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Men's sexual health matters  >  Section 4: Sexual development and function 
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Section 4: Sexual development and function

Men's Sexual Health Matters

Acknowledgements
Definitions
Introduction
Working with men
Starting work with men
Effective approaches
Sexual development and function
Common sexual problems
Resources and organisations

 

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Sexual response and sexual feelings

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Sexual development and puberty

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ACTIVITY Reviewing your sex life

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ACTIVITY Changes during puberty

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Sex - safe and healthy

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Genital care and hygiene

bulletACTIVITY Contraceptive methods

 

 

 

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  Section 4: Sexual development and function

Sexual response and sexual feelings

Learning about sex, sexual relationships and sexual health -a healthy start in life.

It is often believed that men and women have different sexual desires and needs - men are always ready for sex and want to achieve orgasm quickly, whereas women are less interested in sex, more passive, and more interested in affection and love. These assumptions are rarely true. However, common beliefs affect all of us, especially in our relationships with the opposite sex. Many of the problems men encounter in sex are connected to expectations about how men and women should behave, and what men and women are expected to feel during sex.

Assumptions about men's and women's sexual feelings are also based on limited information about how men's and women's bodies behave during sex. Often men do not know about women's sexual desires and have unrealistic expectations of their own sexual capabilities. The same is true for women.

 
 

Sexual development and puberty

Sexual development starts when an egg is fertilised by a sperm. It continues throughout life. Small babies, both male and female, take pleasure in their own bodies and will often touch their genitals. This happens before birth and throughout childhood. 

The major change from boy to man occurs when puberty is reached. Puberty starts at any age between the ages of  9 and 14 years old, with the average age being 11 or 12 years. Boys often become more interested in sex when they reach puberty. They may start to ejaculate by masturbation and when sleeping (having 'wet dreams', see page 27). Their bodies become more muscular and more hairy, and their voices change and deepen. 

Because a boy's body and emotions are changing very quickly, puberty can be confusing or worrying. The messages given to boys at this time about sex, relationships and sexual health have an enormous influence in later life. 

Boys may learn about sex at school or from friends, brothers, magazines or films. Fathers, mothers and other relatives also play an important role in passing on information about sex and discussing feelings and values. 

Some fathers feel awkward or restricted in what they can say to their sons. In many cultures, older men in the community teach boys about growing up and sexual health. If these traditional structures are not there, people working with men can help fathers and other significant men in a boy's life (such as grandfathers, uncles, older boys or youth workers) to be open with and listen to boys at puberty.



    

 

 

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  Section 4: Sexual development and function

 

TALKING TO BOYS ABOUT PUBERTY 
 

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Support fathers, or other older men. Many boys look to their father and other elders for guidance on many issues. Sex and changes in puberty can be part of this.

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Encourage men to answer boys' questions, or to take the initiative in talking with their sons. Being silent may add to a boy's feelings that sex should not be talked about.

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Men may be embarrassed about discussing sexual matters with boys. Acknowledge this, but encourage men to go ahead anyway. Boys will often appreciate a father being honest about his own embarrassment. Alternatively, encourage other men, such as village elders, or older boys, to have a role in boys' sex education. 

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Adult men can use their own life story and experiences to illustrate doubts, fears and questions that a boy may have but cannot express openly.

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Give any information that older men may need.

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Encourage adult men to be there for boys to talk to over time. A single chat is not enough. Letting boys know that their father, or another trusted man, can be approached if they have questions is most important of all.

 

ACTIVITY


REVIEWING YOUR SEX LIFE


This activity aims to encourage men to reflect on what is happening in their lives and how it may be affecting their sexual relationships. 

The following questions can be given to a man to think about on his own. Alternatively, a group could think about the questions individually and then discuss their thoughts together:
 
You and your relationships
 

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What do you like about your life right now?

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What do you find difficult about it?

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How do you feel about: your work, family, close relationships or marriage?

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Do you think that roles of men and women are changing?

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In what ways have changing roles and expectations of men and women affected your life?

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Do you feel that you are different in any way from what is traditionally expected of a man? Is this good or bad?

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What is good about your current sexual relationship (s)?

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What are you dissatisfied with in your sexual relationship (s)?


You and your sex life
 

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How do you feel about your sex life at the moment? Is it how you want it to be?

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What are you most dissatisfied with? What pleases you most?

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Do you feel that you have any problems?

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What are you currently doing about any problems?

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What kind of help would you really like?

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How would you like your sex life to be in the future?


You and your body
 

Take some time alone when you will not be disturbed. Look at your body when you are naked. Try standing in front of a mirror.
 

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What do you like about your body? What don't you like?


Now take a closer look at your genitals.
 

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What do you like about them? What don't you like?

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Is there anything that worries you about your penis and testicles? Who might you talk to about these worries?



