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dilemmas of men’s
Ten years of
Aman has a quick consultation. You deal
(62 out of every 1,000 single men married each year).
This had dropped to 28 per 1,000 by 2000. By contrast
prescription but he hovers. ‘Actually
the divorce rate in 1960 was 1.7 per 1,000 married
there’s something else, doctor… err, I’m
men, rising to 12.7 per 1,000 by 2000. 6 The age at first
seeing this lady and, well, I’m having problems. I was
marriage has also risen. People are more likely to
wondering, err, you know those tablets…?’
have sexual relationships before marriage and to
This scenario has become more familiar over the
start new relationships at various stages of life.
last ten years because of new therapies for erectiledysfunction, greater media attention, and hence
greater public awareness of the problem.
(sildenafil) celebrates the tenth anniversary
The issue of men’s sexual health is not often covered
of its British licence this year. Previous therapies were
in Christian medical publications. Triple Helix
unappealing, ineffective, or little known. Some
article 1 on Viagra
when it was first licensed in 1998,
unlicensed therapies were helpful, while recreational
but since then the issue has hardly been considered.
drugs were often used to enhance performance.
We frequently read about abortion, contraception and
s arrival made a big splash; seductive advertising
teenage sex, but rarely about male sexual dysfunction.
in the medical press was paralleled by provocative
A US study showed that 52% of men aged 40-70
headlines nationally. People became aware not only
experienced some degree of erectile dysfunction
that erectile dysfunction was common, but something
(ED), while 10% experienced complete erectile
could be done about it. That something could be as
dysfunction. 2 Premature ejaculation is also
simple as taking a tablet obtained on prescription.
common, affecting up to 40% of men 3 while
On the one hand was a sense that ‘everybody’s
doing it’, yet on the other the taboo remained. To
We know men consult doctors less frequently than
a man had to admit to his doctor there
women do. 5 Reasons include busyness and lifestyle
was a problem. Fuelled by demand, many private
stress, but also embarrassment, reluctance to admit to
clinics and providers sprang up, and the internet
problems, and fear. Sexual problems carry a particular
became a common source of supply. The blue
taboo. Visiting a doctor about a sexual problem not
only introduces an embarrassing topic but acknow-
across the globe, a symbol of sexual freedom and
ledges that all is not well in the bedroom. This can
rejuvenation for men, as the contraceptive pill had
feel like an admission of guilt, failure or weakness,
been for women. A problem which had been hidden
or even a threat to one’s masculinity. There is also
under the bed-clothes for years suddenly came into
a common belief that nothing can be done anyway.
the limelight and competitors brought other oraltreatments onto the market.
Changing timesThe advent of the contraceptive pill and the legal-
isation of abortion in the 1960s have led to a radical
Christian doctors will meet a range of men
change in attitudes towards sex and relationships.
or similar treatments, or asking for
In 1960 the marriage rate for men was 62 per 1,000
help with sexual problems. Each man will have his
own situation. Some will be married, some
The dilemma is this: is a prescription in certain
cohabiting, some in a new relationship, some having
circumstances tantamount to condoning sin? Or does
an affair. Some will be in homosexual partnerships.
failure to prescribe constitute passing judgment?
Some will be engaging in casual sex. Some mayeven be perpetrators of abuse.
So what is the dilemma? Is there a dilemma at
There are no easy answers, and the decision will
all? Is erectile dysfunction purely a medical problem
ultimately be a matter for each doctor’s conscience.17
which needs to be managed with the best available
It will also depend on the individual situation.
treatment, whatever the context? Or is there an
For a man in a consenting adult heterosexual
relationship, it could be argued we should respecthis lifestyle choice and provide treatment for his
medical problem. We could argue that those in
By its very nature, a sexual problem has several dimen-
long-term relationships are living ‘as if married’ and
sions. Erectile dysfunction is not merely the inability
should be treated as such. While most Christians
to achieve an erection. Emotionally, it often causes
would view homosexual partnerships as wrong, 18
anxiety and loss of self-esteem, and socially, it affects
we must be careful not to judge the couple. And we
the man’s relationship, often leading to awkwardness
must be aware of GMC guidelines and recent legal
and insecurity. The partner’s response may be loving
changes on discrimination. Where we feel unable to
and accepting, or there may be tension and
prescribe, patients are entitled to a second opinion
arguments. The security of the relationship may
if they are unhappy with our decision.
become conditional on the man’s performance.
