Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Abstract

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Fig. 1:. Comprehensive assessment of sexual and gender minorities for sexual dysfunction.

Assessing sexual dysfunction in a patient is multifactorial. It is imperative to understand a patient’s gender identity, birth recorded sex, sexual orientation; sexual behavior and role (top, bottom, versatile, side), comorbidities that could influence sexual function (e.g. vascular disorders, heart disease, depression), medications and substances that could impair sexual function (e.g. SSRIs), patient’s relationship status and psychosocial support, as well as disease characteristics and treatment selection.

Figure 2:. Patient centered conversations based on sexual role.

At consultation inquire about the sexual role of a patient. A patient’s sexual role can influence treatment recommendations, guide conversations, and, when applicable, impact shared decision making. While discussing all treatment-related sexual dysfunctions is important, particular toxic effects of interest include—top: erectile dysfunction, penile changes, anejaculation, dysorgasmia as it relates to the penis, libido; versatile: anodyspareunia, erectile dysfunction, penile changes, anejaculation, dysorgasmia as it relates to the penis and prostate, libido; bottom: anodyspareunia, anejaculation, dysorgasmia as it relates to prostate sensation, libido; and side: climacturia, erectile dysfunction, penile changes, anejaculation, libido. Additionally at consultation and again at follow up, physicians should explain the implications of changing sexual role, the contraindication of combining alkyl nitrites (‘poppers’) with PDE-5 inhibitors, and the time course of abstinence from engaging in receptive anal intercourse with sexual and gender minorities.

Figure 3:. Patient centered consultation guidance for patients with prostate cancer.

To guide patient centered conversations about prostate cancer treatment selection, physicians should inquire about gender identity, sexual orientation, sexual practices, sexual role, gender affirming hormone therapy, gender affirming surgery (specifically genital reconstruction surgery). Answers to these questions will guide patient centered treatment conversations that align with sexual role, sexual orientation, and gender identity and allow for informed treatment selection.