What can we learn? The push and pull of sex in cancer survivors

Let’s start this discussion with 2 cases: LS – age 51 Former professional rugby player/now in high tech sales Divorced x five years (two children from this relationship). Self-professed bisexual. Active on dating scene / pre-morbid use of PDE-5i – on demand, “high sex drive” FH strongly positive for Prostate cancer (father, two pat uncles, older brother) Dx ”aggressive prostate cancer” Chose androgen deprivation therapy and radiation. “My life is ruined – I‘ve totally lost my drive and when I’m stupid enough to try to have sex, even double dose Cialis is getting me half a hard on.” SL – age 36 Married, stable relationship (heterosexual) G2P1 1SA, Mother of 3-year-old boy Engineer (currently working PT) Never had high sex drive, dyspareunia after vaginal delivery, extremely difficult to orgasm since treated with SSRI for GAD / MDD DX NHL (non-Hodgkin’s Lymphoma) three years ago Treated chemotherapy and BMT. Last menstrual cycle was almost three years ago. Last attempt at sex, one year ago. “I feel so sorry for my husband. I have zero sex drive and I am so dry down there that even thinking about sex makes me cringe.” Surviving . . . Many of our patients are cancer survivors. These are patients with significant medical co-morbidities and complexities related to their cancers or the “lifesaving” treatments. Amidst their legitimate fears and anxieties, lists of medications, persistent side-effects, and pain, they are humans with sexual lives. Sexual health and function can be significantly impacted by cancer. The challenges to recover a positive and healthy sex life are real, but not insurmountable. What are some practical approaches to encourage and support your cancer survivor's sexual health: physically, mentally and spiritually? Cancer is common. Two in five Canadians (44% of men and 43% of women) are expected to develop cancer during their lifetime. About one out of four Canadians (26% of men and 22% of women) is expected to die from cancer. Picking up the pieces I offer a simple mnemonic to approaching the discussion of sex in any patient with cancer: The four Ps PERSPECTIVE: Where are they in their cancer journey and how important is sex currently? PREAMBLE: Acknowledging that just the diagnosis itself and certainly all the cancer therapies (chemotherapy, radiation, surgery, hormonal therapies) can be a direct “hit” against sexual function. PERMISSION: Is it acceptable to discuss currently? Perhaps this visit is not the right time, but showing openness to this area might lead to a discussion in the future. PIECES: Meaning all the details or pieces (including anatomy) that work or don’t work well. WHO knew? The WHO definition: “Sexual health is a state of physical, emotional, mental, and social wellbeing in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.” While there are those who identify as asexual, most people are sexual no matter what their age, gender, sexual orientation/preference, culture or belief system is. What do you really need? Let’s also consider Maslow’s “Hierarchy of Needs.” Sexual response involves a complex interaction of physiology, emotions, experiences, beliefs, lifestyle and relationships. Biopsychosocial phenomenon is the term, and it is the interaction of physical, emotional and relational factors that leads to healthy or dysfunctional sexual responding. The impact of cancer is only one in a long list of biopsychosocial factors effecting sex including: mental health, family beliefs, early sexual experiences, partner relationship, partner’s sexual functioning, cognition/beliefs, external stressors, etc. The assault on body image We must also include some discussion of body image. This is how people feel about how they see themselves. Changes to the way people look can affect how they feel. Sexuality can be closely linked to body image. A person can feel sexual, even if they aren’t having sex. Sexuality may also be related to confidence and self-esteem. Sexuality may be affected by changes to your body image. Sexuality can mean something different for everyone and it can change over time. Many people struggle with changes in their body image during or after their cancer treatment; changes which may be temporary or permanent. A cut and paste from a cancer survivor handbook gives the following examples: body changes from surgery hair loss weight loss or gain having a stoma lymphedema decreased sensation loss of body parts or organs scars fatigue, loss of stamina, or loss of energy changes in how the sex organs work treatment-induced menopause feeling differently about how you look feeling like your partner has changed his or her feelings about you. worry about dating and what future partners will think about you. Nuts and bolts If we have worked through the first three Ps of our algorithm, what does the “pieces” discussion need to be? Anatomy used in sexual activity (genito-urinary, breast) can be removed, damaged/distorted, or rendered completely non-functional. This understanding is crucial. In a male patient, we are discussing libido, thereby potential for issues of erectile function, ejaculatory function and what was the pre-morbid status of functioning of their anatomy. A cis man needs his “big head in the game,” a functioning penis, an intact neurovascular system, maybe more and testosterone. In a female patient we also need to focus on libido, (and depending on genito-urinary system) arousal, orgasmic function and overall pain. A discussion of pre-morbid status is crucial. A cis woman would need to be mentally engaged, have functioning genito-urinary structures, an intact neurovascular system and definitiely more, and an adequate hormonal profile. Just say NO to assumptions! And make no assumptions, as high as 10% of your patient population self-identifies as gender or sexually diverse. This is a very different discussion. But here lies the dilemma. No matter what the patient’s gender identity or sexual orientation is, the more open and creative the approach to sexuality is, the more likely we are to have success. A fixed, binary ideology can be extremely devastating if the goals are physically impossible. Low hanging fruit So, the overall approach is to systematically work through these categories and areas of potential dysfunction, make appropriate diagnoses and then specifically focus our therapies. Sounds straightforward? It isn’t. However, breaking it down, categorizing the issues and then coming up with a “game plan” can be a “game changer” for these patients. Sometimes the simplest maneuvers can be surprisingly effective if they are specific and precise. An example of this would be the use of vaginal moisturizer, topical estrogen and lubricant with sexual activity in a woman suffering dyspareunia from genito-urinary atrophy related to hormonal deprivation therapies or chemotherapy induced menopause. Pearls, pearls and more pearls So, in summary: Literally everything in the “cancer world” can have an impact on sexual function. Manage the four Ps - PERSPECTIVE/ PREAMBLE / PERMISSION / PIECES. Only go as far as the patient is comfortable with. Make no assumptions (about anything involving sex or gender). Set realistic goals and achieve them if you can. Be inclusive: there is a whole lot more to sex than traditional P-V intercourse. Communication, communication, communication! Systematically find and fix any “low hanging fruit.” Think outside the box! Don’t give up—things change/evolve! What have I learned? Calgary’s OASIS clinic is an AHS (Alberta Health Services) medical service for dealing with sexual health of cancer survivors and their partners. I act as a medical consultant for many of their patients and I have learned a lot about sex dealing with cancer survivors. It is challenging work but incredibly rewarding. This is just a superficial overview of a complex area of medical practice. I am Interested in any comments you might have in this realm; do you have any insights, “pearls” to share? We can all learn from each other. Dr. Ted Jablonski is a singer-songwriter, emerging playwright and neophyte poet who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta. He finds himself advising medical students at the Cumming School of Medicine and still on the front-line trenches of acute primary care.

What can we learn? The push and pull of sex in cancer survivors

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