The sexual practice of young women in treatment for breast cancer

Abstract

Objective

To understand how the sexual practice (SP) of young women with breast cancer occurs. Method: Qualitative research; that used Symbolic Interactionism and Grounded Theory. Data collection took place between October/2017 and August/2019 in two Centers of High Complexity in Oncology, using a semi-structured guide for interviews. The guiding question was: “Tell me what it was like and what your sex life is like now after the cancer diagnosis”. Participated thirteen women with a sexual partner since the diagnosis of the disease. Results: First diagram: sexual practice is affected due to diagnosis and treatments for the disease; Second diagram: factors that contribute to its resumption are social and (mainly) affective support; Central category diagram: the companion (affective support) is the protagonist of the relationship network. Conclusion: SP is affected by the disease/treatments and its resumption occurs with the support of the partner. Implications for practice: It is necessary to address SP in health care, avoiding the distance between of the couple, reducing the anxieties and doubts of women in this condition.

Keywords:
Women; Body Image; Breast Cancer; Sexual Health; Sexuality

Resumo

Objetivo

compreender como ocorre a prática sexual (PS) de mulheres jovens com câncer de mama.

Método

pesquisa qualitativa, utilizando o Interacionismo Simbólico e a Teoria Fundamentada nos Dados. A coleta de dados ocorreu entre outubro de 2017 e agosto de 2019, em dois Centros de Alta Complexidade em Oncologia, seguindo-se um roteiro semiestruturado para entrevista. A pergunta norteadora foi: “Fale-me como era e como ficou agora sua vida sexual após o diagnóstico do câncer”. Participaram 13 mulheres com companheiro sexual desde o diagnóstico da doença.

Resultados

primeiro diagrama: a prática sexual é afetada devido ao diagnóstico e tratamentos para a doença; segundo diagrama: fatores que contribuem para sua retomada são o apoio social e afetivo (principalmente); diagrama da categoria central: o companheiro (apoio afetivo) é o protagonista da rede de relacionamentos.

Conclusão

A PS é afetada pela doença/tratamentos e sua retomada ocorre mediante apoio do companheiro. Implicações para a prática: É necessário abordar sobre PS na assistência em saúde, evitando o distanciamento do casal, diminuindo as angústias e dúvidas das mulheres nesta condição.

Palavras-chave:
Mulheres; Imagem Corporal; Câncer de Mama; Saúde Sexual; Sexualidade

Resumen

Objetivo

Comprender cómo ocurre la práctica sexual (PS) de mujeres jóvenes con cáncer de mama.

Método

Investigación cualitativa; que utilizó el Interaccionismo Simbólico y la Teoría Fundamentada en Datos. La recopilación de datos tuvo lugar entre octubre de 2017 y agosto de 2019 en dos centros de alta complejidad en oncología, utilizando un guion semiestructurado para las entrevistas. La pregunta guía fue: “Dime cómo era y cómo está tu vida sexual después del diagnóstico de cáncer”. Participaron trece mujeres con pareja sexual desde el diagnóstico de la enfermedad.

Resultados

Primer diagrama: la práctica sexual se ve afectada debido al diagnóstico y los tratamientos para la enfermedad; Segundo diagrama: los factores que contribuyen a su reanudación son el apoyo social y afectivo (principalmente); Diagrama de categoría central: el compañero (soporte afectivo) es el protagonista de la red de relaciones.

Conclusión

La PS es afectada por la enfermedad/los tratamientos y su continuación se produce con el apoyo de la pareja. Implicaciones para la práctica: Es necesario abordar la EP en la atención médica, evitando el alejamiento entre la pareja, reduciendo la angustia y las dudas de las mujeres en esta condición.

Palabras clave:
Mujeres; Imagen Corporal; Cáncer de Mama; Salud Sexual; Sexualidad

INTRODUCTION

Breast cancer in young women (up to 40 years of age)^1,2 is usually infiltrating, of larger sizes, presents advanced stages and greater compromising of lymph nodes and of vascular invasion, negative hormonal receptors, and delay in being diagnosed, which increases the risk of locoregional and distant recurrences, reinforcing the poor prognosis of the disease.³ Treatment for these women includes surgery, chemotherapy, radiotherapy and hormone therapy, either alone or in combination,⁴ which contribute to healing and increase survival, but bring psychological, physical and social damage.

