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BREAST CANCER & SEXUAL SATISFACTION; AN EXPLORATORY SEQUENTIAL MIXED METHOD RESEARCH
DR. NUDRAT MUSHTAQ1
Assistant Professor, Dept. of Sociology-Sardar Bahadur Khan Women University-Quetta, Pakistan
DR. NASIM KHAN MAHSUD2 Assistant Professor, Dept. of Sociology-Allama Iqbal Open University-AlOU, Islamabad Corresponding Author, Email: nasim.khan@aiou.edu.pk DR. UME HABIBA3 Instructor-Sociology, Virtual University of Pakistan
Abstract
Breast cancer is the most prevalent cancer worldwide with an estimation of 7.8 million females alive with it at the end of 2020. In 2020, 25,928 cases of female breast cancer were reported in Pakistan making it the highest among all other malignancies. This research paper is part of a larger research study using an exploratory sequential mixed method research to broadly investigate the impact of breast cancer on a couple's marital satisfaction; this paper highlights the relationship between breast cancer and sexual satisfaction and then its impact on couples' married life. The data collected in the qualitative data collection phase was thematically analyzed and the outcomes were verified in the second phase of quantitative data collection and analysis. The findings of both data approved the prior assumption that the sexual satisfaction of both cancer patients and their spouses is impacted by breast cancer and its resulting in relationship strains.
Key Words: Breast cancer, Sexual Satisfaction, phenomenological approach
INTRODUCTION
Breast cancer is most prevalent cancer worldwide with an estimation of 7.8 million females alive with it in the end of 2020 (WHO, 2021). In 2020, 25,928 cases of female breast cancer were reported in Pakistan making it the highest among all other malignancies. As a disease breast cancer can potentially affect numerous dimensions of a woman's life. A number of disciplines have examined these effects including medicine, psychology, as well as sociology. Researchers have explored several issues resulting from breast cancer treatment diagnosis and treatment including stressful condition and psychological weakness (Linley, 2006), psychological distress resulting in dis-functioning, emotional turmoil in patients in females undergone biopsy (Montgomery & McCrone, 2010), feelings of shame and embarrassment (Kayser & Sormanti, 2002: Venter et al., 2008), psychological impacts of losing a breast and cosmetic as side effects of mastectomy (Giuliano & Hurvits, 2013) and reduced social as well as social, psychological, vocational, and economic problems (Cheville et al, 2008). The negative effects of breast cancer and its treatment on sexual and married life of individuals are stated in many studies (Krok, Telka, & Moron, 2023; Mushtaq & Ali, 2019; Ruiz-Marin et al., 2021). Sexual satisfaction is defined as an implicit feeling rising from an individual's subjective assessment of both the positive as well as negative dimensions related to his/her sexual relationship (Ji & Norling, 2004). The strong relationship between sexual satisfaction and marital satisfaction is established in several studies and marital satisfaction is indispensible in building durable besides strong family relations (Aktas & Bahar, 2022; Bakhshayesh & Mortazavi, 2010; Bilal & Rasool 2020; Schoenfeld et al., 2017; Yoo et al., 2014). Female cancer patients may confront with changes during or after treatment that may disturb their sexual life. All oncology treatments including chemotherapy, radiotherapy and surgery affect sexual health in some ways (Shankar et al., 2017). Studies have shown that disturbed psychological body image besides decreased sexual self-concept as side effect of cancer treatment may result in breast cancer patients' impaired sexual health (Cobo-Cuenca et al., 2018; Teo et al., 2016), vaginal dryness, suppressed libido, infrequent sex and decreased sexual satisfaction are a few problems experienced by female breast cancer patients (Chang et al, 2019;
Shandiz et al., 2016). Some studies (Chang et al., 2019; Harirchi et al., 2012) have established approximately 85% patients suffer from sexual dysfunction after breast cancer treatment, fairly similar results were found by Jing et al., (2019) as their research confirmed the high prevalence of sexual dysfunctions (73.4%) in women with breast cancer.
Nasiri, Taleghani, & Irajpour., (2012) concluded that most couples didn't converse with one another about their feelings and thoughts attributable to the feelings of shame and overlooked their sexual necessities subsequent to cancer diagnosis. Consequently, sexual complications resulted from cancer treatment negatively affected their marital relations. Flynn et al., (2012) established that the discussions of sexual side effects of cancer are often neglected during cancer treatment resulting in lack of anticipated knowledge and support for couples (Gilbert et al., 2013) often attributed to patients and their partners refusing to talk about sexual issues with medical professionals due to cultural taboos (Hill et al., 2011; Wendt, 2017) and healthcare providers' fear of invading patient's privacy (Stilos, Doyle, & Daines., 2008).
