Sexual Inactivity and Sexual Dissatisfaction Among Breast Cancer Survivors and Their Partners

Purpose To measure the sexual activity of breast cancer survivors and their partners to better understand the causes of sexual inactivity and sexual dissatisfaction in this population. We investigated the proportion of sexual activity and sexual dissatisfaction in a cross ‐ sectional study and described their association with sexual health information sexual thoughts, socio ‐ demographic factors, body image, marital satisfaction, and mental health problems. We enrolled 438 eligible couples by convenient sampling. The statistical analysis and graphical work were completed using SPSS and Graphpad Prism.


Introduction
According to the latest statistics on breast cancer rates globally, the number of new breast cancer cases reached 2.26 million in 2020, ranking rst in the world [1]. With the improvement of the quality of cancer treatment, the age-standardized 5-year survival rate for cancer in China increased from30.9% in 2003-2005 to 40.5% in 2012-2015. At the same time, breast cancer survivors have more prolonged survival than other cancer survivors signi cantly [2]. How to improve the short-term or long-term complications of breast cancer survivors and improve their quality of life has become the focus of research. Among them, sexual health problems are the common potential long-term complications during cancer treatment. It was reported that 14%-100% of breast cancer survivors have sexual health problems [2,3].
As an essential indicator of sexual health, sexual satisfaction involves the patient's personal experience and the mutual satisfaction between intimate relationships [4]. Unlike other treatment-related adverse reactions, unresolved sexual problems usually persist or worsen if ignored [5,6]. Sexual health problems (e.g., decreased sexual desire, reduced sexual excitement and arousal, and vaginal dryness and pain) and negative body image after surgery often lead to a loss of sexual intimacy and avoidance of sexual scenes. Then, it will result in decreased sexual satisfaction [5,7,8]. Early sex education, pre-training rehabilitation programs, couples managing sexual change, and intimate relationships can improve the situation [9][10][11][12]. However, most research in this area has focused on the effects of treatment on the sexual health of breast cancer patients while ignoring the effects of proactive needs of partners on the sexual satisfaction of breast cancer patients. In addition to reduced sexual satisfaction, some people may stop having sex for good [5,6]. In an Australian study, 28 % of cancer survivors abstained from sex [13]. US researchers found that in an 18-month follow-up study, 39.3 % of cancer survivors did not have sex [14]. After one year of follow-up in South Korea, 11.5 % of younger breast cancer survivors were not sexually active after treatment [15]. Sexual inactivity was related to age, past chemotherapy, depressive symptoms, and lower perceived attraction in those studies [13][14][15]. Nevertheless, it ignores the problem of misconceptions about sexual activity.
We hypothesized that a partner's proactive needs would reduce sexual satisfaction in breast cancer patients due to post-treatment side effects (body image, anxiety, and depression), and faulty sexual thinking can lead to long-term inactivity in breast cancer survivors. The present study aimed to explore the condition of the sexual health for the breast cancer survivors and the possible associated factors to better understand the causes of sexual inactivity and sexual dissatisfaction in this population.

Participants
The present study as a cross-sectional study was conducted via an online survey between October 2020 and February 2021.The study protocol was approved by the Biomedical Ethics Review Committee of West China Hospital of Sichuan University, (#2020(1257)). All participants provided informed consent before participation. Anonymity is used to protect the privacy of patients during data collection and analysis. The inclusion criteria to participate in the current study: 1 informed consent of the participant has been obtained; 2) married, diagnosed with breast cancer, and completed initial treatment. The exclusion criteria were: 1) not being able to read and write; 2) refusing to participate. Patients who failed to complete the questionnaire with incomplete data were excluded from the nal analysis.

Assessment
Socio-demographic/medical information A modi ed baseline questionnaire was created by the research team based on a review from previous research literature [16][17][18]. We collected the basic characteristics of the participants, including standard demographic information (e.g., gender, age, education level, marital status, employment, income) and medical information related to cancer (e.g., time since cancer diagnosis, treatment type, surgery type, recurrence, and metastasis).

Hospital's sexual health resources
The information related to the hospital's sexual health resources was used to assess the sexual and vaginal health resources currently available to participants. Three questions were in this survey: 1 Does the hospital have regular sex counseling? 2 Did medical providers ask patients about their sexual health history regularly? 3) Are you embarrassed to talk about sexual health with healthcare providers?

