IMPACT ON MANHOOD
Men in this meta-synthesis experienced threats to their masculinity after treatment of prostate cancer. The subthemes for impact on manhood were gender identity and impotence.
The resulting physical and mental alterations that were brought on by the treatment challenged the fundamental principles of what is considered to be masculine. Hedestig et al27 determined that there was a change in self-esteem with regard to masculinity and a feeling of shame. Chapple and Ziebland9(p826) found that the men interviewed deemed it as not being “macho” to seek help for health problems and were therefore reluctant to consult doctors. Age, health status, and values all played a role in how prostate cancer survivors viewed themselves.6 Men’s bodies were now less valuable in a social and personal sense because they failed to conform to many conventional standards of masculinity.28 O’Shaughnessy and Laws32 noted that there was frustration at establishing a new sexual relationship. In another study, African American/black men talked of sexual prowess and maintaining a front of strong silence and indifference.30 This study also identified emotional strength as a valued masculine attribute—to face it like a man and maintain a public masculine image by talking as if they were still sexually active.30 Masculinity was associated with being a breadwinner.9 Independence, potency, and control are major components of masculinity—sickness threatened independence and thus masculine identity.6 This led 1 survivor to liken himself to “a baby.”6(p47) Masculine restraint and an implicit stoicism were favorably contrasted with female emotionality.5 However, the adverse effects of endocrine therapy led some men to experience adverse effects associated with feminization.24 These included hot flushes and breast growth.24 Similarly, in their study, Chapple and Ziebland9 found that hormonal treatment resulted in changes to body shape, hot flushes, mood changes, enlarged breasts, and sickness. Being healthy and demonstrating success and strength in overcoming their illness were seen as a return to masculine norms.25 Some men began to question fundamental assumptions about masculinity and life itself.28 Letts et al29 interviewed men 49 years and older, and most believed that the sexual changes they experienced had no impact on their masculinity.
For most men in the studies, ED and the loss of libido were the most distressing changes and the worst adverse effects they had experienced.6,24,28,29 Problems ranged from decreased ejaculations, less intense orgasms, the inability to maintain erections sufficiently for penetration, and/or a diminished libido.8 The loss of sexual function and potency led to the feeling of having been left “mutilated,”7(p681) “incomplete,”30(p1616) and “unmanly, invisible, or worthless.”32(p104) Sexual performance was viewed as a symbolic expression of manhood, verifiable through procreation, the provision and receipt of erotic pleasure, the objectification of sexually desired others, and competition with other men.8 Sexuality was described by the men in 1 study8(p310) as an incredibly powerful, primal desire, likened to an addiction. Sex is in the mind, and the bloodstream-brain response played a crucial role in upholding their experience of themselves as men.8 Thus, they considered themselves to be dead sexually if they were unable to exercise their masculinity.8 Gannon et al5 found that there was an acute and ongoing sense of loss to engage in penetrative sex and to react to erotic stimuli. The waning ability to maintain an erection detracted from the patients’ manliness.7 Some were unconcerned, some felt frustrated or angry, and others experienced depression.29 One man had made a suicide plan.29 There was anger and embitterment due to lack of preparedness.8 Men who reported poor communication and a lack of response from their physicians were left distressed and angry about the lack of information regarding sexual changes they might experience after treatment.29 One man felt he was a eunuch and not a man anymore.24 Another believed that he now held a hermaphrodite status.9 Some were willing to accept ED if that was the price to pay for prolonging their lives.24 However, for others, the reestablishment of erectile function was a significant aspect of recovery.31 This meant acknowledging ED and using aids and alternative means of intimacy.30
Some men stated that a decline in sexual desire and arousal was seen as a stumbling block, hindering possible future relationships, and having a negative impact on any current relationships.29 Moreover, a reduction in the length of the penis and infertility due to dry ejaculations5 created a sense of inferiority over not quite measuring up compared with other men.8 This was found to be even more pronounced for gay men whose sexual partners were sexually functioning men with whom they could visibly compare.8 The inability to sustain an erection reduced confidence32 and an unwillingness to expose one’s waning sexual function.27 Unlike previously where erections were spontaneous, men now consciously thought about what was happening during arousal and about how long their erections would last.26 Their opinions consisted of not feeling like a “whole man,” a “weak man,” “half human,” “cut down,” and “mutilated.”7(p681) Life came with a price tag, and the price to be paid was sexual functioning.8 Some were willing to accept ED if that was the price to pay for prolonging their lives.24 Impotence was accepted by men with advanced age whose sexual prowess had diminished with age,31 and so ED was viewed as a gradual transition.30 They characterized themselves as sexual beings who defined sex in ways that did not require an erection.6 Although older men deemed it no longer a problem, there was acknowledgment that it was a problem for younger men.9 Young manhood was seen as the time when sexual performance was critical, both as an enactment of masculinity and to conceive children; therefore, treatment was seen as accelerating age by ending youth.30 However, for older men, impotence was accepted by affirming that the task of fathering a child had been achieved.28 Latino men expressed acceptance of ED and adjusted to not having intimate relations easier than African American/black men.30
After analysis, the theme of physical effects included incontinence and physicality, both of which affected men’s bodies.
