The aim of this literature review is to explore women's experience of sexuality after stoma formation during surgery for colorectal cancer. Colorectal cancer is the third most prevalent cancer worldwide with 1.23 million cases diagnosed annually (Ferlay et al, 2010). The National Cancer Registry (2016) states that colorectal cancer is the third most commonly diagnosed cancer and second most common cause of cancer death in Ireland. Each year, approximately 2500 new diagnoses of colorectal cancer are made, of which 750-1100 are in women.
Risk factors for colorectal cancers include older age, family history of colorectal cancer, smoking, a high body mass index, a history of inflammatory bowel disease and polyps (Hinkle and Cheever, 2014).
Common interventions for this type of cancer include bowel resection, anastomosis and, in cases where disease site indicates, stoma formation. A stoma or ostomy is an artificial opening that is created when a diseased part of the colon is removed and remaining healthy intestine is attached to an opening in the abdomen through which faeces is expelled, usually into a pouch (Ramirez et al, 2010). A stoma may be temporary or permanent, and not all colorectal cancer surgery results in a stoma.
Stoma formation presents a number of challenges in terms of quality of life and functioning because normal bowel function is interrupted and faecal matter is expelled in a more visible way. The pouch must be emptied regularly, which can affect social outings and it intrudes into intimacy for both the woman affected and her partner, resulting in sexual dysfunction or a reduction in the quality of sexual life (Dabirian et al, 2010).
Sexual impairment for women can occur as a result of nerves or tissues being damaged during surgery, the psychological effect of surgery on body image and, in cases where the vagina has been shortened or narrowed, dyspareunia (pain during intercourse) (Dougherty and Lister, 2015).
The World Health Organization (WHO, 2017) offered the following definition of sexual health:
‘Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’
This topic became of interest to the author while she was working on a gastrointestinal surgical ward during placement and observed how many women were reluctant to ask about their stoma's effect on their sexual practices. The author also observed in the gastrointestinal clinic that many women presented with complaints of a diminished sex life because of an altered body image and feelings of loss of body function.
Although an extensive amount of research has been done on this topic, as the database search results show, it is a significant problem that is not adequately discussed in the clinical area, which is line with the experience of the author. Because sufficient information around implications for sexual practice is lacking preoperatively many women are taken by surprise and extremely distressed by the profound impact a that stoma can have on their intimate lives.
As a staff nurse, the author is interested in how women experience sexuality after stoma formation and the factors that contribute to a positive or negative experience in the women's opinion. This interest led to the author carrying out this literature review over the course of 2018. Because research pertaining to women in same-sex relationships engaging in penetrative sex after stoma formation is limited, this study examined heterosexual relationships.
Search strategy
A literature search was conducted to gather research around the chosen topic. Five electronic databases were used: Academic Search Complete; PubMed; Medline; Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Health Source Nursing/Academic Edition.
To ensure the findings were accurate, precise and relevant the scope of the literature search was refined from a broad population to women only and from general quality of life to focus on sexuality before it was carried out (Jaffe and Cowell, 2014). Search strings were constructed from the research aim following preliminary trial-and-error searches. These search strings were merged using the Boolean operators ‘AND’ or ‘OR’ and used the terms ‘sexual function’ (or ‘sexuality’ or ‘sexual dysfunction’ or ‘sexual behaviour’ or ‘sexual disorder’ or ‘quality of sexual life’ or’ ‘sexual health’), ‘stoma’ (or ‘colostomy’ or ‘ileostomy’), ‘women’ (or ‘female’), ‘perception’ (or ‘experience’) and ‘colorectal cancer’ (or ‘oncology’ or ‘gastrointestinal cancer’ or ‘colon cancer’ or ‘colonic cancer’ or ‘rectal cancer’ or ‘colorectal tumour’).
Database searches were limited to peer-reviewed literature to increase the likelihood that all documents yielded were reliable, valid and of good quality (Gerrish and Lacey, 2010). Official websites were accessed to ensure that as much relevant literature as possible was found. These included the Health Service Executive (hse.ie), the World Health Organization (who.int), the National Cancer Registry of Ireland (ncri.ie) and Ireland's Department of Health (health.gov.ie). The English language was added as a search parameter because the author did not have the capacity to translate studies in other languages but is aware that this parameter affected retrieval because it excluded studies in other languages.
