Chapter 1
Historical Perspective and Introduction
Preventing teenagers from having unplanned pregnancies is an important goal that has been pursued since the 1970s, when births to teenagers were first diagnosed as a major social problem. Much has been learned about the types of interventions that work and do not work (Kirby, 1997; Moore et al., 1995; Frost and Forrest, 1995; Miller and Paikoff, 1992). A glaring gap, however, is the lack of systematic information about how males could and should participate in pregnancy prevention efforts. This guide begins to fill that void by pulling together—from data on programs around the country—what is currently known about male reproductive behavior and programs designed to influence this behavior.
The guide, funded by a grant from The California Wellness Foundation to inform its statewide Teen Pregnancy Prevention Initiative, is intended for program planners in California and throughout the country who wish to implement programs involving males in teenage pregnancy prevention. It has three main purposes:
- to dispel myths about the target population by providing a description of the male partners of potential teenage mothers,
- to identify established pregnancy prevention programs that have successfully involved males in different settings around the
country, and
- to distill practical lessons from the experiences of these exemplary programs for programs still at the fledgling stage.
In the recent groundswell of interest across the country in targeting males for teen pregnancy prevention, key policy makers have responded to the absence of prevention efforts oriented to the male partners of the teenage mothers. For example, the governor of California and the federal legislators framing the recent welfare reform legislation have called for new program initiatives involving both carrots and sticks to encourage male reproductive "responsibility." At last count 40 states were reported to have strategies to prevent unwanted or too-early fatherhood (Knitzer and Bernard, 1997). Indeed it is now generally acknowledged that teen pregnancy prevention initiatives are not likely to be successful unless they address both partners' concerns and interests.
Although consensus may have been reached about the importance of involving males in teen pregnancy prevention, little is generally known about how to reach them or how to influence their reproductive behavior. However, over the last decade knowledge has been accumulating. The National Survey of Adolescent Males (NSAM) begun in 1988 provides information about trends in young men's attitudes and behaviors that are useful for understanding the perspectives of this population (Sonenstein, Pleck, and Ku, 1989). Prior to this survey, the only national trend data on the reproductive behavior of teens were collected about females. New data from the 1995 NSAM are presented in this guide to provide a national picture of the extent of their risk for participating in pregnancies, with opportunities for influencing their behavior highlighted.
Knowledge has also been accruing about how to develop pregnancy prevention programs that involve males (Dryfoos, 1988; Levine and Pitt, 1995; Moore, Driscoll, and Ooms, 1997). A number of programs have been initiated in communities throughout the country. Their pioneering efforts could provide useful advice and counsel to new initiatives. However these prevention programs are geographically spread out, sponsored by many different organizations, and unconnected to other like efforts. This guide provides a central source of program information so that individuals interested in developing programs to help young males participate in pregnancy prevention will not need to start at ground zero.
The Shifting Landscape of Reproductive Politics
For many years reproductive policy in the United States concentrated almost singly on women. For example men made up only two percent of the clients in the federally funded Title X family planning programs in 1991 and two percent of Medicaid funded family planning in 1990 (Schulte and Sonenstein, 1995). The changed political climate has broadened the focus to acknowledge the critical role men play in human reproduction. Recently, for example, the Office of Population Affairs in the U.S. Department of Health and Human Services announced a limited male initiative, the Young Men/Family Planning Clinic Partnership Program. In this program male high school students will work in Title X family planning clinics to increase service utilization by teen males and to broaden the students' training and employment goals.
Public Health and STD Prevention
One set of pressures prodding public health and family planning providers to be more interested in the reproductive and contraceptive behavior of males is concern about the spread of HIV and other sexually transmitted diseases (STDs). The identification of new STDs that are easily transmitted, for example, has reignited the popularity of condoms as one of the effective ways to prevent transmission of STDs among sexually active populations. Since condoms are used by males, efforts to increase condom use must necessarily target them as well as their female partners. Changing the reproductive behavior of males is a crucial element of strategies to prevent the transmission of STDs.
In addition, rapid treatment of the male partners of females testing positive for bacterial STDs such as chlamydia, gonorrhea, and syphilis is a critical element in slowing the spread of these diseases and preventing reinfection. Increasingly, family planning clinics faced with many female patients testing positive for STDs have started to treat male partners. Indeed STD treatment is one of the primary reasons that family planning clinics give when asked why they have expanded their services to include males (Schulte and Sonenstein, 1995).
