Archival data from the Sex Therapy Center at Stony Brook were analyzed to determine the prevalenc... more Archival data from the Sex Therapy Center at Stony Brook were analyzed to determine the prevalence of desire phase sexual dysfunctions and the effectiveness of treating them with behavioral sex therapy. When cases were rediagnosed with a multi-axial problem-oriented system, increases from 1974-1981 in both the prevalence of desire phase problems and of male low sexual desire were observed. Data suggested that wives display more extreme patterns of sexual avoidance than do husbands in couples seeking sex therapy. Outcome statistics on marital adjustment, overall sexual satisfaction, the frequency of intercourse and masturbation, and patterns of initiation of sexual activity reveal significant positive changes after treatment. These changes are not due to nonspecific factors and are maintained at follow-up. Sex therapy was equally successful for male-centered vs. female-centered problems, for low sexual desire vs. aversion to sex, and for global or lifelong dysfunctions vs. the more recent or situational ones. Posttreatment gains reflect a minimally adequate sexual relationship, however, rather than an optimal degree of intimacy and pleasure.
Testicular cancer patients are at risk for sexual and marital problems because their cancer and i... more Testicular cancer patients are at risk for sexual and marital problems because their cancer and its treatment reduce their fertility and disrupt intimate relationships at a crucial life stage (age 15-34). Chemotherapy, radiotherapy and surgery have successfully increased survival rates, but at the price of infertility and sexual dysfunction. A survey of men treated for nonseminomatous tumors revealed that 20% had low levels of sexual activity, 10% had erectile dysfunction, 6% had difficulty reaching orgasm, and 38% reported decreased orgasmic pleasure. Sexual anxiety related to cancer treatment accounts for much of this dysfunction, but organic factors such as hormonal, vascular or neurologic damage may also contribute. Reactions of couples to infertility and marital conflicts common in this group are discussed. Suggestions for sexual and marital counseling are offered.
The goal of sexual rehabilitation is to restore the patient's ability to engage in intima... more The goal of sexual rehabilitation is to restore the patient's ability to engage in intimate interpersonal relationships. It incorporates the restoration of both self-esteem and bodily function. When appropriate and desired, sexual rehabilitation includes restoring the physical ability to engage in sexual activity. Rehabilitation begins at diagnosis and continues throughout therapy. It addresses the specific desires of each patient and incorporates the contributions of every member of a health care team. An adaptation of Annon's PLISSIT model is appropriate to this multidisciplinary, holistic approach. All patients need permission (P) and limited information (LI); frequently, dispelling myths and eliminating ignorance about therapy are enough to enable patients to resume sexual intimacy. Specific suggestions (SS) help patients whose irradiation, hormone therapy, or radical surgery have resulted in physiologic or anatomic alteration to the genitals or the mechanisms of sexual response. Highly skilled professionals provide intensive therapy (IT), which may include surgical reconstruction, implantation of prosthetic devices, or intensive marital and sexual counseling.
Experience with 100 patients who used intracavernous injection therapy with a combination of papa... more Experience with 100 patients who used intracavernous injection therapy with a combination of papaverine with or without phentolamine for 29 months is analyzed in detail. The largest group of patients had vasculogenic erectile failure (56%). At the end of followup 50% of the patients were no longer performing injection. Those who discontinued injection therapy were slightly older and had more vasculogenic erectile failure. The nonfibrotic complications were mild in all instances and did not result in discontinuation of injection therapy. These complications consisted of small hematomas in 20.9% of the patients, mild discomfort in 13.6% and mild liver enzyme abnormalities in 9.8%. No episode of priapism or infection occurred during therapy. Fibrotic complications consisted of nodules or plaques, and correlated significantly with the number of months on injection and the number of injections. At 12 months the fibrotic complication rate was 31 +/- 8.6%. Our study suggests caution regarding the long-term complication rate of intracavernous injection therapy with these compounds and underscores the importance of routine followup examinations. While injection therapy is an effective form of treatment for erectile failure, it is not a satisfactory alternative for many patients and is associated with a significant fibrotic complication rate.
