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Keywords:

  • body image;
  • breast cancer;
  • men;
  • sexuality

Abstract

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

Abstract:  Breast cancer affects a woman’s body image and feelings of sexuality. Little is known about the perceptions of spouses to the sensitive topics of sexuality and body image. A qualitative inquiry was undertaken using in-depth interviews. A diagnosis of breast cancer brought some relationships closer. Mastectomy by disturbing body image did obliterate sexual relationships for a significant period of time. Women often felt (wrongly) that their partner would be repulsed by changes. More support in relation to sexuality and body image could improve relationships by identifying and clarifying perceptions, and therefore the quality of life.

Breast cancer affects a woman’s body image and feelings of sexuality. Sexuality is a deep, pervasive, and integral aspect of the total human personality (1). Encompassing one’s most intimate feelings of individuality, sexuality underlies the complete range of human experience (2). It exists in all interactions and contexts, and relates directly to our well-being and experience of ourselves as sexual beings (3). Thus, it becomes clear that sexuality is not a concept that can be considered in separation from that of health; sexuality is in fact central to a person’s sense of wellness and self-concept. Body image is an integral concept to sexual health. According to Roid and Fitts (4,5), body image is “a mental picture of the “physical self” and includes attitudes and perceptions regarding ones physical appearance, state of health, skills, and sexuality.”

Body image is also strongly influenced by the perceptions of others. Van der Velde (6) together with Fogel and Lauver (1, p. 7), believe that body image is “developed through internal comparisons of self, both with others and with cultural ideals and through real and imagined feedback from others.” Therefore:

when the physical beauty of a woman’s body is jeopardized by disease or disfiguring treatment, the stimulus value of her body both to herself and others, is demeaned; feminine identity and self-concept, to the extent that they are based on her physical attractiveness are thereby threatened with serious insult (7, p. 7).

The experience of a “grievous assault on the patients’ femininity, and her fundamental sense of herself as a woman” (7, p. 12), seriously impacts on concepts of sexuality and body image which are central to challenges and experiences affecting male/female relationships.

Information obtained from the patients of breast cancer and from clinical experiences of health professionals is documented. However, little is known of the perceptions held by spouses relating to the sensitive topics of sexuality and body image, nor the implications of these perceptions on the breast cancer patient and the relationship.

This study explores the spouse’s perceptions of body image and sexuality in relation to breast cancer, and the implications these hold for the relationship. The research aims to further understand the breast cancer experience and needs of the spouse. Firstly, results of detailed literature review are presented, and secondly, research results of a qualitative study on body image and sexuality.

Literature Review

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

A search of Medline databases identified articles central to the themes of the current study, and findings are summarized in Table 1. Key words used during searching included “breast cancer,”“cancer,”“sexuality,”“body image,”“relationship,”“marriage,”“spouse,”“partner,”“husband.” The Table 1 highlights that significant research relates to:

Table 1.   Summary of Relevant Articles
ReferenceMethodFindings
Henson (10)Lit search: This article discusses breast cancer, sexual functioning and various aspects of the cancer experienceUp to 45% of early breast cancer patients had anxiety or depression. These patients felt less attractive, had significant stress concerning hair loss, and many had lost interest in sex Patients who have undergone mastectomy are significantly more likely to have marital problems as compared to those with benign breast cancer Some men may withdraw from making sexual requests in response to their partner’s anxiety, depression and altered body image. Other partners appear to be disturbed by the physical appearance after surgery. These body image distractions can block arousal and excitement in the male partner Most patients felt that their health care providers didn’t discuss sexual issues despite the fact that they should have been addressed
Bakewell and Volker (16)Lit search: This article considers sexuality and the impact of various breast cancer treatmentsAcute side-effects of chemotherapy that may affect a women’s sense of attractiveness include alopecia (hair loss), pallor, weight gain, nausea and vomiting, and fatigue. Chemotherapy may cause vaginal irritation and dyspareunia (painful intercourse) Ovarian failure, premature menopause, lowered libido, and vaginal dryness are all common side-effects The quality of the relationship influences the perception of sexual satisfaction Alterations in body image, sexual dysfunction, fears of recurrence, and mortality increase women’s fear of rejection by a mate
Mock (11)Questionnaire: This study compares body image in women receiving different types of treatment for breast cancerThe findings show significant differences in body image according to type of surgical treatment experienced Women treated with conservative surgery reported greater satisfaction with their bodies then women treated either with mastectomy or immediate reconstruction There were poorer body images in all breast cancer subjects compared to healthy individuals Rehabilitation following treatment for breast cancer should consider disturbances in body image, self-concept, and interpersonal relationships
Anllo (8)Clinical review: This article reviews findings on marital and sexual function among women with breast cancerFor some couples, the cancer diagnosis has a way of bringing pre-existing problems into sharper focus Some women experience a loss of sexual desire and a decreased capacity for orgasm For many women, it is not until after finishing all their treatment that they begin to realize the full impact of their illness Women whose sexual capacity is compromised by breast cancer may fear that they are depriving their partners of sex and that their partner’s secret wish is to abandon them for someone healthy
Schover (12)Lit search: This paper reviews the evidence that localized treatment for breast cancer precipitates sexual and marital problemsA woman’s overall psychological health, relationship satisfaction, and premorbid sexual life appear to be strong predictors of postcancer sexual satisfaction Clinicians should pay more attention to our patients’ complaints of vaginal pain, dryness, and overall loss of sexual desire during systemic treatment Practical advice on love-making techniques and a clinician’s open attitude towards discussing sexual issues can prevent a great deal of anxiety and sadness as women with breast cancer search for ways to keep their sex life satisfying
Ghizzani et al. (9)Semistructured clinical interviews: This study explores the importance of partner reaction to illness and scarring, and other factors affecting sexualityEmotional support from their husbands was one crucial factor that helped patients to remain open to sexuality and romance, even after the occurrence of a potentially deadly illness Husbands’ loving attention was the vehicle to help them overcome their sense of inadequacy and resistance to showing the wounded breast The younger subjects maintained a prolonged state of emotional distress secondary to fear of the illness and to mourning for the affected breast Acceptance of breast scars for the younger women seemed to be extremely difficult and interfered with sexual desire and spontaneity The capacity to integrate the surgical consequences of the illness in the patient’s daily life depended considerably on the couple’s degree of intimacy
Burbie and Polinsky (17)Clinical review: The authors review the common psychosocial problems associated with changes in sexual functioning and intimacyPhase of the Cancer Experience: Pretreatment: Before treatment, sexual desire often decreases because both patient and partner are dealing with concerns about survival Treatment: The effects of cancer treatment include lack of desire, pain, and feeling sexually unattractive because of hair loss, loss of a body part, nausea, and weight loss or gain. Women may experience premature menopause, yeast infections, hot flashes, and vaginal dryness that may interfere with sexual functioning Post-treatment: 50% of women continued to experience sexual difficulties they attributed to the breast cancer, such as feeling less sexually attractive, having difficulty becoming sexually aroused, having difficulty with orgasm and lubrication, and feeling dissatisfied with their level of sexual activity. Psychological difficulties for the patient may involve impaired self-esteem, depression, altered self-image, fears of recurrence, progressive debility, or death
Walsh et al. (13)Questionnaire: This article explores various aspects of a women’s relationship with her partner75% of the women revealed that their relationship with their partner become closer as a result of breast cancer 25% experienced relational strain following diagnosis, resulting form communication avoidance 35% of women wanted to discuss these feelings but portrayed their partner as emotional unavailable and unwilling to discuss such issues 12% of women reported that they separated from their partner or terminated the relationship after being diagnosed with breast cancer. Most of the women specified that their partner initiated the separation or termination and identified reasons why their partner left. These reasons predominantly included the partners inability to cope Although mostly men initiated separation or divorce, a few women took on this role. Reasons women gave for leaving their marriage like relationship included not receiving emotional support from their partner and viewing their diagnosis as an impetus to leave a relationship that was problematic and not meeting their needs 68% of women reported felling self-conscious as a result of surgical treatment, and revealed that this had consequences for their sexual relationship
  • • 
    The experience of breast cancer, and the effect it has on quality of life, sexuality, and body image (8–13).
  • • 
    Breast cancer is intensely distressing for the patient and her family (10,12,14).
  • • 
    Fifty percept of breast cancer patients may experience traumatic stress symptoms relating to their cancer (15) and up to 45% of early breast cancer patients experience anxiety or depression (10).
  • • 
    Many women feel more self-conscious (13), less attractive (10) and have poorer body images than their healthy counterparts (11).
  • • 
    Common side effects include chemotherapy, radiotherapy, mastectomy, and hormone therapy include vaginal irritation and dryness, painful intercourse, lowered libido, hair loss, nausea, vomiting, premature menopause, and significant psychological disturbances (16).
  • • 
    Fifty percent of women have been shown to experience sexual difficulties following breast cancer treatment (17).

Key findings of the literature review are summarized below in Table 1.

Method—Qualitative Enquiry

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

This study explores the spouse’s perceptions of body image and sexuality in relation to breast cancer, and the implications, these hold for the relationship. In-depth interviews (semistructured) considered questions of the breast cancer experience and the impact on feelings of sexuality. An interview line of questioning was developed, which enabled consistent exploration of themes with participants. All interviews were taped with permission and transcribed using thematic coding. Recruitment of participants was through advertisement in a cancer support organization, the Cancer Council, newsletter, and support groups’ promotion. Ethics approval was provided by the University of South Australia and the Cancer Council, South Australia. Four participants were chosen.

