Astrid Ditte Højgaard1, 2 and Haakon Aars3
(1)
Sexological Centre, Aalborg University Hospital, Aalborg, Denmark
(2)
Sexology Research Centre, Aalborg University, Aalborg, Denmark
(3)
Institute for Clinical Sexology and Therapy, Torggatan 9a, 0181, Oslo, Norway
Astrid Ditte Højgaard (Corresponding author)
Email: a.hoejgaard@rn.dk
Haakon Aars
Email: ha-aars@online.no
33.1 Introduction
Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality. It is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled. That goes for heterosexuals as well as for people with a different sexual orientation.
Homosexual women and men, and bisexual persons, are defined according to their sexual orientation in terms of sexual attraction, behavior, identity, or some combinations of these dimensions. They share the fact that their sexual orientation is not exclusively heterosexual. Homosexual men and women mainly experience sexual attraction to people of the same sex, and they engage in same-sex sexual behavior. Among them are a bisexual subgroup of men and women who are attracted and engaged to both men and women. In this chapter, we will use LGB for the whole group of homosexual and bisexual persons. MSM (men having sex with other men) will be used for the group of homosexual and bisexual men, and WSW (women who have sex with other women) for the group of homosexual and bisexual women.
Revealing one’s sexual identity is called “coming out.” Many LGB persons have difficulty to “come out,” because they fear discrimination or prejudice from other people. Not-revealing happens also in contact with the health care providers. Depending on the culture they live in, many have also the fear for expressing homosexuality in action, because of the inborn shame one has from adolescence and from the surrounding society.
Many health care workers have been poorly trained to address the needs of LGB persons. The average heterosexual physician has very little knowledge about homosexual sexuality and LGB health problems. Besides, they may have difficulties communicating with their LGB patients, or feel uncomfortable providing proper care for them. They see the world through the eyes of heterosexism, often assuming that all patients have or strive for partners of the opposite sex. Some doctors believe they have never met homosexual patients, whereas others say that they “don’t like,” and some even believe that being homosexual is immoral. Many LGB patients have grim experiences facing overt discrimination resulting in reticence.
“Homophobia” is the term used for the fear or hostility many people feel for homosexual people. It can be expressed either as subtle statements or as open harassment and violence.
Of old, the health care of the LGB population tended to get no attention. However, during the last decade, an increasing number of studies have pointed out some important issues concerning risk behavior and coping style. Health care professionals have to be aware that in order to provide optimal treatment for these patients, a nonjudicious and knowledgeable attitude is important.
When patients can be frank with their health care professionals, better results of cancer treatment will be achieved. Besides, cancer screening and routine health care will be more successful when the LGB patient is not afraid of discrimination and when the health care provider is comfortable with these patients and provides care with the same dignity [1].
33.2 Prevalence of Nonmainstream Sexual Orientation and Activities
For this, we will look at the recent UK national survey on sexual behavior [2].
MSM
Sexual experience or contact with another man was indicated by 8.0 % of men. In 5.5 %, that had included genital contact and 2.6 % of men had had at least one male sexual partner in the last 5 years. When asked how to define themselves, 1.5 % saw themselves as homosexual and 1.0 % as bisexual.
WSW
Sexual experience or contact with another woman was indicated by 11.5 % of all women (and by 18.9 % of the group below age 25). In 6.1 % of all women, that had included genital contact and 3.2 % of women had had at least one female sexual partner in the last 5 years. When asked how to define themselves, 1.0 % saw themselves as lesbian and 1.4 % as bisexual.
MSM and WSW
Earlier studies in other Western countries showed more or less similar prevalence [3, 4]. It will be clear that more men and more women have same-sex experiences without identifying themselves as homosexual. We will have to realize that in each community, all over the world, being in Teheran or in Amsterdam, a considerable number of patients seen by the doctor every day are homosexual or bisexual.
This chapter focuses on various aspects of cancer and sexuality in the LGB patient groups.
To be able to provide optimal care, health professionals need some knowledge about relevant differences between the LGB group and the mainstream group. So, we will address first in MSM and then in WSW the next areas relevant for dealing with cancer:
· Different lifestyle/sexual lifestyle
· Different cancer incidence
· Different consequences of cancer treatment
· Different aspects of cancer care
33.3 MSM and Cancer
33.3.1 Different Sexual Lifestyle in MSM
Of course, there are many similarities between gay and straight men. One of them is the wide variety in behavior patterns. They both are easily visually stimulated, and both have a relatively high sexual desire/need. However, in MSM relationships, there is no female partner with a lower sexual desire; so, MSM can more frequently continue from desire into action. In the clinical experience of the author (HA), men tend to find talking about sexual problems more problematic than do women. Intimacy between heterosexual men concerns much prejudice and fear for sexuality. Men seem more afraid than women for intimacy and closeness (afraid to be perceived as gays?). Many men are also more preoccupied with the ability to function “technically” (i.e., the size of the penis, good erection, premature ejaculation, etc.), and their partner is often the only one to discuss their own sexuality. Most men do not talk to other men about sexual problems, and they often establish new relationships right after separating from a partner. The author’s experience is that this applies to gay men too [5].
