Like many women after treatment for breast cancer, Debbie* came to me for sexual health counseling with a primary complaint of dryness “down there” and confusion about the advice she had been given by her primary care provider, as well as the resident training with the gynecologist she had been referred to, and her oncologist. There were discrepancies in their approaches to prescribing local estrogen for her and she did not know what to do. She was scared that if she used the estrogen cream her primary care provider suggested, she would have a recurrence of her cancer. The resident told her that using any form of estrogen would increase her risk not only of a recurrence but also a new cancer. The gynecologist said it was her decision and shook his head when Debbie told her what the resident had said. Her oncologist had told her years ago that estrogen was contraindicated in ER/PR-positive breast cancer and she did not prescribe this for any patients with breast cancer.

Now, 2 years later, while searching for help online, Debbie saw my name and called me. I was able to see her a few days later and in taking her medical and sexual history, I learned a lot about her and her relationship with her husband. Sex had never been a priority for her and since her diagnosis there had been no sexual activity at all. After my first visit with Debbie I saw her husband, Brent*, by himself; he recognized that Debbie had never been that interested but since their sex life was now non-existent, he was feeling disconnected from her and afraid for the future of their relationship. A week later I had a visit with the couple. Brent told Debbie how he felt; I had encouraged him to do so after he told me that they were not “talkers” and usually avoided emotional topics. Debbie’s eyes filled with tears as she listened to him and I was relieved to see her reach out to touch his arm.

I practice resolution-focused counseling and wanted to make some practical suggestions for this couple. They were both eager to reconnect but were concerned that Debbie would have pain with penetration. I repeated that my focus for them was on reconnecting and protecting Debbie from pain, and then I described what I thought would be helpful.

Sensate focus exercises have been used by sex therapists for years. They were developed by Masters and Johnson decades ago and are still suggested by therapists, because they work. The exercises have been widely described and perhaps the best resource to learning more about this is a book called Sensate Focus in Sex Therapy.¹ The exercises are done a few times a week, graduating from non-sexual touch to eventual penetration if desired by the couple. The key is that the individual focuses on their own sensation rather than on what the partner is feeling. This sounds easier than it is, as the reflex is often a focus on the partner. I have found these exercises to be very helpful for couples, especially for those who have gone through treatment for cancer that often leads to a loss of sensuality and a sense of dissociation from the body as a source of pleasure; people of all genders can benefit. Despite these exercises taking the pressure off the goal of penetrative intercourse, I have found that many couples “cheat” and don’t follow instructions. They don’t stay in each stage for the time suggested or they give up too quickly. Some tell me that once they got to the second stage where touching breasts and genitalia is “allowed,” they get aroused and one thing leads to another. And soon they are back where they were before.

I was pleasantly surprised to hear Debbie’s voice when I answered my phone about 3 weeks later. We had set up an appointment for the next week, but Debbie couldn’t wait. She wanted to tell me how things had gone.

“Oh, Dr. Katz,” she started, and I could almost see the expression on her face, “you know Brent was skeptical about the exercises, but it has been just wonderful!”

I kept silent, knowing that she had more to say.

“We started right after we talked to you. Like you said, at first it was weird and well, Brent had to be persuaded, shall we say? But after the first week we both started looking forward to doing them. It’s not difficult to find the time either. In just 3 weeks we’ve really started to connect, you know… I don’t like Brent touching my reconstructed breast and it’s been a relief to be able to talk about this. We don’t talk during the exercise as you told us, but we have had some great conversations afterward. We’ve never talked about sex before, not in a meaningful way. As you know we come from conservative backgrounds and this was just not something anyone talked about. But now we can, and we do, and it’s drawn us so much closer…”

She paused to take a breath and I smiled.

“I just wanted to thank you for suggesting this. It’s made a world of difference to me…”

Then it was time for me to respond.

“I’m really happy that this has worked so well for you, Debbie. We can talk more about what comes next when we meet again next week. Remember that you don’t have to get to Stage 4 where intercourse may happen. This is not a goal of the exercises. The point of it all is to find your level of comfort and reconnect with your body and with Brent. I think you’re well on your way to that and I am really happy for you.”

Debbie interrupted me.

“I know that, Dr. Katz. And that gives me so much confidence and reinforces for me that Brent and I are connected, and that intercourse is not the goal. Well, at least I think that!”

The next week I again met with Debbie and Brent. He was not as enthusiastic as his wife, but I expected that. He was eager to start having intercourse again and was frustrated that if she was aroused, why did they need to wait?  I took a deep breath and explained once again why this was necessary; one step at a time, I reminded them, one step at a time.

Reference

1. Weiner L, Avery-Clark C. Sensate Focus in Sex Therapy. Oxon, United Kingdom, Routledge; 2017.