{"paper_id":"5e4fdf3e-2c68-4755-918d-9e5bac07b3bc","body_text":"Vol.:(0123456789)1 3\nSex Roles (2023) 89:277–287 \nhttps://doi.org/10.1007/s11199-023-01389-3\nORIGINAL ARTICLE\nA Qualitative Analysis of the Fertility Experience and Gender Identity \nin Young Women Following Hysterectomy for Benign Disease\nDaisy Bottomley1 · Lesley Stafford1 · Gina Blowers1 · Charlotte Reddington2,3 · Uri Dior2,3 · Claudia Cheng2,3 · \nMartin Healey2,3\nAccepted: 7 June 2023 / Published online: 6 July 2023 \n© Crown 2023\nAbstract\nHysterectomy may impact young women’s perceptions of their gender identity and fertility status, with implications for qual-\nity of life. However, research into this important area is limited, particularly among women with benign disease. To investigate \ngender identity and fertility in this population, semi-structured interviews were conducted with 18 women who underwent \nhysterectomy for benign disease at age 39 or younger. Women were asked to describe their experience of hysterectomy and \nhow it affected their perceptions of their gender identity, fertility status and overall quality of life. Thematic analysis was \nused to analyse and code responses. Three themes were identified; Implications of Infertility, I am a Woman and Womanhood \nCompromised. Within these themes, 3 sub-themes were identified. Implications of Infertility comprised three sub-themes \ndescribing women’s varied relationships with their post-hysterectomy infertility: Plans Fulfilled, Acceptable Compromise \nand Persistent Grief. A novel finding was that women engaged in a “trade-off”, whereby relief of gynaecological symptoms \noutweighed their desire for a child/further child/ren. The study also found that women with an extensive history of infertility \nmay have more trouble adjusting to the outcomes of their hysterectomy than women who were satisfied with their fertility \nhistory. Counselling around identity and how this can be influenced by fertility status may be needed. Further research into \nthe psychological processes involved in the “trade-off” is also needed.\nKeywords Gender identity · Hysterectomy · Infertility · Pre-menopause · Quality of life · Women’s health · Gynaecological \nsurgery\nHysterectomy refers to the surgical removal of the \nuterus and is a major gynaecological surgery world-\nwide (Hammer et al., 2015). Hysterectomy may be \nconsidered for numerous reasons including benign \ngynaecological conditions, particularly when more \nconservative treatments have been ineffective or have \nbothersome side effects (Laughlin-Tommaso et al., \n2020). For chronic conditions such as endometriosis, \nadenomyosis and fibroids, hysterectomy may reduce \nphysical symptoms such as heavy menstrual bleed-\ning and pelvic pain (Laughlin-Tommaso et al., 2020). \nHowever, women may also experience psychological, \nsocial and emotional sequelae of this procedure (Bay -\nram & Beji, 2010; Elson, 2002), with younger and/\nor pre-menopausal women affected in ways that are \nunique to their life stage. This may include experienc -\ning changes in gender identity (Elson, 2002 ; Elson, \n2005; Cabness, 2010; Solbraekke & Bondevik, 2015) \nand conceptualisations of fertility, which in turn may \nimpact their quality of life. Understanding the effect \nof hysterectomy on women’s quality of life is impor -\ntant, particularly as there is limited literature available \nto guide health professionals working in this field. \nResearch in this area may also help women gain a bet-\nter understanding of the broader risks and benefits of \nundergoing a hysterectomy.\n * Daisy Bottomley \n daisy.bottomley@unimelb.edu.au\n1 Melbourne School of Psychological Sciences, The \nUniversity of Melbourne, Parkville, VIC 3010, Australia\n2 The Royal Women’s Hospital, Flemington Road, Parkville, \nVIC 3010, Australia\n3 Department of Obstetrics & Gynaecology, The University \nof Melbourne, Parkville, VIC 3010, Australia\n\n278 Sex Roles (2023) 89:277–287\n1 3\nGender Identity Following Hysterectomy\nGender identity refers to a person’s perception of having a \nspecific gender and often corresponds with a person’s sex \nat birth (Connell, 1995). Women’s gender identities include \ntraits that have traditionally been considered feminine, \nsuch as passivity, emotionality and nurturance (Connell, \n1995). Hysterectomy and its associated outcomes may alter \na woman’s sense of femininity, and therefore her gender \nidentity (Elson, 2005). Cessation of menstruation post-hys-\nterectomy may partially explain this identity adjustment. \nThere is a strong association between menstruation and \nfemale gender identity with many women perceiving men -\nstruation as connecting them to other women and as being \na process that reinforces femininity (Elson, 2002). Fertil-\nity loss in pre-menopausal women post-hysterectomy may \nalso cause identity disruption. Some literature suggests that \nwomen’s reproductive capacity informs and shapes their \ngender identity (Alamin et al., 2020; Bell, 2019; Miles \net al., 2009). Notably, there is variation in women’s expe-\nriences; some finding their sense of identity unchanged \n(Cabness, 2010) while others report an enhanced sense \nof self, likely associated with the significant reduction in \ngynaecological symptoms (Bell, 2019; Elson, 2002; Elson, \n2005; Solbraekke & Bondevik, 2015).