Changes in sexual roles and quality of life for gay men after prostate cancer: challenges for sexual health providers

Caring for sexual and gender minority patients with genitourinary cancer: A primer for inclusive practices

Recognizing sexual orientation and gender identity (SOGI) is paramount in the management of genitourinary cancers, as sexual and gender minority (SGM) individuals encounter unique healthcare challenges leading to disparities. SGM patients often confront systemic barriers, provider biases, and scarcity of tailored resources, resulting in diminished satisfaction and adverse health outcomes. The evaluation and treatment of genitourinary cancers in SGM patients demand a nuanced, multidisciplinary approach that focuses on the unique health determinants often overlooked by the healthcare system. This review highlights recommendations for the inclusivity of SGM patients within the clinic, from inclusive signage to gender inclusive language. For the evaluation and treatment of SGM patients with genitourinary cancers, it is recommended to employ organ-based language, to utilize validated questionnaires encompassing mental health, sexual behavior, and patient-reported outcomes, and to provide timely referrals to social work and onco-fertility when appropriate. Ultimately, approaching inclusivity through education targeted at both SGM patients and healthcare providers is pivotal for centering care around the patient, improving the quality of life and outcomes for SGM patients facing genitourinary cancers.

Care Needs, Challenges, and Experiences of Sexual and Gender Minority Cancer Survivors in Taiwan: Findings from a Qualitative Study

OBJECTIVES

This study aimed to explore the care needs, challenges, and experiences of cancer care among sexual and gender minority (SGM) cancer survivors in Taiwan.

METHODS

Semi-structured interviews were conducted face-to-face or telephonically with 30 SGM cancer survivors in Taiwan. Data were analyzed using the socio-ecological model and the constant comparative technique. The study used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

RESULTS

The needs, challenges, and experiences of cancer care among SGM cancer survivors were categorized and presented according to the level of the social-ecological model: (1) intrapersonal level: physical and psychological impacts and changes in outlook on life after cancer diagnosis and treatment; (2) interpersonal level: informal social support resources and challenges for developing intimate relationships; (3) community level: formal social support resources and lack of SGM support groups; and (4) societal and policy level: positive and negative experiences with oncology healthcare providers (HCPs), sexual orientation disclosure, and lack of an SGM-friendly environment.

CONCLUSIONS

Multilevel care needs and challenges in cancer care among SGM cancer survivors were identified. Oncology HCPs should be aware of and assess SGM cancer survivors' psychosexual issues and psychological status and provide suitable care resources to individuals. Moreover, training courses on culturally competent cancer care and information on SGM-related health policies (including same-sex marriage) should be provided to oncology HCPs to improve their sensitivity, knowledge, and skills to provide suitable care for SGM cancer survivors.

IMPLICATIONS FOR NURSING PRACTICE

The study findings can be used to design and develop training courses for culturally competent cancer care for oncology HCPs to improve the quality of care and reduce cancer care disparities among SGM cancer patients.

Sexual outcomes in men who have sex with men who underwent radical prostatectomy

BACKGROUND

Sexual difficulties are a recognized consequence of prostate cancer (PCa) treatments. An estimated one in three men who have sex with men (MSM) receive PCa a diagnosis during their lifetime. MSM may experience all types of sexual dysfunction as reported in men who have sex with women (MSW), along with a number of more specific bothersome problems. This systematic literature review aims to evaluate sexual outcomes in MSM who have undergone radical prostatectomy (RP).

METHODS

A systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The searches were made using relevant keywords in the PubMed, Scopus, and Web of Science databases, thus including the whole literature from January 2000 to November 2023. Studies which did not allow to retrieve data on sexual outcomes on MSM treated with RP for PCa were excluded. Data on sexual outcomes and health-related quality of life (HRQoL) were retrieved, mostly including changes in libido, erectile function, ejaculatory disorders, orgasm, climacturia, changes in role-in-sex identity, changes in sexual partnerships, and the presence of painful receptive anal intercourses (AI).

PROSPERO ID

CRD42024502592.

RESULTS

Six articles met the inclusion criteria. In total, data of 260 patients were analyzed. Three main themes emerged: (a) MSM may experience specific sexual dysfunctions due to the different dynamics of their intimacy; (b) the lack of tool validated on gay and bisexual population to assess sexual outcomes (c) the need for a tailored approach that also takes into account sexual orientation throughout the oncological journey.

CONCLUSIONS

MSM undergoing RP may experience similar sexual problems as MSW. Painful AI should be considered a potential post-operative adverse outcome in MSM. Future studies should prioritize validating a questionnaire that explores AI. Healthcare providers should adopt a tailored approach that takes into account sexual orientation throughout the cancer journey.

Investigating the Needs and Concerns of Lesbian, Gay, Bisexual, Transgender, Queer, or Questioning Cancer Patients

The needs and concerns of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) patients with cancer remain poorly understood. This is important as LGBTQ+ patients have an elevated risk of developing certain cancers and have poorer oncologic outcomes compared to non-LGBTQ+ patients. The lack of research may be linked to the complexity of studying the needs and concerns of this patient population. This review aimed to describe the evidence that sought to identify the needs and concerns of LGBTQ+ cancer patients. Studies were extracted using keywords such as "LGBTQ" and "Oncology." Patient participants were excluded if they did not identify as LGBTQ+ and if they did not have cancer or were not cancer survivors. Healthcare professionals were excluded if they were not oncology specific. A total of 22 studies met our inclusion criteria. LGBTQ+ cancer patients expressed concerns surrounding heteronormative assumptions made by healthcare professionals, a lack of LGBTQ±specific cancer support groups, and psychosexual concerns such as erectile dysfunction following cancer treatment. Oncology healthcare professionals lacked the knowledge and education that are required to manage this patient cohort. Further research is required to investigate the needs and concerns of LGBTQ+ cancer patients specifically in the radiation oncology setting.

Heteronormative biases and distinctive experiences with prostate cancer among men who have sex with men: a qualitative focus group study

BACKGROUND

Men who have sex with men (MSM) face many challenges and biases in healthcare. Within urology there is a need to better understand how prostate cancer impacts MSM given the unique ways in which side effects that accompany treatment may affect this population. The goal of this study is to explore the experience of MSM with prostate cancer to advance the existing literature in this area and inform implementation and delivery of clinical practice and policy guidelines.

METHODS

Four focus groups were conducted with a semi-structured interview guide. Using a phenomenological qualitative approach consistent with grounded theory [1] and naturalistic inquiry principles we sought to better understand the direct experiences of MSM with prostate cancer. Audio transcriptions were thematically analyzed to identify themes that impact MSM throughout their prostate cancer journey. An iterative, team-wide classification process was used to identify, organize, and group common codes into higher-order categories and themes.

RESULTS

Patient's choice of provider and their interactions with the healthcare system were strongly impacted by their sexual identities. Participants commented on navigating the heteronormative healthcare environment and the impact of assumptions they encountered. MSM experienced the sexual side effects of prostate cancer treatment in unique ways. Issues with erectile dysfunction and ejaculatory dysfunction had significant impacts on patient's sexual experience, with some describing being forced to explore new modes of sexual expression. Anejaculation was a theme that was distressing for many participants. The emotional impact of a prostate cancer diagnosis was significant in the men interviewed. Common themes included loss of identity and fear for future relationships.

CONCLUSIONS

MSM have unique concerns after prostate cancer treatment that differ from men who don't identify as MSM. It is critical that providers familiarize themselves with the concerns of this patient population regarding prostate cancer treatment. An important step toward reducing heteronormative bias in prostate cancer care is to better understand the goals, identity, and sexual practices of MSM and to provide informed anticipatory guidance.

