Variation in perceptions of genital ablation between aspiring eunuchs and individuals with paraphilic sexual fantasies.

Background: Although uncommon, some individuals assigned male at birth (AMAB) seek voluntary genital ablative procedures, and others fantasize about it. Aim: To learn more about the views of genital ablation and injuries in those who aspire to be castrated as compared with those who only fantasize about it. Methods: A survey was run on the Eunuch Archive internet community. Content analysis was conducted on the responses of 342 AMAB individuals with castration fantasy but no desire for actual surgery (fantasizers) vs 294 AMAB individuals who expressed a desire for genital ablation (aspiring). Outcomes: Study outcomes were responses to open-ended questions about genital ablations and injury. Results: Aspiring individuals were more likely to perceive a "physical appearance benefit" from orchiectomy, but fewer could recall how they first learned about the procedure. Some reasons that aspiring persons gave for desiring an orchiectomy included "achieving preferred self" and "health reasons." Fantasizers, in contrast, worried about the potential side effects of orchiectomy, and more believed there to be no benefit to it. Clinical Implications: Psychiatrists and other clinicians need to understand their patients' views on genital ablation to properly diagnose and provide the best personalized care. Strengths and Limitations: Strengths include a large sample of respondents. Limitations include the accuracy of the anonymous survey data. Conclusions: This study demonstrates divergent interests on genital ablation among AMAB individuals who have not had an any genital ablation yet have intense interest in the topic.

A Proposal for the Comprehensive Care of Men on Androgen Deprivation Therapy: Recommendations From the Multidisciplinary Prostate Cancer 360 Working Group.

INTRODUCTION: To promote comprehensive care of patients throughout the androgen deprivation therapy (ADT) prescribing process, the Prostate Cancer 360 (PC360) Working Group developed monitoring and management recommendations intended to mitigate or prevent ADT-associated adverse events. METHODS: The PC360 Working Group included 14 interdisciplinary experts with a dedicated clinical interest in prostate cancer and ADT management. The working group defined challenges associated with ADT adverse event management and then collaboratively developed comprehensive care recommendations intended to be practical for ADT prescribers. RESULTS: The PC360 Working Group developed both overarching recommendations for ADT adverse event management and specific recommendations across 5 domains (cardiometabolic, bone, sexual, psychological, and lifestyle). The working group recommends an interdisciplinary, team-based approach wherein the ADT prescriber retains an oversight role for ADT management while empowering patients and their primary and specialty care providers to manage risk factors. The PC360 recommendations also emphasize the importance of proactive patient education that involves partners or other support providers. Recommended monitoring and assessment tools, risk factor management, and patient counseling points are also included for the 5 identified domains, with an emphasis on lifestyle and behavioral interventions that can improve quality of life and reduce the risk for ADT-associated complications. CONCLUSIONS: Comprehensive care of patients receiving ADT requires early and ongoing coordinated management of a variety of health domains, including cardiometabolic, bone, sexual, psychological health. Patient education and primary care provider involvement should begin prior to ADT initiation and continue throughout treatment to improve patient and partner quality of life.

Scales for Assessing Male Sexual Function are not Entirely Applicable to Gay and Bisexual Men with Prostate Cancer.

Scales designed for assessing male sexual function may not be suitable for men of all sexual orientations. We reviewed frequently used sexual function scales and examined the item content and documentation of validation. These scales predominantly focus on general sexual function and erection. They lack questions on behaviors relevant to men-who-have-sex-with-men (MSM), such as anal sex, masturbation, or sexual activities outside of committed relationships. Additionally, the validation samples rarely mention inclusion of MSM, revealing a clear gap in the clinical evaluation tools available for MSM, who are experiencing sexual dysfunction from prostate cancer treatment side effects.

Openness to Using an External Penile Prosthesis for Maintaining Sexual Intimacy by Individuals with Erectile Dysfunction: A Cross-Sectional Study.

