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Sexuality at the End of Life


By Anne Katz RN, PhD

In the terminal stages of the cancer trajectory, sexuality is often regarded as not important by health care providers. The need or ability to participate in sexual activity may wane in the terminal stages of illness, but the need for touch, intimacy, and how one views oneself don’t necessarily wane in tandem. Individuals may in fact suffer from the absence of loving and intimate touch in the final months, weeks, or days of life.head:heart

It is often assumed that when life nears its end, individuals and couples are not concerned about sexual issues and so this is not talked about. This attitude is borne out by the paucity of information about this topic.

Communicating About Sexuality with the Terminally Ill

Attitudes of health care professionals may act as a barrier to the discussion and assessment of sexuality at the end of life.

  • We bring to our practice a set of attitudes, beliefs and knowledge that we assume applies equally to our patients.
  • We may also be uncomfortable with talking about sexuality with patients or with the idea that very ill patients and/or their partners may have sexual needs at this time.
  • Our experience during our training and practice may lead us to believe that patients at the end of life are not interested in what we commonly perceive as sexual. How often do we see a patient and their partner in bed together or in an intimate embrace?
  • We may never have seen this because the circumstances of hospitals and even hospice may be such that privacy for the couple can never be assured and so couples do not attempt to lie together.

intimacy-320x320For the patient who remains at home during the final stages of illness the scenario is not that different. Often the patient is moved to a central location, such as a family or living room in the house and no longer has privacy.

  • While this may be more convenient for providing care, it precludes the expression of sexuality, as the patient is always in view.
  • Professional and volunteer helpers are frequently in the house and there may never be a time when the patient is alone or alone with his/her partner, and so is not afforded an opportunity for sexual expression.

Health care providers may not ever talk about sexual functioning at the end of life, assuming that this does not matter at this stage of the illness trajectory.

  • This sends a very clear message to the patient and his/her partner that this is something that is either taboo or of no importance. This in turn makes it more difficult for the patient and/or partner to ask questions or bring up the topic if they think that the subject is not to be talked about.

Sexual Functioning At The End Of Life

Factors affecting sexual functioning at the end of life are essentially the same as those affecting the individual with cancer at any stage of the disease trajectory. These include:go deeper

  • Psychosocial issues such as change in roles, changes in body- and self-image, depression, anxiety, and poor communication.
  • Side effects of treatment may also alter sexual functioning; fatigue, nausea, pain, edema and scarring all play a role in how the patient feels and sees him/herself and how the partner views the patient.
  • Fear of pain may be a major factor in the cessation of sexual activity; the partner may be equally fearful of hurting the patient.

The needs of the couple

Couples may find that in the final stages of illness, emotional connection to the loved one becomes an important part of sexual expression. Verbal communication and physical touching that is non-genital may take the place of previous sexual activity.

  • Many people note that the cessation of sexual activity is one of the many losses that result from the illness, and this has a negative impact on quality of life.
  • Some partners may find it difficult to be sexual when they have taken on much of the day-to-day care of the patient and see their role as caregiver rather than lover.
  • The physical and emotional toll of providing care may be exhausting and may impact on the desire for sexual contact.
  • In addition, some partners find that as the end nears for the ill partner, they need to begin to distance themselves. Part of this may be to avoid intimate touch. This is not wrong but can make the partner feel guilty and more liable to avoid physical interactions.

Addressing sexual needs

senior intimacyCouples may need to be given permission to touch each other at this stage of the illness and health care providers may need to consciously address the physical and attitudinal barriers that prevent this from happening.

  • Privacy issues need to be dealt with. This includes encouraging patients to close their door when private time is desired and having all levels of staff respect this. A sign on the door indicating that the patient is not to be disturbed should be enough to prevent staff from walking in and all staff and visitors should abide by this.
  • Partners should be given explicit permission to lie with the patient in the bed. In an ideal world, double beds could be provided but there are obvious challenges to this in terms of moving beds into and out of rooms, and challenges also for staff who may need to move or turn patients. Kissing, stroking, massaging, and holding the patient is unlikely to cause physical harm and may actually facilitate relaxation and decrease pain.
  • The partner may also be encouraged to participate in the routine care of the patient. Assisting in bathing and applying body lotion may be a non-threatening way of encouraging touch when there is fear of hurting the patient.

