People commonly experience sexual side-effects as a consequence of cancer diagnosis and treatment; this article explores these in men and people born with male reproductive organs. This is a Self-assessment article and comes with a self-assessment test
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Abstract
Both cancer and its treatments can affect a person’s sexual wellbeing, either directly or indirectly. This article – the second in a two-part series about the sexual impacts of cancer – explores these effects on men and people born with male reproductive organs. It discusses how health professionals can approach the subject of sexual wellbeing, and support patients and their partner(s) through such issues. It suggests health professionals use a framework to do this, such as the bring up, explain, tell, timing, educate, record (BETTER) model.
Citation: Pugh J, Buckley L (2024) Sexual effects of cancer: men and people born with male reproductive organs. Nursing Times [online]; 120: 4.
Authors: Julia Pugh is sex and relationships psychotherapist and advanced nurse practitioner, NHS and Perci Health; Lynn Buckley is sex, relationships and trauma psychotherapist and specialist nurse, Perci Health.
Introduction
After a cancer diagnosis, it is common for people to experience difficulties with sexual function, sexual relationships and their sexual identity (Schover, 2019). This can be a direct result of treatment for some cancer types – for example, those of the reproductive organs – or an indirect consequence of treatment for other cancer types (Carter et al, 2018). Treatments including surgery, radiotherapy, chemotherapy and hormone therapy – all of which can be used alone or in various combinations – can all cause negative impacts (Schover, 2019). These include psychological and social impacts, such as altered body image, low mood and relationship changes, and can contribute to distress associated with a person’s sexuality (Han et al, 2020).
This article – the second in a two-part series – will explore the sexual health needs of men and people born with male reproductive organs (transgender women and people who are non-binary, gender-fluid or intersex). The previous article discussed these issues among women and people born with female reproductive organs.
Sexuality remains a component of care that is often overlooked by health professionals (Gilbert et al, 2016). In particular, people who identify as LGBTQ+ may experience increased avoidance of the topic, due to a health professional’s knowledge gap and fear of saying the wrong thing (Rose et al, 2017). This article aims to increase health professionals’ awareness and understanding of the sexual side-effects of cancer treatments to build their confidence and willingness to approach the topic, thereby improving patient care by addressing individuals’ sexual identity, function and relationships (including the impact on partners).
Treatment types
Surgery
There are two aims of surgery as a cancer treatment. These are to:
- Remove the affected area and adjacent tissues to obtain clear margins;
- Debulk the tumour mass, either to make other treatments more effective or for palliation.
Surgical options depend on the tumour site and stage of disease. Information on the surgery common for specific cancers is available on Cancer Research UK’s website.
Some surgical interventions can directly affect sexual functioning. This relates to surgery for pelvic and external genital cancers in particular, which include those of the penis, testicle, prostate, rectum, bladder (Fig 1) and colon. Areas of sexual function that can be affected include:
- Genital size or cosmetic changes;
- Ejaculation changes or inability to ejaculate (also known as dry orgasm);
- Reduced sexual sensation, leading to reduced satisfaction;
- Difficultly gaining and keeping an erection, leading to erectile dysfunction (ED);
- Anal changes, which may affect anal sex;
- Orgasm changes (Zhu and Wittmann, 2022; Rosser et al, 2020).
Surgery that includes the formation of stomas (ileostomy, colostomy or urostomy) can cause physical changes and affect body image and confidence – for example, due to a fear of leakage (Zhu and Wittmann, 2022). Changes in rectal and/or anal anatomy can also affect anal penetration, due to a reduction in the capacity of the anus (Zhu and Wittmann, 2022; Rosser et al, 2020).
Surgery for non-pelvic cancers should also be considered in terms of its impact on sexuality. Surgery to the pituitary gland could result in reduced testosterone and, therefore, sperm production (Yan and Lei, 2022). Limb amputation can cause difficulty with both physical positioning and body image. Patients with maxillofacial and throat cancers who undergo surgery may have functional changes, including tracheostomy, which can cause difficulties with kissing and oral sex (Hoole et al, 2015). People with lung cancer can experience shortness of breath following lobectomy; physical exertion during sexual activity can mean they struggle with increased breathlessness and avoid it (Lindau et al, 2011).
When one considers the body parts and systems that are involved in sexual activity, the list of cancer surgeries that can affect a patient’s sexuality is nearly endless.
Radiotherapy
Radiotherapy can be given alone or with other treatments for many cancer types. It can be delivered as:
- External-beam radiotherapy;
- Internal radiotherapy – for example, via brachytherapy using radioactive implants, such as permanent seeds.
Healthy tissue in or near the treatment field can be damaged due to exposure to radiation; this can cause temporary or long-term issues. In 2022, the Pelvic Radiation Disease Association (PRDA) published best-practice guidance to help health professionals identify and manage pelvic radiation disease. It also supports them in the assessment of sexual issues by providing tools and suggesting how to address and discuss issues with patients.
