Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn Andrea M. Beck, M.Sc.a,*, John W. Robinson, Ph.D.a,b, Linda E. Carlson, Ph.D.a,b a Department of Psychology, University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada b Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada Received 23 July 2007; received in revised form 16 November 2007; accepted 27 November 2007 Abstract
Receiving a diagnosis of and treatment for prostate cancer often results in significant physical side-effects and associated psychosocial stressors that can interfere with the experience of sexual intimacy for couples. Despite the fact that prostate cancer affects mainly older men,the maintenance of sexual intimacy is an important issue to consider, as the majority of older adults continue to value, engage in, and enjoysexual activity throughout their lives. While the current research identifies the challenges that many men face, little is known about thestrategies that couples use to successfully maintain sexual intimacy after prostate cancer treatment. In this review article, the existingliterature on sexual intimacy after prostate cancer is reviewed, a critical analysis of current limitations in our knowledge and understandingis provided, and directions for further research are suggested.
2007 Elsevier Inc. All rights reserved.
Keywords: Prostate cancer; Side effects; Sexual intimacy; Sexuality Prostate cancer is the most commonly diagnosed cancer of prostate cancer interview data strongly suggest that in men Unfortunately, the existing treatments for pros- prostate cancer and its treatment are associated with signif- tate cancer often result in troublesome side effects, such as icant psychosocial challenges for men It has been erectile dysfunction, dry ejaculation, leakage of urine with suggested that the use of global measures of health status in orgasm, penile shrinkage, urinary incontinence, and bowel studies using questionnaires obscures the complex out- dysfunction. The significance of these side-effects, how- comes experienced by men, particularly in terms of psycho- ever, resides less in the mechanics of physical dysfunction social issues In addition to the direct physical effects of and more in the psychosocial implications for men and their prostate cancer treatments, psychosocial issues such as how partners, particularly in the area of sexual intimacy. Some men actually live with erectile, orgasmic, urinary, and couples adapt well to the physical and psychosocial se- bowel dysfunction, how they view themselves, and uncer- quelae of prostate cancer treatment and are able to maintain tainty about their illness and treatment choices, have signif- a satisfying sexual relationship. Many couples, however, find adaptation problematic and experience significant dis- The first challenge that many men face is making in- ruption in their sexual relationships. Even when erectile formed treatment decisions, often due to the lack of con- functioning is restored through assistive aids, many couples clusive information or an abundance of confusing informa- do not resume a satisfying sexual relationship. This article tion about efficacy rates and side effects of various will review the existing literature on sexual intimacy in treatments. The rates of various side effects are difficult to couples after prostate cancer, as well as outline those areas determine with precision, due to differences in treatment technique, length of follow-up, method of data collection, Although questionnaire data sometimes suggest that men definitions of side-effects, and case selection in studies who have received treatment for prostate cancer do not have In one mail-out survey of 349 men who had been treated for a reduced quality of life compared with men with no history prostate cancer 12 to 48 months previously, 24% of prostatecancer patients felt that their treatment decisions werepoorly informed and 16% regretted the decision they had * Corresponding author. Tel.: ϩ403-220-4977; fax: ϩ403-292-8249.
E-mail address: [email protected] (A.M. Beck).
made Interestingly, in this study, greater masculine 1078-1439/07/$ – see front matter 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.urolonc.2007.11.032 ARTICLE IN PRESS
A.M. Beck et al. / Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx self-esteem was associated with the belief that one’s treat- then, is viewed as the opposite of masculinity and is even equated with failed masculinity As such, if men do not In addition to confusing or insufficient information, a prove their masculinity by espousing masculine traits, lack of communication between the patient and his physi- which tend to be in opposition to illness, they are considered cian can serve to make treatment decisions difficult. Some feminine. One may remember the schoolyard names for men report that their treatment is either decided outright or boys who failed to qualify in some way as a “man”, which recommended by their physician without detailed discus- are all suggestive of femininity: sissy, homo, pansy, wimp, sion of the risks and benefits of the various treatments. For etc. Even the phrase “You throw like a girl” holds the instance, in a qualitative study of men who received andro- suggestion that failing to meet the masculine ideal makes gen deprivation therapy, one man reported that his doctor one feminine, and that this is somehow inferior.