Sexual health
The information on sexual health was collected begin with the question of "have you been sexually active in the last four weeks?" Participants who responded with "no sex" skipped to two other questions: a) Why haven't you had sex in the last four weeks? (brief description). b) How satis ed are you with your sex life overall? (having response options for different satisfaction). Participants who answered "having sex" skipped to a female self-reported sexual dysfunction index (FSFI) [19]. The FSFI contains 19 questions on six domains (desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia) [20,21]. This index has a high reliability and validity and is validated in Chinese [22]. The multidimensional scale examined participants' sexual function during the last 4 weeks. The score for each dimension is multiplied by the coe cient of the eld to calculate the total score. A score ≤of 26.55 indicates the presence of sexual dysfunction.
Another question related to their partner's proactive needs was, "Have you ever been sexual demands on your partner?" The answer to this question was used to evaluate the impact of partner proactive needs on patients' sexual satisfaction, which was answered by the survivor's partner.
Patients' sexual knowledge related to their disease All participants were asked four questions about their sexual knowledge related to their disease. 1) Sexual activity may hinder recovery from the disease. 2) Sexual activity may cause cancer metastasis or recurrence. 3) Sexual activity may alter estrogen levels and stimulate breast cancer growth . 4) Have you ever used sex aids to relieve your dryness or pain? At the end of this part, the patients were asked to rate their own sexual thoughts either positively or negatively.
Psychological issues related to sexual activity The psychology related to sexual activity includes anxiety, depression, body image, and marital satisfaction. The Chinese Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression, which was validated previously [17] [23]. It consists of 7 items depression subscale and 7 items anxiety subscale. Each item is rated on a 4-point Likert scale, giving a maximum of 21 points for the depression and anxiety subscales, respectively. A cut-off points of ≥8 in each subscale is identi ed to detect the clinically relevant psychiatric disorder.
Four body image questions were also asked to explore patients' satisfaction with their body appearance. This questionnaire was derived from the QLQ-BR23 scale, which is a speci c tool for assessing the quality of life in breast cancer [24]. 1) Do you feel less attractive because of the illness or its treatment? 2) Do you feel less feminine because of the illness or its treatment? 3) Did you nd it challenging to look at yourself naked? 4) Are you dissatis ed with your gure? At the end of this part, participants were asked to complete a marital satisfaction rating. The higher the score, the higher the satisfaction.

Statistical Analysis
Continuous variables with normal distribution were expressed as mean ± standard deviation (SD), while categorical variables were expressed as frequency. Univariable and multivariate binary logistic regression was performed to gure out the risk factors for sexual inactivity and sexual dissatisfaction. Potential independent variables were rst identi ed by univariable logistic regression. The variables with a signi cance level of P < 0.10 in univariate analysis would be included in the multivariate analysis. The odds ratio (OR) was adjusted by multivariate logistic regression for each potential independent predictor. P < 0.05 was set as statistical signi cance.
Trend test analysis was used to assess the association between partner-requested sexual demand and sexual satisfaction. Statistical analyses and gure generation were performed with SPSS software (version 25.0), and GraphPad Prism (version 7.0).

Basic characteristics of the participants
We collected 475 couples' response data, and 438 couples of them were included in the nal analysis.The mean age of the participants was 46.6±8.6 (mean±SD) years. For all 438 participants, 400 (91.3%) were married, most women lived in the city (290, 66.2%), and 127 (29.0 %) were employed. Duration of disease was de ned as one year (39.7%), one to two years (32.6%), or more than three years (27.6%) according to the date of diagnosis. Most of the patients had undergone a mastectomy (94.3%). Other details of the characteristics of the patients can be found in Table 1.
All participants responded to the hospital's sexual health resources, and only 10.7 % con rmed that the health care provider provided information about sexual health. More than half of the participants suggested that medical providers should regularly ask patients about their sexual health history (66.0%). Most participants reported that discussing sexual health issues with health care providers could be embarrassing (86.1%). Less than a quarter of participants used sexual health aids (22.4%). In addition, we asked participants to report on their partner's sexual desires. We found that sexual dissatisfaction increases as partner-requested sexual demand (p<0.05) ( Figure 1). Nearly half of the participants had misconceptions about the sexual health of breast cancer. The common misconceptions were affected the recovery of the disease (49.8%), it may cause recurrence or metastasis (41.6%), and it alters estrogen levels and stimulates tumor growth (48.9%) (Table 2&4).

Sexual dissatisfaction
Of all participants, 192 (43.8%) were sexual dissatisfaction. The risk factors of sexual dissatisfaction was identi ed through multivariate regression (Table 1&3&4)

