Sex is that one word that can mean and feel so different depending on the context of our lives.

As young teenagers, the word may fill us with a sense of intrigue and excitement; as adults hammering through life, some of us may find it a source of pleasure while others may utilize it to further the meaning of a relationship, and for some of us it may serve as a means to produce children. While the meaning and personal significance of the natural act of sex may change, what probably won’t is the drive and innate need for sex, which to most of us is almost is as important as satisfying our hunger, thirst, or sleep.

While we may each engage in sex for different reasons, our attitudes about sex can be vastly different - often shaped by our experiences, gender identity, sexual preferences, etc.

No matter what our meaning of sex is, there are many situations that can affect our sexual health, and one of these is cancer. It affects all facets of one’s being. One’s physical and mental state is affected and that can have consequences to ones’ personal and familial life. While these challenges may be acknowledged and discussed openly with loved ones, the subject of sex is sometimes tabooed. To approach the subject with a trusted friend, loved one, or doctor may seem unimportant compared to the other challenges of living with cancer. To express desire or the absence of desire with your partner may seem like it should be at the bottom of one’s priority list. Are the natural desires, feelings, physical and emotional needs that were flourishing before a diagnosis expected to be safely put in a drawer to never be opened again?

Many of you may have felt this while going through cancer treatment, either as the partner with cancer, or the loved one who worries about the individual going through this challenging phase.

This article aims to address the myriad of experiences and challenges that men face with a cancer diagnosis and possible ways to maintain or reignite a healthy sexual life.

Among men, prostate cancer is the most common and is usually thought of as the dementor of sexual life. It is important to understand the role that different cancer treatments have for different phases of intimacy.

Cancer and its diagnosis and treatment can affect sexual desire and response.

Often after a diagnosis, individuals may report decreased desire, as one’s focus on getting better. Associated conditions like depression and anxiety can also decrease sexual desire. Some treatments that alter hormonal balance may also affect sexual arousal.

The treatment method that is used can also affect one’s ability to have an erection, as well as its duration and strength. Some men may be able to have an erection but may not find it enough for penetration. Cancer treatment can interfere with ejaculation by damaging the nerves that control the release of semen or sometimes its production which may result in dry orgasms or ejaculation without semen. Dry orgasms may not feel

as pleasurable to some men, while some report increased sensitivity. However, most of these side effects can be minimized through available treatments.

The psychological effects of these outcomes can be far-reaching and are often ignored, and we shall shed light on it in the following section.

Feeling Blue?

Research shows that intimacy and a healthy sexuality help individuals better cope with cancer and its diagnosis. Common feelings and experiences that are faced by individuals with cancer that are often overshadowed by the weight of the diagnosis itself include:

Fear, Low Self Esteem, and Helplessness:

Fear of losing one’s ability to have a normal sexual life is the first response an individual might feel in response to going through a cancer diagnosis and its treatment. The following questions might be common:

“Will I lose my ability to perform?”

“Will I have to undergo surgery that may leave me impotent?”

“What if I can no longer have an erection?

“Will I still be a desirable partner?”

While our heightened fears can definitely affect our ability to cope with the situation at hand, it is important to note that much of these concerns have very little medical evidence of happening.

Society

A lot of importance is placed on sex and its expression. If we feel that threatened we might internalize the notion that our sexual performance is the only measure by which the world values us. We might find ourselves asking questions like “Will I be attractive anymore? “Will I be liked by my partner?” “Will I be able to ever orgasm again?” “Will I ever be able to go on a date again?”

Lack of knowledge and tabooed conversation with your doctor and a lack of standardized care for sexual health can make one feel helpless. This may come out as statements or questions like“My life is over, I cannot do anything.” “What am I going to do?” “I think my life will never be the same again.” I am not me anymore, what is happening? “When will this be over? “Will I ever be normal again?”

Deteriorating Relationships and Mental Health

A life-altering diagnosis, coupled with fear about the future and low self-esteem is bound to affect communication with one’s partner. This may start as miscommunication leading to an uncomfortable altercation which may lead to the inability to experience intimacy, lack of pleasure, or warmth from your partner. And this might lead to a vicious cycle, making us feel alone in the one journey where we most want and need support.

