Men’s Achilles’ heel: prostate cancer and the reconstruction of masculinity

Abstract

The aim of this study was to investigate how Swedish men diagnosed with prostate cancer understand the effects of their treatment in relation to sexual health and masculinity. Utilising a phenomenological and sociologically informed approach, the study involved interviews with 21 Swedish men who experienced problems following treatment. The results showed that participants’ initial response post-treatment, involved the development of new bodily understandings and socially informed strategies to handle incontinence and sexual dysfunction. Due to impotence and the loss of ejaculatory ability following treatments such as surgery, participants re-articulated the meaning of intimacy, as well as their understanding of masculinity and themselves as ageing men. Unlike in previous research, such a re-articulation of masculinity and sexual health is understood as taking place within rather than in opposition to hegemonic masculinity.

Keywords:

• Prostate cancer
• bodily fluid
• sexual health
• masculinity

Introduction

Ideas about masculinity and what it means to be a ‘man’ are intimately tied to certain attitudes, norms and lifestyle choices. Historically, masculinity has been associated with a tendency to neglect emotions and bodily symptoms (Haywood et al. 2017). Thus, psychological well-being, emotional sensitivity and sexual health have not been prioritised (Hyde et al. 2021). Instead, cultural ideals of masculinity have tended to be directed towards men’s abilities and performance, simultaneously socialising them into risky patterns of behaviour (Narasimhan et al. 2021). Men are also less likely than women to discuss and share information about their well-being (Lee and Owens 2002). Indeed, the influence of gendered patterns and normative masculinity configurations can be detrimental to men’s health, and quality of life (Muermann and Wassersug 2022).

Critical studies on men and masculinity can bring new insights into the ways in which men handle illness and psychological stress. Though it is possible to identify structural risk patterns of neglect as regards men’s ways of dealing with health issues, men are not a homogenous category. Health status and how issues concerning health and well-being are dealt with vary depending on parameters such as material circumstances, age and social class (White 2002). Furthermore, men are increasingly engaging in, or are drawn into, the ‘health industry’, paying attention to their physical as well as psychological well-being (Ruane-McAteer et al. 2019). Adding to this, recent developments in society and public health have increased the expectations placed men to take responsibility for their own health, and to strive for gender equity (White 2002; Johansson and Andreasson 2017). These transformations of masculinity must also be understood as implying a reconfiguration of hegemonic masculinity in diverse social, cultural, and political contexts (Connell 2020).

Prostate cancer is one of the most common cancer diagnoses for men, especially with advancing age. While experience is variable and improvements are taking place, treatment for prostate cancer may result in erectile dysfunction, urinary incontinence, bowel dysfunction, arousal incontinence, ejaculatory disturbances, lack of libido, difficulties in intimate partner relationships, and other side effects (Donovan et al. 2016). In relation to historically dominant conceptions of masculinity, the prostate can therefore be understood as the Achilles’ heel of men, as dysfunctions in the prostate may have direct or indirect consequences for how men do gender and sexuality (Chapple and Ziebland 2002; Björkman 2018). This has been addressed in a wide variety of studies, in which the disease and its impact on masculinity has been debated in relation to sexuality, body image, age and more (cf. Muermann and Wassersug 2022).

Framed within an ongoing reconfiguration of hegemonic masculinity, the aim of this study was to investigate how Swedish men diagnosed with prostate cancer understand the effects of their treatment in relation to sexual health and masculinity. We will analyse how men treated for prostate cancer handle the challenges that a diagnosis and the treatment may bring. The focus is on both phenomenological aspects of prostate cancer – how the disease/condition affects men’s bodily self-perception, lifestyles and sense of masculinity – and sociological aspects – that is, how gender and masculinity are understood and negotiated in social situations/interactions (cf. van der Kamp, Betten, and Krabbenborg 2022). The study was guided by the following research questions (RQs):

RQ1: How do the participants narrate their initial recovery and the social implications of the treated body?

RQ2: How do the participants describe the effects of the treatment on their sexual function and health, and what means (if any) are used to reinstate sexuality if needed?

RQ3: How are masculinity and manhood entangled and present in the narratives of the participants?