\nFertility Following Hysterectomy\nGiven the irreversible impact of hysterectomy on the abil-\nity to carry a pregnancy, investigating how this is expe -\nrienced by women and what effect this may have on their \nquality of life beyond gender identity is important. Previ-\nous research points to increased rates of worry, sadness, \nlow self-esteem and relationship breakdown in women \nexperiencing infertility following benign gynaecologi-\ncal disease (Culley et al., 2013). Similar outcomes may \nbe expected in women following hysterectomy; however \nfew studies have explored this issue (Bougie et al., 2020; \nFarquhar et al., 2006; Leppert et al., 2007). Leppert et al. \n(2007) investigated women (N = 1140) following hysterec-\ntomy for benign disease and found that 14% desired a child \nor more children. These women tended to be younger and \nwere more likely to have higher levels of psychological \ndistress at the time of and following hysterectomy. While \nthis suggests a link between removal of reproductive abil-\nity and decreased psychological wellbeing, the fertility \nbackground of the participants was not assessed, making \nit difficult to understand the impact of hysterectomy in \nthe context of individual fertility history. Farquhar et al. \n(2006) described a relationship between hysterectomy \nand feelings of loss regarding fertility but did not assess \nwomen’s fertility backgrounds and how this may have \naffected their experience of grief post-hysterectomy. Nota-\nbly, both aforementioned studies included large numbers \nof women who were medically unable to bear children due \nto their older age at the time of their hysterectomy, hence \ninfertility concerns may have been less significant than in \na comparatively younger cohort.\nTo date, only one study has investigated fertility \nand quality of life following hysterectomy in younger \nwomen. Bougie et al. (2020) studied the prevalence \nof post-hysterectomy regret in women (N  = 71) under \n35 years who had undergone hysterectomy for benign \nconditions between 2008-2015. Participants completed \na validated decision regret survey and health question-\nnaire. Over 90% did not regret their decision and would \nelect to have the hysterectomy again, despite side-effects \nincluding permanent loss of fertility. However, 23.9% \nof women reported wishing to have another child fol-\nlowing hysterectomy. This research used a quantitative \napproach, and whilst post-hysterectomy outcomes were \nidentified, respondents’ narratives were not explored in \ndetail. Qualitative data has the potential to add a rich-\nness to this understanding and tease out the nuances \nand complexities of this experience. For example, it is \nunclear why Bougie et al. (2020) found that the symptom \nrelief experienced by young women following hysterec-\ntomy superseded the irreversible side-effect of fertility \nloss, particularly as previous studies have highlighted \nthe negative impact of this loss (Farquhar et al., 2006; \nLeppert et al., 2007).\nThe Current Study\nFurther investigation is needed to understand how young \nwomen conceptualise their fertility following hysterec-\ntomy, including examining contextual information like \nprevious childbearing and/or fertility difficulties, and age. \nThis approach has the potential to provide information to \nmedical professionals who are discussing the advantages \nand drawbacks of these procedures with their patients, and \nimprove psychological services such as counselling, for \nyoung women. Consequently, this study aimed to investigate \nwomen aged 39 and under in terms of their perception of \ntheir gender identity and fertility following hysterectomy for \nbenign disease, and how these perceptions may enhance or \ndiminish their quality of life. It must be noted that this study \nwas focused on the experiences of cis-gendered women. \nWhile the experiences of trans women undergoing hyster -\nectomy as part gender affirming surgery are important and \ndeserving of further scrutiny (Makhija & Mihalov, 2017), \nthis is beyond the scope of this study.\n\n279Sex Roles (2023) 89:277–287 \n1 3\nMethod\nThis study used a qualitative approach to allow for a \ncomprehensive and deep exploration and understanding \nof the experiences of young women post-hysterectomy. \nWithin this framework, the research was underpinned by \na phenomenological epistemology. This approach aimed \nto produce knowledge based on the subjective and unique \nexperiences of the women participating in this research. \nIt was interested in the women’s thoughts, feelings and \nreflections regarding their hysterectomy and was con-\ncerned with the quality and texture of these perceptions \n(Willig, 2013). The phenomenological standpoint does not \nnecessarily try to uncover what is ‘real’ about the post-\nhysterectomy experience, but rather, is interested in the \ndiversity and complexity of this experience for different \nwomen, accepting many possible interpretations of this \nexperience. To achieve this, the women were interviewed \nusing a semi-structured format; while the questions aimed \nto explore the quality of life areas of gender identity, fer -\ntility and body image, the design of the study allowed for \nthe emergence of unanticipated themes that impact qual-\nity of life. As such, the study has remained faithful to its \nphenomenological underpinnings; it displayed openness \nwhen speaking with the women and the researchers aimed \nto remain reflective and aware of any assumptions made \nwhen conducting the study (Sundler et al., 2019).\nRecruitment\nEthics approval for the study was obtained from the Royal \nWomen’s Hospital (RWH) Human Research Ethics Com-\nmittee (Project #20/27) on 11 November 2020. The current \nstudy was nested within a large-scale survey-based quanti-\ntative study at The Royal Women’s Hospital (RWH). That \nstudy (the parent study) is investigating the impact of age \nand parity on young women’s relief and regret following \nhysterectomy for benign disease. Some of the women who \nparticipated in the parent study also gave consent to be \ncontacted for an interview in future. As such, the current \nstudy recruited participants from the parent study.\nInitially, 21 women aged 36 or under at the time of their \nhysterectomy were contacted by email regarding participa-\ntion. The researchers aimed to recruit the youngest possi-\nble cohort (at the time of hysterectomy) as this population \nwas of most interest to the researchers. From the initial \ngroup of 21 women, 13 expressed an interest in participat-\ning in the study.\nApproximately 1-2 months after the initial inter -\nviews, 10 more women (aged between 37-39 years at the \ntime of their procedure) were contacted, to increase the \nsample size. Five provided consent, then were recruited \n(as above). In total, 18 women participated in the study.