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A gendered perspective on men's reproductive health.

The aim of this article is to identify analytical approaches to situate men within the reproductive health processes. One approach is to identify the circumstances under which men ate considered in the reproductive health discourse, the places in which they are absent and present, and how they condition favorable consequences for women's and children's health. This can be achieved without necessarily challenging the premise that women are the only ones who reproduce or questioning the relationships of power that underlie the experience of sexuality and reproduction. Another possibility is to explore the relational, social, and potentially conflictive nature of sexualized reproduction. This alternative means of analyzing reproduction as a gender relational process rather than as isolated events simultaneously recovers the specific sexual and reproductive characteristics of men and women. In the article we use the gender perspective in order to explore the second approach, so as to imagine these processes without negating the dimension of power.

Key Words: reproductive health, men, gender, power

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The aim of this article is to identify some analytical approaches to situate men within the reproductive health processes, which has been defined as having four basic elements: "the ability for individuals to reproduce, and to regulate their fertility; safe pregnancies and deliveries for women; successful pregnancies in terms of child welfare and survival; and partner relations that are free of the fear of unwanted pregnancy or diseases" (Barzelatto & Hempel, 1990; Fathalla, 1989). In 1994, at the Cairo Conference on Population and Development, freedom to enjoy a satisfactory sex life was agreed to along with the highest level of reproductive health being a factor of reproductive rights. The conference emphasized the reproductive health needs of all individuals, including men--and by doing this, essentially determined that male reproductive health is a fundamental human right. (1) This thereby supports the possibility of rethinking gender relations in the sphere of reproduction. (2)

BIOMEDICAL AND DEMOGRAPHIC APPROACH

One way of analyzing the role of men in these processes is to identify the circumstances under which men ate considered in the reproductive health discourse, the places in which they ate absent and present, and how they condition favorable consequences for women's and children's health. Thus, it is possible to observe how men affect morbidity and mortality during pregnancy, childbirth, and postpartum, in processes of fertility regulation, and in the occurrence of abortion. This can be achieved without necessarily challenging the premise that women are the only ones who reproduce or questioning the relationships of power that underlie the experience of sexuality and reproduction. Much work has been done on surveys of family planning, maternal and child health and, to some extent, sexually transmitted diseases, all of which are considered to be some of the integral components that shape reproductive health. Although in some cases these surveys lapse into oversimplification, the indicators they use reveal aspects that can help interpret some of the health and disease processes in the reproductive sphere. These surveys, however, have given little attention to or have ignored the gender relational dimension of sexuality and reproduction, as well as the characteristics of men's sexual and reproductive behavior. The assumptions used in this approach to interpret various aspects of reproductive health rely on the social actions developed to promote it.

Demography and medicine, disciplines that have studied reproduction, have not devoted special attention to analyzing the reproductive process in men. For instance, men are consistently absent from discussions pertaining to pregnancy. Moreover, there are no indicators for the study of fertility that incorporate men. In fact, social constructs have be, en validated in which maternity is presented as a central dynamic in the gender identity of women. Both these disciplines reflect a vision of men as being distant in the reproductive process, while women are portrayed as receptive and passive: "men make women pregnant, and women get pregnant." Furthermore, as fathers, men are also not expected to have much direct contact with newborn children, at least until they start to walk of talk. Thus, one of the central actors in reproduction is marginalized (with the complicity of men) from fully experiencing fatherhood at a time that is critical for bonding and thus influencing infants' personalities.

In current demographic analyses of reproduction, there are few interpretations that address the issue of power between the sexes. These analytical models legitimize assumptions about gender relations since the paradigms are based on concepts of gender that place men and women in opposing spheres. This type of analysis assigns men the privileged position of defining the socioeconomic context in which biological reproduction occurs. Thus, these assumptions are rooted in how the models used in different disciplines that study reproduction processes are understood and do not accurately reflect men's detachment from biological reproduction and their concentration on social reproduction. The result is that policies and programs are constructed on the basis of knowledge gained from analytical models, which may be based on false assumptions. From an extensive review of articles on fertility, marriage, and the family published in the journal Demography over the last three decades, Watkins (1993) comments that women are considered as producers of children and their primary caretakers--which they do with little help from men while being socially isolated as they carry out these tasks. The author concludes that what is known about men regarding these matters is minimal.

