ORIGINAL ARTICLE

The lived experience of men with advanced cancer in relation to their perceptions of masculinity: a qualitative phenomenological study Sarah Stapleton and Natalie Pattison

Aims and objectives. The aim of this exploratory research was to understand how men experience their advanced cancer in relation to their perceptions of masculinity. Background. There are differences in the way men and women experience illness and health care. There are inequalities in incidence and morbidities of many diseases as well as differences in rates of help-seeking behaviours. Theories on masculinity offer some explanation towards this. Men’s experiences of advanced cancer in relation to masculinity are under reported, published literature suggests that there are certain issues or men dealing with advanced disease that justify investigation. Design. A Qualitative approach using a Husserlian Phenomenological design was conducted. Sample. Eight men (aged 26–68) all with advanced cancer, defined as advanced or metastatic disease for which the patient had exhausted all standard therapeutic options. Methods. In-depth interviews were conducted to capture narratives of the experiences of men. Data were analysed using Colaizzi’s seven stage framework. Results. Themes included thwarted ambition, changing expectations, protection and provision, stoicism and coping, images of illness versus images of masculinity, importance of being a fighter and loss. Conclusion. Findings showed that the experiences of these men were complex and should be handled sensitively. Ideas for gender-specific interventions and further research were developed from the findings in relation to current literature. Relevance to clinical practice. A better understanding and awareness of this in this context will help nurses to consider more subtle challenges that these patients may be dealing with that in turn could affect how they cope with the burden of cancer.

Key words: advanced cancer, lived experience, masculinity, nursing, phenomenology, qualitative

What does this paper contribute to the wider global clinical community?

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Whilst not always possible to make generalisations, inferences from these findings can be made (Williams 2000). Connell’s (1995) concept of hegemony plays across different geographical and cultural landscapes and whilst the representation of the hegemonic ideal may differ from place to place, the concept of it and how it affects men’s behaviours in relation to illness is likely to resonate with many male cancer patients and possibly men with other long-term conditions. There is a paucity of literature in this area which suggests some exploratory work should be performed on how men experience their masculinity at this complex time in their disease trajectory. Findings show that these concepts of masculinity are inextricably linked and identifiable within how men experience their illness. Contradictory to some findings in current literature, the men in this study wanted to disclose aspects about their suffering and cancer and did share and benefit from close emotional interactions with other men with cancer. Even though these men may present to health care environments as confident and coping, they have a huge emotional burden and are experiencing grief and despair often that requires an outlet. The findings suggest a need for better understanding of such issues and the direction for further exploratory work.

Accepted for publication: 8 September 2014 Authors: Sarah Stapleton, MSc, BSc, RN, Clinical Nursing Research Fellow, Drug Development Unit, The Royal Marsden; Natalie Pattison, DNSc, MSc, RN, Senior Clinical Nursing Research Fellow, The Royal Marsden, Sutton, UK

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078, doi: 10.1111/jocn.12713

Correspondence: Sarah Stapleton, Clinical Nursing Research Fellow, Drug Development Unit, The Royal Marsden, Downs Road, Sutton, Surrey SM2 5PT, UK. Telephone: +0208 642 6011 ext 1258. E-mail: [email protected]

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Introduction This article reports findings from a study that examined men’s experience of advanced cancer in relation to constructs of masculinity. Previous work on masculinity and illness has focused on help-seeking behaviours and certain health inequalities (O’Brien et al. 2005, Farrimond 2012) and some studies have investigated the experience of patients with male cancers (Oliffe 2006, Sharpley et al. 2014, Wootten et al. 2014). This study aims to contribute to the understanding of men’s experience of other cancers within the context of masculinities. The study of masculinities has grown over the past two decades. Connell (1995) as a pro-feminist writer provides a theory of masculinities; this seminal work develops the concept of hegemony with a model of four categories of masculinity. A subordinate, marginalised and complicit group all interact dynamically with the hegemony. The hegemony is not a prescribed idea of what masculinity should be, it can vary in different cultures and refers to the dominance of this power group within a society. Men negotiate their position with their own representation of masculinity. This theory that masculinities are complex, socially constructed, dynamic and have a dominant type continue to be supported by other social theorists (Brod & Kaufman 1994, Edwards 2006). Other social theorists discuss new directions with different representations of masculinity but also continue to have a theme of power relations and acknowledge hegemony as a key area in such studies (Whitehead 2002).Having an awareness of the complexities of masculinities and the theories that underpin it are valuable when considering how gender affects health as well as how men deal with illness.

