Intimate and Invasive

At the small family practice in Edinburgh where I work as a physician, I happen to be the only male staff member—all my medical, nursing, and administrative colleagues are female. Perhaps that’s why I see a great many men about their prostate problems and carry out a disproportionate number of prostate examinations. The attitude of most men is an odd mixture of anxiety and jokey bravado; they find it easier to make wisecracks about the prostate than to confess their fear of disease. I’m reminded of a routine by the Scottish comedian Billy Connolly, who joked about reaching an age when his doctor had lost interest in his balls and become curious instead about his ass (cancer of the testes being a young man’s disease).

You can feel the prostate through the thin wall of the rectum, about a finger’s length inside the anus. Visualizing it isn’t easy: imagine a tiny doughnut that sits just under the bladder. Urine passes through the hole in the middle. The usual size comparison (for a young man’s healthy prostate) is that of a walnut. I count the prostate as normal when it’s soft, smooth, symmetrical, with a groove running vertically down the middle, and not jutting back into the rectum.

The gland has a variety of functions. It secretes between a quarter and a third of the fluid that constitutes semen—most of the rest is produced in the seminal vesicles—and its muscular elements contract at ejaculation to expel semen into the urethra and out of the body. It operates as a kind of junction box or valve that controls the flow of fluids, ensuring that urine doesn’t pass out to the testicles during urination and that semen doesn’t go up into the bladder during ejaculation. It helps protect against urinary tract infections, and for some men it’s an erogenous zone.

Women too have glandular tissues around the urethra (known as Skene’s gland) that during orgasm expel fluid into the urethra or the vagina itself. Though this gland is sometimes referred to as the “female prostate,” it rarely causes medical problems. For transgender women taking feminizing hormones, the prostate is very unlikely to cause the kind of problems that I’ll be discussing in men.

The tissues of the prostate are sensitive to circulating levels of testosterone, which stimulate it to grow, and so the prostate increases in size throughout life as long as the testes continue to produce that hormone. Prostate cancers, because they’re made of prostatic tissue, usually grow in response to testosterone as well. By the age of seventy, up to three quarters of men have prostatism (some degree of prostatic obstructive symptoms), which in its more severe forms entails poor urinary flow, difficulty initiating urination, dribbling after urination, and nocturia (having to get up at night to pee). These can all be caused by the gradual growth of prostatic tissues and resultant pressure on the bladder, as well as the tightening of the space through which urine has to pass. To widen this channel and improve flow, a surgical procedure called transurethral resection of the prostate (TURP) is commonly carried out on older men.

For a small proportion of men, these symptoms will turn out to be caused not by this gradual growth but by cancer within the gland. If that’s the case, radiotherapy can help, as can surgery to remove the entire prostate—with attendant risks of incontinence, impotence, and loss of ejaculation. For some men, the loss of the prostate as an erogenous zone is cause for grief. A recent article in The New York Times calls for urologists to be more sensitive to the psychosexual effects of such surgery, in particular for gay men.^*

Sometimes the cancer can be controlled by hormonal manipulation, shutting off the supply of testosterone that encourages the cancer to grow. As a result, men sometimes begin to grow breasts, lose their libido, and become impotent. Cancer of the prostate has a tendency to spread to the bones, and I’ve known several men over the years for whom bone pain or a fracture in a tumor-weakened bone, not trouble with urination, was the problem that brought their cancer to my attention. One fractured his femur while getting up from the toilet; another fractured his spine when he fell off a chair. Prostate cancer is the second most common type of cancer diagnosed in the US (after breast cancer), and it was estimated that almost 35,000 American men died of it in 2021 (5.6 percent of all cancer deaths). It’s an ancient problem: evidence of prostate cancer has been found in the bones of Egyptian mummies and Scythian kings.

Though the prostate has been causing trouble for as long as we have records, it wasn’t noticed by anatomists until 1536, when Niccolò Massa of Venice described a gland situated just under the bladder. In 1600 a French physician, André du Laurens, called it prostatae, which means “the ones who stand before,” i.e., before the bladder. He thought the gland existed in two symmetrical parts (hence the plural), and it wasn’t widely considered to be single (thus “prostate”) until the early 1800s.

