Sexual function outcomes following prostate cancer treatment in sexual and gender minority populations: a mixed-methods systematic review

Introduction

Background

Prostate cancer (PCa) affects approximately 13% of men during their lifetime (1). Although treatments are lifesaving, they are associated with substantial adverse effects on sexual functioning. Sexual dysfunction is among the most frequently reported health-related quality of life (HRQOL) concerns following PCa treatment (2). However, most research in this field has focused on the cisgender, heterosexual populations, resulting in limited understanding of treatment-related sexual outcomes among sexual and gender minority (SGM) individuals.

Sexual orientation refers to an individual’s sexual and/or romantic attraction to others and includes identities such as gay, lesbian and bisexual. In this review, sexual minorities (SM) include gay and bisexual men (GBM) as well as men who have sex with men. Gender identity refers to an individual’s internal sense of gender, which may or may not align with sex assigned at birth or cultural expectations of gender. Gender minorities include transgender women, transgender men and some intersex and non-binary individuals (3). Transgender women remain at risk of PCa because the prostate is typically retained during gender reassignment therapy to reduce surgical morbidity (4). In this review, gender minorities refer to transgender women.

Rationale and knowledge gap

Sexual practices and relational dynamics among SGM individuals may differ from those of heterosexual populations (5,6). Consequently, the impact of treatment-related side effects may vary substantially. Commonly used patient-reported outcome measures (PROMs) assessing sexual function after PCa treatment, including Expanded Prostate Cancer Index Composite, International Index of Erectile Function and Male Sexual Health Questionnaire, primarily reflect heteronormative assumptions (e.g., emphasis on vaginal penetration) (7-9). These instruments may not adequately capture sexual practices beyond penile-vaginal intercourse or assess side-effects that are particularly relevant to SGM populations.

Erectile dysfunction (ED) is the most recognised sexual consequence of PCa treatment (2). However, other treatment-related sexual side effects—including changes in ejaculation, orgasm, and anal sexual function—remain under-recognised as they are not routinely assessed (10). As a result, current PROMs provide an incomplete picture of the sexual sequelae of PCa treatment in SGM patients. Inadequate assessment limits clinicians’ ability to counsel patients comprehensively regarding potential sexual outcomes and may hinder shared decision-making.

In the US, an estimated 97,845–123,006 gay and bisexual PCa survivors experience inadequate access to appropriate care for treatment-related sexual dysfunction (2). Structural and interpersonal barriers contribute to these disparities. In a survey of 112 urologists, 63% reported not routinely asking about sexual orientation, and 26% assumed heterosexuality at first encounter (11). Perceived irrelevance of sexual orientation in clinical care further compounds barriers appropriate SGM post-treatment care. Limited clinical knowledge may discourage gender minority patients seeking care (2). Absence of SGM-specific research and educational resources leave healthcare professionals poorly equipped to counsel SGM patients on PCa treatment choices.

Objective

This review aimed to synthesise existing evidence on patient-reported sexual functioning outcomes among SGM individuals following PCa treatment. Findings will identify current knowledge gaps to inform the development of inclusive PROMs and support the design of education interventions for healthcare professionals. We present this article in accordance with the PRISMA reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0270/rc).

Methods

Search strategy

This review was prospectively registered (CRD42024609973) in the International Prospective Register of Systematic Reviews (PROSPERO). In this review, no historical date limit was applied; all records published up to December 2024 were considered. A comprehensive search was conducted between November to December 2024 across the following databases: EMBASE, Ovid MEDLINE, Global Health, APA PsycInfo, APA PsycTherapy and AMED. Search strategies combined MeSH terms and free-text keywords relating to PCa, SGM populations, and treatment modalities. Treatment-specific search strings were developed for surgery, radiotherapy, hormonal therapy, chemotherapy and focal therapy (Table S1). Separate searches were conducted for each treatment modality. Eligibility criteria were English-language studies of SGM patients with PCa (GBM, men who have sex with men, transgender women, non-binary and intersex people) who had received any PCa treatment, reporting patient-reported sexual health or quality-of-life outcomes, and, where available, differences from heterosexual patients, using any primary or secondary study design. Detailed criteria are summarised in Table S2.

