HUMAN SEXUALITY AND BREAST CANCER PATIENTS SEXUALITY AND BREAST CANCER PATIENTS.”

Sexuality reflects a person’s personality. Cancer, regardless of its location can affect sexuality. Cancer and its treatment have a bio-psycho-social impact on a patient.3 Research has shown that poor physical health and emotional distress can affect sexual health 4. Cancer survivors were reported to have sexual problem after cancer therapy.5following changes in body image. Materials and Methods: Subjects taken for the study were who had come for consultation regarding their physical health including sexual health. 65 subjects with breast cancer patients were included in the study. Informed consent was taken from the cases and it was approved by an Institute Ethics review Board attached to the institute. Basson’s sexual response cycle formed the basis for formulating worksheet given to the patients to record breaks in their sexual response cycle following a sexual encounter they had with their partners (husbands). 5 takes into account the role of intimacy in understanding the women’s sexual response cycle and it is non-linear in nature. This makes the model suitable for studying sexual response cycle in women in health and disease. Based on the model the work sheet was created to understand the sexual response cycle of women with breast cancer, The Breaks in the sexual response cycle were found to due to Biological factors like body image, fatigue and drug therapy along with psychological factors like pain, anxiety and depression. The main motivator of sexual response was physical intimacy and care in these patients.


Introduction
"I hate society's notion that there is something wrong with sex. Something wrong with a woman who loves sex." -Alessandra Torre Human sexuality is a complex phenomenon that reflects our personality. According to WHO (2002), sexuality includes sexual orientation, biological instinct, and well-being of the individual. 1 Http://www.granthaalayah.com ©International Journal of Research -GRANTHAALAYAH [208] It can be influenced by biological, psychological, socio-cultural and religious factors. Even though sexuality is an important element in the health-illness continuum, little or no attention is paid sexuality during cancer care 2 .
Because sexuality reflects a person's personality, cancer, regardless of its location can affect sexuality. Cancer and its treatment have a bio-psycho-social impact on a patient. 3 Research has shown that poor physical health and emotional distress can affect sexual health 4 .Cancer survivors were reported to have sexual problem after cancer therapy. 5 Following changes in body image.
Basson's sexual response cycle 5 takes into account the role of intimacy in understanding the women's sexual response cycle and it is non-linear in nature. This makes the model suitable for studying sexual response cycle in women in health and disease. Based on the model the work sheet was created to understand the sexual response cycle of women with breast cancer. The model takes into account the role of intimacy as one of the major factors that make women appreciate and enjoy sex with the partner. Such intimacy is not felt by majority of the breast cancer patients and it was indeed one of the much neglected areas of women's health in breast cancer patients. 6 ( Figure 1)

Methods
Women who participated in the present study were from larger groups of patients with various psycho-sexual problems who had come for sex counseling at Salem, TN, India. The sex counseling center was a part of The Salem Clinical Diagnostic Center specialized in hormonal Assays. Informed consent was taken from the respective patients. 65 Patients who underwent chemo and radiotherapy after mastectomy were included in the study. A work sheet was prepared following Basson's Model of the sexual response cycle and given to the participants. 5 They were asked to recollect and reflect on a recent sex encounter they had and were instructed to address stepwise manner starting with the reasons for sex, initiating and continuing with the sex experience based on the reasons mentioned; followed by the stimuli and context helping the arousal phase helped or hindered by biological and psychological factors, which led to combined response reflected as sex arousal, leading increased sexual desire followed by the outcome of the experience resulting from the initial sex experience or encounter.
The women selected for the study were interviewed for eligibility to participate in the study, evaluated by certified counselors and psychiatrist. Written Informed consent was obtained from the patients. By email their sexual response cycle entered in the worksheets were studied for finding any break in the cycle.

