Blaming in women with breast cancer subjected to intimate partner violence: A hermeneutic phenomenological study

Abstract

Objective

The present study was conducted to determine the blaming experiences of women with breast cancer subjected to intimate partner violence (IPV).

Methods

This hermeneutic phenomenological study explored blaming experiences of women with breast cancer subjected to IPV. Nine women with a mean age of 47.5 years referred to oncology hospitals in Tabriz (Iran) were interviewed using semi-structured in-depth interviews. Data analysis was performed based on Van Manen's thematic analysis method.

Results

The main theme emerged from the data is “blaming as a shifting cognitive judgment” with three subthemes of patient blaming partner, partner blaming patient, and self-blame.

Conclusions

The findings of the present study revealed that cognitive judgment shifting could be emerged as different types of blaming in the patients with breast cancer exposed to IPV. It is suggested that oncology nurses heed the psychological needs of women with breast cancer through holistic nursing considering couple and family-centered care.

Introduction

Breast cancer was the most prevalent cancer and the main cause of mortality due to cancer in women throughout the world until 2022.^1,2,3 A cancer diagnosis is a turning point in patients' and their families' lives; it can cause familial conflicts⁴ and lead to social, economic, and emotional consequences.⁵ Evidence shows that being diagnosed with cancer makes women prone to harassment.⁶ Women's weakness following the disease and surgery can lead to poor sexual function, in turn potentially paving the way for intimate partner violence (IPV), such as sexual violence.⁷ IPV is a type of interpersonal violence⁸ and a more pervasive than domestic violence.⁹ According to World Health Organization (WHO) definition, IPV refers to any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship.¹⁰ Any form of violence against women such as IPV is a systematic and important social event that should be considered.^11,12

Chronic disease of one partner is among the factors leading to IPV.13, 14, 15 Among women's cancers, due to the role of the breasts in femininity and breast function, breast cancer is of great significance due to its effect on sexual relations and sexuality.¹⁶ These women have problems in their familial relationships during treatment due to a lack of energy or not receiving the necessary support.¹⁷ These factors lead to a higher chance of experiencing IPV compared with other cancers.¹³ Although disclosure of partner violence is often difficult because it is a taboo topic and often considered a “private” matter,¹⁸ the prevalence of IPV among Iranian breast cancer women was reported 90% ¹⁹. Sexual violence is common among mastectomized Iranian women.²⁰

Breast cancer is different from any other cancer and creates lots of challenges in women's lives, especially losing breasts in some patients with breast cancer is a traumatic process for them.²¹ Some patients with cancer may suffer from stigma, shame, depression, anxiety, and anger. Those with the disease often experience stigmatization. Internalization of stigma leads to blaming.²² Studies have confirmed that breast, lung, colorectal, and patients with prostate cancer have the potential to experience blame.22, 23, 24, 25, 26 The nature of blame in different sociocultural contexts is controversial.²⁷

Blaming is a moral judgment that has a cognitive and a social nature. In the cognitive aspect, people make judgments through consideration of causality, intentionality, and mental states. It is worth mentioning that people blame intentional and unintentional events in distinct ways and consider justifying reasons for intentional events, while they consider prevention obligation and prevention capacity for unintentional events.²⁸ Consequently, patients whose diseases might have a relationship with behavioral causes are more vulnerable when experiencing or perceiving stigma and are more likely to experience blaming; for instance, in patients with lung cancer, blaming due to smoking is common.²⁹ The perception of blame among patients with breast cancer has shown in several studies.^24,30, 31, 32, 33, 34 Blaming is a less adaptive strategy that women diagnosed with breast cancer may use. Patients may blame themselves or others for their cancer.³⁵ Self-blame refers to thoughts of blaming oneself for what one has experienced, blaming others refers to thoughts of putting the blame for what one has experienced on others.³⁶ Self-blame in patients with breast cancer has two types, behavioral (resulting from behavior) and characterological (resulting from personal traits that cannot be changed). More than half of the patients with breast cancer reported behavioral self-blame (56.3%) or characterological self-blame (62.3%).^24,30 There are many studies on the causes of different types of cancer in the current body of knowledge.³⁷ However, it is recommended that psychological and personal issues related to cancer should be considered to achieve a deeper and social context-based understanding of treating and coping with cancer.³⁸

Based on the evidence, blaming is a complex mechanism which is used by women with breast cancer to adjust with their disease and treatments. There are different quantitative and qualitative studies in this area; however, the essence of blaming in breast cancer women with abusive partner is not still clear. Therefore, authors decided to explore lived experiences of breast cancer women subjected to IPV about “blaming” by Van Manen's hermeneutic phenomenological approach. The research question in this study is “What are the blaming lived experiences of women with breast cancer subjected to IPV?”

