Portions of the manuscript were presented at the Canadian Association for Psychosocial Oncology Annual Conference and Canadian Psychological Association Convention in 2012.
Wearing my heart on my chest: dating, new relationships, and the reconfiguration of self-esteem after breast cancer†
Article first published online: 6 SEP 2013
Copyright © 2013 John Wiley & Sons, Ltd.
Volume 23, Issue 1, pages 52–64, January 2014
How to Cite
Kurowecki, D. and Fergus, K. D. (2014), Wearing my heart on my chest: dating, new relationships, and the reconfiguration of self-esteem after breast cancer. Psycho-Oncology, 23: 52–64. doi: 10.1002/pon.3370
- Issue published online: 2 JAN 2014
- Article first published online: 6 SEP 2013
- Manuscript Accepted: 12 JUL 2013
- Manuscript Received: 5 JUL 2013
- breast cancer;
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This study investigated women's experiences of establishing an intimate relationship with a new partner after breast cancer diagnosis and treatment.
Fifteen breast cancer survivors, who were either actively dating or in a new intimate relationship that began post-diagnosis, participated in semi-structured interviews. Interview transcripts were analyzed using the grounded theory method.
The analysis yielded Wearing My Heart on My Chest as the core category with three underlying categories: (1) Losing and Regaining Self and Bodily Esteem; (2) Taking the Leap: Dating and the Obligation to Disclose; and (3) Reclaiming of Self through the New Relationship. The categories refer to the experience of profound vulnerability invoked by the history of breast cancer and the act of verbally and physically revealing this past to a new intimate partner. Disclosure entailed a series of successive ‘tests’ of the new partner for his ability to accept the physical and psychological ramifications of breast cancer, with the resulting relationship becoming a vehicle through which women regained self-esteem.
The process of dating and starting a new intimate relationship had the potential to restore women's self and bodily esteem previously diminished by breast cancer. The reconfiguration of self-esteem following breast cancer is thus experienced as an ongoing process that begins with diagnosis and continues well into the new relationship. Copyright © 2013 John Wiley & Sons, Ltd.
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Breast cancer diagnosis and treatment adversely affect women's overall quality of life , with psychological distress common during the first year after diagnosis [1-3]. Dissatisfaction with appearance is a frequently reported concern , with the loss or mutilation of the breast as a result of surgery negatively impacting women's sense of identity, confidence, self-esteem, femininity, and body satisfaction [5-8]. Approximately one-third of women with breast cancer also struggle with sexuality and sexual dysfunction post-treatment [7, 9-11], and for premenopausal women, concerns about fertility lead to additional distress [6, 12].
Although breast cancer is an individual diagnosis, it occurs in a broader interpersonal context, often affecting women's intimate relationships  as well. Breast cancer challenges a couple's ability to cope with illness-related relationship changes, such as increased sexual dysfunction, loss of fertility, fears of mortality and an uncertain future, role changes, and communication difficulties [2, 14-18]. Some women may also become preoccupied with their partners' responses to the diagnosis and/or with fears of being abandoned [15, 19].
Although research suggests there is little empirical basis for such fears [e.g., [19, 20]], Manne noted in her review on the impact of cancer on relationships that couples with a female patient may be at greater risk because of the tendency of male partners to cope through withdrawal . Indeed, there appears to be a slight differential impact of cancer on female patients' relationships in particular. When Glantz and colleagues studied the rate of separation in couples diagnosed with a serious illness, they found that 93% of separations in a the general oncology group occurred when the affected partner was the woman and a total of 20.8% of relationships ended in separation or divorce when the woman was affected with a serious illness compared with 2.9% when it was the man .
Researchers have also found a significant difference on new marriage formation rates between male and female cancer survivors. Syse and Aas reported that although men have similar new marriage rates post-cancer treatment, women experience a 25% marriage deficit, one that is particularly pronounced following ovarian and breast cancers . When Syse compared marriage rates for 12,100 individuals diagnosed with cancer with controls, they found that although no cancer type was correlated with reduced marriage rates in men, and a cancer history in general did not impact women's overall marriage rate as compared with the cancer-free controls, particularly pronounced deficiencies were apparent in women's marriage rates following brain and breast cancer . Such results are disheartening and seem to suggest that significantly more women than men may end up single after a cancer diagnosis.
Most of the research on the impact of cancer on relationships has generally looked at marital status as an inclusion criterion, thus excluding unmarried couples and those women who are dating or are in less committed relationships at diagnosis. The few studies that have taken such relationships into account suggest that women in these relationships face even greater difficulties than those who are married . Holmberg and colleagues found that when breast cancer was implicated as a cause in the dissolution of the relationship, the breakup usually occurred during the early phases of treatment, leaving such women with fewer social and material resources during a vulnerable time.
Taken together, these findings suggest there are a significant number of breast cancer survivors who are non-partnered. In addition, the rate of new marriages for these non-partnered women is lower than for men, suggesting that some barriers are preventing women from forming new relationships post-treatment. Despite the importance of this topic, very little research has been carried out in this area. The few studies that have examined the quality of life of single women 2 and 3 years following breast cancer treatment suggest that dating is a special stressor [15, 25]. In the only study to focus solely on the concerns of unmarried women, Gluhoski et al. found the issue of dating to be of utmost concern, with women reporting pessimism about finding an accepting partner, concerns about disclosure of cancer history, fears of being rejected, feeling sexually undesirable and avoiding sexual relationships, and feeling isolated. Moreover, a number of women reported having been rejected by their partners at the time of diagnosis, leaving them particularly vulnerable to fears around dating .
