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Cancer, Intimacy
and Sexuality
A Practical Approach
In Honor of
Hilde de Vocht
Yacov Reisman
Woet L. Gianotten
Editors
123
Cancer, Intimacy and Sexuality
Yacov Reisman • Woet L. Gianotten
Editors
Cancer, Intimacy and

Sexuality
A Practical Approach
In Honor of Hilde de Vocht

Editors
Yacov Reisman Woet L. Gianotten
Department of Urology Hilversum
Amstelland Hospital The Netherlands
Amstelveen
The Netherlands
ISBN 978-3-319-43191-8 ISBN 978-3-319-43193-2 (eBook)

DOI 10.1007/978-3-319-43193-2
Library of Congress Control Number: 2017930410
© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Yacov Reisman and Woet L. Gianotten
2 Awareness and Paying Attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3 The Value of Paying Attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4 Relevant Aspects of Sexuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Woet L. Gianotten and Yacov Reisman
5 The Various Levels of Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Woet L. Gianotten
6 A Comprehensive Guideline on Sexual Care in Case of Cancer . . . . . . 37
Pierre Bondil
7 Training in Oncosexology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
8 Sexual Consequences of the Various Process Phases. . . . . . . . . . . . . . . . 59
9 Psychosexual Consequences of Cancer Diagnosis. . . . . . . . . . . . . . . . . . 65
Sandra Vilarinho and Graça Santos
10 Sexual Consequences of Pelvic Radiotherapy . . . . . . . . . . . . . . . . . . . . . 71
Luca Incrocci
11 Sexual Consequences of Chemotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . 77
Erika Limoncin, Daniele Mollaioli, Giacomo Ciocca, Giovanni Luca
Gravina, and Emmanuele A. Jannini
12 The Sexual Consequences of Cancer Surgery . . . . . . . . . . . . . . . . . . . . . 83
Marjan Traa, Harm Rutten, and Brenda den Oudsten
v
vi Contents
13 Sexual Consequences of Cancer Medication

and Cancer-Related Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Michal Lew-Starowicz
14 Sexual Aspects of Specific Cancers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
15 Breast Cancer and Sexuality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Johannes Bitzer and Daniela Hahn
16 Sexual Function After Gynaecological Cancer. . . . . . . . . . . . . . . . . . . . 121
Annette Hasenburg and Juliane Farthmann
17 Prostate Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Raanan Tal
18 Sexual Problems Related to Bladder Cancer. . . . . . . . . . . . . . . . . . . . . 141
Wim Meinhardt
19 Sexual Consequences of Testicular Cancer. . . . . . . . . . . . . . . . . . . . . . . 145
Tamer Aliskan, Bahadir Ermec, Samed Verep, and Ates Kadioglu
20 Penile Cancer and Sexuality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Panagiotis Dimopoulos and Dimitris Hatzichristou
21 Colorectal and Anal Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Kevin W.A. Göttgens and Stéphanie O. Breukink
22 Blood and Lymph Node Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Christine M. Segeren
23 Sexual Consequences of Head and Neck Cancer. . . . . . . . . . . . . . . . . . 175
Kate Jones
24 “Dealing with”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
25 Couple Sexual Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Paul Enzlin, Hilde Toelen, and Kristel Mulders
26 Male Sexual Rehabilitation After Pelvic Cancer. . . . . . . . . . . . . . . . . . 193
Michael Geoffrey Kirby
27 Sexual Rehabilitation After Gynaecological Cancers . . . . . . . . . . . . . . 205
Alessandra Graziottin, Monika Lukasiewicz, and Audrey Serafini
28 Sexual Tools and Toys in Oncosexology . . . . . . . . . . . . . . . . . . . . . . . . . 223
29 Special Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Contents vii
30 The Partner. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Paul Enzlin, Kristel Mulders, and Hilde Toelen
31 The Impact of Cancer Treatment on Sexuality and Relationships
for Teenage and Young Adult Cancer Survivors. . . . . . . . . . . . . . . . . . 249
Daniel Kelly and Sofia A. Vougioukalou
32 Sexuality and Cancer in the Aged/Aging Population. . . . . . . . . . . . . . . 257
Felipe Hurtado Murillo, Ascensión Bellver-Pérez,
and Woet L. Gianotten
33 Homosexual Men and Women, Cancer, and the Health Care System. 267
Astrid Ditte Højgaard and Haakon Aars
34 Sexuality and Intimacy at the End of Life . . . . . . . . . . . . . . . . . . . . . . . 279
Hilde de Vocht
In Memoriam: Hilde de Vocht (1960–2016)
The last chapter of this book is on ‘Sexuality and Intimacy at the End of Life’.
This chapter was written by Hilde de Vocht, a bright and courageous woman.
As a psychologist and lecturer in nursing education, Hilde learned about the
professional care to address sexuality, especially in palliative and terminal (end of
life) care.
That became a major line of attention in her daily teaching and in her research at
the Saxion University of Applied Sciences in the Netherlands.
In 2011 her thesis was on ‘Sexuality and Intimacy in Cancer and Palliative Care
in the Netherlands: A hermeneutic Study’.
Hilde was one of the very few people in the world who dared to approach the
sensitive area, where the taboos of cancer, sexuality and death come together.
After having devoted a big part of her career and her life to learning and teaching
how to deal with death, she suddenly was at the other end of the care spectrum.
Shortly after finishing her chapter for this book, Hilde became ill and was found
to have an aggressive form of cancer.
She approached that process with a lightness of being that has impressed many
in her surroundings.
The way she made her final journey was another vivid lesson for the living.
ix
Introduction
1
With the emergence of advanced treatment modalities for cancer, the survival rate
of cancer patients has increased, often leading to long-term survival. Many types of
cancer have gradually evolved from an acute to a chronic disease, and, with the
population growing older, the number of cancer survivors in the population is con-
stantly increasing. The cancer as disease, the diagnosis, and the therapies, they all
can have a negative effect on the quality of life on both the patient and the partner
(and also of other family members). The impact of those various elements of the
cancer process tends to cause a decline in the patients’ level of functioning and on
their ability to maintain intimacy and a healthy sex life with their partner. On the
patients’ part, this will go on for many years even after the cancer treatment has
come to an end. In oncology this evolution has created a shift in focus from cure and
survival to care and improving quality of life.
Sexual dysfunctions are identified among the majority of oncology patients, par-
ticularly those with gynaecological and urological cancers. Studies have shown that
at least 35–50 % of cancer survivors may experience sexual dysfunction as a conse-
quence of the treatment. Although sexual problems are common among cancer
patients, very little professional and therapeutic attention is paid to that aspect of
their life. Cancer patients clearly report that they would welcome information about
sexual matters. They report feelings of abandonment and not being taken seriously.
More so, the patients usually neither receive adequate information regarding the
sexual difficulties they can develop through the cancer treatment strategies nor
regarding possible treatments when sexual difficulties develop. Nowadays, health-
care professionals are increasingly confronted with questions regarding long-term
Y. Reisman (*)
Amstelland Hospital, Amstelveen, The Netherlands
e-mail: uro.amsterdam@gmail.com
W.L. Gianotten (*)
Rehabilitation Centre De Trappenberg, Huizen, The Netherlands
e-mail: woetgia@ziggo.nl
© Springer International Publishing Switzerland 2017 1

