Monday, January 5, 2015

On being selfish

I want to show this photo because this flower reminded me of something I realised a little while ago and then forgot again. This flower came from my garden. The rose bush this flower came from has been growing in my garden, blooming beautiful flowers like this one every now and again for a few years. I love it! I have never encountered a rose bush as “fertile” as this, giving rise to so many flowers and so often. Now, the romantic side of me believes this rose bush is so fertile because it came from a bouquet I was once given out of love. When the flowers died, instead of throwing them out (like normal people do), I cut the stems off, and I planted them in the ground. That was a few years ago. Of course, one of the stems became this most productive plant. So together with this romance theory, every time this plant flowers I believe it is giving me, me specifically, the gift of flowers. But I never cut them off the rose bush… until today.

I've never cut one of my own flowers because I know that the flower will most likely have a longer life without my interference. I water the plant, I prune it sometimes, I try to keep the bugs off it; I like to think that I’m giving it a good life. The truth is its roots are probably deep enough now that it could support itself without my input, but I don’t want to risk it withering from lack of water or something I could have possibly prevented. In the last few weeks its base has become infected with some thing I can’t quite keep off it. But also in the last few weeks she is flowering again. It amazes me how something so beautiful can come from something that is at the same time ill.

What drove me to cut a flower off my plant today? Selfishness. Plainly and simply, I decided today to be selfish. See, I saw how beautiful the flowers on the plant were, and I thought I want to enjoy this one more, more closely, for longer, and I want to do that now. Sunset was coming and I wanted to keep enjoying my flower. I thought, she will die one day, so will I, why not take this moment in our lives and share it together? And, yes, I do get this emotionally attached even to flowers; I’m not even being metaphorical! So today I decided to be selfish and brought my beautiful rose inside with me, to enjoy her beauty (purely for my own benefit, though caring for her – and yet not as best as she deserves).

And what did I remember? It was about selfishness. That in order to love, or at least act on love (and what is love without actions? Non-existent), you have to be selfish. At some point you have to decide and act on that inner impulse, to reach forward and both give and take. There’s no one-sided love; as much as we give, we always take. So you have to at least be self-confident that you are deserving of another’s love – and go about either accepting it or striving for it. Even if we do that thing where (because we “know” ourselves so well) we think others are better than us, that we’re not the best person in the universe for the object of our affection, you have to be selfish or else you can’t truly love. We would never act on love if we didn't decide at some point to be selfish. And, of course, this brings me to a second realisation: that it’s hard to love, because you lack confidence and an accurate sense of self-worth, when you are suffering with depression. It’s like my flower struggling to be beautiful, to blossom and radiate, in the face of whatever illness she is facing. How could I love her in a satisfying way without first deciding that I’m worthy of her beauty and she of my care?

And now is the point where I realise that perhaps, in a way, I can’t help but be metaphorical.

Sunday, December 28, 2014

On eternity

I once met a girl with the word “eternity” tattooed on her body. She was young and so I wondered if this was an ironic play on the Asian characters others get tattooed on themselves. She said simply “it’s just eternity; it means a lot to me”. I chuckled to myself in a kind of self-righteous indignation, and also waiting for her to crack and laugh too and tell me it was just a joke. It wasn't.

Eternity? How does eternity mean a lot to a young girl in their twenties? How does it mean a lot to a girl who I've otherwise only ever heard speak of some or another party, of “having fun”, of fashion, of nothing really meaningful. Really? Eternity? Could she even grasp it as a concept of time-space? Has she ever even dedicated time to the thought of infinity as it applies to the universe we live in, the physics of it. Has she contemplated eternity in the spiritual sense? Or is it more like the scribblings of children “Mary + Joe, 4eva”? Forever? Is it like the way “forever” means to some couples who get married, 'until the divorce'? What the hell does she know about eternity?

And then I thought, hey, what the hell do I know about eternity? And, you know what, I’m actually not that much different. To me eternity is like infinity, a concept that surely somehow exists even though you may not be able to explain it. Eternity exists because even after you die, the world around you keeps going. There were people around you and they saw you die, but they keep on living. After they die too, the world keeps going. There are constants in this world that aren't the lives of human beings, because certainly we’re not eternal. What about the afterlife, that has to be eternal, right? No one knows. There’s religious doctrines out there that say that yes, we are eternal because our spirits are eternal and, like energy, merely change form, but aren't destroyed. And still I say, no one knows. The evidence we have is of this physical world and all this says is that once our body dies, it merely decomposes to its components. End of story; no eternity to any part of us except the subparticles and energy that comprises us and everything around us. There’s infinity because of the expansion of the universe, the ongoing increase of entropy, the extremely small and extremely large processes going on in the universe. All of it, not things a lot of us sit and think about regularly. And certainly not the things that young girl meant by “eternity”.

