Moving Beyond the Prostate

Abstract

As researchers recognize the value in considering gender dynamics within the cancer experience, a majority of the masculinities work has centered on men with prostate cancer. This focus has positioned prostate cancer as the flagship of men’s cancer (and perhaps men’s health). There is value in this research. However, as 78% of men experience cancers of a different type, a narrow focus on prostate cancer does not necessarily account for broader intersections of cancer and masculinity. Argued here are the benefits to expanding the focus of research on men’s cancer experiences. As researchers consider patterns and diversities among men managing an array of cancers, there is opportunity to broaden understanding of the challenges “cancer” can present for men, disrupt assumptions that the study of men’s gendered experience of cancer must be tethered to male sex–specific biology, and enhance the relevance and impact of psychosocial interventions for men living with cancer.

Cancer is the most common cause of death in economically developed countries around the globe (Jemal et al., 2011). There is tremendous diversity in this collection of more than 200 diseases defined by uncontrolled cell division and abnormal tissue growth. However, with its high incidence, often-ambiguous signs and symptoms, challenging treatments, and potential for disfigurement and death, a cancer diagnosis can be among the most exigent experiences an individual will face.

As cancer touches the lives of millions, researchers in the field of psycho-oncology have enhanced awareness of the psychosocial impacts of a cancer diagnosis and explored strategies of reducing cancer risk and recurrence and managing physical and emotional impacts across the illness trajectory. Over the past four decades, this scholarship has valuably integrated the expertise of oncologists with critical contributions from nurses, psychologists, social workers, clergy, and others in an effort to improve the life quality of cancer patients and care providers (Holland & Weiss, 2010). As knowledge develops, more work lies ahead in efforts to develop and enhance targeted and effective supports. Most relevant to this article is the need for increased attention to gender dynamics in psycho-oncology research, including intersections of masculinity and cancer (Bloch et al., 2007; Emslie et al., 2009; Hilton, Emslie, Hunt, Chapple, & Ziebland, 2009; Moynihan, 2002).

Men, Cancer, Gender, and Health

In popular discourse, men are often portrayed as less “thrown” than women by a cancer diagnosis (Seale, 2002), an assertion also pervading some scholarly work. Specifically, as psycho-oncology research has heavily focused on the lives of women, there is an implicit assumption that men are in less need of support due to a “natural” tendency toward stoicism and self-reliance (Emslie et al., 2007; Hilton et al., 2009; Moynihan, 2002). This orientation limits awareness of how men experience cancer and can also “pathologize” women relationally perceived as less able to cope (Moynihan, 2002). Notably, these gendered patterns are not exclusive to the field of psycho-oncology but connect with broader trends in the field of gender and health (Annandale, 2009; Courtenay & Keeling, 2000; Sabo, 2004; Watson, 2000).

Despite these challenges, scholars increasingly accept gender as intimately linked to the health experiences and illness responses of women and men (Johnson, Greaves, & Repta, 2009; Lorber & Moore, 2002; Lyons, 2009). In this research, an important distinction is made between sex and gender. Specifically, the biological sex elements associated with being male (i.e., penis, testes) or female (i.e., vagina, uterus) are distinguished from the social constructions of gender (i.e., appearances, behaviors, attitudes) that define what it means to be a man or a woman within a particular cultural and historical context.

In focusing on gendered processes in health, it is accepted that how an individual perceives the world, including the structure and functioning of his or her body, is socially mediated (Knaak, 2004). Exposure to a variety of gender norms across time, contexts, and intersections of gender and other social locations linked to ethnicity, race, and class (Hankivisky & Christoffersen, 2008) garners a diversity of masculinities and feminities (Connell, 1995; Schippers, 2007). However, these multiple ways of being a man or a woman shape and are shaped by masculine and feminine ideals (Connell, 2009). Even more, social constructionists accept that there are moral implications to an individual’s ability to adhere to binary, relationally constructed patterns and/or to “perform” gender (West & Zimmerman, 1987) in ways sanctioned as more or less appropriate for men and women within the societal “gender order” (Connell, 2009). Although individuals remain agents, capable of creativity and conformity (Meltzer, 1967), powerful social expectations inform interpretations of “reasonable” or “normal” appearances and acts within any given situation, including those linked to health and illness.

Research on gender and health is challenged to balance a consideration of important gendered patterns in the lives of men and women with a recognition of heterogeneity within these populations, and a resistance to assuming that difference is always present (Sharman & Johnson, 2012). However, in recognizing the powerful force of gender, there is an appreciation of the “symphysis” or fusion of nature and nurture (Annandale, 2003). As Butler (2004) asserted, although one might claim a body as his or her own, it is “given over from the start to the world of others, bearing their imprint, formed within the crucible of social life” (p. 21). Within this framework, the study of men’s health can include and surpass the terrain of the male sexed body and attend to “physiological, psychological, social or environmental factors” (Men’s Health Forum, 2004, p. 5). Furthermore, the study of disease in males (i.e., men’s health) is distinguished from men’s health studies, an examination deliberately and purposefully considerate of social influences in men’s experiences of health and illness (Robertson, 2007).

