It’s unfortunately an “unmentionable” subject that even makes many physicians
blush – and many others avoid raising the subject at all. But as growing numbers
of cancer survivors want to resume intimate relations with their partners,
raising awareness of the problem and offering clinical help need to be put on
Prof. Sharon Bober, a clinical and research psychologist at
Harvard Medical School’s Dana-Farber Cancer Institute and the faculty’s
psychiatry department is doing much to increase awareness. In fact, she is
director of the institute’s multidisciplinary sexual health program for cancer
survivors, which is the only sexual health program of its kind in the whole
state of Massachusetts.
One of the handful of Israeli experts in the
field is Dr. Rivka Klein, a Jerusalem-based clinical social worker and sex
therapist who received her PhD in social work at the Hebrew University – but
very few of her colleagues have training in this specific field. Yet when the
two women met for the first time on the occasion of the International Society
for the Study of Women’s Sexual Health conference in Jerusalem, they used the
same terminology and conversed with familiarity, as if they had worked together
Klein was surprised that Bober knows some Hebrew. “I lived
here as a student 25 years ago, and last visited in 2000,” Bober
The conference, at the Crowne Plaza Hotel, brought together
psychologists, psychiatrists, social workers and others who work in the field of
women’s sexual health.
The Harvard psychologist graduated from Clark
University in Massachusetts that since 1994 has managed a bilingual graduate
program and branch campus here. She then did her postdoctoral work at Harvard
Medical School. She was especially drawn to the mix of cancer survival and
“It was not a subject that others were doing,” says Bober. “I
worked with cancer survivors; in the US alone, there are 12 million of them.
Returning to one’s previous level of intimacy can often be a problem, because
surgery, chemotherapy, radiotherapy and hormonal medications may cause a lot of
long-term side effects that interfere with sex.”
She believes that sexual
health is an important quality-of-life issue. As a behavioral medicine
psychologist, she takes an integrative perspective on human
Sexuality, she says, is an experience at the junction of
mind, body and relationship, and cancer treatment can affect all of those
elements. From the first session, she tells patients that sexual dysfunction
deserves as much attention as any other quality-of-life issue; that the problems
should not cause embarrassment or shame; and that there are treatments that
Cancer treatment may result in heart damage, kidney problems
and disruptions of both male and female sexual function.
Men can become
impotent, while women who had ovarian cancer can be propelled into early
menopause. Other types of cancer can also have side effects.
the example of one 38-year-old woman who suddenly lost her ovaries to cancer.
“She hadn’t been told about what would come next in her life. She wasn’t ready
for it. Her doctors told her she should be happy to be alive. But she and her
partner suffered from her hot flashes, vaginal dryness, fatigue, dramatic loss
of estrogen and lack of libido. She was depressed.”
Klein says the Israel
Cancer Association is “very good in its patient support work talking about side
effects. There are also ICA booklets in oncology departments about intimacy and
cancer. But many patients need more information, and their doctors don’t talk –
or even know how to answer.
Usually, either the patient is ashamed to
raise the issue or afraid to embarrass their doctor – or the physician doesn’t
know enough to raise it or afraid to embarrass the patient.”
is an observant Jew, Klein is not shy about discussing the matter with both
women and men – even with modern Orthodox or haredi (ultra-Orthodox) women and
“I find that men will talk to me. Sometimes men prefer to talk to a
woman about these intimate matters because they think that women are more
compassionate than a male therapist. A man who goes to a male therapist may
regard the professional as a mirror image of himself and feel threatened” When
it is helpful, “I tell them that even if a woman loses her clitoris to cancer,
there is a layer of tissue that can still make sexual arousal possible,” says
Klein. “I show diagrams of the physiology and tell them that I can help them.
Even without cancer, a person who suffers a myocardial infarction [heart attack]
and is afraid of physical activity can be rehabilitated and enjoy a good sex
Bober encounters many men who suffered nerve damage when their
prostate tumors were removed. Some benefit from erectile dysfunction drugs, but
some do not. It is very variable. Some men do fine, but 50 percent to 60% never
resume full erectile function,” she says.
The longer patients wait to
undergo rehabilitation of their sexual functions, the harder it is to
“It is very important for them to get oxygen flow into their
penile tissues,” she continues.
“It’s like the need for ordinary
exercise. Under normal circumstances, men get erections at night. The
body does it naturally to increase blood flow. At my center we teach men a
conditioning treatment to get the blood flowing, but not through sex, during the
first six weeks after the catheter is removed. This is a window of opportunity
for them, and without help, it could close.”