Specific strategies for couples who want to continue their usual sexual activities can be suggested depending on what physical or emotional barriers exist. Giving a patient permission to think about their self as sexual in the face of terminal illness is the first step. Offering the patient/couple the opportunity to discuss sexual concerns or needs validates their feelings and may normalize their experience, which in itself may bring comfort.

More specific strategies for symptoms include the following suggestions. senior lesbians

  • Timing of analgesia may need to altered to maximize pain relief and avoid sedation when the couple wants to be sexual. Narcotics, however, can interfere with arousal which may be counterproductive.
  • Fatigue is a common experience in the end stages of cancer and couples/individuals can be encouraged to set realistic goals for what is possible, and to try to use the time of day when they are most rested to be sexual either alone or with their partner.
  • Using a bronchodilator or inhaler before sexual activity may be helpful for patients who are short of breath. Using additional pillows or wedges will allow the patient to be more upright and make breathing easier.
  • Couples may find information about alternative positions for sexual activity very useful.
  • Incontinence or the presence of an indwelling catheter may represent a loss of control and dignity and may be seen as an insurmountable barrier to genital touching.

footprints-leftIt is important to emphasize that there is no right or wrong way of being sexual in the face of terminal illness; whatever the couple or individual chooses to do is appropriate and right for them. It is also not uncommon for couples to find that impending death draws them much closer and they are able to express themselves in ways that they had not for many years.

Complete Article HERE!

The Virginity Myth

Name: Tia
Gender: Female
Age: 19
I have a problem. I’m still a virgin, but my bf thinks I’m not. It’s really my fault he thinks this, cuz I told him I was all experienced and everything. We’ve been going together for about 8 months already and I really want my first time to be with him, but how am I going to act all experienced when I don’t know what I’m doing.

That sure enough is a pickle you got yourself into darlin’. You’ve got some ‘splanin’ to do Lucy!

Funny, because I’m more likely to hear from young women who are not virgins, who want to know how they can fool a new partner into thinking, they are. I guess we can chalk up all this deception and confusion to the powerful associations every culture imposes on virginity…female virginity, that is.

virginityLike most things sexual there is a huge double standard between the cultural and personal importance of virginity between the sexes. The cultural expectations about virginity are also tied to age as well as gender. For example, our society expects its 16-year-old girls to be virgins. To be otherwise, at that tender age, would be a scandal in most communities. But a 35year old woman who is still a virgin is considered an old maid — or worse, a dyke — in our society.

Of course, things are more fluid when it comes to boys and men. On the one hand, a 16year old boy, who is not a virgin, may raise some eyebrows in most communities. But many others in those same communities would praise him for being a stud. On the other hand, a 35year old man who is still a virgin is not only the butt of jokes — or worse, a queer — but he’s also more of a disgrace to his gender than an old maid is to hers. Funny how that works, huh?

I hasten to add that there is a lot to argue with in terms of these arbitrary cultural norms, and I encourage ya’ll to argue away. God knows I do! And you don’t have to buy into them either. God knows I don’t! But till things change these norms are the norms, like it or lump it.

I’d love to know why you felt the need to deceive your BF in the first place? Do the people you hang with, prize sexual experience over sexual innocence for a woman of 19? And what are the expectations of your group regarding a 19year old guy? I’ll bet the expectation is that he not be a virgin. Right?

Well you can see why a lot of people, not just you Tia, find this whole thing just too damned complicated. And rather than adding to the confusion or the deception, I encourage you to come clean with the BF about your cherry.Sign-Virginville-VillageOf

Here’s why I think this is the best policy. First, if the BF is sexually experienced, it will be very difficult for you to hide the fact that you’re not. Besides, like you said in your message to me. “I really want my first time to be with him.” Tell him that, sweetheart! No man is gonna turn that down…ever. Simply put, that is the most sexually charged and treasured sentence in any language.

Begin the big talk with your man like this. “Baby, I got something real special to tell you. You know how I’ve been sayin that I’ve been with other guys and shit? Well that was just my way of keeping all the other guys from pestering me for my junk. Baby, the truth is that I haven’t had sex before now. And the best part of this is I’ve decided that I really want my first time to be with you. My cherry belongs to you, baby”

Like I said, Tia, no man is gonna turn that down. The BF will be so flattered you won’t have to pretend to be something you’re not. Clearing the air like this will also allow you to relax when the magic moment finally happens. And relaxation is the key to enjoying yourself. And you should enjoy yourself.

