LGBTQ+ Topics: Special Considerations for People with Prostate Cancer in the LGBTQ+ Community

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Photo by Valeria Boltneva on Pexels.com

Fiona McMahon PT, DPT (pronouns: She, Her, Hers)-practices in our midtown office

We have talked about prostate cancer many times on this blog. It is an exceedingly common condition and represents 26% of new cancer cases in cis-men, second only to skin cancer, and 14% of cis-men will experience it within their lifetimes. Prostate cancer can affect one’s life dramatically in terms of sexuality, continence, and even their self perception. Even though prostate cancer can have such a dramatic effect on sex and sexuality, there is little information out there on prostate cancer that is not heteronormative. It is estimated conservatively that 3-12% of America’s population self identifies as lesbian, gay, trans, bisexual, queer, or questioning (LGTBQ+). For people in this community navigating a heteronormative healthcare system can be alienating, frustrating, and downright dangerous. Today, we are going to take some time to discuss what is known about prostate cancer specifically in men who have sex with men as well as trans women.

Prostate Cancer Basics

Prostate cancer typically occurs later on in life. It is extremely common and its incidence is rising, likely due to a rise in prostate specific antigen (PSA) testing. Prostate cancer is a very survivable cancer with the 5 year survival rate being estimated at 84-92%. Treatment may include radiation, chemotherapy, removal of the prostate, or some combination thereof. That being said, common side effects of prostate cancer treatment include bowel and bladder incontinence, sexual dysfunction and pain. These side effects can be improved with medication, physical therapy, and lifestyle changes. People who are at risk for prostate cancer are people who have advanced age, African ancestry, live in certain geographic locations, and those who smoke.

Are Men who Have Sex with Men at Increased Risk?

This is the first out of many examples in this blog where we need more research. There are certain conditions that have been associated with men who have sex with men that may be a risk factor or protective against prostate cancer. Men with HIV seem to be an increased risk factor for prostate cancer, however the antiretroviral therapy for it may be protective. See how this is super confusing? Additionally use of supplements, steroids may increase risk for prostate cancer.

These are all pretty strong “mays”. What we do know is that men who have sex with men are less likely to have up to date PSA testing. Black men who have sex with men are even less likely to be up to date with their PSA’s. This fact can be correlated to the subjective experience many men who have sex with men express when navigating a heteronormative healthcare field. We will talk more later about barriers to healthcare in the LGBTQ+ community and ways clinicians can work to reduce these barriers for their patients.

What About Transgender Women?

There is very little reported about trans women with prostate cancer. Prostate cancer in transwomen is relatively rare especially after removal of the testicles. That being said, it can occur if a transwoman has her medical transition later on in life. In the case study cited below, the authors posit that it may be possible for androgen receptors to become more sensitive to androgens when androgens are at a low level. Androgens are produced by the testicles and are thought to contribute to the development of prostate cancer. If small amounts of cancerous or precancerous cells were present on the prostate prior to testicle removal, they may have continued to develop in the presence of the small amount of testosterone produced elsewhere in the body.. All this being said, prostate cancer is a rare condition in transwomen, but it does beg the important questions like, do we remove a woman’s prostate when she is transitioning, which can be a source of pleasure and erotic function for some transwomen. Most experts agree that transwomen with prostates should be screened for cancer. This is an area where more research is definitely needed.

Why One -Size Fits All Fits None

Men who have sex with men and transwomen have different sexual roles and expectations than the hetero and cis-gender community, and applying heteronormative treatment approaches in the sexual rehabilitation of people recovering from prostate cancer can leave a lot to be desired. The prostate can be a huge source of sexual pleasure for some men who have sex with men and  some transwomen. Men who have sex with men are much more likely to report that the prostate as a pleasure center than their hetero and or cis counterparts. A prostatectomy can represent a loss, and should be respected as such. Also for men and trans women participating in penetrative anal sex, the erection requirements are different than those required to participate in vaginal penetration. The penis requires much more rigidity to penetrate the anus than it does the vagina, ( We should keep in mind the requirement to be able to participate in penetrative anal sex may be important for men who have sex with women exclusively.) Detailed sexual histories should be taken for every patient.

Tips for Providers

Only 68% percent of LGBTQ+ patients are “out” to their clinicians. This is an important stat to keep in mind when performing an intake and subsequent treatment with patients. Avoiding heteronormative assumptions, like assuming a man with a wedding ring is married to a woman, can be a helpful step in the right direction. Displaying a rainbow flag somewhere in your office can also set the stage for a more open conversation that can help you better address the needs of your patients. To learn more about this population check out our resources below. For people who are used to viewing the world through a heteronormative lense, this can take a concerted effort, but it is well worth it in the name of improving patient care for all of your clients!