We interviewed 9 sexually active women about sexual function before and after radical cystectomy.... more We interviewed 9 sexually active women about sexual function before and after radical cystectomy. Of the women 6 also had received preoperative irradiation. Seven women resumed sexual activity. All subjects experienced dyspareunia on initial attempts but 6 had overcome the pain at followup 6 to 37 months postoperatively. These women were coitally orgasmic and reported no decrease in pleasure or change in the type of sexual stimulation required to produce orgasm. The results provide knowledge about the physiology of female orgasm and a basis for counseling patients.
Sexual function was assessed before radical cystectomy in 112 men: 20 per cent were sexually inac... more Sexual function was assessed before radical cystectomy in 112 men: 20 per cent were sexually inactive and 35 per cent had erectile dysfunction. Sexual function before cystectomy was an index of general health status and correlated significantly with survival free of disease. Followup data on sexual function were provided by 73 men at an average of 13 months postoperatively. After cystectomy, which was performed via standard operative techniques, 91 per cent of the men experienced some degree of erectile dysfunction but 50 per cent remained sexually active, at least using noncoital stimulation. Thirteen men chose to have a penile prosthesis implanted. Sexual counseling was rated as satisfactory by 80 per cent of the men.
In a previous case series, a psychologist's rating of couples' em... more In a previous case series, a psychologist's rating of couples' emotional adjustment and readiness for donor insemination was predictive of pregnancy rates. We attempted to replicate this finding with an extended series of 120 consecutive couples in which each spouse filled out questionnaires when evaluated for donor insemination. The Stress and Infertility Questionnaire measured specific attitudes and anxieties about donor insemination. The Brief Symptom Inventory assessed psychological distress. The Dyadic Adjustment Scale measured marital happiness. A psychologist used these questionnaires to rate the couple's overall adjustment in regard to donor insemination. Those couples rated as distressed had a session of psychological counselling. Outcome was reviewed at a mean of 20 months after evaluation, with categories of pregnancy, continuing donor insemination, failure to begin the programme, or dropped out. For the 120 couples overall, psychological factors did not predict pregnancy outcome. Younger age of the wife did predict higher pregnancy rates.
Journal of the National Comprehensive Cancer Network: JNCCN
The recent NCCN Guidelines for Survivorship recommend systematic evaluation and multidisciplinary... more The recent NCCN Guidelines for Survivorship recommend systematic evaluation and multidisciplinary treatment of cancer-related sexual dysfunctions. However, most oncology professionals fail to routinely assess sexual problems and lack expertise to treat them. An Internet-based intervention was designed to educate female patients and their partners about cancer-related sexual problems, describe medical treatment options and how to find expert care, and provide self-help strategies. A randomized trial assessed efficacy of the intervention when used as self-help versus the same Web access and 3 supplemental counseling sessions. Survivors of localized breast or gynecologic cancers completed online questionnaires at baseline, posttreatment, and 3- and 6-month follow-up, including the Female Sexual Function Index (FSFI), the Menopausal Sexual Interest Questionnaire (MSIQ), the Brief Symptom Inventory-18 (BSI-18) to assess emotional distress, and the Quality of Life in Adult Cancer Survivors (QLACS) scale. Program evaluation ratings were completed posttreatment. Fifty-eight women completed baseline questionnaires (mean age, 53 ± 9 years). Drop-out rates were 22% during treatment and 34% at 6-month follow-up. Linear mixed models for each outcome across time showed improvement in total scores on the FSFI, MSIQ, and QLACS (P<.001) and BSI-18 (P=.001). The counseled group improved significantly more on sexuality measures, but changes in emotional distress and quality of life did not differ between groups. Program content and ease of use were rated positively. Research is needed on how best to integrate this intervention into routine clinical practice, and particularly how to improve uptake and adherence.