Review of studies

Records were imported into EndNote for de-duplication and screening. Two reviewers (K.A.B. and C.H.C.) independently screened titles and abstracts against eligibility criteria. Treatment modalities were initially searched separately to explore potential differences in sexual outcomes across treatment types. However, as records retrieved from the five searches were largely overlapping, all records were subsequently combined for screening and selection.

Data extraction

Two reviewers (K.A.B. and S.K.) independently extracted data using NVivo software (version 15.0.0). A coding framework was developed iteratively. Initial codes were generated inductively from the data, followed by deductive line-by-line coding to refine and organise themes. The analytic approach is described in detail in Table S3.

Risk of bias and quality assessment

Included studies were independently appraised by three reviewers (K.A.B., A.C., W.M.E.L.). Methodological quality was assessed using the Joanna Briggs Institute critical appraisal checklists appropriate to study design, or the Mixed Methods Appraisal Tool, where applicable (12-14). Discrepancies were resolved through discussion until consensus was agreed. Detailed appraisal results are provided in Table S4.

Data analysis

A convergent integrated approach was used to synthesise and integrate findings across qualitative and quantitative study designs (15). Due to heterogeneity in quantitative outcomes measures and reporting, statistical meta-analysis was not feasible. Quantitative findings were transformed into textual descriptions (‘qualitised’) to enable integration with qualitative data (example detailed in Figure 1). An initial preliminary synthesis was conducted to explore patterns and relationships across studies and form an inductive code framework. This framework was further refined through line-by-line coding, incorporating both inductive and deductive approaches. Codes were organised into sub-themes, which were subsequently grouped into overarching themes. Any disagreements were discussed among the reviewers and resolved by consensus.

Figure 1 Example of the convergent integrated approach to mixed-methods data integration.

Results

Search results

The database search identified 12,511 titles total across five treatment-related searches (Table S1). After screening against eligibility criteria, sixty articles were selected for full-text review. Studies were excluded for the following reasons: irrelevance; not SGM specific; not reporting outcomes of sexual function; abstract only publication; or review article design. Twenty studies met the inclusion criteria. Backwards citation searching of the included studies reference lists revealed 21 additional records for full text review; of which 15 met inclusion criteria. In total, 35 studies were included in the final synthesis (Figure S1).

Study characteristics

Of the 35 included studies, 1,472 SGM patients were included; GBM (n=1,100), gay men (n=329), men who have sex with men (n=42) and transgender women (n=1). A total of 658 GBM and 25 partners were drawn from independent datasets, while 814 patients and 21 partners were drawn from four major datasets across 19 studies. These studies reported findings from different analyses using the same datasets: the Restore 1 dataset (nine studies), the Restore 2 dataset (five studies), the La Trobe University dataset (three studies) and the Western Sydney University dataset (three studies). One study combined results from both Restore 1 and 2. Overall, 54% of the papers and 55% of patients were derived from these four key datasets, indicating that just over half the evidence base is influenced by a small number of underlying cohorts. The key details of these datasets are summarised in Table 1. Included studies were conducted in: USA (n=25), Canada (n=11), Australia (n=9), UK (n=8), New Zealand (n=2), Sweden (n=2), and Ireland (n=1). The La Trobe University dataset stated that 4% of participants originated from 17 other countries but did not specify which. Selected studies were published between 2005 and 2024, and included the following study designs: quantitative cross-sectional (n=15), qualitative cross-sectional (n=15), mixed-methods (n=3), and case study (n=2). Studies reporting ethnicity data (n=25) indicate that the majority of participants are of white ethnicity. The most common treatment was radical prostatectomy. Six studies did not report treatment type. Study characteristics are presented in Table 2.