simply informed him that he would be taking hormone It is also important to note that hegemonic masculinity is therapy and failed to provide him with information or in- phallocentric. That is, it is focused on the penis The volve him in his own treatment decision Even with penis, including its size and performance, is a strong indi- detailed information about potential side effects, some men cator of masculinity in Western culture. To be considered may not believe that they will experience the side effects, or masculine, a man’s penis should be long, have a large underestimate the impact that the side effects will have on circumference, be capable of instantaneous erections, and have the ability to produce explosive orgasms A man One outcome of not having adequate information about who has the outward characteristics of hegemonic mascu- the side effects of the various treatments, of believing that linity, but suffers in private from erectile dysfunction, leak- the side effects will not be experienced, or of underestimat- age of urine with orgasm, or a smaller penis must hide his ing the impact of a side effect, is the difficulty inherent in dysfunction from others to protect his masculine persona.
adjusting one’s expectations with reality. Some men are The notion of hegemonic masculinity is illustrative of surprised by the side effects they experience, even if they dichotomous gender characterization; it holds that an indi- were told about them. Others may be shocked by the degree vidual is either masculine or feminine, rather than espousing to which the side effect distresses them. For example, one characteristics traditionally ascribed to both masculinity and man being treated with hormone therapy reported in a qual- femininity. Inherent in this characterization is the notion itative interview that his weight gain bothered him more that men should be masculine and women should be femi- than he would have predicted It is also common for men nine Given the characteristics of hegemonic mascu- to feel unsure about whether the changes that are experi- linity, it becomes clear how prostate cancer and its treatment enced, particularly psychological changes, are actually due can undermine a man’s sense of identity and masculinity.
to the side effects of the treatment.
The very nature of illness can lead a man to feel dependent, Prostate cancer may also affect men’s relationships with powerless, and incapable of caring for himself. When cou- others. Men vary in the degree to which they feel comfort- pled with the side-effects of prostate cancer treatment, such able disclosing and discussing their experience with prostate as sexual, urinary, and bowel dysfunction, a man’s sense of cancer Some men find that they tend to open up his own masculinity may become fragile. This threat to more after prostate cancer treatment, particularly to other masculinity can interfere with a man’s sexuality, compro- men who are seeking advice about the illness. It has been mising sexual intimacy with his partner(s).
found, however, that the majority of men disclose little Intimate sexual relationships are particularly important about their prostate cancer to others According to the to consider when discussing prostate cancer, because pros- 34 men interviewed for this qualitative study, the reasons tate cancer treatment is associated with profound changes in for lack of disclosure included the perception that they do sexual functioning. While most men describe their partners not need support, avoidance of the threat of illness, avoidance as supportive, many women are, nevertheless, also signifi- of stigmatization, not wanting to burden others, and practical cantly affected by the changes in their partners’ sexuality.
reasons, such as preserving the work environment Even when a woman feels that the changes in her partner’s Another psychosocial outcome of prostate cancer and its sexuality are not difficult to cope with, her partner may treatment is the effect of illness on self-esteem and identity.
nevertheless worry that she is sexually dissatisfied or that A man’s belief in his capabilities and independence is often she views him as less masculine. Moreover, changes in compromised with serious illness. Some research examin- sexual intimacy can have negative effects on couples’ rela- ing the psychosocial sequelae of prostate cancer treatment has suggested that the physical side effects can threaten While many theories of sexuality exist, the biopsycho- men’s masculinity Hegemonic masculinity is a term social model of health, which emphasizes the contribution used to refer to the idealized form of masculinity in a given of and interaction between biology, psychology, and the culture and time In current Western culture, mascu- social environment to determine overall health, may be linity is often equated with characteristics such as stoicism, useful in understanding sexuality in the context of prostate domination, competitiveness, aggressiveness, athletic prow- cancer treatment. A World Health Organization (WHO) ess, independence, control, and virility Femininity, article on sexual health described sexuality as being “influ- ARTICLE IN PRESS
