Male involvement in reproductive health: Incorporating gender throughout the life cycle

II. Gender and the life cycle approach to reproductive health

As previously mentioned, there are serious shortcomings in the reproductive health field because of the lack of knowledge concerning gender from the male perspective. In the broadest terms this means that only one side of gender relations has been investigated, and that virtually all of our theories and applications are to some extent suspect, undoubtedly biased, and will need to be re-thought and amended at some time in the future when data on male perspectives is available. The implications of this lack of male gender theory are significant for the applied fields of population and reproductive health which depend, in part, on the social science literature for theoretical constructs, methodological tools and other applications for the allocation of resources and the design of effective programmes and services.

Given the aforementioned dilemma, there is a need to develop a practical methodological tool for initiating discussion on the topic and beginning to fill in the gaps in our knowledge. In order to facilitate this process, we suggest the utilization of a life cycle approach to examining the hierarchical gender system and its implications for sexuality and reproductive health. The life cycle is a common feature of all human populations and provides a useful format for incorporating interdisciplinary perspectives, including the elusive socio-cultural context. Moreover, the format can be effectively utilized to generate participatory discussions (with colleagues or informants) in settings where little is known about male perspectives.

The life cycle approach has been very useful in the understanding of the prevalence and incidence of stage-wise discriminatory health and education practices affecting women. The assessment by juxtaposition of the male-specific aspects of the life cycle with those of the female can highlight the key issues, characteristics and roles of each gender, thus leading to a pertinent analysis of the actual, ascribed and prescribed roles of each gender, thereby helping to identify significant areas of intervention. A revision of the existent socio-cultural research studies and literature on the issue of gender will permit a fresh look at the main gaps in knowledge, notions, myths, stereotypes and prejudices relating to men that affect male reproductive health motivations and behaviours.

Our general purpose at this initial stage is to suggest basic questions, including raising a series of interrelated issues concerning the confluence of socio-cultural, political-economic, and health factors in order to link them with male involvement programmes.

The Socio-cultural Approach: Holistic Perspectives

Socio-cultural research is based upon a holistic interdisciplinary methodology for examination of specific questions and hypotheses. In the broadest sense, socio-cultural research is based upon investigation of a problem(s) in the larger social, political-economic, and environmental context. The major aim of the approach is to come to a deeper understanding of multi causality as it is reflected in social processes. While no study can effectively incorporate all possible aspects of the holistic context, it is essential to identity a few: key dimensions for investigation. In the present case, we are interested in identifying and understanding the evolution of male gender perspectives on sexuality and reproductive health. Our examination will include political-economic, social-structural and cultural, and socio-medical dimensions.

Examining the Gender System: Male and Female Intersections

In order to analyse the hierarchical gender system in any given society one must begin with a basic assessment of social structure, that is, the major characteristics of social organization that govern social relations. The type and organization of the social structure have major implications for the gender system. Gender perspectives (including those concerning reproductive health and sexuality) are embedded in this larger structure. It is thus necessary to identify the salient characteristics of social structure for each region (or sub-group of interest) and assess its implications for the gender system. For example, in many parts of South Asia, the social structure is patrilineal, and is based upon male descent, authority, and power. As such, all children are born into the kinship group of their father, while females leave the group upon marriage and join the kin group of their respective husbands. Adult males are ascribed formal financial responsibility for their parents (and anyone residing in the parental household) as well as their own households. Accordingly, males are the sole heirs to property (primarily land) upon the death of their father or other male relatives. (In the rare occasions of divorce, the children remain with their father, and mothers must return to their parental household without financial compensation or sometimes rights of visitation with the children). Polygamy is socially sanctioned although generally only affordable by more prosperous households.

The asymmetrical social and economic structure outlined above has major implications for sex preference of children, cost and value of males and females to the household, capital investment in males and females (medical treatment, education, nutrition), socialization processes, and many other aspects of behaviour. In the exercise that follows, we will begin to identify some of the major characteristics of social structure and their implications for the gender system, especially regarding male perspectives on reproductive health. Our example will focus on assessing what is currently known/not known at various stages of the life cycle for the case of South Asia. It is not meant to be a comprehensive exercise, but an illustration of the way in which the socio-cultural context can be linked to reproductive health services to improve them.

