Men Managing Cancer A Gender Analysis

Men managing cancer: a gender analysis
Lisa M. Wenger and John L. Oliffe

School of Nursing, University of British Columbia, Canada
Abstract As researchers consider gendered patterns in mens prostate cancer experiences,
little attention has been devoted to how men manage cancer, more generally.
Drawing on the experiences of 30 Canadian men with a variety of cancer types,
this article details how men engaged illness self-management and help-seeking
activities with lay and professional support persons. Results indicate three broad
responsive strategies: fortifying resources, maintaining the familiar, and getting
through. In these pursuits, the participants drew on a variety of performances to
respond to social contexts demanding that men embody masculine ideals including
strength, control, and stoicism. Considering gendered dynamics in how men
manage the challenges of cancer, this article broadens understandings about mens
cancer experiences by highlighting the drivers orienting participants responsive
efforts and challenging assumptions of help-seeking as essentially problematic for
men in Western society.
Keywords: masculinities, mens cancer, psychosocial oncology support, illness behaviour,
help-seeking
Cancer makes a signicant impact in Western society as a stigmatised and feared disease
(Clarke and Everest 2006). Beyond particularities varying across lives, diagnoses and progno-
ses, the construction of cancer as a mortal illness (Conrad 1987) leaves many reeling post-
diagnosis, often confronted by their mortality for the rst time (Lee 2008) and experiencing
cancer as a threat to a familiar identity (Mathieson and Stam 1995). As researchers recognise
the quality of this threat as gendered (Moynihan 2002), the mens health literature has focused
on connections between masculinities and prostate cancer to locate some of the aforementioned
challenges. The goal of the current research and article is to build upon previous work to pro-
vide a gender analysis highlighting processes underpinning mens efforts to manage cancer,
attending to self-management and help-seeking activities common across a range of cancer
diagnoses.
Men managing cancer
Guided by a social constructionist framework positioning gender as a dynamic performance
(West and Zimmerman 1987), researchers have examined diversity and patterns in how men
perceive, experience and respond to illness. In acknowledging different ways of being a man,
social constructionists describe a hierarchy of masculinities, in which hegemonic ideals prevail
at the top of the gender order (Connell 1995, Connell and Messerschmidt 2005). Although
hegemonic masculine ideals shift over time and place, in Western cultures characteristics
2013 The Authors. Sociology of Health & Illness 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd.
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA
Sociology of Health & Illness Vol. 36 No. 1 2014 ISSN 0141-9889, pp. 108122
doi: 10.1111/1467-9566.12045
including strength, success, control, competitiveness and self-reliance have had remarkable lon-
gevity (Kimmel 1994). Few men embody the power that these and other masculine ideals can
attract, and many men are marginalised or subjugated by virtue of their age, social class, reli-
gion, race, ethnicity, sexual identity, disability and other social positions. However, many men
are complicit in sustaining dominant masculine ideals, giving rise to multiple masculinities,
which include performances toward retaining, regaining, or releasing the power and control
associated with hegemonic masculinity.
Accepting that the doing of health is a form of doing gender (Saltonstall 1993: 12) mens
health and illness behaviour reect varying alignments to masculine ideals. Men can challenge
the relevance and legitimacy of idealised masculine performances to their lives. Yet within
these alternative masculine performances there is evidence of lingering doubt and unease
among men who are unable to embody masculinity or do gender in ways that might lay
claim to occupying the upper echelons of the gender order where men are expected to reside
(Connell 2009).
Related to this, researchers have detailed an array of issues and analyses to signal how mas-
culinities shape and are shaped by mens prostate cancer experiences. As researchers examine
how this disease can trouble masculinities (Broom 2004, Oliffe 2006), men are reported to be
cautious in disclosing their condition and its impacts, drawing on internal resources as they
limit discussions of illness to those who need to know while seeking to sustain a normal
life (Gray et al. 2000, Oliffe et al. 2009), strategies associated with efforts to avoid being per-
ceived as different from other men (Hilton et al. 2009). Described also is how men can be ret-
icent to engage with others around their prostate cancer-induced distress, even as they draw
assistance from partners and peers with cancer to learn about their disease, manage side-effects
or engage in self-health (Mroz et al. 2011, Oliffe et al. 2009, Seale et al. 2006).
As the existing literature has advanced understandings about masculinities and mens pros-
tate cancer experiences, less attention has been devoted to mens experiences of other cancers,
with few exceptions (e.g., Cecil et al. 2010). Although prostate cancer is the most common
cancer diagnosis among men in Western nations, just under 80 per cent of men diagnosed with
cancer are managing a different form of the disease, including luekemia, lymphoma, cancer of
the lung, colon, head/neck and more (Jemal et al. 2011). The limited social science and
behavioural research attention to the lives of men with other cancer types has perhaps inadver-
tently failed to take the opportunity to describe similarities and differences in and across men
(regardless of their cancer site) as well as between men and women (cancer site-specic and
overall). As researchers seek to understand gendered patterns in mens cancer experiences the
eld can be advanced by considering the broader intersections of masculinities and cancer.
