Sultan Qaboos University Medical Journal

Living with One Breast in Women with Breast Cancer after a Mastectomy
--Manuscript Draft--

Manuscript Number: 4332

Full Title: Living with One Breast in Women with Breast Cancer after a Mastectomy

Article Type: Original Study

Manuscript Classifications: 270: Gynaecology; 420: Nursing; 450: Oncology

Manuscript Region of Origin: INDONESIA

Keywords: body image; breast neoplasms; femininity; mastectomy; problem solving; self
concept

First Author: Tintin Sukartini

Corresponding Author: Tintin Sukartini

Universitas Airlangga
Surabaya, East Java INDONESIA

Corresponding Author E-Mail: yulia.indah.permata-2018@fkp.unair.ac.id

Order of Authors: Tintin Sukartini

Yulia Indah Permata Sari

Abstract: Objectives: This study aimed to explore the effects of a mastectomy on body image of
women with breast cancer. Methods: This study used a qualitative phenomenological
approach. This study involved 30 women with breast cancer after a mastectomy
obtained by purposive sampling technique using inclusion criteria: 1) age ≥21 years, 2)
diagnosis of primary breast cancer to stage I-III, 3) able to communicate verbally and in
writing well, 4) time since mastectomy at least 6 months. Data collection was carried
out using semi-structured interviews. Data were analyzed using Van Mannen approach
with the help of NVivo 12 software. Results: Three main themes were identified in this
study: 1) breast meaning, 2) self-concept, and 3) coping strategies among post-
mastectomy women. Breasts are interpreted as a symbol of female identity that reflects
femininity and attraction. Mastectomy results in changes in appearance that can affect
a woman’s body image, self concept and social interactions. Emotional focused coping
and problem solving focused coping are coping strategies used by women after
mastectomy. Conclusion: Breasts are a symbol that is synonymous with femininity,
beauty and attraction. Thus after losing their breasts due to a mastectomy, many
women feel that they have lost their femininity and confidence.

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Abstract
Objectives: This study aimed to explore the effects of a mastectomy on body image of women with breast
cancer. Methods: This study used a qualitative phenomenological approach. This study involved 30 women
with breast cancer after a mastectomy obtained by purposive sampling technique using inclusion criteria: 1)
age ≥21 years, 2) diagnosis of primary breast cancer to stage I-III, 3) able to communicate verbally and in
writing well, 4) time since mastectomy at least 6 months. Data collection was carried out using semi-structured
interviews. Data were analyzed using Van Mannen approach with the help of NVivo 12 software. Results:
Three main themes were identified in this study: 1) breast meaning, 2) self-concept, and 3) coping strategies
among post-mastectomy women. Breasts are interpreted as a symbol of female identity that reflects femininity
and attraction. Mastectomy results in changes in appearance that can affect a woman’s body image, self
concept and social interactions. Emotional focused coping and problem solving focused coping are coping
strategies used by women after mastectomy. Conclusion: Breasts are a symbol that is synonymous with
femininity, beauty and attraction. Thus after losing their breasts due to a mastectomy, many women feel that
they have lost their femininity and confidence.
Keywords: body image; breast neoplasms; femininity; mastectomy; problem solving; self concept

Advanced in Knowledge
- This study provides an overview of the coping strategies used by women who undergoing mastectomy.
- Mastectomy is closely related to a women’s psychosocial condition

Application to Patient Care

- Breast cancer health care teams should pay attention to the psychosocial aspects to women who undergoing
a mastectomy
- Women who undergo mastectomy need psychologist assistance and counseling to help improve their self-
esteem, self-acceptance, and self-confidence.
- Women who undergo mastectomy should have regular check-up which include physical and mental health

Introduction
Breast cancer is the leading cause of cancer deaths in women. As in the rest of the world, the breast cancer
rate in Indonesia is continuing to rise. In Indonesia, breast cancer is the cancer with the highest incidence
totaling 58,256 (16.7%). It is also the second-highest mortality rate reaching 22,692 (11.0%) in 2018.1 East
Java Province occupies the 11th position regarding the prevalence of cancer in populations of all ages in
Indonesia and breast cancer ranks as having the highest number of cases in East Java.2 Nearly 90% of women
diagnosed with breast cancer at an early stage undergo a unilateral or bilateral mastectomy with or without
reconstruction.3

