Sexual script flexibility after a prostate cancer diagnosis: Implications for sexual satisfaction

Abstract

Purpose

To investigate the relationship among sexual functioning, sexual script flexibility, and sexual satisfaction in individuals diagnosed with prostate cancer.

Design

Cross-sectional online survey.

Participants

Sixty-one men diagnosed with localized prostate cancer.

Methods

Online survey of sexual functioning, sexual script flexibility, and sexual satisfaction. Ordinal logistic regression investigated predictors of sexual satisfaction.

Findings

Greater sexual script flexibility was associated with a greater likelihood of being sexually satisfied.

Conclusions

Helping patients explore different ways of being sexual after treatment could help with sexual satisfaction maintenance.

Implications

Patients’ sexual satisfaction may benefit from discussions of issues related to sexuality and ways to work around treatment-related sexual dysfunction with healthcare providers.

Keywords:

• prostate cancer
• sexuality
• sexual functioning
• sexual satisfaction

Introduction

In Canada, prostate cancer is the most commonly diagnosed cancer in males and the third-leading cause of cancer death.¹ With one of the highest five-year net survivals of all cancers, most diagnosed individuals survive and live with the consequences of the disease and its treatments.^2–5 Reduced sexual functioning has been found to be one of the most prevalent and distressing side effects of prostate cancer treatment.^6–9 However, some men and their partners change their sexual practices to work around sexual dysfunction.^6,8,10

The ability to modify one’s sexual practices when experiencing sexual dysfunction may depend on how flexible one’s sexual script is. Sexual scripts include personal rules for essential components of a sexual interaction¹¹ and provide individuals with meaning and direction for sexual behaviors.¹² Sexual script flexibility refers to the ability to change one’s sexual script in response to sexual difficulties. Helping patients to modify their rigid and dysfunctional sexual scripts is one approach to treating sexual problems in sex therapy.¹¹

Two models highlight the importance of coping flexibly with sexual changes after cancer treatment. The first, the Flexible Coping Model,¹³ describes two approaches with which individuals may respond to sexual problems: a “bottom-up” approach involving flexibility in one’s definition of sexual function, and a “top-down” approach involving modifying the importance of sexual function to one’s self-concept. The second model, the Physical Pleasure-Relational Intimacy Model of Sexual Motivation (PRISM model¹⁴) is based on findings that sex for relational intimacy (versus for physical pleasure), sexual flexibility, and sexual communication promote adjustment to treatment-induced sexual dysfunction.

The current study sought to investigate the relationship among sexual functioning, sexual script flexibility, and sexual satisfaction in individuals diagnosed with prostate cancer. Consistent with both the Flexible Coping and PRISM models, we hypothesized that individuals with better sexual functioning would report greater sexual satisfaction and that individuals who were more sexually flexible would report greater sexual satisfaction.

Method

Participants

From January 2018 to October 2019, participants were recruited online via social media, paid advertisements, and emails to prostate cancer support groups, LGBTQ + organizations, and community health centers. Eligible participants were previously diagnosed with localized prostate cancer. The online survey was divided into two parts due to length. Participants created an anonymous ID number to link their responses between the two parts. A final sample of 61 participants who completed all measures of interest for the present analysis (outlined below) is described in this article (see Figure 1).

Figure 1. Recruitment and participation flowchart.

Measures

Demographics and cancer trajectory

Demographic and cancer trajectory questions were included in Part 1 of the survey. Demographic questions included those related to participants’ age, sex, gender identity, sexual orientation, ethnicity, and relationship status. Participants were also asked about their date of diagnosis and Gleason score. Those who underwent active treatment were asked for their treatment modality and wait time. Those who did not were asked to select between watchful waiting and active surveillance.

Sexual functioning

Participants completed the Clinical Practice form of the Expanded Prostate Cancer Index Composite (EPIC-CP¹⁵), a measure of health-related quality of life, in Part 1 of the survey. The three-item Sexual domain was used as a measure of sexual functioning. A domain score was calculated by summing the three item scores. Higher scores indicate worse sexual functioning. In the initial validation study, Cronbach’s α coefficient for the Sexual domain was .80 (present sample: Cronbach’s α =.81).

Sexual satisfaction

Participants completed the International Index of Erectile Function for men who have sex with men (IIEF-MSM¹⁶) in Part 1 of the survey. The IIEF-MSM was modified for the present study to be inclusive of men with sexual partners of any gender. The single-item Overall Satisfaction domain was used to measure sexual satisfaction. Participants rated how satisfied they have been with their overall sex life over the past four weeks from zero (Very dissatisfied) to four (Very satisfied).