Y. Reisman, W.L. Gianotten (eds.), Cancer, Intimacy and Sexuality,
DOI 10.1007/978-3-319-43193-2_1
2 Y. Reisman and W.L. Gianotten
survival, but also regarding physical, emotional, and sexual side effects of cancer
and its treatment. So, talking about ‘survival’ has been and still is the oncology
game with sexuality and intimacy not seen in the same league as survival.
The importance of addressing these side effects has caused a significant growth
of psycho-oncological expertise. However, while attention to psychosocial effects
of cancer and cancer treatment is generally accepted, discussing sexual conse-
quences of cancer in the field of oncological care is still warranted and has only
recently been recognized. This recognition has resulted in the emergence of a new
discipline called oncosexology.
The oncosexology intervention system encompasses a team of multidisciplinary
professionals (physicians, psychologists, social workers, couple therapists and sex-
ologists, oncology nurses, etc.), who together provide to the cancer patients and their
partners up-to-date information and at a later stage adequate therapy focusing on
their sexual and relational needs. It is possible to have a satisfying relationship and
sex life even after these have considerably changed as consequence of cancer, but it
requires adaptation of precancer patterns and acceptance and support by the partner.
In the development of a sound oncosexological line of care, one has to distin-
guish between what the patient needs and what the professional needs. Whereas the
patient needs attention for intimacy and sexuality and the right approach to the vari-
ous disturbances, the professional needs the knowledge and skills to properly
inquire about changes. The professional should also be able to educate and inform
about possible sexual side effects of cancer and treatment and also be able to deal
with disturbances of sexual function, sexual identity, and sexual relationship.
Unfortunately there is no official training in this new area of medicine and sexology.
Teaching and training of those skills fits very well in the biopsychosocial approach.
Even when caused by a biological factor (as is the case in cancer and cancer treat-
ment), in all sexual and intimacy issues, always many psychological issues, social
constructions, relationship issues, satisfaction aspects and context are involved.
Next to dealing with the cancer, the healthcare provider needs as well some addi-
tional skills. One of them is the competence to optimally deal with a variable level
of sexual openness to their patients but also to their direct colleagues and the com-
petence to easily and openly cooperate with professionals of other disciplines.
We believe that in good cancer care the topic of sexuality and intimacy should be
effectively addressed. Problems in this field should be taken seriously and handled
professionally, and, when necessary, the patients or the couple should be referred to a
colleague with oncosexological expertise. Addressing the issue of sexuality and giving
the proper information require a mindset with the right attitude and skills where much
can be done already with a limited amount of knowledge. This new field of oncosexol-
ogy is still lacking sound scientific evidence for many of the used therapeutic modali-
ties. Many of them have been adapted from physical rehabilitation sexology.
In front of you is, to our knowledge, the first practical book on oncosexology.
Because of the lack of practical knowledge and training, we decided to focus on
practical knowledge and skills. We avoid as much as possible epidemiological data
or extensive background information. We aim to give the reader information which
could be used in the daily oncology practice. In our opinion, this book can be a
1 Introduction 3
valuable source of information for various professionals, from the fields of oncol-
ogy, general medical practice, and psychosocial practice and also from the fields of
sexology, sexual health, and sexual medicine.
Diversity is a major “mantra” when dealing with sexuality and sexual medicine.
In the development of this book, time and again we were confronted with diversity
and differences. That made us aware of an important message to the reader of this
book: There is no “one size fits all!” Let’s mention and explain some of the relevant
diversities:
• Patients: Some are young and some are old, some single, and some already 45
years married; some are gay and many are hetero; some nearly never think about
sexuality, and for some others sexuality is a major element in their quality of life.
• Partners: Some who cannot handle the stress of what happens in their life and
some who positively grow into a new role as a very good partner.
• Cancers: Some cancers are far away from the sexual machinery, and some are
localized in the genital organs; some have a good prognosis, and some immedi-
ately send people toward the end of life.
• Cancer incidence: Some cancers are seen seldom and others happen frequently.
And let’s face reality: The same cancer can have a very different incidence in
another country. Comparing incidence rates in various European countries gives
some rather shocking data [1]. The age-standardized incidence rate per 100,000
differs, for instance, for breast cancer from 49 in one country to 148 in another
European country; for prostate cancer, it ranges from 25 to 193; and for colorec-
tal cancer, from 13 to 92.
• Treatments: Some treatments barely influence sexual quality of life and some
others are real joy-killers.
• Professional approach: It is tempting to address the differences between the good
and the bad professionals. But let’s focus on the good ones. There are the techni-
cal professionals who excel in surgery, and there are the psychosocial ones who
excel in reassuring the patients with their fears and worries. Besides, they all
have their cultural luggage. The communication skills we have learned from the
medical curriculum in our own country is found to be different from that of
another country even among countries that seem rather the same [2].
• Culture: Even when we only focus on Europe or on the countries of the European
Community (EU 27), there are great differences, for instance, on the insurance
systems, the approach to euthanasia, the openness to nonmainstream orientation,
the acceptance of medical marihuana use, the general practitioner as gatekeeper
to the medical system, etc. We all have to deal with the reality of the society we
are living in.
• The authors of this book: They form a group with a wide diversity in specialties,
approaches, and expertise. Next to that, they are from 14 different countries.
When selecting the authors, we had kind of a predominantly European perspec-
tive in mind, vaguely with an illusion of European uniformity. Let’s leave it to
the readers to decide if we succeeded in selecting a valuable stew of information,
attitude, skills, and advocacy.
• The readers of this book: Their diversity was a challenge for editors and authors.
Some readers will have been brought up in oncology. They should be aware that
the typical cancer information is intended more for the noncancer professionals.
On the other hand, we recommend the readers who are rooted in sexology or
sexual medicine not to browse too much on the sexology-specific information,
because that information is more geared toward the non-sexuality professionals.
We are very grateful to the authors of the different chapters, who have contrib-
uted with their expertise and intellect and who provide the best possible practical
content. We hope that you, the reader, will find this book informative and useful and
that you’ll enjoy reading it.
The structure of this book is built upon five pillars.
Chapters 2, 3, 4, 5, 6, and 7 will offer some general starting ideas. It will
address aspects of paying attention, the why and
how of sexuality (included sexual function),
a general look at sexual disturbances due to
cancer treatment (sexual dysfunctions), a formal
structure for oncosexological care, and training
aspects for professionals who have to deal
with the topic of sexuality and intimacy.
Chapters 8, 9, 10, 11, 12, and 13 takes a look at the consequences on sexuality
and intimacy after the cancer diagnosis and after
the major treatment strategies (radiotherapy,
chemotherapy, surgery, and medication).
Chapters 14, 15, 16, 17, 18, 19, 20, 21, 22, informs about aspects of sexual change in nine
and 23 different cancers. These are the ones most clearly
known to have much influence on sexuality
and intimacy.
Chapters 24, 25, 26, 27, and 28 deals with various treatment strategies for sexual
disturbances, focusing on rehabilitation aspects
from the perspective of the couple relationship,
of the male patient, and of the female patient
and finally on the use of sexual tools, toys, and
additions.
Chapters 29, 30, 31, 32, 33, and 34 highlights five special groups and situations:
attention for the partner, for the very young with
cancer, for the senior cancer patients, for the
couples with a nonmainstream orientation, and
for aspects of sexuality in the end of life phase.
References
1. Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, et al. Cancer incidence and mortality patterns
in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49:1374–403.
2. Meeuwesen L, van den Brink-Muinen A, Hofstede G. Can dimensions of national culture pre-
dict cross-national differences in medical communication? Patient Educ Couns.
2009;75:58–66.
Awareness and Paying Attention
2
As stated in the introduction, this book consists of five parts each covering a different
area. In this first part, we will start with some basic information before we will dive
into the sexual consequences of various treatments (in Chaps. 8, 9, 10, 11, 12, and
13) and of the various cancers (in Chaps. 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23).
This first part with chapters 2, 3, 4, 5, 6, and 7 focuses on different aspects of paying
attention to sexuality. It will also deal with some relevant aspects of sexuality and
how cancer can impact. And it will give some information on the structure of care
and on the process of training on how to professionally deal with the topic of sexual-
ity in our daily care.
Chapter 3 will deal with the value of paying attention. Why is it so difficult to address this
topic? We’ll look into the underlying taboos among the professionals and the
patients. Paying attention is relevant because sexuality and intimacy are so
frequently damaged by cancer and its treatment. Since sexuality and intimacy
are relevant factors for quality of life, attention for those areas is an integral
part of good care. But also because much of the damage is caused by our
interventions and treatments, so in some way we are responsible to deal well
with those side effects.
This chapter will also give some explanation on why people have sex,
highlighting some of the direct benefits of sexual expression that can
favour care with even some elements of cure.
Y. Reisman (*)
W.L. Gianotten

DOI 10.1007/978-3-319-43193-2_2
Chapter 4 will give in a nutshell information on some relevant aspects of sexuality. It will
deal with sexual function (the sexual response with desire, arousal and orgasm)
and with some general information on sexual dysfunctions.
It will also address some of the relevant differences between the (average)
female and the (average) male. Many of the sexual disturbances between
male and female are (at least partly) the result of misunderstanding differences
and miscommunication.
Chapter 5 will deal with the relation between on the one hand the cancer and its treatment
and on the other hand the impact on sexuality and intimacy. Whereas many
professionals have been educated with the principles of a biopsychosocial
(or biopsychosociocultural) approach, we here use another paradigm. Sexuality
is composed of three important elements: sexual function, sexual identity and
sexual relationship. Knowing that cancer and its treatment can cause sexual
disturbances, we believe that in proper care we should inquire about the
influence on function, identity and relationship. We recommend to do this
inquiring proactively, knowing that the patients themselves are scared to bring
up the topic.
In the process of sex and lovemaking, it is not only the genitals that have a role.
Many other parts of the body are used as ‘sexual equipment’ and can also be
damaged. Since that is rarely mentioned, it will get extra attention in this chapter.
Chapter 6 will approach the area from a totally different perspective. In France, they
have started to develop a clinical practical guideline completely devoted to
sexuality after cancer. This guideline with standards of care describes various
practical questions as ‘For whom?’, ‘Which cancers?’, ‘Who should speak
about it?’ and ‘When and how to speak about it? and also about the role
of oncosexology. This chapter has extra value for health-care managers
who have to think about and deal with the structure of care.
Chapter 7 is about training. In the context of this book, training is in particular
intended for the professionals who are not rooted in sexology and who don’t
feel at ease in discussing sexual function or who don’t feel at ease in dealing
with intimacy.
Whereas teaching can be seen as lecturing on knowledge, training is much more.
Good training offers a mixture of teaching knowledge, allowing space for
necessary attitudinal change, improving practical skills (here especially to
proactively discuss sexuality) and building competence (incorporating the
newly learned capacities with the right attitude in daily practice).
The Value of Paying Attention
3
3.1 Introduction
Cancer is a major public health problem worldwide. Calculating for North-Western