In 2010, EMIS (European MSM Internet Survey) collected data from >180,000 MSM respondents [6]. The most common sexual contact was oral sex, followed by mutual masturbation, with anal sex as the third. In this survey, anal sex had been practised in the last year by 85 %.
For the receptive man (the “bottom”), much pleasure can be gained from the stimulation of the prostate (sometimes called the male G-spot). For the man who penetrates (the “top”), the erection has to be firmer than for vaginal intercourse (because of the strong anal sphincter). In MSM contacts, erection and ejaculation are usually more valued than in heterosexual encounters, and semen has a much more important role in the sexual play (“the eroticization of semen”).
Some MSM have many partners. The EMIS survey asked with how many men they had sex in the last year. For 34 %, that had been with 0–1 man, 46 % had sex with 2–10 men, and 20 % had had sex with >10 men in the last year.
33.3.2 Different Cancer Incidence in MSM
Whereas just another orientation does not increase one’s cancer incidence, several MSM elements increase this risk. The less monogamous lifestyle of some (but not all) MSM increases the incidence of sexual transmitted infections (STI) and HIV. So, it is relevant to pay attention to the various pathogens and their relation to cancer in MSM.
HPV (Human Papilloma Virus)
Subtypes HPV-16 and HPV-18 are important factors in oropharyngeal squamous cell cancer, anal cancer, and penis cancer.
Because of the combination of extensive circulation and microtrauma, receptive anal sex is a major route of transmission for STI with viruses HBV, HCV, and HIV.
HBV (Hepatitis B Virus) and HCV (Hepatitis C Virus)
Whereas part of these infections are self-limiting, others develop a chronic hepatitis that finally can lead to liver cancer. The risk to become chronic is far higher when the patient is also HIV-positive.
HIV (Human Immunodeficiency Virus), the Virus Behind AIDS
In the Western world, a substantial amount of carriers are known and treated. In Europe, it is estimated that between 5 % and 15 % of MSM are HIV-positive. Being HIV-positive is an additional risk factor for the development of some cancers, not only the virus-associated cancers, but also in some non-virus-associated cancers [7]. See Table 33.1 for the relative risk. HIV does not seem a factor in prostate cancer.
Table 33.1
RR (relative risk) to get cancer when hiv-positive [7]
|
Cancer type |
RR |
Virus |
|
Kaposi |
100–1000 |
KSHV (Kaposi sarcoma associated herpes virus) |
|
Burkitt |
20–100 |
EBV (Epstein-Barr virus) |
|
Anal cancer |
10–100 |
HPV (Human papilloma Virus) |
|
NHL |
5–50 |
EBV (Epstein-Barr virus) |
|
Hodgkin lymphoma |
5–20 |
EBV (Epstein-Barr virus) |
|
Liver cancer |
3–10 |
HBV/HCV (hepatitis B/C virus) |
|
Lung cancer |
2–4 |
|
|
Melanoma |
2–3 |
|
|
Head-neck cancer |
1.5–3 |
HPV (Human papilloma virus) |
33.3.3 Different Consequences of Cancer Treatment in MSM
There are some general consequences of cancer treatment. Some MSM give a relative higher value to outer appearance and to sexual performance. Cancer treatments tend to damage both areas. That will cause extra troubles when a substantial part of sexual encounters was found in casual contacts. Cancer damage can also be extra difficult for the single MSM when he is looking for a stable mate.
Besides, there are specific differences related to the combination of a given cancer treatment and the MSM’s sexual lifestyle.
33.3.3.1 Anal Cancer and Rectal Cancer
Radiotherapy in this area damages the elasticity of the anal muscles and the regenerative capacity of the mucous membrane. This will mean that receptive anal intercourse will temporarily or permanently become impossible or painful. Some men also find that the mucosa and skin of the anus are more painfully sensitive after radiotherapy.
33.3.3.2 Colorectal Cancer
When situated low in the pelvis, there is a substantial risk of lost erectile power. Whereas a temporary or permanent ostomy will, for many MSM, be some handicap in having sex with their stable partner, it will be a serious impairment in finding a new partner.
33.3.3.3 Prostate Cancer
Radical prostatectomy and radiotherapy can both diminish the erectile capacity, especially relevant in penetrative anal intercourse. The pleasure derived from prostate massage will completely disappear after radical prostatectomy and can become absent or painful after radiotherapy. After both treatment strategies, there is no more semen, which makes for many MSM the sexual encounter “incomplete.”