Surgical treatment, which removes partial or the entire breast, influences negatively the woman’s self-esteem and self-image, affecting her personal and social life, as the breast is a symbolic organ of the woman. Their absence or mutilation can interfere with their sexuality, making it difficult for them to expose their body to their partner and making it difficult for the couple to practice sex.⁵

Chemotherapy, in addition to the most known adverse events – such as alopecia, vomiting and nausea –, also causes ovarian failure, decreasing the production of estrogen and progesterone, which induces early menopause. This leads to decreased vaginal lubrication and libido, dyspareunia and anorgasmia, factors that contribute to discomfort during sexual intercourse. All of these effects impair sexual practice.⁶

Radiotherapy can cause fatigue, diarrhea, nausea, vomiting and damage to the skin, due to radio dermatitis in the area,⁷ a fact that leads to pain and does not allow touching. Hormone therapy, on the other hand, can cause adverse events similar to those that women experience during chemotherapy, such as lack of vaginal lubrication, dyspareunia and altered libido.⁸ These factors, alone or together, end up causing discomfort during sexual practice.^7,8

There are evidences that breast cancer and all adverse events in its treatment interfere with the couple’s emotional state, sexual function and relationship.⁸ Despite this, research involving the sexual practice of young women with breast cancer is still scarce.

Thus, through these notes in the literature about the interference of treatments in the sexual practice of young women, the objective of this study was to understand how the sexual practice of young women with breast cancer occurs.

METHOD

Qualitative research that adopted Symbolic Interactionism (SI) as a theoretical reference, and as a methodological, the Grounded Theory (GT).

The SI addresses the issue of human behavior, social interaction, interpretation of symbols and their meanings (constructed, modified and reconstructed). This dynamic occurs with the process of human interaction with him/herself (self) and the processing of the meaning of things from interaction with other people (mind). The self/ego of the person’s own self, has two phases: I and me. In the “I” phase, the individual has spontaneous and natural attitudes. In the “me” phase, their attitudes are guided by their interpretations of what others think about the fact/object in question, being the individual socialized.⁹

Human interactions happen within society and, therefore, in SI, it is considered dynamic and capable of modifying acts, attitudes, thoughts, words and interpretations.

With regard to GT, the generation of the theory is possible after the researcher has gone through three stages of data analysis (open, axial and selective coding). GT guides the researcher to build diagram(s), which is(are) the graphic representation of the categories and subcategories of the phenomenon under study.¹⁰

The inclusion criteria for this study were: women diagnosed with breast cancer at most one year ago, who were undergoing treatment for the disease (surgery or chemotherapy or radiotherapy or hormone therapy), aged between 18 and 40 years and who had had a sexual partner since the diagnosis for the disease. The exclusion criterion was: women who were under palliative treatment.

The women were instructed on ethical procedures and on the researcher’s interest in the research topic; the interviews took place in a private place. The recommendations of the Resolution of the National Health Council (CNS) No. 466, of 12/12/2012¹¹ were respected and the study was approved by Ethics Committees [CAAE 69123517.2.0000.5393] and [CAAE 69123517.2.3002.8043].

Data collection took place at two High Complexity Assistance Centers in Oncology (CACON’s A and B), located in the states of São Paulo and Minas Gerais, respectively.

As for the insertion of the researcher who collected the data at CACON B, the link with the service already existed through previous contact, in another research. In CACON A, insertion was gradual, during the period of data collection. The selection of the sampling was intentional, through data collection from medical records, in order to select the women who could be included in the study.

Thirteen social actresses were invited and accepted to participate in the research – and there were no dropouts nor repeating of interviews, which were concluded when was reached the understanding of the phenomenon under study and the appearance of repeated information, without adding value to the understanding of the phenomenon investigated. The interviews were conducted individually, by one of the researchers in this study, as well as the manual transcription; the analysis and interpretation of the data was carried out by this same researcher, with the support of two authors of this work.

Data collection took place between October 2017 and August 2019, with audio recording and notes in a field diary, lasting an average of 28 minutes. The guiding question was: “Tell me how it was like and how your sex life became after the cancer diagnosis”. GT validation took place by means of a research participant (I8) and two experts, one from the research theme and the other from the methodology.

RESULTS

Central Category Diagram

According to the GT, data analysis from the interviews (open and axial coding) was performed. Subsequently, selective coding was carried out, refining and integrating subcategories and categories (selective coding) that emerged from the previous codifications (open and axial), thus building the central category of the study (GT), presented through the following diagram (Figure 1). It should be noted that the diagrams (Figures 2 and 3) were generated from the open and axial coding.

Figure 1
Central category diagram (GT): The sexual practice of young women with breast cancer: understanding the factors that affect its maintenance and those that contribute to its return.

Figure 2
Understanding the sexual practice of young women with breast cancer.

Figure 3
Understanding coping strategies for the resumption of the sexual practice

GT allowed to understand how the sexual practice of young women with breast cancer occurs – with it being affected by the diagnosis of the disease and its treatments – and its resumption by means of social (health professionals) and affective support (partner), being the affective configured as a key element for the effective resumption of the sexual practice of the couple.

First Diagram

The first diagram was consisted of the category “factors that affected sexual practice”, composed of two subcategories, called “the emotional and physical disorders of the discovery of breast cancer” and “treatments for breast cancer” (Figure 2).

The young women participating in the research told us that when they received the diagnosis, their sexual practice was affected because life “lost its grace”, they felt “depressed” and tried to “assimilate” what was happening to them. Their concerns turned to illness and treatments, in addition to the lump in the breast, reported by some, that caused pain. These factors made them not feel like having, neither think about sex at that moment.

