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RHO archives : Topics : Men and Reproductive Health

Annotated Bibliography

This is page 3 of the Men and Reproductive Health Annotated Bibliography. This page contains:

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Dual protection

Bankole, A., and Singh, S. Couples' fertility and contraceptive decision-making in developing countries: hearing the man's voice. International Family Planning Perspectives 24(1) (1998).
This study examined the reproductive preferences and behavior of married men and their wives in 18 developing countries. Its objectives were to understand the role of husbands in reproductive decision-making. The authors analyzed DHS collected between 1990 and 1998 in eighteen developing countries, thirteen in Sub-Saharan Africa, two in North Africa, two in Asia, and one in Latin America. The study considers childbearing goals, whether reproductive goals differ in polygamous versus monogamous marriages, how contraceptive knowledge translates into reproductive behavior, fertility intentions, and contraceptive use. The study's findings are informative and in some cases raise further questions or suggest that more work is needed to understand gender differences in reproductive preferences and behavior. For instance, findings indicate that husbands and wives differ in their fertility goals, and that these differences and their importance regarding reproductive behavior vary across countries and regions. Results show a difference between Sub-Saharan Africa, where couples are more likely to agree on having another child than to stop childbearing, while the opposite is true in Asia, Latin America, and Africa. The study also found that the preference for smaller families tends to occur first among wives and determines husbands' roles in achieving smaller families. Inconsistency in spousal reporting of contraceptive use was found to be evident in all 18 countries included in the study.

Cates, W., et al. Dual vs. Duel(ing) Protection against Unintended Pregnancy and Sexually Transmitted Infections: What Is the Best Contraceptive Approach? Family Health International. (Submitted for publication).
This paper advocates for the use of dual protection that is, use of family planning methods that protect against STIs and unintended pregnancies. It recognizes, however, the dilemma providers face in choosing a single or two-method dual-protection approach. The authors review the advantages and disadvantages of each approach. The two-method dual-protection approach promotes the use of contraceptive methods that are highly effective in pregnancy prevention (sterilization, implants, injectables, IUDs) in conjunction with the condom, which is highly effective at preventing STIs. Arguments against this approach include the difficulty of motivating people to use two approaches, the fear that adding a second method will impair consistent use of the first, concern about stigmatizing the condom by promoting it as a method that prevents disease, and the costs of promoting two methods. The single-method approach relies on the condom to protect against pregnancy and disease. The authors grapple with the consequences of contraceptive failure, the primary drawback of this approach, and suggest that clinicians tailor their counseling messages to individual client's need and motivations.

John Hopkins University School of Public Health. Closing the condom gap. Population Reports, Series H, No. 9 (April 1999).
This issue of Population Reports provides extensive data on current condom use, the effectiveness of condoms as a contraceptive and in preventing STIs, why more people don't use them, and what programs can do to promote condom use (i.e. create a positive image of condoms, change attitudes, improve access, and provide counseling). An extensive part of the report is devoted to AIDS and STI prevention. It includes data on knowledge about AIDS and about the condom's role in preventing AIDS. Two pages are devoted to protecting young people and the lessons learned from sex education and condom distribution programs. Information about female condoms, recent improvements in condom design, and new barrier methods under development also is provided.

Marcham, C. et al. Dual Protection: Reappraising the Condom as Contraception. WHO, Department of Reproductive Health and Research (background document for a meeting held in October 1999).
This discussion paper was prepared for a WHO consultation intended to build a better understanding and a closer alliance between family planning and STI/HIV prevention activities. It begins by providing a historical background of the shift reproductive health programs have been forced to make as a result of the AIDS epidemic in terms of including STI/HIV prevention in the scope of services they provide. The paper addresses the confusion surrounding dual protection and clarifies some of the perplexities by defining the "dual method-dual purpose" and "single method-dual purpose" approaches. The paper advocates for the integration of pregnancy prevention and STI services and supports the condom, when used consistently and correctly, as the only method that protects against STIs and as an effective method of contraception.

