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Journal of Sex & Marital Therapy, 32:389–399, 2006
Copyright © Taylor & Francis Group, LLC
ISSN: 0092-623X print
DOI: 10.1080/00926230600835346
Restoration of Satisfying Sex for a Castrated
Cancer Patient with Complete Impotence:
A Case Study
KAREN M. WARKENTIN
Department of Biology, Boston University, Boston, Massachusetts, USA
ROSS E. GRAY
Psychosocial & Behavioural Research Unit, Toronto Sunnybrook Regional Cancer Centre,
Toronto, Ontario, Canada
RICHARD J. WASSERSUG
Department of Anatomy & Neurobiology, Dalhousie University, Halifax, Nova Scotia, Canada
We present a first-hand account of a fully impotent, testosterone-
suppressed prostate cancer patient who has satisfying, multiorgas-
mic sex using a strap-on dildo. We use his narrative to examine
dildos as an alternative to erectile dysfunction treatments for men,
such as this patient, who find selective inhibitors of PDE-5 inef-
fective and surgical intervention unacceptable. We explore what
conditions allowed this man to progress from suspicious distrust of
the dildo to full acceptance. In terms of making a dildo acceptable
to other patients, we contrast offering it to them as a penile prosthe-
sis in a formal medical setting versus treating it as a toy in fantasy
sex play. Last, we present a neurobiological hypothesis involving
sensory integration to help explain why sex with the strap-on dildo
can be satisfying to a male.
We report a simple, noninvasive strategy for reestablishing orgasmic sex
without erections, based on the experiences of one prostate cancer patient,
and consider the implications of his experience for other patients and their
partners. The patient was diagnosed with prostate cancer 6 years earlier
We thank Deborah McLeod for helpful discussions. This study was supported by the Cana-
dian Institutes of Health Research through its Institute of Gender and Health.
Address correspondence to Richard J. Wassersug, Department of Anatomy & Neurobiology,
Sir Charles Tupper Medical Building 5850 College Street, Dalhousie University, Halifax, Nova
Scotia, B3H 1X5, Canada. E-mail: tadpole@dal.ca
389
390 K. M. Warkentin et al.
and had both a radical prostatectomy and salvage radiotherapy. He is now
in his late 50s, currently free of cancer symptoms but impotent from the
cancer treatments. He is on androgen deprivation therapy, via the LH-RH
agonist Lupron (leuprolide acetate), which suppresses the testosterone that
stimulates prostate cancer cell growth. This has reduced his testosterone
to castration levels, as confirmed by regular blood tests. He no longer has
erections and has a reduced libido, both typical effects of his treatment.
We have worked with the patient to construct the narrative and analysis
presented here and have his approval for the final version. However, he
wishes to remain anonymous.
Most treatments of erectile dysfunction (ED) focus narrowly on restor-
ing erectile function and coitus rather than on improving sexual satisfaction
within relationships. Here, we suggest the use of a strap-on dildo as a med-
ically noninvasive sexual alternative. Dildo sex allows full body contact and
natural, familiar movement patterns, combined with effective genital stim-
ulation. Moreover, it offers a security of sexual performance to the wearer
without the problematic intensification of the coital imperative implicit with
the use of pharmaceutical or surgical therapies for ED. We explore the idea
that dildo use can make sex a lower stress, more playful and collaborative
process.
Surveys and interviews with partially or fully impotent prostate cancer
patients repeatedly reveal great psychological distress associated with the loss
of sexual capability (Althof, 2002; Brucker & Cella, 2003; Clark et al., 2003;
Cooperberg et al., 2003; Dahn et al., 2004; Fergus, Grey, & Fitch, 2002; Gray
et al., 2002; Navon & Morag, 2004; Pirl, Siegel, Goode, & Smith, 2002; Schover
et al., 2004; plus older studies cited therein). Before cancer treatment, patients
are reassured by health professionals that there are interventions to help if
treatments cause impotence. But these interventions are only effective for a
fraction of patients (Schover et al., 2002). Patients on antiandrogen therapy
are particularly unlikely to find the common medical interventions helpful.
The patient discussed here has found a way to circumvent these problems.
HIS STORY
Neither Viagra nor a vacuum erection device worked for me. I am loath to
inject drugs into my penis or have a surgically implanted penile prosthe-
sis, the remaining medical options for treating ED. Not surprisingly, like so
many other cancer patients sexually incapacitated by modern medicine, I
was clinically depressed within a few months of starting hormonal therapy.
