Manhood: The Rise and Fall of the Penis (27 page)

Armstrong writes the way he cycles: straight down the line, always fighting openly and energetically. He’s not the kind of man who hides.

Even just after he had heard the bad news he did not avoid contact with the media. He fought the battle in the open. The Texan’s openness won the respect of friends and enemies alike, in his team and elsewhere.

And at a stroke testicular cancer became a topic in sports reporting and Armstrong became a representative of cancer patients.

His informal ambassadorship soon became official. In December 1996 he set up the Lance Armstrong Foundation, with the aim of fighting all forms of urological cancer by increasing awareness, education and research. Money is collected in the first place through all kinds of cycling events, the largest of which takes place each year at the end of May in his home town of Austin and is christened Ride for the Roses.

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Bilateral cancer

Men who have once had testicular cancer are more at risk than ‘normal’ men of developing cancer in the remaining testicle. Synchronous bilateral cancer occurs in 0.7 per cent and 1.5 per cent develop cancer in the remaining testicle within a year. Only a small number of men are involved, but even so, imagine if it happens to you! Testicular prostheses and testosterone gel, though, make it possible to lead a normal life.

Generally speaking, as has been said, excellent treatment results are achieved with testicular cancer, certainly if one compares them with treatments of other types of cancer. Still the patients and all those involved are confronted with a totally different world. Information, mentoring and support are provided by patient support groups.

Testicular prosthetics

Testicular prostheses have been available since 1940. Before 1973 they were made of the metal vitallium, but since then gel-filled implants have been used worldwide. Prostheses are used, for example when:

•

an undescended testicle has been removed

•

a testicle has been removed because of a tumour

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a testicle has been removed because of a torsio testis that has been discovered too late

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where a testicle has been missing from birth

Why use a prosthesis? Many men feel incomplete without a testicle.

Young men often use one because they do not yet have a sexual relationship, or are frightened of someone seeing, for instance, in the shower after sports or in the sauna or on the beach.

Testicular prostheses come in various sizes, and inserting one is a simple procedure: an incision is made just above the scrotum through which the prosthesis is introduced and if necessary attached. The operation takes about twenty minutes, so that the patient can return home the same day. Research has shown that complications occur only in exceptional cases, and these take the form of: leakage, mostly after a trauma, a haemorrhage, infection, wound dehiscence or an allergic reaction. In order to prevent infection the patient is given antibiotics before and after the operation. In most cases a prosthesis can be claimed on insurance.

In 1999 the radiographer Luca Incrocci from Rotterdam carried out a research project among men with a testicular prosthesis. He examined thirty men aged between eighteen and 75 who had a pros thesis 138

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implanted. The average age of the research sample was 30. With five of these men there were complications. A few results from this research: 20 per cent still had problems with sexual contacts, 20 per cent still had sexual problems, but almost 70 per cent experienced an improvement in body image after insertion of the prosthesis. The latter fact is significant, since that is what a prosthesis implantation is ultimately about! The other problems can in the great majority of cases be solved not through an operation but by consulting a sexologist.

Modern testicular transplantation

As mentioned in a previous chapter, at the beginning of the twentieth century testicular transplants were widely used with the aim of combating the ageing process. At the time there was absolutely no knowledge of the factors determining the ageing process and loss of potency.

Attention turned to the testicles: testicular tissue, either human or animal in origin, was transplanted, mostly in sections, into the scrotum.

Remarkable results were reported for a broad spectrum of ailments, though the research results were rather coloured by personal motives.

The ensuing polemics damaged the development of endocrinology, the science of hormones. That was even more the case with the commercial exploitation of this irrational treatment. In 1935 testosterone was isolated, so that testicular transplants fell temporarily out of fashion.

Due to new technical capabilities in the surgical field new interest was awakened in testicular transplants in the 1960s. Experiments focused on rats and dogs and eventually led to the transplantation of an individual’s own material, in particular with baby boys who had extreme forms of undescended testicles. Transplantation from one human being to another was initially carried out only in the then virtually inaccessible Soviet Union; virtually nothing reached the outside world.

In the 1970s a publication appeared on a successful testicular transplant in a pair of monozygotic twins, one of whom had no testicles and the other two. Inspired by this, two Chinese research teams began a test transplant in human beings. Despite the limitations due to the suppression of rejection in the recipient, remarkably good results were achieved, and a report appeared on the first two children fathered with a transplanted testicle. In the view of the researchers testicular transplantation could be of crucial importance for, for instance,
anorchid
men (literally without testicles), a condition affecting one in 20,000

men. Anorchidy is not life-threatening but if untreated it leads to a loss of libido, psychological problems, premature ageing symptoms and accelerated loss of bone mass. A select group of men with fertility problems might also benefit from testicular transplantation. It could 139

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be used for couples who choose the possibility of having a child independently over new techniques of reproduction and for whom the disadvantages are outweighed by the above-mentioned advantages. Of course female-to-male transsexuals would be eligible for testicle transplantation, though as yet no transplantations from one man to another have yet been carried out. Quite apart from the ethical aspects, it is the side-effects of the medication required after surgery which are the main obstacle to the procedure.

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chapter seven

Ailments of the Penis

You can always rely on a friend, so they say, and hence many healthy young men never stop to think that an erection isn’t a natural occurrence for everyone. In medical jargon we refer to erectile dysfunction –

ed for short: in fact, the word ‘impotence’ is no longer used. Typical erection problems occur when the penis does not become (sufficiently) erect, or when an erection does not last long enough for satisfying sex.

Descriptions like ‘not hard enough’, ‘not long enough’ and ‘satisfying’

are of course highly subjective.

