Queer men navigating prostate cancer are harmed by a healthcare system that sees heterosexuality as the default. This assumption of heterosexuality prevents healthcare professionals from advising and acknowledging how adverse effects of prostate cancer treatment may affect queer men. These effects can be devastating to their sexual expression, sex role identification, and relationships to the queer men’s community. Prior to treatment, providers must have meaningful conversations about the varying treatment options and the respective sexual adverse outcomes so that queer patients can make informed decisions.
A healthcare system that sees heterosexuality as the default is profoundly and irreversibly harming queer men* who are navigating prostate cancer. Prostate cancer is a unique disease as it specifically affects a sexual organ and, therefore, sexual ability. For cisgender men,‡ typical adverse effects from prostate cancer treatment can include erectile dysfunction, orgasm and ejaculation issues, urinary and bowel incontinence, among others. For queer men, these effects can be devastating to their sexual expression, sex role identification, and relationships to the queer men’s community. In some cases, current treatment modalities can permanently damage or remove the prostate, which can make “bottoming” (receptive anal sex) painful or even impossible. A colleague and I performed an integrative review to synthesize scientific literature on prostate cancer in queer men.[1] In general, we found that healthcare providers often make assumptions that their patients are heterosexual, which prevents healthcare professionals who advise men on prostate cancer treatment from acknowledging how adverse effects impact queer men. By disseminating our review, we hope to add to the conversations around this urgent crisis affecting queer men with prostate cancer.
Healthcare providers often make assumptions that their patients are heterosexual by default, which is also known as heteronormativity.[2] Heteronormativity in healthcare ignores the unique needs of queer men by applying a “one-size-fits-all” approach to patients. Whether a healthcare provider acknowledges it or not, queer men with prostate cancer have needs that are different than their heterosexual counterparts. Therefore, heteronormativity leads to non-tailored healthcare, which leaves queer men with prostate cancer invisible.[3]
An initial theme in our literature synthesis was that many queer men identify the prostate as a central component to their sexual expression.[4] Many queer men, especially those who are receptive partners, describe the prostate as the pleasure center of anal intercourse. Traditional scientific literature, however, places the prostate gland among many structures involved in the male reproductive system, focusing on its function in semen creation and ejaculation. This perspective ignores the fact that, anatomically, the prostate and penis share sensory innervation.[5],[6] Hence, in sexual activity, stimulation of the prostate can trigger an efferent impulse similar to that of stimulation of the penis.
Sexual role within queer men’s relationships – such as being a bottom (penetrated), top (penetrator), or versatile (both) in anal sex – is more than just a sexual position. As many queer men know, sexual identity and gender expression is often linked to sexual position.[7] One needs to consider how different prostate cancer treatment affects queer men’s ability to engage in their sexual role.[8] For example, surgical interventions or radiation often destroy sensory innervation and scar the anal canal. Radical prostatectomies (prostate removal) remove the ability of sexual stimulation of the prostate altogether. This leaves the bottom partner permanently unable to enjoy receptive anal intercourse. Not only can the person not experience receptive sex the same way again, but a radical prostatectomy also forces the queer man to renegotiate his sexual role. This may disrupt his sexual position and even his sexuality and personal identity.
For men whose sexual role is a top, adverse effects such as the inability to ejaculate (anejaculation) or maintain an erection can also force a renegotiation of roles. We found in our review that, although many heterosexual men experience similar adverse effects, erections and ejaculation play a more critical visual role in queer relationships.[9],[10] Some men worried that the inability to have an erection would make their partners assume they were sexually not interested. Consequently, many felt isolated from their partners and unable to connect with new partners. Further, the standard definition of successful treatment of erectile dysfunction is a man maintaining an erection rigid enough for vaginal penetration. Anal penetration, on the other hand, needs approximately 33% greater rigidity. As a result, healthcare providers may believe that they have “successfully treated” a queer man for erectile dysfunction, while the issue persists.[11]
With queer-informed healthcare, providers can carefully guide queer men through treatment options for prostate cancer. Prior to treatment, providers must have meaningful conversations about the varying treatment options and the respective sexual adverse outcomes so that queer patients can make informed decisions. For example, a radical prostatectomy may not be the best option for a man who is a receptive partner (bottom). As treatment protocol exists now, if providers are not acknowledging the prostate as a sexual organ, and therefore removing it from men’s bodies without fully explaining said consequences, do queer men with prostate cancer ever receive information resembling informed consent?
