Men's Roles, Sexuality, and Reproductive Health
Axel I. Mundigo, PH.D.
So Paulo, Brazil
July 31, 1995
The address by Axel Mundigo is the third in the International Lecture Series on Population Issues sponsored by the Population Program of the John D. and Catherine T. MacArthur Foundation. The lecture series addresses critical issues in population and development that the world will confront in coming years. Concurrent with the lecture in So Paulo, the Foundation announced its latest round of leadership grants in Brazil, supporting individuals working on population issues. The grants were awarded through the Population Programs Fund for Leadership Development. The fund also supports work in Mexico, India, and Nigeria. The Fund for Leadership Development in Brazil places significant emphasis on an appreciation of the countrys cultural and ethnic diversity, and the recognition of diversity in its expectations of leadership. It encourages especially the emergence of female leadership. The inaugural lecture in January 1995 marked the announcement of the annual leadership awards in Nigeria. The second marked the announcement of leadership awards in Mexico. The final lecture in the series will mark the announcement of the annual leadership awards in India.
Axel Mundigo was chief of the Social Science Research Unit of the Special Program of Research in Human Reproduction of the World Health Organization until May 1995. In that position he developed a series of important initiatives in the field of population and reproductive health, which included research on critical, often sensitive issues, such as contraceptive use dynamics, determinants and consequences of induced abortion, sexual behavior, and the role of men in reproductive health. Between 1978 and 1983 he was senior representative for Latin America and the Caribbean for the Population Council, heading the regional office in Mexico. He came to the Council from two years with the Ford Foundation in Brazil, where he was in charge of developing research and training activities in population. He is one of the founding members of the Brazilian Population Association (ABEP).
Dr. Mundigo has contributed widely to the literature on population and reproductive health. He has written articles on the fertility transition of Latin America, on the population policies of Mexico and China, on induced abortion, on contraceptive choice, on a variety of family planning issues, and on research utilization for policy development. He is a member of numerous professional associations and currently is co-chairman of the new Reproductive Health Research Committee of the International Union for the Scientific Study of Population.
Dr. Mundigo was born in Chile but is a citizen of the United States. He holds a Ph.D. in sociology from Cornell University. Recently retired from the World Health Organization, he will start work later this year as a consultant to the Ford Foundation. His home is in Manchester,Vermont.
The objective is to promote gender equality in all spheres of life, including family and community life, and to encourage and enable men to take responsibility for their sexual and reproductive behavior and their social and family roles. (ICPD, 4.25)
Men and women have very well-defined roles which vary according to their age and are affected by socio-cultural contexts. Men and women are biological entities with clearly defined physiological and sexual characteristics. Mens roles are restricted to the initial phase of the reproductive process, while women carry it to term. Men, just like women, are also a sub-culture in any society. Men take up specific professions, sports, and activities known to be "male" oriented and that tend to change and evolve over time. Men are sexual partners that is, they play a role in sexual initiation, in establishing sexual unions, or in stopping them. Men are husbands and fathers, and as such they are central figures in marriage and in reproduction. Men are contraceptors, and the extent of their participation and behavior in this area has increasingly come into question. Men have critical roles to play as health providers and as teachers. They often have responsibility for advising on matters concerning sexuality and family planning, including contraceptive provision and information to a clientele that consists primarily of women. Lastly, men are important research subjects, given their intrinsic role in reproduction, and as such they have been largely ignored.
The role of men in society, including their sexual behavior, participation in reproductive decisions, and child care involvement, varies from culture to culture, as do the corresponding roles of women. While we aim for universal goals of gender equality, it is important to recognize that in contexts as diverse as China, Japan, Saudi Arabia, Sweden, and Brazil, local custom and tradition, and economic circumstances, will shape what is possible in achieving universalistic goals. In striving toward gender equality, there must be consideration of the biological and psychological differences between men and women. We should also recognize that for men, as well as for women, there are expressions of sexuality that do not conform to what might be the more normative model in a society.
It is clear that women bear greater health hazards associated with reproduction than men, even though it is men who are largely responsible for originating them for example, in a situation where an unwanted pregnancy is followed by an unsafe induced abortion. Furthermore, men are often responsible for the sexually transmitted diseases that their partners endure. Men in many cultures are more likely to initiate or be involved in sexual networks that include more than one partner and thus are more exposed to acquiring, and becoming agents of, disease transmission. Sexual health affects men and women differentially, but it is more frequently the women who take the initiative in areas such as fertility regulation and reproductive health, perhaps because mens involvement in reproductive health, including contraception, has been largely ignored by service programs that have traditionally targeted women. The research literature is fairly devoid of studies that throw light into this area; therefore the discussion that follows is largely exploratory and is intended to stimulate debate and to raise issues for further study and policy debate. Increasing male responsibility in decisions and behavior concerning sexual practices, including a greater participation in family planning, is a key to improving reproductive health and cur-tailing the spread of sexually transmitted diseases, including HIV/AIDS.
Biology has determined that men play a lesser role in the reproductive process than women do. The role of men in this process is circumscribed to one critical activity: sexual intercourse, for which erection and ejaculation are necessary. Beyond that it is important that the male sperm reaches the female ovum, if a conception is desired. Consequently, men are less receptive to some of the nuances of the reproductive process, as the risks associated with pregnancy and childbearing are placed by nature primarily on women.
