Intimacy, Desire, and the Body You're Living In

Here is a number. In a 2024 survey of oncology patients, only 5.4% said their healthcare provider initiated a pretreatment discussion about sexual health and potential adverse effects. A 2025 survey of breast cancer survivors found that nearly three-quarters received no sexual health information at all from anyone on their healthcare team.

Not limited information. None.

This is the chapter about everything those conversations didn't cover. Which is almost everything.

But before that chapter begins properly, this needs to be said: the silence around intimacy and cancer is not only a clinical failure. It is also a cultural one, a communal one, and in some contexts a systemic one that runs far deeper than a busy oncologist's consulting room. For many people reading this, the reason this conversation never happened is not just that the clinical team didn't initiate it. It is that it could not have happened — in the consulting room, or at home, or anywhere visible — because the cultural or community context simply does not permit it. Because discussing sexual health is not done. Because intimacy is private in a way that no app or healthcare encounter should touch. Because asking for this kind of help would expose something that cannot be exposed.

This chapter is written for every one of those contexts simultaneously. It is written for the person who can walk into a GP surgery and ask directly for help. And it is written for the person who cannot. Everything in it that can be done alone, privately, without anyone knowing, is written that way. Because you are entitled to the information and the self-help regardless of whether anyone ever knows you read this page.

The silence — and all the reasons it exists

The clinical reasons come first because they are documented and they are real.

Clinical teams are trained in survival and treatment. Sexual health sits at the outer boundary of what most oncologists feel equipped or authorised to address. Of 133 physicians surveyed in a 2024 study, 31.6% said they never or rarely address sexual health with cancer patients. Only 10.5% felt frequently prepared on the topic. The reasons they gave were lack of training, lack of time, and patient discomfort — in that order. The patient picks up the silence and interprets it as permission not to ask. The conversation never happens. The specific effects of treatment on sexual function — which are predictable, documented, and mostly manageable — go unexplained.

That is one layer of silence. There are others, and they deserve to be named without judgment.

For many people, the discussion of sexual health is not awkward in a clinical context — it is simply impossible. Not as a personal failing but as a real feature of the cultural or community context they live in. A 2023 systematic review of barriers to healthcare for Black, Asian, and Minority Ethnic women in the UK specifically identified cultural and religious barriers to discussing sexual and reproductive health as a major theme. The NHS Race and Health Observatory has noted that cultural sensitivities and taboos can prevent some people from discussing gynaecological problems or accessing services at all. These are not ancient or irrational responses. They are deeply held frameworks about privacy, modesty, and the relationship between the body and community life, and they are held by real people navigating a health system that has rarely made space for them.

Religious frameworks shape what conversations are possible and what forms of intimacy are valued. For many people, sexuality is understood within a specific relational and spiritual context — marriage, faith, community expectation — that gives it meaning and structure but also makes clinical discussions feel intrusive or shameful. This chapter does not ask anyone to abandon those frameworks. It asks: within the life you are living and the values you hold, what information can help you?

For older people, there is a different silence, and it is equally real. Research confirms that GPs have not proactively raised sexual health with older patients, and that some women report experiencing explicit ageism — being made to feel their intimate lives were an inappropriate subject for a healthcare conversation. Adults remain sexually active, and report sexuality as important to quality of life, into their seventies and eighties. If nobody on your clinical team has asked about this because of an assumption about your age, you are entitled to raise it.

For LGBTQ+ people, the silence has its own particular texture. The double bind that Macmillan has documented — that personalised, appropriate treatment often requires disclosure of sexual orientation or gender identity, but disclosure is perceived as risking stigma and discrimination — produces a silence that belongs entirely to the system that created the conditions for it, not to the person navigating it.

All of this is said not as an excuse for the silence but as an honest acknowledgment that you may be reading this in circumstances where the usual advice is not straightforwardly available to you. This chapter provides the information and the self-help tools that work across all those circumstances.

What treatment actually does — the physical picture

The physical effects of cancer treatment on sexual function are near-universal in their occurrence and almost universal in their under-explanation. Up to 90% of women and between 40 and 85% of men report changes to sexual function after cancer treatment. These are not fringe effects.

For women: vaginal dryness from the drop in oestrogen that follows chemotherapy, hormone therapy, ovarian suppression, or surgical menopause. Vaginal atrophy — the thinning and reduced elasticity of vaginal tissue. Vaginal stenosis — narrowing or shortening of the vagina — which can occur after pelvic radiotherapy and which develops gradually rather than immediately. Pain during sex. Reduced natural lubrication. Reduced libido, driven by hormonal changes, fatigue, anxiety, and the accumulated psychological weight of treatment. Changes in sensation and orgasmic response.

For men: erectile dysfunction, which affects 70 to 90% of men on androgen deprivation therapy for prostate cancer and approaches 90% in the first year after radical prostatectomy. Reduced or absent ejaculation after prostate surgery. Reduced libido from hormone treatment. Changes in orgasm and sensation. Penile tissue changes that, if not managed, can become more complex over time.

