TSS thematic workshop on Male Involvement in sexual and reproductive health programmes and services

The idea of involving men in the traditionally female-oriented reproductive health activities is not new. However, relatively few activities have been actually carried out in this domain in spite of the importance of these to advance towards gender equality and to improve both men's and women's reproductive health. With this in mind, the Technical Support Services (TSS) System of the UNFPA and participating UN Agencies decided to undertake a seminar on male involvement in reproductive health, focusing on the operational as well as conceptual aspects from a multi-disciplinary, inter-agency perspective.

Objectives of the workshop

The workshop was jointly organised by FAO and WHO with the close support of UNFPA. It was inaugurated by Ms. Sissel Ekaas, Director Women and Population Division of the Sustainable Development of FAO, Ms. Diane Langston, Manager, NGO Theme Group, UNFPA

Technical & Policy Division, and Dr. Malika Ladjali, TSS - WHO. The speakers underlined the importance of the subject regarding the International Conference on Population and Development (ICPD) and its implementation and the importance of developing inter-agency approaches to tackle it appropriately throughout all the levels of the TSS system.

Background Paper

The CST-TSS paper on MI looks into the socio-cultural aspects that shape male perspectives, based on the socially-embedded gender relations in the different stages of the life cycle, and uses this knowledge to suggest ways to increase men's involvement in reproductive health issues and to improve services. Within this context, information, education and communication (IEC) and advocacy strategies are also suggested. Finally, some recommendations are given for helping UNFPA Country Programmes better address male involvement in reproductive health.

The emphasis on women in much of the gender literature has left male perspectives as the missing link to a true gender approach. Far from arguing that the focus should be only on men, the paper argues for the need to base strategies, be they oriented to men or to women, on the analysis of gender interactions and needs. The paper is meant to help strengthen a component of a broader and more comprehensive gender approach.

Session 1. The male side of gender throughout the life cycle

Male Involvement in Sexual and Reproductive Health (SRH)

The male side of gender throughout the life cycle

The reasons given for these problematic aspects included:

• A female bias in the gender literature, and the consequent lack of knowledge of the male side of gender. The gender literature tends to be by women on women.
• The traditional inability to set up programmes based on understanding gender relations, disregarding the power relations and the gender roles that influence decision-making related to reproductive health.
• The way in which programmes were traditionally institutionalized, through the maternal and child health (MCH) facility of the Ministry of Health. These programmes focused on women and children, in the traditional dyad - and barred men from access to services and from exercising a number of responsibilities in the area of reproductive health of their wives and health of their children.
• Commonly held myths and erroneous assumptions about men's views of family planning, sexuality and health.
• The paucity of data to understand male perspectives and the extent of their involvement in reproductive health issues. The surveys most relied upon for reproductive health (RH) programmes usually ask questions only of women, assuming that they are the ones who make the decisions regarding reproduction and that the men are either not involved or marginally involved. At the same time, programmes lament women's lack of decision power regarding fertility. This ambiguity has many consequences in programme design, implementation and effectiveness.

Lessons learnt

When the aim of programmes is to improve the reproductive health of both women and men, better programmes have to develop concrete strategies to understand and incorporate the male perspective and male needs in the same way as attention is given to women's perspectives and needs. In order to avoid a shift in the locus of control, programmes should aim to incorporate adequate male involvement, not only more involvement. Thus programmes should be based on the understanding of gender dynamics, on how decisions are made and implemented, on the changing needs of both genders and their interaction. Much more needs to be known about the relations between men and women in the particular contexts where programmes will be set up in order to make an effective change. This knowledge will aid in the definition of what is meant by adequate involvement.

Among issues that merit consideration regarding the resources needed to cater to men's reproductive health needs: in the first place, the more services are set up based on an understanding of the underlying gender relations, the more they will benefit both women and men. When adequately set up, services for men will not only address their own needs, but will contribute to relieve women of one of their many burdens. Services for men are not necessarily expensive and do not compete with the already scanty resources available for women's services.

