The Breast of Everything

DR RACHEL NEEDLE: Let's Talk About Sex

March 11, 2021 Comprehensive Breast Care Season 1 Episode 12
The Breast of Everything
DR RACHEL NEEDLE: Let's Talk About Sex
Show Notes Transcript

As clinicians, we find the majority of our patients will experience side effects from their cancer treatment, including a disruption in their sex life. In fact, many say it comes to a screeching halt. They feel their focus should be on beating cancer, not on sex and intimacy, so they don’t even bring up the subject.

During The Breast of Everything podcast, Comprehensive Breast Care surgeons Linsey Gold, DO; and Ashley Richardson, DO; talk candidly and openly on this topic with expert Rachel Needle, PsyD, a licensed psychologist and certified sex therapist. 

Women in general aren’t comfortable talking about sex, and breast cancer patients just assume sex will not happen while they are undergoing treatment. Sex is the overlooked elephant in the room; patients don’t talk about it and many doctors often don’t open the door for a discussion. 

It is okay to talk about it; in fact, it should be discussed. A woman should be talking about how she is feeling on the inside as well as the outside. 

First, it is okay to have sex. 

Some women may lose their sex drive from the time of diagnosis through treatment and even long after treatment. About 50 percent of women who have had breast cancer treatment experience long-term sexual dysfunction, and 40 percent to 100 percent of these dysfunctions are related to how a woman feels about her body. Breast cancer treatment can cause premature menopause, vaginal atrophy, fatigue and depression as well as self-image issues – all impacting a woman’s sex drive. At least 70 percent of women will experience depression during and after treatment. 

Women think, “I’m lucky to be alive, I shouldn’t be wanting to have sex,” however, we are sexual beings! We cannot ignore this. We can remain sexual in our own ways.

Your body is changing and your relationship with your partner also may change. Women worry … “will he still want me?” Studies show that if you had a positive sexual relationship prior to your cancer diagnosis, you will continue to have a positive sexual relationship.

Being informed of what to expect is critical. A patient’s physician is there to provide education, information, support and encouragement. If you are not comfortable talking with your physician, find a certified sex therapist who has the training and knowledge to help you.

So, how do you restore sexuality after cancer?

First, make sure both partners are on the same page. Communicate. Talk about what you like and don’t like and what makes you uncomfortable. You can begin with non-sexual touching, or experiment with different positions. You may have to change your usual ones.

Women may lose nipple sensation, especially those who had plastic surgery following a mastectomy. The nipple does not retain its function or feeling. 

Most important: start the conversation! Redefining sex can be empowering. Rethinking your concept of intimacy can be healing. 

Dr. Needle is the Executive Director of Whole Health Psychological Center and the Co-Director of Modern Sex Therapy Institutes, an organization that provides continuing education and certifications in sex therapy, LGBTQIA affirmative therapy, and much more. You can visit DrRachel.com.

Unknown Speaker  0:01  
Welcome to the breast of everything podcast your trusted resource for breast health information support and encouragement. Your host today are Dr. Lindsay gold, and Dr. Ashley Richardson. A comprehensive breast care. Welcome. Hello, everybody. Welcome to the breast of everything Podcast. I am your host, Dr. Lindsay gold, joined by my partner, Dr. Ashley Richardson. Ashley, How are you this evening? I'm good. How are you? Great. I'm really excited about this topic. During this podcast, we'll be talking about sexuality during and after cancer treatment. How does sex and intimacy affect a woman's life? Should she stop having sex? What about her partner, we will get into all of these answers and so much more. We are so lucky to have as our guest, Dr. Rachel needle, a licensed psychologist and certified sex therapist. She is the executive director of the whole health psychological center, and also is the CO director of modern sex therapy Institute's an organization that provides continuing education and certification in sex therapy, LGBTQIA, affirmative therapy, and many other certifications, including a PhD in clinical psychology for mental health and medical professionals around the world. Dr. Nieto, we are so happy to have you. Welcome. Thank you for having me. So, before we get started,

