The health of men who experience infertility: a social representations study

Abstracts

Objective:

The study describes the social representations of health professionals about the infertile man and analyzes the implications of these representations in care.

Methods:

Quantitative research based on the Theory of Social Representations in the procedural perspective. The study was undertaken at two university hospitals in Rio de Janeiro. The participants were health professionals from the field of biomedicine and humanities who worked in human reproduction. Bardin's Content Analysis was used for analysis.

Results:

The results indicated that the professionals' representations are based on gender issues and that the academic education can interfere in this construction. Infertility in men was represented as a specific problem of women, without considering man as the subject of care.

Conclusion:

The practitioners do not feel prepared to attend to these men. They recognize the precariousness of sexual and reproductive health services, although there are movements towards new care strategies.

Infertility, Male; Sexual and Reproductive Health; Reproductive Rights; Psychology, Social

Objetivo:

Descrever as representações sociais dos profissionais de saúde sobre o homem acerca da infertilidade e analisar as repercussões dessas representações na assistência.

Métodos:

Pesquisa qualitativa, sustentada na Teoria das Representações Sociais na perspectiva processual. Cenário foram dois hospitais universitários do Rio de Janeiro. Participaram profissionais de saúde da área biomédica e de ciências humanas, trabalhadores em reprodução humana. Para análise utilizou-se a Análise de Conteúdo de Bardin.

Resultados:

Os resultados indicam que as representações dos profissionais de saúde estão ancoradas nas questões de gêneros e a formação acadêmica interfere nesta construção. A infertilidade no homem foi representada como um problema específico da mulher, não considerando o homem como sujeito da assistência.

Conclusão:

Conclui-se que os profissionais se sentem despreparados para assisti-lo, reconhecendo a precariedade dos serviços de saúde sexual e reprodutiva para acolhê-lo, apesar da existência de movimentos de novas estratégias de assistência.

Infertilidade Masculina; Saúde Sexual e Reprodutiva; Direitos Reprodutivos; Psicologia Social

Objetivo:

Describir las representaciones sociales de los profesionales de salud sobre el hombre infértil y analizar las repercusiones de esas representaciones en el cuidado.

Métodos:

Investigación cualitativa, sostenida en la Teoría de las Representaciones Sociales en la perspectiva procesual. Se realizó en dos hospitales universitarios en Rio de Janeiro. Participaron profesionales de salud del área de la biomedicina y de las ciencias humanas, expertos en reproducción humana. Se utilizó el Análisis de Contenido de Bardin.

Resultados:

Las representaciones de los profesionales están ancoradas en cuestiones de género y la formación académica interfiere en esta construcción. La infertilidad en los hombres fue representada como un problema del femenino, que no considera el hombre sujeto de la asistencia.

Conclusión:

Profesionales no se sienten preparados para cuidar de ese hombre, reconocen la precariedad de los servicios de salud sexual y reproductiva, a pesar de la existencia de nuevas estrategias de asistencia.

Infertilidad Masculina; Salud Sexual y Reproductiva; Derechos Reproductivos; Psicología Social

INTRODUCTION

Due to the changes in different societies and cultures, which influence the family composition, sexuality and gender relations, man has become increasingly distant from the previously established and disseminated social order¹. Man today differs from the representation of the patriarchal male being in ancient times.

In view of the contemporary world, the biological model of two opposite sexes, man and woman, is no longer understandable; on the opposite, the variations in the gender issue, a phenomenon that has been occurring over time, need to be taken into account, leading to changes today in the anthropological and sociological models of the social gender construction itself². In that perspective, the entire complexity of the concepts involved in the existing differences between men and women with regard to issues related to people's sexual and reproductive health need to be considered.

Society has always interfered in the different moments of human reproduction, ranging from the social organization of the sexual relations between the genders to the decision about having children, whether regarding the number or the chronological age to have them³. In that context, it should be reminded that the reproduction of the human population is inseparable and largely determined by the reproduction of society and the social systems as a whole⁴. It should also be highlighted that that is the context in which the medicalization of reproduction and the interference and control in individuals' ability to procreate emerge.