Session 2. Gender equity and equality

Gender equity and equality

The concepts of gender, gender equity, gender equality and male involvement were discussed. Two different dimensions of male involvement were mentioned: accessibility to services and participation in decision making. The traditional exclusion of men from FP/RH services and the taboo of talking about sexuality had to undergo changes with the arrival of HIV-AIDS and the need to address sexuality and condom use. Condoms, which were formerly seen as 'low-class contraceptives', have now gained recognition as "life-savers".

The need to discuss male sexuality was brought up, given that it is not often discussed, not even in RH/male involvement programmes. Some studies were quoted which showed that many men in various countries have sexual problems. These problems are, however, seldom addressed or attended to, even when the men go to health clinics.

An overview of the disadvantaged position of women, especially in South Asia was presented: lower life expectancy; high maternal mortality; limited reproductive rights; high TFR; large number of women 'missing'. Reference was made to the ICPD-POA, which stresses men's role for bringing about gender equality.

Several issues were raised in relation to male involvement interventions. The issue of how to deal with men in positions of power without further strengthening the power imbalance was raised. The strong focus on women in past population/FP programmes left men out. Women were the primary targets of education programmes, as they were perceived to be the ones in charge of fertility behavior. Later, a reversal of the trend was noted as men, perceived as the primary gate keepers to women's use of health services, and in their role of community leaders were targeted. Some of these programmes have resulted in further strengthening the dominant position of men and reinforced the image of women as dependent actors. In these cases, programmes can have the effect of further strengthening gender inequality. Furthermore, the need to look into male reactions, notably the violent ones, in the context of women empowerment programmes was noted.

Lessons learnt

• The differential perceptions of gender roles between men and women and their link to socialisation were also raised. Designing interventions during the socialization process was therefore seen as pertinent. There is a need to bring about gender equality through the socialization process involving individuals, families and the community. Examples include educating boys on gender issues as well as raising girls' self value and confidence.
• Promoting gender equality, through advocacy efforts, among community, religious and political leaders as well as carrying out gender sensitization sessions for policy makers and planners was seen as primordial. Development and/or revision of legislation that promotes women's rights and facilitates men's involvement were seen as essential output of the process.
• Furthermore domestic violence may arise if empowerment programmes are not well oriented, as men can see their situation as being challenged. This issue has to be addressed and taken into account when designing male involvement programmes, as well as empowerment programmes.
• When not adequately addressed, male involvement programmes that use traditional power structures to be more effective can reinforce existing gender inequalities.

Recommendations

• A thorough gender analysis needs to be undertaken before developing male involvement programmes, with a particular emphasis on the effect of programme interventions on the distribution of power.
• The notion of MI should be expanded beyond male contraceptive use to include indicators such as males seeking treatment for STD and other RH concerns.
• "Traditional" cultures should not be seen or presented as static and our approach to women's empowerment should take this into account so as to refine and interpret our indicators. Many changes have recently taken place in the position of women.

Session 3. Conceptual frameworks and data

This session analyzed the historical and intellectual influences on the policies and research that have given rise to current reproductive health interventions, and brought to light the assumptions that have structured many programmes. The risks of efforts to increase male involvement that do not take into account their potential impact on gender relations were again highlighted. The presentation had a critical take on programmes that enforced gender inequities by making use of men's greater power in an effort to increase contraceptive prevalence.

The presentation concluded with several recommendations:

• Any programme wanting to involve men should clarify for itself at the outset why it should involve them. Aside from a desire to follow the Cairo PoA, what are its motivations for wanting to bring men in? Programmes should consider the risks of doing so for the welfare of the women they serve already, and for the relationships between the men and women they wish to serve.

• 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., women's primary responsibility for children and therefore for fertility control), and about the demographic imperatives of family planning, and they may reinforce those relations when they deal with clients. These effects should be taken into account during the design phase.

• There is no need to delay integration of MI in programmes until all research is carried out. Existing ethnographic research on gender relationships and inequities in specific settings should be sought and used in the process of designing programmes, while new research should be designed to fill in specific gaps.

• Since we are talking about gender and social change, the responsibility for this must be shared with a wide array of institutions and programmes. For too long, the population field has placed the burden of population stabilisation on family planning and reproductive health programmes. Other areas of intervention must be brought into co-operation with this objective.