Although previous research has addressed some of the concerns women have in relation to dating after breast cancer [15, 26], and there has been a call for support and informational resources for single women both in terms of dating and talking to new partners about cancer [27, 28], there has yet to be any actual investigation of how single women seek out and establish new, intimate relationships after breast cancer. The purpose of the present study was therefore to investigate this process, including women's initial concerns and how these were overcome, how the women went about disclosing their past, and the role of cancer in the new relationship. Because of the limited understanding in this area, a qualitative study was conducted. The following research questions were of particular interest:
- What are women's experiences in relation to dating and starting a new relationship after breast cancer?
- What are women's concerns about entering into a new relationship after completing treatment for breast cancer?
- What allows women to overcome their cancer-related concerns and establish a new relationship?
- How is the illness history incorporated and negotiated within new relationships?
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A total of 15 women participated in the study. Inclusion criteria were as follows: (1) female; (2) diagnosis of breast cancer at any stage of disease; (3) between 18 and 80 years of age; (4) actively dating or in a new committed heterosexual relationship (e.g., married, cohabitating, engaged, or steadily dating for at least 6 months) that began post-diagnosis; (5) no psychiatric disorder that would interfere with their ability to communicate coherently or complete the interview; and (6) fluency in English. As it was anticipated that the dating experiences of heterosexual women may be considerably different from those of lesbian survivors, we restricted sample composition to heterosexual women. The rationale for utilizing a homogeneous sample at this stage was based on the paucity of research on this topic in general and our goal to provide a starting point to which other subgroups might be later compared in terms of areas of similarity and difference. The sample was primarily Caucasian, well educated, and with most of the women employed full-time. All of the participants had a diagnosis of primary breast cancer without boney or organ metasteses. Two of the women had had a local recurrence and an additional two women had experienced a second primary cancer in the opposite breast. The participants underwent a wide variety of treatments, with 10 of the 15 women receiving four or more different treatments.
More than half of the participants (n = 8) were in a relationship at the time of the initial breast cancer occurrence. With the exception of one woman whose partner died and who thus was widowed, these relationships eventually ended in separation. At the time of participation, 13 of the 15 participants self-identified as being in a newly established relationship with a minimum duration of 6 months. For the majority of these women (n = 11), their current relationships were their first since their diagnosis. For a summary of demographic, disease-related, and relevant descriptive characteristics, refer to Table 1.
|n (%)||M (range)|
|At diagnosis||15||38.4 years (26–62 years)|
|At study participation||15||46.1 years (31–68 years)|
|Highest level of education|
|Some university/college||2 (13)|
|Currently employed||11 (73)|
|Marital status at diagnosis (n = 14)a|
|In a relationship||8 (57)|
|Marital status at study participation|
|In a new relationship||13 (87)|
|Time lapse between original diagnosis and current relationship||5.9 years (1 month to 19 years)|
|Duration of new relationship||2.9 years (7 months to 9 years)|
|Total number of new relationships since diagnosis|
|Breast cancer history|
|Single primary||10 (67)|
|Second primary (breast cancer ×2)||2 (13)|
|Local recurrence||2 (13)|
|Breast-conservation surgery||5 (33)|
|Single mastectomy||7 (47)|
|Bilateral mastectomy||3 (20)|
|Hormonal therapy||11 (73)|
The study protocol was reviewed and approved by the Research Ethics Boards of both the participating hospital and university prior to commencing with recruitment. Participants learned about the study through healthcare professionals or flyers posted at the hospital, community agencies, and on stakeholder websites across Canada. Of the 15 participants in total, nine were referred by healthcare professionals, three self-referred in response to a flyer, and another three were referred by the other participants. Fifteen of the 19 women who were contacted by phone and provided with more information about the project agreed to an interview. The majority of interviews were in-person and took place either at the hospital (n = 3) or at the participant's home (n = 6). One participant requested that the interview take place in a private conference room at her workplace. When a face-to-face interview was not possible, a telephone interview was conducted (n = 5). Prior to conducting all interviews, participants were asked to sign an informed consent form and complete a demographic and cancer history background questionnaire. The average interview length was 69 min.
All interviews were audio recorded and transcribed verbatim. The text was analyzed by the first author in consultation with the second author using Glaser's approach to the grounded theory method and as adapted by Rennie [29-32]. The text in each interview was divided into meaning units (MUs) or segments of data that represent a separate concept expressed in the data. Consistent with open coding, as analysis progressed, each subsequent MU was compared with the previous categories to determine whether the meaning(s) being conveyed had already been adequately captured by an existing category. This required that previous categories be re-evaluated in terms of newer MUs, sometimes leading to alterations in the labeling of existing categories to better accommodate new, relevant information. If no suitable category was present, the MU was used to develop a new category that all subsequent MUs were compared against. This constant comparative analysis ensured that the emergent theory was grounded in the text.
A categorical framework was developed by systematically grouping related categories in order to achieve a multilevel hierarchy. Lower-order categories were initially sorted such that those with shared meanings were grouped together to form more abstract categories. The lower-order categories thus became the defining properties of these higher-order categories. The higher-order categories were then further examined for relationships with other higher-order categories and organized to form the highest level in the hierarchy. Memos reflecting researcher insights were recorded throughout data collection and analysis and assisted with data conceptualization and organization.
