Masculinities and ruptures after penectomy

Abstract

Objective

To analyze masculinity meanings during penile cancer experience and its treatments.

Methods

Qualitative approach supported in the theoretical framework of medical anthropology and masculinities, with the use of the narrative method. We interviewed in-depth 18 men with penile cancer in a referential Urologic Oncology hospital from the state of São Paulo. Each participant was interviewed on average three times, with a structured script, being the interviews audio-recorded, transcribed, and analyzed according to the inductive thematic analysis.

Results

Six patients were submitted to the partial penectomy and 12 to the total penectomy. Regarding the marital status, six were widowers, two single, three divorced, and 11 married, with an average age of 54 years old. The penis extirpation fostered significant change in the way men performed their masculinities, even the hegemonic. Thus, this experience allowed them to reinterpret their health conditions to identify other hegemonic elements that sustained their masculine images. For a few, it was possible to represent a full man however, others considered themselves half-men.

Conclusion

The illness broke the participant’s biographic flow because, before penile cancer, the hegemony represented them as masculines, however, after the penectomy, they have lost an organ that is socially related to attributes such as strength, power, work, and virility, situation that brought them the necessity to reinterpret being masculine in their culture. To promote integrality of care to man the nursing must consider that masculinities interfere in the process of health and disease.

Penile neoplasms; Penis/surgery; Anthropology, medical; Masculinity; Men’s health; Oncology nursing

Resumo

Objetivo

Analisar os significados das masculinidades durante a vivência do câncer peniano e seus tratamentos.

Métodos

Abordagem qualitativa de pesquisa amparada em referencial teórico da antropologia médica e das masculinidades, com o emprego do método narrativo. Foram entrevistados em profundidade 18 homens com neoplasia peniana em um hospital referência em uro-oncologia do estado de São Paulo. Cada participante foi entrevistado com roteiro de investigação, em média três vezes, sendo as entrevistas audiogravadas, transcritas e analisadas conforme a análise temática indutiva.

Resultados

Seis participantes realizaram a penectomia parcial e 12 total. Em relação ao estado civil, participaram dois viúvos, dois solteiros, três divorciados e 11 casados, com média de idade de 54 anos. A extirpação do pênis promoveu mudanças significativas na forma como os homens performavam suas masculinidades, sobretudo a hegemônica. Portanto, essa experiência lhes permitiu reinterpretar suas condições de saúde na tentativa de identificar outros elementos hegemônicos que sustentassem suas imagens masculinas. Para alguns foi possível representar um homem inteiro, porém outros se consideram agora meio-homens.

Conclusão

O adoecimento rompeu com o fluxo biográfico dos participantes, pois antes do câncer peniano a hegemonia os representava como masculinos, entretanto, após a penectomia, eles perdem um órgão que socialmente traz atributos como força, poder, trabalho e virilidade, situação que lhes trouxe a necessidade de reinterpretar o ser masculino em suas culturas. A enfermagem, para promover o cuidado integral ao homem, deve considerar que as masculinidades interferem no processo saúde e doença.

Neoplasias penianas; Pênis/cirurgia; Antropologia médica; Masculinidade; Saúde do homem; Enfermagem oncológica

Resumen

Objetivo

Analizar los significados de las masculinidades durante la vivencia del cáncer de pene y sus tratamientos.

Métodos

Enfoque cualitativo de investigación respaldado en el marco referencial teórico de la antropología médica y de las masculinidades, con el uso del método narrativo. Fueron entrevistados en profundidad 18 hombres con neoplasia de pene en un hospital de referencia en urología oncológica del estado de São Paulo. Cada participante fue entrevistado con guion de investigación, tres veces en promedio. Las entrevistas fueron grabadas, transcriptas y analizadas de acuerdo con el análisis temático inductivo.

Resultados

Seis participantes realizaron penectomía parcial y 12 total. Respecto al estado civil, participaron dos viudos, dos solteros, tres divorciados y 11 casados, con un promedio de edad de 54 años. La extirpación del pene generó cambios significativos en la forma como los hombres practicaban su masculinidad, sobre todo la hegemónica. Por lo tanto, esta experiencia les permitió interpretar sus condiciones de salud en el intento de identificar otros elementos hegemónicos que sostengan su imagen masculina. Para algunos fue posible representar un hombre entero, pero otros ahora se consideran medio hombres.

