THE MEANI NG OF BEI NG A MAN W I TH I NTESTI NAL STOMA DUE TO COLORECTAL
CANCER: AN ANTHROPOLOGI CAL APPROACH TO MASCULI NI TI ES
Eliza Mar ia Rezende Dázio1 Helena Megum i Sonobe2 Már cia Mar ia Font ão Zago3
Dázio EMR, Sonobe HM, Zago MMF. The m eaning of being a m an wit h int est inal st om a due t o colorect al cancer: an ant hr opological appr oach t o m asculinit ies. Rev Lat ino- am Enfer m agem 2009 set em br o- out ubr o; 17( 5) : 664- 9.
This st udy analyzes t he m eanings t hat m en w it h int est inal st om a at t r ibut e t o t heir color ect al cancer exper ience and it s t r eat m ent . The m edical ant hr opology fr am ew or k , gender ident it y and t he et hnogr aphic m et hods w er e used. A t ot al of 16 m en fr om 40 t o 79 year s of age, r esident s in Ribeir ão Pr et o and neighbor ing cit ies, SP, Br azil par t icipat ed in t he st udy . Dat a collect ion w as car r ied out t hr ough par t icipant obser v at ion and sem i- st r uct ur ed int er view s. Tw o gr oups of m eanings w er e select ed t hr ough induct ive dat a analysis: acknow ledging t he sever it y of t he disease and t he dist r ess of hav ing cancer , and being subm it t ed t o sur ger y and suffer ing fr om a st om a. These m eanings r ev ealed t he t ension t hat dev elops bet w een t r adit ional pat t er ns of m asculinit y and t he new id en t it ies r esu lt in g f r om t h e ex p er ien ce. Th e u n d er st an d in g of t h ese m ean in g s f r om a cu lt u r al p er sp ect iv e fav or s nur se- pat ient com m unicat ion and enables planning of car e appr opr iat e t o t hese pat ient s’ needs.
DESCRI PTORS: color ect al neoplasm s; nur sing; cult ur e; gender ident it y
EL SI GN I FI CADO DE SER UN HOMBRE COM ESTOMA I N TESTI N AL POR CÁN CER DE
COLORECTAL: UN ABORDAJE ANTROPOLÓGI CO DE LA MASCULI NI DAD
El est u dio t u v o com o obj et iv o an alizar el sign ificado qu e los h om br es, con est om a in t est in al, at r ibu y en a la exper iencia de la enfer m edad y al t r at am ient o de cáncer de color ect al. Fuer on ut ilizadas las r efer encias t eór icas de la ant r opología m édica, de la m asculinidad y del m ét odo et nogr áfico. Par t icipar on del est udio 16 hom br es en el int er valo de edad de 40 a 79 años, r esident es en Ribeir ao Pr et o, SP, y r egión. La r ecolección de los dat os fue r ealizada por m edio de obser v aciones par t icipant es y ent r ev ist as sem iest r uct ur adas. Por m edio del análisis in du ct iv o de los dat os, se seleccion ó de los n ú cleos de sign ificados: el r econ ocim ien t o de la gr av edad de la enfer m edad y el sufr im ient o de t ener cáncer , som et er se a la cir ugía y al est om a. Esos significados r ev elan la t ensión que se desar r olla ent r e los est ándar es t r adicionales de m asculinidad y las nuev as for m as de ident idad pr ov ocadas por la ex per iencia. Conocer esos significados, baj o la per spect iv a cult ur al, facilit a la com unicación ent r e enfer m er o y pacient e y per m it e planificar los cuidados adecuados a sus necesidades.
DESCRI PTORES: neoplasias color r ect ales; el enfer m er ía; la cult ur a; ident idad de géner o
OS SENTI DOS DE SER HOMEM COM ESTOMA I NTESTI NAL POR CÂNCER COLORRETAL:
UMA ABORDAGEM NA ANTROPOLOGI A DAS MASCULI NI DADES
O est udo t eve com o obj et ivo analisar os sent idos que hom ens com est om a int est inal at r ibuem à exper iência da doença e do t r at am ent o do câncer color r et al. For am ut ilizados os r efer encias t eór icos da ant r opologia m édica, das m asculinidades e do m ét odo et nogr áfico. Par t icipar am do est udo 1 6 hom ens na faix a et ár ia de 4 0 a 7 9 an os, m or ador es de Ribeir ão Pr et o, SP, e r egião. A colet a dos dados foi r ealizada por m eio de obser v ações par t icipan t es e en t r ev ist as sem iest r u t u r adas. Pela an álise in du t iv a dos dados, selecion ou - se dois n ú cleos de sent idos: o r econhecim ent o da gr avidade da doença e o sofr im ent o de t er câncer , subm et er - se à cir ur gia e ao est om a. Esses sent idos r ev elam a t ensão que se desenv olv e ent r e os padr ões t r adicionais de m asculinidade e as n ov as f or m as d e id en t id ad es p r ov ocad as p ela ex p er iên cia. Con h ecer esses sen t id os, sob a p er sp ect iv a cult ur al, facilit a a com unicação enfer m eir o- pacient e e per m it e o planej am ent o de cuidados adequados às suas n ecessi d ad es.
