Emotional Impact, Relationships, and Intimacy

Chapter Opening — Marcus's Story

Marcus was 58 when he was diagnosed with intermediate-risk prostate cancer. A retired firefighter, he had always been the strong one — the person everyone leaned on. When his urologist said the word "cancer," Marcus did not cry. He did not ask many questions. He went home, sat in his truck in the driveway for twenty minutes, and then walked inside and told his wife, Linda, that everything was fine.

It was not fine.

Over the next several weeks, Marcus could not sleep. He snapped at his grandchildren. He stopped going to his weekly poker game. Linda noticed he was pulling away — not just emotionally, but physically. He flinched when she touched his shoulder. He stopped initiating any affection.

It was not until a nurse at his radiation oncologist's office handed him a distress screening form that Marcus checked the boxes for anxiety, sleep problems, and "concerns about intimacy." That form opened a door. He was referred to a psychologist who specialized in cancer patients, and for the first time, Marcus talked about what he was really feeling: fear of dying, fear of losing his manhood, fear of being a burden, and a deep shame that he could not "handle it" the way he thought he should.

"I spent my whole career running into burning buildings," Marcus said later. "But this — this was the hardest thing I've ever faced. Not because of the cancer. Because I didn't know how to ask for help."

Marcus and Linda eventually saw a couples counselor together. They learned to talk about the changes in their relationship — including the sexual ones — without blame or embarrassment. Two years later, Marcus says the cancer did not destroy his marriage. "It changed it," he says. "In some ways, it made it stronger. But only because we did the work."

Part 1: The Emotional Impact of a Prostate Cancer Diagnosis

A prostate cancer diagnosis is not just a medical event — it is an emotional earthquake. Even when the prognosis is excellent (and for most men, it is), the word "cancer" carries a weight that statistics alone cannot lift.

Research consistently shows that men with prostate cancer experience significant psychological distress. Studies report that men with prostate cancer are nearly twice as likely to experience severe depression and anxiety compared to men without cancer.¹ ² This distress is not limited to men with advanced disease — even men with low-risk cancer on active surveillance report anxiety, particularly around the time of surveillance biopsies and PSA checks.³

The emotional impact typically follows a pattern, though every man's experience is unique:

At diagnosis: Shock, disbelief, fear, and a sense of urgency. Many men describe feeling as though the ground has shifted beneath them. There is often an overwhelming desire to "do something" immediately, even when the medical situation does not require urgency.

During treatment decision-making: Anxiety about making the "right" choice. With multiple treatment options available — active surveillance, surgery, radiation, and others — many men feel paralyzed by the fear of choosing wrong. This is sometimes called "decisional conflict."

During treatment: Stress related to the treatment itself, side effects, disruption of daily routines, and the physical toll on the body.

After treatment: A paradoxical period. While many men feel relief that treatment is over, others experience increased anxiety. The regular contact with the medical team decreases, and the fear of recurrence — sometimes called "scanxiety" — can be intense, particularly around PSA checks.

At recurrence: If cancer returns, the emotional impact can be even more profound than the initial diagnosis, often accompanied by feelings of betrayal ("I did everything right") and hopelessness.

Part 2: Common Emotional Responses

Every man responds differently, but certain emotional patterns are common:

Fear and anxiety are the most frequently reported emotions. Fear of death, fear of treatment side effects, fear of losing sexual function, fear of incontinence, and fear of being a burden to loved ones. These fears are normal and do not indicate weakness.

Anger is common but often unrecognized. Men may feel angry at their bodies, at the healthcare system, at the unfairness of the diagnosis, or at themselves for not catching it sooner. Anger can also be displaced — directed at family members, coworkers, or situations unrelated to cancer.

Grief and loss are natural responses. Men grieve the loss of their health, their sense of invincibility, their sexual function, and sometimes their sense of masculinity. This grief is real and valid, even when the prognosis is good.

Isolation and withdrawal are particularly common in men, who may have been socialized to "tough it out" and avoid showing vulnerability. Many men withdraw from social activities, stop talking to friends, and become emotionally distant from their partners.⁴ ⁵

Depression affects a significant proportion of men with prostate cancer. Warning signs include persistent sadness, loss of interest in activities, changes in appetite or sleep, difficulty concentrating, and feelings of worthlessness. Depression is treatable, and seeking help is a sign of strength, not weakness.

