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Why can't a man be more like a woman?  Ever since the 1960's, well meaning women and men have been engaged in a psychological and political dance as part of their attempt to choreograph new gender roles and gender relationships.  Whether the dance has been the more delicate minuet or the more aggressive tango has varied with the personalities of the dancers.  Yet, throughout much of this process, men have been on the defensive.

      Until the 1960's, men, whether they were crude or refined, rough or gentle, authoritarian or collaborative, benefited from the privileges of gender that were part of the fundamental cultural givens of our society.  When women rose up to protest the damage and disadvantage brought about by this profound privilege imbalance, they often did so fired by the anger we naturally use to protect our wounds.   Sometimes these were the wounds inflicted by oppression and abuse, sometimes the wounds inflicted by overtly demeaning attitudes, and sometimes the less provable wounds inflicted by slight and neglect.  Women, and many men with them, moved forward to fight for new understandings, new assumptions, new words and labels, and new behaviors as part of the effort to create a more evenly balanced, gender authentic, and respectful, society.

      The results of this effort have been varied, good and bad, for both men and women.  In this article, I am focusing on the problematic effect of this gender revolution on men.  While it is difficult to talk about men as a monolithic block- men vary by age, class, education, ethnicity, regional geography, and personality- there are certain thematic truths that affect the overwhelming majority of men to some degree.  Additionally and most importantly, most men want a meaningful love relationship with a woman.  It is about this group that I write.

      The changes wrought by the gender revolution have most visibly been in gender role definitions.  Women began to do 'men things' (in careers, in sports, in hobbies -how many women did carpentry as a hobby before the '60's revolution?), and men began to do 'women things' (change diapers, cook, clean, grocery shop) .  My impression is that this broadening of gender role definition has largely worked well, the sole disadvantage being that men and women have not yet figured out how to double the length of their day to accommodate the doubling of their responsibilities and activities.

      A less visible change has been a shift in the power to define the other.  Women had complained that men defined them, requiring women to exhibit only narrowly defined 'feminine' qualities and behaviors if they were to be loved and accepted by men.  For many women the constriction of self required was unconscious.  The consciousness raising begun in the 1960's, and now an integral part of our social dialogue, brought an awareness of this constriction to the fore, sometimes combatively so.  It has contributed to the ongoing effort by women to discover their gender authenticity.

      Men were often the target of this process.  Men were held responsible- sometimes lovingly and understandingly, sometimes angrily - for having defined women for their own needs.   Men responded sometimes defensively, sometimes acquiescing, sometimes with an "ah ha" of awareness.  Men also began to get defined in unflattering ways.  Traditional male traits, activities, predispositions, patterns of comfort, manners of relating and experiencing, began to be considered, ...well, barbaric, or pathetically 'unrelated', or perhaps the condescendingly 'cute' expressions of boys who had never grown up.  Some women and some men in the world at large, together with many women and many men in the mental health professions, began to conceptualize 'being human' in ways that could be thought to look like 'being feminine'.  The feminist complaint that men had defined god in their own image, looked to be inverted with women defining 'human' in their own image.  Men, in short, were in danger of having their gender uniqueness defined out of acceptability; of having the same thing done to them by women, that they had done to women.

      Probably the most famous line to come out of the movie My Fair Lady is the plaint by Dr. Higgins, "why can't a woman be more like a man?".  Herein lies the tragedy of all social relations.  Too few of us are willing to experience the other beyond the foreshortened limits of our own ideas, feelings, aesthetics, and mannerisms.  This is true nationally, ethnically, religiously, racially, and across class, gender, and even affinity groupings.   We respond to the other as if the other, in his or her difference, is either sadly lacking- i.e. inferior- or an affront to decency and proper values- i.e. a threat.  When we deem others inferior or a threat, we exert ourselves to change, or punish, or restrict, or banish them.   Sadly, much of social relations has consisted of one group treating another group in this way.  In our discussion of gender, it is equally tragic whether men do this to women or women do this to men.

      What might be called the 'feminization of romantic relationships' has put many men on the defensive and made it harder for couples to grow toward that state of  mutuality and empathy - the compassionate understanding of the other-  so essential for a loving and collaborative relationship of equals.  Many traditional 'male' traits -e.g. leaning toward a preference for action over talk, behavior over emotional expressiveness, keeping feelings to oneself to work them out over talking them through, doing things separately over doing things together-  have been viewed as interpersonally 'defective' rather than 'validly different'.  The result is too much unnecessary disappointment, anger, and hopelessness within couples.   Whereas the label 'defective' leads us to want to change it or spurn  it, the label 'validly different' invites us to want to learn about it, and work to accommodate and coordinate our different ways and different needs.  Indeed, many of these traditional male traits together with traditional female traits, when mutually valued and flexibly coordinated, can form a balanced stability in the life of a couple.

      What is needed is a willingness to be interested in, and accepting of, the difference of the other, and a commitment to treating the wounds of the other with sensitivity and validation.

      It is impossible to grow up without being emotionally wounded.  Some of us are lucky, - we were born into a relatively functional and loving family, into a class, ethnic group, race, or country where our exposure to discrimination or interpersonal cruelty was limited -, and our wounds are few and shallow.  Some of us are less lucky, and our wounds are many and deep. 

      We bring our wounds to our romantic relationships for healing. We want our partner to be sensitive and loving, to act in healing ways toward our wounds even when we are not overt about our need.  The most healing gesture we can make to the wounds of a partner is when we offer love and acceptance of their essential self.  Men have been socialized to be unaware of their wounds and their needs in order to be strong.  Men are exceptionally sensitive to having their wounds revealed because they fear they will be viewed as weak and treated with disdain.  They fear both women and other men in this regard. 

