For Teachers & Professionals

Communication About Sexuality in Advanced Illness and Palliative Care Context

Sexual health is an important topic for almost everyone and in every stage of life. Sexuality is an important survivorship issue and remains relevant even in the terminal setting. Terminal patients continue to desire sexual function and intimacy, even though the type of intimate relationships may change over the course of their illness. Some patients may see their sexuality as a means to reinforce emotional connectedness. Although there might be less emphasis on physicality, intimacy (whether verbal or non-penetrative) remains important. 

Palliative care providers’ embracement of interdisciplinary teams may make them most prepared to coordinate care with other specialities in order to comprehensively evaluate and help manage sexual health concerns. While not expected to be sexual health experts, they can provide comprehensive patient-centred care by including sexual health as part of their evaluation. 

In the context of palliative care and oncology, three major themes emerge in providers’ attitudes: avoidance, vulnerability, and denial. While some providers avoided talking about sex because they felt there were other more pressing issues, others assumed that different clinicians addressed the issue with their patients. Sexuality is also seen as distinct from the cancer experience which leads to a denial of the potential impact the illness has on sexuality. 

Practical Tips for Exploring Sexual Functioning With Patients:

1. Explore personal beliefs

Communicating about sexuality with patients who have advanced diseases requires a non-judgmental approach. The topic of sexuality engenders feelings, prejudices, upbringing, and beliefs, all of which influence our assumptions and hesitations. An important first step to having an uninhibited conversation with patients about sexuality is to explore the provider’s level of comfort and personal attitudes toward sexuality in cancer patients. Often practitioners are less prone to translate palliative care principles into practice when it concerns issues of sexuality than when the issues lean towards physical intimacy. This might be also due to stereotypes about the asexuality of old(er) and ill persons.

2. Use a curiosity approach

Ask open-ended questions to permit patients to express themselves. The curiosity approach builds rapport and effectively connects with patients by asking how the illness and/or treatment has affected them, how they feel about themselves, and how their relationship with their partner has changed. The introduction of sexuality early in the palliative care relationship demonstrates to patients that sexuality can be discussed at any point in the illness trajectory. 

3. Pay attention to details

Close attention to details about the patient’s concerns or worries can decrease the impact that physical and psychological symptoms have on sexual function. For example, cancer patients frequently experience pain and fatigue. Palliative care providers can offer behavioural strategies such as napping before intercourse or laying on one’s side to conserve energy. 

4. Gauge the patient’s readiness and desire to discuss

The use of normalizing and validating language can diffuse patients’ anxieties and help them understand how their treatment influences their sexual function. Even if patients appear uncomfortable, a quick screening tool will give providers data points to revisit at a later time. Using a patient-centred approach might be helpful. Some useful frameworks are the 5As-Ask, Advise, Assess, Assist, Arrange, BETTER, ALARM and PLISSIT model.

Palliative care providers are skilled communicators who frequently become involved in difficult situations. Such skills carry over when talking with patients about sexuality in an open-ended and empathic style. The field has challenged medicine to reevaluate ideas about the quality of life and how we care for our patients. Sexuality, therefore, is a fundamental, integral aspect of palliative care. 

REFERENCES

Benoot, C., Enzlin, P., Peremans, L., & Bilsen, J. (2018). Addressing sexual issues in palliative care: A qualitative study on nurses’ attitudes, roles and experiences. Journal of advanced nursing, 74(7), 1583-1594. 

Leung, M. W., Goldfarb, S., & Dizon, D. S. (2016). Communication about sexuality in advanced illness aligns with a palliative care approach to patient-centered care. Current oncology reports, 18(2), 1-6.