Coming to Grips With Benign Prostate Enlargement or Prostate Cancer in Contemporary Japan: Readings From a Cancer-Self

Abstract

This article explores how a group of 35 Japanese men comprehend and verbalize the somatic experience embedded in dealing with benign prostate enlargement, or disquiet/discomfort of developing prostate cancer. Grounded in an adaptation of the sexual scripts theorizing, a set of in-depth, semistructured individual interviews were conducted through a LINE-app videocall from 2021 to 2023. Outcomes of interview were analyzed through a conversational approach, and presented by using three axes: the body, gender, and sexuality. An understanding of the Japanese-civilized-self has rendered somatic knowing problematic and pretended ignorance a strategy to deal with conversations about a condition involving the genitals and body waste. The body refers to a cancer-self who copes with ignorance of the prostate’s anatomy and physiology, the-mechanics-of-urine, and medication/treatment side-effects. Gender is concerned with a cancer-self who grapples with an ailment that “emasculates the self,” and the feminization of care as well as infantilization at medical facilities. Sexuality implies a cancer-self who bears scripts related to asexuality, medication/treatments that affect libido and penile erections, and a tarnished sexual reputation as a “heterosexual man” because prostate stimulation has been associate with homosexuality.

Introduction

Cancer encompasses “the second most common cause of death globally” (Wild et al., 2020, p. ix). In Japan, it has fretted politicians, medics, and academics since the 1960s; nevertheless, it was in the 1980s, when cancer became the “leading cause of death,” and thus a critical public health matter (The Editorial Board of the Cancer Statistics in Japan, 2023, p. 5). Japanese men are, however, more prone to die of cancer. In 2021, Japanese mortality rates were “372.7 for males and 252.1 for females (per 100,000 population)” (The Editorial Board of the Cancer Statistics in Japan, 2023, p. 17), and in 2022, male cancer incidence rates indicate that prostate comprised the most common site (17%), followed by stomach (16%) and colon/rectum (15%); furthermore, population aging might aggravate the situation—by 2070, 40% of the population will be aged 65 or over (National Institute of Population and Social Security Research, 2023). Despite men aged 40 or older grappling with cancer of the intestine, “lung and prostate cancer proportion is larger among men aged 70 or older” (The Editorial Board of the Cancer Statistics in Japan, 2023, pp. 14,16).

An inclusive approach to cancer has required the cooperation of the Ministries of Health, Labor and Welfare; Economy, Trade and Industry; and Education, Culture, Sports, Science and Technology, whose synergy is partly mirrored in the 10-year Strategy for Cancer Control of 2014, which bolsters up “cancer research in cooperation with patients and society, . . .[as well as]. . . cancer eradication, prevention, and coexistence” (The Editorial Board of the Cancer Statistics in Japan, 2023, p. 5). Similar to the World Health Organization (Cao et al., 2020), the action plan Health Japan 21 listed cancer as a lifestyle-related disease, which elicits part of the cultural scripts underpinning a disease whose prevention has mostly become an individual responsibility, because “nutrition and food education” could help avert it (Ministry of Health Labour and Welfare, 2008a), and a “Western type of diet” might be unhealthy and probably cancerogenic (Ministry of Agriculture Forestry and Fisheries, 2013, p. 26; Nippon hinyōkika gakkai, 2018, pp. 112, 201).

A law issued in 2013, which compels the registration of patients together with the facilities where they have been attended, has assisted to survey cancer, improve treatments and homogenize services nationwide. Law implementation has resulted in a database that assesses morbidity and mortality rates, treatment options and prognosis, and facilitates an enhanced scientific perspective toward research, cure and prevention, underpinned by the right to privacy and informed consent (The Editorial Board of the Cancer Statistics in Japan, 2023). The database has also served to gauge onco-economics—every institutional or personal cancer-related monetary issue, to accomplish “financial measures, and efficient and prioritized budgets” about “expense subsidies by [the] national government” associated with testing, treatments, and research (The Editorial Board of the Cancer Statistics in Japan, 2023, pp. 9,11). The Basic Plan to Promote Cancer Control Programs of 2018, has furthered cancer prevention and care through the distribution of coupons for cervical/breast cancer examinations, (re)evaluation and monitoring of cancer, a genomic view of disease, and the continuation of the so-called “treatment-work balance plan” (The Editorial Board of the Cancer Statistics in Japan, 2023, p. 7). From the vantage point of gender, women’s breast cancer prevention has been an element of public health campaigns (Ministry of Health Labour and Welfare, 2008b); nonetheless, despite cancer afflicting more men than women, men’s cancer-related concerns remain almost unaddressed.

Global statistics indicate that in 2023, prostate cancer implicates the second most common type of cancer in men, and in 2020, encompassed the fourth most frequently detected cancer worldwide (The Cancer. Net Editorial Board, 2023). The 2018 Screening Guideline for Prostate Cancer sheds some critical light on the Japanese Urological Association view of best practice, and elucidates how enacting an extensive, “Western type” scheme of prostate cancer screening might not necessarily mean reduced mortality rates (Nippon hinyōkika gakkai, 2018, p. 10). Available testing schemes include: biopsy, digital rectal examination, and prostate-specific antigen testing—the most regularly employed procedure; yet, the Japanese Urological Association hesitates to endorse routine testing, due to three main reasons: inaccuracy—about 20% to 40% of cancers remain undetected after a biopsy, erectile dysfunction caused by a biopsy, and, psychological distress after having detected malignant tumors (Nippon hinyōkika gakkai, 2018, pp. 112, 201).

The guideline raises the theme of treatment availability to caution against “overmedication” and “treatment complications,” especially when medical interventions could diminish “Quality of Life,” and not extend it (Nippon hinyōkika gakkai, 2018, pp. 112, 201). The Japanese Urological Association is reticent about enacting routine testing, and inclined to the wait-and-see approach, which is a strategy to circumvent medicine/treatment side-effects by observing symptoms, and identifying non-harmful tumors that could remain untreated. Hot flashes, urinary/fecal incontinence, urethral stricture, erectile dysfunction, decreased libido, osteopenia, and/or myasthenia might stem from any of the main available treatments, namely, radical prostatectomy, heavy ion radiotherapy, proton therapy, and androgen deprivation therapy (Nippon hinyōkika gakkai, 2018, pp. 151, 160).