Asking how men mobilise self-management and help-seeking strategies to manage their cancer,
this article describes practices that prevail among men with a range of cancers.
Methods
Following university ethics approval, 30 men (aged 33 to 82, mean = 59) were recruited
through a partnership with two non-prot cancer support centres in Ontario, Canada. Recruit-
ment postcards and posters were distributed via the institutions email listservs and service
locations, a process yielding a sample comprising mainly men with experience at these centres,
although several men (n = 4) had not attended these organisations but were referred to the
study by those who had. While this sample is distinct from the broader group of men living
with cancer in that most participants had accessed at least one cancer support centre
service, this recruitment strategy enabled a description of how men both perceived and
2013 The Authors
Sociology of Health & Illness 2013 Foundation for the Sociology of Health & Illness/John Wiley & Sons Ltd
Men managing cancer: a gender analysis 109
experienced these support processes, including how men navigated dominant social expecta-
tions emphasising psychosocial oncology services as providing more women-centred ways of
handling cancer-related illness issues.
Following an initial expression of interest in the study, discussions via e-mail or telephone
claried the mans specic diagnosis and study details, ensuring that potential participants
were comfortable with the research focus prior to meeting them. Interviews were scheduled
with the rst 30 men who indicated an interest in the study, although one man withdrew prior
to the interview and was replaced by the next available respondent. Limited to adults (18 years
of age and older), recruitment was unrestricted by cancer type or prognosis or patients charac-
teristics. Over 80 per cent of the participants had been diagnosed (or their disease had con-
verted to active) within the previous 6 years, and all had been diagnosed within the previous
10 years (range = 0.510 years, mean = 3.4 years). Nearly all were White (n = 28, East
Indian = 1, Asian = 1). Most were parents (n = 23) and heterosexual (n = 27). Nearly all were
born in Canada (n = 27) and all had been residents for more than 10 years (see Table S1 for
patients additional characteristics and medical details). All the men characterised themselves
as healthy prior to their cancer diagnosis, though several had experiences with addiction, abuse
and/or serious injury.
Data collection and analysis
Each man provided his informed, written consent prior to the audio-taped individual interview
and the sessions lasted from 13 three hours (average 1.5 hours). The rst author, a woman
trained in qualitative methods, conducted each interview at a mutually convenient time and
place and the participants details were collected at the end of the discussion. The interviews
were transcribed verbatim and pseudonyms used in participants quotes.
Following a constructivist grounded theory methodology (Charmaz 2006) the research
participants were recognised as experts on their experience and partners in building
knowledge. The research questions focused the interviews on how the men responded to
perceived challenges of illness from the point of diagnosis through post-treatment. Attending
to self-management activities and considering how men built patterns of support (informal and
formal) with others during their illness, the research focus was on the subjective meanings
informing their responses (Blumer 1969). The interviews followed an emergent design frame-
work, with initial sessions organised by grand tour questions (Rubin and Rubin 2005) to stay
grounded in the mens experiences (Charmaz 2006).
Engaging a process of concurrent data collection and constant comparative analysis, the
interviews became progressively more structured, enabling an exploration of the processes
underpinning the mens independent and interactive efforts to manage their illness challenges.
This practice of theoretical sampling, which is at the core of grounded theory, helped ensure
that ongoing decisions about what questions to ask and where to look for more information
were guided by meaningful patterns in the data (Charmaz 2006). As summarised by Corbin
and Strauss (2008: 1445), theoretical sampling establishes a process wherein data collection
leads to analysis. Analysis leads to concepts. Concepts generate questions. Questions lead to
more data collection.
The analyses were conducted by the rst author and moved through four stages: creating
concepts, creating categories, making linkages and building the theoretical story (Charmaz
2006, Daly 2007). Memoing served as an important tool to record thoughts and analytic
insights (Charmaz 2006) and consensus about the ndings and their organisation was achieved
through discussions with academic colleagues. Aligned with the methodologys constructionist
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110 Lisa M. Wenger and John L. Oliffe
foundation, emphasis was placed on building rich categories and producing useful, resonate
and original results (Charmaz 2006). Focused on the common patterns in how men responded
to the challenges of cancer in a powerful social context, contradictions and ambiguity were
worked into the structure of the ndings, rather than positioned as negative cases in an other-
wise orderly process (Daly 2007). A discussion of how these men perceived cancer has been
published elsewhere (Wenger, 2013).
Results
As the men accepted that the medical staff had expertise in treating their disease, discussion
quickly turned to how they handled a disrupted life more broadly. As Micky (aged 62, with
prostate cancer) explained, the other needs [are] more important than the medical needs. The
medical needs will happen, as need be. Focused on managing their illness, the mens stories
highlighted a matrix of responses in the post-diagnosis phase, activities drawing on a combina-
tion of self, lay and professional resources. Underlying this range of self-management and
help-seeking efforts were three broad strategies: fortifying resources, maintaining the familiar,
and getting through (see Figure 1 in Supplementary Information). Although they are presented
as distinct in this analysis, these activities intersected as men handled a range of concurrent,
shifting and emergent challenges.
