Sexual dysfunction and the preservation of manhood: experiences of men with prostate cancer

A longitudinal analysis of sociodemographic and health correlates of sexual health among HIV-infected men in the USA

BACKGROUND

Sexual health among HIV-infected men primarily has been examined in cross-sectional designs. Few have used longitudinal data to measure sexual health change or factors associated with change. Moreover, studies of HIV-infected men disproportionately focus on sexual risk behaviours. The present paper examines temporal changes in sexual health based on measures of sexual activity, erectile function, sex drive, and sex life satisfaction.

METHODS

Data from a prospective cohort study of HIV-infected men (n = 197) in the USA were used. Sexual health measures were based on self-reported sexual activity, erectile function, sex drive, and sex life satisfaction at 12- and 24-month follow-ups. Transition matrices described 1-year sexual health changes. Logistic regression models determined sociodemographic and health-related factors associated with change.

RESULTS

Men reported considerable change in sexual health during the year-long observation interval. Among men who experienced change, younger age, cohabitation, and higher CD4 counts were associated with greater sexual activity over time. Men with more depression symptoms had lower erectile function over time, and higher education and higher income were protective against temporal declines in sex drive and satisfaction. Less disease comorbidity was associated with 1-year improvements in sex life satisfaction.

CONCLUSIONS

Some men in our sample experienced sexual health change, but stability was common for most. Temporal changes in sexual health varied according to age, cohabitation, education, income, and physical and mental health covariates. The present paper highlights the benefits of longitudinal investigations and multidimensional definitions of sexual health.

Passing through the wall: on outings, exodus, angels, and the ark

Classicists have argued that angels in Christian theology were modeled on the eunuchs of antiquity; with angels providing the same services to the Lord in Heaven that eunuchs provided to emperors on Earth. I apply this idea toward understanding the cherubim on the ark in Exodus 25 and the death of Aaron's sons in Leviticus 10. I also suggest that the angel-eunuch analogy can help us understand the psychological impact of androgen deprivation therapy on modern prostate cancer patients. Appreciating this analogy can help prostate cancer patients accept and adapt to the changes they experience.

Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn

Receiving a diagnosis of and treatment for prostate cancer often results in significant physical side-effects and associated psychosocial stressors that can interfere with the experience of sexual intimacy for couples. Despite the fact that prostate cancer affects mainly older men, the maintenance of sexual intimacy is an important issue to consider, as the majority of older adults continue to value, engage in, and enjoy sexual activity throughout their lives. While the current research identifies the challenges that many men face, little is known about the strategies that couples use to successfully maintain sexual intimacy after prostate cancer treatment. In this review article, the existing literature on sexual intimacy after prostate cancer is reviewed, a critical analysis of current limitations in our knowledge and understanding is provided, and directions for further research are suggested.

No less a man: reconstructing identity after prostate cancer

Few diagnoses present as great a challenge to one's life as cancer. Many men each year are confronted with a diagnosis of early stage prostate cancer and find themselves making decisions about treatment in the face of side effects that present often devastating effects, including problems controlling one's urine and an inability to perform sexually. In this paper, we explore the narratives of men who, having chosen and undergone treatment for early stage prostate cancer, are living with the consequences. Faced with what Charmaz calls an 'identity dilemma', how do these men linguistically construct their identities in the face of challenges to their bodily, personal, and social integrity? Drawing upon theories of social languages and Discourses, we examine how men linguistically resolve the identity dilemmas they encounter and in turn construct an identity in response to a question about the quality of their lives in the face of the adverse event of prostate cancer. We present an analysis of the interview narratives of two men and show how they 're-collage' an identity in the face of fundamental changes in their functioning as men. We argue that these men draw upon alternative discourses to construct themselves as whole, competent, and 'no less a man'.

How Prostate Cancer Support Groups Do and Do Not Survive: British Columbian Perspectives

Many prostate cancer support groups (PCSGs) have formed in North America during the past decade, yet their operation or factors influencing sustainability are poorly understood. This article reports micro (intragroup), meso (intergroup), and macro (group/structure) analyses drawn from the fieldwork and participant observations conducted for an ethnographic study of PCSGs based in British Columbia, Canada. The findings indicate that effective group leadership is integral to group sustainability and the recruitment and retention of attendees. At the meso level, intergroup connections and communication were often informal; however, the primary purpose of all the PCSGs was to provide information and support to men and their families. Many PCSGs were uncertain how formal associations with cancer fund-raising societies would influence group effectiveness. Macro issues such as prostate cancer activism resided with individual group “champions” through activities coordinated by provincial and national PCSG organizations. However, activism did not guarantee group sustainability. The study findings reveal why some groups flourish while others appear untenable, and form the basis for discussion about how PCSG sustainability might be best achieved.