DESCRI TORES: n eoplasias color r et ais; en fer m agem ; cu lt u r a; iden t idade de gên er o
1RN, Doct or al St udent , e- m ail: elizadazio@yahoo.com .br ; 2RN, Ph.D. in Nur sing, Facult y, e- m ail: m egum i@eer p.usp.br ; 3RN, Ph.D. in Nur sing, Associat e
Pr ofessor, e- m ail: m m fzago@eer p.usp.br.
I NTRODUCTI ON
L
it er at ur e has, in r ecent y ear s, adm onished about t he im por t ance of m en’s healt h consider ing t heysuffer m ore illnesses t han w om en and t hat t here is a
r elat ion w it h t he const r uct ion of m asculinit y and how
t heir healt h is com prom ised. Given t he im port ant role
t hat occupat ion plays in m en’s ident it y, such as being
t he head of t he house, various problem s can occur in
relat ion t o healt h prom ot ion and disease int ervent ion( 1). I n t h i s scen a r i o , t h e Br a zi l i a n Mi n i st r y o f
Healt h, in August 2008, est ablished t he “ Nat ional Policy
o f I n t e g r a l Ca r e t o Me n ’ s He a l t h : Pr i n ci p l e s a n d
Guidelines” r eaffir m ing t hat har m t o m en’s healt h is
a p u b l i c h ea l t h p r o b l em a n d i t s p r o p o sa l a i m s t o
im p r ov e t h e q u alit y of in t eg r al h ealt h car e f or t h e
Br azilian m ale p op u lat ion . Th e d ocu m en t h ig h lig h t s
t he fact t hat t um or s occupied t he t hir d place am ong
m or t alit y indicat or s and w er e r esponsible for 4 3 . 2 %
of deat hs( 2) of m en bet w een 25 and 59 y ear s of age in 2 0 0 5 . Accor din g t o t h e Nat ion al Can cer I n st it u t e
( I N CA ) , 2 3 1 , 8 6 0 n e w c a n c e r c a s e s i n m e n a n d
234,870 in w om en w er e ex pect ed for 2008( 3). As nur ses, facult y m em ber s and r esear cher s
i n t h e ca n cer f i el d , t h e a u t h o r s o f t h i s st u d y a r e
focused on t he healt h of m en w it h color ect al cancer
( CC) . Th is n eop lasia is r an k ed f ou r t h am on g t h ose
af f ect in g m en an d m or t alit y r at es h av e in cr eased .
Est i m a t e s o f i n ci d e n ce p u b l i sh e d i n 2 0 0 8 p r e d i ct
12,490 new cases of colon cancer in m en and 14,500
in w om en. These num ber s cor r espond t o an est im at ed
r isk of 1 3 new cases for each 1 0 0 , 0 0 0 m en and 1 5
for each 100,000 w om en( 3).
Despit e colopr oct ology adv ancem ent s in t he
pr ev ent ion and ear ly diagnosis of CC, t her e ar e st ill
difficult ies due t o t he populat ion’s lack of k now ledge
abou t t h e r isk s, lat en ess in seek in g car e or lack of
access t o h ealt h sy st em s an d in su f f icien t r esou r ces
f or diagn osis in Br azil. I n gen er al, diagn osis of t h e
d isease is p er f or m ed in ad v an ced st ag es, r eq u ir in g
prolonged hospit alizat ions and culm inat ing in int est inal
st om as for pat ient s( 4).
B r a z i l i a n n u r s e s h a v e s h o w n t h r o u g h
int er pr et at iv e st udies t hat phy sical and psy chosocial
d i s o r d e r s c a u s e d b y CC, s u r g e r y a n d s t o m a
com prom ise t he qualit y life of pat ient s and t heir fam ily
m em ber s( 5 - 6 ).
I n t h e f ace of t h is scen ar io, t h e pr ocess of
r eh ab ilit at in g t h ese p at ien t s f r om a p er sp ect iv e of
m asculinit y is not ew ort hy. I t is not a very w ell st udied
aspect in Br azilian nur sing.
Aim ing t o br idge t his gap, t his st udy analyzed
t h e m ean in g s at t r ib u t ed t o t h e d isease ex p er ien ce
and t r eat m ent am ong m en w it h int est inal st om a.
THEORETI CAL METHODOLOGI CAL
APPROACH
M e d i c a l a n t h r o p o l o g y, m a s c u l i n i t y i n
ant hr opology and et hnogr aphy w er e t he t heor et
ical-m et hodological appr oach used in t his st udy. Medical
ant hr opology holds t hat cult ur e is a sy m bolic sy st em
o f cr e a t i o n o f m e a n i n g t h a t e x p r e ss k n o w l e d g e ,
beliefs, nor m s and values. Fr om t his per spect ive, t he
disease n eeds t o be in t er pr et ed n ot as a biological,
st at ic an d in div idu al pr ocess, bu t as a pr ocess t h at
dem ands int er pr et at ion and act ion in a sociocult ur al
en v i r o n m en t . Th u s, o n e n eed s t o u n d er st a n d t h e
d isease as an ex p er ien ce, as a su b j ect iv e p r ocess.