Yes, it (sexual practice) was interrupted! It was difficult to accept what was happening to me. I couldn’t assimilate, I couldn’t believe it! I didn’t feel like it, I was worried if the treatment was going to work, if I was going to live, I was going to die, how would I stay (I1).

We have a small lump, it hurts (when touching the breast) (I5).

Thus, the announcement of the existence of breast cancer affected them psychologically.

Knowing that I have cancer bewildered me! It messed with my psychological! I can’t (think about sex at that moment) (I11).

The young women said that there were two stages in their lives, one that occurred before and the other after the diagnosis of the neoplasm. The announcement of the disease generated insecurity and fear of losing the partner, perhaps because they built the concept that breast cancer and its treatments modify the body and damage the couple’s emotional relationship.

[...] I was always very confident, I had many boyfriends, I was never alone. Now, I was a little afraid of being rejected, we think that nobody will want to be with you [...] I have cancer! (I4)

The change in the sexual practice of young women is associated with the affective relationship prior to the diagnosis of breast cancer. The changes occurred differently for each woman, as we can see in the statements below.

Today it is obvious that it is not as it was before, because of my indisposition! It is not as often, it is not daily, but it is super easy (I1).

It is better now than before. He is much more affectionate now than before, more concerned with me! (I6)

I was already having problems with my husband in this matter (sexual practice), but, in terms of the disease, nothing changed. It was not better because the marriage wasn’t good. I’m avoiding it because I don’t feel like having it with him (I7).

Thus, in view of the problem created by the diagnosis, the women (and the men) discovered the need to react to this new situation, considering treatments as a priority.

The second subcategory, therefore, addresses the way that the treatments affected the sexual practice of these women. They refer to breast surgery as a “mutilating” procedure, which made them feel “less feminine”, “less woman”, causing difficulties in maintaining the couple’s sexual relationship, due to the shame of revealing the body, the presence of the drain, surgical incision, healing process and difficulty in touching the operated area – factors that affected their self-esteem. Of the 13 women, five had undergone total mastectomy and one had quadrantectomy.

I was left with an open stitch, I was afraid and concerned that maybe if I had it, it could damage the stitches, the healing. The thing here is uncomfortable, the catheter, the expander, sometimes you can’t lie on your side, hug! And afraid, ashamed of showing my body, taking off my clothes, besides that, the desire is the same (I4).

The touch (on the breast), we stay a little like this, but I think the husband stays even more! Because the bruised breast, we feel ugly, there are “ups and downs”! (I5).

Breast reconstruction was not seen as something positive for sexual practice, as it did not rescue the breast and still brought scars, changes in sensitivity to touch, and its strangeness in the sexual relationship.

In the end, that was it, it was the lack of my breast, I miss it when I look at myself, I didn’t get used to it, I don’t feel like having it (sexual intercourse). I will have surgery (breast reconstruction) but I will not have a nipple anymore, it is different from a normal breast. The problem is in my head (in the difficulty of having sex with my partner). It may be that I put the prosthesis and continue with the same paranoia (I2)

Regarding chemotherapy and hormone therapy with tamoxifen, the young women, as they were of childbearing age (reproductive years), developed early menopause – an adverse event of these therapies –, in addition to vaginal dryness, dyspareunia, lack of desire, which influenced in sexual practice. Of the 13 women participating in the research, 12 received chemotherapy for the treatment of cancer.

The penetration is horrible, I can’t have sex with my husband (due to vaginal dryness). Where’s all that desire I had? I miss it, because I know I can have an orgasm, but I don’t have libido anymore. The doctor said that this comes from tamoxifen, because I entered an early menopause. What was going to happen after the age of 50, I’m going through in my thirties ... [...] (I2).

Vaginal dryness and dyspareunia, resulting from the treatment, may improve with the end of the treatment, as shown in the statement.

The difficulty is dryness during the chemo, now it’s back to normal, after the chemo is over! (I9)

To minimize these discomforts, the use of intimate water-based lubricants is indicated, in addition to the use of condoms, to protect women from pregnancy and sexually transmitted infections (STIs).

The doctor prescribed a medicine for me so I don’t feel so much pain! Until then, I didn’t think I could use anything. It will get better, I will have more intimacy, getting closer to my husband, because this issue of the sexual act was being set aside, because of my blocking (I3).

(During) the treatment there is the fact of protecting yourself. I didn’t use a condom, because we tried to get pregnant, now we need to use it. I am afraid that I will get something from him, even though he is healthy. I felt that it (the condom) has taken away the desire for the sexual act, on my part (I3).

In addition, the occurrence of nausea, fever, weight gain, fatigue and headache, also interfered in the couple’s sexual practice.

In chemotherapy, one week, we feel sick! Nausea, nausea, headache, fever, itchy arms, you don’t even want to drink water, you are weak, bad (I10)

Ah, I gained 14 kilos [...] (I1)

We have no relationship after the chemo, because it leaves me tired, panting, doing nothing, you get tired (I5).

