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Upfront About Breast Cancer Podcast

What You Don't Know Until You Do, with Dr Charlotte Tottman: Episode 8

Episode 8: Upfront About Breast Cancer – What You Don't Know Until You Do, with Dr Charlotte Tottman: Learning New Dance Steps: Sexuality and Intimacy   

Let’s be Upfront about the impact of cancer on sexuality and intimacy.  

In this episode of What You Don’t Know Until You Do, with Dr Charlotte Tottman, we hear about sexuality and intimacy using the ‘dance steps’ analogy and how they are impacted by a cancer diagnosis and treatment. We explore contributing factors including body image difficulties, fatigue and other treatment side effects.  

Charlotte discusses common responses and how strategies including communication, humour and learning ‘new dance steps’ can help with connection and closeness, both physically and emotionally with your intimate partner.

We recommend that listeners exercise self-care when listening to this podcast, as some may find the content upsetting. BCNA’s Helpline provides a free confidential telephone and email service for people diagnosed with breast cancer, their family and friends. Our experienced team can help with your questions and concerns and direct you to relevant resources and services. Call 1800 500 258 or email contact@bcna.org.au 

Resources:

Upfront About Breast Cancer is a production of Breast Cancer Network Australia. Our theme music is by the late Tara Simmons, and this episode is proudly brought to you by JT Reid. 

Want to get in touch? Visit our website at bcna.org.au, email us at contact@bcna.org.au, or call our Helpline on 1800 500 258 

TRANSCRIPT:

Ad [00:00:00] BCNA’s helpline provides a free confidential telephone and email service for people diagnosed with breast cancer, their family and friends. Our experienced team can help with your questions and concerns and direct you to relevant resources and services. Call 1800 500 258 or email contact@bcna.org.au.

Kellie [00:00:40] Welcome to Upfront About Breast cancer, What You Don't Know Until You D,o a podcast series with Dr Charlotte Tottman, who is a clinical psychologist specialising in cancer distress. She's also a woman who lived through a cancer diagnosis. And in this episode, we're going to talk intimacy. Charlotte calls it learning new dance steps because the old dance routine often isn't going to cut it after the physical and psychological impact of treatment. A reminder we do need listeners to take self-care when listening to the podcast because this conversation is unscripted and isn't intended to replace medical advice, nor represent the full spectrum of experience or clinical option. Dr. Charlotte

Charlotte [00:01:32] Hi Kellie.

Kellie [00:01:33] New Dance Steps.

Charlotte [00:01:39] Yup. All right. So all kidding aside, this is quite a sensitive subject. Obviously, sexual intimacy. And so it might be triggering for people. And I know you've given a trigger warning, but I'm just doubling down on that. Obviously, everybody's sexuality and intimacy experience is very individual and very private and may cover the full spectrum from, you know, fabulous right through to not good at all. So I just want everyone to be aware that this is definitely not a one size fits all situation, just like the rest of cancer, really? Yeah. So I use the analogy of new dance steps in this sexual and intimacy space because what I kind of figured out was that in a mature relationship and because not for everyone, but for a lot of people who are diagnosed with cancer, they're at a point in their life where they may have been in a relationship for quite a while. And even if they haven't, a mature relationship can frankly be, you know, something that's been going for a couple of years. But you get to a point with your intimacy partner where you've kind of got like a repertoire of intimacy and sexuality kind of moves a bit like a bit like dance steps. So when you engage in your intimacy in sexual activities, what I think happens a lot is that we don't use the same moves every single time, but we draw on maybe a set of moves if you like. And I reckon most people might have like, let's just say, maybe a dozen different kind of moves. Most of the time you might use about, say, seven or eight, and then you add in the other nine, 10, 11 and 12 to sort of, as I say, sets it up a bit from time to time. Now those moves that repertoire has built up over time. They rely on a whole lot of things. Most importantly, they kind of rely on body parts. They rely on bits of you actually being there, being present. But they also rely on things like responses, sexual responses, physical responses, psychological responses. They rely on it, not hurting. They rely on confidence and they rely on familiarity. And all of that stuff comes with time, like I say, in a mature relationship. But once you've had cancer treatment, a lot of that stuff changes. And so if you try and apply those same dance steps and you haven't got those necessary components, it can not work. And when it cannot work, it can feel quite uncomfortable, literally. Physically, there can be pain, but it can also feel emotionally and psychologically uncomfortable. And the human response to that is to withdraw is to step away and what can then start off as being just a little bit of a gap in that intimacy in the relationship can over time turn into a bloody great chasm.

