Volume 185 Issue 8

Making health services more available to and appropriate for Australian men The 6th National Men’s Health Conference, held in Melbourne in October 2005, incorporated the 4th National Aboriginal and Torres Strait Islander Male Health Convention. Since 2003, the Australasian Men’s Health Forum — a not-for-profit peak body for individuals and organisations working with men and boys and their health and social issues, and the organising body of the biennial national conferences — had already been working collaboratively with the organisers of the National Aboriginal and Torres Strait Islander Male Health Convention. As a nation, we need to support Indigenous men, whose health is the poorest of all male population groups in Australia. Over the years of collaboration, it became apparent that the more holistic view of health that Indigenous men hold, as part of their cultural inheritance, could potentially benefit all Australian males. In 2005, a lack of national funding for the Indigenous Male Health Convention prompted a combined event with the National Men’s Health Conference, with some joint sessions and some sessions for Indigenous men on their own. This structured sharing led to an even greater empathy and understanding of the similarities and differences in Indigenous and non-Indigenous men’s health. The combining of the two conferences also enabled the National Men’s Health Conference to further broaden its perspective. Men’s health conferences in Australia have always taken a broad view of health. This is in contrast to international men’s health conferences, which have tended to have an almost exclusive focus on clinical dimensions — the prostate and erectile dysfunction featuring prominently — perhaps reflecting the funding sources of these conferences (World Congress on Men’s Health and Gender; Vienna, Austria <http://www.wcmh.info/>). Although important, a clinical perspective, if focusing too narrowly on disease and malfunction, can miss crucial dimensions, including psychosocial, spiritual and underlying political dimensions. Suicide, for example, is a major issue in men’s health, notably in Australia where, on average, five men a day kill themselves.1 For us to begin to understand and deal with this phenomenon adequately requires social and political perspectives, as well as clinical understanding. The Melbourne conference kept this broad focus on health, as well as the treatment of disease, with sessions on fathering, ageing men and gay men. From keynote addresses by international speakers, insights were gained into male-directed health services in Scotland (Mr Jim Leishman, the Men’s Health Service Coordinator, Northern Health Service, Forth Valley, Scotland — Developing services for men: the Scottish experience) and the building of a national men’s health policy in Ireland (Mr Noel Richardson, Coordinator of National Policy for Men’s Health, Ireland, and Dr Paula Carroll, Health Promotion Department, Irish Health Service Executive — Getting men’s health onto a policy agenda: setting a context to the development of a national policy for men’s health in Ireland.) The lack of a national men’s health policy in Australia was addressed by Micheal Woods in his paper, Dying for a policy: men’s health in Australia. The need for a national men’s health policy was also mentioned in the conference’s opening address, given by Dr Mukesh Haikerwal, President of the Australian Medical Association (AMA), whose presence was an indication of the growing acceptance in the medical profession of the need to consider male-specific issues in health. Of the states and territories, only New South Wales has a men’s health policy, and the AMA committed itself to a “round table” on the need for such a national policy. This has since taken place, and a position paper on men’s health has been issued.2 During the conference, Indigenous men launched the National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males (available from: Ms Jill Turner, Social Health, Health Strategies Branch, Office for Aboriginal and Torres Strait Islander Health, Jill. TurnerAThealth.gov.au). One of the main underlying themes of the conference was to question the assertion that poor health outcomes of men are a result of assumed “bad” male behaviour — typified by statements such as “Men don’t use doctors enough”, and “Men don’t get in touch with their feelings” — and to shift the focus to asking further questions such as: How can we make health services more available to and appropriate for Australian men? (Box 1). The effort to make services more “male friendly” was evident in many of the presentations (Box 2). Further initiatives in this direction would be welcome at the 7th National Men’s Health Conference, to be held in conjunction with the 5th National Aboriginal and Torres Strait Islander Male Health Convention, in South Australia in 2007, supported by the SA Health Department. In Melbourne, we had 303 delegates, including 75 Indigenous men. We look forward to having you join us next year at an even bigger gathering of all those with an interest in men’s health (Conference contact: Greg Millan, Conference Development Officer, Australasian Men’s Health Forum, gmillanATbigpond.net.au). 1 Where do I fit in? Created by Greg Gaul (reproduced with permission of Men’s Health Information and Resource Centre, University of Western Sydney). 2 Examples of presentations about “male-friendly” health service delivery Wow I’m a Dad. Development of a booklet for first-time fathers Alan Grochulski, Royal North Shore Hospital (booklet co-authored by Salih Ozgul) Indigenous men’s health and wellbeing — “there’s more than just football”. The Royal Flying Doctor Service Mental Health Program Brod Osborne and Johnathan Link, Royal Flying Doctor Service, Far North Queensland Driving to good health — commercial drivers encouraged to “think about it” Fiona Landgren, Clare Burns, Communicating for Health Building capacity for health promotion at Fairfax — a case involving the Men@Work Program Nick Petrunoof, John Fairfax Holdings Ltd HealthBreak: Sleep Safe–Work Smart–Health Program Howard, Lehrke, Wilson, Institute for Breathing and Sleep

John J Macdonald DipCD, Med, PhD · Greg Millan ADip Social Work · Mick Adams PhD Student

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD

Objective: To determine the influence of obesity on the diagnosis of age-related androgen deficiency (AD) in symptomatic men according to current Australian guidelines.Design, setting and participants: A community-based cohort of healthy ageing men with symptoms suggestive of AD was studied between May 2001 and February 2003. Men were classified as obese or non-obese according to body mass index (BMI) or waist circumference (WC).Main outcome measure: Diagnosis of AD according to Endocrine Society of Australia (ESA) guidelines.Results: 223 men aged 54–86 years with mean BMI 27.3 ± 0.2 kg/m2 (range 20.5–36.2 kg/m2) were recruited; 99 men were obese (BMI ≥ 30.0 kg/m2 or WC ≥ 102 cm) and 124 men were non-obese. Obese men had lower total testosterone (TT) (12.7 ± 0.4 v 15.0 ± 0.4 nmol/L); P < 0.001) and calculated free testosterone (275.7 ± 7.8 v 299.3 ± 7.4 pmol/L); P = 0.03) levels than non-obese men. TT levels < 8 nmol/L were recorded in 12% of obese men and 1% of non-obese men. Applying the ESA guidelines for the diagnosis of age-related AD, 15 obese men (15%) and 4 non-obese men (3%) were classified as being eligible for androgen therapy supported by the Pharmaceutical Benefits Scheme (PBS); the relative risk in obese men was 1.92 (95% CI, 1.44–2.55; P < 0.001).Conclusion: Obesity is an important determinant of serum TT levels in ageing men. Almost one in seven obese men but only one in 30 non-obese men in our study were eligible for PBS-supported androgen therapy according to Australian guidelines. Although obese men are more likely to have biochemical hypoandrogenism, the clinical implications of this remain uncertain. Studies of testosterone therapy in this group of ageing men are needed to determine whether androgen replacement is beneficial.

Carolyn A Allan PhD, FRACP · Boyd J Strauss PhD, FRACP · Henry G Burger MD, FRACP · Elise A Forbes RN · Robert I McLachlan PhD, FRACP

Objective: To assess the psychosocial impact of the diagnosis of either localised or metastatic prostate cancer (PCA) on patients and their female partners.Design: Observational, prospective study at Time 1 and 6 months later at Time 2 of two groups of couples facing PCA. Time 1 was when patients were first diagnosed with histologically confirmed localised (potentially curable) PCA or metastatic (incurable) PCA.Main outcome measures: Depression and anxiety disorders according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); psychological distress; marital satisfaction.Results: At Time 1, partners had rates of DSM-IV major depression and generalised anxiety disorder twice those of women in the Australian community, and considerably higher than the patients’ rates. At Time 2, psychological distress in partners had lessened but that in patients had increased. On the other hand, at Time 2, partners’ marital satisfaction had deteriorated.Conclusions: To be fully effective, interventions aimed at reducing the psychosocial morbidity of PCA must involve both patient and partner, rather than the patient alone.

Jeremy W Couper MB BS, MMed(Psych) · Sidney Bloch MB ChB, PhD · Anthony Love PhD · Gillian Duchesne BSc(Hons), MB ChB, MD · Michelle Macvean PhD · David W Kissane MB BS, MPM, MD

