Intimacy and Breast Cancer

Dr  Galper Grossman is a Harvard trained radiation oncologist with a degree in public health.  In conjunction with the Eden Center, she is co-authoring “For Hope and Healing: Breast Cancer and Mikveh: A Guide for Women with Breast Cancer and BRCA”.

“I have breast cancer, but I still need my husband“ she cried.  Sarah was diagnosed, thank G-d, at an early stage. She had undergone mastectomy, and was now scheduled for 6 months of chemotherapy to be delivered by a PICC (peripherally inserted central catheter) line, followed by radiation to the chest wall.  Then she got her period and realized to her consternation that the PICC line and its accompanying protective sleeve were potentially chatzizot (barriers) which could invalidate her immersion. Would she not be permitted to immerse in the mikveh for the entire interval that the PICC line would remain in place? She was devastated by the thought that she would be in niddah for the duration of her treatment.  Could it be that for the next six months of treatment, a time of vulnerability when she most needed to be intimate with her husband, she would be forbidden to have relations with him, touch him or even receive his help with activities of daily living such as getting dressed or administering daily injections of blood thinners to prevent the PICC line from clotting? Instead she would need to turn to her 4-year old daughter for help?

Sarah’s mikveh dilemma is not uncommon. A significant number of women with breast cancer or carriers of the BRCA mutation who have undergone risk reducing surgery visit the mikveh.  What are the emotional, medical and halakhic challenges women with breast cancer or carriers of the BRCA mutation face when they visit the mikveh?

During breast cancer treatment a woman’s body can change profoundly from surgeries to the breast which remove part or all of the breast, lymph node dissection which causes arm swelling, reconstruction which leaves scars on the stomach, back, legs and buttocks, radiation which causes redness and peeling of the skin on the breast or chest wall and chemotherapy which leads to hair loss.  The changes can have a profound affect on one’s body image and desire for sexual intimacy during treatment and after.

The emotional challenges of mikveh can be magnified by underlying difficulties with intimacy that many women with breast cancer struggle with.  One study demonstrated that 94% of women with breast cancer stopped having intercourse due to a side effect of treatment and three years after diagnosis, 80% of these women continue to struggle with intimacy.  Shockingly, over two thirds (68%) of women with breast cancer say they were not told about the possible impact of treatment on sex and intimacy, and three quarters (76%) did not receive the support they needed from healthcare professionals. Impaired intimacy was attributed to loss of libido, vaginal dryness, pain on intercourse from hormonal treatment or premature menopause, fatigue, temporary hair loss, diminished self-esteem, weight gain, anxiety over cancer recurrence and fear of infection from physical contact during chemotherapy.  mikveh may be particularly stressful for a woman with breast cancer or a carrier of a BRCA mutation who is grappling with these issues.

The obligation to go to the mikveh can heighten these issues for a religious women. Exposing one’s body to the mikveh attendant may be distressing especially if the woman has not exposed her body to anyone other than her physician (sometimes not even to her husband). Moreover, women may feel torn between wanting physical closeness as an expression of support and intimacy, but not wanting to engage in sex (do we want to say sex or have relations? just asking.). They may be unsure how to deal with the feeling of “obligation” of having sex on mikveh night if they are not up to it, but would still like intimate touch. And they may be unsure whether  they are allowed to go to the mikveh due to a myriad of medical and halakhic issues.

In the absence of information women might assume, as Sarah did, that immersion in the mikveh with a medical device in place is absolutely forbidden.  However, it is unthinkable that a woman with a PICC line in place could be forbidden to her husband for the entire duration of cancer treatment. What is a woman such as Sarah diagnosed with breast cancer who requires six months of chemotherapy with a PICC line in place to do?  Is she prohibited from her husband for the entire duration of treatment?

Following our well-received publication of a pamphlet to increase the sensitivity of mikveh attendants to the needs of women with breast cancer we are preparing an educational booklet on mikveh for women with breast cancer and BRCA carriers.  The booklet identifies potential obstacles and barriers to mikveh use for women with breast cancer, provides direction and guidance in making decisions, outlines the relevant halakhic issues so that they can pose questions to and advocate their needs to their medical team, their halakhic advisors and mikveh attendant.  Our guidebook offers suggestions for women on how to minimize the anxiety associated with mikveh , acknowledges and validates the challenges of intimacy faced by women with breast cancer and carriers of the BRCA mutation, emphasizes the importance halakha places on intimacy in marriage and with the guidance of a leading sex therapist in Israel offers helpful tips to improve intimacy.  We also give suggestions to minimize the medical risks of mikveh during breast cancer treatment. Finally, the pamphlet summarizes the opinions of leading rabbinic authorities on the halakhic status of various potential chatzizot and advises women how to approach mikveh in the face of these potential barriers.

Marital intimacy is especially critical during breast cancer diagnosis and treatment.  The American Society of Clinical Oncology notes, “Sexual dysfunction has been associated with worse quality of life and mood in cancer survivors.  Studies show that sexual dysfunction is also associated with worse fatigue, relationship discord, and intimacy problems. Furthermore, sexual dysfunction is associated with increasing psychological distress, anxiety, and depression symptoms. Therefore, improving cancer survivors’ sexual function may have a positive effect on their quality of life, physical and psychological health, and intimate relationships, thereby decreasing the overall morbidity of their cancer treatment.”  Fostering intimacy by addressing and minimizing the emotional, medical and halakhic obstacles to mikveh improves the quality of life and psychological well-being of women with breast cancer and BRCA carriers.

To her good fortune, Sarah was referred to me and I showed her a draft of our educational pamphlet.  She realized that there are halakhic authorities who permit immersion with the PICC line and protective sleeve in place. With our guidebook in hand, Sarah contacted her mikveh attendant to schedule an appointment better prepared to deal with the anxiety of exposing her body after surgery and fear of intimacy that can follow a breast cancer diagnosis.  With the approval of these halakhic authorities, she immersed herself in the mikveh with a protective sleeve covering the PICC line to prevent water exposure. She will not spend the next six months of treatment forbidden to her husband. Having breast cancer doesn’t have to be synonymous with the added loss of prolonged marital separation or losing your husband for the duration of treatment.