Sexual script flexibility

Participants completed the SexFlex Scale in Part 2 of the survey (SFS¹⁷) to assess sexual script flexibility. The scale consists of 6 items that complete the phrase “When confronted with my sexual difficulty.” Participants rated each item from one (Seldom or never) to four (Almost always). Item scores were summed to create a total score. Higher scores indicate a greater frequency of flexible responses. The SFS demonstrates high internal consistency and good convergent and discriminant validity.¹⁷ In the present study, Cronbach’s α = .91.

Procedure

Participants accessed the survey via the anonymous link presented in recruitment materials and provided their informed consent. Part 1 took approximately 60 min to complete. At the end, participants were presented with a debriefing letter, and were given the option of providing their email address to enter a prize draw and to proceed to Part 2 (30 min). This study received ethical clearance from the Queen’s University General Research Ethics Board (GPSYC-807-17).

Results

Sample characteristics

The mean age of participants was 66.11 years old (SD = 8.07 years). All participants identified as men. On average, participants had been diagnosed with prostate cancer 4.16 years ago (SD = 2.82 years; range: 3 months to 22 years; Table 1).

Table 1. Demographic characteristics.

Variable	n (%)
Sexual orientation
Heterosexual	47 (77.0)
Gay	13 (21.3)
Bisexual	1 (1.6)
Ethnicity
White	56 (91.8)
White + Hispanic, Latino, or Spanish	2 (3.3)
White + Black + Hispanic, Latino, or Spanish	1 (1.6)
White + Asian + Hispanic, Latino, or Spanish	1 (1.6)
Asian	1 (1.6)
Occupational status
Employed	19 (31.1)
Retired	39 (63.9)
Other	4 (6.6)
Relationship status
Single	4 (6.6)
Married, common-law, engaged, committed	48 (78.7)
Divorced	5 (8.2)
Widowed	2 (3.3)
Other	4 (6.6)
Current country of residence
Canada	27 (44.3)
United States of America	13 (21.3)
Australia	6 (9.8)
United Kingdom	6 (9.8)
New Zealand	5 (8.2)
Ireland	1 (1.6)
South Africa	1 (1.6)
Gleason score at diagnosis
2	1 (1.6)
3	2 (3.3)
4	1 (1.6)
5	3 (4.9)
6	10 (16.4)
7	25 (41)
8	10 (16.4)
9	3 (4.9)
10	2 (3.3)
Unsure	4 (6.6)
Treatment modality
Surgery only	32 (52.5)
External beam radiation only	9 (14.8)
Surgery + external beam radiation	7 (11.5)
No active treatment	5 (8.2)
Brachytherapy only	3 (4.9)
External beam radiation + hormones	3 (4.9)
External beam radiation + brachytherapy	1 (1.6)
External beam radiation + brachytherapy + hormones	1 (1.6)

May not sum to total participants because of occasional missing values.

Sexual functioning, sexual script flexibility, and sexual satisfaction

See Tables 2 and 3 for summary statistics and correlations among the measures of interest. We conducted an ordinal logistic regression with a cumulative logit model using PROC LOGISTIC in SAS Studio for Academics to determine if the predictive relationship between sexual functioning (EPIC-CP: Sexual domain) and sexual satisfaction (IIEF-MSM: Overall Satisfaction) was moderated by sexual script flexibility (SFS). We mean-centered the two continuous predictors to create more meaningful zero points for interpretation.

Table 2. Participants’ ratings of sexual functioning and sexual script flexibility by level of sexual satisfaction.

Sexual satisfaction level	n (%)	Mean SFS score (SD)	Mean EPIC-CP Sexual domain score (SD)
Very dissatisfied	28 (45.90)	13.75 (4.53)	9.11 (2.48)
Moderately dissatisfied	6 (9.84)	14.00 (3.58)	4.67 (1.51)
Equally satisfied and dissatisfied	7 (11.48)	16.80 (6.08)	6.57 (4.47)
Moderately satisfied	9 (14.75)	17.44 (4.98)	2.67 (1.87)
Very satisfied	11 (18.03)	18.00 (6.12)	2.82 (3.06)
Overall		15.44 (5.21)	6.30 (3.89)

Sexual satisfaction level is based on participants’ ratings on the IIEF-MSM item which asks: “Over the past four weeks, how satisfied have you been with your overall sex life?”.

Scores on the SFS could range from 6 to 24, with higher scores indicating better sexual script flexibility.

Scores on the EPIC-CP Sexual domain could range from 0 to 12, with higher scores indicating worse sexual functioning.

Table 3. Correlations among measures of interest.

	1	2	3
1. Sexual Satisfaction	1.00	.37**	−.69**
2. Sexual Script Flexibility	−	1.00	−.15
3. Sexual Functioning	–	–	1.00

Spearman correlations were calculated for correlations involving sexual satisfaction; a Pearson correlation was calculated between sexual functioning and sexual script flexibility.