Some boys conceived through artificial techniques may inherit their fathers’ subfertility Clinical assessment of couples unable to conceive naturally often identifies causative or contributory factors associated with the male partner. Male infertility affects one in 20 men, accounts for a third of all infertility, and is a cofactor in over half of assisted reproductive technology (ART) treatments worldwide.1 Primary spermatogenic failure (SgF, also termed idiopathic infertility) accounts for more than half the cases, yet, in most of these cases, its cause is unknown.1 In clinical practice, classification of SgF is based on semen parameters (describing combinations of poor sperm number, motility or function) and reflects an ignorance of the pathogenesis.2 However, recent research has determined that up to 15% of SgF is related to at least six known Y chromosomal deletions, with implications for genetic testing, counselling, assisted reproduction and even subsequent male offspring conceived by ART. Spermatogenesis is a complex process of cell division and structural modification involving the coordinated expression and interplay of many gene products. Recent data point increasingly towards a genetic basis for SgF. In particular, deletions of the Y chromosome — called microdeletions — are the most significant recognised cause of SgF in otherwise healthy men.3 The Y chromosome is 60 megabases (Mb) in size, and comprises a short arm (Yp) that encodes the male sex-determining gene Sry, and a long arm (Yq) (Box). Of the 27 Y chromosome genes identified, nine are located on Yp and the remaining 18 on Yq.4 Twelve of the 18 Yq genes are expressed in a testes-specific manner and are vital for normal sperm production.4 Y chromosome microdeletions in fact involve substantial DNA deletions within the Yq region, ranging from 1.6 to 14.5 Mb and, depending on the deletion type, result in the loss of specific combinations of spermatogenic genes. Accordingly, men with Yq microdeletions are often (but not always) infertile, but many can still father children through intracytoplasmic sperm injection (ICSI),5 using the few viable sperm present in semen or mature spermatids isolated directly from the testis.6 An association between Y chromosomal deletions and infertility was first reported in 1976 by Tiepolo and Zuffardi,7 who detected large Yq deletions in six azoospermic men by routine karyotyping involving chromosomal banding. They proposed that an azoospermia factor (AZF) region was associated with spermatogenesis. Extensive physical, functional and genetic analyses of the Y chromosome8,9 have now identified three AZF regions (AZFa, AZFb and AZFc), which encode spermatogenic genes such as USP9Y, RBMY1, and BPY2 and DAZ (Deleted in AZoospermia) (Box). DNA sequencing of the Y chromosome has identified unique structural features such as large palindromes (DNA sequences that read the same in both directions) that encompass highly repetitive DNA elements.4 Homologous recombination, involving elimination of one repetitive sequence at the expense of another, is believed to be the underlying mechanism that accounts for the random appearance of de novo AZF microdeletions in men. Interestingly, the fathers and brothers of men with Yq microdeletions usually have non-deleted Y chromosomes and normal sperm counts, indicating that these deletions are spontaneous events. The reason for the appearance of Yq microdeletions in some men is not known. We speculate that these deletion events occur during gametogenesis or early preimplantation development and may involve a deficiency in enzymes responsible for normal DNA repair. Up to 15% of men with SgF and sperm densities below 5 million/mL have AZF deletions.3 Variation in the reported incidence of Yq deletions in infertile men has been attributed to factors such as patient selection criteria, the molecular test format, and the propagation of specific Y chromosome types (called haplotypes) within population groups that have different susceptibilities to deletion events. The three identified AZF regions contribute to six different Yq deletion types: AZFa, AZFb, AZFc, AZFbc, AZFabc,8 and the gr/gr subdeletion9 within AZFc (Box). There is no clear relationship between genotype and spermatogenic phenotype, but some generalisations can be made. Most microdeletions (59.6%) involve the AZFc region3 and are associated with the histological appearance of hypospermatogenesis, which is characterised by a reduction in germ cell number, mature elongated spermatids in some or all tubules, and low sperm densities ranging from 5 million/mL to azoospermia.10 Less common Yq deletions involve AZFb (15.8%), AZFbc (13.6%), AZFa (4.9%) and AZFabc (< 1%) regions; such men are often azoospermic and have more severe spermatogenic pathologies, such as arrested germ cell development or the Sertoli-cell-only syndrome. In 6% of cases, Yq deletions that involve regions outside of the three AZF regions have been identified in men with spermatogenic failure.3 Recent investigations of the Y chromosome have identified several smaller deletions within the AZFc region. For example, we have found that one such deletion, called gr/gr,9,11 is more prevalent than AZFc deletions in severely oligospermic or azoospermic men (4.7% v 2.2%, respectively).12 However, we also found gr/gr deletions at a similar frequency in oligospermic men (sperm densities, 5–40 million/mL). Interestingly, gr/gr deletions have also been found in some fertile men who have a particular Y haplotype.13 Thus, gr/gr deletions are relatively independent of sperm density, but significantly associated with infertility. At this stage, the gr/gr deletion appears to be a risk factor for infertility rather than a definitive cause of SgF. The variable sperm parameters observed in men with AZFc and gr/gr deletions could be due to a number of factors, including molecular heterogeneity of the deletion or functional compensation of the lost DAZ gene by its gene homologue DAZLA on chromosome 3. We are currently involved in an international effort to define more precise correlations between sequence variants of these deletions and semen parameters. Vertical transmission of AZFc Yq deletions from infertile men to their sons via ICSI14 and natural conception13 has been reported, the latter underscoring that male fertility is possible even at low sperm output. We have generated a DNA database of more than 150 infertile men and their ICSI-conceived sons, and have identified and mapped the AZFc deletions in three Y-deleted men: in all cases, the same deletion was transmitted to the sons without expansion to other AZF regions.14 Furthermore, analysis of a larger panel of Y chromosomal markers located throughout the AZF and surrounding regions has not identified de novo Yq deletions in 100 ICSI-conceived sons tested to date, indicating that ISCI treatment is not a risk factor for the generation of Yq deletions. However, it seems very likely that these ICSI-conceived boys with AZFc deletions will be subfertile and will need close review as they reach sexual maturation and proceed into adulthood with aspirations for fatherhood. The European Molecular Genetics Quality Network (http://www.emqn.org) has established guidelines for Yq deletion testing and provides an important quality assurance function.15 These laboratory guidelines have been widely adopted and have led to standardisation of Yq testing. The test is based on the analysis of a large panel of conserved molecular markers or genes located within and outside the AZF regions, using multiplex polymerase chain reaction (PCR) on peripheral blood genomic DNA. The pattern of these markers determines the Yq deletion type. Because of the inherent instability of the Y chromosome, it is likely that new Yq microdeletions will be identified and associated with SgF. High-resolution microarrays for chromosome screening will enable further investigation of the Y chromosome in fertile and infertile men, and microarray-based testing may replace multiplex PCR as the gold standard for Y chromosome testing in the future. Given the relatively high prevalence of Yq deletions, most andrology and infertility centres now routinely offer Y chromosome testing to men with severe SgF, especially before ART treatment. Yq deletions have important implications for infertile couples, and genetic counselling following testing is recommended. There are several considerations that support routine assessment of Yq deletions. Firstly, a positive test will provide a firm diagnosis of the man’s problem, which, for some couples with longstanding infertility, can help resolve stress, blame or feelings of guilt. Secondly, knowledge of the type of Yq deletion may assist the clinician in determining the best ART treatment. For example, a Yq microdeletion involving the AZFa or AZFb regions carries a poor prospect of sperm retrieval, even with testicular biopsy,16 thereby questioning the value of this approach and raising donor sperm treatment for discussion. Thirdly, couples should be offered this information, as they must understand that their male offspring will almost certainly be subfertile and require reproductive monitoring from the time of sexual maturation. As the natural history of SgF is poorly understood, it seems wise that consideration be given to sperm storage, as these young men born by ICSI may move from oligospermia to azoospermia before seeking fatherhood. Lastly, infertile men are known to be at increased risk of androgen deficiency17 and testicular neoplasia;18 however, whether the subgroup with Yq deletions have a greater risk also requires careful monitoring. Following genetic counselling about their Yq deletion, most couples still proceed with in-vitro fertilisation using either the male partner’s sperm or donor sperm.19 In a small number of cases, couples have used preimplantation genetic diagnosis to select female embryos for transfer,19 in an attempt to avoid passing on the genetic abnormality to their children. The relationship of Y chromosome deletions and other genetic lesions to male infertility will continue to be an active area of interest. Given the widespread use of ICSI to resolve male infertility, it is important that this research is translated rapidly and appropriately into clinical practice, and that prospective couples are provided with essential information that allows them to be fully informed when making this crucial life decision. The human Y chromosome A: Normal Y chromosome showing AZF regions and representative spermatogenic genes. B: Different Y chromosome deletion types. Dotted lines indicate the deleted regions.

David S Cram PhD · Elissa Osborne PhD · Robert I McLachlan PhD, FRACP

Testosterone is among the oldest drugs in medicine. It has a long efficacy and safety record for its prime role of androgen replacement therapy in men with androgen deficiency. Testosterone and synthetic analogue androgens have also been used in pharmacological androgen therapy (PAT) to produce androgenic effects on marrow, muscle or bone. Although PAT is increasingly being superseded by newer, more expensive drugs, androgens remain cost-effective in many older applications. Androgen misuse is the systematic over-prescribing for unproven medical indications. Misuse is increasingly evident for male ageing (“andropause”) and some other clinical conditions. Further trials for new indications for androgens require reliable safety data, but rising costs may make it increasingly attractive to circumvent the need for evidence by promoting off-label mass marketing. Androgen abuse is the illicit self-administration of often massive doses of androgens for non-medical purposes — notably power sports and body building. In parallel with effective detection reducing androgen abuse in elite sports, more focus is needed on non-sporting cosmetic, recreational and occupational androgen abuse. Despite ongoing androgen misuse and abuse, testosterone remains under-prescribed for younger men with classical androgen deficiency that frequently remains undiagnosed.

David J Handelsman MB BS, FRACP, PhD

Men are at highest risk of cardiovascular disease, chronic lung disease, some cancers, suicide and transport-related injury. An anticipatory approach to men's health in general practice should assess risk for these conditions and offer effective interventions, either to prevent them or manage them early. This requires attention to the barriers, not only to men accessing general practice, but also to appropriate assessment and management, especially among disadvantaged groups.

Mark F Harris DRACOG, FRACGP, MD · Suzanne McKenzie MB BS, FRACGP, MMedSci(Clin Epi)

Metabolic syndrome (MS) refers to the clustering of cardiometabolic risk factors — including abdominal obesity, hyperglycaemia, dyslipidaemia and elevated blood pressure — that are thought to be linked to insulin resistance. MS is associated with increased risk of cardiovascular disease and type 2 diabetes. MS is common, affecting a quarter to a third of adults, and its prevalence is rising, in parallel with increasing obesity and population ageing. Operational definitions of MS have been proposed by the World Health Organization and the National Cholesterol Education Program. Recently, the International Diabetes Federation proposed a global definition that emphasised the importance of central adiposity. In cardiovascular risk assessment, MS encapsulates the contribution of non-traditional risk factors and provides a clinically useful framework for early identification of people at increased long-term risk. It should be used in conjunction with standard algorithms based on conventional risk factors, which better predict short-term risk. Management of MS should emphasise lifestyle interventions (eg, physical activity, healthy diet and weight reduction) to reduce long-term risk of cardiovascular disease and diabetes. Those at increased short-term risk should also have individual risk factors treated according to established guidelines.