Two main onco-economics–related issues in the guideline are: access to robot-assisted laparoscopic radical prostatectomy—the only robotic surgery approved by the National Health Care Insurance, whose availability is restricted to a number of facilities; and prostate-specific antigen testing, which is likely an item of a self-pay“comprehensive health examination” (Nippon hinyōkika gakkai, 2018, pp. 151, 201). The lack of routine testing might have rendered prostate cancer early detection expendable and hinging on a personal income. The guideline recommends that any cancer decision-making process should be grounded in accurate information, respect for personal values, and informed consent (Nippon hinyōkika gakkai, 2018, p. 202).

In this article, a cancer-self refers to the subjectivity of a Japanese man who embodies a number of experiences linked to enduring benign prostate enlargement, the risk of developing malignant tumors in the prostate, and/or the distress of currently coping or having wrestled with prostate cancer. The guideline conveys cultural scripts of a medical practice where early detection, treatment options and prognosis are chiefly intended for an aging cancer-self—although prostate cancer could manifest in men in their 40s, the greatest occurrence is in those aged 50 or over, who have supposedly espoused “Westernized eating habits” (Nippon hinyōkika gakkai, 2018, pp. 112, 201). Inasmuch as prostate cancer comprehends a lifestyle-related disease, a cancer-self largely epitomizes cultural scripts of a male-self whose uncontrollable and irresponsible behavior makes him prompt to disease; a cancer-self is thus likely to be a Japanese man who grapples with prostate cancer due to his literal and symbolic inability to restrain the self.

Against this backdrop, the manuscript answers: How does a Japanese cancer-self verbalize and/or make sense of a range of lived embodying experiences associated with benign prostate enlargement or prostate cancer? The remainder of the manuscript includes: Conceptual grounding, Methods and data, Analysis of results sorted out according to three axes: the body, gender, and sexuality, Discussion, and Conclusion.

Conceptual Grounding

Subjectivity and the Self

A Japanese cancer-self is fathomed via an adaptation of the “sexual scripts” theorizing of Gagnon and Simon (2005) to investigate the embodied encounter that entangles the male-self with the prostate, at three separated but interconnected dimensions of scripting: the cultural, the interpersonal, and the intrapsychic. The cultural entails a composite background that coalesces public and medical discussions along with commonsensical views to underscore that prostate cancer is conceivable a lifestyle-related disease, which makes the self mostly liable for prevention and early detection. The interpersonal dimension incorporates interactions between health care professionals, friends, relatives, and a cancer-self, where they could employ an array of common dispositions that might strengthen their ability to (re)invent and/or (re)alter cultural scripts, and concede that any prostate-related issue entwines an assortment of somatic experiences that might make the self the subject of prostate cancer prevention, diagnosis, and treatment. Finally, intrapsychic scripting indicates the cancer-self’s capacity to partake in an inner conversation where self-reflection permits to filter cultural and interpersonal scripts by answering: What kind of self am I? What kind of self do I want to be? (Simon, 1996).

Scripts do not rule behavior, yet they facilitate an understanding of the “links between macrolevel considerations of sociocultural development and general theories of individual development” (Simon & Gagnon, 1986, p. 97), which helps to object to “determinism and voluntarism” by differentiating culturally imposed practices, from those willingly embraced by the self (McNay, 2000, p. 9). In addition, “[s]ubjectivity, meaning, and consciousness do not exist prior to experience, but are emergent in action and interaction” (Waskul & Vannini, 2006, pp. 2–3), and thus scripts embrace free-flowing intellectual improvisations (Gagnon & Simon, 2005), that serve to further continuous processes of elucidation and signification regarding a medical condition where the prostate has turned into the center of a somatic experience for the male-self.

In keeping with Jackson and Scott (2010), the concepts of the self and subjectivity are employed interchangeably to convey a subtle distinction of diversity and multiplicity that the construct of identity misses. The self and subjectivity contain meanings rooted in our internal motives, forces, desires, expectations, and objectives, which help to contest any form of essentialism, since “the self is . . . a social process going on” (Mead, 2015, p. 188, emphasis added). The self sustains a sense of continuity along with inconsistencies and contradictions, and subjectivity presents a number of layers that are unlikely compressed into the notions of identity or identities, because “subjectivity is produced, negotiated and reshaped via discourse and practice” (Lupton, 1998, p. 26). Nonetheless, in Japan, the self has been traditionally conceived through the theories of the Japanese to allege that Japaneseness could be only comprehended if “one is born a Japanese,” because the Japanese self stems from a “homogeneous and uniracial” society, and a “racially exclusive national culture,” which is different from a “polyracial and heterogenous” Western society (Yoshino, 2001, p. 23).

The Body and the Self

The prostate could be seen as an index of subjectivity where emplacement and sociality conflate to boost physical and intellectual abilities of the self that could generate social interaction, human knowledge, and the will to know. Hence, (re)analyzing how the self and the body have become entangled is noteworthy, where the construct of genital “anatomic confirmation” shed some critical light as it refers to “the separate cultural syndromes that are related to the rearing of girl or boy children” (Gagnon & Simon, 2005, p. 22). Anatomic confirmation has four major consequences: genitalia entails the ontology of the gendered- and sexual-self; the self is structured in between “the taken-for-granted dualisms”—the feminine versus the masculine (Ramazanoglu & Holland, 2002, p. 28); the sexual arises from the genitals; and biological differences and gender tend to become undistinguishable (Bordo, 1999).

