Chapter 25
The Impact of Cancer on the Partner’s Sexuality
Eusebio Rubio-Aurioles
Keywords  Partner • Distress • Bother • Female
sexual dysfunction • FSD
Introduction
Sexual interaction between two individuals may
lead to satisfaction, joy and a sense of intimacy,
or it may lead to frustration, pain and alienation.
Intact sexual function is by no means a guarantee
of emotional satisfaction [1] but may increase
the likelihood chances of positive outcomes in
most cases. On the other hand, sexual dysfunc-
tion typically leads to negative consequences for
the partner. In fact, the very expression of sexual
function usually implies the presence or partici-
pation of a partner, although sometimes the partner
is present only in fantasy.
When a patient develops a sexual dysfunc-
tion, the consequences for the partner should
always be considered [2]. The tendency to treat
“the problem” instead of the patient and his/her
partner context has engendered a relative disre-
gard for partner relationship factors in the emer-
gence of sexual medicine as a clinical field in
the last two decades. Despite the appearance
of very effective therapeutic tools such as the
E. Rubio-Aurioles (*)
Asociación Mexicana para la Salud Sexual, A.C.
(AMSSAC), Tezoquipa 26, Colonia La Joya, Delegación
Tlalpan, Mexico City, DF 14000, México
J.P. Mulhall et al. (eds.), Cancer and Sexual Health, Current Clinical Urology,
DOI 10.1007/978-1-60761-916-1_25, © Springer Science+Business Media, LLC 2011
phosphodiesterase type 5 inhibitors, the need to
include the partner in the assessment and treat-
ment has been neglected and in some instances
even questioned because of the time demand
that including partners in the assessment and
treatment processes would impose on medical
practice. Notwithstanding, there have been
repeated and urgent calls for inclusion of partners
in the assessment and treatment processes [2, 3].
In the case of cancer patients, partner conse-
quences of sexual dysfunction may be compli-
cated due not only to the impact of the loss of
quality in sexual function, but also to the impact
that the cancer diagnosis and its treatment may
have on the partner [4, 5].
This chapter provides a conceptual model that
helps to organize the clinical interventions with
partners of cancer patients. We provide also a
review of the current clinical perspectives and
approaches in this area. Recent publications on
the topic are reviewed, particularly those that
have addressed the impact of cancer on patients’
partners, especially in reference to sexual func-
tion and quality of life. Finally, specific recom-
mendations are made for inclusion of partners in
the healthcare process of patients with cancer.
What is Sexuality? Concepts
of Human Sexuality
Human sexuality is often thought of either as a
broad concept that practically pertains to all
human aspects or, to the contrary, to highly
383
384
specific sets of behaviors that lead to sexual
arousal and orgasm with their components of
pleasure and satisfaction. This extreme views are
not helpful overall to clinicians. Having an
overly restrictive view on sexual function may
stand in the way of understanding some relation-
ship complexities. Perhaps the best example is
the failure to restore sexual health of erection
drugs for a man who has difficulty with erection
since his partner relationship has deteriorated,
and he is unable to perform in the face of his
wife’s disapproval.
According to consensus definition:
Sexuality is a central aspect of being human
throughout life and encompasses sex, gender
identities and roles, sexual orientation, eroticism,
pleasure, intimacy and reproduction. Sexuality
is experienced and expressed in thoughts, fanta-
sies, desires, beliefs, attitudes, values, behaviours,
practices, roles and relationships. While sexuality
can include all of these dimensions, not all of them
are always experienced or expressed. ­Sexuality is
influenced by the interaction of biological, psy-
chological, social, economic, ­political, cultural,
ethical, legal, historical, ­religious and spiritual
factors [6].
This definition was derived in a consensus pro-
cess among over 60 international and national
experts on sexuality and sexual-health-related
issues. Sexual health was defined using a frame-
work similar to the WHO definition of health as
follows:
Sexual health is a state of physical, emotional,
mental and social well-being in relation to sexual-
ity; it is not merely the absence of disease, dys-
function or infirmity. Sexual health requires a
positive and respectful approach to sexuality and
sexual relationships, as well as the possibility of
having pleasurable and safe sexual experiences,
free of coercion, discrimination and violence. For
sexual health to be attained and maintained, the
sexual rights of all persons must be respected, pro-
tected and fulfilled [6].
In the case of a person who is diagnosed with
cancer, specific mental and physical processes
start to impact the person’s general health and also
his or her sexual health. In addition, the partner of
this person suffers an impact on his sexual health
(and his/her general health) that very often goes
unnoticed by the health practitioner. The partner
of a cancer patient very often has to undertake the
E. Rubio-Aurioles
role of care-taker, and in so doing many times he
or she experiences impact on his or her own health
and fails to look for help even if there are inter-
ventions designed to help them [4].
What follows is a conceptual model that is
offered to explain/interpret most of the findings
in the literature on the topic.
Human Sexuality from a Systems
Perspective: The Four Component
Sexual Model
In a previous publication, a model of human
sexuality was proposed based on General System
Theory principles, as proposed originally by Von
Bertalanffy [7]. This theory attempted to state
broad principles by which systems are organized.
Following these ideas, I proposed that sexual
interactions can be best accounted for if four
subsystems (or sexual holons) are considered:
(a) the reproductive potential that all human
beings have; (b) the fact that the species has
developed in a dimorphic way and which trans-
lates into the conformation of a gender identity
in all of us; (c) the potential to develop strong
emotional ties to specific persons both in a pri-
mary fashion (like the bond between mother and
child) and most importantly in a secondary fash-
ion when we develop romantic and other forms
of emotional attachment to specific persons –
a dimension denominated interpersonal bonding
and; (d) the capacity to experience pleasure asso-
ciated to the desire, arousal and orgasmic
responses typical of copulatory behavior that in
fact can occur in many other circumstances
beyond the copulation – a dimension denomi-
nated eroticism [8–11]. This model of human
