Embodied hegemonies: moral dilemmas in the onset of prostate cancer*

2 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To interpret the meaning attributed to men’s experience regarding their body during the development of prostate cancer. Method: Ethnographic study carried out with men and guided by the narrative method and the theoretical frameworks of medical anthropology and the anthropology of masculinities. Information was obtained through recorded interviews, direct observation, and logs from a field journal, which were examined using inductive thematic analysis. Results: Seventeen men participated in the study. During the process of falling ill with prostate cancer, the male bodies were ruled by moral experiences that influenced the way men conducted their relationship with their health and multifaceted masculinity, standing for hegemonic cultural principles and identity affirmation moral dilemmas, which were interpreted with the meaning of embodiment. Conclusion: During the development of the disease, men experience bodily, social, and moral dilemmas that threaten the hegemonic masculinity. Understanding them can help professionals deal with this population.


INTRODUCTION
Gender is a term used in anthropology to define social roles, identities, and ideologies in a group, and because it is built up and deconstructed by culture, it is not either set by the species or predetermined at birth: it is mutable, shaped, and mediated by the social actions that rule it (1) .Consequently, the male gender is an analytical category of potentialities embodying several identities that, depending on the acts upheld by their articulators, value them in their relationships with society.
When falling ill, the male body undergoes a number of changes because it becomes physically vulnerable, causing men to adopt acts that limit their social functions and potentialities, such as dependence on care and embodiment of non-hegemonic identities which make them incapable of upholding types of virility culturally valued among male groups, such as control of the body, its functions, its image, and its actions (2)(3) .
Researchers (4) endorse this statement and specify that the illness caused by prostate cancer (PC), the experience with treatments for it, and the difficulties faced are factors that influence the construction of masculinity and coping strategies of health processes.
The incidence of male cancers has increased worldwide over the years.For 2018, a risk of 66,120 new cases of PC for each one hundred thousand Brazilian men was estimated, and the incidence is six times higher in developed countries, such as United States, Canada, and England (5) .However, the reality of the development of PC goes beyond these numbers, spanning the incorporation of the survivor identity by these men, because the way they care for their bodies and show them to society and the way they deal with their culture and their masculinity before other men relate to local, regional, and global processes that symbolize hegemonic ideologies of what being a sick and surviving man is (1,6) .
In this scenario, the concepts of body and masculinity present themselves as an amalgam, with the first being a substrate in which men uphold their relationships between the biological and social aspects (2)(3) , and the second an analytical source to understand the multiple cultural identities imposed to the male body (7) .These concepts provided the basis for the present study through the theoretical frameworks of the anthropology of masculinities and medical anthropology with the objective of answering the following question: "what is the experience of men regarding their body when developing PC?".
To answer this question, a systematic review of the Brazilian and international literature was carried out in the Latin American and Caribbean Center on Health Sciences Information (LILACS -Literatura Latino-Americana e do Caribe), the Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL).The Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) scientific descriptors "masculinidade", "neoplasias da próstata", "masculinity", and "prostatic neoplasms" were used, with the search refined by the application of the Boolean operator "and".Twenty-seven references published between 2008 and 2017 were selected, in which few studies with a qualitative approach and centered at the topic under consideration were found.Most of the chosen investigations limited their discussion to men's health before their masculinity and sexuality, excluding the body and its symbols.In the face of this scenario, the objective of the present study was interpreting the meaning attributed to the experience of men regarding their body during the development of PC.

Study deSign
This was an ethnographic study guided by the narrative method and the theoretical frameworks of medical anthropology and the anthropology of masculinities.
The narrative ethnographic method was used because it coordinates multiple data collection techniques (triangulations), such as participant observation, interviews, logs from field journals, and documentary analysis, making up a structured field, assuming the organization and ranking of the elements in its content (8) .
As a way to impart meaning to what is lived, this method allows the insertion of life worlds (narrator and listener) as a constructive characteristic of the narrative (merging of horizons) that allows researchers to achieve a tacit knowledge (information about culture that is rooted not only in verbal experiences), with emphasis on life transformations (9)(10) .
According to medical anthropology, diseases are not just a biological or physical process, but also the result of the influence of the cultural context and the subjective experience that the body has problems (11) .From the perspective of the anthropology of masculinities, a theory that examines the positions of power established in gender relationships, health and disease are mediators of the practices through which men and women compromise with the male and female places in society and their effects on the bodily experience and culture (7) .