We also have a duty to protect both our patients
Erectile dysfunction may not only be the cause but the
and others. Somebody requesting Viagra
for a series
manifestation of emotional problems, relationship
of casual relationships is putting his physical and
difficulties, or spiritual issues such as guilt.
emotional health at risk, and may spread sexually
As doctors we need to explore not only what
transmitted infections to others. Somebody having an
is happening physically but what is happening
extramarital affair is harming his wife. One would have
emotionally, socially and spiritually. Is the
strong grounds for saying ‘No’ in these situations. A
relationship compatible with the patient’s value
man having intercourse with a minor of either sex is
system, or is it a source of guilt? Is it a healthy
acting illegally, and we should take appropriate action.
relationship? Is there pressure to have sexual inter-
Whether or not we eventually prescribe in these
course? We may be able to tease out other issues
situations, we may be able to introduce some of
which need addressing. There may be a mental
God’s values within the consultation. One useful
health problem which requires treatment. There may
question is ‘How important is sex within your
be issues which would be helped by counselling.
relationship?’ This gently challenges the assumption
There may be problems within the relationship which
that it is all-important. Encouraging couples to shift
need to be tackled, possibly with the help of a third
the focus away from sex and to spend more time
party such as Relate
. 7 The man may need to think
talking or enjoying each other’s company in other
from the Massachusetts MaleAging Study. Journal of Urology
carefully about whether he is in the right relationship.
ways can be helpful. It may be necessary to
challenge the attitude of a partner whose love
has become conditional on sexual performance.
Having explored these issues, the problem may persist
and we have to decide: are we going to prescribe or
not? What would God have us do in these situations?
Finally we turn to the case of married men with
In the Bible we read that sexual intercourse is given
erectile dysfunction. Often they are more reluctant to
by God to unite a man and a woman within marriage:
come forward and discuss their problems. Yet here
‘For this reason a man will leave his father and
we need to affirm God’s gift of sex within marriage, 8
and women: a cohort study. BJGP
mother and be united to his wife, and they will
encourage them to talk, and at least to consider
become one flesh’. 8 The Ten Commandments forbid
therapeutic options. We need to communicate that
adultery, 9 and both Jesus 10 and Paul 11 endorse this.
this is an important issue worth exploring.
Does this mean we should decline to prescribe
and the like to men who are not married?
We know many of our patients have different
Men’s sexual problems are common, and present in
beliefs, and hence different lifestyles, from our
various scenarios. While we should uphold the Bible’s
own. Jesus taught we should not judge others. 12 He
teaching about sex within marriage, we need to
demonstrated this with the woman caught in adultery,
respect our patients and not to judge. Individual
but then told her to ‘go now and leave your life of sin’.13
doctors will draw the line in different places about
Paul specifically taught that we should not judge
prescribing medication for erectile dysfunction. In
those outside the church. 14 The GMC guidelines on
all situations, we should bear in mind our patients’
Personal Beliefs and Medical Practice
15 state that we
emotional and spiritual needs as well as their medical
should not impose our personal beliefs on patients,
ones, and also the wellbeing of other parties.
nor should we allow our beliefs to prejudice their care.
But we are required to obey God rather than men. 16
Roxana Whelan is a GP in Nottingham
WORKING PAPER 20 THE ECONOMICS OF THE IVF PROGRAMME: A CRITICAL REVIEW Julie Ratcliffe CENTRE PROFILE The Centre for Health Program Evaluation (CHPE) is a research and teaching organisationestablished in 1990 to:• undertake academic and applied research into health programs, health systems and• develop appropriate evaluation methodologies; and• promote the teaching of heal
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