    

 

 

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  Section 4: Sexual development and function

 

ACTIVITY


CHANGES DURING PUBERTY


The aim of this activity is to teach boys what happens to boys' and girls' bodies during puberty. It can be done in a group. 

TIME About 45 minutes.

MATERIALS Two large sheets of paper (large enough for a boy and girl to be drawn on), pens, copies of the illustrations below (adapted and made larger if necessary).

1  On two large sheets of paper, draw the outlines of a boy and a girl.
Ask the group to draw the changes they think happen during puberty.

3  Compare the illustrations below with what the boys have drawn. 
4  Using the drawings and illustrations, discuss the changes that happen during puberty. Answer any questions that group members may have.

 





    

 

 

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  Section 4: Sexual development and function

Male reproductive organs 


Pubic hair
Grows around the penis after puberty. 
Penis Made up of spongy tissue. Normally soft, but fills up with blood and becomes stiff (erect) when a man is sexually excited. 
Foreskin Small piece of skin which covers the glans. It is removed when a man is circumcised.
Glans Head of the penis. Sensitive to touch. 
Scrotum Sac that holds the two testicles. 
Urethral opening Opening through which urine and semen pass. Unlike women, men have the same opening for urine and sexual fluids. It is not possible for urine to pass through the urethra at the same time as semen is being ejaculated.

 


Urethra
Tube through which urine and semen (including sperm) pass out of the body. 
Vas deferens Tube that carries sperm from the testicles to the urethra before the man ejaculates.
Seminal vesicle Small sac at the back of the prostate gland where the thick milky fluid in semen is produced. 
Prostate gland Small gland which produces a thin fluid that forms part of the semen. 
Testicles Glands (which feel like two small balls) which produce sperm and the male sex hormone.
Epididymis Area where sperm are stored in the testicles. 



    

 

 

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  Section 4: Sexual development and function

Female reproductive organs 


Pubic hair
Grows around the vulva after puberty. 
Vulva The different parts of the vulva make up the woman's outside reproductive organs: 
Outer labia Two folds of skin which protect the vulva. 
Inner labia Two smaller folds of skin which lie between the outer labia. 
Clitoris Small bump at the top of the inner labia, filled with nerve endings. It is very sensitive to touch. Stimulating the clitoris can be pleasurable and lead to orgasm. 
Urethral opening Small opening below the clitoris through which urine passes out of the body
Vaginal opening Opening below the urethral opening and above the anus. It leads to the vagina, cervix and uterus. It is through the vaginal opening that menstrual blood passes out of the body, the penis may enter during sex, and babies are born. 
Anus Opening between the buttocks and below the vulva. Faeces (body waste) leave the body through it.

 


Vagina
A moist tube of muscle, normally about 8cm long, which connects the vulva to the inner reproductive organs. It is very flexible. It secretes slippery mucus during sexual arousal. 
Cervix Mouth of the uterus, connecting it to the vagina. It has a very small opening and is kept moist by mucus. A woman can feel her cervix by putting two clean fingers into her vagina and reaching up and forward. The cervix feels round, hard and smooth, with a small bump in the middle. 
Uterine (fallopian) tubes Two tubes that connect the uterus to the ovaries. An egg is released from one of the ovaries each month, and passes along a uterine tube into the uterus. 
Ovaries Two glands, one at the end of each uterine tube, which produce eggs and female sex hormones. 
Uterus (or womb) Hollow sac of muscle, shaped like an upside-down pear, where an embryo develops into a baby during pregnancy.

The vagina and cervix are the lower reproductive tract
The uterus, uterine tubes and ovaries are the upper reproductive tract



    

 

 

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Penis size and shape 
Normally a man's penis is soft and hangs down. When he gets sexually excited (and often when he does not) the penis goes stiff. It grows longer and wider and it sticks outwards and upwards from the body. The penis is used for both urinating and having sex (though it is not possible for urine to be passed at the same time as semen is being ejaculated). 

Penis size varies a little but not much. Penises can look very different when they are soft (not erect or aroused), but are similar in size when erect. A common anxiety that many men have is based on the belief that a large penis makes a man more attractive and a better lover. Some men try to find ways of increasing the size of their penis, but there is no known safe way to do this. 

Penis shape and appearance can also be a worry. Penises come in different shapes. When erect, some penises are straight, some bend to the left or right and some curve upwards or downwards.

Circumcision 
 

Uncircumcised penis  /  Circumcised penis

Circumcision of men means cutting the foreskin at the end of the penis. The foreskin is cut off completely in some cultures and religions, and cut partially in others. In many religions and cultures, circumcision is a sign of belonging. Circumcision does not affect how a penis functions. It makes no difference to a man's ability to give or receive sexual pleasure. 

