As we all know—vicariously, fortunately, for most of us—a diagnosis of cancer changes everything. The false sense of certainty of how life will play out is gone in an instant when the words “you have cancer” are spoken. A person becomes a patient in that moment and they are forever changed. Some will respond with stoicism, others will be reduced to tears; some will panic and some will be forced into a literal fight for their life. And then there are the very few who change in ways that no one would anticipate.

Such was the case for one patient I saw. An active man in his early 60s, a father to three sons just entering adulthood, James* began behaving in a way that could be called “acting out.”  He bought a motorcycle and grew a beard. This might not sound startling, but for a self-described conservative accountant, it was certainly a change. He thought about ending his 29-year marriage but couldn’t face telling his sons. So he stayed in the family home, his motorbike housed in the triple-car garage. On the surface things looked pretty much normal, if anyone was paying attention.

The acting out part was in his sex life and this is where I became aware of what was going on. Within months of his cancer diagnosis, stage III colorectal cancer, he had chemotherapy and radiation followed by surgery to remove the now much smaller tumor. He did not need a stoma and was back to his usual activities within a few months. But his erectile functioning was poor at best. He came to see me to find out what he could do to remediate this. My usual practice is to encourage the patient to bring their partner to our first and subsequent appointments as sexual problems need both partners to be actively involved in finding solutions.

At our first visit, James told me that his wife couldn’t come to the appointment as she could not miss work. He described his treatment history and the resultant loss of erections. I made suggestions and he left with some samples of erectile medication. Two months later he requested another appointment and, once again, his spouse was not able to attend. At this second appointment he confessed all: he had moved into the basement of the house, the marriage was effectively over, but he could not tell his sons. He appeared somewhat embarrassed as he told me all of this. He did not make eye contact and it was obvious that he was having difficulty talking about his situation.

Since he recovered from surgery he has been seeing other women, multiple women, in the hopes that he would be able to function with one of them, he said. He was not emotionally attached to any of them and they were not aware that he was married or that he was seeing many women at the same time. He seemed unaware of the risk of contracting a sexually transmitted infection as he believed that if he was not having penetrative intercourse he was not at risk. I pointed out that he was at risk for herpes, HPV, and other sexually transmitted infections from oral sex, but he just shrugged his shoulders. When I asked him if he knew why he was acting like this, putting himself and the women at risk, he left my office after telling me that I was there to help him get erections and that was all.

These situations are difficult and I have written previously about the moral distress I have experienced when treating a man who was having an affair.¹ Caring for this man was similarly challenging for me as his actions were potentially harmful to him and to the women he was sexually active with, as well as to his spouse if he was still having sex with her. Certainly there were potential emotional consequences of his actions if his family discovered what he was doing.

On the other hand, I felt sympathy for him and his situation. Everyone deals with their cancer and the resultant changes in function differently, and perhaps his sexual activity at this time was a way for him to feel like a man again. Perhaps being in the company of these other women made him happy when his home life was stressful. Or perhaps he wanted to feel alive and youthful again and his actions were a distraction from the reality of his life. Was this the mid-life crisis or a response to an unhappy marriage?

I will never know the answers to the many questions I have about him and his actions; he has never returned to see me. Did I handle the situation correctly? Perhaps I should have not warned him about the risks he was taking with multiple sexual partners and merely advised him about erectile aides.  I sometimes think about him and his coping mechanism. Perhaps what he was doing was trying his best to cope with an altered life, and not acting out after all.

*Name changed to protect patient anonymity.

Reference

1. Katz A. “Doc, please don’t tell my wife”. J Clin Oncol.2011;29:4839-40.