Kellie [00:04:36] Intimacy is like post-treatment adjustment. It's like the next version of you rarely discussed, let alone addressed, because it's after the diagnosis. Most to be, you know, thankful to be still be here. And everything's it seems not minor, but down the scale of things in proportion to the impact.

Charlotte [00:05:02] Yeah, for sure. Often considered fairly low down the totem pole and also socially, it is, you know, fits into one of those again, very sensitive parts of our lives we don't often talk about. We don't often even talk about it with our partners. You know, we probably don't talk about it with a lot of people in our lives. And yeah, when it's not going well, we probably don't talk about it all the more so. Yeah.

Kellie [00:05:31] So the whole premise of the Upfront About Breast Cancer podcast series, including this one with you, is that it's everything you wished you'd asked your health professional and for gosh, or were into or too embarrassed to ask. And this is likely to fall under the latter, isn't it? So I'm going to ask you very bravely to share your intimacy issues or a comparison of before and after. Just to set that up thing.

Charlotte [00:06:06] So before I go any further in the unlikely event that any of my adult children are listening to this, this would be the time to turn off. Nobody needs to hear their parents talking about this sort of stuff. Rob and I have been married for more than 25 years. We had a healthy sex life before cancer diagnosis and our sex life, just like so many of my clients, so many people that I have that I have heard talk about this. It was negatively impacted by cancer diagnosis and treatment. No question about it. It has improved over the last three years, but it's taken work. It's taken a lot of talking. It's taken some strategies and some trial and error. And it's definitely better than it was. It's not back to where it was before diagnosis, and we both acknowledge that it's not ever going to be. And we are both sad about that. But we accept that that is how it is. So the sorts of things that do commonly change and certainly did for me, women who've been on hormone blocking therapy will really again appreciate this, that what hormone blockers do and a lot of women who have hormone positive breast cancer are prescribed this treatment after the hospital based treatment ends. What the hormone blockers do is they basically accelerate ageing so that the oestrogen type gets turned off in your system. And so you kind of become an older woman much more quickly than you would have otherwise on the inside. On the inside and on the outside, so oestrogen is a thing that keeps you. Sorry, lots of uncomfortable language. Oestrogen is a thing that keeps you plump and moist. All your tissues are lubricated. And that means that things like your connective tissue so your skin, your hair, your nails, but also things like the membranes in your vagina are actually not dry. They're not thin, they are plump and moist. Now, when you are on hormone therapy, that all changes. And it means that parts of your body are much more vulnerable to things like friction and to tearing and bleeding. And if you think about that in the context of your vagina, there ain't nothing very nice about that. And as soon as a woman experiences something that feels painful in the sexual intimacy context, very understandably, entirely appropriately, they don't want to do that anymore. And so, you know, a very common, unpleasant side effect of hormone therapy is that you have vaginal dryness, you have vaginal atrophy, you have vaginal vulnerability if you like in terms of your tissues. And that if you engage in something that causes friction, which of course most penetrative intercourse does without lubrication, then you may well get yourself into a situation where it hurts.

Kellie [00:09:14] It's not exclusive to those on hormone blockers?

Charlotte [00:09:19] No, it can be for lots of other reasons. There are people who go into what we call chemical menopause for lots of different reasons. But in any event, you may find that because you are concerned about things like performance, anxiety or body image concerns, or fearing that your partner no longer desires you, you may find that you are more stressed and more tensed, and therefore less relaxed. And I do talk about the very necessity of a relaxed vagina. If a woman isn't feeling relaxed all over, if she's not feeling relaxed in her mind, then the chances that her vagina is going to be relaxed enough to enjoy sexual intercourse is very low. So even if you've got all the lubrication going on in the world, whether provided by your bodily fluids or by some external lubricant, you can have all of that going on and you can still struggle to be relaxed enough to enjoy sex. So back to me and Rob, I definitely was suffering these sorts of side effects. And so in addition to that, so we had that sort of dry vagina and vulnerability to tearing and bleeding. We had the sauna bombs that I mentioned in the last episode. So the horrible, hot flushes that just mean if somebody is trying to get close to you and you are in the middle or starting to have a hot flush, or in fact a hot flushes is provoked by being close to someone all you want to do. Well, certainly all I want to do is always leap out of bed and run out into the cold air because it's so unpleasant and the idea of being physically, you know, on top of someone or then be on top of you or you, you know, absolutely close. Touching all over is just about the last thing your body wants to do. And of course, that's very challenging in the moment because these hot flashes, they don't just don't give you warning, they don't say, I'm going to be there in five minutes. Get ready. They happen in a nanosecond.