Needs and experiences of cancer care in patients' perspectives among the lesbian, gay, bisexual, transgender and queer community: a systematic review

Individuals within the Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) community who are diagnosed with cancer experience inequitable treatment in healthcare systems worldwide, resulting in dissatisfaction, communication challenges with healthcare providers, and a deep sense of disappointment. Stigma, discrimination, and perceived homophobia further heighten the risk of psychological and attitudinal disorders, including depression and suicidal tendencies, among LGBTQ cancer patients. To comprehensively assess the discrimination faced by LGBTQ cancer patients and gain deeper insights into their needs and experiences, we conducted a systematic review following PRISMA guidelines. We searched for relevant articles using specific keywords in reputable databases such as PubMed, Google Scholar, and PsycINFO. We rigorously evaluated article quality using the CASP (Critical Appraisal Skills Programme) checklist. From a total of 75 eligible studies, we carefully selected 14 studies, specifically examining LGBTQ cancer patients who were currently undergoing or had previously undergone cancer treatment. The studies revealed various factors, including unmet needs related to anxiety and depression, instances of discrimination, disparities in care, and inadequate support systems. A majority of patients expressed dissatisfaction with their cancer care and continued to encounter discrimination and disparities throughout their treatment journeys. Consequently, this led to heightened levels of anxiety, stress, depression, and negative perceptions of healthcare providers. Based on these findings, we recommend providing specialized training to social workers and healthcare providers. This training will equip them with the necessary skills and knowledge to deliver culturally sensitive care tailored to the unique needs of LGBTQ cancer patients. By addressing discrimination, reducing disparities, and fostering an inclusive environment, healthcare professionals can strive to ensure that LGBTQ cancer patients receive the care they deserve.

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

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.

Disparities in health-related quality of life among lesbian, gay, and bisexual cancer survivors

OBJECTIVE

This study compared health-related quality of life (HRQOL) among lesbian, gay, and bisexual (LGB) cancer survivors and their heterosexual counterparts in a US population-based sample of cancer survivors.

METHODS

The study utilized data from the All of Us research program. LGB survivors (n = 885) were matched for age, gender identity, marital status, income, education, and cancer site with heterosexual survivors (n = 885) using 1:1 propensity matching. Physical, mental, and social HRQOL were assessed with items from the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

Relative to heterosexuals, LGB cancer survivors reported lower HRQOL in mental and social domains, but not in physical HRQOL. Older age was associated with higher HRQOL across domains. LGB survivors identifying as Black/African American were more likely to experience lower social HRQOL than White survivors.

CONCLUSIONS

This study highlights several disparities in HRQOL that exist between LGB and heterosexual cancer survivors.

Prostate Cancer in Sexual Minorities: Epidemiology, Screening and Diagnosis, Treatment, and Quality of Life

Prostate cancer has the highest incidence among all cancers in men. Sexual minorities, including gay and bisexual men, as well as transgender, were previously a "hidden population" that experienced prostate cancer. Although there continues to remain a paucity of data in this population, analyses from studies do not reveal whether this population is more likely to endure prostate cancer. Nonetheless, several qualitative and quantitative studies have established worse quality-of-life outcomes for sexual minorities following prostate cancer treatment. Increased awareness of this previously "hidden population" among healthcare workers, as well as more research, is warranted to gain further understanding on potential disparities faced by this growing population.

The Effects of Prostate Cancer Treatment on Role-In-Sex in Gay and Bisexual Men: Mixed Methods Results from the Restore-1 and Restore-2 Studies

Gay and bisexual men (GBM) with prostate cancer experience worse sexual and mental health outcomes following prostate cancer treatment than heterosexual men. Emerging evidence suggests that GBM may change their role-in-sex in response to treatment effects. The purpose of this study was to describe the impact of prostate cancer treatment on role-in-sex, to estimate the prevalence of such changes, and to determine the impact on quality of life and mental health. We conducted semi-structured interviews with 30 sexual minority prostate cancer patients. Then, we recruited 401 gay and bisexual prostate cancer patients into a study assessing the effects of rehabilitation. Qualitative data were analyzed using descriptive thematic analysis. Differences in quality of life and mental health outcomes were analyzed using multivariate analyses of variance. Prostate cancer treatment resulted in loss of role-in-sex for many patients. When changes in role-in-sex occurred, the shifts were predominantly from tops to bottoms. Those with a current top role-in-sex had significantly better sexual and mental health outcomes than either versatiles or bottoms. Clinical implications include the need for providers to ask about role-in-sex in order to address disparities in health outcomes by sexual orientation and to provide culturally appropriate care to sexual minority patients.

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update

PURPOSE

To update the American Society of Clinical Oncology guideline on the management of anxiety and depression in adult cancer survivors.

METHODS

A multidisciplinary expert panel convened to update the guideline. A systematic review of evidence published from 2013-2021 was conducted.

RESULTS

The evidence base consisted of 17 systematic reviews ± meta analyses (nine for psychosocial interventions, four for physical exercise, three for mindfulness-based stress reduction [MBSR], and one for pharmacologic interventions), and an additional 44 randomized controlled trials. Psychological, educational, and psychosocial interventions led to improvements in depression and anxiety. Evidence for pharmacologic management of depression and anxiety in cancer survivors was inconsistent. The lack of inclusion of survivors from minoritized groups was noted and identified as an important consideration to provide high-quality care for ethnic minority populations.

RECOMMENDATIONS

It is recommended to use a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity. All oncology patients should be offered education regarding depression and anxiety. For patients with moderate symptoms of depression, clinicians should offer cognitive behavior therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or empirically supported psychosocial interventions. For patients with moderate symptoms of anxiety, clinicians should offer CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should offer cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. Treating clinicians may offer a pharmacologic regimen for depression or anxiety for patients who do not have access to first-line treatment, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved following first-line psychological or behavioral management.Additional information is available at www.asco.org/survivorship-guidelines.

Discrimination of Sexual and Gender Minority Patients in Prostate Cancer Treatment: Results from the Restore-1 Study

This study is the first to quantify experiences of discrimination in treatment undertaken by sexual and gender minority prostate cancer patients. Participants were 192 gay and bisexual and one transgender prostate cancer patients living in the US recruited from North America's largest online cancer support group. In this online survey, discrimination in treatment was measured using the Everyday Discrimination Scale (EDS), adapted for medical settings. Almost half (46%) endorsed at least one item, including 43% that the provider did not listen, 25% that they were talked down to, 20% that they received poorer care than other patients, 19% that the provider acted as superior, and 10% that the provider appeared afraid of them. While most (26.3%) rated the discrimination as "rare" or "sometimes" (EDS=1-3), 20% reported it as more common (EDS≥4). Most attributed the discrimination to their sexual orientation, or to providers being arrogant or too pushed for time. Discrimination was significantly associated with poorer urinary, bowel, and hormonal (but not sexual) EPIC function and bother scores, and with poorer mental health (SF-12). Those who had systemic/combined treatment (versus either radiation only or surgery only) were more likely to report discrimination. This study provides the first evidence that discrimination in prostate cancer treatment, including micro-aggressions, appear a common experience for gay and bisexual patients, and may result in poorer health outcomes.