Springing from genital confirmation, some binaries of gender have been deployed to explicate how and why the male- and female-self involve two “separate but overlapping (and often complementary)” subjectivities that unfold as two dissimilar, but matched forms of embodiment (Wiederman, 2005, p. 496). One of such binaries incorporates the “good-wife and wise-mother” vis-a-vis the father “house-master pillar,” whose validity dates back to until about the Second World War, and was allegedly replaced by the “salaryman” and the “full-time housewife” binary, during the post-war, rapid economic growth era. Both binaries are meant to sway gender and sexual schemata, substantiate “patriarchal heterosexuality” (Ingraham, 1994, p. 204), and give bodily form to a female-self who ought to be svelte, sexually attractive and appealing to guarantee “marriageability” (Boero, 2012, p. 8); in contrast to a male-self who stereotypically appears bodily uninterested, and exhibiting “characteristics, action and intention” to enlarge his capacity to be a successful breadwinner (Cook, 2016, p. 52). Both binaries could be fundamentally adverted to by the “traditional aphorism of ‘men die, women suffer’” (Barry & Yuill, 2008, p. 142, original emphasis), where a male-self likely incarnates lifestyle-related diseases—“headaches from hangovers and a weakened liver from drinking too much, hemorrhoids and stiff shoulders from sitting at his desk for too long, stomach ulcers from irregular diet and stress” (Dasgupta, 2013, p. 2), which might trigger a “death caused by extreme job-related weariness” (Kawanishi, 2009, pp. 38–39). The male-self thus embodies a range of “toxic practices”—emotional restraint, pain endurance, and refusal to seek prompt medical treatment (Messerschmidt, 2018, p. 39; Rosenfeld & Faircloth, 2006), which eventually helps grasp why cancer is more prevalent among men.

The binaries have been dubbed unsound and archaic coordinate systems that improbably attest to how Japanese society has shifted. Chiefly influenced by Connell (1995) theorizing, the constructs of “masculinities” and “femininities” have been utterly utilized to affirm that the male and the female-self embody diversity and impermanence, which is difficult to comprehend by using essentialisms implied in the use of binaries; factors such as “class, occupations, generations and regions” might impact on how the body and the self are connected (Okano, 2009, p. 4). Academics and journalists have prompted an “afresh” binary that combines the “carnivorous girl,” versus, the “grass-eating or herbivorous boy,” to allude to a female-self who is unconcerned about health, and looks for “adventure and career success,” as well as premarital sex, hedonism and divorce (Bardsley, 2011, p. 133; Muta, 2008; Okano, 2009); in contrast to, a male-self who looks for a placid, tranquil, and happy healthy lifestyle—does not smoke or drink, and finds pleasure in homemaking (Bardsley, 2011; Nicolae, 2014), which makes it difficult to understand why cancer affects more men than women.

The Civilized Self

An open conversation about the prostate—a gland located in the genital area, could be problematic, when considering it as an element of what Allison (1996) has identified as the realm of Japanese censorship, which has delineated the cultural scripts related to what sexual displays are permitted and prohibited within public and private spaces in contemporary Japan. Such cultural scripts have originated as early as “the late nineteenth century, when a code of ‘civilized morality” engendered linguistic nuances and appropriate language that have laid most sexual-related conversations hidden from the public eye and to be conveyed by “silence or euphemism” (Pflugfelder, 1999, p. 8, original emphasis). Civilized morality has also entwined cultural scripts involving good manners and proper behavior connected to “civilization and the covering up of bodies and sex in public” (Allison, 1996, p. 161).

Civilized morality has rendered demeanors associated with expelling or eliminating human waste shameful, rather than natural matters connected to functions of the body (Allison, 1996). Similar to European societies, as Elias (1994, p. 51) holds, this has involved civilizing processes that have banished such natural functions from social interaction and displaced them “behind the scenes,” which has meant that verbalizing and/or an inability to conceal or restrain them is embarrassing and indication of a barbaric or uncivilized-self. Similarly, civilized morality has connected breastfeeding or exposing one’s body to bathe, for instance, to indecency, carnality and/or obscenity; furthermore, civilized morality has made sexuality in general to acquire a sense of dirtiness/lewdness and has helped to foster the perception that different forms of sexuality that do not encompass the bounds of male–female marriage are abnormal (Allison, 1996; Pflugfelder, 1999).

Advocates for the theories of the Japanese sustain that civilized morality is indeed ethnically loaded and helps draw a clear distinction between Japan and the West: a Japanese-civilized-self belongs to a “shame culture” where the self is ruled by “social threats to personal honor and reputation”; a Western-civilized-self pertains to a “guilt culture,” where the self is controlled by “internal sanction against the violation of a moral standard” (Yoshino, 1992, p. 33). Nonetheless, although this clear differentiation between the West and Japan lacks empirical evidence, it does reinforce the idea that there is a unique Japanese identity (Yoshino, 1992). Daily life and the interpersonal dimension of scripting, as Bardsley and Miller (2011, p. 9) imply, might assist to buttress the standpoint of distinctive traits of comportment underneath a Japanese-civilized-self, which has been so firmly established in “childhood” that could be perceived as a “second nature” and “innate” marker that helps read a civilized-self in terms of “social class, region, nation, and gender.”

Methods and Data

Sample

This article draws on the conversations with 35 Japanese men. Aged 56 to 78, 16 (45.7%) of them resided in Tokyo, and the rest in Osaka. Four (11.4%) were company workers, 13 (37.1%) self-employed and 18 (51.4%) retired. Eleven (31.4%) were single, 19 (54.2%) married, three (8.5%) widowed, two (5.7%) divorced, and seven (20%) acknowledged to be men who have sex with men. Participants have coped with prostate-related matters for about two to eigth years—4.8 on average, 22 (62.8%) have had prostate cancer detected through a self-pay medical check-up, and ten (28.5%) reported a family member who has suffered cancer. Six (17.1%) developed benign prostate enlargement, 22 (62.8%) underwent a radical prostatectomy, and seven (20%) monitor prostate cancer symptoms through the wait-and-see approach. Twenty-three (65.7%), 25 (71.4%), and 28 (80%) have borne incontinence, decreased libido and/or erectile dysfunction, respectively. All of them have tried traditional Japanese medicine and 29 (82.8%) androgen deprivation therapy; furthermore, seven (20%), four (11.4%), and three (8.5%) have accessed heavy ion radiotherapy, proton therapy, and robot-assisted laparoscopic radical prostatectomy, respectively.