Europe, the percentage of cancer in the adult population, for all stages combined
(diagnosis through survival), is estimated at 4.4 %. From the perspective of sexual-
ity and intimacy, the partners share much of the damage and disturbance; adding
them, approximately 7 % of the adult population is directly involved.
With the advancement of science, technology, and medicine, the numbers of
patients who survive cancer are increasing, and supportive care and rehabilitation is
receiving increasingly more attention. According to the National Comprehensive
Cancer Network guidelines [1], an individual is defined as a cancer survivor from
the time of diagnosis, through the balance of his or her life.
After the diagnostic and the immediate treatment phase, a period with regular
assessment is recommended for all cancer survivors to determine any needs and neces-
sary interventions on the various relevant areas of life. This pertains to the vast and
persistent impact that both the diagnosis and the treatment of cancer can have on the
surviving patient, including the potential impact on health, physical and mental states,
health behaviors, professional and personal identity, sexuality, and financial standing.
Many cancer survivors are left with physical and/or psychosocial late and/or
long-term effects of the illness and its treatment, which can be severe, debilitating,
and frequently also permanent.
Sexuality and intimacy is one of those areas of change that is of concern. In vari-
ous groups of cancer patients the percentage of disturbed sexuality can be very high,
reaching 100 % in some of the cancer treatment strategies. Among the most
Y. Reisman (*)
W.L. Gianotten (*)
e-mail: woetgia@ziggo.nl
DOI 10.1007/978-3-319-43193-2_3
disturbing for impaired sexual function are hormonal therapy and strategies that
involve the pelvic organs. But depression and anxiety, which are common in cancer
survivors, can also contribute to sexual problems. Such developing disturbances of
sexuality and intimacy can cause increased distress and have a significant negative
impact on quality of life of the patient and the partner.
In comparison to other areas of adjustment after illness, the recovery of sexuality may
be hampered by the fact that most patients and partners find it difficult to talk openly
about sex. But there is also a lack of professional attention on the topics of sexuality and
intimacy, which is partially based on the general taboo surrounding sexuality [2].
3.2 Arguments Why This Area Is Not Discussed
In spite of the many questions and concerns about their sexuality, the majority of patients
find it difficult to raise the subject with their health care providers. The health care pro-
viders in their turn are reluctant to talk about this subject, even when they are aware that
their medical interventions seriously interrupt the sexual function and pleasure.
What are the reasons that both parties do not to discuss sexuality? At least one
explanation unconsciously resonates in all parties (society, patients, and profession-
als) – the persistent message that sex is for the young, the healthy, and the beautiful.
3.2.1 Professionals
There are several explanations for professional reluctance. Lack of knowledge is one.
Whereas in some Western countries sexuality or sexology has been part of the curricu-
lum in the vocational training of health care professionals, other countries completely
lack such training. However, having knowledge alone is not enough, since one needs
the skills as well to address a subject that is fraught with many emotions. Some pro-
fessionals fear that they will offend patients by asking questions that are too intimate,
which is in itself surprising since the daily practice of medical professionals is full of
intimate requests and questions (“Can you take off your underpants!”, etc.).
Some are scared to ask because they do not know how to react upon the answer
(“Imagine that there is a problem! Then I don’t know what next to do!”)
Some professionals do not consider discussing sexual disturbances with their
patients as their responsibility. And maybe the most common argument is the
assumption that patients who have a specific concern about sexuality will raise the
topic by themselves. We can be rather clear about that. Time and again it has been
shown that it does not work this way.
3.2.2 Patients
The vast majority of patients and partners also do not feel at ease to bring up such a
sensitive topic themselves, even when their sexuality is seriously disturbed. Some are
3 The Value of Paying Attention 9
not sure whether seeking attention with regard to sexuality would be appropriate
(“Shouldn’t I be happy that I am still alive!”). They can be embarrassed to talk about
sexuality because sex seems so insignificant in the face of death, or they even feel
ashamed to have sexual feelings when so threatened by cancer. Others do not want to
disturb the health care providers, who have done their very best to treat the patient well.
Some patients and partners seem also hampered by the idea that sexual problems
do not exist in a good relationship. That is one reason why we do not ask: “Do you
have a sexual problem?” (and why inquiring about changes in sexual function usu-
ally causes less confusion).
For many women and men, it is in some way difficult to share with a third party
information that belongs to the most intimate aspects of their relationship, irrespec-
tive of having a sexual disturbance and independent of the wish to have their sexual
disturbance discussed and solved.
There can also be some breach of intimacy. Even in very good relationships, it is
not always natural to share with each other the deeper sexual feelings and fears.
That is sometimes seen when the health care provider inquires about sexuality. Then
the patients sometimes respond with “No problem!.” But after having talked at
home with their partners, patients are more amenable on subsequent follow-ups and
clearly want to talk about their disturbances and worries.
3.3 Why Pay Attention
For many patients, sexuality is an important subject that adds to their quality of life.
Patients and their partners want to get information regarding the effects of the ill-
ness and the treatment on various aspects of their lives and also regarding the effects
on sexuality.
As mentioned before, they hope and expect that the health care professionals will
initiate this conversation.
Time and again many patients are disappointed in their health care professionals
because they received little information, support, and practical suggestions regard-
ing the sexual and intimate changes they experienced in the face of cancer. Although
nowadays many professionals are well aware that in case of cancer the topic of
sexuality and intimacy truly deserves attention, this is not implemented in their
daily practice.
The main focus of this chapter is on the “Why” of paying attention. Most prob-
lems in health care need attention and usually there is no chapter in books that
specifically addresses “paying attention.” So, what makes the topic of sexuality and
intimacy so special?
On the one hand, there are patients who bring up the topic of a sexual distur-
bance. Just as with any other problem, they deserve proper attention and if possible
a solution. The subject of sexual disturbance perhaps differs from other problems in
that the topic and discussion, as well as the solutions, could be more “charged.”
But it is obvious that even with serious sexual disturbances, and even when there
is a real desire to be helped, the majority of patients and couples will not freely
bring up their questions, their worries, and their disturbances in the area of sexuality
and intimacy.
So WE have to do that!
We will divide the arguments to do so in three different groups of benefits (or
potential benefits):
• The benefits/obligations of paying attention

• The health benefits of sexual expression and intimacy
• The benefits for the professional relationship
3.4 The Benefits/Obligations of Paying Attention
For most people, sexuality is a relevant aspect of their quality of life and a central
aspect of their well-being. As defined by the World Health Organization and sup-
ported by research, sexuality is one of the major components that contribute to a
sense of fulfilled life. Strangely, this needs to be noted and proven by research. Does
not everybody know so? Apparently not! We suppose that some professionals have
different ideas resulting from negative messages from culture, religion, or education
or even due to their own negative sexual experiences.
When people get into the cancer process, sexuality and intimacy frequently are
disturbed, which brings down their quality of life (and also that of the partner).
Paying attention to quality of life is an important aspect of good care.
After cancer, many of the sexual dysfunctions and disturbances are not the results
of the cancer itself but of our medical interventions. Being responsible for the col-
lateral damage of surgery, radiotherapy, chemotherapy, and medication makes us
also responsible for dealing with those sexual side effects.
Attention can be as well important for sexual identity. Patients (and partners)
who were in the terminal stage of cancer were asked about sexuality and intimacy.
Part of the questions was on how they experienced these inquiries. Surprisingly,
they all were happy with that attention. What does that mean? By this question the
patients apparently felt that they still were seen as alive, as man or woman, or as a
sexual being. So, whereas many professionals are scared that inquiring about sexual
matters is too intrusive, the opposite is true.
Sexual relationship is the other area that could benefit from adequate attention.
As a result of cancer, between 7 and 22 % of couples separate [3]. In the great major-
ity, this relates to couples where the woman has the cancer and the man is the carer.
We suppose that many of those relationship disturbances are caused by their not
being able to deal with the sexual unavailability of the female patient. Separated
(single) patients fare more poorly with more antidepressant use, more hospitaliza-
tion, and less dying at home.
A more relaxed patient and a more relaxed relationship most probably will ben-
efit the recovery and the healing process.
3.5 The Health Benefits of Sexual Expression and Intimacy
For a very long time, society and the medical community tended to consider sex as a
dangerous aspect of life. Only rather recently are we learning about the health ben-
efits of sexual expression [4, 5]. Here we will leave the emotional and social health
benefits and limit ourselves to the physical health benefits. With regard to the cancer
patient’s process, we abstain here also from addressing the long-term benefits (like
less cardiovascular and cerebrovascular incidents, fewer prostate cancers, and better
longevity).
What remains are the direct physical benefits that sometimes can be proactively
put into action. The following are the most important benefits:
• Muscular tension usually is diminished by sexual stimulation and even more by

orgasm. This was found in patients with spinal cord injury and multiple sclerosis,
but applies as well to “normal persons.”
• Pain is known to diminish by distraction (for instance, a romantic movie, a sports
match, or having pleasurable sex). In women there is an extra benefit when the
genitals (especially clitoris and anterior vaginal wall) are stimulated. That sends
a signal to the brain by which endorphin is released and the pain threshold
increases. Stimulation resulting in orgasm produces the greatest increase in pain
threshold.
• Both in woman and in man, the oxytocin level increases by massage, by sexual
excitement, and especially by orgasm. A higher oxytocin level has several ben-
efits. It enhances sleep and it relaxes, it is stress-reducing, and acts as an anxyo-
lytic. Besides, it causes more connection between persons, with increased
intimacy and affection and it temporarily diminishes the autistic aspects of
behavior.
• With satisfying sex there is less depression. This applies both to men and women,
not only for mutual sex but also for solo masturbation (except when sex is sur-
rounded by much guilt and sin).
When relevant, sharing such information with our patients could be seen as good
care. Furthermore, there appear some indications that sex can also have neuropro-
tective effects [6].
3.6 The Benefits for the Professional Relationship
There is a fascinating change between the original fear on the part of many health
care professionals when they consider addressing sexuality and the actual practice
when they have done so.
Initially, professionals are frequently afraid that their questions are “too inti-
mate.” This is surprising since they ask, for example, without any inhibition: “Take
off your pants!” or “Can you open your legs!” or “What is the color of your stool?”
After having started addressing sexuality, a common response of the profession-

