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

Nature Reviews Urology volume 20, pages 332–355 (2023)Cite this article

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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.

Key points

  • Pleasurable receptive anal and neovaginal intercourse occur through the stimulation of the prostate, surrounding pelvic anatomy, and supplying neurovasculature, including branches of the pudendal, pelvic splanchnic and hypogastric nerves.

  • Sexual dysfunctions following prostate cancer treatment experienced by sexual minority men (SMM) include problematic receptive anal intercourse, erectile dysfunction, climacturia, anejaculation, decreased penile length, and changes in orgasm.

  • SMM with prostate cancer should be counselled regarding different treatment-related toxicities depending on their role-in-sex (top, bottom, versatile, side).

  • Anal dilators (to assist with receptive anal intercourse), vacuum pumps (to induce stronger erections for insertive intercourse) and penile constriction rings (to manage climacturia) should be discussed with SMM.

  • Gender minorities with prostate cancer are a heterogeneous cohort with a range of anatomy and hormonal milieu, requiring a nuanced and detailed conversation when discussing treatment options and relevant toxicities.

  • Consultations about prostate cancer with sexual and gender minorities should include counselling on the resumption of receptive anal intercourse, condom use, HIV pre-exposure prophylaxis and anal douching.

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Fig. 1: Anatomy of pleasurable anal intercourse.
Fig. 2: Genitopelvic neuroanatomy of pleasurable anal and neovaginal intercourse.
Fig. 3: Biopsychosocial assessment of sexual health and treatment-related sexual dysfunction.
Fig. 4: Pathophysiology of treatment-related sexual dysfunction in sexual minority men with prostate cancer.
Fig. 5: Patient-centred conversations based on role-in-sex.
Fig. 6: Patient-centred consultation guidance for patients with prostate cancer.
Fig. 7: Anatomy of pleasurable neovaginal intercourse.

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Acknowledgements

Research reported in this publication was supported by the Office of The Director, National Institutes of Health under Award Number DP5OD031876. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Daniel R. Dickstein, Eric J. Lehrer, Richard Stock & Deborah C. Marshall

  2. Department of Radiology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA

    Collin R. Edwards

  3. Department of Pulmonology, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA

    Elizabeth S. Tarras

  4. Department of Radiation Oncology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA

    Matthew Gallitto

  5. Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    John Sfakianos

  6. Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Matthew D. Galsky

  7. Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Joshua D. Safer

  8. Division of Epidemiology and Community Health, School of Public Health at University of Minnesota, Minneapolis, MN, USA

    B. R. Simon Rosser

  9. Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Deborah C. Marshall

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Contributions

D.R.D., B.R.S.R. and D.C.M. researched data for the article. D.R.D. wrote the manuscript. All authors made a substantial contribution to the discussion of content and reviewed and edited the article before submission.

Corresponding author

Correspondence to Daniel R. Dickstein.

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Competing interests

M.D.G. declares research funding from Bristol Myers Squibb, Novartis, Dendreon, AstraZeneca, Merck and Genentech and is a paid advisory board consultant for Bristol Myers Squibb, Merck, Genentech, AstraZeneca, Pfizer, EMD Serono, SeaGen, Janssen, Numab, Dragonfly, GlaxoSmithKline, Basilea, UroGen, Rappta Therapeutics, Alligator, Silverback, Fujifilm and Curis. The other authors declare no competing interests.

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Glossary

Anodyspareunia

Painful receptive anal intercourse.

Bottom

The receptive partner in anal intercourse; although this term has also been generalized in sexual minority culture to include the receptive partner in oral intercourse.

Neoclitoris

A reconstructed or created clitoris.

Neovagina

A reconstructed or created vagina.

Outercourse

A subjective term usually referring to sexual intimacy and pleasure that does not include penetration.

Poppers

Alkyl nitrites, which are inhalants used to relax anal musculature used for receptive anal intercourse.

Role-in-sex

The role a person identifies with during sexual intercourse (for example, top, bottom, versatile, side).

Sexual and gender minority

Individuals who identify as lesbian, gay, bisexual, transgender, gender diverse, asexual, queer and intersex as well as those who do not but whose sexual orientation, gender identity or reproductive development varies from traditional, societal, cultural or physiological norms.

Sexual identity

Refers to a person’s identity more broadly in terms of sexual intercourse and relationships.

Side

A sexual minority man who does not engage in anal intercourse or identify with ‘topʼ, ‘bottomʼ or ‘versʼ.

Top

The insertive partner in anal intercourse; although this term has been generalized in sexual minority culture to also include the insertive partner in oral intercourse.

Vers

Or verse, short for ‘versatile’, a person who engages in both the receptive and the insertive role in intercourse.

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Dickstein, D.R., Edwards, C.R., Lehrer, E.J. et al. Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer. Nat Rev Urol 20, 332–355 (2023). https://doi.org/10.1038/s41585-023-00778-3

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