This is different to 'female circumcision', or female genital mutilation (FGM). This is an operation that involves removing the woman's clitoris and sometimes labia. It can lead to problems with urination, menstruation, psychological trauma, painful intercourse and dangerous delivery. FGM can lead to serious health problems and sometimes death.

Current research is unclear about whether male circumcision reduces the risk of infections, including those transmitted through sex. However, uncircumcised men may transmit infections more easily if they do not regularly wash properly (see page 30). Circumcision may be a risk to health if the instruments used are not properly sterilised, and if the wound is not kept clean while it heals.

 
 
Testicles 
Testicles (balls) hang in a bag (scrotum) outside the body, just behind the penis. The scrotum is usually darker in colour than the rest of the skin, and is hairy. When the scrotum is cold, it becomes smaller and more wrinkled. Many men have one testicle (commonly the left) hanging lower than the other. 

It is usual for testicles to move up and down with changes in temperature. It is important that they do not become too hot, as heat can cause problems with production of sperm and contribute to infertility. It is best for men to avoid very tight clothing, and to wear loose underclothes.

Erections 
An erection is when a penis becomes swollen with blood and gets thicker and stiffer, becoming upright or 'erect'. Blood fills the blood vessels in the penis, making the penis larger. Erections happen not only when a man is sexually excited, but for many other reasons as well, caused by a touch, vibrations, a full bladder or dreams. 



    

 

 

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  Section 4: Sexual development and function

 

Masturbation 
Masturbation means touching or stimulating your own genitals. It can be done with a partner or alone. Most men and many women masturbate, and some start before puberty. Even male babies in the womb can have erections and touch their own penises. 

There are many ways in which men masturbate. The most common is to rub the penis with the hand until ejaculation occurs. Men can also rub their penis against something, for example a pillow or blanket, or by using other objects such as fruit. 

Most men masturbate, whatever their age, and whether they are single or in a relationship. Masturbation is not just 'a second best to sex with a partner' but can be an additional enjoyment. For some men, masturbation accompanies sexual fantasies that they do not feel able to act out with a partner. 

Masturbation does not cause any harm, unless objects are inserted into the end of the penis. These can cause infections. It can also be dangerous to insert the penis into a rigid object such as a bottle, because the penis can expand and get stuck. 

Some people regard masturbation as shameful, or believe that it causes blindness, hair loss or tuberculosis. It does none of these things. Masturbation is not harmful. However, if people are made to feel guilty for masturbating, this can cause emotional harm.

Wet dreams 
'Wet dreams' are ejaculations during sleep. They are not caused by masturbating. They are involuntary, like a sneeze. Wet dreams are fairly common in boys and young men but rarer in older men. They may cause worry or shame if a boy does not know what they are, or if wet dreams are associated with bad feelings about masturbation.

What happens during sex? 
When a man or woman is sexually excited, blood flows to the genital area and the heart beats faster. A man's penis becomes larger and stiffer (erect), and a woman's vagina becomes moister. When a man gets an erection, a bladder muscle closes, so that urine, which passes out of the penis from a different tube from semen, cannot be released at the same time. With increased physical stimulation, bodies become more sensitive. 

When a man has an orgasm, white fluid called semen is ejaculated from the end of his penis. When a woman has an orgasm, her vagina and uterus contract, and more fluid may be released in her vagina. Male orgasms can occur with stimulation of the penis through vaginal or anal intercourse, masturbation or oral sex. Female orgasm can sometimes occur through vaginal intercourse alone, but stimulation of the clitoris is more likely to lead to orgasm. 

After orgasm, or when stimulation stops, the heart rate slows down and the rest of the body returns to normal. This process is very similar in both men and women, except that women may be able to remain sexually excited for longer, and may be able to have more than one orgasm in a short time. Men need a period of recovery before they are ready to ejaculate again.



    

 

 

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  Section 4: Sexual development and function

 


When a woman and a man have unprotected vaginal sex and the man ejaculates (comes), semen enters the vagina. During sex, even before a man ejaculates, semen leaks out of the penis. Semen contains millions of sperm.

The sperm swim up the vagina through the cervix to the uterus (womb) and into the uterine tubes. If a sperm finds an egg it joins the egg. This joining is called fertilisation.

The fertilised egg moves down the uterine tube into the uterus. It settles into the thick lining of the uterus. The egg develops into an embryo (the beginning of a baby). The baby grows in the uterus for nine months. This is pregnancy.

Sex - safe and healthy

Safer sex is any sexual activity that is pleasurable, and avoids unwanted pregnancy, infection and abuse of power. Knowing how to prevent pregnancy and infection requires an understanding of the risks involved in different sexual activities and the ability to reduce the risks.

