It was now clear that the pain in my testicles was simply a referred pain from this cancerous prostate, from an excessive neural stimulation caused by a tumor in the area.
A death sentence, at the very least a death sentence for my fertility. I may, at the time, not have known about the end of my ejaculant; but I did know that now at the age of thirty-six I would indeed be infertile after surgery. Helen and I had been trying for a third child the previous year without success, a failing possibly related to the developing cancer.
“How about if I spend tonight and whatever time I have before surgery masturbating so that we can collect and save and freeze my sperm for the future,” I asked the surgeon. I had begun to see spanking the monkey in biblical terms. Every last mobile sperm cell was precious and deserved an opportunity to head up the vaginal canal and duke it out with its brethren in order to inseminate one of Helen’s eggs.
His response took me aback, “You are facing a lethal disease. How can you possibly be focused on an issue as frivolous as fertility when your life is hanging in the balance? This is not the time to think about having another child.”
If I was not preoccupied with thoughts of death before this conversation, I was now totally obsessed. If, as W. H. Auden pointed out, “Lust is less a physical need than a way of forgetting time and death,” then with lust now verboten, time and death were the only elements of life I was allowed to think about, according to this expert who had my life in his hands.
With the 20/20 vision of hindsight do I now know that reports of my impending death were greatly exaggerated. Sitting here reasonably healthy and vibrant thirty years after the radical prostatectomy, I now know that Helen and I could have had a third child, a child who might have finished college by this time, a child who might have moved on to his or her adult life, a child who might have been raised by an intact family, with a relatively intact father in the picture. If seventy-year-old men can have the hubris to father young children and assume they will live into their children’s adulthood, then physicians cannot assume they can predict the longevity and survival of their patients, even ones with an apparent death sentence hanging over their heads.
Never underestimate the survival instincts of a patient. Never underestimate the possibility of medical breakthroughs in enhancing that survival. Never assume you know how lucky or unlucky a person will be in their length of days. Never tell a man or woman they cannot bring a child into the world, when that child can be a life-giving force in the face of death. Never play god with a patient. Your knowledge of the future is just as limited as anyone else’s.
Never tell a man not to follow his lust, not to spank the monkey, when he is in the midst of grappling with prostate cancer.
CHAPTER 4
What Is the Prostate?
“Each ejaculation contains several billion sperm cells—or roughly the same number as there are people in the world—which means that, in himself, each man holds the potential of an entire world . . . As Leibniz put it: ‘Every living substance is a perpetual living mirror of the universe.’”
—Paul Auster, The Invention of Solitude
“Human strength will not endure to dance without cessation; and everyone must reach the point at length of absolute prostration.”
—Lewis Carroll
The prostate: The one unpronounceable word in medical school. Even in the fifth edition of Shearer’s Manual of Human Dissection, a book I used in my first semester human anatomy class, the prostate is listed as the “prostrate” in the index.
Later, when I was practicing internal medicine before moving into psychiatry, I would be asked by male patients after a rectal exam, “How’s my prostrate, doc?” “Your prostrate feels fine,” I would reply, going along with their humble pronunciation, knowing I could pronounce it no better.
The prostate is a chestnut-shaped organ at the base of the penis in the lower pelvis, partly muscular and partly glandular. It secretes a milky fluid that is discharged into the urethra at the time of the emission of semen, the discharge thus mixing with the seminal fluid from the seminal vesicles at the time of ejaculation and orgasm. The bilateral seminal vesicles lie just above the base of the prostate. The fluid from the seminal vesicles and the prostate empty into the vas deferens, filled with sperm cells from the testicles, to form the fertile ejaculant that perpetuates our species. Interestingly, the seminal vesicles are resistant to virtually all of the disease processes that affect the prostate—no inflammations (as in prostatitis), no cancers.
The word “prostate” comes from the Latin “pro” and “stata,” formerly from the Greek “pro” and “statos.” The prostate stands as a “guardian”—something “placed” and “standing.” In other words, if one loses one’s prostate, from cancer and its various treatments, one loses one’s guardian. Indeed one is barely left standing; one’s penis can barely stand up straight. Losing the prostate can lay a man low—well-nigh prostrate.
Only mammals have prostates. As female mammals developed mammary glands to feed their young, the males developed prostate glands at the same time.
Male cats and dogs have prostates; all the male apes and monkeys have prostates, as do bulls and male elephants,
Not all mammals have seminal vesicles. Carnivorous mammals—meat-eaters like lions—do not have seminal vesicles. For some peculiar reason, not having seminal vesicles while being a meat-eater protects an animal from developing prostate cancer. Almost all animals that have both prostates and seminal vesicles are herbivores—vegetable-eating animals like bulls, apes, and elephants.
Human males are the exception to the rule: We are virtually the only mammalian males who have both the prostate and seminal vesicles and who also eat meat. Our closest evolutionary relative—the pygmy chimp or bonobo—has seminal vesicles and a prostate and only eats fruits and vegetables and greens. Bonobos never develop prostate cancer.
