M LV HEALTH INTERNATIONAL, VOL. 18 NO.3, SPRING 1998 NewsBriefs

TIME 0 FONSET'. F<;>k"'C; p~h~~~ti9!l" Both studies, sup­ AIDS CASE FROM OC STROKE RISK 'M~i'::.8 8Q~ l~,;:·'p~r.~~tfbYFFn P RaG Est.J N'i . and published in 1959 VERY Low ~ ~ :i,:' t\',':_ " :;':: tn~~F ebruary issue ofFertility Decentstudies su~g~s,i:\hit)t~;)an~~~~~~lt9" focused only on '" cientists recently verified '" '. omen taking oralcontra­ the earliest known case of ,.' '. ceptives, especiallypills ~:~~~:;~~:::e;~:~'~. £/ ~~~:~~~~~~~.~~~i~c~ofa ~ ta ,;; AIDS, an African man who W., with higher levels ofestro- acetate (DMPA) and Norplant sperm penetration ~t day three died in 1959. The discovery " gen, ha~e an increased risk of provide effecti~e preg~~ncy pro- in this one subject was unex- suggests the virus first infected suffering a blood clot-induced tection more rapidly after injec- pected, and suggests the need people during the 1940s or early stroke than women not using tion or insertion than previously for more research to determine 1950s. them, but that risk is very low, thought, probably within three better the risk ofpregnancy if In a study published in the according to a study published days for most women. backup methods are not used for February 5 issue ofNature, re­ in the December 1997 British Current international seven days," says Dr. Petta. By searchers looked for signs of Medical Journal. guidelines recommend that the seventh day, all subjects in HIVin 1,213 blood sanlples The low-dose combined couples use a backup method for his study had cervical mucus gathered between 1959 and oral contraceptive pills com­ seven days after administration scores indicating contraceptive 1982 in Africa, where the virus is monly used today carry an even ofthese progestin-only methods, efficacy. .' believed to have originated. One smaller risk than the earlier ifa woman receives the implant In the study ofDMPA sample from a Bantu man who higher-dose pills. The results or injection after the seventh day (Depo-Provera brand), con- lived in Kinshasa, Congo (then from this study, which involved ofher active menstrual cycle. ducted by researchers fronl FHI called Leopoldville) clearly con­ 220 European women ages 16 to Some national guidelines rec- and the Universidade Estadual tained HIVgenetic fragments. 44 who had a stroke, and 775 ommend using a backup for the de Campinas, Campinas, Brazil, The scientists compared others who did not, were consis­ remainder ofthe menstrual 30 Brazilian women ages 18 to the 1959 HIV genetic fragments tent with results from a similar cycle. 40 were injected with the con- with genes from currentver­ 1996 study by the World Health Using condoms or another traceptive between days eight sions ofHIV, ofwhich there are Organization. backup method for less time and 13 oftheir menstrual cycle. 10 distinct subtypes, lettered A "Only first generation would save money for the user One day after injection, 90 per- through J. The researchers oral contraceptives'(high-dose and may encourage better com- cent.of the subjects display~d . found that the 39-year-old HIV estrogen) seem to be associated pliance, thus reducing preg- cervIcal mucus scores that IndI- sample was an ancestor ofsub­ with a higher risk," says Lothar nancy risks. (No backup method cated effective contr~ception types Band D. Subtype Bis the Heinemann ofthe Center for is necessary when the recipient had already been achIeved. dominant strain in the United Epidemiology and Health Re­ is within the first seven days of Asimilar study anlong 42 States and Europe, while subtype search in Berlin, principal author the menstrual cycle.) wonlen using Norplant in the D is most common in Africa. ofthe study. Oral contraceptive "We believe couples should Dominican Republic - This evolutionary continu­ use may cause about three strokes continue to use a backup for conducted by FHI, Asociaci6n ity suggests that all HIV sub­ annually per 100,000 women ages seven days until more research Dominicana Pro Bienestar de la types mutated from one form of 16 to 44, the study says. The very can examine this issue," says Dr. Familia (Profamilia), Johns HIV introduced into people, small increase in risk associated Carlos Petta ofBrazil,a former Hopkins Bayview Medical Cen- probably from monkeys or other with pills, the scientists noted, FHI fellow and principal author ter and Duke University- primates. Discovery ofthis early could be controlled ifdoctors did ofthe DMPA study. He notes indicated contraceptive effec- form ofHIVnlay help experts not prescribe pills to women with that one ofthe 30 subjects in his tiveness by the third day for all predict how the virus will evolve such cardiovascular risk factors as study did not appear to achieve women. "Backup methods of during the coming decades. high blood pressure. contraceptive protection by th~ contraception such as condoms More than 30 million people "Any small risks associated third day. need not be used for more than worldwide are infected with with the use ofOCs certainly are Like other progestin-only three days after [Norplant] in- HIV. Before the discovery ofthe outweighed by the clear benefits methods,both DMPA and sertion, even when the implants 1959 sample, the earliest uncon­ they provide to women ofrepro­ Norplant provide contraception are inserted close to ovulation," tested cases ofAIDS were inthe ductive age," says Dr. Pamela by inhibiting ovulation and by the authors concluded. late 1960s among members ofa Schwingl, an FHI epidenliolo­ causing cervical mucus to Norwegian family. gist who has studied this associa­ thicken, thus preventing sperm tion. "Risks associated with complications ofpregnancy and childbirth are far greater."

2 NETWORK Spring 1998 ·.Ni~if;i~lllibI1sl1eajq~~IT~!lyur~~~I1;jj/j··/ .··.~:tia:lJ~~~;:~~~~~r~···· ·i'j,j ':.:':::: 0 0 0

FAMILY HEALTH INTERNATIONAL, VOL. 18 NO.3, SPRING 1998

1[\1 THIS ISSUE

MEN AND REPRODUCTIVE HEALTH

MALE RESPONSIBILITY FOR REPRODUCTIVE HEALTH •••••••••••••••• 4

MEN'S REPRODUCTIVE HEALTH RISKS ••••••••••••••••••••••••••••••••••••• 7

MALE CIRCUMCISION AND HIV RISK •••••••••••••••••••••••••••••••••••••••• 9

MALE PARTICIPATION IN REPRODUCTIVE HEALTH ••••••••••••••••••• 11

MEN INFLUENCE CONTRACEPTIVE USE •••••••••••••••••••••••••••••••••• 13

REPRODUCTIVE HEALTH PROGRAMS FOR MEN •••••••••••••••••••••••• 28

, ..:::::.:; ..

CONTRACEPTIVE METHODS FOR MEN

EXPERIMENTAL MALE METHODS INHIBIT SPERM ••••••••••••••••••••• 16

.:·AR.T!~&\;PROriUCTiONEDITOR: ,;:, "....:.... CONDOM USE INCREASING •••••••••••••••••••••••••••••••••••••••••••••••••••• 20 ':.t;;i"!!l;!!(~f~lt:"Didk~tsoIl:· :. :'. ..' '. BEHAVIOR AFFECTS CONSISTENT USE ••••••••••••••••••••••••••••••••••• 22

Do CONDOM CHARACTERISTICS INFLUENCE USE? ••••••••••••••••••• 23

REASONS TO HAVE CONFIDENCE IN CONDOMS •••••••••••••••••••••••• 24

ATTRACTING MEN TO VASECTOMy •••••••••••••••••••••••••••••••••••••••••• 26

DEPARTMENTS

NEWS BRIEFS •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 2

RESOURCES ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 32

.·:~~n£yfor:ffitemationiFI>eve1opment~·:--..·.:·,,:: '; Encouraging male responsibility for family planning requires services that protect the reproductive health ofboth men and women. An Ecuadorian farmer, photographed by Carlos D. Conde for Inter-American Development Bank, appears on the cover.

NETWORK Spring 1998 3 Male.Responsib,ilitylor Reproductive Health

The objective istopronzote gender equality in all spheres oflife, indudi!lgfamily and community life, and to encourage and enable men to take responsibilityfor their sexual and reproductive behavior and their social andfamily roles.

," " - Programme ofAction, UN International Conference on Population and Development, 1?94

efore the sexual revolutioninitiated which has pioneered services for nlen since by the pill, menwere a more integral 1985, when its first clinics formen opened. part offamily planning and" other Today, PROFAMILIA"clinics offer a range, reproductive health concerns than ofmale reproductive health services, in ad­ they are today. Ifa couple wished to dition to providing such male contraceptive use contraception, their options were lim~ "options as vasectonlies. "We never have been itedpfimarily to methods requiring a man's interested in subtracting from our services­ participation - withdrawal, periodic absti­ what we need is to do more. We do this by lienee or condoms. looking into what we have, what we can use Hormonal me'thods for wonlen, begin­ better, where the empty space is,"and how to ning with the first oral contraceptives in usewhat we now have more costefficiently 1960, and thesubsequent development of and with more client~orientation. The first intrauterine devices and modern surgical thing is toask clientS what they want." sterilization, led to the development of a While PROFAMILIA and a fewothe~ family planning services community focused successful progranls have found ways to on women, often to theexc1usion"ofmen. encourage nlale partidpation,"ahuge gap Today's challenge, as expressed by the 1994 remains between the rhetoric ofpromoting International Conference on Population and male involvement and "the realities offemale­ Development (ICPD) held in Cairo, is to oriented reproductive health programs," says enhance male responsibility for family plan­ Errol Alexis ofthe New York-based Margaret ning by expanding services in ways that pro­ Sanger CenterInternational, who has tect the reproductive health of both nlen and worked with men and youth for20yearsih women, and by encouraging greater sensi­ the Caribbean,' Africa and the United States. tivity to gender issues. One major obstacle is men's reluctance Some fear tIiat adding services for men to use services. Men lmowlittle abouttheir will result in fewer resources available for" own or women's sexuality, communiCate women, who currently bear most ofthe re­ aboutsexuality very little intheir relation,,:, sponsibility for family planning and other ships, and often believe many sexual myths, " reproductive health concerns. "The idea of says Alexis. "Many men are suspicious of services for men is to add and not to sub­ tract," says Maria Isabel Plata, director of the Asociaci6n Probienestar de la Familia Colombiana (PROFAMILIA) in Colombia, family planning programs because they see them as a conspiracy to undermine their power." . Providers must also overcome false assumptions and generalizations about men. It is easy to say that nlen always want nlore children, are not interested in using contra­ ception, do no"t care about spreading sexu­ ally transmitted diseases (STDs), never share in responsibility ofraising children, . and perpetuate violence against women. Some programs have been designed on these assumptions and therefore exclude ~en rou­ tinely, preventing men from getting help to understand their needs and to change harm­ ful behaviors. Yet surveys show that as men learn about contraception, they want to use . it, and as pressures ofraising large families increase, they want fewer children. I In nearly any country or culture, there are men who share in parenting responsibilities and who stand against violence against women. In a larger context, "gender equality" must be achieved. As used in the ICPD's Programme ofAction, this term refers to an equality in the roles and responsibilities as­ signed to men and women by society, roles that influence all aspects oflife. Providers and health officials should emphasize inter­ dependence and mutual benefits from serv­ ing both sexes, ~ot focusing exclusively on one at the expense, ultimately, ofboth.

PROGRAM ·DIRECTIONS BETTER SERVICES FOR MEN AFFECT ALL FAMILY MEMBERS. FOR EXAMPLE, MEN WHO ARE To serVe men better, programs need to EDUCATED ABOUT REPRODUCTIVE HEALTH ARE MORE LIKELY TO DISCUSS FAMILY reconcile confli~ting opinions and views PLANNING NEEDS WITH THEIR PARTNERS. about men and reproductive health. As part ofthis effort, the U.S. Agency for Interna­ Encourage Men to Support Women's Increase Communication Between Part­ tional Development (USAID) recently es­ Contraceptive Choices. One ofthe fre­ ners. When reproductive health decisions tablished a·Gender Working Group, with quent reasons given by women for not be­ are taken jointly by both partners, these de­ participation from its cooperating agencies ginning or continuing to use contraception cisions are more likely to be implemented. and others working in the international re­ is their partner's opposition. Men who are Men become more supportive by helping productive health field. The group has four educated about reproductive health issues their partners to receive reproductive· health committees that are examining issues related are more likely to support their partner's services when needed and by providing the to gender and reproductive health. One is decisions and to encourage public policies resources needed to obtain these services. A. the Men and Reproductive Health Commit­ that result in women receiving the repro­ 1994 family planning campaign in Bolivia tee, co-chaired by the authors ofthis article. ductive health care they need. Aproject in sought to increase communication! using In the initial meetings ofthis commit­ rural Mali addressed this goal by using men the slogan, "Let's talk 'together." During the tee, representatives from more than 20 to promote family planning in local commu­ promotion, the number ofnew contracep­ agencies have discussed inclusive approaches nities. Many women reported that male tive users and the number ofmen reporting that can serve men's and women's needs, community workers had changed their hus­ their intention to seek reproductive health and can contribute to gender equity. From bands' attitudes towards family planning and services'increased dramatically.3 these informal discussions, here are six gen­ had generated more open communication Some women become pregnant only era:! goals to consider when designing pro­ between spouses about family planning. 2 because they believe their husbands want grams to address men and reproductive more children. But this may not always be health, within the context of gender equity: true. Surveys in several developing countries show that only slightly more men than