Avoiding unwanted pregnancy means that a woman needs to avoid sex with a man during her fertile period, or use a contraceptive. Avoiding an STI means avoiding sexual activity in which semen, vaginal fluids or blood enter your body or come into contact with broken skin, if you do not know whether your sexual partner has HIV or another STI. 

Safer sex activities include non-penetrative sex (stimulating your own or your partner's genitals through masturbation, thigh sex, massage or kissing), using a condom for vaginal or anal sex, or not having sex. Oral sex (mouth contact with male or female genitals) is less risky than unprotected vaginal or anal sex, although some STIs such as herpes can be transmitted through oral sex. There is some evidence that HIV can be transmitted through oral sex. The most risky sexual activity is having penetrative vaginal or anal sex (where the penis enters the vagina or anus) without using a condom. 

When talking about safer sex it is important to remember that it is the activity, and not who you do it with, which may be risky. For example, anal sex is risky whether a man is having sex with a woman or another man. It is not possible to tell if a partner has an STI, including HIV, because many STIs have no symptoms (see page 43). 

Men, and many women, are often brought up to see penetration as a necessary part of sex and other sexual activities as less important steps on the way to penetration. However, many men have had some experience of sexual contact that does not involve penetration, especially as young men. The possibility of rediscovering the pleasures of non-penetrative sex can be a way of interesting men in discussing safer sex.



    

 

 

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  Section 4: Sexual development and function

 

Oral sex 
Oral sex means using the mouth to kiss, lick or suck a clitoris, vagina, anus or penis. There is some risk of transmitting STIs, such as herpes and gonorrhoea, through oral sex. The risk is reduced if semen or vaginal fluid is not taken into the mouth - for example, by using condoms. HIV transmission appears to be possible through oral sex, although the risk is low. Oral sex should be avoided if either partner has cuts or sores on their mouth or genitals.

Penetrative vaginal sex 
It is important for men who are having sex with women to know about preventing pregnancy and STIs (see pages 32 and  33 and 41). In most cultures, decisions about child spacing and contraception are seen as mainly women's concern. Only women can get pregnant, so some men feel that they do not have to be involved in contraception, even though it takes both a man and a woman to make a pregnancy. 

Young men are rarely taught about contraception. Many grow up to be ignorant and uncomfortable about the subject. A first step in encouraging men to be more involved in contraception is good sex education, in which the facts are explained clearly, and the mystery is removed. Knowledge of different contraceptive methods allows men to take part in discussions about contraception with their partners.

Anal sex 
Anal sex is penetrative sex where there is contact between a penis and an anus or rectum (back passage). Although it is illegal in some countries, and considered to be 'dirty' in some cultures, anal sex is a relatively common sexual practice among men who have sex with women, as well as among men who have sex with other men. Anal sex between men and women is sometimes common because it is a way to avoid the risk of pregnancy and to protect the woman's virginity. Although many couples enjoy anal sex, some women say that they do not enjoy anal sex, but that their male partners want to practise it. This can cause problems in relationships. 

The anus is more prone to cuts and scratches than the vagina, so transmission of HIV and other STIs is more likely with anal sex. The risk of transmitting an infection during anal sex is greater for the partner whose anus is being penetrated. The risk can be minimised by using a condom with a water-based lubricant. Stronger condoms made especially for anal sex are available in some places.


MAKING ANAL SEX SAFER 
 

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The penetrator (man putting his penis into the anus) should wear a condom and use a water-based lubricant. The lubricant reduces dry rubbing and makes it less likely that the penis or rectum will be injured, and reduces the chances of the condom breaking. 

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Thicker condoms are safer for anal sex than ordinary condoms.

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Using two condoms does not help. One or both condoms can slip off more easily.

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Water-based lubricant should be put on the anus before penetration. 

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Penetration should be slow and gentle to avoid discomfort and possible damage.

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A man should not penetrate a woman's vagina straight after penetrating her anus without using a fresh condom. This is because germs from the rectum can easily be transferred to the vagina and cause infections. 



    

 

 

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  Section 4: Sexual development and function

 

QUESTIONS AND ANSWERS
 

Men's Sexual Response

There is no clear definition of what is 'normal' and what is not. Everyone is different and some people are more interested in sex than others. A person's interest in sex also changes at different times in his or her life.

Q Can you use pills or potions (aphrodisiacs) to increase your sex drive?
A
There is no known scientific basis for the effects of these substances on sex drive. However, if someone believes that there will be an effect, they may feel one. Many aphrodisiacs are harmless, but some are dangerous. For example, 'Spanish fly' is popular in some countries but it is, in fact, the poison, strychnine, and large doses can kill. In small doses, strychnine causes an irritation of the urethra (the tube through which urine and semen pass) which can be mistaken for sexual stimulus.

