Staying Close after Cancer

“Women often shut down emotionally from their partners [after a cancer diagnosis] for a number of reasons,” says Maureen Ryan, sex therapist and nurse practitioner. “Maybe they’re scared; maybe they’re afraid of what’s to come. So they shut down and build a wall against intimacy.”

It makes sense. Survival has suddenly become a priority. You’re faced with complex decisions, a long and difficult treatment with a big question mark at the end. You may already be stretched emotionally and physically with a career and children at home, and maybe other obligations as well. The demands of a relationship seem overwhelming.

Sex? Fuggedaboudit.

While you probably won’t be interested in sex for a while after treatment, staying connected—maintaining the bonds of intimacy—with your partner is critical. “Studies show that if you had a rewarding sex life pre-cancer, that’s the best indicator about your quality of life post-cancer,” Maureen says.

And if you didn’t, maybe this illness will be the catalyst that allows you to focus on what’s important as a couple. In a speech, sex therapist Emily Harrell points to a Canadian study of breast cancer survivors that found “almost half the couples felt the cancer brought them closer.”

Here are suggestions from doctors and therapists for keeping the flame alive through the tough times:

Talk. This is such a tired bromide, but without communication, what do you have left? Set aside time to talk when you usually feel good and are without interruptions—no cell phone, visitors, or television. You each need to share your thoughts, fears, and anxieties. You need to talk about decisions. You need to explain what you need. If either partner shuts down, the other will feel rejected and isolated. This is a fragile time. You need all the support you can get.

Talk about sex—how you feel about it, what feels good, and what you can’t tolerate right now. “It’s important to tell your partner that even if you don’t want [sex] right now, that you’d like to regain your desire again,” Emily says. “You’re hoping to one day feel the desire to be intimate again.”

And don’t forget to talk about the good stuff. “I think the biggest thing is not letting the cancer consume the relationship,” Emily says. “This can… happen to a lot of couples. Try to spend some time not focusing on the cancer.”

Touch. “We need touch from the moment we’re born until the moment we die,” Maureen says. Touch releases oxytocin—the cuddle drug—and that makes you feel better, like a big belly laugh. Touch heals and reinforces connection.

As Mary Jo Rapini mentioned, it’s important not to make assumptions about your partner’s motives for touching you. He’s probably not after sex, just the feeling of intimacy that can drain away without sex.

If touch is painful, Maureen suggests creating a body map. Draw a simple outline of a body, like a gingerbread figure, and mark the spots where you like to be touched. You can even prioritize what feels good, better, best. Also mark with a red X where you don’t want to be touched. This is a graphic, non-verbal aid for your partner.

Finally, sensate focus is a program developed by Masters and Johnson that incorporates gradually increasing levels of touch, from very light, non-sexual touching and increasing over time to include sexual touch. This can be a gentle way to introduce sexuality slowly and at a pace you can tolerate.

Move the goal posts. As we’ve said many times on MiddlesexMD, sex is much broader than the old penis-in-vagina experience. Explore new avenues of sexual satisfaction, from kissing and cuddling to erotic massage. Take it slow. Do what feels good. Take performance anxiety off the table.

Your body may feel and respond differently now, and sex may be different. But this doesn’t always entail less or loss. According to many couples, the sex can be better. In fact, a new study by the Duke Research Institute found that while cancer changes sexual intimacy and function, often for a long time after treatment, this didn’t correlate with a lessening of sexual satisfaction.

“Sex is about connection,” Emily says. “It’s about love; it’s about intimacy, and that can look a lot of different ways. I find that most rewarding skills that couples learn is not having goal-oriented sex, but really just exploring each other without judgment and experiencing each other and the emotions that they really feel for each other.”

Having “The Talk”—with Your Doctor

Just when you thought you were home free—the kids are grown, and you’ve somehow gotten through multiple birds-and-bees talks. But now you find the shoe is on the other foot, and you’re the one needing information about sex. Maybe a health issue is affecting your sex life, or maybe your body is responding differently, or maybe you’re just not as responsive as you used to be. Where do you go for straight talk about these nitty-gritty topics?

According to a presentation I heard at the International Society for the Study of Women’s Sexual Health (ISSWSH) conference “physicians often do not talk to their patients about sex.” It occurred to me that the effect of this oversight is similar to neglecting the “talk” with our kids, i.e. you end up muddling along with misinformation, rumors, or half-truths.

Oddly, doctors cite similar reasons (excuses?) as the rest of us for avoiding the “talk” with their patients: They don’t have time; they don’t feel comfortable; they don’t know enough about this medical subspecialty to feel competent and helpful.