Recognizing these gendered patterns, researchers are responding to gaps in knowledge related to the particular needs of men with cancer (e.g., Manii & Ammermann, 2008) and the prevalence, effectiveness, and sustainability of interventions designed for this population (Bottorff et al., 2008; Dale, Adair, & Humphris, 2010; Oliffe et al., 2008). Additionally, scholars have considered gendered dynamics in how men communicate about their cancer (Hilton et al., 2009), engage lay understandings (Emslie et al., 2009) and professional support persons (Oliffe & Thorne, 2007), and manage identity challenges propelled by the physical, emotional, and social impacts of cancer and its treatments (Chapple & Ziebland, 2002; Gray, Fitch, Fergus, Mykhalovskiy, & Church, 2002; Kelly, 2009; Moynihan, 1998; Oliffe, 2006). In adopting a gender lens, this research recognizes the relevance of Western masculine ideals prioritizing expressions of power, strength, self-reliance, emotional restraint, and ambition, while acknowledging a plurality of masculinities (Connell, 1995) or diversities across individual men’s lives (Oliffe, 2009). Additionally, scholarship on “embodied masculinities” critically integrates the social and physical as it accepts masculinity as socially entwined with men’s bodies (Connell, 1995) and continually worked out in context.

Describing Men’s Experiences of Prostate Cancer

As this literature enhances understandings of how cancer can pose particular challenges to masculine identities associated with strength and action, the bulk of the extant research centered on men’s experiences has focused exclusively on the experiences of men with prostate cancer, with very few exceptions (e.g., Cecil, McCaughan, & Parahoo, 2010). This emphasis might not be surprising. Prostate cancer is the most common cancer diagnosis among men in Western nations, with older men and Black men at highest risk (Jemal et al., 2011). Additionally, as mortality rates for this disease are lower than those of lung and colorectal cancer and are declining due to treatment advances (Jemal et al., 2011), most men receiving this diagnosis will survive their cancer and may be challenged to manage its enduring social, physical, and emotional impacts. It is critical to understand these men’s experiences and support them during the period(s) of treatment and beyond.

However, men who experience prostate cancer have a multitude of peers in the broader cancer community. Of the 2,975,200 estimated new cancer cases (excluding non–melanoma skin cancers) among men in economically developed countries, 2,326,800 (78%) of these are nonprostate cancers, including lung, colorectal, bladder, stomach, kidney, non-Hodgkin lymphoma, melanoma, pancreatic, and liver (Jemal et al., 2011). Biomedical research considering cancer risks, treatment, and prognosis can benefit from a focus on a single form and/or stage of the disease. However, studies examining gendered patterns in how men perceive, interpret, and respond to cancer can and may well benefit from adopting a broader approach. This more inclusive orientation is supported by how cancer is constructed in Western society. More than a complex of diseases sharing a common pathophysiology and associated with a particular set of therapies (i.e., radiation, surgery, chemotherapy), cancer is stigmatized, feared, and often perceived as distinct from other diseases (Smith, Pope, & Botha, 2005). In particular, as cancer is characterized as a unified, destructive force and the “most feared of modern diseases” (Clarke & Everest, 2006, p. 2591), a predominance of battle metaphors in popular culture can personify cancer, regardless of its form, as an “enemy” (Reisfield & Wilson, 2004; Sontag, 1978).

Considering Men’s Experiences of Cancer (More Broadly)

As research narrowly focuses on the psychosocial needs and experiences of men with prostate cancer, it neglects the experiences of the 78% of men affected by other cancer diagnoses. Beyond the related gaps in understanding the particular challenges these men face, this incomplete narrative about men and cancer is problematic in at least two additional ways. First, as propelled by medical discourse, research on men with prostate cancer often highlights men’s struggles with erectile dysfunction, diminished libido, lost virility, and feminizing impacts of hormonal treatments. Even as researchers recognize that the embodied challenges of cancer and its treatments are not limited to sexual interest or performance, the focus on prostate cancer has emphasized impacts on men’s sexualities. Thus oriented, researchers and practitioners can be led to believe that sexually related impacts are the most relevant to men with cancer or that men are not experiencing other challenges, an assumption that can limit attention to critically important concerns. Second, research centered on this sex-specific cancer can propel assumptions that the study of gendered patterns in men’s illness experiences must be tethered to the specifics of the male anatomy. This perception can be disruptive to ongoing efforts to enhance understanding about how men’s health is influenced by “what it means to be a man” (Courtenay, 1998, p. 279). Said another way, the gendered experience of cancer includes but also extends beyond the prostate.

The tremendous value in examining gender dynamics in the lives of men with prostate cancer is clear. As this literature enriches understandings of how men perceive and experience this illness, it provides insights valuable to designing, delivering, and sustaining psychosocial interventions considerate of men’s needs and preferences. However, if researchers and practitioners are to fully understand intersections of masculinities and cancer and provide effective, comprehensive, and relevant men-centered supports for men with “cancer,” the scope of research must expand. Even as researchers accept that each form of cancer levels specific challenges related to disease process and treatment, there is value in exploring patterns in the lives of men challenged by cancer to perform as strong, active, controlled, and powerful.

As researchers test the utility of current prostate cancer–specific understandings among men with other cancers and inductively derive understandings about what prevails across a range of cancer sites there is opportunity to build on knowledge already generated and enhance an understanding of how cancer challenges and influences masculine identities, regardless of where the disease occurs in the body. Additionally, as researchers distil patterns and diversity in how men perceive and respond to the social and physical challenges of cancer—as an illness rather than a sex-specific disease—there is opportunity to contribute to discussions of similarities and differences among men and women affected by this illness. Thus focused, research is better able to engage with the complexities of gender and the particular impact of cancer.