Nzioka, C. "Obstacles in Managing the Dual Risks of Unwanted Pregnancy and Sexually Transmitted Infections Among Young Men in Kenya." Paper presented at the WHO/UNAIDS Afro Regional Meeting in Pretoria, South Africa (27-29 September 2000).
This paper defines the barriers that face programs seeking to promote dual protection among young men in Kenya. The author provides statistical data on young men's risky behaviors—including early sexual experimentation, multiple partners, paid sex, and irregular and rare condom use—that contribute to high rates of HIV and unwanted pregnancy. He proposes various reasons why young men's awareness of the dual protective role of condoms has not produced behavioral changes, including ineffective AIDS awareness messages, programs failure to address gender power relations and cultural norms, young men's reluctance to seek treatment, misconceptions about condom use, and young men's belief they are invulnerable. The paper also suggests that young men are concerned about cost (of condoms), embarrassed, and lack awareness of sources of condom supplies. The second part of the paper includes information about boys' attitudes regarding sex and reproductive health, and how they view their roles and responsibilities in this area. In the conclusion, the author provides recommendations for how programs can respond more directly to the concerns expressed by young men.

Pranitha, M. "Prevention of Unwanted Pregnancy and HIV Infections: Perspectives of Young Men and Women." Paper presented at the WHO/UNAIDS Afro Regional Meeting in Pretoria, South Africa (27-29 September 2000).
This report summarizes findings from focus group discussions on pregnancy prevention and HIV with young men and women in South Africa. Themes addressed include unwanted pregnancy, knowledge of STI/HIV prevention and condom use, protection against unwanted pregnancy and HIV infection, communication among partners, and use of dual methods of protection. Gender inequality and power issues in sexual relations are pervasive themes throughout the paper, and lead the author to recommend that programs find new and innovative strategies of involving men, challenge traditional gender stereotypes, promote new ways of looking at gender roles, and address gender-based violence. The author advocates the use of peer groups to disseminate health information and redefine sexual norms.

Spieler, J. "Setting the Stage." Paper presented at USAID Open Forum on Dual Protection (October 2000).
This paper, an introduction to a series of papers on Dual Protection presented at a USAID Open Forum on Dual Protection (October 2000), defines dual protection and proposes strategies and actions for integrating dual protection into family planning programs. Dual protection is defined as protection from pregnancy and STIs/HIV either through the use of a condom alone or the use of a condom plus another contraceptive method. Abstinence, or avoidance of penetrative sex, is other means of achieving dual protection. The author highlights implications for service delivery of a dual protection strategy and proposes that effective dual-protection programs require providers and policy makers to change their attitudes and reach out to men. Other proposed actions to achieve results include expanding behavior change communication, promoting condoms, and improving existing condoms.

Stanback, J. "FP/RH Clinic-Based Programs: Dual Protection in FP Clinics." Paper presented at USAID Open Forum on Dual Protection (October 2000).
The paper summarizes the strategy used in Kenya to integrate dual protection in family planning programs and illustrates the difficulty of assessing the outcomes of such programs. With technical assistance from JHPIEGO, the Ministry of Health revised service delivery guidelines to emphasize dual protection. Health care providers nationwide were trained to advise on condom use in addition to contraceptive methods regularly used by clients. Post-training evaluation show a significant increase in the proportion of clients receiving information about dual protection. However, it is unclear what proportion of clients accepted and used condoms. The author concludes that achieving dual protection is difficult because it involves many complex issues. The author proposes (1) using a "threshold matrix" to group people by their reproductive intentions and STI risk, and (2) acknowledging and addressing the barriers to condom use—such as women encountering violent opposition from their husbands—as strategies to increase the success of dual protection programs.

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Gender-based violence

Also see the Annotated Bibliography of RHO's Gender and Sexual Health section.

Barker, G. and Acosta, F. Preventing Violence Against Women in Partnership with Men: Instituto Promundo and Instituto Noos. Rio de Janeiro, Brazil (October 2000).
The paper provides an overview of domestic violence in Brazil and summarizes initial findings on the contributing factors. The paper also includes information about activities Instituto Promundo and Instituto Noos are undertaking. Factors that contribute to male violence mentioned in this paper include (1) sexual or "gender scripts," which justify violence by men; (2) violence against women, which  is deeply rooted in the socialization of men and boys; (3) domestic violence, which is associated to economic stress; (4) the cyclical nature of domestic violence; men who witnessed or experienced physical abuse are more likely to use violence against their own partners and children; (5) violence in intimate relationships, which often starts during adolescence; and (6) men's silence about other men's violence. One of several initiatives described in the paper is a program initiated by Promundo, with funding from PATH. The program trains young men in two low-income communities as peer promoters on prevention of domestic, dating violence, and HIV/AIDS.

