‘We’ve been married now for more than a year, and I’m still not pregnant,’ Nola said with a sigh. ‘Something serious must be wrong, for most of our friends became pregnant within a few months of trying.’ She gave me a resigned look, as if there was nothing left in life.
‘Don’t despair,’ I answered. ‘You have plenty of other friends, whether you know it or not, who are in exactly the same position.’
‘Oh I’ said Nola, brightening a little. ‘I thought Tom and I were a couple of Robinson Crusoes.’
‘Not really. In fact, about ten per cent of marriages fail to reproduce. When you consider there about 100000 weddings each year in Australia, that means that about 10000 of these will go through their married life without the patter of little feet—unless, of course, they can adopt a baby.’
‘Interesting … But it doesn’t solve my problem. Or rather, our problem. We’re desperately keen to have a family. I only took the pill for a few months while we settled down after the wedding. Then, it was the hope of both of us that I’d become pregnant, and we’d be on our way, the family way.
‘So, here I am. What’s more, Tom is willing and ready to go along with any special tests or whatever you advise.’
“I’m glad to hear that,’ I answered. ‘So often the male partner prefers not to become involved. He thinks it is a slur on his manliness, or something. Which, of course, it’s not.’
So the interview wound on. It was typical of many discussions between women and their doctors. It’s a strange world: whilst enormous numbers of women are taking precautions not to get pregnant, a significant number have the reverse problem.
Many women regard it as a slur on their femininity. Psychologically they believe that something is fundamentally wrong with them, that they are odd, different, possibly kinky. Utile do they realize that the more they fill their minds with these thoughts of despair and failure, the less likely they are of becoming pregnant.
*42\45\4*

What is polycystic ovary syndrome (Stein-Leventhal syndrome)?
Polycystic ovary syndrome (PCOS) is a condition in which excess androgen secretion leads to the formation of a number of follicular cysts within the ovary. These are detectable on ultrasound examination. The ovaries might be enlarged, with thickened capsules, or normal sized. The presenting features vary but may include amenorrhoea, infertility, hirsutism, obesity (although patients may be of normal weight) and irregular, profuse menstrual bleeding. The hormonal findings usually demonstrate raised levels of luteinizing hormone (LH), a constant, low-to-normal level of follicle-stimulating hormone (FSH) and high levels of circulating androgens. Complications can arise from high unopposed oestrogen levels, including endometrial hyperplasia and metrorrhagia, and rarely, endometrial carcinoma.

What is the treatment for PCOS?
Treatment is often aimed at reducing these risks by giving oral progestogens, or oral contraceptives, once an endometrial biopsy has been taken to eliminate the risk of endometrial carcinoma. Alternatively, cyproterone acetate, an antiandrogen and progestational agent, can be used to control hirsutism, along with a cyclical oestrogen to induce withdrawal bleeds.
The most distressing complication is often reduced fertility or infertility, which can be treated in specialist clinics with drugs such as clomiphene to induce ovulation. An alternative is spironolactone, which is a diuretic and androgen inhibitor.

What is the connection between PCOS and obesity?
The high circulating levels of insulin found in obese women with the metabolic syndrome stimulate the ovaries to secrete excess levels of testosterone, leading to hirsutism and other androgenic effects. Like oestrogens, androgens are fat soluble and so are absorbed into the adipose tissue until tissue androgen levels are in a state of dynamic equilibrium with levels in the blood. As well as acting as a store for steroid sex hormones, the adipose tissue also changes androgens to oestrogens, a process known as peripheral conversion. The resulting excess oestrogen level interferes with the feedback mechanisms of the hypothalamopituitary axis, disrupting normal reproductive function and the menstrual cycle.
The greater degree of obesity, the more profound is the effect on the ‘normal ovarian function.
*1/312/5*

The significant step forward in preventive medicine came with the alarming realization that health was not just a middle-class luxury. In other words the middle and upper classes began to realize that whether they liked it or not their own health and wealth was deeply involved with the health of the ordinary working people. It is perhaps surprising that industrialists did not see the economic link between the poor and unhealthy working classes and low productivity earlier, but they did not and in 1848 when parliament was debating the first Public Health Bill even the Economist magazine did not see the connection between the two. As we have seen, Petty had been talking about exactly this link over a century beforehand but an Austrian, Johann Peter Frank, was the first to make the assertion that governments were strengthened by healthy, happy workers. His thinking produced the world’s first government medical system, in Germany in 1883.

