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Testicular Cancer Forum

Prostate cancer continues to attract research funding and political attention as the complexities of the disease are unraveled and debated in a uniquely public men's health forum. Screening guidelines and treatment modalities have been featured in prostate cancer research. However, some areas worthy of research are conspicuous by their absence. One such area that has attracted little research is a common diagnostic procedure for prostate cancer, the trans rectal ultrasound prostate biopsy (TRUS-Bx). The TRUS-Bx procedure involves the passing of needles through the rectal wall into the prostate gland in order to retrieve six-12 prostate tissue specimens for analysis. This ethnographic research study explores 14 Anglo-Australian men's experiences of TRUS-Bx, administered without local or general anesthesia, as a diagnostic procedure for suspected prostate cancer. A social constructionist gendered analysis reveals intricate connections between participants' experiences of the TRUS-Bx procedure and masculinities.

Keywords: prostate cancer, men's health, treatment modalities, trans rectal ultrasound prostate biopsy (TRUS-Bx), gender analysis, masculinities

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The majority of prostate cancer research is focused on virtues of screening, potential causes, risk factor identification, treatment modalities, and side effects. However, between prostate cancer screening and diagnosis there is an examination that often takes place: the trans rectal ultrasound prostate biopsy (TRUS-Bx). There has been little published research about the TRUS-Bx and in particular men's experiences of the procedure.

Men with prostate cancer are often asymptomatic (Kozlowski & Grayhack, 2002). Prescribed or requested prostate cancer screening with prostate specific antigen (PSA) blood tests, usually in conjunction with a digital rectal examination (DRE), may reveal an abnormality that indicates the need for further investigation. The TRUS-Bx is often the subsequent test in which a definitive diagnosis of prostate cancer is confirmed or rejected. The TRUS-Bx procedure is performed by placing an ultrasound probe in the rectum. Sound waves emitted by the probe transmit graphics that show the prostate gland, which is usually viewed on a television screen. A spring-loaded needle attached to the ultrasound probe enters the prostate gland through the rectal wall. Tiny pieces of tissue, usually between six and 12 samples, are removed from the prostate via the needles. The samples are examined for prostate cancer cells, and a diagnosis of prostate cancer and its severity can be made (University of Toronto, 2000). Pre TRUS-Bx procedure prophylactic antibiotics are often prescribed to minimize infection risk, and an enema is administered to evacuate the rectum of feces to facilitate visualization and reduce the likelihood of prostate biopsy specimen contamination. The TRUS-Bx is usually administered without anesthetic (Kim, 2000).

No previous TRUS-Bx research utilizing social constructionist gender frameworks was found in the literature, and therefore a review of the literature that informs this study is presented. First, literature pertaining to previous patient-informed research of the TRUS-Bx procedure is described. Second, because a social constructionist gender analysis is used in this research, a brief review of this literature and the implications it has for interpreting the research data is presented.

Much of the TRUS-Bx research investigates biomedical areas, including accuracy of histopathology interpretation and evaluation of techniques for collecting biopsy specimens. Despite this trend, three recent studies investigated men's self-reported symptoms related to TRUS-Bx. Zisman, Leibovici, Siegel, and Lindner (1999) conducted a study that investigated the morbidity associated with TRUS-Bx. Ninety-eight consecutive biopsy patients were enrolled and completed survey questionnaires at three consecutive appointments. Zisman et al. (1999, p. 3) concluded "TRUS prostate biopsy commonly causes a vast variety of complications and has a substantial impact on the patients' well-being." Specifically the findings from their study showed that, prior to TRUS-Bx, 9% of participants reported sexual impairment resulting from anticipation of the scheduled TRUS-Bx and 65% of participants reported anxiety. During TRUS-Bx 96% of participants reported pain (42% reported mild pain, and 16% reported severe pain), and 86% of participants reported discomfort (28% reported mild discomfort, and 30% reported severe discomfort). Following TRUS-Bx, 21% of participants reported sexual impairment, 20% reported decreased libido, 48% reported pelvic pain one-day post-biopsy, and 75% reported anxiety awaiting biopsy results.

Zisman, Leibovici, Siegel, and Lindner (2001) completed a subsequent study with 211 men, and the results supported the findings of the original study, that TRUS-Bx may cause pain, anxiety, and erectile dysfunction. In conclusion, Zisman et al. predicted that measures to relieve anxiety in patients may alleviate pain and recommended that analgesic therapy be used for "younger patients, those reporting moderate to severe intra-operative pain, and those with known prostatic inflammatory infiltrate" (2001, p. 454). They also suggested the risk of acute erectile dysfunction be discussed cautiously with patients who have erectile function before TRUS-Bx.