Gerstein, L. In India, poverty and lack of education are associated with men's physical and sexual abuse of their wives. International Family Planning Perspectives Digest 26(1) (March 2000). Available at:
This article summarizes the profiles of men who participated in a study on gender violence in Uttar Pradesh. Between 18 and 45 percent of husbands in the study reported physically abusing their wives. Data on the profiles of these men is extensive, and includes demographic factors (age, caste, educational level men who physically and sexually abuse their wives), number of violent incidents, sexual and reproductive behaviors including premarital sex and extramarital relationships, and poverty. The study concludes that men with little education and in extreme poverty are more likely to abuse their wives.

Hayward, R.F. "Needed: A New Model of Masculinity to Stop Violence Against Girls and Women." UNICEF Regional Office for South Asia. Paper presented to the WHO Global Symposium on Violence and Health, Kobe, Japan (12-15 October 1999).
This paper summarizes findings and excerpts interviews with men and women activists working to stop the violence against girls and women in South Asia. The author reports on the activities men from Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka from various economic strata are undertaking, what motivates them to do this type of work, the role fathers play in inspiring daughters to become activists, and the commonalties between men and women activists. The Katmandu Commitment on Ending Violence Against Women and Girls in South Asia is annexed to the paper.

Heise, L., Ellsberg, M. and Gottemoeller, M. Ending violence against women. Population Reports Series L, No. 11. Baltimore, Johns Hopkins University School of Public Health, Population Information Program (1999). Available at:
This issue of Population Reports is dedicated to gender-based violence. It explores the cause of violence against women; the role culture plays in condoning such violence, its impact on reproductive health; sexual abuse and coercion; and more. "An Agenda for Change" and an extensive bibliography round out the extensive information provided in this report.

Kaufman, M. "Involving Men and Boys: A Necessary Step in Ending Violence Against Women and Children." Paper presented at UNICEF's Partnership and Participation Section Workshop (March 2000).
The paper provides data about the prevalence of men's violence as well as its origins, which the author categorizes into "The Seven P's of Men's Violence". These are men's power and the submission of women; men's sense of entitlement to privilege; and the social permission we have given to the violence; the impossibility of meeting the psychic demands of manhood and the use of violence as a compensatory mechanism; the psychic armoring which keeps men out of touch with pain and feelings, theirs as well as those around them; the crippling prohibition of expressing emotions; and past experiences as witnesses to violence. The paper then proposes actions to address the problem, such as the use of media campaigns, programs in schools with perpetrators and/or parents, and rallies and marches. Involving men in finding solutions as well as basing these within a gender approach are critical elements of the strategies proposed by the author.

Kaufman, M. "Conflict Resolution: Finding Better Ways to Help Boys and Girls Solve Problems" Paper presented at UNICEF's Partnership and Participation Section Workshop (March 2000).
This paper addresses conflict-resolution approaches introduced in schools as a means to teach boys and girls life skills and techniques for resolving conflicts through constructive, peaceful strategies. It defines conflict resolution as an "umbrella term for different approaches that recognize that conflict is normal and need not be destructive." The author lists key elements of this approach, which are based on the premise that the problem is not conflict but what people do under these circumstances. Turning conflict into opportunity, being non-adversarial, problem-solving, focusing on the problem itself rather than on who is right or wrong, talking it through, are among some of the key elements mentioned. The author ends by suggesting that conflict resolution is a valuable tool for resolving problems between adults and children, serving the dual purpose of adults using and thus promoting a value system that believes in a nonviolent resolution to conflicts.

Kaufman, M. "Positive Strategies with Boys to End Violence" Paper presented at UNICEF's Partnership and Participation Section Workshop (March 2000).
The author begins this paper by explaining how violence is internalized in boys through their socialization. The belief that men should always be in control and are entitled to power contributes to violence in men; as does homophobia, because boys and men use violence as a means of showing they can measure up to the expectations of manhood. The author proposes teaching boys a "language of emotions" to help them understand their own and others' feelings as a strategy to reduce violence. He also suggests that sports should change their emphasis from conquest and competition to fitness and cooperation. The paper ends with brief descriptions of two programs: The White Ribbon Campaign ( and Boys for Babies, aimed at ending men's violence toward women and children.