Discussion
Our study demonstrates that breast cancer survivors have a high rate of sexual inactivity (58.7%) and sexual satisfaction (43.8%), which is consistent with previous research reports [13,25,26]. We found that despite the prevalence of sexual health problems, there were differences in the variables affecting sexual inactivity and satisfaction.
Sexual dissatisfaction and sexual inactivity after a breast cancer diagnosis are a common phenomenon that is undertreated, especially in breast cancer survivors. Through a cohort study, Wettergren et al. has shown that body image, anxiety, and depression were associated with sexual dissatisfaction and have lasting effects on it [25]. Karin et al. suggested that treatment-induced symptoms, depression, and age were predictors of sexual problems [26]. Through a qualitative study, Maryam et al. indicated that adverse sexual function (vaginal dryness or pain, changes in sexual desire, and decreased sexual arousal) leads to decreased sexual satisfaction among survivors [27]. Jennifer et al. concluded that a quarter of couples are not having sex because they are uninterested in it (78%) and too tired (44%) [13]. In the present study, in addition to the previous ndings from other scholars, we found that misguided sexual thinking was strongly associated with sexual inactivity. Meanwhile, body image, psychology, and lack of sexual information from health care providers were more signi cant for sexual dissatisfaction. We also identi ed that the sexual demands of the partner led to increased sexual dissatisfaction among the survivors.
The impact of changes in mental and body image and intimacy on sexual dissatisfaction in breast cancer survivors after treatment has received attention, but misinformation about sex has been ignored. In our study, a particularly important nding is that sexual inactivity is associated with misleading sexual thinking. We investigated misconceptions about sexual activity to cancer recovery, recurrence, metastasis, and stimulating estrogen growth. Nearly half of the participants reported that they believed sexual activity can affect their recovery from the disease (49.8%), causes cancer recurrence or metastasis (41.6%), and may alter estrogen levels and stimulate tumor growth (48.9%). However, sexuality is not a taboo for breast cancer survivors, and no research revealed that sexual activity was related to breast cancer recurrence and metastasis. Changing this misleading thinking of cancer patients needs essential education to the patients and their partners.
Although guidelines for sexual health care for cancer survivors clearly suggest that sexual health resources should be conducive to sexual health [3,28]. In our study, most participants were not provided with therapeutic sexual aids or any other sexual health resources (89.3%). Similar results were found in a study by Sharon et al. [29], which surveyed 25 comprehensive cancer centers a liated with both the National Cancer Institute and the National Comprehensive Care Network. They identi ed that 72% of hospitals did not provide therapeutic sexual aids or any other sexual health resources. Nowadays, health care providers in China pay less concerned about sexual function when treating breast cancer [30]. In our study, the majority of survivors expected health care workers to ask about sexual health regularly (66.0 %). In the present study, our participants reported a higher degree of embarrassment around provider discussions (86.1%), which is contrary to the nding (12.0% )of Chapman et al. [31]. This difference may be caused by the taboo on sex in Chinese culture. This disparity should be further explored and taboos in communication between patients and healthcare providers improved.
Partnered sexual activity was strongly associated with the recovery of sexual function in patients with breast cancer after treatment [6,32]. Partners' initiation of sex predicted a positive trend in the sexual health of breast cancer patients [33,34]. Similarly, intimate partners can buffer patients' cancer-related stress and promoting positive sexual relationships [34]. In the present study, sexual dissatisfaction increases as partner-requested sexual demand. One possible explanation is that problems that don't improve during breast cancer treatment, such as sexual discomfort, anxiety, depression, and self-image issues, all negatively affect a couple's sexual satisfaction [26]. Another possible explanation is that simply dealing with a patient's sexual relationship with an intimate partner may not improve the sexual problems of breast cancer survivors [33,34].
There were a few predictive demographic variables of note in our study, particularly related to residence and education level. Those with higher levels of education and living in cities reported more sexual dissatisfaction than those with lower levels of education and living in the countryside. This disparity should be explored further because it might suggest that patients with lower levels of education are at even higher risk for neglect of discussion and treatment of sexual dysfunction.
In practice, there is a lack of health care in cancer management in China . According to our ndings, the professional sexual education and consultation should be an effective therapy to improve the sexual knowledge of breast cancer survivors. In addition, the impact of the partner's proactive needs on sexual satisfaction also needs to be taken into account when developing couples' therapy together.
To our best knowledge, the present study is the rst cross sectional study to explore the possible factors associated with sexual inactivity and sexual dissatisfaction. As an instinct problem of the observational study, there were unrealized confounders which may decrease the evidence quality of our ndings. Future high-quality longitudinal studies are needed to con rm our ndings.

Conclusions
Patients' sexual knowledge related to their disease was the great barrier to sexual activity. Improving psychological problems associated with sexual activity and providing professional sexual health resources in hospitals can effectively improve sexual satisfaction among survivors. In addition, the impact of the partner's proactive needs on sexual satisfaction also needs to be considered when developing couples' therapy together.

Declarations
Funding This work was supported by the Department of Science and Technology of Sichuan Province, China [grant number 2020YFS0156].

Con ict of interests
The authors declare that no con ict of interest could be perceived as prejudicing the impartiality of the research reported.

Ethics approval and consent to participate
The study protocol was approved by the Medical Ethics Committee of our hospital (#2020(1257))..

Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Consent to Participate
All participants involved in this study gave their informed consent.

Consent to Publish
Patients signed informed consent regarding publishing their data.