Child Support Policy
Another set of influences creating pressure for more intense focus on male reproductive behavior emerges from child support policy. The Child Support Enforcement Program was established in 1975 as a way of recouping from fathers some of the public funds that children on welfare (Aid to Families with Dependent Children) were receiving. Over the years the program has moved from serving just the welfare population to including within its mandate all children with noncustodial parents. In addition, as more children have been born out of wedlock the program has increasingly focused on paternity establishment to create bonds of economic responsibility between children and their fathers. While the program began as unpopular and relatively small, it has now emerged as one of the keystones of federal welfare policy. The current goals of the program include establishing paternity for all children born out of wedlock, and setting and enforcing reasonable and equitable child support orders for all children who have a parent—a father or mother—who does not live with them. Essentially, a primary goal of the program is to ensure that parents assume financial responsibility for any children that they have, whether or not these children are born within marriage.
Some have argued that requiring males to be financially responsible for their children can provide needed motivation for them to avoid unintended pregnancies and births. Since child support enforcement is far from universal at the moment, it is difficult to test this hypothesis. Less than one-third of nonmarital births are estimated to have paternity established, approximately half of custodial parents have child support orders, and only half of these orders are fully paid (U.S. House of Representatives, 1996). Major efforts are under way in many states to improve these statistics. We argue that if males are going to be held responsible for any children they produce, it is time to spend more public resources on helping them to avoid unintended pregnancies (Sonenstein and Pleck, 1995).
Statutory Rape Enforcement
A further recent development has been the call for more rigorous enforcement of statutory rape laws to reduce pregnancies and births among young female teens. Initiatives have been launched in several states including California, Delaware, Georgia, and Florida. While there is substantial state-to-state variation in definitions of statutory rape, in more than half the states the young woman must be under age 16. Many states also stipulate a minimum age difference between the partners, with 4 years the most commonly cited criterion (Donovan, 1997). Thus while statutory rape enforcement may discourage some teenage pregnancies because it results in large penalties, its target population is relatively small—adult males who have sex with very young women (Lindberg, Sonenstein, Ku, and Martinez, 1997).
The Fatherhood Movement
A final set of forces that could potentially promote greater interest in male reproductive behavior is the fatherhood movement. As the feminist movement grew in the 1960s, an initially small group of men recognized that gender roles could be as limiting for males as they were for females. Just as some women wished to participate in the male economic sphere, some men pushed for fuller participation in the female family sphere. Over the years they have been joined by an increasing number of noncustodial fathers' groups that are also interested in participating in their children's lives and have rallied for better enforcement of visitation agreements. More recently many others—both males and females—have become concerned about the increasing absence of fathers in the lives of children in female-headed families. In June 1995 President Clinton launched a government-wide initiative to strengthen the role of fathers in families. As part of this initiative the Department of Health and Human Services is spearheading an examination of its programs and data collection activities to expand and enhance activities promoting fatherhood issues. While most of this effort has focused on fathers "after the fact," after they have become fathers, there is recognition that it is also important to focus on how men become fathers. As part of the Federal Interagency Forum on Child and Family Statistics, a working group is developing recommendations about better measurement and data collection about male fertility behavior.
The time has arrived when there is now a confluence of interests supporting the crucial role of males for family and reproductive policy. It should therefore be no surprise that debates about adolescent pregnancy policy show an increasing interest in the role of males and the development of strategies that involve them in pregnancy prevention efforts.
The Crucial Role of Males in
Pregnancy Prevention Initiatives
Why males were ever excluded from the way we think about pregnancy prevention is puzzling. Sexual behavior involves two partners, and decisions to have sex and to use contraception undoubtedly reflect both partners' perspectives, whether explicitly or implicitly. Yet fertility and family are traditionally ascribed to the world of females—a perspective that has kept us from acknowledging what should have been obvious—that males must be involved in any policy solution to unintended pregnancies among teenagers.
It is well known, for instance, that adolescent boys initiate sex earlier than girls and that they tend to accumulate more sexual partners over their lifetimes. Even though males do not actually get pregnant, it does not make sense to segregate them from prevention efforts when they have sex earlier, more frequently, and with more partners than females of comparable ages.
Contrary to stereotypes about males' disregard for contraception, there is overwhelming evidence that males have played an extremely important role in providing contraceptive protection to teenage females. Even before data were collected from the males, information provided by teenage females showed that male methods of contraception were the main forms of contraception used when they first initiated sex. In 1979, for example, 70 percent of 15- to 19-year-old females reporting that they had used contraception at first intercourse reported a male method—either withdrawal or condoms (Sonenstein, 1986).
