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RHO archives : Topics : Men and Reproductive Health

Annotated Bibliography

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General

AVSC (now EngenderHealth). Men as Partners in Reproductive Health: Workshop Report. Mombasa, Kenya (1997).
This report on an inter-regional workshop on men's involvement in reproductive health addresses gender issues and provides a blueprint for creating male reproductive health programs. It includes a section on how to overcome common obstacles, proposes communication strategies, and provides examples of existing services and information on supportive donors.

AVSC (now EngenderHealth) and IPPF/WHR. Male Participation in Sexual and Reproductive Health: New Paradigms Symposium. Oaxaca, Mexico (1998). Summary of the symposium available at: www.engenderhealth.org/ia/wwm/emwksp1.html. The full report can be ordered at no charge at: www.ippfwhr.org/publications/publication_detail_e.asp?PubID=19l.
One of the outcomes of the symposium was the production of three papers—a Symposium Report, a Literature Review and Five Case Studies—which are summarized below:

  • Symposium Report. This report captures the main themes discussed at this meeting of service providers, policy makers, program directors, and donors from countries throughout the Americas. The topics include masculinities, sexualities, prevention of STIs, violence, and fatherhood. This report provides a comprehensive overview of research and program approaches to involve men in sexual and reproductive health in the Americas between 1995 and 1998. It also identifies program and research priorities.
  • Literature Review. This review includes literature on men and reproductive health themes written between 1990 and 1998. Several pages are devoted to adolescent sexuality. The socialization of boys is addressed under "masculinity/ies." Gender and masculinity, sexuality, STIs, HIV and AIDS, masculinity and sexual and reproductive health, violence, and fatherhood are other topics included in the review. The publication contains abstracts of the papers reviewed.
  • Five Case Studies. This document describes five programs in Latin America that involve men in sexual and reproductive health. These are MEXFAM's program to develop education materials that promote discussion about male involvement and Salud Y Gnero's participatory workshops on masculinity and male involvement in Mexico; CISTAC's work in Bolivia that explores masculinities and methodologies for working in male involvement; and  the work of ECOS with men in the workplace in Brazil.

Clark, S., et al. Increased Participation of Men in Reproductive Health Programs. Report for the Royal Ministry of Foreign Affairs, Oslo, Norway (21 February 1999).
This study was commissioned to inform the ICPD+5 process on how to increase men's participation in reproductive health based on the progress and difficulties encountered since the ICPD (1994). It highlights examples of successful trends and promising program innovations as well as areas where progress is lacking. Examples of progress include greater availability of qualitative and representative quantitative data on men, greater use of condoms, and greater donor awareness and support for male participation in sexual and reproductive health. Examples of problems that are yet to be addressed include unanticipated negative impact of some initiatives, low turnout for male sexuality training, unsustained initiatives, lack of institutional memory, and lack of communication among programs. Unresolved issues include concerns about how to address gender in programs that want to encourage men's participation; how to address men's reproductive rights while consolidating and expanding the reproductive health rights of women; whether and how essential it is to serve male clients only by male providers; and how to balance the strategy of treating couples with the needs of individual women and men. The paper concludes with several recommendations for increasing men's participation, such as disseminating successful initiatives in Scandinavia and an extensive list of research activities. It advocates that the highest priority be given to programs for young men in developing countries. An analysis of regional findings is annexed to the report.

Figueroa, J.G. Some Reflections on the Presence of Males in the Reproductive Process. Based on presentations made at the Seminar of Studies on Masculinity, University Programme of Gender Studies, Autonomous National University of Mexico (Figueroa and Liendro) (1994) and at the Seminar on Fertility and the Male Life Cycle in the Era of Fertility Decline, IUSSP, Zacatecas, Mexico (1995).
This paper is a proposal that advocates for the development and adoption of new conceptual and operational frameworks as well as indicators for analysing reproduction, fertility and reproductive decision-making. It illustrates some of the theoretical and practical complexities that arise in integrating men into the reproductive processes. The author's thesis is that reproduction, in its broadest sense, includes gender organization, masculine and feminine identities, and the exercise of sexuality, factors that are ignored in current demography and medicine. He illustrates how men have either been completely ignored in fertility analysis or are considered as another, usually problematic, factor in the fertility of women, the main focus of analysis. Men's fertility is seldom considered. The paper builds a framework in which reproduction is considered as a dynamic process between couples and linked to much broader factors such as socio-economic, political, demographic and cultural differentiations, masculinity and male identity, gender organization and gender roles, and sexuality. The author proposes gender-specific conceptual frameworks for considering men's and women's views on reproduction. The paper also proposes new indicators to measure men's fertility and wanted pregnancies—for instance, an individual's reproduction rate, estimating the average number of live born children per male, and the average number of children conceived by common accord.

