In the United States, especially in the media, sex is all too often viewed as something only for the young and healthy. Sex appeal is judged by some as a skin-deep sort of beauty rather than based on love, kindness, maturity, or a sense of humor. Based on looks alone, most people may not feel all that attractive to start with. And after being treated for cancer, their self-esteem can often fall even further.

After cancer treatment, it is easy to focus only on the part of the body that has been affected. For example, a woman who has had a laryngectomy may fear she will not be able to find another partner because she has lost her voice.

Sometimes friends and lovers do withdraw emotionally from a cancer patient. This may not reflect so much on how a person looks, but on some feelings or thoughts in the person who is doing the looking. When a husband cannot bear to look at his wife's ostomy appliance, for example, he is often showing deeper feelings. Maybe he is angry because he has to take over his wife's usual tasks of paying bills and doing housework. Or the ostomy may remind him of how sad he would be if she died. It may be easier not to love her so much. He may even be more aware of his own chance of death and that is upsetting him. Yet all these feelings get blamed on a stoma that mars a small part of his wife's body. The husband, in turn, may also feel like a sexual failure and know that he is letting his wife down at a time when she needs him most.

Don't give up on each other. It may take time and effort, but keep in mind that sexual touching between a woman and her partner is always possible. It may be easy to forget this, especially if you are both feeling down or have not had sex for awhile. Review the section, "Keys to keeping your sex life going despite cancer treatment" for some tips to help you and your partner through this time, and read the suggestions we make here to help you through some of the changes that cancer may have brought to your life, your self-esteem, and your relationships. Keep in mind you may need help with the changes caused by cancer that can turn your and your partners' lives upside down. See the section, "Professional help" for more information.

Chemotherapy changes the way you look

The most obvious change caused by chemo will likely be hair loss. You may expect to lose the hair on your head, but other body hair, such as eyebrows, eyelashes, and pubic hair are often affected too. You may also lose weight and muscle mass if you have trouble eating. On the other hand, many women gain weight during or after chemo. Your skin may get darker, become dry and flaky, or you may be very pale. Your nails may become discolored or ridged. And you may also have an infusion (IV) catheter or port placed in your chest or arm.

Some physical changes caused by chemo can be covered up or made less obvious. If you are just starting chemo, you may want to shop for a wig before your hair begins to fall out. If you have very long hair, you may even be able to have it cut off and made into a wig. This is costly, but some people find it worthwhile. Wigs are warm and not totally comfortable, so you may decide to save your wig to wear outside the home or hospital. You can also use scarves, turbans, hats, or caps. Some women leave their heads uncovered. Still others switch back and forth, depending on whether they are in public or at home with family and friends.

It's a good idea for a couple to discuss how each feels about wearing a wig or head-covering during lovemaking. There is no right or wrong decision.

Disguising weight loss, skin color and nail changes, and infusion catheters is a bigger problem. For the most part, clothes that fit well look better. Wearing something too tight or too baggy will draw attention to your weight change. High necks and long sleeves can hide a catheter, but may be too hot in warm weather. Look for thin fabrics that will be cool while covering you.

Sometimes the changes in your body are so upsetting that you can't relax or think positively. Rather than feel like a failure, take this as a sign that some counseling from a health care professional may be helpful. (See the section, "Professional help" for more information.)

Ways to cope with changes in how you look

The keys to feeling good about yourself begin with focusing on your positive features. Try to limit the damage cancer can do to your appearance, your energy, and your sense of well-being. When you are going through cancer treatment, you can feel more attractive by disguising the changes cancer has made and drawing attention to your best points.

The following mirror exercise can help you adjust to body changes:

• What do you see when you look at yourself in the mirror? Many people notice only what they dislike about their looks. When they look in the mirror, they see pale skin, hair loss, an ostomy appliance, or skinny legs. They fail to see a classic profile, a small waist, expressive eyes, or a nice smile.

• Find a time when you have privacy for at least 15 minutes. Be sure to take enough time to really think about how you look. Study yourself for that whole time, using the largest mirror you have. What parts of your body do you look at most? What do you avoid seeing? Do you catch yourself having negative thoughts about the way you look? What are your best features? Has cancer or its treatment changed the way you look?

• First, try the mirror exercise when dressed. If you normally wear clothing or special accessories to disguise changes from cancer therapy, wear them during the mirror exercise. Practice this 2 or 3 times, or until you can look in the mirror and see at least 3 positive things about your looks.

