Male infertility

Investigation of male fertility status using semen analysis is important, as a minority of men with CF (some few per cent only) will be fertile. This is more common with specific gene mutations. However, while the majority of men report they would like semen analysis to be undertaken in order to confirm their fertility status, not all men with CF are either tested or offered semen analysis. Studies suggest that between one in two and one in three men with CF have had semen analysis. Sawyer et al. also showed that the timing of semen analysis is still significantly later than desired: while more than 95 per cent of men said they believed that semen analysis should be offered to men before the age of 20 years, the youngest age of testing in this recent Australian study was 24 years.

The first studies to explore any aspect of the sexual and reproductive health needs of men with CF date from the late 1980s. These early studies showed that adolescent and adult men with CF had very poor knowledge of the sexual and reproductive complications of CF. Of note, Hames et al. found that the majority of both males and their parents were unaware that men with CF were infertile. More recent studies from the last decade in Boston, USA, Birmingham, England, Scotland and Australian have shown increasing awareness of infertility in men with CF: the majority of contemporary men with CF know that their fertility is likely to be affected by the disorder Buy Nolvadex in Canada, and know why this is so.

These studies also identify that between 68 and 84 per cent of men with CF want children in the future. The desire for more information on sexual and reproductive health is a consistent theme across studies. However, despite the improved survival of CF over the past few decades, few studies have directly assessed the impact of future infertility on teenagers with CF. Apart from a qualitative US study that included ten adolescent males (of whom five were not aware of male infertility), our knowledge of the impact of infertility in adolescence has been obtained from the (retrospective) reflections of adult men with CF. This qualitative study informed the development of a quantitative survey of adult men with CF in Australia. Both studies suggest that knowledge of infertility in adolescence is less overwhelming than might be thought. For example, 90 per cent of men reported not being distressed when they first heard about infertility during adolescence. Typical comments were:

• There was no real effect at the time. I just took it as part of CF. (29-year-old who first heard about likely infertility when aged 12)

And:

• I didn’t really think about it much. At the time I wasn’t upset. (27-year-old who first heard when 15)

However, 10 per cent described a significant impact upon hearing of male infertility in adolescence. For example, one said:

• It took me by surprise, I was shocked. (25-year-old who was first told when he was 12)

The impact of infertility appears to become more significant as adolescents and young adults mature and form more intimate and committed relation-ships where there is an expectation of fertility. Typical comments were:

• At first it went in one ear and out the other, but then I thought about it. (20-year-old)

And:

• At the moment it’s not a concern. It’s like it hasn’t really hit me yet. Later, it could be devastating. (19-year-old)

Infertility was reported as an insignificant aspect of CF by only 10 per cent of adult men. For example, one commented:

• I’ve been busy with living, which is more important than having kids. (38-year-old)

The Perspectives, Psychiatric History, and Mental Status Examination

The perspectives methodology requires a certain body of information and data about an individual before it can be fully used. This basic level of knowledge is usually obtained in the initial evaluation, together with psychological assessment and interviews with available patient informants (e.g., family members). The evaluation of the patient consists of a full psychiatric history and mental status examination. These two procedures, in particular, provide information about possible familial predispositions for disorders, key developmental data, personal psychiatric history, history of substance use, and a behavioral assessment of present mental and emotional functioning.

The history and mental status examination have traditionally been the domain of psychiatry, although more and more social workers and psychologists, especially those associated with mental health facilities, now take initial histories and conduct mental status examinations. Indeed, it is the responsibility of the mental health evaluator, regardless of professional group, to provide the information garnered in the history and mental status examination. If the clinician does not obtain a full history and mental status examination in the initial stage of therapy, but rather proceeds without this knowledge to “let the history unfold,” it is nearly impossible to see how the full perspectives methodology could be employed. The clinician seems to have opted for the life story perspective, while information vital for the other perspectives depends on a fortuitous unfolding of the history.

The Perspectives, Clinical Formulation, and DSM-IV-TR Diagnoses

A psychological or psychiatric evaluation consists of the history, mental status examination, and data provided by psychological assessment and informants. The goal of the evaluation is to construct a formulation of the case—the clinician’s summary of the complex interaction of factors that may have influenced the form, content, and function of the disorder that brings the individual into treatment. It is the product, clearly, of the skill and clinical wisdom of the evaluating mental health professional.

