GUYnecology: The History of Male Reproductive Health with Rene Almeling

Today I have an interview with Rene Almeling. She’s associate professor of sociology at Yale University with research and teaching interests in gender and medicine. Using a range of qualitative, historical, and quantitative methods, she examines questions about how biological bodies and cultural norms interact to influence scientific knowledge, medical markets, and individual experiences.

Rene is the author of Sex Cells, an award-winning book that offers an inside look at the American market for egg donors and sperm donors. Her new book GUYnecology examines why there is so little attention to men’s reproductive health and analyzes how this gap affects medical knowledge, health policy, and reproductive politics.

Professor Almeling has also conducted two original surveys. The first on Americans attitudes toward genetic risk with political scientist Shana Kushner Gadarian, and the other on women’s bodily experiences when it comes to IVF.

Dr. Aimee: Welcome, Rene.

Rene Almeling: Thank you so much for having me. I’m really happy to be here.

Dr. Aimee: I hear sweet birds in the background, and I love it. What are those birds doing over there?

Rene Almeling: I have a tiny little patio outside of my office. It’s Springtime here, so they are actually trying to make little bird babies.

Dr. Aimee: They knew that we were going to talk today apparently. I guess the first question that I would love to ask you is what drew you to this topic, digging into biology, cultural norms, and history?

Rene Almeling: The answer to that question goes back quite a long way. Way back in college, I was taking a class on the sociology of gender and my professor had assigned an article about the Baby M surrogacy trial from 1987. I had no idea what it was, as I was a 19-year-old kid taking this class.

I just became completely fascinated by the idea that a woman could be paid to carry a pregnancy and questions about how that makes the pregnancy feel, does it feel different to be gestating a fetus that you’re not genetically related to, that you have no plans to parent. Some of those early questions about the intersection of medical technology and bodily experiences and cultural ideas about gender really were born or conceived in that class long ago.

After that, I spent a couple years working in Washington DC at a women’s health nonprofit. Then I went to graduate school where I began studying egg and sperm donation. That was that first book. All of my books, I apologize that you have to spell out the titles to get the pun. Ever since then, I’ve been in the world of reproduction, medicine, and technologies.

Dr. Aimee: That’s great. GUYnecology, your new book, looks at the history of the study of men’s reproductive health. Why are there specialties for women’s reproductive health but not necessarily a male equivalent?

Rene Almeling: That was really the animating question for this most recent book. Why do we have OBGYN, why do we have women going in every couple of years to have their reproductive organs examined, and there’s no equivalent medical specialty or medical recommendations for men?

Trying to figure out the answer to that question really brought me into the world of the history of medicine. You have to go back a ways to figure out how we get the medical specialties that we have today. I ended up finding out that the answer was really rooted at the end of the 19th Century, so more than 100 years ago, as the medical profession in the United States began to become a profession. To specialize, obstetrics and gynecology were some of the earliest and quickly institutionalized specialties. They formally merged in the 1920s and 1930s, so that’s why we have OB-GYN today.

At the time, in the 1880s and 1890s, there was an attempt to launch a parallel specialty to GYN for men called andrology. It was a group of physicians in New York City, many of them were medical professors at the early medical colleges, and they made the argument that we needed a specialty for men’s reproductive bodies the way we have for women.

The problem was at the time, at the end of the 19th Century, most of what was wrong with men’s reproductive bodies was venereal disease, to use the language of the time. Today we would call the sexually transmitted infections, but syphilis and gonorrhea were just absolutely epidemics, so these doctors were basically trying to specialize in something that was seen as deeply immoral and problematic, and they get laughed out of the pages of medical journals.

That early attempt to launch andrology just quickly completely flames out. About 80 years passes until another group of physicians in the 1960s says, “What about a specialty parallel to GYN for men, why don’t we call it andrology,” and they had no idea that they were not the first ones to think of this. It was a different time, 1960s versus 1880s, but the 1960s and 1970s you have the social movements around gender and patients’ rights, men’s rights. All the social upheaval at the time made it at least thinkable to have a specialty devoted to men’s reproductive health.

