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Mapping men’s anticipations and experiences in the reproductive realm: (in)fertility journeys

Reproductive BioMedicine Online, 3, 27, pages 244 - 252

Abstract

This paper examines men’s experiences of fertility/infertility against a backdrop of changing understandings of men’s role in society and medical possibilities. It presents findings from two qualitative research projects on men’s experiences of engagement with reproductive health services as they sought to become fathers and anticipate impending fatherhood. The findings from both projects provide insights into men’s experiences of (in)fertility and their engagement with services set against cultural ideals of masculinity. Discussions of reproduction have historically focused most centrally upon women’s bodies and maternal processes, leaving little space for consideration of men’s experiences and perspectives. While women’s experiences of infertility/fertility have been characterized in relation to productive or faulty biological processes, male infertility has been largely invisible and male fertility typically assumed. This context provides a difficult terrain for men in which to contemplate the potential of not being able to father a child. The findings discussed in this paper illuminate the ways in which men talk about and make sense of their reproductive journeys. In doing so, it challenges current understandings of masculinity and reproductive bodies and highlights the need to rethink how men are treated in reproductive spheres and how services to men are delivered.

This paper examines the results of two interview studies that explored men’s experiences of fertility and infertility against a backdrop of changing understandings of men’s role in society and rapidly changing medical possibilities. It draws together two separate qualitative research projects that explored men’s experiences of seeking to become fathers. One followed men as they became fathers for the first time, the other was a study of men’s experiences of infertility. The findings from both projects are analysed to provide insights into men’s experiences of fertility and infertility and their engagement with health services, set against current social and cultural ideas of masculinity. Before the advent of fertility treatment, discussions of reproduction focused almost exclusively on the woman’s body. Pregnancy and childbirth was women’s business. There was little consideration of men’s experiences and perspectives. Although male factor infertility is now a leading cause of couples seeking treatment, the focus remains the woman. As assisted reproduction treatment has developed over the last half-century, most social and psychological research has explored the woman’s perspective. The findings discussed in this paper illuminate the ways in which men try and make sense of their own successful or unsuccessful reproductive journeys. In doing so it challenges current understandings of masculinity and reproductive bodies. It also highlights how we need to perhaps rethink how men are treated in reproductive spheres and how services to men are delivered.

Keywords: fertility, gender, male infertility, masculinities, norms, service provision.

Introduction

This paper explores men’s reproductive journeys. It does so through a focus on men’s unfolding personal narratives that document trajectories of fertility and infertility, culminating for some in first-time fatherhood and for others in alternative routes to parenthood, such as adoption. The focus taken is timely, as men who have been largely invisible actors in reproductive and maternal service delivery and planning are increasingly expected to demonstrate their (potential) involvement in fathering and family life through engagement in antenatal preparation and attendance at the birth. These shifts arise in a context where dominant ideas of ‘successful’ masculinity have been conflated with being fertile and able to reproduce.

Exploring men’s experiences of infertility and fertility within a context of societal expectations and assumptions reveal how difficult navigating the reproductive (‘maternal’) realm can be for men, especially when their own sense of successful masculinity comes under scrutiny and is questioned. The findings from the two studies reported below have implications for reproductive service planning and delivery. They bring together biological and social experience and contribute to calls for a move in health-focused research to a more ‘gender-inclusive’ rather than ‘gender-difference’ approach (Annandale and Hunt, 1990, Annandale and Riska, 2009, Emslie and Hunt, 2009, Epstein, 2007, and O’Brien et al, 2005), which will be explored further.

While this study reports on interviews conducted in the UK, the findings add to the relatively small body of literature examining men’s experiences of infertility and fertility internationally. As recent work by Inhorn on male infertility in the Middle East argues, despite international commitments to move towards a more inclusive approach to reproductive health policy (Reproductive Health Initiative, Eager, 2007 ), ‘men’s inclusion in reproductive health remains largely unfulfilled except on the rhetorical level’ ( Inhorn, 2013, p. 50 .).