      The emergence of women from their state of wounded constriction often brought with it an anger over the wound as well as a "my hurt deserves primacy" stance in their relations with men.  Until the 1960's many women had been quite aware of male woundedness, and in successful relationships had sensitively cared for this wounded self without drawing direct attention to it, and with a minimum of mockery.  In the more open and free-wheeling atmosphere of the post-1960's, men were often confronted with:  "I am angry over what has been done to me and my hurt deserves reparations from you;" "if you have a wound too it's not my fault, and anyway my wound deserves first attention;" and "if we're going to address your wound you have to be open about it and expose it to my scrutiny no matter how shameful that feels." 

      Men reeled, and many withdrew in confusion, hurt, self-deprecation, or anger.  Men were unprepared for the anger they faced in partners they thought loved them.  They were confused by the demands being made upon them to change and become something that sometimes felt alien.  They were hurt by the critical or demeaning characterizations of men so casually offered up as simple truths in otherwise benign social discourse.  They were reluctant to expose their hurts for fear that in so doing they would feel, or appear to others, less of a man.  They grew angry in order to manage their hurt and confusion, sometimes counter-demeaning women.  Welcome to our enlightened version of the gender wars. 

      What some men and women lost at this point was the awareness that difficulties, complaints, and disappointments in a relationship can be addressed constructively, that we are not stuck choosing between  merely swallowing our concerns or disdainful combat.

      Men should never forget the great injustice done to women over long periods of time, nor should the difficulties faced by men in the post-1960's be treated by women as fair balance.  We are all capable of being worried about losing what we need or cherish, or having our emotional bruises chafed.  If, because of our worry, we pre-emptively attack or counter-attack others, and those 'others' include the person by whom we want to be cared for and cherished, we damage that which is most precious.   In our collective effort to remediate old damage we can inadvertently cause new damage.  To some extent this has happened in gender relations.

      What is needed now is a fresh and compassionate appreciation of what is unique, idiosyncratic, and, yes, needful about our 'other'.  It  is ironic that we are attracted to partners who are different from us in certain meaningful ways, in fact we are drawn by those differences, and then, in the post-romantic phase of the relationship find ourselves preoccupied with critical feelings toward what has become the unattractive side of those once attractive differences.  We need, instead, in this post-romantic phase, to tutor ourselves to act out of the assumption that what is different about our 'other' is essentially good, and a potential complement to our uniqueness.  Our task is to manage our anxieties and fears of difference so we can stay open to, and even embrace, those differences.  Then we can create relationships full of exhilaration, growth, and safety for both women and men.

Psychosexual dysfunction is a sexual dysfunction that is due to psychological causes rather than physical problems, medical illnesses, or the side effects of medication.
Some of the psychological conditions include:

• Depression
• Anxiety (feelings of nervousness, fear, or worry)
• Traumatic sexual experience (abuse, rape)
• Guilty feelings
• Stress or anxiety
• Uncertainty about your sexual orientation
• Worry or fear about how you are able to perform sexually
• Negative body image

Isolated Brain

In psychosexual dysfunction physical problems have been ruled out. Mental or emotional problems are at the center of the dysfunction.

© 2009 Nucleus Medical Media, Inc.

Risk Factors

Reduced sexual desire or activity is very common among women and men. Often, the condition is treatable, but first it is necessary to determine whether the dysfunction is caused by physical causes (such as diabetes, heart disease, alcoholism, heavy smoking, side effects of medications (a very common cause of decreased libido or desire), or hormonal problems or psychological causes. Only sexual dysfunction due to psychological factors is called psychosexual dysfunction.
A risk factor is something that increases your chances of getting a disease or condition.
The following factors increase your chances of developing psychosexual dysfunction. If you have any of these risk factors, tell your doctor:

• Stress or anxiety from work or social situations
• Recent pregnancy (This can result from the changes in hormone levels that occur after pregnancy, from postpartum depression, or for stress and fatigue that follow pregnancy because of adjusting to a new baby)
• Depression
• Uncertainty about your sexual orientation
• Worry about how you are able to perform sexually
• Fear due to previous disturbing or painful sexual experiences or encounters
• Conflict with your spouse
• Religious, social, or cultural restrictions
• Guilt
• Financial worries
• Family problems
• Abusive relationship with partner
• Negative body image

Symptoms

Symptoms of psychosexual disorder may differ for men and women.
Symptoms for men include:

• Not able to keep an erection
• Ejaculations are premature (occur too soon)
• Ejaculations do not occur
• Not able to become aroused when appropriately stimulated
• Not able to achieve orgasm
• Inhibited sexual desire

Symptoms for women include:

• Not able to become aroused when appropriately stimulated
• Not able to achieve orgasm
• Inhibited sexual desire
• Vaginismus—an unconscious spasm (seizure) or tightening of the muscles around the vagina that interferes with sexual intercourse
• Experiencing pain during sex
• Dry vagina

If you experience any of these symptoms do not assume it is due to psychosexual dysfunction. These symptoms may be caused by other health conditions. If you experience any one of them, see your physician.

