Module 6 Discussion

Safe sex practices on treatment

Patients undergoing cancer treatment are at heightened risk of contracting STIs due to being immunocompromised. Watch the social worker discusses the importance of safe-sex practices on treatment with her female breast cancer patient, Ashley, who identifies as lesbian. Think about how individualize discussions to a patient’s age, gender/gender identity, sexual orientation, sexual activity level/interest, and disease type and treatment. What would be considerations for a heterosexual female?

112 Comments

  1. Angelica Rodriguez

    We should also educate our patients about their partners risk for chemotherapy exposure through bodily fluids. The time length of exposure has always been a gray area. In my area of practice we generally advise female or male condoms depending on their sexual orientation are necessary for at least 3 days after chemo administration or to use throughout treatment if contraception is also needed.

    1. Nicole Herrera

      Yes! That’s a matter I’ve been wondering lately and had never really thought about it too much until progressing through this course. I suppose as Ashley builds more rapport with her social workers and thinks about this initial session, she may have more specific questions or concerns such as this one.

      1. Alexandra Huffman

        Thank you for pointing that out. I think many partners worry about hurting the patient physically, and while we don’t want to scare anyone, it’s important to inform patient and partner.

    2. Michelle Bronzo

      Great question, Angelica. I’ve heard a similar guideline for protection following chemo, however I wonder how this is impacted when someone is on oral chemo. Does that mean that they will always have to use a barrier??

      1. Lisa Cummings

        For our patient’s male or female on oral chemotherapy and immune therapy, we do recommend a barrier protection to prevent against the exposure to the body fluids and prevent pregnancy. We currently have several young males being treated for CLL with oral therapy. They are sexually active and understand it is best not to conceive while on the medication and that they should protect their partners from the body fluids. They have told me that they buy condoms on line in large quantities. At one point, one of the men will want to father a child as he has discussed it with our physician. The physician will need to look into a plan for stopping his medication and then restarting it after conception. I am not exactly certain how that is going to work at this point, because by stopping the medication, his CLL will relapse. These are some very difficult questions and very difficult issues for our patients to navigate.

        Chemotherapy is not the only medication that is in your body fluids. Once when I discussed the whole body fluid issue, I had a patient and her husband state that she was placed on an antibiotic that her husband was allergic to, and after they had intercourse, his penis became very red, irritated and peeled. Just something to think about!

        1. Cecily Smith

          Good information and reminders on oral medications and the need to stay up to current on the latest treatment guidelines and studies in order to provide the best “real time” information to patients.

        2. Joan Coleman

          Wow Lisa that is very informative! I did not realize that antibiotics could have that effect! Something definitely to keep in mind when prescribing.

    3. Laura Petiya

      This thought has never actually crossed my mind. I do see patients usually before they start chemotherapy, but it will likely be something I do mention to patients as many have sexual partners supporting them through their fertility preservation cycles. Thanks!

      1. Robyn Dillon

        Yes, and I am wondering if discussing the potential risk of chemo exposure to (others) sexual partners is a more accepting and a more motivating way to understand the importance of practicing safe sex rather focusing on the risk of infection to self…albeit very important too !!!

        1. Rose Miller

          Good point. This could be a good mode to transition into more sensitive areas.

      2. Jean Melby

        I agree as this isn’t something I was aware of either. I will think hard about how to add this to my conversations also.

    4. Pam Bolton

      All great information and comments. There is a lot of misinformation about chemotherapy exposure through bodily fluids and helpful to know what others are counseling patients about.

      1. Evelyn Joran-Thiel

        In the pediatric oncology world, we adamantly teach parents and AYA patients about protection from exposure to body fluids contaminated with chemo. Chemo usually clears the body within 48-72 hours after administration. This includes contact with saliva and perspiration. Linens soiled with semen or emesis during the 72-hour period should be laundered separately in hot water.

        1. Joan Coleman

          Evelyn — this is good information to keep in mind. Also excellent information to pass onto patients!

    5. Giselle Perez

      This is tremendously helpful to know, because it is not the first thing that comes to mind for me.

  2. Annie Huhnerkoch

    I respected how the therapist was realistic that young adults will likely continue to be sexually active during treatment and while she educated the patient on risks the patient needs to be aware of, there was no shaming involved!

    1. Alexandra Huffman

      From her facial expression, I think the patient appreciated the idea of finding a partner and connecting with someone emotionally and sexually during treatment.

      1. Ashley Moss

        I also appreciated how thoughtful the Social Worker was in framing the idea that patients can and do establish relationships and engage in sexual activity over the course of treatment. It subtly creates hope for patients who may be worried about relationships in the context of treatment.

        1. Jennifer Elvikis

          I agree, it is important for patient’s to feel that sense of normalcy while on treatment and to know that it is OK to date and have the ability to find a partner while on treatment and keep that conversation open. I like also that the therapist presented the opportunity for continuity of care for the patient to keep seeing her while on treatment and that she was very direct.

    2. Cheryl Smith

      Yes – be where they are and non judgmental. It is important to listen and not judge. They will not openly share with individuals if they feel that they are being judged.

      1. Caroline Dorfmam

        I completely agree! It is so important to be non judgmental when working with this population. This will help to establish repoire and to help build a relationship with the patient that will help to foster a continued space for open communication.

    3. Shari Neul

      I agree that providing patients a sense of normalcy and utilizing a non-judgmental approach is best. I am finding that our younger adolescents want to talk about either current relationships or entering into relationships that involve being sexually active. As another person posted, AYA patients will continue to engage in sexual activity, so it is even more imperative that we bring up the topic directly as a way to discuss safety of the patient and the partner, as well as to offer psychoeducation about related issues to help teens be more informed and normalize their experiences/concerns. As we all know, some teens are too shy/embarrassed to ask questions around this topic. Prior to participating in ECHO, I have had a few experiences where the teen will broach the topic but typically with anxiety and discomfort. I feel that as a psychologist, once we have established some rapport and trust, I have a responsibility to broach the topic and provide psychoeducation which takes the pressure off the teen to directly discuss their concerns OR it can result in the teen to have some anxieties alleviated and then a natural conversation can emerge wherein we can assist the teen regarding their unique needs. I am working towards incorporating ways to bring up this topic and provide psychoeducation with my teen patients.

  3. Beth Corcoran

    Looking at the question posed above as well, I think some things to consider outside of contraception include healthy behaviors to help avoid things like UTIs that patients could be more at risk for depending on their anti-cancer treatment as well as ways to help any sexual activity be as comfortable as it can be. For instance, any type of lubricants or preventative measures, particularly for females, if getting radiation may be something to reiterate if this was briefly discussed before radiation was started. Lastly, I think acknowledging that sex may not be something they are interested in at this moment given their circumstances, but how to discuss and navigate this with this partner may decrease their anxiety as well.

    1. Lacey Ballew

      Hi Beth,

      I like your insight on including healthy behaviors as something to consider (not in just heterosexual females). Assessing deeper into a patient’s relationship could play hand in hand with safe sex practices.

    2. Whitney Hadley

      I agree with the last point you made especially, Beth. I think there are a lot of unasked or unaddressed concerned with AYAs when it comes to sexuality – including whether or not they have any desire for sex at the moment. Many of the AYAs I’ve spoken with have questions about communicating this with their partners. Starting the conversation and zeroing in on healthy behaviors and tips for communicating within relationships can be very helpful for these patients.

      1. Karen Long

        I like this idea of teaching AYA’s how to not only think about their own sexual health but how to discuss it with their significant others. This is something that many of my AYAs are very uncomfortable doing

      2. Patricia Sullivan

        Hard enough to discuss with healthy aya’s and then you add cancer and it adds a whole new level of necessity.

        1. Heather DeRousse

          I agree Patricia – so many layers are present when talking with AYAs that have cancer. This discussion clip offered helpful ideas on how to approach the conversation and great insight.

    3. Brianne Baer

      A lot of great thoughts to address the multifaceted topic including UTI, comfort of sex and also anxiety and other emotions related to this. I think especially the anxiety and expectations and pressures are important to address considering their needs and wants may change going through treatment even though their partners needs have not. Great thoughts. Thanks for your insight.

    4. Jodie Jespersen

      Yes Beth! Normalizing the reality that loss of interest in sex during the initial diagnosis phase and ongoing is really important! Suggesting this and following up with any support/information that can be accessed if this becomes a challenge would be a great thing to include.

      1. Angela Yarbrough

        These are all excellent points. I think that discussing the fact that sex might not be a priority at some points during treatment is helpful for patients and partners.

    5. Amy Thompson

      Beth,
      I appreciated your take on the additional discussion of healthy behaviors, interventions such as lubricants, and the needed open-communication between partners to discuss the potential lack of interest in sex for a period of time.
      The discussion of lubricants and vaginal moisturizers are both important and necessary to clarify that they are not used for the same interchangeable purpose; if moisturizers are used as lubricants it can cause discomfort.
      Giving people the “permission” and encouragement to have open communication is so important as often the partners are going through their own difficulty with processing the diagnosis and impact on the sexual relationship; encouraging the couple to really talk can be so helpful for us to promote. Having this additional discussion with the patient can lead to further discussion of ways to be intimate without intercourse, which may be helpful.

    6. Krystal Robinson

      Excellent ideas. I also agree that discussion of UTIs, addressing or working through painful intercourse, and of course risk of STI infection is important.

  4. Tomoko Tsukamoto

    I agree with all the comments posted before me, but I also think that the social worker(counselor/therapist) did a wonderful job within her scope of care regarding the risk of infection to protect the patient. I liked how she provided her business card to stay in touch so that they can keep the dating conversation and the social worker can be available for any questions. I also liked how she explained to the patient that she would circle back to her care team to see if the patient needs to be referred to other resources. The patient would feel that she is supported by the entire care team not only for her cancer treatment but also for her personal life.

    1. Sara Zargham

      I very much agree with this comment! I think the social worker did a good job with generalizing what to be aware of and cognizant of. She never deterred the young adult from continuing her sexual life nor did she use any scare tactics. By giving her her card and info, she left the door open and encouraged the young adult to ask any questions and continue to become familiar with the extra precautions she will need to take.

    2. Shanna Logan

      agreed. She nicely demonstrated advocating for the patient by communicating back to the team. And provided a nice justification for why safer sex practices would be especially important at the moment in the context of her treatment. Giving her a card and inviting her to make contact as needed, alongside putting this topic on the table for discussion would help a young person to discuss sexual health later as needed.

    3. Loraine LLanes

      I agree with my colleagues that the work of the social worker was wonderful in terms of being not judgmental, respectful, giving clear information about the importance of protecting herself and the potential or future partner, from the infective diseases, and from the potential effects of the medication. Besides that, the SW gave her the opportunity of being in touch whenever she needs, which is crucial for supporting the patient during all the health process and for any arisen need of information. But I think that Ashely was almost all the time (it is what the video shows) in silence more than sharing what she really thinks about all the given information by the social worker. I think that it was a very sensitive information, considering the vulnerable heath status of Ashley and the potential dangerous of being more damaged because of her immune system is not working the same. So, I think it could be important to deeply explore the feelings of Ashley after receiving this information: maybe to get a feedback from her to be sure that she really understood the information, and that she is going to manage it in a right way. Knowing is very important for adjusting the behavior, but it is important too to manage fears, frustration, even panic, and senses of disability that could arise after getting this type of information.

  5. Nicole Herrera

    The social worker was appropriate in her language and really made it about safe sex practices. One thing that the social worker could have gone over was listing “safe sex practices” or methods. Are they different from the ones someone without cancer would use? Also, as Ashley is a lesbian (and only assuming that she would be having sexual experiences with a female-bodied person), the social worker should take this into more consideration and go into these safe-sex practices, especially as female condoms are not as widely used or even as commonly known, as male condoms are. It never hurts to ensure that someone is properly informed. You can’t assume that everyone knows what “safe sex” is or has been educated on those practices at all.

    1. Jill West

      100% agree, Nicole. I recently had an 18 year old patient who told me that her and her partner’s preferred safe sex practice was the “pull out method”, and she was realistically not informed about the alternatives. Additionally, I had a 19-year old patient in my office recently who was experiencing some remorse about a particularly risky sexual encounter and had convinced herself that she was pregnant. It was not until about 30 minutes into a tearful conversation that included problem-solving her options for determining whether she was pregnant that she said, “I’m sorry, I’m really emotional right now because I’m on my period.” I did not think to ask whether she had had a menstrual cycle since the risky sexual encounter, because I had (erroneously and naively) assumed that she knew that that would most likely suggest that she was not pregnant. Both of these examples, and both of which occurred relatively recently, highlighted to me how important it is to make sure that we are not assuming that euphemisms like “safe sex” – or even “sex” for that matter – are ubiquitously understood or universal.

      1. Rebecca Babb

        I really appreciate this comment, because now I will think to ask more quickly about LMP in a similar discussion. It is so true that we can never assume what the patient before us understands. We must always ask the questions, even if they seem obvious.

  6. Jessica Cook

    I agree with all of the comments posted before me. I think that the social worker did a good job in being approachable about the subject. I agree that delving a little deeper into and defining “safe sex practices” would be helpful as well as addressing any issues caused by treatment. I also think it extremely important to address that sex may not be of interest as well.

    1. Ashlea OShea

      I love that you addressed the need for specificities about safe sex. I also love that you noted that they may not want to have sex during this time. Addressing their likely decreased libido is important as well.

  7. Kristy Katsetos

    As a SW, I often receive questions about sexual health and optimal sexual safety practices during treatment from my AYA patients. I think it is really important to discuss safety and the differences in practice that they may need to attend to because of treatment. I was somewhat dismayed that this was left to the end of the conversation (after discussing follow-up and giving her a card), as it doesn’t leave the opportunity for the patient to ask questions in the same way that it might if she brought this up in a more open-ended way earlier in the session.
    Additionally, while the discussion on the immune system seemed like a good way to couch the issue, it felt too vague to be helpful or practical, and certainly could have used more specific terms, instructions, and discussion in order for the patient to feel empowered in her decisions after this session.

    1. Shanna Logan

      appreciated your insight and reading this Kristy. Thanks for your input.

    2. Christine Calafiore

      I agree with your observation, Kristy. I appreciate that the social worker did address it and did not show judgment. As we know, it can be uncomfortable to discuss this topic with patients and they may not be open to discussing it with you either. For this scenario, it may have been more beneficial for the patient to have a discussion earlier in the session about sexual health and reviewed it at the end of the session like she did in this clip. The patient was open to the topic and appeared willing to participate in the learning process. Talking about being safe is good but also knowing what could potentially happen if they’re not safe is good to know too.

    3. Brianne Baer

      I agree Kristy. At your institution do social workers initiate these conversations? Currently at our hospital, our physicians initiate these conversations upon diagnosis, but rarely are they discussed in depth again. One of our social workers and I are attempting to build up this aspect of our program and I would like some insight as to how social workers are utilized in this kind of program. Thanks for the insight in your post.

    4. Alisa Barber

      Kristy, thank you for pointing that out. I thought the same thing. If the patient did have more questions or concerns, they may not have felt comfortable bringing them up st the end of the conversation.

    5. Caroline Dorfmam

      I completely agree! Given the common time constraints we all face, bringing this up at the end of an appointment leaves little room for the patient to ask questions. I would have liked for this to be discussed earlier in the appointment.

  8. VichinsartvichaiP

    This is pretty straight forward session which is good. It might make the patient uncomfortable at the beginning but then it will be a lot easier for them to break the ice and talk more.

  9. Hayley Shaw

    I think this is such a realistic conversation that any of us could have with our AYA population. Its naive to think that teens and young adults are not going to be partaking in these activities. It is an important part of our AYAs life, and we should be educating on the ways to have sex safely, rather than assuming they won’t have sex at all. I think this video shows a way of making the conversation more personable and less scientific so that you can create a comfortable and trusting environment for your patient to discuss their sex life and ask any questions they may have. Knowledge is power, so giving our patient’s that power is so important.

  10. Ashlea OShea

    For a self-identified homosexual female, I would also remind her not share sex toys. Having a compromised immune system also means that you are at greater risk for STIs. Sharing sex toys is the same as having heterosexual intercourse without a condom. You are sharing bodily fluids without protection. This is a point that I think gets missed a lot by our heteronormative thinking. There are ways to prevent this via “male” condoms on shared sex toys, female condoms, or dental dams during oral sex.

    Heterosexual women also must ensure that they do not get pregnant, because almost every modality of cancer treatment is a teratogen and can very negatively affect the fetus, the mother, and the pregnancy as a whole. A heterosexual woman needs to think about her increased risk for STIs as well, so condom use. She would also benefit from dental dams if she is going to engage in oral sex. I would advise her not to engage in anal sex, especially. There are 3 main reasons. 1) The anus and rectum can tear more easily than the vagina which can cause excessive bleeding if her platelet count is low. 2) The anus and rectum are better at absorbing than the vagina so there is a greater risk of infection from bodily fluids. 3) If the anus or rectum tear, there is a huge risk of infection from fecal bacteria like E. coli.

    As a rule with our patients, we don’t perform any rectal probing and they are often on stool softeners to avoid this. This would be very important to talk about with homosexual men or men who have sex with men (MSM) as well.

    The last big point for every patient is to make them aware that we also need to protect, not only the patient, but also their partners. Chemotherapy is present in bodily fluids and can harm the partner if sex is unprotected.

    1. Elizabeth Lachat

      Ashlea, you brought up some great points…some I would have never thought of! I hope that courses such as this, are bringing more global awareness to psycho-sexual considerations so that more sex-specific resources can be offered to those undergoing cancer treatment.

    2. Lacey Ballew

      Ashlea, I learned a lot from your comment. I especially appreciate the consideration of protecting the partner as well.

    3. Jill West

      Ashley, I think what you highlighted here is incredibly important and informative. I think you outlined your ideas very clearly and in a straightforward manner, and many of our AYA patients would benefit from data like these being highlighted in a straightforward and nonjudgmental manner. Rather than asking, “Do you use sex toys?” or “Do you engage in anal sex” and covering that information only if the patient responds affirmatively, it makes more sense to me to present all of this information – again, in a clear and concise manner – so that patients can take away the aspects that relate to their current or future sexual practices. I also sincerely appreciate you pointing out that much of the information that gets covered is often done from a heteronormative perspective, and again, I like that what you are pointing out helps to combat that (and because of course these issues could also apply to same-sex or opposite-sex partners).

    4. Michelle Bronzo

      Ashlea– thank you for providing so much valuable information. I had not thought about anal sex and platelet counts, and this makes so much sense. It’s also so important to remind patients about caring for sex toys and making sure they stay hygienic. Thank you!

    5. Shari Neul

      I really appreciate all the specific and very important details you provided regarding safe sexual practices for whatever your sexual orientation or practices. Working primarily with teens and young adults, sharing these details (particularly linking for the patient how treatment affects bodily functioning–i.e., platelet counts, immunocompromised status–and, in turn, how sexual behavior and bodily functioning during cancer treatment introduces many more things to be aware of) can help patients better “think ahead” about and hopefully talk with their partner(s) prior to engaging in sexual behavior. Communicating with AYA patients about wanting to support them in creating / continuing having physically and psychologically safe sexual experiences is important. Having such details you can share with these patients can “open the door” to allowing them to feel comfortable in asking questions, considering options, and leading as “normal” of a life as possible while dealing with extraordinary circumstances.

    6. Sommer Brannan

      Ashlea! You have such great insight, many things I never thought of. It is so important as providers to stay educated and open to many different sex practices to make our patients and their partners feel safe.

    7. Raquel Begelman

      Ashlea, These are all great points, However, many nurses are not comfortable with their own sexuality and/or uncomfortable with talking about sexual activities. Thank you for great reminder for our patients.

    8. Amy Thompson

      Ashlea,
      I really learned a lot from your comment and appreciate you sharing you insight. You mentioned thing to consider that were so very important and could be easily overlooked. Great post!

  11. Elizabeth Lachat

    I think the social worker did a good job at keeping the conversation open, non-judgemental, and allowing some humor so that it didn’t feel so “clinical”. I also think the social worker was mindful of not using hetero-normative vocabulary so that the patient who identifies as a lesbian woman could feel more comfortable engaging in a discussion about her sexual health. This was clearly just an introduction to a discussion about sexual health, but I think it would have benefited the patient to send her home with some reading materials or a list of resources/websites that would enable the patient to explore the topic more on her own and come back with questions.

    1. Cathy Gibson

      That is a good point that I didn’t think about. The way she did bring it up was well done and didn’t lead to any assumptions of her sexual preference.

  12. Lacey Ballew

    It’s important for individualized care for each patient, and having a completed psychosocial assessment is a way to extend the individualized care to provide the proper education. I learned the most from this module and especially appreciated the BLISSS and BETTER assessment tools to further provide the level of individualized care.

  13. Cathy Gibson

    I did think she did a good job of talking to the AYA, but it almost seemed too casual. I think she should of expressed the importance of safe sex a little more clearly.

    1. Fred Wilkinson

      I see both pros and cons of the casual style. For some patients it may show comfort with the topic and open the door for further conversation. For others, it may come across as too familiar or not professional enough. The priority is being authentic.

  14. Linda Rivard

    I work in a pediatric oncology setting – survivorship. Our clinic is starting to see more young adults treated on pediatric protocols – this is not addressed enough or not at all. Pediatric protocols should start including this information if age appropriate. In survivorship – I also counsel on the importance of the HPV vaccine – there is a lot of misinformation on the vaccine. Very great conversation that needs to be brought in to the pediatric setting!!

  15. Jill West

    One thing that I am wondering more about is seeking parental consent for having these types of discussions in pubertal youth who are still minors. The video lecture for Module 6 touched on the necessity of obtaining consent, but did not give guidance about how to do so. In Dr. Klosky’s “bonus” video, he mentioned also that these conversations can be more difficult with many families, especially those who have conservative or traditional belief systems, but also did not really provide guidance on having such conversations. It has been mentioned in both Modules 5&6 that these conversations should occur with all patients, and in Module 5 that the conversation should occur, even, for instance, with a 12-year old, 1:1; alone with parent(s)/caregiver(s); and with the family together. Further, it has been mentioned a number of times that these conversations should take into consideration the patient’s developmental level (amongst other variables), but not necessarily considering or informing us about consent/assent issues in depth (except for young children being unable to provide assent, for instance). I can imagine that many of the more conservative or traditional parents/caregivers with whom I work would question providing their consent for this, and some may not be willing to provide consent. I am curious how others have handled or would handle this situation if it were to arise for them – that is, they want to have a discussion about fertility preservation and safe-sex practices with, say, a teenager, but the parents/caregivers do not provide consent.

    1. Joanna Patten

      I appreciate your comment, Jill. My understanding is that the age of consent varies from state to state with regard to different health information. In Washington state, the age of consent related to mental health and reproductive health is 13, while age of consent for all other health information is 18. That said, a more thorough assessment of “risk” and “developmental level” is important to ensure that risk prevention is also targeted appropriately. As a psychologist, I always request meeting with kids 12 and older alone to complete “a conversation about safety.” I assure parents that if there are any concerns about safety, that we will meet all together to follow-up on those concerns. In addition to assessing history of self-harm/suicidal ideation, I also ask about other things that most teens don’t want to talk about in front of their parents, including gender identity and sexual orientation, sexual behaviors/interactions/relationships, substance use, and exposure to violence. The way that children and teens respond to basic questions typically helps guide the conversation and inform the degree to which risk prevention conversations require more or less extensive detail.

  16. Angela Yarbrough

    The social worker did a good job of broaching the subjects which can be very uncomfortable to discuss. I also appreciate that she gives the option to continue to follow her routinely to discuss dating/sex/relationship issues as those issues will certainly arise as she moves forward with treatment and after completion of therapy.

  17. Bishop Chris

    I would have liked for the SW to ask the patient what her concerns were about sexual activity, safer sex, and intimacy during and after treatment? The topic seemed to be brought up at the end almost as a reminder more than a discussion item that the patient could ask questions about. In addition to more discussion and open ended questions having some written resources on safer sex/ sexual health for the patient to read would have been great. This is such a sensitive and private topic that providing literature as well as professionals to speak with seems like a good idea.

    1. Laura Petiya

      I agree. It would have been a nice introduction into what the patient may be worried about.

  18. Laura Petiya

    Considerations for a heterosexual female would include discussion of using condoms to prevent from STIs but also should include the use of other contraceptive methods to prevent pregnancy and periods during treatment. This should include hormonal contraception if it is not contraindicated and Lupron.

    I did like that during this example there was a point made about kissing and the patients immune system. This is usually not something that a healthy individual has to think about.

  19. Sommer Brannan

    I think as oncology providers sometimes we get so driven to therapy directed care that we forget about the reality that our patients are still living their lives in the midst of a diagnosis. We may have our pre-conceived notions about what type of lifestyle practices our patients should be conducting after diagnosis but we should all be realistic and have an open mind and educate first. I love how the social worker approached the subject more as a confidant rather than telling her what she should and shouldn’t do. I think it’s great that she took it as a chance to open up that she wanted to meet with her more often and that if she didn’t see her sooner rather later that to protect herself especially when she was immunocompromised.

  20. Brianne Baer

    As a pediatric oncology nurse we often have to find creative ways to discuss these topics with patients and their families. For a female in the AYA population often we discuss this topic one on one without family present to ensure the patient has the right environment to express themselves. We want to ensure that our female patients are being safe for themselves and their partners. This not only requires education on contraception to prevent pregnancy but also discussion on how to protect their boyfriends and husbands from chemo possibly excreted in the bodily fluids.

  21. Ashley Moss

    I appreciate the SW efforts to adjust her communication style to be consistent with the patient’s developmental level, though, as many others have brought up in the comments section, it would be critical that more information about “safe sex practices” be provided. This is especially true in the context of variability in sex/health education practices in schools, families, communities, etc. It is unhelpful at best, and potentially harmful at worst to assume patient’s understanding of what “safe sex practices” entails, especially in light of how sexual activity may differ across individuals, with different partners, etc. I would very much want to assess a patient’s behavior in the context of sexual activity, assess their knowledge, understand their sexual identity/sexual partner preferences, and adjust my discussion based on their specific needs.

    1. Jodie Jespersen

      I certainly felt as well that the SW was assuming the patient understood certain language and could draw conclusions that maybe should have been more clearly laid out.

  22. Devon Ciampa

    As much as I appreciate, and think its necessary, for the provider to bring up this topic, in my experience, this is usually a longer discussion. However, it did sound like the provider was planning to talk about it more in the future, but it sounded a little like an after thought and its an important area to discuss. “Safe sex practices” can be interpreted in various ways depending on different factors and it would be have been better to provide more specific information as well as some information for the patient to home.

    1. Christina Wilson

      I agree Devon. I think conversations are typically longer, and providers need to be more explicit in their education to patient regarding what safe sex practices include.

  23. Jodie Jespersen

    I appreciated how the social worker used a ‘light’ approach to this brief conversation, normalizing how sex/intimacy is a normal part of AYAs life and should continue to be regardless of their cancer diagnosis. I do feel that providing some written information on sex and cancer may have been helpful as well, as there is certainly more teaching and information that is necessary to provide our AYA patients including specific recommendations for protecting partners from chemo exposure, contraception use during treatments, etc. I think a helpful addition to this conversation may have also been to throw in that she may have less desire to engage in sex while going through her cancer experience and this is ok/’normal’ as well. I think opening up the conversation and allowing AYAs to know there is a place to have these conversations is key – and as health care providers really we should be the ones to initiate the conversation.

    1. Leah Clark

      I agree that we as health care providers really should be the one to initiate the conversation and I think we do a better job of that when they are starting treatment. I feel like I could do a better job “checking in” with them throughout the course of their treatment.

      1. Jennifer StClair

        Our physicians provide the info at diagnosis as well and the value of the info shared can vary greatly based on the physician’s and patient’s comfort with the topic of sexual health. I believe it would be valuable to have a system where this topic is revisited at regular intervals of treatment.

  24. Christina Wilson

    In considering things that would be appropriate for a heterosexual female patient undergoing treatment, it is important to counsel her on fertility, contraception, safe sex practices (to prevent sexually transmitted infections) as well as intimacy concerns and specific treatment related issues (i.e. previous radiation, surgery that could impact this as well).

  25. Lisa Cummings

    The question asked what considerations would I make for a heterosexual female regarding safe sex practices.

    First I would assess her current understanding of her state of fertility and her current interest in sexual activity (being explicit with types of sexual activity.) I would assess her understanding of “safe sex practices”. I would take into consideration whether this was occurring before, during or post treatment as that could effect some of the responses provided.

    Once I had the above information, I could determine the information needed. I would emphasize that which is most pertinent, but would provide written information for safe sex practices (to prevent STI) and pregnancy prevention based upon the methods that would be safe for her. Breast cancer patient’s are unable to use certain contraceptives. I realize the importance of some information will change as she enters or leaves relationships, and enters or completes treatment. Therefore, it will be important to have follow up with her during survivorship, if she is not already in survivorship. These conversations should not be held only once, but as needed throughout the trajectory of the disease process and growth of the patient. Unfortunately, that is only a dream at our current facility. I hope that our institution will consider developing a network of providers and processes that will better serve the AYA population.

  26. Raquel Begelman

    I agree that there are many assumptions in in this conversation and perhaps the SW already had many discussions of contraception and safe safe sex. However this is a great time to REVIEW about previous discussions and decisions that she has made based on fertility preservation, contraceptions and safe sex practices.

    SW did a great job about reminding the patient about protecting herself during periods of low counts to avoid sick people and kissing.

  27. Caroline Dorfmam

    I think this is such an important topic, and I am wondering how the group would approach this discussion if the patient was <18 rather than over 18? In speaking with colleagues, there have been times when an adolescent's parents are hesitant or become upset when the possibility that their child may be sexually active is brought up. How would others handle this discussion in the event that the parent does not want a provider to have discussions with their child about sex?

  28. Amy Thompson

    Considerations to assess for and discuss with a heterosexual female patient would include determining if she is in a monogamous relationship (married or LT relationship), if she has a S.O., or is she actively dating? We would need to discuss how she identifies, how important remaining sexually active is to her, along with her current activity level all to help guide a specific discussion based on her individual needs. Determining her relationship status and the significance of that status to her life will help guide the discussion specifically to the patient and partner if she has one.
    It will be important to determine what the patient already knows about safer sex practices, especially as they relate to protecting her while in treatment/in an immunocompromised state. It is important that she understands the risk of STIs and the risk of exposure (through kissing and sexual activity) to not only STIs, but also to illness that her body is not currently strong enough to fight. It will be important to discuss contraception methods not only for STIs, but also to avoid pregnancy (if this is a possibility in her situation) during treatment, as patient may have beliefs surrounding her fertility that may/may not be accurate. Precautions of avoiding sexual exposure to bodily fluids during chemotherapy is important to protect patient’s partner and is an important discussion to have with the patient to ensure her understanding and provide a safe place to ask questions.
    These are some of the considerations to discuss with a heterosexual female, while remaining open to listen to what information she is seeking and continue a LT discussion throughout her treatment course.

  29. Laurel Heath

    I really appreciated how she started it off with making sure the patient knew she was available if any concerns or questions came up. Something I would consider if counseling a heterosexual female would be age. If the patient was under 18, I would get parental consent to discuss sex and sexuality. I would try to understand what types of sexual activity the patient has or has not engaged in. If they are not sexually active, I would introduce risks to her health that could occur if appropriate contraception is not used so she could have all the best information for when she decides to become sexually active. I think the biggest thing is letting patients know that you’re available to talk about this topic at anytime because they may not be comfortable discussing it at the initial meeting.

    1. Elizabeth Weisbrich

      I appreciate your discussion Laurel and agree that it was important the social worker let the patient know she was available if she has any questions or concerns. As you mentioned, patients might just be meeting the healthcare professional for the first time and might not be comfortable discussing topics of sexual health at the initial encounter but might reach out later as they think of questions or might be more comfortable at the next meeting. I think developing rapport with patients can have a big impact on the experience.

  30. Leah Clark

    I’m wondering if anyone else has some experience with when to address safe sexual practice – We talk about it at the beginning of treatment and then of course we discuss it anytime the patient or partner brings it up during the course of treatment. But, we don’t have a set protocol for checking back in during treatment about this important aspect of their overall being and health. Anyone else have any experience or thoughts about this?

    1. Janelle Donjon

      I was wondering if there would be a way to add this to initial patient paperwork, but also some sort of prompt in the EMR to readdress at f/u visits?

    2. Elizabeth Robinsion

      You make a great point. I assume that our medical providers are re-assessing for this at each follow up visit; however, given the many things they are juggling, it’s easy to imagine it falling off their radar – or more likely, they have discussed it with patients who have expressed understanding, but as we know, patients need to hear the same information many many times especially in the weeks following diagnosis. Our psychosocial providers following closely after diagnosis would be assessing for this information as well and may have more time/attention to devote to it as we’re zeroing in on the social implications of treatment. Also, our pediatric patients at times tend to divulge more about “sensitive” topics to our social work and psychology staff. In my experience, it’s not uncommon that we are putting these topics back on the medical staff members’ radar to bring back up with patients.