Eunuchs in Contemporary Society: Expectations, Consequences, and Adjustments to Castration (Part II)

INTRODUCTION

There are men in the Western world who are voluntarily castrated and are not male-to-female transsexuals.

AIMS

We surveyed members of this group to understand their responses to androgen deprivation (AD) and how their experiences matched their expectations of AD.

METHODS

We posted a questionnaire on the Eunuch Archive (http://www.eunuch.org) that received responses from 92 voluntarily orchiectomized males who identified as eunuchs. Data from this questionnaire were supplemented with interviews with 19 of the eunuchs.

MAIN OUTCOME MEASURES

Participants completed questionnaire items regarding: (i) the side effects they expected and experienced; (ii) their current physical and psychological condition; (iii) their level of regret; (iv) what they appreciated most about their castrated status; and (v) who performed their orchiectomies.

RESULTS

The most appreciated aspect of castration was the sense of control over sexual urges and appetite (52%). The major side effects experienced were loss of libido (66%), hot flashes (63%), and genital shrinkage (55%). The population had high self-rated sociability, and mental and physical health. Although there was an insignificant reduction in depression after castration, the overall level of self-reported obsessive-compulsive disorders decreased significantly (P < 0.01). Twenty-two percent of the population reported a change in sexual orientation. Many respondents (60%) took supplemental hormone treatments to counteract the side effects of AD. The use of both supplemental testosterone and high-dose estrogen correlated with a significant increase in self-reported sexual desire and activity above the agonadal level (P < 0.001). The majority of the castrations (53%) were not performed by medical professionals.

CONCLUSION

The medical community needs to be aware of men at risk of unsafe castrations in order to provide them with more information on the side effects of AD and access to safe orchiectomies.

Restoration of satisfying sex for a castrated cancer patient with complete impotence: a case study

We present a first-hand account of a fully impotent, testosterone-suppressed prostate cancer patient who has satisfying, multiorgasmic sex using a strap-on dildo. We use his narrative to examine dildos as an alternative to erectile dysfunction treatments for men, such as this patient, who find selective inhibitors of PDE-5 ineffective and surgical intervention unacceptable. We explore what conditions allowed this man to progress from suspicious distrust of the dildo to full acceptance. In terms of making a dildo acceptable to other patients, we contrast offering it to them as a penile prosthesis in a formal medical setting versus treating it as a toy in fantasy sex play. Last, we present a neurobiological hypothesis involving sensory integration to help explain why sex with the strap-on dildo can be satisfying to a male.

The sexuality and social performance of androgen-deprived (castrated) men throughout history: implications for modern day cancer patients

Androgen-deprivation therapy (ADT) via either surgical or chemical castration is the standard treatment for advanced prostate cancer (PCa). In North America, it is estimated that more than 40,000 men start ADT each year. The side effects of this treatment are extensive and include gynecomastia, erectile dysfunction, and reduced libido. These changes strongly challenge patients' self-identity and sexuality. The historical term for a man who has been castrated is 'eunuch', now a pejorative term implying overall social and sexual impotence. In this paper, we review key historical features of eunuch social performance and sexuality from a variety of cultures in order to assess the validity of contemporary stereotypes of the androgen-deprived male. Data were taken from secondary sources on the history of Byzantium, Roman Antiquity, Early Islamic societies, the Ottoman Empire, Chinese Dynasties, and the Italian Castrati period. This cross-cultural survey shows that castrated men consistently held powerful social positions that yielded great political influence. Many eunuchs were recognized for their loyalty, managerial style, wisdom, and pedagogical skills. Furthermore, rather than being consistently asexual and celibate, they were often sexually active. In certain cultures, they were objects of sexual desire for males, or females, or both. Collectively, the historical accounts suggest that, given the right cultural setting and individual motivation, androgen deprivation may actually enhance rather than hinder both social and sexual performance. We conclude that eunuch history contradicts the presumption that androgen deprivation necessarily leads to social and sexual impotence. The capabilities and accomplishments of eunuchs in the past gives patients on ADT grounds for viewing themselves in a positive light, where they are neither socially impotent nor sexually chaste.