In the case of medical knowledge and practice, Castro and Bronfman (1993) analyze the criteria for epistemological interpretation and give examples of how the concepts of nature, the body, subjectivity, the private domain, feelings, emotions, and reproduction are associated with the "feminine," while culture, the mind, objectivity, the public domain, thought, rationality, and production are associated with the "masculine." This is an example of how, rather than ignoring relationships of power, reinforced by social constructs, medical knowledge validates selective gender specializations (Lagarde, 1994a).

Sexism in policies and programs associated with reproduction through contraception further complicates relational analysis. For example, the government institution that provides the widest health service coverage in Mexico trains its doctors with educational materials that affirm that "there are practically no contraindications for tubal ligation, but certain conditions in women may mean that this procedure should be deferred (but not ruled out)" (Academia Mexicana de Investigacion en Demografia Medica [AMIDEM], 1986a, p. 30); whereas "vasectomy is contraindicated for subjects who are in doubt about their decision, are biologically or psychologically immature, are afraid of the possible effects of the operation on their health, or whose decision has been reached on the basis of insufficient or erroneous information, or psychopaths"

(AMIDEM, 1986b, pp. 26-27). Sexism may be observed in institutional prescription and practices that overprotect men and promote the use of permanent methods for women. (3)

The basis for certain studies with demographic data, such as the text prepared by Comision de Poblacion de America Latina and Centro Latinoamericano de Demografia (1993) as background for the Cairo Conference, includes a reference about the percentage of women of childbearing age who are married and are contraceptive users "responsible for their use." The methods are artificially divided into women's and men's methods, and the focus is on the person affected rather than the process of interaction between the man and the woman. Furthermore, the methods in which the man is most obviously present, such as condom, rhythm, and withdrawal, ate regarded as less effective, and hence the fact that they are not promoted by family planning programs goes unquestioned. It can be safely stated that the medicalization of fertility regulation, supported by sexist processes in analytical interpretation, standard-setting, and the pursuit of greater demographic impact, has discouraged men's presence in reproductive processes regardless of the understandings reached between men and their partners.

GENDERED AND RELATIONAL APPROACH

Another possibility for the analysis of men's presence in reproductive health processes is to explore the relational, social, and potentially conflictive nature of sexualized reproduction. This approach recognizes that tensions, conflicts, and disagreements between men and women exist within an environment where multiple actors playing different roles influence reproduction. Hence, a more accurate analysis of men's presence in reproductive health would situate them in specific heterogeneous contexts, so as to avoid single and simplistic readings of a process as complex as reproduction. This alternative means of analyzing reproduction as a gender relational process and not as isolated events for men and women simultaneously recovers the specific sexual and reproductive characteristics of men and women. It is not sufficient to consider the participation of men within the health of women; rather, men should be thought of as actors with sexuality, health, reproductive, and concrete needs that should be considered, in their interaction with women and in their own specific right. Such a gendered approach seeks to explain processes of exclusion (both of men and women) in the study of reproduction and related experiences.

We understand reproductive behavior as a complex process of interrelated biological, social, psychological, and cultural dimensions directly or indirectly connected with procreation. In a broad comprehensive sense, it includes behaviors and events relating to courtship; sexual pairing; union of the couple; expectations and ideals about family; planning the number and spacing of children; the use or not of some contraceptive method; the relationship of the couple during pregnancy, childbirth, and postpartum; participation in the care and rearing of children; and economic, educational, and emotional support for them (Figueroa & Liendro, 1995). This comprehensive definition suggests the presence of relationships and specific dimensions both for women and for men that have been ignored in most analyses.

In spite of this multiplicity of dimensions, women continue to be at the center of analysis concerning reproduction; this has repercussions on the type of indicators used to interpret changes in fertility and the type of policies defined to influence it. The statistics used to characterize fertility (e.g., specific fertility rate, global fertility rate, children ever born) can hardly be imagined to apply to males, not only--as is often argued--because of the practical difficulties of determining how many children they have had, but because little theoretical effort has been made to conceptualize the reproduction of a population differently, not limiting it to what happens with women.

