Please note: This archive was last updated in 2005.

RHO archives : Topics : Men and Reproductive Health

Key Issues

This section provides summaries of emerging research and program issues in men and reproductive health that are relevant to the developing world.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Men's influence on women's health

Involving men in reproductive health has been found to have a positive impact on women's and children's health in a number of ways, including improving MCH care, preventing or reducing STI/HIV/AIDS transmission, and improving contraceptive use-effectiveness and continuation. A study on the impact of providing antenatal education to prospective fathers in India found a significantly higher frequency of antenatal clinic visits and significantly lower perinatal mortality among the women whose husbands received antenatal education (Bhalerao et al. 1984). Furthermore, men participating in antenatal education tend to know more about family planning methods and are more concerned about their partner's nutritional needs during pregnancy (Raju and Leonard, ed. 2000). A study in Egypt has found that husbands who received counseling at the time of their wives' abortions were more likely to be supportive during the recovery period (Abdel Tawab et al. 1997). Enlisting men in the fight against STI/HIV/AIDS is particularly important given that men frequently transmit STIs to their monogamous partners. Research has shown that married women's greatest risk factor for STIs is the sexual behavior of their husbands (Hunter et al. 1994; Foreman 1999). Men are much more likely (eight times) to transmit HIV to women through repeated acts of unprotected sexual intercourse than vice versa (Padian et al. 1997).

Studies have shown that involving men can increase contraceptive adoption, client satisfaction, contraceptive use-effectiveness, and contraceptive continuation. Randomized trials have found that contraceptive adoption was significantly higher among women whose husbands were included in contraceptive counseling compared to women whose husbands were not involved (Fisek et al. 1978; Terefe et al. 1993). A recent randomized study in China has demonstrated improvement in contraceptive use-effectiveness for couples when the husband was involved in contraceptive counseling (Wang et al. 1998). Several studies have shown higher contraceptive continuation among clients whose husbands have been involved in contraceptive counseling. A study in Madagascar found that women were more likely to continue using Norplant implants if their husbands had been involved in the counseling process (Tapsoba et al. 1993).

Top of page

Impact of couple counseling

Increasingly, reproductive health interventions focus on couples rather than on the individual. A review of studies of reproductive health interventions concluded that in most instances a "couple approach" can be more successful than serving individuals (Becker 1996). Improving communication between partners on sexual and fertility-related matters appears to improve contraception use (Salway 1994) but is not necessarily a prerequisite for men's involvement in family planning use (Karra et al. 1997). Even in areas in which the prevailing culture emphasizes men's authority over women, many couples report discussing matters related to family size and contraceptive use (Renne 1993). Programs that use a couple approach must be carefully designed so as not to jeopardize a woman's decision-making and self-determination when they do not agree with their male partner (Becker and Robinson 1998).

Top of page

Impact of gender role expectations on men's health

While discussions of gender issues rightly focus on the serious and negative impact of gender inequities on women (see RHO's Gender and Sexual Health section), gender role expectations prevalent in many societies also affect men. For instance, in many cultures concepts of masculinity may be tied to a man's ability to provide economic support and protection for his family. As it becomes harder and harder for men to fill this role successfully, some men may turn to alternative measures, such as violence, to maintain authority in the family (Barker 1997). Gender role expectations also may make men feel constrained from expressing their dedication to their wives or from participating in the care and nurturing of children or in household management, lest they risk ridicule from friends and neighbors. Societal expectations for men also can lead to threatening situations for the men themselves, such as when homosexual men are subjected to harassment or physical abuse because their sexual orientation differs from the norm.

In addition, in some countries, male gender roles may encourage risk-taking and discourage men from using health care services of any kind, much less reproductive health care services (Rappaport 1984; Moynihan 1998). This is illustrated by cultural expectations for young men to resolve disputes with other men through violence and to prove their manliness by taking risks, such as reckless driving of cars and motorcycles. As a result, there are large differences between young men and women in age-specific death rates due to violence and accidents (Rappaport 1984). Others have suggested that this type of risk-taking behavior also extends to reproductive health risks, such as having sex without condoms (Foreman 1999). For instance, some young men in Kenya glorify acquiring an STI as a badge that confirms manhood (Nzioka 2000). In some regions, men may have sex with men without recognizing this as a potentially risky activity. For instance, in the South Asia region, it is relatively common for men to engage in sexual play with other men, including boys and relatives (Khan 1998).