Background Research thus far has suggested that men who present as ‘highly masculine’ underreport symptoms and can be reluctant to report problems, finding it difficult to discuss emotions and fears (Harrison et al. 1995, Rennoldson et al. 2013, Cecil et al. 2010) Other research suggests that men may delay in seeking help for health-related problems (Oberoi et al. 2014). There is a reported reticence for some men to report symptoms or complaints. O’Brien et al. (2005) conducted a number of focus group discussions in Scotland to investigate to what extent these behaviours are related to constructions of masculinity. Men had an unwillingness to report minor complaints; even in extremis patients felt they should not report, asking for help may put one’s masculinity up for scrutiny. Supporting this work McSorley et al.’s (2014)

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study reports that men use other coping strategies to manage symptoms rather than directly asking for professional help. The experience for male patients with a gender shared cancer, at diagnosis and early treatment is similar with men being reluctant to discuss issues surrounding cancer; however, they initially appear to cope better emotionally than females with the same cancer (McCaughan et al. 2011). There is also an issue as to how masculinities are affected by changes due to treatment-induced sexual dysfunction. Sexual organs and functions can be viewed as central to men’s perception of masculinity (Marshall 2002). Treatments for Prostate cancer in particular can cause urinary incontinence, sexual dysfunction and changes to body image (Sherer & Levine 2014). It is important to add that cancer and treatment-related sexual dysfunction is not exclusive to patients with cancer of the male organs (Maruelli et al. 2014). Such side effects can negatively impact on perceptions of masculinity and indirectly affect other areas of life, such as social, professional and sexuality (Cayless et al. 2010, Saitz et al. 2013, Waller & Pattison 2013).

Methods Study aims The premise of this work is based on the arguments in the literature (Connell 1995) that if the hegemonic ideal in UK society projected in values and beliefs is to be strong, successful and fit, then the consequences of cancer and its treatment is likely to negatively affect males’ patients’ perception of their own masculinity. The aim of the study was to explore the lived experience of male patients with advanced cancer, including any description of events throughout the disease trajectory and treatment effects.

The setting and sample The setting for the research was a clinical trials unit in the UK and a palliative care unit within a tertiary referral cancer centre. The sample included male patients with a variety of advanced cancers (but were not on androgen-deprivation therapies [ADT]) who had exhausted all standard therapies and were attending the unit to take part in a clinical trial, or were receiving palliative care. This group was chosen as they had been through the whole disease trajectory. It was expected that at this stage of their illness, they may have many issues that could impact on perceptions of masculinity. Purposive sampling was used in this study. Fourteen men were originally identified within the specified time frame and of those eight men were asked to participate, © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078

Married None

White British Heterosexual Lives with wife and children White British Heterosexual Lives with wife White British Heterosexual Lives with wife White British Heterosexual Lives with wife White British Heterosexual Lives with wife White British Heterosexual Lives with parents Ethnic origin Sexual Identity Living circumstances

Married One adult daughter White British Heterosexual Lives with wife Partner None

Hockey, cycling

Married Children

Fishing, gardening

Student

Manual or non-manual worker Hobbies

White British Heterosexual Lives with wife

Married Two children minor Married Three adult children Married None Married Two adult

