Impotence after prostate cancer

Experts offer hope to cope

Unfortunately, sexual side effects following prostate cancer treatment are quite common. We asked the authors of Intimacy with Impotence, Ralph & Barbara Alterowitz, to address this important issue. Both are AASECT Certified Sex Counselors and founders of the nonprofit organization The Center for Intimacy After Cancer Therapy. They provide some excellent tips for couples who are struggling with changes that are affecting their sex lives.

Some couples assume that their sex life is over because of impotence. What would you say to couples who are frustrated by impotence?

Ralph: What we say to couples—and tell them in our talks—is that it’s not over, and we show them how they can recover. In long-established relationships, the longer the relationship goes on, a lot of things fall by the wayside. There isn’t the romance. They get locked into a routine. As Honore de Balzac said, the biggest destroyer of relationships is habit and boredom. Couples usually don’t try to go beyond what they are already doing. After the man has had treatment, he’s suddenly devastated that he can’t get an erection any longer – never mind whether he could regularly get an erection before treatment. In his mind, he is thinking about when he was a young stud and could get an erection almost at will. He’s thinking: “I can’t get it up any more, so sex is over.” So you’ve got to get them back to the point of what having a relationship with their partner means, and reinvigorating their relationships, or what Barbara and I call “relearning loving.” 

Barbara: If you’ve had a relationship where you’ve fallen into a rut, where you’ve had sort of mechanical sex—the penis goes into the vagina—then you think that’s the only way you can have sex. The reality is that your sex life doesn’t have to be over, but you will have to learn some new things together, which can be very exciting and really enrich your relationship. But there has to be the willingness to work together. Communication is incredibly important.

While impotence associated with prostate cancer treatment is very common, it does not mean that your sex life is over.

How would you define intimacy? 

Ralph: Intimacy is really having a very close connection with someone. Intimacy can be with people where there is nothing of a physical nature at all, all the way through to physical intimacy. What happens in men after cancer is they can end up withdrawing, because they are focused on one part of their problem—impotence—and that affects the emotional and physical intimacy. 

Barbara: Many people think of just sexual intimacy when they hear the word intimacy. But when you are in a long-term relationship, good sex is really the physical expression of emotional intimacy. Both are very important because when you are emotionally close, you can experience a very strong connection during sex.

When impotence is an issue, many men withdraw. Can you share some insights about that?

Barbara: It is quite common that men become depressed after the diagnosis and treatment, not just because of the occurrence of impotence, but because their whole life has been turned upside down. They recognize their mortality much more dramatically, and they are afraid they might die. A lot of men feel they have lost their identity as a man, because it was so closely linked with their ability to have an erection. That’s something that the partner has to take into account and be aware of. Another reason many men withdraw, not just from sex, but from touching, is because they are afraid it will lead to sex. But most men never talk about it. In one of our support group sessions, we had a member of the clergy—a “professional communicator.” After his prostate cancer surgery, he was impotent and had some degree of incontinence. The first time his wife approached and touched him after his treatment, he turned away, and she never tried again. By the time we talked to him, they had lived like brother and sister for 11 years. Now that’s a tragedy, and what it would have taken was for one of them to take the initiative to say, “Look, there may be some reasons why we may have to do things differently, but having you touch me, and having a physical relationship with you is very important to me. It’s a part of what we are as a couple. So, I would really like to work with you to figure out a way that we can do this even if it’s not the same way we used to have sex.”

Do you think men with impotence often withdraw because they are afraid they can’t please their wives/partners anymore?

Barbara: A lot of men are afraid that they can’t give their wives or girlfriends pleasure anymore, so it’s incredibly important for him to understand that there are plenty of ways to please her. That she’s happy to show him and that they can learn together. The most important thing for her is that they stay physically connected.


Number one, she can tell him she wants to have a physical relationship with him, somehow, someway, even if he can’t have an erection ever again. Secondly she can tell him that there are other ways to give her pleasure and she would like to explore them together with him. 

What are some ways couples can give each other pleasure when impotence makes intercourse impossible?