Embodied masculinity and androgen deprivation therapy

This paper describes the findings from an ethnographic study of 16 Anglo-Australian men treated with androgen deprivation therapy (ADT) for advanced prostate cancer. Utilising a social constructionist gendered analysis, participants' experiences, particularly in relation to embodied masculinity, are described in the context of reduced testosterone that accompany ADT. The findings indicated that participants reformulated many ideals of hegemonic masculinity in response to functional body changes. However, hegemonic masculinity strongly influenced participants' philosophical resolve to "fight" prostate cancer. The findings are considered in broader ongoing debates about essentialist sex and the social construction of gender.

'Sex for life'? Men's counter-stories on 'erectile dysfunction', male sexuality and ageing

Discourse on male sexuality in mid-to-later life has exploded in recent years (Gullette 1998). Attention to this topic has been spurred by the advent of (highly profitable) sexuopharmaceutical 'solutions' to erectile changes affecting older men. 'Success' stories abound in the media and in medical literature related to the restoration of faulty erections and ailing sex lives through drugs such as Viagra (sildenafil citrate), Uprima (apomorphine) and Cialis (tadalafil). In this paper we explore some of the ways in which notions about ageing and male sexuality are changing in popular cultural and medical texts in response to the advent of Viagra and the increasing authority of biomedicine in this area. We also demonstrate how the recent biomedical endorsement of 'sex for life' (the imperative to maintain an active youthful masculine [hetero]sexuality - defined in terms of male orgasm through penetrative sex) may be challenged by the very accounts of older men who are, or have been, affected by erectile difficulties and have used drugs like Viagra themselves. We present the perspectives of mid-to-late life heterosexual men in New Zealand whose stories question the contemporary biomedical privileging of erections and intercourse 'at any cost and at any age'. We argue that the current push to identify and treat so-called erectile dysfunction (and restore erections and penetrative sex to relationships) neglects some men's own experiences of alternative modes of relating sexually that they identify as 'normal', 'healthy', 'enjoyable' and 'satisfying' for them and their partners; and undermines their understanding of such changes as positive outcomes of ageing, experience and maturity.

SEXUAL DYSFUNCTION AFTER RADICAL PROSTATECTOMY: PREVALENCE, TREATMENTS, RESTRICTED USE OF TREATMENTS AND DISTRESS

PURPOSE

Cancer of the prostate (CAP) is one of the most common malignancies affecting North American men with about 215,000 new cases and 35,800 CAP related deaths annually. The most prevalent intervention for localized CAP is radical prostatectomy (RP) with 10-year survival rates approaching 90%. Studies of men in post-RP recovery indicate that 44% to 75% experience sexual dysfunction and more than 60% experience distress in reaction to sexual dysfunction problems. These findings are increasingly significant as prostate specific antigen testing continues to increase CAP detection rates, resulting in more and younger post-RP patients confronting sexual dysfunction.

MATERIALS AND METHODS

A MEDLINE database search was performed for articles published from 1966 to September 2004.

RESULTS

Despite effectiveness 30% to 50% of patients who turn to sexually assistive aids after RP discontinue use within a year. This suggests that the achievement of physical responsiveness to an aid is necessary but it is not a sufficient factor in long-term sexual adaptation. Current research exploring this gap between effectiveness and ongoing use supports a broader perspective of sexual dysfunction emphasizing several factors, including perceptions of inadequacy, anxieties in regard to performance and depression in each member of the couple, overly enthusiastic expectations, partner physical/emotional readiness to resume active sex, the meaning to the couple of using a sexual aid and the quality of the nonsexual relationship of the couple.

CONCLUSIONS

Our findings reveal the need to explore broader strategies for improving patient coping ability and adaptation. They also point to the need to explore the role of resumed satisfying sexuality in overall quality of life following treatment.

Constructions of masculinity following prostatectomy-induced impotence

Large numbers of Australian men are diagnosed and treated for prostate cancer each year. The incidence is exceeding mortality, and men are living longer with prostate cancer and the common treatment[s] side effect of impotence. Despite these epidemiological trends there is little research about men's experiences of impotence following treatment. An ethnographic study of Anglo-Australian men with localized prostate cancer explored participants' experiences of impotence following prostatectomy. In-depth semi-structured interviews with 15 men were analyzed using a social constructionist gendered framework. In particular, the effect of impotence on participants' masculinity, sexuality and intimate relationships was explored. The findings show that participants rationalized forgoing potency prior to surgery as a way of living longer. However, diverse complex reactions accompanied impotence. Whilst most participants redefined masculine ideals of phallocentric sex, the way in which this occurred varied greatly. The findings disrupt essentialist constructions of male sexuality and impotence, and provide valuable insight for clinical practice.

