SexualDysfunctions Flashcards
Why do we care about the sex lives of ill people?
§ Impacts QOL.
§ Survivorship more common.
§ Sexuality is an important and legitimate aspect of all of our lives.
§ Media message => SEX is for the young, beautiful and healthy.
What is sexuality?
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
see slides for graphs
Defining Sexual Health & Sexual Dysfunction
§ 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)
Impact of Illness/Treatment on phases of
the Sexual Response Cycle: Desire /
Excitement
Altered Masculinity /Femininity Body Image Changes Anxiety Depression Fatigue Hormone Imbalance Alopecia Nausea Diarrhoe
Impact of Illness/Treatment on phases of
the Sexual Response Cycle: Arousal
Anxiety / Depression Hormone Imbalance Nerve injury Penile artery damage Peripheral Neuropathy Erectile Dysfunction Vaginal Changes Dyspareunia
Impact of Illness/Treatment on phases of
the Sexual Response Cycle: Orgasm
Anxiety Reduced semen volume Ejaculation disorders Altered orgasmic sensation Delayed Orgasm
Impact of Illness/Treatment on phases of
the Sexual Response Cycle: Resolution
Post coital bleeding
Post-coital pain
Reduced sexual enjoyment
SEXUAL side-effects/difficulties (cancer)
Prevalence % Breast 30 -100 Prostate: erectile dysfunction 14 - 90 Gynaecological ≤ 80 Testicular: dry orgasm ~ 20 Colorectal 6 - 60 Bladder: erectile dysfunction 0 - 86 Head and Neck 33 - 50
Unmet needs % Overall 30-80 Treatment phase 50-65 Post-treatment + Survivorship 30-35
Sexuality after cancer
• The cost of survival
“I just thought ‘thank God I’m alive’.”
• Relationship Impact
“…are we (as a couple) going to survive this?”
“And after treatment I told him…that [sex]
department’s closed!…We probably split for a variety
of reasons.”
Being “sexual” for him
“I could live without it [sex] to be honest, sometimes I’d
rather read my book….but don’t tell my husband, will
you?”
“With a woman, even a cuddle or a kiss is enough for
me but for a man wouldn’t be … you have to go to the
full line. …sometimes I feel like I’m not doing my duty”.
• Fear of resuming sexual intercourse
“[after brachytherapy] …for a long time it was like a nuclear war zone… just keep out ….Chernoble….don’t go anywhere near it! I feel my womanhood has been wrecked….nuclear war has gone off down there.”
• Changes in perception of femininity
“Just a sense of loss; a grieving that I lost my femininity…
[reproductive organs] they are symbols of womanhood,
I suppose”.
Coping with the unknown / information provision
“At first I thought, there is going to be a great big hole there inside of me but the doctor explained that: “Your bladder moves over and this moves over”, and you see, I didn’t know all this and I think nobody really knows unless you’re a doctor”.
• Partners’ response to changes in sexual functioning
“We’ve always had a great sexual life and I felt like he
was backing off from me after the treatment. I thought it
feels like I have some disease and he doesn’t make it near me… but after we talked about it I realised that he was more concerned for me to get better”.
Sexual After-Effects
I wish there had been more information for me to understand what my body and mind would experience for months after… At the time it was ok just to survive and live but now looking back… no information on how I’d ovulate, on sexual sensations, the emotional pain… It was like my body was saying “where is my uterus?”
Cervical cancer patient, age 37
After the surgery) you’re suddenly different, non-performing… you’re almost like the eunuchs …you feel like you’ve been neutered almost. A normal healthy, heterosexual male as far as I know, feels that
[erection] is a powerful thing for him and to have it taken away, takes a bit of you away…. He (doctor) didn’t tell me about the sexual after effects and to be quite honest I didn’t ask.”
Prostate cancer patient, age 54
See slides for diagrams!
BARRIERS: Let’s (not) talk about sex…
System-/clinician-related:
- Embarrassment
- Low priority
- Not my role/responsibility
- Not appropriate/relevant
- Lack of time/privacy
- Lack of knowledge/skills
- Lack of resources/interventions
Perceptions of patients: • Too old • Too ill • Too single • Everyone is heterosexual • It just happens ‘The greatest barriers to good sexual life (in cancer patients/couples) are ANXIETY, MISINFORMATION and IGNORANCE.”