Gerard T Chew MB BS(Hons), FRACP · Seng Khee Gan MB BS, FRACP, PhD · Gerald F Watts DSc, MD, FRACP

In Australia, about 150 000 men aged 16–59 years identify as gay or bisexual, while a similar number identify as heterosexual but have some history of same-sex sexual contact. Pitts, Couch and Smith advise that the clinical implications for these men include more than sexual health concerns. They suggest several consultation skills that can help doctors to recognise these men and better meet their needs. Human sexual practice is diverse. In response to the need to better understand that diversity in the face of the HIV epidemic, a fact became widely known that had previously been understood by few: a significant population of men who do not self-identify as “gay” or “bisexual” sometimes have sexual contact with other men. It was recognised that a descriptor for behaviour, rather than an assertion of social identity, was needed, and the term “men who have sex with men”, and its acronym MSM, came into being. We believe there are “definitional” challenges associated with this term, as well as clinical and practical implications when working with men to whom such a descriptor might be applied. What's in a definition?It is rare for medical journals to include sexuality and sexual behaviour as important components of men’s health and wellbeing. It is even more unusual to acknowledge MSM outside the context of HIV. Use of this acronym in a men’s health context both illuminates and challenges. MSM is a behavioural definition; it does not imply an identity, and it does not consider sexual attraction. We prefer the term “male-to-male sexual practices” (MMSP), as it explicitly acknowledges that the sexual practices, rather than the person, are at issue. The choice of “practices” in the plural also signals that male-to-male sex may incorporate a range of sexual behaviours which may, or may not, include oral and anal sex. How many men fit the definition?The Australian Study of Health and Relationships in 2001 surveyed a nationally representative sample of 19 307 Australians aged 16–59 years. These included 10 173 men, of whom 97.4% identified as heterosexual, 1.6% as homosexual or gay, and 0.9% as bisexual, while 0.1% were undecided or “other”. A lifetime history of sexual attraction that included other men was reported by 6.8%, and sexual experience with other men by 6.0%. Of the men who identified as heterosexual, 2.7% reported having had sex with at least one other man. By extrapolation to the general Australian population, this suggests that there are about 158 000 men aged 16–59 years who identify as heterosexual but have some history of same-sex sexual contact. This is in addition to the 148 000 men who identify as gay or bisexual.1 What are the clinical implications?Sex, risk and MSMWhat does it matter that the patient, whatever his sense of identity, has anal sex with men, and perhaps also has penetrative sex with women? The international medical literature on MSM builds a picture of a risk-taking and at-risk group. They are particularly, if not exclusively, considered in the context of HIV risk, and to a much lesser extent are known to be at risk of other sexually transmitted infections (STIs). We recently completed a study of the knowledge and attitudes of gay men towards anal cancer and human papilloma virus (HPV).2 We know that anal sex carries a high risk of HPV transmission, particularly for men who are HIV-positive, but our study showed that very few gay men had even heard of HPV, and most were not aware of its association with sexual practices. In this regard, they differ little from women, who are at similarly high risk — of cervical cancer — through HPV exposure. MSM are at greater risk of gonorrhoea or syphilis than are other men. However, most consultations with MSM are for issues other than STIs and reflect the profile of health conditions experienced by Australian men. Substance useCertainly, if a category or group is defined only in terms of sexual activity, it is unsurprising that STIs feature large. However, there is some evidence of health risks other than sexual health risks in MSM, which nevertheless derives from HIV studies. These indicate a higher than expected rate among some MSM subcultures of alcohol use, and injecting and other illegal drug use. Men in the Australian Study of Health and Relationships who identified as bisexual were eight times more likely to report a history of injecting drug use, and gay men were twice as likely, as those who identified as heterosexual.3 However, they were no more or less likely than other men reporting a history of injecting drug use to report sharing needles or injecting paraphernalia. In Private lives, our national online survey of health and wellbeing among gay, lesbian, bisexual, transgender and intersex Australians, we found that 38.3% of gay-identifying men reported tobacco use on more than five occasions in the previous month,4 which compares with 26% for Australian men in general.5 Mental healthFindings about MSM are mixed in the area of mental health. Numerous studies have indicated higher rates of depression and anxiety in gay men. A 5-year study in South Australia reported 30% of homosexually active men met the criteria for a major depressive episode, as measured by the Primary Care Evaluation of Mental Disorders screening tool.6 Twenty-seven per cent of the men in the survey were diagnosed with dysthymic disorder on enrolment, while the survey indicated a lifetime prevalence of a depressive disorder of 48%. This is five times the rate for all men reported from primary health care clinics in the United States where the survey instrument was validated.7 In Private lives, which involved 3429 gay men from all Australian states and territories, we found that the prevalence of depressive disorders was high, with 48.7% of men scoring on at least one of the two criteria for a major depressive episode. Nearly a quarter of respondents (23.8%) met the criteria for a major depressive episode, with a similar proportion reporting experiencing depression (24.2%). It is of particular concern that 15.7% of gay men indicated suicidal ideation in the 2 weeks before completing the survey. While the causes are not easily identified, it is probable that living in a society characterised by homophobia is a contributing factor.4 What are the practical implications?Recognition of MSMHow does one recognise MSM? Would the behavioural question be: “Have you ever had sex with a man?” or “Have you had sex with a man in the past year?” and/or “Have you also had sex with a woman?” And how would the word “sex” be interpreted? Presumably, the narrowest definition of MSM would be a man who has experienced anal sex (insertive or receptive) on at least one occasion in his life. However, it is not surprising that publications on MSM almost never offer a definition or, if they do, proceed to bundle MSM with gay, bisexual and other homosexually active men into a single analysis. MSM and their health needs are most likely to evade recognition because of the heteronormative nature of most clinical practice — based on the assumptions that, until proven otherwise, all people have a simple sexual identity, and that it is heterosexual. A gay man who is “out” about his sexuality to his doctor (67.2% of men in the Private lives survey had told their doctors) may find his general health concerns sometimes overshadowed by concerns about sexual health. This may be understandable, given the relatively high rates of HIV and other STIs among these men. However, STIs or any other single issue should not become an overriding focus of any clinician–patient relationship. When, how, and what to ask a man about sex? Simply put, when and if you consider it matters, avoiding a default assumption that the man is heterosexual, even if he is married, partnered with a woman or has children. MSM have wives and children too! In most cases, the need to ask is determined by the presenting condition, and it may not matter so much to whom a man is attracted, or what he identifies as his sexual identity, as what his recent sexual practices have been. So, ask questions about the sex he does, rather than about what he is. Of course, if the presenting problem has to do with a complicated life course perhaps including mental health issues, then questions about sexual attraction and identity could well be the important ones. The case scenarios (Box) show the differing process and outcomes when a doctor recognises, or fails to recognise, the possibilities. For new patients, it may be easy to indicate that a full sexual history is a usual part of an initial consultation, whatever the presentation. For existing patients, sexual history may be best approached indirectly. A statement that hepatitis B vaccination is freely available and recommended for all men who have had sex with another man can be mentioned in the context of reminding all male patients of vaccination schedules. If a clinician (or a practice) takes a “no default assumptions” approach to sex, then the move into questions of sexual attraction, identity and practice will happen when, and if, they matter. Finally, we are confident that it is rare that health articles define the population in terms of a single behavioural characteristic. To think analogously, would we not shrink from referring to WWR (women who reproduce), PWJ (people who jog), or indeed MSW (men who have sex with women)? Is it so surprising that we would prefer the term “male-to-male sexual practices” or MMSP? Case scenarios Scenario 1 — MSM not recognised Rob is a 36-year-old man who lives in a regional town. He is married with three young children and is feeling guilty and highly anxious following an unsafe sexual episode with another man a while ago. He feels he will be able to relieve his anxiety only by having an HIV test. He goes to a local doctor he does not know, as he does not want to use his family doctor, who also treats his wife and children. On the information form, he states that he is married. In the consultation, Doctor A invites him to discuss his presenting problem, and Rob leads into it by saying he is very embarrassed because he has been unfaithful to his wife. Doctor A, sensing his embarrassment, tries to help by asking whether the woman is someone he is having an ongoing affair with and whether he feels she might have had an STI. Not knowing how to get round this, Rob says that he is worried about STIs. Doctor A ends the discussion, which is clearly becoming more uncomfortable, by ordering a series of STI checks and suggesting the affair has been a bad idea and should end. The tests do not include an HIV test. Rob has gained nothing from the visit; he does not return for the test results. Scenario 2 — MSM recognised Rob, still anxious, goes to another doctor in the town to try to have an HIV test. This time he notices a health promotion poster for same-sex attracted people (Figure*) in the waiting room and so feels more confident. He completes the information form again to say he is married but notes an option for “same sex relationship”. These signals lead him to feel safer about discussing his concerns. Doctor B asks why he has come, and he says he has had unsafe sex with someone other than his wife. “Was that with a male or a female partner?” asks Doctor B. He then asks what Rob actually did with that partner. Rob and Doctor B agree that an HIV test is necessary and discuss other STI tests as well. Hepatitis B vaccine is also discussed, along with the levels of anxiety Rob has been feeling. Doctor B takes the opportunity for a reminder about the importance of practising safe sex in the kind of situation Rob describes, but acknowledges that is not always easy. He will see Rob again for his test results, and makes sure he will return by telling Rob he is pleased to have met him and that he would be happy to see him any time he needs to talk about things. When his test results come back negative, Rob and Doctor B use the feeling of relief to talk through some of his health risks and to plan strategies to avoid anxiety in the future. After the consultation, Rob feels less guilty and more in control of his life, and less likely to take risks with his own health and the health of his wife in the future. * This poster and other useful resources are available at http://www.glhv.org.au/ MSM = men who have sex with men. STI = sexually transmitted infection.