The growth of preventive and public health measures in any industrialized country appears to follow a fairly predictable pattern as the country becomes industrialized. First, there is a rush for power, then an increase in exploitation which is difficult to control. Along with this, rural people and even those from outside the country migrate to the major cities, become separated from their own food supply and depend on cash as wages. At the same time death rates rise dramatically and the value placed on individual life is low. But such a system, whether it occurs in nineteenth-century England or twentieth-century Third World countries, produces wealth and makes money available for those who want to spread it around. Historically, individual philanthropists started creating better conditions for their workers and indeed for whole communities and this, combined with the new egalitarianism born as a result of the French and American Revolutions, made the upper classes more aware of the value of keeping the masses healthy.

At the turn of this century another truth began to dawn. About 60 per cent of all the men who volunteered for the British army’s fight in the Boer War were unfit for service. This appeared to shake people’s long-held attitudes almost more than any other single factor and led Sidney Webb to write:

We have become aware, almost in a flash, that we are not merely individuals but members of a community, nay and citizens of the world. . . . In short, the opening of the twentieth century finds us all, to the dismay of the old-fashioned, individualist, thinking in communities!

Slowly, the notion that society was a collection of communities began to develop-rather more slowly in the US than in the UK, partly because of the individualistic frontiersman thinking in the former. But things were on the move and the time was ripe for the second phase in the development of preventive medicine -the scientific approach.

Until this time facts and figures about health were poor, so few lessons could be learned. Simple ‘Bills of Mortality’ had been collected in London since 1603 but it was not until the establishment of the office of the Registrar General in 1837 that guesswork was replaced by real statistics. The availability of verifiable facts now made it possible to enact regulations to prevent frankly harmful behaviour and to promote healthy behaviour and practices. Ordinances to abate noise, control sewage and dispose of decayed matter, dead bodies, filth and stagnant waters go back as far as 1388 and in colonial times several American communities enacted laws to quarantine ships and isolate smallpox. Baltimore organized America’s first board of health in 1793. But effective public health administration was impossible in either country because local parishes and communities overruled national goals. As so often occurs in history, the activities of one man changed all this.

*3/72/5*

Back in the sixties, Brian Sear, an industrial designer, received a brief from British Rail to design toilets for a flashy new interurban train. He took his commission seriously and researched the topic extensively. Besides attending anatomy lectures in London, he did the rounds of hospitals, watched X-ray film of all kinds of ‘stool’ excretion and carefully noted the effects of diet, posture and toilet type.

Sear’s overwhelming conclusion was that humans function best at evacuation when they squat. He claimed he found that 85 per cent of the world’s population squats and is relatively free of the rectal problems which plague people in the West who prefer to sit on elevated toilets.

Realizing that British Rail was conservative, he designed a compromise between a hole in the floor and a pedestal. The important thing was for the knees to be higher than the backside. To achieve this, he lowered the pedestal considerably and replaced the usual flat seat with one that was saddle shaped. The flush system was redesigned to avoid water splashing, and a prototype was then built by Doultons. It was triailed in-house and functioned well.

Needless to say, British Rail panned it and used a conventional toilet instead. Sear, who now lives in Helensburgh, south of Sydney, still believes in squatting and at home has a brick in front of his toilet to raise the knees.

But is squatting really any better for you than sitting? The issue is controversial and the scientific evidence scant. One advocate of squatting, Dr B. A. Sikirov, took twenty men and women who had had haemorrhoids for years and made them change their defecation habits. They could only squat.

In the absence of a squatting lavatory they were advised to use a suitable flat container and they were only allowed to defecate in response to a strong urge instead of at a fixed time each day In fact, they were advised to postpone the attempt until they were absolutely certain of its necessity.

Sikirov claimed that most patients showed significant improvement in their haemorrhoids after squatting. He believes the toilet in its present form should be modified to allow defecation in a squatting position and says a special program may need to be devised to reacquaint man with his natural habits.