A mastectomy is a surgical procedure for breast cancer resulting in permanent changes to a woman's
appearance.4 Breast loss due to a mastectomy is a traumatic event experienced by women.5 Breasts are
considered to be part of a woman's identity, representing femininity, sexuality, beauty, motherhood and giving
them the ability to breastfeed their babies.6 The loss of one breast will also cause self-concept disorders such
as changes in body image, a loss of self-identity, a change in social role, a change in self-ideal and also a loss
of self-esteem.3,7–9 Negative self-concept has a high tendency to result in stress and depression.10
Providing psychosocial support for patients after a mastectomy is one of the nurse's important
responsibilities.11 Among the self-concept disorders that can arise as a result of a mastectomy is related to the
changes in their body image.9 During the process of treating breast cancer, a patient's body image and the
problems related to their condition can affect their physical and emotional health.5 Thoughts about body
image, the possibility of metastasis or breast reconstruction can dominate a patient's daily life. A study into
women with breast cancer undergoing a mastectomy can help to better understand and improve patient health.
Based on these descriptions, the purpose of this study is to explore the effects of a mastectomy on the body
image of women with breast cancer.

Method
Design
A qualitative research design with a phenomenological approach was chosen to explore the impact of a
mastectomy on the body image of women with post-mastectomy breast cancer. The participants in this study
were 30 (thirty) women with post-mastectomy breast cancer that were obtained using a purposive sampling
technique. The inclusion criteria were: 1) age ≥ 21 years old, 2) diagnosis of primary breast cancer stage I -
III, 3) able to communicate orally and in writing and 4) time since the mastectomy was at least 6 months. The
exclusion criteria were: 1) having mastectomy complications and 2) having other comorbidities such as a
diagnosis of secondary cervical cancer and ovarian cancer.

The study was conducted at the Reach to Recovery Surabaya (RRS) community which a support group for
breast cancer sufferers who live in Surabaya, under the guidance of the Surabaya Oncology Hospital and the
Indonesian Breast Cancer Foundation. Data were collected from January - March 2020.

The researchers acted as an instrument in the research conducted, thus the researchers cannot be represented
or delegated. The data collection tools consisted of audio recorders, field notes made during the interview
process, and interview guidelines prepared based on the research objectives. The interview process began by
asking open-ended questions such as "Can you tell us about what you have experienced since you first learned
that your breast must be removed?" The interviews were conducted and had a duration of about 30 - 45
minutes. The data was said to be saturated if more than half of the total participants answered using the same
keywords. The interview process was carried out over 3 meetings. The first meeting was to introduce the
participants and to explain the purpose of the research. The second meeting was to conduct the interview
process according to the agreed time and place. The third meeting was to conduct the interviews related to the
questions that had not yet been answered by the participants. After listening to the results of the interview and
reflecting on the verbatim form, the researcher validated the written results with the participants to ascertain
whether the interview results were appropriate or not.

Thematic analysis of interview transcripts was carried out in detail, highlighted, and was holistic.12 First, the
interview transcript was read carefully and repeatedly. In holistic approach, the researchers must read the text
carefully in order to understand its overall meaning. The researcher then highlights or chooses sentences and
statements that seem important for this study. Second, the researcher develops keywords and concepts through
dialogue with the text. The researchers work to gain understanding and involvement with the phenomenon
and finally, each sentence is analyzed, and through this process, important themes are found. These themes
are then reconstructed into a description of the participants’ life experiences.13 The data analysis process was
carried out with the help of the NVivo 12 software.
LincoIn and Guba’s Framework shows that qualitatvie research must have a component of validity, a test of
credibility (internal validity), transferability (external validity), dependability (reliability), and confirmability
(objectivity).14 The credibility test is done thorugh member checking. Participants are asked to reconfirm the
results of the interviews that have been conducted. After that, they agree that the results of the study are in
accordance with the interviews that have been conducted. The dependability test is carried out during the
consultation activity, which is form the initial determination of the research problem, how to conduct data
analysis, compilation of research activity reports, and sharing of interview transcripts. A follow-up interview
is aimed at clarifying understanding of their experiences to increase trust.

Results
Table 1 shows the characteristics of 30 participants who were involved in this study. All interviewees were
women aged 38 – 65 years old (mean age: 50 years old). The majority of participants were married (86,7%)
and four participants were widowed. Most of participants undergone modified radical mastectomy and three
of them had nipple sparring. The majority of participants were in stage II (50%). Most of participants
undergone chemotherapy and radiotherapy, and five participants were on herceptin.

