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Originally published as JCO Early Release 10.1200/JCO.2008.20.1947 on December 22 2008 © 2009 American Society of Clinical Oncology.
Mastering EmasculationFrom the Department of Anatomy and Neurobiology, Dalhousie University, Halifax, Nova Scotia, Canada. Corresponding author: Richard Wassersug, Department of Anatomy and Neurobiology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, Nova Scotia, B3H 1X5, Canada; e-mail: richard.wassersug{at}dal.ca.
Dr A, a 62-year-old medical school professor, was diagnosed 10 years ago with prostate cancer (PCa). His baseline prostate-specific antigen (PSA) level was 19 ng/mL and his Gleason score was 7 (3 + 4). He had a radical prostatectomy. One month postoperatively his PSA level was 0.08 ng/mL and began to rise, so he went on to receive salvage radiotherapy. His PSA level in the subsequent 6 months rose additionally to 0.28 ng/mL, so within a year he started continuous androgen deprivation therapy (ADT). Since then his PSA level has remained below the detectable limit of 0.04 ng/mL. His testosterone level has stayed below 2 nmol/L. Not surprisingly, he has experienced a number of adverse effects of the hypogonadal state, including impotence. Phosphodiesterase-5 inhibitors were ineffective for his erectile dysfunction, and no other efforts were made to recover erectile function. ADT has lead to profound changes in Dr A, such that he no longer considers himself a man. Through research and self-discovery, however, he has found a way to redefine his current state and has moved on to a rewarding and sexually fulfilling life. Dr A now considers his gender to be that of a eunuch. Although such a label may sound pitifully self-deprecating, it has in fact empowered him, and provides a welcome alternative to either endlessly mourning his former manhood or pretending that little has changed. Surprisingly, he is sexually active, reports that he is orgasmic, and recently got married—to a woman he met after "coming out" as eunuch. He credits his sexual functionality to his acceptance of an altered gender status and considers it far better to view himself as a eunuch than as a mutilated male.
Currently in North America, roughly a half million men are on ADT, and are essentially chemically castrated. Given these enormous numbers, one would expect that these patients would feel little need to hide. However, to be castrated is commonly considered shameful. Because of this stigma, both patients and physicians often strive to depict ADT as something less life-altering than it really is. While to be on ADT is to be deprived, it sounds less traumatic to call it hormone therapy, which implies that the patients are gaining, rather than losing something. Dr A argues that, for some patients, this euphemism may be doing more harm than good. There seems to be little impetus within the medical community to encourage patients to accept, let alone embrace, the emasculating reality of ADT. For example, in its booklet Sexuality and Cancer: For the Man Who Has Cancer and His Partner,1 the American Cancer Society (ACS) encourages men on ADT to believe that it has little impact on their core identity. The booklet states: "Men who have lost their testicles or who are on hormone therapy, often feel like ‘less of a man.’ They fear becoming feminine in looks and personality. This is a myth. Manhood does not depend on hormones, but on a lifetime of being male." The last sentence is then repeated in large bold print, as if repetition makes reality. While the ACS booklet at first recognizes that a patient on ADT may feel like "less of a man," it goes on to suggest that there is little reason for him to feel this way. The text attempts to be positive and gender affirming. However, in doing so, it minimizes the reality of ADT's emasculating effects. In truth, there are no data to support either the ACS's implicit claims that manhood is strictly socially constructed, or that ADT does not carry with it feminizing effects. ADT typically leads to a loss of body hair, genital shrinkage, the development of fat in a postmenopausal female pattern of distribution, loss of muscle mass, hot flashes, and, depending on the drugs used, various amounts of gynecomastia. Thus, ADT both emasculates and feminizes. Men can disguise most of the anatomic alterations caused by ADT with a carefully chosen wardrobe. They cannot, however, hide ADT's effects in one place that is an integral part of many men's lives—the bedroom. Contrary to the unsubstantiated claims in the ACS booklet, many qualitative studies have explored the impact of ADT on PCa patients' sense of masculinity (Cushman et al, submitted for publication).2–7 Though rarely cited in the oncological literature, collectively these papers reach a strong conclusion: patients on ADT despair because they no longer feel or function fully as men. The overwhelming success of the phosphodiesterase-5 inhibitor industry affirms the importance of sexual performance to male identity. Despite the ACS's claim that "manhood does not depend on hormones," men feel most manly when they have a libido and erections, and both are decimated by ADT. Low libido and other psychological effects of ADT not only reduce the quality of life (QoL) of these patients, but also the QoL of their partners. Studies show that the spouses typically suffer psychological distress even more than the patients when their husbands go on ADT.8–12 One small study from Israel suggests that erosion of spousal relations may occur in half of ADT couples.4
Though patients on ADT feel less like men, they do not see themselves as women. Indeed, they are not. Instead, they fit a historically well-defined third gender category. Although most patients would be appalled to be labeled as such, Dr A's self-effacing identity as a "eunuch" is technically correct for individuals on ADT. As disparaging as this label sounds, it opens the way for a new narrative not available to patients who deny the reality of their emasculation. Whereas most patients may strive to downplay the changes in their lives caused by ADT, Dr A argues that to do so prevents patients and their partners from fully mourning their losses and then moving on. Mourning loss is indeed a crucial and well-recognized first step toward successfully adapting to life-altering change.