Guilt can arise in unexpected ways — guilt about burdening a partner, guilt about not being able to work, guilt about the financial impact, or even guilt about having a "good" cancer when others have worse diagnoses.

Part 3: Masculinity and Identity

Prostate cancer strikes at the core of many men's identity. The prostate is intimately connected to sexual function, urinary control, and reproduction — all areas tied to traditional concepts of masculinity.

Treatment side effects such as erectile dysfunction, urinary incontinence, loss of libido, and changes in body composition (particularly with hormone therapy) can profoundly affect how a man sees himself. Research shows that men on androgen deprivation therapy (ADT) experience body feminization — including loss of muscle mass, weight gain, breast enlargement, and loss of body hair — that can challenge their sense of masculine identity.⁶ ⁷

These changes are not trivial. They affect how men feel about themselves, how they interact with their partners, and how they engage with the world. Studies have found that altered masculine self-image can lead to feelings of shame and embarrassment, making it difficult for men to maintain intimate relationships.⁸ ⁹

It is important to understand that masculinity is not defined by a prostate, an erection, or a testosterone level. Many men find that cancer forces them to redefine what strength means — and that vulnerability, honesty, and emotional openness are among the strongest things a person can be.

Exercise has been shown to help counteract some of these identity challenges. A randomized clinical trial published in JAMA Network Open found that supervised exercise improved feelings of masculinity, preserved libido, and improved sexual function in men with prostate cancer — particularly in those with the most severe baseline dysfunction.¹⁰

Part 4: The Impact on Partners and Families

Prostate cancer is often called a "couple's disease" — and for good reason.¹¹ ¹² The diagnosis and treatment affect not just the patient but the entire family unit, particularly the intimate partner.

Partners experience significant distress. A landmark Swedish national cohort study of over 121,000 partners of men with prostate cancer found that partners of men with high-risk disease had a 34% increased risk of major depression (HR 1.34) and a 25% increased risk of anxiety disorder (HR 1.25) — and these risks remained elevated for more than 10 years.¹³ Most alarmingly, partners of men with distant metastases had a 2.4-fold increased risk of suicide (HR 2.38).¹³

Partners often experience more distress than patients. Multiple studies have found that partners report higher levels of emotional disturbance than the patients themselves.¹⁴ ¹⁵ ¹⁶ This may be because partners carry the dual burden of their own fear and grief while simultaneously serving as the primary caregiver and emotional support for the patient.

The caregiver burden is real. Partners often assume new responsibilities — managing medications, driving to appointments, handling insurance paperwork, maintaining the household — while simultaneously processing their own emotional response to the diagnosis. This can lead to caregiver burnout, characterized by exhaustion, social isolation, neglecting one's own health, and resentment.¹⁷

Children and family members are affected too. Adult children may worry about their own cancer risk (particularly sons), struggle with role reversal (caring for a parent), or feel helpless. Younger children may not fully understand the diagnosis but can sense the stress and anxiety in the household.

Communication is key — but often difficult. Research shows that both patients and partners frequently suppress their emotions to protect each other — a phenomenon called "protective buffering."¹⁸ While well-intentioned, this mutual silence often increases distress for both parties. Studies consistently show that open communication — even when difficult — is associated with better psychological adjustment and relationship satisfaction.¹⁸ ¹⁹

Part 5: Talking to Your Partner

One of the most important — and most difficult — things a man can do after a prostate cancer diagnosis is talk openly with his partner. Here are some practical suggestions:

Start the conversation early. Do not wait until side effects appear or emotions boil over. Begin talking about your feelings, fears, and concerns as soon as you feel ready — ideally before treatment begins.

Be honest about what you are feeling. You do not need to have all the answers. Saying "I'm scared" or "I don't know what to expect" is not weakness — it is the foundation of genuine connection.

Listen to your partner. Your partner has their own fears, their own grief, and their own needs. Ask them how they are doing — and truly listen to the answer. Research shows that partners' and survivors' distress are mutually influential.²⁰

Attend appointments together when possible. Having your partner present at medical appointments ensures they hear the same information you do, reduces miscommunication, and makes them feel included in the process.

