Not so long ago, when a woman faced an unintended pregnancy, a sexually transmitted disease, infertility problems, or any other reproductive health matter, she did so alone. Today there is increasing hope that her partner also will be involved in the important decisions and actions that need to be considered at such times. Around the world, programs that foster the concepts of male involvement, male responsibility, and men's participation are gaining ground in helping both women and men understand the importance of men as full partners in the broad range of issues and experiences that fall under the rubric of reproductive health.

What caused the change that many now say has made discussions of masculinity and male roles in reproductive health a hot topic in public health circles? Certainly the International Conference on Population and Development (ICPD) that took place in 1994 in Cairo was pivotal in demanding that men's role in society, with all its ramifications, be revisited. Again, at the Fourth World Conference on Women held a year later in Beijing, the focus on women's empowerment as a critical factor in sustainable development highlighted such concerns as violence and human rights, both of which are deeply embedded in the larger issues of reproductive health across cultures. The ICPD Program of Action represented a milestone: it was the first time a United Nations document spoke so strongly and directly of the need to increase men's responsibility in reproduction and child-rearing, and it demanded a revision of discriminatory practices against women. Similarly, the Platform of Action that emerged from the Beijing conference urged governments everywhere to draw up appropriate legislation supporting the spirit of the ICPD. It also asked that specific programs targeting men and boys be developed to encourage the elimination of discrimination against women in all its forms.

But for some, like Nick Danforth and Errol Alexis, the struggle to include men and to recognize their unique needs as well as their responsibilities, began much, much earlier. Danforth, formerly with AVSC International (Access to Voluntary and Safe Contraception) and a longtime consultant in male involvement in reproductive health, first realized the need for men to be engaged in reproductive health matters in the 1960s when he worked as a reproductive rights advocate. "I identified with the women's movement," he says now, reflecting back. "I thought that it could help to break down sexism for both women and men, because both genders were being stereotyped. Men who cared about women were being ostracized by people who said that men shouldn't be involved. Males were excluded from abortion counseling as well as from working for reproductive rights, a fundamental right that should concern men as well as women. In this way, an important opportunity to talk to both partners was missed." Danforth, who worked with the International Labor Organization in the 1970s to develop and deliver programs that reached men through trade unions, training programs, and other work venues around the world, was instrumental later at AVSC in helping to develop their Men As Partners (MAP) Initiative, now recognized worldwide as a model program.

Alexis, a Senior Program Officer at the Margaret Sanger International Center of Planned Parenthood of New York City, grew up in the Caribbean and remembers being moved by the number of girls whose lives were compromised by early and repeated pregnancies. He recognized early that "men control women's sexuality," but felt that a strictly female focus was missing an important perspective that could help change behavior and enhance reproductive health for both women and men. Alexis now advocates examining male involvement from a paradigm of "power, trust, and pleasure." Men are defensive about their power, he says, and therefore resist family planning programs that are perceived as taking away their manhood. They are also afraid that contraception fosters promiscuity, a trust issue between partners, and a relinquishment of their own pleasure. Such attitudes reflect men's lack of participation, Alexis says, and have resulted in large gaps in knowledge about sexuality. "Practices which keep men out when they want to be involved are counterproductive. Men have as big a stake in this as women and we've been condemning them for too long. There are a lot of good men out there. We need to recognize and support them, which ultimately will enhance the development of women."

Others agree and recognize that there are compelling reasons to include men in reproductive health programs. For example, the only available methods of preventing sexually transmitted diseases (STDs) require cooperation between both partners, an increasingly important consideration in view of the growing HIV/AIDS epidemic. And although men represent about 50% of the world's population, less than one-third of contraceptive use includes male methods or methods that require participation of both partners. (Condoms and vasectomy account for only 9% and 8% of total contraceptive use, respectively.)

In addition, we are learning that men are more interested in reproductive health information than has generally been assumed. Interestingly, results of recent Demographic and Health Surveys among men indicate that in most countries men's approval of family planning matches the approval of women. And of course men have their own sexual and reproductive health needs, which have not been adequately addressed. These include issues as varied as knowledge of male and female sexuality, information about and treatment for infertility, prevention of STDs and HIV/AIDS, communication or negotiation skills for decision-making, and helping men to eliminate physically or emotionally violent behavior towards their partners.

