SRH Care Guidance

The QFP makes recommendations for core family planning and SRH services to deliver to reproduction-age persons, and, for the first time, delineates preventive SRH care services to deliver specifically to men. The QFP makes comprehensive recommendations that reproductive-age men receive family planning services (i.e., contraception and counseling; information on achieving pregnancy; basic infertility care; preconception healthcare; and STI diagnosis and treatment), family planning-related preventive services (e.g., genital examination to assess progress of healthy sexual development), and other preventive services (e.g., lipid screening), and that quality family planning delivery be monitored for women as well as for men (Table 2).

In the context of serving a global audience, the IPPF’s global service package discusses how, in promoting health equity and reducing disparities in SRH morbidity and mortality, the care of males follows evidence-based guidelines and takes into consideration available resources. It outlines an essential SRH service clinical care package that includes the elements described in Table 3. To build an effective global workforce of highly skilled healthcare providers for males, however, SRH care cannot be the sole responsibility of certain specialties and needs to be incorporated into all levels of healthcare systems (Society for Adolescent Health and Medicine, 2018).

In 2018, the Guttmacher–Lancet Commission on Sexual and Reproductive Health and Rights proposed a comprehensive and integrated definition of SRHR and recommended for the first time an essential package of SRHR services and information for all persons, not specifically for males, that should be universally available and that is consistent with, but broader than, the SRH targets of the 2030 Agenda for Sustainable Development (Starrs et al., 2018). Table 4 summarizes the recommended package components, which include the commonly recognized components of SRH (i.e., contraceptive services, maternal and newborn care, and prevention and treatment of HIV/AIDS), but also less commonly provided components: care for STIs other than HIV; comprehensive sexuality education; safe abortion care; prevention, detection, and counseling for gender-based violence; prevention, detection, and treatment of infertility and cervical cancer; and counseling and care for sexual health and well-being. This article recognizes that many countries may not be prepared to provide the full spectrum of services but recommends that governments commit to achieving universal access to SRHR and to making continual and steady progress, regardless of where they are starting.

Components of Male-Friendly SRH Care

Healthcare settings are often not set up to treat male patients (van den Berg et al., 2015), which can negatively affect men’s perceptions of the quality of the SRH services they receive. Even where attention has been given to the service-delivery needs of men and boys, this is often done in a cursory manner that simply adds to existing services tailored to women, rather than sufficiently addressing gaps in SRH care for men (Hook et al., 2018). The Society of Adolescent Health and Medicine’s 2018 Position Statement, “Advocating for Adolescent and Young Adult Male Sexual and Reproductive Health,” states that increasing men’s global access to supportive and comprehensive SRH care will require multilevel strategies and investments to explicitly incorporate men’s health needs (Society for Adolescent Health and Medicine, 2018). Such approaches will need to include clinical, structural, educational, and policy changes required to address the specific preparations needed for healthcare and nonclinical service providers who work with men. The approaches need to ensure that necessary supports are in place for males to access and receive confidential, quality SRH care. This will also require service-delivery models and healthcare provider competencies that reflect male-friendly, nonjudgmental, developmentally appropriate approaches that are sensitive to males’ needs, regardless of sexual orientation, gender identity, and culture; guidelines for establishing supportive, youth-friendly environments and care provision to improve access to, and utilization of, SRH care by males; and measures that aim to reduce persistent social and structural barriers, including, but not limited to, addressing stigma, strengthening social supports, disseminating information about available services, improving healthcare coverage, and addressing issues related to socioeconomics, education, experiences of racism, traditional masculinity beliefs, and geographical access barriers.

The Health Communication Capacity Collaborative (HC3) at Johns Hopkins University provides additional components for high-quality male-friendly SRH care for men, outlined in Table 5 (HC3, 2017).