It is now accepted that the biological, physical body develops in interaction with the social world. Thus, individuals are shaped by the cultures and historical contexts in which they live. The history of reproductive bodies and the medical ‘gaze’ illuminates this in fascinating ways ( White, 2009 ). For example, men’s bodies in earlier times were taken as the ‘norm’ and women’s bodies and reproductive organs were considered to be inferior or faulty versions of those of men’s (Martin, 1990 and White, 2009). Such views have been significantly revised in modern times in part as a result of feminist and other scholarship on women’s bodies and health (Bordo, 1989 and Martin, 1990). Today, developments in medical knowledge and technologies and procedures have expanded reproductive possibilities so that more people, in a wider range of relationship configurations, are able to contemplate parenthood ( Norton et al., 2013 ). These changes have occurred alongside shifts in new ways of thinking and talking about maternal and paternal identities associated with mothering and fathering responsibilities, caring practices and emotional involvement in a child’s life (Miller, 2005 and Miller, 2010). Alongside medical reproductive developments, new discourses have emerged, for example the ‘involved father’ and ‘caring masculinities’ which capture and indicate new societal expectations (if not actual practices) of how men should engage in anticipating, preparing for and doing fathering (Wall and Anrold, 2007 and Knijn and Selten, 2002). These discourses reflect developments in the study of men’s lives, including a much broader theoretical understanding of masculinity as multiple and fluid (Anderson, 2009, Connell, 2005, and Edley and Wetherell, 1999). However, these shifts also emanate from a complex historical backdrop in which assumptions about masculinity and femininity have been narrowly defined and experienced in unequal ways.

It is necessary then to be aware of the legacies of unequal gendered histories when examining contemporary reproductive realms and possibilities for changing practices. It is also important to note that ‘if men are conceived of as primarily responsible for others’ – a recognizable characteristic of masculinity – then their own reproductive health problems may be ‘ignored’ ( Inhorn, 2013, p. 51 ). For men, notions of masculinity, including what it is to be a father and a man, are especially complex in regard to (their) infertility. The few studies carried out in this area confirm that infertility is experienced as a threat to masculinity (Nachtigall et al, 1992, Throsby and Gill, 2004, and Webb and Daniluk, 1999). Conversely, becoming a father is regarded as a measure of successful and dominant masculinity ( Crawshaw, 2013 ). But what happens when men’s reproductive trajectories unfold in unforeseen ways and what social experiences and norms do they draw on to make sense of their experiences in this historically etched maternal domain?

Men, reproductive journeys and anticipated fatherhood: Fertility to infertility

As noted earlier, a recognizable and prized aspect of ‘successful’ masculinities across Western societies is the ability to father a child, to demonstrate fertility and virility – at an appropriate age and stage in a life course. However, unlike motherhood, fatherhood is not assumed to be a major identity for men as is the expectation for women when they become mothers (Becker, 2000, Gannon et al, 2004, and Miller, 2005) and there is continued debate about men’s involvement in this arena (Dolan and Coe, 2011 and McBride et al, 2005). However, while women will have been socialized from a young age in ways which assume maternal futures (and consequently may feel the need to justify any decisions not to reproduce), men are not subject to the same expectations and pressures. While most societies value fertility and parenthood, the implications of not being able to have a child are usually very different for men and women: and so social expectations and consequences of infertility can be profoundly different for men and women ( Dudgeon and Inhorn, 2004 ).

Worries about fertility or infertility often only begin to emerge when a planned-for conception does not happen. As each month passes, anxieties can mount. Most couples should be offered investigations after 1 year ( NICE, 2004 ). The availability of a wide range of fertility treatments (albeit at a cost for most in developed Western societies) has transformed infertility into an experience that potentially can be resolved. But the fertility journey for many will be littered with shattered hopes and agonising decisions ( Wischmann and Thorn, 2013 ). Infertility, in common with most reproductive health issues, remains conceptualized as a ‘women’s problem’. This is exacerbated by the nature of treatments for infertility which focus on the woman’s body. Most people with infertility go through treatment as a couple. In the vast majority of cases the partner will be a man, and in the UK, male factor is now a major cause for which IVF/intracytoplasmic sperm injection is attempted ( HFEA, 2011 ). Yet the medical interventions focus on the woman’s body (blood tests, scans, fertility drugs, egg retrieval and transfer) even if the diagnosis is male factor infertility.

