Dr. Mindy Schiffman

Mindy R. Schiffman, PhD, is a senior staff psychologist at the NYU Fertility Center, a clinical instructor in NYU's obstetrics and gynecology department, and has a private practice in individual, couple and group counseling. Her specialty is helping people cope with the emotional stress of medical illness, including infertility, sexual dysfunction, and grief and bereavement issues. After being awarded her PhD in Clinical Psychology from Columbia University's Teachers College, she completed a two-year post-doctoral fellowship in Psycho-oncology at Memorial Sloan-Kettering Cancer Center. Concurrently, Dr. Schiffman held a joint appointment in the Human Sexuality Program at New York Hospital/Cornell Medical Center, where she studied under Dr. Helen Singer Kaplan, with the expressed purpose of helping cancer patients resolve sexual problems secondary to their cancer.

Dr. Schiffman is certified in sex therapy by the American Board of Sexology. She has been a guest speaker at Gilda's Club, the Young Survival Coalition sponsored by SHARE, and at the LGBT Center's Lesbian Cancer Initiative. She was the editor of a special issue of the Journal of Sex Education and Therapy on Cancer and Sexuality.

Questions & Responses:

Question Seven:

Hi, I need assistance. I had a bilateral mastectomy about 4 years ago. I keloid horribly and the scarring is so bad that I cannot wear a low cut dress without showing a scar in my cleavage. My big issue is that I do not feel sexy with these scars, I am so upset by them that I am not dating anyone at this time. The only man I chose to be intimate with is the guy who was with me during the breast cancer nightmare when I had no breasts at all. Unfortunately, he is not interested in a commitment and I worry it is because of the scars.

Moving forward in my dating life, I am terrified of the rejection if I take off my shirt off with a new partner, the look of disappointment will be gut wrenching. Outwardly, you would not even know I was ill EVER and then I take off my clothes and it looks like I've been attached by a shark (I also have a scar hip to hip from DIEP flap).

Dr. Schiffman:

People scar very differently, and keloids can look very scary. I have known some patients who have gotten steroid injections to soften the scars. Also, the really raw look of a scar takes some time to lessen in intensity. I would recommend that you consult with a dermatology specialist. Meanwhile, you still have your sexiness, or lack of, to deal with. Focusing on the scars and worrying about your partner's reactions are not sexy thoughts. In fact, they are "anti-sexual" and can inhibit sexual desire as well as responsiveness. You don't have to be happy with the scars, but it is important for you to begin to feel more comfortable with your body as it is. Many women (even before cancer) are unhappy about specific parts of their bodies (e.g., thighs, bellies, hips), and think that their partners are also unhappy with that part. Sometimes that is true, but more often it has more to do with the woman's own body image.

To begin to come to terms with your own scars (or other body parts), I recommend starting by touching the scars gently. Feel the different shapes and textures of the scars, and the different sensations you have when touching them. Then, look at your scars regularly while softly caressing them. These body-image exercises should alternate with self-stimulation (masturbation), while having a positive sexual fantasy. Then, I would combine the two—touching your scars while masturbating and maintaining a positive sexual fantasy. This obviously needs to be done over several sessions, and possibly with the help of a sex therapist. In terms of new relationships, you probably will want to introduce your partner to your scars in a gradual way, especially if your scars are so severe right now. It would not be unusual for an intimate partner to want to know about your scars, and if they hurt. This might entail a change in your seduction repertoire, maybe starting out with a sexy chemise, and revealing your entire naked body at a later interlude. Certainly, it makes sense to start out being sexual with a partner with whom you feel emotionally safe.

Question Six:

How do you deal with the feeling of being "touched out"? It seems that when you spend so much time having so many doctors, etc. touching you, that you don't want someone else touching you even if they're doing it in a way that feels good. You just want to maintain that control and ownership over your own body. How do you deal with this within a marriage or relationship?

Dr. Schiffman:

Of course, you need to regain that feeling of control and ownership over your body. Even in a good relationship, you want to feel you are in charge, even if it is that you decide whether or not to let go in a sexual interaction, i.e., give up control. It is essential that you speak to your partner about your feelings. You might want to try touching exercises alone, caressing your own body in the tub or in bed, several times. When you are ready, you can ask for a non-sexual massage from your partner, start with your clothes on the first time. Another time, you might have only your underwear on. You have to feel that you can trust your partner to let you lead, and this is what you must convey to your partner. If your partner becomes aroused while touching you, it is important that your partner ask if you will pleasure him or her—and not try to arouse you in return. At a later date, this request may not have to be so explicit. Slowly, you can allow your partner to touch you in a more sensual or sexual way, with the understanding that at any time you might ask to stop. Again, this is about you taking back your body and allowing yourself to feel pleasure again.

