Changes to Sexual Well-being and Intimacy After Breast Cancer

Jane M. Ussher, PhD; Janette Perz, PhD; Emilee Gilbert, PhD

Disclosures

Cancer Nurs. 2012;35(6):456-465. 

In This Article

Abstract and Introduction

Abstract

Background: Changes to sexual well-being can be one of the most problematic aspects of life after breast cancer, with the impact lasting for many years after treatment, associated with serious physical and emotional adverse effects. However, the primary focus on corporeal changes negates the influence of social and relational constructions of sexuality and illness and the ways in which the meaning of sex is negotiated by individuals and within relationships.

Objective: The aim of this study was to examine changes to sexuality and intimate relationships in individuals who have experienced breast cancer, from a material-discursive-intrapsychic perspective, using mixed-method analysis.

Methods: An online survey containing 47 quantitative and qualitative items was completed by 1965 Australian individuals with breast cancer. Participants were 98% women, with a mean age of 54 years.

Results: Decreases in sexual frequency, response, and satisfaction were attributed to a range of factors, including tiredness and pain, psychological distress and body image, and medically induced menopausal changes such as vaginal dryness, hot flushes, and weight gain. Predominant concerns identified in the qualitative analysis were emotional consequences, physical changes, feeling unattractive or lacking femininity, reconciliation of self to changes, and impact on partner or relationship.

Conclusions: These findings support and extend previous research that reports significant changes in sexual well-being after diagnosis and treatment for breast cancer.

Implications for Practice: The findings are of significance to clinicians because sexual well-being is central to psychological well-being and quality of life, and sexual intimacy has been found to make the experience of cancer more manageable and to assist in the recovery process.

Introduction

Breast cancer is the most common cancer in women and the second leading cause of cancer deaths in women globally.[1] Fortunately, advances in breast cancer screening and treatments have led to increasing rates of survival, with significant proportions of women surviving for 5 years after diagnosis—a rate of 88% in Australia, for example.[2,3] This has led to a focus on quality of life issues in breast cancer research, with particular attention being paid to sexuality. It is now recognized that changes to sexual well-being can be one of the most problematic aspects of life after breast cancer, with the impact lasting for many years after successful treatment,[3–5] often associated with serious physical and emotional adverse effects.[6] Research has shown that when compared with healthy same-aged women, women with breast cancer experience lower levels of sexual satisfaction and have more difficulty maintaining their sexual life.[7] More specific disturbances to sexual well-being include pain; fatigue;[8] decreased vaginal lubrication; nausea; hot flashes; night sweats;[9] vomiting, vaginal irritation, dyspareunia;[10] decreased sexual interest or desire;[11] vaginal atrophy; decreased sexual arousal;[12] numbness in previously sensitive breasts;[13] and difficulty achieving orgasm.[8] Although some women experience the changes to their sexuality after breast cancer positively,[9,14] most evidence shows that women with breast cancer experience a range of serious negative emotions, including depression and anxiety,[15] as well as alterations to their sexual self.[13]

Research has shown that the strongest consistent predictor of sexual problems after breast cancer is lower perceived sexual attractiveness.[4] Women who have a poor body image after breast cancer have lower rates of sexual satisfaction and are more dissatisfied with their sexual relationship than are those with a positive body image.[7] At the same time, it has been argued that although the physical pain of breast cancer and treatment diminishes with time, the experience of emotional pain may persist, as women grieve the loss of their breast or feel as though a part of them has died.[6] Breasts are often positioned as such a significant part of women's sense of self that mastectomy is associated with being "half a woman."[16] This is because the breast is positioned as a signifier of a woman's sexuality and femininity within patriarchal culture, meaning that women with breast cancer are at risk of being positioned outside "normal" femininity, with implications for women's sense of self, body image, and psychological well-being.[17–19]

Until recently, research examining the impact of breast cancer on sexual well-being and intimacy has focused narrowly on women's ability to engage in satisfying sexual activity, their satisfaction with the frequency of that activity,[13,20] and the level of their sexual "dysfunction" after breast cancer, where functional sexuality is conceptualized as penile/vaginal intercourse.[8,13,20] Recent research has shown, however, that engaging in sexual intercourse may not be women's primary focus of sexual concern after a breast cancer diagnosis and that engagement in sexual intercourse does not necessary equate to sexual satisfaction.[13,18] Moreover, the primary focus on the physical effects of breast cancer or breast cancer treatment on sexual behavior assumes that a woman's experience of sexuality is limited to its corporeal dimensions, negating the influence of the social and relational construction of sexuality and illness,[21] and the ways in which the meaning of sex is negotiated by individuals and within relationships.[22] In this vein, research consistently shows that one of the most important and consistent predictors of sexual health in women with breast cancer is the quality of their partnered relationship.[23] A good couple relationship and a supportive intimate partner have been shown to assist women cope with cancer and its outcome.[14,15] In fact, it has been shown that the quality of a woman's relationship is a stronger predictor of sexual satisfaction, sexual functioning, and sexual desire after breast cancer than the physical or chemical damage to the body after treatment.[24,25]

Previous research on sexuality and breast cancer has primarily used quantitative survey methods of data collection.[18] Although quantitative methods can provide information on changes in large samples of individuals, they negate the complexity of women's lived experience and negotiation of sexual well-being after breast cancer.[18] There has been some qualitative research that has examined women's lived experiences of changes to sexuality after breast cancer (see Archibald et al[14]) and the ways in which sociocultural discourses shape the experience and interpretation of sexuality.[17] However, within this research, the psychological and relational aspects of women's experiences are often ignored, physical changes are often minimized, and small sample size limits generalizations that can be made to a broader population of individuals with breast cancer.

The purpose of the present research study was to examine the lived experience of sexual well-being and couple intimacy in a large sample of individuals with breast cancer living in Australia, using a combination of quantitative and qualitative methods. We are adopting a material-discursive-intrapsychic perspective,[18,26] which acknowledges the materiality of physical changes in sexual well-being, as well as the tangible impact of cancer and cancer treatment, women's psychological and emotional experience, and the negotiation of such changes within a relational context, where meaning is constructed in the context of cultural constructions of femininity, sexuality, and illness. The research questions were as follows: What are the changes to sexual well-being and intimacy experienced after breast cancer? What factors are perceived to have caused these changes? How are these changes subjectively experienced by people with breast cancer?

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