Data on MI

The second part of the session focused on the lessons learnt on data collection regarding MI based on experience in the African region where data comes from two main sources: WFS (World Fertility Survey) and DHS (Demographic and Health Survey). Additionally, there are data from socio-cultural and operational research and from situation analysis surveys.

Lessons learnt

• There is a potential bias in the information on men from DHS surveys, given that in many cases the interviewed men are only a subgroup of husbands of interviewed women, and therefore not representative of all men. Furthermore, the size of the sample of men in these surveys largely depends on the size of the so-called main sample (women's). This may lead to results that are not statistically significant and may lead to difficult interpretations on men's involvement in SRH.

• The quest for comparative data has lead to a high degree of standardisation of the questionnaires and collected information that does not allow a thorough understanding of the context-specific determinants of men's RSH.

• The scarcity and paucity of socio-cultural research on men's roles and involvement in SRH largely limits the knowledge on the determinants of SRH behaviour in the region.

Recommendations

• Develop research-driven programs and interventions.
• Nationally representative samples of all men in reproductive age should be targeted in surveys.
• Collect data not only on husbands but also on other men in reproductive ages.
• More surveys could ask men the same questions as are asked of women to give a better gender balance.
• Adapt the questionnaire to the local needs and culture, allowing for information on traditional medicine and traditional healers.
• Participatory research should be encouraged, which means that results should be taken back to the community, which often has a lot to contribute to the knowledge base.
• UNFPA should disseminate the results of its work with the UN Statistical office on the collection and production of sex disagregated data on CD-ROM.

Session 4. Cultural specificity of Male Involvement

Françoise Ghorayeb, FAO, CST Amman
Malika Ladjali, WHO
Marcela Villarreal, FAO
Janet Edmondson, FAO, CST Bangkok

The cultural specificity of men's needs regarding reproductive and sexual health has been neglected in the conceptualization and formulation of SRH programmes. Recognizing needs as culturally bound is the basis for formulating a sound strategy.

The first part of this session addressed the cultural specificity of needs and strategies for MI using FGM as an example. General awareness of the FGM problem has increased considerably and plans for eradication exist in many different places. Considerable financial resources are forthcoming for FGM research, including research in communities where FGM has disappeared. However, male involvement remains elusive and there is a dire need for practical recommendations on how to involve men in the eradication of FGM.

The historical aspects and origins of FGM were discussed pointing to the causal complexity, social control mechanisms and economic interests of those performing FGM and their vested interests in the perpetuation of the practice. As long as there is a demand side represented by the culture and a supply side represented by the economic gains of the health professionals who perform the operation, behaviour change will be slow. Successful examples taking supply factors into account were given, notably an example about an intervention in Burkina Faso. Introduction of legislation has been apparently successful in Burkina Faso and Uganda, but less so in Sudan.

Gender relations should be understood prior to formulating strategies to involve men in RSH. FGM examples illustrate the lack of understanding of male's role in FGM and the contradictory statements given in surveys. A better understanding of gender relations could shed light on the dynamics surrounding decision making regarding FGM and generate hypotheses as to the reasons behind the perpetuation of the practice.

The male side of gender and notably the construction of masculinity were addressed in the second part of the session, as they are topics that remain poorly developed, given the female focus in the gender literature. Men's studies exist now but little is known regarding the relation between the construction of masculinity and sexual and reproductive health. In spite of the many parallels with the construction of the female side of gender, the construction of masculinity has specificities that have many implications for sexual and reproductive health of both men and women.

The programmatic challenge is how to reconcile the male model that rests on domination with the improvement of sexual and reproductive health, which requires gender equality. Socio-cultural research is needed to understand the process of male identity formation in specific contexts so that appropriate IEC/advocacy strategies can be developed. Such programmes could provide a cost-effective way of addressing crucial gender issues. Examples of such programmes include amongst others, constructing alternative models of masculinity, whereby virility is promoted by the exercise of more egalitarian, caring and sharing relations, promoting positive masculinity traits and addressing adolescent boys. Furthermore, men's specific needs in counselling need to be identified and addressed in a gender-sensitive way.