\nParticipants and Procedure\nParticipants were eligible to participate in the study if had \nundergone an elective, planned, hysterectomy for benign dis-\nease. The participants also needed to have had the hysterec-\ntomy 6-11 years before the study, needed to be aged between \n18- 39 years at the time of hysterectomy, and needed to have \nsufficient English literacy and communication skills to con-\nsent and participate in the study.\nAs stated, data were collected via semi-structured inter -\nviews. An interview schedule based on the empirical litera-\nture and clinical experience was developed by the first and \nsecond author (GB and DB), with significant input from \nthe senior author (LS), a clinical psychologist and women’s \nhealth expert, and associate investigators from the parent \nstudy, all gynaecologists. Interviews were conducted by \nDB and GB. Questions aimed at understanding the broad \nimplications of hysterectomy on the women’s quality of life, \nand impacts on their fertility, gender identity, psychological \nwellbeing and sexuality. Data describing participant char -\nacteristics were accessed from the parent study. The inter -\nview data was transcribed verbatim by GB and DB, which \ninvolved listening and re-listening to the recorded interviews \nand documenting what was discussed, word for word.\nResearcher Positionality\nIn terms of reflexivity, care was taken to recognise the \nresearcher’s positions of privilege when interviewing the \nwomen, as highly educated, middle-class, cis-gendered \nwhite women. This relative position of power was dealt \nwith in a sensitive manner, so as not to create feelings of \nintimidation or discomfort during the interviews. Further, \nthe researchers took care to acknowledge their positions as \noutsiders to the experience of having a hysterectomy and \naimed to approach the data with curiosity and interest, rather \nthan imposing pre-conceived ideas around the procedure.\nData Analysis\nNVivo (2020) software was used to store, organise and \nanalyse the data. Thematic analysis was used, as outlined \nby Braun and Clarke (2006). Transcripts were read until \nfamiliarity was achieved. Codes were developed to con-\ndense the data and segment it systematically in preparation \nfor analysis. Following this, codes were merged and rela-\ntionships between them were considered in the creation of \nthemes. Emerging themes were then refined. Data was coded \nuntil saturation was reached; that is, until no new codes or \n\n280 Sex Roles (2023) 89:277–287\n1 3\nthemes emerged from the data set (Willig, 2013). Discus-\nsions about the codes and themes occurred throughout this \nprocess between DB, GB and LS. DB and GB each coded \nthe data separately, and then reached a shared consensus on \nthe codes and subsequent themes through discussion. Inter-\nrater reliability was tested using Cohen’s kappa. LS provided \noversight and feedback regarding coding, emerging themes, \nand the refining of themes. Illustrative quotes were identi-\nfied and edited for clarity, and included in the results section \nto support the data. Data on participant characteristics were \nanalysed using IBM-SPSS Statistics (Version 25).\nResults\nParticipant Characteristics\nEighteen women participated in interviews, which ranged \nfrom 15-90 minutes in length ( Mean = 41 minutes). Mean \nage at the time of hysterectomy was 35-years-old and \n44-years-old at interview. Most women were married and \nhad had children prior to their hysterectomy. Endometriosis \nwas the most common reason for the procedure. See Table 1 \nfor detailed sample characteristics.\nThemes\nAnalysis resulted in the emergence three themes and five \nsubthemes. See Table  2 for a summary of themes and \nsubthemes, frequencies, exemplary quotes and interrater \nreliability.\nTheme 1: Implications of Infertility\nThis theme had three sub-themes and comprised women’s \nconceptualisations of infertility following hysterectomy and \nthe impact on their quality of life.\nPlans Fulfilled Over half the women reported that their \nchildbearing plans were fulfilled before their hysterectomy, \nand the infertility they experienced post-hysterectomy had \nlittle negative impact on their quality of life. In some cases, \nthe hysterectomy resulted in a sense of relief as it provided \nlong-lasting contraception, ultimately strengthening the \nquality of their intimate relationships.\n“I’d already had 4 kids…and I’d had my tubes tied, \nso I was more than happy to have the hysterec-\ntomy.” (P10)\n“Immense relief [following hysterectomy]… because \nI knew there was no way I was getting pregnant… you \ncan continue on with life and not have that worry at \nall.” (P17)\nSome women did not have children at the time of hys -\nterectomy but reported that they never wanted nor intended \nto have them. These women experienced a sense that their \nplans were fulfilled and did not report that their quality of \nlife was negatively affected by their infertility. Rather, this \nwas a neutral or welcome side-effect.\n“I've never really cared about my fertility; I have never \nbeen interested in children. I've never wanted them…\nTable 1  Socio-Demographic and Clinical Characteristics of Partici-\npants\n*Some women had more than 1 reason for undergoing hysterectomy\n**Some women had more than 1 mental health diagnosis at the time \nof hysterectomy. Of the women diagnosed with at least one mental \nhealth condition, 22% of the diagnoses were self-reported, and 33% \nand 44% were given by a general practitioner or mental health practi-\ntioner, respectively\nM(SD) Range\nAge at time of hysterectomy (years) 35 (3.4) 26-39\nAge at time of interview (years) 44 (4.2) 36-51\nNumber of years since hysterectomy 9 (1.9) 6-11\nN %\nMethod of performing hysterectomy\nAbdominal (includes laparoscopic) 14 78\nVaginal 4 22\nSelf-reported reasons for undergoing hysterectomy*\nEndometriosis 10 61\nHeavy menstrual bleeding 8 39\nFibroids 4 22\nAdenomyosis 3 17\nChronic pelvic pain 3 17\nProlapse 1 6\nAdhesions 1 6\nPolycystic ovaries 3 17\nRelationship status at time of hysterectomy\nMarried/Cohabitating 15 83\nUnpartnered 3 17\nHeterosexual\nPrefer not to answer\n17\n1\n95\n5\nHad