You have in your handouts the lists of Biological, Psychological and Social Effects – all of which many of our patients experience and many who have no idea that a medication they are taking could possibly complicate the problem they are already experiencing OR that a simple change in medication or positions could help eleviate the problem!!! Impacting the four phases of sexual response. It is important to know where are clients are being affected so we can better help them find solutions. If their problem is desire, because of fatigue or not being attracted to themselves or their partner than we can help prescribe solutions that focus on that, RATHER than just handing them viagra! Psychological; misbeliefs about the origin of the cancer, guilt related to these misbelifs, coexisting depression, changes in body image, stresses to personal relationships. Can be desire disorder, arousal disorder, orgasmic disorder (pain or unable) and sex pain disorders
An evaluation tool that can be flexible with clinician’s knowledge and experience (Robinson and Annon, 1976) PLISSIT model uses a series of discussions about the specific effects of treatment on sexual function and options for adaptation or resumption of sexual activity Shipes and Lehr, 1982 estimated that 70% of sexual problems related to cancer therapy can be managed by using the first three levels of model
Before Getting Permission: Social Worker must be comfortable with the topic Establish rapport before openly discussing sexuality and use patient’s language and terms Do not wait for the patient to bring up sexuality Normalize questions “Many of our patients taking chemotherapy lose interest in sex. Is this a problem for you?”
Of Course it depends on the relationship you have with the patient and or their significant others that determines the questions you use
Be informed about the sexual implications for your patient Do not assume patients or loved ones know normal sexual physiology Include sex education in all interactions with patients (this could be as simple as providing the ACS booklet Sexuality and Cancer)
Positioning and finding other ways to build intimacy – especially for the single person Suggetion: Sensate focus exercise Worry that sex my cause recurrence Time, encourage not to rush Pouch covers for ostomy patients Changing time of day and positioning for intimacy when there is pain or fatigue “ Sexuality and Cancer”, ACS booklet provides detailed sexual advice and guidance Provide tips on maintaining intimacy without sex, exploring alternative pleasurable activities Direct to self help books, or information on dilators, lubricants, etc Sensate focus exercises Take a bath before sex to relax, use lubricants and change position if concerned about pain
Plastic or rubber tube used to stretch vagina
70% of patients will only need the first three interventions Referral for psychological or sexual therapy may be required for past trauma or troubled relationship Know your limitations and skills, continue to assess needs Support and Compassion = Normalizing and Validating concerns and providing appropriate referrals
Research is extremely important in this area…you have a great population that can easily be assessed so we can learn more and learn how to better provide our patients with information.
Sage Bolte, PhD, LCSW, OSW-C Oncology Counselor Life with Cancer ® Fairfax, VA [email_address]
Describe and discuss the sexual health and intimate needs of AYA’s
Briefly discuss the PLISSIT sexual health assessment model to increase skill of assessing their sexual health needs
1. Information or Event: External events that affect sexual function or affect aspects of sexuality (e.g., disfigurement, positive sexual experiences, etc.) 2. Sexual Esteem : Cognitive, Attitudes, Sexual Schemata 3. Sexual Affect/Feelings: Feelings about sexuality and function: Includes distress or negative/positive . CANCER The Experience of Cancer can bring multiple events New information has to be absorbed into the sexual self. The sexual self could stay stable, or could experience a large effect. 4 . Sexual Behavior and Function
Age at diagnosis contributes to higher sexual dysfunction and distress in childhood cancer survivors, those diagnosed during adolescence or older demonstrated lower functioning and higher distress (Zebrack et al., 2009) .
Age and age at diagnosis was not significant for those diagnosed as young adults and sexual function, sexual esteem and sexual distress were all significantly correlated with quality of life measures (Bolte, 2010) .
Low sexual function does not necessarily mean high sexual distress, but low sexual esteem and high sexual distress does impact QOL (Bolte, 2010).