To be honest, doctors do operate under very tight time constraints in the course of a normal day. Also, sometimes, after talking about health and body parts for years, we forget how uncomfortable it might be for you to bring up what you consider an embarrassing problem. Rest assured, however, that we’ve probably discussed that problem before with someone.

None of this lets anyone off the hook. Sex is an important component to physical and mental health and well-being, and if you have questions or problems, who better to discuss them with than your doctor? If your doctor isn’t taking the initiative, here are some ways to help get the conversation started.

  • Write down your questions. This exercise may help you clarify what you want to talk about, and it will definitely help you to remember everything.
  • Prime the pump. At the beginning of your appointment, mention that you’d like to discuss some sexual issue that you’ve been experiencing. Or, get more specific—that you’d like to explore your options for vaginal lubricants or whether your medication might be diminishing your sexual interest.
  • Be clear, specific, and thorough. Don’t leave something out because it’s too embarrassing or doesn’t seem pertinent. You wouldn’t neglect to mention to your mechanic the little whirring noise in the rear axle when you turn left. Why would you omit an itch or pain or change you experience in your body?
Once you get over the initial hurdle of actually saying the S-word in front of your doctor, you may find it much easier to talk about sex the future. After all, as you told your children all those years ago, sex is just a natural part of life.

The Fifth Component of Great Sex: Exploration and Fun

A while ago, we began exploring the qualities of great sex that were identified in a study published in The Canadian Journal of Sexuality. These qualities were gleaned from interviews with 20 sex therapists and with 44 ordinary people who identified themselves as having experienced great sex. From that material, the researchers gleaned eight characteristics that popped up repeatedly. The list was surprising. Rather than sexual acrobatics or obscure paraphernalia, the list included qualities like connection and authenticity—which would tend to make any relationship great.

One of the qualities we haven’t yet discussed is the willingness to experiment with your partner. Respondents referred to great sex as an “adventure” and a “discovery process” in which they learned new things about themselves and their partners. In the study, however, this quality was often described in a playful, lighthearted context.

Anything we do repeatedly for a long time tends to become routine. We trot along the same worn dog path in which every bump and bend is familiar. After a while, any routine activity, sex included, can become a bore and then maybe a chore. That’s why here at MiddlesexMD, we often prescribe a healthy dose of novelty to spice up the routine—a change of position, place, or props, especially for partners who have been together for a long time.

But great sex goes beyond trying new toys. These respondents seemed to revel in the joyful aspect of experimentation, of trying new things together. Exploring new dimensions of sex wasn’t a test they passed or failed; it wasn’t medicine they took because it was good for them; it didn’t involve one partner trying to “sell” the other on something new. The outcome didn’t matter; how they looked didn’t matter. What mattered was that both partners were engaged in the adventure and were having a good time doing it. Often, too, the exploration uncovered new qualities about the relationship or themselves.

Playfulness has to be genuine, and this joyful experimentation probably also requires another aspect of great sex that the researchers identified: extraordinary communication. But whatever the quality of our communication or spirit of adventure, it’s always possible—and helpful—to be open to new things, to be willing to relinquish the safety of routine and even boredom, and to step into new territory, even if it involves some risk and some energy. And if playing together also contributes to a great sex life, well then, game on.

The Ultimate Couples Project: Pain-Free Sex

I’m still thinking about the research that says lots of post-menopause women have sex even though it hurts. The study I read said many of them think there’s nothing that can be done—that painful sex is a normal part of being a mid-life woman.

I pick up clues to another obstacle in the e-mails I receive as Dr. Barb: We women are reluctant to include our partners in addressing difficulties with intercourse. I’m not sure why this is. Maybe we’re in denial about the changes we’re experiencing. Maybe we’re too used to being the caretakers in our households. Maybe we’re still shy about talking about our genitals and our pleasure.

If I overdo in the garden, my husband will give me a back rub. If a shipment of products for MiddlesexMD arrives after hours, he’ll help me carry the heavier boxes in. When we entertain, we clear the clutter together.

I guess I’m suggesting that you see maintaining your sexuality as the ultimate couples project. A partner who loves you will not want you to endure pain to give him pleasure; and will want you to enjoy intimacy as much as you are able.

You’ll have to talk about it—as you’d tell him where the muscles are knotted after weeding. You can send him this blog post or sit down with our website together to get the conversation moving.

He can plan to take more time to increase your arousal and natural lubrication. Together, you can use lubricant as part of foreplay to increase your comfort. The two of you can experiment with warming lubricants or a vibrator to increase your sensation. And your partner can support your work with dilators or other tools to regain your sexual health.

It’s not too much to ask. Really.

Resolve to Speak Up!

