Prostate Cancer and the Emotionology of Masculinity: Joking,Intellectualization,and the Reconstruction of Gender

Abstract

This article builds on data gathered through focus group interviews with Swedish men treated for prostate cancer. First, we aim to analyse how the participants talk about and handle sensitive issues and common side effects. Second, we investigate how the participants’ feelings about their disease affect or interfere with their understanding of masculinity. The findings illustrate how participants partly break with historical expectations of men as emotionally inexpressive. Instead, in the groups they talk openly about incontinence, erectile dysfunction, and other sensitive issues. At the same time, these discussions can be positioned within certain discursive coping strategies. Using jokes and intellectualizing their health narratives, combined with a problematization and partial redefinition of gender and masculinity, most of the men adapt to their new life situation. The men’s ways of handling their emotions can be situated in the interface between discursive and gendered emotion ideologies, and lived experiences of masculinity.

Prostate cancer is one of the most common forms of cancer affecting men, especially with advancing age. Globally, it has an estimated incidence of 1.3 million and a mortality rate of 359,000 per year (Khazaei et al., 2019). Usually, it is treated with radical prostatectomy, radiation therapy, or hormone therapy, or a combination of these. Prostate-cancer-specific mortality is very low, which is why scholars have paid significant attention to mapping and understanding the adverse effects of prostate cancer treatment (Nolsøe et al., 2021). Indeed, the treatment of prostate cancer is merely the start of a long recovery and rehabilitation process, in which patients face side-effects such as erectile dysfunction, urinary incontinence, bowel dysfunction, arousal incontinence, ejaculatory disturbances, and lack of libido (Frey et al., 2014; Salonia et al., 2017).

The physiological and medical side-effects of prostate cancer treatment may profoundly interfere with the man’s social life, sex life, and mental health (Brüggemann, 2021; Oliffe, 2005; 2009; Tsang et al., 2019), and bring challenges when it comes to coming to terms with one’s identity as a man (Bowie et al., 2022; O’Dowd, 2001). Thus, bodily dysfunctions following treatment for prostate cancer have direct or indirect consequences on how men “do” gender/masculinity, and on their sexual health (Alexis & Worsley, 2018; Oliffe, 2005; 2009; Tsang et al., 2019). This has been addressed in wide variety of studies in which the disease and its impact on masculinity has been debated in relation to for example ethnicity, sexuality, national context, age and more (Bowie et al., 2022; Brüggemann, 2021; Frey et al., 2014; Maliski et al., 2008; Muermann & Wassersug, 2022; Wentzell, 2014).

In a wide variety of contexts, such as work, sport, and sickness, masculinity has been linked to an instrumental approach to the body (Haywood et al., 2017; Mosse, 1999). In Rediscovering Masculinity, Seidler (2004), argues that historically men have learned to treat emotions as signs of weakness and that it is therefore difficult for men to come to terms with their emotional lives and relationships, as it threatens their sense of masculinity. Psychological and physical well-being, emotional sensitivity, and sexual health have consequently not been prioritized or seen as key characteristics of masculinity (Hyde et al., 2021). Instead, cultural ideals of masculinity have tended to “push”, or guide, men into risky patterns of neglect (Narasimhan et al., 2021). It is therefore not surprising that the influence of gendered patterns and normative masculinity configurations may have detrimental effects on men’s health, well-being, and general quality of life (Muermann & Wassersug, 2022).

The current article builds on a qualitative approach to the research. Focus group interviews were conducted with 19 Swedish men who had been treated for prostate cancer (surgical treatment, radiation therapy, hormone therapy, or a combination thereof), special attention being paid to how in the group they talked about how they handled the post-treatment effects on the body and on their sense of self-identity. Moreover, the aim of the study is twofold. First, we analyse how, within the group, participants talked about and handled sensitive issues and common side-effects (incontinence, erectile dysfunction, etc.) of treatment. Second, we investigate how the participants’ feelings about their disease affect or interfere with their understanding of masculinity. Whereas previous research relied largely on data gathered through semi-structured or open interviews (Bowie et al., 2022), this study contributes to scholarly debate through its focus on how a group (per se) of men interacted with one another, and how their interactions can be analysed (cf. Oliffe et al., 2009).

The article is structured as follows: The following section provides a brief overview of relevant research on the gendered dimensions of prostate cancer, men, and emotions. It is then followed by a section describing the theoretical framework of the article, which draws on critical studies of men and masculinity, combined with concepts found in the sociology of emotions. The next section, on method and methodology, considers the sampling process, the benefits of using focus group interview material, and data analysis. That section is followed by a section on findings, which is divided into subsections in which the data is presented and analysed. Finally, the aims of the study is met in a theoretically informed and concluding discussion.