After radiotherapy, people with pelvic cancers – including those of the prostate, bladder, rectum and anus (Fig 1) – are more likely to experience ED than people with non-pelvic cancers; this is due to vascular, nerve and other tissue damage, as well as a reduction in testosterone (PRDA, 2022). There could also be damage to bowel mucosa, which needs to be considered for people who have anal sex (PRDA, 2022). People may also experience changes to bowel and bladder function, which may lead to incontinence; fear of this happening during intimacy may reduce a person’s desire to be sexual (PRDA, 2022).
For trans women who have had gender-affirming surgery to form a vagina, pelvic radiotherapy may cause changes to the tissues. When planning treatment, special considerations should be considered and discussed (Smart et al, 2023).
Radiotherapy for other cancer types can also affect sexuality. Radiotherapy for oesophageal and throat cancers can damage tissues that affect a patient’s ability to kiss and perform oral sex (Hoole et al, 2015). Radiotherapy to the brain may reduce testosterone and sperm production (Erickson and Donegan, 2021). Total body irradiation preceding a stem-cell transplant for haematological cancer will cause infertility (Zavattaro et al, 2021), and the psychological impact of this can influence patients’ interest in sex (Gianotten and Reisman, 2017).
Chemotherapy
Chemotherapy can lower testosterone levels during treatment, which can, in turn, reduce sexual desire and cause difficulties with sexual function (La Vignera et al, 2019). Hair loss, fatigue, nausea, neuropathy, pain and sore mouth are all possible side-effects of chemotherapy that can temporarily interfere with intimacy and how a person feels about themselves.
Chemotherapy can also affect fertility. A patient’s cancer team should consider and discuss this with them during the consent process (Reiser et al, 2022).
Other treatments
As prostate cancer needs testosterone to grow, patients can be given androgen-deprivation therapy to block it (Prostate Cancer UK, 2015). Research by White et al (2015) reported the following side-effects of such therapy, all of which can affect a person’s sexual wellbeing:
- ED (in up to ~85% of people);
- Reduced sexual desire (in 51% of people);
- Reduced ejaculate and diminished orgasm;
- Gynaecomastia (enlargement of breast tissue);
- Weight gain;
- Reduced penile and testicular size;
- Hot flushes and night sweats;
- Fatigue.
Although not available in all hospitals, high-intensity focused ultrasound (HIFU) is also sometimes a treatment option for prostate cancer. It can cause ED, but there is less risk of this side-effect after focal HIFU than there is with whole-prostate HIFU (Prostate Cancer UK, 2023).
Cancer sites
Cancers of the reproductive organs
Prostate cancer is the most common cancer in men and people born with male reproductive organs (White et al, 2015). As discussed, its treatments can cause ED and urinary incontinence, which can affect people’s confidence as well as their physical ability to enjoy sexual pleasure.
Reaching orgasm is possible without an erection, but patients may not be aware of this. After treatment – such as surgery to remove the prostate – people may have dry orgasms, during which they do not ejaculate. This can be a huge adjustment, and they may find it interferes with their sexual satisfaction (Macmillan Cancer Support, 2021). It is important to explore patients’ thoughts and ideas, some of which may be myths or misconceptions; talking about them can reduce distress and help people adjust to the changes in their sexual lives.
There are several physical treatments for ED, including medicines (phosphodiesterase-5 inhibitors), penile vacuum pumps, topical treatments and injections (Macmillan Cancer Support, 2021). The success of these treatments varies for each person and it is important that health professionals offer patients holistic care, being considerate of the psychosocial effects as well as the physical.
People who have some level of incontinence may avoid sexual activity for fear of leaking urine during it. Using a condom may help them and their partner feel more confident to engage in sexual activity, but it may be difficult to introduce condoms if they have not previously been used in the relationship. Communication is key to ensure this is mutually acceptable.
Penile cancer is rare (Cancer Research UK, nd) but, for those affected, it can be very difficult to re-engage in sexual activity after treatment. This can depend on the extent of surgery and whether it has been possible to reconstruct a functional phallus. Additionally, the stigma associated with this diagnosis means a person may feel isolated and not want to talk about their experience. They might feel they have lost their sexual identity as well as their penis.
For patients with testicular cancer, it is also important to consider the impact of treatment on sexuality. Removal of the testicle(s) and other treatments can interfere with sexual interest, sensation and pleasure. Another key consideration is fertility; this may become more relevant several years after treatment, at which point it can affect a person’s sexual relationship again (Kotronoulas et al, 2009).
Treatments for cancers of the reproductive organs can also have some specific impacts for patients who identify as LGBTQ+. Trans women who wish to have future gender-affirming surgery may find that it will be more difficult, or not possible, after some surgical or radiotherapy treatments (Ussher et al, 2023a). Additionally, Ussher et al (2023b) explored the disparity in the care of LGBTQ+ people and the importance of addressing the needs of all patients.
