Yacov Reisman1 and Woet L. Gianotten2
(1)
Department of Urology, Amstelland Hospital, Amstelveen, The Netherlands
(2)
Physical Rehabilitation Sexology, Rehabilitation Centre De Trappenberg, Huizen, The Netherlands
Yacov Reisman (Corresponding author)
Email: uro.amsterdam@gmail.com
Woet L. Gianotten
Email: woetgia@ziggo.nl
28.1 Introduction
The previous chapters of this part module paid attention to various aspects of preventing sexual decline and of sexual rehabilitation after cancer treatment. This chapter will highlight the potential use and some challenges in the introduction of sexual tools and toys in that process.
We will start with some remarks about the emotional connections, being aware that for many patients and for many health care providers, sexual toys and tools are surrounded by taboos, in spite of the fact that they can be a very valuable addition to the treatment.
The next will be a short introduction in constructively dealing with the different ingredients that altogether make up the pleasurable or confusing stew of sexuality. How to deal with the topic of erotic material without being too distant? And also, how to handle the “sex topic” without getting too intimate. We will try to make the reader more at ease in dealing with this area and increase the reader’s competence.
At the end of the chapter, we will address one by one various “additions”,tools, and toys that can be used in oncosexology. As the scientific literature and described experience of the use of tools and toys are very limited, a good part of the expertise of this chapter originated from working with sexual disturbances in people with physical impairment (“physical rehabilitation sexology”). In that patient population, the use of all kinds of aids and devices is inevitable and much more accepted.
28.2 “Taboos” and “Handicaps”
Cancer treatment can be devastating for the sexual health and for the sexual function of the patient and partner. We regularly use the terms “the new me” and “the new we” – a situation that asks for new ways of dealing with those disturbances and adaptation to new forms of sexuality. Health care providers have a wide variety of strategies to deal with those sexual disturbances. In that holistic process, additional benefit can be gained from the introduction of/integration of new technologies such as Internet, or sex toys such as vibrators. The contemplated effect is to help a patient to regain the lost sexual function and finally to reconnect sexually and emotionally with the self or the partner and to improve their sex-related quality of life.
Sex toys are objects or devices that are primarily used to facilitate human sexual pleasure. They include vibrators, penile toys, nipple toys, and penetrating objects. Later in this chapter, we will describe some practical uses of toys.
The world’s oldest known sex toy is a dildo, used 3000 years ago. Till the 1920s, sex toys did not stay outside the medical realm. For centuries, physicians have been using them for treating fertility and sexual disturbances. Two centuries ago, physicians treated, for instance, many female disturbances with “pelvic massage” (what in fact was a form of clitoral masturbation). As a result, many physicians developed chronic strain injury in their arms and hands, and they were relieved when, in the 1870s, an electromechanical vibrator could take over that job. Whereas in the beginning of the twentieth century, the vibrator was ready for the general public, some decades later, both mainstream society and physicians turned their back from vibrator use.
The vibrator re-emerged during the sexual revolution of the 1960s, and since the 1980s, vibrators and sex toys became increasingly visible in the mainstream public culture, but not in the medical practice, and apparently also not in the context of chronic disease and cancer.
In the past decade, the prevalence of experience with vibrator use in the USA was 52 % for women [1] and 45 % for men [2], with even higher rates for the LGBT population. Compared to nonusers, vibrator users had better sexual functioning and a wide array of positive sexual health characteristics. In the context of oncosexology, there is nearly no information on the use of sex toys.
For many people, sex toys do not have a good reputation.
The literature does neither promote masturbation nor consider vibrator use as serious elements of female or male sexual expression, which appears to color the perception of how, why, when, and in what context vibrators are used. Many heterosexual people (especially women), for instance, seem to have a wide range of taboos – arguments against using a vibrator:
· It is “selfish.”
· It can threaten the male partner to become superfluous (no more needed for her orgasm).
· An orgasm by any tool outside the boundaries of her own or her partner’s body is unnatural.
· She is not sure about deserving the joy and pleasure that a vibrator can provide.
· It can be addictive and make you greedy to have as many orgasms as possible.
· Being orgasmic can make one become dependent on the vibrator.
Although the last two arguments have never been proved, they are very frequently discussed and mentioned as a kind of underlying concern.
On the other hand, vibrators (and other sex toys) are nearly never mentioned in the medical literature and also nearly never mentioned by health care providers.
