A SEXUALIDADE DA MULHER COM CÂNCER DE MAMA: ANÁLISE DA PRODUÇÃO CIENTÍFICA DE ENFERMAGEM

Integrative review aimed at analyzing the knowledge produced by Brazilian nursing concerning the sexuality of women with breast cancer, with a view to improving the quality of care delivery. A simultaneous search by word was performed in all the databases listed in the Online Health Library. Ten articles were included, published as from the year 2000, whose authors were nursing professionals. The results revealed that women’s sexuality is often limited to the sexual practice and that only some reports show sexuality as something broader. Women affected by breast cancer have their sexuality compromised and the support provided by their partners helps them with coping and is considered very significant in all stages of the disease. The analysis of the studies reveals that nursing care does not cover this aspect of care and needs to be restructured. This care should be extended to the partners and go beyond the biological dimension. DESCRIPTORS: Breast neoplasms. Sexuality. Nursing. SEXUALIDAD DE LA MUJER CON CÁNCER DE MAMA: ANÁLISIS DE LA PRODUCCIÓN CIENTÍFICA DE ENFERMERÍA RESUMEN: Revisión integrativa que tuvo por como objetivo analizar el conocimiento producido por la enfermería brasileña sobre la sexualidad de mujeres con cáncer de mama, con la finalidad de obtener subsidios para ofrecer una asistencia de calidad. Fue utilizada una busca simultánea por palabras, en todas las bases de datos indexadas en la BVS. Se incluyeron 10 artículos publicados a partir del año 2000, en cuya autoría constaban enfermeros. Los resultados mostraron que la sexualidad de las mujeres muchas veces está restricta a la práctica sexual y apenas unos relatos muestran la sexualidad como algo más integral. Las mujeres afectadas por cáncer de mama presentan dificultad en el ejercicio de la sexualidad y el apoyo del compañero ayuda a hacer ese enfrentamiento, siendo percibido como de extrema significancia en todas las etapas de la enfermedad. El análisis de los resultados evidencia una asistencia de Enfermería que no contempla este aspecto del cuidado, evidenciándose las necesidad de una reestructuración. Esa asistencia debe ser extendida a los compañeros y debe ultrapasar la dimensión biológica. DESCRIPTORES: Neoplasias de mama. Sexualidad. Enfermería. 835


INTRODUCTION
The diagnosis of breast cancer, as well as the whole course of the disease, is permeated by many concerns related to death, mutilation and pain, being a period marked by a lot of anguish, suffering and anxiety. 1 The treatment is performed mainly through surgery, radiotherapy and chemotherapy, and about 50% of women survive for at least 15 years. 2 Surviving this event means adjusting to the new condition, with physical and psychosocial consequences that negatively affect their sexuality and sexual function.
The mutilation resulting from surgical procedures causes inhibition during sexual relations and generates feelings of shame, anguish and embarrassment. 3Mastectomy can be described as a dramatic attack on the body and this situation undoubtedly affects the conception of women as sexual beings. 4he side effects of chemotherapy, such as fatigue, baldness, constipation, nausea, vomiting and weight gain, amongst others, contribute to change the sexual function, since they reduce women's sexual desire and ability to engage in sexual activity. 5ew healthcare professionals value the feelings of low self-esteem and the aspects related to the sexuality of women with breast cancer. 6A similar situation occurs in nursing, which treats sexuality as an invisible and at the same time hidden issue.It is as if sexuality did not exist and was ignored and, when this comes to light, it is not explored for reasons not well known. 7onsidering that the treatments for breast cancer can affect women's sexuality, changes to care practices are required.The need for a broader view of this problem can therefore be highlighted, so that the daily practices, meanings and experiences of these women can be included in nursing care practices.
Baccalaureate nurses need to identify the problems arising from the disease process and implement care practices aimed at promoting the sexual health of patients. 8It can be observed, however, that aspects related to sexuality are rarely explored in the clinical practice, and have only more recently been focused in in nursing research.
Given that these care practices and interventions need to be based on scientific evidence, giving rise to a practice that is based on the scientific knowledge produced, the present study was aimed at analyzing the information produced in Brazilian nursing concerning the sexuality of women with breast cancer, with the purpose of improving the quality of care delivery.