A.M. Beck et al. / Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx enced by the interaction of biological, psychological, social, Recent studies have found that sexual dysfunction in the economic, political, cultural, ethical, legal, historical, reli- male partner is often correlated with sexual dysfunction in gious, and spiritual factors” Sexual health is described the female partner In a study by Shindel et al, 90 as “a state of physical, emotional, mental, and social well- couples in whom the male partner had been treated for being in relation to sexuality” How is this interaction prostate cancer with prostatectomy completed mail-out questionnaires that surveyed the sexual functioning of both At a fundamental level, the act of sexual intercourse is the male and female partner Statistically significant biological. To engage in sexual intercourse, one must have correlations were found between all domains on the male the required genitalia and those genitalia must be in suffi- questionnaire and all the domains on the female question- cient working order. For example, many men cannot engage naire (with the exception of a nonsignificant correlation in sexual intercourse due to erectile dysfunction caused by between male erectile function and female sexual desire), physical illness or injury. Likewise, many females cannot suggesting the possibility that the sexual functioning of engage in sexual intercourse due to pain caused by vaginal females is affected by the sexual functioning of their male dryness or a vagina too small to accommodate her partner’s partners It is important to note, however, that it is penis. It is important to note, however, that many individ- possible that the significant correlations found in this study uals who cannot engage in sexual intercourse nonetheless were due to the naturally high rates of sexual dysfunction in engage in and enjoy sexual activities, such as touching and kissing that produce arousal and orgasm. In addition to A study by Çayan et al. also found a correlation engaging in sexual activities, the desire for and pleasure between the sexual functioning of women and their male associated with sexual intercourse may also depend on bi- partners, but this study included younger participants, a ology. For example, alterations in normal levels of andro- control group, and pre- and post-treatment measures. Thisstudy included 87 women and their male partners, all of gens can cause a man or woman to experience a reduced whom were sexually active. The women were divided into two groups, including those with partners who had erectile Sexuality is, however, much more than biology dysfunction (N ϭ 38) and those with partners who did not Many of the biologically based components of the human have erectile dysfunction (N ϭ 49). Prior to treatment of the sexual response are highly sensitive to emotional and other male partner’s erectile dysfunction, the sexual functioning psychological processes For example, negative mood, of the two groups of women was assessed. It was found that such as depression or anxiety, is associated with both in- sexual desire did not differ between the two groups of creases and decreases in sexual desire, arousal, and orgasm women, but sexual arousal, lubrication, orgasm, satisfac- in men Mood states can even affect erectile func- tion, and freedom from pain were significantly lower in the tioning Depression has consistently been found to be group of women whose male partners had erectile dysfunc- associated with sexual dysfunction, and evidence even sup- ports a causal factor for depression in the onset of sexual After treatment of the male partners with erectile dys- dysfunction Stressors such as illness or financial prob- function, using sildenafil or penile prostheses, the sexual lems can also lead to sexual dysfunction, and attitudes about function of the female partners was reassessed. Sexual de- body image and self perception may shape attitudes about sire did not change from pre- to post-treatment, but sexual arousal, lubrication, orgasm, satisfaction, and pain all im- In fact, experts sometimes note that the most proved significantly in the women after their partners’ erec- important organ for sexuality may be the brain.
tile dysfunction was treated Together, these studies Not only is sexuality highly sensitive to psychological lend support to the notion that sexuality is a social construct, processes within the individual, sexuality is also a social affected by both individuals that make up an intimate sexual construct Sexuality is most often expressed in re- lationship with another person who helps to shape the ex- Sexuality is also at least partly socially constructed by perience and expression of sexuality and bring meaning to culture, religion, and education Ideas about what is the interaction. The response of an intimate partner to an considered normal sexual activity or expression vary across individual’s sexual expression can have the effect of in- person, time, and place. For example, older adults tend to creasing or decreasing sexual desire, arousal, and orgasm.
