Introduction

Throughout history, the human has become the subject of the social and medical sciences as a biological-genetic and sociocultural being and it continues to be so (Kara 2016). The human being discussed here is the body firstly; like the biological body, social body, living body, dead body, healthy body, sick body, disabled body, old body, child body, young body, masculine/feminine body, ugly/beautiful body, obese body, producing body, consuming body, exploited body, guilty/innocent body, suffering body, spiritual body, worker body, and slave/free body [1-3].

In the social sciences, M. Foucault (Discursive Body), Z. Bauman (Producing Body), J. Butler (Asexual Body), J. Baudrillard (İndicator/Consumer Body), Bourdieu (Habitus) and A. W. Frank (Body Management) object that the body is completely approached as a biological being and emphasize the sociocultural, biotechnological, historical reconstruction of the body in the society. In this context, the body definition of the individual finds meaning also with the body identity provided by the society as well as the individual’s own body perception [1]. Also, the appearance anxiety dominates all kinds of sense of health, mental and physical integrity. After all, the society surveils, supervises, suppresses, and judges the body, especially the female body, especially as a result of the identity that it has attributed to the female body and through the roles that it expects from her [1,2]. This pressure appears in the ways of gender discrimination, consumption desire or health-disease patterns. The breast is the main component of the female body definition. Therefore, the meaning that the society attributes to the body highly deepens the meaning that it attributes to the breast which is a part of the female body. The breast points out the femininity, desire, sexual pleasure and breastfeeding in the society and it is also increasingly associated to cancer and death [4]. In that case, what is the fact that worries a woman in the breast cancer or other breast diseases? How will the loss of the breast affect a woman within the social appearance anxiety?

In Turkey the studies in this field have been generally conducted with a biomedical model based. Therefore, in this study, the subject was approached with a sociocultural perspective. In the interviews, open-ended questions about body, woman, beauty, aesthetics, meaning of breast, loss of breast, breast surgery were directed in order to get information about participant life and experiences. Such information is thought to be important because they can represents ideas, emotions, attitudes as a personality, as a cultural reflection. The data obtained discussed with social body theories.

Methods

Study Design and Participants

In this study was used the qualitative research method for it facilitated inference, classification and interpretation. The literature review started in March 2017, and the study was conducted between in June-October 2017. For this descriptive study used a purposive sampling technique, whereby “Particular persons, or events were deliberately selected for the important information” [5]. Inclusion criteria for this study required that participant weren’t previously experience of breast diseases and breast surgery, were in the age range of 18–60 years, did not have a psychiatric history, did not have any another health problem that could affect body image (amputation, visible scar, blindness, visible physical disabilities). In qualitative research it is difficult to determine sample size. The researcher continues to gather data until the stage when the concepts and progress for the possible answer to the research question start to repeat (when the researcher reaches the saturation point) [6]. Twenty patients met this criteria and were included in the sample.

Data Collection and İnterviews

The data was obtained by in-depth individual interviews with 20 women. Interview questions was prepared by one academic who were expert about qualitative research. In interviews used semi-structured interview form which it contented questions such as, ...what could be the reason? … what do you think about?, ...what were you feeling?, ...what would you do in your case? In addition during the interviews, it was aimed to obtain deepen information by questions such as ... what do you mean? ... can you explain a little more?, ... what would you like to change? The interviews were conducted in an average of 30-60 minutes, and, when the participiants allowed, researchers had not only written but also voice recording. At least one interview was held with each participant. A second interview was held when there was information requested to clarify or when adequate information could not be achieved.

Interview responses were subjected to thematic analysis in a qualitative descriptive approach because thematic analysis is a way of ensuring that the analysis remains as close to the intented meaning as articulated by the respondent as possible, that is, “What” is spoken (or written) rather than “How” [7]. The main aim of this research was to determine or ‘capture’ what women feel, like taking a photograph. Three researcher who have qualitative research training, independently of each other generated code list. The researchers made evaluations about the codes and themes created until the consensus was reached [8]. After the analysis was conducted four sub-themes and one main-theme were determined.

Ethical Considerations

Ethical approval for this study was taken from the University’s Ethics Committee of Social Sciences and Humanities. The ethical principles adopted were voluntariness, confidentiality and autonomy. All the participants provided their informed consent before the interviews.

Results and Discussion

The mean age was 36.7 years, 70% of women had at least one child, and 85% were married, and 65% had university graduates. At the presented below, the themes obtained as a result of research are were discussion with a socio-cultural point of view. In this scope; M. Foucault, Z. Baumann, J. Butler, P. Bourdieu, A.W. Frank, M. Yalom and J. Baudrillard’s ‘Social body theories’ was based.