Another adverse event of chemotherapy is alopecia. The loss of hair and eyebrows were characterized by great physical discomfort, causing sadness and anguish, and also caused changes in sexual behavior. Visible to other people, alopecia shows the sick person and the woman less feminine and sexually with another body, which affects sexual practice. In an attempt to improve her body image with her partner, and try to maintain her own self, the woman uses aesthetic resources.

Since the beginning of chemo, I wanted no more (sex)! In fact, it’s the appearance, as I did the first chemo, and it was going to trigger everything (including hair loss), I’ve already blocked myself there! In chemotherapy, the woman has vanity, it is hair that falls, it is an eyebrow. I didn’t feel comfortable, I already blocked myself there (for sexual practice) (I1).

[...] you will have sex with your husband, I don’t stay bald, I wear a turban! I tell him not to put his hand on my head! And I use the turban all night (I5)

In this study, radiotherapy, despite causing a lot of fatigue, did not interfere in the sexual sphere.

I went for a walk and explained to him (doctor) that I am feeling fatigue. I didn’t know that it (radiotherapy) could cause this, and he told me that it can (I6).

Second Diagram

Composed of the category “social and affective support for the resumption of sexual practice”, it presented two subcategories: “the health professionals” and “the partner” (Figure 3).

The subcategory “the health professionals”, characterized as social support, showed that they found it difficult to address the implications that treatments could have on the sexual relationship of the women they care for. The silence that existed between them – health professionals and women – issued commands to the “self” and caused on the women to sexually distance themselves from their partners.

There were some (doctors) that you will talk about the subject (sexual practice), it seems that it is not their area, they do not want to talk about it. When I enter the office, they want to talk about the tumor, they want prescribe things in relation to the tumor, other than that, it doesn’t matter to them (I2).

Nobody told me about it (sexual practice), some questions I asked, there was no guidance (I4).

The women said that when they received guidance, these were superficial, similar to a medicine leaflet.

[...] they just told me like this (the doctor): The hormone makes this happen! They just told me the basics, look, with the hormone you will enter an early menopause, there will be no more lubrication. Like a leaflet (punctual explanation like a medical package insert), you know? Doesn’t the package insert come with contraindications? That’s all they told me! (I2)

The testimonies bring up the taboo, which still exists, in discussing the topic of sexuality in health care, and the woman seems to be “asexual” in the face of “her main problem”, which is cancer.

[...] I only received a piece of paper, which I would then have to read to know that having sex is good for the patient, but nobody explained anything to me (...) so, you skip these parts, when it got to my hands everything was already fine (laughs)! It was already resolved! It is rather us asking, than them talking about it (I6).

Thus, in search of answers to their questions, women resorted to internet research and participation in support groups.

Internet! Everything I want to know (about sexual practice during cancer and its treatments), I go there and Google it, and Google explains a few things to me! I have the doctor who is treating me, I think he had to pass this on! I don’t know if (he) doesn’t have time, because there are a lot of people, but couldn’t they make some time? To have a professional who may be dealing about this with you? (I2)

Where I live there is the pink house, we gather women who have already had breast cancer or someone who is undergoing treatment, another who has already finished, we talk a lot. Then, the girls play, look, have it a lot, if it’s good for your health, even if you don’t want to, have it, it does good (I8)

However, even using the internet and support groups, they felt the need to turn to a health professional to guide them.

I talked to the psychologist and she advised me that I should try to have a normal life (in relation to sexual practice). I was getting kind of restricted on this matter. I am talking to her so that I can understand this, be more calm and try to maintain a healthy, active and fearless activity, that it will (not) harm me in any part of the treatment, because that was what was blocking me and it will not harm me (I3).

Thus, it is understood that the scarcity of information and guidance by health professionals may have contributed to these women experiencing such a period with more suffering and difficulties.

No, no one spoke to me (about sexual practice)! After I stayed with him, then I saw that it doesn’t hinder (I13)

The subcategory “the partner”, characterized as affective support, portrayed that the beginning of this trajectory was marked by challenges, as the companions showed a certain strangeness when facing his wife’s new body situation.

The first difficulty was this of us understanding each other, no matter how much support he gave me, my husband looked at me strangely! That was strange for him! The breast removal! Imagine, you have both breasts, and suddenly, at the time he stares [...]! You see, he tries not to speak, he tries to disguise! At first, he tried to give me as much support as possible, but we are not stupid, the person looks at you that way [...], disguising it, understand? (I2)

Willing to overcome this obstacle, the partners understood that it was necessary to support their wife and help her to overcome the difficulties that presented themselves to the couple. And then, the partner shows up, in their testimonies, as the protagonist of the network of relationships (affective support), throughout the disease process and its treatments.

[...] everyone says it is a phase and it will pass. He says that to me! That my hair will grow, your breast will operate and remove everything, then we put a silicone! He talks like that to me, so it will pass, God willing (I5)

To strengthen the relationship and understand more about what his wife was experiencing, the partner started to go with her to medical appointments, chemotherapy and radiotherapy sessions, in order to answer her doubts and better understand the situation that the couple was experiencing.

Now he went back to work, because from the beginning he stopped, he just accompanied me, he stayed with me at the appointments, chemotherapy, he was always doing things for me! He sometimes asked (the doctor): Look, can she have sexual relationship? But she complains that it hurts a lot [...]! So, we would clear our doubts (with the doctor), he would ask! (I1)

The couple, then, came to the conclusion of the importance of the approaching and of the dialogue between them and that this could contribute to the resumption or continuity of sexual practice.

I feel good talking to him! We always talk, whenever we are together, we talk about it (sexual relationship), about my body, about being together, about him accepting me the way I am, the way I want, the way I can (I4)

And, it is made clear that everything improves when communication between the couple is satisfactory, as the degree of importance of breast loss decreases. Cherishing is made present, with more caring, and the breast, which was the target of the couple’s concerns, is caressed and touched.

So, it’s that sweetness to touch, you don’t know how to do it, do you understand? (I2)

The situations that provided intimacy and showed the partner the marks of surgical treatment, also contributed to bringing the couple closer together, increasing the acceptability of women of their new physical condition.

You know, watch me shower, watch me change clothes! It was only at the very beginning (ashamed to reveal the body)! Then it changed, it returned to normal (I9).

The compliments of the partner, turn into positive actions in coping with the disease, as women feel more valued, loved, and this also encourages them towards the resumption of sexual practice.

The person who is with you has to praise you, even if you are like that! It is what happens to me, which is making me feel good, having found someone to do this for me, he praises me and I feel the way he talks to me and helps in the treatment (I4).

Each woman resumed sexual practice at her own time, and they reported that this (sexual practice) was respected by the partner.

About three months later! Why three months later? Because first I went through the surgery, after the surgery comes the healing, you have that period that you are weak, and mainly, because it is that thing, you lie in bed and he looks (at you without a breast). We liked to do it, we liked sex, but at that time, we were both being strangers, because we didn’t know how to deal with me and I didn’t know how to pass it on to him (I2)

This issue of patience, even understanding people’s time, understanding fears, waiting for my time (I9)

In addition to waiting for the ideal moment, other strategies were pointed out by the young actresses, in the sense that the couple resumed sexual practice.

I am ashamed to take my clothes off. Not the blouse! I won’t! We entered into an agreement, not yet! But he always respects my limit! Maybe if I did not give that limit or if I wanted to take off my shirt, maybe I would not accept it, it would not be so pleasant (I4)

It was in the dark! [...] because it is the same as I told you, it changes, we make less of a mess (laughs)! Yeah, couple games! Now everything is slower. Paced down. You know, that is it! We think it is a super complicated situation (I5)

[...] he (partner) was afraid of hurting the breast. Then, if he rubbed himself on my chest, I would push him back (I10)

The participants also mentioned that they used adaptations of position and of the type of sex.

A sexual practice that we still have today is oral sex, it is what we make use of, oral sex, do you understand? (I2)

[...] the penetration took place, I was lying on my back, and I could not turn to one side or the other, that is how we managed to do it. It is fine, for me, it is great (I6)

Thus, they reported to us about how the couple faced adversity and overcame the challenges in order to resume sexual practice.

DISCUSSION

Studies indicate that the woman affected by breast cancer, who had a harmonious and stable relationship with her partner, tends to continue living in a harmonious relationship, even with the disease – a fact that contributes to a family reorganization and reconstruction, in addition to physical damage, emotional and social effects imposed by treatments.¹² At the same time, relationships with problems tend to get worse or come to an end.¹³

Breast surgery affects femininity and body esthetics, especially in young women, who generally care more about the body. The lack of part, or the whole breast, makes her feel less attractive and creates insecurity towards her partner, affecting sexual practice.¹⁴

For the young women in this study, breast surgery caused disorders in their affective relationships and, when they started to have sex with their partner again, they were ashamed to be naked before them and reveal a “defective body”, which reminded them that they were sick.

In this sense, difficulties with body image and the regret of reducing femininity and sexual appetite may continue, even with breast reconstruction surgery.¹⁵ Thus, it is important to contemplate the concept of self-image, which concerns the mental representation that the person has about their body¹⁶ (self); and self-esteem, the feeling we have towards ourselves, and the acceptance and approval of others is important in the development of this concept by these women.¹⁷

Still in relation to treatments for breast cancer, the literature points out that women undergoing chemotherapy have a higher risk of sexual dysfunction when compared to those who have not received therapy, as they have early menopause, vaginal atrophy, decreased sexual desire, anorgasmia, fatigue and ache.¹⁸

Regarding induced menopause, the research findings are in line with the literature,¹⁹ as the reports show that this adverse event had a negative influence on the couple’s sexual practice. The extent and permanence of damage from estrogen deficiency by chemotherapy will depend on the woman’s age, dose and duration of chemotherapy treatment, the impact being usually more severe in young patients. As chemotherapy can affect reproductive capacity,^18-21 it is believed that it is important to talk to the couple, before starting treatment, about the desire or not to have children for referral to the fertility clinic.

