Why There's No Guy-necology (with Rene Almeling)

Introduction – 00:00

BLAIR HODGES: This is Relationscapes, the podcast where we explore the terrain of gender, sexuality, race, and more. I'm journalist Blair Hodges in Salt Lake City, and our guide in this episode about men's reproductive health is Yale University sociologist Rene Almeling.

RENE ALMELING: You know, you have a group of physicians in New York City who say, well, we have gynecology for women. We need a parallel specialty for men, and we're going to call it andrology for male reproductive health—male reproductive organs. And what happens is they get laughed out of the pages of medical journals.

They are ridiculed at medical conferences for the idea that you would specialize in the reproductive organs of half the population.

BLAIR HODGES: For over a century, medical scientists have invested enormous efforts to understand women's reproductive health. They have a whole field for it: gynecology. But when it comes to men's reproductive health, many of the most basic questions have barely been asked. What counts as healthy sperm? Do men have a biological clock? How do men's bodies impact child health?

These knowledge gaps have real-life impacts. When couples struggle with infertility, people tend to look to women first. And when a baby is born, mothers are more likely to be praised or blamed for how things turn out. But is any of this actually fair? Sociologist Rene Almeling says no. She traces how gender stereotypes have warped our understanding of men's reproductive health—and how that's starting to change.

Her book is called Guynecology: The Missing Science of Men's Reproductive Health, and she joins us to talk about it right now.

If Men Experienced the Messaging Women Experience Around Pregnancy – 02:03

BLAIR HODGES: Rene Almeling, welcome to Relationscapes.

RENE ALMELING: Thanks so much for the invitation to be here.

BLAIR HODGES: So when it comes to making babies, you say that men have been going about our lives without really being bombarded with endless advice about our sperm. That's not the case for women, though. So take us to an imaginary world where men who might be interested in procreating experience the world like women do today.

What would they wake up to? What would the world be like if they had the same kind of messaging that women get about making babies?

RENE ALMELING: Right. Well, as probably almost any of your listeners will attest, there are just sort of endless public health messages to women about their reproductive health, particularly if they're thinking about having children.

There are billboards, advertisements in magazines. Doctors will bring up with women the importance of what they eat and drink, avoiding smoking, and avoiding toxins. And this does not happen at all for men, even though we are starting to gather quite a good bit of data that the health of men's bodies prior to conception can affect the health of their sperm—and potentially the health of their children.

But men are not seeing billboards. They are not being given lists of do's and don'ts by their doctors. They're not hearing about it from friends. So there's definitely a really intriguing gender difference when it comes to reproductive health information.

BLAIR HODGES: And your book is really helpful in helping us understand how we got to where we're at today. I mean, there's an entire medical specialty dedicated to women's reproductive health—that's gynecology—and there's no similar field for men's.

We'll start to unpack how that happened. But before we get to that, let's talk for a second about sex and gender—sex slash gender. You say that tiny slash between sex and gender is a useful distinction, but it can also bring up some misunderstandings.

The basic idea is sex is related to biological aspects of people's bodies, and gender is more about identity and how people live in the world. But you complicate that a little bit to remind us that even science itself packs in some assumptions—some gender assumptions sneak through the back door of what sex is.

RENE ALMELING: Yes, absolutely. I think the go-to thinker in this area for me is Rebecca Jordan Young, who is a scholar at Columbia University in New York. And she's got this concept of “assumption containers.”

She's like, we sort of put a whole bunch of things in the same container. We assume that somebody who has a penis makes sperm, has a male gender identity—da da da, da da. And once you actually start to disaggregate different kinds of body parts from different gender identities, biomedical research has quite a long way to go in terms of being precise about what they're studying.

So just as one example, somebody who might identify as a man may or may not produce sperm, and may or may not have the kind of genetic characteristics you would expect to go with somebody who produces sperm.

I think there's an important effort underway to be more precise about, you know, we're studying sperm—and we have actually done the genetic testing or we've asked people about their gender identity—rather than just assuming all of these things line up in the way we've historically assumed they do.

BLAIR HODGES: And there are still a lot of people who resist this idea. And I assume that's why we hear that police siren behind you—because they are coming for you. [laughs]

RENE ALMELING: That’s because my office is in downtown New Haven! [laughter]

BLAIR HODGES: Oh, okay. Good! I'm glad they're not coming to get us—the gender police.

The metaphor that you use is like a nesting doll. So if we think about a nesting doll—these Russian matryoshkas—you’ve got a doll inside a doll inside a doll. And you say, okay, so the inner doll is like our bodily processes, the actual mechanics of bodies—so sperm and eggs and testicles and ovaries and this kind of stuff.

And then the next would be individual identities and experiences—so how we experience what it's like to be in our bodies. But that's impacted by another doll around us, which is historical and cultural stuff—stuff we learn when we're kids, stuff we learn in movies and TV, and just the assumptions floating around in the culture.

