Sexuality in cancer and palliative care 2: Exploring the issues

What contributes to promote sexual health in cancer palliative care? A realist review

INTRODUCTION

Sexuality is an important determinant of the overall health of a population and remains so at the end of life and in patients with advanced cancers. Despite the abundant literature on sexuality and intimacy, these topics have been rarely discussed in the context of cancer palliative care, and very few interventions to promote sexual health in patients undergoing cancer palliative care have been explored.

OBJECTIVES

In this study we sought to identify which factors and mechanisms contribute to promoting sexual health in cancer palliative care.

METHODS

A realist review was performed according to the guidelines of the realist and meta-narrative evidence synthesis method guidelines. Articles published between January 2010 and June 2021 were searched in 4 databases. Records were screened for their relevance regarding a predefined list of context-mechanism-outcome (CMO) configurations. Abstracts were independently screened by 2 authors before the data were extracted from the full-text articles selected for inclusion. With the use of abductive and retroductive reasoning techniques, each article was examined for evidence of its contribution to one of the CMO configurations, which could be refined when relevant. The data were summarized according to the final CMO configurations.

RESULTS

Of the 2056 articles identified, 38 articles were included in the review. The data reported in these articles contributed to 7 CMO hypotheses: (1) improving communication skills, (2) healthcare provider training, (3) reorganizing the patient environment in care settings or at home, (4) managing sexual symptoms and also general symptoms, (5 and 6) patient-centered counseling or couple counseling, and (7) lifting the taboo.

CONCLUSIONS

The findings reported here highlight various ways to improve sexual health for patients in cancer palliative care but are limited to genital cancers. Further research should consider all types of cancer rather than being restricted to genital cancers.

"To live until you die could actually include being intimate and having sex": A focus group study on nurses' experiences of their work with sexuality in palliative care

AIMS AND OBJECTIVES

To examine nurses' experiences of working with issues of sexuality in palliative care.

BACKGROUND

Sexuality has value for human lives and relations and is important for one's overall well-being throughout life. Guidelines for palliative care state that sexuality should be addressed. Previous research shows that the inclusion of sexuality in general health care is deficient, and there is a knowledge gap on how sexuality is addressed in palliative care.

METHOD

Within a qualitative design, the empirical material was obtained through three focus group interviews with eleven registered nurses working in palliative care. The interviews were analysed using qualitative content analysis.

RESULT

Nurses experience that sexuality has an indistinct place in their work, "sexuality" is a word difficult to use, and differing views are held on whether it is relevant to address sexuality, and if so, when? Although they have experiences involving patient and partner sexuality, which is viewed as sexuality in transformation during the palliative care process, nurses seldom explicitly address patient or partner sexuality. Despite the lack of knowledge, routines and organisational support, they acknowledge the importance of addressing sexuality in palliative care, as they express that they want to do right.

CONCLUSION

Overall, nurses appear to follow differing cultural, interpersonal and intrapsychic scripts on sexuality rather than knowledge-based guidelines. This underlines the importance of managers who safeguard the adherence to existing palliative care guidelines where sexuality is already included. In this work, it is important to be aware of norms to avoid excluding patients and partners that differ from the nurses themselves as well as from societal norms on sexuality.

RELEVANCE TO CLINICAL PRACTICES

The results can be used as a point of departure when implementing existing or new guidelines to include and address sexuality and sexual health needs in palliative care.

Sexual dysfunction in males following low anterior resection

AIMS AND OBJECTIVES

The purpose of this study was to explore the prevalence of sexual dysfunction in males one year after undergoing low anterior resection and to determine whether health care professionals discuss sexual issues with patients after surgery.

BACKGROUND

Sexual dysfunction in males may be a complication after low anterior resection for rectal cancer, but few studies have explored this issue in Taiwan.

DESIGN

A descriptive comparison study design.

