One day in 2006, Bob Krüse developed a throbbing pain in his testicles. After a week of feeling like “he’d been kicked down there,” Krüse went to see his primary care doctor. Tests revealed the 20-year-old college student had testicular cancer.
The news blindsided him. Until that visit, Krüse had never talked to a doctor about his testicular health. While testicular cancer is relatively rare, Krüse’s ignorance surrounding reproductive health is commonplace.
The importance of reproductive health is drilled into cisgender women from an early age: They’re supposed to begin seeing an ob-gyn during adolescence, and then return annually for well-woman exams throughout their adult lives. This visit covers reproductive health matters, such as birth control and STD screenings, as well as basic primary care services, like blood pressure checks.
Just a few years later, a group of elite New York doctors tried to pioneer an analogous men’s health specialty called “andrology.”
There’s no such thing as a “well-man” exam. In fact, one Cleveland Clinic study found that 60 percent of men say they avoid doctors at all costs. Although men can address reproductive health during general checkups, no official or professional society recommends that men see a urologist for a comprehensive pelvic exam at any point in their lives. Many doctors argue preventive urology visits simply aren’t necessary. But some experts and advocates say a universally recommended men’s health visit could help address two problems: poor reproductive health knowledge and skipping care in general.
Rooted in shame
In the mid-19th century, Dr. J. Marion Sims, the “father of modern gynecology,” conducted experimental procedures on the genitals of enslaved women without using anesthesia. The surgical techniques Sims pioneered earned him widespread acclaim and prompted other male physicians to assume their role as “protectors” of women, explains historian Deirdre Cooper Owens in her book Medical Bondage: Race, Gender and the Origins of American Gynecology. With full-throated support from the medical establishment, the burgeoning field of gynecology gained momentum. By 1880, it was an official medical specialty.
Just a few years later, a group of elite New York doctors tried to pioneer an analogous men’s health specialty called “andrology.” They wanted to develop treatments for venereal diseases, which were rampant and typically treated by illegitimate quacks instead of credentialed physicians. This group saw an obvious need for a specialty dedicated to men’s genitals, but other medical professionals laughed at the idea.
If an enormous group of patients is disproportionately prone to earlier death, and we’ve established that the way US healthcare works is part of the problem, it’s hard to justify inaction. But what’s the answer?
“It involved sexuality outside of the bounds of marriage, which at the end of the 19th century, the Victorian era, was a big, ‘no-no,’’ says Dr. Rene Almeling, Yale University sociologist and author of the book GUYnecology.
The andrology movement fell by the wayside by the early 1900s, and urology emerged in its place — sort of. Urology never became the specialty andrologists had in mind. Unlike ob-gyns, urologists don’t see healthy patients for annual visits or become de facto PCPs for women who only make it to the ob-gyn.
A urologist’s expertise also covers both men’s and women’s urinary tract health, and only a small subset of urologists focus exclusively on the male reproductive system.
Dr. Peter Schlegel, a urologist specializing in male fertility at New York-Presbyterian Hospital, chose to pursue his track because “nobody knew anything about it or did much about it,” he says. “This was an area where you could make discoveries and improve care in ways you couldn’t in other areas of medicine.”
If “guynecologists” existed, they might get more men to go to the doctor regularly. Research consistently shows that men are less likely than women to get routine care. What really drives this difference is routine ob-gyn visits.
Recent years have seen an overall trend toward fewer universally recommended preventive health visits. The American College of Obstetricians and Gynecologists, for example, no longer says average-risk women need to be screened for cervical cancer every year. But the annual well-woman exam has bucked the trend, which means that women who skip general checkups, and plenty do, still have an avenue for regular care. In fact, studies show that many women treat their ob-gyns as de facto PCPs (not all experts are fans of this practice).
When male patients seek out Shin to address fertility issues, he’s often the first doctor they’ve seen since their pediatrician.
Not only do men not have a designated men’s health specialist, they also have fewer recommended preventive health services to check off their lists. As a result, it’s easier for men to drop out of healthcare.