And so we'll try to keep all those things in mind as we go, because this book doesn't take a binary approach. It's going to talk about male reproductive health, but you're also mindful that sex and gender are more complicated than that. So I think it's helpful to begin that way.

RENE ALMELING: Yeah, I really appreciate you bringing in that nesting dolls metaphor, because I think it does help people disaggregate the things that normally get mushed together.

And, as I write in the book, pretty much anytime I say male reproductive bodies or men's health, I want readers to imagine this preamble of bodies historically identified as male, or bodies historically categorized as female.

And so that's just a little way toward what you're talking about, which is trying to keep in mind that these are not settled, obvious categories.

The First Push for a Specialty Focused on Men Fails – 06:59

BLAIR HODGES: All right, great. So let's talk about the book's title, Guynecology. It's a great play on words—G-U-Y, the word “guy” is in there. I think a research assistant suggested it at some point. And it reminds us in the book that there's no cohesive medical specialty for men's reproductive health, as we said.

And they almost did, though. You take us back in time to the late 1800s, and there were physicians in the U.S. who tried to get a field like that going. What happened?

RENE ALMELING: Yeah, so this was one of the big surprises in doing this research. So take ourselves back to the end of the 19th century. The medical profession had recently become a profession. The American Medical Association was founded right around 1850, and very quickly physicians said, you know, there's just so much knowledge—we can't keep up. We need to specialize.

And so one of the earliest specialties—two of them, actually—were obstetrics and gynecology. They later merge in the 1920s. But from very early on, we kind of hive off female reproductive health and make it a separate realm of medical knowledge.

And so a couple decades after that point, you have a group of physicians in New York City who say, well, we have gynecology for women. We need a parallel specialty for men, and we're going to call it andrology. So they're drawing on the Greek roots here to really express that parallelism, even in the term itself.

BLAIR HODGES: Right, "andro."

RENE ALMELING: Andro, right. So there's an effort to launch a specialty for male reproductive health—male reproductive organs—called andrology. And what happens is they get laughed out of the pages of medical journals. They are ridiculed at medical conferences for the idea that you would specialize in the reproductive organs of half the population.

And the reasoning behind that is because they were basically specializing in venereal disease, to use the language of the day. So there were epidemics of gonorrhea and syphilis. We didn't have good treatments for them at that point, and they were incredibly stigmatized because it's sexuality happening outside the bounds of marriage.

And so these very elite physicians—professors of medicine in New York City—are like, oh no, no, no. We will back up, and now we will become specialists in the genitourinary system.

BLAIR HODGES: Yes—urology kind of became the thing, and that's still around today. I had a vasectomy—a urologist, that's who did it for me.

RENE ALMELING: Exactly. So these guys became genitourinary specialists around 1905. They cut out the “genito” and said even that's too stigmatized, and they became urologists—which we do still have today.

BLAIR HODGES: And one of the reasons this is really bonkers is because, as we discuss in other episodes, medical science is often over-focused on the male body. And you talk about this as well—that the male body has been viewed by science and medicine as the standard.

And the female body is sort of like a man's body with this other stuff—kind of like a lesser version of a body that's the female. So we would assume that, with that in mind, they would focus a ton on male reproductive health and have that going already—but they didn't.

RENE ALMELING: Yeah, and that really is the kind of orienting puzzle of the research for this book. If you have a male standard body for most of the 20th century—most medical research is being done on male bodies and assumed to generalize to everybody else—then why did they basically ignore the reproductive system?

And so that's where I think we get, sitting next to that male standard body, a female body that has primarily been understood in terms of its reproductive capacity—and primarily studied in terms of its reproductive capacity.

And so that's where you get this missing knowledge—the gap in knowledge is male reproductive health. Putting those two things together.

And I think it's not an accident that some of the first people who started doing research on how male bodily health affects sperm, in the 60s and 70s, were women researchers. Some of those early pioneers who got college degrees after World War II, stayed in the educational system—some of the first women PhDs.

And they were the ones who started asking questions about why we are only studying women's bodies when it comes to reproductive outcomes.

The Second Push for Andrology in the 60s – 11:12

BLAIR HODGES: Right. There was this time when andrology sort of went away, like we said. Urology kind of replaced it—it went away. It would take 80 years, you say, for another push to happen, for doctors to say, you know what, there should be an andrology.

This is the 1960s, and it would take the discovery of things like estrogen and testosterone and labeling them as sex hormones, and then thinking about chromosomes X and Y and labeling those as male and female. So there were these scientific advances that happened. What was the second push for andrology like then, in the 60s?