Consider couples counseling. A trained therapist can help you navigate the emotional and relational challenges of cancer. This is not a sign of a failing relationship — it is a sign of a strong one. Studies show that couple-based psychological interventions improve communication and reduce cancer-related distress for both patients and partners.²¹

Do not assume you know what your partner needs. Ask. And be willing to hear the answer, even if it is not what you expected.

Part 6: Talking to Children and Family

For adult children:

• Be direct and honest. Adult children generally want the truth, even if it is difficult.
• Share the basic facts: what the diagnosis is, what the treatment plan is, and what the prognosis looks like.
• Acknowledge their feelings. They may be scared, angry, or worried about their own risk.
• If you have sons, discuss the implications for their own screening (generally recommended to start earlier than the general population).
• Respect their need for space if they need time to process.

For younger children:

• Use age-appropriate language. "Daddy has some sick cells in his body, and the doctors are going to help get rid of them."
• Reassure them that the cancer is not their fault and that it is not contagious.
• Maintain routines as much as possible — school, activities, bedtime — as consistency provides security.
• Watch for behavioral changes (withdrawal, acting out, sleep problems) that may indicate they are struggling.
• Consider involving a child psychologist if needed.

For extended family and friends:

• Decide together (patient and partner) how much information to share and with whom.
• Designate a "point person" who can update others, so the patient does not have to repeat the story multiple times.
• Be specific about what kind of help you need. "Can you drive me to my Tuesday appointments?" is more useful than "Let me know if you need anything."

Part 7: Intimacy — The Bigger Picture

This is one of the most important sections of this book, and one that is too often overlooked in medical care. More than 80% of men report sexual problems after a prostate cancer diagnosis, yet more than 50% do not receive adequate therapeutic support — a significant care gap.²²

Before discussing the physical aspects of sexual function (which are covered in detail in Chapters 10, 12, and 18), it is essential to understand a fundamental truth: intimacy is not the same as sex, and sex is not the same as an erection.

Intimacy encompasses the full spectrum of emotional and physical closeness between two people — holding hands, cuddling, kissing, sharing fears and dreams, laughing together, and yes, sexual activity in all its forms. Many couples discover that when they broaden their definition of intimacy beyond penetrative intercourse, they find new and meaningful ways to connect.

This does not mean that the loss of erectile function is unimportant — it absolutely is, and there are many effective treatments available (discussed below and in Chapter 18). But it does mean that a satisfying intimate relationship is possible even when sexual function has changed.

Part 8: How Each Treatment Affects Sexual Function

Understanding how different treatments affect sexual function is essential for setting realistic expectations and planning for recovery.

After surgery (radical prostatectomy):

The impact on erectile function is immediate and often dramatic. Even with nerve-sparing techniques, most men experience significant erectile dysfunction in the months following surgery. The CEASAR study, published in JAMA, found that at 5 years, men who underwent nerve-sparing prostatectomy had a clinically meaningful decline in sexual function scores of 32 points (on a 100-point scale).²³ However, recovery can continue for 2 to 4 years after surgery.²⁴

Additional sexual changes after surgery include:

• Anejaculation — the absence of ejaculate during orgasm. This is permanent because the seminal vesicles and prostate (which produce most of the ejaculate) have been removed. Orgasm is still possible without ejaculation.²⁴
• Climacturia — urine leakage during orgasm, which occurs in some men, particularly in the first year. This can be managed by emptying the bladder before sexual activity or using a condom.²⁴ ²⁵
• Penile shortening — a documented consequence of surgery, likely related to nerve injury and reduced blood flow.²⁴
• Changes in orgasm quality — some men report less intense orgasms or altered sensation, though the ability to achieve orgasm is often preserved even without an erection.²⁴

After radiation therapy:

Unlike surgery, the impact on sexual function after radiation is gradual rather than immediate. Erectile dysfunction may develop over 6 to 36 months after treatment due to local neurovascular changes.²⁴ ²⁶ The CEASAR study found a 5-year decline of 32 points for external beam radiation (similar to surgery at 5 years) and 22 points for brachytherapy.²³ A 10-year follow-up study published in JAMA found no significant differences in sexual function between surgery and radiation at 10 years, though men who underwent surgery experienced more years of impairment early on.²⁷

The addition of ADT to radiation therapy has at least a temporary negative impact on libido and erectile function.²⁴ ²⁶

After hormone therapy (ADT):

ADT has the most profound and multifaceted impact on sexual function. Effects include loss of libido (sexual desire), loss of spontaneous and nocturnal erections, erectile dysfunction, decreased penile size, testicular atrophy, and difficulty achieving orgasm.²⁸ ²⁹ These effects are directly related to the suppression of testosterone and are present for as long as ADT continues. Some effects may be partially reversible after ADT is stopped, but recovery is variable and may take months to years.

