When Lisa* was diagnosed with vulvar cancer at age 42, she and her husband knew their ability to maintain sexual intimacy would be tested as Lisa had multiple surgeries to keep the cancer at bay. With patience and diligence, though, they were able to enjoy sex in between more than a dozen surgeries. But five years later, they encountered what seemed like an impossible barrier: The cancer had spread to Lisa’s primary means of sexual pleasure, her clitoris. She descended into a deep depression after her clitoris was surgically removed, and soon after she started chemotherapy and radiation treatment, which triggered early menopause symptoms, including vaginal dryness and atrophy.
Lisa’s oncologist at the Mayo Clinic in Rochester, Minnesota, knew Lisa needed support for the physical and psychological changes she was experiencing, so she referred her to Mayo’s Menopause and Women’s Sexual Health Clinic. There, a team consisting of internal medicine physicians, nurses, physical therapists and psychologist Jennifer Vencill, PhD, collaborate to help patients work through deeply personal issues like sexual pain, low libido and inability to orgasm. These conditions can be a result of menopause, cancer treatment or diseases such as multiple sclerosis.
Lisa was eager for the support. "I felt like surgeons looked at me and said, ‘The cancer is in remission and you look great,’ but at home my affectionate husband had stopped hugging and kissing me because he knew I was still in so much pain from the cancer treatment," she says. "The internal medicine team looked at the whole picture. They wanted me to still be able to be intimate with my husband."
Lisa started to learn about options like hormone replacement therapy and pelvic floor physical therapy that could reduce the pain during sexual intercourse, but these strategies were only part of the solution, says Laura Meihofer, DPT, one of the physical therapists in the clinic. "We see a significant connection between the mind and body, and there is only so much I can do to help patients within my scope of practice," she says. "Dr. Vencill is able to step in and identify the experiences and beliefs that may be preventing the patient from making progress."
A safe place and practical support
Conversations with Vencill helped Lisa and her husband discover that neither of them was enjoying vaginal intercourse because the cancer treatment had changed Lisa’s physiology so dramatically. Vencill suggested other forms of sexual intimacy, including anal intercourse—the thought of which made Lisa uncomfortable initially. But slowly she was able to consider the idea. Vencill offered practical tips and provided a safe place for Lisa to share reservations and questions, and the couple started making progress. "I feel like we are back to the type of intimacy we enjoyed before my depression started," Lisa says.
Like Lisa, many patients see Vencill after standard interventions such as hormone replacement therapy or vaginal moisturizers have not solved their problems with intimacy; often their sexual desire has plummeted and their anxiety about touch has increased. Vencill helps such patients disentangle the connection between touch and pain and address complex psychological issues such as trauma, gender identity, religious beliefs and cultural expectations that may be affecting intimacy.
As Vencill is the only psychologist on a team of six physicians, four nurse educators, four physical therapists, a physician assistant, a nurse practitioner and a psychiatric nurse specialist, her colleagues rely heavily on her expertise in sex therapy. "Dr. Vencill’s role is critical because she helps people feel comfortable sharing more details about their situation," says Carol Kuhle, DO, MPH, a physician on the team since 2013. "She’s also qualified to see both partners, which is invaluable because at the core this is an issue between a couple."
Consequences of a sex-negative culture
Vencill began considering a psychology career focused on human sexuality as an undergraduate at Christopher Newport University in Virginia, where she was simultaneously intrigued by classes on the subject and saddened after witnessing the experiences of college friends who felt ashamed of their early sexual experiences.
"I saw friends dating for the first time and exploring sexuality, and I watched how negatively this went for most people because they had no one to talk to about their concerns, questions or what to expect," Vencill says. "In general, we are not given permission or taught to talk about sexuality in a healthy way in this culture."
During her senior year, Vencill talked to one of her undergraduate psychology professors about building a career specializing in human sexuality, and she learned that this path was uncommon but possible with careful planning. Vencill searched for graduate schools and found what she was looking for in Texas Tech University’s counseling psychology program, where she partnered with Sheila Garos, PhD, to study topics such as the role of appearance anxiety and depression in female sexual functioning. During practicum experiences, Vencill also discovered a niche providing therapy to patients within the LGBTQ community.
"I saw students who were sexual and gender minorities and unable to come out because they were afraid of the backlash," says Vencill, who came out more publicly herself as bisexual in graduate school. "I had many clients who had been disowned or kicked out of family homes."
After earning her PhD, Vencill started a postdoctoral fellowship at the University of Minnesota Medical School’s program on human sexuality, where she taught classes, conducted research and worked with patients who had a variety of sexual health concerns. The two-year experience helped her land her first job as an assistant professor in the program and complete the requirements needed to earn certification in sex therapy through the American Association of Sexuality Educators, Counselors and Therapists. Though she enjoyed the role, she couldn’t pass up the chance to work at the Mayo Clinic when she was recruited for the position in 2018 by a former colleague. "I was very attracted to the opportunity to work at such a highly ranked hospital where I could learn from many of the top health-care providers and specialists in their fields," says Vencill.