have more conservative attitudes about sexual behavior than The partner’s own sexual expression can also shape these younger adults likely due to different dominant views components of sexual response. Clinical data suggests that of sexuality during the eras in which these cohorts were sexual dysfunctions can be both a cause and a result of socialized. In addition, higher education is associated with relationship problems Specific sexual behaviors have more liberal attitudes about sexuality Some research- very different meanings depending on the context in which ers even argue that female sexuality is more affected by they are carried out. For example, sexual intercourse with social and situational influences than is male sexuality and without the consent of both partners distinguishes love- Couples faced with an illness or disability such as cancer inevitably experience changes in patterns of communication ARTICLE IN PRESS
A.M. Beck et al. / Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx and intimacy. When considering cancer, the focus may Why do so many men stop using assistive aids to help initially be on simply surviving the cancer, but ultimately, a restore erections? Despite their relative effectiveness in re- diagnosis of cancer requires individuals to rediscover them- storing erections, assistive aids have been associated with selves, their future, and their meaning in life Changes failure for couples because intercourse using assistive aids may occur in many areas such as roles, finances, indepen- often feels unnatural, forced, and awkward for couples dence, lifestyle, employment, and future health status. The It is possible that each partner’s motivation to preserve illness itself and the changes that are associated with it can sexual intercourse affects the likelihood that a man will try also affect sexual functioning in the patient and sexual more than one treatment Factors that were found to be intimacy between couples. An article in the Journal of the associated with higher motivation to retain erectile func- American Medical Association cited sexual dysfunction as tioning were younger age, better physical health, good pre- one of the top adverse effects of cancer treatment on survi- treatment sexual function, a greater number of lifetime sex- vors in response to a report by the Institute of Medi- ual partners, and a positive view of one’s own sexuality cine and the National Research Council of the National A recent study, however, failed to find a statistically Academies on the long-term adverse effects of cancer and significant association between sexual motivation and the use of assistive aids in 896 men responding to a mail-out Several studies suggest that treatment for prostate cancer survey 4 to 8 years after prostate cancer treatment often compromises men’s sexuality In a mail-out A man’s relationship with his partner may also be asso- questionnaire-based survey study of 349 men who had been ciated with the likelihood of using assistive aids to restore treated for prostate cancer and 398 men with no history of erections. Schover et al. found that men who were currently prostate cancer, men who received treatment for prostate in a relationship were more likely to try assistive aids, cancer reported more problems with sexual intimacy, sexual particularly if their partner had good sexual function and confidence, and masculine self-esteem than men without a was younger in age In addition, newer relationships history of prostate cancer In fact, in two qualitative were associated with a greater likelihood of men trying studies of sexuality after prostate cancer treatment, men reported that the most significant event after treatment was It has been suggested that assistive aids are not used the end or alteration of their sex lives successfully by many couples because these treatments fo- For some men, erectile dysfunction renders inter- cus too narrowly on a specific type of sexual dysfunction course without assistive aids impossible. However, it is (i.e. erectile dysfunction) and do not consider or address the important to note that overcoming the challenges associ- range of biopsychosocial issues relevant to couples ated with erectile dysfunction is rarely as simple as re- These biopsychosocial issues may include patient variables storing erections through the use of assistive aids. The such as anxiety, partner variables such as poor physical most common assistive aids used by men who experience health, interpersonal variables such as relationship quality, erectile dysfunction include oral medications such as and contextual variables such as life stressors sildenafil (Viagra), vardenafil (Levitra), and tadalafil To help couples use assistive aids effectively and con- (Cialis); penile intracavernous injections of synthetic va- sistently, Schover et al. suggest helping couples to develop soactive drugs such as Tri-Mix (a mixture of papaverine, more realistic expectations of the use of assistive aids phentolamine, and prostaglandin); transurethral prosta- In support of this suggestion, it has been found that the glandin administration (the insertion of a prostaglandin majority of couples are initially very hopeful about the use tablet into the urethra); vacuum devices (a plastic tube of assistive aids, even encouraged by their doctors to feel placed over the penis to create a vacuum to draw blood hopeful; unfortunately, the majority experience failure or into the penis); and permanent penile prostheses (usually only partial success with assistive aids In this longi- considered a radical, last-resort treatment) It has tudinal, qualitative study by Gray et al., the men reported been found that approximately 59% of men try at least that they did not anticipate that the assistive aids would