The diagnosis is one element of the formulation that relates the clinical presentation of the particular patient to the larger world of clinical syndromes, disorders, and problematic behaviors. The Diagnostic and Statistical Manual of Mental Disorders-IV-TR and the entire DSM series have been an effort to provide empirically valid and reliable criteria for psychiatric diagnostic categories.

One of the most remarkable achievements of North American psychiatry, the DSM has facilitated research and reliable communication in the mental health field by organizing symptoms and behaviors into psychiatric diagnoses.

– Two extremes are found among mental health practitioners’ attitudes toward DSM-IV-TRdiagnoses. In one camp are those who believe their sole evaluation task is to assign the proper diagnosis according to DSMIV- TR criteria. For these clinicians, determining the proper diagnosis is the goal of the evaluation. Following the intention of the DSM-IV-TR, in reaching a diagnosis they are driven not by theory but by their empirical findings in the patient’s history and mental status examination. Clinical research protocols often are concerned only with diagnosis, because of their interest in study participants that meet the symptominclusion profile.

– In the other camp are mental health clinicians who are quite indifferent to DSM diagnoses and avoid them at all possible costs—excluding requests from third-party payers, of course. This group is more interested in letting the patient’s history unfold in the course of therapy. They tend to see diagnostic categories as unfortunate limitations to the complexity of the person’s psychological history and status. For these clinicians, the formulation of the case is a process constantly open to revision based on new information provided in the course of psychotherapy.

The perspectives methodology assists in both the diagnosis and the formulation of the individual case. After obtaining a full history and mental status examination from the patient, the clinician who employs the perspectives methodology will be able to provide the objective and empirical data required by the DSM-IV-TR while also having garnered sufficient information to develop a rich formulation of the person and the disorder. Diagnosis is not sufficient for clinical treatment in psychiatric disorders or in sexual disorders. More must be said about a case than diagnosis, and this “more” is information that is organized with the perspectives methodology.

The Perspectives and the Biopsychosocial Model

At first glance, the perspectives methodology may seem to be Adolf Meyer’s psychobiology revisited. As later developed by George Engel, the biopsychosocial model urges clinicians, in treating their patients, to take into account aspects of biology, psychology, and culture. In recent years, the model has been of special interest in the treatment of psychosomatic conditions such as chronic pain, where it has proved effective. In psychiatry there has been a renewed call for research on the integration of pharmacotherapy and psychotherapy in the name of biopsychosocial integration.

What, then, is the relationship of the perspectives model to the biopsychosocial model? Simply put, the perspectives provide a method of using the central insight of the biopsychosocial model: that there are multiple determinants of behaviors and conditions arising from biology, psychology, and the social and physical environment. Because nothing a priori is excluded in the biopsychosocial model, its application can pose a heuristic challenge. Recall that Engel’s levels of organization in his systems hierarchy spanned everything from subatomic particles to the biosphere. Granted, no clinician or researcher attempts to consider and control for the universe of possible factors; nevertheless, methodological assistance is needed to decide how to go about considering the literally “too numerous to number” factors that make up our biopsychosocial world – canadian health and care mall.

Enter the perspectives methodology. The perspectives take on the challenge of the biopsychosocial approach to consider nearly everything in the formulation of the individual case and to organize the data into four major perspectives. Employed diligently, these organizing perspectives assist the clinician to consider, if not “everything” in the biopsychosocial universe, at least a great deal more than he or she might consider without the methodology. In addition, the repeated interaction of the perspectives assists the clinician to link together the various strata of the biopsychosocial model in an effective treatment approach.

In the most recent description of his perspectives, Paul McHugh places “the perspectives into a view of human mental life as organized hierarchically into four distinct but interrelated domains from the most neurologically basic to the most individually highly developed.” Table is McHugh’s scheme of how the perspectives relate to each other in the biopsychosocial world and, even more, how they address modes of mental disorders and basic treatment goals. Each of these components interacts with the others; the table expresses how the perspectives are structured from the most basic neurological level to the most complex cognitive one.