NETWORK' Spring 1998 5 women want to have another child (see ar­ such as infertility, sexual dysfunction, pros­ the parents' appreciation ofthis important ticle on page 11). Increased communication tate cancer and testicular cancer. Alack of event. Many provocative concepts are raised between partners improves understanding of services to address these needs contributes in this exercise: whether unmarried men each partner's reproductive preferences and to stress, anxiety and loss ofself-esteem have a right to multiple partners; whether decreases some ofthe consequences ofpoor anlong men. "Men, like women, face differ­ every male involvement program should be communication, such as unintended preg­ ent issues at different stages oftheir life evaluated in terms ofhow it can improve nancy and a large family size. cycle," says]effrey Spieler ofUSAID, a spe­ women's health; and whether a woman's use cialist on male reproductive health. "A criti­ ofcontraception without her husband's Increase the Use ofMale Methods. cal time is during the younger years, when knowledge is aviolation oftrust. Increased use ofmale methods will relieve boys go through a lot ofgender identifica­ Responses to these statenlents will re­ some ofthe burden ofcontraception that tion and modeling. Doing a better job of flect a wide range ofpersonal values, shaped currently is.placed on women. Some programs counseling boys and young men through by cultural, educational and professional are using creative promotional campaigns for proper sex education programs could help experiences, and clearly influenced by one's vasectomy, which nlay expand use ofthis safe address a lot ofissues that emerge later in gender. Those who work in the field ofre­ and effective method (see article on page 26). the life cycle." productive health have an obligation to "Policy-makers and service providers have evaluate their personal viewpoints carefully. alleviated men from responsibility for using Encourage Men to Become More Aware Understanding personal opinions about existing male methods, for example, by focus­ ofRelated Family Issues. Men need to be gender-related issues is a fundamental step ing attention on female sterilization, even to nlore involved in raising children, in encour­ toward better services. With these insights, the detriment ofsuccessful vasectomy pro­ aging schooling for both girls and boys, in we are better prepared to make vital deci­ grams;" explains Dr. Karin Ringheim of reducing violence against women and chil­ sions that may have profound implications USAID in an analysis ofgender issues that dren, and in making resources available to on the lives ofmany men, as well as many influence contraceptive choices.4 As condom meet the needs ofthe family. These are women. use increases in the AIDS era, more family complex, deeply ingrained cultural issues, - Dr. Isaiah Ndong and William R. Finger planning providers are offering condoms as and in many settings, family concerns are a contraceptive choice for those at high risk closely linked to family planning and repro­ Dr. Isaiah Ndong worked in general practice in ofSTDs. Unfortunately, there are few ductive health. In one program in rural his native Cameroon befirejoining AVSC methods currently available for men, and Uganda, for example, more male clients visit International as a medical associate and a team research on new male methods continues at the family planning clinic during the season member ofthe Men as Partners Initiative. He a slow pace (see article on page 16). when school fees are due, says a nurse, be­ and William R. Finger, a Network senior cause that is when "men finally understand science writer/editor, co-chair the Men and Improve Men's Behavior for the Preven­ the burden ofhaving many children, a burden Reproductive Health Committee ofthe USAID tion ofSTDs. The effect ofmen's attitudes that women have understood since before a Gender Working Group. and behaviors with respect to women's child is born."5 health is perhaps most evident in STD pre­ REFERENCES vention and treatment. For prevention pro­ 1. Ezeh AC, Seroussi M, Raggers H. Men's OVERCOMING BIASES grams to be effective, they need to educate Fertility, Contraceptive Use, and Reproductive Pref and treat both partners. Increasing condom The strategy ofcomplementary male erences -DHS, Comparative Studies No. 18. use and changing high-risk sexual behaviors and female services requires many elements Calverton, MD: Macro International, Inc., 1996. are primary STD prevention strategies. to succeed, including a provider's recogni­ 2. Kak LP, Signer MB. The Introduction of tion ofhis or her own personal values about Community-based Family Planning Services in Ru­ Where condoms have been heavily pro­ ral Mali: The Katibougou Family Health Project. moted by social marketing campaigns, con­ gender equity, and how tllese values might CEDPA Working Paper No.2. Washington: dom use has gone up markedly. Increasing result in biases toward men or women. Centre for Development and Population Activi­ condom use is a step toward changing men's One exercise, developed by the Margaret ties, 1993. behavior in a way that directly affects ~eir . Sanger Center International and International 3. Valente TW, Saba WP, MerrittAP, et al. own'health, as well as the health oftheir Planned Parenthood Federation, seeks to help Reproductive Health Is in Your Hands: Impact ofthe partners and wives. But surveys show that people understand their personal values by Bolivia National Reproductive Health Program Campaign. IEC Field Report No.4. Baltimore: The highe~ offering a number ofstatements to which condom use is much outside ofmar­ Johns Hopkins Center for Communication Pro­ each person responds. Groups can share riage than with spo'uses, and wives with little grams, 1996. power to negotiate'condom use can be in­ these comments to help clarify a group's 4. Ringheim K. Whither methods for men? fected by husbands (see article on page 20). gender values. For example, one statement Emerging gender issues in contraception. Reprod says: "A man should be expected to be Health Matters, 1996 No. 7:79-89. Address Men's Own Reproductive present at the birth ofhis child." In some 5. AVSC International, Busoga Diocese's Health Needs. Access to reproductive cultures, men are forbidden from being Family Life Education Program. Reaching Men in present during birth. In other places, includ­ Uganda: A Case Study ofthe Busoga Diocese's Family health services should be an issue ofhuman Life Education Program. (New York: AVSC Inter- rights for both women and men. Men have ing the United States, a man's presence dur­ national, 1997) 10. - their own reproductive health problems be­ ing birth is encouraged as a way to enhance yond family planning and STD services,

6 N ETWC?RK Spring 1998 Men's Reproductive ·HealtbRisks

Threats to men's fertility and reproductiyehealth include disease; cancer and exposure to toxins.

.angers to men's reproductive health concern men very much since the'tradi­ . come in several varieties. Some ­ tional' diseases often were asymptomatic or . namely, sexually transmitted diseases produced symptoms that could be treated (STDs) -are preventable. However, with antibiotics, with no apparent lasting when means ofprevention are un- sequelae for men," says Dr. Willard Cates known, unavailable, unused or fail, STDs can Jr., FHI'spresident and an expert onSTDs. pose a threat not only to a man's fertility and "But some oftheseSTDs affected men indi~ health but to those ofhis sexual partner. rectly;by infecting their partners, these men Other threats, often impaired the fertility ofthe women such as environmen­ .who would have borne their children." tal toxins the)t may Now, however, it is known that such affect men's offspring STDs can reduce men's fertility as well. In­ or reduce sperm fections can block the vas deferens or cause count and thus re­ epididymitis, inflammation ofthe tubes duce fertility, have through whic4 sperm nlove fronl the testes not been consistently to the vas. SexUally transmitted organisms ~ identified. Yet, if particularly Neisseria gonorrhoeae or Chlamydia they do existand can trachomatis - are the most common cause of be pinpointed, they epididymitis in heterosexual men under the may prove to be age of35. When the tubes transporting sperm avoidable. from bothtestes are infected, incidence ofin­ Still other re­ fertility may approach 40 percent. 1 productive· system That infertility affects men, as well as ' conditions, such as women, often is unknown or forgotten. prostate and testicu­ Women, particularly in developing coun-· lar canter, mayor tries, may be blamed and even divorced·. may not be prevent­ based on the belief that they are solely re­ able, but pose no risk sponsible for not bearing children. But men to others. were either thesole cause or a contributing In the AIDSera, factorto infertility in more than halfof greater attention has 5,800 infertilecouples studied by the World been focused on Health' Organization (WHO) between 1979 STDs as primary and 1984. Thismulticenter WHO study reproductive health concluded that male causes accounted for threats. "Before the . between 8t022 percent ofinfertility world­ eraofincurable and wide; both male and female causes ac­ often fatal viral counted for between 21 to 38 percent; and .STDs, STDs did not female causes accounted for between 25 to 37 percent.2

NETWORK Spring 1998 7 Infertility in developing countries is "\iVhen used consistently and correctly, latex ENVIRONMENTAL THREATS widespread, but often preventable. Infertil­ nlale condoms give substantial protection Various environmental factors have ity can be caused by infectious and parasitic against both bacterial and viral STDs, in­ been studied as possible causes of male infer­ diseases. It also often results from poor cluding HIV. Fortunately, condom use in tility. Chronic exposure to high levels of health care practices such as unhygienic or younger populations seems to be going up." arsenic in drinking water in one area of inappropriate obstetric and gynecologic In collaboration with the Komfo Mexico, for example, is believed to contrib­ practices for women, or vascular injuries due Anokye Teaching Hospital in Kumasi, ute to male infertility.s High levels ofafla­ 3 to poorly performed hernia repairs in men. Ghana, FHI conducted a study ofcontra­ toxins, the result of fungi contaminating STDs, however, are the leading preveritable ceptive use at an STD clinic in Kumasi. Half stored agricultural crops, also have been sus­ ---cause ofinfertility.In the WHO study of (47 percent) of 108 sexually active men in pected ofreducing male fertility. Aflatoxins 5,800 couples from 25 countries throughout the study reported that they used condoms were presentin 40 percent ofsemen samples the developed and developing world, African all or most ofthe time. Among condom users, from an infertile group ofNigerian men, couples were more·likely than other couples to 16 percent reported using them solely for compared with 8 percent ofsemen samples . have a'history ofSTDs and infertility diag­ STD prevention and 66 percent reported from a group offertile men.6 noses suggestive ofprevious genital infections. using them both for contraception and STD The question ofwhether men's occu­ prevention. The most common reason given pational exposure to toxins poses risks to by men for not using condoms was desired FAMILY RISKS their offspring remains a "relatively under­ pregnancy (20 percent). In this study, the . studied area in which few epidemiologists or The reproductive health status and be­ vast majority ofmen (89 percent) reported laboratory researchers work and where there havior ofmen playa critical role in main­ that they had no problems obtaining has been no resolution of conflicting data," taining the health ofwomen and children. 4 condoms. says Dr. Andy Olshan, associate professor Men having unsafe sex outside ofmarriage Even the female condom, which has in the department of epidemiology at the may become infected and share their infec­ not been adequately studied as a protection University ofNorth Carolina, Chapel Hill, tion with their wives. measure for viral STDs but may protect NC,USA. The physiology of awoman's repro­ against some bacterial STDs, requires a de­ There is epidemiological evidence sug­ ductive tract means that her risk ofbeing gree ofmale cooperation. In addition, some gesting an association between paternal ex­ infected with STDs, especially HIV, by an men object to the use ofspermicides, which posure to certain toxins and adverse outcomes infected man is much greater than that of a protect against some bacterial STDs. in offspring - including miscarriage, birth man's being infected by a woman. Once awoman is infected, the couple's un­ HElOUR NETOCNY/PANOS PICTURES born children also may be affected. An infected women can transnlit vari­ ous STDs to her fetus, newborn or infant through the placenta, during vaginal delivery or via breastfeeding. In both men and women, sexually trans­ mitted pathogens can lead to cancer. Almost all can­ cers ofthe anus, penis, cervix, vagina and vulva are now thought to be caused by sexually ac­ quired human papilloma virus (HPV). "In the STD preven­ tion area, men are crucial because the main method we have for prevention is the male condom, which requires the male partner's cooperation to

use," says Dr. Cates. MEN WHOSE WORK REQUIRES LONG ABSENCES FROM THEIR FAMILIES, SUCH AS TRUCK

DRIVERS OR MINERS, MAY BE EXPOSED TO GREATER STD RISKS. THESE MINERS WORK IN A

REMOTE INDIAN COAL MINE. 8 NETWORK Spring 1998 In recent years, widespread con­ cern has arisen that diethylstilbestrol (DES), an estrogen-like SYnthetic agent that was prescribed between the' late 1940s and early 1970s in the USA to prevent pregnancy complica­ tions, might induce infertility among these women's children. DES, be­ lieved to have been used by pregnant· women in some developing coun­ tries, is known to cause a rare cancer ofthe vagina and cervix in young women whose mothers received DES during pregnancy, as well as increasing the daughters' risk ofin­ fertility, miscarriage, preterm deliv­ ery and fetal or infant death of their children. Although the largest, most care- . fully conducted study ofadult men exposed in utero to DES did not mea­ sure sperm counts, it showed no im­ pairment offertility or sexual function among these men.wSons of women who took DES while preg­ nant, however, are more likely than . sh.6Wga iliat:ilier~was n6eViden2~Hf~ pro"":.. '....• '.. '.' 2iEalim~IllliEO;\Ma§v<9M;iZti£~~nrian.··. :>:;. unexposed nlen to have testicular abnormalities at birth, including un- . s '~:. .~ t c~;'p ~.aJ):d u.~: !~:.c .>...... ·i m.n. '2.'...• i : 1 t1 descended testicles. This condition, §~~a~y:;tr~IlsmltteU)'. '. '1.1 .;';}.'.·:. "dIseases.r;i.·.·S!.L'.:.(S. ..L1J~\!.').•..•. ·lh!/":%i//.IS..0.. J.. i..i)%. . J.AMJ11997;277(13):1052B57~'·sletn.. .. f()P.hyl.. actlC.. effe.c.t.s; .. F5.5:ee."....•.•.xx..:::lt...•'::p •...... :ce...... •...... •...... ::::'...•...••.•..::..:.'.::..: i;; fact,. clrctimciseo men wereisligl1tly more •... ..•. :.> Ji.J)onBva1iBWBasseHTjiB6ds.\ybtHL&[tY:H:i>/·: ifnot corrected in early childhood, . .~kelytil'ha"ii' litta'h9th):fhacfefjal':frid:fVir~I·· ;Maledr~mtllSI6nral1

PROSTATE CANCER In recent years, the subject of defects and childhood cancers - but it is in sperm count, as well as sampling bias. cancer of the prostate - the diminutive, limited. "Geneticists tend to feel that the Some investigators point out that, in specific walnut-sized gland located deep in a man's probability of toxin-induced mutations of places, sperm counts have been constant for lower abdomen - has generated vigorous sperm leading to a birth defect in offspring is decades or are rising;8 still others nlaintain debate. As yet, there is little medical consen- . very low," says Dr. Olshan. "But more solid that reliable data on the issue simply do not sus about prostate cancer's etiology, recom- . research looking at avariety oftoxic expo­ exist. However, evidence oflow or declining mendations for screening, or usefulness of sures in the laboratory and field is needed, if sperm counts in certain parts ofthe world early detection and treatment. only to close out the issue." remains ofinterest since such regional varia­ The incidence rates for prostate cancer, Similarly, research is not conclusive tions may reflect nutritional, socioeconomic which is rare before age 50, have been par­ regarding theories that sperm counts may be or environmental influences. 9 ticularly high in the developed areas ofthe declining among men worldwide. Based on aninlal data, various re­ world, such as North America, Europe, In 1992, researchers from the Univer­ searchers have' suggested the possibility Australia and New Zealand. These high sity of Copenhagen reported that the aver­ that hornlone-like compounds, such as pes­ incidence rates may, in part, reflect better age sperm count had declined about 50 ticides, might be capable of triggering a fall cancer detection strategies. percent (from 113 million to 66 million per in sperm counts and other reproductive In most developing countries, there are milliliter) over the last half-century.7 This system impairments in humans. However, no guidelines for prostate cancer screening review has been criticized for ignoring any threat to human reproductive health and "very, very few prostate cancer screen­ marked geographical and temporal variations remains unproved. ing programs exist," says Dr. Sanka Ranarayanan of\VHO's International