Unknown Speaker  1:36  
would you mind telling us a little bit about some of the work that you do? Sure, so I see clients. I'm a licensed psychologist, as you mentioned. So I see clients with a range of presenting issues, but I specialize in sex and relationships, and trauma and substance use disorder. And I've done a lot of work with sexuality. And so other psychosocial factors during and after cancer treatment. So interesting. So I just want to start, actually jump in if you want. But sex in general, as a topic, aside from cancer, a lot of times it's just uncomfortable, right for, for people to talk about, and then add the stress of a cancer diagnosis, strains on relationships, or not being in a relationship strains because of the therapy. I mean, it's it's like a perfect storm for a whole, you know, hot mess of psychological issues. Um, what is the type of patient who you see, is there? Is there an overarching theme of problems, you see, what's the most common situation you encounter? Well, I think the biggest issue and one of the reasons that I'm so excited to be able to talk to you today is that it's an issue that, you know, when it comes to sexuality, and intimacy during and after treatment, after cancer treatment, it's an issue that's far too often overlooked. So, you know, people don't really know who to turn to when it comes to this. And oftentimes, physicians don't even really open the door to that. And that's one of the things that I do a lot of educating about, and the, you know, physician community is that is, you know, you don't have I get that, you know, for your job is to really save the person's life essentially, right. Um, but then we have to talk about quality of life. So if you're not, you know, whether you're knowledgeable, or whether you just don't have time to address it, the most important thing is that you open the door by just, you know, saying something along the lines of, you know, most people will experience some sexual intimacy change, you know, after cancer treatment, is, you know, is this an issue for you, or if this is an issue for you, and then give them a flyer or a card, you know, so it's something that I just think is so overlooked. And that is what I would say the biggest issue is, I think you bring up an excellent point, when you say, open the door, and I know Lindsay and I are big advocates about quality of life. So obviously, when we see our patients in the acute setting with a cancer diagnosis, we address surgery and their acute treatment needs. But when we see them in follow up for six months, one year, two years out of a cancer diagnosis, I and I know Lindsey does as well always try and get to how they're really doing on the inside and the outside. And oftentimes, just opening the door, as you mentioned, is a huge relief for patients. And I can't tell you how many times patients will say, well, because you're a female physician, I want to talk to you about this or now that my husband's not in the room because family members often accompany them to their initial visits, but not always the follow up. And once they're in the room alone with us, do they really feel comfortable, kind of opening up to us about those other issues outside of just the cancer diagnosis. Absolutely. Then, you know, here's the thing is that estimates of sexual dysfunction following cancer treatment ranged from 40 to 100%. And I would say that 100% will experience some sort of change whether it's a

Unknown Speaker  5:00  
You know, full on sexual dysfunction or just a change how they feel about their body, you know, how they, you know, what they're able to do with their body or, you know, their part, their interaction with their partner? You know, so there will 100% in my mind and what, from what I've seen be some changes in that way, in our sexuality and our intimacy. Absolutely, I would agree with it. And I'm not a professional, but I would agree with that 100% number, I mean, how could it not right, just dealing with breasts in general, right, and changing the way that they might look or feel, just as a baseline of what we do

Unknown Speaker  5:41  
would affect every single person. And I think to myself, well, no matter how solid your relationship with your partner is, or how good you feel about yourself prior to the diagnosis, your body's changing, and it's experiencing difficult things. So there has to be some level of, you know, change or dysfunction that happens to every single woman. And you're right, we don't address it, probably both because we don't have the time. And we don't know how I mean, locally in our community. I don't even know who I would tell us if they said Who should I go to to talk about this? I don't think I would know. So what certainly help you with some referrals, but

