Ycn-m May 5

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Sexuality and cancer: Sexual problems and communication with patients.
By Joanna Tsatsou, Cancer nurse, Msc, PhDc

WHO defines sexuality equally "a cardinal aspect of human life which encompasses sex activity, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction" ^[1,2]. Sexuality is a core component of quality of life and it is expressed in thoughts, fantasies, desires, beliefs, attitudes, values, practices, roles and relationships. While sexuality can cover all of these dimensions, it is not ever experienced or expressed. Sexuality is influenced by the interaction between  biological, psychological, social, economical, political, cultural, moral, legal, historical, religious and spiritual factors ^[one,2]. Sexuality has likewise been divers as "the process of giving and receiving sexual pleasance and is associated with a sense of belonging or being accepted by another" ^[3]. Intimacy on the other manus is "the sharing of identity, closeness, and reciprocal rapport, more closely linked to communication problems rather than sexual office" ^[4].

In the cancer intendance context, sexuality is characterized as a high priority issue past one to three quarters of cancer survivors and is classified as a major unmet need. Sexual dysfunction after cancer is consistently associated with poor QoL ^[5]. The incidence of long-term, astringent sexual dysfunction is as high as 50% among cancer survivors in the Us ^[vi]. Sexual dysfunction rates of childhood cancer survivors are close to 33%, with women having double the chances of dysfunction than men the United States ^[seven]. In the United kingdom of great britain and northern ireland, 43% of cancer patients reported that their sex lives were adversely affected by anti-cancer therapies. Afterwards chest cancer and cancer of the cervix, prostate and rectum, sexual difficulties accomplish the 70-eighty% ^[5].

Near sexual problems are not caused by the cancer itself, merely by the toxicities of the various cancer treatments. In particular, the damage caused by various therapies to the pelvic fretfulness, blood vessels and organ structures leads to higher rates of sexual dysfunction. Both men and women can accept interruptions in sex activity due to the side effects of treatments such as fatigue, nausea, urinary or fecal incontinence. Sexuality remains of import fifty-fifty for many older survivors. Sexual bug are more unpleasant for those under the age of 65 and those who are sexually agile at the time of the diagnosis of cancer ^[5].

Men with cancer experience common sexual problems such as erectile dysfunction and loss of want. Less mutual are changes in the quality of orgasm, difficulties in achieving orgasm and painful erection ^[vi]. Men who take undergone surgery in the bladder or rectum have higher rates of erectile dysfunction. Sexual problems (as a result of hypogonadism and pelvic nerve impairment) as well occur in men who have received intensive chemotherapy, pelvic radiotherapy or total torso irradiation. Testicular or lymphoma cancer survivors study high rates of sexual inactivity and low sexual want ^[8]. Causes of problems can be multifactorial, including hypogonadism, fatigue, negative mood and stress ^[9].

In women, the virtually common sexual problems are vaginal dryness, pain during sexual activity and loss of sexual desire, and these are ordinarily accompanied by difficulty in arousal and pleasure during sexual intercourse^[5,six]. Cancer treatments increase the risk of sexual dysfunction for women because they cause sudden, premature ovarian failure in women who have not nevertheless entered menopause ^[10]. Alkyliating agents, pelvic radiotherapy (which causes ovarian failure and immediate damage to genital tissues), ovariectomy or hysterectomy and those under the age of 35 are at higher risk for sexual problems. The utilize of gonadotropin agonists or antagonists to create a temporary state of ovarian failure likewise causes sexual problems, although the dysfunction can be resolved when they are stopped. Oestrogen replacement helps with vaginal dryness but does not restore normal sexual function. Hormone therapy can also cause sexual problems. Women taking tamoxifen accept minimal changes in sexual part while aromatase inhibitors tin cause astringent vaginal dryness and discomfort ^[11].

Psychological effects
Sexuality is not just afflicted by the physical furnishings of cancer and therapies simply also by the psychological ones. The diagnosis causes fright, feet and panic thus affecting the sexuality of the person. Sexual desire and activity are significantly inhibited in this phase. In addition, with the implementation of various treatments, stress, uncertainty, losses and sadness increase. There is a modify in body paradigm from alopecia, mastectomy, ostomy, hysterectomy, amputation and modify in cocky-perception (loss of fertility, femininity or masculinity). These non only reduce sexual desire but likewise the feeling that the person is not sexually desirable to their partner. Thus, psychological and biological issues collaborate and contribute to sexual dysfunction. Inevitably, the quality of a couples' intimate and sexual human relationship changes after cancer diagnosis and treatment.

How cancer nurses can help
Cancer nurses, who are a consequent presence for their patients during treatment, virtually often become the person to whom patients confide their concerns and problems, including sexual ones. Nurses are therefore the ones who must brainwash their patient almost the sexual alterations following cancer treatments, assess sexual issues and provide possible means of resolving them or liaise with appropriate sexual services. When nosotros educate our patients on the handling toxicities, we include fertility issues but sexual health is often a neglected issue.