given birth to children prior to hysterectomy 15 83\nPartner supportive of hysterectomy 14 78\nPartner unsupportive of hysterectomy\nNo partner at time of hysterectomy\n1\n3\n5\n17\nMental health diagnosis at time of hysterectomy**\nDepression 9 50\nAnxiety 1 6\nPost-traumatic stress disorder 2 11\nComplex trauma 1 6\nNone 8 44\n\n281Sex Roles (2023) 89:277–287 \n1 3\nlosing that was never really a factor in my decision and \nit's never impacted me since then.” (P09)\n“If you don’t want them [children] and you can’t have \nthem you may as well get rid of the problem… it’s been  \na huge relief that I’ve never had to worry that I would \nbecome pregnant.” (P15)\nAcceptable Compromise A large proportion of the women, \nwith varied fertility backgrounds, described experiencing \nfleeting grief associated with their post-hysterectomy infer-\ntility. However, these feelings were largely resolved by the \ntime of interview.\n“Oh look, there are times where I wish there was \nanother way to have gone through it all, but it is what \nit is, and I deal with it.” (P12)\n“After the recovery, I thought ‘Oh I want to be preg -\nnant again’… but then going through pain and nine \nmonths and then giving birth and looking after the \nbaby, I'm not going to do that again.” (P07)\nIn resolving this momentary grief, many considered their \nfeelings from a pragmatic perspective. The difficulties they \nexperienced prior to their hysterectomy (e.g., severe men-\nstrual pain) seemed to outweigh the potential benefits of \nbearing children. As such, these women engaged in a ‘trade-\noff’; deciding that they could live with their infertility and \nthe associated feelings of loss and grief as this came with the \nadvantages associated with relief of their symptoms.\n“I think it was just knowing that I could no longer \ncarry a child… I’m missing that bit… But then I’ll \nlook at what I went through until I got to that point \nand I don’t know if I could have gone another 10 years \nliving like that (in pain).” (P04)\nA subgroup of women with other medical con-\nditions (e.g., cardiac disease) also engaged in this \n‘trade-off’; however, their infertility was predomi-\nnantly related to these associated conditions rather \nthan the hysterectomy.\n“I would have had more children before I decided to \nhave a hysterectomy. The thing is I couldn't have any \nmore children because I have a cardiac problem…it \nmade my decision a lot easier.” (P06)\nPersistent Grief A minority of women expressed intense and \npersistent sense of grief tied to their loss of fertility. These \nwomen had complex medical histories that included a prior \ndiagnosis of infertility.\n“I've wanted to be a mum since I was 4. I literally  \ngave up career options that would affect my ability to \nparent. And so when it came to the point, where I was, \nlike, ‘Oh, actually, you can't be a parent anyway’ that \nwas a real kick in the head.” (P13)\n“Once the initial euphoria [from resolution of \nsymptoms] had subsided, I really mourned, I really \ngrieved it especially as my friends and my family \nbegan having children and continued having chil-\ndren, I felt really sad that I couldn't ever be in that \nposition …I still feel grief about the fact that I only \nhad one kid.” (P02)\nWhile the hysterectomy may have been the event directly \ncausing the infertility, grief pre-dated the procedure and \nwas the culmination of multiple, historical fertility diffi-\nculties. It is possible that the finality of the hysterectomy \nexacerbated this pre-existing and now persistent grief in \nthis small subgroup of women.\nTable 2  Themes, Subthemes, Frequencies, Examples and Interrater Reliability\nThemes Sub-themes Counts/percentages Example Quote Cohen’s \nKappa\n1. Implications of infertility 1.1 Plans \nfulfilled\n1.2 Accept-\nable com-\npromise\n1.3 Persistent \ngrief\n10/18 (55.6%)\n5/18 (27.8%)\n3/18 (16.7%)\n“I'm quite content. I've got my son, I've got my daughter, very \ncontent” (P11)\n“Being upset and then just kind of going oh well, best thing I \ncould do” (P08)\n“I don’t like the position that I’m in and I don’t like what my \nfuture looks like” (P13)\n.90\n.95\n.89\n2. I am a woman 13/18 (72.2%) “It hasn’t changed my gender identity, I’m a woman, 100% \nthrough and through. Nothing like that is going to change the \nway I feel about being a female and just being me” (P14)\n.98\n3. Womanhood compromised 5/18 (27.8%) “… perhaps I wasn’t as useful as a woman” (P02) .87\n\n282 Sex Roles (2023) 89:277–287\n1 3\nTheme 2: I am a Woman\nThe impact of the hysterectomy on participants’ gender \nidentity was relatively benign. Most participants did not \nidentify any specific changes in the way they conceptu -\nalised their gender identity and feelings of femininity. A \nsense of femininity in this cis-gendered cohort appeared to \nbe well established prior to their hysterectomy. The women \nsynthesised this femininity and their gender identity by \ndrawing together their roles as mothers and wives, and \nthrough their employment.\n“I’m still that female role model for my kids, the \nfemale role model for students that I teach… just \nbecause I’ve had a hysterectomy, doesn’t mean that I  \nam less, or that something is missing… my identity is \nabout the impact that I have on the people around me \nand how I can improve the people around me, if I can \nhelp them.” (P16)\nThe reported minimal impact of the hysterectomy on \ngender identity may have been due to the women’s percep-\ntion of the uterus as an internal organ, and therefore hid-\nden from view. As such, the hysterectomy did not remove \na physically visible marker of traditional femininity, thus \nhaving a reduced impact on gender identity.