Fifteen HCPs include six staff nurses, four medical officers, three specialists and two counsellors with the mean of 8.5 years experiences in managing breast cancer patients were involved in this study. The sociodemographic information of the participants interviewed is presented in Table 1. Three main issues were identified from HCPs regarding in handling sexual dysfunction: scarcity of knowledge, sociocultural influence and specialty-centric barriers (Table 2).
SCARCITY OF KNOWLEDGE
Narrow meaning of sexuality
Most of the HCPs described the meaning of sexuality as purely sexual intercourse. One viewed sexuality as body image or body ideals for both genders, male and female:
Sexuality…if we talk about sexuality, I imagine it as the general appearance of the individual according to their gender, men and women respectively. (Dr H, oncologist, four years of experience)
Dr N, meanwhile, felt that sexuality should be broader in meaning, involving the emotions that couples experience together, their ability to perform gender roles as well as obligations in the relationship:
The meaning of sexuality is extensive, it is not focused on sexual intercourse per se, but more on the husband and wife relationship that results in marital happiness…also the image of the woman, whether she feels herself to be complete or incomplete. (Dr N, surgeon, 11 years of experience)
Unfamiliarity with FSD
Almost all doctors remarked that their lack of exposure to FSD was due to unfamiliarity with the disorder and treatment because it was not covered in their training.
If they develop low self-esteem due to their body image, we can refer them to a plastic surgeon for reconstructive surgery or an implant…But I am not sure the treatments for FSD. (Mrs. K, oncology staff nurse, eight years of experience)
Dr S received complaints from a few patients regarding dryness but not sure how to treat it and refer them to the counsellor.
Lack of training
Lack of training in sexual health and FSD leads to a lower level of confidence in HCPs regarding discussing sexual problems with their patients. As stated earlier, most of them attributed not knowing about FSD to not having the proper training on this topic either during their undergraduate or postgraduate studies. In addition, several HCPs stated that they had never attended any related courses and FSD was never discussed in their continuous medical education program at the hospital level:
We do not have training about FSD and its management, just from our experiences from seeing the patient with sexual problems…I usually will spend time with them …if needed, I refer them to relevant specialists. (Dr N, surgeon, 11 years of experience)
This is in contrast with junior HCPs, for whom sexual health and FSD were included in their undergraduate syllabus. However, knowledge without training caused them to have less experience in handling such patients:
We learn about FSD during medical school. But we rarely handle patients with sexual dysfunction. We saw erectile dysfunction cases; however, we did not know how to manage them. We did not have much exposure. (Dr I, oncologist, two years of experience)
SOCIOCULTURAL INFLUENCES
Sex and privacy, reticence and embarrassment
Many HCPs shared their difficulties in initiating conversations about sexual problems among women with breast cancer because culturally the topic is considered taboo.
Most patients refuse to talk about it…because sexual issues are too private for them. (Dr N, surgeon, 11 years of experience).
This phenomenon has caused some HCPs to consider it to be offensive to talk about sex if their patients did not complain about it first. HCPs were also embarrassed to deal with sexual problems, as many confessed to being too shy to initiate and discuss FSD and sexual health. This made most HCPs keep their quiet and hope that patients would disclose their problem during the first encounter themselves. However, some realized that they are supposed to develop a rapport, take some time and make a move to start the conversation if they want these women to voluntarily to reveal their problems.
I am very shy. I force myself to ask…to provide treatment and save their marriage. I usually say sorry first before I ask about sexual issues because I want to make the conversation as neutral as I can and to develop trust in the patient. (MrsG oncology counselor, 13 years of experience)
The sensitivity of the issue in the community has caused a few HCPs to have trouble finding the appropriate words and ways to ask their patients about sexual problems in a manner that would ensure that patients would be less likely to feel upset.
