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The response of the Finnish man to vasectomy a

S. B. M Ewalds-Kvist , M Rantala d

Selander & K Lertola

b c

c

, V Nikkanen , R. K.

e

a

Department of Psychology , University of Turku , Turku, Finland

b

AVA-KLINIKKA [Fertility Clinic] , Turku, Finland

c

Department of Obstetrics and Gynecology , Turku University Central Hospital , Turku, Finland d

Department of Psychology , Åbo Akademi University , Turku, Finland e

Department of Statistics , University of Turku , Turku, Finland Published online: 19 Aug 2010.

To cite this article: S. B. M Ewalds-Kvist , M Rantala , V Nikkanen , R. K. Selander & K Lertola (2003) The response of the Finnish man to vasectomy, Psychology, Health & Medicine, 8:3, 355-369, DOI: 10.1080/1354850031000135795 To link to this article: http://dx.doi.org/10.1080/1354850031000135795

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PSYCHOLOGY, HEALTH & MEDICINE, VOL. 8, NO. 3, AUGUST 2003

The response of the Finnish man to vasectomy S. B. M. EWALDS-KVIST,1 M. RANTALA,2,3 V. NIKKANEN,3 R. K. SELANDER4 & K. LERTOLA5 1

Department of Psychology, University of Turku, 2AVA-KLINIKKA [Fertility Clinic], Turku, Department of Obstetrics and Gynecology, Turku University Central Hospital, 4Department of Psychology, A˚bo Akademi University, Turku & 5Department of Statistics, University of Turku, Finland


3

Abstract Altogether 112 Finnish males (aged 25 – 67 years) participated in the present research. Of these, 35 underwent conventional and 77 no-scalpel [NS] vasectomy. All were assessed immediately before and 1 year after the vasectomy, by means of Beck’s Depression Inventory [BDI], Taylor’s Anxiety Scale [TAS], the Buss-Durkee Hostility Inventory [BDHI], and Measurement of Masculinity-Femininity [MF]. In addition, changes in angst, sexuality and somatic symptoms were rated by means of Likert scales. The men were divided on the basis of these assessments, into two groups: a psychologically vulnerable vs. a non-vulnerable group. Post surgery, the latter males experienced a greater satisfaction in regards to psychological, sexual and somatic well being as well as in their masculine self-esteem. During the experimental period scrotal discomfort was reflected in a negative change towards vasectomy. Back pain was unrelated to vasectomy technique, but correlated to the immediateness of post-vasectomy coitus. A 10-day post-vasectomy abstinence was recommended. Introduction In Finland the eugenic movement threw its long and ugly shadow over vasectomy until 1985 (Hemminki et al., 1997). Many Finnish physicians received their medical education in Germany (Ainola, 1998) and internalized the idea of reducing the number of individuals considered unfit by means of sterilization (Forsell, 1995). The Finnish sterilization law of 1935, stipulated that severely mentally retarded, mentally disordered, epileptic and criminal individuals ‘may be ordered to be rendered incapable of reproduction’. . . . ‘If there are special reasons’. . . . ‘such a method shall be used to remove the ability to have sexual intercourse’. The methods used were salpingectomy, vasectomy or castration without consent (Mattila, 1999). The number of involuntary sterilized people between 1935 and 1955 was 1908, of which 276 were men (Hietala et al., 1997). Furthermore, men were castrated and the first enforced castration took place in 1935 (Mattila, 1999) and the last in 1958. Altogether 12 males volunteered for castration between the years of 1959 and 1969 (MSAH, 2001). Criticism against the inefficacy of the law of 1935, which rendered only 100 unfit persons sterile per year, inspired the new laws of 1950: the sterilization, castration and abortion laws (Hemminki et al., 1997). Elsewhere, by the late 1940s, in the wake of the Nazi revelations, the Address for correspondence: Dr S. B. M. Ewalds-Kvist. E-mail: [email protected] ISSN 1354–8506 print/ISSN 1465-3966 online/03/030355–15 # Taylor & Francis Ltd DOI: 10.1080/1354850031000135795


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S. B. M. EWALDS-KVIST ET AL.

