Resuming sexual activity

The mind and sex

Sex starts in the mind. The brain is responsible for making you feel interested in sex through feelings, memories, imagination and fantasies. These thoughts are created by what you see, smell, touch, taste and hear.

Levels of sexual desire can vary from time to time due to stress, illness and work. If you are anxious, worried or depressed about the cancer and treatment, you will probably be less aroused by thoughts of sex. Your partner may also be anxious and not feel like having sex.

The mind also affects how you feel about your body and how you think it looks.

The role of hormones

Hormones are like chemical messengers that affect how your body works. They carry information and instructions from one group of cells to another. They control reproduction and growth, and are important for sexual interest and response.

Women

• The major female sex hormones are oestrogen and progesterone, produced in the ovaries, adrenal glands and fatty tissue.
• Oestrogen keeps the vagina moist so it can expand during sex. During ovulation (release of egg) oestrogen levels rise. This can make a woman feel sexual.
• Oestrogen levels fall after menopause. This may cause the vagina to become tight and dry and it may not expand as easily as before. It can also affect sexual desire (libido).
• Progesterone controls reproduction and helps prepare a woman's body for pregnancy.
• Women's ovaries and adrenal glands also make small amounts of male sex hormones, such as testosterone, which increases sexual desire.

Men

• The major male sex hormone is testosterone, produced by the testes (testicles) and adrenal glands.
• Testosterone promotes development of the reproductive organs and secondary sexual characteristics such as a deep voice, facial hair, muscles and sexual desire.
• Men's hormone levels vary widely but most men have more testosterone than they need. A man with a low level of testosterone could have trouble getting or keeping an erection and may lose his desire for sex.

Female sex organs

A woman's sex organs (genitals) are mostly inside her body:

• Vagina - a muscular canal extending from the entrance of the uterus to the outer sex organs.
• Uterus - a hollow muscular organ shaped like an upside-down pear. The uterus, also called the womb, holds and nourishes a fertilised egg (ovum). The entrance to the uterus is called the cervix.
• Fallopian tubes - two long, finger-like tubes that extend from the uterus and open near an ovary. These tubes carry eggs from the ovary to the uterus.
• Ovaries - two small, almond-shaped glands that contain eggs. The ovaries are found on either side of the womb, close to the end of the Fallopian tubes. The female sex hormones, oestrogen and progesterone, are made by the ovaries.

The outer sex organs are called the vulva. They include:

• Mons pubis - the area of fatty tissue covered with pubic hair.
• Labia majora - the outer lips, which protect the vagina.
• Labia minora - the inner lips, which join at the top to cover the clitoris with a fatty hood.
• Clitoris - the main sexual pleasure organ for women. It is located where the labia minora join. The clitoris has a similar role to the penis. When stimulated, the clitoris becomes erect and sends messages of pleasure to the brain.

The breasts and nipples also respond to stimulation. Some women may find that other areas of their body are sensitive to stimulation. These are called erogenous zones and responses are often very individual.

Male sex organs

A man's sex organs (genitals) are mostly outside his body:

• Penis - the end of the penis is covered by the foreskin, if it hasn't been removed by circumcision. The ridge on the underside of the head of the penis, called the frenulum , is usually a man's most sensitive part. At the end of the penis is a narrow opening to the urethra, through which semen and urine pass.
• Scrotum - a pouch of skin found at the base of the penis. It contains the testes.
• Testes - two small, egg-shaped glands that sit behind the penis in the scrotum. The testes (also called testicles) make and store sperm. They also produce the male sex hormone, testosterone. It is normal for one testis to sit higher than the other and to vary slightly in size.
• Epididymis - coiled tubes found behind each testis, where the sperm mature.

The other parts of a man's reproductive system are inside his body. They include:

• Prostate gland - a small gland about the size of a walnut. The prostate sits below the bladder and surrounds the urethra, the tube that carries urine (from the bladder) and semen (from the sex glands) out through the penis. The prostate produces most of the fluid that makes up semen and nourishes the sperm.
• Seminal vesicles - glands that lie very close to the prostate and produce secretions that form part of the semen.
• Vas deferens - transport the sperm from the epididymis to the penis.
• Cowper's glands - tiny, pea-sized set of glands inside the body at the base of the penis. During sexual excitement the gland release a tiny amount of fluid that neutralises any traces of acidic urine that may be left over in the urethra.

The penis, testes and anus are highly sensitive and respond to stimulation. A man's other sensitive areas (erogenous zones) include the chest, nipples, neck, ears and fingers.

Stages of sexual response

The four stages of sexual response for both men and women are sexual desire, excitement or arousal, orgasm and resolution.

Sexual desire - also called libido, is the interest you have in sex.

Excitement or arousal - this is when your body shows signs of getting ready for sexual activity. You can become aroused by seeing someone you like; having a sexual thought or fantasy; having your sexual organs touched; masturbating; or having oral sex.

The body responds to this excitement in various ways: blood pressure and heart rate increase, the breasts or chest become more sensitive and the nipples harden. In women, the clitoris becomes erect and sensitive, and the vagina expands and moistens. In men, the penis hardens, becomes erect and is more sensitive. The scrotum becomes firmer and the testes move closer to the body.