Kim (2000) conducted a study of 50 men undergoing TRUS-Bx. She found those who received rectally administered lidocaine gel (local anesthetic) before the biopsy experienced significantly less pain than those men who underwent the TRUS-Bx without anesthetic. Using a visual analogue score (VAS) to rate intra-operative pain, zero being no pain and 10 being the most pain, 52% of the patients who underwent the procedure without lidocaine rated their pain as five or higher on the VAS of one to 10. Scores of five or higher are considered moderate to severe pain. Only 4% of patients who received lidocaine rated their pain in that range. Kim (2000) concluded that lidocaine gel was an efficient, cost-effective method to reduce TRUS-Bx pain.

One common finding by Zisman et al. (1999, 2001) and Kim (2000) was that many men experienced pain when undergoing TRUS-Bx without local or general anesthetic. However, these survey questionnaire studies depicted pain as a physiological cause-effect reaction to TRUS-Bx. There was no discussion about the cultures and sexual identities of the research participants or contextual information about their TRUS-Bx experiences, including details of what preceded and followed the procedure.

Men's experiences of illness are increasingly being recognized as issues that are socially constructed and depend greatly on how men and their community define masculinity (Bergman, 1995; Charmaz, 1995; Connell, 1995, 2000; Courtenay, 2000; Gordon, 1995; Gordon & Cerami, 2000; Huggins, 1998; Moynihan, 1998). Most recently social constructionist gendered frameworks have been used by Chapple and Ziebland (2002); Fergus, Gray, and Fitch (2002); Gray, Fitch, Fergus, Mykhalovskiy, and Church (2002) and Oliffe (2002, 2004) to research men's experiences of prostate cancer.

Central to social constructionist frameworks is the concept that masculinity is socially constructed and influenced by society, history, social class, and culture (Courtenay, 2000). The type of masculinity the dominant group performs--a "culturally idealised form of masculine behaviour" (Connell, 1987, p. 83)--is referred to as hegemonic masculinity. Many men are strongly influenced by dominant social constructions of masculinity and replicate characteristics of hegemonic masculinity including stoicism, aggressiveness, competitiveness, sexual prowess, and control (Cheng, 1999). The adoption of such attributes also informs improper displays of emotions such as pain and grief (Kaufman, 1994; Nicholas, 2000).

Reliance on hegemonic masculinity is reported to negatively influence men's health and illness behaviours (Eisler, 1995; Connell, 1995; Courtenay, 1998; O'Hehir, Scotney, & Anderson, 1997; Huggins, 1998; Ziguras, 1998) because men respond to society's expectation of toughness and independence that informs a sense of invulnerability, social isolation, withdrawal, and hesitancy or unwillingness to ask for help (Good, Burst, & Wallace, 1994). When illness is discovered it can render men vulnerable, passive, and dependent, traits traditionally assigned as feminine and thus in direct opposition to hegemonic masculinist constructs of invulnerability, activity, and independence (Martino & Pallotta-Chiarolli, 2003). Therefore, anticipated, imagined, and real limitations associated with illness can result in socially constructed subordinate, marginalized, and emasculated forms of masculinity (Charmaz, 1995; Cheng, 1999; Farrell, 1986).

The inverse of the argument that hegemonic masculinity is exclusively detrimental to men's health and incompatible with illness has been presented less often. Nicholas (2000) argued that some characteristics of hegemonic masculinity contributed to rather than detracted from men's health and well-being. Gordon's (1995) study of men with testicular cancer showed that some characteristics of hegemonic masculinity assisted men in coping with illness. Oliffe (2004) reported that competitiveness, physical prowess, and problem-solving ability could assist men to conceptualize and recover from prostate cancer and its treatments.

Hegemonic masculinity also influences men's experience and expressions of pain. Bendelow (2000) reported that men dwell on the physiological dimension of pain and tend to ignore psychological dimensions because boys are actively discouraged from expressing emotions and many men feel obligated to display stoicism in response to pain. Similarly, many authors have noted stoicism and endurance as the most revered masculine responses to pain and physical suffering (Cheng, 1999; Kaufman, 1994; Lee & Owens, 2002; Nicholas, 2000; White, Young, & McTeer, 1995; Young, White, & McTeer, 1994).

Diversity exists in how closely men align to various characteristics of hegemonic masculinity, which accounts for the variation between and within men's reactions to pain and illness. Connell (1995, 1997, 2000) suggests no one pattern of masculinity exists but rather plural masculinities based on different cultures and periods of history that construct gender differently. Helman's (1990) suggestion that culture strongly influences diverse individual experiences of pain is premised on similar sociological frames. He predicts that not all cultural groups respond to pain in the same way, and how and whether people communicate their pain to health professionals is influenced by cultural factors (Helman, 1990). Bendelow (2000), Helman (1990), and Williams and Bendelow (1998), among others, advocate a sociological approach to pain management inclusive of feelings and emotions to enhance and add to the overall understandings of the complex phenomenon of pain.