Survey of the field

Although there is a growing literature on masculinity and prostate cancer in the social sciences, this field of research is found mainly in medicine and the biomedical literature (Stotts 2004; Van Hemelrijck et al. 2013; Tomaszewski et al. 2017). Historical examinations of medical discourse concerning male sexuality and prostatic dysfunction show that as early as the late 19th and early 20th centuries prostatic enlargement was seen as a medical problem (O’Shea 2012). At that time, men were exposed to highly invasive and painful treatments. The idea that the prostate was the centre of the male sexual system prevailed, and this idea was also linked to ideas of sexual dysfunction. Treating prostate disorders was thus equal to treating sexual dysfunction. Although vasectomy was viewed as a possible alternative, during this time castration was the favoured technique for treating prostatic diseases. By the early 20th century, however, new types of operations had been developed. The importance of preserving sexual performance, and thus also upholding masculinity and sexual health, became increasingly important (O’Shea 2012; Johnson 2021). Alongside the modernisation and increased precision of surgical and other techniques, the importance of maintaining potency changed the way prostate cancer was treated. Although the development of nerve-sparing techniques has contributed to reducing the severity of some side-effects, many men still suffer from long lasting implications due to their disease. Furthermore, rehabilitation processes following prostate cancer are influenced by the size and severity of the prostate tumour, the treatment techniques used, and age (Salonia et al. 2017).

In recent decades there has been a growing literature in the social sciences on how men perceive and talk about prostate cancer and the various available treatments (Oliffe 2009; Haddow et al. 2015; Björkman 2018; Bowie et al. 2022; Muermann and Wassersug 2022). This research suggests that masculine ideals are in flux, and there are signs that men – through the learning processes that take place when they are confronted with a cancer diagnosis – refashion or repair their identities and develop new ways of doing masculinity (Oliffe 2009; Langelier et al. 2018; Brüggemann 2021).

In one study Chapple and Ziebland (2002), interviewed 52 men throughout the UK (ranging in age from 50 to 85), mainly white from a middle-class background, on their experience of prostate cancer. The focus was on how the men talked about the surgical procedures and the treatments in relation to their understanding and conceptions of masculinity. The findings suggested that the participants made comments on masculinity spontaneously, without being asked explicitly to make this connection. Men expressed how they felt uneasy becoming dependent on doctors and that their masculinity was threatened by both potential and real loss of potency. However, losing the ability to have an erection and have penetrative sex was also seen as a small price to pay for survival (see also Haddow et al. 2015).

A few years after Chapple and Ziebland’s study, Jonsson, Aus, and Berterö (2009) conducted an interview study in Sweden with men who were newly diagnosed with advanced prostate cancer. This study showed that the participants initially responded with despair and went into a ‘mental vacuum’. Soon, however, they began to seek information and desired to get back to what they considered an ordinary life. The men also talked about having a new perspective on life and a heightened awareness of mortality. Echoing this, Oliffe (2009), showed that men treated for prostate cancer gradually challenged masculine ideals and developed a willingness to talk about and learn from their illness (see also Langelier et al. 2018; Brüggemann 2021).

Although most studies have focused on the experiences of heterosexual (and middle-class) men, there are also studies of gay and bisexually identified men (Filiault, Drummond, and Smith 2008). In an Australian study of 46 gay or bisexual men three subject positions to deal with the effects of prostate cancer treatment were identified (see also Ussher, Rose, and Perz 2017; Danemalm Jägervall, Brüggemann, and Johnson 2019). The ‘mastering youth’ position allowed men to emphasise sexual functionality. Using different biomedical interventions, bodily attractiveness and sexuality was maintained. For these men it was important to ‘not give up’ on sex. The next position, ‘the lonely old recluse’, embodied changes after prostate cancer being constructed as a decline, a reduction, and a ‘blow to the ego’. Finally, the position ‘accepting embodied ageing’, bodily changes were incorporated in and seen as a part of the aging process (see also Sandberg 2011). Changes in the sexual function were therefore not inevitably seen as a threat to masculinity or men’s egos. Similar strategies to manage bodily changes seem quite common in heterosexual men’s narratives (Oliffe 2005; Broom 2005; Danemalm Jägervall, Brüggemann, and Johnson 2019; Brüggemann 2021).

