Introduction

Gynecological cancer is the fourth malignancy in women worldwide [1]. According to the United States Association of Cancer, 109,000 new cases of gynecological cancer were diagnosed in 2019 [1]. It shows that gynecological cancer is an important threat to the women’s health [1]. One of the most important issues of gynecological cancer is its negative effects on sexuality [2]. Because of the multicomplex mental and physical complications of gynecological cancer, sexuality is more affected in these patients than other gynecological diseases such as endometriosis and vaginal prolapse [3,4,5]. A bio-psychosocial model has described physical, psychological, and social aspects of sexuality concept [6,7,8]. In women with gynecological cancer, surgical treatment such as hysterectomy can lead to physical changes in these women’s body and affect some aspects of their sexual life such as sexual function, sexual self-concept, and sexual relations [2, 9]. In addition, changes in female genital organs such as vaginal stenosis, vaginal dryness [10, 11], scar formation in the vagina, and vaginal atrophy can lead to sexual dysfunction [6, 12, 13]. Psychological aspects of sexuality such as being worry about a decrease in sexual activity due to complications of treatment, fear of cancer recurrence after sexual intercourse, reluctance to sexual activity, and stress of infection following intercourse make unpleasant feelings that can lead to have inappropriate sexual interaction with their partner [6]. The effect of treatments on fertility is another challenging issue for these patients that can be negatively influenced their psychosexual balance [14, 15]. Changing in the husband’s point of view is another obstacle to reinitiating sexual and emotional relationships. He may consider his wife as a “patient” or a “child,” not as a sexual partner. These changes may lead to an unpleasant sexual relationship [16]. The social aspect of sexuality concept should be considered in specific religious and cultural context of women with gynecological cancer. In this way, Muslim Iranian women believe that having sexual intercourse is their religious duty, and so avoidance of it is considered a sin. Therefore, they obligate themselves to have intercourse in any situation. In addition, sexual relationship has an invisible nature in this culture, and talking about it is a social taboo [17]. So, sexual problems are not diagnosed that can finally lead to instability in marital life [18]. Hence, sexuality should be considered important as other aspects of the process of treatment in these women [8]. In fact, it is important for nurses to talk about sexual issues with these women, according to their cultural and religious beliefs [19]. Although there have been various studies about clinical aspects and treatment of gynecological cancers, few studies have assessed the sexual problems in these women. The result of the present study will be beneficial for nurses’ awareness of sexual problems, in Iranian women. In conclusion, the aim of this qualitative study was to explore the experiences of Iranian women with gynecological cancer about their spousal sexual issues. The research questions were (a) “How do women with gynecological cancer perceive changes in their sexual life?”, (b) “What problems do these women have in their sexual relations with their husbands?”, and (c) “How do these women deal with their sexual problems?”.

Methods

Design

The study was carried out as a qualitative study [20]. Face-to-face, open-ended, semi-structured interviews were done [21].

Participants

A qualitative study with a purposive sample of sixteen women with gynecological cancer was conducted. The inclusion criteria included (1) women diagnosed with gynecological cancer for at least 6 months, (2) living with the husband, (3) no metastasis based on the medical files, (4) ability to participate in a face-to-face interview, and (5) ability to speak fluent Persian. The exclusion criteria were lack of willingness to continue the interview. One oncologist identified eligible participants. They were selected in brachytherapy ward in Imam Reza Oncology Radiotherapy Center and Women’s Clinic and Cancer Department of Ghaem Hospital of Mashhad city. Then, first researcher contacted face to face with the potential participants when they came for brachytherapy or other treatments, explained the study, and invited them to participate in an in-person interview. After the agreement of candidate, she was briefly informed about the study and the objectives and then signed a letter of consent, and then researcher scheduled a meeting at a time and place where the participant felt comfortable. Seventeen participants were invited for interviews, and one woman declined because of lack of interest. Totally, sixteen women with gynecological cancer participated in the study.