There is little question that biology determines the functional characteristics of what is male and what is female. But the expression of gender, particularly the behaviors associated with masculinity or femininity, is mostly shaped by the external factors that define the environment in which the individual grows. The argument advanced by feminist groups, and also by many professional organizations that promote sexual equality, is based on the premise that gender is less dependent on biology and more on contextual factors. This makes gender, including role re-definitions and scrutiny of proposed changes for example, to increase the role of fathers in child care or for men to be entitled to paternity leave a subject for ideological debate. In this context it is important to recall that societies often have strict norms that affect expressions of sexuality. For example, some societies will accept an open expression of homosexual behavior and others will condemn it, even to the extent of penalizing it as a criminal act. A similar situation exists with regard to prostitution. Additionally, most societies impose serious limitations on the degree to which younger people can express openly their sexual intentions and preferences, including for example the age and circumstances in which young people can enter into sexual relations. In the expression of their sexuality, men generally have greater freedom than women.
Male reproductive physiology is still less well understood than that of the female and is perceived to offer fewer possibilities where "controlled interference in the chain of reproductive events can occur" (Davidson et al, 1985).This has been presented as an explanation for the development of fewer contraceptive options for men as well as comparatively less interest among biomedical researchers to pursue studies in this area.
Efforts to develop viable hormonal contraceptives for men have been frustrated by concerns, both real and imagined, about the side effects of these compounds, including effects on sexuality and sexual behavior (WHO, 1982). More recently, the World Health Organization (WHO) has completed two major clinical trials to assess the contraceptive efficacy and side effects of weekly injections of testosterone enanthate. Further clinical studies are planned with combinations of hormones, expected to have a high level of contraceptive effectiveness and requiring less frequent administration, which may lead to the development of viable and acceptable hormonal contraceptives for men.
Among the new developments in this area is a potentially reversible vasectomy that utilizes intravasal injections of liquid silicone to form removable silicone rubber plugs that block the lumen of the vas deferens. Clinical trials are currently under way with this method, which may prove to be an acceptable alternative to conventional vasectomy for many men. Most of the male methods now undergoing clinical trials are many years away from being ready for commercial distribution. The contraceptive options available to men are still fairly limited.
Sexuality is an expression of emotions that include love and caring common to both men and women. But sexuality can also be used to express anger and violence, such as in the case of rape. Sexuality appears to have somewhat different forms of expression among men as compared to women.
But sexuality is also a universal human attribute linked to ego satisfaction and related to the preservation and continuation of life itself. Sexuality, therefore, can be the expression of a particular personality and should not be confused with masculinity. Rather, expressions of sexuality, including specific attitudes and behaviors, are ways to convey a sense of masculinity, but masculinity extends beyond the purely sexual aspects of life. The behavioral expression of masculinity is not determined by biology; it is largely acquired through socialization leading to the internalization of a set pattern of "male" attitudes and values, which are culturally anchored.
Men frequently exhibit behavior patterns that are recognized as being "masculine" for example, the well-known set of values associated with "machismo". The acquisition of these male values and their expression at various stages in life from childhood to adulthood set men apart from the world of women. As Badinter (1992:14) remarks, "We assume that femininity is a natural condition, and by consequence, inherent, while masculinity must be acquired and must be paid dearly for. Man himself, and those around him, is so unsure of his sexual identity that demands are made that he prove his virility." Men have to perform quite specific, culturally determined rites or tasks to become masculine and to prove themselves in front of women and other men. Because male offspring are accorded unique birth rights that confer on them certain privileges not given to women for example, greater freedom to explore beyond the confines of the household and encouragement to act more independently, more aggressively, displaying their own power boys assume early in life certain attributes of power and superiority, some of them vague in their manifestation, yet essential to establishing their own masculine identity.
The development of a masculine identity comprising the qualities necessary to act the adult male roles expected in a particular society is a long-term process. In many cultures boys and girls, at an early age, are segregated from each other in the home and at school. Men are socialized to be different, to be "masculine" in ways that are culturally appropriate.
In their development from boyhood to adolescence, men are often expected to prove their sexuality by peers or elders, which is a test of their masculinity. This includes proof of their ability to deal with women who, in this instance, are perceived merely as sexual or pleasure objects. Such pressures often lead to first sexual acts that are devoid of emotional content and that may include sexual abuse and violence against women. In general, emotional involvement in sex is more important for women than for men. As Parker in his study of sexuality (1991:59) remarks, "If femininity is understood as a natural force that needs only to be controlled and disciplined, masculinity is seen as anything but certain. Constantly threatened...the virility that marks mature male sexuality must follow a tortuous and troublesome path in coming to be: it must be cultivated through a complex process of masculinization beginning in early childhood."
An adequate sexual education to prepare the adolescent to deal with the problems that arise during puberty rarely takes place within the home. Similarly, at school the required courses on biology, which ideally would include the main functions and processes of the human body, hardly touch on the subject of sex. As a result, adolescents embark on their first sexual activities largely guided by ignorance and trial and error. Many teenagers are ignorant of their bodies, have little under-standing of their reproductive systems, and are not well aware of safe options for pregnancy prevention.
Sexuality as the pursuit of physical satisfaction, and sexuality as part of a process to form affective ties with the opposite sex, especially among adolescents, represent two different dimensions of sexual maturation which do not always occur simultaneously. A study of male adolescent students, conducted in Chile, provides unique insights into these two dimensions by exploring the meaning of sexuality among several groups of adolescents. Middle-class male adolescents saw women as objects for sexual satisfaction and perceived sexuality as containing certain elements of danger given the risks involved. For these students, acting on their own sexual instincts was seen as legitimate, but they did not see that women had the same right to exercise their sexuality.