Ancestry searches were conducted on the reference lists of relevant studies, and literature reviews were sifted to confirm that all noteworthy literature was included in the review (Cronin et al, 2015).
The literature search yielded a large number of results of approximately 80. This was refined by adding peer reviewed to the inclusion criteria, eliminating 50 articles. Scanning titles and abstracts resulted in a yield of 7 studies. A similar search on PubMed yielded approximately 100 results, then adding English as a limitation eliminated 20 articles, and of the rest 7 were deemed appropriate. Four additional sources came from postgraduate students. The studies came from the UK, Australia, Turkey, the Netherlands, Portugal, Sweden, Brazil, Singapore, Iran and the USA. The range of source countries allowed differences and commonalties between cultures to be observed.
Of the 18 articles, 2 were literature reviews and the rest were research studies (Table 1). The research studies included qualitative studies using both semistructured and structured interviews, phenomenological studies and grounded theory, and quantitative studies, consisting of randomised controlled trials (experimental), case-control trials, cohort studies and descriptive analysis. Two were mixed method. Studies were both cross-sectional and longitudinal
| Author(s) and title | Research design | Data collection methods | Main findings |
|---|---|---|---|
| Altschuler et al (2009) | Cross-sectional multi-site study, mixed methods. | Semistructured interview | Spousal acceptance affects women's self-acceptance |
| Andersson et al (2010) | Cross-sectional single-site approach | Interviewed | Many women experienced painful intercourse, low self-esteem and feelings of being less sexually attractive |
| Ang et al (2013) | Literature review | Altered body image, loss of function, self-care difficulties |
|
| Cotrim and Pereira (2008) | Descriptive cross-sectional study | Questionnaires | Adaptation successful when information is sufficient |
| Dabirian et al (2011) | Single site, cross-sectional | Semistructured interviews | Leakage and odour lead to reduction in pleasurable activities. Increased anxiety, isolation |
| Den Oudsten et al (2012) | Cross-sectional | Questionnaires | Lubrication problems (28%) and dyspareunia (39%) |
| Kiliç et al (2007) | Matched cross-sectional | Questionnaires | Decreased feelings of sexual attractiveness, avoidance of intercourse. Better marital adjustment and compatibility with acceptance |
| Krouse et al (2009) | Coss-sectional | Questionnaires | Women engage in coping behaviour and need more support |
| Manderson (2005) | Cross-sectional | Interviews | Stoma intrudes on life and intimacy. Sexuality needs to be reconciled with fear of leakage and loss of control |
| Milbury et al (2013) | Cross-sectional | Questionnaires | 19–62% women experience new sexual problems |
| Paula et al (2012) | Cross-sectional exploratory, descriptive study | Face-to-face interviews | Stoma interferes with sexual partners because of anxiety and fear. Invasion of intimacy and body image |
| Ramirez et al (2010) | Phenomenological, exploratory study | Interviews | Partner support influential. Loss is a compromise against being grateful to survive cancer |
| Reese et al (2014) | Exploratory, quantitative | Questionnaires | Behavioural adjustment, intimate relationships affected. Reluctant to discuss sex with health professionals |
| Sharpe et al (2011) | Prospective analysis | Questionnaire | Anxiety, increasing dissatisfaction. Professionals should assess body image |
| Sun et al (2016) | Mixed method | Questionnaires | Ability to be intimate affected. Vaginal strictures, dyspareunia, partner rejection, failed marriages |
| Taylor et al (2009) | Prospective longitudinal | Interviews | Altered bowel function, body image, fear of intimacy |
| Traa et al (2012) | Systematic review | Worse quality of life than women without a stoma. |
|
| Yilmaz et al (2017) | Descriptive, cross-sectional | Interviews and questionnaires | Difficulty engaging in sexual activity. Change of body perception, spousal problems, isolation |
Each relevant paper was critiqued using a critical appraisal tool (Table 2) and thematic analysis of the findings was carried out (Cronin and Huntley-Moore, 2013). The review of the literature identified three leading themes: bodily disturbance; intimate relationships; and devaluation of sexuality.