But what do I know about eternity? I’ll tell you what I don’t know that I think this girl does: hope. Eternity is a wish, a desire for things like love and marriage and health and prosperity to last forever (or until the end of our days). I've lost that hope. I've let myself become too marred by experience, too dark and pessimistic. I came to realise that this young girl probably does have a much broader concept of eternity than I do. She has a child. She understands love far deeper than I do, and with it the concept of never wanting harm to come to your child – of wanting them to live forever, to be eternal. She’s in love. She remains passionate with her lover, he still makes her smile, surprises her in sweet and charming ways, they still want to impress each other. She enjoys life, looks forward to things, isn't accepting the 9-5 job as her life; her life is at home, and on the weekends, and every moment she can find in which to smile in. These are the things she hopes will last forever. She approaches life with such passion, embracing everything as if it were going to and hoping it will last for all eternity.

What are the things I wish would last for all eternity? These are the things I should focus on. With insight must come responsibility.

Impressive

Sunday, December 21, 2014

A story: "Poetry"

What if I'm brave today?
What if I quit my job?
What if I confess?
What if I take a chance?
What if I'm reciprocated?
What if I'm not?
What if I jump today?
What if I end my life?
What if I smile at a stranger?
What if I cry my insides out?
What if I'm brave today?
What if I die? 
And if I live?
What if I don't like the consequences?
What if there are no consequence?
What if all this is a revolution in a vacuum?
What if I'm really just stupid?
What if I do nothing?
What if I find happiness, here; right here?
What if I cower?
What if I smile at the end of it all?
What if I'm brave?
What if…?
I'm brave.

He writes this in an old notebook. The "poetry" of a pathetic old soul, unsure of whether he's in love or he's finally truly crossed over into mental illness. Is this what aging does to people? You see a flower and it's not even a particularly beautiful flower but you assume it was put there for you, that it was meant for you to notice it, that spring is quickly slipping away and you better embrace this one last remnant of what you felt when you were young and powerful. You see a table in a store and you feel the same sequence of emotions: my life isn't complete until this table enters my life, my house, my sphere. In time the table sits under a bunch of all your unsolved problems, debts to pay, crumbs of the last things you consumed without a thought. You introduced yet another piece of furniture you'd just walk past again, ignore, use, stub your toe on occasionally - and then, only then, with the pain do you remember that, yes, it was once a beautiful tree too. Eventually you forget (or ignore) that you'll do the same with your flower. You will walk past it and notice its withered leaves and petals; it'll have shed its soul for you. For you who ripped it away from its ecosystem where at least it's life and death at least contributed to the universe. You really thought your life, your love, your eyes were worth more than the universe?... You think all these thoughts and say to yourself: my life really is meaningless.

Sunday, December 14, 2014

A story about stuffing up

“And he said unto me, My grace is sufficient for you: for my strength is made perfect in weakness. Most gladly therefore will I rather boast in my weaknesses, that the power of Christ may rest upon me. Therefore I take pleasure in weaknesses, in reproaches, in necessities, in persecutions, in distresses for Christ's sake: for when I am weak, then am I strong.” 
- 2 Corinthians 12: 9-10

Charlotte
I walk into the doctor's office. What exactly do I expect? What's wrong with me? What can she help me with, she asks. I don't know. I think I need something. I don't know. In my grandparents day I would have been having this conversation with a priest or an elder of my church. Church? What if any part of this is holy? Thirty-five years ago marrying in a church, I did not expect that today I would be having this conversation with anyone. What can you help me with?... I haven't been able to sleep in days. I have no desire to eat. I cry all day. Every day. How long has it been, she asks. Two weeks. But two weeks is a long time when you're heartbroken, feeling like the world has been removed from under your feet. I haven't felt present. I don't know why or who I am... Oh, she's looking at me blankly.

