Anne Katz, RN, PhD
Nearly half of cancer patients do not discuss sexuality with their healthcare providers, but that doesn’t mean it isn’t a concern for them, according to Anne Katz, RN, PhD, a Clinical Nurse Specialist with CancerCare in Manitoba, Canada, addressing a large audience at the 2014 ONS Congress. Although patients may be reluctant to discuss the issue, Katz said there are “no excuses” for nurses not to educate them.
Katz polled the audience of her peers about their own level of comfort in discussing sexuality with their cancer patients. Not surprisingly, the responses from this motivated group of attendees were weighted well toward the comfortable side, with 19% describing themselves as “very comfortable” in discussing sexuality with patients and 65% as “somewhat comfortable”. Only 11% said “if my manager is watching”, and a mere 5% characterized discussion of sexuality as “someone else’s job.”
The number one barrier to healthcare practitioners discussing sexuality, said Katz, is lack of knowledge. Other barriers include conservative attitudes, fear of embarrassing themselves, or fear of offending the patient.
One study Katz described indicated that clinicians were also concerned about how they would be viewed by their colleagues if they were known to routinely discuss sexuality with patients. Denial of responsibility and institutional issues were also listed as factors contributing to failure to broach the topic with patients, but Katz emphasized that nurses have a professional and ethical duty to educate patients and reminded them that ONS already has firm guidelines on their responsibilities in this area.
Katz asserted that while some providers may hide behind a “medicalized” approach, employing Latin terms and other means of avoiding direct discussion of sexuality, nurses are ideally positioned to assume leadership roles in discussing this critical issue in the lives of their patients.
“Nurses are the number one trusted health professional, and that trust should give us the confidence to raise this topic with our patients,” said Katz.
Prehabilitation, the interval between cancer diagnosis and start of treatment, is the ideal time to perform a physical and psychological assessment to enable discussion of upcoming changes. Katz said that changes to sexuality must be included in that discussion.
She described several models of sexual assessment that therapists use to assist in the diagnosis and treatment of sexual dysfunction. These models are also appropriate for use in disturbances to sexuality which may occur as a result of cancer and cancer treatment, she said, and they include PLISSIT (Permission, Limited Information, Specific Suggestion, Intensive Therapy), created in the mid-1970s, and its whimsically-named successor, EX-PLISSIT (EX
A more recent model, said Katz, known as BETTER, created in 2003, is focused on provoking dialogue and building a trusting relationship between the healthcare practitioner and the patient. She added that another model which has potential for use in addressing sexual issues related to cancer treatment is one designed for smoking cessation therapy known as Bober’s 5-A’s (Advise, Ask, Assess, Assist, Arrange).
Regardless of what assessment model might be used, Katz encouraged her audience to rehearse their opening line, perhaps in front of the mirror, which would allow them to get the conversation started.
For example: Katz offered the following sample lead-in to a discussion of sexuality with a patient: “Women who have a hysterectomy often have concerns about what changes they may experience in their relationships.” After delivering the lead-in, Katz urged the nurses to wait as long as necessary for the patient to break any ensuing silence.
Katz also elaborated upon some of the more common sexual-related side effects of cancer treatment. Men who have undergone radical prostatectomy could suffer erectile dysfunction, while women on taxanes or aromatase inhibitors might have issues related to low estrogen making intercourse painful. Anti-androgen therapy might result in psychologically devastating genital shrinkage for men, whereas women with mastectomies could experience equally debilitating psychological impacts on their sexuality.
Although noting differences in arousal patterns between men and women, Katz also stressed the importance of outwardly nonsexual aspects of couples’ relationships which might be impacted by changes brought on by cancer treatment, aspects which can be mediated by both verbal and nonverbal modes of communication.
Simple touching between partners, a nonsexual prelude to greater intimacy, is often lost due to psychological factors resulting from response to disease or therapy, but communication can help restore these prerequisites to sexual activity.
“Communication lies at the root of all our relationships. We work in an environment where communication is of upmost importance.”
In conclusion, Katz restated her belief that nurses are best suited for communicating with patients on sexuality. “We understand the treatments, we understand what cancer is, and most important of all, we understand our patients. We do it better, plain and simple.”
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