The results of the study identified 3 main themes: 1) breast meaning, 2) self-concept, and 3) coping strategies.
Breast meaning consists of two sub-themes, namely sexual role and additional reproductive ‘organs’. Self-
concept consisted of 5 sub-themes namely self-image, self-identity, self-role, self-ideal and self-esteem. The
theme of coping strategies consisted of 2 sub-themes, namely emotion-focused coping and problem-solving
focus coping.
Theme 1: Breast meaning
The breast is an accessory gland of the female reproductive system. Breasts are also part of the of women that
distinguishes them from men. This theme is identified through the subthemes of 1) sexual role and 2)
additional reproductive ‘organs’.
Sexual role
In terms of the function of sexuality, breasts are a point of attraction to the opposite sex that can arouse sexual
desire. Breasts also have a meaning associated with femininity and motherhood that distinguishes women with
men.
"Breasts are part of the body anyway, let me say feminine, although now they feel no longer feminine" (P5).
"Breasts show that we are different from men, show femininity, show that mothers can breastfeed" (P7).
"One of the attractions of her woman here (while holding her breasts)" (P9).
Additional reproductive ‘organs’
As an additional reproductive tool, the participants stated that their breasts are an ‘organ’ that perfects women.
"Breasts are a part of me that perfects me as a woman" (P2).
"Breasts are a symbol of female beauty, more beautiful if still perfect" (P6).

Theme 2: Self Concept

This theme was identified through the sub-themes of 1) self-image, 2) self-identity, 3) self-role, 4) self-ideal
and 5) self-esteem.
Self-image
The removal of one or both breasts results in changes in physical appearance. The changes in appearance
experienced include hair loss and finger blackening due to chemotherapy and breast loss due to the
mastectomy itself.
"I feel life is strange (while crying), it was okay, now I have no hair, I'm ashamed that my head is bald" (P3).
"This is the same (while holding her breasts) her breasts are operated on one, so it's flat ya" (P5).
"Then this (while holding his bare head) fell, my fingers turned black, bro, I don't know why, but the doctor
said because of the chemotherapy" (P8).
Self-identity
Breast removal can result in the desire to hide their reality and to change the way that they dress. Most of the
participants stated that they wanted to cover up their bodily shortcomings by changing how they dress and by
wearing loose clothing.
"I wear loose clothes to avoid people's eyes" (P10).
"I wear a veil covering my chest, one of which is to cover my chest, which is only one breast" (P12).
Self-role
After a mastectomy, there are changes in activity that can cause women to not be able to fulfill their roles and
responsibilities. They feel useless and lose their social identity. Most of the participants revealed that they
could not do their housework as before.
"After my operation, I was bathed by my husband so because I was still using a hose, I was only sitting in a
chair, I was bathed. Yes, my husband is thoroughly taking care of me” (P2).
"After the operation, I could not do any activities. My child helps clean the house. In my heart I was very sad,
I hoped to be able to carry out my duties and roles at home, but not yet” (P6).
Breast removal in women can affect their relationship with the environment, resulting in a limited social life
and a tendency to avoid social interactions.
"I avoid going to events that are full of people. I feel insecure about my appearance now" (P10).
Self-ideal
Breast loss also causes concern regarding their sexual life as their husband may not feel that they are ideal as
a wife.
"That affected the relationship with my husband. In the sex life of my husband and wife, I feel that I cannot
serve my husband to the fullest" (P9).
Self-esteem
After a mastectomy, the majority of participants described themselves as imperfect. The participants also
revealed that they did not feel beautiful because their bodies were now incomplete. The participants felt
ashamed of losing one breast. Breast removal can mean that they feel a loss of attractiveness as a woman.
"Before the operation, I felt the same as another woman who had two breasts, but after the surgery, I thought
I was not perfect anymore because my breasts were incomplete" (P1).
"Sometimes I feel sad too, you know as a woman, as a wife if it's not perfect how she feels" (P2).
"Before I was sick, one of the attractions of women is breasts, now it's missing one so it's no longer attractive"
(P6).
"I am very sad, I am ashamed because a part of my body is missing" (P7).
"After the operation, I thought, I was prettier before. In the past, I felt beautiful but now I lost my breast. To
be honest, I feel worse right now (his eyes are starting to look teary with tears)" (P9).
"Frankly, I feel lost. I feel my body is deficient" (P12).

