The Sexual Health Conversation Patients Wish You’d Start: Insights from Dr. Sharon Bober

In light of Sexual Health Awareness Month, I spoke with Dr. Sharon Bober about why sexual health belongs in conversations about cancer care. As oncology clinicians, we’re accustomed to talking about pain, fatigue, and treatment side effects—but how often do we talk with our patients about sexual health even though patients tell us it’s central to their quality of life?

This is a difficult topic to address with patients, and few of us have received training in this area. One of the most important takeaways from this interview for me was that we don’t have to fix it, but we do need to let patients know it’s okay to talk about it. Here is a simple, normalizing question that can break the silence: “Sexual health is often impacted by cancer and treatment. Is there anything distressing you’d like to discuss?” Following are highlights from that interview. I hope you find the conversation as helpful
as I did.

About Dr. Sharon Bober

Dr. Sharon Bober is a clinical psychologist at the Dana-Farber Cancer Institute in Boston, where she is also the founding director of the Dana-Farber Sexual Health Program. She serves as an Associate Professor in the Department of Psychiatry at Harvard Medical School. Dr. Bober leads a research program which includes the development of brief, effective interventions for cancer-related sexual health concerns.

Why Sexual Health Belongs in Cancer Care

Janet: I think the first question everybody probably has is: why discuss sex in the context of palliative care? Aren’t there more important issues to focus on?

Sharon: That’s a question I hear a lot—but interestingly, not from patients. From their perspective, sexual health is a very important quality-of-life issue, right from diagnosis and throughout treatment and survivorship. Patients consistently tell us this matters deeply to them. I completely understand that in palliative care there are so many urgent issues to address, and sexual health often doesn’t even make the list. But my point is that it should be on the list. It doesn’t need to be at the very top, but like pain, mental health, or goals of care, it deserves to be included. Historically, clinicians received little training on pain or end-of-life discussions, but we eventually changed that culture. I believe sexual health is one of the last bastions of taboo, but we can and must move the needle here too.

Broadening the Definition of Sex

Janet: What does sex even mean in the context of palliative care? Is it just about intercourse?

Sharon: I think it’s essential to broaden our definition. Too often, sex is defined narrowly—usually penis vagina intercourse—because that’s how it’s portrayed in popular culture. But sexuality is far more complex. It includes self-image, feelings of vitality, connection, and intimacy with or without physical activity. For people whose bodies have been permanently altered by treatment, it’s about how to still feel like oneself, how to experience intimacy, how to connect. If we cling to narrow definitions, people feel defeated. Helping patients and partners expand their repertoire—to see many ways of giving and receiving pleasure—is liberating. Sexuality is not just an act; it’s an ongoing human need for closeness and affirmation.

The Clinician’s Role in Starting Conversations

Janet: If a couple is referred to you, how do you help them communicate about these challenges?

Sharon: First, I emphasize the importance of clinicians starting the conversation. Patients almost never bring up sexual health on their own, because they don’t want to make their doctor uncomfortable. At the same time, doctors don’t raise it because they don’t want to make patients uncomfortable. So the issue stays invisible. A simple, normalizing question can break the silence: “Sexual health is often impacted by cancer and treatment. Is there anything distressing you’d like to discuss?” If patients don’t want to talk, they’ll say so, but just asking validates their concerns. Clinicians don’t need to solve everything. They just need to acknowledge it and know resources—whether that’s referring to a gynecologist, urologist, social worker, therapist, or pointing to evidence-based resources like the American Cancer Society’s materials. The message is: you don’t have to fix it, but you do need to let patients know it’s okay to talk about it.

Common Sexual and Intimacy Concerns in Life-Limiting Disease

Janet: What are some of the most common concerns related to sexuality and intimacy when people are living with life-limiting disease?

Sharon: One of the most common issues, for both men and women, is low desire. When you’re exhausted, in pain, nauseated, or uncomfortable, it’s hard for anything to feel sexy. And yet, many people still yearn for connection. What often happens is that if couples can’t be sexual in the same way they used to, their relationship shifts into something more companionate or platonic. Sometimes that’s comfortable for both, but other times, one or both partners really miss erotic connection. The key is realizing intimacy doesn’t have to disappear. Touching, kissing, lying naked together—these are not things you do with just anyone; they’re deeply intimate, even if different from what you used to do. Unfortunately, shame and embarrassment keep many couples from talking about this. My role is often to help open that dialogue, normalize the feelings, and encourage couples to explore new ways of connecting.

Women’s Sexual Health After Treatment

Janet: Are there special problems that affect women most when it comes to sexual health after cancer treatment?