Male SRH Life-Cycle Approach

In providing quality male-friendly SRH services, it is important to recognize that men’s SRH behaviors and needs vary across age groups and life stages, as do the factors influencing boys’ and men’s support for women’s and partners’ SRH. Programming should ensure that approaches with men are age-appropriate and provide targeted entry points for each stage of the life course, including opportunities for men’s active engagement in comprehensive SRHR for all, as suggested by general life-course theory (Elder et al., 2003). At the time of publication, a male life-cycle approach for SRH broadly (rather than solely male reproductive health) does not exist. Building on a male life-cycle approach developed by the first author (Shand, 2017), and further refined by Shattuck (2018), the authors provide a life-course approach (figure 2) to guide programming on for engaging men in comprehensive SRH throughout their lives (Shattuck, 2018). The approach considers males in the following stages:

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Figure 2. Areas of intervention along the male sexual and reproductive health (SRH) life course.

Engaging Men as Clients

Studies that examine engaging men as clients have received little attention or mixed results and have been mainly conducted in the United States. Strategies that have been shown to be successful in engaging young men in care have focused on family planning services through established female patients (Fine et al., 2017; Raine et al., 2003). Other successful approaches have focused on increasing STI or HIV screening practices through direct education via standard curriculum-based approaches (Marcell et al., 2013; Philliber et al., 2002; Vandevanter et al., 2005), approaches that are peer-led (Boyer et al., 2007; Johnson et al., 2010) or media-based (Dowshen et al., 2015; Friedman et al., 2014; McFarlane et al., 2015), or approaches that engage youth-serving professionals (Dittus et al., 2014, 2018; Loosier et al., 2016; Perin et al., 2019). However, non-sex-specific strategies (Philliber et al., 2002; Vandevanter et al., 2005) have not always been as successful in engaging males as much as they engage females, in contrast to strategies that specifically target males (Johnson et al., 2010; Marcell et al., 2013; Perin et al., 2019). It is possible that non-sex-specific strategies do not necessarily take into account ways in which young men are lacking in their socialization around healthcare and do not provide clear messages to males about the importance of SRH care promotion.

In the global setting, men have very limited occasions to enter the clinical system, unlike women, who experience maternity care and other related gynecological care or accompany infants and children on occasions that might also result in increases in mothers’ connection to care. Given this, as an example, men in Malawi have been found to perceive the formal health system as unable to address their SRH needs, particularly around their sexual concerns, including physiological challenges (Shand, 2021). Culturally sensitive approaches, including those that understand the role of traditional medicine, have shown success in India in enhancing clinically based care to better reach men and to improve their uptake of sexual health and dysfunction services (Schensul et al., 2004, 2006). One specific procedure where men are the sole targets as clients, especially in sub-Saharan Africa, is voluntary medical male circumcision (VMMC). Male circumcision has been shown scientifically to be partially (at least 60%) effective at preventing HIV acquisition in males who are exposed through heterosexual (vaginal) intercourse with female partners. Since 2007, sub-Saharan African countries with the highest prevalence of HIV have been mobilizing resources to make VMMC available. While initially demand generation targeted adult men, demand has been highest among boys under age 18. However, a 2016 systematic review of the literature revealed a general absence of health services addressing the specific needs of male adolescents, resulting in knowledge gaps that could diminish the benefits of VMMC programming for this population (Kaufman et al., 2016). No standard promotion of an SRH service package exists outside of the minimum VMMC services package that is promoted by the WHO. However, quality of care may be lacking even within the context of the minimum VMMC service package. One study that examined whether the WHO-defined minimum package of VMMC services was received among male adolescents, including HIV testing, HIV prevention counseling, screening/treatment for STIs, condom promotion, and the VMMC procedure, found that although counseling included VMMC benefits, little attention was paid to risks, including how to identify complications, what to do if they arise, and why avoiding sex and masturbation could prevent complications, especially among young adolescents age 10 to 14 (Kaufman et al., 2018). Another study that explored the approaches used during adolescent VMMC counseling and whether these strategies maximize broader HIV prevention opportunities found that HIV prevention and care messages were inconsistent and sometimes totally absent from VMMC counseling sessions (Kaufman et al., 2017). A further study that assessed the perceptions of VMMC facility managers and providers about training content and their perspectives on age-appropriate adolescent counseling found that lack of training for working with adolescents influenced the type of information that was communicated (Tobian et al., 2018). Specifically, providers expressed hesitation in communicating complete sexual health information—including HIV testing, HIV prevention, proper condom usage, the importance of knowing a partner’s HIV status, and abstinence from sex or masturbation during wound healing—with younger males (age < 15 years) and/or those assumed to be sexually inexperienced (Tobian et al., 2018). Finally, to our knowledge, no standardized approaches have been developed to use VMMC as a platform to address unhealthy male gender norms, including those that discourage men’s health-seeking behavior, despite the opportunity that VMMC can provide to take such a gender-transformative approach.