There is a growing number of studies on the relationship between prostate cancer, masculinity, ageing and identity. In a German study of ageing and prostate cancer, the results indicated that many older men framed prostate cancer side effects as something normal, to be expected and anticipated (Schultze, Müller-Nordhorn, and Holmberg 2020). Consequently, coping with the loss of bodily function was seen as “natural" part of the ageing process. A common finding is that prostate cancer often involves treatment related to sexual dysfunction (Incrocci 2011; Sandberg 2011). In this sense, life with prostate cancer and its treatment may entail significant challenges to men’s sexual health and sense of masculinity (Alexis and Worsley 2018). It has, however, been suggested that this field of research has tended to reproduce a stereotypical image of contemporary masculinity, building on an understanding of men as first and foremost virile and sexually performance-oriented (Halpin, Phillips, and Oliffe 2009). Such understandings can be contrasted with the gender ideals promoted in Sweden, where this study is situated, and the policies that support it (Johansson and Andreasson 2017). There is therefore a need for more nuanced and theoretically sophisticated qualitative studies on the relationship between prostate cancer, new therapeutic options, changing masculinities, sexuality, and social class, among other things (Brüggemann 2021; Sandberg 2011).

Theoretical framework

In several studies, Oliffe (2005; 2006) has explored how Connell’s theory of hegemonic masculinity can be used to understand how men redefine and reconfigure masculinity after treatment for prostate cancer. In these studies, the concept of hegemonic masculinity (HM) is used to refer to the dominant forms of masculinity present in a society. Often HM is associated with characteristics such as stoicism, sexual prowess, control, discipline and leadership (Klaeson 2011; Kampf 2012). In contrast to Connell’s own position, and her urge not to equate HM with certain personality traits or social characteristics, the concept has sometimes been used to describe a form of ‘traditional’, orthodox and stereotypical masculinity (see for example Anderson 2012; English 2017; Van Gilder 2019). When talking about the redefinition of sexuality and masculinity, Oliffe (2005), for example, uses the concept of ‘plural masculinities’. In a similar way Brüggemann (2021) talks about plural and ‘caring masculinities’. A central problem with this use of Connell’s theorising however is that HM and other forms of masculine positions are decoupled. Instead, we will suggest that many contemporary transformations in masculinity may be taking place within HM itself, in the context of Swedish society and welfare incentives to promote gender equality among other things.

HM is a historically changing structure and configuration of gender relations and practices (Connell 2020). The form of masculinity that is hegemonic at any given time varies. In contrast to more static theories of patriarchy, HM offers a dynamic and more open account of how different gender orders are formed and reformed, with national and even local variations. Since the publication of Connell’s Masculinities (originally in 1995) there has also been an intense and ongoing academic debate on the concept and its application (Connell and Messerschmidt 2005). Large parts of theorising HM have taken place within a structuralist framework. Using a post-structuralist perspective on HM, it is possible to identify a gradual reconfiguration of hegemony. In contemporary Swedish society, for example, we can see how dualistic gender role models have been gradually defunctionalised and reframed (Johansson and Andreasson 2017). Recent developments in family relationships, towards more gender-equal and gender-neutral forms of parenting, can be interpreted as re-articulations of hegemony (Brandth and Kvande 2009).

Instead of using HM to capture stereotypical masculine behaviours and traits, we argue for approaching HM in terms of the potential for change, to consider what a reconstruction of HM as a social structure might mean. Transformations in masculinity towards increasingly involved and caring fathering practices, tendencies for men to care for their bodies, gender equity, and older men caring for their sexual health should thus not automatically be understood as signs of the fall of patriarchy, but rather as manifestations of an emergent reconstruction of HM. This also means that men and women can position themselves in different ways in relation to HM and develop various subject positions. Paying attention to one’s personal health issues, and to one’s physical as well as psychological well-being, is thus not per se in conflict with HM, but rather a part of a more general redefinition of masculinity, health, ageing and family life. Continuing this line of thought, this article investigates how different masculine ideals are played out in relation to the side effects of prostate cancer treatment, and how men’s different ways of positioning themselves as men also can be analysed as part of the gradual reconfiguration of HM.

Method and research design

This study utilised a qualitative approach to research. Interviews with 21 men aged 50 to 78, who had been diagnosed with prostate cancer and represented diverse methods of treatment, were conducted. Seven of the men had a working-class background and 14 had a middle-class background. All participants self-identified as white.¹ The material consists mainly of men who had undergone surgical treatment (n = 13), but also includes men who underwent hormone therapy (n = 3), radiotherapy and hormone therapy (n = 3), and surgery and hormone therapy (n = 2). Regarding sampling, access to participants was established mainly through one of the project members (Danemalm-Jägervall) who works as a sex and relationship counsellor and a urology nurse at a hospital in southern Sweden. This person’s professional contacts made it possible to ensure variation between participants in terms of the treatment experienced, length of time since their treatment for prostate cancer (stretching between a few months to more than 10 years), side-effects experienced, and more. During recruitment, the men were given an information sheet that included a description of the project, notice that participation was voluntary, and assurance that participation would not influence their care in any way.