In the final part of the session, the dilemma of executing quality research within time constraints e.g. is the rapid research approach adequate for in-depth exploration of individual behaviour, was discussed. The problem of timing of socio-cultural research in the UNFPA programme-cycle and ensuring a multi-disciplinary approach was raised.

A framework for addressing MI in RH being currently applied in four countries in Asia was presented and discussed.

Recommendations

• Include questions on male knowledge and perceptions in all surveys addressing FGM.

• Lessons learnt from successful FGM interventions taking both cultural and health services aspects into account as in Burkina Faso, Uganda and Senegal should be replicated in other programmes.

• Much still needs to be learned about what works in eliminating FGM, as results of experiences are overall not conclusive. The issue of demand and supply is an important one, as is the social structure in which FGM occurs. Care should be taken to initiate a process whereby the community understands and identifies problems and fully participates in the development of strategies adapted to their specific socio-cultural setting.

• There is a need to invest in inter-disciplinary rapid research interventions reflecting the socio-cultural and behavioural profile of the target populations as well as the operational programmatic context using the full potential of the TSS/CST System.

• Socio-cultural research on the construction of masculinity should be used to improve SRH services and programmes.

Session 5. Male involvement: Regional specificities

Presentations of UNFPA funded projects in Nicaragua, Ecuador and Paraguay described projects targeting men in the military. The expected outcomes of these activities included reduction of violence against women through an enhanced awareness and responsibility of males in RH.

In Ecuador, the focus was on educating military officers, soldiers in compulsory military service, and cadets in military schools. Four stages were adopted - selection of one high school and one military unit; training of officers, teachers and student leaders including preparation of materials; training of soldiers and students; and extension of training to more high schools, military units, and the provision of services.

In Nicaragua, the targets were military officers, soldiers, women employees and family members, and policemen. Activities included materials development, training on RH including sex education, STD/HIV/AIDS; prevention of violence; and development of national programmes with continuous training of officers and soldiers.

In Paraguay, the targets were the military and police. Activities included the preparation of training materials, training on RH and provision of RH services including family planning.

Experiences from East Africa focused on the construction of masculinity throughout the life cycle including differences in socialisation patterns, initiation rites, adulthood, and old age. Implications for programming, notably research programming were discussed. The cultural specificity of East Africa with practices such as early marriage, circumcision and surrogate husbands require specific MI strategies that address the couple and relies on a life cycle approach that reinforces positive cultural practices in the context of male involvement.

Experience in East Africa

The construction of masculinity is not homogeneous in the different parts of the region and varies throughout life cycle. Some of the highlights brought up in the paper:

Adolescence is short in many settings and frequently ends with initiation rites including endurance tests.

Marriage and having children are essential for men to be considered "real men" and unmarried men are not considered adults.

Men are never considered infertile, for it is the woman who is assumed to be barren when a couple does not have children.

In old age, masculinity and virility are reaffirmed by having children, frequently with much younger women.

Valued characteristics of men include: being a risk taker, fierce competitor including for women, competent sexual partner, husband, father, decision maker and effective provider.

Cultural barriers to MI: Experiences from West Africa

The presentation stressed the difficulties that programmes tackling issues related to the RH of men face; these difficulties are related to the culture bound interpretations and meanings of RH related symptoms and diseases. In some social groups, the first STD related symptom a boy might have is positively interpreted as a sign of sexual activity and a reflection of virility. In the same vein, a pregnancy caused by an adolescent boy is evidence of his reproductive and sexual performance. Early marriage and early pregnancy are encouraged because they insure the survival of the lineage. Concerning male infertility, examples were given of strategies designed to enable women to procreate outside their matrimonial relationships, which reflects the overriding importance of reproduction. Thus, sterility is not considered to be a problem for men since the line can be continued through other relatives. The value of children varies greatly among different groups. A general strategy is the community based distribution of contraceptives that could be re-visited to progressively integrate other RH services, including elimination of FGM and tailored to local cultures.

These examples show the culture bound aspect of disease and illness perceptions and interpretations, the corresponding health care itineraries, and the implication on men's SRH.

