Renegotiating Sex and Intimacy After Cancer

Resisting the Coital Imperative

Jane M. Ussher, PhD; Janette Perz, PhD; Emilee Gilbert, PhD; W. K. Tim Wong, PhD; Kim Hobbs, MSW


Cancer Nurs. 2013;36(6):454-462. 

In This Article

Abstract and Introduction


Background: Previous research on sex and intimacy in the context of cancer has focused on documenting sexual changes and difficulties, primarily focusing on heterosexual individuals who have sexual or reproductive cancers. Analyses of sexual renegotiation and the social construction of sex are largely absent from the research agenda.

Objective: The objective of this study was to explore renegotiation of sex in individuals with cancer, and in partners, across a broad range of cancer types and relational contexts.

Methods: Semistructured interviews were conducted with 44 people with cancer (23 women, 21 men) and 35 partners (18 women, 17 men), 86% of whom identified as heterosexual. The data were analyzed with theoretical thematic analysis, from a material-discursive-intrapsychic perspective.

Results: Renegotiation of sex or intimacy was reported by 70% of participants, reflected in 3 themes: "resisting the coital imperative: redefining 'sex,'" "resisting the coital imperative: embracing intimacy," and "adopting the coital imperative: refiguring the body through techno-medicine." The importance of relational context was reflected in the theme "the inter-subjective nature of sexual re-negotiation: relationship context and communication."

Conclusions: Whereas previous research has focused on embodied changes associated with sexuality after cancer, or their psychological consequences, the findings of the present study suggest that hegemonic constructions of "sex," in particular the coital imperative, are central to the experience and negotiation of sex and intimacy after cancer.

Implications for Practice: Resistance of the coital imperative should be a fundamental aspect of information and support provided by health professionals who seek to reduce distress associated with sexual changes after cancer.


There is a growing body of research demonstrating that cancer can result in significant disruption to sexuality and intimacy.[1–3] These sexual changes can lead to significant distress and can be among the most negative influences on the social well-being of people with cancer.[1] There are, however, a number of limitations in existing research about sexuality in the context of cancer. The focus has been on embodied aspects of sexual changes, in particular changes to sexual or genital "functioning." This includes a focus on erectile performance in men[4,5] and vaginal dryness or elasticity,[6] sexual dysfunction, or body image changes[7] in women. Although there is a growing body of research examining psychosocial correlates of changes to sexuality after cancer, including the influence of relational context,[8] little attention has been given to renegotiation of sexual practice or intimacy, which has led to a plea for research examining "successful strategies used by couples to maintain sexual intimacy" in the context of cancer.[9(p142)]

There is some evidence that individuals can renegotiate sexual practices following cancer, based on accounts of a small number of participants taking part in studies focusing on sexual difficulties. Men with prostate cancer have reported "different" and "better" sex after treatment,[10(p323)] expressing intimacy through oral sex and touch, rather than penetration.[8,11] Research with partners of people with cancer has also reported renegotiation of sex to include practices previously positioned as secondary to "real sex."[3,12] However, there is a need for further research on sexual renegotiation after cancer, from the perspective of both people with cancer and their partners, across a range of cancer types.

Previous research on cancer and sexuality has focused on cancers that directly affect the sexual or reproductive organs, such as prostate, testicular, breast, and gynecologic cancer.[13–16] Although there are a few studies examining changes to sexuality in nonreproductive cancers, such as lung and colorectal cancer (for examples, see Ramirez et al[17] and Carolan et al[18]), these studies are in the minority. Equally, while sexual changes have been reported by the intimate partners of people with both reproductive and nonreproductive cancers,[3,19] partners are rarely included in research on cancer and sexuality. The focus of research has also primarily been on heterosexual people with cancer, with the experiences and concerns of gay, lesbian, bisexual, and transgender individuals marginalized or ignored.[20,21] The aim of the present study was therefore to examine renegotiation of sex and intimacy in the context of cancer, across a range of cancer types and sexual orientations, in people with cancer and their partners.

