A lecture on sexuality in cancer patients and survivors was recently delivered at our cancer center. Comments were made that it can be embarrassing to ask about sex. The palliative care team noted that similarly it was embarrassing to talk about death and suggested there might be a connection between sex and death. This insight was received with some Freudian resistance.

The palliative care service posited the following hypothesis: that sexual activity neutralizes or is an antidote to death, in biological, philosophical, and psychological realms. Sex symbolically reminds us of death – and then rescues us. This paper will explore the possible connections between sex and death in the cancer and palliative care settings.

Embarrassment is a self-conscious emotion, frequently grouped with shame and guilt. The embarrassed person becomes aware of a breach, real or imagined, of social etiquette or of a taboo. The embarrassment then acts as a form of internal feedback to modify behavior. Sexual relations is an intimate and vulnerable activity, highly controlled by societal norms. As is death. Neither of these – or any topic for that matter – is intrinsically embarrassing. The hesitation and embarrassment of the doctor in broaching a subject reflects his or her sensitivities. Any question on any subject can be asked if addressed courteously and in accordance with the medical ethical principle of beneficence (Varkey Reference Varkey2021).

What is the relationship between sex and death? Other than the obvious (that sex results in birth resulting in death) there is no direct cause and effect. (Sex games that go wrong might be considered an exception). The wider association is implicit and persuasive. There are many examples that support the association between sex and death. We will list several in support of our hypothesis.

The French language describes orgasm as “le petite mort,” the small death. Ostensibly this relates to postcoital sleep. There is an opinion that sleep is equivalent to one-sixtieth of death (Talmud). On another level, a vital part of our life force has been spent. For example: millions of male spermatozoa die with each orgasm that is designed to renew life. We are the lesser.

Baby booms typically occur after periods of extensive death in society. The classic example in recent times was in the West during the 1950s and 1960s after World War II. Powerful subliminal sexual urges arise to replace the dead. Yet there are societies today whose populations are shrinking or dying, because they no longer create enough children to replace the dying. In the West today, in general, contraception and the apotheosis of the individual have split the connection between sex and procreation.

Lifton coined the expression “symbolic immortality” (Lifton Reference Lifton1973). He noted that humans use objects or events in our lives that symbolically keep us alive after we die in order to defeat death. For example, we publish books, we belong to eternal religions, or we have children who have children who have children. We have examples of patients with cancer who prefer not to have anticancer treatment in order to preserve virility and fertility, even if only symbolically, even if it might shorten their lives. Instincts can be stronger than logic.

Sex can be a pathological, neurotic response to the fact or threat of death – necromancy, sexual violence, betrayal (affairs) (Wein Reference Wein2012), fetishes, and promiscuity (Goldenberg et al. Reference Goldenberg, Cox and Pyszczynski2002). A patient reported to me that she once had an abortion. She felt uneasy afterward. Her response was 6 months of extreme promiscuity. Later she understood the connection. Sex was atoning for death, symbolically. She never had children. Death and sex clashed.

The two strongest instinctual drives in man are to reproduce and to avoid death. Death is the price multicellular creatures pay in order to reproduce. In indirect support of this, a movie commentator noted that the enduring success of the James Bond franchise was the contrasting combination of sex and death.

During the sexual act, energy is dispersed and therefore increases entropy. Procreation, the aim of the sexual act, is anti-entropic, although in most instances this is not the outcome of coitus. In general, the force of life reverses entropy by building, healing, and creating. Death is the result of increasing entropy, which is the natural state of the physical universe in which everything tends to greater disorganization (Asimov Reference Asimov1956).

Nevertheless, life is not a polar opposite of death. Nor is sex. Rather they are on a spectrum of entropy, with greater and lesser degrees of disorganization (Asimov Reference Asimov1956).

Where appropriate, sex and death should be asked about early in the disease process – professionally and without embarrassment. It might be that questions about sex are not relevant in the presence of impending death. Nevertheless philosophically and psychologically, the relationship between sex and death remains significant. Contemplating the two as a life narrative, (Viederman and Perry Reference Viederman and Perry1980), in terms of love and loss, of marriage and family, may help tie together the strands of a life story and create another layer of meaning.

John Donne, the great metaphysical poet, composed the poem, The Flea, in the 1590s. In an extended metaphor, Donne contrasts a flea, its life and death, with sexual relations.