Gender stereotypes also can lead men to certain occupations or behaviors that affect their health. For instance, jobs that require seasonal migration or other travel (such as trucking) often are held by men. These jobs remove men from their home environment, resulting in less time with their spouses and families, infrequent opportunities for spousal sexual relations, and increased opportunities for sex outside of marriage or with sex workers (Kootikuppala et al. 1999). In addition, some typically male occupations may affect fertility or overall reproductive health (Keleher 1991). (Also see RHO's Infertility section.) One study of taxi drivers in Italy found that drivers had a significantly lower prevalence of normal sperm compared with controls (Figa-Talamanca et al. 1996). A study of 46 papaya workers in Hawaii found that long term exposure to ethylene dibromide, a common pesticide, resulted in significant decreases in sperm count and percentage of viable and motile sperm and increases in the proportion of sperm with abnormalities compared with non-exposed men (Ratcliffe et al. 1987).

Top of page

Men's reproductive health needs and concerns

Men have varied reproductive health concerns. For instance, a study of men's perceptions of sexual problems in a Mumbai slum community found that men were most concerned with sexual weakness, itching around genital areas, burning sensation during urination, early ejaculation, wounds on the genitals, and white discharge (Ravi et al. 1999). Issues raised by men in Pune, India, include masturbation, consequences of loss of semen, menstruation, pregnancy, and AIDS (Raju and Leonard 2000). A study in Bangladesh of 622 men attending a special "men's clinic" found that the most common complaints were pain passing urine (42%); psychosexual problems such as impotence, premature ejaculation, and sexual dissatisfaction (42%); urethral discharge (38%); and non-reproductive health complaints, such as cough or weakness (18%). A survey of 969 men in the general population of the clinic area found that 17 percent reported psychosexual problems (Hawkes 1998). The pain and discharge reported by these men are likely symptoms of sexually transmitted infections, which may be common among some populations of men. For instance, a study of 137 men attending an urban STI clinic in Mongolia found that 31 percent, 8 percent, and 9 percent were infected with gonorrhea, chlamydia, and syphilis, respectively. In addition, 20 percent of the men had nongonococcal urethritis (Schwebke et al. 1998).

Older men participating in focus groups in Australia identified urinary symptoms, prostate cancer, and sexual function as key concerns. Urinary symptoms were particularly problematic for men whose occupations limited their access to toilets, such as taxi drivers, truckers, or traffic controllers (Pinnock et al. 1998). Research on the extent of sexual dysfunction also is limited, particularly outside the United States (Bortolotti et al. 1997). Incidence increases with age (one large study reported rates of minimal, moderate, or complete impotence in approximately 40 percent of 40 year olds, increasing to 66 percent among 70 year olds) and also may be exacerbated by factors such as smoking, alcoholism, certain chronic diseases, and certain medications.

Some men want more than just information about their own health issues. For example, men participating in focus groups in Colombia also wanted to know how to communicate with children and partners as well as foster new ideas about being gender-sensitive in a changing society (Eshcen et al. 1999).

Top of page

Reaching adolescent males

Young men may be a particularly important audience for "men and reproductive health" programs because they often lack access to health information and services and may be more open to considering new ideas than their older counterparts. The Interagency Gender Working Group (IGWG) Subcommittee on Men and Reproductive Health chose working with adolescent males as one of its three priorities; click here to see their theme statement on adolescent males.

Review of patient records from a New York City clinic serving primarily young, Dominican men found that most had been sexually active for several years before their first visit. In addition, while the majority initially sought services for routine medical services, such as a sports exam or physical, more than a quarter of these patients were also treated for an STI. This highlights the value of offering a full spectrum of health services as a way of drawing men into a program (Armstrong 1999).

Promoting gender equity during adolescence may be more effective than later on in life; evidence suggests that young men frequently are more willing than adult men to consider alternative views about their roles in reproductive health. For instance, research among young men in Colombia found that adolescent males showed a greater interest in and desire to communicate more with women and recognize women's right to decision making (Eschen et al. 1999).

Socialization plays a key role in influencing mens behavior. Although biological differences between boys and girls impact their health and development, the World Health Organizations Department of Child and Adolescent Health (CAH) found that differences in gender socialization have a greater effect (WHO 2000). Thus, identifying socialization factors that shape more gender-equitable boys has implications for more effective program design. Please see Table 1 for more information about promoting gender-equitable versions of masculinity. Also see RHO's Adolescent Reproductive Health section for more information about adolescent issues.

Top of page

Men and HIV

Statistics clearly indicate that men play a critical role in spreading AIDS. Furthermore, men's attitudes about sexuality and sense of invulnerability put women and men at risk (Barker 2000; Foreman 1999). Men are likely to have more sexual partners than women, thus men are at greater risk of becoming infected and transmitting the virus. Drug use is attributed to approximately 10 percent of the world's cases of HIV transmission; 80 percent of these cases involve men (Barker 2000).