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Men's attitudes toward family planning

Dodoo, F.N. Men matter: additive and interactive gendered preferences and reproductive behavior in Kenya. Demography 35(2):229-242 (1998).
This study explores the relative strengths of men's and women's preferences in the determination of reproductive behavior using data from the 1989 and 1993 Kenya Demographic and Health Surveys. The findings indicate that contraceptive use increases when both spouses want no more children. In addition, contraception is two to three times more likely to be used when husbands rather than wives want to cease childbearing. The analysis finds that a wife's preference for stopping childbearing does not translate into increased contraceptive use when her husband wants more children, emphasizing the influence of men on this decision. The author concludes that efforts to improve the status of women or women's negotiation skills with men may be ineffective if the bases of men's reproductive decision making power and men's preferences are not well understood and also addressed through services or interventions. The author further concludes that more must be done to understand the inclinations, preferences, and behavior of men as programs work to implement successful fertility policies in sub-Saharan Africa.

Ezeh, A.C. et al. Men's fertility, contraceptive use, and reproductive preferences. Demographic and Health Surveys Comparative Studies No. 18, Calverton, MD: Macro International, Inc. (1996).
This report analyzes data from DHS surveys of men in 17 countries. The report summarizes regional and gender differentials in fertility levels, reproductive preferences, knowledge of methods, approval of family planning and current use, and intentions for future use. Ample tables and graphs allow for easy access to data and comparison between countries.

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.

Kulczycki A. The determinants of withdrawal use in Turkey: a husband's imposition or a woman's choice? Social Science and Medicine. 200;59(5):1019-1033.
This study investigates why Turkish couples have one of the highest rates of withdrawal in the world, with approximately 25 percent of Turkish couples relying on withdrawal, a percentage which has remained constant for the past twenty years. This study analyzes data from the 1998 Demographic and Health Survey from 1,950 married men. Although there were many variables analyzed, use of withdrawal reflects husbands’ authority and preference over other contraceptive methods, although male authority may have only partial predictive power. The results of this study can provide insight into how the effectiveness of Turkey's family planning and reproductive health programs might be improved.

Roudi, F. and Ashford, L. Men and Family Planning in Africa. Population Reference Bureau; Washington, DC (1996).
This chartbook illustrates the findings from Demographic and Health Surveys in 14 African countries. It includes information about demographic trends, ideal and actual family size, decision making about family matters, family planning knowledge, attitudes toward family planning, family planning practice, and demand for children and need for family planning. The chartbook format is especially useful for those seeking succinct information for presentation to policy makers and others.

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Vasectomy and cancer

Bernal-Delgado, E. et al. The association between vasectomy and prostate cancer: a systematic review of the literature. Fertility and Sterility 70(2):191-200 (August 1998).
The authors conducted a systematic review of the literature and meta-analysis to evaluate the possible association between vasectomy and prostate cancer. Fourteen original studies published between January 1985 and December 1996 were reviewed (five cohort and nine case-control studies. No causal association was found between vasectomy and prostate cancer. Individuals who have undergone vasectomy are not at high risk for the development of prostate cancer.

Moller, H. et al. Risk of testicular cancer after vasectomy: cohort study of over 73,000 men. British Medical Journal 309:295-299 (July 1994).
A large Danish study (of over 73,000 men who had vasectomies between 1977 and 1989) found no association between vasectomy and testicular cancer; data were insufficient to evaluate vasectomy and prostate cancer.

Platz, E.A. et al. Vasectomy and prostate cancer: a case-control study in India. International Journal of Epidemiology 26(5):933-938 (October 1997).
This case control study evaluated the relation between vasectomy and prostate cancer in a population without routine prostate cancer screening in India. 175 prostate cancer cases were compared with 978 controls with cancer diagnoses other than prostate cancer. Standardizing by age, 8.7 percent of cases and 8.3 percent of controls had had a vasectomy. The odds ratio for prostate cancer comparing men who had had a vasectomy to those who did not was 1.48 (95% CI = 0.80-2.72) controlling for age at diagnosis, smoking status, alcohol drinking, and other demographic and lifestyle factors. Risk of prostate cancer associated with vasectomy appeared to be higher among men who underwent vasectomy at least two decades prior to cancer diagnosis or who were at least 40 years old at vasectomy. Although not statistically significant, the results of this hospital-based case-control study are consistent with the hypothesis of a positive association between vasectomy and prostate cancer. Because routine prostate cancer screening is not common in this population, detection bias was unlikely to account for this association.

