ENTRAR            

ORIGINALS

Femenine body image and sexuality in women with breast cancer

Rafaela Blanco Sánchez^1
1Escuela Universitaria de Enfermería Vall d'Hebron, Barcelona (Catalunya), Spain

Mail delivery: Paseo de la Vall d'Hebron 119-129, 08035 Barcelona (Catalunya), Spain

Manuscript received by 13.7.2009
Manuscript accepted by 14.12.2009

Index de Enfermería [Index Enferm] 2010; 19(1): 24-28

How to cite this document

Abstract

The aim was to analyse the experiences of women who had undergone a mastectomy with respect to their sexuality, the factors that contribute to any changes in their sexual behaviour, and the repercussions that could lead to family destructuralisation. The methodology used was based on Qualitative Phenomenological Investigation. Thirty extensive interviews were carried out at the rehabilitation, oncology and radiotherapy centres of the Vall d'Hebron Hospital, and at the gynaecological centre at the Primary Health Care Centre of La Mina (Barcelona). Participants' ages ranged from 20 to 69 years. Analysis of the collective comments from the participants revealed that the most relevant themes were: women with problems with their partners; living with the image of a mutilated body; lack of or diminished interest in sexual relations; loss of a partner; refusal on the part of some men to touch the mastectomy scar; avoidance of total nudity; women for whom their partner had become overly important in their lives; recuperation of sexuality; concern for their survival; women who had not had breast reconstruction and did not wish to do so. Conclusions: In some women breast cancer may cause a breakdown of their relationship with their partners and could be experienced as a problem. On the other hand, in the majority of those women who have been seen to be accompanied at all times by their partners, it is not perceived as such. Nevertheless, not all the women interviewed claimed to either have a partner or want to maintain relationships.
Key-words: Breast cancer/ Mastectomy/ Image/ Sexuality/ Attitudes/ Family destructuralisation.

