Woet L. Gianotten1 and Yacov Reisman2
(1)
Rehabilitation Center, De Trappenberg, Huizen, The Netherlands
(2)
Amstelland Hospital, Amstelveen, The Netherlands
Woet L. Gianotten (Corresponding author)
Email: woetgia@ziggo.nl
Yacov Reisman
Email: uro.amsterdam@gmail.com
Just as in other areas of life, there are many differences between one group and the other. That goes for society, for health problems and for cancer care. Cancers are different, care systems are different, professionals are different, and patients are different. That is both the bother, the challenge and the spice of our work.
When dealing with sexuality and intimacy in cancer care, some groups need extra attention.
This part deals with some of those ‘special groups’.
Successively we will deal with the partner, the lower and the upper age range of patients, the men and women with an orientation different from mainstream and the patients that reach the last stages before dying.
Partners of cancer patients, senior patients and couples at the end of life have in common that they all tend to be forgotten when sexuality and intimacy are at stake. However, many of them have sexual needs as well. Social taboos complicate an open approach towards their sexual possibilities and intimate needs. That is different with the young patients and the gay, lesbian or bisexual patients. We very well know that they are sexual beings and that sexuality plays an important role in their life. That however doesn’t mean that we can easily address sexuality and intimacy, since for many health professionals that seems a bridge too far.
29.1 The Partner
Cancer does not only influence the patient but has also far-reaching consequences for the people in the close surrounding. Especially the partner has to endure much. Although in a very different way, cancer and treatment are also for the partner a major life event. She or he will have comparable fear for death and loss.
In the period of treatment and reconvalescence, many tasks have to be taken over by the partner of the patient, sometimes even the breadwinning role and the parenting role. With the recent developments in many Western societies, a good part of the caring role has also to be taken over by the partner. Those changes in role and activities can have additional influence on the elements of intimacy and sexuality that already can be seriously shaken by the disease and the treatment process.
For some partners, the biggest challenge is, for instance, how to constructively deal with an exhausted partner, when one needs sexual expression so much to recharge their own batteries. Some partners do really need that to be able to continue delivering proper care to the patient. For other partners, the damage to the patient’s appearance can be so disturbing that all sexual desire has gone, despite the fact that the patient is craving for some physical intimacy. Those are the more sad cases. On the other hand, there are couples where the process of cancer diagnosis and treatment creates enough challenges and energy so that their sex life improves.
The authors of this partner chapter are from the Leuven University in Belgium, where they have extensive expertise in the partnership role in cancer and chronic diseases. How to deal with the various couple difficulties is not discussed in this part but in Chap. 25.
29.2 Age
Age is a very relevant element when discussing the area of cancer and sexuality.
On the one hand, because the chance to contract cancer is very dependent on age. Although some cancers occur at a young age, the majority happen in later life. Growing older is indeed accompanied by a strong increase in the cancer risk. The annual cancer incidence per 100.000 population under 20 years is 15, at age 20–39 is 73, at age 40–59 is 410, at age 60–79 is 1.690 and at age 80+ is 4.100 (see Table 29.1) [1].
Table 29.1
Annual cancer incidence per age group from UK
|
Annual cancer incidence per 100.000 population |
|
|
<20 years |
15 |
|
20–39 years |
73 |
|
40–59 years |
410 |
|
60–79 years |
1.690 |
|
≥80 years |
4.100 |
Age is on the other hand relevant because the meaning of sexuality changes over the years. At a young age, sexuality is relatively more characterised by the performance, by the search for a partner and by aspects of fertility and its identity components. At later age sexuality is relatively more characterised by intimacy and frequently complicated by the increase of comorbidity and its sexual side effects.
In this part, we’ll address separately the influence of cancer on sexuality of the young and the senior age groups.
29.3 Young Age
For the young group, the cancer incidence is low, and a high percentage of them can be cured. Whereas the 5-year survival rate in the UK is 49 % for male cancer and 59 % for female cancer, it has reached 82 % for childhood cancer.
The reverse side of the coin is that the treatment tends to cause much damage to sexuality and intimacy. Both directly to sexual function (frequently via hormonal impairment) and indirectly via disturbed fertility (which regularly is accompanied by disturbed identity). In children under age 14, leukaemia is the most commonly diagnosed cancer. Together with intracranial tumours and lymphomas, they account for more than two-thirds of all childhood cancers.
In the group of young adults (15–25 years), germ cell tumours (like testicular cancer) are the most common cancers in men and thyroid, cervix, bowel and ovary cancer in women. With sexuality being very important in this phase of life, the consequences of treatment and rehabilitation obviously will be very important.