It's my husband, I tell her. He had sex with another woman. It's my fault; I haven't had sex with him since the first time this happened. Yes, it's happened before; a few years ago now. I should have known my mother was right; she said if you forgive him once, you have to be prepared that this will be only the first time. How could he? How could she? I don't know her, but what kind of person has no brains about her to get herself into this? That is not a normal person.

Why have I really come here? What is my goal? Do I really intend to continue a relationship with a man of such low character? Oh, he's a wonderful man, but how can this... this... I can only think of the words filth and numb. He used to be so good. We were so good. How do you put your whole family life on the line like that? What do you have to be thinking? He's a man, maybe all men are like this. Doctor, are all men like this? What do I do? She's still just looking at me blankly. Am I wrong in feeling all this? Does he have a problem? Do I? I think it's better if we have a problem, that way we can fix it... Oh God, what am I saying? She's still just looking at me wondering how she can help...

David
I always thought 'yeah, I'm attracted to powerful people, passionate people, people with drive and motivation'. And that may be the case but I think another part of me takes comfort in the weak. Is it because I compare myself to them? I don't know. I’m weak. I'm uncomfortable too. I don't love her like I used to. It happens to all couples. She keeps asking what was I thinking? What was I thinking. Dear, if you would understand that I wasn't thinking. I intended nothing; I thought of nothing but of the moment. They ask of addicts “why do you do it when you know that it’s so bad for you?” But no-one ever remembers how good it feels. People do things because they feel good, not because you want to avoid something worse. It felt good, Charlotte! It felt good! But I can’t tell you that... I tell you I was lonely. Of course, it’s not your fault! It’s not your fault! And this is what makes me most ashamed of this situation. You blame yourself, you hate me, and you think there was a reason and you won’t let up until you find it.

Charlotte, if I told you what attracted me to her it would hurt your soul. It was me; I was what attracted me to this. But to explain to you that it really was about me and not her, well, you just wouldn't understand. You simply cannot understand that she made me feel things about me that you can’t and won’t let me feel anymore. Oh, dear, I’m not blaming you, either. Please understand that’s not what I’m thinking at all. But you shut me down, you tell me what to do, you tell me when and how it’s appropriate to do it. These women, (yes, you know of that one) see me as a worthy person, an intelligent person, a good person. They see ME. And in your way I know you feel the same way about me; that’s the stories you tell your friends. You say I don’t love you anymore, but when did you stop loving me? Why won’t you show me that love? Why did you stop being sweet and caring and loving as we once were? Don’t tell me it’s because of that first lapse; you and I both know it happened much earlier. And THAT I will never understand. Why did you stop laughing with me to start laughing at the pathetic all-adoring little mascot of yours I became?

You ask what these women had that you don’t? Nothing! Absolutely nothing. It felt good to be wanted again, Charlotte. I wish you knew how much. I wish you let me feel this good again. You say you feel numb. Now you feel numb? I've been feeling this way for months and years!.. It’s no excuse, I know.

And now you drag me to this doctor’s appointment. Haven’t I shown you already how ashamed and regretful I am? Must you humiliate me further? A “check-up” on my health you say. Is there something wrong with my brain? Have I contracted some illness? I go along. I have no secrets left, Charlotte. I have nothing left in me.

The doctor
I’m listening. What else am I supposed to do? How can I help? Oh gosh, they never taught me any of this in med school. They don’t teach any of this anywhere. I agree this is a bad situation but do you understand I don’t know what to do either? You’re trying to figure out the direction of your life, and I’m trying to figure out how can I do my job and somehow, I don’t know how, contribute something today. "Empathetic listening", they said something like that in medical school. I resented them for trying to teach me so much communication stuff and not enough medicine. I wish I’d paid attention in case we ever came across this scenario. Fuck, am I feeling sorry for myself in a time like this? Focus, Vanessa. Thirty-five years of marriage, you say. Thirty-five?! I haven’t even been alive that long! I barely know the difference between my right and left and you’re asking me for marital advice? I don’t know. How to make a relationship last? What to do when you find yourself in an unequally-giving relationship? I don’t know. Clearly, I have no idea; I've barely known how to keep myself alive 30-something years and you ask me how to rescue a relationship. Focus. I have to focus. What was my job again?... STI check. Would you like me to run some tests to check for sexually-transmitted infections? Did I really just say that as you started to cry? I’m an idiot. Somebody throw me a frigging bone here! I’ll point out the tissue box on my desk. There, that’s better. You said you can’t eat, sleep, or stop thinking depressive thoughts in the last 2 weeks. Two weeks isn't enough to diagnose you with anything. And did I really just think about diagnosis? Bad shit happened to you, you’re sad, and I’m trying to find pathology in that? Jesus Christ, what the fuck has happened to my common sense, to my morals, to my better judgement? God, don’t ask me what I think your husband was thinking. Was that a rhetorical question? I don’t know. I say I don’t understand it either. Oh God, I’m in fucking agony here… Charlotte, can YOU tell ME what you think I can help you with? And let me just say, I don’t think there’s anything wrong with you. You have every right to be feeling the way you are. I don’t know what else to say to you, but I can tell you that.