\n“I'm quite happy with who I am and what I am. I think I \nwould feel different if I had a mastectomy because then  \nmy boobs would be missing, that would make me feel \nless of a woman, whereas because it was internal, it \ndidn’t particularly bother me.” (P03)\n“Because it [the uterus] is internal… if I had to have a \nmastectomy, that would be a lot more impactful than \nhaving a hysterectomy.” (P17)\nA small group of women commented that the hysterec-\ntomy contributed to increasing their feelings of feminin-\nity and womanhood, mainly due to a decrease in negative \nsymptoms and a resulting greater sense of freedom. For \nexample, some women commented on their enhanced \ncapacity to participate in leisure and work activities, as \nthey were no longer concerned about excessive bleeding \nor pain. While this may have improved their quality of life, \nthese opportunities may also foster an increased sense of \ngender identity, as they may feel more engaged with other \nwomen and able to behave in ways that reflect their desires \nas women.\n“It gave me confidence to feel like a woman without the  \nstresses that come with being a woman… it took away \nany anxiety with the bleeding, what you can wear, what  \nyou can’t wear… the confidence to have sex… I felt \nvery feminine afterwards.” (P10)\n“I feel a measure of freedom now more than I used \nto… because I don’t have to be distracted by worrying \nabout the pain.” (P09)\nTheme 3: Womanhood Compromised\nFor some women, the hysterectomy represented a partial \nloss of gender identity and resulted in diminished feelings \nof femininity. This sense of loss was tied to childbearing \ncapacity (eg. loss of menstruation).\n“Knowing that I no longer had a part of me as a \nwoman…it took me time to realize yeah, it is cool I  \ndon't have to bleed, but I've lost a part of me as a \nwoman.” (P04)\n“[the hysterectomy] did make me want to just go, I’m \n[participant name], I'm not female. I don’t even have  \na womb. Because apparently some people say, ‘Oh, \nyou can’t be female, unless you menstruate’.” (P08)\nSome women commented directly on their sense of iden-\ntity as a mother. While this was not the case for all women, \nincluding those with their desired number of children or dis-\ninterested in becoming mothers, this was disproportionately \nfelt by women who experienced feelings of loss and grief \nafter their hysterectomy.\n“But maybe …less motherly, because you can't be a \nmother… because you're not normal.” (P13)\nI felt like [if] I wasn't going to be a mother again, per-\nhaps I wasn't as useful as a woman.” (P02)\nWomen conceptualised their failure as a mother as inter-\ntwined with their failure as a woman, which ultimately, \nresulted in a diminished sense of self. In some cases, their \nperceived failure as both a mother and a woman resulted in \nnegative self-perception, like poor body image.\n“I felt like a failure as a mother and as a woman \nbecause my body wasn't working. I couldn't deliver my  \nown child myself and my body wasn't working properly  \nthen, it's still not working properly now. It's failing me,  \nit's just not good enough, it's disgusting and useless.” \n(P01)\nDiscussion\nHysterectomy for benign disease is a common treatment that  \nmay impact young, pre-menopausal women in ways that may  \nbe particularly challenging at their life stage. This study \naimed to understand the sequelae of this surgery on qual-\nity of life specifically regarding perceptions of fertility and \n\n283Sex Roles (2023) 89:277–287 \n1 3\ngender identity. The themes identified illustrated women’s \nvaried relationships with their post-hysterectomy infertil-\nity, depending on whether their childbearing plans had been \nfulfilled. Most participants had completed their families by \nhaving children or had never wanted children, thus were \nnot adversely impacted by their infertility. Many women \nengaged in a “trade-off” whereby relief from gynaecologi-\ncal symptoms outweighed their desire for a child or further \nchildren. This is a novel finding and further research into the \npsychological processes involved in this appraisal is needed. \nNotably, this “trade-off” was not experienced by all women, \nwith a small number of individuals with extensive histories \nof infertility continuing to experience grief post-hysterec-\ntomy. This suggests that a subgroup of women may have \nmore trouble adjusting to the outcomes of their hysterectomy \nand require additional psychological support.\nConsidering the post-hysterectomy infertility experiences \nof this cohort in the context of existing literature is chal-\nlenging, due to limited data. However, the strong sense felt \nby women of having achieved their reproductive intentions \nmirrors experiences reported by post-menopausal women \n(Dillaway, 2020; Ilankoon et al., 2020; Salis et al., 2018), \nincluding feeling that they have not only biologically, but \nalso psychologically, surpassed their childbearing years (par-\nticularly when paired with a sense of having completed their \nfamilies) (Dillaway, 2020). While most ‘young’ women in \nthis study were medically fertile at the time of their hyster -\nectomy, they psychologically considered their childbearing \nyears to be over as their familial plans were fulfilled. As such, \nthey did not seem to attach significant emotional meaning to \nthe loss of fertility; their hysterectomy simply being a process \nthat led to improved quality of life.\nSome women coped with feelings of loss associated  \nwith their infertility by reflecting on the benefits of their \nsymptom improvement. This concept builds on the “com-\npromise” suggested by Markovac et al. (2008), that some \nwomen resolve feelings of wanting another child by consid-\nering their lack of pain. Bougie et al. (2020) also found that \nwomen did not regret their hysterectomy, despite relatively \nhigh numbers desiring a larger family. The reasons given as \nto why these women could resolve the feelings of loss asso-\nciated with their hysterectomy involved factors including \ncollaborative decision-making with medical professionals \nand possessing a high level of perceived autonomy when \nconsidering the procedure (Bougie et al., 2020). The current \nstudy suggests that it is the “trade-off” that women make \nfollowing their procedure that influences the low level of \nhysterectomy regret found despite the desire for a child or \nfurther children.