It is estimated that one in eight men will be diagnosed with prostate cancer in his lifetime. The disease is so prevalent, and other than skin cancer, it is the most common cancer diagnosed in American men. According to the American Cancer Society, this year, about 268,490 new cases of prostate cancer will be diagnosed, and nearly 35,000 men will die of the disease.1
Standard-of-care treatment options, including active surveillance, surgery, radiation therapy, hormone therapy, chemotherapy, and immunotherapy, are the same for all men diagnosed with prostate cancer. However, the side effects, such as urinary incontinence, erectile dysfunction, diminished libido, and loss of ejaculate, may impact gay and bisexual men differently than heterosexual men, especially psychologically and emotionally. So, the approaches to oncology care for gay and bisexual patients should be tailored to accommodate their needs, explained Channa A. Amarasekera, MD, Assistant Professor of Urology at Northwestern University Feinberg School of Medicine and Director of the Gay and Bisexual Men’s Urology Program at Northwestern Medicine in Chicago. The program, which opened in August 2021, is the first urology clinic to specialize in care for gay and bisexual men in the United States.
Channa A. Amarasekera, MD
“When I was a urology resident, I noticed that some gay and bisexual men expressed their frustration at not being able to openly discuss their sexual health issues with their medical providers,” said Dr. Amarasekera. “As a result, they sometimes disengaged from their care teams, and that negatively affected their treatment. I knew that gay and bisexual men needed a place where they felt safe to talk about their sexuality and how it plays a role in their overall and urologic health. So, in the summer of 2021, we opened the Gay and Bisexual Men’s Urology Program at Northwestern Medicine.”
In a wide-ranging interview with The ASCO Post, Dr. Amarasekera discussed how prostate cancer and its treatment may affect gay and bisexual men differently from heterosexual men, the importance of asking patients about their sexual orientation, and how oncologists can help their gay and bisexual patients regain their sexual health after prostate cancer.
Increasing Medical Training in Sexual Health for Gay and Bisexual Men
Please talk about why a new approach was needed in the treatment of prostate cancer for gay and bisexual men and how your approach differs from other clinicians?
What our research in lesbian, gay, bisexual, transgender, and queer (LGBTQ) health shows is that many mainstream clinicians have a blind spot generally when it comes to health care for sexual minority patients, particularly regarding urologic health in gay and bisexual men.
Side effects from prostate cancer treatment...may impact gay and bisexual men differently than heterosexual men, especially psychologically and emotionally.— Channa A. Amarasekera, MD
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Although providers may be well intentioned, their medical training is often limited to just 5 hours on the treatment of this patient population. What we found is that gap in training sometimes inadvertently creates tensions between these patients and their physicians, which often leads to substandard care. So, we created the Gay and Bisexual Men’s Urology Program to help address this unmet need.
Understanding How Cancer Treatment Affects Sexual Function in Gay and Bisexual Men
Posttreatment side effects—including urinary incontinence, erectile dysfunction, diminished libido, and loss of ejaculate—are common for all patients with prostate cancer. How does treatment and the aftermath of prostate cancer impact gay and bisexual men differently from heterosexual men?
The biology of prostate cancer is certainly the same for gay, bisexual, and straight men. However, the differences in how the cancer may affect patients come to light when you think about treatment and counseling. First, the prostate can be an organ of sexual pleasure during receptive anal intercourse for this patient population. If you remove the prostate or radiate it, there is the potential for a loss of pleasure for men who engage in this sexual activity.
Another difference is that ejaculate may play a more significant role in sex between men. There is a lot of research showing that men having sex with men focus on ejaculate as a sign of good sex. It may be erotized more than it is with heterosexual men. Consequently, if the ejaculate is diminished, it could diminish the psychological pleasure derived from sex for gay men. Those are two common psychological problems we see with a prostate diagnosis and treatment in this patient population.