PoPulation
Inclusion criteria of the present study were: being diagnosed with PC under treatment for at least three months, being at least 18 years old, and having declared to be in physical and psychic conditions to report their experience.Seventeen men whose therapeutic follow-up was in progress in a teaching hospital in the interior of the Brazilian state of São Paulo participated in the study.

data collection
Data were collected individually using in-depth interviews and observation of the study context.Information gathered through both methods were registered in a field journal at facilities of the hospital complex and places that the participants considered appropriate for reporting their experiences, such as households, street markets, work places, and leisure centers.Collected data were the product of the relationship between researchers and participants during several significant moments of the patients' life, such as appointments and exams, interactions with relatives and friends, and social moments with other men.Each meeting was guided by an initial script to help data collection, clinical data were extracted from the participants' medical records, and information related to their experiences was gathered through in-depth interviews.In the latter, the answers were evoked by guiding questions, including: What do you know about this type of cancer?Why did you have this disease?How does it feel like to deal with the treatments?What has changed in your life?What do you do to take care of your health?Has your life as a man changed?It is important to emphasize that other questions were formulated specifically for each participant as they expressed the meanings of their experiences, so researchers could access the details of each history and actions carried out.After each meeting, data were compiled and analyzed, with the possible reflections recorded in the field journal, allowing to raise new questions that were discussed in further detail in subsequent meetings.Field immersion lasted 36 months and was concluded only when the proposed goal was achieved, data began to become repetitive, indicating saturation, and new meanings were not added.

data analySiS and treatment
Individual narrative syntheses followed by collective narrative synthesis were formulated to understand the reported experiences better.After this step, the texts were submitted to inductive thematic analysis (12) , and similar and specific aspects of the narratives were integrated and presented as a thematic narrative synthesis entitled: "The male body in the prostate cancer disease process".The narratives of the participants are highlighted in italics as primary interpretation, reproduced as they were told, and also exemplify the researchers' analysis.

ethical aSPectS
The present investigation was approved by the Research Ethics Committee of the Ribeirão Preto College of Nursing at the Universidade de São Paulo as per protocol no.054/2013, and all the ethical principles were met during the development of the study, in accordance with Resolution 466/12 of the Brazilian National Health Council.All the participants signed a free and informed consent form and their anonymity was ensured by replacing their real names by fictitious ones.

RESULTS
Regarding social and clinical characteristics, most of the participants were married, Catholic, lived in the city of Ribeirão Preto, located in the Brazilian state of São Paulo, owned their place, were retirees, had incomplete elementary school, and were between 61 and 81 years old.All the participants were submitted to radical prostatectomy and experienced the problems associated with erectile dysfunction and urinary incontinence.Five patients also underwent radiotherapy sessions and three, simultaneously to the conventional medical treatment, resorted to complementary therapies with medicinal herbs and teas.