Th e in d iv id u al ex p er ien cin g a d isease su ch as CC,
at t r ibut es m eanings t o it accor ding t o com m on sense
a n d a c q u i r e n e w k n o w l e d g e i n t h e c o u r s e o f
t r eat m en t( 7 ).
Com plem ent ing t his idea, t he div ision of t he
social w or ld in t o m ale an d f em ale ex p r esses in all
societ ies a different socializat ion. I t is in t his w ay t hat
cu lt u r e collab or at es in t h e cr eat ion of im p licit an d
explicit guidelines t hat govern life in societ y, in w hich
m en and w om en ar e subm it t ed t o differ ent nor m s of
em ot ion , cog n it ion an d p r act ices. How ev er, g en d er
r o l e s a r e n o t f i x e d ; t h e y ca n ch a n g e u n d e r t h e
i n f l u e n c e o f s e v e r a l s o c i a l p r o c e s s e s a s i n t h e
ex per ience of a disease( 7).
St u dies car r ied ou t ov er decades addr essed
only hegem onic m asculinit y, w hich is a ideal cult ural
m o d e l t h a t e x e r t s c o n t r o l o v e r m e n b y t h e
nor m alizat ion of social pr act ices, cont r ast ing w it h t he
f em ale gen der ’s ap pr oach .
Giv en cr it iques of t his m odel, ot her pat t er ns
of m asculinit y are considered( 8). I dent ificat ion of t hese pat t er ns per m it s one t o under st and t he v ar iat ions of
su b j ect iv it y p r esen t in t h e p r ocess of b ecom in g ill,
because st udying m en im plies seeking t heir singularit y
in t he cont ex t of t heir gr oup of r efer ence.
For t h e pr ocess of t h e illn ess ex per ien ce t o
be under st ood w it h indiv idual nuances, one needs t o
d escr ib e t h e p r ob lem et iolog y, it s p hy siop at h olog y,
t he cour se of t he disease, and pr ognosis and t r eat m ent
t h r ou g h a m et h od t h at p er m it s close con t act w it h
Acco r d i n g t o t h e n o t e d a ssu m p t i o n s, t h e
et h n o g r ap h i c m et h o d w as ad o p t ed t o d ev el o p t h e
s t u d y. Th i s m e t h o d a i m s t o p r o d u c e a “ t h i c k
descr ipt ion” of t he m eanings at t r ibut ed by par t icipant s
t o a phenom enon, ex pr essed in language. Based on
t hese m eanings, it is t he researchers’ role t o synt hesize
r elev ant aspect s( 1 0 ).
Th e f ollow in g select ion cr it er ia w er e u sed :
being a resident in Ribeirão Pret o or neighboring cit ies,
SP, Brazil, older t han 18 year s, any level of educat ion;
hav ing a t em por ar y or per m anent st om a for at least
one m ont h; being in physical and em ot ional condit ion
t o p ar t i ci p at e i n t h e st u d y, an d p r ov i d i n g con sen t
t hr ough t he fr ee and infor m ed consent agr eem ent .
A t ot al of 16 m en w it h int est inal st om a, due
t o CC, r egist er ed in t he Pr oct ology Out pat ient Clinic
in t he Hospit al das Clinicas, Univ er sit y of Sao Paulo
at Ribeir ão Pr et o, Medical School par t icipat ed in t he
st udy. Dat a collect ion w as car r ied out bet w een June
and Decem ber 2007 aft er t he appr oval of t he hospit al’s
Resear ch Et h ics Com m it t ee w as obt ain ed.
Sem i- st r u ct u r ed in t er v iew s an d p ar t icip an t
o b s e r v a t i o n , w h i c h a r e p r o c e d u r e s t h a t e n a b l e
i n t e r s u b j e c t i v i t y b e t w e e n r e s e a r c h e r s a n d
par t icipant s( 10) w er e em ploy ed. The follow ing guiding quest ions w er e used: t ell m e how your disease st ar t ed
and w hat you t hink about it ; how w as your sear ch for
t r eat m en t ?; w h at w as it lik e h av in g t o u n der go t h e
sur ger y?; w hat is it like t o be a m an w it h a st om a?
Dat a w as co l l ect ed i n t h e h o sp i t al ( i n t h e
out pat ient clinic and in t he m edical office) and at t he
par t icipan t s’ h om es. I n t er v iew s an d obser v at ion s at
h om es w er e sch edu led. On av er age, t w o in t er v iew s
w er e held for about 60 m inut es w it h each par t icipant
in or der t o com plem ent dat a. Par t icipant obser v at ion
aim ed t o id en t ify p ar t icip an t s’ n on - v er b al b eh av ior,
r elat ion sh ip s an d p r act ices in t h eir h om es an d on
m edical v isit s, w hich is w hen m en r elat e w it h ot her
p at ien t s an d w it h t h e t eam . I n f or m at ion ab ou t t h e
d i se a se a n d i t s d e v e l o p m e n t a n d t r e a t m e n t s f o r
p at ien t s w er e ob t ain ed t h r ou g h t h eir m ed ical f iles.
Dat a w ere regist ered in a field diary and all obt ained
in f or m at ion w as t r an scr ibed af t er w ar ds.
