BOOK SYNOPSIS & SAMPLE

BOOK SYNOPSIS

Vasectomy is widely promoted as a “safe and simple procedure.” Rarely are men or their spouses informed that a life long pain condition, known as Post-Vasectomy Pain Syndrome (PVPS), is caused by the procedure. Months or years after being vasectomized, close to 15% of men will experience pain in one or both testicles, with the pain being severe in approximately 5%. Frequently, the pain is worsened by sex and other physical activities, motivating the sufferer to avoid pleasurable pursuits. Too embarrassed to speak up about the problem, many men suffer in silence, and if they do raise the issue with a physician the problem is often misdiagnosed, particularly when years have passed since the vasectomy. In third world countries where vasectomy is intensely promoted as a “safe and simple procedure,” effective treatment is essentially non-existent. Treatment for PVPS often involves sophisticated microsurgery that is very expensive, not covered by most health insurance plans, and not widely available. For those lucky enough to access treatment there is often no resolution of the pain, as it can recur on the treated side and arise in a seemingly unaffected testicle. Vasectomy: The Cruelest Cut Of All (The Modern Medical Nightmare Of Post-Vasectomy Pain Syndrome) debunks the “safe and simple procedure” myth and calls for an end to vasectomy.

The book was published in 2006, and in many areas of medicine this would mean that much of the information is outdated. However, consistent with how the “safe and simple procedure” rhetoric persists in urology and the larger medical community, an intensive search of the scientific literature almost ten years later failed to reveal any studies that actually significantly advanced our understanding of PVPS. Debate still carries on as to the best treatment, with the same old focus on removal of structures. More encouraging is the experimental application of robotic and computerized controlled surgical techniques, offering the potential of more effective vasectomy reversal in the future.

BOOK SAMPLE

PSYCHOLOGICAL PROBLEMS:

Despite limitations to several studies, there are some clear patterns that emerge regarding the psychology of vasectomy. Foremost is that regret after a vasectomy is predictable when the following apply:

– No children or fewer children than desired.

– Later wishing for more children. Frequently, this occurs when a man has a vasectomy earlier in life, divorces, and then remarries a partner still in her reproductive years. Given the high divorce rate and the low average length of marriage, vasectomy in the twenties or early thirties is easy to regret later on.

– Age less than 30 for what would seem to be obvious reasons.

– Marital difficulties, unstable relationship, and lack of communication. Much as children are no solution to marital problems, vasectomy cannot resolve these problems and might actually worsen them if the man feels pressured by his partner.

– Pressure to have a vasectomy. Some of the studies reviewed make it seem like the decision takes place in an ideal world with both husband and wife sharing the decision 50/50. While this might occur in some cases the reality is often not so ideal. Covert psychological pressures are not uncommon and many men feel guilty if they refuse to have a vasectomy after all their wife went through. There are also overt pressures frequently missed by physicians obtaining consent. Merlin Johnson—Social And Psychological Effects Of Vasectomy—published in The American Journal Of Psychiatry in 1964, reported on 83 men admitted to Seattle Veterans Administration Hospital who received a vasectomy some time prior to admission. In 30 instances the wife, her family, or her physician vigorously pushed for the vasectomy, viewing it as a problem for the husband to solve. In one case the wife’s family actually held conferences of sorts essentially making the decision for the husband. Now if that is not marrying into the wrong in-laws I don’t know what is. 11 of these men were hospitalized for a psychiatric illness within one year of the vasectomy. Merlin Johnson makes a couple of interesting points—That failure to resolve unwanted pregnancy concerns short of surgical methods, likely reflects problems in the marriage that have passed unnoticed, and that the issue of stress associated with one person undergoing a surgical procedure for the benefit of the other has been largely ignore and needs to be explored.

– Recent experience of a personal crisis. A good rule of thumb is, avoid making a major decision until after a personal crisis is well passed and life is stable. Decisions made during a crisis period are usually poorly informed.

– Practice of religion that does not permit vasectomy.