als was that the contact with the patient had become much better. One may suppose
that then the compliance would have also improved (i.e., the therapeutic instruc-
tions and commitments were better followed).
3.7 How
The care for cancer covers a long process with many phases like diagnosis, treat-
ment, recovery, and sometimes a palliative or terminal stage. In addition, patients
(and couples) should be asked about their sexual function at regular intervals. One
reason for repeating the inquiring is because different process phases can be accom-
panied by different sexual side effects. But also because different patients (and part-
ners) can react in different ways during the process, depending on the meaning of
the various elements of sexual response, sexual expression, and intimacy for each of
the partners and for the couple.
Will “repeated inquiring” not lead to “sexological overkill”?
That depends on how it is integrated in the total questioning. It can be very help-
ful to develop a routine where sexuality has a fixed place in the list of areas to be
questioned (for instance, always after questions on fatigue and mood).
It depends also on how questions on sexuality and intimacy are introduced. Both
at the start and at the repeating. Let us give an example of the start:
We know that a substantial amount of people with your type of cancer and
your type of treatment is confronted with changes in sexuality. Many patients
will lose sexual desire and many men will lose their erection. That is a normal
reaction to the treatment. For some couples that is seriously disturbing,
whereas that is far less damaging for other couples. That is not better or worse.
It is the way it is. Because of those possible changes, three things are
important.
1. Now, at the beginning of the process we want to know about the baseline.
So we will ask how things are functioning at this moment, so that it will be
easier to anticipate changes.
2. We will do that regularly in the course of the treatment process, so that we
can see if, when, and how things are influenced and how to deal with that.
3. That information on sexual damage can be very scaring. However, you
should know also that we have solutions for nearly all sexual disturbances.
That is why we ask, but that it is also important for you not to keep silent
when there are questions or worries. Just tell us.
Regarding the repeating, here also it is relevant to mention why things are asked.
Here is an example of the repeating:
Since you have started this medication, did that change aspects of your
sexuality? More precisely, did it influence your sexual desire? (or orgasm,
lubrication, etc.)
Inquiring regularly can be done by interview (or in case of time restriction and
difficulties, by using the Brief Sexual Symptom Checklist as a primary screening
tool) [7] (See appendix).
When a sexual dysfunction is uncovered, a first step in our approach could be
acknowledgment of the dysfunction with some explanations about the possible causes.
This is sometimes already sufficient to improve patient/partner understanding and
allow room for open communication with the professionals but also within the couple.
Open communication in its turn can lead to renegotiation about intimacy and sexuality
and it can also be the start of a process of coping with functions that are lost.
Health care providers have various options for dealing with sexual dysfunctions
and other disturbances in the area of sexuality and intimacy. Examples are:
• Psychotherapy, cognitive behavior therapy, sexual counseling

• Lifestyle modifications such as smoking cessation, going for or maintaining
ideal body weight, engaging in regular exercise, and avoiding excess alcohol
consumption as measures to improve quality of life and diminish as much as pos-
sible sexual inhibiting factors
• Practical adaptations in the area of indirect causes of sexual disturbances, like
fatigue, pain, or vaginal dryness
• Prescribing medication or interventions
• Using of tips and tricks; including toys for functions that are lost
These will be described in the following chapters.
Final messages of this chapter:
1. Even with serious sexual disturbances, the great majority of patients and partners
do not bring up the topic of sexuality and intimacy.
2. Patients and partners are different and the various stages of the process have dif-
ferent consequences for sexuality.
3. So, there is no “one size fits all” in this area.
4. Final conclusion: WE have to address this area, we have to fine-tune the solutions to
the couple’s needs and we have to learn how to do that as effectively as possible.
No approach in cancer deserves to be called holistic as long as sexuality

and intimacy have not been adequately addressed.
3.8 Appendix
References
1. National Comprehensive Cancer Network (NCCN) guidelines. https://www.nccn.org/profes-
sionals/physician_gls/f_guidelines.asp#supportive.
2. Carr SV. Talking about sex to oncologists and about cancer to sexologists. Sexologies.
2007;16:267–72.
3. Glantz MJ, Chamberlain MC, Liu Q, et al. Gender disparity in the rate of partner abandonment
in patients with serious medical illness. Cancer. 2009;115:5237–42.
4. Whipple B, Knowles J, Davis J. The health benefits of sexual expression. In: Tepper MS,
Owens AF, editors. Sexual health, vol. 1. Westport: Psychological Foundations, Praeger; 2007.
p. 17–28.
5. Gianotten WL, Whipple B, Owens AF, et al. Sexual activity is a cornerstone of quality of life.
An update of “The health benefits of sexual expression”. In: Tepper MS, Owens AF, editors.
Sexual health, vol. 1. Westport: Psychological Foundations, Praeger; 2007. p. 28–42.
6. Spence RD, Voskuhl RR. Neuroprotective effects of estrogens and androgens in CNS inflam-
mation and neurodegeneration. Front Neuroendocrinol. 2012;33:105–15.
7. Reisman Y, Porst H, Lowenstein L, et al (editors). ESSM Manual of Sexual Medicine. 2nd Edn.
Medix Amsterdam. 2015.
Relevant Aspects of Sexuality
4
4.1 Introduction
This chapter will focus on the various biological elements of sexuality and sexual
function.
We will start with some relevant male–female (M-F) differences, which is in
some way a “touchy topic,” since it is difficult to clearly distinguish the nurture
aspects (education and social impact) from the nature aspects (biology). Touchy
also because cultures tend to approach this differently with, on the one hand, some
traditional cultures where women are not seen as equal and, on the other hand, egali-
tarian cultures where every M-F difference is categorically denied.
After that we will look at the sexual response and part of the “physical condi-
tions” (such as anatomy, hormones, neurotransmitters, etc.) that are needed to let the
sexual response take place. We will focus on those conditions that are relevant in the
context of cancer and its treatment.
Finally, we will change from sexual function to “sexual dysfunction” and we will
address some of the typical processes behind various sexual disturbances. Whereas
in this chapter sexual dysfunctions will be approached in a general way, the next
chapter will deal with the more typical cancer-treatment-related disturbances with
ample attention not only for sexual function but also for sexual identity and sexual
relationship as relevant pillars of sexuality.
W.L. Gianotten (*) • Y. Reisman

Rehabilitation Centre De Trappenberg,
Huizen, The Netherlands
e-mail: woetgia@ziggo.nl; uro.amsterdam@gmail.com

DOI 10.1007/978-3-319-43193-2_4
18 W.L. Gianotten and Y. Reisman
4.2 Male–Female Differences
Part of the behavior as a girl or a boy and later as a woman or a man is shaped by
the influence of parents, peers, media, and culture. Underlying these nurture ele-
ments, there is also a strong influence of nature, which starts very early in the uterus.
Without the addition of androgen hormones the fetus will develop into female
(female is the default). In case of an XY chromosomal pattern, the fetal testicle
develops and starts producing testosterone, responsible for the development of the
male genitals and for the typical male wiring in the brain. From shortly after birth till
the beginning of puberty, there are no gonadal hormones acting. In spite of that, there
are many differences in behavior when we compare boys and girls as groups. Boys
and men are relatively more function-oriented, whereas girls and women are rela-
tively more people-oriented. This is not better or worse, it simply is the way it is.
Then, when puberty commences, the gonadal hormones become active in two dif-
ferent ways. On the one hand, gonadal hormones have the “organizational” task of
guiding the ripening of the body from girl to woman and from boy to man. This task
is completed at the end of adolescence. The other is the “activational” task of orches-
trating reproduction, sexuality, and also other aspects of behavior. The same gonadal
hormones are responsible for a substantial part of (the differences between) male and
female behavior. This hormonal “activation” will continue till at an advanced age.
Estrogen and progesterone are key elements for the woman, regulating the
monthly cycle, with also influence on the mood. These two hormones more or less
disappear after the last menstruation. Women have also androgen hormones (falsely
called “male hormones”) with testosterone (T) as the main androgen. In her fertile
life, half of the androgens originate in the ovaries, the other half in the adrenal
glands. After menopause, the ovaries also gradually stop producing androgens, but
the adrenal glands continue to produce T.
In men, androgens are the key gonadal hormones, with 95 % originating from the
testicles and 5 % from the adrenal glands. Men do not have a sharp drop in hor-
mones. Till the age of 40, the T-levels are more or less stable and after that there is
an annual diminishing of 1–1.5 %.
Both in the man and in the woman, the androgen hormones have a major role in
sexual behavior with T as the number one for sexual thoughts, for sexual desire, and
for arousability, but also for some less-sexual aspects of behavior like mood and
assertiveness.
So long as men or women are in good enough health, their T-levels suffice for
sexual desire till at an advanced age. In men, the T-level is 10–15 times higher than
in females and that probably is an important part of the explanation for the differ-
ences in sexual behavior. In bed, men tend to be more focused on penetration, on
genitals, on orgasm (and on sexual performance), whereas women tend to be more
focused on relationship, intimacy, and on sensuality. The high male T-level is prob-
ably also responsible for his higher assertiveness and lower emotional sensitivity.
Another important difference is the rather even-tempered mood in most males ver-
sus the rather fluctuating mood in most women, because of hormonal changes
throughout their monthly cycle and pregnancies.
4 Relevant Aspects of Sexuality 19
To recap: (1) This is not giving a value of better or worse, and (2) these are group
observations, which neither means that all men or all women fit into this pattern, nor
does it mean that there is something wrong when they do not. Moreover, hormones
are not the only determinants for the above-mentioned aspects, as our culture, edu-
cation, upbringing, norms, and values have also important influence.
4.3 Sexual Response
Sexual response (or sexual function) is the potency of the sexual machinery. It is a
series of emotional and physical changes that occur when a person becomes sexu-
ally aroused and engages in sexually stimulating activities including intercourse and
masturbation. In a simplified version we tend to say that there are three phases:
sexual desire, sexual arousal, and orgasm. Originally, they were described as fol-
lowing each other in this order. That is what happens in many men. If not slowed
down by the partner, many men tend to continue more or less as in a linear process
from desire to arousal (horny and erection) and then orgasm/ejaculation as the
rounding off. For many women it is rather different, as is seen especially in longer-
standing heterosexual relationships. A common scenario is as follows: the man
(with his higher T-level and accordingly more sexual desire) initiates erotic contact.
The woman is not (yet) in the mood. When the man plays it well and pleases her
enough, she will develop sexual excitement before achieving sexual desire. The
“last” step of orgasm is also different for many women. Depending on mood and
context of the moment she may like to have an orgasm, but many women can have
full sexual satisfaction without having had an orgasm. This is difficult for many
men, since their “function-oriented perspective” in some ways seems to dictate that
his partner should have an orgasm. Combined with lack of good communication,
this appears to be one of the reasons why some women fake an orgasm.
Context plays an important role in what will or will not happen, and this is far
more relevant in women than in men.
We will discuss each of the three phases with special attention to the perspective
of the cancer patient.
4.4 Sexual Desire
Although often called “butterflies in the belly,” sexual desire is situated in the brain.
This part of sexuality is strongly guided by androgen hormones. In the upper range of
serum concentration, the level of testosterone is said not to really correspond with the
level of sexual desire. However, in the lower range (as regularly found after cancer
treatment) T seems to be a very relevant element for sexual desire. There is much vari-
ety in desire. Proactive (or “spontaneous”) desire is the common pattern in about 75 %
of men and in 15 % of women. Responsive desire is the common pattern in 5 % of men
and in 30 % of women. Others will have mixed patterns and some 6 % of the women
lack both spontaneous and responsive desire (existing independent of cancer) [1].
During the majority of time neither man nor women have sexual desire. The context
should be good enough and they should be receptive in order to get “in the mood.” For
this process a minimum amount of androgens seems necessary. Desire is also depen-
dent on the neurotransmitter balance (with dopamine as desire-increasing factor and
serotonin as desire-diminisher). Another relevant physical factor (or condition) for
desire is energy. Next, one needs sufficient stimuli to get into the sexual mood. Here we
see also male–female differences. Whereas for women relational stimuli are relatively
more important, visual stimuli are far more relevant for both mainstream and gay men.
4.4.1 Sexual Excitement/Sexual Arousal
This phase is mainly guided by circulation. Arousal is partly a nongenital phenom-