Kellie [00:11:26] at the most inopportune times, usually, and not just in intimacy.

Charlotte [00:11:31] Indeed, indeed. So so there was that stuff going on. I had a double mastectomy, so I don't have any breasts anymore. And sorry, and I know this is way too much information. But it's the topic in dance steps, at least. Probably, I'd say probably three of a dozen. Maybe dance moves

Kellie [00:11:55] In the old dance moves

Charlotte [00:11:56] In the old dance moves, definitely in the old dance moves related to my breasts. And so the fact that there are no longer any breasts there means that that repertoire, those moves are now just not possible. You don't have the equipment. We recognise that. And instead of going, okay, well, we have down to nine dance moves. We have actually tried to create some other dance moves now. Are they the same now? Are they better or worse? Doesn't really matter. They are what we've got. We've we found to our surprise that the upper quadrants of my back are actually quite sensitive. Who knew? That sort of become the top half of my back has become part of the new dance. In our in our repertoire, we have lube in every everywhere we go, we have lube. We've got lube in cupboards and bags and we've got a shack at the river and whenever we're going anywhere. I mean, if we ever go anywhere again, you can go one of the things we always say to each other. We call it the Goop. Have you got the Goop? And on the couple of occasions I call this experiential learning experience, your learning is like where you learn the hard way you learn by doing. Like when we forgotten the goop. Oh gosh, do we? Yeah, we remember that. So now we have goop everywhere and we've experimented with all different types of Goop. And we've certainly worked out the stuff that works for us and on occasions we have slipped and kind of got out it. Maybe we can, you know, maybe we could. Maybe things are different now. Now, now things are no different. Things are things are the way they are. So Goop, we must and goop we do. We bought a little tiny, tiny vibrator. We call it the honey bunny. It's the size of a what do you call it, a lip balm. When I saw it online, I thought, You've got to be joking, that's so small, it'll get lost. And then I thought, Well, I mean, you know, call this research and development for my work. I'm just going to buy it.

Kellie [00:14:26] Tax deduction, tax deduction $29.

Charlotte [00:14:29] Um, I thought, I mean, really? How bad could it be? So I bought it. It is microscopic, like it's about as long as my thumb. It's got 10 settings. It lives in a in a glass case, as in like a spectacles case in a, you know, bathroom cupboard next to the lube. And it comes out on special occasions. And it's hilarious. It was very it's been very funny. And I think that's probably the most important thing about it is that it gave us a way to reconnect with laughter and it is really helpful for foreplay. Because it's a little lit, it doesn't really do anything more useful than foreplay, but foreplay is good because that's where we're missing my breasts. We're missing those dance steps. So Honey Bunny,

Kellie [00:15:20] Does foreplay become? Does foreplay become more important? Post a diagnosis.

Charlotte [00:15:28] I think that there's certainly an argument to say yes for women. It does, because I think that particularly around that sort of dry vagina thing, the more foreplay, the more likely you are to get aroused and therefore be ready for if you're going to have penetrative intercourse, you're going to be ready for it. But I think the other thing that's really important about foreplay is that that's the intimacy part of the sexual dance routine, if you like, that's where you start to break down those worries about, am I desirable? Are things still okay between us? Is still turned on by me, you know, is our relationship going to be okay? All that stuff is happening in in women's minds, and we are reassured through that foreplay process. So I think it is really important. And Honey Bunny has been really good for us. The other thing that's good is hotel sex. Hotel sex is something that I routinely prescribe. Now this is obviously not easy to do. It costs money. You've got to organise. Often you've got to organise time. Maybe, you know, childcare or that sort of stuff. But there is something qualitatively different about sex somewhere other than your bedroom at home.