Procedures and data collection

Interviews were carried out in the patients’ free time. Quiet interview locations were chosen. The interviews questions were like “Was your sexual life affected after being diagnosed the disease? This question was followed by “If so, what kind of sexual problems did you experience? And in continue researcher asked “How did you deal with your sexual life problems?”. The purpose of asking follow-up questions was to clarify relevant aspects of the subject. All interviews were conducted in Persian by the first researcher and audio recorded. The data collection was performed between April 2019 and September 2019. The interviews lasted approximately 40 min (30–60 min). Field notes were written after each interview, and the interviews were transcribed in Persian immediately.

Data analysis

Data analysis was performed along with data gathering. Conventional content analysis according to Lundman and Graneheim’s method was used [22]. Coding process was done in Persian. For improving the research quality, two qualitative experts with PhD in nursing regularly reviewed the research progress and provided guidance and suggestions about the research design, data collection, and data analysis. One coder, a PhD candidate in nursing with a qualitative research focus, processed the data at each time point. First, the coder would read the entire transcript of each participant’s interview for several times to ensure data immersion and gain a sense of the experiences as a whole. Then, the transcripts were hand-coded line by line independently to identify possible coding units related to the sexual issues experiences of participants, based on the actual words or phrases. Then, the coder consulted about the extracted codes with two qualitative experts. The coding units were condensed according to shared characteristics. Several additional abstract coding units were extracted and clustered into subthemes and themes through an iterative and inductive process. The data were saturated after sixteen interviews with the participants. The encoding process was carried out in MAXQDA 18.

Trustworthiness of the study

To ensure creditability of the study, the author had a long-term engagement with the subjects and established a proper relationship with the participants. Moreover, the researcher provided encoded interviews to the participants to check if the extracted codes match their experiences. In addition, the codes and concepts were examined by experts of this type studies. Dependability was addressed by selecting a sample of women that had rich experience through sexual life after gynecological cancer. Confirmability was assessed by comparing the results with earlier studies, transferability was done by findings the widest diversity of participants, and also the authors tried to explain all parts of method of study in detail for future researches [23].

Results

Totally sixteen women with gynecological cancer took part in the study. Demographic information are shown in Table 1. The results of conventional content analysis revealed three themes that are described in continue. Table 2 includes quotations pertaining to each theme.

Table 1 Demographic and clinical characteristics of the participants (n = 16)
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Table 2 Relevant quotations for each subtheme
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Patient’s struggle to maintain the sexual monopoly of the husband

One of the main themes of this study was the women’s attempt to maintain and continue sexual intercourse with their husband. In fact, some of them were concern about unmet husband’s sexual need because they were not able to have sexual intercourse due to the disease and expressed their feeling by compassion for their husbands. Some of the participants felt that their husbands are in torment because of unmet sexual needs. In addition, they were worried that their spouses would satisfy their sexual needs outside the home. So, they tried to provide their husbands’ sexual needs by themselves, not by another woman. Therefore, they wanted to know about the times that were safe for them to have sexual intercourse. Some patients also tried to think of other ways of sexual relationships such as anal and oral sex and also touching and massaging the sensitive parts of their husbands’ bodies. Although, they believed that anal sex is forbidden in Islamic religious, they had to do it for satisfying their husbands’ need.

Deterioration of intimacy

The second theme found in this study was deterioration of intimacy. Obviously, participants were in deeply unpleasant physical and mental situations such as concern about their sexual life, fear of death due to the disease, and concern for the future of their children life. So, they could not exhibit and experience the pleasant intimacy in their marital life after cancer. Also, side effects of chemotherapy and other therapies on the appearance of patient’s body were important factors that led to husband’s avoidance of expressing intimacy. In addition, the process of cancer treatment was a tedious and stressful experience for the couple and makes them irritable and dissociable, so they were not interested in showing their affection such as caressing and kissing to each other. Some participants mentioned that hysterectomy was another cause of decrease in their husbands’ level of intimacy. In fact, the husband thought that if his wife has no uterus, she will no longer be a real woman. On the other hand, some husbands tried to show more affection to their wives, but patients felt sense of pity in sudden changes of their husbands’ behaviors and bothered from this artificial affection. Finally, when women understood that their husbands were in the pressure of unmet sexual needs and their marital life was in danger of deterioration, they persuaded themselves to allow their husbands for short-term marriage. Therefore, they better could control their spouses’ sexual behavior.