For many young men, if the girl becomes pregnant she is to blame because she has not been careful and has failed to take the necessary precautions: she is the one who could have taken a pill and didnt. The reaction of males confronted with an unwanted pregnancy is an important aspect that has not been well researched and deserves considerably more exploration.
In many contexts men report having more sexual partners than women over their lifetime: in the United States, 56 percent of the adult men surveyed said they had five or more partners since age 18, as opposed to 30 percent of the women; the median for men is six partners and for women two, over an entire lifetime (Lauman et al, 1994). In Britain, the same relationship was 44 percent for men as opposed to 20 percent for women and in France, the men had about the same proportion, 45 percent, but women substantially less, 14 percent. Despite these figures, in general in the countries studied a remarkable stability and faithfulness exist within unions. In the United States, more than 80 percent of those interviewed had only one partner during the past 12 months (or no partners at all), and among married couples that proportion reaches 96 percent. Unfaithfulness, in fact, appears to be relatively rare; 90 percent of the women and more than 75 percent of the men declared never to have had extramarital affairs (Lauman et al, 1994). These patterns, however, are not similar across cultures or regions.
The study of sexual networks is useful to understand the propagation of sexually transmitted diseases, including HIV/AIDS (Klovdahl, 1985). Gay men, among whom the prevalence of HIV/AIDS is high, often operate within extensive sexual networks. Sexual networks are essentially "personal" or egocentric in nature they start with one individual and his sexual contacts. A sexual net-work includes at least three persons: the focal point and at least two other persons, mostly of the opposite sex, linked through common sexual relations.
Sexual networks can be of many types and configurations, as shown by a study in Netburi, a central province of Thailand. For example, open networks are common in Thailand, where it is widely accepted for married men to visit commercial sex establishments regularly; they see it as a way of adding variety to married life. The practice is not equated with being unfaithful. Women are expected to accept it and not question their husbands on these activities (Havanon et al, 1992:10).This practice is also fairly common in other countries of East Asia, for example in Japan and Korea.
There are also closed networks, such as in polygamous marriages where one man, who is the head of the household, has sexual relations with several wives. These exist among tribal societies in West Africa, in Muslim countries where polygamous arrangements are permitted and considered as normal familial configurations by the Muslim religion and even in traditional rural Latin American society, where the casa chica phenomenon is quite widespread.
At least two different types of sexual networks have been identified: the focused pattern, such as that identified for East Africa, Thailand, and parts of Latin America, with men having extra-marital sex primarily with commercial sex workers; and the diffuse pattern that includes both men and women, but where sexual networking is confined within a community through exchange of partners according to the demand and supply of women. The diffuse pattern of sexual behavior has been fairly well documented for southwest Nigeria, where partner exchanges are high but HIV is low due to their diffuse nature (Orubuloye et al, 1992).
Gender is a crucial aspect in the study of sexual networks, and increasingly, attention has shifted toward males, traditionally considered a difficult population to reach. As Anderson (1992:34) has noted, "Very little behavioral research has been directed towards the question of who mixes with whom... but also about who those partners were, in order to ascertain their rates of sexual partner change." Orubuloye, Caldwell and Caldwell (1992:344), however, point out that "men are more likely than women to disclose fully the extent of their sexual activities." They also note that men are more likely to provide accurate information on their sexual partners than are women, and that they may have better information about their partners other partners, thus improving the chances to determine the structure of a larger sexual network. The same point has been made by Helen Pickering (1988:239) based on her experience studying prostitutes and their clients in Gambia. While this refers to interviewing in African contexts, it is still an open question whether men in other societies may be equally open to questions concerning their sexual behavior.
Understanding sexual network patterns is very important to the determination of how HIV/AIDS expands over large amounts of territory. Shirley Lindenbaum (1993) has called attention to the "cultural geography" of sexuality. Work in Africa shows that focused patterns prevail in areas of high HIV prevalence for example, between Uganda and Tanzania, where movement across borders of illicit trade has contributed to the spread of AIDS there. G.K. Lwihula (1992) notes that highly mobile, conspicuous young businessmen have permissive sexual behaviors, visiting prostitutes where they trade. Although they have close-knit social networks, they are vaguely aware of the consequences of their behavior but they usually blame the prostitutes for passing around socially transmitted diseases (STDs). They do not seem to realize that they are part of a sexual network that is spreading these diseases.
African ethnographic literature abounds with similar examples. What do these examples tell us about the more monogamous but divorce-prone contemporary Western cultures? Pausing for a moment to look back at 19thcentury bourgeois society, we can safely assume that marital tensions arising from infidelity did exist and that the threat of sexually transmitted diseases, particularly of syphilis, was as serious an issue as AIDS is today, although it was probably less openly discussed. At that time there was no cure for syphilis as there is no cure for HIV infection today. Today sexuality is more openly expressed and tensions may be intensified as marital fidelity is less strictly enforced than previously, yet the resolution of these conflicts is easier through divorce. Divorce (or in some contexts separation) is now more easily obtainable and less socially stigmatized. In a sense, divorce is a safety valve protecting one or both partners as new sexual partnerships are formed. The new unions again conform to the socially acceptable rules of normal marriage, which condemn external sexual contacts.