Lessons learnt

• Men in the military constitute a priority target group. Men in the military are an itinerant group, prone to high-risk sexual behaviour potentially resulting in STD-HIV and unwanted pregnancy. Risky sexual behaviour is also encouraged by traditional ideas and stereotypes related to masculinity, which is an essential aspect of the subculture of the military. Sailors and truck drivers also constitute a priority group and have been targeted in projects in Africa.

• Research that incorporates a revised conceptualisation of risk, beyond its medical meaning, as a socially constructed phenomenon where perceptions and interpretations are shaped by personal experiences imbedded in the socio-cultural and economic contexts is needed. Furthermore, issues like the construction of masculinity, its relationships to family dynamics and to socialisation need to be explored.

Recommendations

• Review experiences and extract lessons learned regarding interventions in the military. Translate the Latin American experience to case studies documenting the process, problems and outcomes. Examine the multiplier effects of the initiatives by describing what has been achieved, what the impact on RH is, and whether the strategies and interventions can be applied to the larger society. Furthermore there is a need to describe in greater detail the training content and modalities, knowledge gained; and how it translates into behaviour modification (preventive activities). The information generated would feed in the process of developing a more structured approach to be used in MI programmes and strategies formulation.

• Programmes for personal development already existing in military institutions should be capitalised on and used as entry points for RH sensitisation programmes for the military and the police. These groups should be targeted given the fact that they may have to deal with perpetrators of gender based violence.

• Carry out research on community-based distribution to improve access to RH services.

Session 6. Men as partners: Research, services and lessons learned

Men as Partners Initiative

Main lessons learned from their experience include:

• Consider gender as a key lens through which to understand the situation
• Realize that men are concerned about and interested in RH
• Reach out to men with special communication strategies
• There is no magic formula: try new service delivery models
• Try to understand men's needs holistically
• Integrate services for men into existing structures or services for greater sustainability
• Much can be done at no/low cost
• Support leadership at all levels for working with men
• Recognize the need to work on difficult or troubling issues
• When a well-intentioned effort goes astray, learn from it
• Recognize the need to continue to ask questions

Community based strategies to involve men in maternal health

Amongst the lessons learnt are:

• Engage all family members in support of safe motherhood
• Involve official and unofficial community leaders
• Establish a system for Emergency Transport
• Establish locally based and run credit schemes
• Training of health providers of both sexes is crucial
• The RESCUER project in Uganda is a success story and offers many lessons to be learned

AVSC's work in Ghana is an example of using several tools: advocacy, research, and training, to achieve the goal of initiating and integrating male involvement programmes. A team from Ghana held focus groups with men, women, and service providers in select communities where information and services for men were to be initiated, and were designed to elicit from the participants what the community members wanted in terms of services for men.

It turned out that among men's biggest concerns are sexual performance and impotence. Thus, when Planned Parenthood Association of Ghana decided to initiate services for men at their clinic in Accra three days a week, they "marketed" the men's clinic as providing assistance on "impotence, infertility, and premature ejaculation". AVSC went to Accra and held training for providers in several aspects of working with men, including communicating with men about issues of sexuality.

Country experience in Male Involvement: Profamilia in Colombia

Male programs have three basic goals:

1. To offer sexual and reproductive health services, including family planning.
2. To provide a range of self-sustainable health services.
3. To involve both men and women in sexual and reproductive health, without forgetting the fundamental rights of women.

Lessons learned

• The organisation of sexual and reproductive health programs directed specifically and exclusively to men is essential to their success.
• Sexual and reproductive health services other than family planning are essential to guaranteeing the financial sustainability of programs for men.
• The key person in a sexual and reproductive health program for men is not the urologist or surgeon, but the counsellor who provides information and counselling.
• The importance of offering confidential information and counselling is crucial to the development of programs for men.
• Advertising the program and its services via the mass media is necessary to create awareness and promote the program among possible users.
• The development of sexual and reproductive health programs for men demands strong administrative leadership, clearly defined objectives and strategies, and the implementation of work plans.
• The development of programs for men requires an excellent management information system, both programmatic and financial.
• High-quality services and careful evaluation of quality are essential to any program's success.
• Men should be included in the development of family planning and sexual and reproductive health programs from the time they are adolescents (via youth centres).