During an internal workshop of the CST Harare, a preliminary version of this paper was presented. A working group composed of UNFPA Country Representatives and CST advisers reviewed the following matrix from a southern African perspective. In terms of the female adolescent, the group proposed focussing on the topic of the declining age of menarche in southern Africa. The group stressed that virginity is not always highly valued in all societies and that first sexual encounters are often associated with rape, incestuous relationships, as well as with confusion and physical and psychological pain. Sugar daddies are a consequence of the economic situation, as well as young daughters being forced into prostitution. Although there is shame associated with menstruation, there are also positive rituals for it associated with womanhood. There are many female-headed households and even child-headed households. The notion of delayed marriage is being replaced by a pre-marital relationship. The implications these facts have for reproductive health programmes are that promotion of responsible sexual and reproductive behaviour should be addressed within a broader sociopolitical context. It should be recognised that particularly for adolescents, economic survival and empowerment have major influences on their behaviour. The information, education and communication (IEC) strategies applied need to be more sensitive to how masculinity is defined. The examples provided for this region differ significantly from those in this document, which is additional evidence of the need to emphasise the socio-cultural approach.

For purposes of the current exercise, the South Asian model will be examined throughout four basic stages of the life cycle: Infancy and Childhood; Adolescence; Adulthood; and Older Ages. In order to conduct a similar exercise in other regions, it will be necessary to analyse the four life cycle stages according to the socio-cultural context which affects the way they are defined.

SOCIAL STRUCTURE AND THE GENDER SYSTEM: IMPLICATIONS FOR RH AND SEXUALITY THROUGHOUT DIFFERENT STAGES OF THE LIFE CYCLE

INFANCY AND CHILDHOOD

COMMON ISSUES TO BOTH GENDERS

Socialization processes which inculcate ideas of male power and authority and female subordination

FEMALE

MALE

Sex selection via testing for the purpose of eliminating female foetuses.

Preferential treatment with respect to investment of household resources for food, medical treatment, education, etc.

Neglect and induced morbidity and mortality (including infanticide) to eliminate female infants in situations of economic crisis.

Socialization processes whereby males are taught that daughters are less valuable than sons to the household and thus may be treated dismissively.

Differential allocation of food and medical treatment with implications for morbidity (including stunting and RH problems) and mortality.

Concepts of manhood which emphasize male dominance, power, authority, and entitlements are inculcated.

Concepts of womanhood that emphasize a secondary, subsequent and supportive, rather than a leadership role.

Formal economic responsibilities for the household in adult life are firmly ingrained.

Differential allocation of educational resources with implications for empowerment.

Rites of passage ceremonies with implications for health, RH, and socialization into male roles as prescribed in the social structure.

Rites of passage ceremonies with implications for health, RH, and socialization into female roles as prescribed in the social structure.

KEY INFORMATIONAL NEEDS

More in-depth knowledge of male perspectives on socialization processes during childhood (including rite of passage ceremonies); concepts of manhood and their inculcation in childhood; male perspectives on the differential treatment and roles of girls and boys.

Formulation of appropriate curricula and material in formal and non-formal education programmes, including the evaluation of existing curricula and pedagogical material, teacher and health worker training, counselling, parental/family involvement, etc.

IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES

Develop an Advocacy/IEC strategy directed to both parents and children, to promote the value of the girl-child, the value of education for her, to promote the value and importance of sharing life roles and responsibilities based on each individual's comparative advantage, the importance of equal care and nourishment for both genders

ADOLESCENCE

COMMON ISSUES TO BOTH GENDERS

1. Transition from childhood to young adulthood (physical and social).

2. Increasingly delayed marriage due to education and migration for education and work.

3. Breakdown of traditional familial controls on courtship, marriage and sexuality.

4. Lack of information and education regarding RH and sexuality.

5. Influence of role models in definition of behaviour.

FEMALES

MALES

Menarche

Expected to provide labour (and sometimes financial support to the household) before marriage. In some societies daughters are expected to forgo schooling and work to provide resources for the education of their brothers.

Formal financial responsibility for the parental household in old age.