enon (with increased pulse, blood pressure, breathing, and muscle tension). The
genital part of arousal (erection and lubrication) is the result of hypercongestion of
the penile and the perivaginal circulation.
In the man, the smooth muscles in the cavernous body relax and the intracavern-
ous space fills with blood. Then, the veins are compressed so that the pressure
increases, causing a “full penis.” Because the space is surrounded by the very tight
tunica albuginea, when the pressure increases, the penis becomes hard and erect,
because the space is surrounded by the very tight tunica albuginea.
In the woman, hypercongestion takes place in the clitoris and vessels surrounding the
vagina with the consequence that fluid permeates through the vaginal wall. This lubrica-
tion has two functions. One is for fertility (with good lubrication favoring sperm sur-
vival). The other function is a mechanical one (“oiling the vaginal cylinder”), to prevent
damaging the vaginal mucosa and to prevent pain during intercourse. So, proper circula-
tion is a major condition for good arousal. The regulation of sexual arousal takes place
via two centers in the spinal cord. These centers are also part of a reflex arc. Part of the
erection and lubrication are the direct (reflex) result of genital stimulation.
For proper development of the arousal one needs good neural connections from
the centers in the spinal cord to the external genitals. These nerves are located close
to the prostate and the uterus. And finally, a complex interplay takes place between
opening arteries, closing veins, and relaxing cavernous muscles. In that process
nitric oxide and many other molecules, neurotransmitters and enzymes are involved
in orchestrating the arterial vasodilation and venous vasoconstriction, with an
important role for the endothelium.
In the excitement phase, testosterone has a small role via receptors in the brain,
necessary for arousability (the ability to become “horny”).
4.4.2 Orgasm Phase
The major physical conditions for orgasm are intact nerves and a proper neurotrans-
mitter balance. And, of course, proper stimulation.
In orgasm, there are also clear differences between the male and the female. Male:
For many males, orgasm and ejaculation are experienced as the same. Whereas they
4 Relevant Aspects of Sexuality 21
always coincide in ±96 % of the men, the other 4 % of men have learned to have an
orgasm without ejaculation (and they can have that several times consecutively).
After ejaculation, the man enters a refractory period (“falling in the black hole”).
His system has to be “reset,” which can take 15 min in a young man and up to a full
day in an aged man.
Female: Most women do not have such a refractory period. Besides, women can have
orgasm in more different ways. Roughly, 90 % of the women can have an orgasm via
stimulation of the clitoris; 25–35 % via stimulation (tapping the cervix and anterior
vaginal wall) during penetration; some via fantasy only or via breast stimulation
only. At least half of the women can have more than one orgasm in a row.
4.5 Androgens/Testosterone
In the context of this book, the role of androgens deserves extra attention because
androgen levels are frequently disturbed by various cancer treatment strategies.
Androgen deprivation treatment (ADT) for prostate cancer is a chemical way of castra-
tion. Whereas in ADT the castration is intended, most castration is an unintended side
effect of treatment. That is the case in nearly all gynaecological cancers because surgi-
cal removal of the ovaries is part of the treatment. Total body irradiation and radio-
therapy in the pelvic area can cause ovarian damage and testicular damage with
permanent or temporary hypogonadism. This can happen also after extensive chemo-
therapy, as happens for instance in ovarian cancer and in blood and lymph cancer before
stem cell transplantation. Radiotherapy and chemotherapy can also affect the adrenals,
which during the woman’s fertile life are responsible for 50 % of her androgens.
Hypogonadism can also be found after high dose of opioids. Hypogonadism is
the condition with too low gonadal hormones (testosterone).
Androgens are not only needed for sexual desire and arousability. They have
many different functions. A substantial shortage of testosterone can be accompa-
nied by a decrease in or loss of:
• Sexual desire
• Arousability (no more becoming horny)
• The ability and strength of orgasm (especially in women)
• Genital sexual sensations (“It is like dead flesh”)
• Spontaneous and sex-related erections
• Muscular strength (stamina)
• Bone density and muscle mass
• Mood
4.6 Sexual Dysfunctions
Disturbances of the sexual response usually are called sexual dysfunctions.

There are many biological, psychological, relational, social, and cultural fac-
tors that have a role in causing, or maintaining a sexual dysfunction or in
aggravating an existing one. With or without preexisting sexual dysfunctions

there can be the consequences of cancer and its treatment.
In this chapter, we will address the more general aspects of sexual dysfunction,
with some oncology relationships and in the next chapter we will more specifically
address the oncologic relationships.
4.6.1 Sexual Desire Problems
In discussing desire, one has to acknowledge the importance of context. During the
major part of the day, people have no sexual desire. Then, when one of a couple gets
in the mood and invites action, the other is not always ready (or not yet ready) for
action. This does not mean there is a desire problem. We should differentiate
between sexual aversion (“I really don’t want to be involved”) and absence of desire
(or no desire). The latter situation is very common in many situations of daily life.
Clear examples are seen in mothers with young children.
Absence of sexual desire is normal when testosterone (T) has diminished. Several
reasons for hypogonadism have been mentioned above.
Another reason for low desire is fatigue, a common complaint in many cancer
patients. Fatigue can also be “caused” by low T. When faced with the combination
of chronic fatigue and low sexual desire (as for instance frequently found after treat-
ment for blood/lymph cancer) we should also consider lowered T as one of the
causing factors, especially in persons who formerly experienced good desire.
Absence of proactive sexual desire can also be the side effect of neurotransmitter-
influencing medication. Especially, SSRI and SNRI antidepressants are known to nega-
tively influence sexual desire (and as a matter of fact, also the other phases of the sexual
response). The group of paroxetin, citalopram, and venlafaxin (together representing
more than half of all outpatient antidepressant prescriptions in many Western European
countries) is known to negatively influence sexual desire in >60 % of patients [2].
Besides these physical killjoys, there are also emotional reasons. In a large meta-
analysis, 38.2 % of cancer patients were found to suffer from depression, anxiety,
adjustment disorder, or dysthymia [3]. These conditions will diminish desire for the
majority of patients (although a small number of persons desire more sex when they
get depressed).
The changed social situation can be another reason for low sexual desire. The part-
ner will change as well. On the one hand, the diagnosis is a major life event accompa-
nied by fear of loss. On the other hand, the caring role and taking over of many tasks
that formerly were done by the patient can cause serious fatigue, leading to an absence
of sexual initiative or seduction also from the partner’s side.
4.6.2 Arousal Problems
Arousability is a first condition for real arousal. Without sufficient androgens one
cannot become “horny.” With regard to genital arousal problems there is a big dif-
ference between male and female. One could suspect that side effects of disease and
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The Alabama Claims.
During this year the long disputed Alabama Claims of the United
States against Great Britain, arising from the depredations of the
Anglo-rebel privateers, built and fitted out in British waters, were
referred by the Treaty of Washington, dated May 8th, 1871, to
arbitrators, and this was the first and most signal triumph of the plan
of arbitration, so far as the Government of the United States was
concerned. The arbitrators were appointed, at the invitation of the
governments of Great Britain and the United States, from these
powers, and from Brazil, Italy, and Switzerland. On September 14th,
1872, they gave to the United States gross damages to the amount of
$15,500,000, an amount which has subsequently proved to be really
in excess of the demands of merchants and others claiming the loss
of property through the depredations of the rebel ram Alabama and
other rebel privateers. We append a list of the representatives of the
several governments:
Arbitrator on the part of the United States—Charles Francis
Adams.
Arbitrator on the part of Great Britain—The Right Honorable Sir
Alexander Cockburn, Baronet, Lord Chief Justice of England.
Arbitrator on the part of Italy—His Excellency Senator Count
Sclopis.
Arbitrator on the part of Switzerland—Mr. Jacob Stampfli.
Arbitrator on the part of Brazil—Baron D’Itajuba.
Agent on the part of the United States—J. C. Bancroft Davis.
Agent on the part of Great Britain—Right Honorable Lord
Tenterden.
Counsel for the United States—Caleb Cushing, William M.
Evarts, Morrison R. Waite.
Counsel for Great Britain—Sir Roundell Palmer.
Solicitor for the United States—Charles C. Beaman, Jr.
The Force Bill.
The 42d Congress met March 4, 1871, the Republicans having

suffered somewhat in their representation. In the Senate there were
57 Republicans, 17 Democrats; in the House 138 Republicans, 103
Democrats. James G. Blaine was again chosen Speaker. The most
exciting political question of the session was the passage of the
“Force Bill,” as the Democrats called it. The object was more rigidly
to enforce observance of the provisions of the 14th Amendment, as
the Republicans claim; to revive a waning political power in the
South, and save the “carpet-bag” governments there, as the
Democrats claimed. The Act allowed suit in the Federal courts
against any person who should deprive another of the rights of a
citizen, and it made it a penal offense to conspire to take away any
one’s rights as a citizen. It also provided that inability, neglect, or
refusal by any State governments to suppress such conspiracies, or
their refusal to call upon the President for aid, should be deemed a
denial by such State of the equal protection of the laws under the
14th Amendment. It further declared such conspiracies “a rebellion
against the government of the United States,” and authorized the
President, when in his judgment the public safety required it, to
suspend the privilege of habeas corpus in any district, and suppress
any such insurrection by the army and navy.
President Hayes’s Civil Service Order.
Executive Mansion, Washington, June 22, 1877.