Unknown Speaker  6:29  
not just the physical changes to right, that's a huge event. And I'd love to get to know what some of those are. But it's also the changes within the relationship. So, you know, oftentimes the the partner becomes caregiver. Oh, definitely. Right. And even when they're not, you know, they're you, you know, other partner could change, they might be scared to touch them. What's that, you know, both? Both the patient and their partner don't always know what's Okay, and what's not okay, is it even okay to resume sexual activity? And, you know, it is, you know, from going through chemotherapy, for instance, is that dangerous for my partner? Um, these are questions that I get all the time, I think the other important aspect is their mental health, I mean, ladies will often come into the office and say, you know, I just am so grateful that I'm cured, that I've overcome all of my treatment, am I selfish for being concerned about this? Am I vain or shallow for being more worried about x over their breast cancer treatment, and, you know, you really have to talk them off the ledge to say you have several years of life left. And that is important, and we need to have resources to help guide men. And I think, you know, this shift from I should feel lucky to be alive, right? Yes, of course, living is a privilege. So we should, but with medical advances, most cancers are being caught early, and therefore their increased survival rates. So you know, the focus, oncology care really is being shifted for, for many from treatment and managing the disease to improving quality of life. And that's what we really need to be focusing on. Absolutely. I'm going to tell a little story for two seconds about my first like exposure to,

Unknown Speaker  8:05  
you know, what people might be willing to share with you. The, we offer, you know, breast reconstruction to every woman who has, you know, a medically appropriate candidate. And I always tell the story of the oldest woman I ever had the privilege of

Unknown Speaker  8:26  
doing a mastectomy on who, who opted to have reconstruction was 82. And she had one son, and he was in the consult with her. And I said, Well, I mean, I'm happy to send you to a plastic surgeon if you'd like to discuss reconstruction, and the son who was 60, you know, kind of scoffed and was like, yeah, you know, whatever. And then she said, she turns to him and says, I'll have you know, that I have a gentleman friend, and he's 15 years younger than me, and we have relations. And this poor son's face turned white. I mean, I thought he was gonna have a stroke. And he just picked himself up and walk right outside the door. Anyway, I mean, we laughed and I, at the time, I was only in my early 30s. I was stunned. You know, I have a pretty good poker face, but that was rough. And in the first post op appointment, this lovely elderly woman had her drains in and she said, when I resumed sexual relations, I gotta tell you, I don't know I may not have kept my cool because I was shocked. But I thought to myself after you know what, I hope I'm that 82 year old one day, yeah, I was still able to, you know, comfortably have sex and talk about it. And it was great, but I suspect that's kind of uncommon. No, I mean, we're sexual beings still. Remember that? Most of us, most of us so it's it's actually not you know, people remain

Unknown Speaker  10:00  
Sexual in their own ways, and some similar to how they've been their whole lives. And for some, it changes somewhat, but they're still sexual beings and engaging in sexual activity or having that desire. So, you know, that's something that I think is important. Remember, no matter how old we are, that that's a part in part of most of us what, when you meet with ladies and console, Do you often have their partner kind of come in with the visit as well? And or do you address both of them individually? Or how do you really go about meeting with these ladies to get to get to their underlying issues or concerns, I mean, it's always my preference to meet with them as a couple, or, you know, if they're willing to both partners are willing are all partners. So you know, that's my preference, and then oftentimes, I meet with each of them once alone, and then the rest together, that's not always an option. So, you know, I take what I can get with them, but that that's my preference. Because, you know, there's a number of so we can talk about both physical and emotional changes, right, when it comes to cancer. And I think they both are impacted in a variety of ways. I mean, we can't, you know, forget about the changes, you know, the physical changes, but then side effects, but also the treatment that treatment impacts mood. And a lot of women will become anxious and or depressed during and following cancer treatment. And while depression in itself can result in changes in libido and other sexual issues can arise if depressions untreated. Also, when it comes to like anti depressant medications, there are side effects as well, that becomes sexual that becomes sexual. So, um, there's a lot that we have to think about both physically and emotionally. Yeah, definitely. I mean, you know, most of the literature says that at least 70% of women in their first year of their, after their cancer diagnosis through treatment will experience some level. That means, you know, clinical depression. So and of course, a lot of the medications, like you said, that we use, we're, we're fairly quick to prescribe them, you know, we want people to be able to, you know, deal and tolerate their treatment, but particularly in breast cancer, with the majority of breast cancers being, you know, hormone driven, we, we give these ladies medications that, essentially, either put them in menopause when they weren't or cause, you know, side effects of menopause, like, you know, vaginal dryness, a trophic, vaginitis. All that So, so we may take a relationship that was, you know, good and normal and, you know, make put a lot of stressors on it just from the medication alone, even if they get through the diagnosis. Sometimes they still have that to deal with, particularly the younger ladies. Is that something that you see? Absolutely. So you know, there's two sides of that. So let's talk about the first he said, You know, there are a range of issues that can affect sexual dysfunction of female cancer survivors. So we have you mentioned the vaginal atrophy, which is thinning and inflammation of the vaginal walls, which can occur due to the decline in estrogen and often make the vagina dry. So as a result, people may experience painful intercourse. Other effects include, you know, hypoactive, sexual desire disorder, which is low levels of sexual desire, fear of recurrent stress, anxiety, changes in the body so it's like their self image are among the most significant changes that occur following treatment that are specifically with breast cancer and got a logical camp gynecological cancers, but you know, anything that alters the breast, which is you know, what most women are often defined, as you know, we, you know, we put a lot of pressure on ourselves and when it's removed, or parts of it removed, it can have a significant impact on body image and self image, which has the potential in itself to diminish sexual functionings and feelings of sexual attractiveness. So, you know, I think that's one huge part of it. So what advice do you give to discuss with these ladies or modalities do you address in regards to how to treat these changes and their bodies or to get sexual with their partner? Sure. And I think, you know, let's first address that we have to remember that there's oftentimes a partner not always and few people will take into account how the relationships are impacted. So there are actually studies that show that survivors who have a good sexual relationship before treatment do continue having satisfying relationships after surgery, but we have to remember that support is important and what it was like before so we don't walk into this thinking that everybody has had a positive sexual relationship before this. So we don't know where that started. Um, so a lot of couples may not have been, you know, truly intimate and use their bodies anyway. So you know, it isn't too late. You asked what we can do. So there are a lot