We have offices in both midtown and downtown locations. If you are dealing with prostate cancer, please give us a call at

212-354-2622 (Midtown)

212-267-0240 (Downtown)

Fiona McMahon PT, DPT practices at our midtown location

fiona2018

Blogs: 

The Special Care Needs of the LGBTQ+ Community

Resources:

Gay & Bisexual Men Living with Prostate Cancer from Diagnosis to Recovery https://www.amazon.com/Gay-Bisexual-Living-Prostate-Cancer/dp/1939594251

A Gay Man’s Guide to Prostate Cancer

https://www.amazon.com/Prostate-Journal-Psychotherapy-Monographic-Separates/dp/1560235527

Malecare https://malecare.org/

Healthcare Equality Index: A tool to find hospitals with established and effective policies for improving LGBTQ+ care http://www.hrc.org/hei/search

Sources

Ussher J, Perz J, Simon Rosser B. R. Gay & Bisexual Men Living with Prostate Cancer from Diagnosis to Recovery. New York: Harrington Park Press, 2018. Print

Quinn G, Sanchez J, Sutton S, et al. Cancer in lesbian,gay, bisexual, transgender/transexual and queer/questioning populations (LGBTQ). CA Cancer J Clin. 2015;65(5):384-400

Rosser S, Merengwa E, Capistrant B, et al. Prostate cancer in gay, bisexual, and other men who have sex with men: a review. LGBTQ Health(3)1. 2016; 32-41

Turo R, Jallad S, Prescott S, et al. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy.

What is Neater than your Peter? A Guide to Penile Health and Function Part 1: Premature Ejaculation

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Fiona McMahon PT, DPT

Ladies and Gentlemen, it is finally time to go for this blog and go on a deep dive to discuss at length (pun not intended), the physiology, health, and function of an amazing organ, the penis! A couple years ago we talked about testicles in our blog, All About Testicles, which remains one of our most popular blogs. Now it is time to travel north and talk about how people with penises can best care for them and how to address things that may go wrong from time to time. This blog will periodically cover different issues that can (ahem) arise with penises. Today we will go over premature ejaculation. But before we can do all that, lets review how the penis works.

As an organ, a healthy penis is an amazingly complex organ despite it’s seemingly simple exterior. It is the tail end of the urinary system, provides amazing sensation, carries sperm to the outside world, delivers a substance that can neutralize the acidity of the vagina in order to make it more hospitable to sperm, and is able to use the muscles around it to raise the blood pressure in the penis higher than that of the outside body, in order to maintain erection.

The penis is not one tissue all the way through. It has what’s called the tunica albuginea which is the wrapping for the erectile parts of the penis. This guy is really important because it closes off the vein returning blood flow from the penis to keep the penis erect during arousal. Inside the tunica albuginea is the corpus carvernosum and corpus spongiosum. No, these two tissues are not Harry Potter spells, but critical parts of penile infrastructure. The corpus cavernosum fills with blood during erection and helps make the penis hard. The corpus spongiosum keeps the urethra from getting clamped shut during erection so the sperm can get out.

How Does The Penis Get Hard?

Usually, in response to sexual stimulation, the smooth muscles (the involuntary ones, not the pelvic floor) will relax allowing the small blood vessels within the penis to fill with blood, the result is the tunica albuginea ( the wrapping of the erectile parts of the penis) will compress on the veins of the penis, thus preventing the blood returning back to the body. The trapped blood in the penis will cause the penis to get hard and stand up. The lovely muscles of the pelvic floor, specifically the ischiocavernosus will contract to further increase the blood pressure within the penis and keep the penis erect.

What Happens with Ejaculation?

Ejaculation occurs with orgasm. It is possible to have an orgasm without ejaculation if you have had a procedure like a prostatectomy. For a normally functioning penis, ejaculation occurs with orgasm and is what carries the sperm and other fluids to the outside world. The contractions felt in orgasm are what propel the sperm through the penis and to the outside world. The bulbospongiosus is responsible for these contractions and is part of the pelvic floor.

