Original Research

Facilitating sexual health discussions with prostate cancer patients: The perspectives of radiation therapists

Nape M. Phahlamohlaka, Penelope Engel-Hills, Hesta Friedrich-Nel

Received: 19 May 2025; Accepted: 06 Aug. 2025; Published: 12 Dec. 2025

Copyright: © 2025. The Author(s). Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: Radiation therapists (RTTs) play a supportive role in patient counselling; however, their involvement in addressing men’s sexual health challenges remains poorly documented.

Aim: This article explores the perspectives of RTTs on the role of facilitating sexual health discussions with patients receiving radiotherapy for prostate cancer.

Setting: The study was conducted at two academic hospitals in Gauteng province, South Africa.

Methods: A cross-sectional, prospective survey design was employed, with a purposive sample of 50 RTTs. Data were collected using a structured, paper-based questionnaire. Quantitative data were analysed using descriptive and inferential statistics with IBM Statistical Package for the Social Sciences version 29, while qualitative responses were coded and analysed thematically using ATLAS.ti 23. Four themes were identified following thematic analysis of narrative responses.

Results: The study achieved a response rate of 96.0% (n = 48). A majority of the RTTs (64.6%) acknowledged having sexual health discussions with male patients, with 56.3% considering sexual health essential during patient counselling. No significant associations were found between curricular inclusion of sexual health and qualification level (p = 0.065), work experience and handling of sexual health (p = 0.228), gender and avoidance of discussions (p = 0.181), and age group and handling of sexual health (p = 0.723). Four themes were identified following narrative responses.

Conclusion: The results from this study suggest that most respondents acknowledged the importance of conducting sexual health discussions with patients during radiotherapy, although their involvement appears to be inconsistent.

Contribution: This article highlights the potential to enhance supportive care for sexual health in patients receiving radiotherapy for prostate cancer by leveraging the role of RTTs.

Keywords: oncology; prostate cancer; radiotherapy; counselling; supportive care; sexual health challenges.

Introduction

Radiation therapists (RTTs) are known to assist with patient counselling on managing radiation-induced side effects and provide psychosocial support to patients in collaboration with radiation oncologists.^1,2,3,4,5,6 Nonetheless, the supportive care for sexual health and related psychosocial issues in patients with cancer receiving radiotherapy is reported to lack continuity in oncology settings.^7,8 Several studies highlight the need to address the lack of discussions about sexual health issues between cancer patients and oncology health professionals, including RTTs.^{9,10,11,12,13,14}

Radiation therapists are frontline oncology health professionals who play a pivotal role in patient care by interacting daily with cancer patients over extended treatment periods, usually lasting several weeks.^10,15 This consistent, close contact with patients fosters unique and trusting therapeutic relationships, positioning RTTs as both technical experts and vital sources of emotional support.^16,17 It has been highlighted that this proximity places RTTs in an ideal position to provide supportive care to address sensitive topics, such as sexual health, intimacy and sexual function, which are areas often overlooked in cancer care.^{10,16,18,19,20,21,22}

The origin of this article is the first author’s unpublished doctoral thesis, which explored the experiences of patients in terms of supportive care for sexual health during radiotherapy for prostate cancer. It also investigated the perspectives of RTTs on including sexual health into routine patient counselling practices. The doctoral study aimed to develop a model to facilitate supportive care for men’s sexual health in patients receiving radiotherapy for prostate cancer. This model promotes the involvement of RTTs in facilitating supportive care for sexual health in cancer patients in collaboration with radiation oncologists.

The aim of this article is to explore the perspectives of RTTs on the role of facilitating sexual health discussions with patients receiving radiotherapy for prostate cancer to leverage their role in improving supportive care in radiation therapy departments. The anticipated outcome of this research is to promote the inclusion of sexual health topics into routine patient counselling facilitated by RTTs during radiotherapy.

