Sex after cancer — the hardest part can be opening up about problems

When first diagnosed with prostate cancer at the age of 45, John, a Miami artist, was told he needed to have his prostate removed.

Concerned this would lead to incontinence and an inability to have sex with his wife, John asked the surgeon about alternatives. His surgeon brushed aside these concerns, telling him to focus on removing the cancerous gland and curing his disease.

Now 56, John wound up having surgery, radiation, female hormone therapy and a laundry list of corrective surgeries, including, finally, a penile implant. Still battling the persistent cancer, he is now able to have sex with his wife, albeit not as much as before the diagnosis.

“I went two years without a love life,” said John, who requested that his last name not be used. “Frankly, all those years of not having that type of activity is very trying on a relationship. Even though my wife is wonderful, as a male, my identity is tied up in that act. It is important that it came back into my life.”

Regaining sexual activity after a cancer diagnosis is a subject few men want to talk about. Yet psychologists who work with cancer patients say that, especially for men, a return to sexual health is a key component of their recovery.

“Men are reluctant to reach out for help — they are macho in general,” said Sameet Kumar, a clinical psychologist at Memorial Cancer Institute in Hollywood. “It’s a tough group to say to, ‘Let’s talk about sexual health.’ They will shy away from it even though they are desperate for help. It’s different for men and women. We judge our overall health by how potent we are.”

Prostate and colorectal cancer are the two cancers that directly cause sexual dysfunction in men. However, any cancer requiring chemotherapy will affect a man’s sexual desire, since a reduced sex drive is a common side effect of chemotherapy.

Prostate cancer is the No. 1 cause of cancer in men, diagnosed in an estimated 80 percent of men who reach age 80.

After prostate surgery, up to 90 percent of men have difficulty achieving an erection, although results are improving with the latest surgeries, called “nerve-sparing surgeries.” Adding to the mix is the fact that most men over age 70 are already experiencing some erectile dysfunction.

“The desire is intact, what is off is the erectile function,” said Christina Pozo-Kaderman, a sex therapist and clinical psychologist at Mount Sinai Comprehensive Cancer Center in Miami Beach.

These days, comprehensive cancer centers like Mount Sinai, Memorial Cancer Institute and UM’s Sylvester Comprehensive Cancer Center have psychologists and sex therapists on staff to work with cancer patients on issues of depression as well as sexual dysfunction.

The primary role of these psychologists is to educate patients experiencing sexual dysfunction — and their partners — that their experience is normal and that their sex life will likely return.

They also educate patients about treatments available for men needing help achieving erections.

“Oftentimes all that is required is education,” Kumar said. “The man is getting a lot of pressure from his partner, so sometimes we get the partner to come in for education as well and tell her, ‘You need to back off a little bit.’ There is a lot of stuff going on at home about their inability to perform.”

Pozo-Kaderman agrees. Many times, she will have one session with a male cancer patient, tell him about what he can expect with his sex life, and then never see him again. “I assure him, your sex drive will come back after chemotherapy, just like your hair and energy will,” she said. “In most cases, just education for the man is a relief.”

That was the case with a 28-year-old Miami lawyer who was diagnosed with lymphoma and undergoing chemotherapy and came to see Pozo-Kaderman. He told her he was depressed because his sexual desire had completely dried up.

“He said, ‘I look at women and I know they are pretty but I have no desire to pursue them,’ ” she said. “He said, ‘If this is what my life is going to be, what’s the point.’ He was single and good-looking, and a big part of his sense of himself was his sex life.”

Pozo-Kaderman assured the man his sexual desire would return after his chemotherapy ended. If it doesn’t come back within six months, come back and see me, she instructed the young man.

Sure enough, the man never scheduled another appointment with the psychologist. And when Pozo-Kaderman saw him in the waiting room of the hospital one day, he shot her a “thumbs up” and a smile.

But, for older men or men having their prostates removed, the situation is a bit trickier. Those men are encouraged to attempt to have erections about two months after prostate surgery to increase the blood flow into the penis.

“You want the blood flow to start so the tissues are getting the blood in there,” Pozo-Kaderman said.

In these cases, the first step for sex therapists is to prescribe erectile-enhancing drugs like Viagra or Cialis. If the drugs don’t work, the next step is to inject medicine directly into the penis, which usually produces an erection.

For those who shudder at the words “injection” and “penis,” Pozo-Kaderman is quick to assure them the procedure is not really painful, just uncomfortable. The injections are done by the patient or his partner at home.

If these therapies don’t do the trick, therapists may refer patients to surgeons for penile implants. In penile-implant surgery, a small rod is inserted into the penis, which is activated through a pump at the bottom of the testicles to produce an erection on demand.

John went through this entire regimen before having a penile implant. Like many of the male patients treated by psychologists specializing in cancer, he also benefited from therapy with his wife and an anti-depressant to treat his depression. He and his wife see a psychologist at Sylvester Comprehensive Cancer Center, where he is receiving his cancer treatment.

For psychologists who work with cancer patients, education of oncologists about potential sexual dysfunction is every bit as important as education of patients.

Oncologists and oncology surgeons in particular are focused on ridding the body of cancer or treating cancer and do not usually ask their patients about their sex lives. And, unlike women, men do not typically turn to psychologists for help when battling depression or other psychological problems.

While patients are embarrassed to bring up the subject of sex to their doctors, doctors tell Pozo-Kaderman, “Why ask about it if we don’t know what to do about it.”

Kumar agrees, saying “The hardest part is starting the dialogue.”

“What I feel comfortable is it has gotten better than it has been,” he said. “It’s better in 2014 than it’s ever been.”