Once couples embark on treatment for infertility, they are entering uncharted territory. Secrecy, isolation and stigma often shroud the months (or even years) of treatment (Cousineau and Domar, 2007, Miall, 1986, and Whiteford and Gonzalez, 1995). Men, in particular, can have a difficult role to play as the main focus of treatment is on their partners, leaving them with a supportive role for which there is often no role model in their social circle. The desire to be strong and stoical means that men can find it hard to have open discussions about their feelings ( Hudson and Culley, 2013 ;Malik and Coulson, 2010 and Miller, 2013b). Research on men’s involvement in preparation for parenthood and encounters with maternity services more generally have reported feelings of ‘detachment’, ‘uncertainty’ and ‘incompetency’ amongst men as they experience maternity services and hospital processes (Draper, 2002, Deeney et al, 2012, Locock and Alexander, 2006, Miller, 2010, and Miller, 2013a). However, there has been a discernible shift in a changing research agenda which increasingly considers men from the perspective of being ‘partners in reproduction’ (Dolan and Coe, 2011 and Lohan et al, 2011).

This paper examines the narratives of men’s experiences of infertility and of first-time fathers. It shows that, across three domains – men as reproductive actors, men as onlookers and men as supporters – there are parallels in the ways they make sense of their reproductive journeys. In examining these narratives, also examined is men’s role in the reproductive journeys they undertake with their partners and how services to support men and their partners are delivered. The findings from the two studies offer rich new insights into the experiences of individuals that will resonate for others and be helpful to individuals going through similar experiences.

Materials and methods

This work uses the results of two studies: (i) an infertility study, which included men still going through treatment or who had finished treatment; and (ii) a fatherhood study, which explored men’s experiences of first-time transition to fatherhood once pregnancies were established. Both studies are UK based using qualitative research methods. The methods used enabled rich accounts of individual experience to be collected, but from smaller samples than would be used in quantitative research. The aims here were to explore personal experiences in uncertain and unfolding contexts rather than to produce large-scale generalizable results.

Infertility study

In the infertility study, a qualitative design was used comprising narrative and semi-structured audio-recorded interviews with 38 people (including 11 men) conducted from 2007 to 2009. A maximum variation sample was sought of participants who were still going through treatment or had finished treatment ( Coyne, 1997 ). Variation was sought across causes, treatment received, successful and unsuccessful treatment, those living with and without children, geography and funding of care (NHS or private). With approval from the UK Anglia and Oxford multicentre ethics committee (1999, reference no. 99/5/17, with extension granted 2003, reference no. 03/5/016), participants were recruited through GP surgeries, specialist consultants, support groups, online newsletters and word of mouth. Interviews were conducted by LH in people’s own homes. Interviews were carried out individually, even if both partners were contributing to the study. The interviews had two parts – an unstructured narrative section in which participants were asked to tell their own story with as little interruption as possible to highlight aspects that were important to them. This was followed by a semi-structured section where questions were asked following a series of prompts to explore particular issues that had emerged from anticipated themes and literature review. The interview was audio recorded with informed consent.

The sample included men who were still receiving treatment (three), but the majority (eight) had completed treatment. Three had male factor infertility, three had fertility problems because of female factors, three due to both partners and two had unexplained infertility. Of those who had completed treatment, six had children or were expecting and two had adopted children. The age range was 34–64 years (but one man was interviewed 20 years after treatment was completed) and men were recruited from England and Scotland. They were white, employed, heterosexual and either married or living with their partners at the time of the interview. The men were employed in a range of skilled and semi-skilled jobs that would position the majority of them as middle class.

Participants in both studies met the inclusion criteria of either experiencing a period of infertility and treatment or having a wife/partner with whom they were anticipating the birth of their first child. Exclusion criteria included any men not currently experiencing either of these events and/or where English language skills were limited.

The interviews were transcribed verbatim for analysis. They were analysed thematically using the organizational support of NVIVO 7 software ( Richards and Richards, 1994 ), which was used to support a modified grounded theory approach using the ‘one sheet of paper’ (OSOP) method ( Ziebland and McPherson, 2006 ). A qualitative interpretative approach was taken combining thematic analysis with constant comparison so the data was explored for themes already known from the literature and emergent themes (Miles and Huberman, 1994 and Pope et al, 2000). In developing this article, both authors have reviewed each other’s data.

