Psycho-Oncology

Psycho-Oncology 19: 1–11 (2010)

Published online 26 May 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1582

Review

Psychological adjustment among male partners

in response to women’s breast/ovarian cancer risk:
a theoretical review of the literature
Kerry A. Sherman1,2, Nadine A. Kasparian3,4 and Shab Mireskandari4,5
1
Department of Psychology, Macquarie University, Sydney, NSW, Australia
2
NSW Breast Cancer Institute, Westmead Hospital, Sydney, NSW, Australia
3
School of Women’s and Children’s Health, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
4
Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
5
Prince of Wales Clinical School, University of New South Wales, Kensington, NSW, Australia

* Correspondence to: Abstract

Department of Psychology,
Macquarie University,
Sydney, NSW 2109,
Australia. E-mail:
kerry.sherman@mq.edu.au
Received: 6 November 2008
Revised: 23 March 2009
Accepted: 29 March 2009
Objective: For women at high risk of developing hereditary breast and/or ovarian cancer the
process of undergoing genetic testing is anxiety provoking and stressful, entailing difficult and
complex decisions. Partners of high-risk women are frequently perceived by the women as a
source of support during this challenging time. Utilising Self Regulatory Theory, this paper
provides a theoretically guided overview of existing data to delineate how partners respond
emotionally and behaviourally to the woman’s high-risk status.
Methods: An extensive literature search was undertaken. Online searches of MEDLINE,
CINAHL and PsycINFO databases were conducted, reference lists of all publications
identified were examined; and the databases were searched for authors identified in these
publications.
Results: The systematic search yielded 10 published studies on at-risk women and their male
partners; one study did not investigate male partner distress as an outcome variable.
Heterogeneity of methodology in this literature precluded quantitative meta-analyses of study
outcomes. Review of the evidence suggests that the genetic testing process may be distressing
for some partners, particularly for partners of women identified as mutation carriers.
Associations were identified between partner distress and partner beliefs about the woman’s
perceived breast cancer risk; partner feelings of social separation and lack of couple
communication; and partner perceptions of being alienated from the testing process. Lack of
partner support was found to be associated with increased distress of the tested woman at the
time of testing and following results disclosure. Data are lacking on the role of partner beliefs
about breast cancer, partner perceived consequences of genetic testing, and personality factors
such as information processing style, on partner distress.
Conclusions: The high level of behavioural and psychological interdependence that exists
between a tested woman and her partner means that future research seeking to understand the
coping and adjustment processes of partners needs to adopt a dyadic, transactional approach
that is grounded in psychological theory. Specific suggestions for future research in this context
are delineated.
Copyright r 2009 John Wiley & Sons, Ltd.
Keywords: cancer; oncology; breast cancer genetic risk; partner; psychological adjustment

Overview: women at high risk of developing
breast/ovarian cancer
An estimated 10% of all breast and ovarian cancers
are attributable to a hereditary breast–ovarian
cancer (HBOC) genetic predisposition associated
with mutations in two genes, BRCA1 and BRCA2
[1–3]. Predictive genetic testing on affected and
unaffected family members aims to distinguish
between mutation carriers and non-carriers [2,4].
Healthy female mutation carriers have an average
lifetime risk of breast cancer of 45–65%, and
10–40% of ovarian cancer [5]. Non-carrier family
members are regarded as being at average breast/
ovarian risk. Genetic risk assessment involves the
provision of blood for genetic testing as well as
genetic counselling prior to, and following, the
disclosure of test results [6]. By providing more
accurate cancer risk information, genetic testing
allows mutation carriers to clarify the need

Copyright r 2009 John Wiley & Sons, Ltd.