Sexual quality of life following a cancer diagnosis: a qualitative study

Sexual quality of life (SQoL) challenges are prevalent and persistent for people with a cancer diagnosis. Using a qualitative design, this study investigated the impact of a cancer diagnosis on SQoL in participants (N = 18) with a current or past cancer diagnosis of various sites and severity. Thematic analysis identified three themes: gender attachment, vulnerability, and growth vs. fixed mindset. The theme of gender attachment related to the impact of understanding SQoL based on heteronormative definitions of masculinity and femininity. The second theme of vulnerability suggested that pre-existing relational or personal challenges can amplify the impact of a cancer diagnosis on SQoL. The third theme of growth vs. fixed mindset explored how cognitive flexibility and optimism can support SQoL, while a rigid and pessimistic mindset can exacerbate SQoL challenges. The findings of this study build on the traditional medical understanding of SQoL and can inform SQoL support in cancer care settings.

Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel

BACKGROUND

Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships.

AIM

We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.

METHODS

The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).

OUTCOMES

Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.

RESULTS

The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.

CLINICAL IMPLICATIONS

The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.

STRENGTHS & LIMITATIONS

The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.

CONCLUSION

The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.

LGBTQI cancer patients' quality of life and distress: A comparison by gender, sexuality, age, cancer type and geographical remoteness

Background

There is growing acknowledgement of the psycho-social vulnerability of lesbian, gay, bisexual, transgender, queer and/or intersex (LGBTQI) people with cancer. The majority of research to date has focused on cisgender adults with breast or prostate cancer.

Study Aim

This study examined psycho-social factors associated with distress and quality of life for LGBTQI cancer patients and survivors, across a range of sexualities and gender identities, intersex status, tumor types, ages and urban/rural/remote location using an intersectional theoretical framework.

Method

430 LGBTQI people with cancer completed an online survey, measuring distress, quality of life (QOL), and a range of psycho-social variables. Participants included 216 (50.2%) cisgender women, 145 (33.7%) cisgender men, and 63 (14.7%) transgender and gender diverse (TGD) people. Thirty-one (7.2%) participants reported intersex variation and 90 (20%) were adolescents or young adults (AYA), aged 15-39. The majority lived in urban areas (54.4%) and identified as lesbian, gay or bisexual (73.7%), with 10.9% identifying as bisexual, and 10.5% as queer, including reproductive (32.4%) and non-reproductive (67.6%) cancers.

Results

Forty-one percent of participants reported high or very high distress levels, 3-6 times higher than previous non-LGBTQI cancer studies. Higher rates of distress and lower QOL were identified in TGD compared to cisgender people, AYAs compared to older people, those who identify as bisexual or queer, compared to those who identify as lesbian, gay or homosexual, and those who live in rural or regional areas, compared to urban areas. Elevated distress and lower QOL was associated with greater minority stress (discrimination in life and in cancer care, discomfort being LGBTQI, lower outness) and lower social support, in these subgroups. There were no differences between reproductive and non-reproductive cancers. For the whole sample, distress and poor QOL were associated with physical and sexual concerns, the impact of cancer on gender and LGBTQI identities, minority stress, and lack of social support.

Conclusion

LGBTQI people with cancer are at high risk of distress and impaired QOL. Research and oncology healthcare practice needs to recognize the diversity of LGBTQI communities, and the ways in which minority stress and lack of social support may affect wellbeing.

Affirming Care for Sexual and Gender Minority Prostate Cancer Survivors: Results from an Online Training

Sexual and gender minority people have unique, unaddressed healthcare needs following prostate cancer. The research team along with a group of established subject matter experts developed a training and companion materials for healthcare professionals to address this need. Post-assessment evaluation was reported in frequencies and percentages by combining results from learners who attended an original, live web-based training and learners who completed the same training on-demand via a Learning Management System. Learners from both the live and archived training reported that the training increased their knowledge to effectively work with sexual and gender minority prostate cancer survivors. Learners also reported gaining new resources and strategies they could apply to their work. Results indicate the training fills an educational gap for healthcare professionals and supports the need for additional training of healthcare professionals focused on the healthcare needs of SGM cancer survivors.

Prostate cancer disclosure and sexual orientation: Understanding outness to healthcare providers as a situational or consistent phenomenon

OBJECTIVE

In this study, we investigated if outness is more a situational or a consistent characteristic in gay, bisexual, and other men who have sex with men (GBM) treated for prostate cancer and how the disclosure of sexual orientation impacts provider discussions of sexual side effects.

METHODS

Data came from Restore, an online cross-sectional survey of 193 GBM prostate cancer survivors living in North America and were analyzed using various statistical models.

RESULTS

Disclosure of sexual orientation and of living with prostate cancer were not significantly correlated. Participants who were out regarding sexual orientation were more likely to report that their surgeons and urologists discussed the sexual side effects of treatment.

CONCLUSION

Outness appears to be a situational phenomenon. GBM prostate cancer survivors who were out regarding sexual orientation received more discussion surrounding sexual side effects of prostate cancer treatment from their providers.

PRACTICE IMPLICATIONS

It is important for healthcare providers to inquire about patient's sexual orientation to provide holistic care to these patients to address health disparities within this group.

Recruiting an underserved, difficult to reach population into a cancer trial: Strategies from the Restore-2 Rehabilitation Trial for gay and bisexual prostate cancer patients

BACKGROUND/AIMS

Sexual minorities are small and under-researched populations that are at disproportionate risk for cancer and poor cancer outcomes. Described as a "hidden population," the principal research challenge has been to develop effective methods to identify and recruit such cancer patients into cancer studies. Online recruitment strategies, as well as targeted clinic recruitment using patient-entered sexual orientation and gender identity data from electronic medical records have potential to transform recruitment, but studies testing the effects of how to recruit using these have not been published.

METHODS

In 2019, we conducted a naturalistic, three-arm, stratified prospective study to compare three recruitment strategies: (a) clinic based recruitment of prostate cancer patients from gay health and urology clinics; (b) directly from the gay community; and (c) online recruitment (through cancer support, sex/dating, and social sites). For each strategy, we estimated time, workload, and direct costs involved. To study how recruitment strategy may affect sampling, we tested for retention rates, demographic and outcome differences across sites. Using these methods, we successfully recruited 401 gay and bisexual prostate cancer patients into a randomized, controlled, 24-month trial testing an online sexual and urinary rehabilitation curriculum tailored for this population.

RESULTS

There were seven key results. First, it is possible to recruit substantial numbers of sexual minority men into prostate cancer studies provided online recruitment methods are used. Second, we observed big differences in dropout during study onboarding by recruitment source. Third, within online recruitment, the online sex/dating application (app) was the most successful and efficient, followed by the cancer support site, and then the social networking site. Fourth, while clinics were the cheapest source of recruitment, they were time intensive and low in yield. Fifth, the cancer support site and sex/dating app recruits differed by several characteristics, with the former being more rehabilitation-focused while the latter were younger and more sexually active. Sixth, we found almost no differences in outcomes across the three online recruitment sites. Seventh, because retention in online studies has been a concern, we confirm very low attrition at 3- and 6 months into the trial.

CONCLUSION

For sexual minority cancer research, more research on how to use sexual orientation and gender identity electronic medical record data for clinic-based recruitment is needed. For other small or hard-to-reach populations, researchers should compare and publish online versus offline recruitment strategies.

Sexual Dysfunction in Gay and Bisexual Prostate Cancer Survivors: A Concept Analysis

Sexual dysfunction is a common side effect of prostate cancer (PCa) treatment, yet it remains poorly defined in the literature. Current definitions are based on heteronormative assumptions which do not consider the unique experiences of gay and bisexual (GBM) PCa survivors. The purpose of this paper is to use Walker and Avant's method to conduct a concept analysis of sexual dysfunction among GBM in the context of PCa survivorship. The review included 46 articles published between 2002-2019. The following attributes were identified: (1) erectile dysfunction, (2) ejaculatory change (anhedonia/anejaculation), (3) urinary incontinence/climacturia, and (4) anodyspareunia. For GBM PCa survivors, sexual dysfunction involves reduced or abnormal functioning of four core elements of a sexual encounter, which inhibit GBM from engaging in and being satisfied with sexual activity.