Cycling Walking Swimming Golf, wood turning Dog walking

Extreme sport, uphill skiing, mountain climbing, travelling Married Two adult

Renal carcinoma Manual Sarcoma Disease type

Cricket, football, swimming

Non-manual

Metastatic colon Prostate not on ADT

Non-manual Manual

P4 52 P3 54 P2 63 P1 26 Age

Table 1 Participant characteristics

Colaizzi’s (1978) seven-stage framework was used as a method of data analysis. This method is a descriptive approach which follows the following stages: acquiring a sense of each transcript, extracting significant statements, formulation of meanings, organisation of formulated meanings into theme clusters, exhaustively describing the phenomenon and finally returning to the participants for respondent validation. Due to the nature of the patient group, it was not possible to get participant validation as the participants had become too unwell or had died. There was a de-brief at the end of each interview to ensure the patients and the researcher reached a consensus on the data collected. This is something to consider when studying a group of patients with advanced disease. Whilst respondent validation can be a marker for credibility, it is not the sole criterion. There could also be ethical issues surrounding returning transcripts in this patient group, the narratives may contain difficult issues and requiring people to re-read transcripts without any support or help to interpret may cause distress to the participant. As per Coliazzi’s (1978) framework, 190 significant statements were then extracted from the eight transcripts. Significant statements (statements that appeared to hold particular pertinence for the patient or the researcher) were translated into formulated meanings (meanings that

P5 68

Data analysis

Non– small cell lung cancer Non-manual

P6 63

P7 64

A Husserlian phenomenology approach was chosen to underpin the research design, to allow participants to express their experiences in their own words, without the influence of researcher interpretation. In-depth open interviews were conducted by (initials), who was a senior nurse within the unit. There was a list of cues for the researcher as required, and the interviews were recorded on a digital audio recorder. Interviews were transcribed verbatim into text. The interviews ranged from 35 minutes to one hour long. Data were collected between January 2011–July 2011.

Oesophageal

Design and data collection

Gastric carcinoma Manual

P8 45

with the aim of achieving a sample that reflected a range of social backgrounds, age and cancers (in order to provide a sample reflective of Connells groups). All agreed to participate. Eight male participants aged between 26–68 took part in the study. The study was reviewed and approved by the National Research Ethics Service via the Research Ethics Committee (Table 1).

Non-manual

Masculinity and advanced cancer

Thymoma

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conveyed the patients’ intentions of what they were saying about their experiences). These were statements that were powerful, evoked strong memories for the participant and that recurred insomuch as they were common sentiments to many of the participants. The theme clusters were collapsed into 14 emergent themes that highlighted the message of the narrative. Further reduction collapsed the clusters into seven emergent themes. The following diagram demonstrates this Fig. 1.

Findings The seven final themes of thwarted ambition, changing expectations, protection and provision, stoicism and coping, images of illness versus masculinity, the importance of being a fighter and loss were experienced by all of the men to varying degrees.

. . . I was comparing myself with my friends and that was sort of no comparison . . .. I felt useless in comparison with my male friends. P1

There is an alternative perspective to the illness thwarting ambition, some participants refer to spending a major part of their lives at work and one man acknowledges that the halting of career progression meant being able to re-evaluate priorities and spend more time with his family. However, during periods of hope and feeling better, the pull of ambition and looking forward to the future returned: yes but the truth is, if you could wave a magic wand and make this all go away it wouldn’t be long before I went back to how I was before, in fact over the last five years there was one point that, I mean I know its not correct now but there was one point where things were going well and I believed that I might have got better and I started thinking well what could I be doing next

Thwarted ambition All participants discussed ambition as being something important to them, both at work and in their personal lives. A diagnosis of cancer impacted on this aspect of their life halting progression. Some participants had stark experiences of their lifestyles having to change dramatically: It was the perfect job . . . I had it all; in the most fantastic place with the most fantastic house it was all there . . .. I was kind of cheated out of that plum job if you like. P4

For these men, ambition was integral to their masculinity. Comparisons with peers who were successful only served to enhance the difficulty in dealing with this. One man describes the experience of comparing himself to his peers, leaving him feeling stagnant and immobile:

Thwarted ambition and limitations on success Sex life is gone but its no longer important Changing priorities The moment your life changes Reliance on others Protection and taking care of others as a key aspect of being a man Breadwinner Being there for others You just have to get on with it Ignoring serious symptoms “Other people don’t want to talk so I say I am fine”

and it surprised me how quickly I changed back to that way of thinking, its still there that drive to progress its quite interesting. P8