Methods

Study design

To investigate the blaming experiences of patients with breast cancer subjected to IPV, six steps of Van Manen's hermeneutic phenomenological method³⁹ (Table 1) were used to explore blaming which is a multidimensional and complex concept that depends on context, personality, and culture.²⁸ Using hermeneutic phenomenology provides deeper insight into gender and victimology researches.⁴⁰ Moreover, the hermeneutic phenomenological method constitutes rigorous and consistent processes of the ethical dimensions of the daily experience, which are difficult to be accessed by other usual research methods.⁴¹ Since the research team aimed to assess experiences of blame in an abusive relationship of patients with breast cancer, hermeneutic phenomenology was utilized to determine the experiences.

Table 1.

Application of Van Manen's six step approach.

Six methodological steps proposed by Van Manen (1990)	Researcher's activity in study
Turning to the nature of phenomena	Thinking and writing pre-assumptions about blaming in woman who have breast cancer and subjected to intimate partner violence (these where the result of working of first author as a oncology nurse), formulating the phenomenological question
Investigating experiences as we live it	In this step researcher concerned with performing in-depth interview and prolong engagement with participant to investigate the lived experiences
Reflecting on essential themes	Reflecting on the themes identified from the interviews, conducting thematic analysis through holistic and selective approach
Hermeneutic phenomenological writing	Writing transcript to make the participants' insights visible, writing about subthemes and themes, writing and rewriting to creating phenomenological text according to the participants' quotes.
Maintaining a strong and oriented relation to lived experiences	The researchers tried to remain focused on the research question by creating strong and deep relationship with text and main phenomenon.
Balancing the research context by considering parts and whole	Researcher attempt to make a balance in the field of linking whole and parts by constantly review of whole and parts through holistic and selective approaches and according to the main research question

Participants and setting

Nine women with breast cancer aged 40–60 with a mean age of 47.5 years were recruited into the study. Participants were selected using purposive sampling. Inclusion criteria were women with breast cancer (1) who were living with their partners at the time of cancer diagnosis, (2) all participants were aware of their cancer diagnosis and treatments, and (3) with at least 6 months since their cancer diagnosis. No limitation in the incidence age and grade of cancer was considered. The participants were, on average, in an abusive relationship for 23.4 years (x^∼ ​= ​23.4) (Table 2). This study was conducted in the oncology hospitals of Tabriz. Tabriz has the largest oncology center in northwest Iran. An intimate partner in this study means a person who is/was the current or former husband of participants. The study was approved by the ethics committee of Tabriz University of Medical Sciences. The initial interviews were conducted to identify women exposed to IPV based on questions of the Abuse Assessment Screen scale (AAS).⁴² Initial interviews were conducted in outpatient clinics or inpatient oncology centers where patients were referred for treatment or follow-up. The location and time of the main interview was determined according to the agreement of the researcher and the participant. Then, the researcher invited the eligible women to participate in the study after explaining the study objectives and receiving written consent. The interviews were conducted mainly in the consultation room of the oncology outpatient clinic. Two interviews took place at the participants' homes.

Table 2.

The participants’ demographic information.

Participants	Age, years	Duration of marital life	Duration of the disease (Years)	Type of surgery	Stage of cancer	Number of children	Patient's educational status	Husband's educational status
1	48	25	9	Mastectomy	Stage Ⅱ	2	Associate's degree	High school diploma
2	45	26	(Metastasis to the ovary) 11	Mastectomy	Stage Ⅳ	2	High school diploma	Associate's degree
3	50	34	3	Mastectomy	Stage Ⅱ	3	First grade of guidance school	High school diploma
4	60	45	(Metastasis to colon from a year before) 16	Mastectomy	Stage Ⅳ	2	Illiterate	Illiterate
5	50	25	1	Mastectomy	Stage Ⅲ	2	5th grade of primary school	5th grade of primary school
6	41	13	2	Mastectomy	Stage Ⅱ	1	Bachelor's degree	Bachelor's degree
7	47	15	7 (months)	Mastectomy	Stage Ⅳ	1	5th grade of primary school	5th grade of primary school
8	40	10	2	Lumpectomy	Stage Ⅰ	1	Bachelor's degree	Bachelor's degree
9	44	18	3	Mastectomy	Stage Ⅲ	3	High school diploma	Bachelor's degree