Strategy 1: fortifying resources
Fortifying resources focused on ensuring the patients had enough supplies to overcome the
uncertainty that cancer brought into their lives. Most participants described entering illness
with limited knowledge about cancer terminology, their disease or the health-care system. Con-
currently, many described how their diagnosis had emphasised their bodys weak spots. In
this context, the men detailed their efforts to sustain their existing health and bolster their can-
cer-specic cognitive and physical defences through (i) knowledge building and (ii) physical
strengthening.
Knowledge building
As novice sick people, most men sought opportunities to better understand their illness, with
some, like Terry (82, with leukaemia), arguing for the value in taking responsibility for their
care by learning what theyve got and ... what they will receive. Gathering Internet or print
resources and consulting experts, the men efforts focused on four key areas of learning: under-
standing their disease, making wise decisions, resolving the diseases impacts and re-envisioning
their future. The assistance of others was key, as clinicians and peers with cancer held the
information they required and their family and friends helped gather information by attending
appointments, performing their own research and/or facilitating connections with sources of
knowledge. This activity intensied after diagnosis, as the men prepared for and engaged in
treatments but it could continue after the treatments ended as the men faced emerging
challenges.
Upon diagnosis, most men sought to understand their disease. Although they were offered
details from their physician at diagnosis, the shock accompanying the news of cancer could
limit their ability to absorb this information. Often turning rst to cancer-specic websites,
many men wanted to understand the origin and functioning of their disease and to learn medi-
cal terminology as a means to asking clinicians the right questions. Chris (72, with lymphoma)
explained: I think the biggest thing is understand what youve got ... what causes it, why
did you get it. While praising the accessibility of online information, many used this
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resource cautiously, noting as Clint (52, with kidney cancer) did, that Internet resources can be
inaccurate or fuel the negative. Similarly, Brad (63, with liver cancer) explained that he val-
ued his physicians expertise, because theres a lot of very valuable information [online] but
theres a lot of hokum as well. For most men, wanting to understand their cancer led them to
engage with diverse forms of support in order to make accurate appraisals about the quality of
what could be divergent information. In this respect, understanding the disease was also reliant
on the participants recognising that what counted as credible and useful information was
ultimately up to the individual.
Men with choices of treatments or those who were reluctant to fully accept a prescribed plan
could be frustrated by their lack of clarity about the effectiveness of particular treatments and
some clinicians reluctance to provide specic directives related to which treatment would be
the best choice for them Describing the importance of doing their own research, the men
recognised the utility of Internet resources while again prioritising their consultations with
health experts as well as treatment-matched peers in efforts to make informed decisions. In
accessing these resources, some turned to cancer support groups while others engaged experts
in their existing social networks. For example, John (80) turned to medical friends to explore
options for his Waldenstroms macroglobulinemia, Marc (56) relied on a sibling in the health
eld to make choices regarding his colorectal treatments and Jakob (66) described how a
family friend trained in radiology provided information on prostate cancer treatments. This
process helped to narrow their treatment options and could also bolster the mens condence
in their choices. As Jakob explained, hearing the experiences of men at a support group
reinforced for me, you know, that I was heading in the right direction. Drawing on the
participants own strength-based problem-solving abilities, this consultation process could
continue throughout their illness, particularly among those facing ongoing treatment decisions.
The men valued the guidance of their health-care providers, including doctors, nurses, phar-
macists and naturopaths, as they sought to reduce the impacts, or manage the physical morbid-
ities caused by their disease and/or treatments. However, as they recognised that clinicians
could not help them address all their needs, many men sought opportunities to compare notes
with those experiencing similar treatments. As Gerrard (47, with lymphoma) conrmed, You
just want to know, hey Im getting this, is that normal? Are you getting that too? In addition
to cancer support groups, Internet-based chat sites were valued for this type of information. As
Jack (50) explained, an online lymphoma community gave him instantaneous feedback to his
questions about handling side-effects, an opportunity he valued more than waiting for over a
month for the next face-to-face group meeting.
Although initially they focused on the physical impacts of the disease, some men also
sought information on handling its emotional impacts, particularly the anxiety accompanying
their diagnosis and the distress that could take hold post-treatment. Describing they had had
little direction from their health-care providers on these matters, the men consulted others with
cancer or visited cancer centres to develop the skills to manage their anxieties (e.g., medita-
tion, yoga and courses on cognitive and emotional intersections). Many described being
invited, encouraged, or pushed by friends, family or clinicians to visit a cancer centre; receiv-
ing an impetus to consult they often appreciated. Joseph (55, glioblastoma multiforme)
explained, Ill be honest with you, I had never heard of [the centre], but when a friend who
attended the centre because of her breast cancer invited him to attend the relaxation and visu-
alisation classes, he said sure, explaining, So she brought me up here [pause] and that was
it. I was in the door. The process of handling impacts continued across the course of illness
as men turned to others for information to help them manage acute and chronic challenges.