These men had all their pathways altered and were unable to progress with career plans which impacted on their perceptions of masculinity. Changing expectations Several participants discussed how expectations changed at varying junctures of the disease. During times of ill health, how one looks was not regarded as important by these men but after treatment side effects have resolved, appearance became important again, changing expectations and accepting that things will have to change was also a common expression:

Thwarted ambition Changing expectations Protection and provision Stoicism and coping Images of illness versus images of masculinity The importance of being a fighter Loss

Brotherhood and friendship is a coping mechanism Looking ill means feeling physically ill Loss of strength “ a weaker me” Metaphors of fighting the cancer Loss of control Loss of the future

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Figure 1 Emergent themes with overlapping concepts.

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I suppose the goalposts change at first you just want to get through

I turned from being Captain Hurricane to being this little wispy

your treatment and get better and once that’s done your expecta-

thing. Anyway I was compared to Gollum (skeletal character) and

tions change. P1

that’s what I was like. P4

its embarrassing to go swimming now and get undressed in front

Several participants describe using physical tasks to test themselves to prove maintenance of levels of fitness; this provides them with reassurance that they still have some level of physical capacity as well as proving emotionally beneficial:

of other people. P5

Several participants express a desire to go back to the way that things were precancer. There are descriptions of measurements/comparisons made to precancer status, men describe using fitness as a measure or the return of normal function meaning the return of one’s role and authority in work situations. Apart from the physical you just want to go back to the way that things were before but they are not. P2

Juxtaposed to these examples within the same participants were expressions of acceptance that the person with cancer is different. Adjustments to the limitations were discussed: I have adapted what I do to take into account the restrictions that the illness places upon me. So am I happy about it, No but I get on and play the hand I have been dealt really. P4

A large number of participants discussed sex as something that had changed in their lives since being diagnosed and starting treatment, many said that they just did not feel like having sex anymore. Most of these men did not see the reduction in sex a problem, their expectations about this part of their life had changed it was no longer a priority: I think that on the sexual side that things have been affected, I don’t know why, if it’s to do with the cancer or not but I just don’t feel like it. P6

Discussed by the men within the theme of changing expectations was the difficulty in accepting loss of strength. The participants described changes in their standards of physical performance:

I kind of test myself to see if I can still do it, last week I managed to get round a circuit which is quite tough, so I have been quite lucky with the sport side of things I have managed to maintain it on the whole. P8

This gave some level of satisfaction. For others at times when physical ability decreased, it caused feelings of frustration and despair: although I do feel very tired. That is the thing that affects me the most, I wouldn’t say I get angry but I get frustrated, I have not got the energy to do little things, I would like to do things but I have to sit there and read a book and do the crossword or watch the television and I want to be out here doing something. P5

These physical changes led to changing priorities and expectations of what was important and could be achieved during a disease journey that is punctuated with periods of feeling well and feeling ill. These changes impacted on other areas and the next theme of protection and provision is also influenced by this. Protection and provision Most participants discussed the role of the breadwinner in the family and felt it was their role to provide financial support for the family. This role was threatened by illness and long treatment regimes. This was a stressful and major concern of these men: Well yeah, although we have got to look at that, errm I am the only breadwinner at the moment, my wife lost her job last year and that caused quite a lot of pressure . . .. The whole family is depending on you. P8

Well obviously I don’t go cycling anymore because it uses a lot of my energy and the walking, I carried on doing the walking for as long as I could but I can’t do that anymore. P8

The previous useful, functional, strong male body has now become weaker which creates a feeling of uselessness, not being fit for purpose. Strength and physical ability was seen as an integral part of manhood to these men. One participant who had previously been extremely strong and fit, creates vivid imagery to demonstrate this, he found the change very visible and experienced it deeply:

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078

Many of these men expressed this as the main aspect of manhood that was important to them. They did not want to give up this role and wanted to feel that they were vital to the family unit: It made me feel I suppose that they don’t really need me after all, but they do. P4

One man describes the decision of handing this role over to his wife formally predicting his impending deterioration and death:

