Impact of androgen deprivation therapy on sexual function: a response

Abstract

Dear Editors,We appreciate the growing interest in sexual health for cancer patients and survivors. Mazzola and Mulhall's recent paper, 1 however, creates the impression that rewarding sex is not possible for prostate cancer patients on androgen deprivation therapy (ADT). This impression, we believe, is not scientifically justified, and may be a disservice to prostate cancer patients and their partners in that it could act as a negative placebo, i.e., the opposite of an aphrodisiac. It was unfortunate that the authors did not use their paper to explore positive pathways for sexual interaction and arousal among ADT patients. Instead, readers may be left with a rather discouraging outlook on the prospect of sexual intimacy and pleasure for androgen-deprived cancer patients.Historically and culturally, there are data to show that castrated males are not obligatorily asexual. While most historical eunuchs were castrated before puberty, they were considered to be everything from asexual to hypersexual depending on the culture. 2 Postpubertal eunuchs, whether the one million Hijra of India 3 or the contemporary Westerners castrated (frequently by self-surgery) as treatment for Male-to-Eunuch gender dysphoria, 4 continue to display both sexual interest and ability.Our data show that many modern-day voluntary eunuchs maintain not only sexual interest, but also sexual activity (manuscript in prep.). Of 203 adult males who were voluntary castrated (chemically or physically) and either used no hormone supplementation or took minimal estrogen to prevent osteoporosis and hot flashes, 4% reported an increase in sexual activity, either masturbation or with a partner, 24% reported no change and 45% reported some reduction in sexual activity. Only 27% reported becoming asexual, a result that many of them had sought. As reported previously, 5 these men ranged in age from 181 to their 80s, with a mean age in the mid-forties. Sexual function was self-reported in a brief questionnaire that we designed to acquire data on sexual fantasies, sexual attraction and sexual activity in the months before and after castration. Based on the information that the respondents provided us, we could assume that the vast majority of these men were functionally intact before being androgen-deprived.One contributing factor for androgen-deprived males to maintain sexual interests is likely to be estrogen supplementation. Wibowo et al. 6 recently reviewed a wealth of animal studies showing that estrogen in androgen-deprived males raises libido above castrate levels. Furthermore, Wibowo et al. have now expanded this review to include castrated males of 27 species ranging from amphibians to mammals. Of these, 14 (13 mammalian) species exhibit elevated sexual interest following exogenous estrogen administration. This further strengthens the notion that androgen deprivation needs not terminally eradicate libido. We acknowledge, though, that this effect is not universal and differences between species could be attributable to innate species differences, diff...

Gender Preference in the Sexual Attractions, Fantasies, and Relationships of Voluntarily Castrated Men

“…This finding is further supported by research indicating that estrogen treatment can help increase sexual interest above the castrate level in other human populations. 9 , 10 For example, in two small studies on patients with prostate cancer, more patients who were taking high-dose estrogen to suppress testosterone remained sexually active than those who were surgically castrated. 30 , 46 In addition, many male-to-female transsexuals who receive estrogen therapy are sexually active.…”

“…Nevertheless, some castrated men remain sexually active despite being deprived of testosterone. 9 , 10 This has been reported for a proportion of patients with prostate cancer on androgen-deprivation therapy 10 , 11 , 12 and male-to-female transsexuals. 13 Preservation of sexual interest in individuals who are surgically castrated appears to be enhanced by testosterone replacement therapy or high-dose estrogen treatment.…”

“… 13 Preservation of sexual interest in individuals who are surgically castrated appears to be enhanced by testosterone replacement therapy or high-dose estrogen treatment. 7 , 9 Brett et al 7 noted that some 22% of respondents in their study of voluntarily castrated men claimed to experience a change in their sexual orientation after castration. For this reason, we expanded our study to explore how sexual attraction, fantasies, and relationships change after castration.…”

Hypogonadism in Male Sexual Dysfunction

“…Low testosterone levels in adult males change sexual interest even at the level of sexual fantasies [44,45]. Even daydreaming is modulated by normal testosterone levels [45,46]. Autostimulation and sexual actions are active behaviors, dependent on testosterone levels.…”

Castrati Singers—All for Fame: A Commentary

“…Recent research on postpubertal eunuchs finds that, while their sexual abilities may diminish, they do not necessarily become asexual. Their interests may also broaden, with fewer of them being exclusively heterosexual or homosexual in sexual attraction [11]. The Papal Bull of Pope Sixtus V in 1587 forbade the marriage of eunuchs and castrati, not because they were incapable of sex but because their sexuality was believed to corrupt women [12].…”