For men, experiencing incontinence represented a loss of control,6 and thus, the male role was threatened by these urinary symptoms.9 Reoccurring problems involved loss of control of the stool reflex and leakage from the bowel,27 poor urine stream, hesitancy, terminal dripping, retention, and uraemia.9 Anal bleeding was also quite common.9 Men described themselves as “being like a baby,” requiring infantile dependence on family members or loved ones,30(p1614) needing diapers,24 and having to wear pads and dark clothing to disguise wet patches and leakage-related embarrassment,26 making it impossible to have a normal social life.7 Losing control of urine was seen as disrespectful to others who witnessed the problem and played heavily on 1 man’s psyche.32 There was constant checking to make sure urine had not leaked into their clothes.25 Men were left acutely embarrassed and anxious.32 There was worry that the odor would be smelt7 and that urine leakage could also occur during arousal or at orgasm.26 Fear of involuntary leakage during sexual activity made it impossible to even think about sex.30 Ultimately, the condition was summed up as an “abnormal masculine state” that impacted on their lives.32(p102)
Chapple and Ziebland9 described the male role as being threatened by a lack of energy. Study participants stated that, after treatment of prostate cancer, they experienced tiredness, limpness, and decreased muscle strength.24 Men reported that everything was going in “slow motion.”24(p107) Their waning physical strength was seen as a loss, and this culminated in them experiencing grief as a result.7 In their study, Maliski et al30 found that physical strength allowed men to feel competent. Work was a venue in which physical strength was displayed, especially for Latino men.30 Treatment affected their ability to work.9 Prostate cancer was thus a challenge to men’s sense of being a man by limiting their ability to provide for their families and to feel strong and independent.30 The loss of physical strength contributed to feeling impotent.30 Moreover, men became sedentary and less active, leading to an increase in body weight.32 Others had to give up the sport they once enjoyed.9 Some were reduced to small jobs around the house that were ascribed to as women’s work.30 A new attentiveness to their bodies arose,24 and every little itch became a subject for insecurity, which often caused worries that their cancer had returned and spread.24 The body was now viewed as a valuable commodity that had to be maintained.28 There were increased vigilance and attention to self.5 Men developed a newfound sense of vulnerability and a greater sense of caution.5
In this analysis, the main theme of mental well-being encompassed emotive responses and fears and anxieties and how these impacted on men’s psychological well-being.