RESEARCH GAP
Sexual satisfaction is proved to be a major contributor in marital satisfaction and breast cancer affects the sexual performance of females (Mushtaq & Ali., 2019), nevertheless sexual issues are considered as taboos and have a conservative view in most Asian countries. Moreover, discussion of sexual issues is regarded as shameful and misconduct (Zangeneh et al., 2023). While research has focused on several impacts of breast cancer patients including psychological, emotional, social, spiritual, and economic issues, studies on the sexual effect of breast cancer both on patients and their partners is limited and barely existent in Pakistan. This study therefore aimed to explore the phenomenon from the perspective of both patients and their husbands to add to available knowledge of how patients and their spouses experience sexual issues after breast cancer; individually as well as a couple.
RESEARCH METHODOLOGY
The qualitative phase of the study focused on exploring the couples' unique experience of breast cancer and identifying the factors influencing their sexual relationship by applying phenomenological approach. The data in qualitative phase was collected in one-to-one in-depth interviews of 24 respondents (12 couples) using a developed interview guide along with added open ended questions. In-depth interviews were audio-recorded, transcribed and analyzed professionally to identify emerging themes. Once the analysis of qualitative data was completed, emerged themes were adopted to develop a 5 point Likert scale including 47 items, for quantitative data collection. The
Alpha test was applied to test the reliability of data collection tool nevertheless present research paper merely includes analysis of 09 items measuring sexual satisfaction of patients and their husbands. The quantitative data was collected from a sample of n=558 through convenience sampling. The sample of study participants was drawn from Nuclear Medicine, Oncology and Radiotherapy Institute (NORI) hospital, Islamabad.
DATA ANALYSIS AND RESULTS Table 2.Survey participant demographics and clinical characteristics (n= 558). Variable Response Frequency
Age
Male 34-39 years 1 (0.4%)
46-51 years 118 (42.3°%)
Female Above 57 0 (.0%)
40-45 years 122 (43.7%)
Level of Education
Male Diploma 19 (6.8%)
Middle - Metric 76 (27.2%)
Female Diploma 14 (5.0%)
Illiterate-Primary 86 (30.8%)
Employment Status
Male Unemployed 15 (5.4%)
Employed 264 (94.6%)
Female Employed 64 (22.9%)
Unemployed 215 (77.1%)
Years of Marriage
Male Above 21 years 9 (3.2%)
10-15 years 173 (62%)
Female Above 21 years 9 (3.2%)
10-15 years 173(62%)
Breast Cancer Stage
Female Stage III 84 (30.1%)
Stage I 22 (7.8%)
Data is presented as mean of minimum and maximum correspondingly. The age of male respondents was in the range of 34-57 years with a majority of 118 (42.3%) were in the age group of 46-51 years while for the same range the majority female respondents 122 (43.75) were in the 40-45 years of age. The data shows that 86 (30.8%) females were illiterate while only 14 female respondents (5.0%) had a professional degree or diploma. The majority of male respondents 76 (27.2%) were in the category of middle to metric and 66 male participants of study were illiterate or had primary level education. Among 279 female respondents of study, majority 215 participants were unemployed which made them (77.1%) of the sample while only 22.9% (64 females) were employed however only 15 male respondents (5.4%) were unemployed and 94.6% (264 males) were employed. Majority respondents 347 (62%) were married for 10-15 years while 9 couples were married for more than 21 years. There are 5 stages of caner categorized on the basis of locality, size and spread in body. The above data demonstrates that majority women were patients of stage 3 cancer at the time of data collection.
Table Themes from Qualitative Data Analysis
3. Emerged themes of Sexual Satisfaction and Resultant Survey Items
Sample Phrase Codes Resultant Survey Items
Sexual Frustration
Affection
misinterpreted
with sexual
advance
Distressed
Sexual
Experiences
Sexual
Dissatisfaction
Hazily Informed about Sexual Complexities
I get irritated, like it's not something new we have been married for so many years and she has suddenly started reacting as this is a new thing.
I feel frustrated and annoyed. I can understand that it is difficult for her but she should also understand my situation.
"Every time I ask my wife for sex she refuses by saying she has pain or it hurts that definitely annoys me. I haven't enjoyed sex for last 3-4 years"
"I am often reluctant to show my affection because she habitually misinterpret it as a sexual advance and reacts strangely which destroys my mood."
"...she has got an excuse of her disease which she uses as a weapon to get sympathy and to avoid sex at the same time"
"She has much pain and makes noise that I get irritated"
My sexual needs and desire don't matter to her, I want to live a normal life but it is not possible for me obviously I am stressed and this affects my family and marital life."
"My wife and I didn't know if we can still have sex or not after my wife was diagnosed with breast cancer but no doctor guided us in this matter and we were so ashamed of asking any question then during our hospital visits we exchanged information with other patients and their spouses but they had diverse opinions.
