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Mary B. Uhlenhopp, RN, MS, MPH
Many patients suffer from significant changes and disruptions in their sexual function during and after their cancer treatment. These patients are in need of an opportunity to discuss such changes with their healthcare providers, but all too often are not given the opportunity. Often, members of the healthcare team are not comfortable discussing these issues, are not fully knowledgeable regarding loss or change in sexual function secondary to cancer treatment, or do not feel they have the skills to appropriately raise the issue with their patients.
Tore Borg, Manager of Nursing Services at the Norwegian Radium Hospital, Oslo, suggested during his talk Wednesday, September 15, at the 10th ECCO meeting in Vienna that there is more information available in the popular press and media regarding sexuality and sexual function than in the healthcare literature.[1] He stressed that it is the obligation of the healthcare team and, more specific, nurses, to treat the whole person and not neglect the importance of a patient's sexual identity. He referred to a rather thorough definition of sexuality: as an integral part of the whole person, integrating the physical, emotional, intellectual, and social aspects of our being. Sexuality in his definition was described as much more than sex, which therefore cannot be destroyed by cancer or cancer treatment, yet it is often significantly changed and inhibited. Contrary to what is portrayed in the media, sex is not reserved for the young, healthy, and beautiful. Borg stated that although the frequency of sex may decline somewhat with age, sexuality does not. He urged the audience of nurses to question whether nonverbal messages -- such as the discussion of sex or thoughts about sex being immoral -- are sent to the older patient population.
Numerous types of cancer and their treatment can negatively influence sexual function. Many of the physical changes that can occur as a result of cancer and its treatment are summarized in Table I.
Table I. Specific Physical Changes Caused by Cancer and Its Treatment
Gynecologic Cancer Colorectal Cancer
- Surgery can result in physical injury to female genitalia
- Radiation often results in vaginal dryness
- Urinary problems are common, such as urinary incontinence
- A hysterectomy can result in pain and discomfort during intercourse
Prostate Cancer
- Presence of a colostomy may inhibit sexual relations due to malodorous discharge and presence of a pouch
- Uterus may be tilted following colon resection, causing discomfort during intercourse
- Clitoral sensitivity can be diminished following certain types of treatment
- Men may experience impotence or retrograde ejaculation
Testicular Cancer
- Men may be left impotent if gland and seminal vesicles are removed
- Prostatectomy can lead to disturbances in ejaculation
- Fibrosis in pelvic area can cause discomfort
- Hormonal treatments generally diminish libido
Penile Cancer
- Surgery may cause impotence
- Hormone therapy diminishes libido
Bladder Cancer
- In cases of partial amputation residual sexual function is often poor
- Sexuality/libido are greatly diminished where sexual organs are directly affected
Breast Cancer
- Incontinence or changes in urinary function may inhibit libido
- Sexuality/libido are greatly impaired when sexual organ is affected (eg, mastectomy or altered appearance with breast conservation)
- Sensitivity is diminished if nipple is removed
A diagnosis of cancer and its subsequent treatment can also have psychological effects and negative consequences on sexuality. Borg indicated that any type of cancer could have a profound impact on sexual health. He limited his discussion to three areas for the purpose of this lecture:
- Change in self image (ie, the way one perceives oneself or the personal perception of one's own body). Cancer diagnosis and treatment can destroy the patient's sexual identity (eg, "I'm not a man anymore.").
- Crisis related to loss. The psychological experience of the loss of an organ is dependent upon the meaning this organ has been given as part of the person's own identity. Patient may experience phases of grief (eg, depression, isolation, and withdrawal).
- Sin and shame. Some patients see loss or the occurrence of cancer as retribution or punishment for past behaviors.
The health professional can help patients come to terms with these concerns with the following approaches:
Knowledge: healthcare professional must be aware of the sexual changes that result from the disease and treatments.
Empathy: healthcare professionals should understand how diagnosis and treatment can effect the whole person.
Professionalism: Recognize your own sexual issues, feelings, and problems and how they may negatively influence your own ability to help your patient.
Communication: Provide an opportunity for the patient to discuss concerns and feelings.The PLISSIT model (Permission, Limited Information, Specific Suggestions, and Intensive Therapy), developed by Aaron and Robinson, can play an important role in helping patients discuss and accept the complications caused by cancer and its treatment.[2] Patients have permission to speak, and healthcare professionals need to be willing to listen. Healthcare professionals are in the position to share their knowledge of sexual changes that may take place. Offer specific suggestions about ways in which patients may express themselves sexually. Discuss how the partner may also feel the loss. Finally, offer intensive therapy where necessary, such as making referrals to experts for prostheses, psychotherapy, or psychiatric consultation.
In general, Mr. Borg concluded, healthcare professionals, particularly nurses, can provide quality care to patients only if we acknowledge them as whole beings, rather than negate and deny their sexuality and sexual concerns.
References
- Borg T. Cancer and its consequences on sexuality. Abstracts and Proceedings from ECCO 10. Sept 12-16, 1999; Vienna, Austria. Abstract 89.
- Cooley ME, Yeomans AC, Cobb SC. Sexual and reproductive issues for women with Hodgkin's disease. II. Application of PLISSIT model. Cancer Nurs. 1986 Oct;9(5):248-255.
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