Foumbi, J. and Lovich, R. Role of Men in the Lives of Children. New York: UNICEF (1997).
This background paper is part of an ongoing effort to better understand the role that men can play in the lives of children and women. UNICEF's support of activities that focus on men and boys is presented. The paper includes lessons learned and suggestions for the design and evaluation of programs that seek to enhance the positive role of men in the lives of children and to achieve balanced roles and responsibilities within households.

Ndong, I. and Finger, W.R. Male responsibility for reproductive health. Network 18(3) (1998). Available at: www.fhi.org/en/fp/fppubs/network/v18-3/nt1831.html).
In their introduction to this issue of Network, Ndong and Finger provide an overview of key elements in men's involvement in reproductive health. They include program priorities such as encouraging men to support women's contraceptive choices, increasing communication between partners, increasing the use of male methods, involving men in the prevention of STIs, addressing men's reproductive health needs, and encouraging men to become more aware of related family issues and overcoming client and provider biases.

Raju, S. and Leonard, A., eds. Men as Supportive Partners in Reproductive Health: Moving from Rhetoric to Reality. Population Council (2000). Available at: www.popcouncil.org/pdfs/menaspartners.pdf).
This publication summarizes 20 case studies on male involvement in India. It provides a wealth of information on the practical aspects of involving men in reproductive health programs. The case studies emphasize partnership between men and women with the objective of improving women's reproductive health, decreasing maternal morbidity and mortality, and improving child welfare. The document includes a discussion of common findings and recommendations for future actions.

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Men's influence on women's health

Abdel-Tawab, N. et al. Counseling the Husbands of Postabortion Patients in Egypt: Effects on Husband Involvement, Patient Recovery and Contraceptive Use. Final report. Population Council, Asia and Near East Operations Research and Technical Assistance Project, Cairo, 1997 December [12], 35 pages. (USAID Contract No. DPE-C-00-90-0002-10).
This study in Egypt evaluated the impact of counseling husbands of abortion clients on their level of support postabortion. The main education and counseling themes for the husbands included (1) the woman's need for rest and nutrition, (2) postabortion warning signs, (3) return to fertility with two weeks, and (4) the need for family planning. The overall impact of the counseling was small, but among subgroups there were some significant effects. For example, among couples with no female members at home to help in the recovery process, the husbands who received counseling were significantly more likely to provide a high level of support to their wives. The counseling was acceptable to both husbands and wives. It was concluded that, as long as the woman's right to privacy is protected, counseling of husbands should be included in postabortion care services.

Berer, M. Men. Reproductive Health Matters. Number 7: 7-10 (May 1996).
This introduction to a compilation of articles on men and reproductive health summarizes key issues related to the topic. The commentary raises questions about the rationale for involving men, men's power as decision-makers, strategies for involving men, and balancing women's needs versus men's needs. The author also provides insight regarding what women want from men related to sexuality and reproductive health.

Bhalerao, V.R. et al. Contribution of the education of the prospective fathers to the success of maternal health care programme. Journal of Postgraduate Medicine 30(1):10-12 (January 1984).
This study evaluated the role of involving prospective fathers in the care of pregnant women attending a clinic in Bombay, India. Beginning in October 1982, pregnant women attending the Clinic were requested to ask their husbands to meet with the resident medical officer of the center. The outcome of the maternal health care program for the 270 women whose husbands were invited and came (Group 1) was compared with the outcome of the same program for 405 women whose husbands could not be invited (Group 2). The husbands who attended the center were educated individually and in groups about their role in nutrition and health of their wives during pregnancy and their responsibility in subsequent child rearing. The physiology of pregnancy, complications of pregnancy, and the possible ways and means of preventing the complications were explained in detail. The husbands also were told to encourage their wives to attend the antenatal clinic of the center as often as possible. The main difference between the two groups was a significantly lower perinatal mortality in Group 1. Furthermore, more women in Group 1 accepted postpartum sterilization than women in Group 2. This effort confirms that the involvement of prospective fathers is possible and pays good dividends even in an uneducated and low socioeconomic community.