This situation began to change when a close lesbian friend, who was
aware of my cancer treatments and the sexual dysfunction they had caused,
refused to accept my giving up on life. She told me that she uses a strap-
on dildo. She claimed that she got genuine sexual satisfaction from this and
Satisfying Sex for a Castrated Cancer Patient 391
thought I could too. I was very skeptical. A dildo is not innervated, and
I imagined that sex performed with such an appliance would be wholly
contrived and not a sensual act at all. My friend persisted in encouraging me,
arguing that sexual satisfaction is as much in the brain as in the groin.
It took me more than a year to act on her suggestion. I was embarrassed
to go into a sex shop to buy a dildo. I had never used sex toys. I was
afraid that I would feel foolish and humiliated by using a strap-on penis.
To do so meant facing fully, frontally (so to speak), the functional failure
of my own flaccid phallus. Despite my reservations, I eventually agreed to
experiment with a strap-on dildo. My expectations, though, were muted. At
most, I thought I might be able to please my partner. But I honestly did not
envision recreating a fully satisfying sexual experience.
My lesbian friend took the initiative to get me going on this project. She
fabricated a harness that was customized to fit me and took me shopping for
a dildo, which she insisted I consider “a toy.” I don’t think I could have even
walked into the sex shop without her. I was worried that I might be identified
and mocked by someone who knew me. In the store I debated buying a
dildo that looked relatively natural or one that was beyond the realm of real
anatomy. I finally selected one that was similar in size, shape, and angle
to my erect penis before cancer treatments, to the best of my recollection.
It is made of silicone, which makes it durable, appropriately stiff, yet still
flexible, like a natural erect penis. Beyond that, the dildo that I bought bears
little resemblance to a human penis. Granted, it has an expanded “head,” like
the real glans penis but a uniformly smooth shaft, with none of the irregular
surface texture caused by real-life veins. And it is purple! Clearly, it does
not constitute a realistic bio-mimetic prosthesis. I knew then that I could not
seriously think of this piece of purple plastic as a medical appliance. This
was important in my reconceptualizing the situation. Whatever I was going
to do with the dildo was not in anyway a “cure” for ED nor was it meant
to restore my masculine sense of sexuality. If this was going to work, it was
because it was something completely different. I had to stop thinking about
this clinically and accept the idea that I was heading into the theater of the
absurd, and I was going to play the part of a lesbian!
Before this purchase, I discussed extensively with my partner whether
she was willing to have sex with me wearing a strap-on dildo. She was at
first hesitant but ultimately supportive of the exploration. We have now used
the dildo many times. It caught me by total surprise how natural intercourse
felt with this strap-on device. I discovered that my hip movements with the
dildo on were the same as during normal intercourse. Our body contact and
embrace was full and natural, as well. The first time that we used the dildo,
my partner reached down and held my penis in her hand. She had coated her
hand with the same lubricant used to coat the dildo and stimulated my penis
in synchrony with my pelvic movements. There was little sensory difference
between this act and intercourse—my penis was not in her vagina but it
392 K. M. Warkentin et al.
did not know that. It was in a wet, warm place being firmly mechanically
stimulated. My hindbrain took over, and I carried the act through to orgasm,
to the sexual satisfaction of both my partner and myself.
My partner had not discussed with me her plan to hold my glans penis, so
I was totally surprised by that action. I had not expected to achieve an orgasm
and was astonished that it happened. At first I, thought it was the novelty
of her holding my penis that brought me to climax. I thus feared that being
aware, and then self-conscious, of this activity would defeat its effectiveness.
This, however, has not been the case. If anything, sexual satisfaction has
become easier, because both of us have come to accept the dildo as part
of our sex play. Each time we use it, it becomes further imbued with the
knowledge of the previous sexual satisfaction it has provided. It is thus now
both a normal and at the same time erotic part of our lives.
We have both been able to have orgasms many times using the dildo.
The knowledge that it will never become flaccid means that my having an
orgasm need not prohibit further penetrative sex. The dildo gives me the
sexual capacity to serve my partner more reliably than I might have been
able to achieve as a potent male (with or without Viagra). Significantly, my
partner claims that she could not previously have an orgasm simply by penile
penetration. However, with the dildo, I am able to continue pelvic thrusts
long and hard enough that she now regularly achieves an orgasm in the
missionary position. We have also used the dildo with me lying on my back
and my partner sitting on it, so she has control of the movement. This was
sexually pleasurable for her, although I have not achieved an orgasm in this
position.