Many men have occasionally have found that their erection is not always equally strong, or sometimes even fails to materialize. ‘Problems’

requiring treatment arise only when symptoms persist for a longer period. ed can adversely affect one’s experience of sex, can damage one’s sense of self-worth and put pressure on a relationship. Many men experience not achieving an erection as a sign of inadequacy. As a result an erection problem can play into the hands of one’s fear of failure, creating a vicious circle. Sometimes there is also embarrassment about seeking help, since it is estimated that only 15 per cent of men with ed consult a doctor. There are conflicting reports from researchers about the frequency with which erection problems occur. At any rate they are much more widespread than most people think.

It is clear that as one gets older the chance of ed increases. One’s sexual appetite may flag somewhat with age, arousal is no longer so intense, the blood vessels are no longer so supple, other physical ailments appear and older men often take medication that adversely affects their erection.

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Psychological or physical?

Not only patients but doctors too consider it important to decide whether the erection problem is caused by psychological or physical factors. Why is that? In the case of a patient with a duodenal ulcer not much attention is usually given to underlying psychosocial problems.

A prescription for medication to inhibit or neutralize stomach acid is soon written out, and constitutes what is known as symptomatic treatment. In the case of ed, however, the patient does not get off so lightly: the experts must, as far as they can, determine whether the problem is psychological or physical in origin. That is probably why many men are ashamed to reveal their erection problems. Research by gps showed that over 85 per cent of men with an erection problem needed help, but only 10–15 per cent had actually sought help. Once he has gone to his gp the man with ed who does not react, or does not react positively to an erection pill prefers to be referred to a urologist rather than to a sexologist. The former works with various types of apparatus, syringes and needles, or may decide on an operation. For many men that is obviously less threatening than having to talk to a sexologist about all kinds of details of their failed love life. Men have a relatively strong tendency to rationalize. Research into gps’ treatment methods showed that a consultation in which the erection problem is first broached lasts on average thirteen minutes, and in only 10 per cent of cases is the partner present.

The patient can, in the best-case scenario, expect the following questions: is the problem in getting an erection or in maintaining it? If an erection can be achieved, the blood supply is probably adequate.

How long does the erection last? Does the erection disappear before or during coitus, and how long has the problem been going on? Is it affected by the position of the body? (In terms of coital position men are vulnerable in the missionary position: the moment they start making coital movements relatively more blood is channelled away towards their legs, which can be at the expense of the blood supply to the penis – certainly if there is hardening of the arteries. In a nutshell:

‘It’s a choice between sex and legs.’ Other questions probing the cause of the erectile dysfunction include: are there any apparently unrelated physical ailments? What about the use of medication, alcohol, tobacco and drugs? Urologists also often use a questionnaire.

What is the situation among non-Western men? Is ed more common among them? Do they deal with the problem differently?

According to gps, Muslim men often broach sexual problems via a physical complaint. An erection problem may be presented as pain in the penis, knee or abdomen. The complaint is probably expressed in a 142

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veiled way because discussing psychosocial and sexual problems with an outsider is taboo in Islamic culture, while ‘being ill’ is accepted.

Turks and Moroccans also generally expect to be prescribed drugs.

Injections are more highly valued than tablets, powders or supposi -

tories. With Turkish men potency and fertility are crucial for their sense of self-worth, vitality and pride. Consequently erection problems can be seen as a loss of vitality or even as the approach of death.

Psychosocial aspects of the problem are dealt with at length: is the ed linked to a particular partner (how do you ask that clearly and yet discreetly?), or is it connected with tiredness? Was there any unpleasant psychosocial event associated with the first occurrence of the problem? What are conditions like at work and what are the prospects, or are there perhaps worries that subconsciously demand too much attention? Has something happened to the permanent partner to make her/him less attractive? Are there nocturnal and morning erections and are you able to masturbate as before? How is your appetite for sex?

What does the man actually think about the situation and how is his partner reacting?

In the first volume of his
Essais
the great French philosopher Michel de Montaigne (1533–1592) went into these problems at length.

Montaigne wrote in a fluid, improvised style, with a string of associative leaps. He tells of a friend of his who had heard a man say that he lost his erection the moment he wanted to penetrate a woman. He was so overcome with shame at his flaccid member that the next time he was in bed with a woman he couldn’t put it out of his head, and the fear that the same disaster would befall him again was so great that it prevented his member from becoming erect. From that moment on he was unable to achieve an erection, however much he desired a woman. The shameful memory of each setback tormented and dominated him more and more.

Montaigne’s friend had become impotent when he lost his unshakeable rational control over his penis, which in his eyes was an essential component of normal masculinity. According to the philo -

sopher Alain de Botton, Montaigne did not blame the penis: ‘Except for genuine impotence, never again are you incapable if you are capable of doing it once.’ Because of the frightening idea that we have complete mental control over our bodies, and the terror of deviating from the normal pattern, the man could no longer perform. The solution was to adjust the pattern, and render the event less traumatic by accepting that the loss of power of the penis was an innocent blip in one’s love life.

Montaigne took the unforeseen caprices of the penis out of the dark recesses of unspoken shame.

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Montaigne knew a nobleman from Gascony who could not maintain his erection with a woman, who fled home, cut off his penis and sent it to the lady in question ‘to make amends for his insult’.

Montaigne had better advice:

Married folk have time at their disposal: if they are not ready they should not try to rush things . . . It is better . . . to wait for an opportune moment . . . Before possessing his wife, a man who suffers a rejection should make gentle assays and overtures with various little sallies; he should not stubbornly persist in proving himself inadequate once and for all.