Diagnosis

Your doctor will ask about your symptoms, your medical history, and your sexual history. Your doctor will also perform a physical exam. Make sure to tell your doctor about all the medications you are currently taking. Your doctor may also ask questions about your partner.
Tests may include the following:

• Blood tests to check for problems in your hormones or blood vessels (arteries and veins)
  • Your doctor will most likely test your testosterone level. Testosterone is the hormone that creates sexual desire in both men and women.
• Depression scale to measure depression
• Mini mental state examination (MMSE)
  • A test to gauge mental awareness and judgment (also known as cognitive functioning)
• Additional tests for men:
  • Snap gauge—A gadget used by physicians to help distinguish if the difficulty maintaining or achieving an erection is due to a physical condition or psychological reasons. You wear the Snap-Gauge for two nights in a row to determine if you experienced erections during your sleep—most healthy men experience several erections in their sleep each night.
  • Vascular assessment—Your doctor needs to make sure the blood flow to the penis is sufficient
• Additional tests for women:
  • Gynecologic examination to rule out any physical causes
    • Your doctor will most likely examine your external and internal genitalia, manually and with a speculum (a medical instrument that is used to open the vagina slightly wider so that the cervix can be seen more easily).
    • Cultures and vaginal samples may be taken to test for any underlying conditions.

If your doctor does not find anything significant from the examination or these tests, your doctor may refer you to a psychologist or psychiatrist.

Treatment

Talk with your doctor about the best treatment plan for you. The most appropriate treatment will depend on the cause of the psychosexual dysfunction.
Some medications can alleviate the symptoms (for example, medications to alleviate erectile dysfunction or to help overcome vaginal dryness). However, to successfully manage psychosexual dysfunction, it is important to treat and manage the mental and emotional issues that underlie the problem.
Treatment options for psychosexual dysfunction include the following:

Medication

Medications may be prescribed to treat the symptoms. Medications differ for men and women.

Medication/treatments for men include:

• For erectile problems:
  • Phosphodiesterase inhibitors—(Viagra [sildenafil], Cialis [vardenafil], Levitra [tadalafil])–A phosphodiesterase inhibitor enhances blood flow in the penis and makes it easier to develop and sustain an erection. The medication is provided in a pill.
  • Vasoactive agents—(phentolamine or papaverine)–This type of medication is given by injection. The medications cause blood vessels in the penis to expand. This increases the blood flow to the penis and results in an erection.
  • Testosterone replacement therapy—This might be helpful for some men, though there is little supporting evidence.
  • Mechanical devices—There are a number of mechanical devices that men can use to maintain an erection. These include:
    • Constriction devices—A binding device is placed at the base of the penis to slow the outflow of blood to produce and maintain an erection.
    • Vacuum devices—A device that creates a suction is placed over the penis. The suction causes blood to flow to the penis to produce and maintain an erection.
• For premature ejaculation
  • Medications in the SSRI family, such as Paxil (paroxetine) have been shown effective. They may be used on a daily basis, or several hours prior to intercourse
  • Anesthetic creams may be useful

Medications for Women Include:

• Testosterone replacement therapy (the hormone testosterone is thought to increase sexual activity and enjoyment, though this has not been proven)
• Vaginal estrogen creams or rings.
• Lubricants—used to ease vaginal dryness

Psychotherapy

You talk and work with a psychiatrist, psychologist, social worker or licensed counselor to figure out ways to deals with stressful or painful issues.

Sex Therapy

Sex therapists assist you by encouraging communications, teaching you about sexual fantasies, and helping you focus on sexual stimuli.

Behavioral Therapy

A psychiatrist, psychologist, social worker or licensed counselor works with you to unlearn automatic behaviors.

Marriage or Relationship Counseling

Couples meet with a psychologist, social worker or other type of mental health professional to discuss issues, including communications problems.

Prevention

There are no known ways to prevent psychosexual dysfunction.
To help reduce your chances of developing psychosexual dysfunction, take the following steps:

• Stay aware of your psychological or emotional health.
  • Call your doctor or mental health provider if you feel the problems surfacing again, you are experiencing excessive stress, or you anticipate a stressful situation in the near future.
• Spend time alone with your partner often, especially nonsexual intimate time, to help maintain the relationship. This will most likely lead to increase sexual interest.
• Continue to communicate openly with your partner about intimacy and sexual issues.

Resources:

American Psychological Association (APA)
http://www.apa.org

International Society for Sexual Medicine (ISSM)
http://www.issm.info

Sexual Function & Infertility
American Urological Association
http://www.impotence.org

Sexual Health Issues
National Institutes of Health, US National Library of Medicine
http://www.nlm.nih.gov

Society for Sex Therapy and Research (SSTAR)
http://www.sstarnet.org

Society for the Scientific Study of Sexuality
http://www.sexscience.org

Canadian Resources:

Canadian Psychological Association
http://www.cpa.ca/cpasite/home.asp

Sex Information and Education Council of Canada (SIECCAN)
http://www.sieccan.org

The Society of Obstetricians and Gynaecologists of Canada
http://www.sexualityandu.ca/home_e.aspx

