From Love and Fidelity to Infidelity- Individual Experiences of Women with Breast Cancer Regarding Relationships with Their Spouses

Abstract

Background and Objective:

Breast cancer and its treatment processes not only involve the patients but also their spouses and can impact on mutual relationships. Spouses of women with breast cancer may experience devastating consequences of the disease in their marital and sexual relationships. Therefore, in the present study we aimed to investigate individual experiences of women with breast cancer in their relationships with their spouses.

Materials and Methods:

This was a qualitative study with a conventional approach to content analysis. A purposive sampling method was used to select 12 patients with breast cancer visiting the Chemotherapy Clinic in Zabol in 2016. Semi-structured interviews were employed for data collection. Data trustworthiness was checked and data were analyzed based on the steps proposed by Graneheim and Lundman. Ethical issues were considered.

Results:

Three main categories and ten sub-categories were extracted. The three main categories were surrounded by misery, from emotional to practical companionship and influencebeing imposed upon someone else.

Conclusion:

The findings showed paradoxical experiences of the women under study ranging from love and fidelity to infidelity. This indicates that some spouses do not adequately support for their sick wives. Therefore, health professionals should provide support, guidance and training for couples, including sex therapy and counseling services, so that spouses can better support their wives.

Introduction

Breast cancer is the most common type of cancer among women around the world (Torre et al., 2017). Breast cancer is the most common type of cancer in Iranian women (Hosseinzadeh et al., 2014). Onset of breast cancer in Iran is at least one decade younger than developed countries(Afsharfard et al., 2013). Since the breast is a symbol of beauty, motherhood and sexual attractiveness, breast deformity or removal (mastectomy) has adverse consequences in sexual relationships of the couples(Khajehaminian et al., 2014). The patients foster a negative body image. It is very difficult to describe feelings of a person who loses one or both breasts. This is because mastectomy is the end of femininity. A woman with breast cancer probably avoids intimacy with other people. She may also avoid taking a shower due to her disfigurement (Bagheri and Mazaheri, 2015). In addition to psychological disorders, these patients suffer from marital dissatisfaction and weak relationship with their spouse (Shareh, 2016). Various studies have shown that the women undergoing mastectomy due to breast cancer are less willing to have a sexual relationship with their spouse (Jassim and Whitford, 2014; Yusuf et al., 2013). In other words, diagnosis and treatment of breast cancer affect not only the patients, but also the spouses(Kim et al., 2015). It is essential that the nurses as a supporter of patients understand the patients’ experiences during treatment and recovery (Blais et al., 2014). Therefore, nurses should be aware of the patients’ feelings to help women with breast cancer and their families, so that they can cope with the disease (Manne et al., 2014). Although spouses of women with breast cancer are more important than other family members for the patient (Rhibna Neris and Yokoyama dos Anjos, 2014), the spouses and their problems with their ill partners were rarely studied (Nekoueifard and Jahangiry, 2014). On one hand, successful support and caring for the patients require a comprehensive understanding of problems of those people experienced this case (Elahi et al., 2015). On the other hand, quantitative methods cannot be used to study this case-scenario. A qualitative method should be used to describe experiences of the participants by understanding their emotions and listening to them. Therefore, the author aimed to explain experiences of women with breast cancer in their relationships with the spouses using content analysis. Hopefully, the study depict a unique image of human experiences to help the treatment team to implement health care strategies.

Materials and Methods

This was a qualitative study with a conventional approach to content analysis. Experiences of 12 women with breast cancer were investigated in their relationships with the spouse. The statistical population consisted of women with breast cancer visiting the Chemotherapy Clinic in Zabol. The participants were selected using a purposive sampling method. The research location was the Chemotherapy Clinic of Imam Khomeini Hospital in Zabol. The participants consented to participate in the study. Sampling was continued until data saturation. Criterion for data saturation was failure to achieve new concepts and codes in subsequent interviews. Face to face In-depth semi-structured (HNS) interviews with open-ended questions were used for data collection at every morning. Some of these questions are given here. “Talk about your experiences when you were notified of breast cancer? How did your spouse react when he was notified of your disease? How much your private life has been affected?”.

