Discussing Sexuality with Cancer Patients : Oncology Nurses Attitudes and Views

Turkey is a country where sexuality is not spoken about within the family, sexual education is not included in the curriculum of schools and sexual myths accepted as taboos by individuals are common. Sexuality is regarded as shameful and sinful in this society that is becoming more and more conservative. In Turkey, since many parents received no education regarding sexuality from their parents, they do not have much knowledge about sexuality and generally avoid talking about the subject with their children. Many studies determined that children and adolescences in schools wanted to receive education about sexuality; however, they are deprived of opportunities regarding sexual education or counseling. The absence of sexual health education in the curriculum of many schools giving health education causes problems regarding the evaluation of a patient’s sexual health, the discussion of their sexual problems and the provision of counseling for health personnel who are responsible for the nursing and treatment of patients (Set et al., 2006; Calisandemir et al., 2008; Golbaşı and Evcili, 2013). However, sexuality, which is an important indicator of the quality of life for all individuals, is as important as cancer patients (Blagbrough, 2010; Hordern et al., 2009; Goker et al., 2011; Fouladi et al., 2013). However, due to the aforementioned reasons, patients abstain from accepting help regarding sexual


Introduction
Turkey is a country where sexuality is not spoken about within the family, sexual education is not included in the curriculum of schools and sexual myths accepted as taboos by individuals are common.Sexuality is regarded as shameful and sinful in this society that is becoming more and more conservative.In Turkey, since many parents received no education regarding sexuality from their parents, they do not have much knowledge about sexuality and generally avoid talking about the subject with their children.Many studies determined that children and adolescences in schools wanted to receive education about sexuality; however, they are deprived of opportunities regarding sexual education or counseling.The absence of sexual health education in the curriculum of many schools giving health education causes problems regarding the evaluation of a patient's sexual health, the discussion of their sexual problems and the provision of counseling for health personnel who are responsible for the nursing and treatment of patients (Set et al., 2006;Calisandemir et al., 2008;Golbaşı and Evcili, 2013).However, sexuality, which is an important indicator of the quality of life for all individuals, is as important as cancer patients (Blagbrough, 2010;Hordern et al., 2009;Goker et al., 2011;Fouladi et al., 2013).However, due to the aforementioned reasons, patients abstain from accepting help regarding sexual

Discussing Sexuality with Cancer Patients: Oncology Nurses Attitudes and Views
Umran Oskay 1 *, Gulbeyaz Can 2 , Sukran Basgol 1 problems that are caused by cancer and its treatment, or health experts serving in oncology departments accept these problems as caused by cancer treatment, believe problems concerning sexuality are natural, and refuse to talk about the effect of treatment on sexuality with their patients (Stilos et al., 2008;Blagbrough, 2010;Olsson et al., 2012).Taylor and Davis (2006) report that nurses are at the first rank among health personnel to whom patients can easily explain themselves and can be effectual in removing their concerns regarding sexual life and sexual health (Taylor and Davis, 2006).Therefore, among multidisciplinary team, especially nurses have important duties as counselor and guide in determining the factors affecting sexual functions of cancer patients, problems that may be encountered in sexual matters, and providing assistance to these individuals in order to overcome these problems (Hughes, 2000;Jolley, 2002;Dattilo and Brewer, 2005).However, it is impossible for the nurses serving in Turkey's health system not to be affected by the moral values of Turkish society regarding sexuality.Apart from cultural ones, many factors prevent nurses from evaluating the sexual health of patients and providing counseling to them (Krebs, 2008;Hordern, 2008;Algier and Sultan, 2008;Pınar, 2010;Gölbaşı and Evcili, 2013).Even though sexual counseling is known as an important part of nursing care, many studies report that nurses have difficulties in Umran Oskay et al dealing with this issue (Gordon, 1982;Shell, 2007;Julien et al., 2010;Oskay et al., 2011;Chun, 2011).
The aim of our study is to determine, the views and attitudes of nurses caring for cancer patients towards sexual counseling.