INTRODUCTION: Erectile dysfunction (ED) can lead to reduced sexual intimacy in men. The external penile prosthesis (EPP) is a device to help them participate in penetrative sex. AIM: We investigate factors that may affect the willingness of individuals with ED to try an EPP and explore how the EPP could be presented most effectively to such patients to enhance their willingness to try an EPP. METHODS: Recruitment for this cross-sectional study occurred in-person and online. 147 participants (60.0 ± 14.3 years old; all experiencing self-reported ED) completed a survey containing both validated measures and questions specific to this study. The survey was open to English-speakers over the age of 18 who self-reported experiencing ED. MAIN OUTCOME MEASURE: The primary outcome was participants' willingness to try an EPP based on their level of knowledge about using the EPP. Secondary outcomes included the influence of the sexual function, sexual distress, ED history, age, relationship duration, sexual flexibility on willingness to try an EPP. We also collected feedback from participants' on how and where they would like to be introduced to the EPP option. RESULTS: Most participants indicated a preference for being introduced to the EPP after trying some ED treatments (51.0%). Participants did not have strong preference regarding the setting where they were informed about the EPP. The majority however preferred having a sexual health therapist/counsellor (28.6%) or physician (25.9%) as the person introducing the EPP to them. Participants' willingness to try the EPP increased with more information about the EPP presented to them (P < .001). Personalization of the EPP to match one's own penis was preferred by 38.7% of participants. Referring to this aid as an 'external penile prosthesis' was significantly more preferred over alternative labels, such as a "belted prosthetic phallus" or "strap-on dildo" (Ps < .001 for both). Multiple regression analyses showed that only sexual script flexibility was associated with the initial willingness to try an EPP (P < .01). CLINICAL IMPLICATIONS: Clinicians should consider presenting the EPP to men with ED, who desire maintaining penetrative sexual intercourse with their partners. STRENGTH AND LIMITATIONS: This is the first study to explore factors influencing the willingness to try an EPP. Further research is needed to establish the efficacy of EPPs for maintaining sexual activity and satisfaction in the real-life setting. CONCLUSION: This study informs clinicians about effective ways to introduce the EPP to patients with ED who wish to maintain insertive/receptive sex. Fu F, Duthie CJ, Wibowo E, et al. Openness to Using an External Penile Prosthesis for Maintaining Sexual Intimacy by Individuals with Erectile Dysfunction: A Cross-Sectional Study. Sex Med 2022;10:100559.

Every Story Is Different: Experiences With Body Changes Related to Cancer.

One of the important aspects of stakeholder engagement in cancer care and system planning is hearing from individuals who have been diagnosed with cancer about the impact of the diagnosis and treatment on their lives. Hearing stories from the perspectives of cancer survivors offers opportunity to gain new insight and understanding about experiences of being diagnosed and treated for cancer. This article presents ten short narratives about survivors' perspectives on body image and cancer. Each story is unique but, taken together, the picture they create is one of facing challenges, discovering personal resilience, and moving forward to engage in living. The stories emphasize the importance of communication and support from healthcare providers and understanding needs for a person-centered cancer care system.

Evaluating Patterns and Factors Related to Sleep Disturbances in Prostate Cancer Patients.

Prostate cancer patients may experience disturbed sleep as a result of their diagnosis or treatment. This study sought to evaluate disturbed sleep and excessive daytime sleepiness in newly diagnosed patients and those receiving androgen deprivation therapy (ADT). This study was conducted with 74 patients. Subjective data using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) and actigraphy data on ADT/ADT-naïve patients were collected. The prevalence of poor sleep quality, determined from PSQI and ESS scores, was 50% and 16.7% respectively. Those on ADT (n = 20) had poorer sleep quality as determined by significantly higher PSQI scores (70 vs. 40% scoring > 5) and were more likely to have poor sleep quality, sleep latency, and sleep efficiency than ADT-naïve patients (n = 40). Actigraphy data showed that ADT patients slept significantly longer (7.7 vs. 6.8 h), experienced a higher Fragmentation Index (48.3 vs. 37.4%), and had longer daytime nap duration (64.1 vs. 45.2 min) than ADT-naïve patients. The use of objective measures such as actigraphy in the clinical arena is recommended and may be used as a valuable tool for research into sleep assessment in prostate cancer patients.

Development of a Sexual Quality of Life Questionnaire for Men-Who-Have-Sex-With-Men With Prostate Cancer.