Q Can sex weaken a man?
A
No, it cannot physically weaken a man. Most men feel tired for a short time after ejaculation, but there is no medical evidence to suggest that either having sex or not having sex makes any difference to a man's physical health. This includes masturbation.

Q If a man does not have sex, will his testicles become swollen with unreleased sperm and cause him pain?
A
No. Sperm are only a small part of the semen (which is produced and stored in the prostate gland). Like other substances in the body, sperm die and are re-absorbed back into the bloodstream if they are not ejaculated. This process is normal, harmless and painless. 

Q Do men need to have sex more often than women?
A
Many men say that they feel a very strong need t o have sex. Some men use this argument as a way of persuading or forcing their partners or others t o have sex when they do not want to. However, biological and sexual responses of both men and women are similar, and vary from one individual to another.

Q Can a circumcised man last longer in sex?
A
There is no evidence of this. Control of ejaculation is not affected by the foreskin or lack of it, but by a man's ability to control his state of arousal. (See also page 39).

Genital care and hygiene

Keeping genitals clean is necessary for preventing infections. The penis, testicles and anal area should be regularly washed with clean water. It is especially important to wash the tip of the penis and under the foreskin, if there is one. This reduces the risk of bacterial infections due to the build-up of smegma, a white, cheese-like substance that causes an unpleasant smell. 

Regular washing is also important because it means that men are more likely to notice anything unusual {such as lumps, spots, sores or discharge} as soon as it occurs.

ENCOURAGING HYGIENE 
 

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Parents can show young boys how to clean their genitals from an early age, and make this a routine part of washing.

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It can seem insulting to tell men that they need to pay more attention to cleanliness. Therefore, include instructions about genital hygiene in general health education materials such as leaflets and posters.

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Emphasise positive aspects of hygiene: men are much more likely to pay attention if they get the message that sexual partners prefer men who have clean genitals and clean underclothing!



    

 

 

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Testicles 
Testicles are sensitive and can be damaged if they are hit hard or kicked. Spots and bumps are quite common on the scrotum and penis and don't usually mean anything. If lumps appear, or if a testicle remains close to the body and does not drop down into the scrotum, the man should see a doctor. 

All men should be encouraged to check their testicles regularly for any lumps or unusual changes (see below). Men may often delay seeking medical help until a problem has become a crisis. It is important to promote the importance of prevention and regular check-ups to avoid serious illness.

There are many possible causes of lumps or other changes in a man's testicles. Some are serious and some are not. Most potentially serious problems can be avoided if the early signs are noticed and medical help is sought quickly. Cancer of the testicles is rare, but it can affect young men and the number of cases is increasing. Early diagnosis of testicular cancer makes the chances of recovery very good. Every man can learn a simple way to check himself for early changes, so that he can seek treatment in good time.
 

 
Testicular self-examination 

Check your testicles about once a month. It's best to do this when they are warm and hanging loosely, and the skin of the scrotum is soft.
 

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Hold the scrotum in the palm of your hand and notice the size and weight of each testicle. Remember that it is usual for one testicle to hang lower than the other. Examine each testicle in turn, using both hands to roll the testicles between thumbs and fingers. The testicles should feel smooth. Look for any lumps, hard areas, or swellings.

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Notice that there is one lump that should be there on each testicle - the epididymis, where sperm are stored. This lies at the top and back of each testicle. Learn to recognise these lumps and check for any other lumps.

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Check both testicles carefully. If there is something unusual it will probably be in only one testicle, so watch for any differences between the two. 


Other signs of possible problems are a dull ache in the groin or abdomen, heaviness in the scrotum, or pain in the testicle itself. 

Remember that anything unusual about your testicles is not necessarily a sign of cancer. It could be due to a less serious problem. Ask a doctor straightaway about anything unusual that you notice.

Many problems with testicles are much less serious if they are treated early. Regular checking can prevent major problems from developing. 



    

 

 

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  Section 4: Sexual development and function

Contraceptives 

 

DESCRIPTION

PROTECTION FROM PREGNANCY PROTECTION FROM HIV/STIs AVAILABILITY ADVANTAGES DISADVANTAGES
CONDOM
 

Latex tube which is rolled onto the man's erect penis before having sex. The man ejaculates into the condom. The condom is more effective in preventing conception if used with a spermicide. Sometimes condoms are already lubricated with a spermicide. If not, they can be lubricated with a water-based lubricant. Very good, if used properly and consistently. Very good, HIV and other infections cannot pass through. Widely available in most countries from bars and shops as well clinics. Inexpensive. Rarely any side effects (a few people get irritation from latex). Only need to use when having vaginal or anal sex. Some people choose to use condoms during oral sex. Can be difficult to use without teaching. Men need to agree to use. Can break if used wrongly or beyond use by date, or if there is a lot of friction (for example during 'dry sex', or if an oil-based lubricant is used.
FEMALE CONDOM
 