Conclusión

La enfermedad rompió con el flujo biográfico de los participantes, ya que antes del cáncer de pene, la hegemonía los representaba como masculinos; sin embargo, después de la penectomía, perdieron un órgano que socialmente trae atributos como fuerza, poder, trabajo y virilidad, situación que les produjo la necesidad de reinterpretar el ser masculino en su cultura. Para promover el cuidado integral del hombre, la enfermería debe considerar que las masculinidades interfieren en el proceso salud y enfermedad.

Neoplasias del pene; Pene/cirurgía; Antropología médica; Masculinidad; Salud del hombre

Introduction

Penile cancer represents less than 1% of malignant tumors worldwide. In the epidemiological panorama of distribution of the new cases of this cancer we identified, that in India, in 2008, it represented 3.32% of the total of diagnosed neoplasms; in Africa, in 2013, more than 20%; in Latin America, in 2013, from 10% to 20% of the total. In Brazil, according to the last data published, in 2013, the incidence was estimated at 0.13%.(¹)

The male experience in front of the penile cancer diagnosis exposes the patient to the confrontation of possible penectomy, total or partial. Thus, the relevance of the penis in the male body and the compromise of this organ is discussed by virility. A north American study that established a relationship between male sexual experiences and the self-report of penile length identified that men with higher sexual experience worried more about the penile length, in contrast to the inexperienced. Such difference occurred by the influence of the sexual competence and feat fomented by the sense of masculinity.(²)

In the United Kingdom, in an investigation about the representation of the penis in magazines for the male public, it was identified that men receive information about their masculinities through the social world. There was a highlight to the male representation through the penis, using body medicalization or by discussion of male behavior understood as negative to society, such as in the case of violence.(³)

Considering the male symbology socially imbricated to the penis, researchers, when studying the illness caused by prostate cancer, described a feeling of impotence and a sense of absence of the body control that prevents the development of daily activities, as well as the resistance to the search for health services. We believe that the cause of such resistance is because the medical examination symbolizes the violation of the male identity, once that it makes men vulnerable.(⁴) In this context, the disease and the prostate cancer treatment tends to resemble what happens in the case of penile cancer.

To implement the approximation to the theme “illness caused by penile cancer”, we carried out searches in literature, highlighting that only one research paper was published in the last five years, which focus was on the way that the disease process influenced participants’ personal experience.(⁵) Noticing the gaps about the penile cancer thematic and its repercussions in men’s lives, we questioned: what are the male experiences related to the penile cancer and its treatments? That way, this investigation aimed to analyze the meanings of masculinities during the experience of penile cancer and its treatments.

Methods

This is a qualitative approach, using a theoretical framework for the medical anthropology(⁶) and masculinities.(⁷) We used the narrative method to operationalize the presentation of the results, according to the assumptions of the interpretative paradigm. We structured the text according to the principles of the Consolidated Criteria for Reporting Qualitative Research.(⁸)

For medical anthropology, the culture acknowledges the man as a being aware of his thoughts and practices. Thus, to understand the illness process, it is necessary to interpret how the described contexts affect the subjectivities of the ill person and employ meaning to their experiences.(⁶)

The use of masculinities in this context helped the researchers to interpret how it is to be a man, especially during penile cancer. By mentioning masculinity, we recognize an analytical concept of male social practice as a hegemonic pattern and other multiple configurations(⁷) in which masculinity should be analyzed in the local, regional and global context.(⁹)

This study was carried out in the follow-up clinic for men in treatment for penile cancer of a reference hospital for the treatment of urological cancer in São Paulo state countryside. The established inclusion criteria were: diagnosed with penile cancer, under outpatient follow-up, and over 18 years old. We approached 28 men who attended the pre-established criteria, however, only 18 accepted participating in the research. We presented to them the informed consent form, requesting their signatures for approval and agreement to participate in the research.