Communicating with patients about sexuality includes numerous concerns by patients and healthcare professionals alike. Unfortunately, healthcare professionals are often reluctant to raise the topic of sexuality. This can exist due to inadequate education, a fear of personal or patient embarrassment or overstepping professional boundaries, lack of cognition about appropriate resources for problems identified or because other cancer care issues accept precedence during brief patient encounters ^[12]. On the other mitt, patients are frequently unwilling to ask nearly sexual problems, likewise fearing embarrassment or that their feelings must be unimportant or taboo since providers did not mention them ^[12,13]. Yet, patients experience that sexual health is a priority, and they are willing to hash out sexual problems when given the opportunity ^[12] , even though many would prefer that a healthcare professional person instigate the word ^[fourteen]. It has also been noted, that patients' and healthcare professionals' views and expectations differ around sexual health discussions, contributing to patients' unmet sexual needs ^[xv].

A sensitive approach
So, when nurses or other healthcare professional, discuss sexuality with patients a sensitive approach is essential. When nurses implement sexual assessment and follow-upwards at their routine assessments they experience more comfy with the discussion. First of all, nurses should find appropriate timing for each patient and inquire permission to discuss and so provide non-judgmental, accurate information that moves from less to more sensitive issues over time and avoiding use of medical jargon. Sexuality discussions should be neutral to sexual orientation and gender, avoid cultural stereotyping and move from one topic to another with a normal flow_. And so, assessments and interventions should exist individually tailored to the specific age, gender, developmental level, sexual orientation, and disease type, stage, and handling plan as well as the identified concerns and issues raised by the patient. The goal is to build a trusting and supportive relationship with the patient, in order to enhance the advice about sexual problems, support sexual self-esteem and provide appropriate resources and referrals ^[xvi].

To facilitate the communication betwixt patients and healthcare professionals, models for sexual assessment take been created, but few have been developed specifically for cancer patients. The most oft used model is the PLISSIT model described by Annon in 1974 ^[17].  Some other ordinarily used model in cancer care is the BETTER ^[xviii]. These assessment models may help healthcare professionals to assess and nourish to their patients' sexual health needs.

In summary, sexuality in cancer patients is negatively affected past many factors both physical and psychosocial. Patients require specific sexual intendance to overcome the physical and emotional sexual problems resulting from cancer and its treatments. In society to ensure better intendance, cancer nurses must learn and accost sexual issues. Didactics is the key to ensuring adequate guidance and advice is given to cancer patients and that this highly unmet need of sexuality is addressed. There is a significant correlation betwixt sexuality and quality of life. Sexual health should therefore be systematically monitored by multidisciplinary teams and interventions implemented through integrated care to improve it.

1. World Health Organization. Sexual health-a new focus for WHO, No. 67. Geneva: Department of Reproductive Health and Research, World Health Organization; 2004.
2. World Wellness Arrangement. Defining sexual health: Re­port of a technical consultation on sexual health. Gene­va, Switzerland. 2002. Available from https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf
3. Shell JA. Sexual issues in the palliative care population. InSeminars in oncology nursing 2008 May 1 (Vol. 24, No. 2, pp. 131-134). WB Saunders.
4. Mercadante S, Vitrano V, Catania V. Sexual bug in early and late phase cancer: a review. Supportive Care in Cancer. 2010 Jun;xviii(6):659-65.
5. Schover LR, Van der Kaaij M, van Dorst et al. Sexual dysfunction and infertility as belatedly furnishings of cancer treatment. EJC 2014; (Supp 12), 41-53.
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8. CJ, Sanchez Varela V, Mauch P, Bober S.Sexual performance in long-term survivors of Hodgkin's lymphoma. Psychooncology .2010;xix:1229–33
9. CE, Schover LR, Dahl AA, Fossa A, Bjøro T, Loge JH et al. Practise male lymphoma survivors have dumb sexual function? J Clin Oncol .2009;27:6019–26.
10. Schover LR. Premature ovarian failure and its consequences: vasomotor symptoms, sexuality, and fertility. J Clin Oncol .2008;26:753–8.
11. J, Nilsson K, Evers AS, Kallak TK, Poromaa IS.  Sexual dysfunction in women on adjuvant endocrine therapy after breast cancer. Menopause .2013; 20:162–8 .
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13. Krebs L. What should I say? Talking with patients about sexuality issues. Clinical journal of oncology nursing. 2006 Jun 1;10(3):313.
14. Julien JO, Thom B, Kline NE. Identification of barriers to sexual health assessment in oncology nursing practice. In Oncology Nursing Forum 2010 May ane (Vol. 37, No. 3).
15. Lally RM. Sexuality: everything you might be agape to enquire only patients need to know. ONS news/Oncology Nursing Gild.. 2006 Sep;21(9):i-4.
16. Krebs LU. Sexual assessment in cancer intendance: concepts, methods, and strategies for success. In Seminars in oncology nursing 2008 May 1 (Vol. 24, No. two, pp. 80-90). WB Saunders.
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