sexuality bears a close resemblance to the cur-
rent WHO working definition quoted in the pre-
vious section: while the WHO working definition
has more elements than the four subsystems
identified in the holon model, the other elements
proposed in the WHO definition are in fact a
result of the particularities of the organization of
the primary four elements: sex, gender identities
and roles are derivatives of the second holon that
25  The Impact of Cancer on the Partner’s Sexuality
Reproductive Gender
potential Identity
Interpersonal Eroticism/
Bonding Sexual function
Fig. 25.1  Sexual subsystems (holons)
translates at the psychological level into gender
identity, eroticism and pleasure represent expres-
sions of the fourth holon: eroticism; intimacy
relates to one of the most clear expressions of the
interpersonal bonding capacity of human beings;
reproduction relates to the reproductive potential
and; sexual orientation is an expression of the
particular organization of eroticism and interper-
sonal bonding sexual holons. Figure 25.1 repre-
sents these four sexual subsystems or sexual
holons, each holon interacts with the other three
basically through the meanings that experiences,
feelings and behaviors produce with human
development and social interaction [11].
The Impact of Cancer on Sexuality
from a Systems Perspective
The diagnosis and treatment of cancer can have
a profound impact on sexuality of the individual
or couple. This chapter will present a review of
the evidence that has been published on this
particular topic but, as means of introduction,
we will present a conceptual model of how these
impacts are organized using the systems per-
spective just presented, immediately followed
by a review of the supporting evidence that has
been published.
385
The reported impact of cancer on sexuality of
patients is presented in Fig.  25.2 organized by
sexual subsystem that is impacted.
There are several cancers that impact
­reproductive ability in a direct way and
many, as a result of treatment maneuvers.
Reproductive potential is affected particularly
in couples who are in the reproductive years of
life: a not uncommon case is the female part-
ner of a prostate cancer patient who was plan-
ning a pregnancy before the diagnosis or a
younger woman who develops breast cancer,
or a young man that develops a cancer that
will shorten his life. In each of these instances,
the reproductive function of sexuality can be
severely impaired.
Cancers that directly impact body parts
(through cancer itself or its treatment) and which
are critical for body image constituents of gender
identity usually can affect the patient’s self-
image and his/her concept of himself or herself
as a man or a woman. In other instances, the
­disability that cancer or its treatment may lead to
limit one or more aspects of what is to be socially
expected in the patient’s sex role as a provider or
care-taker role of children in the family. The
patient’s sense of gender identity, especially in
its sense of being able to fulfill his or her roles,
can be severely impacted.
The diagnosis or treatment of cancer can impact
the interpersonal bond between patient and his or
her partner. The transition from a ­sexual-partner
role to a patient-in-need-of-care role, as well as the
stress that a real threat to life may pose to the indi-
vidual, can impact in a ­significant degree the inter-
personal bond of the patient and the partner.
Sometimes, the pre-existing relationship dysfunc-
tion experiences a worsening because of the stresses
generated by the life-threatening condition.
The impact of cancer on the sexual function
of the individual patient is often significant, as it
is reviewed in detail in other chapters of this
book. The cancer itself or its treatment as well as
associated depression or anxiety resulting from
or aggravated by the cancer processes are likely
to cause problems in sexual function ranging
from erectile dysfunction, ejaculatory dysfunc-
tion and loss of sexual desire in the man, to
386
• Cessation of reproduction because
• of cancer or its treatment
• Shortening of expected lifespan
that will prevent fulfill parental role
Reproductive
potential
Interpersonal
Bonding
• Modification of role form
partner/lover to patient in need of
care
• Stress in the relationship due to
the life threatening condition might make
worse pre-existing relationship
dysfunction
Fig. 25.2  Impact of cancer on sexual holons
pain, arousal and orgasm difficulties and desire
impairments in the woman.
Impact of Cancer on the Partner’s
Sexuality from a Systems
Perspective
The adverse effects that cancer can cause on
patients’ sexuality may cause, in turn, an adverse
effect on the partners’ sexuality. The following
sections present a review of studies and pub-
lished data on these effects. Here, a conceptual
model is proposed to understand these changes
in an orderly fashion, identifying the sexual sub-
system that is most directly affected.
Figure 25.3 is a representation of the different
effects that cancer might have on partner’s sexual-
ity. In Fig.  25.3a the impact on reproductive
potential is represented: while this impact is seen
only among patients and partners that have not
fulfilled their reproductive desires, when this is
E. Rubio-Aurioles
• Self image transformed because
of mutilating treatments specially
in sexually dimorphic body parts
(breast, genital area)
• Impact on provider/care taker role
because of disease or treatment
Gender
Identity
Eroticism/
Sexual function
• Sexual dysfunction created by
direct action of cancer, its
treatment or secondary to
depression and /or anxiety
resulting from the diagnosis and/or
treatment of cancer
the case such as in cases on prostate cancer when
the female partner is still in reproductive age and
with plans to procreate with the cancer patient, the
impact on her reproductive potential is clear as it
is the impact of gender-related expectations –
some women do see themselves as complete
women when they become mothers.
Figure 25.3b represents the impact on gender
identity of cancers that alter the self-image due
to alterations of body parts that are critical for
the identification of the person as woman or man.
Gender identity can be also impacted by the
impairment of expected social roles as provider
or care-taker in the family. The impact on the
partner of these changes can inflict stresses on
the interpersonal relationship or the capacity to
see the partner as a sexually attractive person.
Figure  25.3c represents the potential conse-
quences of cancer for the roles’ partners may have
before and after the cancer: ranging from partners
in an equal level relationship to caretaker–patient
relationship. If the couple had a dysfunctional
relationship, the stress generated by the threat to
25  The Impact of Cancer on the Partner’s Sexuality 387