Subjects

Participants were chosen to represent a variety of views of breast cancer and sexuality. For example, one participant was the partner of a woman who was diagnosed breast cancer 30 years ago, followed shortly after by a mastectomy. He identified himself as being proactive in seeking information relating to breast cancer during the time of his partner’s illness. He spoke openly about his experience and his perceptions of body image, sexuality and support, and services. His partner also participated in this study. The third participant provided information to those with poor sexual health; she is involved in the prevention, promotion, and education programs relating to sexual health and well being. The fourth participant was a community support person for a cancer council. Thematic analysis was used to identify all data that related to the research classified themes. These themes were then catalogued into related patterns and subthemes. Patterns emerged and are presented as key themes.

Results and Discussion

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

The area under discussion is very personal and sensitive. Key themes found were:

  • • 
    Perceptions of each spouse and breast cancer sufferer may be wrong and confused.
  • • 
    The process of cancer diagnosis and treatment is a journey, which takes time to work through.
  • • 
    No advice was available or acknowledgement that sexual counseling is needed, as services are aimed at much younger people.

These themes will now be considered in depth.

Relationships and Sexuality

Relationships have been shown to experience substantial stress during breast cancer, with reports that 25% of breast cancer patients suffered relational strain, 35% felt their partners to be emotionally unavailable, and 12% reported a separation (13). Although Walsh et al. (13) indicated that separations were mostly initiated by men who were unable to cope with issues relating to their partner’s cancer, the first participant commented to the contrary that the psychological pain experienced by women is a major contributing factor to relationship dissolution.

The partner, the second participant, reflected on her experience and agreed that although it is commonly perceived that male partners are responsible for separations, it may well be that women wrongly perceive their partners to be uninterested and repulsed, and so remove themselves emotionally and sexually.

It appears that breast cancer diagnosis has a way of bringing pre-existing marital problems into the limelight (8). However, for a proportion of patients and their partners, breast cancer has been shown to create a greater sense of closeness in the relationship (13). This was certainly the case for participants 1 and 2, who both believe their relationship is greater, overall, as a result of the experience. Nonetheless, this did not occur without an initial and lasting blow to their sexual relationship. The sexual relationship ceased entirely for at least 12 months, and even 5 years after surgery, sexual activity was not quite the same. The participants commented that a lack of sexual satisfaction may be one reason why men initiate separation.

Some men may withdraw from making sexual requests as a consequence of feeling disturbed by physical appearance after surgery or in response to their partner’s anxiety, depression, and altered body image (10). For participant 1, it was simply about giving his partner time to heal and come to terms with the surgery. He considers that his respect for his partner’s desire for time and space contributed to a strengthening of their relationship. In spite of a decrease in sexual activity, he believes that their sexual relationship actually went through “a healing process,” in relation to breast cancer.

In regards to his ability to cope with changes in the relationship and support his partner, participant 1 acknowledges that not all men may be as understanding and proactive. Indeed, participant 1 may be substantially different from the majority of population of interest, i.e., spouses of breast cancer patients. Researchers have hypothesized that that those who experience greater relational strain and difficulties relating to body image and sexuality, are those spouses who find communication more difficult and therefore those who are unwilling to participate in the present study.

The current research has argued that sexuality is a deep, pervasive, and integral aspect of the total human personality (1), and is in fact central to a person’s sense of wellness and self-concept. Despite its importance, Henson (10) found that healthcare providers simply do not discuss sexuality and related issues. Participant 1 confirmed that:

we weren’t getting told anything that was happening…Like what was going to be the effects of chemotherapy, what was going to happen, how we could help our wives…sexuality, sexuality how that was going to interrupt their sexuality, how it was going to interrupt and stuff up the whole life of our lives too, because it was a rude turn around for us as well.

Participant 3, from a sexual health support service expressed a similar concern and sadness that women who are suffering from breast cancer are simply not counseled in regard to issues relating to sexuality, let alone their partners. During a recent sexual health nurses network night organized by participant 1, a breast cancer patient presented her experience in regard to sexuality stating that no one had talked her through how she was feeling and strategies to move on from how she was feeling, particularly about the mastectomy. It appears that even now, in a time of increasing focus on holistic and primary health care, sexuality issues are often not addressed by health care professionals.