We humans are too clever for our own good. We have planted the seeds for our own destruction—if not the destruction of our species, then at least the destruction of our prostates. When our evolutionary predecessors 600,000 years ago developed the capacity to cook, we became committed carnivores. When the earth’s climate and temperatures stabilized 10,000 to 12,000 years ago, we human beings began to domesticate animals. We quit running after animals and instead began to herd them and breed them in captivity. We also became much more sedentary.
The only other animal to develop clinically significant prostate cancer with any regularity is the dog—the pet that eats from our human table, the pet that eats virtually the same food—and meat—as people.
The prostate and its ruination via prostate cancer may truly be the ultimate sentinel, the ultimate tiny chestnut-shaped canary in the human coal mine. This highly vulnerable organ is indeed trying to tell us something essential. We ignore this organ at our own risk.
CHAPTER 5
My So-Called Life
“I read where you don’t suffer comforters lightly, but I have to tell you I was shocked to read about your (prostate) cancer. It doesn’t pay to write a wonderful story like ‘What the Cystoscope Said’ not so long as Aristophanes is God.”
—From a letter from Philip Roth to Anatole Broyard
“God is the greatest comedian but He’s playing to an audience too afraid to laugh.”
—Voltaire
No comedy within miles. All tragedy. It was the day after my experience of reading the Philip Roth review in the New York Times in May of 1985. It was the end of the academic year at the University of Maryland where I had been a staff psychiatrist at the University Health Center for the past four and a half years. It was now two months post-radiation and seven months post-surgery. All I had was dead pelvis on the mind.
I was leading a psychotherapy group, the final one of the semester before the summer break. A couple of students were graduating; a couple of others were finishing up a year or two of treatment and were ready to move on with their lives without therapy. Several others would continu
e in the group in the coming academic year. We were all saying our good-byes.
The group already knew from previous leavings that we had a ritual for these departures. We gave the parting member a psychological gift, and the parting member returned the favor: We shared with that member our appreciations and resentments, our hopes and fears for this patient. We recognized the psychological and emotional accomplishments of this patient in his or her therapy; and we acknowledged the potential psychological pitfalls this patient may face in the future, given his or her specific emotional vulnerabilities. The departing member shared his or her appreciations and resentments about the others in the group, including me.
What a boon, what a reward for all of us. Even in a group that had as its most significant value that of openness and honesty, we could be more open and honest when we are exiting, when we had less fears of inadvertently hurting someone. Just as parents learn the most about parenting from their children, I as a psychiatrist learn the most from my patients—how I could have handled situations differently, what helped and what did not help, what they may have resented about my interactions with them.
Group therapy can be remarkably powerful with young adults, with undergraduates and graduate students. There is no better way to break through shame and self-consciousness, no better way to create an environment of unconditional acceptance, an experience that may never have occurred during some members’ childhoods. There is no better way to recognize that one is not alone, that others are experiencing similar struggles, that others are experiencing seemingly worse problems than one’s own. There is no better way to begin to trust one’s own instincts and beliefs, to recognize one’s own therapeutic capabilities, in helping others as well as oneself, without necessarily having to rely on the therapist, the so-called authority. Students begin to develop their own voice, to recognize their own authority. This evolution of their own voice culminates in their sharing with me and the rest of the group their appreciations and resentments as they leave the group. When a group clicks, it becomes a corrective emotional experience for everyone in the group—and a deeply gratifying experience for me as a psychiatrist.
Not so that day. A brain fog, a blur. Dead pelvis . . . Dead penis . . . Dead pelvis. For the first time in my professional career, I was simply going through the motions. I was unable to compartmentalize, unable to keep my personal problems separate from my work.
One of the students, a Trinidadian woman who had been in the group for over two years, approached me after the ninety-minute session. “Dr. Steinberg, did you forget that I am graduating next week?” she asked quietly and sheepishly and forlornly.
“Oh, my goodness. What was I thinking? Of course I knew you were graduating. I am so, so sorry. I cannot believe that we forgot to share with you our hopes and fears for you and we forgot to hear your feedback. I don’t know what happened to my brain today.” I knew all too well what happened to my brain, to my whole body. I stood there cringing. I could barely stop from cursing at myself.
She did not have to remind me that graduating from the University of Maryland was no small deal to her. She was the first in her family to ever have gone to college and to seek out psychiatric help and to overcome the stigma of psychiatry in her culture. Whatever problems and struggles her family may have had, she was not going to pass it on to the next generation.
She did not have to remind me how seriously I took my work. In the seven years since completing my psychiatry residency, I had come to recognize the profound and almost blind trust that patients place in me—me, a person who was a perfect stranger until that first meeting with them. To hear a student’s emotional distress, to know that he or she has reached the end of his or her tether: It filled me with awe that people had enough faith and confidence in me and my professional abilities to open up about the most shattering and shameful parts of their lives. A public trust that I had never wanted to betray.
I had forgotten to give this young woman a final gift from me and the group. She had not had the opportunity to give her final gift to the group. No closure. The group, for her, had died with barely a whimper.