Men’s health specialists could also help fill in knowledge gaps. For women, common patient experiences like choosing birth control and getting Pap test results help ensure they’re not completely clueless about issues related to their genitals and hormones. Women get used to discussing their fertility and the factors that affect it inside and outside the exam room, before their prime childbearing years are out of sight.
This gender dynamic makes reproduction “a women’s responsibility, women’s business and solely a matter women should deal with.”
That’s not the case for men, even though fertility problems lie with male partners in about 50 percent of cases among straight couples. Shin says many male patients don’t have the facts straight when it comes to a range of gender-specific problems. These include prostate cancer, which affects 1 in 7 American men, and low testosterone, which some compare to a milder version of menopause. When male patients seek out Shin to address fertility issues, he’s often the first doctor they’ve seen since their pediatrician. They’ve typically paid little attention to infertility until it affects them personally.
We see this cultural norm bear out in the lack of urgency surrounding hormonal birth control for men (i.e., a male “Pill”). Researchers have been developing different contraceptive drugs for years, but none have made it onto pharmacy shelves.
A path forward
Historically, sexism has made the exam room less hospitable to women: Doctors take women’s pain less seriously, and subjugation of women is baked into the origins of gynecology. Because most early medical research exclusively involved men, many medical schools still teach budding doctors to treat illnesses based on the anatomy and physiology of a 154-pound male. But women still live longer than men, and data indicates consistent healthcare use factors into this disparity. If an enormous group of patients is disproportionately prone to earlier death, and we’ve established that the way US healthcare works is part of the problem, it’s hard to justify inaction. But what’s the answer?
Normalizing these conversations could not only help men get the care they need but also shift some sexual and reproductive healthcare responsibilities onto men’s shoulders.
Some experts still hold out hope for a 21st-century version of andrology, but others aren’t so sure. Almeling thinks the moment has passed, but says she could see primary care physicians helping to fill in the awareness gap by having more in-depth discussions about men’s genital health and infertility early on.
She also believes that increased recognition of gender diversity in healthcare can extend benefits to cisgender men. Cultural taboos surrounding men’s reproductive health drive many men into inaction about fertility and other issues. Normalizing these conversations could not only help men get the care they need but also shift some sexual and reproductive healthcare responsibilities onto men’s shoulder.
Some providers are moving away from traditional gender labels. A number of gynecology practices now refer to all patients as “pregnant people” to account for cisgender women as well as people assigned female at birth who now identify as transgender, nonbinary or gender nonconforming. Other providers are going beyond language shifts, and embracing a ACOG 2013 rule allowing gynecologists to treat men for certain issues, such as anal cancer.
A growing group of healthcare professionals is working to improve transgender healthcare, and some of their ideas might be worth borrowing. For one, experts encourage transgender patients to learn how their sex organs and hormones might influence their need for cancer screenings, and to talk openly about the topic with their providers. This approach might make clinical interactions more comfortable and productive for cisgender men too.
Outside the healthcare system, digital health companies are positioning their services as complements to traditional medical care — following the lead of women’s telehealth, tracking apps, and testing-kit companies. One new-ish company, Posterity Health, offers virtual visits and diagnostic testing for men who want to learn more about their fertility.
Advocates like Krüse, now 35 and free of cancer, believe community-building is key to getting men engaged in their reproductive health. He runs a 2,000-person Facebook group to provide men with testicular cancer support, guidance and information. This dovetails with a number of movements focused on men’s unmet health needs. Most famously, there’s ‘Movember, which promotes month-long mustache solidarity (and charitable donations) to increase awareness of multiple men’s health issues. Other initiatives include Men’s Sheds, a mental-health organization that brings men together through hands-on projects to discuss their emotions, well-being and health.
But online forums, mustaches and outdoor bonding sessions can’t replace going to the doctor. That’s why Krüse has become vigilant about getting regular checkups — and he advises other men, in all states of health, to follow his lead. Unless andrologists make a comeback, men need to use the healthcare experts available to them. That means they can either see their primary care providers regularly, and start talking about issues from low T to aging sperm, or they can stay in the dark.
“Everything from cancer to men’s mental health can be treated,” Krüse says. “We just need to take the first step to getting help and not be ashamed about it.”