Navigating Cancer: Understanding Relationship Strain and It’s Impact

Guest Blog Post – By Christopher Brett-Renes BPsySc, GradDipPsyc, MScMed (Sexual Health Counselling), MACA (Level 3) 

Psychosexual Therapist. Associate Lecturer, Postgraduate Program in Sexual & Reproductive Health, Westmead Clinical School, University of Sydney. Expert Advisor for Healthy Male (Previously known as Andrology Australia)

Ten minutes before I started writing this post, I got a call from a very close friend in Sydney. The doctors had ‘found something’ and wanted to do further investigations. I asked if it was cancer. She replied, “the C word has not been used yet, but everything else has.” Cancer, just the very word, can put the fear of God into the happiest, most outgoing person.

When we hear that word, our minds are flooded with ideas of what we think cancer is, often informed by what we have seen on TV and in films. Many years before I went into mental health, I worked in palliative care, and since going into my current line of work, I have worked with both individuals and couples who are going through the journey of cancer or have survived it. 

In this blog, I will be discussing how cancer impacts sex, sexuality and relationships for women. 

When we say the phrase ‘sexual health’, our minds can be casted back to long and boring classes in high school about condoms and where babies come from. It is a little more complex than that. In 2006, the World Health Organisation defined sexual health as:

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction 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, protected and fulfilled.

As you can see, sexual health is rather extensive. It is important to keep in mind that when we talk about sex, there is a lot more to it than just reproduction – it does involve pleasure.

The impact of not talking about sex with patients

Research has shown many times that doctors (more so than nurses) are rather uncomfortable talking about sex with clients, and this is no different for women who have been diagnosed with cancer. It has been shown that for women of all ages and across all cancer types, sex is important, and that sexual problems during and after treatment are common (Kennedy and Leiserowitz, 2015).

In one study, researchers found that 50% of breast cancer survivors experienced some form of sexual difficulties (Burbie and Polinsky, 1992). Cancer treatments can cause some significant sex-related side effects, including vaginal dryness and irritation, lowered libido, painful intercourse, and premature menopause (Bakewell and Volker, 2005). Research has also shown that battling cancer is not just stressful and worrisome, but for a lot of women (50%) it is traumatic (Butler et al, 1999), and 45% of patients experience depression or anxiety (Henson, 2002).

The lack of discussion by healthcare professionals around sex, be it due to lack of training or their personal feelings of awkwardness with the topic, can and does do harm to the client, their partners and their families. Kennedy and Leiserowitz (2015) summed it up perfectly when they wrote: 

‘[T]he exclusion of sexual health concerns in the global counselling about cancer and its treatment conveys that it is less worthy of consideration than other health issues. The consequence is that patients often feel isolated to cope by themselves with the physical and psychological suffering associated with a change or loss in their sexual life’.

For many women, cancer does not just impact their bodies (both internally and externally), but also their very notion of what it means to be a woman. Our erotic self is informed by many factors, from how we see ourselves, the gender we identify as, our sexuality, the influence of gender roles, our interests both sexual and non-sexual, our own unique styles, our culture, and our religion.

Over the years I have had a number of clients who didn’t mind that they lost their breasts to cancer; and I have also worked with women who say that it was the overt sign of their femininity and influenced the dresses they wore, the blouses they bought, and the partners they attracted. Without them, they said they felt unattractive, broken and disfigured.

The impact on women of childbearing age

For centuries, society has told women that their principal role is to bear children. Even today there is a lot a pressure on women, whether they are in a couple (“So, when are you planning on having children?”) or single (“Oh you better hurry up, your biological clock is ticking”) to grow our worldly population. Despite the societal pressure, many women (not all) do dream and aspire to have their own children and be a mother.

Unfortunately, cancer can take many dreams away. For some women treatment-related menopause or cancer of the reproductive organs can rob a woman of her ability to have a child. For other women, the risk of a cancer reoccurrence impacts on their decision to try for or grow their family. Some women who experience this heartache can be left feeling like they don’t have a purpose. Many, have to relive the trauma over again when people ask that rather invasive question, “Do you have children?”

As a gay man with a partner of 17 years, I have never been asked this question. We could have a whole tribe of children, but it is not a question that men have to experience, or at least not as frequently, as women do.

What can I do?