The clinicians there share insights about patients with one another throughout the day and also meet monthly to discuss difficult cases and topics that affect the team. The cases may include patients who are struggling with treatment recommendations or not progressing because of fear, anxiety, sexual shame or partner issues.
During these interactions, Vencill’s experience with LGBTQ health has guided colleagues as they treat an increasing number of sexually diverse patients. "Dr. Vencill has helped me learn how to avoid microaggressions and structure my treatment in a way that is supportive of their needs," says Meihofer. In the past, for example, when patients talked about pain with anal sex, Meihofer shied away from the topic. Vencill has helped her become more knowledgeable about products and practical steps that can help her leverage physical therapy techniques to treat patients who desire pain-free sex outside of traditional penile-vaginal intercourse.
When Vencill saw the clinic’s brochure about ideal pelvic floor positioning during intercourse, she pointed out that all the images represented heterosexual sex. Now the clinic is revamping the brochure. She also noticed that the name of the clinic, which includes the phrase "Women’s Sexual Health," could alienate transgender individuals. "If someone from the community is trying to access sex therapy, I want all genders, orientations and body types to feel welcome," she says.
Working on an interprofessional team has also deepened Vencill’s understanding of the biological processes related to sexual health, which "makes me a more effective therapist to my patients," she says. Now she knows when to encourage patients to check in with providers who may have unknowingly prescribed medications that can have sexual side effects, and how to address health concerns about different products.
"There is a common cultural misconception that using vaginal estrogen products containing hormones will elevate the patient’s cancer risk," says Vencill. But these products provide hormones locally—only to the vulva and vaginal tissues—rather than circulating throughout the body, and are safe for many women to use, she says.
Building body confidence
Vencill also works to facilitate stronger communication between providers and patients. Nurse educators often introduce patients to vibrators or vaginal dilators as part of medical treatment, but if patients’ expressions or questions suggest that they are uncomfortable with these products, the nurses refer them to Vencill. "Sometimes people have so much anxiety that they can’t really absorb all the information I am sharing with them," says Ginny Hartert, RN.
In some cases, trauma is the source of the anxiety. "I’ve had patients who did not tell the doctor about experiences with molestation, rape or traumatic medical procedures, but this came up during physical therapy," says Meihofer. Other times they tell her about partners who don’t believe in foreplay or want the patient to engage in painful intercourse. "We can hand these cases to Dr. Vencill and may need to pause physical therapy treatment until she works with them."
Often, anxiety is rooted in the fear of pain during intercourse, which can lead to an association between intimacy and pain. Many patients have suffered for years under the assumption that intercourse is supposed to be painful or that there is no treatment for pain, says Vencill. She explains to patients that penetration doesn’t have to be the primary goal of sexual intimacy. "I urge patients to start by creating a ‘menu’ of pain-free activities that create physical and emotional intimacy without sending the patient into panic mode, like holding hands or lying naked next to one another," Vencill says.
A number of patients are also unfamiliar with the basics of sexual physical anatomy, such as the location of the clitoris, vagina and urethra. Vencill educates people in a shame-free environment and inspires body confidence, says Meihofer. "So, when they talk to partners or a physical therapist, they can use the right terms without being embarrassed that they were never taught to explore their sexual anatomy."
Vencill also helps many patients understand the difference between responsive and spontaneous sexual behavior. Spontaneous desire—random sexual thoughts and urges that are usually hormonally driven—is often emphasized in American culture yet tends to decline with age, which leaves many people believing that sexual intimacy disappears during and after menopause, says Vencill. Patients learn that sexual desire is also possible in response to stimulation like touch. "This form of intimacy requires communication, patience and a change in how we frame sexual desire, but if mindfulness is developed within this framework, intimacy can be cultivated," she says.
Influencing medical students
While Vencill is part of a team that witnesses the value of sexual health daily, most health-care providers are not privy to this reality. To help medical students and residents become more aware of this aspect of care, Vencill teaches a session during the gynecology rotation that covers how to take a thorough and inclusive sexual health history. First-year medical students also regularly shadow her during patient visits.
"Health-care providers often feel nervous about asking patients about sexual health because they worry about offending people or facing questions they won’t know how to answer," says Vencill. "But as providers we need to model that this is an important part of health and nothing to be ashamed of."
Although patients may not answer questions about sexual functioning the first time, research has shown that having a health-care provider ask about sexual health increases the likelihood that patients will reach out for care if a problem occurs in the future, says Vencill.
"So often I see a light bulb go off when patients realize that there are treatments for a lot of their sexual health concerns," Vencill says. "They start to understand that this is a normal aspect of health and intimately connected to their well-being."
*Last name withheld to protect the patient’s privacy.
"Psychologists on the Team" is a regular feature in which the Monitor explores the work of psychologists on interprofessional teams.