Human reproduction in a historical-social context is understood as an icon of fertility and inscribed in the same space where the Christian role of each individual is constructed, and these constructs are elements that strongly interfere in the sexuality between men and women⁵.

The references linked to human reproduction have been are remain strongly linked with the female element, whose focus is centered on family planning, on the pregnancy-puerperal cycle, on contraceptive methods and on abortion. The male has always been granted the mastery of sex and pleasure, with a view to fully living his sexuality, without the need for concerns with procreation issues, the latter focused on women only.

Nevertheless, man did not remain blind to human reproduction matters, considering that this reproduction is linked to the common sense of constructs like masculinity, paternity and virility. These factors grant a social status, inducing man to the condition of good procreator and reproducer². In this line of thinking, difficulties to procreate in man entail a social and personal impact, often compromising his self-esteem, affection and understanding about the symbolism of the male role in the social context.

The trajectory in search of reproduction is distinct for men and women. This can also be verified in human reproduction services, where the male figure is reduced to the woman's companion or when he is asked to undergo some test or procedure⁶.

Nowadays, the literature suggests that infertility is understood as a situation of the couple, independently of whether the ideology is male, female, both or idiopathic. In this perspective, similar relevance needs to be attributed to each member of a couple going through this situation, however, without ignoring the peculiar characteristics of each gender. This fact is not a reality yet in Brazilian health services, considering that most of the specialized human reproduction services emerge from the woman's health area, from gynecology for example⁷.

The frequent contact in this type of care not only remits to the existence of a range of care for these men, in view of the different professional education area, but to the non-systematic manner in which many of these professionals attend to them. In addition, the apparent difficulty or even inability of many professionals to deal with men in infertility situations is verified. Welcoming their complaints, their specific demands in the human reproduction services remains something incipient and conflicting, mainly due to these men's limited participation in reproductive health services⁸.

The lack of proactive actions in search of specialized care, like in human reproduction, contributes to the reduction in the number of men involved in health care. Men normally mobilize less energy to solve issues involving the emotional, like in the case of infertility⁹.

Nevertheless, despite this scarce participation, it is verified that the experience of infertility in men reveals new demands for the sexual and reproductive health professionals. This circumstance has aroused discussions and required new attitudes, with a view to the reconfiguration of the care delivered in this area.

In this context, infertility in men gains form as a cultural and psychosocial object, to the extent that this situation leads the health professionals to a way of thinking, promoting a more concrete meaning in their care actions. This elaboration process is based on the experiences, on the information system, on their academic background, on the values, attitudes and standards. The experience with infertility in men gains social thickness for the health professionals, due to the fact that infertility is a public health problem, in which the professionals should heed both the cultural relevance involved in a discussion that reaches concepts like gender, family, masculinity, among others¹⁰.

In view of the considerations about the thoughts and actions of the health professionals who work in the field of human reproduction, the objectives in this study are to: describe the social representations of health professionals about men who experience infertility and analyze the repercussions of these representations in view of care delivery.

This study is justified by the need to discuss the care health professionals offer to men who experience difficulties to procreate, with a view to contributing to the effective inclusion of men in sexual and reproductive health services.

METHODS

Research with a qualitative and descriptive approach, in the framework of the procedural Social Representations Theory (SRT), aiming to discover the contents of the social representations. The choice of the SRT is due to the fact that it can centralize the perspective on the relation subject-object-subject, taking into account the sociocultural and psychosocial factors¹¹. The research was developed at two teaching hospitals in Rio de Janeiro, which have human reproduction and infertility outpatient clinics. Both are referral institutions for this type of treatment and are highly considered due to their commitment to care, teaching, research and community services.

Access to the research sites happened after approval for the project had been obtained from the Research Ethics Committees at Anna Nery School of Nursing and Instituto de Atenção à Saúde São Francisco de Assis of the Universidade Federal do Rio de Janeiro, under opinion 10/2010, and from Hospital Universitário Pedro Ernesto of the Universidade do Estado do Rio de Janeiro, under opinion 2637/2010, in compliance with Resolution 466/2012, which regulates research involving human beings.