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Not being able to look after the family was a fear for many of the participants but also seen as an inevitable outcome at some point. Planning for a future without them was something some of the participants were doing as a way of continuing the protective element in the future after their death. The protective and providing role of the men within the family was a strong theme throughout the narratives. Another element of protection discussed was that of covering up one’s own feelings so as to protect others from hurt. Several participants admitted to saying they were ‘alright’ covering up how they really felt so as not to cause hurt or distress to others: I’d generally keep it to myself and I’d let the wife know I was fine, cause I would keep it from here cause she is a real big worrier and generally I was you know a day or a day and a half then I would be fine. P2

The mechanism of nondisclosure as a way of maintaining the protective role within masculinity may go some way to explaining the previous evidence we see with a lack of help seeking and underreporting.

There is a reported value in close, honest interactions with male friends, colleagues and the expression of emotion within these interactions is not feared but discussed fondly: I had a friend I had not seen for a while and he came on spec and I opened the door and he just went ‘fucking hell mate’ and we just sort of threw our arms around each other and we burst into tears. P4

One man describes the support services at the local hospice as for his wife, he would not benefit from them. Men should deal with it but it was okay for women to receive this extra emotional support. There is a perceived expectation that men will deal with things in this way: I think there is probably a general rule that men just say oh I will get on with it. P3

Nonreliance on the medical world was also seen as a measure of health, it seems that health care was seen by most of the participants as a female domain, it was often the female in the family that managed the health needs of their partners. Even in extremis, men were reluctant to call for medical help, one man recalls his experience of a previous heart attack: I had really bad indigestion and I thought that is all it was but then the next night I had a really like pain and even then I hesitated to call anyone or tell anyone, but then I got help and I was having a heart attack, so since then I always check but I had been fine since. P3

Stoicism and coping Most of the men said that they were happy to talk freely about what was happening to them but they felt that people outside of their close family demonstrated blocking tactics to avoid the subject: Some people don’t want to know, in fact generally people don’t ask questions, well, I don’t mind talking about it so I find that a bit strange, or they don’t think they ought to ask questions . . . suppose they shy away from it more they don’t ask me much and I just say well y’know I am fine I suppose and that’s the end of the conversation. P2

In contrast to this, there were also several reports of the importance of friendship with other men as being important and useful to help with dealing with the cancer and treatment. This was seen as important and described as useful in terms of emotional support. Role modelling and respect for other men was described. One man talks with great respect for a friend who died of cancer when he witnessed his terminal days: He was so brave, Starts crying “he was so brave that he set the bar, he set an example for me. But I know that I will be like that some day” (talking of a friend’s death from cancer). P5

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The data from these men suggest that men are reticent to seek help, and that they describe how the expectation or construct from others is that men are less likely to seek help. Men in this study seemed to deal with things stoically.

Images of illness versus images of masculinity Weight loss, hair loss and pallor were the main physical signs of illness that came with both the disease and treatment. The descriptions of this conjured up vivid imagery for some men that represented illness and death: I looked like sort of the living dead, a sort of zombie from a movie with drawn skin, just sort of a bony horrible creature. I think people were shocked when they saw me. P4

One man gets comfort from being with other cancer patients; he does not feel as isolated as when in everyday life: I like coming here, cause sometimes when you sit somewhere and you feel people know what’s wrong you feel like a leper but when you come here everyone is in the same boat. P3

Hair loss is discussed to varying degrees by the men who have all received chemotherapy at some point. It seems that

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hair loss is a difficult side effect for men to deal with, they disliked the problem but mainly saw it as something they had to deal with it: I can’t get over the fact and I will never get over the fact that my hair didn’t grow back, its not nice, its not, I’ve sort of got used to it now. P1

Changes in appearance made the illness tangible and real to others as well as the participants themselves.