Fatherhood study

In the transition to first-time fatherhood study, a qualitative longitudinal design was used to collect interview data on men’s experiences of first-time transition to fatherhood once pregnancies were established. The sample consisted of 17 men who responded to study posters/leaflets and opted into the study (a requirement set by the University Research Ethics Committee, registration number 050114, approval granted 29 March 2005). They were interviewed across approximately 2 years in their lives in which they became fathers. The iterative research process involved interviewing the men on up to four separate occasions, followed by an end-of-study postal questionnaire used to collect data on their experiences of participating in the study. Data was collected in individual interviews carried out at 7–8 months antenatally, once the pregnancy was well established, and post-natally 6–12 weeks following the birth, then at 9–10 months and finally when their child was 2 years old. The majority of participant’s were interviewed in their homes in the evenings or at weekends, a minority chose to be interviewed either at their workplace or at Oxford Brookes University. The interviews included exploratory and open-ended prompt questions on areas around expectations, birth, fathering experiences, perceptions of self and identity, caring, work intentions and practices. In this article, data from the first antenatal interviews only are used.

The interview approach gave the men the opportunity to narrate their accounts of anticipating and later experiencing fathering in the ways they chose. The sample of 17 men who participated in this (longitudinal) study were all white, employed heterosexual and living in dual-earner households in the south of England. They were employed in a wide range of semi-skilled and skilled jobs that would position the majority of them as middle-class, The mean age of the participants was 33.7 years at the time of the first interview; ages ranged from 24 to 39 years. In the UK, average paternal age is on the increase and the mean age of fathers in England and Wales had increased to 32.1 years in 2003 ( Bray et al., 2006 ).

The interviews were recorded with the participants’ permission. At the end of the study, transcripts of the interviews were sent to those who wanted them as a token of thanks, rather than for data-checking purposes.

Data analysis

Analysis of the data was initially individual, thematic and temporal, involving examining how and when the men drew on different discourses to narrate their initial intentions and later experiences of the birth and early practices of caring. These individual stories were then compared and patterns identified across the whole data set (see Miller, 2010 for further details of data analysis).

All names used are pseudonyms.

Results

Following data analysis, common, dominant themes emerged in both studies even though the original focus had been on different stages of men’s reproductive/fathering journeys. These themes included men feeling at times marginal as onlookers, detached from or humiliated by procedures and services and unable to provide support to their wife/partner in ways they would normally anticipate doing. The time taken either to conceive, or come to terms with a diagnosis of infertility, is also invoked by the men as an indicator of their virility and so masculinity. Their experiences of reproductive practices and services were experienced as undermining and contrary to their masculine sense of self, which would normally be experienced as relatively autonomous, where emotions are under control and protection and provision for loved ones is an accepted dimension of their adult masculinity. These findings clearly have implications for service planning and delivery and will be discussed later. In the findings now reported, men’s accounts of their journeys from attempts at conception to, for some, first-time fatherhood and for others unresolved infertility are documented.

The results are divided into three inter-related themes. These follow the reproductive journey from diagnosis/confirmation of pregnancy through to birth or further tests or adoption and are as follows: (i) men as reproductive actors; (ii) men feeling marginal and as ‘onlookers’ in reproductive settings (e.g. hospitals, clinics); (iii) men unable to provide support to their wife/partner in ways they would normally anticipate doing.