For people of any gender and any sexual orientation: reduced desire driven by fatigue, anxiety, depression, hormonal change, and the psychological experience of what the body has been through. Body image changes including scarring, prosthetics, stomas, weight changes, and hair loss. Pain from surgical sites, from neuropathy, from hormone-related joint changes. The specific psychological dimension of a body that surprised you badly, that now feels less trustworthy and less known — a body that is harder to inhabit with ease.

These effects are described because you deserve to know they are real, they are common, they are documented, and — in most cases — they are manageable. Most of them are not things you simply have to accept as the permanent cost of survival.

What you can do yourself — no conversation required

This section comes before the clinical options because it is the most accessible, the most private, and for many readers the most immediately useful. Everything here requires no appointment, no referral, and no disclosure to anyone.

Vaginal dryness and discomfort. The most important practical thing for anyone experiencing vaginal dryness, discomfort, or pain with any sexual activity is this: vaginal moisturisers are available over the counter at any pharmacy, supermarket, or chemist, without a prescription and without any conversation. They are not lubricants. They work differently — applied two to three times a week, they draw moisture into the vaginal tissue and improve its condition over time, rather than just providing temporary comfort during sex. UK brands widely available include Replens and Yes VM. They can also be ordered online for delivery to your home. Using them consistently and regularly, not only when preparing for sexual activity, makes a real difference over weeks.

Lubricants — used during sexual activity — reduce friction and discomfort. Water-based lubricants are the most widely available, work with condoms, and suit most people. Silicone-based lubricants last longer. Both are available at pharmacies and supermarkets without any conversation or prescription.

Pelvic floor exercises. The pelvic floor is the group of muscles that supports the bladder, bowel, and uterus, and its condition affects both physical comfort during intimacy and urinary control. Pelvic floor exercises can be done entirely privately, with no equipment, at any time of day. The technique: tighten the muscles you would use to stop the flow of urine, hold for a count of five, release, repeat ten times. Build up gradually to longer holds and more repetitions over weeks. Do this at least once a day.

For people who have had pelvic radiotherapy. Vaginal dilators — medical devices used to maintain vaginal elasticity and prevent the narrowing that radiation can cause — may have been recommended to you. They are available to purchase online and from pharmacies, and they are used with lubricant, gradually and gently, following the instructions that come with them. If you were given dilators and stopped using them because it was uncomfortable or confusing, you were not alone in that. The process is more manageable with guidance — if you can access it from your clinical team, a review of the technique often resolves what made it difficult.

For men without a prescription. Vacuum erection devices — pumps that draw blood into the penis mechanically — are available without a prescription and have a reasonable evidence base. They are particularly useful for men in whom the nerve pathways affected by surgery are recovering, as they maintain blood flow to penile tissue during that period. Available from pharmacies and online.

The changed body — and why it matters how you think about it

Your body has been through significant medical intervention. It has been cut, irradiated, chemically treated. It may look different, move differently, feel different from the inside. It may have scars that are visible or hidden. It may have lost something structural — a breast, a testicle, a uterus, a bowel segment — or gained something functional — a stoma, a prosthetic, a changed sensation landscape. The relationship you had with your body before cancer — the largely unconscious, background relationship of simply living in it — has changed.

For people with stomas specifically: the adjustment to a changed body is significant and has its own particular demands. The Colostomy UK helpline (0800 328 4257, free) and the ileostomy association (ia.org.uk) both provide specific support around intimacy and body image, including from people who have navigated this themselves. The practical questions — positioning, managing a bag during intimacy, talking to a partner — are all questions other people have asked and found ways through.

Body image concerns after cancer are entirely legitimate. They are not vanity. They are a normal human response to real change in something fundamental. And they are consequential: people who have not been able to process those concerns tend to have worse outcomes around intimacy and relationship — not because they are doing something wrong, but because the psychological and physical dimensions of intimacy are inseparable.

This is not a demand that you process your body image concerns on any timetable. It is a recognition that they are real and they matter, and that there is support available for them.

If you can access clinical help

For women. Vaginal oestrogen — topical, applied to the vaginal area in the form of creams, pessaries, or rings — is highly effective for vaginal atrophy and dryness. It is distinct from systemic HRT: the oestrogen is absorbed locally and the systemic absorption is minimal. For many women, including some with hormone-sensitive cancers, vaginal oestrogen is considered appropriate — but this is a specific conversation to have with your oncologist. For women with cancers that are not hormone-sensitive, vaginal oestrogen is straightforwardly available via GP prescription and is among the most effective interventions available.

Pelvic floor physiotherapy — referral via your GP or CNS — addresses both the pain and muscle tension components of sexual difficulty. Ask your CNS whether there is a pelvic floor physiotherapy service connected to your cancer centre.

Psychosexual therapy addresses the intersection of physical and psychological aspects of sexual function. It is available on the NHS in some areas, and privately through COSRT-registered therapists at cosrt.org.uk.