Background and Literature

Generally, ageing, particularly men’s ageing, has not been addressed as an embodied process (Gillearde & Higgs, 2014). Monaghan and Robertson (2012) argue instead that “…men and masculinities have largely been ‘ignored’ in social scientific and feminist studies of ‘intimacy, the emotions and heterosexuality’” (p. 146; see also Robertson & Monaghan, 2012). However, in recent decades, scholars have shown an increased interest in this field, studying challenges to and opportunities for men’s embodiment and their health promotion (Gillearde & Higgs, 2014; Oliffe, 2006; Ussher et al., 2017).

Influenced by feminist and other critical perspectives, the dominant position in sociological literature has been to debate men’s emotional lives in terms of inexpressiveness, that relates to both health and patriarchal privilege (de Boise & Hearn, 2017). Sharp et al. (2022), for example, conducted focus group interviews with men on their perceptions of mental health and preferences as regards the promotion of their own mental health. The study showed that participants shared an understanding of different barriers to mental health promotion, which were connected to their limited emotionality and emotional awareness. In addition, the men felt that by openly acknowledging their mental health problems they would run the risk of incurring negative judgement. The authors conclude that “Accordingly, the effectiveness of potential remedies is deeply reliant on knowing, engaging, and working with – as well as reworking – some masculine ideals about how men engage in mental health promotion in specific locations” (Sharp et al., 2022, p. 15). Similarly, Hoyt et al. (2013) focused on how aspects of masculinity are related to poorer physical and psychological outcomes in men with cancer (see also Corboy et al., 2019). The results indicate that when the side-effects of the treatment threatened the men’s gendered self-identity, they also lost their ability to use emotion-regulating coping processes. Addressing men’s self-image might then be crucial to engendering a more adequate regulation and understanding of emotional processes.

The fact that gender norms play a significant role in men’s understanding of side-effects, such as erectile dysfunction and lack of libido has also been acknowledged by others (Alexis & Worsley, 2018; Muermann & Wassersug, 2022; Oliffe, 2005; Oliffe et al., 2009; Sharp et al., 2022; Tsang et al., 2019). Wentzell (2014), for example, suggests that the treatment of erectile dysfunction is more successful among those who collaborated with their partners and adopted biological understandings of their “problems”, whereas those who expressed negative feelings about their performance and their masculine identity, also had too high expectations of the pharmaceutical treatment, and their aim of restoring their masculinity often failed. In a wider perspective men’s (in)ability to talk about experiences of vulnerability, grief, and loss has also been connected to their underreporting of depression and other mental health issues (McNess, 2008). There are also several meta-reviews on these issues. In systematic review Bowie et al. (2022) for example conducted a thematic meta-synthesis of qualitative studies paying an interest in men’s experiences with body image, self-esteem and masculinity, whilst living with prostate cancer. This study show how prostate cancer and its treatment has an important effect on men’s health, and that questions concerning masculinity is vital when considering coping mechanisms (see also, Alexis & Worsley, 2018; Frey et al., 2014; Muermann & Wassersug, 2022).

Though the idea of men being emotionally inexpressive is certainly present in the literature, such descriptions have been challenged by perspectives suggesting that many men now practise “softer” or “more emotional” forms of masculinity, demonstrating private experiences in care, parenting and partner relationships to mention a few (de Boise & Hearn, 2017; Hooks, 2004). It has also been suggested that emotions always influence social action, though this has not been fully incorporated in scholarly debate on men and men’s emotions and behaviour (Reeser & Gottzén, 2018). Pease (2012) has suggested that social scientists aiming to understand emotions have sometimes taken the somewhat “easy way out”, by suggesting that men tend to repress their emotions, rather than actually exploring how men understand their emotions (socially and discursively), and how this connects to different gender norms. As suggested by de Boise and Hearn (2017), however, a growing body of literature acknowledges that men have an active understanding of their emotional lives, and that more emotional forms of masculinity are practised (Galasinski, 2004; Holmes, 2015; Reeser & Gottzén, 2018; Roberts, 2013). The present article aims to contribute to this literature, zooming in on how side-effects and bodily issues are discussed within a group of men treated for prostate cancer.