Adolescence is an important moment in a mans life since it marks the onset of sexuality and the adoption of behavior patterns that have implications for adulthood. For a boy it means leaving the world of his mother and of the women in the household and establishing a "male" identity. This requires the gradual shifting of role models toward his father and adapting to those provided by other boys or adult males around him. During adolescence sexuality matures and enters an active phase that includes sexual exploration and the first sexual acts. Usually there is less of a problem for boys to express their sexuality than for women. The notion of virginity, which has traditionally applied to women, is now disappearing or less strong than before. In a recent study of sexuality in the United States, for example, among those born during the 1970s, only 5 percent of the women and 2 percent of the men had arrived "virgin" to their wedding night (Lauman et al, 1994).
Sexual behavior has important effects on reproductive health for male adolescents as well as for the women with whom they engage in sex, particularly when sexual intercourse occurs within a sexual network that might include both girlfriends and commercial sex workers. For example, in the area of contraception, the behavior of adolescents raises a number of important questions: Why do adolescents often initiate their sexual life without any contraceptive protection? Why do they hold negative views of the condom? Why do they view contraception as the responsibility of their female partners? Why do they act as if pregnancy is not their responsibility if it occurs? Why are they oblivious about protecting themselves or their partners against sexually transmitted disease? Very little research has been conducted to answer such questions.
Adolescence is a period generally marked by a variety of exploratory and risk-taking activities, including sexual behavior. As a result of unprotected sexual practices, adolescents may have to confront major dilemmas for which they are ill prepared, including unwanted pregnancy, abortion, early marriage and/or parenthood, and sexually transmitted disease. To the various risks of unprotected sex is added today the fear of death if HIV/AIDS has penetrated the sexual net-work within which an adolescent is active.
One of the outcomes of urban life is the weakening of the traditional family and the spread of new values promoted by a media-dominated, consumer-oriented society that uses sex to advertise products. This has an impact on young people and has led to the emergence of an adolescent sub-culture known for its sexual freedom and expression. Greater sexual freedom results in earlier sexual experimentation and initiation among males, but increasingly young women are also becoming sexually active early. This happens despite the fact that for the older generations sex among adolescents is considered to be a "bad" thing and is to be discouraged, particularly for their daughters.
The double standard in these attitudes is obvious; more often boys are supposed to be freer than girls to explore sexual domains. For example, a study by Sonenstein (1991:162) in the United States shows that among young women aged 15-19, the number claiming to have had sexual intercourse grew from 47 percent in 1982 to 53 percent in 1988; among young urban men aged 17-19 the proportion rose from 66 percent in 1979 to 76 percent in 1988.The survey on the sexual behavior of American adults (Lauman et al, 1994) showed that the basis for having sex also changed dramatically in the past generation. The authors report that in previous generations most women had sex for the first time because of affection, and only a minority (13 percent) as a result of peer pressure. In contrast, in the 1990s, 37 percent of the younger females declared that the reason they had sex for the first time was peer pressure. Furthermore, 29 percent of young females said that their first inter-course was not wanted or that it was forced. This is in stark contrast to the response of younger males, who said that peer pressure accounted for only 4 percent of their reason for first intercourse, and 92 percent reported "wanting it." The authors of the survey noted, "While the general concern about the problem of sex among young people has been directed toward issues of morality, pregnancy, and disease, it is clear that the problems of gender misunderstanding and the potential for violence in young peoples sexual lives have been generally unaddressed." (Reported in Trubisky, 1995:1). In addressing issues of adolescent sexuality it is important to remember that in non-western societies for example India, the Caribbean, and Africa early adolescent sexual activity, including early marriage, has been the norm for a long time. Again the importance of custom and tradition are the determinants of sexual behavior in these diverse cultural contexts.
One of the ways in which adolescent males typically initiate sexual life in many societies is with a commercial sex worker. The Netburi study in Thailand indicates that prostitution has always existed in the main towns and that males frequent prostitutes at a fairly early age. The average age at first visit reported in this study was 17 years (Havanon et al, 1992). Premarital sexual experience among male adolescents is also common in Latin America, a region where prostitution is fairly widespread. For example, among men aged 15-19 years, the percentage reporting premarital sexual experience in surveys of adolescents was 42 percent in Costa Rica, 44 percent in Mexico City, 73 percent in Rio de Janeiro, Salvador, and So Paulo, and 78 percent in Jamaica. The age at first inter-course for men tended to be around 15 and for women 17 years.
The Latin American surveys also reveal that few men or women use any contraception at the time of their first sexual intercourse. Men who reported using any form of contraception when they first had sexual intercourse ranged from 14 percent in Quito and Guayaquil to 31 percent in Mexico City. The large majority did not use any contraception at all, and the proportion of women who reported that they had used a method of contraception was only slightly higher. Most young men declared that they had not expected to have sex, that they knew little about contraception, and that they thought this was the girls responsibility (Robey et al, 1992).
Increasing contraceptive knowledge, access, and use among adolescents and young adults is one of the critical challenges in reproductive health policy today. Unprotected adolescent sex leads to high rates of unwanted pregnancy. In Latin America, according to data from the Demographic and Health Surveys, between 41 and 47 percent of thebirths to women 15 to 19 years old were unintended in Bolivia, Brazil, the Dominican Republic, El Salvador, Peru, Trinidad, and Tobago. In Central America, with the exception of Costa Rica, two-thirds of the women 15 to19 years old are likely to have a child before they reach age 20, and not necessarily unintended or unwanted. Marriage in these countries has traditionally occurred at younger ages: between one-fifth and one-fourth of women marry before age 20 in Central America, and some of these marriages take place because of unintended pregnancies (Population Reference Bureau, 1992).