Themes

Three overarching themes emerged referring to patient-reported sexual outcomes in SGM populations: (I) sexual implications of treatment; (II) psychological implications; and (III) relational implications. Figure 2 shows how these themes interact and are influenced by minority stress theory. Perception emerged as a central, cross-cutting construct linking all three themes. Changes in sexual function influenced individuals’ perceptions of self, which in turn shaped concerns about how they were perceived by others. The sexual implications theme captured the range of treatment-related physical effects and their impact on sexual functioning in SM patients. These effects extend beyond physical symptoms, contributing to psychological distress and influencing intimate relationships. The psychological implications theme explored the mental and emotional impact of treatment-related effects, with particular emphasis on the importance of the ‘role in sex’, especially among GBM. The term ’sex-role’ refers to individuals’ preferred positional role in sexual activity, ‘top’ being the insertive partner, ‘bottom’ being the receptive partner and ‘versatile’ taking part in both. Sex-role emerged as an important determinant of how specific side-effects were experienced. For many SM individuals, sexual identity and self-concept are closely tied to sexual role and their ability to fulfil that role. PCa treatment has been shown to result in greater disruption to sexual roles in non-heterosexual populations (16). Consequently, the perceived impact of specific sexual side effects varied according to an individual’s sexual role.

Figure 2 Theme interactions and influence of minority stress theory. SGM, sexual and gender minorities; STI, sexually transmitted infection.

The relational theme encompassed SGM individuals’ interactions with healthcare professionals, sexual partners, and the wider SGM community, highlighting how treatment-related sexual changes shaped relational dynamics and experiences of support or marginalisation.

Sexual implications

ED

ED was a highly prevalent side effect following PCa treatment, with 49–90% of participants experiencing erectile difficulties across studies (17,18). In the Restore 1 dataset, 85% of participants rated their erections as insufficiently firm for intercourse (19). ED negatively impacted self-esteem and sexual confidence, particularly in relation to casual sex and initiating intimacy with new partners (20,21). Participants described ED as damaging to identity and masculinity, contributing to feelings of reduced sexual viability. ED also affected partners’ perceptions, with some interpreting erectile difficulties as lack of sexual interest, and was reported to contribute to relationship strain or breakdown (22-25).

Anejaculation

Anejaculation (loss of semen during an orgasm) was commonly reported following surgical or radiotherapy treatment due to prostate removal or radiation. In the Restore 1 dataset, 94% of participants reported loss of ejaculate post-treatment (18). Comparative data from the Western Sydney Dataset (measuring HRQOL outcomes in 140 GBM vs. 225 heterosexual men) indicated that the impact of anejaculation was greater amongst SM patients than heterosexual men (26). Across many studies, participants described a strong sense of loss associated with the absence of ejaculate (22,23,27-30). Thirteen studies reported distress linked to the lack of visible semen (22-28,30-34) and five described orgasms as feeling ‘incomplete’ (23,25,29,30,34). Ejaculation was frequently framed as a marker of masculinity, with semen being a material deliverable of sexual competence. Although some participants were indifferent to ejaculatory changes, others expressed disappointment, affecting sexual satisfaction (27,29,30,33,35). In a study of 124 GBM with PCa and 21 male partners, 52% reported being somewhat or very concerned about their ability to ejaculate (30).

Orgasm changes

Participants reported a spectrum of orgasmic changes following treatment, ranging from odd, reduced intensity to complete anorgasmia (23,28,29). Reduced intensity was commonly attributed to anejaculation, resulting in shorter or incomplete orgasms (23,25). In the Restore 1 dataset, 87% of 193 GBM reported altered orgasm sensation (18). In another study of 96 non-heterosexual men, 36% of those attempting penetrative sex reported rarely or never feeling satisfied with their ability to achieve orgasm (18,34). Conversely, four studies report intensified orgasms in some participants, described as more diffuse and intense (22,27,30,34).

Anal sex changes

Changes in sensation during receptive anal intercourse were frequently reported, with loss of the prostate identified as a contributor to reduced pleasure (20,22,27,30,36). In one study, 64% of gay participants identified the prostate as a key source of sexual pleasure. Changes in anal sex practices were more common amongst non-heterosexual than heterosexual individuals (59% vs. 12%) (16). Only 22–27% of GBM rated erectile function as adequate for anal sex post-treatment (19,30), and 42–65% reported pain during receptive anal intercourse (18,37). Inability to perform anal sex was described as particularly distressing, contributing to feelings of sexual inferiority (30).