This article thus contributes to the existing body of peer-reviewed literature, albeit limited, that emphasises the need for involvement of RTTs in facilitating discussions on sexual health with cancer patients receiving radiotherapy.^9,10,23 It also aligns with studies in the literature that underscore the importance of integrating sexual health into comprehensive oncology care.^24,25,26,27 The significance of this article lies in foregrounding the perspectives of RTTs on initiating and including sexual health discussions as part of routine patient care.

Methods

Study design and setting

A prospective cross-sectional study was conducted in the radiation therapy departments of two academic hospitals in Gauteng, South Africa, to explore the perspectives of RTTs on facilitating sexual health discussions with men receiving radiotherapy for prostate cancer.

Population and sampling

The target population comprised of 60 RTTs from the selected hospitals. An adjusted sample size of 50 was deemed appropriate to set a baseline study for the supportive role development of RTTs in South Africa. A purposive sampling approach was used to select respondents based on the inclusion and exclusion criteria (Table 1). The sample size was determined using Cochran’s modified formula for finite populations, as shown next.^28,29,30,31

Step 1: Calculation of sample size (n₀) using Cochran’s formula (Equation 1):

n₀ = initial sample size (267)

e = margin of error (0.06)

p = the fraction of the population (p = 0.5 for maximum variability)

Z = z-score corresponding to the desired confidence level (for α = 0.05, Z is 1.96)

Step 2: Cochran’s modified formula for finite populations (Equation 2):

n = adjusted sample size, n₀= 267, N (population) = 60

n = 267/(1 + (267 –1) / 60)

n = 50

Data collection

Data were collected over a period of 3 months (01 September 2021–30 November 2021). Data collection commenced after ethical clearance and gatekeeper approval were received from the relevant institutional research ethics committees, radiation therapy department heads and hospital management. A quantitative survey with supporting open-ended questions was used to generate textual data to complement the Qualitative data with narrative responses, providing contextual nuances beyond Likert-scale responses.³² Given the busy nature of South African oncology settings and limited staff, a paper-based questionnaire was the most practical and accessible way to collect data from RTTs. Questionnaires were couriered to the participating hospitals and administered on-site with the support of a research assistant. Completed forms were returned anonymously via secure drop-boxes located at each hospital. The data were captured electronically into the QuestionPro online survey software using an online version of the paper-based questionnaire. A pilot test study was conducted with five RTTs to validate the research instrument to assess its content and face validity before data collection.^33,34 No significant modifications were required after the pilot test study.

Data analysis

Descriptive data analysis was used to describe trends in the dataset, and a contingency table, also known as cross-tabulation, was used to compare two categorical variables of interest linked to the studied phenomenon, using IBM Statistical Package for the Social Sciences (SPSS) Statistics version 29 (IBM Corporation, ARMONK, New York, United States). Fisher’s exact test was the most appropriate method for assessing the statistical significance of associations between the categorical variables of interest, given that this test yielded valid results for small sample sizes.^35,36 The thematic analysis approach was used to analyse narrative responses.^37,38 The handwritten responses from the questionnaire were transcribed into Microsoft Word and then imported into ATLAS.ti 23 for coding. Individual codes were organised into related categories to identify overarching themes or key ideas emerging from respondents’ narratives in response to specific questions.

Ethical considerations

Ethical principles of autonomy, non-maleficence, beneficence and justice were upheld throughout the study, following the Declaration of Helsinki.^39,40 The study received ethical approval from the Cape Peninsula University of Technology (reference number: CPUT/HW-REC 2020/H15) and the Human Research Ethics Committee of the University of the Witwatersrand (reference number: M2011123). The heads of the radiation oncology departments at the participating academic hospitals granted gatekeeper permission. Participation was voluntary, with the option to withdraw at any time without waiving any participant rights. An information sheet was attached to the questionnaire. To protect the anonymity of respondents, implied consent was obtained for this survey.⁴¹ The first page of the questionnaire included the statement that completing and returning the questionnaire constituted implied consent to participate in the study. The first author employed the QuestionPro online survey tool to capture and archive the data. Data were reported confidentially without revealing identifiable information about the respondents. Completed paper-based questionnaires will be destroyed after research articles related to this study have been published.