Materials and Methods
The present study prepared in descriptive design was conducted through filling out an on-line survey published on the website of Oncology Nurses Association between June and September, 2013.The website of Oncology Nurses Association was chosen since it provides patient nursing guides which are continuously used by oncology nurses.The consent of Oncology Nurses Association was taken in order to conduct the present study.
Online survey published on the web site of the Turkish Oncology Nurses Association.Nurses serving in an oncology clinic for at least a year and caring for an oncology patient were invited to participate in the study.Nurses serving in oncology clinics for at least a year, caring oncology patients and accepting on-line participation consisted the sample in this study.
The data collection tool of the study was an interview form which was prepared by the researchers benefiting from the literature and which includes demographic information of the participants, an evolution of sexual health in cancer and questions regarding counseling.Then, the survey was reorganized after taking expert views of seven oncology nurses working in different oncology clinics (two gynecology-oncology nurses, two chemotherapy nurses, one medical oncology nurse and two radiation oncology nurses) and uploaded to the website of the association.Nurses who are members of the association were invited to participate in the study via e-mails.In addition, an invitation was published on the website.The participation in the study was based on voluntariness through the internet.
The data obtained from the study were evaluated using IBM SPSS Statistics 21 (Istanbul University, Istanbul) package program.Descriptive statistics as percentage value, arithmetic mean, median, minimum and maximum values were used in evaluating the distribution of characteristics of participants; Chi-square test was used in comparing categorical data and student t test was used in comparing mean values.p<0.05 value was accepted as significance criteria in evaluating all statistical findings.

Results
The present study conducted with the participation of nurses serving in oncology institutions of Turkey was completed with the participation of 87 oncology nurses from 19 provinces and six regions of Turkey (45 university hospital nurses, 28 private hospital nurses and 14 state hospital nurses).Most of the nurses were supervising nurses of the oncology clinics they serve.Therefore, the results of the present study also demonstrate the approaches of the clinics toward the sexual problems of cancer patients.
All of the nurses whose age average was 35.20±7.46 years (Range 20-55) were female; most of them were married and had a postgraduate degree.The evaluations determined that most of the nurses were living in metropolises, in Marmara Region and serving in medical oncology units in public hospitals.Median working year in the nursing profession was found to be 14 years (x=14.03±8.05,range 1-34 years).In addition, median working year in the oncology field was six years (x=7.64±6.24,range 1-27 years).
All nurses stated that cancer patients had sexual problems and most nurses (87.4%) stated that they consider discussing issues about patients' sexual life as a part of their profession.However, contrary to these results, 88.5% of the nurses stated that they do not evaluate the sexual life of their patients, 67% stated that they expect the patient or physician to start the conversation about the issue, and 86.8% of the patients were not willing to talk about the issue.
The study determined that even though 97.7% of the nurses believed the necessity to discuss sexual concerns and problems with cancer patients, 47.1% talked only with the patients demanding information about their sexual problems, 36.8% never talked about this issue with their patients and 43.7% stated that the gender of the patient was important in discussing this issue.52.9% of the nurses stated that they give information, which they obtained from their clinic experiences, about the effect of cancer treatment on sexual life when necessary.
The nurses participating in the study stated that the most important three subjects that should be dealt with during sexual counseling with patients were the effect of cancer on sexual life (98.9%), the effect of cancer treatment on sexual life (97.7%)and the attempts to deal with sexual problems throughout cancer treatment (95.9%), respectively.In addition, 83.9% stated that there was an absence of a booklet, manual, etc. explaining   the effect of cancer and its treatment on sexual life in their clinics.Although, 63% of the nurses thought they had insufficient knowledge and education regarding sexual counseling, the study determined that regarding the questions that cancer patients asked about sexuality during cancer diagnosis and treatment, most of the nurses replied to those questions without feeling uncomfortable (Table 1).The present study also examined the reasons for ignoring sexual counseling given to cancer patients.Even though many other reasons were defined, nurses stated the most important three reasons as the absence of a routine regarding sexual evaluation and sexual counseling, the belief that the patient would be ashamed and perceive it as a loss of privacy, and the self-evaluation of nurses as being insufficient in this subject (Table 2).The present study examined the effect of educational level, marital status and working year in the nursing profession and the nurses' oncology unit on their views and attitudes towards sexual counseling (Table 3).The evaluations found that the most important variable determining the beliefs and attitudes of nurses towards sexual counseling was working year in the profession.In addition, the period of working year in oncology units and education were also found effective: The number of nurses who stated that sexual counseling was a part of their profession was higher for those who had masters/PhD degree and had working years over 15 years.
The number of nurses who stated that the gender of patients was important in discussing sexual issues was found higher in nurses who aged below 35 years (t=-2.748,p=0.008) and worked less than 15 years.
The rate of evaluating sexual life and discussing sexual concerns and problems with patients was higher in nurses with more than 15 years of service.
The rate of evaluation about sexual life was higher in nurses who served in oncology clinics more than seven years (Table 3).