Kellie [00:16:51] So it doesn't need to be a hotel. It just needs to be somewhere somehow other than the normal place, correct?

Charlotte [00:16:56] Yeah, absolutely. So high dose sex could be a euphemism for anything, really, just not where you would normally have sex and usually away from. If you like the humdrum demands of life where you can feel just like you're stepping, if you like out of, out of your life into a little bubble and it and it doesn't have to be for long, it can be. I mean, it can be an afternoon, but you know, preferably would maybe be a weekend. But I think that that the reason that hotel sex is good. It's good for those reasons because you're away from the demands of life, but it's also because human beings do this thing where we we pair an emotional response with certain environments or event. And so most people, maybe not, if you're a worker who travels for work, but most people might think about a hotel as being somewhere, you might go on holiday, where you might go, where it feels a bit special. It's a sort of thing that you might have good memories about. So that pairing or the association is that it's a positive one. And so if I go to somewhere like that, I'm more likely to feel kind of like I might be smiling. I might feel relaxed. I might have a good vibe. And that's going to be helpful in terms of feeling kind of relaxed and ready to engage in that intimacy experience.

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Kellie [00:18:56] What about when you don't feel like it after the whole ordeal of breast cancer? However long?

Charlotte [00:19:07] Yeah, the libido suffers. Totally, totally. And that is, I didn't mention that before, but that is absolutely one of my experiences is that my libido has left the building totally, and I have to sort of think my way back into it. I think it is incredibly common for people to feel not the least bit sexy after cancer treatment and to also perhaps be, you know, rethinking some stuff about, you know, maybe their relationship or their role in the relationship and how the relationship has run, particularly in the sexuality and intimacy department. It's a very important message that. In no way should anyone ever be engaging in anything that they don't want to do or don't feel comfortable with ever. Having said that, I think that when we have to come to grips with the fact that our bodies are different and that our libido is different. We can also benefit from recognising that may have an impact on a relationship that's really important to us. And so, then things like sexuality and intimacy might be about more than just what I feel like physically doing in that moment. It might be about how important is this relationship to me? How much do I value being connected with my partner? And so. What what's important to me? And so for me, I now am okay with the fact that I don't have to feel really sexually aroused or like it's front of mind for me. I can go, OK, I'm I want our relationship to continue to be, you know, what it what it's been. I want I want to love Rob and I want him to. I want to give him the chance to love me, and I'm okay with the fact that it feels different and I can still have sex and it can still be good and it doesn't have to be the way it was before. For me to be okay with doing, doing that.

Kellie [00:21:24] When you break that down. Does that sound a bit like? I'm going to have sex because I love you, not because I want it.

Charlotte [00:21:37] I think it's a really hard distinction to draw and it's a very personal one, and I would never, ever, ever be cancelling anyone to do anything that I didn't want to do. But I guess it's what you want to do or why you want to do that thing.

Kellie [00:21:51] Okay. So conversely, if we go, usually you've got you have a connection with someone and then there's intimacy and then there's sex. But say, if you. If there is no sex. In the relationship. Does that work backwards? Then it starts to break down the intimacy and what we become isolated? Does it affect the communication?

Charlotte [00:22:18] They're all connected. And when I'm doing this work with clients, I have a whiteboard in my consulting room and when we find ourselves talking about sexuality. One of the first things I do is stand up and write three words on the whiteboard. One is sexuality. One is intimacy and one is communication. And I draw arrows between them. And basically the point that I make is that. You can't really have good sexuality experiences without intimacy, and you can't have intimacy without communication. So often some often people will come in thinking, we're going to talk about sex, we're going to talk about the sexual act. And what we end up talking about is communication. We end up talking about, are you guys relating to one another? Are you guys spending time together? Are you talking about this stuff? Are you? Are you having conversations as uncomfortable as these are about the changes to your body, to how you feel to your anxieties, about desirability, body image, performance, trust, all that stuff is the really important stuff. You get that stuff starting to starting to happen in the communication department. Then you can build on that to enhance intimacy and then towards sexuality. So they are absolutely all connected and you don't have anything without communication.