Less access to higher education than males thus creating knowledge and power imbalance.

Expected to seek education, find wage labour job and delay marriage for an extended period in order to support the education of siblings, provide capital for the household, build house for parents, etc.

Traditional family controls to avoid initiation of sex. Virginity highly valued.

Parental pressure to postpone sexual activity during period of delayed marriage (to avoid untimely

Boyfriend pressure for initiation of sex.

Peer pressure for initiation of sex during period of delayed marriage.

Early sexual experiences often associated with pain, physical mistreatment, unwanted pregnancy and STDs.

Definition of manhood tied to initiation of sex (which sometimes leads to commercial sex).

Breakdown of traditional system with onset of out- migration.

Usually free from suspicion of being infertile.

Females not prepared to negotiate sexuality in Post- traditional settings.

Sex often related to expectation of physical pleasure and experience but no expectation that men should help women to feel the same way.

Sexuality related to expectation of love and marriage.

Increased risk of STD/HIV associated with migration to cities for work and education.

In some societies, pressure to prove fecundity before marriage.

Risk taking behaviour associated with definition of masculinity.

Increased risk of pregnancy and STD/HIV associated with migration to cities for work and education.

Responsibility for sexual outcomes seen as female.

Transmission of HIV/AIDS is increased due to gender disparities in relationships; for example when there is a large age difference.

The inculcation of shame regarding menstruation leads to lack of proper knowledge of hygiene (with implications for infection), lack of attention to RH issues (including RTIs and STDs), and related health problems.

Male peer groups from young age and also mass media often promote a direct identity between masculinity and dominance in decision making.

KEY INFORMATIONAL NEEDS:

Information concerning RH, sexuality, and gender relations issues confronting adolescents who migrate to cities for education and work during the period of delayed marriage.

Participatory research involving adolescents in identifying problems and finding solutions and identify effective strategies and channels for informing, promoting and sustaining healthy reproductive behaviours.

Information relevant to the constellation of factors necessary for the design of adolescent and "male friendly" services.

Deeper understanding of male perspectives concerning sexuality (especially roles and obligations for different types of partners); sexual initiation; "dating" and courtship behaviour; RH and sexuality knowledge and practices.

Risk-taking behaviour and its determinants. Health-seeking behaviours.

IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES

Based on an understanding of the determinants of behaviour and of risk behaviour, design an EC strategy to avoid unsafe behaviour.

Promote responsible sexual and reproductive behaviour, keeping in mind is that if men do not take full responsibility for their sexual and reproductive behaviour, it is not due to their irresponsible nature, but because they are acting within a set of cultural norms that determine gender relations, gender roles and acceptable behaviour for each gender.

Advocate for the implementation of a sexuality and reproductive health education programme.

In the services for adolescents, incorporate components to teach sex negotiation skills, skills to counter peer pressure, decision-making skills, components to make each gender understand the other gender's expectations regarding sexuality and sexuality outcomes.

Develop an EC strategy that fosters masculinity definitions not linked with early practice of sexual relations

Identify healthy and socially acceptable rites of passage for men.

Link RH programmes with job creation programmes.

Insure confidentiality in services.

ADULTS

COMMON ISSUES TO BOTH GENDERS

1. Lack of information regarding RH and sexuality for both sexes.

2. Increased labour migration (including rural/urban, circular, and international) and exposure to increased STD/HIV infection.

FEMALES

MALES

Patrilocal marriage (women join the kinship group of their spouses upon marriage) thus disenfranchising them from familial social and power networks.

Patrilocal marriage. Men establish an independent household and are expected to assume formal responsibility for the economic foundation of the family.

Polygamy. The hierarchical system of power within the household gives senior wives control over access to food and other household resources thus positioning women in competition with each other for economic resources. This often leads to health problems for minor wives who lack sufficient access to food and medical treatment especially during pregnancy.

Division of labour which marginalises the roles of men in various aspects of parenting.

Lack of knowledge of female RH issues (particularly regarding pregnancy, childbirth, and post-partum) due to rigid division of gender domains.

