Sexual self-schema and depressive symptoms after prostate cancer.

The experience of prostate cancer diagnosis and treatment involves numerous physical and emotional stressors that increase patients’ risk for emotional distress and depression. The 24 months following radical prostatectomy or completion of radiation treatment for prostate cancer are especially demanding, characterized by relatively rapid changes in physical and sexual functioning including erectile dysfunction, blunted sexual responsiveness (e.g., erections that are less firm, subjective experience of feeling less aroused) and lessened overall engagement in sexual activity [1–2]. These sexual changes have been linked to increased risk for depressive symptoms and poorer health-related quality of life [3–8], though substantial heterogeneity across men exists. Despite this, few factors that distinguish patients’ relative risk for distress following loss of sexual functioning have been established, leaving researchers and clinicians with little guidance on identifying vulnerable patients or viable targets for intervention. One characteristic with potential to account for some of the heterogeneity in men’s responses to adverse sexual changes that follow prostate cancer diagnosis and treatment is a man’s view of himself as a sexual person - his sexual self-schema (SSS). Self-schemas are cognitive generalizations about the self [9–11] and, in this case, generalizations about sexual aspects of the self. As conceptualized [12–13], SSS are manifest in current experience, guide sexual behavior (past, present, and future), and influence the processing of sexually-relevant information. In men, SSS has three factors: passionate/loving (e.g., sensitivity, sensuality) which includes feelings of love and passion toward sexual partners; powerful/aggressive (e.g., direct, independent) which shares conceptual overlap with agency and assertiveness; and open-minded/liberal (e.g., liberal, broad-minded) which can denote sexual openness [13]. Men differ in the degree to which they are “schematic” (i.e., high scorers on all factors) vs. “aschematic” (i.e., low scorers on all factors) and these differences are associated with numerous experiential, behavioral, attitudinal, affective, and cognitive differences in the sexual domain [12, 14–15]. Stated simply, a man who is schematic – that is, scores high on sexual SSS – can be sensitive and warm and experiences emotions of passion/love more easily than his aschematic counterpart, and yet still perceives himself as sexually powerful, experienced, and direct. He also tends to be more open-minded and liberal in his sexual attitudes. Compared to aschematic man, schematic men are more sexually experienced, have a broader repertoire of sexual behaviors and report higher levels of sexual arousal. With regard to relationships, they experience greater feelings of passionate love and are more likely to have romantic attachments. Conversely, aschematic men have a narrower range of sexual experiences, have fewer lifetime sexual partners, and are less likely to be involved in romantic relationships [13]. Further, in timed information processing laboratory tasks, schematic men have demonstrated a preference for positively-valenced self-referential words [13]. SSS has also been associated with espousal of traditional and restrictive concepts of masculinity [16–17]. The development of SSS is likely shaped by past social, sexual, and affective experiences and influence how sexual information is processed [9]. Because of their role in affective and attentional processes, it has been suggested that individual differences in SSS constitute a cognitive diathesis in a diathesis-stress model of sexual dysfunction [18], conferring vulnerability to poorer sexual outcomes and perhaps a more difficult psychological trajectory in the face of sexually relevant stressors. For instance, data from gynecologic cancer patients suggests that the combination of a negative SSS and low sexual satisfaction heightened survivors’ risk for psychological distress, including depressive symptomatology. Moreover, among women with more positive SSS, higher sexual satisfaction was related to better quality of life, suggesting that these women tend to benefit more from a satisfying sexual life than women with more negative schemas [19]. There are important conceptual differences in men’s and women’s SSS that are relevant to the discussion of SSS as a diathesis or protective factor. Studies among women also revealed three factors: two of which have a clear positive (e.g., passionate/romantic, open/direct) valence and one of which has a clear negative valence (e.g., embarrassed/conservative), allowing for a discussion of positive and negative sexual self-views among women and consistent with the pattern of results described above. In contrast, men were overall less likely to endorse negatively valenced items1 Of course, there are high and low scorers, but it is difficult to characterize men’s SSS as positive vs. negative given the scale’s content [for a more thorough discussion, see 12–13]; thus men’s SSS is seen on a single dimension of schematic (high scorers) to aschematic (low scorers), as described above. To our knowledge, only two studies have examined SSS among men with cancer, both in the prostate cancer context. Neither study aimed to examine the relationships among SSS, sexual outcomes, nor psychological adjustment, but the results suggest an important role for schema in this population. Schover et al. [2] found that schematic men were more likely to attempt to remediate erectile dysfunction and engage in sexual activity than aschematic men, consistent with the notion that schematic men were more motivated to maintain their sexual identity following treatment. In a subsequent study, Schover and colleagues [21] examined differences between African-American and white men who had undergone radical prostatectomy or radiation therapy for localized prostate cancer (N=1220). In this sample, African-American men evidenced higher scores on SSS than White men (M=110.9 vs. 105.2, p=.04); they were also more likely to endorse the belief that erections are essential to sexual activity (p=.006), reported greater interest in preserving erectile capacity (p<.0001), and willingness to seek help for sexual difficulties (p=.01). Based on these findings, the authors concluded that African-American men might be more vulnerable to the sexual consequences of their treatments than their White counterparts. The present study examines the relationships among men’s SSS, sexual outcomes, and psychological adjustment following treatment for prostate cancer. There were two aims. First, following a clinical description of the sample, we tested the covariation of SSS and sexual outcomes. Second, we tested the possibility that SSS exacerbates the impact of sexual morbidity on depressive symptoms (i.e., moderation). We anticipated that men who reported higher levels of sexual dysfunction and less engagement in sexual activity would report increased depressive symptoms. However, we expect that the impact of sexual dysfunction and low sexual engagement will have a more negative impact on schematic men, who are more oriented toward their sexual selves.