SEXUALITY & INTIMACY for Men after Cancer

1. SEXUALITY & INTIMACY for Men after Cancer Karen Syrjala PhD Co-Director, Survivorship Program Director, Biobehavioral Sciences a member of the

2. Topics: • How does cancer affect sexualityfor men? • What can you do about it?

3. What male cancer survivors say: “Sex really hasn't changed since my treatment. I have always been a sexual person and enjoy it immensely.” “Definite change in size of my penis, testicles and hardness of my erections. Wondering what is the cause. Treatment, medications, age?” “The summary is: 1) I have a little less desire, 2) my orgasms are less intense, 3) I have some anxiety over will I be able to stay hard enough, long enough to satisfy my partner?” “I've held back from relationships after treatment. Some of this has been concerns like "would a women want me when my life expectancy is uncertain…" “[After 2 years] it is only recently returning to normalcy.”

4. Fears of survivors & partners • “What if I can’t perform?” • Demanding too much • Rejection fear: • “He/she can’t find me attractive when I look like this.” • “He/she won’t be responsive if I ask so why ask?” • Talking will make it worse

5. Other Barriers and Beliefs • When it’s time, I’ll / he’ll / she’ll feel like it • Being alive is enough • He/she doesn’t want to talk about it • Nothing can be done so it’s cruel to bring it up • If it’s a problem, she/he’ll bring it up • It will take care of itself with time

6. Sexual Function Quality & Quantity Men recover in sexual quality and frequency rates by 2 years. But remain below rates for men without cancer. Syrjala et al. Blood, 2007

7. After Cancer: Who has more sex problems? • Poorer sexual function before treatment • Older age, especially for males • Poorer physical function at 1 year • Lower relationship satisfaction before treatment • Not returning to sexual activity by 1 year • Depressed or anxious

8. CHEMISTRY IS NOT MERELY CHEMICAL! • In the age of Viagra, Levitra, and Cialis, men and women hope for a simple solution to sexual problems after BMT • Although pills work for some, erections and orgasms are just ingredients in sex, not the whole recipe! • Affection, communication, patience, and creativity cannot be bottled!

9. MOST COMMON SEXUAL PROBLEMS for MEN • Lack of desire for sex • Erection problems • Pain with erection or climax • Premature ejaculation common in young men, but not related to cancer treatment • Most problems reaching orgasm occur because of lack of desire or pleasure

10. CAUSES OF PAINFUL SEX FOR MEN • Scar tissue in urethra or pelvic area (adhesions) can cause pain at ejaculation • From treatment: some men may develop skin inflammation on penis, unable pull back foreskin or develop curve or bend in erection, pain with erection (may resolve but needs treatment attention)

11. WHERE DID MY SEX DRIVE GO? • Treatments reduce the levels of androgen hormones (like testosterone) that stimulate sexual desire in the brain • Medication side-effects (meds for pain, nausea, anxiety or depression) • Feeling lousy (pain, nausea, fatigue) • Feeling unattractive or unable to function sexually • If intercourse or ejaculation is painful, hard to get in the mood • Performance anxiety: lack of erection leads to worry

12. HOW ERECTION WORKS • Signal from brain, through spinal cord, to nerves surrounding prostate and along the urethra • Nerves direct soft tissue inside shaft of penis to relax • Blood flows in like sponge filling with water • Pressure shuts off drainage system of veins • As pressure builds, penis becomes stiff

13. TREATMENTS THAT CAUSE ERECTION PROBLEMS • Pelvic radiation therapy can scar small blood vessels, gradually damaging nerves too, resulting in loss of erections • Some chemotherapy can reduce testosterone or damage nerves (alkylating agents – cytoxan)

14. HOW EJACULATION WORKS • As arousal builds, prostate and seminal vesicles contract, feeling of “inevitability” • Bladder neck squeezes shut and semen gathers below it, in urethra • Sensory nerves fire, causing rhythmic contractions of muscles at base of penis • Semen spurts out of penis and man feels pleasure of orgasm

15. DRY CLIMAX: MUSCLES CONTRACT & ORGASM FEELS GOOD, BUT NO SEMEN • Pleasure may be weaker, same, or stronger

16. Avoiding Ejaculation Emphasis,Performance Anxiety • Take time in foreplay rather than rushing to use an erection and creating more anxiety • Do not make orgasm during intercourse for your partner a goal that creates performance anxiety • Try self-stimulation earlier in the day or have sex more often • Numbing creams don’t work well, and numb partner too!