The study participants were 20 health professionals with a higher education degree who work in human reproduction. The universe that complied with the inclusion criteria at both institutions corresponded to 25 professionals, five of whom were on holiday and medical leave, totaling 80% of these professionals in both scenarios. These were divided in two groups based on their professional background: the biomedical area grouped the testimonies from the nursing and medical professions, and the second group, from the field of humanities, which grouped psychology and social service professionals, with 10 participants from each segment. This classification was established due to the importance of highlighting the different professional groups who work with infertile men. The SRT underlines that the range of individuals and their respective attitudes are a starting point to discover how the groups can construct a stable and foreseeable world based on this diversity¹¹.

The inclusion criteria were: health professionals from the two groups who attended to men medically diagnosed with infertility, classified as masculine or double; that is, when both elements of the couple face difficulties to procreate, and were working in the human reproduction specialty for at least one year. The exclusion criteria were: health professionals who work in this area, in the laboratory part, such as biologists and biomedical professionals.

The linguistic-verbal data collection technique was used, by means of a form to characterize the health professionals and a script for individual and semistructured interviews, recorded in MP3 with the participants' consent. The data were produced between October 2010 and February 2011, with the participants' agreement and signing of the Free and Informed Consent Form, respecting the ethical criteria, secrecy, privacy and the possibility to interrupt the participation in the research without any negative effect.

The results were analyzed by means of Bardin's Content Analysis¹². This analysis was organized in three phases: pre-analysis, exploration of the material and treatment, using the theme as a Registration Unit. In the pre-analysis, the produced data were organized, separating the material in the two groups for the purpose of floating reading and familiarity with the material. The exploration permitted clipping the produced data in context and registration units. The data were organized in categories and subcategories, analyzed in the light of the proposed theoretical framework.

RESULTS AND DISCUSSION

Characterization of the participants

The 20 research participants are between 20 and 50 years old. Fourteen are female and six male. As regards the declared religion, 10 indicated being Catholic. Concerning the marital status, 13 declared they were living with a fixed partner, six were single and one widowed. With respect to the conclusion of a professional course, the graduation date varied between four and 24 years. Four participants held a Ph.D., five an M.Sc. and nine a specialization degree. The length of experience in human reproduction ranged from one to seven years. Eleven participants referred having a close relative with an infertility-related problem, and one declared that he experienced this situation.

The analysis of the data about the Social Representations of men going through infertility gave rise to three categories: Infertility is a woman's thing; a Threat to Masculinity/Virility and the Infertile Man: the silence. In the analysis of these representations' repercussions in view of care delivery, two categories emerged: the health professionals' lack of preparation in health services to attend to infertile men and the search for new care strategies.

Social Representations about men who experience infertility

1^st - Category - Infertility is a Woman's Thing

According to the discourse, the fact was evidenced that the idea was social and culturally constructed that infertility is a female problem/fault/responsibility¹³. This representation is primarily due to the fact that pregnancy, delivery and birth are phenomena that have not transcended the female body yet and, therefore, the inability and/or difficulty to procreate and aspects inherent in the female gender.

That is not an important problem for men, they generally don't even think of it, they just think if women charge them, because it is not something inherent to men. The infertility issue is more important for women, because they get pregnant, breastfeed, want to enjoy the pregnancy, feel the child in their womb. (Interview 2 - Professional Biomedical Area).

Infertility is a major responsibility for women. Women generate, and not being able to have children for women is like being disabled. Men keep watching more, it's not that important. (Interview 1 - Professional Humanities Area).

In common sense, maternity remains a preponderant factor in the female identity nowadays. That is part of common sense to the extent that this representation was strong in both groups, for all testimonies from the biomedical area and six from humanities. This representation indicates how human thinking is impregnated with meanings, enriching the fabric of reality for each being¹¹. The biomedical professionals believe that the cause of infertility is an organic failure, restricted to the biological body, while professionals from humanities attribute the infertility situation to psychological causes as well.