number of eugenic sterilizations fell sharply, but in Finland it began to rise rapidly (Nowak, no date). It reached its peak between 1956 and 1963 when 3573 out of a total of 7530 eugenic sterilizations were performed under the laws allowing enforced sterilizations without consent on legally competent persons (Hietala et al., 1997; Myyrylaïnen, 1999). Thus, about 11,000 sterilizations were enforced out of a total of 57,000 legal sterilizations between 1935 and 1970. In the 1960s, about 300 eugenic sterilizations were performed (Myyrylaïnen, 1999). These regrettable events ‘in our nation’s best interest’ (Mattila, 1999) have not been forgotten (Lindberg, 1997) and still contribute to a fusion between the two concepts ‘sterilization’ and ‘castration’ (Mattila, 1999). This has given vasectomy a bad reputation, and has contributed to the small and disproportional number of vasectomized Finnish males. After the enactment of the sterilization law of 1970 no further enforced sterilizations were carried out (Hietala et al., 1997), but persons with special difficulties with contraception were granted sterilization (Bradley, 1998). After 1970, information about vasectomy as a contraceptive choice began to be given and 700 males had volunteered to undergo vasectomy by 1971. Thereafter, the number of vasectomies dropped again and varied annually between 400 and 500. The final transition of vasectomy to a solely contraceptive tool was confirmed in the Finnish sterilization law of 1985 (the Sterilization Law 31 January 1985; No.125/1985), the Statute of 24 May 1985 (No. 427/1985). From 1986 to 1995 the number of those voluntarily vasectomized varied annually from 480 to 853 out of a total number of sterilizations on 11,354 to 13,483 persons (Rantala et al., 1998). In 1996 altogether 1737 vasectomies out of a total of 14,037 sterilizations were carried out (ibid.). A promotional campaign was launched in 1995 in Turku (Southwest Finland), the purpose of which was to enhance motivation for vasectomy and thus to diminish the gap between the number of female and male sterilizations (Rantala et al., 1998). Vasectomy is considered a short, reliable, typically outpatient, cheap and easy-to-do operation (Clenney & Higgins, 1999; Rantala et al., 2001). Female sterilization requires inpatient hospital resources and vasectomy was promoted for low cost/high benefit reasons. Katila and Rimon (1979) studied 107 vasectomized Finnish men for hereditary, medical, social and contraceptive reasons for 4.7 years retrospectively. In other countries, already in the middle of the 1960s, systematic long-term follow-ups of voluntarily vasectomized men were published (Rodgers et al., 1965; Ziegler et al., 1969). Elsewhere, vasectomy aftermath in the form of psychological distress (Luo et al., 1996) and sexual dysfunction (Buchholz et al., 1994) was studied. Also somatic discomfort (Hirschowitz et al., 1988) particularly pain in the form of a chronic post-vasectomy pain syndrome with unknown cause have been reported (Rich, 2001). In addition, the different effects of vasectomy techniques have been focused on (Clenney & Higgins, 1999) and the no-scalpel (NS) technique has been found to be superior with regards to concomitant pains (Choe & Bell, 2000; Rantala et al., 2001). In this study, to the knowledge of the authors, for the first time in Finland, psychological, sexual and somatic variables were assessed before and one year after vasectomies which were done solely for contraceptive reasons. Both conventional and no-scalpel (NS) techniques were used. The establishment of an adequate control group is known to be difficult, partly because couples tend to use some method of contraception and partly because of the mistaken expectation that sterilization would solve problems that are unrelated to the desire to end childbearing (Alder, 1984). In this study, this problem was addressed by comparing two group levels of psychological, sexual and somatic factors in vulnerable and non-vulnerable personalities. Surgery serves as an effective threat of body damage (Kanto, 1996) and fear of body damage is known to cause exaggerated inappropriate reactions and reactivated castration fears (Janis, 1974, p. 109) particularly in vulnerable persons. Genital surgery, more than other types of surgery, is known to elicit psychological stress in the form of altered mood


FINNISH VASECTOMY

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state, anxiety, irritation, impaired sexuality and somatic symptoms (Arnett et al., 1986; Dias, 1983; Lalinec-Michaud & Engelsmann, 1985). Particularly in vulnerable personalities pronounced psychological, sexual or somatic distress post surgery, when compared to nonvulnerable individuals, may come to light (O’Hara et al., 1989). Our present results show that pre-post surgery personality traits are stable in the form of intraindividual correlations over the experimental period of 1 year as follows: aggression (rs (77) = 0.649, p = 0.000), angst (rs (74) = 0.342, p = 0.001), anxiety (rs (76) = 0.531, p = 0.000), and depression (rs (75) = 0.462, p = 0.000). Furthermore, the personality traits are intraindividually correlated: anxiety agrees with aggression (rs (78) = 0.403, p = 0.000), angst (rs (75) = 0.430, p = 0.000), and depression (rs (78) = 0.522, p = 0.000). Vulnerable personalities were defined as emotionally excitable men whose mood states were reflected by higher than average scores in aggression, angst, anxiety and depression. Non-vulnerable personalities were defined as those males with a low score in these same variables. The aim of the study and the rationale for the present analysis were to reveal potential vasectomy aftermath by distinguishing the psychological, sexual and somatic post-surgery responses from their pre-surgery levels of expression in Finnish males. Further, to study psychological aftermath in vasectomized males exhibiting ‘vulnerable’ personalities, that is, displaying higher than average group levels of aggression, angst, anxiety and depression. Consequently, the following hypotheses were tested: . . .

Do Finnish men change their response to vasectomy after a period of 1 year as a result of no longer being distressed by the risk of unplanned pregnancies as regards psychological, sexual and somatic factors? Do vulnerable Finnish vasectomized men, more so than the non-vulnerable, reflect the distress of being rendered infertile in enhanced psychological, sexual and somatic responses post surgery? Does the no-scalpel vasectomy technique produce fewer complications than the conventional technique?

