Selfconcept body image sexual identity

Cancer has the potential to influence development of self-concept, a key task, among young people (Rowland 1990). Alterations in physical appearance, including weight changes, hair loss, amputations, placement of catheters to facilitate treatment administration, scars and alterations in skin colouration and texture, not only make children and teens feel different from peers but also may represent frightening changes in the body with an adverse impact on self-esteem. Fears that the body will never return to its original appearance, of not being recognized by others or of being mistaken for an individual of the opposite sex, often lead to shame, social isolation, and regressive behaviours (Die-Trill and Stuber 1998). These sometimes sudden alterations in body image are often perceived by patients as a threat to their well-being, causing anxiety. Also, self-image and life outlook appear to be worse among survivors who perceive treatment-related physical limitation as being moderate to severe when compared with survivors who perceive late effects as being only mildly or not at all limiting (Zebrack and Chesler 2001). It is notable that the perception of limitation and not an actual physical or visible 'disability' appears related to self-image and life outlook. For example, respondents who indicated mild or no limitations included individuals with amputations or other noticeable effects of treatment (i.e. scars), suggesting that some survivors with physical or visible effects of cancer did not necessarily see themselves as having limitations.

Chemotherapy and radiation treatments sometimes make patients feel as if their bodies are not their own. Their well-remembered physical responses often are thrown out of kilter by the mood-changing and physique-altering effects of drugs. Changes in body image stem from both the physical effects of treatment and the wrenching feeling that there is an internal battle going on between good cells and bad cells (Chesler and Barbarin 1987). Some investigators have noted that for adolescents, changes in appearance (i.e. hair loss, weight gain) are even more troublesome than the pain of treatments (Orr, Hoffmans and Bennetts 1984).

Many adolescents report that the treatment is worse than the disease (Ross and Scarvalone 1982) and that the bodily changes that accompany chemotherapy and radiation make it more difficult to develop a positive body image (Zeltzer 1993). The effect on physical appearance is especially disruptive for females (Zeltzer etal. 1980). Pendley, Dahlquist and Dreyer (1997) examined body image in adolescents who completed treatment and found that adolescents who had been off treatment longer reported more negative body image perceptions and that childhood cancer survivors may not recognize body image concerns until several years after treatment ends. Whether based on reality or not, persistent negative perceptions may result in a loss of sex appeal and virility or a distorted body image producing feelings of inferiority, low self-esteem and incompetence (Zeltzer 1993).

A special consideration related to self-image is the subject of sexual identity. It is during adolescence that individuals come to realize that they are sexual beings; adolescents begin to develop sexual identities and conceptualize their reproductive capacity. Adolescents display concern about attractiveness to peers and many begin to explore intimate relationships. It is not surprising, then, that cancer and associated treatments and side-effects would impact on their burgeoning sexuality. In a self-report survey assessing sexual attitudes and experiences of 30 adolescent and young adult survivors and 50 healthy age-matched controls, Puukko and colleagues (1997) reported that survivors differed significantly from controls with regard to their inner sense of sexuality with images of sexuality being more restrictive and attitudes being more negative, although age at initiation of dating and sexual activity, frequency of sexual intercourse and opinions on sexual behaviour were similar in both groups. In comparing the sexual concerns of adolescent patients with those of a healthy comparison group, Chambas (1991) reported that adolescents with cancer commonly raised concerns about the impact of treatment, whereas healthy teens' concerns centred around physical appearance or puberty. While healthy adolescent girls expressed concerns about pregnancy (it could 'ruin my life') adolescent cancer patients were more concerned about the potential effects oftreatment on their future ability to have children.

The comment from a childhood cancer survivor below exemplifies how young adult survivors' sense of self and 'feeling normal' may be associated with perceived peer expectations and uncertainty about whether or not they may be able to have children of their own:

When they said I couldn't get pregnant I was very upset. I felt guilty, like it was something I wouldn't be able to do and everybody else could do it. All these teenagers were having children and not wanting them, and I wouldn't even have a choice. I wasn't exactly the cautious teenager. I just didn't think I could have children. We didn't use a lot of protection, because I thought I couldn't. You just think that every woman should be able to have kids and that's the one thing you were made to do, is to have children. And when you're told that you may not, you don't even have the option of doing that, it's taken away from you, then you feel horrible, because you definitely want one when they say you can't have one. I thought I was just weird. I remember praying when I was 19 and saying, 'God, why can't I just be like all the other girls? Why can't I just have kids? Why can't I have that option, why can't you give me that option?' And no sooner did I say that, I had my son. I got pregnant a couple months later. It was weird, but I just wanted to be like them [other friends having babies], I wanted to be normal. Most girls they think they're gonna keep a man by getting pregnant. That's not why I was doing it. I was doing it because I wanted to have a baby. I wanted to see if I could have a baby. (Zebrack et al. 2004, pp.689-699)

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