I was struck by this sentence in a report on research with women aged 45 to 65 experiencing menopause: “As a generation, they have yet to develop a voice for this situation, and many remain silent rather than proactively seeing help.”

Really? We are the generation who, in high school, bought Our Bodies, Ourselves to better understand menstruation and sex. We pushed the boundaries to study science, go to medical school, become executives, compete for construction jobs, run our own businesses. We bought Marlo Thomas’s “Free to Be You and Me” for our kids.

But in my own experience as a physician, I see evidence that it’s true. When my practice included women of all ages, patients came in ready to talk in detail about physical symptoms—and emotional effects—related to pregnancy or fertility or uncooperative or uncomfortable periods. I don’t recall as many conversations about symptoms of menopause, especially as they related to sexuality.

In the last few years, since I’ve focused my practice on mid-life women, those who come to see me are ready to talk. This may have encouraged me to think we’ve made more progress than we have; this “REVEAL” (Revealing Vaginal Effecs at Mid-Life) study is a useful reality check. This research found that 41 percent of postmenopausal women had not talked to anyone about their sexual health in the previous year. Just over a third had talked to a health care provider; fewer—30 percent—had spoken to their partner or significant other.

The oldest women in the study—60 to 65—were least likely to have spoken to anyone at all. The younger women—45 to 49—were more likely to have spoken to someone: health care providers, partners, and then female friends.

Why does any of this matter? Consider the other findings of this research:

  • While almost all of the women surveyed were familiar with hot flashes as a symptom of menopause, fewer than half were aware that vulvar/vaginal pain was another symptom.
  • A quarter of those surveyed experienced pain during sex; most of those women still have sex—in spite of the discomfort—at least once a month.
  • The majority—80 percent—of the women who experienced pain during sex assumed it was a “normal part of getting older.”

That’s a whole lot of women who aren’t aware that sex can still be pleasurable and pain-free, even after menopause. And it’s a whole lot of women who won’t even broach the topic with their health care providers, because they assume that nothing can be done.

So! Clearly, it’s up to you! I imagine a whole lot of conversations between best women friends, women and their partners, sisters… and, for the sake of the next generation, between us and our daughters.

There are symptoms of menopause beyond hot flashes, night sweats, and mood swings. Decreasing hormone levels affect our vaginal and genital tissues, but they don’t spell the end of sexuality—or comfortable intercourse. There are things any woman can do to restore or preserve her sexual health, and we need to talk about them!

Sounds like a great resolution for 2011.

Boomer Sex: We’ve Got a Lot to Learn

When the results of a new AP-LifeGoesStrong.com poll of the boomer generation about sex and relationships were released last month, the news media highlighted two seemingly contradictory findings, illustrated by these headlines:
  • “Poll: Baby Boomers Sex Confident”
  • “AP Poll Says Boomers Are Unhappy with Sex Lives”

The first story focused on the fact that the majority of people between the ages of 45 and 65 believe that they have “pretty much learned everything there is to know about sex.” The second article reported on the percentage of boomers who say they are “dissatisfied” with their sex lives. Nearly a quarter -- 24 percent -- of the 45-65 group said they were frustrated with their lovemaking (compared to 12 percent of 18-29 year olds and 17 percent of the 66-plus crowd).

Hmmm. I wonder if there’s a connection.

My first reaction -- and I speak as a medical doctor who specializes in menopause care and hears about the sexual lives of boomer women on a daily basis -- is that I don’t believe a person of any age can know everything there is to know about sex. In my experience, it’s hard for a person to understand her own sexuality -- how her body works, what she really needs and wants -- and impossible for her to know everything about her partner’s desires and expectations in the bedroom.

A closer look at the poll’s results reveals a significant gender gap around these findings in the 45-65 age group. While 59 percent of boomer women said they know all there is to know about sex, only 48 percent of their male counterparts share that level of confidence. On the other hand, 48 percent of men age 45-55 said that their partners don’t want to have sex as often as they do, while only 13 percent of women in that age group made the same complaint.

Sex therapist Dr. Ruth Westheimer, who helped develop the questions for the poll, says that the most important issue the findings highlight is that men and women in this age group have very different expectations in bed.

"We worry so much about teens and sex, but this poll indicates a need for a call to action for this segment of the population to become more sexually literate," she says. "It is not necessary for a couple to be in exact sexual synch, but if a couple's appetites grow too far apart, then that indicates that there is not enough communication about sex in the relationship."

Of course, communication is an essential component of satisfying sex. But I also wonder if what women who say they know everything there is to know about sex are really saying is that they’ve lost interest in sex as they know it. That the kind of stimulation that excited and satisfied them when they were younger no longer does the trick. Real “sexual literacy” for both women and men at midlife requires knowledge about how our bodies are changing and what we can do to help each other have physically and emotionally satisfying sex lives as we grow older.

