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.