28.3 Reintroducing and Reconstructing
Here, we will try to address various aspects that can make up the pleasurable stew of sexuality and on how to constructively deal with that. Whereas some couples are sufficiently happy with physical intimacy, without missing the sexual aspects of it, we will focus here on those other patients and couples who lack the sexual aspects.
Tools and toys have various roles. Examples are enhancing arousal, enhancing orgasm, or replacing muscular power. Since desire is more or less phase 1 of sexual expression, we will start with that.
Sexual desire comes in many different forms and fluctuates over time. In some people and at some moments, there is proactive desire. Far more frequently, desire is a response that only develops as a result of stimuli and conditions. After cancer treatment, those conditions frequently have become rather poor, and much effort is needed to get back on track. Then, one actively has to work on conditions and stimuli to re-enter the playing field of intimacy and sexuality.
Sexual function can indeed be imagined as the final sum of stimulating and inhibiting factors (or called more simplified “accelerators” and “brakes”). Inhibiting factors can at least partly be counterbalanced by more stimulation.
An example: a man with multiple myeloma treatment is very tired and has no more proactive desire. On his birthday, his wife dresses very sexy and performs a fascinating striptease for him. In spite of his strong fatigue, the husband gets sexual desire and they continue into a sexual encounter that is satisfying for both of them.
The previous chapters have dealt with disturbing conditions like relationship, hormones, fatigue, neurotransmitters, and pain. Many other conditions tend to get less attention in health care.
There are numerous “common” inhibiting or distracting conditions: social media, television in the bedroom, kids walking in, a too cold room, bad hygiene, etc. [3]. Just mentioning such factors to the couple can enhance some action. On the other side, there are the “common” stimulators. A clean, well-groomed body, good smell (with perfume or incense), romantic music, and a cozy room can allow the development of an erotic atmosphere. Men are in general more easily influenced by “sexual” and visual stimuli, whereas women tend to be more easily activated by romantic elements and full personal attention. That is not better or worse, and indicating that difference will in most couples provide some recognition and understanding.
Time is another relevant factor, for instance, important in massage, kissing, and hugging. With low desire, one needs more time to build up some amount of excitement or even some amount of feeling again at ease. In sexology, we traditionally used sensate focus exercises to distract from too much function-driven attention. Here, the first part is not even sensate focus, but focus on intimacy and reconnection. And from there, gradually maybe back to regaining sexual function.
Part of discussing sexuality in the context of rehabilitation is kind of a game in which the health care provider makes the patient or couple re-interested in the opportunities and challenges of sexual expression and intimacy without personally becoming part of that process.
Explicitly dealing with sexuality is indeed like a challenging trip between Scylla and Charybdis. On the one hand, there is the collusion of silence. For instance, when ‘discussing sexuality’ is experienced as too intimate or too irrelevant (“single”; “too old”; “too ill” etc.). Let us assume the reality that a substantial number of cancer patients have disturbances in the area of sexuality and intimacy. Then, when health care providers do not address that area, there is a good chance that the patient will conclude that this is a no-go area. When on the other hand the topic is adequately addressed, it usually will allow the couple to open up this discussion. The same goes for masturbation or for the use of erotica or toys. In the situations where such activities seem rather relevant, our not-addressing it can make that a no-go area in the relation between the couple and us and probably also among the partners.
On the other hand, there is the risk of getting too intimate. In our wording, our voice, our nonverbal expression, and our connection, we should keep some amount of distance. An example is when an erotic exercise or a sexual tool is recommended.
When I say: “I recommend to use that vibrator!” there is a chance that I will virtually get into the patient’s bedroom. That will happen less easy when I say: “Some patients with the same troubles have used such a vibrator. For some of them it gave good results. Maybe that is something for you to consider?”
The introduction of a tool into a sexual experience may have a significant personal, psychological, and emotional impact, also affecting the relationship with the health professional who recommends the device. Although it sometimes can seem practical, sex toys should not be sold by health care professionals, because they are in fact border violations and easily creating undesirable emotions (in psychotherapy called transference) [4].
Sexual toys can be recommended or introduced for different reasons. First, because of highlighting the idea of pleasure, joy, and fun in lovemaking. They may re-create novelty in a relationship where cancer has taken away the vigor [3]. They can assist in increasing arousal, redevelop sensuality, rediscover, or widen the range of sensations, and in many cases they appear more “erotic” than equivalent medical equipment. Vibrators for instance can serve as an important part of the sexual repertoires for both men and women, and have demonstrated positive sexual health outcomes among individuals who use such products.
