by Stephanie Marie Leiva Espinosa, Marcela del Carmen, and Don S. Dizon Massachusetts General Hospital Cancer Center, Boston, MA
Patients diagnosed with cancer have a reason to be optimistic. Breakthroughs in screening, surgical treatment, and medical therapy for malignancies have created a scenario where for many, cancer is curable, and even for those in whom cure is not a realistic option, living with cancer is more and more synonymous with other chronic conditions, such as heart disease or diabetes. As evidence, the American Cancer Society estimated that in 2013, the 5-year relative survival rate in the United States alone was approximately 70 percent.1 As a result, estimates are that cancer survivors constitute a population nearing almost 13 and 30 million in the US and worldwide, respectively.2
These figures highlight the importance of longitudinal care of patients treated for cancer, which must extend beyond the immediate diagnosis and treatment. Indeed, the sequelae of therapy may linger long after it has completed. For many patients, chief among these concerns are issues related to sexuality and intimacy. Yet, while the high prevalence of sexual dysfunction has been well established, much less is known about the impact of cancer on intimacy. This is important because sexual health encompasses both aspects, and though the literature is limited, they do show that both are important to survivors.3
It is essential that sexuality not be confused with intimacy. While they are very much connected, one does not necessarily rely on the other. On the one hand, sexuality encompasses the feelings, orientation, and capacity to partake and enjoy eroticized experiences; on the other, intimacy is a much broader sense- a state of closeness or “belonging”.
For women, the relationship between intimacy and sexuality was delineated in a seminal paper by Basson and colleagues.4 In the Basson model, a want for intimacy drives the sexually “neutral” woman to seek out and respond to sexual stimuli, which results in arousal and sexual desire. Once desire has been fulfilled, satisfaction ensues, which acts as positive feedback towards the drive for intimacy. This model is useful because it establishes the psychological and physiologic influences on female sexual health, and it treats sexuality and initmacy as independent though interactive.
So, what do we know about intimacy issues following treatment for cancer? Not as much as we would hope. Much of the literature regarding cancer survivors and sexual health has concentrated on the impacts of cancer diagnosis and treatment on penis-vaginal intercourse (sometimes referred to as the “coital imperative).3 In addition, many papers that discuss intimacy use the term almost interchangeably with sexual acts, whether it be penis-vaginal, oral, or other forms of intercourse.
To emphasize the coital imperative in one’s view of sexual health represents an alarmingly limited vantage point that ignores both the complexity of sexual practices (eg, same-sex couples) and the importance of intimacy, especially when it comes to measuring sexual satisfaction. This was illustrated in a methodological study conducted by Perz and colleagues which involved 44 people with cancer, 35 partners, and 37 health professionals.3 Patients, their partners, and clinicians had highly variable views on what defined sexual satisfaction and how it was rated. This study showed that while clinicians may concentrate on the ability to perform sexually, the assumption that the inability to perform translates into the lack of intimacy should not be supported. This study suggested that intimacy beyond intercourse was valued by patients, and that alternative means to express intimacy can be highly satisfying.
For patients living beyond cancer, sexual health is as important as cardiovascular health. However, this view should not be assumed to be limited to a specific act (or lack of the ability to perform it). As with our current drive for patients is to provide with personalized treatment approaches, so too must the therapeutic planning for patients with issues related to sexual health. It is not enough to ask about one’s sex life. Clinicians should engage and discuss both sex and intimacy with their patients in order to get a broader understanding of both needs and interests, with the aim to help both a patient and her partner. This is also true for women without current partners, in whom the desire for intimacy may be more important to discuss than the ability to have intercourse.
While our patients live beyond cancer, and for those who have completed first-line therapy, begin their quest to define their own “new normal”, sexual health remains an important aspect of life. Sexuality and intimacy help govern sexual health and we must help our patients navigate potentially new territory as part of survivorship. This may be more important for those who find their sex life has changed, whether it be to dyspareunia, excessive vaginal dryness, or loss of sexual desire. In these patients, helping them and their partners explore their intimacy needs as a component of sexual health by encouraging communication and other ways to express emotion, access, and tenderness.
1. Cancer Facts & Figures 2013. at <http://www.cancer.org/research/cancerfactsfigures/cancerfactsfigures/cancer-facts-figures-2013>
2. GLOBOCAN 2008. at <http://globocan.iarc.fr/summary_table_pop_prev.asp?selection=225900&title=World&sex=0&window=1&sort=0&submit=%A0Execute%A0%20(>
3. Perz, J., Ussher, J. M. & Gilbert, E. Constructions of sex and intimacy after cancer: Q methodology study of people with cancer, their partners, and health professionals. Bmc Cancer 13, 270 (2013).
4. Basson, R. Female sexual response: the role of drugs in the management of sexual dysfunction. Obstet. Gynecol. 98, 350–353 (2001).