Describing how cancer troubled their anticipations of the future, many men sought to
re-establish a vision for what lay ahead. Here they most often employed rational, matter-of-fact
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approaches to preparing themselves and their loved ones for an altered future. Gerrard (47,
with lymphoma) explained he could not control what the future held, but in seeing it more
clearly he could prepare for its challenges: it wasnt going to change anything, but maybe just
being prepared ... because I have a family ... you know, also getting them prepared. The focus
in these discussions was often on the physical impacts of the disease (e.g., pain or inconti-
nence), rather than emotional or relational shifts. As Brian (33, with leukaemia) said, I wanted
to know how I was going to die if I was going to die. I wanted to know, you know, this organ
fails rst.
To enable this re-envisioning, the men solicited information from health providers on how
procedures would be conducted, how other patients had faired, the impacts of treatment and
their survival odds. Again, the participants described some physicians as lacking the time or
inclination to provide such details and they therefore turned to peers with cancer, online and
in person, to learn what their future might hold. Soliciting the experiences of those who had
travelled a similar path, the details learned could provide reassurance and help the men antici-
pate challenges but could also exacerbate their fears. As Michael (60) noted, he was trauma-
tised by the horrid stories aired at his rst prostate support group meeting. Similarly, Earl
(56, with prostate cancer) detailed how he met with a friend who had experienced the disease
to learn about what he might expect, only to be left reeling: So it is kind of like, Holy Jesus,
do I want to go through this? The information the men gathered from others through these
consultations informed their efforts to mitigate anticipated disruptions, a process explored in
the section on maintaining the familiar.
Physical strengthening
Many men also focused on fortifying their body as a means to overcoming or minimising the
impacts of the disease. Some men attributed their survival, in part, to their physical strength or
vitality prior to diagnosis. John (80, Waldenstroms macroglobulinemia) explained that medical
experts told him that one of the reasons he did so well was because he was in such good
physical shape due to a lifetime of exercise. Similarly, the men emphasised the role of a strong
body in getting through treatments and avoiding disease recurrence, noting the importance of
adhering to tailored exercise regimes leading up to, during, and post-treatment. To augment
exercise, men described their discipline in avoiding foods that fuel cancer and ensuring a
healthy diet amid reducing relevant risk factors including smoking and excessive exposure to
the sun.
Although often presenting these as their independent efforts, the mens stories highlighted
how others had helped them to initiate and sustain their lifestyle changes, particularly their
change of diet. While nutritionists or naturopaths might inform their efforts, partners and fam-
ily members played an important role in altering their menus and monitoring their food intake.
Arthur (68, with colorectal cancer) explained how his partner took a lead in adjusting his diet,
acknowledging proudly that she was:
[T]he cook. She feeds me, so I eat the chicken, I eat the sh [and] ... thats good and ...
and so when I travel or go away shes sitting on my earlobe ... telling me what I can eat
and not eat.
The men recognised these adjustments as evidence of their commitment to a strong body. As
Pete (62, with myeloma) explained, his daily walks following a stem cell transplant demon-
strated that he hadnt given up on [his] body. Further, this summonsing of resources towards
ensuring strength was acknowledged as an ongoing project. Jakob (66, with prostate cancer)
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noted the dangers of being complacent: You think you have things under control ... you back
away from doing all the good things that you were doing.
Strategy 2: maintaining the familiar
As much shifted during their illness, the men sought to mitigate disruptions in their life and
the lives of others. Oriented towards holding onto various ideals of normal life, this strategy
included: (i) minimising exposure, (ii) staying in the game, (iii) limiting others burden and
(iv) reasserting the self. Family, friends and health providers could facilitate or disable these
endeavours and by virtue of these dynamics others participated in the mens co-construction or
preservation of a familiar self.
Minimising exposure
Sensitive to being perceived as weakened or dying, the men used framing and shielding tech-
niques to manage others perceptions of them and guide interactions. Early in their illness
some men delayed telling others about their cancer until they had sufcient details to frame
their situation for others and perhaps reconcile themselves to their situation. Partners were
often brought in early on, but men seeking to protect their loved ones could also limit what
they shared in their intimate relationships. As Randy (52, with head/neck cancer) explained, he
delayed telling his wife about his cancer because he did not know what would happen and
didnt really want to put anyone else through that [pause] ah, ordeal. In addition, the men
managed the conversations around cancer-related impacts, presenting themselves as doing
ne or appealing to others to view them as unchanged. Andrew (42) described how he told
friends he would not accept pity because of his lymphoma, noting, I wasnt broken. Simi-
larly, they placed an emphasis on taking control to avoid the perceptions of others that cancer
had become their primary marker of identity. As Fred (68, with lymphoma) explained, he sent
out a clear message to family and friends, emphasising that they should understand that:
Number one Im not afraid of it. [And] I do not want you ever to talk to me about having
cancer .... I am living with cancer but cancer doesnt have me and I dont have cancer. It is
a disease .... Im living with it and thats where we started out.
