Sexual Health

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):

Let’s talk about SEX!”

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Males in Mammography

This month’s blog was written by Beverly Scragg, Lecturer in Radiography in the School of Health Sciences at the University of Salford (see Bev’s bio below*).

Hi, I’m Bev, and I’m a radiographer – there’s a starter for a confessional, if ever there was one. I worked regularly in the breast screening service between 2003-2018 (I still keep my hand in, even now, on the symptomatic side), and I want to contribute to the debate in allowing male radiographers in mammography – I’ll draw from the evidence base, social media and my experience to do so, giving you some food for thought and points for debate in the upcoming #MedRadJClub tweet chat.

It seems like a long time since the Equalise group brought their motion to the 33rd Annual Delegates Conference, asking for the Society & College of Radiographers to approach the NHS Breast Screening Programme (NHSBSP) to discuss allowing male radiographers to perform mammography.

Well, something is moving, as I hear that e-mails are sliding into inboxes asking for participation in Public Health England’s research into that very subject. The debate is surely on. For those of us who don’t know, mammography is the only specialist area of the radiography profession that is exempt from the Equality Act 2010 in order to protect ‘patient comfort’, but this status is reasonably being questioned by male radiographers, who argue that this is discrimination.

In a nutshell, on the one hand, seemingly, we have the needs of the patients and on the other the needs of the radiographers – simples. Hang on, that’s a bit simplistic, isn’t it?

It is, it really is. The issue is multi-faceted and complex, as you’d expect, and a recent excellent narrative review by Ashton & Warren-Forward has aimed to uncover what the evidence is saying about this – we all love a bit of evidence in this profession! (Ashton and Warren-Forward, 2019)

This under-staffed profession, I should say. Mammographers in England are becoming scarce, according to the workforce survey published by Public Health England back in 2016. Over 50% were aged over 50, working part time and likely to retire in the next ten years. There’s a 15% vacancy rate too, so there’s not many of them around to start with. Now let’s look at how thinly we spread that workforce. NHSBSP screens 2.1 million people annually, and that number is going to get 8% higher as the population increases. After you take that into account, the Age Extension trial will also make the number of women eligible for screening go up – by as much as 28%. (Public Health England, 2016)

That’s a lot of examinations, and that’s only screening – we’ve not included the symptomatic mammogram figures. With a female only mammographer policy, we’re making our potential workforce smaller – this is surely a contributory factor to the looming workforce crisis. Is this policy a reasonable one?

Let’s consider the men in all this. Men rarely get screened (apart from those whose genetic predisposition to breast cancer make them eligible to be included in the screening programme), but they do visit symptomatic breast clinics, which are tailored to suit female clientele. Men feel a range of negative emotions including shame and anxiety when dealing with male breast problems; it’s reasonable that we should be able to offer them an environment that is suited to their needs as well as that of others to reduce their embarrassment, surely. Interestingly, a small survey by Kipling, Ralph & Callanan in 2014 reported that only 20% of men were embarrassed in clinic. Over 30% were anxious, but 99% wouldn’t want to be seen in an all-male environment if it meant that they had to wait longer. (Kipling, Ralph and Callanan, 2014)

Strange – why would they have to wait longer? Well there’s another facet of the problem. The illusion of choice in the UK healthcare provision. The NHS is a very big machine, providing healthcare to the masses – exclusive, tailored experiences are not provided, because we need the efficiency from economy of scale. So, if you want something out of the ordinary, then we need time to arrange that – the feeling is that it delays your diagnosis or treatment, but it’s your choice. Sometimes, I do wonder if we gently discourage these requests, at the same time as giving people ‘choice’. Why do I say that? Well, I wrote a blog on this topic before on the WoMMeN website – and one of the comments below that blog gives us this insight:

“the leaflet said if I requested a female for a transvaginal ultrasound, that they would try to accommodate my wishes but couldn’t guarantee that one would be available, so basically saying that I had no real choice” (Scragg, 2017)

This echoes my friends experience. As a child sexual abuse survivor, he wanted an all-female team for a minor but intimate surgical procedure; that took an extra ten months to arrange. Ten months to guarantee an all-female environment? Really? Lose your allotted slot in the NHS diary, people, and it will cost you. Is choice elsewhere in the NHS given lip service? It seems so. If we were to give people ‘choice’ for mammography, we have to do it properly, surely?

Speaking of intimate procedures, mammography is now classed as one, meaning that chaperones can be requested – this caused a not insignificant flutter of disquiet when first announced in breast screening – in the symptomatic service too, I’m sure, although it was the thought of conjuring staff up on a mobile van as opposed to a static hospital site that seemed to be the greater challenge to us. Is it reasonable to assume that chaperones will be requested more often if males performed mammography? It’s a question that any research might want to consider so that any objections to males relating to chaperone use can be validated or refuted.

We do need to be mindful that mammography is intimate. Another comment below the blog was from a sex abuse survivor who made many points, among them this:

“For those who don’t know the difference, an annual breast exam is vastly different in the amount of “handling” of the breast required for a mammogram.”

