Why intimacy so often changes
Sexuality does not stop mattering because someone has cancer. The American Cancer Society notes that studies show sex, sexuality and intimacy are just as important to people with cancer as to people without it. Yet the NCI describes problems with sex as common during and after treatment, and notes that they can last longer than other side effects.
Some of those changes come from the body: surgery, radiation, chemotherapy, hormone therapy and some medicines can all affect sexual function. Others come from the mind. The NCI lists anxiety, depression, worry and stress as possible causes of sexual problems on their own. In most people the two are tangled together, which is why both medical and emotional support can matter.
Body image, grief and desire
Cancer can leave visible and invisible marks: scars, hair loss, weight changes, an ostomy, the loss of a breast or limb, or the loss of fertility. The NCI describes these losses as real and says that anger and grief about changes in your body are natural. It also notes that feeling bad about your body can lower your sex drive, which can then make you feel even worse about yourself.
Fertility loss can bring a particular kind of grief, whether or not you had firm plans for children. The NCI notes that, depending on your age, your treatment and the time since treatment, you may still be able to have children, and that families come together in many ways. Questions about fertility belong with your medical team; the feelings around them can be part of therapy.
Common emotional worries include:
- Feeling less attractive, or not wanting to be seen without clothes
- Fear that sex will hurt, or that you will not be able to perform
- Worry that your partner sees you as a patient now, not a lover
- Grief over fertility or plans for a family
- Feeling like a different person than you were before treatment
Partners have their own fears. The NCI notes that a partner may be afraid of hurting you, or may hold back because they think you are not feeling well. Two people can each be waiting for the other to make the first move, and each can read the other's hesitation as rejection.
What belongs with your medical team
Physical changes, such as erection problems, vaginal dryness or pain, numbness, changes in orgasm, menopause symptoms, and fertility questions, belong with your oncology team, gynecologist, urologist or primary care doctor. Many have treatments or practical solutions. The ACS advises not to assume your doctor or nurse will ask about sex; you may need to start the conversation yourself.
Questions worth bringing to your medical team include:
- Will my treatment affect my sex life, and for how long?
- Is it safe to be sexually active during treatment, and are there times I should avoid it or take precautions?
- What can be done about the changes I am noticing?
- Can you refer me to a specialist, sex therapist or counselor?
The NCI notes that most people can be sexually active during treatment but should confirm this with their doctor, because there may be times when the risk of infection or bleeding means holding off, and some treatments call for condom use. A psychologist cannot answer those medical questions, but can help you feel steadier about asking them.
Talking with your partner
For many couples, talking about sex is harder than talking about cancer. The American Cancer Society suggests deciding ahead of time what you want to say, choosing a private, unhurried moment, and having several short conversations if one long one feels like too much. It also suggests explaining or showing physical changes to your partner, saying what feels good and what hurts, and remembering that sexual intimacy involves more than intercourse.
It may help to name what you want plainly. The NCI encourages letting your partner know whether you want sex or would rather hug, kiss and cuddle, and trying to talk about concerns without blame. "I miss being close to you, and I'm scared" can open a conversation that months of silence could not.
If you are single, the questions are different: when to tell a new partner about cancer, scars or fertility, and how to handle the fear of rejection. The NCI suggests waiting until you feel a sense of trust and friendship before telling a new date about your cancer.
Closeness beyond sex
Intimacy is not only physical. The NCI offers several ways couples can stay connected while sexual problems are being worked out: focusing on talking and renewing your connection, protecting time together with phones and TV off, spending time together without being physical, and learning new kinds of touch, since areas that used to feel good may now be numb or painful. Holding, hugging and cuddling still count.
Some couples also find it helps to talk about the relationship more broadly, since distance in bed is often connected to distance elsewhere. How Cancer Can Affect a Marriage or Partnership covers that wider strain.
Where therapy can fit
The ACS notes that a counselor can often help with sexual problems caused or worsened by anxiety or depression, and the NCI observes that talking with someone alone or with your partner may help when sexual changes start to strain a relationship. Therapy will not fix a physical side effect, but it can address the shame, grief, fear and communication problems that often come with one.
Dr. Lehmann offers psychotherapy for intimacy and sexual concerns and for the broader emotional side of cancer. If you are wondering whether individual or couples sessions would suit your situation, ask when you call. If a particular kind of sex therapy matters to you, ask about her training and approach.