APPENDIX G

THE BIOLOGICAL AND HEALTH ASPECTS OF MALE FERTILITY: IMPLICATIONS FOR USE OF REPRODUCTIVE HEALTH CARE SERVICES

Eugenia Eckard

Office of Population Affairs

Prepared for NICHD Workshop "Improving Data on Male Fertility and Family Formation" at the Urban Institute, Washington, D.C., January 16-17, 1997


Introduction

There are a number of important differences between males and females that affect their fertility. Males are potentially almost unlimited in their number of offspring, while females are not. Also, females can be certain about motherhood, while males can not be certain of paternity. Due to these and other biological realities, it is important that we obtain information from both males and females to fully understand their fertility-related behavior as well as be able to provide the types of services that can best meet their reproductive health needs.

While the male is able to reproduce during a larger proportion of his life than a female, he is practically ignored by the medical community in matters related to reproductive health. In a society that expects women to be primarily responsible for taking the necessary steps to avoid pregnancy, the service delivery community has tended to disregard her male partner. Even though men have expressed the belief that they should share the responsibility for birth control with their partners, family planning efforts have been directed almost exclusively toward women. However, due to the increasing public costs of unintended pregnancy, the negative impact of absent fathers and issues of child-support enforcement, as well as the growing concern about AIDs and STDs, more attention than ever is being focused on males.

Research has provided some of the much needed information about male fertility-related attitudes and behavior but more information is needed. Also, because much of the information about males' family-planning behavior is based on reports from women, it is crucial that there are more efforts to obtain similar information directly from the men. By attempting to understand the experiences and perspectives of men, we may better understand their attitudes about personal responsibility and other issues influencing their use of reproductive health services. This paper examines these issues and addresses the relevant data that currently exist and that are needed to further understand these issues.



Biological Differences

Recognizing the biological differences between males and females is necessary for understanding their differential effect on fertility. Biology, just as much as the environment and culture, must be considered in the overall picture of human sexuality. Biology acts to set potentials or limits in each individual which establish the parameters within which culture and environment can exert their influence. As Udry (1996) states, "the variance in individual biology partially determines the choices we make."

At birth, there is no visual means of distinguishing the sexes aside from the genital differences. However, the sexes are known to develop with different physiological capabilities. Within the first 28 days after birth, about 25 percent more males than females die. The higher ratio of male to female deaths continues throughout life. The factors involved in these different mortality figures obviously reflect inherent physiological sex differences.

Boys grow faster than girls for the first 6 months of life. At the age of puberty, girls and boys experience physical changes that render them capable of reproduction. The production of new hormones in girls results in breast growth and the onset of menstruation. Boys, for whom sexual maturity occurs about one or two years later than girls, experience changes in their body and their voice.

Evidence exists which reveals that, as adults, men are more likely than women to experience erotic arousal by visual stimuli. Men often enjoy feelings of stimulation just from observing women. Women, on the other hand, are more likely to be aroused by what is often referred to as "sweet talk," possibly due to having significantly greater auditory acuity than men.

Also of significance to our understanding of the differences between the sexes is the fact that the differential treatment accorded them by society also influences their behavior. From the moment an infant is born, its biological sex influences how it will be treated by society. Possibly the most important fact about the baby for those aware of its birth is its sex. Equipped with this information, people feel they are better able to choose the appropriate clothes and toys for the newborn.

Early on, boys tend to exhibit what are regarded as male characteristics such as physical aggression, assertiveness and dominance, while females tend to be passive, nurturant, and dependent. These characteristics are reinforced and perpetuated by cultural and societal influences, thereby affecting their behavior in every aspect of their lives.

While recognizing the biological basis for behavior, it is also important to understand the manner in which this behavior is affected by societal forces. According to Udry (1996), biological factors affect behavioral predispositions, while social forces control how those predispositions are expressed. One possible area of societal influence that could do more to promote responsible behavior for men in particular is the community of health care providers.



Males' Use of Health Care

In general men tend to neglect their heath. To better grasp the issues related to males' use of reproductive health care services, it is important to understand their reluctance to seek medical services altogether. One possible explanation may be found in their early socialization. Boys are told not to cry, not to show their feelings, to be a man, not a sissy or a cry-baby. A result of this conditioning could be men's reluctance to ask for help from anyone, including medical care providers. For many men, sickness means weakness and a threat to their masculinity. The suppression or denial of feelings of pain and the attempt to stay tough may result in self-destructive behavior among men such as drinking, using drugs, dangerous driving, as well as violent and abusive behavior.