Theme 3: Coping Strategy

Changes in their appearance and physical condition will result in stressors experienced by the sufferers,
therefore coping strategies are needed to overcome these stressors. This theme was identified through two
sub-themes: 1) emotional-focused coping and 2) problem-solving focused coping.
Emotional focus coping
Coping strategies that focus on emotions include denial, self-blame and withdrawal from social interactions.
Denial is one of the acceptance reactions to the conditions expressed by participants where there is
disagreement with reality. This involves denying reality or refusing to accept the reality of the loss of their
breast(s).
"I never thought that I would be in this condition, having breast cancer and having to lose one of my breasts"
(P5).
"At first I was refused, there was no way I would get cancer ..." (P7) (P8).
The participants tend to blame themselves for what they are experiencing and they have a negative view of
themselves.
"It's all my fault, can't take care of my food, my lifestyle ..." (P3).
The loss of one breast can cause feelings of shame that can make post-mastectomy women withdraw from the
social environment.
"After this illness, I did not dare to leave the house ..." (P3).
"I didn't leave the house and joined the PKK gathering" (P8).
Problem-solving focus coping
Coping strategies that focus on problems are in the adaptive category where the participants can overcome the
problems that they experience in several ways including improving their spirituality, relaxing and sharing their
experiences with fellow sufferers.
"Every time I want to do what I pray, let the heart be calm" (P1).
"I pray, pray that I will be given peace in facing my present condition" (P4).
"Yes, usually pray, I hope this disease is quickly removed" (P6).
Besides praying, the participants also carried out activities such as listening to music. Listening to music is
part of the distraction technique used to overcome the anxiety that is experienced.
"When I'm alone I sometimes listen to favorite songs to relieve stress" (P4).
Some of the participants engaged in substitutive activity while waiting for treatment by reading a book.
"Read and read books to not get bored ..." (P7).
Talking and sharing their experiences is one of the activities that distract the individual's attention from
thinking. It can also help them to take action to deal with their stressors.
"By sharing stories and sharing experiences with fellow sufferers there, it can provide information that doesn't
be afraid, all of them have gone through such a process" (P5).

DISCUSSION
Theme 1: Breast meaning
This research was conducted to learn more about the women's perception of the effects of the mastectomy on
their body image. For some of the participants in this study, breasts symbolize femininity, beauty and
motherhood. Previous research has confirmed that the breast is one of the most important symbols of
femininity.15 Breasts can also be sites of sexual pleasure for women. It is a bodily location from which, whether
shared with a partner or not, they may derive delight. Their breasts, whether youthful or aged, can be part of
a feminine and sexual identity that may play an intimate role in a woman’s ability to give and receive pleasure.
Their breasts are not merely a site of discursive oppression; they may also be a site of empowerment whereby
women can gain personal fulfillment.16
Theme 2: Self-Concept
In this study, the majority of women had negative judgments regarding their self-image after undergoing a
mastectomy. This shows that women experience negative emotions due to the physical changes resulting from
surgery. Studies related to this problem have reported that women consider their appearance to be imperfect,
disproportionate, and unattractive after undergoing a mastectomy.17 Women who experience a negative body
image after breast loss often try to change the way that they dress to overcome the discomfort that they feel.
Many women find it difficult to dress comfortably and to adjust to their new bodies after a mastectomy.18

Breast loss due to a mastectomy will be considered by many women as a serious blow to a woman's self-
identity and feelings.19 The existing studies emphasize women's breasts as a symbol of femininity, beauty and
attraction, and they are seen of as complementary for women.15 Thus after losing their breasts due to a
mastectomy, many women have lost their femininity and confidence. 20,21

Previous studies reported that women felt unable to carry out their daily activities such as shopping, cleaning
the house, and washing clothes due to the limited movement of their arms after the operation.22 Women who
cannot fulfill their role in life after undergoing a mastectomy will experience loss related to the things that
they used to easily do. This situation can affect their emotional reactions which can ultimately affect their
body image negatively.21 After losing their breasts, some women want to avoid social interactions because
they feel insecure about their changed appearance.23 Other studies in several countries also report general
findings on the negative impact of a mastectomy on a woman's social life.24