a b
• Self image transformed because
•Cessation of reproduction because of mutilating treatments specially
Reproductive Gender •of cancer or its treatment Reproductive Gender
in sexually dimorphic body parts
potential Identity •Shortening of expected lifespan potential Identity
(breast, genital area)
that will prevent fulfill parental role •Impact on provider/care taker role
because of disease or treatment

PATIENT PATIENT

Eroticism/ Eroticism/
Interpersonal Interpersonal
Sexual Sexual
Bonding Bonding
function function

Reproductive Gender Reproductive Gender

potential Identity potential Identity

PARTNER PARTNER

Eroticism/
Eroticism/ Interpersonal
Interpersonal Sexual
Sexual Bonding
Bonding function
function

c d
Reproductive Gender
potential Identity Reproductive Gender
potential Identity
• Sexual dysfunction created by
direct action of cancer, its
PATIENT treatment or secondary to
PATIENT depression and /or anxiety
resulting from the diagnosis and/or
treatment of cancer
Eroticism/
Interpersonal Interpersonal Eroticism/
Sexual
Bonding Bonding Sexual
function
function
Reproductive Gender
Identity Reproductive Gender
potential potential Identity
• Modification of role form
partner/lover to patient in need of
care PARTNER PARTNER
• Stress in the relationship due to
the life threatening condtion might
make worse a pre-existing relationship
dysfunction Interpersonal Eroticism/ Eroticism/
Sexual Interpersonal
Bonding Sexual
function Bonding
function

