Masculinities of prostate cancer survivors: a qualitative metasynthesis

To identify the production of knowledge in the health literature about masculinities in the context of prostate cancer survivors and to analyze the implications of this relationship for the maintenance of health care.

Method:

Metasynthesis of 21 qualitative studies, performed in the LILACS, MEDLINE and CINAHL databases, with the scientific descriptors of DeCS and MeSH terms masculinity, prostate neoplasms.

Results:

Illness due to prostate cancer imposes numerous changes in male relationships, especially the non-dominance of the body and vulnerability to treatments and their consequences. The cultural values surrounding the disease and the hegemonic behaviors have implications for the health care of men.

Conclusion:

It has been shown that this relationship makes it difficult to communicate about the disease, marital relationships and family support, mainly influencing neglect of health. The knowledge produced is useful to promote the engagement of men in strengthening care.

Descriptors:
Men’s Health; Prostate Neoplasms; Nursing Oncology; Masculinity; Metasynthesis

Question	Yes (nº)	Patially reported (nº)	No (nº)
1. Were the research objectives clearly stated?	19	1	1
2. Is the qualitative methodology adequate?	17	3	1
3. Was the design of the research adequate for the achievement of the proposed objectives?	16	5	-
4. Was the recruitment strategy adequate to the research objectives?	17	2	2
5. Were the data collected to address the research question?	18	3	-
6. Was the relationship between the researcher and the participants properly considered?	11	4	6
7. Have ethical questions been considered?	8	8	5
8. Was the analysis of the data sufficiently accurate?	20	1	-
9. Were the results clearly reported?	20	1	-
10. Does the research bring contributions?	11	9	1

