This is the first of a two-part unit on the issue of sexuality after stoma formation. It explores the physical and psychosocial issues related to sexuality following stoma formation, outlines relevant literature and highlights the importance of holistic nursing care for these patients.
Taylor, S. (2008) Sexuality following stoma formation 1: Background. Nursing Times; 104: 16, 26-27.
Sarah Taylor, BSc adult nursing, RGN, is staff nurse, St George’s Hospital, south London.
- Understand the importance of discussing sexuality with patients - and partners - before and after stoma formation.
- Identify common psychological concerns about sexuality. following stoma formation.
Healthcare professionals often find it difficult to discuss sexuality with patients due to embarrassment and perceived lack of interest from patients (Black, 2000). However, evidence suggests most people undergoing stoma formation have concerns about sexuality (Galt and Hill, 2002). Equally, these researchers suggested that patients are often too embarrassed to ask questions, perhaps believing practitioners will not be interested. This means that sexuality and stoma is often neglected as an area of care.
In western society huge emphasis is placed on body perfection, and body image and sexuality are inseparable. Moreover, Kelly (2001) argued body image involves more than the physical, including the emotional experiences of pleasure and pain, and must be considered as everything that defines us as human. White (1997) reported it as a major concern for many stoma patients, causing about 25% to suffer a psychological health issue within a year of surgery. Peri-operative care of stoma patients is imperative to ensure good psychosocial outcomes and improve quality of life.
Stomas are artificial openings created on the body surface as an alternative route for waste removal when the normal route is no longer viable. It is estimated that over 13,000 people undergo stoma formation in the UK annually (Baxter and Salter, 2000; cited in Simmons et al, 2007). Stomas are created for a variety of reasons (see box below). They can be permanent or temporary, which may determine how patients adapt to lifestyle changes.
Conditions requiring stoma formation
Most common indication:
Most common indication:
Source: Kirkwood (2005)
The reason for formation can also affect adaptation. For example, surgery to remove a tumour is life saving, yet often patients’ feelings about the resulting stoma relate to the fact that it serves as a reminder of their disease and the uncertainty of treatment outcomes (Manderson, 2005).
There are many physical and psychosocial health issues attached to stoma formation, which can cause patients distress after surgery. It is necessary for healthcare professionals to understand these issues to provide appropriate care for patients, especially since early intervention is known to improve health outcomes (Black, 2000).
The literature contains many opinion pieces and articles on the subject of body image and sexuality but recent research in this area tends to be from outside the UK, and mainly focuses on body image and quality of life as a whole, rather than sexuality as a separate issue (Krouse et al, 2007; Wu et al, 2007; Persson and Hellstrom, 2002).
However, one study highlighted the high incidence of sexual dysfunction following rectal cancer surgery and the need for effective communication between patients and healthcare professionals about this during all stages of care (Hendren et al, 2005). Although body image and sexuality are closely related, sexuality itself requires specific care outside the umbrella of quality of life, as it is very private and individual.
Clinimed Resource for Education and Specialist Training (CREST, 2006) published RCN-accredited best-practice guidelines for the care of patients with stomas, highlighting sexual function as a separate area. However, it made only brief reference to psychosocial issues, focusing more on physical disturbances.
Sexuality is not merely the ability to have sexual intercourse but encompasses comfort, human contact, security, self-worth and bonding in a relationship (Borwell, 1997), all of which are inextricably linked to body image.
There is no Department of Health guidance specifically relating to the care of patients with stomas, while even the Ostomy Patients’ Charter (cited in White, 1997) makes no mention of specific psychological care. It is therefore questionable whether current psychological care relating to patients’ sexuality is based on evidence or professional belief about what it should entail.
Sexual concerns regarding stoma formation are often psychosocial in origin, especially in terms of body image, evident in most current research that focuses on patients’ self-efficacy and perceived personal control (Wu et al, 2007; McVey et al, 2001). These worries include feeling unattractive, others noticing the bag under clothing, and concerns about odour, leakage and the bag coming off during sexual activity. It is known that formation of a stoma negatively impacts on sexuality and body image (Krouse et al, 2007). Persson and Hellstrom (2002) found that all patients interviewed after stoma formation believed they had become more sexually unattractive.
Issues around sexuality and stoma formation should be addressed early in order to re-establish normal sexual relationships after recovery. Although a potential change in sexual health would not be life-threatening, it can be distressing, lead to relationship breakdown and affect quality of life, so it is considered a major part of ostomists’ care.
Poor psychosocial health can in turn adversely affect physical health. Marek and Boehnlein (2007) stated that, while a certain amount of anxiety and stress can aid pre-operative education and coping, too much may reduce patients’ abilities to make informed decisions and, ultimately, lead to protein breakdown, increased risk of infection, delayed wound healing and electrolyte imbalance. These evidently affect post-operative recovery, making management of anxiety and stress a major aim for nurses. Deterioration in physical health can affect sexuality both in terms of sexual functioning - such as achieving or maintaining an erection and vaginal dryness - and psychologically, since poor physical health can lead to fatigue, depression and negative body image (White, 1997).
Pre-operatively, stoma nurses often speak to patients about every aspect of care, both physically and psychosocially. Sexuality can be affected physically through damage to the nerves during surgery, and psychologically due to body image issues, partner perception and loss of libido (Manderson, 2005; White, 1997).
Before stoma surgery, patients’ partners tend only to be concerned with their loved one’s survival but, following surgery, can suffer as many sexuality issues as their partner (Persson et al, 2004), so it is often appropriate to include partners in this aspect of care. However, it may also be beneficial to discuss patient concerns alone since they may hold back some information if their partners are present.
Although nurses play a vital part in ostomists’ care, Nicholls (1996) pointed out that surgeons should fully explain the procedure and risks and benefits to patients pre-operatively, so nurses should not be expected to disseminate such information without prior input from surgeons. Nurses can, however, contribute by reiterating information and answering further questions, including any relating to sexuality.
Nurses should discuss changes in body image with patients, and how any issues can be dealt with, as this can bring to light issues about the impact on sexuality. Broaching the subject of sexuality within another topic, or without asking direct questions, is likely to lead to better outcomes than opening the subject immediately (Salter, 1996), as this is a less intrusive method of obtaining information on a subject many patients find embarrassing and private.
Manderson (2005) argued that cultural background can influence the extent to which patients will discuss such issues but the subject should always be sensitively broached to give patients and partners the option of expressing concerns.
Clearly, sexuality in relation to stoma formation is an important issue. It is essential patients and their partners have adequate time to discuss such issues in a supportive and confidential environment. This is rarely achieved behind curtains in a bay where others may be listening, so discussions should take place in a private area where possible. Nurses should ensure that both physical and psychosocial issues surrounding sexuality and stomas are discussed, and prompt action is taken to minimise deterioration in quality of life.
CREST (2006) Caring for Stoma Patients: Best Practice Guidelines. High Wycombe: Clinimed.
Galt, E., Hill, H. (2002) What About Sex? For People with a Stoma and Their Partners. Cambridge: Dansac Ltd.
Hendren, S. et al (2005) Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer. Annals of Surgery; 242: 2, 212-223.
Manderson, L. (2005) Boundary breaches: the body, sex and sexuality after stoma surgery. Social Science and Medicine;
61: 2, 405-415.
Persson, E., Hellstrom, A.L. (2002) Experiences of Swedish men and women 6-12 weeks after ostomy surgery. Journal of Wound,Ostomy and Continence Nursing; 29: 2, 103-108.