Racial/Ethnic Differences in Health-Related Quality of Life Among Gay and Bisexual Prostate Cancer Survivors

Introduction

Prostate cancer treatment has established effects on the health-related quality of life (HRQOL) of patients. While racial/ethnic differences in HRQOL have been explored in heterosexual patients, this is the first study to examine racial/ethnic differences in a cohort of sexual minority prostate cancer survivors.

Methods

We used data from the Restore-1 study, an online cross-sectional survey of sexual and gender minority (SGM) prostate cancer survivors in North America, to explore the association between race/ethnicity and HRQOL. General mental and physical HRQOL was assessed using the Short-Form Health Survey version 2 (SF-12). The frequency and distress of prostate cancer specific symptoms was assessed using the Expanded Prostate Cancer Composite (EPIC) scale. Multivariable linear regression was used to estimate mean differences in HRQOL between sexual minority men of color and their white, non-Hispanic counterparts after adjustment for pertinent demographic and medical characteristics.

Results

Among 190 participants, 23 (12%) self-identified as non-white and/or Hispanic. In unadjusted analysis, sexual minority men of color compared to their white counterparts reported worse HRQOL scores in the EPIC hormonal summary (73.8 vs. 81.8) and hormonal function (70.9 vs 80.5) domains. Clinically important differences between men of color and their white counterparts were seen in the EPIC bowel function (mean difference (MD): -4.5, 95% CI: -9.9, 0.8), hormonal summary (MD: -8.0, 95% CI: -15.6, -0.4), hormonal function (MD: -9.6, 95% CI: -17.6, -1.6), and hormonal bother (MD: -6.7, 95% CI: -14.4, 1.1) domains. After adjustment for covariates, clinically important differences persisted between men of color and white, non-Hispanic men on the hormonal summary (74.4 vs. 81.7), hormonal function (71.3 vs. 80.3), and hormonal bother (77.0 vs. 82.7) domains.

Conclusions

This exploratory study provides the first evidence that sexual minority men of color may have worse HRQOL outcomes compared to white, non-Hispanic sexual minority men following prostate cancer treatment.

Divergent Perspectives of Filipino PLWH, Their Partners, and Care Providers on Sexuality After an HIV Diagnosis: A Q-Methodological Analysis

ABSTRACT

This study explores the perspectives that Filipinos with professional and personal experience with people living with HIV hold about sexuality after an HIV diagnosis. Twenty people living with HIV (PLWH), 11 partners of PLWH, and 10 HIV care professionals in the Philippines were asked to rank-order 54 statements about sexuality post-HIV diagnosis. They shared the reasoning behind their rankings on an online survey platform. By-person factor analysis was done, with factors extracted based on principal component analysis followed by varimax rotation. The analysis yielded six factors with 22 males' and 3 females' Q-sorts exemplifying the views regarding sexuality post-HIV diagnosis: to be human, is to be sexual; information is power; fear of being othered; partnership for enhanced sexuality; disclosure and trust; and communication is foundational. This study revealed diverse viewpoints about sexuality after an HIV diagnosis. HIV care professionals play a decisive role in addressing concerns relating to the sexual health and well-being of newly diagnosed PLWH.

An adapted cognitive behavioral stress and self-management (CBSM) intervention for sexual minority men living with HIV and cancer using the SmartManage eHealth platform: Study design and protocol. (Preprint)

Background

Objective

Methods

Results

Conclusions

International Registered Report Identifier (IRRID)

Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study

BACKGROUND

Existing measures of sexual functioning in prostate cancer survivors focus primarily on erectile function and do not adequately measure the experiences of sexual minority men.

AIM

To develop and psychometrically evaluate a new scale to measure sexual functioning among sexual minority men with prostate cancer.

METHODS

Sexual minority prostate cancer patients (n = 401) completed an online battery of urinary and sexual functioning tests in 2019, including a new 37-item instrument about their sexual functioning post-treatment for prostate cancer.

OUTCOMES

We used confirmatory factor analysis to determine the construct validity of a new scale including five subscales: a four-factor model for all participants (n = 401) evaluated Sexual Satisfaction, Sexual Confidence, Frequency of Sexual Problems, and Urinary Incontinence in Sex. A single-factor model completed only by participants who had attempted or desired receptive anal sex (n = 255) was evaluated in the fifth subscale: Problematic Receptive Anal Sex. To evaluate criterion validity, we calculated the intercorrelations between each Sexual Minorities and Prostate Cancer Scale (SMACS) subscale and four related scales: the Expanded Prostate Cancer Index Composite-50 (EPIC), the Functional Assessment of Cancer Therapy-Prostate, the Brief Symptom Inventory-18, and the International Consultation on incontinence questionnaire. Cronbach's alphas were calculated to measure internal consistency (ie, reliability).

RESULTS

Cronbach's alpha values ranged from 0.64 to 0.89. Loadings (0.479-0.926) and model fit indices were strong (Root Mean Square Error of Approximation: 0.085, Standardized root mean squared residual: 0.063, comparative fit index: 0.927, Tucker-Lewis Index: 0.907). For criterion validity, Sexual Satisfaction, Sexual Confidence, and Frequency of Sexual Problems were moderately correlated with EPIC function and bother scores (r = 0.50-0.72) and Urinary incontinence in sex correlated moderately with EPIC Urinary Function and International Consultation on incontinence questionnaire scores (0.45-0.56).

CLINICAL IMPLICATIONS

The SMACS can be used by clinicians and researchers to comprehensively measure sexual functioning in sexual minority men, in conjunction with existing scales.

STRENGTHS AND LIMITATIONS

This new scale is validated in a large, geographically diverse cohort of sexual minority cancer survivors and fills an important gap in existing measures of sexual functioning. Limitations include a lack of a validation sample.

CONCLUSION

The SMACS is a valid and reliable new scale that measures sexual minority men's experience of urinary incontinence in sex, problematic receptive anal sex, and sexual distress. Polter EJ, Kohli N, Rosser BRS, et al. Creation and Psychometric Validation of the Sexual Minorities and Prostate Cancer Scale (SMACS) in Sexual Minority Patients-The Restore-2 Study. J Sex Med 2022;19:529-540.

Health Disparities of Sexual Minority Patients Following Prostate Cancer Treatment: Results From the Restore-2 Study

PURPOSE

The NIH has identified sexual and gender minority persons as a health disparity population but little is known about cancer outcomes in these populations. The purpose of this study was to identify disparities in sexual minority prostate cancer patient-reported outcomes, to examine within group differences, and to test for alternative explanations for identified differences.

MATERIALS AND METHODS

In 2019, we recruited 401 gay and bisexual prostate cancer patients into the Restore-2 study, a randomized controlled trial of rehabilitation program tailored for sexual minority men.

RESULTS

Compared to the normative (heterosexual) EPIC sample, participants had significantly worse urinary, bowel and hormonal function, better sexual function, and no difference on bother scores. They also had worse depression and overall mental health, and worse physical, social/family, functional, prostate specific and overall well-being quality of life outcomes. Across measures, no differences by age, gay versus bisexual orientation, race/ethnicity, and relationship status were observed. Those who had hormonal treatment had worse sexual and hormonal function than those who had radiation or surgery only. Those with a longer time since treatment had better urinary function. Differences remained when participants were matched to normative samples on cancer stage and time since treatment.

CONCLUSIONS

This, the largest study of sexual minority prostate cancer patients to date, confirms health disparities in prostate cancer quality of life outcomes. Findings appear reliable and robust. To improve the clinical care of prostate cancer, it will be important to address the health disparities experienced by sexual minority prostate cancer patients.