It is well known that the prevalence of chronic musculoskeletal pain is higher in women than in men [1]. Furthermore, most studies on laboratory pain demonstrated that women report higher pain intensity, especially regarding mechanical stimuli [2], [3], and demonstrate lower pain thresholds [4], [5], [6], [7]. With respect to other modalities of pain stimuli, findings are more controversial [8], [9], [10], [11].
The mechanisms of the enhanced sensitivity to mechanical stimuli in women are not yet fully understood. However, the influence of gonadal hormones has been empirically substantiated [12].
Hypotheses associating the differences between sexes with psychosocial factors have also been advanced [13]. The concept of gender roles assumes that a female or male identity is mainly determined by cultural and social norms or differential reinforcement of behaviour. Thus, the behaviour of expressing one’s pain could be shaped by social norms and reinforcement. A plausible assumption is that females willingly reveal their pain and receive positive social feedback, whereas males are not encouraged or even punished for expressing their pain [14]. Some studies supported the influence of role stereotypes on pain. For instance, male participants revealed less pain when being tested by female experimenters wishing presumably to appear as a “tough guy” in front of an attractive woman [15]. Therefore, we would expect individuals endowed with a distinct feminine role concept to express more pain.
Only a few studies so far have examined the relation between gender role and experimental pain and reported some controversial results. Otto and Dougher [7] found that in men masculinity correlated with the mechanical pain threshold level. Myers et al. [16] showed gender role identity to be associated with pain tolerance, but not with the pain threshold. Sanford et al. [17], furthermore, reported femininity, but not masculinity to correlate with pain tolerance. On the contrary, Fillingim et al. [18] did not find any influence of gender role on thermal pain sensitivity in women.
We intended to re-examine the effect of sex and gender on pain sensitivity to mechanical stimuli in a laboratory environment. Gender role was conceptualised in line with Bem’s conception of androgyny (BSRI; [19]). According to Bem [19], it is defined by the two independent dimensions of “masculinity” and “femininity”. Hence, females and males can have a more female or, respectively, male self-concept according to the difference between the values on the feminine and the masculine scale. We assumed that gender role predicts pain responsiveness in addition to sex. An interaction between both factors was also expected.
Furthermore, we wanted to examine whether psychological trait characteristics act as a mediator between sex or gender and pain. As potential mediators we selected the following variables because there was evidence that they correlate to pain: depressive symptoms (DE: [20], [21], [22]), catastrophising (CA: [23], [24], [25]), fear of pain (FoP: [26], [27], [28]) and pain coping strategies (CO: [29], [30]). They were reported to also differ between females and males (DE: [31]; CA: [32], CO: [33]; FoP: [34]).
Various pain parameters (threshold (PT), intensity (PI), unpleasantness (PU), sensory and affective quality of pain (SP, AP)) were assessed. The following assumptions were examined:

• Both gender role and sex and their interaction explain differences in pain responsiveness (two main effects and an interaction effect in a two-factorial analysis of variance).
• The selected psychological variables correlate with sex and gender as well as pain and are, assumingly, mediators of the effects of sex and/or gender.

Sample

Subjects were students recruited within the University. They were informed by notices of a study on pressure pain perception and that they would either receive credits for their participation, or a small monetary reward. Before the experiment informed consent was obtained from each subject. The study was approved by an institutional review board. Their mother tongue had to be German to prevent misunderstandings regarding the questionnaires that needed to be filled in. Exclusion criteria were acute pain at the time of the experiment and/or persistent pain, consummation of alcohol on the day of the experiment and pain medication during the 48 hours preceding the experiment. Pregnancy prohibited participation as well as bruises or injuries at the site of the pain application (forearm). We recruited 35 women and 39 men with a mean age of 23.1 years (SD=2.5; range 18–33).

Independent organismic variables were sex and gender role. Dependent variables were PT, PI and PU, as well as SP and AP. Potential mediators of the effects of sex or gender (DE, CA, FoP, COP) were assessed by questionnaires. As a control variable, blood pressure, which is known to influence pain responses and can differ between sexes [35], was measured as well as the menstrual phase and the intake of hormonal contraceptives in women.

The stimuli were applied by means of a Fischer pressure algometer [37]. The intensity was regulated by the experimenters, who pressed a force gauge fitted with a rubber tip (1 cm²) as steadily as possible onto the skin of the subject. The gauge’s rubber tip was placed on the inner forearm between wrist and arm crook at distance of 4–5 cm from the skin fold near the elbow.
After some practice, a good reliability of the procedure can be expected (see [38]; ICC=0.80–0.92). Pre-tests had revealed a good reliability (re-test and inter-experimenter) of threshold measures (pre-test: interval of trials 5 minutes; four trials, two experimenters).
Before measuring the pain responses in the main study, subjects received three test stimuli on the right and left thigh to acquaint them with the procedure. The two experimenters were female.

After the application of the standard stimulus within the six trials the questionnaire for sensory and affective pain quality (Schmerzempfindungsskala; SES; [39]) was presented to the subjects. The questionnaire measured the sensory dimension (SP) of pain sensation by 10 items, like “pulsating” and “stinging”, and the affective dimension (AP) by 14 items, like “intolerable” or “exhausting” on a 4-point scale. A sum score was calculated for each scale. Reliability of the scales is reported to be high (Cronbach’s α=.81–.96).

A very clear result of our study is that females respond in a more sensitive manner to mechanical pain stimuli than males. They exhibited a lower pain threshold, described the pressure stimulus (lying in the medium range of intensity) as being more intense and unpleasant and used a greater number of descriptors for the sensory characteristics of the stimuli. Though affective pain did not differ significantly between sexes, females tended to evaluate the pressure stimuli as emotionally more aversive. Effect sizes range from d=.41 (AF) to d=1.04 (PI). In this respect, the findings of the majority of earlier studies were replicated (e.g. [2], [49]) and extended by additional data on pain parameters so far rarely assessed in the context of gender studies.
This study was based on a sample of subjects in their early adulthood (year of birth 1974–1982), i.e. on individuals from different birth cohorts than those reported on in earlier publications (see [49]: year of birth of participants in 16 studies: 1904–1972). Thus, it can be concluded that sex differences in response to mechanical pain are not birth cohort dependent. Compared to effect sizes reported by Riley et al. [49] for experimental pain (d=.56) those observed in our study are even higher (average d=.77). In their latest review Fillingim et al. [3] underline that the higher pain responsivity in females is one of the most stable findings in clinical and experimental pain research.
The expected effect of gender role identity analysed as a dichotomous variable, however, was not observed in any of the analyses; the association with pain response parameters (as indicated by explained variance in ANOVA) was close to zero. Moreover, no interaction of sex and gender was observed. Hence gender role did not explain any variance in pain responses above that which was explained by sex. Furthermore our additional expectation of gender role to be a mediator of sex effects was not confirmed.
Our results are thus in accordance with those found by Fillingim et al. [18], who also came to a negative conclusion regarding the effect of gender role. The results of three studies which had demonstrated some effect of gender on some pain response parameters – Otto and Dougher [7], Myers et al. [16] and Sanford et al. [17] – had been inconclusive in regard to the direction and the domains of influence. The recent review on gender role effects given by Fillingim et al. [3] in his extensive overview on sex and gender differences in pain supports the inconsistency of findings in this area of research.