Kansai Gaidai University ethics board sanctioned this project that did not involve a random sample; any Japanese men eager to converse about their prostate-related “issues” was welcomed. Four acquaintances of the principal investigator assisted in the snowball sampling recruitment process—47 men were contacted, but 12 (25.5%) declined the invitation, which started by an explanation of research aims and methods. Given that interviews were conducted through a LINE-app video-call, all participants provided verbal informed consent, which was audio-recorded at the beginning of the first encounter and verified by an independent witness who was a colleague of the principal investigator at Kansai Gaidai University. Informed consent occurred with the proviso that the rights to skip “uncomfortable” questions and stop participation at any time be protected, and collected-information be handled confidentially, used only for academic purposes and anonymized. Here, pseudonyms are used, and data that could reveal participants’ personal identification has been deleted or changed.

All informants were interviewed twice for about 60 minutes each time; the second time was to confirm and/or deepen into information or details presented in the first conversation. This encompassed 70 in-depth, semistructured individual interviews carried out in Japanese, from 2021 to 2023. Underpinned by a “conversational approach,” every encounter was recorded upon participants’ agreement, and topics were introduced in a way that they could further communication flow and mutual understanding (Green, 2023, p. 7). The use of “prompts, probes and loops” was key to obtaining detailed descriptions of experiences, stimulating introspection and reflection, and relaying a longitudinal perspective on prostate-related matters (Oliffe, 2009, p. 81). Data were collected and analyzed by the principal investigator—a non-Japanese academic male, who speaks Japanese fluently, has lived in Japan for about 20 years, and whose current areas of research are health, gender, sexuality, and ethnicity.

Analysis

The analysis started by transcribing the interviews; every stated word together with pauses, hesitations, and interruptions were included in the transcripts but not measured. Next, transcripts were translated into English—no apparent issues related to meanings were found. Afterwards, a range of initial key concepts and themes were created to categorize data; the software Ethnograph assisted in simplifying the process through a grid of “systemic networks” that presented the transcripts attached to main and subsidiary codes (Bliss et al., 1983). Differences, commonalities and connections were asserted by two comparative approaches: “intra-data”—the conversation with the same participant, and “extra-data”—the conversations with each informant vis-à-vis the rest of the participants. Extracts of interview are quoted word-for-word in this article to enable comprehension of theorizing, and ellipses are used to indicate that extracts were modified to avoid repetition and communicate meanings comprehensively.

Principal investigator’s emplacement concerning “assumptions, values, and motivations affect the interpretation of findings” (Oliffe & Thorne, 2007, pp. 152–153); consequently, the interviews do not mirror “the real world,” they all express segments of the participants’ life histories that facilitate a reading of how the male-self and the prostate interweave when considering cancer. In many instances, the conversations comprised past events that are subjective reflections and/or recollections shaped by “interviewees current situations” (Green, 2020, p. 5).

Results

The Body

Initially, the interviews centered on the body to explore the ways a cancer-self observed, made sense, and talked about the body “from the first-person viewpoint” as a lived-experience “from the inside” (Hanna, 1995, pp. 341, 343), as Tanaka-san (aged 67, from Osaka, self-employed, married) elaborated:

. . . for a 67-year-old guy, like me . . . trying to understand how peeing and the prostate are connected was the first problem . . .

Why?

. . . sometimes I had the urge, but in the toilet, nothing came out . . . at times it was a bit of a problem, because I was in the middle of something important and had to rush to the toilet for nothing . . . I assumed, it was the kidneys or the bladder, much to my surprise, it was the prostate . . .

Was it?

Yes, I learned that the bladder stores the pee that has traveled out of the kidneys through the ureters . . . then, the pee goes out of the body from the bladder through the urethra, but when the prostate gets bigger, pushes against the bladder, and might cause urinary retention . . . I was truly worried, but lucky . . .

Lucky?

Yes, a growing prostate could mean cancer . . . it seems that as we age the prostate gets bigger. So, I’m just getting old . . . How do you call it? . . . Andropause?

Is that true?

hmm . . . nobody knows for sure. . . but, it’s kind of a normal thing for aging men, that’s why they say peeing problems and aging often go hand-in-hand. Now, I have to keep a close eye, to detect anything unusual. . . especially, blood or pain when peeing. . .

Some of the conversations circulated around the intrapsychic dimension of scripting to indicate the enfleshment of the-mechanics-of-urine, which refers to comprehending how urine moves in the body, along with a methodical exercise of somatic surveillance—monitoring frequency, quantity, stream direction, pain, and/or blood in daily urination—to identify potential prostate issues.

Alluding to an andropausal or aging-self was a recurrent argument for the elder participants to normalize how the body and the prostate become entangled. For the younger, the prostate itself was ostensibly almost completely “terra incognita,” and thus experiencing the-mechanics-of-urine was puzzling, as the conversation with Ogawa-san (aged 56, from Osaka, company worker, single) illustrated:

. . .honestly, I had no idea about where the prostate was, and what it was for. . . worse is that I didn’t feel anything. . .

What do you mean?

. . .pain or something, I didn’t feel anything. . . running to the toilet frequently was a bit of a problem. . . at night more than five times. . . the doctor said, it’d be that I was taking a bit too much liquids before going to bed. . . also, had to check if there was anything unusual when peeing. . .

Then?

. . .paying attention to peeing was odd. . . peeing is kind of automatic. . . I drank less tea before going to bed. . . sometimes there was a bit of leaking after peeing, and going to the toilet frequently became almost normal. Then, I had some pain and a burning sensation when peeing. . . difficult to understand, though. . .

Understand?

. . .that peeing and the prostate were related. Logically, it was something in the kidneys or the bladder. It was actually that the prostate was swollen and pressuring on the bladder. . . a common aging men condition, the doctor said, but I was only 53. . .

What happened then?

. . .my level of the prostate-specific antigen testing kept getting higher, and a couple of times there was some blood in my pee. . . a biopsy, confirmed it was cancer, and got the prostate removed. . .

How are you now?

Not bad. . . have been taking meds for the last three years. . . side-effects can be harsh, though. . . especially incontinence after the biopsies and surgery. I have used incontinence-pants for a long while. . . really distressing, kind of everything moving around peeing. . . worse, I can’t really talk about it. . .