Conceptual Framework

The potential threats to masculine self-identity stemming from cancer, its treatment, and the ensuing emotional impact, redefine to a certain extent how men think, act, and handle issues involving the body, sexuality, and intimacy (Kampf, 2013). Though men do not necessarily reduce their self-identity to sexual functions, research on prostate cancer have paid a great interest in sexuality and lost sexual functions (Bowie et al., 2022; Tsang et al., 2019). However, it is also important to go beyond this connection between masculinity and sexuality, and to situate this research in relation to how men deal with uncertainty, the emotional and physical turbulence of the disease and its treatment, and the existential questions brought forward in critical moments in life. According to Robertson;

The process of (male) identity formation, then, is not just something achieved by individuals in isolation, it is not simply intrapsychic, occurring and being sustained within the confines of one’s mind. Rather it is intersubjective, formed, and re-formed through interactions in everyday life, through the movement of real bodies in real space, yet also influenced by normative bodily representations. (Robertson, 2007, p. 83)

Theorizing embodied masculinity, gender norms, and the enactment of masculinity in everyday life, we draw on scholarship that engages with Connell’s (2020) concept of hegemonic masculinity (HM). According to Connell, men (and their emotional lives) are linked to each other in a hierarchic way, whereby some bodies and emotions are more valued, and more normative, than other bodies and emotions. Accordingly, men’s different subject positions are structured hierarchically, and dominated by what Connell calls HM. There is of course an extensive literature on Connell’s theory, and it’s applications to men’s health, in general, and prostate cancer, specifically (Brüggemann, 2021; Connell & Messerschmidt, 2005; Johansson & Ottemo, 2015). HM is also filled with different cultural appropriations and descriptions of masculinity. For example, in certain versions HM turns into a more classical, restrained, disciplined, and emotionally disconnected masculinity, and in other versions men can be described as both disciplined and caring, and emotionally present (Haywood et al., 2017). Though there is a variability in terms of how masculinity is understood and enacted; in a broader perspective, however, it is usually approached as an experience that is performed or done through practices and that refers to other men, emotions and bodies (Hearn, 2004; Kimmel, 2008; Reeser & Gottzén, 2018; Robertson, 2007).

In line with this, in the present article we will investigate the emotional terrain of men treated for prostate cancer against the backdrop of the idea of the complexity inherent in hegemonic masculinities. We will, however, not focus on different ways of doing masculinity per se, but rather try to capture, analytically and empirically, the emotionology of different expressions of embodied masculinity as it is discussed in a group of men and in relation to thoughts about ageing, sexual dysfunction, incontinence, and more. Consequently, in the article, emotions and masculinity are approached in a sociological and intersubjective sense.

In order to do this we will also use the ideas and theories of Hochschild (2012), who argues that there are certain expectations as to how a person should feel in certain social situations. This is conceptualized as emotion ideologies. These emotion ideologies operate then through different feeling rules, which dictate the appropriate, or expected intensity and direction of different emotions, displayed in a particular situation or life predicament (cf. Seidler, 1997; 2006). What Hochschild suggests is that men, like women, navigate or regulate their emotions through such rules or strategies. Often this manifests itself when there is a discrepancy between felt emotions and the gendered cultural expectations/ideologies of emotions, or when there are disjunctions between performance and culturally learned expectations (de Boise & Hearn, 2017; Wetherell, 2012).

Method and Research Design

This study is part of a larger umbrella project in which different aspects of prostate cancer, masculinity and health have been analysed using a qualitative approach to the research. In this overarching project, consisting of different work packages, we have conducted individual interviews with healthcare professionals (urologists, a sexologist, nurses), and with men treated for prostate cancer and their partners (Andreasson & Johansson, 2022). In this study, however, focus group interviews with men treated for prostate cancer were conducted. The use of focus group interviews has also been shown to be a successful method for studying how different groups relate to well-delimited questions/problems (Krueger, 2014; Morgan & Krueger, 1998).

Regarding sampling, access to participants was facilitated mainly by one of the project members (Danemalm-Jägervall) who is a sex and relationship counsellor and a urology nurse at a hospital in southern Sweden. Through her contacts with patients a total of 19 men divided into four focus groups (4–5 in each) participated (Campbell et al., 2020). Some of these had previously been interviewed within the umbrella project (n = 9). During recruitment, all participants were given an information sheet that included a description of the project, notice that participation was voluntary, and assurance that potential participation would not influence their care in any way. The participants were all heterosexually identified and in the age range 51–78 (median = 69). Most had undergone surgical treatment (n = 15), but there were also men who had undergone radiation and hormone therapy (n = 1), surgery and radiation (n = 1) and surgery and hormone therapy (n = 2). Some of the men had just recently been treated for prostate cancer, whereas others had been treated approximately 10 years ago. Three of the men were single and the rest were in a relationship/marriage. In the sampling we sought to ensure variation among the participants (age, form of treatment, side-effects etc.). This was done with the intent to ensure that the data gathered could meet our aims in a nuanced manner. Except for three participants that had previously met through their engagement in a patient organisation, participants did not know each other before the study.