Discussion
Sexuality is a vital component of quality of life and overall health.A cancer diagnosis can affect many aspects of patients' daily routine, including their sexuality.Many oncology patients have fears and concerns about the fact that their marriage will be at risk and their sexual and emotional relationships with their spouses will be affected because of sexual problems due to cancer and its treatment (Dattilo and Brewer, 2005;Quinn and Browne, 2009;Keskin and Gumus 2012).Nurses play a key role in determining and struggling with the sexual concerns and problems of cancer patients as a counselor and guide (Kotronoulas et al., 2009).However, it is stated that health care professionals focusing on the treatment of the disease might ignore the sexual problems observed in cancer patients.In Turkey, literature includes few studies on this issue (Can, 2004;Pınar, 2010;Gölbaşı and Evcili, 2013).Therefore, this study was conducted in order to determine the views and attitudes of oncology nurses caring for the individuals with cancer in Turkey towards sexual counseling.
This study was conducted with the participation of professional oncology nurses working in oncology departments of state hospitals and residing mainly in the Marmara region.These nurses reflect the general structure of the oncology services.Participants, mainly with undergraduate degrees, are nurses who have been in the profession for many years and are experienced oncology nurses in caring for cancer patients.This indicates that the results obtained from this study could be used as a resource in determining the views and attitudes of oncology nurses caring for individuals with cancer in Turkey towards sexual counseling.
Most studies report that nurses consider sexual evaluation and counseling as a part of their job, however they had difficulty in performing this service and would avoid discussing this issue with patients (Butler and Banfield, 2001;Mercer et al., 2003;Magnan et al., 2005;Huang, 2013).In this study, all of the nurses claimed that cancer patients had sexual problems and 87.4% of the nurses stated that they considered the process of discussion on sexual issues with their patients as part of their duty.Yet, 88.5% of the nurses stated that they did not evaluate the patients' sexual life, 67% of them said that they expected the patient or the doctor to start the conversation on the issue and claimed that 86.8% of the patients were not willing to speak about the issue.These results are consistent with other studies and are not surprising when our country's cultural values are considered (Stead et al., 2003;Hautam and Miettinen, 2007;Zeng et al., 2011).In