Really?

. . .it’d be that I’m single. . . it’d be a Japanese thing, not sure. . . talking isn’t easy. . . I feel, it’s part of being Japanese. . .

Embodying the-mechanics-of-urine complicated further when they turned into an issue enmeshed in an understanding of Japaneseness. Okuda-san (aged 77, from Tokyo, retired, single) casted some light:

. . .although it’s just a matter of time that everyone’ll face urine and prostate issues, nobody seems to be willing to talk about it. . .

Why?

Not sure. . . it’s kind of gross. . . I don’t know why, it’s boorish, lack of good manners. . .

Manners?

Hmm. . . yes, not sure, it could be something that became a Japanese thing, like Valentine or Christmas. . . something adopted from the West. . . what I can tell you is that since childhood, we learn that talking about peeing or poohing is weird, coarse. . . so, the main problem is that you don’t feel like talking about what’s happening to you. . .

Was that your case?

Yes. . . first, it was embarrassing to have people waiting because I had to pee frequently, also a bit scary when I found some blood when ejaculating. . . then, incontinence after a couple of biopsies, and after the surgery. . . I got the prostate removed about six years ago, and have used incontinence-pads. . . also the odor. . .

What odor?

. . .the reek of pee. . . as if my entire body were impregnated with pee. . . I had to change pads frequently to skip skin-irritation. . . also, the shame of being unable to get radiation therapy, because I didn’t empty my bowels or bladder correctly. . .

What do you mean?

Hmm. . . to get better treatment and least side-effects, I had to empty the bowel and the bladder almost completely. . .on top of that, I dealt with all this alone. I didn’t have anyone around and didn’t feel like talking about this. . . it’d be a Japanese thing. . . or maybe it’d easier, if I were a woman. . .

Why so?

. . .not sure, women use sanitary towels for menstruation. . . just guessing. . .

The analysis suggested cultural scripts connected to an interpretation of Japaneseness that has rendered the-mechanics-of-urine a “vulgar” and “dirty” topic of conversation. Rationalizing was challenging. For some of the interviewees, it was reasonable to assume cultural scripts connected to a “Western” influence that has turned into an element of a Japanese civilizing process through the interpersonal dimension of scripting—daily life interaction and common sense; yet, everyone concurred that it has transformed into an element of the intrapsychic dimension of scripting via an understanding of the Japanese-civilized-self because since a very early age, they have learned that talking about body waste and genitalia was “injurious to public morals” (Allison, 1996, p. 163), so the “oddity” of monitoring and discussing urination. Assertions suggesting that men and women would grapple differently with the-mechanics-of-urine and body odors veered the conversations toward gender matters.

Gender

In exploring how gender impinged on the somatic experience of coping with prostate cancer or benign prostate enlargement, the narrative portrayed cultural scripts regarding a female-self whose body is susceptible to “leakage and seepage,” and thus better qualified to endure revulsion and abjection entrenched in the embodiment of disease (Gatrell, 2008, pp. 9–10), as Ishikawa-san (aged 75, from Tokyo, self-employed, married) elucidated:

. . .in retrospect, I’d say. . . incontinence is one of the worst things a man can face. . . .I’ve struggled with incontinence for years. . .

Have you?

Yes, I got prostate cancer about four years ago. . . waited to see how it progressed for two years, meanwhile, had some biopsies that got me incontinent, then I got incontinence again after having the prostate removed. . . but, the shame of becoming smelly and unable to control urine was unbearable at times, though troublesome, wearing pads became normal. . . honestly. . . women are better at dealing with this. . .

Are they?

Yes . . . my wife has had urinary problems and stuff at least twice, when she got pregnant. . . it’s easier for women to catch urinary-tract-infections, and of course, they’re kind of trained to deal with menstruation and stuff. . . this could be a difference between men and women. . .

Really?

. . .hmm. . . yes, women are kind of better connected to their bodies. . .

Are they?

. . .How to put this? . . . Hmm. . . they know better their bodies, and are able to keep an eye on someone else’s bodies too. It’s kind of a natural thing. . . changing children’s diapers is usually a women’s duty. This is actually a bit funny. . . men are meant to have everything neat and controlled. . . deep inside me, all the mess around peeing makes me kind of weak, unmanly. . .

Is that true?

Yes, I think so. . . I had even some quarrels with my wife, because she was always instructing me . . . smells and skin irritation was annoying . . . it’d be that I’m 75 years old, ask younger men. . .

At the intrapsychic level of scripting, a cancer-self could be entrapped by the taken-for-granted dualisms, where illness reduced ‘man’s status’ and yielded emasculation (Green, 2023, p. 5). A leaky cancer-self who endured incontinence and was unable to have the body under control, was rather “unmanly.”

Although the younger participants tended to disagree that an “unruly body” made the male-self feeble and/or unmasculine, the conversations evinced that this was not only a generational difference. Some of those who championed a critical viewpoint highlighted that taken-for-granted dualisms were difficult to object to, because they have largely become an active element of cultural and interpersonal scripts underpinning current medical practice. Talking with Hamamaru-san (aged 65, from Osaka, company worker, single) helped clarify:

. . .prostate cancer has turned my life upside down for the last past four years. It’s been taxing. First, it was scary when I found some blood in my semen, and I’m still withstanding incontinence. . . some guys feel that incontinence makes them like less of a man. . .

Why?

Hmm. . . not sure, it’d be that incontinence-pads could be like sanitary towels. . . I guess leaking out urine could be like menstruating or something. . .

Is that also your case?

No. . . hmm. . . side-effects can be harsh. That’d be a test to your sense of masculinity. . . you need to be a tough guy. . . but to me what’s really a test to masculinity is bearing doctors and nurses, they can make you feel really that you’re not a complete man, that you miss something . . .

How come?

. . .well, I’m single, and their frame of reference seems to be a heterosexual couple. It seems that you need to bring your wife when you see a doctor. . . as I’m single. . . I feel sometimes that they find kind of difficult to deal with me, that’s why my elder-sister comes along with me. . .

What for?