To analyze the quality of life and psychological adjustment after surgical therapy for localized ... more To analyze the quality of life and psychological adjustment after surgical therapy for localized renal cell carcinoma. Postal questionnaires including measures of quality of life (SF-36) and the impact of the stress of cancer (Impact of Events Scale) were completed by 97 patients who had undergone radical or partial nephrectomy for localized renal cell carcinoma. Data were analyzed for the group as a whole and comparing the partial nephrectomy and radical nephrectomy groups. The variables examined included the impact of the type of partial nephrectomy (elective versus mandatory) and the amount of self-reported renal tissue remaining. The quality of life for the group as a whole was good, with no significant differences between the sample and U.S. norms for an age and sex-matched community sample on both the mental and physical health composite scores. Having undergone a partial versus a radical nephrectomy did not influence the patients' overall quality of life. Multiple linear ...
Sexual dysfunction has only recently been recognized as a highly prevalent side effect of adjuvan... more Sexual dysfunction has only recently been recognized as a highly prevalent side effect of adjuvant aromatase inhibitor (AI) therapy for breast cancer. A cross-sectional survey using standardized measures of female sexual function was designed to provide a detailed view of sexual problems during the first 2 years of adjuvant AI therapy and secondarily to examine whether sexual dysfunction leads to nonadherence to this therapy. Questionnaires were mailed to all 296 women in a breast oncology registry who had been prescribed a first-time AI for localized breast cancer 18-24 months previously. Items assessed medication adherence, demographic, and medical information. Scales included the Female Sexual Function Index, the Menopausal Sexual Interest Questionnaire, the Female Sexual Distress Scale-Revised, the Breast Cancer Prevention Trial Eight Symptom Scale to assess menopausal symptoms, and the Merck Adherence Estimator(®) . Questionnaires were returned by 129 of 296 eligible women (43.6%). Respondents were 81% non-Hispanic white with a mean age of 63 and 48% had at least a college degree. Only 15.5% were nonadherent. Ninety-three percent of women scored as dysfunctional on the Female Sexual Function Index, and 75% of dysfunctional women were distressed about sexual problems. Although only 52% of women were sexually active when starting their AI, 79% of this group developed a new sexual problem. Fifty-two percent took action to resolve it, including 24% who stopped partner sex, 13% who changed hormone therapies, and 6% who began a vaginal estrogen. Scores on the Adherence Estimator (beliefs about efficacy, value, and cost of medication) were significantly associated with adherence (P = 0.0301) but sexual function was not. The great majority of women taking AIs have sexual dysfunction that is distressing and difficult to resolve. Most continue their AI therapy, but a large minority cease sexual activity.
Infertility is a frequent consequence of cancer therapy and is often associated with psychologica... more Infertility is a frequent consequence of cancer therapy and is often associated with psychological distress. Although adult survivors prioritize fertility and parenthood, this issue remains unexplored among adolescent males. This study examined future fertility as a priority (relative to other life goals) at time of diagnosis for at-risk adolescents and their parents. Newly diagnosed adolescent males (n = 96; age = 13.0-21.9 years) at increased risk for infertility secondary to cancer treatment prioritized eight life goals: to have school/work success, children, friends, wealth, health, a nice home, faith, and a romantic relationship. Patients' parents (fathers, n = 30; mothers, n = 61) rank-ordered the same priorities for their children. "Having children" was ranked as a "top 3" life goal among 43.8 % of adolescents, 36.7 % of fathers, and 21.3 % of mothers. Fertility ranked third among adolescents, fourth among fathers, and fifth among mothers. Future health was ranked the top priority across groups, distinct from all other goals (ps < 0.001), and fertility ranked higher than home ownership and wealth for all groups (ps < 0.001). For adolescents, low/moderate fertility risk perception was associated with higher fertility rankings than no/high risk perceptions (p = 0.01). Good health is the most important life goal among adolescents newly diagnosed with cancer and their parents. In this relatively small sample, adolescents prioritized fertility as a top goal, parents also rated fertility as being more important than home ownership and financial wealth. Health care providers should communicate fertility risk and preservation options at diagnosis and facilitate timely discussion among families, who may differ in prioritization of future fertility.
