in Reproductive Health
EuroPROFEM - The European Men Profeminist Network http://www.europrofem.org
Male Involvement in Reproductive Health
Family Care International
and responsibility of men: The signers of the ICPD Programme of Action agreed that it is important
for men to take more responsibility for their sexual and reproductive
behaviour and family life. Everyone is more aware than ever of the need to
involve men in reproductive health programmes. Several NGOs are also
conducting research to determine what men's reproductive health needs are,
and to better understand their sexual, marital, parenting, and family
Women have long been the almost exclusive focus of international family planning and reproductive health programmes. Services for men have been relatively few and far between, as have efforts to include them as partners in services for women. More recently, however, male involvement in reproductive health has become a popular theme among reproductive health programme designers, policy makers, and population researchers. Still, exactly what "male involvement" means remains open to widely divergent interpretations.
This paper attempts to clarify what male involvement could mean, and how it has been interpreted in programmatic and research efforts. An analysis of socio-cultural and intellectual influences on the policies and research that give rise to and provide the context for reproductive health interventions, reveals the assumptions that have structured many programmes. We are fortunate to be able to rely on the Programme of Action from the 1994 International Conference on Population and Development (ICPD) in Cairo, as it provides language far more visionary than what is reflected in most reproductive health programmes. What are the concrete ways in which this vision can be translated more effectively into efforts to include men in reproductive health?
I. The Meanings of Reproductive Health and Male Involvement
Our problems in trying to involve men in reproductive health are fundamental. We are faced with questions about the very definition of reproductive health, and of male involvement and what both should entail.
1.1. What is Reproductive Health?
Although the term Ďreproductive healthí had seeped into usage before the 1994 ICPD, it gained wider acceptance only after the conference. At the conference, the interpretersí difficulty in translating the term into other languages was a harbinger of discussions about its meaning that have continued in the intervening five years.
Programme descriptions written since the Cairo conference are riddled with references to the Ďreproductive healthí services these programmes provide. To the extent that the term "reproductive health" has merely replaced "family planning," however, programmes remain unchanged. Family planning programmes naturally emphasized family planning methods, while reproductive health programmes are meant to be considerably more comprehensive. By invoking the concept of health, the newer term makes reference to a much broader idea of well-being than the provision of family planning services, and simultaneously is held to a considerably higher standard. Thus an important objective of this work is to look at ways in which reproductive health programmes do something more than provide methods of contraception, even if men are also the recipients of these services.
One of the most important contributions of the ICPD document was to state that family planning programmes should not be the only means of carrying out a countryís population policy and demographic goals. Yet in developing countries one of two scenarios seems to prevail: reproductive health programmes that have been built upon former family planning programmes are overseen by ministries of population or planning rather than health ministries; or are situated in health or family planning ministries that are strongly clinical in orientation and ill-equipped to cope with the broader social goals of reproductive health. The "measures of success" of all of these bodies will naturally differ substantially. Given the history of family planning and reproductive health, and the orientation of these ministries, the placement of reproductive health programmes works against attempts to move away from an exclusive emphasis on family planning and to provide broader health services.
The implications for reproductive health programmes are serious. On the one hand, reproductive health rhetoric requires that programmes take responsibility for a greater range of services and information. But most governments are reluctant to drop the "quick and easy" family planning approach to population planning for a multi-sectoral collaboration to achieve population objectives. This, then, is the context within which most reproductive health programmes are being asked to take on the mantle of the ICPD vision.
1.2. What is Male Involvement?
In keeping with the above discussion, the concept of male involvement in reproductive health is also ambiguous. In fact, our discussion of reproductive health raises the first question one needs to ask: male involvement in what? Ranging from setting out a bowl of condoms in the family planning clinic waiting room to educating men about womenís health and gender roles, attempts to involve men vary enormously.
In developed countries, efforts to involve men began as early as the late 1970s, with attempts to make women-oriented family planning clinics more inviting to men. Not much progress has been made over the past 20 years (see, e.g., Gordon and DeMarco 1984), though men are in general more welcome than they are in developing country reproductive health clinics. In developing countries, the tendency has been to exclude men from reproductive health work other than vasectomy or condom distribution. The management of family planning programmes by ministries of population planning meant that the most efficacious means of controlling population growth were pursued: permanent or at least long-term methods among women, who because of their involvement with children and their position in society, tended to be more compliant patients and customers.
Feminism can be credited in large part with sparking the shift toward greater concern with men and their roles in reproductive health. Women were being held solely accountable for "bad behaviour" (excessive childbearing) when the anthropological literature increasingly showed the locus of decision making to reside in units larger than individual women: in couples, in families, in communities. To some extent this turned the family planning reasoning on its head: rather than looking to womenís adoption of family planning as the source of social change, we began to see social and cultural change as fundamental to womenís use of contraception.
The emergence of the HIV/AIDS epidemic also played an important factor in increasing attention to men. Often for the first time, demographers were compelled to address sexuality, a glossed-over aspect of studies of fertility, and looking at sexuality meant looking at partnerships and gender roles. An additional major source of pressure to increase male involvement has been a sort of menís movement within the reproductive health field. Menís advocates argue that men, who are often less likely to seek out health care anyway, have long been excluded from an important area of health care services; that in all fairness, they also deserve some of the basic services that comprise reproductive health care. These, then, were some of the factors culminating in a more holistic and social change approach to population stabilization articulated in the Programme of Action of the ICPD.
1.3. Why Involve Men in Reproductive Health?
But some strong advocates of the use of family planning for population stabilization remain unconvinced that to involve men in reproductive health is a worthwhile endeavour; the evidence for this in the structuring of new reproductive health and family planning programmes rather than any sweeping statements made on the topic. In their view, it is far more cost-effective to promote womenís use of family planning (see Schuler et al (1995) for the strategic reasons to focus on women). Women, who are primarily responsible for rearing children, are likely to be more committed to contraceptive use than men, goes the reasoning.
Three reasons are most often given for involving men in reproductive health: 1) expanding the range of contraceptive options; 2) supporting womenís contraceptive use; 3) preventing the spread of sexually transmitted infections (PATH 1997). Taken alone, these three reasons are highly clinical in orientation, and focus on contraception and sexually transmitted disease. Supporting womenís contraceptive use is a worthy cause, but this motive could be more usefully be expressed as, "the support of contraceptive use by men and women." In most settings, social change must occur to change people's ideas about contraceptive use, health childbearing, and sometimes even sexuality; bringing about this social change is a powerful reason to involve men in reproductive health. "As programs move toward a concept of shared responsibility for family planning and reproductive health, reaching men with information and services regarding their own reproductive health as well as that of their partners becomes essential" (PATH 1997: 7).
A fourth and, in the view of this author, the most compelling reason for involving men in reproductive health is to use the forum of reproductive health programmes to promote gender equity and the transformation of menís and womenís social roles; this reason is least often given as a justification for including men, however, though the implications of male involvement are broader than are often noted (Green et al 1995).