Reproductive Gender
potential Identity

PATIENT

Interpersonal Eroticism/
Bonding Sexual
function

Reproductive Gender
potential Identity

PARTNER

Interpersonal Eroticism/
Bonding Sexual
function

Fig. 25.3  Impact of sexual changes of cancer patients on partner sexuality from a systems perspective. See text for
description of the five different diagrams (a–e)

life and quality of life can easily make the pre- ability to experience the interaction with the
existing problems in the relationship significantly patient as erotic determining the appearance of
worse. These changes can impact the partner’s sexual difficulties or dysfunctions.
388
Figure  25.3d represents the potential effects
of cancer on sexual function of the patient. These
changes have been reviewed in detail in other
chapters on this book. There is evidence that the
sexual dysfunction precipitated, maintained or
worsened by the cancer, the cancer diagnosis
through its psychological impact, and the cancer
treatment does impact the sexuality of the partner
in many dimensions: when the reproductive
needs of the partner have not been fulfilled the
impact is clear, the gender identity of many people
whose partner cancer that determines sexual
dysfunction such as the disappearance of sexual
desire can be impacted with feeling of rejection
and isolation. The fact that the cancer patient can
become sexually unavailable can impact the
nature of the interpersonal bond with his or her
partner, creating a nonsexual bond and finally,
the presence of a sexual dysfunction will deter-
mine a deterioration of the partner sexual func-
tion that might translate into dysfunctional
levels.
Figure 25.3e represents the complex interac-
tions among these effects. What is important
from a clinical-intervention point of view is to
recognize that the several types of effects do not
necessarily impact directly on the sexual func-
tion of the partner, but potentially indirectly
though effects on other areas on the partner’s
sexuality.
In the following sections, recent studies and
articles that have addressed these issues will be
briefly reviewed. The review will touch on litera-
ture documenting the impact of sexual dysfunc-
tion on the female or male partner, and the impact
that cancer may have in general, as well as
­specific types of cancer and their impact on the
sexuality of partners.
Impact of Male Sexual Dysfunction
on Partners
There is now a large body of data on the impact
of erectile dysfunction on the female partner.
The Female Experience of Men’s Attitudes to
E. Rubio-Aurioles
Life Events and Sexuality (FEMALES) study
[12] included the responses of 293 female part-
ners of men with erectile dysfunction to a ques-
tionnaire that investigated their frequency of
sexual activity and the nature of their sexual
experience, both before and after the develop-
ment of the partner’s erectile dysfunction.
Women participating in the FEMALES study
reported lower frequencies of sexual activity,
lower levels of sexual desire, arousal or orgasm
and satisfaction with sexual relationship com-
paring the measures after and before the
appearance of erectile dysfunction in the part-
ner. In a recent reanalysis of this data set an
analysis of the concordance and discordance of
answers given by the male and the female part-
ners was presented [13]. A high level of con-
cordance was encountered for most of the items
investigated: the perception of the female part-
ner on the level of functional impairment and
the frequency of male erection difficulty was
strongly associated with assessment made by
the male partner. This high level of concor-
dance was also demonstrated in the develop-
ment of a questionnaire that when answered by
the female partner gives the same quality of
information for detection of erectile dysfunc-
tion compared with the information given by
the male partner [14].
A qualitative study to identify areas of
impact and clues for detection of the male
erectile dysfunction by the female partner was
part of the development of the female erectile
dysfunction detection scale (FAME) [14]. The
descriptors identified are relevant for the
present discussion as they portrait very well
the female experience of her partner erectile
problems. These categories are reproduced in
Table 25.1.
The effect of erectile dysfunction on female
sexual function and on the quality of sexual
quality of life of the female partner can be
restored if proper treatment for the male erectile
dysfunction is implemented. A clinical trial using
a double blind placebo controlled and random-
ized design evaluated the impact of the treatment
with vardenafil on the female sexual function
25  The Impact of Cancer on the Partner’s Sexuality
Table  25.1  Impact of male erectile dysfunction as
perceived by the female participants in two focus groups
[14]
Psychological impact on the man
  Anger
  Anxiety over sexual performance
  Denial of erectile failure
  Depressive mood
  Loss of confidence in obtaining erections
Psychological impact on the woman
  Increase of female somatic complaints
  Anger in the woman
Impact on the relationship
  Preoccupation with unfaithfulness of the woman
  Fear of unfaithfulness of the man
  Woman feels rejection
  Man becomes aggressive
  Man blames woman for erectile failure
  Man seeks reassurance of his male identity
  Man concedes failure in his male duties
  Man compensates for failure with other behaviors
  Communication about erectile failure becomes
