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Keywords:

  • embodied masculinity;
  • hegemonic masculinity;
  • prostate cancer;
  • androgen deprivation therapy;
  • men's health

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

This paper describes the findings from an ethnographic study of 16 Anglo-Australian men treated with androgen deprivation therapy (ADT) for advanced prostate cancer. Utilising a social constructionist gendered analysis, participants’ experiences, particularly in relation to embodied masculinity, are described in the context of reduced testosterone that accompany ADT. The findings indicated that participants reformulated many ideals of hegemonic masculinity in response to functional body changes. However, hegemonic masculinity strongly influenced participants’ philosophical resolve to ‘fight’ prostate cancer. The findings are considered in broader ongoing debates about essentialist sex and the social construction of gender.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

Prostate cancer is the most common male cancer in several developed countries including the United States and northern and western Europe (Bray and Atkin 2004). Although the cause is unknown, with increasing age, most men will develop microscopic foci of prostate cancer (Yatani et al. 1982) and the incidence is expected to rise exponentially as greater numbers of men reach older age (Remzi, Waldert and Djavan 2004). Many men are also living longer with prostate cancer, as indicated by the death rate being significantly lower than the incidence rate (Boyle, Severi and Giles 2003). Current trends in the epidemiological data suggest that increasing numbers of men will be living with prostate cancer in the future.

Approximately 14 per cent of newly diagnosed cases will reveal evidence of metastases or advanced prostate cancer, where the tumour has spread beyond the prostate gland to other parts of the body (Parker et al. 1996). Prostate cancer cell growth initially depends on the presence of androgens such as testosterone (Meredith 2000), and the contemporary treatment for advanced prostate cancer involves chemical castration through androgen deprivation therapy (ADT) (Waldman and Eliasof 1997). Androgen deprivation therapy, usually administered by three-monthly injections, blocks testosterone production to slow the growth and spread of prostate cancer (Meredith 2000). Many treatment side effects – including diminished libido, impotence, muscle wasting, increased body fat, weight gain, labile mood, reduced concentration, hot flushes, fatigue and gynaecomastia (breast development) – have been reported (Kozlowski and Grayhack 2002). Men's experiences of ADT and its side effects are intricately connected with embodied masculinity and provide unique circumstances in which to consider essentialist and social constructionist debates.

Masculinity – essentialist versus social constructionist frameworks

Long-standing debate continues about the oppositions, tensions and connections between essentialist and social constructions of masculinity. DeLamater and Shibley Hyde (1998), amongst others, explored the feasibility of attempts to synthesise (theoretically and empirically) essentialist and social influences in a single theory, a process they referred to as ‘conjoint’. They claimed that the basic definitions of essentialism and social constructionist theories prohibited compatibility. Essentialism relies on a notion of essences, with an implication (found in positivism) that the true essences can be known directly and objectively. Social constructionists argue the opposite – that we cannot know anything about true essences or reality directly, but rather that humans always engage in socially constructing reality (DeLamater and Shibley Hyde 1998). When positioned in epistemological frames it seems reasonable that essentialism and social constructionist theory provide people with distinctly different ways of thinking about sex and gender.

The separateness of these frameworks becomes less coherent, however, and perhaps fragile in the context of health and illness. Turner described it as ‘bizarre’ to argue that there are no organic foundations to human activity and claimed ‘sociological theory has effectively neglected the importance of the human body in understanding social action and social interaction’ (1992: 822). Although this may have been the case, in the last decade the body has been ‘brought back in’ to sociological debate about gender (Williams 2003). This has been theoretically important because it has helped ‘to recast people's thinking about the status of the body in analyses of gender and power’ (Evans 2001: 132). Emotions, like the body through which they flow, have also been a focus of sociological interest (Williams 2003). The challenge, however, remains to ‘bring in’ biology in non-reductionist terms (Latour 2004) and move toward a more integrative phase of social theorising (Williams, Gabe and Calnan 2000, Williams 2003).

Hegemonic masculinity and the male body

Hegemonic masculinity is a central concept in social-constructionist-gendered frameworks and two usages of the term can be distinguished in much of the current literature (Flood 2002). First, hegemonic masculinity may mean no more than those masculine ideals that are most commonly subscribed to in a social formation (Tosh 2002). These include characteristics such as domination, aggressiveness, competitiveness, sexual and athletic prowess, control and stoic emotional display (Cheng 1999). Second, hegemonic masculinity signifies a position of cultural authority and leadership, constructed in relation to various subordinate masculinities as well as in relation to women (Connell 1987, 1995, 2000). Although many men are complicit in sustaining hegemonic masculinity, individuals vary in their replication of, and relationships to, the aforementioned ideals (Connell 1995, Good, Borst and Wallace 1994). It is therefore commonplace to view masculinities as multiple, contested, dynamic and contradictory, based on different cultures and periods of history that construct gender differently (Connell 1995, 1997, Courtenay 2000, O’Brien, Hunt and Hart 2005).

Although there is no singular male body type, dominant discourses are powerful in their persuasion of what is or is not valued in terms of male embodiment (Whitehead 2002). The idealised male body is sexual, muscular, athletic, and disciplined to embody control, presence and the promise of power (Connell 1995). In the public sphere, male bodies are expected to look and operate in specific ways. Men learn to treat their bodies as discrete and separate (Seidler 1997) and muscularity and bodily posturing are implicated in the self-regulatory policing practices of a normative masculinity (Martino and Pallotta-Chiarolli 2003). Self-control and discipline of the masculine body are also deeply cultured expectations (Morgan 1993). As Loeser states:

. . . the postures, tensions and texture of a muscular body are one of the main ways in which the power of men is seen as part of the order of nature. . . . A man's presence (fabricated or real) is dependent upon the promise of power he embodies (2002: 56).