Results

Of the 50 RTTs, 48 responded to and completed the survey for analysis, yielding a response rate of 96%. All completed and returned questionnaires were eligible for inclusion in the analyses. None of the questionnaires were excluded because they were illegible or incomplete. Four themes were identified from respondents’ qualitative responses.

Respondent demographics

Table 2 summarises the demographic characteristics of the respondents. Key variables captured included gender, age range, highest qualification attained, years of work experience and job position. These characteristics contextualised the results by offering insights into the respondents’ demographic profile.

Regarding gender, 77.1% (n = 37) of the participating RTTs identified as female and 22.9% (n = 11) as male. In terms of age, the age group with the largest representation was 31.1–57 years (39.6%, n = 19), followed by 21.1–25 years (33.3%, n = 16) and 25.1–31 years (20.8%, n = 10). One respondent was younger than 21 years, and two did not disclose their age. Regarding educational qualification, 31.3% (n = 15) of the respondents held a national diploma (NDip), 25.0% (n = 12) held a bachelor’s degree, 22.9% (n = 11) had an honours degree, 16.6% (n = 8) had a bachelor of technology (BTech) degree and 4.2% (n = 2) had a master’s-level qualification. In terms of work experience, 33.3% (n = 16) reported 5.1–15 years, 27.1% (n = 13) reported less than 2 years, 20.8% (n = 10) reported 15.1–40 years and 18.8% (n = 9) reported 2–5 years of professional experience. In the job position category, 50.0% (n = 24) were in junior positions, 33.3% (n = 16) were in senior positions and 16.7% (n = 8) held chief positions.

Attempts by radiation therapists to discuss sexual health questions with patients

To uncover opinions about whether respondents avoid sexual health questions during radiotherapy for prostate cancer, the following question was asked of the respondents: ‘How do you deal with patients with prostate cancer who ask you questions about sexual health challenges?’ The results of this question are shown in Figure 1.

FIGURE 1: Radiation therapists’ avoidance of questions on sexual health.

The results indicate that nearly two-thirds of the respondents (64.6%, n = 31) reported that they never avoid patients’ questions about sexual health during radiotherapy. In contrast, 8.3% (n = 4) acknowledged that they sometimes or often avoid such questions, while 3.1% (n = 1) indicated that they always avoid addressing sexual health concerns.

The extent to which radiation therapists consider sexual health during patient counselling

Respondents were asked to rate the importance of the following statement in the context of patient counselling: ‘RTTs should consider sexual health when counselling patients with prostate cancer’. A Likert scale was used to rank the statement from high to low priority. As shown in Figure 2, the survey results highlight the extent to which respondents prioritised sexual health during patient counselling sessions.

FIGURE 2: Ranking of sexual health topics during patient counselling by respondents.

More than half of the respondents (56.2%, n = 27) indicated that sexual health topics were of high importance in patient counselling. A smaller proportion (16.7%, n = 8) regarded it as a moderate priority, while 20.8% (n = 10) remained neutral. Only a minority (6.3%, n = 3) considered sexual health to be a low priority during patient counselling.

Cross-tabulations

Inclusion of sexual health content in curricula by qualification

The inclusion of sexual health content in the curricula by qualification was investigated to determine whether there was an association between the curricular inclusion of sexual health topics in radiation therapy education and the qualification level of respondents. Table 3 summarises the respondents’ responses on the frequency of including sexual health topics during their training, categorised by the highest qualification attained.

Respondents holding an NDip and BTech differed notably in their perception, with 33.3% (n = 5) of NDip holders and 50.0% (n = 4) of BTech holders indicating that sexual health was seldom included. None of the BTech group reported always, while 20.0% (n = 3) of the NDip group did. Among the bachelor’s degree holders, 50.0% (n = 6) reported seldom and 41.7% (n = 5) always. Of the honours degree holders, 45.5% (n = 5) reported seldom, 27.3% (n = 3) sometimes and 27.3% (n = 3) always, with no one reporting almost always. Master’s degree holders split evenly between never (50.0%, n = 1) and almost always (50.0%, n = 1). Despite these differences, the association was not found to be statistically significant (p = 0.065).