Men on ADT may not experience a physiologic desire for sex, but clinical experience suggests that some men wish to continue sexual activity as an important aspect of their relationship — based on psychological desire, maintaining intimacy, and attending to their partner's needs.²⁴

After active surveillance:

Active surveillance is associated with the best preservation of sexual function, with only mild decline over time (20-point decline at 5 years), largely attributable to aging.²³ However, the anxiety of living with untreated cancer can itself affect sexual desire and performance.

Part 9: Medical Treatments for Erectile Dysfunction

A stepwise approach to managing erectile dysfunction after prostate cancer treatment is recommended by the NCCN Survivorship Guidelines and the American Cancer Society.²⁵ ²⁸ ³⁰

Step 1 — Oral medications (PDE5 inhibitors):

These are the first-line treatment for erectile dysfunction. They include sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). They work by increasing blood flow to the penis. Dosing should be titrated to optimal effect.²⁸

• They require some intact nerve function to work, so they are more effective after nerve-sparing surgery and radiation than after non-nerve-sparing surgery.
• Daily low-dose tadalafil (2.5–5 mg) may be used for penile rehabilitation — the concept of maintaining blood flow and tissue oxygenation to prevent fibrosis and preserve erectile tissue.²⁴ ³¹
• They are contraindicated in men taking nitrates (nitroglycerin) for heart disease.
• It is worth revisiting PDE5 inhibitors even if an initial trial was unsuccessful, as some men recover nerve function up to 2–4 years after surgery.²⁴

Step 2 — Vacuum erection devices ([VEDs](/rare-disease/vascular-ehlers-danlos-syndrome)):

A plastic cylinder is placed over the penis, and a pump creates a vacuum that draws blood into the penis, producing an erection. A constriction ring is placed at the base to maintain the erection. VEDs are effective, noninvasive, and can be used in combination with PDE5 inhibitors. They have also been shown to be effective for penile rehabilitation.³¹ ³²

Step 3 — Intraurethral suppositories (MUSE):

A small pellet of alprostadil (prostaglandin E1) is inserted into the urethra using a disposable applicator. It dissolves and increases blood flow to produce an erection within 5–10 minutes.²⁴

Step 4 — Intracavernosal injections (ICI):

A small needle is used to inject a vasoactive medication (such as alprostadil, papaverine, or a combination called "trimix") directly into the side of the penis. This produces an erection within 5–15 minutes that typically lasts 30–60 minutes. While the idea of an injection may seem daunting, most men report that it is less painful than expected and that the results are reliable. Early use of injections can promote recovery of spontaneous erectile function.³¹ ³²

Step 5 — Penile prosthesis (implant):

When other treatments are ineffective, a surgically implanted device can provide reliable erections. Modern inflatable prostheses consist of two cylinders placed inside the penis, a pump in the scrotum, and a fluid reservoir. Satisfaction rates are high — up to 90% — because the device provides on-demand erections.³² This is the most invasive option but is often the most reliable for men with severe, treatment-resistant ED.

Testosterone replacement therapy (TRT):

The SPIRIT trial, published in JAMA Internal Medicine in 2026, was the first randomized, placebo-controlled trial of TRT in prostate cancer survivors. In 136 men with low-grade, organ-confined prostate cancer treated with radical prostatectomy who had hypogonadism, 12 weeks of TRT significantly improved sexual activity (by 0.91 daily events), sexual desire, well-being, body composition, and physical function compared to placebo — with no biochemical recurrence during treatment or 3-month follow-up.³³ However, TRT is contraindicated in men with active or metastatic prostate cancer and in men receiving ADT. These findings apply only to carefully selected men with low-grade disease after prostatectomy, and longer-term safety data are still needed.³³