2 K. A. Sherman et al.
for frequent surveillance and/or risk-reducing
measures [7–9], and to determine the possibility
of having passed the gene mutation to their
offspring [10–12].
Information derived from genetic testing is
highly complex and inherently difficult to interpret
[5,13]. Also, limitations in existing technology and
restricted availability of affected family members
may mean that tested individuals receive incon-
clusive results [14,15]. Individuals receiving incon-
clusive results, or those who are not offered genetic
testing and receive counselling alone, face the
psychological implications of living with sustained
uncertainty concerning their risk status [13,15–18].
Moreover, risk-reducing measures offered to
mutation carriers do not provide complete protec-
tion [19], and carriers may experience ongoing
worry about the possibility of having passed the
genetic mutation to their children (or future
children). Therefore, individuals with a family
history of breast/ovarian cancer are presented
with several challenges regarding their decision
to undergo genetic testing, and the implications
that testing will have for themselves and their
family [13].
Genetic testing and hereditary cancer is a family
matter [20,21], and social support from family
members, particularly partners, is a key resource in
enabling at-risk women to cope with the process
[22,23]. Partners may assist mutation carriers to
cope with their objectively verified cancer risk and,
for those women with inconclusive results, to cope
with the uncertainty of this testing outcome [24].
Less partner support and inhibited communication
about hereditary cancer have been associated with
greater cancer distress at the time of testing and 6
months following result disclosure [23]. Indeed,
among married mutation carriers, a women’s
perceptions of receiving partner support at the
time of testing are predictive of her cancer-specific
distress up to 2 years following testing [25]. Yet
when male partners are perceived by the tested
woman as being supportive, they are also perceived
as experiencing worry and anxiety, doubling the
burden of worry for the woman [26]. Unfortu-
nately, many tested women report difficulties in
communicating with their partner about hereditary
cancer, and may be reluctant to discuss these issues
in order to protect the partner from psychological
distress [23]. This protective buffering may in turn
lead to greater communication barriers and rela-
tionship discord [21].
Clearly, the support that the woman’s partner
provides during this challenging time will be
limited by his own ability to cope with the
situation. Unfortunately, while at-risk women have
been studied extensively, no attempt has been made
to systematically review data on how her partner
copes with, and adjusts to, this experience, or to
incorporate these findings within a unifying theo-
Copyright r 2009 John Wiley & Sons, Ltd.
retical framework. The importance of theory to
guide research endeavours cannot be underesti-
mated, and the adoption of a theoretical frame-
work serves as a guiding and focal point from
which to delineate a review of empirical studies. In
this paper, we utilise Self Regulatory Theory (SRT)
as a theoretical approach to understanding male
partners’ responses to their wife’s or female
partner’s participation in HBOC genetic risk
assessment. A central tenet is the notion that
individual responses to health-relevant threats are
determined by how the individual cognitively and
affectively processes information relating to the
threat [27–30]. The relevance of SRT (for a review,
please see [31]) to understanding individuals’
responses to genetic risk information has been
demonstrated empirically. This review is concerned
with male partners of at-risk women, and the term
‘partner’ will be used to denote the male partner
and ‘woman at risk’ to denote the female partner
who is contemplating, or has undergone, genetic
risk assessment.
A theoretical approach to understanding
male partners’ responses to HBOC risk
Considerable research has demonstrated that an
individual’s responses to a health threat cannot be
understood purely in cognitive terms or within a
strictly rational model of behaviour [32]. SRT
recognises individuals’ beliefs about and percep-
tions of an illness (i.e. their illness representations),
as key mediating links between health threats and
responses to them [29,30,33]. The theory delineates
five core dimensions of illness representations:
identity of the threat (i.e. perceived signs and
symptoms of, as well as past experiences with, a
disease); causal attributions (i.e. beliefs about the
cause(s) of an illness, such as genetics, stress, fate);
time-line (i.e. beliefs about illness development
and duration); consequences (relating to somatic
and psychosocial aspects of quality of life); and
controllability in terms of prevention and cure.
Variations in these representations, as well as in
perceived risk and demographic variables, will
evoke different responses to the same illness or
health risk. Typically, this model has been applied
to describe and predict responses of an individual
to their own health threat; in this review, however,
we will extend the application of this model to
a health threat that involves vicarious experience,
rather than direct threat per se. That is, we
will apply SRT to understanding male partners’
responses to the woman at risk for breast/ovarian
cancer.
Within the HBOC context, according to SRT,
there are a number of factors underlying the
processing of cancer risk information and are