Now andrology does exist. It’s still very small. Most people have never heard of it, especially in the US. In other countries it is a little bit better known. We have this world where we do have a lot of medical attention and medical knowledge and medical advice for women about reproduction, but to this day the lack of medical info structure, which is most clearly seen in the lack of a specialty for men, means that men don’t get the same advice and knowledge base that women do.

Dr. Aimee: You follow a hypothetical man through his day in the book. Can you tell us a little bit about that journey that he goes on?

Rene Almeling: I was trying to think about it, as I was studying something that doesn’t exist. Men’s reproductive health, certainly there are some urologists who focus on male fertility, there are some OBGYNs who will talk to their female patients about their male partner’s health, but in general, there is so little attention to men’s reproductive health that I was trying to think about how to tell a story about something that isn’t there. I came up with an imaginary person, who of course I gave the terribly generic name of John.

John wakes up and the story is that his eyes crack open, and he sees this book on his nightstand of how to produce healthy sperm. He takes a lukewarm shower, so he doesn’t cook his sperm. He’s changing his diet and the shampoo that he uses, all to avoid toxic exposures. The idea was to say here’s a world that women do live in when they are trying to get pregnant and to follow all of the advice, what does that look like for men?

It is a fictional story that starts a very academic scholarly book with lots of data in it, but it does start out with a fictional story. The impetus for that was this relatively new body of research which sort of has the umbrella term paternal effects. Paternal effects research shows that the age of a man’s body and the health of his body and his exposures to toxins will not affect things like sperm count or how well sperm swims, but that they can damage the genetics inside of sperm, potentially with consequences for his children.

That’s relatively new medical knowledge. I have done interviews with the average American man, so I can say most American men have never heard this at all, because they’re not seeing a doctor who is telling it to them, they’re not sitting in a health class where they’re hearing it. I really wanted to dive into this new body of medical knowledge and figure out how to begin communicating that to men in the public.

Dr. Aimee: That saying you are what you eat. Your children are what you eat, and then your children are what your sperm donor eats. What are some of the consequences of there not being a specialist for men’s reproductive health?

Rene Almeling: I think that there’s several different ways that you can think about that question. You can think about the consequences for individual men and individual couples who are trying to or are interested in having children. If men aren’t getting basic advice about their age and their diet — the evidence on diet is not as strong as the evidence on paternal age or paternal toxic exposures, but if they’re not thinking about what kinds of chemicals they’re exposed to, then those couples are missing out on some amount of information that might help them make better decisions about reproductive health on an individual level.

I’m a sociologist, so I’ll sort of span out to the societal level. I think that as a society if we are primarily issuing public health messages around women’s reproductive health then we are missing major opportunities to improve the health of men and potentially their children. That’s not something that just individuals can do. I can wave my wand and say every single individual in this country should do a better job. We have to make investments as a society in public health and quality health care, and clean air and clean water, and healthy food, and all of the things that we know and still don’t do, unlike many other countries around the world.

I think about the lack of attention to men’s reproductive health not only as it affects individuals but how it affects our policy making as a society, and I think we have to tackle both of those issues at the same time.

Dr. Aimee: That’s so important. As far as your research, that also involves speaking to men about what they know about reproductive health. I’m so curious to see what you learned and discovered when doing that.

Rene Almeling: This is one of my favorite things to do as a sociologist. We do surveys, we do qualitative interviews, we go and observe people, we dig in the archives to do historical work, but I really do love sitting down with people and talking about how you think about your life and how you describe your own experiences.

In the sociological literature on reproduction, just like clinicians don’t talk to men, sociologists don’t talk to men. We have decades of research now on reproduction that is mostly interviews with women about abortion, contraception, birth, pregnancy, and all the things, but we rarely talk to men. This was one of the first interview studies with men from the general public, so not men in fertility clinics, not men in sperm banks, but just your average men from the general public.

I asked questions like, “How do you define a man’s role in reproduction, what is that to you? How would you describe the relationship between an egg and a sperm?” Because it was one of the first studies to do this, I really had very few hypotheses about what it was that they were going to say. That made those interviews interesting, because every single one I was like, “Oh my gosh, I can’t believe they said this.”