the male body in the develoPment of ProState cancer
The prostate was recognized as an organ present in the male body, but because it is located in a region socially ruled by cultural standards and values, men identified its functions related to biological and social characteristics as follows: (...) being useful to provide the urine jet with pressure, being responsible for blood circulation in the penis, helps during sex, related to macheza (masculinity), strength, beard, body hair and muscles, and above all, has the function of connecting them with the things in the world and make people recognize that the things they do differ from those that women do (...), that is, establishing their gender identity and masculinity (Cauã, Marcos, Joaquim, Miguel, Fabio, and Reinaldo).
In the narrators' lay explanation model, the sign that their body was not normal came as a body change, expressed when men could no longer perform their physiological functions with the same naturalness than before and ended up feeling helpless, vulnerable, and with no control of their body.The problem was initially described by Jesus, Lázaro, Murilo, and Antônio as a discomfort similar to what women feel when they are about to get their periods, and evolved until the urine got stuck and came out little by little (dysuria) (...).
Feeling pain, being different from other men, feeling like crap because the body does not work anymore (...), concern with the body and proximity to death were some of the meanings related to PC symptoms, which encouraged patients to seek the biomedical model to find what was wrong with their body (Rodrigo, João, and Antônio).
According to the narratives, the participants had their specific diagnostic exams for PC out of moral obligation, to meet the requests of their relatives and the social environment; they said that (...) they had no option: it was either that or death (Rodrigo, Miguel, and Thiago).Driven by the moral feeling of acting according to the cultural environment, the narrators underwent PC screening tests to not overturn the social standards that rule their masculinity.
Doing the digital rectal exam and biopsy was understood (...) as if the act touched the capital M of men, something embarrassing and painful, compared to a rape (Cauã and Reinaldo), a violation of their male physical identity, something that would make them feel defeated, humiliated, tortured and that embarrassed them, because it put them in a situation contrary to that of the dominant male image they incorporated when they were healthy (Vladimir, Lázaro, Lúcio, Reinaldo, and Fábio).They opted to seek the medical health system to detect the disorder in their body and, when submitted to the tests, they felt like an ox in a slaughterhouse (...), different from many men because they let other guy touch their body and literally take out a piece (during the biopsy) ( João and Joaquim).Because they are ruled by the moral obligation of affirming their masculinity through their acts, they experienced the dilemma of (...) living between a rock and a hard place, given that either they did what they think is right or what the others think is right (...), that is, either they took care of their sick body and got away of the principles of their masculinity, or they did not take care of their body and kept their morale (Alexandre, Mateus, and Tony).
In face of this moral obligation, present in the experience of sick men, the way Marcos, Jesus, Rodrigo, and Antônio found to cope with the feeling of being a (...) weak and sick man was to end up letting go of their body and carrying on with the guilt (...) of being a deserter of hegemonic masculinity, because they began offering health care (search for PC detection and treatment) to their biological body.
Even with the several issues surrounding the choice of treatment, Reinaldo, Cauã, Rodrigo, and Miguel felt that they were (...) at a crossroads, without knowing which path to follow (...), because adhering to a treatment is indispensable to fulfill the moral expectation of searching for a cure for the disease, as mentioned in this excerpt: (...) my family and people in general began pissing me off for me to take the prostate away from my body... they intervened in my choice, put me on pressure day and night, without my will (...).
Regarding the option for adhering to medical treatments, the narrators took into account several cultural factors from their social experiences.For Alexandre, Fábio, Lúcio, and Mateus, chemotherapy and radiotherapy were passed over procedures, because according to their narratives (...) we did not want to lose ourselves, have this image of another man, who we are not... stay indoors and use those wipes (...) we feel dry, with a rash (...), the treatment destroys the male body inside and outside.From Jesus' and Marcos' perspectives, hormone therapy would be one of the last things they would do to recover their normality, given that hormones cause changes in their body and social image and (...) turn them into another man, the appearance of the body changes and nobody respects them anymore because it is transvestites that use this hormone thing (...) and, in the participants' opinion, we need our body to be 100% for people to see us as we are, that we are still masculine, even after the disease.
All the men examined in the present study were submitted to prostatectomy, but only 13 suffered from the fear of not being a man after the surgery because, according to them, (...) men get gelded and end up losing the morale they took a lifetime to build up.People see us as men and expect us to act as such, if we do not do man things anymore people treat us as if we were women, that is, with care, because we are fragile (...) (Cauã, Marcos, Joaquim, Miguel, Fabio, Reinaldo, Alexandre, Mateus, Tony, Jesus, Rodrigo, João, and Antônio).
The way the participants formulated the stories about the treatment is noteworthy, because these patients emphasize the acceptance of the surgical procedure of prostatectomy as the standard therapy to reestablish body normality.In the participants' opinion, this occurred because of the absence of other medical options that did not involve changes in their body, masculinity, and life plans.Consequently, the patients see this option as the best one to deal with difficult situations but it does not prevent them from suffering from the absence of the organ, as the following excerpt, common to all the 17 narrators, illustrates: (...) we feel really bad about it, we feel like crap because the doctor threw our prostate away, that was ours (...) It was our masculinity!What about now?How are we going to carry on our life with our wife?How can we be men with a broken body?People will no longer respect us! (Cauã, Marcos, Joaquim, Miguel, Fábio, Reinaldo, Alexandre, Mateus, Tony, Jesus, Rodrigo, João, Antônio, Vladimir, Lázaro, Lúcio, and Thiago).
For the participants, the greatest impact was not the loss of the prostate, but of their functions, symbols, and representations of the male body, a life transition shared by all of them as something that leads them to not have objectives to carry on because (...) it does not make sense to be a man like that, because it is impossible to be a full person!This makes us down and we feel frustrated, small, and sad!We have left many things behind: work, masculinity, morale, health, and nearly our wife, all because of this disease!(cry) (Cauã, Marcos, Joaquim, Miguel, Fábio, Lázaro, Lúcio, and Reinaldo) But everything is possible in life!So we could lose anything except our morale, (...) because it is what gives you respect, value, but even that cancer took away from us.Now we are a different type of man, we do not play the male role and nobody respects us ( João and Alexandre).We had to learn to be always leaking (incontinent), weak to do anything (tired), useless for sex (impotent), effeminate, hairless (side effect of hormones), and yet we claim that we are men even without feeling this way because men fight until the end of their life (...) (Cauã, Marcos, Joaquim, Miguel, Fábio, and Lúcio).