It is important to note here that although biology determines much of our reproductive roles, the social overlay of our gender roles is at least as important for determining how we fulfill our sexual and reproductive roles in a given setting (Mundigo 1995). To some extent, an exclusive focus on the instrumental promotion of family planning methods among women takes refuge in the biological basis of reproductive role differentiation, when we must attend to not only reproduction but sexuality itself.
1.4. Scope of this paper
This paper is essentially an analysis of approaches to working with men in reproductive health. It undertakes to describe and examine the ways in which research on family planning and reproductive health, and the policy context in which programmes are developed shape and, to some extent, constrain programmes. The review is not comprehensive but attempts to illustrate some of the patterns that arise when family planning and reproductive health specialists, who have largely focussed on women, turn their attention to men. Policies, research, and programmes have reinforced each other in constraining the ways we think of including men in reproductive health. The paper concludes with an analysis of the implications for the explicit and implicit frameworks for programmatic efforts, and recommendations for ways that male involvement can reflect a more transformative approach to gender relations.
II. Moving toward the vision articulated in the ICPD Programme of Action
2.1. Language of the ICPD Document Concerning Men and Reproductive Health
Gender inequality and the dominance of men in many areas of life are increasingly understood as important considerations for the development of any programme in sexual and reproductive health. Less widely accepted is the notion that sexual relations and reproductive health are a forum in which culturally informed notions of gender are played out. Reproductive health work therefore requires great sensitivity to gender dynamics and social factors that may appear tangential to health. It is difficult to develop a "gender neutral" intervention without thoughtfully anticipating the impact on gender relations of whatever the programme might be.
The language of the Programme of Action is far more comprehensive than most population specialists would suspect (see Box 1 for relevant excerpts). The document states, for example, that "Men play a key role in bringing about gender equity since, in most societies, men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and programme decisions taken at all levels of Government. It is essential to improve communication between men and women on issues of sexuality and reproductive health, and the understanding of their joint responsibilities, so that men and women are equal partners in public and private life" (Paragraph 4.24).
Some players in the family planning and reproductive health field have interpreted the ICPD Programme of Action merely as a guide to "how to do family planning better." But the document provides a larger vision of the social changes and multi-sectoral activities required to stabilize population and increase human welfare. "Respectful and harmonious partnership," "sensitivity and equity in gender relations"-- the programmatic implications of these are clearly greater than much of the work that has been done in the area of male involvement. Unfortunately, what this means is that every person, programme, and policy at every level must take responsibility for bringing this kind of change about. Yet what one often finds in family planning and reproductive health programmes is that philosophical changes have just entered the consciousness of people at the highest administrative levels, and have often not permeated intervention work.
As often happens, then, the translation of principle into practice has been slower and narrower than this vision might suggest. This research analyses the Planís language on men and interprets it in light of programme and policy changes. A look at constructions of masculinity and femininity in different contexts suggests the important constraints on policies and programmes posed by gender norms and expectations.
Understanding the ways in which male involvement is structured is essential to seeing whether interventions simply build on and consolidate male power in decision making and allocation of resources, thereby potentially eroding womenís power; or whether they thoughtfully take gender relations into account to find ways of enhancing womenís status and involving men in supportive partnerships. Just as the emphasis on womenís contraceptive use and reproductive health reflected an acceptance of womenís exclusive responsibility for childbearing and rearing, the ways in which men are introduced into existing programmes or programmes are designed for men reflect understandings of their roles and how and where they can fit into reproductive health care interventions.
2.2. Defining Reproductive Health Jointly
Reproductive health involves the well-being and participation of individuals and their partners. In the sexual and reproductive health arenas, can we argue that the concept of jointly determined health is more central than in other areas? In invoking men as partners, we are concerned with the concept of shared health not just shared responsibility. Reproductive health reflects both social and physical realities involving partners: communication, cooperation, comfort, and the state of being free of disease, for example.
It is clear that women bear greater health hazards associated with reproduction than men, even though it is men who are largely responsible for originating them--for example in a situation where an unwanted pregnancy is followed by an unsafe induced abortion. Furthermore, men are often responsible for the sexually transmitted diseases that their partners endure (Mundigo 1995: 5).
While the basic sentiment of this statement is hard to argue with, the way in which are men are culpated seems a function of the ways in which men are not only able to but allowed to walk away from reproductive health. In other words, there is to some extent a backlash exactly because menís non-involvement has been permitted socially and supported programmatically for decades. Programmes permitted and even at times promoted the disengagement of men from family planning activities, and are now faced with the challenge of addressing the "problematic" social behaviours they once condoned.
From a concept of jointly determined health arises one of the fundamental principles of male involvement in reproductive health: that we cannot limit ourselves to the clinical care of individuals whom we treat as if they existed in a social vacuum. Indeed, we have a responsibility to concern ourselves with the social implications of our "neutral" interventions.
III. The Treatment of Men in Reproductive Health Policy, Research, and Programmes
3.1. Policy formulation and the treatment of men in reproductive health programmes
This section describes the factors influencing how reproductive health programmes have been structured, where they have resided in government ministries, and why. We all know that health programmes have closely associated mothers and children to the exclusion of men. The term "maternal and child health" trips easily off the tongue, and our field is filled with examples of the primacy we give to the mother-child relationship.
Although this paper is largely about reproductive health programmes in developing countries, it is important to mention here the impact of political shifts in donor countries and the consequent changes in reproductive health programmes. In developed countries, an important source of funding in this area, conservative swings in government have at various times made support of international population efforts unpopular. Family planning advocates, during these periods, have had to strategise about ways to present the purpose of their work, i.e., it reduces child mortality, or it enhances the status of women. Of note in the United States, for example, are factors driving a concern for menís doings, including welfare reform and an emphasis on fatherhood as part of this effort. Advocates for women, particularly teenagers, welcome the expansion of the obsessive focus on adolescent girls to the boys and men who play an important role in their childbearing.
In light of the directives that came out of the Cairo ICPD meeting, one other factor deserves special notice. Starting in the 1950s, when mortality declines led to dramatic growth rates in developing countries, population growth and its control were identified as a development issue at the national level, and a security issue at the international level. Early on, family planning was identified as the principal means of carrying out national population control programmes--if womenís fertility could be reduced, population growth could be checked.
Because of this population-control motive for family planning, the international donor emphasis in these "health" programmes was on contraceptive prevalence and couple years of protection. Therefore, long-term methods like sterilization, the pill, and IUDs were seen as more reliable--they would contribute to the achievement of demographic goals. Out of this situation, of course, arose a vocal feminist resistance to the promotion of certain methods of family planning in developing countries, including some not permitted by food and drug control boards in the West. It is important to mention this aspect of the history of family planning, because it gave rise to the regrettable situation we see today, where womenís advocates and population planners in some developing countries find themselves in opposition to one another. While seeing the merits of reduced family size for women's well-being, feminists must position themselves staunchly against the distribution of problematic drugs and methods under the auspices of population control programmes. Likewise, population planners would do well to enlist the aid of womenís advocates, but their commitment to demographic objectives, sometimes at the expense of women's health concerns, has alienated these important potential allies.