Archival data from the Sex Therapy Center at Stony Brook were analyzed to determine the prevalenc... more Archival data from the Sex Therapy Center at Stony Brook were analyzed to determine the prevalence of desire phase sexual dysfunctions and the effectiveness of treating them with behavioral sex therapy. When cases were rediagnosed with a multi-axial problem-oriented system, increases from 1974-1981 in both the prevalence of desire phase problems and of male low sexual desire were observed. Data suggested that wives display more extreme patterns of sexual avoidance than do husbands in couples seeking sex therapy. Outcome statistics on marital adjustment, overall sexual satisfaction, the frequency of intercourse and masturbation, and patterns of initiation of sexual activity reveal significant positive changes after treatment. These changes are not due to nonspecific factors and are maintained at follow-up. Sex therapy was equally successful for male-centered vs. female-centered problems, for low sexual desire vs. aversion to sex, and for global or lifelong dysfunctions vs. the more recent or situational ones. Posttreatment gains reflect a minimally adequate sexual relationship, however, rather than an optimal degree of intimacy and pleasure.
Testicular cancer patients are at risk for sexual and marital problems because their cancer and i... more Testicular cancer patients are at risk for sexual and marital problems because their cancer and its treatment reduce their fertility and disrupt intimate relationships at a crucial life stage (age 15-34). Chemotherapy, radiotherapy and surgery have successfully increased survival rates, but at the price of infertility and sexual dysfunction. A survey of men treated for nonseminomatous tumors revealed that 20% had low levels of sexual activity, 10% had erectile dysfunction, 6% had difficulty reaching orgasm, and 38% reported decreased orgasmic pleasure. Sexual anxiety related to cancer treatment accounts for much of this dysfunction, but organic factors such as hormonal, vascular or neurologic damage may also contribute. Reactions of couples to infertility and marital conflicts common in this group are discussed. Suggestions for sexual and marital counseling are offered.
The goal of sexual rehabilitation is to restore the patient's ability to engage in intima... more The goal of sexual rehabilitation is to restore the patient's ability to engage in intimate interpersonal relationships. It incorporates the restoration of both self-esteem and bodily function. When appropriate and desired, sexual rehabilitation includes restoring the physical ability to engage in sexual activity. Rehabilitation begins at diagnosis and continues throughout therapy. It addresses the specific desires of each patient and incorporates the contributions of every member of a health care team. An adaptation of Annon's PLISSIT model is appropriate to this multidisciplinary, holistic approach. All patients need permission (P) and limited information (LI); frequently, dispelling myths and eliminating ignorance about therapy are enough to enable patients to resume sexual intimacy. Specific suggestions (SS) help patients whose irradiation, hormone therapy, or radical surgery have resulted in physiologic or anatomic alteration to the genitals or the mechanisms of sexual response. Highly skilled professionals provide intensive therapy (IT), which may include surgical reconstruction, implantation of prosthetic devices, or intensive marital and sexual counseling.
Experience with 100 patients who used intracavernous injection therapy with a combination of papa... more Experience with 100 patients who used intracavernous injection therapy with a combination of papaverine with or without phentolamine for 29 months is analyzed in detail. The largest group of patients had vasculogenic erectile failure (56%). At the end of followup 50% of the patients were no longer performing injection. Those who discontinued injection therapy were slightly older and had more vasculogenic erectile failure. The nonfibrotic complications were mild in all instances and did not result in discontinuation of injection therapy. These complications consisted of small hematomas in 20.9% of the patients, mild discomfort in 13.6% and mild liver enzyme abnormalities in 9.8%. No episode of priapism or infection occurred during therapy. Fibrotic complications consisted of nodules or plaques, and correlated significantly with the number of months on injection and the number of injections. At 12 months the fibrotic complication rate was 31 +/- 8.6%. Our study suggests caution regarding the long-term complication rate of intracavernous injection therapy with these compounds and underscores the importance of routine followup examinations. While injection therapy is an effective form of treatment for erectile failure, it is not a satisfactory alternative for many patients and is associated with a significant fibrotic complication rate.