Sir:—I desire to call your attention to the following paragraph in a
letter addressed by me to the Secretary of the Treasury, on the
conduct to be observed by the officers of the General Government in
relation to the elections:
“No officer should be required or permitted to take part in the
management of political organizations, caucuses, conventions or
election campaigns. Their right to vote and to express their views on
public questions, either orally or through the press, is not denied,
provided it does not interfere with the discharge of their official
duties. No assessment for political purposes on officers or
subordinates should be allowed.”
This rule is applicable to every department of the Civil Service. It
should be understood by every officer of the General Government
that he is expected to conform his conduct to its requirements.
Very respectfully, R. B. Hayes.
Some of the protests were strong, and it is difficult to say whether

Curtis, Julian, or Eaton—its three leading advocates—or the
politicians, had the best of the argument. It was not denied, however,
that a strong and very respectable sentiment had been created in
favor of the reform, and to this sentiment all parties, and the
President as well, made a show of bowing. It was fashionable to
insert civil service planks in National and State platforms, but it was
not such an issue as could live in the presence of more exciting ones;
and while to this day it has earnest and able advocates, it has from
year to year fallen into greater disuse. Actual trial showed the
impracticability of some of the rules, and President Grant lost
interest in the subject, as did Congress, for in several instances it
neglected to appropriate the funds necessary to carry out the
provisions of the law. President Arthur, in his message, to Congress
in December, 1881, argued against its full application, and showed
that it blocked the way to preferment, certainly of the middle-aged
and older persons, who could not recall their early lessons acquired
by rote; that its effect was to elevate the inexperienced to positions
which required executive ability, sound judgment, business aptitude,
and experience. The feature of the message met the endorsement of
nearly the entire Republican press, and at this writing the sentiment,
at least of the Republican party, appears to favor a partial
modification of the rules.
The system was begun January 1st, 1872, but in December, 1874,
Congress refused to make any appropriations, and it was for a time
abandoned, with slight and spasmodic revivals under the
administration of President Hayes, who issued the foregoing order.
By letter from the Attorney-General, Charles Devens, August 1,
1877, this order was held to apply to the Pennsylvania Republican
Association at Washington. Still later there was a further exposition,
in which Attorney-General Devens, writing from Washington in
October 1, 1877, excuses himself from active participation in the
Massachusetts State campaign, and says: “I learn with surprise and
regret that any of the Republican officials hesitate either to speak or
vote, alleging as a reason the President’s recent Civil Service order.
In distinct terms that order states that the right of officials to vote
and express their views on public questions, either orally or through
the press, is not denied, provided it does not interfere with the
discharge of their official duties. If such gentlemen choose not to
vote, or not to express or enforce their views in support of the
principles of the Republican party, either orally or otherwise, they, at
least, should give a reason for such a course which is not justified by
the order referred to, and which is simply a perversion of it.”
Yet later, when the interest in the Pennsylvania election became
general, because of the sharp struggle between Governor Hoyt and
Senator Dill for Governor, a committee of gentlemen (Republicans)
visited President Hayes and induced him to “suspend the operation
of the order” as to Pennsylvania, where political contributions were
collected.
And opposition was manifested after even the earlier trials.
Benjamin F. Butler denounced the plan as English and anti-
Republican, and before long some of the more radical Republican
papers, which had indeed given little attention to the subject, began
to denounce it as a plan to exclude faithful Republicans from and
permit Democrats to enter the offices. These now argued that none of
the vagaries of political dreamers could ever convince them that a
free Government can be run without political parties; that while
rotation in office may not be a fundamental element of republican
government, yet the right of the people to recommend is its corner-
stone; that civil service would lead to the creation of rings, and
eventually to the purchase of places; that it would establish an
aristocracy of office-holders, who could not be removed at times
when it might be important, as in the rebellion for the
Administration to have only friends in public office; that it would
establish grades and life-tenures in civic positions, etc.
For later particulars touching civil service, see the Act of Congress
of 1883, and the regulations made pursuant to the same in Book V.
Amnesty.
The first regular session of the 42d Congress met Dec. 4th, 1871.
The Democrats consumed much of the time in efforts to pass bills to
remove the political disabilities of former Southern rebels, and they
were materially aided by the editorials of Horace Greeley, in the New
York Tribune, which had long contended for universal amnesty. At
this session all such efforts were defeated by the Republicans, who
invariably amended such propositions by adding Sumner’s
Supplementary Civil Rights Bill, which was intended to prevent any
discrimination against colored persons by common carriers, hotels,
or other chartered or licensed servants. The Amnesty Bill, however
was passed May 22d, 1872, after an agreement to exclude from its
provisions all who held the higher military and civic positions under
the Confederacy—in all about 350 persons. The following is a copy:
Be it enacted, etc., (two-thirds of each House concurring therein,)
That all legal and political disabilities imposed by the third section of
the fourteenth article of the amendments of the Constitution of the
United States are hereby removed from all persons whomsoever,
except Senators and Representatives of the Thirty-sixth and Thirty-
seventh Congress, officers in the judicial, military, and naval service
of the United States, heads of Departments, and foreign ministers of
the United States.
Subsequently many acts removing the disabilities of all excepted
(save Jefferson Davis) from the provisions of the above, were passed.
The Liberal Republicans.
An issue raised in Missouri gave immediate rise to the Liberal

Republican party, though the course of Horace Greeley had long
pointed toward the organization of something of the kind, and with
equal plainness it pointed to his desire to be its champion and
candidate for the Presidency. In 1870 the Republican party, then in
control of the Legislature of Missouri, split into two parts on the
question of the removal of the disqualifications imposed upon rebels
by the State Constitution during the war. Those favoring the removal
of disabilities were headed by B. Gratz Brown and Carl Schurz, and
they called themselves Liberal Republicans; those opposed were
called and accepted the name of Radical Republicans. The former
quickly allied themselves with the Democrats, and thus carried the
State, though Grant’s administration “stood in” with the Radicals. As
a result the disabilities were quickly removed, and those who
believed with Greeley now sought to promote a reaction in
Republican sentiment all over the country. Greeley was the
recognized head of this movement, and he was ably aided by ex-
Governor Curtin and Col. A. K. McClure in Pennsylvania; Charles
Francis Adams, Massachusetts; Judge Trumbull, in Illinois; Reuben
E. Fenton, in New York; Brown and Schurz in Missouri, and in fact
by leading Republicans in nearly all of the States, who at once began
to lay plans to carry the next Presidential election.
They charged that the Enforcement Acts of Congress were
designed more for the political advancement of Grant’s adherents
than for the benefit of the country; that instead of suppressing they
were calculated to promote a war of races in the South; that Grant
was seeking the establishment of a military despotism, etc. These
leaders were, as a rule, brilliant men. They had tired of
unappreciated and unrewarded service in the Republican party, or
had a natural fondness for “pastures new,” and, in the language of
the day, they quickly succeeded in making political movements
“lively.”
In the spring of 1871 the Liberal Republicans and Democrats of
Ohio—and Ohio seems to be the most fertile soil for new ideas—
prepared for a fusion, and after frequent consultations of the various
leaders with Mr. Greeley in New York, a call was issued from
Missouri on the 24th of January, 1872, for a National Convention of
the Liberal Republican party to be held at Cincinnati, May 1st. The
well-matured plans of the leaders were carried out in the nomination
of Hon. Horace Greeley for President and B. Gratz Brown for Vice-
President, though not without a serious struggle over the chief
nomination, which was warmly contested by the friends of Charles
Francis Adams. Indeed he led in most of the six ballots, but finally all
the friends of other candidates voted for Greeley, and he received
482 to 187 for Adams. Dissatisfaction followed, and a later effort was
made to substitute Adams for Greeley, but it failed. The original
leaders now prepared to capture the Democratic Convention, which
met at Baltimore, June 9th. By nearly an unanimous vote it was
induced to endorse the Cincinnati platform, and it likewise finally
endorsed Greeley and Brown—though not without many bitter
protests. A few straight-out Democrats met later at Louisville, Ky.,
Sept. 3d, and nominated Charles O’Conor, of New York, for
President, and John Quincy Adams, of Massachusetts, for Vice-
President, and these were kept in the race to the end, receiving a
popular vote of about 30,000.
The regular Republican National Convention was held at
Philadelphia, June 5th. It renominated President Grant
unanimously, and Henry Wilson, of Massachusetts, for Vice-
President by 364½ votes to 321½ for Schuyler Colfax, who thus
shared the fate of Hannibal Hamlin in his second candidacy for Vice-
President on the ticket with Abraham Lincoln. This change to Wilson
was to favor the solid Republican States of New England, and to
prevent both candidates coming from the West.
Civil Service Reform.
After considerable and very able agitation by Geo. W. Curtis, the