BACKGROUND: Prostate cancer (PCa) is often diagnosed early with prolonged survival, which makes sexual quality of life (QoL) an increasingly important treatment consideration, but existing QoL questionnaires have limited applicability for men who-have-sex-with-men (MSM) beyond penile erections and penetrative sex. AIM: We aimed to create a validated survey instrument for assessing a variety of sexual activities beyond penile insertive sex for MSM after PCa treatment. METHODS: Based on our previously published survey findings, we have generated a prototype questionnaire with 13 different domains, reviewed by both healthy MSM and pilot-tested by MSM treated for PCa. OUTCOMES: We report here on progress in developing the questionnaire and demonstrate the complexity of MSM sexual side effects resulting from PCa treatment(s). RESULTS: Statistical analysis of 204 responses from MSM treated for PCa showed that each domain performed well individually (Cronbach's alpha coefficients ranged from 0.80 to 0.95; item-total correlations ranged from 0.16 to 0.89), with many significant intercorrelations between the domains (ranged from -0.048 to 0.93). CLINICAL IMPLICATIONS: The questionnaire can contribute to clinical diagnosis and treatment decisions that best fit the preferred sexual practices of individual MSM. STRENGTHS & LIMITATIONS: The current questionnaire considers a much broader repertoire of MSM's sexual practices and preferences than other currently available questionnaires. The high intercorrelations between the many parameters demonstrate that problems in one domain can affect other domains. This preliminary analysis warrants further exploration with a larger sample size. CONCLUSIONS: Once validated our questionnaire should help develop tailored psychosocial supports for MSM experiencing sexual dysfunction after PCa treatment and help newly diagnosed MSM with PCa make treatment decisions informed by their preferred sexual practices. Wibowo E, Dowsett GW, Nelson CJ, et al. Development of a Sexual Quality of Life Questionnaire for Men-Who-Have-Sex-With-Men With Prostate Cancer. Sex Med 2022;10:100480.

Prostate Cancer From a Sex and Gender Perspective: A Review.

INTRODUCTION: Factors influencing patient behavior regarding risk of prostate cancer (PCa) and outcomes of PCa treatments are poorly understood. Similarly, how PCa treatments affect patient sexual function and sense of their masculinity has not been fully investigated. A better understanding of the relationship between sex and gender for patients with PCa could significantly improve their care and quality of life. OBJECTIVES: To review how concerns about sex and gender influence men's attitudes toward PCa screening, diagnosis, and treatment. To explore how PCa influences sexual function and self-perceived masculine identity. To examine contexts for PSA screening for transgender individuals. METHODS: We reviewed biomedical and sociological literature exploring the impact of PCa on patient sexual function and self-perceived masculinity using OVID, PubMed, and other databases. We similarly reviewed how masculine gender norms influence patient willingness to engage with PCa screening, diagnoses, and treatment. RESULTS: Gender norms and sexual function concerns influence patient engagement in all aspects of PCa care. This includes PSA screening, digital rectal examinations, active surveillance, and androgen deprivation therapy (ADT) amongst others. ADT is particularly challenging to sexual function, self-esteem, and masculine identity. Our research suggests that sex and gender are not separate concepts, but rather tightly intertwined, particularly when dealing with the realities experienced by patients with PCa. CONCLUSION: Interventions to help patients deal with the challenges of PCa and its treatment are likely to be most effective if they concurrently address patients' sexual needs and understanding of gender norms. PSA screening should be considered for transgender individuals who are at greater risk of cancer and on long-term hormone therapy. More research is needed on how concerns over sex and gender influence PCa screening, diagnosis, and treatment. There is also a need for long term data on the oncological outcomes of prolonged exposure to hormone therapy for patients who are transgender. Muermann MM, Wassersug RJ. Prostate Cancer From a Sex and Gender Perspective: A Review. Sex Med Rev 2022;10:142-154.

A 2-year prospective analysis of insomnia as a mediator of the relationship between androgen deprivation therapy and perceived cognitive function in men with prostate cancer.