Climacturia

Climacturia was reported by 49% of GBM in the Restore 1 dataset (18). Participants described embarrassment, unpredictability, and reduced spontaneity, contributing to avoidance of sexual activity and feelings of unattractiveness (22,23,28,30,33). Anxiety about partners’ reactions disrupted common sexual practices of SM, including oral sex and mutual masturbation (23). For some, climacturia led to cessation of sexual intimacy with both casual and long-term partners (22). Although some partners adapted using practical strategies to collect the urine, this was described as mechanising sexual encounters (25). Restore 2 data demonstrated significantly worse urinary, bowel, and hormonal function among GBM compared with heterosexual men (38).

Incontinence

Non-sexual urinary incontinence was reported by 64.2% of Restore 1 participants (18). Fear of leakage limited engagement in physical, social, and everyday activities, including exercise and grocery shopping (24,29,39).

Loss of libido

Participants frequently described diminished or absent desire for sexual intercourse or masturbation following treatment (17,20,30). Responses varied, with some continuing to attend gay sex venues without sexual interest (out of habit or for exercise), whilst others stopped sexual activity completely (20,22,25,28,30,32). In one study of 124 GBM and 21 partners, 50% reported little or no sexual enjoyment post-treatment, compared with 4% pre-diagnosis (30). Experiences of libido loss ranged (20-22,25,27,28,30) from distress and feelings of castration (27) to neutrality or acceptance (22). In one case, reduced libido due to hormone treatment was perceived positively, facilitating conformity within in a heterosexual marriage (27).

Penile changes

Penile shortening and curvature were commonly reported following treatment, affecting 66% of Restore 1 participants (18). Interviews with 46 GBM highlighted substantial perceived reduction in length and girth, with significant impact on self-esteem and psychological wellbeing, including suicidal ideation in one case (30). Participants attributed the severity of impact to the centrality of penis size within gay male sexual culture, where frequent visual comparison of genital appearance can strongly shape self-esteem and perceived desirability. Focus group data from Latino and Black gay men discussing side effects of PCa treatment highlighted additional pressure related to racialised sexual stereotypes and anxiety about judgements of sexually adequacy (31).

Use of sexual aids

Use of sexual aids was widespread. In the Restore 1 dataset, 87% had used erectile-enhancing medications and 75% reported using pornography to maintain sexual interest (18). Sildenafil and injectable therapies (e.g., alprostadil) substantially improved sexual activity following treatment, particularly for insertive roles (‘tops’), and supported re-engagement with sexual and social spaces. However, even when effective, reliance on aids reduced spontaneity and imposed ongoing financial burden, particularly in the US (22,25,40).

Psychological implications

Emotional responses

Sexual dysfunction was a significant predictor of overall quality of life in the Restore 1 cohort (19). Compared with heterosexual men, GBM reported poorer HRQOL, masculine self-esteem and treatment satisfaction, along with greater ejaculatory concern, psychological and cancer-related distress (26). Fear of initiating intimacy, due to loss of confidence, embarrassment and anticipated partner reactions, were widely reported (20,21,28,30,33,39,40). ED, climacturia, penile changes, scars and weight gain were cited as contributing factors to fear of initiating intimacy (21,24,28,30,40). Changes in body image contributed to feelings of unattractiveness and sexual inadequacy, with depression associated with both cancer diagnosis and loss of sexual self-esteem (27-30,36,38). Some participants reported suicidal ideation due to sexual dysfunction. Grief, anger, frustration, and regret were commonly expressed, particularly regarding inadequate pre-treatment information about psychosexual side effects (20-23,25-27,29,31,32,37). Some men regretted their decision to undergo treatment due to the impact on sexual function (25,28,30,39). These emotions often led to withdrawal from their sexual communities (21,24,25,27,28,30-33,36,39,41).