likely to influence the male partner’s emotional
Psycho-Oncology 19: 1–11 (2010)
DOI: 10.1002/pon
Partner adjustment to women’s cancer risk
responses and adjustment to the health threat
presented to the woman at risk.
1. Illness representations: The male partner holds
his own beliefs about possible causes of breast/
ovarian cancer, the signs and symptoms
associated with these cancers, the likelihood
of prevention or cure, and the consequences of
genetic testing. These beliefs may be unique or
shared with the woman at risk.
2. Perceived risk: This relates to the way in which an
individual construes risk or susceptibility to
breast/ovarian cancer. We focus on the male
partner’s perceptions of the woman’s risk for
breast/ovarian cancer and how this may impact
his subsequent response to her genetic test results.
3. Coping skills: Self-regulatory competencies or
coping skills are concerned with strategies for
dealing with specific barriers to, and maintenance
of, physical/psychological adjustment to cancer
risk information, including strategies such as
acceptance of risk status and anxiety manage-
ment. Male partners are likely to possess a
unique set of self-regulatory skills for coping with
the woman’s high-risk status, and his coping will
likely impact not only his own adjustment, but
that of the woman at risk as well.
4. Personality: Recent revisions of SRT [31]
highlight the potential moderating role of
personality factors on an individual’s
adjustment to disease risk (or disease risk of
one’s partner). Monitoring information
processing style has been identified as a
potent moderator of responses to health
threats, influencing cognitive, behavioural and
emotional responses to health threat informa-
tion [27,34–39]. Specifically, individuals display-
ing a high monitoring style tend to vigilantly
scan for threatening cues and actively seek
health threat-related information, whereas low
monitoring individuals tend to avoid informa-
tion and invoke methods of distraction from
health-threatening cues [27,40].
Applied to the partners of women at risk, SRT
identifies a range of psychological factors that
should be addressed to facilitate adjustment to
genetic risk assessment. Given the emphasis on
individual processing of genetic risk information
within each couple, the woman at risk and her
partner are likely to respond uniquely to this
information, potentially resulting in clearly differ-
entiated psychological responses and adjustment to
the situation. Moreover, individual responses will
in turn, interact with each other to create a
complex interplay determining the overall couple
response to the health threat situation. Each of the
relevant individual processes will now be system-
atically reviewed with respect to adjustment and
distress among partners of at-risk women.
Copyright r 2009 John Wiley & Sons, Ltd.
3
Literature search strategy
Three strategies were employed to conduct the
literature search: (1) MEDLINE, CINAHL and
PsycINFO databases were searched using the
following key words individually and/or in
combination: breast cancer, ovarian cancer, genetic
testing, genetic counselling, hereditary diseases,
BRCA1, BRCA2, couple(s), partner, spouse,
husband, family, family members, and family com-
munication; (2) reference lists of all publications
identified were examined; and (3) the abovemen-
tioned databases were searched for authors identi-
fied in these publications. Studies were considered
eligible for inclusion in the literature review if they
were published in a peer-reviewed journal and were
in the English language. A systematic literature
search yielded 10 published studies on at-risk
women and their male partners [7,12,24,41–47].
All studies either primarily investigated partners of
high-risk women or included partners when in-
vestigating women themselves; however, one of
these studies [45] did not investigate male partner
distress as an outcome variable. The research was
conducted with approval of the Institutional Ethics
committee.
Genetic testing from the partners’
perspective: psychological adjustment
To date, nine studies have examined psychological
adjustment among partners of women who have
undergone genetic testing for HBOC risk, including
two qualitative and seven quantitative studies (see
Table 1). There is considerable variation between the
quantitative studies in this area, in terms of study
design (four cross-sectional, three prospective),
sample characteristics (four studies included women
unaffected by cancer only, three studies included
cancer-affected and -unaffected women), and assess-
ment points (two studies examined pre-test distress
only, two studies assessed short-term impact of
testing, one study assessed long-term impact of
testing, and two studies assessed post-testing distress
only). Given this heterogeneity, sufficient data were
not available to enable a quantitative meta-analytic
synthesis of results with respect to reported distress
levels among partners. However, review of the
evidence suggests that the genetic testing process
may be distressing for a small subset of partners,
particularly for partners of women identified as
mutation carriers (e.g. [7,42,43]).
Similar to the findings for HBOC women (for
review please see [48–50]), the available studies
show that mean distress scores reported by
partners are not indicative of clinical pathology.
However, up to 17% of partners, particularly those
who have recently learned that their wife is a
mutation carrier, report elevated levels of anxiety,
Psycho-Oncology 19: 1–11 (2010)
DOI: 10.1002/pon
 4