METHOD
The research method used was the integrative literature review which, through a critical analysis of studies, permits a general summary of a knowledge area under development, and also points out existing gaps.It is a method of compilation of previous researches, in which conclusions are drawn, providing a broader understanding about the subject of study. 9n order to guide the present study, the following questions were developed: has sexuality been an object for nursing knowledge production?What knowledge had Brazilian Nursing produced about the sexuality of women with breast cancer?
The research was carried our between February and March 2010 and used the following descriptors related to the theme: breast cancer (synonymous of the descriptor breast neoplasms), sexuality and professional nursing practice.In order to broaden the search of articles, these words were combined.
The inclusion criteria for this review were: Brazilian production; articles whose authors included nurses; publication as from the year 2000; and fully available articles.The articles dealing with other kinds of cancer other than breast cancer, productions developed by other professional categories, dissertations, theses and books or chapter of books were excluded.
The source of bibliographic data was the Online Health Library (BVS), with access through the Internet.The simultaneous search for words was used in all databases listed in the BVS (BDENF -Professional Nursing Database; LILACS -Latin-American and Caribbean Literature on Health Sciences; MEDLINE -Literature Analysis and Retrieval System on-line; Coleciona SUS -National Collection of Information Sources of the SUS; MS -Collection of the Library of the Ministry of Health; WHOLIS -Information System of the Library of the WHO).
Table 1 shows the number of articles found in each database, according to the words used.After careful reading of the title and summary to verify compliance with the guiding question and inclusion criteria, the sample was composed of 10 articles in total, found in the databases BDENF and LILACS.In the other databases of the BVS, no articles that matched the inclusion criteria required in this study were found.It is worth noting that some articles were listed in more than one database.
The articles included in the review were read in full, categorized and evaluated with the help of a previously developed data collection instrument, 9 which presented the following items: identification, institution where the study was undertaken, type of scientific journal, methodological features of the study and evaluation of methodological rigor.These were analyzed and the summary was developed in a descriptive way through thematic categories, using the Content Analysis technique.This process uses broad inductive reasoning, in which themes and categories emerge from the data through careful examination and constant comparisons. 10

RESULTS
According to the place where the studies were developed, three articles were carried out in specialized services of universities, six were developed in hospitals and one in a preventive institution.
Concerning the journals, the studies were published in nine different journals, seven related to professional nursing and two multidisciplinary.
As for the subjects of study, nine articles had women who had performed mastectomies as samples.The number of participants varied from five to 24.Only one study had the partners of these women as subjects of research.The identification and methodological characteristics of the 10 articles selected are presented in table 2.

Type of study Objectives Sample
Rodrigues, Silva, Lopes 11

Descriptive qualitative study -level VI
To analyze the perception of women with mastectomies about their sexuality, emphasizing the changes noted and the participation of partners.
21 women with breast cancer, mastectomy performed for at least three months, being treated at the Cancer Prevention Institute of Ceara and married or in a de facto relationship.

Qualitative approach -level VI
To understand the meaning of mastectomy for women during the post-operative period of breast cancer, who were being treated at the Mastology Outpatient Care Center and radiotherapy and chemotherapy sectors.
24 women who had performed surgery for breast cancer; being treated at the Mastology Outpatient Care Center and additional radiotherapy and chemotherapy treatments.

Phenomenological qualitative -level VI
To expose the meaning of expressions of sexuality by women submitted to radical mastectomy due to breast cancer.
15 women with breast cancer, submitted to radical mastectomy, regardless of the post-operative period.

Qualitative approach -level VI
To identify the type of social support offered to the sexual partners of women with breast cancer and how they see this support.
Nine partners of women with breast cancer, participants of the Teaching, Research and Care Group for the Rehabilitation of Mastectomized Women at EERP/USP.