3.2. Images of men in demographic research on fertility and family planning
The importance of research in buttressing policies and programmes cannot be underestimated, much as researchers might at times like to separate their objective inquiries from applied use of the information. Research reflects the assumptions made by programmes and their evaluations, and it solidifies their assumptions and structure by making them "scientific." The links between programmatic work and social science research are naturally close, since both reflect similar assumptions about menís and womenís roles. The approaches to both endeavours have been constrained by powerful assumptions about gender roles. It is thus imperative that existing work be analysed so that these limitations will be understood and exceeded.
3.2.1. Men had been neglected in demographic research...
Men have had a low profile as subjects in demographic research on reproduction (Greene and Biddlecom 1997). Empirical research and the theoretical bases for demographic research have mutually enforced one another in this oversight. Demographers justified the exclusion of men from their research by pointing to the ill-defined span of menís reproductive lives, their assumed inability to report on their progeny, the unlikely chance that they would be at home to be interviewed by a survey taker, and the frequency with which children ended up in the custody of their mothers at the end of a marriage. Polygyny and extramarital partnerships further dashed any hopes for tidy, lasting pairings that would facilitate analyses based on data from men.
The tendency to generate cross-national rather than cross-cultural data also limited demographersí focus to broad categories that make generalizations possible. On the one hand it makes sense to collect data at the administrative level and at the unit that will, after all, be administering health or population policy. But the fact that many surveys in developing countries have been funded by developed-country consortiums has created a strong tendency to collect cross-national data.
Perhaps most important for this discussion of male involvement, however, is the strong bias toward a western family that powerfully limited demographic conceptualizations of the issues, and therefore data collection, and analysis. Through the establishment of international family planning programmes funded by developed nations, these assumptions about gender roles were propagated throughout the developing world. The demographic accounting system for biological phenomena like births and deaths was not principally concerned with explaining why these things happened the way they did. Frozen within this accounting system were strong assumptions about womenís (primary) and menís (secondary) roles in childbearing, and the consonance of the views of husbands and wives.
Let us take just a moment to explore the nature of the assumptions about gender roles. "In short, we have regarded men as important economically but as typically uninvolved in fertility except to provide sperm and to stand in the way of contraceptive use. As Watkins (1993) argues, Ďmodernization [theory] and the New Household Economics share similar understandings of men and women... Men work outside the home, whereas women are responsible for activities associated with the production of children and domestic servicesí" (Greene and Biddlecom 1997: 7). By holding women entirely accountable for children, our field made it widely acceptable to collect fertility data from women only.
Similarly problematic was the assumption that husbands and wives agree simply on matters relating to fertility. This would mean that the coupleís preferences could accurately be represented by hearing what a woman had to say about her childbearing plans and contraceptive use. Greene and Biddlecom (1997) argue that the notion of the romantically elided desires of husbands and wives in developed countries map nicely onto the notion that husbands might completely dominate their wives in other settings. In either case, information on one spouse was assumed to be sufficient to provide for analyses of fertility. As Lesthaeghe (1989) has pointed out, however, these assumptions are highly problematic, particularly where marriage and childbearing are more tenuously linked, or where spouses have more financial independence from one another.
Financial independence is, of course, just one aspect of marital power, just one determinant of the husbandís or wifeís relative position in the kinds of negotiations that are a basic part of partnership. "By routinely excluding men from demographic analyses regardless of cultural context, research has treated husbands and wives as entirely analogous individuals in a dyad. The neglect of power relations both inside and outside the relationship has made it difficult to make sense of reproductive decisions in different contexts" (Greene and Biddlecom: 8). The role of power relations has increasingly been recognized by demographic researchers, and this gives us another imperative to know more about both men and women.
We have been speaking of preferences--what about the actual marital and childbearing experience of individual partners? The model we are describing here assumed that the partners had identical childbearing experience. It further assumes that either the relationship is monogamous and that all childbearing occurs within that union, or that the divergent experience of the other spouse does not matter or has no influence over childbearing of the current partner.
Marital arrangements that diverge from the Western monogamous ideal provide a good example of socio-cultural systems that... make traditional demographic research on womenís fertility alone less appropriate: polygyny (Speizer 1995), marital infidelity (Orubuloye et al 1992), and marital instability (Rao and Greene 1993) illustrate these points well (Greene and Biddlecom 1997: 16).
Such cultural "deviance" from a culturally-specific monogamous norm has increasingly pushed demographers to reevaluate their categories and assumptions.
3.2.2. Men now receive more attention in demographic research
Interest in menís demographic roles has been on the rise over the past few years, as witnessed by numerous review articles and analyses of what we canít know about fertility by studying only women. Box 2 presents a summary of the reasons for this shift. Feminist thinking among researchers has certainly played an important role in influencing the meaning of childbearing, child rearing, and marital roles in womenís lives. This line of thought has advanced the study of the sexes in relation to one another and not just of womenís characteristics as determinants of fertility (see Presser 1997).
At the policy level, feminist activism has strongly affected the formulation of health and population policy and the definition of what is important to study. It is activists concerned with womenís total responsibility for contraceptive use, among others, who have pushed the notion of "male responsibility."
The inability of classic demographic transition theory, the idea that all populations eventually will pass through the same mortality and then fertility declines, to explain fertility decline in many settings has also promoted more culturally-informed research on childbearing. Gender roles are at the core of the cultural roots of fertility, and thus this shift to looking at cultural variation rather than cross-cultural similarity has led to much research on gender. The concurrent rise in the use of qualitative data has also led to more nuanced examinations of gender roles in different settings, and this requires more information about and from men. The units of analysis have expanded as well, from a strict focus on individuals, to more attention to couples, families, and social (e.g., Bongaarts and Watkins 1996) and sexual (Bond 1995) networks.
Although with each passing day men are featured more often in demographic studies of fertility, "demography has a tendency to care about men simply because of their association with women, who continue to be the primary focus; and to care about women simply because of their reproductive role" (Greene and Biddlecom 1997: 18). But more recent research, including the body of work that came out of Family Health Internationalís Womenís Studies Project (Barnett and Stein 1998), has focussed on women's well-being. Now that fertility decline has taken place in so many settings, do we, in fact, see resultant improvements in womenís status? This is a key question in determining the way that interventions seek to involve men in reproductive health.
3.2.3. Still, men have been misrepresented in traditional demographic research...
Let us now turn briefly to a look at the limited ways in which men have been portrayed in demographic research. As a result of the fact that men were of no interest for such a long time, and later were included only insofar as their wives were interviewed, we are left with somewhat distorted accounts of menís behaviours and preferences. These accounts and the gaps in them consequently fortify any original assumptions concerning menís roles.
