How to have a comfortable discussion on sexuality

A common complaint among women with breast cancer is that their concerns about sex and sexual function are brushed off. “When I asked my doctor about having sex, he said, ‘Hey, right now we're focused on keeping you alive. Aren't you lucky just to be here?'” Responses such as this ignore the significance of intimate relationships to patients' quality of life.

Clinicians may be uncomfortable asking patients about their sexuality and how their cancer is affecting it, and often do not know what to say when a patient raises the issue. Lynne Kolton Schneider, PhD, is a psychologist based in Boca Raton, Florida, who specializes in sexuality for patients with chronic conditions such as cancer. She also conducts educational seminars for clinicians on how to identify patients with quality of life issues related to sexuality who may need referral to a specialist. Schneider talked with Oncology Nurse Advisor about what oncology nurses should know about sexual health therapy and what they can do for patients who need it.

“The important thing is to let clinicians know they don't have to be able to provide [sexual health] therapy,” Schneider explained. “My sessions are not intended to train clinicians in sexual health therapy. The focus is to learn to recognize patients' issues, provide basic information, possibly offer specific suggestions, how and where to find referrals, and help clinicians feel more comfortable discussing this subject.”

The reality is that cancer and its treatments significantly impact sexuality. Directly, surgical interventions can impair patients' ability to have an erection, have children, or perform in some way. Some medications also affect sexuality. Many women who are breast cancer survivors take antiandrogenic medications that induce early menopause. Women experience hot flashes, vaginal atrophy, painful intercourse, and loss of libido. These symptoms tend to be worse when initiated by cancer treatments than when they manifest as natural menopause.

In addition, cancer has many indirect effects such as fatigue and altered body image, along with worries about sexuality in the future. Sexuality is not only the act of sexual intercourse and the ability to have an orgasm or an erection; it encompasses self body image, fertility, intimacy, and physical communications such as touching, fondling, and other activities that demonstrate affection.1

In a survey of 1,965 patients with breast cancer, 85% reported changes to their sexual well-being after breast cancer and 68% wanted information on these changes;2 however, only 41% obtained such information. Of the respondents, 39% talked with their oncologist about sexual changes and 21% spoke to their breast care nurse. Those who talked with their breast care nurses rated their satisfaction highest (60%), and satisfaction was rated lowest in the patients who talked with their oncologists (34%).

Oncology nurses are well positioned to address the full spectrum of health issues that come with cancer. Just as bowel and bladder function, thirst, and hair are aspects of the patient as a person that are affected by cancer, sexuality is also an aspect that may be affected. As patients with cancer move from “taking in” to “taking hold” to “taking on” their cancer, they become ready to talk about their sexuality.3 Nurses should be able to provide support as the patient deals with the changes from diagnosis through treatment, and especially during rehabilitation. However, while oncology nurses realize they should talk to patients about sexuality, usually they do not.

PLISSIT MODEL

“Give yourself, the clinician, permission to do only what you're comfortable with,” Schneider tells her trainees. She advocates using the PLISSAT model, which was developed by Jack Annon, PhD, DABPS, DABFE, DABFM, FACFEI. The acronym PLISSIT stands for permission, limited information, specific suggestions, and intensive therapy. Use of this model is a matter of knowing your limitations and your comfort level.

Permission This stage is when clinicians give patients permission to have the issue or to talk about it. Some oncology nurses may be comfortable just at this stage, and that is fine. Nurses can acknowledge that cancer affects patients' sexuality, and just ask their patients if the cancer impacts their sexuality. Patients are given permission to say, “I do not like how I look,” or that they do not know if they will be able to perform sexually. These statements can be acknowledged with a response such as, “A lot of patients feel that way. I'm not the best person to speak with, but let me find someone who is.”

Limited information Nurses who are more comfortable talking with patients about sexuality, or have more knowledge of the subject, can provide limited information. This information can be as basic as a referral or contact information for a resource.

Specific suggestions At this stage, the nurse is comfortable discussing sex and sexual functioning with patients. Schneider suggests responses such as, “Have you considered trying a different position? You may experience less discomfort in another position,” if pain or discomfort is the issue. If fatigue is the issue, the nurse may say, “Have you tried changing the time you engage in these behaviors? Perhaps waking up an hour earlier will help because when you are rested, your body responds the best.”

Intensive therapy Patients who need help at this stage should be referred to someone who is skilled in providing intensive therapy. Nurses should be aware of the limitations of their knowledge and training, as well as their comfort level. Referrals allow the nurse to address patients' concerns about their sexuality while working within their own limitations and comfort level. 

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