Repair of the Threatened Feminine Identity

Experience of Women With Cervical Cancer Undergoing Fertility Preservation Surgery

Hiroko Komatsu, PhD, RN; Kaori Yagasaki, MSN, RN; Rie Shoda, RN; Younghui Chung, RN; Takashi Iwata, PhD, MD; Juri Sugiyama, MD; Takuma Fujii, PhD, MD

Disclosures

Cancer Nurs. 2014;37(1):75-82. 

In This Article

Results

"Fertility preservation repairs the threatened feminine identity in women with cervical cancer" emerged as a core category (Figure). Each stage of the formation, repair, and reconstruction process of the feminine identity was characterized by 3 aspects: awakening femininity, fertility preservation, and keeping open a window for hope. The whole process was influenced by external events and social interactions with others as "significant others" and "generalized others."

Figure.

Fertility preservation repairs the threatened feminine identity.

Before the Surgery

Cancer Diagnosis as an External Event. Applying the assumptions of symbolic interactionism to this study, interactions with events affect the meaning of fertility preservation. A diagnosis of cancer raises a woman's awareness of her own mortality and disturbs normative life expectations including reproduction and marriage. Future motherhood is threatened by the disease. Participants had to decide whether to maintain fertility by weighing risks against benefits (survival vs fertility preservation).

I did not realize that I might be dying. When my doctor said that it [fertility preservation] would not cause you to sacrifice your life, I realized I did not think about it at all. (No. 1 [married])

Identity Crisis: Awakening Femininity. The diagnosis of cancer challenged the women to think about their fertility, which shook the foundation of their feminine identity. A reflective process (self-interaction) occurred in women who were diagnosed with cervical cancer.

I had not thought about it [fertility] very deeply. But I was forced to think about it seriously. (No. 13 [married])

The possibility of removing the uterus by hysterectomy, which means losing fertility, increased anxiety in these women diagnosed with cervical cancer.

I felt insecure about the loss of the uterus rather than worrying about the surgery at that time. I didn't think I could bear a sense of loss of the uterus. (No. 2 [married])

Because the uterus is still a symbol of womanhood for many Japanese women, the loss of the uterus causes despair.

I thought it would be miserable if I lost my fertility. (No. 8 [single without partner])
I heard that I might have to undergo hysterectomy during the operation. What am I going to do if that happens? That's what I thought. (No. 12 [single without partner])

All women who chose radical trachelectomy wished to have children eventually, but it emerged that maintaining fertility in and of itself had significant meaning for a woman.

The ability to conceive… I believe I was 34 years old at that time. I strongly felt that removing the uterus at the age of 34 years was an issue for me as a woman. So I decided to undergo the surgery. (No. 10 [single with partner])
I have to accept it if I don't have any children in my life. However, it makes me wonder what I want to do as a woman. If I can keep it (the uterus), I want to keep it. (No. 13 [married])
Since the diagnosis, I was wondering which direction would make me happy. That's more important than bearing children or remaining childless. (No. 8 [single without partner])

The following statement clearly shows the difference between "infertile" and "presumably fertile" and the perception that the ability to conceive validates for the woman that she is not incomplete:

First of all, to become infertile and being presumably still fertile are completely different for me. (No. 8 [single without partner])
(When I look at children) I am afraid I could not bear it. Even a little hope is OK. It is much better if I have a little hope for childbearing, even though actually I have no children in my life. It is better to be dying while I still have the hope to have children someday. (No. 2 [married])

The quote below expresses what these women felt, specifically, the loss of confidence and lowered self-esteem, in comparison with healthy women:

I am afraid that no men would go out with me without the uterus. Also, I wonder if I really deserve to go out with a man if I have no uterus. I will have such feelings if I have no uterus. (No. 8 [single without partner])

Social Interactions. Feminine identity is also conceptualized by social interactions with others. How others see the woman and what others expect of her are also important.

Partner/Parents: The woman's partner and parents are her "significant others," and their beliefs and attitudes influence her decision making.

He told me that I could make the decision. Having a child is not everything in our life. He said that he would be with me in any case. (No. 15 [married])
In my case, my parents had a strong voice. My mother insisted that if fertility preservation surgery was available, certainly most women would choose it. (No. 7 [engaged])

Social Norms: The feminine identity is also affected by "generalized others." The woman compares herself with social norms including normative gender roles. The traditional Japanese family is characterized by patriarchy. One of the primary roles of the wife of the eldest son is to produce a son and heir. Although the Japanese family system is changing, the legacy of the traditional family persists in some families, particularly those who run a family business or who live in rural areas. One participant mentioned her concern about potential negative effects on her relationship with her parents-in-law, if she cannot fulfill the expected gender role function within society.