\nUnsurprisingly, this “trade-off” was not universal; a \nsmaller number of women experienced persistent grief fol-\nlowing their hysterectomy that was directly tied to their \ninfertility. This is broadly consistent with other research, \nwhich indicates that fertility loss after hysterectomy may \nbe linked to increased psychological distress and regret for \nsome women (Leppert et al., 2007 ; Farquhar et al., 2006). \nBeyond these studies, there has been little in the literature \nexamining the complexity and mechanisms associated with \nwomen’s grief following hysterectomy. Women in the cur-\nrent study each felt their grief over an extended period of \ntime, and this preceded their hysterectomy. It is possible \nthat prior, ongoing difficulty with fertility (which may dis-\nproportionality impact women who undergo hysterectomy \nfor benign conditions, such as endometriosis) (Culley et al., \n2013), may play an important part in the onset of this psy -\nchological distress and subsequently, may worsen quality \nof life. These experiences of long-term grief are consistent \nwith the infertility literature more broadly (Ferland & Caron, \n2013; McBain & Reeves, 2019), including suggestions that \nwomen who remain involuntarily childless tend to experi-\nence their grief indefinitely even if they eventually adjust to \ntheir circumstances (Ferland & Caron, 2013).\nMost women reported stable or enhanced gender identity \npost-hysterectomy, which is in line with previous literature \nin the cis-gendered population (Cabness, 2010; Elson, 2005; \nSolbraekke & Bondevik, 2015). However, the current study \nsuggests a novel rationale for the stability of gender identity. \nPreviously, it has been suggested that menstruation and the \npresence of the uterus are important factors in constructing \nwomen’s gender identities (Elson, 2002) and the removal \nof these processes/organs may lead to diminished feelings \nof femininity. Yet many women in the current study did \nnot assign this meaning to their uterus or menstruation but \ncommented that external physical markers like breasts were \nmore important for maintaining their femininity. This find-\ning is reflected in literature on women undergoing mastec-\ntomy; the removal of the breasts representing a potential \nchallenge to femininity and decreased feelings of womanli-\nness (Glassey et al., 2016). It is possible that the removal \nof visible indicators of femininity is more detrimental to \nwomen’s perceptions of gender identity than the removal of \nfeatures hidden from personal and public view.\nThe idea that external expressions of femininity are \nimportant in maintaining gender identity may also explain \nwhy after hysterectomy, some women in this study experi-\nenced identity enhancement due to an increased capacity to \ndemonstrate their femininity (e.g., ability to wear tradition-\nally feminine dresses). This is consistent with the findings \nof Solbraekke and Bondevik (2015) and as such, hyster -\nectomy may augment and strengthen a woman’s sense of \ngender identity. Markovic et al. (2008) similarly suggested \nthat some women could participate in more social and occu-\npational activities post-hysterectomy, which increased their \nability to embody their femininity in practice. The current \n\n284 Sex Roles (2023) 89:277–287\n1 3\nstudy builds on this research and suggests that in the Austral-\nian context, hysterectomy may reinforce identity stability or \ngenerate identity enhancement for some women.\nA small portion of participants linked their hysterectomy \nto a decreased sense of femininity, as their perception of \nthemselves as mothers and women was challenged post-\nprocedure. Notably, these participants had all experienced \nlong-standing fertility difficulties. There is evidence that \nprotracted infertility may not only disrupt, but also prevent \nthe formation of gender identity in women, particularly as \nit pertains to femininity and womanliness (Alamin et al., \n2020). The current study suggests that it is perhaps not the \nhysterectomy in isolation that causes gender identity disrup-\ntion, but rather, that the hysterectomy further diminishes a \nwoman’s sense of gender identity which has already been \nimpacted by infertility.\nUltimately, the contrasting themes regarding gender \nidentity support the overarching findings of Elson (2005), \nwho acknowledged the variability in women’s relation-\nships with their gender identity following hysterectomy. \nThis study illustrates that women are diverse in their con-\nceptualisations of femininity and womanhood and derive \nidentity from different aspects of their lives. While some \nwomen tie their identity to their role as mothers (or lack \nthereof), others are perhaps moving towards more ‘mod-\nern’ perceptions of what it may mean to be a woman. For \nexample, some women linked their identity to how well \nthey performed in their occupational role. As such, this \nstudy suggests that whether gender identify is enhanced, \nstable or diminished post-hysterectomy may depend upon a \nwoman’s context and how she conceptualises her identity.\nLimitations and Future Research Directions\nThe cross-sectional study design was both a strength and \na limitation. The study aimed to recruit women once a \nsubstantial period had elapsed after their hysterectomy, \nso that participants had had time to process, consider and \ncontemplate the implications of the hysterectomy on their \nquality of life. These longer-term reflections on the hys-\nterectomy experience are lacking in the literature and have \ndirect clinical utility for health professionals who may be \nable to communicate these longer-term experiences to \nwomen considering the procedure. However, as the aver -\nage time between interview and hysterectomy was 9 years, \nthe absence of shorter intervals may have impacted the \nbreadth of the post-hysterectomy experiences reported. \nIndeed, there is evidence suggesting that women’s quality \nof life differs depending on the length of time since recov -\nery (for example, some women have a decreased quality of \nlife immediately after hysterectomy which improves over \ntime (Lee et al., 2009). It is unclear why this improvement \noccurs, and as the current study was not longitudinal, this \ntrajectory could not be evaluated. However, further study \nof this would provide valuable information on the entirety \nof the post-hysterectomy experience.