Hmm. . . to take care of me . . . as if I couldn’t follow instructions and stuff. . . as if women were like naturally oriented to look after people. . . this has made my elder-sister a bit too intruding. . .

Why?

. . .the doctor said that treatment after having the prostate removed might cause erectile dysfunction and loss of sexual appetite, I wanted to see if there was any option. . . but she immediately agreed, and suddenly I was like being ignored, she and doctor were deciding everything. . . keeping an active sexual life was kind of important to me, but not to her. . .

What happened then?

. . .we had an argument, but in the end, we did as she wanted, I had the prostate removed. . . she thinks that a 60-year-old man is too old to think about sex and stuff. . . she was acting really like my mum, I was treated like a child. . .

At the interpersonal level of scripting, health care professionals appeared actively endorsing the feminization of care. The married men had routinely their wives attending the consultation room together with them, dealing with explicit requests to oversee the health of their husbands, and even being admonished when their task was deemed inefficacious. The single participants were customarily expected to have a female relative to receive medical instruction and/or decide on medical course of action, which unveiled cultural and interpersonal scripts where single men were likely regarded as an “onerous medical cancer-self.”

At the intrapsychic level of scripting, feelings of being infantilized and/or emasculated linked to the feminization of care were common to the majority of the interviewees. The narratives, however, indicated that the ontology of those feelings was not only connected to the interpersonal dimension of scripting underneath daily interactions with health care professionals. Gennai-san (aged 66, from Tokyo, self-employed, single) pointed out cultural scripts revolving around a Japanese-civilized-self and a gendered-male-self underneath the conundrum of discussing prostate cancer:

. . .of course, prostate cancer implies fear of dying, and shame at dealing with incontinence and stuff, but the mortification of a disease located in the groin is stronger. . .

Is it?

. . .it’s like common sense, we don’t talk about it, we don’t touch it. . . it’s like talking about a private thing, that’s why they call it. . . your private parts. . .

Is that your case?

Hmm. . .yes, I think so. Only some people know that there was blood in my pee and that I’ve had urinary issues for about five years. Four years ago, I was detected cancer, and was recommended hormones. . . it kind of works. . . cancer is still enclosed, so there’s no need to get the prostate removed for the time being. Sadly, treatment has made me kind of asexual. . .

What do you mean?

Hmm. . . I haven’t had the urge to have sex for a long while, and though I’ve tried, couldn’t get an erection. . . it’s not something I want to talk about. . .

How come?

. . .well, it’s clear, my pride as a man is kind of lost. . . I didn’t want to let anyone know that I have prostate issues. I don’t think it’s me only, though. . . many guys don’t want to be tested for prostate cancer. . . they fear of cancer, but fear more of being seen as losing self-esteem. . . even if they knew they might have cancer, they don’t want to get tested. . . they do as if they didn’t have anything. . .

So, why did you get tested?

. . .I had to. . . Peeing and ejaculating was a bit painful, and got some bloody urine too. I wanted to check what was wrong. . . but, before going to see a doctor I asked around and saw the Internet too. . . it’s kind of strange. . . many guys think that prostate problems mean losing an erection, as if the prostate were the organ that helped to keep an erection. . . very few guys know where the prostate is, and what is for. . . when they realise that it is located in the genital area, they kind of confirm that it actually produces erections. . . treatment might cause erectile dysfunction, not the prostate itself. . .

Prostate cancer has been culturally scripted as a disease that effeminates the self: an ailment that produces erectile dysfunction. Many of the conversations implied a cancer-self who, at the intrapsychic level of scripting, preferred to “feigning ignorance” and voicelessness, rather than conceding that he was coming to grips with an ailment that was making him “emasculated.” Despite most of the participants living through prostate-related issues for about 4.7 years on average, only some of them identified the prostate as the gland that produces seminal fluid. Bonding the prostate to sexual functions swerved the conversations and served to explore how prostate cancer and sexuality were interweaved.

Sexuality

Some of the encounters vividly mirrored the Japanese Urological Association’s viewpoint that prostate cancer has been culturally scripted as a disease of an aging-self: “a disease that is after all overwhelmingly a disease of older men” (Valier, 2016, p. 195), which in the recollections of most of the participants, it meant that an aging body and sex were incompatible. Kimura-san (aged 67, from Tokyo, self-employed, married) fleshed out:

Hmm. . . I don’t know what’s worse, dying of cancer, or a life without satisfaction. . .

What do you mean?

. . .I got benign prostate enlargement about two years ago. . . it was kind of mixed feelings, a shock, because I didn’t know what exactly benign prostate enlargement was, but relief, as it wasn’t cancer. . .

What is benign prostate enlargement?

Hmm. . . it’s the enlargement of the prostate, it isn’t cancer, so won’t kill me, but as the prostate oppresses the bladder, I got incontinence and have worn incontinence-pants since being diagnosed. . . the bad news is that I’m under androgen deprivation therapy too. . .

What is androgen deprivation therapy?

Hmm. . . hormone therapy. . .

What for?

. . .to prevent prostate cancer. . . I don’t have tumors or anything, but I might develop them. . . so, it’s just in case. . . this has gotten me erection problems, fatigue and night-hot flushes. . .

Did you ask for it?

No, not really, but as I was 64, it’s a kind of a tacit understanding that I shouldn’t be concerned about sex and stuff. . . as if 64 were really old. . . though I disagreed, my wife said that it was just to be on the safe side, so I gave up. It’s very difficult to go against the idea that old men don’t want to have sex. . .

How do you cope with your sex life, then?

Hmm. . . it’s like we always get intimate, have intimacy. . . touching, petting, caressing, hugging. . . perhaps, we aren’t having sex. . . better say, we got our own form of sex. . .

Although, cultural scripting related to “ageist notions about sexuality in later life” were particularly problematic for a younger cancer-self, there was an overall agreement that medication/treatments, androgen deprivation therapy in particular, which seemed customary treatment for anyone dealing with prostate-related issues, were rather distressful, because medication/treatments usually resulted in diminished sexual appetite and erectile dysfunction (Slevin & Mowery, 2012, p. 260). In the event, some of the participants, at the interpersonal level of scripting, tended to look for intimate connections or “flexible . . . ideas of sexuality and intimacy” (Bender, 2012, p. 213).