Methods Subjects Questionnaires were distributed to 113 men voluntarily seeking a vasectomy for contraceptive reasons at the Turku University Central Hospital (TUCH), (Table 1). Of these, one did not agree to complete the questionnaire and was therefore omitted. The Department of Gynaecology and Obstetrics, TUCH, initiated an information campaign in June 1995 through the national media. This campaign was aimed at diminishing the gap between the number of female and male sterilizations (Rantala et al., 1998). During the vasectomy campaign men were allowed access to a vasectomy without referral. According to the sterilization law (I 62, 31.1.1985/125), those asking for a vasectomy had to meet the criteria of either having at least three children or being 30 years old. All clients met the criteria and the first vasectomies were performed at the end of August 1995. The last client was operated on in the middle of December 1996. Until May 1996, the vasectomies were performed by means of the conventional method (n = 35, [31.2%]) after which, the procedure was carried out by means of the no-scalpel (NS) method (n = 77, [68.8%]), (Rantala et al., 1998; 2001). The clients were offered sperm banking facilities for their semen for a fee of 750 FIM (125E) for a period of 5 years in case of regret, after this period the semen will be stored for an annual fee of 150 FIM (25E). The vasectomy candidates answered questionnaires immediately before and 1 year after the surgery.

Knowledge Aggression Angst Anxiety Depression Masculinity

Educational level

Occupational classification

Vasectomy method

Number of children

Family situation

Age Marital status

Variable

Single Married Divorced Living alone Living with partner 0 1–3 4–5 Conventional No Scalpel 0. Technical, physical, social science, humanist and artistic work 1/2. Administrative, managerial, clerical and sales work 3/5. Agriculture, forestry, fishing, transport and communication work 6/7. Manufacturing & related work 8/9. Service work, work & workers not elsewhere classified Primary school Junior or basic high school Senior high school or vocational training Institute or vocational college College or University about male organ Buss-Durkee Hostility Inventory Self-rated Taylor’s Manifest Anxiety Scale Beck Depression Inventory Marke-Gottfries: Masculinity – Femininity

Item

4.3 8.3 13.3 5.0 3.4 6.5

2.4

39.9

M

Table 1. Patients’ characteristics

0.20 0.27 1.39 0.27 0.38 0.20

0.09

0.59

SE

0–8 2–6 0 – 54 0 – 14 0 – 20 0 – 10

0–5

25 – 67

Range


112 7 88 16 6 95 3 95 13 35 77 14 24 21 32 21 15 10 32 37 17 91 108 108 108 108 101

n 100.0 6.3 28.6 14.3 5.4 84.8 2.7 84.8 11.6 31.2 68.8 12.5 21.4 18.8 28.6 18.7 13.4 8.9 28.6 33.0 15.2 81.3 96.4 96.4 96.4 96.4 90.2

%

111 91 108 108 108 108 101

98

112

111

101

111

112

n

99.1 81.3 96.4 96.4 96.4 96.4 90.2

100.0

99.1

90.2

99.1

100.0

%

358 S. B. M. EWALDS-KVIST ET AL.

FINNISH VASECTOMY

359


Procedure Vasectomy. All operative interventions were performed on out-patients under local anaesthesia by means of lidocaine. A conventional vasectomy involves cutting two incisions in the surface of the scrotum and then cutting off a 2 cm long piece of both vas deferens. The remaining free ends of the vas are ligated with stitches. The no-scalpel (NS) vasectomy is performed by using a special sharp-tipped forceps to penetrate the skin at only one point of the scrotum. A ring-shaped clamp aimed at grasping the vas is the second major instrument needed. Thereafter, the vas is cut off in accordance with the procedure for the conventional vasectomy. The conventional procedure requires about 38 min (SE = 4.82) as opposed to the NS- method which takes approximately 25 min (SE = 2.28). For the conventional technique, the mean dose of lidocaine without adrenaline was 193 mg (SE = 5.85) and for the NSmethod 51 mg (SE = 3.13). Both methods make use of surficial stitches to close the wound (Rantala et al., 1998). Sterility control. Since the operation is not effective immediately after the surgery, the subjects have to use other forms of contraception until the sperm has cleared from the vas deferens. To find out if our subjects were sterile, their semen was examined after at least 10 ejaculations and a period of 10 weeks after the surgery. When the sperm was confirmed incapable of producing offspring, other contraceptive methods were no longer needed. Questionnaires. Genital surgery is known to elicit responses in the form of altered mood state, anxiety, irritation, impaired sexuality and somatic symptoms (Arnett et al., 1986; Dias, 1983; Lalinec-Michaud & Engelsmann, 1985) particularly in vulnerable personalities (O’Hara et al., 1989). The choice of the questionnaires was based on these facts and on their known fitness for use in Turku. For example, male BDI mean of the Finnish males aged 40 years was known (Mattlar et al., 1988). Thus, altogether the questionnaires were aimed at assessing psychological, sexual and somatic variables (e.g. Arnett et al., 1986; Gath, 1987; Janis, 1974; Lalinec-Michaud & Engelsmann, 1985) and were previously ethically approved for a pilot study about the effects of gynaecological surgery. The timing for administering the questionnaires was in agreement with earlier research (e.g. Miller et al., 1991). The clients completed the questionnaires 30 min before the vasectomy. Post-surgery forms were mailed to those vasectomized 1 year after the sterilization. Altogether 71.4% (80/112) agreed to answer the form post-surgery. The psychological form (Table 1) comprised the complete Beck’s Depression Inventory [BDI] (rtt = 0.93) (Beck et al., 1961), 20 questions of Taylor’s Anxiety Scale [TAS] (rtt = 0.87) (Taylor, 1953); 20 questions of the Buss-Durkee Hostility Inventory [BDHI] (rtt = 081) (Buss & Durkee, 1957) including guilt, indirect aggression, irritation, and negativism. Furthermore, 16 questions of the Measurement of Masculinity-Femininity [MF], (parts including ‘paintings’: rtt = 0.69 and ‘animals’: rtt = 0.81 for males) (Marke & Gottfries, 1967) were used. Likert 5-step scales and semantic differentials (0 – 69 mm) were used for self-rated angst as well as other self-rated psychological, sexual and somatic variables. The subjects were divided into two subgroups on the basis of their scores indicating vulnerability according to the criteria presented in Table 2. Younger clients were compared to older males; those married were compared to divorced males. In terms of aggression, approximately one third of the males scored lower than the mean (8.3 scores) and were compared to the third who were more vulnerable in this respect. Males lacking self-rated angst were compared to those who scored higher than average on angst. Those who scored higher than an average of five scores were considered vulnerable with regards to TAS. The depression groups were established on the basis of the average BDI depression score (X = 5.6, SD = 5.2) for Finnish