de Schutter, M. "Men and Women's Sexual and Reproductive Health Needs: Competition for Limited Resources or Shared Concerns?" Pan American Health Organization/World Health Organization. Paper presented at AWID Conference Panel on "Male Involvement in Sexual and Reproductive Health: Hindrance or Help to Gender Equity?" (November 12, 1999).
This presentation examined the question of how to balance men's and women's health needs and interests, given that resources are limited and needs are abundant, including whether the criteria currently exist to set priorities in this area. The author examined current gender inequities and women's disproportionate burden in sexual and reproductive health, particularly in the LAC region. For instance, the current contraceptive use ratios clearly show gender inequities. Given that women bear most of the burden of sexual and reproductive ill health, the author called for special, separate health services for men. The author also questioned the ability of health sector reforms to provide opportunities for including men's needs and men's role as partners without taking away much-needed resources from women's health, given the lack of emphasis on health promotion and prevention, both key strategies in the work with men. The author identified gaps in the research regarding the benefits of involving men in reproductive health programs. The author concluded that, given limited financial and human resources and data that document proven successful strategies with men, at present it is difficult to commit fully to men's health.

Fisek, N.H. and Sumbuloglu, K. The effects of husband and wife education on family planning in rural Turkey. Studies in Family Planning 9(10-11):280-285 (October-November 1978).
The authors studied the effects of a comprehensive program of family planning education on the knowledge, attitudes, and practice of rural married couples of reproductive age in Turkey between June 1974 to May 1976. Data from a baseline survey were used to assign each of 33 villages to a husband-wife education group, a wife-only education group, or a control group. The groups were similar in terms of (1) the use of effective contraceptive methods, (2) the educational level and age distribution of the women, and (3) the number of surviving children. The information presented to the wives was designed to overcome specific factors that hindered contraceptive use. The emphasis for the husbands was on the adverse effect of high fertility for the family and for the nation. Data collected by auxiliary nurse midwives and in beginning, middle, and end-of-study surveys revealed a significant increase in acceptors in both study groups, with a greater increase in the husband-wife group and a corresponding decrease in discontinuation rates. Measurable changes in attitudes occurred, but these were not statistically significant. The educational activities of this program were absorbed into the regular duties of the district family planning staff; the cost otherwise would have been $25.80/husband and wife/year and $16.50/wife/year. The husband-wife group showed a significant increase in contraceptive use in the second year. The results of this study reveal the importance of continuous and routine involvement of men in family planning education.

Greene, M.E. "The Benefits of Involving Men in Reproductive Health." Presentation at the meeting of the Association for Women in Development (Draft) (November 1999).
This analysis looks at how men are being involved in reproductive health and the potential benefits to themselves and others of doing so. The benefits of involving men in reproductive health largely are determined by how programs are involving them. This paper provides examples of the types of male involvement efforts with the greatest potential for promoting gender equity. The analysis concludes that policies that promote gender equity serve the interests of men as well as women, as they increase men's choices and their possibilities for learning and development, as well as the survival and happiness of family members, and they combat the negative aspects of socially constructed aspects of masculinity. The equal participation of men in sharing power over reproductive decision-making and in creating healthy and responsible sexual relationships with their partners also is seen as both a means to promoting women's rights and gender equity, and an end in itself.

Helzner, J.F. Men's involvement in family planning. Reproductive Health Matters 7:146-154 (May 1996).
This article looks at the issue of men's involvement in family planning from a gender perspective. The author discusses the importance of taking into account the interplay between men's and women's roles, rather than focusing on women's situation (or men's) alone, with the aim of increasing equality between men and women. The author examines the gender dynamics of contraceptive methods and other issues of male control related to women's reproductive health. The article cautions against implementing men's involvement programs that result in worsening existing male dominance.

