Sex after breast cancer

Many of us find it hard to talk about sex and it can be even harder after breast cancer. At the time of diagnosis, sex is the last item on a traumatic agenda and yet survival focuses on a part of the body that is associated very strongly with it. A woman learns that her life may depend on the removal of part or all of her breast. The impact of a partial or full mastectomy will be enormous for her.  She may wonder at the time how she will cope but the first priority is to stay alive, deal with ‘the rest’ later.

But ‘the rest’ can be far deeper, more emotionally challenging than she or her partner ever realized. Physical wounds will heal but the emotional, spiritual and sexual recovery from breast cancer can take much longer. The loss of a breast can threaten femininity, self image, sexuality and confidence in ways a woman may never have experienced before.  While most women will continue to enjoy sexual intimacy after breast cancer, others may find problems overwhelming and the consequences devastating.

‘I’ve lost a body part. I have no libido, am not having sex any more and I’m afraid if I do, my partner will reject me and I cannot cope with that - and I have the most outrageous hot flushes, mood swings, and then there’s the vaginal dryness!’ Not exactly dinner party conversation or topics others feel comfortable discussing, so issues surrounding sexual intimacy following breast cancer surgery and treatment can often remain invisible to friends and family. Well-meaning supporters say, ‘At least you didn’t lose a leg’, not realising the depth of hurt their words may cause.

Surgery and treatment can create physical and emotional changes for a woman that she may not fully understand, causing confusion, insecurity, sadness and grief, a loss of self confidence and belief in herself as a woman, often accompanied by a sense of shame, guilt, incompleteness and fear that she may never enjoy an intimate sexual relationship again. Emotional pain can be accentuated by physical changes - chemotherapy induced menopause (causing vaginal dryness, mood swings, loss of libido, general fatigue), discomfort and/or weakness of shoulder and arm, tenderness at the surgery site and other effects from radiation treatment.

A woman may grieve for the loss of her breast and sometimes feel she is no longer a ‘real’ woman. At worst, she may feel mutilated, violated, socially isolated and sexually unattractive. A woman not in a relationship may wonder, ‘Why would anyone want me now?’ If she does find someone, at what point would she tell him or her that she has only one breast? Wait until the heat of the moment and say, ‘Surprise!’ or tell beforehand and risk her potential lover running for the hills. Sadly, some relationships falter and do not withstand the emotional onslaught of cancer.

Most women do not experience all of these issues but many will encounter some problems that can be worked through successfully over time. Partners, friends, family and other women who have experienced breast cancer can help. Raising issues with a surgeon or oncologist can be a good place to start but it may be up to a woman to initiate the discussion.

New Plymouth sex therapist Jane McPherson believes open and honest communication can help couples find ways to cope sexually with the changes. The impact of cancer on partners is often overlooked and including them, every step of the way, can help their understanding of the experience. Compromises can be reached to maintain and enhance a loving relationship. ‘The most important concept to understand,’ says McPherson, ‘is that a woman needs to define her own sexuality and sexual pleasure and come from that place of personal respect and expression. Ownership of one’s sexuality is the key to confidence – and that can be very attractive!’ A woman may only want to be held, cuddled and have the opportunity to be listened to and nurtured by a warm supportive partner. This may work well for her partner too who will also be dealing with stress and fear.

McPherson also feels society identifies the breast too strongly with sex and that there is so much more to a woman than her breasts. ‘Equating ‘breast’ with ‘sex’ is like having only one flower in the garden when there are thousands of beautiful and colourful flowers out there.’ Most women find their partners to be loving and supportive throughout breast cancer and the relationship is strengthened by the experience. A woman progresses to discover a new identity and self worth, a surprising strength, wisdom and diversity of character. ‘Women begin to see themselves as complete flowers,’ says McPherson, ‘not just one petal.’

But problems seldom solve themselves. If the journey of breast cancer becomes exceptionally difficult, assistance from a professional may be essential. Some counsellors specialise in grief and loss and a relationship counsellor can help a woman and her partner find ways to deal with the changes and pressures a breast cancer diagnosis can bring. Specific sexual problems may arise within a relationship and a natural reluctance to discuss such private issues should not prevent couples from seeking help from a sex therapist.  These professionals help to restore and nurture sexual confidence that can be damaged by the experience of breast cancer.

Talking about sex

Talking about sex is good for us, especially when an experience with breast cancer may have created problems with sexual intimacy and self image. However, New Plymouth sex therapist Jane McPherson admits this may not always be easy.

‘Open discussion and exploration of women’s sexuality has, historically, not been encouraged,’ she says. ‘Even though our society has done much to liberate women from this hangover we often do not see ourselves as sexual creatures. Couples can find intimate subjects difficult to talk about at the best of times and when there is trauma, it can be much harder.’

Feelings of loss and grief can follow a breast cancer diagnosis and working through them is a necessary process. Talking it out with someone trustworthy – a close friend, partner or a counsellor – can help identify the problems, process them and allow healing to begin. ‘There is no avoiding the grieving process,’ says McPherson. ‘It’s important to have someone who can meet you wherever you are – join you in your internal world – and move through it with you. There is nothing like having someone who will shout, throw things and get angry with you! It’s all about communication, sharing thoughts and feelings that are often better out than in.’