360



Table 2. Criteria for dividing men into subgroups after vasectomy Item

Group I

n

Group II

n

Age (years) Civil state Aggression (scores) Angst (scores) Anxiety (scores) Depression (scores) Opinion of vasectomy (scores)

25 – 35 Married 5=6 5=1 5=2 5=6 15 – 57

18 59 18 29 17 59 25

44 – 67 Divorced 4 = 11 4 = 14 4=7 4=7 68 – 69

20 11 22 23 20 15 26

males aged 40 years (Mattlar et al., 1988). Those who scored seven or more were considered prone to be vulnerable in this sense. In addition, the clients’ knowledge about the male genitals was tested before and after vasectomy by means of a figure of the male organ comprising the completion of eight questions. Furthermore, questions about the client’s opinions about the necessity to undergo a vasectomy (range 15 – 69 scores) as well as their motivation for seeking a vasectomy were answered in the post-surgery questionnaire. Statistical analysis. For analysing differences among several items between groups the MANOVA test (Wilks’ Lambda) was carried out in the first phase. If the hypothesis was rejected, individual items were then analysed by means of the LSD-method (Rencher, 1998). When a change from before to after surgery of many items was of interest simultaneous corrections were made (Bonferroni-correction). In some case repeated measurement analysis of the variance was used. Furthermore, Pearson w2 and Spearman Correlation Coefficient were computed. The computations were done by means of SPSS (6.1 & 9.0) as well as by SAS (8.2) for MS Windows.

Results Impact of background factors The vasectomy candidates’ background factors such as age, marital status, family situation, number of children, vasectomy technique used, occupational classification, educational level, knowledge about male genitals and personality traits in the form of degrees of aggression, angst, anxiety, depression and masculinity, are presented in Table 1. With regard to age younger clients (25 – 35 years) were compared to older males (44 – 67 years), (Table 2) by means of MANOVA (Wilks’ Lambda was 0.715, df = (5,32), p = 0.0476). As a general rule, younger clients were more satisfied with their sexuality post surgery. For example, they enjoyed a higher quality of coitus (X = 64.83, SE = 1.13 vs. X = 58.80, SE = 1.96) and expressed a greater satisfaction with ejaculation in general (X = 66.56, SE = 0.87 vs. X = 62.25, SE = 1.48), with adequacy of ejaculation (not too slow) (X = 63.06, SE = 2.30 vs. X = 51.80, 3.14 as well as with erection (X = 65.11, SE = 1.01 vs. X = 50.85, 3.00). However, the duration of erection was not rated to differ between age groups post surgery. With regard to self-rated masculinity, the younger males compared to the older, rated themselves as more masculine (X = 62.22, SE = 2.15 vs. X = 53.95, SE = 2.24) although their masculinity assessed by means of MF did not differ (n.s.) between age groups post vasectomy. Over time from before to after surgery both younger (X = 63.55, SE = 1.96 vs. X = 28.00, SE = 7.12, DX = 35.56, CI95 = 18.25 – 52.85, t(17) = 4.34, p = 0.000) and older males