For men. Phosphodiesterase-5 inhibitors — sildenafil (Viagra), tadalafil (Cialis) — are available on NHS prescription for men with erectile dysfunction after cancer treatment. For post-surgical or post-radiotherapy ED, they are often recommended to be taken regularly as part of a penile rehabilitation programme designed to maintain blood flow to penile tissue while the nerves recover. If you have not been offered this and you have erectile dysfunction after prostate cancer treatment, ask your GP or urology team specifically, using the words penile rehabilitation programme. Vacuum erection devices, alprostadil, and penile implants are available for men in whom oral medication has not been effective. If you have tried the first step and it has not worked, ask about the next one.

For everyone. Low libido after cancer treatment has multiple simultaneous causes — hormonal, physical, psychological — that typically need to be addressed together. Fatigue, untreated hot flushes, depression, and pain all suppress desire. Addressing those things — in the chapters preceding this one — creates the conditions where desire can return. Testosterone therapy — for some women and for some men post-treatment — is worth discussing with a GP when low libido persists after other contributing factors have been addressed.

Older people — and the assumption that needs naming

Most clinical teams do not ask older patients about sexual health. Research confirms this, patients report it, and the evidence for it is unambiguous.

The assumption behind this silence is that sexual health stops mattering after a certain age. The evidence directly contradicts it. Adults remain sexually active and report sexual expression as important to quality of life into their seventies and eighties. What changes is often the form — physical closeness, touch, holding, tenderness becoming more central — and these changes are normal and deserve clinical attention, not assumption-based silence.

If you are an older person who has not been asked about this by anyone in your clinical team, and if you want to open the conversation, the words that tend to work are: I'd like to talk about how treatment has affected my intimate life and whether there is anything that can help. If that is dismissed or deflected, that is a failure on the part of the clinical encounter, not a signal about what you deserve to ask for.

And if you do not want to open the conversation, everything in the self-help section above is available to you privately and completely.

If you are LGBTQ+

The physical effects of cancer treatment on sexual function are not different by sexual orientation or gender identity. What is different is the experience of navigating a system that was not designed with you in mind, and the additional weight that carries.

Cancer information has historically been written for heterosexual, cisgender people, and many people who don't fit that description describe not seeing themselves in the resources available to them. Macmillan has developed its cancer and LGBTQ+ information in partnership with OUTpatients — the UK's only LGBTIQ+ cancer charity — specifically to address this. That information is at macmillan.org.uk/support-for-lgbtq-affected-by-cancer, and it covers sexual health, relationships, and treatment impacts in an LGBTQ+-specific context.

OUTpatients itself — at outpatients.org.uk — provides peer support, advocacy, and signposting specifically for LGBTIQ+ people affected by cancer.

Switchboard, the national LGBTQIA+ helpline, can discuss anything relating to sexuality, gender identity, sexual health, and wellbeing. All volunteers identify as LGBTQIA+. The number is 0800 0119 100, free, available every day from 10am to 10pm.

The partner conversation — when it's possible

If you are in a relationship, there is a specific difficulty that sits in the middle of all of this that is worth naming directly.

Your partner has also been through something. They have been frightened for you, caring for you, managing their own fear alongside yours. And now they may not know how to approach you — uncertain whether intimacy is welcome, uncertain whether they will cause pain, uncertain whether wanting to be physically close is appropriate given everything. The result of this double uncertainty — yours and theirs — is often a silence that grows and becomes harder to break.

The practical thing that helps is making the conversation explicit rather than waiting for the right moment. Not the perfectly articulated conversation — just a beginning. Something like: I want to talk about this because I don't know how to start and I think you don't either. That is enough to open something.

Couples counselling or psychosexual therapy involving both partners is available through Relate — relate.org.uk — which offers relationship and psychosexual counselling face to face, by phone, and online.

This section is offered where it applies. For people whose relationship context makes this kind of direct conversation difficult or impossible, the self-help in this chapter is available to you without it.

What to do this week

If you are experiencing significant vaginal bleeding after intercourse, penile discharge, or any new physical symptom during sexual activity that concerns you, contact your GP or clinical team. Some of these symptoms need assessment to rule out specific causes and should not be attributed to treatment effects without proper evaluation.

• Macmillan on sex and cancer (booklets available by phone) — macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/sex-and-cancer
• Macmillan LGBTQ+ cancer support (in partnership with OUTpatients) — macmillan.org.uk/support-for-lgbtq-affected-by-cancer
• OUTpatients — UK's only LGBTIQ+ cancer charity — outpatients.org.uk
• Switchboard LGBTQIA+ helpline — free, 10am to 10pm, all volunteers LGBTQ+: 0800 0119 100
• Colostomy UK helpline — stoma and intimacy support, free: 0800 328 4257
• Relate — relationship and psychosexual counselling — relate.org.uk
• College of Sexual and Relationship Therapists — find a registered therapist — cosrt.org.uk
• Menopause and Cancer — UK-specific cancer-context sexual health — menopauseandcancer.org
• Macmillan Support Line — free, 8am to 8pm, seven days (booklets by post): 0808 808 00 00