Before the focus group interviews were conducted, all of the participants were informed about the methodological procedure. We explained that an open conversation within the group was sought, rather than a situation in which the researchers asked specific questions that the men would be expected to answer. Inspired by the work of Haug (1999), the researchers opened conversations using certain conversational “triggers”. These triggers could vary between the groups, but usually they concerned things/memories/events that could generate emotional responses in relation to the disease. For example, the participants could be asked to complete comments such as: “When I got my diagnosis, I felt…”; “My condition and the side-effects of prostate cancer have impacted my relationship and intimate life in the following ways…”; or “When I think about my body after treatment I think or feel…”.

After the triggers were given, the men were instructed to discuss and reflect on the triggers within the group. The purpose of this procedure was to capture embodied experiences and emotions (Brown et al., 2011). When the group felt that one trigger had been thoroughly reflected on, a new one was presented by one of the researchers, who acted as moderator in the conversations. The focus group interviews, which were approximately 2 hours in length, were conducted in a conference room at a hotel. They were preceded by an initial brief mingle session over tea and coffee, to allow the men and the researchers to chat and get to know one another, and after the interviews were finished, all of the participants were invited to enjoy a meal together. These measures were seen as conducive to establishing relationships of trust within the group (Fangen, 2005). As one participant commented, “meeting you guys who share similar experiences, instead of being alone with one’s worries, has been fantastic”. The focus group interviews were recorded and transcribed verbatim.

In the data analysis, we initially read the transcriptions several times to familiarize ourselves with the data, which was then sorted and coded. The analyses were conducted in a dialectical process moving between data, previous research, and central theoretical concepts; based on this process, the data were then sorted into themes. Paying an interest in prostate cancer patients’ ways of expressing emotions in relation to side-effects of the treatment, the participants ways of using humour, intellectualising the disease, and redefining masculinity emerged as recurrent thematic responses. In line with Braun and Clarke (2006), our analysis could be described as a theoretically informed thematic analysis. This means that themes related to our theoretical interest in the area (see previous section) were generated early in the process. The analysis was thus theoretically informed and driven, rather than approached completely inductively. As suggested by Braun and Clarke (2006), writing was initiated early on in the process, with the “jotting down of ideas and potential coding schemes, and [it should] continue right through the entire coding/analysis process”, and is thus seen as an “integral part of the analysis, rather than something that takes place at the end, as it does with statistical analyses” (Braun & Clarke, 2006, p. 84). Therefore, themes were gradually refined through the dialectical process of moving between reading and writing the data and applying the theoretical tools.

All names, places, or other potentially personal identifying details were pseudonymized in the data analysis process. Contact details, audio files, and transcriptions of interviews have been kept on an external hard drive that was stored in a locked safe after processing. Formal ethical approval to carry out the study was granted by the Swedish Ethical Review Authority (Ref. No. 2021–01,955).

Findings

In our presentation of the findings, the focus groups, rather than the individuals in the groups, are seen as our main object of study. This section has been divided into three thematic subsections. In the first and second sections we illustrate how humour and intellectualism are used among the men as emotional responses to embodied side-effects. Such responses may be seen as strategies of distancing, thus fitting into the discursive narrative of men as emotionally inexpressive (Sharp et al., 2022). At the same time, we will illustrate that such emotional responses also are submerged or situated within conversations, in which lived embodied side-effects and emotional responses are at the heart of the discussions. There is a reflexivity, a negotiating approach, in the conversations. This is further developed in the third subsection in which the men talk about how the disease and its treatment have impacted their sense of manhood and masculinity.

