HL8 - Psychosexual adjustments following illness Flashcards
Why do we care about the sex lives of ill people?
- Survivorship more common
- Something often left unaddressed as seen as taboo
- Sexuality is an important and legitimate aspect of our life => impacts Quality of Life
- YET stereotypical, narrow perceptions of sexuality & sexual life are common, underpinned by:
- application of the biomedical model (neglects psychological factors in offering help - may just address the physiological changes )
- media messages => SEX is for the young, beautiful & healthy
What is sexuality?
- Associated with:
- loving relationships and intimacy
- sexual activity
- physical appearance => body image
- No such thing as ‘normal’ or ‘average’
- About satisfaction for the individual
- With chronic illness, often compare to how things were before - about acknowledging the changes post-illness & create a new optimal sex life
How do we define sexual health and sexual dysfunction?
- Sexual health is “a state of physical, emotional, mental and social wellbeing relating to sexuality. It’s not merely the absence of disease, dysfunction or infirmity.’’ (WHO)
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Sexual dysfunction is “the various ways in which an individual is unable to participate in a sexual relationship … he / she would wish.” (WHO)
- Doesn’t have to be with a partner
What is the sexual response cycle and impact of illness/treatment?
What is the prevalence of sexual side effects?
- Shows it is something that needs to be addressed
- Just because there is not specific treatment of a ‘sexual’ area doesn’t mean they are not still impacted the same
- When receiving treatment - people don’t want to talk about sexual side effects - there are 50-65% of people who want to know about it during treatment
What are the specific impact of cancer on women’s sexual health?
- Prevalence of SD in women with cancer is 66%
- Prevalence is highest in gynecological cancer
- Research scarce in non-Western countries (e.g., Asia) due to stigma and lacking resources
- Why is prevalence so high?
- Vaginal dryness/spasms due to chemotherapy
- Lack of viscous vaginal fluid -> painful sex
- Mental preoccupation with dysfunction -> reduced arousal
- Low estrogen due to chemotherapy -> atrophy, pain
- Why is prevalence so high?
Why might women state they gave up sex during treatment?
- Cost of survival
- Relationship impact
- May encourage partner to seek other means
What are the common beliefs of men and women about sexuality after treatment has ended?
- Felt being sexual specifically for partner
- Fear of resuming sexual intercourse
- Changes in perception of femininity and also masculinity (in men)
How does the response of a sexual partner impact sexual functioning during/after treatment?
- It can be difficult - need more communication to assure partner as they may be suffering from low self-esteem
- Can grow apart with time
How are beliefs of self-compassion and body image different in cancer?
- Australia: n = 279 breast cancer survivors
- Self-compassion explained the relationship between body image disturbance & distress
- Self-compassion could be a protective factor in lowering body image related distress
Why is psychosexual assessment important?
- Find people who need help and match services to their needs
- Need help accepting changes
- Might have a lack of anatomical knowledge to understand consequences of treatment on sexual activity
- People often are too afraid to ask
What are the psychosexual adjustments made in consultations?
- Only in 25% of consultations addressed these issues - most of the time just physiological
- Sexual side effects of cancer treatment is seldom discussed
- Greater prevalence of communication is associated with male gender of patient and greater provider experience
- e.g. more available
- Measures of provider communication differ across studies
What is the “conspiracy of silence”?
Lack of communication of sexual issues
Sexual issues remain largely invisible to clinicians
How is sexual health communication after a heart attack?
Only 52% are comfortable with discussing it
What are the main barriers to talking about sex?
- Individual and societal attitudes and factors reported by health professionals as the biggest barrier to routinely discussing sexual impact, concerns and rehabilitation options in the context of a chronic illness diagnosis
- Embarrassment / discomfort
- Low priority
- Not my role/responsibility
- Not appropriate/relevant
- Less important factors
- Lack of time/privacy
- Lack of knowledge/skills
- Lack of resources/interventions/training
- Takes work to address these barriers
What is the misconception of patients when it comes to talking about sex?
- Too old
- Too ill
- Too single
- Everyone is heterosexual
- It just happens
- Greatest hindrance to good sexual life is anxiety, misinformation and ignorance
What are the benefits when sex is discussed?
Medical professionals (not psychologist) often neglect psychological, relationship and cultural domain
What are the limitations of sexual assessment tools?
- Most measures assess / rely on:
- physical/functional aspects - coital intercourse, arousal, orgasm
- some level of recent sexual activity and having ready access to a sexual partner
- So can alienate those who are single
- Low scores may be misinterpreted => may be attributable to other factors (e.g., a poor or no relationship or partner’s health)
- Medical treatments can impede sexual responses / physiology => a need to move measures of sexual wellbeing BEYOND physical function & sexual responses
- Subjective QUALITY OF SEX life is a better outcome measure to assess overall sexual satisfaction
What is a good method to ask the right questions in sexual assessment?
What is the PLISSIT model for assessment?
- Simple and guiding
- Most commonly used model for discussing and addressing sexual issues in a medical setting:
- PERMISSION: Respectfully raise the topic of sexuality so that patients feel that they have permission to discuss it.
- LIMITED INFORMATION: Provide information on common sexual changes common to their treatments; correct any understandings and myths; provide resources (e.g., booklets, website links)
- SPECIFIC SUGGESTIONS: Taking into account sexual history and relationship status; provide specific strategies for dealing with sexual problems.
- INTENSIVE THERAPY: Refer to a specialist (e.g., people with premorbid sexual concerns, mental health problems or complex sexual problems) - 10 - 20%
What are the specific suggestions for psychoeducation?
- Normalise and validate cancer or treatment side effects affecting sexual life
- Explain rationale for recommending rehabilitation strategies
- Provide access to resources referrals
- e.g. female genital pain
- Knowledge about vaginal moisturisers etc.
- Leaflet directing to recovering after pelvic radiation therapy increased what women tried to deal with the pain
- e.g. male pain - erectile dysfunction
- Oral medications
- Injection therapy
- Vacuum erection devices
- Tendency to focus on restoring of erection dependent sexual practices → Important to encourage erection-independent sexual activities as well as relational INTIMACY, and physical affection
- e.g. female genital pain
How to we break the cycle of silence through psychosexual training and interventions?
Need the clinicians to be the ones initiating the cycle
What are the key principles for intervention?
- Introduce routine clinical assessment for sexual morbidity (esp. in ‘high impact’ disease groups)
- Include partners (if possible/always check if desired!
- Intervene early (when medically safe)
- Consider ‘prehabilitation’
- Encourage sex despite low libido
- Combine rehabilitation aids
- Promote renegotiation / flexibility of sexual practices
- Foster realistic expectations: extent of & timeline for recovery
- When is the right time to worry about the return of sexual behaviours
- Prepare patients to manage failures
- Normalise grieving process
- Establish sexual rehabilitation pathways/referral network
What is sex like after illness?
- ALL individuals have the right to experience good sexual health
- according to their individual needs and preferences
- recognising that for some people this is not a concern
- ALL health professionals can support patients/couples in their psychosexual recovery
- post-treatment sexual function & satisfaction can be improved
- achieving intimacy is always possible = MAIN GOAL
Sexual rehabilitation is an essential component of comprehensive health care