And what about sex? Deciding to be sensual or sexual in the midst of grief may not happen overnight, but McPherson believes it will happen. ‘It’s a cognitive shift,’ she says, ‘a conscious decision that will arrive in its own time. It’s a decision to be gorgeous, sexy, to find other ways to feel good about yourself and accept that you are still a wonderful, vibrant woman. It’s about allowing yourself to enjoy and love who you are and understand that life can still be fantastic. Little treats along the way reinforce this – pampering, new clothes. It’s not all about the breasts! Making this decision to be sensual is important in stimulating sexual energy’.

However, feelings of being ‘incomplete’ or ‘no longer a real woman’ may persist for some time and can have an ongoing impact on how a woman feels about herself sexually. ‘A woman who identifies with her own sexuality and wants sexual energy in her life is more likely to have internal dialogue supporting her own beliefs in her attractiveness,’ says McPherson. ’She will be open and playful around sex and her self esteem won't be reliant on a partner’s validation. It is important to her to feel right inside herself and she sets scenes and conditions that help to express these feelings. This is the key to being a vital, sexy, gorgeous woman. It is the enjoyment of one’s own sexual energy that is important and this can be expressed through our senses in a number of different ways – perhaps by dancing or music, clothing and so on.’

McPherson is the first to admit that the issue of self image post surgery can be complex. ‘How we think we look isn't necessarily how others see us at all,’ she says. ‘A fear of rejection may intensify a negative body image and exacerbate the situation.’ Some women may need professional help to regain confidence. McPherson believes women should be given ample time to make choices about breast reconstruction or a prosthesis. ‘Women undergoing surgery within the public system should not be pressured to choose reconstruction at the time of their initial breast cancer surgery if they are unsure,’ she says. ‘A woman is frightened and focused on survival – then she needs time to grieve and work through her feelings, so reconstruction should be offered later as an option. It’s part of the healing process.’

A heterosexual societal myth in our culture depicts males as the holders of all sexual knowledge. ‘Males are the ‘sexperts’, says McPherson. ‘There is an acceptance that the male need for sex has priority over the female need for communication. If the male is having great sex he will then feel loved and this will enable him to fully connect with his partner and his own inner world. Women are socialized into placing the needs of others before their own. They are the relationship caretakers and will take on the responsibility for their man's sexual pleasure.’

The majority of women have wonderful, supportive partners who are not at all threatened by the loss of her breast. However, in extreme cases, some men go into a state of shock. Such relationships may have been troubled before breast cancer and the stress of the diagnosis and treatment is too much. Men may display radical behaviour that is completely out of character. For example, they may reject their partner by leaving her or not wanting to touch her. They may emotionally deregulate and become impulsive. In such rare situations, McPherson urges women and their partners to seek professional help.

Chemotherapy and hormonal treatments can induce a premature and sudden menopause.  One of the most profound symptoms associated with menopause is loss of libido. A woman may lose interest in sex altogether. ‘The brain is the biggest sex organ,’ says McPherson. ’Orgasm during sleep because of dreams is an example of its power.’ Stimulating the brain in a different way may arouse sexual desire and discovering this can require effort and energy. The stimuli may include things that a couple have never tried or thought of: erotica, sex ‘toys’, a different type of foreplay (taking more time with prolonged stimulation), massages and loving caresses. ‘It is important to communicate to your partner what is working for you,’ says McPherson, adding that a woman should not be pressured in to full on sex until she is ready and this may take patience and commitment from both. ‘Some of the stimuli may not be 100% sexual,’ she adds. ‘Dancing, watching the waves roll on to the beach, setting a romantic scene with candles, music and quiet conversation. Women always want their men to talk to them but often ‘always’ becomes ‘sometimes’. Make your man talk to you! This can be very romantic!’  Other physical symptoms of menopause that affect sexual activity – vaginal dryness, thinning of vaginal wall and discomfort during sex – can be largely dealt with by a good doctor.

A single woman who has experienced surgery for breast cancer may wonder when to ‘tell’ a prospective partner that she has only one – or no – breasts. ‘The sooner the better,’ advises McPherson. ‘It is important that in any serious relationship you feel you can tell this person anything – being open and honest is vital. If you tell and the person cannot handle it, then quite possibly you wouldn’t want to be with them anyway.’ Harbouring ‘the secret’ can often add power to it and the issue of physical changes post surgery becomes more serious to a woman than it necessarily would be to a potential partner. So once again, communication is the key. ‘Finding the energy for life anew after recovery from breast cancer can be very attractive,’ says McPherson. ‘Some women feel more independent, self aware and confident, sensual and sexual.’

Time, understanding, patience and communication will help restore sexual confidence but if problems cannot be solved, seek professional help. ‘Sexuality adds colour, depth and spice to life,’ says McPherson, ‘and a woman needs all those things in her life after breast cancer!’