Box 3, which depicts the various ways in which we could gather information on men, helps to convey how the information we have can be distorted. If we know nothing of men, we have clearly decided that they are not important in our studies of family planning and reproductive health. Since we have no information on them, our suspicions of their unimportance are confirmed. We could, on the other hand, have information only on men from their partners. This would be a moderate improvement, but enables us to look only at men currently in unions, and often only those who are formally married. A further widening of our scope has at times permitted the collection of information on specific "manly" topics, such as income and employment, from men. We are not likely to learn much about fertility preferences here.
The inclusion of husbands is a further step in the right direction, though again, is selective only for men who are currently in union and acknowledged by their spouses. Given the ways in which people in many cultures depart from the monogamous norm, we are missing out on interesting segments of the male population. Finally, we arrive at the conclusion that if we are seriously interested in male involvement in sex, fertility, family planning, and reproductive health, we had best study them for themselves, and not only as appendages of women, whose fertility often remains the main item of interest in such surveys.
As Greene and Biddlecom (1997) have shown, several powerful stereotypes about men guided much research on both women and men: Men are both ignorant and irresponsible with regard to fertility control; they block womenís contraceptive use while at the same time being themselves sexually promiscuous, and to top it off, do not invest as they should in their children. In different settings these generalizations may be more or less true; but that is not relevant here. The point is that this complex of (for a long time) largely unsupported notions about menís roles in family and sexual life determined the direction and content of research on fertility and contraceptive use and family planning programmes.
3.2.4. Some research is required for programme development -- but not too much
The above statements could imply that we need to rush out and interview as many men as possible before we can develop any policy or programme initiatives on male involvement. That is not the message this paper means to communicate. We have, in fact, huge amounts of information collected by anthropologists and other researchers in related fields that is of direct relevance to our work in reproductive health. It is possible to develop well-informed programmes and to base our research on those, enabling us to move forward while we wait for additional primary research on men.
Programmes should attempt to involve men with attention to these themes, and not be hindered by the fact that more research is needed. Several thematic changes are required, including the creation of closer linkages with work on female empowerment. To make the conceptual linkage acknowledges the social change required for this kind of work. Therefore, research should look at both men and women, at their conceptions of gender roles and masculinity and femininity, and how these relate to their reproductive roles.
3.3. Menís Changing Roles in International Reproductive Health Programmes
The course of programmatic efforts to involve men in reproductive health has parallelled the changes undergone in the area of research on reproduction. The emphasis, even in more recent attempts to deal with the issues, has been on family planning delivery and the control of sexually transmitted disease, a much less ambitious approach than that advocated in the Programme of Action.
Over the past four decades, menís roles in international family planning efforts have followed a fairly homogenous course, even in widely divergent cultural settings. Early family planning work was more symmetrical in its provision of the relatively few methods available to both men and women. The advent of the Pill, the IUD, Depo Provera, and Norplant, each in its time, contributed to an increasing skewing of family planning efforts in the direction of women. The spread of sexually transmitted diseases and the emergence of HIV/AIDS encouraged more attention to sexuality, an area neglected in family planningís and demographyís one-sex approach to fertility. To work with sexuality necessitates an understanding of peopleís social relations, their emotions, and their views of themselves -- all "soft" topics that were more difficult to deal with than straightforward method use.
For a long time, family planning advocates argued for support for their work by pointing to the impact of reduced family size on womenís mobility, empowerment, and health. In the 1990s, the question has been turned around: after the international population communityís many successes in promoting family planning, have there been measurable effects on womenís well-being, which was, after all, a primary justification for the work? Have women reaped the extolled benefits of their increased contraceptive use? The term "unfinished transition" (Population Council 1996) was coined to identify the improvements in the status of women that were promised by family planning advocates to be one of the positive results of declines in fertility.
What are the implications of this for structuring male involvement? A lack of clarity about what should be done to increase male involvement in reproductive health and whether it should be done has meant that in spite of considerable discussion of the issues involved, innovative programmes have not necessarily been forthcoming. What do we do about reproductive health problems that affect men only, such as urological disorders and prostate and testicular cancers? A review by Green et al (1995: 1) suggests that most of the reproductive health problems faced by men are not life threatening, but do affect quality of life for both men and women. Menís multiple roles -- as sexual partners, parents, family and household members, community leaders, and gatekeepers -- affect their stake in reproductive health (Green et al 1995). How should we respond to the multiplicity of men's and women's roles -- and should we work within existing programmes or with the development of new ones?
IV. A Critical Analysis of Explicit and Implicit Conceptual Frameworks
As this paper has explained, men and women are constructed in various ways by programmes, and these constructions are revealing of implicit and explicit motivations for serving or including them in various ways. This next section explores the practical implications of adopting these frameworks for reproductive health work. How are the structure and objectives of programmes determined by assumptions about the roles men play in reproductive health?
Many organizations and individuals working with reproductive health and family planning have articulated their own visions of what "male involvement" means or should mean. The orientation of each vision is revealed by the language used to describe programme strategies and goals (see Box 4 for a descriptive list of some of the terminology and justifications for male involvement). Should men be encouraged to take more responsibility for their sexual activity, including contraceptive use? Should they be more involved in existing reproductive health programmes for women? Should they participate actively in reproductive health programmes at all levels? Or should men be brought in to reproductive health programmes as clients in and of themselves? These questions must be considered by any programme wishing to increase male involvement.
4.1. Male involvement frameworks: Themes and differences
In his brilliant book Homo Hierarchicus, Louis Dumont criticizes the tendency within the social sciences to emphasize classification and categorization rather than the nature of relationships between categories. He argues that modern social science has relied upon analytic categories and singular identities to the point that it tends not to see the contextual connections affecting every person, institution, or social action. Taking the right and left hands as an illustration of his point, Dumont suggests that they are not simply equivalents (as is misleadingly implied by the common descriptor "hand"). Instead, they are defined in relation to each other and have highly differentiated cultural meanings. Similarly, it is important to recognize that a culturally created system of gender likewise determines the positions, relationships, and roles of men and women. For that reason it is much more effective to take a systemic, relational approach to understanding social and sexual roles, particularly with regard to how men and women interact.
Returning to Box 4, three general terms are more fundamental than the rest and deserve discussion first. Male involvement appears at the top of the chart, as it seems to be the most comprehensive and useful term (thus its use in the title of this paper as well). Involvement can be of many kinds. Male participation is likewise quite broad, but implies participation in existing reproductive health activities, usually services for women. Male responsibility is less comprehensive than the first two terms. The term reflects the widespread belief that men have been "irresponsible" and now should take their fair share of responsibility for birth control use and STD control. Many men may well be irresponsible, but this cannot form the basis for a positive reproductive health programme that seeks to involve men and women in a transformative way. Nonetheless, I have used the term here because it represents a portion of current discourse on these issues.