I n d u ct i v e a n a l y si s w a s p e r f o r m e d i n t w o
st ages: or dinat ion of dat a t ex t s for each par t icipant ,
ident ificat ion of m eanings giv en t o t he ex per ience in
a set of t ext s or in each individual t ext , w hich per m it t ed
iden t if y in g em pir ical cat egor ies by con sider in g t h eir
c o m m o n a n d d i s t i n c t a s p e c t s . B a s e d o n t h e s e
cat egor ies, t he m eanings given t o t he exper ience w er e
int er pr et ed consider ing t he par t icipant s’ sociocult ur al
cont ex t( 10).
A m o n g t h e 1 6 p a r t i c i p a n t s , t h r e e w e r e
bet w een 40 and 50 year s old and 13 bet w een 51 and
79 y ear s old; 12 had per m anent and four t em por ar y
st om as; t im e of t he int est inal st om a var ied fr om one
m ont h t o seven year s. Thir t een pat ient s w er e affect ed
by r ect al can cer, t w o by sigm oid n eoplasm an d on e
b y sy n ch r o n o u s ca n ce r o f t h e si g m o i d co l o n a n d
r ect u m . Th ese ch ar act er ist ics con f ir m t h at r ect u m
can cer is m or e f r equ en t t h an color ect al can cer an d
m o r e p r e v a l e n t i n m e n i n t h e m a j o r i t y o f
popu lat ion s( 3 ).
I n r e l a t i o n t o s o c i a l c h a r a c t e r i s t i c s , w e
h i g h l i g h t t h a t : t e n w e r e m a r r i e d , si x r e si d e d i n
Rib eir ão Pr et o an d t en in t h e su r r ou n d in g r eg ion ;
e l e v e n r e p o r t e d b e i n g n o n - p r a c t i c i n g Ca t h o l i c ;
p r of ession s v ar ied : d r iv er, f ar m w or k er, m ech an ic,
a m o n g o t h e r s. Si x w e r e r e t i r e d , se v e n w e r e o n
sick leav e, t w o w er e u n em p loy ed an d on e of t h em
w as w or k in g . I n com e v ar ied f r om on e t o f iv e t im es
t h e m i n i m u m w a g e , c u r r e n t a t t h e t i m e ; t w o
p ar t icip an t s h ad n o in com e an d f ou r r eceiv ed on ly
m i n i m u m w a g e . Ni n e h a d n o t co m p l e t e d m i d d l e
sch o o l , w h i ch i s co n si st en t w i t h t h ei r o ccu p at i o n s
( b ef or e d isease) an d r ed u ced salar ies ( or b en ef it s
f r o m r et i r em en t ) . Gi v en t h ese ch ar act er i st i cs, t h e
m aj or it y of p ar t icip an t s ar e con sid er ed p ar t of t h e
w o r k i n g cl a ss, ch a r a ct er i zed b y w o r k er s i n u r b a n
cen t er s w h o l i v e i n p o o r f i n an ci al co n d i t i o n s, d u e
t o r ed u ced occu p at ion al q u alif icat ion an d a low lev el
o f e d u c a t i o n w i t h c o n s e q u e n t l i m i t e d a c c e s s t o
p u b lic ser v ices su ch as ed u cat ion an d h ealt h( 1 1 ).
RESULTS AND DI SCUSSI ON
Ack now ledging t he sev er it y of t he disease
Am ong t he signs and sym pt om s indicat ive of
problem s in t he int est inal syst em , inform ant s describe
diarrhea, bleeding, t hinning st ool and hem orrhoids t hat last ed
m o n t h s. Th ese sy m p t o m s w er e co n si d er ed l o w i n
sever it y and individuals t r ied t o solve t hem using lay
know ledge such as hom e r em edies, m uch spr out , guava and
par sley t ea. As t hese signs int ensified, im peding t hem
i n ca r r y i n g o n w i t h t h e i r d a i l y r o u t i n e , t h e y r e
-ev al u at ed t h e i m p o r t an ce o f t h ese sy m p t o m s an d
s o u g h t s o l u t i o n s i n t h e h e a l t h c a r e s y s t e m a s
exem plified in t he follow ing. I ’d go t o t he bat hr oom but it ’d
t ake a lot t o com e out ( feces) , t hen it ’d com e out wit h a lit t le pellet
of blood. I t got m ore frequent . Aft er one year I went t o t he doct or.
st ool w as t iny j ust like cat ’s st ool, t her e w as blood. I t hought it
w as not hing.
An i n t er p r et a t i v e( 6 ) st u d y d escr i b e s t h e se s a m e b e l i e f s a n d p r a c t i c e s , a n d t h e r e a r e n o
d if f er en ces b et w een m en an d w om en . I t is k n ow n
t hat m en delay t heir sear ch for pr im ar y car e ser vices
because, due t o hegem onic st er eot ypes of m asculinit y,
t hey neglect car ing for t heir healt h( 1- 2) as pr esent ed ear lier.