As directed by Glaser and Strauss  and Glaser , data analysis occurred simultaneously with data collection, which was terminated only when the categories were considered theoretically saturated and no new information was gained from additional interviews. This was deemed to have occured after approximately 12 interviews; however, three additional interviewees were sampled on the basis of the emergent theory (e.g., interviews were conducted with two women who had dated but were not in a current intimate relationship). The analysis of these additional interviews served as further confirmation that theoretical saturation had been achieved. Moreover, a total sample size of 15 has been shown to be more than adequate for saturation in the literature [33, 34]. There is some evidence that metathemes become evident by as early as six interviews , whereas finer themes require an initial sample of 10 interviews and data saturation occuring when no new themes emerge from three additional consecutive interviews . Moreover, there is evidence that a sample of 15 is adequate for fulfilling the purpose of the present study, which was to describe a shared experience among a homogenous group of women rather than to compare two groups, which may require a larger sample .
Several validity checks of the emerging descriptive categories and the hierarchical structure were in place. The first author analyzed the initial few transcripts in consultation with the second author. Moreover, because data analysis occurred in tandem with data collection, a type of validation occurred in which emergent themes were incorporated into the interview protocol that subsequent participants were able to speak to and further qualify. Consensual validation also occurred whereby members of the Psychosocial Oncology Lab at York University analyzed randomly chosen segments of the text, and emergent interpretations were compared against the categories that the first author had come up with. The initial coding scheme was also reverse validated whereby laboratory members were provided with a list of random, discrete MUs and a list of category names in random order and were asked to identify which MUs fit which category names. This process yielded significant overlap and only minor adjustments to the category names. The development of the final hierarchical model and grounded theory was further consensually derived by both authors.
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A total of 164 lower-order categories were generated and then organized into 14 higher-order categories. These, in turn, provided the defining features of the three upper-most or main categories leading to the development of a single core category encompassing the experience of dating and starting new intimate relationships following breast cancer: Wearing My Heart on My Chest. This statement signifies the profound emotional vulnerability experienced by women in relation to revealing their cancer history and physical disfigurement to a new intimate partner. Although it was up to the women to decide when and how the process of revealing occurred, it generally required the presence of a psychologically ‘safe’ other and, specifically, an intimate partner who responded with acceptance and care to the woman's initial disclosure of breast cancer. As a result, the dating process consisted of successive ‘tests’ that required the women to risk revealing increasingly private and sensitive aspects of themselves at the same time as the strength of the new partner and the safety of the relationship was being tested for their ability to accommodate the woman's breast cancer history and its complex sequelae.
The establishment of an intimate relationship with a new partner thus unfolded in a stage-like process that entailed the following: (1) Losing and Regaining Self and Bodily Esteem pertaining to the women's individual struggles with the psychological, emotional, and physical impacts of the illness and the process of reclaiming one's self and bodily esteem after treatment; (2) Taking the Leap: Dating and the Obligation to Disclose, which is the process of dating and the ‘testing’ of the new partner for his ability to accept the breast cancer; and (3) Reclaiming of Self through the New Relationship, which speaks to the ways in which the cancer was negotiated in the new relationship and how the new relationship became a vehicle for self-acceptance. The categorical framework is described in the following text and summarized in Table 2. Block quotations used to illustrate the categories are identified with a pseudonym and the participant's age in brackets.
|Losing and regaining self and bodily esteem|
|Relationship(s) that ended||7 (47)|
|Faced with a ‘deformed’ body||13 (87)|
|Feeling second rate||12 (80)|
|Reconstructing bodily esteem||13 (87)|
|Reclaiming agency and striving for self-acceptance||11 (73)|
|Taking the leap: dating and the obligation to disclose|
|Dating readiness||14 (93)|
|The cancer conversation||15 (100)|
|The man test||14 (93)|
|Intimacy as the ‘ultimate’ test||15 (100)|
|His receptivity to her cancer||13 (87)|
|Reclaiming of self through the new relationship|
|A special sort of guy||13 (87)|
|When relationships work||12 (80)|
|Negotiating cancer in the new relationship||15 (100)|
|His acceptance as a bridge to self-acceptance||14 (93)|
Losing and regaining self and bodily esteem
For the majority of participants, the breast cancer experience resulted in an assault on the women's sense of self and bodily esteem, creating new insecurities, exacerbating old ones, and irrevocably changing the women's identities. Despite there being variation in degree of negative impact, nearly every participant felt that it was essential to find a way to cope and learn to accept themselves, at least to a certain degree, before they could contemplate dating. The extent to which the women had actually come to realize this goal varied, with a few women continuing their personal struggles with self-acceptance despite having found a new partner.
Relationship(s) that ended
For several participants, the loss in self-esteem came by way of feeling abandoned by a significant other at the time of the initial illness. Seven of the women in the sample who were in a committed relationship at the time of diagnosis viewed breast cancer as a ‘trigger’ that led to the dissolution of the relationship. According to participants, these couples found themselves growing apart as the men increasingly withdrew and distanced themselves from the women and their cancer. Distancing also occurred sexually, with most of the couples' sex lives ceasing after treatment. In one instance, the woman did not want to ‘poison’ the intimacy she and her partner shared with the toxic chemicals in her system; in another case, a participant recalled her partner losing interest in her post-mastectomy
After my mastectomy, he never touched me, he never wanted to have relations with me and all that, so that also, I think made me feel worse about myself. And then I [kept] asking him, I [would] say “Don't you find me attractive anymore?” And he would brush me off. (Mary, 53)
Women described feeling deeply inadequate in these relationships, with a common barrier to ending the relationship being the concern that they were somehow ‘damaged’ and thus undesirable to a new partner:
I honestly thought that I was like broken. Like you know I was used goods. I thought I was kind of not good anymore and thinking I'm not worth being in a relationship, because you're thinking the first one who supposedly loved me, doesn't want to be with me, doesn't want to commit. So why would someone who doesn't know me, and he doesn't already love me, why would someone else love me? (Julia, 34)
Their partners' abandonment or rejection thus worked to sow the first seeds of insecurity, leading a number of participants to feel resigned to the possibility of remaining single forever.