One should keep in mind that they do not replace sexual intimacy and bonding.
28.4 Various Additions, Tools, and Toys in Detail
28.4.1 Desire-Enhancing Additions
Many of the common erotic appetizers are widely accepted and known to many patients. However, in part of the couples, the competence to use them apparently has gone up in smoke in the course of the cancer journey. When their desire needs a boost, it can be useful to actively pay attention to those appetizers. We will mention some of the more common ones.
Massage oil. Recommend to go shopping together for a massage oil that is pleasantly smelling for both. Next, let them find instructions for mutual massage. Applying skin-nourishing oil can be extra relevant on radiated skin. Slow-speed massage tends to be more beneficial.
Smell can be very influential. Smells seem to be connected to our “reptile” brain. The right perfume, after-shave, incense, or flowers can easily set us back in our erotic past.
Memories can anyhow be an efficient detour to desire. Maybe the couple can focus on remembering the smell, music, or pet names of the beginning of their relationship when they were not patients but lovers.
Visual elements are strong cues for men. A sexy dress (and sexy undressing) can improve his sexual mood (that is why many men want to have sex with the lights on).
Internet offers a myriad of X-rated pictures and film clips that not only can add pleasure, but also support the badly needed desire or arousal. Knowing that “porn” is for some the delicacy of forbidden fruit, but for others the gateway to hell, we have to be careful when mentioning such possibilities and be aware of the culture of the couple and their sexual alliance.
Moisturizers are intended to keep the vagina healthy, regardless of sexual activities [5]. They hydrate the vaginal mucosa in women with low estrogenic status, especially the group of breast cancer patients with hormonal treatment. It is a nonhormonal approach to vaginal atrophy, which usually also restores the proper vaginal pH, reducing vaginal infections. Moisturizers have to be applied 2–3× per week (and in some women even more frequently). Available are, for instance, a polycarbophil-based gel (Replens®) or suppositories with hyaluronic acid.
Lubricants have several different functions.
· They can enhance pleasure, for instance, by improving “the feel” and by easing genital massage.
· They can improve genital arousal. That is, for instance, clearly seen in men who use a lubricant during masturbation. We tend to tell that a lubricant will give a 10 % better erection.
· They can substitute vaginal lubrication and prevent dryness and pain during sexual contact. That is especially important when the lubrication capacity has been damaged, which happens, for instance, after vaginal radiotherapy, after nonnerve-sparing radical hysterectomy or with beta-blocker medication.
Whereas some couples use lubricants as a replacement for arousal, health care professionals better do not recommend that strategy. With sufficient and adequate stimulation, most women can lubricate by themselves (even when there is vaginal atrophy!).
· They can ease the process of vaginal dilation (and vaginal examination).
· They are absolutely necessary in any anal penetration, since the anus has no own lubricating capacity.
Next to saliva, there are artificial lubricants that come from four different groups: oil-based, water-based, silicone-based, and plant-oil-based.
· Oil-based (“petroleum-based”) lubricants can be good for external use, but should not be used in a vulnerable vagina. They have several disadvantages. They can destroy latex condoms or toys and as such increase the risk for pathogen transmission.
Some have an unpleasant odor, but others are suitable especially for external massage.
· Water-based lubricants are good for in the vagina. When used outside the vagina, they quickly dry up which makes them not suitable for male masturbation.
Especially for adding fun, there are lubricants on the market with smells or flavors. These are not recommended for use in women with vulnerable vaginas. The same goes for glycerin-containing lubricants, because they increase the risk of vaginal infections.
· Silicone-based lubricants are waterproof. They are extremely slippery and last much longer, but they are also more expensive. When showering after having used silicone lubricant, the floor of the shower can become extremely slippery.
A fair amount of silicone lubricant is especially indicated for anal penetration.
· Plant-oil-based lubricants can be used in the vagina, and also as body massage oil. They are said to protect and feed the vaginal mucosa (but, they are not moisturizers!).
28.4.2 Saliva Substitutes (“Oral Lubricants”)
Dry mouth (xerostomia) is a serious problem after radiotherapy for head and neck cancer. It can complicate talking with disturbance of social contact, and it will diminish the oral elements of sexual contact. Without saliva, there is little joy in kissing, and giving oral sex is nearly impossible.