Men and HIV

Beyond VMMC, research has asserted that there is a “blind spot” when it comes to HIV service responses to men (Shand et al., 2014): men are less likely than women to be tested for HIV or to initiate and adhere to HIV treatment (Cornell et al., 2011). Men’s reluctance to access testing and treatment leads to poor health outcomes: upon initiating antiretroviral therapy (ART), they have higher CD4 counts and more complications than women, and they are more likely to die while on ART (Naidoo et al., 2017). Globally, men accounted for 58% of the estimated 1.0 million AIDS-related deaths in 2016 (Druyts et al., 2013), often as a result of seeking help only when they are very ill. When men do not know their HIV status, they are more likely to engage in risky sexual behaviors (Lynch et al., 2010). Intersecting forms of discrimination based on race, class, sexuality, gender identity, and disability further impede men’s access to HIV services (Dworkin et al., 2011; Peacock et al., 2009), despite the fact that MSM, for example, are 24 times more likely to have HIV than the general population (UNAIDS, 2017). A further innovation in HIV prevention, preexposure prophylaxis (PrEP), is highly effective at reducing HIV infections among people at high risk of HIV infection when taken regularly, and it has been a successful prevention technology among gay men and other MSM. However, the global scale of PrEP remains limited (UNAIDS, 2017), and studies in certain countries find that additional information and support are required to boost PrEP uptake and adherence among men (Garnett et al., 2017; Liu et al., 2017; Rolle et al., 2017). Given this context, UNAIDS produced a report in 2017 specifically focused on reaching out to men and boys to address the blind spot in the response to HIV (UNAIDS, 2017).

Men and STIs

The global prevalence of four curable STIs—chlamydia, gonorrhea, trichomoniasis, and syphilis—remains unacceptably high in adult men, as well as women, with around one million new cases acquired each day (Newman et al., 2015). Male gender norms around risk-taking can lead some men and boys not to use condoms, and therefore to contract an STI and to be less likely to access STI care, treatment, and support (Peacock et al., 2009). A lack of sensitization among some providers, limited confidentiality, insufficiently targeted materials, and STI services not being integrated into standard protocols for male wellness checks can create additional barriers to men’s diagnosis and treatment. As with HIV, specific vulnerable groups of men, such as MSM, migrants, sex workers, those identifying as nonbinary, and members of transgender communities, may face particular stigma and discrimination in seeking STI care (Collumbien et al., 2008; Hook et al., 2018).

Men and Infertility

Infertility estimates among men have been conducted mainly in developed countries. For example, one household-based study in the United Kingdom found that approximately 10% of men had tried to get their partner pregnant for 12 months or longer but did not (Datta et al., 2016). However, only half of these men had ever sought infertility services, with far fewer young adult men seeking care (Datta et al., 2016). A 2018 systematic review found that, despite reproduction-age male and female adults desire for children, the majority lacked information about infertility risk factors and had low-to-moderate fertility awareness, with greater awareness seen among women, more educated persons, people reporting difficulty conceiving, and those who planned their pregnancies (Pedro et al., 2018). Qualitative research with men in Malawi has found that cultural norms around the importance of male fertility render male infertility shameful and emasculating, and that men use traditional health services for infertility concerns due to limited fertility services in the formal health system (Shand, 2021).

