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20 January 2022

By Kalli Spencer 

According to the American National Institutes of Health sexual minorities refers to “gayand bisexual-identified individualsplus those who do not self-identify but who experience same-sex sexual attractions and/or behaviour”. Gender minorities are those people who “identify as non-binary or transgender, or with a gender that doesn’t align with social and cultural expectations for their birth-assigned sex (e.g., agender, gender fluid, genderqueer).” The terms contrast the majority population, which includes cisgender, exclusively heterosexual-identified and oriented persons.  According to the Australian Bureau of statistics (2016) 3.6% of males and 3.4% of females described themselves with a minority sexual identity, which may be an underestimate of the true percentage. It is important to note that whilst a single umbrella term is used to denote the community, it is a diverse community and not one statistic or research output applies to all.  Historically sexual and gender minorities (SGM) on average have higher illness burdens, worse treatment experiences and poorer outcomes. There are also unique psychosocial challenges such as cancer related distress and sexual concerns, often with less support from biological family. In the medical literature there is evidence to show that SGM patients have higher levels of oncological healthcare dissatisfaction, gaps in patient-provider communication, access issues and a deficiency in information specific to their health care needs.

SGM people are as diverse as heterosexual people in their sexual behaviour. A healthcare provider would therefore need to specifically enquire about sexual practices. Because same-sex sexual behaviour has multiple options and roles-in-sex, a clinician may have to ask a very detailed assessment to fully comprehend the patient’s situation and concerns. As a group compared to older heterosexual men, older SGM are more likely to be single, sexual (both with self and others), to have more lifetime partners, and to view their sexual health as a core component of their identity. Some couples may be monogamous, while others have relationships open to other partners (usually with rules about how this is handled). For SM men in heterosexual relationships, they may have similar understandings with wives and other female partners about their sex with male partners. SGM individuals who are closeted, by definition, typically do not reveal their sexual liaisons to others. The most common sexual behaviours between gay, bisexual and other men who have sex with men are masturbation (both with and without anal stimulation), oral sex, and anal sex, followed by rimming (i.e., analingus). While some men may prefer being both the receptive and the insertive partner in sex (called being “versatile”), other men discover they prefer being the insertive partner (termed a “top”) or the receptive partner (termed a “bottom”). In this age cohort, and in some racial/ethnic minorities, being the receptive partner still carries additional stigma, making bottoms less likely to admit to being the receptive partner and to ask relevant questions about the effects of treatment on their behaviour1.

A common practice to be aware of includes the use of nitrites (termed “poppers”) to enhance sexual sensation during sex which should be avoided before PDE-5-inhibitors such as sildenafil or tadalafil are prescribed for erectile dysfunction. Ejaculate is very important to some SM men, and they may experience a profound sense of loss and chronic depression following prostate cancer treatment specific to loss of ejaculate. Oral sex is a common practice particularly with new partners and in casual dating, so concerns about urinary incontinence and its effects on sex and dating should be anticipated. Gay pornography and culture highlights prostate stimulation as the ultimate source of sexual pleasure (e.g., through digital stimulation during masturbation and penile stimulation in receptive anal sex). Most SGM use a water-based or silicone-based lubricant when having anal sex. In addition, about half of SM report enema use before receptive sex. A minority of SGM engage in “fisting” sex practices, where a partner’s hand, fist and/or arm is inserted into the anus1.

So what can healthcare providers do to improve the experience and outcomes for SGM patients?

According to the Restore-1study most providers (63% urologists and 74% oncologists) do not ask about sexual orientation at first assessment2. While 77% of participants had disclosed their sexual orientation to their primary provider, significantly less were “out” to their urologist (60%), surgeon (59%), or oncologist (56%). At first assessment, they recommend providers ask all patients screening questions. The response of the provider is critical. During their interviews the study team discovered that when the oncologist or urologist treated the topic sensitively, disclosure appeared to increase patient trust in the doctor-patient relationship. It is important to affirm the disclosure, for example by saying, “Thank you for letting me know. That’s really helpful information for when we discuss the effects of treatment.”

In the Restore-1 study, prostate cancer patients were asked what the most common problems they had post-treatment, and whether these were discussed with them by their clinicians prior to treatment2. Most patients recalled that providers discussed loss of ejaculate, erectile difficulties, and urinary problems with them, but many noted clinicians failed to discuss with them other prevalent issues such as: loss of sexual confidence, loss of desire, sense of orgasm, changes to the colour, length or curvature of their penises, urinary problems in sex, and the ability to orgasm or loss of pleasure during receptive anal sex. When clinicians do discuss these issues, it prepares patients for what to expect, empowers them to make more informed treatment choices and encourages them to contact them when experiencing any of these issues.