Keep Your Head—and Your Heart

We’ve talked before about the fact that sex is different for women. Rosemary Basson, MB, FRCP, of the University of British Columbia, describes a couple of ways that women experience arousal differently.

First, women are more likely to respond to stimuli than to have an interest in sex sparked out of thin air.

Second, emotional intimacy matters to women. A lot. It’s usually a prerequisite for becoming sexually aroused.

I mention this now, in the weeks leading up to the holidays, for a reason. Holidays are often an emotional time to begin with: Will the kids get home? Will they spend time with me? Will the ex cooperate in scheduling events? Will my mother-in-law/grandson/nephew be polite about the gifts I’ve found?

The women I know also carry more of the burden for preparing for the holidays than their partners do—however well intentioned those partners may be! There’s decorating, cooking, baking, shopping, wrapping—all on top of a social calendar that’s more full than usual.

It’s easy for the holidays to fall short of expectations, partly because we’re so busy, partly because we’ve been encouraged (remember Norman Rockwell!) to think of holidays as idyllic family times. And, many of us harbor hopes that—somewhere—our holidays will also have some romance.

That’s why I come back to Rosemary, stimuli, and intimacy. As you’re navigating the next few weeks, carve out some time for you and your partner. Spend some time together—even in the midst of a holiday party. I’m reminded of the hints Marnia Robinson includes in Cupid’s Poisoned Arrow: From Habit to Harmony in Sexual Relationships. She calls them “attachment cues”; you can read more about them on our website, but here are some I think you can get away with even at the office party:

  • smile, with eye contact
  • touch with skin-to-skin contact (a hand, a cheek)
  • prepare your partner something to eat (or drink)
  • gaze into each other’s eyes
Give it a try, and let me know if it helps you feel more connected amidst the hustle and bustle. And if you have a way to preserve room for yourself and your partner during the holidays, please share. What makes for romantic interludes for you?
December 13, 2010

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Another Way to Stay in Touch

We love hearing from our readers and our customers. We’re thrilled when we hear from someone who’s gotten unstuck in her sex life because of information or products we’ve been able to supply.

Two recent messages, for example: A husband e-mailed us in happy disbelief that his wife’s use of vaginal dilators had enabled them to have comfortable sex for the first time in two years. A woman e-mailed to say that Yes vaginal moisturizer had eliminated her pain.

On a lighter note, we got a lot of response on Facebook when we shared—just in time for Thanksgiving—research that proved the scent of pumpkin pie is arousing—especially for men! A few extra pies were baked, we’re guessing….

We keep looking for ways to continue the conversation. We’ve started an e-mail newsletter so a couple of times a month we can highlight recent research or discussions, tell you about new products, and report on other events we’re involved in. We’ll even, from time to time, offer special gifts to folks who subscribe to the newsletter

Even if you’re already a blog subscriber, we invite you to consider signing up for the newsletter or “liking” us on Facebook. Hey, consider it a practice of mindfulness: We know that the more we think about sex, the more sex we have!

Extraordinary Communication: The Fourth Component of Great Sex

When they listed “communication” as an essential component of “optimal sexuality,” participants in the groundbreaking study published last year in The Canadian Journal of Human Sexuality were talking about a lot more than talking.

Their descriptions of “extraordinary communication” often suggest a state of “heightened empathy” in which partners share themselves with each other completely, using touch and other senses as well as words. Nonverbal communication, the ability to convey and understand feelings and desires purely through physical contact, was considered essentialbefore, during, and after a sexual encounter.

In fact, the kind of communication the study participants refer to seems to have little connection to the conversations about sex that therapists and doctors like me recommend to couples experiencing problems with their sexual relationships. That kind of talkI like when you touch me here, how does it feel when I do this, would you like to try something new?may be important, even necessary, to achieve the “extraordinary communication” that makes for great sex. But the actual experience of it takes place in the moment, in the acute and continual awareness of how partner and self interact and respond.

As one study participant puts it, extraordinary communication is the ability to recognize “even if you’re not told, that one kind of touch elicits a certain response in your partner and another does not.”

It occurs to me that this deep empathy is what my patients are expecting, looking for, hoping for when they protest that talking about sex diminishes or even ruins the act itself. We all wish our partners could know exactly what we want and how we feel without being told.

But in my experience, this kind of extraordinary communication doesn’t happen unless couples first invest time and effort in a lot of pretty ordinary communicationhonest and explicit talk about sex and feelings and desires.

What’s your experience?