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(X = 57.95 SE = 1.99 vs. X = 22.33, SE = 6.62, DX = 35.62, CI95 = 22.05 – 44.19, t(20) = 5.75, p = 0.000) changed their opinion about the necessity of having vasectomy from a more positive to a more negative attitude. Prior to surgery, 20% of the divorced men banked their semen. On the psychological level the divorced males feared conceiving more than married males prior to surgery (X = 34.56, SE = 4.91 vs. X = 22.01, SE = 2.33, DX = 7 12.55, CI95 = 7 23.97 – 7 1.14, t(98) = 2.18, p = 0.032). Post surgery it was revealed by means of MANOVA (Wilks’ Lambda = 0.886, df = (2, 67), p = 0.017) that the divorced men felt more unhappy (X = 44.64, SE = 4.14 vs. X = 55.56, SE = 1.55) and less healthy (X = 44.64, SE = 3.88 and X = 55.56, SE = 1.76) than married men. The clients had on average 2.4 children, though three men had no biological child. The majority of the men lived with a partner, were educated at an institutional level and were working in manufacturing or related work. The education of the males was normally distributed and correlated positively with their initial knowledge about male genitals (rs(90) = 0.384, p = 0.000) and with the subjects’ perception of their quality of life (rs(111) = 0.232, p = 0.007). How do I feel 1 year after the surgery? Psychological and somatic variables changed over time within the subjects from before to 1 year after the surgery. As a rule, psychological variables improved, as opposed to somatic symptoms that were more pronounced post surgery. The confidence intervals for the changes were Bonferroni corrected. The changes were found in a decrease of general fearfulness (X = 16.05, SE = 1.79 vs. X = 5.90, SE = 1.09, DX = 11.80, CI95 = 4.25 – 16.05, t(77) = 4.76), as well as in fears related to coitus (X = 26.29, SE = 2.56 vs. X = 10.59, SE = 2.07, DX = 16.53, CI95 = 7.44 – 23.97, t(74) = 5.26) and particularly in fear of unplanned pregnancies (X = 23.40, SE = 2.43 vs. X = 2.39, SE = 0.42, DX = 13.09, CI95 = 14.47 – 27.56, t(74) = 8.88). The latter fact was obvious in divorced men changing from before to after surgery significantly their level of fears related to unplanned pregnancy (X = 31.36, SE = 5.94 vs. X = 2.09, SE = 0.98, CI95 = 10.33 – 48.22, t(10) = 5.10, p = 0.000). Somatic symptoms in the form of back pain (X = 10.51, SE = 1.62 vs. X = 16.79, SE = 1.89, DX = 7 10.64, CI95 = 7 11.6 – 7 0.96, t(75) = 3.26) and flatulence (X = 12.67, SE = 1.67 vs. X = 17.24, SE = 1.71, DX = 7 9.09, CI95 = 7 11.6 – 7 0.02, t(75) = 2.78) increased. Flatulence correlated positively with annoyance (rs (79) = 0.277, p = 0.007). An in-depth analysis of the phenomenon of back pain, led to the discovery that those vasectomized men who engaged in coitus 0 to 4 days after the operation suffered from more back pain, than those postponing their first post-surgery coitus from 11 to 40 days (F[1, 41] = 4.50, p = 0.040). Moreover, the correlation coefficient, rs (75) = 7 0.222, p = 0.028, indicates a negative relationship between back pain and number of days to first post-surgery coitus. Scrotal discomfort in the form of pain lasted on average 10.05 (SE 3.82) days, in the form of haematoma 11.08 (SE 1.18) days and soreness 17.92 (SE 4.18) days. Vasectomy and aggression The BDHI aggression comprised feelings of guilt, indirect aggression, irritation, and negativity. It was revealed by means of MANOVA (Wilks’ Lambda = 0.0628, df = (6, 33), p = 0.013) that the most divergent clients with regard to BDHI aggression, varied in their

362


anxiety level post vasectomy (Table 2). The ‘low-aggressive’ males suffered less from anxiety (X = 4.72, SE = 0.47 vs. X = 6.73, SE = 0.76) than those exhibiting a higher degree of aggression (Table 2).


Vasectomy and angst When subdividing vasectomized males according to their scores of self-rated levels of angst (Table 2) several psychological, sexual and somatic variables were found to differ between groups (Table 3). The non-vulnerable vasectomized subjects, in comparison to the more angst prone, felt more masculine and thought that their partners agreed with their level of self-rated masculinity. However, their MF assessed masculinity from pre to post surgery correlated at the highest level of significance (rs (71) = 0.674, p = 0.000). As a rule, men lacking angstvulnerability were psychologically better adjusted and more satisfied with their lives post vasectomy. They were sexually more satisfied and frequently engaged in coitus also rating their partner’s sexual satisfaction higher than those men more vulnerable in this respect were. The latter group experienced more somatic symptoms, for example, insomnia, tachycardia and tremor (Table 3). Vasectomy and anxiety [TAS] From Table 2 it can be seen that about a quarter of the vasectomized males were assigned to a low-score anxiety group and about a quarter to those who were more vulnerable in TAS. By means of MANOVA (Wilks’ Lambda = 0.485, df = (5, 31), p = 0.000) it was indicated that the non-anxious males, as opposed to those more anxious, were easily sexually aroused (X = 55.00, SE = 3.16 vs. X = 42.55, SE = 3.85), were sexually satisfied (X = 65.12, SE = 1.01 vs. X = 53.4, SE = 2.01), felt healthier (X = 57.65, SE = 3.24 vs. X = 46.85, SE = 3.77) and slept better (X = 8.59, SE = 2.41 vs. X = 25.65, SE = 3.94). Vasectomy and depression (BDI) The vasectomized males were divided into two groups on the basis of the average BDI depression score for Finnish males aged 40 years (X = 5.6, SD = 5.2) (Table 2) (Mattlar et al., 1988). By means of MANOVA (Wilks’ Lambda = 0.529, df = (15, 55), p = 0.000) significant results for aggression, angst and TAS were gained for the BDI groups. Vasectomized males scoring 5 6 on the BDI were less aggressive (X = 7.66, SE = 0.41 vs. X = 10.25, SE = 0.61), suffered to a lesser extent from angst (X = 8.81, 1.41 vs. X = 21.67, SE = 4.42) and were less anxious (X = 4.08, SE = 0.31 vs. X = 8.5, SE = 0.97). Men scoring low on BDI felt calmer (X = 43.68, SE = 1.83 vs. X = 28.67, SE = 4.19) and were more satisfied with their masculinity (X = 57.56, SE = 1.38 vs. X = 49.33, SE = 3.4) and thought that their partners are also more satisfied with their masculinity (X = 57.32, SE = 1.26 vs. X = 46.08, SE = 4.26). These group differences are in accordance with those presented for depression in Table 3. With regard to sexuality, BDI-vulnerable men are unsatisfied with their sexuality in the following aspects: frequency of coitus (X = 38.5, SE = 4.22 vs. X = 48.81, SE = 1.89), adequacy of ejaculation (not too slow) (X = 44.92, SE = 3.91 vs. X = 60.25, 1.28), erectile functioning (X = 52.42, SE = 4.04 vs. X = 61.12, SE = 1.31, partner’s sexual satisfaction (X = 46.83, 4.25 vs. X = 57.98, SE = 1.26) and their own sexual pleasure (X = 54.83, SE = 2.79 vs. X = 60.75, 1.07). BDI-non-vulnerable men were more satisfied with their state of health (X = 55.97, SE = 1.65 vs. 41.42, SE = 3.61) (Fig. 1).

