Background
Advances in transplantation techniques and supportive therapy have dramatically improved outcomes following hematopoietic stem cell transplantation (HSCT). However, HSCT remains associated with numerous short- and long-term downstream effects, including persistent psychological distress symptoms and quality of life (QoL) deficits, which contribute to significant morbidity.1–4 In particular, sexual dysfunction is a common complication that can persist for many years after transplantation.5–7 Indeed, long-term sexual dysfunction is reported by approximately 50% of male and 60% to 80% of female HSCT survivors.8–10 Although prior research suggests that post-HSCT sexual dysfunction is associated with relationship dissatisfaction,11,12 few studies have examined the distinct associations of sexual health with QoL and psychological distress.
A range of biopsychosocial factors, including sexual desire and arousal, erectile function, orgasm, and psychological well-being, contribute to sexual health among survivors across all cancer types.13–15 HSCT has the potential to impact nearly all aspects of sexual health, ranging from physical effects (eg, vaginal dryness and stenosis, erectile dysfunction) to psychosocial challenges, such as relationship challenges and body image concerns.16,17 Specifically, HSCT survivors report a variety of sexual health issues, including decreased sexual interest and satisfaction, as well as functional difficulties with arousal and orgasm, vaginal discomfort, and erectile dysfunction.10 Thus, targeted supportive interventions to address both physical and psychosocial factors affecting sexual health in HSCT survivors are needed but lacking.
A nuanced understanding of the relationship between sexual health domains (including global satisfaction with sex, interest in sex, and sexual function) and patient-reported QoL and psychological distress will further inform the development of comprehensive sexual health interventions for HSCT survivors.18–20 Therefore, this study aimed to explore the associations of sexual health domains with patient-reported QoL and psychological distress in patients undergoing HSCT who were at least 3 months posttransplant. We hypothesized that higher ratings of sexual health domains would be associated with improved QoL and reduced anxiety and depression symptoms.
Methods
Study Design
We performed a cross-sectional secondary data analysis using combined baseline (ie, preintervention) data from 2 randomized sexual health intervention trials (ClinicalTrials.gov identifiers: NCT03803696 and NCT03967379) involving patients undergoing autologous or allogeneic HSCT at Massachusetts General Hospital and Dana-Farber Cancer Institute.21,22 Data from these 2 trials were pooled because identical eligibility criteria, assessments, and timepoints were applied in both studies. The Dana-Farber/Harvard Cancer Center Institutional Review Board approved both studies.
Study Participants
Inclusion criteria for the parent trials included adult patients (aged ≥18 years) with a hematologic malignancy who were at least 3 months post–autologous or –allogeneic HSCT and were able to read and complete assessments in English. Patients were excluded if they had relapsed disease requiring treatment, were >5 years posttransplant, or had a history of prostate cancer, because these patients have unique needs that may not be addressed by the sexual health interventions. We also excluded patients with uncontrollable psychiatric or cognitive conditions that the treating clinician believed prohibited the ability to provide informed consent and comply with study procedures.
Sociodemographic and Clinical Data
Participants self-reported demographic information, including age, race, sex, relationship status, education, and income. Clinical data, such as cancer type, transplant type, transplant intensity, and conditioning regimen, were obtained from the electronic health record.
Study Measures
In this secondary analysis, we analyzed data collected from study measures at baseline (ie, at enrollment and prior to randomization).
Sexual Health Domains
Global Satisfaction With Sex
We assessed global satisfaction with sex using the PROMIS Sexual Function and Satisfaction Measure.23–25 Scores for global satisfaction with sex range from 4 to 25, with higher scores indicating better patient-reported satisfaction.
Interest in Sex
We assessed interest in sex using the PROMIS Sexual Function and Satisfaction Measure.23–25 Scores for interest in sex range from 2 to 10, with higher scores indicating greater patient-reported interest in sex.
Sexual Function
The 3 sexual function domains assessed were orgasm pleasure for all participants, erectile function for males, and vaginal discomfort and lubrication for females, using subscales from the PROMIS Sexual Function and Satisfaction Measure. The orgasm pleasure subscale contained 3 items (range, 3–15), erectile function had 11 items (range, 0–55), vaginal discomfort had 11 items (range, 0–55), and vaginal lubrication had 5 items (range, 0–25).23–25 We report the raw PROMIS scores, with higher scores indicating better sexual health outcomes, except for vaginal discomfort, where higher scores indicate more discomfort.
