Women s sexual wellbeing after a cancer diagnosis PONZ Forum 20 September 2014

Transcription

1 Women s sexual wellbeing after a cancer diagnosis PONZ Forum 20 September 2014 Leena St Martin Clinical Psychologist Gynaecology Outpatients Greenlane Clinical Centre Auckland District Health Board LeenaSM@adhb.govt.nz

2 Overview Psycho-sexual impact of cancer on patient and partner Impact of diagnosis Impact of different treatments How health professionals can help

3 What do we know about normal sexual relationships?

4 Female Sex Response Cycle (Basson) Emotional Intimacy Needs Seeking out & being receptive Emotion & Physical Satisfaction Enhanced Intimacy Arousal & Sexual Desire To Continue Spontaneous Sexual Desire Sexual Arousal Sexual Stimuli Biological & Psychological factors

5 Critical psychological points along the cancer continuum ( Diagnostic phase Shock Fear Disbelief/Denial Anger Guilt/Shame Treatment phase Recurrence of disease Survivorship

6 Diagnostic phase: sexual impact Usually time of crisis, multiple tests Need to tell others e.g. partner, children, colleagues. But may lack suitable language e.g. for genital anatomy down there, women s bits, for recto-anal cancer? Embarrassment due to site of disease, ignoring early symptoms (e.g. pain, bleeding, discharge), attributing symptoms to ageing, poor hygiene etc. Stress and threat to life may cancel thoughts of sex, or may increase desire for connection

7 Extra challenges posed by lower genital tract cancers Guilt - feels punished for sexual behaviour Fear of being contagious to partner Fear of potentially invasive treatment Potential loss of fertility

8 Impact of treatment: typical psychological issues Focus shifts to coping with treatment and side-effects Identity shift to a cancer patient Low self efficacy - feeling out of control Functional impairment not able to perform normal tasks or roles Relationship at stake/stalemate Depressive thinking, catastrophising what if this doesn t work?

9 Treatment phase: Sexual impact Treatment typically involves surgery, RT and CT Impact will vary depending on site of RT and surgery Radical body image/sexual self-concept change due to treatment effects which can be sudden alopecia, allodynia, weight gain/loss, whether breast reconstructed or not, presence of stoma. Loss of self as sexual being, gendered being.

10 Treatment phase: sexual impact Loss of sensitivity due to Hormone loss Dissection of nerves and blood flow to pelvic erogenous zones Pelvic/abdominal scar may be numb, tingling or painful Dyspareunia due to Vaginal walls thinned Loss of natural lubrication Vaginal atrophy producing tearing and bleeding after penetration Vaginal shortening or stenosis

11 Vulval cancer further challenges Explaining diagnosis to others where is the vulva? Genital disfigurement due to surgery may involve removal of clitoris and vulva Wound care complications Lymphoedema Mobility restricted Fear of further surgery to contain disease

12 Extra challenges posed by treatment for head and neck cancers Impact on upper body visible (disease site and treatment impact) Ability to tolerate sensation and sensory information can change during disease course Radiation effects: tissue fibrosis (stiffening), dry mouth, mucositis, sore throat, swallowing difficulties, dental effects Surgical impact: neck dissection, skin grafts, reconstruction

13 Extra challenges posed by treatment for head and neck cancers Tracheostomy (change to breathing, blowing nose, speech, swallowing, taste, coughing) Prosthetic devices may be required Chemotherapy effects: as for RT but more severe (may need feeding tube)

14 Psychological interventions Emotional support and validation! Sadness, fear, anger Regular mood assessment may need targeted treatment via medication or psychological therapy Address communication with partner Review what social support is available

15 Relevant DSMIV diagnoses (American Psychiatric Association 2004) Mood disorders - Adjustment disorder or depression affects 47% of patients with cancers (Derogatis et al 1983) Depression 20-35% (Dean 1987; Jacobsen et al 1993) Anxiety disorders 30% (Bodurka-Bevers et al 2000) Body dismorphic disorder Post-traumatic stress disorder % depending on cancer and treatment