• Once you are comfortable seeing yourself as a stranger might see you, try the mirror exercise when dressed as you would like to look for your partner. If you've had an ostomy, for example, wear a bathrobe you like. Look at yourself for a few minutes, repeating the steps in the first mirror exercise. What is most attractive and sexy about you? Pay yourself at least 3 compliments on how you look.

• Finally, try the mirror exercise in the nude, without disguising any changes made by the cancer. If you have trouble looking at a scar, bare scalp, or an ostomy, take enough time to get used to looking at the area. Most changes are not nearly as ugly as they seem at first. If you feel tense while looking at yourself, take a deep breath and try to let all your muscles relax as you exhale. Don't stop the exercise until you have found 3 positive features, or at least remember the 3 compliments you paid yourself before.

The mirror exercise may also help you feel more relaxed when your partner looks at you. Ask your partner to tell you some of the things that are enjoyable about the way you look or feel to the touch. Explain that these positive responses will help you feel better about yourself. Remember them when you are feeling unsure.

Changing negative thoughts

Your thoughts can make a sexual experience good or bad. Become more aware of what you tell yourself about how attractive or sensual you feel. You may be setting yourself up for failure with thoughts like, "How could someone want a woman with one leg?" Almost all of us have put ourselves down now and then. But there are ways to turn these thoughts around.

• Write down the 3 negative thoughts you have most often about yourself as a sexual person. Some may be connected to your cancer treatment, but other thoughts may have started years ago.

• Now write down a positive thought to counter each negative thought. For example, if you said, "No one wants a woman with a urostomy," you could say to yourself, "I can wear a lacy ostomy cover during sex. If someone can't accept me as a lover with an ostomy, then they are not the right person for me." The next time you are in a sexual situation, use your positive thoughts to override the negative ones you usually have. If you have a favorite feature, this is a good time to indulge yourself a little and play it up.

If negative thoughts intrude and you find yourself overwhelmed or discouraged, you may want to talk with your cancer team about working with a mental health professional. This can help you adjust to your new situation.

Overcoming depression

Staying active is a good way to reduce stress and your risk of depression. Talk to your doctor about the kinds of physical exercises that are right for you. As long as you don't overdo it, exercise will help you feel vital and healthy during and after treatment. You can also reduce the pain and nausea that some cancer treatments cause by learning skills to help you relax. Many methods of relaxation can be learned from DVDs, videos, CDs or books, although training by a mental health professional probably works best.

If depression lasts more than a couple of weeks, talk to your doctor. What doctors call clinical depression has a number of symptoms. These include the following:

• lack of interest in sex or other things that usually give you pleasure
• being unable to feel pleasure at all
• not being able to sleep
• changes in eating habits (don't count those that are due to chemo or cancer treatment)
• fatigue or tiredness (don't count tiredness from your cancer treatment)
• trouble concentrating
• feeling worthless and hopeless

Depression can be treated with medicine and sometimes other methods that may improve your sleep, appetite, energy, and ability to feel pleasure. In turn, this can help your self-esteem and desire for sex. Talk with your doctor if you think you might be depressed.

Some of the newer anti-depressants, such as selective serotonin reuptake inhibitors (SSRIs), may make it harder to reach orgasm. If this is something that is a problem for you, talk to your doctor about it. There are other anti-depressants that may not have that effect on you.

Dealing with grief and loss

It is common to feel grief over the losses linked to your cancer diagnosis and treatment. You may also notice sadness, anger, and even hostility toward those close to you. Cancer changes your sense of self, that is, how you think of your body and yourself. This can disturb your well-being, and affect how you see yourself sexually. It can also affect your ability to maintain relationships.

Grief is a normal response as you give up your old ideas of yourself and begin to find new ways to cope with the changes in your life. It may take time for you to recognize some of these losses and changes. This means new ones may come up even after you think you are finished grieving. This, too, is normal. It can help if you can share your grief with someone close to you. If there is no one near you that you want to confide in, you might prefer to see a mental professional. Just as it is important to take care of pain in your body, painful feelings also need to be dealt with.

Rebuilding self-esteem

Feeling attractive is just one part of your self-image. Dr. Wendy Schain, a psychologist who counsels men and women who have had cancer, describes self-esteem as a set of bank accounts:

• One account contains the net worth of your physical self -- what your body can do and how you look.