The interviewer author had training before start the formal interview. The author was impartial during the interviews and allowed the participants to express their emotions. Probing questions were also used if necessary. In this research, the interviewer visited the research location and invited those patients with breast cancer who were willing to participate in the study. Objective of the study was explained to them. The interviews were performed in a relaxed environment. The interviews lasted from 45 to 60 minutes based on conditions and mood of the participants. We had not repeat interviews. All interviews were recorded by the author, typed word by word, reviewed, coded and immediately analyzed. In fact, data collection and analysis were carried out simultaneously and continuously. The collected data were analyzed using a conventional approach to content analysis. Each interview was carefully read to fully understand the content. Important statements were underlined and coded (primary coding). The participants’ own words were used for initial coding and perceptions of the author were used for implicit codes. Then, the codes with identical concepts were isolated to reveal the content. These codes were categorized as singular categories and sub-categories. The collected data were analyzed according to the steps proposed by Graneheim and Lundman (Graneheim and Lundman, 2004). NVivo software used for data management.

The text of the coded interviews was given to the participants for credibility of the findings. The text were confirmed by the participants and matched with their experiences. The text was revised in some cases. Resulting codes and concepts were assessed and consulted with research experts and colleagues to achieve dependability. Several colleagues were asked to recode some parts of the text of the interviews. Then, the codes were matched to confirm transferability. The patients with different demographic characteristics and experiences were included in the study. The author measured all aspects of true behavior, events and experiences. The author fully explained all phases of the study to achieve confirmability. In addition, details of the research were carefully documented to provide an opportunity for external supervisors to evaluate the study. Ethical principles in the research were letter of introduction, informed consent of the participants to record the interview, confidentiality and willingness to quit the study at any time.

Results

Individual characteristics of the participants are presented in Table 1. Analysis of collected data revealed three main categories including 2 category and 10 sub category (Table 2).

Table 1.

Demographic Characteristics of Women with Breast Cancer

	Number	Percent
Age
>40	9	75
40-50	3	25
Range	28-47
Mean (standard deviation)	36(±6)
Marital status
Married	10	83
Divorced	2	16
Education
Primary school	7	58
Diploma	3	25
Academic	2	16
Occupation
Housewife	12	100
Treatment type
Surgery-chemotherapy	8	66
Surgery-radiotherapy-chemotherapy	4	33

Table 2.

Main Categories and Sub-Categories Extracted from Data Analysis

Sub-category	Category	Main category (theme of categories)
Rejected Helplessness Spiritual companionship Spiritual meditation Sexual tolerance Companionship	Support	From love and fidelity to infidelity
Burden of caring on the spouse Fear of losing the spouse Dissatisfaction of the spouse Sexual dysfunction	Being imposed upon someone else

A: Support

Experiences of women with breast cancer revealed that many of them felt that they had been mistreated by their spouse. Examples of mistreatment are being rejected and helpless.

Being rejected

A review of the experiences of women with breast cancer revealed that some women with cancer were mistreated by their spouse. Their husbands also threatened to divorce them. Their spouses did not accompany their wives during treatment process. The women were rejected and given divorce demand letter by their husbands at the time they needed their husbands most.

“My husband was absent in the first day I underwent chemotherapy, I’d love him to be there and encourage me but my husband get mad when I tell him to take me to chemotherapy. He says it is not my business to look after you. Tell your mother, father, brother or sister to take you to chemotherapy.” (35-year old woman undergoing chemotherapy).

Helplessness

A review of experiences of women with breast cancer revealed that many of them were given negative feedback such as bitterness, misunderstanding and lack companionship, dodging responsibility and boredom that implies helplessness and lack of support. However, they need to be supported by their spouse. Many of them are mistreated and rejected by family of their spouse. The mother-in-law often encourage his son to divorce his wife and dishearten her daughter-in-law. These factors intensify helplessness of the women by two-fold.

“My husband is a driver. He does not have time to take care of me, but I realized that he does not want to look after me even when he is free. He says I’m tired, I don’t have time for you. I don’t want to be your beck and call every time you desire. I have my own life. He frustrates me (35-year old women undergoing chemotherapy)

Spiritual companionship

Experiences of women with breast cancer revealed that they were spiritually accompanied by their spouse. They were given emotional support. Their spouses ignored aggression of their wives. They showed that were satisfied with their wives. The women were heartened by their husbands.

