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Before the sexual revolution initiated by the pill, men were a more integral part of
family planning and other reproductive health concerns than they are today. If a couple
wished to use contraception, their options were limited primarily to methods requiring a
man's participation -- withdrawal, periodic abstinence or condoms.
Hormonal methods for women, beginning with the first oral contraceptives in 1960, and
the subsequent development of intrauterine devices and modern surgical sterilization, led
to the development of a family planning services community focused on women, often to the
exclusion of men. Today's challenge, as expressed by the 1994 International Conference on
Population and Development (ICPD) held in Cairo, is to enhance male responsibility for
family planning by expanding services in ways that protect the reproductive health of both
men and women, and by encouraging greater sensitivity to gender issues.
Some fear that adding services for men will result in fewer resources available for
women, who currently bear most of the responsibility for family planning and other
reproductive health concerns. "The idea of services for men is to add and not to
subtract," says Maria Isabel Plata, director of the Asociación Probienestar de la
Familia Colombiana (PROFAMILIA) in Colombia, which has pioneered services for men since
1985, when its first clinics for men opened. Today, PROFAMILIA clinics offer a range of
male reproductive health services, in addition to providing such male contraceptive
options as vasectomies. "We never have been interested in subtracting from our
services -- what we need is to do more. We do this by looking into what we have, what we
can use better, where the empty space is, and how to use what we now have more cost
efficiently and with more client orientation. The first thing is to ask clients what they
want."
While PROFAMILIA and a few other successful programs have found ways to encourage male
participation, "a huge gap remains between the rhetoric of promoting male involvement
and the realities of female-oriented reproductive health programs," says Errol Alexis
of the New York-based Margaret Sanger Center International, who has worked with men and
youth for 20 years in the Caribbean, Africa and the United States.
One major obstacle is men's reluctance to use services. Men know little about their own
or women's sexuality, communicate about sexuality very little in their relationships, and
often believe many sexual myths, says Alexis. "Many men are suspicious of family
planning programs because they see them as a conspiracy to undermine their power."
Providers must also overcome false assumptions and generalizations about men. It is
easy to say that men always want more children, are not interested in using contraception,
do not care about spreading sexually transmitted diseases (STDs), never share in
responsibility of raising children, and perpetuate violence against women. Some programs
have been designed on these assumptions and therefore exclude men routinely, preventing
men from getting help to understand their needs and to change harmful behaviors. Yet
surveys show that as men learn about contraception, they want to use it, and as pressures
of raising large families increase, they want fewer children.1
In nearly any country or culture, there are men who share in parenting responsibilities
and who stand against violence against women.
In a larger context, "gender equality" must be achieved. As used in the
ICPD's Programme of Action, this term refers to an equality in the roles and
responsibilities assigned to men and women by society, roles that influence all aspects of
life. Providers and health officials should emphasize interdependence and mutual benefits
from serving both sexes, not focusing exclusively on one at the expense, ultimately, of
both.
Program directions
To serve men better, programs need to reconcile conflicting opinions and views about
men and reproductive health. As part of this effort, the U.S. Agency for International
Development (USAID) recently established a Gender Working Group, with participation from
its cooperating agencies and others working in the international reproductive health
field. The group has four committees that are examining issues related to gender and
reproductive health. One is the Men and Reproductive Health Committee, co-chaired by the
authors of this article.
In the initial meetings of this committee, representatives from more than 20 agencies
have discussed inclusive approaches that can serve men's and women's needs, and can
contribute to gender equity. From these informal discussions, here are six general goals
to consider when designing programs to address men and reproductive health, within the
context of gender equity:
Encourage Men to Support Women's Contraceptive Choices. One of the frequent
reasons given by women for not beginning or continuing to use contraception is their
partner's opposition. Men who are educated about reproductive health issues are more
likely to support their partner's decisions and to encourage public policies that result
in women receiving the reproductive healthcare they need. A project in rural Mali
addressed this goal by using men to promote family planning in local communities. Many
women reported that male community workers had changed their husbands' attitudes towards
family planning and had generated more open communication between spouses about family
planning.2
Increase Communication Between Partners. When reproductive health decisions are
taken jointly by both partners, these decisions are more likely to be implemented. Men
become more supportive by helping their partners to receive reproductive health services
when needed and by providing the resources needed to obtain these services. A 1994 family
planning campaign in Bolivia sought to increase communication, using the slogan,
"Let's talk together." During the promotion, the number of new contraceptive
users and the number of men reporting their intention to seek reproductive health services
increased dramatically.3
Some women become pregnant only because they believe their husbands want more children.
But this may not always be true. Surveys in several developing countries show that only
slightly more men than women want to have another child. Increased communication between
partners improves understanding of each partner's reproductive preferences and decreases
some of the consequences of poor communication, such as unintended pregnancy and a large
family size.