Hunter, D.J. et al. Sexual behavior, sexually transmitted diseases, male circumcision and risk of HIV infection among women in Nairobi, Kenya. AIDS 8(1):93-99 (1994).
This cross-sectional case-control study looked at risk factors for HIV infection among 4,404 women in Nairobi, Kenya. Data were gathered using structured questionnaires and clinical testing for various STIs. Two hundred and sixteen women (4.9%) were HIV-1-positive. Although risk of HIV was significantly increased among unmarried women and among women with multiple sex partners, most seropositive women were married and reported only a single sex partner in the last year. Women with a history or current evidence of STI were at significantly increased risk; the prevalence of these exposures was low, however. Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV. Only 5.2 percent of women reported ever having used a condom. These data suggest that, among women who are not in high- risk groups, risk of HIV infection is largely determined by their male partner's behavior and circumcision status.

Padian, N.S. et al. Heterosexual transmission of human immunodeficiency virus (HIV) in northern California: results from a ten-year study. American Journal of Epidemiology 146(4):350-357 (August 15, 1997).
To examine rates of and risk factors for heterosexual transmission of human immunodeficiency virus (HIV), the authors conducted a prospective study of infected individuals and their heterosexual partners who have been recruited since 1985. A total of 82 infected women and their male partners and 360 infected men and their female partners were enrolled. Over 90 percent of the couples were monogamous for the year prior to entry into the study; fewer than 3 percent had a current sexually transmitted infection (STI). Overall, 68 (19%) of the 360 female partners of HIV-infected men (95% confidence interval [CI] 15.0-23.3%) and two (2.4%) of the 82 male partners of HIV- infected women (95% CI 0.3-8.5%) were infected. History of STIs was most strongly associated with transmission. Male-to-female transmission was approximately eight-times more efficient than female-to-male transmission and male-to-female per contact infectivity was estimated to be 0.0009 (95% CI = 0.0005-0.001). Infectivity for HIV through heterosexual transmission is low, and STIs may be the most important cofactor for transmission.

Tapsoba, P. et al. "Involving Husbands to Increase the Acceptability of Norplant in Antananarivo, Madagascar." Paper presented at the 121st Annual Meeting of the American Public Health Association, San Francisco, California, October 24-28, 1993, 12 pages (1993).
This study conducted at two family planning clinics in Madagascar from December 1989 to December 1991 investigated whether involving husbands in Norplant counseling and education had an impact on method continuation and acceptability. Clients choosing Norplant self selected into two groups, those including and those excluding husbands in counseling activities. Clients with no preference were randomly assigned to a group. Some 496 clients were recruited during the study period. Husband involvement led to lower discontinuation rates (2.3 percent among husband counseled couples versus 8.2 percent among others). Husbands who had received counseling were less concerned about the side effects of the method and the majority of counseled husbands and their wives reported being satisfied with the method.

Terefe, A., et al. Modern contraception use in Ethiopia: does involving husbands make a difference? American Journal of Public Health 83(11):1567-1571 (November 1993).
This study was undertaken to determine the relative efficacy of home visitation with and without husband participation on the use of modern contraception in Ethiopia. A randomized field trial of a family planning education intervention using home visitation with and without husband participation was conducted in Addis Ababa, Ethiopia, from August 1990 to December 1991 and included a 12-month postintervention follow-up. A total of 266 experimental and 261 control subjects were entered, of whom 91.7 percent and 88.9 percent, respectively, were followed through 12 months. A greater proportion of couples in the experimental group were practicing modern contraception at 2 months (25% versus 15%) and 12 months (33% versus 17%) following home visits intervention. By 12 months, experimental subjects were less likely to have defaulted and more likely to have started using modern contraception following an initial delay. The inclusion of husbands in family planning programs will result in relevant increases in the use of modern contraception. Researchers noted that there was a post-education delay of greater than 2 months in the initiation of modern contraception for most couples.

