Shining a light on LGBTQIA+ sex and cancer

Talking about sex can be uncomfortable. If you are LGBTQ+ you may have at some point been on the receiving end of personal questions from others about who does what, with whom and how. This level of curiosity from people outside the community can make the experience of talking about sex feel intrusive. However, talking about sex is important, especially when we think about cancer. Your sex life may be affected by your treatments and it's important that you are able to discuss these changes with your partners and cancer care team.

Ask for a private space to talk

Starting a conversation about sex with a nurse or doctor might feel strange, especially if you are in a public area like a ward or outpatient department. If you are struggling to open up about things in those environments you can always ask for a private space to discuss personal matters. Alternatively, try asking if you can email them later with your questions. This gives you time to plan what you want to talk about and be sure you’re not forgetting anything. Remember, it’s completely okay to tell your doctors the gendered/de-gendered language that you use for your body and ask them to do the same.

‍

‍

Discuss your fertility options

Before starting treatment, anyone who is fertile and is considering having a family in the future should be given the opportunity to discuss their options. If you feel that your clinical team is not giving you the same level of consideration as a straight person, consider raising this with them if you feel safe to do so. If you would rather, you can also speak to someone else in the department. If you feel that you are not being listened to or supported, contact the patient advice and liaison service (PALS) in your hospital to raise the issue.

Prioritise good communication, co-operation and consent when it comes to sex

Being diagnosed with cancer can change the way we see or feel about our bodies, making it harder to share it with others. Whether this is a result of physical changes, fatigue or a low mood, many things can get in the way of engaging in or enjoying sex.

"I am living with colorectal cancer.... I am living with pouches attached to my abdomen… and I have got plenty of scars... The impact with the new image ,especially sexual partners is very challenging in terms of showing myself to them completely naked. I did not get to that point yet but I'm working on it. So probably in the future, I will be able to show my new body to somebody else, and be proud of it.” - Anonymous trans patient

When discussing sex with current or new partners, it is important to prioritise good communication, co-operation and consent. Don’t be afraid to talk about what usually works for you, what doesn’t and what has changed. Discuss setting boundaries based on your interests, confidence or comfort to make it easier to relax into the moment. This might be useful if there is a particular part of your body that is sensitive after treatment or that you don’t want to be touched, such as radiotherapy sites or Hickman lines. The same applies for any psychological trauma you have related to your body after treatment. This can also be an opportunity for your partner to share any fears or concerns they have about having sex that otherwise might have been misinterpreted.

Think about the environment you're creating

If you are struggling to get in the mood, think about the environment that you are creating and if this is helping you lead into sex. Are you feeling turned on or feeling obligated? Are you picking a time of day where you have enough energy? Are you making time for intimacy? Sitting with a partner and openly discussing sex gives you an opportunity to connect without the expectation of it leading into anything straight away. It can provide a safe space to discuss boundaries, consent and preferences so that when you do have sex later, you are both aware of eachothers needs and are on the same page. Remember, consent is an ongoing process. Just because you have discussed something prior, it does not mean you have to go through with it. You can withdraw your consent at any time for any reason, even if you have already begun to have sex.

Sometimes the pressure to perform can get in the way of enjoying the moment. These feelings are often based on social constructs that give us an expectation of what sex “should be”. Consider thinking of sex as a buffet of activities and pleasures across your whole body and remember, non-penetrative sex is sex. For some cancer patients with targeted treatments, penetrative sex may become more uncomfortable or difficult to acheive. Changing the way you have sex and exploring new options for pleasure with a partner can be a way to simultaneously deal with the effects of cancer whilst also bringing you closer together.

Discuss how sex might be different

Some men after treatment for prostate cancer may struggle to keep a firm erection which makes anal sex more difficult. Pleasure from the prostate after treatment may also be reduced or absent which is important for passive or versatile partners. Anal and bowel cancer treatments can also make anal sex more difficult or no longer an option. It is important to talk openly with your partner about these changes before, during and after treatment. You may need to discuss how sex will be different and find new ways to be intimate. These conversations might include ideas like switching roles, non-penetrative sex and introducing sex toys amongst other things.