Coping with Cancer and having a Laugh

Due to narrowly defined gender configurations, in the literature we often find an image of men as silent – as having difficulty addressing and talking about distress, sickness, and weakness (Andreasson & Johansson, 2022). Such imagery, however, does not correspond to the discussions that took place in the focus group interviews conducted for this study. Quite the contrary: in the interviews, the men openly addressed sensitive, and personal issues concerning both bodily dysfunction (incontinence, erectile dysfunction), and psychological effects (depression, sense of being mutilated), even though they had just met. The following excerpt exemplifies this, as after introducing himself to the group one of the participants almost immediately starts to talk about the side-effects he experienced following treatment, here in the form of incontinence:

Catheters, yes. And the first week, I was standing when peeing, anyway, really, it was like [he makes a sound], it was like a tap being turned on. And then you get a bit confused, you don’t know what to do. “Does it have to be like this?” you wonder. But then it just gets better and better. And then I went back to my job after two weeks, and I used a small diaper. I started working after a month, and then I brought the diapers with me [laughs] to work. They really laughed themselves to death at my work [laughing]. (Karl, focus group 3)

While in the groups the men tend to describe the side-effects of the treatment openly and in detail, however, there is also a certain degree of distance. In agreement with Seidler (1997; 2006), we find a tendency to use specific discursive strategies when addressing sensitive issues. One recurring emotional response to the leaking body, as in the above quotation, was to first describe and talk about the predicaments of the body, and then to joke about the experienced awkwardness of it, signalling some degree of emotional distance and control. Below we find another example of this.

Interviewer: Like if you’re dating, when should you tell the woman about your condition? Maybe not on the first date, but maybe on the second?

Olof: Or do you tell her on the first date, to save time?

Erik: “Hello, my name is Nisse, and I am peeing on myself.” [laughing] (focus group 2)

In the discussions the men affirm that everyday life is troublesome and demands considerable planning of how to handle potential problems. Indeed, they talk a great deal about their “leaking bodies”. They also address sexual dysfunction, as below.

Roger: Well, it’s the sexual thing, getting a hard-on, and this has become a problem, you could say, but ... and I’ve tried some Viagra products, but I don’t know. They say it takes effect gradually. It’s been six and a half months now, so it can get better, but I had hoped I’d be on track again sooner than this. But it’s not like that, is it? But I don’t know, and this thing about injecting it into your cock. Well, I tried it once. Damn, I didn’t like it. I mean, it stings and stuff like that.

Ragnar: It’s like the nurse says, that you’re going to get a magnificent hard-on [laughs]. But it hurts so much, it’s like “Don’t touch me, or I’ll die!” (focus group 1)

Echoing previous research (Brüggemann, 2021; Hoyt et al., 2013; Oliffe, 2005), the men openly debate and discuss the side-effects and the emotional distress that prostate cancer treatment may cause. Using sarcasm and humour, however, the men try to handle and cope with the inadequacy of the body and adapt to their new life situation. Interwoven in the narratives is the admittedly dysfunctional and ageing body (Gillearde & Higgs, 2014; Wentzell, 2014). The joking and laughing in the group may, of course, be understood as a strategy to create emotional distancing, and as part of masculine-connoted culture (Cohen & Taylor, 1993; Oliffe et al., 2009), as if the group is adapting to the gendered emotional ideology or narrative of the stoic man in control, and who (if losing control) can at least laugh about the situation. Such an interpretation fails to capture the complexity of the social dynamic in the groups, however. What is illustrated is rather how the men openly talk about their leaking bodies, their sexual inabilities, their sense of being mutilated, at the same time – when sharing their own and the others’ experiences – filtering these experiences discursively through the notion of the joke. Emotions are given a direction and to some extent there are expectations on how they are to be displayed within the group (cf. Hochschild, 2012). The emotionology of the laugh is anything but distant; it is ever-present – it is embodied, and expressed inter-subjectively, in social responsivity. Jokes become a way of navigating and regulating emotions as well as notions of ageing masculinities (Holmes, 2015; Robertson, 2007). This is not to be seen as inexpressiveness, but rather as a way of opening up the social situation and creating a space in which those who find themselves in similar life situations, experiencing similar side-effects from their cancer treatment, can discuss sensitive issues (see also Pease, 2012).

Intellectualized Health Narratives of Cancer

Whereas joking can be seen as one emotional response to prostate cancer treatment (Oliffe et al., 2009), another strategy that the participants use when addressing their predicaments, is to intellectualize their narratives of the disease. Intellectualizing cancer manifests itself in different ways in the narratives, but it is primarily exemplified in the ways in which the participants tend go into detail about their medical situation and prostate cancer trajectory. Below is an illustrative example of this when Bertil presents himself at the beginning of the interview.