More recent evidence from the 1988 NSAM provides further justification for integrating males into pregnancy prevention initiatives. These data show that one of the biggest shifts in teenagers' reproductive behavior that we have observed in recent time is the improvement in teenage males' contraceptive behavior. Between 1979 and 1988 condom use doubled. By 1988 more than half of all sexually experienced 15- to 19-year-old males said that they had used a condom at last intercourse (Sonenstein, Pleck, and Ku, 1989), and further increases in condom use have been observed in the 1990s. This evidence comes from the reports of both male and female teenagers (Abma, Chandra, Mosher, Peterson, and Piccinino, 1997; Kann, Warren, Collins, et al., 1993 ). These shifts in male teenagers' behavior demonstrate that they can be influenced to adopt new behaviors and that programs designed to change male reproductive behavior will not necessarily fall on
deaf ears.
Most of the descriptive information about male partners in this guide comes from new data collected in the 1995 NSAM, which interviewed 1,729 males—a sample that is representative of males ages 15 to 19 living in households in the contiguous United States. Our analyses are intended to provide a nationally representative picture of the reproductive attitudes and behavior of teenage males. They show the proportions of teens engaging in behaviors that put them at risk of pregnancy, where they are getting information about protecting themselves, and where programs are likely to encounter them. Until recently such information was not collected, leaving program planners to rely on their own devices to obtain information about these important clients.
It should be noted, however, that not all the male partners of teenage girls are themselves teenagers. On average the male is 2 to 3 years older than the female, a pattern that is repeated among adults. Thus many older teen females who are 17, 18, and 19 years old are highly likely to have partners in their twenties. Analyses of birth data confirm this pattern. In 1988 two-thirds of the fathers of babies born to mothers under the age of 20 were in their twenties (Landry and Forrest, 1995; Lindberg, Sonenstein, Ku, and Martinez, 1997). Thus it is important to realize that some of the males who should be involved in teenage pregnancy prevention efforts are not teens. To the extent possible, we have attempted to integrate information into this guide about these male partners of older teenage females, and we have also looked for prevention programs that include males in their twenties. In spite of these efforts, most of the information found is about teen males. Obtaining more information about men in their early twenties is crucial for expanding prevention efforts to this population.
Programs Included in this Guide
One of the goals of this guide is to identify prevention programs that have successfully involved males using different approaches and agency settings. The first selection criterion involved the setting of the program. Because there was already an extensive literature on school-based sex education and on school-based clinics, 1 we decided not to include these types of programs in our search for promising prototypes even though most of them are coeducational and therefore involve males in some way. Because developers seeking to implement these types of programs have a number of other resources to consult, we concentrated our efforts on looking for other types of programs to increase the variety of prototypes developers can consider. We do include other school-based programs that are not explicitly sex education or school-based clinics.
The second selection criterion concerned the meaning of "involving males." 2 This was our decision rule: A crucial ingredient for programs that "involve males" is that they focus on the male role in reproduction. It is not enough that a program have participants who are males; the program content must discuss explicitly the male perspective on reproductive behaviors (sex, contraception, childbearing, and parenting). This decision is as important in defining the programs we have chosen to highlight as the decision about what types of programs to cover. Whether they are single-sex programs or include both males and females, to be included they must concentrate on reproductive issues from the male perspective.
A third criterion for selecting programs was that they acknowledge prevention of pregnancy as an explicit primary or secondary program objective. We adopted this requirement when it became clear that there are "fathers" programs helping males in their parenting roles that do not deal with the issue of pregnancy prevention. Some of these programs may indirectly lead men to be more careful about having subsequent unintended pregnancies or births. However, since programs can only be held responsible for achieving the goals that they have set for themselves, we only include programs that are trying to help men to avoid unintended pregnancies or births as an explicit goal.
A final set of criteria dealt with the selection issue of which programs can best provide advice to other programs. Since there has been an explosion of interest and support for programs involving males in teen pregnancy prevention, many programs have been implemented only recently. Many promising prototypes are almost certainly among this new generation of programs, but we decided to select those that had withstood the test of time, defined as operating for at least three years. These programs have completed their planning and implementation stages and have gained experience with program operation at scale. In addition, we decided to include only larger programs—arbitrarily defined as ones that served at least 50 males in the last year. Smaller program prototypes, however successful, are not included in this guide.