The Social Construction of Sex: Reifying the Coital Imperative

With a few notable exceptions,[4,8,11] acknowledgment of the social construction of sex, and the "politics of heterosexuality," which define "sex" as penis-vagina (coital) penetration, has been absent from previous research on cancer and sexuality.[22(p315)] Social constructionist theorists take a critical stance toward essentialist conceptualizations of sex and sexuality, instead viewing our understanding of "normal" and "abnormal" sex as the result of the representations, beliefs, and practices that circulate in a particular cultural context, at a particular point in time.[23] These socially organized meanings given to sexuality, which tell us what sex is, serve to "set the horizon of the possible" in terms of sexual desire and behavior.[24(p16)]

The biomedical model of sex positions sex as a physiologically driven act, and heterosexual penis-vagina intercourse as "natural" or "real" sex, with other forms of sexual activity deemed to be preliminary "foreplay," an optional extra, or simply a substitute if the "real thing" is not possible.[25] Described as the "coital imperative,"[25(p44),26(p229)] this biomedical model of sex is enshrined in definitions of "sexual dysfunction" in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association,[27] used to diagnose inability to perform coital heterosexual sex as pathological, in both cancer and noncancer contexts. The coital imperative is not confined to the biomedical domain; it is also reflected in discursive representations of "real" or "normal" sex within popular culture,[28] reinforced by advertisements for Viagra, that promise sexual fitness and "functionality" across the life span and the restoration of premorbid coital abilities if dysfunction is experienced.[10]

These discursive representations provide the context within which men and women learn the meaning of sex and the sexual scripts they should follow in order to be "normal." The centrality of the coital imperative to sexual scripts is evident in accounts of heterosexual individuals positioning "real sex" as penis-vagina intercourse.[26,29] Even when sex is acknowledged to be "more than intercourse," involving activities such as oral sex or mutual masturbation, coital penetration is positioned as the inevitable outcome.[26(p232)] The progression of sexual acts that precede intercourse is also conceptualized as less intimate, as play or fun, in contrast to intercourse, which is positioned as a serious act, which represents the "ultimate intimacy."[29(p49)]

Coital sex is also central to gendered subjectivity. Women who cannot engage in coital sex, because of illness or pain, have been reported to describe themselves as an "inadequate woman" or "inadequate partner,"[30(p294)] expressing concern that their ability to fulfill relationship roles is disrupted.[31] At the same time, the ability to maintain an erection and perform coital sex has been described as the essence of the male role,[32] and as central to masculine gender identity.[33] In this vein, men who experience difficulties in attaining or maintaining an erection report humiliation, despair, and the feeling that they are worthless or not a "real man."[11,33]

Constructions of Sex in the Context of Cancer

Social constructions of "normal" sex provide the context within which individuals construct and experience changes to sexual feelings or behavior following cancer. Previous research has established that the maintenance of penetrative sex, tied to dominant constructions of masculinity, is a major concern of men who experience prostate and testicular cancer,[4,8] with a range of pharmaceutical and mechanical sex aids utilized to address erectile problems.[5,8,11] It has also been reported that many heterosexual women who experience absence of sexual desire, sensation, or pleasure following cancer continue to engage in coital sex, regardless of pain or discomfort.[34] Although there has been little discussion in the research literature about why this is so,[22] women's adherence to the coital imperative, associated with ideals of heterofemininity, is one plausible explanation.

The present study incorporates knowledge about the social construction of sex within a material-discursive-intrapsychic (MDI) approach,[35] the theoretical framework that guides the research. This approach acknowledges the materiality of physical changes in sexual well-being, as well as the tangible impact of cancer and cancer treatment; the psychological and emotional experience of people with cancer and their partners; and the negotiation of such changes, where meaning is constructed in the context of social constructions of gender, sex, and illness. The research questions addressed in this study were: How do people with cancer and partners of a person with cancer (PWC) maintain sexual intimacy, or renegotiate sexual practice, in the context of cancer? Which strategies are positioned as effective, and which strategies are positioned as less effective?