Sub-theme 1: Perception of Body

It is accepted that the body that represents the presence in the outer world is a language of communication or a communication tool and even it gets ahead of the language and the word in conveying messages. Also, through “Communicative body” concept, the body sometimes falls at the centre of the social relationship [1].

The first way of the woman to communicate is her body, indeed she talks with it. (Participant A).

M. Foucault draws attention that the concepts such as insanity, disease, life, language, crime, sexuality are problematized through discourses and how these concepts are used by the power in controlling the body. According to M.Foucault, the body is passivated and disciplined by being problematized through the insanity, disease, and crime discourses by the knowledge and the power that surround it. While doing this, many factors and tools like ideology, religion, politics, medicine, sexuality, consumption culture, image culture, technology, secularization, several definitions (black white), healthcare services that are similar to the population policies, love, violence are used. At this point, the female body is objectivized [1,9-11].

Mostly the society comments and talks about your body... that is, it is the property of the society, of the mother, of the father, of the husband, of your children, of your friends... of everybody... (Participant F).

Her body is hers and also not hers, that is…a deposit... it is her creation. (Participant B).

She says “I make my decisions” but somehow... then I “make what others say” (Participant A).

The gender theorist Judith Butler, who considers the body as the focus of the power system, also accepts that the existence is possible only in the way that another being perceives it. Within this context, when a person is perceived by another one, he/she leaves his/her current form and turns into how he/she is perceived. This point of view, that forms the reference point of the gender problematic and many feminist theorists, underlines that the woman exists in the society in the way that the man perceives her but not with her identity [12,13]. For this reason, the major criticism towards the sublimation of masculinity in the patriarchal societies has been made by the representatives of the radical feminism who have come into view after the World War Two. Because the position of the woman in the traditional societies is mainly determined by the traditional roles and statutes. And these roles and statutes are the divisions of labour based on the gender. The woman has to perform the roles of a housewife, wife (female), motherhood, and care in order to sustain her traditional position. These roles expresses the expectations of the society from the individual. It is assumed that these expectations are standardized again by the society with the cultural values and norms compulsively. As a result, the expectations for the social roles appear as an element of oppression of pressure on people [1].

As the main duty of the woman is to give birth to a child, raise him/her, be a family, I take the decisions about my body with my husband... (Participant E).

The woman is weak alone, without the man but this is also what the society teaches her... Expressions like “You are a woman, a woman can’t, women do not understand, women are weak” are always repeated starting from the childhood. At the end, we also become dependant (Participant B).

The participants have stated, as well as defining the female body as a communication, that the body was a deposit, the weakness (against the male body), and the dependency is taught to the woman by the society, the body of the women do not belong to them, it belongs to their mothers, fathers, husbands, children, friends, that is, to the society. When viewed in that way, it is observed how far the woman’s status perception in the society is from the individualism. F. Lamas’s quote: “It is better to look good than to feel good.” summarizes that the female body belongs to the society rather than herself.

Sub-theme 2: Aesthetics and Beauty

The body’s being visible within the social life is associated the increasing power of the science and economy that comes with the secularization. However, it is claimed that the religious restriction, definition and discipline has given their place to the other factors of pressure [1,2]. According to Baudrillard, in the consumption culture in which the difference between the real needs and the fake needs disappears, the body, especially the female body, has turned into a consumable item. Moreover, the female body shapes the consuming body with the pressure of being healthy, being slim, having an aesthetic appearance, being young, being fit and with ideal body definition [14]. Within this context, the healthy body is the most important command of the consumption society and the aesthetics, proportion, and care are the criteria of the healthy body [3]. And according to Baumann the health is reproduced with pressure and defining death as a final disease has made the individual and his/her body dependant on the medicine [3,15].

I feel weak when people see me uncared, as if I am unhappy, sick... (Participant H).

Women should be elegant, well-groomed and weak... because this type of women look aesthetics, proportional... (Participant J).