Session 7. IEC/Advocacy to improve Male Involvement in SRH

Effectively addressing Male Involvement in SRH

The presentations focused on advocacy and IEC strategies to reach policy and decision-makers as well as men themselves taking into account the socio-cultural context.

An overview of the three components of a Knowledge, Attitudes and Practices (behaviour) KA(B)P communication model (Advocacy-IEC-Service Delivery) was presented.

Two issues were subsequently highlighted, namely: what should the priorities in SRH programming of scarce resources be in light of gender equity? And based on an analysis of the behavioural and contextual causes of the problem, what are the objectives for involving men in terms of advocacy, IEC and service delivery?

The second presentation tackled the non-formal educational programmes in the labour sector where men often predominate. Some of the issues highlighted include the following:

• Diversification of communication channels, such as through women, in places where men are at work, at play, at prayer, at entertainment places, as well as existing networks, such as trade unions, co-operatives, clubs, press, etc.
• Responding to men's needs and to what they see as their problems.
• Involving both men and women at the planning and designing stage of IEC strategy development.

Strategies and approaches

• Collection and assessment of baseline information to identify socio-cultural, political and health problems relating to gender roles and responsibilities, and how best to approach these problems within a community setting.
• Integration of information and counseling into existing programmes and activities, such as in schools, work settings, youth and sports group activities, male gathering places, community outreach, and community centres.
• Identification and promotion of convincing arguments through encouraging reflection and discussion; promoting change and solutions from within the community; segmenting the target population to ensure focused messages; formulating a national policy which could serve to institutionalise political commitment and to promote consensus among leaders to advocate for consistent support to RH, including a recognition of men's special needs; using humour and entertainment as an IEC tool for raising sensitive issues and topics; addressing negative myths on how people perceive men's attitudes and behaviour; engaging media practitioners and sustaining media interest in gender issues.
• Use of other means of communication, such as traditional folk media, tapping popular gathering places (e.g. markets, fairs and festivals), photographs and cartoons, personal stories, and using quotes and statements from well-known and respected persons in the community.
• Starting where there is the best chance of success by identifying people most receptive to change and trying something new, and by enlisting the support of known and admired individuals and groups.

Recommendations

• Male involvement should not be seen as a problem but as part of the solution to issues in SRH.
• Use peer group pressures as an essential element in programmes that wish to challenge prevailing ideas about masculinity and gender roles.
• Promote the positive -- rather than the negative -- sex images of men. Use positive aspects of masculinity, avoid reinforcing male power as well as accusing men, and promote new gender images.
• Use marketing strategies to attract clients' attention by being proactive through the use of professional media designers and attractive designs in the development and production of advocacy and IEC materials.
• Avoid being moralistic and hypocritical in messages and materials in order to better target young audiences.
• Promote research on gender issues in SRH, using both qualitative and quantitative tools.
• Evaluate the impact of male involvement programmes and devise indicators such as increased couple communication and participation of men in child rearing.
• Given the difficulties in evaluation of IEC activities (e.g. due to the time lag between the message and behavioural change), less traditional evaluation methods should be developed and applied.
• IEC activities should be designed to be culturally sensitive. Operational and socio-cultural research is required for this purpose.
• Target groups should be involved in the formulation and design of IEC materials, so that they become stakeholders, develop a sense of ownership of the materials and of the messages.

Session 8. Male Involvement in SRH in ICPD + 5 Activities

The results of three roundtable discussions and four technical meetings undertaken to advance toward the implementation of the Plan of Action of the ICPD (POA), were presented. Crosscutting issues discussed included women's empowerment, changing male reproductive behaviour and gender violence. Highlights of the conclusions were that change in male behaviour was necessary for the empowerment of women and that reduction of STDs requires not only services but also changes in gender roles.

Such behavioural change by men means adoption of responsible sexual and reproductive behaviour and their support for the right of women to make their own reproductive choices and their right to information and access to services. Furthermore, it was concluded that rather than being considered part of the problem, men should be considered part of the solution.

