Reclaiming Intimacy: Addressing the Sexual and Relational Impact of Genital Cancer Treatment

Introduction: Cancer Care Beyond Survival

Advances in cancer treatments worldwide have significantly improved survival rates. ¹ For example, the five-year relative survival rate for female breast cancer has increased from 75% in the 1970s to over 91% in the 2020s, highlighting significant progress due to modern treatments. ²

People are living longer with cancer and the effects of its treatment, which often include profound impacts on their perception of themselves as sexual beings, as well as on their sexual function and relationships. ³ For instance, research indicates that over 80% of cancer survivors report changes in sexual health post-treatment, impacting their overall quality of life. ⁴

However, these advances have not been matched by efforts to address the psychosocial and relational challenges that survivors face. There is an urgent unmet need to integrate holistic care that supports sexual function and relational wellbeing into traditional oncology treatment protocols and integrated care pathways. ⁵

Impact of Genital Cancers on Sexual Function and Relationships

Genital cancers profoundly affect sexual function and relationships. These impacts are multifaceted, involving physical changes, emotional and psychological challenges, and shifts in relational dynamics.

Physical Changes Post-Cancer and Treatment

Treatments for genital cancers often result in significant physical changes. Surgeries for cervical, uterine, or vulvar cancers can lead to scarring, reduced vaginal elasticity, or even complete stenosis and obliteration of the vagina. Urinary symptoms may include urgency, frequency, retention and incontinence. Treatment with dilators or fingers can be difficult and challenging. Radiation therapy frequently exacerbates these issues by causing fibrosis and atrophy. ⁵

For men undergoing treatments for prostate or rectal cancers, erectile dysfunction and penile fibrosis are common, affecting self-esteem and sexual relationships. ⁶

Chemotherapy can induce ovarian failure, leading to abrupt menopause with symptoms like vaginal dryness, hot flashes, and loss of libido. Sexual side effects include difficulties with arousal, orgasms and pain with intercourse. ⁷ This can lead to distress, confusion and difficulty maintaining sexual arousal and intimacy.

Infertility is an important consequence of treatment for cancer and can be challenging to handle. Options for ovum or sperm banking need to be made available for patients if they wish to preserve their option for fertility in the future. ⁸

Psychological and Emotional Challenges

The psychological effects of cancer and its treatment range from problems with dealing with the diagnosis, cost of treatment and uncertainty around results of treatment. Patients may struggle with body image issues due to scars, stomas, or weight changes, leading to feelings of unattractiveness. ⁹

Women may feel “less feminine” when the appearance of the breasts or genitals is altered and even with hair loss. Changes in reproductive or sexual function may affect both men and women, causing loss of self-esteem and confidence. Anxiety and depression, already prevalent during cancer treatment, are often exacerbated by these challenges, creating a cycle of distress that impacts both individual and relational wellbeing. Pre-operative counseling, multidisciplinary surgical teams, and expectation setting regarding structure and function can help patients to deal with these challenges. ¹⁰

Relational Dynamics

Cancer treatments, including their logistical and financial strain, can often shift relationship dynamics. Partners may become caregivers, altering the balance of the relationship and sometimes diminishing sexual intimacy. ¹¹ Cultural taboos around discussing sexual issues in the face of morbidity and mortality can complicate matters, leaving partners to navigate these challenges in silence. Open communication and counseling are critical to addressing these issues, helping couples reestablish trust and intimacy. In cases of terminal cancer, partners need the opportunity to voice their concerns and how their needs can be accommodated in the caregiving process. ¹²

Treatment-Related Sexual Dysfunction

Sexual function is impacted through the diagnosis, investigation and management of cancers, especially genital cancers. Clinicians hesitate to talk about the sexual side effects of treatments, assuming a sexual relationship cannot be a priority in cancer care. Treatment can be lifesaving as well as life-affirming, and resuming sexual activity can play an important part in the patients’ ability to deal with the inevitable mortality and morbidity that diagnosis and treatment of cancer brings.