Background: Several studies on experimental mechanical pain suggested a strong influence of sex demonstrating females to be more sensitive. We examined the hypothesis that not only sex but also gender role affects pain responsiveness and looked for mediators of this effect.
Method: As indicators of pain the threshold the intensity and the unpleasantness of pressure stimuli were measured, as well as sensory and affective quality of pain. The gender role of 74 students was assessed by the Bem Sex Role Inventory (BSRI). Furthermore several psychological variables assumed to be potential mediators (catastrophising, fear of pain, depressive symptoms, pain coping) were obtained.
Results: ANOVA revealed significant main effects of sex in all pain variables except affective quality of pain. Contrary to our hypothesis gender role had no influence on pain responses, neither was there an interaction of sex and gender. Fear of pain just missed the significance level identifying it as mediator of the sex effect on affective pain.
Conclusions: In summary, our study corroborated previous findings that women are more responsive to mechanical pain stimuli with effect sizes being medium to large, whereas gender role did not predict any of the assessed pain parameters. No convincing evidence was found that the influence of sex is predominantly mediated by psychological characteristics of the individual.

Keywords: gender role, sex, pain responsiveness, fear of pain 

Hintergrund: Eine Reihe von Studien zur experimentellen Schmerzwahrnehmung (Druckschmerz) zeigte, dass weibliche Versuchsteilnehmer sensitiver auf Schmerzreize reagierten. Wir untersuchten die Hypothese, dass nicht nur das biologische Geschlecht, sondern auch die Geschlechterrolle die Schmerzreaktivität beeinflussen und ob Mediatoren dieser Effekte zu identifizieren sind.
Methode: Als Schmerzreaktionsparameter wurden die Schmerzschwelle, die Intensität und Unangenehmheit der Schmerzreize erhoben, ebenso wie die sensorische und affektive Schmerzqualität. Die Geschlechterrolle von 74 Pbdn. wurde über das Bem Sex Role Inventory erfasst. Verschiedene psychologische Variablen, von denen angenommen wurde, dass sie eine Mediatorfunktion haben könnten, wie die Katastrophisierung, Schmerzangst, depressive Symptomatik und Schmerzbewältigungsstrategien wurden ebenfalls erhoben.
Ergebnisse: ANOVAs zeigten signifikante Haupteffekte des Faktors biologisches Geschlecht bei allen Schmerzvariablen mit der Ausnahme der affektiven Schmerzqualität. Entgegen unserer Hypothese hatte die Geschlechterrolle keinen Einfluss auf die Schmerzreaktionen, noch ergab sich ein Interaktionseffekt. Angst vor Schmerz verfehlte das für die Feststellung einer Mediation festgesetzte Signifikanzniveau knapp.
Schlussfolgerungen: Die Ergebnisse bestätigten die bisherigen Befunde einer erhöhten Schmerzsensibilität von Frauen hinsichtlich mechanischer Reize, wobei sich mittlere bzw. hohe Effektstärken ergaben. Dagegen konnte die Geschlechterrolle keine Varianz aufklären. Es wurde zudem keine überzeugende Evidenz dafür gefunden, dass psychologische Variablen (habituelle Eigenschaften der Person) den Einfluss des biologischen Geschlechts mediieren.

Schlüsselwörter: Geschlechterrolle, biologisches Geschlecht, Schmerzwahrnehmung, Schmerzangst 

Semen analysis evaluates a man's sperm and semen. It is done to discover cause for infertility and to confirm success of vasectomy.

Semen analysis is an initial step in investigating why a couple has been unable to conceive a child. Abnormalities of sperm and semen can cause male infertility. Semen is the thick yellow-white male ejaculate containing sperm. Sperm are the male sex cells that fertilize the female egg (ovum). They contain the genetic information that the male will pass on to a child.

Vasectomy is an operation done to sterilize a man by stopping the release of sperm into semen. Success of vasectomy is confirmed by the absence of sperm in semen.

The semen analysis test is usually done manually, though computerized test systems are available. Many laboratories base their procedures on standards published by the World Health Organization (WHO).

The volume of semen in the entire ejaculate is measured. The appearance, color, thickness, and pH is noted. A pH test looks at the range from a very acid solution to a very alkaline solution. Semen, like many other body fluids, has a standard pH range that would be considered optimal for fertilization of the egg to take place. The thick semen is then allowed to liquify; this usually takes 20-60 minutes.

Drops of semen are placed on a microscope slide and examined under the microscope. Motility, or movement, of 100 sperm are observed and graded in categories, such as rapid progressive or immotile.

The structure of sperm (sperm morphology) is assessed by carefully examining sperm for abnormalities in the size and shape in the head, tail, and neck regions. WHO standards define normal as a specimen with less than 30% abnormal forms. An alternative classification system (Kruger's) measures the dimensions of sperm parts. Normal specimens are allowed 14% or less abnormalities.

Sperm are counted by placing semen in a special counting chamber. The sperm within the chamber are counted under a microscope. White blood cells are recorded; these may indicate a reproductive tract infection. Laboratories may test for other biochemicals such as fructose, zinc, and citric acid. These are believed to contribute to sperm health and fertility.