Men as Contraceptive Users

The disproportionate SRH burden on women is often clearly encapsulated by the focus on research into, and service provision for, contraception. At the level of research, national demographic health surveys (DHS), which typically cover the 15- to 59-year-old age range, ask women much more comprehensive and specific information about contraceptive use than men. While DHS include male surveys, the continued growth of which is to be encouraged, the male surveys contain fewer questions on contraception (than the female surveys), typically only ask men about ever-use of male methods (not all methods) if at all, and, within the surveys’ sexual activity section, ask about men’s current contraceptive use only in the context of which method was used during last sex. By contrast, questions in DHS female surveys on current, and ever-use, of contraception cover all methods and are within the family planning section of the survey. As a result, broader national assertions on unmet need and ever-use can only be made from DHS female data sets. Similarly, the largest collection of cross-country data on contraceptive prevalence, the UN Population’s World Contraceptive Use database (UNDESA, 2019), provides up-to-date family indicators solely for women of reproductive age. While comparable data are limited, shared responsibilities for SRH can be explored through examining contraceptive prevalence and method choice. An analysis of UN Population Division data and DHS series data by Ross and Hardee (2017), outlined in figure 3, found that, globally, the prevalence of male methods (vasectomy, male condom, withdrawal, and rhythm) was 15.7% among married/in-union women in 2015. Men’s contraceptive use, therefore, represents just one quarter of all contraceptive use worldwide. In the 48 least developed countries of the world, where unmet need for contraception is often highest, Ross and Hardee found the percentage be to even smaller, 6.8%, with male methods representing a very small part of overall contraceptive use.

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Figure 3. Prevalence of male versus female contraceptive methods. Note that the rhythm method is separated from the other three male methods in order to reflect its more collaborative character (versus vasectomy, male condom, withdrawal).

Source: Ross and Hardee (2017). Green Open Access License.

An analysis of shifts over time is also instructive, demonstrating the extent to which women’s method use, particularly within relationships, dominates. While overall modern contraceptive use doubled between 1970 and 2015, men’s use of contraception has remained relatively constant. Looking at the 21 years following the aforementioned 1994 ICPD conference, Ross and Hardee found total use of male methods rose by only 2.9 points (from 10.7% to 13.6%) within 106 developing countries, as shown in figure 4. Much of the increase was reflected in the increased use of male condoms during the period—a trend widely associated with extramarital sex, particularly in context of HIV and STIs (Ankomah et al., 2013)—while use of the rhythm and withdrawal methods remained steady, and rates of vasectomy (the only permanent contraceptive method for men) fell during this period. This highlights that there has been insufficient attention to reaching men as contraceptive users in their own right, a factor compounded by the fact that there has been no expansion of the contraceptive methods available for men since the 1960s, as explored below.

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Figure 4. Prevalence of male contraceptive methods from 1994 to 2015.

Source: Ross and Hardee (2017). Green Open Access License.

Despite the fact that vasectomy has many advantages over female sterilization, including being a highly effective, relatively inexpensive, and low-risk procedure (Shih et al., 2011), limited awareness among providers and clients, and persistent myths related to its side effects, such as fears of poor sexual performance, significantly affect vasectomy demand (Shattuck et al., 2016). Despite the potential of withdrawal as an effective and appropriate method in certain situations (Jones et al., 2009), very little research has been done on this method among men and their partners (Hardee et al., 2017). Research also shows that socioeconomic status (Kabagenyi et al., 2014), religious and cultural beliefs (Perry et al., 2016), and gender norms (Hardee et al., 2017) can directly impact men’s contraceptive use. Despite the dual protection benefits offered by the male condom, it is often not seen as an appropriate contraceptive method within an established partnership (Ntata et al., 2013), thus further reinforcing the responsibility of women to prevent unintended pregnancy.

