Prostate Cancer Community Spotlight: Dr. Channa Amarasekera

Dr. Channa Amarasekera is director of the Gay and Bisexual Men’s Urology Program at Northwestern Medicine in Chicago. It has been described as the first of its kind in the U.S. The program seeks to improve the experience of gay and bisexual men, including those with prostate cancer, who seek urologic care. We talk to Dr. Amarasekera about the program and about what doctors can do to better support their gay and bisexual prostate cancer patients. The responses have been lightly edited.

Establishing the program

Why did you decide to create it?

When I was a urology resident at Northwestern, some gay patients would express their frustration at not being able to openly discuss their health issues. As a result, they would sometimes disengage from their care team, which negatively affected their treatment. They needed a place where they felt safe to talk about their sexuality and how it plays a role in their overall health.

This led me to focus my research year on LGBTQ health as it relates to urology. Our team found mainstream medical education had a blind spot regarding the urologic health of gay and bisexual men, and other sexual minorities. While doctors are well-intentioned, their training in culturally sensitive care is often limited. We found that this gap sometimes inadvertently created tension between patients and their health care team, which led to substandard care.

This summer, Northwestern Medicine and the Department of Urology gave me the opportunity to take what our team had learned and put it into practice. It was overdue. Sexual health plays a central role in many aspects of urologic care. Our program meets the needs of LGBTQ people and helps us improve care for the community.

How many people have you seen, and what do you hope to achieve moving forward?

As of my writing this, we have seen over 200 gay and bisexual men at the clinic. They present with prostate cancer as well as a variety of urologic conditions like BPH (enlarged prostate gland), low testosterone, Peyronie’s disease, and erectile dysfunction, among others.

Moving forward, we hope to obtain data from our patients about their experiences both in our clinic and with the healthcare system in general. By learning about their needs and preferences, we hope we can improve care for this community at Northwestern and beyond.

Prostate cancer care among gay and bisexual men is a young field. There are many aspects that are poorly understood. I see the clinic as a dynamic place that grows with the people we see here. Our goals are to listen to people and build a program around them, then use what we learn to educate doctors. Ultimately we plan to create a blueprint for similar clinics around the country.

Needs being overlooked

Many medical resources focus on the experiences of straight men. How can this affect gay and bisexual people?

A heteronormative approach to prostate cancer care can create a sense of isolation for gay and bisexual men. A cancer diagnosis is difficult enough, and a care system that makes gay and bisexual people feel invisible does little to advance our mission to help everyone navigate the challenges posed by prostate cancer.

What are doctors typically not discussing with gay and bisexual people?

Many doctors may not realize that the needs and concerns of gay and bisexual men during prostate cancer treatment are different from those of straight men. The biology of prostate cancer is the same for all men, but that is only part of what care requires. Doctors should ask about a person's sexual orientation, but they should also go further and discuss how prostate cancer and its treatment can impact their gay and bisexual patients’ sexual lives.

Important questions that should be considered during the treatment decision-making process are: Is anal intercourse important to overall sexual satisfaction? Do you prefer to be the anally insertive or anally receptive partner? Or are you versatile? Does your ability to ejaculate play a significant role for you or your partner? The answers will help guide care teams before, during, and after treatment.

Another issue that is often ignored in the treatment of gay and bisexual men: Does the patient have a romantic or life partner? Counseling is usually geared to the needs of women whose partners have prostate cancer. Men must also be adequately counseled. If they aren’t, their partners’ health and quality of life could suffer in the long run.

Often, care is focused solely on a patient’s erections, as if sexual pleasure starts and ends there. That is not true for any man, and it is particularly not true for gay and bisexual men.

Sex and prostate cancer treatment

How can the sexual side effects of treatment affect gay and bisexual people, in particular, and why should doctors recognize this?

First, doctors need to be aware that the prostate is an organ of sexual pleasure during anal intercourse. One researcher has called it the male equivalent of the “G spot” in women. If the prostate is removed, so is the potential pleasure for men who are anally receptive. Care teams need to prepare patients for that possibility.

The prostate does not play a similar role for most men in heterosexual relationships (although it can). As a result, many doctors don’t discuss the possible loss of anal pleasure or the possibility of pain with receptive anal intercourse (particularly after radiation therapy). Patients may be embarrassed or otherwise reluctant to bring it up.

Similarly, the strength of a person's erection may be more important for gay and bisexual men. That is because anal penetration requires a more rigid penis than vaginal penetration.

Ejaculate also plays a significant role in sex between men. Research has shown that gay and bisexual people with prostate cancer have greater concern about loss of ejaculate than heterosexual people. It is often eroticized and is the physical evidence of a satisfying sexual experience between 2 men. If it is diminished, it could similarly diminish the psychological pleasure derived from sex for both partners.

When treating prostate cancer, or other prostate conditions, the effect these treatments have on the prostate, rectal health, ejaculatory function, and other areas important to sexual health are often overlooked. Right now, most men are not appropriately counseled about these issues.

Creating more support for gay and bisexual people

What can doctors do to ensure that gay and bisexual patients feel heard and supported?

We have to meet people where they need us to be.

We have to ask the right questions and counsel people about the potential impacts of treatment relevant to them. If we don’t, we violate our patients’ rights surrounding informed consent. This can have significant impacts on quality of life and satisfaction with treatment.

We need to be aware of the array of gay and bisexual men’s sexual repertoires and focus treatment and counseling accordingly.

We are still learning so much from our treatment of gay and bisexual men in a space that is specifically designed for them. We are creating tools to measure aspects of sexual function that are specific to gay and bisexual men, such as sexual function as it relates to receptive anal intercourse. That will provide us better opportunities to track their progress and shape our approach to care for these patients.