Male sexual and reproductive health among the Aboriginal and Torres Strait Islander population

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In traditional Australian Aboriginal society there was no word for health as it is understood in Western society¹. Traditionally and today, the Aboriginal view of health encompasses a holistic matrix of family connections, land and community. Implicit in this is control over the physical environment, self-dignity, community cohesion, self-esteem and social justice. Thus, the Aboriginal perspective of health identifies closely with the World Health Organisation's Declaration of Health as a state of optimal physical, mental and social wellbeing, a basic human right that includes spiritual, sensual, sexual and emotional aspects of life².

Aboriginal and Torres Strait Islander men's health

Aboriginal and Torres Strait Islander people comprise approximately 2% of the Australian population³. Approximately one-third live in rural regions and one third in remote communities where they represent 18% of the total population³.

Despite a huge investment in Aboriginal health in recent years, the health status of Aboriginal and Torres Strait Islander men has not been given appropriate attention. Most attempts to improve Aboriginal and Torres Strait Islander men's health have failed, perhaps in significant part because they have been based on Western medical approaches to health. Today the situation among Aboriginal and Torres Strait Islander men is that they are the least healthy group in Australian society^1,3,4. They have consistently poorer outcomes across a range of health indicators and a greater incidence of major illnesses such as diabetes, hypertension and cardiovascular disease than the Australian population as a whole⁴. This is mirrored by the psychosocial status of Aboriginal and Torres Strait Islander men who have a low educational level and a correspondingly high rate of unemployment, which leads to a low income and high dependency on social security benefits^3,4,5-7. All of these factors compound the cycle of poverty that is fed by the low self-esteem and depression associated with the loss of traditional male roles⁸. This and the prevalence of racism in Australian society is the legacy of colonisation⁷.

Associated with poverty and compromised mental health are the risk factors of poor nutrition and the use of harmful substances (smoking and alcohol abuse) (N Hayman, M Wenitong, oral presentation, 1997)^3,4 both of which worsen the situation of Aboriginal and Torres Strait Islander men. However, the major killers of this group are the so-called preventable diseases that among other population groups are considered manageable with lifestyle changes: diseases of the circulatory system (myocardial infarction and strokes), injury and poisoning, respiratory diseases, cancers and endocrine disorders (predominately diabetes) (N Hayman, M Wenitong, oral presentation, 1997)^1,4. These 'preventable diseases' become lethal when added to the impact of intergenerational trauma (eg loss of culture and the affect of 'the stolen generation')⁹, the poverty cycle, a lack of health education, and cultural and language barriers to accessing appropriate health services. So lethal is this combination that in 1989, the life expectancy for Indigenous males was quoted as 56 years, 19 years less than the figure for all Australian males¹.

The situation of Aboriginal and Torres Strait Islander men is desperate and these issues must be addressed urgently. Apart from the alleviation of individual suffering, it is the personal philosophy and belief of one of the authors (MA), that in the Indigenous community if the man is not well, the family will suffer; if families are suffering then the community will not function. Aboriginal and Torres Strait Islander men's health issues need to be addressed so the community can function to its full potential and begin to flourish.

Barriers to health care among Aboriginal and Torres Strait Islander men

The structure of many existing health services work against the management of Aboriginal and Torres Strait Islander men's health problems. While Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander men share a reluctance to seek medical attention and to discuss sexual and reproductive health issues with their doctor or even their partners^10-12, an additional barrier to Aboriginal and Torres Strait Islander men presenting for treatment is the lack of culturally appropriate health clinics. In some Indigenous communities' cultural mores do not allow a male to look at his sisters or his mother-in-law (so-called poison relationships) let alone talk to them; however, the make-up of health services is such that the majority are operated by females managers and doctors (M Adams, pers. obs.). A fundamental clinical issue for Aboriginal and Torres Strait Islander men is being able to access primary health-care clinics conducted and controlled by the Aboriginal community where cultural norms and expectations are part of the structure.