The Harvard therapist also
tells women patients about the need for stimulation.
“The penis is more
obvious, but it’s the same for clitoral stimulation. If a woman suddenly goes
into premature menopause and has low desire, she needs to stimulate blood flow
to the clitoris by various means.”
She also partners with a team of
physical therapists who help patients with weak pelvic floor muscles. Pelvic
physiotherapy is well-developed but too-little used, she says, as a treatment
for both men and women who have undergone pelvic radiation and are dealing with
the weakening of tissues.
In addition to her research and clinical work,
Bober regularly teaches physicians about how to talk openly about sexuality
after cancer. She has 40 professionals in her Dana Farber team.
are a lot of people who specialize in sexual medicine, but only a small subset
who work with cardiac and cancer survivors and medical illness. Even younger
cardiologists and oncologists may feel no obligation to talk about sexual
function with their patients or don’t like to discuss it themselves. We have
studied primary care doctors, many of whom weren’t prepared for broaching the
Klein adds that in Israeli medical schools, only a few hours of
the entire curriculum are devoted to sexual health.
“In American culture,
you hear about sex constantly, and also about breast cancer and other tumors.
But there is a taboo on discussing treatment for sexual problems that result
from them. Even many married couples who had good sex lives before don’t talk
about the issue,” says Bober. “It’s sad. Couples who had a good sex life didn’t
have to talk about it, as things were working properly, but afterwards, it’s
like the ‘elephant in the room.’”
Observant Catholic cancer patients she
encounters in her practice “seem to have more trouble talking about such issues
than other religious groups,” Bober says. “I tell them sex is not just about
penetration. Sexuality is a whole lot of other things. If you can’t do that any
more, your tool kit is not empty. There is much more to intimacy.”
problem cuts across a variety of Israeli religious and ethnic groups, adds
Male cancer survivors can get testosterone pills or patches, but
the hormone may cause cardiac problems and in older men, it might even cause
Women can’t always be given estrogen to improve their
sexual function. The pharmaceutical industry would love to find a magic pill.
Medications could have a huge placebo effect [making patients feel better
because they think pills help], Bober continues.
But “patients usually
need psychological treatment, an integrative mind/body model. Women who have had
a mastectomy, for example, usually feel very unattractive.
Men are happy
if their partners have breast reconstruction, but women feel different because
the surgery does not restore breast sensation, which is a big part of arousal.
Different erotic zones must be explored for the same result.”
As Jews of
Ashkenazi origin are statistically more likely to carry the BRCA gene – which
significantly raises the risk of premenopausal breast and ovarian cancer – Bober
asks Klein about prophylactic surgery to remove the organs to avoid the
“It is becoming very common in the US among BRCA carriers,”
notes Bober. “I currently am treating a 27-year-old BRCA carrier who is
undergoing prophylactic surgery.
Abdominal fat is often used to replace
breast tissue. If you saw them naked, you wouldn’t even know.”
answers that Israeli women in the same situation tend to avoid
“Here, prophylactic oophorectomy [removal of the ovaries to reduce
the risk of ovarian cancer] is much more common than prophylactic mastectomy,”
Bober has received a US National Cancer Institute grant to
develop a sexual health intervention for young, high-risk women who undergo this
Many women who become prematurely menopausal suffer
from vaginismus, in which dryness makes sex painful. The good news, continues
the psychologist, is that “many patients don’t need extended psychological
treatment. Education and information about lubricants, for example, may be
enough. Our center recently made a video on the subject to help. But American TV
wouldn’t broadcast a serious program on such subjects, even though sex talk is
The McMillan Cancer Center in the UK has a very nice, free
video. But much more informational material is needed.”
Klein, who has a
private practice, also works in a public health fund once a week so patients who
can’t afford it can get care by paying a nominal fee.
“I don’t want the
lack of money to prevent people in distress from getting help. I usually ask
couples to come together to a session at least the first time.”
decade, agree Bober and Klein, they hope the subjects of sexuality, therapy and
cancer will have “come out into the open.” They also both feel it is a “great
privilege” to do the work they do.
“It would be great if not only doctors
were educated and willing to discuss these issues, but patients were also
willing to hear about them,” they conclude. “There is no reason why people have
to suffer in silence. They have suffered enough already.”
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