Faced with a ‘deformed’ body
Although only a third of the sample experienced the breakup of an intimate relationship post-diagnosis, every woman interviewed experienced some assault on self/bodily esteem due to treatment effects such as scarring, mastectomy, hair loss, and/or weight gain. Many of the women expressed hatred toward their body, using words such as ‘deformed’, ‘ugly’, ‘disgusting’, and ‘mutilated’ in relation to themselves and expressed concern that they might ‘repulse’ or evoke ‘pity’ in others. Most of the women expressed feeling as if they had lost a part of their femininity along with their breast(s), with several woman equating the loss of their breast(s) to a deeper, more fundamental loss of womanhood: ‘Do you feel like you're a full woman or three-quarters of a woman right? I feel in my chest I'm half male, half female.’ In contrast, there were a few participants who were not as devastated by the loss of a breast, and these tended to be older in age. As one 68-year-old woman stated, ‘I'm still a woman regardless of whether I happened to have one, two, or no breasts. I'm still me.’
Feeling second rate
Related to the disfigurement was a sense of not being ‘good enough anymore’ as an intimate partner. This loss of esteem, in turn, contributed greatly to the women's diminished confidence when contemplating dating. Moreover, the women tended to compare themselves with other women not affected by breast cancer, thus always ending up falling short in their own estimation, ‘I was like, ready to be single for the rest of my life. Because I was thinking “Who would love me? Who would love my body like this?” No one would feel attracted to me in any way.’ The women also expressed a sense of responsibility for taking experiences away from future partners that they could otherwise have with another woman who did not have a cancer history such as the ability to provide a partner with a biological child.
Reconstructing bodily esteem
Despite the toll that diagnosis and treatment had taken on the women's identities, most participants felt that it was essential to try to accept their disfigured bodies as an inroad to regaining their self-esteem. However, many participants spoke of the reconstruction of bodily esteem as a gradual process, noting that ‘it took some time after the mastectomy to like look into the mirror and go “OK this is my body”.’ It was also viewed as very much an individual process with every woman finding her own way, ‘be it reconstruction, no reconstruction, tattoo, you know, whatever’. As this woman went on to explain:
… and that's part of why I got the tattoo. This is my body now, how am I going to make it feel better for me, right? Living with this, “What am I going to do to make myself feel pretty?” It's just how I decided to like that part of me again. (Kim, 31)
Reclaiming self/bodily esteem was also deemed to be a never-ending process. In many ways, reconstructing bodily esteem required that the woman find acceptance in her new body, rather than strive to return to the old. Moreover, despite any and all efforts, the women believed that they would never be truly free of breast cancer given that their scars served as a constant ‘reminder everyday when you're getting dressed and bathing that you've gone through this and, you're not quite a whole woman anymore’ – both for themselves and any future partners.
Reclaiming agency and striving for self-acceptance
More broadly, women reported having to come to terms with the psychological and emotional impact of the diagnosis and the need to incorporate cancer into their sense of self. This was talked about in terms of a gradual transformation – one that occurred through a process of accommodating the cancer into the self-schema, accompanied by a sense of mourning for what was, followed by an acceptance of what is and what will be. For example, one woman spoke of the deep sense of loss of who she used to be and her struggle to find herself once more:
When I went through my breast cancer, for quite some time after I'd look at pictures of myself, and I'd go, who's that girl in that picture? I don't know who she is…because you lose so much? Not just your breasts, but you lose that whole – I lost that real carefree, fun loving girl. It's my whole being, like who I was, it's really quite different… that woman. I can now look at pictures and I'm okay. That person is now really me integrated right? And this is just my life and my journey. (Anne, 47)
Although some women felt that their values and priorities changed as a result of this ‘brush with death’, others felt that they were able to remain ‘true’ to who they were or that they had simply become ‘a little more me’. In addition to self-acceptance, several of the women gained a sense of empowerment, strength, and independence as a result of having had to deal with the breast cancer on their own. As one woman noted, ‘You learn how much you can take and how strong you can be. So it's, I wouldn't say character-building, but it's character-identifying 'cause you're like, I guess I had it in me all along but I really didn't know it.’
Taking the leap: dating and the obligation to disclose
Get to a place where you are comfortable with yourself and then everybody will be comfortable with you…It's like riding horses, it is. A horse can only be as brave as the rider, if you're scared of something the horse is going to pick up on it and be scared of it too. (Kim, 31)
The participants' experiences varied with respect to how long after diagnosis they started dating, with some entering a new relationship immediately after diagnosis and others waiting until treatment was finished. A number of women talked about a period during which they could not even begin to contemplate dating someone new because they had yet to come to terms with their diagnosis, their altered bodies, or a previous breakup. As women came to feel more secure, however, they began to think more actively about dating, weighing both the pros and cons and preparing themselves to take the leap and risk opening themselves up to another. Part of the struggle included the need to convince themselves of their desirability despite the cancer:
All these doubts and these fears pop in your mind and it's, “Why would someone want to be with me?” But then you say, “Okay because I'm a nice person.” So you're kind of arguing with yourself and you're going back and forth like saying oh c'mon but you have this, oh not but you're really nice, and it's just back and forth and I think I tried to keep positive about a positive future. And I think that's what kind of helped me get there. Because it's so easy to make yourself feel like you're not good enough anymore. (Julia, 34)
Although the majority of the women retained a positive outlook about the possibility of meeting someone accepting, all had certain expectations of the type of man they expected to meet. These, in turn, were defined by preconceived notions of the type of man who could cope with cancer and breast loss or disfigurement, such as someone who was older, had ‘his priorities in the right place’, or who had some past experience with cancer. Others conceived of this hypothetical ‘other’ as someone who struggled with his own feelings of inferiority, perhaps someone who ‘had some sort of medical issues’ himself or who did not measure up to some conventional standard for physical attractiveness either. Somewhat paradoxically, however, the women reported being more strict about personality and prepared to hold out for someone who would treat them exceptionally well and ‘who's gonna stick around’.