As things stand, it is usually only when serious illness occurs that Aboriginal and Torres Strait Islander men will consult a doctor, and even then when cultural requirements are not met, the nature of their illness may be concealed¹³. Take the example of an Aboriginal Elder who went to see a doctor about a lump on his penis. He left the clinic with a prescription for antibiotics and his lesion remained unassessed. When he became aware the doctor was a woman he changed his presenting complaint to a sore throat⁶. When Aboriginal and Torres Strait Islander men are too embarrassed or 'shamed' to go to the health centre because men cannot talk to female doctors about men's problems, cultural insensitivity in the health service increases their risk profile^6,7.

Lack of data on Aboriginal and Torres Strait Islander male sexual health

Indigenous writers say that biomedical research has traditionally been assembled for political advancement, ignoring the presence of or unique circumstances of Aboriginal communities while regarding Aboriginality as a problem to be solved^14-16. So it comes as no surprise, that while there is a growing interest in promoting men's health, a literature review reveals very little that specifically addresses the health issues of Aboriginal and Torres Strait Islander men.

Ethical issues in Indigenous research

Anecdotal evidence suggests that sexual and reproductive disorders (for example, erectile dysfunction, commonly referred to as impotence) are prevalent among Aboriginal and Torres Strait Islander men because of their high rate of cardiovascular disease and diabetes. Unfortunately there are no statistics to define the extent of the problem.

It is essential that social researchers obtain an understanding of Aboriginal and Torres Strait Islander issues and history before they attempt to investigate social behaviour or health issues among this group. Approaching the research of any Indigenous health issue, such as Aboriginal and Torres Strait Islander men's health, demands the intertwining of ethical concerns with appropriate methodology. Many of the observations and opinions in this article result from a qualitative, ethnographic study¹². This was conducted through a process of fieldwork, which included participant observation, interviews, group meetings and data collection. Data analysis was followed by reporting back to participants in a cyclical fashion. This qualitative approach allows the researcher to use Aboriginal ways of working by meeting with the participants in social and kin networks.

Once appropriate methodology is decided, gaining entry to the study site is a process of tact, respect and understanding of the community. Mindfulness of the cultural, political and social protocol and the structure of the community in which the research is to be undertaken is essential. It is important for visitors to acknowledge that they are entering Aboriginal people's tribal land. This is their country and they set the rules.

Meetings will be held with key stakeholders, such as the Health Service's Council of Management and the Elders of the community ('gatekeepers' who control the flow of knowledge) to gain their approval and support. The study, its aims, the methodology and sample must be explained and ownership of the research report negotiated.

The position of one of the authors (MA) as both Indigenous man and academic ('insider' and 'outsider') allowed a participatory role in his research. The Aboriginal and Torres Strait Islander men and women who provided cultural, historical, generational and gender perspectives on men's health and wellbeing were engaged with as facilitators and decision-makers¹⁷. Regardless of insider or outsider status, if a researcher is not respectful of the cultural, political and social structure of the community, the study may not proceed. In the research referred to, consent for the study was given by the Council of Elders and others who held recognised positions within the community¹². All this occurred on a verbal basis. No written consent was made.

Finally, it is important to bear in mind the community's previous experience with research projects. The fact that numerous research projects have been conducted on Aboriginal health can give participants the impression that Aboriginal people are the most observed culture in the world. When the results of such research appear consistently to have little impact on improving participants' health, there may be little enthusiasm for the study.

Andrology Australia collaborates to promote Aboriginal and Torres Strait Islander male health

Because the effects of sexual disorders on male mortality, quality of life and wellbeing have not been understood among the Aboriginal and Torres Strait Islander community, the need for research has not been given a high priority. However, if the problem is to be understood and managed, the lack of data must be addressed. Raising awareness of these issues among the men and their community is a starting point.