However, there can be other concerns about treatment side effects as well, especially for the partner of these patients. For example, if a patient receives low-dose–rate brachytherapy, which involves implanting radioactive seeds within the prostate gland, the partner’s penis may absorb some of the radiation dose during receptive anal intercourse, which can be dangerous for the partner.
Providing Resources to Restore Sexual Health
Please talk more about how the lack of medical training and lack of research in the treatment of LGBTQ patients may contribute to the dissatisfaction they may feel regarding the attention paid to their sexual needs. How can oncologists improve their knowledge about the sexual health of this patient population and the sexual health of heterosexual patients as well?
I think oncologists, urologists, and physicians in general tend to have a difficult time talking about sexual health because it is a sensitive topic. It requires a lot of time and trust, which is difficult to develop within the constraints of a clinical encounter.
Gay and bisexual men need a place where they feel safe to talk about their sexuality and how it plays a role in their overall and urologic health.— Channa A. Amarasekera, MD
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In terms of education, creating programs for practitioners about what is different about LGBTQ sexual health compared with heterosexual sexual health would be useful. In fact, we are creating a continuing medical education curriculum on LGBTQ health and sexual needs, so that is a start.
It would also be helpful for clinicians to have brochures on sexual health for sexual minorities. These tools may signal to patients that these clinicians are open to having that conversation and have resources available to all patients regardless of their sexual orientation.
Asking About Sexual Orientation
How can oncologists learn about the sexual orientation of their LGBTQ patients so as to ensure that the sexual health concerns of these patients are addressed?
Many patients diagnosed with prostate cancer are in their 60s or older and came of age in a very different time, when society was not as accepting of LGBTQ individuals. Many patients, regardless of their sexual orientation, are reluctant to talk about sex with their health-care provider, so if you do not ask about a patient’s sexual orientation, you can set up a “don’t ask, don’t tell” dynamic, which can be a problem.
The onus is on the physician to ask about sexual orientation, and there are two ways of doing it. Clinicians can put the question on the patient intake form, so it becomes a routine question every patient is asked, and patients can decide whether to check the box. The other solution is to ask the question, in a conversational and nonjudgmental way, during a medical exam as part of the patient’s sexual and medical histories.
How can oncologists more effectively communicate the side effects of prostate cancer treatment on the sexual health of gay and bisexual men to help them preserve their intimate relationships?
The first step is to let patients know that you are open to having that conversation by asking each patient about his or her sexual orientation. As I mentioned, currently, there is not a uniform patient intake form that includes a question about sexual orientation. However, having this information is important because many physicians assume patients are heterosexual and will counsel gay and bisexual men on the effects of prostate cancer treatment that might be more pertinent for heterosexual men. That could be isolating for patients who are gay or bisexual.
Knowing the information before meeting with the patient is helpful, because the physician can tailor his or her talk about treatment side effects based on the patient’s sexual orientation. Being curious to learn if or how treatment side effects may impact diverse patient populations differently is also helpful. Having resources within the clinic for referrals to sexual health experts who can counsel patients on preoperative or other pretreatment issues and what they can expect after treatment is also of benefit.
Karen M. Winkfield, MD, PhD
Making Informed Decisions
How is the Gay and Bisexual Men’s Urology Program helping patients regain their sexual and overall health after prostate cancer?
The most important change is that many patients meet with me before any type of treatment begins. This helps patients understand how each treatment could potentially impact their sexual function, and they get to make an informed decision about what they want to do. That is empowering for patients, because they have some say regarding how they want to proceed and an understanding of how treatment will impact their sexual life and life in general going forward.
After treatment, the clinic provides a safe place for patients to talk about how their sexual function has been affected, and it helps oncologists understand how to help their patients regain their sexual health.
DISCLOSURE: Dr. Amarasekera reported no conflicts of interest.
1. American Cancer Society: Key Statistics for Prostate Cancer. Available at www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed September 26, 2022.