Clearly, then, the perspectives methodology is not antithetical to the biopsychosocial model. In addition to the organizing function, at least three of the four perspectives—disease, behavior, and life story perspectives— assume there are biological and psychosocial components in the genesis and treatment of psychiatric disorders. The remaining perspective, dimension, seeks to measure constructs that are biological, cultural, and psychological. In that sense, the perspectives are built on and employ the biopsychosocial model.

The perspectives thus are a methodological supplement to the biopsychosocial model, because they help organize and apply the latter model in the individual cases presented to a mental health clinician. If the biopsychosocial model is a unified theory that seeks to explain all causes, the perspectives are much more modest in their aim. The perspectives model suggests the methods one might employ to put the biopsychosocial model into rational practice. In many ways, the perspectives are the operational testing and application of biopsychosocial theory.

The perspectives help one to avoid using a ritualized invocation of the biopsychosocial model and then proceeding with a treatment regimen that ignores key elements. A recent survey of 54 (of 118 polled) U.S. medical schools suggested that while many attempts are made to teach biopsychosocial medicine to future physicians, there are generally still barriers in the development of a unified curriculum that might be described as “biopsychosocial.” This survey of medical schools is prob ably a good indication of most treatment approaches today: the biopsychosocial is invoked as the model guiding evaluation and treatment, but barriers remain to its being as influential as it might be. The perspectives are an attempt to provide a way of increasing the effectiveness of the biopsychosocial model.

Just as with the biopsychosocial model, it is not a question of “new” knowledge in employing the perspectives. Every aspect of the perspectives has already been written about and employed clinically. It would be erroneous, therefore, to expect some new information from the perspectives themselves. What is original is the structured organization of the perspectives. The essence of the working of the perspectives is dialectical. They take the clinician’s “I know such and such” and invite him or her to hear, “But you must also consider your patient from this other perspective.” Then, from the application of the newly adopted perspectives, the clinician achieves a fuller appreciation of the disorder and approaches for treating the disorder.

The Perspectives and Sexual Science

Despite the amount of information abroad about sex, we are only beginning to understand the multifactorial causes of sexual behavior, especially the interaction of biological effects and cultural contexts. Nowhere is this more apparent than in the shift in the causal attributions that have been applied to male sexual arousal in the past twenty-five years. Until the mid-1970s, a combination of the life story and behavior perspectives was used to explain erectile dysfunction in the vast majority of cases. Only those men who had obvious neurological and/or vascular diseases were thought to have “organic” causes of erectile dysfunction. All other men with erectile dysfunction had “performance anxiety” or “spectatoring” (behavior perspective), or the sexual dysfunction was an expression of some unresolved conflict arising earlier in life (life story perspective).

Enter, in the early 1990s, the disease perspective, with its interest in physiological function in sexual arousal. Basic research on nitric oxide’s effect on penile arousal was applied by Pfizer Pharmaceuticals, which produced and marketed sildenafil, Viagra. With the advent of the oral medication in 1998, many speculated that there would no longer be a need for a psychological approach to erectile dysfunction: the pill would solve everything. Erectile dysfunction was to be considered a medical disorder and treated with medical interventions. The disease perspective had nearly replaced the behavior and life story perspectives as the operative perspective on male erectile dysfunction. Female viagra online Australia

Other clinicians did not remain silent about what appeared to them as a reductionistic reliance on the medical/disease perspective. Social constructionism theorists, researchers, and experienced sexual clinicians, writing and speaking largely from the life story perspective, challenged the rise of the medicalization of sexuality (the disease perspective). Their argument was that human sexuality is a far more complex reality than the achievement of reliable erections. They pressed for the inclusion of psychological and relational factors distinct from physiological function when researchers wanted to report on the efficacy of a treatment for sexual disorders. Although these theorists did not intend to employ a four-perspectives methodology, they did in fact work with this method. They took a prevailing perspective and brought other perspectives into dialogue with it.

The four perspectives, each through its relativity to the others, offer checks and balances to the reductionism that may result from the application of a single perspective. There is a constant “but what about . . . ?” refrain that requires the sexual scientist and clinician to consider something they may have overlooked or prematurely dismissed. In all areas of psychiatric thought—but perhaps most in sexual behavior, with its biological, psychological, and cultural components—the four perspectives provide an open-ended dynamic for looking at cases and problems with new questions.