Programmes designed to serve men primarily as reproductive health clients emphasize the need to provide reproductive health services to men in much the same fashion that women have received these benefits. They are concerned with the availability of male contraceptive technology, and services tailored to menís needs. These reproductive health interventions frequently seem more attuned to issues of male sexuality than are many programmes for women. Of greatest interest are often programmes for adolescent boys and young men, as this work tends to be more socially innovative.
In many social settings, male health care workers are able to approach male clients, and may advocate for partnership and the support of womenís reproductive health. This role for men in reproductive health is primarily a clinical one, yet has broader social implications in a field whose personnel have historically been more likely to be women. In some settings, the presence of men in what has largely been a womenís domain may be problematic; in others, it may increase the quality and standing of the services in the eyes of the community.
Child health and womenís health care services now commonly appear in tandem, but involving men as fathers is a relatively promising way to involve them as well. In the past, health and family planning services have emphasized menís financial responsibilities, while less has been asked of men with regard to their commitments of time and effort. Were fathers somehow more involved in the health care of other family members, reproductive health services could include them more easily. Some work in safe motherhood has brought men in by giving them specific information about pregnancy and birth, and by defining and valorizing specific roles that men and often only men can fill. As many midwives have noted, if men were more closely familiar with labour and delivery, their involvement might more easily be encouraged, while at the same time their respect for women would be enhanced.
The final approach to male involvement is the focus on men as partners of women, an area of great promise for the kind of gender role change the ICPD document outlines. The safe motherhood initiative referred to above is an example of a creative way to involve men more closely in the process of childbearing. In preventing and treating sexually transmitted infections, for example, involving both/all partners is fundamental. For many reasons, issues relating to sex may often ignite episodes of domestic violence, or sex may be the means through which the violence is carried out. For this reason, domestic violence is increasingly understood as a reproductive health issue (Heise et al 1995), and must be anticipated and addressed by reproductive health programmes. Understanding the reasons that some men may be reluctant for themselves or their partners to use contraception is key in overcoming resistance to other kinds of reproductive health care. The perspective of men as partners may also open possibilities for synergies in health care.
4.2.1. Obstacles to including men in reproductive health programmes
It is hoped that the rationale for including men in reproductive health programmes is clear thus far. Since many people involved in reproductive health work are not enthusiastic about including men, let us review some of the primary objections to involving men in reproductive health in Box 5. They settle rather neatly into two types: feminist and administrative. The concerns of womenís advocates are those that bring us together for this discussion. If men are to be involved in reproductive health, they must be included with careful attention to the risks that their inclusion poses to womenís autonomy, privacy, and health. Will they be in direct competition for limited resources currently devoted to the care of women? Will women lose the modicum of power afforded them by services exclusively for them? Does the new concern with male involvement in reproductive health indeed reflect concern with male sexuality whereas family planning focussed relentlessly on womenís fertility?
Why, then, are men to be included in reproductive health activities? Is the objective to increase contraceptive prevalence? To promote womenís health needs which will continue to remain the primary focus of reproductive health programmes? To provide for menís own reproductive health needs? Or to contribute to communication between the sexes and mutually empowering partnerships? Each of these motivations would necessitate slightly different approaches, and each has as its correlates differing objections to involving men in reproductive health.
This paper argues that many of these objections to including men tacitly reflect the assumption that family planning is a key component of population policy rather than part of wider health care objectives. Population policy is important, and for that reason, the provision of family planning certainly is as well. But the focus on the demographic efficacy of family planning significantly constricts its impact in terms of a broader interpretation of health care.
On the administrative side of certain male-involvement strategies, low cost-effectiveness is the primary obstacle that policy makers seem to report. Yet there is little data assessing the relative cost-effectiveness of carefully designed and more appropriate programmes for men. More importantly, to what measure of success does this "cost-effectiveness" refer? There are indicators that fertility reduction is the objective, including concern that "the cost-effectiveness of male involvement may be difficult to determine because it requires measuring the indirect influences men have on their partnersí use of contraception" (Danforth and Green 1997: 9). This lingering and limiting emphasis on family planning and contraceptive use is in considerable tension with the much further-reaching reproductive health orientation many programmes now officially endorse.
It is vital to acknowledge that at this stage there are few good models for male involvement work, and little research measuring the impacts and benefits of male involvement in family planning and reproductive health. This gap will rapidly resolve itself as we work toward greater clarity as to what male involvement means, what it should accomplish, and how we might develop programmes oriented toward social as well as medical understandings of reproductive health.
4.2. Programmes with varying objectives and their impact on gender dynamics
It is important to repeat here an idea presented earlier in this paper. Gender inequality is acknowledged as an important challenge in the development of any programme in sexual and reproductive health. Still not as widely accepted is the idea that sexual relations and reproductive health are an arena for the playing out of culturally informed notions of gender inequality. This reality makes it virtually impossible to develop "gender neutral" interventions around this highly charged set of relations. There is no social institution, no social behaviour, no culturally determined individual preference relating to reproduction that is does not prescribe different behaviours and meanings for men and women. For that reason, we cannot, and should not "neutralize" gender; rather, we need instead to work toward gender sensitivity with the aim of addressing disparities in power and self-determination that typify the lives of women in so many places. Box 6 lists some relevant areas in which gender divergence is significant with regard to reproductive health, and therefore necessitates attention to social inequities. Involving men must be done with the awareness of the delicate balances of relations which can be rearranged by any intervention.
4.2.2. Ways in which men have been included in reproductive health programmes
There are ways and ways of being "gender sensitive" in the development of programmes. Schuler et al (1995) have raised the important distinction between accommodating to gender relations and addressing them in Bangladesh's family planning programme, where "accommodation to gender-based social inequality has been its weakness as well as an important factor in its success" (1995: 133). This particular style of woman-focussed community based distribution, "instead of attempting to engage men, ... places the responsibility for family planning disproportionately on women, who lack the resources to deal with its costs and risks" (1995: 133). They go on to point out that, "the family planning programís woman-centered approach motivates women to take responsibility for family planning. In using contraceptives, however, as in most of what they do, Bangladeshi women are extremely dependent and vulnerable" (1995: 136). The authors conclude by arguing that womenís subordination should be addressed directly, as contraception is not a solution, whatever effects it may be posited to have on womenís status.
There are also certain "neutral" interventions which, in fact, seem to consolidate gender inequities, and are therefore harmful. This discussion therefore focusses on the unintended consequences of different approaches to involving men in reproductive health. Given the limitations to the length of this paper, the text takes the didactic approach of presenting examples of a more problematic variety in each area of male involvement.