Understanding the larger gender dimensions of male involvement in issues of sexuality and reproductive health has led to new strategies for ensuring an environment in which women secure and maintain control over their lives with the support and engagement of men. At the United Nations Population Fund (UNFPA), for instance, the programmatic focus is currently on shared rights and responsibilities. "Our main goal," says María José Alcalá, Program Officer in the Latin America and Caribbean Division, "is to sensitize men to gender equity, to support women in reproductive health and decision-making, and to meet men's needs." To this end, UNFPA is working in Nicaragua, for example, to train the armed forces in a broad range of reproductive health issues, including violence prevention, gender sensitivity, and shared responsibility. The program there "has met with quite a bit of enthusiasm," Alcalá reports. "It's an innovative strategy to go where the men are and to convert them into community leaders, especially in cultures of violence." Nicaragua has also started a group called Men Against Violence, in which men work on masculinity issues in cooperation with feminist organizations. Says Alcalá, "Men are tired of sitting back doing nothing. They want to act in partnership with women." This attitude is reiterated in the testimony of men who participate. "We have to review where we stand," one member of the group offered. "Enough of pointing out what we don't like. Let's propose what we really want. I think the most important thing that we men have lost is the ability to express tenderness." Adds another: "It's easy to say: 'We're against violence,' because it gives us status, but it's harder to say, 'We are for tenderness.' This embarrasses 'real' men. But being against violence isn't enough. . . ."

In other initiatives, Father's Day Inc., a group of men in Jamaica, launched a media campaign in 1996 to foster more positive role models and to combat the stereotype of irresponsible males in a part of the world where approximately 40% of households are headed by women. In Peru, nongovernmental organizations are launching theatrical competitions that allow participants to select their own themes and audiences to reflect on such topics as violence and sexuality. Bolivia has a Working Group on Masculinity, and a Men and Families project now being developed with support from the International Planned Parenthood Federation (IPPF) and The Population Council will explore approaches that are working successfully to provide access to reproductive health services for men as well as engaging them in counseling, partner support, and child-rearing. IPPF is also launching a major reproductive health initiative in the Caribbean that will serve as a model for subregional activities in the future. This initiative will use gender relations as a framework for improving women's health, insuring informed choices, and involving men as partners. It will rely heavily on community-based dialogue, clinical services, counseling, and institutional capacity-building. UNFPA is also working with the Inter-American Parliamentary Group to train judges, police, and parliamentarians in Latin America to be more sensitive to gender issues.

AVSC's Men as Partners Initiative helps health service providers, policymakers, and funding agencies around the world design programs that involve men in family planning and reproductive health. MAP was launched with the goal of increasing men's constructive involvement by raising their awareness and support of the reproductive health choices of their partners, increasing their awareness of behavior that can safeguard the reproductive health of their partners and themselves (especially prevention of STDs), and increasing access for couples who are interested in using male contraceptive methods or other methods involving direct participation by men. Research has been a key part of the MAP Initiative and a series of case studies have been conducted in Colombia, Pakistan, Uganda, and the United States. Lessons learned from these sites were documented and shared at a MAP workshop held in Kenya in May 1997. A second workshop will take place in Latin America in 1998.

Among the lessons learned from the MAP Initiative is the "importance of starting early." Educating youth is key to influencing social norms before they take hold. It is equally important to remind males in their teens and 20s of the importance of safe and considerate sexual behavior. Successful adolescent programs reach out to young men in their own environments, make services accessible, and provide a broad spectrum of services to address the complex needs of adolescents. The case studies also reveal that male involvement in reproductive health can be activated or increased by providing STD services at maternal and child health and family planning clinics, developing workplace programs that incorporate reproductive health information and services, and designing outreach and services geared to couples. Male-only clinics and counseling that provides confidential and understanding guidance can also make a big difference in male participation.

Although some people involved in male-oriented programs caution that women's health services and women's autonomy may be threatened by the recent emphasis on men, research has shown that male-oriented services can provide a revenue base that is beneficial to both men and women. As one provider in Bogotá, Colombia, says, "We're in the business of helping as many people as we can. If that means that some fees from men pay for some women's services, that's fine." More importantly, most agree, "it is better to err on the side of educating men," as Nick Danforth puts it. "The benefits of these programs far outweigh the risks, and in the long run, we need to strengthen both women's and men's programs and services."

Dr. José Antonio Solís, Acting Director of the Health Promotion and Protection Division at the Pan American Health Organization, agrees. "The bottom line," he says, "is that men need to understand and talk about reproductive health, and that we need to improve the dialogue about equity and equality. Both men and women are individuals with capabilities and with social restrictions. These restrictions can be modified so that they can share career opportunities, sexual pleasure and responsibility, childbearing and child-rearing, and participation in community and political life."

Such mutual participation, along with sound reproductive health, calls for more than rhetorical commitment. It means the sharing of domestic work and child care, avoiding violence of any kind, building negotiation and other communication skills, and the willingness to be open to nothing short of cultural transformation.

It is a hopeful sign that a growing number of men everywhere appear ready to begin meeting that challenge.