Quality of Life
To assess QoL, we used the 47-item Functional Assessment of Cancer Therapy – Bone Marrow Transplantation (FACT-BMT).26 The FACT-BMT assesses well-being across 5 domains with separate subscales for physical, functional, emotional, social, and BMT-specific concerns.26 Scores range from 0 to 164, with higher scores indicating better QoL.27
Psychological Distress
We assessed psychological distress using the 14-item Hospital Anxiety and Depression Scale (HADS). The HADS contains two 7-item subscales that measure depression and anxiety symptoms over the past week.28 Scores on each subscale range from 0 to 21, with a score ≥8 indicating clinically significant anxiety or depression.28
Statistical Analysis
We used Stata, version 18.0 (StataCorp LLC) to perform all statistical analyses and considered a 2-sided P value <.05 as statistically significant. To describe participants’ characteristics, we used proportions for categorical variables and descriptive statistics (eg, mean, standard deviation [SD]) for continuous variables. Each sexual health domain and its relationship with QoL, depression, and anxiety were modeled separately using multivariate linear regression models to assess the relationship between sexual health domains and QoL, adjusting for age, gender (except sex-specific predictor models), education, and transplant intensity. We adjusted for these sociodemographic and clinical factors because they may be associated with sexual health in the HSCT population and could confound our results.29,30 We also used separate multivariate regression models to examine the relationship between sexual health domains and psychological distress (ie, depression and anxiety) adjusting for the same sociodemographic and clinical factors as in the QoL models. Given the exploratory nature of these analyses, we did not adjust for multiple comparisons.
Results
Participant Characteristics
Table 1 summarizes participant demographics. Data from 185 patients were included, with a mean [SD] age of 54.8 [14.1] years. Of the participants, 88.1% identified as White and 35.1% identified as female. Additionally, 83.2% were married or living with someone, and 93.5% identified as heterosexual/straight. Regarding cancer type, 49.7% had leukemia and 26.5% had lymphoma. With respect to transplant type, 20.5% underwent autologous HSCT, 54.0% received myeloablative allogeneic HSCT, and 25.4% received reduced-intensity allogeneic HSCT.
Participant Characteristics
| Characteristic | n (%) |
|---|---|
| Total patients, N | 185 |
| Age, mean [SD], y | 54.8 [14.1] |
| Sex | |
| Male | 120 (64.9) |
| Female | 65 (35.1) |
| Race | |
| Asian | 2 (1.1) |
| Black | 11 (5.9) |
| White | 163 (88.1) |
| Othera | 9 (4.9) |
| Hispanic | |
| Yes | 13 (7.0) |
| No | 167 (90.3) |
| Missing | 5 (2.7) |
| Relationship status | |
| Married or living with someone | 154 (83.2) |
| Noncohabitating relationship | 8 (4.32) |
| Single, never married | 11 (5.95) |
| Divorced/Separated | 8 (4.32) |
| Loss of long-term partner/widowed | 4 (2.16) |
| Religion | |
| Christian | 67 (36.2) |
| Other Christian | 62 (33.5) |
| None | 26 (14.1) |
| Other | 29 (15.7 |
| Missing | 1 (0.5) |
| Education level | |
| High school graduate/GED or less | 34 (18.4) |
| Some college or college graduate | 88 (47.6) |
| Some postgraduate, graduate, doctoral, or professional | 63 (34.1) |
| Income | |
| <$25,000 | 14 (7.6) |
| $25,000–$49,999 | 23 (12.4) |
| $50,000–$99,999 | 44 (23.8) |
| $100,000–$149,999 | 42 (22.7) |
| ≥$150,000 | 58 (31.4) |
| Missing | 4 (2.2) |
| Hematologic malignancy type | |
| Leukemia | 92 (49.7) |
| Lymphoma | 49 (26.5) |
| Other | 44 (23.8) |
| Sexual orientation | |
| Heterosexual/Straight | 173 (93.5) |
| Gay/Lesbian | 6 (3.24) |
| Bisexual | 3 (1.62) |
| Option not listed | 2 (1.08) |
| Unsure | 1 (0.54) |
| Transplant type | |
| Autologous | 38 (20.5) |
| Myeloablative allogeneic | 100 (54.0) |
| Reduced-intensity allogeneic | 47 (25.4) |
| Employment status | |
| Employed full time | 87 (47.0) |
| Unable to work due to illness/disability | 46 (24.9) |
| Retired | 37 (20.0) |
| Otherb | 15 (8.1) |
| Satisfaction with sex, mean [SD] | 11.3 [4.7] |
| Interest in sex, mean [SD] | 5.4 [2.0] |
| Orgasm pleasure, mean [SD] | 8.0 [3.8] |
| Erectile function, mean [SD] | 27.3 [13.4] |
| Vaginal discomfort, mean [SD] | 36.5 [12.4] |
| Vaginal lubrication, mean [SD] | 10.7 [5.5] |
| FACT-BMT overall score, mean [SD] | 109.9 [18.6] |
| Anxiety, mean [SD] | 5.2 [3.8] |
| Depression, mean [SD] | 4.3 [3.0] |
Abbreviation: FACT-BMT, Functional Assessment of Cancer Therapy – Bone Marrow Transplantation.
