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
main definitions appearing will be analysed:
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
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
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
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
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
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
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
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
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.
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.
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
participants have been informed about the objectives of the study
and their written expressed consent has been demanded, having warranted
information confidentiality and anonymity.
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.
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".
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
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
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
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.
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
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
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".
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".
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
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
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".
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:
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".
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
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.
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".
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".
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.
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
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
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.
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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