Given that gender issues and partner relations do not take place in a vacuum, it was stressed that the socio-cultural context needs to be taken into account to effectively address MI. It was noted for example, that the reduction of STDs and the associated consequences in health and social well being requires not only services but major changes in the most intimate aspects of human relationships, values and norms regarding gender roles and power imbalances between women and men. Service and communication campaigns must include sexuality and gender power issues.

Field office survey on Male Involvement

• At least 36 countries have taken measures to broaden or promote men's responsibility in sexual and reproductive health.
• Advocacy campaigns have been most helpful in increasing men's use of condoms and vasectomy.
• In a few countries, NGOs are developing innovative approaches to promote men's support for their partners during pregnancy and their involvement in childcare.
• Some countries have strengthened legislation that defines men's support roles and responsibilities in the family, especially regarding child support.
• Given the health orientation of reproductive health policy in most countries, little attention has been given to the psychosocial, gender, emotional and sexual aspects of reproductive health. Notably, there is no RH programme that is based on the gender approach.

International Conference on Male Involvement in Baku

A report of this conference, which focused on the role of men in population and reproductive health programmes in Central Asia was presented. The objectives of the Conference were to improve understanding of gender related concepts, to increase awareness of male reproductive health needs, to integrate male involvement in different cultural contexts and to demonstrate the application of innovative cost-effective male involvement initiatives.

Some common issues which emerged were the need to focus on partnership between men and women, as it was noted that current programmes are women focused with limited information available on men's RH status and needs. In addition, the absence of test facilities for RH services for men and the lack of trained health providers for males as well as of IEC materials and financial resources was noted. The Conference stressed that there is a need to ensure that services for men do not take away from services for women.

Common proposals for action included reformulation of national RH policies to include RH services for men, training of service providers on RH for men, including counseling and actively involving NGOs, especially for IEC and sexuality education for young men.

Recommendations

• Service providers should be trained in order to improve their technical skills, communication abilities and supervision techniques, enabling them to communicate clearly with empathy and with respect for human rights, gender equality with sensitivity toward the socio-cultural context. They should be sensitized in crucial gender issues including violence against women.

• Governments should create an enabling environment through participatory processes at all levels of society for women's empowerment and male involvement in promoting sexual reproductive rights in a human rights framework. This requires the adoption of a gender perspective that accounts for the different realities and constraints that confront men and women.

• Programmes specifically for women are essential means for addressing gender inequalities and inequities.

• Investments are needed to support men's contribution to the sexual and reproductive health of their partners. Information and services for boys and men themselves need to be increased to enable them to take responsibility for their own reproductive and sexual behaviour (e.g. information on and access to contraceptive methods that provide protection against STD/HIV). These investments, however, must not detract from programmes and services for women.

• Sex education that promotes gender equality, human rights and training for the police and the judiciary as well as changes in the curricula for medical and nursing schools, and teachers' colleges are required.

• Given that adolescent girls are especially vulnerable to reproductive health problems, not only because of the risk of pregnancy but also because of their lower societal status, compared to boys, special attention must be given to promote their sexual and reproductive health.

• However, the needs of adolescent boys, whose concerns are often overlooked also need to be addressed.

• Critics and adversaries should be engaged through IEC and advocacy interventions, on the basis of research on their objections and concerns. Effective spokespersons at all levels should be trained using these results.

• Controversial topics and cultural taboos should be addressed.

• A range of social actors should be involved in the promotion of the ICPD PoA concerning male involvement, including men's organizations, professional organisations, business and government, the industrial and private sector. The entire range of civil society should be engaged in social mobilization.

• UNFPA should make systematic efforts to develop reproductive health programmes based on gender relations.

• Although use of gender terminology is common in programmes and project documents, guidelines and skill training on gender integration to facilitate the operationalization of gender should be developed/undertaken systematically.

• More attention needs to be given to regional and cultural specificity.

Session 9. Adolescent boys: Special needs

The session started by discussing the definition of adolescence. One of the difficulties to define it arises from the fact that the nature and duration of the transition between childhood and adulthood depend on the socio-cultural context in which it takes place.