RENE ALMELING: Yeah, well—and I think before I answer that, next to those scientific advances around health and medicine and genetics were also gigantic cultural and social shifts. So in the 60s and 70s, we've also got social movements for women's rights and patients’ rights and men's rights.

So we really do start to think about the relationship between bodies and societies in a different way that makes it even possible to think of one of these male specialties.

So in the 1960s, you get another group of physicians and scientists who say, we're going to create something called andrology. They did not know they were not the first to think of this.

BLAIR HODGES: They didn't have Google to look it up.

RENE ALMELING: And so they created a specialty area both for basic scientists—biologists who study sperm—but also endocrinologists, some of the physicians who do end up focusing on fertility or male reproductive organs in other ways.

And so there's a new journal called Andrology that gets launched. There's the International Society for Andrology. And so starting in the 60s and 70s, you do get this kind of—I don't want to say embryonic—but you get a tiny specialty for male reproductive health.

But they're still small to this day. They're mostly people who focus on the biological technicalities of sperm. So you find them in the U.S. in fertility clinics. In other countries, andrologists are a little bit better known—they do things around erectile dysfunction or other sexual health issues. But in the U.S., there's still less than 800 andrologists.

BLAIR HODGES: Your book is really helpful at getting us to think about how medicine advances and what it actually takes. You point out that this is when journals could be published, conferences could be held, societies are founded, grant money is given, schools are developed, mentors are produced—in order to build a field of knowledge about men's reproductive health.

That's all the stuff they would need. And that had already been happening for gynecology for all those decades, and now they're trying to get that off the ground in the 60s.

So we go from the late 1800s to the 1960s and then even up to the present, and we still don't see a unified medical specialty on men's reproductive health. I think your book does a really great service in showing the cultural factors that drove us here—race and class.

RENE ALMELING: Well, and I think the primary driver of the lack of attention to male reproductive health relative to female reproductive health really is gender. I mean, certainly gender is always intersecting with social processes around race and class and sexuality, but the primary driver was really gender.

There was no place in the medical ecosystem or the scientific ecosystem that you could plug andrology into.

And so, yeah, if you have—for OB-GYN—they had all of that. They had the journals, they had the annual conferences. People would go, they would meet each other, they had funding streams.

And to this day—I was just at a conference a couple of weeks ago—people were still having a conversation about where and how you plug male reproductive health into medical training, into scientific training. There's still no organized specialty that focuses on it.

There's much less in terms of funding streams to support people doing research on sperm and health. So I think it remains a problem to this day that there's not that kind of medical infrastructure.

And just to spin that out even a little more, it's not really obvious how you go about that. One of the big debates that happens both in the conclusion to my book—and then I've done some work since with physicians—is it's not clear to me that we do need a specialty for male reproductive health.

I think that's where some readers will see a call for more attention and think, oh, you need a specialty. But I think actually, if you had a specialty for male reproductive health next to the specialty for female reproductive health, it just reifies the idea that human bodies come in two flavors—and kind of underscores and reinforces that gender binary in a way that is not necessarily helpful.

So that's probably getting a little ahead of where your questions are, but I would just spin that medical specialization story out a little bit.

BLAIR HODGES: I think it's useful to point out.

That's Rene Almeling, a professor of sociology at Yale University, and we're talking about her book, Guynecology: The Missing Science of Men's Reproductive Health.

What's Up with Sperm – 16:15

BLAIR HODGES: Okay, so as you said, maybe there doesn't need to be a set field per se, but knowledge has been created all along anyway in different places about men's reproductive health.

They were, as you said, looking into things like sexually transmitted diseases, contraception, sexual health, infertility, and these types of things. So let's talk about how the understanding of sperm shifted over these years.

People were studying sperm. It's not like nobody was looking at it at all. What was the thinking about sperm, and how did that change over the course of the failures of the field of andrology to develop?

RENE ALMELING: I think the first thing to say about this is, when we're thinking about reproductive health and how we think about the bodily health of individuals who may or may not be getting ready to conceive, those questions have historically been asked almost exclusively about women and people who were assigned female at birth.

There are innumerable biomedical research agendas—lots and lots of studies about reproductive outcomes—that don't include men or people who are assigned male at all. And so I think that as we start to see an increase in research on sperm and male reproduction in the 60s and 70s, where it really ticks up is in the early 2000s.

I don't do a deep dive into the causal story behind some of that in the book, but I do think the rise of research on genetics and then epigenetics makes possible new questions about sperm and how sperm might matter.

BLAIR HODGES: Okay, so that makes sense why it took that long. As you said, the early studies would look at sperm fertility. So they were looking at sperm counts, sperm motility—is it swimming along, how good is it? What does the shape look like? Is it going to be able to get to the egg and enter the egg?

That's what they were looking at. And then later, in the 2000s, they start actually thinking about the genetic material. And this is where newer science is showing that men's health impacts a baby's health—apart from whether the sperm can swim fast or make it—it's also the genetic material.

