Sexuality And Breast Cancer Treatment

There are many ways in which standard breast cancer treatments affect a woman's sexuality, both in the short and long term.  The removal of even part of a breast (lumpectomy), let alone the complete removal of one or both breasts, represents a loss and a change in a part of the body that is loaded with sensitive nerve endings and very involved in sexual arousal.  Having only a lump removed along with surrounding tissue, can involve severing nerves that were very involved in producing physical sensation in that area. In addition, the alteration in physical appearance caused by breast surgery, may cause a woman to experience herself as less womanly and less sexually desirable. As if that is not enough to process, females who undergo chemotherapy, will usually be thrown into menopause, with all of the changes that entails, such as fatigue, possibly severe hot flashes and decreased vaginal lubrication. Being jolted into menopause via chemotherapy is a very different physical and psychological experience than the experience of a natural and gradual cessation of menses occurring over a period of years. Adding to the menopausal effects of chemotherapy, drugs like tamoxifen and aromatase inhibitors are routinely prescribed to further reduce and suppress estrogen. Sex can become painful, and the walls of the vagina can atrophy and become very thin and dry. Vaginal yeast infections and urinary tract infections are also more likely to occur. (For more information on this, see Dr. Michael Krychman's blog post http://community.breastcancer.org/blog/sex-matters-vaginal-dryness/.)

The good news is that breast cancer survivors are still very capable of experiencing sexual desire and sexual pleasure. However, due to all of the physiological changes induced by breast cancer treatment, women often come to feel that they need to become acquainted all over again with who they are as sexual beings. This realization may come as a surprise, since oncologists often glide over these sexual sideeffects, in their zeal to rid the body of cancer, and because psycho/sexual/emotional aspects of cancer treatment are complex and outside of their area of expertise and comfort. It is important for cancer survivors and psychotherapists who work with them, to understand that along with physical and emotional healing, time and patience may be required for patients to uncover the sexual trauma related to the treatment, and to discover who they now are as sexual beings. Living in the realm of "the new normal", cancer survivors may need to learn what works now for them sexually.  For example, where and for how long they want to be touched in order to achieve sexual arousal and gratification, may be different from before cancer treatment. Partners of cancer survivors also need to be educated that what was pleasing and stimulating before the treatment, may be different now, and that their partners' bodies may not function in the same way.

Reflections on the Psychology of Prophylactic Mastectomy

In an earlier blog post,  Psychology and Prophylactic Mastectomy, I summarized an op ed piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" that appeared on Sunday, July 26th, 2014 in the New York Times.  In her article, Ms. Orenstein offered some possible psychological motivations for why women choose to have a healthy breast removed after being diagnosed with breast cancer in the other breast, despite the fact that survival is not increased by doing so.  I would like to offer additional thoughts on psychological motivation.

Loss Of Control

Breast cancer patients like other cancer patients where extensive treatment is required, usually undergo the experience of a profound loss of control over their lives. Asking the question, “Why me?" is one way that cancer patients attempt to regain some control or at least some understanding about possible causation.  Some spend a lot of mental energy reviewing their lives and wondering what may have triggered or contributed to the development of the cancer.

Humans want and need to feel that they have a certain amount of control over their lives in order to function in calm, organized and productive ways. We want to believe that if we eat properly, exercise often, avoid cigarettes, get enough sleep, maintain the correct weight, and so on, then we will be able to avoid serious physical illnesses, at least until old age.  Mass media plays to these hopes. Our newspapers, health newsletters, and journals are replete with reports of studies in which associations have been found between a myriad of foods, vitamins, and behaviors and a lower or higher incidence of some type of cancer, continually reinforcing the idea that if we can just figure out what to do and then do it, we will be able to greatly reduce our chances of getting cancer. People are encouraged to imagine that they have more control over what happens to their bodies then they, in fact, have. When a cancer diagnosis is made, it is often a shocking reminder of how little control we actually do have. In addition to feeling shocked or frightened, a patient may also feel a sense of shame over having failed to do what was necessary to prevent the cancer.  Making the decision to have a healthy breast removed may offer a chance to regain some sense of being in control, and may also serve to diminish any guilt or shame over not having done the "right" things to prevent the cancer.

Religious Contributions

In some religions, such as Roman Catholicism, sex is viewed as primarily for procreation, and for the pleasure of married men.  Roman Catholic women are encouraged to engage in sexual relations only to have children and to please their spouses. Women who engage in sex for their own pleasure, or who use some form of birth control, are induced to experience varying degrees of conscious or unconscious guilt or shame. Sexuality may be experienced as a burden, something that has to be managed and dealt with, something that can lead to sinful behavior and eternal damnation. Breast cancer may be consciously or unconsciously viewed as a punishment, and giving up a breast, as a way to pay for one's sins, thereby restoring a sense of virtue as well as the possibility of a blissful afterlife in heaven with God.

Other psychological issues

Some women are conflicted about their sexuality or sexual attractiveness because they grew up in families in which their physical beauty or sexuality was the cause of jealousy, anxiety or sexual abuse.   In these situations, sacrificing a healthy breast may serve to expiate guilt or shame and the patient may actually experience relief when the breast is gone.

Prophylactic mastectomy has not been shown to affect survival in those who are not at increased genetic risk for breast cancer.  One can have still have a cancer recurrence in the tissue that's left or in some other part of the body.

Psychology and Proplylactic Mastectomy

On Sunday, July 26th, 2014, the New York Times printed an opinion piece written by Peggy Orenstein titled "The Wrong Approach to Breast Cancer" in which Ms. Orenstein relays the results of a study published in 2009 in The Journal of Clinical Oncology, showing that the rates of mastectomy with contralateral proplylactic mastectomy (removal of the unaffected breast) jumped dramatically for those with very early stage breast cancer between 1998 and 2005 (Tuttle et al, 2009).  Most of these women did not have an increased genetic risk for the disease. Ms Orenstein points out that this occurred even though this surgical procedure has virtually no survival benefit, i.e. women who choose to have this, are apparently not living longer according to a recent study that appeared in the Journal of the National Cancer Institute.  In one study, young women chose to have this done even though the majority knew that this procedure would not prolong life.  They even often cited enhanced survival as the reason.  In addition, there are often complications and side effects associated with contralateral proplylactic mastectomy (CPM) and breast reconstruction such as infections, ruptured implants and lack of sensation in the reconstructed breast.

Why are women apparently so willing to give up a healthy breast even when they are informed that it will not increase their survival?  Ms. Orenstein cites several possible psychological  motivations such as the desire to flee from the diagnosis and put the whole thing behind them as quickly as possible. She mentions the power of "anticipated regret" - i.e. women want to feel that they have done everything they can to prevent a recurrence, especially when they have young children. "Patients will go to extremes to restore peace of mind, even undergoing surgery, that paradoxically, won't change the medical basis for their fear."  She aptly points out that self-sacrifice has long defined what it means to be a good mother.

Breast Symbolism, Breast Cancer and Psychological Impact

In 2004 prominent psychoanalyst, Joyce McDougall, described how the mutilating breast cancer treatments women are subjected to, invariably arouse considerable psychological distress that can include the loss of the feeling of bodily integrity, disturbance in self-image and the sense of subjective identity, as well as changes in feelings of sexual identity. “With the loss of the breast, the essential symbol of femininity is felt to be destroyed,” McDougall wrote. (See McDougall, J. (2004), The Psychoanalytic Voyage of a Breast Cancer Patient in The Annals of Psychoanalysis: Psychoanalysis and Women, 32:9-28, Hillsdale, NJ, The Analytic Press.)

Due to the current lack of scientific knowledge about effective ways to both prevent and treat cancer, without putting patients through poisonous and assaulting treatments, a cancer diagnosis of any type has the potential to trigger a myriad of emotions and complex psychological trauma. Because the female breast is so symbolic and laden with conscious and unconscious meaning, it is especially important when thinking about breast cancer to consider what may be going on in patients', family members' and medical providers' minds.  Breasts universally symbolize femininity, nurture, sexual maturity and fertility. The idea of a toxic presence in the breast shakes the idea of life-giving sustenance right to its core.  In many cultures, the female breast is a defining characteristic of female attractiveness and sexual desirability, so when a woman is faced with losing a breast, she will often feel threatened and challenged in many different ways, in addition to having to cope with the idea of having a life-threatening disease.