Why Women Have Been the Primary Target

For too long, men have been excluded from the domains of sexual responsibility and reproductive health. This is the result of policy and program emphasis on women as the key figures in contraceptive decision-making. Both traditional and modern methods of family planning focus solely on the woman because avoiding unintended pregnancy or limiting family size is almost always considered a female concern.

The reasons services have primarily been targeted to women is because women experience the consequences of the unwanted pregnancy more directly. Since the introduction of the pill and other effective methods, the most reliable methods of reversible contraception are female methods. Also, early contraceptive development was spurred by political pressures and financial support from feminists who sought a method by which women could regulate their own fertility. Following the success of the oral contraceptive for women, little interest developed for waging a comparable all-out campaign for a male method.

Reason for Attention to Males

The serious consequences of unintended pregnancy and their increasing public costs has brought long overdue attention to the issue of male responsibility in pregnancy prevention. Judicial and legislative actions have come about that are intended to hold men accountable for their involvement in childbearing. The negative impact of the absent father on the child's development has also spurred attention to men.

Due to the AIDS epidemic, renewed interest in the use of contraceptive methods for disease prevention has occurred among scientists, public health officials and the general public. Therefore, a large part of the explanation for the focus on men has been motivated by concern about HIV and other sexually transmitted diseases. Also, efforts to avoid both the risks of HIV and STD infection requires the use of dual methods, which necessarily involves the active participation of both the male and female.



Factors Affecting Male Use of Contraceptives/Condoms

There have been a number of studies on male fertility behavior and attitudes toward contraceptive responsibility (Billy et al., 1993; Ku et al., 1994; Marsiglio, 1993; Pleck et al., 1993; Tanfer et al., 1993; Zelnick and Kantner, 1980). Findings from these studies shed light on important aspects of male sexual responsibility, covering such topics as background characteristics, attitudes about fatherhood and attitudes toward contraception.

A substantial body of literature pertaining to the determinants of condom use has also emerged. Factors that have been found to influence use of condoms include perceptions of reference group behavior (i.e., whether the male thinks his male peers use condoms); knowledge about condoms, contraception, pregnancy risk, and AIDS; sex education and exposure to other sources of information; and personality factors such as self-esteem and locus of control.

Conservative sex role beliefs have been found to be related to negative attitudes toward male contraceptive use and the belief that contraceptive responsibility is solely that of women. The belief that men share responsibility in preventing pregnancy is associated with consistency of condom use. Males who are married and more educated agree more often with the view that contraception is not only the woman's responsibility.



Barriers

One of the barriers to the utilization of contraception by males is a lack of perceived susceptibility to the problem of unintended pregnancy. Another barrier particularly with young males is a lack of knowledge about pregnancy risk and contraceptive methods. Misinformation concerning health hazards associated with contraceptives has also been shown to influence men's behavior. Another potential impediment to effective contraceptive utilization may be sexual assault.

Many studies have also documented a significant relationship between the perception that condoms reduce male pleasure or are embarrassing and low levels of condom use. One of the major reasons given by men for not using condoms is because of embarrassment involved in obtaining them. Also, condoms are perceived as inconvenient and difficult to use.



Limited Contraceptive Options

The level of male involvement in the use of contraceptives may reflect the limited options available to men. The methods currently available for men are condoms, withdrawal, periodic abstinence, and vasectomy, none of which has the widespread acceptability of some methods for women. A serious drawback of the condom, withdrawal, and periodic abstinence is men's lack of confidence in their effectiveness. Coitus-dependent methods tend not to be as accepted as coitus-independent methods. The difficulty and expense of reversal still limit the appropriateness of vasectomy to those wishing to stop rather than space childbearing; and the method's irreversibility remains the biggest obstacle to its acceptability. Where as vasectomy is little used, it is associated with impotence, loss of virility or physical weakness.

New methods of male fertility regulation currently undergoing clinical trials have the potential of being effective as well as reversible, non-surgical, and long-acting. Injectable or implantable hormone methods for men are as yet experimental. A pill for men remains a distant prospect.



Male Reproductive Health Issues

Men have particular health care concerns of their own and suffer from problems which need attention. These include fears of sexual inadequacy, ignorance about sexual and reproductive functioning, risk of STDs, risk of unwanted pregnancies, problems of infertility, or misunderstandings about how male and female-controlled contraceptive methods work.



Avoiding Pregnancy

While a number of factors are related to a man's belief that preventing pregnancy is solely the woman's responsibility, there is evidence that a significant proportion of males are motivated to avoid pregnancy. Research indicates that the main reason men report using condoms is actually for birth control (Sonenstein and Stryker, 1997).