difficult
  Woman becomes concerned with man’s health
Sexual satisfaction of the woman
  Erection feels less satisfying
  Sexual desire diminishes in the woman
  Foreplay produces less arousal in the woman
which improved significantly when female
sexual function was considered as a whole, and
in the domains of desire, arousal, lubrication,
orgasm and satisfaction [15]. The quality of
sexual life of both the male and his female
partner was also improved when couples were
treated with daily doses of tadalafil as reported
in another double blind placebo controlled and
randomized clinical trial [16]. Finally, treat-
ment of erection dysfunction with sildenafil
was also shown to improve the rates of sexu-
ally satisfying encounters and sexual function
and intercourse success rates in a placebo con-
trolled trial [17] and in an open label trial, it
improved the quality of sexual life of the
women partner [18].
There is considerably less information with
respect to other male sexual dysfunctions and
their impact on the female partner. One report
389
that examined the frequency of sexual dysfunc-
tion among female partners of men with prema-
ture ejaculation offers some information [19].
Female partners of men with premature ejacu-
lation had higher frequency of sexual dysfunc-
tion (77.7%) than controls with no sexual
dysfunction partners (48.2%), the most common
problem was problems with arousal sensation
and orgasm, when all domains were considered
(desire, arousal sensation, arousal lubrication
and orgasm) significantly higher rates were
found among partners of men with premature
ejaculation. In a review of studies that have
addressed the impact of premature ejaculation
on psychosocial function and partner effects,
Rosen and Althof [20] concluded that women
are impacted by premature ejaculation as much
as their male partners and possibly more; studies
included report high levels of interpersonal
difficulty, avoidance of discussion of sexual
problems with partner and lack of satisfaction
with relationship in general.
No published reports were available for this
review on the impact of male desire problems on
sexual function in their female partners. However,
given the clear role that sex has as a form of vali-
dation of one’s attractiveness and desirability, it
seems reasonable to assume that the disappear-
ance of one’s partner sexual desire has an impact
on how the partner feels about herself or himself.
This observation is supported by the author’s
clinical experience.
Likewise, there is a paucity of research addres­
sing the impact of male sexual dysfunction on
male partners for the case of same sex couples.
There are, however, a number of reports in the
literature indicating that there are specific issues
in gay couples that create special clinical needs
such as the impact of homophobic or heterosexist
attitudes and the consequence in societal isola-
tion; however, many other aspects of the interac-
tion among gay couples actually share the
dynamics and particularities with heterosexual
couples [21, 22]. It is possible that similar effects
on the male partner of the male with sexual dys-
function are observed, but this area clearly needs
further research.
390
Impact of Female Sexual
Dysfunction on Male Partners
There is surprisingly little published data on the
impact of female sexual dysfunction on the male
partners’ perceptions and function. There is a cul-
tural assumption that asserts that the one who
suffers the effects of the diminished quality of
sexual interaction is the female partner, but this
assumption is based entirely on cultural stereo-
types that portray males as reflexive and insensi-
ble participants in the couple dynamics. Clinical
practice support the idea that a man whose female
partner experiences a sexual dysfunction cer-
tainly realize the problem, and the reactions that
have been documented in the male sexual dys-
function literature: feelings of rejection, lack of
validation of one’s identity, isolation and the like.
The old idea that in sex, men are the “doers” and
women the passive “recipients,” seems to pervade
the current literature. The untruthfulness of this
assumption was critiqued effectively more than
40 years ago by Masters and Johnson [23].
The more adjusted the couple is, the less
impact a woman’s sexual dysfunction will have
on female distress level [24]. The issues investi-
gated by authors looking at the effects of partner
compatibility on the distress associated with
female sexual dysfunction included: too little
foreplay before intercourse, too much foreplay
before intercourse, partner more interested in sex
than the female, lack of perceived partner’s ability
to do things right during sexual activity, lack of
perceived personal ability to do things right during
sexual activity, partner’s sexual needs that the
female is not willing to satisfy, female sexual
needs that partner is not willing to satisfy, partner
not attractive enough, poor communication about
sex, and partner sexual dysfunction (erectile dys-
function or premature ejaculation). All of these
factors were associated with higher levels of sex-
ually related distress in the female.
Information on the impact of female sexual
dysfunction on lesbian couples is also scarce and
anecdotal [25, 26]. Again, in addition to topics
specific to sexual orientation, the impact on partners
resembles the pattern observed among hetero-
sexual population.
E. Rubio-Aurioles
