Intimacy and Sex After Prostate Cancer: Suggestions for Men and Couples
This article shares options and insights for men and couples seeking to strengthen physical intimacy after prostate cancer treatment. Therefore, it includes frank language on relationships, sex, and sexual practices. You may wish to consider your surroundings while reading.
Navigating This Article
Changing how we think about sex and intimacy
Options for toys to support intimacy
Sex after localized prostate cancer treatment
Options if you both feel ‘stuck’
Extra advice for gay and bisexual men
How to find a ‘regular’ therapist
How to find a certified sex therapist
Another free resource: FrankTalk.org
Prostate cancer treatment often causes side effects like erectile dysfunction, orgasm difficulties, and decreased libido. While medical interventions can help, changing how we think about and have sex can decrease frustration and deepen intimacy.
One way to learn to do this is through sex therapy, a type of no-contact psychotherapy (talk therapy) specifically focused on sexual health. PCF sat down with prostate cancer survivor and licensed and certified sex therapist Paul Nelson to hear about his journey and advice for approaching sex and intimacy after prostate cancer treatment. This interview has been lightly edited for clarity.
You’re a prostate cancer survivor, and many of your clients are, too. What concerns do they bring to you when they walk through your door?
Every client I see comes to me because they want to have sex according to a blueprint in their brain that they learned from porn, movies, or as a teenager [talking with other teenagers]. They see sex as a performance, a sequence of steps they have to perform. And they think that if they don’t ‘do’ sex the ‘right’ way, they’re a failure.
So I tell clients, let’s step back for a minute. I bet your partner doesn’t want to have sex with a porn star, and you probably are not a porn star, right? So why do you want to be one?
Meanwhile, women have been taught, ‘If you’re hot enough, he’ll get an erection.’ So if something goes ‘wrong’ [during sex], women think it’s probably their fault. My wife used to say that every woman believes from reading [magazines] that the minute a penis goes inside her, the Earth is supposed to burst into song. And that doesn’t happen, right? And when it doesn’t, the woman thinks, ‘What’s wrong with me?’
These are the pernicious lies about sex that we all share. We think sex must be performed a certain way, and that it mainly involves our genitals. A penis in a vagina can be part of your sexual expression, but it’s not ‘sex.’ A vagina is about reproduction. A clitoris is about sex. A penis can be about sex and pleasure, but it’s not everything.
So, you’re asking prostate cancer survivors and their partners to drop the cultural conditioning in which sex is a performance or a sequence of required steps. So how should they—and all of us—think about sex instead?
The definition I really embrace is that sex is a form of communication. It is communicating through touch. Sex means that I touch my partner in a way that communicates to them how I feel about them.
And neither men nor women nor any gender in between can communicate very well with their genitals, right? My penis can’t express love very well, or laughter, or silliness. It doesn’t function that way.
So, sex is not about genitals. Sex is setting aside time to touch each other in a way that makes us feel loved. So that when you’re done, you feel connected, bonded, accepted, understood, seen, and appreciated.
Another thing we’ve all been taught is that sex isn’t over until the man has ejaculated. But sex isn’t about orgasms, and it’s not your job to give your partner an orgasm. It is your job to say, ‘Would you like an orgasm, and how can I help?’ Your partner may not feel like having one, so ask.
And you can have great sex without orgasms. Getting away from the tyranny of orgasm is a liberating experience.
Okay, so now that we’re thinking about sex differently, what can men and couples do differently in bed?
There’s a great book I give guys called The Whole Lesbian Sex Book: A Passionate Guide for All of Us. I tell guys, ‘I want you to learn to have sex like a lesbian. I want you to learn to make love to every inch of her body.’ Many women are just not that into penetration. And many men would like to get off the ‘erection bandwagon’ as well.
So I tell couples, let’s learn to give each other loving, erotic massages.
I recommend the book The Ultimate Guide to Erotic Massage, which shows how to touch each other for pleasure. We’re not talking about deep tissue or Swedish massage. We’re talking about caresses. Most of us have never learned this, so this book is a great guide.
I also tell guys that touch is the foundation of sex, and the whole body is a playground for touch. Sex is not your penis and it’s not her vulva. You can work up to that, but first let’s make love to the small of her back, or her shoulders.
And while you’re giving a massage, you can ask, ‘Does this feel okay? Should I go harder, or maybe massage someplace else?’ We can learn to ask for what we want. If we can get used to asking for what we want when it comes to massage, then it’s easier to ask for what we want when it comes to sex.