NETWORK Sprinf[1998 9 Agency for Research on Caricer, based in In 1993, a National Institutes ofHealth REFERENCES Lyon, France. "In developing countries with (NIH) panel in the United States stated that 1. Berger RE. Acute epididymitis. Sexually very limited health care resources, money is providers should continue offering and per­ Transmitted Diseases. Ed. Holmes KK, Mardh P-A, allocated to more pressing problems. Also, it forming vasectomy. The panel recom­ Sparling PF, et al. New York: McGraw-Hill, Inc., is not yet clear that screening is really ben­ mended that further research be conducted 1990. eficia1." to clarify any possible risk, but "nothing es­ 2. Cates W, FarleyTMM, Rowe PJ. World­ wide patterns of infertility: is Africa different? Lancet Incidence rates of prostate cancer are sential has changed in regard to this issue 1985;2(8455):596-98. related to race. In the United States, the since 1993," notes Dr. Pamela Schwingl of 3. Kuku SF, Osegbe DN.Oligo/azoospermia 1994 incidence ofthe cancer among African FHI, an epidemiologist .who has studied the in Nigeria. Arch Andro11989;2 2(3 ):233 -38. American men (234.4 new cases per 100,000 relationship. : 4. Adu-Sarkodie Y, Steiner M], AttufuahJD. men) was significantly higher than that for Whether yasectomy increases the risk Contraceptive use at an STD clinic in Kumasi, . white American men (135.3 per 100,000 ofprostate cancer in developing countries is Ghana. Unpublished paper. Family Health Interna­ men).ll Elevated rates ofprostate cancer the subject ofan on-going study coordinated tional, 1998. 5. Leke RJ, OdumaJA, Bassol-Mayagoitia S, have been observed in Temperate and by WHO inv()lving 1,200 men in China, et al. Regional and geographical variations in infer­ Tropical South America (especially Brazil) Nepal and the Republic ofKorea. FHI is tility: effects ofenvironmental, cultural, and socio­ where substantial numbers ofpeople of collaborating with researchers at the Korean economic factors. Environ Health Perspect 1993; African descent reside. Among African site. FHI is also collaborating with research­ 101(SuppI2):73-80. countries, those with higher incidences of ers at the University ofOtago in New 6. Ibeh IN, Uraih N, Ogonar JI. Dietary prostate cancer also have relatively higher Zealand on a similar study begun in 1997. exposure to aflatoxin in human male infertilityin per capita incomes and life expectancies. I2 Results ofa recent study ofmore than Benin City, Nigeria. Int J Fert Menopausal Stud 1994;39(4):208-14. Dietary and environnlental factors 1,000 men in Mumbai (Bonlbay), India sug­ 7. Carlsen E, Giwercman A, Keiding N, et al. might contribute to risk, as well. Asian im­ gested an association between vasectomy Evidence for decreasing quality ofsemen during migrants to the west coast ofthe United and prostate cancer, particularly among men past 50 years. BMJ 1992;305(6854):609-13. States have had higher prostate cancer inci­ who underwent vasectomy at least 20 years 8. FischH, GoluboffET, OlsonJH, etal. dence rates than those who remained in before cancer diagnosis or who were at least Semen analyses in 1,283 men from the United Asia, with incidence rates for second genera­ 40 years old when they had avasectomy.I6 States over a 25-year period: no decline in quality. tion Asian inlmigrants nearing the average Another study involving about 750 men Fertil SteriI1996;65(5): 1009-14. 9. Swan SH, Elkin EP, Fenster L. Have sperm rate for Caucasian Americans. 13 Various from 12 cities in China, a country where densities declined? Areanalysis of global trend data. studies have suggested that a high-fat diet both the use ofvasectomy and the incidence Environ Health Perspect 1997;105(11):1228-32. might accelerate the rate ofgrowth ofestab­ ofprostate cancer are increasing, suggested 10. Wilcox AJ, Baird DD, Weinberg CR, et lished prostate tumors. The American Can­ that vasectomized Chinese men may be at al. Fertility in men exposed prenatally to diethylstil­ cer Society recommends that men limit increased risk for prostate cancer. 17 bestrol. N EnglJ Med 1995;332(21):1411-16. intake ofhigh-fat foods from animal sources Another risk for men is testicular can­ 11. Recent trends in prostate cancer incidence and eat five or more servings offruits and cer, which is relatively rare, and is almost and mortality, November 21, 1997. National Can­ cer Institute. (http://cancernet.nci.nih.gov). vegetables each day. Vitamin E may reduce always curable iffound early. Itcan be 12. Kehinde EO. The geography ofprostate the risk, according to a recent study among treated with surgery, radiation therapy, che­ cancer and its treatment in Africa. Cancer Surveys more than 29,000 men in Finland. About motherapy, surveillance, or a combination 1995;23:281-86. half ofthe men took 50 mg ofvitamin E of these therapies. 13. Whelan P. Are we promoting stress and daily, and this group experienced 32 percent No one really knows what causes tes­ anxiety? BMJ 1997;315(7121):1549-50. fewer cases ofprostate cancer than among ticular cancer, ~ut accumulated data have 14. Heinonen OP, Albanes D, VirtamoJ, etal. men who did not take Vitamin E supple­ convincingly demonstrated that vasectomy Prostate cancer and supplementation with alpha­ tocopherol and beta-carotene: incidence and mor­ ments. Foods rich in vitamin E include veg­ does not elevate the risk oftesticular cancer. tality in a controlled trial. J Natl Cancer Inst etable oils, particularly those fronl safflower, ADanish study in which 73,917 vasecto­ 1998;90(6):40-46. sunflower and cotton seeds; wheat germ and mized men were identified from hospital 15. Mettlin C, Natarajan N, Huben R. Va­ whole grains; and whole nuts, such as al­ and pathology registers between 1977 and sectomy and prostate cancer risk. AmJ Epidemiol monds. 14 1989 demonstrated no increased risk oftes­ 1990;132(6):1056-61; Schwingl PJ, Guess RA. Questions remain about whether vasec­ ticular cancer in the groUp.I8 This data is sup­ Vasectomy and cancer: an update. Gynaecol Forum tomy increases prostate cancer risks. Apos­ ported by results from the United Kingdom 1996;1(1):24-28. 16. Platz EA, Yeole BB, Cho E, et al. Vasec­ sible association between vasectomy and Testicular Cancer Study Group.I9 tomy and prostate cancer: acase-control study in increased risk ofprostate cancer was sug­ Notably, testicular cancer is more com­ India. IntJ EpidemioI1997;26(5):933-38. gested in 1990, but the researchers later dis­ mon in white men than in men of other 17. Hsing AW, Wang RT, Gu FL, et al. counted their own findings. Since 1990, races. Incidence rates in Switzerland and Vasectomy and prostate cancer risk in China. several studies have looked at a possible link Denmark - approximately eight new cases Cancer Epidemiol Biomarkers Prev 1994;3(4):285-88. between vasectomy and prostate cancer. per 100,000 men per year - are among the 18. Meller H, Knudsen LB, Lynge E. Risk of However, a plausible biological mechanism world's highest. testicular cancer after vasectomy: cohort study of over 73 000 men. Br MedJ 1994;309(6950):295-99. for the association has yet to be identified, -Kim Best 19. United Kingdom Testicular Cancer Group. study results have been inconsistent, and Aetiology oftesticular cancer: association with con­ reported elevations in risk have been small. IS genital abnorrnali!ies, age at puberty,infertility, and exercise. B!vI J 1994;308(6941):1393-99~

IONETWORK Spring 1998 Male Participation in Reproductive Bealtb

Surveys suggest men have a strong interest in family planning and other reproductive health issues.

en are more interested in reproduc­ avoided serving men in the belief that many tive health than most people think. women need privacy and autonomy in re­ Recent surveys and studies seem to productive health matters. contradict popillar views about "The assumption ofmany health-care men's participation and involve.:. providers that men are uninterested in taking ment in family planning - for example, that responsibility for family planning has become most men know little about contraception, a self-fulfilling prophecy," says Dr. Cynthia do not want their partners to use it, and are Green ofWashington, a consultant who has not interested in planning their families. studied male participation extensively. Most Individual attitudes and behaviors observers agree that family planning pro­ among men vary enormously, ofcourse. On grams have made little effort to consider balance, however, the evidence suggests that men's reproductive health needs or to reach many more men would participate ifthey men, and that as a result men have few con­ had more opportunity to do so. tacts wid! the reproductive health care sys..;, While some family planning programs tern. "In Africa, men are brought up to think have been interested in involving men for that family planning or reproductive health more than a decade, only recently has men's are woman's issues," says Dr. David participation become the focus ofsubstantial Awasum, a physician from Cameroon who attention. Why now? One important reason chairs the Men's Participation Task Force at has been rising global concern over the rapid Johns Hopkins University's Population spread ofHIV.l "The prominence ofHIV/ Communication Services (PCS) in Baltimore, AIDS has opened up the discussion ofsexual MD, USA "No wonder they lack information behavior," says Mary Nell Wegner, director and do not participate actively with their of the Men As Partners Initiative at New spouses or partners." York-based AVSC International. Programs The 1994 International Conference on to prevent HIVhave focused on both men Population and Development (lCPD), held and women with nearly equal attention, in in Cairo, reminded the world audience that contrast to family planning programs, which good reproductive health is the right ofall have focused mainly on women, she and people, men and women alike, and that to­ other experts say. gether they share responsibility for reproduc­ Traditionally, family planning pro­ tive matters. By emphasizing gender - the grams have viewed women as their primary prescribed roles men and women play in clients for three reasons: it is women who be­ society- the conference drewattention"to come pregnant; most contraceptive methods the fact that, if men are left out ofthe repro­ are designed for women; and reproductive ductive health equation, they are unlikely to health services can be offered conveniently be able to exercise responsibility. The con~. as partofmaternal and childhealth ser­ sensus reached in Cairo is that neither vices. 2 Some family planning programs have women nor men are likely to enjoy good reproductive health until couples are able to

. ., ~ N ETWOR"K SfJfinrtJ998 " reach men as individuals and as mem­ bersofcouples, contraceptive use might rise considerably. While the 15 countries represent onlyportions ofAfrica and Asia, there is astriking consistency among them regarding male interest in reproduc­ tive health, enough so to suggest a similar level ofmale interest else­ where. Only a fewDHS have inter­ ,viewed men in Latin America and the Caribbean (Brazil,Domin..icariRe­ public, Haiti and Peru); however, ini­ tial results suggest a similar pattern of male interest. For example, in Brazil, men are even more likely than women to say that they do not want to have more children.In Haiti, 92 percent of men surveyed approve ofcontraceptive use and in Brazil, 86 percent approve. The 15 African and Asiancoun­ tries in,the Ezeh analysis offer a developing-country portrait of-male participation'from several perspec­ tives. In addition to measuring senti-. ments about whether men approve of family planning and'men's family size, intentions, these'surveys gauge male awareness ofcontraceptive options, their concerns about sexually,trans­ mitted diseases and their use ofcon­ traception: discuss sexual matters and make reproduc- ,' SIMILAR ATTITUDES, tive decisions together} "For the first time', According to recent DHS,'menare Approval-:- Most ,men, likemost women, . Cairo established clear policy language ' more likely to approve offamily planning approve offamily planning.-Inseven,of 15 about men's participation and provided a and to know about contraception than stereo­ surveyed countries, at least?O percent of foundation for family planning donors and types about men suggest. Based on data col- , men approve ofusing contraception.Ap­ programs to act on," says Wegner. lected from men in 15 countries -,II in proval is lowest in West Africa. -Even in this As interest in men's participation has sub-Saharan Africa, plus Bangladesh, Egypt~ region, however, men's approval appears to grown, mor.e attention is being paid to ' Morocco, and Pakistan - Alex Ezeh and ' be on the rise. In Ghana, for example, the lea'rninghow to fe,ach,men effectively. colleagiIes at Macro International, I~c., the percentage of-men who approve offamily "Family planning programs are looking for U.S.·~based organization that organizes and, , planning rose from 77 percent in '1988 to 90 ways to become more inclusive," says Dr. helps conduct the DHS, report thatin most percent in 1993. Within most ofthe COUll,:, Green. More surveys are interviewing men, countries "the reproductive preferences and tries men are less likely than women to ap­ as well as women, and' some surveys are'in­ attitudes of men and women toward family prove offamily planning. This fact in part terviewing couples. The Demographic and planning are simihir."4 may explain why men often are pictured as Health Surveys (DHS), for example, now The '15 studies reveal a "KAP gap" obstacles to contraceptive use. Nevertheless, collect comparable data about family plan­ among men - a contradiction between the in some ofthe countries(Ghana, Malawi ni~g attitudes and practices from men, in level of "knowledge and attitudes" about and Pakistan) men are more likely than addition to a long-standing practice of inter­ family planning compared with "practices" women to approve offamily planning. In viewing women. Also, more qualitative data (KAP).Men's contraceptive use islower nearlyall countries surveyed, better-:educated are becoming available from focus-group than might be expected, given their overall men express greater approval offamily plan­ research and in-depth studies. As research­ levels ofapproval and knowl~dge. Between ning than do men with less education. ers obtain more information, stereotypes are one-quarter and two~thirds ofmen surveyed giving way to amore factual portrait of-men. want no' more children, yet neither these Family size - Inmost surveyed countries, men northeir partners were using contra­ the number ofmen who want to have an­ ception. 5 The implication ofsuch findings is other child is only slightly higher than the that, ifprograms could,find better ways to number ofwomen who want another child.

