Assessment of Sexual Function in People With Cancer
General Factors Affecting Sexual Functioning Evaluated in Assessment
Current sexual status
Premorbid sexual functioning
Psychosocial Aspects of Sexuality
Medical Aspects of Sexuality
No clear guidelines address sexuality during the stages of disease and its treatment. When therapeutic decisions are being made, providers should offer education and information to patients, ideally with the partner present, regarding known risks of sexual morbidity associated with cancer treatments. Oncology professionals should assist patients and their partners by asking specific open-ended questions to validate the importance of sexual health concerns, thus providing an environment in which the patient and couple are encouraged and feel safe to express personal concerns. Assessment should be sensitive to the subtle ways in which changes in sexual function affect men’s self-image and masculine identity. Providers should examine their own thoughts and feelings regarding sexuality. When providers are not comfortable addressing issues of sexuality, their patient’s concerns should not be ignored or dismissed. Referrals should be offered to alternate resources. Although some patients may not want to discuss their sexual health, providers should at least offer the option, conveying that sex is an appropriate topic to cover during future visits.
Because sexual function is one important aspect of quality of life, the follow-up oncology visit is a key opportunity for health care providers to assess whether a cancer patient is experiencing sexual problems. Although it would be ideal if an oncologist carried out the sexual assessment, time constraints and lack of training or comfort in discussing sexual issues often interfere with this goal. Furthermore, many people who have finished their cancer treatment have their routine follow-up care with a primary practitioner rather than an oncology specialist. At least in oncology settings, it may be helpful to designate and train a member of the team, such as an oncology nurse or social worker, as the expert on sexuality issues. That provider can take responsibility for asking about a variety of quality-of-life issues, including relationships and sexuality. A minimal sexual assessment might consist of asking the following question: “Many cancer survivors notice changes or problems in their sex lives after cancer treatment. Do you have any problems or concerns related to sexuality?” Simple problems can be handled with immediate reassurance or advice, but the oncology team should also build a network of specialists willing to help cancer patients with sexual issues, including mental health professionals trained in sex therapy, gynecologists familiar with women’s concerns about hormone replacement or dyspareunia, urologists who specialize in treating male sexual dysfunction, and infertility specialists who can treat younger patients who are interested in having children.
The literature contains a number of articles and resources that address sexual assessment, with many specific to cancer patients.[2-5] The Kaplan model provides a useful interview guide to evaluate sexual problems in healthy and medically ill individuals, focusing on the chief complaint, sexual status, psychiatric status, family and psychosocial history, relationship assessment, summary, and recommendations. Kaplan’s model has been applied to oncology settings, with brief descriptions of the assessment for each part of the interview.[3,7] The PLISSIT (permission, limited information, specific suggestions, and intensive therapy) model  is another model of assessment and intervention commonly used as a framework for sexual rehabilitation in cancer care and medical illness.[5,9-12]General Factors Affecting Sexual Functioning Evaluated in Assessment
Once a possible sexual problem has been identified, the most important assessment tool for the oncology health provider is a clinical interview with an individual man or woman, or with a couple. The following brief list of factors known to impact current sexual functioning should be included in an assessment; the patient’s specific sexual concerns or needs at the time dictate the approach and content of the discussion.Current sexual status
In the evaluation of an individual’s sexual function, the initial phase of assessment serves to clarify the nature of the individual’s problem and/or complaint. A variety of aspects of current sexual function should be addressed, including the frequency of experiencing spontaneous desire for sex; ease of feeling subjective pleasure with sexual stimulation; energy for sexual activity; and signs of physiological arousal, including the ability to achieve and maintain a firm erection for a man, and vaginal expansion and lubrication for a woman. The ability to reach an orgasm is another important measure of sexual function. It is helpful to ask what types of sexual stimulation can trigger an orgasm (i.e., self-touch, use of a vibrator or shower massage, partner caressing, oral stimulation, or intercourse). Pain in the genital area that occurs with sexual activity should be described in detail: “Where is the pain? What does it feel like? What kinds of sexual activity trigger it? Does it happen every time? How long does it last?” When these lines of inquiry elicit a sexual problem, the interviewer should ask when the problem began, especially whether a cancer diagnosis or particular treatment occurred close in time to onset of the problem. Because many people who have cancer take prescription medications that can interfere with sexual function, including antihypertensives, antidepressants, or psychotropic medications, the interviewer should find out whether a new medication or change of dosage was prescribed at the problem’s onset.Premorbid sexual functioning
