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An Approach to Evaluation of Sexual Problems in the Cancer Patient Leonard R. Derogatis and Suzanne M. Kourlesis CA Cancer J Clin 1981;31;46-50 DOI: 10.3322/canjclin.31.1.46

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An Approach Evaluation to of SexualProblems the in Cancer Patient

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Leonard R. Derogatis,Ph.D. Suzanne M. Kourlesis, MA.

The Prevalence of Sexual Dysfunction in Cancer Patients

in women who have experienced radical vulvectomies.' Dysfunction as high as 75 percent has also been reported in early To date, no formal epidemiologic studies stage cervical cancer,9 and Dennerstein et of the prevalence sexualdysfunction al' of report a 37 percent rate among females among cancer patients have been pub who have undergone hysterectomies for lished. The problem is considerable, how non-malignant conditions. ever, and some empirical data are avail Sexual dysfunctions in cancer pa able. Devlin et al' report an approximately tients, however, are not restricted to can 50 percent rate of dysfunction in post-co cers that attack functional genital organs. lostomy males, while the rate for males Breast cancer, for example, attacks the undergoing radical prostatectomy is 85 to patient's basic self-concept through dis 90 percent.2 For prostate cancer, external tortions in body image and sexual iden megavoltage radiation is reported as pro tity.A high incidence of sexual problems ducing dysfunction in 40 to 85 percent of was reported in two studies by Maguire patients y von Eschenbach.3 b Although and associates,'2'3 and Jamison and her relatively cancerof thetestis rare, isone colleagues reported sexual disturbances in ofthemost common cancers among males one-fourth of their patients,'4 which were inthe20 to34 yearage group,and a num thenverified witha separatetudyof the s ber of studies indicate ejaculatory dys patients' mates.'5 Sexual problems inbreast function in the 85 to 95 percent range for cancerpatients were found to be age re thesepatients.4'5 lated in two reviews by Polivy;'6-'7 in a In women undergoing pelvic exenter recent study of 146 patients by Silberfarb ation,dysfunction approaches100 per and his colleagues, mate role distur cent,6-7 a finding similar to that observed banceswere the most frequently reported problem. Other forms of cancer (lung, blood, stomach) are also likely to involve sexual disturbances due to the general debilitation and dysphoria associated with the disease and itstreatment.ancers thatresult C in cosmetic changes(head,neck,bone)fre quently cause marked alterations in self image that preclude sexual intimacy for the patient. CA-ACANCEROURNALORCLINICIANS J F

Dr. Derogatis is Director, Division of Medical Psychology, The Johns Hopkins University School of Medicine, The Iohns Hopkins Hos pital, Baltimore, Maryland. Ms. Kourlesis is Research Assistant, Division of Medical Psychology, The Johns Hopkins University School of Medicine, The Johns Hop kins Hospital, Baltimore, Maryland.
46

How Cancer Affects Sexuality disease process itself can compro The
mise sexuality. Genitourinary cancers of

either a primary or metastatic nature can make sexual intercourse impossible, ei ther through damage to the primary or
gans or to their nerve supplies. Less di rectly, but equally emphatically, the weakness and debilitation associated with most late stagecancers frequently become serious obstacles to sexual union. treatments The forcancercan alsodis rupt sexuality. Ablative surgery that in volves sacrifice of essential autonomic innervation or of functional organs them selves, cytotoxic chemotherapies, exter nal megavoltage radiation, and surgical implantation of 25!can all result in tem porary or permanent sexual alteration and dysfunction.n addition,hemo I c therapy can also result in sterility among males'9and in prematuremenopausal symptoms among females.2 Psychological disorders concomitant with, or inreaction to,thediagnosis treat and ment of cancer can also cause sexual dysfunction, usually as a result of loss of libido.nxietyand depressionon A c cerning the outcome of treatment, ability to function, death, and a host of other issues can negatively affect sexual desire or performance.

longer inflict sexuality on his wife, or the role-conscious wife who perceives the disease as emasculatinghus her band. Counterproductive Myths and Attitudes
Only recently as human sexuality h been included intheformalcoursecurricula in medicalschools. Previously, sexualmat ters were rarely discussed by the physi cian, and patients were left to their own devices tolearn thesexual implications of their illness. This situation is now im proving, but myths and negative attitudes are still prevalent among many clinicians, standing in the way of satisfying sexual

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relationships between cancer patients and their partners.