Premature Ejaculation

Here is where I would normally supply you a pithy little statistic like “ 1 in 4 men will experience premature ejaculation in their lifetime”. Unfortunately, I cannot provide any such statistic for this subject because so few people talk about this problem. The clinical definition of premature ejaculation is a little wonky too, and has not consistently been used in research, therefore prevalence data are likely inaccurate. The International Society for Sexual Medicine (ISSM) , in an attempt to improve the medical definition of premature ejaculation defines it as:

  • Ejaculation that always or nearly always occurs within about 1 minute of vaginal penetration from the first sexual experience (Defined as lifelong premature ejaculation)
    • OR
  • A clinically significant reduction in latency time, often to about 3 minutes or less (defined as acquired premature ejaculation)
  • Inability to delay ejaculation on all or nearly all vaginal penetrations; and
  • Negative personal consequences, such as distress, bother, frustration, and/or avoidance of sexual intimacy (Althof 2014)

If you are a gay or bi-man, or a man who does not have vaginal intercourse you are probably well aware how problematic this definition is. Currently, it is the ISSM’s stance that there is insufficient evidence to draw up criteria for men who have sex in ways other than vaginal intercourse.

As you can tell by the definition, premature ejaculation is divided up into 2 subgroups, lifelong and acquired. The distinction is relatively new in the research and can help patients find better ways to treat their premature ejaculation.

Potential causes of premature ejaculation include:

  • Hypersensitivity of the glans( head) of the penis
  • Issues with serotonin
  • Erectile dysfunction*
  • Either stopping or starting drugs
  • Chronic pelvic pain syndrome*
  • History of rushing early sexual encounters
  • Prostatitis*

*These are conditions treated at Beyond Basics Physical Therapy

What to do about premature ejaculation?

Don’t ignore it. Performance anxiety and premature ejaculation can often become a vicious cycle, where one will promote the other. Regardless of how your symptoms started, there is a lot that can be done to improve your sex life.

If you have prostatitis or chronic pelvic pain come to physical therapy. Did you know 90-95 percent of cases of “prostatitis”/chronic pelvic pain are musculoskeletal in nature… ahem… this is one of the most common conditions we treat at Beyond Basics. Overactive muscles, those in the abdomen, legs and pelvis can contribute to symptoms of prostatitis/chronic pelvic pain, (i.e. burning urination, painful ejaculation, sitting pain, genital pain, defecatory pain, urinary or bowel frequency, urgency, retention, incomplete emptying, etc.,.). Physical therapy can go a long way to treating and curing these symptoms by relaxing and lengthening your overactive muscles and strengthening weaker muscles. Prostatitis is a vast subject that requires its own blog. Luckily for you, I already wrote one. Check it out here.

If you are experiencing erectile dysfunction along with premature ejaculation, get thee to a doctor. I already explained to you how amazing the penis is as an organ. Its function is reliant on blood flow, thus problems with erection, especially in younger people may be an early sign that something may be up with your vascular system. Once systemic causes have been ruled out, get thee to physical therapy. We spoke earlier about how the penis requires blood flow and muscles to work properly; pelvic floor physical therapy can restore the function and improve the vascular health of the muscles vital to erection. Erectile dysfunction is yet another subject that could use its own blog. Again, luckily for you, I already wrote one. Check it out here.

If you don’t think erectile dysfunction, prostatitis or chronic pelvic pain is causing your premature ejaculation, there is still a lot you and your urologist can do. There is new work revealing that certain medications and psychotherapy can really help reduce premature ejaculation. You are not alone in this and you deserve to start feeling better.

Thank you so much for reading our blog, if you think physical therapy can help you. Please give us a call at either our midtown location 212-354-2622 or our downtown location 212-267-0240. We are offering free phone consultations at both offices for a short period!

fiona2018

Fiona McMahon PT, DPT is currently practicing from our midtown location

 

 

Althof S, McMahon C, Waldinger M, et al. An Update of the International Society of Sexual Medicine’s Guidelines for the Diagnosis and Treatment of Premature Ejaculation (PE). Sex Med. 2014; 2(2) 60-90

Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016

Dean R, Lue T. Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction. Urpl Clin North Am. 2005; 32(4): 379-v

Herman H. “Male and Female Health Wellness and Sexual Function”. New York. 19-20 May 2018

Quinn P. A Multinational Population Survey of Intravaginal Ejaculation Latency Time. J Sex Med. 2005; 2(4) 492-497

PH101: Potty Issues with Kiddos

Fiona McMahon PT, DPT

Did you know kids can suffer from pelvic floor dysfunction too? Pelvic floor dysfunction in children can result in pain, bladder holding or constipation, embarrassing soiling accidents, frequent nighttime accidents, as well as trouble going potty. For most kids, there is an underlying physical component that needs to be addressed by an expert pediatric pelvic floor physical therapist.