It is particularly crucial for medical providers to be aware of not just how their patients are being physically and emotionally impacted, but also how they, themselves, are being affected. Medical providers need to be trained to be sensitive to their own emotional reactions and conflicts; they are in the unenviable position of having to offer and impose harsh and sickening treatments that permanently alter their patients physiology as well as external appearance. When physicians lack emotional self-awareness, they are at increased risk of causing unnecessary harm either to patients or to themselves. With patients, they may push for treatments that statistically only reduce the chances of cancer recurrence by a very small percentage, or they may fail to adequately inform patients about the extent of various treatment side effects, i.e. what life will likely be like, both while going through treatment and maybe for years afterward. With themselves, physicians may slide into problematic coping mechanisms such as alcohol abuse, gambling addictions, or abusive behavior directed at medical subordinates or their own family members.

Psychotherapists working with women who are being treated for breast cancer or who have undergone treatment in the past, also need to tune in to what psychological conflicts, emotions, attitudes and trauma are being activated in their own minds as they listen to their patients.  The more effectively the therapist does this, the more she will be able to help her client access her own unfelt emotional trauma, with the aim of containing it and working it through.

Lymphedema - An Ongoing Common Side-effect of Breast Cancer Treatment

Scotland Forest. Photo by Dr. Guerra

There is recent evidence to suggest that lymphedema, a condition that can result from having lymph nodes removed or radiated as part of breast cancer treatment, is something that many patients and their families are often told little or nothing about.  Some recovering breast cancer patients only find out about lymphedema at some point after their surgery, from a concerned nurse, blood draw technician, internist or fellow cancer survivor.

Lymphedema refers to "the build-up of fluid in soft body tissues when the lymph system is damaged or blocked". (See www.cancer.gov - National Cancer Institute). Symptoms in a breast cancer survivor include swelling and/or a heavy feeling in the arm, a tight feeling in the skin and trouble moving a joint in the arm. When a person is at increased risk for lymphedema, she always has to be thoughtful about physical activity involving that arm such as gardening, household chores and working out in a gym. Anything that will cause the build-up of lymph in the arm (e.g. cuts, scrapes, bug bites, heavy lifting, hot tubs), has to be monitored or avoided, in order to avoid the possibility of inflammation and lymphedema.  Blood pressure checks and blood labs have to be done using the other arm.

Mainstream breast cancer treatment in its current form - the gift that keeps on giving.

Women, Cancer and Anger

Because women are less likely then men in our culture to be able to fully engage with negative feelings like anger and frustration, they may be at a psychological disadvantage in this particular way when facing a cancer diagnosis. Since a cancer diagnosis typically evokes an intense and complicated set of feelings, the ability to manage and use emotions in a constructive way is crucial.

The importance to psychological health of allowing oneself to fully feel one's anger and other negative feelings is greatly misunderstood in the United States. Women in particular, are not authorized by the mainstream culture to fully engage with these emotions, and many find it difficult to allow themselves to be aware of their anger, let along use it to maximize coping strategies. Instead they often misidentify anger as hurt or annoyance and/or will themselves to "get over" it as quickly as possible.  Anger often takes the form of passive aggressive behavior, emotional manipulation, submission or depression.

As any cancer survivor knows, there is plenty to be angry about when going through a cancer diagnosis and treatment regimen. Patients need access to their anger in order to empower them to ask medical providers for information, and to persist until they get the answers they need to make appropriate treatment decisions. Anger is also an important component of coping with the many noxious side-effects associated with most of the treatment protocols currently in use.  Finally when a woman is in good command of her darker emotions, she is more likely to respond in an appropriately self-protective way when faced with intrusive, inappropriate, lame and insensitive comments coming her way from medical providers, relatives, co-workers, friends and acquaintances.

Women need to take charge of their cancer journey.  They are much more likely to do this and do it well, when they have access to all of their feelings. In the United States, we need to continue to look at why we keep believing and thinking that anger is not compatible with womanhood, and what the reasons are for continuing to deprive females of one of the most empowering coping mechanisms there is.