A soft, thin polythene tube which covers the inside of the woman's vagina, similar to the male condom. It can be used with a spermicide. Very good, if used properly and consistently. Very good, HIV and other infections cannot pass through. Not widely available. Expansive in most places. No side effects. Only need to use when having sex. Some women can use without men knowing. Not easily available in most countries. Expensive. Can be difficult to insert.
DIAPHRAGM and CAP
 

Rubber 'cap' that fits over the woman's cervix to prevent sperm entering. Needs to be fitted initially by a health worker. A diaphragm or cap is put into the vagina before having sex and left in for at least six hours, but not more than 24 hours after sex. It is then washed for re-use. It should be used with spermicide. Very good if used properly. No protection against HIV. Some protection against some STIs such as
genital warts.
Not available in every county. Only need to use when having sex. Can be re-used For two years. Does not need access to health worker after initial fitting. Needs trained health worker to fit. Some women find it difficult to insert and take out. Needs to be refitted every two years, after pregnancy, or if the woman gains or loses weight.
SPERMICIDES
 

Chemicals designed to kill sperm in the vagina and prevent sperm from entering the cervix. They take the form of foam, vaginal film, cream, gel or pessaries. They should be used with barrier methods (condom, female condom, diaphragm or cap). Poor if used on own. No evidence yet of reducing HIV risk. Some protection against bacterial infections. Widely available. Only need to use while having sex. Does not need access to health worker. Some people are allergic.
CONTRACEPTIVE PILL (the pill)
 

Daily pill containing hormones that prevent ovulation (release of an egg from an ovary).  Excellent if taken correctly. None. Available in most areas from family planning clinics. Do not need to think about it while having sex. Can switch to another method if necessary. Need to be prescribed by a health worker. Needs to be taken daily. Needs to be taken daily. Some side effects. Many conditions in which it should not be prescribed.
HORMONAL IMPLANT (often known as Norplant)
 

Six small, thin tubes inserted under the skin in the woman's upper arm. The tubes slowly release a hormone which prevents ovulation. They must be inserted and removed by trained health workers. Effective for up to five years. Excellent. None. Widely available in some countries.  Do not need to think about it while having sex. Can be used without man knowing Long-lasting Can cause irregular periods. Some conditions in which should not be used. Must be removed by trained health workers.
INJECTABLE CONTRACEPTIVES
 

The most common injectable is DMPA (or DepoProvera).
Injection given at a clinic every three months. It prevents ovulation.
Excellent. None. Widely available in some countries.  Do not think about it while having sex. Can be used without man knowing. Can cause irregular periods. Need access to health worker every three months. Cannot stop immediately if side effects. Many conditions in which it should not be used.


Can be difficult to use without teaching. Men need to agree to use. Can break if used wrongly or beyond use-by date, or if there is a lot of friction (for example, during 'dry sex), or if an oil-based lubricant is used.



    

 

 

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  Section 4: Sexual development and function

 

 

DESCRIPTION

PROTECTION FROM PREGNANCY PROTECTION FROM HIV/STIS AVAILABILITY ADVANTAGES DISADVANTAGES
INTRAUTERINE DEVICE (IUD)
 

Small piece of plastic or copper that Excellent is put in the uterus (womb) by a trained health worker. It has a fine string attached to it that the woman can feel to ensure that it is still in place. The IUD prevents fertilisation.

Excellent. None. Increased risk of pelvic inflammatory disease (PID) following insertion or via string. Available in most areas from family planning clinics, but often only to women who have had children Do not need to think about it having sex. Women can check that it is in place herself. Heavier periods for some women. Needs access to health worker to insert or remove. Some conditions on which should not be used, especially history of STIs.
NATURAL FAMILY PLANNING Only having sex during the stages of  the menstrual cycle when the woman cannot get pregnant. It involves recognising these stages, including body temperature and changes on cervical mucus. Good if used properly. None. Can be used by any couple who know about woman's cycle. No side effects. Couples share responsibility for family planning. No expense. Requires commitment of both partner. Requires careful observation and record-keeping.
FERTILITY AWARENESS

Using a woman's knowledge of her menstrual cycle to decide when to use a contraceptive and when to have unprotected sex. A woman who wishes to become pregnant may have unprotected sex at the stage in her cycle when she can become pregnant, but use a barrier method (condom, female condom, diaphragm or cap) at other times to protect against HIV/STI transmission.