According to Bourdieu, the body, in one sense, is the object in which the class taste, elitism, desire and pleasure, that determines the social status of the individual, are materialised. In this way, the body becomes an important part of the cultural capital [13]. For this reason, in the society, especially the female body is forced to be objectified through the healthy, slim, aesthetic, young, fit and beauty discourses, for the sake of creating the ideal body [1]. At this point, the body is almost completely an object that gains meaning in the view of the others, constituting the society, and is degraded to exposure and show, based on the social pleasure and desire. This forcing, which is mostly performed by the media and medicine (surgery) is the new duties, new roles and even new jail of the woman, to let her gain a place in the society in the way that it is addressed in the social sciences [1]. For this reason, feeling beautiful or ugly, that is, being perceived as beautiful by the others, especially by the men, in the society becomes a very important factor that forms the woman’s sense of self. Women are more exposed to pressure with regards to having a beautiful body, compared to men, as the beautiful-aesthetic-erotic-pleasure-desire concepts are degraded to the body, especially the female body [1-3]. It seems that the patriarchy continues its existence with the impositions of ideal female body in consumption society.

Appearance is everything, your body is very important both for you and the others, if you are beautiful, I think you are very lucky... (Participant C).

Appearance is very important for a husband, men always want to see and like a woman... (Participant G).

In the study, women are described with bodily beauty, elegance, and aesthetics concepts. Also, the body, seen and perceived from the masculine point of view forms the base of the woman’s body perception.

Sub-theme 3: Perception of Breast

Marilyn Yalom has started her book ‘A History of the Breast’ with the quotation of “When poets mention about the death they call it as ‘the place without the breast’”. She has sought for answers to her questions within the parts of holy breast, erotic breast, domestic breast, political breast, psychological breast, commercialised breast, medical breast, free breast and the breast at the milestone. She has mentioned that the breast is a means of sexual beauty and the most important jewel of the feminineness especially for men. According to Yalom, the characteristics of breast-feeding and giving pleasure of the breast are the facts that shape the fate of women. Also, she has emphasized that many studies in medicine have attributed a value to women as the ones who give birth and feed [4]. Within this context, while the question “Who does the body belong to?” has not found an answer yet, the question of “who does the breast belong to? has been a matter of debate; does it belong to the child during the breastfeeding period? Does it belong to the woman or man who fondles it? Does it belong to the clothing industry that works to produce a more attractive cleavage? Does it belong to the judges of religion and morals who insist that the breasts should be covered chastely? Does it belong to the doctor who reshaped the breast of the woman? Does it belong to the media that dictates the ideal body sizes? Or does it belong to the woman which is a part of her own body?

The breast is also known as the furthest sexual organ... the breasts are also important for the continuation of marriage as the sexuality is important in marriage (Participant H).

The fatty tissue that we try to hide when we reach adolescence and to show when we become an adult… (Participant C).

While the breast, which has been expressed by the women informants in the study, was associated with sexuality, femininity and motherhood (breastfeeding). it was considered that the roles of motherhood and being a wife are determinant in the breast perception.

Sub-theme 4: Perception of Breast Lose

The breast points out the aesthetic appearance, feminineness, desire, sexual pleasure and breastfeeding in the society and it is also increasingly associated with cancer and death. The breast cancer is an outbreak that is hard to cope with. Yalom has stated that women are under the obligation of bearing both sides of the breast, indicating giving and taking life. Also, she has said ‘The breast is, in fact, the incarnate form of the tension between Eros and Thanatos -life and death- in a visible and perceivable way for women’ [4].

On the other hand, the surgery means hope for the breast cancer. The breast diseases often result with the surgical intervention to the breast and even the breast is lost. However, it is obvious that the body of the individual is intervened. Therefore the breast surgery negatively affects the body perception with the change of the physical appearance by causing a part of the woman to be taken out and also it may be perceived as the loss of the femininity, fertility, attractiveness and sexuality [4,16]. As the breast intertwines with the subjective perceptions of the women on their sexual identity and appearance. it has been included that the breast surgery creates the feeling of the loss of femininity for a woman [17,18]. Özer, has emphasized that breast cancer is a physically, spiritually and socially complex disease in which both the life and the femininity are perceived to be under threat by women [19]. Therefore, it is thought that the breast surgery has a complex, sociocultural meaning. In this context, according to Frank, who has considered the disease of the body as a field of social analysis, ‘’The disease stories” of “The patients” have different meanings than individual pain and suffering”. The ‘Truth’ is hidden in the discourses related to the diseased bodies and has a quality from private experiences to the public [3].

The woman without breast is left half like a tree without fruit, she loses her glory, her magnificence disappeares... (Participant B).

I think if my husband doesn’t want me if I undergo mastectomy... I think the sexuality would be a problem, I think about how I would breastfeed if I had a child... I cry continuously... I wonder what other think of me... I may feel like a jerk, I get lonely... (Participant C).

As I want a child, I think the loss of the breast would be terrible for me. I feel like I would not be able to stand with her with this disease, it is very hard…(Participant C).

