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Zach Klaassen: Hi, my name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. I'm delighted to be joined today by Dr. Daniel Dickstein, who is a radiation oncology resident at the Mount Sinai School of Medicine in New York. Dr. Dickstein, thanks so much for joining us today.

Daniel Dickstein: Thank you for having me.

Zach Klaassen: We are going to discuss your fantastic publication that came out earlier this year in Nature Reviews Urology, looking at sexual health and treatment-related sexual dysfunction in sexual and gender minorities in prostate cancer. So you guys, this is a big publication. It's a big cited journal, so congratulations on that, and we're excited to talk about that today.

Daniel Dickstein: Thank you.

Zach Klaassen: Just give us a little background, the genesis, how it came about. It's not just a review article, I mean, this is a powerful journal, and you guys did a great job with it. How did the idea come about? How did it come together?

Daniel Dickstein: Totally. When I started residency, I started on the genitourinary service. While I was on that service, I was learning about prostate cancer. I was learning about the ropes of being a resident, and I was sort of maybe robotic in this way because I just wanted to survive the service. But every single patient I would talk to that patient about the different treatment choices. From a radiation perspective, sometimes we would have to discuss the differences between external beam radiation and brachytherapy and how those two treatments might impact quality of life differently.

I think that prostate cancer is very interesting in that a lot of patients live for quite some time, so then they'll live with the side effects of treatment. For every patient I would discuss with those patients, how do treatments impact penile erections, and specifically really penile erections necessary for vaginal intercourse or heterosexual intercourse.

Then one day as I was going about just doing my daily thing as just a new resident, asking my questions because I had no idea what was happening or asking my questions to my attending and my co-residents, I went to a patient's room. I was doing a new consult, seeing a new patient, discussing the different treatment options. I feel like I had it down by now. I knew what I was doing. I could get through this consult, go to the next patient, keep it moving. The patient asked me, "Well, how do these treatments impact anal?" He actually spoke to me a little bit colloquially. He might've known that I ... Whatever. I think that what he may have sensed is that I am gay, and I was sort of surprised by the question, but I also wasn't because it made sense in the moment, but I wasn't prepared for the question.

No one told me that this was going to happen. I was passing out SHIM scores left and right, and I was contouring or coloring in the penile bulb. I knew the vessels that supplied the penis for an erection. I knew a lot about an erection, but I really didn't know how treatments impacted receptive anal intercourse. I asked my attending who was so nice, and he didn't really know. He was like, "Oh my God, I don't know." Then I asked my co-residents. They didn't know.

Then I was sort of sitting there and I was like, "Oh my God. This really actually is resonating with me as a gay male living in sort of a heteronormative, heterocentric society." We have so much information on the impacts of treatment on penile erections. We have also treatments for erectile dysfunction. We have ways to mitigate or try to mitigate treatment-related erectile dysfunction, and we know not one thing about how these treatments impact sexual and gender minorities, receptive anal intercourse and the treatment-related side effects. That's what began this entire journey, if you will.

Zach Klaassen: That's great. So tell us a little bit more. I mean, you go through in the article a lot about the differences in sexual dysfunction from a sexual minority male that differ from a heterosexual male. So just walk us through some of those differences, and you sort of alluded to it earlier a little bit.

Daniel Dickstein: I think the first aspect is after you identify that a patient is a sexual minority male or a gay and bisexual male or a gender minority, just knowing if they engage in anal intercourse, are they the insertive partner, the receptive partner, both versatile or neither, which is colloquially called the side. Then after knowing that, then there are different sexual dysfunctions that might impact them differently than ... Well, just might impact them differently. So for example, a insertive partner might care about erectile dysfunction similarly to a heterosexual male or they might care about penile length and penile shape. In the article, I do discuss how penile size might be more important to gay and bisexual men. But I do believe that's also important to heterosexual men. I discussed how there was a study that showed there was no difference.

But for a receptive partner, they're going to want to know how do these different treatments impact their ability to have pleasurable receptive anal intercourse. How does surgery, removing the prostate impact their ability to have an orgasm from the prostate? How does radiation, which is damaging, or external beam radiation, which is damaging the lining of the rectum, it's killing the prostate, it's damaging that area ... How does that impact receptive anal intercourse? How does brachytherapy impact receptive anal intercourse? Understanding how those different treatments impact the ability to have pleasure from receptive anal intercourse is, I think, a big component of the article.

Zach Klaassen: Yeah, absolutely. I think leading into the next section that you guys talk about is what are some of the ... We know the treatment options for heterosexual men. It's obviously Cialis and Viagra and vacuum erection devices and inflatable penile prosthesis.

Is there differences, particularly from the partner, in terms of how we treat sexual dysfunction after prostate cancer treatment?