Dowry. Payment of expensive dowry to husband's family as part of marriage contract. The practice has lead to severe cases of abuse and sometimes mortality to wives whose families have not settled their contractual arrangements.

Lack of knowledge regarding dangers of differential access to food and nutrition for male vs. female children and wives.

Lack of knowledge and awareness of male RH issues and concomitant lack of services.

Traditional practices "birth traditions" concerning pregnancy, childbirth, and the post-partum period which can have dangerous consequences for mothers (food taboos, binding of the uterus, "sweating," etc.).

Monopoly of most knowledge of health issues.

Traditional ideas about where and how to deliver babies.

Outcomes of sexual relationships related to morbidity and mortality, abortion.

Seen as responsible for contraception and as guilty for infertility.

Accepted double standard in sexuality.

Lack of knowledge about the implications of rape and other sexual and domestic violence on the other sex.

In some societies, dowry to be paid to wife's family.

Expression of male power and legitimacy over the partner in sexual matters.

KEY INFORMATIONAL NEEDS

Information on RH, sexuality and gender relations from the male perspective.

Information concerning different perspectives on sexuality and RH among males and females.

Information concerning social and physiological issues concerning female menopause.

Information on different perspectives on number, spacing and role of children in the family.

Information concerning the socio-cultural and gender context of HIV transmission.

IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES

Develop an EC strategy to raise awareness among men of reproductive health risks and effects of harmful practices.

Design EC approaches that target men's informational needs regarding RH, sexuality, nutrition and to promote healthy behaviour.

Develop programme components to promote quality communication between spouses and promote gender equality.

Conduct participatory research (as with adolescents) which involves adult males in identification of current problems and solutions, including design of "male friendly' services.

Raise awareness among men about the value of women's work and contribution to the household.

Provide counselling and treatment for both men and women related to rape and sexual violence.

OLDER AGES

COMMON ISSUES

Lack of knowledge of health, RH and sexuality issues among and regarding older men and women

FEMALES

MALES

Longevity and age differences with spouses lead to greater frequency and longer periods of widowhood.

Sexuality and RH Issues not addressed by men in part due to conflict with male ideals of power and control (extending to the body).

Gain of status and power in household in older ages.

Longer period of fertility can lead to fatherhood later in life.

Loss of power, status, property through widowhood.

Increased poverty.

Loss of power after son assumes role of household head and/or retirement in some societies.

Major responsibilities for care of aged.

Sexuality and RH issues not addressed due to lack of knowledge, neglect, discrimination, poverty and no provision of services.

Extra-marital partners among those who can afford it is a mark of status, manhood and accomplishment may create increased risk of STD/HIV infection.

KEY INFORMATIONAL NEEDS

Basic information concerning RH and sexuality problems (physical and social) for men and women in order to assist with the design of better services.

IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES

Develop informational and social support programmes for both men and women on menopause, clarifying commonly held myths.

Create awareness of the risks of AIDS transmission.

Create awareness of each gender's reproductive health concerns during this period.

Promote communication between partners on sexuality/reproductive health issues.