When an unwanted pregnancy occurs, the consequences are particularly hard for young women who either bear the child or seek an illegal, unsafe abortion. If the decision is to bear the child, it often means putting an end to education and better career prospects. It can also mean a life as a single mother, a condition that in many parts of the world is the object of considerable social stigma.
Since women bear the actual pregnancies, males are not often asked questions about their own reproductive behavior. Recent surveys in Latin America, however, are including these questions. For example, from 10 to 20 percent of males aged 15-24 years in Rio de Janeiro, Recife, and Curitiba, in Brazil, report that they made their partner pregnant, which is somewhat lower than the pregnancies reported by women of the same age: 17 to 25 percent. Men more than women reported their first pregnancies had been unintended. Most revealing are the cases in which the men did not go on to establish a permanent union with the pregnant woman: between 37 and 57 percent of the males did not provide financial or moral support to the woman. From 32 to 60 percent of the unmarried males 15-24 years of age reported that their partners had an abortion when they discovered their pregnancy, the higher proportion being young men in Rio de Janeiro. Also the proportion of males who participated in that decision was particularly high in Rio de Janeiro - 60 percent (Morris, 1993).
There is little doubt that adolescent sexuality is a very complex issue and that patterns of sexuality vary from society to society. Information on whether young people had sex and at what age is less important than the circumstances, particularly the emotional dimension and the nature and quality of the relationship at that moment. Increasing adolescent male responsibility - particularly with regard to the consequences of their sexual actions for their female partners is an urgent need in the field of reproductive health.
Men have been called "the forgotten 50 percent of family planning" (Potts, 1992).The use of male methods is very low and it is probably lower now than it was in the past, when modern female contraceptive options were not available.
A recent WHO study report on user perspectives on contraceptive methods concludes, " The acceptability of male methods remains a research question" (WHO, 1995). Male methods include: condom, withdrawal, abstinence (rhythm), and vasectomy. None of these options is a very popular one and condom use remains low despite the enormous amount of advertisement that has followed the out-break of the AIDS epidemic. Vasectomy is not widely adopted in most developing countries, with the exception of some provinces of China where its use has increased rapidly in recent years.
In some countries, men make the decisions about contraception, particularly where withdrawal is widely used. For example, in Turkey, coitus interruptus is the method most commonly used by couples. It is also backed up with legal and safe abortion services if it fails. A study of withdrawal in Turkey concludes that the method should not be labelled as either primitive or inadequate. The study notes that withdrawal has played a major role in Turkeys fertility decline, and that the use of this method depends on the nature of the intimate relationship between husbands and wives. It points out that there is no need for any external agent to be involved, that withdrawal requires no medical supervision and no training, and that there is no cost involved. The study concludes by saying that use of withdrawal in Turkey is an indicator "that men are not always less concerned than women about limiting their families" (Cilingiroglu, 1994).
Rhythm is more complex than withdrawal, as it involves the cooperation of the male to abstain according to the timing of the female cycle. Its efficacy depends more on the woman and her ability to determine accurately the safe period.
Among the male methods currently available, the condom merits special discussion. It offers the unique advantage, if properly used, of protecting both against pregnancy and sexually transmitted diseases. In the age of HIV/AIDS, it offers one of the more powerful defenses against the sexual transmission of this dreaded disease. Despite its obvious advantages, condom use accounts for only 3 to 4 percent of all methods used in most developing countries.
In Brazil, a study conducted in 1991 (Berquo and de Souza) had as its main objective understanding the perceptions and use of the condom among a group of young people that included university students, bank office workers, and industrial workers. The authors reported that a national survey conducted in 1987, which included a sample of 30,000 women aged 15-24 years, showed that among the 70 percent of respondents who used a method of contraception, only 1.8 percent had used the condom. In part this reflects the fact that, for many couples, there has been a real separation between sexual relations and reproduction as a result of the adoption, primarily by women, of highly effective methods of contraception.
With the advent of AIDS, new individual behavior patterns have emerged which are also reflected in the larger society. It is precisely this new disease that has brought back the condom at a point in history when this method was, for many people, a thing of the past. Sexual intercourse once again includes preoccupation with sexually transmitted diseases that now threaten people regardless of sex, age, or class status. One of the changes noted by the Berquo and de Souza study in Brazil is that there may be a lowering, on one hand, of unwanted pregnancy among younger people who before did not use any method but now turn to the condom for disease protection while, on the other hand, there may be an increase in unwanted pregnancies among those people who formerly used a more efficient method, such as oral contraceptives, but now abandon it in favor of the condom.
The condom has lower efficacy rates than hormonal methods or IUDs. The Berquo and de Souza study of condom use included 300 young adult males, aged 18-30 years, of whom 66 percent were single, 31 percent married, and 3 percent separated. When they were asked, "Do you know what a man can do to avoid making a woman pregnant?" between 90 and 96 percent mentioned the condom. A good proportion of these young men, between 30 and 40 percent, also mentioned coitus interruptus and a smaller percentage vasectomy.
In more pointed questions, a large number of industrial workers did not have a clear idea of what to do to protect themselves against sexually transmitted disease. A majority of these men, 80 percent, had used the condom at least once in the past, but when sexually active men were asked about use during the previous month, only 30 percent had used a condom, the highest use level being among the university students. The study concludes that despite the recent health prevention campaigns, the condom is still perceived more as a method to avoid pregnancy than as a means to prevent STDs, and especially AIDS.