Doctors studying this newly discovered gland realized that it had something to do with reproduction and sexuality. Until the late eighteenth century it was widely believed that female orgasm was necessary for conception, and the prostate was thought to bring this about by splashing seminal fluid onto the cervix with pressure. Almost as soon as the gland was known, it became the subject of jokes and moral opprobrium: prostatism was believed to be caused by masturbation, sexual promiscuity, coitus interruptus, or, in older men, having more sex than was considered proper for their age. In an era before antibiotics, many men suffering chronic venereal disease would have experienced scarring of the urethra, the symptoms of which are very similar to prostatism.

Ericka Johnson, a medical sociologist and professor of gender and society at Linköping University in Sweden, has charted the evolution of these ideas in A Cultural Biography of the Prostate. She describes the ambivalence with which the prostate and prostatic disease have been seen across the centuries: both as objects of taboo and joke-worthy shame, and as haunting terrors to which men are afraid to confess. It’s of course customary to make jokes about things we find embarrassing, and even Johnson’s publishers can’t resist a joke about prostate examinations: the cover of the book sports a blue manicule, its extended index finger poised beneath the O of PROSTATE. It’s difficult to imagine a publisher choosing to illustrate a cultural history of female sexual organs with a finger sliding menacingly toward an O, but perhaps the choice simply emphasizes one of Johnson’s points: that diseases of male sexual organs have been and continue to be considered very differently than diseases of female sexual organs.

Johnson has been studying men’s health for the past fifteen years. The prostate and its problems came up again and again in her reading, as did a phrase: “It is probably the prostate that is haunting him.” It’s a formulation I haven’t heard used in English but that she reports as common in her native Swedish. “What could be more interesting than a gland that haunts?” she asks. She decided to investigate more deeply and received funding to recruit nine colleagues from disciplines that spanned medical sociology, the history of medicine, anthropology, sexual therapy, and feminist studies. It was a fruitful collaboration. “Anthropology- and sociology-trained researchers engaged with urologists, nurses, psychologists, and sexologists, sometimes thinking along with them, other times using them as informants,” she writes.

Johnson and her team discovered how, before modern surgery and antisepsis, men with severe prostatism died early of either urinary retention (which can lead to kidney failure) or what was known as “the catheter life”—using nonsterile primitive catheters to empty their bladders. She reports that the resultant scarring and infection led to a mortality rate of 8 percent a month, and that surgical operations at the time had a mortality rate of 40 percent. Various other therapies were tried: electricity passed between the rectum and testes, metal rods inserted into the bladder, and, in the late 1800s, castration. “In the practice of removing the testicles, one can see a parallel to the way the female body was being treated by medicine at the time,” Johnson notes.

Many studies have been made of the tendency to remove or otherwise treat the female sexual and reproductive organs in an attempt to cure other health problems that were plaguing the patient. Removal of the uterus and/or ovaries has been put forward as a solution to tumors and growths in the uterus, but also as a treatment for general female malaise, discontent, “hysteria,” or even masturbation.

It makes sense that early perspectives on anatomy and physiology imagined the prostate and uterus as parallel organs: both are muscular tissues highly responsive to sex hormones. But in another way this makes no sense at all, and to read medical history is to become aware of just how quickly the assumptions by which each age understands the body become obsolete. Just as Johnson uncovers similarities in the approaches that physicians have taken toward the prostate and the uterus, she looks at the differences between the ways rectal and vaginal examinations are taught in Swedish medical schools—a difference I recognize from my own training in Scotland:

While the gynecological examination was embedded in lectures and course literature about care for the patient’s discretion, respect for and wonder at their reproductive anatomy, and concern over any potential emotional history of abuse or fear the patient might be carrying with them into this intimate and invasive examination, the prostate examination was taught and conducted as a straightforward, disease-focused process which the patient (and, to a large extent, the medical student) was expected to perform in a perfunctory way.