Defecation Dizziness Insomnia Tachycardia Tremor Urination

Coital satisfaction Coital frequency Coital quality Ejaculation (too slow)3 Ejaculation (too fast)3 Ejaculation (pleasure of) Erection (duration)3 Erection (rigidity)3 Orgasm Sexual arousal Sexual pleasure Sexual satisfaction (‘partner-rated’)

Annoyance Calmness Depression Fatigue Fear of pregnancy Happiness Masculinity (self-rated) Masculinity (partner-rated)

Item

0.31 4.4 5 7.52 6.2 1 1.9 1.03

65.64 52.32 65.14 62.18 55.25 66.61 61.14 65.0 65.21 55.18 64.86 61.43

5.0 46.3 2.28 17.76 1.0 54.83 60.62 61.03

X

(0.13) (1.67) (2.04) (1.99) (0.69) (0.60)

(1.00) (3.10) (0.82) (1.63) (3.56) (0.70) (3.10) (0.85) (1.25) (2.77) (1.02) (1.36)

(1.78) (2.83) (0.52) (3.29) (0.39) (2.38) (1.69) (1.50)

(SE)

Note: 1Angst 1 = 0 – 1 score, 214 – 53 scores of self-rated angst, 3The higher the sum of scores the more adequate the function

Somatic (Wilks’ Lambda = 0.557, df = (6, 45), p 5 0.0001)

Sexual (Wilks’ Lambda = 0.445, df = (12, 35), p 5 0.0014)

Psychological (Wilks’ Lambda = 0.285, df = (8, 41), p 5 0.0001)

Variable

Angst 11

7.70 11.96 26.4 4 17.87 11.22 7.87

56.75 42.4 54.3 50.45 37.15 59.6 45.35 52.95 60.2 45.9 50.95 47.7

25.95 30.8 6.4 2 38.43 2.81 44.23 47.58 45.24

X

Angst 22

(2.56) (2.49) (3.39) (4.21) (2.92) (1.92)

(2.16) (3.20) (1.97) (3.11) (4.16) (1.83) (4.31) (3.33) (1.80) (3.39) (2.11) (2.79)

(3.38) (2.62) (1.23) (3.05) (0.85) (2.44) (2.28) (2.79)

(SE)

Table 3. Significant differences between males lacking angst and those more prone to experience angst with regards to psychological, sexual and somatic events


7 7.39 7 7.51 7 18.92 7 11.66 7 9.32 7 6.84

8.89 9.92 10.84 11.73 18.10 7.61 15.79 13.05 5.01 9.28 13.91 13.73

7 20.95 14.53 7 4.15 7 20.67 7 1.81 10.40 13.05 15.8

DX

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* The higher the sum of scores the more adequate the function FIG. 1. Significant psychological, sexual and somatic differences between the two depression groups.