Regarding the adjuvant treatment modality, other adverse events appear – such as increased body weight^22-26 –, reinforcing the importance of having a physical exercise routine, which can help to reduce adverse drug events, relieve anxieties and concerns. Experts say that physical activity is even able to improve the prognosis of the disease.^27,28

Both obesity and alopecia affect physical appearance and lead to changes in sexual behavior,^29,30 as well as mastectomy, and these adverse events damage the body image and modify the woman’s self, based on her interpretation of the symbols; or even through her social interaction with her partner.

The haircut must be guided before the chemotherapy phase, as the woman and the people get used to the new face; so, when the hair starts to fall out, there is a decrease in suffering. The use of makeup is also another important guideline, as it can contribute to raise self-esteem, remembering the importance of advising the woman to talk to the oncologist and see which products are clear for use, so as not to cause allergic reactions and other damages.

Another factor that also affected sexual practice was the use of condoms, recommended in order to avoid pregnancy and sexually transmitted infections (STIs). A pregnancy, during chemotherapy, can cause damage to the fetus³¹ and, because it is an immunosuppressive treatment, STIs can be more easily installed.³² The use of condoms should be of primary orientation to the couple, because, in a stable union in our society, it is little accepted.

In this study, the guidelines from health professionals (social support) were incipient and little enlightening as to the adverse events of treatments in the couple’s sexual practice. They would even guide, but only when the women and/or partners reported to them and asked for some kind of clarification. The little or lack of guidance contributed to the partners of these women, together with them, to seek strategies to resolve the situation that afflicted them. The study revealed that the partner (affective support) has particularities that surpass, in intimacy, other family relationships. The partner’s presence was essential in all stages of the treatment of his wife, who needs his support for the rehabilitation process.³³

Thus, aware of the importance of this role, the partner begins to support his wife in difficulties and encourages her to overcome the challenges, as she understands that together they will overcome adversity more easily, with the emotional support of each other.³⁴

In order to provide this support, the couple begins to reinvent themselves and adapt the sexual relationship to the current circumstances, and consequently, the surgical scar is not revealed during the sexual act, as the woman wears clothing, has sex only in the dark, agree not to touch the operated breast, in addition to varying positions in the sexual act, corroborating with studies already carried out.^13,35,36

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The central category is configured: the partner presents himself as the protagonist of the network of relationships (affective support) in the whole process of the disease and treatments for his wife’s breast cancer. She is faced with a new condition permeated by physical and emotional disorders, which affect the couple’s sexual practice. He understands what was happening to her and is willing to contribute, helping her to overcome the difficulties arising from this process, providing an adjustment of the situation.

With such procedure, the partner valued and empowered her, encouraging her to overcome the fear and insecurity of having sex with him, thus resuming sexual practice. The difference in this process, therefore, was the fact that the partner was ready to adjust the relationship for the resumption of the sexual practice.

The theme is still little discussed in the literature and health professionals have difficulty in addressing it during their work practice, requiring transformations, especially in the academic training of these professionals. In relation to nurses already inserted in the job market, there is a need for reflection and ways to train them for such an approach during their work.

As future perspectives for work involving this young audience, the possibility of investigating the habits and lifestyles of these women is envisaged.

ACKNOWLEDGMENT

To the General Director of the Federal Institute of Education, Science and Technology of the South of Minas Gerais - Campus Muzambinho, for the authorization of the leave for qualification, according to public call notice CPPD - Muzambinho No. 03/2018.