Good if used properly. Very good when using a barrier contraceptive. None during unprotected sex. Can be used by any couple who know about the woman's cycle. No side effects. Couples share responsibility for family planning. No expense. Requires commitment of both partner. Requires careful observation and record-keeping.
BREASTFEEDING Breastfeeding on demand can reduce the risk of pregnancy in the first six month by delaying ovulation. Most breastfeeding women start to ovulate after six month, even if they have not had a period. Good if breastfeeding exclusively on demand for the first six months.  None. Almost all women who have given birth can breastfeed if given support. Free. Not reliable after six months. Women with HIV may prefer not to breastfeed.
WITHDRAWAL This is when the man takes is penis out of the vagina before ejaculating (coming). Poor, because sperm may be releases before ejaculating. None. HIV has been found in semen releases before ejaculating. Available to all men. Useful if no other method is available. Man needs to think about it while having sex. May not be able to withdraw before ejaculating.
STERILISATION
(VASECTOMY)
This involves cutting the vas deferens in men to prevent sperm from joining semen (see page 36), or cutting or blocking the uterine tubes in women to prevent the egg and sperm from meeting. Excellent. None. Available from some health clinics by trained doctors. Do not need to think about it having sex. Requires operation under local anaesthetic (men) or general anaesthetic (women). Not easily reversible. Small chance of infection after operation.
EMERGENCY CONTRACEPTION
 

Can be used after unprotected sex if  the woman may have become pregnant. It takes the form of pills or an IUD. Pills should be taken within 72 hours of unprotected sex. The IUD can be inserted up to five days after unprotected sex.

Excellent if taken within time limits.

None.

Not widely available. Important option after safe sex 'accidents'.

Either method must be given by a trained health worker. May not be acceptable to some people who regard emergency contraception as abortion. 




    

 

 

Men's sexual health matters    36  Page 37  38  top of page

  Section 4: Sexual development and function

 

How to use a male condom
 
How to use a male condom


1
Check the expiry date on the condom packet. Take the condom carefully out of the packet.


2
Place the condom on the tip of the penis when it is hard and erect, but before it touches the partner's genitals. Make sure that the rolled-up condom rim faces outwards.

How to use a male condom

3 With the other hand, pinch the tip of the condom to remove any trapped air, and unroll the condom to cover the penis.

4 After intercourse, withdraw the penis carefully, but before it becomes soft. Hold the rim of the condom against the penis, so that semen does not spill out.

How to use a male condom

5 Slide the condom gently off the penis, and knot the open end.

6 After using the condom, throw it away safely.



How to use a female condom
 

How to use a female condom


1
Open the packet carefully.

2 Hold the small ring (at the closed end of the condom) between the thumb and middle finger. (Some women prefer to take out the small ring before insertion to make the condom more comfortable. )

How to use a female condom

3 Find a comfortable position, either lying down, sitting with your knees apart or standing with one foot raised on a stool. Squeeze the small ring and put it into the vagina, pushing it inside as far as possible with the fingers.


4
Put a finger inside the condom and push the small ring inside as far as possible. (It is also possible to insert the condom by putting it onto the erect penis before intercourse.) 

How to use a female condom

5 Make sure that part of the condom with the outer ring is outside the body. The outer ring will lie flat against the body when the penis is inside the condom. 

When the penis enters the vagina, make sure that the penis is inside the condom.


6
Immediately after sex, take out the condom by gently twisting the outer ring and pulling the condom out, making sure that no semen is spilt.




7 After using the condom, throw it away safely.



    

 

 

Men's sexual health matters    37  Page 38  39  top of page

  Section 4: Sexual development and function

 

Condoms 
Condoms are relatively cheap or free, easy to obtain, have no side effects and are easy to use. As well as preventing pregnancy, condoms offer the best protection against STIs including HIV and AIDS.

Questions and Answers 

Condoms

Q Do condoms take away the pleasure of sex - like having a sweet with its wrapper on? 
A
Wearing a condom does make sex feel different. But condoms are now made much thinner than they used to be. Knowing that both people are protected can make sex more relaxed and enjoyable. Wearing a condom can also make a man's erection last longer. Some men say that they prefer using a female condom instead of a male condom, especially for anal sex.

Q If I wear a condom, will my partner think I've got an infection?
A
More and more people now understand the importance of condoms for preventing infections as well as pregnancy. But if your partner asks you why you are wearing a condom, this is a chance for you to explain that it is to protect both of you.

Q Do condoms interrupt sex?
A I
f you plan to use condoms and have some nearby, they can  be put on more easily. Many men find that their erection sometimes goes down for a while when they put on a condom. It can help if the man's partner helps to put on the condom. It is important to make sure that the condom does not slip off the penis. Remember that if someone has an STI from having unprotected sex, this will be far more of an 'interruption' to a healthy sexual relationship than using a condom is.

Q Are condoms difficult to use?
A
Condoms are not difficult to use if you have learned how to use them and practised beforehand (see the diagram on page 34). Practise putting a condom on something like a banana or a bottle with a long neck, before you try one on yourself. You can also practise putting one on yourself, to gain confidence before you use one with a partner.