There is a high value associated with the ‘ideal’ male body and qualities of physical strength and physical aggression, which are in marked contrast to the feminine (Evans 2001). A ‘real’ man is large, hard and strong (Peterson 1998) and there can be intense social pressure to be ‘seen’ as masculine – for many men their body provides a vehicle to demonstrate masculinity (Donaldson 1991, Lee and Owens 2002, Sabo 1986).

Men's sexualities are social practices, intricately connected with embodied masculinity that ascribes specific desires and actions (Connell 2003). The most frequently told story of hegemonic male sexuality describes powerful, natural, uncontrollable penis-centred characteristics that drive men's insatiable appetite for penetrative sex (Edgar 1997, Kilmartin 2000, Lee and Owens 2002, Lips 1997, Plummer 2005, Rathus, Nevid and Finchner-Rathus 1997). The presence of the penis and testes signifies distinction from femininity (Martino and Pallotta-Chiarolli 2003). Moreover, the size and functionality of these male organs are central to men acting on their sexual urges (Edgar 1997, Lee 1996, Lee and Owens 2002, Zilbergeld 1992). Most heterosexual men's dominant pattern of sex is erection, penetration and climax (Metcalf 1985) and the full and firm erection is generally viewed as the linchpin for this phallocentric model of sex (Marshall 2002). There are also strong cultural assumptions that proper sexual activity involves the insertion of the penis into the female partner's vagina (Lee and Owens 2002). Very few men experiment with sensations of the non-erect penis due to the prioritisation of the erection in notions of healthy and satisfying male sex (Potts 2000).

The masculine mind is also expected to operate in specific ways that are unemotional, objective and logical (Morgan 1992). Emotions are identified with weakness and being ‘strong’ means being in ‘control’ of emotions (Seidler 1997). Strength of mind is revered in life and business where decisiveness emanates self-confidence and independence commensurate with masculine control, skill and style. The mind is active, has a special kind of unity with the body and is associated with ideological constructions about specific masculine ways of thinking – such as being reasonable and ‘doing’ rationality – and these ‘qualities’ enable men to occupy distinctive and often privileged places (Morgan 1993).

The older, ill masculine body

As men grow older, the authoritative gaze on them changes (Sabo and Gordon 1995) and older men can become subordinate within cultures that idealise youth (Fleming 1999, Thompson 1994). Although the traditional Western view of ageing has been associated with loss, dependency and decline, the large number of ‘baby boomers’ approaching retirement and the increased life expectancy of those already retired have contested and re-shaped notions of what it is to be old (Buchbinder 2002, Williams 2003). In the context of male sexuality there is widespread acceptance of the biological tradition that decline is a natural consequence of the ageing process or the result of a cultural tradition that favours sexual activity as a youthful endeavour, but regards it as unhealthy, unscrupulous and unsightly in later life (Katz and Marshall 2003, Marshall 2002, Marshall and Katz 2002). However, medical treatments for erectile dysfunction have raised alternatives to the essentialist and social limits of how older men's sexuality can be expressed. Restoration of age-depleted erectile efficiencies including fullness and firmness, ejaculatory force and refractory period are now possible (Levy 1994, Marshall 2002). Nonetheless, the biomedical focus on penis functioning and disregard for disorders of desire has been criticised for perpetuating phallocentric ideals of male sexuality (Marshall 2002, Potts, Gavey et al. 2003, Potts, Grace et al. 2004).

Illness is directly connected to ageing (Whitehead 2002) and, according to some authors, can render men vulnerable, passive and dependent – traits traditionally assigned as feminine and thus in direct opposition to hegemonic masculinist constructs of invulnerability, activity and independence (Charmaz 1995, Martino and Pallotta-Chiarolli 2003, Skord and Schumacher 1982). The ill, disabled male is often subjugated to the realm of the ‘abnormal’, the ‘feminine’, the ‘not male’ (Loeser 2002), and a profound sense of loss and changed identity occurs when the ill body of the present is compared to the body of the past (Charmaz 1995, Devins 1994).

The inverse of the argument – that masculinity is incompatible with illness – has been presented less often. Watson (2000) refuted claims of men's unitary health behaviours and homogeneous disadvantage by virtue of gender roles, and illustrated that embodiment provided the ground on which the dynamics of gender could be used to understand how masculinities and health and illness behaviours come together. Nicholas (2000) suggested it is important to clearly distinguish between the harmful effects and potential strengths in what he described as traditional gender roles. Some characteristics of masculinity may assist men in conceptualising and coping with illness – as illustrated in Gordon's (1995) study of men with testicular cancer.

Previous research

Only a few studies have focused on men's experiences of being treated for prostate cancer with ADT. Clark et al. (1997) conducted focus group interviews to develop a survey questionnaire to measure the psychosocial impact on men treated with ADT. The survey was subsequently completed by 201 men and showed substantial regret associated with treatment choice and reduced quality of life [QoL] (Clark, Wray and Ashton 2001). A longitudinal study by Green et al. (2002) indicated increased QoL related to improved urinary symptoms but decreased sexual, social and role functioning following ADT. Depressive disorders were reported to be more prevalent (Pirl et al. 2002), and individualised information was preferred by patients treated with ADT in order to cope with psychosocial issues (Shapiro et al. 2004).