Fear of cancer recurrence and PSA anxiety in patients with prostate cancer: a systematic review

PURPOSE

The impact of prostate cancer on the mental wellbeing of patients is increasingly being appreciated. Two important aspects of this include fear of cancer recurrence (FCR) and prostate-specific antigen (PSA) anxiety. However, their prevalence, severity and associating factors remain poorly understood. Therefore, this review aims to evaluate the current evidence for the prevalence, severity and associating features of PSA anxiety and FCR.

METHODS

A systematic search of MEDLINE, EMBASE and PsycINFO databases was conducted by two independent reviewers. Observational studies measuring FCR and PSA anxiety in prostate cancer using validated measures were included. Outcome measures were prevalence of significant levels, mean scores and significant correlations of FCR and PSA anxiety scores with patient, disease, treatment or other mental health and quality of life outcomes.

RESULTS

One thousand one hundred forty-eight individual records underwent screening with 32 studies included. Median prevalence of significant FCR and PSA anxiety was 16% and 22% respectively across all studies. Longitudinal studies demonstrated severity of both symptoms peaks at diagnosis, with little variability, even several years following this. Evaluating associating factors revealed younger age, generalised quality of life and mental health symptoms to be important factors for both outcomes. Few studies evaluated associations and differences between other patient, disease and treatment characteristics.

CONCLUSION

FCR and PSA anxiety are prominent symptoms for prostate cancer patients and importantly when present, are associated with poorer quality of life and mental health symptoms. Screening for these constructs and referral to appropriate services should form part of routine follow-up care.

Health service providers' perspectives on the influence of modern health systems on adolescents' sexual health practices in Umguza and Mberengwa districts of Zimbabwe

BACKGROUND

Health service providers play a significant role in crafting and implementing health policies and programs that manage adolescent sexual health-related issues at different health system levels. These influence adolescent sexual behaviours and practices.

AIM

This study explored the roles of health service providers in managing adolescent sexual issues and how this impacts their sexual behaviours and practices. The study further probed the health service providers on how the indigenous health system could be integrated into the modern health system for effective management of adolescent sexual health related issues.

METHODS

A qualitative cross-sectional survey was conducted on purposively selected health service providers in health facilities in Mberengwa and Umguza districts. Data was collected using unstructured interviews that were recorded, transcribed verbatim, and thematically analysed. Findings were presented as clearly defined as superordinate and subordinate themes.

RESULTS

A total of five superordinate themes and 19 subordinate themes emerged from the interrogated data. The superordinate themes were: overview of adolescent sexual health issues, role of modern health system in adolescent sexual health issues, challenges encountered, indigenous health system factors that could be factored into modern health systems, and strategies to foster the integration of indigenous health system and modern health system. The subordinate themes explored in-depth the findings of the key stakeholders under the five superordinate themes.

CONCLUSIONS

From the findings, it can be concluded that health service providers play an essential role in shaping and providing adolescent sexual health services that adolescents utilise despite challenges that have reduced demand for these services. Therefore, there is a need to point out that there is a window of opportunity to foster collaborations between the indigenous health system and the modern health system as they strive to serve the adolescents to the best of their ability though in different contextual settings.

Anxiety and Depression Status and Influencing Factors of MSM in the Post-COVID-19 Epidemic Period: A Cross-Sectional Study in Western China

This study aimed to explore the psychological status and influencing factors of men who have sex with men (MSM) during the stable period of the COVID-19 epidemic, to provide a reference for the mental health counseling of MSM, and to provide a scientific basis for this group to actively respond to public health emergencies. A cross-sectional survey was conducted on the demographic characteristics, epidemic experiences, risk perception, and COVID-19-related attitudes of MSM in western China, and MSM anxiety and depression were assessed by using the Anxiety Self-Rating Scale and the Center for Epidemiological Studies Depression (CES-D) Scale. The incidences of MSM anxiety and depression in the post-COVID-19 epidemic period are 21.7% and 38.0%, respectively. Logistic regression analysis showed that in terms of anxiety, high controllability of the epidemic (OR = 0.7616) is a protective factor. Thinking that they are more susceptible to COVID-19 (OR = 1.6168) and worrying about another outbreak of the epidemic (OR = 1.4793) are risk factors. In terms of depression, being able to protect themselves from being infected with COVID-19 (OR = 0.6280) is a protective factor. The role of anal sex as “0”/“0.5,” and believing that they are more susceptible to COVID-19 (OR = 1.3408) are risk factors. The sudden outbreak affected the psychological state of MSM and even caused negative feelings of anxiety and depression. These findings suggest that prevention and education should be strengthened, and effective intervention measures should be taken as soon as possible, to improve the mental health of MSM.

Comorbidity Prevalence and Impact on Quality of Life in Gay and Bisexual Men Following Prostate Cancer Treatment

Introduction

Studies have demonstrated worse health related quality of life (HRQOL) outcomes in gay and bisexual men (GBM) following prostate cancer treatment compared to heterosexual men potentially due to differences in comorbidity burden.

Aim

To establish the prevalence of comorbidities and their association with HRQOL metrics in GBM following prostate cancer treatment.

Methods

We evaluated HRQOL and prevalence of comorbidities in 193 GBM from the United States and Canada in a cross-sectional, online survey: the Masked for Review. HRQOL was measured with the Expanded Prostate Cancer Index Composite (EPIC) and the 12-Item Short Form Health Survey (SF-12).

Main Outcome Measures

Our outcomes included comorbidity prevalence, mean differences for HRQOL scores by comorbidity status, and mean differences for HRQOL by comorbidity count.

Results

GBM were found to have a higher prevalence of blood vessel disease and mental health disorders but lower prevalence of obesity and type 2 diabetes when compared to published data in general prostate cancer populations. Statistically significant reductions in HRQOL metrics were associated with mental health diagnoses, diabetes, and obesity. Increased number of comorbidities was also associated with reductions in HRQOL metrics in nearly all categories.

Conclusion

These results suggest that the worse QOL outcomes in GBM following prostate cancer treatment may be due to differences in comorbidity burden. This study is the first to evaluate the relationship between comorbidities and HRQOL outcomes in GBM. Limitations of this study include a small sample size and cross-sectional study design. If confirmed in larger, longitudinal, clinically confirmed studies, these findings indicate a need to intervene on and consider comorbidities in GBM diagnosed with prostate cancer.

Haggart R, Polter E, Ross M, et al. Comorbidity Prevalence and Impact on Quality of Life in Gay and Bisexual Men Following Prostate Cancer Treatment. Sex Med 2021;9:100439.

The Challenge of Coming Out to Providers by Gay and Bisexual Men With Prostate Cancer: Qualitative Results from the Restore Study

This study investigates the experience of communicating sexual orientation by gay, bisexual and men who have sex with men (GBM) to physicians involved in their prostate cancer care. Methodology consisted of qualitative analysis conducted on 30 in-depth interviews of GBM recruited from a national online cancer support site. Results revealed four key strategies around sexual disclosure. These ranged from explicitly outing themselves to selective or non-disclosure. Disclosures had unpredictable multiple outcomes ranging from increased trust in the patient-physician relationship to seeking alternate treatment. We concluded competent care is achieved when physicians know their patient's sexual orientation, and are trained in them.