After treatment of prostate cancer, men experienced a wide range of thoughts, feelings, and emotions. For some, there was difficulty comprehending they had cancer24 or a sense of ambiguity at having survived.28 This uncertainty often gave way to the reality of their new situation. There was a general opinion that their quality of life had changed for the worst25 and a longing for life as experienced before the diagnosis.7 Most men were reluctant to share their feelings with others29 and kept their innermost thoughts to themselves.7 One study noted that men did not want to appear weak in the eyes of their peers.25 Consequently, a sense of being alone became prevalent,7 with men feeling emotionally isolated28 and alone in their decision making.27 Their self-perception and self-esteem were significantly affected, leading to feelings of inadequacy and embarrassment due to urinary leakage, ED, and smaller genitalia.26 Some men felt that they should have received more information about adverse effects, the likelihood of reoccurrence, and available management strategies.26 One man said that his consultant’s attitude made him feel terrible.9 Another likened himself to being treated like “a piece of meat” and believed that he was given false hope.29(p503) Hedestig et al27 noted that the men he interviewed felt a loss of control and exposure from the adverse effects of the treatment. Chapple and Ziebland9 found that the men in their study were unable to mentally cope with the lack of control. This resulted in destructive behavior such as drinking alcohol excessively.26 In addition, men also experienced a sense of grief and bewilderment over why it had to be them.7 Some men constantly dwelled on their issues, which led to the development of clinical depression,8,32 expressing considerable anger and frustration toward the medical system for failing them.28 Men with progressive disease reported greater emotional impact and more difficulties adjusting to their new condition.26 Despite the severe emotional distress, Kelly28 observed that, having survived, gratitude was often expressed when the fates of those not so fortunate were considered. Oliffe31 adds to this notion by reporting that the men in his study were glad to be alive.
Fears and Anxieties
Arrington6 established that the treatment of prostate cancer scared men because of changes to their identity. A plethora of negative thoughts often accompanied this transition. Most experienced “shock, anger, depression, disappointment, a sense of loss,”27(p7) and “frustration and despair.”29(p499) Thoughts about the future were associated with “worry, anxiety, or sadness.”7(p683) Being affected by prostate cancer evoked fears about whether the disease would end their life27 or explode to other parts of their body,24 perpetuating a feeling of gloominess inside27 and anxiety at the possibility of dying alone.25 Maliski et al30 found that there was the added fear of losing their partner. This fear of being alone also encompassed single men. In 1 study, a gay man was troubled by the idea of disappointing a prospective lover and becoming the object of ridicule and slanderous gossip.8 Thus, there was a great reluctance to share their diagnosis and treatment with their peers for fear of embarrassment or stigmatization and concern about seeming to be seeking sympathy or causing embarrassment to others.25 The mere thought of disclosure, for some, entailed confronting a wall of socially constructed shame.8 For single men, there was a fear of discovery by becoming unavailable both socially and sexually.5 Hedestig et al27 found that issues were kept in the men’s own secret area. Admittance of their problems was portrayed as a “coming out” experience.8(p311)
The last theme dealt with men coming to terms with their new selves and how this changed their outlook on life. The 2 emerging subthemes were support and coping.
Men sought empathy and understanding from their spouses/partners.32 Partners were supportive in terms of diagnosis and treatment.26 Oliffe31 noted that some men required support from their partners to consciously break from the ideals of hegemonic masculinity. Their partner’s lack of interest or desire for sexual relations lessened the pressure on them to perform.29 Those wives who understood and did not expect or demand sex were given increased respect by their partners.30 There was mutual agreement that it was more important to take care of the cancer than worry about their sex lives.6 Despite this, they were concerned about how their partners would be affected by the changes,26 were aware of the stress experienced by their loved ones, and were appreciative of their support.24 Arrington6 described this dependence on wives, children, and friends as oaks who needed to lean on others to prevent themselves from falling. Men reported great trust in doctors who provided them with adequate information and ample opportunity to ask questions.26 Seeing the same physician built confidence.7 By disclosing their diagnosis, Grunfeld et al25 discovered in their study that men had received advice and support from others who had undergone similar experiences or had secondhand knowledge to pass on. Some men expressed a need to communicate with other patients with prostate cancer in order to share their experiences.7
Men used a variety of coping mechanisms to overcome the psychological aftermath of treatment. They tried to keep dark thoughts away; avoided sitting still; used humor, often gallows humor; maintained a positive attitude; and tried to strike a balance between worrying about the future and their daily lives.24 Being in nature or working physically was a strategy to reach an inner peace,27 as were positive lifestyle changes.26 Some sought to strengthen their bodies as much as possible after cancer through physical fitness, seen as a way of reclaiming vestiges of a former self,28 as too was a change in diet, eating healthily and taking vitamin supplements,28 exercising, and going to a health provider more regularly.30 Grunfeld et al25 observed that men hid their physical impairments to maintain and present a strong self—a need to appear as capable of coping and emotionally unaffected. As a result, social situations were avoided,5 especially in new social interactions with the potential for intimacy.26 Some men were able to explore new sexual horizons.8 Expressing sexuality was performed through touch rather than penetration.31 The Latino men in the study by Maliski et al30 talked about not seeing themselves as dominant over female partners but having respect for others and being honest and helpful. Strength was redefined, in their eyes, as having had cancer, undergoing treatment, and surviving.30 Fathers stated that being a good example to their children was more important than macho bravado,30 and this was a way of coping after treatment. Other men tried to emphasize their former masculine identities28 or spent time alone and not thinking about the illness.7 By reflecting on the former self, or considering the fates of other men, they came closer to comprehending their own situation.28 Hedestig et al27 solemnly noted that the men interviewed were focused on living in the present, leaving what had happened in the past behind, and not making far reached plans for the future.