However, such strength-based framing efforts could be challenging to sustain. As Clint (52,
with kidney cancer) noted, despite efforts to remain positive with his children he got caught a
couple of times struggling to hide his anguish. Confronted with their own vulnerability, many
men avoided being seen by others as compromised by limiting contact with them. Brad (63,
with liver cancer) avoided a road trip with friends because he struggled with frequent toilet
breaks, Jack (50, with lymphoma), experiencing chemo-brain, refused to run errands by
himself, and Keith (55) stopped attending family meals so others would not witness his tears
of pain while eating during his treatments for throat cancer. Recognising others expectation of
what a cancer diagnosis can mean, these activities allowed the men to feel they had some con-
trol over their narrative.
Staying in the game
The men also sought to stay active and continue making contributions in the work place, in their
family and in the community. Sustaining pre-cancer activities or establishing replacement pursuits
to t their altered capacities garnered varying degrees of vitality. As Fred (68, with lymphoma)
noted, maintaining daily exercises in the hospital normalised the abnormal. Continuing paid
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employment was also central to the participants worklife identities and among men forced to take
leave for treatment, returning to work was a key indicator of recovery. As Dan (49, with head/
neck cancer) insisted, keeping life normal rested on getting back to work as soon as possible.
The men who were unable to return to work established new routines by volunteering in their
communities, blogging or staying busy at home by taking on additional projects (e.g., renova-
tions) or embracing domestic work, including cleaning or meal preparation. In the absence of paid
work, these activities assisted men to reclaim a sense of purpose. Andrew (42, with lymphoma)
explained that his blog gave me a project to do throughout my cancer treatment, noting, instead
of having a job to go to [clears throat] I had my blog to write.
Limiting others burden
Looking toward a challenging future of lost income, incapacitation or death, the men drafted
their wills, built up their bank accounts and/or prepared their family to take over their roles. In
the present, the men managed their medical appointments so that others would not miss work,
avoided family, social and work activities where they felt they would be a drag and resisted
soliciting help with practical items. With the acute threat of dependence, asking others to take
over activities could feel like giving in to the illness, as Joseph (55, glioblastoma multiforme)
explained. Similarly, many were careful in accepting offers of assistance. Although making use
of medical supports and practical help offered by their family (people they viewed as provid-
ing expected support), many men refused help from non-family members, perceiving these
offers of assistance to be unnecessary, exceeding normal patterns of exchange or difcult to
repay. As Randy (52, with head/neck cancer) explained, although he reluctantly accepted his
neighbours help in mowing his lawn (a favour he would return), he redonated a food basket
given to his family by a charity because, We were never in the position that we really needed
that.
(Re)asserting the self
As the men accepted their clinicians expertise in treating their disease, their stories highlighted
their efforts to protect a valued self within the medical system. Some used the language of
self-advocacy but the spirit of this attitude was oriented towards a more fundamental goal as
the men challenged others to recognise their individuality as people, not just patients and as
they drew boundaries in the care they were given. Firstly, even as many identied their posi-
tive experiences in the medical system, the men recognised that one could be lost within it.
Some took an active role in navigating the system, demanding diagnostics or procedures, peti-
tioning for better drug coverage or severing relationships with clinicians they viewed as insen-
sitive. Additionally, the men sought to shift their physicians attitudes in the course of their
treatment, challenging their physicians to see them. For Fred (68, with lymphoma), a man
with professional experience in the health system, this meant telling his doctor he was doing a
piss poor job, while Jakob (66, with prostate cancer) used an indirect strategy to assert con-
trol, staying seated to challenge his doctor to extend the consultation.
Secondly, the men established criteria for how they would live and die. Although they often
accepted treatments they viewed as essential, the stories they told showed their willingness to
resist procedures perceived to be exerting too great a restriction on their life. For example,
Dan (49, with head/neck cancer) rejected a pain medication that left him too drowsy to drive.
Keith (55, with head/neck cancer) refused a feeding tube that would restrict him from travel-
ling to an important family event and Brian (33, with leukaemia) went against his familys
wishes in choosing not to have a risky procedure, noting that a life in which cancer was
taking over was not worth living.
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Strategy 3: getting through
As the men endured physical and social restrictions, their sadness over their personal and
familial disruption and fears of death infused their illness with disquiet and anguish. To man-
age this they engaged self-management efforts focused on restricting their emotions, as they
distanced themselves from feelings, practiced trust or sought to stay present. In these efforts,
some men emphasised that a visible display of emotions was a sign of weakness owing
from a loss of control. As Gerrard (47, with lymphoma) noted, all hell breaks loose when
you start to cry. But even men who described themselves as normally emotional sought to
become numb, particularly during the treatment period. Although efforts at restriction domi-
nated, many men also engaged with their emotional struggles through interactive efforts, turn-
ing to others for help as they showed worry, found comrades and sought guidance. Notably,
while restricting their emotions complemented their efforts to fortify their resources and main-
tain the familiar, engaging with their emotions could be disruptive to these strategies. Further,
in contrast to making indirect requests for help in the fortifying resources strategy, the efforts
integrating emotional engagement were more often required by the men to explicitly solicit
help from resources lying outside their existing networks.
