In 1992, Dr. Helen Singer Kaplan, a sex therapist who had been diagnosed with breast cancer, stated, “The potentially devastating sexual consequences of the adjuvant treatments for breast cancer have been virtually ignored.” Not much has changed since 1992. Oncologists and other physicians rarely initiate providing information on the sexual impact of breast cancer and its treatment, they rarely ask about sexual adjustment, and they are even less likely to offer help. As a result, many women and their partners suffer in silence. They may believe their experiences are unusual or their sexual difficulties reflect their failure to deal with breast cancer well enough. How unfortunate this is, because the negative impact of breast cancer on sexuality is profound and widespread and because we can take steps to understand and resolve this problem.

One study of 50 women who had been diagnosed with breast cancer at least one year earlier revealed that two-thirds of the women reported a significant reduction in sexual desire with half experiencing an absence of any sexual desire. Over one-third found intercourse painful while nearly half reported problems with lubrication and achieving orgasm. Only two women out of the 50 said they had no sexual difficulties. These results are typical of studies that have been done on the impact of breast cancer.

Many reasons can be identified for the negative impact of breast cancer and its treatment (e.g., surgery, chemotherapy, radiation) on our sexuality, but the most important factor is estrogen depletion resulting from chemotherapy. This often causes reduction in libido or sexual desire, loss of vaginal lubrication, changes in the vaginal walls, and possible shrinking of the vagina. This makes intercourse painful and difficult rather than pleasurable and rewarding.

Other physical side effects of chemotherapy, especially when it causes premature menopause, include severe hot flashes and fatigue, further contributing to our loss of interest in sexual relations.

Although some of the changes in our sexual feelings do have a psychological basis, it is important to keep in mind that these changes are caused primarily by chemotherapy and have a genuine physiological basis.

Breasts are universal symbols of femininity and sexuality. When they become diseased, we can feel like our bodies have betrayed us. With breast cancer, we may lose not only all or part of a breast and our reproductive capacity, but also our view of ourselves as being sexual and alluring. The body that pleased us and our partners and may have given life to our children is now harboring disease and is causing us to feel anxious and worried about our futures. It is hard to feel erotic when we have these thoughts about our bodies. Some women may be very troubled by the visible physical impact of breast cancer. Hair loss, changes in weight, alterations in skin and nails, as well as, of course, changes in the appearance of our breasts can affect our self-image and our feelings about exposing ourselves and being intimate with our partners. Although for most women these reactions are not as powerful and enduring as their physiological reactions to chemotherapy, changes in self-image may well have a negative impact on sexuality.

One of the least likely causes of sexual difficulties in breast cancer survivors is rejection by their partners. The good news is that most husbands and partners are not put off by the physical changes that accompany breast cancer and are as attracted to their wives and partners as they ever were. Of course, there are exceptions. One man I saw for counseling had seen his mother die of breast cancer. Intimacy with his wife brought up fears and images that were so painful for him that he could not tolerate closeness with his wife. Another man had enormous self-doubts about himself and feared that he would cause his wife physical pain if they had intercourse.

Certainly, we should pay attention to our partner’s feelings, but more often than not, the source of the sexual difficulties is not in our partners. Sometimes we inadvertently create a situation in which our partner no longer seems to desire us. We may give subtle messages that sexual intimacy is nowhere near the top of our list. We may fall asleep watching television night after night, talk about how physically uncomfortable and exhausted we are, change our style of dress so that our body is disguised, and withhold hugs and pats that may be a prelude to greater intimacy. Under circumstances such as these, our partners may understandably conclude we are not interested in intimacy and may believe they are helping us by not making advances. A destructive cycle can ensue if we, in turn, believe our partners are rejecting and disinterested, and we withdraw further.

Fortunately, we do not need to suffer in silence. Hopefully, what you have already read has helped you to realize how common it is for breast cancer and its treatment to have a negative impact on sexuality. There is much we can do to improve our sexual self-images, our sexual functioning, and our sexual relationships:

Always Be honest with yourself and your partner.

If you are experiencing difficulties, think about what they are, when they happen, what they feel like and talk about them with your partner so that you both understand as clearly as you can what is happening.

Tell your gynecologist about your sexual difficulties and ask for help.

Although most breast cancer survivors should not take estrogen because it has been associated with an increased risk for breast cancer, other medical approaches are being investigated that may alleviate sexual symptoms while posing less risk. For example, many women who have been treated for breast cancer are suffering from testosterone deficiency and find that creams or other products containing testosterone are helpful.

Another possibility is the Estring.

Left in the vagina for three months, this releases estradiol, the human form of estrogen. Herbal remedies like black cohosh have also been found helpful. Keep in mind that the use of these products with breast cancer survivors has not been well studied and may pose health risks. You must consult your gynecologist, ask many questions, and even do some reading before you decide whether these or other medical products are right for you.

Try an over-the-counter lubricant.

Products such as Replens, Astroglide, Moist Again, and K-Y lubricants, used regularly, can increase vaginal lubrication and comfort. These can be purchased without a prescription, have been viewed as safe for cancer survivors, and can make a considerable difference in the physical experience of intercourse. Experiment using these products alone or in combination to determine what is most helpful to you. Also, using lubricants on a regular basis, every few days rather than only when you anticipate being intimate, can increase your daily physical comfort and allow for more spontaneity.

Use your brain as well as your body.

The brain has been referred to as our most powerful sexual organ. If we believe that we are no longer sexually desirable, that belief may become a self-fulfilling prophecy. On the other hand, if we can enhance our sexual self-esteem and restore our enjoyment of intimate times with our partners, we are likely to find that our sexual desire increases as does our lubrication and ability to experience orgasms. Although it may be difficult, try to think creatively about what you can do to enhance yoursexual feelings. One woman who felt uncomfortable with her appearance after a double mastectomy found that wearing lacy camisoles while being intimate with her husband was helpful. Sexual aids such as romantic or sensual videos, exciting magazines, and vibrators may be helpful. One woman for whom sex and arousal had been easy and routine before her cancer treatment found that she and her partner now enjoyed a bubble bath with candlelight and champagne on special evenings. Not only did that enhance her feelings of sexuality and desirability, but intimacy now became more special than it had ever been. Think about what you can do to set a scene that will help you to feel more sensual and enjoy more fully your intimate relations.

Establish realistic expectations.

Unfortunately, you may never experience the kind of sexual experience you had before cancer. However, keep in mind that a sexual experience consists of three parts: sexual desire, capacity to reach orgasm, and a sense of emotional gratification and intimacy. Even if one or both of the first two have been negatively affected by breast cancer and its treatment, a sense of gratification can still emerge from a sexual experience with a beloved partner.

See the whole picture.

Sexuality is only one aspect of an intimate relationship. Strengths in other aspects of the relationship–such as love and commitment to family, shared interests and activities, a common vision and lifestyle, and enjoyment of being together–can far outweigh the problems presented by sexual difficulties.

Remember that counseling can be empowering.

You may find that you are uncomfortable with some of these suggestions or that they do not work for you. Counseling may offer you some help. Seek out a licensed mental health professional who has experience in treating people who have been diagnosed with cancer. Think about whether you are more comfortable talking to a woman or a man. Then make an appointment. The person may be able to offer some ideas or to help you work through some of the old and new issues that may be limiting your enjoyment of sexuality.

Use self-talk to focus on what is right for you.

Emphasize the positive, focus on the love between you and your partner, and the intimacy that you do share. Consciously and deliberately think of yourself as desirable and attractive; you will probably succeed in convincing yourself of the truth of this statement. Enjoy all aspects of your relationships and celebrate your survival!

Dr. Linda Seligman is a psychologist in private practice in Fairfax, Virginia and a professor at George Mason University. She is also a nine-year breast cancer survivor. Author of Promoting a Fighting Spirit, she has written, lectured, and worked intensively to help people cope with cancer.