ساخت مردسالاری زیر ناتوانی ناشی از پروستاتکتومی جنسی

Large numbers of Australian men are diagnosed and treated for prostate cancer each year. The incidence is exceeding mortality, and men are living longer with prostate cancer and the common treatment[s] side effect of impotence. Despite these epidemiological trends there is little research about men's experiences of impotence following treatment. An ethnographic study of Anglo-Australian men with localized prostate cancer explored participants’ experiences of impotence following prostatectomy. In-depth semi-structured interviews with 15 men were analyzed using a social constructionist gendered framework. In particular, the effect of impotence on participants’ masculinity, sexuality and intimate relationships was explored. The findings show that participants rationalized forgoing potency prior to surgery as a way of living longer. However, diverse complex reactions accompanied impotence. Whilst most participants redefined masculine ideals of phallocentric sex, the way in which this occurred varied greatly. The findings disrupt essentialist constructions of male sexuality and impotence, and provide valuable insight for clinical practice.

Apart from non-melanoma skin cancer, cancer of the prostate is the most commonly diagnosed cancer in Australian males (Cancer Council Australia, 2001). Although the cause of prostate cancer is unknown, Australia's aging population is likely to result in increased numbers of men being diagnosed and treated for prostate cancer. Many men are also living longer with prostate cancer, as indicated by the death rate which is significantly lower than the incidence rate (Australian Institute of Health and Welfare (AIHW), 2000). Current trends in the epidemiological data suggest that, in the future, greater numbers of Australian men will be living with prostate cancer and its treatment side effects. Prostatectomy (surgical removal of the prostate gland) offers the best prognosis for localized prostate cancer [cancers confined to the prostate gland that have not spread to other parts of the body] (Australian Cancer Network, 2001). However, treatment side effects can occur and the Australian Cancer Network (2001) estimates that the incidence of urinary incontinence is 5–35%, and impotence 30–90% following prostatectomy. Much of the research about prostatectomy-induced impotence is biomedical. In particular, there have been extensive reporting of the effectiveness of treatments such as vacuum erection device (VED), Sildenafil (ViagraTM), Alprostadil Intracavernosal (CavajectTM penile injections), topical gels and penile implants (Coleman, 1998) and men's treatment compliance (Basson, 1998). Little research exists about men's experiences of impotence following prostatectomy (Butler, Downe-Wamboldt, Marsh, Bell, & Jarvi, 2001). A meta-analysis of ‘quality of life’ research by Meuleman and Mulders (2003) revealed a mismatch between the high rate of impotence and low impact on sexual quality of life reported by men following prostatectomy. One study suggested that men accepted impotence when initially diagnosed and treated for prostate cancer; however, most men experienced difficulties adjusting to long-term impotence (Yong, 1998). Recently, researchers have begun to explore treatment-induced impotence using social constructionist gendered frameworks. A grounded theory study by Fergus, Gray, and Fitch (2002a) used a masculinity framework to investigate men's adjustment to impotence and found that most men redefined their sexuality and preference for penetrative sex when potency was lost. A narrative analysis of three men's experiences of prostate cancer and the connections with hegemonic masculinity was reported by Gray, Fitch, Fergus, Mykhalovskiy, and Church (2002). They concluded that impotence can “be a big deal for some men, and is at least a concern for most” (Gray et al., 2002, p. 55). Chapple and Ziebland (2002, p. 831) reported that prostatectomy induced impotence did not affect participants’ sense of masculinity, and it was generally perceived as a “small price to pay”.

The rationalization to treat, fight and survive prostate cancer rendered impotence inconsequential prior to prostatectomy. Hegemonic masculine ideals of phallocentric sex contributed to the expectant simplicity of how impotence would be. If an erection, as the starting point, could not be achieved then penetrative sex was no longer an option. The leap of logic here is that libido, emotions and the need to continue established patterns of intimacy would simultaneously disappear with impotence. Connell's (1983) assertion that a phallocentric model of sex separates men from their sexuality was illustrated by many participants in this study. As previously reported by Chapple and Ziebland (2002), Fergus et al.(2002a) and Gray et al.(2002) most men redefined their sexuality and masculinity following impotence. Specificities of how intimacy was redefined through activities such as shared interests and physical touch, as previously discussed by Gordon (1995) and Fergus, Gray, & Fitch (2002a) and Fergus, Gray, & Fitch (2002b), were also strongly represented in this study. Factors such as advanced age and long-term relationships, as well as illness contributed to participants’ preparedness to live with impotence. However, a lifetime of sexual practices based on phallocentric representations of masculinity resided beneath some men's seemingly rational justifications to choose life over potency. The complexity and diversity between and within participants’ accounts demonstrated the lack of straight forwardness in predicting if, how and when men redefined masculinity in response to impotence. The abstraction of sexuality from men's lives, which is common in much of the impotence research has perpetuated and replicated rather than challenged essentialist explanations of male sexuality. The separateness of sexuality from personhood is particularly problematic. Without explicit links to what precedes and follows impotence there is limited scope to think differently or offer contextual accounts of men's sexualities. Social constructionist gendered frameworks have enabled us to move beyond essentialist positions, and report patterns as well as contradictions in masculinities research. Gendered analyses also provide important information for clinical practice, and based on the findings from the present study three recommendations are made. First, all potential side effects of prostatectomy need to be discussed with men prior to surgery. Specifically, the implications for living differently as a result of surgery, rather than side effect incidence rates should be central to pre-prostatectomy discussions. This is not to suggest accurate estimations can be made about how life might be following prostatectomy. However, it is clear that prostatectomy, as well as prostate cancer result in significant changes, and discussion about sexuality rather than sexual function would better serve men. Second, post-operative care should include designated human resources that actively encourage men to talk about their sexuality prior to hospital discharge. The much cited stoicism that precludes men from talking, or being talked to about impotence perpetuates and justifies the lack of empirically grounded understandings of men's sexualities. The current research demonstrated that when men are given permission and safety to talk they have much to offer about their emotional, as well as physical experiences of impotence. Third, mechanical and chemical treatments will not appeal to all men, and this in itself disrupts the uniformity of men's sexuality. For those men who choose to treat their ‘erectile dysfunction’ concepts of rehabilitation, gradual recovery and altered sexuality should be explicitly discussed. The aforementioned recommendations are intended to assist clinicians to consider and anticipate the diverse needs of men undergoing prostatectomy.