Data collection

Semi-structured individual in-depth face-to-face interviews were conducted at places where the participants were comfortable. All the interviews were recorded as audio files and were transcribed by the researcher. Also, the participants were assured about the confidentiality of the interviews. The average interview duration was 45 ​min. Six interviews were conducted at outpatient cancer centers and three at patients’ homes. Only one participant was interviewed twice. The interviews were conducted from November 2021 until April 2022. Data saturation was occurred after interviewing 7 participants when no new data emerged within a category, and its characteristics and relations had been identified. Two more interviews were conducted for further certainty. Sample interview questions are presented in Table 3.

Table 3.

List of interview questions.

What kinds of treatments have you had?

Can you tell me a little about your relationship with your partner?

How is your partner reaction to diagnosis of your disease?

How your disease impact on your relationship with your partner?

Which behavior of your partner annoyances you after illness?

At the end of the interviews, the participants were asked to express any further opinions they might have.

Data analysis

Data analysis began after each interview was conducted, recorded, and transcribed. MAXQDA20 software was used for data management. The data were analyzed using the holistic and selective approach of Van Manen's thematic analysis.43 Based on holistic approach, interview text was reviewed several times and overall meaning of the text was considered. Through selective approach, thematic statements that appeared in the text to illuminate the essence of the phenomenon were selected. Formulated statements were then categorized, leading to the extraction of themes and subthemes. This process continued until the main theme hidden in the lived stories of the participants emerged.

The findings were provided to the participants to receive their feedback.

Rigor To strengthen the rigor, Guba’s criteria (credibility, confirmability, dependability, and transferability) were applied.⁴⁴ To enhance credibility, the researcher has prolonged engagement and trust-based communication with the participants, and also asked participants to review their transcripts and offer additional perspectives. Dependability was increased through using documentation. To achieve transferability, the researcher attempted to provide a clear description of the process of data collection and analysis, the findings in rich detail and the characteristics of the participants. We employed external audit as a tool to enhance the conformability of the findings. All members of the research team approved the data analysis process and final extracted themes.

Ethical considerations

Tabriz University of Medical Sciences ethics committee approved this study (IRB No. IR.TBZMED.REC.1400.842). A system of coding was used to keeping participant's identity and information confidential. All participants provided signed consent form.

Results

Main theme

Based on Van Manen's holistic and selective analysis⁴³ performed by the research team, one main theme with three subthemes were identified: “blaming as a shifting cognitive judgment” which included subthemes of patient blaming partner, partner blaming patient, and self-blame (Table 4).

Table 4.

Experiences of breast cancer women subjected to intimate partner violence of blaming.

Main theme	Subthemes	Categories
Blaming as a shifting cognitive judgment	Patient blaming partner	Psychological violence Physical violence Economic violence
	Partner blaming patient	Stigmatization Disrupted self-concept
	Self-blame	Feeling of guilt Acceptance of blame Frustration

The participants' experiences showed that living with an abusive partner and suffering from cancer puts a lot of psychological pressure on this population of women, which leads to shift their cognitive judgment to blaming. This results are described by quotations.

Subtheme 1: Patient blaming partner

According to the participants' experiences, women who had lived with abusive partners for years believed that psychological pressures and stress resulting from their partners' misbehavior had gradually led to the development of their breast cancer. For instance, one of the participants who had lived with her non-supportive partner for 25 years said, ‘He did not care about anything (food, clothing, the future, etc.) from the day we started our life together. I lived a stressful life. Stress made me ill. I handled my son's disease alone. I even remember one they called and reminded me of the doctor's appointment. It cost one million Toman each time I went there. My friend asked me ‘Were you supposed to take your child to the doctor?’ and I said I could not afford it. Ten minutes later, she called and said her partner would transfer money to my account to take the child to the doctor. These things have led …. actually … (Choking with tears); when I talk about it my face gets numb. He never supported me during my illness.’