Restricting
Although anger and frustration were accepted as normative aspects of their cancer experience,
many men sought to distance themselves from anxieties and sadness. Their strategies included
immersing themselves in other pursuits (e.g., television or work), using humour to lessen the
weight of their fears, limiting the time spent thinking about challenges and avoiding exposure
to others expressions of grief. Wondering if this was a male thing, Jim (60, with myeloma)
explained, Theres not a damn thing you can do about it anyway so you might as well ignore
it. These efforts were often accompanied by the refrain it is what it is, while for men with
terminal or chronic conditions this was further nuanced by an assertive disclaimer that every-
ones going to die, whether by cancer, a heart attack, or a car accident.
The men also sought to restrict their emotions by practicing trust, an orientation displacing
fears with a condence in forces they accepted as being more powerful than cancer. This
approach was highlighted as the men emphasised the value of maintaining a positive attitude
or trusting that they would survive this disease. Trust was also evident as the men described
their faith in those perceived as yielding inuence over the situation: medical providers and,
for some, God. As Dave (65, with colorectal cancer) explained, Youve got to believe in the
system. Similarly, some men trusted in themselves, describing a willingness to follow their
intuition and detailing how their survival through other challenges (e.g., abuse, addiction or
depression) bolstered their condence in their ability to endure the cancer experience. As
Micky assured the researcher, his experiences with poverty left him condent that even at
ones lowest ebb, you can always go back up!
Finally, many participants restricted their emotions by focusing on the present. Taking their
illness day-by-day, some used meditation, yoga or other strategies to resist troublesome what
if scenarios. These efforts could create discomfort, particularly when they were perceived to
be linked to more feminine activities. Pete (62, with myeloma) explained, Yoga ... to me, it
was something guys dont do. But when the men engaged in these activities their participation
could help them to to calm their fears. As they focused on the present the men described
compartmentalising their illness into manageable pieces. Oscar (59, with head/neck cancer)
described this as going into survival mode, Brian (33, with leukaemia) framed it as rolling
with the punches and Arthur (68, with colorectal cancer) drew on a sporting metaphor, liken-
ing chemotherapy rounds to innings of a baseball game (a game, he noted, that had gone to
extra innings): I had 12 innings [laughing] and, and I got through them. More than restricting
2013 The Authors
emotional undertows, this approach afforded some boastfulness within David and Goliath bat-
tles. Additionally, in focusing on the present, men could nd joy amid despair. Jack (50, with
lymphoma) described how he and a friend sharing a terminal diagnosis chose to spend an
afternoon enjoying a drink and smoke, nding respite from a troubled future:
Im looking at [my friend] saying ... guess what, lets have a big fat joint and a glass of
scotch because you know what, its not going to hurt us is it? And hes killing himself
laughing and hes saying, yah youre right, lets ... we might as well enjoy an afternoon.
Although the men often focused on their own activities, many also recognised how others
facilitated or hampered their efforts, praising those who helped to distract them and/or bol-
stered their positivity and resisting those who emphasised the negative.
Engaging
Concerned with festering internalised emotions, some men valued opportunities where they
could show worry. In contrast to the teary times framed as uncontrollable, articulating their
turmoil was a deliberate, interactive activity. In this process, the men were not asking others
for solutions but wanted to release pain and break with their stoicism to fully express them-
selves. As Michael (60, with prostate cancer) said, although this was difcult, in telling my
story it is owning that that part of me that I have to deal with, which I do believe is part of,
of the healing.
Men who reached out for help beyond their existing networks valued the candour of peers
who had cancer, noting that conversations with them reached a deeper level. In sharing their
experiences with those in the same boat they found comrades who could handle their story
and, as Bill (61, with leukaemia) emphasised, they understood. The connections to and per-
mission of others in this cancer context normalised what the men were feeling, quelled their
concerns about being crazy and reducing their feelings of isolation. Brian (33, with leukae-
mia) explained:
[All] of a sudden you realise someone else out there is at least going through the same thing
you are. I dont know if I can describe why thats comforting other than just to know that
youre not alone.
Finally, the men sought guidance on how to live with and beyond cancer. In contrast to inter-
nalising their anxieties, these efforts helped the men to address the big questions as they
sought others wisdom to navigate the path ahead or re-envision their future. As Dave (65,
with colorectal cancer) noted, he wanted to learn how to plan my own future. Similarly,
Jakob (66, with prostate cancer) drew on others to assure him that his diagnosis was not the
end of the world.
Some men, particularly those who constructed themselves as being different from other
men, were comfortable talking about challenges and had support networks close at hand or
moved quickly to secure additional support. However, the participants in this study more often
struggled to share their pain with others, with many describing how they delayed this process
until they had no other choice or emphasising they were motivated by an opportunity to help
someone else.