Rosenberg, L. et al. The relation of vasectomy to the risk of cancer. American Journal of Epidemiology 140(5):431-438 (September 1994).
A U.S. research team that previously reported an association between vasectomy and prostate cancer found no association between vasectomy and any cancer in a study of 4,126 men with cancer and 7,027 controls.

Zhu, K. et al. Vasectomy and prostate cancer: a case-control study in a health maintenance organization. American Journal of Epidemiology 15;144(8):717-722 (October 1996).
This case-control study was conducted in Washington State to evaluate the relationship between prior vasectomy and the risk of prostate cancer. The study compared 175 men newly diagnosed with prostate cancer during 1989-1991 with 258 controls, matched to cases on birth year and membership in a health maintenance organization. Analyses showed that the odds ratio for prostate cancer associated with vasectomy was 0.86 (95 percent confidence interval 0.57-1.32) after adjustment for confounders. The odds ratio estimate did not differ substantially by age at vasectomy or time since vasectomy. However, the odds ratio estimate for prostate cancer associated with vasectomy tended to be increased among men who had a father or brother with prostate cancer; the authors state that the increased risk may be related to detection bias or differential participation rates due to both vasectomy status and a family history of prostate cancer. The results suggest no overall association between vasectomy and prostate cancer.

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New contraceptives for men

AVSC International and Reproductive Health Alliance Europe (RHAE). Male contraception: Planning for the future. Report of a symposium held in London (May 12-13, 1999).
This report includes summaries of discussion about developments in male contraception, including the status of research on methods of contraception for men and the time frame for these methods becoming available; service delivery needs regarding working with men, including the importance of gender issues; and development of a draft research agenda to meet the needs of service providers as they prepare for new male contraceptive technologies.

BBC World News. Male pill breakthrough. (April 14th, 1999). Available at:
Results from limited clinical trials of a contraceptive pill (containing progesterone) and hormone patch (containing testosterone) for men are encouraging. A three-month course of the pill used in combination with the hormone patch reduced the number of active sperm to zero in most of the 23 men tested. Once men stopped taking the pill patch, their sperm counts gradually returned to normal. Further research is needed to refine the method.

Best, K. Contraceptive update: experimental male methods inhibit sperm. Network 18(3) (Spring 1998) Available at: 5.html.
This article includes a table ( summarizing research on experimental male methods to inhibit sperm.

Cohen, P. Sugar pill holds promise for male contraceptive. New Scientist 149(2019) (March 2, 1996).
In the description of this study's results, the addition of a sugar pill to male rat drinking water reduced fertilization rates by 98 percent. 

CONRAD. Mechanical barrier methods for men: Tactylon. (1999).
This summary of the development of improved male condom materials concludes that new materials resist breakage and deterioration when stored under adverse conditions and increase user comfort.

CONRAD. Systemic hormonal methods for men. (1999) Available at:
This report includes information on the development of systemic hormonal methods for men, including androgen/progestin combinations, androgens in combination with other suppressive agents, and GnRH analogs.

CONRAD. Systemic nonhormonal methods for men. (1998) Available at:
This article reviews systemic nonhormonal methods for men that are currently under development, including testicular and post-testicular agents and immunocontraceptives.

Lissner, E.A. Frontiers in nonhormonal male contraception: a call for research (1994). Available at:
This paper describes the current state of research in two areas of nonhormonal male contraception: vas-based methods (no-scalpel vasectomy, chemical injection, injectable plugs, the Shug, and SMA) and heat methods (simple wet heat, artificial cryptorchidism, polyester suspensories, and ultrasound). The paper summarizes issues of safety, effectiveness, convenience, and reversibility for each potential method.

Waites, G. Male contraception: hormonal aspects. International Society of Andrology Newsletter (1997). Available at:
This site reports on a symposium sponsored by WHO. The three speakers addressed the progress in the development of hormonal means of suppressing sperm production in men of reproductive age and the likely efficacy and safety of such methods. Approaches discussed included a combination of progestin with relatively low dose androgen supplementation; development of long-acting testosterone esters to replace testosterone enanthate (TE) for intramuscular application; GnRH analogues for sperm suppression; and several new male antifertility diterpene epoxide compounds that have been isolated from root extracts of the plant Tripterygium wilfordii.

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