DEFINING & TREATING SEXUAL DISORDERS
Being diagnosed with cancer and undergoing treatment can have a significant impact on all levels of one’s life. Fortunately, even unlike several decades ago, most people who are diagnosed with cancer will go on to live for many years. There are stages of diagnosis, treatment, and recovery that each have different impacts on sexual functioning as well. Nearly 50% of cancer patients report issues with sexual functioning. Utilizing a multi-disciplinary approach to treating sexuality issues during or after cancer treatment is essential given the complex intersections of physical, psychological, emotional, and relational dynamics.
Helen Singer Kaplan, the pioneer of the field of sex therapy, created a beneficial decision tree that visually outlines how sexual disorders can be defined and treated in a context of these intersecting physical, psychological, emotional, and relational dynamics:
SEXUAL RESPONSE CYCLE & IMPACTS OF CANCER
Another useful approach to treating sexual dysfunctions after cancer is to understand how cancer impacts each stage of the sexual response cycle. Starting in the 1960’s until today, researchers have developed various models of sexual response. In summary, there can be three or more stages of sexual response, including: excitement, desire, plateau, orgasm, and resolution, depending on the model used. It has been thought that while men have a more linear sexual response style, (i.e. excitement, plateau, orgasm and resolution, women have a more circular sexual response style involving thoughts, feelings, and desire at times developing as a result of arousal. Regardless of the model used, there is an opportunity for sexual dysfunctions to develop along each step. How these sexual dysfunctions are developed out of a response to cancer diagnosis or treatment is the focus of this scope of our practice.
COMMON FEMALE SEXUAL DYSFUNCTIONS
Below is a list of common sexual issues or dysfunctions that develop during cancer diagnosis and treatment. This list is not exhaustive and each woman’s experience of her sexuality during cancer may produce a unique set of challenges. It should also be mentioned, however, that many women will receive a diagnosis of cancer after they already have a sexual dysfunction, relationship issue, or history of sexual abuse. Pre-existing sexual issues or trauma can be amplified or expanded by the journey through cancer treatment and recovery. In addition, a woman’s partner may have their own set of pre-existing sexual issues, which also impacts her sexual functioning in the face of cancer.
Altered Body Image
Depending on the type of cancer that a woman has, she may have significant changes to her body, e.g. loss of one or both breasts. In addition, changes during cancer treatments such as loss of hair or pubic hair can impact how a woman perceives and experiences her body. Body image and functionality can be key in sexual desire as well as sexual functioning.
Loss of Sexual Desire
Women’s sexual desire is complex and multi-faceted. In contrast to many men, whose sexual desire is spontaneous as a result of being touched, seeing sexual images, or thinking sexual thoughts, women’s sexual desire is the product of many aspects of a woman’s overall functioning. For example, the way she feels about herself, her relationship with her partner, her comfort with her own body, the types of thoughts she has about sex, her overall emotional state, her energy level, etc. When these varied aspects of women’s life are functioning well, sexual desire tends to grow naturally out of them. In contrast, when one or more of these areas is not functioning well, low sexual desire may result.
Many women experience low sexual desire during or after cancer treatment, and at times their sexual desire may not return to the same level even after complete recovery from cancer. Mental and physical fatigue, increased levels of depression and anxiety, relationship stress, and physical changes are very common during treatment and recovery. Any of these changes can impact women’s sexual desire.
Sexual arousal includes all of the physical, psychological, and emotional changes that take place during the sexual response cycle. Women can feel physical arousal before sexual desire or physical arousal after experiencing sexual desire. Depending on the type of cancer and cancer treatment, there may be physical changes in the body that impact the ability to become aroused. For example, the nerves supplying the pelvis may be damaged or severed during a total hysterectomy or physical changes will result in a woman’s inability to produce her own lubrication during sexual arousal. In addition, many women cope with cancer treatments that are invasive and painful by dissociating from their bodies. Given a connection to one’s body is central to fulfilling sexual experiences, being disconnected can impede levels of sexual arousal. In addition, cancer and its treatments can leave a women associating her body with negative thoughts or anticipating pain.
Difficulty with Orgasm
Utilizing the decision tree previously outlined, there can be physical, psychological, emotional, or relational reasons why a woman does not reach orgasm. There may be nerve damage that prevents orgasm or makes the type of stimulation needed to achieve orgasm different post-treatment. A woman may also have anxiety about sexual activity and be unable to let go during sexual arousal, which leads to an inability to climax. Alternatively, a woman may not feel comfortable with her partner due to changes in physical appearance and may not be able to orgasm with her partner as a result. Each of these reasons for an inability to orgasm requires a unique sex therapy treatment approach.
Sex positive education, masturbation skills training, and relearning one’s body after cancer treatments may be essential. In addition, learning to grow in one’s sexual expression, trying new methods of partner sex and pleasuring, and deepening communication are key to regaining successful sexual functioning.