Data Analyses
Breaks in the sexual response cycle was identified using conceptual content analyses. A negative or positive response was considered as a break in the cycle. 8-9 following the sexual encounter between the partners. Any other reasons to avoid to continue the cycle, or absence of arousal, if medications or tiredness hinder the response, mastectomy or the loss of hair or body weight were taken factors that hinder the continuation of sex response cycle and they were taken as breaks in the sexual response cycle. The age group of the participants were from 45 years to 60 years (M= 46; SD= 12.5). All the Participants were married (100 %).

Breaks in the Cycle
Interruptions in participants' sexual response cycle was analyzed through concept content analysis. Out of the possible 11 breaks an average of 6.4 breaks in the cycle was observed (6.4; SD 1.85). and the findings are summarized in Table.1 What reasons for sex had negative emotions or lack of desire in having sex or participating in sexual activity, the fear following diagnosis of cancer and therapy are shown in Table.2. The initiation of engaging in sex then followed a NO or YES and there was more of NO than YES (Table.1.and 2) Sexual Arousal 3 04.6 7.
Outcome 5 07.5 The stimuli like touch, cuddling or kiss and the context or the environment were not significant players in the sexual response cycle. Rather the loss of a breast and the sudden bodily changes in the patient and followed by the partner's hesitation to indulge in sex had negative impact and receptivity to such negative responses mitigated the desire to have sex.  intimacy" by the patients to be cuddled and the protective embrace of the partner were the psychological factors that promoted sexual activity.

Feedbacks
The commonness of feedback different phases of the cycle was calculated and expressed in the Table.3 • Reasons to have sex was mostly for intimacy.
• Stimuli and context: touching, cuddling, sometimes kissing. The initiation of sexual response cycle brought the patient close to the partner and to some extent to make her partner happy. • Biological factors, loss of body image, body part, pain, fatigue were the major factors that hindered and broke the sexual response cycle.

Discussion
Masters and Johnson described a "sex response cycle" that included four phases, 1.Excitement, 2. Plateau, 3. Orgasm and 4. Resolution. This model showed only the physiological changes during the response cycle. It also assumed that each phase occurs one after the other without any overlap. This linear model was improved by Kaplan Model which included desire as a component along with excitement and orgasm phases. This model also was linear in nature It also envisioned that orgasm to end in the cycle. Basson's Model was found to be relevant for the present study as it incorporated intimacy as one of the major components of the cycle.
In the following Figure it is shown that receptivity to sex stimuli are hindered by depression, drugs, fatigue apart from low self-esteem due to body image. This hindrance or inhibition did not enhance subjective sex arousal with a moderate aversion to sexual activity and therefore, preventing in indulging regular sexual activity. It is said that during sexual response cycle the genital arousal and subjective cognitive appraisal of sex stimuli need to be synchronous for an enhanced sexual activity and orgasmic response. Such an orgasmic response leads to the release of oxytocin, minimizing menstrual tension, relaxation of body and reducing toxins production which may be carcinogenic. It also includes an unique sexual behavior which if it culminates ejalculatory response will result in ecstasy, sometimes spiritual communion and relaxation. If there is a desynchrony between the genital and subjective emotional response to sex stimuli may lead to loss of interest in sexual activity. The loss of genital sensations along with subjective arousal will impact the whole health of a cancer patient. Therefore, it will be worthwhile to understand the sexual responsive cycle of a breast cancer patient to suggest or intervene therapeutically to salvage the cycle. The intimacy component therefore will help propagate the sexual response.
It is suggested enhanced sexual arousal followed by orgasmic response will release oxytocin and endorphins to have sedative effect. Such a sedative effect may help a cancer patient overcome anxiety in the form of frigid behavior. Figure 4. Therefore, one must understand that human sexuality is more than a biological phenomena. It is a living experience which makes one understand how one view her personality and her body. Majority of the time health professionals spend time in treating the patient rather that the patient's sexuality. Many health professionals feel uncomfortable to discuss sexuality with the patient due to cultural issues as well as lack of information regarding human sexuality in a cancer patient.
Human sexuality is one of the major components of the well being of an individual and therefore studies related to sexuality (WHO,2000) in cancer patients need to be undertaken to promote the health of the cancer patients.