And the overwhelming majority of women are thrilled about this [erotic massage approach]. Many guys will go home and talk to their wives and come back to me and say, ‘My wife said she’s been telling me this for 30 years, and I haven’t listened.’
Wow, that’s great. What about sex toys? Do you recommend them?
Yes, absolutely. Some people think of sex toys as giant [toys designed to go inside the body] or something. Most people don’t want that in their bed—it makes guys feel insecure, and many women are not that into it either. Most sex toys are best left outside the body.
So I tell guys, focus on toys that stimulate, and that are pleasurable. A silk scarf or a hairbrush can be a sex toy—something that can be rolled on the skin, or that can slide across the skin. Or you can use ice cubes or chocolate sauce. I tell guys to get online and order some fun stuff.
In addition, every guy should have at least a couple of penis rings [also known as a constriction band]. These go around the base of the penis and trap blood, so a 60% hard erection maybe becomes 80%, which is pretty usable. Some people also like masturbation sleeves. And vibrators are great. The Hitachi magic wand is good.
Low libido is a common side effect of hormone therapy for prostate cancer. How can men and couples deal with this?
I see a lot of guys who are on ADT, which can lower your sex drive [and cause other sexual side effects, like difficulty getting an erection]. I tell them, don’t rely on your libido to run your sex life. You shouldn’t have sex because you’re aroused, and you shouldn’t have sex because you want an orgasm. You should have sex because the relationship deserves it.
So, set aside time, and give each other wonderful, loving touch. It’s going to look like very different from the sex than you’re used to. But that’s okay.
Thinking about a different situation now—what if someone has had localized prostate cancer treatment: surgery and/or radiation?
If a client has been cleared [by his doctor] to have sex six weeks after surgery, I say, ‘Whether or not you have an erection, get back to having sex.’ And during radiation, if you have enough energy, keep having sex. It may not be intercourse, but it should be sex, because the relationship deserves it.
That makes sense. Now what if the couple hasn’t had any support to handle the sexual side effects of prostate cancer treatment, and now they’ve sort of reached an impasse. Maybe they’re not even touching each other much. Do you see this?
Yes, and it’s important for guys to know this is very normal. Many clients will tell me, ‘I feel sexually broken.’ We all want to avoid pain, right? And if we have erectile dysfunction, and touching our partner reminds us of intercourse, then suddenly we’re thinking, ‘I can’t do that anymore. I’m broken.’ And so, we stop touching our partner, because it reminds us that we’re ‘broken.’
And the partner is bewildered by this. They wonder: ‘What happened? He doesn’t even touch me anymore.’
This is very common, and it’s important for partners to know that it’s not personal, it’s not about you. He’s not touching you because if he does, it reminds him that he feels broken. And once we can get away from that idea [that we’re broken] and learn to make love to every inch of her body, then most women are dancing in the street.
What about gay or bisexual men, or any man who wants to have sex with other men? Do you have specific advice for them?
Yes, certainly. First, men are much kinder [about sexual health issues] than other men give them credit for. So, if you are a gay guy or a man wanting to have sex with a man, and you tell a prospective partner, ‘Listen, I have a hard time getting an erection,’ most men will tell you that’s okay. They might want to touch your genitals a little bit, but most will say that they’d rather kiss, or have oral sex. Most men who have sex with other men are very amenable to sex with a guy who can’t get an erection.
What if someone wants to be the receptive partner during anal sex after having localized treatment for prostate cancer?
Great question. First, after prostate cancer surgery, it’s hard to even sit down. The whole perineum is very inflamed, and needs time to heal. So, I tell guys to wait at least eight weeks after surgery [to be a receptive partner]. And then, when you do it, it should not hurt at all. If [anal intercourse] hurts or feels tight, anal dilators are available, which are not the same as vaginal dilators. Anal dilators can be very helpful. I also tell guys to slow down, use smaller toys, and work their way up.
And remember that anal intercourse is not only the domain of gay or bisexual men. It’s very important not to reinforce that stereotype. A lot of straight men also enjoy [being penetrated anally/rectally]. The same advice applies about going slowly and everything else.
That’s great. Are most sex therapists comfortable working with clients of all genders, identities, and so on and talking about all kinds of sex? Because regardless of who you have sex with, the topics that come up might feel quite sensitive.