Results of semen analysis for infertility must be confirmed by a second analysis seven days to three months after the first. Sperm counts may vary from day to day.

Semen analysis to confirm success of vasectomy is concerned only with discovering if sperm are still present. Semen is collected six weeks after surgery. If sperm are seen, another specimen is collected 2 to 4 weeks later. The test is repeated until two consecutive specimens are free of sperm.

A man should collect an entire ejaculate, by masturbation, into a container provided by his physician. To examine the best quality sperm, the specimen must be collected after two to three days of sexual abstinence, but not more than five to seven days. The specimen must not come into contact with any spermicidal agents used by a female partner for birth control purposes. The man should not have alcohol before the test.

A semen specimen to investigate infertility must be brought to the testing laboratory within one hour of obtaining it. Timing is not as critical for the postvasectomy test but the semen must be kept at body temperature. The most satisfactory sample is one obtained in the lab rather than at home.

WHO standards have established these normal values:

• volume less than or equal to 2.0 mL
• sperm count greater than or equal to 20 million per mL
• motility (movement of the sperm) value is greater than or equal to 50% with forward progression, or greater than or equal to 25% with rapid progression within 60 minutes of ejaculation
• morphology greater than or equal to 30% with normal forms
• white blood cell count less than 1 million per mL.

If infertility continues, despite normal semen analysis and female studies, further tests are done to evaluate sperm function.

Abnormalities of semen volume and liquidity, and sperm number and morphology decrease fertility. These abnormalities may be inherited or caused by a hormone imbalance, medications, or a recent infection. Further tests may be done to determine the cause of abnormalities.

Despite this standardization, human semen evaluation continues to be influenced by subjectiveness of the investigator and a lack of objective measurements for sperm morphology continues to be a problem.

There is an an ongoing debate on which criteria should be applied to define normal spermatozoa and which classification of abnormal forms is most appropriate.

Studies on sperm morphology should concentrate to obtain measurements and biological data of spermatozoa which are functionally active. Only then the definition of normal can be achieved and clinically useful criteria can be adopted.

However, the definition of a normal spermatozoon as described by WHO in 1992 is different from that used by other authors (17,21,22,31). The evaluation of the morphology of human spermatozoa varies widely between and sometimes even within laboratories. While most investigators agree on the appearance of a normal spermatozoon, standardized analysis is difficult because of the use of different staining techniques which are not always suitable for optimal examination from head to tail (Figure 1). For example, the techniques for preparing morphology specimens have been expanded from three to five.

The difficulty in classifying human sperm morphology is mainly caused by the large variety of abnormal forms found in the semen of infertile men. Only certain types of abnormalities can be analyzed objectively (11).

The definition of ‘morphological normal’ is still discussed, as well as the clinical relevant limits for the rate of pathologic forms.

What is a normal spermatozoon ?

The WHO’s definition of a normal spermatozoon is not based on any biological data. As a consequence, the implementation of new standards has resulted in some controversy. However, sperm morphology was found to correlate more closely with fertilization rates than sperm count and motility (2).

Because it is not possible to determine the fertilizing potential of individual human spermatozoa, physiological endpoints other than fertilization must be studied to obtain insight into the mechanisms by which sperm morphology influences the fertilization process, e.g. examination of morphologic characteristics of spermatozoa recovered from cervical mucus and/or those binding to the zona pellucida.

The strict criteria of sperm morphology (e.g. Kruger’s criteria) use the examination of spermatozoa that had penetrated cervical mucus for the definition of normal spermatozoon. Even by using strict criteria it is difficult to determine if results between studies are really comparable.

In order to avoid subjectivity, over the past 20 years numerous studies describe image analysis techniques in the assessment of sperm morphology. These techniques allow objective characterization of different sperm forms. Automated methods may help, but there remains a lack of biological data to support the use of computer-aided semen analysis in clinical settings.

Recent evidence suggests that sperm morphology assessment by relatively simple and inexpensive methods can provide prognostic information similar to that obtained from some of the more elaborate sperm function tests.

Criteria of the World Health Organization

WHO 1987

The WHO manual in 1987 describes a normal spermatozoa: ‘An oval head shape with a regular outline and acrosomal cap covering more than one-third of the head surface. The head: length : 3-5 µm, width : 2-3 µm; lenght/width ratio : 1,5-2. The midpiece: 7-8 µm, long,straight and regular in outline, slender, less than 1/3 of width of the head. The tail: at least 45 µm in lenght, slender, uncoiled and regular in outline.’

Spermatozoa were classified into normal, having head defects (amorphous, small,large,pyriform,tapering), midpiece defects (including cytoplasmic droplets) and tail defects (Table 1). At least 200 spermatozoa need to be examined in an attempt to reduce technical variation.

Sperm morphology is determined using brightfield illumination at x1000 magnification, after preparing air-dried Papanicolaou-stained smears. All slides were read blind by an experienced highly trained technician who produced consistent and reliable results.

WHO 1992

In keeping with the move to a more strict definition of sperm morphology, WHO has redefined what they consider to be a normal spermatozoon and subsequently set an ‘empirical reference value of 30% normal forms and above as normal’ (36).

A normal spermatozoon has an oval head shape with regular outline and a well-defined acrosomal region covering 40-70 % of head; vacuoles occupy less than 20% of the head area. The head: length : 4-5,5 µm, width : 2,5-3,5 µm and lenght/width ratio : 1,5-1,75; no cytoplasmic droplets more than 1/3 of the size of a normal sperm head. No dimensions and no description of a normal midpiece are mentioned. Defects are described, e.g. insertion of the tail in more than 90% of the head’s longitudinal axis is abnormal. No dimensions and no description of a normal tail are mentioned, only defects are described.

