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

Discussion

These findings support and extend previous research that reports significant changes in sexual well-being after diagnosis and treatment for breast cancer. In a previous survey of 863 women that examined self-reported changes to sexual functioning after breast cancer, it was found that one-third reported that cancer had a negative impact on their sexuality.[21] In the present study, the largest study of sexual well-being in the context of breast cancer published to date,[18] the proportion was far greater, suggesting that one-third may be a significant underestimate. Decreases in frequency of sex, sexual arousal, interest, and desire, as well as in sexual pleasure, satisfaction, and intimacy, 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. However, accounts of material changes to the body and relationships, as well as intrapsychic consequences, cannot be separated from discursive constructions of illness, femininity, and (hetero)sexuality, which give meaning to the experience of sexuality after breast cancer: a material-discursive-intrapsychic interaction.[18,29] For example, the focus on vaginal dryness experienced by women with breast cancer as a major cause of sexual difficulty, as well as the paucity of accounts of renegotiating sexual activity when coital sex was painful or difficult, illustrates the dominance of the coital imperative in the construction and experience of heterosexuality.[30] Challenging the coital imperative through the exploration of noncoital sexual practices should thus be central to professional advice and support for individuals with breast cancer.

Although some individuals experience the changes to their sexuality after breast cancer positively, most evidence shows that people with breast cancer experience a range of serious negative emotional changes because of disturbances to their sexuality.[14] Having to adjust to the removal or alteration in appearance of the breast, loss of bodily hair, feeling "old" before their time, concern about weight gain or loss, and partner difficulty in understanding feelings can exacerbate these negative emotional changes, as was found in the present study. Although some have argued that such changes are more prevalent in individuals with preexisting anxiety, depression, or sexual dysfunction,[8,31] it has also been reported that most women who experience negative changes to their sexual well-being also experience negative emotional changes.[14] The findings of the present study confirm these reports in a large sample of individuals with breast cancer and provide further insight into the nature of these effects.

The accounts in the present study also illustrate not only the intersubjective nature of changes to sexual well-being in the context of breast cancer—the importance of relationship context and partner reaction—but also the complexity of the woman with breast cancer's own response. Although partner rejection was consistently associated with women's feelings of negativity about the body or femininity, partner support did not always alleviate these negative feelings. The way the woman felt about herself and her ability to accept the changes to her body also impacted upon the way she positioned her body after breast cancer, allowing her to still feel like a sexual woman or, conversely, to feel "neutered," as one participant described herself.

At the same time, accounts of relationship change after breast cancer confirm previous research reports that the diagnosis of cancer can change the relational dynamics between people with cancer and their life partners, which can affect the sexual relationship.[32,33] Couples living with cancer have reported communication problems or increased conflict and, in some instances, have attributed relationship breakdown to cancer,[34–36] as was found in the present study. Conversely, it has been argued that couples living with cancer are no more likely to separate than couples in the general community[37] and that cancer can have had a positive effect on couple relationships,[35] bringing people with cancer and their partners closer together,[38] through creating greater intimacy.[39] These conflicting findings have led Hagedoorn et al[40(p24)] to conclude, in their meta-analysis of distress in couples coping with cancer, that further research is needed on "just how much cancer intrudes upon and organizes the daily lives of couples confronted with the disease." The findings of the present study make a substantial contribution to addressing this plea, through exploring both negative and positive accounts of the impact of cancer on sexual relationships.

Although the experiences of partners are often neglected in research on sexuality and intimacy after cancer, there is growing acknowledgement of their unmet needs in this area.[41,42] Reported disruptions include decreases in their own sex drive, fear of initiating sex with their partner, difficulty regaining a level of "normality" within the sexual relationship, and feeling unwanted and unattractive because of cessation of sex.[43,44] Many of these findings have been confirmed and extended by the findings of the present study, which reported on partner experiences from the perspective of the person with breast cancer. This reinforces the need to include partners, as well as people with cancer, in future research in cancer and sexuality. At the same time, the accounts of individuals who are not in a relationship highlight the importance of sexual well-being for those with breast cancer who are currently single and the need for support, if requested, to alleviate fears or concerns about entering a new relationship. Sexuality is not only a relational issue; changes in sexual well-being, and in sexual desire and arousal, can also affect those who are not in a relationship.

Future research in this area could address some of the issues not addressed in the present study. It would be useful to include partners in the sample to examine the interactional dynamics of sexual well-being after breast cancer. It would also be useful to conduct interviews to examine changes to sexuality in more depth and use standardized questionnaires to assess the impact on psychological well-being and the association of changes to sexual well-being with relationship dynamics and satisfaction. The sample in the present study was composed largely of Anglo-Australian women. Future research could usefully include individuals from a diverse range of cultural backgrounds, as expectations and experiences of sexuality may be shaped by cultural identity, as well as a greater proportion of men, who are often omitted from breast cancer research.[18]

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