For the data collection, we used an instrument to collect sociocultural information, a field diary, and a structured script with the following guiding questions: What do you know about this type of cancer? Why do you have this disease? How is it to deal with the treatments? How is your life now? What do you think about the future? Did your life as a man change? Why?

We investigated the participants in-depth in distinct environments (house, square, bar, ice-cream parlor, tillage, and hospital) according to their solicitation, respecting confidentiality. It is worth pointing out that even though some interviews occurred in public spaces, the researcher and the interviewee kept their distance from people that could hear the conversation and paused the interview when someone approached. Each participant was interviewed on an average three times, in a period of 20 months from June 2015 to January 2017, with digital media audio-recorded. We interrupted data collection when the produced corpus of data attended the proposed objectives. Because there was more than one interview with each participant, the following interview validated the produced data before, once the researcher remade the questions and contested the participant to ratify what was said before.

The analysis and data collection occurred in parallel. We analyzed each interview according to the inductive thematic analysis(¹⁰) through the transcription and familiarization of data. Later, we carried out the codification and recodification of the data and the elaboration of representative themes for the participants’ universe.

We strengthen identified themes through each meeting with the participants and the final themes organized according the structure of the narrative method, which proposes the construction of a narrative text through three steps 1) the life before the studied phenomenon, 2) the plot of the story told; and 3) the interpretation that corresponds to the wise comprehension of narrative history. (¹¹)

For the conduction of this research, the authors used the theoretical and methodological framework adopted and were supervised by a researcher/author with expertise in qualitative methodology and cultural studies.

Considering the involvement of human beings, the ethical care of the researchers, and in compliance to the 466/2012 and 506/2016 resolutions of the National Health Council, the research was submitted and approved by the Research Ethics Committee on Humans from the Ribeirão Preto School of Nursing from the Universidade de São Paulo, #073/2014 and Appreciated Certificate of Ethical Appreciation (ACEA) #07484812.0.0000.5393. We identified the participants with fictitious names when cited in the text.

Results

Among the participants, six patients were submitted to the partial penectomy and twelve to the total penectomy. Regarding the skin color, four self-declared white, ten brown, and four black. Two were widowers, two single, three divorced, and eleven married. The average age was 54 years old. Thirteen had children, and five did not. Thirteen completed middle school, one incomplete, three were illiterate, and one completed high school. Nine were retired, four developed self-employment activities and five mentioned not working, that is, did not have an individual monthly income, being supported by family and friends donations. Amongst the ones who worked, the individual monthly income varied from one to six minimum wages.

The analysis process allowed us to summarize the experiences in the representative theme denominated “Male Liminarities: to be a full man or half-man” as presented in figure 1, and later by the narrative synthesis.

Figure 1
Data analysis process representation

Male Liminarities: to be a full man or half-man

Participants, after the penectomy, searched for other attributes to still identify themselves as men in their social group, even recognizing that there were significant changes in daily life and in the way of expressing their masculinity. In other words, they kept the idea of a full man, although they did not have a penis (in its totality) and the meanings attributed to it.

Before the disease, my social life was very active, but now it has reduced 99,9%. My sexual life weakened a lot, I still have a sexual life, a little, but I have! When I tried sex the first time after the surgery, it was normal. My wife lives a normal and peaceful life, as it was like before or even better. The importance of the sexual relation depends on the partner, it is very difficult to explain. (Field note: considering that most men affected by penile cancer developed professional activities that require physical strength, the disease limited them)

I cannot lift anything, and here in my city, you don’t find a job where you stay still. When I need help, I contact my family. (Field note: after symbolizing about the attribute of work in man’s life, they talk about recreation)

My hobbies are going out to a cafeteria, a bar, a barbecue party and drinking a beer for fun. On Saturdays I like to go fishing, I spend the entire day there with my wife. (Field note: Following, they symbolize the resignification of masculinities)

Being man for me is being able to do everything. And you need to have responsibility, to be a hard worker, to have your name clean, to have character, no legal actions against you, no jail, these things. You don’t need to have a penis to be a man, there are a lot of women that are more man than others. (Heraldo, Bruno, Célio, Alessandro, Ítalo, Marcelo, Davi, Fabrício, Gabriel e Luiz)

For other participants, the penis removal and the consequences of the treatment promoted limitations that lead them to rethink their masculinities once they understand that their new life experiences do not sustain the male being, constructed and present in their social groups. Thus, they feel fewer men than the rest. It is created, then, the idea of half-man.