Handling of sexual health questions by work experience

A cross-tabulation was performed to investigate the association of how respondents with varying work experiences handled questions about sexual health (Table 4). The significance of the statistical relationship between these two categorised variables regarding respondents’ consideration of men’s sexual health was tested.

Table 4 indicates that sometimes avoid was the most frequently reported response across all experience levels, with the highest proportion observed among RTTs with 2–5 years of experience (77.8%, n = 7). The tendency to always avoid increased with experience, especially among those with 15.1–40 years of experience (40.0%, n = 4). Less than 10.0% at any level reported never avoiding these discussions. Work experience and how respondents handled sexual health questions were not found to be statistically correlated (p = 0.228).

Handling of sexual health questions by age group

Cross-tabulation was performed to investigate the association of how respondents across different age groups handled questions about sexual health. The data were visually represented using a stacked bar chart to enhance the interpretability (Figure 3).

FIGURE 3: Cross-tabulation of handling of sexual health questions by age groups.

Figure 3 shows that sometimes avoid was the most common response across all age groups, with the single respondent under 21 years answering the same. There is a visible increase in always avoid across subsequent age categories, from 6.3% (21.1–25 years) to 10.0% (25.5–31 years) and up to 50.0% (unknown years). Never avoid was only indicated by the 25.5–31-year age group (10.0%), being absent in the other age groups. No statistically significant relationship was found between age group and handling of sexual health questions (p = 0.730).

Avoidance of discussing sexual health issues by gender

Table 5 presents the responses by gender regarding the tendency to avoid discussing sexual health issues with male patients receiving radiotherapy for prostate cancer. Table 5 shows the distribution of responses across the five agreement categories, from strongly disagree to agree, highlighting the differences between female and male respondents.

Table 5 shows that 46.0% (n = 17) of the female respondents disagreed with the statement on avoiding sexual health discussions, compared to 20.0% (n = 2) of the male respondents. Meanwhile, 40.0% (n = 4) of male respondents strongly agreed versus 16.2% (n = 6) of female respondents. In addition, 30.0% (n = 3) of male respondents and 13.5% (n = 5) of female respondents agreed that they avoided such discussions. The association between gender and avoidance of sexual health discussions was not statistically significant (p = 0.181).

Themes identified

Four main themes were identified following the analysis of the free-text responses: (1) perceived responsibility for comprehensive care, (2) patient referral culture, (3) sexual health communication challenges and (4) role uncertainty within the scope of practice.

Theme 1: Perceived responsibility for comprehensive care

Respondents acknowledged the importance of including sexual health discussions in routine patient care and striving to offer helpful advice to patients seeking information on sexual health-related questions during radiotherapy for prostate cancer. It was evident that the respondents viewed their role as more inclusive concerning patient counselling and did not disregard the sexual health topic:

‘Sexuality plays a big part of the person’s whole self and as a RTT, it is part of our duty to provide one patient with holistic care.’ (Resp31, 31 Years, Female)

‘We need to understand and be educated in all aspects of our scope of work.’ (Resp13, 25 Years, Female)

‘I usually attend to almost every question I get from patients to minimise their anxiety.’ (Resp14, 26 Years, Male)

‘Prostate patients become anxious about their sexual health; therefore, it is important to reassure them about their concerns.’ (Resp22, Unknown Age, Male)

Theme 2: Patient referral culture

This theme highlights how RTTs often defer sexual health counselling to other oncology team members in the radiation therapy department. It appears that respondents tried to provide advice and knowledge to the best of their ability when approached by patients, and then referred them to a radiation oncologist for further information. It was also noted that some respondents answered only what was being asked by the patient and never initiated the sexual health topic:

‘Refer pt to people better equipped to answer their questions.’ (Resp35, 48 Years, Female)

‘I try to answer them as best as I can; otherwise, I refer them to the oncologist if they still want more information.’ (Resp19, 30 Years, Female)

‘I answer truthfully and professionally, and if I don’t have enough knowledge, I refer the patient to the Dr.’ (Resp39, 53 Years, Female)