\nAnother limitation of the study was that the participants \nwere recruited from a specialist metropolitan women’s \nhospital (RWH). While the women would have received \ntop-tier medical care, the study was conducted on a single \nsite and therefore cannot be generalised to other groups of \nwomen. These include those that receive their hysterecto-\nmies in private hospitals or in regional centres, which may \ndiffer in terms of quality of care provided. Future studies \nmight consider including women from a diverse range of \nprivate and public hospitals, to ensure that different care \nexperiences prior, during and following hysterectomy are \ncaptured.\nPractice Implications\nThe current study suggests that for most women who \nundergo hysterectomy, the procedure vastly improves qual-\nity of life. However, there are some women who experience \ngrief associated infertility and associated gender identity \ndifficulties. It is therefore important for health care work -\ners to gauge each individual woman’s fertility background \nprior to their hysterectomy. The findings from this study \nindicate that women with an extensive history of infertility \nmay have more difficulty adjusting to the outcomes of their \nhysterectomy; thus adequate psychological supports should \nbe available and accessible to these women. Counselling \naround identity and how this may be influenced by fertility \nstatus may also be required.\nConclusion\nThe current study sought to understand the post-hysterectomy \nexperience of women younger than 39 at the time of surgery, \nspecifically in relation to perceptions of fertility and gender \nidentity. Findings from the study generally support previous \nliterature, particularly as it pertains to improvement in qual-\nity of life. However, there are novel findings from this study \nthat require further research. The finding that women engage \nin a “trade-off” where desire for a child/further child/ren is \noutweighed by the relief associated with the elimination of \ngynaecological symptoms is worthy of exploration, particu-\nlarly the psychological processes involved in this appraisal. \nThe relationship between infertility and gender identity in \nthis study, in the specific context of hysterectomy is also an \narea that could be re-visited in future research. The findings \nfrom the current study can be used to form part of a prelimi-\nnary evidence base around the post-hysterectomy experience \nand can inform health professionals working in this area.\n\n285Sex Roles (2023) 89:277–287 \n1 3\nInterview Schedule\nHello <confirm participant’s name/identity>\nThis is <name> calling/checking in about the study \ninvestigating quality of life after hysterectomy for benign \ndisease. Thank you for agreeing to be interviewed for this \nstudy.\nLet me just remind you about the study.\nThe aim of this project is to learn more about how hav -\ning a hysterectomy for benign disease affects quality of life. \nSpecifically, we are interested in learning about the impact \nof hysterectomy on female identity, body image, fertility, \nsexual functioning and sexuality and psychological func-\ntioning. The interview is going to be recorded and will be \ntranscribed and then analysed. The recording will be stored \nin a secure location and destroyed after the completion of the \nstudy. If at any point you would like me to stop the interview \nor the recording, please let me know and I can do that. This \ninterview can also be conducted across multiple sessions to \nbreak it up, if needed.\nIf it appears that it may be appropriate to pause or stop \nthe interview, I may suggest this. If there are any questions \nhere that you do not want to answer, or you wish to have a \nbreak or stop, please just let me know and we can do that.\nIf, after or during this interview, it seems that you might \nbenefit from psychological support, we can discuss options \nfor referral and/or debriefing. Do you have any questions \nbefore we continue?\nFirst, I am going to ask you a few background questions. \nThese are not recorded. I will tell you when I am going to \nstart the recording.\nBackground questions (for verification, not recorded)\n• When were you born?\n• When did you have your hysterectomy? (approximate \nmonth/year)\nI am now going to start recording\nPlease confirm your consent to this audio-recorded \ninterview\n 1. How did you come to have a hysterectomy?\n   Prompt: What experiences led you to consider hav-\ning a hysterectomy?\n   Prompt: Do you recall what type of hysterectomy \nyou had? (Were your ovaries or cervix removed as \nwell?)\n   Prompt: What symptoms were you experiencing \nprior to your hysterectomy?\n   Prompt: How long were you having these symptoms \nprior to surgery?\n   Prompt: How did your symptoms affect your day to \nday life (probe work, family, partner, friend domains)\n 2. What impact did the hysterectomy have on your symp-\ntoms, if any?\n   Prompt: can you describe the course of your recov-\nery?\n   Prompt: Did you notice that things improved \nquickly? Go up and down? Take a long time?\n   In this research we are interested in understanding \nhow your hysterectomy has changed your quality of \nlife. By quality of life we mean the standard of health, \ncomfort and happiness you experience. Quality of life \ncan affect different areas, some of these being physical, \npsychological, social, family and environmental areas. \nWith this in mind...\n 3. Can you tell me how the hysterectomy has affected \nyour QoL, if at all?\n 4. How has your body changed physically, if at all, since \nundergoing the hysterectomy?\n 5. Have those changes impacted your body image? What \nI mean by body image is the way you think and feel \nabout your body.\n   Prompt: Have these thoughts or feelings impacted \nhow you perceive your level of physical attractiveness?\n 6.  How does your body image impact your life (QoL) \nmore generally?