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The trouble with men is ... highlighting sexual health

David Evans
RN BA(Hons) PGDipPsycholCouns PGCE MPhil
Educational Consultant in Sexual Health

Men's health, particularly male sexual health, is an area of healthcare that appears to get very little direct mention or attention. It may be argued that this lack of attention, in itself, can contribute to an increase in some of the very poor - but largely preventable - indices of ill-health. No truer is this than in the specific area of sexual health.

Highlighting male sexual health
Poor statistics for male health make sad reading, but they needn't do! Many of the indices, such as mortality and morbidity figures, compare male against female, when it would be more appropriate to focus instead on preventable versus inevitable, and very few poor statistics for men would actually then come out inevitable.
The relatively recent developments in the concepts of sexual health show how some carers associate this, in the narrowest of ways, with unintended conceptions and sexual infections.(1) However, whilst acknowledging the role that males play in conceptions, and the ever-increasing numbers of new sexual infections, the Men's Health Forum insists that male sexual health must also include:(2)

  • Testicular cancer: 200 per 100,000 of 15-50 year olds diagnosed.
  • Prostate cancer: the commonest cancer in UK men, with over 21,000 new cases and 8,000 deaths in 1999.
  • Benign prostatic hyperplasia (BHP).
  • Premature ejaculation (PE) and erectile ­dysfunction (ED).

These conditions are compounded by poor and inadequate education on sex, sexualities and sexual health and a "crisis" in the nation's sexual health services.(3,4) There are also problems jointly related to mental health and sexual health, such as sexual orientation-related violence, poor self-esteem and lack of equal rights and protections.(5-8)
Given the holistic influence and wide-ranging nature of sexual health problems affecting males of all ages, orientations, ethnicities and health status, nurses working in primary care settings are ideally placed to deal with healthy living options, preventative healthcare and early detection initiatives. The three issues for primary care highlighted here are: premature ejaculation (PE), erectile dysfunction (ED), and poor and inadequate sexual health education across the age ranges, abilities and other personal indicators.

Premature ejaculation
At least 1 in 3 males experience problems of premature ejaculation at some point in their lives.(2) For those who are shy and embarrassed to talk about sexual matters, especially for those with a strongly sex-typed ("macho") persona to portray, the sequelæ might include internalised problems, such as low self-esteem, anxiety, performance- related stress, through to social and interpersonal problems. (9) These might include increased dependence on alcohol or drugs and problems with initiating or maintaining satisfying (sexual) relationships. That PE is often glossed over, as if it's "just a phase" a person will grow out of, can serve to compound problems of personal inadequacy in those who do not appear to grow out of it, as well as minimising the impact of it when erroneously comparing it to other problems: "It could be worse - you might have a real illness!"
Men, in particular, are prone to feel that they are wasting a healthcarer's time with such issues. However, if primary care nurses, including those working with children and young people, were to proactively mention PE, such as in health awareness and education sessions for boys and men, they might begin a whole process of improved access to healthcare, by dispelling myths, as well as developing the potential for future therapeutic health encounters.
Premature ejaculation can effectively be overcome using various resources, such as desensitising creams, the Masters and Johnson method, the simulation and squeeze techniques, and masturbation. The Sexual Health InfoCenter states that "the best way to fighting premature ejaculation is learning how to identify and control the sensations leading up to orgasm". The Masters and Johnson method does just that and, although it requires a great deal of patience and practice, it is very effective. Openness about the naturalness of masturbation and ejaculation is yet another way to prepare the way for genuine dialogue on sexual problems such as PE.(10,11)

Erectile dysfunction
If PE is erroneously thought of as applying exclusively to younger males, then ED is often equally mistakenly seen as being just an issue for more elderly males. It can happen at any time in life, although it is predominantly seen in men aged 40 and over, increasing with intensity for numerous reasons, such as health issues (diabetes, hypertension and vascular degeneration), smoking and high alcohol intake, and psychosocial or mental health issues such as stress and depression. However, only 1 in 10 men ever receive treatment for ED, and nearly half of those waited in excess of 2 years before they actually mentioned it to a professional carer!(2) In the light of publicity about Viagra (sildenafil), many men continue to experience judgemental disapproving attitudes from carers, especially if they are unmarried or gay, and particularly if they are HIV- positive. Another problem is lack of healthcarer involvement in treatment with the sexual partners. The partner may be accustomed to the lack of sexual activity between them both; to "treat" one without dealing with the other might lead to some unexpected happenings!

Poor and inadequate education
Many of the complaints about sex and sexuality education appear to be repeating the same issues throughout the generations: "it's too little, too late", "too reproduction- orientated" and "excludes teaching safer sex as pleasurable". Also, education fails to address males in ways that they best learn, and about issues that are important to them. This latter complaint is significantly related to all nonheterosexual males, for whom reproductive sex education bares little relevance; at the same time, the number of UK males under 24 years old who have sex with other males (especially gay and bisexual) is now at an all-time high. Education that supports traditional sex-typed ("macho") images of what it is to be a man does not celebrate diversity and does not protect the rights, freedoms and safety of nonheterosexuals, including gay, bisexual and transgender males. The macho male and reproductive focus can give an impression that sex is solely a performance issue, not for fun and mutual satisfaction, that a "real man" is always "up for it", and that contraception is still the woman's responsibility.

