World Journal of Psycho-Social Oncology Volume No 5

Original Article Open Access

Psychosexual problems of cancer patients and their spouses Results of an open ended survey

1K Sreerekha, 2Manoj Pandey, 1Anupama Thomas

  • 1Regional Cancer Centre, Trivandrum, India
  • 2Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
  • Submitted: November 30, 2011;
  • Accepted December 31, 2011;
  • Published: January 4, 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction:

Diagnosis and can treatment of cancer is associated with disruption of physical, physiological, psychological and sexual functions. We carried out an open ended survey to know the sexual morbidity and what does the patients and spouses think cause these dysfunctions.

Patients and methods:

A total of 100 patients and their spouses were interviewed using an open ended questionnaire. The questionnaire had questions related to 7 construct areas that were identified using a literature search and expert opinion. These 7 construct areas namely cosmesis, physical barriers, psychological factors, activities of daily living, social aspects, physiological-sexual factors and religion were included in the open ended questionnaire

Results:

The survey population consisted of 56 women and 44 men with cancer and their spouses. Of these 47 were sexually active at the time of interview. A total of 57 patients had completed the treatment and 36 were on treatment while 7 were waiting for the initiation of treatment. Nearly equal number of patients had primary in head neck region, breast, genitourinary and lymphoproliferative disorders. The physiological reasons, spouse related factors and erectile dysfunction were found to be the most common problems faced by the patients. Besides, these fatigue, pain, lack of arousal, problems of early ejaculations were also identified. Only 9 patients reported that there were no sexual issues that they faced, six of these reported to be sexually inactive.

Conclusions:

The results of the present survey show a high psychosexual morbidity in patients with cancer. The reason for sexual problems ranged from physical barrier to reasons like financial problems. Loss of cosmesis and pain was also found to be affecting sexual function. A need is seen to improve the patient spouse; patient physician communication which may in turn might improve the patients’ sexual function.

Introduction

Diagnosis of cancer and its treatment disrupts every aspect of human life. Apart from physical disabilities, psychological problems encountered by these patients are also of paramount importance. Disturbances in quality of life and activity of daily living occur early and are well researched. Psycho-sexual problems and partner related issues are also being increasingly recognized. The initial work concentrated on the patients of rectal and genital tract cancers where anatomic or treatment sequels physically impede sexual activity. In rectal cancer this is in form of retrograde ejaculations or erectile dysfunctions resulting from injury to autonomic nerves in pelvic dissections [1,2]. Later the effect of stoma was also studied and led to modifications in surgical techniques and introduction of sphincter preserving surgeries.

In gynecological cancers, the sexual dysfunction resulting from shorter length of residual vagina leading to dysperunia, hormone deprivation due to oopherectomy leading to loss of libido and dry vagina and atrophic vaginitis, and radiation changes have been found to directly influence the sexual quality of life. Recently, it has been found that loss of body image, loss of feminity, fear of sexual relations, depression and anxiety have also been found to effect sexuality [3]. This has been found to be even higher in patients who have also been sexually abused [4]. Late effects of treatment like bowel and bladder symptoms too have been found to effect sexuality in cancer survivors [5]. This study was carried out to explore the sexual problems faced by the cancer patients and what is the magnitude of these problems.

Material and methods

Between April 2006 and December 2006 an open ended survey was carried out to find out and gain understanding of the sexual dysfunctions and related psychological issues faced by cancer patients undergoing treatment with curative intent and their spouses. To determine the extent to which sexual activity is affected and what is extent of communication in this regard with their partners and doctors.

An interview was carried out using an open ended questionnaire with 100 cancer patients and their spouses. Using the information from experts as well as literature, 7 construct areas were identified where the cancer patients are likely to face problems. These 7 construct areas namely cosmesis, physical barriers, psychological factors, activities of daily living, social aspects, physiological-sexual factors and religion were included in the open ended questionnaire and the patients were asked to rank them from 1 to 7. Patients were also asked to communicate any other thing they want to (appendix 1).