Identity changes

Non-heterosexual men were significantly more likely than heterosexual men to report changes in sex role post-treatment (59% vs. 12%) (16). Loss of ability to perform insertive roles was described as particularly damaging to identity and masculinity, with many unable to adapt to another role (21,25,30,33,36,39). Some participants adapted by shifting roles (e.g., as a receptive partner, ‘bottom’) or developing new sexual practices (17,23,28,32,33). Participants identifying as versatile (both insertive and receptive) reported a greater role adaptability associated with post-treatment effects (31). For many SM patients, their perception of identity relies heavily on their role in sex and their ability to fulfil that role. Impacts varied by sexual role: ‘top’ were more affected by ED, erectile aid efficacy, and loss of masculinity (21,22,25,28,30,31,33,35,39); whereas ‘bottoms’ were more affected by anodyspareunia and loss of stimulation during receptive anal intercourse due to prostatectomy and nerve damage (18,20,22,27,29,36,37,42).

Mindset

Mindset strongly influenced adjustment to sexual side effects. While regret and distress were common, some participants reached a state of acceptance, reframing sexual changes as a part of ageing or survivorship (32,39). Several GBM reported prioritising survival over sexual function and redirecting focus towards non-sexual activities and personal growth (25,30,31). A broader, multifaceted conceptualisation of masculinity—not solely dependent on sexual functioning—supported psychological resilience in some participants (28).

External and relational implications

Healthcare experiences

Amongst 100 gay men, 77% reported feeling comfortable disclosing their sexual orientation to clinicians, with disclosure associated with higher masculine self-esteem (43). Recognition of sexuality by health care professionals positively influenced care experiences (30). However, heteronormative assumptions, limited discussions of SGM-specific sexual partners, and experiences of discrimination were frequently reported. These experiences often led to fear and reluctance to disclose sexuality. Only 6% of GBM in the Restore 1 dataset reported discussions with their clinical teams about receptive anal intercourse related pain or complications (44). Poor communication about sexual side effects resulted in SM patients feeling misinformed about treatment consequences and uncertain about rehabilitation options (28,32,41). Healthcare discrimination related to sexual orientation was associated with poorer mental health and HRQOL (44,45).

SGM community

Sexual activity within the gay community was described as a key source of social connection (20,21,23,40). However, fear of community rejection due to sexual dysfunction led to social withdrawal and isolation (24,28,31,33,41). Ageism, body ideals, and racialised stereotypes intensified pressures on sexual desirability, particularly amongst Black and Hispanic men (46).

Sexual partners

Participants in long-term partnerships reported relationship strain and changes in intimacy, and in some cases, relationship dissolution due to the sexual consequences of treatment (17,22,25,30,36). Some adapted with open relationships and use of erectile aids (21,23,25,31,33,36). Those with supportive partners who embraced the ‘new normal’ seemed to experience more positive outcomes (23,33,35). Disclosure of sexual dysfunction to new partners caused anxiety and embarrassment (21,23,24), with some likening this to an endless ‘coming-out process’ (16). Some reported using condoms so that partners did not discover their inability to ejaculate (22). Participants with human immunodeficiency virus (HIV) reported difficulty finding long-term partners, and that treatment-related sexual dysfunction made this more difficult (31). Others reported there being less awareness of PCa within the gay community, with its impact being ‘overshadowed’ by HIV and acquired immunodeficiency syndrome (AIDS) (21). Despite challenges, GBM reported higher sexual confidence and functioning than heterosexual men in some studies (26,38).

Sexual health

In the Restore 1 and 2 datasets, post-treatment condom use in anal intercourse was low. For example, condom use was reported in only 16 of 121 (8%) participants engaging in insertive anal sex in the previous three months, and in only 35 of 120 (29%) of those who engaged in receptive anal sex. For receptive anal sex, 35 of 120 participants (29%) reported partners using condoms, while 39 (33%) reported unprotected receptive anal sex. Erection difficulties were cited as a barrier to condom use, with participants reporting post-treatment diagnoses of sexually transmitted infections (STIs; 8 men) and HIV (3 men) (19). In another study of 401 GBM patients, 11% were diagnosed with post-treatment STIs (47). Risk factors for post-treatment STIs included multiple sexual partners, non-monogamous sexual relationships, time since PCa diagnosis, better sexual function, and use of injectable erection aids.