When there is some remaining salivary function, saliva stimulants can be tried: chewing gum, ascorbic acid (and parasympathicomimetic medication), etc. Saliva can also be substituted. Depending on what is intended, one can use water, vegetable oil, or artificial saliva (with xanthan gum, oxygenated glycerol esther, mucin, or carboxymethyl cellulose) [6].
The most relevant point for the professional is that oral aspects of sexuality and intimacy are included in the discussion and the care.
28.4.3 Dildos
The dildo is a rod (usually resembling a penis). Since thousands of years, dildos have been used for increased sexual pleasure and illusion.
Some women need to have the vagina full for optimal excitement or to have a more intense experience of orgasm. For that purpose, a dildo can be the substitute for an erection when the male partner can no more have or keep an orgasm, or when he is too tired for intercourse.
It can be fastened on a belt as a strap-on dildo. When the man uses a strap-on dildo, he can make the normal coital movements without the fear of losing erection or slipping out of the vagina (and the woman can have the experience of penetration). This can restore the man’s sexual excitement via a process called “multisensory integration,” and in this way repair his sexual identity [7]. This can be the solution for men after complete erectile dysfunction, but also for men with complete or partial penectomy (after penile cancer).
28.4.4 Dilators
Vaginal dilators are rods in different sizes intended to keep or to redevelop sufficient vaginal space. When used as a preventive strategy, the regular dilation has to keep the tissue stretched and take care that the vaginal walls do not agglutinate (grow together). As a treatment strategy, the dilation has to regain width or length and elasticity of the tissues.
In oncology, there are several indications (or combinations) for dilating:
· Vaginal narrowing due to radiotherapy and sometimes surgery.
· Vaginal narrowing due to hypogonadal atrophy.
· Vaginal narrowing due to vaginal cGvHD (chronic graft-versus-host disease).
· Vaginal shortening due to radiotherapy and radical surgery.
When counseled properly and done well, regular dilation will give the woman confidence again that she can have an object inserted in the vagina without pain [5]. For part of the women, the goal is allowing the penis. Then, one should be aware of the possible discordance between the size of the penis in erection and the vaginal elasticity as a cause for dyspareunia. Size matters; so, inquiring about the penis in erection seems necessary. The usually recommended 30 mm diameter for the largest dilator is frequently less wide than the fully erected partner’s penis.
For other women, the aim is to be able to tolerate without pain a speculum or vaginal ultrasound probe, the common elements in post-cancer follow-up.
Dilators (or “trainers”) are usually hard or semisoft and available in sets with increasing sizes. Dilating always has to be done with enough artificial lubrication. Especially in cGvHD and after squamous cell cervical cancer, estrogens should be added to keep the mucous membrane in optimal condition (but they are forbidden after cervical adenocarcinoma).
Properly motivating the patient is a very important part of this approach [8]. When relevant, we should address the additional benefits of genital arousal by vibration and by sexual arousal.
Using a vibrating dilator or the “live penis” for dilatation can boost the genital circulation and vaginal health. Including the penis can also become part of enhancing or reshaping intimacy.
28.4.5 Donut for Too Short Vagina
When the vagina has become much shorter and less elastic due to cancer surgery or radiotherapy, a long penis easily can cause dyspareunia. Some couples succeed in preventing such trouble when the woman tightly adducts her legs (elongating the canal) and by other intercourse positions. Some women put their fingers around the base of the penis. This can be done as well with a donut-shaped soft pillow around the base of the penis. There are no such gadgets available. But one can look in the building store for self-made (and very cheap) solutions with the soft material used for isolating water pipes.
28.4.6 Vibrators
Although many people automatically consider a vibrator to be a penis-resembling device that has to enter the vagina, a vibrator is nothing more than a vibrating device.
In the cancer area, vibration can be used for several functions:
· Increasing stimulation. Especially the deeper layers of the genital tissues seem to respond to vibration. It works both in the woman and in the man. Although it is seldom recommended, a vibrator can really help in diminished erectile capacity.
· Increasing genital circulation/vasocongestion/oxygenation. Adding vibration most probably will improve the benefits of dilation. In the same way, vibration could be added to erectile rehabilitation after pelvic cancer treatment.
· Upgrading stimulation to orgasm, when the orgasm potency has been decreased, for instance, after surgery for spinal cord tumors or under SSRI treatment. Or upgrading to ejaculation for fertility purpose.