• The second account is your social self -- how easily you get along with others and the emotional support you can count on.

• In the third account is the total sum of your achieving self -- what you have done in school, work, and personal and family relationships.

• The fourth account is for your spiritual self -- your religious and moral beliefs and the strength they give you.

During your life, you make deposits in your accounts, but when a crisis like cancer comes up, you must also make withdrawals. Going through cancer treatment has costs. It takes time, and may take away some of your physical ability to function. It can harm your relationships with others, your career goals, and sometimes your faith. When funds from one of your accounts become low, you may need a "loan" from one of the others to balance your account.

Try to be aware of the costs of cancer in your life. Make a special effort to get new deposits for the accounts that remain active. By doing so, a drain from one area of your self-worth will not bankrupt you entirely. If your cancer treatment has affected your looks, focus on the love and care you get from friends and family who react to you on a deep level of intimacy. If treatment interrupts your work, use some of your energy to enrich your social or spiritual life.

Although you may sometimes feel that all your accounts are getting low, a more careful look should reveal some areas where "income" is still flowing in.

Good communication: The key to building a successful sexual relationship

The most important part in keeping a healthy sexual relationship with a partner is good communication. Many people react to cancer by withdrawing. They think their partner will feel burdened if they share their fears or sadness. But when you try to protect each other, each suffers in silence. No couple gets through cancer diagnosis and treatment without some anxiety and grief. Why not discuss those fears with one another so that you shoulder the load together rather than alone?

Sexual sharing is one way for a couple to feel close during the stress of an illness. But if your partner has been depressed and distant, you may fear that a sexual advance might come across as a demand. You can bring up the topic of sex in a healthy, assertive way. It is usually not helpful to accuse ("You never touch me any more!") or demand ("We simply have to have sex soon. I can't stand the frustration!"). Instead, try to state your feelings positively. ("I really miss our sex life. Let's talk about what's getting in the way of our being close.")

Overcoming anxiety about sex

Many couples believe that sex should always happen on the spur of the moment, with little or no advance planning. But sometimes you are dealing with a cancer-related symptom or treatment side effect that makes it impossible to be as spontaneous as you would have been in the past. The most important thing is to open up the topic for discussion and begin scheduling some relaxed time together. Couples need to restart their lovemaking slowly.

Part of the anxiety about resuming sex is caused by the pressure to satisfy your partner. One way to explore your own capacity to enjoy sex is to start by touching yourself. Masturbation is not a required step in restarting your sex life, but it can be helpful. By touching your own genitals and bringing yourself to orgasm, you can find out if cancer treatment has changed your sexual response without having to worry about frustrating your partner. It can also help you find out where you might be tender or sore, so that you can let your partner know what to avoid.

Many of us may have learned as children that masturbation was wrong or shameful. But it is a normal and positive experience for most people. Most men and women have tried touching their own genitals at some time in their lives. Many people who enjoy good sex lives with their partners still masturbate sometimes. Men and women in their 70s, 80s, and 90s often still enjoy self-stimulation.

If you feel relaxed with the idea, try stroking not just your genitals, but all of the sensitive areas of your body. Notice the different feelings of pleasure that you can have.

The self-help books listed in the "Additional resources" section can help you feel more relaxed about masturbation. Later you can teach your partner any new discoveries you make about your body's sensitive zones. Even if cancer treatment has not changed your sexual responses, you may find some new caresses to enhance your sexual routine.

Self-stimulation

• Research has shown that masturbation is the most common sexual behavior in humans. Although more common in men, women also enjoy self-pleasuring.

• Self-stimulation may not be okay with your personal and religious belief system and should not be forced. The most important aspect of being sexual is feeling comfortable with your personal thoughts and beliefs.

• Self-stimulation is a real sexual behavior that does not have to be seen as a negative alternative to sex with a partner. Many people in healthy relationships still masturbate.

• You may discover that gently stroking not only your genitals but other areas of your body gives you a sense of well being. Many women find their breast area, nipples, and other areas of their body highly sensitive to touch. Different women find different parts pleasurable. Take time to explore your body. Some areas may be sensitive from surgery or radiation; you may choose to avoid these areas for now. Try exploring these areas again later.

• If you feel comfortable, plan for some private time when you won't be interrupted and gently explore your body to find your erogenous (highly sensitive) areas. You may want to involve your partner in your discoveries or you may choose to keep these new discoveries private. Many find that they enjoy this erotic pleasure during their shower.

