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The psychological impact of androgen deprivation therapy (ADT) in prostate cancer

By Dr Kenneth Gannon and Dr John Barry

Prostate cancer is the most common type of cancer in men and has become the third most common cause of cancer death in the UK, with almost 12,000 men dying from it every year (Prostate Cancer UK, 2018), slightly more than the number of women who die from breast cancer. Compared to White men, African Caribbean men are three times more likely to develop the disease and tend to do so at a younger age and in a more aggressive form.

Similarly to estrogen in some types of breast cancer, testosterone is associated with the development and course of prostate cancer. Androgen Deprivation Therapy (ADT) is a commonly used treatment for advanced prostate cancer, although it may also be used to treat disease confined to the prostate. Up to 50% of men being treated for prostate cancer may receive ADT.  It reduces symptoms and increases survival times by stopping testosterone production (Connolly et al, 2012). However this causes a range of serious side effects, including erectile dysfunction, genital shrinkage, loss of libido, hot flashes, osteoporosis, loss of muscle mass, breast enlargement, anaemia, fatigue, risk of diabetes, risk of cardiovascular disease and of potentially fatal cardiac events (Holzbeierlein, Castle & Thrasherl, 2004; Thompson, Shanafelt, Loprinzi 2003). ADT has also been linked with an increased risk of developing some types of dementias, though findings are inconsistent and the increased risk appears to be small.

ADT can impact mental health too. For example, it may increase mood swings (Cary, Singla, Cowan, Carroll, Cooperberg, 2014) and tearfulness (Ng, Woo, Turner, Leong, Jackson and Spry, 2012).  Depression may also occur as a result of testosterone reduction and the associated problems (Lee, Jim, Fishman, et al., 2015).

Understandably, some of these physical and mental symptoms can impact a man’s sense of his masculinity (Oliffe, 2006). Compared to patients having what might sound like more radical treatments (e.g. prostatectomy or radiotherapy), patients on therapy with hormones have relatively low HRQoL scores (Bacon et al, 2001).

Not all studies are in agreement (perhaps due to differences in methodology), but there is evidence that ADT is also linked to impairment to executive cognitive functioning, causing problems in planning, initiating and sequencing goal-directed behaviours, and memory issues. Further research is required on this issue. There is also some evidence that because of the reduction in testosterone, men on ADT perform less well in spatial cognitive abilities (Cherrier, Aubin & Higano, 2009).

In conclusion, prostate cancer treatment with ADT has a range of psychological implications for men and their partners. Some of these implications are in need of further research, especially treatment-related decision making, survivorship and the experiences of men from ethnic and sexual minorities.

If you have concerns about prostate cancer, contact https://www.prostatecanceruk.org/

About the authors

Dr Kenneth Gannon is the Clinical Research Director and Research Degree Leader at the University of East London. His chapter ‘Men’s Health and Cancer—The Case of Prostate Cancer’ covers various topics, including sexuality and ethnicity, and appears in the new book The Palgrave Handbook of Male Psychology and Mental Health

Dr John Barry is a Chartered Psychologist and co-founder of the Male Psychology Network and Male Psychology Section of the British Psychological Society. He is one of the editors of, and contributors to, The Palgrave Handbook of Male Psychology and Mental Health. https://doi.org/10.1007/978-3-030-04384-1

From the back cover of the Handbook of Male Psychology:

“This handbook brings together experts from across the world to discuss men’s mental health, from prenatal development, through childhood, adolescence, and fatherhood. Men and masculinity are explored from multiple perspectives including evolutionary, cross-cultural, cognitive, biological, developmental, and existential viewpoints, with a focus on practical suggestions and demonstrations of successful clinical work with men”.

References
Bacon, C. G., Giovannucci, E., Testa, M., & Kawachi, I. (2001). The impact of cancer treatment on quality of life outcomes for patients with localized prostate cancer. The Journal of urology, 166(5), 1804-1810.

Cary, K.C., Singla, N., Cowan, J.E., Carroll, P.R., and Cooperberg, M.R. (2014). Impact of androgen deprivation therapy on mental and emotional well being in men with prostate cancer: analysis from the CaPSURE registry. Journal of Urology, 191, 964-970.

Cherrier, M. M., Aubin, S., & Higano, C. S. (2009). Cognitive and mood changes in men undergoing intermittent combined androgen blockade for non‐metastatic prostate cancer. Psycho‐Oncology, 18(3), 237-247.

Connolly, R.M, Carducci, M.A. & Antonarakis, E.S., (2012) Use of androgen deprivation therapy in prostate cancer: indications and prevalence. Asian Journal of Andrology 14:2, 177-186

Holzbeierlein, J.M., Castle, E. & Thrasher, J.B. (2004). Complications of androgen

Lee, M., Jim, H.S., Fishman, M., et al. (2015). Depressive symptomatology in
men receiving androgen deprivation therapy for prostate cancer: a controlled comparison. Psychooncology, 24, 472-477.