2^nd - Category - A Threat to Masculinity/Virility

Although infertility was represented as a female problem, some professionals acknowledge that, when this difficulty is determined by men, the male image is strongly compromised, threatening their masculinity and virility, according to the following reports:

Perhaps they even relate it to the matter of their male power, this history of virility. (Interview 1 - Professional Humanities Area).

I think that what bothers men when they face difficulties to have children is much more linked to the guarantee of their self-image as men than to the problem itself. (Interview 2 - Professional Biomedical Area).

If, for men, the ability to procreate is related to the social status of masculinity and virility, the absence of this capacity includes them in a class of individuals who are not entitled to share this status, due to their problem¹⁰. Paternity still seems to have a sense of recognition by the social group in a public sphere, where the difficulty to fertilize would entail the feeling of social non-belonging and the denial of masculinity due to the incompetence to perform their role. And it is exactly this identification that involves group knowledge and the emergence of common sense, as well as justification patterns¹⁴.

For the health professionals, the inability to have children mainly affects their recognition as men. In this perspective, there are signs that the exercise of male sexuality, in the domestic sphere, is hostage to the male fertilization capacity. This fact not only refers to the biomedical professionals, but also to the humanities group, totaling the 20 interviewees. Hence, the majority tends towards this representation in this group.

The human reproduction capacity is strongly associated with virility and male sexual willingness. (Interview 3 - Professional Humanities Area).

A very serious problem for most men, because it refers to their male, their masculine condition. (Interview 4 - Professional Biomedical Area).

Socially, the difficulty to procreate is marked as a deviation, which reveals their social statute as the biological statute. The fact that sterility has been considered a problem in the course of history in different cultures and societies indicates that the social deviation precedes the understanding of the biological deviation³. This deviation turns into a social reality, structured in the relations between individuals and groups. The masculinity concept in society is related to certain keystone determinants of sexual behaviors, which in turn are located in the framework of a complex set of not only biological and psychological, but also social and cultural factors². Therefore, according to the testimonies, this is due to the need to attest that man's sexuality and sexual power are not compromised.

The difficulty undoubtedly ends up influencing different aspects of man's social life, mainly in such a macho society as ours, in which infertility is mixed up with impotence. (Interview 6 - Professional Humanities Area).

Others turn this into a motive to jump the fence and need to prove that they are men. (Interview 7 - Professional Biomedical Area).

As the arrival of a child is understood as the concrete proof of fecundity and, consequently, of masculinity, being historical and culturally linked with the sexual act, the lack of success of this proof determines interference in the social, cultural, health area and in sexual life and can alter men's behavior towards their social context¹⁵.

3^rd - Category - The infertile Man: the silence

This category derived from the participants' assertion that men mention little or nothing about the health problems in general and, consequently, do not talk about the problems related to their infertility condition either. This materialized the ideas, objectifying the infertile man as the man of silence.

Men do not talk about their intimacy, mainly about the difficulty to have children. They are pure silence. (Interview 8 - Professional Biomedical Area).

Men are silent with regard to this theme. It is hard for a man who cannot have children to spread the word. (Interview 1 - Professional Humanities Area).

This thought can be explained when analyzing that, in Judaic-Christian societies, infertility is a prohibited theme mainly when the affected subject is the man. Infertility in this population segment affects a vital aspect in the way men perceive themselves, as they feel they are affected in the two ancient drives that have defined the male attitudes and behaviors over the centuries: their virility and capacity to procreate². This silence about sexuality and masculinity can also remit to the interest in expulsing, denying or reducing what one does not want to assume¹⁶. This situation can explain men's denial and distancing, as the appropriation of a social practice depends on whether it seems acceptable to the individuals in the context of their values¹⁷. This symbolism of the silence rests on the still hegemonic model of masculinity, strongly identified with the image of the heterosexual, virile, powerful and infallible man that remains in force in society. This category showed no distinction between the groups, as it emerged from eight biomedical and six humanity professionals.