And now you've brought your husband? What do you want me to say? How can I help you? How can either one of us be helped here, David? Stop telling me your story; it's inconsequential to me. Tell her! No, I'm being selfish and thinking only that I'll be late home again because you're spilling your guts out to me. Tell me. Cleanse your soul. Teach me things so that one day I may understand men and women like you and your wife. We've both stuffed up, David. And today I shouldn't have come to work.

Sunday, December 7, 2014

On people wasting your time

One day I was talking to someone who said to me "I'm sorry to be wasting your time". She was very depressed. I mean depressed in the classical sense, not just meeting medical criteria. I mean being so low that you don't even feel sad anymore, you feel nothing, as if you were dead already. I said to this lady that we're human beings and you don't waste your time with other human beings, we merely share it. I have realised since making that statement that there is no such thing as one-way or one-sided relationships. Even when you love someone and they don't feel the same way about you, that is still not a one-way interaction. We're human beings, and even if we want to believe that we live in a world where there are only material things, words, and other physical things like light, sound, movement, etc., that is simply not all there is. We have a rich inner world, we create metaphysical tracts we call relationships, we create and (most of live by) social norms. As annoying and as inconvenient as it sometimes is, we simply cannot go back to saying we are just carbon-based life-forms existing in a physical world that have no impact on each other's inner or external spaces. When you console your depressed friend, it isn't just for them, it doesn't just involve them; you don't just give without also taking away from the experience.

In clinic I sometimes see people who apologize to me for wasting my time. And it's not the ones that as a doctor you usually think of as 'wasting your time', like the drug seekers and malingerers. It will usually be someone with a mood disorder who feels they are a burden to everyone, including their treating clinicians. But then they quickly point out, "I know you're getting paid, but..." Which is right, I do get paid to do my job! A few years ago a patient said to me that he was sorry for taking up my time with his depression, and "knew" that I only did it because it was my job and I couldn't kick him out. I said to him, "actually I can kick you out". He looked at me, surprised, I guess. I explained, yes, this is my room and I am in control of what happens here. If I want you out of my room, I can make that happen. Stuff etiquette, stuff protocol, stuff that constant thought in the back of every doctors head of "how will this look in court?" Yes, I told the patient, I could if I wanted to kick him out of my room, and I can even go as far as terminating our therapeutic relationship altogether, not just that day's consultation. This was not an emergency situation, and terminating the consultation abruptly would not really affect his mental/physical health, so I had every right to ask him to leave my room – if I wanted to. But then I asked the patient, and "do you know why I haven't kicked you out of my room?"

I asked this question aloud for two reasons, and one of them was to buy some time to ask myself this same question. Do I care? Really, do I care about this patient? I mean "care" as in does this person's predicament truly concern me in a sense that it affects me emotionally? Well, no. I care about my mum, my friends, my partner, my pets, and my own physical health. I can't care for or about every patient in that way or I'd make a terrible and over-involved clinician. Of course, I "care" from a healthcare/clinical point of view of wanting my clinical management to better and not worsen the patient.

