Lesbian, Gay, Bisexual, and Transgender Issues

People identifying as lesbian, gay, bisexual, or transgender (LGBT) often experience unique issues and needs in the context of cancer care. These include experiences and fear of discrimination within heteronormative healthcare environments, assumptions of cisgender/heterosexual identity, exclusion of same-sex partners from care, and a lack of relevant supportive care and information resources. There are also unique impacts of cancer and treatment on LGBT sexuality and fertility. To provide the best possible care for LGBT people living with and after cancer, providers must understand the specific needs of LGBT people and be aware of strategies to deliver inclusive healthcare services. This chapter presents key background information to contextualize the needs of LGBT people with cancer before discussing specific challenges that LGBT people may face when accessing cancer care. We provide guidance for general cancer care, as well as specific concerns regarding the sexual health and fertility needs of LGBT patients. Finally, we outline issues for consideration by healthcare services seeking to advance LGBT awareness and improve care for this patient group.

Provision of Sexual Health Support

Changes to sexuality and intimacy are a common consequence of cancer and cancer treatment. Such changes are multifaceted and associated with a range of negative physical and emotional outcomes for both people with cancer and their partners, as well as changes to roles and intimate relationships. This chapter examines cancer treatment side effects and their impact on sexuality and sexual functioning, risk factors for experiencing sexual difficulties, and the clinical management of sexual changes. We also address barriers to effective communication about sexuality and sexual changes and explore specific cultural or ethical challenges when providing support to people with cancer and their partners. Clinical management and effective communication, by providing general sexual health information and advice, as well as intensive therapy, are outlined, following the PLISSIT and BETTER models. The potential impact of information and advice, in terms of renegotiated sexual practice, is examined, illustrated through case examples.

Couple Therapy for Sexual Dysfunction

Relational strain can be activated by cancer or the effects of its treatment, reducing couple communication and marital satisfaction over time, especially when sexual intimacy declines. Meta-analyses show a modest benefit from couple therapy, with some evidence suggesting better outcomes for couples where one or both partners have greater distress or cancer-related concerns. Presenting problems can include role or transition challenges, communication failure, loss of mutual consensus and conflict, boundary violations, fractures and frustration with sexuality or intimacy. Assessment of the couple includes understanding their experience of the oncology diagnosis and its treatment, their family-of-origin and relational background, coping styles, impact on communication, cohesion, and sexuality alongside any agendas they bring. Behavioral couple therapy strategies can facilitate constructive communication and problem solving to restore intimacy and connectedness during and after treatment. In the advanced cancer setting, existentially oriented models examine grief, death talk, caregiving, and preparation for dying. A search for continued meaning and purpose can empower the couple to live life out to the full, while also preparing for a good death and considering bereavement needs for the survivor.

Principles of Treatment of Sexual Dysfunction

The prevalence of cancer-related sexual dysfunction and body image problems varies according to diagnosis and treatment, but they affect at least half of those treated for pelvic malignancies or breast cancers and greater than a quarter of patients with other cancers. This chapter on psychosexual and psychoeducational issues outlines the impact of cancer treatment on psychosexual well-being (e.g., body image and sexual dysfunction) in males and females. It describes mechanisms to identify psychosexual problems and how to assess the potential needs of patients according to cancer site. It provides recommendations for effective evidence-based interventions to manage psychosexual problems according to presenting symptoms.

Provision of Onco-Fertility Support

The chapter considers issues where oncologic therapy can lead to partial or complete damage to the gonads (ovaries or testes), thus impairing fertility or reducing the fertile lifespan. We discuss the relatively new discipline of onco-fertility, which considers patients’ psychosocial needs, including sexual health, intimate relationships, and the affordability of fertility-preservation measures. Referral and counseling for fertility preservation should be performed as soon as possible after the cancer diagnosis. Assessment of reproductive potential should be offered to all cancer patients. Healthcare professionals should be proactive regarding fertility-preservation counseling. A multidisciplinary team consisting of oncologists, fertility specialists, specialized nurses, mental health professionals, psycho-oncologists, social workers, and support groups should be available when dealing with infertility as a side effect of cancer therapy. Shared decision making regarding fertility preservation is an important issue. Partners may need psychological counseling referrals as well, or couple counseling on communication and sexuality.

Psychological Treatment of Individual Sexual Dysfunction

Cancer patients struggle with sexual problems after cancer treatment. They often discover the sexual side effects after treatment and must learn how to manage their bodies, which now function differently, and work to continue to be sexually active with their partners. Recovering confidence in their ability to function in their sexual relationships means that they must grieve for their sexual losses, understand their new sensitivities, manage altered body capacities, and develop an expanded sexual repertoire. In their relationships, they must learn to communicate about their needs. If they are single, anxiety about starting a new relationship must be managed through the development of confidence that they can still be good lovers despite their altered sexual function. A thorough biopsychosocial assessment helps identify physical changes, psychological vulnerabilities, and relationship areas that will have to be addressed to maintain sexual viability and satisfaction. Psychosocial as well as biomedical interventions are needed in guiding patients toward recovering an ability to function well sexually. Reliance on multiple relevant disciplines and addressing couple issues can lead to patients’ renewed confidence and satisfactory functioning in their intimate relationships after cancer treatment.

Adolescents and Young Adults

Adolescents and young adults (AYA) represent a unique patient population with a number of age-specific care needs that should be understood and attended to as a part of comprehensive cancer care. The effects of cancer and its treatment on sexual functioning and fertility are common and ranked as among the most distressing survivorship issues faced by this age group. Difficulties associated with sexuality, body image, and intimacy; facing infertility risk; and coping with loss of fertility are all relevant issues for patients across disease and treatment groups. Further, when cancer occurs during this age range, its sequelae can disrupt key developmental tasks and have long-lasting effects on areas of life connected to and affected by sexual and reproductive health problems. Patients are often not fully informed about the sexual side effects and infertility risks associated with treatment and as a result are typically unprepared for the challenges they experience. This chapter describes the challenges AYAs face related to their sexual and reproductive health after a cancer diagnosis, provides information for screening patients for heightened distress and dysfunction, and reviews treatment strategies to help clinicians prepare to discuss these complex issues with AYA patients and survivors.