Sunday, February 18, 2007

Diagnosis Cancer: Let's Talk About Sex

A February 17th article on Medical News Today ( reported that the lack of communication about sexuality and intimacy is a prime issue for caregivers of patients with cancer. This finding was based on a study conducted by University of Western Sydney researchers who sought to evaluate how caregivers discuss and negotiate sexuality and intimacy when caring for a partner with cancer and to gauge the most effective cancer support services.1

In this study, caregivers completed questionnaires (n=131) and detailed interviews (n=20). Results from this study demonstrated that 80% of respondents indicated that a cancer diagnosis had a detrimental impact on their sexual relationship with their partner. Both male and female caregivers (86% and 76%, respectively) reported that cancer had affected their sexuality. Caregivers indicated that lack of communication both between the couple and with healthcare providers was a major issue. Failure on the part of healthcare providers to discuss sexuality and intimacy concerns with a couple made it difficult for caregivers to communicate their feelings. According to the study’s lead researcher, Dr Emilee Gilbert, “Part of the willingness to raise the topics of sex and intimacy probably stems from not being given the license to talk about it. Those feelings left them feeling angry, upset, and resentful of healthcare professionals.”1

When healthcare providers did not approach the subject of sexuality and intimacy, caregivers believed they could not mention this subject or voice their concerns. If this sensitive topic was mentioned by healthcare providers, it was only briefly touched on or discussed during an inappropriate time (eg, after the diagnosis of cancer was made). Conversely, when healthcare providers raised the topic of sexuality and intimacy and allocated sufficient time for questions and discussion, caregivers reported an excellent experience.1

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Human sexuality is a complex, multifaceted phenomenon with biologic, psychologic, physiologic, interpersonal, and behavioral components. While sexuality varies by patient and partner(s); age; gender; religious, personal, and cultural values; and life experiences; it is apparent that some type of standardized assessment or discussion should be facilitated by providers.2 “Breezing” over this topic, or omitting it altogether negatively affects patients’ health outcomes, as well as their sexual partners’ lives. Are healthcare providers ignorant or merely negligent when it comes to the sexual health of patients with cancer and their partners? Do they generalize that older patients or those with certain cultural or religious beliefs do not have sex or would be offended if sexuality was mentioned, even in a clinical setting? Does a diagnosis of cancer mean abstinence?

In Gilbert and colleagues’ study, healthcare providers did not discuss sexuality because they felt that it would have been “intrusive” or “disrespectful.” Other factors that may have prevented both provider and patient and caregiver from discussing sex included age, gender, and culture.1 Regardless of the reason, it seems from this study that healthcare providers are holding back because of their emotions or assumptions of their patients and their partners.

Complete healthcare should be just that: evaluating biologic, behavioral, psychologic, and sexual health. For healthcare providers to omit or casually mention sexual health is equivalent to examining only half of the body, taking only one blood pressure reading, or describing only the positive benefits of a respective treatment. Therefore, providers are offering incomplete healthcare. Healthcare providers cannot expect that patients or their caregivers will automatically mention sexual health issues, particularly in the healthcare setting. While some healthcare providers may feel that conversations about sexuality may be taboo in cancer, what about having this same conversation with patients postpartum? Do providers refrain from discussing sexual health and offering guidance to women and their partners after delivery?

A diagnosis of cancer prompts several concerns and questions in the minds of patients and their partners, including prognosis, adverse effects of treatments, ability to work, and participation in activities of daily living. Sexual health might not be an immediate concern, but one that the healthcare provider must discuss and anticipate down the road. While cancer cannot be cured, scientific and medical advancements within the past decade have increased survival, remission rates, and quality of life. Therefore, healthcare providers are now viewing certain forms of cancer not as a “life sentence” but rather a “chronic condition.” When caring for patients with chronic conditions, particularly diabetes, are there not protocols, guidelines, algorithms, regularly scheduled assessments of global health, disseminated education, and health discussions driven by healthcare providers? In men with diabetes, do providers initiate discussions regarding the potential for erectile dysfunction and other sexual issues? Essentially, patients and their caregivers hope for a return to some sense of normalcy, one that entails their lifestyle routines, including sexuality and intimacy.

Sexual dysfunction in the presence of different tumor types is well established and highly prevalent. Across tumor types, prevalence ranges from 40% to 100%. Causes of sexual dysfunction in cancer can been both physiologic and psychologic.2,3 Furthermore, compared with the physiologic side effects of cancer therapies, sexual problems do not tend to resolve within the first few years of disease-free survival. In fact, they remain constant and fairly severe.2 Not only are sexual problems bothersome, they prevent a return to normal posttreatment life.2,4

My recommendation is to treat sexual health as a component of global health; one that is evaluated, discussed, and followed during the long-term. Perhaps it would behoove healthcare practitioners to standardize a sexual health questionnaire for patients and their caregivers to complete. After reviewing their responses, providers could segue into a dialogue about the biologic and behavioral aspects of cancer and cancer treatment and their effects on sexual health. Next, just simply ask the patient and their partner if they have any questions or immediate or long-range concerns about their sexual health. Finally, offer guidance and additional literature, and follow-up with the patient and their caregiver to ascertain if their needs have been met, or if they require referral. This approach has appeared to work for other chronic conditions, why not cancer?

1. Danninger L. Intimacy and sex: the unspoken casualties of cancer. February 17, 2007. Available at: Accessed February 2007.
2. National Cancer Institute. Sexuality and reproductive issues (PDQ®). Health professional version. January 23, 2007. Available at: Accessed February 2007.
3. Derogatis LR, Kourlesis SM. An approach to evaluation of sexual problems in the cancer patient. CA Cancer J Clin. 1981;31:46-50.
4. Bokhour BG, Clark JA, Inui TS, et al. Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med. 2001;16:649-655.

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