Of the 15 women interviewed, eight actively sought out a partner by creating online profiles or agreeing to be set up. For women who met their partners online, there was greater sense of control and safety. In contrast, women who met their partners unexpectedly often did not necessarily feel ready for an intimate relationship; yet, because the relationship progressed ‘slow as molasses’ or was initially approached as a friendship, it created a non-threatening environment that allowed the women time to overcome their reservations.
The cancer conversation
Soon after meeting the new potential partner, deciding when and how to reveal the cancer history was a top concern for most women. Part of what made disclosure so difficult was the fear and expectation of being rejected. Another part was the struggle with the when and how of disclosure:
I remember a great debate in my mind, you know, so when do you do this? Do you do it up front and say, okay if he doesn't like this, so be it, that's the end of that relationship? Or, do you wait 'til there's some possible intimacy about to happen and then spring it on? It's a hard decision, how and when do you do this? (Grace, 66)
Most women had no doubt that verbal disclosure had to occur and that they ‘should say something’ and preferably before physical disclosure due to a sense of moral obligation ‘to warn, it's almost like a warning’ to the men. One woman felt that having had breast cancer in particular meant there had to be two conversations, not just one:
When it does come to breast cancer versus other cancers, it's kind of like there's two conversations: there's the conversation about like “oh by the way, I had cancer and yes, I will be okay.” Like that's one half of it…. But then it's like okay, “And this is what my body looks like.” (Hanna, 40)
Most women also agreed that disclosure had to occur early on and that it required being upfront and honest about everything in relation to cancer. Such full disclosure was considered to be important as a way of preventing greater pain to both later on if he decided he could not ‘accept and live with what package I offered, the entire package that came with me being me’. One woman went to the lengths of preparing a written script to help guide the disclosure process:
I kind of wrote everything out from start to finish, like everything that he would need to know about me from having had a previous partner, engaged, cancer, surgery, treatments, future medication, unknown future, everything… like I typed it up, and I printed it off and I just literally sat him down and just read everything to him. (Julia, 34)
Another woman felt that it was important ‘not to just drop it “I had breast cancer.” I like to start it off with a little story’ and using humour to disarm the man, she goes on:
I usually tell them there's something I have to tell you and they're like OK what? And then my line is that there's no right or wrong reaction to what I'm going to tell them, so they freeze up immediately, like was she a man? Like that's usually, that's usually the joke that I try to bring up, like I'm not a man but… (Sarah, 35)
The man test
Across all participants, verbal disclosure of cancer history constituted the first test of the partner's ability to accept the breast cancer. If the man passed this test, the relationship could proceed to the physical level; if he failed, the relationship would go no further. The cancer conversation was thus inextricably tied to a test of each man's character and his ability to accept her, with the women remaining hypervigilant with respect to the men's facial, physical, and verbal responses, as one woman conveyed in the case of a ‘failed test’:
As soon as we talked about it, it was more that he wasn't looking me in the eye and he didn't ask me anything. It was more like, “oh OK”. I'm like “well, you know is this going to be a problem? Because like I'm still going through this.” He's like “no, no, no it's fine.” But you know you could just tell. So like we finished our date and a couple of emails back and forth, but I didn't pursue it. (Sarah, 35)
It was equally important that the man demonstrate interest by inquiring more about her experience. This communicated to the women a genuine interest in her as a person and provided both relief and reassurance.
Intimacy as the ultimate test
Most of the women felt much more ‘aware’ and ‘protective’ of their bodies and, consequently, much more selective about who they allowed to see their scars. Participants were highly attuned to the potential to be hurt by a man who showed any degree of repulsion and safeguarded themselves from possible rejection by allowing only the men who had ‘passed’ the first test of verbal disclosure to proceed to the ‘ultimate test’ of intimacy.
Not only did verbal disclosure of the cancer history have to occur prior to physical disclosure but verbal disclosure also had to include a description of the scars. This was deemed necessary, in part out of the same moral obligation that led the women to disclose their breast cancer history in the first place, as a way of building trust. This way of inoculating the partner was in fact quite common. The majority of the women gradually prepared the men by first, educating them around what happens during treatment and/or reconstruction and the resulting scars and then by showing them the prostheses before revealing their scars or, alternatively, very gradually revealing their scars a little at a time. When it came down to being intimate, the majority of the women were anxious and felt the need to hide their disfigurement from their partners initially, preferring to keep the lights dimmed and their scars covered. A few, however, chose to be more revealing of their mastectomies from the beginning. The men, being responsive to their partners, tended to relinquish control to the women, following the women's lead and respecting their comfort level.
His receptivity to her cancer
According to the participants, the majority of partners were generally quite receptive of the women and their disclosures, be it verbal, physical, or both. They showed a genuine interest in the woman's breast cancer experience by generally engaging in, rather than withdrawing from, cancer-related discussion. Most of the men showed a surprising lack of concern, telling the women over and over that their cancer history does not matter. One woman, for example, in describing her partner's response to her disclosure of her double mastectomy, was relieved when he said, ‘What difference does it make? It's you that's the person, not the breasts.’ Interestingly, a number of women felt, in hindsight, that they might have supplied too much information in their attempts to prepare their partners, drawing unnecessary attention to their scars, ‘when I finally did show him the scars he's like, “well they're not as bad as you said” ’. Many of the participants echoed the sentiment, saying that ‘men don't nearly think as much about our bodies as much as we do’.