Marian K Pitts PhD, AFBPS, MAPS · Murray A Couch BA(Hons) · Anthony M A Smith PhD

It often falls to general practitioners to identify and manage service-related mental health problems It has long been recognised that veterans may experience mental health problems after military deployments, and that these can be overlooked in the context of concern about physical injuries. Primary care practitioners, both military and civilian, are often the first port of call for affected veterans, and are best positioned to assess these patients and commence care when necessary. As over 85% of Australia’s trained forces are male, these health problems are particularly relevant for men’s health. American research on veterans from recent Middle East deployments shows high rates of psychological problems.1 Interestingly, British research on the same conflict found that problems are limited to reservists, with no elevated rates of mental health problems among regular personnel.2 Although local data are unavailable, it is reasonable to assume that Australian veterans from Afghanistan and Iraq will not be exempt. We learned much from the experience of Vietnam veterans, with their initial difficulties closely resembling those of younger veterans presenting today. While much attention is paid to post-traumatic stress disorder, evidence suggests that other anxiety, depression, and substance-misuse disorders are equally common.3 Providing effective mental health care for veterans presents particular challenges. For many reasons (including personality, military culture, deployment experiences, and adjustment to civilian life), veterans may be reluctant to acknowledge or report psychological problems. They may have poor mental health literacy, may avoid treatment, and can be hard to engage when they do present. Many have developed unhelpful strategies for managing distressing emotions, often channelling them into anger and aggression or covering them with substance misuse. Such strategies may have been adaptive in combat, but in civilian life they alienate the veteran from key sources of support. Veterans often present to general practitioners with physical health complaints that mask concerns about psychological issues. Early detection and appropriate intervention often become the responsibility of GPs. Once it is determined that the patient is a veteran, a few simple questions about sleep, family relationships, mood, anger, and substance use can provide an opening for intervention. The information in the Box identifies strategies and resources available to assist the mental health and wellbeing of veterans. Resources for veterans and their doctors The Australian Defence Force (ADF) has improved post-deployment screening, increased emphasis on mental health literacy and self-care, and attempted to improve the accessibility, acceptability and quality of care. This may help military personnel to not minimise health problems for fear of career damage. http://www.defence.gov.au/dpe/dhs/mentalhealth An enhanced career transition assistance scheme has been introduced by the Department of Veterans’ Affairs (DVA) and ADF for personnel discharging for medical reasons, to facilitate transition back to civilian life. http://www.defence.gov.au/dpe/dpectap The relatively new Military Rehabilitation and Compensation Act 2004 (Cwlth) focuses on vocational and psychosocial rehabilitation. This follows the Veterans’ Vocational Rehabilitation Scheme, which is designed to support veterans’ efforts to retain or return to employment while ensuring no loss of compensation entitlements in the process. http://www.dva.gov.au/health/younger/younger.htm In June 2005, the DVA released alcohol practice guidelines for practitioners helping veterans with alcohol problems. These guidelines cover screening and assessment through to treatment of comorbid alcohol misuse and post-traumatic stress disorder (PTSD). http://therightmix.gov.au/professionals.asp The DVA has produced an excellent self-help website for veterans with alcohol problems. http://www.therightmix.gov.au The Vietnam Veterans’ Counselling Service (VVCS) provides individual and group-based interventions to all veterans (not just from Vietnam), as well as their partners and children. VVCS also offers programs such as anger management, lifestyle management, heart health, and retirement preparation courses. http://www.dva.gov.au/health/vvcs Veterans with an accepted mental health disability are eligible for treatment from specialist mental health providers in the community, including psychiatrists and clinical psychologists. In addition, the DVA continues to fund high-quality treatment programs for veterans with PTSD across Australia. These accredited, group-based programs have demonstrated outcomes which match or better international equivalents.4 http://www.acpmh.unimelb.edu.au/mentalhealth/treatmentPrograms.html Other useful websites include: the US National Center for PTSD http://www.ncptsd.org the UK National Institute for Clinical Excellence PTSD guidelines http://www.nice.org.uk/page.aspx?o=248114 the US Veterans Affairs PTSD treatment guidelines http://www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm the Australian Centre for Posttraumatic Mental Health http://www.acpmh.unimelb.edu.au

John A Cooper MB BS, FRANZCP · Mark C Creamer PhD · David Forbes MClinPsychol, PhD

Men’s health needs, health beliefs, and health-related behaviour are different to those of women Our current research examining young men aged 15–44 years presents worrying epidemiological evidence — a picture of men dying prematurely of conditions such as ischaemic heart disease and cancer, at a time when screening and treatment for many of these diseases has improved (Box).1 This evidence suggests that these men are either not following health advice or not using health services soon enough for effective remedial treatment. Here, we argue that there is a need for health professionals to rethink service provision for young men. What is “men’s health”?Men’s health may be defined as “. . . any issue, condition or determinant that affects the quality of life of men and/or for which different responses are required in order for men (and boys) to experience optimal social, emotional and physical health”.2 This definition highlights that men’s health is concerned with a broader range of issues than specific diseases of the male reproductive organs. In general, epidemiological evidence suggests that men and women have different health challenges through the lifespan, with men consistently having the higher mortality across all countries surveyed from conception onwards.3,4 For most disease states, men appear to have a higher rate of premature death and are more susceptible to the effect of worsening socioeconomic status.1,4 Men’s poorer social and emotional wellbeing is also reflected in higher suicide rates;1,4 for example, in Australia, men are four times more likely than women to commit suicide in the age range 15–44 years (1206 male deaths and 291 female deaths in 2001).1 Men are also more likely to die from drug and alcohol misuse.4 If the health challenges facing men and women are different, then you might expect that there should be visible recognition of this in the way services are configured and the way health policy is framed. Similarly, if men and women differ in the way that they use health services, having one service for all is likely to end up serving men or women (or both) inappropriately. What do we know about men’s help-seeking behaviour?As interest in men’s health has grown during the past 5–10 years, there has been a corresponding increase in research suggesting that men do differ from women in their help-seeking behaviour,5-8 with sporadic and infrequent use of services, lack of engagement with health material, and a tendency to delay when faced with health problems of key concern. These problems appear most pronounced in younger men. We suggest there may be three main reasons for these findings and offer suggestions as to how services might be reconfigured. Firstly, men are not invited to engage actively with health services in the same way that women are from puberty onwards for non-illness related reasons (eg, within formal screening programs, and for contraception and antenatal care). This leads to men failing to recognise the range of health service provision available and its link with preventive health practices. Secondly, it can be argued that most health service provision is female-orientated, with services predominantly provided during the day, when men are more likely to work full-time, have less opportunity for flexible working, and are often in precarious employment where taking time off for visits to doctors may be perceived as a sign of vulnerability, by the men themselves and by their peers and employers. Thirdly, beyond these structural constraints, there is another difference between men’s and women’s health behaviour that merits consideration. How men and women manage their health and wellbeing is, in part, predicated on their own health beliefs and how these beliefs affect their health behaviour — whether these beliefs differ between men and women is, therefore, germane. For example, patterns of premature mortality among young men suggest that risk-taking is a significant factor, and rates of premature death from disease processes also implicate aspects of men’s lifestyles.1,4 But this question goes deeper: we need to explore both the intrinsic drivers of men’s behaviour and how society moulds men’s values, attitudes, and behaviour. It is widely accepted that the expression of masculinity is socially constructed and there are multiple masculinities.9 In Western cultures, there is a restrictive conceptualisation of masculinity, which limits men’s choices and appears to have a negative influence on their health.10 For example, at the individual level, gender roles may partially explain a variety of risk-taking behaviours (such as unsafe sex, binge drinking, and steroid and other drug use).10,11 In addition, stigma and the fear of discrimination may work against men with mental or physical health difficulties. Together with the social pressures relating to full-time work and the current work environments for men, the so-called benefits, or patriarchal dividend, that men are said to enjoy can also be a powerful negative force for men experiencing problems.10 Where do we go from here?As the mortality data confirm, men’s health is not as good when compared with women’s, but such direct comparison with the way women manage their own health may be inappropriate, as we are not comparing like with like. Thus, the challenge that men face with regard to their help-seeking behaviour is a complex issue,12 which is not amenable to a “quick fix”. The common perception that men are being stubborn, or in denial, about their health is clearly simplistic and, if it is true, may be as much a product of socialisation and how services are structured as it is about individual choice. Nevertheless, we cannot maintain the status quo and wait for some sort of “new man” to emerge — the current and future threats to men’s health are too pressing. The increases in skin cancer, in young male obesity with its related health risks, and in substance use all suggest a pressing need to target the young man. There is already considerable recognition within Australia,13 as elsewhere, that men’s health requires specific attention and that health services and policy need to take this into account in making knowledge and services more accessible to men, for example, via specialist men’s health care clinics, and men’s health information nights held in men-friendly environments (such as pubs and sporting clubs) or the workplace.14 This work is already being taken forward through the ongoing activities of the Men’s Health Information & Resource Centre at the University of Western Sydney; the GPs4MeN group; the biannual National Men’s Health Conference; and, in 1997, the House of Representatives Standing Committee on Family and Community Affairs’ discussion of a National Men’s Health Policy.15 Nevertheless, as with many other countries, these initiatives have yet to permeate into mainstream action.16 The fact that a number of Australian organisations have begun implementing such innovations is to be celebrated; however, these approaches could be further developed. This includes tackling boys’ and men’s beliefs about their health from an early age through both formal education and more broad-based health promotion campaigns, with more focus on providing services and education through the workplace, as has been done successfully in Europe and the United States. For example, the Internet-based weight loss campaign run by the Men’s Health Forum in England with British Telecom workers saw 4000 men lose an average of 2.2 kg over the 6-week program. More fundamentally, there is a need for the public, the health care professions, and policymakers to recognise that men’s health needs, health beliefs, and health-related behaviour are different to those of women. The recognition of Men’s Health as a field of practice in its own right, to stimulate the development of research, debate, education and practice, would seem a prerequisite step. Patterns of mortality in young men and women Our study1 was the first international analysis of patterns of mortality in young men and women (aged 15–44 years). Data from 44 countries were considered using the World Health Organization Statistical Information Service Mortality Database. We found that men were at greater risk of premature death, with accidents and suicide being the key causes in the earlier years. Deaths as a result of disease processes became markedly more prominent in the 35–44 years age group.

Alan White PhD, RN · Helen J Fawkner BSc, MSc, PhD · Mike Holmes PhD

The lack of an evidence base for formulating men’s health policies means existing programs and practices for men are influenced by prevailing cultural norms concerning men or habitual health service attitudes towards them. Factors impeding the development of an effective health policy for men include a preoccupation with limited clinical perspectives (an emphasis on the prostate and erectile dysfunction) and a common assumption that all health problems in men are a result of “masculinity” and “men behaving badly”. Viewing men’s health in terms of gender and health and the socially constructed differences between men and women is important, but does not provide all the perspectives required for meeting men’s health needs. A “social determinants of health” approach to men’s health would help Australia and Australian medical practitioners move away from policies and practices that perpetuate negative views of men and ignore the complexity of their health problems. The result would be a more evidence-based approach to men’s health policy, and the likelihood of improved health outcomes.

