, I said that comments or questions will be welcomed if left, in writing, at Reception. Although there have been none, I have been asked if letters to the editor, intended for publication, are acceptable. My reply is “Of course”, provided that my decisio
Journal of Pathology J Pathol 2007; 211 : 241–251 Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/path.2098 Review Article Skin ageing and its treatment L Baumann* Department of Dermatology, University of Miami, Miami Beach, FL, USA Abstract L Baumann, Department ofDermatology, University of The effects of chronic sun exposure on skin are r