Navon and Morag (2003a, 2003b, 2004) published three papers from a qualitative interview study of 15 men who received hormone therapy treatment for prostate cancer. In one paper, they described diverse changes to patients’ relationships with their spouse following treatment. Eight interviewees reported that changes to their personality and bodily appearance created physical and emotional distances between them and their spouse. Conversely, seven participants’ relationships were characterised by more emotional companionship (Navon and Morag 2003a). Descriptions about how participants contended with body feminisation, sexual dysfunction and the disruption of spousal intimacy through self-redefining, self-distancing and self-solacing cognitive techniques were also reported (Navon and Morag 2003b). In addition, liminal states, based on participants’ ability to classify themselves into culturally available categories, were described (Navon and Morag 2004). One thematic finding, ‘maleness without a full sense of masculinity’, described how body feminisation following ADT resulted in a ‘betwixt and between state’ in which participants did not feel fully male or define themselves as feminine (Navon and Morag 2004: 2341).

Social-constructionist-gendered frameworks have also been used to analyse men's prostate cancer experiences. A grounded theory study by Fergus, Gray and Fitch (2002) involved 18 participants treated for prostate cancer with radiation therapy, prostatectomy and/or ADT with results indicating that most men redefined their sexuality and preference for penetrative sex when potency was lost. Chapple and Ziebland (2002) interviewed 52 men about the effects of prostate cancer and its treatments on their masculinity. They reported that participants (n = 32) treated with hormones experienced additional and sometimes profound effects on libido, energy, ability to work, body shape and competitiveness when compared with men treated with other modalities. In particular, lack of libido adversely affected some participants’ sense of masculinity (Chapple and Ziebland 2002). Based on their study, Chapple and Ziebland (2002) suggested that gender was largely a social construction, but hormones, and therefore essentialism, subtly affected the way men and women reacted to each other and how gendered roles were played. Further, they recommended that, rather than duality, ‘the physical body as well as culture should be considered when trying to explain what it means to be masculine, and how illness may affect men's sense of masculinity’ (Chapple and Ziebland 2002: 820). The present study engages with these theoretical debates, and explicitly considers how the physical body is referred to in social constructionist gender research.

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

Sample

After obtaining ethics committee approval, preliminary fieldwork and participant observations were conducted at monthly meetings of two Melbourne-based prostate cancer support groups (PCSGs) over six months. A great deal was learned about men's experiences of prostate cancer during this time and the research design and questions were strongly influenced by what was observed at PCSG meetings. Several different starting points were used to recruit participants and included PCSGs, media advertisements and postings to various prostate cancer internet sites. The research reported in this paper grew out of a larger ethnographic study of 35 men who had prostate cancer. Early in the data collection and analysis it was identified that participants treated with ADT had many unique embodied experiences that were not shared by men who had undertaken either radiation therapy or prostatectomy. Therefore, the data from a sub-cohort of 16 participants who were being treated with ADT at the time of interview were abstracted and analysed and form the basis for this paper. Other findings from the larger study, including participants’ experiences of prostatectomy-induced impotence, were analysed separately and have been reported elsewhere (Oliffe 2005).

Participants signed a written informed consent and completed an in-depth, semi-structured, audio-taped interview. A purposeful criterion sample was used to reduce variation within the cohort (Patton 1990) and all participants were Anglo-Australian (defined as originating from a Welsh, English, Scottish or Irish background, at least second generation Australian-born) heterosexual men, with a current female partner. Participants’ self-reports of libido, erectile function and frequency of penetrative sex were diverse; however, 15 of the 16 participants considered themselves potent prior to being treated with ADT. Socio-demographic and medical data are described in Table 1.

Table 1.  Socio-demographic and medical data
Age
at diagnosis M (SD) (R = 55–82 years)64.31 (8.02)
at interview M (SD) (R = 55–87 years)67.31 (9.42)
Partner status
Partnered n (%)16 (100%)
Years with current partner M (SD) (R = 1–66)37.5 (14.41)
Employment
Full- or part-time paid employment n (%)10 (62.5%)
Retired n (%) 6 (37.5%)
Treatment
ADT only 4 (25%)
ADT and Radiation therapy11 (68.75%)
ADT and Prostatectomy 1 (6.25%)
Treated with ADT at time of interview16 (100%)

Twelve of the 16 participants had previously been treated for prostate cancer with radiation therapy or prostatectomy and ADT was either used as an adjuvant therapy or subsequently initiated when tumours were found to have extended beyond the prostatic capsule.

Data collection

Individual interviews were conducted mostly at participants’ homes during 2001 by the principal investigator (a registered nurse, heterosexual male in his late thirties) and averaged two hours in duration. Participants were encouraged to tell their stories about living with prostate cancer, and specific questions about feelings and thoughts related to ADT were introduced as appropriate to the flow of the interview. The prompts were guided by the overall research question: How does prostate cancer and ADT inform and influence participant's masculinity, particularly in relation to embodied masculinity? All but two participants collaborated in the co-production of their final transcript by providing comments, corrective feedback and answering additional questions (Acker, Barry and Esseveld 1983).