This meta-synthesis aimed to explore men’s sense of masculinity after treatment of prostate cancer, capturing data that were attributed under 4 themes and 8 subthemes to form an integrated look beyond the analysis offered by any single qualitative study alone. The current review highlights how cultural interpretations of masculinity inform how men act and behave in response to the outcome of treatment. Their changes in physical condition led to mental and emotional anguish, which men confronted and had to adapt to, and cope with, in varying manners.
Hegemonic masculinity is described as a way in which male privilege is reinforced by supporting conformity to an idealized version of masculinity.14 Hegemonic masculinities work to oppress women and other men through a range of ideals and practices such as competition, aggressiveness, and heterosexuality.15 In her essay on hegemonic masculinity and the cultural construction of ED, Potts35 describes how the erect penis, through its representation of the phallus at a symbolic level, is the essence of male sexuality. Failure of the penis to become erect denotes the deficiency of the man—his failure to robustly represent the phallus.35 With the loss of sexual function as a result of ED, the collated evidence showed that men viewed this as the biggest threat to their masculinity. The loss of the erection equates to the loss of their manhood, unveiling opinions of feeling mutilated and unmanly. Potts35 echoes these sentiments by asserting that the loss of the power to pierce and thrust de-sexes and submits the man to powerlessness, leaving him emasculated and feminized. In comparison, a quantitative survey suggested a tendency for men to conflate their performance with their masculinity.36 Interestingly, this was not only the case for heterosexual men but also for gay men, who stereotypically are associated with feminine attributes and are therefore identified as “unmanly.”14(p37) Yet, gay men could visibly compare their penis length with their partner’s and were in, arguably, a more disadvantaged position to feel inadequate. Fergus et al8 came to the conclusion that, irrespective of sexual orientation or ethnocultural identity, having sex is integral to being a man. Some turned to aids to help them reestablish their erections. As Potts35(p94) notes, “therapeutic success is measured by his restoration to phallic manhood.” Gannon et al5 underline this principle, agreeing that, by providing sex aids, medical practitioners are, in a sense, colluding with powerful discourses that construct male sexuality in terms of penetrative sex.