METHODS

A descriptive comparison design was used, and a group of 133 participants underwent a low anterior resection procedure for rectal cancer. The results were compared with those of a group of males who underwent colectomy (n = 58) for colon cancer. The following instruments were used: the five-item version of the International Index of Erectile Function, personal demographics and medical variables.

RESULTS

The results showed that the prevalence of erectile dysfunction among the low anterior resection patients was 97·0% (129/133), and the erectile dysfunction prevalence was 75·9% (44/58) for the males who underwent colectomy. The generalised linear model showed that after controlling for hypertension and stoma, the low anterior resection group had worse sexual function than those in the colectomy group, and stoma was also a factor that impacted patients' sexual function. The results also revealed that only 32·8-35·3% of health care providers talked about sexual dysfunction with people who have rectal cancer prior to surgery.

CONCLUSION

This study demonstrated that men who have undergone low anterior resection have a high risk of sexual dysfunction and that health care professionals infrequently discuss these issues with patients.

RELEVANCE TO CLINICAL PRACTICE

When patients are diagnosed with rectal cancer and before they undergo surgery, an assessment and discussion of sexual function issues should be incorporated into standard care. Continued follow-up after hospital discharge and evaluations of sexual function are vital factors for male postoperative rectal cancer patients.

Representations of nurses regarding sexuality of women treated for breast cancer in Brazil

The development of new treatments has improved survival and quality of life among cancer patients. Nurses are expected to answer questions and to provide orientation regarding patients' sexuality since it is an important aspect of life. The main objective of this paper is to understand the representations of sexuality among nurses working with women who survive breast cancer after diagnosis and during treatment assuming that their representations may affect communication with the patient. This is a qualitative study using an in-depth guideline which involved interviews with 28 nurses living and working in the southeast of Brazil. The narratives were submitted to a content analysis and categories of representations were identified and are discussed here. Several representations of sexuality were found in the nurses' discourses. Some of the nurses' representations may be expected to hinder their ability to provide helpful orientation regarding the sexual lives of these patients.

An integrative review of sexual health issues in advanced incurable disease

The sexual health needs of people with advanced incurable diseases are underexplored and under assessed by health care practitioners and under studied by researchers. The loss of sexual health can impact a person's overall quality of life and well-being. This integrative review of the literature presents the current state of the science and was conducted to identify and summarize publications in the professional literature related to the sexual health needs of people with advanced illness. A systematic search of 18 databases for studies conducted between 1960 and April 2012 in the English language that focused on the sexual health needs of people with life-limiting illnesses was conducted. Findings document that studies regarding the sexual health of patients with life limiting illnesses are generally narrative reviews, expert opinions, or exploratory in nature. Of the 30 possibly relevant abstracts and titles identified, there was only one prospective or case control trial focusing on sexual health in this population thereby offering the practitioner little research evidence to inform clinical practice. Increasing our understanding of the sexual health needs of people facing the end of their lives is crucial if we are to conduct appropriate assessments and initiate relevant treatments. Further prospective research is required to assess and establish the sexual health concerns of people along the disease trajectory of incurable illness as well as those imminently facing the end of their lives.

Análise da comunicação acerca da sexualidade, estabelecida pelas enfermeiras, com pacientes no contexto assistencial do câncer de mama

Investigou-se como se desenvolve a comunicação acerca da sexualidade, estabelecida pelas enfermeiras, com as pacientes mastectomizadas. Trata-se de estudo qualitativo, do tipo descritivo-exploratório. Participaram 28 enfermeiras e foram utilizadas entrevistas em profundidade. O material foi submetido à análise de conteúdo temática. Houve variações nos discursos das enfermeiras, articuladas em quatro categorias: a enfermeira não comunica questões de sexualidade; comunica com discurso evasivo e com negação da sexualidade no cuidado; utiliza da comunicação fragmentada, própria do modelo biomédico; e se vale da comunicação acolhedora, integrada, junto a familiares e à equipe de saúde. Evidenciaram-se dificuldades das enfermeiras em contemplarem questões da sexualidade na produção dos cuidados em saúde. Espera-se que este estudo possa suscitar o interesse por novos conhecimentos acerca da interface da sexualidade e dos cuidados na formação em enfermagem, favorecendo a informação e capacitação de outros profissionais da equipe.