When sex is discussed…
Physical domain
e.g. hormonal/body changes, pain, fatigue, lack of sensation
§ Psychological domain
e. g. emotions: anxiety, depression
cognition: body image, negative thinking) motivation: self-efficacy
§ Relationship domain
e.g. relationship discord, fear of intimacy lack of communication
§ Cultural domain
e.g. religious beliefs, social norms cultural values
A need for an INTEGRATED bio-psycho-social MODEL to assess and manage sexual difficulties
Asking the right questions
Sex is not just Coital intercourse
Sexual satisfaction is not just Preserved functionality
Acknowledging but not over-emphasizing the ‘Gender Divide’
“Women tend to be more interested in the journey of loving. Men tend to be more interested in the destination” (Levison)
Intimacy does matter
Quality vs. Quantity: Predictors of sexual adjustment
• Gynaecological cancer (n=53) • Quality (rather than quantity) of sexual interaction was the best predictor of overall sexual life • A small change in perceived quality => a large impact on overall sexual life/function => a predictor of QoL
Important to assess satisfaction/‘qualitative’ aspects of sexual life
Sexual Assessment Tools: Limitations
Most measures rely on:
• physical/functional aspects - coital intercourse, arousal, orgasm
(Althof & Parish, 2013)
§ some level of recent sexual activity and having ready access to a sexual partner (Baser, Li, & Carter, 2012)
Ø Low scores may be misinterpreted and may be attributable to other factors (e.g. a poor or no relationship or partner health)
Ø Medical treatments can impede sexual responses / physiology => a need to move the measure of sexual wellbeing beyond physical function & sexual responses (Bober & Varela, 2012)
Ø Subjective quality of sex life is a better outcome measure to assess overall sexual satisfaction (Juraskova et al., 2012;Davison et al. 2009)
PROMIS Global Satisfaction with Sex Life scale
• 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:
- How satisfied have you been with your sex life?
- How much pleasure has your sex life given you?
- How often have you thought that your sex life is wonderful?
- How satisfied have you been with your sexual relationship with a partner?
- When you have had sexual activity, how much have you enjoyed it?
- When you have had sexual activity, how satisfying has it been?
- I am satisfied with my sex life
Strategies: BETTER model
Bring up the issue
Explain that sexuality is part of QoL, and patients should be aware that they can talk about this with the care team
Tell the patient that appropriate resources will be found to address their concerns
Timing may not be appropriate now, but they can ask for information at any time
Educate patients the sexual side effects of their treatment
Record should be made in the patient chart that this topic was discussed
The PLISSIT Model for assessment
Most commonly used model for discussing sexual issues in a medical setting
§ PERMISSION: Raise the topic of sexuality so that patients feel that they have permission to discuss it.
§ LIMITED INFORMATION: Provide information to address the sexuality concerns of the patient including sexual sequelae common to their treatments
§ SPECIFIC SUGGESTIONS: Taking into account sexual history and relationship status; provide specific strategies for dealing with problems.
§ INTENSIVE THERAPY: Refer to a specialist those patients who have premorbid sexual concerns, mental health problems or more complex sexual problems.
Specific suggestions: Female Genital Pain
Vaginal moisturisers
Vaginal lubricants
Vaginal Dilators
Specific suggestions: Erectile dysfunction
Ø Oral medications
Ø Injection therapy
Ø Vacuum erection devices
Ø Penile implants
Discussing sexual issues with patients
10% Intensive Therapy (referral to a specialist) 50% Specific suggestions 100% Limited Information 100% Permission
Psycho-education resources
• RCT of a psycho-educational booklet to improve
communication about psychosexual adjustment in women undergoing radiotherapy for gynaecological and anorectal cancer
(PhD project: F Lubotzky – supervisors: Juraskova, Butow, Hunt)
• 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
Rekindle sexual life after cancer
• Personalised, user-friendly, highly
interactive ONLINE psycho-educational
resource for cancer patients AND
partners
• Validated sexual interventions incorporated into 7 self-led web-based modules • Tailored according to: • Type of user (patient &/or partner) • Gender of user • Sexual orientation • Phase II RCT stage
Psychological Interventions Can Help
Typical content:
• Focus on intimacy and physical connection,
not necessarily sexual intercourse
• Use of biomedical treatments for sexual dysfunction (e.g. vaginal dilators, moisturisers/lubricants, pumps)
• Communication skills training to talk to partners and providers
Barriers to uptake and retention:
• Patients are unaware of available resources; lack of referral
• Embarrassment (patients and/or providers)
• Lack of engagement (either or both partners)
• Minimal attention to partners (not included or assessed)
Mindfulness-based CBT for sexual problems
A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer
(Brotto et al, 2012, Gyn Onc)
Australian version found- improvements in sexual intimacy & communication and emotional intimacy
Principles for INTERVENTION
§ Introduce routine clinical assessment for sexual morbidity (esp. in ‘high impact’ disease groups) § Include partners (if possible/desired) § Intervene early (when medically safe) § Consider ‘prehabilitation’ § Encourage sex despite low libido § Combine rehabilitation aids
§ Promote renegotiation / flexibility of sexual practices
(Juraskova, 2015; Walker et al, 2015; Ussher et al, 2013)
§ Foster realistic expectations: extent of & timeline for recovery
§ Prepare patients to manage failures
§ Normalise grieving process
§ Establish sexual rehabilitation pathways/referral network
