Palliative care applies to the entire course of cancer, from diagnosis to death, and enhances quality of life (1). Bruner and Boyd (2) assert that the promotion of sexual health is vital for preserving quality of life and is an integral part of total or holistic cancer management. Often, the innate desire to express and experience sexual and emotional closeness is abruptly and irreversibly changed by the cancer diagnosis and/or its treatments (3). Schover et al. (4) report sexuality to be one of the first elements of daily living disrupted by a cancer diagnosis. Treatments and/or the disease itself can cause changes in sexuality, but healthcare providers rarely ask about sexuality issues because of concepts about the importance of sexuality in the context of the disease (5). According to Leiblum et al. (6), all patients regardless of age, sexual orientation, marital status, or life circumstances should have the opportunity to discuss sexual matters with their healthcare professional. But it is not easy to talk about despite living in a culture that is saturated with overtly sexual images, graphic lyrics, and explicit advertising (7).

According to Tomlinson (8), the main difference between taking a history about a sexual problem and an ordinary medical history is the level of embarrassment and discomfort of the patient and the healthcare provider. A discussion of sexual changes can begin by acknowledging the sexual changes brought about by the cancer or the treatment of the cancer (9). Sexual changes after treatment is not routinely addressed or only barely touched on despite patients having significant needs for education, support, and practical help with managing them. Maslow (10) described sexual activity to be a basic need on his hierarchy of needs while love and connection to others were at a higher level. Everyone has a lifelong need for touch and emotional connection to others regardless of current relationship status (11). But touching changes with cancer. Often the partner becomes the caregiver, changing dressings, and managing drains and wounds, and intimate touching decreases and becomes treatment related. Sexual intercourse is not the defining characteristic of a person’s sexuality; a sexual relationship includes the need to be touched and held along with closeness and tenderness (12,13). Malcarne et al. (14) report that because of the emotional and physical changes in the person with cancer, the quality of a couple’s relationship can be altered even by successful treatment.

In order for providers to begin assessing sexuality in people with cancer, they must first understand what sexuality encompasses. It is a broad term including social, emotional, and physical components (15). It is not just genitals or gender but includes body image, love of self and others, relating to others, and pleasure (15). It is genetically endowed, phenotypically embodied, hormonally nurtured, is not age related, but is matured by experience and cannot be destroyed despite what is done to a person (16,17). Sexuality includes affection, sexual orientation, sexual activity, eroticism, reproduction, intimacy, and gender roles and encompasses feelings of trust (18,19).

Masters and Johnson (20) described the human sexual response cycle that begins with libido or the desire for sexual activity. Gregoire (21) reports that men are more attracted to visual sexual stimuli, whereas women are more attracted to auditory and written material, particularly stimuli associated within the context of a loving and positive relationship. Women are not linear in their sexual response, but more circular (22) and may experience sexual excitement before they have a desire for sexual activity. Sexual excitement is the phase where the penis becomes rigid enough to use and in the female, the vagina lubricates and enlarges in depth and width, and the clitoris enlarges (23,24,25). Erection is the male counterpart to vaginal lubrication from the sexual physiology perspective (26). Orgasm is the height of sexual pleasure and the release of sexual tension. The penis emits semen through muscular spasms and there are rhythmic contractions of the vagina and the cervix lifts up out of the vaginal vault. The last phase of the cycle is the resolution phase where the genitals return to their normal, non-excited state. During this phase, there is an evaluation of the sexual experience as well as relaxation and contentment (27,28). The refractory period, where the genitals are resistant to sexual stimulation, happens during this stage. In males, this period can be a matter of minutes in youth, but take days in older men or with certain medications or medical conditions like cancer.

Sexual expression is influenced by cultural norms, past experiences, and the developmental stage of the individual (19,24,29). Expressions of sexuality include style of dress, values and attitudes, as well as hugging, touching, kissing, acting out scenarios/fantasies, sex toys, masturbation, sexual intercourse, oral genital stimulation, either alone or with others (11,19,30). Sexual behaviors may involve oral, vaginal, and/or anal penetration (30). Sexual behavior is influenced by
religious beliefs, age, education, level of comfort with one’s body and physical functioning, experiences of sexual abuse and trauma, their partner’s wishes, and comfort level with one’s own sexual orientation and gender identity (31,32).

Sexual dysfunction is failure of any aspect of the sexual response cycle to function properly (33). Goldstein et al. (34) report that 90% of sexual dysfunction cases have a psychological component and 75% have clear physiologic sources, so there is a significant overlap. But when a person with cancer has sexual dysfunction, it is mostly physiological. Causes of sexual dysfunction include psychosocial/interpersonal stressors, medical illness, depressive illness, medication, and sexual disorders (DSM-IV) (35). According to Gregoire (21), a sexual problem includes physiological dysfunction, altered experiences, one’s own perceptions and beliefs, partner’s perceptions and expectations, altered circumstances, and past experiences. Causes of sexual dysfunction in a person with cancer are often treatment related due to the changes in physiological, psychological, and social dimensions of sexuality and disruption in one or more phases of the sexual response cycle (11,36). Radiation and surgery can have longlasting effects on sexuality due to chronic pain, scarring, and body image issues. Besides chemotherapy, biologic agents, and hormones, there are numerous medications that can have sexual side effects that range from decreased desire to difficulty reaching orgasm. Many of these medications are used in palliative care (21,37,38,39,40,41) and include the following:

Table 51.1 provides a list of menopausal symptoms and sexual side effects.

Menopausal symptoms can be very distressing to women and interfere with sexuality because of the changes on her body (53). These changes happen gradually in women without cancer and they have time to adjust and enjoy sexual activity 5 to 10 years longer with fewer sexual problems than women with cancer who rapidly experience menopause (54,55). One should note that while dyspareunia assumes pain with penile-vaginal intercourse, it may be a source of distress as well for women with same-sexed partners, where touch and/or finger or object penetration is uncomfortable (56). Katz (57) found that physical appearance was important in gay culture and having a partner show acceptance of treatment-or disease-related physical changes was comforting. Table 51.2 describes types of sexual dysfunction (35,58,59,60,61) as defined by the DSM-IV (35).

It should be remembered that sexual dysfunctions are not all or nothing phenomena, but occur on a continuum in terms of frequency and severity. Comorbidity of sexual dysfunctions is common. Gregoire (21) reports that almost half the men with low libido also have another sexual dysfunction, and 20% of men with erectile dysfunction have low libido. The patient’s partner and their relationship probably have a more profound effect on sexual health than on any other aspect of health. Sexual dysfunction in men is not as complicated as in women and is usually associated with age and illness. Ideally male testosterone levels should be tested before beginning cancer treatment as a baseline indicator of a man’s normal level (62). Table 51.3 describes sexual dysfunctions and possible causes (21,35,38,63,64,65,66,67,68,69,70,71,72).

Men with colorectal cancer report more problems with sexual function related to their surgeries than women with similar treatment for similar diagnoses (73,74). Some studies show that partners of patients with cancer experience more psychological distress than their cancer-affected mate (75,76,77,78,79). Neese et al. (80) note that less than half of men with sexual dysfunction believed that their partners supported them in their efforts to find help.

Body image is a key aspect of sexuality and includes one’s feelings and attitudes about one’s body (18,81). Body image changes can profoundly alter feelings of attractiveness, an important aspect of sexuality (9). External changes that are visible to others as well as internal changes affect body image (18,82). Temporary body changes include the following:

Permanent body changes may have been temporary, but became permanent and affect body image and include the following:

Mitchell et al. (83) assert that mood can affect sexual functioning in a negative or positive way. Psychological issues that can alter sexual functioning include the following: