Maturitas 66 (2010) 397–407

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Sexuality after breast cancer: A review

Gilbert Emilee ∗ , J.M. Ussher, J. Perz
Gender, Culture and Health Research: PsyHealth, School of Psychology, University of Western Sydney, Locked Bag 1797, Penrith South DC, New South Wales, Australia

a r t i c l e i n f o a b s t r a c t

Article history: It is widely recognised that women’s sexuality can be particularly complex after breast cancer, with sex-
Received 13 January 2010 ual changes often becoming the most problematic aspect of a woman’s life. The impact of such changes
Received in revised form 29 March 2010 can last for many years after successful treatment, and can be associated with serious physical and emo-
Accepted 31 March 2010
tional side-effects. The objective of this paper is to review research on breast cancer and sexuality from
the years 1998 to 2010. Research has documented a range of physical changes to a woman’s sexual-
ity following breast cancer, including disturbances to sexual functioning, as well as disruptions to sexual
Keywords:
arousal, lubrication, orgasm, sexual desire, and sexual pleasure, resulting from chemotherapy, chemically
Breast
Cancer
induced menopause, tamoxifen, and breast cancer surgery. Women’s intrapsychic experience of changes
Sexuality to sexuality includes a fear of loss of fertility, negative body image, feelings of sexual unattractiveness,
Material–discursive loss of femininity, depression and anxiety, as well as alterations to a sense of sexual self. The discursive
Intrapsychic construction of femininity and sexuality shapes the way women construct and experience their illness
Review and their body – leading many women to try to appear ‘normal’ to others post-breast surgery. Finally, the
quality of a woman’s partnered relationship consistently predicts sexual health post-breast cancer – rein-
forcing the importance of recognising the intersubjective nature of issues surrounding breast cancer and
sexuality. It is concluded that analyses of sexuality in the context of breast cancer cannot conceptualise the
physical body separately from women’s intrapsychic negotiation, her social and relational context, and
the discursive constructions of sexuality and femininity: a material–discursive–intrapsychic interaction.
© 2010 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
1.1. Toward a material–discursive–intrapsychic approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
2. Materials and methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
2.1. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
3.1. Changes to sexuality after breast cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
3.1.1. Material effects – changes to sexual functioning following diagnosis and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
3.1.2. Intrapsychic effects – how physical changes impact on emotions and body image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
3.1.3. Socio-cultural and discursive issues – the construction and experience of breasts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
3.1.4. Relationship context and sexual renegotiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406

1. Introduction

Breast cancer is the most common cancer in women world-

∗ Corresponding author. Tel.: +61 2 9772 6720; fax: +61 2 9772 6757. wide, and the second leading cause of cancer deaths in women
E-mail address: e.gilbert@uws.edu.au (G. Emilee). [1]. Fortunately, advances in breast cancer screening and treat-

0378-5122/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.maturitas.2010.03.027
398 G. Emilee et al. / Maturitas 66 (2010) 397–407
ments have led to increasing rates of survival, with 50% of women
surviving for 5 years post-diagnosis [2]. This has led to a focus
on quality of life issues in breast cancer research, with particu-
lar attention being paid to sexuality, as it is now recognised that
women’s sexuality can be especially complex after breast cancer
[3]. The impact of sexual changes can last for many years after
successful treatment [2,4], and are often associated with serious
physical and emotional side-effects [5]. The purpose of this review
is to examine the available research on breast cancer and sexuality,
and to highlight the importance of examining the material, discur-
sive and intrapsychic aspects of sexuality in the context of breast
cancer.
1.1. Toward a material–discursive–intrapsychic approach
Until recently, research examining the impact of breast can-
cer on sexuality was primarily conducted from a positivist–realist
paradigm [6], privileging the physical and material aspects of
women’s experience. Research focused on women’s ability to
engage in satisfying sexual activity, their satisfaction with the
frequency of that activity [6,7] and their level of their sexual
‘dysfunction’ post-breast cancer, where functional sexuality is con-
ceptualised as penile/vaginal intercourse [8]. Recent research has
shown, however, that engaging in sexual intercourse may not be
positioned as women’s primary focus of sexual adjustment and
satisfaction after a breast cancer diagnosis and that engagement
in sexual intercourse does not necessary equate to sexual satis-
faction [6]. Moreover, the primary focus on the material effects of
breast cancer on sexual behaviour assumes that a woman’s experi-
ence of sexuality is limited to its physical dimensions, negating the
influence of the social construction of sexuality and illness [9].
As a counterpoint to the primacy of positivism and realism,
research from a social constructionist paradigm has provided
insight into women’s lived experiences of changes to sexuality after
breast cancer (see [10]), and the ways in which socio-cultural dis-
courses shape the experience and interpretation of sexuality [11].
These social and cultural discourses teach us about what is ‘nor-
mal’ and ‘abnormal’, and profoundly impact on how we come to
construct our understanding of sexuality. However, within this
paradigm, intrapsychic and intersubjective aspects of women’s
experiences are often ignored, and the physical body is either posi-
tioned as the passive object of socio-cultural constructions, or it
is absent from explorations of lived experiences of sexuality after
breast cancer. In other words, the physical dimension of illness
can get neglected by social constructionists who tend to explore
the constructions and meanings ascribed to symptoms rather than
the materiality of the illness, the functioning of the body, and the
impact this has on a person’s life.
In order to address the limitations of both realism and construc-
tionism, this review will adopt a material–discursive–intrapsychic
perspective [12], which acknowledges the materiality of sexual
changes following breast cancer, women’s intrapsychic experience
of such changes within a relational context, and the influence of the
discursive construction of femininity and sexuality.
2. Materials and methods
2.1. Data extraction
The literature for the years 1998–2010 was reviewed using
the search engines Medline, PsychInfo, Scopus, and Sage using
the keywords breast cancer and sexuality/sexual functioning. The
years 1998–2010 were chosen for review, as a preliminary search
revealed that, in contrast to the proceeding decade (1987–1997)
[13,14], this decade has lacked a systematic review of literature in
the area of breast cancer and sexuality (for an exception see [15]
which has focused on younger women). Qualitative, quantitative
and mixed method studies that examined the physical and psy-
chological changes to the sexuality of women after a breast cancer
diagnosis were included, as were studies that discussed the ways
in which discourses shape a woman’s experience of her sexual-
ity post-breast cancer. Articles on ‘quality of life’ were excluded
because within these papers sexuality is typically assigned a more
marginal role. Studies were thematised and grouped into the
following broad categories: material effects of breast cancer on
sexuality, intrapsychic effects, socio-cultural and discursive aspects
of sexuality and breast cancer, and relationship context. Details of
individual studies are presented in Table 1 .
3. Results
3.1. Changes to sexuality after breast cancer
3.1.1. Material effects – changes to sexual functioning following
diagnosis and treatment
Research with Western women has found that the disturbances
to sexual functioning frequently reported following the diagno-
sis and treatment of breast cancer include: dyspareunia [16];
fatigue [8]; vaginal dryness [17–19]; decreased sexual interest or
desire [20]; decreased sexual arousal [21]; numbness in previ-
ously sensitive breasts [6]; difficulty achieving orgasm [8,16]; and
lack of sexual pleasure [9]. Research in non-Western cultures has
yielded similar results to those found with Western women. Dimin-
ished sexual desire, decreased orgasm, vaginal dryness, coital pain,
decreased sexual activity, [22] deterioration of the sexual relation-
ship, a loss of interest in their partner, sexual dissatisfaction, have
also been reported by Iranian, Turkish, and Chinese women after
breast cancer [23–25].
Research has also consistently shown that women with breast
cancer who undergo chemotherapy are at higher risk for sexual
dysfunction after treatment than those who have not received
such treatment [17,18,20,26]. Chemotherapy is the most signifi-
cantly associated with problems of arousal, lubrication, orgasm,
and sexual pain [27] – issues that are particularly common soon
after treatment [28]. Whilst research has found that radiation is
associated with feeling medically ‘invaded’ [5], it is not as likely
to be associated with decreased sexual desire as is chemotherapy
[29]. The impact of chemically induced menopause (CIM) on sexu-
ality has been associated with decreased sexual desire; pain during
intercourse; vaginal dryness; decreased sexual arousal; a severe
or complete loss of pleasurable sexual sensations; and decreased
frequency or intensity of orgasms [10]. The combination of loss of
sexual function, premature menopause and the associated symp-
toms of vaginal dryness tends to be particularly severe [17], and
can be devastating for young women who may also be concerned
with loss of reproductive opportunity [19]. However, the evidence
of a link between treatment with tamoxifen and sexual function-
ing is somewhat contentious. Ganz et al. [17] found no difference
in sexual functioning between women treated with or without
tamoxifen, whilst Mortimer et al. [30] found that some women
treated with tamoxifen complained of pain, burning or discomfort
with intercourse, vaginal tightness, hot flashes, and negative feel-
ings during intercourse. There has also been much recent research
examining the impact of breast cancer surgery on the sexual func-
tioning of women, though the results are mixed. Some have found
that women who received breast conserving surgery report fewer
problems associated with sexual interest than women who had a
mastectomy [18,31], and that women who have had a mastectomy
experience difficulty relaxing and enjoying sex, difficulty reaching
orgasm [28], as well as a decreased frequency of sex post-surgery
Table 1
Material, intrapsychic, and discursive approaches to sexuality in the context of breast cancer.
Study Aims
[16] Identify the treatment,
personal, interpersonal, and
hormonal factors in breast
cancer survivors (BCS) that
determine sexual function
[19] Evaluate quality of life and
reproductive health outcomes
in younger female breast
cancer survivors
[27] Measure levels of totals
androgen activity in breast
cancer patients and predictors
of sexual dysfunction
[30] Define incidence of sexual
dysfunction in women with
breast cancer treated with
tamoxifen
Sample and Design
55 BCS; age range 41–69; no
evidence of recurrent disease;
time since treatment (range 3
months–16 years)
577 women; average age 49.5
(range 30–61.6)
29 patients; average age 47;
time since diagnosis 37.5
months; since end of treatment
30 months; premenopausal
diagnosis of stage l or II breast
cancer; terminated adjuvant
therapy; 38% mastectomy, 72%
radiotherapy, 65.5%
chemotherapy
57 patients; average age 53
years (range 36–84); average
duration of tamoxifen use was
12 months (range 2–24
months)
Design
Survey: convenience sampling
between July and September
2002; through follow-up
wellness clinics
Survey: participants were
recruited via two tumour
registries
Survey: participants identified
through oncology clinic. Blood
samples
Survey: participants identified
through oncology centres;
vaginal smears also performed
Outcome measures
Depression, body image, sexual
functioning, marital
satisfaction, and demographics
Health-related quality of life,
reproductive history and
menopausal status, depression,
sexual activity
Sexual functioning,
relationship, depression,
quality of life
Depression, sexual history,
physical and psychologic
symptoms
Findings Material, intrapsychic,
discursive
• Poor sexual functioning Material
across desire, arousal,
lubrication, orgasm,
satisfaction, and pain
• Level of depression unrelated
to sexual arousal, lubrication,
orgasm, or sexual pain
• BCS with more relationship
problems reported poorer
arousal, lubrication, orgasm,
and sexual satisfaction
• Body image related to sexual
satisfaction
• Hot flashes and night sweats Material
increase with age
• Breast sensitivity most
G. Emilee et al. / Maturitas 66 (2010) 397–407
frequently reported in younger
women
• Vaginal dryness and
dyspareunia parallel changes
in menopausal status
• Younger women at greater
risk for sexual dysfunction
• Sex problems more prevalent Material
in BCS than health women
• Chemotherapy negative
effect on arousal, lubrication,
orgasm, and pain
• Relationship problems
predict lack of sexual desire
• Androgen activity did not
affect sexual functioning
• 54% of BCS complained of Material
pain, burning, or discomfort
with intercourse
• 32% noted vaginal tightness
more than 50% of the time
• 66% routinely used a vaginal
lubricant with intercourse
• Sexual desire, arousal, and
ability to achieve orgasm
unaffected
• 11% reported pain or
difficulty with intercourse
before adjuvant therapy, 44%
after
• Incidence of vaginal dryness
rose from 19% pre-adjuvant
therapy to 54% after
• All BCS noted hot flashes
more often
399

Table 1 (Continued. )
Study Aims
[8] Determine the frequency of
body image and sexual
problems in younger women
post-breast cancer treatment
[18] Identify variables predictive of
sexual health in breast cancer
survivors
[17] Examine health-related quality
of life (HRQOL), partner
relationships, sexual
functioning, and body image in
breast cancer survivors (BSC)
in relation to age, menopausal
status, and type of cancer
treatment
[20] Examine the psychosocial
problems faced by young
women with breast cancer
Sample and Design
549 women; 50 years or
younger at first breast cancer
diagnosis; 2–7 months
post-diagnosis
Sample 1: 472 women; average
age 52 (range 31–87). Sample
2: 662 women; average age 53
(range 29–83). 1–5 years
post-diagnosis; completed
adjuvant cancer therapy;
considered to be disease free;
no prior history of treatment of
other cancers
864 BSC; average age: 57.4
years (range 31–88 years); 1–5
years post-diagnosis;
completed adjuvant cancer
therapy; considered to be
disease free; no prior history of
treatment of other cancers
220 women; average age 43.5;
months since diagnosis range
from 4 to 42 (average 23)
Design
Survey: participants identified
through Cancer Registries
using Rapid Case
Ascertainment procedure
(RCA) between 1994 and 1997
Survey 1: participants
randomly identified through
Cancer Registries, medical
oncologists computerised
listings, and hospital/clinic logs
between 1994–1995; and
1996–1997 for Survey 2
Survey: participants randomly
identified through Cancer
Registries, medical oncologists
computerised listings, and
hospital/clinic logs between
1994 and 1995
Survey: recruitment via
hospitals; diagnosis of breast
cancer within the past 3 years;
aged 50 years or under at time
of diagnosis; at least 3 months
post-diagnosis
Outcome measures
Body image, sexual activity,
and sexual problems
Health-related quality of life,
body image, communication
and affection in partnered
relationships, sexual
dysfunction, sexual interest
and satisfaction, body image,
physical problems in the
partner
Health-related quality of life,
body image, communication
and affection in partnered
relationships, sexual
dysfunction, sexual interest
and satisfaction, body image,
physical problems in partner,
relationship of medical factors
to sexual functioning
Problem areas including:
marital; sexual, body image;
interaction with children;
dating; premature menopause;
pregnancy concerns; work
concerns; impact of physical
symptoms
400
Findings Material, intrapsychic,
discursive
• Problems with menstruation Material, intrapsychic
• Concern about weight
gain/loss
• Vaginal dryness
• Body image problems
• Problems with sexual
functioning
• Problems with sexual
interest, arousal, enjoyment,
relaxation, or orgasm
• Fatigue making sexual
relations difficult
• Concern about hair loss
• Sexual interest, dysfunction Material, intrapsychic
and satisfaction were
significantly related to
G. Emilee et al. / Maturitas 66 (2010) 397–407
menstrual and hormonal
status, history of
chemotherapy, presence of hot
flashes, vaginal dryness, or
partner sexual problems
• BCS level of depression Material, intrapsychic
similar to the general
population
• High level of physical
symptoms, especially
menopause related, compared
with healthy age-matched
controls
• Similar sexual functioning
compared with healthy
age-matched controls
• Greater risk of sexual
dysfunction in women less
than 50 no longer
menstruating
• Greater risk of sexual
dysfunction in women who
have received chemotherapy
• Lack of effect of tamoxifen on
sexual functioning
• Sexual functioning greater Material, intrapsychic
problem than lack of sexual
interest
• Body image moderate
concern
• Most bothersome symptoms
were hot flashes, weight gain,
unhappiness with appearance,
and vaginal dryness
[21] Describe variation in
menopausal symptom distress
and who women interpret and
manage symptoms
[9] Describe the sexuality of
sexually active and inactive
women following breast cancer
[22] Identify sexual dysfunction and
its related factors in Iranian
women post-diagnosis
[23] Assess psychosexual and body
image aspects of quality of life
in Turkish BSC treated by
mastectomy or breast
conserving treatment (BCT)
[24] Describe factors affecting
sexuality of women with breast
cancer receiving treatment
[25] Examine association between
broad range of characteristics
and sexuality among BCS in
Hong Kong
27 women who received
adjuvant therapy; average age
40.8 years; time since diagnosis
average of 4.5 (range 1–9)
863 BCS; average age 55.8;
diagnosed 1–5 years prior to
the survey
82 BCS; average age 49.9;
average time since diagnosis
2.5 years
112 BCS; average age 50 (range
31–65); 46% undergone
modified radical mastectomy,
54% BCT; average time since
diagnosis 48 months (range
24–143 months)
40 BCS; aged 40–49 years;
sexually active; 60% receiving
chemotherapy, 40% hormonal
therapy. 40 healthy women;
aged 40–49 years; sexually
active
200 BCS; average age 43.6; 99%
surgery, 69% chemotherapy,
63% radiation, 51% hormonal
therapy
Unstructured interviews:
participants identified through
oncology networks; data
collected from 1996–1998;
Grounded Theory approach
Survey: participants identified
through tumour registries, and
medical records
Survey: participants identified
through oncology wards and
private offices
Survey: participants identified
through case record review
Survey: participants identified
through oncology clinic
throughout 2003
Survey: participants identified
through oncology hospital
between 2005 and 2006
How women interpret,
appraise, and respond to
menopausal symptoms
Sexual function, sexual history,
sexual behaviour, dating and
efficacy of communicating
about cancer, menstrual
history, depression,
relationship satisfaction
Body image, sexual activity,
sexual relations
Psychosexual functioning,
body image
Sexual functioning, depression
Psychosocial well-being,
quality of life, body image,
sexual health, clinical factors
• Vaginal dryness, insomnia, Material, intrapsychic
menstrual cycle changes, hot
flashes, pain, changes in mood
and cognition, decrease in
libido, and weight changes
• On global measures, BCS Material, intrapsychic
levels of sexual functioning
and satisfaction similar to
same-aged, healthy women
• One third reported that
cancer had a negative impact
on their sexuality
• Discomfort touching breast
area
• Undressing uncomfortable
• Having sex naked was
uncomfortable
• Problems with lubrication
G. Emilee et al. / Maturitas 66 (2010) 397–407
when excited
• Genital pain
• Pain interfered with sexual
pleasure
• Decreased desire Material, intrapsychic
• Decreased vaginal lubrication
and sexual excitement
• Decreased orgasm
• Body image, marital
satisfaction, BCS level of
education, and perceived
husband’s attitude were all
related with sexual satisfaction
• Decrease in frequency of Material, intrapsychic
sexual activity
• Deterioration in sexual
relationships
• No difference between
mastectomy and BCT in sexual
attractiveness
• BCT associated with better
body image than mastectomy
• BCS had difficulty with Material, intrapsychic
arousal, orgasm, satisfaction
during treatment
• No difference in sexual desire
across BCS and healthy control
• When depression increased,
sexual satisfaction decreased
• Relationship issues at core of Material, intrapsychic
sexual distress
• Menopausal symptoms
linked to sexual problems
401

Table 1 (Continued. )
Study Aims
[29] Examine sexual changes
experienced BSC in Japan
following surgery, and their
information needs
[28] Examine sexual problems in
younger women diagnosed
with breast cancer during the
first year after surgery
[10] Explore women’s accounts of
how chemically induced
menopause (CIM) impacted
sexual functioning
[31] Evaluate survey on personal
satisfaction after different
types of breast cancer
treatment
[36] Assess the sexual function of
younger BCS and document
their interest in sexual
enhancement products
Sample and Design
85 BCS; age range from
20–60+; all were in a partnered
relationship; 34% radiation,
60% chemotherapy, 73%
hormone therapy, 6% BCT
209 women under the age of
50; average age 43 (range
29–50); 56% chemotherapy,
45% mastectomy, 47%
radiation, 28% hormone
therapy
30 BCS; average age 45 (range
31–57); 33% chemotherapy,
20% tamoxifen, 47% tamoxifen
and chemotherapy
207 patients; average age 49
(range 29–84). treated for
either BCT (40.1%), modified
radical mastectomy (MRM)
without delayed breast
reconstruction (52.2%), or
MRM with delayed breast
reconstruction (BR)
115BCS; average age 37.8
(range 27–66); average age at
time of diagnosis 35 (range
24–46); average age at time of
treatment completion 35.7,
35.7% still receiving treatment
Design
Survey: participants identified
through oncology clinic in 2005
Survey: baseline, 6 weeks after
baseline, then 6 months later;
participants identified through
hospitals
Semi-structured in-depth
interviews; responses from
cancer support groups,
community advertisements;
Thematic analysis; Grounded
Theory approach
Survey: participants identified
through their hospital surgical
management unit;
retrospective completion
between 2004 and 2005
Survey: responded at an
annual meeting in 2006
Outcome measures
Sexual activities, sexual
relationship
Sexual functioning, partner
relationship, quality of life,
body image
Experiences of sexual changes
associated with CIM;
emotional impact of negative
sexual changes
Body image, self esteem, and
sexual life
Sexual functioning
402
Findings Material, intrapsychic,
discursive
• Decrease in frequency of sex Material, intrapsychic
post-surgery 58.9%
• Decline in the quality of sex
• Chemotherapy significantly
correlated with decreased
sexual desire
• Decreased interest in sex
49.3%
• Chemotherapy related to Material, intrapsychic
sexual problems early after
surgery, but not long term
• Impact on chemotherapy on
menopausal status an
important factor affecting
sexuality
• Strongest predictor of sexual
problems was lower perceived
attractiveness
• Body image, partner
G. Emilee et al. / Maturitas 66 (2010) 397–407
relationship, or QOL not related
to sexual problems
• Decreased desire Material, intrapsychic
• Pain during sex
• Decreased sexual arousal
• Decreased
frequency/intensity of orgasms
• No changes to sexuality for
23%
• Positive change to sexuality
for 13%
• Worry, guilt, frustration, loss,
indifference
• 81.3% of BR reported having a Material, intrapsychic
satisfactory sexual life
compared with 37% of MRM
and 57.7% BCT
• 75% of BR reported that
surgery did not affect their
sexual life compared with
39.8% of MRM and 66.3% BCT
• 68.8% of BR had no reduction
in their sexual wellness,
compared with 32.4% of MRM
and 60.2% of BCT
• 47% very interested in using Material, intrapsychic
massage oils to enhance sex
• 76% very interested in using
personal lubricants to enhance
sex
• 42% very interested in using
dildos or vibrators to enhance
sex
• Sexual enhancement
products for sexual enjoyment,
to alleviate pain, increase
partner intimacy
[41] Examine the meaning of
sexuality to palliative patients
[6] Describe aspects of sexuality
that were important to women
after breast cancer treatment
[42] Explore how patients and
health professionals
communicate about sexuality
and intimacy in palliative
cancer care
[43] Explore how patients and
health professionals construct
sexuality and intimacy in
cancer
[44] Examine the information
concerns of spouses of women
with breast cancer
[5] Examine women’s specific
references to breasts and
breast cancer in women’s
illness narratives
[33] Explore how women talk about
their ‘breast(s)’ as a body part
that o longer exists, or has
been transformed by surgery
10 palliative patients; age
range 44–81; broad range of
cancer types
18 women; average age 50.5
(range 35–68); time since
diagnosis (range 6 months to
more than 10 years)
50 patients: age range 22–85;
broad range of cancer types;
time since diagnosis ranged
from less than 1 year to over 10
years
32 health professionals: range
from 1–3 years experience to
over 10 years experience in
palliative care
As above
39 men and women (30 BCS, 9
spouses); average age (range
34–76)
17 BCS; age range from 32 to
64; lumpectomy, mastectomy,
radiation, chemotherapy and
tamoxifen; 3 bilateral
mastectomies, 2 breast
reconstructions
38 BCS; average age of 58
(range 35–78); average age of
breast cancer onset 46.5 (range
22–69)
In-depth interviews:
participants identified through
hospices, hospital, and home
care service
One-to-one interviews;
responses to community
advertisements; Grounded
Theory approach
Semi-structured interviews:
health professionals &
patients; recruited from
hospital setting between 2002
and 2005. Textual analysis &
participant feedback
As above
Unstructured focus groups:
participants identified through
support group
In-depth narrative interviews;
snowball sampling from cancer
support groups;
Phenomenological analysis
Face-to-face – interviews (20);
written narratives (18);
purposively recruited using
snowballing and personal
referrals
Meaning and expression of
sexuality
Sexuality, role performance,
self-image, sexual functioning
Unmet needs, mismatched
expectations, communication
strategies
Shaping of sexuality and
intimacy in clinical settings
Information needs
References to the breast as the
site of cancer and radiation,
femininity, sexuality, body
image
Narratives of experiences of
breast cancer
• Sexuality provides and Intrapsychic
important emotional
connection
• Decreased frequency of sex
• Importance of sex to quality
of life
• Lack of discussion about sex
by health care professionals
• Barriers to expressing
sexuality in institutional care
• Altered sexual self Intrapsychic, discursive
• Loss of bleeding; loss of
sexual sensations; loss of
womanhood
• Sexuality more than the act
of sex
• Open communication needed Intrapsychic, discursive
by patients about sexuality and
G. Emilee et al. / Maturitas 66 (2010) 397–407
intimacy
• Caution health professionals
against making assumptions
about patients’ sexuality
• Sexuality is a ‘plastic’ concept Intrapsychic, discursive
• Sexuality assigned a marginal
role to treatment issues
• ‘Expert’ forms of
communication engaged in by
health professionals to the
denial of patients’ sexual needs
• Verbal information from Intrapsychic, discursive
health professionals important
for spouses
• Information needs of spouses
often overlooked
• Patient most often the source
of information for the spouse
• Four narratives emerged: the Discursive, intrapsychic
medicalised breast; functional
breast; gendered breast;
sexualised breast
• The breast is part of the self Discursive, intrapsychic
• Mastectomy is akin to having
something ‘taken’ away or
stolen
• Self-consciousness about the
visibility of the surgery site
403

Table 1 (Continued. )
Study Aims
[3] Examine women’s experiences
of embodiment after breast
cancer
[38] Examine changes to partner’s
sexuality post-cancer
[35] Examine factors that lead to
successful or unsuccessful
sexual renegotiation
post-cancer for couples
[37] Examine sexual attitudes,
functioning and behaviours pre
and post-breast cancer in
African American and White
women
Sample and Design
12 BCS; age range 42–77; 1–24
years post-diagnosis
156 partners of a person with
cancer; average age 57 (range
28–79); broad range of cancer
types; average time since
diagnosis 3.48 years
20 partners of a person with
cancer; average age; broad
range of cancer types; average
age 53 (range 29–76); average
age of partner 56 years
147 women (72 African
American and 75 white
women); 45% of white women
aged <50; 46% of African
American women aged <50;
49% white women vs 38%
African American women
received lumpectomy, 28%
white women vs 13% African
American women received
mastectomy with
reconstruction, 23% white
women vs 50% African
American women received
mastectomy without
reconstruction
Design
In-depth interviews and focus
groups; each woman
interviewed on 2 occasions;
phenomenological and
feminist approaches
Survey: participants recruited
via support groups, hospital
clinics, community
advertisements
In-depth interviews: purposive
selection from participation in
larger mixed methods study;
May-Dec 2006; Grounded
theory approach
In-depth interviews: purposive
selection from participation in
larger mixed methods study;
May–December 2006;
Grounded theory approach
Face-to-face interviews:
participants selected from
their participation in larger
mixed methods study
Outcome measures
Women’s stories of breast
cancer
Changes to sexuality, feelings
about changes, couple
communication, the caring
role, experiences with health
professionals
Accounts of changes to the
sexual relationship,
renegotiating the sexual
relationship, and the caring
role
Sexual history, sexual health,
sexual functioning
404
Findings Material, intrapsychic,
discursive
• Loss of breast Discursive, intrapsychic
stimulation/numbness
• Loss of bodily symmetry, and
need to manage appearances
• CIM constraints upon
sexuality—i.e., vaginal dryness,
pain
• Cessation or decreased Material, intrapsychic,
frequency of sex discursive
• Renegotiation of sexual and
non-sexual intimacy
• The caring role led to changes
in the dynamics of the sexual
G. Emilee et al. / Maturitas 66 (2010) 397–407
relationship
• Lack of discussion about
sexuality and intimacy form
health professionals
• ‘Alternative’ sexual practices’ Material, intrapsychic,
can be repositioned as the discursive
norm
• Couple communication
central to successful sexual
renegotiation
• Coital imperative acts as a
barrier to renegotiation
• Dominant discourses of
masculinity and femininity
shape heterosexual practices
• Cultural differences regarding Material, intrapsychic,
comfort with vaginal discursive
intercourse, bodily touching
and oral sex
 G. Emilee et al. / Maturitas 66 (2010) 397–407
[29]. However, others provide little evidence of a link between type
of surgical treatment and sexual functioning [26,32].
3.1.2. Intrapsychic effects – how physical changes impact on
emotions and body image
Whilst some women experience the changes to their sexuality
after breast cancer positively [5,10,17], the majority of evidence
shows that women with breast cancer experience a range of seri-
ous negative emotional changes as a result of disturbances to
their sexuality, including fear of loss of fertility, negative body
image, feelings of sexual unattractiveness [2], loss of femininity
[10], depression and anxiety [22] as well as alterations to their sex-
ual self [6]. Having to adjust to the removal of their breast or to the
alteration in appearance of the breast, loss of bodily hair, loss of
menstruation and childbearing capacity, feeling ‘old’ before their
time [6], concern about weight gain or loss, and a partner’s greater
difficultly understanding one’s feelings [8] can exacerbate these
negative emotional changes. Although some have argued that such
changes are more prevalent in women with pre-exiting anxiety,
depression, or sexual dysfunction [8,24], the potential emotional
impact of disturbances to sexuality is an issue for a large proportion
of women with breast cancer. Women who report negative changes
to their sexuality can also report worrying about what causes these
sexual changes, how long the changes will last, the extent to which
the changes may impact on their intimate relationship, and how
they can cope with the sexual changes.
Although the physical pain of breast cancer and treatment
diminishes with time, the experience of emotional pain may per-
sist as women grieve the loss of their breast or feel as though a
part of them has died [5]. In this vein, breasts are often positioned
as such a significant part of women’s sense of self that for those
who undergo a mastectomy having one breast is associated with
being ‘half a woman’ [33]. Research also shows that the strongest
consistent predictor of sexual problems after breast cancer is lower
perceived sexual attractiveness [28], and that women who have a
poor body image after breast cancer have lower rates of sexual satis-
faction and are more dissatisfied with their sexual relationship than
those with a positive body image [16]. Overall, however, it is sug-
gested that body image and sexuality are most significantly affected
by breast cancer during the first year of survivorship, and that body
image is more likely to be affected by mastectomy compared to
breast conserving treatment or breast reconstruction [8,17]. For
example, studies have shown that mastectomy patients are more
likely than women who have received breast conserving surgery
or reconstruction to dislike their appearance without clothes [23],
avoid looking at themselves in mirrors [5], and feel embarrassed,
ugly or self-conscious [33]. Women who receive breast conserving
surgery also report fewer problems with dressing, body image, and
being naked, than women who have had a mastectomy [31].
3.1.3. Socio-cultural and discursive issues – the construction and
experience of breasts
Research that has taken a social constructionist approach to the
issue of sexuality and breast cancer has been largely concerned with
the ways in which socio-cultural and medico-scientific discourses
shape a woman’s construction and experience of her illness and her
body. Langellier and Sullivan [5] examined how these discourses
are embedded in women’s ‘breast talk’, and found that women talk
about four different, but highly interrelated types of breasts. The
‘medicalised breast’ – constructed as a physical body part with dis-
ease; the ‘functional breast’ – constructed as a symbol of women’s
emotional abilities to nurture others; the ‘gendered breast’ – con-
structed as a symbol of femininity, beauty, and sexual desirability;
and the ‘sexualised breast’ which incorporates the look and feel of
the breast. These types of breasts are positioned in women’s talk
as ‘belonging’ not only to themselves, but also to their children,
405
husbands and lovers. This is exemplified in Thomas-MacLean’s [3]
interview study, where women who had undergone a mastectomy
described feeling a loss of bodily symmetry post-breast cancer
surgery that led them to ‘manage appearances’ or ‘hide their defor-
mity’ from others. Women have also reported wearing a prosthesis
to appear ‘normal’ to those in public, and to avoid being viewed
as asymmetrical or less than whole by husbands, male partners, or
children [33]. It has been argued that this is because within patri-
archal culture there is a focus on the breast as a ‘daily visible and
tangible signifier’ of a woman’s femininity for both herself and for
others [11]. A particular type of breast is both privileged and nor-
malised – the breast that is round, not sagging, and firm. The woman
with breast cancer is thus potentially positioned outside ‘normal’
femininity [34], which can have serious implications for women’s
sense of self, body image, psychological well-being, and sexuality.
3.1.4. Relationship context and sexual renegotiation
One of the most important and consistent predictors of sexual
health in women with breast cancer is the quality of their part-
nered relationship [10,18,22]. In fact, the quality of a woman’s
relationship is a stronger predictor of sexual satisfaction, sexual
functioning, and sexual desire after breast cancer than the phys-
ical or chemical damage to the body after treatment [16,25,27].
Research has shown that if women can renegotiate their sexual
practices when the type of sex they had pre-cancer is no longer
desirable or possible, they are more able to manage the changes
to their sexual relationship [35]. However, there is a distinct lack
of research that examines sexuality after cancer from a relational
and social perspective, with much of the existing research focus-
ing on the effects of breast cancer on the sexuality of the individual
woman. This negates the ways in which the experience of sexuality
is shaped by the relationship and social context, including how a
woman positions her partner post-cancer, how the partner posi-
tions the woman post-cancer, whether sex is positioned as taboo
in the context of cancer, and whether sex is openly communicated
about.
The issue of sexual renegotiation post-cancer is particularly
important as there is a dearth of research examining the strategies
used by women and their partners to alleviate their sexual concerns
following breast cancer [36]. It has been reported that many women
with breast cancer want information about how to use lubricants
to combat vaginal dryness [10], as well as how to use vibrators,
dildos or other sexual enhancement products as part of their post-
cancer sexual repertoire, and where to purchase these products
[36]. Health professionals can play a key role in ameliorating con-
cerns surrounding sexuality and intimacy after breast cancer [24],
offering specific suggestions related to sexual positioning or the
use of sexual enhancement products [36,37], concrete suggestions
about how to adjust to these changes and how to expand their sex-
ual repertoire [10], as well as information that may allow partners
to help women adapt to the changes. However, in a recent study
only 30% of couples who were coping with breast cancer had dis-
cussed sexuality with a health professional, suggesting that this is
an aspect of quality of life that is often neglected [38].
4. Conclusion
This review has demonstrated that there is compelling evidence
that breast cancer can have a significant impact on a woman’s
sexuality, both physically and psychologically, influenced by the
discursive construction of ‘normal’ sexuality and femininity and
a woman’s relationship context. Whilst each of these areas has
been considered separately, reflecting the existing research in this
field, it is important to acknowledge that they are irrevocably con-
nected. The physical body cannot be conceptualised independently
406 G. Emilee et al. / Maturitas 66 (2010) 397–407
from women’s intrapsychic negotiation, her relational context, and
the discursive constructions of sexuality and femininity in a par-
ticular socio-cultural context: a material–discursive–intrapsychic
interaction. Future research is needed within a framework that
acknowledges this inter-relationship, in order to elucidate the com-
plex and multi-faceted consequences of breast cancer on sexuality,
for both women and their partners.
The findings outlined in this review are of significance to clini-
cians, as sexuality is central to psychological well-being and quality
of life [39], and sexual intimacy has been found to make the experi-
ence of cancer more manageable and assist in the recovery process
[40], and to be central to couple closeness and quality of life in
palliative care [41]. Whilst cancer can have an impact on sexuality
across the whole range of cancer types [38], breast cancer has a
number of unique consequences because of the positioning of the
breast as a signifier of feminine sexuality, and it’s role as a source of
erotic pleasure and stimulation. This suggests that clinicians should
be particularly sensitive to the consequences of breast cancer for
women’s sexuality and body image, as well as the consequences
for their partners. However, research evidence suggests that sex-
uality is often not addressed with individuals with cancer, or with
their partners, and even when sexuality is discussed, it is not at a
level which is satisfactory to the majority of couples [38]. Research
reports of mismatched expectations and unmet needs in relation to
communication about sexuality between health professionals and
individuals with cancer [42,43], suggests that further education and
training of health professionals are required, in order that they will
be able to advise couples affected by cancer on issues of sexuality
and intimacy, and address their unmet needs in this arena [44].
Competing interests
The authors have declared that they have no conflicts of interest.
Provenance and peer review
Commissioned and externally peer reviewed.
Acknowledgements
This review forms part of a larger cross sectional project,
‘Multiple perspectives on sexuality and intimacy post-cancer,
leading to the development and evaluation of supportive inter-
ventions’ funded by an Australian Research Council Linkage Grant,
LP0883344, in conjunction with the Cancer Council New South
Wales, National Breast Cancer Foundation, Westmead Hospital, and
Sydney West Psycho-oncology Network. The chief investigators on
the project were Jane Ussher, Janette Perz and Emilee Gilbert, and
the partner investigators were Gerard Wain, Kim Hobbs, Sue Car-
rick, Gill Batt and Kendra Sundquist. Thanks are offered to Caroline
Joyce for research assistance and support.
References
[1] World Health Organisation, Breast cancer: prevention and control, avail-
able from http://www.who.int/cancer/detection/breastcancer/en/index.html;
2009 [web page; cited 10.12.2009].
[2] Bertero C, Wilmoth MC. Breast cancer diagnosis and its treatment affecting the
self. Cancer Nurs 2007;30(3):194–202.
[3] Thomas-MacLean R. Beyond dichotomies of health and illness: life after breast
cancer. Nurs Inquiry 2005;12(3):200–9.
[4] Andersen BL. In sickness and in health: maintaining intimacy after breast cancer
recurrence. Cancer J 2009;15(1):70–3.
[5] Langellier KM, Sullivan CF. Breast talk in breast cancer narratives. Qual Health
Res 1998;8(1):76–94.
[6] Wilmoth MC. The aftermath of breast cancer: an altered sexual self. Cancer
Nurs 2001;24(4):278–86.
[7] Hensen HK. Breast cancer and sexuality. Sex Disabil 2002;20(4):261–75.
[8] Fobair P, Stewart SL, Chang S, D’Onofrio C, Banks PJ, Bloom JR. Body image
and sexual problems in young women with breast cancer. Psycho-oncology
2006;15:579–94.
[9] Meyerowitz BE, Desmond K, Rowland JH, Wyatt GE, Ganz PA. Sexuality follow-
ing breast cancer. JMST 1999;25:237–50.
[10] Archibald S, Lemieux S, Byers ES, Tamlyn K, Worth J. Chemically induced
menopause and the sexual functioning of breast cancer survivors. Women Ther
2006;29(1/2):83–106.
[11] Young IM. Breasted experience: the look and the feeling. In: Leder D, editor.
The body in medical thought and practice. Dordrecht, Netherlands: Kluwer
Academic Publishers; 1992.
[12] Ussher JM. Women’s madness: a material–discursive–intra psychic approach.
In: Fee D, editor. Psychology and the postmodern: mental illness as discourse
and experience. London: Sage; 2000. p. 207–30.
[13] Moyer A. Psychosocial outcomes of breast conserving surgery versus mastec-
tomy: a meta-analytic review. Health Psychol 1997;16(3):284–98.
[14] Shover L. Sexuality and body image in younger women with breast cancer. J
Natl Cancer Inst 1994;16:177–82.
[15] Kinamore C. Assessing and supporting body image and sexual concerns for
young women with breast cancer: a literature review. J Radiother Pract
2008;7(3):159–71.
[16] Speer JJ, Hillenberg B, Sugrue DP, et al. Study of sexual functioning determinants
in breast cancer survivors. Breast J 2005;11(6):440–7.
[17] Ganz PA, Rowland JH, Desmond K, Meyerowitz BE, Wyatt GE. Life after breast
cancer: understanding women’s health-related quality of life and sexual func-
tioning. J Clin Oncol 1998;16(2):501–14.
[18] Ganz PA, Desmond K, Belin TR, Meyerowitz BE, Rowland JH. Predictors
of sexual health in women after a breast cancer diagnosis. J Clin Oncol
1999;17(8):2371–80.
[19] Ganz PA, Greendale GA, Petersen L, Kahn B, Bower JE. Breast cancer in
younger women: reproductive and late health effects of treatment. J Clin Oncol
2003;21(22):4184–93.
[20] Avis NE, Crawford S, Manuel J. Psychosocial problems among young women
with breast cancer. Psycho-oncology 2004;13:295–308.
[21] Knobf TM. The menopausal symptom experience in young mid-life women
with breast cancer. Cancer Nurs 2001;24(3):201–11.
[22] Garrusi B, Faezee H. How do Iranian women with breast cancer conceptualise
sex and body image? Sex Disabil 2008;26:159–65.
[23] Alicikus ZA, Gorken IB, Sen RC, et al. Psychosexual and body image aspects of
quality if life in Turkish breast cancer patients: a comparison of breast conserv-
ing treatment and mastectomy. Tumori 2009;95:212–8.
[24] Can G, Oskay U, Durna Z, et al. Evaluation of sexual function of Turkish women
with breast cancer receiving systemic treatment. ONF 2008;35(3):471–6.
[25] Zee B, Huang C, Mak S, Wong J, Chan E, Yeo W. Factors related to sexual health
in Chinese women with breast cancer in Hong Kong. Asia Pac J Clin Oncol
2008;4:218–26.
[26] Thors CL, Broeckel JA, Jacobsen P. Sexual functioning in breast cancer survivors.
Cancer Control 2001;8(5):442–8.
[27] Alder J, Zanetti R, Wight E, Urech C, Fink N, Bitzer J. Sexual dysfunction after
premenopausal stage I and II breast cancer: do androgens play a role? J Sex
Med 2008;5:1898–906.
[28] Burwell SR, Case DL, Kaelin C, Avis NE. Sexual problems in younger women
after breast cancer surgery. J Clin Oncol 2006;24(18):2815–21.
[29] Takahashi M, Ohno S, Inoue H, et al. Impact of breast cancer diagnosis and treat-
ment on women’s sexuality: a survey of Japanese patients. Psycho-oncology
2008;17:901–7.
[30] Mortimer JE, Boucher L, Baty J, Knapp DL, Ryan E, Rowland JH. Effect of
tamoxifen on sexual functioning in patients with breast cancer. J Clin Oncol
1999;17(5):1488–92.
[31] Markopoulos C, Tsaroucha AK, Kouskos E, Mantas D, Antonopoulou Z, Karvelis
S. Impact of breast cancer surgery on the self esteem and sexual life of female
patients. JIMR 2009;37:182–8.
[32] Rogers M, Kristjansen LJ. The impact on sexual functioning of chemotherapy-
induced menopause in women with breast cancer. Cancer Nurs
2002;25(1):57–65.
[33] Manderson L, Stirling L. The absent breast: speaking of the mastectomied body.
Feminism Psychol 2007;17(1):75–92.
[34] Spence J. In: Morley D, editor. Cultural sniping: the art of transgression. London:
Routledge; 1995.
[35] Gilbert E, Ussher JM, Perz J. Re-negotiating sexuality and intimacy post-cancer:
the experiences of carers in a couple relationship with a person with cancer.
Arch Sex Behav; DOI: 10.1007/s10508-008-9416-z.
[36] Herbenick D, Reece M, Hollub A, Satinsky S, Dodge B. Young female breast
cancer survivors. Their sexual function and interest in sexual enhancement
products and services. Cancer Nurs 2008;31(6):417–25.
[37] Wyatt GE, Desmond K, Ganz PA, Rowland JH, Ashing-Giwa K, Meyerowitz
BE. Sexual functioning and intimacy in African American and White
breast cancer survivors: a descriptive study. Womens Health 1998;4(4):
385–405.
[38] Hawkins Y, Ussher JM, Gilbert E, Perz J, Sandoval M, Sundquist K. Changes in
sexuality and intimacy following the diagnosis and treatment of cancer: the
experience of informal cancer carers. Cancer Nurs 2009;32(4):271–98.
[39] World Health Organisation. The world health organisation quality of life assess-
ment (whoqol). Soc Sci Med 1995;41:1403–9.
[40] Schultz WCM, Van de Wiel HBM.Sexuality, intimacy and gynaecological cancer.
JSMT 2003;29:121–8.
 G. Emilee et al. / Maturitas 66 (2010) 397–407 407

[41] Lemieux L, Kaiser S, Pereira J, Meadows LM. Sexuality in palliative care: patient
perspectives. Palliat Med 2004;29(s):121–8.
[42] Hordern AJ, Street AF. Communicating about patient sexuality and inti-
macy after cancer: mismatched expectations and unmet needs. MJA
2007;186(5):224–7.
[43] Hordern AJ, Street AF. Constructions of sexuality and intimacy after cancer:
patient and health professional perspectives. Soc Sci Med 2007;64(8):1704–18.
[44] Rees C, Bath P, Lloyd-Williams M. The information needs of spouses of
women with breast cancer: patients’ and spouses’ perspectives. J Adv Nurs
1998;28(6):1249–58.