12 NETWORK Spring 1998 MEN INFLUENCE CONTRACEPTIVE USE

Men play important roles in supporting a couple's reproductive received husband-wife counseling (33 percent), compared with use health needs. Effective use ofacontraceptive method, and even satisfac­ among couples in which women were counseled alone, without their tion with the method chosen, is often influenced by men. Aman's sup­ husbands (17 percent), according to scientists at Addis Ababa University port often contributes to better use offemale methods and, for many in Ethiopia and McGill University in Montreal, Canada. couples, a male method may be an excellent choice. The educational team members were all women who were gener­ Also, male participation in preventing sexually transmitted dis­ ally well-known within the neighborhoods where home visits took eases, includingHIV, is crucial. Aman must actively participate for a place. They worked in the early evenings and weekends after normal couple to use latex condoms correctly and consistently, and he must working hours, thus making it easier to arrange visits when both hus­ remain faithful ifa couple seeks protection through a mutually monoga­ bands and wives would be present. Investigators designed the study to mous relationship. elirilinate factors that could distort their findings. For example, the edu­ Both the ·1994 International Conference on Population and Devel­ cational teams were not aware ofthe purpose ofthe research, and each opment in Cairo and the 1995 Fourth World Conference on Women in team generally visited an equal number ofhomes where both husband Beijing recognized the important role ofmen in improving reproductive and wife were present compared with homes where only the wife was health. Consensus statements from both conferences say better ways to available. "The differences [in contraceptive use] can be attributed to reach men with reproductive health services are needed. husband involvement in the intervention program and have not been In Latin America, Africa and Asia, several programs and research confounded by demographic, reproductive, or knowledge and attitude studies illustrate ways that male involvement contributes toward a disparitiesbetween'the two study groups," the scientists concluded.2 couple's reproductive health needs. Norplant use in Bangladesh - An FHI study in Bangladesh suggests Bolivia's Casa project - An educational effort in Bolivia called Casa that involving husbands in Norplant counseling sessions can improve de la Mujer (The Women's House) has worked closely with women's continuation rates for the contraceptive implant. C,ounseling included most urgent reproductive health needs. The Casa team is convinced information about side effects, insertion and removal procedures, and that working with couples offers optimal success. how men can help when their partners experience side effects. In one Santa Cruz neighbor­ . After three years, continuation hood,pelvicexaminationsof47 rates were substantially higher women indicated that only one among women whose husbands were woman was not infected with an STD. counseled (42 percent continued us­ "In many cases, ifthe man is not ing Norplant) compared with women treated at the same time, our efforts whose husbands did not receive are in vain," saysMaria Luz Bacarreza, counseling (32 percent continued a Casa nurse. Yet getting men in­ use). The study among more than volved in any reproductive health ef­ 600 urban and rural women in four fort is often difficult. At a Casa 'clinics provided counseling·for both community workshop on reproductive women and their husbands for about health for couples, only one man ap­ two-thirds ofthe cases and for peared. He quickly left, embarrassed women only for the remaining third. 3 to be the only man present. ILLUSTRATION FROM A CASA DE LA MUJER PAMPHLET. In addition to counseling, hus­ But by a second workshop held bands received asimple brochure on in the same community, the project , the method, including a discussion of succeeded in encouraging several men to attend after two nurses visited the supportive role husbands can' play. Previous research had shown that several couples' homes to explain the workshops. Following this partici­ a common re'ason for discontinuation in Bangladesh was "personal rea­ pation, even more men were willing to tak~ part in a third session. "It is sons," which.included objections from husbands.4 difficult to convince men to participate," says Bacarreza. "Nevertheless, - Nasb Herndon once they get involved, men often come up with a hundred questions and are very active in the workshops."l REFERENCES 1. Paulson 5, GisbertME, Quiton M. Case Studies ofTwo Women's Ethiopian husbands - As inmost sub-Saharan cultures, men in Health Projects in Bolivia. Research Triangle Park, NC: Family Health Ethiopia tend to dominate a couple's decision about family size and International, 1996. whether to use contraception. Astudy in Addis Ababa suggests that in­ 2. Terefe A, Larson CPo Modern contraception use in Ethiopia: does volving husbands in family planning education significantly influences a involving husbands make a difference? AmJPublic Health 1993;83(11): 1567-71. couple's decision on whether to begin using contraceptives. 3. Amatya R, Akhter H, McMahan], et al. The effect ofhusband More than 500 married women who were not using any modern counseling on NORPLANT contraceptive acceptability in Bangladesh. method agreed to home visits by a two-member family planning educa­ Contraception 1994;50(3):263-73. tional team. About halfofthe women received this counseling alone, 4. Akhter H, Dunson R, Aniatya R, et al. Afive-year clinical evalua­ while the education for others was given to' both husband and wife. Af­ tion ofNORPLANT contraceptive subdermal implants in Bangladeshi ter one year, contraceptive use was nearly double among couples who acceptors. Contraception 1993;47(6):569-82.

NETWORK Spring 1998 13 This finding shatters one of ~ the most widespread myths ~ · about men - that men gener- ~ ally want much larger families ~ than do women. In most ofthe ~ , 15 countries, the differences ~ 0:: in reproductive intentions ~ ~ between men and women are l&.I · small. The fact that men are ~ somewhat more likely to want another child, however,.helps account for the finding that, even though men tend to know somewhat more about contraception than do women, they are less likely to approve ofits use. In Kenya, Morocco and Pakistan, only a minority ofmen want to have another child, and in Egypt and Bangladesh less than one- third ofmen want another child. In West Africa, how- ever, men are substantially SURVEYS INDICATE MANY MEN WOULD PARTICIPATE MORE IN FAMILY PLANNING IF more likely than women to GIVEN THE OPPORTUNITY. MEN IN NIGER HOLD A VILLAGE MEETING. want another child. In Niger, the extreme case, 93 percent ofmen want to . heard ofAIDS and most know that sexual Contraceptive use - Men are more likely have another child compared with 82 per­ intercourse can transmit it. While the sur­ than their partners to report using contra­ cent ofwomen. veys also reveal much misinformation about ception, according to the 15 surveys. One HIV, they show that many people know possible explanation is that some men may be Awareness - In almost all 15 countries that using condoms is a means ofprotec­ reporting condom use outside ofmarriage. surveyed, men are more likely than women tion. In ZiInbabwe, for example, 57 percent Another possibility is that some women may to know about contraception. Surveys, how­ ofmen cited using condoms as a way to not acknowledge use ofcontraception to ever, report only whether respondents have avoid contracting AIDS; and in Tanzania, survey takers, since they are using it without heard ofthe various contraceptive methods. 55 percent. In Kenya, however, only 36 per­ their husbands' knowledge. Whether the They do not gauge the depth ofknowledge, cent ofmen who believe that people can pro­ explanation lies primarily in men over­ including whether respondents know how to tect themselves against AIDS identified reporting contraceptive use or women use methods correctly. In all 15 countries, a using condoms during sex as a means ofpro­ under-reporting use is unknown. Men's majority ofmen know about at least one tection. participation in family planning cannot be modern method and one traditional method. In most developing countries preva­ measured simply on the basis ofuse ofmale­ In all but one African country (Rwanda is the lence ofcondom use is typically below 5 oriented methods - withdrawal, condoms, exception), a higher percentage of men than percent. So widespread are STDs that pro­ and vasectomy - because few satisfactory con­ ofwomen know ofa modern method. In grams need to promote and provide traceptive choices have been designed for men. Egypt, Morocco, Bangladesh, and Pakistan, condoms for disease protection as well as Experts agree that the more husbands men and women report similar levels of for family planning. Although there is little and wives discuss family planning with each · awareness. The gap between men's and information about condom use for STD other, the higher the level ofcontraceptive · women's awareness ofcontraception is prevention versus family planning, "family use. Itis not clear whether discussion offam­ greater in countries where overall knowl­ planning service providers need to recog­ ily planning stimulates its use or whether edge is low. nize that many women would benefit using family planning invites discussion of greatly from using condoms to prevent the topic - probably, both statements are Sexually transmitted diseases - The STDs, plus another method to prevent true. Remarkably, in six West African coun­ spread ofHIV and other sexually transmit­ pregnancy," says Dr. Green. "For clients tries surveyed, only one couple in every four ted diseases has brought an increase in who need both pregnancy and STD protec­ had discussed family planning during the pre­ awareness and use ofcondoms. For example, tion, programs should encourage dual use, vious year. Studies also show that when hus­ in Kenya, Tanzania, and Zimbabwe, where even though it raises costs." bands approve offamily planning or when HIV and other STDs are widespread, DRS wives think that husbands support it, the wives results show that virtually all men have are more likely to use contraception. Yet

14 NETWORK SprinK1998 some wives typically report that their hus­ usually is offered as part ofmaternal and More emphasis on men's participation bands disapprove offalnily planning, when child health services and is typically done by in reproductive health could help draw at­ in fact the husbands themselves report that women. Programs that have relied entirely tention to the need to do more for women as they approve. on women outreach workers have had diffi­ well. Increasing men's participation may culty in reaching men. Thus, many family help improve women's programs because planning clinics need to learn how to wel­ more men would understand and be likely to PROGRAM IMPLICATIONS come men, while service providers need support better reproductive health care -, Where programs have reached men, training in how to counsel men about repro­ for women, as well as for themselves. male attitudes have changed and contracep­ ductive health. - Bryant Robey and Megan Drennan tive use has increased. Nevertheless, reach­ Particularly urgent is the need to im­ ing men with reproductive health care is prove sexual responsibility among young Bryant Robey is editor and Megan Drennan is a more difficult than reaching women, for men, including more condom use. Sexual writer/1·esearcherfor Population Reports, pub­ whom maternal and child health services are activity often begins at ayoung age and be­ lished by the Population Information Program, designed. "Health care programs cannot do fore marriage. Because life-long attitudes Centerfor COlnmunication Programs, The Johns the saIne things to reach men that they do and behavior patterns often form during Hopkins School ofPublic Health in Baltimore, for women," Dr. Green observes. Since youth, addressing the needs ofyoung men MD, USA. Robey prepared this article as apri­ many men are reluctant to seek reproductive can have a long-term impact. vate consultant, while on leave from Johns health care, Wegner says, "you have to take Hopkins. Drennan, who is writing aPopulation advantage ofevery available opportunity; you Reports issue on men's participa­ have to go to where men are." SEAN SPRAGUE/IMPACT VISUALS tion, provided editorial and re­ According to Dr. search assistance. Awasum, "to have an impact you have to reach men in REFERENCES places where they congregate 1. Danforth N, Roberts P. in large numbers." In Africa, Better Together: A Report on the for example, because almost African Regional Conference on all men follow football (soc­ Men's Participation in Reproductive cer),)ohns Hopkins Health. Baltimore: Johns Hopkins University's PCS is reaching Center for Communication Pro­ grams, 1997 j Green CP. Male Re­ men with reproductive health productive Health Services.' A Review information and services by ofthe Literature. New York: AVSC sponsoring the "Challenge International, 1997. CUP" - where "CUP" 2. Green CP, Cohen SI, stands for "Caring, Under­ Belhadj-EI Ghouayel H. Male standing Partners." The CUP Involvement in Reproductive Health, football matches bring thou­ Including Family Planning and Sexual Health, Technical Report 28. sands ofmen together, often New York: United Nations Popu­ with their wives and children, lation Fund, 1995. to watch teams compete and 3. Danforth N,Jezowski T. at the same time learn about Beyond Cairo: men, family plan­ and receive reproductive ning, and reproductive health. health care. To communicate Presentation at the American Pub­ with men effectively through lic Health Association Annual Conference, Washington, mass media, experts agree October 31, 1994. that programs need to under­ 4. Ezeh AC, Seroussi M, stand men's views and needs, Raggers H. Men's Fertility, Contra­ then use this knowledge to ceptive Use, and Reproductive Prefer­ design messages for them. ences, DHS Comparative Studies No. 'Men have fewer oppor­ 18. Calverton, MD: Macro Inter­ tunities than women for re­ national Inc., 1996. 5. Roudi F, Ashford L. Men ceiving counseling about & Family Planning in Africa. reproductive health care from Washington: Population Refer- service providers because so ence Bureau, 1996; Ezeh. ' few men are reached by re­ productive health care. Fam­ SURVEYS INDICATE MOST MEN, LIKE MOST WOMEN, APPROVE OF FAMILY ily planning counseling PLANNING. THIS FAMILY LIVES IN MOKATTAM, CAIRO, IN EGYPT, ONE OF 15

COUNTRIES IN A DHS ANALYSIS OF ATTITUDES TOWARD FAMILY PLANNING.