Th eir sear ch t o ob t ain a m ed ical d iag n osis
w as a ch allen g e f or t h em ; t h ey h ad t o g o t h r ou g h
r ef er r a l s b et w een d i f f er en t p h y si ci a n s a n d h ea l t h
in st it u t ion s, deal w it h sch edu les f or m on t h s ah ead,
had t o r epeat exam s, t o leave t heir j obs, t o deal w it h
a lack of financial r esour ces t o m ov e ar ound, am ong
o t h e r d i f f i c u l t i e s . Th e s e h a r d s h i p s c e r t a i n l y a r e
in st it u t ion al bar r ier s f ou n d in t h e access of m en t o
healt h ser v ices( 1 2 ).
The colonoscopy and rect al exam s left , in all
part icipant s, bodily and em ot ional m arks. The rect al exam
was t he first one. Then, t he ot her ( colonoscopy) . This was a hard
one, in a bad sit e, weird posit ion… I was sweat ing and t rem bling,
[ …] it was em barrassing. I t ’s a weird t hing. Men were creat ed not
t o be t ouched t here ( anus) ; [ …] I felt a lot of pain. I t hurt s us!
Th e r e c t a l e x a m i s d e s i g n e d t o d e t e c t
h a r d e n e d m a s s e s , c h a n g e s i n t h e r e c t u m a n d
bleeding. Thr ough t he colonoscopy t he phy sician can
see t he int est inal w all and obser v e any abnor m alit y ;
it also per m it s t ak in g a biopsy. For t h e pr ofession al
syst em , t hese exam s ar e effect ive and of low cost( 4). For t h e in f or m an t s, t h ese p r oced u r es r ep r esen t an
in v asi o n o f t h ei r p r i v acy, h u r t i n g t h ei r m an h o o d ’s
dignit y, due t o t he physical and em ot ional discom for t
of being t ouched in a sit e t hat is not supposed t o be
accessed by ot her s( 13).
Th r ou gh ou t t h e ex am s, in for m an t s r epor t ed
t h at t h ey st ar t ed t h i n k i n g ab ou t t h e p ossi b i l i t y of
having a serious illness. Ever yt hing I need r ight now is him
( doct or ) saying t hat I have cancer .
The diagnosis disclosur e w as r em ar k able for
t h e in f or m an t s, cau sin g em ot ion al dist r ess, an x iet y
and per cept ion of fragilit y. He ( physician) j ust said I had
t o have an ur gent sur ger y. I expect ed t hat t he bag w ould be for
only t w o or t hr ee m ont hs. Now , he said I ’m going t o have it for
life. I t w as difficult ! I ’m st r ong, I don’t get dow n easy w it h a
disease. But it w as a shock… a big scar e!
Aft er t he diagnosis, t he disease has a nam e
- cancer - and t he pat ient suffers a rupt ure in his life
biogr aphy; his ident it y is alt er ed; he is now a pat ient
w it h can cer. I n p eop le’s im ag in at ion , r eg ar d less of
gender and social class, t he represent at ions of cancer
ar e of a fat al disease t hat causes m uch suffer ing and
leads t o sev er e lim it at ions( 5- 6). Fr om t his per spect iv e, m en f eel v u ln er ab le, f r ag ile, ack n ow led g e t h ey w ill
not cor r espond t o t he socially est ablished st andar ds
of m asculinit y, feel m ar ginalized and subj ect ed t o t he
k now ledge and pr act ices of t he m edical m odel( 8, 13).
The dist r ess of having cancer, under going sur ger y and
a st om a
Th e diagn osis disclosu r e in it iat es a pr ocess
of quest ioning: w hy have I developed t his disease at
t his m om ent in m y life? Am ong t he differ ent st r at egies
em ploy ed, m en r ecalled fam iliar cancer sit uat ions. A
wom an younger t han m e got it in t he int est ine and had no chance,
she’s gone; I lost a cousin who had an operat ion and it cam e back
( t he disease) . The concept ion of fat alit y w as com m on. [ …] all
t he t im e hear ing and seeing: look, t her e’s no cur e for cancer ; it ’s
a t o u g h d i se a se ; I t h o u g h t i t h a d n o cu r e. W i t h t h e i r
ex per ien ces in t h e h ealt h car e con t ex t , t h ey st ar t ed
t o d iscov er t h e m ed ical cau ses of t h e d isease an d
r elat ed t hem w it h t heir pr evious lives, food habit s and
consum pt ion of alcohol. I at e t oo m uch r ed m eat , sausage.
Nev er lik ed gr eens and fr uit s, r ev ealing t heir lack of k now ledge about t he r isk s of t he disease.
For som e, r eligious beliefs w er e r epor t ed as
t h e cau se of t h e d isease, f r om a p er sp ect iv e of a
profane life. I never had anyt hing. He ( God) said: let m e punish
you a lit t le. You have t o suffer a lit t le.
A har d w or k er ’s life and ex posur e t o nat ur al
phenom ena also gav e m eaning t o t he disease onset .
I ’ve been a suffer ing per son since m y childhood. I t hink t hat
because of m y har d life of cut t ing cane, r iding in over cr ow ded
and subst andar d w or k t r ucks, picking cot t on, being exposed t o
cold, dust .
I t has been show n t hat t her e is gener alizat ion
i n t h e d i f f e r e n t w e s t e r n s o c i a l g r o u p s , w h e n
a s s o c i a t i o n s a r e e m p l o y e d b e t w e e n t h e d i v e r s e
elem ent s of hum an life( 5- 6,11). Poor w ork condit ions are h ig h lig h t ed b y t h e in f or m an t s, con sist en t w it h t h e
w or k in g class’ condit ion.