Women who have undergone a mastectomy are worried that changes in their appearance will hurt their sexual
life with a partner.25 Following on from the previous research which states that breast cancer patients, in
general, are unable to carry out their functions as women, they realize that their sexual attraction has
disappeared and they are worried that their breasts are no longer beautiful.26

The physical changes due to a mastectomy are proven to reduce self-esteem and negatively affect their body
image. This includes the emergence of shame and low self-esteem associated with an imperfect physical
condition.18 The quality of life of breast cancer patients is influenced by their self-esteem. According to the
research, self-image significantly influences self-esteem which results in the emergence of shame in the
sufferers and a low body image.7 The previous research mentioned that there is a significant relationship
between self-esteem, quality of life and depression. Low quality of life will reduce self-esteem and low self-
esteem will increase the rate of depression.27

Theme 3: Coping Strategies

The coping strategies focusing on the emotions expressed by the participants are namely maladaptive coping.
Denial is the first response when someone experiences loss.28 Denial is a form of avoiding all thoughts about
the possible effects of cancer. This can look beneficial because while it might not eliminate their negative
mood, it can help the women with breast cancer stay away from negative thoughts and feelings, thereby
encouraging feelings of hope for a positive health outcome.29,30 Self-blame is a form of helplessness
concerning the problem faced by blaming themselves without the presence of an optimal self-evaluation.31
Women with breast cancer who undergo a mastectomy tend to blame themselves for what they are
experiencing and they have a negative view of themselves. This will have an impact on their withdrawal from
the social structures present.32 According to the research, women with breast cancer will blame themselves
after a cancer diagnosis is made30. The time for this to impact can be 4 months, 7 months or even a year after
diagnosis. Self-blame is associated with increased symptoms of anxiety and depression.33 Self-blame is a
maladaptive behavior and it will have a long-term effect on the psychological adjustment of the breast cancer
patients.31 The withdrawal experienced by the participants is due to the feeling of shame because of the loss
of one breast due to surgery. The results of the previous studies show that the patients who use coping
strategies to withdraw have a significant risk of poor long-term psychological adjustment. This will also
disrupt their cortisol rhythm.34

The coping strategies that focus on problems are in the adaptive category where the participants can overcome
the problems experienced in several ways such as improving their spirituality, relaxing, doing their preferred
activities and talking. Upon undergoing long-term treatment for breast cancer and its psychological condition,
some of the participants have taken part in more activities. Praying is important to overcome psychological
stressors and to calm their feelings.35 Praying is proven to be effective at helping them to heal.36 The research
shows that patients who always pray to the creator are proven to have a higher percentage of recovery
compared to non-religious people. Confidence and spirituality are very sensitive things.37 Listening to music
is part of the distraction technique used to overcome anxiety. This is because music works on the limbic system
which will be delivered to the nervous system. This regulates the contraction of the body's muscles and reduces
tension. Music helps to improve the quality of a person's life by producing positive changes in their behavior.
Previous research states that listening to music is an option when seeking to reduce the symptoms of
depression, fatigue, and pain. This is because listening to music will affect the emotional and psychological
state of the cancer patients.38 Reading a book is also one of the distraction techniques that can be used to
overcome anxiety.39 The participants tried to improve their coping strategies by sharing stories about their
experiences related to breast cancer with other sufferers. This can reduce their level of depression and improve
their psychological well-being. One way to improve the coping of the cancer patients is by getting them to
share stories about their experience to avoid a decline in their psychological well-being and depression.40

The limitations of this study are that it only focuses on the changed body image experienced by women with
post-mastectomy breast cancer. This study could be better by conducting a deeper exploration of the
biological, psychological, social, spiritual, and cultural elements. The 5 elements are inseparable and a
disruption to one element is a threat to the other elements. It is hoped that this small exploratory study can
provide a picture related to the body image experienced by post-mastectomy women and that it can contribute
to improving the supportive care related to the body image of women suffering form cancer who have been
treated with a mastectomy.

Conclusion
Breast loss due to a mastectomy as experienced by the participants can negatively affect body image and self-
image. Breasts are a symbol that is synonymous with femininity, beauty and attraction. Thus, after losing
breasts due to mastectomy, many women have lost their femininity and confidence. The coping strategies used
by the patients vary and are both adaptive and maladaptive in terms of adapting to the changes in their
appearance. Emotion-focused coping and problem-solving focused coping are the coping strategies used by
women with post-mastectomy breast cancer.