In addition to increasing uptake of existing male contraceptive methods, it is also necessary to expand the current limited range of methods for men beyond condoms, withdrawal, and vasectomy; such an expansion could have a significant impact on pregnancy prevention (Dorman & Bishai, 2012) as well as bring men into contact with other essential health services (Hook et al., 2018). The 2018 Guttmacher-Lancet Commission on SRH (Starrs et al., 2018) highlighted the need to increase the range of male methods. In particular, there is a gap in the provision of a reversible method for men that falls between a short-acting and a permanent method (Hardee et al., 2017), for which studies in the 21st century have confirmed that there is demand (Glasier et al., 2000; Kabagenyi et al., 2014). While research and development of novel male methods continue, such as work on the male pill, greater global investment and prioritization are required to successfully bring new male methods to market.

Male Sexual Dysfunction Concerns

Sexual dysfunction refers to the various ways in which an individual is unable to participate in a sexual relationship as they would wish. Male sexual dysfunctions include excessive sexual drive, male dyspareunia (pain during ejaculation), premature ejaculation, orgasmic dysfunction (delay or absence of orgasm), male erectile disorder, sexual aversion or lack of sexual enjoyment, and lack of, or loss of, sexual desire (WHO, 2016). Health systems often do not offer specific services for men around sexual dysfunction, which are often less commonly discussed and are stigmatized. This is despite the fact that research across 29 countries found that 28% of men 40 to 80 years old reported having at least one sexual dysfunction (Nicolosi et al., 2004). Poor sexual performance can run counter to normative and cultural ideas of what a “real” man should be (Hook et al., 2018; Shand, 2021) and has been linked to psychological distress among men (Nachtigall et al., 1992). Community-based studies have also demonstrated that there are culture-specific explanations for various sexual health issues in men and for men’s related treatment-seeking, particularly around sexual problems and dysfunction. The studies’ findings suggest that interventions to engage men should be culturally tailored (Verma et al., 2001, 2003).

Men as Supportive Partners in Contraception and Family Planning

Past work shows that women whose partners disapprove of modern contraception methods are unlikely to use them (Ezeanolue et al., 2015). Significant barriers also remain due to couples’ difficulties in communicating about contraception, which further impact on use. Approaches that engage men as SRH partners have successfully improved the environment for, and the use of, female contraceptive methods. For example, increasing men’s knowledge of the fertility cycle and reproductive systems can improve men’s support for their partners’ contraceptive use (Croce-Galis et al., 2014). Couples’ communication can be addressed by improving men’s and women’s ability to have effective conversations about their family-planning expectations (Lasee & Becker, 1997; Shattuck et al., 2011). Gender-transformative interventions that work with husbands (Shattuck et al., 2011) and fathers (Doyle et al., 2018) at the household level can improve couples’ communication and increase contraceptive use within relationships. The interventions use a male-to-male education approach, which has the benefit of normalizing male discussion and competence in what is traditionally a woman’s domain (Shattuck et al., 2011). They also have the advantage of promoting greater gender equity and improving shared decision-making around SRH (Greene & Levack, 2010). Other promising approaches to engaging male partners have included male-only educational talks, male-targeted behavior change campaigns and communication activities, and the integration of family planning content into nonhealth activities, such as agriculture and sanitation projects (Lundgren et al., 2012). In general, interventions that have been found to be effective not only have targeted individuals and couples but also have taken a wider socioecological approach that has aimed to understand and target different levels of influence, including family, community, social norms, and structures (Barker et al., 2007). Overall, the rigor of the evaluations of engaging men as partners in contraception and family planning varies, and few of the effective approaches have been taken to scale.