Wal Bowles, an ex-pilot, aircraft engineer and aircraft accident investigator from Sydney, has found a way of enabling people to squat on an ordinary toilet without actually resting on the porcelain. Squatting on the porcelain is dangerous as it can shatter and cause awful injuries. He has invented a device which converts an ordinary toilet into a squatting one. Called ‘In Lieu’ it’s made of moulded plastic and fits around the base of the toilet. It allows the toilet to be used in a full squat or in the usual sitting position.

Bowles’ interest in squatting began about thirteen years ago when he was forced to use a squat trench in the bush. He was so impressed with the feeling of ease that resulted that he began to use his investigative skills to explore the issue. ‘Squatting has absolutely fantastic potential, if only people can be persuaded to do it,’ he says.

Sydney colorectal surgeon and director of anorectal physiology at St George Hospital, Dr David Lubowski, disputes that squatting has a beneficial effect. He says the true incidence of haemorrhoids in developing countries, where people squat, is entirely unknown. Even if it were known, there would be other factors, such as diet, to consider.

Further, he says the methodology in the Sikirov trial was problematic and its conclusions are not scientifically valid Lubowski says the relationship between straining at stool and haemorrhoids lies in the downward movement of the pelvic-floor muscles.

It used to be thought that haemorrhoids were simply due to varicose veins of the anal canal but this theory is known to be incorrect. It’s now accepted that haemorrhoids are caused by the prolapse of the three little cushions of tissue which are found immediately inside the anus. These are sometimes referred to as anal lips. These cushions can prolapse if the muscles which normally support them are damaged as a result of chronic excessive straining at stool. Such muscle damage is brought about by a stretch-induced injury of the pudendal nerves. Injury to these nerves is central to the development of haemorrhoids.

Avoiding straining is an essential part of the treatment for haemorrhoids since this avoidance prevents abnormal pelvic-floor descent and pudendal nerve damage. If squatting were to have an effect, it would have to reduce the amount of pelvic-floor descent during straining compared with straining in the conventional sitting position. Lubowski and colleagues tested this and found no difference in the amount of downward movement.

*18\136\4*

The diaphragm forms a barrier across the cervix so that most sperm stay in the vagina and cannot get up into the uterus and tubes to meet an egg. If a sperm doesn’t join with an egg you cannot get pregnant.

It is not necessary to use spermicide with a diaphragm but some women like to use it. We will talk about spenmc.de ma later session, but it is a special type of cream or gel. The idea is that if any sperms get around the edge of the diaphragm, spermicide will kill them. Tests have been done to see if diaphragms work better with spermicide. Results seem to show that diaphragms probably work just as well with or without spermicide, so it’s up to you. Whatever you prefer.

How effective are diaphragms? If diaphragms are used correctly they are 85 t0 95 percent effective. That means if 100 women used diaphragms as their method of contraception for a year, between five and 15 of them would have an unplanned pregnancy. Some people say they use a diaphragm as their method of contraception, but in fact they don’t use it every time they have sex. Sometimes they forget to use it, or they haven’t got it with them, or sometimes they just don’t want to use it. If you don’t always use it, it obviously can’t work as well as it should.

Other reasons for accidental pregnancies while using a diaphragm could be that the diaphragm was not covering the cervix. It can sometimes squeeze into the vagina in front of the cervix although it usually feels uncomfortable there, so you’d normally be aware that something wasn’t right. If you lose a lot of weight the diaphragm may not fit properly anymore, and some sperm may be able to get around the rim and up through the cervix. These are good reasons to check that your diaphragm fits properly and is in the correct place.

*15\132\4*

Coming on time. One or the ironies about assisting premature ejaculators to slow down is that they often expect fast results. They ask for a quick fix and want to be cured’ in one consultation. The last thing they feel they can tolerate is a drawn-out program that takes weeks to complete.

But there is no proven quick fix for this condition. Short-term measures are available but these mostly yield short-term results. The experts generally agree that it takes several weeks to achieve a lasting change in ejaculatory patterns.

Every man can learn to control his ejaculation provided he has no neurological abnormality. It is simply a reflex that can be brought under voluntary control. Like children who are taught urinary control through heightened sensory awareness, through knowing what it feels like to have a full bladder, so men suffering PE can heighten their sensory awareness and gain more control.

But in trying to slow themselves down, many men often use methods which ultimately make the condition worse. They attempt to switch off. As the crucial moment approaches, they try thinking about something completely unrelated to what is happening. Some calculate their tax, some bite the insides of their cheeks or remember the last funeral they attended — anything to get their minds off the inevitable. Others drink or use an anaesthetic ointment to dull sensation.