Masculinity is also inextricably tied to sexual orientation (Connell, 2003). The institution of heterosexuality is inherently gendered and rests upon the assumed normality of specific forms of social and sexual relations between women and men (Kilmartin, 2000). Male heterosexuality itself is not merely a matter of specific sexual desires and practices; however, in the context of this research dominant social constructions of male heterosexual performance are most relevant. Most heterosexual men's dominant pattern of sex is erection, penetration, and climax (Metcalf, 1985), and this model prescribes that the heterosexual man is the one who penetrates, and the female partner is the penetrated (Lee & Owens, 2002). There is a binary logic in this model that the receptive person is passive and feminine and the insertive person is active and masculine (Kippax & Smith, 2001). Furthermore, internal physical examinations are also socially constructed in Anglo-Australian cultures as feminine, a necessity in the interests of female reproductive health (Oliffe, 2004). It is not a cultural expectation that men routinely undergo internal physical examinations, especially when it involves the anus. Part of this receptive experience is the heteronormative structured nature of the act itself, in so far as the anus is stamped as the most private and shameful part of the body (Kippax & Smith, 2001; Oliffe, 2002). Moreover anal penetration is associated with homosexual, subordinate forms of masculinity (Kippax & Smith, 2001).

Hegemonic masculinity also signifies a position of cultural authority and leadership, not just in relation to other masculinities, but in relation to the gender order as a whole (Connell, 1987, 1995, 2001). Health-care systems, as well as illness, can marginalize men because health institutions are "constructed as masculine and defined as a domain of masculine power" (Courtenay, 2000, p. 1395). Men who are ill, regardless of their achievements, social status, and power, can be rendered subordinate by the regulations and roles that are enforced by health-care cultures. Furthermore, as Courtenay (2000, p. 1395) suggests, male physicians can impose masculine hierarchies that marginalize patients by maintaining "power and control over the bodies of men who are not physicians." An example of this is offered by Miaskowski (1999), who suggests gender bias may exist in how health care professionals respond to men's and women's reports of acute and chronic pain. She recommends that future research to determine how patient factors, such as pain behaviours, as well as information about the health-care professionals (including the gender of the clinician), influence the clinical management of pain (Miaskowski, 1999).

The purpose of this study was to investigate participants' experiences of TRUS-Bx using a social constructionist gendered framework. Contextual understandings were developed, inclusive of what preceded and followed the TRUS-Bx through participant informed answers to two research questions:

* Why do some men experience pain and anxiety when undergoing TRUS-Bx? * How is the TRUS-Bx experienced and expressed by the participants, particularly in relation to embodied masculinity?

METHOD

Qualitative research is increasingly being recognized as an effective way to develop a broad base of medical and scientific knowledge, investigate complex health problems (Baum, 1995), and develop contextual understandings about the way people approach illness (Nations, 1986). In this study, a qualitative ethnographic approach, which has a long history and tradition in both masculinities (Connell, 2000) and public health research (Gifford, 1998a), was used. Ethnography is defined as the science of description (graphic) of a group of people and their culture (ethno) (Vidich & Lyman, 1994). The overarching characteristic of an ethnographic approach is its commitment to cultural interpretation (Patton & Westby, 1992; Punch, 1998; Wolcott, 1990), and the emphasis has gradually shifted from a study of societies as wholes to particular communities or segments of societies (Van Valsen, 1967). The present study, a microethnography, focuses on a specific setting and cultural events "giving emphasis to particular behaviours in particular settings" (Wolcott, 1990; p. 64). The approach is effective for explicating the ways in which cultural beliefs and practices and social relations affect health outcomes (Gifford, 1998a).

PARTICIPANTS

After scientific ethical committee approval, research participants were informed verbally and in writing via a Plain Language Statement of the specificities of the study. Each participant completed a written informed consent that included information about confidentiality, the interviewee's access to the transcription, and right to withdraw at any time. I explained that I was a registered nurse but had no clinical experience in urology and nursing men with prostate cancer. This information was volunteered to avoid the interviews' turning into therapeutic situations, and it was made clear that it was the interviewees' experiences and perceptions that were valued in this research.

In the first instance, participants were recruited from prostate cancer support groups (PCSGs), however many of these men had previously participated in a variety of prostate cancer research projects. I was reticent to recruit all participants from PCSGs because a core group of men who were well versed in discussing "their" TRUS-Bx may have become the dominant hegemonic voice and narrowed the focus of the research prematurely. Therefore, seven participants were recruited from PCSGs, and seven participants who had not attended PCSGs were recruited through advertisements in regional and city newspapers.