Umran Oskay et al
Turkey, the general perception is that sexual issues are a taboo subject and the unwillingness of nurses to speak of the issue with their patients as a result of bias on sexuality are the general indicators of our society's value judgment.
The present study determined that although 97.7% of nurses believed that it is necessary to discuss sexual concern and problems with cancer patients, 47.1% of them stated that they discuss the issue with their patients who ask for information on sexual problems and 36.8% of the nurses stated that they never had a word on the issue with their patients.52.9% of nurses stated that they could give information, which was gained as a result of their clinical experiences, to the patient about the effects of cancer treatment on sexual life.The present study also determined that nurses are aware of the fact that their patients have sexual concern and problems.In addition, the nurses had opinions on what topics are covered by the counseling to be given to cancer patients.But it is worrying that 36.8% of the nurses ignored sexual issues by never mentioning it to patients, nearly half of them did not answer the questions, and 63% of them did not have enough knowledge and education on the issue.Few schools in Turkey include sexual health education in their curriculum.Therefore, for health care professionals, practicing a topic in their clinic routine, which has not been dealt at schools, is obviously difficult.
Most studies reported that the main reason that nurses' do not discuss sexual concern and problems with their patients is because of insufficient time, focusing on the cancer treatment and patients' unwillingness to talk about the related issues, insufficient knowledge, general views and attitudes towards sexual issues and the concern that the patient would feel a loss of intimacy (Tsaii, 2004;Beck and Justham, 2009;Saunamaki et al., 2010;Huang et al., 2013).In a systematic review by Kotronoulas and et al (2009), which covers 18 studies, it is stressed that taboos and prejudices of nurses would hinder discussions on sexual issues (Kotronoulas et al., 2009).In the present study as well, the idea that the patient would feel ashamed and his/her privacy would be damaged and insufficient knowledge and experience, and considering the topic as a taboo, can be regarded as the most significant reasons.These results were consistent with the literature.However, the absence of a routine practice regarding the evaluation of sexual health in clinics can be considered as a different factor compared to the other studies (Akkuzu and Ayhan, 2013;Stilos et al., 2008;Kreps, 2008).The main reason for this is, in Turkey, the actual medical treatment of cancer for cancer patients is the most important issue of all and the rest is considered as unimportant.Sexuality, with this view, is a topic of least importance and consideration.In the patient portfolio, one or two questions that are about sexual evaluation are generally not asked and ignored.Lack of knowledge on the issue, incorrect or inaccurate beliefs and attitudes make sexual concerns and problems invisible.Further evidence that indicates ignorance on the issue when brought up is that 69% of nurses inform the patients that there is not an expert or medical unit to which the patients can be sent when they have sexual problems.
The present study also found that 43.7% of the nurses stated that the gender of the patients was important when discussing sexual issues with them.Cultural structure and values of the society and prejudices about sexuality would provoke feelings of shame and hesitation for individuals.For this reason, when discussing sexuality with nurses, it might be preferable to discuss these issues with the same gender for a more comfortable communication.It is not difficult to understand that discussing sexuality, which is becoming more and more taboo in Turkey, with male patients would make them ashamed and nurses would choose to focus on the treatment of the patient rather than discussing such issues, which might make them misunderstood easily.
Most studies stated that clinics having booklets, manuals etc., which cover useful information on sexual concerns and problems for cancer patients would contribute to the counseling and discussion of sexual issues between nurses and patients (Magnan et al., 2005;Kutmec, 2009;Zeng et al., 2011;Huang et al., 2013).This study found that 89.9% of the nurses worked in clinics where such booklets and manuals were not found.In Turkey's health care system, the main criterion is the treatment of patient.It is not surprising that sexual health is ignored since the decrease in the level of quality of life resulted from the problems observed during the diagnosis and treatment process.Absence of a routine and materials on the issue in the clinic makes the health care professionals' counseling duty more difficult and causes them to ignore the issue.
The study also indicated that the number of nurses with more than 15 years of experience and who considered sexual counseling as part of their job had higher frequency of evaluation concerning sexual life and rate of encouraging patients to discuss sexual concerns and problems.Also, the frequency of evaluation about sexual life of nurses with seven years and more experience in oncology was higher, too.Moreover, among the nurses aged below 35 and with experience less than 15 years, the number of those who stated that the patient's gender mattered on discussing sexual issues was higher.Haboubi and Lincoln (2003) found that young nurses had evaluated patient's sexuality more often than elder nurses (Haboubi and Lincoln, 2003).Stead et al stated that newly appointed nurses had difficulties in assessing and discussing on patients' sexual life (Stead et al., 2003).The results of the studies by Saunamaki et al (2010) and Julien et al (2010) determined that elder nurses were more comfortable in assessing patients' sexuality when compared to younger ones (Julien et al., 2010;Saunamäki et al., 2010).Webb (1988) stated that young nurses should abandon their prejudices on sexuality, or else, this would create an obstacle in discussing sexual issues with patients (Webb, 1988).It is a known fact that women, as they get older, have a higher statute and become more reliable in Turkey.This is also true for those nurses who are always present near the patient and responsible for the care of him/her throughout the whole process of diagnosis and treatment of cancer.The fact that the nurses working for long years are older and have more professional and life experience, as they are older they feel comfortable in stating their opinions and thoughts could be considered as a contribution to their state where they are also more DOI:http://dx.doi.org/10.7314/APJCP.2014.15.17.7321Oncology Nurse Perceptions of Sexual Counseling in Turkey comfortable in assessing and discussing sexual life of their patients and patient's gender becomes less important (T.R. Ministry of Family and Social Policies, 2012).The results of this study are consistent with those aforementioned studies (Kağıtçıbaşı, 1988;Turan et al., 2011).Contrary to the general view that newly appointed nurses would have more reformist and idealistic thoughts on the profession and would be more open to different ideas, they are so passive and biased with regard to discussing sexual issues with patients.And this is evidence that there are not that many differences regarding social and cultural norms concerning sexuality between countries.
The present study found that nurses had difficulties in evaluating the sexual life of patients and sexual counseling with them.Main obstacles with regard to this issue could be summarized as the perception that the patient would not want to speak on these issues, insufficient knowledge and experience, considering the issue as taboo and significance of the gender difference.Also, the absence of a routine sexual assessment and counseling in clinics, lack of materials of booklets or manuals to give to the patients would hinder nurses to take initiative.
It is important for nurses in our country to break their prejudices and get rid of taboos on discussing and providing counseling about sexual issues with their patients and improve themselves on the issue with inservice programs.However, only the attempts of nurses would not be sufficient.In Turkey's health care system, individual patient's sexuality is the most neglected and least important area.For this reason, it is necessary to put sexual health education into the curriculum of nursing, medical and all health schools, to create forms in order to assess the sexual health of patients within the health care system, prepare guide books and booklets for cancer patients, and to make health care personnel aware of the issue.It is inevitably true that taking these steps with government policies makes the biggest contribution to improvement in this area of cancer patient care.

Table 1 . The Attitudes of Nurses Towards The Questions of Cancer Patients about their Sexual Concerns and Problems (n=87)
*More than one answer is given

Table 3 . The Variables Determining, the Views and Attitudes of Nurses Towards Sexual Counseling
*Fisher p