RENE ALMELING: Exactly right. And I think that to this day, when people hear sperm and they think health, they are still thinking in terms of those characteristics—sperm count, motility, morphology. Those have been the way we've characterized sperm since the early 20th century.

BLAIR HODGES: Before I read your book, that's where I was—for real. Yeah.

RENE ALMELING: And so even to this day, public health information about sperm most often names its effects on sperm count—on how many there are, or can they swim. And so there is an enormous effort needed to shift people's thinking—not only about the external characteristics of sperm, but also how a man's own health, his age, his exposures to toxins, are affecting all the cells in his body, including his sperm cells.

And that can affect the genetic material inside sperm in ways that are still being studied. But for example, there's pretty good evidence that increasing paternal age has been associated with an increased risk for miscarriage, birth defects, and childhood illnesses.

And that is still news to most people, even though that research has been building, I would say, over the last 10 or 15 years.

Sperm Health Factors – 19:39

BLAIR HODGES: Yeah, well, it's funny because we think, oh, men can reproduce into their old age. Women kind of have this cutoff around 40 or a little bit thereafter, where we're like, okay. We even think it's not safe for a woman to get pregnant at that point.

But a guy can reproduce, et cetera. We're not thinking about the genetic components of the sperm because sperm gets replenished regularly for a lot of people. But it can contain healthier or unhealthier code, depending on a person's age and other factors you mentioned.

But let's dig into them a little bit more—talk about the main factors that impact male sperm health: age, behaviors, and environmental exposures.

RENE ALMELING: Right. And I think the research here is probably strongest when it comes to age and paternal smoking. So the American Association of Epidemiologists has been saying since 2010 that if men are thinking about contributing to the conception of a child, they should stop smoking.

Heavy smokers have what's called germline mutations in their sperm, where they're actually potentially affecting the cancer risk for their children.

So those are the two areas where we have a lot of good data. The data on paternal alcohol use, paternal drug use, and different environmental exposures is just much less conclusive.

BLAIR HODGES: Because we haven't looked at it! [laughs] Isn't this weird?!

RENE ALMELING: Right? Exactly!

BLAIR HODGES: But say what we do know.

RENE ALMELING: I mean, the environmental exposures research is always difficult to do because we're constantly being exposed to all kinds of toxins.

BLAIR HODGES: And there are so many variables, how are you going to account for, like

RENE ALMELING: Exactly.

BLAIR HODGES: Unless it's way obvious—maybe you live next to some sort of nuclear plant and there was a leak or something—but it could be anything in our food. It could be all kinds of things. It could be different types of work that men are doing.

You point to a lot of different things that make it hard to pin down, right?

RENE ALMELING: Exactly. Well, and I think this is where we could really bring in the issue of racialized inequalities and class-based inequalities. We have a lot of good data from the environmental justice movement about the kind of relative poisoning of people that is happening due to toxic exposures—water—

BLAIR HODGES: —and air pollution. Lower-class and usually Black, Indigenous, and people of color neighborhoods tend to be exposed more. So yeah, they can trace it there.

RENE ALMELING: Right. And I think the important thing to do here is also to say there is probably an increased risk in terms of men's own bodily health—their exposures, their behaviors—but there is still a lot of work to be done on quantifying exactly how big that risk is.

And so some of the clinicians and scientists that I'm in conversation with will say, well, we don't really want to worry men. We don't want to scare men—which I think is something we never say when it comes to women.

BLAIR HODGES: Yeah. Oh my goodness.

RENE ALMELING: But yeah, that would give us an opening to say that when it comes to reproductive health information for the general public, we can do much better than we've done with public health messaging around women's reproductive health.

I don't want to just take the blame and the anxiety and the kind of stigmatizing people for their health outcomes and just spread that around to everybody else. I think the newness of male reproductive health gives us an opportunity to think about how to do a much better job when we consider people's health outcomes and what causes those.

And it's not just happening at the level of individual bodies and individual behaviors.

BLAIR HODGES: Yeah. Your book is so helpful on this because not only is it showing us how medical knowledge is produced, but also how it's sent out to the public.

Lots of new knowledge is being produced, but researchers and health officials aren't always sure how to send it out. There's newspaper reporting, there are popular books, there are government agencies—but they've usually, again, focused on what women need to be doing.

Here in my home state of Utah, we have this “baby your baby” thing where it's geared toward moms—about prenatal vitamins and diet and exercise and all kinds of things. But men could pay a lot more attention to this.

Researchers are starting to see that, for example, men can exercise or do certain things months ahead of when they help conceive a child that can impact their sperm. There are behavioral changes men can make in diet and exercise and different areas that can impact the health of their sperm.