The first person I told was my wife. After telling my family, I told my friends. Neighbors do not need to know your intimacies. (Field note: A few men revealed being afraid of talking about the disease)

I thought people would ignore me, not be friends anymore for thinking that it’s a contagious disease. A funny person could joke about it saying there is the dickless man or a man that is not a man. Someone already told me that I almost turned into a woman. (Field note: the visibility of penile cancer is motive of comparison to the feminine)

It is visible when the man does the surgery. If a woman does this kind of surgery (referring to uterine cancer) it is invisible because the uterus removal is internal, so she does not feel much. (Field note: They proceed to talk about their sexuality after the treatment)

After the surgery, I took a year, nine, or ten months to keep a sexual relationship. I thought that this would end up in divorce. (Field note: Men create confrontation strategies to deal with their new condition)

I do not attend public places that show my body, like toilets, swimming pools, etc. It was complicated to talk about this with my first partner. I brought her home, and after one hour, I had to say it to her. I was very ashamed, but she was already there and liking it, so we kept going. The region where my penis was is sensitive, so when the girl stimulates it there is this liquid, and I feel pleasure, but it is not like before. I can still do some hand job (masturbation) because there is a little part that still gets hard. It was difficult, I had professional help, psychologists, doctors, and nurses that attended me that started cheering me up for that. (Ailton, Alex, Carlos, Geraldo, Haroldo, Milton, Pedro e Ricardo)

Discussion

In the participants’ narratives, they express their impressions about this new way of being, but the conceptions about the man they were before penile cancer, that they understand as normal, they underlie. The body before the illness provided pleasure, connected to a culture that this man had as appropriate to his male stereotype, thus, he was dominant and pursued his power at the workplace, in the sexual relations, in the role of provider of the family, in the financial independence and the control of the functions of his body.

In some western cultures, the man is socially seen as strong, sovereign, virile, and not feminine. In this perspective, there is a hegemonic masculinity considered a pattern, in which is expected the incorporation of moral behavior that society credits to its male stereotype.(¹²) Researchers highlight that masculinity is a status that must be constantly demonstrated and validated in cultural relationships, proving the masculine being as a valuable reputation. (¹³)

Based on the conceptions of hegemonic masculinities, participants of the study symbolized in their narratives the implications and conflicts triggered through penectomy, damaging their social, affective, work relations, and recreation. In this discussion, the concept of normality stands out, connected to hegemonic masculinity recognized before the sickness as normal, ideal to be followed.

For the culture, the concept of normality is related to the shared beliefs in a group. To exist a hegemonic masculinity, one must follow symbolic norms that society values in identity relations for a man. Sometimes these patients develop strategies to resignify their daily life as they carry out activities, seeking the maintenance and the return of normality imposed before.(¹⁴)

A study about men with severe hemophilia described that they lived stigma given that they were incapable of living according to masculinity ideals because their condition prevents them from achieving social expectations deposited in men. To minimize this impact, strategies of management may be applied to neutralize the stigma imposed and allow them to distance themselves from the illness. (¹⁵)

The illness process took them from normal to pathological, not only the body but what is deviating from the hegemonic because it led them to experiences of passivity, affectivity, dependency, depression (in some cases), and fragility. The power that they pursued of themselves and others today is a moral factor that imprisons them for not feeling free anymore to express their masculinity, constituting a new identity: the half-man.

The men of this investigation went from healthy to sick, and after the treatment, they have changed again, now they have difficulties performing as hegemonic. These changes may cause negative emotions in men given the concern with the male reputation in front of society and makes them more resistant to changes to stop following as much as possible its norms.(¹⁶)

A few participants of this study recognize themselves as half-men. They are survivors that were able to circumvent the death associated with people with cancer, however with some sequels. Cancer removed the male hegemony, their bodies and actions do not allow them to identify as full men. There was a rupture in the identity and an addition to new elements (isolation, absence of the penis, limited sexuality, work absence) that shaped them as half-men.