Aft er acknow ledging t he sever it y of CC, t hese
m en agr eed t o t he m edical t her apies of sur ger y and
colost om y because life is at r isk. How ever, t he decision
t o a c c e p t t h e c o l o s t o m y, w h e t h e r t e m p o r a r y o r
per m anent , w as a m om ent of dist r ess and indecision.
Som e accept ed it w it h r esignat ion. [ …] you have t o face it ,
w hat can you do? I got t ot ally dow n in t he dum ps. I t w as ver y
difficult ! Ot her s init ially r efused, but ended up consent ing. I
got sad, t hen I accept ed it . I t happened, so you have t o face it
K n o w l e d g e , v a l u e s a n d b e l i e f s w e r e
r econsider ed in t he pr ocess of giv ing m eaning t o t he
life t hr eat and t he need t o hav e t he body alt er ed. We
u n d e r st a n d t h a t t h i s p e r i o d w a s m a r k e d b y t h e
m eaning of r upt ur e in t he m ale v iew of inv incibilit y,
ca u si n g a r u p t u r e w i t h so m e d o g m a s r e l a t e d t o
m asculinit y and pow er, m ar ked by im ages of a st r ong
and r esilient body. Thus, m ale pow er also echoes in
t h ei r ex p er i en ce w i t h CC, l ead i n g t o a p r o cess o f
r esig n at ion w it h t h e sit u at ion , a cu lt u r al r at ion ale
ch ar act er i st i c of p eop l e b el on g i n g t o t h e Br azi l i an
w or k ing class( 5, 11).
Be i n g r e a d y t o u n d e r g o t h e t r e a t m e n t i s
relat ed t o life values and how life is present ed. I n t he
condit ion of hav ing CC, r eadiness is pr esent ed fr om
a per spect iv e of hope in t he t her apeut ic r esult s, not
n e ce ssa r i l y i n a cu r e , b u t i n t h e i n t e r r u p t i o n o f
sy m pt om s an d t h e ch an ce of r ecov er in g t h e con t r ol
of t he body and life( 14).
I nit ial r eact ions w hen t hey saw t he st om a and
f i n d i n g t h a t t h ey h a d l o st sp h i n ct er co n t r o l w er e
dram at ic. When I w oke up and saw t hat lit t le ost om y bag at m y
side… Gosh! I t w as a shock, hor r ible! I t w as hor r ifying t o look at
a piece of int est ine. A piece of m e is on t he out side…
The m em or ies of w hen t hey saw t heir body
t r ansfor m ed by t he colost om y w er e expr essed in cr ying
and w it h sorrow, show ing t hat m en also cr y, but t his
is a pr ivat e and not public behav ior. These em ot ions
w er e ex pr essed in a sph er e of m ale com plicit y w it h
t he researcher, w ho, in t urn had t o respect it .
The body is t he exist ent ial base of t he hum an
b ein g an d cu lt u r e. I n com m on sen se, social v alu es
at t r ibut ed t o t he body ar e t he r esult of discour se and
i n t e r e s t t h a t g e n e r a t e p e r s o n a l a n d c o l l e c t i v e
at t r ibut es t o w hat it m eans t o be a m an( 15). We believe t h at t h e sy m b olism g iv en t o t h e colost om y m od els
t he t r ansfor m ed body, gener at ing conflict due t o t he
l o ss o f t h e p r e v i o u s l i f e , e ch o i n g t h e h e g e m o n i c
m ean in gs of m ascu lin it y.
Over t im e, looking at t he st om a is not so scar y,
but t he par t icipant s ack now ledged t hat it s daily car e
r equ ir es ch an ges in sev er al aspect s of lif e an d can
lead t o em barrassing sit uat ions. [ …] w hen I st ood up t he
bag got loose. I had t o hur r y up t o t he bat hr oom and clean it up.
The ot her day I w ent t o a child’s bir t hday and t hen gas st ar t ed t o
com e out . Ever ybody looked at m e; eat ing habit s had t o change,
t he fr equency I go t o t he bat hr oom , clean it up. I t ’s kind of
uncom fort able t o leave t he house, it let s gas loose, m akes noises.
All par t icipant s lear ned how t o car e for t heir
colost om y. I f, at t h e b eg in n in g , t h ey d ep en d ed on
car egiver s, over t im e all of t hem acquir ed confidence
in self- car e and t hey w er e able t o over com e t his st age.
I cut , w ash and put it again all by m yself.
Learning t o live w it h changes in t heir int est inal
sy st em an d w it h a colost om y w er e p r ocesses t h at
d e m a n d e d i n t e r n a l a n d e x t e r n a l r e s o u r c e s t h a t
a p p r o x i m a t e ch a r a ct er i st i cs r el a t ed t o t h e f em a l e
gender : sensit iv it y, car e, dependency and fr agilit y( 12). Af t er ov er com in g t h is st age, t h e sear ch f or
get t ing back cont r ol of life is a difficult t ask because
t hey are concerned w it h sexual act ivit y. You’r e less m ale.
You get w eaker … Have no desir e. I have desir e, but w it h no
erect ion.