NETWORK Spring 1998 15 Experimental Male Metbods Inbibit Sperm

he development ofnew male contra­ general use, they have provided an impor­ ceptive methods seems to move at tant foundation of knowledge that may lead an agonizingly slow pace. Despite to more successful contraceptive prototYPes. years ofresearch, no modern con­ traceptive drug currently exists for men, whose most effective choices are limited HORMONAL APPROACHES to condoms or vasectomy. Ways to suppress sperm production Even the more promising experimental through ~ormonal means include an experi­ male methods are at least a decade away mental injection developed by the Popula­ from,general use. Experts say alack ofcom­ tion Council that seeks to stimulate an mercial interest and funding have held back ilnmune response to gonadotropin hor- research. Progress also has been slow be­ .mone-releasing hormone (GnRH), a hor­ cause of the chalJenging physiological task mone that is essential tosperm production. ofcontrolling the male reproductive system. The New York-based Poputation Simply put, awoman's ovulation is easier to Council is conducting a preliminary study interrupt than a man's sperm production. A among 20 volunteer men in Santiago, Chile woman produces one egg a month; a man in a trial that will take about two years to produces hundreds ofmillions ofsperm complete. Asingle injection is expected to daily. And, while an adult woman is only produce effective contraception for up to fertile until menopause, a man continues to one year and, when discontinued, should produce sperm throughout his adult life. allow a return to fertility. The experimental Nevertheless, a number ofintriguing injectable is composed of GnRH that is research projects are seeking new modern combined with a much larger protein, which methods for men. These experimental pro­ acts as a delivery system. In this case, the totypes typically use one of two mechanisms protein is tetanus toxoid, which is widely ofaction. One approach is aimed at sup­ used throughout the world as a tetanus pressing the production ofsperm, either by immunization. hormonal or non-hormonal means. Another "When injected into the body, the seeks to inhibit the fertilizing ability of GnRH-carryitig tetanus toxoid stimulates a sperm, usually bydisrupting a key step in the man's immune system to produce antibodies. complex process of conception. These antibodies then inactivate GnRH pro~ Most research is focusing on suppress­ duced naturally inthe man's body, resulting ing sperm production. The basic -idea is to in sperm suppression. As an additional ben­ inhibit or neutralize gonadotropins, hor­ efit, men using this combina'tion wouldalso mones that control such reproductive func­ be protected from tetanus infections. tions as sperm production. Already, studies One drawback ofneutralizing GnRH, have shown the contraceptive efficacy in however, is the suppression oftestosterone, men ofa variety oftestosterone derivatives, a hormone that in men generates libido and which work by suppressing sperm produc­ secondary sexual characteristics. Thus, men tion. "While some ofthese derivatives have who use the GnRH injection al~o must use a drawbacks that make them undesirable for substitute for testosterone called 7-alpha" EXPERIMENTAL MALE CONTRACEPTIVES

Contraceptive prototypes for men use one of two mechanisms of action: some suppress sperm production, either through hormonal or non-hormonal means; others inhibit the ability of sperm to fertilize the ovum, usually by disrupting a key step necessary for conception.

AGENT How IT WORKS RESEARCH STATUS

HORMONA~ SUP-RRESSION OF SPERM PRODUCTION

Gonadotropin hormone­ • Stimulates immune system to inactivate Two-year safety trial ofgonadotropin hormone­ releasing hormone (GnRH) the body's natural GnRH, suppressing releasing hormone (GnRH) combined with tetanus coupled with protein sperm production toxoid protein recently begun in 20 men. • Annual injection

7-alpha methyl-19­ • Suppresses sperm production Efficacy trials ofMENT implant under way; long­ nortestosterone (MENT) • Annual implant term toxicology testing not yet conducted.

Testosterone buciclate (TB) • Suppresses GnRH secretion and thus TB injectable tested in a WHO-supported study sperm production indicates stronger dosage necessary for reliable • Three-month injection contraception. Trials ofTB injectable and progestogen may begin in 1998.

Testosterone undecanoate (TV) • Suppresses GnRH secretion and thus Studies among men under way in China ofTU sperm production injectable; studies of two-month TU injection with • One or two-month injection a progestogen planned.

Testosterone enanthate (TE) • Suppresses GnRH secretion and thus Provided effective contraception in 98 percent of sperm production 399 men in a two-year WHO trial, but not • Weekly injection considered desirable for general use because weekly injections are required.

TE/progestogen combination • Suppresses GnRH secretion and thus Combination ofTE and progestogen achieved sperm production initial contraception sooner than TE alone, but • Weekly injection ofTE, daily not considered desirable for general use because progestogen pill weekly injections are required. • .- . • • --.. •

Gossypol • Suppresses sperm production Recent pilot study oflow-dose gossypol pill • Daily pill indicates effective contraception without danger­ • Irreversible in some men ous potassium depletion. Larger efficacy study of 320 men planned.

INHIBITION OF-FERTILIZING ABILITY OF SPERM . - .... ~.

Nifedipine • May prevent sperm enzyme action needed Research planned to find variations of this drug for fertilization that may specifically target sperm without • Daily pill producing systemic side effects.

Mifepristone (RU 486) • Makes sperm temporarily immotile Research is seeking chemically-similar compounds • Daily pill that may target sperm without producing mifepristone's undesirable side effects.

Sperm surface protein • Antibodies attached to sperm block Immunization of male guinea pigs with sperm fertilization surface protein has demonstrated reversible • Vaccine contraception. Other animal studies planned.

NETWORK Sp1'ing 1998 17 methyl-19-nortestosterone, or MENT, testosterone enanthate (TE), a synthetic The contraceptive ability ofanother which is slowly released into a man's body derivative oftestosterone. The study in­ derivative, testosterone buciclate (TB), was using an implant rod inserted under the skin volved 399 men in nine countries in Asia, tested in a"WHO-supported study con­ ofa man's upper arm, similar to the Australia, Europe and North America. The ducted in Germany in 1993 and 1994, but an Norplant system used by women. This helps agent's contraceptive efficacy proved to be appropriate dosage to achieve azoospermia to restore normal sexual drive and secondary comparable to that of female hormonal or severe oligozoospermia in all men has not sexual characteristics, such as the growth of methods. In 98 percent ofthe study subjects, yet been identified. 4 Higher doses ofTB will facial hair. TE weekly injections either totally sup­ be the focus of further studies. TB can be The current study in Chile is designed pressed sperm production or greatly re­ injected at three-month intervals.

to examine safety issues. Ifresults are en­ duced it, providing effective contraception. Meanwhile, some of the concerns aris- I couraging, the immunocontraceptive's effi­ Furthernl0re, the method was reversible, ing from administration of androgens (such cacy will then be studied in a trial expected with fertility restored within two to three as TE) alone have been addressed in studies to enroll up to 150 subjects, says Dr.J.F. months after the last injection. of progestogen-androgen conlbinations. Catterall, director of reproductive physiol­ Unfortunately, injections needed to be Among the advantages ofsuch combinations ogy at the Population Council. given weekly to achieve contraception. "Fol­ are: the combined regimen appears to sup­ While initial Population Council inves­ lowing the trial, many men wanted to con­ press spermatogenesis more rapidly and per­ tigations focused on using MENT only to tinue the contraceptive nlethod and were haps more effectively than androgen-alone maintain libido, this agent used alone may disappointed when told they could not do treatment; progestogen doses necessary to also provide successful sperm suppression. so," says David Griffin, a "WHO scientist. suppress gonadotropin secretion and inhibit "That MENT alone could suppress sperm "However, it was recognized that weekly spermatogenesis are much lower than an­ production while maintaining libido came as injections ofTE would not be an attractive drogen doses; the androgen's role is prima­ a surprise to us and others in the field," says option to men at large. Thus, research ef­ rily to replace the endogenous testosterone Dr. ElofJohansson, biomedical research forts have focused on the development of inhibited due to gonadotropin suppression director ofthe Population Council, who longer-acting testosterone derivatives that by the progestogen; thus, the androgen can adds that long-term toxicology testing in could be injected at intervals oftwo or three be given less frequently and at lower doses.s animals remains to be done and clinical trials months." Asix-month study comparing weekly among men are in the early stages. Under Researchers also realized that TE has injections ofTE (100 mg) alone and the this approach, MENT would probably be other limitations, including an inability to weekly injections with daily oral doses of delivered via one to several implants. If produce total azoospermia in all men, which levonorgestrel (500 Ilg) showed that the MENT proves to be an effective and safe increases the risk ofcontraceptive failure. l combination was a more effective and contraceptive, "it would make the develop­ Another drawback is that the onset ofcon­ quicker-acting contraceptive method (ap­ ment ofan implant both simpler and traception is relatively slow, usually two to proximately five weeks faster) than testoster­ cheaper than we once thought," he says. three months. Acouple would need to use one alone. 6 Another study in which TE MENT, which is chemically sinlilar to another method for months after injections (100 mg) injected weekly was conlbined with testosterone, is 10 times nlore potent than began. the progestogen cyproterone acetate (CPA) testosterone. It has the advantage ofbeing There also is some concer"n about ad­ in a daily oral dose ofeither 25 mg or effective via gradual, constant release at verse side effects, chief among them the 12.5 mg showed suppression ofsperm pro­ small doses that do not overstimulate the effects from suppressing high density lipo­ duction without detectable adverse effects.7 prostate or affect muscle mass. TheMENT protein cholesterol (HDL) levels. HDL is Trials ofan injectable combination of implant being developed by the Population important in cholesterol renloval from arte­ TB and the long-acting progestogen Council is expected to be effective for one rial walls, and epidemiological data have levonorgestrel butanoate, two compounds year and should be reversible. shown an association between low levels of jointly developed by "WHO and the National HDL and an increased risk for coronary Institutes ofHealth (NlH), are likely to begin artery disease. Significant decreases in HDL this year or next after reformulation and sta­ TESTOSTERONE DERIVATIVES have been observed in large-scale studies of bility tests ofthe compounds are completed, Suppressing sperm production byad­ healthy men receiving weekly injections of says Dr. Michael Mbizvo, manager ofmale ministering testosterone derivatives has TE 200 mg for periods ofone to two years. 2 contraceptive research in the \VHO Human been studied for many years. Although test­ However, it is uncertain whether lowered Reproduction Programme. The combination osterone produced naturally in a man's body HDL alone is a direct cause ofcoronary dis­ regimen is expected to provide contraception is essential for sperm production, an excess ease. Some researchers have noted that TE's for three months at a tinle. amount inhibits gonadotropins, thus causing effect on HDL probably reflects the rela­ Other studies supported by WHO will a large decrease in natural testosterone lev­ tively high peak levels and fluctuations of investigate the contraceptive efficacy and els in the testes and hampering sperm manu­ plasma testosterone produced by weekly TE acceptability ofanother injectable- facture. administration. The effect, they have hy­ testosterone undecanoate (TV). Efficacy The most comprehensive study to pothesized, might be avoided by using long­ studies with TU alone, injected monthly, are demonstrate this relationship was a two-year acting preparations of testosterone. 3 being done in China with funding from trial conlpleted in 1994 by the World \VHO, the Andrew W. Mellon Foundation Health Organization (WHO) of injectable

18 NETWORK Spring 1998 and the United Nations Population Fund, gossypol depleted potassium levels, a condi­ with improving the feasibility ofgossypol as says Griffin, and an acceptability study is tion that sometime led to dangerous heart­ a male contraceptive by developing a highly 'being financed by VVHO. beat irregularities. Also, some men appeared purified form ofgossypol and devising a Hormonal contraceptive methods are to become permanently sterile. means to coat tablets to prevent oxidation by most likely to become available first as More recent studies by South-to-South light or heat. injectables or iInplants, but more attractive Cooperation in Reproductive Health have delivery systems, such as pills or skin patches, focuse'd on smaller doses that may be safer. may be possible. The Population Council is "A pilot study in a small group offive Brazil­ DISRUPTING SPERM FUNCTION in the early stages ofdeveloping apatch. ian men ofa pill called Nofertil that contains Afew researchers are seeking ways to low-dose gossypol has demonstrated its effi­ impede the ability ofsperm to fertilize eggs. cacy in suppressing spermatogenesis within Two well-known pharmaceutical agents NON-HORMONAL SUPPRESSION two to three months oftreatment without have been shown to cripple sperm. While hormonal methods ofsperm depleting potassium levels," says Dr. Nifedipine, routinely used to treat high suppression have tended to dominate male Sheldon Segal of the Population Council, a blood pressure and migraine headaches, ap­ contraceptive research, some scientists are leading expert on gossypol. Jf approved by pears to stop the discharge ofenzymes from intrigued by a non-hormonal substance that the Brazilian Ministry ofHealth and fund­ the sperm cell that are needed to penetrate does not affect androgen levels, and there­ ing is obtained, South-to-South plans to an egg's protein coating. Thus, ~perm are fore does not influence libido or sexual char­ conduct a trial ofNofertil in 320 Brazilian unable to fertilize an egg. Leading a tealn acteristics. Called gossypol, an extract from men at 10 centers beginning this year. investigating nifedipine's contraceptive po­ natural cottonseed oil, it has achieved reli­ The low-dose gossypol pill is pro­ tential is Dr. Susan Benoff, associate profes­ able contraception in Chinese men. In the duced by the Brazilian pharmaceutical sor ofobstetrics and gynecology and cell doses given during early studies, however, company Hebron, which Dr. Segal credits biology at North Shore University Hospital, New York University School ofMedicine. BERYL GOLDBERG Her interest was inspired by the observation that many men taking nifedipine for mi­ graine headaches or high blood pressure became sterile. Amajor obstacle to develop­ ment ofthis male method, she says, has been a concern that nifedipine could cause dan­ gerously low blood pressure and heart rates. Over the last two years, however, Dr. Benoff says her team has taken a research approach that may ultimately lead to new drugs that target sperm cells exclusively, thus reducing the possibility of circulatory system side effects. Dr. Benoff notes that this form ofmale contraception is at least 10 to 15 years from general use. Mifepristone, the French drug for­ merly called RU 486, has been shown to disable sperm by acting on the sperm mem­ brane. Dr. Etienne-Emile Beaulieu of the French Institut National de la Sante et de la Recherche Medicale reports that mifepristone prevents sperm from using calcium. Lacking calcium, sperm cannot move normally or fertilize eggs. Unfortu­ nately, mifepristone interferes with certain hormonal functions. "However, we have tested and found a number ofcompounds

Continued on page 31

A FATHER AND SON, IZAMAL, MEXICO.