It is disturbing to lose breast... it may be like losing femininity... of the woman who has ascribed too much meaning to the physical appearance… (Participant B).

If I have to undergo mastectomy, this would extremely affect me, as a person who gives importance the physical appearance, I would think to have psychological aid... (Participant G).

The breast surgery and the loss of the breast were expressed with the feeling of the deficiency, the loss of femininity, sexuality, and breastfeeding, and loneliness, inferiority. Therefore, women make sense of the breast surgery with regard to the outer terms rather than the inner terms, as the anxiety of not being liked by their husbands, the loss of motherhood and femininity.

Main- theme: Fear of Loss the Social Role

The losing the breast may be perceived as the loss of the social status for the woman. Because the breast is a must of the judgments of motherhood, sexuality, femininity, beauty and aesthetics that the society has constructed in the individuals’ bodies. The woman who has lost her body perception and her breast, which is an important determinant of her social status cannot fulfil the motherhood and femininity roles that are expected by the society. Aguilar Cordero, et al. (2013) emphasized in their study the strong relationship of the breast with the sexuality and physical attractiveness and reported that the lose of breast diminishes the femininity [20]. Sun, et al. (2018) in their study have reported the perceptions of losing the breast were filled with contradictions, tensions and uncertainties while negotiating the discrepancy between the “Self and body” and the societal expectations of femininity and womanhood [21]. Elmberger, et al. (2008) reported that the woman with the breast cancer experienced anxiety about failing to act as a ‘Good’ mother for their children and they had difficulties in fulfilling their responsibilities as a parent [21]. Aguilar Cordero (2014) Also emphasized that it the reason for the destructive effect of the diagnosis of the breast cancer in women was explained with the sense of loss [22,23]. Campbell-Enns, et al. (2015) reported that the breast cancer generally challenged a woman’s identity, self-esteem, body image and the relations with her husband. In additional, were emphasized in their study that the breast surgery mostly becomes an experience of loss [16]. This loss is perceived not only as the loss of breast physiologically but also as the loss of the social identity. Boquiren, et al. (2013) reported that the patients with the breast cancer, who approved the internalization of the of thetraditional social gender roles and attitudes more, observed herself more and experienced feeling shame more due to body, had more body image disorder and they had worse life qualities [24].

Conclusion

In the results of the study, it has been witnessed that the body perception of the women has been based on the masculine point of view in the society and that the motherhood and femininity roles also are determinant in the breast perception. When the women lose their breast, which is an important determinant of their social position, they thought that will not be able to fulfill the roles of motherhood, femininity and sexuality that the society expects. In addition, it was found that breast lose (due to cancer or disease) was similarly stated to be the loss of aesthetics, beauty, motherhood, femininity. For the reason, this loss was also interpreted as a woman’s loss of social function, loss of identity and even feeling loneliness, inferiority. Summarize we can say that the loss of breast appears as a broad concept that includes the emotional, intellectual and sociocultural components. For this reason, it is considered that the care practices, that ignore the social domain related to the breast diseases and surgery, cannot explain the sociocultural-oriented behaviors or thoughts. Therefore, must be careful consideration of the ‘social role function’ in the nursing care of women with breast cancer or breast diseases. At this point, Roy’s Adaptation theory can be recommended for the identification of ‘Social cohesion need’. Also, the use of the different nursing models with the theories social can be recommended for the next studies.

In the literature review conducted, the physiological needs in the nursing theories and models have been focused. On the other hand, the social needs have been described as domains that are difIn the literature review conducted, the physiological needs in the nursing theories and models have been focused. On the other hand, the social needs have been described as domains that are difficult to define but they couldn’t be clarified neither in the practice nor in the research. At this point, Roy’s Adaptation theory can be recommended for the identification of ‘Social cohesion need’. Also, the use of the different nursing models with the theories social can be recommended for the next studies. Sister Calliste Roy’s Adaptation Model defines the human as a “Holistic, adaptive system”. The role-function domain mentioned in the model is explained as the fact that the individual displays the behaviors expected by the society in order to sustain his/her position. These behaviors required to provide the social cohesion include the primary roles; the role of the gender (male, female), secondary roles; different roles (mother, father, teacher etc.) and the tertiary roles (president of foundation etc.) The basic requirement underlying this is defined as the social cohesion requirement. Based on this theory, it is considered that the awareness of the ‘Social cohesion need’ in the breast surgery care management will support the patients to adapt to their new lives and affect the life quality positively [25].

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