Such methods take a man down the wrong track. They distract him from his sensations and slow him down by reducing his desire and excitement. But what he really needs is to prolong his pleasure by learning to stay in control while he is highly aroused and excited.

The squeeze method, developed by Masters and Johnson, requires the partner to stimulate the man until he is close to the point of ejaculation. When he warns that he is about to climax, the partner squeezes him hard behind the head of the penis. This causes a partial loss of the erection. When he is back in control, stimulation recommences. Ultimately, the aim is for him to become sensitive enough to forestall orgasm on his own. The technique progresses from manual stimulation through various stages to complete intercourse.

The stop-start technique, devised by Dr James Semans in the 1950s, was ignored for years and then taken up again and considerably refined. It begins much like the squeeze method. The difference is that the partner stops stimulating the man when he asks her to, before the point of inevitability. Instead of a squeeze, there is simply a pause. As this technique progresses, the couple do not stop, they just change pace. With a trained therapist, both the stop-start and squeeze methods are successful with more than 96 per cent of men. They can take anything from four weeks to four months to learn.

The ‘testicular tug’ is another method. Just before ejaculation, a man’s testicles rise. If his partner tugs them down, ejaculation can be delayed, but this can be difficult to do.

There are several shorter ways of treating PE, none of which can be guaranteed to produce lasting results on its own. These include the use of tablets, ointments and sprays.

Drugs such as Prozac and Anafranil are known to retard ejaculation. But these drugs may have other, unwanted side effects and have to be taken with care. When therapists do prescribe them, it is mostly in conjunction with behavioural treatment programs.

Injections which allow men to maintain an erection for thirty to sixty minutes can also be used to treat PE. Over several weeks they may help men gain confidence and break the old patterns of rapid intercourse. But side effects may include scarring, development of fibrotic nodules (which may lead to a curve in the penis shaft) and prolonged erection (priapism).

Often the partners of men with PE are unwilling to discuss, contribute to or cooperate with therapy of any kind. They may take the PE personally and misinterpret it as a sign of rejection or as an indication that the man has someone else. Where the man is not in a stable, secure relationship it is important that successful treatment occur as soon as possible so that he does not lose an opportunity with a new partner.

There are basically two types of PE: primary and secondary. Primary PE occurs when the man’s penis is hypersensitive. He can desensitise and learn control using the methods outlined above. Secondary PE often results when there is an element of erectile dysfunction because of physical or psychological problems. The man is so anxious about losing his erection before he has ejaculated that he rushes to finish. By treating the erectile difficulty, the secondary PE problem is often automatically cured, too. Depending on its cause, erectile difficulty can be treated medically, surgically, with injections, with prostheses or with psychological counselling.

*11\136\4*

Where do you get condoms? You can buy condoms and water-based lubricant at Family Planning Centres, chemists, Sexual Health Clinics, vending machines, supermarkets, petrol stations, and by mail order.

What do condoms cost? You can buy condoms in their own little packets, one at a time, for about 25 cents at Family Planning Centres. The average cost ranges from $6 to $12 for packs of 12, from supermarkets and chemists. Water-based lubricant comes in single-use packets which cost about 25 cents at Family Planning Centres, and in tubes for between $5 and $10.

Some other questions people ask about condoms.

Q. Why do condoms break?

A. Latex rubber is perishable, which means that it can harden,

and crack or tear easily after a certain period of time. Heat and humidity can also affect latex rubber, so condoms should be kept in a cool, dry place.

It is best to buy condoms from somewhere that is air-conditioned, like a supermarket, and not where they have been stored in the sun. Do not keep condoms in the glove box of your car. If you keep them in your wallet, throw them out after a week.

Condoms should be used before the expiry date on the packet otherwise the latex may have perished and they are very likely to break. You should not use oil-based lubricants like petroleum jelly or massage oil with condoms, because they can make the condoms break too.

Condoms may break because you have not used enough water-based lubricant They can also break if you don’t leave enough space at the end of the condom for the semen to collect

Q. Why do condoms slip off?

A- Condoms may slip off if you wait too long after ejaculation before withdrawing because the penis gets softer and smaller in size.