Approaching vaginal examinations with care and sensitivity does seem merited and appropriate, and the men I see for prostatic examinations seem to expect a disease-focused encounter. But rectal exams are also intimate and invasive, and Johnson wonders whether the difference in approach to the prostate and the uterus has evolved because of the supposed differences between male and female patients. Older men are, she says, the group generally perceived as the standard for whom traditional medical care is designed. “We don’t imagine them to be a group prone to have experienced abuse or traumatic events in the past,” she writes, and so middle-aged and elderly men are, paradoxically, the group for whom the fewest allowances are made.

Throughout the 1800s, if you suffered urinary troubles, a visit to the doctor could get you a diagnosis of prostatitis, prostatisme vésical, le prostatisme, prostatic hypertrophy, prostatorrhoea, or prostatic obstruction. In her conversations with urologists, Johnson finds that our diagnostic categories today can be just as opaque and indistinct, and our theories about causes just as confused. “I have heard of modern doctors who will still blame a wild youth for an older man’s problems,” she writes, “though this is more often associated with riding motorcycles in the cold and damp than with promiscuity.”

A Cultural Biography of the Prostate devotes an entire chapter to prostatitis, a diagnosis frequently given to men who suffer from chronic pelvic pain, even when there is little or no evidence of infection or inflammation. It’s no easy matter to demonstrate the growth of bacteria within prostatic fluid, and the urologists in my city encourage me to assume bacteria are present in any man who suffers chronic pelvic pain and whose prostate gland is tender when I put my finger on it. They recommend that I presumptively eradicate the bacteria with four to twelve weeks of strong antibiotics. But as Tim Parks described in his brilliant memoir Teach Us to Sit Still (2010), pelvic pain can have other origins than infection—in Parks’s case, chronic muscular strain. Johnson cites a study estimating that 90 percent of chronic pelvic pain in men falls into this noninfective category, but most men still end up on antibiotics. (Johnson approvingly quotes Teach Us to Sit Still, but not the book that Parks cites as the inspiration for his own journey of recovery, David Wise and Rodney Anderson’s A Headache in the Pelvis, first published in 2003.)

Johnson disapproves of the diagnostic silos of modern medicine, and I nodded in agreement at her account of how bodies with prostates and uteruses are too often funneled to very different specialists when suffering essentially the same symptoms. The field of urotherapy has arisen to address this gap—urotherapists are usually physiotherapists who have specialized in the relief of pelvic muscle tension. Nine out of every ten men with symptoms of prostatitis might be getting the wrong treatment; clearly doctors need to do better at managing chronic pelvic pain, wherever and in whomever it occurs.

Misinformation and misunderstandings spread to conversations around the PSA test, too. Prostate-specific antigen (PSA) is a protein that maintains the fluidity of semen, to better facilitate the motility of sperm. Small amounts of it leak from the prostate into the blood, where it can be detected. Cancerous prostates tend to leak more of this PSA into the blood than healthy prostates, but not always; for Johnson, the PSA is a “test that congeals…angst into a worry which eats away at many men.” On a weekly basis I’m approached by men who’d like a PSA blood test, “just to check” and because they believe it will accurately screen for cancer. But the majority of men with elevated PSA will not turn out to have cancer, though they’ll endure scans, follow-up blood tests, and biopsies in order to be sure. Checking the PSA does mean that dangerous cancers can sometimes be identified early, but it can also lead to extremely invasive tests and aggressive treatments that in many cases aren’t really needed. A large proportion of prostate cancers grow so slowly that it’s possible for a man who has one to live out his life without ever needing treatment.

In the ten minutes I have allocated for each patient, I often have to embark on what feels like an introductory class in statistics, but there are some helpful visualizations available that illustrate just how unreliable PSA tests can be for someone who is otherwise asymptomatic. As Johnson writes, “People want it to find cancer and save individual lives, but they also critique it for finding too much cancer and destroying lives when applied across a whole population.” Some of the urologists Johnson interviews refuse to have a PSA test; one tells her that to get it would be to start “down that slippery slope.” When celebrities whose cancer has been serendipitously revealed through a PSA test go public, they often drive anxiety in the wider population, as do various patient pressure groups. This is confirmation bias in action.