The more the partners displayed acceptance, the more revealing the women became. Thus, just as the men took their cues from the women, the women also adjusted how much they were willing to expose as a result of the men's reactions. Not all women, therefore, ended up revealing their bodies fully to their intimate partners, even with time. The men as well had individual ways of coping with the women's bodies. One woman remembered, for example, that her partner proactively ‘prepared himself to see me by going online and looking at pictures of women who had had a mastectomy, so that he, he told me that after the fact, so that he wouldn't be totally shocked’.
Reclaiming of self through the new relationship
A special sort of guy
Once the men were deemed to have passed the ultimate test through positive reception to the women's cancer histories as well as their bodies, the relationship could proceed to the next stages. Given the possibility of rejection, the women who did find an accepting partner thus perceived themselves as ‘lucky’ and the men as quite ‘special’. When asked what the women thought made these particular men so different, several of the women emphasized their partner's defiance of outside influence:
He's one of those people who doesn't like to be like everyone else, right? … So I think a lot of men not being able to deal with stuff is outside influence and he's always been somebody that doesn't accept outside influence. And so I think that that was really a part of how it was a lot easier to stay with me, because he didn't worry about what other people thought. He didn't care if I walked around not wearing my beanbag boob and just had one, he wasn't embarrassed. (Kim, 31)
Moreover, the men tended to be much more open minded to adapting their life plans to fit around the women's limitations, such as starting a family in less traditional ways. The women also listed a character-building past as a possible influence. Several of the women's partners had had a brush with adversity, such as an illness including cancer, or a tragedy that enabled them to be less materialistic. There were some exceptions, however, where an experience of loss instead made it more difficult for the man to accept her cancer history.
There emerged a general prototype in relation to one's current or ideal partner that was mentioned by nearly every woman. This entailed an individual who was warm, empathic, strong, solid, and unwavering. The women were seeking and finding men who demonstrated not only an ability to accept the cancer but, more importantly, an ability to stand by the women and not abandon them in the event of a recurrence. As one woman said of her partner, ‘it's like when people say that somebody's their rock they haven't met [current partner], because he's like a mountain, he's like seven million rocks put together, he's just so stable it's unbelievable.’
When relationships work
The qualities of the new partners, combined with the women's changed values post-breast cancer, thus opened the door for stronger, better, deeper relationships, according to participants. Women who were satisfied in their current relationships described having ‘connected on a deeper level’, ‘deeper than just love… it encompasses such respect for everything, what you say, what you don't say, how you feel, what you want for the future’. Not all women, however, were completely happy in their new relationships. One woman, for example, felt somewhat unfulfilled and disappointed in her new relationship and new partner. This sense of dissatisfaction was tied to a lack of physical intimacy and intellectual stimulation, factors that made her question whether she was settling:
Like is this all there is for me out there? Is this as good as it gets for me? Because there's still a little part of me that thinks…maybe I'm not the most desirable, like, physically and, maybe this is the best thing as good as it gets, if I didn't have [current partner] maybe I'd have nobody. (Anne, 47)
For another woman, dissatisfaction in the new relationship stemmed from her partner's lack of demonstrated interest in her history with cancer. She, in turn, was afraid to broach the subject once again for fear that any such discussion might drive him away:
It's almost like I don't want to trigger, I don't want to remind him, I don't want the idea to be implemented in his head, “Oh yeah that's right she's got cancer I forgot about that”, you know? Like I don't want to… it might make him think too much, that it might get the process going in his head, “oh yeah” like this and that, and “what happens if?” (Kate, 47)
Negotiating cancer in the new relationship
Women also required that the men remain respectful of their autonomous decisions in relation to cancer. As a result, the cancer remained separate from the couple on a certain level, with the women retaining the ultimate say regarding treatment, reconstruction, pregnancy, lifestyle choices, or anything else that might directly affect the women's health. Another common feature of the successful new relationship was that the men were able to accept unconditionally the role of the cancer as an inevitable part of the couple's life. Although the idea of the cancer faded into the background with time, many of the women commented on how it nevertheless held a presence within the relationship, one that became more pronounced around follow-up appointments. With every follow-up appointment or news of someone dying from cancer, the anxiety and fear of recurrence actively intruded into the couples' lives. The degree to which the women shared their fears with their partners varied, depending in large part on the perceived safety of the relationship. When the relationship context felt less secure, women avoided raising the topic of cancer and disclosing their fears.
The need to accommodate cancer's intrusion on the relationship was also apparent in relation to the women's often reduced libido or when the couple engaged sexually. It was in the context of the couple's ongoing sexual interactions that women spoke of accepting their partners' limitations. A few participants for example made a point of expressing that they did not resent their partners for not being able to touch the scarred areas of their chest. Most women showed great understanding that the men's avoidance was not a direct rejection of them but instead may be born out of respect for the women's own comfort level with having the men touch their scars or perhaps the man's own personal limitations. More specifically, some partners retained a certain distance from the women's affected breast(s), preferring not to touch, or in some cases, even see, the scarred breast tissue. This was independent of whether the women underwent reconstruction and whether it was the couple's first intimate encounter together.
Most of the women who chose to undergo reconstruction chose to do so not prior to starting the new relationships but rather once they had established a new intimate relationship. Many of the women actually discussed reconstruction with their partners prior to making a decision, and many partners in fact attempted to convince women not to undergo the procedure. Moreover, although some of the women who underwent reconstruction reported increased self-esteem and confidence, even those who chose not to have reconstruction found other means (e.g., a tattoo) through which to regain self/bodily esteem. Indeed, reconstruction had very little predictive power over women's self-esteem and confidence; rather, it was the combination of a supportive and committed partner along with one's own self-acceptance that helped restore confidence.