Kellie [00:23:46] The hesitancy, I guess, can come from both sides after treatment and so much else going on. You might have one partner who's just having already been through enough. I'm exhausted, my body's exhausted. This is going to hurt. I'm tired. And maybe the partner is doesn't want to break them as if, like, there's probably some nervousness there too.

Charlotte [00:24:14] Absolutely. And for the partner sort of on the sidelines or right, you know, hand in glove through the whole diagnosis and treatment experience, they can be. The last thing that they want often is to cause any distress, any more discomfort for the person who they've watched go through such a lot and often, obviously often not always, but often it's a bloke and blokes are often fixers. And so this this period of time where they have been unable to fix this, to take this distress away, to take the cancer away, to take all the pain and suffering away, they then often, you know, they don't want to be that guy who's pressuring their partner to pardon my language, get back in the saddle. So that's definitely a component. And of course, what this can lead to is coming from an absolute place of love. It can lead to a distancing and a barrier. And it's if you like, it's a barrier born of love, but it's a barrier nonetheless.

Kellie [00:25:28] Hmm. So what you were saying before, when we if there is an example of painful sex or something that wasn't pleasurable? Yes. The brain pairs that to this is not fun. The body then tenses and it's

Charlotte [00:25:45] Tense and.

Kellie [00:25:47] We start to avoid it.

Charlotte [00:25:48] Yeah, absolutely. And the next time. And because, you know, there may well be this concern from a partner to sort of like, you know, don't a rash, you don't want you to feel uncomfortable, don't want you to feel any pressure if you add in. The last time was painful. Then you've got a recipe for less and less sex. And what we know about sex is that sex begets sex. So the more sex you have and this and this is the case with most things where you have an activity or a behaviour that that goes well, then your brain goes, Oh, OK, well, that that was OK. I could do that again. Similarly, where you have a behaviour and activity that doesn't go well, your brain goes, Yeah, and don't do that again. So it's kind of like an upward spiral or downward spiral. And so therefore, if you have good sex or, you know, good enough sex, then you're likely to have the feeling of like a little bit more of that, just as unfortunately in reverse.

Kellie [00:26:45] So intimacy is obviously very important. Is it as important when you don't have a partner?

Charlotte [00:26:54] I think it's really important regardless of your relationship status. And I'm obviously, you know, this episode, I've been talking about it from my point of view and how it was for Robin and me, but I think it's really important regardless to recognise how things have changed for you. And if you're a single person or in a like not in a relationship or you might be in a new relationship or you might be interested in a new relationship, then I think it's about understanding the changes that have happened to you in terms of your your physical form and also psychologically and not avoiding. It's back to that kind of the risk of the avoidance because of discomfort, because of fear, because of change. I think that feeling aroused, feeling desired, feeling comfortable with your body is all connected to intimacy. And so, you know, I think I need shares in Honey Bunny, but get yourself a vibrator, get yourself some lube and relax and enjoy your body and how your body can feel. I think it's a it's a tricky space, and I have a lot of young women particularly talk to me about this, about how to navigate new sexual experiences with new partners in the wake of things like mastectomies and the other changes that happen as a result of cancer. And again, I come back to communication is the biggest, most important factor. If you can develop a connection and trust with someone, you can build intimacy and you can build sexuality on that. But if you don't have communication, you've got nothing.

Kellie [00:28:45] What about your new mattress that you mentioned in our last episode? That was the best thing ever. Was it still the best thing ever when all of a sudden you've got this big bed?

Charlotte [00:28:57] Hmm. My husband's over the other side of the room? Yes, it was an interesting example of how you can kind of fix one problem and create another or exacerbate another. So we got this massive. I mean, it's not the biggest bed you could get, but it's a king size bed. We got this when I was really struggling with insomnia and the sauna bomb hot flushes. It made a huge difference to to my sleep. So definitely was great in that respect. But. Previous to that, Robin, I had slept, I can't believe I'm saying this, we slept in a double bed for years and years and years. I reckon we spent 15 years sleeping in a double bed and then maybe for five years, we slept in a bit longer. You know, in a queen size bed. So we'd been used to being pretty close. And all of a sudden there was just this massive distance between us. And so we weren't having what I'd call kind of incidental contact. We weren't having that feeling of like foot against foot or back against, but in the bed we just were. I don't know, I was Africa, and I kind of do my geography, so I won't even try to imagine. But Western Australia and Tasmania, anyway, we were a long way apart. And so that did not help. And we even now we have to more consciously and we were reasonably tactile. We have to more consciously sort of touch one another. It doesn't just sort of happen because we happen to be in the bed together.

