My thoughts on how the cancer experience–diagnosis and treatment–influences patient sexuality could have been blended into my December 2013 blog regarding quality of life issues in cancer patients. There is, however, a keen visceral interest in the association of sex and the emotional baggage associated with cancer, and I want to touch on it seperately. In many, this pleasurable slice of life’s experiences can continue, despite having to share the stage with that villainous disease. At a minimum, the exploration of sexuality by the cancer patient doesn’t necessarily have to be abandoned–said another way, the two are not automatically mutually exclusive. That said the cancer experience is often like a thunderous intrusion into the psyche of most individuals. In their popular source book for patients, Choices (1), Morra and Potts point out that since a substantial percentage of the general population has pre-existing sexual problems caused by stress, it’s certainly understandable why cancer and cancer treatments might change sexual relationships. Let’s explore this!
The treatment of malignancies of the sex organs and adjacent areas—prostate, perineum, penis, testicles, vagina, ovaries—and also of certain endocrine glands all obviously have a direct impact on sexual performance, some to a greater degree than others. Treatment of other cancers, while not causing a direct compromise of sexual capability, can create embarrassment and self-consciousness that alter a person’s self-esteem and sexual prowess. Such is seen with breast cancer treatment; colon cancers in which there is a need for a colostomy; various head and neck cancers that require disfiguring surgery like jaw and tongue removal, laryngectomy, gastrostomy, and tracheostomy tubes; limb sarcomas that require amputation; and many others. These are identifiable physical problems that can alter the very dynamic of sexual relations. Beyond these factors, however, are the subtle and intangible matters that compromise a person’s sex drive—such things as alteration of smell and taste, xerostomia (dry mouth), esthetic compromise related to loss of hair, breasts, and muscle mass, depression, fatigue, anxiety, and insomnia, to name a few. Prior to the development of contemporary prostate operations, the radical prostatectomy was invariable associated with profound erectile dysfunction–not so now. Even now in these patients, and also with other cancers in both sexes, the general loss of sexual appetite is not an insignificant matter.
The quintessential example of cancer’s intangible impact on sexuality is seen in females with breast tumors. For better or for worse, in our culture, breasts epitomize femininity. Sexual allure, love making, infant nursing—all of these are equated with womanliness, and the breasts are a focal point that, when altered can dramatically influence the sense of sexual self. The time in which radical mastectomy was frequently employed is mercifully past, and the esthetic impact of breast operations has been substantially mitigated by the skills of reconstructive surgeon. Within the domain of the bedroom, however, this is far more complicated, and must involve the maturity and sensitivity of one’s partner(s).
Despite the employment of contemporary organ sparing and reconstructive treatment strategies, the discovery of a breast mass is frightening. It is easy to give the objective reassurance that the vast majority of breast masses turn out to be benign. Even though that is factually accurate, the inner fears felt by patients are primordial, and the mere finding of a breast mass can evokes multiple issues and emotions, many of which are unrelated to cure. This topic is the subject of much literature, and I only mention it in a passing way, because it is of such a concern for patients and oncologist alike. As it pertains to the latter, guidance into the right support system is a primary concern for the entire cancer team. I have written before – and it certainly applies to this population of patients – almost all of those in whom there is a suspicion of cancer are frightened. In doing research for the development of my book,The Cancer Experience; the doctor, the patient, the journey (2), I interviewed a number of women breast cancer survivors (male breast cancer is very unusual), and I was struck with the difference of attitude relative to age. Not surprisingly, older women were less concerned about the implications for their sexuality and zeroed in more on the cure issue. What did surprise me was that several women confessed that following the treatment of their cancer, they had sensed in their partner a very subtle change—not so much a lack of sexual attraction, but a concern or a feeling of avoidance of disease. They sensed in their partner a fear of contagion. One woman said she felt like “untouchable goods.” It’s interesting to speculate whether this was only a product of the imagination, but those that related this feeling were intelligent and perceptive, and not individuals prone to hyperbole. When I first encountered this most private of thoughts, my first inclination was to dismiss it as an ill-perceived notion; surely no intelligent partner could be concerned with the contamination of their own body by cancer. However, I am reminded of a time in the not too distant past when people with oral cancer queried me about transmissibility to their partners, and I might add, on several occasions, their partners asked me privately about their own safety. My dogmatic response at the time was a resounding no: “There’s nothing to worry about”. Since then, we have learned of the carcinogenic capabilities of the human papilloma virus—first in the uterine cervix, and more recently in the oral pharynx. As a result, the dogma of the past must be altered to consider the reality of oral-genital, and genital-oral transmission of this virus. Said another way, this is a sexually transmitted disease (STD). I say this so that the reader is not dismissive of the fact that some partners may have a sense of personal fear to which they would perhaps never admit but which is well within the perceptive capability of a woman keenly in tune with her mate. When combined with existing concerns about the impact of her breast cancer on her personal appeal, the emotional calculus becomes complex. I make no attempt to guide the reader in understanding these complicated psychological issues. Instead, I seek only to alert them to their existence and to emphasize the need for physician comprehensiveness in dealing with cancer patients, no matter what their sex, no matter what the type of cancer. This is not work for shortsighted dilettantes who may be technically elegant, but ignorant and/or dismissive of the big picture.
On repeated occasions in my book (2) I have mentioned the benefits of a doctor touching and making physical contact with a patient. So it is with cancer victim and partner. I am convinced that most humans gain solace from being touched, and being in a relationship should provide ample opportunity to indulge this most human of needs. It is my impression that much of the sexuality needs of the cancer victim and partner stop short of actual sexual intercourse. Instead, the comfort afforded by caresses and other expressions of affection are important for both partners, regardless of who is afflicted with the disease. Having cancer is a provocative experience—not only of anger, but also of sadness. The spiritual impact of another’s love and concern is especially valuable to the one who has the cancer. Anger is more of an individual matter, and working that emotion out is accordingly more of a singular endeavor. On the other hand, sadness can and should be shared.
Physicians are sometimes uncomfortable having a dialogue about these matters with cancer patients, and if such is the case, they should refer the patient and their partner to a sex therapist or a psychotherapist who works with couples. Those therapists who are well trained usually belong to one of the two following organizations: American Association of Sex Educators, Counselors and Therapists; and National Association of Oncology Social Workers. Additionally, the American Cancer Society is an organization replete with resources for advice and counsel.