John J Macdonald

With united, sustained action, general practice organisations and practitioners can help stop our men dying or “diseasing” too early What is it with men’s health? Ten years ago, men’s health nights in pubs were all the go. Now we don’t even have those. There’s the occasional event or TV item, but always a one-off. Women’s health researchers, practitioners and advocates get lots of resources and publicity, and good on ’em. But men are still dying too early from stuff that can be prevented. (Anonymous man, Daylesford, Victoria, 2006) As National Convenor of GPs4Men, the Australian General Practitioners’ Network for Men’s Health, I hear occasional comments like this from patients I see in my full-time rural general practice. Recently, I have run into colleagues who, noting the absence of men’s “health bites” in the media, ask if I’m still involved. My answer is “yes, but differently”. “Spare” time previously spent on activities with GPs4Men, particularly liaison with members, has been leached away by work on the Royal Australian College of General Practitioners’ (RACGP) position statement on men’s health (to match the 1997 position statement on women’s health), now endorsed and available on online,1 and the ongoing RACGP men’s health curriculum review. GPs4Men was founded in 2003 in response to the lack of policy and funding for men’s health on a national level. Australia still has no national men’s health policy, despite the existence of a women’s health policy since 1989. It would be naïve to suggest that simply developing a policy would be sufficient to deal with all the challenges of men’s health — policy without adequately funded programs = “piffle”. Yet, for those of us involved in men’s health, there remains an overwhelming desire to see a formal acknowledgement by the federal government (whether a policy, position statement or other document) of the broad and unique issues of men’s health, and a preparedness to fund a national program to address these issues. I wonder whether the government’s problem might be that the problem seems “too big”. A multiplicity of interest groups — including sociologists, “masculinists”, “men’s shed” workers, community nurses, endocrinologists, GPs, urologists, social workers and educators — all hold valid points of view. But has this very diversity led to an apparent government standstill due to “overload”? Whatever the reason, GPs simply must do something about Australian men’s health. The recent RACGP health inequalities study clearly demonstrated the appallingly high mortality rates for men compared with women across the socioeconomic spectrum.2 Notably, it showed that: the mortality rate for 25–64-year-old men in the most socially advantaged group of the population was higher than that for 25–64-year-old women in the most socially disadvantaged group; and men in the most socially disadvantaged group had a mortality rate nearly double that of the most socially disadvantaged women. Further, there can be no argument that groups of men — Indigenous men, war and service veterans,3 and men affected by poverty — are at high risk of health problems and have specific medical needs. At present, the federal government’s response seems to be to restrict funding largely to men’s sexual health programs — based, presumably, on the unassailable assertion that testes and prostates are unequivocally male. The problem with this approach is that it ignores key issues; not only the stark statistics, but also the differences between how men and women view their bodies (especially in dysfunction), and in how they use the health care system. The major recipient of federal funding in men’s health ($4 million over 4 years) — the male reproductive health centre, Andrology Australia — runs excellent community and medical education programs. However, it is beyond this organisation’s terms of reference to tackle the crucial issue of men’s underuse of the health care system. It would again be simplistic to suggest that simply finding ways of bringing men into more effective contact with GPs would solve the problems of men dying or “diseasing” too early. Many other issues also demand attention, from men’s involvement in pregnancy and postnatal depression, to masculinity issues in schools and the workforce, to addictions, to social isolation and relationship problems. Nevertheless, bridging the chasm between GPs and their potential male patients is crucial, as GPs are the key providers of primary health care. Marketing health to men needs to be viewed as a crucial and do-able component of any worthwhile campaign to improve men’s health. Such marketing is too important to just be left in the hands of a group of enthusiastic health professionals. Men’s health needs the sort of marketing expertise used by those who are intent on persuading teenagers to smoke. It should be sustained, professional, well funded and be driven by clear goals. Men’s health is also desperate for high-profile sustained support. The Prime Minister’s newly appointed obesity ambassadors, Harry Kewell and Kieren Perkins, should have their portfolios enlarged to encompass the broader issues of men and their health. We need the support of influential figures like the Prime Minister and the Minister for Health to achieve this. Their early morning walks and bike riding, respectively, serve as excellent examples for Australia’s men. The membership of GPs4Men (of about 70 individual GPs and almost a third of the 118 Australian Divisions of General Practice [ADGP]) believes that it is the responsibility of the GP Reference Group organisations — the RACGP, the ADGP, the Australian Medical Association (AMA) and the Rural Doctors Association of Australia (RDAA) — to make a joint submission to our federal government for a federally funded men’s health program that puts into action a men’s health policy. It is up to those who fund health care to find ways of taking Australia’s overworked GPs to where men are more comfortable using their services, especially the workplace. It is up to those who deliver health care to identify the best way forward. Not only united but also sustained effort will be required from general practice organisations. The AMA produced a position statement on men’s health in 2004,4 but has since seemed to move on to other priorities. The RACGP has had a Women’s Health Taskforce since 1997; surely it is time for the college to have an active Men’s Health Taskforce. The ADGP is moving slowly towards greater activity in men’s health, with a session dedicated to men’s health at its upcoming national forum on the Gold Coast in November this year. Many GPs and Divisions would respond to local needs for men’s health programs, but cannot because of lack of funding. The RDAA has also expressed its broad support for men’s health; understandably so in the light of the dire state of rural men’s health. In the absence of any structural or funded initiatives, there is still much being done and that can be done in general practice. All GPs (and possibly all medical practitioners) should consider how they can increase the uptake of their services by the “unreachable” group — 30–60-year-old men. I believe that general practice has some way to go before we can feel satisfied with how we market health to our male population. “Man-friendly” appointment systems and consulting times with after-work times and more on-the-day appointments, waiting rooms, and reception staff are key parts of a “whole-of-practice” approach, as are outreach services to workplaces and other venues. Similarly, a “whole-of-consultation” approach involves offering options to the men we do see which take into account the fact that many men prefer a more physically-based approach to lifestyle prescription, and may require specific direction about follow-up. Community resources which meet men’s exercise needs are often lacking. For many men, a trusting relationship with a personal physician or practice is built over a series of consultations. Australia’s men, our women’s and men’s groups and our GPs believe that men’s health is much more than sexual health — this is not the case in much of the developed world. We therefore have a great opportunity to lead the world, or at least to share the lead in the important area of men’s health.

Gregory O Malcher DObstRCOG, DCH, FRACGP

Fathers may be unintentionally marginalised by perinatal health services and by the maternal focus of social practices surrounding new babies. There is increasing recognition that a father’s depression and anxiety in the perinatal period can have serious consequences for his family. Health services could better support new fathers by providing them with information on parenting from a father’s perspective, or by running father-specific sessions as part of routine antenatal care programs.

Richard J Fletcher MMedSci · Stephen Matthey PhD · Christopher G Marley MB BS, FRACGP