Surgery

Surgical interventions for cancer, especially radical surgeries like pelvic exenteration or prostatectomy, can disrupt nerve pathways essential for sexual function and pleasure. While nerve-sparing techniques offer some hope, they are not always feasible. Educating surgeons in tissue-sparing surgical techniques can help mitigate these problems. Rehabilitation through physiotherapy and sexual counseling is critical to help patients adapt to these changes. ¹³

Radiation Therapy

Radiation therapy often leads to fibrosis and reduced elasticity in vaginal or penile tissues. For women, this can result in painful intercourse, while men may experience difficulty achieving or maintaining erections. Ovarian and testicular failure can trigger hormone changes that compound these issues. ¹⁴

Chemotherapy and Hormonal Therapies

Chemotherapy-induced systemic side effects include hormone suppression, fatigue, hair loss, gastrointestinal upset and neuropathy. Chemotherapy-induced menopause is often abrupt and severe, with symptoms like vaginal dryness and loss of libido profoundly affecting sexual function. Hormonal therapies, commonly used in breast and prostate cancer (anti-androgens and anti-estrogens), exacerbate these issues by reducing estrogen or testosterone levels. ¹⁵

Addressing Sexual and Relational Health in Oncology Care

Holistic and integrated cancer care must include proactive measures to address sexual health and relational dynamics. This involves routine screening, individualized rehabilitation strategies, and partner involvement.

Routine Screening and Counseling

Healthcare providers should normalize discussions about sexual health during oncology care. Tools like the Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF) can help assess patient concerns. Counseling sessions can provide essential support, enabling patients and their partners to navigate changes together. ¹⁶

Rehabilitation Strategies

Rehabilitation should include both physical and emotional support. Vaginal dilators, lubricants, and moisturizers can help women manage vaginal stenosis, while men may benefit from erectile aids like vacuum devices or medications. A risk-benefit analysis and discussion of appropriate hormone therapies may help prevent total obliteration of the vagina and improve quality of life. Pelvic floor physiotherapy, supervised by trained professionals, can improve blood flow, elasticity and strength, enhancing sexual satisfaction. Mind-body therapies such as mindfulness and yoga can also help patients manage anxiety and rebuild a sense of control.^17,18

Partner Involvement

Engaging partners at all stages of diagnosis and treatment through couple-based therapy or support groups can foster understanding and intimacy. Open communication is vital, enabling couples to redefine their sexual relationship and explore new ways of connecting. ¹⁹

The Indian Context: Bridging Cultural and Healthcare Gaps

In India, cultural taboos often prevent open discussions about sexual health, leaving many patients without support. Less than 10% of oncologists in India routinely address sexual health concerns, and over 80% of cancer survivors report unmet sexual health needs. ²⁰ This underscores the urgent need for training healthcare providers to integrate sexual health into cancer care. Policies must prioritize resources for sexual rehabilitation, even in resource-limited settings, to help patients and their partners navigate these deeply personal challenges. ²¹

Research and Policy Recommendations

Promoting clinical research into the sexual side effects of cancer treatments is essential for developing targeted interventions. Research highlights vaginal stenosis prevention strategies in radiotherapy-treated patients, emphasizing routine use of dilators and education for patients. ²²

Quality of life research post-breast cancer shows the critical role of addressing sexual health as a core component of survivorship. ²³ Studies on cervical cancer survivors have shown that radiation therapy leads to long-term sexual dysfunction requiring targeted intervention. ²⁴ Research on fertility preservation and sexual health interventions for young cancer patients has shown significant benefits. ²⁵

Psychological support systems and sexual counseling integrated into oncology care are essential to alleviate long-term relational impacts. ²⁶ Male cancer survivors report improved quality of life when sexual function is addressed proactively through evidence-based practices. ²⁷

Global oncology guidelines highlight the importance of sexual health as an indicator of holistic recovery. ²⁸ Comprehensive policies should ensure that healthcare providers are equipped to address these issues and that resources for rehabilitation are widely accessible.^29,30,31

Conclusion: Beyond Cancer Survival

Addressing sexual and relational health is integral to improving the quality of life for cancer survivors. Multidisciplinary approaches, cultural shifts, and proactive policies are necessary to support patients and their partners in navigating life beyond cancer treatment. By recognizing and addressing these challenges, we can move beyond survival to truly support cancer patients in reclaiming their lives.