  31. Janelle Donjon

    To me, this video seemed the most relaxed and comfortable. The Social Worker spoke to the patient at a level that reminded me of how she might be talking with a friend. I like how she added the part about not “making out” with someone who is coughing and sneezing and that she acknowledged these were things she probably did not have to think about before, but were important to think about now.

  32. Jennifer StClair

    Patients undergoing cancer treatment are at heightened risk of contracting STIs due to being immuno-compromised. Watch the social worker discusses the importance of safe-sex practices on treatment with her female breast cancer patient, Ashley, who identifies as lesbian. Think about how individualize discussions to a patient’s age, gender/gender identity, sexual orientation, sexual activity level/interest, and disease type and treatment. What would be considerations for a heterosexual female?

    A conversation about sexual health with a heterosexual female should include:
    – the conversation would vary depending on the patient’s age and history of sexual activity
    – encouragement for the consistent use of birth control methods to avoid unintended pregnancy during treatment
    – encouragement for the consistent use of birth control methods to avoid contracting a STI/STD
    – reminder of lower function of the patient’s immune system and the increased risk of contracting infections
    – discussion of potential impact of diagnosis/treatment/side effects on the patient’s sexual interest
    – discussion of potential physiological changes that impact a patient’s sexual abilities and/or feelings towards intimacy

  33. Elizabeth Weisbrich

    I appreciated that the social worker kept the conversation framed around safety and immunosuppression which is important for patients to know regardless of age, gender, sexual orientation, etc. I also agree with other posts that it is important to discuss not only the patient’s safety but the safety of their partner and also consider ways to prevent contraception during treatment and for a period of time after treatment. I’ve also done a literature review to determine best practices when it comes to chemo precautions after chemotherapy but it is a gray area. I think considerations I might keep in mind is that I most likely won’t know a patient’s sexual orientation so keeping an open mind, not making assumptions, and individualizing the education based on what they share and what questions the patient has.

  34. Connor Moltzan

    As a grad student and intern (for social work) who is new to having these talks with patients, these videos were great examples. It is still going to be a few weeks until I’m the person having these talks, but watching this and the lecture I felt my knowledge and confidence increase and that I’m near readiness for being in this role. This video, watching another social worker, has emphasized what my role can be. This whole training has opened up my eyes to the gaps in oncofertility and how all-encompassing oncofertility is: it’s much more than just fertility and preserving. Going forward I definitely want this to be a focus of my work.

    Reading everyone else’s insights about bodily fluids and condoms has been helpful. Regarding the former I’m sure being exposed to chemotherapy via fluids isn’t something most patients think of; I’d have to check the readings.

  35. Tiffany Edwards

    While I thought the social worker in this vignette did a great job in discussing what can be a very sensitive topic for some, I would have liked to see her engage more collaboratively with the patient during this exchange. In particular, asking the patient more about her thoughts concerning the matter, ask if she had any specific questions or concerns, of if this is an area that she had even given thought to or were concerned with. I also agree with many of the other participants regarding not only the health of the patient but also the health of any current or future partners.

    1. Ashley Van Hill

      I would agree that getting a feel for what the patient already knows and any specific questions they might have is even sometimes just a good way to begin the conversation. The patient’s input during an interaction is always important.

    2. Loraine LLanes

      I totally agree with you Tiffanny and Ashley, I posted up a comment related to yours.

  36. Ashley Van Hill

    Providing proper education to our immunocompromised patients regarding their risk for infection is so important. This includes the discussion revolving around STI’s. If it is an adolescent or young adult female, you can always start the conversation by talking about birth control and the need to prevent a pregnancy with chemotherapy. Considerations for a heterosexual female would be whether or not she is in a relationship or has more than one partner, if she is currently using some form of birth control and determining what that method is, and also taking into consideration the intensity of treatment and duration.

  37. Loraine LLanes

    I have enjoyed a lot this Module 6, first of all because is one of the field I more work with people with different chronic illnesses (endocrine disorder, neuroendocrine disorders, neurological disorders and some cancers in this area). It has been very important for me to see a real transdisciplinary approach while reading the different texts and articles suggested, and to learn much more about how to explore and especially how to promote de sexual health in AYA oncological patients.

    I would like to thank all the colleagues for your shared comments and suggestions about how to manage the topic in an individual way, considering the great human diversity (from gender, sexual orientation, age, religion, culture, health status, etc.). I totally agree with all of you.

    I would like to emphasize about one important aspect of the sexual health: and it is the purpose of human communication and affection implicit in all sexual expression. I think that one of the main aspects that we all must to stimulate when sharing with a patient and or his/her family about the sexual health is to protect this purpose, and to explore with them the multiples ways of achieving it: with or without a partner, with any gender or sexual orientation and identity, at any age, at any health status, and so on.

    In my experience it has been very interesting how some worries disappear or attenuate when the focus of the attention goes from just the bodies or the genitals, to the relevance of sharing, loving, communicating, and feeling validated as a human been, as a result of sexual relationships. Another positive effect I have encountered is a psycho social empowerment and the construction of the sexuality area as a space of enjoying, giving and receiving in multiple ways, not just bodily. This is just one aspect of the complex area of sexuality, but I consider it crucial, joined to the other discussed aspects (contraception, sexual protection, etc.), in order to promote sexual health especially in vulnerable populations, because it is transversal to all sexual expressions and because it legitimize the human sense of sexuality.