I believe in being honest to my patients, so I knew I wanted to word my response to this man in the most honest way I know how, and "care" was not the word I wanted to use. Why don't I kick you out my room when you're cleared depressed and have reached out to me for medical help? The first reason is because I understand why you sought me out in the first place.  You reached out for medical help because you felt you couldn't help your own self anymore, that you're unable to be helped, and not only that but that you're also unworthy of help. Those last two points are exactly why you asked the question in the first place. The second reason I haven't kicked you out my room is because I see your potential. And I see this because I am on the outside looking in. Depression is like being inside a deep, dark, empty, silent, and very still void. I'd say it's like a well, but in reality there is not even a bottom and there are no sides for a reference point. You can't see outside of the void – and when you're truly in that melancholic/pre-suicidal depression, there is no will left to want to see outside of the well. But I'm on the outside! I'm your clinician and I am on the outside looking in and can tell you that there is something outside of the void and you can and will get outside of its grip if we do things that seem pointless right now. This is exactly what I mean when I say I can see the potential in another person. (Of course there’s no point at all in this situation to disclose to patients that I understand depression so well because I have been in that void before. In fact I think this changes nothing in terms of how well any clinician can manage this scenario. I don't have to have experienced diabetes personally, for example, to understand it and treat it.) Patients may believe they're a waste of time and space when they're depressed, but I strongly disagree on this point. I disagree especially because, as I said, I truly do believe that we don’t waste time with other human beings, we merely share it.

I believe that sharing time with other people isn't a waste of time; that of every interaction you gain and you give, that of every interaction you learn, that every moment shared changes you as you in turn change others. And yet believing this as long as I have and as fundamentally within myself as I do, a few days ago I almost convinced myself that someone was wasting my time. And then I remembered back to my own words, and asked can people actually waste your time? And, you know; no, I still don’t think I got it all wrong in the first place. What happened was that I was responding emotionally, wanting to blame others for disappointing and hurting myself. It was easier to say “you’re wasting my time” than to admit that it was me who had unrealistic expectations. I felt very drained, raped almost on a cognitive/spiritual level, for giving so much of myself when really I was asked of nothing. And then I was upset about indifference? How absurd it seems now that I've had time to re-analyse the situation. It was like I had walked past a building, said to myself, ‘hey this is a bank’ and started pouring money into it – and then I got upset and angry when this building kept only taking and storing what I gave it but gave me no returns, let alone interest or growth. And am I to blame the building or my own delusional self for this feeling of exhaustion? Myself, of course. And yet I can take this experience and say that really that no time was lost, I merely shared a moment and learnt a very valuable lesson.


¿Qué escondes, mi flor blanca?
¿Qué hay bajo la próxima capa?
¿Es un escorpión?
¿Es tu corazón?
¿Son los gusanos que te comerán viva por no dejarte ver?
¿Son mariposas esperando su re-nacer?





Tuesday, November 25, 2014

On obesity

Just a photo of a nice croc I saw
I read an article recently about how to best manage obesity as a society. It wasn't a medical journal, though, it was an economics/finance/management report published by the McKinsey Global Institute. It was written by business analysts and economists; which was interesting to me as usually I see these articles about obesity in the context of public health and medicine. And it got me thinking about just how did obesity become a problem. The report is very interesting and I certainly don’t intend to repeat it all; in fact what I’m writing here are merely my own insights and opinions that took this article as a starting point. But if you get the chance, read at least the executive summary of the McKinsey report here.

Food has always been a necessity for us humans, and obesity is not a new thing. The problem is the high prevalence of obesity and the subsequent high rate of health problems for which obesity is a major contributing factor. You then recall times from history like the great depression and wonder how did we overshoot so much that now obesity – an excess – is the problem. The thing is that perhaps the exact same things that brought us out of the great depression brought us to high rates of obesity.

Towards the end of the great depression, a lot of interesting things began to happen. Yes, there was the onset of World War II, which brought about destruction – and subsequently, at it's conclusion, a great need to re-create, produce, manufacture, and re-build the world! Industries soared. Governments and commercial enterprises became really good at economics and business. Extremely good.  And with the end of the great depression, of course, food became more than a rationed commodity, more than a human need, it became a highly lucrative commercialised industry more than it had ever been in our society. The success story of business and industry tracks that of obesity rates. Every strategy that led industry to thrive, also drove obesity rates to rise.

Think about all the strategies that make businesses successful, and then you finally may get closer to finding an answer to the question of how did we as a society let obesity rates rise to the levels they are today. Well, firstly, a great business needs a product that is desirable. What is a more desirable consumable than food? And more than being a desire, it is an actual human need! Food is one of those things that would sell even if it wasn't advertised anywhere.

