No Excuses--Talk to Your Patients About Sexuality After Cancer

Sexuality after cancer is an under-discussed topic between healthcare providers and patients, and nurses especially have an important role to play in raising the subject with patients, according to Anne Katz, PhD, RN, FAAN.

Katz, a clinical nurse specialist and certified sexuality counselor at CancerCare Manitoba, has made it her mission to educate healthcare providers about talking to patients about the effects of cancer on sexuality. At the PER^® 36th Annual CFS^® in New York City, she spoke to nurses about why and how these conversations should occur.¹

Why Have the Conversation?

Talking about the effects of cancer on sexuality is important to patients and their partners. However, it is not just about sex, Katz said, adding that sexuality involves ideas about body image, self-worth, comfort, and identity.

Yet, provider barriers—such as providers’ lack of knowledge, and in turn confidence; avoidance of assessment and interventions; conservative attitudes; embarrassment; fear of offending patients; denial of responsibility; institutional issues; and lack of awareness around guidelines–still exist. According to a 2011 study, 45% of individuals with cancer who participated in the study had never received information from an oncology provider about how cancer would affect their sex life.²

“This is malpractice.... We are failing our patients,” Katz said, adding that some oncology providers may see their role as just helping to cure patients of cancer, but this is in fact doing a disservice to their patients. Cancer affects many aspects of a patient’s life. Therefore, it is the job of the oncology nurse to be aware of all the sexuality-related effects, identify the issue, and help the patient through their journey.

Excuses, Excuses

Throughout her career, Katz has heard all types of excuses from nurses as to why they don’t talk to patients about sexuality and cancer. “Probably the number one reason nurses don't talk to patients about sexuality is: ‘I don't know enough about it. What if the patient asks me a question and I don't know the answer?' I think that's a terrible excuse,” Katz said, “because we are always asked questions that we don't know the answer to.”

Other excuses, she said, are that it is too embarrassing and that nurses are afraid of offending patients; however, nurses discuss embarrassing topics about bodily functions like hair loss, skin rashes, and diarrhea with patients all the time. Katz recommended for nurses to raise the topic in a compassionate, caring way so that patients will not take offense.

Framing the Conversation

While patients are being short-changed by the lack of conversation around this issue, nurses and other healthcare providers say it is not their job. “The oncologists think it's the nurse's job, the nurse thinks it's the social worker's responsibility, the social worker thinks it's the navigator's responsibility, and the patient is left with many unanswered questions.”

In these situations, it is the nurse’s role to identify when there is a problem and find help for the patient. To that end, Katz recommended two models that could provide a framework for guiding nurses through these conversations: the “CARD” and “5 As” models.

The first helpful model that nurses can use to raise the topic of sexuality is the CARD model:

• C: Practice an easy prompt beginning with “Cancer treatment can affect sexual health, which is important to many women and men, and to couples' quality of life.”
• A: Ask how the patient is doing, and if there are any issues they would like to discuss.
• R: Use resources and referrals and have these ready before having the conversation.
• D: Document that the conversation took place.

The 5 As model, based on a model used to encourage tobacco cessation, is a bit different: ask, assess, advise, assist, and arrange. To start, Katz suggested that nurses ask the patient a general question such as, "How has your relationship been since you started chemotherapy?” or, “How is your partner responding to you now that you are having radiation?”

Then, she added that nurses should assess the issue and find resources that can help, such as an endocrinologist, gynecologist, primary care provider, sexuality counselor, or family/marital therapists, so the conversation will flow smoothly.

Finally, nurses should arrange for follow-up with the patient to find out whether the sources that were recommended met the needs of the patient.

Validation and More

Often, patients with cancer are looking for validation that their sexual issues are not uncommon, even perhaps expected. They want to know that what they're going through is something that is common for others receiving the same treatment.

“As a sexuality counselor, I see people on referral, and not infrequently, a patient will walk into my office and say, ‘I have been experiencing x, y, and z. Do you know of anyone who has had a similar experience?’” Katz said. “And I say, ‘Absolutely. It is extremely common for women who are on aromatase inhibitors to have severe vulvar-vaginal dryness.’ And women will often say, ‘Ok. That's all I wanted to know.’”

Katz noted that nurses have the power to influence how their patients navigate their cancer experience, and that sexuality is a quality-of-life issue that should not be ignored. Therefore, nurses should raise the topic so that patients can be validated and know they are heard, and then refer the patients to appropriate resources for help, she concluded.

References

• Katz A. Cancer and sexuality: the nurse’s role. Presented at: PER^® 36th Annual CFS^®; November 7-9, 2018; New York, NY.
• Flynn KE, Reese JB, Jeffery DD, et al. Patient experiences with communication about sex during and after treatment for cancer. Psychooncology. 2012;21(6):594-601. doi: 10.1002/pon.1947. ncbi.nlm.nih.gov/pubmed/21394821. Accessed November 15, 2018.