Increase the Use of Male Methods. Increased use of male methods will relieve
some of the burden of contraception that currently is placed on women. Some programs are
using creative promotional campaigns for vasectomy, which may expand use of this safe and
effective method. "Policy-makers and service providers have alleviated men from
responsibility for using existing male methods, for example, by focusing attention on
female sterilization, even to the detriment of successful vasectomy programs,"
explains Dr. Karin Ringheim of USAID in an analysis of gender issues that influence
contraceptive choices.4 As condom use increases in the AIDS
era, more family planning providers are offering condoms as a contraceptive choice for
those at high risk of STDs. Unfortunately, there are few methods currently available for
men, and research on new male methods continues at a slow pace.
Improve Men's Behavior for the Prevention of STDs. The effect of men's attitudes
and behaviors with respect to women's health is perhaps most evident in STD prevention and
treatment. For prevention programs to be effective, they need to educate and treat both
partners. Increasing condom use and changing high-risk sexual behaviors are primary STD
prevention strategies. Where condoms have been heavily promoted by social marketing
campaigns, condom use has gone up markedly. Increasing condom use is a step toward
changing men's behavior in a way that directly affects their own health, as well as the
health of their partners and wives. But surveys show that condom use is much higher
outside of marriage than with spouses, and wives with little power to negotiate condom use
can be infected by husbands.
Address Men's Own Reproductive Health Needs. Access to reproductive health
services should be an issue of human rights for both women and men. Men have their own
reproductive health problems beyond family planning and STD services, such as infertility,
sexual dysfunction, prostate cancer and testicular cancer. A lack of services to address
these needs contributes to stress, anxiety and loss of self-esteem among men. "Men,
like women, face different issues at different stages of their life cycle," says
Jeffrey Spieler of USAID, a specialist on male reproductive health. "A critical time
is during the younger years, when boys go through a lot of gender identification and
modeling. Doing a better job of counseling boys and young men through proper sex education
programs could help address a lot of issues that emerge later in the life cycle."
Encourage Men to Become More Aware of Related Family Issues. Men need to be more
involved in raising children, in encouraging schooling for both girls and boys, in
reducing violence against women and children, and in making resources available to meet
the needs of the family. These are complex, deeply ingrained cultural issues, and in many
settings, family concerns are closely linked to family planning and reproductive health.
In one program in rural Uganda, for example, more male clients visit the family planning
clinic during the season when school fees are due, says a nurse, because that is when
"men finally understand the burden of having many children, a burden that women have
understood since before a child is born."5
Overcoming biases
The strategy of complementary male and female services requires many elements to
succeed, including a provider's recognition of his or her own personal values about gender
equity, and how these values might result in biases toward men or women.
One exercise, developed by the Margaret Sanger Center International and International
Planned Parenthood Federation, seeks to help people understand their personal values by
offering a number of statements to which each person responds. Groups can share these
comments to help clarify a group's gender values. For example, one statement says: "A
man should be expected to be present at the birth of his child." In some cultures,
men are forbidden from being present during birth. In other places, including the United
States, a man's presence during birth is encouraged as a way to enhance the parents'
appreciation of this important event. Many provocative concepts are raised in this
exercise: whether unmarried men have a right to multiple partners; whether every male
involvement program should be evaluated in terms of how it can improve women's health; and
whether a woman's use of contraception without her husband's knowledge is a violation of
trust.
Responses to these statements will reflect a wide range of personal values, shaped by
cultural, educational and professional experiences, and clearly influenced by one's
gender. Those who work in the field of reproductive health have an obligation to evaluate
their personal viewpoints carefully. Understanding personal opinions about gender-related
issues is a fundamental step toward better services. With these insights, we are better
prepared to make vital decisions that may have profound implications on the lives of many
men, as well as many women.
-- Dr. Isaiah Ndong and William R. Finger
Dr. Isaiah Ndong worked in general practice in his native Cameroon before joining
AVSC International as a medical associate and a team member of the Men as Partners
Initiative. He and William R. Finger, a Network senior science writer/editor, co-chair the
Men and Reproductive Health Committee of the USAID Gender Working Group.
References
- Ezeh AC, Seroussi M, Raggers H. Men's Fertility,
Contraceptive Use, and Reproductive Preferences - DHS, Comparative Studies No. 18.
Calverton, MD: Macro International, Inc., 1996.
- Kak LP, Signer MB. The Introduction of
Community-based Family Planning Services in Rural Mali: The Katibougou Family Health
Project. CEDPA Working Paper No. 2. Washington: Centre for Development and Population
Activities, 1993.
- Valente TW, Saba WP, Merritt AP, et al. Reproductive
Health Is in Your Hands: Impact of the Bolivia National Reproductive Health Program
Campaign. IEC Field Report No. 4. Baltimore: The Johns Hopkins Center for
Communication Programs, 1996.
- Ringheim K. Whither methods for men? Emerging gender
issues in contraception. Reprod Health Matters, 1996 No. 7:79-89.
- AVSC International, Busoga Diocese's Family Life
Education Program. Reaching Men in Uganda: A Case Study of the Busoga Diocese's Family
Life Education Program. (New York: AVSC International, 1997) 10.
For more information, visit Family Health International's Website at www.fhi.org
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