Female YA childhood survivors reported higher means of problems with all aspects of sexual functioning than male survivors, however, all were significant with aspects of quality of life (Zebrack et al., 2009) Zebrack, B., Foley, S., Wittmann, D., & Leonard, M. (2009). Sexual functioning in young adult survivors of childhood cancer, Psycho-Oncology.
From: Zebrack, B., Foley, S., Wittmann, D., & Leonard, M. (2009). Sexual functioning in young adult survivors of childhood cancer, Psycho-Oncology.
Young adult cancer survivors demonstrated significantly different sexual self perceptions than their healthy peers (lower sexual esteem, higher sexual distress, lower sexual functioning).
Sexual history of non-consensual sexual incidences was higher for all participants than US reported average (23.9% females and 17.7% males compared to average of 18% and 3%). What might this imply for the care of our AYA patient?
“ I guess, side effects of post-treatment like my specific case is, I had a bone marrow transplant [3 years ago] and I have transplant rejection issues called Graft-versus-Host. And it’s – I’m being treated for that, so that’s – it’s also introducing a lot of physical limitations in terms of flexibility and skin – my skin is very tight. I mean, just – like, I have trouble bending down on my knees. So, you know, I mean, just trying to bend in certain positions sometimes is impossible or my skin feels like it’s going to rip. So, I mean, that – I mean, I’m talking – like I said, I’m talking physical limitations [around sexual health] is basically the main thing that cancer introduced for me. But that’s not – it also introduced, I suppose, some mental limitations…Well, obviously the physical limitations are, you know, hammering down on my mental state of mind because, okay, I can’t perform, you know, because of this, this and this. And so, I mean, it’s bogging me down like emotionally sometimes I just don’t – I don’t even feel like trying.” (Bolte, 2010)
“Part of providing good care to all my patients is knowing about many aspects of their lives. Cancer impacts all areas of your life. One aspect that is important for me to ask about is your sexual history. Everything you tell me is confidential unless I feel it is harmful to you, your treatment or your cancer”.
“Often times long term survivors have questions that come up about quality of life issues, such as sexual health and intimate relationships, that they didn’t necessarily know to ask when first diagnosed. Many survivors may experience some challenges as it relates to their sexual function or questions around sexuality. Do you have any concerns?”
Obtaining Permission from patient or parent to initiate sexual discussion and legitimize sexual concerns. Normalize and Generalize questions.
Has cancer affected the way you feel about yourself? The way you view yourself?
Has this condition interfered with your being (or having) a boyfriend/girlfriend/partner?
Has this condition affected your ability to perform sexually?
Remember to make no assumptions about sexual history or sexual orientation
Also important to remember that there are several young patients we treat who have been sexually traumatized and we may be violating this trust and/or re-traumatizing their experience if we aren’t asking permission to touch them
Some girls and boys feel embarrassed or confused about the changes that happen to their body during treatment. Lets talk about that.
Some people who are going through an illness like yours have been concerned about their sexuality, have you had any concerns?
Some girls and boys who are getting treatment for their cancer experience changes in the development of their private parts, have you had any concerns?
You have been through so much since your diagnosis. This may affect the way you see yourself as a teenager and may affect your friendships, how are you doing?
You must be wondering how all of this will affect you sexually or in your future. Let’s talk about that.
You have been through so much since your diagnosis. This may affect the way you and your partner interact and the time you take to be together. Often times, intimacy is impacted during the course of treatment. How are you doing?
(For the parent) Some parent’s put so much energy into their child that they lose interest in other things, especially taking time out to be with their partner. How have you been affected?
“ Today, the physician [nurse or social worker] who treats oncologic diseases should no longer join the collusion of silence about sexuality any more than he should join the collusion of silence about death. Sexuality [and intimacy] is part of life and, hence, a part of cancer patients and their families”
(Devita, Hellman, Rosenberg. (1985). p. 2055).
Devita, Hellman, Rosenberg. (1985). CANCER. Principles and Practice of Oncology. JB Lippincott Company, Philadelphia