ALTHOUGH AMERICAN culture is saturated with overtly sexual images and suggestive advertising, one place where most of us never hear about or talk about sex is in our doctor's office.

Last month, the Institute of Medicine released a hallmark report, "Cancer care for the whole patient: Meeting psychosocial health needs." This document calls for a new standard of cancer care that tackles a broad range of often unaddressed psychosocial issues, such as coping with accompanying mental health issues, work and financial disruptions as well as caregiver burden. However, sexual functioning is barely mentioned.

Even though more than one in three Americans will face a cancer diagnosis at some point in their lives, rates of disease-free survival after five years continue to grow. With more than 10 million long-term cancer survivors in the United States, attention is increasingly turning from avoiding death to quality of life.

According to Leslie Schover, a leading authority on cancer and sexuality at the University of Texas M.D. Anderson Cancer Center, at least half of breast, prostate, colorectal or gynecological cancer survivors are left facing sexual dysfunction as a significant, enduring side effect of treatment. Changes in body image, erectile dysfunction, pain, and loss of desire are exceedingly common difficulties and nobody seems to be talking about them. However, like the discussion of sexual functioning missing in the Institute of Medicine report, conversations about sex and intimacy within the healthcare setting are similarly absent for many cancer patients at every step, from diagnosis through long-term survivorship.

For patients who have already had to endure the physical, emotional, and financial challenges of managing a cancer diagnosis and treatment, the additional loss of sexuality and intimacy is not only painful and embarrassing, but can also become an insurmountable challenge.

Surgery, chemotherapy, radiation, and hormonal therapies all have the potential to result in dire consequences that can be both immediate and long lasting. Mastectomy, colostomy, and other physical disfigurements after surgery must affect one's sex life. Hormonal therapy for prostate cancer depletes a man of testosterone. Such a therapy may be life-saving, but is devastating to a man's sex life.

The majority of prostate cancer survivors find themselves struggling with erectile dysfunction and severe lack of desire for years after treatment, burdened also with feelings of being damaged and depressed. In addition to the complex issues involved with body changes, possible infertility, and body image after breast surgery, many young breast cancer survivors feel wholly unprepared for the impact of chemotherapy-induced early menopause, which can have a powerful and negative effect on sexuality including pain, loss of desire, and decreased physical response.

Although the consequences of cancer treatment on sexuality are often quite significant, the good news is that a variety of helpful treatments and practical solutions exist, many of which are easy to use and readily available. Brief sexual rehabilitation counseling has been shown to be enormously beneficial to both individuals and their partners.

However, somebody has to start talking about sex. Few medical and mental health professionals are ever taught how to talk to patients about sex and many health professionals avoid talking about sex because it feels like too "risky" a topic. Because of this, patients and professionals often find themselves in an awkward dance in which neither partner knows who should lead or what to say. Not surprisingly, the doctor's office often remains a sex-free zone.

Considering the fact that sexuality is such a central, life-affirming element of human experience, it is tragic that we have done such an inadequate job of integrating the treatment of sexual functioning into patient care.

If we strive to integrate talk about sexuality and intimacy into cancer patient care, we need to start educating medical and mental health professionals how to talk about sex in a frank and skilled manner. It's time to start talking about sex - only then can we attain our mission to truly address the cancer patient as a whole person.

Sharon L. Bober is a psychologist with the Perini Family Survivors' Center of the Dana-Farber Cancer Institute and an instructor in psychiatry at Harvard Medical School. Elyse R. Park is a psychologist affiliated with the Institute for Health Policy of Massachusetts General Hospital and an assistant professor in psychiatry at Harvard Medical School. 

SOURCE:  By Sharon L. Bober and Elyse R Park, Boston.com