HIV and STDs

Interest in avoiding infection from HIV and STDs makes screening for these diseases important to men. Evidence exists, however, that some men are unaware that a person infected with an STD could be asymptomatic. Many also have the misperception that a routine physical exam could determine whether or not they were infected.



Male Infertility

Artificial insemination with husband's semen is one of the treatments provided in cases of male infertility. Evaluation of sperm morphology is usually conducted to determine sperm count and sperm motility.



Impotence related to Testicular and Prostate Cancer

Current reproductive technology provides hope for future procreation by men facing sterilizing cancer treatment. Certain medical technologies are available to protect the reproductive potential of adult males undergoing sterilizing cancer treatments. The present clinical means for preserving the potential reproductive capacity of men at risk is cryopreservation of sperm before treatment begins, followed by assisted reproductive technology when pregnancy is desired.



Age-related Reproductive Health Issues

The consequences of adolescent sexual behavior continues to be a major public health concern. Large numbers of adolescents engage in sexual activity without protection either from pregnancy or sexually-transmitted diseases. While a great deal of information has grown on the subject of sexual activity and pregnancy-related behaviors of adolescent females, not nearly as much is available about adolescent males.

Males tend to initiate sexual activity at younger ages than females. The peer group is often one of the most powerful influences on adolescent behavior and in many instances is the principal source of sex education for male adolescents. According to Anderson (1989), some young men may become involved with peer groups that emphasize "sexual prowess as proof of manhood, with babies as evidence" A traditional masculine ideology was also found to be related to the increased belief that pregnancy enhances masculinity (Pleck et al., 1993).

Much of the response to the problem of teenage pregnancy and the possible risks of AIDS and STDs among young people has been in the form of school-based prevention efforts. Many of these efforts have focused primarily on increasing knowledge and teaching communication skills, with the intended outcome of reducing behavior that place young people at risk of pregnancy, HIV and other STDs.

Many of the partners involved in teen pregnancy are older men. However, the characteristics of the teen father and the extent to which teen fatherhood adversely affects his subsequent life outcomes is relatively unknown. The unique reproductive health concerns of this subgroup need to be explored.

Older Men

While there is nothing comparable to male menopause, men do experience changes during middle-age. Male hormone levels decrease with age and older men suffer from decreased sperm production, diminished sexual desire, and loss of lean muscle mass. They also experience shrinkage of the testicles after age 40 and have an increased risk for enlargement of the prostate by age 50.



Couple Dynamics Influencing Family Planning Decisions/Behavior

Research has shown that attitudes and behaviors of men are affected by the type of relationship in which they are involved. Evidence reveals that unmarried couples in which the men report more committed relationships are more likely to use birth control more often and more effectively than couples in less serious relationships. A study by Inazu (1987) showed that men in more serious relationships reported being more concerned about the well-being of their partner than those in casual relationships. Similar results were found in a focus-group study by Landry and Camelo (1994) where it was revealed that communication between partners about contraception was least likely to occur in casual relationships. There is also evidence that the couple's degree of communication about contraception predicts level of contraception among adolescents (Polit-O'Hara and Kahn, 1985).

Studies of females indicate that condom use is higher when females ask men to use condoms. Findings also indicate that males' perception that the partner would appreciate his using a condom is an extremely important factor in men's use of condoms (Sonenstein and Pleck, 1995).



Male Infertility

The causes of male infertility are largely undetermined, and our knowledge of the external factors affecting the male reproductive system is still limited. In particular, the role of specific environmental and occupational factors is not completely clear. However, there is evidence that exposure to certain physical and chemical agents encountered in the occupational environment might affect the male reproductive system (sperm count, motility and morphology, libido, and fertility) and/or related pregnancy outcomes (spontaneous abortion, stillbirth, low birth weight and birth).

Various confounding factors related to lifestyle (smoking, alcohol and diet) or socioeconomic status may also affect sperm quality or pregnancy outcomes. Some cases have demonstrated that stress can also adversely affect reproductive function.



Effects of Childhood Sexual Abuse on Males

Non-voluntary first sexual intercourse is correlated with earlier initiation of sexual activity, as well as increased numbers of lifetime sex partners. Findings pertaining to the long-term effects of child sexual abuse in males have revealed problems including guilt and self-blame, low self-esteem and negative self-image, problems with intimacy, sexual problems, compulsions, substance abuse and depression. A number of clinicians' case studies indicate that male survivors of childhood sexual abuse may experience attempts to prove their masculinity by having multiple female sexual partners, sexually victimizing others, and confusion over their gender and sexual identities, and a sense of being inadequate as men.



