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.