The importance of being a fighter The theme of fighting the cancer runs throughout the narratives. Fighting and positivity whilst being realistic were described as important tools to deal with the illness. To contextualise, all of the men had a terminal prognosis and it was important for them to be seen to understand this but at the same they wanted to demonstrate that they had not ‘given up without a fight’. It seemed to be an important mechanism that even though a treatment was unlikely to work that they should give it a go as doing nothing was not an option: yeah, I am not one for giving in, they say I am a fighter, I don’t think I am a fighter but, I just want to live. P3

Loss Many of the men had previously been used to being in control of themselves and others, decision-making was integral to who they were and with the cancer came a loss of this ability: there is no control here, there is desire for control there is will, there is praying, there is doing the best you can but its out of my control and I think that is something that I and most humans I think are not used too. Something that you can’t control, this you can’t control, I suppose that’s hit the nail of the head really. P4

Control was something that was lost as a result of the disease, how this was handled by health care professionals also enhanced the feeling of loss of control: yes, I think that is difficult to deal with, especially when you are used to being in control of things and making decisions, suddenly your control over things is gone, that’s hard. P8

Many of the men reported this loss of control as a contrast to precancer life and something that was difficult to deal with. This loss of control over their future led to sadness and the acceptance that there would be a loss of life, there was a deep sorrow that loved ones would be left behind without them, one man describes it as losing his dream:

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078

Masculinity and advanced cancer for me that is a tragedy really and errm we are not going to grow old together, our plan was that I should die at 88, that was the day on which we would have probably had enough of each other my daughter would be married my son would be settled, (wife’s name) would probably have had enough of me I would have probably had enough of her by then, that was always the plan, its been taken out of our control. P4

This was the subject that provoked most of the emotion in the participants with several of them openly crying at the prospect of a lost future with their families and the hurt that would be experienced by their families. None of the men appeared to have difficulty with expressing emotions freely and there was no apparent embarrassment of crying; it seemed natural for men to let out their emotions in this way.

Validity, reliability and rigour Study rigour can be seen through description of the methods and analytic processes and transparency in how data were reached. However, there are some limitations to the study. Due to the qualitative nature and the small sample size one could argue that generalisability could be a limitation, although as Williams (2000) argues there can still be moderatum inferences made from qualitative studies. Another limitation of this study is that no participants from varying ethnic backgrounds and men who identified themselves as gay were recruited. Interviewing men as a woman may well have affected the interview and it is important to consider how this could have shaped the findings. However, the rich data yielded suggest that it could even have had a positive effect. The palliative care service was reconfigured with no inpatient care facilities on one site; therefore we were unable to recruit palliative patients. If these participants had been included in the study providing different representations, a broader perspective on masculinity may have been obtained.

Discussion The findings from this study are novel in that they are a description of how men with advanced cancer perceived their masculinity and how they were affected by the disease and treatment they had received. What emerged as new, was how even in patients with a limited prognosis, aspects of masculinity are important to the patients’ self-perception and identity and that the consequences of advanced cancer has a negative impact causing distress to the men. The narratives in this study also showed how health care

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professionals approach men during interactions can also impact on masculinity particularly in terms of loss off control. Previous work suggests that some men prefer to hide feelings and not disclose information about their cancer. However, the men in this study said they wanted to talk about their cancer and did so in the right situation. Previous work on patients with prostate cancer suggested that men did not feel the need to disclose feelings about their cancer, even in terms of spousal support and that there was a low perceived need for emotional support for this patient group (Gray et al. 2000, Boehmer & Clark 2001), however, this current study shows that most of these men relied on and received close spousal support. Whilst some of them consciously chose not to disclose to partners as part of their protective role. The findings in this study suggest that men wished to disclose in the right circumstances and also benefitted from close emotional interactions, particularly from other men with cancer. The men in this study did not talk of how they look in terms of attractiveness, rather that their appearance was a representation of their illness, a visible marker of their cancer. This view is similar to the findings from a Swedish study looking at young adult cancer patients’ (men and women) experiences of the body after a cancer diagnosis. Snobohm et al. (2010) performed a phenomenological study investigating the experience of altered body image on this patient group. They also found that the participants could not separate the view of their body from the illness and that physical changes also manifest mentally. This echoes some of statements from the men in this study who reported that looking ill made them feel ill and these physical changes had a negative impact on self-image. Men in this study were adversely affected by the changes in body size, hair loss and pallor in terms of masculinity. This finding is similar to results by Ricciardelli (2011) who suggests that there are strong links between appearance, self-–identification and masculinity, hair and hair loss is an important aspect of this. Rasmussen et al. (2010) performed a participant observation study which aimed to explore how cancer survivors with varying types of cancer experienced the changes in their body appearance. They found that the participants experienced changed attitudes from others, difficulty in discourse and blocking tactics, such as changing the subject in conversation when it erred on feelings, from others happened as a result of the changed appearance. This is consistent with findings from this current study where the men talk of feelings of paranoia, marginalisation and lack of confidence due to appearance.

