Trainer, speaker to universities and charity organisations, therapist and author, Julia Pugh is a couples and psychosexual therapist, with over 15 years of experience working in various medical settings. Julia is dual-trained as a Member of the Institute of Psychosexual Medicine (IPM), a qualified COSRT member and a BACP member. Julia works in the NHS and private health care, specialising in supporting people with long-term health conditions and their impact on sexual function and wellbeing (for example, people affected by cancer, physical disabilities, and menopause). We know that Julia’s experience, extensive knowledge, and therapeutic background will offer us key insights into surgery, couples, and psychosexual therapy – so with that let’s get right to our Q&A.
What are common challenges people may face after surgery in their relationship?
Some common challenges of post-surgery recovery include feeling vulnerable and dependent, when previously the person may have been independent. Being able to communicate their needs effectively, when it comes to pain, for example, may not be easy and therefore this comes out in frustration or being withdrawn.
Within relationships, it can then be difficult to negotiate how that person would like to be cared for, and one very common challenge after surgery is relationship role changes. When one person becomes a ‘patient’ and more dependent, and the other person is perhaps taking on the carer role, it can be hard on both partners. One partner may be feeling like they are under pressure; they may want to help but also feel overwhelmed by the new responsibilities. Often communication can deteriorate, conflicts can arise, or partners may feel disconnected.
Body image is another area that can impact on relationships. Depending on the surgery, this could mean that a person who has had surgery has some body image changes which require a period of adjustment. The initial worries or concerns about what that might look and feel like can be very different to what it actually looks and feels like later on in their recovery, but this can be a real source of anxiety. The partner might be saying things like “it looks fine to me”, or “It’s not as bad as I thought it was going to be”, and the person affected may feel their experiences and worries are being minimised.
How can surgery affect intimacy and desire?
I think this depends on the journey to surgery and the expectations afterwards. If the surgery is an emergency or due to something life-threatening, then it can take time to adjust or deal with the emotions associated with the events and the need for surgery. Alternatively, if it has been a long journey to surgery with side effects such as physical deterioration, this may interfere with the relationship and desire for intimacy in a different way.
In terms of the sexual response cycle, this includes desire, arousal, and satisfaction. There can be biological and physiological interplay, or mind and body interplay, as I would describe it to people, which can be disrupted when someone has surgery. The recovery period may take several months or even longer to rehabilitate, and often the priorities are getting back to independence and work or hobbies. This can mean there is a period where people are unable or uninterested in being sexually intimate or worried about engaging in sexual activity.
Pain can be a key factor here, but also how that person now sees themselves and how connected they feel with their body. It’s not just about positive body image, but about how the body is affected. This is particularly the case with erogenous zones such as breasts and genitalia that have changed as a result of surgery, including nerve damage. Fatigue is also a huge interference in terms of intimacy. Surgery can massively affect the motivation for sex – you might feel really tired, in pain, and feel a disrupted sense of self and identity.
When you are recovering, it is a period in your life where you’re not in your usual work role or family role, and you may feel less like yourself. The foundation of our sexual scripts is predicated on us feeling like ourselves and being able to express that. Often this is a transient period, and as you recover and get back to all your regular activities you are able to re-engage with intimacy, but sometimes you can get stuck, and it is useful to get support to navigate this either individually or with a partner.
How important is communication and mutual understanding?
Very important – and communication is more than using words. It can be actions or what is not explicitly expressed that lead to miscommunication and incorrect interpretation. Acknowledgement and recognition that partners often feel as unsure as the person who has had surgery is crucial. It can be just as hard watching your loved one or somebody that you really care about in pain, and the behaviours which stem from that can often be misinterpreted if not explicitly discussed.
Couples may not have been intimate or even kissed for days or weeks. This could be because one person looks fragile and in pain. It may be interpreted by the person recovering that they are not attractive to their partner, but it could be that their partner doesn’t want to put pressure on them or be inconsiderate by asking for affection at that time.
So yes, communication is key and if your behaviours are not clear then they can be misinterpreted. Knowing what you want and asking for it is key, and sharing how you feel can really help.
How can therapy help?
Therapy is witnessing and observation that can help raise awareness about unhelpful patterns of behaviours between partners and support new ways to move forward to communicate in a constructive and loving way.
I would say that therapy can be really helpful to provide a safe space to explore these kinds of difficulties because often in life, when events such as surgery happen, they can bring up a lot of other things that have happened previously that resonate with feeling dependent or inadequate – and either partner can feel like that. Therapy can be very useful in terms of supporting couples to identify what is present and what is past, and if there is tension, how that could be dissipated.
It also helps both partners to see what is good about how they are loving and supporting each other in this space.
How does psychosexual therapy differ, and how can it support couples through these life-changing events?
Psychosexual therapy is useful for discussing topics that you may struggle to talk about, such as sex, because many people feel embarrassed or unable to find the right language, or they may feel overwhelmed if there is sexual difficulty. People may also be unsure if it is a physical or psychological issue, and a qualified and experienced psychosexual therapist can help normalise the conversation to enable exploration of the mind-body connection.
Psychosexual therapy helps people address sexual problems individually or in their relationships. It’s not necessarily just about being sexually intimate or a sexual activity, it’s about how you see yourself as a sexual person, and that can be disrupted for any reason. It could be surgery, or a job loss, or having a baby, or many different things. You may not explicitly make that connection, but actually what can be really helpful through psychosexual therapy is understanding how your difficulty relates to your desire or interest in sex and which stage of the sexual response cycle has been impacted: your arousal, satisfaction or pleasure.
Psychosexual therapy supports people to recognise that surgery is a significant life event which causes changes in the physical body. It is perfectly legitimate that this could impact our intimate relationships and how we relate to ourselves and each other.
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Co-founder and director of Leone Centre, 20+ years of experience in supporting people, and offering valuable knowledge through Couples Counselling and Individual Counselling. Before becoming a therapist, I worked in the financial sector.
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