Data analysis

The analysis was part of the process of the research during the data collection phase, rather than something that occurred exclusively at the end (Gifford 1998). Excerpts from field notes and participant observations were added to transcripts to provide a sense of the whole interview. Through repeatedly reading participant interview data and field notes, ideas and interpretations about recurring, converging and contradictory patterns of interaction were developed (Sandelowski 1995, Spradley 1980). Key phrases were highlighted and jottings made in the columns of the transcripts about ideas and interpretations.

The transcripts were managed using NVivo 1.2 and data were sorted based on participants’ discussions about how their body looked, and how their mind and body functioned in the context of being treated for prostate cancer with ADT. Categories of ‘body aesthetics’, ‘bodily functions’ and ‘the mind’ were developed. Data were then arranged in sub-categories under each heading, and descriptive notes for each of the sub-categories and exploration of the relationships between them were made. Particular single-coded and multiple-coded segments were extracted and, as analysis continued, the relevant literature and social constructionist gender frameworks were revisited. Participants’ relationships to hegemonic masculinity, inclusive of the aforementioned characteristics and power discourses, were central to the analyses of the data. Themes, along with illustrative examples from the data, were identified and developed into storylines as recommended by Morse and Field (1995). The term ‘theme’ refers to coherent behavioural and belief patterns identified in participants’ accounts (both within and across transcripts) (Morse and Field 1995, Stenner 1993). The data were organised and re-organised several times and three themes resulted from the data analysis: (a) feminine features and lost masculinity, (b) uncontrollable fatigue, impaired thermoregulation and impotence, and (c) inconsistent affect and cognition.

Results and discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

Body aesthetics: feminine features and lost masculinity

Androgen deprivation therapy resulted in many aesthetic changes and, rather than a masculine signifier and resource, the atypical male body became a site of transition and uncertainty. Participants described the development of breasts, weight gain, decreased muscle mass and reduced penis and testes size, all of which were explicitly linked to ADT. Breasts were feminising, and participants depicted a gender duality in which some ‘flesh on the chest’ was immediately about being female. William described ‘worrying about whether [his] breasts [were] increasing in size’ and quipped ‘I should have just bought myself a 36 D cup’ prior to commencing ADT. Randwick suggested that he had ‘breasts . . . some of the females would be quite happy to have’. Vincent had ‘little breasts’ and Sam was ‘embarrassed’ that he ‘got a couple of boobs’ but asserted, ‘what can I do about it? If I don't have the treatment I end up in a box so you have to live with it’.

Although participants talked about flesh, much of what was shared related to locating their own selves within particular historical perspectives, social classes and cultures, all of which intersected with masculinity (Connell 1995, Donaldson 1991). Randwick told the story of his body over time, and described a muscular working class body from the past and explained that he had been a ‘real’ truck driver because he not only drove the truck, he ‘packed and unpacked the load’ that it carried. This demanded muscle and strength, which his normal masculine body provided. However, his body had been invaded by an unfamiliar feminine torso and it was not a true representation of Randwick's body, its history or its achievements:

From the neck down to the waist, it's not my normal body. I've always had a truck driver's body, because I've always been a working person . . . now, that body to me is not mine.

Deviation from the masculine ideals of low body fat and well-defined muscles also ensued. Weight gain often accompanied the loss of muscle and implied an undisciplined, less masculine body. William was unable to control his weight, and the extra kilograms he carried misrepresented his commitment to wellbeing and recovery through daily exercise and a healthy diet. William explained:

I'm not particularly vain, but I'm desperately trying to lose weight . . . I'm very much aware of the fact that my waistline is starting to increase and it's not through eating.

Similarly, John was ‘much more inclined to sit down and not exercise’ and had consequently ‘put on weight’. Verlow was ‘losing muscle power with it [ADT]’ and had ‘to ask people to lift anything . . . reasonably weighty’; Vincent became reliant on his two sons to do the heavy manual labour in their family-owned and operated market gardening business:

I don't try and pick up the 200 or 300 bags of whatever . . . I just leave it. I have learnt, or been told to get to the back of the queue. I've had to ease off.

The freedom to inhabit public spaces also faltered for some participants due to a fear of being ‘seen’ as a lesser man. Randwick stopped swimming at the beach because he ‘felt self-conscious . . . instead of being reasonably firm, I think people must say, God, he's a flabby old fellow’. He recalled:

I've always had firm arms and a firm body. I've never been one that's had to worry about a beer belly or loose flesh . . . maybe at 74 it shouldn't worry me but it still is an annoying thing.

A lifetime of looking and therefore being male became fragile as a body familiar, yet foreign, took on a preferably ‘secret’ double life of its own.

The penis and testes as male signifiers (Martino and Pallotta-Chiarolli 2003) were perceived by most participants to have reduced in size following ADT. Eddie noticed his ‘shrunken penis’ and although ‘the drug company said “no there are no effects like that” . . . I tell you it definitely shrinks’. Berti's testes ‘instead of being like a chicken's egg’ had shrunk to be ‘like a pigeon's egg’. John did not ‘seem to be as large in that department as [he] used to be’ but was ‘unsure what that is a result of’. Kevin's ‘testicles have shrunk to damn near nothing’. Roy did not ‘know how long it took for it [ADT] to shrink things up, change me . . . but it did’. William suggested that ‘everything seemed to get smaller’. One evening he looked down as he took a spa with his wife and noted:

I could see this tiny . . . really shrivelled-up looking little penis, and the boys [his sons] came in. I said, ‘Have a look at this. This is what happens to you when you take these bloody female hormones. You see, your old man's got nothing to show’.