Good luck

An (extremely long) Tale Of Woe

First Name: Sam
Age: 22
Gender: Male
Location: North Carolina, USA
Wow, where do I even begin….

I am a 22-year-old gay male and believe that I may have SOME form of erectile dysfunction. I emphasize “some” because it is possible for me to get hard, firm erections, but I’m ALWAYS by myself when I do.

I have been able to give myself orgasms since I was in preschool. I did not masturbate the “traditional” way that men do (or ejaculate) until I was in 6th grade. Before that, I would lay down with my hands cupped around my crotch area and would “hump” into them until I felt an orgasm sensation and would then stop. In 6th grade I began to look at gay internet porn, and, seeing how most of those men masturbated, began to emulate the process. I even practiced “edging” often, beginning in 6th grade, as I had read on the internet at that time that it built up sexual stamina and led to powerful orgasms.PERFORMANCE_ANXIETY_pic_02_3

I would say that since I’ve been able to have orgasms (beginning in preschool), I would have one usually at least once a day. There were days here and there where I wouldn’t, but I guess an average would be 6 out of 7 days per week, with an average of twice per day. Of course, it’s hard to average them out since I’ve been having them for so long.

I did not start having sexual intercourse until my freshman year of college when I was 18, with my roommate at that time. Even that first time, I had problems maintaining my erection. I also had to use my hand and masturbate in order to have the orgasm, which took much longer than when I’m by myself. My roommate and I engaged in sexual intercourse regularly for the latter 2 and a half months of my freshman year, and every time, I had to have an orgasm by masturbating. Oral sex would not work, his hand would not work, and we did not engage in anal sex.

From ages 19-20, I had very little intercourse, but regularly masturbated (almost always to porn), and had no problems maintaining an erection and achieving orgasms. I hooked up with older men occasionally during this time, and again, could not have an orgasm unless I masturbated. It was also slightly more difficult to get an erection than by myself watching porn, and always took me longer to achieve orgasm than by myself. I had my first experience with anal sex (as a “top”) during this time as well, and could not ever reach orgasm, same with oral sex and hand-jobs.

When I was 20 I met and began dating my first boyfriend. We were together for 10 months, and while I enjoyed my time with him, our sex life was poor. We did not engage in anal sex except once, because we both considered ourselves tops. The one time we engaged in anal sex I tried to be the bottom, but did not enjoy it at all and had to stop. We did engage in oral sex, but I could never achieve orgasm that way. Again, I had to masturbate in order to have an orgasm. Not only that, but I began to have significant trouble sometimes to get an erection. Also, it took a lot longer for me to reach orgasm when I masturbated with him. By myself with porn, I could reach orgasm as quickly as 5-7 minutes. With him, it often took me at least 20 minutes, and it was usually 25-35 minutes.

loving legsAfter we broke up, I began to hookup a little more frequently then I had in the past, but it was not that often. Whenever I did, again, I always had to masturbate to achieve orgasm, and it took me a long time to do so. AND, during some of these hookups, I simply could not even achieve orgasm myself, as I started to have difficulty maintaining or even getting an erection. I highly doubt it was because of my sexual partners, because I would not hookup with someone I was not sexually attracted to. Also, I usually could have erections during foreplay, but when it came to the “big finish” my erection would start to wane or just become completely soft, and nothing I did or thought about changed that. Once, I achieved orgasm from barebacking (which I have not done since and luckily did not contract HIV or an STD), and there was also only one time where I hooked up with a guy and achieved orgasm from him giving me oral sex, although I believe this was because I refrained from masturbating for the past few days beforehand.

I am 22 now, and am starting to worry that I will not be able to ever have any good sex with someone else other than myself. In almost all of my most recent hookups, I have had to use a cockring to get an erection, and even then sometimes it doesn’t even help. Also, in almost all of my most recent hookups, it either takes me around 30 minutes to masturbate to orgasm, or I simply can’t have an orgasm because of lack of an erection. However, if I am by myself watching porn, I do not have any trouble getting and maintaining “rock-hard” erections and reaching orgasm.