| Are the results valid? | |
|---|---|
| Research question/aims/objectives |
|
| Methodology/research design |
|
| Population and sampling |
|
| Data collection |
|
| Data analysis |
|
| What are the results? | |
| Findings |
|
| What do the results mean? | |
| Discussion of findings |
|
Source: Cronin and Huntley-Moore, 2013
Findings
Bodily disturbance
Disturbance was a dominant theme in the literature reviewed. This theme identified psychological and physical disturbances, namely body image disturbance and reduced self-rated attractiveness. Several qualitative studies (Cotrim and Pereira, 2008; Ramirez et al, 2010; Paula et al, 2012; Yilmaz et al, 2017) and quantitative studies (Kiliç et al, 2007; Sharpe et al, 2011; Milbury et al, 2013) identified the psychological and physical effects of stoma formation on women.
Several studies acknowledged that stoma formation can impinge on the body image of women with colorectal cancer, and the detrimental effect that this disturbance can have (Kiliç et al, 2007; Cotrim and Pereira, 2008; Ramirez et al, 2010; Yilmaz et al, 2017). Body image can be described as how women see themselves and their attitudes towards their own bodies.
In the case of a stoma formation, there is an alteration of a function that is generally taken for granted—that of defecation. Stoma sound, odour and appearance all contribute to a poorer body image and satisfaction with the self (Weerakoon, 2001). A descriptive cross-sectional study conducted in Turkey (n=57) (Yilmaz et al, 2017) noted that the involuntary opening of an ostomy because it lacks a sphincter results in changes in bowel habits, frequency and flatulence and can induce a feeling in the woman that she has lost a sense of control over her body. This study was limited with regards to the fact that the findings were potentially generalisable only to those with the same characteristics as the participants. The taboo on sexuality in Turkey affected women's willingness to answer and compromised the size of the sample (Yilmaz et al, 2017).
The change in physical appearance, resulting in visible expulsion of faeces, is often perceived as compromising personal hygiene and feelings of being dirty, due to social aversion to faeces. This can pose a great conflict in cultures where hygiene is an integral part of religion, such as those in Turkey and Iran and, because of increasing multiculturalism, Ireland.
Another descriptive cross-sectional study (Milbury et al, 2013) identified that the quality of life of women with a stoma is poorer than that of their counterparts who have not had the procedure; women exhibit high levels of depressive symptoms after surgery, and impaired body image leads to distress and a significant decrease in self-rated attractiveness. Altered perception of body image, increased anxiety and lowered self-esteem lead to women feeling less sexually adequate. The appearance of the stoma being red and quite ‘angry’ can be unsettling for many women and hard to accept (Milbury et al, 2013). Thorough consultation with the woman regarding stoma placement is vital to ensure that it is not on a fold of skin, or in an area that can inhibit normal manner of dress, which would further disrupt a woman's sense of body perception.
A study in Australia using prospective analysis suggested that health professionals should assess body image in patients who are to undergo stoma surgery to predict the likelihood of depression and anxiety postoperatively.
The stoma can be a breach of normality for many women, and one of the challenges is managing both their own and others' disgust (Sharpe et al, 2011). Cultural aversion to faeces presents an obstacle to desirability when they are visible in a pouch and can be detrimental to women's sexual arousal. It can be difficult for women to accept their new condition as an ostomised person, be it temporary or permanent (Manderson, 2005).
Together, these issues result in feelings of a perceived loss of femininity, dissatisfaction with appearance and diminished sexual attractiveness. These undesired changes to body image lead to conscious efforts to disguise the stoma bag and often feelings of embarrassment or shame. Cotrim and Pereira (2008) and Paula et al (2012), in two cross-sectional studies undertaken in Portuguese-speaking countries, found that these changes in body image can be most damaging to younger women as they cope with this perceived loss. This loss can extend to a sense of loss of control, choice and independence as well as normative sexuality.
Intimate relationships
It was evident from the included studies that intimate relationships were a key factor in sexual function. For married women or those with partners, there is fear of partner rejection and difficulty in maintaining the relationship as both parties adapt. Several qualitative studies show that partner refusal or acceptance contributes significantly to the woman accepting or rejecting her stoma and adapting to altered sexuality and intimate relations, while single women are affected by fear of disclosure and a similar fear of rejection (Manderson, 2005; Andersson et al, 2010; Dabirian et al, 2010; Taylor et al, 2010; Traa et al, 2012), as did a mixed-method study (Altchuler at al, 2009). This subtheme of this was specific sexual disturbance.