William's advice to his sons also demonstrated how hegemonic masculinist messages are transmitted to young boys.

Participants were not necessarily aware of this potential side effect prior to treatment, and only one participant (Kevin) discussed the subsequent changes with his doctor. Kevin explained that, following a physical examination, the doctor agreed his testes were small, but as long as they were not tender there was no cause for concern. Although many participants rationalised the changes through essentialist constructions as a by-product of treatment-induced hormone shifts, surprise and uncertainty about the clinical significance, as well as the appropriateness of revealing the transformations to their doctor, were strongly represented.

Visual representations of masculinity were disrupted, and the history, as well as the future, were submerged and perhaps questioned within bodies of increasingly unfamiliar dimensions. Although the body did not necessarily look disabled or diseased, participants were reminded by anatomically emasculated, feminised features that they did not physically exemplify the promise of power (Loeser 2002), control (Morgan 1993) or strength (Evans 2001, Lee and Owens 2002, Peterson 1998). Many participants compared and described their body in relation to hegemonic masculine ideals, and at the level of body aesthetics, masculinity and illness – or in this case treatment side effects – were incompatible, as previously reported by Charmaz (1995), Martino and Pallotta-Chiarolli (2003) and Skord and Schumacher (1982).

Bodily functions: uncontrollable fatigue, impaired thermoregulation and impotence

Energy levels and functionality decreased following ADT and affected physical, social and sexual aspects of participants’ lives. Ron had worked as a builder all his life, but in retirement even the chores around the home had become exhausting. He confirmed ‘it takes you all day to do what you used to [be able to] do all day’. Vincent had been forced to re-assess the sustainability of his business because of the discordant relationship between his energy levels and the physical work that was required:

We are winding things down . . . we are not chasing business outside. Like sourcing produce out. It is a good business but I am physically tired.

Trent experienced a ‘loss of energy’ which he found ‘quite debilitating’. He explained that gardening was a ‘sort of therapy . . . to be able to get my hands dirty in the bush’ and suggested that it ‘probably goes back to my upbringing. I was brought up on a rural property’. Since commencing ADT, however, a lifetime of work in the garden had been replaced by a passive, helpless view of the work that needed to be done:

I just sit in a chair and read the paper . . . I just could not physically cope with things that I had been used to doing. I would go to do things and found I ran out of energy very quickly. A quarter hour of exertion and I was absolutely buggered . . . I really had to convince myself that there are things that needed doing and they can all wait.

Various social activities were also affected. Vincent had given up golf because he no longer had the energy, and consequently had ‘lost touch’ with many of his ‘closest mates’. William had lost the freedom to enjoy a night out with friends, and his wife was ‘very much aware of it’:

When we go out somewhere, she’ll just keep an eye on me and as soon as she starts to see me fade, she’ll say ‘look, we’re going’. And, we come home and often I’ll just crash into bed and that's it, I sleep.

Fatigued bodies were unable to deliver in terms of both physical prowess and social presence. The inability to provide physical labour threatened long-standing relationships with traditional gender roles of breadwinner, provider and protector. Being unable to keep up, let alone compete with other men (and women) also forced participants to reformulate and re-locate many previously held practices of ‘doing’ gender.

Sedentary lifestyles were a common consequence of fatigue yet, paradoxically, elevated body temperature and sweating that ordinarily accompanied physical exertion occurred during inactivity. These hot flushes were strongly associated with female menopause. Sammy was told by a female nurse that he would ‘probably get hot flushes’ when he started ADT. The nurse suggested, ‘that's our revenge on you blokes’. Verlow could ‘understand what women go through now with their change of life. It must be terrible, because these [hot flushes] are not very pleasant’. Typically, hot flushes occurred suddenly when participants were sitting watching television or sleeping. Body temperature was no longer predictable and clothes were layered and delayered in response to internal rather than environmental changes.

The libido and erectility performances synonymous with hegemonic male sexuality were also dislocated by ADT. Many participants and their partners jointly decided that impotence was a regrettable but accepted part of being treated for prostate cancer. Trent and his wife had agreed that ‘sex was not the most important thing in our lives, and that we could cope without me being potent’. William and his wife refused the offer of sexual counselling because they could cope with any sexual changes together. William explained that he was ‘very lucky’ because:

I've got a wife who is . . . very caring and considerate and gentle and humorous, and wrap all those things up together and it means if I can't perform, she doesn't get upset about it and if she doesn't get upset about it, I don't get upset about it.

When ADT was commenced most participants experienced profound loss of libido and potency, but suggested impotence was not difficult to accept because sexual desire had also vanished. Eddie had ‘no desire, no erection’ because ADT ‘just cuts it off completely’. Although he ‘thought that would be a problem’ it was not because ‘in your brain . . . you know that's it’. Sam said ‘it's just like turning off a tap . . . you’re not thinking about it so it doesn't matter’. Ron's potency was ‘just not there in a physical sense’, which ‘made no difference emotionally’ because he did not have any sexual desire. John described how his desire for penetrative sex had changed:

You would rather cuddle up with your wife and pat her on the bottom and just go off to sleep. You think isn't it peaceful and nice. I have just come to bed and I am going to go to sleep instead of the carry on of the last 30 years trying to plan how you are going to get the wife to have sex.