Sexuality encompasses one’s most intimate feelings of individuality (2) and relates directly to our well-being and experience of ourselves as sexual beings (3). For breast cancer patients, the current research has found that the amputation of a breast affects a woman and her sexuality in a profound and lasting way. Participant 2 feels that she has never fully come to terms with the dramatic assault on her body caused by the mastectomy, and this undoubtedly affects her conception of her self as a sexual being. Research has indicated that many patients of breast cancer feel more self conscious (13), less attractive (10) and have poorer body images than their healthy counterparts (11). The results of the current study support these findings.

Summarizing the importance of sexuality, participant 4 said:

Sexuality for people who’ve had cancer, can be a very healing thing. That relationship that you have with your partner, the intimacy, the sensuality …that’s often what people crave…Yes, sexuality is a part of us from life to death.

Sexuality and body image are clearly central to one’s identity, self-concept and relationships, and, all of these aspects are severely compromised during breast cancer. Our society needs to improve our understanding of the experience of breast cancer and the effective ways of providing support; the impact of cancer can be lessened, for the patient and her partner.

Conclusion

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

This research illuminates the fact that breast cancer has significant implications for the patient and her spouse in regard to body image, sexuality and their relationship. In summarizing, the main findings of the current study:

  • • 
    Mastectomy is an amputation, which disturbs body image and obliterates sexual relationships for a significant period of time.
  • • 
    Women find it exceedingly difficult to come to terms with the breast scar, and may wrongly perceive their partners to be repulsed and disturbed by changes in their body.
  • • 
    Despite being an important aspect of the breast cancer experience, sexuality and body image are topics that are not often discussed by healthcare professionals, with the patient or her partner.
  • • 
    Supports have been established by the Cancer Council, but sexuality and body image issues may not be broached, and those services relating to the partners of breast cancer patients are not well utilized.
  • • 
    Breast care nurses may play an important role in discussing sexuality and body image with patient’s and her partner, but lack of time and agencies to refer to, continue to be barriers.
  • • 
    Sexuality, body image and relationship support services are not well established outside of SHine and Relationships Australia, and these particular services may not be appropriate or targeted towards our population of interest.

Conclusions drawn from this study indicate that the following strategies would lead to better outcomes for the sexual health and wellbeing of both those diagnosed with breast cancer, and their partners:

  • • 
    Internet support groups may be a viable method through which to target men’s health issues, and support them in regards to body image and sexuality, further studies need to investigate effective methods through which to target men’s health issues.
  • • 
    Greater exploration of the potential to increase services relating to body image and sexuality for the patient and her partner would be of benefit.
  • • 
    Breast care nurses and healthcare professionals should be helped to be more aware of the impact breast cancer has on sexuality and body image, and be comfortable discussing these issues with the patient and her spouse.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References

Funding from the Cancer Council, South Australia is acknowledged. Timely advice and generous supervision from Dr. Murray Drummond, University of South Australia is acknowledged.

References

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Method—Qualitative Enquiry
  5. Results and Discussion
  6. Conclusion
  7. Acknowledgments
  8. References
  • 1
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  • 2
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    Roid G, Fitts W. Tennessee Self Concept Scale: Revised Manual. Los Angeles, CA: Western Psychological Services, 1998.
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    Pikler V, Wintercrowd C. Racial and body image differences in coping for women diagnosed with breast cancer. Health Psychol 2003;22:6327.
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    Van der Velde CD, Body images of one’s self and of others: developmental and clinical significance. Am J Psychiatry 1985;142:52737.
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    Anllo LM. Sexual life after breast cancer. J Sex Marital Ther 2000;26:2418.
  • 9
    Ghizzani A, Pirtoli L, Bellezza A, Velicogna F. The evaluation of some factors influencing the sexual life of women affected by breast cancer. J Sex Marital Ther 1995;21:5763.
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    Henson H. Breast cancer and sexuality. Sex Disabil 2002;20:4.
  • 11
    Mock V. Body image in women treated for breast cancer. Nurs Res 1993;42:1537.
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    Schover LR. The impact of breast cancer on sexuality, body image, and intimate relationships. CA Cancer J Clin 1991;41:11220.
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    Walsh SR, Manuel JC, Avis NE. The impact of breast cancer on younger women’s relationships with their partner and children. Fam Syst Health 2005;23:8093.
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    Ganz P, Rowland JH, Desmond K, Meyerwitz BE, Wyatt G. Life after breast cancer: understanding women’s health-related quality of life and sexual functioning. J Clin Oncol 1998;16:50114.
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    Butler LD, Koopman C, Classen C, Spiegel D. Traumatic stress, life events, and emotional support in women with metastatic breast cancer: cancer-related traumatic stress symptoms associated with past and current stressors. Health Psychol 1999;18:55560.
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    Bakewell RT, Volker DL. Sexual dysfunction related to treatment of young women with breast cancer. Clin J Oncol Nurs 2005;9:697702.
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