Research and pilot projects are helping to fine-tune successful strategies and identify essential elements to involve men in HIV/AIDS prevention and treatment. Important program considerations include:

  • Developing frameworks that place men alongside women in the global response to HIV and AIDS (Aggleton 2000).
  • Finding more gender-equitable forms of socialization.
  • Breaking the silence and stigma associated with HIV/AIDS, including men having sex with men and substance abuse.
  • Providing men with the space and security to talk about sexuality.
  • Finding ways to encourage men to take care of themselves, their partners, and their families (Aggleton 2000; Barker 2000; Foreman 2000; Raju and Leonard 2000).

Literature about men and HIV is expanding rapidly. The Panos Institute recently became an official partner of UNAIDS for the 2001 World AIDS Campaign. As part of this effort, the institute created four documents on men and HIV in Zambia, Malawi, Zimbabwe, and Swaziland that are available on the Panos Institute website.

For more information about HIV/AIDS, please see RHO's HIV/AIDS section. For information about male circumcision in relation to HIV/AIDS, please see RHO's HIV/AIDS Key Issue on male circumcision and HIV and the Special Report from the September 2002 Male Circumcision Conference.

Top of page

Dual protection

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 another means of achieving dual protection (Spieler 2000). Dual protection is one of three priority areas of the IGWG Subcommittee on Men and Reproductive Health (also see the IGWG statement on dual protection).

To date, dual protection promotion in clinics is rare, difficult to achieve, and a sensitive issue to discuss. Important considerations in dual protection programs are people's reproductive intentions, STI risks, and cultural norms such as gender inequity (Cates et al.; Marcham et al. 1999; Nzioka 2000). Barriers to condom use need to be acknowledged and addressed.  For instance, some women may face violent reactions from their husbands if they suggest using condoms (Stanback 2000).

For more information about condoms and other family planning methods, please see RHO's Contraceptive Methods section.

Top of page

Gender-based violence

Gender-based violence, as defined by the United Nations General Assembly, includes all acts or threats of violence that result in, or are likely to result in, physical, sexual, or psychological harm and/or suffering to women. Gender-based violence is another priority theme of the IGWG Subcommittee on Men and Reproductive Health; click here to see their theme statement on gender-based violence. The most common forms of violence against women are abuse and coerced sex that can occur in childhood, adolescence, or adulthood (Heise et al. 1999). Female genital mutilation (FGM) comes under the rubric of gender-based violence.

According to the World Bank, the health burden "from gender victimization among women aged 15 to 44 is comparable to that posed by other risk factors and diseases, including HIV tuberculosis, sepsis during childbirth, cancer and cardiovascular disease" (Heise et al. 1999).

Recent studies attribute men's propensity to violence to "men's contradictory experiences of power" as follows:

  1. the impossibility of meeting the multiple demands of manhood and the use of violence as a compensatory mechanism;
  2. the psychological armoring, which keeps some men who commit violence from being in touch with the feelings and the pain of those around them and of their own pain;
  3. the crippling prohibition of the expression of a range of emotions by men in most cultures, which buries feelings such as hurt, terror, and fear, and channels them into forms of emotional expression that are permitted: anger and aggression, which can flare up as violence;
  4. past experiences as witnesses to violence against their mothers, experiences witnessing violence against others, and experiences as boys or young men in which violence was directed against them (Kaufman 2000).

Strategies to work with men on addressing violence encourage men to reflect on their lifestyles, the costs of their violence and the possible gains from being more caring and affectionate (AVSC and IPPF/WHR 1998).

For more information about gender-based violence, see the Violence against women discussions in RHO's Gender & Sexual Health Overview and Key Topics areas.

Top of page

Outcomes of "men and reproductive health" programs

While large-scale, long-term programs addressing men's various roles in reproductive health are lacking, there are numerous small, pilot programs across the globe that address issues such as family planning, sexually transmitted infection prevention, men's roles in families, and issues of gender equity, among other topics. The response from men to these programs has been overwhelmingly positive, with most men welcoming the opportunity to participate in and improve the health of their families.

Numerous regional conferences involving policy makers, program managers, and researchers as well as comprehensive reviews of programs addressing men have resulted in summaries of lessons learned and suggested strategies for the most effective approaches to reach men (Robey et. al. 1998; Liow et al. 1996; Danforth and Green 1997; Green et al. 1995; Healthlink Worldwide 1998; Drennan 1998; Johns Hopkins CCP 1997; FOCUS 1998; IPPF/RHO and AVSC 1998; Wegner et al. 1998; Davidson 1998; HIM 1999; Yinger 1999). It is worth noting, however, that the emphasis of the majority of programs carried out to date has been on involving men in contraceptive use and decision-making in addition to extending other reproductive health services to men. As such, the results may not be applicable to newer initiatives that approach the issue from a gender equity perspective.

