Whereas most prior quantitative studies have examined correlations between and predictors of sexual wellbeing, mood and QOL [28, 29], this study is unique in examining distinct subgroups of women who may share certain sexual and psychosocial factors. The cluster analytic approach used in the present study allows us to extend previous findings by characterizing subgroups (profiles) of women who differ in their sexual and psychosocial wellbeing and risk factors.
Overall, study findings are consistent with prior research in women with cancer showing that women reporting higher versus lower sexual well-being tend to differ in their physical and psychological health outcomes . For instance, prior qualitative studies have demonstrated that women report a range of experiences in response to cancer survivorship, from significant negative consequences of treatment on women’s sexual function and relationship to growing closer together with a partner and finding new ways for experiencing intimacy [31, 32]. Our findings are also consistent with results of prior quantitative studies demonstrating that mood, sexual wellbeing and relationship quality are generally correlated for women after cancer [33, 34]. In this vein, a number of studies have found that cancer survivors who have better sexual communication are more responsive to each other’s needs, may engage in more effective coping, and experience less distress, better sexual functioning, and report better relationship satisfaction [29, 35, 36] than women with poor sexual communication.
A key finding that extends previous research was that three distinct subgroups of women treated for cancer emerged that differed in their reports of sexual and psychosocial wellbeing. Slightly over one-third of the sample fell into cluster 1, the higher-adjustment group, which was characterized by better sexual adjustment and relationship adjustment, mood, and quality of life. Women in this cluster were also distinguished by greater self-efficacy, or confidence, in communicating with their partners about changes in sex and intimacy after cancer treatment. In sum, they were doing very well in a range of domains of sexual and overall health. The largest group, however, was cluster 2, the intermediate adjustment group, which was characterized by lower adjustment on measures of sexual and relationship function, but better adjustment on measures of QOL and mood. The findings for this group are intriguing because they indicate that the lower adjustment in the sexual wellbeing outcomes for women in this group seem independent of their mood or QOL. Women in this group may be engaging in coping skills that prevent their sexual problems from impairing their mood or QOL. Another possibility is thatthey may have had high premorbid mood, which could have acted as a buffer against the impact of sexual problems on their overall wellbeing. Finally, women in cluster 3, the lower-adjustment group, reported worse sexual wellbeing, worse mood, and worse quality of life compared to the other two subgroups of women, suggesting that women in this group may be struggling with many aspects of recovery and survivorship extending beyond their sexual lives. This is the group that may have the least amount of resources, whether in terms of their mood or relationship, to call upon to buffer against their sexual problems, leading to worse overall outcomes, although this is conjecture.
One noteworthy finding was that sexual distress had the largest effect size difference between groups, signifying that it was the measure that best distinguished the clusters of women. The fact that this measure tracked most closely with the levels of adjustment represented by the clusters may be partly explained by the nature of sexual distress as capturing a higher-level appraisal of the sexual problems women are experiencing [37, 38]. For instance, whereas some women may experience low desire and feel distressed as a result, others may experience the same low desire without singificant distress. Indeed, distress constitutes an important component of sexual disorders and one that clinical guidelines in oncology recommend should be assessed when screening for sexual function problems. Our findings are in line with these clinical recommendations and suggest that sexual distress may serve as a useful barometer for women’s overall cancer-related sexual adjustment .
When differences between clusters in demographic characteristics were examined, there appeared to be some patterns that may be helpful to describe the groups. Both age (cluster 1 members more likely to be older than cluster 3 members, p = 0.04) and years in relationship with their partner (cluster 2 members more likely to be in a longer relationship than cluster 3 members, p = 0.04) differed significantly between groups. Other differences in demographics by cluster were not significant, but trends may bear examining, such as the larger proportion of women in cluster 3 in the lower education and income categories. Further research is warranted to understand how social and economic factors influence psychological and sexual adjustment after cancer.
Results of this secondary data analysis should be interpreted in light of the study’s strengths and limitations. The findings are generalizable to a relatively broad cancer survivor population in the U.S., as participants represented a wide age range and types of cancer. This is a strength because most prior studies have tended to focus on survivors of breast and gynecologic cancer [2, 40]. Yet, individuals diagnosed with non-reproductive cancers can rate sex as equally important as those with cancers affecting the reproductive organs (e.g., breast and gynecologic cancers) , supporting the premise that sexual wellbeing should be studied in women across a range of cancer diagnoses. A limitation of the sexual function (FSFI) scoring is that women who are not sexually active will have low scores (e.g., items about arousal, orgasm, or pain scored as ‘0’), though they may be sexually inactive for many reasons, including limitations of their partner to participate in sexual activity. Future studies should consider ways of addressing this issue, whether by limiting enrollment based on sexual activity status, using measures that can assess sexual function irrespective of sexual activity status, or including additional questions about reasons for sexual inactivity and potentially considering these responses in analyses.
Although we took into account both conceptual and practical considerations when selecting the three-cluster analysis model for interpretation, alternative cluster solutions and interpretations may also be viable. There are multiple potential guidelines suggesting sample size for cluster analysis, and our full sample may have been underpowered. The sample size was not such that we could do subgroup analyses and this study should be replicated in a larger sample. In addition, because the original study was a cross-sectional survey of women with widely variable time since treatment, it is not possible to determine whether women’s characteristics, and thus the differences between clusters, represent pre-cancer personal and relationship characteristics or effects of cancer treatment. All participants were partnered, so inferences should be limited to partnered survivors. In addition to replication of findings in larger samples, we also suggest replication studies in samples with more socioeconomic and racial/ethnic diversity. Further research is needed to design and test the efficacy, effectiveness, and costs of tailored interventions based on level or degree of need. While many studies have focused on sexual health and fertility in younger cancer survivors, the largest – and growing – age group of cancer survivors are older adults. As fatigue, diabetes, and poorer self-rated health are found to be associated with decline in sexual wellbeing for older adults, assessing and intervening for sexual wellbeing in this patient population is also warranted . Finally, we did not examine partner factors such as sexual function or mood, which could have a bearing on women’s sexual adjustment and should be examined in future studies.
These results have important clinical implications. Findings suggest that many women report positive psychosocial and sexual adjustment after cancer, which may come as welcome news to clinicians. For instance, clinicians may wish to incorporate the message that many women can still enjoy satisfying relationships and wellbeing even in the face of sexual difficulties with their patients, who may find this encouraging news. In addition, findings suggest that a stepped approach to sexual health care for women with cancer may be most appropriate and that such an approach could include different interventions, both in terms of content and format (e.g., duration, intensity), depending on the profile of adjustment. For example, whereas all women after cancer should receive assessment of cancer-related sexual concerns and education on effects of treatment on sexual function , a relatively small number of women will likely require intensive and complex sexual health treatment or sex and relationship therapy. Specifically, results of this study suggest that particular attention could be paid to efforts at assessing and managing sexual issues for women in the lower adjustment group, given how wide-ranging the impact of their cancer seems to be on various facets of their well-being. Clinicians may find it useful to consider whether a patient’s sexual difficulties are co-occurring with difficulties in mood and relationship quality, as this could suggest that an interdisciplinary approach addressing not only the patient’s sexual concerns, but also aspects of their emotional and relationship functioning could be beneficial. By contrast, we suspect that the women experiencing sexual difficulties but who report largely positive adjustment otherwise, could potentially benefit from a focused sexual wellbeing intervention. More work needs to be done to examine the content and format of interventions that would best meet the needs of each of these groups.