Men as reproductive actors

The men in both studies have all been involved in attempts to conceive a baby. Where conception is eventually achieved, the news of impending fatherhood is met with a range of responses dependent, in part, on how long the process of trying to achieve conception has taken. Responses ranged from feeling ‘a sense of achievement’ (Mike) and having ‘kind of proved your virility’ (William) following ‘immediate’ conception, to a powerful sense of relief, happiness and continued concern, where the pregnancy has taken a long time to achieve:Well it was wonderful. I just felt sort of, well very happy because we had been trying for some time and kind of got the feeling that it was never going to happen (Chris, fatherhood study)Well it was quite exciting. I think we’d been trying to have a baby for just under 2 years … But also because we’d looked into it I think I was aware of all the statistics about the quite high chance of an early miscarriage and that sort of thing so otherwise very sort of pleased and excited that I didn’t want to count on it or tempt fate or whatever (Graham, fatherhood study)

Graham here alludes to what are widely held views that very early pregnancy is perceived as a ‘risky’ and uncertain period. In the fatherhood study and earlier companion study on transition to motherhood ( Miller, 2005 ), ideas of not ‘tempting fate’ or making public a pregnancy until after the first 12 weeks had passed was commonplace. But for those where conception does not occur and infertility treatment is embarked upon, other more complex issues can emerge. Regardless of the cause, men can experience infertility as a threat to their masculinity and their sense of self. While most infertility treatment is focused on their partner or wife, the requirement to produce spermatozoa in the clinic, on demand, was central in men’s accounts and described as ‘awkward’ and ‘humiliating’. However, the humiliation is often recounted in the context of recognizing that their partner is subject to many more tests. Brian, who was given a 3% chance of having children with his wife due to his low sperm count, made the following comparison:Why, why does Michelle have to go through all the pain of it all. It’s horrible (Brian, infertility study)

Martin also discovered that his sperm quality contributed to the couple’s fertility problems:So there clearly was a problem with me. So we came to terms with that and Naomi’s feelings. I think it took me a while just to be so relaxed about talking about it as I am these days. There is a perception, I use the word perception, a perception out there of how you think people will respond to you. You know, your peers, the lads down the pub, everyone that you know. So, are they going to look at you? Do you feel less of a man? How does that affect you and it took me a while just to get it into perspective (Martin, infertility study)

In this extract, Martin tentatively reveals his reactions to the confirmation that there was a ‘problem’ with him. He rehearses scenarios in which he imagines how others will respond to this news. His own ideas of masculinity and manhood are called into question alongside concerns about how others might perceive him as a consequence of his fertility problem. Clearly this is not an aspect of his self, or taken-for-granted masculinity, that he feels able to share with the ‘lads down the pub’. In contrast to the expectant fathers, where pregnancy served as evidence of their virility, men experiencing infertility felt challenged as they had to come to terms with this diagnosis and contemplate how to, and who to, share such information with.

Men feeling marginal and as ‘onlookers’

The data on men’s experiences of infertility highlighted just how sidelined they felt. The language they used included the words ‘overlooked’, ‘spare part’, ‘ignored’ and being treated as a ‘bystander’. This resonates with the findings in other research on men and reproduction, but may be heightened in the context of infertility ( Draper, 2002 ; Locock and Alexander, 2006 ). Martin, whose wife ultimately conceived twins with donor egg and donor spermatozoa said:Sometimes you feel like a bit of a bystander as well, because physically your partner’s going through everything. They’re the ones on the operating table having eggs collected, and embryos put back in, having the drug protocols, they are the focus of all the treatment. And sometimes you are almost like a spectator and you feel a bit outside of it (Martin, infertility study)

Martin’s feelings of being marginal to the process were exacerbated when the couple decided to try donor sperm treatment in Spain:When you start donor, I needn’t even have gone. I didn’t even need to go to Spain I wasn’t even needed for that bit. So there is a risk that you feel totally irrelevant (Martin, infertility study)

Even though men are not the focus of most processes associated with reproduction, for example scanning and monitoring, when conception fails to occur, naturally their marginality can feel heightened as various infertility treatments are embarked upon. Tim, whose wife was still in treatment, described how he found it hard watching his wife’s egg collection:So it is quite distressing to see someone in the pain, but nothing you can do about it, because you know it is only going to carry on until they have got all the eggs out, or as many as they can, so … (Tim, infertility survey)

Men reporting feelings of being ‘marginal’ or ‘detached’ from the processes and events associated with reproduction were also found in the fatherhood study once the pregnancy was achieved. As Stephen explains in the following extract:There was a point sort of halfway through sort of the second trimester where I felt that I wasn’t involved at all, it was a very personal thing to Claire and that was quite horrible. Trying to find ways to get in and share it and things like that (Stephen, fatherhood study)

Trying to ‘find ways in’ was an action shared by several of the men in the fatherhood study as they sought to demonstrate their intended involvement in fatherhood to their wife/partner. But although societal expectations increasingly emphasize ‘involved fatherhood’, the men found the antenatal period a daunting and unfamiliar territory, similar to the feelings of detachment experienced by some of the men in the infertility study. Reproductive medicine and maternity services have, inevitably, a primary focus on the woman’s body. This can lead men to feeling a sense of responsibility, but also of not belonging, and so unease. In the fatherhood study, this was especially the case at the time of the birth, as demonstrated in the following section.