NETWORK Spring 1998 19 Condom Use Increasing

Social m~rketing campaigns to prevent AIDS have made coridomsreadilyaccessibleand affordable.

ven though many men say they do ofAIDS is much highernow, andcommuni­ not like using condoms, condom cation campaigns have shownthar condoms, use is increasing sharply since it is a are an effective solution." primary strategy for AIDS preven­ However, say Stallworthy and other tion amongpeople at risk. experts, even more condoms need to be used Condom sales through social market­ in high-risk sex. Many factors affectthe lilll­ ing campaigns have ris'en dramatically in ited acceptance ofcondoms. An individual's some countries,with tens ofmillions of knowledge, attitudes and awareness ofrisk ,condoms sold annually wherethere was are critical to condom use. The dynamics , hardly any condom use a ,:, between sexual partners'playacrucial role, decade ago; From 1991 such as whether the couple talks freely to to 1996, annual social each other aboutprotectionagainst disease ,marketing sales in­ and unwanted pregnancy, arid whethersex is creased aboutfive-fold voluntary for both parties. The attitudes and ,in the Mrican country of pronouncements ofparents, church leaders, Ethiopia (to 21 million) ,peers, entertainluent figures and political and by nine times inthe leaders shape 'community norms about LatinAmerican country condoms. ofBrazil (to 27 million). Men arid women give many reasons for Aprogram that began in not using condoms, including fear that 1993 in Asia's Vietnam condoms will fail, lack ofsensation or inter­ has typically doubled its rupted sexual pleasure, and not perceiving, 'sales each year, to 31 the risk ofdisease. Studiesin 14countries by million by 1996. 1 theWorld Health Organization's Global "Social marketing Programme on AIDS reported that the most campaigns have made important reason people reported for not condoms,accessible and using condoms was that condoms reduced forthe most part afford­ sexual pleasure.2Women often mention able, which were major they fear men's reactions to suggesting con­ barriers to use in the dom use. past,""says Guy "It IS' clear thatwe have increased use, Stallwotthy, director of , that we have met a demand that emerged technicalservices for with AIDS," says Stallworthy; "But is there a Population Services plateau effect taking place? Are we able to International (PSI), a persuade, more people to use condoms? To U.S.-based nonprofit increase sales at this point,we have to organization that coor­ change societal'norms;" dinates many ofthe Experts emphasize theimportance of world's largest condom sustained behavior change, not justpersuad­ social marketing cam­ ing a person to trya condomonce. "Con­ 'paigns. "People also dom use has increased because people are have a better sense of protecting ,themselves and their families personal risk. Awareness from disease," says Donna Flanag~n, an FHI behavior change specialist. "With AIDS prevention messages, including condom use, wehave to keep motivating and reminding people to 'change, 'because most people would prefer not to use acondom. But we also have to move on to messages thaten-' courage men and women to sustain their use of condoms.'" ,

OUTSIDE MARRIAGE \Vho uses condoms and under what cir­ cumstances? Recent surveys indicate that condomsareusedniostofteh outside ofmar­ riage. In some areas where AIDS prevention campaigns include, highly visi~le condom' promotion, use also is increasing among married couples; Worldwide, only 5 percent ofmarried women ofreproductive age report using condoms, when asked about choice ofcon­ traceptive method. Among developing countries, 3percent reportusing condoms, with only a handful ofdeveloping countries reporting more than 10 percent, including risks of being-infected bytheir partner and, , regions of the world, have made condoms, the Republic ofKorea, Singapore, C,osta their difficulty in. negotiating condom use," widely available and accessible. By 1996, Rica and Jamaica. (Condom use in a few a PSI survey report concluded. 5 social marketing campaigns were being con­ industrial countries is also high, above 10 Young people are using more condoms ducted in 60 countries worldwide. 7 These percent in Scandinavian countries ahd ac~ where campaigns fo'cus onyouth. "But in campaigns'use c~mmercial' marketing tech­ counting for nearly half ofall ,contraceptive manyareas, we're still inthe stage,ofgener- , niques' including market research, message use in Japan.)3 '., ating demand among youth," says Dr. Ann testing, advertising and consumer education, Measuring condom useis difficult be­ McCauley, formerly of the ~.S.-bas~d as well as better access to products and af-, cause they maybe used sporadically, often FOCUS on Young Adults'program. "The fordable pricing. Generally, the price is sub­ outsideofmarriage. In the 1994 Zimbabwe key problem for youth is still access. Most sidized to encourage buyers while also Demographic and Health Survey (DHS), for adults do not approve of sex among un~ assuring adequate profit incentivesf~r mer­ example, five times q-lore married men re­ married youths and hence do not approve chants who sell them. ported using condoms during'the preceding of giving them'easyaccess to condoms. Condom promotion campaigns have four weeks with a non-spouse(60 percent) Pharmacists won't sell to youth in many encountered obstacles. As recently as 1990, than with awife (12 percent). Married countries. Also, many youth are too embar­ forexample, the word "condom" was pro­ women reported using condoms,3 8 percent rassed to ask for condoms. And cost remains hibited in advertising in Kenya. Today, con-' ofthe timewith non-spouses and 7percent an obstacle in many areas." ,dom advertisingis permitted in many parts with husbands. Despite such high figures, Since the AIDS epidemic, married men ofthe world where such advertising had only'2 percent ofthemarried women re­ have indicated more interest in usingcondoms once been restricted or banned. ported using condoms for their primary for contraception. In Ghana and Kenya, ~here Other pro~otional effortshave also family planning metho"d.4 smveys were, conducted in 1988 and 1989, been successful. In Nepal, a sales force con­ In areas where social marketing cam­ respeciively, and again in 1993 for both coun- . centrated on the highways into the country paigns have heavily promoted condoms, tries, the portion ofmalTied men who said 'fro~India, where truckers and commercial surveys indicate an increase in condom use. they would like to use condoms as their con­ sex workersmade this an area with high rates For exam.ple, in the gold mining area of traceptive method jumped sharply. The por­ ofHIV transmission.' Increasing from only South Africa, where men work and live for tion tripled in Ghana (from 5percent to ,16 three outlets in 1994, dozens of pharmacies, months away from home, about two ofevery percent) and doubled in Kenya (from 6per­ tea shops, liquor shops and others businesses three men used condoms during sex ou~ide cent to14 percent).6 currently offer condoms along these high­ ofmarriage. These men also used condoms ways.8 In Thailand, the government devel­ more often with their wives, with use during opeda nationwide" 100 percent coridom" the last sex act jumping from 1Rpercent to SOCIAL' MARKETING program at commercial sex establishments, ·26 percentfrom 1995 to 1997. "This in­ International funding for AIDS pre­ requiring that sex workers always use a con­ crease is important, given the concerns that vention campaigns and,specifically, the ex­ dom. Condom use at commercial sex estab­ have been expressed about married women's parision ofsocial marketing programs in all lishments increased from about 14 percent

NETWORK SP?'ingJ998 ,21 ... :.:....:... / .....

when the program began in 1989 to 90 per­ Another example comes from Interna­ skills, such as how to communicate with a cent in 1994 and is credited with a sharp de­ tional Planned Parenthood Federation partner about the importance ofusing a con­ crease in STD rates. 9 (IPPF) affiliates in Brazil, Honduras and dom. Also, clients have to believe that "While AIDS prevention campaigns focus Jamaica. Initially, the three programs re­ condoms work. on those having multiple sexual partners, social sisted condom promotion. Most staff had While many family planning providers marketing can also have an impact on condom never opened a condom package to let a and potential condom users believ~ that use among married couples. In Vietnam, a client touch the condom, nor had they dem­ condoms are not reliable, FHI research has campaign begun in 1993 by DKT Interna­ onstrated how to use one correctly. found most condom breakage and slippage tional advertising the Trust condom resulted in Staff training used penis models for happens to a small minority ofusers. Coun­ a sharp increase in sales anlong married practicing correct use and provided other seling can identify persons at increased risk couples in cities. lO information, including details about stor­ ofcondom failure (breakage or slippage), age, use oflubricants and promotional tech­ who may need more intensive information niques. The training helped overcome staff and attention regarding consistent and cor­ FAMILY PLANNING PROGRMIS resistance, says Dr. Ney Costa, director of rect use. "A history ofcondom failure and Until AIDS, condoms were not gener­ Sociedade Civil Bem-estar Familiar no less experience in using condoms are the ally well promoted by family planning clin­ Brasil (BEMFAMlBrazil). "Before, staff most important risk factors for future fail­ ics. Providers assumed they were for disease members might say, 'here it is.' Now they ure," says Alan Spruyt, FHI senior research protection and that they were not very effec­ have clients put them on a model and ex­ analyst. tive at pregnancy prevention. To varying plain how to store them." Spruyt and his colleagues conducted a degrees, family planning programs have be­ The project promoted condoms in the prospective study among 386 men using gun to incorporate disease prevention and broader context ofintroducing sexuality 1,810 condoms in Mexico, Philippines and the importance ofcondoms into their pri­ into family planning. To increase tlle use of the Dominican Republic. The men who re­ mary mission ofproviding contraception. condoms, people need knowledge about ported condom failure during the year prior "We have made condom use part ofour HIV transmission, what types ofsexual be­ to the study were more likely to experience regular community presentations on family haviors can put a person at increased risk of failures during the study, compared with planning methods," says Marfa Isabel Plata, infection, and how to change those behav­ those who did not experience failure during executive director ofAsociaci6n Probienestar iors. Discussing such issues requires coun­ the year prior to the study.ll Most behaviors de la Familia Colombiana (pROFAMILIA), selors with an ability to talk about sensitive that could lead to condom failure can be ad­ the largest nongovernmental family planning and private issues. People have to change dressed by instructing clients on correct use, provider in Colombia. Use has increased due attitudes towards condoms, such as acknowl­ such as not using oil-based lubricants (which to the AIDS epidemic, she says. edging their risk ofinfection. And, they need

22 NETWORK Spring 1998 weaken the integrity oflatex), not opening 4. Central Statistical Office (Zimbabwe) and 8. Making prevention work - global lessons the package with teeth or sharp objects, and Macro Internationai,'Inc. Zimbabwe Demographic from the AIDS control and prevention (AIDSCAP) not re-using the condom. and Health Survey 1994, Summary Report. Calverton, project, 1991-1997. Unpublished paper. Family MD: Central Statistical Office and Macro Interna- Health International, 1997. ~ William R. Finger' .tional, Inc., 1995. 9. Nelson KE, Celentano DD, Eiumtrakol S, 5. Meekers D. Going Underground and Going et a1. Changes in sexual behavior and adecline in REFERENCES After Women: Combating Sexual Risk Behavior among HIV infection among young men in Thailand. N 1. The World Bank, European Commission, Gold Miners in South Africa. PSI Research Division EnglJMed 1996;335:297-303; Rojanapithayakorn Joint United Nations Programme on AIDS. Con­ Working Paper No. 13. (Washington: Population W, Hanenberg R. The 100 percent condom pro- ' fronting AIDS - A World Bank Policy Researc~ Report. . Services International, 1997) 15. gram in Thailand. AIDS 1996;10(1):1-7. . (New York: Oxford University Press, 1997) 112~ . 6. Ezeh AC, Seroussi M, Raggers H. Men'i ' 10. Goodkind D, Anh PT. Reasons for rising 2. Mehryar A: Condoms: awareness;attitudes Fertility, Contraceptive Use, and Reproductive Prefer­ condom use in Vietnam. Int Fam Plann Perspect and use. In Cleland], Ferris B, eds. Sexual Behaviour ences - DHS, Comparative Studies No. 18. (Calverton, 1997;23(4): 173-78. and AIDS in the Developing World. (London: Taylor MD: Macro International, Inc., 1996) 26. 11. SpruytA, Steiner M],]oanis C, et a1. Iden­ and Francis, 1995) 124-56. 7. The World Bank, 164.' tifying condom users at risk for breakage and slip­ 3. United Nati0Ils, Department of Economic page: findings from three international sites. Am J and Social Resources.~World Contraceptive Use, 1994,' , Public Health 1998;88(2):239-44. poster. New York: United Nations, 1995. o @ Reasons to Have Confidence in Condoms

By Dr. Erin T. McNeill FHI Research Scientist

Note: The following is acondensed version ofa "When used correctly and consistently, chapter appearing in FHI's recently published The condoms are an effective means ofpre­ Latex Condom - Recent Advances Future venting STD/HIV. A woman's fertile Directions. For information about ord~ring this period is intermittent, but men and publication, please see page 32. women can be at risk ofcontracting an STD, including HIV, at every intercourse. Study after study has shown that condonls fused regularly and correctly, latex are extrenle1y effective against STDs if they condoms are very reliable and effective, are used consistently and correctly. In many a powerful nleans to prevent pregnancy cases, a person does not know his or her and disease. However, condoms are not partner's STD status. In cases where part­ being used as much as they should be, ners are not infected, intermittent condom mainly because ofnegative perceptions use will seem to protect against transmission among users and health-care providers alike. in a proportion ofcases since no STD was in Here are several good reasons to have fact present. However, if one partner is . greater confidence in latex condoms: HIV-positive, then there is a guaranteed risk ofexposure to infection at every unpro­ "When used correctly and consistently, tected intercourse, and inconsistent condom condoDls are an effective means ofpre­ use offers little protection against HIV, venting pregnancy. Pregnancy rates for compared with nonuse. condoms range from 3percent to almost 14 percent. This means three to 14 out of 100 Latex condoms provide an impenneable women get pregnant in a year using only mechanical barrier. Latex condoms are condoms for contraception. However, these impermeable to bacteria, viruses and sperm. pregnancies are not due primarily to con­ Therefore, unless a condom breaks or com­ dom failure. Higher pregnancy rates during pletely slips off in a clinically significant typical condom use reflect inconsistent and manner, i.e., during or after ejaculation, or incorrect use. Ifawomen does not use a has manufacturing defects such as pinholes condom during just one fertile phase in a (which are extremely rare), users are not year, she has a four-times higher risk ofbe­ exposed to semen or viral particles. coming pregnant than ifshe uses condoms (Condoms only fornl a barrier between the consistently and experiences occasional penis and vagina, yet some sexually trans­ breakage. Moreover, the risk of breakage is mitted viruses, such as human papilloma concentrated in certain couples. This means viruses, or genital warts, can be transmitted that the majority ofcouples who use via skin-to-skin contact between the scrotal condoms consistently are at very low risk of pregnancy.