A purposeful criterion sample was used to reduce variation within the cohort (Patton, 1990), and Anglo-Australian (defined as originating from a Welsh, English, Scottish, or Irish background, at least second-generation Australian-born) heterosexual men with a current female partner were invited to participate in the study. Participants ranged in age from 46 to 74 years and were diverse in terms of education, employment background, and socioeconomic status. Participants had erectile function prior to their TRUS-Bx, which they underwent without local or general anesthetic in Australia between 1997 and 2001. The TRUS-Bx results confirmed a diagnosis of prostate cancer for all participants.

DATA COLLECTION

As part of a larger ethnographic study, preliminary fieldwork was conducted at monthly meetings of two Melbourne-based prostate cancer support groups (PCSGs) for six months. At the PCSG meetings participant observations were made, and as Willms and Johnson (1993) predicted, by virtue of being there, I was drawn into the discussions. The PCSGs provided a safe place in which men had the permission of other men to speak about prostate cancer issues and, as a consequence, the dialogue was open and at times emotional. One issue that was discussed on many occasions was pain and discomfort associated with the TRUS-Bx procedure. Despite my clinical nursing background, I had no prior knowledge of the specificities of the TRUS-Bx. However, I was soon learning about the procedure from the men at the PCSGs and became interested in understanding the cultural meanings of TRUS-Bx. I had not anticipated this emerging theme in the initial research design; however, as Spradley (1980) suggested, ethnography provides a way of knowing from the bottom up, a way of knowing in which the study participants inform the research questions and themes.

Data were collected through in-depth semi-structured individual interviews. The interviews were completed at participants' homes, averaged 90 minutes in duration, and were tape-recorded throughout. The interviews usually began by asking participants to describe how they came to have a TRUS-Bx, and the subjects of feelings, thoughts, and context were introduced as appropriate to the flow of the interview. Although specific interview questions were developed, conversations rather than questions and answers usually took place and determined how the interview information was obtained. The interviewee-guided investigations ensured participants' experiences were central to the interview (Reinharz, 1992), and this was particularly effective in gaining contextual understandings--including information about the events leading up to and following TRUS-Bx. Participant observations and field notes were made during the interviews and provided adjunct information to the interview transcripts. Data were collected through preliminary fieldwork, participant interviews, and observations over an eight-month period, which enabled me to focus on events and reactions that happened again and again and to gain deep cultural understandings (Woods, 1992).

The interviews were audio-taped and transcribed verbatim to provide an accurate record of the dialogue. Considerations about the validity of the study involved member checking (Acker, Barry, & Esseveld, 1983), in which participants were provided with transcripts from their interviews, asked for personal perusal, and invited to comment, give corrective feedback, and answer additional questions. All participants collaborated to varying degrees in the co-production of their final transcript.

DATA ANALYSIS

In ethnographic studies, analysis is acknowledged as a part of the process of the research during the data-collection phase rather than something that occurs exclusively at the end (Gifford, 1998a). Following each interview the hard copy transcripts were read at least six times as recommended by Spradley (1980). Through reading the transcripts multiple times, each subsequent interaction with the text yielded new thoughts (Sandelowski, 1995). Key phrases were highlighted and notes made in the columns of the transcripts about ideas and interpretations. Each transcript was also proofread against the interview audiotapes, and excerpts from field notes and participant observations were added to provide a sense of the whole interview. The transcripts were managed using NVivo 1.2, which facilitated sorting the data. Initially, facts that closely aligned with the research questions were extracted to fracture the data and facilitate new insights (Sandelowski, 1995). Three broad categories were used to organise and retrieve the coded data--pre TRUS-Bx, during TRUS-Bx, and post TRUS-Bx. This enabled the data to be coded, organised, and retrieved and some preliminary analysis to be completed without separating data segments from their contexts. Subcategories were developed for each of the broad categories. For example, contextual understandings about participants' pre TRUS-Bx experiences were developed through subcategories including fear, stoicism, denial, uncertainty, delay, urgency, and mortality. At this stage of the analysis, sub-categories often overlapped and were nested within one another, and descriptive notes for each of the subcategories and exploration of the relationships between them were made. Eventually, the theme of anxiety was developed to encompass participants' pre TRUS-Bx experiences. The term "theme" here refers to coherent patterns identified in participants' accounts (both within and across transcripts) (Stenner, 1993).

Particular single-coded and multiple-coded segments were extracted using NVivo 1.2 and thought about creatively to develop and explore themes. Specific questions suggested by Spradley (1980) provided a starting point to begin identifying and explaining emerging themes. Examples included (1) is there information derived from the cultural group that appears contradictory, and (2) what kinds of conflicts are occurring between people in social situations? As analysis continued, the relevant literature and social constructionist gender frameworks were revisited to further develop the analysis. The themes were developed into story lines, and the literature was interwoven with the findings as recommended by Morse and Field (1995). Writing up the research results is also interwoven with data analysis and facilitates the development of more sophisticated explanations and descriptions of the cultural patterns and rules (Denzin, 1994; Gifford, 1998b).