Introduction

    There is an specific behaviour specially interesting within the habits of participation in social life: the attitudes manifested towards cancer. Such term 'attitudes' is used when analyzing individuals who do not suffer from cancer. An environment of discretion surrounds the cancer diagnosis. Breast cancer (BC) is the most frequent cancer affecting women in the world. In Spain, during the year 2000, 14.934 new cases of breast cancer were diagnosed and 6.381 deceases due to this cancer occurred. An impact increase of BC, which is mainly a consequence of its screening,^1,2 has been observed according to the International Agency for Research on Cancer (IARC), both in Spain and in the developed countries. The mortality gross rate in Spain in 1998 was 28,63 per 100.000. The net rate for the world population was 15,63 per 100.000. During the last years a clear decrease of the mortality due to BC has been observed in developed countries.³ The relative survival rate of this tumour after five years is 77.9%, for the cases diagnosed between 1990 and 1994 in Cataluña. Theses values are similar to European average.^4,5 They represent the 29.8% of the potential years of life lost (PYOL) among women. The most important risk factors of BC are: age, BC history in the family, factors linked to the reproductive and hormonal history, certain benign alterations of the mammary glands and post-menopausal obesity.⁶
    The main definitions appearing will be analysed:
    Sexuality: The World Health Organisation defines sexual health as the aptitude to enjoy the sexual and reproductive activity adapting it to the personal and social ethic criteria. This definition implies the lack of fears, feelings of shame, guilt, unfounded beliefs and other psychological factors that inhibit sexual activities or disturb and hinder sexual and reproductive relations.⁷ Casares defines sexuality as the set of anatomic and physiological conditions which characterise each gender,⁸ while the Royal Academy of the Spanish Language -RAE- amplifies the concept adding the sexual appetite, and the inclination to carnal pleasure.⁹ We observe that sexuality is the junction of nature and the social structure. It is a social product. It is a concept far beyond reproduction as it not only deals with the managing of demography of human groups, but also keeps the social order that holds them. The sphere of reproduction is one of the multiple parts of sexuality. Nevertheless, sexuality is built following social and cultural guidelines which are more and more distant to questions related to reproduction.^10,11
    Image: Casares defines it as the figure or representation of something which is perceived by the senses.⁸ The RAE extends this definition as the set of features that characterise a person or an entity in front of society.⁹ According to Pericot, one of the difficulties faced when analysing the image and its communicative functions is, without any doubt, the absence of rules that warranty an adequate interpretation of its contents. Images, like words, do not obey an ideal of exactitude nor are subject to precise nor foreseeable rules in spite of occurring in a certain social context.¹² The body image is the mental representation of the body that we have.^15,16 Such representation can be divided into several components: perceptive, cognitive/emotional and behavioural levels. In the behavioural plane, the person acts or behaves in divers manners: he or she can develop adequate or inadequate habits, face or avoid certain social situations, reject looking at himself at the mirror, etc.¹³ Every characterisation of cancer describes its effects as slowly damaging vitality, putting desire out and removing sexuality. Such was the meaning that the term cancer had when it was used for the first time as a metaphor. The fear of suffering cancer far exceeds the fright produced by other diseases.¹⁶
    Attitudes: Casares and the RAE define the attitudes as the stance of the human body. They are the mood or disposition manifested in any way.^8,9 The complex genesis of the attitudes is set on two main bases: the individual psyche and the socio-cultural interaction. These two pillars of the attitudes determine systematically the person's behaviour towards a certain object, towards an abstract idea, etc. The acquisition of a certain attitude is a slow process of progressive learning of emotional and affective answers to certain events very much linked to the ailment under analysis.¹⁷
    One of the barriers that prevent the early cancer detection, based on its initial symptoms, is originated by the community attitudes towards this pathology. Dent Owen, Kerry in 1982, has detected four attitudes in the population: 1) anxiety when faced with the term cancer; 2) denial of the threat that it entails; 3) fatalism about prevention; 4) fatalism about the disease control. These attitudes generate a restraint for the recovery, specially within disadvantaged socio-cultural environments. Including some variations related to more precise and scientific information,¹⁹ Florez Lozano points at the importance of controlling fatalist attitudes, as they lead to less encouraging prognosis.²⁰
    Regarding the aesthetic ideal, Bañuelos holds that it is much more than only a corporal shape. Goffman pointed out in his essay about "the stigmas" that people are normally more tolerant to "physical deviations" than to "character deviations.²¹ Nevertheless, the body has traditionally been a much more important "value" for women. For this reason, women are more discriminated and put under pressure with their body upkeep.²²
    Currently, the life expectancy for ill women who suffer this neoplastic process will mainly depend on the moment when the diagnosis is given.²³ If there is an early diagnosis the probabilities of recovery are maximum, having even the possibility to avoid the scary mastectomy. This kind of intervention is perceived as a direct attack to the base of their femineity, affecting ostensibly the woman's integral sexuality.^24,25
    The objectives of this study are: a) analysing the experiences of mastectomized women related to their sexuality, the factors that make some of them abandon their former sexual habits and its repercussion on the family unstructuring. b) Analysing the behaviour derived from the loss of their feminine identity. c) Illustrating how the women who have couple problems, those who do not have couple problems and those who do not have a couple, live their sexuality.

Methodology

    Qualitative phenomenological approach. 29 interviews in depth were answered by women with BC in the province of Barcelona. The range of ages covered goes from 20 to 69 years old. Women were selected using the snow ball system based on strategic informants in collaboration with the Service of Rehabilitation, Oncology and Radiotherapy of the Hospital Vall d'Hebron, and the Gynaecology Service of the Health Primary Assistance Centre (CAPS) of La Mina, Barcelona.
    Interviews were done in sites preferred by the patients. Their duration had a range between 90 and 180 minutes and they were registered in audio tapes later transcribed and interpreted following the qualitative method usual analysis techniques. The technical cards description and its application to the analysis of patients and health professionals.^26,27
    The participants have been informed about the objectives of the study and their written expressed consent has been demanded, having warranted information confidentiality and anonymity.

Results/Discussion

    In the search of the BC phenomenon and mastectomized women, the life undergoings have several common points that constitute their reality and permit the construction of the phenomenon of their experience. The topics which emerge with highest relevance are gathered bellow.