The sense of "doing no harm" must extend to the social implications of reproductive health programmes. Programmes strongly reflect assumptions about sex roles (e.g., womenís primary responsibility for children and therefore for fertility control), and about the demographic imperatives of family planning, and thereby reinforce those relations when they deal with clients. As Skibiak (1993) has shown in Bolivia, programmes marginalise men and minimize male participation by "restricting the dissemination of information through selected gender-specific channels or by reinforcing gender stereotypes that for cultural reasons are not likely to be challenged or discussed openly" (1993: 5), i.e., assuming male objections to and female responsibility for contraceptive use.
Menís use of contraceptive methods -- Fewer male contraceptive methods exist, to be sure, and each has a distinctive position in the range of possibilities. Condoms have gained enormously in popularity over the past 20 years, due in large part to the rise of HIV/AIDS and other STDs. Traditional family planning programmes have never taken withdrawal very seriously, even though it is widespread especially in certain settings such as Turkey (Unalan 1998) and Sicily (Schneider and Schneider 1996). And vasectomy has enjoyed periods of popularity but has not caught on in many places because of unaddressed fears of its effects on male strength and virility (see, e.g., Khan et al 1997).
In response to a backlash against forced vasectomy, the Indian family planning programme for decades made little effort to promote the method. Sterilization remains the most commonly used methods by couples in reproductive age. Since considerable time has passed, is it not now appropriate to start marketing vasectomy, a much less serious surgery than female sterilization? Little effort has been made to clarify for Indian men and women the actual effects of vasectomy, because health workers themselves are not enthusiastic about it -- it is widely understood to reduce menís physical strength, and people who rely on menís physical labour are therefore fearful to risk it.
In spite of new research on a male contraceptive pill, withdrawal's grudging acceptability, and other advances in male contraception, "In practice, participation in family planning has been measured by contraceptive usage, particularly in respect of women. In respect of male participation however, measures of success have been based on the manís awareness of the methods of family planning... Only in isolated cases have men been asked if they personally participate in family planning. Logically, therefore, programmes and projects appear to operate from the erroneous premise that contraception is the responsibility of women and that men by implication, are not supposed to contracept" (Popoola 1994: 11-12, emphasis added). Not only do programmes operate from this premise; they have communicated it to their workers and clients.
Finding that menís fertility preferences are more closely associated with couple contraceptive use, another researcher concludes that
more must be done to understand the inclinations, preferences, and behaviors of men. Unfortunately, even scholars who acknowledge a male role often prescribe (along with making family planning amenable to male needs) improvements in the situation of women (e.g., schooling) or in male-female communication, as means of enhancing the outcomes of womenís negotiations with men, without addressing menís fertility demands (Bongaarts and Bruce 1995; Phillips et al. 1997). Implicit here is the hint of a female right usurped by men. If, however, the reproductive decision is, by cultural right, a manís decision and menís fertility preferences are high, then it is unclear how effective the independent status of women or an improvement in communication will be (Karra et al. 1997) (Dodoo 1998: 239).
This quotation is reported here in such length because it expresses several troubling sentiments that shed light on the present discussion: that men's fertility desires should be addressed for reasons of fairness that imply symmetry in gender relations; the denial of gender inequity through reference to efforts to increase women's negotiating power; and the complete acceptance of men's dominant position in certain cultural settings as justification for focussing on men in family planning efforts.
Menís encouragement of womenís contraceptive use --
This activity is more inherently problematic from a gender perspective than some of the other kinds of interventions. Capturing some of the pitfalls in this work, one heavily cited article on Ghana reports that "...spousal influence, rather than being mutual or reciprocal, is an exclusive right exercised only by the husband" (Ezeh 1993: 163). The author goes on to conclude that, "a program that targets men as a means for reaching and altering their wivesí reproductive behavior will fare much better than one that targets women as a means for reaching their husbands" (Ezeh 1993: 173, emphasis added). Joesoef et al (1988) confirm the efficacy of this approach for Indonesia using the same language. The involvement of men as lobbyists for their wives' contraceptive use is unselfconsciously being advocated.
The vocabulary of equity and equality in many studies is a clue to the problem. This same study by Ezeh attributes the "limited impact of family planning programs in Ghana and most of sub-Saharan Africa to the continued neglect of men as equal targets of such programs. The need to target and involve men equally in family planning programs cannot be overemphasized" (Ezeh 1993: 173, emphasis added). The use of "equally," and "equity" with regard to men and women is well-intentioned but completely overlooks gender power inequities and the role of advocate with the wife that has been identified for men. This treatment of the sexes as if they were symmetrically related is precisely the critique that Dumont makes in offering the example of the right and left hand, which we treat as symmetrical though they are profoundly distinguished by their organic relationship with one another.
Ironically, it is because some organizations have given some thought to gender that they endorse working with male opinion leaders. They need to give a little more thought to it, however, in the view of this paper. The large family planning programme in Navrongo, Ghana has made efforts to work with community leaders (men) to increase contraceptive use (by women) without making any effort to influence social relations. The programme is described as "a bold new program aimed at altering villagersí knowledge, attitudes and practices with regards to family planning" (Population Council 1992: 1), and it seems to have done that. But it is strictly limited to increasing adoption of methods, mostly by women, and shows no sign of challenging the position occupied by powerful male opinion leaders. "...anecdotal evidence confirms menís dominant role with regard to family health matters, while also pointing to high rates of teenage and unwanted pregnancies. It is strongly felt that unless men can be persuaded to take a positive and active interest in maternal/child health, family planning will make few inroads in the area" (Population Council 1992: 1).
Addressing gender is not easy, and one is simultaneously critical of and sympathetic with the Al-Seeb Pilot Community-based Male Motivation Project in Oman, which appears to have been an entirely "accommodating" programme. Married men were their primary audience, and the message (key to a communications programme) was that "birth spacing has benefits for every member of the family and that when a father makes a decision to space births he provides health and happiness to his family" (Johns Hopkins Center for Communications Programs 1997: 38). The report of this project says nothing about any effort to address the gender inequity this message builds upon.
Sexually transmitted disease -- The major orientation of global HIV/AIDS prevention programmes has been to promote condom use, yet this is bound to fail without closer attention to gender relations (e.g., Worth 1989). Without working on menís (and womenís) stereotype of women as sexually passive, women will remain unempowered to suggest use of a condom before sexual relations. Furthermore, the social values and sexual double standards that permit men to seek out prostitutes and to have sexual liaisons outside their primary relationships without communicating about them with their partners have been addressed in very few places.
Condoms have also been promoted by employers concerned with the economic impact of HIV/AIDS in their workforce (e.g., Henry 1995). In Tanzania, condoms were provided for HIV control without addressing the gender issues of sexual activity Ė and the use of condoms remained limited to menís casual relationships. "Tanzanian men may be using more condoms, but chances are they are using them with casual sex partners, not their wives... ĎWhen the husband is [HIV] positive, the wife will always be there to take care of him. But if his wife is positive, she might be thrown out,í" stated the administrative director of the Tanzania Electric Supply Company, Ltd. (Henry 1995: 21). Yet no effort has been made to address this problem, either through talk of sexuality, relations with oneís spouse, or how families could be kept together.