From the data obtained, the frequency of the problems listed by the patients and the frequency of the ranks given for the 7 construct areas were calculated.

Results

The survey consisted of 56 women and 44 men with cancer and their spouses. Of these 47 were sexually active till the time of interview while 53 were not. A total of 57 patients had completed the treatment and 36 were on treatment while 7 were waiting for the initiation of treatment. Site of primary cancer is detailed in (Table 1).

The physiological reasons, spouse related factors and erectile dysfunction were found to be the most common problems faced by the patients (Table 2). Besides, these fatigue, pain, lack of arousal, problems of early ejaculations were also identified. A few patients also reported financial problems as the cause of sexual dysfunction. Only 9 patients reported that there were no sexual issues that they faced, six of these reported to be sexually inactive and stated that they are too old to have sex and have grown up children.

The spouses of the patients reported diminishing of the sexual drive and arousal, disruption of climax cycle due to partner experiencing pain or not showing any interest (non participation in sexual act or being passive), and early ejaculation as the most important causes of sexual dysfunction. A couple of spouses reported to be suspicious of their partner and thought the disease could have occurred due to this and avoided sexual contact with the partner. Two of these spouses sought sexual satisfaction elsewhere.

Table 1 : patients demography
Variable N %
Sexually active 47
Not active 53
Site
Head neck 27 25.5
Breast 23 21.7
Genito urinary 21 19.8
Lymphoproliferative 19 17.9
Others 5 4.7
Pretreatment 7 6.6
On treatment 36 34
Post treatment 57 53.8
Female 56 52.8
Male 44
Table 2: Frequency of problems identified by rank
Problem Fisrt rank Second rank Third rank Forth rank
N N N N
Erectile dysfunction 13 0 0 0
Fatigue 9 0 2 0
old age 6 1 0 0
Physiology 23 16 6 2
Psychological factors 11 14 2 1
Spouse related factors 14 4 3 1
Treatment related 6 4 1 1
Lack of privacy 1 3 2 0
No issues 9 1 0 0
Early ejaculations 2 2 0 0
No orgasm 1 0 0 0
Lack of arousal 1 0 0 0
Financial problems 0 1 1 2
Reduced frequency 4 4 0 0
Faith in god helps to adjust 0 2 1 0
Suspicious about partner 0 0 1 0
Physical problems 0 1 0 0
No nocturnal erection 0 1 0 0
Pain 0 3 0 0

Patients were also asked to rank the seven areas that were identified by the literature search and expert discussions. Of these, physical barriers to sex were ranked first by 24% of the patients and second by 7%. Psychological problems were ranked first by 14% followed by interference with activity of daily living and physiological problems like pain. Cosmesis was ranked first by only 2 patients and religion by 1 (Table 3).

Table 3: ranking of identified areas by patients
Rank1 Rank2 Rank3
1 Cosmesis 2 - -
2 Physical Barrier 24 7 2
3 Activities of Daily
Living
11 7 6
4 Social 9 3 -
5 Psychological 14 6 4
6 Physiologial-
Sexual
12 3 -
7 Religion 1 - -

Discussion

The results of the present survey shows that all cancer patients and their spouses face psychosexual problems only the magnitude and communication in this regards differ. Physiological problems faced by the patients due to disease and treatment sequel are the foremost. Some of these are unavoidable while others can be dealt with proper treatment delivery and counseling. As the number was small in this study no attempt was made to look at these disabilities by site of primary cancers and treatment given for the primary.

Alder et al (2008) [6] looked at the effect of androgen deprivation on sexual dysfunction in premenopausal patients with breast cancer and found sexual dysfunction in 68% of their patients, this was attributed to the menopause attained due to cancer chemotherapy and hormonal therapy. Both high dose as well as conventional chemotherapy has been found to be associated with sexual dysfunction [7]. Vaginal lubricants, and moisturizers may help to reduce vaginal dryness and dysperunia in this subset of patients [8].