I’ve worked here in this town for many years, the family is here... yeah, we’re separated now, but I have three children who live here, have good contact with them and all that. Yeah, and in 2006, in the fall, I took a test, started when I was about 55 years old. I took a test every year, because I wanted to stay a little ahead of this damn disease. And the sixth year there, my PSA was 6.8 – that was in 2006, in the fall. And I thought it went quick, with taking a biopsy and stuff. So, January 15th, 2007, I had a total prostatectomy. Yes, the operation went well, but the cancer came back. Shit! After a year, I had 36 radiation therapy sessions, I think it was. Then it continued. After 5 years it came back again and we continued with hormones – the injections that I still use to this day, that is, every 3 months, after the implant there, in the abdomen there. But I feel pretty good, or I feel fine. And there are other little ailments here and there, but this thing with the oestrogen has... well, now I’ve had it since 2012, so it.... I can do it now and.... I’ll get some cramps, I still get them, yes. (Bertil, focus group 4)

When Bertil introduces himself to the group he goes into detail about his physical condition and the process of being treated for prostate cancer. Following this logic, the men often talk a great deal about their medical situation, and their self-presentation becomes intertwined with a medical discourse (see also Xu et al., 2011). One thing that the men talk extensively about is their Prostate-Specific Antigen (PSA) tests. In the discussions the men tend to return to their own values (before treatment and after treatment), and different so-called threshold values, as defined by the medical profession. In fact, many of the men mention their PSA value when introducing themselves, though not necessarily if they have children or grandchildren. PSA is clearly seen as an important part of understanding the disease. In one of the focus groups (1), two men start to compare their values and their age at diagnosis. Having established this, they then go on to discuss what the numbers suggest in terms of severity, if the cancer has spread, and how soon they got their treatment. This way of filtering the discussion through the medical gaze is a way of intellectualizing and narrate the disease.

At the same time, the men are not trying to act according to what is expected by the medical professionals. They also address their emotional response to their medical predicament in detail. In another interview, similar to the participants quoted above, one of the participants, Jonas, described his medical condition to the group, only to continue to talk about his emotional state after being diagnosed. He said:

It’s clear that I was really down, quite a lot, and I sometimes still am or feel that I am, so that ... I lose energy and disappear a little. It feels as if I have no energy. And then I get angry with myself. I can’t mow the lawn or anything like that. (Jonas, focus group 2)

The conversation between the men proceeds and they talk about their side-effects and how they have impacted their lives. Jonas becomes increasingly upset and breaks into tears. Several of the other men offer their support, they acknowledge his experience of not being able to engage in family life, to take responsibility in the garden, and perhaps to be the man he wants to be by saying “I´m sorry to hear this” and “that sounds tough” (cf. Johansson & Andreasson, 2017). The emotional and physical challenges of the disease and its treatment are shared within the group. Private experiences and emotions such as fatigue, anger, and sadness are discussed, acknowledged, and empathized within the group, bringing forward an emotional expressive masculinity (de Boise & Hearn, 2017; Hooks, 2004). As the discussions continue, the emotional responses are also narratively embedded in a medical domain, thus becoming intellectualized, again. How this can sound is exemplified below:

So, then I had surgery, and yes, you know, you wake up there and feel like shit, and think everything is stupid, but so far, my PSA values have been below 0.1 and that’s... it’s good, and I have hope ... and I’m functioning. I mean, you’re 69, you’re not 17; you don't have a hard-on for 14 days when you bike past a clothesline with a bra on. I mean, it’s not like that, so you have to be happy with what you’ve got. (Erik, focus group 2)

The recovery process, hopefully leading “back” to a functional sex life, is repeatedly discussed in terms of disappointment and challenges among the men, sometimes also described as part of an expected ageing process (see also Hoyt et al., 2013; Hyde et al., 2021). Although, as a group, they validate each other in the emotional turbulence they have experienced, they also tend to joke about it, or turn to particularities of the disease and its treatment. Technical procedures, details of nerve-sparing radical prostatectomy, the numbers of nerves on different sides of the prostate, numbers of radiation therapies undergone, and PSA values are all part of the health narratives put forth. In the discussions the men talk about the loss of potency and other sexual problems, incontinence, and the social consequences of the treatment for the disease, and how these have impacted their sense of self and manhood (Brüggemann, 2021; Hyde et al., 2021; Oliffe, 2005; Oliffe et al., 2009). Such emotions are then given a direction, dictating the appropriate intensity of how such emotions are expected to be expressed and felt in relation to one’s age (Hochschild, 2012).

Reconsidering Sexuality and Masculinity

The previous two sections illustrate how the participants navigate the appropriate or expected intensity and direction of different emotions connected to their disease and its treatment. Through what could be described as “feeling rules” (Hochschild, 2012), emotions are thus displayed and discursively dealt with within the group. As illustrated, embodied side-effects are ever present in these discussions. In this section we will focus more directly on the notion of masculinity.