When I had a prostate gland, sexual arousal that did not lead to ejacula-
tion was frustrating, and I found it incomprehensible when a woman claimed
she had pleasure from sexual stimulation yet had not had an orgasm. After my
prostate was removed, I discovered that I too could have incremental plea-
sure from sexual stimulation and enjoy sex without orgasms. I can also have
multiple orgasms! Without a prostate gland, my orgasms are less anatomically
focused, radiating across my pelvis. They are of variable intensity but some-
times massively cathartic. When I have multiple orgasms, they are usually 2
or 3 within one minute or 2. I find it easiest to achieve orgasms when my
partner wants me to, especially in the context of mutually satisfying dildo
intercourse, but far more difficult on my own.
Iamfascinated by the eroticism that has developed between my partner,
myself, and our dildo. For example, one morning, after having sex the night
before, I went to the bathroom and found the dildo sitting upright on the
counter-top wearing one of my favorite neckties. My partner had decided to
personify and personalize it. I interpreted this as a signal to me that the dildo
pleased her and did so because of its association with me.
On another occasion, I was waiting for my partner’s arrival and decided
to put on the harness and dildo ahead of time. I covered myself and the
Satisfying Sex for a Castrated Cancer Patient 393
dildo with a bathrobe, but there was no mistaking the fact that when I looked
down there was sticking out what looked like a large firm erection. For a
brief instant, it brought back my fear that wearing a dildo would force me
to confront in a demoralizing fashion my own failed phallus, my mutilated
masculinity.
But that was not at all what I felt. Instead, I felt joyfully empowered.
My thoughts went to a glib one-liner from my lesbian friend: “A dyke with
a dildo can outlast a male anytime.” I realized that that was equally true
for a prostate cancer patient with a dildo, and I almost started laughing. I
was playing a role and doing it better than I ever could before I became
impotent. I had acquired a performance capability that surpassed “male” and
I was thoroughly enjoying the “play” part of sex.
When I reported this experience to my lesbian friend, she suggested that
my partner and I explore oral sex with the dildo. Once again, my first thought
was, “That’s absurd.” But since everything else she suggested had worked
better than I could have imagined, my partner and I took on the challenge.
Simply stated, there has now been enough acceptance of the dildo as a sexual
object—and transference from “object” to “organ”—that the visual image of
my partner mouthing the dildo was indeed highly erotic in the context of
our sex play. On another occasion, in order to tease me, my partner started
playing with the dildo in a flirtatious fashion outside of the bedroom. I found
the activity erotic and sufficiently distracting that I had to ask her to stop so
that I could concentrate on what I was doing.
DISCUSSION
On the Psychological Context of Dildo Refusal and Dildo Use:
Changes Over a 5-year Period
We believe several factors may have contributed to this man’s initial refusal
to try a strap-on dildo and his later acceptance and enthusiasm. First, his
relationship with the lesbian friend who suggested that he try the strap-on
is pivotal. He has been close to this woman for 16 years, and he considers
her a role model. Over the years, she has shared a great deal of personal
information with him about her nonerection–dependent sexual practices and
experiences.
Despite her recommendation and his high regard for her, he was un-
willing initially to try the dildo alternative. Key obstacles to him were the
unnatural appearance of the dildo and the fact that it was not innervated.
He felt that he would not be able to identify with this inanimate object; it
would not “be him.” At one point, he expressed mild interest in the possi-
bility of a personalized prothesis cast from a mold of his own erect penis.
But his impotence and aversion to injecting drugs into his penis to achieve
an erection precluded that possibility. At that time, he had a normal libido,
394 K. M. Warkentin et al.
despite his lack of erections. Hormonally, he was, and perceived himself to
be, fully male. He was frustrated with his sexual limitations but not depressed
or despairing. This is the period during which he tried Viagra and a vacuum
suction device.
When he began Lupron treatments, his attitude changed. He gave up
even the idea of sexuality and felt life was not worth living. After a few
months on Lupron, the turning point came when his lesbian friend finally
convinced him that his sexuality need not be testosterone dependent. He let
go of trying to regain what he had been before and embarked on a path
to create a new personal and sexual identity. The acceptance that he had
somehow fundamentally changed, on Lupron, allowed him to be more open
to a process of experimentation to find out who he could be, sexually, in
this new state.
As well as the continued support of his lesbian friend, a second pivotal
factor was a new sexual relationship. His partner is a woman with whom he
had been friends for many years. They had spoken at length about his cancer
treatments and their effects on him over the years, and she had been under-
standing and supportive. When she got involved with him, she knew his con-
dition and wanted to work with him to see what kind of sexuality they could
create together. Thus, although she was initially hesitant about the dildo,
she was fundamentally open to alternative sexual practices and to a process
of mutual discovery. Her support, openness, and active participation in the
process have been critical to the development of his new sexual practice.
Who Owns that Phallus?