The aim of this purposive sampling was to gather data that reflected the range of experiences and diverse features of men’s understanding of prostate cancer and its treatment (Campbell et al. 2020). Fieldwork mainly took place face-to-face in a secluded room at the hospital where one of the authors works. Due to COVID-19 restrictions at the time, a few participants preferred to participate in interviews online. In these cases, Zoom or other online communication technology was used (Janghorban, Latifnejad Roudsari, and Taghipour 2014). Using a semi-structured interview template, we asked participants about their perspectives on being diagnosed and treated for prostate cancer, and the effects of that treatment on their daily life. We also asked them about how their disease had come to influence and possibly change their understanding(s) of masculinity and intimate relationships (cf. Brüggemann 2021). The interviews, which lasted about an hour in length, were audio recorded and transcribed verbatim.

Regarding data analysis, the intention was to leverage different approaches to the research questions, to search for clues as to the various ways in which the participants understand their everyday lives in relation to their medical and social situation (Tarrant 2021). Throughout the process of data analysis we followed the ‘listening guide’ as described by Walby (2013). At the core of this guide is a relational understanding of the social world, which means that selves are always understood as enmeshed in relationships with others. In line with Walby, we applied a processual approach to data analysis, which was conducted in four steps.

Firstly, we identified the main plot being described by the participants. We took part in our participant’s narratives and reactions to being diagnosed. In doing this, we also reflected on our own role and position as researchers, considering the role of power in the social relationships of research and treatment. Secondly, following this reflexive stage, we focused more closely on the ways in which different participants narrated their stories and constructed their subjectivities/masculinity, in relation to the plot being diagnosed and treated for prostate cancer. Thirdly, we read and re-read the transcripts, looking for multiple voices within one story, and broadened our analysis to include the relational matrix in which the self is enmeshed; that is, how the notion of ‘I’ was narrated in relation to others. In particular, we focused on how men talked about their intimate relationships with their partners. The different narratives from the interviews were interpreted in relation to social positional and relational factors. Finally, an analysis of how the narration of the self-linked up with broader cultural discourses and structural forces was conducted. This includes how the narration of the self was related to broader discourses on topics such as age, sexuality and bodily function (Hankivsky 2012). The analysis was connected particularly to gender theory and sociologically informed theories of masculinity.

Concerning ethical considerations, all names, places, or other potentially personal identifying details were pseudonymised in the data analysis process. Contact details, audio files, and transcriptions of interviews were kept on an external hard drive that was stored in a locked safe after processing. Ethical approval to carry out the study was granted by the Swedish Ethical Review Authority (Ref. No. 2021-01955).

Results

Recovery: managing the leaking body

Perhaps unsurprisingly, when talking about their expectations following treatment the participants’ initial priority was survival and being able to recover from cancer. Thereafter, their interest turned to two common side-effects of treatment: problems with incontinence and erectile dysfunction. As the men recover, the variability of side-effects in relation to the type of treatment becomes embodied and additional problems are mentioned (Xu et al. 2011). Sture, who went through radiation and hormone therapy, talks about his side-effects, and how they impacted his daily life.

When it comes to prostate cancer there are basically three things that it takes a lot of time to deal with. One is incontinence, the second is that you can get burned on the large intestine, and the third is impotence. (…) I always try to be aware of my situation, and practise what I call ‘preventive peeing’. I have to sit when peeing because there can also be leakage from the rectum. So, these are the kinds of things you must deal with. (Sture, 71, pensioner, former director of social services)

For Sture, as well as others, bodily leakages become a threat to their everyday autonomy, often leading to the development of new routines. Although most of the participants described incontinence as a challenge, there were ways of dealing with it. Håkan, who was operated on some 6 months ago, said:

After the operation, when I was at home again, I woke up during the night, and I was totally…I mean I had diapers, but I was totally wet, kind of. I could not turn off the flow. Then I thought ‘Okay, so this is what I must live with now’. However, after a week or two it got better. I was almost dry again. So, although I use protection – diapers – it’s much better now. It’s like it was before the operation (Håkan, 69, pensioner, former engineer)

Some of the men, like Håkan, managed to adjust fairly well to their new situation, and in Håkan’s case his daily Kegel exercises seem to have paid off. Although he described himself as ‘almost dry’, later in the interview he also talked about the development of a new bodily awareness due to his predicament. He explained that he was always alert in different social situations, making sure not to get ‘too excited’ or ‘laugh too much’, as such emotional reactions could cause urinary incontinence. The deteriorated function of the bladder has thus become not only a physical but a socio-emotional limitation, and he tries hard to control his body through emotional management (cf. Martínez-Morato et al. 2021). Other men had more pronounced urinary incontinence, and for them there was always a need to be aware of where the nearest toilet was.