And we're not getting the word out there as much. It's almost like we think women are the ones responsible for babies and men aren't—or something. That's unusual.

RENE ALMELING: Yes, exactly. I think certainly we've got that going on in the background of this. And I would say, too, when it comes to diet and exercise, there is not super strong evidence that men's behaviors in those areas affect their sperm as much as their age, their cigarette smoking, and their toxic exposure.

So I do think if people are listening and thinking, okay, what individually could I do if I'm thinking about this—those are the things I would concentrate on.

BLAIR HODGES: Oh, that takes the air out of my—I was going to do a vitamin ad after this. I was going to say I'll just cut that out.

RENE ALMELING: What is happening is that there are plenty of companies trying to figure out how to make some money on all of this.

BLAIR HODGES: Okay, cool. Thanks for that clarification.

That's Rene Almeling, and we're talking about her book Guynecology: The Missing Science of Men's Reproductive Health. She's a professor of sociology at Yale University.

How Men Reacted to Updated Information – 25:16

BLAIR HODGES: All right, so in the last part of your book—this gets really interesting—you survey a bunch of people about reproductive health.

You wanted to see how people describe their own role in reproduction, especially men and people who identify as men. So first you asked a lot of open-ended questions, like: what's a man's role in reproduction? What were the kinds of answers you got from such a broad question?

RENE ALMELING: Yeah, well—and again—just like scientists and clinicians don't talk about male reproductive health, we social scientists do a whole lot of research on reproduction, and we've mostly interviewed women.

So this is one of the first interview studies with men from the general population about how they think about reproduction—which kind of blows my mind.

BLAIR HODGES: Doesn't that scare you—that you're like, oh no, if it's me doing it for the first time? Oh no.

RENE ALMELING: Right, exactly. And so we do have interview studies with men who are getting fertility treatments, or I have interviewed men who are donating sperm in sperm banks. So we had men in these sites of reproductive significance, but just not your average, everyday guy and how he thinks about this stuff.

So I'm interviewing men, and I ask them this question: if you had to describe a man's role in reproduction, how would you describe that?

And I had no idea what they were going to say. There were no hypotheses from the previous literature. And they end up pausing and stumbling around a little bit, but the pauses are also indicating we don't have a cultural script for this.

We don't have a way that we say men are involved. So they stumble around a bit, and then they come to this three-part answer: men’s role in reproduction includes having sex, providing the sperm, and then being dads.

More generally, providing for the family—providing financially, emotionally, et cetera. So there was, interestingly, a lot of similarity in the answers that I got, even though it's not necessarily something people had ready to say.

BLAIR HODGES: And you would dig a little deeper with them. You'd specifically ask them next how they describe the relationship between the sperm and the egg.

And some of these answers were so funny and interesting. What stood out to me was how ideas about gender roles would get wrapped up in how they described how sperm and egg interact.

RENE ALMELING: Yeah. So here I did have at least a hypothesis about what people were going to say, because there is a very famous article by an anthropologist named Emily Martin, who about 30 years ago went into a biology lab and found that biologists were telling a story about eggs and sperm in which the sperm was competitive—racing, trying to get to the egg—which was passively lying there.

And so she wrote this very famous article about how our ideas about masculinity and femininity had influenced the way biologists were talking about eggs and sperm, and the way medical textbooks represented them.

That’s the story that I heard in high school—this agentic sperm and passive egg. And I did, from almost everybody I interviewed, hear that story.

But about half the people also told a second egg-and-sperm story, which was so fascinating to me—there's another metaphor out there. And that one was a much more egalitarian metaphor, where people talked about eggs and sperm coming together. They were two halves of a whole. Neither one was the leading agent making it happen.

And I think that second metaphor is more rooted in a genetic understanding of fertilization as being 50/50. So that's evidence that we do have changing metaphors about human fertilization—which have nothing to do with eggs and sperm themselves.

This is just about how we talk about them and how our ideas about gender change, and then we talk about eggs and sperm in different ways.

BLAIR HODGES: I don't remember who it was, but there was a feminist scholar decades ago who started to break down the idea of what sperm was doing.

She was like, okay, we have this idea that sperm is the conquest—it goes in and penetrates the egg, very much like a penis penetrating a vagina. But she was saying, no—the egg takes in the sperm. The egg is kind of the one doing the work, taking it in.

And even that small shift in how you describe something simple—like this going into this—can make a big difference in how you think of men and women.

RENE ALMELING: Yeah. And I think you're probably describing Emily Martin's article, because she was observing in this biology lab at the time that they were figuring out that's actually what was happening.

Sperm are not going in any one direction—they're kind of flailing all over. And the female musculature, the tract, is pushing them up toward the egg. And the egg—the process is called chemotaxis—the egg actually sends out chemical signals.