24 NETWORK Spring 1998 skin and the perineum. Therefore, even in­ latex protein allergens during processing. and external quality control and quality as­ tact condoms cannot prevent the transmis­ Manufacturers are also aware ofthe poten­ surance is now in place to ensure high qual­ sion of all organisms. The female condom, tial risk posed from using talc as a dry lubri­ ity ofcondoms. In the era ofAIDS, the which covers more of the external genitalia, cant, and n1any are shifting to cornstarch. condom is considered a potentially life-saving may afford greater protection.) Broken or However, since cornstarch may not be en­ medical device, and as such is subject to strict leaky condoms certainly expose couples to tirely without risk, the search for a better quality standards. Through both worldwide risks, but not using condoms exposes people and safer dry finishing powder continues. and regional standards bodies, minimum to a far higher n1agnitude ofrisk. acceptable quality levels are enforced, son1e Condom use is improved by the right by law and others through consensus guide­ Most users do not break condoms, and a lubricant. Wet lubricants placed on fin­ lines. The wide net cast by current standards proportion ofbreakage is preventable. ished condoms prior to packaging include bodies ensures that the great majority of Most people who use condoms, especially water-based lubricants, alone or with sper­ condoms (including condoms supplied by once they gain experience with them,. rarely micide added, and liquid silicone. The evi­ international donors) are manufactured to experience breakage or slippage; condom dence suggests that using appropriate high standards. failure is actually concentrated among a quantities ofthe right types oflubricant (in small percentage ofusers. Studies have iden­ manufacturing and during use) decreases While it is not yet clear how well the test tified characteristics ofcondom users that breakage and increases satisfaction with standards predict results dudng human seem to be associated with more frequent condoms. Use ofwater-based lubricants may use, a combination oftests can provide condom breakage and slippage. Ahistory of increase slippage, but data suggest that the clear guidance on the quality ofcondoms condom failure and inexperience in using protective effect against breakage mayout­ in the field. The current battery of tests ­ condoms are the characteristics most weigh any risk ofincreased slippage. There condom dimensions, package integrity, lu­ strongly associated with condom failure. is no evidence that spermicidally-lubricated bricant quantity, water leakage, tensile prop­ Some research also suggests thatyoung age, condoms confer any advantage by increasing erties, and air-burst properties - assure that not living with one's sexual partner, low efficacy against pregnancy or disease, in newly manufactured condoms conform to level ofeducation, having multiple sexual spite of a consumer perception that spermi­ international standards and specifications. partners, low income and large penis size are cidallubricant ought to do this. Indeed, But uncertainty still surrounds the validity of correlated with increased risk ofcondom there is some preliminary evidence that these tests in assessing condom deterioration breakage or slippage. Studies also suggest spermicidal lubrication n1ay promote leach­ over time and predicting performance in hu­ that certain behaviors are associated with ing oflatex allergens, thereby potentiating man use. For the time being, acombination increased breakage or slippage, including: the risk ofallergy. Since spermicidally­ of condom age and relevant tests (air-burst, improper storage, rough handling of lubricated condoms also have a shorter package integrity and lubricant quantity) condoms, improper technique in putting on designated shelf life, silicone is a preferable should be used to assess possible condom a condom, not encouraging natural vaginal lubricant. deterioration. No single laboratory test is an lubrication, using excessive added lubricants adequate surrogate for condom performance (especially oil-based), lengthy or vigorous Condoms in intact foil packages last at during use. sex, anal intercourse, loss oferection prior to least five years. Adequate packaging is cru­ In time, condoms made ofnon-latex, withdrawal, and re-use ofcondoms. Some cial to the long-term integrity oflatex synthetic materials may replace latex con­ failures may be prevented through counseling condoms. Plastic packages expose condoms dom use in part or altogether. Synthetic to avoid obvious problems like opening con­ to greater and more rapid deterioration condoms made from thermoplastic elas­ dom packages with sharp objects. from oxidation, humidity, ozone and ultra­ tomers have several advantages over latex violet light than do foil packages. When condoms. They have more controllable Today's condom is manufactured with properly sealed in foil packages, modern' physical properties such as strength and can greater precision. Latex condoms are bet­ latex condoms are quite resistant to adverse be fashioned in any shape and size. They ter formulated, processed, finished and environmental conditions and will retain may transmit heat better than latex, allowing packaged than they have ever been. During their quality for at least five years and prob­ for greater sensitivity during intercourse. formulation, there is greater control over ably longer. Thus, all condoms should be However, only two synthetic condoms are the chemical processes of oxidation and vul­ packaged in aluminum foil, or foil-plastic being sold: the Avanti male condom (London canization, which reduces the risk ofcon­ laminate packages. International Group) and the female condom dom failure due to aging. Also, current (Female Health Company). Unfortunately, knowledge about stress and strain properties Quality control and post-production the limited availability and relatively high during use enables manufacturers to adjust quality assurance help ensure a reliable cost ofsynthetic condoms mean that most the latex formulation in ways that optimize product. In addition to many specific im­ consumers will need to rely on latex condom performance. In recognition ofa provements in all aspects oflatex condom condon1s for the foreseeable future. growing concern about latex allergy from a manufacture, an extensive system of internal variety ofother products, condom manufac­ turers are making greater efforts to remove

NETWORK Sp1,oing 1998 25 Attracting Men to VasectoIDY

How to promote vasectomy, and how much to promote it, may be keys to expanding method use.

" oadside billboards in the United Promotional campaigns in developing II Kingdom draw attention to the two countries have also been successful. In l round handles ofa surgical instru- Colombia, vasectomy promotions include a II ment, arranged to suggest a man's radio campaign. InJamaica and Uganda, liI lJ) testicles. "Handled with care," brochures are distributed. Providers in Sri reads the billboard, "Marie Stopes Vasec­ Lanka, Mexico, Kenya and other countries tomy Clinic; call in confidence." Inquiries encourage word-of-mouth promotion by about vasectomy increased dramatically af­ satisfied clients. ter the campaign began last fall. Campaigns need to be put in the larger "Promoting vasectomy is critical," says context ofpromoting all contraceptive Julie Douglas ofMarie Stapes International methods. "The point is not to promote one (MSI) in London, who coordinated the cam­ method over another, but rather to make paign. "There is a lot less information avail­ sure that potential family planning clients able about vasectomy, compared to women's know ofall oftheir choices," says Mary Nell methods. Plus, men do not go to the doctor Wegner, director of AVSC International's for regular checkups." The United Kingdom Men as Partners Initiative based. in New is one ofthe few countries in the world where York. Determining exactly how to promote about the same percentage ofmen (16 percent) vasectomy, and how much to promote it, and women (15 percent) use sterilization. may be keys to expanding this underused Every year, MSI launches avasectomy method. promotion that includes advertising in local newspapers and on billboards at football SAFE, BUT UNDERUSED stadiums. This year's campaign includes an eye-catching poster at subway stations and Correcting misunderstandings about on buses that shows a maD;'s torso, naked the method and even making men aware of except for a white fig leaf. "Vasectomy? this option can be among the goals ofinfor­ We've got it covered," reads the poster. mation campaigns. Even where people have "These are light-hearted and bold heard ofvasectomy, many continue to be­ ideas, with some shock value," says Douglas. lieve incorrectly that it affects a n1an's sexual "Men are tense and worried about vasec­ performance or impairs his strength. Cor­ tomy. Will ithurt? How will it affect my sex rect information is crucial in any promo­ life? Being light-hearted helps open the tional effort and in personal counseling. door." Douglas is quick to point out that Vasectomy does not affect the production of such slogans are too suggestive for many male hormones that control sex drive and developing countries, where MSI has not such masculine features as facial hair. Vasec­ been as explicit in vasectomy campaigns. tomy simply prevents sperm from entering Prevailing social norms should guide the the ejaculate. The provider cuts the vasa content ofpromotional campaigns, she says. deferentia, through which sperm travel from the testicles to combine with semen. After vasectomy, the testicles continue to produce "While vasectomy is safe and effective, it is Research in Brazil, Colombia and sperm, and the sperm eventually degenerate underused. About 45 million couples world­ Mexico also found that nlen's concerns and are excreted like other body cells. wide rely on vasectomy for contraception, about their wives, and the wives themselves,..... Vasectomy is effective, safe, quick to compared with about 150 million for female play an important role in a decision to have a perform and has few side effects. The proce­ sterilization. Over the last decade, promo­ vasectomy. Men said they had vasectomies dure typically takes minutes to complete, tional efforts in Colombia, Kenya, Mexico and because of"its advantages over female steril­ requires only local anesthesia, and only a other countries have resulted in some in­ ization and temporary methods, [their] con­ small proportion ofmen experience short­ creased use~ but even there, less than 1percent cern for their wife and her health, their term blood clotting or infection, considered ofmarried couples ofreproductive age use va­ desire to share responsibility for family plan­ to be minor pioblenls. Questions remain sectomy. Only in China, the Republic ofKorea ning, and the freedom from unintended about whether vasectomy may increase the and a few developed countries (Australia, pregnancy that vasectomy confers," the risk ofprostate cancer, but available research Canada, the Netherlands, United Kingdom study reports. 5 is not conclusive (see article on page 7). and United States) do 10 percent or more of Research in Colombia has found that Pregnancy rates are thought to be less than 1 couples rely on this method. 3 various promotional techniques can be ef­ percent, although no long-term effective­ fective, including word ofnlouth. 6 The ness studies have been conducted similar to Asociaci6n Probienestar de la Familia WHY MEN USE IT research on fenlale sterilization. Colombiana (PROFAMILIA), the largest The no-scalpel approach emphasizes In an MSI questionnaire returned by fanli1y planning provider in Colombia, has that no knife is necessary, which comforts about 500 men who received a vasectomy been a leading vasectomy promoter for some men. Using a puncture instrument to in 1997,27 percent said they chose vasec­ nearly two decades. "Our outreach for va­ gain access to the vasa, the no-scalpel proce­ tomy to relieve their partner from using sectomy is constant," says Maria Isabel dure requires less anesthesia and is just as contraception. Another 31 percent said they Plata, PROFAMILIA director. "Word of effective as the incision mouth is the best way approach.AJso, men to promote it. We recover faster and they stress quality of care. experience less pain, When we have happy bruising and infection clients, we get nlore compared with men clients." who used the incision Word-of-mouth method, according to an promotions can be FHI study.l structured, sometimes Vasectomy is not involving couples. In a immediately effective training course in because viable sperm Kenya for providers, 17 remain for weeks in the men~volunteered to urethra above the cut share their vasectomy vasa. International experience. Many of guidelines recommend these men had never that couples use another spoken about their va­ method ofcontracep­ sectomy, and a sense of tion, such as condoms, UNITED KINGDOM BILLBOARD PROMOTES VASECTOMY. solidarity emerged for 12 weeks or 20 among the group. ejaculations, after which these residual had completed their family, and vasectomy Some appeared in media campaigns, others sperm should be gone. However, men was the best permanent form of contracep­ volunteered at clinics to talk with men con­ should be advised to return ifpossible for a tion. sidering vasectomies, and still others worked follow-up senlen analysis, to verify that no In a six-country study involving in­ with couples in outreach efforts. As a result sperm are present (azoospermia). Without depth interviews with 218 couples, virtually ofthe group's work, men in the area "were an analysis, couples cannot be certain that all couples cited economic reasons and a much more likely to consider vasectomy and azoospermia has been achieved. Like all concern for women's health as a motivating to use condoms and were less likely to be­ contraceptive methods, vasectomy is not factor for not wanting any more children. lieve rumors associated with other methods perfect and failures do occur. The exact time The results were remarkably similar across than were men in other regions," explains a to azoospermia, which means the complete the six countries surveyed - Bangladesh, summary of the program. 7 absence ofspernl in the ejaculate, is not Kenya, Mexico, Rwanda, Sri Lanka and the - William R. Finger known. Preliminary data from FHI and United States. In every country, many AVSC International research indicate a wide couples chose vasectomy because it was a variability in the time and number ofejacu­ safer choice than tuballigation.4 Continued on page 32 lations before men reach azoospermia. 2

NETWORK Spring1998 27 Abandoning Self-defeating Behaviors

Port-au-Prince, HAITI - "At first, the men different attit:udes for dealing with life's in our program tended to see themselves as problems. It also promotes clear, direct alone," says Gessy Aubry, director of GLAS, communication. the Groupe de Lutte Anti-SIDA (Group in "Although TA is well known in the de­ Struggle Against AIDS), an HIV prevention veloped world, many experts were unsure program conducted at Port-au-Prince work­ whether it.could be successfully.used in the places ranging from utility companies to developing world to enrich an HIV preven­ bottling plants. tion program," says Aubry. "But after we "The men tended to be concerned only translated the idea ofTAinto the native lan­ with their own welfare. They often had guage, taking into account our students' dominating attitudes towards women," she frame ofreference, it became our biggest says. "Then, gradually, very gradually, they success. It was the key thing that had been began to appreciate that they could get missing." something for themselves by behaving in ways that also benefited women. They also learned through their women colleagues GRADUAL EVOLUTION how women think, and began to accept them Overall, GLAS provided HIV preven­ better." tion education to nearly 20,000 workers, Accompanying these changes in many predominantly male and primarily between men's hearts and minds were important 15 and 49 years old. changes in behavior that served to protect The workplace project evolved gradu­ them better from AIDS. The program, ally. At first, GLAS offered only a single, which ended in 1996, consisted offour hour-long session involving a general intro­ phases, but the final phase was the key to duction to sexually transmitted diseases, bringing about behavioral change, says notably HIV and its prevention. Asecond Aubry. Itfeatured awidely-used educational session instructed workers on condom use. tool for personal growth and change, called Surveys ofworkers inspired a third transactional analysis (TA). phase ofthe workplace project: an open­ This psychological approach focuses on ended discussion hour in which workers who teaching adults how to abandon often pain­ had participated in the first two sessions ful and self-defeating strategies, typically could ask questions, analyze rumors and be­ learned during childhood, and how to develop liefs about HIV/AIDS, and talk about per­ sonal issues. "This was very important for a setting like Haiti because many ofthe people with whom we worked were superstitious and believed that AIDS was a supernatural disease, a curse placed upon you by people who wish to harm you," says Aubry. "Re­ versing these beliefs and replacing them with the understanding that men can protect themselves against AIDS by changing sexual behaviors represented major progress in the work." . Still, after the three sessions, some men and women continued to put themselves at risk for HIV infection. Puzzled by this be­ havior, Aubry decided that its source must be a lack ofself-esteem and poor communi­ cations skills; she decided intensive psycho­ logical support groups featuring TA could get to the heart ofthe matter. Intensive interventions such as this are rare in developing countries. "I knew, hav­ ing used TA in communication courses for professionals, that it was a marvelous way to "Working with both men and women "Women acquired more self-confidence help people obtain equilibrium in their was very helpful in pinpointing gender dif­ and better comnlunication skills. While TA ­ lives," says Aubry. "TA does not consist of ferences," says Aubry. "Men needed to be has been regarded as something that should difficult concepts ... it simply teaches a per­ helped to put aside dominating attitudes, but _only be offered to literate people, myexperi­ son how to use the powers and pitfalls ofhis TA helped them think about - perhaps for ence shows that the concept ofTA can be or her unique psychological makeup to the first time in their lives - the reasons for understood by anyone," says Aubry. "What's change behavior and make better decisions." their attitudes and actions and to break be­ more, once it is put into practice, the change With funding from FHI's AIDS Con­ haviors down to their origins. Also, it often in people's lives tends to be pernlanent, trol and Prevention (AIDSCAP) Project, gave them a sense ofresponsibility for their making these individuals better parents, Aubry created 20 support groups (two each actions, a deep respect for their partner in workers and citizens." in 10 different workplaces) that met monthly life and an appreciation of the importance of -Kim Best for eight months, during which participants parenting. learned TA. Each group included both men and women.