But food is advertised – and very well; a great marketing strategy is one of the fundamentals of a successful business. The interesting thing is that the food that receives the most advertising is the least nutritious and yet most energy-dense. Unfortunately as a society we developed technologies and became really good at modifying our environment so as to minimize the amount of energy our own bodies expend. Our progress as a society, our advancement, is because we built efficient machines that use external energy to do the hard labour we previously took on. We walked greater distances, lifted more, did more physical work just in our everyday than we do now. And hence the large disparity between the energy content of what we consume (that energy-dense food advertised so heavily) and the energy we expend – with excess energy being stored in our bodies as fat.

Marketing isn't just about direct advertising, though. It even involves exploiting existing societal norms and evolving new ones. What do I mean by this? Actually this concept is the most wide-ranging aspect of how business, and food as an industry, has grown. But let’s take, for example, just two interesting quirks of us human beings: 1) we perceive more as better, and 2) we perceive bigger as better. Have you ever tried to buy just a Big Mac at McDonald’s? Well, let me tell you it costs nearly as much as a Big Mac meal, with the fizzy drink and the fried potato chips included. We all prefer to get more for our money, so we do end up buying a much higher energy intake for just a few cents more. But it’s not just about the big bad fast food giants, even our supermarkets do it.  They sell us even staple foods, but at a cheaper rate if we buy more of it. Why? Not because they think “poor, poor, undernourished people; let them have more food”. No, they do it because we are consumers, and only consumers to them. They sell us more so we pay more (we think we’re making a saving, but the reality is companies never underprice their items even in the “deals” they give us). The concept of portion size is similarly related. And portion size isn't just about how big our meals are, but the fact that because our foods are so energy-dense and our lifestyles for the majority of us are so sedentary, the physical-size of our meals isn't even what we’re really talking about here. And who does know what we are talking about when we say things like “portion-size”, “recommended daily intake”, “calories”, “kilojoules”, etc? Not that many of us! Education about nutrition and its relation to health and lifestyle are severely lacking in our society…

I want to conclude this topic of discussion with a direct passage of recommendation from the McKinsey report I mentioned earlier:
“Education and personal responsibility are critical elements of any program aiming to reduce obesity, but they are not sufficient on their own. Other required interventions rely less on conscious choices by individuals and more on changes to the environment and societal norms. They include reducing default portion sizes, changing marketing practices, and restructuring urban and education environments to facilitate physical activities.”
What do you notice about these recommendations? If you’re like me, then you will have noticed how most of the things suggested that we need to try to do as a society to combat obesity are the complete opposite of everything you need to do to have as great and successful a business as the food industry in industrialized countries is. We became obese not merely because we ate too much, but we ate more than we needed to because the food industry needed to grow its profits. I think in health care we particularly need to take note of this. Sometimes we think we must help individuals (or blame them, as we sometimes do), but the truth is individuals were helped in their demise by large industries and corporations who focused on our consumption/profit value rather than the effect of their products on our health.

Sunday, November 9, 2014

On sex and illness

Back in the day, the general thought about romantic partnerships was that the woman had to be dutiful, and part of her duty was to make sure her man was getting sufficient sex to keep him happy. This was prior to the 1960s (though in many cultures and countries this is still a very prominent idea). Back then, men made up the greatest proportion of the salaried workforce, and men’s ideals dominated the media. A by-product of this era that I find particularly interesting is the notion that men (and women) need sex to be happy, and that sex is a necessity to keep relationships strong and lasting.

A question us health professionals often overlook when consulting our patients is the importance of sex to them – they are, of course, human beings just like us and therefore have the same interest in it that we do. There was a time when we were all being urged to tell our cardiac patients to abstain from sex for a certain period of time after a cardiac event or surgery – and the message got through to us and them. We became good at dishing out advice to patients that sex after heart problems is a big no. Patients, motivated to obey as they didn't want to suffer complications from what is a very serious health issue, listened and took this very seriously too. A lot of us, however, forgot to frame anything but the negative to our patients and advise them that sex is OK too, and bar a few restrictions, it was OK to resume it. It was like as if as health professionals we thought that patients are sex-crazy insatiable beasts that cannot resist the urge to have sex straight after having (often) extremely painful chest surgery and/or losing a large amount of physical endurance. The reality we were forgetting is that very often after cardiac events, people (yes, patients are people too) become depressed, and with depression often comes an actual loss in libido. Suddenly after a major health scare we are faced with the realisation that our life isn't infinite, that our risk of dying is a lot higher than we once thought, and that we now have a chronic illness that you just can’t shake off and pretend like nothing ever happened. Our patients’ whole lives change, priorities change, relationships are tested and adjusted – and there we are as health professionals thinking that our patients actually want to have sex after considering all this! Yes, some do, but the majority probably also would benefit from being reminded that once they’re ready, sex is OK.

