A Clinical Sexologist talks about how to accept and grow with the inevitable changes that come with prostate cancer. It's “back to school” for learning a whole new sexuality when it comes to prostate cancer.


By Paul R. Nelson, CCMA, CSE, President
Erectile Dysfunction Foundation and Founder of FrankTalk.org


John sank heavily into the chair in my office. “I haven’t had sex in nine months,” he said. “I have gotten to the point where I don’t even want to think about it. It’s just too painful. Every time I feel anything at all, I am reminded that I’m still damaged goods.”

John was your typical post radical prostatectomy patient. His surgery went well, his surgeon was great. The cancer was probably gone. Incontinence was but a memory. The third, and increasing, concern was return of sexual function; the hunt for the elusive erection. But he wasn’t having much success.

He had been told to take the usual oral drugs a couple times a week, to no result. His surgeon kept telling him to wait and see. He was tired of waiting and even beginning to regret his choice of cancer treatment. So, he was now moving onto trying injections - which is what brought him to my desk. He was about to have his first lesson.


“Well, you’ve been having sex, just not intercourse, right?” I asked.

“I’m tired of just the foreplay. I want real sex,” he replied.

“OK. So anything other than intercourse is not real sex?” I asked.

He snorted, “What are you gonna do without an erection?” 


And so John and I began a conversation which was going to last months about what real sex was. What did sex look like? What did he think sex should be? It took sometime, but John eventually stopped focusing on what he could not do, but on what he could do. And best of all, what he could do, ended up being far from second-string sex!

Believe it or not, when I have this conversation with young men, they tend to be thrilled with learning a whole new way of thinking about sex. Many of them are happy to relieve some of the performance pressure they put on themselves when it comes to getting and maintaining an erection. Older men, well entrenched in habits and mindsets, tend to have a more difficult time – “Can’t teach an old dog new tricks” is the axiom that comes to mind!

There are dozens of lies that our culture has taught us about sex. But one of the most pervasive un-truths I come across is that no one needs to be taught how to have sex – it will come naturally. To a point, this is true. When we rely on basic instincts, couples do manage to assure the survival of the species quite readily.

But what if you’re done procreating? Shouldn’t the sexual activity change as well? Alas, for most couples, it does not. Well past child bearing years, most couples are still solely engaged in procreative sex. Sure, it’s nice. It’s comfortable. It can be the meat and potatoes of sex. But, this kind of sexual expression can be incredibly limiting and often frustrating. It requires a usable, and durable erection and a well-lubricated, flexible vagina – both of which tend to fade with age and health.

I have often said that the unhappiest prostate cancer survivors are the ones who want to have sex just like it always was. The truth is prostate cancer has changed us forever. Many things in life will never be the same again, and sex is just one item on that list. For survivors of prostate cancer, attaining a usable, durable erection becomes the primary focus of their sexual medicine treatment. And frankly, getting men an erection is really pretty easy. I assure our patients that medical science can get most men an erection. But the resurrected erection is not always the answer. 

Just as prostate cancer survivors have to learn new aspects of bladder control, we also have to learn sex in a whole new way. In fact, most of us need to become students of sex. Most of us have found that relying on the old standby of sexual activity is usually going to present quite a challenge. But most men run out of ideas past oral sex or manual stimulation. What else is there?

Betty Dodson, the famous octogenarian sexuality educator once told me, “Paul, tell your boys (my patients) to remember, a vagina is for babies; a clitoris is for sex!” I do tell most of my patients this. It might sound a bit obvious, but most men really do not think of sex this way. And, if all they’ve been practicing is procreative sex, no wonder! Most women do not climax from intercourse without direct clitoral stimulation.

I often tell men that if they asked their female partner what her top ten sexual activities would be, she might well place vaginal intercourse somewhere around number ten! I was talking to one couple in their forties and I made that statement. He looked at his wife and said, “Really?” She shrugged and said “You never asked....” He was shocked. He figured if it felt so good to him, it must feel just as good to her.

The fact is, we all need to be students of anything we care about. We learn about our careers, child rearing, travel and vacations, and even prostate cancer! But the vast majority of people never really become students of sex and sexuality. After dealing with prostate cancer, it is incumbent on us all to learn everything we can about our new sexual reality.

Having fulfilling sex while living with prostate cancer takes dedication, hard work, and, above all, education. I find many couples tend to be afraid of exploring new sexual expressions. This is totally understandable – after 20 - 30 years of sex, it can be hard to change!

So, where to begin to become a student of sexuality? It can be trickier than you might think. Simply gathering information is not the answer. Education is very different than information. A good student gathers information, then synthesizes it through their previous knowledge and value system to come up with their authentic education.

Studying sex can be scary. It can push the envelope of your comfort zone. You might even bump up against some values you are uncomfortable with. Everyone has to learn to navigate the topic in their own safety zone. But don’t let fear stop you. The resulting knowledge is worth the risk! 


Don’t rely on:

  • Porn. Porn is fantasy; not a documentary. Porn does not resemble good sex in any way.
  • Sex Shops. The employees are not trained. The products are often poor.
  • Google. Misinformation can outweigh real information. 

Do rely on:

  • Your Library/Bookstore. Books on sexuality tend to be vetted for quality.
  • Professional Organizations. Their resource lists are usually screened.
  • Sexuality Professionals. Talk to a sex educator, counselor, or therapist. 



Begin by coming up with a better definition of sex. I usually tell our patients that “Sex is any touch with erotic intent,” or “Sex is adult play.” See if you can broaden your definition of sex so that it is not defined by what you do or don’t do.

I encourage couples to put intercourse on the back burner for a few weeks and spend their time relearning each other’s bodies. Massage is the basis for almost all sexual activity. Learn to give sensuous, even erotic, massages. They are far easier than therapeutic massages. Long, gentle, gliding touches are what is required. Refined coconut oil from your local grocery store is the best personal lubricant you can buy. Try it!

Watch some instructional videos on massage, and better sex practices. The Sinclair Institute has some great educational videos. [1]

For some reason in our culture, marital aids, or sex toys, seem to be connected with the pornographic. This is far from the truth. If sex is play, equate play with toys. We often find that when men have a toy in their hand, they do become more playful, relaxed, and less focused on their penis. Buy only quality toys – sadly, they are not inexpensive.

Finally, explore, learn, read, experiment. This journey of sexual exploration will bring you closer than ever. Having prostate cancer definitely changes your life and the lives of those close to you. But take this time to find a new reality and new sexuality that, while different, can be far better, more fulfilling and more connecting than ever! 


[1] h p://sinclairins tute.org/ 

Paul Nelson is a nationally recognized male sexuality educator and advocate. He is an AASECT Certified Clinical Sexuality Educator as well as a Certified Clinical Medical Assistant (CCMA). He is president of the Erectile Dysfunction Foundation (501c3) and founder of FrankTalk.org, the first non- commercial online community for men with sexual dysfunctions. A survivor of prostate cancer at the age of 47, Paul began this work after his surgery, when he discovered that there was very little authentic information to help men with sexual issues. The foundation grew out of FrankTalk.org when it became obvious that there was no other patient advocacy or support organization to help men. Paul has been featured on ABC News with Diane Sawyer, the New York Times, National Public Radio, the BBC, MTV, Women’s Health Magazine and many regional media outlets. He is on the Board of Advisors for the Private Gym and blogs for Betty Dodson, Talking About Men’s Health, Prostate Cancer Research Institute, and The Good Men Project.