** p < .01.

The interaction between sexual functioning and sexual script flexibility was not significant, b = 0.023, SE = 0.015, Wald χ² = 2.18, p = .14. Thus, we ran the more parsimonious cumulative logit model without the interaction term; the continuous predictors were uncentered. The score test for the proportional odds assumption was violated, χ²(6) = 12.66, p = .049. We proceeded to run a partial proportional odds model, using PROC LOGISTIC’s SELECTION option to determine which effects exhibited nonproportional odds. The final model included all equal slope parameters, as well as unequal slope parameters for sexual functioning.

We examined the odds ratio for sexual script flexibility, as well as the odds ratios for sexual functioning at each level of sexual satisfaction. The odds ratio for sexual script flexibility was 1.15 (95% Wald CI [1.02, 1.30]); an increase in sexual script flexibility was associated with an increase in the odds of reporting greater sexual satisfaction. With regards to sexual functioning, for the response function comparing individuals who reported being “Very satisfied” with their overall sex life versus all other participants, the confidence interval for the odds ratio contained one (95% Wald CI [0.64, 1.16]), indicating that participants in either group were equally likely to have greater sexual satisfaction. The confidence intervals for the remaining odds ratios did not contain one; a decrease in sexual functioning was associated with a decrease in the odds of reporting greater sexual satisfaction (Figure 2).

Figure 2. Odds ratios.

Discussion

Previous qualitative research has reported that some individuals treated for prostate cancer adopt new sexual practices post-treatment to maintain a satisfying sex life (Boehmer and Babayan 2004).^8,10,14 To our knowledge, this study is the first to quantitatively measure sexual script flexibility in this population and to investigate how it relates to sexual functioning and satisfaction. As hypothesized, greater sexual script flexibility was associated with greater likelihood of being sexually satisfied, above and beyond one’s level of sexual functioning.

In previous research, experiencing a greater number of sexual issues has been associated with lower sexual satisfaction.¹⁸ It follows that those who can find ways to be sexual despite these issues would be more satisfied with their overall sex life. Qualitative research on prostate cancer patients and their partners has found that sexual flexibility separated sexually active couples from those who had ceased sexual activity since treatment.¹⁴ In an online survey that asked individuals diagnosed with prostate cancer about changes they had made to their sexual practices since their diagnosis, many discussed reframing their sexual practices, such as by engaging in less frequent penetrative activities and more frequent partnered oral and manual stimulation, or attempting anal penetration and prostate stimulation for the first time.¹⁰ Having a partner who was willing to try different activities was important for reframing their sexual practices.

The results of the present study have implications for patient healthcare. Discussions of issues related to sexuality and ways to work around potential treatment-induced sexual dysfunction could benefit patients’ sexual satisfaction. As one participant in Fergus et al.’s⁸ study stated, “If you’ve got 10 fingers and a tongue, sex ain’t dead.” The sentiment behind this humorous statement is reflected in both the PRISM and Flexible Coping models.^13,14 Reese et al.¹³ discuss clinical implications of the Flexible Coping Model for individuals with cancer. By focusing specifically on the concept of flexibility, the model is a targeted form of sex therapy that can be used in cancer treatment settings with limited counseling time. The authors also suggest that patient informational materials incorporate this model, providing information on the concept of flexibility and highlighting ways in which patients can be flexible in their approach to sex. The authors stress the importance of assessing cancer patients’ sexual concerns as well as their flexibility. The results of the present study suggest that specific assessment of patients’ sexual script flexibility may be particularly helpful.

Limitations and directions for future research

It will be important to replicate these results in larger samples. Time since diagnosis ranged greatly; future research might take a longitudinal approach in investigating how the relationship among sexual functioning, sexual satisfaction, and sexual script flexibility changes over time. Nearly a quarter of participants in our sample identified as gay or bisexual; research that compares sexual script flexibility in heterosexual and gay/bisexual men diagnosed with prostate cancer may be important in developing relevant models and counseling approaches. Further, expanding this research to diverse patient populations experiencing sexual dysfunction as a result of their disease and/or treatment, regardless of their specific cancer diagnosis, is also warranted. Finally, research on the flexible coping model developed by Reese et al.¹³ should investigate the impact of this targeted form of sex therapy on patients’ sexual script flexibility and their overall sexual satisfaction.

Conclusions

Prostate cancer is common. The high survivorship and many treatment options mean that most diagnosed individuals are living with the disease and treatment side effects. Sexual script flexibility, in addition to sexual functioning, are significantly associated with sexual satisfaction in men diagnosed with localized prostate cancer. Helping patients explore different ways of being sexual after treatment could help them to maintain their sexual satisfaction.

Disclosure Statement

The authors have no relevant financial or non-financial conflicts of interest to report.

Funding

This work was supported by a Prostate Cancer Canada Movember Discovery Grant (Grant Number: D2017-1850).