Another interesting scenario is sex in the context of cancer. I mean specifically cancers that affect tissues that we traditionally would associate with sex: breasts, prostate, testes, etc. As an example, let me consider women who have the most common type of breast cancer, those which are hormone-related/responsive. Treatment of their cancers often involves surgery, scars, and sometimes very marked deformity. All this in areas of their body often thought of as very intimate, sensitive, and defining of one’s sexual identity. Radiation treatment does similar, and sometimes making an area that was once so sensitive in a positive way, extremely tender.  Medically, to achieve remission of their cancers, these women often have to be put in a state of sudden menopause. And then come all the effects that go with menopause: vaginal atrophy, loss of libido, low mood, hot flushes, etc. You put all of this together and can you imagine how hard it is not only to think of sex, but to actually enjoy it in the way these women once did. Now think of the effect this has on a relationship if we aren't being open and honest on what people with these types of cancers are going through.

It’s no big leap of the imagination to conclude that a lot of relationships often become sexless after cancer affecting what we predominantly think of the sexually-defining features of our body. For those who are not in a relationship at the time of diagnosis, entering or re-entering a relationship is equally as daunting and is often delayed by many many years. Now, as an example (because I have seen this scenario a few times in my own practice), consider a heterosexual couple where the woman becomes diagnosed with breast cancer. Initially, both partners become concerned about the physical well-being of the partner affected by the cancer. The couple shares common goals: for the woman to survive the cancer, and for her to tolerate the treatment as best as possible. Of course, despite our best personal support networks and the best-meaning friends, family, and health professionals, cancer diagnoses and treatments are very isolating. Everyone may know what you’re going through, they may care about you and want the best for you, but only you are going through it in mind and body. It’s a sad fact of life, that at times no matter who’s around you, you feel very alone. The cancer treatment begins and ends for the woman, but the emotional adjustment takes a lot longer. Sometimes it takes a very long time, and though couples never forget the cancer, they sometimes forget to speak of the less “heavy” things of life, things like sex. And more than simply not speaking of it, sex during and after cancer becomes taboo. I mean, such greater things are in question when the cancer diagnosis came up: mortality, strength, survival, endurance, support – who can think of the mundane things of life like sex? But time passes and life and relationships continue once the acute cancer story is done with.

And, yes, we do think of sex. Not just the partner who hasn't been sick, either! We know that the person who has survived cancer has all that physical and emotional stuff to deal with, scarring, pain, deformity, loss of libido, low mood, etc. How can you possibly have sex again? Unfortunately, this same information is often locked up inside with shame, fear, and the desire that if we just ignore the issue it will all just go away. If we return to the example of the woman with breast cancer, the partners of these women often do not know her struggle beyond the acute cancer story. No one talks about it. And so they wonder what they’d done wrong, what did they do during the woman’s struggle to turn them off them sexually still so many years down the track? Can they ever undo this and how? Is this it; is this just how it is after cancer? Does a sexless marriage mean a loveless one? Is it wrong to still be sexually attracted to the woman she is despite her body changing? Has this got nothing to do with the cancer? Has it really got nothing to do with it at all, and the only reason the woman isn't leaving is because she’s grateful for his support during her cancer battle? Is gratitude enough to continue a seemingly loveless marriage? These thoughts are very emotionally painful – and I think very important to talk about. Similarly, I've known of men who won’t approach their partners sexually after cancer treatment for fear that she won’t want it, can’t have it, and just not knowing (and unable to ask?) how it will be different for her. Women may react to this in the way that, ‘hell, not only did I just go through cancer, now my partner doesn't even want to touch me or know me sexually’. And so the cycle of sexual abstinence continues…

And what do I conclude? That we talk about sex. That it becomes neither an expectation in relationships nor a forgotten burden. That health professionals to their patients about it, but more importantly, that couples talk to each other about it. And that we be allowed to form our own conclusions as to the importance of sex in relationships.