Several articles discuss the importance of and profound effect that spousal acceptance can have on women's acceptance of their stoma (Manderson, 2005; Krouse et al, 2009; Altschuler et al, 2009; Taylor et al, 2010; Andersson et al, 2010; Traa et al, 2012). The stoma intrudes into the intimacy of both the woman and her partner, so boundaries need to be established with partners (Manderson, 2005).
In their matched cross-sectional, case-control study (n=246 case, 245 control patients) Krouse et al (2009) found that in long-standing relationships, it can be difficult for the partner to maintain a position as a lover and assume the role of a caregiver during the postoperative period. Many women feel uncomfortable undressing or being seen naked after stoma formation, leading to new practices in sex such as turning off the lights or wearing a nightgown throughout. This study was limited because the cross-sectional design provided no baseline sexual function or improvement with time.
Traa et al (2012) found in a systematic review of 24 studies that varied in methodology that women's sexuality can be threatened by the bag, leading to an increased need for support. Women typically tended to engage in more coping behaviours and needed more support than men to accept their stoma because of a fear of contamination, a fear of the bag bursting in bed and apprehension regarding the reaction to this by their partner.
Dabirian et al (2010) found that half the women in their study (seven out of a sample of 14) became sexually inactive after stoma surgery; much of this was because of partner rejection and the partner's inability to reconcile sexuality with their partner's new condition (Dabirian et al, 2010; Reese et al, 2014). Many engagements, relationships or marriages fail because of a woman's reluctance to allow her partner to assume the role of her informal caregiver. In a qualitative study conducted in Sweden using a narrative cross-sectional approach, Andersson et al (2010) explored the experiences of women's partners and found that they had their own fears and anxieties, such as injuring the stoma during sex.
Spousal support is central to a woman's personal adjustment and is instrumental to her feeling normal. A withdrawal or lack of support contributes to negative feelings, which in turn affect adjustment negatively. Some partners lack the desire or ability to provide support, unwilling to take on the role of care-giving during the postoperative period. In a cross-sectional, multi-site, mixed-method study carried out in the USA, Altschuler et al (2009) found that some women remained in a sexless relationship because of familiarity, and felt that they would not be comfortable with anyone else. Some partners readily accepted their wives' stoma, viewing it as a ‘change in plumbing’ that did not diminish their value as women, which contributed hugely to a woman feeling normal. This study was limited by the older age of participants (>60 years), so it is difficult to apply its findings to a younger population. Ramirez et al (2010) conducted a phenomenological, exploratory study (n=30), which recognised that partner support is paramount, as some partners do not recognise oral sex as a sufficient form of intimacy.
A stoma can make it difficult to maintain and/or attract or feel confident about attracting a partner and, as a result, a lot of women engage exclusively in masturbation for sexual satisfaction as a result of the fear of being rejected (Manderson, 2005).
The cessation of penetrative sex can lead couples to explore new ways of engaging, such as through oral sex or non-sexual intimacy such as just sleeping next to one another. In a single-site, cross-sectional study undertaken in Iran, Dabirian et al (2010) identified that the trying emotional changes incurred by stoma formation can make it very difficult for women to re-establish or maintain relationships. Fear of rejection was high and self-esteem became lower. Better marital adjustment led to more acceptance and better compatibility. The findings of this study are limited because, unlike quantitative data, qualitative data cannot be extrapolated to wider populations.
In a qualitative study conducted in Australia, Manderson (2005) recognised that disclosure to new partners can be a source of severe anxiety and distress to women because they have to decide on an appropriate time/place to tell new partners. Similarly, Traa et al (2012), in a systematic review, identified that, like married women, single women develop a fear of contamination and, while a bag bursting in a woman's own bed comes with its own anxiety, the fear and apprehension is more intense at the idea of this happening in another's bed and the disgust a new partner may feel towards this.
