The social taboos that surround body matter elimination are legion, so that, when a stoma is raised as a surgical procedure, as either an elective procedure or an emergency one, the individual's body image changes for ever. Stoma is derived from classical Greek meaning 'mouth' and is used as a medical term meaning 'artificial opening' (Black, 2000).
Body image, the mental picture of physical being that individuals retain, develops from birth onwards and continues throughout life; it is related to different factors affecting its formation and dynamics. A crisis such as the formation of a stoma leads to an alteration of body image and an awareness of the meaning of the change in appearance and function of an individual (Black, 1992). An individual's behaviour can be examined in several domains: physical, cognitive, emotional, cultural, sexual and economic. Feelings of violation of the body boundaries, degradation, mutilation and restriction occur. The intensity of emotional reactions to body changes is related less to the severity of the disability than to the assigned importance of the structure, and this appraisal depends, among other factors, on the individual's immediate social situation and past experiences. It follows that the importance assigned to the function will also be a determinant in the severity of the emotional reaction.
Many factors affect the patient's ability to adapt to an alteration in body image, and these are relevant to both the patient and the patient's family. These factors include, but are not limited to, the disease process, diagnosis, treatment, and medical and nursing care within the hospital and on return to the community. Most people feel that bodily elimination is a private function, managed best in one's own home. This can be related to the common notion that dirt is harmful to both the individual and others. In furthering the notion that dirt is essentially disorder and offends against order, elimination is not a negative movement but a positive effort to organize the environment (Douglas, 1966). By reordering our environment we make it conform to an idea. An individual with a stoma sees him- or herself as a person who has transgressed certain social expectations and failed in certain personal responsibilities.
Excretion and excretory behaviour are rigidly controlled in each culture and in each society, and in western societies there are strong prohibitions on the uncontrolled passage of urine and faeces. Prohibitions concerned with excrement are numerous, and it has been associated with madness, danger and witchcraft. To excrete through a different body exit requires a specific schema, which the individual and his society must understand if the individual is not to become a marginal member of that society. The western world enforces rigid laws in association with the civilized disposal of human waste by means of the private act of excretion, and the raising of a stoma can risk placing the individual in a liminal position as a person who may be dangerous to society. As human beings we draw boundaries between ourselves and the outside world. When these boundaries break down we find it profoundly disturbing, and when something in the system that we have conceived breaks down it violates something intrinsic to our sense of ourselves. Most people deal with this disturbance by denying what is happening. Littlewood (1985) suggests that, in western culture, if one can define oneself as sick when acts of excretion occur in the wrong place, they can be forgiven or managed in such a way as to ensure that the transgressor is not socially ostracized.
The individual who loses control over bodily elimination is presented with sensory phenomena (sounds, odour) that were previously within his or her control (Klopp, 1990). In addition to the person's own perception of these phenomena (actual or potential), the social perception of the phenomena becomes an issue, because of their very nature. We learn to control elimination at an early age, in private, so that exteriorizing the bodily structures that we use for elimination and loss of control over the accompanying sensory phenomena inevitably result in a changed body image. The change in body image after stoma surgery can be equated with a rite of passage, one that is not purifactory but prophylactic.
Following stoma surgery the individual's status within society is not being restored but redefined, and while being redefined passes through a transitional state that is deemed by society to be dangerous. After stoma surgery anxiety or even terror is expressed in relation to pollution beliefs. Although pollution beliefs are a cultural phenomenon, fear is exhibited by the individuals in understanding how they will be able to modify their behaviour and hide their stigma on their return to the culture and society in which they live (Goffman, 1963).
It is important to identify the specific areas most likely to affect patient outcome after stoma surgery. The most important area is the adaptation of patients to their change in body image, both internally and externally. In seeking to derive a framework it is necessary to consider the implications of stoma surgery. The sources of stress to patients admitted to hospital, especially those undergoing surgery, have been described by many researchers, among them Cohen and Lazarus (1982). For the patient undergoing stoma surgery, additional sources of stress arise: threats to body integrity, permanent physical damage, loss of autonomy and control, and the fear of the possibility of a histological finding of a life-threatening disease. Although profound distortions in body image are rare, there are many anxieties about the body and its image in relationship to its orifices, boundaries and bodily fluids. Stigmatization by exteriorizing excretory organs, especially later in life, may lead to an individual having problems with the re-identification of self or to the development of self-disapproval. This may be expressed in distortion of the total self, giving rise to confusion and negative changes in the individual's self-perceptions. People who had previously high self-esteem expectations, or those who take great pride in their appearance, care very much how others will perceive them and will find it more difficult to accept changes in body image and presentation of self. A stoma that is disfiguring to the body will be equally disfiguring to the mind. In addition, violation of the body's intactness can be perceived at a fantasy level as a physical or sexual assault. Kelly (1985) writes:
. . . for the rest of the day I felt utterly wretched, sad and overwhelmed by a sense of loss and failure. I was not upset by the loss of my bowel per se but rather by the loss of its function. The sense of failure came from viewing my body as being wrecked by surgery. What really alarmed me were the physiological consequences, especially the incontinence and smell. These I believed would become the defining characteristics of my social identity and everything about me, my relationships, and the way others viewed me would be conditioned by these.
The major consideration in terms of adaptation to the change in body image after stoma surgery would seem to the length of time that the grieving process takes. Parkes (1972) outlined the stages that appear to occur in all individuals with a change in body image:
• Realization: characterized by avoidance or denial of the loss of the part followed by experiences of unreality or blunting.
• Alarm: characterized by anxiety, restlessness, fear and insecurity.
• Searching: characterized by acute episodic feelings of anxiety and panic and preoccupation with loss.
• Grief: characterized by feelings of internal loss and mutilation.
• Resolution: characterized by efforts to construct a new social identity.
In adapting to body image change after a stoma, Sutherland et al. (1952) were quoted as saying that an immense price is paid by the patient with a stoma for the cure and relief of the disease, which incorporates not only physical discomfort, but also psychological and social trauma. Devlin et al. (1971) looked at the effect of stoma surgery and found how devastated the patient with a stoma can be and how life could be quite complicated. Padilla and Grant (1985) suggested that there is a relationship between the quality of life and self-esteem among individuals with a stoma and that most stoma patients had positive perceptions. They suggested that individuals with poor psychological recovery outcomes would not return to their employment, would become reclusive and refuse contact with their social group and even their families. Wade (1989) indicates that a patient facing stoma surgery also faces the prospect of a change in appearance and loss of control over elimination.
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