· Substituting muscular activity. For instance, when a patient is very tired and cannot physically stimulate partner or self to the desired level. Then, a vibrator only needs to be kept in place, and it will take over the action.
Vibrators are available in an extremely wide range of shape, size, power, and target organ, with most of them being intended for pleasure/fun and some intended for fertility enhancement. The most relevant point is that we learn how to include them in our treatment approach and how not to not-mention them.
28.4.7 Eros®
The Eros® is the only FDA-approved sexual toy. It has a cup to cover the clitoral hood and a special way of vibration by intermittent suction. It is recommended after vaginal radiotherapy and has benefits both for sexual function (better lubrication) and for vaginal health [9]. Currently, there are comparable, but cheaper, devices that also give direct vibration.
28.4.8 Male Vibrator
For the man with limited hand function due to neurological damage and for the man with decreased sensations due to chemotherapy damage, there are various masturbating tools that can be applied around the penis. They do their job while the man needs not to take additional action (especially relevant when there is no partner).
28.4.9 Penile Constriction Device
A common toy and tool for improving erection is the cock ring or constriction band. When tightened around the base of the penis, the device prevents the penile blood from flowing back through the superficial penile veins. Then, the blood stays in the cavernous body and maintains the erection. Too long exposure can cause permanent damage. So, the ring should be released within 20 or 30 min, immediately after orgasm, and not be used at all when under influence of alcohol or drugs.
Metal cock rings (especially when applied proximal to the testes) have the danger of painful erection, completely blocking the backflow and permanent damage.
In cancer patients, flexible constriction bands have three different functions:
· Improving erection.
· When applied tight enough to close the urethra, a constriction band can prevent urine leaking during sex play or during orgasm (as happens after radical prostatectomy). This is especially important during oral sex.
· As part of the vacuum treatment.
28.4.10 Vacuum Erection Device
When the erectile potency is completely gone, a constriction band will not improve erection by itself. Then, one first has to fill up the penile circulation, which can be forced by applying vacuum. An airtight cylinder is placed over the penis, and a pump realizes negative pressure, creating penile blood engorgement. The constriction band, that before has been put round the base of the cylinder, now is shifted to the base of the penis, and the cylinder can be removed.
This method does not work without some exercising and some manual skill.
28.4.11 Tongue Function Replacement
Whereas most sexual devices are developed for sexual pleasure and fun, some can make the transfer to a therapeutic device. Sqweel® is one of them. It is a turning wheel with soft silicone tongues for oral stimulation. Extensive surgery of the tongue (as in the Commando procedure) will severely impair oral sex, which is for some a pity. However, when oral stimulation was the important way to be stimulated or to receive an orgasm, such tongue damage can become a disaster. With this device, the female partners of some patients succeeded to regain orgasm.
28.4.12 Nipple Devices
Breasts and nipples have several functions in sexuality and intimacy. The own (breasts and) nipples are relevant for sexual identity. They are also a major erogenous zone for the majority of women and for a relatively small part of men. Breasts and nipples have also an important sexual meaning for many partners. When cancer treatment has damaged or taken away such function, what practical solutions could be considered?
When breasts or nipples are gone: erotic substitutes with tassels, clips, or sexy lingerie can sometimes do. Next to visually influencing the partner, it can boost the erotic identity of the patient.
When the sensitivity is considerably diminished: extra stimulation by oral suction, a nipple suction device, or strong vibration.
Especially when sensitivity is completely gone: consider using other erogenous zones or developing new ones. Some patients discover the erogenic capacities of the paresthetic border area between absent sensitivity and normal sensitivity.
Conclusion
Sexual well-being is the result of a complex interplay between physical health and the psychological makeup of patient and couple. Sexual health care professionals have dedicated themselves to a biopsychosocial evaluation and treatment model. Traditionally, treatment paradigms focused either on aggressive medical intervention or on intensive psychological therapy. Gradually, we have moved to a more integrated approach where sexual pharmacology, behavioral interventions, sexual devices, and accessories coupled with counseling are combined as the new mantra for successful treatment. In this approach, sexual aids (tools and toys) can be a useful treatment addition for numerous sexual problems. But, depending on the culture and the relationship of the couple, dealing with these products can also lead to embarrassment, confusion, and nonadherence to treatment. Sexual health care providers should be aware of these issues and should be able to adequately deal with that.
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