But the interesting thing in my interviews was that nobody told that third metaphor—that the egg would be in charge or the egg was driving the action.

So I call that a missing metaphor, in the same way we've got a missing science of male reproductive health.

Metaphors for Impregnation – 30:26

BLAIR HODGES: Right. And so you point out that all the men you talked to started off with the conquest story—that the sperm's going to the egg—and then half of them tacked on the egalitarian version of, oh, and then these two things come together and make a baby.

But you say that a third of the women only told the egalitarian version—they didn't start with the conquest thing.

RENE ALMELING: Yes. And so this is where I will say, in terms of social scientific methods, this was a relatively small interview study with 55 people in a small town in the northeastern United States.

So it's not something where I can take those numbers and extrapolate to any broader population, but it definitely gives us some preliminary evidence that there might even be gender differences in who tells which kind of fertilization story.

BLAIR HODGES: Yeah, there's a quote here I'll read. It says, “Biological stories are powerful. They both reflect and produce our collective understanding of our bodies and ourselves.”

And I began to wonder if men who thought in more egalitarian ways about gender relations were more likely to tell the second story. A lot more research needs to be done, right, Rene? But what do you think? Do you think the men who tacked on that additional story might be more likely to say, hey, I'm a partner with my spouse—we work together? Maybe they'll have more egalitarian life ways if they're thinking in more egalitarian ways about sexual reproduction?

RENE ALMELING: Well, I think it's really hard to tell which way the arrow is going, right? Is it how they think about eggs and sperm that shapes how they think about their relationships, or vice versa?

But I think not only do we have demographers and national-level survey researchers finding that younger people and more educated people are more gender egalitarian—so I think this is shifting more broadly—but I would also add that as we increase the visibility of trans people and people who are gender nonbinary, that's also unsettling our cultural beliefs around sex and gender.

And I would hypothesize that as that becomes a more culturally acceptable way of thinking about gender, we're probably going to see even further change in how we think about all kinds of bodily processes that have historically been gendered.

BLAIR HODGES: Well, after you asked men their thoughts about how reproduction worked, you also wanted to introduce them to some of the new knowledge that's been produced about sperm and men's reproductive health, because you wanted to see how they would react to it.

Would it change the ways they thought about reproduction? So you had this pamphlet that you would share, and some of the things in it, for example, say that men can damage their sperm by drinking alcohol, smoking cigarettes, using drugs, taking certain medications, coming into contact with toxic substances, eating unhealthy foods, and being overweight.

And then it says that women aren't the only ones with a biological clock. New research shows that as men age, their sperm is more likely to be damaged. It tells men that their sperm takes two to three months to grow inside the body.

And then it lists things that doctors encourage men to do if they're planning to have a baby—like eating a healthy diet, limiting alcohol, not smoking or using drugs during that time, and avoiding sexually transmitted diseases.

So you introduced them to this pamphlet. What kind of reactions did you get? Was this pretty big news to most of the people you talked to?

RENE ALMELING: Yeah, there were very—you know, I was doing these interviews in 2015, and at that time there was even less than there is today. And there's still not much out there about male reproductive health.

So several of the people I interviewed said, you know, can I take this with me? Can I share it with my friend who's thinking about becoming a dad?

There was a lot of interest, which I was happy to see because it suggested to me that there is a receptive audience among men for some of this information.

But I also asked them not only to tell me how they were reacting to the information, but I said, imagine somebody that you know well—imagine one of your male friends. How would they react? And that's one way that we get around what we call social desirability bias, where people are giving us the answers they think we expect.

And so that's where I heard things like, oh, well, men don't really care about their health—they think they're invincible. Or, we all know that we should be eating better and taking better care of ourselves, but none of us actually do it.

BLAIR HODGES: And then, importantly, a lot of the men—especially men who were members of racialized minorities or lower income—would say things like, you know, I don't have complete control over the work that I do, or the chemicals I encounter at work, or the food I have access to. Certain foods are more expensive, or there are food deserts.

RENE ALMELING: Right. They pointed to health care inequality—enormous inequalities in the U.S. in terms of who has access to health care—and various forms of racialized inequality.

And so I think that's really powerful data coming from individuals—that it's not just individual decision-making that determines whether someone has healthy sperm or not.

The health of all of our bodies is really shaped by broader social, structural, and historical forces. And we have to take that into account if we're going to think about how to improve everybody's health.

How to Spread the Word – 35:31

BLAIR HODGES: Well, I mean, what do you suggest when it comes to spreading information like this about men's reproductive health?

You already mentioned that you don't necessarily see the need for a full-on andrology field—you'd kind of like to see a reproductive health field develop more generally, right? But in terms of spreading that kind of information, who are we looking to?