The other dimension of the term reproductive health has to do with the health-disease binomial. The main causes of death in many men reflect a process of self-destruction and exposure to danger, very often deliberate and intentional, so that some authors have classified men as a "risk factor" for their own health and the health of women, children, and other men (Bonino, 1989; De Keijzer, 1992). The causes of women's deaths, on the other hand, reflect social and personal abnegation with regard to the right to care for themselves and to prevent situations that put their health at risk (Elu, 1992a, 1992b; Garza & Freyermuth, 2000; Langer & Romero, 1998; Sayavedra & Flores, 1997), sinee they assume responsibility for the health of their children and their partners--who may intentionally put themselves at risk--before their own. Basaglia (1984) talks of women as "being for others," while the literature on men (Figueroa, 1998; Fuller, 2001; Leal & Faehel, 1998; Viveros, 1998) depicts them as being "self-centered." A process of healthy interaction between the people participating in reproduction presents considerable complexities and suggests differences between them that need to be explored in theory, analysis, and practice.

Another issue explicitly raised in reproductive health is sexuality, with the understanding that reproduction should be as important as having a satisfactory sex life. Studies on women found that many women negate their sexuality in terms of the possibility of enjoyment and pleasure, so that it is experienced with guilt or as pleasure for others (Amuchastegui & Rivas, 1999; Lamas, 1998; Rivas, 1998). On the other hand, studies on men show that the characteristics of their sexuality include competition, violence and homophobia and are experienced as a drive and source of power (Cazes, 1994; Hernandez, 1995; Szasz, 1998). This confirms differences in reproductive experience and interpretation between men and women, which are not easily reconciled when imagined as independent processes.

Within this context, we propose to use a gender perspective as a frame of reference to imagine the processes involved in reproductive health in a relational sense. Without denying the exercise of power, we are interested in showing that this presupposes the existence of a free being over whom power is exercised and who may potentially react to this relationship (Foucault, 1988). (4) Such power implies relations of permanent tension that need to be validated in some way through the participation of those involved in the different phases of the relationship (De Barbieri, 1991).

Scott (1996) points out that gender is one of the elements in social relations that ate based on the differences perceived between the sexes, that is, the hierarchical and specialized social constructs that are based on biological differences. It also plays a significant role in the power dynamics between men and women. Indeed, since gender is a social construct, it must be upheld or risk being undermined, or at worst considered illegitimate. Hence, gender is the source of permanent tension in social relations and raises questions about many histories of reproduction, sexuality, and health that have been taken for granted. These ultimately go unquestioned and ate accepted and replicated. To speak from a gender perspective implies recognizing that there are culturally available symbols that support normative concepts and processes, that there are political and institutional concepts that sanction these processes, and that these symbols shape the subjective identity of individuals; hence it is not easy to recognize them.

As an example, in daily (popular or nonscientific) language and knowledge, we find elements that evince a division between men and women in terms of reproduction, with different expectations for each one and unequal social valuations. Women's status changes when they become pregnant, while this does not apply to the vast majority of men. Pregnancy is considered a physiological, psychological, and social experience of women, something far removed from men's experience. Women are called "pregnant women" and, in the perception of many females, this involves being valued differently once they are pregnant (Figueroa, Aparicio, & Palma, 1994; Figueroa & Rivera, 1993; Palma, Jacome, & Palma, 1992).

Moral judgments about individuals whose sexual practices are not circumscribed to a conjugal union (which are negatively sanctioned by society) change when it is discovered that the woman is pregnant, due to the very fact that she is to be a mother (Lagarde, 1994b; Riquer, 1996). Something very different happens in the case of men, since the nine-month period preceding childbirth lacks ah equivalent or applicable categorization for them. For that reason, it is often believed that men experience nothing more during that process than indifference, uncertainty, or expectations about what is taking place in the "womb of their mate." In other words, fatherhood is usually interpreted as a phenomenon experienced as of the moment of childbirth or even as of the time at which contact is established between a father and his son or daughter (this may not necessarily be right at the time of childbirth). Thus, there is a difference between the timing of motherhood and fatherhood (De Keijzer, 2000; Fuller, 2000).