Another participant, who had gotten married at 16 and lived with her suspicious partner for 34 years, believed that her partner's constant controlling behavior, the limitations he had created, and his physical violence were the causes of her disease. She described, ‘I was 16; he used to always wake me up and ask me why I had looked at someone. Then he beat me. When someone wakes you up like that, you are terrified. Once he woke me up, tied me up, and hit me. I have been terrified like that a lot; I think this is the cause of my disease. I say to myself why should every misfortune happen to me; why haven't my sisters-in-law experienced this kind of problem; they are healthy because their partners are good; mine hurts me. It is not only my breast; I also have goiter and I have had coronary angiography. All of these happened because of the stress he caused. I cannot go out, so I am always at home, and when you are at home for a long time, you begin having unsettling thoughts.'

They even believed that their partners’ suspicious behaviors had caused to metastasis of cancer. One participant noted: ‘Since (the month of) Ordibebesht when my disease relapsed, his behavior has become much worse. He came into the room grabbed me by the throat, threw me on the ground, dragged me by my hair, and hit me on the head; my daughter stopped him with a lot of effort. I wanted to escape through the window, and when I climbed down, I slipped and fell on the hard floor of the basement. My brothers came over and took me to the hospital. They called the cops. I stayed with my mother for the next month. I had pain in my liver, and when I went for an ultrasound, they realized there was something in my liver.'

Another example of a patient who believes that her partner's controlling behaviors have caused her illness described, ‘He had a bad temper from the beginning, and I had gotten used to it. The doctor says that you should ignore it. I do not have freedom and it is not possible for me not to care. For example, I cannot just get up and go somewhere to have a good time. He tells me wherever I go I must go with him and come back with him. I have not been to my mother's for 5 or 6 years. No one has come to our house, and we have not gone to anyone's house. We used to go to our parent's neighborhood and see them, but I could not see my siblings. That is why I was always stressed. Eventually, this stress defeated me.'

Another problem the participants mentioned was that living with a constant fear of physical violence had led to diseases in them and their children: ‘I swear to Hadrat Zaynab that it was him that made me ill. He hit me so hard that I was dizzy for two days. Fear made me like this. My children became ill because of fear. Fear of what? Whenever he came home, we were afraid because he was always angry. He hit me for no reason. He hit us when we were just sitting there and not doing anything.

Another participant believed that the pain and sorrow resulting from her partner's apathy and stinginess were the causes of her disease: ‘He does not respect me. When I ask him for something, he says he will buy it, but I should wait. I would have died if it was not for the people around me. My mother-in-law interfered a lot. He did not give me money. They do not respect women. I believe that sadness makes you this way. My partner said it was because of milk congestion; doctors mentioned other causes, but I believe sadness and greed make you ill. I do not know anything about milk congestion or other causes; they are lies.

Some participants experienced psychological violence for years due to being ignored and not being accepted as independent people who were not even allowed to leave the house alone; some had constant fears of being assaulted for false reasons or no reason at all. Several participants were subjected to physical violence sometimes accompanied by sexual violence by their partners before the disease until its relapse. Participants reported that they were also economically restricted by their partners and were not even allowed to buy medicine for headaches. They were not financially provided for by their partners.

Subtheme 2: Partner blaming patient

In some cases, participants reported that their partners blamed them and told them that their behaviors such as idealism, tendency to help others, obsessive behaviors, and unnecessary stress had led to their current condition. For instance, one of the participants provided for her family by herself, despite having a partner. She was accused by her partner of being an idealist who put herself under a lot of stress. ‘He tells me that I am the cause of my illness. Who likes chemotherapy? Chemotherapy is so difficult. Even if I have a headache, he says it is your fault. He says ‘do not think about everything. For example, he says ‘do not buy this rug for the house and do not think about it. I cannot do this. My daughter is engaged, and I always think about the expenses of her marriage. My partner says ‘take it easy so you won't be stressed.’