One of the patients with breast cancer mentioned that her husband dealt with her nervous condition as follows.

“My husband is attentive all the time, he was at my side at all phases of the disease. He did not leave me alone. He did not complain and ignored my madness, even when I’m angry most of the time, especially when I have recently underwent a chemotherapy session, my husband tolerate me and do not get tired of me” (36-year-old woman undergoing mastectomy)

Spiritual Meditation

Experiences of women with breast cancer revealed that they are mentally meditated by their husbands. Their spouse have kept the disease a secret, so that their wives would not lose themselves to the disease and get distressed. The spouses shoulder the burden of the disease themselves.

One of the patients with breast cancer stated: “My husband knew everything. The physician had told him everything from the beginning but he did not reveal anything, so that I would not guess anything. Maybe he thought that I would lose myself, so he kept everything a secret” (37-year-old woman undergoing chemotherapy)

Sexual tolerance of the spouse

Experiences of women with breast cancer revealed that some spouses less demand sex since they understand their wives and do not want to disturb their wives in their illness. In other words, they cope with these new conditions.

One of the patients with breast cancer stated: “My husband is very kind and does not demand sex because he thinks that I cannot do it and I will be frustrated if he persists (37-year-old woman undergoing chemotherapy).

Companionship

Experiences of women with breast cancer revealed that they have witnessed companionship of their husbands in the treatment process. Their spouse cooperated in the treatment of patients and tolerated reduction in usual capabilities of their wives. They met all wishes of their wives in the treatment process and gave their wives great emotional and financial support.

One of the patients with breast cancer stated: “No one supported me during my illness like my husband. He was my only companion in years of illness. I was completely satisfied with him. I was inundated with his love and kindness. No one loved me as him. He wrapped me up in a blanket, hugged me and took me to chemotherapy. After the chemotherapy, I was too tired to get out of bed and go to toilet. So, he gave me toilet container and washed me himself. He always told me, just be with me at home, don’t do anything, just stay with me” (47-year-old housewife)

B: Feeling imposed upon someone else

Experiences of women with breast cancer revealed that the disease has imposed huge burdens both on the patient and her spouse. This feeling involves heavy burden of caring for the wife on the spouse, fear of losing his wife, dissatisfaction of the spouse and sexual dysfunction.

Heavy burden of caring on the spouse

Experiences of women with breast cancer revealed that huge burdens are imposed on the spouse due to taking care of the patients such as new living conditions, excessive job pressures, tiredness from doing housewife duties and the patient’s disability to do her duties.

One of the patients with breast cancer stated: “My husband only worked outside home and did not do anything at home before my illness. He did not bother with preparing anything for breakfast, lunch and dinner. But now my husband do everything since I’m taking chemotherapy drugs and cannot do anything. He look after the kids and the home. He cleans the dishes, prepare the kids for school, prepare food, etc., which makes him too tired and he would get mad sometimes” (36-year-old woman undergoing mastectomy).

Fear of losing the spouse

Many women with breast cancer are afraid that their husband would leave them, do not tolerate them and marry someone else.

One of the patients with breast cancer stated: “I’m always afraid that my husband will be influenced by others. I always thinks that I will lose my husband because I cannot look after my children, so I am anxious all the time” (35-year-old woman undergoing chemotherapy).

Dissatisfaction of the spouse

Experiences of women with breast cancer revealed that they are afraid of dissatisfaction of with their spouse because they cannot satisfy their husbands’ needs. They are afraid of being alone. They are afraid that they husbands are not happy in life. They are worried that they are no longer attractive and their husbands would not notice them.