To this we would have to add the division of labor in reproductive activities carried out by men and women. While the activities of the former are primarily to provide economic support, women are generally viewed as the primary caregivers of the entire family unit (Salles & Tuiran, 1998; Schmukler, 1989). The separation between the public and private spheres, synonymous with "outside the home" and "inside the home," contributes to limiting equal opportunities for men and women and thus how they develop as individuals (Brachet-Marquez, 1996). (5) This split also impacts how reality is classified and assessed and coincides with understanding the roles of individuals who join together to reproduce. (6)

The gender perspective as a theory, methodology, and practice, as it is now incorporated into the discussion of sexuality and reproduction, allows us to question the value attributed by men and women to reproductive events. It enables us to reconstruct the historical process that led to assigning men and women different rights and responsibilities and permits actors to be identified in any process of validation, and to review how norms evolved to mold reproduction into the specific contexts that currently exist. Without such analysis, the incorporation of men appears to be a forced exercise, since the practice and conceptualization of reproduction is not radically questioned.

REPRODUCTIVE HEALTH CONCERNS THAT INCLUDE MEN'S EXPERIENCES

Demographic research concerning fertility and contraception has centered on an analysis of women and their reproductive decisions. However, we should point out that in the 1950s (Stycos, 1958) groundbreaking research was conducted in Latin America in an attempt to examine the role that women and men played at that time in the drop in fertility. The research conducted by Stycos (1958) considered the factors that motivate reproductive behavior within families by examining attitudes, beliefs, and practices that played a role in reproductive decision-making.

It is worth pointing out that despite the contributions this study made toward understanding the reproductive process, this type of research was later abandoned, while studies geared to measuring only women's fertility gained predominance. It was not until the 1980s that Caldwell (1982), in his micro-demographic studies on Africa and India, took up the interest in understanding decision-making processes regarding reproduction. While analyzing the accounts and perceptions of women and men, he discovered the decisive role that families and lineages play in demographic decisions.

Recently, studies have been carried out in ah attempt to examine the social and cultural motivations of men for regulating their fertility or not (Omondi-Odhiambo, 1997; Ringheim, 1993; Szasz, 1998). While some efforts have also been made, particularly in rural zones, to study the cultural and economic factors associated with the sphere of reproduction, such research makes explicit reference to the presence of men (Castro & Miranda, 1998; Lerner & Quesnel, 1994; Lerner, Quesnel, & Yanes, 1994). In all of these studies, an outstanding feature is the consideration of the social structures and norms that regulate sexual behavior, marital unions, and reproduction. Nevertheless, there is disagreement about the way men and women are viewed in their relationship in terms of the physiological process of pregnancy, as well as the social significance that pregnancy has for individuals of both sexes.

MEN'S ATTITUDES REGARDING FERTILITY

Based on information from interviews with men and women, research has been conducted in Latin America to explain the role men played throughout the reproductive process. Studies also examined men's sexuality and fertility regulation. Insofar as the presence of men in the reproductive process is concerned, it is interesting to note that in rural areas in Mexico, there is evidence of the men's principal role (i.e., by exercising power in decision-making) (Castro & Miranda, 1998). Nevertheless, there are also indications of the growing marginalization of men in decision-making processes regarding reproduction and contraception, while the intervention of physicians is favored (Lemer et al., 1994). A survey about men's role in reducing fertility in Cuba, conducted by Fraga and Alvarez (1998), found that the role of Cuban males in defining the number and spacing of their children has weakened, whereas women ate more likely to decide the timing of having children and the final number of off-spring. In Brazil, research conducted by Goldani (1994) in the northeastern part of the country shows that men's influence in determining fertility predominates. This becomes apparent when the total fertility rate of women is closer to the ideal number of children reported by men than to the ideal number of children reported by women. According to this author, power relations between the members of a couple would be a factor of greater importance in rural settings.

In analyzing men's attitudes about sexuality and fertility regulation, we find a paradox. Whereas, according to some research, men consider that the sphere of sexuality is predominantly masculine, with men wielding strict control over females' sexuality--either through fertility or the use of violence (Castro & Miranda, 1998; De Keijzer, 1995; Szasz, 1998)--the realm of reproduction and its regulation is perceived by men as an area dominated by women and, for that reason, they feel that fertility regulation should be up to them. Although in the opinion of many men it is the responsibility of both spouses to do something to avoid having children, in practice many men prefer not to use any contraceptive method for regulating fertility (Goldani, 1994; Secretaria de Salud, 1990; Szasz, 1998).