After radical prostatectomy, part of the men will have urinary incontinence during orgasm, which is especially burdensome in oral sex. Then, a tight elastic constriction band round the penile base could offer a simple and proper solution.
ADT (androgen deprivation treatment), the chemical castration resulting in very low testosterone levels will also result in no semen, because for semen production testosterone is needed.
Research concerning MSM diagnosed with prostate cancer is sparse, but indicates that prostate cancer impacts their sexual life significantly more than it does in heterosexual men [8, 9].
33.3.3.4 Radiotherapy
Radiotherapy in the pelvic area (for prostate, bladder, and colorectal cancer) is regularly accompanied by long-lasting diarrhea, which is very disturbing in receptive anal intercourse.
33.3.3.5 Chemotherapy
Chemotherapy (and also total body irradiation) as in case of blood/lymph cancer can be accompanied by reactivation of viral infections (causing painful/distracting oral herpes, genital herpes, or anal condylomata).
33.3.4 Different Aspects of Dealing with Cancer in MSM
Not all men are the same, and not all MSM are the same. So, it will be obvious that information on the man’s preferred sexual scripts is very relevant. With open and nonjudgmental asking, the cancer professional can learn about the man’s sexual preferred habits (his “love map”). That is important in the process of “shared decision-making,” especially when the possible treatment strategies can have very different sexual side effects. Knowledge and information are prerequisites for proper, fine-tuned cancer care. This process should include maximum integration of the patient’s partner.
33.4 WSW and Cancer
33.4.1 Different Lifestyle/Sexual Lifestyle in WSW Women
Whether general lifestyle in WSW adds to their risk of developing cancer is controversial.
Several studies have pointed at a risky lifestyle among WSW involving greater odds of smoking, drinking more alcohol, and having a higher BMI than among heterosexual women at any age group.
However, others have found that the lifestyle of this population generally is in accordance with the recommendations regarding smoking, fat intake, and alcohol consumption.
The frequency of sex is lower among WSW, compared with heterosexual, and particularly with bisexual women in all age groups.
The common sexual practices among WSW are genital rubbing (99.8 %), vaginal fingering (99.2 %), genital scissoring (90.8 %), cunnilingus (98.8 %), and vibrator use (74.1 %). One may expect that the nipples are important erogenous sources for WSW. The common practice of using dildos will increase the risk of HPV transmission [10].
A substantial proportion of WSW also have had sexual experiences with men. Thus, having had a male sexual partner was reported by 82.3 % of Swedish WSW, 39.5 % in the last 5 years, and 4.9 % in the last year. One-fifth of WSW had been pregnant, and one in ten had given birth. A similar proportion had had an induced abortion. That WSW do not exclusively have sex with women was also seen in a study from California in which similar numbers of WSW had had male sex partners.
In some WSW circles, women take a butch or femme identity. A butch is best described as a masculine, tough-appearing woman in contrast to the softer femme identity, which is more anonymous feminine, less provocative in conservative societies, and more easily passes without notice. The butch women are the least accepted socially. Most WSW know the concept, but adherence to the stereotypes seems to be cultural and has varied through the twentieth and twenty-first centuries. In some settings, it is regarded as a role play where masculine and feminine characteristics are exposed and used for inspiration. In other circles, it is disre- garded as suppressive and against the principles of feminism. In a study of 516 butch and femme-identifiedhomosexual and bisexual women, it was found that butch women were more at risk; in comparison to femme-identified women, they had significantly fewer routine gynaecological examinations; also, they perceived poorer treatment in health care settings. In spite of them regarding LGB-positive health care as essential, they had more difficulty finding LGB-positive medical doctors.
Other studies have confirmed that women with a butch expression are more reluctant to seek help. It must therefore be concluded that the women with the more androgynous appearance might be in greater need of support and open-minded medical health care.
33.4.2 Different Cancer Incidence
Does the WSW lifestyle add to increased cancer incidence and mortality?
33.4.2.1 Breast Cancer
WSW are more exposed to breast cancer risk factors. Compared to women in heterosexual relationships, women in same-sex couples have greater age-adjusted risk for breast cancer (RR = 3.2, CI 1.01–10.21). However, this was not found to influence their overall risk for mortality in a recent study comprising 136,174 women, of which 693 were living with a woman [11].
In a study in which WSW women were compared with their heterosexual siblings, the WSW sister had significantly higher 5-year (p < .0001) and lifetime (p = .001) risk for developing breast cancer. Thus, being WSW adds more cancer risk to a sibling. One of the explanations offered in addition to the possible impact of a risky lifestyle is that WSW have fewer and later pregnancies, and therefore lactate less. Regarding breast cancer screening, there is evidence that sexual orientation does not influence behavior. Thus, mammogram was performed equally frequent among heterosexual (84 %), bisexual (79 %), and homosexual (82 %) women during the last 2 years.
