My name is Sean Ralph, and I currently work as a radiation therapy on-treatment review advanced practitioner. In my experience, many health professionals feel uncomfortable discussing sexuality and relationships with patients, regardless of their sexual orientation or the type of sex they’re having. When these subjects are approached, they are often either glossed over or the narrative is led by the preconceived ideas of the health professional and not the concerns of the patient.
The use of vaginal dilators for patients undergoing pelvic radiotherapy is a prime example of this health professional-led narrative. Patients are advised to use dilators shortly after radiotherapy to prevent vaginal stenosis, which can make sex and pelvic examinations uncomfortable and painful. A colleague who underwent radiotherapy for a gynaecological cancer once told me how annoyed she was by the conversation around these dilators. Her main concern was not simply the ability to continue having penetrative sex, but how the treatment was going to affect the sensitivity of her clitoris and therefore the amount of sexual pleasure she could achieve moving forward. The somewhat scripted conversation from her health professional left no room for these concerns and she was subsequently left with a lot of unanswered questions.
Health professionals are often reluctant to discuss sex and relationships because they are worried about offending or upsetting patients. In my professional role I discuss sexual function with men with prostate cancer on a daily basis, providing guidance on appropriate treatments and referrals to medical reps to be fitted for a vacuum erection device. With my female breast cancer patients undergoing endocrine treatment I ask about vaginal atrophy, which can cause vaginal discomfort, itching, and pain during sex, providing samples of vaginal moisturisers and lubricants for those experiencing problems. To date I have only had one patient become visibly embarrassed by these questions, and upon reflection this was because her relatively new partner had attended clinic with her. However, despite that embarrassment she popped back into the clinic room later to ask for some of the lubricant samples.
Hormone therapies for breast and prostate cancer have very obvious effects on sexual function, and in the radiotherapy setting we need to be mindful that it is not just the treatments for breast and pelvic malignancies that can also cause significant changes. How would you be able to kiss your partner if you have trismus (and can’t open your mouth properly) or persistent xerostomia (dry mouth) following head and neck radiotherapy? What about oral sex with these conditions? What effect might either or both of these issues have on your relationship?
Because of the inadequacy of health professionals to provide truly holistic sexual healthcare, and also the inability of existing prostate cancer support groups to comfortably support sexual minority patients, I co-founded Out with Prostate Cancer in 2013. This organization is the UK’s first prostate cancer support group for gay and bisexual men. At the support group meetings a significant amount of time is spent discussing sexual function, relationships, treatments for erectile dysfunction (ED), and the members’ experiences of health professionals trying to help them address these issues. A year or so ago a new member attended the group. When he introduced himself he explained that he is bisexual, his wife (who he has children with) is also bisexual, and that they have an open relationship. No one batted an eyelid and the conversation continued on in its usual very informal, light-hearted manner. Upon reflection it struck me that perhaps if this gentleman had attended a “general” prostate cancer support group and told them that he was bisexual, their jaws might be on the floor. If he then went on to tell them that his wife is also bisexual and they have an open relationship, they’d probably all fall off their chairs. Unfortunately I could imagine a lot of health professionals having a very similar reaction, in a much more nuanced manner of course, but patients can read between the lines.
Thus, when discussing sex and relationships with patients we need to be open to the idea that some people have unconventional relationship configurations. In their wonderfully progressive introductory book, ‘The Psychology of Sex’, Meg-John Barker (they/them pronouns) proposes a more inclusive definition of sex that legitimizes variations in sexual desire, sexual practices, body parts, and relationships; moving away from the penis-in-vagina man-woman definition of “proper sex”. Health professionals would do well to keep this inclusive definition in mind when addressing the sexual health and relationship concerns of their increasingly diverse patient populations.
The results from Angela’s mixed methods study are very promising, with “85% of radiation therapists strongly agreeing/agreeing that all patients with cancer, regardless of cancer site, can experience issues which may affect sexual health.” 92% also strongly agreed/agreed that sexual health is an important part of a person’s overall quality of life. As a profession, we are very well placed to help patients with their sexual health concerns following treatment, particularly with the proliferation of advanced practice roles. We should therefore build on the progressive attitudes identified in Angela’s study, to better address the frequently overlooked sexual health concerns of our patients.
With our minds now open to sexuality in all of its messy diversity, it is important that we keep our ears open to the everyday conversations with patients that may hint to deeper concerns regarding sexual function and relationships. As far as I am concerned when you enter a healthcare environment as a health professional you leave your hang-ups at the door and you do the best for your patients, and that means talking about sex and relationships, and all of the sticky things surrounding those two words.
With this month’s #SexyMedRadJclub Tweet chat looming ever closer I will leave you with the words of Salt-N-Pepa (now that’s the hip-hop group, not the condiments):