17. DOES TESTOSTERONE HELP? • IF TESTOSTERONE LEVELS ARE LOW, testosterone can help with desire • May be helpful in ‘low-normal’ not just ‘below-normal’ • Also energy, muscle capacity, initiative • Testosterone plus PDE-5 Inhibitors (cialis, levitra, viagra) can help some men with desire and erections • But not without risks

18. WHAT DO PDE5-INHIBITORS DO? • Viagra, Levitra, Cialis are PDE5-inhibitors • They help keep chemical reaction going to make spongy tissue relax inside penis • Makes it easier to get erection, especially if problem is mild or based on anxiety • No impact on desire or orgasm itself • May be easier to reach orgasm with a firm erection

19. IF YOU NOTICE LOSS OF VISION, CALL YOUR DOCTOR IMMEDIATELY!* WHERE IS THE PHONE? *TV AD FOR CIALIS

20. Men Prefer a Pill, but if ED is Severe, Pills do not work well. How much hassle is it worth to have hard erections?

21. WHEN NO ERECTION = NO AFFECTION • Men with erection problems often stop initiating sex or affection • Partners may be afraid to seem demanding by asking for touch • Result is not only loss of intercourse, but decreased nonsexual affection • Women rate this as more upsetting than the loss of sexual pleasure

22. CAN THERE BE SEX WITHOUT AN ERECTION? • Men are more focused than women on erections and intercourse • Most women have easier time reaching orgasm with manual or oral stimulation • Many couples enjoy non-intercourse lovemaking without firm erections • Most cancer treatment leaves desire, skin sensation, and orgasm intact

23. ISSUES FOR COUPLES TO DISCUSS • Erections may not be spontaneous • An erection may not be the barometer of a man’s desire for his partner • A man still needs foreplay, even if it is not necessary in order to get an erection • He may have a dry climax

24. PILLS TO ENHANCE SEXUAL DESIRE • No aphrodisiac yet, i.e. desire booster • Testosterone may increase risk of prostate cancer • PDE-5 Inhibitors may or may not help erections, require some planning, long term risks not really known • Be careful of claims for herbs or vitamins for men • Will give you urine full of vitamins!

25. STRATEGIES FOR STIMULATION • Exercise promotes good feelings about your body • Focus on your good points physically • Delight your senses • Give yourself permission to enjoy sexual fantasy and erotica • Talk to your partner about sexual fantasies and communicate about mutual pleasures and interests • What puts you in the mood for sex?

26. COMMUNICATION… • SET ASIDE TIME: Talk and listen! • Listen, try to remain open to the discussion. Keep the words non-blaming and ‘I’ focused. • Chance are both partners are interested in improved intimacy and sexuality. • Sensitive subject takes sensitivity, timing, neutral setting. (Not when you are tired or in bed expecting sex.) • Agree on a time, decide if prefer a neutral professional to assist.

27. MORE COMMUNICATION • Discuss your own fears and vulnerability • Appearance • Physical sexual response • Rejection/loss of relationship • Survival and recurrence • Recognize “hot topics” and know when to take a break

28. GOING BACK TO ‘DATING’ • Start with a plan for intimate time, not sex • Avoid the performance focus on sex • Remember the fun of “petting” • Try sex in the shower or tub • Get in the mood with dancing • Practice all by yourself • Try a “mini-vacation”: make time for sex

29. SETTING THE STAGE FORSEXUAL SHARING • Create a mini-vacation • Block 2 or more hours on a regular basis • Set the scene (music, lighting, candles) • Set realistic goals • Enjoy time together • Rediscover pleasure of physical touch • Learn your partner’s preferences • Begin with intimacy: talking and listening,kissing and caressing

30. BARRIERS TO SEEKING HELP • You need to bring up the topic with your doctor • Insurance may not cover all of the costs, especially mental health treatment • Both partners in a couple need to understand the range of treatments available and agree on one

31. SOLUTIONS IN FINDING HELP • Written materials: • ACS Sexuality and Cancer Booklets • Sexuality and Fertility after Cancer, Leslie Schover, 1997 • See an endocrinologist • See a sexuality specialist • Talk to sexual counselor with your partner