Men’s Support for Women’s Access to Safe Abortion

Multicountry research, using the International Men and Gender Equality Survey (IMAGES), has found that, among women who had ever terminated a pregnancy, male partners in all countries (except one) were significantly involved in the decision to seek an abortion (Barker et al., 2011). Available evidence also suggests that women’s desire to avoid disclosing pregnancy to men out of fear of their reaction and the implications, as well as men’s own views on accessing abortion services, influenced whether some women sought safe or unsafe abortion services and the urgency of them doing so, if at all (Hook et al., 2018). Men can play a positive role in women’s access to safe abortion services, by supporting access to information and by providing economic resources (Freeman et al., 2019), and evidence also shows that men’s support during postabortion care can facilitate a more rapid physical and emotional recovery for women (Abdel-Tawab et al., 1999). A study of men’s engagement in premarital abortion in India found that men played an instrumental role, significantly aiding women’s access to safe and quality abortion care, by accompanying their partners to the clinic and by supporting women in secretly navigating the related challenges due to the social stigma of unwed pregnancy (Kedia et al., 2018). In general, the evidence base in this area is extremely limited, and few programmatic approaches have sought to engage men to increase women’s safe abortion access (Coyle & Rue, 2009). Overall, men’s involvement in abortion decision-making remains too often negative, and it is therefore critical to ensure that where men are involved, it is in a manner that is respectful and supportive of women’s decisions about their bodies (Barker & Sippel, 2017), and that, given men often control decisions about the institutions and laws that govern abortion access and quality, men are encouraged to advocate in support of greater access for women to safe and legal abortion services (Hook et al., 2018).

Men as Supportive and Equal Partners in Maternal, Newborn, and Child Health (MNCH)

Research has found that engaging men as supportive partners in MNCH can positively affect the health outcomes of women, newborns, and children (Doyle et al., 2018) and challenge the perception that pregnancy and childrearing are the woman’s domain. The involvement of fathers pre- and postpartum can increase women’s use of maternal health services, positively influencing their behaviors and providing emotional support (Levtov et al., 2015). It can further provide an opportunity for men and women to discuss contraceptive use and family planning, support shared decision-making (Shand, 2018), and provide a meaningful shared experience for couples. Men’s engagement in MNCH, when undertaken using gender-transformative approaches, can also advance gender equality, including increasing men’s participation in domestic work and taking their wives to doctor appointments (Hook et al., 2018), improving couple communication, increasing the value of girls, and reducing intimate partner violence (Doyle et al., 2018). Men’s involvement in antenatal care visits can also provide an important entry point to broaden men’s own engagement with the health system, to provide education to men regarding health behaviors, and to screen and treat for male-specific health problems (Hook et al., 2018). As a result, city governments, such as some municipalities in Brazil, have incorporated criteria for recognizing facilities as “father-friendly” (Stern et al., 2015), and the evidence base on positive impact of men’s engagement in MNCH continues to grow (Hook et al., 2018). Despite this, too few MNCH programs have sought to specifically target men. In most parts of the world, men are still unlikely to attend the birth of their children (Levtov et al., 2015), with culturally constructed gendered roles for men in many contexts remaining a significant barrier to their doing so and to being engaged in broader MNCH programs (Levtov et al., 2015). In addition, the health system, including the attitudes, actions, and limited skills of healthcare providers, can provide significant barriers to male involvement in MNCH (Aguayo et al., 2012).

Men’s Support for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)

Men can also play a critical role in successful PMTCT programs, with fathers’ involvement in such approaches being found to decrease the risks of infant HIV infection and of infant mortality (Aluisio et al., 2011). Where an expectant father is tested for HIV and counseled on PMTCT, an HIV-positive mother is more likely to return for follow-up, successfully take ART, and adhere to breastfeeding recommendations, which are important to prevent perinatal HIV (Farquhar et al., 2004). Engaging men in PMTCT also provides an entry point for working with men to challenge inequitable gender norms and to increase their own uptake of HIV testing and treatment, addressing the aforementioned challenges. Despite this, there is a significant gap in engaging men in PMTCT within programming, as reflected by WHO’s specifically commissioned report on the topic (WHO, 2012).