In the programme of one Madagascar employer who provided family planning to employees (Severo et al 1996), workers who spent considerable periods away from their families had a high incidence of sexually transmitted disease. When they left for work, they were given condoms by a project distribution worker, which eventually reduced the companyís high costs of penicillin, the solution they had originally settled upon. Again, however, there appeared to be no effort to address men's use of prostitutes or to unite families separated by men's long absences.
Safe motherhood -- Another area of work in which men have been drawn in has been that of maternal mortality. Efforts to address morbidity and mortality necessarily rely on the participation of other members of a womanís household, in addition to health workers and the woman herself. This is an area in which efforts to involve men seem to have been relatively successful (see, e.g., Howard-Grabman et al 1994). Pregnancy, labour and delivery are arenas from which men are consistently excluded in developing countries, and were until recently in developed countries. By giving fathers and other family members more information about the health risks involved in the whole process, and by clarifying for them the important roles they could fill with regard to identifying and responding to problems, this initiative found constructive ways of recruiting men to support womenís reproductive health and to learn more about their own.
Fathering -- With fathering, as with involvement in reproductive health in general, the emphasis should be on equal participation, not just equal responsibility. As this paper has mentioned with regard to research, "responsibility" defines a more limited role for men, who, in a sense, are then being invited only to shoulder their economic and contraceptive burdens. Again, the orientation is a negative one. Engle and Breaux (1998) note that social change has led to "a retreat from family obligations...; men have less to gain from and less to give to their families" (1998: 12). Yet men and their families have considerable affective resources to offer one another, if menís roles can be expanded in creative ways.
Programmes need to be based on the expectation that men will participate in fathering, the social role and not only the financial role, as they can be drawn into the rewarding processes of childbearing and parenting. In another article, Engle and Alatorre Rio (1994) recommend workshops for adolescents of both sexes and adult men on masculinity and femininity, efforts to get men directly involved in childrenís health care, birthing, and child care. "Greater attention to the role of the father in childrenís welfare is not intended to be a return to male authority in the home" (Engle and Breaux 1998: 13).
In Ghana, one effort to promote fathering has been to involve men in Daddies Clubs (IPPF 1990). Enthusiastically praised in the organizational literature, the Clubs "meet weekly after work and enjoy activities as diverse as lectures, films, indoor games, and debates," where there is apparently some discussion of family planning related issues. Though never formally evaluated, the clubs were independently observed to degenerate into meetings at the bar among men who have children, contributing directly to their absence from home where they are needed though with the intention of getting them more involved in their parenting roles.
Menís reproductive health -- This is in some respects the most controversial approach to involving men in reproductive health. As mentioned above, when we address reproductive health issues that are unique to men, we are potentially talking about tradeoffs with resources for womenís reproductive health. In very real ways that have to do both with menís and womenís health risks as well as the structure of programmes for each sex, the approaches to menís and womenís reproductive health are not equal. In programmes for men, there is often more concern with menís sexuality than there is for womenís sexuality in womenís reproductive health programmes (witness the controversy over the coverage of Viagra in US health insurance policies that still fail to cover contraception). An account of a failed menís reproductive health clinic in San Francisco (Gordon and DeMarco 1984) showed that men themselves didnít share the perception that there was a need for reproductive health services. Competition was felt with the womenís programme, and the menís programme was not cost-effective, since few men came there to get contraceptive services. In developing countries, the situation is somewhat different, because of the few alternatives to health care services that are associated with family planning clinics.
Male health workers Ė There are many caveats to recommendations to recruit and promote male health workers in developing country settings, the primary one being that in many places, women are reluctant to seek out services in settings where they will come into contact with men. There are also few examples of creative use of their roles in such settings. Here are two examples in contrast with one another.
In Peru, male contraceptive distributors were recruited, and were found more likely to serve male clients (Foreit et al 1992). "The study suggests that CBD programs can influence method and client mix by recruiting more men as distributors. Finally, the results also demonstrate that successful programs for males can be incorporated within existing CBD structures and do not require special training or client materials... Males may be more difficult to recruit than females because they are more likely to be employed and have less time to volunteer, or because the small commissions available from selling contraceptives do not attract them" (Foreit et al 1992: 61). In some sense, this kind of male involvement is about men and women as sales people, an acceptable approach if we are absolutely resolved with regard to what programmes wish to "sell." The report is able to describe the work in gender neutral terms because the project is totally focussed on distribution of commodities, and not on the social relations that determine and are affected by their distribution.
A male doctor and abortion provider writes an interesting account of the supportive role that male health personnel can play in relation to a couple seeking out abortion (Gianotten 1996). The male doctor is in the position of supporting the man, promoting respect for the female partner undergoing the procedure. "I believe that the male doctor has a better position to reach the potential of the male partner... the male doctor can use his gender as a tool in making the differences between being male and female understandable. There are many gender differences which become visible in the process of an abortion. Above all man and woman have a different set of emotions, of coping with them and of handling the emotions of the partner in distress" (Gianotten 1996: 3). In this case, the male health worker acknowledges the gender issues raised by the situation, and his unique relationship with the male partner, and makes use of them to promote better understanding.
Employer-based reproductive health work Ė Management is drawn to participate in family planning and reproductive health programmes for various reasons. Epstein (1996) has shown that a higher percentage of female workers stimulates the initiation of employer-based services, because of concern over time lost due to pregnancies. Motivation for the work influences the nature and measure of success of these programmes. In Zambia, Macwanígi (1995: 16) found that top management personnel didnít participate directly in the programmes, with negative effects on workersí attitudes. There is always a risk that the association of family planning with the employer increases pressure on employees to adopt methods in fear of their jobs. This concern has been raised with regard to Bangladeshís armed forces programme (AVSC 1991), with the risks that military discipline might extend into enforced vasectomies.
Reports on employer-based work in Jamaica and Tanzania showed one problem to be that few organizations have policies on how to treat people with HIV/AIDS, and the implications for employees can be terrible (AIDScaptions 1995). In Tanzania, "one manager reported that people at his workplace who are believed to be carrying HIV are tested without their knowledge. Positive results are reported not to the person who is infected, but to the personnel department and to that personís closes relative, because the company does not have people trained to give pre- and post-test counseling" (Henry 1995: 20). This clearly shows the orientation toward the needs of the company rather than its employees.
4.2.3. Newer Areas of InterventionĖGreater Promise for Innovative Involvement of Men?
Three newer areas of intervention may offer greater promise for the innovative involvement of men.