Impact of Cancer Diagnosis
and Treatment on the Partner’s
Sexuality
Psychological Impact of Cancer
on Partner
In recent years there has been a growing awareness
of the impact of cancer diagnosis and treatment on
partner’s sexuality and couples’ interpersonal
issues. The challenges that cancer brings to both
patients and partners are worth considering.
A review by Pitceathly and Maguire [4] offers a
perspective on the impact of cancer on the couples’
relationship that can be summarized as follows.
Psychological distress and psychiatric mor-
bidity is common among partners of cancer
patients. While most partners adjust to the diag-
nosis, about 20–30% develop psychiatric mor-
bidity in the form of major depressive disorder,
anxiety or adjustment disorders. Since most
studies are performed only at a specific point in
time, Pitceathly and Maguire [4] point out that
the actual prevalence is likely much higher if one
considers the progression of the cancer over
time. Psychological difficulties sometimes are
not recognized by partners, and it is estimated
that only half of those with psychological
­problems will actually seek help.
The psychological impact of cancer will vary
depending on vulnerability, intrapersonal and
interpersonal factors. Among the vulnerability
factors it seems that females are more likely than
males to develop depression and affective disor-
ders (an association that has been described for
the general population but that holds true for
partners of cancer patients) [4].
Personality factors (e.g., high levels of neuto-
ticism) and a previous history of depressive dis-
orders also increase vulnerability. The stage of
the cancer and the number and degree of symp-
toms are also of relevance: psychological prob-
lems and morbidity increase as the illness
progresses, particularly when patients are suffer-
ing from advanced and terminal disease [4].
There are intrapersonal factors that can play a
protective or precipitating role in the development
25  The Impact of Cancer on the Partner’s Sexuality
of psychological problems. The partner coping
style, that is the person’s characteristic strategies
to deal with life problems or traumas, has been
described as a factor: partners and caregivers that
have an avoidance coping style are more likely to
develop problems, when the partner uses a more
problem focused coping style the frequency of
mental health problems decreases. The appraisal
of the cancer in the partner has been linked to the
quality of the adjustment: partners who have opti-
mistic appraisals tend to be less depressed than
those with negative appraisals [4].
A number of interpersonal factors also medi-
ate the appearance of psychological complica-
tions. The amount and quality of informal
support (family, friends) seems to exert a protec-
tive role. The quality of communication with
partner also has some protective role. Of special
note is the quality of the marital/sexual relation-
ship of the couple prior to cancer, as it predicts
psychological problems in the partners/carers.
Couples that had a supporting and close relation-
ship do better. However, the quality of the rela-
tionship can be difficult to evaluate in some
instances because the impact of the cancer can
deteriorate the relationship. Psychological prob-
lems in the partner are less common when the
needs for medical information are met [4].
In summary, Pitceathly and Maguire [4] review
effects on cancer patients who develop high levels
of emotional distress or psychiatric morbidity and
have more negative reactions to the patient’s ill-
ness. The use of avoidance as a coping style is
related to more psychological problems in the
carer. Deterioration of the couple relationship
may also affect the partner’s adjustment and fac-
tors such as personality, gender, age and marital
difficulties predating the cancer may play a pre-
cipitating role. Formal and informal support
seems to be helpful in adjusting to the cancer.
Sexual and Intimacy Effects
of Cancer on the Partner
Hawkins et al. [5] investigated with qualitative
data the changes in sexuality and intimacy after
391
cancer using open-ended questionnaire responses
of 156 care-givers of persons with cancer who
were also sexual partners. In depth interviews
with an additional 20 participants completed the
information. Most participants reported an
impact of cancer in the sexual relationship: 64%
of those with “nonreproductive” cancer types
and 84% of partners caring for a person with
cancer involving “reproductive” sites. Cessation
or decreased frequency of sex and intimacy was
reported by 59% of the women and 79% of the
men. Renegotiating of sexuality and intimacy
was reported only by 19% of the women and
14% of the men. The main reasons for the
changes in sexuality given by participants were:
impact of cancer treatments, exhaustion due to
caring and repositioning of the person with can-
cer as a patient, not as a sexual partner. Additional
reactions to the impact of cancer on sexuality
included reports of self-blame, rejection, sad-
ness, anger and lack of sexual fulfillment
although positive impacts were also reported
like acceptance of the changed sexual relation-
ship and increases in closeness and intimacy.
As stated, most participants in the Hawkins
et al. [5] study reported complete cessation of
sexual activity or a marked decrease in fre-
quency. For those experiencing a complete
cessation, the “end” of the sexual relationship