These feelings sometimes can be overwhelming and may result in significant mental health issues, which can inhibit one’s recovery. It is also important to note that the treatment itself can induce a lot of mental health issues that can then be worsened by issues of self-esteem and sexual performance.

As men, you may have encountered performance anxiety previously to some degree. This may be heightened during treatment or even after its completion, where constant fears of satisfying your partner just like before looms overhead. Anxiety is actually a deterrent to having a healthy sexual life. If you already are fearful and then factor in treatment side effects that impair one’s performance ability, it makes us more vulnerable to these negative experiences. In some cases, it can lead to an aversion to intimacy or poor sexual response which can affect one’s well-being.

Strategies to Reduce Treatment Effects on Sexual Health

Talking to your treatment team:

The most important step to set the foundation for the course of treatment is loosening the stigma around sexual health. Make an appointment with a member of your healthcare team to discuss possible hurdles and potential solutions regarding sexual health before treatment if possible.

Asking questions that are important to you is a crucial part of the discussion when making treatment decisions.

Communication with your partner:

Talking with your partner about what may change or what has changed in your sexual life will set reasonable expectations. Sometimes, it can be helpful to start by talking to each other about your feelings, wishes or concerns about non-sexual topics before you start talking about sex.

The following statements might be useful as you transition the conversation to one about your sexual life “I have something to say, but I find it difficult to talk about.” “You may have noticed that I’ve been avoiding situations where we might end up being intimate or having sex.” “You don’t seem to be in the mood for sex lately. Is there anything you would like to talk about?” “Have you noticed that we’ve fallen into a routine when it comes to sex? “Do you ever think about us being more adventurous?”

Communication with your partner should not be limited to conversations related to intimacy as including your partner in any decision about therapies, treatments, or devices will allow him/her to become an active partner in your care as well. Emotional closeness and sexual sharing are ways a couple can feel closer during the stress of an illness. It's important for your partner to understand the procedures and discuss any fears or questions with you and/or the health care team.

Overcoming anxiety about sex and dispelling sexual myths:

Cancer-related symptoms or treatment side effects may impact your ability to be as spontaneous as you once were in the past. The most important thing is to be open about

the topic with your partner and ensure you have a relaxed time together. Masturbation is not a required step in resuming your sex life, but it might help. It can also help you find out where you might be tender or sore, so you can let your partner know what to avoid. It can also be helpful to ask “What do I do that you like?” or “Let me tell you what you do that I like” to keep those channels of communication open.

Common sexual myths

• Sex is only for the young, healthy, and beautiful
• Erections, penetration, and orgasm are necessary to feel sexually satisfied
• Cancer treatment has irreversible effects
• Sex may make cancer worse or increase the risk of it coming back
• Sex interferes with treatments

Myths such as these can end up affecting your perspective about sex and give you a distorted view. A healthy view is one that sees sex as an act of mutual intimacy and emotional bonding rather than an obligation that must be fulfilled.

Empathetic sexual activity with your partner

The good news is that you can learn how to feel pleasure during and after cancer treatment. It helps to take time to get to know what or where one’s ‘on and off switches’ are for sexual arousal during and after treatment. Surgical sites, areas around stomas, and scar tissue often feel uncomfortable, numb, or even painful. Getting back to being intimate with your partner may help you feel more confident

In addition, modify sexual activity to conserve energy by considering different positions, aids, and masturbation as strategies that may make sex more comfortable and enjoyable.

• Intimacy and maintaining sexual health can be more challenging in people who are single. They may live alone and/or far away from family and friends and any form of intimacy
• They may be dating or thinking about getting back into the dating scene. This can lead to worry about how a future partner might react when they learn about their cancer or that a body part has been removed, or if there are fertility problems.
• They might be newly single after a relationship that was going on before their diagnosis and/or treatment

To start dating again is a personal choice that can be affected by a multitude of factors. To share your journey or cancer history is also a personal choice and there are no right and wrong decisions.

Sex and intimacy are not everything but it is something and we all deserve a little something.

*Sharika Amin is a licensed Clinical Psychologist working in Kashmir with Doctors Without Borders.

Sharika received her MPhil in Clinical Psychology at Dr. Ram Manohar Lohia Hospital (PGIMER) and Masters in Clinical Counseling and Applied Psychology at Delhi University.  We thank Sharika for volunteering and helping the GRACE community!