Sex and intimacy after cancer

Sex after cancer changes for most people, at least for a while, and the reasons are usually concrete rather than psychological. That matters because concrete problems have concrete solutions. Silence is the main obstacle: people assume it is inevitable, or feel it is trivial next to survival, and so never mention it.

• Vaginal dryness, tightness and pain, from treatment-induced menopause, pelvic radiotherapy or hormone therapy.
• Erectile difficulty and changed orgasm, after prostate or pelvic surgery, radiotherapy or androgen deprivation therapy.
• Low desire, from hormonal change, fatigue, pain, low mood or medication — including some antidepressants.
• Altered sensation after surgery or nerve damage.
• Body image, after scars, stoma, breast surgery, hair loss or weight change.
• Fear — of pain, of failure, of being seen, or that sex is somehow unsafe. It is not: sex does not cause recurrence and cancer is not transmissible.
• Relationship dynamics — months of being patient and carer do not switch off cleanly.

1. Start with non-sexual touch and closeness with the explicit agreement that it goes no further. Removing the expectation removes most of the pressure.
2. Add exploration without a goal. Sensation may have changed and needs mapping rather than assuming.
3. Use plenty of lubricant, take time, and stop if it hurts — pain teaches avoidance quickly.
4. Have sex at the time of day when your energy is best, which is rarely late at night.
5. Talk outside the bedroom, not during. "I want to, and I am frightened it will hurt" is a complete and useful sentence.
6. If you are single, plan how and when you will tell someone new — most people find rehearsing it makes it far easier.

You will not embarrass them, and it is a legitimate clinical issue. A direct opening works best: "Since treatment, sex has become painful — what can be done?" or "I have had erection problems since surgery and I would like help with that."

If you get a dismissive response, ask specifically for a referral — to a pelvic floor physiotherapist, a psychosexual therapist, a menopause clinic, or a urology or gynaecology service.