Another participant has a partner who does not believe in medical treatments and has delayed the diagnosis and treatment. This led to metastasis to the ovary for the participant. However, the partner considers chemical drugs as the cause of his wife's cancer. ‘Before this condition, I went to the health center. They said I should examine my breasts. I went home and realized there is something in them. I told my partner, but he did not pay attention. He said it was nothing. He said all women experience this after the nursing period. If we get sick, he says he does not believe in doctors; he says doctors worsen the pain. He says you take drugs like candy, and you are like this because of all the medicine you take.’

Another participant from a rural area had been living with a hypersexual partner and was forced to have unwanted sex all the time; this made her hate having sex, and her partner accused her of being obsessive. ‘He forced me to have sex even the night I had my baby; I got blood all over my body, and I went to wash myself in the spring the day I gave birth. I was furious and full of hatred, but I could not do anything. He always tells me I am obsessive and I have cancer because I stay in the water a lot. He blames me and tells my children to bring me food separately because I have cancer.’

Some participants stated that after they were diagnosed with cancer, their partners questioned their personalities and behaviors to justify their violent behavior and blame them for having cancer. For instance, partners accused participants of being dishonest, obsessive, idealistic, or oversensitive regarding their health. These labels disrupt patients’ self-concepts, which in turn leads to self-blame.

Subtheme 3: Self-blame

It seems that women who live with partners who blame them for a long time are affected by their suggestions and gradually accept that they have played an indirect role in the development of their disease. Consequently, they feel guilty and blame themselves for their partners’ abusive behavior and blaming.

For example, one participant, who worked in a hospital and had lived with her nonsupportive partner for years and provided for her family of four by herself, stated: ‘My mood changed significantly after the disease. I became impatient and I cannot tolerate things like before. I feel I have caused problems. I think this disease causes 30% of my partner's behaviors, and I am the cause of all the problems because I have regressed physically, sexually, and even financially. Since I started chemotherapy and during the last ten years, we have had sex five times. In the beginning, the doctor said we should be careful; it was physically painful for me, and I felt my partner was getting distant. He is a man after all; his mood changed.’

Another participant who had lived with her paranoid partner for years expressed her experience of self-blame as follows: ‘My partner hated divorce from the beginning. He says there must be honesty instead of divorce. I keep thinking if we had not talked about my previous lover before we got married, he would not have become so suspicious and annoyed me so much that I would get cancer. If I had gotten divorced when I left and went back to my mother's, and if had not tolerated him because of my children, I would be healthy now.’

Another participant stated that: ‘He had a bad temper from the beginning; I had gotten used to it. I am a timid person and do not talk back. I talk to myself, because I was conditioned like this from the beginning, and I had not said anything or stood up to him; I have always been ashamed and thought that this has caused me pain. Then I say it is fine; this is life. I say his bad temper might be due to our financial problems. My treatment costs have increased. After four sessions of chemotherapy, they said I should go to radiation therapy. I have had 16 or 21 radiation therapy sessions so far. Once every three months, I go to a doctor and say to myself I might have caused my disease. I have stored my pain in myself and have not opened up to anyone. Now, I have cancer, and it has caused a lot of costs for my partner.’

The participants experienced a feeling of guilt in the first stage. The psychological and physical decline resulting from cancer treatments, additional costs imposed on their partners, and some behaviors such as being timid and/or not being able to stand up to their partners' violence are factors that they mentioned as leading to spouse violence. In the next stage, these women accepted that their partners’ misbehavior is associated with their personality traits or physical and psychological changes. As a result, they felt frustrated (Fig. 1).

Fig. 1.

Subthemes of blaming as a shifting cognitive judgment.

Discussion

The lived experiences of women with breast cancer showed that they experienced blaming as a ‘shifting cognitive judgment’ in three forms of patient blaming partner, partner blaming patient, and self-blame. In this study, participants believed that their partners created negative feelings such as stress, fear, anger, and hatred in them and should be blamed for the development of cancer; this theme was labeled as ‘patient blaming partner.”