Discussion

This review synthesised current evidence on patient-reported sexual outcomes among SGM following PCa treatment. Across studies, treatment was associated with substantial disruption across interrelated domains of psychological wellbeing and complex relational dynamics involving partners, clinicians and the wider SGM community. Collectively, these findings indicate a distinct, and in some cases, amplified impact of PCa-related sexual side effects in SM populations. However, the review also highlighted a substantial underrepresentation of gender minority individuals in the current data of this topic, precluding meaningful conclusions for this group. The results underscore the need for inclusive PROMs, targeted clinical education, and focused research addressing neglected SGM subgroups, particularly gender minorities.

Under-recognised sexual side effects, such as anejaculation, climacturia and anodyspareunia, emerged as major sources of distress. Many participants described these symptoms as unexpected, reflecting limited pre-treatment counselling. For some, unanticipated changes contributed to frustration, anger and treatment regret. These findings suggest persistent gaps in clinician awareness of how specific side-effects intersect with SGM sexual practices. Previous work by Dickstein has similarly highlighted the need for structured approaches to proactively assess sexual and gender identity to support tailored, inclusive cancer care (48).

The findings are consistent with broader evidence that oncology clinicians rarely enquire about sexual orientation, gender identity, or sexual role. Ussher et al. identified three clinician orientations—inclusive-reflective, egalitarian and anti-inclusive—and reported that most clinicians do not routinely ask about sexual or gender orientation, often perceiving it as clinically irrelevant. Although an egalitarian approach may appear neutral, treating all patients ‘the same’ may perpetuate feelings of invisibility among SGM patients and exacerbate unmet needs. In contrast, an inclusive-reflective approach—actively acknowledging SGM identities and integrating them into care planning—has been proposed as best practice (49). Low rates of enquiry about sexual orientation, gender identity and pronoun use have been reported among oncologists more broadly (50,51).

Heteronormative design of existing PROMs and underlying assumption that SGM do not require distinct considerations likely reinforces gaps in care. Widely used measures inadequately capture domains such as climacturia, anodyspaerunia, loss of prostate-related pleasure and changes to role-in-sex, all of which were frequently reported as highly impactful (52). Furthermore, sexual orientation and gender identity data are rarely collected in oncological research, limiting understanding of SGM-specific outcomes contributing to evidence gaps, particularly in gender minority populations (53). International guidance has similarly emphasised the absence of routinely collected sexual orientation and gender identity data, as well as identified barriers to disclosure arising from prior experiences of healthcare discrimination (2).

Emerging instruments, such as the Sexual Minorities and Prostate Cancer Scale (SMACS), represent progress towards inclusive assessment. The SMACS includes domains assessing sexual satisfaction, confidence, role-in-sex, urinary incontinence during sex and receptive anal sex-related concerns. However, validation has been largely limited to GBM, with minimal data among gender-minority individuals. Further psychometric validation across diverse SGM populations is required.

Our findings suggest several sexual side effects appear to disproportionately affect SM patients, likely reflecting differences in sexual practices and the centrality of sexual role to identity. For many GBM, roles such as ‘top’ or ‘bottom’ are closely linked to masculinity and self-identity. Consequently, ED, anejaculation and anodyspareunia may disrupt not only sexual activity but also identity and relationship positioning. Oral sex and mutual masturbation are common practices among GBM (54), which may heighten the visibility and impact of climacturia and anejaculation. Anal penetration typically requires 33% more erectile rigidity than to vaginal penetration, potentially amplifying the functional impact of ED in men who engage in anal intercourse (55). In addition, the prostate is frequently described as a site of pleasure for individuals engaging in receptive anal intercourse; prostatectomy and radiation-related rectal injury may therefore have unique implications for receptive partners (44).

These findings can also be understood through minority stress theory, which posits that SM health disparities arise from chronic exposure to prejudice and social stigma-related stressors (56). Distal stressors include discriminatory laws, overt victimisation and microaggressions, while proximal stressors involve psychological processes such as internalised stigma (rejecting oneself) and anticipated stress (57). Within this framework, treatment-related sexual dysfunction may compound pre-existing concerns regarding identity, masculinity, and safety in healthcare if SGM patients ‘reveal’ their identity. When SGM-inclusive pre-treatment counselling, PROMs and rehabilitation pathways are absent, structural and interpersonal minority stressors may be intensified.