Wang, C.C. et al. Reducing pregnancy and induced abortion rates in China: family planning with husband participation. American Journal of Public Health 88(4) (1998).
This study examined the impact of educating both the wife and the husband about family planning on reducing pregnancy and induced abortion rates in China. Data were obtained from a systematic random sample of women of reproductive age working in 21 factories in Shanghai. 1,800 nonsterilized married women were selected from 27 work units. The intervention differed from the usual family planning programs in that it provided education to women on-site and included education for husbands. Education stressed communication between spouses, sharing responsibility for contraception, and appropriate timing of abortions. The intervention was conducted from January 1991 to September 1992. The odds of pregnancy and abortion were lowest, but not significantly, among women who participated in the education with their spouses. Women using IUDs and receiving the educational intervention with their spouses were significantly less likely to experience a pregnancy and abortion than other subgroups (the educational intervention alone or usual family planning care).

World Health Organization (WHO). Men's role in improving reproductive health. Progress in Human Reproduction Research 47 (1998). Available at: www.who.int/reproductive-health/hrp/progress/47/news47_1.en.html#3.
This brief article highlights the importance of male involvement for the improvement and protection of sexual and reproductive well-being of both men and women. It explores the challenges that face researchers, including the determination of appropriate services for men, the need for contraceptive methods for men, and the importance of gender-sensitive agendas. The authors conclude that research into these issues is necessary if gender inequity is to be overcome.

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Impact of couple counseling

Becker, S. Couples and reproductive health: a review of couple studies. Studies In Family Planning 27(6):291-306 (November-December 1996).
This article reviews studies that collected and matched data from both sexual partners on objective reproductive events, attitudes, and intentions, as well as studies that assessed the effectiveness of interventions that targeted couples. For actual reproductive events (e.g., number of live births, ever-use of contraception, years married, abortions), identical responses to the same question occurred less than 90 percent of the time. With respect to fertility and family planning attitudes and intentions, partner concordance was in the range of 60-70 percent. Reproductive health interventions targeted at both partners have resulted, in most cases, in higher rates of contraceptive use and are especially important to reducing transmission of sexually transmitted diseases, including AIDS. The author concludes that couples are the most appropriate focus for reproductive health programs, but acknowledges that costs of program expansion and other issues must be addressed.

Becker, S. and Robinson, J.C. Reproductive health care: services oriented to couples. International Journal of Gynecology and Obstetrics 61(3):275-281 (June 1998).
This paper outlines possible approaches to integrating couples into the following clinical services: sexual health, sexually transmitted diseases, contraceptive sterilization, contraception, infertility, obstetric care and breast feeding, infant health, and abortion. Implementation of a couple approach to reproductive health services requires that family planning clinics become more "couple-friendly" and health care professionals are trained to examine and care for both men and women. Culturally sensitive operations research on interventions that promote couple participation in contraception is needed. In traditional patriarchal cultures, such an approach has the potential to increase men's involvement as a cooperating participant rather than a domineering patriarch.

Karra, M.V. et al. Male involvement in family planning: a case study spanning five generations of a South Indian family. Studies in Family Planning 28(1):24-34 (1997).
This study examines male involvement in family planning practice and decision making in one Indian family over five generations. Data were collected from 152 living family members: information about an additional 26 members who were deceased or unavailable for interview were gathered using interviews with their children and siblings. The majority of the contraception used in this family consisted of male methods (condoms, vasectomy, natural family planning), particularly among older generations who had limited access to methods for women. The participation of men in this family was not necessarily dependent upon changes in gender relations, such as increased spousal communication. Many men in the family reported being motivated to use male methods by external factors, such as desire for the improved economic status of a smaller family.

Renne, E.P. Gender ideology and fertility strategies in an Ekiti Yoruba village. Studies in Family Planning 24(6):343-353 (November-December 1993).
This case study from Nigeria examines the effects of gender ideology—beliefs about the nature of women and men and their appropriate behavior in society—on reproductive decision making. Despite the persistence of a strong gender ideology emphasizing men's authority over women and traditional beliefs discouraging couple communication about reproductive matters, the research found that many couples discuss family size preferences and contraceptive use. The increased reporting of couple communication about these issues compared with previous research was attributed to higher educational attainment of women and increased availability of contraceptives.

