A diagnosis of cancer compounds the complexities of AYA development. Sexual health, function, interpersonal relationships and self-image (physical and psychological) are all factors that have an impact on the development of self-esteem during the transition periods into and throughout early adulthood [43, 44]. Adolescent and young adults with a cancer diagnosis report a substantially reduced quality of life compared to their peers without a cancer diagnosis [34], particularly in areas of emotional and social functioning [45, 46]. Recent studies have begun to reveal the complexity of the effects cancer and its treatment can have on AYA sexuality beyond sexual functioning. Young adults with cancer may have problems with body image and poorer sexual self-concept and adjustments compared with healthy peers [47]. Common cancer treatments (chemotherapy, radiotherapy and surgery) impinge on AYA physiological, emotional, psychological and sexual well-being [48, 49] and also heighten areas of distress like pain, fatigue, depression and anxiety [50]. In their study exploring the psychosocial impact of cancer on newly diagnosed AYA cancer patients, Bellizzi et al. [51] found 40.4 % 15–20 year olds reported cancer had a negative impact on sexual function/intimate relationships. Although the cancer experience may disrupt, delay and complicate the process of sexual development it does not always bring it to a halt; sexual identities, desires and practices continue, and relationships show resilience [52].

Open and frank discussions about sexuality, sexual practices and intimacy are relevant and appropriate areas of psychosocial assessment when working with AYA cancer patients [53]. They are areas that should be revisited not only as the cancer pathway progresses (including palliative and end of life care) but also as the AYA matures during treatment and into survivorship; not all sexual behaviour during AYA is risky, but it is known to be a time of sexual experimentation. Adolescents and young adults need information and support to understand how their sexual behaviour (risky or otherwise) may need to be modified as a result of either their cancer or more likely its treatment.

Contraceptive and sexual health needs of AYA undergoing cancer therapy should be addressed as a separate issue from fertility preservation. The median age for first sexual intercourse is now 16 years in most industrialised countries, and over 50 % of young adults remain fertile after their cancer treatment [54, 55]. Provision of verbal, written, age-appropriate and relevant information should be freely available to AYA cancer patients in a variety of mediums and languages. Many younger patients may find it too confronting or personal to discuss this topic, so the response of professionals should be sensitive, non-judgemental and tailored to individual need of the patient. It is, however, important that professionals working in AYA cancer care receive adequate training on the potential legal, ethical, moral and boundary management issues they may encounter when dealing with sexual health concerns.

Removal from the context of their normal social and peer network by hospitalisation and decline in physical ability may impact on developing sexuality [44]. The loss of independence, reduced autonomy and forced dependence on parents and others for care and social and financial support reduce self-esteem and self-confidence [56]. The physical side effects of cancer can compound these losses as AYA lose their physical image of self and an alteration in the perception of how others see them. These concepts may individually or in combination potentially impair relationship formation/function, decrease dating opportunities and alter sexual function. Global effects on functional role may also delay education/training, limit lifestyle options and compromise future goals, i.e. partnerships and parenthood. For older adolescents and early young adults, cancer may not only limit experimentation with different sexual partners but also the experience of positive, sexually arousing, intimate sexual relationships that are necessary in order to build sexual self-esteem and confidence [57–59]. Studies show that AYA with cancer differ significantly from peers by reporting lower sexual experience, lower self-esteem and how the fear of being rejected may delay sexual experimentation, dating and consequently the formation of meaningful couple and sexual relationships [57, 60, 61].

After cancer, dating and relationship formation may also be affected by reluctance or fear of disclosure regarding their cancer history [62], body image and sexual difficulties caused by cancer. These can be caused by a combination of the physical impact of cancer, the side effects of treatment and psychological issues raised by or distinct from cancer. Sexual dysfunction is one of the most common and distressing consequences of cancer treatment [63, 64]. Although some sexual-related adverse effects are short term, many survivors face long-term effects such as treatment-induced menopause, altered gonadal function and altered body image [60].

Both experienced and novice professionals may experience confusion and dilemmas when faced with certain sexual health issues; adequate supervision and support for staff should be considered when planning such services. One of the most challenging areas for professionals can be responding to concerns or disclosure of abuse during work with AYA and their sexual health. Adolescents and young adults may experience a broad range of neglect or abuse intentionally or by omission from parents/carers, other adults, organisations or their intimate partners. Healthy relationships (regardless of sexual orientation) require respect, trust, communication and responsiveness between those involved. Many young people have not been taught or witnessed these skills, especially if they have grown up in a home, community or society where violence and exploitation occurs. Intimate partner violence (IPV) may include psychological or emotional violence, stalking, physical violence and sexual violence such as non-consensual sexual contact and rape [65], all of which can have a negative effect on health throughout life [66]. Likewise non-partner sexual abuse/violence should be considered. In a world where the global movement of people across and within countries can no longer be simply described as ‘business or pleasure’ and local populations become increasingly diverse, professionals need to be alert to concepts such as human trafficking and female genital mutilation (FGM).

Human trafficking is the recruitment and movement (by coercion, deception or abuse of vulnerability) across and within borders for the purposes of exploitation through forced sex work, domestic servitude and low-paid labor and it affects an estimated 2.5 million people worldwide [67, 68]. As this chapter is about sexual health, it may be natural to focus on young people trafficked for sex work; however, those trafficked into domestic or other work often experience sexual abuse and violence [67]. Healthcare providers are one of the few professionals likely to interact with people who have been trafficked [69]. All professionals working with AYA should receive training to recognise those who have been trafficked and on how to assess and respond to their social needs as well as their medical needs. The WHO defines FGM as procedures that involve partial or total removal of the external female genitalia or other injuries to the female genital organs for non-medical reasons. It is estimated that >125 million girls and women alive today have been cut in the 29 countries in Africa and Middle East where FGM is concentrated, most in childhood but some in adolescence or adulthood [70]. There is no medical benefit for FGM, and it is banned in many countries across the world; those working with young women with cancer should be aware of relevant processes and policies if they think young women are at risk of FGM or have had FGM and wish to seek psychological or medical support as a result.

Health professionals and patients alike continue to experience embarrassment in talking about the sexual consequences of treatment, resulting in a tendency to avoid such discussions in medical follow-up consultations [53, 101, 102, 113–115]. The ability to establish a discussion about how treatment may impact on the sexual function and confidence of a teenager or young adult may prove more challenging than discussions with older adults due to the developmental stage of the young person where they may not have established their sense of sexual identity, sexual self-esteem or confidence within the context of what are often transient/evolving relationships [25, 53].

Aubin and Perez [116] propose that clinical assessment of treatment-induced sexual concerns in this age group benefits from inclusion of information from the clinical interview, medical records and self-report questionnaires (PROMS), suggesting that a comprehensive assessment should address the following domains:

These authors also raise the importance of creating a direct and open communication style, similar to a life-coaching or mentorship approach, to work in partnership with AYAs to explore sexual concerns and deliver psycho-education whilst ensuring maintenance of clear and mutually agreed boundaries of privacy and confidentiality [116].