Articles Type of study Objectives Sample
Barbosa, Ximenes, Pinheiro 15 Qualitative approach -level VI To understand the effect of mastectomy in the performance of women's roles; To understand the feelings of women submitted to mastectomy in light of discovering about the breast cancer and the mastectomy; To identify the roles performed by women before and after mastectomy; to verify the support which affects the role performance of women submitted to mastectomy.
Seven women submitted to mastectomies who attended the Self-help, Training, Research and Care Group for Mastectomized Women (GEPAM) at the University of Ceará.
Caetano, Soares 16 Qualitative approach -level VI To understand the effects of mastectomy on women based on Roy's Theory of Adaptation, in relation to self-esteem.
10 women with breast cancer, assisted at a referral unit in the North of Ceará state, in the oncology sector.
Azevedo, Lopes 17 Qualitative study with phenomenological approach -level VI To understand the surgical impact on the perception of their own body and the relation of their body with other people.
Five women submitted to radical mastectomy.

Gonçalves, Arrais, Fernandes 18
Qualitative approach -level VI To identify the reaction of women facing breast cancer diagnosis, as well as the changes in the daily lives of these women after mastectomy, describing the coping mechanisms used to overcome the difficulties arising from the surgery.
15 women who had mastectomies performed five years earlier and in a steady relationship.Women who participated in the meetings of the GEPAM of the Nursing Department at the Federal University of Ceará.

Phenomenological qualitative -level VI
To understand the meaning that women attribute to breast loss, especially concerning sexual life.
Eight women during the post-operative period after mastectomy.Surgical and Gynecological Clinic of the University Hospital of Juiz de Fora-MG.
Tallhaferro, Lemos, Oliveira 20 Qualitative, descriptive and exploratory study -level VI To identify the problems faced by women submitted to mastectomy in their context of life.
10 women with breast cancer/submitted to mastectomy, in a steady relationship, being treated at the Outpatient Care Center of the Base Hospital (São Jose do Rio Preto).
The studies were aimed at understanding mastectomized women face in their context of life, and the effects of mastectomy on role performance, identifying the changes, as well as the coping mechanisms and support networks.Some were more directed to the perception of sexuality and sought to understand the meaning of the breast to sexual life and how women see their bodies after the procedure.The study approaching the partners was aimed at identifying the type of support offered and how this support is viewed.
The topics covered in the articles analyzed were grouped and subdivided into thematic categories: Concept of sexuality; Partners' support; and Changes to sexuality arising from breast cancer.Table 3 shows the summary of the information according to categories.To a large part of the studied women, the concept of sexuality is limited to the sexual relation itself.Some women attributed this concept to body image.

Souto, Souza 13
Women's sexuality is mainly expressed by the heterosexual relationship.It has also been expressed through the recognition of feelings such as the love, support and concern showed by their partners.Tallhaferro, Lemos, Oliveira 20 Sexuality appears as to sexually serve the partner and is also associated to partnership, involving the more affectionate side.Madeira, Almeida, Jesus 19 The changes to the body image lead to self-rejection and affect the relationship with the other.Sexuality reduced to the breasts.

Partners' support
Rodrigues, Silva, Lopes 11 The importance attributed by women to the participation of their husbands in all stages of the disease, affectively sharing the emotions, doubts and concerns, is evident.The fear of separation, indifference and neglect by their partners leads to a personal unbalance.
Souto, Souza 13 The importance of their partners' affection and care (satisfaction in being in their company; impression that they have fewer problems).
Tallhaferro, Lemos, Oliveira 20 The importance of the partners' full support for the recovery of women is evident.Most partners offer the necessary support to their partners.The spouse plays an essential role during all stages of the treatment, and the interaction between patients and their partners throughout the restructuring of their integrity is equally essential.
Madeira, Almeida, Jesus 19 The fear of losing their partners appears.Chances of continuing with a satisfying sexual relationship with their partners, when these are able to deal with the new situation.
The support of their partners seems to increase these women's confidence.Not having a partner may mean not having expectations in relation to sexuality.Barbosa, Ximenes, Pinheiro 15 The husbands' participation and initiative are strong determinants in the quality of the marital relationship.Women need affection.
Gonçalves, Arrais, Fernandes 18 Mastectomy results in two types of behaviors by the partners: dedication and support and lack of companionship.Support and dedication give women the strength to seek better conditions of life.But the lack of companionship discourages the pursuit for coping mechanisms.Also in relation to the partners, women are afraid of being rejected and abandoned.
Biffi, Mamede 14 The social support offered by the partners was a demonstration of affection, understanding the situation experienced by their wives, even if in a silent way.This support works as an incentive to self-care strategies and assistance with household chores.