BACKGROUND: Androgen deprivation therapy (ADT) may affect cognitive function in men with prostate cancer (PCa). This study examined whether insomnia symptoms mediate the relationship between ADT and perceived cognitive function and whether depressive symptoms, fatigue severity, and physical activity moderate the strength of this relationship. METHODS: This was a prospective study of ADT recipients (n = 83) who were matched with control patients with PCa who were not on ADT (n = 92) and with controls with no history of cancer (n = 112) over a 2-year follow-up period. Perceived cognitive function and satisfaction were assessed with the Everyday Cognition Scale. Insomnia was assessed with the Insomnia Severity Index. Multilevel mediation analyses were conducted to estimate the indirect effect of ADT on perceived cognitive function through insomnia symptoms. Exploratory moderated mediation analyses assessed whether the indirect effect of ADT on perceived cognitive function through insomnia symptoms was dependent on levels of fatigue, depression, or physical activity. RESULTS: Insomnia symptoms significantly mediated the relationship between receipt of ADT and perceived cognitive function (P < .001) and satisfaction with cognition (P < .001) after controlling for comorbidities. Men with greater fatigue had a more pronounced association of ADT with insomnia severity. Men with greater depressive symptoms had a stronger association between insomnia severity and worse perceived cognitive function. Physical activity was not a significant moderator of the relationship between ADT and perceived cognitive function. CONCLUSIONS: Insomnia influenced the relationship between ADT and perceived cognitive abilities. Interventions to address insomnia, fatigue, and depression may improve perceived cognitive function.

Hormones and visual attention to sexual stimuli in older men: an exploratory investigation.

BACKGROUND: Testosterone is associated with sexual desire and performance in men, but little is known about cognitive mechanisms underlying this relationship. Even less is known about the influence of estradiol, despite its production from testosterone, and high receptor density in brain regions related to male sexual behavior. METHOD: We used eye-tracking to compare men's visual attention to images of fully clothed (i.e. neutral) and minimally clothed (i.e. sexy) models in three groups: androgen-deprived (n = 6) and not androgen-deprived with prostate cancer (n = 11), and healthy controls (n = 7). We also assessed effects of serum testosterone, estradiol, and sex hormone-binding globulin levels. RESULTS: We found no group effect for fixations to sexy compared to neutral images, and no influence of testosterone on either total fixations, or proportion of fixations to sexy images. In contrast, we found that sex hormone binding globulin positively predicted total fixations, and estradiol positively predicted proportion of total fixations on sexy images--regardless of androgen treatment status. CONCLUSION: Our results suggest that visual attention to sexual stimuli in men may be significantly affected by hormones. This has potential implications for clinical populations that experience sexual side effects, such as prostate cancer patients on androgen deprivation therapy.

"My son was castrated as a result of a medical error. Is it OK to raise him as a eunuch?"

A 12-year-old boy lost both testes after testicular torsion. He is now 14, and his father wants to know if the boy should immediately start supplemental testosterone or if he might reasonably choose to live as a eunuch. The boy does not yet express any strong opinion except that he is embarrassed about his weight gain. We advised the father that there is no need to rush the decision as the boy could at least delay testosterone therapy until his teens or early 20s and still go through male puberty with little risk of adverse health effects. We seek to know if others endorse our endocrinological advice. The boy's father wants to be honest with his son about the social challenges the boy may face if he elects to delay or avoid puberty altogether and chooses to openly identify as a eunuch.

Factors Associated with "Survivor Identity" in Men with Breast Cancer.

Cancer patients vary in their comfort with the label "survivor". Here, we explore how comfortable males with breast cancer (BC) are about accepting the label cancer "survivor". Separate univariate logistic regressions were performed to assess whether time since diagnosis, age, treatment status, and cancer stage were associated with comfort with the "survivor" label. Of the 70 males treated for BC who participated in the study, 58% moderately-to-strongly liked the term "survivor", 26% were neutral, and 16% moderately-to-strongly disliked the term. Of the factors we explored, only a longer time since diagnosis was significantly associated with the men endorsing a survivor identity (OR = 1.02, p = 0.05). We discuss how our findings compare with literature reports on the comfort with the label "survivor" for women with BC and men with prostate cancer. Unlike males with prostate cancer, males with BC identify as "survivors" in line with women with BC. This suggests that survivor identity is more influenced by disease type and treatments received than with sex/gender identities.

"Partner", "Caregiver", or "Co-Survivor"-Might the Label We Give the Partners of Cancer Patients Affect the Health Outcome of the Patients and Their Partners?