I have become particularly concerned about this problem now, because I have begun to date someone and engage in sex with him for the past few weeks. When we first had sex I topped him anally and had a good erection. But we still masturbated together to completion. Ever since the first time though, I have had a LOT of difficulty just getting an erection period. Cockrings do not help, and oral sex and foreplay don’t really help either. Sometimes when we make out for a while I’ll start to get kind of hard, but then when I try to get ready to penetrate him or simply masturbate with him, I’ll go soft again. I’ve been able to reach orgasms sometimes when I masturbate with him, but my penis is usually semi-soft when I reach orgasm, and again, it takes more effort and certainly more time to do so then when I’m alone watching porn. He is incredibly good FleshJacklooking, good at sex, and very passionate, so I know it is not him. Luckily, he does not mind when I cannot perform, he says he likes me for me and that everything is fine, and he thinks that I shouldn’t worry about it. But at this point, I really can’t help but worry about it…

The last time this problem happened I had willingly decided to not have an orgasm for three days beforehand, hoping that it would help the issue. But unfortunately, it did not help or change anything. I’ve decided to completely stop viewing or watching any pornography whatsoever, and have also decided that when I masturbate I will avoid as much contact with my hand and, instead, use my FleshJack (the gay version of FleshLight) with the “Squeeze” texture (their most “realistic” anal texture). I have not had sex with him since I decided this (which is the day I’ve written this question, May 27, 2015).

I apologize for this EXTREMELY long inquiry, but I didn’t want to leave out any details of my sexual history in case they were important. I’m wondering if masturbating regularly since preschool has anything to do with my poor performance. And I’ve considered that I’m “overthinking everything” when I engage in sex and maybe that’s preventing me from getting erections with other men, but I’m such a sexual person that I can’t think of anything but dirty, sexual thoughts when I’m with another man, yet it just doesn’t seem to work. I do start to focus on not being able to get an erection if I’m not getting one for 5-10 minutes, but during that time beforehand, I’m not thinking about anything other than the pleasure, so I don’t see what I’m doing wrong. The problem is beginning to be REALLY embarrassing and I’m concerned that if I’m already having these problems at only 22 years of age, I’ll likely have the worst of erectile dysfunction problems in the future.

I suppose my main questions are:
1) What could be causing this to happen?
2) Is my proposed method of completely avoiding porn and masturbation via my hand an appropriate solution?
3) Do you have any specific suggestions or general advice that can help me with this problem and/or my sex life?

Again, I apologize if this is way too long; I’ve just never been so concerned about it before. I’m 22, I should be able to get rock hard erections easily, but I feel like a 70 year old man who just “can’t get it up.” ANY advice you can give me will be sincerely appreciated.

Whew, Sam, that was like the War And Peace of sex advice questions.

It’s perfectly clear that you are worried about your sexual response. But I’m gonna guess that your worry is actually making things worse. Before I respond to your three questions, I want to say; get thee to a therapist! You need to sit down with a sex-positive therapist and work through this stuff with him/her. This is super important, don’t just blow it off. If you need a referral, see the Directory of the American College of Sexologists to find someone in your neck of the woods. I also offer remote therapy via Skype or phone. See my Therapy Available page.

whewNow to your questions in the order you asked them…
1) What could be causing this to happen?
Everything you tell me points to performance anxiety. I’ve written and spoken a great deal about this issue over the years. Use the CATEGORIES pull down menu in the sidebar to your right. Scroll down till you find the main category, Sex Therapy. Under it you will find the sub category, Performance Anxiety.  You’ll find tons of information.

2) Is my proposed method of completely avoiding porn and masturbation via my hand an appropriate solution?
It might be, but not for the reason you suspect. Again, you need to discuss this with a therapist. It’s important and more involved than I have time and space to lay it out for you.

3) Do you have any specific suggestions or general advice that can help me with this problem and/or my sex life?
Yeah, chill the fuck out! Honesty, that’s the best thing you can do right now. Then, with the help of a therapist, work through your problems, put in place a program to rebuild your partnered psychosexual response one step at a time. You’ll probably begin with sensate focus training, stress reduction, and relaxation exercises.

A molehill becomes a mountain

My problem is Sexual dysfunction, I can have a hard on and keep it for penetration but if I have to use a condom I lose my erection, most of the time. I also take to much time to cum. Most of the time I loose my erection and I can’t finish what I’ve started. I would like to find a solution for this, because I have been like this for a long time, and it is really frustrating for me. I do appreciate your help and look forward to hear from you.

Sounds to me like you’re racing to the finish line. Hey, where’s the rush? You may be experiencing a bit of performance anxiety, but I don’t think it’s a full-blown sexual dysfunction quite yet.