We interviewed 9 sexually active women about sexual function before and after radical cystectomy.... more We interviewed 9 sexually active women about sexual function before and after radical cystectomy. Of the women 6 also had received preoperative irradiation. Seven women resumed sexual activity. All subjects experienced dyspareunia on initial attempts but 6 had overcome the pain at followup 6 to 37 months postoperatively. These women were coitally orgasmic and reported no decrease in pleasure or change in the type of sexual stimulation required to produce orgasm. The results provide knowledge about the physiology of female orgasm and a basis for counseling patients.
Sexual function was assessed before radical cystectomy in 112 men: 20 per cent were sexually inac... more Sexual function was assessed before radical cystectomy in 112 men: 20 per cent were sexually inactive and 35 per cent had erectile dysfunction. Sexual function before cystectomy was an index of general health status and correlated significantly with survival free of disease. Followup data on sexual function were provided by 73 men at an average of 13 months postoperatively. After cystectomy, which was performed via standard operative techniques, 91 per cent of the men experienced some degree of erectile dysfunction but 50 per cent remained sexually active, at least using noncoital stimulation. Thirteen men chose to have a penile prosthesis implanted. Sexual counseling was rated as satisfactory by 80 per cent of the men.
In a previous case series, a psychologist's rating of couples' em... more In a previous case series, a psychologist's rating of couples' emotional adjustment and readiness for donor insemination was predictive of pregnancy rates. We attempted to replicate this finding with an extended series of 120 consecutive couples in which each spouse filled out questionnaires when evaluated for donor insemination. The Stress and Infertility Questionnaire measured specific attitudes and anxieties about donor insemination. The Brief Symptom Inventory assessed psychological distress. The Dyadic Adjustment Scale measured marital happiness. A psychologist used these questionnaires to rate the couple's overall adjustment in regard to donor insemination. Those couples rated as distressed had a session of psychological counselling. Outcome was reviewed at a mean of 20 months after evaluation, with categories of pregnancy, continuing donor insemination, failure to begin the programme, or dropped out. For the 120 couples overall, psychological factors did not predict pregnancy outcome. Younger age of the wife did predict higher pregnancy rates.
Journal of the National Comprehensive Cancer Network: JNCCN
The recent NCCN Guidelines for Survivorship recommend systematic evaluation and multidisciplinary... more The recent NCCN Guidelines for Survivorship recommend systematic evaluation and multidisciplinary treatment of cancer-related sexual dysfunctions. However, most oncology professionals fail to routinely assess sexual problems and lack expertise to treat them. An Internet-based intervention was designed to educate female patients and their partners about cancer-related sexual problems, describe medical treatment options and how to find expert care, and provide self-help strategies. A randomized trial assessed efficacy of the intervention when used as self-help versus the same Web access and 3 supplemental counseling sessions. Survivors of localized breast or gynecologic cancers completed online questionnaires at baseline, posttreatment, and 3- and 6-month follow-up, including the Female Sexual Function Index (FSFI), the Menopausal Sexual Interest Questionnaire (MSIQ), the Brief Symptom Inventory-18 (BSI-18) to assess emotional distress, and the Quality of Life in Adult Cancer Survivors (QLACS) scale. Program evaluation ratings were completed posttreatment. Fifty-eight women completed baseline questionnaires (mean age, 53 ± 9 years). Drop-out rates were 22% during treatment and 34% at 6-month follow-up. Linear mixed models for each outcome across time showed improvement in total scores on the FSFI, MSIQ, and QLACS (P<.001) and BSI-18 (P=.001). The counseled group improved significantly more on sexuality measures, but changes in emotional distress and quality of life did not differ between groups. Program content and ease of use were rated positively. Research is needed on how best to integrate this intervention into routine clinical practice, and particularly how to improve uptake and adherence.