An individual’s past (pre-illness) sexual development, preferences, and experience are vital to assessment of sexual status. The level of sexual functioning before diagnosis and treatment, interest, satisfaction, and importance of sexual functioning in the relationship all influence the patient’s potential distress related to current sexual status. Individuals who have already experienced sexual difficulties may be especially vulnerable to the effects of treatment. Clinicians should be careful not to make assumptions regarding the patient’s previous sexual experience or the importance of sexual expression.Psychosocial Aspects of Sexuality
The patient may or may not have an available partner at the time of diagnosis. Sexuality should be taken no less seriously by the clinician or the patient if there is no partner. For patients with a partner, the clinician should consider and discuss the duration, quality, and stability of the relationship before diagnosis. Additionally, as many patients fear rejection and abandonment, the clinician should inquire about the partner’s response to the illness and the patient’s concerns about the impact of treatment on the partner.[15-17] Partners share many of the same reactions as patients in that their most significant concerns typically relate to loss and fear of death. Moreover, the partner’s physical, sexual, and emotional health should be considered relative to his/her previous and current sexual status in a complete assessment. A clinician should recognize that most couples experience difficulty discussing sexual preferences, concerns, and fears even under ideal circumstances and that sexual communication problems tend to worsen with illness and threat of death.Psychological status
The affective spectrum during cancer treatment ranges from disbelief to clinical depression and typically changes over time. Anxiety and depression are the two most common affective disruptions among patients with cancer and both have been found to have deleterious effects on sexual functioning.[3-5,7,18] A clinician should be aware of current mental status and any history of depression or other psychiatric disorder, previous psychotherapy, treatment with psychotropic medication, and/or hospitalizations. Current use of psychotropic medications should also be reviewed with respect to impact on sexual function. Cancer treatment can produce changes to the body that negatively impact body image and self-esteem.[4,5,19] Commonly, patients have difficulty seeing themselves as sexually attractive during and after treatment. Identifying body-image disturbances is important to incorporate into goals of care and rehabilitation. Frequently, the couple experiences changes of social roles during treatment. An individual’s identity and sense of worth may be threatened when role changes occur.[4,15] The partner’s participation in the patient’s physical care often negatively impacts feelings of sexuality. Younger couples, more than older couples, may be vulnerable to problems with playing alternative or new domestic roles and experiencing the myriad life and financial stressors associated with treatment.
To better illustrate the relationship between sexual health and psychological health, numerous sexual, physical, and psychological measures were examined in a cross-sectional study of 186 partnered women who had gynecologic cancers. Diagnoses included endometrial, ovarian/peritoneal, cervical, and vulvar cancers. Most women had stage I to stage III cancers and were white, college educated, and married. Their mean age was 55 years. Sexual morbidity was defined as a summed score of the following five factors:
- Appearance/desire (seven items).
- Satisfaction/activity (six items).
- Arousal (seven items).
- Lubrication (four items).
- Pain (four items).
Sexual morbidity was moderately and significantly correlated with depression (r = 0.34) and traumatic stress (r = 0.30). It was also low-moderately correlated with body image (r = 0.25); and with both components of the Medical Outcomes Study—Short Form 12: physical health (activity interference/general health, r = 0.34) and mental health (calm/downhearted, energy, emotional problems, r = 0.25). Sexual morbidity was moderately to strongly and significantly correlated with fatigue (r = 0.44). Sexual morbidity also contributed uniquely and significantly to depression, accounting for 48% of the variance; body change stress, 26% of the variance; and psychological quality of life, 31% of the variance. The authors concluded that addressing sexual morbidity may improve psychological health.Medical Aspects of Sexuality
The clinician should ascertain past medical history with a particular emphasis on other concurrent medical illness for which the patient is receiving treatment. Comorbidity contributes to risk of sexual dysfunction and additional decrease in social and role functioning, mental health, and health perceptions. Medical illnesses that impact the endocrine, vascular, and nervous systems are all known to have a potential deleterious effect on the sexual response cycle.[13,21,22] Diabetes, hypertension, vascular disease, multiple sclerosis, and many other disorders impact sexual function, particularly the quality of erections in men. Two textbooks extensively review the impact of chronic illness and disability on sexual function.[13,22] In addition, with the growing body of evidence demonstrating the severity and chronicity of fatigue in cancer survivors, the co-existence of cancer-related fatigue may be a major barrier. In a descriptive cross-sectional study, fatigue was significantly and moderately correlated with all sexual functioning and satisfaction measures in 175 women with gynecologic cancer. Therefore, assessing and addressing cancer-related fatigue, even in long-term survivors, is important.