His acceptance is a bridge to self-acceptance
He's just perfect. Not perfect, but he's just perfect for me… He provides me with what I need, and accepts me for who I am, accepts me through the past that I've gone through, and accepts me for the future that we have together [even though] we don't know what it's going to be like. (Julia, 34)
As the relationship progressed, the men's embracing of each woman's cancer history and her body was both reassuring and psychologically healing for the women. The man's acceptance, in turn, made it easier for the woman to accept her own past, her current body, and living with future uncertainties. The women thus became more comfortable with their breast cancer. Rather than pitying the women for what they had gone through, the men appeared to generally admire the women for their fighting spirit. Indeed, several of the men demonstrated a love for the woman not despite the cancer but in part because of it, as one woman recounted in relation to her first date with her current partner:
He walked me to the car, he said he had seen that pink lay and then pink magnet and he thought to himself this girl either a) has had breast cancer or b) has someone very close to her who's gone through breast cancer. And he said that as soon as I thought that I liked you even more. (Julia, 34)
Although there were some exceptions, the majority of partners lovingly embraced the scarred side of the women just as they did the non-scarred: ‘he's traced it with his hand the one that is the large one [scar], the radical one, the other one he's just, it doesn't bother him, at all. He's just very loving and thoughtful.’ Such demonstrations, whether verbal or physical, of full and complete acceptance of the breast cancer part of the woman, were a generally quite unexpected yet pleasant surprise that helped restore and renew women's confidence and self-acceptance:
Oh, it changed the way I thought of, the way I saw myself.... It's just, you just don't feel pretty and you want to hide your body, and with his reaction, it totally changed everything and … you start feeling not so bad about yourself. And if he doesn't care what I look like underneath my clothes, then I'm not gonna worry about it. Because he loves me for me, not for what I look like. (Alice, 42)
In instances where the men, for various reasons, did not display full and unconditional acceptance, the women were, correspondingly, less able to accept themselves. This sense of comfort and security within the relationship was also related to the woman's ability to trust that the man really understood the implications of a cancer history and that he knew what he was getting himself into and was not blind to the possibility that cancer could recur.
Establishing a new intimate relationship after breast cancer thus had the power to create a psychologically healing environment for participants. When the women's profound vulnerability, as conveyed by the core category, Wearing My Heart on My Chest, was met with acceptance and care, this experience had the ability to accelerate and restore the self-esteem that was diminished by breast cancer and the physical and emotional scars left behind after treatment. Thus, what might have begun as the woman's individual coping process with the assault to her self/bodily esteem, gradually, through a series of passed ‘tests’ went on to become a shared process of the new couple as a unit. In satisfactory relationships, this process furthered the women's ability to integrate the traumatic changes brought about by breast cancer and foster self-acceptance.
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Although previous research shows that dating is a top concern for unmarried women post-breast cancer , little is known about the actual unfolding of the dating process or the role of cancer in newly established relationships. The current study sought to fill this gap in the literature by drawing upon in-depth interviews with breast cancer survivors. Consistent with past research [e.g., [25, 26]], the findings revealed that relationship issues were indeed a prominent concern for women who found themselves unmarried or single after breast cancer. Although there was some variation with respect to age, with the older women in the sample focusing less on the changes to their physical appearance than the younger women, most participants reported feeling physically deformed, less of a woman, and/or inadequate and second rate. This struggle with body image and self-acceptance was inextricably intertwined with the process of dating and the expectation of rejection by prospective male partners.
Sociocultural antecedents that regard breasts as objects, and more broadly, the female body as a socially constructed object to be looked at and evaluated , likely strongly influence the perspectives of heterosexual women facing breast cancer. In the present study, women reported feeling discomfort and anxiety about the possibility of facing critical evaluation from potential male partners after losing a breast. Many noted a desire to hide their bodies from men's gazes. Viewing themselves as potential male partners might see them may have led many of the women to internalize disgust for their scarred bodies in accordance with body objectification theory .
Participants also tended to compare themselves against other healthy women in their own age bracket when it came to dating, thus engaging in upward comparisons and leading to increased feelings of dejection and lowered self/bodily esteem [36, 37]. Many women felt not only that they came up short in terms of appearance but that they also could no longer fulfill the expected societal role of a woman, including that of bearing children. A few also felt flagged as no longer healthy, thus feeling less than optimal as partners and leading to expectations about having to settle for a less than ideal partner for themselves.
Moreover, although one-third of the women in our sample reported having had reconstruction, each woman reported having done so not for her partner but rather for her own self-esteem, ‘the “I” portion’, as one participant noted. Irrespective of the decision to pursue reconstructive surgery or not, most women were able to attain a sense of self-esteem with time such that there appeared to be minimal differences in confidence between women who underwent reconstruction and those who did not. The men's reactions also appeared to be relatively unaffected by reconstruction, as many of the partners were described as the types to care little about the women's physical appearance in the first place. However, given that such men were overrepresented in the present study, it is possible that there are men whose attitudes toward reconstruction would differ from those discussed in this sample.
