In Bogota, Columbia, one of Profamilia's 8 male-only family planning (FP) clinics, which provide vasectomies and counsel men on topics such as how to avoid sexually transmitted diseases and how to cope with the needs of their families, can barely satisfy the demand for condoms. Providers explain this phenomenon in a country where the contraceptive prevalence rate for condoms is very low by suggesting that the men simply had to be asked to try condoms. Men not only have to be asked, however, they have to be asked in the right way. With resources for women still scarce, many FP personnel believe that it would be a waste of time to focus efforts on men. Others point out that FP clinics are female-centered are and suggest that men must be viewed as a very important part of any effort to prevent unwanted pregnancies. With the presence of AIDS in the heterosexual community, male contraception has moved from being desirable to being essential. Also, through the worldwide focus on women's status worldwide, many women are feeling empowered to demand an increased male role in contraception. The Chinese no-scalpel technique for vasectomy has spread throughout much of the world, and 42 million couples rely on vasectomy. However, in many developing countries, most men insist on achieving their desired family size and typically have more children than women. Despite this interest in producing babies, men rarely participate in child care activities. Through a variety of new male-targeted programs in the US and in developing countries, new techniques to involve men in FP responsibilities will be developed and disseminated. In the meantime, women will get center-stage at the 1994 International Conference on Population and Development in Cairo, and men will continue to receive condoms in Bogota.
Supporters applauded when Norplant arrived in the UK but did not know that many women would be refused Norplant. The main reasons for refusal are expense (US$239) or a waiting list delay of months to receive the 5-year contraceptive implant. A bureaucracy of letter writing and approvals at various levels before clinicians can provide Norplant service is responsible for the waiting lists. Counseling, insertion, and eventual removal are included in the price. Family planning clinics and general practitioners cannot afford to buy the number of Norplant systems requested. Women are accustomed to having free access to family planning and contraceptives through the UK's National Health Service. Inaccessibility differs from region to region, because each local health district decides how much money it will allocate to Norplant. Some health districts have decided not to provide Norplant at all because it is too expensive. Thus, many women seek Norplant from the family planning clinic of Marie Stopes International (US$375) in London or from private physicians who charge an even higher price. UK family planning providers want to increase the number of outlets with trained personnel to insert Norplant. As of early 1994, 40 such outlets existed. In some of these clinics, however, the physician may be in just 1 day a week. Some family planning specialists fear that UK's Norplant-distribution system is setting a precedent of refusing women newer methods as they develop. The UK Family Planning Association is documenting every telephone call about Norplant to press the government or the manufacturer to take actions to ease the situation. It appears that the National Health Service will cover Norplant.
A new female sterilization method, the insertion of quinacrine hydrochloride pellets into the uterus, has created controversy, because of the potential for coercive use. Supporters of quinacrine believe that its ease of insertion and effectiveness make its use ideal for protecting women from unwanted pregnancy. The UN reports that 23% of reproductive age women worldwide have chosen sterilization. Quinacrine was developed during the 1970s by a Chilean gynecologist. Jaime Zipper first used quinacrine as a sterilizing agent in the 1970s in liquid form. The drug was used originally for malaria treatment. Quinacrine is attractive due to its low cost (a dollar for two insertions), the ease of insertion, and the few side effects (minor cramping and fever). The methods appears to be 95-97% effective. Field trials are being conducted in 11 countries. Current clinical trials, undertaken by the Vietnamese Ministry of Health and published in Lancet, reveal that only 818 pregnancies occurred among 32,000 women using quinacrine. No deaths and only eight serious complications occurred compared to 30 deaths and 1800 serious complications from surgical sterilization. Opponents contend that the research methodology is questionable, because there was insufficient follow-up. Results are based on subsets and extrapolation to the entire study population. Critics desire more research on the potential for coercive use. The president of the Boston Women's Book Collective considers that more retrospective research is needed before confirmation of its safety. Another perspective is that the relative risk of having a baby in a rural developing country is much higher than the quinacrine risk. This position is argued by Marie Stopes International. The president of the Center for Research on Population and Security (Dr. Mumford) agrees that many people are being denied a life-saving method, and the process of review, because of the controversy, does nothing for the many women dying each year in childbirth or due to unsafe abortion.
While female genital mutilation has been brought into the open and is a topic of much conversation, the global community has yet to invest the necessary funds or devise a blueprint for eradication. International agencies defend their response by citing their concern that a full-blown attack on the traditional practice will simply drive it underground. Female genital mutilation can range from cutting or removing the clitoris to full-scale excision and infibulation of the genitalia. In fact, international agencies can do little more than provide funds and resources to local nongovernmental organizations working to eradicate the abuse. Population Action International (PAI) notes that recent publicity has made female genital mutilation a "hot topic." The US Congress is considering legislation to outlaw the practice that is being imported along with immigrants. PAI claims that the US Agency for International Development (USAID) was reluctant to become involved in the controversy, but USAID officials say that African nations were reluctant to accept USAID's help. USAID has funded research studies on female genital mutilation and expects that its approach will follow the lead of other international agencies that have integrated eradication programs within existing projects. To date, local efforts to eradicate the practice have led to only minor successes because female genital mutilation is intrinsically tied to the status of women in developing countries. Experts insist that local organizations must lead the eradication effort with funding from international agencies.
Vasectomy has a shaky reputation in the US, but 500,000 men nonetheless undergo the procedure annually in the country. 15% of US men over age 40 are vasectomized. Dr. Edward Giovannucci of the Harvard School of Public Health in a study of 10,000 vasectomized men and 38,000 nonvasectomized men found the rate of prostate cancer in vasectomized men to be 113 per 22,000 compared to 70 per 22,000 among men who were not vasectomized. Controversy ensued its publication in the Journal of the American Medical Association and an expert panel at the National Institutes of Health was quick to pronounce that the new findings warranted no change in vasectomy procedures or counseling. The controversy continues. Giovannucci's detractors argue that the study is simply a dangerous attack on an already underused contraceptive method and that the report is fueled more by hunger for media attention than by sound science. Supporters counter that the findings are being carelessly dismissed to protect vasectomy in the US.