One of the patients with breast cancer stated: “This illness is killing my husband because I cannot do anything at home. He gets upset when he sees me like this. He wishes that I was never affected by breast cancer. He sometimes complain about this disaster. He says that we were very happy. What has happened to us? He cannot tolerate the house without me taking care of everything. He cannot believe that I cannot do anything. He is very upset. This scares me” (36-year-old woman undergoing mastectomy)

Sexual dysfunction

Many women with breast cancer were dissatisfied with their inability to have sex with their spouses. They do not enjoy sex and were no longer interested in sex but they force themselves to do so to satisfy their husbands since they think they are obliged to do so. Some of them are frustrated, reluctant and do not get aroused due to chemotherapy, which make them hate having sex.

One of the patients with breast cancer stated: “Although I was frustrated, reluctant and disinterested in having sex due to my medications, I forced myself to have sex with my husband because I hated to dodge my responsibility and my conscience bothered me” (45-year-old housewife undergoing mastectomy)

Discussion

Experiences of women with breast cancer in relationships with their husbands showed that they all had no common experience. Some had unpleasant experiences and felt that their spouse had mistreated them, did not want to continue living with them and felt imposed on their husbands. However, some other had enjoyable experiences. They were satisfied with emotional and practical companionship of their husbands. It can be implied that experiences of these women can be described in a range from love and fidelity to infidelity.

Support

Rejection was one of the experiences of women with breast cancer, M and J (2011) also confirmed this feeling in patients with breast cancer and wrote that this feeling along with interpersonal problems such as decreased intimacy as stressors lead to depression and mental illness. Yusuf et al., (2013) also showed that women with breast cancer feel imperfect and unattractive due to breast removal (mastectomy) and are worried that their husbands would leave them.

Helplessness due to lack of husband’s support was also one of experiences of women with breast cancer. Luszczynska et al., (2007) also emphasized the importance of husband’s support. He wrote that cancer patients are permanently threatened by relapses, high-risk life and social-psychological-occupational changes. In this case, the spouse and his emotional support can help the patient to cope with the disease. Esmaeili et al., (2012) emphasized that support of the patient’s family and especially the spouse are the most important demand of the patients after diagnosis of cancer. Taleghani et al., (2006) also found out that support of relatives and particularly support of the spouse are important factors in coping of patients with the disease.

The results implied that studied women felt mistreated by their spouse because of rejection and helplessness. However, some studies suggest that husbands cannot accompany their wives in illness since they cannot cope with new situations. They love their wives but they cannot tolerate new conditions. Bigatti et al., (2011) studied spouses of wives with cancer. They showed that these spouses acquired high scores of depression and were less willing to use problem-oriented adaptive methods. Alacacioglu also wrote that large events like serious illness affects not only the patient but the whole family according to the system theory. Thereby, spouses of cancer patients deal with many problems including fatigue, sleep and eating disorders, mood disorders, communication and sexual problems, disturbance in work and lifestyle and low quality of life. They should support their wives in daily activities and take more responsibility for home and children (Alacacioglu et al., 2014). At the same time, they are not sure that they can support and care for their spouse. They are afraid of losing their spouse. Therefore, they need specific training on how to care for their spouse (Rhibna Neris and Yokoyama dos Anjos, 2014). Lin et al., (2013) confirmed this issue and wrote that women and men do not think alike in understanding needs of their sick partners. Usually, male caregivers less understand their spouse. Therefore, health professionals should pay more attention and help men to cope with the disease and tolerate suffering of their wives. According to these materials, a part of negative reactions of spouses of studied patients are caused by great unexpected problems and lack of necessary sources of support.

The present study showed that some women were satisfied with companionship of their spouse during the illness. They were mentally sponsored by their spouse and enjoyed their companionship during the treatment process. Probably, companion husbands raised positive feelings in the wives, which continued over treatment process. Li and Loke (2013) also reviewed 35 articles on positive aspects of caring for a cancer patient in a review paper and suggested that caregiver of cancer patients not only were self-satisfied, but also grow positively, received reward and experienced greater intimacy with their caregiver. Lin et al., (2013) Also studied experiences of male caregivers of cancer patients in a qualitative study. They showed that the husbands seek a happy life, commit to their responsibilities and continue to love each other despite great suffering (Li and Loke, 2013).