Kellie [00:30:23] And I guess, like you were saying before, when you were at a practice. Yes. Touch, whether it be intimacy or sex. Yes. One begets the other, begets the other.

Charlotte [00:30:36] Absolutely. And you do you so quickly. I mean, there's this whole thing in physical wellbeing where we say you deconditioned much faster than you recondition. So you lose the repetition. You lose the habit really quickly of some of that sexuality, intimacy stuff and rebuilding it can feel really clunky and really effort fall. And if we're used to it having been smooth and kind of like, you know, like I was saying, like we had all the moves, you know, we'd been practising those moves for 25 years. We knew exactly where and when and when to do the shuffle and when to do the little, you know, skip and hop. And now suddenly, it all feels like we're where we're wearing like, you know, big leaden shoes. You kind of go out and I do, I want to bother.

Kellie [00:31:26] And that also might provoke feelings of shame.

Charlotte [00:31:31] Yes, and guilt and women are really, really good at gilt. And again, you know, back to this, this issue of consent, it's very, very important. And you know, people shouldn't be doing things because they feel pressure or guilted into it, whether it's jilted by themselves or jilted by other people. But these emotional psychological components to this stuff are really important. And they're big, they're big, meaty, weighty things. And they're not the things that we sit around and talk about a lot. So we are often sitting with it quite privately, quite intensely. I'm just really conscious about, I guess, talking about the sort of the quality of the sexual experience. So, I've already mentioned that my libido has left the building, and I've said that we've Rob and I have been able to kind of work effectively together to get back, you know, our sex life to being better than it was three years ago, but not what it was before diagnosis. I hardly ever orgasm. And previously I would have maybe let me think I don't know, maybe 60 percent of the time that we would have sex. I would have orgasm. Now it would be maybe five percent of the time. And so it's a big change. I'm sad about that, but I've decided really and we've we've talked about this and this is where again, I come back to that communication stuff. I've decided that I'd much rather have the intimacy, the connection, the love with Rob, the laughs with Rob, even if I don't have an orgasm than to have none of that as well as no orgasm. So I think just reflecting on that stuff around, whether it's okay to fake it or how we should be. It's about what works for you and about the value that you place on the intimacy experience in addition to or separate from the sexual experience. And it really does come down to whatever works for you. And what works for me is intimacy.

Kellie [00:33:36] OK, so for whatever reason, different things happen to different people and we need some new moves or we need a way back to.

Charlotte [00:33:47] What we need is a way forward. That's true. We need a way forward. We need a way and my way forward with our new moves. And it is really about again, it's back to that whole adjustment process of dropping resistance, recognising that, you know, if you don't have the same physical form and you don't have the same confidence and familiarity because things are different, then instead of trying to continually, you know, scramble to recreate what you used to have and feel and then be frustrated that isn't going to do anything helpful for sexuality intimacy. It's about going OK. We have got a slightly modified version. We've got to work with here. We've got some of our old dance steps that are still going to work. We can still use, but we've got to sex it up with some new stuff.

Kellie [00:34:42] What are some of the ways? That can move someone forward if they are in a position of either the communications down or they're feeling awkward about how to engage in sexual activity after treatment, what are some of the ways they can release the pressure and start new?