Changes to sexuality arising from breast cancer
Rodrigues, Silva 11 Mastectomy and other treatments contribute to reduce sexual desire, changes the body image, in relation to the perception of their own body and self-esteem.Women have no sexual desire.
Tallhaferro, Lemos, Oliveira 20 The couple's sexual relationship is compromised by the emotional stress, pain, fatigue, changes to body image and self-image.However, some reports show that mastectomy did not change women's sexual life.
Biffi, Mamede 14 The distancing of the couple, directly affecting their sexual relationship, was also expressed by partners as a difficulty faced after their partners' mastectomy.Some partners become stressed when there is sexual abstinence.
Caetano, Soares 16 Changes to the perception and devaluation of their own body.The removal of the breast is reflected in the marital relationship.They stopped or changed their sexual activity (stress, anxiety, depression).Barbosa, Ximenes, Pinheiro 15 They experience changes to their sexuality after mastectomy.The loss of the breast is seen as threatening to their sexuality, and the surgical treatment causes feelings of rejection and disapproval of the condition.Women feel sad and concerned with their marital relationship.

Azevedo, Lopes 17
The disease is marked by mutilation, pain, loss of sexual desire, impotence and rejection.The mutilation of the body is reflected in sexual life (interpersonal relationship difficulties).The removed organ plays a key role in the relationship between women and their objects of desire.

Gonçalves, Arrais, Fernandes 18
Women submitted to mastectomy feel incapable of pleasing their partners.This dissatisfaction with their bodies affects the quality of the marital relationship.They feel ashamed of undressing, being touched by their partners, thus compromising the sexual relationship.
Ferreira, Franco, Queiroz 12 After mutilation, women take time to absorb and incorporate the new image (negative feelings such as sadness, weirdness and concern).The shame of their husbands affects their sexual life, and the marital relationship is compromised by this avoidance.