We note that the field of male involvement prevention programs has not progressed sufficiently to have developed a rigorous evaluation literature. Few of the programs covered in this guide have been formally evaluated and none have used rigorous experimental or quasi-experimental designs. The programs we have included have all been successful in recruiting male participants and keeping them engaged in program activities. In other words, male program participants have voted with their feet for these programs. Also the fact that these programs have been able to sustain themselves over time indicates that they have gained support from funders as well as participants. An important next step will be to submit some of these prototypes to more rigorous evaluation to assess their ultimate impact on unintended pregnancies and births.
We have selected 24 programs to demonstrate the variety of approaches that can be used for addressing the male role in teen pregnancy prevention. Of the programs, five are set up around clubs or youth groups, seven are primarily health focused, and seven are oriented to schools. Indeed most of the health-focused projects are in fact based in schools. Schools are overwhelmingly the most popular site for these interventions, even after the most common types of school programs, sex education and school-based clinics, have been purposely excluded. Programs oriented to sports, employment and training, and criminal justice settings are represented by single nominees. Given the numbers of teen males who have links to these settings, there appears to be a lot of room for further program development in these areas.
We were unable to locate program models fitting our criteria that are oriented to the following audiences: youth in health maintenance organizations or other managed health care, 3 Asian youth, and males in their twenties who have sex with teenagers. These are all relevant populations for teenage pregnancy prevention efforts in California as well as throughout the country.
How the Guide Is Organized
The rest of this guide is divided into three major sections and five appendices. Chapter 2 provides a description of males who are likely to get involved in teen pregnancies and births. Using recently collected information from the 1995 National Survey of Adolescent Males we examine:
- How many males are sexually involved with teenage females and who are they?
- What is the nature of the sexual relationships males have with teenage females?
- What are teenage males doing to protect themselves and their partners from unintended pregnancy and sexually transmitted diseases?
- Where do these males get information about contraceptive protection?
- What organizations are these men involved in that could potentially be settings for pregnancy prevention programs?
Chapter 3 introduces the 24 promising prevention programs that focus on the male role in reproduction. For each of these programs we have prepared a description that covers:
- Program philosophy and history,
- What the program does,
- What kinds of males it includes,
- How the program is funded and staffed,
- What barriers it faced and overcame, and
- What lessons would be useful to other program developers.
This chapter also provides guides so that program developers can identify the programs that might be most relevant to their own circumstances. Programs are classified by their organizational settings, the ages of their participants, their annual budgets, and other special features such as cultural orientation.
Chapter 4 pulls together our observations across these programs about the common lessons that have been learned by these programs. There are practical lessons about the types of activities that attract and engage males and program materials that are popular with the programs. There are common experiences in terms of the barriers to program implementation and approaches used to overcome these hurdles. Finally we examine the elements of program philosophy shared by many of these successful programs. We conclude that careful attention to program philosophy about male development is a crucial determinant of programs' ability to attract a critical mass of male participants.
The Appendices include a wealth of information that we hope will be useful to program developers. The first appendix describes our study methodology—how we canvassed the country for teenage pregnancy prevention programs involving males and how we conducted the National Survey of Adolescent Males. We include the questions used in the National Survey of Adolescent Males so that programs wishing to assess their program participants' reproductive behavior can obtain measures that can be calibrated to national survey data. The second appendix provides contact information for the 24 programs, including notes about the willingness of program personnel to provide assistance to program developers. The third appendix lists all the programs involving males that we found by state. Many of these were too new or too small to be included in the more detailed program descriptions. The fourth appendix lists materials used by the highlighted programs, including curricula, videos, pamphlets, and activities. The fifth consists of a list of references for this guide that should be useful to programs that are just starting out.
Notes
1. See Kirby 1997 for a review of this literature.
2. This question was the subject of extensive discussion at a meeting of the guide's advisers.
3. One program in a health maintenance organization demonstrated that a half-hour slide-tape program with a personal health consultation for teen males resulted in more effective contraceptive practice one year later (Danielson et al., 1990). This program no longer exists, but a User's Guide, a complete set of program materials, and evaluation instruments are available from The Program Archive on Sexuality, Health and Adolescence (PASHA), Sociometrics Corporation, 170 State Street, Suite 260, Los Altos, CA 94022-2812, 1-800-846-3475.