The thing that I learned from talking with 40 men from all walks of life, less educated to more educated, there were men who were homeless or unemployed, men who were very financially successful, men who were fathers and men who were not, men who were white, men of color, I had a lot of variety in my sample to try to get the lay of the land out there. What I found was that even though men really didn’t know what to say when I first asked them, “What’s a man’s role in reproduction,” they all stumbled around like, “I’ve never thought about that before. What is a man’s role in reproduction?”

At the end of the day, they define it as a three-part role of having sex, providing sperm, and being a dad. Which is interesting because if you went and asked women, “How would you define a woman’s role in reproduction,” I don’t think a lot of women would say having sex or providing an egg, unless they are having difficulty and need to provide an egg. But it makes sense because these are the ways that men’s bodies are involved in reproduction, that they have sex and that they provide the sperm for fertilization.

That was then where I really went on a deep dive into how men think about their sperm. I don’t know how far you want me to go down that road, but I’m happy to talk more.

Dr. Aimee: Obviously, I could talk about this all day. This is so fascinating to me. And this is super fun because I do the same kinds of things, but my survey groups are usually in elevators where I ask people who are in a confined space things like, “How many people here know that a woman can freeze her eggs?” I love what you do and what you’re talking about.

What should people who are wanting to grow their family know about women’s health and what to look for? How would you change the framework that guys work within when it comes to how they think about their roles if you were in charge of the world? Obviously, there are few people that know more than you about this, so what would you do if you oversaw public policy?

Rene Almeling: I thought a lot about this question when writing, especially writing the conclusion of the book of what’s next, what comes out of a recommendation about the history of inattention to men’s reproductive health. I think that there are several things that are fairly easy to do.

One of them is to tackle the lack of education at present that we provide men, almost in any forum. The men that I spoke to had not really heard about paternal effects. They were really interested in knowing more details about how many cigarettes it is until I really am increasing the cancer risk for my children, or what I do about the pesticides that I work with if I can’t not work with pesticides, or whatever it is. They wanted more information and they wanted detailed information. First, we need the scientists to do more and better research about what exactly the risk levels are that are associated with men’s age, health, and exposures.

Then for men, many of them said they hadn’t really heard anything about their own reproductive system since high school in a health class or a sex ed class. I think maybe there were one or two who had spoken to a doctor who had ever raised the question of his own reproductive health. I think adding information about men’s reproductive health to high school sex ed and health classes is going to be an easy way to capture them.

I think running a public health campaign, because men don’t necessarily go to the doctor as often as women, they’re not seeing specialists in men’s reproductive health the way that women are. I think a generalized public health campaign is one way to do it.

Then I think when it comes to reproductive health care providers, reproductive health as an umbrella is technically a gender-neutral term. It has been synonymous with women’s health, and now it’s starting to stretch just a little to include transgender and gender nonbinary people. So, we’re thinking about reproductive health for not just women but maybe trans, and we’re talking about pregnant people and not just pregnant women.

I would like to take that reproductive health umbrella and expand it even further to think about men’s reproductive health because there’s already an info structure in place through places like Planned Parenthood the VA and OBGYNs who could raise these issues for the patients they’re seeing and to start thinking about not just the reproductive health of women’s bodies but the reproductive health of all bodies.

Dr. Aimee: I started throwing egg freezing parties in 2014, and I thought of throwing sperm freezing parties because my parties weren’t about freezing eggs. My parties continue to just be about fertility education and the term is just gimmicky. I did throw a sperm freezing party, I think it was maybe in October 2016. That’s the last one that I did. Perhaps we start classes, and we can go on a sperm freezing party campaign just for the education piece of it.

I think that your book will hopefully not change minds, but I feel like the more people are aware of it, the more people will be talking about it around the dinner table, and they’ll realize how important sperm quality is when it comes to making babies. It’s not just, what I say is, going to a bar, having a shot of tequila, having sex, and making a baby. We need to prepare a little bit more. Our society really depends and relies on healthy sperm.

Rene Almeling: The issue of preparing to have children, I completely agree with you for people who are in a position to be thinking about that and to do that. But then there’s this very robust statistic that 50% of all pregnancies in the United States are not planned.