In a descriptive cross-sectional study carried out through interviews and questionnaires in Turkey (n=57), Yilmaz et al (2017) recognised that a lot of women will isolate themselves and withdraw from social activities because they feel less sexually adequate. The change of appearance comes with a perceived compromise in hygiene, particularly in a country like Turkey where Islam is the prevalent religion. In a phenomenological, exploratory study conducted in the USA (n=30), Ramirez et al (2010) identified that women must first learn to manage their own disgust and become reconciled with their altered functioning before they can manage the reactions of others. The changed body and function can be challenging for women to deal with because they require the idea of sexuality to be restructured. This study was limited because the participants were mostly Caucasian, which makes it rather difficult to determine if sexual adaptations differ by race or ethnicity.
Several studies included found that stoma formation can be more detrimental to younger women; they are less likely to be married or have maintained a long-term relationship, which can make disclosure to potential partners inevitable. Younger women also find it harder to reconcile their own feelings of diminished femininity and altered body image (Cotrim and Pereira, 2008; Krouse et al, 2009; Milbury et al, 2013).
Specific sexual dysfunction
A qualitative study and several quantitative studies, including an exploratory descriptive study (Milbury et al, 2013; Reese et al, 2014; Yilmaz et al, 2017), examined the physical effects that stoma formation has on sexual function in women. The most commonly used assessment tool to measure this was the Female Sexual Function Index (FSFI). This is a 19-item questionnaire that generates scores on six domains including desire, arousal, lubrication, orgasm, satisfaction and pain. A higher score indicates better function (Rosen et al, 2000; Reese et al, 2014).
A recurrent theme was that women who have colostomies or ileostomies have lower scores on this questionnaire than the general population. Yilmaz et al (2017) found that all female patients experienced dysfunction and difficulty engaging in physical acts of intimacy; loss of libido and vaginal tightness and dryness were among the most common complaints.
Milbury et al (2013) suggested that 19–62% of women experience new sexual problems because of leakage of stool and flatulence. Women experienced vulvovaginal atrophy, dryness/pain, loss of desire and significant interference because of incontinence. The women found dyspareunia to be severe and, as a result, almost always experienced inhibited orgasm. The cross-sectional nature of this design did not allow for inferences about causality; only a prospective study could do this. The participants were predominantly Caucasian, which makes it difficult to identify whether their experiences differ from those of other ethnic groups.
Similarly, Reese et al (2014) identified that 50% of women experienced sexual difficulties because of dyspareunia, odours during sex and vaginal tightness. This study identified that, while a decrease in sexual activity is normal for a short period following any major surgery, in the case of colostomy formation in women, this problem has a prolonged duration. This study was strengthened by validated comprehensive measures and a prospective deign. Direct effects on sexual function can be caused by damage to nerves during surgery and blood supply to the genital areas, as well as direct scarring. In cases where the rectum has been removed, the angle of the vagina can change, making certain sexual positions more or less comfortable. Direct trauma to the vaginal wall can result in the vagina narrowing, causing loss of perineal sensation, discomfort and vaginal dryness (Weerakoon, 2001).
Devaluation of sexuality
Devaluation of sexuality is a significant theme. Various studies, including qualitative, quantitative, mixed-method research and systematic reviews, have reported that patients are often reluctant to enquire about implications for sexual practice while health professionals prioritise physical health over sexual health (Kiliç et al, 2007; Andersson et al, 2010; Dabirian et al, 2010; Sharpe et al, 2011; Paula et al, 2012; Den Oudsten et al, 2012; Traa et al, 2012; Ang et al, 2013; Milbury et al, 2013; Reese et al, 2014; Sun et al, 2016).
Several studies have addressed the fact that much of the information women receive preoperatively sets out the effects that the stoma may have on their bodies medically but not on their sexual lives (Dabirian et al, 2010; Paula et al, 2012; Ang et al, 2013; Milbury et al, 2013; Reese et al, 2014; Sun et al 2016). Sexuality is an integral part of the whole person and should be included to provide holistic care (Ang et al, 2013). Women commonly report a lack of sufficient information to enable them to identity and adapt to changes (Reese et al, 2014). The transition from hospital to home is an important time in which the woman should be well supported and this should be comprehensive and not limited to technical care of the stoma. This enables women to prepare for self-care, accept their stoma, verbalise any frustrations or fears, clarify misconceptions and alleviate anxiety. Counselling and management should be provided to facilitate discussion of sexual dysfunction (Sun et al, 2016).