Queer men need access to culturally safe and informed healthcare, but in order to support this need, systemic healthcare institutional and policy changes must begin to address the aforementioned prostate cancer disparities. Medical and nursing education must reinforce the importance of tearing down heteronormative barriers to care while also acknowledging that the prostate is a sexual gland that, when stimulated, results in sexual pleasure. Providers must allow the patient to define and describe their sexual expression and what the prostate means to them. Practice guidelines need to be updated to include, and highlight, the needs of queer men with prostate cancer, with the expectation that treatment options, and their sexual side effects, are thoroughly explained. Acknowledging sexual role is critical in helping queer men make informed treatment decisions. Providers, educators, and healthcare policy advocates must begin implementing real solutions for queer men with prostate cancer.
* I use “queer” as an umbrella term for all sexual minority men with a prostate including, but not limited to gay, bisexual, homosexual, queer, and same-gender loving.
‡ This article focuses on cisgender men. However, I acknowledge the importance of discussing trans-women, gender-queer, and intersex individuals with prostates, but I believe that, given the historical context and unique challenges of navigating healthcare as a trans* or intersex person, the issue of prostate cancer in trans* and intersex individuals warrants its own article.
Acknowledgements: The author would like to thank Dr. Mark Lazenby for his skillful editing & advice and Lisa Marchlewski for her helpful critiques.
References:
[1] Moore, M.A., Batten, J. and Lazenby, M., 2019. “Sexual Minority Men and the Experience of Undergoing Treatment for Prostate Cancer: An Integrative Review”. European Journal of Cancer Care. DOI:10.1111/ecc.13031
[2] Utamsingh, Pooja Dushyant, Laura Smart Richman, Julie L Martin, Micah R Lattanner, and Jeremy Ross Chaikind. 2016. “Heteronormativity and Practitioner–Patient Interaction.” Health Communication 31: 566-74.
[3] Supra note 1.
[4] Supra note 1.
[5] Drake, R. L., A. W. Vogel, and A. W.M. Mitchell. 2018. Gray’s Basic Anatomy. 2nd ed.
Philadelphia, PA: Elsevier, Inc.
[6] Levin, RJ. 2018. “Prostate‐Induced Orgasms: A Concise Review Illustrated with a Highly Relevant Case Study.” Clinical Anatomy 31: 81-85.
[7] Johns, Michelle Marie, Emily Pingel, Anna Eisenberg, Matthew Leslie Santana, and José Bauermeister. 2012. “Butch Tops and Femme Bottoms? Sexual Positioning, Sexual Decision Making, and Gender Roles among Young Gay Men.” American Journal of Men’s Health 6: 505-18.
[8] Lee, Tsz Kin, Ariel Baker Handy, Winkle Kwan, John Lindsay Oliffe, Lori Anne Brotto, Richard Joel Wassersug, and Gary Wayne Dowsett. 2015. “Impact of Prostate Cancer Treatment on the Sexual Quality of Life for Men-Who-Have-Sex-with-Men.” 12: 2378-86.
[9] Moore, M.A., Batten, J. and Lazenby, M., 2019. “Sexual Minority Men and the Experience of Undergoing Treatment for Prostate Cancer: An Integrative Review”. European Journal of Cancer Care. DOI:10.1111/ecc.13031
[10] Katz, Anne, and Don S Dizon. 2016. “Sexuality after Cancer: A Model for Male Survivors.” The Journal of Sexual Medicine 13: 70-78.
[11] Gebert, Sam. 2014. “Are Penile Prostheses a Viable Option to Recommend for Gay Men?”. International Journal of Urological Nursing 8: 111-13.