This research also had a commitment to reflexivity, and my own constructs were acknowledged in the entire research process. I am a registered nurse and heterosexual male in my late thirties, and my experiences, personal and professional, influenced the research design and decisions about what constituted data through to the data analysis. Pure representation was not espoused; rather, as Streubert Speziale and Carpenter (2003) assert, it is acknowledged that culture is ever-changing and dynamic, and therefore the findings from this study were applicable within the context of this research.

RESULTS

The findings were organized around three themes: (1) Pre TRUS-Bx anxiety, (2) TRUS-Bx penetration, pain, and stoicism, and (3) post TRUS-Bx mortality. A social constructionist gendered analysis of the findings was used to explicate the connections between participant masculinities and TRUS-Bx. Verbatim quotations were used to demonstrate key points. In order to link the data to specific men, pseudonyms were used in the presentation of the findings.

PRE TRUS-Bx ANXIETY

The discovery of prostate cancer was incremental and multi-factorial for many participants. There was a period prior to diagnosis during which a continuum of medical investigations ultimately proved a diagnosis of prostate cancer. This involved the transition from being a well man, often with no prostatic symptoms, to being a man with cancer of the prostate gland. It was a quantitative journey in which PSA and DRE scores provided preliminary evidence of potential prostate pathology. However, the espoused inaccuracy and unreliability of the PSA and the subjectivity associated with DRE provided hope for many men that there had been a mistake in the numbers preceding the definitive TRUS-Bx.

The period post-PSA, with or without the DRE but preceding the TRUS-Bx procedure, was a time of anxiety for many participants. Uncertainty surrounding the invasive nature of the procedure coupled with the impending TRUS-Bx results undermined many characteristics of hegemonic masculinity. Steve recalled, "In coming to it, I was very nervous about it ... it was nerve racking." Archie worried about the "whole nature of the procedure," which he anticipated would be "like a rectal exam to the nth degree." Don was "fairly naive about the biopsy" procedure itself, but "thinking about bigger issues of "Is it [cancer] going to kill me straight away?" was a major source of anxiety in the weeks leading up to his TRUS-Bx.

In the moments immediately preceding the TRUS-Bx procedure, participant anxiety was heightened. Arnold "saw a huge bundle of stuff on the table, and the ultrasound head, the gun, and all the rest of it; I realized where that had to go and I didn't feel that good." He was also "incredibly anxious to know the results." Archie was rendered passive with childlike helplessness as he lay semi-naked on the procedure table, vulnerable and without control.

   You are on your side in a foetal position. Most men ... with their
   pants down feel a bit vulnerable.... I am a person who likes to be
   in control of things and control of my body, in control of my
   circumstances.... To be put in that situation, I am clearly not in
   control. (Archie)

A key part of the self-control needed to align oneself with hegemonic forms of masculinity is to conform to rules of stoic emotional display and demonstrate rationality rather than weakness. So, although many participants privately experienced anxiety, self-doubt, and uncertainty, publicly their vulnerabilities were submerged beneath more hegemonic forms of masculinity. When Archie found out that his PSA was high, he requested to have the TRUS-Bx as soon as possible because he "would rather find out now," and besides "I [he] was prepared to bet on myself [himself] being okay." Ben "was aware that a lot of people with an elevated PSA don't necessarily have cancer" and "didn't particularly expect it [prostate cancer] to happen to me [him]." He postponed his TRUS-Bx twice because it was "awkward to fit in" with his interstate work commitments. "It would have spun out to six weeks" before he got "someone else" to go to "another important meeting" so he could have the TRUS-Bx.

The urgency to undertake the TRUS-Bx varied, but participants were committed to knowing for certain if they had prostate cancer. Diagnosis, and therefore TRUS-Bx, was constructed as a logical, rational step to identify and treat prostate cancer. So while many participants admitted anxiety to themselves, without the definitive diagnosis of prostate cancer, they were able to legitimize a stoic public affect. After all, men who admit weakness publicly do not meet hegemonic masculine ideals.