be one of these assistive aids to treat erectile dysfunction Schover et al. also suggest incorporating sexual counsel- Despite relatively high success rates of many assistive ing, focusing on areas such as increasing communication aids, over 50% of men who try assistive aids discontinue and stimulation skills, into the routine care offered to cou- their use after trying them When surveyed 4.5 years ples after prostate cancer treatment Supporting this after treatment, only 30% of men who had received treat- suggestion, in the longitudinal, qualitative study mentioned ment for prostate cancer were still using assistive aids to above, couples reported having difficulty talking together treat erectile dysfunction While men are most likely to about their sexual functioning and felt that they did not try noninvasive treatments, such as Viagra, the more inva- sive treatments, such as penile intracavernous injections and Research tends to confirm that the effects of erectile prostheses, are associated with the highest success rates dysfunction after prostate cancer treatment reach far beyond It has also been found that men who try more than one the physical impairment itself For example, one quali- treatment are more likely to have success tative study that explored men’s perceptions of their quality ARTICLE IN PRESS
A.M. Beck et al. / Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx of life following prostate cancer treatment using seven focus a wife or female partner. It is, therefore, important to con- groups comprising 48 men, found that the four major do- sider the effects of prostate cancer on the female partners of mains of men’s sex lives that were affected after treatment men who have received treatment for prostate cancer. Very included the quality of sexual intimacy, relationships with few studies, however, have examined the experiences of women, sexual thoughts, and masculinity It should be women after their husband or partner has received treatment noted that these research findings are based on men who felt comfortable sharing their experiences of prostate cancer Most of the existing research suggests that women tend treatment in a group format. However, the findings of Clark to respond to sexual dysfunction after prostate cancer treat- et al., which surveyed men who had received treatment for ment by stressing the trade-off, asserting that giving up prostate cancer via mail-out questionnaires, lends support to sexual intercourse to ensure their partners’ survival is the findings of Bokhour et al. that prostate cancer is worthwhile In one prospective study, men’s and wom- associated with compromised sexual intimacy, lowered con- en’s perceptions of the threat of erectile dysfunction prior to prostate cancer treatment were examined Like studies Further support for the assertion that the deleterious of men after prostate cancer treatment, the men in this study effects of prostate cancer on sexual intimacy are due to consistently reported that the loss of erectile functioning more than the physical impairment associated with erectile would threaten an important part of their identity. However, dysfunction can be found by examining the effects of other men also reported that their wives were less concerned side effects of prostate cancer treatment. For example, sex- about the potential loss of erectile function than they were.
uality has been found to be affected by urinary incontinence This was confirmed by the women in this study, who tended and bowel dysfunction in addition to erectile dysfunction to stress other important dimensions of their relationship, It appears that urinary incontinence and bowel dysfunc- such as companionship. The women tended to report that tion affect sexuality through a preoccupation with personal they were more concerned about the implications of erectile hygiene, fear of embarrassment, avoidance of physical con- dysfunction for the men, rather than for themselves, noting that erectile dysfunction might compromise the men’s sense The leakage of urine with orgasm has been found to of masculinity Despite this confirmation of men’s occur in approximately 20% to 45% of men after radical interpretations of their wives’ feelings about sexual inti- prostatectomy In one study, almost half of the men macy, it was found that couples tend to stop communicating with orgasm-related incontinence reported that it caused about their sex lives after the treatment decision has been significant bother; many men coped by urinating before made Men assume that their wives are not affected by intercourse and using condoms. While these studies exam- the change in their sexual intimacy because the women do ined the rates of orgasm-related incontinence, no study has yet examined the effects on sexual intimacy. It is possible In a qualitative study that included interviews with ten that this side effect of radical prostatectomy causes signif- couples between 4 and 8 weeks after the male partner had icant distress and disruption to sexual intimacy for men.
Gray has suggested that the changes in men’s sexuality undergone prostatectomy, it was found that the female part- after prostate cancer treatment might be due to the threat ners felt that they had to deal independently with the bur- men experience to their feelings of masculinity As the dens associated with their partner’s illness and took on previous description of hegemonic masculinity outlined, various tasks, such as finding pads for their husbands, pro- men’s masculine identities are often defined by character- viding emotional support, screening phone calls, and pro- istics such as independence, competence, and virility, all of viding information to friends and family The women which can be compromised with prostate cancer treatment.