Charlotte [00:35:05] I've got a couple of strategies that I routinely recommend. One is a thing called No Sex Mondays. And that sounds a bit weird. This is a strategy that's born of the fact that a lot of women report being reluctant to engage in foreplay and intimacy behaviours because they aren't yet ready to go back to penetrative intercourse. And they worry that if they get into some heavy kissing or some touching that, that will, if you like, send a green light signal to their partner that that that they're up for the lot, that they're ready to completely engage in a sexual activity. And so rather than talking about it, which would be good, but we don't we then avoid and we don't we don't kiss and we don't touch and we don't do anything. And so what I say to women, because when I ask the question like, are you worried that if you if you start with foreplay and if you get aroused that you're your partner is going to assume and interpret from your from your sounds, from your touch, from your responses that you are ready to go to the next sexual step. People also often say yes and I'm not ready, and so I don't want to do even that much. So I say to them, Okay, well, let's maybe look at No Sex Mondays and it doesn't matter which day of the week you choose, but essentially you make an agreement with your partner where on that particular day, each week, each of you can. If you want to engage in as much intimacy behaviour as you like, you can get as aroused as you like. But under absolutely no circumstances can you have penetrative intercourse. And what this does is it gives people the freedom. Women in particular to be able to engage in that intimacy behaviour and feel no pressure that it is going to lead to that next step that they are not yet ready for. And it's a really helpful strategy, but it's got a big caveat, and the caveat is that if you ever break the rule and you get so aroused that you sort of go, Oh, never mind, let's just get on with it. Come on, let's, you know, let's do it. The problem will be that it will break the spell and that from then on, you will never it will never work again because you will never trust that one or both of you won't break that agreement again, even if you broke it off with perfectly good intent the first time. So it does have to be a strategy that you are very resolute about following, but it can be a really lovely, safe way to engage in lots of really sensual intimacy behaviours without the threat, if you like, of the next step that you might not yet be ready for.

Kellie [00:38:00] OK? What about date nights? Do they work?

Charlotte [00:38:03] Date nights are great and date nights don't have to be a big deal. I mean, they can be a big deal, but date nights is something that I again prescribe a lot. I often will recommend that people take a turn about, so it might be my turn. So I generally try and suggest that it's a regular thing. If it's a regular date in the diary, nobody has to take responsibility for the initiative of like, Oh, when are we going to, you know, find time. It's like every second Tuesday is date night something like that just in the diary. And it can be, you know, a, you know, candlelit dinner, but it can equally be a burger at the local park. It, you know, if you're allowed to go there under COVID restrictions. But the point is it can be big, it can be small. But really, what it's about is just a bit of couple time away from life, work, kids, parents, responsibilities and usually, I recommend that there be some guidelines, I'm not really into rules, but some guidelines around topics of conversation, so it's not where you want to go and decide when you're going to, you know, move child I to school be. It's about going and actually connecting with one another and just shooting the breeze, talking about stuff that doesn't really matter. No pressure and just spending time connecting again.

Kellie [00:39:31] So is this not the time to bring up how you're feeling about the intimate part of the relationship? If communication is so key and it leading to, you know, good communication, good intimacy, good sex? Is that not the space to bring it up in?

Charlotte [00:39:51] I think it, it can be, but it shouldn't be sort of reserved or allocated as just for that. So I think primarily this time should be about reconnecting about again. It's that thing that I was talking about before, about pairing events with emotions. If we use that date night experience exclusively to discuss things that make us feel a bit uncomfortable. Pretty soon, those date nights aren't going to happen because people are going to go, Oh God, I don't know if I can do it again. Whereas if those date nights are like a time where it's like, Oh, that that was nice, that felt nice, that felt or that was, you know, they made me laugh or or we got to talk about something else that mattered, but it felt good. Then those date nights are going to keep happening. So I think that it can be judiciously, it can be an opportunity, but I wouldn't be recommending it at the beginning of date nights. Not like, Hey, let's start date night so we can sort out our sex life. It's more like, Hey, let's do some date nights because we need to. We need to reconnect.

Kellie [00:41:00] What about the danger of assumptions?

Charlotte [00:41:04] Yeah. I said assumptions are dangerous generally really in life. And so being explicit is really important. And again, this just comes back to communication. I. I certainly was really worried that Rob would view my body and view me differently after the surgery, and we've had a lot of conversations about it. And the thing that I sort of got to a point with it was that I got to a point where I had to trust what he was telling me. I had to trust that when he said to me, I really loved your breasts and I really miss your breasts. But. I'd rather you be here and I love you regardless, and I'm attracted to you regardless. After a while, I just had to trust that that was the truth because I think that we do this thing when we're worried called reassurance seeking, which is where you go back and you keep saying, Are you sure, really? I mean, really? And at some point I just got to a point where I was like, Well, I just have to believe him and let it go. And that was that was OK. That worked. I don't know if I don't know if it works for everyone, though. I think that's a really hard that's a really hard part of relationships. So I, I guess I had assumed that he would not find me as attractive. He, I think, also might have assumed that I would be less interested in sex and the only way to get past these assumptions, because the assumptions lead to us behaving in line with them. And that is that if he thinks that I'm not less interested in sex and he's not going to like, say, Hey, do you feel like a bit of a quick one? The behaviour is consistent with your assumptions, then the only alternative is to start to talk about it.