Newer survey evidence from Latin America, collected among sexually active, unmarried male adolescents and young adults (aged 15-24), is indicative of the emergence of a more positive attitude toward the condom. In Haiti, 34 percent of male young adults reported having used the condom during the last month. Similarly, in Jamaica, 69 percent, in Guatemala City, 40 percent, in Costa Rica, 53 percent, and in several Brazilian cities between 56 and 82 percent, reported either having used the condom or that their girlfriends were using the pill (the most widely used method) during the last month (Morris, 1993).
In addition to the scarcity of male contraceptive options, very few family planning clinics are geared to the needs of males. The lack of such services is particularly acute in the developing world. One notable exception is Colombia where PROFAMILIA - a large nation-al family planning program - has been successful in developing male clinics with the purpose of performing vasectomies and distributing condoms, as well as providing diagnoses and treatment for sexually transmitted disease. Since the program's start in the early 1970s, the number of vasectomies performed by PROFAMILIA rose from 92 in 1970 to 1,064 in 1973., doubling that number by the middle of the next decade as the program expanded (Vernon et al, 1991). In 1992 PROFAMILIA performed 5,872 vasectomies, as several new clinics for men were opened in Colombian cities (Jezowski,T, 1994). Similarly PROPATER is very active in Brazil with programs for men.
In the traditional role, the husband was responsible for the economic well-being of the family, while the wife was in charge of everything else, including reproduction and especially child rearing and home care. A study of families conducted in Peru showed that in 80 percent of the cases, it was the husband who decided where to live - whether to settle within the larger household of his parents or live independently - and who took most initiatives on economic issues (Ferrando, 1993). These traditional roles are slowly changing, and the participation of men in areas that have been traditionally female is helping to re-define inter-spousal relations and create a more symmetrical situation within marriage.
Issues of equality in sexual negotiations, shared responsibility of outcomes, control of household resources, and joint decisions concerning contraception and desired number of children are increasingly becoming an important topic for discussion in policy debates on population and family planning. What need to be resolved, if it is at all possible, are the tensions inherent in the differences and functions of each sex, on the one hand, and the goal of gender equality, on the other. In some ways these tensions between the sexes can be seen historically in adjustments to economic systems - for example, capital-ism, which required highly specialized economic activities and strong managerial controls, particularly in Western or industrialized societies. Occupations emerged that were typically either male or female. At the household level this led to the emergence of the patriarchy - a household with a male figure dominating most of the decisions, but in particular the economic ones. As Badinter (1992:17) notes, patriarchal-ism conferred special attributes to men: "The male was always defined as a very privileged human being, equipped with additional qualities which remained unknown to women. Men were assumed to be stronger, more intelligent, more courageous, more responsible, more creative, and more rational." This hierarchical situation, with its con-notation of male superiority, is rapidly changing, although in some cultural contexts it is still fairly predominant. It is in this respect that goals of gender equality require careful negotiations so as not to appear as cultural imperatives imposed from above or from outside. In fact, the process of social change that is occurring as part of the globalization of culture, the greater access by women to education, and their increased participation in technical and professional positions is rapidly threatening past male dominance.
The roles of men and women within the household are also affected by these changes. Tensions within marriage as the roles of women and men undergo change are also on the increase and are often resolved through divorce. At a societal level, requests for a more egalitarian society, in which women have equal access and equal pay in labor markets and greater power in the control of household resources, are voiced by organized women's groups and have gained greater legitimacy. The emergence of advocacy groups demanding equal rights for women has been an important recent phenomenon. They have strongly challenged the powerful patriarchal dominance of the male within the family and the community that characterized the past.
At the same time, little is known about how and to what extent men have responded to some of these changes. For example, the avail-ability of information on the extent of male involvement in reproductive decisions remains a fairly uncharted territory, yet a crucial one from a policy standpoint. Highlighting the need for greater equality, responsibility, and harmony within the family, the International Conference on Population and Development (ICPD) remarked that "Men play a key role in bringing about gender equality since, in most societies, men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and program decisions taken at all levels of Government" (ICPD, p.28).
Gender power relations within marriage, particularly the degree of dominance and asymmetry, are important because they determine the role of each spouse in the management of the household resources and of their children. They also affect marital sexual behavior, including the types of sexual expression and the degree of coercion or violence that may be considered acceptable within the relationship. By extension, the nature of gender power relations also influences the socialization of children in areas having to do with their own perception of masculinity, sexuality, and power. In order to deal effectively and correct the problems associated with gender inequality in the world today, one first step would be a major effort to understand its origins - basically to answer the question: What is the main cause of gender inequality? This would have to be done taking into consideration the societal context in which men and women live.
How the transmission of sexual norms, of scripts of power positions within the household, of gender-typed behaviors, and other relevant information occurs within the family and across the generations is not well understood. What is clear from a gender perspective is that there are important differences, with points of entry for discussion of some of these issues - particularly those of a sexual nature - being somewhat easier for women than for men. For mothers, the topic of menstruation is a natural and necessary step for discussion with their daughters which centers on a specific change in bodily functions and which is directly linked to puberty and sexuality. Similarly, mothers can explain sexual intercourse and pregnancy, as being part of a process, in a more natural way.