Lifestyle factors, including smoking and substantial alcohol consumption, are also risk factors for sexual morbidity. In men, cigarette smoking may induce vasoconstriction and penile venous leakage. In large amounts, alcohol is a strong sedative-hypnotic, producing decreased libido and transient erectile dysfunction.
Pharmacologic treatment for cancer and chronic illness in general is often a necessary and integral component of health maintenance. Some pharmacologic treatments, however, may have direct or indirect deleterious effects on sexual function through multiple physiologic and psychologic pathways. Pharmacologic agents that may negatively affect sexual response are addressed in the section on pharmacologic effects. A number of resources provide further delineation of the mechanisms for changes in sexual function associated with these agents and include listings of specific medications and known effects on sexual function.[4,24-26]
Brief questionnaires that measure sexual dysfunction may be helpful, particularly when screening larger groups of cancer patients for sexual dysfunction or when conducting research on sexuality as an aspect of quality of life. The International Index of Erectile Function (IIEF, 15 items) and the Brief Male Sexual Function Inventory (BMSFI, 11 items) are well-validated scales measuring aspects of sexual function and satisfaction in men.[27,28] Sexual problems can also be identified with a briefer five-item scale, the Sexual Health Inventory for Men (SHIM), which is a validated self-report scale that can be used to identify erectile dysfunction in a variety of clinical settings. For women, there are several brief measures with established psychometric properties that assess sexual functioning and satisfaction: the Brief Index of Sexual Functioning for Women (BISF-W, 22 items), the Sex History Form (SHF, 46 items), the Changes in Sexual Functioning Questionnaire (CSFQ, 35 items), the Derogatis Interview for Sexual Functioning (DISF/DISF-SR, 25 items), the Female Sexual Function Index (FSFI, 19 items), and the Golombok-Rusk Inventory of Sexual Satisfaction (GRISS, 28 items).[13,29,30] These scales vary in their reliability, validity, method of attainment (i.e., patient vs. clinician rates; structured vs. semistructured), type and number of symptoms assessed, and time frame of assessment. To accurately reflect changes over time, one must obtain systematic assessment of premorbid, baseline, and follow-up levels of sexual function and satisfaction.
In addition to paper-and-pencil self-report measures of sexuality, some medical evaluations of the adequacy of the physiological response are available. For men, some of the more useful evaluations include the Rigiscan, a computerized electronic instrument that measures the adequacy of nocturnal erections; penile ultrasound studies to document hemodynamics of erection; and hormonal assays. In women, the use of the vaginal maturation index to measure estrogenization, a careful pelvic examination to identify sources of pain that occur during sexual activity, and hormonal assays are most common. More sophisticated measures of vaginal blood flow or sensory thresholds have been studied but have not gained wide acceptance.
Review of the literature highlights the need for prospective studies with longer-term follow-up, validated measures, and larger sample sizes. In particular, issues of sexual recovery in women have received too little clinical attention and research.References
- Bokhour BG, Clark JA, Inui TS, et al.: Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction". J Gen Intern Med 16 (10): 649-55, 2001. [PUBMED Abstract]
- Lamb MA, Woods NF: Sexuality and the cancer patient. Cancer Nurs 4 (2): 137-44, 1981. [PUBMED Abstract]
- Roth AJ, Carter J, Nelson CJ: Sexuality after cancer. In: Holland JC, Breitbart WS, Jacobsen PB, et al., eds.: Psycho-oncology. 2nd ed. New York, NY: Oxford University Press, Inc., 2010, pp 245-50.
- Schover LR: Sexuality and Fertility After Cancer. New York, NY: John Wiley and Sons, 1997.