Includes American Indian, Native Hawaiian, and not identifying as any of the races listed.
Includes student, caring for home and family, unemployed and looking for work, and other than all the groups specified.
Association of Global Satisfaction With Sex With QoL and Psychological Distress
In multivariate analyses (Table 2), greater global satisfaction with sex was associated with better QoL (B = 0.988; P=.001) and fewer symptoms of depression (B = −0.119; P=.017) and anxiety (B = −0.124; P=.038).
Multivariate Regression of Global Sexual Satisfaction, QoL, and Distress ≥3 Months Post-HSCT
| Variable | Coefficient | 95% CI | P Value |
|---|---|---|---|
| QoL | 0.988 | 0.422 to 1.554 | .001 |
| Depression | −0.119 | −0.216 to −0.021 | .017 |
| Anxiety | −0.124 | −0.242 to −0.007 | .038 |
Adjusted for age, sex, education, and transplant type.
Abbreviations: HSCT, hematopoietic stem cell transplant; QoL, quality of life.
Association of Interest in Sex With QoL and Psychological Distress
In multivariate analysis (Table 3), greater interest in sex was associated with better QoL (B = 2.651; P=.001) and fewer symptoms of depression (B = −0.387; P=.003). Interest in sex was not associated with anxiety symptoms.
Multivariate Regression of Interest in Sex, QoL, and Distress ≥3 Months Post-HSCT
| Variable | Coefficient | 95% CI | P Value |
|---|---|---|---|
| QoL | 2.651 | 1.162 to 4.140 | .001 |
| Depression | −0.387 | −0.642 to −0.132 | .003 |
| Anxiety | −0.271 | −0.581 to 0.039 | .086 |
Adjusted for age, sex, education, and transplant type.
Abbreviations: HSCT, hematopoietic stem cell transplant; QoL, quality of life.
Association of Sexual Function With QoL and Psychological Distress
In multivariate analysis (Table 4), orgasm pleasure (B = 1.056; P=.004) and erectile function (B = 0.277; P=.036) were associated with better QoL. However, there were no associations between orgasm pleasure or erectile function and depression and anxiety. Additionally, no associations were found between vaginal discomfort or vaginal lubrication and QoL or psychological distress.
Multivariate Regression of Sexual Function, QoL, and Distress ≥3 Months Post-HSCT
| Variable | Coefficient | 95% CI | P Value |
|---|---|---|---|
| Orgasm pleasure | |||
| QoL | 1.056 | 0.342 to 1.771 | .004 |
| Depression | −0.104 | −0.226 to 0.018 | .095 |
| Anxiety | −0.027 | −0.176 to 0.123 | .727 |
| Erectile function (males only) | |||
| QoL | 0.277 | 0.019 to 0.535 | .036 |
| Depression | −0.027 | −0.069 to 0.139 | .191 |
| Anxiety | −0.029 | −0.079 to 0.021 | .256 |
| Vaginal discomfort (females only) | |||
| QoL | −0.040 | −0.446 to 0.367 | .845 |
| Depression | 0.018 | −0.053 to 0.090 | .610 |
| Anxiety | 0.039 | −0.053 to 0.130 | .404 |
| Vaginal lubrication (females only) | |||
| QoL | 0.700 | −0.209 to 1.609 | .129 |
| Depression | −0.103 | −0.265 to 0.058 | .205 |
| Anxiety | −0.067 | −0.272 to 0.139 | .517 |
Adjusted for age, education, transplant type, and sex (for orgasm pleasure only).
Abbreviations: HSCT, hematopoietic stem cell transplant; QoL, quality of life.