Table 1. Studies examining psychological distress among male partners in relation to the genetic testing process, presented in chronological order
Authors Country N Carrier status of Disease status Mean duration Design and Mean distress scores Proportion of
women at risk of womena of couple Measures sample report-
relationship ing elevated
distress levels
Baseline Post-test Post-test
(Pre-test) (Short-term) (Long term)

DudokdeWit The Netherlands 8b High-risk women eligi- Unaffected Not reported Cross-sectional IES IES-A 5 1.3 (0.7) Not examined Not examined Not reported
et al. [12] ble for direct mutation IES-I 5 1.4 (0.6)
testing for the BRCA1
gene
Lodder et al. The Netherlands 66 High-risk women who Unaffected Not reported Cross-sectional IES IES-I 5 Not Not examined Not examined. General

Copyright r 2009 John Wiley & Sons, Ltd.

[42] had decided to have HADS reported anxiety 5 17%
genetic testing IES-A 5 Not General
reported depression 5 12%
HADS-A 5 4.3 (5.6)
HADS-D 5 3.0 (3.1)
Lloyd et al. [41] United Kingdom 8 Women with a family Unaffected Not reported Qualitative (in-depth Some partners reported that the surgery had had no impact at all, Not applicable
history of breast interviews) while others noted an upheaval in family life, stress involved with the
cancer, who had under- supportive role, relationship strain, and financial strain due to lost
gone prophylactic bilat- work time while acting as a carer. Most partners were pleasantly
eral mastectomy surprised with the surgery outcomes, but some were initially shocked
Lodder et al. [7] The Netherlands 56 High-risk women Unaffected Not reported Prospective Partners of carriers Partners of carriers Not examined Post-test anxiety
found to be mutation IES IES 5 3.0 (3.0) IES 5 5.8 (7.4) Partners of
carriers or non-carriers HADS HADS-A 5 4.4 (3.8) HADS-A 5 5.7 (4.8) carriers 5 35%
HADS-D 5 3.3 (3.5) HADS-D 5 4.4 (4.1) Partners of non-
Partners of Partners of carriers 5 13% (sig.
non-carriers non-carriers diff.)
IES 5 5.6 (6.6) IES 5 3.9 (5.2) Post-test
HADS-A 5 4.3 (3.5) HADS-A 5 3.3 (3.9) depression
HADS-D 5 2.7 (3.0) HADS-D 5 2.1 (2.5) Partners of
carriers 5 18%
Partners of
non-carriers 5 3%
Metcalfe et al. Canada 59 BRCA1/2 mutation Mixed 25.8 years Range: Cross-sectional IES Not examined Not examined IES-A 5 7.27 (9.5) Intrusion 5 7%
[43] carriers who had (44% affected) 2.5–50 years IES-I 5 7.44 (7.9) Avoidance 5 13%
undergone testing 1–5
years prior to study
Bartle-Haring USA 5 Self-referring women Mixed Not reported Prospective —
et al. [47] with a family history of IES IES 5 4.6 IES 5 2.75 IES 5 0%
breast–ovarian cancer HSCL HSCL 5 1.43 HSCL 5 1.45 HSCL 5 0%
Manne et al. USA 118 High-risk women who Mixed (75% 22 years Prospective Partners of carriers Not examined Partners of carriers Not reported
[24] had decided to have affected) (SD 5 14.6) Range: IES IES 5 12.11 (3.2) IES510.37 (12.05)
genetic testing 1–55 years BSI BSI 5 16.96 (4.3) BSI 5 16.70 (4.0)
K. A. Sherman et al.