The other aspect is the relation with survival. For nearly all cancers, the 5-year survival is highest in the young adult group. This group of cancer survivors can suffer for many decades from sexual and other treatment side effects. A robust explanation behind the long-term sexual disturbances is the high percentage of immediate endocrine complications, growth hormone deficiency, primary hypothyroidism and premature ovarian failure [2]. Besides, extended survivorship is in a later stage accompanied by new (‘second’) cancer and cardiac failure.
29.4 Seniors
As can be seen in Table 29.1, cancer incidence strongly increases with advancing age. The median age at diagnosis of all cancers combined is 69 years for men and 67 years for women. The process of growing older is indeed accompanied by an increased risk to contract cancer (and to die as a result of cancer). That goes both for the individual person and for society.
In the current era, the age of the population is clearly increasing. Between 1990 and 2012, the life expectancy at birth rose, according to the WHO, globally from 64 years to 70 years, in Europe from 72 years to 76 years, and in the European Union, that life expectancy at birth is even higher with 83 years for female and 77 years for male. Obviously that increasing age is the very important explanation behind the increased cancer incidence.
What about the sexual flexibility and possibilities in the process of ageing? Physiological changes don’t play such a big role. In healthy ageing, the major part of sexual functioning will not go down. However, the frequently accompanying morbidity, comorbidity and medication can easily damage sexuality.
Another relevant aspect in sexual relationships of the higher age group is the loss of partners. Becoming single again is a very relevant aspect for women. They have not only a longer life expectancy, but they were also married to a man of several years older. So the average European woman will survive her spouse for 7–8 years. One may expect that the new generations of senior women will not accept a life without intimacy and sexual expression.
29.5 Minority Groups
Sexual health professionals tend to pay more than average attention to minority groups. So we have been wondering about minority groups in oncosexology. In how far are the cancer and sexuality connections the same for gay and lesbian people? For convenience’s sake, we use the acronym LGB (lesbian, gay, bisexual).
It became clear that there are several very relevant differences between the LGB and the ‘straight’ group. That goes for the medical care, for the cancer incidence and for the cancer and treatment consequences.
From a group perspective, the cancer incidence pattern is different. The woman’s reproductive history influences her risk for breast cancer and gynaecological cancer. As a result lesbian women will have a higher rate of several of those cancers and added to that are the cancer consequences of different lifestyle factors.
Part of the cancers are the result of sexually transmitted viral infections. Lesbian women tend to have less sexual intercourse, so they will have less cervical cancer. Gay men on the other hand tend to have a wider range of sexual contacts than straight men, so they will have more cancers that can develop because of HIV-related immunodeficiency, more HPV-related cancers (penis, head-neck, anus) and more HBV- and HCV-related liver cancer.
When falling ill, the LGB group usually doesn’t get as good care as mainstream patients. Many health-care providers will never ask about orientation and assume that every patient is heterosexual. And many LGB patients are too scared to disclose their sexual orientation or relationships. Those factors result in impeded communication and low-quality care [3].
After recovery from cancer, the aftermath of the process can also be different. For lesbian women, appearance is valued relatively less than in heterosexual women, so a mastectomy or a stoma tends to cause less damage.
On the other hand, gay patients tend to value both external appearance and sexual performance more than mainstream male patients. As a result, cancer treatment in gay men can damage more than average the gay and bisexual identity and relationship.
The last area to be covered is the sex itself. Most heterosexual professionals (even in sexology) don’t know what usually happens during LGB sex. And within the LGB group, they tend not to talk about that to the outside world. Those factors easily can cause problems when cancer treatment seriously disturbs various elements of sexual function and sexual play possibilities. Because we are convinced that that area needs attention as well, we have asked the authors to share relevant information.
29.6 End of Life
The last chapter deals with the patients (and the partners) who reach the palliative and the terminal stage before they finally will die. This stage tends to be surrounded by extra taboos. Whereas for part of the patients and relatives there is the taboo of death, for many health-care professionals, the taboos lie more in the area of physical contact, intimacy and sexuality in this stage. Just as happens in other moments of life, patients and their partners now show also a wide range of reactions and needs in the area of intimacy and sexuality.
29.7 Epilogue
In the common opinion, usually shown in the movies and the media, sex is only for the young, the healthy and the beautiful. Our patients deserve professionals who know better and who can deal with the wide variety and patterns of sexuality and intimacy in the wide diversity of patients and partners.
References
1.
Aziz NM.Late effects of cancer treatment. In Ganz PA. (editor). Cancer Survivorship; Today and tomorrow. New York, Springer Science+Business Media LLC. 2007: 54–76. http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age.
2.
Aziz NM. Late effects of cancer treatment. In: Ganz P, editor. Cancer survivorship; today and tomorrow. Springer; 2007. p. 54–76.
3.
Katz A. Gay and lesbian patients with cancer. In: Mulhall JP, Incrocci L, Goldstein I, Rosen R, editors. Cancer and sexual health. New York: Humana Press; 2011. p. 397–403.CrossRef