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Enhancing Sexuality and Self-Esteem After A Breast Cancer Diagnosis Authors : Judi Johnson, Ph.D., RN, FAAN, and Linda Klein, BS Affiliations: Judi Johnson is a founder of "I Can Cope" and a health consultant, Minneapolis, Minn.; Linda Klein is a medical writer, Sillwater, Minn. Adapted with permission from Klein L. Exploring self-esteem and intimacy. In: Johnson, J., Klein L. I Can Cope: Staying Healthy with Cancer. 2nd ed. Minnetonka, Minn; Chronimed Publishing; 1994 and from I Can Cope Course Materials, American Cancer Society Patient Education Program, Altanta, GA; 1994. Copyright © 1995, Judi Johnson and Linda Klein What is Sexuality? Because the popular media bombard us with messages emphasizing the importance of sexiness, people sometimes come to view sexuality narrowly, i.e. sexuality equals sexual intercourse. However, sexuality is much more than a physical act. Sexuality refers to all the feelings we have about ourselves as sexual beings and the ways we express those feelings to others. Intimate relationships that are based on love transcend sexual intercourse and involve not only the physical bond between lovers but also the intimacies of family and friends. The evolution of healthy sexuality involves three stages: learning to love yourself, learning to love others, learning to love together. Love of Self While growing up, many people are taught that to love oneself is to be "selfish," and self-love became an unpopular notion; but unless you can love yourself, you will have a hard time loving others and an even harder time allowing others to love and accept you. Yet even women with a strong sense of self-worth sometimes question their self-image when cancer enters the picture. They no longer feel lovable, even to themselves Love of Others People who are secure and comfortable with themselves are prepared to reach out and care for others. Instead of always striving for personal happiness, these individuals can achieve equal satisfaction through seeing others happy. However, reaching out and caring for other people's wants and needs are difficult when you are preoccupied with your own health. After a cancer diagnosis, it is easy to regress and again become consumed with yourself. Loving Together People in secure relationships meet each other's needs by loving together, and this means more than just sexual intercourse. Loving together means "being of one mind" with another human being, knowing that a synergy exists -- that the sum of the two parts is stronger than the two standing alone. Loving together may mean touching, holding, hugging, sharing intimacies, providing mutual support, or just "being there," even though no words are spoken. People who love together find a natural balance between giving and receiving love. Many people with cancer report that one of their most difficult adjustments was learning how to receive love and support without feel guilty. Effect of Breast Cancer on Sexuality and Self-Esteem Love of self, love of others, loving together -- this triad of sexuality -- may be affected by a breast cancer diagnosis. Most women report changes in three areas: body image, role assignments, and intimate relationships. Body Image Changes Breast cancer and its treatment can result in many physical changes, including loss of a breast, loss of hair, weight gain (or weight loss), and changes in skin texture. Interestingly, many women report that hair loss was more damaging to self-esteem than loss of a breast. Yet in American culture, where women's breasts are a major symbol of female sexuality, losing a breast can significantly affect intimate relationships. The impact of this loss varies, of course, according to the importance both partners placed on sexual intercourse, how important the woman's breasts were within that sexual relationship, and the stability of the relationship before surgery. Overall, most breast cancer patients cope well, especially if their psycho sexual health prior to diagnosis was satisfactory. The following pointers may help you adjust to a new body image: Look at yourself, touch yourself, become comfortable with your new body, and accept this body by affirming that the old body had to change. The new body is healthier, stronger, and more vibrant. Seek support of others, preferably before surgery. American Cancer Society Reach to Recovery volunteers can share firsthand experience on overcoming this loss. Inquire about the possibility of reconstructive surgery. Attempt to involve your partner soon after surgery, so that both of you become familiar with the body change simultaneously. Have the courage to break the silence barrier and communicate feelings, wants, and needs created by this body image change. Open communication is the only antidote to misconceptions. Role Changes Because "what we do" often defines "who we are", a change in roles can dramatically affect a person's self-image. For instance, many women with breast cancer have been homemakers for years. Now another family member temporarily assumes that role. This can be uncomfortable for everyone, especially the patient. The rhythm in the home is interrupted. It seems everyone has a part in a new play, but no one has the script. What does a person say or do next? Who makes the next