Addressing these gaps requires system change. Routine collection of sexual orientation and gender identity data, inclusive communication training for clinicians, and rehabilitation pathways that explicitly acknowledge diverse sexual practices and identities are essential to improving sexual outcomes for SGM patients following PCa treatment.

Sensitivity discussion

A sensitivity analysis was undertaken to assess the potential influence of the four large datasets on the thematic findings. Specifically, we compared the frequency of sub-theme reporting between the 19 ‘big dataset’ studies and the 16 independent studies. Details of our sub-analysis can be found in Figure 3. Across most domains, independent studies were at least as likely, and often more likely, to report individual themes. While large cohort studies consistently captured core functional issues, independent studies more frequently identified themes relating to identity, emotional impact, partner experiences, and SGM perspectives. These findings indicate that the thematic structure is not driven solely, or even predominantly, by a small number of large datasets.

Figure 3 Frequency of reporting each sub‑theme in the 4 big datasets versus independent studies. SGM, sexual and gender minorities.

However, the inclusion of several large cohorts introduces a potential risk of non-independence and overrepresentation, which remains an important limitation. Reassuringly, the sensitivity analysis suggests that this has not resulted in disproportionate weighting of themes from these big datasets, supporting the robustness of the overall findings.

Strengths and limitations

This review has several strengths. A comprehensive search strategy was conducted across multiple databases and treatment modalities. A mixed methods approach, inclusion of both qualitative and quantitative studies, enabled a nuanced synthesis of a limited and heterogenous evidence base. The convergent integrated method facilitated triangulated findings and credible conclusions. Independent screening and quality appraisal by multiple reviewers enhanced methodological rigour and reduced risk of selection bias.

Several limitations should be acknowledged. A primary limitation of this review is the heavy reliance on a small number of overlapping datasets. Overall, 57% of the studies and 55% of patients were derived from four key datasets (Restore 1, Restore 2, La Trobe University, Western Sydney University). This indicates that the evidence base could be influenced by a small number of underlying cohorts and limits the independence of the findings. We have tried to mitigate this limitation through a sub-analysis detailed in our sensitivity analysis.

The independent studies outside the large cohorts were generally small and predominantly qualitative, limiting generalisability. The evidence base is also heterogeneous, with overlapping datasets and variable methodological quality, which reduces overall certainty in the findings. Most participants were English-speaking, of White ethnicity and highly educated, with only one study including a Spanish-speaking cohort, so the results may not reflect the experiences of racially, linguistically or socioeconomically diverse SGM populations. All data were collected in high-income countries with high-quality healthcare, and we only included studies published in English, which may have excluded relevant research from non-English-speaking or lower-resource settings. Despite the stated aim to investigate outcomes for gender minority patients, representation was extremely limited; only one transgender woman was included across all studies, precluding meaningful analysis and highlighting a major gap in the literature rather than a limitation of this review alone. Although risk of bias was assessed at the individual-study level, we could not apply a formal summary certainty of evidence framework [such as Grading of Recommendations Assessment, Development and Evaluation (GRADE)] because of the mixed-methods design and heterogeneity. There is also a risk that our findings are affected by publication bias, as studies with null or negative results are less likely to be published and therefore harder to identify, and although we used a comprehensive, multi-database search strategy, we cannot exclude the possibility that unpublished or non-English language studies were missed.

Clinical implications for urologists

Pre-treatment counselling should routinely address not only erectile function but also orgasms, ejaculation, anal sexual practices, and relational and identity changes, tailored to the patient’s sexual role and practices. Integrating a structured digital tool into consultations could help clinicians systematically ask about gender identity, sexual orientation, and specific sexual practices, ensuring that SGM patients and non-heteronormative sexual practices are explicitly considered. A single, comprehensive information resource on SGM inclusive sexual side-effects after PCa treatment would also be extremely helpful for patient but also healthcare professionals’ education. The team at Guy’s and St Thomas’ Hospital is currently developing a tool for this purpose.