These conversations should also factor in which type of prostate cancer treatment you are receiving as this will affect how long you will need to abstain from receiving anal sex. This time frame can vary, needing six weeks for surgery, two months for external beam radiotherapy and six months for permanent seed brachytherapy. People who have had their prostate completely removed will be unable to ejaculate, also known as a dry orgasm. This can also happen after radiotherapy. For men sleeping with men, this might change the way that you approach the concept of climax. Try discussing with your partner what the goals of sex are to you. It might also help to practice some mindful masturbation and get comfortable with any changes to your orgasm or ejaculation so you are less self-conscious about this in front of partners.

“Some people just put up with the side effects because they want the cancer gone but sex is an important part of life and your relationships.” - Sean, Consultant Radiographer

‍

Advocating for yourself and your pleasure is important

If you have a vagina you may have been given vaginal dilators after radiation treatments around the groin or pelvis. Dilation therapy may be triggering if you are not used to having anything in your vagina due to personal preferences, sexual practices or gender dysphoria. Although this form of therapy is important to avoid excessive scarring or shortening of the vagina, it may seem that your healthcare professionals are prioritising the concept of penetrative sex. Your attention may be more focussed on any changes to clitoral sensitivity. It is important that you discuss treatment goals with clinicians so you can resolve any confusion related to your care. If you are not out to your health team, this may feel like a difficult conversation to have but advocating for yourself and your pleasure is important. If you are taking testosterone, you may already have experienced changes to your vagina that makes insertion more difficult or uncomfortable. It’s therefore important to make sure that you are using a good amount of lubrication when undergoing dilation therapy.

Using lube can help to make sex safer and more comfortable after treatment. A good quality water based lube is the least irritating for the body. Silicone based lubes are longer lasting and can be used in wet environments like the shower but they can degrade silicone sex toys, so pick the right lube for kind of sex you plan to have. You definitely don’t want to spill silicone lube though so consider buying it in a pump bottle! In addition to choosing the right lube free of potential irritants, patients experiencing vaginal dryness or discomfort should avoid harsh soaps, perfumes, problem fabrics and cheap sex toys. Personal preference also plays a large part in what lube you will end up using, so head to a professional sex shop and see what is available. If you’re nervous to go alone, take your partner or a friend. There will often be testers and the staff will be more than happy to help you find what you’re looking for. Don’t be shy, it’s what they’re there for! Try browsing the rest of the store for anything else that may be exciting and can encourage a positive environment for sex.

Consider setting boundaries for hookups via messages before meeting

Navigating hookups might seem daunting after treatment if cancer has affected your confidence or energy for meeting new people. You might also be weighing up whether you want or need to disclose your health and when is the best time to do so. This will be a decision based on multiple factors and is going to change from person to person and what you are looking for. If you are feeling conscious about how treatment has changed your body or the way you have sex, consider discussing and setting boundaries via messages before meeting.

Be mindful however, meeting new partners for sex always carries a potential risk, so continue to take all the usual precautions to stay safe when doing so. If you decide that you do not want to tell people about your health, this is also completely okay. You do not owe your story to everyone you meet. It may be that it is not immediately important to you if you’re just hooking up or it might be that you are looking to date and want to broach the topic later on. Developing trust between yourself and someone else can be a strong foundation for feeling safe in disclosing sensitive information. If you need additional support navigating this, contact a local psychosexual or relationship therapist who can guide you with strategies and support.

Kink can help to reimagine ways of having sex

Exploring kink can be another way to reimagine the way you are having sex. It can help with reestablishing or adjusting sexual roles with a partner or give you new options for masturbation. Finding new ways to be aroused can help you navigate any physical changes or loss of sensation as a result of treatment. The kink community also has a developed understanding of consent that may provide you with tips for communication and seeking continuous consent with a partner during sex. Polyamory can open up new options of intercourse and members of this sex-positive community can help you navigate how to do this safely.

If you were previously engaging in chemsex, cancer may have put a stop to this. This means that you will be dealing with the adjustment to sober sex on top of cancer related concerns. Chems can provide a fast-track to feeling aroused or in the moment and can sometimes cover for when we’re feeling uncomfortable or are dealing with shame. If you are struggling with these issues, reach out to a psychosexual therapist who will be able to guide you towards a healthier and safer sex life as you move forward.