Part 10: Beyond Erections — Redefining Sexual Intimacy

This may be the most important part of this chapter. Medical treatments for erectile dysfunction are valuable, but sexual recovery after prostate cancer is about much more than achieving an erection. Sexual dysfunction is complex — it involves physical, psychological, and relationship dimensions that all need attention.²⁴ ³⁴

The concept of a "new sexual paradigm":

The American Cancer Society Survivorship Guidelines recommend that mental health professionals trained in sex therapy help couples develop a "new sexual paradigm" — a reimagined sexual relationship based on current function and willingness to engage in sexual exploration.²⁰ ²⁴ This means letting go of what sex "used to be" and discovering what it can become.

Pleasure-focused intimacy:

A biopsychosocial sexual rehabilitation program that studied over 900 prostate cancer patients found that the most common recommendations given to patients were penile rehabilitation (84% of visits) and "pleasure-focused" intimacy (71% of visits) — meaning shifting the focus from performance to pleasure, from erections to connection.³⁵ Other frequently recommended psychosexual strategies included:

• Dedicated time for intimacy — scheduling time for physical closeness without pressure for intercourse
• Simmering — maintaining low-level physical affection throughout the day (touching, kissing, flirting) to keep the emotional and physical connection alive
• Sensate focus exercises — a structured approach developed by Masters and Johnson in which couples take turns touching each other's bodies for pleasure without the goal of intercourse or orgasm, gradually rebuilding comfort and connection
• Sexual aids — vibrators, lubricants, and other devices that can enhance pleasure for both partners³⁵

Orgasm without erection:

Many men are surprised to learn that orgasm is possible without an erection. The nerve pathways for orgasm are partially separate from those for erection. While orgasm quality may change (some men report less intensity), the capacity for pleasure often remains.²⁴

Intimacy without sex:

For some couples — particularly those dealing with the effects of ADT — sexual activity may not be possible or desired for a period of time. This does not mean intimacy has to stop. Physical closeness (holding hands, cuddling, massage), emotional vulnerability (sharing fears and feelings), and shared experiences (walks, meals, travel) are all forms of intimacy that sustain a relationship.

Part 11: The Partner's Sexual Health and Needs

An often-overlooked aspect of sexual recovery is the partner's own sexual health and needs. Research shows that a partner's sexual function and satisfaction can significantly affect the patient's erectile function recovery — and vice versa.²⁰ ²⁴

Partners have their own sexual needs. The loss of sexual activity affects both members of the couple. Partners may experience frustration, feelings of rejection, grief over the loss of their sexual relationship, and their own sexual dysfunction (particularly postmenopausal women who may have vaginal dryness or discomfort).²⁰

Partners may feel guilty about their needs. Many partners suppress their own sexual desires because they feel it would be selfish or insensitive to express them while their loved one is dealing with cancer. This silence can create distance and resentment.

Open communication is essential. Couples who talk openly about their sexual needs, fears, and desires — even when the conversations are awkward — tend to have better outcomes than those who avoid the topic.¹⁸ ²⁰

Partners should be included in sexual rehabilitation. The American Cancer Society Survivorship Guidelines explicitly state that partners should be included in usual prostate cancer survivorship care, including sexual recovery planning.²⁰ Shared decision-making should include both the patient's and partner's needs.²⁰

For heterosexual couples with postmenopausal female partners: Nurses and clinical support staff can provide education about methods to increase lubrication and sexual pleasure, including vaginal lubricants and, when appropriate, low-dose vaginal estrogen.²⁰ ³²

Part 12: Couples-Based Interventions — What the Evidence Shows

Several evidence-based interventions have been developed specifically for couples coping with prostate cancer:

TrueNTH Sexual Recovery Intervention: This randomized controlled trial tested a web-based program with 6 modules addressing expectations for sexual and emotional consequences of treatment, rehabilitation strategies, and guidance toward sexual intimacy recovery. The program was tailored to treatment type and sexual orientation. While it did not improve overall satisfaction with sex life at 6 months, couples in the intervention group engaged in sexual activity sooner after treatment. Over 85% of participants would recommend the program to other couples.³⁶