Resear ch er s on sex u alit y h av e sh ow n t h at
a d v a n c e d a g e a n d i l l n e s s d o n o t n e c e s s a r i l y
au t om at ically im ply an en d of sex u al life. For t h ese
m en, sexualit y is linked t o t heir genit alia, t hat is, t he
r eal and phy sical act iv it y of t he sex ual act , w hich is
ch ar act er ist ic of t h e h eg em on ic m ascu lin it y v alu es
held by t he w or king class, r egar dless of age r ange( 8). A n o t h e r r e p o r t e d d i f f i c u l t y w a s t h e
im p ossib ilit y t o g o b ack t o w or k , esp ecially am on g
t he seven m en on sick leave and t he t w o unem ployed.
I feel t ied up… depending on ot her s. My pr evious life is over . As
a m an, I per ceive m yself as a failur e. I t ’s a disappoint m ent . My
m ain concer n is t o suppor t m y fam ily. I st ill haven’t m anaged t o
ar r ange sick pay.
I n t h e c o n t e x t o f t h e w o r k i n g c l a s s , a n
occupat ion is a r efer ence for t he const r uct ion of t he
m asculine ident it y. I t is acknow ledged as m oral value
t hat sust ains t he honor of t he head of t he fam ily and
enables m en t o have personal self- realizat ion( 5,11). Not being able t o w or k due t o t he disease leads t hem t o
financial har dships and dependence, w hich m ake t hem
p er cei v e t h em sel v es as a b u r d en t o t h e f am i l y, a
m ar g in alized m an .
Magical- r eligious beliefs, fam ily m em ber s and
fr iends for m a suppor t net w or k t o help t hem in t heir
uncont r olled life, w hich cr eat es com plicit y am ong all
of t hem , t o deal w it h pr oblem s and t o find solut ions,
r esult ing in per cept ions of m ar ginalit y being k ept in
t he pr iv at e spher e.
I n t h e c o n t e x t o f s e v e r e d i s e a s e , t h e
t em por alit y of life is an im por t ant aspect and per m it s
one t o r esum e cont r ol. Now , I ’m get t ing used t o it . I t ’s
nor m al, I ’m slow ly r ecover ing.
Get t ing used t o t he colost om y and feeling nor m al
ar e im ages t hey const r uct about t heir alt er ed bodies,
i n d i v i d u a l s p r o j e c t t h e m s e l v e s i n t o t h e s o c i a l
e n v i r o n m e n t , i n t h e e x p r e ssi o n o f e m o t i o n s a n d
t hr ough t heir social r oles. Thus, r esum ing life w it hin
n or m al st an dar ds is a desir e t h ey h av e in or der t o
obt ain a sense of cont r ol ov er social st andar ds.
A n o t e w o r t h y f a c t i n t h e p a r t i c i p a n t s ’
nar r at ives as t hey r efer r ed t o get t ing back t o nor m al
life w as t he sym bolic concept ion of honor t hat guided
expect at ions and act ions of m en at hom e and in social
life, a hegem onic m asculinit y st andar d. Being a m an is
t o be a per son w ho com plies w it h his obligat ions, in t he r ole of
fat her and husband. Being a landm ar k at hom e and at w or k.
We under st and t hat t hese m en, w ho belong
t o t he w or king class and sur vived CC w it h colost om y,
p u t t h e i r l i f e a t r i s k , i m p o s i n g n e w p a t t e r n s o f
m ascu l i n i t y su ch as su b o r d i n at i o n , co m p l i ci t y an d
m arginalizat ion( 8). Over t im e, t hey cr eat e expect at ions of r ecov er in g t h eir id eal, d om in an t an d h eg em on ic
posit ion so t h at t h ey w ill h av e t h e f eelin g of bein g
r eint egr at ed in t he social w or ld.
I n analyzing t hese m eanings, w e believe t hat
nur sing has an essent ial r ole in ack now ledging m ale
subj ect iv it ies of m en affect ed by CC w it h t em por ar y
or perm anent colost om y, w hich are const ruct ed in t he
sociocu lt u r al lif e. Bein g at t en t iv e t o t h ese p at ien t s’
r eact ions is necessar y w hen t hey per ceiv e t he sam e
d i se a se o r t r e a t m e n t d i f f e r e n t l y w i t h t h e a i m t o
pr eser v e t heir ident it ies. Thus, t he need for specific
s u p p o r t d u r i n g c a r e d e l i v e r y t o m e n i m p o s e s a
r e f l e c t i v e b a s e f o r p r o f e s s i o n a l s t o p l a n t h e i r
in t er v en t ion in t h e p r ocess of t h e r eh ab ilit at ion of
pat ien t s w it h can cer at all lev els of h ealt h car e. I n
t h i s w ay, t h e g u i d el i n es o f t h e Na t i o n a l Po l i cy o f
I nt egr al Car e t o Men’s Healt h in t he car e of m en w it h
CC w ill be t hen incor por at ed.