DOI: 10.1002/pon
Psycho-Oncology 19: 1–11 (2010)
Partner adjustment to women’s cancer risk 5

Abbreviations: IES, Impact of Events Scale (Total score); IES-A, Impact of Events Scale (Avoidance score); IES-I, Impact of Events Scale (Intrusion score); BSI, Brief Symptom Inventory; HADS, Hospital Anxiety and Depression Scale; DASS, Depression,
Avoidance 5 12%
signalling a need for further psychological assess-

depression 5 8%
Qualitative (in-depth Partners of mutation carriers and women with unknown mutation Not applicable

Intrusion 5 4%
ment and possible clinical intervention [42,46].

anxiety 5 4%
Importantly, partner distress is associated with

General

General
distress experienced by the at-risk wife [46], and
partner adjustment was associated with themes of: dealing with the worry about the chances of one’s children devel-
status most commonly reported themes relating to distress. Better

decision-making, satisfaction with their supportive role, and being

situation as a team with their wife, greater partner involvement in

optimistic. The need for additional support for partners was highlighted
oping breast cancer is a common and shared

IES-A 5 6.1 (8.3)

BSI 5 15.18 (3.1)

IES-I 5 4.4 (6.5)

IES 5 1.18 (2.2)

concern [21,26,43,44,46].

DASS 5 18.2

The term ‘affected’ is used to indicate women with a personal history of breast and/or ovarian cancer. The term ‘unaffected’ is used to indicate women who do not have a personal history of breast and/or ovarian cancer.
non-carriers

Another key finding is that partners of HBOC

Partners of

mutation carriers report significant increases in

(20.3)
general and cancer-specific distress in the short
term following test result disclosure, while
the opposite is observed for partners of non-
Not examined

carriers [7]. Although some data suggest that these

patterns of distress are not sustained [24,43], there
are no published prospective data on psychological
outcomes among partners beyond 6 months after
test result disclosure. Thus, more studies are
needed to shed light on the trajectory of psycho-
BSI 5 16.27 (3.7)
IES 5 8.45 (10.5)

Not examined

logical distress among partners in this context.

non-carriers
Partners of

Psychological adjustment and perceived risk

Cross-sectional IES

There are very few data to elucidate male partners’

Anxiety, and Stress Scale; HSCL, Depression and anxiety subscales of the Hopkins Symptom Checklist. N refers to the sample size for partners only.

perceptions of their wife’s HBOC risk—highlight-

interviews)

ing an area in which more research is necessary.

(SD 5 11.2) Range: DASS

Currently, we know that when partners do express

distress prior to disclosure of test results, they are
most concerned about the possibility of the woman
15.6 years Range:

developing cancer, and that their children may be

6–31 years

1–46 years
18.3 years

mutation carriers [43]. Through individual inter-

views, Mireskandari et al. [44] found that partners’
optimistic beliefs about their wife’s chances of
developing cancer were commonly accompanied by
reports of better partner adjustment. A follow-up
Unaffected

Unaffected

quantitative study [46] found that: (a) on average,

partners perceived their wife’s chances of develop-
ing breast cancer as higher compared with the
average woman of similar age; and that (b)
had undergone genetic
were non-carriers, and

High-risk women who

testing 1–94 months

perceived breast cancer risk was strongly associated

5 were of unknown
mutation carriers, 3

with psychological distress reported by partners.

7 women were

mutation status

prior to study.

These findings suggest a positive association

between perceived risk and distress, but the
available data are not prospective, so a causal path
cannot be delineated at this point in time.
15

95

Psychological adjustment and illness

representations

Interviews reveal that many partners avoid focus-

ing on potential testing outcomes in advance,
choosing to believe in the possibility that their
Australia

Australia

Includes 6 males, 2 females.

wife is not going to be a carrier, thereby postponing

distressing thoughts until the time of test result
disclosure [42]. Moreover, there appears to be a
Mireskandari et al.