Unknown Speaker  15:00  
A lot of different things that it all really depends on where someone has started and what their presenting issues really are. So we want to understand that.

Unknown Speaker  15:09  
But we don't want to assume that the changes that they're that are being experienced are being experienced in the same way, by everybody. So it's important to, you know, understand where they're coming from, be able to use it as an opportunity to create a different level of intimacy and communication within the relationship.

Unknown Speaker  15:29  
There are a lot of suggestions that I have for restoring sexuality after cancer. So we want people to as soon as they're comfortable resume affectionate touch, right, because a lot of times it has been lost. So they can do this through even non sexual touching, or sexual touching, that doesn't involve the genitals or just, you know, take it slowly holding hands hugging, kissing, caressing, um, you know, so we don't want to, we don't have to start with sexual touch, we want to make sure both partners are on the same page with things, we want to help them practice different ways of sexual expression. So maybe different positions, so positions they may have loved in the past, and may have been part of their sort of sexual script might not be ones that are enjoyable or even doable anymore. So we're gonna have to experiment with them and be comfortable with trying different things.

Unknown Speaker  16:22  
And so for a lot of people, for instance, maybe deep penetration isn't, you know, and, and, you know, placing weight on the scar or things that we might, they might want to avoid. Um, I don't know how much you want me to get into, I have a lot of suggestions I could give Oh, it is so fascinating to me. And, sadly, the amount that we don't know, I don't want us to actually, but I'm just going to assume, as as, as providers, just the amount that we don't know, a couple of years ago, I had come across an article, I don't even know were written by a patient long and the short of the article was, she had nipple sparing mastectomy, and although she was, you know, happy with the cosmetic outcome, she was really upset, because nobody had discussed with her preoperatively, the fact that she would no longer have nipple sensation. And so this was this whole article about how she was kind of like angry about it. And then I took it as, you know, advice to the provider, like, this is really important to a lot of women, and you need to let them know, up front, when there were discussing surgical options. So from that article forward, I changed my discussion with ladies and I am, you know, always very, very clear and specific about the fact that even though we can save your nipples, you know, they, they might look the same, but they do not retain sensation or function. So, you know, you have to decide if it's an issue for you. Because if it's a really big issue, that if you don't know about it, we're not doing our job, we're doing you a disservice by not sharing that information. 100%. And again, it's and I don't blame physicians, right? It's, it's, you are focusing on keeping somebody alive, and they're, you know, it's time consuming. And and, you know, off the next I just think it's important that the discussion is started, and at least by a physician, by a nurse by someone else in the office, a lot of and I did part of my internship at the Cancer Institute of New Jersey, so they actually had, you know, people on staff, they had therapists, like myself on staff, you know, training, training, the medical staff, as well as going into the rooms during consults, or during, you know, follow ups, or, you know, having the opportunity to meet with people ourselves. So they let the patients know, this is important. We know, this is a big issue. We're giving you this resource, I think that's so very valuable. And also the information that you've shared is fascinating. Lindsey took the words right out of my mouth, and also extremely valuable. And us being able to just reference this podcast for future patients is so helpful, because, you know, like you said, We don't always have time and although we are really trying hard to put this into our survivorship program and make sure that we're addressing it with patients, both before surgery as well as long after surgery is sometimes it just gets lost in the weeds because there's lots of things to address. And I think being able to reference this podcast will be wonderful for patients.