  38. Patricia Sullivan

    It is important as all have said to not forget to bring this up regularly to our aya population. It is unlikely they will bring it up on their own so asking and encouraging conversation is crucial to the health of our patients.

  39. Erin Murphy-Wilczek

    I agree with most of the comments above that the social worker did a great job engaging the patient as well as creating a safe non-judgmental space for the client to articulate thoughts and feelings around her post treatment concerns around intimacy. Perhaps materials on could have been provided with her as well as raising the topic of STI.

  40. Vogl Stacey

    I felt like this was a giggly filled conversation where the word sex was lighter than the other words. I watched it three times because I thought I imagined it. I know that this is another population but I also l know that this is a very important topic. I feel like this was an information given rather than an open discussion having. This can be a scary and embarrassing time for AYA and to know that someone is on your side is better than no one. I guess maybe I am looking at this a little differently and would have preferred to have her be a little more informative with a resource other than her card.

  41. Krystal Robinson

    The social worker did an excellent job in this clip. I believe it would also be important to process with the patient their baseline sexual health, and what their perception of changes in their body, sexual health, overall sexual desire, etc will be over the course of treatment and after. Then, provide psychoeducation accordingly. Other considerations would be type of sexual activity and providing education about safe sex practices among all types of intimacy, not just traditional sex practice. Also a discussion of not only STIs, but also pregnancy, UTIs, use of lubricants, treatment related fatigue and its impact on desire, as well as perception of self, and how that may change as a result of treatment or intimacy challenges. I would also talk with this patient about how to discuss these issues with their partner in a way that felt safe, comfortable, and open. We could even role play the discussion in the room to help the patient feel comfortable broaching the topics to their partner.

  42. Mary Caldwell

    Having worked in acute leukemia I was aware of educating patients about the risk of infection when counts are low. Some patients are alos very thrombocytopenic so we educate about trauma and bleeding, then possible infection secondary to the epithelial integrity being lost….One question I have heard discordant views on is the in regards to the chemotherapy in body fluids and risk of exposure to the partner. Does anyone know of good data on this to share?

  43. Christopher David

    I think her emphasis on immune system was good. She presented as very clear and compassionate in her approach.

  44. Remie Mills

    To be honest, when I discuss safe sex practice with patients I have been so focused on making sure the patient is not exposing their partner to chemotherapy, I have neglected to think about the risk for STI. This will definitely be in my teach material tomorrow! I don’t tend to shy away from these discussions. The timing has to be just right to get the patient to open up and discuss it. I would hate to embarrass them by mentioning it in front of their parents or grandparents (they are often present for chemotherapy teaching.) I have been lately taking time at the end of the teaching with the patient individually just to make sure I am addressing any sensitive topics. It is so important to be non-judgmental. Our patients deserve an open mind!

  45. Jennifer Elvikis

    I also feel like the therapist did a great job being direct with the patient about the information. Another consideration for patients that has come up would be contraception while on chemotherapy treatment. While chemotherapy always has a short term impact on ovarian reserve and most patients will stop cycling while on treatment, this is not a guarantee of inability to conceive. It is important that birth control is discussed (as the lecture mentioned, sometimes two different types) to prevent pregnancy while on treatment. It is never a guarantee that a patient couldn’t get pregnant while on treatment, so it is important to discuss sexual activity and practices with the patient to be sure that they are aware of the risks involved and potential to get pregnant while on treatment.

  46. Annie Lopez

    I agree, I feel that the therapist was very real and up front with the patient. I feel that being direct and “real” with our young adults is very important to helps them feel more comfortable in discussing this topic.

  47. Rebecca Babb

    One of the biggest things I have gained from this course is a comfort with talking about this with the adolescents and young adults in my practice. I have become more comfortable talking about fertility and sexual health with young people in the same straightforward way I talk about the myelosuppression that comes from treatment. I absolutely believe that AYA patients can sense if the clinician is uncomfortable with the topic, and that is less likely to lead to a productive discussion. I have definitely appreciated the video clip examples.

  48. Megan

    Has anyone had a married patient lose interest in their spouse after treatment? I have a patient who no longer wants to have sex with their spouse, but is attracted to other people.

  49. Elizabeth Arthur

    We are fortunate at our institution to have a sex therapist and a women’s sexual health psychologist who specializes in care after cancer. I refer patients to them if they are having relationship challenges, low libido, or sexual distress. I have not encountered a situation where my patient lost interest in a spouse but had interest in others.
    When thinking about ‘safe sex’, I also think about how sex has other meanings, such as currency. Some patients tell me that they have no desire for sex, and in fact it hurts after treatment, but they ‘get through it’ to please and satisfy their partner. They feel they want to do that in order to have continued support from their partner — which may be in the form of emotional support, financial support, etc. Our cancer patients may be vulnerable to this situation due to loss of independence after cancer treatment. Do they feel they must have sex, or endure an abusive relationship, in order to maintain their resources. Is this another form of ‘unsafe sex’?

  50. Eileen McMahon

    There are so many incredible comments in this discussion thread. I have learned not only from the Social Worker in the clip but from all of the participants! I really appreciate the various important aspects mentioned (immunosuppression and infection risk, chemotherapy risk to partners, safer sex risk and reviewing what safer sex actually is, addressing libido and that it may decrease or remain the same (everyone is different), that certain sexual practices confer more risk especially in an immunocompromised or haematologically compromised individual, and that coercive sex can still exist in this context). I also agree with some others that the way the Social Worker brought it up seemed almost like an afterthought and I myself would not be bringing it up at the very end after I had given my contact information, it would be closer to the beginning at a time when the patient could speak freely without feeling the session was over and there wasn’t the time to discuss.

Leave a Comment