1 INTRODUCTION

A child's cancer diagnosis and treatment profoundly impact parents, both individually and as a couple. After a child's diagnosis, parents are challenged by abrupt changes to daily routines and increased tension between work and family responsibilities, all while grappling with the difficult process of treatment and fear of losing their child.^1-6 Parents experience an understandable shift in focus towards supporting their child during intensive cancer treatments often taking on responsibility for life-and-death decisions.^{1-5, 7} These challenges impact parents’ functioning as individuals and as a partnership.^{4, 8-14} While multiple studies have shown that separation and divorce do not appear to be more common among parents of a child with cancer than those without,^15-17 parents of children with cancer have reported negative changes to their spousal relationship, including the quality of communication within the partnership,^{18, 19} higher marital dissatisfaction^{1, 20} and reduced sexual intimacy.^{1, 7, 21, 22}

Understanding the impact of childhood cancer on the parental relationship is important given the central role this relationship plays in family functioning and cohesiveness.³ Social-ecological frameworks of disease specify how parental and wider family functioning may in some cases be impacted by, and impact, a child's cancer course.^23-25 A positive family environment characterised by higher cohesion, and lower conflict, has been associated with better adjustment in children to a childhood cancer diagnosis.^26-28 Conversely, marital dysfunction has been found to adversely affect the psychological wellbeing of parents,^{29, 30} with the potential to directly and indirectly impact children.³

Intimacy is central to positive partner relationships. It encompasses emotional, social, sexual and intellectual components,³¹ is positively correlated with marital satisfaction^32-34 and has been found to act as an effective buffer against stress.^{29, 35, 36} Satisfaction with sexual intimacy has also been found to increase perceived relationship quality and in turn reduce instability in spousal relationships over the longer term.³⁷ In the context of childhood cancer, parents with higher levels of emotional attachment and affection in their spousal relationship have been found to have more positive marital adjustment in terms of coping with emotional distress.³⁸

Quantitative and qualitative studies to date have mainly focused on exploring the impacts of childhood cancer on parents’ marital functioning by examining parents’ experiences as individuals^{10, 35, 39} and by assessing levels of marital satisfaction,^{21, 29, 36, 38, 40} and coping mechanisms.^{8, 29, 38, 41, 42} Few studies have investigated childhood cancer's impact on parents’ perceptions of their intimacy, especially sexual intimacy, and intimacy in the period shortly after completion of their child's cancer treatment. This study aims to bridge this gap in knowledge, thereby informing psychosocial support for parents of children affected by cancer. We used a qualitative approach to investigate parents’ perceptions of the impact that their child's cancer had on their partner relationship, focusing on emotional and sexual intimacy.

2 METHODS

3 RESULTS

3.2 Impact of childhood cancer on parents’ relationship

Our analysis derived four main themes and 12 subthemes characterising the impact of childhood cancer on parents’ perceptions of emotional and sexual intimacy within their partner relationship (Figure 1 and Table 4).