MEN AND THE EXPERIENCE OF CONTRACEPTIVE USE

When we think of the practice of fertility regulation as one of the basic components of the reproductive process, that is, the ability to reproduce and influence reproduction, the presence of men is very contradictory. This is because men are usually seen as either obstacles to or supporters of their partners' fertility regulation, but not as the ones who are able to regulate their own fertility. When asked, men are likely to reject reproductive responsibilities.

Arias and Rodriguez (1998) document men's rejection of reproductive responsibilities in their analysis of condom use in the Mexican context while trying to identify changes in sexual values in men's experience as a result of condom promotion. The authors find that some men continue to live "ready for intercourse" and that they also differentiate in their condom use, depending on the "type of woman" with whom they are having sex. Women they know and whose cleanliness and non-promiscuity the men take for granted do not require condom use, but this is not the case for unknown women, who may be promiscuous and may similarly be having intercourse with many other men. In spite of the negative connotation, many men say that it is not necessary to use a condom with their partners, since "the women are faithful and only have relations with them"; thus, there is a double moral standard in sexual practices of some men.

Although different studies have revealed men's opposition to the use of contraceptives, there is research that documents the acceptance of vasectomy in Latin America and suggests that men are prepared to become involved and indeed that they want to be, but that there have not been methods and programs directed specifically to them (Alvarado, 1995; Castro, 1998). Evidence compels us not to be naive in this reading and to be more critical in interpreting the reproductive context of men.

In studies by Bean, Pruitt, Swicegood, and Williams (1983) and Miller, Shain, and Pasta (1991) on how couples decide on the use of permanent contraception, the authors report that the interaction between the partners and agreement between them is significant in determining what type of method they will use. Married partners with more open communication tend to opt for vasectomies. In marriages where communication is poor, tubal ligation is more likely to be the contraceptive chosen. The authors document the social experiences that enhance a woman's likelihood to negotiate decisions about the type of method to be used. Andres, Gold, Berger, Kinch, and Gillett (1984) find that decisions on sexuality, reproduction, and contraception can be explained more clearly in terms of the characteristics of the couple's relationship. This is particularly true in partnerships with liberal attitudes.

Diaz, Diaz, and Townsend (1992) analyze men and women's participation in family planning in the context of Latin America and comment that certain family planning and maternal and child health programs have focused on demographic efficiency. This, in conjunction with excessive authoritarianism in the relationship between the service provider and the client, has generated unequal participation in the field of fertility regulation. To this must be added excessive powers in decision-making on the part of men and the absence of an integrated perspective of women as human beings; women's sexual welfare is neglected. Nevertheless, there are few studies that explore the influence of health service providers in the negotiating processes that men and women undertake prior to choosing a particular contraceptive. Such studies have been undertaken in spite of the fact that health care providers play a central role in some Latin American settings (Cervantes, 1998; Figueroa, 1999).

MEN AND THE PRACTICE OF ABORTION

Abortion is another way of controlling fertility, not as a method of contraception but as recourse to terminate ah unwanted pregnancy. Leal and Fachel (1995) document the case of Brazil, where men have liberal attitudes about their sexuality, but are conservative in regard to abortion being a women's right. On the other hand, women's comments about sexuality are more conservative, but they are more liberal in terms of abortion. They believe abortion is a woman's right, "since they are the ones that get pregnant." This differentiated moral value judgment is confirmed in Mexico, where the findings of Nunez and Palma (1991) show that adolescent men reported abortion more often than women, possibly because the former are subject to less moral and legal sanctions. There are also some men who say they do not know the outcome of pregnancies in which they know they have been involved. They do not appear to be accustomed to being accountable for what occurs in their sex life.

In discussing the role of men in the decision to abort, Tolbert and Morris (1995) give examples of how different models of gender relations can influence the various decisions that are made concerning abortion. The greater the equity in the different spheres of social undertaking, the more transparency there is in negotiations between men and women on abortion. Nevertheless, there have not been enough empirical studies to support this thesis.

Contraception, as well as the practice and discussion of abortion, raise questions within heterosexual relationships, perhaps more for the man, as he is faced with a partner that has new opportunities. These arise from the use of contraceptives but also from the enrichment of her options in life. According to Castro and Miranda (1998), contraception challenges the identity of women by enabling them to develop projects other than maternity. However, contraception constitutes an even greater challenge to the male population by reopening the issue of the way they interact with people of the opposite sex, without necessarily having altered the components of their gender identity.