Repercussion of these representations on care delivery

1^st - Category - Lack of preparation of health professionals at the services to attend to infertile men

This category was the most frequent with regard to the repercussions of the health professionals' social representations about infertile men at the human reproduction services. Among the 20 testimonies, 13 are in this category, seven from Humanities and six from Biomedical sciences.

In a space prepared for women, it is not easy to make men feel that comfortable. And men are not equipped to think about reproduction. (Interview 8 - Professional Humanities Area).

Yes, I face difficulties. It is very difficult to deal with men, because the service is not prepared and not appropriate to attend to the male public, the majority here is gynecologist. Talking about reproduction with a woman is easy. (Interview 9 - Professional Biomedical Area).

The fact that, historically, men do not think about health was one of the explanatory elements this group gave for not attending care or for timidly participating in human reproduction services. These testimonies reinforce that the couple's reproductive problems have always been attributed to women, while it is difficult to work with men with regard to these issues³. Due to the fact that, until today, human reproduction has been created and developed inside gynecology services raises an obstacle in the approach of these infertile men.

In addition, the health professionals perceive that the services' physical structure is inappropriate to attend to men, when their sperm needs to be examined or collected for tests or procedures. Many of the testimonies indicated the lack of welcoming and appropriate institutional routines as causes of their absence, including other factors, such as functioning hours, which they consider inappropriate for work reasons.

These professionals were educated in a sphere of women's health care, mainly in gynecology, strengthening the idea that the health services are ineffective and that the professionals lack training to cope with men in the field of human reproduction^2,6.

I find the services very unprepared to deal with men. I think that the sole places where you see men more frequently are occupational medicine, urology and orthopedics. In the reproduction area, we have to evolve to make the male figure more frequent, but I don't even know if that is possible, because you'd have to change the way men are. Men are not built to attend health services and that influences their health. (Interview 4 - Professional Biomedical Area).

For the 13 professionals in this category, the male figure is imperceptible, which can be explained by their historical absence from health services¹⁸. They reported that man was not made to take care of himself and, in this line of reasoning, they do not expect man to attend the services in search of care. The role differences associated with the social gender imaginary explain why care is characteristic of the female universe⁸. This refers to the culture of risk and violence that permeates men's lives, in which health care may mean taking care of illness¹⁸. This category unveils that, for these professionals, there seems to exist a strong scapegoating of men, underlining their absence almost sole and exclusively as their responsibility, exempting both the services and the health professionals from their invisibility.

In view of the representation in the categories: Infertility is a woman's thing and The infertile man: the silence, one can understand the recognition of the health professionals' lack of preparation at the human reproduction services, as man, being imperceptible to these professionals, continues as an adjuvant of woman's health care, without being the subject of their care.

2^nd - Category - New strategies for care delivery to infertile men: a gender issue

This category remits to a counter-hegemonic representation to what the testimonies referred to as the male role and to what is observed as care delivery to men in the human reproduction services. Six professionals from the area of humanities expressed ideas that led to the establishment of this category, considering that man would also be affected if they had the desire to be a father and had difficulties to procreate. These professionals attempt to act in a different manner in their care, trying to construct strategies that permit attracting men to the service, so as to promote welcoming and high-quality care.

The social representation reflects human thinking and action in compliance with a standard established by a group¹¹. It is identified that, in this group, man starts to be seen in a distinguished way, that is, with a perspective that can understand him as an individual who needs care and assistance in the sexual and reproductive health sphere⁷.

This category evidences a change movement in the humanities group regarding the representation of men going through infertility. These professionals are overcoming archaic values, which are transformed in parallel with other social changes related to fatherhood and masculinity. For these professionals, man is part of the sexual and reproductive health scenario, needs to be welcomed at the services and, therefore, the professionals need to be prepared to attend to this protagonist. They acknowledge that they need further professional qualification, that the human reproduction services need to adapt to man, that the governmental policies demand commitment to gender issues; nevertheless, these bottlenecks do not paralyze them. They indicate the need to break with the traditional care models based on the classical logic of the health-disease process and search for care strategies that involve participation, promote empowerment and male autonomy:

The fact that pregnancy happens in the woman's body is a complicating element, because man is external to this context. I attempt to bypass this fact, constructing methods that approach man to the decision, whether regarding pregnancy or medical interventions, so that he feels like a co-author of the decision and becomes co-accountable for the action. (Interview 5 - Professional Humanities Area).