Vasectomy and technique The conventionally operated clients were on average aged 39.5 (SE = 1.4) years in agreement with those subjected to the NS-method (40.2 (SE = 0.6) years, n.s.). Regarding psychological factors, males subjected to the conventional operation, as opposed to those operated by the NS method, reported more post-surgery fears of pregnancy during coitus (X = 16.86, SE = 3.95 and X = 6.94, SE = 2.09, F[1, 76] = 5.96, p = 0.017). Regarding somatic factors, the conventionally operated reported more problems with urination (X = 6.21, SE = 1.48 and X = 2.80, SE = 0.88, F[1, 76] = 4.44, p = 0.038) as well as with perspiration (X = 34.75, SE = 2.71 and X = 25.41, SE = 2.71, F[1, 76] = 5.01, p = 0.028). On the other hand, no significant difference was found between clients concerning the vasectomy method in terms of the number of days of scrotal haematoma, pain and soreness or between times to first postvasectomy coitus. Vasectomy and banking semen The 19 out of 75 who banked their semen were superior in knowledge post surgery (X = 5.91, SE = 0.53 vs. 4.57, SE = 0.35, DX = 1.34, CI95 = 7 2.60 – 7 8.71, t(52) = 2.15, p = 0.037) but did not differ in any other respect from the other males. Vasectomy and opinion The client’s positive or negative opinion about the necessity to undergo a vasectomy was unrelated to surgery technique. By means of GLM repeated measures, it was indicated that the


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time span of 1 year impacted significantly on the client’s opinion about vasectomy (F[1, 17] = 43.60, p = 0.000). An interaction between time and experienced scrotal pain (F[1, 17] = 2.10, p = 0.019) was found. In addition, the perceived necessity to undergo a vasectomy varied in accordance with experienced scrotal pain post surgery. This was indicated by means of ANOVA (F[1, 16] = 1.97, p = 0.029) and t-test that a change from a positive to a negative opinion about the necessity to undergo the operation took place during the experimental period (X = 60.17, SE = 1.02 vs. X = 24.79, SE = 3.43, DX = 35.38, CI95 = 28.36 – 42.40, t(75) = 10.05, p = 0.000). On the basis of the clients’ opinions concerning vasectomy they were divided into subgroups (Table 2) and analysed by means of MANOVA (Wilks’ Lambda = 0.678, df = (9, 41), p = 0.045). A third disliked and a third were extremely positive towards the operation. Post surgery the extremely positive males rated themselves as more masculine (X = 51.96, SE = 2.85 and X = 59.76, SE = 2.22) and thought that their partner perceived them as more masculine, too (X = 49.64, SE = 3.45 and X = 61.8, SE = 2.01. The positive group experienced a greater coital satisfaction (X = 58.64 SE = 2.29 and X = 65.91, SE = 1.05), and thought that their partner were more sexually satisfied after surgery (X = 50.16, SE = 3.45 and X = 59.65, SE = 2.01). The perceived quality of coitus was enhanced (X = 54.76, SE = 2.55 and X = 64.31, SE = 1.29), as well as sexual pleasure in general (X = 54.16, SE = 2.45 and X = 63.69, SE = 1.68). Furthermore, the positive group reported more partner support regarding their decision to undergo sterilization (X = 62.54, SE = 1.77 and X = 47.92, SE = 4.59). On the other hand, the positive group endured more back pain post surgery (X = 19.92, SE = 3.99 and X = 10.76, SE = 2.08). Motivation and satisfaction with vasectomy The reasons why the subjects were motivated to choose vasectomy as a contraceptive tool were reported as follows: 74.7% wanted to ease the partner’s contraceptive burden, 2.5% reported economical reasons, 3.8% wanted to share the responsibility for a globally growing population and 19% reported NUD reasons. Altogether 51.9% of the vasectomized felt that the sterilization was a positive experience and 78.1% thought that the operation enhanced their sexuality, 96.3% did not regret their vasectomy and 82.6% were prepared to recommend the operation to others. Still, there are significant differences between the experience of vasectomy and its reported impact on sexuality (X2 = 31.51, p = 0.012) as well as between reported satisfaction and readiness to recommend the operation to others (X2 = 39.33, p = 0.000). Furthermore, there is a significant negative correlation (rs(79) = 7 0.282, p = 0.006), between experienced scrotal pain and readiness to recommend vasectomy to others as well as between knowledge about the reproductive organs and one’s readiness to recommend the operation to others (rs(55) = 7 0.307, p = 0.011). Discussion To the knowledge of the authors, this was the first time in Finland that vasectomized men were studied non-retrospectively during a 1-year experimental period. In comparison to other countries (Rodgers et al., 1965; Ziegler et al., 1969), the present study is late in coming. The sterilization and castration laws as well as the constitutional changes profoundly impacted on Finnish society and contributed to the bad reputation of vasectomy (Bradley, 1998; Rasimus, 1997). It is worth noting that the present clients were on average 14 years old, when the Finnish Marriage Bill rescinded the stipulation that sterilization was a precondition for marriage for epileptics (Mattila, 1999). Further, they were on average 15 years old when the