33.4.2.2 Ovarian Cancer
Because of increased rates of nulliparity among homosexual women, the risks of ovarian cancers may be higher, but this has not been studied in detail. Many lesbian women lack the protection that oral contraceptive pills provide in the prevention of ovarian cancer.
33.4.2.3 Endometrial Cancer
Endometrial cancer can be expected to be more frequent due to nulliparity and obesity. Many lesbian women also lack the protection that oral contraceptive pills provide in the prevention of endometrial cancer.
33.4.2.4 Cervix Cancer
This could be expected to be less frequent due to less frequent or no heterosexual vaginal intercourse (and HPV transmission). However, women who only have sex with women can also contract HPV. Thus, HPV DNA has been found in 13–30 % of WSW women and in 19 % of women who never had had sex with a man. That HPV can be transmitted sexually between women necessitates screening procedures among WSW – but do they adhere to recommendations?
Regarding PAP smears, WSW underutilize this screening method. Young homosexual/bisexual females have 30 % lower odds of having a PAP smear within the last year, and almost 40 % higher odds of being diagnosed with a sexually transmitted infection, as compared with the completely heterosexual group. Also, it was found that the lifelong odds of having a PAP test was very low, as compared with that in completely heterosexuals. In an Israeli study, only 22.2 % of WSW had ever had a PAP smear.
The reason for not undergoing screening procedures was fear of discrimination; the women who did not disclose their orientation to their GP were less likely to be routine screeners.
33.4.2.5 Other Cancers
It is not known whether there is an increased prevalence of oropharyngeal cancers among women primarily practicing oral sex. Regarding colorectal cancers, frequencies of colonoscopy or sigmoidoscopy do not differ by sexual orientation in women.
33.4.3 Different Consequences of Cancer Treatment
Most studies have addressed breast cancer. The consequences of ovarian, lung, oropharyngeal, and colorectal cancer have not been elucidated in this population.
Homosexual women are more prone to suffer from side effects of treatment, perhaps because of the reluctance to seek early help. The vaginal dryness and vulnerability of the vaginal mucosa due to anti-estrogenic treatment have a negative impact on the possibilities of vaginal fingering and other penetrative sex that are important for WSW. As in heterosexual relationships, the loss of the areola area impairs an important erogenous zone. Scarification and dysesthesia can even make fondling unpleasant or painful. Homosexual women with breast cancer have fewer concerns regarding body image, and they also are less prone to opt for breast reconstruction. Thus, it seems that changes in body image are less problematic for a woman whose partner is another woman.
33.4.4 Different Aspects of Dealing with Cancer in WSW
WSW cancer survivors do not seem to be more anxious or depressed than comparable heterosexual women. It has even been expressed in some qualitative interviews by some of the women that they are better off than heterosexual women.
It might be speculated that WSW cancer survivors are met by more understanding by their same-sex partners than heterosexual women do. In several studies concerning relations and sexual function after breast cancer, WSW report lower levels of sexual concern, and have fewer body image concerns. Compared with a similar group of heterosexual women, they show less disruption in sexual activity and fewer conflicts with their partners. WSW have less family support, but are more prone to use support from friends. As some of these women live with primarily female friendships, the chance of knowing another woman with cancer is large. As family support sometimes is lacking, friends take over, thus enhancing the group knowledge of the perception of being a patient with cancer.
However, the cancer diagnosis affects WSW as much as other women, and it has been found that WSW breast cancer survivors do not have a better quality of life as compared to heterosexual women.
33.4.5 Are WSW Overt to the Health Care Professionals?
In spite of the medical professionals’ increasingly open attitude, a large majority of WSW claim to be unable to disclose their sexual orientation to their GP and chose not to discuss sexual health issues with them.
Middle-aged and older WSW women are the least informative about their orientation, as it is perceived that their clinicians are either negative or not well enough informed, and some women have experienced overt discrimination [12]. Women who disclose their sexual orientation to their primary care physician are more willing to have routine screening than those who do not.
WSW women’s perceptions of heterosexism and homophobia in health care settings influence significantly to their use of breast self-exams, and particularly PAP screening.
The patients’ discomfort with the health care system is probably mirrored by a reciprocal discomfort from the health care system with these patients. Even in countries where homosexuals are protected by law, the attitudes of young doctors are more or less skeptical toward treating WSW women on equal terms with heterosexual women.
Not surprisingly, women who have encountered prejudice in their health care delivery are more prone not to adhere to cancer-screening guidelines. Also, they drop further visits even in case of serious illness, and vice versa; women who meet health care professionals who are knowledgeable and sensitive to WSW issues are significantly more likely to have had a PAP test within the last year, even when controlling for age, education, income, and insurance status.
33.5 Good Practice
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
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