was reported as a sudden event: “our sex life
disappeared overnight…” “A big chunk of
your life is lost”… …“you are a widow with
­somebody that’s still around” are extracts of
interviews presented by authors that reveal the
nature of the feeling reported by participants
of this study.
Interestingly, some participants found ways
of renegotiating sexual and nonsexual intimacy:
men (12%) where more likely than females (1%)
to report having developed alternative sexual
behaviors than those practiced before the cancer,
the changes included changed sexual positions,
or alternative means of stimulation such as oral
sex, massage, masturbation or the use of a vibra-
tor. On the other hand, women (18%) were more
likely than men (5%) to report that renegotiation
included nonsexual intimacy such as hugging
and cuddling.
392
For almost a third of the women (28%) and
half the men (47%) participating in the Hawkins
et al. [5] study the caring role resulted in a repo-
sitioning of the person with cancer as a patient,
which subsequently influenced their sexual rela-
tionship. The following excerpt from one of the
interviews is illustrative of this point: “I feel dis-
gusted with myself that I would inflict sex upon
a dying woman, having said that my wife does
not object and occasionally welcomes it, saying
it is a life giving and loving act and part of our
sacrament… I was never a fast lover, nut now
I try to get it over and done with for her [45 year
old man caring for a 44 year old wife with breast
cancer].”
For some care-takers the cancer and conse-
quent changes in sexual activity in their lives
have facilitated more intense feelings of close-
ness and intimacy, for others these changescre-
ated feelings of sadness, rejection, anger,
exclusion, self-blame and sexual frustration.
One finding reported by Hawkins et al. [5]
has direct implications for clinical care. Only
20% of partners of persons with cancer par-
ticipating in the study reported that they had
had a discussion on sexuality with the health-
care professional. The rate varied with the
type of cancer: 50% of those with a partner
with prostate cancer, 33% for brain, 33% for
pancreatic, 30% for breast, 29% gynecologic,
20% for cancer affecting a sexual organ, 17%
for colorectal/digestive, 17% for mesothe-
lioma, 9% for hematologic and 0% for respira-
tory. What is even more disturbing is the fact
of the 20% of participants who had had a dis-
cussion with the health professionals, only
37% indicated that they were satisfied or very
satisfied. When participants were interviewed,
the accounts are openly critical of the health-
care professionals on the point of discussion
of sexuality: they reported being told things as
“oh, you do not need to know that and things
like that,” or that they were “irresponsible to
be thinking about children” in response to a
question on fertility, for the majority they
simply indicated that sexuality was not dis-
cussed at all.
E. Rubio-Aurioles
Psychosocial Impact on the Partner
of Men with Prostate Cancer
The case of prostate cancer represents a special
one as advances in prostate cancer treatment are
leading to a growing proportion of patients living
with the effects of cancer and its treatment. In a
review of the literature about the psychosocial
adjustment of partners of prostate cancer patients,
Couper et  al. [27] present the following sum-
mary: Prostate cancer can have marked psycho-
social repercussions for the partner. Studies have
reported that partners are frequently more dis-
tressed than patients. Although distress may
diminish over time, a proportion of partners
remain adversely affected years after the death
of the patient. According to this review, partners
of prostate cancer patients are more active in
seeking information and making treatment deci-
sions than partners of women with breast cancer.
Also, there is some evidence that involving the
partner of prostate cancer patients in treatment
decisions and planning helps the patient to
increase his well-being. A prevalent concern
exhibited by patients is related to sexual func-
tion: partners tend to reassure patients who expe-
rience erectile dysfunction and do not address
their own sexual needs. Urinary incontinence, on
the contrary, may have a greater adverse psycho-
logical impact on the partner than on the patient
himself.
Social support, coping style that employ
problem solving strategies or seek social support
instead of avoidance or impulsive seem to pro-
tect the partner. A number of interventions which
incorporate the partner could be devised but
authors point out to the need for research in this
area. Logical alternatives would be interventions
that increase protective factors: coping style and
social support [28].
The sexual function of the female partner of
the prostate cancer patient has been evaluated in
a study that utilized validated measures for both
the male and female sexual function. Although
the reported response rate to an invitation sent to
1,134 couples was extremely low (8%, 90
­couples) female sexual function was correlated
25  The Impact of Cancer on the Partner’s Sexuality
to male erectile function: the more affected the
erection function, the lower the indexes of female
sexual function. Perhaps more interestingly, par-
ticipants indicated that their sexual function
assessed subjectively had decreased significantly
in 58.4% of participants, and a further 20.2%
indicated that it had decreased somewhat [28].
