Psychosexual issues in advanced cancer

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Psychosexual issues in advanced cancer

• Dr Kate Bullen
• Psychology Department
• Aberystwyth University
• Wales, UK

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Scope

• Define the issues
• Identify the challenges
• Examine patient needs
• Consider specific examples gynaecological and
  prostate cancers
• Explore barriers to communication
• Suggest ways of improving clinical practice

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Learning outcomes

• Knowledge
• Understanding
• Share experience
• Opportunity for reflection

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Defining the issues

• Cancer/life threatening illnesses impact on all
  aspects of function

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Defining the issues

• Cancer challenges a sense of self Who I
  think I am
• Self concept includes a subjective evaluation
  relative to
• Body image
• Self esteem
• Social roles
• Reactions of others

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Defining the issues psychosexual function

• Sexual wellbeing encompasses sexuality and
  physical and psychological sexual health matters
• Multi-faceted and complex
• Interwoven with beliefs, stereotypical thinking,
  prejudice, assumptions
• Social constructions of sexuality influenced by
  age, gender, cultural beliefs

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Factors affecting sexuality in cancer
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Defining the issues psychosexual function

• In acquired/chronic illness psychosexual issues
  may include
• Low self esteem (loss of control loss of role)
• Inability/reluctance to engage in sexual activity
  (impaired function feeling unattractive/unloved
  inability to express feelings)
• Difficulty with existing relationships, or making
  new relationships

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Sexuality in cancer/palliative care context

• Variables affecting psychosexual issues
• Different issues at different stages of disease
  trajectory/cancer journey
• Dynamic interaction

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Examining patient needs

• Discussing sexual matters difficult for many
  people
• Research supports the importance of the issue
  (Bullen et al. 2009 Horden Street 2007
  Lemieux et al. 2004).
• Patients think sexual function should be
  considered as part of their care
• Will discuss their concerns if given appropriate
  opportunity
• Sexuality expressed in multiple ways not only
  about intercourse although may remain important
  aspect

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Examining patient needs

• For many patients/partners sexuality includes
• - Connectedness
• Intimacy
• Belonging
• Sharing
• Being able to maintain sense of being sexual
  requires
• Dignity
• Respect
• Opportunity

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Re-cap

• Advanced cancer challenges psychosexual function
  in, and for, diverse ways and reasons
• Not restricted to the physical aspects of
  function
• Complex and challenging aspect of care for
  practitioners
• Considered important aspect of care by patients
• Expectation that should be addressed by
  practitioners
• Specific examples illustrate the demands
• Possible ways to improve practice

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Gynaecological Cancers

• Lagana et al. (2001) reported the most frequently
  reported sexual problems include
• Pain
• Premature ovarian failure
• Changes in vaginal anatomy
• Emotional distress
• Body image (loss of fertility)
• Sexual self-concept
• Complex interaction between physical and the
  psychological leading to potential psychosexual
  problems

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Gynaecological Cancers

• Rasmusson Thome (2008) small scale
  qualitative study with 11 Swedish women
• Reported the most frequently reported sexual
  problems include
• Women had lack of knowledge about the body
• Sought conversations with sexual relevance
• Wanted
• Involvement of partners
• More in-depth knowledge
• Information given by competent/sensitive staff

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Prostate cancer

• Wittman et al. 2009 reported the most frequently
  reported sexual problems include
• Incontinence
• Impotence/erectile dysfunction
• Body image (hot flushes fatigue bone fragility
  weight gain loss of muscle mass)
• Reduced libido
• Similarities but distinctive differences to
  gynaecological cancers
• Ties with social construction/stereotype of
  gender

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Prostate cancer

• Bullen Chichlowska (in prep) small scale
  qualitative study with 8 UK couples (advanced
  PCa)
• Reported the most frequently reported sexual
  problems include
• Sense of loss frustration
• Body image concerns weakness hot flushes
• Heightened emotional responses/irritability
• Implications for maintenance of intimate
  relationships and concept of being male/manly
• Scoping exercise by UK Prostate Cancer Charity in
  2010 identified the importance of psychosexual
  concerns

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Barriers to communication

• Various challenges/barriers to effective
  communication
• Patient related issues embarrassment
  uncertainty
• appropriate language
• Environment physician factors (professionalism
  appropriateness skills the medical model).
  Space factors (suitable space for conversation
  privacy etc)
• Culture religious/ethnic considerations
  societal stereotypes and prejudice (sexual
  activity and age)

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Improving clinical practice

• Reflexive practice
• Overcoming prejudice/preconceived ideas
• Development of rapport
• Providing opportunities
• Development of appropriate skills
• Understanding the limits of competence
• In the UK the National Institute of Clinical
  Excellence (2004) recommendations for Palliative
  Care suggest a graded process from general to
  specific interventions

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Maintaining psychological health

• Biopsychosocial perspective

• Observation
• Communication
• Building rapport

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How to assess the problem?

• Clinical skills

• Psycho-metric approach

• Listening to patient
• Providing appropriate venue to allow open
  discussion
• Giving permission to speak
• Acknowledgement of importance of intimacy
• Non-judgmental attitudes
• Reflection on own feelings

• Questionnaires
• Finding the right materials
• Various possibilities
• Trial and error, or
• Systematic review
• Advantages and disadvantages

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Cognitive Behavioural Therapy (CBT) Principles
Identification of the concern
Generation of strategies
Implementation and evaluation
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Ex-PLISSIT specific model for addressing
psychosexual issues in chronic illness/disability

• Originally developed by Annon (1976)
• Expanded to include reflection (Taylor Davis
  2007)
• Four levels of assessment
• Helps healthcare professionals identify their
  role in assessment/evaluation of individual
  sexual needs
• Based on cognitive behavioural (CBT) principles

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Extended PLISSIT Model

• Four levels of intervention
• Permission (P)
• Limited Information (LI)
• Specific Suggestions (SS)
• Intensive Therapy (IT)

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Extended PLISSIT Model

• Permission giving normalises sexuality at every
  stage
• Not just initially, but throughout the process
• Use of open ended questions enable permission
  giving
• Many people with this condition have concerns
  about sexuality. Is there is anything you would
  like to talk about or ask?
• Many people experience impotence as a side
  effect of this drug. Is that something that you
  have experienced?

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Extended PLISSIT Model

• Sexuality is a dynamic concept changing with
  circumstances
• Reviewing and reflection is important for patient
  and practitioner
• Since we last spoke are there any other things
  you have thought of
• When we last spoke, you mentioned and we
  discussed . How has it been since then?

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Summary

• Discussing psychosexual/relationship concerns is
  challenging
• - for patients and practitioners
• Need to acknowledge own limitations be
  responsive to patient verbal and non-verbal
  communication
• - expertise is not achieved overnight
• Important to reflect within teams and share good
  practice
• Models such as Ex-PLISSIT can help to structure
  interventions

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Resources

• Comprehensive list of references available via
  Tove/Kirsten/website
• My contact details
• Kate Bullen (kab_at_aber.ac.uk)
• Thank you. Tak. Diolch yn fawr.