Myth: Elderly individuals are not interested in Sex Despite increasing evidence to the con trary,2,-22 many people still believe that there is a precipitous decline in libido when an individual reaches age 55, and that by age 65 the person is essentially asexual. There is evidence of reduced in terest in sex by the aging male, but many menperhaps even a majorityremain vitally interested in sex well into their sixth and seventh decades. Among elderly fe males there is also evidence of some re duction in interest; however, the most fre quent deterrent to satisfying sex for these women is the absence of an interested part ner. This myth has a disproportionate in fluence on cancer patients due to the higher incidence of most cancers among elderly people. Becoming ill frequently does not
alter the importance patients. Myth: illness of sexuality to elderly

image alterations are not often rec Body

ognized as contributing to sexual dys function. Negative body image is prev

alent among individuals suffering from sexual dysfunction, even when they have no organic illness.Many cancer pa
tients suffer mutilating surgery or un pleasant cosmetic side effects of other treatments. A patient who feels physi cally repulsive or unattractive has little

chance of effective functioning in sexual

relations. reaction f others the patient's The o to illness alsohave a profoundeffect can on thepatient's sexuality. Spousesand familymembers can be sources great of strengthncombatingcancer; i however, they can also unwittingly render the pa tient asexualfor example, the caring and distraught husband who can no VOL31,NO.1 JANUARY/FEBRUARY 1981

Precludes

Sexuality

It is true that during the acute stages of

many seriousllnesses thedebilitation i and

that sometimes follows, libido is markedly dampened. This does not mean, however, that the patient will never again become
47

sexually motivated. With cancer patients, sexual investment may recur even after disfiguring or mutilating procedures or treatments. More than at any other time in their lives, these patients need infor mation and guidance about how and when they can resume their sexual relationships. Although the oncology treatment staff may not have all the answers, they should still appreciate the intensity and legitimacy of these needs. Myth: Sex is Ancillary and Unimportant to the Cancer Patient Too frequently, focus on cure or amelio ration of the cancer relegates the patient's sexual functioning to a low priority in the eyes of the treating physician or surgeon, regardless of how important it is to the patient. This unilateral decision has been traditionally justified by the statement, the doctor knows what's best for you; however, the willingness of patients to challenge this system and take a more ac tive role in treatment decisions is clearly on the upswing.23 The increasing impact and appreciation of the concepts central to quality of life philosophy are forcing the realization on cancer care specialists that being is not a categorically positive alive status. Sexual intimacy is one of the most rewarding and sought after experiences life
has to offer; its importance is not dimin ished by the unfortunate experience of de veloping cancer.

patient toan expert inthearea, preferably to a sex therapist familiar with medically

related dysfunctions. This is because sex ual dysfunctions arising from organic dis orders often present different problems
than do those of psychogenic origin with

out medical complications. Evaluation of the Sexual Need Status of the Cancer Patient
The health professional workingto detect or alleviate the sexual problems of the can cer patient needs data on the following:

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Current Status of the Patient's Sexual Functioning

Do sexual problems currently exist? The answer depends on whose judgment is crit icalthe patient's or the health profes sional's. Unless the patient's evaluation is

inconsistent with known facts, the health

professional should accept the patient's report. The clinician needs to know how the patient feels about himself/herself as a sex ual person, the frequency of sexual activ ities, and quality of performance. If prob lems exist, when did they begin, and how

long have they lasted? One must learn the context in which the difficulty was first experienced and determine the course of the dysfunction (i.e., progressive inability to function; sporadic problems; dysfunc
tion more frequent at first, but now ap parently remitting). If possible, sexual functioning and any sexual problems should also be discussed with the spouse. Often,

Myth: Expertise Concerning Sexuality is beyond the Realm of the Oncology Team

a very different picture of the quality of

sexual life emerges after speaking to a pa tient's partner. The patient's impressions about the clinical sexual disorders. Nonetheless, this etiology sexual of problemsareimportant, does notmitigateheiresponsibility t r todo particularly todetermine whetherhe orshe everything possible aid in preserving feels in some way responsible or views the to their atients' p sexuality. theveryleast, problem as some sort of punishment. If the At the oncologist should raise the topic ini patient says that sexual functioning is un affected, it is still necessary to determine tially, assess the patient's sexual status, and wherever possible offer sexual coun whether interest in sex remains high; the seling and guidance. If the situation is too core problem may be one of desire rather complex, the oncologist should refer the than performance.

Few health care specialists in oncology have also been trained to diagnose and treat

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CA-ACANCEROURNAL J FORCLINICIANS

History of Sexual Functioning

A sexual history does not have to include
a detailededicalhistory, m particularly if

longer physically attractive. The clinician

should also be able to recognize the mar

no particular problems exist. It is impor tant, however, to establish a sexual fre quency baseline and an estimate of the
patient's previous sexual interest; the cli

riage that has been in gradual sexual de cline for years with neither partner retain ing much investment in the sexual aspects of the relationship. Often a serious illness
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such as cancerwillbe used as an excuse

nician should also determine whether the individual has ever experienced sexual
dysfunction in the past and, if so, the na ture of the problem. If a current problem exists, more time should be spent, establishing the patient's sexual postures, attitudes, and experi encesif possible, in a developmental framework. Family attitudes toward sex uality during the patient's childhood, ad olescent experiences, sexual behavior as a young adult, and the predominant sexual pattern throughout adulthood should all be elicited. The interviewer should also find out whether the patient sought professional help for any problems and if the treatment offered was effective. By the time the sexual history has been completed, the clinician should feel that he has an appreciation of the patient's typ ical levels of sexual performance and in vestment, as well as some idea about whether the patient is sexually conserva tive or liberal. This issue can become im portant when the disease or its treatment either temporarily or permanently pre cludes sexual intercourse in the usual man ner. In these cases, alternatives that would be perfectly acceptable to a more liberal patient might be viewed as perverse and totally unacceptable to a more conserva tive individual.

to terminate sexual relations.

In assessing the nature of the sexual problem it is critical to determine precisely

what physical insults the patient's body has sustained, and the options left open by the trauma or disease. The patient's current
psychological status must also be consid ered so that dysfunctions associated with clinical levels of depression or anxiety are

recognized as such. The clinician should

come away from this evaluation with an appreciation of the patient's physical ca pacities and psychological readiness to use them.

Formulation of a Treatment Plan

A treatment plan does not have to be a formal set of strategies based on the latest knowledge of human sexual functioning; it should use common sense and be based on a thorough knowledge of the patient and his or her sexual functioning. Many problems will be solved by just the chance to discuss them; patients need to hear that their sexual concerns are completely nor mal. Patients with other problems may re quire information about the limitations of performance inherent in the condition. They should be given the opportunity to become desensitized to a surgical mutila tion or alteration. Some problems will re sist simple strategies based upon accep tance, information giving, and new learning; the oncology team should refer these pa tients to competent specialists in the treat ment of sexual dysfunction. Regardless of how the sexual prob lems of the cancer patient are addressed, the most fundamental step we must take is to accept sexuality as an inherent and important aspect of being human. We should work to treat the problems that arise in this area with the same excellence and commitment we devote to other aspects of cancer care. 49

Assessment of Basis for Current Problems

One of the more difficult decisions that the health care team may have to make is to determine whether dysfunction is basically biogenic or psychogenic in nature. Fre quently, both factors may be operating for example: dyspareunia related to post surgical tenosis, s embedded in an anor gasmia based on the patient's belief that she is now scarred and mutilated and no
VOL. 31, NO. 1 JANUARY/FEBRUARY981 1

References 1. Devlin HB, Plant JA, Griffin M: Aftermath of surgery for anorectal cancer. Br Med i
3:413418,1971. 2. iewett Hi: The present status of radical pros tatectomy for stages A and B prostatic cancer. Urol Clin North Am 2:105124,1975. 3. von Eschenbach AC: Sexual dysfunction fol lowing therapy for cancer of the prostate, testis, and penis, in Vaeth iM (ed): Frontiers of Ra diation Therapy and Oncology: Proceedings of the 14th Annual San Francisco Cancer Sym posium, 1979. Basel, S Karger, 1980, vol 14, 13.Maguire P:Psychiatric problems mas after

tectomy, in Brand PC, van Keep PA (eds):

Breast cancer: Psycho-social Aspects of Early Detection and Treatment. Baltimore, University Park Press, 1978.

Downloaded from caonline.amcancersoc.org by on March 3, 2011 (American Cancer Society, Inc.)

14. iamison KR, Wellisch DK, Pasnau RO:

Psychosocial aspects of mastectomy: I. The woman's perspective. Am J Psychiatry

135:432436, 1978. 15. Wellisch DK, Jamison KR, Pasnau RO:

Psychosocial aspects mastectomy:II. of The man's perspective. Am J Psychiatry 135:543546,1978.

and fecundity treatment after fortesticular tomy on a woman's feminine self-concept. i tu Nerv Ment Dis 164:7787, 977. 1 mors.Urology 7:3538, 1976. 17. Polivy i: Psychological effects of radical 5. Kedia KR, Markland C, Fraley EE: Sexual mastectomy. Public Health Reviews 4:279293, function following high retroperitoneal lymph 1975. adenectomy. J Urol 114:237239, 975. 1 6. Dempsey GM, Buchsbaum Hi, Morrison J: 18. Silberfarb PM, Maurer LH, Crouthamel CS: Psychosocialaspects of neoplasticdisease: Psychosocial adjustment to pelvic exenteration. I. Functional status of breast cancer patients Gynecol Oncol 3:325334,1975. during different treatment regimens. Am J Psy 7. Donahue VC, Knapp RC: Sexual rehabili tation of gynecologic cancer patients. Obstet chiatry 137:450455,1980. Gynecol 49:118-121, 1977. 19. Schilsky RL, Lewis Bi, Sherins Ri, Ct al: 8. SewellHH, EdwardsDW: Pelvic genital Gonadal dysfunction in patients receiving cancer: body image and sexuality, in Vaeth iM chemotherapy for cancer. Ann Intern Med (ed): Frontiers of Radiation Therapy and On 93:109114,1980. cology: Proceedings of the 14th Annual San 20. Chapman RM, Sutcliffe SB, Malapas IS: Francisco Cancer Symposium, 1979. Basel, S Cytotoxic-induced ovarian failure in women Karger, 1980, vol 14, pp 3541. with Hodgkin's disease. I. Hormone function. 9. Abitol MM, DavenportiH: Sexualdysfunc JAMA 242:18771881,1979. tion after therapy for cervical carcinoma. Am 21. Martin CE: Marital and sexual factors in iObstetGynecol 119:181189, 974. 1 10. Dennerstein L, Wood C, Burrows GD: relation to age, disease, and longevity, in Wi.rt Sexual response following hysterectomy and RD, Wmokur G, Rolf M (eds): Life History oophorectomy. Obstet Gynecol 49:9296, 977. Research in Psychopathology. Minneapolis, 1 University of Minnesota Press, 1975. 11. Derogatis LR: Breast and gynecologic can cers. Their unique impact on body image and 22. Martin CE: Sexual activity in the aging sexual identity in women, in Vaeth iM (ed): male, in Money i, Musaph H (eds): Handbook of Sexology. New York, Excerpta Medica, Frontiers of Radiation Therapy and Oncology: 1977. Proceedings of the 14th Annual San Francisco 23. Fiori N: Patient perspective, in Vaeth iM Cancer Symposium, 1979. Basel, S Karger, (ed): Frontiers of Radiation Therapy and On 1980, vol 14, pp 111. 12. Maguire P: The psychological and social cology: Proceedings of the 14th Annual San consequences of breast cancer. Nursing Mirror Francisco Cancer Symposium, 1979. Basel, S Karger, 1980, vol 14, pp 4850. 140:5457,1975.

pp 4250. 4. Bracken RB, iohnson DE: Sexual function

16. Polivy i: Psychologicaleffects of mastec

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