The term 'andrology' is defined as the study of the diseases, body structures and physiology peculiar to men, especially the reproductive organs (the equivalent to gynaecology for women). Andrology describes the work of the Andrology Australia (The Australian Centre of Excellence in Male Reproductive Health)¹⁸. Andrology Australia is a 1999 Commonwealth Government initiative developed to assist Australian men with a range of reproductive-health problems by generating knowledge about and providing education in male reproductive health. Administered by the Monash Institute of Reproduction and Development (Monash University, Victoria, Australia) under the direction of Professor David de Kretser, Andrology Australia is 'a centre without walls'¹⁸.

Collaboration

Concerned Aboriginal and Torres Strait Islander men with a special interest in male health (male health workers, researchers and doctors) met with Andrology Australia in Darwin in May 2002 with the aim of understanding the impact and researching the prevalence of male sexual and reproductive disorders in Aboriginal and Torres Strait Islander communities.

The meeting defined a number of issues associated with the poor sexual and reproductive health of Aboriginal and Torres Strait Islander men, such as the lack of gender-specific health education in Aboriginal and Torres Strait Islander communities and the fact that most Aboriginal and Torres Strait Islander men lack the knowledge of their own bodies necessary to assess the merits of treatment options, or even to understand the implications of male health disorders. Few Aboriginal and Torres Strait Islander men are aware that supposedly unrelated medical conditions can cause or contribute to male reproductive-health problems. This is not surprising, because an assessment of men's health rarely includes the sexual and reproductive areas.

Anecdotal information is not an adequate base for intervention, so a research base of male-specific health disorders will be developed among Aboriginal and Torres Strait Islander communities¹⁰. A health surveillance system will collect accurate data on the prevalence of disorders such as prostate disease (including prostate cancer), hormone (androgen) deficiency, erectile dysfunction, testicular cancer and male infertility. However, because the life expectancy of Aboriginal and Torres Strait Islander men is significantly lower than that of non-Aboriginal and Torres Strait Islander Australian men, it may be found that disorders usually prevalent among old men (such as prostate cancer) are not as significant in Aboriginal and Torres Strait Islander communities. Because other medical conditions may contribute significantly to male reproductive health problems, comprehensive assessment of men's health must be encouraged.

Andrology Australia and a nominated Aboriginal male health professional (co-author, MA) are in the processes of establishing specific projects relating to Aboriginal and Torres Strait Islander men's health¹⁰. The scope of the task requires the establishment of partnerships with organisations in both the private and public sectors, such as peak health bodies, research institutions, and community and consumers organisations. Longer-term work will be built on current expertise, community resources and existing research and experience in male reproductive health¹⁰.

Recommendations

In summary, the lack of data on the prevalence of male sexual and reproductive health disorders, and the need for sexual-health education are considered key areas to be addressed if the health of Aboriginal and Torres Strait Islander men is to be improved. This may be achieved with attention to the following strategies:

• Collection of accurate data on the prevalence of male sexual and reproductive health disorders in Aboriginal and Torres Strait Islander communities


• Education of Aboriginal health workers


• Education of Aboriginal and Torres Strait Islander communities.

In order for any community education to be effective, Aboriginal and Torres Strait Islander communities must take an active role in the development of health education resources. It is suggested that an appropriate and effective strategy to assist with improving the awareness of male reproductive health issues must involve the following:

• Community consultation to ensure culturally appropriate methods are used when dealing with gender issues


• Community involvement to maximize the traditional family support structure and ensure 'ownership' of the process


• Ethical consideration to ensure the community is empowered, rather than exploited


• Advice and support from Australian State, Territory and Federal Aboriginal and Torres Strait Islander agencies.

Disorders of the reproductive organs are common in men and become more prevalent as men age. With an increased life expectancy and ageing men's improved health status, these health problems start to become significant issues and can affect a man's quality of life if left untreated. Many men are reluctant to discuss sexual and reproductive health issues with their doctor or even their partner, however many of these health problems can be readily treated when diagnosed early.

The situation of Aboriginal and Torres Strait Islander men is complicated by their psychosocial disadvantage and associated health risk factors, their language and cultural barriers to appropriate health care and their lack of health education. Because of this, any discussion of Australian men's health must include the unique needs of Aboriginal and Torres Strait Islander men.