According to cognitive theories of blame, blame is essentially a judgment or evaluation that people make about an agent considering their actions, attitudes, or personality.²⁷ Psychological adjustment to threatening life events, such as confronting breast cancer diagnosis, is influenced by cognitive judgment of the events.²⁴ Cognitive appraisals or how a person views a situation have been conceptualized as a precursor to coping with a stressor.⁴⁵ Because of the aversive and unpredictable nature of the disease, patients with cancer may search for a cause or reason for their diagnosis.⁴⁶ Evidence shows that women diagnosed with breast cancer reported more frequent use of maladaptive cognitive emotion regulation strategies such as self-blame and blaming others which can lead to maladaptive behaviors and are not conducive to patient rehabilitation.³⁶

Couples may react as a unit, not as individuals when facing cancer.⁴⁷ Therefore, cancer is considered an ‘our’ disease.⁴⁸ When one member of a couple gets cancer, stressors such as stressful relationship patterns, conflicts in roles, responsibilities, sexual function, and self-concept affect both of them,⁴⁸ and their romantic relationship is influenced by cancer.⁴⁹ Consequently, relationships of patients with cancer with their partners are of great importance since these patients consider their partners as their main source of support. Support can include positive behaviors (eg., encouraging the patient) or negative behaviors (eg., blaming and criticizing the patient).⁴⁸ When couples try to cope with the stressors associated with cancer, they may suffer from latent blaming, which can threaten their psychological adjustment and increase their distress. Blaming led to higher distress in those who experienced lower dyadic adjustment.²⁹ In these conditions, anxious couples reach a dead end in their interactions, and mutual blaming and accusation occur in couples who experience higher levels of distress.⁴⁹ Accordingly, considering the nature of the disease and its negative impacts on couples’ relationships, it seems that mutual blaming is a common coping mechanism in these couples. This can be the case, especially in cancers like breast cancer, which create sexual concerns about disease effects on the intimate relationships of the survivors.⁵⁰

The participants of this study had all experienced living with an abusive partner. They considered specific types of IPV in their partners’ behavior leading to their cancer development and blamed their partners for their cancer. It seems that the blaming of an abusive partner by the patient is a common response in cancer. Evidence shows that searching for reasons of the disease is a natural reaction to being diagnosed with cancer, and one of the main ‘reason’ identified by patients with cancer is to blame oneself or others.²¹ Negative occurrences such as diseases are attributed to external factors (eg., lifestyle), and positive ones such as health are attributed to internal factors.⁵¹ Naturally, in stressful situations, people tend to unconsciously look for the reasons to reduce their fears and uncertainty.³⁸

In the process of coping with cancer, patients enter the stage of anger, which follows denial. The most common question asked in this stage is ‘Why me?’ In this stage, patients start looking for reasons and might blame themselves or others for what has happened to them.²¹ The association between stress and cancer is in line with some scientific evidence. There is an extensive and strong theory about the effects of psychological processes and unknown physical processes on the development of cancer.²⁹ However, stress is an imminent risk factor with a negative effect on the nervous, endocrine, and immune systems.⁵² The extra pressure of stress and sadness can lead to high chances of inflammation and neoplasia in any anatomic system of the body.⁵³ Chen et al claimed that there is a direct relationship between stressful events and cancer development.⁵⁰ However, some researchers claim that there is no relationship between chronic stress and breast cancer.^54,55

The interpretation of the results of this study also indicates that there can be a connection between the women's personality traits and the incidence of breast cancer. The results of several studies confirm this relationship.^51,56, 57, 58 However, some studies have rejected the relationship between personality traits and cancer.⁵⁹ The present study clarifies that ‘mutual blaming’ can exist in violent relationships of couples which one of them has cancer and has many psychological consequences. Therefore, it is suggested to be considered in psychological intervention programs.