16 Ref: Cooke, K (1994) Real Gorgeous. Australia: Allen & Unwin

17 Post-traumatic stress disorder (PTSD) Direct personal experience of an event that involves actual or threatened death or serious injury, or a threat to the physical integrity of self or others (APA 1994 p424) Symptoms include autonomic hyperarousal traumatic re-experiencing behavioural & cognitive avoidance of triggers

18 For better for worse, for richer, for poorer Assess relationship satisfaction and quality of emotional intimacy Has any sexual relationship been maintained? How satisfying was sex pre-morbidly? Involve partner in therapy if indicated Discuss alternatives to intercourse

19 In sickness and in health Partner or Caregiver? Difficult to feel sexual desirous of partner when we are closely involved as a caregiver How is the caregiving partner getting their needs met? Address any inaccurate interpretations of patient s behaviour they are making What does caregiving partner feel they have capacity for?

20 Female sexuality and ostomy Difficulty explaining surgery to new sexual partner with consequent fear of rejection Fear of appearing naked Fear of damaging stoma leading to leakage Fear of potential odour and noise from stoma Sexual inhibition due to concern for partner Removal of rectum changes angle of vaginal barrel with potential impact on comfort with penetration and quality of orgasm Uterus may also change position

21 Sexual activity with ostomy Empty pouch before sexual activity to prevent leakage or dislodgement Ensure stoma fits well so remains close to body Consider use of scents Avoid foods that produce strong odours, flatus and loose stools Advise patients to eat at regular times to help prevent gas formation during sexual activity

22 Disgust and other difficult emotions Saliva, sweat, semen and body odours can all change as well as overall body habitus Acknowledge disgust, guilt, sadness etc as valid emotional responses to partner s changed physical presence Offer individual sessions to each partner as indicated to fully allow for exploration of topic

23 Protecting the body envelope Ensure willingness, desire and arousal are present before addressing the possibility of vaginal penetration/intercourse Explore embodiment, particularly the meaning of penetration /entering the body

24 Damaging sexual activity Impact for women Low desire + low arousal + female tendency to self-sacrifice = painful intercourse and distance from partner Increased self-care + wellness + partner support + entitlement to value own sexuality = recovery from painful intercourse and/or enhanced sexual potential

25 How health professionals can help Keep educating ourselves! Normalise the presence of relationship and sexual concerns at all stages of cancer journey Allow expression of all emotions, including difficult ones Listen and validate, reassure where appropriate

26 How to help Consider benefits of partner being present when giving information but also allow privacy for individual needs Assume nothing regarding patient s knowledge of anatomy, especially genital anatomy Have written and visual information on offer

27 Relationship and sex therapy Assist couple to explore sexuality by attending to practical issues privacy, optimising medication Maximise opportunities when mood and energy are ok Comfort lubrication, positioning, continence management

28 Reclaiming Sexuality After Cancer woman s touch.com Effects of Cancer Treatment Damaged Body Image Body Dissociation Diminished Libido Radiation Effects Surgical Trauma Sexual Health Requires Emotional Health Healthy Skin Healthy Nerves Healthy Blood Vessels Healing Strategies Support For Grief Good Sex Diet Practising Calm Taking Time for Arousal Vitamin D and Fish Oil Chemotherapy Damage Vacuum Pumps Daily Exercise Arousal and Orgasm Difficulties Embracing the new Normal Vibrating Massage Engorgement Difficulties Moisturising Sexual Lubricant Making time for Sex

29 PLISSIT (Annon 1976) Permission - ensure privacy - and enough time - before opening discussion about sensitive topics Limited information - assess patient s understanding and preference for information Specific suggestion Treatment options, techniques to improve sexual wellbeing Intensive therapy - refer to support services and/or psychological therapy for debrief, emotional support and further intervention

30 Concluding comments Psychological (and therefore sexual) impact of cancer diagnosis will vary depending on individual circumstances Body parts associated with appearance, femininity, lifegiving potential, and relationship function/currency indicate greatest sexual impact Normalise multidisciplinary approach to restoring sexual wellbeing e.g. via referring to psychological/ psychosexual therapy

31 Cancer & Sexuality resources Private therapists: