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Sex and Intimacy

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Overview

 

  • Sexuality encompassing sexual feelings, activities, and attraction, is impacted by breast cancer treatment. The psychosocial impact of sexual dysfunction and a decrease in libido often go unaddressed. 

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  • Occupational therapists can collaborate to develop strategies and engage partners to support women throughout the treatment and recovery process.

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  • Intimacy is broader than a sexual relationship between two people, expanding to the unspoken moments of tenderness during a caregiver relationship.

Professional Insights

Danielle Centi OTD, OTR/L - George Washington University, Assistant Professor of Health, Human Function, and Rehabilitation Sciences â€‹

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Overview

  • Constraints: 

    • Main reasons for OTPs neglecting to address sexuality in day to day interactions: 

      • Staffing shortages

      • Time constraints 

      • Focus on functional ADLs rather than social 

      • Priority by insurance companies, creating a challenge to prioritize psychosocial needs 

  • Patient

    • During treatment there is a lack of privacy and dignity which can impact a woman.  They feel they are in a ‘fish bowl” being observed

    • Requiring support for basic ADLs can have a negative impact on a person’s perception of themselves as a sexual being

    • There is a significant amount of trauma from a cancer diagnosis and treatment that is not being addressed

  • Assessment

    • Rather than relying on specific test assessments, which can be useful to establish a baseline, the focus is more on creating a personal relationship with the patient. The comments or self deprecating jokes that a person makes is oftentimes more accurate as a self assessment than a test
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Clinical Interactions

  • Intimacy awareness:

    • Intimacy is more than a sexual relationship and involves engaging in vulnerable conversations with a partner

    • Assisting in personal hygiene (showering, using the bathroom, grooming routines)

    • Occupational therapists need to educate colleagues on the full scope of sexuality and intimacy issues outside of a physical sexual context 

  • Caregiver Relationship

    • Caregivers often face challenges balancing roles as a romantic partner and adapting to new level of intimacy required by daily hygiene tasks

    • These experiences impact perceptions of self of  the individual undergoing treatment and the caretaker 

    • Impacted individuals may appear withdrawn and unmotivated to an outside perspective, and are unfairly labeled as such
       

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Click below to learn more from Danielle Centi 

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Ceddeth Richardson OTD, OTR/L, - George Washington University, Assistant Professor of Health, Human Function, and Rehabilitation Sciences
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Overview

  • Obtain consent to have the partner/family in the room for treatment sessions - Ensure conversations includes the client rather than it becoming a conversation about the client  

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Clinical Interactions

  • Therapists can open the door to the conversation by saying “ if you have any questions about intimacy, please feel free to ask. This is an area that we cover and can help with” 

  • Validate the feelings of the individual - oftentimes referring to social groups is a helpful tool  

  • A patient may have concerns about diagnosis related sexual challenges while their partner may not charge these worries. This creates psychosocial challenges to be addressed during OT sessions  

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Click below to learn more from Ceddeth Richardson 

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Matthew Cordova, Clinical Psychologist Ph.D. -   Palo Alto University​

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Overview

  • If symptoms are addressed from a prehabilitation standpoint there would be less of a posttraumatic impact 

  • Center treatment sessions around the person with breast cancer, providing autonomy to choose to include a partner in the session  

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Clinical Interactions

  • Menopause may be induced or reinduced - if an individual has already been through menopause, symptoms may worsen

  • Anti-estrogen medications that block and reduce the likelihood of recurrence may have an impact on hot flashes, vaginal dryness with intercourse. At a younger age: challenges with fertility can occur  

Click below to learn more from Matthew Cordova
 

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Catherine Benedict, PhD - Clinical Assistant Professor at Stanford University School of Medicine​

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Overview

  • Individuals impacted by breast cancer at a younger age have a different set of needs. Topics of focus may be educational attainment, early career development, fertility (impacted by chemotherapy), and dating/relationships. 