TRUS-Bx PENETRATION, PAIN, AND STOICISM

The research participants had female partners and erectile functioning at the time of their TRUS-Bx. Many participants' reliance on dominant social constructions of male heterosexual performance were disrupted by the anal penetration they experienced during the TRUS-Bx. Ron remarked that "it was all very new to me; I had never had anything like that before." He described himself as a "typical male" and perceived the TRUS-Bx as "an invasion of privacy, my space" and an "embarrassment," which left him wondering "what next?" Arthur "didn't enjoy the DREs or that sort of stuff," and the TRUS-Bx "wasn't distasteful for me, but it wasn't what I enjoyed." Archie found it "demeaning having a ... great fat thing shoved up your anus." Clark thought "what a bugger of a job this would be, putting a thing up someone's behind and taking biopsies all the time." Following the TRUS-Bx, Eddie asked "how big" the ultrasound probe was. When the clinician showed it to him, Eddie commented that "it was quite small" and the TRUS-Bx experience "has cured any of my [his] homosexual tendencies."

Participants experienced diverse levels of pain and discomfort during the TRUS-Bx procedure. Clark found it "a bit uncomfortable, but not painful," Eddie suggested "it didn't probably hurt that much," and Arthur asserted "it was not painful at all." Sean was less certain about what he felt and attempted to differentiate between pain and discomfort: "I didn't find it painful, but it was fairly uncomfortable, and I mean, where the line is I don't know." Many participants revealed comparative experiences of pain. Ben compared the TRUS-Bx pain levels with his post-operative bladder spasms, and Vincent's previous experiences of injury and pain were comparatively more demanding than his TRUS-Bx: "It [TRUS-Bx] was certainly uncomfortable.... I do recall wincing a few times ... there was far more pain ... by far the worst pain I had was bladder spasms ... there were a couple of days which were excruciating."

   I have had a knee reconstruction. I have banged my head a few
   times, I was in a pretty ordinary car smash a few years ago, and I
   don't think it [the TRUS-Bx] was anything. I have had a lot more
   pain than that. (Vincent)

Dominant masculinist responses were also used to describe pain. Yanni was able to "put up with it," and John could "handle" pain. The pain performance descriptors were seemingly contradictory with concurrent acknowledgements that Yanni found the procedure "traumatic" and John needed to "hang on like grim death." Clearly, there was tension between some participants' reliance on masculine ideals of pain tolerance and experience of the TRUS-Bx.

Most participants aligned with dominant forms of masculinity when confronted with TRUS-Bx pain. However, many participants became uncertain of their ability to sustain their pain tolerance and stoicism as the TRUS-Bx continued. Anxiety about the level of pain, as well as the ability to endure pain, was strongly represented in participant interviews:

   The first one ... "ouch that hurt" ... they did seven. By the end of
   it, the tension in my body, I could sort of feel I wasn't
   relaxed ... I was close to blacking out. They sat me up, and I felt
   very faint
   (Don)

"Each one of those shots seems to increase the discomfort ... it becomes a matter of endurance, as the pain and discomfort seems to accumulate," described Trent. William "was ready to say to him, look, don't worry about a sixth one, I've had enough." "My shirt was ringing wet when I got finished [sic] with that [TRUSBx].... I just don't know whether apprehension came into it. You can't fake sweating. I am not a sweater. I am pretty lean" (John). The sound of the procedure was also a feature of other participants' descriptions of the TRUS-Bx: "The worst part about it was bringing the slide out; it was like loading a gun and firing each round one by one. By the fourth one you thought, "God, get it out'" (Eddie); Arnold explained, "I was counting every one of those wangs as I heard the needle come in and out ... at the end I felt very unsettled, so the nurses just lay me down on the bed and rubbed my hand."

Many TRUS-Bx procedures continue to be administered without a local or general anesthetic in Australia. During fieldwork, I attended a public prostate cancer information evening. A prominent Melbourne-based urologist stated that anesthetics were not being used for TRUS-Bx in Victoria, Australia, because Medicare (the national government medical funding agency) did not rebate the anesthetic cost. In contrast, during later fieldwork, two Brisbane-based urologists indicated that they included a light general or local anesthetic for all TRUS-Bx patients. This was a perplexing inconsistency given that Medicare is a national funding body, yet disparity existed between and within the states of Australia. Medicare confirmed that item "37219 TRUS prostate biopsy" attracted an anesthetic benefit and has done so since at least 1998; hence, the direct cost of TRUS-Bx anesthetic is refunded to the provider through the government rebate (Australian Department of Health and Ageing, 2002). Although the anesthetic cost is retrievable, indirect costs related to the use of general anesthetics, such as extended procedure time, increased inpatient stays, medical supplies, and human resources, may add to the providers' costs and inhibit the use of TRUS-Bx anesthetics.

Regardless of the financial implications, the use of local or general anesthetic is ultimately at the discretion of the clinician administering the TRUS-Bx, and presumably the decision is primarily based on clinical assessment of the patient. Some participants suggested disparity in clinicians' estimations of their pain during TRUSBx. Ron was told an "anesthetic wouldn't be necessary" but subsequently experienced "the most uncomfortable half hour I have ever spent." John was told "it would be mildly discomforting and nothing to worry about" but "found it pretty damn painful." Clinicians' pain predictions were further complicated in that the clinician performing the TRUS-Bx may not have met the patient prior to the procedure, as the clinician was not necessarily the treating doctor. As a consequence, unfamiliarity may have also increased participant anxiety.