That’s why I talk about both the importance of educating people who are in a place to hear it and who have the financial resources to think about something like egg freezing or to think about planning to have children. There’s a lot of people who don’t necessarily sit down and pull out their calendar to say, “Okay, three months from now, I have to get my sperm in shape.” That’s why I think at the same time as we’re both thinking about reproductive health, if we think about increasing the general health of a population, that has all kinds of benefits beyond just having children but would also potentially improve bodily health for if and when they do have children.

Dr. Aimee: Right. I have these ideas, but no one agrees with them or wants to implement the ideas. One of them is on birth control pill boxes. There should be a little card, “Have you thought about your fertility?” There are all these women who have these heartbreaking stories; at 17 years old they start birth control; they stop at 32 and realize that they’re out of eggs. It’s the same thing, maybe cigarette boxes, “Is there a chance that you might be trying to have a baby in the next three months?”

Rene Almeling: Right. Because I’ve studied sperm for almost 20 years, I get emails from all over, and there are some countries that do put warnings about sperm on cigarette boxes. That is something that we could think about.

For more than 10 years the epidemiologists through their professional association have been saying every single man who is thinking about conceiving a child should stop smoking because heavy smoking comes with a raised risk of cancer for their children. That is just not a message that is getting to the general public because we don’t have the proper megaphone. There’s no society of men’s reproductive health that has the status and money to really make that message fully head out into the world in the way that it needs to.

Dr. Aimee: Right. This is totally a random thought, but this last week Joe Biden announced a campaign that if a certain percentage got vaccinated then there would be free beer for everybody. I was just like sperm, that’s what I’m thinking. I’m just curious, did you have any thoughts as a sociologist about the public health impact of that messaging at all?

Rene Almeling: I didn’t go there. I had a conversation with some of my colleagues about could this work and how do we get those vaccination rates up. But I think you’re absolutely right. I think the interesting thing, and one of the things that I did for the book was, it wasn’t a formal meta-analysis, but it was a pretty good look at the scientific research, evidence-based, for paternal effects starting in the 1970s when that literature really started to pick up speed. There’s still a big question mark about alcohol.

From working with sperm banks for research for my first book, they definitely know that alcohol for sperm donors who were drinking too much, having too much fun the night before, and they come in, and their sperm cells don’t look as good, or the semen volume is down. So, there are short-term effects of alcohol, but the question of whether alcohol actually affects the genetics inside sperm is definitely still an open question.

Things like paternal age, there is pretty good evidence that increasing paternal age comes with an increased risk of both childhood conditions and some adult-onset conditions for people’s children. Like I said, smoking is one of those things that they know.

Any time you are studying environmental toxins, or toxins in the home and the workplace, it’s incredibly difficult to specify the dose of just that particular exposure, because we’re all being exposed to so many things at the same time. There’s a lot of epidemiologists who will say we are pretty sure that toxins are not good for sperm, either the count, or the shape, or the swimmability, the motility is the formal term. They’re pretty sure that these things are not good for sperm or the genetics inside of them, but it’s hard to really get good risk numbers that you could give to an individual man.

Dr. Aimee: I agree. I feel like if someone, let’s say, has other chronic medical problems, diabetes, or high blood pressure, then the alcohol clearly isn’t going to help. But I agree with you.

What do you think OBGYNs can do? You mentioned them being partners in this public awareness campaign that I’m theorizing you’re going to start as more people read your book. What can OBGYNs and doctors in general do?

Rene Almeling: This was another thing that I’ve thought about. Where in the medical system could we increase the level of attention?

OBGYNs are interesting because, of course, they are often seeing women who are thinking about reproduction or they’re asking questions about women’s reproductive plans and either then recommending contraception or preconception or prenatal care. OBGYNs are a natural place for physicians to raise questions with their women patients. Of course, then this requires women to do the work of learning about men’s reproductive health so, for those who are heterosexually partnered, they can pass that on to their husbands or their male partners.

That is adding on more work for women but would be a potential pathway. I put my gender hat on, and I was like I don’t love the fact that women are already making the appointments, and having to do the research, and having to take care of their own bodies, and now they have to learn about their male partners. If I put my gender hat on, that’s my concern. Then at the same time, logistically, women talking to OBGYNs is an obvious place to raise questions about men’s reproductive health.