Mireskandari et al.

discrepancy between expectations that the woman

holds about her own responses to the genetic
testing process, and the responses that her partner
[44]

[46]

expects of her. While most women undergoing

b
a

Copyright r 2009 John Wiley & Sons, Ltd. Psycho-Oncology 19: 1–11 (2010)
DOI: 10.1002/pon
6 K. A. Sherman et al.
testing anticipate no adverse emotional conse-
quences following identification of a mutation,
almost two-thirds of partners foresee adverse
emotional consequences for their wife following a
positive result [42]. Yet fewer partners (approxi-
mately 20%) report anticipating emotional con-
sequences for themselves if their wife receives a
positive result [42].
Little is known, however, about the role of
specific beliefs on the adjustment of partners
following test result disclosure. Retrospective data,
collected up to 5 years post-disclosure, indicate that
partners viewed the testing process positively and
were supportive of their wife’s decision to undergo
testing [43]. SRT predicts that greater belief in the
utility of genetic testing and efficacy of preventive
options will be associated with reduced psycholo-
gical distress among partners, particularly those
whose wife is a carrier. However, it is unclear
whether these positive beliefs have any causal role
on the subsequent psychological adjustment of the
partner or the test participant, or whether the
positive beliefs may be the result of better adjust-
ment. Only one quantitative study has examined
the hypothesis that perceived efficacy of available
preventive options is associated with reduced
psychological distress, and the study findings did
not provide support for this hypothesis [46]. More
prospective investigations are needed to clarify the
role of positive beliefs on partners’ adjustment and
to examine whether inconsistencies in anticipated
reactions to genetic testing have any pervasive
impact on subsequent psychological adjustment.
Perceived consequences and psychological
adjustment
Representations relating to potential genetic testing
consequences are likely to impact psychological
adjustment, particularly for mutation carriers and
their partners. Values and goals related to child-
bearing and children are known as important
motivators among women undergoing genetic
testing [45]. For both the women and their
partners, orientation to, and planning for, the
future may be modified in light of genetic risk
information. Interview data suggest that some
partners perceive negative consequences of being
a mutation carrier, and that they modify their life
goals accordingly (e.g. becoming more cautious
about risky undertakings; increasing quality time
spent with the woman at risk) [44]. However, it is
not known how these changes in values and goals
subsequently impact on psychological adjustment
of the partner and his at-risk wife.
There is minimal evidence detailing the conse-
quence of a positive test result on subsequent
childbearing decisions. A study involving a large
Utah-based kindred found that following result
Copyright r 2009 John Wiley & Sons, Ltd.
disclosure, female carriers and women with unknown
mutation status reported lower interest in child-
bearing than non-carriers [45]. In addition, among 18
male spouses of tested individuals, a reduction in
intentions to have children was clearly evident
among all partners of carrier women, compared
with half of the partners of non-carrier women, who
indicated a desire for children in the future [45].
Partners with children and whose wife was found to
be a carrier report experiencing heightened stress and
worry, particularly if they have daughters [44].
Hence, among couples of childbearing age,
mutation carrier status may have negative con-
sequences on long-term goals to have children,
leading the couple to question their desire to have
children or delay having children indefinitely
[51,52]. This may, in turn, impact on the psycho-
logical adjustment and relationship dynamics of
the couple. Researchers have yet to explore the
emotional ramifications of this goal-changing
process among partners, as well as the rippling
effects that this may have for the couple relation-
ship. Such a research question may be particularly
suited to qualitative methodologies, at least in the
first instance.
Self-regulatory ability and psychological
adjustment
Women at high risk have identified their partners
as being primary providers of cancer-specific
support as well as being active participants in
decision-making processes regarding screening
and/or prophylactic measures [53]. Unfortunately,
women at risk do not always receive quality
support from their partners, with reports of
partners lacking insight into the woman’s feelings
and limiting discussion within the couple [54].
Hence, the partner’s ability to provide this much-
needed support to the woman is challenged by his
simultaneous need to manage any personal distress
arising from the cancer risk situation and his ability
to understand the situation fully. It is therefore
important to consider factors that may limit
partners’ capacity to provide support.
Many partners report feeling alienated from the
testing process and receive no support at the time
of result disclosure [43]. While most tested women
report openly discussing genetic testing with