In the anthropological perspective, each rupture corresponds to a frontier that they exceed, consequently, the experienced flux expands itself with the arrival of new cultural and social elements that will influence their daily life.(¹⁷) Thus, men that follow cultural hegemonic patterns present a flux that identifies their masculinity through their actions. But, with the penectomy, this flux is broken and transcends the social frontier that will require man the appropriation with new elements of masculinity that, minimally, keep him in the male social status.

Diseases whose trajectory is lengthy, in the case of HIV/aids and cancer, tend to promote biographic ruptures in the patient’s life, and to each rupture, new experiences are added to their flux of life. In a research carried out with HIV-diagnosed young patients, it was observed that the moment of biographic rupture promoted three attitudes: the search for elements of their story, the confrontation of the current reality, and the perspective for the future.(¹⁸) Each mentioned attribute occurred so that the patient could handle elements to deal with the illness.

For men, the penis socially represents a symbolic status of masculinity and dominant identity. Without these attributes, it is like declaring yourself a deserter of this culture and conforming yourself to social judgment. As evidenced in the narratives, many penectomized men searched for confrontation strategies, isolating themselves or declaring that they are normal or that they can perform sexual practices. However, with this insertion in-depth, we noticed that these dialogues are paradoxical, defense strategies to feed the hegemony.

A study conducted in Australia with individuals in reconstruction and recovery of their narrative identity and their mental health explained that all participants searched for self-control for their disease that varied according to each life’s story. When analyzing the situation, according to the complex adaptive system theory, it was determined that it was only possible because of the adaptive capacity for building a new narrative identity.(¹⁹) In the investigated context, we detected a period in which the patient lives the disease because, according to the age and diagnosis, the renegotiation with the male identity changes.(²⁰)

We emphasize among the narratives of this study that the penectomized man searches for components that legitimate the hegemony status, even when there are no elements that ratify his male identities, such as the penis and its representations. The participants narrated feeling more vulnerable after the penectomy, once that now they present difficulty in maintaining their social and sexual relations. When they approach the social environment, there is a risk of exposure of what they consider confidential (the penectomy), therefore, it is not enough that men recognize themselves as male society must do it too.

Men’s experience with penile cancer was ruled by various interpretive concepts that help sustain the meaning of the experience as the agency of the normal after the penectomy. They used strategy confrontation to deal with the moral barriers imposed in surviving. We may affirm that, in the local masculinities’ context, the penis is an organ that symbolizes and regulates the male hegemonic experiences of their stereotype. In its absence, it is only supportable by the feeling of being in control of the hegemony again. Thus, men live in a context with limitations and their management takes them to the maintenance of the experience of living as a half-man.

This study’s limitations are related to the context of the identified masculinities, a situation justified by the regional coverage of the investigated group. However, although the data show, mostly, regional masculinity representation, there are elements that represent the way men can perform their global masculinity, such as the search for attributes that ratify their social hegemony.

The nursing must appropriate itself of that knowledge to comprehend that, to men, the process of illness and the product of this experience is constructed through the ruptures of their lives and, consequently, the adaptations to these new realities are painful because it involves the way they see themselves masculines in society. Thus, to handle the male subjectivities incorporated into the health-disease process is to provide integral care in nursing and health.

Conclusion

In this study, we reached the proposed objective because we identified that the disease interrupted participants’ biographic flow. Before penile cancer, the men performed their masculinities confident that the hegemony represented them. After the sickness and the penectomy, they have lost social attributes of power such as work, physical strength, and virility. In the attempt to recover their hegemonic discourses, they listed elements that maintain them in the status of male dominance, comparing themselves to the non-penectomized men.

Acknowledgements

This research was supported with grants by the São Paulo Research Foundation (FAPESP) protocol #2013/14891-4.

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Edited by

Associate Editor (Peer review process): Camila Takao Lopes. (https://orcid.org/0000-0002-6243-6497). Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Publication Dates

• Publication in this collection
  11 Mar 2022
• Date of issue
  2022

History

• Received
  24 Oct 2020
• Accepted
  26 May 2021