Some SGM patients are reluctant to ask specific questions related to sexual activity after procedures. Specific advice may need to be given after a prostate biopsy that one can insert a finger with gentle stimulation as soon as they feel comfortable. For insertion of a penis or dildo of penile width, they should wait about two weeks to allow sufficient time for healing. For penetrative sex, both surgery with nerve sparing and radiation have similar effects on the ability to get erections. For receptive sex, radiation therapy is not recommended as about 1-in-5 patients will have radiated bowel and not be able engage in sex after treatment. After a radical prostatectomy it is advisable to wait at least 6 weeks before inserting a finger and a minimum of 8 weeks for anything more.

Sexual rehabilitation after treatment has some specific differences, for example, with erectile concerns, anal sex requires greater rigidity than vaginal sex, which makes it more challenging. The study group are testing a protocol of a combination of sildenafil, vacuum pump, masturbation, and specific tailored education to improve erectile function sufficient for anal sex. They are also testing the effects of anal dilators on anodyspareunia (painful anal intercourse), and a combination of pelvic floor and sexual exercises to address urinary incontinence during sex.

The study found that SGM were at an increased risk of sexually transmitted and HIV transmission after treatment. One proposed theory is due to anodyspareunia after treatment leading to those in discomfort opting to have sex without a condom. To accommodate erectile dysfunction caused by treatment, many tops experiment with becoming the receptive partner. This can increase their HIV risk twenty-fold. Several men in couples may open up their relationship to other partners either because the insertive partner had erectile dysfunction or the receptive partner had anodyspareunia from treatment. Some patients who previously preferred oral sex may change preference to anal sex to avoid embarrassment about arousal incontinence or climacturia (incontinence associated with orgasm). Health care providers should discuss condom use when talking about erectile dysfunction as well as pre-exposure prophylaxis (PrEP).

In terms of outcomes older cohorts may be less likely to disclose their sexual orientation to their specialist (unless asked), are more at risk of being assumed to be celibate, and more likely to have less social support. Some reports from the USA have documented increased discrimination, abuse, and violence towards SGM in care facilities. Most (81%) older SGM adults fear entering nursing homes or assisted living because of potential discrimination. Many SM in this situation end up retreating to the closet out of fear for their safety, and concerns of rejection.

Compared to gay-identified men, bisexual-identified men have even worse outcomes across a variety of health metrics, although research in this group is lacking. An Australian study found that many clinicians reported lacking confidence in treating transgendered and intersex patients which can be linked back to insufficient medical training2.  Patients with less social support had significantly worse sexual, hormone and bowel bother symptoms, and worse mental health. While female partners of heterosexual patients tend to focus on survival, husbands/male partners appear equally concerned about the sexual effects of treatment. Because SM patients may both be men, both patient and partner may be more likely to handle the patient’s diagnosis alone.

It is important to avoid “heteronormativity” in clinic environments, patient education materials, and advertising and to ensure the entire team is trained including receptionists, security staff and patient navigators. This includes “man cave”, “sports-oriented,” and other machismo-themed waiting rooms and advertising, intake forms that describe a spouse as female or patient gender as binary only, questionnaires that define sexual functioning as erections or vaginal penetration (or sex as reproduction), and patient education that omits any mention or images of SGM. Co-design and modifications can be achieved in collaboration with LGBTQI stakeholders3.

Clinicians should not treat “all patients the same” and be aware of their own personal biases, cultural assumptions, and the need for cultural humility in providing care. Cultural humility requires “a lifelong commitment to self-reflection and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations”1.

Revision of medical school curricula should include the health care needs of SGM to produce patient centred clinicians. Content should pertain to the LGBTQI community in general and then specifically to each sub-group3.  While the differences in provision of minority versus majority care can seem overwhelming at first, the study team have found that it can make clinical practice more varied and exciting.

The Shine A Light prostate cancer support group for gay and bisexual men and transgendered women is affiliated with the PCFA and is a safe space for anyone from the LGBQTIA+ community with any cancer type. For more information and to connect with the group contact PCFA on 1800 22 00 99 or email enquiries@pcfa.org.au

 

References:

1. Rosser BRS, Rider GN, Kapoor A, Talley KMC, Haggart R, Kohli N, Konety BR, Mitteldorf D, Polter EJ, Ross MW, West W, Wheldon C, Wright M. Every urologist and oncologist should know about treating sexual and gender minority prostate cancer patients: translating research findings into clinical practice. Transl Androl Urol 2021;10(7):3208-3225. doi: 10.21037/tau-20-1052

2. Rosser BRS, Kohli N, Polter EJ, et al. The Sexual functioning of gay and bisexual men following prostate cancer treatment: Results from the Restore Study. Arch Sex Behav 2020;49:1589-600.

3. J.M. Ussher, J. Perz, K. Allison, Chambers S et al., Attitudes, knowledge and practice behaviours of oncology health care professionals towards lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) patients and their carers: A mixed-methods study, Patient Educ Couns 2021; https://doi.org/10.1016/j.pec.2021.12.008i.

 


About the Author

Kalli Spencer

Kalli Spencer
MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)

Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.

Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.