While accepting a gender shift away from manhood is likely to be disconcerting and difficult for most patients, it helps Dr A appreciate, as positives, some of the changes that come with androgen deprivation. These include increased emotionality and freedom from the impulsivity correlated with high testosterone. Accepting these changes may have also prompted him to explore sexual practices that are not erection dependent.
Emotionality and Empathy
Senior Statesman Versus Mutilated Wimp Today we use terms like "impotent" or "neutered" to imply, not simply erectile dysfunction (ED), but political powerlessness (Cushman et al, submitted for publication). To be a "eunuch" now metaphorically means to be a wimp of no consequence. However, for most of the last 3,000 years, all major stable governments in Asia had eunuchs as senior advisors in their inner court.13 The word chamberlain itself comes from the idea of the eunuch as the guardian of the chamber. The chamberlain oversaw the inner court and was privy to the highest business of state. The respect that eunuchs had as advisors could not be accounted for by their age. Due to their low testosterone levels, there was little likelihood of them impulsively escalating potentially dangerous conflicts. Instead they were valued for their levelheaded counsel. Dr A, too, notes an increased ability for objective thought regarding the needs of others that he did not possess before his hypogonadal state.
Sexual Freedom Whereas many PCa patients struggle to maintain or recover male functionality, Dr A has gone to the other extreme. While other patients explore penile injections with various combinations of phentolamine, papaverine, and alprostadil, or even surgical implants to restore erections, Dr A has taken a different approach—one that has precedent in the disability literature.
Because of our tendency to understate the impact PCa treatments have on sexual function, many treatment programs lead patients to believe that, with a bit of effort, they will be able to overcome problems that arise in this area. For example, the ACS supports a sexual recovery program that encourages patients with ED (from primary treatments) to remain hopeful and progressively explore each ED treatment in turn until they find one that works.(15) There are three problems with this approach. First, it belies the ACS's suggestion that one need not have erections to be a man. Secondly, since this approach solely focuses on erectile function, it offers little promise for individuals that suffer not only from ED, but also from low libido—like most patients on ADT. Lastly, this approach can be incredibly demoralizing for patients who go through each possibility without ever finding a cure. Each consecutive treatment failure lowers the individual's self-esteem and further cuts away at his sense of manhood. Dr A's sexual activities do not require erections. Rather, they include oral and manual genital stimulation, as well as the use of dildos. These are sexual practices beyond those currently offered in most ED clinics. Sexual gratification under these conditions requires, however, reconceptualizing one's sexuality and gender performance. A first step towards making this work is acknowledging the severity and permanence of the disability. There are parallels between Dr A's sexual strategy and those employed by spinal cord patients who regain a high QoL. Consider the choice faced by a paraplegic patient—he can struggle to recoup bipedality, or he can redefine himself as wheelchair dependent. Many spinal cord patients in a wheelchair can move faster and more efficiently than most people can run. But this mobility first requires that the patient accept that he is never going to walk as he did before. Like the spinal cord patient, who accepts that he will never of his own volition stand erect again, Dr A accepts the fact that his penis will never do that either. Those who have spinal cord injury, yet recover their sexuality, provide insight into how sexual recovery might be possible for a patient like Dr A. In fact, in some ways patients impotent from PCa treatments have a disability equivalent to a spinal cord injury, but one that selectively affects motor outflow at the S2, 3, and 4 levels. Like most higher spinal cord injuries, the PCa patient's disability is bilateral and severe enough to cause atrophy of the nonfunctional extremity. Dr A saw the movie Sexuality Reborn (1992, Kessler Medical Rehabilitation Research and Education Corp, West Orange, NJ), which shows a pathway to sexual recovery after spinal cord injury. The film makes the point that a paraplegic patient singularly focused on recovering the ability to walk is not likely to recover sexually. Likewise, the permanently impotent PCa patient who is singularly focused on recovering erections is similarly unlikely to find sexual pleasure from non–erection-dependent sex play. In one amazing scene in Sexuality Reborn, we see a quadriplegic patient getting intense sexual pleasure from his wife kissing the back of his neck. Were he not a spinal cord patient, this cervical sex play might be considered a fetish. But because he has overcome his sexual dysfunction through imagination, eroticization, and transference, his transposition of erotic tissue from his genitals to his neck is a triumph. Dr A also found his way to the case studies by Gray and Klotz16 and Warkentin et al17 about a PCa patient on ADT who has orgasmic sex using a strap-on dildo. That patient believes that the full body contact with his partner and the natural movements of coital sex that are possible with the strap-on dildo—plus the direct stimulation to his flaccid penis by his partner's hand during sex—carries him to orgasm. To a patient singularly intent on recovering erections, this modus operandi would amount to an admission of defeat, but to Dr A it is sexuality reborn. Sex therapists trying to help patients with severe ED often promote noncoital sex play. Although sex with a strap-on dildo involves an artificial rather than a real penis, it may in fact be particularly effective in that it allows for otherwise normal copulatory movements. The dildo option is currently being recommended by a small number of psychologists and sex therapists working with PCa couples in Canada. One of the surprising things to emerge so far from their studies is that couples are by and large not shocked by this suggestion (D. McLeod and J. Robinson, personal communication, August 2008). Many couples facing the harsh reality of permanent ED are ready to try something novel that is a complete departure from traditional ED treatments.