I was positioning a client for her first mammogram once; she was quiet but compliant; I then noticed that she was quietly crying on the third view. When I asked what the matter was, she replied ‘oh, it just brings it all back, just carry on, get it over with’. After trying to ascertain whether she was in any pain, I eventually realised what she meant, and carried on, as quickly and as gently as I could. I don’t know whether she ever came back for her second visit. The lady who comments on the WoMMeN blog also says:

“Bottom line … male mammographer … I would walk out without the exam.”

I feel that the issue of choice, especially in such a sensitive area as sex abuse survivors, needs to be considered, as strong reactions such as this will be encountered – 20% of women have experienced some form of sexual assault since the age of 16 (Flatley, 2018).

But hold on, here – we have male gynaecologists and breast surgeons, are we not just hypocritical? Are we closing our eyes to discrimination? The narrative review by Ashton & Warren-Forward indicates clearly that in some countries, female clients would be accepting of a male mammographer; or had no preference for gender. So, should we not take the opportunity to change the norm, and make it normal for males to be involved in this examination? (Ashton and Warren-Forward, 2019)

In a symptomatic setting, this may be the way forward. In a screening setting, health behaviours can be different; someone may make an informed choice to attend but then barriers, such as logistics, or cultural perceptions may prevent that. Health promotion efforts that I have been involved in within socio-economically deprived areas are all about removing barriers – one of those things was, I’m afraid to say, emphasising that no males were in attendance in breast screening, as this was identified as a barrier by the clientele. Screening has to have a 70% uptake to be effective and we’re only just hitting that target in the UK – anything that may deter the 70% from attending impairs the programmes’ ability to detect small cancers.

When research indicates that 9% would not go through with the exam, (Fitzpatrick, Winston and Mooney, 2008; Warren-Forward et al., 2017) then we need to consider the impact on uptake. Can we take a 9% loss in attendance? Screening attendance is more likely for those in the higher socioeconomic brackets (Douglas et al., 2016) – has UK research considered yet whether these are the women who are also indicating that gender is not an issue for them? If they are, then to quote a line from one of my children’s favourite films, The Lorax, ‘you’re not the target market’. The women that we need to target to increase uptake are the ones who aren’t. I’m going out on an academic limb here, drawing from my own low socioeconomic background, and imagining a group of lower socioeconomic bracket women watching a group of higher socioeconomic bracket men arguing that they are discriminated against. I don’t think it gets much purchase, in that context.

Context is everything, and a systematic review of contextual factors and uptake (albeit not based on the UK health model) found that uptake was higher among female providers (Plourde et al., 2016); indicating a preference that was echoed worldwide in the recent narrative review (Ashton and Warren-Forward, 2019). It’s a preference for women by women – but is it also unlawful discrimination? What do we choose? Research needs to provide the answer, but without upsetting the proverbial apple cart.

I hope this has raised some points for you to discuss; join the #MedRadJclub tweet chat and add your voice to the debate.

References:

Ashton, J. and Warren-Forward, H. M. (2019) ‘Males in mammography: A narrative review of the literature’, Radiography. doi: 10.1016/j.radi.2019.05.001.

Douglas, E. et al. (2016) ‘Socioeconomic inequalities in breast and cervical screening coverage in England: are we closing the gap?’, J Med Screen, 23(2), pp. 98–103. doi: 10.1177/0969141315600192.

Fitzpatrick, P., Winston, A. and Mooney, T. (2008) ‘Radiographer gender and breast-screening uptake’, British Journal of Cancer, 98, pp. 1759–1761. doi: 10.1038/sj.bjc.6604385.

Flatley, J. (2018) Sexual offences in England and Wales: year ending March 2017. London. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/sexualoffencesinenglandandwales/yearendingmarch2017.

Kipling, M., Ralph, J. E. M. and Callanan, K. (2014) ‘Breast Care Psychological Impact of Male Breast Disorders: Literature Review and Survey Results’. doi: 10.1159/000358751.

Plourde, N. et al. (2016) ‘Contextual factors associated with uptake of breast and cervical cancer screening: A systematic review of the literature’, Women & Health. Routledge, 56(8), pp. 906–925. doi: 10.1080/03630242.2016.1145169.

Public Health England (2016) NHS Breast Screening Programme: National radiographic workforce survey. London.

Scragg, B. (2017) Can men be mammographer technicians?, http://www.wommen.org.uk. Available at: http://wommen.org.uk/blog/2017/04/26/can-men-mammographer-technicians/.

Warren-Forward, H. M. et al. (2017) ‘Perceptions of Australian clients towards male radiographers working in breast imaging: Quantitative results from a pilot study’, Radiography, 23(1), pp. 3–8. doi: http://doi.org/10.1016/j.radi.2016.05.006.

Bev’s bio*:

I qualified in 1995 and have worked in the North West of England for all that time – working in breast screening but never letting go of my general out-of-hours radiography. I’ve collaborated with various people from the University of Salford and published some research in the field of breast screening – my interest is loosely based on ‘quality’, so Social Media use, compression, image quality, interval cancers. I am currently employed as a lecturer in Radiography, but also a bank radiographer.