What About Men’s Reproductive Health?

In her latest book, GUYnecology: The Missing Science of Men’s Reproductive Health, sociologist Rene Almeling asks why all the public health messages about healthy childbearing seem to be aimed at women. What about the research that shows that men’s health is relevant to the condition of their sperm, and can profoundly affect the health of their children? Why did it take so long to be researched in the first place, never mind disseminated to the public? What does that mean for how men currently understand their reproductive health? And why isn’t there a robust reproductive health specialty for men, the way that women have obstetrics and gynecology (OB-GYN)?

Almeling’s primary discipline is sociology, and she uses in-depth interviews with a demographically diverse group of 40 men and 15 women to great effect. Her interview questions are thoughtful and evocative. For example, anyone familiar with anthropologist Emily Martin’s landmark article on the cultural attributes of the egg and the sperm will appreciate why Almeling asked her subjects, “How would you describe the relationship between the sperm and the egg?”¹ Fascinatingly, she found that while nearly all of her male interviewees invoked the narrative critiqued by Martin, in which an active sperm pursues and penetrates a passive egg, a significant subset of her more educated interviewees added a second narrative, in which two equal halves come together to make a whole. This was often described in terms of genetics, but not always. The range of metaphors and descriptions from her interviewees are evocative. They ranged from the pre-modern (“I would describe it as the sperm being the seed of creation and the egg being the host.”²) to the modern concept of competition amongst active sperm (“It’s like a dance floor in an Italian club. . .The men are fighting to get there.”³) to the liberal modern marriage (“It’s a very sort of sharing relationship where you share halfway. It’s like a very perfect wedding.”⁴). It is this kind of detail from the interviews, and Almeling’s analysis of it, that make GUYnecology an engaging and informative read.

Almeling’s gentle, dry, and punning humor pops up throughout the book, and I completely believed in her as an interviewer on this sensitive topic, which I think requires humor as a crucial component of interviewer empathy. I interviewed a large number of women and men about menstruation while researching my first book, and there, too, the release of laughter during interviews could be key. I particularly appreciated her observation that halting speech, discomfort, and laughter entered into the conversation when the available cultural “scripts” were meager or absent. Men could talk comfortably about their role as provider and father to children, for instance, but hesitated and laughed when trying to discuss the role of sexual intercourse and sperm in their reproductive lives. It is hard enough for a male subject to talk about sex with a female interviewer; but it’s that much harder when there isn’t a “normal” way to do it.

As part of the interviews, Almeling presented subjects with a public health fact sheet she had created about paternal effects, modeled on the kinds of fact sheets commonly given to women who are trying to conceive or who are newly pregnant. Readers who have experienced the guilt and anxiety that commonly accompanies the deluge of advice thrust at childbearing women may experience a certain schadenfreude at the idea of men facing one of these theoretically neutral fact sheets. Let men worry that they have already irremediably damaged their sperm, or feel guilty for what they were eating and smoking when they conceived their child, and wonder if any problems are their fault! Or, readers may have the same instinct as the many journalists and professional organizations that have, as Almeling describes in a chapter on the dissemination of information about paternal effects, downplayed the risks of aging fathers and rushed to reassure men that everything will probably be ok. I personally felt some of each. Either way, reading a sheet aimed at men brings these feelings into bracing visibility, and implicitly raises the question of how we ought to be addressing reproductive risk for both men and women.

Almeling’s conclusion about what should be done with regard to male reproductive health and paternal effects is, happily, parallel to what many feminists have recommended with regard to women’s reproductive care: she believes that what is needed is a combination of broad research and attention to social and environmental structures of health and illness. Her answer is not primarily to teach men to blame themselves for every reproductive mishap, but rather to encourage them to fight, for example, for safeguards against dangerous pollutants, unsafe working conditions, and social support for younger childbearing for everyone.