(including vasectomy and condoms), infer­ AClinic for Her, and One for Him tility testing and treatment, STD diagnosis and treatment (including HIV testing), sex therapy, lab services fOf sperm counts, and Bogota, COLOMBIA - At one time, a man "I work with men of all ages, adoles­ hormone, urine, and blood testing. seeking reproductive health services at cents to men in their 80s," he says, "and Men attracted to the clinics for anyone Clinica Piloto ofthe Asociaci6n men of all incomes, education and types of ofits numerous health services can also re­ Probienestar de la Familia Colombiana personality. Despite their differences, men ceive counseling about reproductive health (PROFAMILIA) faced a and family planning is­ challenge. He had to DEBBIE ROGOW sues. One measure ofthe share the clinic entrance success is that the number with women and walk ofvasectomies performed into a waiting room filled at PROFAMILIA clinics with women, most of has steadily risen from whom would look at him, 1,241 in 1985 to 6,825 in many ofwhom would 1995. stare. Clearly, many men Apopular service would feel intimidated. offered at the men's clinic Today, however, in Bogota is sexual dys­ Clinica Piloto in Bogota function consultation. offers men their own all­ Says former clinic director male clinic, focusing spe­ Dr-.Juan Carlos Vargas: cifically on their needs. "Our staff includes sex Since 1994, the men's therapists who are consid­ clinic has even been lo­ ered the country's best cated in a different build­ experts on sexual dysfunc­ ing, across the street from tion. Demand for such the main family planning consultations channels clinic. many men to the clinic, at Efrain Patino, a PROFAMILiA CLINIC FOR MEN IN BOGOTA. which point we can ad­ counselor at the men's dresS'overall reproductive clinic since it opened in health care." 1985, says the first men to come to the know that when they come here they will get PROFAMILIA staff also visit places that clinic, initially supported by New York­ good, comprehensive care and, when they men frequent, particularlyworkplaces, to based AVSC International, requested vasec­ get such care, they often are very grateful." discuss reproductive health matters and tomies. But now, on an average day, Patino Services offered at the clinic include sometimes perform exams. sees at least 40 men whose visits represent an urological procedures (including in-patient array ofreproductive health concerns. surgery), general medicine, family planning

NETWORK Spring 1998 29 MEN'S SPECIAL NEEDS health services. "Men tend not to admit that worried about; yet, the doctor who examines Separate facilities or services are not they are ignorant about matters concerning him is astonished at how ad~anced the prob­ the only way to reach men. PROFAMILIA sex or reproductive health," Patino says, lemis." offers men-only clinics in two large cities, "although it is often clear during counseling "Building confidence is the key. I try to yet has found the nUlnber ofmale clients sessions that they are learning something keep up regular contact with clients, particu­ increasing at its clinics in smaller cities, completely new." larly those with ongoing problems. One of where separate facilities are impractical. "Also, ifthey have a health problem, my greatest satisfactions is to meet former Much of the credit goes to staffwho are sen­ they tend to try first to go to the pharmacy patients later and have them remember me.. sitive to men's complex needs. In the male and get drugs that mayor may not work. In this way I know I've had an itnpact on clinic in Bogota, counselor Patino spends Furthermore, men are not as direct as their lives." approximately 15 minutes with each client, women and tend to minimize problems. Itis ...:.....Kim Best discussing concerns before and after guiding not unusual for a man to tell me he has a the client to an appropriate provider. small amount ofsecretion that he is not at all Note: More information about this topic is found Traditional ideas about the roles and in Profamilia's Clinics for Men: ACase responsibilities ofmen often are barriers to Study. Men as Partners in Reproductive helping men obtain the best reproductive Health. New York: AVSC International. 1997.

accepting personal responsibility. Team­ .Games of Risk for Men at Risk building skills, for example, are developed in the minefield exercise. Later, the young men work on platforms and climbing apparatus, Gettysburg, PA, USA - In an outdoor area ANlIP meets weekly for seven sessions which heightens the sense ofrisk. Ifthey known as "the minefield," an odd assort­ and involves up to 12 young men who attend continue to progress as a team, theyeventu­ ment ofitems have been randomly placed, alternative education classes for teenagers ally have the opportunity to climb a 40-foot ranging from cuddly stuffed animals to whose behavior has resulted in their removal tower.

mousetraps. Some have signs saying they are from traditional schools. "These are young GETTYSBURG COLLEGE harmless, but others are labeled as posing men, mostly 16 to 18 years old, who are risks for sexually transmitted diseases not functioning well in a traditional (STDs). school setting, possibly are on probation, Agroup ofyoung men pair offwith may have had drug or alcohol problems, each other, then one verbally guides his or may have family issues such as neglect, blindfolded partner around the risky items. abuse or violence," Crouthamel says. In this game, points are given whenever a "Many have responded very positively and blindfolded man touches a "risky" item, and I believe a more mainstream group of accumulating so many points results in an young men might react even more en­ "infection." Generally, about 20 percent of thusiastically." With a grant from the the teenagers have "acquired" an STD by Pennsylvania Department of Health and the end ofthe game. the Family Health Council of Central This exercise is just one ofseveral ac­ Pennsylvania, the Family Planning arid tivities in the Adolescent Male Involvement Health Center in Gettysburg conducts Program (AMIP),in Gettysburg, a small city the program. ..~ea~ Washin~ton best knqw~ to Americans . '''On~ thing w:e quickly figured out as the site ofa battlefield during the American was. that male 'adoiescellts, unlik~ females, Civil War. The games help yoUng men under­ have trouble r~lating to 'each 9ther on a '~tand 'reproductive ~ealth risks, says Marianne chatty, intimate basis. Young men re.:. Crouthamel, program coordinator. ' spond to an action-oriented format," she At the heart of the small program is the says. idea thar-youth drawn to impulsive and risky To that end, the initial sessions take behaviors can learn to respect risks and pre­ place at a series ofoutdoor obstacles at pare for them through challenging physical Gettysburg College called the Challenge activities and mentors whose professions are Course. The college helps organize activi­ naturally dangerous. ties designed to develop skills"in team­ SECURED BY A SAFETY HARNESS AND ROPES, AN building, resisting peer pressure and AMIP PARTICIPANT CLIMBS A TALL POLE IN AN EXERCISE THAT HELPS YOUNG MEN UNDERSTAND

REPR9DUCTIVE HEALTH RISKS.

30 NETWORK Spring 1998 During these initial sessions of practic­ CLINIC VISITS fear." During the last session for one group, ing techniques to keep themselves safe, the The young men receive information seven of 10 young men requested STD testing-­ young men also are taught about sexual risk about contraception, prevention of STDs and a few requested HIV testing. reduction by two certified paramedics. "Be­ and social skills to help them negotiate and "We were extremely surprised and cause we were dealing with youth who were maintain healthy relationships. Final ses­ pleased that these kids were now self-assessing risk takers, we very much wanted to involve sions include visits to a family planning their risk and acting responsibly upon their as mentors men whose occupations involved clinic and a health clinic. Coordinated by a assessments," says Crouthamel. "Further­ risk-taking, but in a positive sense," says physician, the tours include an opportunity more, the young men who requested STD Crouthamel. to be tested for an STD. Dr. Kenneth testing wanted to receive the test results in Says Scott Anderson, a paramedic who Stephan, the physician, is a familiar figure to the group, not privately. They obviously felt works with the program: "They could not the young men since he occasionally partici­ there was strength for them in the group, understand why risk reduction would be pates in earlier sessions. that they had worked hard together and important to them personally. Information "The boys seemed nervous with my 'would share the results, regardless of their is not enough ifindividuals cannot envision presence at first, but warmed up," Dr. outcome." a future for themselves worth protecting. Stephan says. "I feel that having a physician -Kim Best True understanding was not possible with­ involved plants the seed for the youth to be out first addressing on the obstacle course comfortable with doctors or clinics. Then, the central concept ofself esteem." they will be willing to make use ofus without

Experimenful n~e ~Ietltods pigs with the sperm surface protein PH-20 2.Wu FCW, FarleY1MM, Peregoudov A, et renders the animals reversibly infertile. al. Effects oftestoster~ne!tlanthate in normal men: Continuedfrom page 19 Most ofthe infertile males have shown some' experience from a multigenter efficacy study. Fertil . SteriI1996j65(3):626-36j VVHOj Meriggiola MC, testicular inflammation, and the researchers Marcovina S, Paulsen.CA, et al. Testosterone that are different from RU486, yet related are investigating strategies to eliminate this enanthate at a dose of200 mg/week decreases chemically, that act specifically on sperm inflammation, Dr. Primakoff says. The re­ HDL-cholesterolle~els in healthy men. IntJ and not on these other [hormonal function] search group also has identified a number of Andrology 1995;18(5):237-42. receptors. So, though RU 486 may never be other sperm surface proteins that might in­ 3. Wu, 626. fully developed as a male contraceptive, I hibit fertilization. 4. Progress in research into new methods of Another research approach involves an fertility regulation for men. Progr Human Reprod Res believe it may prove to be the inspiration for 1995j33:2. extract, triptolide, from the herb a successful male contraceptive compound," 5. Griffin PD. Methods for the regulation of hesays. Tripterygium wilfordii, which comes from the male fertility. Ammal Technical Report 1995. Ed. Van Meanwhile, avaccine that uses sperm root ofa vine found in southern China. In Look PFA. Geneva: World Health Organization, surface proteins as agents to provoke an im­ WHO-sponsored work on triptolide, no 1996. mune response that causes infertility is being genetic mutations or toxicity were s~~n in 6. Bebb RA, Anawalt BD, Christensen RB, et investigated in rodents. Development of bacteria or mice. "Anon-"WHO funded al. Combined administration oflevonorgestrel and study ofthe effectiveness of triptolide to testosterone induces more rapid and effective sup­ such a contraceptive vaccine for men is con­ pression of spermatogenesis than testosterone inhibit fertilization in marmoset monkeys is sidered to be many years away. Research alone: a promising male contraceptive approach. that aims to block fertilization by attaching in the late planning stages and may begin J Clin Endocrinol Metab 1996j81(2):757-62. antibodies to asperm surface protein essen­ later this year," says Griffin ofWHO. 7. Meriggiola MC, Bremner WJ, Paulsen CA, tial to fertilization is being directed by Dr. -Kim Best et al. Testosterone enanthate (TE) and low doses of Paul Primakoff, professor in the Depart­ cyproterone acetate (CPA) for contraception in ment of Cell Biology and Human Anatomy REFERENCES men. 10th Intemational Congress ofEndocrinology. Program and Abstracts 1996j2:734. at the University of California at Davis. 1. World Health Organization Task Force With funding from the National Insti­ on Methods for the Regulation ofMale Fertility. tute ofChild Health and Human Develop­ Contraceptive efficacy oftestosterone-induced azoospermia and oligozoospermia in normal men. ment, Dr. Primakoff and his colleagues have Fertil SteriI1996j65(4):821-29. found that immunization of male guinea

NETWORK Sp1'ing 1998 31 VasectonlY Continuedfrom page 27

REFERENCES 3. United Nations, Department of Eco- " 5. Vernon R. Operations research on pro­ 1. Family Health International. Final Re­ nomic and Social Resources. World Contraceptive moting vasectomy in three Latin"American coun­ p01t: A Comparative Study ofthe No Scalpel and the Use, 1994, poster. New York: United Nations, tries. Int Fam Plann Perspect 1996;22(1):26-31. Standard Incision Method ofVasectomy in Five , 1995. 6. Vernon R, Ojeda G, Vega A. Making Countries. Research Triangle Park, NC: Family 4. Landry E, Ward V. Perspectives from vasectomy services more acceptable to men. Int Health International, 1996. couples on the vasectomy decision: asix-country Fam Plann Perspect 1991;17(2):5"5-60. " 2. Family Health International. Time to study. In Ravindran TKS, Berer M, Cottingham 7. AVSC International. Men as Partners in Azoospermia After Vasectomy: Expanded Study ­ J, eds. BeyondAcceptability: Users' Perspectives on Reproductive Health Workshop Report - Mombasa, Final Report. Research Triangle Park, NC: Contraception. (London: Reproductive Health " Kenya, May 1997. (New York: AVSC Interna­ Family Health International, 1997. Matters, 1997) 58-67. tional, 1997) 14.