Q Are condoms reliable?
A
Condoms are generally reliable if they are used correctly (see page 34) and consistently. Condoms can sometimes slip off or even tear, but they are the best method of protection available against transmission of infections during sex, and they are an effective way of preventing pregnancy. 

Q Isn't protection the woman's responsibility?
A
Protection is the man's responsibility as well as the woman's. Would you want to rely completely on someone else for your own safety? Is this fair to the woman?

  


This activity aims to teach participants about contraception, and to give them practical experience of handling contraceptives.

TIME At least one hour.

MATERIALS A collection of contraceptives available locally, and drawings of methods that do not need contraceptives, such as withdrawal. 

There may be much embarrassed laughter during this activity but this is all part of the process of getting used to contraceptives. 

1  Ask the group to sit around one large table or in a circle on the floor. 
2  Layout all the contraceptives. Encourage the men to pick them up and handle them.
3  Ask the group members to say what they know about each one.
4  Ask volunteers to say who they think would use each contraceptive method, and why  - for example, unmarried men or older women with several children.

5 Now answer any questions or explain any items which were not understood.



    

 

 

Men's sexual health matters    38  Page 39  40  top of page

  Section 4: Sexual development and function

 

Kenya
Promoting vasectomy
A mass media campaign was held in Kenya to promote vasectomies. The project was aimed mostly at men, but also at partners and health workers. Radio and television programmes were broadcast in the city. In rural areas, mobile cinemas broadcast programmes. Adverts were placed in four daily papers. Men who had had vasectomies spoke as 'satisfied customers' and information was given about local family planning clinics. After the campaign, the number of vasectomies more than doubled. 

Johns Hopkins Center for Communications Programs, 1997, Reaching men worldwide (see Resources page).

 

Bangladesh
Working with religious leaders
The Family Planning Association of Bangladesh tried hard to increase access to different contraceptives at community level. However, they were not very successful. Religious leaders had a strong influence, particularly with men, and were often hostile to family planning organisations. 

In 1984 the FPAB started to involve religious leaders and gain their support. An expert with experience of both family planning and religious education made contact with the leaders to reduce their fears about family planning and its impact on religious teachings.

This led to a re-evaluation of the teachings of Islam on family planning. With the support of respected religious scholars, the religious leaders were encouraged to attend seminars. Courses for religious leaders and marriage registrars were organised, and a national conference for religious leaders was held. 

The leaders' support for family planning had a tremendous impact among men, and male opposition to family planning has been greatly reduced as a result of the programme. 

Ahmed Neaz, 'Converting Bangladesh's influential religious Leaders', Planned Parenthood Challenges 1996, No 2 (see Resources page).

 
 
Vasectomy 
Vasectomy is a small and very safe operation which stops a man from releasing sperm into his semen. Vasectomies cannot usually be reversed and so are suitable only for men who have had all the children they want or who are sure that they do not want children. 

The operation consists of cutting the vas deferens (see diagram on page 24) and tying up both ends of the cut vas deferens so that sperm cannot join the semen before ejaculation. It is done under a local anaesthetic and takes only a few minutes. There are usually no physical side effects, with only a small amount of bruising and soreness. For a while after the operation a man must use another method of contraception until tests confirm that no more sperm are being released

A new, 'no scalpel' method of vasectomy is also now available in some countries. This uses only a small hole instead of two cuts in the scrotum. Less anaesthetic is needed, there is less chance of infection, less soreness and bruising, and recovery time is shorter.  

A volunteer listens to a villager's views on religion and family planning, Bangladesh.


Vasectomy does not affect a man's sex drive. Ejaculation and orgasm will be the same, and semen is still produced as before. The only difference is that there are no sperm in the semen. Sperm are still produced in the man's testicles but are absorbed back into the bloodstream (as they would be if they were not ejaculated).


Abortion 
When women and couples do not have good access to contraception, they sometimes use abortion as a form of birth control. Men are often excluded from this process, seeing it as a matter for women only. 

Abortion can be upsetting, even for people who do not feel that it is morally wrong. It can be very dangerous and lead to infection, infertility or death if it is carried out unhygienically. However, an abortion carried out hygienically by trained personnel in early pregnancy carries a very low risk of danger. In general, abortion carries more risk to a woman's physical and mental health than other forms of birth control. The best way to prevent the need for abortion is for men and women together to make sure that unwanted pregnancies do not happen. Men have an important role in sharing responsibility for contraception. 

A man whose partner has an abortion may have strong emotional reactions. He may need encouragement and support to talk about his feelings. Women who are having abortions may need the support of their male partners. Health workers can help both partners by providing information and the opportunity for them to talk about their feelings. 



    

 

 

 
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