Practice and policy issues
Clearly, there is a need to help overcome significant barriers found in attitudes to/of/by men concerning sex, sexualities and sexual health. It is in this regard that the trouble with men is threefold (see Box 1).

[[NIP17_box1_36]]

The problems identified in Box 1 are not new. How often have we heard colleagues say "Men: they never come to clinic!" or "I hate teaching the boys - they never take sex seriously like the girls"
Reflection must benefit practice. Reflective practice affords us opportunities to analyse problems and explore effective and innovative ways in which to address them. Of course, some attitudes to sex, sexualities and sexual health are intricately bound with personal messages and social representations or expectations about boys, men, sex, age, orientations, abilities, ethnicities, and so on. Indeed, some of these messages and representations of masculinity can be real barriers to appropriate service provision, such as:

  • Perceived "masculinist" identities.
  • The (in)convenience of the service provided.
  • Acceptability of effective condom usage.

Each of these barriers may also be multifaceted and built one on top of the other, lying heavily upon the individual male.

Clinical governance and the future
So, we know what the situation is, and the national governments in the UK each have a strategy to deal with some of the sexual ill-health problems. Localising the situations for males and sexual health in your practice area requires overcoming many of the barriers outlined here. Only then will men be touched by sexual health education and the required services.
One way of analysing the problems is to perform a Force Field Analysis (FFA). This effective tool can help to overcome some of the barriers facing service provision. It clearly puts your service aim - men's sexual health needs in our practice - in the centre of the page. It explores the various restraining forces, or hindrances, to achieving this aim. Then, using skills, resources and government initiatives to improve on sexual health, the facilitating forces are explored to counteract all the restraining forces. The aim in undertaking a FFA will be related to the local situation, and may be determined in response to questions such as: "Why don't men come to our service?", "How come we have a higher incidence of teenage pregnancy in our area - where are the boys?" or "If up to 1 in 10 people are gay or lesbian, what safer sex services do we offer to these groups?" An important starting point is to create a climate in which men's sexual health can be discussed openly and without embarrassment, shame or judgement.(2)
One significant national nursing initiative that can contribute to improving sexual health in general, as well as men's sexual health, is the RCN Sexual Health Skills distance- learning programme for the development of practice and lifelong learning. This course is not only for RCN members, but for all registered nurses, midwives and health visitors. It aims to empower learners to:

  • Accurately discuss sexual health issues with clients (eg, by making an appropriate sexual health assessment).
  • Demonstrate a working understanding of sexual infections, including HIV.
  • Confidently and competently demonstrate ­condom usage, as well as accurately describe ­various methods of contraception.
  • Work to accepted protocols (eg, Patient Group Directions) in providing emergency hormonal ­contraception.

Conclusion
It seems incomprehensible in 2004 that male sexual health problems are known about and yet, on the one hand, boys and men are often so "dreadful" in proactively accessing appropriate services, and on the other hand, healthcare professionals continue to bemoan the fact that men and boys are so poor at accessing their services. What is needed is a reappraisal of more effective ways in which, as healthcare professionals, nurses can move out of their routine domains of service provision and meet men's sexual health needs: where the men are at, physically, emotionally and educationally.

[[NIP17_pp_37]]

References

  1. RCN Sexual Health Strategy - ­guidance for nursing staff. London: Royal College of Nursing; 2001.
  2. Men's Health Forum. Private parts, public policy - improving men's sexual health. London: Men's Health Forum; 2003.
  3. Her Majesty's Inspectorate. Sex and relationships, Ofsted Report HMI 433. London: Her Majesty's Inspectorate of Schools; 2002.
  4. House of Commons Health Committee. Sexual health. London: The Stationery Office Limited; 2003.
  5. NAW/CCC. A strategic framework for promoting sexual health in Wales ­- post consultation action plan. Cardiff: Health Promotion Division, National Assembly for Wales/Cynulliad Cenedlaethol Cymru; 2000.
  6. Department of Health. The National Strategy for Sexual Health and HIV. London: Department of Health; 2001.
  7. Scottish Executive. Enhancing sexual wellbeing in Scotland: a sexual health and relationships strategy: a ­consultation paper. Cited at http://www.scotland.gov.uk/library5/health/eswss.pdf on 24.02.04.
  8. DHSSPS. Consultation document - A five year sexual health promotion strategy and action plan. Northern Ireland: Department of Health, Social Services and Public Safety; 2003.
  9. Evans DT. Internalized oppression. In: Eadie J, editor. Sexuality - the ­essential glossary. London: Arnold Publishers; 2004.
  10. Howe J. A natural remedy: giving patients permission to masturbate.Nurs Stand 1995;9:46-7.
  11. Yamey G. Sexual and reproductive health: what about boys and men? Education and service provision are the keys to increasing involvement. BMJ 1999;319:1315-6.

Resources
RCN Sexual Health Skills distance-learning course
E:sexualhealthpnd@rcn.org.uk
T:020 7647 3741
Teenage Pregnancy Unit Resources for boys and young men
W:www.info.doh.gov.uk/tpu/tpu.nsf
Men's Health Forum
W:www.menshealthforum.org.uk
Project for Advocacy, Counselling and Education
W:www.pacehealth.org.uk
Sex Education Forum
W:www.ncb.org.uk
NEED course (Nurse Education in Erectile Dysfunction)
Pfizer Ltd UK Walton Oaks Dorking Road
Surrey KT20 7NS