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enactment of the sterilization law of 1970 stipulated that no more enforced sterilizations were to be carried out (Hietala et al., 1997). Our participants were on average 30 years old when the law was passed which finally made the transition of vasectomy to a purely contraceptivemotivated operation. The awareness of being at risk for unplanned pregnancies produces psychological distress for many couples at a fertile age. Persons who fear contraceptive failure have been found to report a decline in anxiety and increased sexual arousal post vasectomy (Vaughn, 1979) in agreement with the present results. In addition, anticipatory peri-operative unpleasant emotions attribute to a decreased sense of fear post surgery (Kanto, 1996), which is revealed in forms of decreased self-rated angst and correlates positively with surgical satisfaction. The hypothesis that Finnish men respond on some level over time as a result of no longer being distressed by the risk of unplanned pregnancies is confirmed in the changes of decreased fearfulness in general and particularly in fears related to coitus and pregnancy. If it had been possible to administer the questionnaires at least 1 month prior to surgery, the changes in the level of general fearfulness over a year might have been smaller. Altogether 96% did not regret their vasectomy and 83% of the men would recommend the operation to others. Our percentages agree with those from Sweden, where 97% had no regrets and 87% would recommend the operation to others, when asked retrospectively 10 years after the surgery (Hedman et al., 1991). Given that the numbers are accurate and neither based on a social desire of responding to health-care personnel nor on self-deceptive enhancement of no regrets (Meston et al., 1998), a discrepancy between claimed satisfaction and the perception of the surgery as something advisable remains. Participants with more knowledge, higher education and a better quality of life prior to surgery, are less inclined to recommend sterilization to others. The unwillingness to recommend vasectomy may be due to scrotal discomfort, which is considered to be an underestimated side effect and the major reason for dissatisfaction after voluntarily seeking vasectomy (Choe & Kirkemo, 1996). Nevertheless, 4% of the males did regret their vasectomy. Regret is claimed to be a complex psychological process comprising vasectomy aftermath, altered health and image as well as lack of partner support (Alder, 1984; Miller et al., 1991; Wolfers et al., 1973). The second aim of the present paper was to study vulnerable persons’ responses post vasectomy. Vulnerable persons and those who do not completely comprehend the loss of the reproductive capacity as well as those subjected to physical discomfort with concomitant social stress, may not be able to withstand the threat implied by sterilization (Alder, 1984; Luo et al., 1996; Miller et al., 1991; Taylor, 1997). These men might have benefited from counselling prior to surgery. Preparatory communication outweighs its potentially harmful effect (Janis, 1974), although an overdose of fear-arousing information may restrain the client. In Sweden, when the effect of information prior to surgery was studied, 18 men out of 108 never went through with the vasectomy (Ekman Ehn & Liljestrand, 1995). Presently, as hypothesized, vulnerable vasectomized men were psychologically distressed, sexually unsatisfied and somatically responsive. More angst-prone vasectomized men suffered, for example, from enhanced sympathetic arousal in forms of insomnia and tachycardia. Likewise, more depressive men were prone to unsatisfactory sexual experiences in the form of lack of adequacy of ejaculation and erectile functioning. The depressed vulnerable man also thought that his partner was sexually unsatisfied. The transition to infertility is known to add to a depressive mood state (Luo et al., 1996) with concomitant impaired sexuality (Wolfers et al., 1973) and in the present study also accompanied by a sense of impaired masculinity. The latter may reflect decreased self-esteem. In contrast, the sterilized man not vulnerable to a depressive mood state believes that he is more masculine and thinks that his partner also perceives him as more masculine post surgery. This fact agrees with a theory postulating that vasectomized may


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adopt stereotyped masculine behaviours to deny the loss of the reproductive function (Vaughn, 1979). This hints at the possibility of compensatory exaggerated feelings for a reduced sense of masculinity or reactivated castration fear (Miller et al., 1991). In reality, the assessed degree of masculinity remained stable over the experimental year. Earlier findings (Choe & Kirkemo, 1996; Rose et al., 1991) of a high frequency of complaints, apart from 24 h postoperatively, indicate that pain and swelling are the commonest complications. In this study, men vasectomized by means of the conventional technique, suffered more from urinary problems than those vasectomized by the NS technique. This agrees with the fact that the NS technique has been reported to be associated with fewer complications than the conventional technique (Nirapathonporn et al., 1990; Skriver et al., 1997). On the other hand, the vasectomy technique did not reflect in number of days of scrotal haematoma, pain and soreness or in time to first post-vasectomy coitus. As a general rule, men having intercourse within 4 days post surgery were found to suffer from back pain, more so than those waiting at least 10 days do. The importance of having a rest following the sterilization to avoid psychological complications, has been previously stressed (Luo et al., 1996). Presently, a good rest is needed more so for somatic reasons. A debate on possible longterm post-vasectomy health risks has been on-going. Some researchers find vasectomy harmful (Bernal-Delgado et al., 1998; McDonald, 1997) as opposed to other researchers who consider vasectomy harmless to health (Platz et al., 1997). In summary it appears that vasectomy, despite its historical ballast and bad reputation, is a satisfactory contraceptive tool for those Finnish men that opt for it. The present vasectomy candidates were assessed psychologically, sexually and somatically prior to surgery and divided into two groups on the basis of their degree of vulnerability concerning BDI, BDHI, TAS, and self-rated angst. Vasectomy was thought to constitute a response-eliciting threat on some level for the vulnerable males who de facto were found to be poorer in their psychological, sexual and somatic adjustments post surgery. However, men vasectomized by means of the NS technique experienced fewer problems with urination and fewer fears related to conception after surgery in comparison to those conventionally operated. A positive opinion towards the surgery correlated with the availability of partner support and with the experience of improved sexuality. Back pain seemed to emerge from engagement in intercourse immediately after surgery. We strongly recommend a 10-day-period of sexual abstinence post vasectomy.

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