The grounded theory analysis further showed the cancer taking center stage during the dating process. The women took a self-protective approach to dating by either consciously or inadvertently putting potential new partners through a series of successive ‘tests’ to gauge the safety of the other and the new relationship. Despite the potential negative reactions that disclosure might entail, there was no doubt in the women's minds that it had to occur. Although most of the current research on disclosure pertains to the process of disclosing a cancer diagnosis to an existing partner or family member [e.g., [38, 39]], there were some commonalities with the present investigation, such as the motivations behind disclosure, the use of ‘strategies’, and the potential benefits gained as a result. For example, the women in the current study reported various motivations for disclosure, the foremost of which was a sense of obligation to ‘warn’ their prospective partner about their history. In the context of dating, disclosure also served as a type of test of the potential partner, whereby his reactions to each progressive disclosure would dictate the further development of the new relationship. Consistent with other disclosure literature [e.g., , women remained hypervigilant to men's reactions and also used the men's receptivity to infer their character and their desirability and safety as long-term mates.
Participants also reported various strategies for disclosure, including educating their new partners by preparing them with information and inoculating their partners by revealing their scars only gradually. Similar to past research [38, 39], disclosure had a number of perceived benefits, particularly concerning the women's prioritization of the importance of being open and communicative about their cancer. Self-disclosure motivated by the well-being of others has been shown to lead to psychological benefits [40, 41]. In choosing to be honest with their potential partners, the women reaped various positive consequences, such as increased support, acceptance, and relief. Moreover, several of the women identified that disclosure early on was essential not only for mitigating expectations but also for building trust and safety. This self-disclosure early in the dating process may have therefore had the inadvertent positive effect of establishing the norm of open communication in the developing relationship, thus fostering the subsequent formation of a more secure attachment [42-44].
An additional notable finding was that the experience of the men's unconditional acceptance in the context of a secure attachment relationship in turn had a profound effect on the women by helping to restore their self/body esteem. Many of the women in relationships perceived to be secure reported that their new intimate partner's love and acceptance not only gave them hope but also restored their sense of femininity, desirability, and self-acceptance, thus serving a healing function. Therefore, the socially constructed aspects of body image  came in a sense to work to the women's advantage within the context of a safe, accepting relationship.
The present findings therefore underscore the significant and possibly unique role that an intimate other assumes in helping women restore their self/body esteem after treatment for breast cancer. It should be noted, however, that not all women described feelings of security and/or satisfaction in their new relationships. A subgroup of women reported withholding their fears from their partners and continued to experience body image issues. They expressed notable concerns about their physical worth along with a certain resignation with respect to having to settle for a less than ideal relationship or alternatively, an unwillingness to share their fears with their partner for fear of being abandoned by them.
Although findings from this study extended the current state of knowledge about dating after breast cancer, it was not without limitations. Despite attempts to obtain variation in race, ethnicity, and age, the current sample was primarily white and younger than 50 years. In addition, the majority of the women in our sample who were in newly established relationships reported high levels of relationship satisfaction, suggesting the possibility of an overrepresentation of women who had been successful in establishing a satisfactory relationship. Despite this possibility, an adequate level of variability was achieved that gave greater insight into both positive and negative experiences with dating and new relationships.
Moreover, another limitation of this study was the exclusion of lesbian participants. Participation was initially restricted to women in heterosexual relationships as a way of obtaining a more homogenous sample based on the assumption that women in same sex relationships may experience both their altered bodies and the dating process differently. There may be important differences in same sex relationships that would highlight the effect of sociocultural antecedents on women's perceptions of themselves and their bodies in relation to others. It is possible, for example, that in intimate relationships, lesbians may feel less defined or may resist being defined by societal notions of feminitiy and womanhood, which would then impact how they approach dating and how they relate to a new intimate partner. Moreover, there are challenges unique to lesbian couples that make relationship adjustment post cancer treatment more complex. For example, the presence of both breasts in the well-partner may highlight the loss or disfigurement of a breast in the partner who has been treated for cancer . Future studies comparing new intimate relationships of lesbian breast cancer survivors to heterosexual relationships may help better answer how this experience differs across sexual orientations.
The present study was also limited to breast cancer survivors. It is highly likely that although some commonalities may exist between breast cancer survivors' and other cancer survivors' experiences with starting new relationships, it was not the purpose of the present study to explore all such experiences. Future research, however, should consider the possibility of extending the present grounded theory to include other cancer and/or health populations. Moreover, although it cannot be assumed that the current sample is representative of all breast cancer survivors' experiences with new relationships, a range of experiences were captured in the present grounded theory, as evidenced by variation in participant backgrounds and sample saturation.
Despite these limitations, the findings provide a starting point for understanding the process of establishing new relationships after breast cancer and have several important implications. The findings validate the challenges associated with dating and the concern it presents to women who find themselves in the position of wanting to start a new relationship after breast cancer. Given that many women feel pessimistic about future relationships post-diagnosis, psychoeducational initiatives stemming from this analysis may help others feel less hopeless and discouraged about meeting a new intimate partner. Providing women with practical information about how others have overcome their fears and anxiety in order to date and establish new intimate relationships post breast cancer may prove inspiring. Moreover, unmarried women with breast cancer, and specifically those with significant body image concerns, appear to form a vulnerable subpopulation that may benefit from psychosocial interventions and support groups tailored to these particular issues. Overall, the current findings may help sensitize health professionals to the very specific challenges single women face after breast cancer and the importance of supporting their reclaiming of self/bodily esteem, in addition to their general emotional and physical recovery, after breast cancer diagnosis and treatment.
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This research was funded in part by Social Sciences and Humanities Research Council (SSHRC) Graduate Scholarship awarded to the first author. We also thank the members of the Psychosocial Oncology Lab at York University for their help with validation of emerging theory and, particularly, Masha Koroleva, Dana Male, and Amanda Pereira for their assistance with transcribing.
Conflict of interest
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There are no potential conflicts of interest to report.
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