DISCUSSION
The narratives show the changes experienced during the development and treatment of PC: the examined men reflected essentially the common meanings of the explanation model of the disease and, in their search for therapeutic solutions usually seen as a threat to the normality of their body, turned these into sick bodies ruled by moral powers that violated the socially established symbols of the hegemonic male identity.
Men cultivate a close bond with their masculine organ, of which the prostate is the symbolic extension that represents the utmost virility, a place in which relationships of gender and of support of their masculinity are established (13) .Keeping the prostate normality means standing for prejudices connected with these men's cultural identities, central values of their stereotypes ruled by society and seen as natural.
From this perspective and based on the testimonies, the critical reflection on the explanation model shared by the patients allows to infer that the moral principles ruled by masculine culture take on an active role in the life flow of these men, because these precepts limit the patients to implicitly judge what is considered right or wrong according to the gender stereotype.
For many men, undergoing tests to detect a disease is like being violated in a non-consented sexual intercourse, a physical procedure that breaks with the masculine habits of being inviolable and affirming their moral identity (14) .However, in the Western culture context, adopting behaviors to try to keep a healthy body has been understood as a moral www.ee.usp.br/reeuspRev Esc Enferm USP • 2019;53:e03494 obligation because it is a mandatory social action in favor of a sick body (15) , considered not just a right but also a social duty.Moral experience pervades men's life in their social interactions and, because it is a regulatory power established between community and the structures that rule it, it does not have the legal value that decrees and laws imposed by the state do.Nevertheless, it has a symbolic and moral value capable of regulating practices and behaviors in the sociocultural environment (16) .
Regarding the cognitive and motivational structures that influence social behavior, moral obligation is stressed in masculine health relationships, translating as the capacity to act according to the representation of social standards and laws that cause men to deliberately guide the actions of their bodies as a moral duty to be fulfilled, even against their will (17) .From this perspective, morality reflects habits which have a collective nature: rules, duties, and values shared by social groups (18) .Oriented by this paradigm, the narrators defend their body in an attempt to affirm their hegemonic masculine role and not being perceived as deserters of their moral standards.Consequently, during the transformation of their identity from healthy to sick men, they incorporate acts of misogyny, behaving according to the costumes socioculturally shared as correct for their gender identity.
In this context, the meanings revealed by the narrators regarding their changed body image gain prominence, especially when this image is associated with cancer therapies, such as chemotherapy, radiotherapy, hormone therapy, and mutilating surgical procedures, that transform male bodies, setting them apart of the hegemonic moral identity (4,14) .
Adopting the body image of a healthy man has become a moral obligation standardized by culture so men uphold hegemonic identity values (19) .However, following hegemonic identity standards of masculinity means renouncing the reflection established between the image of a real body shaped by the disease and that of an ideal body imposed by social standards.For men, developing the disease was a physical as well as a moral transformation, in which the standards of a functioning body are constantly valued by the culture that pervades its existence.
Corroborating these observations, researchers (1,6) state that moral, social, and cultural values rule male behavior and guide their body experiences.The development of the moral identity of masculinity that threatens to differ from hegemonic relationships was the product of causes and effects of the practices of the examined sick men.Men with PC underwent changes in their biological body, which impacted on their social body, promoting, in the first instance, a moral conflict about what is conceivable for the male and female genders.Thus, regarding the symbolic structure that runs these relationships, the authors interpret that, in their anthropologic essence, the narrated senses have an embodiment meaning.
The anthropology of masculinities considers the body as a surface on which culture stamps its gender (1) , a substrate that incorporates cultural values, standards, and symbols arranged among social power structures that rule them, in a standard encompassing biological and social aspects coexisting in constant dialogue (20) .
The male body connects men with the world, and the social body is objectified according to the perception of the physical body, the physical experiences offered by it, which are influenced by social categories and specificities of each culture.Researchers (21) claim that there is a constant exchange of physical and social experiences in the process of adopting a sickened body, in such a way that the actions of each category complement each other.
From the anthropological perspective (2,(21)(22) , the social body is not the only responsible for explaining the standard practices established between men and their environments, given that bodies are not surfaces unresponsive to the introduction of cultural elements.Biological differences encourage the production of social practices.As a consequence, the biological body and its changes must also be understood, because their relationships influence and are influenced by social rules.The present discussion brings up the biological body determined by anatomy, physiology, hormones, phenotypes, and genotypes that provide the individual body with explanations (20) .
According to the anthropology of masculinities (1,7) , male bodies must be seen from a relational gender perspective, that is, bodies are shaped and have a gender associated with them by common local knowledge of moral and symbolic production, which derives from a social and cultural formulation rather than natural data.It is considered, then, that bodies are endowed with their own acting (capacity of acting or of being an agent based on culture), because it produces senses.In this specific case, the embodiment of the men suffering from PC is not a process, but a state constantly created, because masculinities and gender are subordinate to cultural standards, which are created historically based on masculinity and health practices, in addition to the plural senses and meanings about the body.
Researchers (2,21) see a sick body as a canvas on which symbols are registered, causing men to interpret their experiences and body techniques in a personal manner and in connection with their cultural rules.Therefore, it is not pertinent to limit the discussion on the experience of men with PC to the physical body, because it does not represent these individuals fully.It is necessary to carry out a dense interpretation of the body, capable of recognizing both its acting and social development, so the biological and social bodies come close in a joint explanation rather than isolated ones (20) .The anthropology of masculinities (1,7) advocates that sick male bodies must be understood within this amalgam of feeling and representations because they are simultaneously objects and agents of social practice.
Over their experiences, the narrators recognized that, during the PC development, their biological body got sick along with their social one, given that the former was deprived of the normality of their expected physiological and identity functions according to gender stereotypes, and the latter devoid of their traditional expressions that fit men in a moral position of standing up for their masculinity.It was also noteworthy that, in taking on the state of a sick body, Embodied hegemonies: moral dilemmas in the onset of prostate cancer Rev Esc Enferm USP • 2019;53:e03494 men lose control over themselves: they no longer dominate their body techniques and begin being dominated by the body techniques of the disease.This loss of power among the relationships established by the triad masculinity, society, and culture is recognized as a dissociative factor of masculinity and moral power of hegemonic identities attributed to men.In hegemonic masculinity, the social rule that men are untouchable beings prevails, not allowing that body techniques such as PC screening tests and treatments violate their body (7) .
Body techniques refer to the way men use their body before the moral power regulated by culture: the way they speak, pray, dance, hug, move, and present themselves, among other forms of expressions that characterize them as belonging or not to a certain society (22) .
In the face of these relationships, it is understood that the male body is not only a technical instrument resulting from cultural interaction.It is, above all, a practical place of male empowerment in which moral habits exercise their normative power.It is by means of men's body techniques and daily conventions that bodies made sick by PC are disciplined according to the dominant form of local masculinity.Thus, the values revealed in the narratives emphasized the body techniques specific to a hegemonic body, for instance going out with the family, working, dominating body functions, and submitting to risky activities, as factors that promote the insertion of men in a social and family locus, in a moral identity endowed with hegemonic evaluative actions.In this context, the body dysfunction resulting from PC (lack of control of body functions) is a reason for social disapproval regarding the rules of the local hegemonic masculinity in force, because men incorporate factors that weaken their gender expression.
The senses and meanings discussed in the narratives show that social and body actions are culturally built up, upheld, and standardized.When embodied by sick men, the several faces of masculinity allow to interpret that it is not limited to having muscles: it is also a body and moral identity, although these are ruled by standards, values, and cultures, being strengthened by body techniques and weakened by the transformations imposed during the development of the disease and its consequences.These diverse faces of masculinity influence the way men share the senses of their experiences and recover the health of their biological and social body.