Essentialist explanations were relied on to rationalise the absence of sexual cravings that, in turn, resulted in participants no longer needing or outwardly grieving the loss of penetrative sex. The majority of participants explicitly identified lack of libido as a facilitator to their acceptance of impotence. Grief and reduced masculinity due to the loss of sexual desire – previously reported by Chapple and Ziebland (2002) – was not supported by the findings from the present study. Instead, a masculine self was preserved and intrinsic desire, rather than dominant social constructions, was realised as the prerequisite to wanting penetrative sex. Implicit to some participants’ reconciling deviations from phallocentric ideals was the absence of their partners’ libido and/or the passive, dutiful nature of female sexuality in general. Archie was able to achieve ‘partial erections’ but because ‘desire is pretty minimal’ he was not interested in having sex. He explained that he had ‘no sensory perception at all’ so ‘if we have foreplay or whatever, I get no gratification from that . . . it's [his penis] just an appendage’. Randwick predicted ‘he’ll [his penis] never look me in the eye again. He just looks at the ground forever’. However, it did not matter because:

The urge that is inside you . . . for instance, the shower fanning down on you, that urge would come up. But now, there's nothing that I feel.

Participants expressed their sexuality in diverse ways. More traditionally female aspects of non-sexual touch and physical closeness were common expressions of affection. Ron and his wife would ‘touch and feel and cuddle and kiss each other’, and Archie suggested he and his wife had ‘become closer . . . more affectionate to each other more often. So that has occurred in place of it’.

A few participants were willing to experiment with altered sexual performances, where fondling and petting occurred despite the absence of an erection. John explained that:

Fifty per cent of the human race never gets an erection and they have their love life and are very happy with it. Suddenly we [John and his wife] have just sort of swapped over to some extent. It is a more feminine approach to love making but it doesn't upset me at all . . . that allows you to be perhaps more submissive . . . I was nearly always the initiator, but I mean there is a difference in having an erection and not having an erection. If there is no erection then they’re more in control than they previously were.

With the exception of the oldest participant, Berti, who was 87 years old and had recently begun a new relationship with a woman 30 years his junior, participants did not attempt to re-establish potency through chemical or mechanical treatments. However, even Berti's use of a vacuum erection device (VED) demonstrated his willingness to experiment rather than an overt reliance on penetrative sex:

It works to a point. I've had better erections . . . My partner had a hysterectomy so it's not life or death. The last time we fiddled around I think was about six or seven weeks ago. It's not a weekly thing or a bloody daily thing . . . just sometimes I say, oh, I better pump him up I suppose. We get a lot of fun out of it. We’re laughing while we’re doing the bloody thing. This is half the problem, I think.

Participants’ acceptance of impotence was further evidenced by their disinterest in treatments for erectile dysfunction, and this finding illustrated previous assertions by Marshall (2002), Potts, Gavey et al. (2003) and Potts, Grace et al. (2004) about the limitations of erectility treatments that assume the presence of sexual desire. Factors such as older age and poor prognosis also influenced participants’ preparedness to accept, rather than treat, erectile dysfunction. Impotence did not bother Roy, because:

I have had a good life, been successful in many . . . achievements . . . have a wonderful wife, and I still think of her as when I met her, sweet 16, going on 17 . . . plus, I am 83, God struth.

Kevin asserted that he had a ‘fairly well-developed sense of who I am’ and suggested ‘if you haven't by the time you’re 63 you’re in trouble’. His self-assuredness had become less reliant on penetrative sex with each passing decade. He had, however, aligned closely with phallocentric ideals as a younger man:

You were at your peak at 17, 18 years old, but certainly by the twenties and thirties and even forties, yeah, I was well into it, but yeah, I'd say in my fifties, I was starting to slow down anyhow, it was less of an issue.

Energy was preserved in order to maximise recovery and promote wellbeing and many relationships focused on survivorship rather than penetrative sex. Gary explained that he had ‘had wonderful help from [his wife]’, she had ‘been the backbone’:

She doesn't show it but I know that she's had to deal with a lot . . . we hung on together, battled on through it [prostate cancer] together, which we still do.

The body's internal controls malfunctioned under the influence of ADT and, with Kryptonite-like effect, many-gendered performances were abruptly ended. Older age and illness had partially eroded some gendered performances but participants perceived that a biological disconnect occurred as a result of ADT, which in turn severed many tentative but nonetheless pre-existing connections to hegemonic masculinity. Essentialist constructs enabled participants to interpret functional alterations as a fait accompli, the product of a scientific cause-effect relationship, which in and of itself, provided a masculine, positivist way of rationalising the inevitability of the changes. However, masculinity continued to be constructed in interactions (Connell 1995), and alternate gendered performances were taken up by participants, in line with the essentialist and social limits inherent to older age and illness.

The mind: inconsistent affect and cognition

Instead of consistently demonstrating the decisiveness, stoicism and rationality expected of men (Morgan 1992), emotions strongly linked to femininity were experienced and expressed by many participants. Labile mood and altered thought processes, actions typified as female hormone-induced, were commonly described. In contrast to his lifelong ‘happy-go-lucky’ disposition, Randwick had become ‘much more sentimental’ and would ‘quietly wander away for a cry’ if something upset him. Randwick had never enjoyed touch but had ‘turned a bit more that way’ under the influence of ADT, and was physically closer to his grandson than he had been with his own son:

My grandson has always been one to come in and kiss his grandfather . . . but my son, that was never there. I thought the world of him . . . but the physical contact not so much at all. But it is definitely there now.