Having a life partner significantly extends survival for most cancer patients. The label given to the partners of cancer patients may, however, influence the health of not just the patients but their partners. "Caregiver" is an increasingly common label for the partners of patients, but it carries an implicit burden. Referring to partners as "caregivers" may be detrimental to the partnerships, as it implies that the individuals are no longer able to be co-supportive. Recognizing this, there has been some effort to relabel cancer dyads as "co-survivors". However, many cancer patients are not comfortable being called a "survivor", and the same may apply to their partners. Cancer survivorship, we argue, could be enhanced by helping keep the bond between patients and their partners strong. This includes educating patients and partners about diverse coping strategies that individuals use when facing challenges to their health and wellbeing. We suggest that preemptive couples' counselling in cancer centers may benefit both patients and their partners.

An Educational Program to Help Patients Manage Androgen Deprivation Therapy Side Effects: Feasibility, Acceptability, and Preliminary Outcomes.

Androgen deprivation therapy (ADT), a common treatment for prostate cancer, is associated with physical, psychological, and sexual side effects that reduce patients' quality of life. The authors designed an educational program to prepare patients for managing these side effects. This paper describes an implementation model for national dissemination of the program, testing its feasibility and acceptability at the institutional and patient level. Postprogram changes in patients' self-efficacy to manage side effects and side effect bother are also explored. Patients on or anticipating ADT enrolled in the educational program. Pre and post intervention questionnaires measured patient satisfaction with the program, side effect bother, and self-efficacy to manage ADT side effects. The ADT Educational Program was deemed feasible and acceptable. Five of six targeted sites successfully launched the program with sufficient patient enrolment. Patient attendees were highly satisfied. Self-efficacy, bother, and use of management strategies were interrelated. Lower bother was associated with increased self-efficacy and more use of management strategies, and increased bother was associated with lower self-efficacy and less use of management strategies. Based on pre-post scores, improvements in patients' self-efficacy to manage ADT side effects were also observed. Results demonstrate that this brief educational program is feasible and acceptable to patients and cancer care institutions. The program appears to promote self-efficacy and the uptake of ADT management strategies for ADT side effects. The results of this study support the program implementation and suggest that improvements in self-efficacy after program participation may help patients adapt to ADT side effects.

How Are Patients With Prostate Cancer Managing Androgen Deprivation Therapy Side Effects?

BACKGROUND: Androgen deprivation therapy (ADT) for prostate cancer has numerous side effects. Clinical guidelines for side effect management exist; however, these are not always integrated into routine practice. What remains undocumented and therefore the objective of this study, is to describe patients' willingness to employ established strategies. PATIENTS AND METHODS: Study participants were 91 men who had attended an educational program (ie, attend a class plus read a book), designed to prepare patients for managing ADT side effects. Three months later, patients completed the ADT Management Strategies Inventory, to determine use of strategies. Descriptive analyses were conducted. RESULTS: At the time of class attendance, the average ADT duration was 133 days. Patient preferences for a variety of strategies for each side effect are presented. Highlights include: a high degree (> 65%) of patients using or willing to use exercise to manage medical risks and physical side effects. Forty percent of patients continued to engage in non-penetrative sexual activities, despite reduced sexual desire and erectile dysfunction. CONCLUSIONS: When educated about options, patients are willing to use a wide array of ADT management strategies. Consequently, health care providers should ensure that patients know about side effects and how to manage them. Exercise appears to be the single best strategy to encourage, because it is helpful in managing many side effects (eg, weight gain, muscle weakening, fatigue) and reducing medical risks of ADT (eg, cardiovascular disease, type II diabetes, and osteoporosis). A general trend was patient's preference for behavioral and lifestyle strategies over pharmacologic interventions.

Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery.