REFERÊNCIAS

• ¹
  Elkum N, Dermime S, Ajarim D, Al-Zahrani A, Alsayed A, Tulbah A et al. Being 40 or younger is an independent risk factor for relapse in operable breast cancer patients: the Saudi Arabia experience. BMC Cancer. 2007;7(222):222. http://dx.doi.org/10.1186/1471-2407-7-222 PMid:18053234.
  » http://dx.doi.org/10.1186/1471-2407-7-222
• ²
  Cammarota MC, Santos GC, Daher JC, Esteves BP, Barcelos LDP, Soares DAS et al. Reconstrução mamária em mulheres jovens e suas peculiaridades. Rev Bras Cir Plást. 2018;33(1):3-11. http://www.dx.doi.org/10.5935/2177-1235.2018RBCP0002
  » https://doi.org/http://www.dx.doi.org/10.5935/2177-1235.2018RBCP0002
• ³
  Anders CK, Johnson R, Litton J, Phillips M, Bleyer A. Breast cancer before age 40 years. Semin Oncol. 2009;36(3):237-49. http://dx.doi.org/10.1053/j.seminoncol.2009.03.001 PMid:19460581.
  » http://dx.doi.org/10.1053/j.seminoncol.2009.03.001
• ⁴
  Lopes JSOC, Costa LLA, Guimarães JV, Vieira F. A sexualidade de mulheres em tratamento para o câncer de mama. Enfermería Global. 2016;43:369-87.
• ⁵
  Prates ACL, Freitas-Junior R, Prates MFO, D’Alessandro AAB, Veloso MF. Indicadores de insatisfação relacionados à imagem corporal em pacientes submetidas à mastectomia. Rev Bras Mastologia. 2014;24(1):23-8. http://dx.doi.org/10.5327/Z201400010005RBM
  » http://dx.doi.org/10.5327/Z201400010005RBM
• ⁶
  Santos DB, Santos MA, Vieira EM. Sexualidade e câncer de mama: uma revisão sistemática da literatura. Saude Soc. 2014;23(4):1342-55. http://dx.doi.org/10.1590/S0104-12902014000400018
  » http://dx.doi.org/10.1590/S0104-12902014000400018
• ⁷
  Hammerschmidt KSA, Rosa LM, Alvarez AM, Radunz V, Tomasi AVR, Valcarenghi RV. Comportamento sexual das mulheres em tratamento radioterápico. Cienc Cuid Saude. 2016;15(1):194-201. http://dx.doi.org/10.4025/cienccuidsaude.v15i1.25064
  » http://dx.doi.org/10.4025/cienccuidsaude.v15i1.25064
• ⁸
  Verenhitach BD, Meideiros JN, Elias S, Nazário ACP. Câncer de mama e seus efeitos sobre a sexualidade: uma revisão sistemática sobre abordagem e tratamento. Femina. 2014;42(1):1-8.
• ⁹
  Blumer H. A natureza do Interacionismo simbólico: teoria de comunicação: textos básicos. São Paulo: Mosaico; 1980.
• ¹⁰
  Strauss A, Corbin J. Técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre: Artmed, 2008.
• ¹¹
  Resolução n. 466, de 12 de dezembro de 2012 (BR). Dispõe sobre diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União, Brasília (DF), 13 jun 2013.
• ¹²
  Silva CMC, Vargens OMC. Woman experiencing gynecologic surgery: coping with the changes imposed by surgery. Rev Lat Am Enfermagem. 2016;24:e2780. http://dx.doi.org/10.1590/1518-8345.1081.2780 PMid:27579935.
  » http://dx.doi.org/10.1590/1518-8345.1081.2780
• ¹³
  Sampaio ACP. Mulheres com câncer de mama: análise funcional do comportamento pós-mastectomia [dissertação]. Campinas: Universidade Católica de Campinas; 2006.
• ¹⁴
  Silva SÉ, Vasconcelos EV, Santana ME, Rodrigues IL, Leite TV, Santos LM et al. Representações sociais de mulheres mastectomizadas e suas implicações para o autocuidado. Rev Bras Enferm. 2010;63(5):727-34. http://dx.doi.org/10.1590/S0034-71672010000500006 PMid:21103764.
  » http://dx.doi.org/10.1590/S0034-71672010000500006
• ¹⁵
  Inocenti A, Santos MA, Loyola-Caetano EA, Magalhães PAP, Panobianco MS. Repercussão dos efeitos da cirurgia reconstrutora na vida de mulheres com neoplasias da mama. Texto Contexto Enferm. 2016;25(2):1-9.
• ¹⁶
  Capisano HF. Imagem corporal. In: Melo J Fo, organizador. Psicossomática hoje. Porto Alegre: Artes Médicas; 1992. p. 179-92.
• ¹⁷
  Peña CG. Enfrentando o câncer: cuidados com a imagem pessoal. São Paulo: Senac; 2013.
• ¹⁸
  Young-McCaughan S. Sexual functioning in women with breast cancer after treatment with adjuvant therapy. Cancer Nurs. 1996;19(4):308-19. http://dx.doi.org/10.1097/00002820-199608000-00007 PMid:8768689.
  » http://dx.doi.org/10.1097/00002820-199608000-00007
• ¹⁹
  Ganz PA, Greendale GA, Petersen L, Kahn B, Bower JE. Breast cancer in younger women: reproductive and late health effects of treatment. J Clin Oncol. 2003;21(22):4184-93. http://dx.doi.org/10.1200/JCO.2003.04.196 PMid:14615446.