editor of Harper’s Weekly, an Act was passed March 3d, 1871,
authorizing the President to begin a reform in the civil service. He
appointed a Commission headed by Mr. Curtis, and after more than
a year’s preparation this body defeated a measure which secured
Congressional approval and that of President Grant.
The civil service law (and it is still a law though more honored now
in the breach than the observance) embraced in a single section of
the act making appropriations for sundry civil expenses for the year
ending June 30, 1872, and authorize the President to prescribe such
rules and regulations for admission into the civil service as will best
promote the efficiency thereof, and ascertain the fitness of each
candidate for the branch of service into which he seeks to enter.
Under this law a commission was appointed to draft rules and
regulations which were approved and are now being enforced by the
President. All applicants for position in any of the government
departments come under these rules:—all classes of clerks, copyists,
counters; in the customs service all from deputy collector down to
inspectors and clerks with the salaries of $1200 or more; in
appraisers’ offices all assistants and clerks; in the naval service all
clerks; all lighthouse keepers; in the revenue, supervisors, collectors,
assessors, assistants; in the postal really all postmasters whose pay is
over $200, and all mail messengers. The rules apply to all new
appointments in the departments or grades named, except that
“nothing shall prevent the reappointment at discretion of the
incumbents of any office the term of which is fixed by law.” So that a
postmaster or other officer escapes their application. Those specially
exempt are the Heads of Departments; their immediate assistants
and deputies, the diplomatic service, the judiciary, and the district
attorneys. Each branch of the service is to be grouped, and admission
shall always be to the lowest grade of any group. Such appointments
are made for a probationary term of six months, when if the Board of
Examiners approve the incumbent is continued. This Board of
Examiners, three in number in each case, shall be chosen by the
President from the several Departments, and they shall examine at
Washington for any position there, or, when directed by an Advisory
Board, shall assign places for examination in the several States.
Examinations are in all cases first made of applicants within the
office or department, and from the list three reported in the order of
excellence; if those within fail, then outside applicants may be
examined. In the Federal Blue Book, which is a part of this volume,
we give the Civil Service Rules.
When first proposed, partisan politics had no part or place in civil
service reform, and the author of the plan was himself a
distinguished Republican. In fact both parties thought something
good had been reached, and there was practically no resistance at
first to a trial.
The Democrats resisted the passage of this bill with even more
earnestness than any which preceded it, but the Republican
discipline was almost perfect, and when passed it received the
prompt approval of President Grant, who by this time was classed as
“the most radical of the radicals.” Opponents denounced it as little if
any less obnoxious than the old Sedition law of 1798, while the
Republicans claimed that it was to meet a state of growing war in the
South—a war of races—and that the form of domestic violence
manifested was in the highest degree dangerous to the peace of the
Union and the safety of the newly enfranchised citizens.
The Credit Mobilier.
At the second session of the 42d Congress, beginning Dec. 2, 1872,

the speaker (Blaine) on the first day called attention to the charges
made by Democratic orators and newspapers during the Presidential
campaign just closed, that the Vice-President (Colfax), the Vice-
President elect (Wilson), the Secretary of the Treasury, several
Senators, the Speaker of the House, and a large number of
Representatives had been bribed, during the years 1867 and 1868, by
Oakes Ames, a member of the House from Massachusetts; that he
and his agents had given them presents of stock in a corporation
known as the Credit Mobilier, to influence their legislative action for
the benefit of the Union Pacific Railroad Company.
Upon Speaker Blaine’s motion, a committee of investigation was
appointed by Hon. S. S. Cox, of New York, a noted Democrat
temporarily called to the Chair.
After the close of the campaign, (as was remarked by the Republic
Magazine at the time) the dominant party might well have claimed,
and would have insisted had they been opposed to a thorough
investigation and a full exposure of corruption, that the verdict of the
people in the late canvass was sufficient answer to these charges; but
the Republican party not merely granted all the investigations
sought, but summoned on the leading committee a majority of its
political foes to conduct the inquest.
The committee consisted of Messrs. Poland, of Vermont;
McCreary, of Iowa; Banks, of Massachusetts; Niblack, of Indiana,
and Merrick, of Maryland.
Messrs. Poland and McCreary—the two Republicans—were
gentlemen of ability and standing, well known for their integrity,
moderation, and impartiality. General Banks was an earnest
supporter of Horace Greeley, upon the alleged ground that the
Republican organization had become effete and corrupt: while
Messrs. Niblack and Merrick are among the ablest representatives of
the Democratic party; in fact, Mr. Merrick belonged to the extreme
Southern school of political thought.
Having patiently and carefully examined and sifted the entire
testimony—often “painfully conflicting,” as the committee remarked
—their report ought to be considered a judicial document
commanding universal approval, yet scraps of the testimony and not
the report itself were used with painful frequency against James A.
Garfield in his Presidential canvass of 1880. There has not been a
state paper submitted for many years upon a similar subject that
carried with it greater weight, or which bore upon its face a fuller
realization of the grave responsibilities assumed, and it is the first
time in the political history of the United States that an all important
investigation has been entrusted by the dominant party to a majority
of its political foes.
The report of the committee gives the best and by far the most
reliable history of the whole affair, and its presentation here may aid
in preventing partisan misrepresentations in the future—
misrepresentations made in the heat of contest, and doubtless
regretted afterwards by all who had the facilities for getting at the
facts. We therefore give the
OFFICIAL REPORT OF THE CREDIT MOBILIER

INVESTIGATING COMMITTEE.
Mr. Poland, from the select committee to investigate the alleged

Credit Mobilier bribery, made the following report February 18,
1873:
The special committee appointed under the following resolutions
of the House to wit:
Whereas, Accusations have been made in the public press,
founded on alleged letters of Oakes Ames, a Representative of
Massachusetts, and upon the alleged affidavits of Henry S. McComb,
a citizen of Wilmington, in the State of Delaware, to the effect that
members of this House were bribed by Oakes Ames to perform
certain legislative acts for the benefit of the Union Pacific Railroad
Company, by presents of stock in the Credit Mobilier of America, or
by presents of a valuable character derived therefrom: therefore,
Resolved, That a special committee of five members be appointed
by the Speaker pro tempore, whose duty it shall be to investigate
whether any member of this House was bribed by Oakes Ames, or
any other person or corporation, in any matter touching his
legislative duty.
Resolved, further, That the committee have the right to employ a
stenographer, and that they be empowered to send for persons and
papers;
beg leave to make the following report:
In order to a clear understanding of the facts hereinafter stated as
to contracts and dealings in reference to stock of the Credit Mobilier
of America, between Mr. Oakes Ames and others, and members of
Congress, it is necessary to make a preliminary statement of the
connection of that company with the Union Pacific Railroad
Company, and their relations to each other.
The company called the “Credit Mobilier of America” was