If all outlets for venting anger come with heavy costs, then unresolved injustice simply simmers Some time back, my high school matriculation class held a reunion at a Tamworth motel. Many of us hadn’t seen each other for 27 years. Over those years, people, and times, had changed in unexpected ways. I was surprised by the vehemence of one former classmate, who berated me for still having my hair! Then I was angered by another, who now radiated the same kind of menace as the crims he’d put away in the intervening years. What really threw me, though, were the four or five separate occasions when I was pulled aside by someone wanting to personally apologise for “the way they had treated me” all those years ago. Their change in awareness was heartening, their behaviour sincere. Yet I was left groping for words. There was no Indigenous–settler lingua franca from which I could pull a response. I thought back to a particular, clued-in science teacher taking my class to task — in code — for negative responses to “a particular class member’s difference”. Then there were the examples, over the years, of my presence provoking inexplicable hostility: puzzling kicks in the shin in the primary school playground, group taunts at Cubs and Scouts, or the quick-fisted farm boy who spotted me as soon as I turned up at high school. I’d come to believe, though, that the problem was me — that, in some irremediable way, I was simply unacceptable. Not so much that I didn’t, but that I could never, measure up. My mother dealt with our Aboriginality like her mother before her, by simply denying it. My father’s side of the family made their way from Ireland to the south of New South Wales around the 1860s. My mother grew up in Gadigal country in the 1920s, less than a kilometre from “The Block” in Sydney’s Redfern, yet the family fiction bequeathed to her was that her father came off a boat from Trinidad. Detective work, much later on, teased out a different picture of my grandfather. What emerged was a Gamilaroi man from the north-western slopes of NSW. It took my experience as a psychologist — in particular, work with blackfellas in crisis — to bring home to me that my tussles with identity in fact echo those of many other Aboriginal men. * Clayton’s tonic: the non-alcoholic, Scotch whisky look-alike advertised as “the drink you have when you’re not having a drink”. The West Indian fantasy was neither unique nor unusual. The historian who coined the term “stolen generations”, Peter Read, estimates that 100 000 Australians deny, or are denied, their Aboriginality.1 This country is awash with dubious “ancestors”, such as Javanese royalty and surprisingly skinny-legged Māori. When I work with medical students, registrars or even long-practising mental health professionals, I see them struggle to grasp how such severance from self came about. Our education system has failed them: they have only the haziest idea of how all-encompassing — and how deleterious to Indigenous wellbeing — was the system of “Clayton’s”* apartheid that still ruled in the 1950s and 60s. (For example, the Queensland Government’s Aboriginals Preservation and Protection Act 1939 was still affecting the way its enforcers went about their business as late as 1969.) In a sense, this is not surprising. The Australia that decreed that newly married women must give up their jobs is incomprehensible to contemporary young women, yet this was just one of a range of social strictures applying at the time. My daughter’s high school friends thought it “weird” that business shirts for men only came in colours from the late 1960s on. The “white shirt” mentality ruled more than men’s wardrobes: expectations about how one should present were proxies for inflexibility about how one should behave — for Indigenous Australians, about how one should be. When you’re unaware how far-reaching was the control of Aboriginal lives by mission managers, “The Welfare” or police, it’s hard to comprehend the lengths to which Aboriginal Australians went to escape that control. Many simply identified as Indian, Fijian, Italian . . . whatever would get the authorities off your back and keep your children by your side. Tamworth was blindingly “white”. Apart from Wilga and her brother at my school, and my mother, there were few black faces to be seen in town. The experience of growing up “brown”, in a landscape configured for something else, shaped an isolation that took a long time to resolve. A continual awareness of underlying antipathy — one that occasionally snapped its leash — left me confused and angry. Walking the few blocks from home to high school churned my stomach. My arms and legs lost connection, my head went down as I broached the rows of early arrivals astride Globite school cases, a gauntlet that ran from school gate to assembly area. My anxiety played out bodily and mentally. The facial tics of early high school years progressed to specific obsessions and compulsions: counting to 15 before making any major, or even minor, decision; washing and rewashing; scratching imaginary itches throughout a conversation. I functioned sweetly in some environments, but fell apart in others. I left for university with relief. As long-standing Aboriginal social exclusion and the bite of lived racism played no small part in my mental distress, letting go my anxieties was never going to be a straightforward task. There was no prescription. Education, the opportunities of improved income, a strengthening of identity — the usual suspects — all played a useful role. Negotiating my hybrid identity and the contradictions of the Australian mantra of a “fair go” meant I learnt as much off campus as on. My high school belief in an omnipresent “British justice”, for example, was swiftly quashed at 18, as I left an Armidale pub. From a group of otherwise strictly Anglo-Celtic students, I was the one selected to see the inside of a steel-benched police wagon, then introduced to a new sport: speed up and brake . . . speed up and brake . . . Your head quickly becomes intimate with metal. For blackfellas, racial profiling is no new-millennium phenomenon, though fresh manifestations stoke old fires. If all the outlets for venting anger come with heavy costs, then unresolved injustice simply simmers — a physical charge that won’t go away. As the Acting Social Justice Commissioner noted in his analysis of responses to the 1997 Bringing them home report:2 The Indigenous sense of injustice is so deeply inscribed that it forms an expectation of injustice [emphasis added].3 Personal narratives are a way to comprehend the push of the past into the present. They can, though, label the teller as both victim and whinger. This is a risk that needs to be run. Unless settler Australia comprehends the pervasive, yet casual, nature of state-sanctioned violence in Indigenous lives — in particular in male lives4 — it will remain puzzled as to the violent responses engendered in turn. My experiences are small beer compared with those of many other blackfellas. I wasn’t attacked with a broken pool cue, in the proud, pioneer town of Orange, as was a nephew of mine; I didn’t have to jump from a slowing-down car, on a remote Tasmanian road, to avoid a bashing from the group who’d offered me a lift, as did a former partner of my sister. Racist violence, immediate or threatened, is the razor wire around Aboriginal lives. The effects are potent. If enough are served up to you, small beers will still get you drunk. The experience of the Foundation President of the Australian Indigenous Doctors’ Association, Dr Louis Peachey, gives insight into the treatment dilemmas facing non-Indigenous health professionals in a non-reconciled Australia — why they may still fail to grasp the full magnitude of the combined effects of social stress and percolating threat within Indigenous life contexts. Peachey was astounded to discover, some years ago, as a young man on a night out with non-Aboriginal friends, that whitefellas didn’t feel a need to check every dance hall, pub or party for problematic people, quick exits or, failing that, for the availability of makeshift weapons (reported by Peachey in a speech given at the Australian Indigenous Doctors’ Association Annual Symposium, Sydney, 2003). Aboriginal Australians live in a climate of thick air: often the sense is that the storm may break at any moment. The work of the US researcher, Bruce Perry, suggests it can be psychologically fraught to leave the living culture of a Native American or Canadian reservation, a Māori whānau or hapu (extended family or tribal group), or an Australian Aboriginal community to become a “minority” individual in a Western cultural framework.5 I grew up with a distinct awareness that I was “Other” to the default setting. For Murri, Koori or Nyoongah men, this doesn’t occur in a historical vacuum: a number of authors have noted the concurrent, spirit-sapping loss — through colonisation — of our traditional Indigenous male roles.6,7 The “Othering” process, then, extends the experience of loss. The primary way it unfolds is through mechanisms that demean or diminish. In conservative-led Australia, the dominant equation is a simple one: member of a “minority” = reduction in regard.8 The infantilisation of Indigenous men has served the colonial project well. Even innocuous-seeming advertisements have played a significant role in reinforcing an image of people insufficiently civilised — or evolved — to be worthy of owning the land that was taken from them. For 40-odd years, from the end of World War I to the diminution of overt stereotyping in the 1960s, Pelaco shirts — crisp, white and tailored just right — became a market leader under the logo of “Pelaco Bill”, a skinny caricature of Aboriginal maleness: brown, maniacally grinning, barefoot — in fact naked, apart from his crisp, white . . . You get the drift. Bill’s “Kriol” (read “kiddie English”) caption, the original Pelaco slogan, completed the picture: Mine tinkit they fit.9 In an Australia that refuses the cultural imbrication of Aotearoa/New Zealand, or the “we’re a nation of minorities” pluralism of Canada,10 “Othering” continues, serving ends related to the apogee of “wedge politics” and notions of being “comfortable” with history. Cultural practices are now the locus of intense attack. Aboriginal “men’s business” — the gender-specific cultural imperative alive in urban, as much as remote, settings — is in the process of being repositioned as an archaism, other to “Australian” values. In recent federal government and media forays, it is portrayed as a dangerous, alien tenet — the cultural motif underpinning monstrous violence against women and children.11,12 Such attacks “sanitise” our history and continue an inexplicable blindness to the contemporary consequences of past policies. In particular, they obscure the disastrous legacy of “Clayton’s” apartheid and ignore the contribution of a range of variables — such as poverty, overcrowding, overincarceration and transgenerational trauma — that are well recognised for their potency.13-15 They threaten not only to derail promising initiatives that work with, rather than against, Indigenous culture, but also to subsume a complex public health issue under a simplistic law-and-order response. Conversely, things are turning around, at least in terms of Indigenous male dynamism for change. In the past decade, Indigenous male health conferences and health service innovations have championed a need to see “men’s business” as the positive social force it has always been for blackfellas.16,17 In these forums, participants say they want to regain a sense of a valued role for Aboriginal men — a concept quite distinct, it needs pointing out, from hegemonic masculinity, yet imbued with the potential to turn around our health outcomes.18,19 The change of heart so evident in that Tamworth function room — people growing up, not just growing older — has not yet made it to Canberra. Demonising Aboriginal men as a precursor to mainstreaming Indigenous services is not only inexcusable vilification, but demonstrably ineffective public health policy.20 As with any distinct population, generic approaches just don’t cut the mustard. The only services that are likely to deliver real improvements in Indigenous male health are ones tailored to our cultural and contextual realities. Ask us why we avoid mainstream services, and we’ll tell you — we think they don’t fit.

Dennis R McDermott BEc, BA Hons(Psych), MA

Aboriginal and Torres Strait Islander males arguably have the poorest health of any racial group in Australia. In 1999–2001, it was estimated that they have a life expectancy of 56 years (compared with 77 years for all Australians) and that 75% of Indigenous males die before 65 years of age (compared with 27% of their non-Indigenous counterparts).1 The recent media debate on the abuse of women and children in Indigenous communities unfortunately failed to highlight the very poor health status of Indigenous men and the fact that Indigenous male death rates from assault are similar to, if not higher than, the rates among females.1 This does not challenge in any way the critical plight of women and children in these communities and their need for protection, but does add some context to the debate, which has thus far depicted Indigenous males as perpetrators of violence rather than being, also, victims. The interpretation that community violence somehow reflects Aboriginal gender constructs also confuses the issue. The violence against women and children occurring in some communities is by no means a part of traditional culture, in which both men and women have valued, specific and complementary roles. There have been numerous calls for Aboriginal and Torres Strait Islander male leadership in this area. Indigenous men have themselves attempted to take on this mantle at a national level over a number of years, following the Ross River Aboriginal and Torres Strait Islander Men’s Health Conference in 1999. Indeed, a group formed at this conference produced a National Framework for Improving the Health and Wellbeing of Aboriginal and Torres Strait Islander Males2 in 2003, but this has not subsequently been implemented. Aboriginal men’s groups have existed at a local level for many years. These groups attempt to work with Indigenous men to address the many issues facing them and their families. Rather than addressing male issues exclusively, the groups place a high priority on a “whole of family” approach. They address male roles and the loss of these — teacher, hunter and lore-man, but also father, provider, partner and community leader — and include such things as diversionary programs, domestic violence programs and parenting programs.3,4 The groups comprise grassroots Aboriginal and Torres Strait Islander men who are committed to making a difference, but they are largely unfunded and generally too poorly resourced to have the broader “systems” community approach that is known to be necessary. While some of these men’s groups function very well, others have floundered, and struggle with governance and finance issues. This is not completely unexpected, as, while these men are expected to take responsibility and leadership upon themselves, many are untrained in any aspects of governance and finance and come from communities with low literacy and numeracy levels. To learn to incorporate and run an organisation and to manage a business, in often dysfunctional circumstances, requires capacity development, skills transfer and support. None of the preceding removes Indigenous men from their “personal” responsibility to ensure the health and safety of their women and children, but it does indicate a need for other Australians to help and support those who are attempting to address their own issues in a spirit of mutual responsibility. In contrast with the media portrayal of Indigenous men as perpetrators of violence, the accompanying excerpt from “Do’s and Don’t’s” rules for an Aboriginal men’s group (Box) illustrates the simple principles this group has developed.3 It is simplistic in the extreme to suggest that radical changes, such as relocating all remote Aboriginal communities to urban centres, will fix the problems,5 while failing to address the underlying issues of loss of self-esteem, culture, land and identity. The following is taken from an assignment by an 18-year-old Aboriginal male student health worker, describing the plight of Aboriginal men in his community: In my community our men are always being put lowest down to the ground, that is why they are always fighting with each other and committing suicide, because we know that white people think we are “apes” and so forth . . . If our young Aboriginal men have this perception of their place in this “lucky” country, we have a long way to go. However, positive change can be accomplished in time, and the health professions will have a role. We rightfully call on Indigenous men to stand up and be the leaders they were traditionally, but it will require a broad approach, with support from Australia as a nation and powerful groups such as the medical profession, as well as Indigenous men themselves, to comprehensively address these issues. Excerpt from “Do’s and Don’t’s” rules formulated by an Aboriginal men’s group Do’s Don’t’s Be loving, kind, compassionate, forgiving, respectful, honest and truthful Hate, reject and put down people Support family by working and paying bills Argue and fight in front of kids Have a job, employment Abuse wife or kids Be a role model for wife and kids Gamble money away Communicate with wife and kids regularly Be a slave to alcohol, drugs or gambling Resolve conflict by talking rather than fighting Be violent to others and families Show more positive leadership in family and community Be ashamed of who you are Teach your kids to read Be selfish — think of others