Chinese nurses' attitudes and beliefs toward sexuality care in cancer patients

BACKGROUND

The importance of having nurses address patients' sexuality concerns is emphasized by a growing body of literature. Most relevant studies were conducted in Western cultural settings.

OBJECTIVE

The purpose of this study was to describe Chinese nurses' attitudes and beliefs regarding sexuality care in cancer patients.

METHODS

A descriptive and correlation design was adopted. Data were collected by an inventory of Sexuality Attitudes and Beliefs Survey.

RESULTS

Oncology nurses (n = 199) were recruited from a tumor hospital in China. The study results indicate that most Chinese nurses (76.4%) perceived sexuality as too private an issue to discuss with cancer patients, and 63.8% assumed that most cancer patients lacked interest in sexuality because of their illnesses. The results also show that most nurses (77.9%) did not make time to discuss sexuality issues with patients, and nearly 70% did not feel confident and comfortable discussing cancer patients' sexuality concerns.

CONCLUSION

Helping nurses overcome barriers to addressing patients' sexuality concerns requires a careful assessment of their attitudes and beliefs. This study added insights into Chinese nurses' attitudes and beliefs surrounding the sexuality issues of cancer patients.

IMPLICATIONS FOR PRACTICE

In this study, nurses reported that they were less likely to make time to discuss sexuality issues with cancer patients; thus, future research needs to identify specific factors keeping nurses from incorporating sexuality care into practice. Additionally, most nurses felt less confident and uncomfortable in addressing cancer patients' sexuality concerns. More training related to sexuality care is needed for Chinese nurses.

Is there a place for sexuality in the holistic care of patients in the palliative care phase of life?

Being diagnosed with a life-limiting condition is a traumatic event. The journey to the moment of death is usually only done once--so it is a time of fears and uncertainty. Sexuality is particularly vulnerable at this time. It may be difficult for both patient and partner to deal with the changes in sexuality without professional assistance. It is "sexuality" rather than "sex" that defines the meaningful relationships people have with themselves and significant others. When sexuality is lost or changed, important benefits may be lost. Studies show that many patients do value sexuality and want assistance in making the best of their sexual potential during the palliative care phase. Health professionals regularly acknowledge the importance of sexuality for their patients but have difficulties acting on their beliefs. Sexuality, within the patient's functional ability and desire for it, must be acknowledged and included in holistic management. It is the health professional's responsibility to raise this issue.

Dealing sensitively with sexuality in a palliative care context

Sexuality is integral to a person's identity and is encompassed in holistic palliative care. Current directives emphasize psychosocial support that is sensitive to a variety of issues, including sexuality, and offer community nurses the mandate to facilitate expressing sexuality. Nurses fail to address sexuality for a variety of reasons. Appreciating patients' individuality and avoiding making assumptions are some of the requirements to enabling expression of sexuality. Nurses need wisdom and determination to discuss such issues, and it is important that they recognize opportunities and cues as they arise. This article provides an examination of the issues surrounding sexuality outlining an approach that captures' constant attention to details. This guides the 'what', 'how' and 'why' sexuality in palliative care can be addressed. Ethics and safety aspects are briefly discussed and implications for practice suggested. Educating staff and focused education for the patient can positively influence sexuality and individuals' quality of life.

