See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/221727063

Changes to Sexual Well-Being and Intimacy After Breast Cancer

Article in Cancer Nursing · January 2012

DOI: 10.1097/NCC.0b013e3182395401 · Source: PubMed

CITATIONS READS

162 2,029

3 authors:

Jane M. Ussher Janette Perz

Western Sydney University Western Sydney University
354 PUBLICATIONS 10,283 CITATIONS 190 PUBLICATIONS 5,623 CITATIONS

SEE PROFILE SEE PROFILE

Emilee Gilbert
Western Sydney University
34 PUBLICATIONS 2,054 CITATIONS

SEE PROFILE

All content following this page was uploaded by Jane M. Ussher on 25 January 2018.

The user has requested enhancement of the downloaded file.

Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Jane M. Ussher, PhD

Janette Perz, PhD
Emilee Gilbert, PhD

Changes to Sexual Well-Being and

Intimacy After Breast Cancer
K E Y W O R D S Background: Changes to sexual well-being can be one of the most problematic
Breast cancer aspects of life after breast cancer, with the impact lasting for many years after
Coital imperative treatment, associated with serious physical and emotional adverse effects. However,
Distress the primary focus on corporeal changes negates the influence of social and
Intimacy relational constructions of sexuality and illness and the ways in which the meaning of
Mixed methods sex is negotiated by individuals and within relationships. Objective: The aim of this
Qualitative study was to examine changes to sexuality and intimate relationships in individuals
Relationships who have experienced breast cancer, from a material-discursive-intrapsychic
Sexual well-being perspective, using mixed-method analysis. Methods: An online survey containing
Survey 47 quantitative and qualitative items was completed by 1965 Australian individuals
with breast cancer. Participants were 98% women, with a mean age of 54 years.
Results: Decreases in sexual frequency, response, and satisfaction were attributed
to a range of factors, including tiredness and pain, psychological distress and body
image, and medically induced menopausal changes such as vaginal dryness, hot
flushes, and weight gain. Predominant concerns identified in the qualitative analysis
were emotional consequences, physical changes, feeling unattractive or lacking
femininity, reconciliation of self to changes, and impact on partner or relationship.
Conclusions: These findings support and extend previous research that reports
significant changes in sexual well-being after diagnosis and treatment for breast
cancer. Implications for Practice: The findings are of significance to clinicians
because sexual well-being is central to psychological well-being and quality of
life, and sexual intimacy has been found to make the experience of cancer more
manageable and to assist in the recovery process.

Author Affiliations: Health Services and Outcomes Research Group, School Correspondence: Jane M. Ussher, PhD, Health Services and Outcomes
of Medicine, University of Western Sydney, Penrith, Australia. Research Group, School of Medicine, University of Western Sydney, Locked
This study was commissioned and funded by Breast Cancer Network Bag 1797, Penrith, NSW 2751, Australia ([email protected]).
Australia, in the form of a research contract with the University of Western Accepted for publication September 22, 2011.
Sydney. DOI: 10.1097/NCC.0b013e3182395401
The authors have no conflicts of interest to disclose.

456 n Cancer NursingTM, Vol. 35, No. 6, 2012 Ussher et al

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
B
reast cancer is the most common cancer in women and uality is limited to its corporeal dimensions, negating the in-
the second leading cause of cancer deaths in women fluence of the social and relational construction of sexuality
globally.1 Fortunately, advances in breast cancer screen- and illness,21 and the ways in which the meaning of sex is
ing and treatments have led to increasing rates of survival, with negotiated by individuals and within relationships.22 In this
significant proportions of women surviving for 5 years after vein, research consistently shows that one of the most impor-
diagnosisVa rate of 88% in Australia, for example.2,3 This tant and consistent predictors of sexual health in women with
has led to a focus on quality of life issues in breast cancer re- breast cancer is the quality of their partnered relationship.23 A
search, with particular attention being paid to sexuality. It is good couple relationship and a supportive intimate partner
now recognized that changes to sexual well-being can be one have been shown to assist women cope with cancer and its
of the most problematic aspects of life after breast cancer, with outcome.14,15 In fact, it has been shown that the quality of a
the impact lasting for many years after successful treatment,3Y5 woman’s relationship is a stronger predictor of sexual sat-
often associated with serious physical and emotional adverse isfaction, sexual functioning, and sexual desire after breast
effects.6 Research has shown that when compared with healthy cancer than the physical or chemical damage to the body after
same-aged women, women with breast cancer experience treatment.24,25
lower levels of sexual satisfaction and have more difficulty Previous research on sexuality and breast cancer has pri-
maintaining their sexual life.7 More specific disturbances to marily used quantitative survey methods of data collection.18
sexual well-being include pain; fatigue8; decreased vaginal lu- Although quantitative methods can provide information on
brication; nausea; hot flashes; night sweats9; vomiting, vaginal changes in large samples of individuals, they negate the com-
irritation, dyspareunia10; decreased sexual interest or desire11; plexity of women’s lived experience and negotiation of sexual
vaginal atrophy; decreased sexual arousal12; numbness in pre- well-being after breast cancer.18 There has been some qual-
viously sensitive breasts13; and difficulty achieving orgasm.8 itative research that has examined women’s lived experiences of
Although some women experience the changes to their sex- changes to sexuality after breast cancer (see Archibald et al14)
uality after breast cancer positively,9,14 most evidence shows that and the ways in which sociocultural discourses shape the ex-
women with breast cancer experience a range of serious neg- perience and interpretation of sexuality.17 However, within
ative emotions, including depression and anxiety,15 as well as this research, the psychological and relational aspects of women’s
alterations to their sexual self.13 experiences are often ignored, physical changes are often mini-
Research has shown that the strongest consistent predictor mized, and small sample size limits generalizations that can be
of sexual problems after breast cancer is lower perceived sex- made to a broader population of individuals with breast cancer.
ual attractiveness.4 Women who have a poor body image after The purpose of the present research study was to examine
breast cancer have lower rates of sexual satisfaction and are the lived experience of sexual well-being and couple intimacy
more dissatisfied with their sexual relationship than are those in a large sample of individuals with breast cancer living in
with a positive body image.7 At the same time, it has been Australia, using a combination of quantitative and qualitative
argued that although the physical pain of breast cancer and methods. We are adopting a material-discursive-intrapsychic
treatment diminishes with time, the experience of emotional perspective,18,26 which acknowledges the materiality of phys-
pain may persist, as women grieve the loss of their breast or ical changes in sexual well-being, as well as the tangible impact
feel as though a part of them has died.6 Breasts are often of cancer and cancer treatment, women’s psychological and emo-
positioned as such a significant part of women’s sense of self tional experience, and the negotiation of such changes within a
that mastectomy is associated with being ‘‘half a woman.’’16 relational context, where meaning is constructed in the context
This is because the breast is positioned as a signifier of a of cultural constructions of femininity, sexuality, and illness.
woman’s sexuality and femininity within patriarchal culture, The research questions were as follows: What are the changes
meaning that women with breast cancer are at risk of being to sexual well-being and intimacy experienced after breast can-
positioned outside ‘‘normal’’ femininity, with implications for cer? What factors are perceived to have caused these changes?
women’s sense of self, body image, and psychological well- How are these changes subjectively experienced by people with
being.17Y19 breast cancer?
Until recently, research examining the impact of breast
cancer on sexual well-being and intimacy has focused nar-
rowly on women’s ability to engage in satisfying sexual ac- n Method
tivity, their satisfaction with the frequency of that activity,13,20
and the level of their sexual ‘‘dysfunction’’ after breast cancer,
where functional sexuality is conceptualized as penile/vaginal
Design
intercourse.8,13,20 Recent research has shown, however, that en- The participants were drawn from the membership of the
gaging in sexual intercourse may not be women’s primary fo- peak national organization for Australians affected by breast
cus of sexual concern after a breast cancer diagnosis and that cancer. Participants responded to an e-mail invitation to com-
engagement in sexual intercourse does not necessary equate plete an online survey. A mixed-method approach was adopted
to sexual satisfaction.13,18 Moreover, the primary focus on where qualitative and quantitative data are integrated and pre-
the physical effects of breast cancer or breast cancer treatment sented. The research protocol was reviewed and approved by
on sexual behavior assumes that a woman’s experience of sex- the university human ethics research committee.

Sexual Well-Being and Intimacy After Breast Cancer Cancer NursingTM, Vol. 35, No. 6, 2012 n 457
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Procedure n Results
SURVEY

The survey was available for online completion for a 14-day The Impact of Breast Cancer on Sexual
period in December 2010. The survey contained27 quantita- Well-Being and Relationships
tive and qualitative items based on insights from an extensive In answer to a question on the impact of breast cancer or breast
literature review, discussions with stakeholders, and previous cancer treatment on sexual well-being, most of the 1956 par-
research conducted by the project team. The survey examined ticipants reported a decrease in frequency of sex (78%), energy
the experience of sexual well-being and pathways around help for sex (76%), sexual arousal (74%), feeling desirable (73%),
seeking for people with breast cancer in Australia. interest in sex (71%), sexual pleasure (64%), satisfaction with
sex (62%), and intimacy (60%) (Table 3). No change was
reported by most participants in the areas of ‘‘partner in-
ANALYSIS terested in sex’’ (64.3%) and ‘‘communication with partner
Descriptive statistics with measures of central tendency were about sexual needs’’ (50.5%); however, a considerable pro-
calculated for ordinal data derived from quantitative survey re- portion of the sample also reported decreases in these areas.
sponses. For frequency data, percentages are calculated based Only 7.2% of the sample noted an increase in the area of
on the number of participants who completed each item and ‘‘communication with partner about sexual needs,’’ with this
rounded up for readability. For items with multiple options, being the largest recorded increase.
percentages do not total 100 because participants could choose Of 1954 participants who described which aspects of breast
cancer or breast cancer treatment were perceived to have affected
more than 1 response. Thematic analysis28 was used to analyze
sexual well-being (Table 4), the most frequent responses were
the open-ended responses. This involved independent reading
tiredness (71%), vaginal dryness (63%), hot flushes (51%), and
of responses to each question by 2 members of the research
feeling unattractive (51%). When asked what had been tried to
team, to ascertain the major themes emerging and to develop
deal with changes to his/her sexual well-being after the onset of
a coding frame, based on notions of consistency, commonality,
breast cancer, the most common response, reported by 61% of
and the function and effects of specific themes. The entire data
1598 respondents, was talking to partner/husband, followed by
set was then coded using NVivo, a software package that as-
lubricant (57%), exercise (45%), reading information booklets/
sists with the organization and analysis of textual data. De-
leaflets (31%), talking to a health professional (26%), anti-
mographic information is provided for longer quotes, which
depressants (20%), psychotherapy/counselling (16%), sex aids
are omitted to enhance readability from shorter quotes. This (14%), medications (11%), and books (11%).
article will focus on accounts of changes to sexual well-being
Of 1999 respondents who described the impact of breast
and relationships after breast cancer.
cancer on their sexual relationship, 24% said it was affected
‘‘dramatically’’; 26%, ‘‘considerably’’; 32%, ‘‘somewhat’’; and
only 15%, ‘‘not at all.’’ Of the 1348 participants who an-
swered a question asking whether their partner had experi-
Participants enced any negative consequences because of their breast cancer,
A total of 2210 participants attempted to answer the survey, the most common reports were fear of hurting me during sex
with 1965 responding to all questions, representing an 88.9% (52%), lack of interest in sex (37%), difficulties in commu-
completion rate. Although a minimum sample of 381 was nication (34%), tiredness (28%), and change in role (seeing
required to reach a 95% confidence level, accepting a 5-point me as a patient) (20%). Table 5 illustrates these reports, as well
confidence interval, a larger sample increases the statistical as the other reported effects. The pattern of these proportions
power of the study; therefore, all of the data that were col- in all of the above items did not differ according to age, rela-
lected were analyzed. The average age for participants was tionship status, sexual orientation, or current stage of cancer
54.1 years; the sample was predominately female, self-identified treatment. More than 400 participants (n = 413) responded
as Anglo-Australian, and had further tertiary education and/or to an item inquiring into the influence of cancer upon their
training. Most participants were partnered and heterosexual, ability to enter into a new relationship, with 57% indicating
with children. Table 1 presents the complete sociodemographic that it had had an impact. The most frequently identified
descriptive statistics for the sample. issues were related to feelings around appearance and the
The breast cancer and treatment status profile for this sam- perceptions of others with ‘‘body image/attractiveness con-
ple is presented in Table 2. On average, it had been 3.9 years cerns,’’ noted by 77% of the subsample, followed by ‘‘lack
since participants received their diagnosis of breast cancer. of confidence’’ (66.5%), ‘‘not feeling desirable’’ (65%), and
At the time of diagnosis, for 74.6% of the sample, the type ‘‘fear of rejection’’ (46.5%). Of these concerns, ‘‘not feel-
of cancer diagnosed was early-stage breast cancer. Currently, ing desirable’’ and ‘‘fear of rejection’’ were more commonly
45.6% of the sample had finished their treatment, with a reported by women seeking new heterosexual relationships
similar proportion (45.5%) indicating that they were receiv- (63.8% and 45.4%, respectively) compared with women seek-
ing treatment. Menstruation had ceased for 77.8% of the ing a new same-sex relationship (14.3% and 0%, respectively).
sample who described themselves as postmenopausal. The most common physical effects reported were fatigue

458 n Cancer NursingTM, Vol. 35, No. 6, 2012 Ussher et al

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(46.5%), vaginal dryness (42.9%) and upper body or other changes to sexual well-being after breast cancer. The most
pain (22.8%). commonly reported feelings were ‘‘devastating’’ and ‘‘depressing,’’
with other descriptors including ‘‘confusing,’’ ‘‘disturbing,’’ ‘‘soul
destroying,’’ ‘‘shocking and unexpected,’’ ‘‘frustrating,’’ ‘‘trau-
The Subjective Experience of Changes to matic,’’ and ‘‘demoralizing.’’ For most women, these feelings
Sexual Well-Being After Breast Cancer were associated with a loss of interest in sex or not experienc-
ing pleasure during sex, as illustrated by the following ac-
A total of 1259 participants, all women, provided answers to
counts: ‘‘I find that I have no desire for sex. When I have sex
an open-ended question asking about subjective experience of
I find that it was not enjoyable which then made me feel
changes to sexual well-being after breast cancer. The most
guilty’’ (47-year-old woman, locally advanced breast cancer,
common responses related to emotional consequences, physical
2 years postdiagnosis); ‘‘Very upsetting. I love my husband
changes, feeling unattractive or lacking femininity, reconcilia-
very much and our relationship is very good. My physical
tion of self to changes, concerns about impact on partner or
body does not arouse or respond like it used to’’ (51-year-old
relationship, and partner support and relationship improve-
woman, early breast cancer, 3 years postdiagnosis).
ment, outlined below.
A significant proportion of women reported sadness and
loss because of sexual changes, with one saying ‘‘I feel a sense
DEVASTATION, DEPRESSION, AND SADNESS:
of loss, as if part of me has died,’’ and another saying, ‘‘I felt
EMOTIONAL CONSEQUENCES
like my heart had been ripped out. Very empty.’’ Many
More than a third of the 1259 open-ended question respon- women also told us that they ‘‘miss the sexual aspect of my
dents (n = 439) described negative emotional consequences of life,’’ as illustrated in the following account.

Table 1 & Sociodemographic Characteristics of the Study Sample (N = 1956)

Characteristic % (n) or Mean Range (SD)
Age 54.1 years 18Y84 years (9.4 years)
Gender
Female 98.8 (2185)
Male 0.2 (5)
Cultural background
Anglo-Australian 89.1 (1910)
European 8.8 (188)
Aboriginal/Torres Strait Islander 0.3 (8)
Asian 1.5 (32)
Middle Eastern 0.1 (4)
African 0.1 (2)
Highest level of education
Completed secondary school 34.1 (701)
Trade/apprenticeship qualification 5.2 (107)
Certificate/diploma 24.4 (501)
Tertiary education or higher 36.3 (745)
Relationship status
Partnered, living together 80.1 (1747)
Partnered, not living together 5.2 (113)
Not in a relationship 14.7 (321)
Period of time
Partnered, length of relationship 24.8 years 2 monthsY59 years (12.9 years)
Not partnered, time since last relationship 7.2 years 2 monthsY49 years (7.2 years)
Gender of partner
Male 98.0 (1994)
Female 2.0 (41)
Children
Yes 84.2 (1830)
No 15.8 (343)
Relationship end since onset of breast cancer
Yes 7.4 (158)
No 92.6 (1970)
Current sexual relationship
Yes 77.2 (1662)
No 22.8 (491)

Sexual Well-Being and Intimacy After Breast Cancer Cancer NursingTM, Vol. 35, No. 6, 2012 n 459
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 2 & Breast Cancer and Treatment Status Profile (N =1956)
Characteristic % (n) or Mean Range (SD)
Diagnosis
Years since first diagnosis 3.9 years G1Y32 years (4.6 years)
Stage at diagnosis
Early breast cancer 74.6 (1602)
Locally advanced breast cancer 19.9 (428)
Secondary breast cancer (spread to other parts) 4.2 (91)
Don’t know/unsure 1.3 (27)
Current treatment status
Completed treatment 45.6 (974)
Currently receiving treatment 45.5 (971)
Between rounds of treatment 1.2 (26)
Subsequent diagnosis of breast cancer 6.8 (145)
Subsequent diagnosis of a different cancer 0.8 (18)
Menopausal status
Postmenopausal 77.8 (1697)
Perimenopausal 13.4 (292)
Premenopausal 8.8 (192)

I feel as if an integral part of my life is no longer well PAINFUL SEX AND ABSENCE OF DESIRE: PHYSICAL
within my reach. Although I am getting older and CHANGES TO SEXUAL WELL-BEING
therefore might be expected to lose interest in sex to a
certain degree, sex has been an important component Approximately one quarter of the 1259 open-ended question
of my life until I started receiving treatment for breast respondents (n = 249) described the changes to sexual well-
cancer. I worry about my loss of interest in sex and being after breast cancer in terms of physical changes, in-
I miss the sexual aspect of my life (65-year-old woman, cluding vaginal dryness or prolapse; absence of sexual desire,
early breast cancer, 3 years postdiagnosis). arousal, or orgasm; erectile dysfunction; and absence of breast
sensitivity or breast tenderness: ‘‘Enjoy the sexual experience
A substantial number of women told us that they experi- but very conscious of my breast and the fact they have no
enced feelings of loss because of the changes in their rela- feeling. Weight put on the breast can be painful’’ (48-year-old
tionship with their partner, feeling that a ‘‘door was being woman, early breast cancer, 2 years postdiagnosis); ‘‘Main prob-
closed’’ and they could not always discuss it. The ‘‘totally lem is lack of interest and vaginal dryness. Husband VERY
unexpected’’ nature of changes to sexual well-being was also supportive but doesn’t initiate sex as often because he doesn’t
a source of distress for many participants, who told us that want to be pushy as he knows I just can’t be bothered a lot
they had been given no information about what to expect: of the time’’ (50-year-old woman, early breast cancer, 3 years
‘‘Terrible! I am young and had not expected the side effects postdiagnosis).
sexually that come from menopause and treatmentsIvery Vaginal dryness or prolapse can lead to painful coital sex.
sad’’ (26-year-old woman, early breast cancer, 3 years post- This was an experience commonly reported by women, which
diagnosis); ‘‘Devastating. A complete shock, no one tells you can sometimes lead to avoidance of sex: ‘‘Sexual intercourse is
that it ruins your sex life’’ (61-year-old, secondary breast can- very painful. We can get pleasure from mutual masturbation,
cer, 3 years postdiagnosis). but penetration for me is very, very painful. It is almost like

Table 3 & The Impact of Breast Cancer or Breast Cancer Treatment on Sexual Well-Being (N =1956)
Area Decreased No Change Increased
Frequency of sex 77.9 (1427) 20.3 (372) 1.8 (33)
Energy for sex 76.0 (1379) 22.4 (407) 1.5 (28)
Sexual arousal 73.6 (1344) 24.2 (442) 2.2 (40)
Feeling desirable 73.4 (1385) 25.1 (473) 1.6 (30)
Interest in sex 71.4 (1308) 26.1 (479) 2.5 (45)
Sexual pleasure 64.2 (1151) 33.8 (607) 2.0 (36)
Satisfaction with sex 61.9 (1096) 35.6 (630) 2.5 (44)
Intimacy 60.4 (1090) 34.5 (623) 5.1 (93)
Communication with partner about sexual needs 42.4 (746) 50.5 (889) 7.2 (126)
Partner interest in sex 32.4 (565) 64.3 (1120) 3.3 (58)
Data are presented as % (n).

460 n Cancer NursingTM, Vol. 35, No. 6, 2012 Ussher et al

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 women reporting that they had ceased sexual activity or
Table 4 & Aspects of Breast Cancer or Breast
endured uncomfortable or painful sex to please their partner.
Cancer Treatment That Have Affected
As one woman commented, ‘‘There is physical and emotional
Sexual Well-Being (N = 1956)
pain involved in having sexVI worry that I only doing it to
Item % (n) keep him happy, not at all for myself.’’ Women also reported
Tiredness 71.0 (1387) that the physical consequences of cancer or cancer treatment,
Vaginal dryness 63.3 (1237) including tiredness, nausea, feeling ‘‘sore’’ or ‘‘uncomfortable,’’
Hot flushes 51.2 (1000) and weight gain, affected their sexual well-being: ‘‘Sex is the
Feeling unattractive 50.8 (993) last thing on your mind when your chest hurts, you lose all
Weight gain 48.8 (953) your hair, you are tired and feel very unattractiveVyou just
Difficulty being aroused 45.8 (894) want to survive and get through’’ (35-year-old woman, sec-
Feeling uncomfortable exposing my body 44.0 (860) ondary breast cancer, 1 year postdiagnosis).
Medication adverse effects 39.0 (762) In contrast, a very small number of women reported in-
Loss of confidence in myself 38.4 (751)
creased sexual pleasure or desire, ‘‘increased libido,’’ or that
Depression/anxiety 37.8 (738)
sex was a way of feeling ‘‘real and alive’’ during treatment: ‘‘I
Change in size or shape of breast 37.6 (734)
Difficulty reaching orgasm 35.9 (701) went from not feeling a desirable woman to feeling the more
Loss of sensation 35.8 (700) sexually interested and excited I have ever been’’ (50-year-old
Reduced nipple sensation 35.4 (692) woman, early breast cancer, 2 years postdiagnosis); ‘‘I am
Pain during intercourse 33.4 (653) shocked that my libido has increased’’ (35-year-old woman,
Anxiety about sex 28.6 (558) early breast cancer, 2 years postdiagnosis). These cases may be
Early menopause 28.1 (550) in the minority, but they suggest that detrimental effects of
Appearance changes (eg, hair loss) 27.0 (527) breast cancer on sexual well-being cannot be assumed to be
Pain in upper body 26.9 (525) the case for all women.
Relationship changes 22.8 (446)
Fear 21.4 (418)
Loss of identity 17.0 (332) I’M NOT REALLY A WOMAN ANYMORE: FEELING
Anger 16.3 (319) UNATTRACTIVE AND LACKING IN FEMININITY
Lymphedema 16.3 (318)
Approximately one-fifth of the open-ended question respon-
Guilt 12.6 (246)
Feelings of shame 10.2 (200) dents (n = 212) reported feeling unattractive or lacking in
Othera 36.9 (722) femininity after breast cancer and told us that, as a con-
Erectile difficulties (for men with breast cancer) 100.0 (5) sequence, they felt that this affected their sexual well-being.
a
Thus, women described themselves as being distressed because
Each less than 10%: increased sensitivity (9.9%, n = 193), thrush (8.4%, of ‘‘negative feelings about my body’’ or because ‘‘I don’t feel
n = 164), vaginal discharge (8.0%, n = 157), irregular menstruation (6.1%,
n = 120), weight loss (3.9%, n = 76), and more energy (0.6%, n = 12). attractive at all anymore.’’
When first diagnosed, I was alone, so sex not important,
now it is naturally more important, and having no breasts
my husband is wearing a condom with cut glass attached to
it’’ (65-year-old woman, early breast cancer, 6 years post-
diagnosis). A number of women gave accounts of dealing with Table 5 & Perceived Consequences of Breast
these physical changes by renegotiating coital sexual activity after Cancer or Treatment Upon the Partner
breast cancer, primarily through the use of lubricants. In some (N = 1348)
instances, this was positioned positively, as an effective solution: Item % (n)
‘‘Breast cancer diagnosed Oct 2008. Met new partner (widower)
Jan 09 and commenced sexual relationship Feb 09. No probs Fear of hurting me during sex 52.5 (708)
except dryness due to Arimidex (use lubricant)’’ (67-year-old Lack of interest in sex 36.9 (498)
Difficulties in communication 34.1 (459)
woman, early breast cancer, 3 years postdiagnosis). In other
Tiredness 27.8 (375)
instances, lubrication was described as ‘‘messy’’ and as interrupt- Change in role (eg, seeing me as a patient) 20.0 (269)
ing the spontaneity of sex: ‘‘The only way to have sex is with Erectile difficulties 19.0 (256)
lubrication which is messy and I find it extremely frustrating Fear 17.7 (238)
and annoying for not only me but for my husband as the first Depression/anxiety 17.0 (229)
thing I reach for is my bottle of lubricant’’ (38-year-old woman, Anger 15.6 (210)
early breast cancer, 9 years postdiagnosis). Masturbation was Anxiety about sex 13.8 (186)
also described as a solution, with one 75-year-old woman Difficulty being aroused 12.4 (167)
with locally advanced breast cancer, 1 year postdiagnosis, Difficulty in reaching orgasm 10.5 (141)
telling us: ‘‘As a still attractive older woman no sexual partner Othera 11.4 (153)
means masturbation an option on occasion.’’ These accounts a
Each less than 10%: guilt (6.8%, n = 91), taken a different sexual partner(s)
of renegotiation were in the minority, however, with most (2.3%, n = 31), loss of identity (1.6%, n = 22), and more energy (0.7%, n = 9).

Sexual Well-Being and Intimacy After Breast Cancer Cancer NursingTM, Vol. 35, No. 6, 2012 n 461
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 now sometimes makes me feel less feminine considering sexual well-being or having reconciled themselves to such
my fiancé was always a ‘‘boob’’ man (41-year-old woman, changes since the diagnosis of breast cancer: ‘‘It really hasn’t
early breast cancer, 6 years postdiagnosis). worried me all that much’’; ‘‘This is something we have both
Other women provided more pejorative comments about come to terms with and manage accordingly’’; ‘‘I was too
themselves, feeling ‘‘old and ugly,’’ ‘‘maimed,’’ ‘‘grotesque,’’ tired to care.’’ Others positioned changes in sexual well-
‘‘mutilated,’’ a ‘‘freak,’’ ‘‘damaged goods,’’ ‘‘like an old has being as temporary and looked forward to improvements in
been,’’ ‘‘undesirable,’’ and ‘‘deformed,’’ feelings that were as- the future: ‘‘I hope I will ‘get back to normal’ after I finish
sociated with breast scars, reconstruction, hair loss, and weight treatment. I feel I need to conserve my energy for healing
gain: ‘‘I hate to look at myself. I can’t look in the mirror. I at this time.’’
can’t even touch myself to see if the lump is still there. I At the same time, for a small number of participants, the
can’t stand to be looked at or touched. A hug is all I can cessation of sexual activity was welcomed: ‘‘now I have a
bear’’ (48-year-old woman, locally advanced breast cancer, reason to say no’’; ‘‘In some ways a relief’’; ‘‘Being over 70
1 year postdiagnosis). These feelings led many women to and never very partial to sex it was fine.’’ For other women,
hide their bodies from their partner, saying ‘‘I don’t want sex was positioned as unimportant or as less important than
my husband to see or touch my breast’’ or ‘‘I don’t feel like other aspects of health since the diagnosis of breast cancer,
exposing my breast and have partner touching it and seeing which meant that changes to sexual well-being were accepted:
it.’’ Many women also reported feeling ‘‘like I was a different ‘‘Other things seem more important and my partner has been
person,’’ ‘‘my femininity was ripped off overnight,’’ ‘‘not so caring that sex seems quite unimportant’’; ‘‘Find I am fo-
really a woman,’’ ‘‘less womanly,’’ ‘‘less of a person,’’ or ‘‘an cused on how my health rather than sex.’’ A few women com-
inadequate partner’’: mented that sex had never been important: ‘‘after so many
years of marriage we have become very good friends, so sex is
Horrible!! I’m 28 and have been married for 9 months not that important’’; ‘‘did not have sex before and not having
and have had sex probably 4 times in that time. I used to it now’’; ‘‘the need for sex was no longer part of my life.’’
enjoy it very much and now have no physical pleasure
from it and barely ever do it. This has impacted on my
LETTING MY PARTNER DOWN: CONCERNS ABOUT
identity as a woman and as a wife, has made me consider
IMPACT ON PARTNER OR RELATIONSHIP
my partner having an affair because I am not able to
satisfy him sexually (29-year-old woman, early breast For a number of women, approximately one-fifth of the
cancer, 1 year postdiagnosis). open-ended question respondents (n = 190), the impact of
In some instances, this feeling was associated with partner changes in sexual well-being for their partner was their major
rejection, which confirmed the woman’s fears, as is illustrated in concern: ‘‘It made me feel as though I was neglecting my
the following accounts: ‘‘Husband avoided my reconstructed husband but I just don’t feel the same about sex as I use to.’’
breast, which made me feel it wasn’t a ‘normal’ thing’’; ‘‘he says I I’d say I’ve had less than 5 orgasms in 12 months
have ‘mutilated my body.’ It isn’t a pretty sight, and I don’t like and I am not even bothered which is not how I use to be.
it either, but I’m stuck with it.’’ In contrast, other women de- I worry about how my partner must feel as I struggle
scribed partner support as alleviating their fears about being to appear interested when we have sex. We are close
‘‘unattractive’’ or ‘‘deformed’’ or of their partner helping to but I know he would like more from me (34-year-old
address their lack of ‘‘confidence in body image’’: woman, early breast cancer, 1 year postdiagnosis).
Initially, I felt that I was unattractive, even deformed. Approximately 10% of the open-ended question respon-
I worried that my husband wouldn’t love my body as dents (n = 126) told us that their relationship had experienced
before. He tells me over and over that he loves me difficulty, or broken down, because of changes to their sexual
even more now so... I have to get over it and just believe well-being after breast cancer. Comments included the
him (60-year-old woman, early breast cancer, 1 year following: ‘‘It was all very difficult, and placed a big strain
postdiagnosis). on my relationship’’; ‘‘my husband had affairs behind my
Partner support or acceptance did not always alleviate backIour marriage is all but finished although we are still
women’s negative feelings about their body or femininity, together’’; ‘‘my husband did not react well and subsequently
however, as illustrated in the following account: ‘‘although left.’’ A number of women also told us that existing rela-
my husband says he has no problem with my body as it tionship difficulties had been exacerbated by the occurrence of
nowII have a problem with it!II just can’t get passed [sic] breast cancer: ‘‘he does not seem interested anymore in sex at
this feeling. This affects our intimacy greatly!’’ (47-year-old all. It had been a bit of a problem previous to my diagnosis
woman, early breast cancer, 2 years postdiagnosis). and has got much worse since’’; ‘‘my diagnosis just exac-
erbated problems that already existed in my marriage. A non
communicative relationship just got worse.’’
IT REALLY HASN’T WORRIED ME: NO CHANGE OR
Most respondents attributed these relationship changes or
RECONCILING SELF TO CHANGES IN SEXUAL WELL-BEING
breakdown to their own disinterest in sex: ‘‘I went from a
Approximately one-tenth of the open-ended question respon- high libido to no libido or interest at all, my husband re-
dents (n = 123) described having experienced no change in placed me in less than 2 months’’; ‘‘pre diagnosis sex was fun

462 n Cancer NursingTM, Vol. 35, No. 6, 2012 Ussher et al

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
but now I have no desire. My relationship with husband found a very considerate amazing beautiful partner. I also still
is strained and stressed. He still wants sex but I am not feel sexy and whole and goddess like.’’
aroused.’’ For other women, these relationship changes were
When I was first diagnosed, I went through a terrible
attributed to their partner becoming their ‘‘carer,’’ ‘‘brother,’’ time of feeling undesirable, fearing disfigurement
or’’ housemate’’ and thus no longer their lover. As one woman and seeking affirmation. I felt very needy. I sought
told us, ‘‘I feel the relationship with my husband has become reassurance and was firmly rejected. Although upsetting
like housemates rather than husband and wife.’’ Difficulties in at the time, this was paradoxically helpful in forcing
communication were also described as causing relationship me to face up to my future independently and take
tension: ‘‘Very hard to come to terms with since my partner ownership of what was happening to me. The effect
isn’t good at communicating and in denial about my health of the surgery was much less disfiguring than I’d feared,
issues’’; ‘‘Devastating, communication became very strained and my confidence has returned. I’ve since had an
for the first time in our relationship.’’ affirming sexual relationship (62-year-old woman,
early breast cancer, 1 year postdiagnosis).
These accounts suggest that relationship difficulty or break-
WE’RE CLOSER NOW: PARTNER SUPPORT AND down does not mean the end of sexual relationships for women
RELATIONSHIP IMPROVEMENT with breast cancer, as new relationships can develop and can be
A small proportion of women, approximately one-tenth of rewarding both emotionally and sexually.
the open-ended question respondents, described feeling closer
or experiencing greater intimacy with their partner since the
diagnosis of breast cancer: ‘‘Whilst the act of sex has de-
creased the intimacy between us has increased in other ways’’; n Discussion
‘‘Our relationship has moved to another level of loving
without sex’’; ‘‘I actually feel more secure in my relationship These findings support and extend previous research that re-
postdiagnosis.’’ Breast cancer was also described as offering ports significant changes in sexual well-being after diagnosis
an opportunity to renegotiate intimacy to meet a woman’s and treatment for breast cancer. In a previous survey of 863
needs, often addressing needs that had been there before women that examined self-reported changes to sexual func-
breast cancer. One woman described this as ‘‘freedom’’ from tioning after breast cancer, it was found that one-third reported
sex, whereas another described increased ‘‘flirtiness and that cancer had a negative impact on their sexuality.21 In the
warmth,’’ which resulted in a richer relationship with her present study, the largest study of sexual well-being in the
husband, with whom she had developed ‘‘a deep unspoken context of breast cancer published to date,18 the proportion
bond that is much richer than the earlier sexual moments.’’ was far greater, suggesting that one-third may be a significant
Better communication since diagnosis was also reported by a underestimate. Decreases in frequency of sex, sexual arousal,
number of female participants: ‘‘we communicate our needs interest, and desire, as well as in sexual pleasure, satisfaction,
much better than before my diagnosis’’; ‘‘I found that we and intimacy, were attributed to a range of factors, including
communicated better regarding issues during treatment and tiredness and pain, psychological distress and body image, and
since.’’ Having a supportive partner who accepted the medically induced menopausal changes, such as vaginal dryness,
changes the woman was experiencing and who exerted ‘‘no hot flushes, and weight gain. However, accounts of material
pressure’’ for sex or was ‘‘willing to wait until I’m willing’’ changes to the body and relationships, as well as intrapsychic
was also described as a ‘‘the most important thing’’ by a consequences, cannot be separated from discursive construc-
number of women: tions of illness, femininity, and (hetero)sexuality, which give
meaning to the experience of sexuality after breast cancer: a
At diagnosis we were both so devastated and I felt material-discursive-intrapsychic interaction.18,29 For exam-
that I would never be able to have sex again but as ple, the focus on vaginal dryness experienced by women with
time goes on and acceptance happens our sex life has breast cancer as a major cause of sexual difficulty, as well as
improved thanks mainly to my partner’s attitude that the paucity of accounts of renegotiating sexual activity when
he loves me and does not find anything different about
coital sex was painful or difficult, illustrates the dominance
me (65-year-old woman, early breast cancer, 1 year
postdiagnosis). of the coital imperative in the construction and experience
of heterosexuality.30 Challenging the coital imperative through
Having a secure relationship before breast cancer was the exploration of noncoital sexual practices should thus be
described as important for a number of women, allowing the central to professional advice and support for individuals with
couple to cope with changes in sexual desire or activity: ‘‘we breast cancer.
are very secure in our relationship and agreed that intercourse Although some individuals experience the changes to their
was not high on the list of needs. Support, sharing conver- sexuality after breast cancer positively, most evidence shows
sations and just being together was more important.’’ Equally, that people with breast cancer experience a range of serious
a number of women described new relationships developing negative emotional changes because of disturbances to their
since diagnosis and treatment for breast cancer, sometimes sexuality.14 Having to adjust to the removal or alteration in
after a previous relationship had ended after cancer: ‘‘I have appearance of the breast, loss of bodily hair, feeling ‘‘old’’

Sexual Well-Being and Intimacy After Breast Cancer Cancer NursingTM, Vol. 35, No. 6, 2012 n 463
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
before their time, concern about weight gain or loss, and sexuality. At the same time, the accounts of individuals who
partner difficulty in understanding feelings can exacerbate are not in a relationship highlight the importance of sexual
these negative emotional changes, as was found in the present well-being for those with breast cancer who are currently single
study. Although some have argued that such changes are and the need for support, if requested, to alleviate fears or
more prevalent in individuals with preexisting anxiety, de- concerns about entering a new relationship. Sexuality is not
pression, or sexual dysfunction,8,31 it has also been reported only a relational issue; changes in sexual well-being, and in
that most women who experience negative changes to their sexual desire and arousal, can also affect those who are not in
sexual well-being also experience negative emotional changes.14 a relationship.
The findings of the present study confirm these reports in a Future research in this area could address some of the
large sample of individuals with breast cancer and provide issues not addressed in the present study. It would be useful
further insight into the nature of these effects. to include partners in the sample to examine the interactional
The accounts in the present study also illustrate not only dynamics of sexual well-being after breast cancer. It would
the intersubjective nature of changes to sexual well-being in also be useful to conduct interviews to examine changes to
the context of breast cancerVthe importance of relationship sexuality in more depth and use standardized questionnaires
context and partner reactionVbut also the complexity of the to assess the impact on psychological well-being and the as-
woman with breast cancer’s own response. Although partner sociation of changes to sexual well-being with relationship
rejection was consistently associated with women’s feelings of dynamics and satisfaction. The sample in the present study
negativity about the body or femininity, partner support did was composed largely of Anglo-Australian women. Future
not always alleviate these negative feelings. The way the woman research could usefully include individuals from a diverse
felt about herself and her ability to accept the changes to her range of cultural backgrounds, as expectations and experi-
body also impacted upon the way she positioned her body after ences of sexuality may be shaped by cultural identity, as well
breast cancer, allowing her to still feel like a sexual woman as a greater proportion of men, who are often omitted from
or, conversely, to feel ‘‘neutered,’’ as one participant described breast cancer research.18
herself.
At the same time, accounts of relationship change after
breast cancer confirm previous research reports that the di-
agnosis of cancer can change the relational dynamics between n Conclusion
people with cancer and their life partners, which can affect
the sexual relationship.32,33 Couples living with cancer have The findings outlined in this study are of significance to cli-
reported communication problems or increased conflict and, nicians, as sexual well-being is central to psychological well-
in some instances, have attributed relationship breakdown to being and quality of life and sexual intimacy has been found to
cancer,34Y36 as was found in the present study. Conversely, it make the experience of cancer more manageable and to assist
has been argued that couples living with cancer are no more in the recovery process.27,45 Health professionals can play an
likely to separate than couples in the general community37 important role in ameliorating concerns surrounding sexual
and that cancer can have had a positive effect on couple rela- well-being after breast cancer, offering specific suggestions re-
tionships,35 bringing people with cancer and their partners lated to sexual enhancement products, emotional adjustment
closer together,38 through creating greater intimacy.39 These to sexual changes, and information for partners.31,46 How-
conflicting findings have led Hagedoorn et al40(p24) to con- ever, the finding that only 25% of participants in the present
clude, in their meta-analysis of distress in couples coping with study had discussed sexual well-being with a health profes-
cancer, that further research is needed on ‘‘just how much sional, despite the high levels of distress reported, is a matter
cancer intrudes upon and organizes the daily lives of couples of concern. This seems to confirm previous findings that few
confronted with the disease.’’ The findings of the present health professionals engage discussions of sexual well-being
study make a substantial contribution to addressing this plea, with people with cancer, even in areas where it might be ex-
through exploring both negative and positive accounts of the pected, such as breast cancer.47,48 Further research is needed to
impact of cancer on sexual relationships. examine barriers that prevent discussion of sexual well-being
Although the experiences of partners are often neglected after breast cancer with a health professional. Further edu-
in research on sexuality and intimacy after cancer, there is cation and training of health professionals are also required, in
growing acknowledgement of their unmet needs in this order that they will be able to advise couples affected by breast
area.41,42 Reported disruptions include decreases in their own cancer on issues of sexual well-being and address unmet needs
sex drive, fear of initiating sex with their partner, difficulty in this arena.
regaining a level of ‘‘normality’’ within the sexual relationship,
and feeling unwanted and unattractive because of cessation of
ACKNOWLEDGMENTS
sex.43,44 Many of these findings have been confirmed and
extended by the findings of the present study, which reported Thanks are offered to Michelle Marven and Astrid Keir from
on partner experiences from the perspective of the person with Breast Cancer Network Australia for their advice on the
breast cancer. This reinforces the need to include partners, as survey and the interpretation of the data and to Caroline Joyce,
well as people with cancer, in future research in cancer and Emma Hurst, and Lauren Kadwell for research assistance and

464 n Cancer NursingTM, Vol. 35, No. 6, 2012 Ussher et al

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 support. Finally, we thank all of the individuals with breast 25. Zee B, Huang C, Mak S, et al. Factors related to sexual health in Chinese
cancer who completed the survey and shared their personal women with breast cancer in Hong Kong. Asia Pac J Clin Oncol. 2008;4:
218Y226.
stories of sexual well-being after breast cancer with us. 26. Ussher JM. Women’s madness: a material-discursive-intra psychic ap-
proach. In: Fee D, ed. Psychology and the Postmodern: Mental Illness as
Discourse and Experience. London, England: Sage; 2000:207Y230.
References 27. Schultz WCM, Van de Wiel HBM. Sexuality, intimacy and gynaeco-
logical cancer. J Sex Marital Ther. 2003;29:121Y128.
1. World Health Organization. Breast Cancer Prevention and Control. 28. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res
2009. http://www.who.int/cancer/detection/breastcancer/en/index.html. Psychol. 2006;3:77Y101.
Accessed September 5, 2011. 29. Ussher JM. Unravelling women’s madness: beyond positivism and con-
2. Australian Institute of Health and Welfare. Australia’s Health 2010. structivism and towards a material-discursive-intrapsychic approach. In:
Canberra, Australia: Australian Institute of Health and Welfare; 2010. Menzies R, Chunn DE, Chan W, eds. Women, Madness and the Law: A
AIHW Cat. no. AUS 122. Feminist Reader. London, England: Glasshouse Press; 2005:19Y40.
3. Bertero C, Wilmoth MC. Breast cancer diagnosis and its treatment 30. Gavey N, McPhillips K, Braun V. Interruptus coitus: heterosexuals ac-
affecting the self. Cancer Nurs. 2007;30(3):194Y202. count for intercourse. Sexualities. 1999;2(1):35Y68.
4. Burwell SR, Case DL, Kaelin C, et al. Sexual problems in younger women 31. Can G, Oskay U, Durna Z, et al. Evaluation of sexual function of
after breast cancer surgery. J Clin Oncol. 2006;24(18):2815Y2821. Turkish women with breast cancer receiving systemic treatment. Oncol
5. Andersen BL. In sickness and in health: maintaining intimacy after breast Nurs Forum. 2008;35(3):471Y476.
cancer recurrence. Cancer J. 2009;15(1):70Y73. 32. Ben-Zur H, Gilbar O, Lev S. Coping with breast cancer: patient, spouse,
6. Langellier KM, Sullivan CF. Breast talk in breast cancer narratives. Qual and dyad models. Psychosom Med. 2001;63(1):32Y39.
Health Res. 1998;8(1):76Y94. 33. Gilbert E, Ussher JM, Hawkins Y. Accounts of disruptions to sexuality
7. Speer JJ, Hillenberg B, Sugrue DP, et al. Study of sexual functioning following cancer: the perspective of informal carers who are partners of
determinants in breast cancer survivors. Breast J. 2005;11(6):440Y447. a person with cancer. Health. 2009;13(5):523Y541.
8. Fobair P, Stewart SL, Chang S, et al. Body image and sexual problems 34. Zahlis EH, Shandis ME. Breast cancer: demands of the illness of the
in young women with breast cancer. Psychooncology. 2006;15:579Y594. patients partner. J Psychosoc Oncol. 1991;9(1):75Y93.
9. Ganz PA, Rowland JH, Desmond K, et al. Life after breast cancer: 35. Badr H, Carmack Taylor CL. Social constraints and spousal communi-
understanding women’s health-related quality of life and sexual function- cation in lung cancer. Psychooncology. 2006;15(8):673Y683.
ing. J Clin Oncol. 1998;16(2):501Y514. 36. Kornblith AB, Anderson J, Cella DF. Quality of life assessment of
10. Ganz PA, Greendale GA, Petersen L, et al. Breast cancer in younger Hodgkin’s disease survivors: a model for comparative care. Oncology. 1990;
women: reproductive and late health effects of treatment. J Clin Oncol. 4:93Y101.
2003;21(22):4184Y4193. 37. Schover LR. Myth-busters: telling the true story of breast cancer sur-
11. Avis NE, Crawford S, Manuel J. Psychosocial problems among young vivorship. J Natl Cancer Inst. 2004;96:1800Y1801.
women with breast cancer. Psychooncology. 2004;13:295Y308. 38. Dorval M, Guay S, Mondor M, et al. Couples who get closer after breast
12. Knobf TM. The menopausal symptom experience in young mid-life cancer: frequency and predictors in a prospective investigation. J Clin
women with breast cancer. Cancer Nurs. 2001;24(3):201Y211. Oncol. 2005;23:3588Y3596.
13. Wilmoth MC. The aftermath of breast cancer: an altered sexual self. 39. Manne S, Ostroff J, Rini C, et al. The interpersonal process model of
Cancer Nurs. 2001;24(4):278Y286. intimacy: the role of self-disclosure, partner disclosure, and partner re-
14. Archibald S, Lemieux S, Byers ES, et al. Chemically-induced menopause sponsiveness in interactions between breast cancer patients and their
and the sexual functioning of breast cancer survivors. Women Ther. 2006; partners. J Fam Psychol. 2004;18(4):589Y599.
29(1/2):83Y106. 40. Hagedoorn M, Sanderman R, Bolks HN, et al. Distress in couples
15. Garrusi B, Faezee H. How do Iranian women with breast cancer coping with cancer: a meta-analysis and critical review of role and gender
conceptualise sex and body image? Sex Disabil. 2008;26:159Y165. effects. Psychol Bull. 2008;134(1):1Y30.
16. Manderson L, Stirling L. The absent breast: speaking of the mastecto- 41. Reichers EA. Including partners into the diagnosis of prostate cancer: a
mied body. Feminism Psychol. 2007;17(1):75Y92. review of the literature to provide a model of care. Urol Nurs. 2004;
17. Young IM. Breasted experience: the look and the feeling. In: Leder D, ed. 24(1):22Y38.
The Body in Medical Thought and Practice. Dordrecht, the Netherlands: 42. De Groot JM, Mah K, Fyles A, et al. The psycho-social impact of
Kluwer Academic Publishers; 1992:215Y232. cervical cancer among affected women and their partners. Int J Gynecol
18. Gilbert E, Ussher JM, Perz J. Sexuality after breast cancer: a review. Cancer. 2005;15:918Y925.
Mauritius. 2010;66:397Y407. 43. Sanders S, Pedro LW, Bantum EO, et al. Couples surviving prostate
19. Spence J. Cultural Sniping: The Art of Transgression. London, England: cancer: long-term intimacy needs and concerns following treatment. Clin
Sage; 1995. J Oncol Nurs. 2006;10(4):503Y508.
20. Hensen HK. Breast cancer and sexuality. Sexuality Disabil. 2002;20(4): 44. Harden J, Schafenacker A, Northouse L, et al. Couples’ experience
261Y275. with prostate cancer: a focus group. Oncol Nurs Forum. 2002;29(4):
21. Meyerowitz BE, Desmond K, Rowland JH, et al. Sexuality following 701Y709.
breast cancer. J Sex Marital Ther. 1999;25:237Y250. 45. World Health Organization. The World Health Organisation Quality of
22. Gilbert E, Ussher JM, Perz J. (Re)negotiating the sexual relationship in Life Assessment (WHOQOL). Soc Sci Med. 1995;41:1403Y1409.
the context of cancer care: informal carers’ experiences of caring and 46. Herbenick D, Reece M, Hollub A, et al. Young female breast cancer
gender practices in couple relationships. Arch Sex Behav. 2010;39(4): survivors. their sexual function and interest in sexual enhancement prod-
998Y1009. ucts and services. Cancer Nurs. 2008;31(6):417Y425.
23. Ganz PA, Desmond K, Belin TR, et al. Predictors of sexual health 47. Hawkins Y, Ussher JM, Gilbert E, et al. Changes in sexuality and in-
in women after a breast cancer diagnosis. J Clin Oncol. 1999;17(8): timacy following the diagnosis and treatment of cancer: the experience of
2371Y2380. informal cancer carers. Cancer Nurs. 2009;32(4):271Y298.
24. Alder J, Zanetti R, Wight E, et al. Sexual dysfunction after premeno- 48. Hordern AJ, Street AF. Communicating about patient sexuality and
pausal stage I and II breast cancer: do androgens play a role? J Sex Med. intimacy after cancer: mismatched expectations and unmet needs. Med J
2008;5:1898Y1906. Aust. 2007;186(5):224Y227.

Sexual Well-Being and Intimacy After Breast Cancer Cancer NursingTM, Vol. 35, No. 6, 2012 n 465

View publication stats

Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.