It is clear that men developed different strategies to navigate their social landscape, depending on the severity of the side-effects experienced. The subjective experience of significant bodily change affected men’s lifestyles and their ease of movement. For some participants, this meant rarely visiting public places at all, at least not if easy access to public toilets was limited. In such cases, the fear of becoming ‘a smelly old man’, with urine stains on their clothes, gets the upper hand and the leaking body becomes the old, emasculated, humiliated and asocial body; symbolising lack of control and a ‘return to babyhood’ (Twigg 2004).

A reorientation of sexuality and partner intimacy

A well-known side-effect of prostate cancer treatment, besides urinary incontinence, is impotence and the loss of sexual function (Hyde et al. 2021). In a way, the image of the prostate cancer patient is that of an impaired, weakened and impotent masculinity (Brüggemann 2021), as exemplified below.

I mean it’s almost exclusively the erection problem. I mean, to be able to get hard. In your head, that is part of being a man. Definitely.

Interviewer: Why do you think you think that?

Yeah, I don’t know. It’s been like that for ages and at all times, I guess. Manliness, it has to do with the ability to get an erection, and to be manly when it comes to sex and sexuality and so on. It kind of feels like that. It’s part of a general understanding, I think. I’m not going to say it’s from how you were raised, or in your genes. I don’t know, but this is how I experience it anyway. (Ragnar, 78, pensioner, previously chief accountant)

For Ragnar, and several others, changed physical abilities were connected to more general ideas about what it means to be a man. The leaking body was not understood as sexy, nor was the inability to get an erection (Alexis and Worsley 2018). Although Ragnar was unable to identify the origin of these ideas, he perceived them as a sort of general understanding concerning how one should be, and what one should be able to accomplish as a man. Another participant, Rolf, also talked about this kind of ideal. He described how his sex life had changed as the result of his own and his wife’s medical conditions.

Of course, you miss having [penetrative] sex because that is something really…. it’s the silver lining in a relationship, right? But now it is like this, and we have come to accept it, both of us. The intimacy we have today is that I caress her to orgasm, and then we have Bondil [erection stimulant], so she can masturbate me to ejaculation. (…) But the orgasm is totally different today, in comparison to what it used to be before the operation. Before, you build up this feeling, the feeling of orgasm, it builds in your body, during intercourse. Then you have this relief, the orgasm, and it gradually fades, the feeling. But today it’s not much of a feeling really, it’s not that the feeling builds up in your whole body. My wife does her thing and then all off a sudden comes the orgasm. There’s about four, five seconds warning before it happens, then it comes, and then it’s more like … ‘Well that’s it, how about a cup of coffee?’ (Rolf, 70, pensioner, former electrician and IT technician)

After his operation, Rolf sometimes struggled with erectile dysfunction. With medical support he could, however, engage in what he perceives as an altered and somewhat arranged sexual life. His wife also suffered from diabetes, which had resulted in dry mucous membranes, making penetrative sex difficult. Together they have developed a new form for intimacy (Sandberg 2011). It is not like before, and it is not the ‘same feeling’, but it is something that they have developed together.

The men often expressed how they missed sex as it used to be, in terms of being able to ‘get hard naturally’, to feel ‘how the orgasmic feeling builds up in the body’, and then ‘to properly ejaculate’ during penetrative sex. They also developed ways of coping with the fact that their body had changed. The apparent changes in the body, in combination with the cultural images of ageing male bodies under threat, activate different subjective strategies to respond to the challenge (Klaeson 2011). Sture has reconsidered and reformulated his sexual ‘needs’ to develop a new platform for intimacy and sexuality.