Title	Objective	Relation between PC and Masculinity
Impaired sexual function and prostate cancer: a mixed method investigation into the experiences of men and their partners⁽¹1 Siegel R, Ma J, Zou Z, Jemal A. Cancer Statistics, 2015. CA Cancer J Clin. 2015;65(1):5-29. doi: 10.3322/caac.21254 https://doi.org/10.3322/caac.21254... ⁾	To explore issues related to sexual relations, by men and their wives or partners, after the diagnosis and PC doctor treatment.	Men believed that PC and change in their sexual function did not impact their masculinity, stimulating health care neglect. However, their partners felt that their masculinity was modified after the PC.
As arranhaduras da masculinidade: uma discussão sobre o toque retal como medida de prevenção do câncer prostático ⁽ ¹⁸18 Gomes R, Nascimento EF, Rebello LEFS, Araújo FC. [The touched masculinity: a discussion about the digital rectal exam for prostate cancer Prevention]. Ciênc Saude Colet [Internet]. 2008 [cited 2018 Nov 03];13(6):1975-1984. Available from: http://dx.doi.org/10.1590/ S1413-81232008000600033 Portuguese. http://dx.doi.org/10.1590/ S1413-8123200... ⁾	To analyze the meanings attributed to the rectal touch, seeking to reflect on the underlying issues of masculine speech from aspects of the hegemonic model of masculinity.	The rectal examination does not only touch the prostate, it touches on several symbolic aspects of what it is to be masculine, implying health care.
Dealing with a troublesome body: A qualitative interview study of men's experiences living with prostate cancer treated with endocrine therapy⁽¹⁹19 Ervik B, Asplund K. Dealing with a troublesome body: a qualitative interview study of men's experiences living with prostate câncer treated with endocrine therapy. Eur J Oncol Nurs [Internet]. 2012 [cited 2018 Nov 03];16(2):103-108. Available from: doi:10.1016/j.ejon.2011.04.005 https://doi.org/10.1016/j.ejon.2011.04.0... ⁾	To present the experiences of men with PC in the face of bodily changes and how these changes influence their daily lives.	The body is a way of demonstrating masculinity. A weakening of the body is interpreted by the sick as a threat to masculine values. Influencing significantly on how men perceive and take care of their body.
Embracing life after prostate cancer. A male perspective on treatment and rehabilitation⁽²⁰20 Dieperink KB, Wagner L, Hansen S, Hansen O. Embracing life after prostate cancer. A male perspective on treatment and rehabilitation. Eur J Cancer Care (Engl) [Internet]. 2013 [cited 2018 Nov 03];22(4):549-558. Available from: https://doi.org/10.1111/ecc.12061 https://doi.org/10.1111/ecc.12061... ⁾	To explore the experiences of radiotherapy treatment of participants in PC rehabilitation program and address the spouse's involvement in the rehabilitation process.	Bodily changes and lack of sexual practices had a major impact on how participants felt as men versus radiotherapy in treating PC. This treatment threatens the relationship between the spouses to put in judgment the masculinity of the sick person, which makes difficult in the rehabilitation.
The language of prostate cancer treatments and implications for informed decision making by patients⁽²¹21 Rot, I, Ogah I, Wassersug RJ. The language of prostate cancer treatments and implications for informed decision making by patients. Eur J Cancer Care (Engl) [Internet]. 2012 [cited 2018 Nov 03];21(6):766-775. Available from: doi:10.1111/j.1365-2354.2012.01359.x https://doi.org/10.1111/j.1365-2354.2012... ⁾	To explore whether the language used for PC treatment has implications for patient decision-making.	The language around the PC is not so clear and enlightening. This leads to a process of disinformation for the sick person, making decisions difficult, which is followed by certain treatments that expose them to effects on their self-image and physical health, thus threatening their masculinity.
'You know I've joined your club... I'm the hot flush boy': a qualitative exploration of hot flushes and night sweats in men undergoing androgen deprivation therapy for prostate cancer⁽²²22 Eziefula CU, Grunfeld EA, Hunter MS. 'You know I've joined your club... I'm the hot flush boy': A qualitative exploration of hot flushes and night sweats in men undergoing androgen deprivation therapy for prostate cancer. Psychooncology. 2013;22(12):2823-2830. doi: 10.1002/pon.3355 https://doi.org/10.1002/pon.3355... ⁾	To analyze symptoms such as hot flashes and night sweats developed in men with PC after androgen deprivation therapy.	Androgen deprivation therapy promotes reactions similar to female menopause. These affect the beliefs of male hegemonic behaviors related to inability to meet their expectations with their traditional gender roles in terms of physical activity, work and sexual activity.
Perceptions of physically active men with prostate cancer on the role of physical activity in maintaining their quality of life: possible influence of androgen deprivation therapy⁽²³23 Keogh JWL, Patel A, MacLeod RD, Masters J. Perceptions of physically active men with prostate cancer on the role of physical activity in maintaining their quality of life: possible influence of androgen deprivation therapy. Psychooncology. 2013;22(12):2869-75. doi: 10.1002/pon.3363 https://doi.org/10.1002/pon.3363... ⁾	To analyze the perceptions of older men with PC regarding their quality of life and physical activity after diagnosis, the potential benefits and risks associated with being physically active.	Androgen therapy reduces the level of quality of life, leading to decline or cessation of sexual activity and greater concern with the return of their physical activities. These effects affect the way men perceive their masculinity.