There was evidence to clarify that men of advanced age, who were usually married, were able to cope with the loss of erectile function—deemed as something that diminished with age and time regardless. Erectile dysfunction was further accepted by those who had the chance to raise a family, lamenting that their ability to father children had been fulfilled. They had support from their partners, which eased the pressure to perform, and did not feel the procedure had altered their perceptions of masculinity. The study by Letts et al29 found that most men 49 years and older believed that the sexual changes they experienced had no impact on their self-concept as a man, although this was rationalized based on the alternatives of succumbing to the cancer. In contrast, younger men were more likely to suffer emotionally from ED, especially within the context of hegemonic masculinity that invokes them to be sexually active. The disparity in research on this issue can therefore be attributed to the ages of the participants involved. Social pressure would seem to make this situation more stressful, particularly as men commented on hiding their affliction from their peers or avoiding the chance for intimate encounters altogether, remaining complicit with dominant ideals.15 Indeed, 1 man described his disclosure as a “coming out” experience.8(p311) Kahn14 coined the term subordinate masculinity to describe aspects of masculinity that are viewed as denigrate forms of masculinity. Gay masculinity, he states, can be viewed as subordinate masculinity because it is marginalized. As gay men are said to “come out,” in this context, we can see how prostate cancer survivors now consider themselves as marginalized, self-exiled from the sphere of dominant masculinity. For these younger men, there is a sense that they had potentially been robbed of their ability to have children and that future relationships may have been jeopardized. Thus, they were unable to fulfil their sexual role and came to express fear that their partner would leave them.30
Across the sampled ethnicities, African American/black and white men were seen to have a more strenuous time adjusting to ED than Latino men. This is likely due to cultural intricacies. Within Latino communities, the use of the term machismo has often been a source of controversy, associated with a type of domineering masculinity that suppresses anything else.14 Our findings showed that Latino men valued being a good role model and provider for their families and were less concerned with restoring sexual vigor. Because of historical and ongoing racial discrimination and prejudice, Harris37 interprets that African American male youth of low-income social status have redefined masculinity to emphasize sexual promiscuity and disdain for feminine qualities. There is more focus on predominant heterosexual values and rejection of vulnerability. The adverse effects of treatment robustly challenged these culturally imposed, deep-rooted misogynistic traits. Gough15(p2481) deduces that “masculinity is constructed narrowly as unhealthy and enduring, offering little hope of change.”
The adverse effects of prostate cancer were seen as instigating a loss of control. Potts35 highlights that having control over the body is an important component in the achievement of healthy sexuality. We found that when men were not feeling in control, they suffered acutely. Their independence was diminished. They were left unable to perform simple tasks or enjoy previous physical activities. Incontinence represented the adverse loss of control. Urine and stool leakage reduced men to describing themselves as babies who could not get a hold of their bodily functions. The same was true for sexual function, although erections could be sustained through aids. Some men spoke of being “feminized”—particularly when experiencing the effects of hormonal treatment and unable to perform physically laborious tasks. Potts35(p94) adds weight to this interpretation, opining that, after men are emasculated, they become feminized and “like a woman—he has no control over his body.” The thought of being feminized was portrayed in a negative light because it goes against the very notions of hegemonic masculinity. Gannon et al5 saw that masculine restraint and stoicism were favored over perceived female emotionality.
With their emotions bottled up, confidence dwindled, and men found themselves having low self-esteem. Kelly28 found that those who lacked control directed considerable anger toward the medical system, which, in their eyes, had failed them. The data clearly indicate that those men who were informed about the postoperative effects of their treatment, and were in continuous contact with the same physician, were more likely to cope with the changes.7,26 Evidence suggests that men who were not prepared, and felt their physician was not forthcoming or supportive, were wracked with emotional turmoil, often leading to depression and despair and, in the case of 1 man, being suicidal.29 It is important then that medical practitioners are clear and concise about the consequences of treatment and give survivors continuous aftercare and support.29 Many of the researchers7,26,29,31,32 agreed that men needed to be given an open forum in which to discuss their problems, worries, and sexual changes. Arrington6 found that men wanted to discuss their sexual concerns with someone and desired a forum in which to do this, whereas Hanly et al26 suggested that sexual counseling should be offered. Quantitative findings by Wootten et al38 showed that those living with ongoing sexual dysfunction experienced a significant impact on their psychological adjustment and needed psychosocial intervention after treatment of prostate cancer to assist them with the management of residual symptoms. Although evidence proposes that men limit what they talk about, and with whom,24 they must still be given the opportunity to talk to others about their experiences. Nurses are therefore pivotal in encouraging men to address their gender identity concerns with other survivors.