The findings indicated that blaming patients disrupts their self-concept. Patients with breast cancer usually experience a negative self-concept because they may think they have lost their familial roles as women and cannot take care of their families due to the disease.⁶⁰ A change in the self-concept is one of the most common and destructive changes. Patients with a disrupted self-concept tend to blame themselves.⁶¹ The experiences of the participants in the present study also indicated that patients begin to blame themselves due to their spouses' blaming them and the changes in their self-concept. They gradually start to feel guilty that their behaviors may have led to their spouses' misbehavior and in turn created stress and led to the development of cancer. Patients give in to their spouses' blaming and accept that their behavior and personality are the sources of all problems. As a result, they eventually feel frustrated. Self-blame can affect cancer patients' treatment preferences and the type of treatments they follow or reject.³⁸ In cases of IPV, when the victim is believed to have the ability to control the situation, they are usually blamed and are expected to be accountable for their situation, when the situation is out of the victim's control, they might not be deemed worthy of being sacrificed and this may lead to sympathy.³⁸ These women are reproached not only by their spouses but also by their relatives who believe they could have controlled the situation and avoided IPV and stress. For example, one participant's daughter, instead of sympathizing with her, blamed her mother for being timid and not standing up to her father; this led to a feeling of guilt for the participant. Women with breast cancer may feel guilty when diagnosed or even years after it.⁶² Feeling guilty can lead to frustration, loss of control, and sorrow in cancer patients.⁶³ Finding of the current study confirms these feelings. There is also a chance that some women do not leave an abusive relationship because they blame themselves for their partners' insulting behavior,⁶⁴ which can increase feelings of guilt, shame, and self-blame.⁵⁶ Most participants of this study could not leave their abusive partners for several reasons, such as their children, and they felt that they had to tolerate their partners' abuse. This would later lead to self-blame, for example, thinking that they would not have had cancer if they had left their partner and not submitted to the stress caused by their partner's abusive behavior. The findings indicated that women with breast cancer began to blame themselves because they accepted their partners' blaming, gradually becoming frustrated. Sachdeva supports these findings; frustration can be due to numerous reasons, such as unmet needs, fear of failure in treatment, and low quality of life.⁶⁵ Frustration is a complex feeling that can lead to many consequences. On occasions, patients stop self-care or even treatment due to frustration. Frustration often leads to depression and strong feelings of anger.⁶⁶

Therefore, due to the significance of the breasts and their functions in intimate and romantic relationships, providing couple-centered and patient-centered care instead of disease-centered care is necessary in planning intervention programs for patients with breast cancer, especially those who feel trapped in an abusive relationship. Vulnerability of patients with cancer due to the emotional distress they experience highlights the importance of a comprehensive individual and human-centered approach.⁶⁷ Effective cancer management is achieved when a multidisciplinary team exists – a team containing proficient nurses who play a key role.⁶⁸ Nurses are an essential part of this efficient multidisciplinary team because nurses often spend more time with patients than other healthcare providers.⁶⁹ Therefore, oncology nurses (both in-patient and out-patient), as well as nurses in community-based primary care can encourage patients to express their concerns and psychological stress during healthcare provision by being aware of the different types of psychological distress that patients with breast cancer may experience so that these patients are screened and followed up effectively. Furthermore, due to their close and long-term contact with patients with cancer, oncology nurses can help nursing researchers by sharing their experiences of these patients’ stressful lives.

Limitations

The limitation of this study was that the participants were mostly middle-aged women with breast cancer whose experiences might not reflect those of other ages of women (women less than 40 and elderly women) with breast cancer who are subjected to IPV.

Conclusions

Women with breast cancer who are simultaneously subjected to partner violence undergo changes in cognitive judgments that could lead to the experience of partners mutual blaming and the patients self-blame. Blaming oneself or others for a disease can have adverse psychological effects on patients and partners interactions. Therefore, vulnerable people such as breast cancer women experiencing IPV or those with life-threatening conditions and their partners must be identified as soon as possible and provided with psychological services to be able to cope with stressful situations. Also, due to the knowledge gap regarding the role of chronic stress in the development of cancer, more extensive studies are needed to enable healthcare providers to support patients with cancer and their families by comprehensive preventive interventions.

CRediT author statement

Leila Sheikhnezhad: Conceptualization, methodology, data curation, formal analysis, writing original draft. Hadi Hassankhani: Conceptualization, methodology, formal analysis, reviewing and editing. Erika Metzler Sawin: Methodology, reviewing and editing, supervision. Zohre Sanaat: Reviewing and editing. Mohammad Hasan Sahebihagh: Conceptualization, methodology, formal analysis, reviewing and editing, project administration. All authors had full access to all the data in the study, and the corresponding author had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Declaration of competing interest

The authors declare no conflict of interest.

Funding

This project was supported by the deputy of research of Tabriz University of Medical Sciences. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Ethics statement

This study was approved by Tabriz University of Medical Sciences ethics committee (IRB No. IR.TBZMED.REC.1400.842). All participants provided signed consent form.

Data availability statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical restrictions.