Every urologist and oncologist should know about treating sexual and gender minority prostate cancer patients: translating research findings into clinical practice

In 2016, the NIH designated sexual and gender minorities (SGM) a health disparity population. The next year, the American Society of Clinical Oncology highlighted the need to improve the suboptimal cancer and survivorship care received by SGM populations. There are currently no evidence-based training programs in culturally competent care of prostate cancer patients who are gay, bisexual and/or transgender. In this selective review, we summarize findings from the largest quantitative studies focused on sexual minority prostate cancer survivors and from 65 interviews with NIH staff, clinicians, and cancer clinics in 11 US cities. The report is divided into three parts and uses a question and answer format to address 21 questions relevant to clinicians providing care to SGM prostate cancer patients. First, we identify population-specific issues that are culturally relevant in the care of SGM patients with prostate cancer. While a body of research has emerged on sexual minority prostate cancer patients, the literature on gender minorities is limited to single case reports and inadequate to inform practice. This review covers definitions, population size, cultural and historical context, sexual behavior, population invisibility, sexual orientation and gender identity (SOGI) in the electronic medical record, disparities and evidence of discrimination in treatment provision. The second part focuses on promoting evidence-informed, patient-centered care. This includes current practices in assessing sexual orientation, management of disclosure of sexual orientation, how to address common problems sexual minority men experience post-treatment, common questions sexual minority patients have, management of urinary incontinence, HIV and STI risk during and post-treatment, and sub-groups of sexual minority patients with worse outcomes. It then identifies how male partners differ in prostate cancer support, current research on rehabilitation for sexual minority men, issues in advanced prostate cancer, and things to avoid with minority patients. Finally, we examine the cultural divide between provider and patient, advocating for cultural humility when working with minority patients. Training programs and continuing education can help providers both to become more aware of their own cultural assumptions, informed about health disparities, and able to provide quality care, and to make clinics more welcoming to SGM patients.

Health outcomes of sexual and gender minorities after cancer: a systematic review

PURPOSE

Cancer research on sexual and gender minority (SGM) populations is gaining momentum. The purpose of this systematic review was to examine what is currently known in the research literature regarding patient-reported health outcomes after cancer treatment among SGM populations.

METHODS

In March 2021, a medical librarian conducted a systematic keyword search on PubMed, Embase, Scopus, Web of Science, PsycINFO, ClinicalTrials.gov , and the Cochrane Central Register of Controlled Trials. The primary inclusion criterion was assessment of at least one physical, psychosocial, emotional, or functional patient-reported health outcome related to the impacts of cancer diagnosis and/or treatment. Articles that met inclusion criteria were reviewed in their entirety, charted in a Word Table, and assessed for quality. Quality considerations included study design, sampling approach, diversity of sample, measures used, and analytic procedures. Studies were synthesized based on type of cancer study participants experienced.

RESULTS

Sixty-four studies were included in the final analysis: most were quantitative, secondary analyses or cross-sectional studies with convenience samples, and focused on people with a history of breast or prostate cancer. Differences between sexual minority men and women in terms of coping and resilience were noted. Few studies reported on experiences of transgender persons and none reported on experiences of intersex persons.

CONCLUSIONS

A growing literature describes the patient-reported health outcomes of SGM people with a history of cancer. This study summarizes important between-group differences among SGM and heterosexual, cisgender counterparts that are critical for clinicians to consider when providing care.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual orientation and gender identity are relevant to cancer survivors' health outcomes. Subgroups of SGM people have differential experiences and outcomes related to cancer and its impacts.

Health outcomes of sexual and gender minorities after cancer: a systematic review

PURPOSE

Cancer research on sexual and gender minority (SGM) populations is gaining momentum. The purpose of this systematic review was to examine what is currently known in the research literature regarding patient-reported health outcomes after cancer treatment among SGM populations.

METHODS

In March 2021, a medical librarian conducted a systematic keyword search on PubMed, Embase, Scopus, Web of Science, PsycINFO, ClinicalTrials.gov , and the Cochrane Central Register of Controlled Trials. The primary inclusion criterion was assessment of at least one physical, psychosocial, emotional, or functional patient-reported health outcome related to the impacts of cancer diagnosis and/or treatment. Articles that met inclusion criteria were reviewed in their entirety, charted in a Word Table, and assessed for quality. Quality considerations included study design, sampling approach, diversity of sample, measures used, and analytic procedures. Studies were synthesized based on type of cancer study participants experienced.

RESULTS

Sixty-four studies were included in the final analysis: most were quantitative, secondary analyses or cross-sectional studies with convenience samples, and focused on people with a history of breast or prostate cancer. Differences between sexual minority men and women in terms of coping and resilience were noted. Few studies reported on experiences of transgender persons and none reported on experiences of intersex persons.

CONCLUSIONS

A growing literature describes the patient-reported health outcomes of SGM people with a history of cancer. This study summarizes important between-group differences among SGM and heterosexual, cisgender counterparts that are critical for clinicians to consider when providing care.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual orientation and gender identity are relevant to cancer survivors' health outcomes. Subgroups of SGM people have differential experiences and outcomes related to cancer and its impacts.

Sexual Dysfunction in Men Who Have Sex With Men

INTRODUCTION

Historically, sexual health research has focused on men who have sex with women (MSW) and most research examining the sexual health of men who have sex with men (MSM) has focused on HIV transmission. Despite a high prevalence of sexual health disorders among MSM, there is limited research that has evaluated the diversity of sexual issues in these patients.

OBJECTIVES

The purpose of this review is to describe the unique sexual behaviors, concerns, and dysfunctions of MSM by evaluating the literature on sexual health in this specific patient population.

METHODS

A PubMed literature search was conducted through December 2020 to identify all relevant publications related to the sexual health, sexual practices, and sexual dysfunction of MSM. Original research, review articles, and meta-analyses were reviewed, including comparisons of sexual behavior and dysfunction between MSM and non-MSM populations and between gay/bisexual men and heterosexual men. Approximately 150 relevant articles were reviewed and 100 were included in the manuscript.

RESULTS

Minority stress can lead to an increase in high-risk sexual behavior, sexual dysfunction, and mental health disorders in MSM. MSM engage in a variety of sexual behaviors, which can lead to differences in sexual dysfunction, such as anodyspareunia during receptive anal intercourse. MSM have higher rates of erectile dysfunction than non-MSM counterparts. MSM have unique activators of sexual pathologies, such as insertive anal intercourse for Peyronie's disease. Prostate cancer treatment may cause MSM to change sexual roles and practices following treatment due to ED, anodyspareunia, or decrease in pleasure from receptive anal intercourse after prostatectomy.

CONCLUSION

MSM have been neglected from sexual medicine research, which translates to disparities in health care. Further research that focuses on the MSM population is necessary to better educate healthcare practitioners so that MSM patients can receive adequate care that is tailored to their specific needs. PJ Cheng, Sexual Dysfunction in Men Who Have Sex With Men. Sex Med Rev 2021;XX:XXX-XXX.

Prostate cancer and sexual consequences among men who have sex with men

Prostate cancer and its treatment frequently lead to sexual side effects that negatively impact personal identity, sexual function, and intimate relationships. The sexual consequences of prostate cancer treatment on men who have sex with men (MSM) differ in some ways from what is observed in heterosexual men. This review summarizes literature from the past two decades exploring how MSM are affected by, and adapt to, prostate cancer treatment. The evidence on whether prostate cancer has a lower prevalence in MSM is unclear but lower screening rates are well-documented within this population. Prostate cancer treatment affects urinary, bowel, and sexual function in both MSM and heterosexual men. These changes may have different sexual and psychological ramifications in MSM when compared to heterosexual men. A common concern among MSM treated for prostate cancer is absence of support, both from the medical profession and in some cases from their own communities. Many MSM with prostate cancer have developed coping strategies and altered sexual practices to accommodate side effects. Lessons learned from this population may have relevance to sexual wellness in non-MSM prostate cancer survivors. Concise recommendations for caring for MSM with prostate cancer are provided.