I’ve also known men who have had surgery unnecessarily through poorly interpreted PSA tests: one patient of mine became infertile from surgery he almost certainly didn’t need. Men like this are reluctant to speak out or complain about treatments that turned out to be needless for them, because they’re embarrassed to admit to impotence and incontinence, and they’re aware that those same treatments might yet prove lifesaving for others. Because these men are often older, it’s too often assumed that their fertility or sexual function no longer matters.

Thirty years ago, Anatole Broyard, a former editor at The New York Times Book Review, wrote a series of reflections on his prostate cancer. He was diagnosed in August 1989 and died of the disease fourteen months later. In 1992 his reflections were published together with some other writings under the title Intoxicated by My Illness. “Intoxicating” isn’t usually how we think about illness, but the image and the alliteration are characteristic of Broyard—a showman of letters who wrote about the indignities of hospital treatment with audacity and candor, and who seemed to have wanted in his writing to prioritize celebration over consolation, revelation over commiseration.

It’s among my favorite books, and one I’ve recommended to patients and medical students alike for its elegantly conveyed insights into the experience of becoming a patient. One of many memorable passages describes the kind of doctor Broyard would have liked best. He wanted one skilled in the use of metaphor, able to describe the “ruin” of his body in more poetic terms than those ordinarily used by doctors, with language like “Art burned up your body with beauty and truth” or “You’ve spent yourself like a philanthropist who gives all his money away.” Broyard also sought a doctor capable of seeing through any bluster he might put on to cope with something “powerful and demonic” like illness: “To get to my body, my doctor has to get to my character. He has to go through my soul. He doesn’t only have to go through my anus.”

In Year of Plagues, a memoir of prostate cancer diagnosed and treated through the pandemic year of 2020, the poet Fred D’Aguiar similarly longs for a medicine infused with metaphor, for physicians capable of meeting his questions of mortality with authenticity rather than clinical detachment. Broyard wondered if literary criticism could wither cancer, while D’Aguiar is more circumspect:

I wonder if art is up to the task of healing. If autosuggestion helps in any perceptible fashion, or if a positive outlook is tantamount to my mind fiddling while the Rome of my body burns. For I burn with cancer.

Thankfully for the reader, metaphor is what D’Aguiar, not his physician, excels at. He teaches creative writing at UCLA, and as a poet he loves to reside in uncertainty and doubt, in Keats’s celebrated negative capability. But as a patient he wants what we would all want in his situation: rock-solid certainty. Can his cancer be cured, or can’t it? “My skin, my flesh and bones, my nerve suit of consciousness, we are all going down together on the Titanic of my being. Let the music play on.”

His symptoms come on slowly throughout the autumn of 2019; he finds great difficulty navigating public space with a reduced bladder capacity:

Every time I embarked on a task—it could be anything, a meeting or car journey or shopping expedition—I wondered when my bladder would announce its presence. And what an announcement: a twisting of my innards located in the area behind my pubic bone, a sharp sense of a wild flame from a naked torch deliberately glanced against my body but improbably from inside my body, a burst of this sharp feeling that radiated down my legs and up my back.

After three or four months of this, D’Aguiar drags the flame of his cancer into a UCLA clinic, where a semiretired oncologist

unceremoniously stuck his index and middle finger into my anus and up my rectum, and swiped along the tube as if to wipe my interior clean. That was a new feeling, of some blind, doubleproboscis creature released in my rectum and bumping into its architecture to forge deep into me.

His prostate is twice the size it should be, and blood tests suggest cancer.

During the long series of tests and the torment of waiting to find out if his cancer has spread, he wonders whether his experiences of illness are inflected by race, but no—he does not experience the illness as a Black man but as a man unaccustomed to illness: “I have to Ngũgĩ wa Thiong’o my mind; that is, decolonize the mental frame of my cancer, which has colonized my body.” With a Vietnamese clinician he exchanges banter about the legacies of American colonialism, about the luck of being able to “reap the benefits rather than the penalties of a colonial or imperial encounter,” but remains convinced that American health care is broken. Even with his good insurance, D’Aguiar can’t be treated effectively without hefty co-payments:

The richest capitalist nation in the world works by bleeding its citizens at every turn…. It makes sense that the poor and Black in the nation die earliest of all groups and the rich live long and healthy lives.