– The belief that vasectomy = castration. Vasectomy does not seem to interfere with the production and release of male hormones, and hence does not reduce masculinity. However, many men and particularly those of certain cultures, such as Latinos, equate the ability to inseminate females with masculinity. This is not an either or belief and there are varying degrees of adherence to it, something missed in every study reviewed. In other words the belief—Vasectomy makes me less of a man, needs to be evaluated on a scale such as:

1 2 3 4 5 6 6
Not at all true           100% true

     I suggest that all vasectomy counselors use this scale and not recommend vasectomy to anyone in the 6 to 7 range. Attitudes can change but typically not from 6-7 to 1-2. Those in the 3 to 5 range will likely respond well to education.

– High interest in sperm banking prior to vasectomy. Interest in this strategy clearly indicates that the man is uncertain about vasectomy, and he should be encouraged not to proceed with it.

     I strongly recommend that when even one of these factors is present vasectomy not be performed. Furthermore, it is the responsibility of contraception counselors and physicians performing vasectomy to adequately assess these considerations with each patient.

     A relatively unexplored area has to do with the impact of vasectomy on depression and anxiety. Luo Lin and colleagues—Psychological Long-Term Effects Of Sterilization On Anxiety And Depression—published in Contraception in 1996, compared 500 vasectomized men to 500 similar but non-vasectomized men in two counties and two cities in China. They used the Center for Epidemiologic Studies Depression Scale (CES-D Scale) and the Self-Rating Anxiety Scale (SAS). Scores on the depression scale revealed that sterilized men were 4 times as likely to be depressed as were non-sterilized men, particularly higher educated, wealthier, relatively older men who lived in cities. Men fitting this profile also tended to be over 4 times as likely to suffer from anxiety than were men in the non-vasectomized group. They conclude that vasectomy is a risk factor for depression and anxiety and advise that patients be counseled before, during, and after sterilization. The recommendation to counsel after vasectomy is a very interesting one as it might go a long way to prevent or minimize depression and anxiety.

     When chronic pain results from vasectomy adverse psychological states can be expected. Schover—Psycho¬logical Factors In Men With Genital Pain—published in the Cleveland Clinical Journal Of Medicine in 1990, found that men suffering from testicular pain showed signs of Major Depression (a severe form of depression) and frequently abused chemical substances. Chronic pain patients commonly abuse narcotic medications and other substances as a way of self-medicating for the pain, and also the depressed and anxious mood states that almost invariably arise from ongoing pain conditions. The skeptical response of some physicians to their complaints does not help them cope with the pain and usually worsens symptoms of psychological suffering. Any physician who doubts the suffering of patients with PVPS should volunteer to have sandpaper surgically placed adjacent to the vas, epididymis and testicle on at least one side.

     Several studies report little impact of vasectomy on psychological and sexual states and seem to fall in line with the “safe and simple” rhetoric. In an interesting article—A Methodological Critique Of Research On Psychological Effects Of Vasectomy—published in Psychosomatic Medicine in 1974, William Wiest and Lois Janke argue that study design flaws result in a positive bias, or in other words, the studies over-represent the favorable side of vasectomy. One key issue is that most studies rely on questionnaire responses that likely underreport pain and negative results. Men who are suffering might not be as likely to fill out the questionnaire due to preoccupation with their symptoms, or resentment resulting in a lack of desire to cooperate. It would seem at first consideration that men who are suffering should be more interested in responding, but ironically it often goes the other way as they attempt to cope by blocking off reminders of the suffering. Face to face verbal interviews not surprisingly produce higher rates of negative symptom reporting.

     William Wiest and Lois Janke also suggest that the high reported satisfaction rate might reflect some trait of men who choose vasectomy—they are “yea-sayers” or otherwise disposed to please the investigator by providing answers they believe are wanted. An important psychological process that also likely plays a role is cognitive dissonance reduction. Cognitive dissonance is a state of psychological tension that arises when two cognitions (thoughts) are incompatible, such as “I want to remain healthy and fit.” and “I had a vasectomy that might impair my health and cause suffering.” How the mind resolves this unpleasant mental state is by altering one or both of the cognitions so that they align. In this instance a man is unlikely to believe he does not want to remain healthy and fit, nor is he able to deny that a vasectomy occurred. The only way to resolve the dissonance is to downplay any adverse affects by minimizing them to the self and others. This results in a positive response bias with underreporting of negative results. For all these reasons most studies based on questionnaire responses, which are the definite majority, probably underreport psychological and even physical symptoms.

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