Despite the diminishing stigma about mental health care in the past twenty-five years, this was still 1985. No one came to a psychiatrist without some trepidation and hesitation. My public trust was to make that experience as comfortable and pleasant and rewarding and beneficial as possible. Abiding by the Hippocratic Oath—“Above all, do no harm”—was not nearly enough. For college students, it was essential that they had a truly constructive and valuable experience. Their lives were very much ahead of them, and it was crucial for them to feel comfortable seeking out further treatment, if necessary, in the future.
Months later, with some bitterness, she let me know that I “must not have cared enough” about her to recognize the milestone of her graduation and the significance of her leaving therapy.
It was one thing for my despair, my dead pelvis, my distractions, to affect me and only me; it was quite another for this despair to have a profound effect on my patients, on Helen, on my daughters. The despair did not come right away, when the pelvis died. No, it came weeks later with the events of everyday life—a simple article in a book review section, a devastating mistake in my day-to-day professional routine. Then I asked, as did Tolstoy’s Ivan Ilyich, “What is this for? . . . Why all this horror? What is it for?”
“You’re a good candidate for a penile implant,” noted my surgeon, not surprised at all by my impotence and dead pelvis. Yeah, just what I need—a piece of plastic with a balloon apparatus stuffed into my penis. Leave my fucking (or non-fucking) penis alone, I wanted to shout into the phone. “I’ll think about it,” I politely replied.
“Boxers box,” said A. J. Liebling. And surgeons? Wind them up and they only do surgery. I needed something different for now. No more surgical interventions. Let everything heal to whatever extent it can from the prostatectomy and the radiation. Let me ponder my predicament for a bit.
Can I use this horror, this despair, this muddle as a call to action? I wanted to do something. But what? My helplessness, and the powerlessness of my physicians, was palpable. My so-called life was a mess.
CHAPTER 6
Mesmerized
“Nothing that befalls anyone is ever too senseless to have happened.”
—Philip Roth
“When a man knows he is to be hanged in a fortnight, it concentrates his mind wonderfully.”
—Samuel Johnson
It was all so retro. In the midst of my confusion and despair and helplessness in the months after surgery and radiation, I turned to the nineteenth century, to Franz Anton Mesmer and to Ivan Pavlov for guidance and mentorship. Unlike Pavlov, however, I was looking for salvation, not salivation.
Mesmer was the Google of the eighteenth century, the first name or noun that became a verb. Just as we might google now, people in eighteenth century Europe became mesmerized. Hypnosis, or mesmerism, played a significant role in the peculiar history of psychiatry, with Mesmer having been one of the earliest influences on Sigmund Freud. In 1779 in his dissertation “Mesmerism: The Discovery of Animal Magnetism,” Mesmer hypothesized that human beings were endowed with a special magnetic fluid, a kind of sixth sense, which when liberated could produce near-miraculous healing effects. Until controversy and charges of quackery curtailed his career, Mesmer claimed to have magnetized and cured hundreds of patients, many of whom would be considered now to have had what we call psychological conversion reactions, such as hysterical blindness and hysterical paralyses.
Had Mesmer helped to heal people with cancers or other deadly illnesses, diseases that now can be defined and delineated by pathology slides and X-rays? No one knows, but several of his disciples were able to use hypnosis or mesmerism as a method of anesthetizing and treating patients in India and England. Had Mesmer been able to see something, this magnetic fluid, that none of the rest of us had been able to see? No one knows.
In his epilogue to War and Peace, Le
o Tolstoy, fascinated with hypnosis, wondered what allowed certain armies to win battles and wars and what allowed various peoples to make major migrations, from west to east or east to west, or, in apocryphal biblical terms, from inside Egypt to an exodus outside of Egypt. Some kind of powerful force might be able to drive us to unimaginable heights. We have all seen it—a force that allows an athletic team to be beautifully synchronized so that the whole is greater than the sum of its parts, and the team achieves more than anyone could have expected.
All I had been looking for was some semblance of control. Helpless, helpless, helpless. Was it possible for me, though, to synchronize all of my efforts, to pull together all of my powers, to have access to my magnetic fluids or sixth sense in order to stay alive as long as possible? To alter the quality of my life in such a way as to regain some semblance of being a sexual being? Could I find a way to create good team chemistry within my body—for all my organs and tissues and cells to be working in a coordinated way—in an effort to live a rich and full life? No self-sabotage allowed. No Freudian death instinct allowed. No self-destruction allowed.
The day before I left the hospital in Manhattan in mid-October of 1984, after the prostatectomy, I called an old medical colleague of mine who was versed in the Simonton approach to cancer treatment. Designing a program to maximize one’s sense of control in the face of abject powerlessness, Carl Simonton, a radiation-oncologist, and his wife Stephanie Matthew-Simonton, a psychotherapist, developed an approach that used mental imagery to help in recovery. Their premise, bizarre in retrospect, was that the cancer patient had caused his own demise and thus had the power to undo his own demise. Yes, blame oneself and blame the victim. The fault is not in the stars but in ourselves.
The Simontons described cancer patients who believed they had somehow “made” themselves ill. Forget about the possibility of simply being star-crossed. We somehow can believe we have complete control over our destiny.
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