• Some women feel happy with exploring and self-stimulating. Take time to find your comfort level with this type of sexual activity. The process differs from person to person, so do not rush or force yourself to do anything that makes you uncomfortable.

Rekindling sexual interest

Every now and then we all have sexual thoughts or feelings, but sometimes we ignore or forget about them. Your sexual thoughts can be used to improve your sex life, Try keeping a "Desire Diary." Here's how:

• Every day for a week, prepare a sheet of paper that will become your Desire Diary. Take it with you wherever you go. When you have a sexual thought or feeling, write it down. Note the time of day and whether you were alone or with someone. Also note what you did about the thought.

• Look at your Desire Diary to see if there are any patterns, such as certain settings, people, or times of the day that help you feel more sexual.

• Once you have noted some patterns, you can begin putting yourself in the situations that spark a sexual mood such as exercising, planning a relaxed evening out with your partner, making a special effort to look and feel sexy, reading a steamy story with sex, watching a movie with a romantic or sexual plot, or fantasizing about a sexual encounter.

• Get your partner's help at some point. Discuss any fears either of you has about your sexual relationship. If you have questions about medical risks, you and your partner should discuss them with your doctor.

If these efforts fail to rekindle your sexual interest, think about seeking some sexual counseling. For more information, please see the "Professional help" section.

Sexual activity with your partner

When you feel ready to try sexual touching with your partner, start with plenty of time and privacy. Plan for a time when you aren't too tired and when any pain is well controlled. You may want to create a relaxed environment. For example, you could light the room with candles or put on some soft, romantic music. Although you may feel a little shy, let your partner know that you would like to have some time to be physically close.

You could even make a date for this purpose. You might say, "I feel ready for sex again, but I'd like to take things slowly. Would you be in the mood tonight to try a little touching? I can't promise that it will go perfectly, but we can have fun trying."

It is a good idea for couples to put some limits on their touching the first few times they try sexual activity after cancer treatment. A good way to start is with a special session devoted to all-over body touching. This is the way body touching works:

• Each partner takes a turn touching and being touched. One partner lies face down on the bed, allowing the other partner to touch the entire back, from toes to scalp. After about 15 minutes the partner lying down turns over so the front of the body can be touched.

• The first time you try a touching session, avoid the breasts and genitals. Your goals are to feel relaxed and to experience sensual pleasure. It is not important to get sexually excited. If you agree on these goals prior to starting, the touching should not be frustrating. This type of session takes the nervousness and pressure out of being close again.

• While being touched, your job is to be self-centered and tuned in to your own feelings. Don't worry about your partner's thoughts or feelings. When you are doing the touching, enjoy the shape and texture of your partner's body. Try many different types of touching, varying from light stroking to a firmer touch, much like a massage.

• If you both feel relaxed during the first touching session, you can add some genital touching the next time. Over a few sessions, partners can slowly spend more time on genital caresses, until each one is able to reach an orgasm through stroking with a hand, or oral sex, if that is comfortable for both of you.

Many couples don't talk much about sex. But after cancer treatment, your sexual routine may need to change. This calls for clear communication. This is not the time to let embarrassment silence you. Be sure to let your partner know, either in words or by guiding with your hand, the kinds of touches you like best. Try to express your desires in a positive way. For example, "You have the right place, but I'd like you to use a light touch," rather than, "Ouch! That's too rough!" Save intercourse until both partners really feel ready for it.

Making intercourse more comfortable

If you still have some pain or feel weak from cancer treatment, you may want to try new lovemaking positions. Many couples have found one favorite position, particularly for intercourse, and rarely try another. The best-known way to have intercourse is in the "missionary position," with the man lying on top of the woman. But after cancer treatment other ways might be more comfortable. You may be able to enjoy intercourse more if both of you lie side by side, either facing each other or with your back next to your partner's front side. Another position that may work well is for you to sit or kneel astride your partner. This allows you to move more freely while your partner relaxes or touches you.

The illustrations below are some ideas for positions that may help in resuming intercourse.

There is no magic position that is right for everyone. You and your partner need to find the one that is best for you. Small and large pillows can help as supports. Keeping a sense of humor can always lighten up the situation.

Last Medical Review: 11/10/2008
Last Revised: 11/10/2008