Q. Why do condoms sometimes leak even though they are not broken?

A. Condoms may leak from the open edge if you wait too long after ejaculation before withdrawing because the penis gets softer and smaller and the condom doesn’t fit tightly any more. They may also leak if you don’t roll them down far enough over the penis.

Q. Can you get condoms that are not made of latex rubber?

A. Non-latex, polyurethane condoms are available in other countries. They are not approved for use as a contraceptive in Australia so you cannot buy them here, but you can get them via the Internet

*8\132\4*

The Bobbitt syndrome. John Bobbitt has become a household name. Before his wife mutilated him, he was an unknown bankrupt. Afterwards, the former US marine was fielding invitations to chat shows, being paid $2500 a radio appearance, considering film and book offers and receiving a constant stream of letters from women offering to rehabilitate him sexually. Today he’s a media and would-be movie star. You would think he was the first man ever to have his penis amputated and then surgically reattached. He is not. It has happened dozens of times.

In Sydney alone, at least six penis reattachments have been done. In Japan and Thailand the phenomenon is well recorded, and it was recently published that eighteen of the operations have been performed in Bangkok. There is even a report of an incompletely severed penis which was restored in Germany as long ago as 1929.

Not all of these amputations were performed by disgruntled partners. Many have been the result of self-mutilation and some were the result of accidents. Mothers ‘hearing voices’ have also been known to mutilate their sons.

But microsurgeons don’t like to talk about any of this. They fear that publicising the events that necessitate the reattachment will lead to copycat behaviour. Already, several cases have been reported in the wake of the Bobbitt publicity. In one case, a Turkish woman severed the penis of her lover, claiming he regularly forced her to have ‘divergent’ sex. In another, an American woman declared that years of abuse drove her to cut off her husband’s testicles and part of his penis as he lay in a drunken sleep. Years before Bobbitt, a Queensland woman removed her husband’s penis and then put the severed piece in a garbage disposal unit and turned it on. The man managed to rescue it and then get himself to a hospital, where it was sewn back on. Today he says that although he can get an erection he still has problems because of scarring and damaged nerve-endings which cause numbness.

Reattaching a penis is difficult and time-consuming, but microsurgeons say it is not as complex as rejoining a severed hand, which has a more intricate internal structure. Apart from the surgeon’s skill, the ultimate success of the reattachment depends on the way the penis is cut off and on the condition of the amputated section. Major arteries, veins and nerves need to be rejoined and replanted, and the urethra tube through which urine passes must be reconnected. Urinary function is more easily restored than erectile function because the penis is essentially a sponge of little blood vessels which inflate like a balloon when filled with blood during erection. The penis contains three inner tubes which have to be very tightly stitched together so they are blood-tight. Besides the urethra, arteries, veins and nerves being reconnected, the inner capsule, the outer capsule and the skin have to be joined. It can take five to eight hours, depending on the injury.

Bobbitt is confident that he will eventually lead a normal sex life. He has good reason for optimism. Many men in Bobbin’s position have regained competent erectile power.

A Sydney man who had an experience similar to Bobbitt’s in 1985 tried out his repaired penis in Kings Cross and told journalists it passed the test and that he enjoyed the experience very much. Once the nerves regenerate, some erotic sensation does return, but this takes time.

Penis amputation is reported more in Japan and Thailand than anywhere else and is usually the result of self-mutilation. In Japan, this mutilation has been known to precede harakiri, a national form of honourable suicide.

Apart from the physical and psychological horror of penis amputation there’s a real danger that the man may bleed to death. When Bobbitt arrived at hospital, the urologist who assisted the operation said there was a large amount of blood where the penis should have been. Bobbitt’s wife had thrown the penis into a bush, from which it was later recovered. If it had not been found, his doctors say their only option would have been to sew up the stump.

The blood and nerve supply from the arm were also used, and a piece of the man’s twelfth rib was put inside the penis to give it some rigidity. This rib is cartilage, not bone, and resulted in the penis being semi-erect. The new penis was connected to the powerful artery that feeds the legs, so that when the man became aroused, blood would rush in from this artery and complete the erection. Because his testicles were intact, the man was able to ejaculate. Fortunately, men who have their amputated penises reattached retain their virility and fertility because their testicles and reproductive systems are unharmed If all goes well, Bobbitt should be able to father children without needing to resort to artificial insemination.

*4\136\4*