Orgasm - the peak of sexual response. Sexual excitement or arousal can lead to an orgasm but this doesn't always happen. The nervous system creates intense pleasure in and around your sex organs, causing muscles in the genital area to contract in rhythm and send waves of feeling through your body. Breathing becomes faster and shallower, heart rate and blood pressure increase and you may sweat.

In women, orgasms can vary in length and intensity, and can be reached in different ways, depending on how the body is stimulated. In men, an orgasm usually happens simultaneously with ejaculation, which occurs when the muscles around the base of the penis squeeze in rhythm, pushing the semen through the urethra and out of the penis. It is possible to have an orgasm without ejaculating. This is called a dry orgasm.

Resolution - breathing, heart rate and blood pressure return to normal. Some women are able to be excited again within a few minutes. Men usually cannot be aroused again immediately, but may still enjoy the intimacy of kissing and stroking afterwards.

Masturbation - or self-pleasuring - can be a positive and satisfying way to enjoy sexual activity when you don't have a partner or you aren't ready for intimacy with a partner. It can help you find out what your body is capable of sexually and how it might respond to intimacy. Many couples enjoy mutual masturbation as an alternative to penetrative sex.

Talking about sex and intimacy

Communication is vital.

• If you have a partner, discussing your fears, concerns, preferences, desires and expectations can help improve your sexual experience.
• Try not to let embarrassment get in the way of sexual enjoyment. Avoiding the topic can lead to frustration and misunderstanding.
• Talk about when you think you'll be ready for sex and ask how your partner feels.
• Discuss whether your partner should do anything differently, how they can help you prepare and what level of intensity you prefer.
• If you're not interested in sex, let your partner know you are not rejecting them, just sexual activity.
• Suggest what you are happy to offer instead, e.g. a hug or a kiss, a massage, or a form of non-penetrative sex, such as oral sex or masturbation.
• Show your partner any physical changes so you both get used to your different appearance.
• Plan ahead, particularly the first few times. After treatment, you may need to be less spontaneous.
• Be patient. You will probably find any problems you have will get better with time and practice.
• Remember that there are other important aspects of your relationship; many relationships are not dependent on sex to maintain them.

Information for partners

If your partner has had cancer there may be many changes you will need to adapt to. There are many ways that can help you both adapt:

• Let your partner know that even though they have had cancer and they may have changed physically and emotionally, you still love them and find them attractive.
• Remind yourself of your partner's other qualities, such as their sense of humour, intelligence, smile or generosity.
• Talk to your partner. Ask them to tell you or show you what feels good or what is sensitive to touch.
• Be prepared to go at your partner's pace. Give them to the time and space to recover.
• If your partner isn't ready for sexual contact, try other ways of showing your love, e.g. through gentle hugging or stroking.
• If sexual penetration is too difficult or not desired, be creative in finding others ways to satisfy each other.

You may have other worries about your partner's illness and how this might affect you and your sex life.

• If your partner has radiotherapy, they will not be radioactive once they return home.
• If your partner has chemotherapy, use a condom for protection from drugs in your partner's body fluids if you have intercourse or oral sex within 48 hours of treatment. Use latex gloves if you use your hands for penetration.
• It is not possible for your partner to transmit cancer to you through intimate activities such as kissing or intercourse.
• If you are your partner's primary carer, it may be difficult to switch between the roles of carer and lover. Address this problem early on by talking to a counsellor about how you're feeling and how physical needs in your relationship can be met.

People without partners

Many people face cancer and its treatment without the support of a partner. In time, you may wish to meet new people and start a relationship, or you may decide that you don't want to be in a relationship, either because of what you've been through or for other reasons. This is a natural reaction and it's your choice. If you wish to be in a relationship, finding a new partner can seem daunting:

• You may worry about starting a relationship and then getting ill again.
• You may fear how a new partner will react when told about the cancer.
• It can be difficult to decide when to tell a new partner about the cancer.

Some suggestions are:

• Wait until you've been out a few times and feel things could develop before discussing the cancer.
• It may help to practise what you want to say beforehand.
• At first, you don't have to go into a lot of detail. Just reveal what you're comfortable with.
• Before starting sexual activity, talk to your partner about any changes to your sexual function.
• Take things slowly and show your partner changes to your body so that you both can get used to them.
• If a new relationship doesn't work out, don't automatically blame the cancer. Remember that not every relationship worked before you had cancer.
• Sharing your concerns with someone in a similar situation may help.

If you are in a same-sex relationship

It is important that you feel your sexuality is respected and included when discussing how you are affected by treatment. Although many major issues will be the same for you as for heterosexual people, recognition and validation of your sexuality is a crucial part of receiving support. Your clinical team should be able to openly discuss your needs and support you through treatment.

• Try to find a doctor with whom you feel comfortable talking about your sexuality and relationships.
• If you have a partner, take them along to doctor's visits.
• Include your partner in discussions about your health and treatment plans.
• Seek help from services for same-sex attracted people through ACON, an organisation promoting health and well-being of the gay, lesbian, bisexual and transgender (GLBT) community.