TABLE 4. Themes and subthemes with illustrative quotes

Theme	Subtheme	Quotes
Emotional distance	Shifted focus	‘Umm the kids took a lot of focus, but in saying that, the kids took a lot of focus for both of us. We did grow apart ….’ (mother of an 8-year old, 28 months post treatment) ‘I don't like to talk about myself too much, I'd rather just talk about the two kids that—the two people in our lives that matter the most…’ (mother of a 10-year old, 11 months post treatment)
	Different coping styles	‘I was in my own little bubble, and he was trying to get in there, into that bubble, but I wasn't really interested. I just wanted to get through it on my own… Everyone copes with things differently and that's what we realised. We realised that he wanted to have more attention and wanted to talk to me and talk about things, and whereas I wanted to not talk about it and just get on with it’. (mother of a 3-year old, time post treatment unknown) ‘I think it was easy way out for him to just switch off from it all and that really hurt because the times when I needed him was when he wasn't there’. (mother of an 11-year old, time post treatment unknown)
	Physical separation	‘I think at the time of his diagnosis management, [marital relationship] strained in many ways because you don't see each other, and we tended to be passing like ships in the night. Not certainly what you call a normal relationship when you're dealing with a child with a serious illness’. (father of a 13-year old, 4 months post treatment)
Loss of sexual intimacy	Physical exhaustion	‘I mean, we were in hospital. When you're not, you're bone tired at the end of the night. You've worked through everything that needed to be done that day, you had a kid that's just been through surgery…’ (mother of a 4-year old, 17 months post treatment) ‘You're spending large quantities of your life in hospital, and when you get home and into your own bed, you just go to sleep’. (mother of a 7-year old, 12 months post treatment)
	Practical constraints	‘Obviously when you're at [charity accommodation] all in one room together, it's virtually impossible. And when he'd come up [to the hospital] and when we were at my mum and dad's house, obviously that's not possible. Like I said, you know to be able to find some time when they're all asleep…It's not an easy thing to do’. (mother of a 2-year old, 23 months post treatment) ‘The fact that I was spending so many nights obviously away from my wife, I think out of the eight months that [child] was in and out of hospital, I think I spent about 10 or 15 nights at home. So it doesn't allow for much time to be intimate…’ (father of a 4-year old, 9 months post treatment)
	Not a priority	‘I would say at the beginning, it kind of feels a bit odd. Slightly wrong to be doing that, when your daughter's in the room next door going through what she's going through… I spoke to other parents about that and they were the same’. (mother of a 7-year old, 12 months post treatment) ‘I remember thinking I will never be able to smile again…It took a long, long time before you could consider anything that was joyful. You know, we were in a completely different head space…’ (mother of a 5-year old, 21 months post treatment)
Strengthening of the relationship	Support from partner	‘I think looking back we did extraordinary well through such a horrific time. He was very involved so it wasn't completely all on my shoulders’. (mother of a 6-year old, 12 months post treatment) ‘I guess looking back before this happened I was still as supportive of him. We're quite a good team, when one of us is down the other one picks up the slack and then if the other one's down the other one just picks up’. (mother of a 4-year old, 6 months post treatment)
	Coping as a team	‘I think it actually brought us a bit closer as a team…We kind of support each other, and we just did what we had to do. I guess you see each other in a different light and I probably saw the softer side of him and supportive side of him and the stronger side as well’. (mother of a 15-year old, 27 months post treatment)
	External help	‘Fortunately, we were both strong enough to get through that and we had plenty of other people around that had concerns for our wellbeing and how we were’. (mother of a 4-year old, 17 months post treatment) ‘I think straight after [diagnosis], we just kind of coasted along while [child] was getting his treatment. Then afterwards was when it kind of hit us. So we went through a bit of a rough patch and went to counselling and things. But yeah we're fine now’. (mother of a 3-year old, time post treatment unknown)
Other life stressors	Pressures of child rearing	‘The kids took a lot of focus for both of us. We did grow apart, but we're both also of the thinking that you know marriage is hard work anyway’. (mother of an 8-year old, 28 months post treatment)
	Existing relationship problems	‘I think there is not much intimacy anyway so from there I don't know whether that umm comes with the picture but I guess you know general exhaustion and things, I don't know. [Child's diagnosis] compounded the existing situation maybe….’ (mother of a 6.5-year old, 20 months post treatment)
	Mental health challenges	‘We were probably having difficulties prior to the diagnosis with his mental health issues’. (mother of a 2-year old, 23 months post treatment) ‘It wasn't a good time. He was suffering quite severe depression’. (mother of an 11-year old, time post treatment unknown)

4 DISCUSSION

This study sought to examine the impact of childhood cancer on parents’ relationships, with a focus on emotional and sexual intimacy. We did this through a semi-structured interview with parents in the early years following their child's cancer treatment. Many parents in the study reported a decline in both emotional and sexual intimacy with their partner, which sometimes persisted beyond their child's cancer treatment. Key contributors to these changes included parents shifting their focus to prioritise their child's wellbeing over their own and their partner's needs, as well as practical and physical constraints associated with their child's treatment. Physical exhaustion and discord arising from different coping styles also contributed. Despite reports of emotional and sexual distancing, many parents acknowledged their relationship was strengthened as a result of their child's cancer experience.

Parents’ reports of compromised emotional intimacy align with findings from previous studies. Negative changes to emotional intimacy are especially common during intense periods like diagnosis and treatment.^{36, 40, 53} Most previous studies suggest that intimacy issues largely resolve over the long-term,^{36, 53} yet our results indicated that for some parents they continued through the early years after treatment. Physical separation due to hospital stays and in some cases geographical distance made it difficult for couples to maintain effective communication and share the psychological burden of caring for their child, both of which have been associated with low levels of marital satisfaction in a child's early survivorship.⁹ These challenges are likely exacerbated by the ‘tyranny of distance’ in Australia, with families from rural and remote locations typically having to travel long distances to access tertiary care. Challenges associated with physical separation are likely to have been further exacerbated by the COVID-19 pandemic in recent years, with increased logistical complexity around caregivers accessing and visiting hospitals, and the movement of individuals between households. Previous research indicates that perceived difficulty meeting a partners’ emotional needs, lack of emotional closeness and negative perception of closeness are associated with long-term relationship strain.^{8, 36, 53, 54} Our findings highlight the value of providing support for families, which reduces the need for physical separation and facilitates parents sharing the demands of caring for their child during treatment (e.g., treating children closer to home, providing families with access to accommodation close to treatment centres, which allows more than one parent to stay).