Some clinicians' expectations of men undergoing TRUS-Bx may also have influenced their decision not to provide local or general anesthetics. Wayne's TRUS-Bx pain tolerance was validated by his clinician. The clinician assured Wayne that "we have had big blokes here on this table who have cried getting this [TRUS-Bx] done," but comparatively "with no anesthetic, you don't." Clark complied with the clinicians expectations because he "was in their hands ... and if he said, 'this is what we will do, it is going to be a bit uncomfortable,' then righto, I'll go along with that." It is acknowledged that clinicians may offer different insights into the administration of TRUS-Bx procedure. However, it is clear that some participants (such as Wayne and Clark), responded to clinicians' expert advice as well as their own expectations that the TRUS-Bx would not be painful. Arnold "didn't think about" reporting his pain to the clinician because:

   I was focused on having something that I didn't like, something
   that was intrusive, ending. At that stage, I was just counting,
   because I knew there were only two more to go and then it would
   finish, so my focus was on the end and when it would stop.

Stoicism extended beyond the denial of pain and was underpinned by shame and embarrassment for some participants. Despite wondering "what have they bloody done to me now," Clark did not ask the doctor about the possible connections between his impotence, loss of libido, and the TRUS-Bx:

   The intrusive examination [TRUS-Bx] upset something ... once
   they got in and took a biopsy, sex just died. Whatever it did, it
   just affected my sex drive. Maybe it upset a chemical imbalance;
   there was just no interest any more. I don't know what it was or
   why it was, but it was gone. It was hard to get an erection where I
   didn't have a problem before.

Arthur explained that during his TRUS-Bx "one of the veins on my rectum was sliced ... it opened up a hole, and I lost three to four units of blood ... virtually passed out ... and had to stay in overnight." Despite the "glancing blow" Arthur summated that the TRUS-Bx was "done efficiently, effectively, and quickly so I wasn't complaining."

POST TRUS-Bx MORTALITY

The official moment of receiving the TRUS-Bx results was a particularly emotive event, and many participants were confronted by illness cultures, subordinate forms of masculinity, and their mortality. Clark thought, "Christ, what's going on here? And, I said, 'Now what happens next? Can I get a second opinion, because this can't be right?'" Ron explained the diagnosis was a "real kick in the backside. Never really had anything all that much wrong with me, and all of a sudden here I am ... we [he and his wife] both broke down and cried." When Wayne "first heard I had it, I thought well that's the end of it ... that's death's door. See I only live a couple of doors up from the undertaker, and I couldn't walk past that place for a time." Although the diagnosis of prostate cancer was usually based on a continuum of screens and tests, shock and the realization of mortality were strongly represented in participants' descriptions of receiving their TRUS-Bx results.

DISCUSSION

Previous social constructionist gender research has reported connections between masculinity, health behaviours (Eisler, 1995; Connell, 1995; Courtenay, 1998; O'Hehir, Scotney, & Anderson, 1997; Huggins, 1998; Ziguras, 1998) and illness (Chapple & Ziebland, 2002; Charmaz, 1995; Cheng, 1999; Farrell, 1986; Fergus, Gray, & Fitch, 2002; Gray, Fitch, Fergus, Mykhalovskiy, & Church, 2002; Martino & Pallotta-Chiarolli, 2003; Oliffe, 2002, 2004). However, the findings from this study showed that the "places" in between health and illness, when participants' prostate cancer was suspected but not diagnosed, was a significant period when many aspects of dominant masculinity were undermined. It is important to note that most participants' illness experience began prior to their formal diagnosis of prostate cancer. Health services and professionals were encountered during this time, and the TRUS-Bx was experienced when participant uncertainty and anxiety were heightened. Although many participants subscribed to public stoicism during this period, the possibility of illness disrupted masculine ideals of control, independence, and self-reliance.

Previous research by Zisman et al. (1999, 2001) and Kim (2000) indicates that pain and anxiety are common patient experiences when undergoing TRUS-Bx in the conventional way (without anaesthetic), and these are strongly represented in this study. Furthermore the findings from this study show how dominant social constructions of masculinity influence men's embodied experiences, effectual expressions, and pain experiences during TRUS-Bx. The findings are consistent with Bendelow (2000), who predicts masculinity is intricately connected with men's experiences of pain. The complexities of these connections are evidenced by the way participants constructed a gendered self in response to what were often unfamiliar health services and embodied experiences.