Question Five:

I've been in medically induced menopause (zoladex shots) for 2 1/2 years. Aromasin sucks any remaining estrogen out of my body. The quality of my sex life pre-treatment was very good. Now it's horrible. Not only do I not have any desire, but sex is actually painful. When I urinate afterwards the pain is very intense. I dread it. This is taking quite a toll on our marriage.

I've tried many different kinds of KY and astroglide, and even replens. My GYN says I have vaginal atrophy. She suggested a vaginal suppository (haven't tried that yet) but doesn't have any other suggestions. She's not comfortable prescribing a vaginal cream due to the studies that imply systemic absorption. Are there any other solutions? I don't want to live the rest of my life like this.

Dr. Schiffman:

The question of pain during intercourse or penetration after menopause is a common one. There are several issues that need to be addressed. The first is the pain…having repeated painful sexual encounters (and sometimes only one) leads to anxiety (read, fear) in anticipation of the next painful encounter, increasing the likelihood that you will not be receptive to penetration, and it is more likely that it will be painful.

My recommendation is: STOP having intercourse. Then, treat the cause of the pain.

After menopause, especially surgically or chemically induced menopause, you should plan to use a water-based, non-glycerin lubricant all the time. Most of these lubricants can be ordered on-line, but the suppository-type (which keeps you lubricated for several days) requires a prescription. Lubricants alone may not address the issue of vaginal atrophy, the thinning and inflammation of the vaginal walls.

You may need to use graduated vaginal dilators to help stretch the vagina, but in a controlled way. Graduated dilators are like dildoes of gradually increasing widths, and require a prescription. The treatment starts with the smallest dilator and lots of lubricant. You relax the introitus, the muscle at the entrance of the vagina (this muscle is the one you use to stop the flow of urine midstream, and you can practice learning to relax that muscle), then insert the dilator. The theory is to gradually increase the size of the dilators until you get to penis size, and then introduce your partner. With the partner, I recommend the woman take the superior position (on top), so she has control of putting the erect penis inside her.

The goal is to get comfortable with penetration, keep the woman in control, improve communication, then add sexual fantasy or other specifics, and hopefully, end up with more spontaneity and comfort during intercourse. Clearly, this kind of treatment is probably best done with the guidance of a sex therapist.

Question Four:

I just read that there is nothing inherently sexual about nipples. In other words, the sexual arousal felt when someone touches your nipples is in your head. Is this true? If so, why does it feel so good? I miss my one nipple and keep waffling on the idea of a prophylactic mastectomy because I'm afraid of how much I would miss the other. However, if this is true, I have been thinking that I could train my mind to be aroused by other sorts of touch. Obviously all kinds of touch can be arousing, but I have always found nipple stimulation to be a great and special part of sex and I'm seeking some way to replace it.

Dr. Schiffman:

Losing one or both breasts and nipples, and losing that special part of arousal during a sexual interaction, is an emotional loss as well. But there is an aspect of what you say that is true, regarding sexual arousal being in our heads. Nipples do have many nerve endings, and when touched, can be very sensitive. Some people don't like to have their nipples touched because they are so sensitive. Others get little arousal from having their nipples caressed. Many others have learned to associate sexual arousal with having their nipples touched. It is true that you can train yourself to be aroused by other places being touched.

There are many erogenous zones besides the breasts, nipples and genitals...and with some non-demand sensual touching, you and your partner can find more of these areas. Using erotic fantasy and pairing sexual arousal with touches to say, the skin near your underarm, can make that part of your body more aroused by sensual touches. The sensation may not be identical to that of touching the nipples or breast, but with practice it can feel pretty close to it.

Question Three:

I can not get used to the sensation of my breast-with-expander being touched. I can't stand for my husband to touch it and even when I touch it in the slightest way, it just bothers me. It sort of hurts in a tingly way - like rubbing too hard on a leg or arm that has gone numb - not a good feeling! Should I expect this feeling to get better when I get an implant?