Our results concerning the decreased frequency of parents’ sexual intimacy builds on the small number of studies in this area.^{1, 7, 20} Parents in the current study generally did not perceive this change as problematic. This is congruent with previous research that suggests that emotional intimacy may be more valued by parents, and is a better predictor of relationship satisfaction than sexual intimacy.^{33, 55} Although decreased sexual intimacy during times of stress is commonly reported by parents, studies to date have not provided an in-depth understanding of the underlying causes in the context of childhood cancer. Parents in our study expressed that they found sexual intimacy incongruent with their child's pain and suffering and described a reluctance to prioritise themselves and their own needs. From parents’ reports, we found no evidence of functional sexual difficulties, or reduced sexual pleasure, highlighting the impact of the stressors associated with childhood cancer on psychological rather than biological aspects of parents’ sexual relationship. Our findings may be useful to normalise changes to sexual intimacy for parents of children affected by childhood cancer.

Crucially, not all parents experienced negative impacts on their relationship with their partner. Some parents demonstrated resilience through coping together as a couple, sharing responsibilities and seeking external support. Consistent with previous studies, parents in our study described benefiting from practical support and encouragement from their partner,^{4, 56, 57} with several parents reporting that the experience of childhood cancer strengthened their relationship. The positive relationship outcomes expressed by some parents in our study align with research suggesting the experience of childhood cancer can lead to positive adjustment and psychological growth in some family members.^{58, 59} Nevertheless, our finding that many parents were experiencing additional life stressors outside their child's cancer experience, including significant mental health challenges, speaks to the importance of thorough psychosocial assessment by healthcare professionals. Such assessment should incorporate broader stressors impacting on parents’ lives, including the short- and long-term impacts of the COVID-19 pandemic, as well as identifying and considering current supports available to them.

This study is one of few to explore the impact of childhood cancer on parents’ emotional and sexual intimacy. Using PAIS, a well-validated semi-structured interview tool,^{46, 47} our findings provide an important ‘snapshot’ of parents’ functioning in their child's early survivorship. While most participants in our study were parents of children who completed cancer treatment in the last 5 years, some completed treatment as long as 10 years ago. This heterogeneity may have impacted our findings in a number of ways as the challenges parents experience can both ease with time^{60, 61} or become established and/or worsen.^{10, 62} Although generalisability is not typically the aim of qualitative research, we acknowledge that this study does not capture all parents’ experiences. Parents who self-selected to participate in Cascade may have differed in terms of their functioning and/or psychological distress from other parents of childhood cancer survivors. Indeed, parents’ ratings on the Emotion Thermometers Tool at baseline indicates that our sample was not highly distressed. As is common in paediatric research, we experienced difficulties recruiting fathers, likely resulting in a less nuanced understanding of fathers’ perspectives.^{4, 63-65} The relative over-representation of mothers may have influenced our findings, as mothers may express more psychological and/or marital distress than fathers,² as well as having different perspectives on intimacy.⁶⁶

Further, our sample only included one parent dyad, and our narrow definition of the family environment, with a focus on cohabiting partners, precluded us from exploring the perspectives of divorced and separated couples, nor parents who were widowed or single and may have had a partner living separately. We acknowledge that families can be diverse in structure, and that parents who did not fit our study inclusion criteria may also experience disruption to their emotional and sexual intimacy in the context of their child's cancer diagnosis. Finally, the requirement that parents be able to speak English in order to participate also limited the involvement of parents from culturally and linguistically diverse backgrounds. Future research should include perspectives from culturally and linguistically diverse as well as more structurally diverse families, parents living separately from their partner, and parents who have separated/divorced. Future research should also focus on recruiting more parent dyads, address the challenge of recruiting fathers, and explore the issue of relationship strengthening directly.

5 CONCLUSION

While many parents described negative impacts on the emotional and sexual intimacy resulting from their child's cancer experience, some also perceived a strengthening of their relationship. We identified several factors that contributed to decreased emotional and sexual intimacy, knowledge that may be valuable for healthcare professionals providing support for couples navigating their child's cancer experience. Our findings suggest that it may be useful to support parents to successfully navigate situations in which each of them react and cope differently, as well as encouraging couples to invest in strengthening their relationship as being protective for the whole family unit as well as contributing towards self-care.

CONFLICT OF INTEREST

The authors hereby declare there are no conflicts of interest.