‘I feel I don’t have full knowledge about that issue, so how do I give them advice.’ (Resp03, 39 Years, Female)

Theme 3: Sexual health communication challenges

This theme captures the various barriers that respondents encountered when attempting to engage in sexual health discussions with patients with prostate cancer. The findings reveal, to some extent, an interplay of sociocultural, religious, age, gender and interpersonal factors affecting sexual health communication between patients and RTTs:

‘It all depends on how old the patient is; since I am African, it is not easy to engage in sexual health conversation with older people. Because I regard them as my patient.’ (Resp27, 24 Years, Female)

‘I am not comfortable with speaking to patients about sexual health, especially male patients.’ (Resp24, 31 Years, Female)

‘Prostate pts feel more comfortable speaking to male health professionals about their sexual health as they feel the male health professionals can relate to the topic.’ (Resp20, 22 Years, Female)

‘Some religions do not allow males to discuss sexual topics with people except their partners.’ (Resp16, 20 Years, Male)

Theme 4: Role uncertainty within the scope of practice

This theme captures how respondents experienced uncertainty about their role in addressing sexual health concerns, particularly in the context of supportive care for sexual health. Although many respondents recognised the importance of patient support, their engagement was often constrained by a doubtful understanding of their scope of practice. These findings on perceived role uncertainty, with some respondents feeling unprepared or professionally restricted from initiating or addressing sexual health discussions, are evident in the following quotes:

‘Counselling is done by the sisters and doctors. RTTs remind the patients and make sure they understand and give clarity or send to the doctor.’ (Resp18, 24 Years, Male)

‘It is beyond my scope, but I do send them to the doctor as per requirements of our department.’ (Resp25, 25 Years, Male)

‘I am a professional. I would talk to the patient if necessary but as a radiotherapist it is not my place to start that conversation.’ (Resp43, 46 Years, Female)

‘RTTs only discuss what is written in their scope of practice. Lack of sexual health education during studies.’ (Resp30, 25 Years, Female)

Discussion

This article explored the perspectives of RTTs on the role of facilitating sexual health discussions with patients receiving radiotherapy for prostate cancer, to leverage their role to improve supportive care in radiation therapy departments. It is necessary to explore the knowledge, attitudes and barriers that challenge oncology health professionals from discussing sexual issues with cancer patients in oncology settings to assist them in overcoming these challenges.^9,42,43 Respondents acknowledged the important role of offering comprehensive care, which encompasses sexual health support for patients undergoing radiotherapy for prostate cancer. However, their active engagement in having sexual health discussions with patients appeared to be inconsistent. This observation is consistent with the findings of other research studies, which also noted the minimal involvement of RTTs in addressing sexual health concerns.^10,44 In addition, many oncology health professionals working with cancer patients tend to avoid sexual health discussions, often citing barriers such as limited training, time limitations, staff shortages, language barriers and discomfort from both patients and staff when addressing sexual health topics.^9,45,46

A prevalent culture of referral to radiation oncologists for sexual health counselling emerged, with some respondents distancing themselves and citing it as beyond their scope of practice. These trends align with prior research showing that role uncertainty, institutional barriers and a lack of training reduce oncology health professionals’ engagement in sexual health discussions.^47,48 Without a clear scope of practice on patient counselling and targeted sexual health education, RTTs are unlikely to initiate sexual health discussions and will continue to rely on patient referral because of limited knowledge and expertise. Several studies have highlighted that while RTTs receive extensive training on caring for cancer patients, they seem to lack training emphasising psychosocial aspects, particularly sexual health counselling.^10,17,23

The demographic profile of respondents showed a predominance of female respondents (77.1%, n = 37), with 40.82% (n = 19) of all respondents falling within the age range of 31.1–57 years. Statistical analysis suggested that the demographic characteristics of the respondents were not predictors of behaviours facilitating sexual health counselling. In addition, no significant associations were found between curricular inclusion of sexual health content and qualification level (p = 0.065), work experience and handling of sexual health questions (p = 0.228), gender and avoidance of sexual health issues (p = 0.181), and age group and handling of sexual health questions (p = 0.730). However, the narrative findings painted a different picture, suggesting that sexual health communication challenges, particularly those rooted in age differences, gender dynamics and cultural or religious norms, emerged as additional barriers. This is consistent with the literature reporting sociocultural factors as obstacles to sexual health discussions.^14,49,50 This contrast suggests that, while personal factors are perceived as barriers, the underlying influences may lie in broader systemic and institutional conditions, underscoring the need for further large-scale research to fully understand these dynamics.