The relational dimension of reproduction also requires explicit explanation of men's experiences in the sphere of sexuality. The fact that sex is physically hazardous to men and women but that reproduction is risky only for women is a critical item in our proposal to consider reproduction as a relational process.

SEXUALITY IN MEN

Kaufman (1987) interprets sexuality in men as an exercise of power and relates it to obsessive masculinity, which he presents as an ideology, as the personification of men's power. But the need to be constantly proving that one is a man generates a process of fragility among men and permanent doubt about their own manliness. Thus, they combat with interiorized violence that ensures or supports the assumed fulfillment of virility (Hernandez, 1995). Kaufman (1987) analyzes the triad of male violence as an essential element in the construction of masculinity, while it also helps to interpret the experience of their sexuality. This violence is focused on women, children, and other men and may include violence against the self as well. In another article, Kaufman (1994) documents contradictory experiences in the exercise of power by men and recognizes that the experience of masculinity can be painful (Cazes, 1994; Szasz, 1998).

Horowitz and Kaufman (1989) add the dimension of conflicts and tensions to thinking on men's sexuality, describing it in terms of being a way of exercising power over women, over homosexuality, and even over the body. They argue that masculinity has been constructed as an unconscious renunciation of bisexuality in the face of which conflict and fear are experienced, so that this should be given a heterosexual reading (see Hernandez, 1995; Szasz, 1998). A process of reification facilitates such norms, which assumes an inherent attraction to women. These standards perceive women as sexual objects and commercialize their bodies as products to be consumed. Thus, women end up being debased and dismembered as a function of the sexual interests of men.

In reconstructing the stereotype of men's erotic sexuality in a patriarchal culture, Lagarde (1994a) assigns it the following attributes: an actively-experienced behavior generating pleasure and personal well-being; an assumption of male domination defined by the exclusivity and multiplicity of heterosexual relations; a disintegrated view of the female body as a privileged partial object of male desire; the restriction of satisfaction in erotic-sexual relations to the genitals and to intercourse; homophobia as a reaction to behaviors that elude the accepted paradigm (Nunez, 1999) and rejection of feminization of their behavior. In analyzing reproductive processes, it is very important to consider these characteristics since they condition male erotic sexuality, which is difficult to distinguish from reproductive sexuality. This distinction is not the same among women, for whom eroticism and reproductive sexuality are very often bound together.

Kimmel (1994) explores masculinity in depth as homophobia. He discusses the fears, shame, and silences in the construction of gender identity, commenting on the fear men have of each other in the process of constructing this identity. The endeavor "not to be homosexual," as one of the central aspects of the process of being a man, generates a deep fear of not being a real man and being humiliated by other men. Thus, the fear and stigma of being considered effeminate is so strong that violence is generated as a feature of manliness and masculinity, in so far as it is a source of power over women and over other men. The author argues that it is ironic that men hold virtually all the power and still do not feel that they ate powerful, so they continually have to demonstrate it. Artificial competition with other men is created, so that they end up living closed in on themselves in their own discourse (Cazes, 1994; Nunez, 2001). From childhood on, a solitary confrontation with other men is generated, limiting the development of solidarity as a feature of personality.

While Horowitz and Kaufman (1989) recognize that male sexuality has been interpreted as something that needs to be moderated, controlled, and contained on account of its capacity for aggression, reification, domination, and oppression of women; they feel that it is feasible to construct proposals for a theory of liberation. Hence, they attempt to explain repression and "excess aggressiveness" in men, to identify areas of sexual conflict and to discuss activity, passivity, and bisexuality. They also consider the process of social repression of an innate human polysexuality as an important factor.

However, analysis of "sexualized reproduction," as we have come to call it, is complicated by incorporating what is known of many men's sexuality. In a heterosexual logic, sexuality for reproductive purposes is confronted with a sexuality that "is for others." This type of sexual exercise tends to be negated by self and by society. This enormously complicates any possibility of satisfactory, pleasurable, and equitable interaction. Yet, to ignore these references would enormously limit any comprehensive view.

New research methods must address the lack of analytical tools for conducting a follow-up on men's sexual and reproductive events. This is linked to the double standard underlying the behaviors of women and men, which are more restrictive for the former and more ambiguous for the latter. Women are expected to account for their sex lives (especially with regard to their reproductive consequences), while men are encouraged by society to exercise their (genital) sexuality without a need to be aware of the consequences of their sexuality; men are also not expected to assume responsibility for those consequences.