To analyze the quality of life and psychological adjustment after surgical therapy for localized ... more To analyze the quality of life and psychological adjustment after surgical therapy for localized renal cell carcinoma. Postal questionnaires including measures of quality of life (SF-36) and the impact of the stress of cancer (Impact of Events Scale) were completed by 97 patients who had undergone radical or partial nephrectomy for localized renal cell carcinoma. Data were analyzed for the group as a whole and comparing the partial nephrectomy and radical nephrectomy groups. The variables examined included the impact of the type of partial nephrectomy (elective versus mandatory) and the amount of self-reported renal tissue remaining. The quality of life for the group as a whole was good, with no significant differences between the sample and U.S. norms for an age and sex-matched community sample on both the mental and physical health composite scores. Having undergone a partial versus a radical nephrectomy did not influence the patients' overall quality of life. Multiple linear ...
Sexual dysfunction has only recently been recognized as a highly prevalent side effect of adjuvan... more Sexual dysfunction has only recently been recognized as a highly prevalent side effect of adjuvant aromatase inhibitor (AI) therapy for breast cancer. A cross-sectional survey using standardized measures of female sexual function was designed to provide a detailed view of sexual problems during the first 2 years of adjuvant AI therapy and secondarily to examine whether sexual dysfunction leads to nonadherence to this therapy. Questionnaires were mailed to all 296 women in a breast oncology registry who had been prescribed a first-time AI for localized breast cancer 18-24 months previously. Items assessed medication adherence, demographic, and medical information. Scales included the Female Sexual Function Index, the Menopausal Sexual Interest Questionnaire, the Female Sexual Distress Scale-Revised, the Breast Cancer Prevention Trial Eight Symptom Scale to assess menopausal symptoms, and the Merck Adherence Estimator(®) . Questionnaires were returned by 129 of 296 eligible women (43.6%). Respondents were 81% non-Hispanic white with a mean age of 63 and 48% had at least a college degree. Only 15.5% were nonadherent. Ninety-three percent of women scored as dysfunctional on the Female Sexual Function Index, and 75% of dysfunctional women were distressed about sexual problems. Although only 52% of women were sexually active when starting their AI, 79% of this group developed a new sexual problem. Fifty-two percent took action to resolve it, including 24% who stopped partner sex, 13% who changed hormone therapies, and 6% who began a vaginal estrogen. Scores on the Adherence Estimator (beliefs about efficacy, value, and cost of medication) were significantly associated with adherence (P = 0.0301) but sexual function was not. The great majority of women taking AIs have sexual dysfunction that is distressing and difficult to resolve. Most continue their AI therapy, but a large minority cease sexual activity.
Infertility is a frequent consequence of cancer therapy and is often associated with psychologica... more Infertility is a frequent consequence of cancer therapy and is often associated with psychological distress. Although adult survivors prioritize fertility and parenthood, this issue remains unexplored among adolescent males. This study examined future fertility as a priority (relative to other life goals) at time of diagnosis for at-risk adolescents and their parents. Newly diagnosed adolescent males (n = 96; age = 13.0-21.9 years) at increased risk for infertility secondary to cancer treatment prioritized eight life goals: to have school/work success, children, friends, wealth, health, a nice home, faith, and a romantic relationship. Patients' parents (fathers, n = 30; mothers, n = 61) rank-ordered the same priorities for their children. "Having children" was ranked as a "top 3" life goal among 43.8 % of adolescents, 36.7 % of fathers, and 21.3 % of mothers. Fertility ranked third among adolescents, fourth among fathers, and fifth among mothers. Future health was ranked the top priority across groups, distinct from all other goals (ps < 0.001), and fertility ranked higher than home ownership and wealth for all groups (ps < 0.001). For adolescents, low/moderate fertility risk perception was associated with higher fertility rankings than no/high risk perceptions (p = 0.01). Good health is the most important life goal among adolescents newly diagnosed with cancer and their parents. In this relatively small sample, adolescents prioritized fertility as a top goal, parents also rated fertility as being more important than home ownership and financial wealth. Health care providers should communicate fertility risk and preservation options at diagnosis and facilitate timely discussion among families, who may differ in prioritization of future fertility.
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