Studies has shown that men redefine their sexuality and masculinity following common side-effects of prostate cancer treatment, such as erectile dysfunction (Alexis & Worsley, 2018; Bowie et al., 2022). In the focus group interviews, the men often found it difficult to define masculinity. Often though, it was associated with sexuality and potency, exemplified as below.

Everything was just spinning, regarding family and above all potency and life after treatment, sex-life after treatment. Yeah, it was a traumatic period for me, but I got into care quite quickly, so I was grateful. There was a lot of crying for me, actually... It was what affected me, that my manhood would disappear. (Sture, focus group 1)

Most of the men in this study were born in the 1940s, and early 1950s, and had children in the 1970s and 1980s. In that sense, they may lag a bit behind when it comes to the broader discussion on gender and masculinity in Swedish society. Some of the men also indicated that they might have “more traditional views on gender”, when it comes to, say, the division of labour in the family, and how they understand manhood and its relationship to sexual ability (Haywood et al., 2017). At the same time, they are not totally unaffected by the context of the Swedish welfare state, which in recent decades has heavily promoted the idea of gender equality through numerous policies (generous parental leave and childcare systems, incentives to engage women in the labour market, etc.), and an ongoing problematization of manhood and masculinity (de Boise & Hearn, 2017; Johansson & Andreasson, 2017).

This thing about masculinity – I never actually thought about it. What masculinity? Is there something special about masculinity or something? Is it synonymous with something else? I haven’t paid much attention to this thing about masculinity. Is it about showing strength? What is the strength then? Is it in the penis, or is it a physical activity, or is it in the head? What is masculinity? I don’t know, so I don’t really care about it. On the other hand, not being able to have intercourse and penetration, it’s a problem, but I can live with that, too. It may have something to do with age, when you’re like me, 73 years old, then... This thing about sex, and penetration, well, it’s nice. Damn nice! Sure it is. And do I miss it? Yes, I do. But again, I can live with that. (Frans, focus group 3)

Instead of focusing on sexual (in)abilities, Frans is trying to problematize the meaning of manhood and masculinity in general, somewhat disconnecting it from ideas about sexual abilities and performances (Hordern & Street, 2007). Also, age is used as a reason for not bothering too much about sex and sexual function (Jackson, 2016; Kampf, 2013).

The men tend to adapt to their new life circumstances, and a potentially reduced sexual capacity. Lowering expectations by referring to age is one way of coping with a different sexual life (Gillearde & Higgs, 2014); distinguishing between masculinity and sexuality is another. When sexual capacity and function are held separate from masculinity, the emotional stress of not being able to perform penetrative sex is reduced, and it can also be constructed as a problem that can possibly be treated to some extent. For some of the men, the way back to an adjusted, but functioning sexuality and lust is a matter of using different technical aids, potency drugs, injections, and other tools in combination with embracing a broader approach to intimacy (that sex is more than penetrative sex).

I think, for my part anyway, initially it was more the fear of this being something definitive – that was what I felt then. I kind of didn’t think too much about other things. But afterwards, you felt that, as if it... no, it didn’t work a 100% like it did before. Then you start to get a little worried and start to think about it. Actually, I just felt that “Well, it can be fixed in another way then.” I’ve been given some tools and things like that, and I think it’s helpful for my needs anyway, so it’s fine. We have a sensible sex life today, but it’s not a spontaneous thing where you sit in front of the TV and say: “Hey, are you up for it?”. (Sture, focus group 4)

Some of the men involve their partners in the development of a strategy for a life without penetrative sex or an adjusted sex life (Gilbert et al., 2016). Making this kind of adjustments and engaging in emotion work are described as key to maintaining an intimate relationship. Ragnar says the following:

Britta, my wife, we discussed... well, we talked about this right from the beginning. We have always been 110% open with each other. And she says “Okay, sex is not everything in life. We have so much else in common.” Then I’ve had incontinence problems 24/7 since I had the surgery, and I still do. And I don’t know, I’ve done all these pinch exercises, that it’s quite strange that I can pee at all during these years (laugh). So I have done all these exercises. It doesn´t help. And the doctor said that: “If you don’t get rid of it in the first year, you’ll never get rid of it”, and he was right, unfortunately. (Ragnar, focus group 3).