The fact is that closeness and intimacy are not exclusively about penetration. I think that’s important. One must find other forms of stimulation and satisfaction; we had that before (the treatment), too, without reflecting on it. The need for intimacy is no less. Physical intimacy is often devalued, when talking about human needs. And we have those needs. When it gets colder, we need to lie down beside each other – we need the physical intimacy. (Sture, 71)

As suggested above, the reorientation of sexuality involved not only coming to terms with one’s owns bodily capabilities and need for intimacy, but also the need for an understanding partner and the ability to discuss paths to sexual health (Brüggemann 2021). This was particularly true for men who receive hormone therapy, for whom there may be no interest in sex at all.

No, I don’t miss it any longer. It’s more, almost, like in the last couple of months it has mostly felt like a necessity to try – to be honest and a bit dramatic. I’m not going to exaggerate but it is more in that direction.

Interviewer: To do it for your partner?

Yeah, I’m not doing it for my own sake, more for the wife if there’s pleasure in it for her. (Simon, 75, pensioner, former truck driver)

Among participants the relational perspective was repeatedly underscored, as men described how they developed new repertoires and forms of intimacy with their partners. For some this process was understood as rather painful and connected to feelings of failure, coercion and being less of a man. For others, and particularly in relation to thoughts about ageing and the ageing body, other aspects of intimacy were understood as becoming more important (Gillearde and Higgs 2014).

The means of reinstating sexual function varied greatly between participants, ranging from relational support from a partner to biomedical erectile support, penis pumps and penis injections. These kinds of support also need to be set against the fact that men themselves tend to medicalise something that is thought about in terms of spontaneity and lust. However, men also show a strong ability to restructure their sex life and health, and to address the challenges of dealing with an altered sexuality. In doing so, the importance of having sustainable and functional intimate relationships is highlighted.

Reformulating masculinity

Generally, participants’ thoughts about masculinity focused on how their intimate relations and self-image had changed as the result of treatment for prostate cancer. For some, the notion of masculinity was strongly connected to ideas about sex and sexual ability. Ture, for example, talking about his lost interest in intimacy because of hormonal therapy, said, ‘I have dealt with this since 2007 – that your manliness disappears’. This kind of understanding was shared by other participants, but sometimes discussions about loss of sexual ability opened the door to a broader reflection on masculinity and manhood.

The desire for sex and sexual ability are definitely a part of masculinity. But they are not the only thing. It’s like my opinions are perhaps a bit old-fashioned, in this context, probably. I haven’t thought about it so much really.

Interviewer: What is it that you think would be old-fashioned opinions?

Well, yeah, that the man is over…the provider and all that, you know. I’m the man of the house, and all that. And maybe I’m not, I dunno, but it’s that kind of opinion I’m referring to. (Henrik, 75, pensioner, former IT technician).

For both Ture and Henrik, erectile dysfunction, decreased interest in sex and the absence of ejaculation were talked about in terms of emasculation (see also Muermann and Wassersug 2022). In the above excerpt, these problems are embedded in a broader context in which Henrik describes what it means to be a performance-oriented breadwinner, who is in control of his woman, the family and its finances. Another participant talked about this in a similar manner, although seemingly from a different position.

I almost think I’ve lost all this…I mean, masculinity. I don’t know really. What is masculinity? I mean, I think that my wife and I are as equal as we can be, really. And when you think about the children and all that, you know…I don’t know if I’m masculine.

Interviewer: Has this changed over time, compared to how it was previously?

Nah, I think I’ve been pretty much the same throughout my adult life. Yeah, I think so. I haven’t changed that much. As regards manliness, it feels a bit strange in a way. I don’t know why. We have shared things equally. (Sten, 72, pensioner, former head of administration)

In these narratives, discussions that initially focus on sexual and physical abilities are gradually, and to different degrees, redirected and reformulated. In the process, some participants tended to linger on lost abilities, and what can be described as a more traditional understanding of masculinity (emphasising the role of the breadwinner, control, ability to have penetrative sex, etc.). Others, however, seemingly embraced what they perceive as changing ideals of masculinity. They situated themselves in an ongoing debate about masculinity in relation to gender equity, involved fatherhood and dual earner families, and expressed critical views on society’s ‘toxic gender order’ (Johansson and Andreasson 2017; Tarrant 2021).