Family Planning Policy and Programs Affecting Service Delivery to Males

Evidence reveals that only a small proportion of the clients served by family planning clinics are men. Despite evidence which shows that men, including adolescent males, are motivated to use condoms and have expressed the belief that they should share the responsibility for birth control with their partners, family planning efforts have generally ignored them. Policy and program efforts that have primarily targeted women have made it unlikely for men to recognize the potential benefits of family planning services for themselves.

One possible explanation for the lack of involvement of men in family planning services is the fact that the provision of condoms, the primary reversible method of contraception available to men, does not require a medical setting, as well as the fact that this method can easily be made available to the female clients.

Other possible reasons may include the attitudes of the service providers, financial constraints, and lack of training about how to provide services to men. Physicians and/or family planning providers, for example, may assume that their clients would find a contraceptive unacceptable for men and might consequently be reluctant to recommend the procedure. Thus, the resistance of physicians could interfere with attempts to improve awareness and use of male methods.

The structural barriers that affect women's use of family planning services may also apply for men such as inaccessible delivery hours, difficult to reach facilities, and cost of services. Both a lack of information about the types of reproductive services that are available for men and about where the services that exist can be obtained may also serve as barriers to utilization of services by men.

Without special strategies to attract men, it is unlikely that men will seek services at family planning clinics even when they know they are available to them. Men may view these clinics as places for women and their children to go, and consequently may find it difficult to enter them. However, as Sonenstein and Pleck (1994) so aptly stated, "males are not a lost cause for preventive efforts."



What We Need to Know

We need to have more information about the medical and health services available to young men at risk for parenting. Information is also needed about men's use of and awareness of the availability of family planning services as well as their intention to use these services if they were available. We also need to determine the knowledge and perceptions of men about reproductive health services as well as their feelings about their experiences with these services.

We need to know why few males turn to family planning clinics or other sources of reproductive health care for contraceptive services. We also need to know the characteristics of the men who do seek reproductive health services.

Also needed is information about whether or not there are institutional or structural barriers to males' use of reproductive health services. Are there perceived social pressures which inhibit or encourage use of family planning or other reproductive health services. These forces can include partner relationships, cultural norms, and experiences with health care providers.

We need to identify ways to encourage males to use reproductive health services and to identify elements of a service delivery system that are amenable to change and improvement to ensure their use. More information should be obtained from clinics serving larger proportion of males to see how they have succeeded in attracting them.

More information is also needed about the impact of various intervention strategies on male contraceptive behavior.

The attitudes and beliefs of non-sexually active adolescent males are unknown. The factors that influence their abstinence need to be investigated further to determine their level of responsibility for contraception when they later become sexually- active.

The majority of relevant behavioral research on men is focused on their use of condoms and rarely on their support of or participation in their partners' use of various methods. Information about males' knowledge regarding effective contraceptive practices and about the female reproductive-cycle need to be obtained.

We do not have information on experiences with child abuse that may impact interpersonal and decision-making skills among young men. More research is needed to identify and examine the factors involved and to determine how these experiences affect men's attitudes about male responsibility in pregnancy prevention.



References

Marsiglio, W. 1993. "Adolescent Males' Orientation Toward the Reproductive Realm: Paternity and Contraception." Family Planning Perspectives, 25: 22-31.

Pleck, J.H., F.L. Sonenstein, and L.C. Ku. 1993b. "Masculinity Ideology: Its Impact on Adolescent Males' Heterosexual Relationships." Journal of Social Issues, 49(3): 11-29.

Polit-O'Hara, D., and J.R. Kahn. 1985. "Communication and Contraceptive Practices in Adolescent Couples." Adolescence, 20(77): 33-43.

Sonenstein, F.L. and Jeff Stryker. 1997. "Why Some Men Don't Use Condoms: Male Attitudes About Condoms and Other Contraceptives." Sexuality and American Social Policy, a seminar series published by Henry J. Kaiser Family Foundation.

Sonenstein, F. L. and J. H. Pleck. 1995. "The Male Role in Family Planning: What Do We Know?" Discussion Paper Series, The Urban Institute, UI-PSC-21.

Tanfer, K., W.R. Grady, D.H. Klepinger, and J.O.G. Billy. 1993. "Condom Use Among U.S. Men, 1991. Family Planning Perspectives, 25: 61-66.

Zelnik, M., and J.F. Kantner. 1980. "Sexual Activity, Contraceptive Use and Pregnancy Among Metropolitan-Area Teenagers: 1971-1979." Family Planning Perspectives, 12(5): 230-237.