I was less persuaded by the book’s historical arguments presented in the first few chapters. Almeling suggests that historians have failed to notice the surprising absence of a medical specialty of “andrology” on par with gynecology because they have typically broken the history up into the study of women’s reproductive health and the study of men’s sexual health, without examining men’s and women’s health together. In other words, they are naïve about how gender operates. I don’t think this is actually the explanation.

I think one major cause of the overwhelming primacy of gynecology, both as a medical discipline and as an object of historical inquiry, is that women’s reproductive functions are, in fact, vastly more complex and more potentially threatening to health and life than men’s. After all, we aren’t discussing a paternal mortality crisis in the country today, and it isn’t because we are ignoring all the men who are injured or killed in the course of having children. J. Marion Sims, the “father of modern gynecology,” established the specialty on the bodies of enslaved women whose debilitating childbirth injuries he treated via repeated surgical experimentation. There really isn’t a male equivalent to the pregnancy and birth-related aspects of OB-GYN. Historians tend not to like dealing in counterfactuals, which is perhaps another reason they have not explicitly asked the question of why a specialty in men’s reproductive medicine did not develop. But I would wager that if andrology had developed with the robustness of OB-GYN, 1970s feminists would have demanded to know why men received equal medical attention when in fact women’s bodies do so much more of the work.

Another reason for the lack of attention to male-linked reproductive outcomes is subtler and more interesting. Historically, natural philosophers and medical writers from ancient Greece through the nineteenth century attributed surprisingly little about birth outcomes to the quality of the ingredients contributed to the fetus from the sex act, compared with how much they harped on the woman’s role as incubator. Some warned that sex during menstruation could produce “monsters,” but so long as a man could ejaculate, he was assumed to have done his duty. Infertility, miscarriage, and birth anomalies were most often attributed to deficiencies in a woman’s womb or habits. As I describe in The Myth of the Perfect Pregnancy: A History of Miscarriage in America (published after GUYnecology went to press), this same overwhelming focus on the woman’s body and activities during pregnancy rather than the condition of the gametes persisted in pregnancy advice manuals even after modern embryology and genetics revealed that at least half of miscarriages were due to chromosomal anomalies.

Today’s public health messages aimed at women still focus predominantly on how women can improve the condition of their bodies to sustain a healthy pregnancy, rather than how to protect the health of their gametes. Recent campaigns to boost preconception health may begin to change this, but even those campaigns are mostly about how to ready the body to carry a pregnancy. If we start paying attention to sperm health, it will be a welcome innovation in attending to how the condition of gametes, beyond their genetic contents, matters for both men and women.

As Almeling accurately describes, the physicians who first attempted to establish an andrology specialty in the 1890s were experts at treating syphilis and other sexually transmitted diseases. Because they dealt with stigmatized disease, they were ridiculed and ignored, and andrology failed to get off the ground. In useful chapters detailing the interrupted and halting development of andrology, Almeling shows how the lack of institutional infrastructure and researcher networks then meant that research in the area was not supported, setting up a vicious cycle. While andrology has a smaller scope than OB-GYN by dint of its purview, research into men’s reproductive health trails even in the areas for which the two sexes are most parallel.

Almeling concludes GUYnecology with a thorough methods appendix that should be of value to many researchers. It provides useful behind-the-scenes details for a variety of research methods Almeling employed. Almeling enriches her analysis by narrating some of her research sleuthing rather than hiding it all “under the hood,” for instance describing why she added a number of interviews with gay men and with women to her research sample as her study unfolded. I enjoyed seeing her thought process, and found her conclusions more convincing because I could see the soundness of the process.

Lara Freidenfelds

Lara Freidenfelds is a historian of health, reproduction, and parenting in America. She is the author of The Myth of the Perfect Pregnancy: a History of Miscarriage in America and The Modern Period: Menstruation in Twentieth-Century America. Sign up for her newsletter and find links to her op-eds and blog essays at www.larafreidenfelds.com.

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