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Authors Wassersug RJ, Lyons A, Duncan D, Dowsett GW, Pitts M.
Review Date September 2013
Citation Urology 2013;82:565-571
Urinary incontinence and erectile dysfunction are common side effects of prostate cancer treatments. In some men these symptoms persist and lead to decreased quality of life. There is some evidence that men who are not exclusively heterosexual might be underserved by the health care system and the effects of prostate cancer treatments may differ between heterosexual and non-heterosexual men.
The authors wished to determine if heterosexual and non-heterosexual men treated for prostate cancer differ in diagnostic and treatment outcomes, and in measures of physical health, sexual function and well-being, before and after treatment.
A questionnaire was posted online (from Dec 2010 to April 2011) asking about the diagnosis, treatment, and sexual experiences of men diagnosed with prostate cancer. Men were also asked to provide details on sociodemographic information, sexual identity and practices, antidepressant medication, bone pain and urinary incontinence. The survey was advertised through over 40 prostate cancer support and information organisations in the USA, Australia, Canada, UK and New Zealand and through social media.
Men in groups defined as heterosexual or non-heterosexual were compared using logistic and linear regression models that controlled for country.
Data from 556 men were included in the analysis: 460 self-identified heterosexual and 96 self-identified non-heterosexual men. Age at diagnosis was similar in the two groups but Gleason score at diagnosis was lower for the non-heterosexual men: 61% of non-heterosexual men reported a Gleason of 6 or lower compared with 34% of the heterosexual men (p=0.02). The two groups did not differ with respect to the proportion who received specific treatment modalities or the incidence of urinary incontinence, the proportion who reported bone pain (as a marker of disease progression), the proportion taking antidepressants (as a proxy measure for mental health), or the proportion reporting erectile dysfunction after treatment. However, non-heterosexual men rated the degree (on a 5-point scale) to which they were bothered by an inability to ejaculate as more bothersome than did the heterosexual men: mean score 3.3 in non-heterosexual men versus mean score 2.7 in heterosexual men (p=0.04).
The findings of this study do not support the view that non-heterosexual men are underserved by the medical system; the data indicate that non-heterosexual men had their prostate cancer diagnosed at an earlier stage than heterosexual men. Treatments and side-effects were similar between the two groups although non-heterosexual men tended to find loss of ejaculation more distressing than did heterosexual men.
Points to Note
- Although there are some obvious limitations to this study it has attempted to investigate an important question, that is, whether non-heterosexual men are receiving similar services for prostate cancer as heterosexual men.
- The data do not support the hypothesis that non-heterosexual men are underserved by medical services with respect to prostate cancer.
- The fact that non-heterosexual men tended towards diagnosis at an earlier stage was surprising based on previous studies and the authors suggest it is due to non-heterosexual men possible having more regular health checks, especially HIV screening.
- The authors explained the higher degree of bother caused by loss of ejaculation in non-heterosexual men as due to the importance of ejaculation to men who have sex with men, as a definitive sigh of sexual gratification. However, there are no data or references in the paper to support this assertion.
- Limitations of the study include possibility of a biased sample given it was an online survey and there was no way to determine the response rate; the sample of non-heterosexual men was small (n=96) and from several countries with differing health systems, so it is difficult to draw conclusions; the sample was drawn from affluent Western populations likely to be men of a higher socioeconomic status with good access to healthcare.
- The study does draw attention to possible differences between heterosexual and non-heterosexual men with prostate cancer and the need to better understand whether services for prostate cancer screening, diagnosis and treatment should take into account a man’s sexual identity.