During treatment the last thing on your mind may be sex when you are feeling nauseous and your life is dictated by the days and times of various appointments. However, while sex might not be on your mind, connection, love, support, warmth, and still feeling desired by your partner may very well be. So below are some things to keep in mind and try:

1. Educate yourself: Sun Tzu in his classic book on military strategy The Art of War, gave us the great quote of “Know thy enemy”, and this applies to the battle with cancer as well. In this case the weapon of choice is knowledge. By asking your doctor questions about how the cancer and its treatments may impact your sex and fertility), or through talking to a sex therapist, you can plan how to handle those challenges. 
2. Set a day:
   1. If you are unable to have sex: We sometimes take the “for better or for worse, in sickness and in health” bit of wedding vows a bit too literally, and while our partners are spending all their time taking care of us in sickness, it is important to set any time we can for connection. This might be developing a ritual around your treatment, for example if you have chemo once a week and spend three days throwing up, on that fifth or sixth day you might drop the kids off with a friend or your parents and go and have a coffee together. You might feel like you have nothing to talk about, and that’s ok: talk about silly stuff, laughter is actually really great for our health. 
   2. If you are able to have sex: if your treatment allows you to be sexually active, then work out a way to fit it into your treatment program. Now you might say, “What about the spontaneity?” This is about sexual connection, and being aware of your limitations during this time, and enjoying the connection. 
3. Dealing with Separation: Sometimes cancer can lead to extensive periods of separation, particularly if you are from a rural area and need to go to metropolitan hospitals for treatment. The above can be adapted to a point for those periods of distance. That might mean setting a date night where you watch a movie together while on zoom, or it might mean setting a time each day to Facetime each day (if you have the capacity). Creative thinking and thinking out of the box is very useful in this situation, and remember two things: 1) there is no such thing as a silly idea (and sometimes silly is what you will need) and 2) you won’t know unless you try.
4. Lube, lube, lube: If you are experiencing vaginal dryness due to your treatment, then lube is going to become your best friend. Talk to your doctor about treatments for vaginal dryness that you can use in conjunction with the lube to relieve some of the inflammation and discomfort.
5. Window of tolerance: When we are sick, unwell, or in pain, our threshold for tolerating the stresses of life is greatly diminished, and as a result this can have an impact on our relationships. The window of tolerance, developed by Clinical Professor of Psychiatry Dan Siegel, is a term used to describe the zone of arousal that people are typically able respond to the demands and stresses of everyday life calmly, rationally, and without much difficulty. During difficult times, such as dealing with a diagnosis of cancer, or treatment, our window of tolerance narrows, and as a result we can respond to the demands and stresses of everyday by either becoming HYPER- aroused (anxiety, tense, emotional outbursts, anger and impulsive) or HYPO- aroused (numb, depressed, feeling shame, shut down and disconnection). Mindfulness, engaging in things that bring you pleasure, having hobbies to name just a few– activities that help you feel balanced, relaxed and in control, will help widen your window of tolerance, and as a result reduce conflict between you and your partner during these difficult times. 
6. Love languages: I use Gary Chapman’s The 5 Love Languages a lot with my clients. The book looks at how we both like to express as well as receive love, and includes touch, words of affirmation, quality time, gifts, and acts of service. Knowing how we as well as our partner like to receive love can help bring us closer, so in the context of cancer, and treatment, knowing how we like to receive love as well as how our partners like to, can help build and maintain closeness and romance during a time that can be very straining on your relationship. 
7. Four horsemen: Research by John and Julie Gottman has shown that there are four conflict styles that can predict the end of a relationship. They are:
   1. Criticism: verbally attacking your partner’s character or personality;
   2. Contempt: attacking your partner’s sense of self with either insults or abuse;
   3. Defensiveness: this is described as “victimizing yourself to ward off a perceived attack and reverse blame”; and
   4. Stonewalling: withdrawing from your partner as a way to avoid conflict and in doing so conveying to your partner a sense of disapproval, distance as well as separation. 

Sometimes the cancer journey can span over weeks, months, even years of treatment. With that comes stress, strain and tension on the relationship, and with that can come conflict, so it is important to be aware of the 4 horsemen so you can nip it in the bud before it gets too bad. How do you address the 4 horsemen? The Gottmans thought of this as well, and for each of the 4 horsemen they developed what they called the 4 horsemen antidotes, which includes:

1. Gentle Start up: talk about what you are feeling. Use “I” statements and express a positive need;
2. Build a culture of appreciation: this is important generally for relationships. To build a culture of appreciation, remind yourself of the positive qualities of your partner, and practice gratitude, remember that they chose you, and they chose to spend their time with you, which is a rather awesome thing when you think about it. 
3. Take responsibility: the Gottmans say this perfectly: “accept your partner’s perspective and offer an apology for any wrongdoing”.
4. Physiological self-soothing: it is ok to take time out, walk away from the fight, deescalate your emotions with a soothing or distraction exercise, and then come back when you feel you will be able to handle the conversation for a more productive outcome.

The ideas that I have outlined above are about maintaining a healthy and positive relationship during your journey with cancer, while mitigating as much harm as possible. There were topics that I didn’t get a chance to discuss, but I hope that the ones that have been outlined above can help you and your partner either during your treatment, your recovery, and remission.

By Christopher Brett-Renes BPsySc, GradDipPsyc, MScMed (Sexual Health Counselling), MACA (Level 3) 

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X The Awakened Mumma , Author of ‘A Woman’s Guide to Navigating the Invisible Cancer Load‘