L24 Psychosexual Adjustment

Question 1

Identify dimensions of sexuality

Answer 1

• It can be associated with:
- loving relationships and intimacy
- sexual activity
- physical appearance => body image is an important component of sexuality
There is not such a thing as Normal or Average

Question 2

Define: Sexual health and Sexual dysfunction

Answer 2

Sexual health is a state of physical, emotional, mental and social well-being relating to sexuality. It’s not merely the absence of disease, dysfunction or infirmity.
- Sexual dysfunction is ‘the various ways in which an individual is unable to participate in a sexual relationship … he / she would wish’. World Health Organization (WHO)

Question 3

Desire / Excitement impairement caused by 9

Answer 3

Altered Masculinity / Femininity 
Body Image Changes
Anxiety 
Depression
Fatigue 
Hormone Imbalance
Alopecia 
Nausea 
Diarrhoea

Question 4

Arousal (erection men, lubrication in women) impaired by 8

Answer 4

Anxiety / Depression
Hormone Imbalance
Nerve injury
Penile artery damage
Peripheral Neuropathy
Erectile Dysfunction
Vaginal Changes
Dyspareunia (painful intercourse for women)

Question 5

Orgasm impaired by 5

Answer 5

Anxiety
Reduced semen volume
Ejaculation disorders (e.g. after prostate cancer, nothing comes out when they orgasm) Or, instead of semen, urine comes out.
Altered orgasmic
Delayed Orgasm

Question 6

Resolution impaired by 3

Answer 6

Post coital bleeding (cervical cancer symptom, vaginal wall could be damaged by radiotherapy)
Post-coital pain
Reduced sexual enjoyment

Question 7

Sexuality after cancer

Answer 7

themes of relationship impact
Partners’ response to changes in sexual functioning.
Fear of resuming sexual intercourse
• Changes in perception of femininity
Being sexual for him (qualitative vs quantitative reasons for sex)
Coping with the unknown / information provision

Question 8

Outline models for undertaking psychosexual assessment

Answer 8

PROMIS Global Satisfaction with Sex Life scale (Flynn et al. 2013)
Allows for a subjective assessment of overall satisfaction with sex life beyond any explicit definitions of sex, relationship status or functional abilities
• Gender and sexual preference neutral
• Appropriate for use across cancer types
In the past 30 days:
1. How satisfied have you been with your sex life?

Strategies: BETTER model
The PLISSIT Model for assessment

Question 9

Strategies: BETTER model

Answer 9

1. Bring up the issue
2. Explain that sexuality is part of QoL, and patients should be aware that they can talk about this with the heath care team
3. Tell the patient that appropriate resources will be found/recommended to address their concerns
4. Timing may not be appropriate now, but they can ask for information at any time
5. Educate patients the sexual side effects of their treatment
6. Record should be made in the patient chart that this topic was discussed

Question 10

The PLISSIT Model for assessment

Answer 10

Most commonly used model for discussing sexual issues in a medical setting
1. PERMISSION: to raise the topic of sexuality so that patients feel that they have permission to discuss it.
2. LIMITED
INFORMATION: Provide information on common sexual changes common to their treatments; correct understandings/myths; provide resources (e.g. booklets)
3. SPECIFIC
SUGGESTIONS: Taking into account sexual history and relationship status; provide specific strategies for dealing with problems.
4. INTENSIVE
THERAPY: Refer to a specialist those patients who have premorbid sexual concerns, mental health problems or more complex sexual problems.
(Annon JS, Journal Sex Education and Therapy, 1976)

THE FIRST TWO STAGES HAVE TO BE EXaMINED FOR EVERY PERSON, YOU DON’T HAVE TO BE TRAINED IN THIS. Specific suggests half the patients, intensive therapy 10%

Question 11

Specific suggestions: Female Genital Pain

Answer 11

Vaginal moisturisers
Vaginal lubricants
Vaginal Dilators

Question 12

Specific suggestions: Erectile dysfunction

Answer 12

Oral medications
Injection therapy
Vacuum erection devices
Penile implants
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

Question 13

Psychosexual TRAINING & INTERVENTIONS

Answer 13

breaking the cycle of silence
• Clinicians wait for the patient to voice their concern SHOULD NOT WAIT
• Patients want to know about post-treatment sexual issues
• Patients want clinicians to raise the topic
• Clinicians are reluctant to initiate the discussion SHOULD NOT BE

Question 14

Psycho-education resources

Answer 14

RCT of a psycho-educational booklet to improve communication about psychosexual adjustment in women undergoing radiotherapy for gynaecological and anorectal cancer
• Compared to control booklet (n=38), the study booklet (n=44) led to:
• greater knowledge about radiation-induced sexual side effects + sexual rehabilitation options/self-care strategies
• higher adherence with dilator use - sustained at 3, 6, 12 months follow up

Question 15

Principles for INTERVENTION 11

Answer 15

1. Introduce routine clinical assessment for sexual morbidity (esp. in ‘high impact’ disease groups)
2. Include partners (if possible/desired)
3. Intervene early (when medically safe)
4. Consider ‘prehabilitation’
5. Encourage sex despite low libido
6. Combine rehabilitation aids
7. Promote renegotiation / flexibility of sexual practices
8. Foster realistic expectations: extent of & timeline for recovery
9. Prepare patients to manage failures (do most effective trmt first, not just least invasive)
10. Normalise grieving process (losses in fertility or erectile dysfuntion)
11. Establish sexual rehabilitation pathways/referral network
    (Juraskova, 2015; Walker et al, 2015)