Barbara: The most important thing is to have sensual sex. Once you lose that focus on the erection, and stop worrying about it, you can just focus on giving each other pleasure, and having a sensual experience together. That opens up a whole new world for a couple. It all starts—and can sometimes finish—with sensual touching, and that means not just touching the genital area or the breasts. Your whole body is an erogenous zone. The skin is the largest sexual organ. You could have a whole session of just touching and not even go further than that, or you could use it as a starting point. Sensual kissing is also incredibly important. Focusing on the sensual aspect of touching the lips against each other, and having long sensual kissing sessions opens up a whole new world to a lot of couples. People can read erotic poetry together, or watch erotic videos together. I’m not talking about pornographic videos because porn is totally un-sensual. But there are organizations, like the Sinclair Institute, that publish videos of real couples making love, not having porno type of sex. Joint masturbation or one masturbating the other, oral sex, and here’s something that a lot of people don’t think about: Even if you don’t have an erection, you can rub the penis around the clitoral area, and it’s an incredibly sensual experience for both partners. It feels wonderful and can bring both to orgasm very easily. Rubbing the penis between the breasts or between the cheeks of the behind, or touching different parts of the woman’s anatomy with the penis, and of course, touching all over. Using vibrators or sex toys can be helpful. You can act out fantasies together, which also means sharing and communicating. Another important concept is to go slow, because when you slow down the whole process, you open yourself up to a different world of pleasure. Forgetting about the “quick grab and I’m going to have penetration and an orgasm and it will all be over in five or 10 minutes,” really helps. By slowing down, you can have more sensual sex. It’s really about focusing on each other and experiencing each other's bodies.

In your book, Intimacy with Impotence, you write about using “exploration sessions” as a way for couples to enhance intimacy with impotence. How can a wife/partner suggest this?

Ralph: A woman can say, “Look I’ve been doing some reading, and I know your sensitivity has changed in different places, and I’d like to have an exploration session.” This takes the demand off the man. 

Barbara: She can also say, “Tell me where it feels good.” Because of sensitivity changes—and because some nerves have been damaged and others are not—maybe there used to be places where he used to go to heaven when she touched him, and now he doesn’t feel anything there. She doesn’t know that. If she touches other places where he was previously not as sensitive, they may give him the greatest pleasure, but she only knows if he tells her. So encouraging an exploration session and saying, “Let me understand where it feels good for you,” may open him up. By the way, he should reciprocate and have an exploration session on her too, because over time our bodies don’t stay the same. The same thing that made her feel great at 25 is different than at 45. But I would suggest in most cases that she does an exploration session on him first. 

What would you say to wives/partners who are apprehensive about being the initiator of sex, especially if impotence is an issue?

Ralph: Most of the time, thinking that men should take the initiative and the woman should wait until she is approached, or the word many women use—seduced—fits the romantic concept of older couples. And it is a self-defeating approach because of the man’s situation and the way he feels. Men who have had hormone treatment lose libido–the urge to start love-making. But they can be receptive to the woman when she initiates. There have been some studies done where men on hormones, who were shown erotic videos were able to get erections, which is generally not known. If a woman initiates the amorous event, what happens is that even though the man doesn’t feel the urge to initiate, his brain still has a memory of what it felt like to make love and have an orgasm. And if she initiates, that jump starts or kicks in the memory bank, and he will respond. Some men may not be receptive because he’s afraid he won’t be able to follow through and others may still be withdrawn, resistant, and not even talk about it. Even if he doesn’t want to hear it openly, she can leave him notes. She can say “I love you. I want to go back to our physical relationship, and whatever happens is okay with me.”

Barbara: Chances are he won’t bring the subject up. At some point you have to take the initiative, and don’t wait too long. You also have to set the stage all day long. Do a lot of touching during the day, and not always sexual touching. Keep that physical touching in the relationship alive throughout the day. Behaving in a loving way, all day long, makes both partners more receptive to an amorous event. And showing your love all the time is a great way to live. Either partner can pick or buy a flower and give it to the other, saying “this is just because you’re great.” Renewing loving ways to reset a couple’s loving environment can help the partners to recapture the magic of their relationship–and who wouldn’t want that?

HisProstateCancer thanks Ralph and Barbara for their insights on intimacy with impotence.

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