Men as supporters and stoics

Across both studies, the men often described their primary role as being a supporter to their partner, which was also connected to feeling a sense of responsibility. In the infertility study, this included helping with injections and attending as many appointments as possible. But their role was described in ways which convey their sense of feeling marginal and primarily passive, for example providing hand-holding support, which a lot of men found difficult. In the fatherhood study, being supportive was a theme running through the antenatal period, but it was at the birth that providing support was most actively envisaged.

In the infertility study, Simon described how his wife made major changes to her lifestyle but there was little he felt he could contribute.I felt to a certain degree helpless … The only thing I could do was to be there to support, and I can’t remember whether I did that, you know, physically with flowers and things like that as well as whatever, but I hope I gave her enough support in that period. It was tough, very tough (Simon, infertility study)

Tim also reflected on the delicate balancing act he felt he needed to perform:So there is a balancing act somewhere. You don’t want someone who is a cold fish and you don’t want someone who is as emotional as you are under the hormone treatment (Tim, infertility study)

Other men, as the following extracts show, talked of their role in providing support:It is difficult because again as a man, there isn’t much you can do apart from be there and offer as much support as you can. Be there (Oliver – IS)It is support really. That’s all you can do. And I’m sure everyone says that because there isn’t a lot else you can do. … It’s not like I can go, I want to do IVF so I’ll carry the child (James, infertility study)

Some men described wanting to be able to fix and so resolve the situation, taking a lead in researching options for treatment. These men presented their approach as stoical, pragmatic and solution-orientated even in the face of disappointment:I am very stoical the ways I think, I look at things anyway, so it’s a fact that being an engineers as well it’s like oh something is broken we can get it fixed and that is what the medical world is there for (Tim, infertility study)Straight away I’m thinking ok so what options are open to us, being practical (Brian, infertility study)

But stoicism comes at a price. This stoical role, with a focus on supporting their partners, may also have provided some men with a distraction from reflecting on their own emotional needs ( Malik and Coulson, 2008 ). For the men in the infertility study, watching their partners go through invasive treatments, such as egg retrieval involving being sedated and incoherent, was often experienced as distressing. Similarly supporting their partners through procedures of egg collection, with the associated anxieties about number and quality of eggs retrieved, was experienced as personally stressful, but in a context where stoic support for their partner remained an overriding concern. In the following extracts, Martin describes struggling to manage his own disappointment and knowing that he will have to manage his wife’s as well, while George reveals his sense of isolation as his wife undergoes embryo transfer:When the cycle fails I can almost deal with the failure easier than I can with what’s coming. The upset that I know how she’s hurting and she’s feeling. That absolutely horrible place to me. And I just want to put it right (Martin, infertility study)It is very, very anxious. As a man there’s nobody to talk to, you know, absolutely nobody (George, infertility study)

Across both the studies, many of the men express their sense of shock at seeing partners in a medical context for the first time either as part of infertility treatments or at the (hospital) birth. But clearly there are few outlets for men to articulate their own anxieties about, or in, these formal medical settings. Their role as bystander, stoic supporter and witness is demanding and emotionally draining (and ultimately rewarding in the fatherhood study), and there is shared sense of not always having performed their role well. For men involved in infertility investigations and treatment, this can be a protracted period of medical engagement in which emotions shift as hopes and treatment cycles come and go and grief at not being able to conceive a longed-for child may be experienced.