For fathers, by contrast, their sons do not experience an equivalent marker indicating the onset of puberty. Early episodes of ejaculation, wet dreams, or erections are not really equivalents to menstruation. Fathers, therefore, are less likely to approach or discuss the subject of sexuality with their sons at a time when this would be appropriate and beneficial. Hence the role of fathers in preparing their male offspring in matters having to do with sexuality appears to be less evident, and is, as a consequence, less frequent. In former times, particularly among certain cultural groups, there were well-established rites of passage that marked the change of boys into sexually mature young adults.
A benefit of parental discussions of sexuality with children might be to counter-balance the strong media exposure in which sex is delivered to children in a variety of explicit or implicit messages, many of them inaccurate. The older generation - also affected by the more explicit sexual language common today - has different perceptions of the sexuality of young people. Fathers and sons, in this respect, often live in different worlds.
A similar situation occurs in the classroom between male teachers and their adolescent students (Palma, 1993:125-131).What is actually happening in many societies is a challenge to traditional sexual norms and behaviors from the bottom up. Influenced by the media and by their peers, young people have become the leading force in the sexual revolution while the older generations, unable to engage in an open dialogue with them, try to contain change by withdrawing into established conventional positions. Religion also plays an important role in opposing change, particularly when the change is toward greater sexual freedom. It is interesting in this respect that the Catholic Church continues to be strongly opposed to the use of condoms even though government and private agencies working in HIV prevention advocate their use.
Despite the changes that have occurred in recent times, the role of men as husbands and fathers in many societies continues to emulate the traditional values of patriarchalism. The father perpetuates the values that he grew up with, influencing his male children's education, including sexual development and attitudes toward the opposite sex. It is precisely at this point that the opportunity exists for changing value systems and norms that define the core of society. At issue is how we can succeed in changing the value orientation of the new generations - and who will do it. Can fathers do it? And if they can, what exactly should these new values and orientations be? In fact a new ideology, gender sensitive, with new values and moral codes, has yet to be clearly defined.
A more egalitarian approach to household responsibilities - with increased duties for both men and women in areas such as child care and education, and more activities in which the couple may strengthen the quality of their own relationship - is needed for healthy social change, but research shows that men tend to remain more conservative on these issues than women (Amato and Booth, 1995).
Among these extended or new male responsibilities would be increased participation in contraception and reproductive decisions, and greater participation in raising their children, especially their male children.
Improving effective communication between partners on fertility decisions and fertility regulation may be an important factor in increasing effective contraceptive use, particularly in African countries where contraceptive prevalence is very low. Research in Ghana has shown that among a sample of 4.448 women and a 50 percent sample of their husbands, half of the wives believed that their husbands approved of family planning. But when the men were interviewed, a surprising majority, 70 percent, said they approved of it. Overall, 39 percent of the women did not know or misreported their husband's opinion regarding family planning, indicating poor inter-spousal communication on these issues. There was also substantial discordance in ideal family size between spouses (Salway, 1994).The benefits of improving inter-spousal communication was shown by an educational experiment in Ethiopia which led to an important uptake of modern contraception among 527 women non-users. When the husband was involved, contraceptive use rose to 47 percent. When the husband was not involved, use rose to only 33 percent (Terefe and Larson, 1993).
In general, it can be said that males worry less about contraception than women do, but many studies show that they are not totally uninvolved. The degree of involvement in fertility and family planning decisions varies in different cultural settings. The role of males in the decision to have an abortion remains particularly vague as there has been practically no attention paid in the research literature to this issue.
In many Asian societies but also in other regions of the world, there is a strong parental preference for male children, which may stem from a need to maintain family traditions that require a male heir to honor their ancestors or continue the patrilineal descent of the family. In many societies, another important reason is to ensure that the parents will have proper care in old age, which is assumed to be a sons responsibility. As Lloyd (1993:31) puts it, "Not all parents can afford the luxury of being fair, and one easy way to differentiate between children is according to sex. Both mothers and fathers may see different payoffs to investments in their sons vis-a-vis investments in their daughters, and these will vary across societies according to marriage custom and family organization."
In most countries the sex ratio at birth is biologically stable, remaining at about 104-106 male births per 100 female births in the absence of external interference, such as sex-selective infanticide, sex-selective abortion, or sex-selective under-reporting of birth statistics. In China the sex ratio at birth has been increasing since the 1960s and 1970s, when it was close to the normal value of 106, to 114 baby boys born for every 100 girls in 1989. This unusual increase in birth ratios has attracted a great deal of attention among researchers and policy-makers, as well as human rights activists (Zeng Yi et al, 1993).The high sex ratio at birth has been linked to Chinas one-child family policy which restricts the number of children for most families to only one child, although there are some exceptions, primarily in certain rural areas. Among the explanations given for this large increase in the proportion of male children being born is the use of prenatal sex identification (which has been declared illegal by the Chinese authorities), followed by gender-specific induced abortion. Another explanation is the giving away for adoption of baby girls who are not officially reported. Zeng Yi and his colleagues, using survey and hospital data, conclude that these two causes - sex selective abortion and under-reporting of girls - are the main reasons for the high sex ratio at birth in China today. They rule out infanticide as a cause. Although pre-natal sex identification is illegal in China, it is widely practiced. They conclude that "Strong male domination and discrimination against women have a long history and have not yet been fully eradicated in spite of great progress made in China, especially during the second half of this century" (Zeng Yi et al, 1993:296).
