Extreme measure
MEDICINE JOHN ROWAN WILSON
Manson considered the minister of Sinai in a cold distaste. He said carefully : 'Don't you realise there are people with a quarter of your stipend who would give their right hand to have children? What did you get married for?' His anger rose to a sudden white heat. `Get out—quick—you—you dirty little man of God!'
Thus Dr Andrew Manson, the general prac- titioner in A. J. Cronin's best-seller The Citadel, published in 1937. All the wretched pastor of Sinai had done was to ask his general practitioner for advice on contraception. It couldn't happen now, of course, you will say comfortably. But I have to confess, to the shame of my profession, that not so very long ago I heard a young schoolmaster insulted by a surgeon in a hospital outpatients for making a request which seemed to me just as reason- able as that of the unfortunate clergyman in the novel. He had asked to be sterilised.
His circumstances cried out for some kind of radical solution. He already had four children which his income could hardly sup- port, he had a high failure rate with mechanical contraception and his wife suffered from side- effects if she took the Pill. They were both extremely intelligent, stable people. They be- lieved that they had a responsibility towards each other, their existing children, and society generally, to call a halt to any further repro- duction. It was hard to see why his request should be so roughly dismissed. Yet the surgeon concerned acted as if it were an indecent sug- gestion.
In fact, male sterilisation is the simplest, cheapest and most effective method of contra- ception yet devised. The operation, which goes under the name of vasectomy, is a very much smaller procedure than female sterilisation, since one doesn't have to open the abdominal cavity. Two small incisions are required, through which the surgeon ligatures and divides the ducts leading from the testicles which carry the spermatozoa. Neither sexual desire, nor the capacity for intercourse, are in any way affected. After about three months the man is sterile and has no need to use contra- ception again for the rest of his life.
What are the arguments against this pro- cedure? One which held sway for many years was based on doubts about its legality. This led the medical defence societies to discourage doctors from performing it. for fear of either prosecution or civil litigation. It is now con- ceded that the operation is not illegal, and indeed never has been. It may carry the danger of a lawsuit if carried out without proper written consent from the parties con- cerned, but this is true of all forms of surgery. The Medical Defence Union met this difficulty in 1965 by publishing a suggested form of consent for male sterilisation; since then sur- geons have been much more willing to operate.
The other objection sometimes raised is that the operation, unlike ordinary contraception, is irreversible. This is not necessarily so. If the procedure is correctly performed, it is possible to rejoin the ends of the ducts at a later operation, with a roughly 50 per cent chance of success in restoring fertility. In any case, a grown-up man should surely be allowed to make up his own mind whether to accept the risk that he will change his mind, and want more children after all. One cannot act as nursemaid to patients beyond a certain point.
There is another factor, less commonly men- tioned in public but nevertheless of consider- able importance; this is the deep-rooted prejudice felt by many surgeons against opera- tions which are performed at the request of the patient for his own convenience. To men like my surgical colleague who told off the schoolmaster, sterilisation was an example of self-indulgent 'candyfloss' surgery, akin to face- lifting or plastic operations to rejuvenate the female breast. This view is sometimes defended as a proper concern with priorities. But it is only too often a cover for a moralistic and essentially puritanical attitude of mind.
Fortunately. prejudice against sterilisation is diminishing. A major contribution to enlighten- ment has come from the Simon Population Trust, which launched a voluntary sterilisation programme in 1966. This organisation has made information available to the public on the advantages of vasectomy and has built up a panel of surgeons who are willing to carry it out. It claims that 2,000 men have already been sterilised through the agency of this pro- ject and that the numbers are increasing yearly. It hopes to establish vasectomy clinics throughout the country. Soon, one hopes, the operation will be made freely available to any- body who wishes it and is a suitable candi- date for it.
But, of course, the principal value of male sterilisation lies not in England but in coun-
tries with a large immediate birth-rate problem and a population still not advanced enough to make proper use of contraceptives. In India, for example, it is now apparent that ordinary family planning measures have proved totally inadequate to deal with the population explo- sion; it has been estimated that in spite of all the government's efforts only about 2 per cent of India's 95,000,000 couples of repro- ductive age use contraception in a regular and effective way. There is no doubt that the most effective attack on the situation would be a programme of vasectomy for all males with over three children. This could solve India's problem within a generation, and it is the only thing that could. The Indian government knows it, but it is baffled as to how to push it through. It is hardly likely, in a country like India, that sufficient men would volunteer. Compul- sion? Well, it has been seriously suggested. Goodness knows what Dr Manson would say about that.
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