Sex Therapy New York

Survivors are slow to seek help for sexual problems

Psychologists are helping cancer patients cope with treatment’s impact on their sex lives.

By Rebecca A. Clay, Monitor Online

“Insult to injury.” That’s how Leslie R. Schover, PhD, author of Sexuality and Fertility After Cancer (John Wiley and Sons, 1997), describes the sexual dysfunction that is an all too common byproduct of cancer treatment.

About 50 percent of breast cancer survivors and 70 percent of prostate cancer survivors suffer sexual problems such as loss of desire, painful intercourse or erectile dysfunction, she says. Yet only 10 percent of cancer survivors seek help for such problems.

That’s now changing. Several trends are prompting an increasing awareness of cancer survivors’ sexual needs. One is the ever-increasing number of cancer survivors. Another is the growing acknowledgment of sexuality in the older people who are cancer’s most frequent victims.

Today Schover and other sex therapists specialize in helping cancer survivors regain their lost sexuality.

“Most survivors don’t need 15 sessions of sex therapy,” says Schover, a staff psychologist at the Cleveland Clinic Foundation. “What they do need is to understand the impact treatment has on sexual functioning and learn how to accommodate those changes.”

Rethinking sexuality

Those changes are often not what patients–or their health-care providers–expect. Take breast cancer treatment, for example. According to conventional wisdom, sexual dysfunction in breast cancer survivors is the result of changes in body image after mastectomy.

Not so, says Schover. When she compared women who had had mastectomies with those who had had reconstruction, in fact, she found little difference between their rates of sexual frequency or satisfaction. Although changes in body image are an important issue, she says, the bigger impact comes from chemotherapy. The drugs may plunge younger women into premature menopause and sap their desire for sex, she says.

Treatment for gynecologic cancers can have an even more devastating impact on sexuality, says Barbara Andersen, PhD, a professor of psychology and obstetrics and gynecology at Ohio State University. Radiation can kill the vaginal cells that produce lubrication, for instance, making intercourse painful. Hysterectomy and ovarian removal can induce premature menopause for young women. Treatment for vulvar cancer involves genital disfigurement.

When Andersen conducted the field’s first longitudinal study of gynecologic cancer patients, she found that 30 percent to 50 percent of women with early-stage cervical, endometrial and ovarian cancer had sexual problems. The rate soared to 60 percent to 80 percent for women with vulvar cancer.

One of the biggest problems, says Andersen, is the abruptness of the changes these women experience.

“They literally go from having reasonable sex lives to having to cope with considerable sexual difficulty,” she explains. Moreover, they are often convinced that their sexual problems are all in their heads.

Physicians, too, may not be completely aware of the sexual difficulties their patients may experience, say Andersen, noting that they may not forewarn patients of the sexual changes likely to occur. Even if they do, she says, they may not know how to advise patients to cope with the anticipated difficulties.

Andersen and other psychologists have been working to educate physicians and other health-care professionals about the need to alert patients to potential sexual dysfunction and treatment options. Possible solutions range from artificial lubricants to hormone replacement therapy.

Other psychologists are aiming interventions directly at patients. Sex therapist Mary Ann Aposhian, PhD, for instance, will soon begin leading group therapy sessions for gynecologic patients as part of a study led by psychologist Cheryl Koopman, PhD, of the Stanford University School of Medicine. Prompted by an oncologist’s request for help, the pilot study will offer participants a dozen support group sessions led by Aposhian.

“There’s such a sense of shame, loss and confusion,” says Aposhian, a private practitioner in Palo Alto. “Survivors’ guilt–a feeling that cancer survivors shouldn’t talk about something like sexuality–plays into it as well.”

Focus groups and her own clinical experience have already given Aposhian a sense of what issues are most important to survivors. These include body image, feelings of betrayal and changing relationships with partners. Not surprisingly, issues differ according to women’s age and circumstances. Younger women may find it easier to talk to partners about sexuality. On the other hand, they may not have long-time partners willing to work through sexual problems. Some also face a devastating loss of fertility.

“Most survivors don’t need 15 sessions of sex therapy. What they do need is to understand the impact treatment has on sexual functioning and learn how to accommodate those changes.”

Leslie R. Schover Cleveland Clinic Foundation

Other psychologists are helping men with cancer cope with sexual problems. Sex therapist Ursula S. Ofman, PsyD, for instance, works with prostate-cancer survivors in her Manhattan practice. Helping men make treatment decisions and deal with changes in body image and functioning after treatment are priorities.

“In prostate cancer, there is no good treatment decision,” Ofman explains. “There’s so much trade-off involved.”

A radical prostectomy, for example, can lead to impotence and urinary incontinence. Radiation can cause ongoing changes in the body’s vasculature that can interfere with erectile function. And because testosterone can help most prostate cancers grow, physicians often prescribe androgen-depleting medication that feminizes men’s bodies. The softer hair, flabbier flesh and filled-out breasts that result can make men too self-conscious for sex, says Ofman.

Educating men about these changes is key, she says. Learning that testosterone feeds cancer, for example, many men forego sex out of the mistaken belief that sexual activity will produce testosterone and make the cancer worse.

“A big part of this work is simply reassuring people,” says Ofman.

Meeting partners’ needs

Of course, patients aren’t the only ones who need help when cancer strikes. Partners often need help, too, emphasizes Sandra B. Haber, PhD, a psychologist in private practice in Manhattan. She and psychologist Barbara Wainrib, PhD, are currently revising their book Prostate Cancer: A Guide for Women and the Men They Love” (Dell Publishing, 1996).

Helping couples mourn the loss of their pretreatment sexuality is a crucial first step, says Haber, noting that even penile implants, injections and Viagra can’t restore sexuality to what it was. But just as important is helping couples get beyond the idea that intercourse is the ultimate in sexuality. A big part of Haber’s work is encouraging couples to explore other forms of sexuality.

Although some couples turn incommunicative, says Haber, others find that the disease and its aftermath actually bring them closer together.

“My wife and I found new ways of doing things,” says a survivor featured in Haber’s book. “Now I think about sex more than I did before…. Actually, I never really thought about sex before; I just did it. What a waste.”

Rebecca A. Clay is a writer in Washington, D.C.