RENE ALMELING: You know, I think—and I sort of alluded to this earlier—but since writing the book, I have been in conversation with physicians from a number of different specialties where male reproductive health bumps up against the edge of it: pediatrics, adolescent medicine, sexual health, endocrinology, OB-GYN, urology. So there's a number of physicians who are leaders in those specialties trying to pay more attention to male reproductive health.

I actually convened, with a bioethicist colleague and an OB-GYN colleague, a meeting with about 30 of the “sperm people” from the social sciences and the biomedical sciences about a year ago. We had everybody speculate about how we pay more attention to sperm—how we think about the intersection of sperm with health and politics.

And one of the answers we came to was that it might need to be high school health education and high school sex education classes—which are, sort of infamously, patchy around the U.S. Not everybody gets it.

But for a lot of the men I interviewed, the last time they heard anything about their own reproductive system was in high school. So I think that might be the best place to figure out how to make this part of the curriculum and make that information more broadly available.

Not all men go to the doctor, so they're not necessarily going to hear it there. Certainly the CDC and others could do some basic public health messaging around this, which they still haven't done.

BLAIR HODGES: Why do you think they haven't?

RENE ALMELING: There is one page on the entire CDC website about male preconception health—which nobody would Google, ever.

BLAIR HODGES: Yeah, yeah—I wouldn't even think to look.

RENE ALMELING: Right, exactly. And even if you find that page, it's still very general. It's about, you know, like what you said—avoid STDs, make a reproductive life plan.

So it's not anything about the effects of toxins on sperm or this kind of thing. So there's some pretty low-hanging fruit—to use another loaded metaphor!—in this realm of things we could do to get this information out there more broadly.

The Seedy Underbelly of Eugenics – 38:01

BLAIR HODGES: Now this raises some difficult ethical questions too that you talk about in the book. This discussion about reproductive health has roots in eugenics.

This is the idea that “proper” ways of procreating will create healthier bodies, and that we need to pay attention to who’s procreating so that we can get the best possible human race.

And this was connected to racist ideas about white people being out-reproduced by people of color. There was concern that society would degenerate if white people didn’t keep up.

So when we’re thinking about reproduction—and we’re telling women and men how to make the best chances for their baby to have good health—there’s also this underside of eugenics, and maybe some ableist ideas about not having babies with certain disabilities.

So let’s spend a minute talking about that side of things.

RENE ALMELING: Yes, absolutely. And even much of the terminology or language in this area is fraught with eugenic echoes. People will talk about “high-quality sperm” or even “healthy sperm,” which suggests that there is sperm that is unhealthy or damaged.

And so in the conclusion of the book, I reflect a little bit on how this is important health information, but we have to be very cautious about not taking that next step that eugenicists were happy to take—which was to start saying who should or should not be reproducing on the basis of “quality.”

I think even thinking about genetics in terms of quality is something we should not be doing. I think this is really about thinking in terms of population health. How do we think about whether or not a body is healthy?

This goes back decades for public health researchers—we know what it takes to improve the health of all bodies, whether they are reproducing or not. That includes access to good health care, clean air, lead-free water—these basic public health infrastructure elements. Those benefit everybody's body, whether or not they're planning to have kids.

And so that's actually where I end up coming down. It’s sort of the pie-in-the-sky recommendation that many medical sociologists and public health folks make at the end of a book—which is: why do we spend enormous amounts of money on high-tech medical interventions when we already know some of the basic things that actually work?

So I think that's one way to avoid falling into that eugenic trap—by focusing not on any one person's or one group's reproduction, but on how we improve the health of everyone.

Sex Cells – 40:44

BLAIR HODGES: That's Rene Almeling, a professor of sociology at Yale University, author of the book Guynecology: The Missing Science of Men's Reproductive Health.

And Rene, you've also written a book called Sex Cells—another pun. Sex Cells, spelled C-E-L-L-S: The Medical Market for Eggs and Sperm.

How did that book connect with this one? Did this book kind of grow out of that research?

RENE ALMELING: Yeah. So the book on Sex Cells is about the market for egg donors and sperm donors in the U.S., and that was my first book. It came out of my dissertation research, where it was one of the first big comparative studies of how we organize the market for eggs versus the market for sperm.

And I also found that there are various ideas about gender shaping the ways that egg donors were recruited. So they were asked to “give the gift of life,” whereas sperm donors were thought to be doing this kind of job—an easy job—for money. So there were all kinds of ways that gender made itself a part of that market as well.

And then, yes, this more recent book on Guynecology grew out of that, because I had been paying attention to sperm for a very long time and started seeing some of these headlines around 2010, 2012, about male biological clocks and paternal effects and the effects of male bodily health on sperm.

And that was where I was just kind of like, well, why—how did this take so long to ask this very basic question? So they're definitely connected. I don't know that I'm going to be doing anything else on sperm for a while, though.

BLAIR HODGES: You're all spermed out.