  » http://dx.doi.org/10.1200/JCO.2003.04.196
• ²⁰
  Archibald S, Lemieux S, Byers ES, Tamlyn K, Worth J. Chemically-induced menopause and the sexual functioning of breast cancer survivors. Women Ther. 2006;29(1-2):83-106. http://dx.doi.org/10.1300/J015v29n01_05
  » http://dx.doi.org/10.1300/J015v29n01_05
• ²¹
  Ochsenkühn R, Hermelink K, Clayton AH, von Schönfeldt V, Gallwas J, Ditsch N et al. Menopausal status in breast cancer patients with past chemotherapy determines long-term hypoactive sexual desire disorder. J Sex Med. 2011;8(5):1486-94. http://dx.doi.org/10.1111/j.1743-6109.2011.02220.x PMid:21366876.
  » http://dx.doi.org/10.1111/j.1743-6109.2011.02220.x
• ²²
  Martins LC, Ferreira C Fo, Del Giglio A, Munhoes DA, Trevizan LL, Herbst LG et al. Desempenho profissional ou doméstico das pacientes em quimioterapia para câncer de mama. Rev Assoc Med Bras. 2009;55(2):158-62. http://dx.doi.org/10.1590/S0104-42302009000200019 PMid:19488651.
  » http://dx.doi.org/10.1590/S0104-42302009000200019
• ²³
  Tartari RF, Busnello FM, Nunes CHA. Perfil nutricional de pacientes em tratamento quimioterápico em um ambulatório especializado em quimioterapia. Rev Bras Cancerol. 2010;56(1):43-50.
• ²⁴
  Silva BB, Fernandes RC, Martins KA, Machado MGI. Influência da quimioterapia no peso corporal de mulheres com câncer de mama. Comum. Ci Saúde. 2010;21(3):245-52.
• ²⁵
  Peto R, Davies C, Godwin J, Gray R, Pan HC, Clarke M et al. Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100 000 women in 123 randomised trials. Lancet. 2012;379(9814):432-44. http://dx.doi.org/10.1016/S0140-6736(11)61625-5 PMid:22152853.
  » http://dx.doi.org/10.1016/S0140-6736(11)61625-5
• ²⁶
  Sampaio HAC, Oliveira NM, Sabry MOD, Carioca AAF, Pinheiro LGP. Influência do tipo de terapia antineoplásica sobre marcadores antropométricos e dietéticos em mulheres portadoras de câncer de mama. Rev Bras Cancerol. 2012;58(2):223-30.
• ²⁷
  Prado BBF. Influência dos hábitos de vida no desenvolvimento do câncer. Cienc. Cult. 2014;66(1):21-4.
• ²⁸
  Seixas RJ, Bosso AGO, Marx AG. Exercício Físico Aeróbico e Câncer de Pulmão: um Estudo de Revisão. Rev Bras Cancerol. 2012;58(2):267-75.
• ²⁹
  Freire MM, Hagen BM, Lima CF, Oliveira LLF, Pinto LMTR, Santos AAP. Câncer de mama e seus tratamentos: repercussões na sexualidade vivenciada por mulheres. Rev. Enferm UFPE Online. 2017;11(11):4511-4.
• ³⁰
  Machado MX, Soares DA, Oliveira SB. Significados do câncer de mama para mulheres no contexto do tratamento quimioterápico. Physis Rev Saúde Col. 2017;27(3):433-51. http://dx.doi.org/10.1590/s0103-73312017000300004
  » http://dx.doi.org/10.1590/s0103-73312017000300004
• ³¹
  Costa TS, Capeletti CP, Mello ML, Vieira PR, Brum MD, Krabbe EC et al. Escola, sexualidade, práticas sexuais e vulnerabilidades para as infecções sexualmente transmissíveis. Rev. Interd. Ens. Pesq. Exten. 2016;4(1):75-84.
• ³²
  Kelvin JF, Steed R, Jarrett J. Discussing safe sexual practices during cancer treatment. Clin J Oncol Nurs. 2014;18(4):449-53. http://dx.doi.org/10.1188/14.CJON.449-453 PMid:25095299.
  » http://dx.doi.org/10.1188/14.CJON.449-453
• ³³
  Talhaferro B, Lemos SS, Oliveira E. Mastectomia e suas consequências na vida da mulher. Arq Ci Saúde. 2007;14(1):17-22.
• ³⁴
  Hirschle TMR. Mulheres mastectomizadas e seus parceiros: representações sociais do corpo e satisfação sexual [dissertação]. João Pessoa: Universidade Federal da Paraíba; 2016.
• ³⁵
  Gasparelo C, Sales CA, Marcon SS, Salci MA. Percepções de mulheres sobre a repercussão da mastectomia radical em sua vida pessoal e conjugal. Ci Cuid Saúde. 2010;9(3):535-42. http://dx.doi.org/10.4025/cienccuidsaude.v9i3.12557
  » http://dx.doi.org/10.4025/cienccuidsaude.v9i3.12557
• ³⁶
  Rocha JFD, Cruz PKR, Vieira MA, Costa FM, Lima CA. Mastectomia: as cicatrizes na sexualidade feminina. Rev. Enferm. UFPE Online. 2016;10(5):4255-63.

Edited by

ASSOCIATED EDITOR

Ana Luiza de Oliveira Carvalho

Publication Dates

• Publication in this collection
  10 May 2020
• Date of issue
  2020

History

• Received
  12 Dec 2019
• Accepted
  13 Mar 2020