Regaining Sexuality after Breast Cancer

By Laurie Watson, PhD, LMFT, as told to goop

Our sexuality is made up of four parts, and all of them are hit by breast cancer. There’s our body self-image, physical changes (to our breasts, vulva, and vagina), and sexual functioning, including desire, arousal, and orgasm. When there’s a relationship with a partner, that also goes through changes and recovery. And it turns out—from the research that I did for my doctorate—that the most central issue here tends to be the engagement of the partner in the treatment.

1. BODY SELF-IMAGE

First, there’s grief over the changes, things that used to be easy. Maybe a woman used to have great libido and easy orgasms and was proud of her body. And suddenly she has suffered breast loss. With chemotherapy, she may have lost her hair and her eyelashes. She’s lost many of the markers that say to the outside world, “I am feminine. I am a woman.” She has to dig deep in her soul to find, Now what? What is my femininity all about? How do I convey that in a sexual relationship? And how do I look in the mirror and still see me, still see the self I recognize?

The mind has to process all this and catch up to the sudden trauma that is cancer. And we have to grieve the multiple losses.

People who love you may be so concerned about your survival that they minimize the losses you’re facing with your body. They’ll say things like, “Well, at least you survived.” Or “At least you’ve got your health back.” They don’t always stand with you and validate that this has been terrible for you. It’s changed so much about how you see yourself in the world and as a sexual being. We have to go there and grieve with people in this situation.

2. PHYSICAL CHANGES TO BREASTS, VULVA, AND VAGINA

Physiologically, the first and foremost injury is to the breast, and it’s a massive injury. I call it an amputation because I want the shock value of the word to hit the public. Breast loss sounds sanitized, but when you talk about amputating a breast, it hits us in a more visceral way, this being a feminine, intimate part of us. And the nipples are often a powerful sexual arousal pathway. A woman told me, “He touches my nipples, and I feel it in my vagina.” If a woman had nipple orgasms or that was the way she became aroused, loss of her nipples may mean that she has to develop a new pathway of arousal.

If you have estrogen-positive breast cancer, you take estrogen-blocking medications such as tamoxifen or aromatase inhibitors. And if you’re postmenopausal, you have to go off all estrogen therapy. That can mean a dry vagina, which could mean painful intercourse. It could also mean that touch is painful because the labia and the clitoris tend to atrophy and become dry without estrogen. There is a little bit of good news about estrogen: The North American Menopause Society has said that vaginal estrogen may be appropriate for some breast cancer survivors, as it has a very local effect, not significantly raising systemic estrogen for those with hormonally sensitive cancers. Also, using vitamin E suppositories and getting one of those little vitamin E capsules, poking a pin in it, squeezing it, and putting the oil on your vulva and the rim of the vagina can be helpful for those not able to use estrogen.

Choosing whether or not to have breast reconstruction is, of course, a very personal choice. You may ask, especially if you’ve had cancer, do you really want to introduce a foreign substance into your body? In terms of self-image, the research shows that unless a woman makes a deliberate decision to remain flat, her self-image goes through less trauma when she has reconstruction as soon as possible rather than later or not at all.

3. THE SEXUAL CYCLE: DESIRE, AROUSAL, ORGASM

Usually desire is repressed because of exhaustion, because of the pills that take away our estrogen, and because testosterone is also suppressed. We’re going to have to work a lot harder and ask our partners to work a lot harder with fantasy, erotic stories, romantic settings, and other things that may arouse us.

And arousal is going to take longer than before. Vibrators are not just toys. They’re tools when we have breast cancer—and when we’re postmenopausal. Use a lubricant every single time. Even if you think you will get lubricated, it’s smart to use a lubricant because we want to make sure that the tissue doesn’t tear. Fragile tissue becomes friable, and little micro tears can cause pain.

I think that libido is fueled by orgasms. We don’t have to have an orgasm every single time we make love, but having orgasms gives a physiological reward that feeds our libidos. I suggest that partners offer a night to you, with no demand that you have an orgasm. The partner can say, “I want to give you pleasure that includes genital pleasure and touching.” They can move from a slow erotic massage down to a slow genital massage. Your body has endured so much. We want to make you feel good in your body.

And we want to help people reach orgasm if they choose to. Some of it is patience. Your body is probably not going to work the way it used to. This doesn’t mean you’re not going to have as powerful sensations, but give it a little more time. Only about 15 percent of young, cancer-free women reach orgasm through sexual intercourse, so if there’s pain with intercourse, I would recommend clitoral orgasms to maintain desire and to bring blood flow to the area for healing. This can also bring stress relief and the release of oxytocin, which promotes bonding with our partner. In the face of mortality, orgasm gives us a chance to feel magnificently alive and well in our bodies.

A note on advocating for your sexual well-being: Having breast cancer can be depressing and anxiety-producing. Doctors may prescribe an SSRI (selective serotonin reuptake inhibitor), but that may depress your libido and can also make it more difficult to reach orgasm. There are meds that can manage mood without the sexual side effects. We want people to be assertive about their needs. Doctors are doing the best they can. They’re trying to save lives, but doctors are not sex therapists. Doctors are humans who are often anxious about talking about sex. Unless the patient directly brings it up, they might not say, “Oh, by the way, there’s going to be this consequence that you’re going to have to endure sexually.”

4. WHEN THERE’S A PARTNER

I think that the sexual relationship is one of the most healing components. Your partner seeing you as beautiful and expressing that out loud says, “You are desirable.” Sometimes, if we’re not feeling attractive, we need somebody to hold up the mirror that says, “I see you as beautiful. I see you as attractive. I desire you.” That is potent medicine for feeling sexual again.

We co-regulate as partners in a sexual relationship. The partner also needs to be held. They go through fear of losing their partner, fear of losing their sexual relationship, fear of hurting their partner during the sexual encounter. Many partners take the stance of “I won’t tell you about my fear and burden you because you’re dealing with enough.” But then the problem is that the couple can’t mourn their losses together. They can’t get on the same page because they’re not being frank with each other in tactful, loving ways. A loving partnership can help a couple pull each other through.

Laurie Watson, PhD, is an AASECT certified sex therapist, a licensed marriage and family therapist, a licensed clinical mental health counselor, and a certified emotionally focused therapist. Watson is the founder and director of Awakenings Counseling for Couples and Sexuality in North Carolina and has 30 years of experience working with couples and individuals on love and sex. She cohosts the podcast Foreplay Radio – Couples and Sex Therapy and is the author of Wanting Sex Again: How to Rediscover Your Desire and Heal a Sexless Marriage.

This article is for informational purposes only. It is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. To the extent that this article features the advice of physicians or medical practitioners, the views expressed are the views of the cited expert and do not necessarily represent the views of goop.

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