A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer

Treatment of early-stage cervical and endometrial cancer has been associated with significant sexual difficulties in at least half of women following hysterectomy. Despite the fact that women report such sexual side effects to be the most distressing aspect of their cancer treatment, evidence-based treatments for Female Sexual Arousal Disorder (FSAD), the most common sexual symptom in this group, do not exist. We developed and pilot tested a brief, three session psychoeducational intervention (PED) targeting FSAD in 22 women with early-stage gynecologic cancer. The PED consisted of three, 1-h sessions that combined elements of cognitive and behavioral therapy with education and mindfulness training. Women completed questionnaires and had a physiological measurement of genital arousal at pre- and post-PED (sessions 1 and 4) and participated in a semi-structured interview (session 4) during which their feedback on the PED was elicited. There was a significant positive effect of the PED on sexual desire, arousal, orgasm, satisfaction, sexual distress, depression, and overall well-being, and a trend towards significantly improved physiological genital arousal and perceived genital arousal. Qualitative feedback indicated that the PED materials were very user-friendly, clear, and helpful. In particular, women reported the mindfulness component to be most helpful. These findings suggest that a brief 3-session PED can significantly improve aspects of sexual response, mood, and quality of life in gynecologic cancer patients, and has implications for establishing the components of a psychological treatment program for FSAD.

ORIGINAL RESEARCH—WOMAN'S SEXUAL HEALTH: Prevalence of Psychiatric Illness in Women in an Oncology Sexual Health Population: A Retrospective Pilot Study

INTRODUCTION

Oncology patients often present to healthcare providers with a history of pre-existing psychiatric conditions. Associated treatments are well known to impact sexual functioning. The identification of these confounding conditions and medications is an integral part of the comprehensive management of sexual dysfunction in oncology patients.

AIM

To report the prevalence of psychiatric diagnoses and agents in an oncology sexual health clinic.

METHODS

A retrospective review was performed using 204 sequential charts of patients who attended the Sexual Health Program at Memorial Sloan-Kettering Cancer Center from March 2003 through August 2004.

MAIN OUTCOME MEASURES

All patients were evaluated by a sexual medicine gynecologist and received an extensive medical history, psychosexual assessment, and a focused gynecologic examination.

RESULTS

Fourteen patients (7%) did not have cancer and were excluded from further analysis. Of the remaining 190 patients, the median age at initial visit was 48 years (range 22-76) and the majority of patients were menopausal (87%). The most common diagnosis was breast cancer (44%). One hundred twenty-eight patients (67%) had prior pelvic surgery and 43 (23%) had prior pelvic radiation. The most frequently encountered sexual complaints were dyspareunia (65%), vaginal dryness (63%), hypoactive desire disorder (46%), and orgasmic dysfunction (7%). At initial presentation, 52 patients (27%) reported having a prior or concurrent psychiatric diagnosis and 72 (38%) were taking an anti-depressant and/or an anxiolytic. Treatment recommendations for sexual dysfunction consisted of psychosexual counseling, psychiatric referral, vaginal moisturizers and lubricants, hormonal therapy with minimally absorbed vaginal estrogen suppositories, vaginal dilators, and/or skilled exercise.

CONCLUSION

Psychiatric conditions are commonly encountered in the oncology population as are the medications to treat them. Because it is well established that these medications are often implicated in sexual dysfunction, further research is needed to determine the mechanism of action within the desire pathway of the cancer patient and treatment of such disorders.

Sexuality in palliative care: patient perspectives

This qualitative study investigated the meaning of sexuality to palliative patients. Face-to-face interviews were conducted with ten patients receiving care in a tertiary palliative care unit, a hospice or by palliative home care services in their homes. Several themes emerged. Emotional connection to others was an integral component of sexuality, taking precedence over physical expressions. Sexuality continues to be important at the end of life. Lack of privacy, shared rooms, staff intrusion and single beds were considered barriers to expressing sexuality in the hospital and hospice settings. Only one subject had previously been asked about sexuality as part of their clinical care, yet all felt that it should have been brought up, especially after the initial cancer treatments were completed. Home care nurses and physicians were seen as the appropriate caregivers to address this issue. Subjects unanimously mentioned that a holistic approach to palliative care would include opportunities to discuss the impact of their illness on their sexuality.