The affective spectrum during cancer treatment ranges from disbelief to clinical depression and typically changes over time. Anxiety and depression are the two most common affective disruptions among patients with cancer and both have been found to have deleterious effects on sexual functioning.[3,4,5,7,18] A clinician should be aware of current mental status and any history of depression or other psychiatric disorder, previous psychotherapy, treatment with psychotropic medication, and/or hospitalizations. Current use of psychotropic medications should also be reviewed with respect to impact on sexual function. Cancer treatment can produce changes to the body that negatively impact body image and self-esteem.[4,5,19] Commonly, patients have difficulty seeing themselves as sexually attractive during and after treatment. Identifying body-image disturbances is important to incorporate into goals of care and rehabilitation. Frequently, the couple experiences changes of social roles during treatment. An individual's identity and sense of worth may be threatened when role changes occur.[4,15] The partner's participation in the patient's physical care often negatively impacts feelings of sexuality. Younger couples, more than older couples, may be vulnerable to problems with playing alternative or new domestic roles and experiencing the myriad life and financial stressors associated with treatment.
To better illustrate the relationship between sexual health and psychological health, numerous sexual, physical, and psychological measures were examined in a cross-sectional study of 186 partnered women who had gynecologic cancers. Diagnoses included endometrial, ovarian/peritoneal, cervical, and vulvar cancers. Most women had stage I to stage III cancers and were white, college educated, and married. Their mean age was 55 years. Sexual morbidity was defined as a summed score of the following five factors:
- Appearance/desire (seven items).
- Satisfaction/activity (six items).
- Arousal (seven items).
- Lubrication (four items).
- Pain (four items).
Sexual morbidity was moderately and significantly correlated with depression (r = 0.34) and traumatic stress (r = 0.30). It was also low-moderately correlated with body image (r = 0.25); and with both components of the Medical Outcomes Study—Short Form 12: physical health (activity interference/general health, r = 0.34) and mental health (calm/downhearted, energy, emotional problems, r = 0.25). Sexual morbidity was moderately to strongly and significantly correlated with fatigue (r = 0.44). Sexual morbidity also contributed uniquely and significantly to depression, accounting for 48% of the variance; body change stress, 26% of the variance; and psychological quality of life, 31% of the variance. The authors concluded that addressing sexual morbidity may improve psychological health.
Medical Aspects of Sexuality
The clinician should ascertain past medical history with a particular emphasis on other concurrent medical illness for which the patient is receiving treatment. Comorbidity contributes to risk of sexual dysfunction and additional decrease in social and role functioning, mental health, and health perceptions. Medical illnesses that impact the endocrine, vascular, and nervous systems are all known to have a potential deleterious effect on the sexual response cycle.[13,21,22] Diabetes, hypertension, vascular disease, multiple sclerosis, and many other disorders impact sexual function, particularly the quality of erections in men. Two textbooks extensively review the impact of chronic illness and disability on sexual function.[13,22] In addition, with the growing body of evidence demonstrating the severity and chronicity of fatigue in cancer survivors, the co-existence of cancer-related fatigue may be a major barrier. In a descriptive cross-sectional study, fatigue was significantly and moderately correlated with all sexual functioning and satisfaction measures in 175 women with gynecologic cancer. Therefore, assessing and addressing cancer-related fatigue, even in long-term survivors, is important.