Bowel cancer
Bowel cancer does not usually have a direct effect on the function of an erection. However, a person’s ability to get an erection or enjoy sexual pleasure can be affected by the serious diagnosis and the ongoing effects of treatment, such as bowel changes, pelvic pain or having a stoma.
People who previously received anal penetration may find it painful after surgery or may feel worried about it. This is often a difficult topic for them to raise with health professionals, due to perceived judgements or prejudices (Rose et al, 2017). Health professionals can address this by opening the conversation by saying, for example: “It is common for people affected by cancer to have worries about their sex lives – I wonder whether you have any concerns or questions about this?” This can be done as part of Mick et al’s (2003) BETTER model, which is shown in Table 1 and discussed below.
Psychosocial effects
A person may not come to terms with, or appreciate, the impact of their cancer diagnosis and treatment for a long time. It is common for them to be in a ‘fight-or-flight’ state, in which they are only able to cope with, and process, immediate concerns and actions. Once in recovery, however, people may begin to consider the long-term effects of their treatment, and this can bring up many feelings, such as grief, loss and anger. For patients who were not sexually active during treatment, restarting sexual activity with a partner or starting a new relationship can make their worries more prominent (Reisman and Gianotten, 2017).
People who have a negative sexual experience – for example, ED, pain or being unable to have an orgasm – may find this distressing and worry about it happening again. This can happen both during sexual activity with another person and during masturbation. After this, the person may avoid opportunities for sex due to a worry and fear of failure. This can lead to negative thinking or ‘spectating’, in which they feel unable to connect to their body or the experience they are having. This anxiety can lead to further worry about the potential impact on their current relationship or potential partners (Wylie, 2004). Highlighting what is happening and helping the person to communicate their worries can alleviate distress and help them to feel more confident about engaging in sexual activity.
For some people, ED and/or loss of sexual enjoyment result in them becoming less confident in themselves. This can affect them at work or socially, and some may feel less ‘like a man’ due to their ‘broken’ parts. Rates of depression and anxiety are high in people affected by cancer (Naser et al, 2021), and some people may have medication to help with this. Some of these medications can reduce interest in sex and the ability to have an erection and/or reach orgasm (Lew-Starowicz, 2017).
Cancer can cause “difficult times” in a relationship, and the change to a couple’s sex life may be a factor (Benoot et al, 2017). Partners can often be overlooked, but they also need to adjust to changes in the sexual relationship and may worry about hurting or putting pressure on their partner. It can be difficult for people to talk openly, which can leave partners feeling undesired, lonely and helpless (Benoot et al, 2017). Encouraging good communication between partners can help them to navigate changes in their sex life.
Box 1 lists ways to support patients and their partners. Different models and frameworks are available to help introduce and address the topic of sexual issues with patients, two of which are:
- Mick et al’s (2003) BETTER model (Table 1);
- Annon’s (1976) PLISSIT model – this is described in the previous article in this series.
Box 1. How to support patients and partners
- Sex can be difficult for people to talk about, and they may believe they cannot talk to a health professional about it. Having open conversations and addressing their individual concerns is the first step to effective support
- It is often assumed that men prefer a solution-focused approach, so they are offered physical treatments. To signpost people to the right support, be aware that the mind and body work together to support sexual pleasure
- Navigating changes in sexual function often requires negotiating alternative sexual patterns, which can be empowering for patients and their partner(s)
- Knowing where to signpost people can help you feel more confident to ask them about their concerns; remember, you do not need to have all the answers and many cancer charities have excellent resources to support people
- Consider your own thoughts and feelings about talking about sex and sexual problems, and how you can practise being more confident in this component of care
- Try to be open, non-discriminatory and aware of any unconscious biases that you may have
- Familiarise yourself with the sexual symptoms and side-effects that people may experience, depending on their type of cancer and treatment
- Use a model to help address sexual issues with patients, such as Mick et al’s (2003) BETTER model (Table 1) or Annon’s (1976) PLISSIT model
- Consider further training in this area of specialism, either through the College of Sexual and Relationship Therapists or the Institute of Psychosexual Medicine
BETTER = bring up, explain, tell, timing, educate, record; PLISSIT = permission, limited information, specific suggestions, intensive therapy.
Conclusion
Men and people born with male reproductive organs whose cancer and/or treatment affects their sexuality require support to navigate both the changes to their physical abilities and the psychological and psychosocial impacts on their sexual wellbeing. Developing knowledge and confidence on the topic of sexual wellbeing following a cancer diagnosis will help health professionals manage this often-missed component of care.
Key points
- Due to the varied systems involved in sexual activity, it can be affected by treatments for a wide range of cancer types
- The impacts on patients’ sexuality can be physical, psychological and/or social
- Cancer and its treatments can directly and indirectly cause erectile dysfunction
- Cancers of the reproductive organs can have specific impacts for people from the LGBTQ+ community
- Frameworks are available to help health professionals support patients and their partners
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