Trying to fulfil a caring, strong yet unaffected supportive role can be a source of great distress for men and ‘contrasts strongly with traditional gender roles, where men experience social pressure to display behaviour that shows they are strong, tough and in control’ ( Malik and Coulson, 2008 , p. 28) In the fatherhood study, men too could be seen to be subject to social pressure resulting from expectations of their role at the birth. These expectations emerged during the antenatal interviews as men anticipated taking on an interpreter role – usually linked to managing the birth plan – during the birth. Graham thinks ahead to his role at the birth in the following extract:We have talked about my role and it was a key part of the class and reassuring and if necessary being a bit of an interpreter and standing up for Rebecca to the professionals on her behalf and that sort of thing. I imagine it’s going to be a pretty stressful experience because obviously she will go through a lot of pain and worry and I sort of have to go through it (laughs) precariously with her (Graham, fatherhood study)

But when labour commences and births unfold, most of the men found that their anticipated role as active birth partner, who would manage the birth plan, had to be discarded. They were left feeling helpless, passive onlookers, while painful and sometimes ‘brutal’ births were witnessed, as the following extracts convey.I just found it really hard to just see Claire go through all this pain and know it wasn’t going to stop (Stephen, fatherhood study)It was horrible, knowing that there’s nothing … you normally, if she’s in pain, I would comfort her, stroke her hair, hold her, but she didn’t obviously want me to touch her … (Gus, fatherhood study)But Polly did decide to have the [pain relief] because it was more painful than she expected and I couldn’t really, you know, I sort of felt that kind of time, was the kind of time that I could have made a difference, but I went along with it … eventually [it was a] forceps delivery (Joe, fatherhood study)

Maintaining an appropriate – strong and protective – role at the birth and keeping to the birth plan is a concern for many of the men in the fatherhood study. However, the men’s experiences of attending the birth of their child leaves many feeling that they have failed in some way as they are unable to protect their partner from pain and as birth plans are jettisoned. As Richard observes:The other thing the preparation classes don’t say … they don’t say you will be standing there and you’ll feel really useless (Richard, fatherhood study)

Across the two studies, men voice their often-difficult experiences of feeling marginal and side-lined as their wives/partners undergo reproductive processes and procedures. It is apparent that the men are caught up in changing societal expectations about men as reproductive actors who are expected to prepare for and be involved in reproduction/fatherhood in ways not expected of earlier generations. However, other aspects of masculinities remain more enduring, for example their desire to protect and support their partner and remain in control of their emotions in these spheres historically etched as maternal. This can mean that men experience feelings of powerlessness and anxiety, but in circumstances where there are fewer opportunities – both personally and in current service provision – for such experiences to be (acceptably) openly expressed. The implications of these findings for service provision are explored further below.

Discussion

Societal changes have, in recent years, shifted expectations in relation to men’s emotional involvement in family and fathering practices (Dermott, 2008, Featherstone, 2009, Henwood and Procter, 2003, Hobson, 2002, Marsiglio and Pleck, 2005, and O’Brien et al, 2007). More sensitive understandings of gender and masculinities are one aspect of these changes, which have also reframed reproductive health ‘as a basic human right’ (Dudgeon and Inhorn, 2004 and Hadley and Hanley, 2011). In Western societies, men are now more visible figures in what were once almost exclusively maternal spheres. From antenatal preparations, presence at birth, to hands on caring afterwards, the emotionally involved father is a recognizable figure in modern ideas of parenthood.

But research findings, including those presented in this paper, confirm that men’s involvement and sense of partnership in reproductive spheres has so far only been partially accomplished ( Chin et al., 2011 ; Deeney et al., 2012 ; Dolan and Coe, 2011 ; Draper, 2002 ; Locock and Alexander, 2006 ; Lohan, 2007 ; Miller, 2013b ). The rhetoric of involvement does not match men’s actual experiences. This mismatch is further complicated by men’s reluctance to disclose experiences they regard as evidence of deficiency or weakness and contrary to mainstream ideals of ‘normal’ masculinity (e.g. investigations for infertility or feeling out of control while ‘witnessing’ childbirth) to others, including friends and service providers. In many ways, their reluctance underscores the complexity of seeking to reconfigure reproductive domains and meet changing needs in arenas which have historically largely excluded men, and so service provision has not been designed in such a way that men’s emotional needs are addressed, supported or retrospectively explored (e.g. debriefing after treatment). These findings give rise then to questions about how well men are prepared for their reproductive journeys and the ways in which service provision could help to reduce the gap between the rhetoric and men’s personal experiences of reproductive involvement. In what ways should men’s involvement and service planning and provision seek to promote gender inclusivity and/or acknowledge gender difference?