Mark Wenitong BMed

I know what men want. Men want to be really, really close to someone who will leave them alone — Anonymous The ideal man — Philip Patston, comedian, consultant, columnist and (among other things) recovering social worker and human rights activist. He is gay, disabled, vegetarian and English. Six years ago, Philip created Diversityworks, now a multi-faceted enterprise that includes a business group offering expertise in managing diversity and change, and a trust that runs projects to improve diversity and professional participation in the arts <http://www.diversityworks.co.nz>. Philip lives in Auckland and travels regularly in New Zealand. His work has taken him to Australia, the United States, Canada, the United Kingdom and Belgium. In 2004, in making a radio documentary on romance which played in 10 countries around the world, I spoke to several people who experience disability. For the blokes, the theme of being disabled and male in society came up repeatedly, including issues of responsibility, dependence, dominance, and public perception. Compared with the traditional role of the strong male provider, men who experience disability are often perceived as vulnerable, needy and dependent. Over the years, I have come to understand that in many ways, like gay men, disabled men can choose to feel either shackled or liberated by the perception that they are less “manly” than their non-disabled counterparts. As a gay man who experiences disability as a result of cerebral palsy, I have a unique experience of being male. I am bound by neither heterosexual nor non-disabled role stereotypes. I feel no compulsion or expectation to be “a real man”. And yet, at the same time, I cherish my distinctive maleness, which I experience to be a healthy balance of masculine and feminine. In some ways, as I argue here, I am the ideal man. Men, function and disabilityThe four themes that emerged from my conversations with men with disabilities — responsibility, dependence, dominance, and public perception — correspond to a set of traditional male role attitude items that I stumbled across in an article about masculinity and its impact on adolescent male heterosexual relationships.1 Here are some laments of the real man: It is essential for a guy to get respect from others. A man always deserves the respect of his wife and children. I admire a guy who is totally sure of himself. A guy will lose respect if he talks about his problems. A young man should be physically tough, even if he’s not big. It bothers me when a guy acts like a girl. I don’t think a husband should have to do housework. Men are always ready for sex. I subscribe to a definition of disability based on a model that acknowledges that attitudes and barriers in society disable people more than their impairment, and this may lead to a loss of function. But what is function? Function has a vast array of meaning, ranging from the very pragmatic and physical to the somewhat esoteric or spiritual. Function is implied in all of the following: Task — work or assignment, often important or difficult. Job — paid trade or profession, something needing to be done or dealt with. Utility — the quality or state of being useful. Occupation — an activity on which time is spent; may be paid or unpaid. Role — the usual or expected function of someone, the part played in a given social context. Meaning — what something means, what someone intends to express. Purpose — the reason something or someone exists. I believe that, in our culture, men are mostly valued for the more pragmatic, physical realms of function (task, job, utility, occupation), whereas women are more valued for the esoteric, spiritual elements (role, meaning, purpose). This is, of course, a generalisation, but one that corresponds to the traditional male role attitude items listed above. When I compare what disabled and non-disabled men are valued for, aspects of function stand out as the great divide. For example, I am seldom asked the obligatory question, “What do you do?” People assume I don’t do much of any import, because I have a physical impairment. I’ve also noticed that men are far less comfortable than women with issues of impairment and disability. It’s women, far more often than men, who offer assistance, unless it’s something overtly physical like putting my wheelchair in my car. And it’s women who are far more prevalent as workers in the disability sector. However, when you examine the impact of the loss of function for men, women and people who experience disability, one thing is very clear: men have a lot more to lose. Loss of function particularly pushes blokes’ buttons. Why? It seems to me that, in a primal sort of way, male identity is situated in the realm of physical function. Male creativity is concerned with external manipulation — making things, building things, doing things — so impairment and disablement fundamentally threaten male identity. I have argued that the essential difference between the sexes is that men create “without” and women create “within”. Consider these differences between men and women: men’s sexual organs are outside the body; women’s inside. Men cannot conceive and create children, as women can — inside them. Men gather information primarily through their sense organs located primarily on the outside of their bodies whereas women gather much information through their intuition, their feelings, inside their body. And finally, without getting too much into the sex stereotype debate, look at household roles — women’s domain is generally inside and men’s, outside. My conversations with the men in the documentary made me realise that when men are threatened with loss of function, they experience huge levels of fear. I consider fear to be the absence of love (and, conversely, love the absence of fear). When people act out of fear, their actions are characterised by drive (fear of not succeeding), low creativity and judgement. Conversely, when people act out of love, they are passionate, highly creative and accepting. The idea of losing function leaves men uncreative, intolerant and driven by the fear of losing control, independence, positive public perception and responsibility. The ideal man?So how does all this make me, a gay man who experiences disability, an ideal man? Firstly, I think I have successfully surrendered control. There are aspects of my life — the result of stigma, disablement, homophobia and the like — that I cannot control. I no longer expect to control everything. More than anything, I have developed the ability to trust that everything is perfect. Secondly, I accept that, to live the busy, autonomous lifestyle that I have chosen and created, dependence on personal assistants and funding to employ them is necessary. Thirdly, I ignore public perception. Simply put, though it is still hard sometimes (especially when he’s cute), I have learnt to reject rejection. Finally, I take responsibility. I am not a victim of circumstance. I’ve moved away from my personal “fight for rights” towards a quest for creativity and identity, and a spiritual understanding of the purpose disadvantaged people have (and choose) to help humanity evolve. Sure, disabled gay men have rights and we are not yet well afforded them — this is indeed the last bastion of human rights, and breaking it down will require recognition by society that the mix of disablement and homophobia that blokes like me experience is a complex social construct, not a catastrophic personal tragedy. But while humanity catches up, I’ve chosen to move on and create an identity based on who I am rather than who I am not. Part of my creative process has been to understand and believe I am here to raise human consciousness about diversity. At the same time, I am empowered by the notion that even though it’s bloody hard at times, my soul made a choice to live this life. Which leads me to believe that that soul must be a masochist, but such is the sacrifice one makes to be the ideal man!

Philip Patston

If we are to raise healthy boys, we may need to re-examine our values Many of the studies looking at health in adolescent boys and girls suggest that the fostering of resilience, derived from a sense of “belonging”, is of prime importance.1 This is in accord with recent endocrinological findings which demonstrate that, being social mammals, humans have a genetically programmed need for “bonding” mediated by the hormone oxytocin, which is generated by touch and sex.2 Such bonding is not just to a sexual partner but involves a web of belonging that permeates multiple strata in the total community. The feeling of belonging results from many things, including connections with parents and families, and adult support for independence and competency. Reflecting on my personal experiences as a boy, then a man, teacher, husband, step-father, father, grandfather and general practitioner, I would like to give my opinion of what young men need to help them develop a feeling of belonging. Boys need a father (and a mother). A father has special significance for a boy because of shared gender. Even if the quality of fathering he experiences is poor, a boy deserves to know who his father is, and to be helped to understand (and be reminded) that what he does with his genetic heritage is ultimately his own choice. Boys need to be valued by their families. Boys need families that value them, their input and company from birth to adulthood and beyond. Boys need male teachers and male role models. Boys need the attention, acceptance and approval of men. An involved father is a great asset, but it is not enough. Even boys with fathers appreciate the attention of men outside the family. While we expect the love of our family, the affection of someone to whom we are not related is a special compliment, a boost to our self-esteem. At school, boys need male teachers, in particular male teachers who appreciate boys’ needs and interests and take a personal interest in them. Boys need peers to whom they feel close. Creating close friendships requires time to develop familiarity and trust. Our shifting populations can interfere with bonding and produce superficial friendships based on fashion and peer pressure, which can cause more harm than good. Boys need touch. When most forms of physical contact between men, older and younger boys are banned or discouraged — for fear of injury litigation or because it may be interpreted as being abusive or homosexual in nature — we are also denying boys the feeling of being wanted, loved and valued by other males. Boys need risk. Boys need to feel competent in typically masculine activities such as camping, fishing, sport and other physical activities. Our litigious society, in trying to eliminate injury, is also reducing risk — the very thing that provides the challenge that many boys thrive on. If we fail to provide such activities supervised by caring men with whom boys feel a bond of respect and affection, they may pursue their own, often ill-advised, forms of risk-seeking behaviour in street gangs and vandalism. Boys need to be taught how to cope with life. Boys don’t need protection from the adversities of life; rather, they need help to learn how to cope with them. It is useful for boys to experience adversity in its various forms — it is, after all, nature’s way of providing risk, challenge and experience. If life is made “perfect” for our children, adult life will be a shock. Thus, learning how to cope with disasters would be more useful than avoiding disaster altogether, and treating a disaster as an irrevocable calamity would be more harmful than accepting it as merely another life experience. Boys need discipline. Boys need to know who’s in charge, and authority needs to be backed with strength. Fair limits consistently enforced are essential. Drug use, sexual assault, alcohol misuse, theft, violence, vandalism and “hooning” all need to be dealt with rapidly and decisively. But there is also no place for victimisation and abuse. Discipline needs to be administered not in anger but with respect for the developing boy. Boys need reassurance about their sexuality. Size of penis is just one of the sexual preoccupations of maturing boys, yet when harmless, non-intimate “locker room” activities are overly interpreted as gay or, unsupervised, become opportunities for victimisation or abuse, boys may turn to the sexual exploitation of women in order to test their sexuality. The need for sexual reassurance is a normal stage of development, which, if frustrated, may increase the incidence of abusive sexual behaviour and paedophilia.3 We need to develop ways to reassure boys about their sexuality that do not involve abuse or exploitation. Boys also need to be shown a sexuality that loves and values its partners rather than treats them as objects for personal gratification — to control sex rather than be controlled by a hormone-driven hunger for orgasm. Boys need a proud masculinity. Boys need to be taught to have pride in, and for, the constructive expressions of masculinity — integrity, responsibility, care and protectiveness. These “boys’ needs” hint at the broader changes our society could make that would bring net gains for us all. We need to place priority not on careers and money as the gateway to “power”, but on valuing families and friends as our greatest asset and source of pleasure. It is a biblical message to look towards each other rather than towards external things — to “turn the hearts of the fathers to the children” (Malachi 4:6). But is our society too materialistic to heed it?*