Look for the category pull down menu in the sidebar to your right. Scroll down till you find the category — Sex Therapy. Under that category you will find a subcategory labeled PERFORMANCE ANXIETY.

You’ll find loads of information about this issue in both written and podcast form.performance anxiety

Here’s an example of what you’ll find…

Simply put, there’s a difference between the psychosexual response we have when we are alone and the one we experience with a partner. There’s probably nothing wrong with your unit. It’s all in your head…or your mind, to be more exact. And I’m not being flippant.

Here’s how performance anxiety works. Say I have a less than satisfying sexual experience for one reason or another. Before I know it, I’m replaying the incident over and over in my mind’s eye till that’s all I can think about. The proverbial molehill has become a mountain, don’t ‘cha know. I then bring my anxiety to my next encounter. My hyper self-consciousness primes me for more disappointment. And I’m all prepared to interpret the disappointment as a failure. Well, you can see where I’m going with this, huh? My fears become self-fulfilling and I find I’m beginning to avoid partnered sex and my relationship flounders, I develop a full-blown sexual dysfunction and my self-esteem takes a nosedive. My preoccupation with my problem makes it less likely that I’ll be fully present during sex with my partner, which pretty much scuttles my sexual responsiveness and any hope for spontaneity.

Get thee to a sex-positive therapist ASAP! Believe me this is nothing to fool around with. Check out the directory at The American College of Sexology for a therapist near you.  If you can’t find anyone near you and you really need to talk to someone, check out my Therapy Available page.  I do remote therapy/counseling via Skype or phone.

When I see this sort of thing in my private practice, I always begin the therapeutic intervention by calling a moratorium on fucking of any kind. This immediately takes a great deal of the pressure off the couple. From there we begin to rebuild the partnered psychosexual response one step at a time. We begin with sensate focus training, stress reduction and relaxation exercises. I have the greatest confidence in this method; it succeeds over 90% of the time.

Good luck

He Can’t Cum!

Name: Alice
Gender: Female
Age: 19
Location: Minnesota
My new boyfriend is really frustrated and doesn’t want to have sex anymore because he can’t come. He says he’s had this problem for a while and hasn’t come with any girl for over a year. I see how upset he is and I know he still wants to sleep with me, but says it hurts when he gets excited and nothing happens. Is there something I can do? I tell him to see a doctor but I don’t think he will. Thanks a lot!

Wow, that’s a bummer Alice. Unfortunately, you don’t supply me with enough information for me to make an educated guess about what might be up with him. Does he have erections? Does he masturbate? Is he on any medications? These are the first questions I’d ask him. Since he isn’t here and neither are you, I’m gonna make a stab in the dark.cover up

If I had to guess, I’d say your man is suffering from a real bad case of performance anxiety. He doesn’t need a medical doctor; he needs to learn to relax and be in the moment. If this is an arousal phase issue then that should help. If it’s and orgasmic phase issue, relaxing and enjoying the pleasure will also help.

Here’s how performance anxiety works. Say a fella has a less than satisfying sexual experience for one reason or another. Before he know it, he replaying the incident over and over in his head, till that’s all he can think about. The proverbial molehill becomes a mountain. He brings his anxiety to his next sexual encounter. His hyper-consciousness primes him for more disappointment. And he’s ready to interpret all disappointment as a failure. And this can interrupt either the arousal phase or orgasmic phase of our sexual response cycle.

Well, you can see where I’m going with this, huh? His fears become self-fulfilling. Before he knows it, he begins to avoid sex. His relationships suffer. He develops a full-blown sexual dysfunction. And his self-esteem takes a nosedive. His preoccupation with his problem makes it less likely that he’ll be fully present during sex with his partner, which pretty much fucks up his sexual responsiveness and any hope for spontaneity.

It sounds to me like performance anxiety is putting a damper on his sexual arousal and thus short-circuiting the rest of his sexual response cycle, including orgasm.

This is nothing to fool around with, especially for someone at his tender age. When I see this sort of thing in my private practice, I always begin the therapeutic intervention by calling a moratorium on fucking of any kind. This immediately takes a great deal of the pressure off the couple. From there we begin to rebuild the partnered psycho-sexual response one step at a time. We begin with sensate focus training, stress reduction, and relaxation exercises. I have the greatest confidence in this method. It succeeds over 90% of the time.

Good luck

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