Women with couple problems after the mastectomy. The woman knows that her breasts represent an important sexual appeal for the man. This is the origin of their worry for developing an illness in this part of their body and the big terror felt when they have to accept a mutilation while facing a malign disease in the mammary gland.
    Nevertheless, the orgasm sexual activity can be reached without breasts. However, as the qualitative study done by Blanco²⁸ points out, when a woman suffers a breast amputation she experiences difficulties to accept her new image having an effect in her sexual relations although she might orgasm occasionally. We find E-8, a 45 years old woman, who manifests how they have come back to normality and have taken up sexual relations: "I think it would work better if I had both breasts, I don't know, because I don't like to see myself nude with only one breast. Yes, we have normal relations, but I also think that for him I am a very little attractive woman, on the top of that I have only one breast and a small one, men are attracted by women with big breasts, I can not be sexually very attractive like this. The relation with my husband was not working well and we have ups and downs".

The mutilated corporal image originated by the loss of one or both breasts. The corporal mutilation due to BC arouses a big number of psychological reactions with a strong emotional impact in the population. Radical mastectomy is perceived by women as the most aggressive procedure as the acceptance of the disease is a difficult and slow process for them.²⁹ Character seems to be a crucial factor for analysing the attitudes and determining a reaction to the disease; it seems that women with a "masculine" character might not suffer intense psychological reactions as they are not deprived of their "femineity" when loosing one of their breasts.²⁰

Renunciation or decrease in sexual relations in the mastectomized woman's life. According to Arraras, the problems detected in the sexual behaviour could be related to corporal image disorders. The comparative analysis of groups distributed according to the type of surgery done is consistent with the results published in other monitoring analysis and the works review done by Kiebert, cited by Arraras. All of them find consensus about the differences appeared in the corporal image area. Only the 24% of the women had non problematic sexual activities, and a 50% enjoyed it. These numbers point at the sexual functioning as one of the most affected aspects.^24,25
    Sexual functioning, behind mastectomy, appears distorted in groups of women that illustrate the rejection of some of them to be touched or caressed by their husbands, even certain time after the reconstruction.
    E-3, a 50 years old woman, mentions the difficulties to take up again sexual relations: "My husband never says anything. Although it seems to me that he would like to have a complete woman, he has not rejected me. I did not accept myself and I have been fighting for a long time, and he respected me, the poor one. I haven't been able to take up again the couple relations, I can't, I don't feel like".
    E-20, a 37 years old woman: "Listen, I was nude in front of my husband two days after the surgery, as he helped me to take a shower and I had no swabs on. My reaction when I saw myself without one breast was thinking that I was alive and that was my main focus, being alive, feeling fine.He hasn't touched my wound, he said that he was afraid, I am not sure if he was afraid, or it was a question of respect, or it made him feel sick, let's put it that way, he has not touched my wound. this is something I noticed he stopped doing".

Loss of the couple and solitude. Some women have felt alone and abandoned by their couples and such feeling has worsen the existing already lukewarm relations. In other cases the man has not been able to stand the emotional pressure. Several women explain that they have lost their couple:
    E-29, a 46 years old woman: "There is a lack of intimacy as couple. I needed his affection, because when I was feeling very bad, we were at bed and he left the bed and moved to another room for letting me sleep, but this was not what I needed. I have had very hard nights and I was alone".
    E-30, a 22 years old woman: "I do not have a couple, I had one. What did it happen? He got anxious with all what had happened to me. He said to me that he needed some time because he was overwhelmed and all of that. We had been going out for a bit more than three years, and I received the news badly. I guess that what he said was true, he left me because he was feeling bad".

The mastectomized woman protects her body avoiding bare nudes. Mastectomy is lived in the shape of "fear". Such fear emerges taking the form of anxiety, constant concern or even "jealousy" in the couple relation as the insecurity is still bigger. The affective reward can be very much affected as the woman experiences this trauma as an authentic "castration", renouncing to get undressed in front of her husband. This is the case of E-8, a 45 years old woman: "I did not get undressed in front of him because I did not want him to see me. I went home with the staples and I did not want him to see me. And he said that there was no problem, that we would not press me. In any case I would have needed him to insist, I guess I felt like, I gave an image which was not real because I was afraid of his rejection, his look of non-acceptance".