\n   One of the more specific interests we have in this \nresearch is understanding how a hysterectomy can \nimpact a woman’s sense of identity. What I mean by \nidentity is how you see yourself, what makes you, and \ncharacteristics that define you. Specifically, we’d like \nto know how you feel about your gender identity, that \nis, to what extent you feel like a woman, and your feel-\nings of femininity.\n 7.  Can you tell me how the hysterectomy has changed \nyour gender identity, if at all?\n   Prompt: can you give me a specific example of how \nthe hysterectomy has made you feel this way?\n   Prompt: what thoughts do you have when you feel \nthis way?\n 8.  How does your sense of gender identity impact your \nlife (QoL) more generally?\n   Prompt: Is your happiness or health impacted by \nyour sense of gender identity?\n   Now I’m going to ask you a few questions about \nyour fertility. What I mean by fertility is your ability \nto have children.\n 9.  Did your perceptions of your fertility influence your \ndecision to have a hysterectomy?\n 10.  How have you felt about your fertility since the hys-\nterectomy?\n\n286 Sex Roles (2023) 89:277–287\n1 3\n   Prompt: have you wanted the option to become preg-\nnant since the hysterectomy?\n 11.  What influence do you think your age at the time of \nyour hysterectomy had on your decision to have the \nsurgery?\n   Prompt: Do you think you were too young to make \nthe decision to have a hysterectomy?\n   Another focus of this research is understanding how, \nor if at all, having a hysterectomy affects a woman’s \nsexual functioning and sexuality. When I talk about \nsexual functioning and sexuality, I am talking about a \nrange of things, such as your desire to have sex, your \nsatisfaction with sex, and your feelings of intimacy \nwith a partner.\n 12.  Can you tell me a bit about what your sex life was like \nbefore your hysterectomy?\n 13.  How has your sex life changed, if at all, since having \nthe hysterectomy?\n   Prompt: Can you say whether you think this was as \na result of the hysterectomy?\n   Prompt: Can you give me a specific example of how \nit has changed?\n 14.  How has the way you think and feel about yourself as \na sexual being changed, if at all, since having a hyster-\nectomy?\n   Prompt: How do these thoughts and feelings impact \nyour sex life?\n 15.  How has your sex life since your hysterectomy \nchanged your quality of life, if at all?\n   Prompt: How has it changed?\n   Prompt: Has it changed over time?\n 16.  How has having a hysterectomy affected the intimacy \nin your relationships, if at all? By intimacy I mean the \nfeelings of emotional and physical closeness in your \nrelationship.\n   Prompt: Has it changed over time?\n   Prompt: Has it been different with different partners?\n 17.  How prepared and informed do you think you were \nabout how having a hysterectomy would affect your \nsexuality and sexual functioning?\n 18.  How has your overall mood changed, if at all, since \nhaving your hysterectomy?\n   Prompt: what was your mood generally like prior to \nyour hysterectomy\n   Prompt: what has your mood been like generally \nsince having your hysterectomy?\n   Prompt: are there any other feelings (anxiety, stress) \nyou feel since having your hysterectomy?\n 19.  In retrospect, what do you think of your decision to \nhave the hysterectomy?\n   Prompt: Do you regret it? Do you feel relieved?\n   Prompt: Would you do it again and why/why not?\n   Prompt: What would you do differently?\n 20.  Do you think, in retrospect, that you were adequately \ninformed and your expectations were well managed \nabout the outcome of the surgery prior to you having a \nhysterectomy?\n   Prompt: Has that changed over time?\n   Prompt: What was missing and what do you wish \nyou knew now?\n   Prompt: Importantly, would that change your deci-\nsion if you had known that now.\n 21.  Are there any general comments you would like to \nmake in relation to your hysterectomy?\n 22.  Do you have any questions?\n   Thank you for your time.\n   End recording\nAuthors’ Contributions DB, GB, LS and CR, contributed to the design \nof the research, DB and GB collected the data, LS, GB and DB ana-\nlysed the data, DB wrote the manuscript, and LS, GB, CR, UD, MH \nand CC reviewed the manuscript and provided feedback. DB imple-\nmented the feedback and prepared the manuscript for publication.\nFunding Open Access funding enabled and organized by CAUL and \nits Member Institutions.\nData Availability The datasets generated during the current study are \navailable from the corresponding author on reasonable request.\nDeclarations \nEthical Approval and Consent to Participate Ethics approval was \nreceived from the Royal Women’s Hospital Human Research Ethics \nCommittee (Project #20/27) on 11 November 2020. Consent to partici-\npate was obtained from all individual participants included in the study.\nConsent for Publication The participants provided consent for the \nresearch to be published.\nConflict of Interests The authors have no conflicts of interest to de-\nclare.\nOpen Access  This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article's Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article's Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. To view a \ncopy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.\n\n287Sex Roles (2023) 89:277–287 \n1 3\nReferences\nAlamin, S., Allahyari, T., Ghorbani, B., Sadeghitabar, A., & Karami, \nM. T. (2020). Failure in identity building as the main challenge  \nof infertility: A qualitative study. Journal of Reproductive Fertil-\nity, 21(1), 49–58. https:// www. seman ticsc holar. org/ paper/ Failu re-  \nin- Ident ity- Build ing- as- the- Main- Chall enge- Alamin- Allah yari/ \n85981 32f91 c5609 712bff  f19e 6a75c 42240 80584\nBayram, O. G., & Beji, K. N. (2010). Psychosexual adaptation and \nquality of life after hysterectomy. Sexuality and Disability, 28(1), \n3–13. https:// doi. org/ 10. 1007/ s11195- 009- 9143-y\nBell, A. 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Introducing qualitative research in psychology.  \nOpen University Press.\nPublisher's Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}