- Lamb MA: Sexuality and Sexual Functioning. In: McCorkle R, Grant M, Frank-Stromborg M, et al., eds.: Cancer Nursing: A Comprehensive Textbook. 2nd ed. Philadelphia, Pa: WB Saunders Co, 1996, pp 1105-1127.
- Kaplan HS: The Evaluation of Sexual Disorders: Psychological and Medical Aspects. New York, NY: Brunner/Mazel Inc, 1983.
- Auchincloss S: Sexual dysfunction after cancer treatment. Journal of Psychosocial Oncology 9 (1): 23-42, 1991.
- Annon JS: The Behavioral Treatment of Sexual Problems. Vol 1. Honolulu, Hawaii: Enabling Systems, Inc, 1975.
- Penson RT, Gallagher J, Gioiella ME, et al.: Sexuality and cancer: conversation comfort zone. Oncologist 5 (4): 336-44, 2000. [PUBMED Abstract]
- Gallo-Silver L: The sexual rehabilitation of persons with cancer. Cancer Pract 8 (1): 10-5, 2000 Jan-Feb. [PUBMED Abstract]
- Sipski ML, Alexander CJ: Impact of disability or chronic illness on sexual function. In: Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 3-9.
- Waldman TL, Eliasof B: Cancer. In: Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 337-354.
- Schover LR, Jensen SB: Sexuality and Chronic Illness: A Comprehensive Approach. New York, NY: The Guilford Press, 1988.
- Talcott JA, Manola J, Clark JA, et al.: Time course and predictors of symptoms after primary prostate cancer therapy. J Clin Oncol 21 (21): 3979-86, 2003. [PUBMED Abstract]
- McNeff EA: Issues for the partner of the person with a disability. In: Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 595-616.
- Stead ML: Sexual function after treatment for gynecological malignancy. Curr Opin Oncol 16 (5): 492-5, 2004. [PUBMED Abstract]
- Wimberly SR, Carver CS, Laurenceau JP, et al.: Perceived partner reactions to diagnosis and treatment of breast cancer: impact on psychosocial and psychosexual adjustment. J Consult Clin Psychol 73 (2): 300-11, 2005. [PUBMED Abstract]
- Wise TN: Sexual functioning in neoplastic disease. Med Aspects Hum Sex 12: 16-31, 1978.
- Whipple B, McGreer KB: Management of female sexual dysfunction. In: Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 511-536.
- Levin AO, Carpenter KM, Fowler JM, et al.: Sexual morbidity associated with poorer psychological adjustment among gynecological cancer survivors. Int J Gynecol Cancer 20 (3): 461-70, 2010. [PUBMED Abstract]
- Lue TF: Contemporary Diagnosis and Management of Male Erectile Dysfunction. Newton, Pa: Handbooks in Health Care, 1999.
- Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997.
- Carpenter KM, Andersen BL, Fowler JM, et al.: Sexual self schema as a moderator of sexual and psychological outcomes for gynecologic cancer survivors. Arch Sex Behav 38 (5): 828-41, 2009. [PUBMED Abstract]
- Crenshaw TL, Goldberg JP: Sexual Pharmacology: Drugs That Affect Sexual Functioning. New York, NY: WW Norton & Company, 1996.
- Weiner DN, Rosen RC: Medications and their impact. In: Sipski ML, Alexander CJ, eds.: Sexual Function in People With Disability and Chronic Illness. Gaithersburg, Md: Aspen Publishers, Inc, 1997, pp 85-118.
- Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther 34 (876): 73-8, 1992. [PUBMED Abstract]
- Rosen RC, Riley A, Wagner G, et al.: The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49 (6): 822-30, 1997. [PUBMED Abstract]
- Rosen RC: Evaluation of the patient with erectile dysfunction: history, questionnaires, and physical examination. Endocrine 23 (2-3): 107-11, 2004 Mar-Apr. [PUBMED Abstract]
- Althof SE, Rosen RC, DeRogatis L, et al.: Outcome measurement in female sexual dysfunction clinical trials: review and recommendations. J Sex Marital Ther 31 (2): 153-66, 2005 Mar-Apr. [PUBMED Abstract]
- Meston CM, Derogatis LR: Validated instruments for assessing female sexual function. J Sex Marital Ther 28 (Suppl 1): 155-64, 2002. [PUBMED Abstract]
- Schover LR, Montague DK, Lakin MM: Sexual problems. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 5th ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1997, pp 2857-2872.