RECOMMENDATIONS FOR THEORY, RESEARCH, AND POLICY

To talk of reproductive health with regard to men implies questioning the symbolic and real discrimination of women in the spheres of sexuality and reproduction, together with the processes that exclude men. This requires re-examining and understanding the power-based framework that influenced the assignment of different responsibilities and rights to men and women. Lamas (1994) points out that the symbolic efficacy of the process lies in its ability to mask relations of power and Institutionalize inequality. Nevertheless, the feminist paradigm has contributed to an "awakening of consciousness" in many women and has had an influence on the lives of several men as well.

By questioning the "obvious," explicitly positing the limits of unilaterally defined stereotypes and norms, the gender perspective has helped to identify leads for the reconstruction of the social environment. Recent developments in the field of reproductive health challenge the manner in which health and reproduction are analyzed, partly by directly involving sexuality and explaining the presence of males in this dynamic. The concept of health as a right of all people compels recognition of gender equality as a basic premise for its attainment, calling into question the models of social and institutional relations that have been constructed to shape the setting for reproduction.

The gender perspective offers the possibility of rethinking the manner and significance of being a man and being a woman, explaining discrepancies in the moral authority attributed to individuals who are actors and authors of the social environment, reformulating norms, and even reshaping our significance as individuals. Nevertheless, when only superficially incorporated it may give rise to a process of collective manipulation in which we complacently feign to change and are simply familiarizing ourselves with the discourse that is preventing us from reconstructing the reality in which we find ourselves. To incorporate the gender perspective into reproduction means venturing into a painful process of rethinking our identities. This is no easy matter since it involves recognizing differences, negotiating freedoms, assuming responsibilities, and, above all, settling conflicts collectively. It is not confined to interaction between members of the two sexes, but involves members of different social groups, institutions, and the people with whom they interact.

In an earlier paper (Figueroa, 1995a), we proposed to develop strategies to analyze the reproductive process within the context of power relationships between men and women. To achieve this, we considered men as individuals who construct a way to reproduce that involves interacting with their body, with their sexuality, and with the way in which they live their masculinity, without overlooking but without becoming completely consumed by their relations with women. The aim was to document a man's relationship with his body, his follow-up to the consequences of his coital relations, the type of interaction established to prevent pregnancies, the transactions constructed around reproductive preferences, male self-esteem with regard to reproductive capacity, and the role of the "feminine" in the construction of masculine identity.

We also proposed guidelines to construct more precise processes for conducting research on men in reproductive health. We suggested documenting the enabling conditions for negotiating with oneself and with the surrounding social models; documenting the contradictions generated by the dichotomy between being a man and being a woman; generating a critical understanding of the culture of exclusion surrounding the behavior of human beings; documenting our relationship with our bodies, and constructing new discourses to cover the realities we are trying to explain.

At this juncture it is possible to explore this reading in greater depth, on the basis of the four components identified in the definition of reproductive health cited in the first paragraph, on the assumption that we are aiming to counteract imbalances in each of these spheres while envisaging comprehensive well-being. The central proposal is to develop a framework that can be used to analyze the interactions occurring between different social actors and document the experience of men and women in their interactions.

Theoretically, the idea of thinking of reproduction in relational terms is attractive, although it is a drive recognized as an individual capacity, since its implementation assumes an encounter between two people. This obliges us to rethink how to define the presences (envisioned both analytically and in terms of rights and responsibilities that come into play) of those individuals throughout the processes ensuing from reproductive encounters. Otherwise, the fact that they have different physiological experiences will continue to condition, to a great degree, the experiences socially expected of men and women. (7) In different analytical proposals, progress has been made in considering men as individuals with knowledge, attitudes, motivations, and practices in reproductive processes, but a feminized type of language to name, order, and classify reproductive events is still being used.

As for the needs of sociodemographic research, we have certain proposals conceived for the male population in particular, although their analogies with women can be direct. The research questions that we propose are: What contradictions and critical situations do they identify in reproduction: in the assignment of tasks (rights and responsibilities), in the pleasures associated with relating to one's children, and in the decisions that are made and in the exclusions that are perceived? How do they interpret, experience, and value the different sexual roles and expectations for men and women: as something natural and evident; in terms of violence and coercion; in terms of links between sexuality and reproduction; in terms of control, power, or mutual satisfaction; and in terms of something that depends on the individuals and the contexts?