Sexual health is not the patient’s priority
In elaborating on the influence of culture on women with breast cancer, Dr H realized that Malay culture is more entrenched in east coast states, particularly in suburban and rural areas:
When I was in Kota Kinabalu, most of my patients, including Malays, were concerned about body image and their sexual life… Maybe (they are from) the urban area. They were more open. In Kelantan, most Malays are wearing ‘baju kurung’, thus physical appearance is not important…maybe sex is not essential for them too. (Dr H, oncologist, four years of experience)
HCPs revealed that most patients under their care seemed more worried about their disease and the treatment’s side effects.
They are more concerned about skin dryness and itchiness after radiotherapy. Even cervical cancer patients who receive radiotherapy for the pelvic area only complain about vaginal dryness rather than telling us about sexual dysfunction. (Dr I, oncology doctor, two years of experience)
HCPs also explained that their patients choose to turn to religion when they are sick because they believe illness to be a trial from God. Thus, it is thought to be a more appropriate time for patients to ask for healing of their illness as well as forgiveness:
They focus more on their family; the problem arises after they get cancer. And some patients said the important things for them now are to seek God’s forgiveness and abide more frequently to religion. (Mrs A, surgery staff nurse, 11 years of experience)
These women choose to provide sexual satisfaction only for their spouse while they suffer from breast cancer and ignore their own satisfaction.
When asked about sexual intercourse, patients said it is like before. When I asked about satisfaction, they kept quiet... They do it [sexual intercourse] just to give their spouse sexual satisfaction. For them, this is enough. (Dr E, psychiatrist, four years of experience).
They told us that their desire for sex was reduced and they were not involved in sexual intercourse as much compared with when they were younger (under 40 years). They said their husbands did not bother [them] much on that. (Dr L, oncologist, three years of experience)
Sexual discussion and social status
The appropriate social status is viewed as an important element in taking sexual history and having discussions on sexual health with women with breast cancer. Many HCPs realized that gender difference and being single prevented them from obtaining adequate sexual history from these patients since they felt less comfortable and embarrassed.
I have seen a conversation between a female patient and a male doctor. The doctor asked how her sexual relationship with her husband was. The patient started to cry and then was reluctant to talk further. The male doctor then offered her to see a female doctor. She agreed. (Mrs J, oncology staff nurse, four years of experience)
Age is another factor that is commonly considered as a cut-off point to discussing sexual health with patients. Many HCPs perceived sex as not important to elderly patients.
Sexuality for them… is more about spending their lives together, like touching and caressing each other, not sexual intercourse. (Mrs D, surgery staff nurse, five years of experience).
SPECIALITY- CENTRIC
Low priority for sexual health
Multidisciplinary approach is prudent for HCPs to manage their patients’ problems in a holistic manner. They were more focused on treating the cancer itself and explaining the side effects of treatment.
In breast cancer, we only concentrate on her cancer. For sexual problems, we rarely ask because our main concern is to identify any complications from the chemodrugs. (Mrs C, oncology staff nurse, 19 years of experience).
I do not have much information on that because I rarely ask about sexual problems in my patients. I concentrate more on financial and emotional issues. (Mrs D, oncology counselor, 15 years of experience).
There were no referrals from other health disciplines to the psychiatrist for appropriate FSD treatment.
I never get referral from other department for these problems. (Dr E, psychiatrist, four years of experience).
Time and privacy limitation.
Limited resources and the overwhelming number of patients who visited oncology clinics lead to HCPs not having enough time and no privacy to screen for FSD:
We cover about 40 patients per day only in the morning session. We also get referrals from our ward if any problems arise with in-patients from other departments and from other hospitals. […] More time is needed for complicated cases and we focus more on their disease rather than talking about sex. (Dr O, oncologist, two years of experience).
We shared two medical officers in one room, hence there is no privacy for the patient to discuss on sexual problems. {Dr A, medical officer, two years of experiences).
Difficulty to spend a suitable time also acts as a barrier for HCPs to discuss sexual issues with their patients even though patients admit in the ward. The stage of the disease and the side-effects of medications also limit the conversations about sexual issues.