Unpleasant bed-life experiences

The third theme was unpleasant bed-life experiences. It means that the participants did not have a proper feeling during their intercourse. Anxiety was reported as one of these unpleasant experiences. Patients’ concern about the husbands’ reaction to unpleasant appearance changes in their genital system during intercourse, and concerns about cancer recurrence after vaginal sex were most important issues related to anxiety. Therefore, some patients exhibited an aggressive response to their husbands’ request for having sexual intercourse. Feeling of sexually assault during intercourse was reported as another unpleasant bed-life experience. The reason was that some of the patients were forced to participate in sexual intercourse.

Discussion

These findings showed the experiences of the sexual issues of Iranian women with gynecological cancers. As the participants noted, it was not just the sexual activities that were affected by the disease, but also the intimate relationships between couples were affected as well. Anderson et al. (2020) showed that, since gynecological cancers directly affect the female sexual organs, some of participants felt that they have lost their womanhood after losing their ovaries, cervix, and uterus, and this causes emotional and sexual problems in their marital life [24]. Hence, the first theme of our study was “participant’s struggle to maintain the sexual monopoly of the husband.” In fact, after the disease, women were concerned about the way the sexual needs of their husbands would be met; so they were trying to cover these needs inside the home. Roudi et al. reported the experiences of sexual interactions in Iranian women after menopausal surgery. Their participants were concerned about their husbands’ relationships with other women as they were not able to fulfill their sexual needs [25]. It is notable that some sexual behaviors, such as the freedom to choose sexual partner or partners, are different in the various cultures [26]. For example, it is legally among Shias to have temporary marriage. In fact, men are allowed to have another wife, especially when the first wife is not able to meet their marital responsibilities. But because of cultural obstacles, temporary marriage is still unacceptable in most of people in Iranian society [27]. As the results showed, Participants resisted to their husband’s remarriage. Therefore, they tried to find more information about alternative ways of sexual relationships (non-vaginal intercourses) to meet their husbands’ sexual needs. On the other hand, anal and oral sex were stressful challenges for the participants. Gilbert et al. (2010) mentioned the alternative ways of sexual intercourse after cancer like playing with partner’s sex organ and using a vibrator. But the most important point is that such behaviors were not a main part of the couples’ sexual intercourse before the disease [28]. Janghorban et al. (2015) studied the silence in sexual relationship in Iranian women and concluded that talking about sexual issues was a taboo even in married couples. In fact, most of couples in Iran do not talk to each other about their sexual needs and sexual fantasies and feel ashamed for talking about that subjects, because they believe that these behaviors are not religiously acceptable [17]. Deterioration of intimacy was another finding of this study. As the disease got worse, participants felt that their husbands were not as interested to them as they had been in the past. So, because of mental and spiritual tiredness of the disease, some women were reluctant to respond to their husbands’ affection [28]; on the other hand, the levels of expressing intimacy were decreased in husbands because of the pressure of burden and fatigue [29], high levels of distress, anxiety, and unpleasant feelings such as loneliness, miserable, insecurity, and life crisis [30]. Therefore they failed to show their intimacy as they had been in the past. Also Gilbert et al. (2010) reported about a decrease levels of intimacy in couples after the diagnosis of cancer [28]. Hysterectomy was another subject that led to the reluctance of sexuality and therefore intimacy in husbands. So, many of the husbands had a problem with it. This had a negative effect on the intimate relationships in the couples. Shirinkam et al. (2018) examined sexual experiences in women after hysterectomy and reported a decrease in husband’s intimacy due to bad feelings after the surgery [31]. It is showed that another factor that caused to lack of intimacy in these patients and their partners is the fear of lack or decrease in fertility that is much more painful than cancer itself for them. So, fertility preservation has a fundamental importance for these women and can improve their quality of life [14, 15]. The findings also highlighted the compassionate intimacy from the husbands. Nasiri et al. reported the compassionate intimacy from men after diagnosing breast cancer in their wives [27, 32]. Another finding of this study was the unpleasant experiences during sexual intercourses in couples after gynecological cancer due to the physical and mental side effects of cancer and its treatments. As mentioned previously, unmet sexual needs arise specially in the partner of patient because of reduction in couples’ emotional relationships due to the new situation. So, husbands experience contradictory feelings, such as concern about the health of their spouse, need for the sexual relationships, and the accompanying sense of sin, which can drive the couples apart and lead to conflicts. Sexual concerns of the husbands include decreased libido, feelings of being unwanted, and fear of restarting sexual activity and sense of lonely in the sexual relationship [29, 30]. In addition, the studies in Iran have shown that because of social and cultural barriers, most couples do not talk about their problems in sexual relationships, and so these problems are not recognized and remain untreated and finally lead to conflict between couples [27, 32, 33]. Another unpleasant experience in sexual relationships of the participants with gynecological cancer was anxiety during intercourses.