John ‘noticed different mood swings’, he was ‘quicker to anger with a particularly intense rage, but conversely I was very sentimental and tears flowed quickly’. Berti recalled that he would ‘get grumpy . . . sulky’ and ‘wouldn't talk’ to his wife, ‘sometimes I blamed her, but it was me really’. Archie suggested ADT ‘induces flatness’ and ‘flashes of rage’, which he had to consciously control:

I've found that I've got massively enraged in a spontaneous way. Something triggered it and it's like a step function. My temperament, all of a sudden there's this almighty change. I wanted to hit someone. At another time, I wanted to choke someone to death. I just controlled it and it subsided.

John had become ‘even fuzzier [mentally] than you usually are’. He confirmed his essentialist beliefs about the cognitive and behavioural changes:

We think our way through things and we act according to our thoughts and we find out that a heck of a lot of what we do is hormone-driven, which I guess shouldn't be any great surprise.

Two months after commencing ADT, Trent had a ‘nervous breakdown’ and his ‘wife took control’ and they went to a beachside resort until he ‘settle[d] down’. Trent explained that at the time:

I just couldn't cope. Mentally, emotionally couldn't cope. Couldn't cope with anything.

The power, control and strength of the masculine mind (Morgan 1993, Seidler 1997) had altered and reproduction of the dominant affect – stoicism – was often problematic. Rather than illness creating emotions of sadness, fear, anger and vulnerability these changes were consistently attributed to hormones.

Although participants recognised that their mind was altered in capacity and affect, masculine ideals were strongly relied upon and expressed through courage, survivorship and commitment to recovery. In particular, grit, determination and the will to fight cancer were consistently discussed by participants. Ron explained:

You have to fight these things . . . be prepared not to accept it . . . if you didn't you might as well go and dig yourself a hole and pull the lot in on top of you.

Even when the odds seemed insurmountable an egalitarian defiance was offered by Roy, who knew that he had a short time to live. During our interview he spoke with a shortness of breath and audible wheeze, as he explained his inevitable transition:

I say to family I've got a lot of things to tell Mum and Dad, and my two brothers and my sisters when I get there [heaven] . . . of course the general knowledge is that's not possible, but I say it must be a good place. I've never heard of anybody coming back.

Although humour is at work here, Roy presented a strong and dignified, perhaps courageous, acceptance of death.

Despite the relative lack of testosterone, hegemonic masculinity strongly influenced participants’ behaviours. Kevin explained his hot flushes and reduced testes size through detailed essentialist explanations of how ADT interacted with his body. However, his stoicism, cynicism and resilience remained over a lifetime:

I've never been a bouncy, jovial, sort of optimistic type of person. I'm more sort of your stoic that expects that things will be tough, and invariably they are and you cop it sweet.

Trent described how ADT had changed his masculinity:

I don't go much on the macho stuff these days. I don't have to go out and punch somebody's lights out to make me feel like a man.

Although these changes were likely enforced by the limits inherent to an ill and aged body, Trent embodied masculine ideals by situating himself as a prostate cancer survivor, and publicly speaking to other men and women about his experiences. Indeed, he felt ‘like a man these days when I can get up in front of a group of men and say “look this is what happened to me” . . . these are things you should be looking out for’. Courageous, inspirational and expert, Trent's public body, although ill, was explicitly masculine through survivorship. Similarly, Archie worked to raise community and government awareness of prostate cancer:

I am actively involved with others in helping . . . I am doing a weekend course . . . trying to get media attention for prostate cancer and making myself available to speak publicly at various forums . . . lobbying politicians.

There are numerous masculine exemplars – such as Kirk Douglas's book entitled My Stroke of Luck, the Michael J. Fox Foundation for Parkinson's Research and Lucky Man memoir, and Christopher Reeves's autobiography Still Me– where courage, power and working for the ‘cure’ are publicly revered and applauded. The management and spiritual, if not physical, recovery from illness demonstrated through such testimonials may have provided some participants with a template for embodying masculinity.

Participants’ alignment to dominant social constructions of masculinity were further evidenced by their answers to an interview question in which they were asked ‘When do you most feel like a man?’. Most participants referred to traditional masculine roles such as breadwinner and protector and/or through embodying competitiveness and strength:

I pride myself as a bit of a handyman . . . so lumping wood around and hammers and saws . . . when I'm with my granddaughter . . . I still fill the old function footing the bill for bloody near everything . . . I'm able to be a good provider (Kevin).

Working or doing normal chores . . . I definitely feel fully male there (Randwick).

I have a typical male ego . . . Can't say that I have developed any effeminate tendencies . . . I don't wear lace on my underpants or anything like that . . . I don't ever not feel like a man (Ron).

You have scared living hell out of the other side and you are running down the field and they are all ducking for cover . . . they are picking themselves up from the ground saying ‘I will get that bastard, next time’ (John).

When I'm with my wife (William).

When I'm with [my partner], because I can protect her. I can love her . . . I can be with her. I can be her escort (Berti).