In 2020, as the death toll from Covid mounts, particularly among Black people, D’Aguiar is torn between terror of his cancer and terror of the virus. His urologist stops answering e-mails, and the LA hospitals become overwhelmed, so it looks as if his surgery will be postponed. But then, about two thirds of the way through the book, his operation is performed—six hours under anesthetic in which his prostate, vascular ganglia of the pelvis, and “nearly three dozen” lymph nodes are cleared in a harvest D’Aguiar imagines as a series of scythe cuts, “pendulum to the left and clear, pendulum right, clear,” until he wakes up in the recovery room. His surgeon reports that everything cancerous that could be found has been removed. It will be three months before he will know if the operation has been successful.

What follows are strange weeks of convalescence in which D’Aguiar is empty and exhausted, cloaked in a relentless sadness without tears. His book casts a valuable spotlight on what is so often glazed over in illness narratives: the importance of giving time to convalescence and the uneasy consolations that can be found in the transformation of perspective that severe, life-threatening illness can bring.

Year of Plagues is a complicated book, given over to fugues and furies against the cancer itself, which is visualized as a character with whom D’Aguiar can dialogue. His cancer admonishes him:

You do not have to keep pumping those drugs into your body that slow you down. They only give you hot flashes, cold sweats, constipation, headache, dizzy spells, and breathlessness…. Forget about your prostate.

In places it becomes a howl of grief, betrayal, and indignation, articulating the emotional and existential devastation of a cancer diagnosis. When he begins to grow breasts and feels his gender identity liquefy, D’Aguiar eloquently explores the bodily transformations that so interest Johnson and her research team: “I feel neither male nor female. My crotch attached to clear principles of pleasure along a masculine trajectory has retreated into pure functionality.”

For Johnson, “the prostate is surprisingly present—even in its absence—in our cultural imaginary.” Her book is valuable for summarizing the shifting attitudes toward this strange, hidden gland, and illuminating how far we still have to go. D’Aguiar’s memoir shows just how much progress has been made in prostate treatment in the past thirty years: men with prostate cancer (and good insurance) now have access to detailed 3D scans to map the full extent of the cancer, and robot-assisted surgery to clear it. Broyard died not much over a year after diagnosis. D’Aguiar concludes his memoir with the words “for now, I live.”

At root, Ericka Johnson’s fascination is with the ways in which experience of the prostate and of prostate cancer are culturally inflected, interpreted, and managed by the medical profession and by society at large. She writes as an academic but brings insights from other parts of her life. She describes the indignation she felt, when pregnant and when potty-training a toddler, at the lack of public toilet infrastructure in her hometown, convinced that it had been designed with the needs of men in mind. In the course of her research she came to realize her error: it had been designed only with some men in mind, young men with large-capacity bladders. Her book may be too academic in style for some general readers, but it is to be applauded for its ambition; it seeks to broaden the discourse around men’s health in the clinic and the academy. I hope her work influences attitudes in the public sphere, too.

Of the two thousand male patients registered with my medical practice, more than a hundred will be suffering from prostate problems at any one time, and as many as twenty will be living with prostate cancer or coping with the aftereffects of its treatment. Prostate problems are common enough that every week I sign reams of prescriptions for the drugs that mitigate them, and every month or so I have to write up or administer the hormone injections that shrink the cancer. Within the time constraints put upon me, I always believe myself to be sympathetic to my patients, considering them as sexual beings no matter their age, no matter their sexual preferences, and aware that prostate cancer is an identity threat as well as an existential one. But these books have made me look again at my practice and reassess the care and respect with which I approach these men and their worries. In medicine there’s always room for improvement; as physicians faced with the ailing prostate, we need to do so much more than simply put our finger on it.