Yes, absolutely. The first major training that sex therapists go through is called a sexual attitude realignment, which is [a very immersive experience that] challenges trainees’ attitudes and preconceived notions about sex. Because of this training, certified sex therapists are very comfortable talking about all kinds of sex and sexual behaviors. And in addition, they are trained to work people who are gay, bisexual, trans, and so on.
Now I want to switch gears a little. In your view, what’s the urologist’s role in all this?
In my view, we need to take this responsibility [for sexual health] off the shoulders of urologists [who treat prostate cancer. Note that urologists who treat cancer have a different specialization than urologists who are trained in sexual medicine].
Right now, many urologists are tasked not only with prostate cancer surgery and managing the acute stages of cancer treatment, but also with their patients’ overall [emotional and psychosexual] health. This is not fair to them. They’re not trained for it.
So, let’s involve mental health providers right from the start. At a urology appointment where someone is diagnosed with prostate cancer, let’s book an hour into that appointment that’s just time with a therapist, to get support for the immediate emotional impact of the diagnosis.
And if that’s not possible, then let’s send the patient to a therapist across the street who can help figure out what’s needed—whether that’s pelvic floor rehab, sex therapy, or whatever else. I don’t just mean handing out a card with a therapist’s name on it. I mean let’s have the urologist say, ‘Here’s the therapist you’ll sit down with, and they’re in the building next door.’
But right now, this is usually not how things work. Instead, the work [of supporting patients after diagnosis] falls on the urologist’s shoulders, and it really shouldn’t. I really want my doctor to focus on my cancer.
Given that urology and mental health are usually NOT integrated, how do you find a good therapist? Let’s start with how to find a ‘regular’ therapist, not a sex therapist. Are most ‘regular therapists’ able to provide good support for clients dealing with cancer?
Yes, most regular therapists are well equipped for this. They can support a patient who’s dealing with how this is a real blow, coping with feelings, reframing thoughts, handling concerns about mortality, providing support if your wife or kids are worried, and so forth. For all these concerns, most regular therapists can do a good job.
If this is what you’re looking for, you can go to Psychology Today [a database of licensed therapists throughout the United States]. And you can filter by zip code, insurance plan, and specialty.
You may just need a couple of visits, or maybe six months, or a year. Everyone is different. But my advice is, don’t wait for a doctor to send you to therapy. Many patients with cancer live with real distress for which they are not getting help.
Okay. Now what about a sex therapist? How can you find a good one, and how do you know someone really is a sex therapist if they say they are?
Keep in mind that most regular therapists have very little training in sexual health. So, if you want psychotherapy focused on sexual health, I would go straight to a sex therapist.
A sex therapist is a regular, licensed therapist who has completed additional training and certification in human sexuality. The only U.S. organization that certifies sex therapists is the American Association of Sexuality Educators, Counselors and Therapists (ASSECT). They have a referral directory for people to find a certified sex therapist.
That’s great. Does insurance cover these types of therapy?
Yes, if someone is diagnosed with prostate cancer, insurance usually will pay for psychotherapy without any questions. This is because of the trauma or emotional impact of the cancer diagnosis. [NOTE: even if a therapist does not accept insurance, they can provide a ‘superbill’ that you can submit yourself to get reimbursed for part or all of therapy, if your insurance plan covers outpatient mental health.]
Also, everyone offers online therapy now, so even if the therapist isn’t near you, you can still work with them.
Last, please tell us about your own prostate cancer journey and the patient forum you created after you were diagnosed and treated.
I was diagnosed with prostate cancer the day after my dad died of it. In 2009, when I was treated [for localized prostate cancer], I looked all over for a website where I could ask questions about sexual dysfunction. And there was nothing. All the websites out there were just scams—they were trying to sell you something [that didn’t work]. And all the prostate cancer patient forums were for men with very advanced disease, where sexual health issues were not the priority.
So, one day, my wife asked me, ‘Why don’t you start a website?’ So, I started FrankTalk.org, a free online forum for any man struggling with sexual dysfunction of any kind. There are no experts—it’s all just man to man. About half have prostate cancer, but it’s for anyone with erectile dysfunction, low libido, and so forth.
As of now almost 18,000 men are signed up for the forum, and we get about 50,000 visitors a month.
That’s terrific. Thanks for sharing these resources, and for this incredibly helpful discussion!
My pleasure.