On the extent of son preference within the family in other countries, there may be discrepancies between men and women about the desired sex composition of their children, which may lead to larger families than otherwise desired. For example, how do male perceptions of the economic implications of large family size affect his needs or preferences for male progeny when several daughters have already been born? The determinants of family size through negotiations of sex preferences, and how these affect use of contraception, is an important area for further exploration. Lloyd (1993:33) has suggested that "bringing men into the picture" is necessary to get a better perspective on how the more traditional husband-wife unit works, makes decisions, and invests in their children. This better perspective will also provide "a more realistic view of the family" in all its complexity and manifestations, and thus lead to improvements in social and population policies.
The role of men as providers of health care, particularly in the provision of family planning services, is a critical one. As health providers they receive more training on the physiological or mechanical aspects of contraception (e.g., how to insert an IUD, how to perform a D&C) than on the kind of advice and assistance they ought to give to women faced with personal problems or the need to make an adequate choice of method (for example, a woman who does not want more children yet whose husband opposes her use of contraception). Physicians often provide information using medical terminology that is not always well understood by women of lower education. This is of special importance when dealing with side effects, a major reason for method discontinuation. Furthermore, in some societies women prefer female to male health providers, which further impedes good communication.
Male teachers, particularly in matters dealing with sexual education and contraception, are a very important source of information and knowledge. However, their training as sexual educators is often very limited and therefore they often use very ineffectual approaches. The enormous increase in teen-age pregnancy attests to the failure of educational systems and family planning programs to deal with this particular sub-group of the population. Undoubtedly more research is needed that addresses these issues.
In this respect, it is also important to note that generating more information on male sexual and fertility behavior continues to be a challenge. Males can be more difficult subjects to reach, as men traditionally work outside the home, return at later times, and are less regular than women in keeping to specific hours. In some cases, interviewing men may require late evening assignments for field researchers. Interviewing men requires male interviewers and may also add costs to research. There are also questions about the reliability of mens answers to certain questions, as is shown by discrepancies when husbands and wives are asked the same questions. Men may tend to exaggerate their sexual prowess. On the other hand, the evidence so far indicates that men seem as willing as women to respond to survey or open-ended questionnaires on issues that touch on intimate behavior. The opening up of a dialogue on issues relating to sexuality, a direct consequence of the AIDS epidemic and related prevention campaigns, may be a factor in assisting franker discussions. It is now an opportune time, therefore, to reverse the record of the past three decades of fertility and family planning research, which concentrated almost exclusively on women, by increasing the attention to men.
There is little question that achieving greater gender equality is a moral imperative, albeit a very difficult one to achieve. The underlying social, economic, and ideological conditions that prevail in many parts of the world will have to undergo drastic change to achieve success in this area. Advocacy for gender equality must take place within a realistic framework that considers the existing diversity among nations.
In the formulation of comprehensive sexual and reproductive health policies, the consideration of mens needs for information and services requires new and forward-looking approaches. While the goal set in the ICPD Program of Action is to increase male responsibility in all areas relating to family formation and human reproduction, there are cultural and ideological barriers that need to be overcome to get greater male involvement. Some of these are of a religious nature, while others are simply dictated by long-held traditions and by economic systems. To overcome these barriers, important transformations in the conditions that prevail in most societies would have to be achieved. Furthermore, with divorce and other forms of marital dissolution becoming increasingly common, the number of female-headed house-holds has increased (Bruce and Lloyd, 1992). As a result, women are having to face a double parental role that is extremely difficult for them and their offspring.
The patriarchal role of men in the family is being challenged, and new roles for men are emerging. Men are not one large homogeneous category, nor are all men equally committed to participating in contraceptive or child care decisions. An important group of males that deserves special attention is adolescents and young adults, in particular those who are sexually active and at risk of contracting sexually transmitted disease, including HIV/AIDS. Young people must also confront the consequences of unwanted pregnancy, including early parenthood or abortion, if preventive measures are not taken before sexual intercourse takes place.
From these concerns an important question emerges: Whose role is it to ensure that men, including adolescents, modify their sexual and reproductive behavior to become the responsible citizens that international agreements seem to require? Is it the family, the father, the school, the health care system, the family planning programs, or a constellation of these? The answer seems to point to the latter as offering the best solution, yet that requires policies that coordinate efforts occurring at various levels within a society. One way to a solution could be the comprehensive framework offered by reproductive health. This frame-work encompasses sexual health, sexual education, sexually transmitted disease, contraception, unwanted pregnancy, and abortion, as well as the biological and behavioral dimensions of these components. Governments may consider investing in reproductive health services for men, and private sector institutions may mobilize resources to deal with the educational and family components. Another challenge is to increase the societal dialogue on this issue by improving the quality of the baseline information available for example, on the participation of men in contraceptive choice within unions or in the formulation of goals for the familys desired composition. Similarly, a greater understanding of sexual networks and their composition and the extent to which they operate as open or closed systems, including information on all the sexual partners involved, would be useful to understanding sexual behavior and patterns. Ultimately, the improvement of policies will depend on the quality of the information available on these issues, which has been one of the most neglected areas in population and family planning studies.
From a sexual health perspective it is essential that parents, particularly men, be instructed and stimulated to help guide their children to achieve the transition from pre-adolescence to the adult phase with appropriate information on sexuality and contraception. Women should encourage their husbands to be more assertive in assuming this role and responsibility. This would be an important step in helping children to develop into sexually healthy and responsible adults.