SPECIAL ISSUE: Working with the Sexual Consequences of Cancer and its Treatment

Despite cancer remaining a disease many people fear, there is much to celebrate when modern treatment has resulted in more than 2 million people living with and beyond cancer in the UK alone. This impressive survival statistic is one on which clinicians and services, particularly in developed countries, continue to build (MacMillan, 2013).

However, what is more difficult for both clinicians and people affected by cancer to acknowledge are the 500,000 people whose daily lives are adversely affected by the longer term consequences of cancer treatment. For those working in sexual medicine and psychosexual therapy it is important to recognise that an estimated 350,000 people in the UK experience sexual consequences of cancer and its treatment (MacMillan 2013). Yet despite such need, this aspect of cancer survivorship still receives scant attention in medical education (Galletly et al 2010; Clegg et al 2016), service provision and research (Forbat et al 2011; White et al 2011; MacMillan 2013; Adams et al 2014).

Prevalence rates of sexual difficulties associated with cancer and its treatment vary widely depending on primary diagnosis, treatment modality, method(s) of assessment and threshold criteria for severity and type of sexual difficulty or dysfunction. However, levels tend to be higher than those encountered in the general adult population, as illustrated in a recent survey of people after pelvic radiotherapy where 24% of women and 53% of men experienced adverse treatment impacts on their ability to have a sexual relationship, persisting for many up to 11 years post-treatment (Adams et al 2014). In clinical practice, the aetiology of sexual difficulties associated with cancer is commonly a mixed picture of organic sexual changes with psychological and relational contributors that vary but tend to warrant an integrated psychosexual and biomedical management.

Examples of female sexual difficulties can be seen after breast or gynaecological cancer treatments that affect oestrogen levels resulting in reduced vaginal lubrication, which can cause dyspareunia (sexual pain), reduced enjoyment and orgasmic difficulties. Pelvic radiotherapy may cause vaginal dryness, adhesions and fibrosis, stenosis and vaginal shortening, again resulting in pain and an inability to have penetrative intercourse. Breast surgery may alter appearance and sensation, while pelvic and vulval surgery can lead to vaginal shortening or stenosis, altered vascular supply and nerve damage or reduced clitoral sensitivity resulting in sexual pain or orgasmic changes.

Whereas in men, loss of desire and erectile dysfunction (ED) may result from hormonal changes secondary to treatment for prostate cancer, as a result of nerve damage following pelvic surgery or radiotherapy, or as a result of changed body image due to weight change associated with treatment. Reduced orgasmic intensity, dry or retrograde ejaculation and climacturia are also reported as having a negative impact on men's sexual expression following cancer treatment.

The papers in this special issue reflect current research and practice in cancer and sexuality but, importantly, they also explore the challenges experienced by patient groups under-represented in published literature to date and highlight innovative practice and health professional training.

The study by McClelland et al provides important insights from women diagnosed with metastatic breast cancer about what they wished they had known about the effect of illness and treatment on their sexual lives, including suggestions for improved sexual health support for women living with advanced disease.

Katz's review explores the sexual effects of prostate cancer treatment beyond the individual to highlight the needs of couples and strategies to assist men and their partners to negotiate a new way of being sexual in the aftermath of treatment. While the paper by Grayer offers therapists a practice review of how emotionally focused therapy (EFT) for couples can offer a safe haven from which to explore sex during and after cancer.

Given the relative paucity of published research that address the sexual adjustment challenges faced by gay and bi-sexual men affected by prostate cancer, this special issue includes three papers that specifically focus on the information and sexual rehabilitation needs of these men and their partners. Heyworth et al describe an innovative public education initiative by members of the UK's LGBT Cancer Support Alliance, who developed postcards to raise awareness and improve information for the LGBT community living with and recovering from prostate cancer. While two companion papers by Rosser et al offer rich qualitative data from 19 American gay and bi-sexual men describing the effects of radical prostatectomy on sexual function and behaviour together with the broader impacts men experienced in their self-reported emotional well-being, sexual identities and sex role in relationships.

The final paper in this special issue focuses on innovation in health professional communication training in cancer and sexuality. Butcher et al used design activism through art installations to challenge health professional-patient communication. It addresses the understanding of the role of personal assumptions and expectations in communications with the disempowered patient to enable more meaningful conversations.

The papers in this special issue highlight the need for sexual rehabilitation in oncology to broaden its practice and research horizons from the traditional narrow gaze of biomedicine (White et al 2013; Kirby et al 2014; White et al 2015) to one that can more readily encompass diversity and integrative practice in sexology and psychosexual therapy, to more effectively reach out to those whose sexual lives have been affected by cancer and its treatment.