Cognitive Behavioral Therapy (CBT) and Mindfulness for Couples: A randomized trial of 68 prostate cancer survivors and their partners compared 4 weeks of couples' CBT, couples' mindfulness therapy, or no treatment. Both CBT and mindfulness significantly improved sexual distress and sexual satisfaction at 6 weeks compared to control. Qualitative analysis showed that mindfulness led to greater personal impact on couple intimacy.³⁷

Exercise and Psychosexual Education: A randomized clinical trial published in JAMA Network Open found that supervised exercise improved sexual function in men with prostate cancer, with the greatest improvements seen in men with the worst baseline function. The addition of psychosexual education and self-management (PESM) showed trends toward additional benefit.¹⁰

Psychological Flexibility Interventions: Research using the actor-partner interdependence model has shown that prostate cancer distress negatively affects psychological flexibility in both patients and partners, which in turn reduces self-esteem and relationship satisfaction. Interventions aimed at enhancing psychological flexibility may improve relationship functioning for both members of the couple.³⁸

A systematic review and meta-analysis of couple-based psychological interventions found that these programs significantly improved communication and reduced cancer-related distress for spouses, though effects on anxiety and depression were not statistically significant.²¹

Part 13: Intimacy and Sexual Health for Single Men

Not all men with prostate cancer have partners, and single men face unique challenges:

• Treatment side effects can be dispiriting, and without a partner's support, men may have difficulty coping or engaging in rehabilitation.²⁰
• The prospect of dating with erectile dysfunction, incontinence, or other side effects can feel overwhelming.
• Single men may become isolated, which research suggests can increase the risk of prostate cancer-specific mortality.²⁰

Practical advice for single men:

• Engage in sexual rehabilitation even without a partner. Penile rehabilitation (PDE5 inhibitors, vacuum devices) helps preserve tissue health regardless of relationship status.
• Consider joining a support group — either in person or online — where concerns about dating and sexual function can be discussed openly with other men who understand.
• When ready to date, consider when and how to disclose your diagnosis and any functional changes. There is no single right answer, but many men find that honesty early in a relationship builds trust and reduces anxiety.
• Referral to a psychologist, support group, or peer counselor can provide an environment in which single men can address recovery concerns as well as concerns about finding a partner.²⁰

Part 14: Sexual Health for Gay, Bisexual, and Sexual Minority Men

Gay and bisexual men (GBM) with prostate cancer face unique sexual health challenges that are often overlooked in standard clinical care.³⁹ ⁴⁰ ⁴¹

Unique concerns include:

• Receptive anal intercourse (RAI): Prostate cancer treatments — particularly radiation therapy and surgery — can affect the ability to engage in comfortable receptive anal intercourse. A study published in the International Journal of Radiation Oncology found that sexual minority men engaging in RAI after radiation reported worse orgasm ability, orgasm pleasure, and increased anal discomfort compared to population norms. The addition of ADT was associated with substantially worse outcomes across all sexual domains.⁴²
• Role-in-sex changes: Research from the Restore studies found that prostate cancer treatment resulted in loss of sexual role for many patients, with shifts predominantly from "tops" to "bottoms." Men who maintained a "top" role had significantly better sexual and mental health outcomes.⁴³
• Climacturia and anejaculation may have different implications for GBM depending on their sexual practices.³⁹
• Penile shortening can affect both insertive and receptive sexual function.³⁹
• Lack of tailored information: GBM frequently report that healthcare professionals do not provide information relevant to their sexual practices, and that mainstream support groups cater primarily to heterosexual men.⁴⁰ ⁴¹

The Restore-2 Trial: This was the first randomized controlled trial of sexual rehabilitation tailored specifically for sexual minority men with prostate cancer. The 24-month study of 401 GBM found excellent acceptability and feasibility of the tailored program, though no significant differences in sexual outcomes between intervention and control groups. The authors concluded that sexual "accommodation" — adapting to changed function — rather than "rehabilitation" may be a more realistic goal. Participants reported enduring use of sexual aids including vacuum pumps, anal dilators, and penile constriction rings.⁴⁴

What GBM should know:

• It is important to tell your doctor about your sexual orientation and sexual practices so that treatment discussions can be tailored to your needs.⁴² Clinical trials investigating sexual outcomes after prostate cancer treatment have historically not collected sexual orientation data, which perpetuates uncertainty about optimal management for GBM.³⁹
• Seek out support groups and resources specifically for GBM with prostate cancer (see Support Resources below).
• Receptive anal intercourse may elevate PSA, which is important to know for screening and monitoring purposes.⁴¹
• The NCCN Survivorship Guidelines note that sexual health recommendations should be followed for gender diverse survivors as applicable, with the involvement of appropriate healthcare specialists.²⁸

Part 15: Intimacy During and After Hormone Therapy (ADT)

Hormone therapy presents unique challenges to intimacy because it affects not just erectile function but the very desire for sexual activity. When testosterone is suppressed, many men experience a profound loss of libido — they simply do not think about sex or feel motivated to pursue it.²⁸ ²⁹

What partners need to understand:

• The loss of sexual desire on ADT is a direct biological effect of testosterone suppression — it is not a reflection of the patient's feelings toward the partner.
• Some men on ADT wish to continue sexual activity despite reduced physiologic desire, motivated by psychological desire, maintaining intimacy, and attending to their partner's needs.²⁴
• PDE5 inhibitors may be less effective during ADT because the underlying drive (testosterone) is suppressed, but they can still be tried.²⁴
• Rarely, some men on ADT can achieve erections with partner stimulation.²⁴

Maintaining connection during ADT:

• Focus on non-sexual physical affection: holding hands, cuddling, massage, kissing.
• Maintain emotional intimacy through regular, honest conversations about feelings and needs.
• Exercise together — physical activity has been shown to improve feelings of masculinity, preserve libido, and improve overall well-being during ADT.¹⁰
• Acknowledge the grief. Both the patient and partner may grieve the loss of their sexual relationship. This grief is valid and should be expressed, not suppressed.
• Consider couples counseling or sex therapy to develop strategies for maintaining connection.²⁰ ²⁸

Part 16: When to Seek Professional Help

Not every emotional challenge requires professional intervention, but certain situations warrant referral:

Seek help if you experience:

• Persistent sadness, hopelessness, or loss of interest in activities lasting more than two weeks
• Thoughts of self-harm or suicide (call 988 immediately)
• Severe anxiety that interferes with daily functioning or sleep
• Inability to make treatment decisions due to overwhelming fear
• Significant relationship conflict or communication breakdown
• Sexual distress that is not improving with medical treatment alone
• Social isolation or withdrawal from previously enjoyed activities

Types of professional support available:

• Psychologist or psychiatrist — for depression, anxiety, and adjustment disorders
• Couples counselor — for relationship and communication challenges
• Sex therapist — certified by AASECT (American Association of Sexuality Educators, Counselors and Therapists) for sexual function and intimacy concerns²⁸
• Sexual health specialist — may come from urology, psychology, oncology, or rehabilitation medicine backgrounds²⁸
• Social worker — for practical support, insurance navigation, and connecting with resources
• Support groups — peer support from other men who understand the experience. Both in-person and virtual options are available.
• Pelvic floor physical therapist — for urinary and sexual rehabilitation²⁸

Questions to Ask Your Doctor

1. "Is it normal to feel this anxious/depressed after a prostate cancer diagnosis?"
2. "Can you refer me to a psychologist or counselor who specializes in cancer patients?"
3. "What should I expect regarding sexual function after my specific treatment?"
4. "Are there medications or devices that can help with erectile dysfunction?"
5. "Should my partner and I consider couples counseling or sex therapy?"
6. "Is there a support group — in person or online — that you recommend?"
7. "I am a gay/bisexual man — how might treatment affect my specific sexual practices?"
8. "How long should I wait before trying sexual activity after treatment?"
9. "Are there exercises or lifestyle changes that can improve my sexual function?"
10. "My partner is struggling — are there resources specifically for caregivers and partners?"

Myth vs. Fact

Myth: "If I can't get an erection, my sex life is over."

Fact: Erections are one part of sexual function, but intimacy encompasses much more. Orgasm is often possible without an erection. Many couples discover new and deeply satisfying ways to connect physically and emotionally. Multiple treatments are available — from oral medications to vacuum devices to injections to implants — and a stepwise approach can restore function for most men.²⁴ ²⁸ ³²

Myth: "My partner doesn't need support — they're not the one with cancer."