Participants' differentiation between pain and discomfort and references to pain tolerance were informed by dominant social constructions of masculinity. There is honour in enduring pain, and men who overcome pain are revered and celebrated in Anglo-Australian cultures. Historically, the pastoral frontier yielded symbolic images of masculinity that were tough, resilient, and enduring. These characters included the bushman who worked the land and livestock in extreme climates and terrain and the Anzac digger on the killing fields of Gallipoli. More recently, corporate competitive sports have provided arenas for elite athletes to demonstrate physical prowess regardless of pain and injury. Common to dominant historical and contemporary social constructions of Anglo-Australian masculinity is the hegemonic hero who, despite injury and overwhelming odds, crashes through the "pain barrier" to conquer all before him.

Subscription to masculine ideals provided many participants with a script to follow and gender performance to emulate. Participants were reluctant to admit pain to clinicians, and this is an example of what Courtenay (2000) identifies as the power institutions such as medicine and health services can have over men. It is likely that participants' stoicism and reluctance to inform clinicians of their pain, discomfort, and anxiety influenced the continued practice to administer TRUS-Bx without local or general anesthetic. Furthermore, dominant forms of masculinity may also have influenced clinicians' expectations of participants' pain tolerance during TRUS-Bx. In these interactions participants' denial of pain and clinicians' expectation of pain tolerance were complicit in sustaining hegemonic forms of masculinity. This finding illustrates B endelow's (2000) and Miaskowski's (1999) prediction that gender influences the experience and treatment of pain.

Participants' TRUS-Bx pain was inextricably linked to anxiety and was more than a single sensation caused by a specific stimulus. Penetrative aspects of TRUSBx as well as the significance of the impending results contributed to the anxiety and pain that many participants experienced. This finding strongly supports Bendelow (2000), Helman (1990), and Williams and Bendelow's (1998) proposed sociological approach to pain management. Dominant social constructions of male heterosexual performance, previously described by Metcalf (1985) as erection, penetration, and climax, were dislocated during TRUS-Bx. Participants were receptive and therefore passive and feminine through the anal penetration that occurred with TRUS-Bx. The findings showed a heteronormative social discourse existed for many participants, one that was implied but not informed, known but not challenged. Such ambiguity made it difficult to admit vulnerability around the anus due to dominant notions of heterosexuality as well as homophobic fears.

Participants also strongly associated cancer with mortality, and the TRUS-Bx results were a defining moment that confirmed the presence of cancer. During the continuum of screening and diagnostic tests, many participants conceptualized the need to know if they had prostate cancer using dominant masculine constructions--including rationality and problem-solving. Paradoxically, many characteristics of hegemonic masculinity, such as control and self-reliance, became fragile in the moments and months leading up to a diagnosis of prostate cancer. The tension and contradictions between and within hegemonic masculine ideals were especially evident at the moment of diagnosis. The problem of prostate cancer was confirmed, and most participants were shocked and confronted by their mortality. Participants' recall of pain intensity may have also been heightened by the results that ultimately accompanied the TRUS-Bx procedure.

CONCLUSION

This study describes the experiences of 14 men who had TRUS-Bx without a local or general anesthetic and gives insight into how masculinities and TRUS-Bx interconnect and potentially collide. The findings suggest that clinical practice should be cognizant of patients' experiences. Complex interactions need to occur in which health-care professionals are willing to listen and men are willing and able to speak about their TRUS-Bx experiences. It is not the responsibility of men to prove that they are in pain. However, clinicians cannot be charged with the responsibility to provide TRUS-Bx anaesthetics unless men report their pain. The conundrum remains that poor health literacy levels as well as reliance on hegemonic forms of masculinity inhibit many men from speaking up in audible tones.

PRACTICE AND RESEARCH IMPLICATIONS

Given that little research has been conducted regarding TRUS-Bx, there are numerous possibilities for future investigation. The results from this study also raise many research questions. For example, what are men's experiences of TRUS-Bx in other countries? How are social class and ethnicity interconnected with men's experiences of TRUS-Bx? How do clinicians decide the need for TRUS-Bx anesthetic? Further TRUS-Bx research, inclusive of patients and clinicians, would provide contextual understandings on which to develop clinical practice guidelines.

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Special thanks to Sally Thorne, Tina Thornton, and the three anonymous reviewers for their feedback on the earlier drafts of this manuscript. I wish to acknowledge all the men who spoke with me about their experiences of the TRUS-Bx. Their willingness to inform will benefit many men who will face this procedure in the future.

Correspondence concerning this article should be addressed to John Oliffe, School of Nursing, T 289-2211 Wesbrook Mall, University of British Columbia, Vancouver, BC V6T 2B5 Canada. Electronic mail: oliffe@nursing.ubc.ca.

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