Daniel Dickstein: It really depends on the sexual dysfunction. I think that one way to sort of mitigate sexual dysfunction is asking a patient's role in sex. A lot of patients who identify as a bottom might not care about erectile dysfunction as much as someone who's a top. But let's say a patient who does have problematic receptive anal intercourse after treatment or you could discuss this even before treatment, and there needs to be more evidence really on this topic, but you could suggest an anal dilator. Basically there are vaginal dilators, which we use during radiation treatment. We use anal dilators sometimes after just proctological surgeries. So how does an anal dilator, how could that help with some of the side effects for preventing problematic receptive anal intercourse after treatment for prostate cancer?

I think climacturia, which is orgasm-related urinary dysfunction, that could apply to both heterosexual and gay and bisexual men. But discussing that with gay bisexual men and penile constriction rings, which is basically putting at the base of the penis which could help an erection but also prevent urination during orgasm, and then pelvic floor exercises.

I would say the last point of all of this is we do prescribe sildenafil and tadalafil to help with erectile dysfunction. I believe it's really important to also recognize in the sexual minority male community that a lot of these patients also take a recreational drug called poppers. So someone who's a verse, who's both the insertive and receptive partner, they might be taking this drug, which are nitrites. Basically if you combine those with sildenafil or a PDE5 inhibitor, you can have very dangerous side effects. So it's just really important to discuss that with patients, to tell them not to combine those drugs.

Zach Klaassen: That's a great point, and I think those points lead into ... I want to share a slide with our viewers. You guys have a very, very helpful sort of an algorithm looking at patient-centered consultation and guidance. I think you started off our conversation by saying, I started talking to people, and when you ask questions and you're listening and you can pinpoint what their sexual preference is. I think this is a fantastic figure of how folks can sit in the clinic and sort of dial down specifically what's important to the patient. Why don't you walk us through this figure.

Daniel Dickstein: Okay. This is a figure which outlines how to approach a patient with prostate cancer who arrives to the clinic. First you'll ask gender identity. Then after you discover gender identity, if the patient identifies as a man, then you'll ask sexual orientation and sexual practices. The patient will then identify as heterosexual, gay, bisexual, someone who doesn't identify as heterosexual. For the heterosexual patients, you'll guide treatment discussions as is. For sexual minority men, you'll ask role in sex. They are top, bottom verse, side, and we discussed how to guide conversations from there and discuss treatments.

If a patient walks in and after asking what's the gender identity and the patient identifies as a woman, non-binary, transgender, trans feminine general, then you'll ask sexual orientation, sexual practices as well as gender-affirming hormone therapy and also genital gender-affirming surgery. It's important to recognize that patients might have just began their gender-affirming hormone therapy. They may have been on the gender-affirming hormone therapy for a very long time. A patient may have undergone genital gender-affirming surgery. A patient might plan on having genital gender-affirming surgery. A patient might be undecided or a patient might not ever plan on having that surgery. So it's really important to understand those questions because that could also really guide treatment discussions for sexual toxicity and just treatment in general.

After you go through if the patient's on a gender-affirming hormone therapy, then you discuss treatment. After you understand all those answers to those questions, you then discuss treatment, effects of treatment on reconstructive surgery, and you really align treatments that work best with patients' sexual orientation, gender identity, and role in sex.

Zach Klaassen: That was fantastic. I think this is a very helpful figure, and our listeners will appreciate this because quite frankly, the comfort level might not be there for the physician. But having an algorithm like this is something that we can use in the clinic. So I think this is really, really well done. We've had a great conversation. Is there anything from the paper that you want to touch on that we haven't touched on yet?

Daniel Dickstein: No. I think this was great. I appreciate you having me here. I think the one thing I would want to add is really just thanking my mentor and co-authors on this paper. I wouldn't have been able to do this without them and all of their help and input, and this is so multidisciplinary. I also really want to thank the editor-in-chief of Nature of Use Urology, Dr. Fenner. I wouldn't have been able to do this without her. I think it's really important to sort of recognize how different scientific publishing companies can really make an impact and really showcase a really important issue. I really want to thank her and the entire Nature Reviews Urology team as well.

One more thing I want to say is this article is comprehensive, and there's a lot to take in, and I really just encourage people to try and to make the effort. We all make mistakes. I make mistakes all the time. It could be hard to really ask these questions. You don't know if you might offend a patient or make a mistake, say the wrong thing. But I really do genuinely believe that trying and making a mistake is better than not trying at all and doing nothing and being apathetic to the entire situation. I believe patients and people can feel when someone else is trying and trying to help, and it's okay to make mistakes. We all do. But all I ask is just try.

Zach Klaassen: That's a great conclusion to a great conversation. Thank you so much, Dr. Dickstein.

Daniel Dickstein: Thank you.