William J Phillips FRACGP

“Woody” Photograph courtesy Alistair Dewar Two days before my 58th birthday, I was diagnosed with prostate cancer. That day, in 2003, when my life suddenly changed in so many ways, is one I’ll never forget. I genuinely feel for doctors faced with the unenviable task of passing on such horrible news. There is no easy way of doing it, but I often wonder if they are aware of the emotional “fallout” when the patient leaves their rooms. The urologist told me that six of the eight core biopsy samples were positive and that the cancer was a real “nasty”. With a Gleason score of 9 (indicating a very aggressive tumour), it could not be ignored. I don’t remember much else about our conversation, but I was given some literature to read and I do recall that we discussed treatment options. I left his rooms armed with requests for pathology and radiology tests. I remember walking back to my car, calling my wife and then completely falling to pieces. My life simply collapsed in front of me. My wife hurried home from work and somehow I managed to drive home and wait for her there. My decision about treatment needed to be based on a few facts: Gleason 9, a high prostate specific antigen (PSA) level of 10, and a greater than 80% coverage of the prostate capsule, with a strong possibility that the cancer had metastasised. After a lot of reading and discussion with the doctors, I decided on high dose rate (HDR) brachytherapy, in conjunction with external beam radiation and hormone treatment. At present, I am undergoing watchful waiting with biannual blood tests and I am very confident I have beaten this cancer. The emotional falloutA diagnosis of cancer raises many emotions. I recall the fear and terror when I was told of the diagnosis. I recall the horror of being told I would effectively be chemically castrated during the hormone treatment. I recall the embarrassment of being prepared for brachytherapy — as a man, I was not used to this sort of invasion of my body and perceived dignity. I recall contemplating the possible outcomes — incontinence, osteoporosis, life on hormone treatment and, as is inevitable whenever the word cancer is mentioned, death. I am blessed with a wonderful wife, and family and friends who shared many of my ups and downs as I underwent treatment and faced the uncertain outcomes, but, like many men in similar situations, I essentially carried all the fears and frustrations in my own head and naïvely thought I was in control. I battled on with this questionable strategy, as I tried to cope with the various aspects of my illness: Zoladex [AstraZeneca] (hormone) implants; preparing myself for brachytherapy; 5 weeks of external beam radiation; after-effects of the radiation treatment — burning and proctitis; initial incontinence and ongoing impotence; changes to my body — issues such as significant weight increases, breast enlargement, hot flushes, tiredness and, after brachytherapy, the changes to my anatomy. From the moment of diagnosis, we patients enter a different world. We need to learn a new language — terms such as “watchful waiting”, “radical prostatectomy”, “HDR”, “brachytherapy” (I initially thought Brachy was a doctor who had developed the treatment), “Gleason scores”, “PSA”, and so on — all are so foreign. Thrust into this new world, I felt frightened and out of control, but I still told myself I had to cope on my own. As the treatment took effect, I appeared to be doing very well. With the exception of impotence, everything was working fine. My PSA level was down and my testosterone level was returning naturally. But emotionally, I was still fearful and bewildered. The impact on my daily lifeBy October 2004, some 16 months after diagnosis and 10 months after my radiation treatment had finished, it became clear that my business — a small affair comprising myself and three employees — was in trouble. As I became aware of my situation, the “demons” started to appear and by February/March 2005, they were appearing every night. Sleep was fitful and difficult. For the first time in my life, I did not want to go to work. I was worried about my staff and their ongoing security. I worried about my wife. I was unable to focus on anything relating to work, and fearful of the phone ringing. By April, my business was failing badly. I was unable to maintain normal commitments, and the financial burden was too much. My moods and emotions were overwhelming and I began to seriously contemplate suicide. The pressures of business, the personal battle, the fears, the emotions, the weaknesses, or at least what I perceived as weaknesses, my pride — all imploded. The true impact of the past 2 years’ battle really hit me. Accepting helpWith some encouragement from a close friend, I sought help from my general practitioner. I am now taking antidepressants and, if nothing else, I am coping with my problems. I am now able to evaluate situations and not panic, and I am no longer existing on a daily dose of fear. My company has been wound up and, although I have been left with debt above and beyond anything someone my age would choose to have, I consider myself fortunate. Through close contacts within my industry, I am now very happy in a sales development role with another company, and this has given me a new lease on life. Eventually, I began seeing a psychologist, which has also been very helpful. What have I learned from the roller coaster of the past few years?On a personal level, friends and family have stuck by my wife and me, and most certainly I have gained a great deal of patience and understanding. Having faced my mortality, I now see the world and people in a completely different light, and things I once took for granted have taken on a new importance. After a wonderful 38-year marriage, I feared that our financial difficulties would have a crushing effect on my wife. Naturally, she now worries a great deal about our future but, like many women in similar situations, she has been supportive and strong and our relationship is more solid than ever. My experience has also encouraged me to be a little more outspoken about the psychological consequences of prostate cancer treatment. In retrospect, I think I was depressed for some months before I received help, but I was reluctant to acknowledge any weaknesses. Certainly, no one recognised any symptoms of depression in the close monitoring of my physical recovery. I clearly managed to hide my fears and thoughts from them. It is all well and good that a doctor asks if you are doing OK. My gut feeling is that most men would say they were fine, irrespective of their true feelings. I certainly did, and many of the men I have spoken to or have met who have been through prostate treatment have said the same thing. The doctor’s first and absolute priority is to eradicate the prostate cancer, to ensure, where possible, the patient’s complete physical recovery. In doing this, though, the psychological aspects of the treatment and the recovery often seem somehow to be left to one side. I don’t believe doctors ignore this aspect. However, in the midst of referrals to the urologist, radiation oncologist, endocrinologist, and scans and blood tests and so on, how the patient is coping psychologically does not receive enough attention. I would suggest that, for men with prostate cancer, doctors should consider routinely referring their patients to a psychologist or social worker, and should also help them to get in touch with other men in the same situation through a support group. Where to from here?My most recent blood tests show my PSA level at 0.4 and my testosterone level back around 27. I am still struggling with impotence, but I believe improvement is possible. I am continuing to take antidepressants and the doctor believes I should keep taking them until the fallout from the collapse of my business has been cleared up. The personal financial burdens still weigh heavily on me and some level of concern remains. Consultations with a psychologist have helped me enormously, and I think there is only a little way to go to resolve my personal issues. I will continue to be active in cancer support groups, as I believe there are many men struggling alone with their problems, and much still needs to be done to raise the public’s awareness of prostate cancer, just as women have battled to raise the profile of breast cancer. The plight of men with prostate cancer should receive the same level of understanding. We need to help those involved in treating prostate cancer to accept that dealing with the inevitable psychological problems is as important as fixing the physical problem.

Ian Woodhouse

To the Editor: We report three cases of locally acquired Entamoeba histolytica infection in men who have sex with men (MSM) in Sydney, New South Wales. E. histolytica is an invasive pathogenic amoeba that can cause invasive intestinal and extraintestinal amoebiasis. Entamoeba dispar is morphologically identical but is considered non-pathogenic and non-invasive.1 The three patients presented with a 1–3-week history of diarrhoea and abdominal pain. Routine bacterial cultures were negative for pathogens. Ova, cyst and parasite investigations showed cysts and trophozoites of E. histolytica/dispar complex in permanently stained, fixed faecal smears. Stool samples were tested for E. histolytica and E. dispar by polymerase chain reaction (PCR), using a previously described method.2 All three patients were positive for E. histolytica by PCR; sequencing of the amplicons verified the presence of E. histolytica DNA. The three patients presented within a 12-month period in 2005–2006. All were homosexually active men (ages, 31–53 years) who lived in inner Sydney. None had a history of overseas travel within the previous 5 years, suggesting that the infections were locally acquired. High rates of intestinal parasitism are found in MSM throughout the world. Oral–anal and oral–genital sexual practices are reported to predispose to infection with enteric pathogens, particularly protozoa. A 1991 study reported a higher prevalence (37%) of E. histolytica/dispar complex in a homosexual population in Sydney when compared to non-MSM.3 However, that study did not differentiate between the two species E. histolytica and E. dispar. Amoebiasis has become endemic in MSM in Japan and causes significant morbidity and mortality; complications such as colitis and liver abscesses occur more frequently in homosexual and bisexual men than in heterosexual men.4 Similar findings on amoebiasis are reported from Taiwan, with MSM at increased risk for invasive amoebiasis and intestinal colonisation with E. histolytica.5 The discovery of E. histolytica infection in MSM in Australia is of public health concern and highlights the importance of continued surveillance, as the organism has the potential to become endemic in the gay population and to cause significant morbidity. Clinicians should also be aware that E. histolytica is present in urban settings in Australia and should be included in differential diagnoses.

Damien J Stark · Rashmi Fotedar · John T Ellis · John L Harkness

Kinky One My brother boxes school bus shadows, keeps me from the point of the in-and-out elbow. I ask mum to bring home a straight comb: I could uncurl myself, the kinky one. Gone tender-tipped, yet dug-in like an echidna disturbed — only spikes showing — a big boy emerges, nights, to forage verandah dark for the milkman’s promise, steals lacy glimpses, learns to love to watch. The grown man, thick-skinned, dreams such puzzles as having his spleen removed. My dog works a raw-hide bone day in, day out, hoping to loosen the knot.

Dennis R McDermott BEc, BA Hons(Psych), MA