When discussing side-effects and treatment options, urologists should prioritise potential impacts on ED, anejaculation, orgasmic function, anal function and climacturia framing these within the patient’s own sexual priorities rather than a generic model. Urologists should proactively open a conversation about the patient’s sexuality and the sexual practices they engage in. These findings are consistent with recent survivorship research showing that GBM survivors report distinct psychosocial and informational needs and face additional barriers to accessing appropriate support, reinforcing the need for targeted, identity-affirming interventions (58). Existing decision-support models, such as Dickstein’s (48), can be used alongside summary tables of treatment-specific sexual side-effect to support shared decision-making, particularly for patients whose sexual role or practices make certain side-effects more consequential. For example, ED may be especially impactful for patients who identify as ‘tops’, whereas anodyspareunia is likely to have a greater impact on those who identify as ‘bottoms’. Since the completion of the search, emerging evidence has suggested that treatment modality may differentially affect sexual roles among SM men, with early findings indicating that external beam radiotherapy may better preserve function among insertive partners, while radical prostatectomy may be less detrimental for receptive partners (59). These preliminary findings reinforce the importance of role-specific counselling and highlight the evolving nature of the evidence base (60).

Post-treatment, rehabilitation should extend beyond erectile aids to include structured follow-up on sexual identity, emotional responses, partner relationships, and community connection. Referrals to specialist sexual counselling, peer- or partner-inclusive support groups, and tailored resources for SGM can help patient and their partners adapt to enduring changes in sexual function and identity.

Future implications

Substantial evidence gaps remain. Future research should prioritise recruitment of underrepresented populations, including racial and ethnic minority groups, non-English speakers, individuals with lower educational attainment and socioeconomic backgrounds. Research involving transgender women and other gender minorities is virtually absent and is particularly urgent.

Inclusive PROMs such as the SMACS require validation in larger and more diverse cohorts to ensure broader applicability. Routine collection of sexual orientation and gender identity data in oncological research is essential to enable more accurate characterisation of disparities.

Educational programs for health professionals are also needed to improve confidence and competence in discussing sexual health with SGM patients (48). Training should emphasise inclusive communication, awareness of diverse sexual practices, and understanding of how treatment-related effects may differentially affect sexual roles. Such interventions have potential to improve shared decision-making and reduce disparities in survivorship outcomes.

A review of ClinicalTrials.gov identified two ongoing trials investigating PCa in SGM populations, indicating increasing recognition of this issue (61,62). Future clinical and survivorship pathways should incorporate routine enquiry about sexual orientation, gender identity, and sexual practices when discussing treatment options, ensuring that recommendations align with individual priorities and sexual wellbeing.

Conclusions

Our results suggest SM individuals experience distinct and, in some cases, disproportionately burdensome sexual outcomes following PCa treatment. Compared with heterosexual counterparts, SM populations in this review reported poorer urinary, bowel and hormonal function, greater distress related to anejaculation, and more substantial changes in anal sexual practices and sexual role. This indicates alterations in sexual role are closely tied to identity and community belonging, amplifying the psychosocial impact of treatment-related side effects. The studies suggest functional consequences of specific side effects are strongly influenced by individual sexual practices and role-in-sex.

Limited clinician awareness and inadequate SGM-inclusive assessment tools contribute to gaps in anticipatory counselling and survivorship care. Improving routine collection of sexual orientation and gender identity data, validating inclusive PROMs, and strengthening clinician education are essential steps towards delivering equitable, patient-centred PCa care for this underserved population.

Acknowledgments

The abstract was presented at the British Association of Urological Surgeons Conference 2025 in Manchester. It was well-received by the audience and won the best e-poster prize in its category. It was also presented at the American Urological Association Conference 2026 in Washington DC.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0270/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0270/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0270/coif). K.A.B. holds an unpaid position as chair of the KCL men’s health society. T.Y. and A.C. have received grants from the Movember charity and Prostate Cancer UK. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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