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The findings that men had to accept, but had difficulty with the transition of social roles such as protector and breadwinner is demonstrated in other research on men’s recovery from cancer. Vaartio et al. (2003) investigated men’s experiences from a diagnosis of cancer to recovery, they also found that men struggled to deal with these changes but an important mechanism for coping was physical restoration. The men in this study did not have the capacity for full physical restoration so relied on other coping processes. A strong theme in the findings was that of the importance of fighting the disease and there are many examples of battle metaphors and fighting with the cancer throughout within the narratives. The use of such terminology when discussing cancer is well documented and debated (Easlea 1981, Hodgkin 1985).In the case of the current study, the men themselves utilised the battle metaphors and acknowledged that fighting was an important coping mechanism, having weapons to fight with, such as further treatment and support from colleagues was important but one would postulate that if the patient themselves is offering the metaphor it should not be dismissed as a means of expression. Penson et al. (2004) do acknowledge the possible dangers in using such terminology but accept that they are firmly ingrained in our culture and may help give patients some meaning to their experience, they report that the point is to find a common language that strengthens the alliance and demonstrates empathy with the patient. One would suggest that the use of such metaphors may be particularly useful for male patients but should be used with an awareness of the language and context, with the lead being taken from the patient. It was demonstrated in the findings that masculinity that is socially constructed is integral to the participants lives both pre and postcancer. Connell’s (1995) domains of masculinity are identifiable within the discussions of these men in this study. Aspects of hegemony for the precancer patient are visible within the narratives, the men precancer can identify some aspects of the hegemony that they can align themselves with and seem to either fit in with the hegemony or at least be complicit with it, however, the consequences of cancer and its treatment can make it difficult for the patient to live up to the hegemonic ideal appears to be embedded in our values and beliefs. This can result in the men moving into a more marginalised or subordinate representation of masculinity.

Relevance to clinical practice These findings are particularly relevant to practice as they offer a different perspective to some of the published litera© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1069–1078

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ture regarding men’s needs for disclosure and support. This different perspective includes the ability to discuss issues surrounding their cancer, particularly with other men who have cancer, issues surrounding loss that are linked with certain aspects of masculinity, and the need for help with finding ways of coping with these multiple losses or changes. The findings here will hopefully encourage nurses to enquire deeper when supporting men who are dealing with cancer. Men with advanced cancer have a burden in terms of symptoms and treatment side effects, the impact on perceptions of masculinity can add to that burden in terms of adapting and coping and this may not be initially obvious to the health care professional. An enhanced understanding of the complexities of masculinity in relation to the cancer experience will help nurses to better consider their patient’s needs.

Conclusion These male patients often presented to the unit in which they were being treated as coping well and appeared on the surface to have accepted their situation. The findings from the study showed that they had complex adjustments to make as well as finding ways of coping with the extreme sadness and emotion of the illness as on deeper investigation they appear to grieve for the loss of their former lives, loss of control and

loss of the future. In the midst of all this, they still feel obliged to maintain the gendered roles that they had, especially in terms of protection and provision for their families. Increasingly through the disease trajectory the ability to perform these roles is adversely affected, which in turn affects how they cope and deal with adjustments. Presumptions that men do not require close emotional support are often incorrect, but the way in which men access this support and who it comes from needs careful consideration. How men experience the health care services they come into contact with and how professionals deal with male patients are both influenced by concepts of masculinity.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

Conflict of interest There is no conflict of interest to report for this work.

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