partners, almost a quarter of women in one study
chose not to do so [21], and other studies report
that some women make private decisions about
genetic testing in isolation from their partner
[24,55]. These findings are mirrored in reports of
mutation carrier women who feel socially separated
from their partner and experience a diminution in
partner communications [56]. In particular, tested
women and their partners may not be proceeding
at the same rate through a reintegration process
Psycho-Oncology 19: 1–11 (2010)
DOI: 10.1002/pon
Partner adjustment to women’s cancer risk
following positive result disclosure, leading to a
misunderstanding of each other within the couple
unit [26]. Information-seeking strategies are com-
monly adopted by male partners as a means of
managing the health threat situation, with poorly
informed male partners more likely to experience
distress, resentment and poor adjustment [44].
The complex interplay between the supportive
role and subsequent adjustment of the tested
woman and her partner is demonstrated in two
prospective studies [24,57]. Carriers who perceived
their partners to be anxious and non-supportive at
the time of testing experienced heightened distress
up to 2 years post result disclosure [57]. Similarly, a
study of mostly affected high-risk women and their
partners identified low partner support as being
associated with distress in the tested woman [24].
Partners also reported difficulty in providing
support to their distressed wife [24]. The reciprocal
association between having a ‘burdensome, non-
supportive’ partner and the elevated distress levels
of the test participant suggests that perceptions of
the supportiveness and adjustment of partners have
a pervasive influence on the test participant’s post-
test distress levels [57].
With little or no support specifically available for
partners, these men often resort to accessing the
woman at risk herself as a primary source of
support during the testing process [43]. This places
the tested woman in a difficult position as she is
being asked to provide support to her partner [26],
while she herself may be struggling to effectively
manage the situation [43]. Partners with less
education, a group more likely to experience
distress, are also the most eager to receive
additional support from clinic staff and sources
other than their at-risk wife [43].
The extent to which the tested woman is able to
provide her partner with adequate support will be
partly dependent on the couple’s ability to com-
municate effectively, which may be compromised in
this context, particularly for carrier women [56].
An inability to communicate with their wife about
their cancer risk has been reported as an additional
source of strain among partners and is potentially
linked to elevated partner distress [44]. In contrast,
in the HBOC context, open communication with
one’s wife is associated with lower general distress
among partners [46].
Personality and psychological adjustment
To date, only one study has investigated the
specific influence of monitoring attentional style
on male partner responses to genetic risk, and as
predicted, this study found that high monitoring
style and greater perceived breast cancer risk for
the woman were associated with higher general
partner distress [46]. Studies from other genetic risk
Copyright r 2009 John Wiley & Sons, Ltd.
7
contexts have shown that monitoring style influ-
ences the decision-making processes in which at-
risk individuals engage [37,58,59]. Extrapolating
from these results, it is possible that the match or
mismatch of monitoring styles within couples will
have implications for adjustment, coping, decision-
making and relationship quality [60,61].
From the individual to the couple
perspective
Using SRT we have examined the ways in which
specific individual factors may influence male
partner adjustment to the genetic risk situation.
Partners’ adjustment, however, is not solely a
function of individual responses, but is inextricably
linked to the overall adjustment, coping and
communication approaches of the woman at risk.
Participation in the genetic testing process may
potentially change marital relationships [23]. While
the process of waiting for test results is challenging
for most partners, following negative test result
disclosure many partners report that their marital
relationship returns to its pre-test status [44], and a
substantial minority of partners of mutation carrier
women retrospectively report becoming closer to
their wife following result disclosure [43]. However,
some partners report that the experience of under-
going genetic testing has a negative impact on the
marital relationship, particularly for partners of
mutation carrier women [46]. This may be due to a
diverse range of factors, such as the partner’s
distress concerning his wife’s increased risk,
inhibited communication, pressure placed on the
partner to provide emotional support for his
distressed wife, and worries about one’s children’s
cancer risk [22,23].
Similar outcomes have been reported in other
genetic testing contexts [62,63] and in responses to
illness [64–72]. The added strain on the couple
relationship may derive from each individual
having inadequate coping resources from which
to draw during this challenging time. In the case of