Dr. Schiffman:

Let me start by commending you on getting right back to sexual activities so early after your mastectomy. However, it is important to avoid having an unwanted painful experience during a sexual activity because you may then avoid it, or anticipate pain the next time…also, not a good feeling, and one I consider "anti" sexual.

Expanders generally stretch the skin more than the implant, to allow the breasts some natural droop. It is also natural for the body to form scar tissue after surgery, which can also feel numb to painful, depending on how your body scars. Massaging the breasts can loosen the scar tissue, and you need to ask your medical professional how to do this without hurting yourself…this is usually recommended with the expander and once you get your implants. The massage is not the sensual type. Some women even require cortisone shots to soften the scar tissue.

Most women report that they recover sensation over time. Be patient, but see your doctor. And then try some gentle touching again, at a time when you are not planning to be sexual...just to relearn what your new breasts enjoy, and to have your partner learn what feels best to you.

Question Two:

How do you get past the mastectomy during sex? I mean, my husband still wants to have sex, but always wants to have my top half covered. He says it's so he isn't distracted by the missing boob and loses the mood. I have felt the same way, about not wanting to be distracted and have to think about cancer during sex, but now would like him to want me even with this change in my body.

I fully understand on a mental level why he feels this way, but emotionally would like to feel completely accepted. Is there something we can do to get past this, or does it just take time?

Dr. Schiffman:

This is a difficult and common concern. It sounds like you are more comfortable with your mastectomy than your husband is. Your body is not the same, and that does take some getting used to, but avoiding the missing breast probably won't help.

Your partner may need some time and help getting comfortable with your scar and your lack of symmetry, but not in the midst of sex. I would recommend that you orchestrate some non-sexual sessions with your partner. First, have your partner just look at your mastectomy, really look. Next, your partner should touch the scar and the entire area. Tell your partner how it feels to you while being touched, if certain areas feel numb or painful. Let your partner tell you how he feels touching your scar. At another time, if you are both comfortable, your partner can touch your breast and your mastectomy in a sensual way, even using his mouth or tongue, to turn you on. The goal here is to remind your partner that giving you pleasure may help with his pleasure as well, and seeing that you are turned on by having your breast area touched may do that. Your partner need not respond sexually—and I'm guessing that he is worried about losing his erection during sex, so this takes the pressure off him. He may also need to substitute his sad or angry thoughts about your missing breast with more positive, sexual thoughts.

If things don't get better over a period of several months, don't hesitate to see a sex therapist.

Question One:

If you've lost your sex drive completely, is there any hope that it will come back?

How do you get back into the swing of things? Other than spend time with each other, etc. I totally feel guilty because we haven't been intimate in so long - the guilt gets in the way of getting into the mood.

Dr. Schiffman:

First of all, I would like to thank the Young Survival Coalition for inviting me to guest host, Ask the Expert.

Sexuality is such an essential aspect of life. It is especially important after a trauma, like breast cancer, to find a way back. Probably the hardest part is just getting started again, working out how to negotiate that beginning, and where things will go with your partner. Many women assume they have to feel like they want sex or "be in the mood" in order to begin a sexual interaction, but the feelings of arousal or desire may come after touching has already begun. Just give yourself permission to be open to the possibility of getting turned on.

I suggest letting your partner know that you would like to be sexual again, but haven't been feeling as spontaneous as you once did (this may be especially true after a surgical or chemical menopause). Let your partner know that you'd like to start some more intimate touching, but might not feel ready to "go all the way." This means talking to your partner "outside the bedroom" some time before any interlude is even contemplated, and deciding what you feel comfortable doing at this point, and what you don't feel comfortable doing. Your partner may also have reservations about certain activities.

You and your partner might instead begin, what sex therapists call, a "non-demand" exercise…that is a sensual interaction that does not (necessarily) end in sex. An example of this is just kissing and holding one another, or soaping one another in a shower or bath. Another example is touching each other's entire bodies, with or without undergarments depending on your initial level of comfort, but excluding the genital and breast areas at first, and finding other areas of the body that are responsive to sensual contact. The goal is to begin sensual touching again, feeling comfortable being touched, enjoying the sensations without worrying about your response or your partner's response, enjoying being with your partner as you can be with no one else. Allowing yourself to have sexual fantasies during these interludes is also helpful. The sexual interludes should continue at this level until you are more comfortable to go on to the next level, which might include genital touching.

I will address touching the breast area in a subsequent post.