A review of sexuality, health, and reproduction from a men's perspective reveals important discrepancies in relation to women. These differences are permeated by relations of power and the social norms that nurture and justify these unequal relations. Moreover, the actions of individuals who repeat rather than question, watch out for, punish, and sanction transgressions, lend these norms their strength. Hence, research strategies on the presence of males in reproductive health may be centered on documenting the different stages of reproduction and the main conflicts that arise at each of these stages that impede the well-being of men, women, and their children. It is necessary to identify the type of norms that exist in this regard, how they effect individuals of both sexes, and how men and women participate in conflict resolution (Figueroa, 1995b). We must also examine how the experience of an individual's sexuality increases the risks of such conflicts and how institutional norms and disciplinary interpretations of reproductive processes have obstructed equity in relationships.

Another possibility is to document cases which in practice appear to transgress the stereotypes and models that have proved to be existentially inadequate, to see how to approach and manage their social costs. This involves reconstructing the way in which specific people see themselves as having the capacity, authority, and social support to question such stereotypes. It also means that men and women must live in readiness to reinvent themselves as people and redefine their gender identity, going beyond selective gender specializations.

In terms of social policies that influence reproduction directly or indirectly, we believe that incorporating sexuality into the definition of actions linked to reproductive processes and explaining the presence of men in such processes open up the possibility of more integral personal exchanges. Nevertheless, we should warn against the risks of trying to create standards for other spaces of individuals' rights on the basis of oversimplified perspectives (mostly those of a biological nature), which further prevent individuals from exercising their rights based on fairness and respect for the rights of others.

At this point men need to be made present in real, symbolic, and scientific terms in the relational processes of health, sexuality, and reproduction. This will permit reconstruction of the reproductive and sexual specificity of men: in talking about themselves, documenting transgressions, learning to recognize needs, decoding the history of inequalities, generating collective care of their bodies, ha recreating themselves through parenthood, constructing new discourses, and, ultimately, promoting a renewed encounter of subjectivities.

Nevertheless, there will be those who would simply prefer not to question roles of take gender to its ultimate consequences, but rather to confine themselves to improving the health conditions of some people. That is valid, but can hardly be expected to ensure the presence of men in a comprehensive sense, that is, as beings who reproduce themselves in a contradictory, affective, complementary, and painful interaction with women and with other men.

NOTES

(1.) This was a global conference where all the governments of the world agreed to a Plan of Action that refers specifically to reproductive health and rights (Family Care International, 1994).

(2.) The discussion that follows applies particularly to the Latin American context.

(3.) According to data from the most recent national survey conducted in Mexico in 1997, 44.7% of the women who use contraceptives chose tubal ligation, while only 1.8% answered that her partner has received a vasectomy.

(4.) According to Foucault (1988), the term power has two dimensions: zero sum power (power over) and the sum of power (power with and for). The former is established when one dominates over another, which increases the power of one and decreases the power of the other. This is a power that dominates by using authoritarian hierarchies and imposing rules. The second type of power encourages change; it is basically about power sharing and reform to satisfy the common good.

(5.) Note that the public sphere is overvalued by being associated with economic activities while domestic work, which is primarily carried out by women, is undervalued.

(6.) See Figueroa and Rojas (2000) for a discussion on the gender assumptions underlying research on reproduction carried out by demographers, medical doctors, and psychologists, as well as the analytical and political categories used by feminist proposals.

(7.) We must mention that our concern in this article is not sexuality per se nor in its broad meaning, but in the sexual realm of reproductive behavior.

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Parts of this text were originally published in Spanish as "Algunos elementos para interpretar la presencia de los varones en los procesos de salud reproductiva" (Figueroa, 1998).

Correspondence concerning this article should be address to Juan-Guillermo Figueroa-Perea, Colegio de Mexico, Camino al Ajusto No. 20, Codigo Postal 01000, Mexico, D.F. Electronic mail: jfigue@colmex.mx.

International Journal of Men's Health, Vol. 2, No. 2, May 2003, pp. 111-130.

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