DISCUSSION
The studies analyzed in this review show that most women have a view of sexuality that is centered on the genitals and sexual act.The concept and meaning they attribute to sexuality are largely expressed by a concept reduced to the sexual act itself, 11 or even reduced to the breasts. 19When they are asked how they feel sexually after mastectomy, women express a concept of sexuality that, to be experienced, needs the other person, given that their answers always mention their partners. 13The lack of ownership of their own bodies, or even the disbelief in the ability to please themselves on their own, seems to lead women to place their sexuality in the hands of the other person. 21ome reports show the association of sexuality and body image, 11 being expressed by feelings of love, support and concern by their partners. 13In this broader perspective, sexuality also includes, besides sex, companionship, love, acceptance and happiness. 20n addition, a concept of sexuality connected to gender domination is observed. 20Sexuality is totally separated from a natural expression of human beings and becomes a social obligation where there are no choices.Notwithstanding all the difficulties women face as a result of breast cancer, they cannot forget their social role as a wife which, amongst other duties, involves sexually serving their partners.This issue relates to the conceptions of female sexuality in society.Women do not have the autonomy to experience their sexuality and, as a result, find it difficult to admit to their partners their unwillingness to perform the sexual act. 22his position taken by women indicates that male control over women's sexuality still exists, reinforcing gender inequalities. 21This social pressure tends to hinder the restart of sexual activity by women, who have the basic need for intimacy, including mutualism, respect and communication.
Having a perfect body seems to be a social and cultural condition to have a satisfactory sexual performance.Consequently, the partial or total absence of the breasts compromises sexuality.The loss of the breasts is very significant and it is very difficult for the women themselves to accept this, so they show feelings of dissatisfaction as a result of having these changes made to their body. 20A lot of effort is required in order for women to accept their current condition, because the "emptiness" caused by the absence of the breasts transcends the physical body. 19e shame felt becomes even stronger by the uncertainty as to how this new image will be received by their partners. 19Women avoid being exposed and, in some cases, believe that they do no longer suit their partners, 13 even fearing abandonment.The breasts represent femininity and their absence could mean an interruption of women's love life.Without them, women feel excluded from society and sexually rejected. 19he support from their partners seems to really affect the sexual experience of women with cancer and it was considered very significant in all stages of the disease.In the studies analyzed, women talk about the kind of sexuality that, to be experienced, needs the other person and, as a result, they feel threatened when the other person shows lack of understanding and threatens to abandon them under these circumstances.
In circumstances where women can expect understanding and dedication from their partners, they feel more confident and able to cope better with the situation. 19To enjoy one's company means to have affection and care. 13When partners are able to look at the operated area and accept the new image of the women, the so feared risk of abandonment is extinguished. 20n the other hand, the indifference and fear of being rejected may further worsen the chances of self-organization and restructure.The lack of understanding on the part of the partners means failure in coping.The opinion and position of partners are so significant that, when women do not have a partner, they feel relieved that they do not have to meet expectations and give explanations. 19omen with breast cancer present a commitment in the performance of their sexuality, due to the mutilation and changes to body image, pain, fatigue, queasiness after chemotherapy, loss of sexual desire, emotional stress and fear of having their current condition worsen.
Women often feel ashamed and embarrassed in front of their partners and avoid sexual relations because exposing their deformities is considered painful. 12Under this view of separation from their partners, which is mistaken at times, women feel that there is a lack of interest and rejection on their part and end up emotionally and sexually withdrawing.Sexual desire can be affected by the dissatisfaction with their own bodies and by not accepting the loss of the breasts.It is as if the changes limited the performance of sexuality. 15,17,20nitially, there are other concerns in relation to women's recovery, and the sexuality is experienced or felt after some time. 13he analysis of the studies show an assistance in which this aspect of care is not included and which requires a restructuring in the care delivered. 19The professional nursing practice may contribute to the promotion of sexual health 15 by approaching the sexuality of women with breast cancer.For this, it is necessary to eliminate discrimination 13 and overcome cultural obstacles, which prevent an open and clear communication about sexuality and sexual problems.Healthcare professionals need to be aware of the need for psychosocial adjustment of these women. 20Proper training is essential, so that nurses can provide holistic care, with early detection and prevention of sexual problems. 23exuality is not a concept that can be considered separately from health, representing a central factor in maintaining wellbeing and self-esteem. 24herefore, it needs to be incorporated to the discussions and be a part of care in order to avoid that patients become filled with concerns, as well as feel alone and abandoned.

FINAL CONSIDERATIONS
The diagnosis and treatment for breast cancer affect the sexuality of women, both physically and emotionally.Many women need help to overcome the trauma of the disease and the treatment, as well as to fully resume sexual activity.
It is essential to draw up a care plan for these women with direct effect on issues related to sexuality.This care should be extended to the partners, who need to be encouraged to be closer to the women and participate in the whole process, given that the importance of such support has been evident.Nursing needs to consider the sexual partners as support and work with the difficulties they face while dealing with the disease of their partners, turning them into elements of support during rehabilitation.
This restructuring of the care provided requires a type of care that goes beyond the biological dimension and views women in all aspects.It requires the action of a multidisciplinary team.
Studies about the sexuality of women with cancer are generally descriptive, and research showing strong evidence, that is, about intervention or even evaluation, is rare.The reduced number of articles found which have nursing professionals as the authors of the studies, shows the lack of Brazilian scientific production about this theme.