The public health policies, particularly the National Program of Integral Care to Man's Health¹⁹, concerning the inclusion of man in health services, observe his specificities, and should be able to promote changes based on the academic and social education the professionals receive today and tend to perpetuate this picture.

As men and women are entitled to have access to health services, offered in an equalitarian an balanced manner, proposed as a universal human right and established in the Unified Health System, the conditions are needed to construct several services, without compromising what women have previously conquered, to the detriment of men's rights.

FINAL CONSIDERATIONS

The social representations of health professionals who work with human reproduction regarding men who experience infertility indicate that both the reified knowledge and common sense interfere in the formulation of their social representations. For the participants from the biomedical area, the origin of infertility in man rests on physical disability matters, an organic failure, that is, part of an embodiment process that was learned during their academic education. Nevertheless, the common sense that infertility is inherent in the female gender still persists in the elaboration of these professionals' representations.

A silence remains about the issues involving male infertility, in which neither friends nor relatives know about the situations that affect men. This whole silence about the inability to procreate is submerged in the representation of the male as a social and cultural elaboration that man is a procreating being and that this reflect his masculinity, strength and capacity.

As the biomedical professionals represent infertility as a "woman's thing", they do not acknowledge man as the subject of his care, feeling unprepared to deal with this men in terms of sexual and reproductive health, especially in view of the difficulty to procreate.

For the humanities group, infertility originates in physical and bodily aspects, demonstrating that this is a majority representation, as it appears strongly in both groups. This segment associated the organic failure with the psychological aspects though, also representing infertility as something female. It is concluded, however, that this group starts to question this majority representation, in view of the incipient representation towards considering man in the health environment, mainly related to sexual and reproductive health.

Thus, these research results indicate a trajectory of changes and ruptures in the traditional models of thoughts and behaviors, although the abandonment of the cultural dogmas of masculine identity has not been identified yet. In this context, the professionals represent men with infertility as subjects whose masculinity and virility is threatened.

They acknowledge the precariousness of health services in human reproduction to welcome men and the professionals' lack of preparation to attend to them. Finally, a rereading and repositioning are verified in search of new care strategies with a view to including these men as protagonists in the human reproduction context.

These research results show that the social representations of the health professionals who work in the field of human reproduction about men going through infertility receive cultural influence from gender issues: male and female. This fact is evidenced when the health professionals, independently of their professional category, represent that infertility in men is still focused on as a specifically female problem - woman, which hampers their approach with a view to directly addressing this clientele.

These representations are established in the social contexts the health professionals live in as well as in their academic education, in a symbolic construction that rests on cultural values, beliefs, experiences and a reified universe.

These health professionals' Social Representations about this infertile man interfere in care delivery, often impeding the health services from being capable of welcoming them or impeding that the men who do attend the service see themselves as part of the service.

The need for changes should be highlighted from the perspective of the professional education to cope with the challenges related to gender issues in the social reality men are attended in. Nevertheless, it is known that this change is not simple, not a mere exchange of places between the holder of power and behavior towards a sociocultural empowerment in Western societies, in which neither men nor women are benefitted.

Therefore, there is an urgent need for the professionals who work in man's health to be capable of breaking with the masculinity paradigm that defines the male gender as castrating and repressing femininity, from education until the daily professional reality. These are oppose to men and women solely based on bodily characteristics, transporting prejudices, hampering the inclusion of men into the spaces needed for health care.

The study was limited by the universe incorporate in the two study contexts, demanding an expansion to other private health institutions with a demand for assisted human reproduction.

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Publication Dates

• Publication in this collection
  Oct-Dec 2014

History

• Received
  27 Mar 2014
• Accepted
  15 July 2014