A key component to the sexual satisfaction that this patient has achieved is
that he and his partner are working together. Her acceptance of the dildo
matches if not exceeds his, and his satisfaction is enhanced by the equality
that the partners achieve in their sex play. For dildo sex to be effective,
it likely requires, at least initially, a cooperative “suspension of disbelief”
and a willingness in both partners to play along with the game in order
to begin creating the positive experiences that will become self-reinforcing.
Such cooperation within a couple appears essential for a strap-on dildo to
work as well as it has for this man and his partner. Although this patient
acquired the dildo on his own, by the end of his narrative, he considers the
dildo to belong to both him and his partner. This joint ownership is quite
unlike a penis, which may act like it “has a mind of its own” (Friedman,
2001) but is clearly the sole property of the man of whose body it is a part. A
dildo is quite different. Since it is detachable, a woman can take possession
of it. She can share a sense of potency that was previously solely the man’s.
This seems to have happened in this case, where it works to the satisfaction
of both partners.
Satisfying Sex for a Castrated Cancer Patient 395
Is It a Medical Prosthesis or a Sex Toy?
A strap-on dildo is simple, inexpensive, and noninvasive. Yet this patient,
who was clearly quite distressed about his lost sexuality, was initially very
resistant to experimenting with such a device. This suggests that, although
some impotent men may be inspired to try dildo sex, others–probably many
others–may resist exploring this alternative.
The success in medical treatment of ED suggests that some patients may
be willing to consider dildo sex if it is prescribed by their physicians. Gray
and Klotz (2004) discuss this approach. For instance, a doctor could prescribe
a “belted prosthetic phallus” for his impotent patients and then refer them
to a sexuality clinic in a medical setting for instruction on how to use the
appliance. Although such medicalization of sexuality is problematic, it may
nevertheless be the most acceptable route for some couples.
For other patients, such as the man described here, a dildo may be more
effective if viewed not as a medical treatment for ED but as a sexual alterna-
tive or enhancement. For him, the dildo worked because “it was something
completely different,” a toy with which he and his partner played.Inorder
for him to achieve sexual satisfaction, he “had to stop thinking about this
clinically and accept the idea that [he] was heading into the theater of the
absurd.” It worked not because it was a medically prescribed treatment for
his disability but because it was a sex toy.
If other patients can profit from the experience of this man, careful con-
sideration must be given to the subtleties of how to introduce dildo sex to
patients. Some patients may find a “belted prosthetic phallus” acceptable
and a dildo not. For others, like this patient, it may be best to take sexual-
ity completely away from the medical arena of impotence, dysfunction, and
“treatment” for sexual failure and move it into the realm of play, communi-
cation, and a collaborative project with a partner. Toys have long been a part
of human play and human communication.
Is It an Acquired Fetish?
This patient rapidly shifted from his initial view of the dildo as a somewhat
ridiculous piece of purple plastic to finding it a highly erotic and personal ob-
ject in association with his partner. From one perspective, one may view this
as the development of a fetish. Effectively, the repeated positive experiences
that this man and his partner have had with the dildo transformed it in both
of their minds into a sexually charged object and created a mutual sense of
ownership. This suggests that couples need not approach dildo sex with the
idea that it will work for them or any prior sense of eroticism associated with
the object. They need only the willingness to try it, to experiment. Any posi-
tive reinforcement through sexual satisfaction will increase the effectiveness
of the dildo as a sex toy or tool for them in the future.
396 K. M. Warkentin et al.
On the Biomechanics of Copulation and the Dildo Advantage
Although using a strap-on dildo may initially seem a poor match to natural
penile copulation, it has several mechanical advantages over treatments that
focus on achieving an erection for vaginal penetration. Vacuum devices and
many penile implants distend the shaft of the penis but do nothing to stiffen
the root of the penis within the body. This leads to a “hinge” effect, where
the shaft is stiff, but freely bends at its base. Similarly, drug treatments such
as Viagra, unless they are 100% effective, leave the penis only semifirm.
These conventional interventions may produce a “stuffable” penis but make
it difficult to maintain normal copulatory movements. Coitus is then easily
interrupted. This is a common problem with these treatments, which can be
extremely frustrating for both the man and his partner (Tomlinson & Wright,
2004).
A dildo completely circumvents this problem. A strap-on dildo can
closely match the natural size, shape, stiffness, and angle of a man’s erect
penis, allowing him to make completely natural hip thrusts. Even though
he cannot feel the dildo within his partner, he can move naturally without
fear of coming out of the vagina. Our patient credits these movements and
associated full body sensations with a critical role in his reestablishment of
orgasmic sexuality.