Studies show that women are more inclined to engage in emotional work and support than are men (Thomeer et al., 2015). In our data, several of the men also stress the importance of having a partner who is involved in the emotional processes that the men go through. Adjusting their expectations and using the available tools seems to be a common way to approach and face the challenges of living with a reduced capacity for penetrative sex (Wentzell, 2014). Reconstructing sexuality and masculinity, problematizing expectations, using the notion of the ageing body, and identifying biological limitations resulting from treatment, the men also find new ways to develop and strengthen their intimate relationships, as hegemonic notions of masculinity is discursively problematized (Haywood et al., 2017; Hearn, 2004; Johansson & Ottemo, 2015).

Discussion and Conclusions

The present study shows that the rehabilitation process after prostate cancer treatment can be a prolonged and emotionally turbulent period in men’s lives. In line with previous research (Alexis & Worsley, 2018; Bowie et al., 2022; Brüggemann, 2021), our participants must cope with, on the one hand, bodily disturbances and the leaking and impotent body, and on the other, how such bodily changes impact their health, masculinity, and self-identity. We have shown how the men create an openness with each other in the focus groups, demonstrating their preparedness to talk about highly personal and sensitive issues. The inexpressiveness of masculinity, that has been previously found in the literature, does not fully capture the sort of emotional work taking place in our data, dealing with questions concerning sexual health, ageing, and the ‘bruised’ bodies of men. Though the men frequently use humour in the focus groups, this is interpreted not merely in terms of a strategy to distance themselves from potential embarrassment and arising from problematization of masculinity. Rather, the emotionology of the humour is embodied, and is in sync with the men’s emotions, when socially dealt with. Laughing together is also a way to show respect for each other’s emotional situation. Though the humour may be direct and sometimes even “raw” (describing dysfunctional bodies, failed attempts to have penetrative sex, etc.), there is also a caring quality to the men’s ways of communicating about such sensitive issues in the group (see also Reeser & Gottzén, 2018; Robertson, 2007). Such “raw” humour about the predicaments of the treated body is largely shared among the men.

Another way to emotionally deal with and handle their new life situation, and their bodily vulnerability, relates to how the men talk about the disease, the treatment, and the different technical aids available to them to enhance sexual function and incontinence. Going into detail, the men are discursively embedding their experiences in a medical health narrative, intellectualizing their conversations. This can be interpreted as an emotional coping strategy to contain the post-operative emotional turbulence that occurs, and as a gendered way of discursively enforcing masculinity (through medical knowledgeability). At the same time there is an interrelatedness, and movement, between such contextualization of the challenges the men are experiencing, and the vulnerability they express when discussing the body, health, aging, and sexuality.

Looking at how emotional reactions connected to prostate cancer (and its treatment) impact or interfere with notions of hegemonic masculinity, the findings illustrate how the men navigate between, on the one hand, stereotypical cultural ideas about performance-oriented, sexually functioning, young bodies, and on the other, their aim of adapting to a life in which the ageing and treated bruised body, as well as its capabilities, takes a new route. For some of the men, a problematization and potential redefinition of masculinity, and lowered expectations on sex and intimacy, is a way to adapt to life post-treatment. These men are prepared to re-develop their sexual life and to find alternative pleasures in intimate life with their partners, in which penetrative sex is given a less central role. Other men are more inclined to struggle to regain their sexual ability and to use different tools and aids to achieve this goal – by intellectualizing their challenges, for example.

Investigating men’s ways of dealing with the side-effects of prostate cancer treatment and its emotionology, this article has illustrated how participants’ emotional reactions interfere with or oppose, in various ways, their understandings of masculinity. We argue that their ways of talking about and handling emotions can be situated in the interface between discursive and gendered expectations (Seidler, 2004), and lived experiences of masculinity, and self in daily intimate life. New life predicaments create a need for emotional agility – between learned expectations (emotion ideologies manifested in masculine inexpressiveness and emotional strategies) (Hochschild, 2012), on the one hand, and a desire to reshape and redefine the meanings of manhood and sexual health, on the other. In conclusion, it is in this emotional social “spatiality” that masculinities are touched upon, and explored in relation to sexual health, ageing, and the body.

The current study contributes to a growing body of research on men and their emotional lives in the context of prostate cancer care and treatment. For the benefit of both patients and healthcare professionals, it illustrates the benefits of using focus group material in studies on prostate cancer masculinities and the emotional lives of men suffering illnesses. Though further research is needed on the matter, the study suggest that group-based approaches might be helpful for men struggling with side-effects following treatment, and that it might be productive for professionals to engage in discussions on ways to reconceptualising masculinity in therapy (in combination with incentives to restore previous capabilities).