It is very upsetting for a parent, guardian or caregiver to see a child suffer with pain or embarrassment, but there is so much that can be done to help out children with these issues. We use positive charts to develop short term and achievable goals to reinforce  behaviors and steps towards healthy toileting. Simple techniques like improving toilet posture, practicing deep breathing with bubbles, using a timer to assist in times voiding, educating the parent/guardian/caregiver on the colon massage, developing a core stability and stretching program, and more can go a long way towards improving bowel and bladder symptoms.

If your child is suffering from urinary or fecal accidents, bed wetting, skidmarks, or painful defecation, join me on  May 2nd at 7pm , to discuss pelvic floor dysfunction in children, common conditions affecting pottying, and practical tips you can use to make potty time easier.

This is our last Pelvic Health 101 class of the spring series. We want to thank for an awesome season! Keep your eyes on the blog for the Fall’s PH101 classes!

RSVP here

 

To Learn More Today, Check out our other blogs on the pediatric pelvic floor!

The Scoop When Kids Have Trouble with Poop

Pediatric Bowel Part II: How to Make Pooping Easier for your Kiddo

Pelvic Health 101 Spring 2018 (2)

 

World AIDS Day

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Today, December 1st 2017, is World AIDS Day. World Aids Day has been held on the first of every December since 1988. World AIDS Day works to spread awareness of the disease and to remind the general public that AIDS and HIV still must be taken seriously and that there is still a lot of work to do in order to prevent the transmission of new cases, as well as to better care for those who are infected with the disease.

What is AIDS/HIV?

AIDS (acquired immunodeficiency syndrome), is caused by a virus called human immunodeficiency virus (HIV). HIV can be treated in order to prevent AIDS, however there is currently no cure for HIV.

HIV causes AIDS by attacking the immune cells of a person’s body, which can leave a person vulnerable to infections that otherwise would not have made them sick. These infections are referred to as opportunistic infections, an opportunistic infection is a signal that someone’s HIV may have progressed into AIDS.

As said earlier, HIV doesn’t always have to progress to AIDS. Antiretroviral therapy (ART)  can work to help keep the immune system healthy, as well as lower the risk of transmitting the virus to others. People on ART have dramatically improved lifespans. It is imperative to get on ART as soon as possible to lessen the effects the HIV virus has on your immune system.

HIV Testing

1 in 7 people infected with HIV do not know they have the virus. Testing is necessary to start treatment and reduce harm done to your immune system as well as risk of transmission to others.

According to AIDS.gov, you should be tested if:

  • You have had sex with someone who is HIV positive, or someone whose status you were unsure of since your last test
  • Had tuberculosis or hepatitis
  • Used shared needles
  • Been diagnosed with another type of sexually transmitted disease

HIV/ AIDS and Physical Therapy

Physical Therapists do not treat AIDS or HIV, rather, they treat the symptoms of AIDS/HIV and HIV/AIDS treatment to allow patients to live as fully and independently as possible. Both the disease itself and the treatment for it have effects like increasing fatigue, decreasing strength and endurance, and increased pain. Physical therapy can help by tailoring programs to help with pain, ability to perform everyday tasks, improve heart health, balance, endurance, strength and flexibility.

You can mark today by doing a number of things:

Wear a red ribbon to spread awareness

Donate to groups that work to help people living with AIDS and help to prevent its transmission:

United Nations (UN AIDS)

https://donations.unaids.org/

UNICEF

https://www.unicefusa.org/donate/support-unicefs-hivaids-programs

Sources:

AIDS.gov

Resources:

HIV/Screening:

National HIV Testing database: https://gettested.cdc.gov/

Physical Therapy Month

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Fiona McMahon PT, DPT

October is National Physical Therapy Month. During Physical Therapy Month we take time to inform the public about the benefits of physical therapy as well as focus on a particular issue affecting the lives of our patients. This month the APTA (American Physical Therapy Association) has decided to address the current opioid crisis. At Beyond Basics Physical Therapy, we addressed the treatment of chronic pain and the effect opioids can have in the blog titled “Navigating Life with Chronic Pain: Part 1 “. I highly recommend looking back at this blog to learn more about the pain science behind chronic pain and what you can do to treat it. Keep you eyes open for our upcoming blog, “Navigating Chronic Pain”: Part 2, for more on specific treatments.