Facing erectile dysfunction due to prostate cancer treatment: perspectives of men and their partners

A well-known side effect of prostate cancer treatment is erectile dysfunction. However, little is known about how men and their sexual partners think about the threat of erectile dysfunction prior to prostate cancer treatment. Twenty-one patients who had been diagnosed with early prostate cancer, but not yet treated, and 13 female partners of these men were recruited from two urologists' offices. In separate, semistructured individual interviews with men and their partners, thoughts about the threat of erectile dysfunction were solicited. Men's reactions to the possibility of losing their sexual capacity due to prostate cancer-related treatment were linked to their current level of sexual function. Women reacted to erectile dysfunction by stressing the existence of other relationship dimensions, whereas they were aware about the gravity of their male partners' feelings about potency. Finally, both men and women alike had concerns about the implications of erectile dysfunction on their relationship. Physicians advising men about treatment options should consider exploring men's current sexual function, thoughts about identity, and especially men's relationship situation. Physicians addressing these issues with men and their partners should provide resources for counseling.

The downside of Viagra: women's experiences and concerns

While much is known about the efficacy and safety of sexuopharmaceuticals used by men for the treatment of erectile difficulties, there remains a dearth of knowledge on the perspectives and experiences of their sexual partners. In particular, few studies have focused on the possible detrimental effects for women of Viagra use within a heterosexual relationship. In this paper we report on a qualitative study based in New Zealand, which involved in-depth interviews with 27 women whose partners used Viagra. A number of key dimensions were identified, three of which revealed issues and concerns for women regarding the use of Viagra by their male partners: the neglect of women by those producing and prescribing Viagra; the embodied relationship (which encompasses physical and psychosocial effects of Viagra use); and broader socio-cultural implications (e.g the impact of 'the culture of Viagra' on understandings about sexuality in older age, and on ideas about male and female sexuality). We argue that while previous medically-oriented research in this area has generally assumed an unproblematic link between Viagra use and the resumption of penetrative sex within heterosexual relationships, more attention needs to be paid to partners' perspectives and desires, and to the specific dynamics of any given relationship. Moreover, while the publicity surrounding Viagra may potentially facilitate more positive attitudes to sexuality in older age, it may also produce a societal expectation that 'healthy' and 'normal' life for older people requires the continuation of 'youthful' (energetic) sex lives focused on penetrative intercourse.

Measuring patients' perceptions of the outcomes of treatment for early prostate cancer

BACKGROUND

Compared with careful attention to the physical (eg, urinary, bowel, sexual) dysfunction that may follow treatment, little attention has been given to the behavioral, emotional, and interpersonal changes that the diagnosis of early prostate cancer and subsequent physical dysfunction may bring.

OBJECTIVE

To construct patient-centered measures of the outcomes of treatment for early prostate cancer.

RESEARCH DESIGN

Qualitative study followed by survey of early prostate cancer patients and group of comparable patients with no history of prostate cancer. Analysis of focus groups identified relevant domains of quality of life, which were represented by Likert scale items included in survey questionnaires. Psychometric analyses of survey data defined scales evaluated with respect to internal consistency and validity.

RESULTS

Qualitative analysis identified three domains: urinary control, sexuality, and uncertainty about the cancer and its treatment. Psychometric analysis defined 11 scales. Seven were generically relevant to most older men: urinary control (eg, embarrassment with leakage), sexual intimacy (eg, anxiety about completing intercourse), sexual confidence (eg, comfort with sexuality), marital affection (eg, emotional distance from spouse/partner), masculine self esteem (eg, feeling oneself a whole man), health worry (eg, apprehensiveness about health changes), and PSA concern (eg, closely attending to one's PSA). Four scales were specific to the treatment experience: perceived cancer control, quality of treatment decision making, regret of treatment choice, and cancer-related outlook.

CONCLUSION

The scales provide definition and metrics for patient-centered research in this area. They complement measures of physical dysfunction and bring into resolution outcomes of treatment that have gone unnoticed in previous studies.