Table 6.

The associated factors on sexual functioning of CCSs.

Risk factors	Key findings	Detailed information or examples	References
Demographic-related factors
Gender	•Females were more significantly affected in their sexual functioning than males.	□the overall mean sexual symptom score for females was more than twice that of males.	23,37
	•Male survivors more frequently reported sexual dysfunction.	□male survivors felt sexually less attractive than females.	30,44
	•The common sexual problems in females are different from males.	□females were most common in the domains of interest in sexual activity, orgasm ability and vulvar discomfort labial. □males often concerned about sexual satisfaction, interest in sexual activity, and erectile dysfunction.	7
	•The correlation between sexual satisfaction and sexual functioning.	□a stronger correlation in females than males.	45
	•Response to sexual problems.	□half survivors were willing to seek advice when experiencing sexual problems. □males preferring a physician and females were likely to consult with a friend.	30
Age	•Survivors treated in adolescence had a delay in achieving sexual milestones compared with survivors treated in childhood.	□e.g. dating, touching under clothes, female masturbation, and sexual intercourse.	42
	•Older age had significantly less sexual experience, poorer sexual functioning, and higher incidence of erectile dysfunction.	□the older age (50+ years vs. 20–29 years) was statistically significantly associated with erectile dysfunction among males. □females with older age (45–54 years vs. 18–24 years) exhibited higher levels of sexual dysfunction. □sexual dysfunction survivors were statistically significantly older than non-cases.	9,10,28,44
	•Longer time since diagnosis was related to better sexual functioning.	□the weakly correlated possibly be explained by a better adjustment over time. □this relationship was not seen in sexual development.	45
	•Age at cancer diagnosis or time since diagnosis neither influences psychosexual development nor sexual functioning.		29,38,41
Educational attainment	•A relationship between educational attainment and sexual functioning among.	□higher education was less likely to report dysfunction in certain sexual domains in females and the domain of interest sexual activity in males. □the risk of sexual dysfunction in females with college degrees was 0.56 times lower than those without.	7,10
	•No statistically significant difference in sexual functioning by different education levels in young adult survivors.		37
Marital/Relationship status	•Marriage has an impact on sexual dysfunction.	□survivors who had been married had a significantly greater sexual dysfunction than patients who had not been married or single. □two studies found this phenomenon only happened in female survivors.	10,37,44
	•Partnered survivors have better sexual functioning than single ones.	□survivors who were in a partnership or had a relationship reported higher levels of satisfaction and lower rates of sexual dysfunction than those who were single.	7,38,45
Income and race	•A relationship between income and sexual functioning.	□male survivors from Southern California with income less than $25,000 reported significantly more sexual symptoms.	37
	•A correlation between race and erectile dysfunction.	□the Hispanic ethnicity and Black race were independent risk factors for erectile dysfunction in male survivors.	9
	•No statistically significant differences between survivors with and without sexual dysfunction regarding household income, or race/ethnicity.		10
Treatment-related factors
History of surgery	•A relationship between the history of surgery and sexual functioning.	□history of surgery involving the spinal cord or sympathetic nerves, history of prostate surgery, and pelvic surgery associated with erectile dysfunction. □pelvic surgery was a risk factor for female sexual dysfunction. □females with surgery or radiation to the pelvis had significantly lower sexual satisfaction and pain domain scores than patients who did not. □history of surgery with external effects was closely related to sexual functioning.	10,28,29,44
Treatment intensity	•Some association between treatment intensity and sexual functioning.	□there was a positive correlation with sexual dysfunction if the testicular radiation dose was more than 10 Gy. □CCSs who had received more intensive treatment were more likely to report dysfunction, assessed by the Intensity of Treatment Rating scale. □neurotoxic treatment intensity was also a risk indicator of psychosexual development, CCSs with high-dose neurotoxic treatment showed less sexual experience, bad relationship status, and even less likely to have children.	7,28,39,40
	•No relationship was found between treatment intensity and sexual functioning.	□survivors with radiation therapy showed a similar trend in sexual satisfaction scores, compared with patients who did not. □no difference was found in exposures to any chemotherapy, including alkylating agents, or radiation therapy between survivors with and without sexual dysfunction, except oophorectomy.	10,29,38
Type of cancer	•A relationship between some specific cancer type and sexual functioning.	□Germ cell tumors, renal tumors diagnosis, and leukemia had higher risk of sexual dysfunction in female CCSs. □CNS tumor was more frequently reported sexual arousal problems, low sexual satisfaction, low frequency of sexual activity, less sexual partners compared with other diagnoses.	10,30
	•No differences were found between sexual functioning and type of diagnosis.		23,29,37,38,45
Psychological-related factors
Emotional symptoms	•Emotional distress was a potential risk factor on sexual functioning, both males and females.	□sexual functioning was significantly correlated with all subscale and global measures of distress. □survivors who were difficult to relax during sexual intercourse exhibited higher levels of sexual dysfunction. □survivors with greater emotional distress were more likely to report sexual dysfunction.	7,29,37
	•Survivors experiencing sexual dysfunction reported higher levels of emotional problems.	□survivors reporting sexual dysfunction reported greater depressive symptoms, somatization, anxiety, mental health functioning of SF-36 scale, as well as a greater overall symptom index score. □91% of survivors with sexual problems reported psychological distress, including concern about their sexual ability and worry about partners' reactions, from one qualitative study.	32,37
	•The relationship was prominent among females.	□females with depression symptoms reported more sexual dysfunction. □female with sexual dysfunction demonstrated significant limitations on emotional functioning, mental health, and social functioning.	10,23
Body image	•Body image is an established risk factor currently affecting sexual functioning.	□survivors with greater body image disturbance were more likely to report sexual dysfunction. □males with greater body image dissatisfaction were more likely to report erectile dysfunction, as well as in general groups. □CCSs with no sexual problem had statistical significantly better body image scores. □a qualitative study identified CCSs with sexual dysfunction described concern about the perceptions of other people on their altered body image due to cancer and its treatment, particularly their intimate partners.	7,9,32,41
	□Body image disturbance was not associated with sexual satisfaction.		38
Self-esteem	•CCSs with no sexual problem had statistical significantly higher Rosenberg self-esteem scale scores.		44
Physiological-related factors	•Some association between physical function and sexual dysfunction.	□low serum testosterone levels and low lean muscle mass increased the risk of sexual dysfunction. □survivors experiencing sexual dysfunction reported poorer functioning across all subscales of the SF-12 including physical functioning, role physical and fatigue. □CCSs with higher physical component scores were more likely to show no sexual problem. □77% of CCSs with sexual problems described physical problems, such as vaginal dryness, pain, and fatigue in a qualitative study.	9,23,32,44

Note: CCSs, childhood cancer survivors; CNS, central nervous systerm.