…and how a woman can productively respond
The following vignettes have titles inspired by some things a doctor or other health care professional should not say to a woman. Each statement is followed by what a woman can say in response to help move the conversation in a better direction and an example of how the doctor might salvage the situation. These vignettes are inspired by things I’ve actually heard doctors say and are informed by empirical evidence from more than two decades of research and clinical practice in the field.
Let’s imagine a woman with breast cancer who complains of very painful intercourse that began when she first had sex a few weeks after completing chemotherapy. The pain got worse a few months after having her ovaries removed and starting an aromatase inhibitor medicine that she expects to take for five or ten years. She also has had both of her breasts removed and reconstructed, but has lost all breast sensation, which was really important for her sexual arousal and orgasm in the past. She had no notable sexual difficulties before cancer treatment. She has a loving partner.
Vignette 1. It’s in your head. You need to relax.
How a woman can respond: I definitely can say that both cancer and this unexpected painful sex problem have caused me and my partner some worry and grief. It can be hard to relax sometimes. But are you sure the problem might not be partly due to some correctable dryness in my vagina caused by taking my ovaries out and the medicine that is blocking all of the estrogen in my body? And, as you can imagine, even though my reconstructed breasts look great in a sweater, the unexpected numbness doesn’t help the situation.
Doctor: You know what, come to think of it, you are on to something there! Sexual function involves mind and body. While the brain is an important sex organ, so are your breasts, your ovaries and your vagina. You have cancer and you have had cancer treatments, both of which can interfere with sexual physiology and function. I owe you a sincere apology for saying these problems are in your head. These problems are not imaginary and they are not your fault. You are not alone. There are resources to help you, like a gynecologist, a pelvic floor physical therapist and a sex therapist, couples therapist or psychologist if you feel that would be helpful. I am also going to make some time to talk with our breast surgeons to see that we all work toward doing a better job counseling women about what to expect in terms of breast sensation and sexual function after mastectomy.
Vignette 2. You are lucky to be alive.
How a woman can respond: You are right and I am so grateful to you for saving my life that I really didn’t want to bother you with my sexual function problems. But there are days when I just don’t know if I can stick to this treatment for another five years. What’s life without ever having sex with my spouse again? I love her so much and even though she’s been so good to me during cancer, I’m actually worried she’ll leave me.
Doctor: Thank you for setting me straight. The benefit of surviving cancer is that you have more life to live and I know you want to live it to the fullest. Research published by WomanLab researchers in the New England Journal of Medicine shows that most people, of all ages, value their sexual function as an important part of overall health and life, so it’s no surprise that sex is important to you. Some aspects of your treatment are likely interfering with your sexual function. Raising this issue is an opportunity for us to focus on how to get you back to the level of functioning that you want for this phase of life, including your sexual function. If you’d like, I’ll ask your spouse to come in from the waiting room. We can let her know that we are going to get help for your sexual function problem like we are doing for the other expected side effects of your cancer treatment.
Vignette 3. You need to try harder.
How a woman can respond: I really believe that if I try harder to eat healthier or exercise more, I can do those things. But I’m not sure how I can try harder to stop the splitting pain and bleeding from my vagina when I try to have sex. Do you have any suggestions for specific things I can try? I’ll promise I’ll try them really hard!
Doctor: When you put it that way, I can see that my suggestion isn’t very helpful. Please let me try a different approach. Most sex happens between two partners. Here are some resources about sex after cancer that I recommend for you and your partner to read. As long as you are having pain with intercourse, it will be difficult to have full sexual desire and arousal. If you are in pain, your loving partner is also likely suffering because it feels terrible for your partner to hurt you. We can treat the causes of your pain and then we should see improvements in your overall sexual function. Continuing to try to have intercourse without treating the pain could actually make things worse.
VIGnette 4. Were you sexually abused as a child?