Also, when traditional ED treatments are not completely effective, they
fail to provide adequate stimulation to the glans penis during intercourse.
Without the penis being fully erect and at the proper angle, pressure on
the penis and stimulation to the glans is reduced. Many men after surgery,
radiation, and hormonal therapy report that they need extra penile stimu-
lation to achieve an orgasm. All current treatments for ED, however, focus
on vaginal penetration rather than glans stimulation.Infairness, these treat-
ments are designed to help the male recover coital capability. However, if
they are not fully effective, they cause less rather than greater stimulation to
the glans. In using a strap-on dildo, the penis is external so it can be stim-
ulated manually, providing more pressure to the glans. It is not obvious to
the penis itself where it is (Friedman, 2001). Provided it is in a moist envi-
ronment and stimulated firmly and rhythmically, the sensation can induce a
climax.
Finally, when traditional ED treatments are not perfect, they can under-
mine a man’s confidence in his ability to provide sexual satisfaction to his
partner. The acceptance of a dildo circumvents this psychological problem,
because both the man and partner can be fully confident that the dildo will
remain erect.
Although the sex described here is farther from natural intercourse than
that provided by other ED therapies, it offers enhanced penile and vaginal
stimulation. Consequently, it may be more sexually satisfying for both part-
ners than what can be achieved with other ED treatments that focus only on
penile penetration.
Satisfying Sex for a Castrated Cancer Patient 397
A Neurobiological Hypothesis on Dildo Eroticism
Recently, Ehrsson, Spince, and Passinghan (2004) used functional magnetic
resonance imaging (fMRI) to explain the strange “rubber-hand illusion.” In
this illusion, a person watching a brush stroking an artificial hand, while his
or her own hand is out of sight but simultaneously being stroked, develops
a sense that the rubber hand is their own. The fMRI established that the
illusion happens because of “multisensory integration in the premotor cortex”
(Ehrsson et al., 2004, p. 876).
Could a similar illusion apply to the strap-on dildo? Part of the psycho-
logical success of the dildo for our patient was how “real” it both felt and
looked to him. When it was strapped to his hips by the harness, it rested on
his pelvis in the natural position and angle of his own erect penis, before he
was impotent. This allowed for full body contact between him and his part-
ner in a completely natural, copulatory posture. Thus this may have provided
enough proprioceptive and tactile stimuli to produce sufficient “self-specific
intersensory correlations” (Botvinick, 2004) for a sensory illusion, like the
rubber-hand illusion, to occur.
During coitus in the missionary position, this man could not see the
dildo. Hence, this is not completely analogous to the rubber-hand illusion,
which involves integration of visual and tactile stimulation. However, Ehrsson
et al. have extended their earlier work on multisensory integration to show
that visual input is not essential and that multiple sensory information of
a purely tactile nature can induce the same illusion of ownership (Ehrsson
et al. 2005). Our patient describes intense erotic sensation from both sexual
intercourse in the missionary position with the strap-on dildo and watching
his partner performing fellatio on the dildo. Given concurrent manual stim-
ulation to the man’s flaccid but out of sight penis, these situations would
closely mimic the simultaneous tactile-tacile and visual-tacile input in the
rubber-hand illusion.
Of course, it remains to be seen if multisensory integration takes place in
the brain to provoke a genuine genital illusion equivalent to the rubber-hand
illusion as described by Ehrsson et al. (2004, 2005). Having a man in an fMRI
machine wearing a dildo while his partner has the dildo in either her vagina
or her mouth and simultaneously strokes his penis, sounds like the ultimate
kinky science experiment. Yet there is a serious context for doing such a
study. Establishing a solid neuroanatomical basis for a “rubber-penis illusion”
may help make a strap-on dildo an acceptable, noninvasive, cost-effective
treatment for ED for the 85% of men treated each year for prostate cancer
who experience some ED as a result of their treatment (Schover et al., 2002).
CONCLUSION
A strap-on dildo, in conjunction with manual penile stimulation, allowed our
fully impotent patient to achieve sexual satisfaction and concurrently satisfy
398 K. M. Warkentin et al.
his partner (Gray & Klotz, 2004). For some impotent patients, this simple
noninvasive approach may work better than more established ED treatments.
More research is needed to see how effective a dildo is for other patients
and, if it is effective, to identify the best way of presenting this option to
patients and their partners.
It should be noted that the current cost of one dose of Viagra or similar
drugs (e.g, vardenafil, adalafil) is $8–10 US. The cost of a penile implant
generally ranges from $12,000 to 25,000 US. The total cost of a good quality,
off-the-shelf dildo and harness is less than $200 US.
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