RENE ALMELING: Yes, exactly.

Why Rene Studies This Subject – 42:17

BLAIR HODGES: Do you find that people are curious about your own personal connection to it? Because as a person who has studied eggs and sperm and all of this, do people wonder?

I mean, you talk about how science is situated, right? And the questions we ask are generated by our experiences and stuff. So do people ask, like, are you a mom? Do you get a lot of questions about that?

RENE ALMELING: I do. And I think all social scientists who are doing research on these topics get asked those questions.

And as we teach our graduate students in methods classes, everybody is producing knowledge from a particular standpoint—you just can't escape it. We are humans studying humans.

The thing that's so funny about having done this now for 25 years is that when I was a graduate student studying egg donors, I was asked, well, surely you must be interested because maybe you're an egg donor—because I was 23. And now I'm in my mid-40s, and people say, well, did you use an egg donor?

So that has changed over the course of my life. But I have not ever had any personal connection to the reproductive technologies I've studied, or to any of these medical specialties around sperm. Although, as my partner and I were trying to have a child, I did drag him along to an appointment to see if they would say anything to him about his sperm—and they did not.

I did wrap my own family into the research process at different points.

BLAIR HODGES: That's Rene Almeling. We're talking about the book Guynecology: The Missing Science of Men's Reproductive Health.

Regrets, Challenges, & Surprises – 43:47

BLAIR HODGES: All right, Rene, we like to conclude every episode with regrets, challenges, and surprises.

This is an opportunity for you to talk about something you might change about the book now that it's out—something you kind of regret about it—or something that was most challenging in creating the book, or something that surprised or changed you as a person in the course of doing that research.

You can speak to one, two, or all three of those things—it's up to you.

RENE ALMELING: Okay, what a great last question.

I would say the thing that just pops right into my head is that the entire process of researching and writing this book on male reproductive health felt a little bit like a tightrope.

And that is because I was writing it at a time when there had been enormous and concerted attacks on women's reproductive rights—their access to abortion, even their access to contraception. And now we're seeing challenges to access to IVF.

So to be writing about male reproductive health at such a fraught time for reproductive politics in the U.S. made me feel like, on almost every page, I wanted to say: male reproductive health is important, but this does not mean that men should have any decision-making power whatsoever over pregnant people's bodies.

Which I do say at a couple of points in the book. But that's the thing that felt most difficult in writing it—and it has only become more difficult since the book came out in 2020.

BLAIR HODGES: Yeah, you're the researcher that's like, what about men? [laughs]

RENE ALMELING: Exactly. And yet I would say that, as a gender scholar, it is crucial that we don't only talk about women and we don't only study women, because that's part of the whole point of saying gender affects everybody.

BLAIR HODGES: That's right. How about any challenges or surprises? Did you bump into any of those?

RENE ALMELING: I mean, I was actually really surprised to find out about this episode—you know, this goes way back to the beginning of our conversation—but this episode in the 1890s where there was an attempt to launch the specialty.

And I think, if we play out that thought experiment of what it would look like if that had succeeded, reproductive healthcare probably looks really different. There were a couple of historians who, in a sentence or two, had mentioned andrologists at that time. But I kind of had to go learn how to be a medical historian in order to write this chapter.

So that was a really intriguing discovery, and I think it's powerful for understanding the story of how we got to this point—this male standard body and this female reproductive body.

BLAIR HODGES: Yeah, I enjoyed that. I hadn't heard anything about that either. And so the stuff that you found was really eye-opening, especially in terms of how medical knowledge is produced and how contextual that knowledge is.

I think we all need to keep that in mind. I'm very science-minded—I love the sciences—but I also try to be humble about it and recognize that we're all situated, and we've got plenty more to learn.

RENE ALMELING: Right. Well, and the whole point of research like this is to try to figure out how to make science and medicine better.

It's not an anti-science critique, it's not an anti-medicine critique. But if we are able to identify the ways that different cultural beliefs around gender, race, class, or sexuality are shaping the science we make, then it will help us do a better job.

BLAIR HODGES: Well, that's Rene Almeling, a professor of sociology at Yale University, author of the book Sex Cells: The Medical Market for Eggs and Sperm, and also the book we talked about today, Guynecology: The Missing Science of Men's Reproductive Health.

Rene, I really appreciate you taking the time to talk about the book with us.

RENE ALMELING: Thank you so much for having me. I really enjoyed it.

Outro – 47:33

BLAIR HODGES: That's it for this episode of Relationscapes. And if this is your first time with us, welcome to the journey. I hope you'll check out some other episodes while you're here.

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Mates of State provides our theme music. I'm your host, Blair Hodges, an independent journalist in Salt Lake City, and I hope to spend more time with you soon here on Relationscapes.

Transcripts - Rene Almeling