Fact: Research shows that partners of men with prostate cancer often experience equal or greater psychological distress than the patients themselves. Partners of men with metastatic disease have a 2.4-fold increased risk of suicide.¹³ ¹⁴ Partners deserve — and need — their own support.

Myth: "Talking about my feelings will make things worse."

Fact: The opposite is true. "Protective buffering" — hiding emotions to spare your partner — actually increases distress for both people. Open communication, even when difficult, is consistently associated with better psychological adjustment and stronger relationships.¹⁸ ¹⁹

Myth: "Depression and anxiety are just part of having cancer — there's nothing you can do."

Fact: Depression and anxiety are treatable conditions, not inevitable consequences of cancer. Cognitive behavioral therapy, mindfulness-based interventions, exercise, medication, and support groups have all been shown to reduce psychological distress in men with prostate cancer.¹ ² ¹⁰ ²¹ ³⁷

Myth: "If I'm on hormone therapy, there's no point in trying to be intimate."

Fact: While ADT suppresses libido and erectile function, many men on ADT wish to maintain intimacy based on psychological desire and relationship connection. Non-sexual physical affection, emotional closeness, and — for some men — assisted sexual activity remain possible and meaningful.²⁴ ²⁸

Myth: "Gay and bisexual men have the same sexual concerns as heterosexual men after prostate cancer treatment."

Fact: Gay and bisexual men face unique challenges, including effects on receptive anal intercourse, role-in-sex changes, and a lack of tailored clinical information. It is important to discuss sexual orientation and practices with your healthcare team so that care can be appropriately individualized.³⁹ ⁴⁰ ⁴²

Key Takeaways

1. Emotional distress is normal and common — men with prostate cancer are nearly twice as likely to experience depression and anxiety compared to men without cancer. Seeking help is a sign of strength.¹ ²
2. Prostate cancer is a couple's disease — partners experience significant distress, often more than the patient. Open communication and shared decision-making improve outcomes for both.¹³ ¹⁸ ²⁰
3. Intimacy is not the same as sex, and sex is not the same as an erection — broadening the definition of intimacy opens the door to meaningful connection even when sexual function has changed.²⁴ ³⁵
4. Effective treatments exist for erectile dysfunction — a stepwise approach from oral medications to vacuum devices to injections to implants can restore function for most men. Penile rehabilitation should begin early.²⁸ ³¹ ³²
5. Professional help is available and effective — psychologists, sex therapists, couples counselors, and support groups can all make a meaningful difference. Do not wait until you are in crisis to seek help.²⁰ ²¹ ²⁸

Support Resources

Emotional and Psychological Support:

• Cancer Support Community — cancersupportcommunity.org — Free counseling, support groups, and education. Helpline: 1-888-793-9355.
• CancerCare — cancercare.org — Free professional counseling and support groups (in person, phone, and online).
• National Suicide Prevention Lifeline — Call or text 988 — 24/7 crisis support.
• Crisis Text Line — Text HOME to 741741 — Free crisis counseling via text.
• AnCan Foundation — ancan.org — Virtual peer-led support groups for prostate cancer patients and caregivers.
• PC-PEP (Prostate Cancer Patient Empowerment Program) — pcpep.org — Evidence-based online program combining physical, mental, and social support.

Sexual Health and Intimacy:

• AASECT (American Association of Sexuality Educators, Counselors and Therapists) — aasect.org — Find a certified sex therapist near you.
• Sexual Medicine Society of North America — smsna.org — Find a sexual medicine specialist.
• NCCN Survivorship Guidelines — Sexual Health — nccn.org — Evidence-based recommendations for sexual health after cancer treatment.

For Partners and Caregivers:

• Caregiver Action Network — caregiveraction.org — Education, peer support, and resources for family caregivers.
• Family Caregiver Alliance — caregiver.org — Information, services, and advocacy for family caregivers.
• Well Spouse Association — wellspouse.org — Support for partners of people with chronic illness.

For Gay, Bisexual, and Sexual Minority Men:

• Out With Prostate Cancer — outwithprostatecancer.com — Resources and community for LGBTQ+ men with prostate cancer.
• Malecare — malecare.org — Support groups including LGBTQ+-specific prostate cancer groups.
• National LGBT Cancer Network — cancer-network.org — Resources and support for LGBTQ+ cancer patients.

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