Unknown Speaker  19:36  
Yes. Are there some resources that you point patients to, you know, to maybe do some, you know, research on their own, or looking into, is there anything specific we can maybe share with our ladies, you know, tomorrow in the office? Yeah, I mean, the American Cancer Institute does or the American Cancer Society

Unknown Speaker  20:00  
I believe does have some great books, like little booklets on that address sexuality after cancer. So, you know, that's a great place to go. And even having some of those in your office could be helpful

Unknown Speaker  20:16  
to give out and you know, I just say they're welcome to look me up. Well, your your website is excellent. I did look at it whole health psych.com correct me if I'm wrong, but it is. It is really excellent. You know, in the COVID age, I don't have I don't know how much video consultation you were doing before. But I imagine like everybody else that the telehealth has increased during COVID and maybe will stay post COVID. Have you noticed some changes in your practice? In that respect? Yeah, I do a lot of via telehealth and so that allows me greater flexibility and to remain safe. So yeah, I have a whole health site calm and then you know, Dr. Rachel calm, which you know, Rachel spelled ra ch l that has some of my media resources on it that people can can look at. And we even have some trainings on my other my training website, modern sex therapy Institute's calm on cancer and sexuality. Well, Ashley, and I need to get with it.

Unknown Speaker  21:24  
Get with the program. Totally agree. We're starting the conversation. That is the most important thing. We are opening the door. Yes, yeah. Well, we are we need to do a better job. And you know, not coincidentally, we left our third partner, you know,

Unknown Speaker  21:41  
Dr. Eric Brown, out of this conversation, not necessarily because he's a male, but

Unknown Speaker  21:49  
because he's a male. Uh, but I do think it is probably that much more challenging for, you know, our male colleagues to try and have this discussion with ladies. And so, you know, resources are good, even, like you said, Rachel, just a flier, something, some information where they can,

Unknown Speaker  22:12  
you know, get in touch with somebody well, and even being able to just reference your website. So many times ladies just asked for a resource or a website or something they can go to that we trust. And so I think that's so important for today, but well, we really, thank you so much, Rachel, for joining us today. The information you provided will be so helpful for so many women. Thank you so much for having me. If there's listeners looking for more information, like Dr. Nieto said, you can go to her website Whole Health psych.com or Dr. Rachel calm if there are any providers, listening to this who needs some training? Rachel, you said modern sex therapy institutes. Yep. Calm calm. Yeah. So I'm definitely going to have to check that out.

Unknown Speaker  22:59  
So thank you, thank you again, so much. Um, we could have 12 podcasts on this topic. Or maybe that's just me. I could keep going. But it's excellent.

Unknown Speaker  23:09  
So thank you all for listening to the breast of everything. I am one of your host, Dr. Lindsay gold. And I'm Dr. Ashley Richards then thank you everybody. You've been listening to the breast of everything podcast with your hosts and board certified breast surgeons, Dr. Lindsay gold and Dr. Ashley Richardson of comprehensive breast care. If you have a subject you would like the surgeons to discuss, please email your suggestions online at comp breast care.com. That's co mp BREAST ca r e.com. The doctors want to hear from you. The views thoughts and opinions shared in this podcast are intended for general education and informational purposes only and should not be substituted for medical advice, treatment or care from your physician or health care provider. Always consult your health care provider first.