Although many physical performance indicators were no longer possible, hegemonic masculinity guided the talk and language of gender, and participants demonstrated the contradictory, fluid construction of identity, in which masculinities were reformulated in response to context rather than being fixed, or uniform.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

Generalisability is neither the aim nor claim of this study and the limitations of a small sample size, from which the findings have been drawn, are acknowledged. Furthermore, cohort-specific factors including Anglo-Australian cultures, older age and poor prognosis, as well as the potential effect of a male interviewer in terms of what participants shared, are recognised as contextual factors that influenced the subsequent findings from this study. Nonetheless, the results from this study contribute to a small but intriguing body of research about men's experiences of ADT, and have important implications for clinical practice, the application of hegemonic masculinity in men's health and illness research, and essentialist and social constructionist analyses of sexed/gendered bodies.

In terms of clinical practice, both providers and patients considering the use of ADT should be aware of the diverse experiences that can accompany this treatment. Androgen deprivation therapy is commonly perceived as conservative and non-invasive, which in part relates to the minimally disruptive frequency and mode of administration as well as the negligible post-treatment recovery time. However, as evidenced by the findings from this study, men can be affected in deeply gendered ways, and candid discussion and subsequent time to contemplate all potential treatment side effects should precede commencement of ADT. This is an especially important consideration, given the increasing obscurity of watchful waiting (monitoring prostate cancer without treatment interventions) and preponderance to actively treat prostate cancers regardless of tumour severity or patient age. After ADT was commenced, most participants in this study did not consult providers about treatment side effects and, as a result, it was unclear how healthcare professionals might manage uncertainty in response to men's anxiety about embodied loss. As evidenced by the participant interviews in this study, with permission, men can break with the ideals of stoicism and self-disclose about ordinarily private matters. Explicit encouragement and ongoing opportunities for men to debrief with healthcare professionals could therefore contribute significantly to understandings of men treated with ADT and could ultimately inform the design of interventions best able to meet their needs.

Through this study two theoretical issues are also implicated in the analyses of empirical data using social-constructionist-gender frameworks. First, the characteristics and power discourses of hegemonic masculinity become particularly problematic in the context of older and/or ill men. Connell (1995) suggested hegemonic masculinity symbolised financial and physical freedom, and was most likely filled by white, heterosexual, middle class men. Furthermore, characteristics of hegemonic masculinity, listed by Cheng (1999) amongst others, include sexual and physical prowess, and are synonymous with youth and middle age. As identified by Fleming (1999) and Thompson (1994), little attention has been paid to the masculinities of older men and, as a consequence, there is limited understanding of what is collectively idealised as the hegemonic masculinity of older men. This is a critical consideration because the majority of men in developed countries are in their forties, fifties and sixties and if, as Connell (1995) suggested, many men are complicit in sustaining hegemonic masculinity, the critical masses are middle-aged and older men.

A shared vision of hegemonic masculinity seems theoretically naïve and an appropriate re-positioning may be the plurality of hegemonic masculinities. For example, the peroxide pony-tailed, athletic, affluent David Beckham is conceivably a contemporary exemplar of hegemonic masculinity for many young men. He is successful, powerful and self-reliant; as a player and celebrity he threatens to be bigger than the game of soccer itself. Yet it would also seem entirely reasonable to suggest that older men who have prostate cancer might construct and relate to very different models of hegemonic masculinity. Perhaps the actor Robert De Niro best embodies masculinity for this group of men through his survivorship and prostate cancer activism. Just as the plurality of masculinities has facilitated contextual understandings of gender, so too should the notion of what is culturally idealised by large numbers of older men.

Second, the findings from this study offer rich empirical data to consider further the duality of essentialist and social constructionist frameworks. Participants conceptualised body and mind changes through essentialism, but were reliant on dominant social constructions of masculinity in how they ‘did’ or ‘performed’ gender. Connell's (1987, 1995, 2000) assertion that masculinity refers to male bodies directly, symbolically and indirectly, is congruent with the analytic and social constructionist frames used in the present study. Yet Chapple and Ziebland's (2002) recommendation that the physical body, as well as culture, be explicitly considered when trying to explain what it means to be masculine, and how illness may affect men's sense of masculinity, is entirely appropriate, given the atypical male bodies that occur as a result of ADT. However, the most theoretically sensitive way to integrate biology in non-reductionist terms, as recommended by Williams et al. (2000) and Williams (2003), is to investigate how testosterone, and its absence, is socially constructed.

Utilising Connell's (2000) concept of masculine bodies as arenas, the conduct of everyday life for men who are treated with ADT for prostate cancer is organised in relation to an illness arena, defined by the social structures and processes of human recovery. This arena may include changes to the body aesthetics and functionality, and the search for masculinity, intimacy and sexuality in a body that is simultaneously different and familiar. Therefore, we are not denying the altered state of the body in social constructionist frameworks, but the intent and endeavour is to ascertain how the altered body is reformulated, rejected and/or reconciled in relation to masculine ideals. The exploration of essentialism through social constructionist frameworks is recommended as a meaningful way of examining how the ‘objective facts’ are constructed. This approach will promote thoughtful engagement about how masculinities – inclusive of the intersections between gender, culture, class, age and heterosexual partnerships – are mediated by illness experiences.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References

Thanks to Dr. Maria Pallotta-Chiarolli, Dr. Joan Anderson and Tina Thornton for their feedback and guidance on the earlier drafts of this manuscript. This research and publication has been supported by the Canadian Institute of Health Research (CIHR) Psychosocial Oncology Research Training (PORT) post-doctoral fellowship award. Special thanks to the participants who gave so freely of their time and shared ordinarily private experiences and thoughts.

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  3. Introduction
  4. Methodology
  5. Results and discussion
  6. Conclusion
  7. Acknowledgements
  8. References
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