12.2 (8.8) Sexuality in pall care

Question 1

List four benefits derived from sexual and intimate expression

Answer 1

Reduce emotional distress, anxiety, depression *
Pain relief/ heightened pain threshold*
Distraction
Muscle relaxation*
sleep*

Question 2

Until what part of a person’s illness can sexuality and intimacy remain important?

Answer 2

Last days

Question 3

What are potential barriers to sexuality and intimacy from a patient partner’s perspective? Name 3 examples

Answer 3

• Inability to negotiate other forms of intimacy when penetration no longer available
• Lack of couple communication*
• Seeing the patient as asexual or childlike due to loss of bodily control (e.g. catheter)
• Increased dependency of patient*
• Anticipatory grief*
• Curative focus and unwillingness to have intimate connection (“giving up hope”)

Question 4

What are HCP barriers to discussing patient sexuality in clinical setting? Name 4 examples

Answer 4

• MD related: Lack of knowledge, discomfort around communication
• Patient related: not seeing patients as sexual beings, feeling vulnerable to reactions of patients, making assumptions (e.g. patient too unwell, uninterested, etc.)
• Topic related: “taboo topic”, fear of crossing medico-legal boundaries, reducing sexuality to erection, menopausal status and levels of libido
• Setting related: feeling vulnerable to reactions of colleagues, discouragement of sexual expression within hospital setting

Question 5

What can HCPs do to help encourage intimacy? Name 4 examples

Answer 5

• Self-reflecting on personal and professional influences that shape beliefs of pt sexuality (MD related)*
• Check assumptions with patients (patient related)*
• Provide opportunities for patients and partners to discuss intimacy (topic related)*
• Facilitate renegotiation re: amount and type of sexual contact between patients and partners
• Empathic listening and acknowledgement of distress
• Give permission to patient and partner to engage in intimacy (e.g. lie in hospital bed together) (setting related)*

Question 6

Who on the multidisciplinary team should discuss issues of sexuality and intimacy with a patient?

Answer 6

All team members should be spotters of issues - if provider uncomfortable having detailed conversation, start conversation then arrange referral to an expert with patient persmission

Question 7

What kind of training model for clinicians can be helpful to reduce barriers and increase confidence in discussing topic of sexuality?

Answer 7

Brief communication skills training model

Question 8

List four changes relating to sexual function that occur in women as they age

Answer 8

Vaginal atrophy: tissue thinning/more fragile
Vaginal dryness: Reduced natural lubricant 
Reduced libido
Hot flushes

Question 9

List four changes related to sexual function that occur in men as they age

Answer 9

Increased time to achieve erection
Less rigid erection
Decreased seminal fluid (semen)
decrease in size and firmness of testes
Orgasmic strength and pleasure

Question 10

List five medical conditions that can cause changes in sexual function

Answer 10

Stroke
MS
PD

Cancer

HTN
Hypotension 

DM
Renal failure

Depression 

FS: VINDICATE-NP

Question 11

Chemotherapy induced reduction in androgens may cause what three symptoms

Answer 11

Decreased mood
Decreased libido
Decreased energy

Menopause symptoms in women

Question 12

What should clinicians advice patients and partners re: intimacy post chemo? (Name 2)

Answer 12

1. Use protection for 48h post chemo as cytotoxic waste can be excreted through any blood and body fluid (condom, dental dam)
2. Discuss the risk of pregnancy while on chemo

Question 13

List three causes of dyspareunia (genital pain during intimacy) in pt w cancer

Answer 13

Premature menopause secondary to chemo

Radiotherapy local effects

Hormone treatment reducing circulating androgens

Question 14

How does radiation affect sexuality?

2 general, 2 local

Answer 14

• General SEs of rads (nausea, fatigue, diarrhea, skin reactions)
• Infertility
• Pelvic rads -> Vaginal tissues can become thin, ulcerated, scarred, shinking/shortening
• Pelvic rads -> Vascular damage leading to reduced blood flow = dry vagina
• Erectile dysfunction

Question 15

What can a clinician advice a female patient who is receiving pelvic rads?

Answer 15

Encouraged to have sexual intercourse/use vaginal vibrator or dilator 3-4 times/week to reduce changes of vagina shrinking

Question 16

A pt has temporary radiation implants inserted. How would you counsel them on issues related to sexuality and intimacy?

What if patient has permanent radiation implants (e.g. brachytherapy)?

Answer 16

Once temporary implant removed - safe for contact including sex

Permanent implant - avoid close contact with people for first few days while radiation is most active, then use condom for several days post procedure

Question 17

Who are considered “hidden communities” in pall care related to addressing sexuality?

Answer 17

• Patients who don’t reflect heterosexual norms
• Young adolescents
• Elderly people
• Single people

Question 18

What are some general practical advice that can be given to increase intimacy?

Provide 3 advice.

Answer 18

• Having realistic expectations (relearning intimacy takes time)
• Coping with physical disfigurement by wearing night wear to conceal scars, use fantasy to imagine themselves as whole people
• Setting the scene - creating a relaxed environment, fluffy towels
• Pelvic floor muscle control and self-stimulation

Question 19

A patient has dyspnea and would like to be sexually intimate with their partner. Provide 3 advice

Answer 19

Manage SOB
Well ventilated room, fan, comfortable bed*
Explore gentle intimacy 
Use waterbed to conserve energy*
During sex, control SOB with pursed lip breathing *
Avoid long kisses *
Avoid positions that restrict breathing or put pressure on chest*

Question 20

A patient has fatigue and weakness and would like to be intimate. Give 3 pieces of advice

Answer 20

Choose time of day when pt has most energy *
Explore different positions to conserve energy *
Avoid extreme temperature
Avoid heavy meals*
Avoid etoh*

Question 21

A patient has urinary incontinence and would like to be intimate. Provide 2 pieces of advice

Answer 21

Encourage bath or shower as location for foreplay or post coital relaxation

Utilize shower chair, disabled bath or fluffy towel over incontinence sheet

Question 22

List four ways of increasing privacy for patients in the clinical setting

Answer 22

Do not disturb sign for door
Knock before entering room
Provide double bed
Partner bathe patient or bathe with patient
Provide massage oils, music etc

Question 23

What sexual aids can be offered to women and men? List 3 for each

Answer 23

Women:
- Vaginal moisturizer (e.g. Replens)
- Vaginal lubricant (water or silicon based)
- Topical or systemic estrogen (however controversial)

Men:
- Sexual rehab to regain erectile function
- Cialis, Viagra (phosphodiesterase 5 inhibitor drugs)*
- Penile injection therapy
- Penile implant *
- Vacuum pump erection device*

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