Creating a Safe Space Is the First Step in Initiating Sexual Health Conversations With Patients With Cancer


The most important thing that an oncology nurse can do to help a patient navigate their sexual health is repeatedly offer them permission to have conversations surrounding their health.

Sage Bolte, PhD, LCSW, CST

Sage Bolte, PhD, LCSW, CST

Although not every patient with cancer will experience a sexual health crisis during treatment, every patient with cancer will experience some form of sexual health change, according to Sage Bolte, PhD, LCSW, CST. Therefore, it is important that oncology nurses establish that they are someone a patient can turn to if, and when, they want to discuss issues related to their sexual health.

“Every single one of them will have sexual changes,” Bolte, chief philanthropy officer and president of the Inova Health Foundation, said. “They will have questions, whether it's during treatment, after treatment, or 3 years after treatment. [Nurses] will be the one that they reach out to so that they don't feel scared and isolated and confused when those issues come up.”

“[With some populations], it is still not necessarily generationally appropriate [to have these conversations], and it may be uncomfortable for them,” she added. “So, it is [often] our providers [who need] to be the ones to bring forward the conversation.”

In a presentation during the 47th Annual ONS Congress, Bolte, along with Elaine Wittenberg PhD, FACH, an associate professor at California State University, and Joy Goldsmith, PhD, a professor of health communication at the University of Memphis, discussed effective communication strategies for oncology nurses addressing sensitive topics with their patients.

To better engage with their patients, oncology nurses may need to ask themselves: “What is my comfort level discussing sexual health?” and “What are my particular strengths in helping patients and their partners reclaim their own bodies?”

Nurses may also need to reflect further and ask themselves how comfortable they are with their own body and sexuality, their own positive image, and whether they are themselves at a place of peace to overcome their own personal barriers and initiate these conversations.

“It is OK if you're uncomfortable with those words,” Bolte noted. “We're taught to be a little uncomfortable with those words. [But], we have to look at what triggers that discomfort so we can show up for our patients without showing that discomfort.”

Furthermore, nurses can help promote more meaningful dialogue by keeping the conversation patient centered and positive. For example, Bolte says it is a better approach to tell a patient, “Cancer and its treatments have such significant impacts on all aspects of our lives, including our sexual health–this is normal. I would love to provide you with some information” rather than telling them, “You can discuss sexual failure with me” or “I am trained not to laugh.”

Overall, Bolte recommends looking for “very simple, non-threatening ways to open a conversation with the information that [the patient] is providing.”

Modes of Communication

To best address these issues, Bolte recommends the “Ex-PLISSIT Model” as an ideal approach. The ex-PLISSIT model calls for health care providers to:

  • Ask permission at every stage and every visit to assess and inquire about a patient’s sexual health;
  • For patients with limited information, guide them towards resources such as written information and available education;
  • Offer specific suggestions, such as counseling,
  • And refer intensive therapy, if necessary, as well as to keep a current network for patient referrals.

In addition, Bolte also highlighted the following useful conversation starters to aid oncology nurses who may feel uncomfortable beginning these discussions:

  1. Is there anything that would be important for us to know about your sexual history or sexual health to best support you during the time we are caring for you?
  2. What concerns or questions do you have about changes in or the continuation of your sexual needs?
  3. In what way has your sexual relationship(s) with your partner(s) or self changed?
  4. What information or resources can I provide to help you improve your sexual health?

Physiological Changes

It is important to note that the impact of cancer on sexual health may not always be transparent. Beyond the cancer itself, there is often a pressing psychological distress related to the diagnosis and treatment on both the patient and their partner. Different treatments yield different side effects and alterations as well, and can impact relationships during and after treatment, Bolte said.

Some common physiological changes from therapy-related adverse effects (AEs) that male patients with cancer experience include chemo-brain, joint discomfort, neuropathy, and hair loss, among others. Neurovascular damage stemming from chemotherapy, radiation, or surgery is also common and can result in erectile disorder (ED). Endocrine changes can reduce testosterone levels and result in reduced libido, osteoporosis, and vasomotor flushing, and physical stamina can be affected, as well.

Lastly, penile length may be reduced, infertility can occur, and body image changes may emerge.

Bolte advised proactive conversations with patients and ensure that they know what to expect so they do not feel frustrated with their care team. She explained that, for example, many men do not realize that penile length reduction is a possibility until after it occurs.

“The power of information is so important in preparing our patients for what to expect,” she said. “[This patient] has managed and adjusted, but not knowing [what to expect] created more distress and frustration with his medical team.”

In contrast, female patients with cancer may experience many of the same treatment-related side effects including chemo-brain, joint discomfort, etc. However, these patients may also undergo acute or premature ovarian failure and experience consequent issues related to ovarian failure including decreased libido, infertility, “natural menopause,” osteoporosis, hot flashes, and mood changes. Fatigue and decreased physical stamina, as well as body image changes, may also occur.

“For women, the No. 1 complaint is the changes in the vaginal strength or the changes in natural moisture—[issues] which can be addressed,” she said.

Treatment Approaches

For patients who need specific information for their vaginal health, counseling and education is important to address the following concerns: for those who are experiencing genitourinary symptoms of menopause, advice to stretch, strengthen, and moisturize is important. Additional treatment options including vaginal laser therapy, and hormonal treatments.

If the patient is noticing an increase in infections, this could indicate that their Ph balance is off and should be addressed as such. Furthermore, changes in vaginal moisture should be discussed with partners as well as the patient.

For male patients who need specific information for their penile health, counseling and education is important, and as well as addressing expectations and practices for sex (oral, vaginal, anal). Nurses caring for patients who are experiencing these problems should consider other contributing factors such as age, previous erectile dysfunction, distress, and transplant, and other concurrent health problems such as diabetes, heart issues, etc. Hormonal treatment, vacuum devices, or a referral to a physical therapist or urologist may be appropriate. Partners’ wishes and desires should also be a part of the conversation.

Finally, information regarding sexual health should address ways to make sexual activities more pleasurable, such as time of day, partner/patient expectations, positioning, lubricants, lidocaine, and dilators, as well as prolonged foreplay. Desire is also an important thing to address, as creating a sensual environment can help improve some conditions.

Key Takeaways

Overall, nurses can have a major impact by giving patients permission to discuss their concerns surrounding their sexuality, Bolte said.

“If [the only change] you [make] leaving today with your patients is to give them permission, you are doing a phenomenal job,” she said, noting that permission means allowing them to feel safe having these conversations—which opens the door for specific informative conversations when questions do arise—and recognizing that the issues that these patients are facing are both challenging and normal.

Conversations around sexual health should feel just as comfortable as conversations about any other cancer-related symptom, she concluded.


Bolte S, Goldsmith JV, Wittenberg E. Tools of the trade: communicating sensitive topics. Presented at: 47th Annual Oncology Nursing Society Congress; April 27-May 1, 2022; Anaheim, CA.

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