For October’s Physical Therapy Month, the APTA has decided to address specific policy changes that need your support to help fight the opioid epidemic. The time for addressing the opioid epidemic is now (honestly, it should have been years ago). According to the APTA, 1 in 3 opioid users report they are physically addicted to opioids, and 4 in 5 new heroin users begin their addiction by misusing opioids. Even more staggering, heroin deaths now outnumber deaths due to gun homicides. This issue is an issue we, at all levels of healthcare must fight.

The APTA is advocating for these 6 policy changes to help fight the opioid crisis

1.Repeal the Medicare Therapy Cap: To allow patients on medicare to receive the care they need from their physical therapist

2. Remove Federal and State Restrictions that Impede Access to a Physical Therapist: Allow patients to see physical therapists without an MD’s referral

3. Ensure Comprehensive Insurance Coverage for Physical Therapy

4. Provide Fair Physical Therapy Copays Under Insurance: Reduce high copays and deductibles for physical therapy to lessen the incentive to turn to cheaper opioids over physical therapy as a pain treatment.

5. Allow Physical Therapists to Perform to the Full Extent of Their Education and Training: Physical therapists hold doctoral degrees and should be allowed to practice their full scope of services.

6. Protect Patient Choice of Physical Therapy Treatment: Patients should be able to select the therapist of their choice, not the one the MD selects.

If you have chronic pain, please choose physical therapy first. It is a much safer and more effective option than opioids. The physical therapists at Beyond Basics Physical Therapy are well trained and experienced in treatment of chronic pain conditions. Call today.

Marathon Update: Sickness When to Run and When to Take a Break

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Fiona McMahon PT, DPT

Hi everyone I am writing you from week 22 of training for the NYC marathon. This year I am running the marathon, sponsored by Beyond Basics Physical Therapy, in order to support New York’s Team Tisch in raising money for multiple sclerosis research. Currently, we are only about 1000$ from our goal, time is getting tight so don’t forget to donate today. Click here to donate to Team Tisch MS NYC Marathon to support research for treatment and prevention of multiple sclerosis.

Today, I want to write about a fact of life for almost every human being, illness. Getting sick can be vexing for just about every marathon runner. It puts us in this nearly existential running dilemma, “Do you run and risk getting more sick?” or “ Do I take the rest, and miss a potentially race making run?”. The question can sometimes make you feel even more lousy than whatever you are actually sick from.

In my training for this marathon, I have been confronted with this question way too many times. I’ve been sick 4 times in the last 22 weeks, total bummer, but I live in a super crowded city and work with children so I am not surprised. P.S. Working with kiddos is the best thing ever and is totally worth whatever puke, snot ridden illness I get, so I am definitely not complaining.

A lot of runners have “the neck rule”. I first came across this rule as a high school runner, and I see it all over running publications. It has been a useful tool for me for years in determining when to take a knee and focus on feeling better. The neck rule is not necessarily running exclusive, so feel free to apply it to most workouts. Basically it goes like this, if your symptoms are above the neck, i.e. congestion, sore throat, etc, you are generally safe to run. If your symptoms are below the neck, i.e. fever, vomiting, diarrhea, muscle aches, etc, it is time to give your body a rest and let your immune system do its thing. It can be so frustrating to skip a run, especially when your illness falls on a major training session, but in the long run, you will end up healthier and you will be able to return to your prior level of performance sooner. This doesn’t necessarily mean that head only symptoms mean you absolutely should run. It’s a basic guideline: if you are feeling too run down and fatigued to run, listen to your body, it’s pretty smart.

When you are starting to feel better go back into things slowly. Once your fever has been gone for about 24 hours without fever reducers, vomiting or diarrhea have cleared, and you can eat and drink normally, ease back in. Plan your next run on a treadmill or in short loops by your home so you can cut it short if need be. You don’t want to be stuck 8 miles out from home, finding you are still really worn down from being ill. Been to that show and got that T-shirt.

Marathon training is as much mental as it is physical. The mental challenges can present themselves in surprising ways. One of the biggest pitfalls runners “run” (oops, not sorry about that pun) into following an illness, is the desire to cram all of the mileage they have missed into a few days following an illness. Don’t do it. Most training plans are designed to challenge the body at a level it can tolerate as well as provide enough rest to build up strength and functional reserves. Adding a huge glut of extra miles in the middle of it, can really throw things off and put you at a greater risk of injury or even additional illness. Let those miles go and be confident in the fact that you allowed your body to heal and get to full strength.

Please click here to donate to TISCH Multiple sclerosis research.

Additionally, check out my progress in physical therapy here:

 

And for more on training while sick, click here.

 

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On September 20th, 2017 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes:

Pelvic Health 101 Fall 2017