move? Positive change in human relationship usually involves risk. Family members and friends must take that risk by initiating actions and discussions to improve communication and ease the transition into new roles. The following pointers may make adaptation to role changes easier: Accept the help of others, and recognize that loving together means both giving and receiving. Be open and receptive to new roles. Change often results in growth, and this life change may present the opportunity to take a new, more interesting role. Stories abound of cancer survivors who gave themselves permission to indulge in a long-held vocational fantasy. Changes in Intimate Relationships Body image changes and role changes related to a breast cancer diagnosis can create changes in intimate relationships. Even though sexual feelings and needs many now be different, they are still a vital part of a relationship. Partners have a responsibility to identify how their feelings have changed and to state clearly what they need from each other. The following statements may prove helpful in initiating a discussion of sexual relations: For the Woman with Cancer I need to be caressed and loved, but I don't think I'm ready for intercourse tonight. My sexual appetite just isn't as strong anymore. But I need your closeness and support now more than every before. My body has changed so much, I don't feel very lovable. But that doesn't mean I don't need and want your love. For Her Partner I'm afraid of hurting you. Tell me what is comfortable for you. I know it's irrational, but I can't help feeling your cancer might be contagious. Please give me time to adjust. I'm afraid you will think I'm taking advantage of you, asking you to have sex when you have been through so much. Tips on Getting Physical If sexual intercourse was a comfortable and enjoyable part of your life before cancer, most likely it will be again. Consider the following points as you adapt to the emotional and physical challenges created by breast cancer. Survival Overshadows Sexuality When everything is put in perspective, just being alive comes out on top. Fear, depression, fatigue and anxiety all combine to take the wind out of a person's sexual sails. Women need to take one day at a time and be patient with themselves. Once the immediate crisis has passed, it is likely that sexual interest will return. Total Worth Is Not Based on Physical Attributes You may not look the same, but you still have the same needs and desires as you had before illness struck. Friends and loved ones will continue to love and value you as long as you let them. Bloom where you are planted. Loved ones are usually glad to nurture the new growth. The Most Potent Sex Organ Is Between Your Ears Overcoming the shock of new scars, missing body parts and the existence of cancer itself is not an overnight process. Yet a cancer diagnosis can't stop the mind from creating new forms of sexual expression. Experiment and explore different ways of achieving intimacy including touching, holding, kissing, massage, and just being close. Change takes time, and you could take the pressure off intercourse by contracting with your partner for a specific period of abstinence. Then use this time to explore and rediscover your own sensuality. Reaching a mutually satisfying sex life will happen one step at a time. Communicate, Communicate, Communicate Can communication be emphasized too much? Not in this case. The more that couples talk and share, the closer they will become. Patients and health care professionals need to work together to legitimize the topic of sexuality from the outset of treatment and leave the doors to communication open. Consider Counseling Because sexuality and self-worth are closely linked, resolving sexual concerns quickly and early is vital to overall health. Booklets that may be helpful include the American Cancer Society's Sexuality and Cancer for the Woman Who Has Cancer and Her Partner and Sexuality and Cancer for the Man Who Has Cancer and His Partner. If your problems seem overwhelming or you suspect that you are depressed, seek a qualified therapist or counselor. It is not a sign of weakness to admit you need help. Finding the Right Words One woman with cancer seemed to speak for many when she shared the following words: "Can you sometimes just come and hold me? Make me feel like a child again . . . dependent again . . . taken care of again. I am not as strong as I seem. Nor am I as self-sufficient as I choose to seem. Will you let me lean on you sometimes, just a little bit? I don't want words or promises. I want the peace of a child knowing that she is loved . . . and cared for . . and held . . . silently." If these words are appropriate to your situation, share them with a loved one and ask for intimacy you need. I Can Cope "I Can Cope" is a patient education and group support program for patients with all types of cancer. It was designed to help patients learn about the disease, cope with daily health problems, communicate with others like themselves live with limitations find resources Part of this program focuses on coping with sexual changes. To determine the availability of this program in your area, contact your local unit of the American Cancer Society.

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