Combatting gender-based violence -- Domestic violence is increasingly acknowledged as a reproductive health issue by practitioners and researchers (Rao and Waters 1993; Heise et al 1995). One suggested response to domestic violence is to link reproductive health services more closely with institutions that are better able to address these issues (see e.g., Barnett and Stein 1998). Early efforts by the reproductive health field to respond to this violence has tended to focus on women since they most often present the problem to reproductive health workers, and most current services are directed at women. A study of male attitudes in Gujarat, India, found widespread sexual violence and coercion, reflecting women's low status; yet the solution the paper concludes with, "only strong advocacy and major social changes which could empower the women could alter this equation" (Khan 1997: 15), disappointingly avoids suggesting what men might do.
Working on changing social expectations and attitudes is more complicated than responding clinically and practically to the consequences of violence. Some interesting work has been done with men, one example of which is Mexico's Colectivo de Hombres por Relaciones Igualitarias (CORIAC) (Liendro 1997). Men who are themselves dealing with violence, most often their own, meet voluntarily to discuss the nature of their relationships with women, the ways in which they have internalized macho and limiting concepts of masculinity, and how to understand their own emotions better, to identify which situations risk becoming violent. "We have to break the myth of the violent man as the exception, as pathological, because the problem is cultural. That's why we propose the concept of re-education rather than therapy" (Liendro 1997: 49).
Working with adolescents in a broader range of interventions -- As we have noted, reproductive health is an area in which gender relations are strongly expressed and enforced. During the adolescent years, young people are inculcated with the principles of their future roles as adult men and women -- principles which tend to offer boys greater freedoms, and girls greater constraints (Mensch et al 1998). In nearly all societies, girls and women's sexual behaviour is more strongly regulated -- and in many developing countries in particular, its control is a matter of individual and family honour and a lightning rod for sentiments about proper behaviour (Greene 1998a).
Thus it is that if we are able to find ways of working with adolescents on gender-related issues and reproductive health, we have really accomplished something. Gender is a powerful organizing system and pervades all areas of life. Schooling and domestic roles are often contingent upon the primary demands of reproductive roles. School girls in Kenya, for example, may seek out sugar daddies in an effort to pay school fees, thereby exposing themselves to the risks of pregnancy and disease, and paradoxically, of being expelled from school (Mensch and Lloyd 1998). Boys in Kenya generally pay no consequences of impregnating girls, while pregnant girls are expelled from school. For reasons such as these, we must address issues and institutions apparently unrelated to reproduction in our multi-sectoral programmes for young people (Mensch et al 1998a).
Many conceptualizations of male involvement present a much more ample vision of working with boys, mentioning their "need to meet societal expectations of men" (PATH 1997). The notion seems to be that boys can still be influenced, while men, after all, who are fully inhabiting these societal expectations. With adults, approaches to reproductive health are more inevitably clinical in orientation, and efforts to influence the social circumstances of sexual expression, contraceptive use, communication, and other aspects of reproductive health are rare. The episodic sexual relations of unmarried youth require special consideration, so even girl-oriented programmes promote condoms and are more likely to include young males than programme for adults (Green et al 1995).
Understanding Masculinity and Femininity and How They Structure Reproductive Roles Ė Research from Thailand illustrates the usefulness of looking at masculinity and its relationship with sexual behaviour, though there is an ongoing debate as to what use to make of the information. Sexual encounters with commercial sex workers most often follow from episodes of public drinking (Fordham 1995). Supporting prostitution in Thailand are the following factors: the expectation that women will be sexually inexperienced and men sexually experienced at the time of marriage, the importance of potency as an element of masculinity, and high tolerance for "excessive drinking among Thai men and for the rowdy and reckless behavior that may result" (Van Landingham et al 1993: 299).
Fordham (1995) takes the analysis one step further, distinguishing between different types of social gatherings involving drinking and, just as importantly, the different kinds of sex that Thais experience in marriage and outside it. "It is here in the public sphere that, as Mulder (1992: 76) puts it, 'expectations about his [males'] virility' are proven in 'typical acts of virile behaviour, such as impressing others by their boldness, womanising, or big-spending' (1992: 103)" (1995: 170). As in much of Latin America, the wife and mother is associated with images of nurturance, warmth, and control, and the sensual side of her nature is devalued. Thus "the significance of these practices [seeking out prostitutes] likes not in their scripts per se, but in their relationship to the normative sexual practices of the domestic sphere" (Fordham 1995: 171). Continuing the investigation, VanLandingham (1998) finds that in these group settings, men often push each other into doing things they are reluctant to do, or for which they require the "courage" given them by the alcohol they consume.
This work has attempted to clarify what the ICPD Programme of Action has to say with regard to male involvement, and has indicated some approaches to take and others to avoid. The language of the document provides remarkably comprehensive instructions for increasing male involvement, yet efforts to involve men frequently are not as attentive to their social impact as they need to be to fulfill its vision. Several recommendations are offered to guide programmatic efforts to involve men in reproductive health:
1. Clarify objective of involving men
It seems almost too simple to mention, but any programme wanting to involve men should clarify for itself at the outset why it would like to involve them. Aside from a desire to repeat the Cairo rhetoric, what are its motivations for wanting to bring men in? It should consider what the risks of doing so are for the welfare of the women it already serves, and for the relationship between the men and women it wishes to assist.
2. Anticipate the impact of programmes on gender relations
A greater sense of "doing no harm" is needed in programme development, and it must extend to the social implications of reproductive health programmes. Programmes strongly reflect assumptions about sex roles (e.g., womenís primary responsibility for children and therefore for fertility control), and about the demographic imperatives of family planning, and they reinforce those relations when they deal with clients. The impact of any intervention on gender relations needs to be anticipated and addressed.
3. Conduct research -- but don't hide behind it
The parting refrain of papers on male involvement is often the recommendation that "more research on men is needed in order for interventions to be developed." There is much existing ethnographic research that would shed light on gender relationships and inequities in specific settings. Traditional demographic data are not necessarily more useful given the new directions in which male involvement must go -- they are laden with assumptions, and often work to involve men in activities whose basic premises have not been questioned from a gender equity perspective.
4. Multi-sectoral social change
The treatment of male involvement as a separate activity directly reflects the ways in which the social themes we see in our particular area of work, i.e., reproductive health, are treated in a vacuum with few links (conceptual or practical) being made to other areas. Since we are talking about gender in a larger sense, we are talking about social change, and the responsibility for this must be shared with other institutions and programmes. For too long, the population field has placed the exclusive and complete burden of population stabilization on family planning and reproductive health programmes. Other areas of intervention must be brought into cooperation with this objective.
The reasons for involving men and the frameworks used to do so are closely bound up with one another. The most widespread seems to be the recruitment of men to facilitate women's contraceptive use. This follows naturally from the conclusion drawn by earlier studies that portrayed men as "obstacles" to women's contraceptive use. The second most commonly pursued goal is to provide reproductive health services for men, much as they have been provided for women. This in itself is not objectionable; less acceptable are the assumptions that 1) there is complete symmetry between the sexes that calls for services for men completely on the basis of "fairness"; and that 2) clinical approaches to men's sexually transmitted diseases and contraceptive needs will be enough.
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