Leave assumptions at the door

If you are trans, are having sex with someone who is trans or are both (T4T) it is a good idea to leave assumptions at the door when navigating sex and each others' bodies. By approaching an encounter without prejudgments it is easier to have an open and honest conversation to discuss intimacy, pleasure and setting expectations and goals for sex. Entering sex without assumptions does not mean being completely passive however. Showing enthusiasm to your partner during sex with appreciation for and agency in their pleasure is important. Expecting a trans partner to guide you in every action may be read as hesitancy and could be misinterpreted as unwillingness or discomfort.

Communication is key

Communication is important because it not only helps you describe your pleasure and how you seek it, but it also allows for boundary discussion including how we talk about or label our bodies. This can also affect whether the sex you’re about to have will be gender affirming and a positive experience. Not shying away from these conversations demonstrates mutual respect and contributes to a sex positive environment. Not every question will have an immediate answer, but the conversation is key in moving forward together.

This level of open communication is also important if things don’t work out. If any person loses interest, be sure not to ghost each other and instead have a conversation as to why it has ended, even if the explanation is brief. This lets someone understand why things didn’t work and helps them to not make assumptions about whether it is related to them being trans or having cancer which they may otherwise internalise and could become a barrier to sex or intimacy in the future.

Cancer can create very real barriers to pleasure

Gender dysphoria or internalised transphobia can make it harder to find comfort in sex. You may be feeling dissociated from your body or may have trauma associated with particular parts of yourself which make it harder to assign pleasure to them. Cancer treatment can also bring trauma so a potential combination of the two may feel debilitating. Certain cancers will also mean that you have gone through an incredibly gendered service and you may still be recovering from that experience physically and mentally. As a trans person and as a cancer patient, you may also be taking certain medications that affect your hormones and desire to have sex. These are all very real barriers to pleasure.

But it's possible to reconnect with your body...

A potential way to navigate these experiences and their associated trauma is through mindful masturbation. Through seeking pleasure by yourself you can attempt to reconnect with your body before trying to share it with others. Trans positive and ethical pornography such as The Crash Pad Series may help in reestablishing sex’s assumptions and the expectations that are normally shown in mainstream sexual media. Sex toys can also help with autoerotic play and finding new ways to explore your body. Toys that feature a high level of stimulation may help with overcoming reduced sensation as a result of surgical or hormone treatments. Two great non penetrative options are the pressure wave clitoral stimulator or a Doxy wand which has many attachment types. These toys can also be used with other people.

“It is ok to allow yourself to enjoy parts of your body that don’t bring you joy” -Emma, trans woman

It's ok to seek support

If you feel like you want to talk to a professional about sex related issues you can discuss this through your treatment team or arrange it independently. You can self refer for psychosexual support at most sexual health centres without ever needing to involve your cancer team or GP. Available services may vary depending on your location, so check your local sexual health centre’s website or email them to find out how to make an appointment. Not all psychosexual therapists deliver relationship therapy so be sure to understand which issues you want to discuss so you can seek the correct support.

Sex is valid, healthy and human

There are multiple ways that cancer can affect our ability to confidently and comfortably engage in sex. When we take a broad look at our LGBTQ+ community, this can seem even more complex. The important take home message is that sex is a valid and healthy, human behaviour. It is completely okay to want information or support on how to continue having sex during or after treatment, no matter where your cancer is situated. Between your cancer care team, psyschosexual services and our charity you already have a network of resources ready to support you.

Don’t be afraid to reach out.

_______________________________________________________________

Written by: Stewart O'Callaghan (they/them) - Founder & Director of OUTpatients

Thanks to: Philip Kelly (he/him) - Clinical Psychologist in HIV + Sexual Health, Royal London Hospital

Sean Ralph (he/him) - Consultant Radiographer in Prostate Radiotherapy, Leeds Cancer Centre

Emma Frankland (she/her) - Artist & Writer

‍

Find your local NHS sexual health information and support:

LGBTQ+ sexual health and support services in London:

Dean Street / 56T

CliniQ