Some of the participants were suffered from the side effects of chemotherapy and radiotherapy such as vaginismus and vaginal dryness. In some cases, these problems were not resolved using lubricant gels and lotions. So, the intercourse is interrupted, and husbands begin to complain about the problem. All of these problems can cause stress and anxiety in the participant. If the problem appears again in the next intercourses, the participant begins to feel anxious and would not have any desire for sexual relationships. Other studies in the field of cancer and disorders in sexual intercourses reported vaginismus and its effects on creating disorders in sexual intercourses [27, 34]. Another finding of this study was avoiding from sexual intercourse. The aggressive and nervous reactions by women to any sexual request from their husband, neglecting the spouses’ sexual needs and refusing to sleep with husband in the same bed, were the problems reported by the participants. Trying to scare husband from sexual intercourse was one of the ways to dissuade him from internal sex. For instance, some participants scared their husbands from special medicine or device in their vagina and said that it might hurt him if they have sexual intercourse. Shirinkam et al. (2018) also reported avoidance of sexual intercourse from women with cancers [31]. Errihani et al. (2010) studied the sexual relationships in Moroccan women after diagnosis the cancer and reported that the participants tried to find excuses and ways to run away from having sexual intercourse with their husbands [35]. Ak (2020) reported that Muslim women especially in Asian countries do not have the right to have sexual desire because it is an ashamed issue for them and their cultures. It seems that this feeling of reluctance to have sexual relations will be exacerbated in these women during diseases such as gynecological cancers [18]. Another finding was feeling sexual assault during sexual intercourse with their husbands. Some women reported that their husbands forced them to have sexual intercourse without considering their mental and physical condition. Lack of other financial supports was reported from some patients as a reason for accepting their husbands’ request for sexual relationships. Forcing them to have sexual relations was as disgusting as a sexual assault. Women only agreed to do these relationships in order to maintain their marital life. In addition, participants believed that they never forget the sexual assault by their husbands. Some studies also reported that the participants agreed to do these sexual relationships only to protect their marriage [36,37,38,39]. Despite all the problems of gynecological cancers for the participants, most of them tried to keep their sexual relationship with their husbands and forgot about their own matters. In fact, the concepts of sexual relationships are varying in different cultures. In some context, sexuality is viewed as an expression of love, devotion, and intimacy, while in some other cultures, sexuality is viewed as a source of pleasure. However, in some Muslim countries such as Iran, the meaning of sexual relations is reproduction and marital duty. Therefore, sexual dysfunction in these cultures leads to different problems [26]. Del Pup et al. suggested that the health professionals should pay more attention to the sexual issues of their participants and support them to solve concerns in this subject with considering their religious and culture beliefs [38].

Limitations

Despite all attempts to have the widest diversity in the sample group, the results represent the sexual life of a few married women with gynecological cancers. It is notable that the results highlight specific aspects of sexual problems of the patients.

Conclusion

Physical problems such as vaginal stenosis lead to fear of sexual intercourse in women with gynecological cancers. Some women forced themselves to continue their sexual intercourse because they think it is required by religious rules. Patients are not aware of the effects of gynecological cancer on their sexual relationships, because in Muslim context, sexuality seems to be a taboo, so women may avoid asking questions about their sexual problems, and it can finally lead to the end of marital life in these women.