Salway, S. How attitudes toward family planning and discussion between wives and husbands affect contraceptive use in Ghana. International Family Planning Perspectives 20(2):44-47 (June 1994).
Data on 661 married couples obtained from the 1988 Ghana Demographic and Health Survey were analyzed to examine the attitudes and preferences of couples toward family size, family limitation, and contraceptive use as well as the degree of communication and discussion between husbands and wives. Both the husband and wife in 77 percent of couples shared like attitudes toward family planning: 73 percent approved of family planning. Yet 39 percent of the wives either did not know or misreported their husband's attitude. Even though 76 percent agreed that they wanted no more children, only 44 percent reported the same responses on ideal family size. Only 35 percent of wives and 39 percent of husbands who knew at least one contraceptive method had talked to their spouse about family planning in the last 12 months. Significant independent variables of current contraceptive use included urban residence (RR = 1.53; P < 0.01), wife's attitude toward family planning (RR = 8.85; P < 0.01), and discussion of family planning between spouses (RR = 2.15-2.17; P < 0.01).

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Impact of gender role expectations on men's health

Barker, G. and Loewenstein, I. Where the boys are: attitudes related to masculinity, fatherhood, and violence toward women among low-income adolescent and young adult males in Rio de Janeiro, Brazil.Youth and Society 29(2):166-196 (1997).
Qualitative research with 127 low-income young men and women (ages 14 to 30) in Rio de Janeiro found rigid gender roles with males displaying widespread machista values. Males viewed violence toward women as acceptable in many circumstances, with more widespread violence against women reported among youth who live in low-income, marginal areas of the city. The research also identified a small but important minority of progressive males who questioned traditional machista attitudes. In focus group discussions, more progressive males were frequently criticized by machista males. Individual in-depth interviews found that being able to question predominant machista values was related to having a meaningful relationship with a role model who promoted nontraditional gender roles. The research highlights important ways of working with adolescent males to encourage more flexible gender roles. The paper also includes a literature review of research on the social construction of masculinity in Brazil.

Figa-Talamanca, I. et al. Effects of prolonged autovehicle driving on male reproductive function: a study among taxi drivers. American Journal of Industrial Medicine 30:750-758 (1996).
This study of taxi drivers in Rome was designed to test the hypothesis that exposure to factors such as prolonged sitting, exhaust, and excessive heat might adversely affect the reproductive health of these workers. Researchers interviewed 201 taxi drivers and took biological samples from 72 subjects. These were compared with samples from 50 control subjects from a variety of occupations. Compared to controls, taxi drivers had a significantly lower prevalence of normal sperm (45.8% versus 64.0%). The association was stronger with increased time on the job.

Foreman, M. (ed.). AIDS and Men: Taking Risks or Taking Responsibility. London: Panos Institute (1999).
This 250-page book contains contributions from Mexico, Tanzania, Ghana, Uganda, Kenya, Russia, Brazil, Malawi, Thailand, Ivory Coast, and Bangladesh. In every country, the behavior of men drives the HIV/AIDS epidemic. Men tend to have more sexual partners than women—and therefore more opportunity to contract and transmit the virus. Men generally decide the frequency and form of intercourse—and many men refuse to use condoms or to have fewer sexual partners. Men's behavior is frequently determined by cultural norms that identify masculinity with sexual prowess; in many cultures to "be a man" is to have frequent sexual intercourse, often with more than one partner. Men's behavior also is associated with risk, such as using drugs or refusing condoms.

Keleher, K.C. Occupational health: how work environments can affect reproductive capacity and outcome. Nurse Practitioner 16(1):23-34, 37 (January 1991).
This comprehensive review describes occupational hazards to both male and female reproductive health. Occupations with potential risks to men include autoworkers, ceramic and pottery makers, painters, agricultural workers, and laborers involved in the manufacture of medicines, dyes, and other organic compounds.

Khan, S. South Asian male sexual behaviours and their impact upon male children and youth. Naz KiI Pukaar 21:14-17 (April 1998).
Male-to-male sex is widespread and routine in South Asia across all socioeconomic categories and areas of residence. To ensure that girls remain virginal until married, young men and boys are routinely segregated from young women and girls. Extremely close, affectionate bonds of friendship and intimacy among males are instead created, sanctioned, and even encouraged by society. Friendship and intimacy between males extends into male-to-male sex play and the release of sexual energy. Considerable male-to-male sexual behavior occurs in family environments between uncles and nephews, cousins, friends, and brothers.