Ng, E., Woo, H.H., Turner, S., Leong, E., Jackson, M. and Spry N. (2012). The influence of testosterone suppression and recovery on sexual function in men with prostate cancer: observations from a prospective study in men undergoing intermittent androgen suppression. Journal of Urology, 187, 2162-2166.

Oliffe, J. (2006). Embodied masculinity and androgen deprivation therapy. Sociology of Health and Illness, 28, 410-432.

Prostate Cancer UK (2018). We call on UK to step up as new figures show prostate cancer now a bigger killer than breast cancer. Accessed online 7th May 2018 on the internet [here]

Soloway, C. T., Soloway, M. S., Kim, S. S., & Kava, B. R. (2005). Sexual, psychological and dyadic qualities of the prostate cancer ‘couple’. BJU international, 95(6), 780-785.

Thompson CA, Shanafelt TD, Loprinzi CL (2003) Andropause: symptom management for prostate cancer patients treated with hormonal ablation. Oncologist, 8, 474-487

 

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Is there an alternative to the new APA guidelines for working with men and boys?

by Dr John Barry

The APA’s Division 51 (Men and Masculinities) recently released their guidelines for working with men and boys. While guidelines on this topic are much needed, the APA’s contribution leaves room for improvement. In this article I will outline issues with two of their 10 guidelines:

Guideline 1 of the APA guidelines suggests that “masculinities are constructed based on social, cultural and contextual norms”. However although it is true that masculinity is, in part, constructed, it is also partly innate.

What is the evidence that masculinity is, in part, innate? Well, sex differences in cognition and behaviour  are found worldwide, and their universality suggests something that transcends culture. Moreover, most of these clearly map onto masculinity. For example, the tendency to being more competitive, aggressive (physically), and interested in sports than women maps onto the male gender script of being a fighter and winner. The tendency to working longer hours, working in male-typical occupations, exploring the environment, more willing to take risks, maps onto the male gender script of being provider and protector.The tendency to show less fear, less crying, more inclined to substance abuse (self-medication) maps onto the male gender script of having mastery & control of one’s emotions.

The crucial point for therapy is that because some aspects of masculinity are innate, changing them is not a simple case of cognitive restructuring or behaviour change, any more than changing other deeply-held aspects of gender identity or sexual identity is straightforward or even desirable.

However we live in a culture steeped in the ‘gender similarities hypothesis’, telling us that there are ‘more similarities than differences’ between men and women. Of course this idea is not wholly untrue, but it typically deflects our attention away from the fact that it is the differences between men and women that ‘make all the difference’. Thus in many ways we are not encouraged to notice sex differences, and we might even experience cognitive dissonance if we are asked to focus on sex differences and consider the implications for, to take one example, treatment approaches in psychology.

Guideline 3 states that “in the aggregate, males experience a greater degree of social and economic power than girls and women in a patriarchal society”. This statement is an example of what we have identified as gamma bias in psychology, a type of cognitive distortion in which examples of male privilege are magnified and female privilege is ignored or explained away. Examples of male disadvantage are boys’ educational achievement and the high rates of male suicide. Examples of female advantage lighter prison sentences and gender quotas in science jobs. In fact recent evidence has found that men are disadvantaged in many countries worldwide, especially those with medium to high levels of development.

Therapists who believe that guideline 3 is true of their male clients might understandably struggle to find much empathy for them, and a male client might struggle to believe they will find much empathy from such therapists too.

As an alternative to guidelines 1 and 3, I would suggest that we recognise that masculinity is to some degree innate and potentially positive for mental health, and the vulnerabilities of male clients are more important to us, as therapists, than any hypothesised patriarchal power. We shouldn’t presume that the bad behaviour of the minority of men are representative of some underlying aspect of men in general, and we should recognise that negative views of men are a barrier to an appropriate level of therapeutic empathy.

I would encourage Division 51 to revise their guidelines to bring them in line with research evidence and common sense. I would also urge authors of any other guidelines relating to male mental health to make similar revisions. After all, men seek therapy less than women do even when suicidal, so we need to do what we can to make therapy more male-friendly.

Is there an alternative to the new APA guidelines for working with men and boys? Well the forthcoming Palgrave Handbook of Male Psychology and Mental Health offers practical advice to therapists and a more positive theoretical perspective on men’s mental health and male psychology in general. Guidelines based on this handbook will be issued soon, and I hope the 32 chapters offer therapists and academics a realistic and useful way of understanding and working with men.

 

About the author

Dr John Barry is a Chartered Psychologist and co-founder of the Male Psychology Network and Male Psychology Section of the British Psychological Society. He is one of the editors of, and contributors to, The Palgrave Handbook of Male Psychology and Mental Health

 

The Palgrave Handbook of Male Psychology and Mental Health will be released in April 2019.

From the back cover:

“This handbook brings together experts from across the world to discuss men’s mental health, from prenatal development, through childhood, adolescence, and fatherhood. Men and masculinity are explored from multiple perspectives including evolutionary, cross-cultural, cognitive, biological, developmental, and existential viewpoints, with a focus on practical suggestions and demonstrations of successful clinical work with men”.

https://doi.org/10.1007/978-3-030-04384-1

 

 

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