Experience to date suggests that effective men and reproductive health programs:

  • add services for men without subtracting from ongoing services for women. This has been done by adapting existing services and by charging fees for the additional services provided for men;
  • are carefully tailored to a specific subgroup of men. Men are not one homogeneous group. Their needs vary by age, culture, marital status, sexual orientation, and education;
  • make an effort to involve men in the program design and implementation. For example, recruiting satisfied clients to attract other clients (AVSC 1997); involving women in program design and implementation also is important to ensure that the needs of both sexes are considered. While women are highly effective as service providers in programs for men, it is recognized that appropriately trained and motivated male staff can make a positive difference. In some instances, the social-cultural environment can influence men's discomfort in receiving services from a female health care worker (Nzioka 2000).
  • with few exceptions, have integrated services for men within existing services rather than establishing independent services for men. For instance, existing clinical services can be altered to meet men's needs by offering separate hours for men, training staff in men's reproductive health needs, ensuring the availability of educational materials for men, and implementing other relatively simple changes. Further research is needed on whether this approach in any way compromises services for women;
  • give service providers in-depth training in the technical and counseling skills needed to work with male clients and with couples;
  • often do not follow a traditional, clinic-based model. They deliver services where men are: at their place of work, at home, or at recreational settings;
  • are attentive to men's needs, such as their working hours, need for privacy, and need for respect and compassion;
  • make a strong effort to involve the community from the beginning, especially community leaders and "gate-keepers" for the men whom the program wishes to reach;
  • provide a wide range of services (e.g., family planning, STI prevention and treatment, cancer screening, sexual health counseling, and general physicals), which helps attract enough male clients to generate adequate fees for services;
  • have a system in place for program monitoring and evaluation. This system should include indicators to measure the amount and quality of services and the impact of the program, with particular emphasis on the gender-related consequences of the program to both women and men.

Top of page

Men's attitudes toward family planning

Data on men's attitudes toward family planning have only recently been collected. Research suggests that in many regions men view family planning favorably and can have a strong influence on the use of contraception. For example, research in Kenya suggests that contraception is two to three times more likely to be used when husbands rather than wives want to cease childbearing (Dodoo 1998). Results from Demographic and Health Surveys in 17 different nations in Asia, North Africa, East Africa, and West Africa support the following overall conclusions:

  • Men and women have similar reproductive preferences and attitudes toward family planning (with the exception of West African countries).
  • Men are no more opposed to family planning than women.
  • Men tend to identify reproduction as a female responsibility (Population Reports 1999).
  • In many countries, men are as favorable to condom use as women.
  • Men's approval for and intentions to use family planning methods are similar to women's (with the exception of West African countries) (Ezeh et al. 1996; Roudi and Ashford 1996).
  • Some men are suspicious of family planning programs, believing they undermine men's power (Ndong and Finger 1998).

Results such as these are supported by qualitative studies. For example, a study of male involvement among five generations of a South Indian family found that men readily accepted condom use and vasectomy, even though they may not have liked some of the specific characteristics of the method (Karra 1997).

Additional research is needed on both men's and women's attitudes toward use of and decision-making regarding reproductive health care services, with particular emphasis on how differences between men and women affect women's equality in decision-making.

Top of page

Vasectomy and cancer

Research on the long-term effects of vasectomy is ongoing. Although some studies have suggested a possible link between vasectomy and prostate cancer (see Outlook, Volume 13, Number 1), two recent studies and one meta-analysis have found no overall increased risk (Bernal-Delgado et al. 1998; Platz et al. 1997; Zhu et al. 1996). These findings support results of two earlier studies; the first found no association between vasectomy and any cancer (Rosenberg et al. 1994) and the second found no association between vasectomy and testicular cancer (Moller et al. 1994).

Top of page

Contraceptive methods for men

Five currently available contraceptive methods are designed for use by men or require men's active participation—condoms, female condoms, vasectomy, natural family planning (NFP), and withdrawal. Each of these methods has unique advantages that may be attractive to some family planning clients. For instance, male and female condoms protect against sexually transmitted infections, vasectomy is safe and highly effective (in addition to being less expensive than female sterilization), and NFP and withdrawal are hormone-free and readily available at no cost to the user. These last two methods also promote communication and cooperation between partners. Despite these advantages, none of these methods is perfect, and many men and women would welcome the arrival of new contraceptives that men could use. Furthermore, the male condom is the only male contraceptive method that effectively protects against STIs and HIV.

Research continues on both permanent and reversible methods for men, though most methods under development will require at least 10 more years of research and testing before they are ready for introduction (Best 1998; AVSC/RHAE 1999). Types of methods being investigated include:

For more information about contraceptives, see RHO's Contraceptive Methods section.

Top of page