As supportive care becomes increasingly recognised as an integral component of quality oncology care, RTTs are well-placed to facilitate and add value in providing supportive care for sexual health in radiation therapy departments. Moreover, studies suggest that it is essential to enhance the sexual health knowledge of oncology health professionals regarding patients with cancer. This can be achieved by introducing sexual health-based continuing education programmes, ensuring the availability of resources (educational material and clinical checklists) and implementing training in the day-to-day oncology practice.^9,42

Limitations and strengths

This article serves as a reference study investigating the involvement of RTTs in supportive care for sexual health with cancer patients receiving radiotherapy in South Africa. Although the study was limited to two academic hospitals with a small sample size, the researchers acknowledge that the results are still impactful, given the small community of RTTs in South Africa. The results of this article cannot be generalised to broader radiation therapy settings, but still provide meaningful insights into the knowledge, attitudes and practices of RTTs concerning sexual health discussions with patients. The researchers used a quantitative survey instrument with open-ended questions that enabled the respondents to provide narrative expert opinions and enrich the overall results. The study was conducted in two urban metropolitan cities in the Gauteng province of South Africa, drawing diverse perspectives from a varied population of RTTs.

Conclusion

The outcome of the study shows that although most RTTs recognise the importance of including sexual health in patient counselling during radiotherapy for prostate cancer, their involvement appears to be somewhat inconsistent. While narrative responses from respondents indicate that challenges in sexual health communication could be attributed to personal factors of both patients and RTTs, the statistical analysis of the quantitative data revealed no significant associations between demographic characteristics and the involvement of RTTs in facilitating supportive care for sexual health in patients with cancer. This suggests further research on this topic on a large scale. Radiation therapists tend to refer patients to radiation oncologists because of perceived professional role uncertainty, unpreparedness and a lack of formal sexual health counselling training to confidently address sexual health topics. To conclude, RTTs are open to facilitating supportive care for sexual health with patients, but their challenge is that they feel unprepared and lack self-confidence. The researchers call for further research on this under-researched topic of the role of RTTs in cancer care to improve comprehensive cancer patient counselling in radiation therapy departments.

Acknowledgements

The authors gratefully acknowledge Ms. Adelina Kometse and Ms. Prevania Pillay for their valuable assistance in facilitating data collection at the selected academic hospitals. The authors also thank all RTTs for participating and responding to the questionnaire. The contribution of Ms. Maryn Viljoen in verifying the statistical analysis of the quantitative data presented in this article is gratefully acknowledged.

The author reported that they received funding from National Research Foundation of South Africa and Department of Higher Education and Training through the University Capacity Development Grant Staff for Postgraduate Studies at the Central University of Technology, Free State, which may be affected by the research reported in the enclosed publication. The author has disclosed those interests fully and has implemented an approved plan for managing any potential conflicts arising from their involvement. The terms of these funding arrangements have been reviewed and approved by the affiliated University in accordance with its policy on objectivity in research.

Nape M. Phahlamohlaka contributed to the conceptualisation, design, data analysis and writing of the manuscript. Penelope Engel-Hills and Hesta Friedrich-Nel were involved in the conceptualisation and final draft of the article, with both authors contributing equally to this research article. All authors have read and approved the final article.

This research was funded by the National Research Foundation of South Africa and Department of Higher Education and Training through the University Capacity Development Grant Staff for Postgraduate Studies at the Central University of Technology, Free State.

The data supporting the findings of this study are available from the corresponding author, Nape M. Phahlamohlaka, upon reasonable request.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings and content.

References