  • Fertility preservation and family building decisions will be impacted by socioeconomic status due to the costly nature and insurance doesn’t typically cover it 

  • The medical system is set up to provide high contact support, frequent visits, treatments, and medical staff available. After treatment, people feel alone when the message is to just go back to “normal life” and left floundering, as a lot has changed for both the patient and caregiver.  

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Clinical Interactions

  • Individuals may disassociate as a coping mechanism during treatment. In the post treatment survivorship space, reconnecting with the body and coming to terms with this new normal is a learning curve. 

  • It is common for couples or partners to have difficulty managing the change in roles and responsibilities. In many ways, relationships become closer in some areas and more distant in others. It is important to normalize and validate their experiences and have a point of referral if necessary  

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Click below to learn more from Catherine Benedict  

Dr. Lydia Chevalier, PhD - Dana Farber Cancer Center, Instuctor in Psychiatry Harvard Medical School â€‹

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Overview

  • Opening the conversation surrounding sex and intimacy for individuals with breast cancer  is powerful. Afterward, they can be directed to resources referred to specialized professionals. Many times individuals don’t realize the challenges they face are a side effect of cancer treatment. 

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Clinical Interactions

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  • Dating: the cancer journey doesn’t need to be disclosed on the first date - keep it vague and identify fi that person is safe and respects your boundaries 
    Often young cancer survivors feel behind others in their life experiences, specifically dating and sex/intimacy. Writing down concrete plans and practicing conversations is effective in easing anxiety around the topic. 

  • To open the conversation and make women comfortable answering intimate questions, generalize the experience by stating: “Many women with breast cancer say that they had changes to their body, image, their relationships, or their sexual function after cancer or during cancer. Has that happened to you?
    Partners are brought in during follow-up visits oftentimes for 2 reasons: to problem solve or if a challenge like low sex desire is occurring and a partner believes it is not cancer-related.  

  • Problem solving: facilitation occurs to problem solve sex barriers - partners learn to be creative as sex life may look different now (specifically heterosexual couples may have to turn to other methods aside from penetrative vaginal sex).  

    • Older couples in good standing tend to have a solid foundation to communicate about these topics but in heterosexual couples, the male partner may be challenged with their sexual function challenges (ex. Erectile dysfunction). Younger couples: oftentimes these individuals have many contextual factors at play (oftentimes young children and busy jobs) with less time to focus on their intimate relationships

    • Fear of recurrence plays a role in deciding which vaginal lubricant to use. Vaginal estrogen is very effective and recommended to address sexual function and dryness.Research shows it is generally safe for breast cancer survivors, but the word estrogen creates fear among individuals. 

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Click below to learn more from Dr. Lydia Chevalier 

OT Insights

  • If symptoms are addressed from a prehabilitation standpoint there would be less of a posttraumatic impact 

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  • The key to securing insurance coverage for sessions focused on sexuality is strong documentation to show that the cause of sexuality issues is breast cancer and its treatment

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  •  Recognizing intimacy extends beyond a sexual relationship and includes aspects of caregiver training  

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  • It is valuable to initiate the conversations around intimacy: patients always have the option to decline,, but it demonstrates openness to discuss at a later time

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  • Partner issues can be addressed in a partnered or separate session. There could be billing challenges with a session if the woman is not present​​

  • Education can be provided to the woman and her partner on how cancer treatment may impact the woman’s bodily functions and how this may extend to impact their sexual relationship â€‹â€‹

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  • Sex (partnered and self pleasure) and intimacy should be discussed as an ADL â€‹â€‹

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  • Validate feelings of individual during vulnerable times  - utilize support groups â€‹â€‹

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  • Understand the physical changes that can be taking place such as menopause or reintroduction of menopausal symptoms

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  • The medical system is set up to provide high contact support, frequent visits, treatment sessions,  and medical staff available. After treatment, occupational therapists should provide support during the physical rehabilitation process as patients return to daily living,  

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  • Individuals may disassociate from their body during the treatment, and may require support to reconnect with their body. 

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