Successful recovery of mobility for the spinal cord patients and sexuality for an impotent PCa patient like Dr A both involve incorporating a mechanical device into their lifestyle. PCa patients might thus look on using a dildo as the same as using a wheelchair. Walking and using wheels are different ways of getting around. Similarly, a functional penis and a dildo are different things. However, when a patient's legs or penis no longer work, novel biomechanics may be required. If PCa patients on ADT can accept that the past cannot be resurrected, they may find their way to a new and rewarding future.
The author(s) indicated no potential conflicts of interest.
Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. American Cancer Society: Sexuality and Cancer. For the Man Who Has Cancer and His Partner. Atlanta, GA: American Cancer Society, 2001. p.1–84. 2. Chapple A, Ziebland S: Prostate cancer: Embodied experience and perceptions of masculinity. Sociology of Health & Illness 24:820–841, 2002.[CrossRef] 3. Fergus KD, Gray RE, Fitch MI: Sexual dysfunction and the preservation of manhood: Experiences of men with prostate cancer. J Health Psychol 7:303–316, 2002. 4. Navon L, Morag A: Advanced prostate cancer patients' ways of coping with the hormonal therapy's effect on body, sexuality and spousal ties. Qualitative Health Research 13:1378–1392, 2003. 5. Navon L, Morag A: Liminality as biographical disruption: Unclassifiability following hormone therapy for advanced prostate cancer. Soc Sci Med 58:2337–2347, 2004.[CrossRef][Medline] 6. Gray RE, Wassersug RJ, Sinding C, et al: The experiences of men receiving androgen deprivation treatment for prostate cancer: A qualitative study. Canadian Journal of Urology 12:2755–2763, 2005.[Medline] 7. Oliffe J: Embodied masculinity and androgen deprivation therapy. Sociology of Health & Illness 28:410–432, 2006.[CrossRef][Medline] 8. Kornblith AB, Herr HW, Ofman US, et al: Quality of life of patients with prostate cancer and their spouses: The value of a data base in clinical care. Cancer 73:2791–2802, 1994.[CrossRef][Medline] 9. Soloway CT, Soloway MS, Kim SS, et al: Sexual, psychological, and dyadic qualities of the prostate cancer ‘couple’. BJU International 95:780–785, 2005.[CrossRef][Medline] 10. Kim Y, Kashy DA, Wellisch DK, et al: Quality of life of couples dealing with cancer: Dyadic and individual adjustment among breast and prostate cancer survivors and their spousal caregivers. Ann Behav Med 35:230–238, 2008.[CrossRef][Medline] 11. Hagedoorn M, Sanderman R, Bolks HN, et al: Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects. Psychol Bull 134:1–30, 2008.[CrossRef][Medline] 12. Beck AM, Robinson JW, Carlson LE: Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. Urol Oncol epub ahead of print on February 22, 2008. 13. Aucoin M, Wassersug RJ: The sexuality and social performance of androgen-deprived (castrated) men throughout history: Implications for modern day cancer patients. Soc Sci Med 63:3162–3173, 2006.[CrossRef][Medline] 14. Finucci V. The Manly Masquerade: Masculinity, Paternity, and Castration in the Italian Renaissance. Durham, NC: Duke University Press, 2003. p.1–316. 15. Canada AL, Neese LE, Sui D, et al: Pilot intervention to enhance sexual rehabilitation for couples after treatment for localized prostate carcinoma. Cancer 104:2689–2700, 2005.[CrossRef][Medline] 16. Gray RE, Klotz LH: Restoring sexual function in prostate cancer patients: An innovative approach. Canadian Journal of Urology 11:2285–2289, 2004.[Medline] 17. Warkentin KM, Gray RE, Wassersug RJ: Restoration of satisfying sex for a castrated cancer patient with complete impotence: A case study. J Sex Marital Ther 32:389–399, 2005.[CrossRef] Submitted September 16, 2008; accepted November 18, 2008.
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Copyright © 2009 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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