women undergoing BRCA1/2 testing, their reliance
on male partners for support is likely to be buffered
by access to other sources of support such as their
wider social networks, whereas men faced with a
health-related crisis often rely solely on their
spouses for support [66,73]. Therein lies a dilemma
for male partners of women at risk: they are
expected to provide support to their wife, while
experiencing elevated levels of distress themselves,
yet they have fewer additional sources of support
to which they can turn.
Given the high level of behavioural and
psychological dependence that develops between
couples [74,75], any research seeking to understand
the coping processes and adjustment of male
partners in the genetic testing context needs to
Psycho-Oncology 19: 1–11 (2010)
DOI: 10.1002/pon
8 K. A. Sherman et al.
consider the couple context as well as the broader
social context [76]. The difference in adjustment
outcomes between individuals and couples is likely
to be a complex interaction of couple-based
factors. This point is evidenced by research
exploring couple relationship factors and distress
among women anticipating genetic testing. Women
at risk often perceive their male partners as highly
influential in decision-making, yet negativity and
lack of support from the partner has a profound
effect on the wife’s levels of distress [53]. Moreover,
couple communication about genetic risk is an
ongoing process and is likely to influence decision-
making as well as adjustment outcomes [21]. There
is clearly a need for studying responses to genetic
testing using a dyadic, transactional approach, and
for understanding the woman at risk and her
partner within the larger context of their attach-
ment patterns and social support network [20,77].
In particular, the adoption of theoretical frame-
works that focus on diverse aspects of individual
and couple functioning such as family dynamics
and psychodynamic approaches [78], the life cycle
perspective [79,80] and attachment theory [81],
along with the individual approach typified by
frameworks such as the self-regulatory model,
would enhance further research in this area.
Limitations of the available literature and
directions for future research
The available literature provides valuable insight
into the experiences of male partners of women at
increased risk of breast/ovarian cancer, yet there is
still much work to be done in this area. Little is
known about the experiences of partners of women
affected with cancer compared with partners of
unaffected women. Theoretically, there are impor-
tant reasons to believe that the experiences of these
two groups of male partners may differ [20]; yet we
lack empirical data on this issue.
Given the scarcity of empirical papers in this
area, selection criteria for inclusion in this review
were by necessity, quite broad, particularly in terms
of the rigour of the research undertaken. Metho-
dologically, while the common use of validated
measures is a major strength of research in this
area, the published data are primarily descriptive
and the reported findings are based on relatively
small sample sizes [12,41,44,45]. Few studies
including partners have adopted prospective
designs [7,24] and so we have only limited data
on the trajectory of partners’ emotional responses
to genetic testing over time. Also, several studies
have either failed to provide information on the
duration of the couple relationship at the time of
study participation, or have not adjusted for this
variable in statistical analyses [7,12,41,45]. Thus,
we currently lack information on the role of
Copyright r 2009 John Wiley & Sons, Ltd.
developmental factors in partner adjustment.
Related to this, it would be interesting to investi-
gate whether differences in adjustment exist for
younger versus older couples. Further, key aspects
of SRT have been overlooked completely. For
example, there are currently no data on partners’
attributions for their wife’s breast/ovarian risk,
despite evidence of a link between causal attribu-
tions and psychological responses such as anxiety,
depression and denial in other disease contexts
[82,83]. Similarly, we also strongly encourage
researchers to further explore the potential inter-
play between personality characteristics, such as
monitoring style, and psychological adjustment
among partners, as well as the potential implica-
tions of the genetic risk situation for sexuality and
individual and marital adjustment. The concerns
related to sexuality have been completely over-
looked in this literature, yet are known to be key
issues raised in psychological counselling of
couples. Thus, this review has clearly delineated
suggestions for future research and provided a
rationale for funding of research that focuses on
the partner perspective in its own right and in
relation to the at-risk woman. The findings of this
work could be particularly fruitful in terms of
developing and trialling interventions and/or
resources to assist partners struggling emotionally
to come to terms with their wife’s situation.
Acknowledgements
Dr Kasparian is supported by a Post Doctoral Clinical
Research Fellowship from the National Health and Medical
Research Council of Australia (NH&MRC, ID 510399).
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