Using this classification scheme, all borderline forms are considered abnormal.

Head defects are: large, small, tapering, amorphous, pyriform, vacuolated or double heads or any combination of these.

Neck or midpiece defects are: bent or abnormal thin.

Tail deffects include short, multiple hairpin, broken, irregular width or coiled tails, tails with terminal droplets or any combination of these.

A minimum of 200 spermatozoa is counted and a stage micrometer is used to aid interpretation.

The teratozoospermia index is a measure of the average number of defects per spermatozoa, which could be used to improve the correlation between sperm morphology and fertility.

Basic semen evaluation is performed after liquefaction of the specimen. Two morphology slides are prepared for each patient and are stained by the quick-stain technique ( Diff-Quick solution 1 and 2). Special care is taken to clean the slides thoroughly with 70% ethyl alcohol before use and not more than 5 ul of semen is used to prepare the slides as thin as possible. The slides are reported on the same day. The morphology is evaluated by two independent observers.

The Strict Criteria

Another important evaluation aiming to clarify male fertility is the strict criteria for sperm morphology (Kruger’s or Tygerberg’s criteria 1986) (17).

Strict criteria of sperm morphology established by Kruger et al. define normal spermatozoa as having an oval configuration with a smooth contour ( Figure 2). The head in lenght is 5-6 µm, the diameter( width) is 2,5-3,5 µm and the width/lenght ratio is 1/2-3/5. The acrosome is well-defined, comprising 40-70% of the distal part of the head. No abnormalities of the neck, midpiece or tail and no cytoplasmic droplets of more than half of the sperm head are accepted. Borderline forms are considered abnormal.

The amorphous-head group is divided into two categories:

• slighty amorphous, with a head diameter of 2,0 - 2,5 um, with slight abnormalities in the head’s shape but with normal acrosome.
• severely amorphous, with no acrosome at all and those with an acrosome smaller than 30% or larger than 70% of the sperm head; completely abnormal shapes also are put into this category.

Neck defects are also classified in two categories:

• slightly amorphous, referred to those sperms with debris around the neck or a thickened neck but with a normal shaped head.
• severely amorphous, referred to those sperms with a bended neck or midpiece of more than 30%, or a severely amorphous head shape, as described.
• All other abnormal sperm forms- round, small, large, tapered, double head, double or coiled tail, cytoplasmic droplets-are classified following the WHO classification.

Normal and borderline forms grouped together are called ‘the morphology index ’. Patients with a morphology index less than 30% will have a severe reduction in fertilization as compared with patients having an index greater than 30% (17). In Kruger’s practice, the normal forms considered alone are called the ‘percentage of ideal forms’ (PIF). A PIF greater as 4% is considered favorable and less than 4% unfavorable. At least 200 cells per slide are to be evaluated. A micrometer in the eyepiece of the microscope is used for routine measurements.

In order to improve the strict criteria, in 1987 Menkveld defined a  normal  spermatozoon, based on the appearance of spermatozoa found in good periovulatory cervical mucus of the upper part of the endocervical canal. These spermatozoa are usually in an apparently homogenous population( Figure 3). The morphological classification used by Menkveld is based on a modification of the methods of Mac Leod and Gold (1951) and Eliasson (1971) .

The head must have a smooth oval configuration with a well-defined acrosome comprising approx. 40-70% of it. The normal head has a lenght of 3-5 µm, width of 2-3 µm and a width/lenght ratio of 3/5- 2/3. The range of variation within the normal population is shown in Figure 4. The most important difference between this classification and other methods is that Menkveld regards borderline-normal head forms and/or spermatozoa with nearly oval heads with no gross abnormalities as abnormal. Neck, midpiece or tail defects are considered abnormal. The midpiece lenght is 1,5 times the head lenght, the width is less than 1 µm, slender and axially attached. The tail measures 45 µm in length, appears uniform, uncoiled and is slightly thinner than the midpiece. Cytoplasmic droplets (remnantes) which comprise less than ½ the size of the sperm head are accepted. These are strict criteria.

Spermatozoa are classified into seven groups (Figure 5): normal (whole sperm), large, small, elongated (tapering), duplicated and amorphous heads, all with or without the presence of a cytoplasmic droplet and/or tail, neck and/or midpiece defects. The seventh group consist of spermatozoa with a normal head but with a tail and/or a neck and/or a midpiece defect and/or the presence of a cytoplasmic droplet.

At least 100 but preferably 200 spermatozoa are evaluated. Inexperienced workers should use a built-in micrometer when they begin with morphology evaluations. The normal dimensions for spermatozoa stained with the Diff-Quik method (used by Kruger) are larger than those based on the Papanicolaou method.

In order to improve the evaluation of sperm morphology , Davis and Gravance (1994) have emphasized the sensitivity of sperm classification methods when only two morphometric variables are used (lenght and width of the head, for example). Based on linear models as an appropriate mean of describing the size relationship between phenotypic characters, they show that small changes can significantly alter the percentage of normal sperm within a specimen.(9).

A new expression of sperm morphology parameters is the sperm deformity index (SDI), described in 1996 (2). This is a method by where the whole spermatozoon is assessed by the strict criteria and classified more than once if more than one deformity exists. Both normal and abnormal sperms are considered and the average number of deformities per sperm is determined to give a value to this index. This index reflects the balance between the prevalence of sperms with multiple structural deformities and the proportion of sperms with normal morphology in a semen sample.

Computer-assisted methods of sperm morphology evaluation

Over the past 20 years, in order to avoid subjectivity, numerous studies that incorporate image analysis techniques in the assessment of sperm morphology have appeared. These techniques allow objective characterization of different sperm forms.

