Earlier this year, Sage Bolte, PhD, LCSW, CST, FAOSW, discussed the definition of the sexual self, ways that cancer and its treatments impact the sexual self, and the Ex-PLISSIT (extended permission, limited information, specific suggestions, intensive therapy) assessment model to an audience at the midyear Academy of Oncology Nurse & Patient Navigators conference.
“Being diagnosed with cancer is a life-altering experience. And with that comes so many tremendous losses, including the loss in their sexual health,” said Dr Bolte. Cancer can directly impact sexual function, and cancers of the sex organs can make sex uncomfortable or even impossible, but cancer therapy can have an equally profound effect.
In 2018, there was an update on fertility and sexual health to the American Society of Clinical Oncology Clinical Practice Guidelines. These guidelines recommend that healthcare providers address the possibility of infertility, provide education, and obtain informed consent prior to treatment.
Healthcare providers should discuss fertility preservation, make any necessary referrals, and advise patients of the potential threat to fertility as early as possible. The guidelines also state that healthcare professionals should provide guidance on sexual health issues and have conversations related to common problems early and often.
“Sexuality and intimacy are critical pieces of quality of life (QOL),” Dr Bolte stated, adding that sexual health is one of the last things providers ask about because they are more focused on managing patients’ symptoms and mental health and educating them about their disease. Sexual health is equally important to these other areas of focus, and these discussions should start early to prevent some of the distress that patients feel, she continued.
QOL studies have identified the concerns of cancer survivors, such as changes in sexuality. The prevalence of altered sexuality is high and can persist for a prolonged period.
QOL studies have identified the concerns of cancer survivors, such as changes in sexuality. The prevalence of altered sexuality is high and can persist for a prolonged period. Altered sexuality has a negative impact on the QOL of the cancer survivor and their intimate partner(s). Anywhere from 10% to 100% of patients will experience some form of sexual dysfunction.
Dr Bolte discussed the physiologic alterations in men and women diagnosed with cancer. Men may experience neurovascular damage resulting in erectile disorder by undergoing chemotherapy, radiation, or surgery. They may experience decreased testosterone leading to decreased libido, osteoporosis, and vasomotor flushing. Men may also experience infertility, fatigue, and decreased physical stamina, and anal sex may be impacted. Male children treated for cancer may experience delayed or absent puberty.
Women may experience treatment side effects, such as chemo brain, joint discomfort, neuropathy, and weight gain or loss. They may also experience fatigue and decreased physical stamina, surgical scarring, lymphedema, and acute or premature ovarian failure.
Dr Bolte then discussed the potential barriers perceived by healthcare professionals to successfully evaluate the sexual health and intimacy of their patients. Some of these barriers include not knowing the information, inefficient resources, a lack of privacy for personal discussions, and not knowing where to send their patients.
“There is no privacy in oncology. Few infusion bays are private, yet we talk about bowel habits, and we talk about symptom management, and the challenges they are having with their kids, but what if we did that the same way, in the same tone…talked about their sexual health, their relationships. If we all did that, we would change the way that care was provided,” Dr Bolte explained.
There are ways of integrating sexuality into daily practice assessments, such as through routine QOL screening. This can be done through an interview and assessment model, such as the Ex-PLISSIT model.
It is important to obtain permission to initiate sexual discussions and legitimize sexual concerns. Permission can be obtained by using relationship-neutral language, informing the patient/partner that discussion of sexuality is part of routine assessment, being mindful of cultural and religious issues, and inquiring about previous sexual trauma and history. It is also important to provide limited information on the possible effects of cancer and treatment on sexual functioning.
Healthcare professionals should provide written information or a referral list and normalize the information by providing examples or statistics. Specific suggestions should be provided for the identified concern, as well as any needed or available prescriptions. The sexual partner should be included in this counseling to facilitate a discussion between the couple, normalize potential problems, potentially identify the partner’s concerns, and enlist the partner’s support.
Dr Bolte emphasized that cancer and its treatments often lead to significant sexual health issues, yet this aspect is frequently overlooked by healthcare providers.
Cancer can have a critical impact on sexual health, and it is necessary to integrate sexual health discussions into patient care. Dr Bolte emphasized that cancer and its treatments often lead to significant sexual health issues, yet this aspect is frequently overlooked by healthcare providers. She outlined the Ex-PLISSIT model as a structured approach to addressing sexual health concerns, which includes gaining patient permission, providing limited information, offering specific suggestions, and referrals for intensive therapy when needed.
Dr Bolte stressed that sexual health is integral to overall QOL and should be routinely addressed to mitigate distress and enhance patient care, advocating for more open and routine conversations about sexual health in oncology settings.
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