"Sex Can Be a Great Medicine": Sexual Health in Oncology Care for Sexual and Gender Minority Cancer Patients

Purpose of review

Until recently, sexual and gender minority (SGM) people have been largely invisible in health care and health services research. However, understanding the needs and experiences of SGM cancer patients is critical to providing high-quality care, including needs and experiences related to sexual health. In this narrative review, we highlight that the literature on sexual health for SGM people with cancer is lacking, summarize existing literature on disparities affecting SGM patients with cancer, and discuss factors associated with these disparities. We conclude with recommendations and suggestions for future research in this area.

Recent Findings

Emerging evidence suggests that SGM people are at a higher risk for breast, cervical, endometrial, HPV-related, and lung cancers, as well as poor cancer outcomes, due to behavioral risk factors and health care system factors (e.g. lower access to health care insurance, discrimination in non-affirming care settings, negative health care interactions with providers). Additional research suggests that lack of clear guidelines for cancer screening in SGM patients, particularly for transgender and gender diverse patients, negatively impacts cancer screening uptake among SGM people. A growing number of studies have suggested greater sexual challenges following cancer treatment for sexual minority men with prostate cancer, while other studies highlight positive outcomes for sexual minority women following cancer treatment, such as benefit finding and resilience. Research on transgender and gender diverse patients is lacking.

Summary

Collection of sexual orientation and gender identity data across clinical enterprises and population-based surveys, mandatory health care provider training on cultural and clinical competency with SGM patients, and additional research inclusive of and focused on SGM cancer patients are key strategies to advance evidence-based clinical cancer care for diverse SGM populations.

Comparing the Mental Health of Sexual Minority and Heterosexual Cancer Survivors: A Systematic Review

Purpose: Sexual minority (SM) individuals are more likely to experience mental health concerns than heterosexual individuals. However, little is known to date about the psychological needs of SM cancer survivors. The objective of this systematic review was to identify whether SM cancer survivors experience disparate psychological outcomes compared with heterosexual cancer survivors. Methods: PubMed/MEDLINE, PsycINFO, CINAHL, Web of Science, and ProQuest databases were searched systematically to identify studies that compared mental health outcomes between SM and heterosexual survivors. A standardized data extraction form was used to extract data from eligible articles. The Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to assess study quality. Results: Twelve studies met the inclusion criteria and assessed distress, depression, anxiety, perceived stress, and mental and emotional quality of life (QOL). Most studies enrolled survivors diagnosed either with female breast cancer or with prostate cancer. Most studies reporting on mental health among women found no differences between SM and heterosexual survivors. Studies conducted among men found that SM survivors experienced higher distress, depression, and anxiety, and lower emotional/mental QOL than heterosexual survivors. Conclusion: The findings of the present synthesis suggest that mental health disparities may exist among SM men diagnosed with cancer, particularly prostate cancer. More research is required to identify mental health disparities among SM survivors diagnosed with other cancers, as well as predisposing and protective factors. In addition, mental health screening and interventions are needed for SM men after cancer diagnosis.

The Sexual Functioning of Gay and Bisexual Men Following Prostate Cancer Treatment: Results from the Restore Study

Prostate cancer is the second most common cancer in gay, bisexual, and other men who have sex with men (GBM). Few studies have assessed the effects of treatment on GBM's sexual behavior. For an online survey, 193 gay and bisexual men with prostate cancer were recruited from the North American's largest online cancer support group. Sexual functioning was measured using the Expanded Prostate Cancer Index Composite (EPIC) and a tailored Gay Sexual Functioning Inventory (GSFI). GBM have worse EPIC urinary and hormonal function and worse hormonal bother, but better sexual function and bother scores than published norms. In the GSFI, two-thirds of participants described their sexual functioning, post-treatment, as fair to poor. Only 22% reported erections sufficient for insertive anal sex. For receptive anal sex, one-third met criteria for anodyspareunia. Over half reported urination problems during sex or at orgasm. Erectile difficulties were common, severe, and a reason cited for not using condoms. Three men HIV seroconverted post-prostate cancer treatment. Differences in function and bother scores were observed by type of treatment, age, race/ethnicity, sexual orientation, but not relationship status. Sexual functioning significantly predicted long-term mental and physical health. GBM scored significantly worse on mental health and better on physical health than published norms. Sexual recovery after prostate cancer treatment is problematic for most GBM. Research to develop more effective sexual recovery, tailored to the needs of GBM treated for prostate cancer, is needed. Six implications for clinicians treating GBM with prostate cancer are identified.

Aging and Sexual Health: A Cross-Sectional Survey of Patients in a Canadian Urban Academic Family Health Team

Primary care physicians are in a position to recognize sexuality as a core component of health. Data examining the sexual behaviours of Canadians over the age of 50 and the role of primary care in this domain is lacking. A cross-sectional survey was administered to patients over the age of 50, which assessed the importance of sexual activity, problems, and preferences in discussing sexual health with their primary care providers. A total of 39 per cent of patients indicated ongoing sexual activity and 52% of male participants reported current sexual activity compared with 25 per cent of females (p < 0.01). More males reported sexual activity as important than did females (69% vs. 45%, p < 0.01). Participants identifying sexual health concerns discussed physical dysfunctions more than emotional, social, or global health concerns (p < 0.01). More male participants discussed sexual health concerns with their family physician than did females (p < 0.01). The results of our study indicate that many individuals over the age of 50 continue to be sexually active, and that physical and non-physical concerns directly impact participation in sexual activity.

Prostate cancer in sexual minorities and the influence of HIV status

Prostate cancer is the second most common cause of cancer-related death in men in the USA, but the effect of prostate cancer diagnosis and treatment on men in a sexual minority group, including men who have sex with men and transgender women, is poorly understood. Efforts to study this population are complicated, as cancer registries do not routinely collect information on sexual orientation. As a result, epidemiological data regarding this population have come from small studies that have included disparate rates of prostate cancer screening, diagnosis and treatment. Qualitative studies indicate that prostate cancer is experienced differently by sexual minorities, with distinct health-care needs that arise owing to differences in sexual practices, social support systems and relationships with the medical community. Notably, sexual minorities have been reported to experience poorer health-related quality of life outcomes than heterosexual men, and tend to have less robust social support systems, experience increased psychological distress caused by sexual dysfunction (areas of which are unmeasured after treatment), experience isolation within the health-care system and express increased levels of dissatisfaction with treatment. The incidence of prostate cancer actually seems to be decreased in men from sexual minorities living with HIV, despite there being no differences in screening and treatment, with poor cancer-specific mortality. Although the literature on patients with prostate cancer in men from sexual minority groups has historically been sparse, peer-reviewed research in this area has grown considerably during the past decade and has become an important field of study.