In this place of discomfort, the men carefully selected safe witnesses. Although many valued
their partners or friends as supports, the intensity of their experience could exceed the normal
boundaries of these relationships. As Clint said, he sought support outside his familial network
because he was worried that his wife, although she was strong, would collapse if she were
2013 The Authors
saddled with the full extent of his anguish. Moreover, some men viewed those close to them
as not being open to discussing emotions, describing how messages from friends and family to
come back strong or be all right after the treatments left them feeling that these others did
not anticipate or want to hear about their enduring emotional pain. More directly, some
described how others shut down emotional discussions. Recounting an exchange with his adult
son, Dave (65, with colorectal cancer) explained how he tried to share his deeper feelings,
but his son stopped him, explaining to his father: Im there for you ... Ill sit and cry with
you [and] hold your hand but talking about it ... is ... is not such a good thing. Similarly,
Michael (66, with prostate cancer) described his male friends as being reluctant to talk with
him about his feelings, noting, I dont think they mean to pull back or mean to be distant, its
just the fact, what do we say? Combined with their own discomfort and concerns about bur-
dening others, this dynamic left some men struggling to access support from those who were
safe, willing or able to help.
Discussion and conclusions
Consistent with Robertsons (2007) observation that men facing illness can legitimise clinical
help-seeking, the participants in this study accepted medical support as critical to treating their
cancer. However, as these men managed their cancer by drawing on a mix of individual and
interpersonal resources, their illness stories extended beyond the clinicians ofce. Attentive to
these processes across a diversity of lives and types of cancer, this article enhances
understanding of how men manage cancer. Specically, it shows there are fundamental
commonalities across cancer types and challenges assumptions that help-seeking is essentially
problematic for men.
Firstly, this study supports much of what has been reported in the masculinities and prostate
cancer literature. The activities in the fortifying resources strategy are consistent with studies
detailing mens efforts to build up prostate cancer-related knowledge (Bottorff, et al. 2008,
Breau and Norman 2003, Seale, Ziebland, and Charteris-Black 2006) and enhance their own
physical wellbeing (Gray et al. 2000, Kelly 2009, Oliffe et al. 2009). The activities in main-
taining the familiar and getting through strategies align with research describing how men with
prostate cancer can pursue a normal life (Gray et al. 2000, McCaughan and McKenna 2007),
including their attempts to limit disclosure, reassure others, avoid asking for help, sustain their
familiar roles and relationship dynamics (Gray et al. 2000, Kelly 2009) and manage their
emotions through withdrawal and humour (Chapple and Ziebland 2002, Oliffe et al. 2009).
Furthermore, although some men do conde their struggles to their partners (Gray et al. 2000,
Kelly 2009), the unease in engaging emotions, including the care men took to select safe
supports, resonates with the discussion by Johnson et al. (2012) of guarded vulnerability in
mens depression, as men recognise their emotional struggles and the risks of not being able to
justify their actions in seeking and accepting help (Addis and Mahalik 2003, Moller-
Leimkuhler 2002, OBrien et al. 2011, Oliffe et al. 2010). Additionally, the justication
process these men used to navigate this challenge (i.e., their sense of their self as different,
the severity of their condition or their desire to help others) resonates with discussions of how
men can legitimise help-seeking that deviates from masculine ideals by drawing on other
identities (Galdas et al. 2007, Robertson 2003), emphasising the acuity of their need (Johnson
et al. 2012) or reconstructing acts as being aligned with masculine responsibilities (Noone and
Stephens 2008).
In the context of the similarities in this research with previous work, there may be some
benet in anticipating that the challenges and practices associated with prostate cancer are
2013 The Authors
relevant to men with cancer more generally. Although there are important differences related
to the content of information that men require in responding to the particulars of their cancer
type and stage, commonalities emerge in how men with cancer manage their illness. This is
not surprising, given the social construction of cancer and the commonalities in how it is
understood to invade the body. Even more, each man was challenged to manage an illness that
is disruptive to an embodied masculinity associated with action and strength (Robertson 2007).
Rather than limiting efforts to develop and deliver men-specic, prostate cancer resources, a
dominant focus in current practice, there is evidence for the value in producing gender-
informed cancer programmes for men. This more expansive approach holds the potential for
greater efciency and impact and demonstrates a commitment to supporting all men with can-
cer. Further, it is possible that the orienting goals identied in this study (i.e., fortifying
resources, maintaining the familiar and getting through) might resonate with the experiences of
men managing other serious or chronic illnesses (e.g., heart disease) and help-seeking more
broadly. Additional research is required to address these questions.
Secondly, as this article shows that men are complementing their self-management strategies
with activities drawing on a range of support persons it contributes to discussions of mens
help-seeking more broadly. There is a signicant body of research exploring mens help-
seeking (Addis and Mahalik 2003, Galdas 2009), much of which is focused on the
pre-diagnostic use of clinical support (Wenger 2011). However, in contrast to assertions that
mens help-seeking is essentially in conict with masculine ideals or requires negotiations
away from hegemonic scripts (e.g., McVittie and Willock 2006), the ndings drawn from the
current study show that participants demonstrate little hesitation in rallying health providers,
peers with cancer and family and friends to help them understand and combat their disease.