3. My spouse discourages me sexually.
6. I feel annoyed due to my spouse's manipulative sexual behavior
4.My spouse frequently confuses love with sexual advance
2. After cancer, my spouse despises sex.
5. I and my partner doesn't share same sex interest after cancer
1. My sexual relationship with my spouse is satisfactory.
9.Sometimes my spouse mistreats me
8. I never talk about our sexual problems with anybody except my spouse 7. I can easily converse my sexual problems to my spouse
Table 3. demonstrates the process of developing survey questions. Once the data analysis of qualitative phase was completed, survey items representing specific themes were developed by considering participants' views and experiences.
Table 4. Indicating Mean and Standard Deviation for Sexual Relationship & Issues
Sexual Relationship & Issues Female Male
Ite Statement Mean N St.De Mean N St.De
m v v
No.
My sexual relationship with my spouse is 3.35 279 1.517 3.43 279 1.518
satisfactory.
After cancer, my spouse despises sex. KA\/ cnoi iCf^ Hic/~m ir^a^c mp 2.61 3 59 279 779 1.469 1 488 1.488 2.80 ? 61 2.61 279 779 279 1.450 1 475
My spouse discoui ages me sexually. My spouse frequently confuses love with 3.57 2.80 2/9 279 1.513 2.89 279 1.475 1.424
sexual advance
I and my partner doesn't share same sex interest after cancer I feel annoyed due to my spouse's manipulative sexual behavior I can easily converse my sexual problems to my spouse I never talk about our sexual problems with anybody except my spouse Sometimes my spouse mistreats me
2.84 279 1.397
3.13 279 1.533
3.25 279 1.334
2.55 279 1.579
3.63 279 1.408
2.63 279 1.418
3.03 279 1.424
3.32 279 1.328
2.61 279 1.610
3.54 279 1.374
The 9 items presented above are sorted from the complete scale on the basis of their relatedness to sexual issues and relationship. The mean scores of female respondents were found for satisfactory sexual relationship (3.35), spouse doesn't enjoy sex (2.61), sexual frustration (3.59), misinterpreted affection (2.80), unequal sexual interest (2.84), unfair use of sex (3.13), discussion of sexual issues (3.25), sexual discussion with third person (2.55), and inappropriate treatment (3.63). However, male respondents showed mean score as satisfactory sexual relationship (3.43), spouse doesn't enjoy sex (2.80), sexual frustration (2.61), misinterpreted affection (2.89), unequal sexual interest (2.63), unfair use of sex (3.03), discussion of sexual issues (3.32), sexual discussion with third person (2.61), and inappropriate treatment (3.54). High similarity was found in the responses of both male and female respondents as both scored highest for inappropriate treatment from spouse (3.63 for female respondents with a standard deviation of 1.408) and (3.54 for male respondents with a standard deviation of 1.374).
DISCUSSION
The study findings revealed that against the common perception, breast cancer is not really infrequent in younger females. As for current study, 4.3% and 43.7% patients were between the age group of 34-39 and 40-45 years respectively, indicating the occurrence of breast cancer in young age. Partridge (2018) established that females developing breast cancer at comparatively young age viz. below the age of 45, defy with different issues special to their life phase including the outcome of disease on their careers, personal besides social relationships, sexual functioning, along with ability to give birth and raise children. The results also exhibited that both partners in couples confronting breast cancer experienced several issues alone or together in sexual relationships as emerged themes directed by data analysis. The frequency and quality of sexual activity besides satisfaction were categorically deteriorated attributed to either psychological effects of cancer including temperamentality, resentfulness, depression or loss of sexual desirability or it can resulted from physical complications induced by breast cancer for instance pain, fatigue, nausea, dyspareunia because of the vaginal dryness (in case of menopause), trouble in reaching to orgasm, difficulties in arousing mentally and physically. Loss of sexual interest and painful intercourse is mentioned by patients in prior studies too (Aktas & Bahar, 2022; Mushtaq & Ali, 2019; Tahir & Khan, 202). Graziottin (2008) indicated the frequent neglect of the biological issues in the clinical settings consequently disturbing physical intimacy besides sexual satisfaction of breast cancer patients immensely. Sexual dissatisfaction is reported by both male and female study participants. Tahir & Khan (2021) stated that married females in Pakistani society are considered legitimately responsible for fulfilling their spouse' sexual needs and failing in doing so results in marital problems, present study found similar results.
RECOMMENDATIONS
Sexual dissatisfaction plays a vital role in straining married couples thus resulting in marital dissatisfactions and despite the well-known effect of breast cancer on sexual satisfaction, every oncology treatment focuses on physical cure of the patients overlooking their emotional and psychological complications. The results of present in accordance with previous studies (Carroll,
RUSSIAN LAW JOURNAL Volume XI (2023) Issue 5
Baron, & Carroll, 2016; Den Ouden et al., 2019; Rottmann et al., 2022) suggest including couple-based sexual counseling in treatment phase.
DISCLOSURE
The authors reports no conflict of interest in this work.
AUTHORS CONTRIBUTIONS
All authors contributed in data analysis, drafting and revising the article and final approval of the
version to be published.
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