FI NAL CONSI DERATI ONS
Aim ing t o analyze t he m eanings given t o t he
CC and t he ost om y exper ience am ong m en belonging
t o t he w or king class t hr ough t he t heor et ical fr am ew or k
o f m e d i c a l a n t h r o p o l o g y, o f m a s c u l i n i t y a n d
e t h n o g r a p h i c m e t h o d , w e f o u n d t h a t m a scu l i n i t y
p a t t e r n s b e c o m e a l t e r e d , a s s i m i l a t i n g r u l e s o f
s u b o r d i n a t i o n , c o m p l i c i t y a n d m a r g i n a l i z a t i o n .
How ever, ov er t im e, as t hey over com e pr oblem s, t he
rules of t he hegem onic m asculinit y predom inat e again
so m en can f eel t h ey ar e par t of t h eir social gr ou p
on ce m or e.
The analy zed m eanings cont r ibut e t o healt h
pr ofessionals’ r eflect ions, especially nur ses, r egar ding
t heir suppor t and car e deliver y t o t his gr oup of client s
w it h specific needs.
REFERENCES
1. Gom es R, Nascim ent o EF. A produção do conhecim ent o da saú de pú blica sobr e a r elação h om em - saú de: u m a r ev isão bibliogr áfica. Cad. Saúde Pública 2 0 0 6 m aio; 2 2 ( 5 ) : 9 0 1 - 1 1 . 2 . Min ist ér io d a Saú d e ( BR) . Polít ica n acion al d e at en ção int egr al à saúde do hom em : pr incípios e dir et r izes. Br asília ( DF) : Minist ér io da Saúde; 2 0 0 8 .
3. Minist ér io da Saúde ( BR) . Secr et ar ia de At enção à Saúde. I n s t i t u t o N a c i o n a l d e Câ n c e r ( I N CA ) . Co o r d e n a ç ã o d e Pr e v e n ç ã o e V i g i l â n c i a d e Câ n c e r. Es t i m a t i v a s 2 0 0 8 : I n cidên cia de Cân cer n o Br asil. Rio de Jan eir o ( RJ) : I NCA; 2 0 0 7 .
4 . Habr - Gam a AA. Cân cer color r et al: a im por t ân cia de su a pr ev en ção [ Edit or ial] . Ar q. Gast r oen t er ol. 2 0 0 5 ; ( 4 2 ) : 1 . 5 . D á zi o EMR. O si g n i f i ca d o d o e st o m a i n t e st i n a l e n t r e hom ens: um est udo et nogr áfico [ t ese] . Ribeir ão Pr et o ( SP) : Escola d e En f er m ag em d e Rib eir ão Pr et o/ Un iv er sid ad e d e São Pau lo; 2 0 0 8 .
6 . Mar u y am a SAT, Z ag o MMF. O p r o cesso d e ad o ecer d o por t ador de colost om ia por câncer. Rev Lat ino- am enfer m agem 2 0 0 5 m ar - ab r ; 1 3 ( 2 ) : 2 1 6 - 2 2 .
7. Helm an CG. Cult ur a, saúde e doença. 4ª ed. Por t o Alegr e ( RS) : Ar t m ed; 2 0 0 3 .
8 . Co n n el l R. Mascu l i n i t i es. Ber k el ey ( USA) : Un i v er si t y o f Calif ór n ia Pr ess; 1 9 9 5 .
9. Langdon EJ. Cult ur a e pr ocessos de saúde e doença. I n: Jeolás LS, Oliveir a M, or ganizador as. Anais do sem inár io sobr e cult ur a, saúde e doença. Londr ina ( PR) : Edit or a Fiocr uz; 2003. p . 9 1 - 1 0 5 .
1 0 . Cr an g M, Cook I . Doin g et h n og r ap h ies. Lon d on : Sag e Pu b l i ca t i o n s; 2 0 0 7 .
1 1 . Cost a MCS, Rossi LA, Lopes LM, Ciof f i CL. Sign if icados d e q u a l i d a d e d e v i d a : a n á l i se i n t er p r et a t i v a b a sea d a n a ex per iência de pessoas em r eabilit ação de queim adur as. Rev Lat in o- am en f er m agem 2 0 0 8 m ar - abr ; 1 6 ( 2 ) : 2 5 2 - 9 . 1 2 . Schr aiber LB, Gom es R, Cout o MT. Hom ens e saúde na p au t a d a Saú d e Colet iv a. Ciên c. saú d e colet iv a 2 0 0 5 j an -m ar ; 1 0 ( 1 ) : 7 - 1 7 .
1 3 . Gom es R. Sex u alid ad e m ascu lin a e saú d e d o h om em : pr opost a par a u m a discu ssão. Ciên c. saú de colet iv a 2 0 0 3 ; 8 ( 3 ) : 8 2 5 - 9 .
1 4 . Th o m é B, Esb en sen BA, D y k es AK, Hal l b er g I R. Th e m eaning of hav ing t o liv e w it h cancer in old age. Eur opean Jou r n al of Can cer Car e Dec 2 0 0 4 ; 1 3 ( 5 ) : 3 9 9 - 4 0 8 . 1 5 . Fer r eir a FR. Os sen t id os d o cor p o: cir u r g ias est ét icas, discur so m édico e Saúde Pública [ t ese] . Rio de Janeir o ( RJ) : Escola Nacional de Saúde Pública/ Fundação Oswaldo Cruz; 2006.