Loe (2012, p. 278) stressed that “pleasure is a social and relational process,” which according to the conversations, it was a process that went beyond the interpersonal dimension of scripting of heterosexual couples in the bedroom. It was a process influenced by cultural scripts shored up by medical practitioners. Toishi-san (aged 69, from Osaka, self-employed, married) relayed:

. . .dealing with meds and treatments can be truly harsh, all they make you physically weak. . . the psychological burden is heavier, though. . .

Why?

. . .cancer was detected at a very early stage, and now I’m okay, but, it’s stressful to think that cancer might come back. . . looking back. . . I’d say that the worst is that I got like castrated. . .

Castrated?

. . .I got erectile dysfunction. . . it kind of hurts my feelings. . . I feel like less manly. . . like losing self-worth. . . it took me a long time to understand, and find other ways to get pleasure, but when I was kind of accepting the situation, the doctor suggested that there were actually some treatments that could get me back to normal and have an erection. . .

What did you do?

. . .hmm. . . I tried for a while, but it wasn’t really gratifying, because it was difficult to have a long-lasting erection, and my wife was not really happy and willing to have sex, either. . .

Why?

Hmm. . . after menopause, she was not really into sex and stuff. . . so we kind of gave up and look for a means to enjoy. . . this new phase of our lives. . . it’s funny, though, how my life hangs on meds. . .

What do you mean?

. . .meds cure me, but these same meds get me another problem that can be solved by taking more meds. . . it’s like moving all the way around meds. . .

Some of the interviewees and their partners attempted intimate connections that disapproved of cultural scripts conveying that “a firm erection is fundamental to satisfying sex” (Gilbert et al., 2013, p. 890). Interpersonal interactions with health care professionals, who actively indorsed “the pharmacology of sex” (Loe, 2001, p. 98), rendered their attempts mostly futile. In coping with side-effects, at the intrapsychic level of scripting, some of the participants were introduced medical interventions that might help “sexual-(re)engagement” and boost male pride, through the (re)attainment of penile erections. This inadvertently served to confirm cultural scripts that the sexual is ontologically affixed to the genitals and that “real” sex necessitates penetrative sex.

In delving further into side-effects, not only did the analysis picture a cancer-self eagerly embracing the use of any medication and/or device that could help regain full-control over penile erections, it also unveiled intrapsychic level of scripting that elicited a different reason for feigning ignorance of the prostate. Suzuki-san (aged 65, from Tokyo, company-worker, single) explained:

. . .hmm. . . some guys might say that it’s a Japanese thing, that it’s a private thing, actually, they don’t want to talk about the prostate because people might think that they are gay. . .

How come?

Well, to put it bluntly, the prostate is like the clitoris. . . so, prostate stimulation is a great way to get pleasure. . .

Is it?

Yes, I think so. . . .it’s not a simple thing. . . in Japanese, we name it tokoroten and only a skilful guy can do it. . . touching the prostate when having anal sex, when it’s well done, he can make you ejaculate. . . that’s why removing the prostate should be the last resort. . . removing the prostate is like depraving men of a form of sexual enjoyment. . . the overuse of androgen deprivation therapy is the same. . . androgen deprivation therapy makes it difficult to get an erection to reach the prostate, even if you take Viagra or something. . . don’t take me wrong. . . I know that prostate cancer might kill you, but men should be fully informed about treatment options and how they affect their sexual life, so they can realise what suits them better. . . unfortunately, it wasn’t my case. . .

Why not?

. . . I got the prostate removed without knowing that there’re many guys who could fight cancer without surgery. . . it doesn’t mean that I have given up my sexual life. . . the surgery and treatments had let me unable to have erections. . . but massaging the prostate of my partner can be equally pleasurable. . . looking at him enjoying sex is a form of enjoying sex for me too. . .

Is it a common practice among men?

Hmm. . . difficult to know. . . it is maybe. . . but not many guys would tell you that they’re having the prostate massaged or something, because they might be seen as gay. . . they wouldn’t want to talk about it, or say that they don’t know anything about the prostate. . . some of them would tell you that Japanese people don’t talk about private things. . . better ask around. . .

Through some of the conversations, the prostate was a gland that has been culturally scripted as “the male g-spot,” which mostly intimated prostate stimulation through anal sex as a pleasurable practice (Rose et al., 2017, p. 2), and therefore knowing or the will to know about the prostate elicited a cancer-self keenly engaged in homosexual intercourse. Sexual preference was not specific criterion for recruitment and thus participants were not asked directly about it. Some of the interviewees who tended to express a strong disapproval of what they considered the over use of androgen deprivation therapy and admitted to be men who have sex with men, stated that a cancer-self would be deliberately disingenuous, rather than jeopardizing his sexual reputation by being regarded as a homosexual.

Discussion

In the aged-Japanese society more men than women suffer from cancer and prostate cancer looms large. Situation that is far from unique. The latest available worldwide statistics indicate that one out of eight, and one out of ten men and women, respectively, would develop cancer during their lifetimes (Fidler-Benaoudia & Bray, 2020), with prostate cancer being “the second most common cancer in men” (Soerjomataram & Bray, 2020, p. 28). In this light, a set of in-depth, semistructured interviews with a group of Japanese men assisted in exploring how they have come to grips with benign prostate enlargement or prostate cancer. The sexual scripts theorizing was instrumental to investigate how the three dimensions of scripting mediate the perceptions of social life and lived experiences of a cancer-self when he himself made sense of them and had to explain them to others, which undeniably conveyed particular views and experiences of reality that incorporated both overlapping and inconsistent elements of each dimension of scripting.