Sharon: Definitely. Treatments often intensify menopausal symptoms or trigger premature menopause. That means women experience profound genitourinary changes—dryness, thinning of tissue, pain, fragility, increased urinary infections. These issues impact women’s genitourinary health regardless of whether they’re sexually active. For example, women may find that they have itching or vaginal discomfort without sexual activity or suddenly they are getting urinary tract infections, and they have no idea it is related to estrogen loss. What’s shocking is how little guidance women receive on managing these kinds of common changes related to menopause. Vaginal estrogen, for example, has very strong evidence behind it and was shown at ASCO to be safe even for cancer survivors. It not only improves vaginal comfort and health of the genital tissue but also dramatically reduces UTI risk. Yet it’s under-prescribed. And let’s not forget the psychological symptoms of menopause—brain fog, concentration issues, emotional changes. These can be addressed with cognitive rehabilitation, ADHD medications, or, in carefully selected cases, systemic hormone therapy, which is being reevaluated today with a more nuanced understanding of risk. Women of all ages—from 55 to 85—deserve accurate, individualized advice, and too often they’re overlooked because of assumptions about age, relationship status, or sexual activity.

Inclusive Care for Lesbian Women

Janet: And what about lesbian women—are there unique concerns for them?

Sharon: Lesbian patients frequently face bias, neglect, or awkwardness because providers are unsure how to ask. Too often, sexual health measures and assumptions are heteronormative, focused on vaginal penetration. For lesbian women, this can mean irrelevant or even harmful advice. In reality, their concerns—low desire, intimacy, body image—are similar to others, but the framework needs to be affirming. The most respectful approach is to ask permission: “Would it be okay if I asked about sexual health? Are there concerns you’d like to share?” That opens the door for patients to define what matters most in their sexual lives. This kind of inclusive questioning ensures their needs aren’t ignored.

Body Image and Intimacy

Janet: Body image comes up a lot. How do you help patients struggling with it?

Sharon: Body image is huge. After invasive treatments, people often feel their body has betrayed them. They may avoid mirrors or describe living “from the neck up,” trying not to acknowledge their altered body. It’s not only about appearance—it’s about feeling disconnected from one’s own body. My role is to help patients renegotiate that relationship, often through compassion and forgiveness. For example, some find it useful to “forgive” their body, recognizing it didn’t choose to get sick either. This reframing helps reduce anger and grief. Importantly, I don’t push people to love their bodies if that feels false. Instead, we focus on how they can still find pleasure and intimacy by shifting attention to other parts of the body or new forms of connection. Grief is an inevitable part of this, and it’s possible to feel both grateful and grieving at the same time. Acknowledging loss allows people to move forward without abandoning intimacy.

Men’s Sexual Health

Janet: Do men have special issues that come up most often?

Sharon: Yes, erectile dysfunction is a major concern; it’s very common with aging and especially after different types of cancer treatment such as treatment for prostate cancer and colorectal cancers. But that’s just one piece. Men may also experience changes in orgasm or ejaculation. For gay men, the loss of ejaculation can be especially profound because of its cultural and relational significance, yet it often goes unacknowledged. Simply validating that loss can be very meaningful. Another critical point: many men don’t know you can have an orgasm without an erection. That’s not intuitive if all your life those two have been linked. Learning that orgasm is largely neurologically driven can open new doors for pleasure. Unfortunately, shame and cultural myths about masculinity make men avoidant. They fear starting something they can’t finish. By educating men and normalizing different sexual expressions, we can relieve pressure and help them reclaim satisfying intimacy.

Returning to Sexual Activity After Treatment

Janet: Sometimes patients are told not to have sex during certain treatments, but no one circles back later to say it’s safe again. Do you see that?

Sharon: Constantly. Patients may be told, appropriately, during chemo or transplant that they’re vulnerable to infection and should avoid sexual activity. But then years pass, and no one tells them it’s safe again. I’ve seen people abstain for five or six years, unnecessarily, because no one “gave permission” to resume. That’s heartbreaking, because it’s preventable. It underscores the importance of revisiting the topic and explicitly updating patients: what was once unsafe may be safe now. Without that guidance, fear keeps them from living fully.

In Closing

I’d like to offer a huge thank you to Dr. Bober for sharing her time with me and I encourage you to share this newsletter with colleagues who may find it valuable in their own practice.

In the coming weeks I will be posting the video of this interview on my website. In the video, we go into more detail on each of the areas discussed here.

If you’d like more insights and resources, please visit the Special Topics: Discussing Sexuality section under Resources on my website for additional information designed to support oncology clinicians in addressing sexual health.