Across the two studies whose findings are reported here, the men shared a range of emotions including being ‘onlookers’ (rather than feeling involved), feeling distressed by being unable to comfort or relieve the pain their partners experienced and being left feeling helpless – rather than stoical – by aspects of the processes either they or their partner underwent. These findings are supported by a growing body of research on men’s childbirth experiences, which confirm a similar dissonance between ideals of involvement and partnership – and even ‘rights’ – and less fulfilling individual experiences (Chin et al, 2011, Deeney et al, 2012, Draper, 2002, Dudgeon and Inhorn, 2004, and White, 2007). Men’s experiences of infertility can be even more complex because, alongside the challenges infertility poses to men’s notions of masculinity, being able to demonstrate a commitment to fatherhood is also challenged. For example, finding an appropriate role to play as infertility investigations and treatment with their partners is undertaken. It has been argued that whereas women are able to demonstrate their commitment to conception through treatment, for men it is not so straightforward ( Becker, 2000 ) and men can feel that they carry the burden of proving a commitment to treatment, as well as being side-lined or marginalized in consultations (Carmeli and Birnbaum-Carmeli, 1994 and Meerabeau, 1991). While this imbalance is beginning to be redressed, the need for further research in this area is apparent ( Culley et al., 2013 ;Hadley and Hanley, 2011, Malik and Coulson, 2008, and Throsby and Gill, 2004).

It is timely then to urge (re)consideration of how men are envisaged and treated as reproductive and paternal actors in current service provision. Spaces in which men can feel comfortable and able to share concerns and fears about impending fatherhood or the threat of not being able to have children ( Malik and Coulson, 2008 ) – all new topics and emotions for most men as they embark on reproductive journeys – are currently largely missing from most reproductive services which are focused primarily on women. How far men are, or should be, considered beyond a largely supportive role during fertility treatment, antenatal preparation and post-natal care has become a matter of debate. However, the findings reported in this paper lead us to propose a more thoughtful inclusion of men into reproductive realms, which simultaneously acknowledges the gendered differences which have historically patterned men’s and women’s lives and which in some areas continue to do so. Taking account of these circumstances, how could opportunities be created for men to share any fears and concerns with service providers and/or other men in settings which permit them to express emotional needs and vulnerabilities without fear of sanction?

Most fundamentally, what does the organization of current service provision signal about societal assumptions in relation to men, masculinities and fatherhood? While some research has identified some reluctance on the part of service providers and/or women to fully engage men as involved reproductive actors ( Deeney et al., 2012 ; Dolan and Coe, 2011 ), other research has flagged a growing association between men and mental health problems such as post-natal depression, which suggest significant needs may be going undetected and/or unmet (Dave et al, 2010 and White, 2007). The findings from the accumulating body of in-depth, qualitative research which has prioritized men’s descriptions of their experiences suggest that, notwithstanding the complex factors which have patterned assumptions and practices in reproduction, it is time for reappraisal and a more nuanced response to men as reproductive actors.

Acknowledgements

With thanks to the men who participated in these studies and generously shared their experiences and the referees for their comments on an earlier version of this paper.

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Footnotes

a Health Experiences Research Group, Department of Primary Health Care Sciences, University of Oxford, Oxford OX1 2ET, UK

b Faculty of Humanities and Social Sciences, Oxford Brookes University, Oxford OX3 0BP, UK

lowast Corresponding author.

fx1 Dr Lisa Hinton is a senior qualitative researcher with the Health Experiences Research Group, in the Department of Primary Health Care Sciences at Oxford University. She has a special interest in eHealth and women’s health and is responsible for two online modules, on infertility and on life-threatening conditions in childbirth ( www.healthtalkonline.org ). Lisa has also spent time as a health specialist with the Health Select Committee at the House of Commons and as a visiting researcher at the King’s Fund.