Kellie [00:43:14] And if these strategies don't work, it is worth considering getting some help.

Charlotte [00:43:19] Yeah, I often at the outset of therapy with any client will offer to invite in their partner for one or more sessions. I'm very used to doing therapy with more than one person in the room because this is the stuff. I mean, cancer just doesn't happen to the person diagnosed. It happens to them and the people around them. Like I was saying at the beginning of the episode, the issue is intimacy and sexuality. Is that what can start off at the beginning as just sort of being a little sliver of disconnection can very quickly become this chasm where, you know, you might still be friends. You might be able to co-parent effectively, but you might have lost a whole lot more that you didn't even realise, you know, it was almost sort of happening without you realising it. So I think giving people the opportunity to come and talk with someone in a safe place. The difference about discussing this sort of topic with a therapist is that it is a more controlled environment, and the therapist can sort of act as a bit of a translator and interpreter and also help you navigate some of the discomfort around this. And it's also the sort of thing that if you find it pretty challenging, especially in the first couple of guys, you can kind of leave the discomfort in the therapist's room. You know, I sort of that's what I say to people is like, you can get all the discomfort out and leave it here and then you can go away again. And that can feel a bit nicer than maybe trying to navigate this stuff in your family, home or your marital bedroom.

Kellie [00:44:49] Like anything, I think after a diagnosis it can take time, but it's worth the effort and be kind to yourself.

Charlotte [00:44:57] Absolutely. And there is no rush and I think actually probably slower and gradually, you know, baby steps that certainly I mean, we're three years down the track and we're still sorting this stuff out is definitely better. Any sort of behaviour change is better done in small increments. It's more sustainable and practise does definitely help practise and repetition does help, builds up familiarity and confidence. And all of that stuff makes you feel more relaxed and more positive towards being in that intimate space

Kellie [00:45:31] Practise and a good lube.

Charlotte [00:45:32] And a really good lube

Kellie [00:45:34] Or perhaps humour is the best lubricant of all.

Charlotte [00:45:38] Yes, I think that's a very good note to end on. Any time you can introduce humour into this sort of space, it's the antidote for anxiety. It's the antidote for stress. It's the antidote for frustration. As soon as you can laugh or smile, you actually physically feel different.

Kellie [00:45:55] It sounds like a good movement. So from will, actually from one movement to another. We hope you'll join us for our next episode of Upfront About Breast Cancer What You Don't Know Until You Do when we talk exercise, now, this one might feel a little mundane and annoying, but it works. And Dr. Charlotte is going to tell you why and how to do it if this episode on those new dance steps has helped you. Don't forget to share it and subscribe to ensure you never miss an episode. And if you have a few minutes, please complete the survey that you'll find in the show notes. This survey will help us to tailor and create content that's useful and relevant. And if you're looking for information tailored to your diagnosis, download My Journey dot org dot au. And don't forget BCNA’s online network to for peer support, it's always open. You'll find it on the website BCNA dot org dot. And coming up next time, we're talking exercise? Yes, it's annoying because it works.

Episode preview [00:46:55] Now it is actually part of regular conversations and recommendations from oncologists. That you do, where possible, some regular exercise during treatment, and there is now very solid research that supports that, things like the effectiveness of chemotherapy is enhanced by regular exercise.

Kellie [00:47:17] Our theme music for this series is by the late Tara Simmons, who lost her life to breast cancer. We're very grateful to her family for allowing us to use her music. I'm Kellie Curtain. It's good to be upfront with you.

Ends [00:47:34] Thanks for listening to Upfront About Breast Cancer, What You Don't Know Until You Do with Dr Charlotte Tottman brought to you by the Breast Cancer Network Australia and proudly supported by JT Reid.