Ethical Approval
This study received ethical approval from the Health Research Ethics Commission of the Faculty of Nursing
Universitas Airlangga with number 1869-KEPK on December 26th 2019.

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Table 1. Participants' Characteristics
Age Marital Status Caregiver Occupation Stadium Types of mastectomy Type of Treatment
(before/during the
sickness)
P1 (59 y/o) Married, 2 children Family (husband) Self employer IA MRM sinistra Chemotherapy
P2 (47 y/o) Married, 2 children Family (husband) Housewife II B MRM dextra Chemotherapy
P3 (52 y/o) Married, 3 children Family (husband) Self employer II B MRM dextra Chemotherapy and
herceptin
P4 (47 y/o) Married, 1 child Family (husband) Lecturer II A Nipple-sparing Chemotherapy and
mastectomy radiotherapy
P5 (51 y/o) Married, 2 children Family (husband) Housewife II A Nipple-sparing Chemotherapy and
mastectomy radiotherapy
P6 (50 y/o) Married, 2 children Family (husband) Housewife III B MRM dextra Chemotherapy and
radiotherapy
P7 (51 y/o) Married, 3 children Family (husband) Banker II A MRM dextra Chemotherapy and
herceptin
P8 (60 y/o) Married, 2 children Family (husband) Retired II A MRM sinistra Chemotherapy
P9 (53 y/o) Married, 3 children Family (husband) Civil servant II B MRM sinistra Chemotherapy,
radiotherapy, and
herceptin
P10 (41 y/o) Married, 1 child Family (husband) Civil servant III A MRM dextra Chemotherapy,
radiotherapy, and
herceptin
P11 (50 y/o) Married, 3 children Family (husband) Housewife I MRM sinistra -
P12 (46 y/o) Married, 2 children Family (husband) Housewife II A MRM sinistra Chemotherapy
P13 (60 y/o) Married, have no Family (husband) Retired IA MRM sinistra Chemotherapy
children
P14 (53 y/o) Widow, 1 child Family (child) Merchant III B MRM dextra Chemotherapy
P15 (53 y/o) Married, 2 children Family (husband) Civil servant III C MRM sinistra Chemotherapy
P16 (40 y/o) Married, have no Family (husband) Banker III C MRM sinistra Chemotherapy
children
P17 (39 y/o) Married, 2 children Family (husband) Housewife III B MRM sinistra Chemotherapy
P18 (55 y/o) Married, 1 child Family (husband) Housewife III B MRM dextra -
P19 (44 y/o) Widow, 2 children Family (husband) Housewife II B MRM dextra Chemotherapy
P20 (46 y/o) Married, 3 children Family (husband) Lecturer II A Nipple-aerola complex Chemotherapy
skin sparring mastectomy
 P21 (44 y/o) Married, 2 children Family (husband) Housewife III A MRM sinistra Chemotherapy
P22 (43 y/o) Married, 2 children Family (husband) Housewife III B MRM dextra Chemotherapy
P23 (59 y/o) Widow, 3 children Family (children) Merchant II B MRM dextra Chemotherapy
P24 (65 y/o) Widow, 3 children Family (children) Housewife III A MRM dextra Chemotherapy
P25 (55 y/o) Married, 2 children Family (husband) Merchant II B MRM dextra Chemotherapy
P26 (55 y/o) Married, 3 children Family (children) Housewife II B MRM dextra Chemotherapy
P27 (40 y/o) Married, 2 children Family (husband) Housewife III B MRM sinistra Chemotherapy,
radiotherapy and
herceptin
P28 (51 y/o) Married, 2 children Family (husband) Jurnalist II A MRM dextra Chemotehrapy
P29 (55 y/o) Married, 3 children Family (husband) Civil servant III B MRM dextra Chemotherapy and
radiotherapy
P30 (38 y/o) Married, 1 child Family (husband) Self employer II A MRM dextra Chemotherapy
P: participants; MRM: Modified Radical Mastectomy
 Table 2 Themes Distribution

Themes Sub-themes
Breast meaning Sexual role
Additional reproductive ‘organs’
Self-concept Self-image
Self-identity
Self-role
Self-ideal
Self-esteem
Coping Strategies Emotional focus coping
Problem solving focus coping