Loss of masculine identity, marital affection, and sexual bother in men with localized prostate cancer⁽²⁴24 Zaider T, Manne S, Nelson C, Mulhall J, Kissane D. Loss of masculine identity, marital affection, and sexual bother in men with localized prostate cancer. J Sex Med 2010;9(10):2724-2732. doi: 10.1111/j.1743-6109.2012.02897.x https://doi.org/10.1111/j.1743-6109.2012... ⁾	To describe the prevalence of concerns related to erectile dysfunction and the decrease of masculinity among men treated by PC.	The PC led men to experience deprivation of sexual activity as well as the devaluation of male self-image, since they developed unsatisfactory male behaviors such as: difficulty in achieving erection, non-ejaculation, and decreased sexual desire.
Prostate cancer, masculinity and food. Rationales for perceived diet change⁽²⁵25 Mróz LW, Chapman GE, Oliffe JL, Bottorff JL. Prostate cancer, masculinity and food: rationales for perceived diet change. Appetite. 2010; 55(3):398-406. doi: 10.1016/j.appet.2010.07.009 https://doi.org/10.1016/j.appet.2010.07.... ⁾	To observe the role of Nutrition in PC prevention and recovery due to observations that typical Western dietary pattern, foods rich in meat and fat, low fruit and vegetable consumption associated with high incidence and mortality.	Masculinity influences the choice of foods for PC patients. Understanding of male ideals helps to understand how men follow dietary change.
Gender relations, prostate cancer and diet: Re-inscribing heteronormative food practices⁽²⁶26 Mróz LW, Chapman GE, Oliffe JL, Bottorff JL. Gender relations, prostate cancer and diet: re-inscribing hetero-normative food practices. Soc Sci Med. 2011;72(9):1499-1506. doi: 10.1016/j.socscimed.2011.03.012 https://doi.org/10.1016/j.socscimed.2011... ⁾	To explore the dietary practices of Canadian couples guided by a framework of gender relations to expose how performances of masculinity and femininity interact to shape the diets of men with PC.	Men became more interested and involved in their diets after a PC diagnosis, a practice that can be interpreted as a project unrelated to a hegemonic role, inducing other masculinities in the face of the PC.
Men, Food, and Prostate Cancer: Gender Influences on Men's Diets⁽²⁷27 Mróz LW, Chapman GE, Oliffe JL, Bottorff JL. Men, food, and prostate cancer: gender influences on men's diets. Am J Mens Health. 2011;55(2):177-87. doi: 10.1177/1557988310379152 https://doi.org/10.1177/1557988310379152... ⁾	To develop nutritional interventions related to PC in men, in order to involve them in a healthy diet.	Some men with PC make changes in their daily lives, food is one of them. They change their diets with unhealthy, typically male, foods, and impede nutritionist interventions. This factor is an impediment to the promotion of health actions to man.
Masculinities and patient perspectives of communication about active surveillance for prostate cancer⁽²⁸28 Oliffe JL, Mróz LW, Davison BJ. Masculinities and patient perspectives of communication about active surveillance for prostate cancer. Health Psychol. 2013;32(1):83-90. doi:n10.1037/a0029934 https://doi.org/10.1037/a0029934... ⁾	To describe the connections between masculinities and patient's perspectives on communication with male doctors.	The men's ideals defended during the consultations influence what can be understood as useful and useless communication between male patients and physicians, concerning the PC impacts. Doctors' communication to patients was viewed as a threat to male ideals by promoting hierarchies that broke the trust alliance between them.
Sexuality in the context of prostate cancer narratives⁽²⁹29 Klaeson K, Sandell K, Bertero CM. Sexuality in the context of prostate cancer narratives. Qual Health Res. 2012;22(9):1184-1194. doi: 10.1177/1049732312449208 https://doi.org/10.1177/1049732312449208... ⁾	To understand the experience of men diagnosed with PC regarding their sexuality.	Having a PC is like having the elixir of life stolen because your sexuality ends and your masculinity is threatened. The men were concerned about their intimacy and the maintenance of their masculine identity, having difficulty relating intimately to their partner, to approach the subject with other people.
"The only way I know how to live is to work": A qualitative study of work following treatment for prostate cancer⁽³⁰30 Grunfeld, EA, Coates LD. "The only way I know how to live Is to work": A qualitative study of work following treatment for prostate cancer. Health Psychol. 2013;32(1):75-82. doi: 10.1037/a0030387 https://doi.org/10.1037/a0030387... ⁾	To explore the meaning of work among PC survivors and describe the links between masculinity and work after PC treatment.	PC causes psychological sequels, including vulnerability and uncertainties about the future related to work. It hinders the maintenance of the work routine due to the side effects of the treatments. Work is highlighted as a value of masculinity, and the side effects of treatments have implications for maintaining this identity.
