Sexual and reproductive health: what about boys and men?

Education and service provision are the keys to increasing involvement

Boys and men have been left out in our efforts to improve sexual and reproductive health. A national survey of family planning clinics by the Family Planning Association showed that young men are much less likely than women to access sexual health services.1 The United Kingdom government is currently assessing the feasibility of a screening programme for Chlamydia trachomatis. Its two pilot studies are focusing on women, but some argue that this “calls into question our ability and commitment adequately to address the sexual health needs of heterosexual men.”2 Why should we turn our attention to men? And how can we foster men's responsibility towards sexual and reproductive health? These questions were considered recently at the fifth seminar of the European Society of Contraception in Amsterdam and several proposals made.

Objections were raised to focusing on men's needs, including the concern that this may jeopardise reproductive health services for women and that men already have too much power over decisions affecting women's fertility and sexual health. Nevertheless, increasing evidence exists that ignoring the sex education and sexual health needs of young men has important and wider social and health consequences.

There is widespread research and media interest in the idea of male adolescence as a negative and chaotic experience and a poor preparation for adulthood. Yet the few services provided for boys seem not to help. Boys consulted by the Sex Education Forum said that their formal sex education is “too little, too late, too biological” and that it fails to prepare them to deal with sexual relationships, contraception, abortion, and their sexual identity.3 Similarly, a qualitative study among 39 boys aged 11-21 in the Norwich region showed them united in denying the utility of their sex education.4

One result is a failure among young men to use contraception or engage in safe sex A survey of 1919 college students showed that only 10% used condoms consistently.5 Boys have been overlooked in tackling high teenage pregnancy rates, as recognised in the recent report from the UK government's social exclusion unit.6 Data from annual behavioural surveys and from the sexually transmitted disease surveillance programme in the United States show an increase in unsafe sex among men who have sex with men.7 Few studies have addressed young men's involvement in decisions about termination of pregnancy, though one qualitative study of the attitudes of teenage boys showed a desire to be involved and to receive emotional and social support.8 Little research has been done into the possible emotional sequelae of termination decisions for men.

Three broad approaches exist to improving men's participation in activities concerning sexual health, though there is a frustrating lack of evidence to show that these initiatives will have social or clinical impact. Firstly, experts in sex education argue that we should start with what boys want, rather than what adults think they need.3 This means that boys should participate in developing education programmes, influencing the content, delivery, and setting of their sex education. This approach was used by the Sex Education Forum3 and the Family Planning Association9 in developing practical guides to working with young men.

Secondly, we should be more honest to young men about the barriers to using condoms and practising safe sex, including embarrassment, fear of failure, and loss of sensitivity. A basic concept is to understand the anxieties of young men starting their sexual “careers.” Initial difficulty in using a condom may influence a young man's attitudes to condoms forever (A Kubba, personal communication). Practising condom use during masturbation may alleviate anxiety, and one author has argued that healthcare systems should pay for condoms for such practice.10 In discussions with young men about sex, we should include notions of pleasure and not just prevention, for many pleasurable activities are also safe ones. Increasing the range of contraceptive choices for men will be empowering for both men and women, and a recent international survey found that most men would consider taking a “male pill.”11

Finally, we need to make sexual health services more accessible to boys and men. We should consult them locally to assess their needs, advertise services in an informal and attractive way, broaden the settings of service provision, and provide for specific groups such as young gay men and men from ethnic minorities. Motivating men to take a more active interest in sexual and reproductive health could be rewarding for us all.