Dabirian et al (2010), Ramirez et al (2010) and Taylor et al (2010) found that women felt that their preoperative education insufficiently prepared them for the changes they would go on to experience. Dabirian et al (2010) and Den Oudsten et al (2012) found that evaluation of sexual health is not prioritised and attention should be paid to sexual function in the healthcare setting. Many felt that self-care education was too prescribed, impersonal and too late (Taylor et al, 2010). Cotrim and Pereira (2008) identified that women were 40% more successful in adaptation and reconciliation with their stoma when education has been multifaceted and has included explanation of the potential physical, mental and sexual effects before and after the procedure. However, this study was limited by the use of a convenience sample and being confined to one assessment.
Many women find it difficult to discuss sex with health professionals, feeling they may appear ungrateful for life-saving surgery by being concerned about the outcome for their sexual lives. They accept the loss of their sexuality as a compromise for survival (Ramirez et al, 2010). Women find that some professionals brush off questions about sex, because they are not equipped to answer them. They commonly receive dissatisfactory answers to questions such as ‘you'll soon be normal’ or ‘you'll get used to it’. This unsatisfactory answering of questions is not acceptable and frustrating to women (Paula et al, 2012). Several studies were conducted in countries in which sexuality is a taboo subject, which made discussing it with health professionals difficult (Kiliç et al, 2007; Dabirian et al, 2010; Yilmaz et al, 2017). Milbury et al (2013) found that, where patients did not mention sexuality, health professionals did not address it and assumed it was not an issue, which led to closed, restricted communication.
Implications for nursing practice
Based on the findings from these studies, the author considers that the implications for practice include the need for nurses to provide comprehensive education on how to manage leakage and odour, which can help alleviate fear of this occurring during intercourse (Ramirez et al, 2010).
The implications of these findings for nurses will vary, as the studies spanned a range of cultures and countries, where practices may vary. Training, counselling and coaching are all integral parts of care that should be available to all women preoperatively and postoperatively to address and resolve any issues they may be facing. Nurses should assume a supportive role to prepare the woman for her future with a stoma, equipping her with the skills required and providing a supportive environment.
Many patients find it difficult to discuss sex with health professionals and feel they are not informed with enough information preoperatively to identify and adapt to changes that occur. Milbury et al (2013) identified that older women in particular are reluctant to discuss sexuality because they feel that they are too old to be concerned with this, and feel they may be judged or seen as ungrateful by mentioning it. As a result, these women are more likely to no longer engage in sexual activity. Nurses should ensure that any patient who wishes to discuss her sexual practices can do so openly and without fear of being judged.
Stoma care clinical nurse specialists should take a holistic approach to the whole person and not be limited to technical care of the stoma (Paula et al, 2012). Nurses can also provide information and access to counselling for spouses and partners to help them adapt, which in turn will improve their acceptance of the woman to her altered functioning (Altschuler et al, 2009).
The author considers, based on these studies, that sexual health/function is commonly overlooked in healthcare settings with health professionals prioritising physical and mental health over sexuality. Adequate support for sexual dysfunction through the clinical nurse specialist and other agencies would benefit women undergoing stoma formation.
Conclusion
The purpose of this literature review was to examine women's experiences of sexuality after stoma formation. The main themes are bodily disturbances, including psychological and physical changes, intimate relationships and devaluation of sexuality. Body image has a direct effect on self-esteem, and a lowering of body image led to feelings of being less sexually attractive.
Physical changes in the body lead to difficulties in engaging in penetrative sex, which require exploration of new positions or acts of intimacy. Married women face the challenge of anticipating spousal acceptance or refusal, while single women have the issue of exposing their stoma to potential partners and reconciling their reaction.
Thorough pre- and postoperative education that includes impact on sexual function has been found to lead to better coping and adapting to the woman's new status of having a stoma. Open communication with health professionals allows women to voice any concerns or anxieties without fear of being judged.
A limitation of this study was that none of the studies explored same-sex relationships. All the studies examined penetrative sex within heterosexual relationships but did not examine any same-sex relationships to explore difficulties that these women may face with their sexuality after undergoing surgery. The author is also aware that women in same-sex relationships enjoy penetrative sex through the use of sex toys digitally and are therefore also affected.
As the studies were conducted in various parts of the world, they showed that women had similar experiences of sexuality after stoma surgery internationally.