Another place I think would be for pediatricians who are in general seeing male patients who are 16, 17, 18 years old and could have a chat with them before they either go off to college or join the military at the last physical they get before they turn 18 or 19. Pediatricians are often the last ones to be doing preventative health care with men. Until they walk in the door at age 50 for a colonoscopy, because they’re not seeing anybody on a regular basis in between there. Internal medicine folks, if they have a man who is between the ages of 20 and 50, could be asking questions at their checkup to say, “You’re here for a wellness visit. Let’s talk about your reproductive health as well.”

I think there’s a lot of places where you could add it to what I know is a very long list of things to discuss with patients. But because men aren’t going to the male version of an OBGYN every two years, that’s why it requires a little bit of creativity to think about where to plug this kind of advice in.

Dr. Aimee: The name of your book, GUYnecology, obviously it’s easy to remember. You could have people go to your website, do a course, that would work. I’m just planting ideas.

Rene Almeling: That’s a great idea. I hadn’t thought about that. I could provide continuing medical education.

Dr. Aimee: Absolutely. An online course where people could sign up. The OBGYN could just say, “Go to GUYnecology.com, I really want you to learn more about male reproductive health.”

Rene Almeling: That’s a great idea. I had not thought of that. I’m writing it down.

Dr. Aimee: There has been more attention given to male fertility in the last few years. Why do you think that is, why a shift now?

Rene Almeling: This is another good question. Because I have studied first sperm donors and now men and reproductive health, and in particular sperm, I have been thinking about male reproductive bodies professionally for about 20 years, so I have also noticed that there has been an uptick in the number of media stories, the level of attention, people want to talk about it a little bit more. I don’t have a good answer for why since 2015 or 2017.

Dr. Aimee: Is there anything else you’d like to add for our listeners today?

Rene Almeling: I really appreciate you having me on today to talk about this issue of men’s reproductive health, which I just think is so incredibly important. Obviously, I’ve written an entire book about it, so I think that this is something we should be talking about more.

I think one of the things that I want to make sure that people realize is just how interested men themselves were in learning this information. I think that’s a question that has come up over the decades. People have been trying to develop a male contraceptive pill, there’s always this question of are men going to be interested. We live in a dramatically changed world in the past two or three decades where gender norms have changed, our definitions of what constitutes family have changed, we are newly open to all kinds of family formations, so the world looks really different.

I think our notions of who men are and how they think about reproduction and family also need to change. I just think that’s an important message that I want to underline as we talk about this specific issue of men’s reproductive health.

Dr. Aimee: Awesome. I didn’t ask you too much about it, but I want you back on to talk about Sex Cells. For people who don’t know about that book, can you tell us a little bit about that book before we end today?

Rene Almeling: Yes. My first book was a look at the market for egg donation and sperm donation in the United States. I went around to some of the oldest and largest sperm banks and some of the oldest and largest egg agencies, and I talked to staff about what makes a good donor and how they decide who gets to be a donor. Then I interviewed donors themselves, sperm donors and egg donors, about how they decided to be a donor, how does it feel to have genetically related children out there, what was the actual process of donating like.

That was really a look at how egg donors and sperm donors are donating the exact same thing, they’re each providing half of the genetic material you need to create an embryo, and yet they have very different understandings, there are very different technologies involved, very different bodily experiences, and very different thoughts about the relationship to the offspring that are all informed in part by our ideas of gender and parenthood.

It’s an earlier book, so it’s about 10 years old now. I haven’t been at egg agencies and sperm banks for a while, so I’m sure things have changed somewhat, but I think talking with the donors and hearing what they had to say still really holds true to this day.

Dr. Aimee: I agree. I would love to have you back on to talk about Sex Cells. Thank you for writing that book. Thank you again, Rene, for all your work. I’m so excited that I got to meet you today. It was truly such a pleasure and an honor to have you on. Thank you.

Rene Almeling: Thank you so very much. It was such a pleasure to meet you. Thank you for all the attention that you bring to these issues.

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