Discussion
In this study of HSCT survivors, global satisfaction with sex and interest in sex were associated with QoL and psychological distress (ie, symptoms of depression and anxiety). In contrast, sexual function was not associated with psychological distress in this population. Although orgasm pleasure and erectile function were associated with better QoL, female sexual function domains (vaginal discomfort and lubrication) were not. These findings underscore the importance of satisfaction with and interest in sex as key sexual health constructs in HSCT survivors that warrant further investigation.
Although sexual health significantly contributes to well-being in HSCT and other cancer populations,5,31,32 most HSCT survivors report no discussion about sexual health with clinicians.7 In this study, we found that sexual health domains, particularly global satisfaction with interest in sex, were strongly associated with QoL. The impact of these domains on QoL is likely multifaceted and potentially bidirectional in the HSCT population. Survivors often experience QoL impairments due to a number of biopsychosocial factors, including symptoms of graft-versus-host disease (GVHD), medications, secondary malignancies, fatigue, and cognitive impairment, all of which can compromise sexual function.2,16,33–36 However, our findings suggest that despite these functional deficits associated with HSCT, interventions aimed at improving sexual health, especially interest in and satisfaction with sex, may also enhance QoL through complementary biopsychosocial processes.22,32
Interestingly, we found that patient’s satisfaction with and interest in sex were associated with symptoms of psychological distress. However, sexual function—specifically orgasm pleasure, erectile function, and vaginal discomfort and lubrication—was not associated with symptoms of depression or anxiety in HSCT survivors. It is plausible that a lack of sexual interest and satisfaction may reflect on a patient’s sense of intimacy and connection with their partner,37 which can exacerbate their symptoms of depression and anxiety. This is especially relevant given that some HSCT survivors experience clinically significant anxiety and depression from the pretransplant phase until years after transplant, with the prevalence of psychiatric diagnoses nearly twice that of the general population.7,18,32,33 Because our findings are based on a cross-sectional analysis, it is also plausible that psychosocial distress may predispose to and worsen sexual health among HSCT survivors.7 Indeed, pre-HSCT anxiety and depression have been shown to predict decreased satisfaction and interest in sex, respectively.38 Fatigue and stress are also known risk factors for decreased libido, and HSCT survivors may experience poor body image, further contributing to sexual health concerns.7 Nonetheless, these findings suggest that supportive care interventions targeting interest in and global satisfaction with sex may play an important role in improving both QoL and psychological distress following HSCT.32 A more comprehensive understanding of the relationship between sexual health domains and psychological distress is needed to ascertain the directionality of this association.
Because HSCT survivors report persistent, long-term challenges with sexual function throughout treatment and recovery,5–7 our findings have important clinical implications for enhancing sexual well-being in this population. Like many cancer therapeutics,39 HSCT may compromise sexual intimacy by altering sexual arousal, desire, function, and satisfaction, due to the physical and psychological changes commonly experienced by survivors.17 Although survivors may struggle with interest in or the ability to engage in sexual activity, our findings suggest that supportive care interventions aimed at enhancing interest in and satisfaction with sex may improve patient-reported QoL, reduce psychological distress, and ultimately boost sexual health. Additionally, further work is needed to guide the optimal timing of sexual health interventions across the treatment and recovery continuum, because both patient factors (eg, body image, psychological distress) and clinical factors (eg, posttransplant complications such as GVHD) may change over time.22,40
Our study has several important limitations. First, the sample was relatively homogenous, consisting primarily of White, educated patients receiving care at urban tertiary-care hospitals. This may limit the generalizability of our findings to patients from ethnic minority or underserved backgrounds, who may experience different biopsychosocial and cultural factors that impact overall sexual health.41 Second, most participants were married or living with someone and identified as heterosexual. Given that relationship status influences sexual experience,42 our findings may not be applicable to individuals who are single or not in heterosexual relationships. Third, due to the cross-sectional design of the study, we cannot draw conclusions about causal or bidirectional relationships between sexual health domains and patient-reported outcomes. Finally, although we controlled for transplant type in our analyses, most participants received allogeneic HSCT. As a result, our findings may not generalize to patients who received other cellular therapies, especially considering differences in posttransplant complications such as GVHD, which can impact sexual function.
Conclusions
Our study highlights the importance of sexual health in the HSCT population, with sexual satisfaction and interest in sex being associated with both QoL and psychological distress. Although further research is needed to comprehensively understand the factors that promote sexual health in this population, interventions aimed at enhancing sexual satisfaction and interest in sex may improve QoL and psychological well-being in HSCT survivors.