As representações sociais de homens sobre o câncer de próstata ⁽ ³¹31 Araujo JS, Conceição VM, Silva SED, Santana ME, Vasconcelos EV, Sousa RF. The social representations of men about prostate cancer. Rev Pesqui Cuid Fundam [Internet]. 2013 [cited 2018 Nov 03];5(2):3893-3884. Available from: doi: 10.9789/2175-5361.2013v5n2p3884 https://doi.org/10.9789/2175-5361.2013v5... ⁾	To identify the social representations of men about the PC and its masculinities in relation to the disease, and to analyze its implications for health.	The capacity for reproduction and pleasure are indispensable for the construction of traditional masculine identities. The PC leads to consequences such as impotence, which causes men to seek health care. This quest goes against the ideals of masculine virility.
Re-constructing masculinity following radical prostatectomy for prostate cancer⁽³²32 Gannon K, Blanco MG, Patel A, Abel P. Re-constructing masculinity following radical prostatectomy for prostate cancer. Aging Male. 2010;13(4):258-64. doi: 10.3109/13685538.2010.487554 https://doi.org/10.3109/13685538.2010.48... ⁾	To investigate how men build and rebuild their masculinities after radical prostatectomy for the PC.	Erectile dysfunction among prostatectomized men fuels the belief that cancer is inconsistent with the role of gender or sense of masculinity as it has a major impact on the masculine identity of men. Those who cannot achieve erection and pleasure for the judged as having a trivialized masculinity.
The impact of prostate cancer on partners: a qualitative exploration⁽³³33 Wootten AC, Abbott JM, Osborne D, Austin DW, Klein B, Costello AJ, et al. The impact of prostate cancer on partners: a qualitative exploration. Psychooncology. 2014;23(11):1252-8. doi: 10.1002/pon.3552 https://doi.org/10.1002/pon.3552... ⁾	To explore experiences of spouses or intimate partners of men diagnosed and/or treated to understand the personal impact of the PC on the partner.	Coping with the PC and the decrease of the masculinity coming with the treatments demand a dedication not only of the sick but also of their spouses. The spouses who were active in supporting the sick, reported feeling more adapted and secure to face changes in the masculinity of the partner.
Talking about sexuality: desire, virility, and intimacy in the context of prostate cancer associations⁽³⁴34 Klaeson K, Sandell K, Berterö CM. Talking about sexuality: desire, virility, and Intimacy in the context of prostate cancer associations. Am J Mens Health. 2013;7(1):42-53. doi: 10.1177/1557988312458143 https://doi.org/10.1177/1557988312458143... ⁾	To explore how some Swedish men experience and communicate their sexuality.	The PC and its impacts on the masculinity of the sick have been identified as a threat to the male identity due to loss of libido and vulnerability. These issues were difficult to share in gender-based social judgment. Masculinities defended before the disease are confronted with the sexuality change.
Sexuality and exercise in men undergoing androgen deprivation therapy for prostate cancer⁽³⁵35 Hamilton K, Chambers SK, Legg M, Oliffe JL, Cormie L. Sexuality and exercise in men undergoing androgen deprivation therapy for prostate cancer. Support Care Cancer. 2014;23(1):133-42. doi: 10.1007/s00520-014-2327-8 https://doi.org/10.1007/s00520-014-2327-... ⁾	To explore the impact of androgen deprivation therapy on the sexuality of men with PC and the effects of exercise on this experience.	Treatment against PC led participants to experience decreased sexual desire, decreased erection, erectile dysfunction, and lack of orgasm or libido. These experiences interfered in the representation of masculinities in society. The practice of exercise helped to manage this experience positively.
Defining young in the context of prostate cancer⁽³⁶36 Chambers S K, Lowe A, Hyde M K, Zajdlewicz L, Gardiner R A, Sandoe D, Dunn J. Defining young in the context of prostate cancer. Am J Mens Health. 2015;9(2):103-114. doi: 10.1177/1557988314529991 https://doi.org/10.1177/1557988314529991... ⁾	Interpretive phenomenological analysis to define what it means to be young and to have prostate cancer.	Male constructs and life-course perspectives are important concepts that help expand our understanding of "being young with prostate cancer" beyond chronological age.
The impact of prostate cancer on men's everyday life⁽³⁷37 Appleton L, Wyatt D, Perkins E, Parker C, Crane J, Jones A, Moorhead L, Brown V, Wall C, Pagett M. The impact of prostate cancer on men's everyday life. Eur J Cancer Care (Engl). 2015;24(1):71-84. doi: 10.1111/ecc.12233. https://doi.org/10.1111/ecc.12233... ⁾	It highlights how men deal with the disease and treatment and the strategies they employ to manage their diagnosis next to daily life.	The impact of the research procedures emerged as particularly significant in the way men adjusted and handled their diagnosis.

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[1] Corresponding Author: Jeferson Santos Araújo E-mail: araujojs@unifesspa.edu.br