Where this process became more problematic was when the men were required to ask for help
in handling their vulnerability. In these situations, the men described their discomfort in dis-
cussing their distress or sense of loss; an unease that could delay their requests for help and
leave many of them feeling cautious about who was a safe support.
Three factors appear critical in explaining these patterns: the quality of the concern, the nat-
ure of the relationship with the support person and the style of the request. Firstly, as the men
found it easy to solicit help in fortifying their resources, they noted the importance of learning
about their disease and enhancing their bodys resistance. These efforts, consistent with strate-
gies of adaptive help-seeking (Karabenick and Newman 2006) align with arguments that men
diagnosed with illness can engage certain supports as being driven by a moral obligation to
discipline their body back into proper functioning (Robertson, 2007), construct themselves as
responsible service users (Farrimond 2011, Johnson, et al. 2012, Noone and Stephens 2008)
and use help-seeking to preserve or restore a prioritised masculine presentation (OBrien et al.
2005), particularly when handling concerns they perceive as normal (Addis and Mahalik
2003). In a society valuing health, a drive toward healthiness is not always disruptive to hege-
monic ideals: it can be used to demonstrate power, control and even self-reliance (Crawford
1994, Farrimond 2011). Secondly, the men drew on supports they saw as useful and appropri-
ate: disease experts (health providers and cancer peers) and those charged with their care (their
family and friends). Lastly, as these individuals were often prepared to help the men, requests
for help could be indirect, including the fact that the men could rely on others to offer support.
Notably, the use of indirect methods of help-seeking is a recognised strategy for accessing help
when direct requests are culturally or socially problematic (Kim et al. 2008).
In contrast, as the men struggled to engage others help in acknowledging their emotional pain,
recognising their losses and rebuilding their future, they recognised this process as conicting
with masculine ideals of self-reliance and emotional restraint, a pattern observed in research on
mens help-seeking related to mental health challenges. Furthermore, as this process often
2013 The Authors
required deviations from normal interaction patterns and networks, including reaching out to ther-
apists and peers with cancer, the men were often forced to employ a more direct and often
uncomfortable request for help. Not only were others less likely to offer emotional support, the
men perceived others (lay and professional) as less prepared to assist with these issues.
This pattern aligns with research detailing how clinicians can fail to anticipate mens
emotional needs (Moller-Leimkuhler 2002), construct men as bad at emotions (e.g.,
Seymour-Smith et al. 2002) or provide resources reinforcing masculine ideals as they ignore
mens vulnerability as bodies and selves (Kelly 2009, Gray et al. 2002). Simply, the men were
not alone in referencing masculine ideals. Combined with their own discomfort, this dynamic
could reinforce mens perceptions that emotional struggles were unexpected, abnormal or best
handled on their own. In the interactive work of help-seeking, institutional and interpersonal
forces can create an environment in which physical or informational resources are plentiful for
men living with serious illness, while support around vulnerabilities is scarce. These dynamics
are not surprising but they emphasise an important distinction in the broader discussion of
masculinities and help-seeking.
The insights offered in this article can be further advanced by research focused on subgroups
of men in terms of their age (including paying special attention to young adult mens experi-
ences), socioeconomic status, race/ethnicity, sexual identity and more. Additionally, there is value
in exploring the impacts of these responsive strategies and examining similarities and differences
with womens responses to cancer (Wenger and Oliffe 2012). Although more research is required,
the current article highlights the value of considering gender dynamics in how men manage can-
cer, not just prostate cancer. Even as the composition of activities varies across the individual
realities of each mans life, the common strategies of fortifying resources, maintaining the famil-
iar, and getting through enhance our understanding of mens responsive activities during illness,
including the intersections of self-management and help-seeking strategies they engage in a soci-
ety that anticipates strength, control and stoicism in men. The ndings offered here offer guidance
to those seeking to support men with a range of cancers, organising attention to the underlying
goals orienting their efforts and sensitising researchers, practitioners and lay support persons to
the broad strategies that men use to manage the challenges of cancer.
Address for correspondence: Lisa M. Wenger, School of Nursing, 302 6190 Agronomy Rd,
University of British Columbia, Vancouver, BC Canada V6T 1Z3
e-mail: lisa.wenger@nursing.ubc.ca
Acknowledgements
Thanks to Dr Kerry Daly for his guidance in the analysis and to Drs John Beaton, Susan Lollis, Ted
McNeill and Joan Bottorff for their feedback on earlier drafts of this manuscript. This research and publi-
cation have been supported by a the Social Sciences and Humanities Research Council Doctoral Fellow-
ship and the Psychosocial Oncology Research Training post-doctoral fellowship award. Special thanks to
the participants of this study who generously shared both their time and their stories and to the cancer
centres for their generous assistance with recruitment.
Supporting Information
Additional Supporting Information may be found in the online version of this article:
Table S1. Patients characteristics and medical details
2013 The Authors
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