References
- 1.↑
Chow EJ, Cushing-Haugen KL, Cheng GS, et al. Morbidity and mortality differences between hematopoietic cell transplantation survivors and other cancer survivors. J Clin Oncol 2017;35:306–313.
- 2.↑
Braamse AM, Gerrits MM, van Meijel B, et al. Predictors of health-related quality of life in patients treated with auto- and allo-SCT for hematological malignancies. Bone Marrow Transplant 2012;47:757–769.
- 3.↑
Gratwohl A, Baldomero H, Frauendorfer K, Urbano-Ispizua A. EBMT activity survey 2004 and changes in disease indication over the past 15 years. Bone Marrow Transplant 2006;37:1069–1085.
- 4.↑
Snowden JA, Sánchez-Ortega I, Corbacioglu S, et al. Indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant 2022;57:1217–1239.
- 5.↑
Bober SL, Varela VS. Sexuality in adult cancer survivors: challenges and intervention. J Clin Oncol 2012;30:3712–3719.
- 6.↑
Bevans M, El-Jawahri A, Tierney DK, et al. National Institutes of Health hematopoietic cell transplantation late effects initiative: the Patient-Centered Outcomes Working Group Report. Biol Blood Marrow Transplant 2017;23:538–551.
- 7.↑
Li Z, Mewawalla P, Stratton P, et al. Sexual health in hematopoietic stem cell transplant recipients. Cancer 2015;121:4124–4131.
- 8.↑
Humphreys CT, Tallman B, Altmaier EM, Barnette V. Sexual functioning in patients undergoing bone marrow transplantation: a longitudinal study. Bone Marrow Transplant 2007;39:491–496.
- 9.↑
Syrjala KL, Kurland BF, Abrams JR, et al. Sexual function changes during the 5 years after high-dose treatment and hematopoietic cell transplantation for malignancy, with case-matched controls at 5 years. Blood 2008;111:989–996.
- 10.↑
Syrjala KL, Roth-Roemer SL, Abrams JR, et al. Prevalence and predictors of sexual dysfunction in long-term survivors of marrow transplantation. J Clin Oncol 1998;16:3148–3157.
- 11.↑
Hensel M, Egerer G, Schneeweiss A, et al. Quality of life and rehabilitation in social and professional life after autologous stem cell transplantation. Ann Oncol 2002;13:209–217.
- 12.↑
Yi JC, Syrjala KL. Sexuality after hematopoietic stem cell transplantation. Cancer J 2009;15:57–64.
- 13.↑
American College of Obstetricians and Gynecologists. Female sexual dysfunction: ACOG practice bulletin clinical management guidelines for obstetrician-gynecologists, number 213. Obstet Gynecol 2019;134:e1–18.
- 14.↑
Kim P, Clavijo RI. Management of male sexual dysfunction after cancer treatment. Urol Oncol 2022;40:389–394.
- 15.↑
Priviero F, Webb C. Biology of iatrogenic sexual dysfunction in men and women survivors of cancer. Urol Oncol 2022;40:366–371.
- 16.↑
Booker R, Walker L, Raffin Bouchal S. Sexuality after hematopoietic stem cell transplantation: a mixed methods study. Eur J Oncol Nurs 2019;39:10–20.
- 17.↑
Syrjala KL, Schoemans H, Yi JC, et al. Sexual functioning in long-term survivors of hematopoietic cell transplantation. Transplant Cell Ther 2021;27:80.e1–12.
- 18.↑
El-Jawahri AR, Traeger LN, Kuzmuk K, et al. Quality of life and mood of patients and family caregivers during hospitalization for hematopoietic stem cell transplantation. Cancer 2015;121:951–959.
- 19.↑
DeFor TE, Burns LJ, Gold EM, Weisdorf DJ. A randomized trial of the effect of a walking regimen on the functional status of 100 adult allogeneic donor hematopoietic cell transplant patients. Biol Blood Marrow Transplant 2007;13:948–955.
- 20.↑
Syrjala KL, Donaldson GW, Davis MW, et al. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Pain 1995;63:189–198.
- 21.↑
Areej El-Jawahri JBR, Traeger L, Dizon DS, et al. Randomized trial of a multimodal intervention to enhance sexual function and quality of life (QOL) in hematopoietic stem cell transplant (HSCT) survivors. J Clin Oncol 2024;42(Suppl):Abstract 12003.