The data showed that a number of men were open to new interpretations about masculinity. Oliffe31 observed how positions of masculinity, sexuality, and intimacy were redefined, with 1 man wishing to express his sexuality through touch rather than penetration. Shifting focus to other pleasures in life and pursuing different sexual avenues were key aspects in helping men overcome their sense of loss. Potts35 argues that so-called sexual dysfunction is a product of prevalent cultural narratives about human sexuality. These men were able to overcome the restraints of culturally imposed hegemonic masculinity and displayed their sexuality in other ways as previously alluded to. They adapted to their new sense of self and generally accepted that the loss of sexual function was a necessary sacrifice to prolong life.8 Although this was not usually a smooth transition, the evidence found that those in long-term relationships benefited from the support of their families and loved ones. Quantitative research reinforces this point in that most of those surveyed with wives or partners felt that they had sufficient emotional and psychological support but would have benefited from a sexual counsellor.39
Implications for Practice
We would like to recommend that communicating the adverse effects of prostate cancer treatment by healthcare professionals to patients with prostate cancer should be more forthcoming because this may prepare patients for changes that may affect their perceived masculinity. Some patients were not adequately apprised of the adverse effects, and unduly, the transition period became a struggle for some of them. If communication from healthcare professionals is more conspicuous, perhaps this could help in men’s adjustment to the changes that may result from prostate cancer treatment.
Healthcare professionals may also be in an ideal position to offer support to patients or refer them onto support groups where they could seek help. Coping with changes to one’s masculine identity and sexual function can be shocking and difficult to come to terms with. Sign posting patients to groups where they may meet other men in similar situations, to discuss issues affecting them, would be prudent. This may enable them to adjust to the changes to their masculine identity and sexual relationships. Because of the emphasis of some in restoring their sex lives, there is a particular need for discussions in this area.
Limitations and Future Research
Although sufficient data were collected, there were a number of limitations restricting the scope of this study. We tried to capture experiences from a cross-section of men. The results yielded articles from western, English-speaking countries only. More research looking at survivors from different backgrounds, socioeconomic statuses, and geographical locations would have broadened the depth of the study. The demography is restricted to white, black, Latino, and an undetermined portion of Asian and Indian men. None have been treated in isolation. Although homogenized, we recognize that this in itself is a limitation of the study. Experiences of other ethnicities have not been catered for, and although an all-inclusive analysis is impossible, we identify this as a further limitation. In addition, although some studies incorporated gay men, none centered entirely on their individual experiences or that of any other sexuality. Further qualitative studies should consider looking primarily at prostate cancer survivors of other ethnicities and sexualities. This could help develop person-centered, holistic responses based on the needs of these individual groups.
Men’s own experiences took precedence in this study, and so the impact of their treatment on family members, loved ones, and friends was excluded. Including perceptions from third sources could have contributed to painting a larger picture of how men who had overcome prostate cancer would be perceived by others. This could, in part, help build on the insight into men’s sense of masculinity—whether the views espoused in this analysis are shared by other men. Incorporating feminine points of view, from partners or spouses, could serve to counter, or reinforce, the claims made by the men in the qualitative studies. Future research could also embody fertility education or support for men before therapy.
This meta-synthesis contains the first collation of qualitative research based on exploring men’s sense of masculinity post–prostate cancer treatment. This review found that men’s sense of masculinity diminished after treatment of prostate cancer. Cultural influences and dominant ideals of what it means to be a man informed much of their opinions. There was an existential crisis when forced to confront the changes made to their bodies and the unfavorable depiction of becoming feminized. Men either redefined what masculinity meant in their eyes or tried to reemphasize their manhood as it existed before the treatment. Older men coped with the transition better than their younger counterparts and were more likely to report that their masculinity had not been affected by the treatment. Consideration for younger men is therefore needed. More information and communication, from the start and throughout recovery, are required to better inform patients of the outcomes. Such transparency will provide them with a crutch on which to adjust themselves. In addition, it would be beneficial to have open forums through which to encourage men to talk frankly about their masculine identities. We recommend that nurses are pivotal in helping to alleviate the fears and anxieties that men may experience post–prostate cancer treatment. Nurses need to be aware of men’s emotional anguish and should develop a person-centered, holistic approach to deal with this issue.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved
Masculinity; Men; Meta-synthesis; Prostate cancer; Qualitative research