My parents told me, "We wish you would decide to remove the uterus," and my husband said the same thing. I know this is an old-fashioned way of thinking, but my husband is the eldest child, and the only son in his family. So I wanted to have a child in consideration of my parents-in-law. I know it's the old-fashioned way of thinking, but I told my parents and my husband that I hoped they would understand it. (No.5 [married])

Radical Trachelectomy

Repair of Identity: Fertility Preservation. Once they decided to undergo radical trachelectomy, all participants showed strong determination and expressed their intention to have no regrets. Some of the women imagined their childless life or the worst case scenario of cancer recurrence before the surgery. These results show that, for women undergoing radical trachelectomy, fertility preservation does not simply mean childbearing, although maintaining the ability to conceive is significant.

The best way is to remove everything. That's definite. Despite my internal conflict, it's up to me to make a decision. (No.13 [married])
I have already made up my mind. Even though recurrence may occur in the worst case, that's what I chose. I was relatively optimistic, or I was not thinking so seriously about potential negative effects. Once I decided, I just moved on. (No. 11 [single with partner])

After the Surgery

The surgery was an external event, and a reflective process (self-interaction) occurred again after the surgery. All participants were satisfied that they had undergone trachelectomy.

(Are you satisfied that you underwent trachelectomy?) Yes! I'm satisfied. (No. 6 [married])
My uterus was preserved in my body. Now I don't feel I'm so inferior to other women, which I had felt before the surgery. (No. 10 [single with partner])
Even if I have no children, or the cancer comes back eventually, I think I will not regret the surgery later. (No. 8 [single without partner])

External Events and Social Interactions After the Surgery. Complications, fertility treatment, and fears about unhealthy baby and recurrence after the surgery were all external events, influencing the meaning of fertility preservation, as well as social interactions with healthcare providers.

Postoperative Complications and Fears of Recurrence (External Events): Most participants experienced postoperative complications, which might affect their course after fertility preservation.

It was painful at the pelvic examination. Usually ultrasonography is not painful. Indeed, it was not painful before the surgery. (No. 4 [married])

The women were usually allowed to resume sexual activity 6 months after the surgery, but the women and their partners were concerned about the effects of postoperative physical changes on sexual activity and tried to avoid any trigger for recurrence, including attempting conception.

Because the vagina was shortened, it might be sensitive. I was so scared. So I didn't feel like trying it [sexual activity]. It's OK if we didn't have sex. (No. 5 [married])
We didn't have any sexual life. My husband said, "Like in the case of recurrence [5-year survival], I will not touch you for 5 years. I want to take care of it [your body]." (No. 5 [married])

Uncertainty of Fertility Treatment and Fears About an Unhealthy Baby (External Event). It is common that women who have radical trachelectomy need assisted reproductive technology (ART). The difficulty of fertility treatment often made the woman feel uncertain.

I took it easy. I thought I might be pregnant soon. But when I listened to my doctor and took various kinds of tests, I realized that it would not be easy because of my age in addition to the disease. (No. 14 [single with partner])

Also, some women were concerned about the baby's health and preferred a voluntary childless life after fertility preservation surgery.

If a baby is born and found to be disabled… I don't want to run such a risk. I may not want to have any children. That's my honest feeling. (No. 7 [engaged])

Healthcare Providers (Social Interactions). Healthcare providers may have a positive or negative impact on the woman. One of the participants perceived her healthcare provider as helpful:

My doctor reminded me of the point by saying, "You'd better try hard for half a year or a year because you underwent the surgery for that." I had almost forgotten it. Oh, yes. That's right. (No.3 [engaged])

But another perceived her provider raising the same issue as pressure:

To preserve the uterus means to have the ability to conceive. I strongly feel that the hospital people expect me to get pregnant soon and have a child. That direction is better for them. (No. 2 [married])

Reconstruction of Identity: Keeping Open a Window of Hope. The surgery is a pivotal point at which the women began to redesign their life perspectives. They gained their emotional stability and enhanced self-esteem. Although the value of childbearing remained important, regaining control of their reproductive capacity had shifted their outlook. Some participants reported an even stronger determination to bear a child after the surgery. Of these women, some were ready to attempt conception with ART.

We're going to have a baby. I underwent radical trachelectomy because of childbearing. The surgery equals childbirth. This is the first step. I'll try it (ART). That's what I thought at that time. (No. 5 [married])
I heard that fertility treatment would be required. So rather than imagining it, I thought I would just move forward. (No. 6 [married])

In contrast, some were reluctant to try ART and wished to attempt conception spontaneously.

I believe he (the partner) wants a child, but fertility treatment may be too much. (No. 13 [married])

Furthermore, any obsession with childbirth diminished rapidly after the surgery, and the women's priorities shifted from motherhood to wider womanhood. The idea that "being a woman is not just having children" was evident in the narratives of these women. The important thing is maintaining "a little hope," and the perception was that a window of hope is kept open for all women who preserved their fertility.

It [the surgery] led to a fundamental change. Now I am not so obsessed with a child. Of course, I want my child but not so badly as before the surgery. In the past, I could not stop thinking about it. Now, such feelings have diminished. (No. 4 [married])
I really want to get married, but basically I don't like children so much. I doubt that marriage equals childbearing. I don't have any such idea. (No. 8 [single without partner])
I want to enjoy fashion as much as I can. I try to enjoy life as I did before the surgery, in my present physical condition. (No.12 [single without partner])

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