Pain during sexual activity may be caused by emotional and psychological reasons or physical reasons. Many cancer treatments can alter a woman’s sexual anatomy, e.g. vaginal dryness due to changes in hormone levels, damage to the blood supply of tissues, scarring that prevents vaginal stretching, or alterations in the structure of the vagina. In addition, there are several pain models that outline the psychological and emotional processes of experiencing pain once, and then later anticipating and catastrophizing that pain will occur again. Pain can also be psychosomatic, meaning that women who have not processed traumas associated with sexuality or cancer treatment, may use pain as a way to avoid thinking about their original trauma. In this way, pain can be a psychological mechanism of avoidance and only by working through underlying traumas can a woman break free from her cycles of sexual pain.
COMMON MALE SEXUAL DYSFUNCTIONS
Loss of Sex Drive
As mentioned previously, loss of sex drive is common with most people who are diagnosed with and treated for cancer. For men, testosterone levels are a major determinant of libido. Many cancer treatments, e.g. treatment for prostate cancer, can place men on an androgen deprivation therapy, which lowers testosterone levels and produces multiple negative side effects: lowering of sex drive, production of hot flashes, fatigue, lack of ejaculate, changes in fat distribution in the body and development of breasts (gynecomastia), and erectile dysfunction. Any of these physical changes can also contribute to loss of sexual desire from a psychological and emotional standpoint as well.
Loss of erections is common in cancer treatments for men, and it not only impacts sexual functioning but sexual self-esteem and even relationship functioning. It is very common to have loss of erections after surgery for prostate cancer. Treatments for prostate cancer can have different negative side effects that can impact sexual functioning for men. Significant side effects of surgery include incontinence and erectile difficulties, which may or may not get better over time. Significant side effects for radiation include frequent urge to urinate or pain with urination and/or rectal irritation that may lead to diarrhea or pain. Erectile problems can also occur 1-2 years after radiation treatment.
It is important to talk with your physician about possible nerve damage due to prostate cancer treatments. Depending on the extent of nerve damage, there may be a significant permanent loss of erections. It can take 1-2 years before erections can return after treatments, so establishing reasonable expectations is important. In addition, finding ways to experience sexual pleasure with your partner during that time can be very important to your own sexuality and also your relationship. Erection medications, such as Viagra, a vacuum pump, or a penile self-injection can be used to aid in having erections.
Due to the physical and emotional changes that take place after cancer treatments and loss of sexual function, working with a sex therapist with your partner can provide sexual skills training in light of these changes, as well as increasing communication to buffer the strain of the changes in the sexual dynamic. For some couples, facing sexual dysfunction in the light of cancer can be the first time that they have ever talked in-depth about their sexual relationship or personal preferences. Learning new skills to work with the changes is not only possible, but can lead to an enhanced and more connected sexual relationship. This is a positive side effect of cancer diagnosis and treatment that most men do not anticipate.
Pain With Orgasm
Pelvic or bowel surgery after a cancer diagnosis can lead to difficulty achieving orgasm or painful orgasms. In colon cancer, if the colon is removed, men may have scar tissue inside their abdomen and pelvis, which can cause pain with orgasm. A man with these symptoms may need to see a physical therapist specializing in pelvic floor therapy, as well. In addition, men who have pain with orgasm may develop a negative pain-avoidance cycle as previously outlined for women above. Avoiding sexual activity for fear of pain can impact not only the man, but also his relationship, which makes sex and relationship therapy useful in this context.
Altered Body Image
Like women, men can have changes in body image after cancer diagnosis and treatment. One of the most common outcomes of bladder cancer, for example, is the required use of an ostomy, or artificial passage into the body in which urine is collected outside the body in a bag. This can drastically impact one’s body image, specifically in sexual situations. In addition, certain cancer treatments can cause the penis to shrink upwards into the body, which can be devastating to some men.
Learning to talk about your feelings as your body images changes is important. Many men are not comfortable talking about their feelings, especially with regard to body image and sexual functioning. Finding support from peers can also be helpful as one can learn practical strategies from others who are further ahead in their journey. Understanding changes is important to normalizing them. Once one has normalized their experience they are less likely to feel shame, and more likely to be open about their feelings.
Urinary leakage after a radical prostatectomy for prostate cancer is very common. Leakage can happen any time, including during sexual activity. This can cause men to avoid sex for fear of leakage when they become aroused, which they may find embarrassing. Finding strategies to cope with this can be helpful. Some strategies include: sexual activity in the shower, wearing a condom during intercourse, using a constriction band, emptying your bladder before sexual activity, or being treated by a physical therapist. Many times, talking about the problem and finding solutions is the first step towards resolving the issue.
THERE IS HOPE
Treatments for sexual dysfunctions in the context of cancer may be similar to treatments to the sexual dysfunction without cancer present. However, utilizing a multi-disciplinary approach and working with your medical doctor may be more relevant in the face of cancer given the physical changes that result from cancer and it’s treatments. There is hope for healthy sexual functioning after cancer diagnosis and treatment, and perhaps an evolved and enriched sexual relationship for you and your partner.