Kootikuppala, S.R. et al. Sexual lifestyle of long distance lorry drivers in India: questionnaire survey. British Medical Journal 318(7177): 162 (January 16, 1999).
This study investigated the sexual lifestyle of long distance lorry drivers in India, who have much higher rates of HIV infection than the general Indian population. A questionnaire was administered to a total of 5,709 long distance lorry drivers passing through a check post between March 1994 and August 1994. 87 percent of subjects (4,949 men) reported having multiple sexual partners; only 11 percent of these men (563) used condoms during commercial sex. The percentage using condoms decreased with increasing age. In the 21-30 age group (n = 1,766), 78 percent of unmarried sexually men with multiple partners (331/425) reported having 31-60 sexual partners during the past 12 months. Almost half of subjects (2,714; 47%) drank alcohol daily early in the morning. A significantly higher proportion of men over 40, compared with men under 21, had multiple partners and misused alcohol and a lower proportion had AIDS knowledge.

Moynihan, C. Theories in health care and research: theories of masculinity. British Medical Journal 317:1072-1075 (October 17, 1998) Available at: www.bmj.com/cgi/content/full/317/ 7165/1072).
This article presents a sociological view of masculinity. The author examines various theories of masculinity and gender stereotypes and discusses the ways in which these views of masculinity affect both men's use of health services and treatment by the medical community. Specific examples include men's feelings related to loss of sexual organs after treatment for testicular cancer.

Rani M, Figueroa ME, Ainsle R. The psychosocial context of young adult sexual behavior in Nicaragua: looking through the gender lens. International Family Planning Perspectives. 2003;29(4):174-181.
This article reviews gender norms among young adults in Nicaragua and how these norms affect their sexual and health-seeking behaviors. The study surveyed 552 never-married women and 289 never-married men, aged 15 to 24, about their perceptions of social pressure to engage in premarital sex; attitudes toward premarital sex and premarital pregnancy; perceived sexual activity among peers and siblings; communication with parents on sexuality issues; the psychosocial context of sexual debut; and preferred sources of information on sexuality issues. Most young men (83%) reported that they had received direct encouragement from at least one person in the last year to engage in premarital sex, and at least half perceived that their father, siblings, other relatives, and friends approved of premarital intercourse. In contrast, women held more negative attitudes toward premarital sex and were more often discouraged by parents or siblings from engaging in sex. In conclusion, reproductive health programs for young Nicaraguans need to address gender-based double standards, which raise the risk of unplanned, unprotected sex and unintended pregnancy.

Rappaport, B.M. Family planning: helping men ask for help. In: Men's Reproductive Health. Swanson, J.M. and Forrest, K.A. (editors). New York: Springer, 245-259 (1984) (Springer Series: Focus on Men, Vol. 3).
This chapter examines the experiences of the staff of New Ways in Health Education in conducting men's programs. The key problem in developing health programs for men is with the pervasive, rigid roles in which men are placed almost from birth. The lack of male involvement in family planning is part of an overall failure to involve men in health care programs in general. Strategies for outreach to men generally have fallen within four groups: no strategy (simply opening a clinic and waiting for male clients), female model (using a successful female recruiting method to recruit males), macho modeling (endorsement of male involvement in contraception by highly regarded figures) and the male oppression strategy (focusing on the idea that men are as oppressed as women). These approaches have been ineffective and simply promote the rigid adherence to the male role that undermines the ability to involve men in caring and responsible roles in their sexual relationships. A new strategy involves two key assumptions: that the full involvement of men in family planning would be of enormous value to everyone concerned, and that while women bear the greater burden of the rigid sex-role expectations in this society, men also are hurt by these roles. The chapter provides examples of programs dealing with partners of abortion clients, teenagers, and men concerned about infertility and presents special techniques for counseling men.

Ratcliffe, J. et al. Semen quality in papaya workers with long term exposure to ethylene dibromide. British Journal of Industrial Medicine 44:317-326 (1987).
This study compared sperm characteristics of 46 men exposed occupationally to ethylene dibromide with 43 non-exposed men. The analysis controlled for potentially confounding factors such as smoking, caffeine and alcohol consumption, age, and history of urogenital disorders. Significant differences in sperm count, viability and motility, and morphology were found. The exposure levels of the men studied were near or well below recommended maximum levels.

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