INFANCY AND CHILDHOOD
COMMON ISSUES TO BOTH GENDERS
Socialization processes which inculcate ideas of male power and authority and female subordination
FEMALE	MALE
Sex selection via testing for the purpose of eliminating female foetuses.	Preferential treatment with respect to investment of household resources for food, medical treatment, education, etc.
Neglect and induced morbidity and mortality (including infanticide) to eliminate female infants in situations of economic crisis.	Socialization processes whereby males are taught that daughters are less valuable than sons to the household and thus may be treated dismissively.
Differential allocation of food and medical treatment with implications for morbidity (including stunting and RH problems) and mortality.	Concepts of manhood which emphasize male dominance, power, authority, and entitlements are inculcated.
Concepts of womanhood that emphasize a secondary, subsequent and supportive, rather than a leadership role.	Formal economic responsibilities for the household in adult life are firmly ingrained.
Differential allocation of educational resources with implications for empowerment.	Rites of passage ceremonies with implications for health, RH, and socialization into male roles as prescribed in the social structure.
Rites of passage ceremonies with implications for health, RH, and socialization into female roles as prescribed in the social structure.
KEY INFORMATIONAL NEEDS More in-depth knowledge of male perspectives on socialization processes during childhood (including rite of passage ceremonies); concepts of manhood and their inculcation in childhood; male perspectives on the differential treatment and roles of girls and boys. Formulation of appropriate curricula and material in formal and non-formal education programmes, including the evaluation of existing curricula and pedagogical material, teacher and health worker training, counselling, parental/family involvement, etc.
IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES Develop an Advocacy/IEC strategy directed to both parents and children, to promote the value of the girl-child, the value of education for her, to promote the value and importance of sharing life roles and responsibilities based on each individual's comparative advantage, the importance of equal care and nourishment for both genders
ADOLESCENCE
COMMON ISSUES TO BOTH GENDERS 1. Transition from childhood to young adulthood (physical and social). 2. Increasingly delayed marriage due to education and migration for education and work. 3. Breakdown of traditional familial controls on courtship, marriage and sexuality. 4. Lack of information and education regarding RH and sexuality. 5. Influence of role models in definition of behaviour.
FEMALES	MALES
Menarche
Expected to provide labour (and sometimes financial support to the household) before marriage. In some societies daughters are expected to forgo schooling and work to provide resources for the education of their brothers.	Formal financial responsibility for the parental household in old age.
Less access to higher education than males thus creating knowledge and power imbalance.	Expected to seek education, find wage labour job and delay marriage for an extended period in order to support the education of siblings, provide capital for the household, build house for parents, etc.
Traditional family controls to avoid initiation of sex. Virginity highly valued.	Parental pressure to postpone sexual activity during period of delayed marriage (to avoid untimely
Boyfriend pressure for initiation of sex.	Peer pressure for initiation of sex during period of delayed marriage.
Early sexual experiences often associated with pain, physical mistreatment, unwanted pregnancy and STDs.	Definition of manhood tied to initiation of sex (which sometimes leads to commercial sex).
Breakdown of traditional system with onset of out- migration.	Usually free from suspicion of being infertile.
Females not prepared to negotiate sexuality in Post- traditional settings.	Sex often related to expectation of physical pleasure and experience but no expectation that men should help women to feel the same way.
Sexuality related to expectation of love and marriage.	Increased risk of STD/HIV associated with migration to cities for work and education.
In some societies, pressure to prove fecundity before marriage.	Risk taking behaviour associated with definition of masculinity.
Increased risk of pregnancy and STD/HIV associated with migration to cities for work and education.	Responsibility for sexual outcomes seen as female.
Transmission of HIV/AIDS is increased due to gender disparities in relationships; for example when there is a large age difference. The inculcation of shame regarding menstruation leads to lack of proper knowledge of hygiene (with implications for infection), lack of attention to RH issues (including RTIs and STDs), and related health problems.	Male peer groups from young age and also mass media often promote a direct identity between masculinity and dominance in decision making.
KEY INFORMATIONAL NEEDS: Information concerning RH, sexuality, and gender relations issues confronting adolescents who migrate to cities for education and work during the period of delayed marriage. Participatory research involving adolescents in identifying problems and finding solutions and identify effective strategies and channels for informing, promoting and sustaining healthy reproductive behaviours. Information relevant to the constellation of factors necessary for the design of adolescent and "male friendly" services. Deeper understanding of male perspectives concerning sexuality (especially roles and obligations for different types of partners); sexual initiation; "dating" and courtship behaviour; RH and sexuality knowledge and practices. Risk-taking behaviour and its determinants. Health-seeking behaviours.
IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES Based on an understanding of the determinants of behaviour and of risk behaviour, design an EC strategy to avoid unsafe behaviour. Promote responsible sexual and reproductive behaviour, keeping in mind is that if men do not take full responsibility for their sexual and reproductive behaviour, it is not due to their irresponsible nature, but because they are acting within a set of cultural norms that determine gender relations, gender roles and acceptable behaviour for each gender. Advocate for the implementation of a sexuality and reproductive health education programme. In the services for adolescents, incorporate components to teach sex negotiation skills, skills to counter peer pressure, decision-making skills, components to make each gender understand the other gender's expectations regarding sexuality and sexuality outcomes. Develop an EC strategy that fosters masculinity definitions not linked with early practice of sexual relations Identify healthy and socially acceptable rites of passage for men. Link RH programmes with job creation programmes. Insure confidentiality in services.
ADULTS
COMMON ISSUES TO BOTH GENDERS
1. Lack of information regarding RH and sexuality for both sexes. 2. Increased labour migration (including rural/urban, circular, and international) and exposure to increased STD/HIV infection.
FEMALES	MALES
Patrilocal marriage (women join the kinship group of their spouses upon marriage) thus disenfranchising them from familial social and power networks.	Patrilocal marriage. Men establish an independent household and are expected to assume formal responsibility for the economic foundation of the family.
Polygamy. The hierarchical system of power within the household gives senior wives control over access to food and other household resources thus positioning women in competition with each other for economic resources. This often leads to health problems for minor wives who lack sufficient access to food and medical treatment especially during pregnancy.	Division of labour which marginalises the roles of men in various aspects of parenting. Lack of knowledge of female RH issues (particularly regarding pregnancy, childbirth, and post-partum) due to rigid division of gender domains.
Dowry. Payment of expensive dowry to husband's family as part of marriage contract. The practice has lead to severe cases of abuse and sometimes mortality to wives whose families have not settled their contractual arrangements.	Lack of knowledge regarding dangers of differential access to food and nutrition for male vs. female children and wives. Lack of knowledge and awareness of male RH issues and concomitant lack of services.
Traditional practices "birth traditions" concerning pregnancy, childbirth, and the post-partum period which can have dangerous consequences for mothers (food taboos, binding of the uterus, "sweating," etc.). Monopoly of most knowledge of health issues. Traditional ideas about where and how to deliver babies. Outcomes of sexual relationships related to morbidity and mortality, abortion. Seen as responsible for contraception and as guilty for infertility.	Accepted double standard in sexuality. Lack of knowledge about the implications of rape and other sexual and domestic violence on the other sex. In some societies, dowry to be paid to wife's family. Expression of male power and legitimacy over the partner in sexual matters.
KEY INFORMATIONAL NEEDS Information on RH, sexuality and gender relations from the male perspective. Information concerning different perspectives on sexuality and RH among males and females. Information concerning social and physiological issues concerning female menopause. Information on different perspectives on number, spacing and role of children in the family. Information concerning the socio-cultural and gender context of HIV transmission.
IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES Develop an EC strategy to raise awareness among men of reproductive health risks and effects of harmful practices. Design EC approaches that target men's informational needs regarding RH, sexuality, nutrition and to promote healthy behaviour. Develop programme components to promote quality communication between spouses and promote gender equality. Conduct participatory research (as with adolescents) which involves adult males in identification of current problems and solutions, including design of "male friendly' services. Raise awareness among men about the value of women's work and contribution to the household. Provide counselling and treatment for both men and women related to rape and sexual violence.
OLDER AGES
COMMON ISSUES Lack of knowledge of health, RH and sexuality issues among and regarding older men and women
FEMALES	MALES
Longevity and age differences with spouses lead to greater frequency and longer periods of widowhood.	Sexuality and RH Issues not addressed by men in part due to conflict with male ideals of power and control (extending to the body).
Gain of status and power in household in older ages.	Longer period of fertility can lead to fatherhood later in life.
Loss of power, status, property through widowhood.
Increased poverty.	Loss of power after son assumes role of household head and/or retirement in some societies.
Major responsibilities for care of aged.
Sexuality and RH issues not addressed due to lack of knowledge, neglect, discrimination, poverty and no provision of services.	Extra-marital partners among those who can afford it is a mark of status, manhood and accomplishment may create increased risk of STD/HIV infection.
KEY INFORMATIONAL NEEDS Basic information concerning RH and sexuality problems (physical and social) for men and women in order to assist with the design of better services.
IMPLICATIONS FOR REPRODUCTIVE HEALTH PROGRAMMES Develop informational and social support programmes for both men and women on menopause, clarifying commonly held myths. Create awareness of the risks of AIDS transmission. Create awareness of each gender's reproductive health concerns during this period. Promote communication between partners on sexuality/reproductive health issues.