Attempts are currently being made address the gender-specific disorders of Aboriginal and Torres Strait Islander men. However, only when sufficient resources are available to assist Aboriginal and Torres Strait Islander men to take responsibility for their own health and to deal with the crippling social issues they face will major improvement occur.

David de Kretser
Director
Andrology Australia
(The Australian Centre of Excellence in Male Reproductive Health)

Mick Adams
Doctoral Student

Carol Holden
Project Manager
Andrology Australia
(The Australian Centre of Excellence in Male Reproductive Health)

References

1. National Aboriginal Health Strategy Working Party. A National Aboriginal Health Strategy. Canberra: Australian Government Printing Service, 1989.

2. World Health Organisation. Declaration of Health. Geneva: World Health Organisation, 1978.

3. Australian Institute of Health and Welfare. Australia's Health. The sixth biennial health report of the Australian Institute of Health and Welfare, Cat. no. AUS 10. Canberra: Australian Institute of Health and Welfare, 1998.

4. Primary Health Care Group, Commonwealth Department of Human Services and Health. Draft National Men's Health Policy. Canberra, ACT: Australian Government Publishing Service, 1996.

5. Bellear S. Men's Business. In: Proceedings, Nationals Men's Health Conference, Canberra, 10-11 August 1995. Canberra: Australian Government Publishing Service, 1996.

6. Swan P, Rapheal B. Ways Forward. National Consultancy Report on Aboriginal and Torres Strait Islander Mental Health, Parts 1 & 2. Canberra: Australian Government Publishing Service, 1995.

7. Burdekin B. Human Rights & Mental Illness. Report of the National Inquiry into the Human Rights of People with Mental Illness. Canberra: Australian Government Publishing Service, 1993.

8. Dodson PL. Royal Commission Into Aboriginal Death In Custody. Regional Report of Inquiry into Underlying Issues in Western Australia, Vol. 2. Canberra: Australian Government Printing Service, 1991.

9. Human Rights and Equal Opportunity Commission. Bringing Them Home. A guide to the findings and recommendations of the National Inquiry into the separation of Aboriginal and Torres Strait Islander children from their families. Canberra, ACT: Human Rights and Equal Opportunity Commission, 1997.

10. Andrology Australia (The Australian Centre of Excellence in Male Reproductive Health). Andrology Australia. Annual Report 2001 Melbourne: Monash Institute of Reproduction and Development, Monash Medical Centre, 2001.

11. Hayman N. Medical and Clinical Issues for Indigenous Men. In: Proceedings, 1st National Indigenous Male Health Convention, Ross River NT Australia October 1999. Darwin: Aboriginal Men's Health Policy Unit, Territory Health Service, 1999.

12. Adams M. How Aboriginal and Torres Strait Islander men care for their health. An Ethnographic Study. (MA thesis). Western Australia, Curtin University of Technology, 2002.

13. Leahy TG. Indigenous Men and the Potential of the General Practice Consultation a Brief Overview of Effective Strategies to Improve Health. In Proceedings, 2nd National Men's Conference, Fremantle, Western Australia, 1997. Perth, WA: The Men's Health Teaching and Research Unit School of Public Health, Curtin University, 1997.

14. Dodson M. The Wentworth Lectures. The end in the beginning: re(de)finding Aboriginality. Australian Aboriginal Studies 1994; 1: 2-13.

15. Nakata M. Anthropological text and Indigenous standpoints. Journal of Aboriginal Studies, 1998; [no vol. or pp].

16. Connell R, Schofield T, Walker L, et al. Men's Health. A research agenda and background report. Canberra, ACT: Commonwealth Department of Health and Aged Care, 1999.

17. Hammersley M, Atkinson P. Ethnography, 2nd edn. New York: Tavistock, 1993.

18. Monash Institute of Reproduction and Development. Andrology Australia 2001. Available online from: http://www.andrologyaustralia.org (accessed December 2002).