1. Body Image & Relationships
Introduction – area not always been addressed very little training locally and very few services to referral onto . Something we identified when coming into this role.
Encompasses sexuality with in the presentation
Relevant to survivorship . Palliative care and end of life
We are aware that it can be a sensitive subject which can be difficult for the patients and the health professional

2. Aims of The Session
To increase awareness of body image and sexuality issues in Palliative Care
Provoke thought/encourage discussion
Develop Skills
We have the next hour and three quarters
We want you to talk and share some experiences , hope we can learn from you
Group work
Hope to give you the confidence and tools to start opening conversation with patients

3. Group Work Ice breaker : communication ,Love Sex
DON’T WORRY ABOUT WHAT YOU WRITE DOWN, GO FOR IT ! WRITE IT DOWN NOBODY IS GOING TO SEE IT
How did that make you feel?
Imagine how patient feel when taking about sexuality issues , professionals don’t know what words to use.
Patients don’t know when to fetch the subject up , what words to use
Willy story

4. Shag
Could be a fabric ie carpet, hairstyle or British slang word used to describe sexual intercourse.
Willy story – ‘conk on’ patient describing erection, urostomy.
Understanding patients terminology, using terms patients understand.

5. Body Image Concerns in Palliative Care
The way we look
The way we feel
Our roles and identity
The way our body works
Not just about sexual intercourse
Manliness or Femininity
Expressing intimate feeling of ourselves
Body image is about many things , feelings Characteristics that make up your own sexuality identity
About who we are and about how we feel as a man or a women
Sexual attitudes vary enormously – influenced by experiences ,upbringing , genetic make up , cultural or religious beliefs , hormones , age
At diagnosis or end of life sexuality ,sex life not a priority

6. How we Look
Body image is a mental picture we have of our own appearance
Changes in body image can cause feelings of distress that go far beyond the physical effects of CA treatment
Western society – strong emphasis on appearance, constantly surrounded by media images of attractive healthy, perfect bodies
Research suggests that people operate using a ‘beauty is good’ stereotype, taught from an early age eg Beauty and the Beast, Cinderella and the Ugly Stepsisters.

7. Definitions of Body Image
Body Reality
Refers to the body as it really is.
Raw material + life influences.
Body Ideal
What we think we should look like + ideal body function.
Ideal of what we should be like is carried in our head.
It includes the space around us.
Body Presentation
How we present our bodies to the world.
Tension between body reality and body ideal.
Body Image Model (Price 1990)
Body Reality - the body as it really is. Influenced by nature (genetics) and nurture (diet and exercise).
Affected by illness – hair loss, weight loss/gain, surgery (amputation, scarring, stomas).
Body Ideal – A norm of body contours, size and proportion (constantly changing and susceptible to multiple influences).
Body Presentation – How we dress, make up, hairstyles.
Throughout life individuals attempt to sustain balance between the 3 components. One component changes such as body reality through surgery it is accommodated through 2 other components.
e.g change neckline of clothing (body presentation) to hide scarring or may alter their perception of the importance of this aspect of appearance (body ideal)

8. Individuality Body reality is unique Me behind the body
Being non judgemental
Not making any assumptions ,
For example Tattoo , what we wear

9. How Does a life Limiting Disease Affect How we Feel?
Fear /anxiety
Anger /frustration
Guilt
Desire
Contagion
Isolation/shame
Loss of self esteem/confidence
Embarrassment
Ask group ?
Fear- disease progression ,Dying, leaving love ones, pain
Anger –How disease is impacting on life . Not being able to do what you use to
Desire – loss , fear
Isolation – lifestyle change – not able to socialise
Loss of self esteem – Role change
Embarrassment – Breathless how we look

10. Relationships Level of importance doesn’t change
Expression of sexuality changes
More emphasis on verbal intimacy
Hugging/ kissing/ eye contact/ touching
1. Roles and relationships can change – look at other ways to be intimate
Go at different rates can get stuck in one response hard to move past diagnosis
3. Difficult watching a loved one go through illness , carer loved one goes through the same process
Partners can be over looked can become frustrated don’t know how to cope have to stay strong show no emotion
Protective of partner- tell story of Catherine loss of role as mother wife

11. What Stops a Patient Asking for Help?
Body Image and relationship wasn’t a problem surviving was
Had much more important questions to ask
Did not know it was going to affect me in this way
I thought the professionals would tell me all I needed to know
Did not know what sort of help is available
How would I know how I feel?
Important we address body image and sexuality
83% of couples felt that sexual relationships were important in maintaining a loving relationship
70% of men & women reported experiencing sexual problems
Being alive was enough
The subject was left out of consultations so not aware of issues they might experience

12. Barriers Identified by Health Professionals
Why would they have a problem
I wouldn’t like someone to ask me
Too old
Too ill
If they want to talk about it they will ask
Don’t have the skills- I have never been taught
Don’t have the time
Embarrassment
Its private
Heath professionals did not provide opportunity to discuss sexuality / body image
Health professional should ask permission and should be revisited several times

13. P.L.I.S.S.I.T. P- Permission LI- Limited information
To feel comfortable about voicing concerns/ anxieties.
LI- Limited information
Acknowledgement of conversation
SS- Specific suggestions
Suggestions/ advice
IT- Intensive therapy
Referral on
Overview
Ask permission to discuss sexuality issues
Patients need to know we are aware / interested , gives the massage subject is ok to discuss
P- ASKING
Li- BEEN HEARED , PAY ATTENTION- story of anal cancer patient
SS- Get on bed, knock on door , use of oramorph before sex
IT- senior nurse , sexual therapy , my story about PT with rectal cancer

14. TREATMENTS Erectile Dysfunction:
Lifestyle interventions- smoking, alcohol, weight, exercise, diet, stress
Oral medication e.g. Viagra
Vacuum pumps
Penile injections/pellets
Vaginal problems:
Lube/silk, HRT/topical
Vaginal dilators for vaginal narrowing
Different positions
Pelvic floor exercises
Talking Therapy
ED- mild moderate or severe
Lifestyle- reduce fat in diet
Viagra – increases the blood supply to the penis taken 1hr before sex. Not recommended if you have heart problems sde effects heart burn dizziness, headaches, visual
Vac pump increases blood flow to the penis then the band applied
Vaginal dryness- surgery or menopause, hormone treatment
Surgery or DXT
Talking therapy- counselling psychosexual therapy- explore issues and work out ways to overcome them

15. End of Life Care We become guardians of body image Lack of control
Body breached by procedures/ equipment
Body image in death
Personal care , mouth care, how they look how family members remember them , Bladder , bowels
3. Syringe driver , catheter, be discrete
4. Pay attention to how we look, body in bed warm

16. https://youtu.be/pkS4eMHv0HE

17. “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel”
Maya Angelou
All feel vulnerable about sexuality
Sex is important
Sex problems normal after treatment