In the present study, spiritual companionship of some of the spouses was so great that the wives felt mentally meditated by their spouses. The spouses kept secret the disease, so that the wives would not be distressed, shoulder the burden of the disease alone and lose themselves to the disease. Esmaeili et al., (2012) also suggested that there is no consensus among various societies on how to inform the patients of cancer. In Iran, many cancer patients find their illness from different sources. Lashkarzadeh et al., (2012) believe that this issue stems from cultural norms, which imply that open and explicit discussion about diagnosis and prognosis of cancer is cruel. Agha Hosseini et al., (2010) also mentioned that eastern culture is family-centric. In this culture, family members may try to protect their family members from the disease by keeping it to themselves. Thereby, the family members sacrifice themselves by dividing stress of the disease among themselves and protect the patients from the disease. This result shows the necessity to hold meetings and conferences on time and style of disclosing cancer to the patients. In this regard, a unique protocol was introduced because it can prevent mental breakdown of the patients and their families.

Imposed upon someone else

Experiences of women with breast cancer revealed caring for patients has imposed huge burdens on the spouses due to such factors as dissatisfaction of the spouse with new living conditions, excessive job pressures, and tiredness from working inside and outside the home, patients’ incapability to do their tasks. Moradi et al., (2013)also confirmed this issue and showed that diagnosis of breast cancer has huge negative impacts on both wives and their husbands, Cancer as a psychological distress makes many change in emotional and sexual function and satisfaction. It also decreases quality of life. Spouses of women with breast cancer reported such symptoms as mental distress, changes in emotional and sexual satisfaction and function and decrease in quality of life (N et al., 2013). Duggleby et al., (2012) and Lopez et al., (2012) also showed that spouses of patients with breast cancer are the main caregiver and suffer from many physical, cognitive and psychological stresses.

In the present study, heavy burden of taking care of the wives underlie fear of dissatisfaction and losing the husbands. Therefore, the wives sought to satisfy their husbands. Lamiyan et al. studied the patients with breast cancer and showed that most of the participants were concerned about absence of their spouses (Lamyian et al., 2007).

In the present study, women were dissatisfied with their sexual dysfunction. They did not enjoy and were not interested in sex but they felt obliged and forced themselves to do so in order to satisfy their spouses. Sexual dysfunction in women with breast cancer was reported in several studies (Holzner et al., 2001; Khajehaminian et al., 2014). Jassim and Whitford (2014) also pointed out that some women with breast cancer force themselves to satisfy sexual needs of their husbands despite their low sexual desire because they are worried that their husbands would marry someone else (Shareh, 2016). Azizi et al., (2010) also reported low marital satisfaction and the need for sex therapy and counseling services in patients with cancer. Heydari et al., (2008) reported that married patients with cancer were satisfied with marital life and sexual relations. These confounding results are probably due to different cultural norms. However, the need for sex therapy and counseling for these couples was reported in all of these surveys in order to reduce sex-related problems caused by the disease.

A limitation of the study is that the results cannot be generalized to the entire population.

In conclusion, in this study, experiences of women in relationships with their spouses and their reactions were described in a range from love and fidelity to infidelity. In other words, all women do not have identical experiences. Some had pleasant experiences and mentioned emotional and practical accompaniment of their spouses but some other felt that they were rejected and helpless. Their spouses had mistreated them. They also felt that they were imposed upon their spouses because their husbands were dissatisfied with them due to heavy burden of caring for them and their sexual dysfunction. They were afraid of losing their husbands. However, review of related articles suggested that spouses of these patients suffered from many problems due to the disease and should be supported. Therefore, these men probably cannot cope with new conditions since they do not provide adequate support for their wives. This necessitates guidance, support and training for the spouses by health professionals. In addition, sex therapy and counseling can improve their sexual relationships.

Contribution of authors

Hagar Nouri Sancholi (HNS):

Design and implementation of research, data collection, data analysis, article editing.

Mozhgan Rahnama (MR):

Designing and implementation of research, data analysis, article compilation.

Hossein Shahdadi (HS):

Data Analysis.

Mahdieh Poodineh Moghaddam(MPM):

Data Analysis.

Blue A, Pink B, Green C, et al (2000). TITLE. Asian Pac J Cancer Prev, Volume, 322-4.

Conflict of interest

There is no conflict of interest between the authors.