The method of Moruzzi (1988) for quantification and classification of human sperm morphology by computer-assisted image analysis is semi-automated (25). Sperm heads are imaged through a microscope (NA=1.3) sampled at 0,125 um intervals and measured on an image analysing system. Measurements included stain content, lenght, width, perimeter, area, and arithmetically derived combination. Additionally, each sperm image is optically sectioned at right angles to its major axis, to give a measure of lenghtwise heterogeneity of shape. According to this method, the percentage of normal sperm heads can be accurately predicted using just four sperm head measurements. This classification procedure distinguishes normal from abnormal sperm with 95% accuracy and correctly assigned 86% of the sperm to one of 10 shape classes.

The system described by Perez-Sanchez (1994) is based on the evaluation with a video digitizer board, a brightfield microscope with a 100x immersion objective, two monitors and the image analysis software (31)(Figure 6). Cells are displayed live on the video monitor and each sperm head image is processed automatically using a specific image analysis program for image enhancement and thresholding. Analysis of the sperm midpiece and tail is not included in the program. The system detects the boundary of the sperm head and the outline is displayed as white overlays superimposed on the video image. The set of morphometric parameters used by Perez constitutes a set of characteristics which is valid for characterization of the majority of morphological types of spermatozoa.

Conclusions

The association between semen quality and male infertility has been known for more than 40 years.

Having reviewed the literature, it seems clear that strict morphology has a clinical relevance, being an excellent biomarker of sperm fertilizing capacity, in vivo and in vitro, independent of motility and concentration (27).

Sperm morphology evaluation is considered to be a highly subjective procedure because, unlike the haematopoietic cells for example, the difficulty in classifying human sperm morphology is caused by the large variety of abnormal forms found in the semen of infertile and fertile men. Only certain types of abnormality can be quantitated objectively (11).

Normal sperm morphology needs to consider two points. The first one is the proportion of spermatozoa with normal morphology in semen and the second is the definition and the characterization of the normal spermatozoa.

According to WHO criteria, a normal ejaculate must have at least 30% normal sperm.(36). For the stricter criteria, fertile men have > 14% normal forms in their semen and men with < 4% of normal forms are subfertile. According to Kruger’s criteria, IVF outcome was suboptimal when normal sperm morphology was less than 14% and worst if it was under 4%.(17). The sperm deformity index is a more reliable predictor of the outcome of fertilization in vitro than the proportion of normal sperm morphology.(2).

WHO recommends that each laboratory recruits fertile men (a reference population) in order to investigate and determine the real cut-off values for normality in that laboratory (28). These men are very difficult to recruit, therefore only a few laboratories actually perform this analysis (3).

During the past 15 years there has been an increase in total motile sperm count, secondary to an increase in semen volume, and a decline in normal morphology. Both are independent of the age and the duration of abstinence in fertile men (5).

There is a debate on this subject and some of the arguments discussed by different authors are the analize techniques used by laboratories and the influence of environmental factors on sperm morphology.

A number of authors, under in vivo conditions of conception, have demonstrated that the pregnancy rate was significantly higher in cases of better sperm morphology (13). But, particulary under the usual in vivo conditions of conception, pregnancy rates are influenced by a multiplicity of different parameters.

It seems that sperm morphology evaluated for strict criteria has definitive advantages over the other (liberal) criteria evaluation methods in the prediction of in vivo and especially in vitro fertilization rates (22).

Other publications’ unavoidable conclusion is that sperm morphology according to WHO classification can be a vigorous predictor of IVF outcome (24). Therefore, further investigations of semen morphology and male fertility according to WHO may be clinically rewarding.

There are papers which emphasize the importance of inclusion of abnormalities in the acrosomal region during sperm morphology assessments and suggest that previous emphasis placed on sperm head dimensions in the classification of normality is justified only in cases of extreme deviation of the normal (12).

Neither abnormal sperm concentration, nor abnormal sperm morphology are significantly associated with reccurent spontaneous abortion (14).

Kruger’s opinion is that the existing classification of abnormal and normal shaped sperms are in need of revision by those involved in the field. Scanning electron microscope is worth further evaluation as a tool in the accurate scoring of normal sperm morphology.

The advantage of using strict criteria in morphology evaluation is the fact that the measure is reproducible between patients and between different technicians performing the test. It also allows the clinician to classify the patient into one of two specific groups ( < 14% and >14% normal morphology), giving a reliable criteria to plan the approach for future IVF cycles (17).

For clinicians responsible interpreting results to patients, it is important to emphasize that 0% strict criteria does not necessarily implicate that no normal sperm is present: it only signifies that no sperm meeting a set of criteria was observed in the sample (24).

Nevertheless, even in cases of severe teratozoospermia fertilization may be possible; most promising is the development of intracytoplasmic sperm injection ( ICSI ) as the treatement of first choice in these cases.(27).

Another conclusion is that only one standard method should be recommended for the preparation of morphology slides in order to ensure inter-laboratory comparability of results and to enhance the value of sperm morphology analysis for predicting fertility (23). At present there are five techniques of sperm preparation. For practical purposes, the Papanicolaou method seems the most suited, due to its widespread use.

Sperm morphology must only be considered as an indicator of fertilization potential, not as an absolute indicator of sterility. The aim should be to find the minimum sperm parameters associated with specific methods of seminal treatment and with culture techniques which can lead to a single, common stategy for male infertility problems.

The Human Fertilization and Embryology Authority (1991) and WHO (1993) strongly suggest that for the treatment of infertility both partners must be evaluated in order to exclude subtle problems.

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