CONCLUSION
The narratives of the present study emphasized the cultural characteristics and moral questions that regulate the body during the development of PC, as well as the dilemmas faced by men to keep the hegemony of their masculinity.The main subject of the present investigation was the meaning of embodiment, because the body was explored as a place to formulate senses while falling sick, ruled by social standards that value masculinizing practices.These norms influenced the search for medical care, the execution of screening tests, and the adherence to conventional treatments for the disease.Motivated by a moral feeling, the examined men shared the dilemma of not taking care of their body and keeping their hegemonic masculinity or taking care of their body and renouncing to this hegemony.Consequently, the biological and social bodies present themselves in disharmony during the development of PC, because in the culture of the studied men there is the belief that they are inviolable, strong, and virile beings, capable of controlling their body and not letting themselves down by the disease.
The senses described in the present investigation increase and deepen the knowledge of the characteristics of the experiences of men with PC reported in the literature.For being sure that these local masculinities are fundamental for nurses to reflect on the care delivered to men in these circumstances, the authors stress that the masculinities showed in the present study coexist and interact with other regional and global masculinities, which may complement and expand the understanding about the development of PC.
In addition to the focus on care to men with PC, the present study brings nurses the cultural lens that pervades the male identity and its relationship with the male body during the disease progress.Cultural and masculinity issues bring up a cultural and social patchwork full of senses that can help nurses and other professionals deal with sick men.