It has been thought that the body image disturbances and sexual dysfunction will be more in patients undergoing mastectomy compared breast conservation, however, recent study in 112 Turkish patients showed no difference in terms of sexual dysfunction irrespective of type of surgical procedure [9]. They also identified that the sexual dysfunction occurred early and hence a need for proper counseling before the start of the treatment could not be understated [9]. Similar results have been reported by other authors [10]. This was in contrast to the earlier study of avis et al (2004)[11] and Gorisek et al 2009 [12], who found higher sexual dysfunction in patients undergoing mastectomy. The problem was attributed to lack of interest in sex to a greater extent while the effect of body image was found to be moderate. Similar results in premenopausal patients have been reported by Burwell in 2006 [13].

Though not enough data is available the testosterone therapy appears to be one alternative that may help the patients in improving vaginal dryness, dysperunia, loss of libido, and help in overcoming difficulties with orgasm [14]. However, its use cannot be universally recommended due to limited data on its safety [15]. Limited data is available in women with bilateral mastectomy (prophylactic), and this suggest even a lower body image and sexual interest that become apparent within first year of surgery in nearly half of the patients [16]. Sexual problems have also been studied in special populations with breast cancer; worse sexual functioning has been found in Hispanic women, despite nearly same body image [17]. positive cognitive restructuring, wishful thinking, emotional expression, disease acceptance, increased religious practice, family and social support, and yoga and exercise are found to be the common coping strategies in women with breast cancer [18].

In the present study the erectile dysfunction and spouse related problems were ranked quite high and were seen in substantial number of patients. Similar observations have been made by others [19,20,21,22,23]. These problems are common in patients who are treated for prostate cancer or rectal cancers, however, in patients who do not undergo surgery or radiation of pelvis these problems are encountered. It is suggested that beside loss of innervations, psychological factors like depression may also contribute to erectile dysfunction.

A number of our patients reported having psychological problems as has been seen in the literature. Christie et al compared the sexual adjustment in Hispanic and non Hispanic women and found that Hispanic women had significantly less sexual desire, greater difficulty relaxing and enjoying sex, and greater difficulty becoming sexually aroused and having orgasms than non-Hispanic White women [17]. Presence of distress has been found to adversely affect the sexual functioning [24,25].

High levels of mutual constructive communication between Patients and partners leads to greater marital adjustment, regardless of their own sexual satisfaction, while marital adjustment leads to sexual dissatisfaction at low levels of mutual constructive communication [19], thus suggesting that communication is an important factor in psycho-sexual dysfunction as has been observed in the present study. Park et al too found the communication to be an important factor and suggested that patient-physician communication too is important factor in predicting sexual morbidity [26]. Interpersonal sensitivity refers to the predisposition to perceive and elicit criticism and rejection from others; lack of sociability refers to chronic difficulties taking the initiative in interpersonal situations, Siegel et al., showed that the interpersonal sensitivity is related to sexual dysfunction and not the sociability [27]. Rowland et al., [28] showed in a randomized control trial using a group education intervention improve the communication and partner adjustment thus reducing the sexual morbidity. Molton also showed similar results with group therapy in prostate cancer patients [29].

Conclusions

This study demonstrate high rate of psychosexual problems in Indian cancer patients, and suggests that interventions may help some of these patients overcome their problems and live a healthy life.

Authors Contribution

MP: Designed the study, helped with analysis and interpretation of results and edited the final version for publication.
KS: Conducted the study, collected and analyzed the data, prepared the draft.
AT: helped in collection of data and analysis and interpretation of data.

Acknowledgement

The authors wish to acknowledge the help of Dr. K Ramdas, Radiation oncology, RCC Trivandrum and Mr. Bejoy C Thomas, currently at Tom Baker Cancer Centre, Canada.

Competing interests

The authors declare that there are no competing interests

Funding Support

Nil

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