also reported that initially the threat of their husband’s The challenge is less with the physical side effects of pros- erectile dysfunction was difficult to deal with, but like the tate cancer treatment as it is with the meaning of these previous study, the majority of women stressed the impor- effects for men’s masculine identities. In a qualitative study tance of their husband’s survival and suggested that their that examined men’s beliefs, values, and performances re- husband’s erectile difficulties were probably more difficult garding masculinity in relation to prostate cancer, the main theme was found to be the preservation of manhood It Another qualitative study that included a focus group is important to note that even men who knew that their with 10 couples, however, found that women were con- treatment choice would likely lead to sexual difficulties cerned about their sexual relationship with their partner were surprised after treatment to find that sex was not after prostate cancer treatment Many of the women simply an isolated activity in their lives, but was closely reported that they and their partner did not communicate related to their identity Gray and colleagues have found enough about sexual issues. Some women also reported that that many men must redefine masculinity to successfully they felt unattractive and unwanted when their husbands withdrew or withheld physical affection or did not respond Sexual intimacy occurs in relationship with another per- to their attempts to initiate physical intimacy. A lack of son. For survivors of prostate cancer, this person is usually romance and sex that felt artificial, involving too much ARTICLE IN PRESS
A.M. Beck et al. / Urologic Oncology: Seminars and Original Investigations xx (2007) xxx–xxx planning and too little spontaneity, were among the other men abandon its use within months. Clearly, maintenance of concerns voiced by the women in this study sexual intimacy involves more than the restoration of erec- A particularly interesting finding from the prospective tile function. Unfortunately, little is known about why cou- study by Boehmer and Babayan is that most couples be- ples abandon the use of assistive aids and the strategies that lieved that their sex life would continue after treatment might help them to maintain sexual intimacy in their rela- In fact, couples believed that their sex lives would be main- tionships after prostate cancer treatment. Research that ex- tained through the use of assistive aids, not by an alteration amines the ways in which couples successfully adapt to in their sexual practices. This is a very important issue, for prostate cancer and its treatment to maintain sexual inti- when one considers that the majority of men and their macy is, therefore, important to consider.
partners do not maintain their pretreatment sex lives even While the existing research has shed some light on the with the availability of assistive aids, this finding suggests common challenges to men after receiving treatment for that prior to treatment most couples do not fully appreciate prostate cancer, few studies have focused exclusively on the the psychosocial effects that prostate cancer treatment side issue of sexual intimacy after treatment for prostate cancer.
effects can have on men and their partners.
While changes in sexual functioning and sexual identity Rolland’s Family Systems-Illness Model conceptu- have emerged in past studies as important issues for men alizes the successful adaptation of a couple to illness and after receiving treatment for prostate cancer, research that disability as a fit between the psychosocial demands of the focuses exclusively on the issue of sexual intimacy is illness and the couple’s resources and style of functioning.
needed. In addition, very few studies have examined the Rolland suggests that couples who can openly communicate experiences of both men and their female partners. This is about and tolerate their own and their partner’s fears of loss, an important issue, considering that sexuality is predomi- ambiguous and sometimes shameful feelings, and changing nantly expressed in interaction with an intimate partner. As roles are likely to successfully adapt their relationship to such, understanding the experience of sexual intimacy after illness and disability. Couples who have relatively flexible prostate cancer necessitates an examination of the experi- rules surrounding roles and who can communicate without ences of both partners. According to family systems theo- criticism, defensiveness, contempt, or withdrawal may tend ries, a change in one family member affects other family to better maintain relationship satisfaction members so considering the couple when seeking to One way that couples might be helped to openly com- understand issues of sexual intimacy after treatment for municate about and address sexual difficulties after prostate prostate cancer is necessary and warranted.
cancer treatment is through psychosocial interventions.
Finally, the majority of studies have focused on the However, the literature is extremely limited in this regard.
problems encountered after prostate cancer treatment, rather Only one study has tested an intervention to rehabilitate than the ways in which couples successfully adapt to the sexual functioning for prostate cancer survivors and their side-effects of prostate cancer treatment to maintain sexual partners This intervention included education about intimacy. As such, research focusing on the successful strat- prostate cancer and sexual functioning, as well as education egies used by couples to maintain sexual intimacy would on and practice with the skills of sexual communication and deepen our understanding of sexual intimacy after treatment stimulation. The intervention was associated with improve- for prostate cancer. Couples who have been successful in ments in sexual functioning for both partners, as well as a maintaining a sexual relationship might be able to share the decrease in overall distress for the males Unfortu- “secrets of their success,” providing guidance for the devel- nately, the treatment gains had diminished by 6 months opment of more effective interventions for those couples postintervention, strongly suggesting that more research is who struggle to maintain sexual intimacy after prostate needed in this area to understand the strategies that might help couples to adapt to prostate cancer treatment and main-tain sexual intimacy.
Taken together, the literature suggests that men who References
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Grazing-Angle Fiber-Optic IRRAS for in Situ Cleaning Validation Michelle L. Hamilton, Benjamin B. Perston, Peter W. Harland, and Bryce E. Williamson Department of Chemistry, Uni V ersity of Canterbury, Christchurch, New Zealand Remspec Corporation, Sturbridge, Massachusetts, U.S.A. Abstract: ever, the combination of a grazing-angle IRRAS sampling Grazing-angle Fourier transform infrared

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