incorporated by the Legislature of Pennsylvania, and in 1864 control
of its charter and franchises had been obtained by certain persons
interested in the Union Pacific Railroad Company, for the purpose of
using it as a construction company to build the Union Pacific road.
In September, 1864, a contract was entered into between the Union
Pacific Company and H. M. Hoxie, for the building by said Hoxie of
one hundred miles of said road from Omaha west.
This contract was at once assigned by Hoxie to the Credit Mobilier
Company, as it was expected to be when made. Under this contract
and extensions of it some two or three hundred miles of road were
built by the Credit Mobilier Company, but no considerable profits
appear to have been realized therefrom. The enterprise of building a
railroad to the Pacific was of such vast magnitude, and was beset by
so many hazards and risks that the capitalists of the country were
generally averse to investing in it, and, notwithstanding the liberal
aid granted by the Government it seemed likely to fail of completion.
In 1865 or 1866, Mr. Oakes Ames, then and now a member of the
House from the State of Massachusetts, and his brother Oliver Ames
became interested in the Union Pacific Company and also in the
Credit Mobilier Company as the agents for the construction of the
road. The Messrs. Ames were men of very large capital, and of known
character and integrity in business. By their example and credit, and
the personal efforts of Mr. Oakes Ames, many men of capital were
induced to embark in the enterprise, and to take stock in the Union
Pacific Company and also in the Credit Mobilier Company. Among
them were the firm of S. Hooper & Co., of Boston, the leading
member of which, Mr. Samuel Hooper, was then and is now a
member of the House; Mr. John B. Alley, then a member of the
House from Massachusetts, and Mr. Grimes, then a Senator from the
State of Iowa. Notwithstanding the vigorous efforts of Mr. Ames and
others interested with him, great difficulty was experienced in
securing the required capital.
In the spring of 1867 the Credit Mobilier Company voted to add 50
per cent. to their capital stock, which was then two and a half
millions of dollars; and to cause it to be readily taken each subscriber
to it was entitled to receive as a bonus an equal amount of first
mortgage bonds of the Union Pacific Company. The old stockholders
were entitled to take this increase, but even the favorable terms
offered did not induce all the old stockholders to take it, and the
stock of the Credit Mobilier Company was never considered worth its
par value until after the execution of the Oakes Ames contract
hereinafter mentioned.
On the 16th day of August, 1867, a contract was executed between
the Union Pacific Railroad Company and Oakes Ames, by which Mr.
Ames contracted to build six hundred and sixty-seven miles of the
Union Pacific road at prices ranging from $42,000 to $96,000 per
mile, amounting in the aggregate to $47,000,000. Before the
contract was entered into it was understood that Mr. Ames was to
transfer it to seven trustees, who were to execute it, and the profits of
the contract were to be divided among the stockholders in the Credit
Mobilier Company, who should comply with certain conditions set
out in the instrument transferring the contract to the trustees. The
Ames contract and the transfer to trustees are incorporated in the
evidence submitted, and therefore further recital of their terms is not
deemed necessary.
Substantially, all the stockholders of the Credit Mobilier complied
with the conditions named in the transfer, and thus became entitled
to share in any profits said trustees might make in executing the
contract.
All the large stockholders in the Union Pacific were also
stockholders in the Credit Mobilier, and the Ames contract and its
transfer to trustees were ratified by the Union Pacific, and received
the assent of the great body of stockholders, but not of all.
After the Ames contract had been executed, it was expected by
those interested that by reason of the enormous prices agreed to be
paid for the work very large profits would be derived from building
the road, and very soon the stock of the Credit Mobilier was
understood by those holding it to be worth much more than its par
value. The stock was not in the market and had no fixed market
value, but the holders of it, in December, 1867, considered it worth at
least double the par value, and in January and February, 1868, three
or four times the par value, but it does not appear that these facts
were generally or publicly known, or that the holders of the stock
desired they should be.
The foregoing statement the committee think gives enough of the
historic details, and condition and value of the stock, to make the
following detailed facts intelligible.
Mr. Oakes Ames was then a member of the House of
Representatives, and came to Washington at the commencement of
the session, about the beginning of December, 1867. During that
month Mr. Ames entered into contracts with a considerable number
of members of Congress, both Senators and Representatives, to let
them have shares of stock in the Credit Mobilier Company at par,
with interest thereon from the first day of the previous July. It does
not appear that in any instance he asked any of these persons to pay
a higher price than the par value and interest, nor that Mr. Ames
used any special effort or urgency to get these persons to take it. In
all these negotiations Mr. Ames did not enter into any details as to
the value of the stock or the amount of dividend that might be
expected upon it, but stated generally that it would be good stock,
and in several instances said he would guarantee that they should get
at least 10 per cent. on their money.
Some of these gentlemen, in their conversations with Mr. Ames,
raised the question whether becoming holders of this stock would
bring them into any embarrassment as members of Congress in their
legislative action. Mr. Ames quieted such suggestions by saying it
could not, for the Union Pacific had received from Congress all the
grants and legislation it wanted, and they should ask for nothing
more. In some instances those members who contracted for stock
paid to Mr. Ames the money for the price of the stock, par and
interest; in others, where they had not the money, Mr. Ames agreed
to carry the stock for them until they could get the money or it
should be met by the dividends.
Mr. Ames was at this time a large stockholder in the Credit
Mobilier, but he did not intend any of these transactions to be sales
of his own stock, but intended to fulfill all these contracts from stock
belonging to the company.
At this time there were about six hundred and fifty shares of the
stock of the company, which had for some reason been placed in the
name of Mr. T. C. Durant, one of the leading and active men of the
concern.
Mr. Ames claimed that a portion of this stock should be assigned
to him to enable him to fulfill engagements he had made for stock.
Mr. Durant claimed that he had made similar engagements that he
should be allowed stock to fulfill. Mr. McComb, who was present at
the time, claimed that he had also made engagements for stock
which he should have stock given him to carry out. This claim of
McComb was refused, but after the stock was assigned to Mr. Ames,
McComb insisted that Ames should distribute some of the stock to
his (McComb’s) friends, and named Senators Bayard and Fowler,
and Representatives Allison and Wilson, of Iowa.
It was finally arranged that three hundred and forty-three shares
of the stock of the company should be transferred to Mr. Ames to
enable him to perform his engagements, and that number of shares
were set over on the books of the company to Oakes Ames, trustee, to
distinguish it from the stock held by him before. Mr. Ames at the
time paid to the company the par of the stock and interest from the
July previous, and this stock still stands on the books in the name of
Oakes Ames, trustee, except thirteen shares which have been
transferred to parties in no way connected with Congress. The
committee do not find that Mr. Ames had any negotiation whatever
with any of these members of Congress on the subject of this stock
prior to the commencement of the session of December, 1867, except
Mr. Scofield, of Pennsylvania, and it was not claimed that any
obligation existed from Mr. Ames to him as the result of it.
In relation to the purpose and motives of Mr. Ames in contracting
to let members of Congress have Credit Mobilier stock at par, which
he and all other owners of it considered worth at least double that
sum, the committee, upon the evidence taken by them and submitted
to the House, cannot entertain doubt. When he said he did not
suppose the Union Pacific Company would ask or need further
legislation, he stated what he believed to be true. But he feared the
interests of the road might suffer by adverse legislation, and what he
desired to accomplish was to enlist strength and friends in Congress
who would resist any encroachment upon or interference with the
rights and privileges already secured, and to that end wished to
create in them an interest identical with his own. This purpose is
clearly avowed in his letters to McComb, copied in the evidence. He
says he intends to place the stock “where it will do most good to us.”
And again, “we want more friends in this Congress.” In his letter to
McComb, and also in his statement prepared by counsel, he gives the
philosophy of his action, to wit, “That he has found there is no
difficulty in getting men to look after their own property.” The
committee are also satisfied that Mr. Ames entertained a fear that,
when the true relations between the Credit Mobilier Company and
the Union Pacific became generally known, and the means by which
the great profits expected to be made were fully understood, there
was danger that congressional investigation and action would be
invoked.
The members of Congress with whom he dealt were generally
those who had been friendly and favorable to a Pacific Railroad, and
Mr. Ames did not fear or expect to find them favorable to movements
hostile to it; but he desired to stimulate their activity and
watchfulness in opposition to any unfavorable action by giving them
a personal interest in the success of the enterprise, especially so far
as it affected the interest of the Credit Mobilier Company. On the 9th
day of December, 1867, Mr. C. C. Washburn, of Wisconsin,
introduced in the House a bill to regulate by law the rates of
transportation over the Pacific Railroad.
Mr. Ames, as well as others interested in the Union Pacific road,
was opposed to this, and desired to defeat it. Other measures
apparently hostile to that company were subsequently introduced
into the House by Mr. Washburn of Wisconsin, and Mr. Washburne
of Illinois. The committee believe that Mr. Ames, in his distributions
of stock, had specially in mind the hostile efforts of the Messrs.
Washburn, and desired to gain strength to secure their defeat. The
reference in one of his letters to “Washburn’s move” makes this quite
apparent.
The foregoing is deemed by the committee a sufficient statement
of facts as to Mr. Ames, taken in connection with what will be
subsequently stated of his transactions with particular persons. Mr.
Ames made some contracts for stock in the Credit Mobilier with
members of the Senate. In public discussions of this subject the
names of members of both Houses have been so connected, and all
these transactions were so nearly simultaneous, that the committee
deemed it their duty to obtain all evidence in their power, as to all
persons then members of either House, and to report the same to the
House. Having done this, and the House having directed that
evidence transmitted to the Senate, the committee consider their
own power and duty, as well as that of the House, fully performed, so
far as members of the Senate are concerned. Some of Mr. Ames’s
contracts to sell stock were with gentlemen who were then members
of the House, but are not members of the present Congress.
The committee have sought for and taken all the evidence within
their reach as to those gentlemen, and reported the same to the
House. As the House has ceased to have jurisdiction over them as
members, the committee have not deemed it their duty to make any
special finding of facts as to each, leaving the House and the country
to their own conclusions upon the testimony.
In regard to each of the members of the present House, the
committee deem it their duty to state specially the facts they find
proved by the evidence, which, in some instances, is painfully
conflicting.

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Cancer is a major public health problem worldwide. Calculating for North-Western

3.2 Arguments Why This Area Is Not Discussed

3.3 Why Pay Attention

• The benefits/obligations of paying attention

3.4 The Benefits/Obligations of Paying Attention

3.5 The Health Benefits of Sexual Expression and Intimacy

• Muscular tension usually is diminished by sexual stimulation and even more by

3.6 The Benefits for the Professional Relationship

After having started addressing sexuality, a common response of the profession-

• Psychotherapy, cognitive behavior therapy, sexual counseling

No approach in cancer deserves to be called holistic as long as sexuality

W.L. Gianotten (*) • Y. Reisman

© Springer International Publishing Switzerland 2017 17

4.2 Male–Female Differences

4.3 Sexual Response

4.4 Sexual Desire

4.4.1 Sexual Excitement/Sexual Arousal

This phase is mainly guided by circulation. Arousal is partly a nongenital phenom-

4.4.2 Orgasm Phase

4.6 Sexual Dysfunctions

Disturbances of the sexual response usually are called sexual dysfunctions.

aggravating an existing one. With or without preexisting sexual dysfunctions

4.6.1 Sexual Desire Problems

4.6.2 Arousal Problems

The 42d Congress met March 4, 1871, the Republicans having

Executive Mansion, Washington, June 22, 1877.

Very respectfully, R. B. Hayes.

Some of the protests were strong, and it is difficult to say whether

An issue raised in Missouri gave immediate rise to the Liberal

After considerable and very able agitation by Geo. W. Curtis, the

At the second session of the 42d Congress, beginning Dec. 2, 1872,

OFFICIAL REPORT OF THE CREDIT MOBILIER

Mr. Poland, from the select committee to investigate the alleged

The company called the “Credit Mobilier of America” was

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3.2 Arguments Why This Area Is Not Discussed

3.3 Why Pay Attention

3.4 The Benefits/Obligations of Paying Attention

3.5 The Health Benefits of Sexual Expression and Intimacy

3.6 The Benefits for the Professional Relationship

4.2 Male–Female Differences

4.3 Sexual Response

4.4 Sexual Desire

4.4.1 Sexual Excitement/Sexual Arousal

4.4.2 Orgasm Phase

4.6 Sexual Dysfunctions

4.6.1 Sexual Desire Problems

4.6.2 Arousal Problems