The analysis presented the embodiment of the prostate as a form of an index of subjectivity that enabled a reading of an embodied-male-self in contemporary Japan. At the intrapsychic level of scripting, the bodily experience of grappling with a medical condition was central in the memories of a cancer-self, which allowed him to comprehend what self he was and what self he wanted to be. In circumventing the polarizing views of “biological determinism” vis-a-vis “social determinism” (Connell, 1995, p. 52), the enfleshment of the-mechanics-of-urine encompassed a somatic experience circulating around an almost “unknown” gland, whose enlargement might be symptom of cancer, and provoked real pain and/or a burning sensation during urination, as well as the presence of blood in urine or semen. A cancer-self was thus confronted with constant somatic surveillance, (re)learning how to empty the bladder and bowels, medication/treatment side-effects, as well as unpleasant smells and irritation generated by the use of incontinence-pads.

Considering the embodiment of benign prostate enlargement or prostate cancer as a purely somatic experience could be misleading. The conversations indicated that the experience was “nuanced, complex” and influenced by “interaction, social organization, institutional arrangements, cultural processes, society, and history” (Waskul & Vannini, 2006, p. 2). An element of the sociality underneath embodying the prostate was connected to a version of what a Japanese-civilized-self means that have made the-mechanics-of-urine and genitalia-related conversations be dealt with euphemism, silence, and/or pretended ignorance. A gendered-cancer-self via intrapsychic scripting uncovered another layer of the sociality entrenched in the embodiment of benign prostate enlargement or prostate cancer, which similar to Green (2023), swayed men–women power relations and casted doubt about what “true masculinity” was; a leaking body “feminizes” a cancer-self. Alike Australian men (Oliffe, 2003), interpersonal scripting through the interactions with health care professionals added a nuance of how gendering a cancer-self (re)created taken-for-granted dualisms through the feminization of care, which largely prompted feelings of emasculation and infantilization. Prostate cancer culturally scripted as an ailment that causes erectile dysfunction and thus feminizes the self, has resulted in a cancer-self unwilling to know and feigning ignorance.

The literature has highlighted three major issues concerning prostate cancer and quality of life: “sexual function,” “intimacy,” and “awareness of aging” (Hoyt et al., 2020, p. 306), which were an element of the biological/social processes that a Japanese cancer-self came to grips with. In looking at the embodiment of benign prostate enlargement or prostate cancer from a sexuality-related perspective, in line with research on sexuality and aging Japanese men, some of the participants located “the source of their wellbeing in continuing to sustain sexual desire” (Moore, 2010, p. 150). However, they were/felt “neutered” by medication/treatment side-effects, and cultural/interpersonal scripts revolving around the idea that aging meant asexuality. As Loe (2012, p. 292) underscored, “[o]pportunities for intimacy, pleasure, and stimulation do not disappear in late life,” and the analysis of conversation unveiled a cancer-self who endorsed intimate connections decentered from the genitals, but who was challenged by “the pharmacology of sex” (Loe, 2001, p. 98), and cultural scripting that “real” sex necessitated vaginal penetration. The link between prostate cancer and sexuality exposed a cancer-self who found pleasure in prostate stimulation and advocated for careful consideration of “treatments. . .[that]. . . could cause a dramatic fall in libido as well as difficulty maintaining an erection” (Chapple & Ziebland, 2002, p. 837), but who tended to feign ignorance to protect his reputation as a “heterosexual man.”

Concerning implications for medical practice, public health and men’s health in general, the applicability of the construct of cancer-self, which was theoretically developed to analyze the conversations with the participants in this study, needs to be corroborated by clinicians dealing with benign prostate enlargement or prostate cancer at Japanese/non-Japanese settings. In structuring plans of care for an onco-self, the impact of unawareness of the prostate’s anatomy and physiology, and the-mechanics-of-urine, as well as the construct of Japanese-civilized-self, the strategy of pretended ignorance, and the prevalence of the feminization of care should be thoroughly considered. Cultural scripts that have connected benign prostate enlargement or prostate cancer to an ailment that emasculates the self, have made an aging-self synonym of asexuality, and have linked prostate stimulation to homosexual behavior should be fathomed when exploring interpersonal interactions between health care professionals and an onco-self. Finally, the theoretical frame of reference that served to read benign prostate enlargement or prostate cancer through cultural, interpersonal and intrapsychic dimensions of scripting ought to be assessed when investigating other medical conditions within/outside Japanese communities.

A main limitation of this study revolved around exploring the interpersonal dimension of scripting concerning benign prostate enlargement or prostate cancer only through the experiences of a cancer-self, which was particularly problematic when reporting and trying to grasp the social and relational processes underpinning pleasure, intimacy, and the feminization of care.

Conclusion

In answering how a cancer-self comes to grips with a range of lived-embodying experiences amalgamated with benign prostate enlargement or prostate cancer, the conversations with a group of Japanese men elicited the clinical quandary of a physical affliction whose medication/treatment side-effects could be overwhelming, and somatic knowing and the will to know being socially and medically problematic. Ignoring the prostate’s anatomy and physiology, as well as its links to the urinary system was a major issue concerning somatic knowing, which complicated further when a cancer-self was actually unwilling to know about a health condition that could be at odds with cultural, interpersonal, and intrapsychic scripts related to a Japanese-civilized-self, gender, and sexuality. A discomfited cancer-self might avail himself of pretended ignorance to grapple with morally injurious conversations about the genitals and body waste, and an ailment that allegedly emasculated the self and put at risk his sexual reputation.

Interpersonal interactions of a cancer-self with health care professionals drew the salience of the feminization of care to come to grips with benign prostate enlargement or prostate cancer, whose unintended consequence could be medical practices that (re)produce gender inequality, and the understanding that taken-for-granted dualisms are still a valid reference to grasp Japanese gender relationships. In theorizing men’s health within Japanese society from the viewpoint of the participants in the study, despite some of them clearly exhibiting reflexivity, and at the intrapsychic level of scripting, they frowned upon the ways the male-self and health have been traditionally entwined, their attempts to exercise agency were largely thwarted by medical practice underpinned by cultural, structural, and interpersonal scripts where the female- and the male-self have been conceived as “naturally” prone to provide care, and ontologically embodying health-related toxic practices, respectively.

Finally, not all participants have faced prostate cancer; nonetheless, almost everyone has tolerated the same iatrogenic consequences of medication/treatment, which enlarged cultural scripts that prostate cancer is essentially a disease of an asexual aging-self.