I think I’ve become more secure in my manhood and in the masculinity that I want to pursue in terms of being a vulnerable, sensitive, open and present person. I want everyone who meets me to feel that I’m there and that I’m myself. I’m not playing a role; this is the authentic me that they meet. I think I’ve become better at this. (Kjell, 70, pensioner, former reporter)

Situated within dominant societal expectations concerning gender equality in Swedish society, it is notable that several participants found it quite difficult to address their new condition and the side-effects of treatment in terms of masculinity. The links between an ageing body and sexual dysfunction and broader patterns of masculine gender norms also varied, both between and within participants. Nonetheless, participants did identify various solutions and compromises, positioned on a continuum stretching from a somewhat nostalgic approach to a more reflexive understanding of gender norms in transition. At a more general societal level, in the context of ideals of gender equality in Swedish society, this way of positioning identity and masculinity can be understood as a slow, ongoing reconfiguration of HM. However, putting forward a more sensitive, intimate manhood can also become a way of managing and coping with the loss of sexual function.

Discussion and conclusion

In this study of men who had had surgery or other treatment for prostate cancer, we find roughly two approaches and strategies for managing the side-effects of the treatment that connect to broader patterns of masculinity (Ussher, Rose, and Perz 2017). On the one hand, some men cited difficulty in addressing their disease and the side-effects of the treatment in terms of masculinity and identity and had difficulty in reframing sexuality and intimacy. This approach is characterised by a somewhat nostalgic (old-fashioned) understanding of masculinity. It constitutes a position that tends to hark back to a younger and more capable body and self, that was more able to perform, both sexually and in the organisation of the family (Gott and Hinchliff 2003). This position seemed to be more dominant among the older members of the sample, as well as among men from working-class backgrounds.

On the other hand, there were participants who talked about the need to reconfigure masculinity and find ways of constructing their identity as men and intimate partners, emphasising gender-equity ideals and partner empathy (Brüggemann 2021). This group also showed a capacity to use a more reflexive and negotiating approach to masculinity and identity. Instead of mourning a lost masculinity and lost bodily functions, they looked for other ways to enjoy intimacy and life after cancer. Most of the participants adopting this position seemed to come from a middle-class background and had successful careers before becoming pensioners. The reconfiguration of HM was also more visible in this group. Adopting a sensitive, intimate, and gender-equal masculine position, fits well with the family and gender ideals currently promoted among the middle-class in the Swedish society.

The men in this study were all born in the 1940s and 1950s. They were young in the 1960s and had formed families in the 1970s. At this time, radical changes were taking place in the Swedish political landscape, social reforms made it possible for families to share parental responsibility, and both men and women were able to use generous parental leave benefits to stay at home with their infants. While women were still the main caregivers of children, the incentives for and expectations on men to become more gender-equal were strong. These changes helped to create fertile ground on which many men in contemporary Swedish society have been able to reframe their masculinities.

Previous research has tended to understand the above developments as indicating a cleavage between HM – understood as ‘traditional masculinity’ – and the adoption of more plural and caring masculinities (Oliffe 2005; Brüggemann 2021). As a complement to such a perspective, we argue that this phenomenon is best understood as part of an ongoing reconfiguration of HM in Sweden and in some other countries. Within HM, certain generational sentiments and ways of looking at masculinity, sexuality and men’s health are gradually being replaced by alternative ways of constructing a gender-equal, and more sensitive/sensual masculinity. This also affects men’s’ ways of questions of sexuality, potency and the loss of bodily function. In this context, stereotypical or ‘traditional’ understandings of masculinity are not reflected in men’s health behaviour but may be understood as representing a public discourse about men’s health that is being challenged, and which men (such as our participants) must engage with (Oliffe 2009). While these developments and changes are more evident among middle-class men, there are also notable changes among working-class men. Further research is however needed on how different socio-cultural, and national contexts (especially their welfare systems), impact on men’s plural ways of ‘doing’ masculinity, and sexual health in the context of prostate cancer and its treatment.

This study further highlights the relevance of addressing issues of masculinity and sexual health in national care programmes for prostate cancer, in clinical work (rehabilitation in general and sexual counselling in particular), and in support groups for men with prostate cancer, their partners and other relatives. The current study also contributes to a growing body of research that can be used in the design of the information given to patients before cancer treatment, and the development of sexual rehabilitation following treatment. For the benefit of both patients and healthcare professionals, it points not only to the significance of researching prostate cancer masculinities, but also the need for future studies utilising gender perspectives.

Additional information

Funding

Funding for this study was provided by The Kamprad Family Foundation for Entrepreneurship, Research & Charity, no: 20210010.

Notes

1 See Taitt (2018) for a review of incidence, detection and mortality as influenced by race, ethnicity and geographic location.