Anxiety and Depression Associated with Anal Sexual Practices among HIV-Negative Men Who Have Sex with Men in Western China

This study aimed to explore the prevalence and influencing factors of anxiety and depression among human immunodeficiency virus negative (HIV-negative) men who have sex with men (MSM) based on anal sex roles, so as to provide a scientific basis for the management of mental health conditions. Data were obtained from the baseline in a cohort study with a two-year follow-up period in western China. The Self-Rating Anxiety Scale and Center for Epidemiological Studies Depression Scale were used to assess anxiety and depression symptoms, respectively. The prevalence of anxiety and depression in 1771 MSM was 26.03% and 37.83%. Among them, 182 anal sex role “0” MSM who only had receptive anal sex with men reported the highest prevalence of anxiety and depression (31.32% and 46.15%), 467 anal sex role “1” MSM who only had insertive anal sex with men (22.27% and 32.76%), and 1122 anal sex role “0.5” MSM who engaged equally in both insertive and receptive anal sex intercourse with men (26.74% and 38.59%), respectively. Logistic regression analysis revealed that the influencing factors of anxiety include anal sex role “0”/”0.5”, low educational level, female sexual partners, frequently searching partners on the Internet, sexually transmitted diseases (STD) diagnosed by doctors, and no HIV counseling. Anal sex role “0”/”0.5”, rural area, casual male partners, female partners, STD diagnosed by doctors, frequently searching partners on the Internet, no HIV counseling, no condom use, and daily alcohol use were found to be associated with depression. In conclusion, early identification and intervention of anxiety and depression symptoms in HIV-negative MSM should be carried out, especially for anal sex role “0” MSM. Furthermore, key intervention and psychological counseling should be taken into consideration for MSM with a low education level, high-risk behaviors, and high-risk perceptions.

Understanding Prostate Cancer in Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women: A Review of the Literature

PURPOSE OF REVIEW

a)Prostate cancer in sexual and gender minorities is an emerging medical and public health concern. The purpose of this review is to summarize the state of the science on prostate cancer in gay, bisexual, and other men who have sex with men (GBM) and transgender women (TGW). We undertook a literature review of all publications on this topic through February 2017. With 88 unique papers (83) on prostate cancer in GBM and 5 case reports of prostate cancer in TGW), a small but robust literature has emerged.

RECENT FINDINGS

b)The first half of this review critiques the literature to date, identifying gaps in approaches to study. The second half summarizes the key findings in eleven areas. In light of this admittedly limited literature, GBM appear to be screened for prostate cancer less than other men, but they are diagnosed with prostate cancer at about the same rate.

SUMMARY

c)Compared to other men, GBM have poorer urinary, bowel, and overall quality-of-life outcomes but better sexual outcomes after treatment; all these findings need more research. Prostate cancer in TGW remains rare and under researched, as the literature is limited to single-case clinical reports.

The Influence of Companion Animals on Quality of Life of Gay and Bisexual Men Diagnosed with Prostate Cancer

There has been almost no research on associations of companion animals with quality of life in sexual minorities. Because gay and bisexual men have less social support than their heterosexual peers, some have argued that pet companionship could provide emotional support, while others have argued the opposite, that having a pet is another stressor. This analysis examines the association between having dogs, cats, both animals, or no animals and quality of life using the 12-item Short Form (SF-12) mental and physical composite quality of life scores for gay and bisexual prostate cancer survivors, post-treatment. Participants were 189 gay, bisexual, or other men who have sex with men, who completed online surveys in 2015. Linear regression analysis found that participants with cats and participants with dogs had lower mental quality of life scores than participants without pets. After adjustment for covariates, mental health scores remained significantly lower for cat owners, dog owners, and owners of both animals compared to those of participants who did not have pets. No differences were seen for physical quality of life scores after adjustment. We conclude that pet companionship may be a net stressor for gay and bisexual men following prostate cancer treatment. As this is the first study of pet companionship in sexual minorities, further research is needed to confirm the reliability of these findings, generalizability, and temporality of the association.

Health-related quality of life by human immunodeficiency virus status in a cross-sectional survey of gay and bisexual prostate cancer survivors

OBJECTIVE

Prostate cancer is the most common invasive cancer in gay and bisexual men (GBM). Despite the unique sexual and urinary concerns of this group, studies of prostate cancer rehabilitation have primarily focused on heterosexual men. GBM also have high prevalence of human immunodeficiency virus (HIV), which may be associated with lower health-related quality of life (HRQOL). We examined the association between HIV status and HRQOL in a cohort of GBM with prostate cancer.

METHODS

Data from the Restore study, a cross-sectional online survey of GBM treated for prostate cancer, were used to examine this association. The Expanded Prostate Cancer Index Composite (EPIC) assessed function, bother, and summary measures in four domains: urinary, sexual, bowel, and hormone. Overall physical and mental HRQOL was assessed using the Short-Form Health Survey (SF-12). Multivariate analysis of variance and linear regression were used to evaluate the association between HIV status and HRQOL scores after adjustment for demographic and sexual characteristics.

RESULTS

Of 192 participants, 24 (12.4%) reported an HIV diagnosis. After adjustment for covariates, HIV-positive status was associated with lower scores on the EPIC urinary (mean difference [MD]: -13.0, 95% CI, -21.4 to -4.6), sexual (MD: -12.5, 95% CI, -21.9 to -3.2), and bowel (MD: -5.9, 95% CI, -11.7 to -0.2) domains. No significant associations were observed between HIV status and other outcomes.

CONCLUSIONS

HIV status may be associated with poorer urinary, sexual, and bowel HRQOL in GBM prostate cancer survivors.

Comparing the Mental Health of Sexual Minority and Heterosexual Cancer Survivors: A Systematic Review

Purpose: Sexual minority (SM) individuals are more likely to experience mental health concerns than heterosexual individuals. However, little is known to date about the psychological needs of SM cancer survivors. The objective of this systematic review was to identify whether SM cancer survivors experience disparate psychological outcomes compared with heterosexual cancer survivors. Methods: PubMed/MEDLINE, PsycINFO, CINAHL, Web of Science, and ProQuest databases were searched systematically to identify studies that compared mental health outcomes between SM and heterosexual survivors. A standardized data extraction form was used to extract data from eligible articles. The Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies was used to assess study quality. Results: Twelve studies met the inclusion criteria and assessed distress, depression, anxiety, perceived stress, and mental and emotional quality of life (QOL). Most studies enrolled survivors diagnosed either with female breast cancer or with prostate cancer. Most studies reporting on mental health among women found no differences between SM and heterosexual survivors. Studies conducted among men found that SM survivors experienced higher distress, depression, and anxiety, and lower emotional/mental QOL than heterosexual survivors. Conclusion: The findings of the present synthesis suggest that mental health disparities may exist among SM men diagnosed with cancer, particularly prostate cancer. More research is required to identify mental health disparities among SM survivors diagnosed with other cancers, as well as predisposing and protective factors. In addition, mental health screening and interventions are needed for SM men after cancer diagnosis.

Gay men's experiences of sexual changes after prostate cancer treatment-a qualitative study in Sweden

Background: The needs of gay men after prostate cancer treatment are becoming visible. This patient group reports a more negative impact of treatment than heterosexual men. Yet, gay men's experiences of post-treatment sexual changes are still little explored. This study aims to determine specific concerns of gay men's post-treatment sexual practices. Methods: A qualitative study design was deployed using semi-structured interviews as data. Participants were purposefully sampled through advertisements and the snowball method. Eleven self-identifying gay men aged 58-81 years and treated for prostate cancer participated in interviews during 2016-2017. The interviews were transcribed, coded and thematically analysed. Results: The analysis highlights sexual changes in relation to the physical body, identity and relations. Problematic physical changes included loss of ejaculate and erectile dysfunction. Some respondents reported continued pleasure from anal stimulation and were uncertain about the role of the prostate. These physical changes prompted reflections on age and (dis)ability. Relationship status also impacted perception of physical changes, with temporary sexual contacts demanding more of the men in terms of erection and ejaculations. Conclusions: Gay prostate cancer survivors' narratives about sexual changes circle around similar bodily changes as heterosexual men's, such as erectile problems and weaker orgasms. The loss of ejaculate was experienced as more debilitating for gay men. Men who had anal sex were concerned about penetration difficulties as well as sensations of anal stimulation. Additional studies are required to better understand the role of the prostate among a diversity of men, regardless of sexuality.