- 22.↑
El-Jawahri AR, Reese JB, Traeger L, et al. Multimodal mobile application to address sexual dysfunction in hematopoietic stem cell transplant (HCT) survivors. Transplant Cell Ther 2024;30(Suppl 2):S45.
- 23.↑
Flynn KE, Lin L, Cyranowski JM, et al. Development of the NIH PROMIS Sexual Function and Satisfaction measures in patients with cancer. J Sex Med 2013;10(Suppl 1):43–52.
- 24.↑
PROMIS Sexual Function and Satisfaction Manual. Accessed February 27, 2024. Available at: https://www.healthmeasures.net/images/PROMIS/manuals/PROMIS_Sexual_Function_and_Satisfaction_Measures_User_Manual_v1.0_and_v2.0.pdf
- 25.↑
PROMIS Sexual Function and Satisfaction Scoring Manual. Accessed February 27, 2024. Available at: https://www.healthmeasures.net/images/PROMIS/manuals/Scoring_Manual_Only/PROMIS_Sexual_Function_and_Satisfaction_Scoring_Manual_04Nov2024.pdf
- 26.↑
McQuellon RP, Russell GB, Cella DF, et al. Quality of life measurement in bone marrow transplantation: development of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) scale. Bone Marrow Transplant 1997;19:357–368.
- 27.↑
FACIT.org. FACT-BMT: Functional Assessment of Cancer Therapy - Bone Marrow Transplantation. Accessed February 27, 2024. Available at: https://www.facit.org/measures/fact-bmt
- 28.↑
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–370.
- 29.↑
Sabanagic-Hajric S, Memic-Serdarevic A, Sulejmanpasic G, Mehmedika-Suljic E. Influence of sociodemographic and clinical characteristics on sexual function domains of health related quality of life in multiple sclerosis patients. Mater Sociomed 2022;34:188–192.
- 30.↑
Moreno-Lozano M, Durán-Ortíz S, Pérez-Zavala R, Quinzaños-Fresnedo J. Sociodemographic factors associated with sexual dysfunction in Mexican women with spinal cord injury. Spinal Cord 2016;54:746–749.
- 31.↑
Donovan KA, Thompson LM, Hoffe SE. Sexual function in colorectal cancer survivors. Cancer Control 2010;17:44–51.
- 32.↑
El-Jawahri A, Fishman SR, Vanderklish J, et al. Pilot study of a multimodal intervention to enhance sexual function in survivors of hematopoietic stem cell transplantation. Cancer 2018;124:2438–2446.
- 33.↑
El-Jawahri AR, Vandusen HB, Traeger LN, et al. Quality of life and mood predict posttraumatic stress disorder after hematopoietic stem cell transplantation. Cancer 2016;122:806–812.
- 34.↑
Pidala J, Anasetti C, Jim H. Quality of life after allogeneic hematopoietic cell transplantation. Blood 2009;114:7–19.
- 35.↑
Battiwalla M, Tichelli A, Majhail NS. Long-term survivorship after hematopoietic cell transplantation: roadmap for research and care. Biol Blood Marrow Transplant 2017;23:184–192.
- 36.↑
Fenech AL, Van Benschoten O, Jagielo AD, et al. Post-traumatic stress symptoms in hematopoietic stem cell transplant recipients. Transplant Cell Ther 2021;27:341.e1–6.
- 37.↑
van Lankveld J, Dewitte M, Verboon P, van Hooren SAH. Associations of intimacy, partner responsiveness, and attachment-related emotional needs with sexual desire. Front Psychol 2021;12:665967.
- 38.↑
Vencill JA, Kirsch JL, McPherson K, et al. Prospective association of psychological distress and sexual quality of life among hematopoietic stem cell transplant survivors. J Clin Psychol Med Settings. Published online April 14, 2024. doi:10.1007/s10880-024-10013-9
- 39.↑
Higano CS, Zarowski C, Wassersug R, Elliott S. Sexual health after cancer therapy. J Oncol Pract 2016;12:305–306.
- 40.↑
Newcomb R, Traeger L, Jones B, et al. Design and development of a multimodal digital intervention (SHIFT app) to address sexual dysfunction in hematopoietic stem cell transplant (HSCT) survivors. Transplant Cell Ther 2024;30:1106.e1–13.
- 41.↑
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281:537–544.
- 42.↑
Rye BJ. The sexual self as a function of relationship status in an emerging adult sample. Behav Sci (Basel) 2023;13:505.
