Sexual Health in Cancer Survivorship

A cancer diagnosis and subsequent treatment can impact many areas of life —physically, emotionally, psychologically and cognitively. But one of the most commonly affected areas of life impacted by disease and treatment — sexual health and intimacy — is often underestimated, according to world-renowned sexual medicine gynecologist and survivorship medicine expert Michael Krychman. To gain further insight on sexual intimacy in cancer survivorship, CURE magazine spoke with Krychman, executive director, The Southern California Center for Sexual Health and Survivorship, about the impact of cancer on sexual health, discussing the issues during clinical visits and simple solutions for optimal quality of life.

Should issues with intimacy and sexual health be anticipated with a cancer diagnosis?

Krychman: The vast majority of people diagnosed with cancer have issues with sexual intimacy at some point. The extent to which they’re impacted really depends on a lot of variables — type of cancer, the patient’s age, the grade and the treatment.

Clearly, if someone has early-stage cancer and is able to be treated in a less aggressive way, it may still have an impact on a variety of things, but not to the extent as it would for someone who is aggressively treated with chemotherapy, radiation or surgery. Cancer does change how you think about yourself, look at yourself and feel about yourself as a sexual person.

What sexual health effects can be associated with cancer diagnosis and treatment?

There are certainly a lot of things that are quite similar between both men and women, and I would say that they’re broken down into different classes. There are direct and indirect effects.

Direct effects from chemotherapy, radiation or surgery can include pain, fatigue, and issues with desire, arousal and achieving orgasms. Women can experience vaginal dryness and loss of sensation, which can easily lead to feeling a loss of femininity. Procedures resulting in scarring can also alter the patient’s view of themselves as a sexual person

Indirect effects are results of treatment that negatively impact sexual health, including stress, financial concerns, difficulty finding comfort and losing strength. If you have radiation and can’t even put your arm around your partner, it may become a big issue. It affects a variety of different things, and it impacts the whole relationship.

For patients, is the psychological or physical aspect more impactful on sexual health?

I think that it’s a dual issue. It’s a dual process, and it really depends on the person — every person is different. In terms of perception, the disease changes the way that people view themselves as sexual beings, in particular, and this causes sexual self-esteem issues.

It’s estimated that for breast cancer, anywhere between 50 percent and 100 percent of people have issues and that’s really related to the fact that people can be diagnosed at a variety of different stages and grades.

For clinicians, it’s a balance. You can’t treat a problem if you don’t know that one exists, and I think that it’s important that you talk about the issue. Clinicians need to create a comfortable environment. They don’t need to be experts, but they need to make themselves available for partial assessments and be able to refer patients to specialized clinics. Silence is the biggest deterrence.

Are patients typically apprehensive to talk with their providers about sexual health and intimacy?

I think that patients want to talk about it, but they don’t know how and they have their own hang-ups. Why do they have their own hang-ups? I think it’s because they feel like they have a laundry list of things to discuss and there’s only a certain amount of time to talk to their doctor. They also don’t want to embarrass their clinician.

Then there is this “conspiracy of silence.” Patients feel that if sexual health were important, their health care provider would raise the topic during the visit. At the same time, the health care provider feels that if it were important to the patient, the patient would bring it up. So, either side is waiting for the other to talk about it first and, ultimately, nobody brings it up.

Patients often think that they’re being selfish and should just be thankful they are alive, but it’s not about being selfish — it’s about quality of life.

Are there gender discrepancies in discussing sexual health in cancer survivorship?

Both men and women are very uncomfortable talking about this issue. And believe it or not, men speak up more often because it’s much more acceptable for men to be sexualized in our society. Every day on television, we see ads for Viagra, Cialis and Levitra; presidential candidates talking about erections, famous athletes talking about testosterone — for men, it is very common to have that discussion. Women, however, are not allowed to be sexual in our society, so this is an issue.

How can nurses and health care providers ease patients into conversations about sexual health issues?

I think that breaking the silence is the most important thing. Again, you can’t treat a problem if you don’t know that one exists. Talking with patients about sexual health and intimacy in survivorship decreases isolation, normalizes the problem, and lets them know that they’re not crazy.

Sometimes, it’s a challenge for providers. Clinicians can feel inadequate about their knowledge of treatment, but it’s important to know that there are a lot of simple solutions. There are hormone therapies, non-hormonal moisturizers and lubricants, herbal supplements and vaginal dilators. It’s also important for providers to be aware of the many facilities and experts that focus on sexual health and reclaiming sexual intimacy in order to refer patients in need.

What is your overarching message to survivors who feel that they may never regain a normal sex life?

My message is one of hope. There are simple solutions, and the best predictor of how you will do after is how you did before. Not everyone is going to be forthcoming and able to help you, but it’s important to recognize that there are solutions: sexual health is important for survivorship, and you have to advocate for your own health.

My philosophy is that sexual health is general health. There is emerging data showing that regular sex, ejaculations and orgasms, may lead to lower grades of chronic disease and decrease chronic illness. It’s also known that sex can decrease the risk of cardiovascular disease and increase immunity, and other studies have linked regular sex to lower rates of prostate and breast cancer.

I think that the power of sexual intimacy — the ability to change your hormones, improve emotional closeness, boost your immunity — is existential. We need to make sure that we don’t underestimate what we’re doing in terms of sexual health in cancer survivorship.