Side note: As many as 20-30% of my patients admit to a history of abuse and more than half of those report sexual abuse or rape, when asked. But we have to be careful not to suggest to women that the cause of their symptoms must be abuse. I had one patient say that a doctor convinced her that the cause of her sexual function problems after cancer treatment was a history of childhood sexual abuse that she had repressed or “blocked out.” She had grilled her siblings and mother about childhood abuse and had sought psychological evaluation to determine if she had repressed traumatic memories. She could uncover no such history. On examination, she had obvious, correctable physical problems that, when treated, cured her dyspareunia.
What a woman can say: I grew up in a loving, affectionate family and have had healthy, respectful relationships. I never had any problems with my sexual function before cancer treatment. Do you only see sexual function problems after cancer in women who were abused?
I was sexually abused as a child, but I received help to cope with that terrible experience and I’ve not had any sexual difficulties at all since my husband and I married 35 years ago. I appreciate your concern about sexual abuse, but it seems to me that these problems are more likely related to my cancer treatment. Would it make sense to focus on that?
Doctor: I should have framed my question differently by saying that I ask everyone about a history of abuse – physical, emotional and sexual. I routinely ask because, unfortunately, abuse is a common problem and it can affect a woman’s sexual function and overall health even many years later. Women with a history of abuse are more prone to sexual function problems, but the majority of women with sexual function problems do not have a history of abuse. I think there are some correctable issues coming from your cancer treatment that we can address. And it is my responsibility as your doctor to say that, if you have been abused, I am terribly sorry that happened to you and it is not your fault.
Vignette 5. You have the vagina of an 80 year old!
What a woman can say: I’m guessing that’s not meant to be a compliment. It would help me if you could be more specific about what your observations about my vagina mean for recovering my sexual function.
Doctor: We’ve known each other a long time, so I thought it was ok to joke, but I was too cavalier with my comment. Please forgive me. My observation is that the skin on your vulva and the lining of your vagina are very thin. When I insert the speculum to look inside your vagina I can see a small tear around the opening that probably bleeds some when you try to have sex and might even burn after sex when you urinate. These changes can happen in women taking estrogen-blocking medications. As a side note, so you don’t walk away with the wrong impression about 80 year old vaginas, researchers at WomanLab have studied vaginas of older women and find that some have plenty of estrogen. Fun fact: it appears that 80 year old vaginas in North America today have more estrogen than they did in the 1960s and that African American or Black women have higher vaginal estrogen levels than other women. Here’s the link to their study if you want to know more.
Vignette 6. This might hurt, baby, but I know you’ll still love me.
Side note: I am very sad to report that I actually heard a doctor in training utter words like this to a patient as he prepared to insert a speculum in her vagina during a gynecologic exam. Rest assured that doctor was dismissed from gynecology training. A doctor should NEVER speak to a patient in sexual or diminutive terms under any circumstance and every doctor should know that words said to a woman when she is undergoing a gynecologic examination can easily be understood or misunderstood in sexual or demeaning or humiliating terms. Furthermore, medical ethics prohibits sexual acts and relationships between a physician and patient – a rule stated even in the Hippocratic Oath. Unfortunately, research shows that gynecologists and psychiatrists are the doctors most likely to violate this prohibition.
What a woman can say: Stop this exam right now! The words you are saying to me are totally inappropriate! I am not your baby and I do not love you! (We all know, it’s really, really hard for a woman to speak up when she finds herself in a shocking situation with a doctor or another person who holds power over her and most women don’t speak up in the moment. But, let us all agree that this response would be 100% legitimate.)
Doctor: I am horrified at my terrible behavior. I have wronged you and I am very sorry. I am going to get help for us both and I will make sure I never say anything like that again to a woman in my care.
WomanLab’s mission is to ensure that every woman and everyone who loves and cares for woman has the knowledge to preserve and recover sexual function across life’s ages and stages. These vignettes are intended to spark some thinking about how we do and don’t communicate, to illustrate realistic scenarios and to try to close – with some practical tips – what I see as a communication gap about female sexual function that is a root cause of some very unnecessary suffering.
Edited by Chenab Navalkha