The husband becomes the fundamentals of the mastectomized woman's life. The husband or affective partner acquires an enormous importance for the psychic and sexual recovery of the woman after undergoing mastectomy. If she finds moving and sincere support from her partner the conflict of accepting mastectomy will be easily solved. The couple continuity seems more feasible when the husband is only worried about his wife's life. Tejerina states that if the woman can not rely on her husband she must look for support in the rest of her family and friends.³⁰
    E-1, a 53 years old woman: "My husband is a real angel, he has helped me a lot, and he has suffered a lot, always on my side helping me to make it less dramatic. He went with me to radiotherapy every day. and I think these things have brought us closer. For this reason, it does not represent a problem for the relation; on the contrary, it brings us closer".

Recovering sexuality. Within the study there is a group of women who state not having couple but having sexual relations. They explain that they have not received the first rejection from anyone else but from themselves. They declare to be in process of accepting the new reality:
    E-14, a 31 years old woman: "I don't exactly have a couple, I have a relation, not for living in couple; it works for other things. I have been able to have relations without problems, yes, they are satisfactory, yes, yes, but I mean, you can not go like a wild animal. The first mechanism of rejection emerges from yourself. And nobody will reject you more than you reject yourself, this is for sure".
    E-18, a 47 years old woman: "I think that I have been lucky not to have a couple when it happened, it is much more painful if you have a couple, if you ask yourself if you are desirable or not, etc. . I did not have to go through that. Therefore, I did not feel less feminine, nor less of a person, nor less of anything. I don't have a couple. I haven't had to face getting undressed in front of a man".

Worry for preserving life. Non-reconstructed women. Once life is preserved there are other needs that arise. Some women state that they don't find necessary to reconstruct their breasts. Life is the main issue; they have not undergone reconstruction and they do not think of facing it. They reflect other vision of the process and the decision taking in which reconstruction is not considered.
    E-2, a 51 years old woman: "Looking at myself in the mirror was not too painful, no, it was impressive,. you think you look ridicule and the aesthetics is ugly. My husband, he is so brave, he looked as if everything was ok, I have never noticed the slightest rejection from his side, even when I left hospital he cured me. I talked about the possibility of reconstruction although I am reluctant. I remember one day I told him 'I will do it for you, I would not do it for myself', and he said to my, 'for God's sake, no way!. I use the normal prosthesis but I will not go on reconstruction".
    There are also some women who have always cultivated their figure in general and their beauty in particular for themselves. Even if their husband or partner does accept feminine mutilation they cling on their disgrace and scape from seeing their new image. These situations are named "anti-narcissism" as such patients do now want to contemplate themselves. In this sense doctors and nurses use to help them accept their new corporal reality. Part of the treatment starts when the woman is able to look at her scar and manifest all her "pain" for the loss of her breast:
    E-11, a 52 years old woman: "And she told me 'if they had to remove one breast I would prefer to die'. For me, it had always been clear that I would prefer not to die, I did not know how was I going to face it but I preferred not to die. I can raise my arm and say 'this is placed very badly', and I can deal with it so normally that the other day I went to the Language School and I forgot to put on the prosthesis. I am very vain, they have bothered me a lot.there are certain things that you can not wear".

Conclusions

    Suffering from BC can result in the break-up of some women's couples and can be lived by them as a problem. Nevertheless this will not be the case for the most of the women suffering from such disease, who will be accompanied by their partners at all times; not all the women declare to have a couple nor desire to have relations.
    Patients appreciate the wise move of the nurses who facilitate the husbands the possibility to help their wives shower during the first days after mastectomy. This situation, where both find each other alone in front of the shower with the saline and the undressed wound, makes it possible for the women to receive care when showing their new image.
    Some women have declared not having had relations during the mastectomy period but having retaken them after the breast reconstruction. Some other do not remove the bra in order to feel comfortable and have satisfactory relations.
    Nurses have unbeatable conditions to listen to the problems that mastectomized women have to go through. It would be a great help for those women to prudently ask them if they have been able to take up again their couple relations, if those are satisfactory or if they have any difficulty.
    Middle class young women with an university degree, and women older than 40 years with primary education undergo reconstruction. On the contrary, middle-high and high class university graduates do not chose reconstruction. For the former ones, it is not so important to have or not have a breast. The crucial issue is life and health. Probably this difference is linked to what different women consider important when negotiating their couple relation.

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