Impact on the Partner of Women
with Breast Cancer
Despite the rather abundant literature on the psy-
chosocial impact of breast cancer on the patient,
limited attention has been given in the literature
to the impact on the partner. A brief comment in
a report that included 558 patients that had com-
pleted primary treatment for breast cancer com-
ments that 60% of patients were sexually active
at the end of their breast cancer treatment; the
limitations to sexual activity were reported by
patients as follows: 1/3 reported no limitations,
24.4% reported not having a partner, or reported
problems related to partner as the reason for lim-
itation of sexual activity: 7.2% reported that
partner was not interested, 8.8% reported that
partner had physical problems that precluded
sexual activity, and 4.7% reported that partner
was too tired [29].
The impact of breast cancer will be covered at
length elsewhere in this book. There is also some
evidence that the influence of psychological
response on survival of breast cancer does impact
the survival rates on breast cancer patients [30].
Body image has been shown to be clearly related
to sexual satisfaction in women [31]. Clinical
experience indicates that the frequency with
which it is the male partner that experiences dif-
ficulties in recognizing the patient as a sexual
being is frequent and troublesome. The impact
on sexuality of breast cancer patients has been
shown to be related to the degree of alteration of
parts of the body that impact body image and
feelings of attractiveness: among 1,957 breast
cancer survivors 29.8% of patients undergoing
lumpectomy reported negative impact on sex
393
life, compared to 45.4% of those who underwent
mastectomy with reconstruction and 41.3% of
those who had mastectomy alone [32]. How
much of these effects are related to partner reac-
tions deserves to be explored and empirically
tested, although the conclusion from clinical
experience is that the partner reaction, ability to
cope and adjust to the changed body image of
his (or her) partner and the ability to develop a
more integrated form of interaction with the
complete person, and not with a specific body
part, are critical for the adjustment of the couple
to the new situation.
Clinical Intervention of Health Care
Professionals
This chapter has reviewed the evidence that
documents the impact on the partner’s sexuality
when cancer is diagnosed and treated. While
partners are usually reluctant to be treated when
his or her partner is being treated for a life-
threatening condition, the evidence suggests that
ignoring the needs of partners can be detrimental
to them and to the patients themselves: when a
more positive outlook is constructed the survival
rates can be improved, at least in some forms of
cancer [30].
While the inclusion of the partner in the
healthcare plan of the cancer patient might seem
unnecessary and be viewed as a unnecessary
investment on the part of the health care profes-
sional, the reality is that with a relatively brief
intervention, the inclusion of the partner in the
process of cancer treatment or rehabilitation can
improve the outcome of the therapeutic efforts of
the healthcare team.
Table 25.2 presents a series of questions that
have been adapted based on the consensus
approach developed by Dean et  al. [3]. These
questions can serve as a lead in during the con-
sultation of the cancer patient to assess and sug-
gest avenues for improvement or referral when a
patient is being treated for a cancer condition.
394
Table 25.2  Questions that clinicians can use addressing
the impact of cancer and its treatment on partners
sexuality
Have you spoken with your partner about your sexual
ability?
Is your partner supportive of you getting treatment to
improve your sexual satisfaction or his/her sexual
function or satisfaction?
Does your partner have any concerns about the
treatment impacting your sexuality?
Does your partner want to come and talk to me or to
another doctor about improving your sex life
together?
Do you know if your partner has any concerns about
her/his own sexual function, or about any other
health issues?
Is there anything else I should know to help me
understand the impact that cancer has in your
sexuality?
Modified after Dean et al. [3]
Conclusion
This chapter has presented an integrated vision
of the impact of sexuality of the partner of can-
cer patients. The evidence reviewed indicates
that cancer patients and their partners experi-
ence significant effects in multiple domains.
A conceptual model has been proposed for
understanding these effects. While sexual
health has been neglected by medical practice
for many years, the fact is that sexual health
remains a central aspect of health and well-
being for individuals and couples. While
improving quality of life of cancer patients has
become a more recognized goal of clinical
intervention, addressing the sexual needs of
partners can change the quality of life of can-
cer patients, as well as improving the chances
of survival as the recent research on the effects
of psychological consequences on cancer sur-
vival (at least on breast cancer) has shown [30].
Overcoming the obstacles to address these
needs is a responsibility of health care profes-
sionals generally; we hope the present review
might provide a tool toward this end, which
ultimately will benefit our patients.
E. Rubio-Aurioles
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