INTRODUCTION: It has been theorized that there are 2 subgroups within the male-to-female (MtF) transgender population: individuals who are predominantly androphilic and those who are predominantly gynephylic or interested in both male and female partners. AIM: To explore the role of a dichotomous distribution of age at dysphoria onset in individuals diagnosed with MtF gender dysphoria. METHODS: 40 patients who presented to a surgical clinic in Germany for gender-affirming surgery (GAS) were included in this study. Their age distribution was plotted as a histogram and the population was then divided at the median self-reported age of onset of gender dysphoria-that is, those 17 years and younger and those 18 years and older. The 2 groups were then compared with regard to demographic data, partnership history, various quality of life parameters, as well as sexual orientation and sexual history. MAIN OUTCOME MEASURE: Self-designed questionnaires for demographics and sexuality, Questions on Life Satisfaction and Body Image (FLZM), Freiburg Personality Inventory, Rosenberg Self-Esteem Scale, and Patient Health Questionnaire were used. RESULTS: Early-onset, gender-dysphoric MtF patients underwent GAS at a much younger age (mean 32.7 vs 43.8 years, P = .004), but had similar characteristics regarding weight, height, body mass index, marital status, and living situation to individuals who reported later onset of gender dysphoria. Preoperatively, they showed greater depressive symptoms (4.6 vs 3.3 points, P = .045), which disappeared after GAS. Following surgery, the younger MtFs were predominantly attracted to men (52.6%), whereas individuals who were diagnosed with late-onset of gender dysphoria preferred women or both men and women (85.7%) as sexual partners (P = .010). Younger trans individuals were more frequently sexually active (73.7% vs 42.9%, P = .049). CONCLUSION: Our findings suggest that there are 2 MtF populations that differ in age of dysphoria onset, sexual history, and multiple personal details including sexual orientation. These data may be used to improve care to transgender individuals by providing treatment reflecting their sexual interests. Zavlin D, Wassersug RJ, Chegireddy V, et al. Age-Related Differences for Male-to-Female Transgender Patients Undergoing Gender-Affirming Surgery. Sex Med 2019;7:86-93.

Androgen Deprivation Alters Attention to Sexually Provocative Visual Stimuli in Elderly Men.

INTRODUCTION: Testosterone is known to regulate male sexual interest, but the exact way that androgens influence men's sexual cognition remains unclear. AIM: To investigate the influence of androgen deprivation (AD) on visual responses to sexually suggestive stimuli in men treated for prostate cancer with AD therapy. METHODS: Patients with AD-treated prostate cancer, patients with prostate cancer not on AD therapy, and age-matched healthy control participants were exposed to images of male and female runway models fully or minimally clothed. Eye tracking was used to compare looking behavior among groups. MAIN OUTCOME MEASURES: Proportion of fixations on fully clothed vs minimally clothed models and proportion of fixations on target areas of interest (ie, legs, chest, pelvis, and face) of fully clothed and minimally clothed models were analyzed and compared among groups. RESULTS: Although men not on AD exhibited a larger proportion of fixations on the minimally clothed compared with the fully clothed images, there was no difference between the 2 image types for men on AD. This was true regardless of whether the images depicted male or female models. Groups did not differ in their fixations to target areas of interest. CONCLUSION: These results suggest that testosterone can influence men's visual attention to sexual stimuli; specifically, AD can attenuate the time spent fixated on sexualized targets. Palmer-Hague JL, Tsang V, Skead C, et al. Androgen Deprivation Alters Attention to Sexually Provocative Visual Stimuli in Elderly Men. Sex Med 2017;5:e245-e254.

What do urologists think patients need to know when starting on androgen deprivation therapy? The perspective from Canada versus countries with lower gross domestic product.

BACKGROUND: Androgen deprivation therapy (ADT) side effects are numerous and negatively impact prostate cancer patients' quality of life. There is considerable discrepancy though among Canadian urologists regarding what ADT side effects and side effect management strategies. Little is known about global differences in ADT patient education. METHODS: International respondents were recruited via online posting and at an international urology conference. Hypotheses suggest that economic and cultural differences influence patient education practices; therefore, international respondents were divided into 3 categories (high, medium, and low gross domestic product). RESULTS: No differences were found between responses from Canadian urologists and high GDP countries. Compared to responses from low GDP countries, Canadian urologists are more likely to endorse informing patients about: osteoporosis, loss of muscle mass, weight gain, fatigue/sleep disturbance, relationship changes, cognitive changes, and loss of body hair. Infertility was the only side effect more often disclosed by urologists in low GDP counties. Recommended management strategies for hot flashes are more likely to be pharmaceutical in Canada, and behavioral in low GDP countries. Management strategies for gynecomastia are emphasized more in low GDP countries. Physical exercise is endorsed consistently more often by Canadian urologists. CONCLUSIONS: ADT educational practices vary greatly between Canada and lower GDP countries. Factors that could contribute to differences include economics (e.g., ADT drug costs), differences in side effect presentation due to different ADT drugs used, racial differences in perceived side effect burden, disease status at ADT commencement, and cultural differences in patient-physician shared-decision making.