For boys, it is a formative period for the construction of masculinity and the basis for future relationships with women. Adolescence is also a time of sexual experimentation since in many cultures, boys, unlike girls, are expected to acquire sexual experience. There may be peer pressure on boys to have premarital sex. This may lead to casual or commercial sex with multiple partners, which can be very risky, particularly in this era of HIV/AIDS.

In the case of Africa, it was noted that social, economic and institutional changes (such as migration to the cities, civil conflicts, military service, unemployment and poverty) were putting strains on the family structure and its control on adolescents' behaviour.

In the case of the Middle East and Arab States, it was emphasised that sexual taboos were strong and that communication between parents and their children on sexual issues was poor. It was pointed out that services related to reproductive health were only for legally married couples (Tunisia being an exception): the unmarrieds only receive information. IEC is not always linked to service provision.

Both adolescent boys and girls have considerable needs for reliable information and secure, confidential services related to sex and sexuality but the specific needs of boys and girls are very different. There is a tendency for programmes for adolescents to neglect adolescent boys and their needs, although the devastating effect of AIDS in some countries has led to a new attention to boys. In some countries, it has been found that the problem for boys is not so much lack of knowledge but lack of behavioural change based on this knowledge.

It was noted that the few programmes that exist for youth tend to be small in scale, reaching a very limited population and led by NGOs.

Various problems were mentioned regarding sexual education at school:

• programmes tend to be too cognitive and not put sufficient emphasis on life skills
• over-crowded classrooms are not conducive to discussion
• training of school counselors in inter-personal communication and in ARH may be poor
• school health facilities do not cover RH
• teachers are sometimes not comfortable with the sexual content of curricula and may avoid it.

Adequate information was considered crucial for adolescents. There was considerable discussion of the role of parents in communicating with their children regarding sex and of the need to devise appropriate strategies to improve it. Additionally, the role of peers in transmitting information and in education efforts was viewed as very effective and strategic.

As concerns programmes for adolescents, a major shortcoming was the lack of "real" participation in programme design and implementation, their participation too frequently being only symbolic.

Recommendations

• Advocacy is needed with governments in order to raise awareness of the reproductive health problems of youth and their consequences and the need to include both boys and girls in ARH programmes, and to strengthen national level programmes.

• Programmes should work in partnership with youth.

• Better use should be made of indigenous channels for communicating about sex to adolescents and more cultural sensitivity should be exercised throughout programmes.

• Other existing channels which can reach boys should be encouraged to incorporate SRH in their activities - scouts, religious groups, extra-curricular activities of schools, youth centres, vocational training, workplace.

• Educational programmes for boys address not only the physiology of sex but also sexuality and affection. They should provide life skills and not just information.

• A greater documentation of experiences, including lessons learned is needed.

Working groups took place during two afternoons where issues were debated around topics outlined above. The recommendations of the group work were presented and discussed during the plenary session. Recommendations were included with the final recommendations.

Session 10. Final recommendations

General recommendations

• Male involvement in SRH programmes should be considered within the framework of gender equity, equality and the empowerment of women. Thus, the contribution towards gender equality should be included within the objectives in all male involvement in SRH programmes. Gender relations should be taken into account in:
  • Baseline information
  • programme formulation and implementation
  • assessment of the impact of the programme

• Male needs - including those regarding their sexuality - should be incorporated and female sexuality should be given more consideration in RH programmes.

• The counselor is a key actor for the success of SRH programmes for men and should be given due attention.

• Male roles and needs vary throughout the different stages of the life cycle and different strategies are needed accordingly. Phases of the life cycle should be addressed not only in biological terms but also in socio-cultural terms.

• More socio-cultural and behavioural research is needed in order for male involvement to be effective and to contribute to gender equity. Analyses of the gender system, including expressions of manhood and construction of masculinity are necessary before designing programmes.

• Consider socio-cultural and other secondary data research that already exist in many countries even if not directly related to RH services, before embarking on new research.

• As women become empowered in male dominated societies and changes occur in existing gender relations, the male reaction could be violent. Programmes should take into account possible repercussions of their interventions on existing gender relations.

• Take a holistic approach to RH issues, including advocacy, working together with multiple partners (UNFPA, agencies, NGOs, private sector).

• Evaluation is a critical component of MI programmes, and it should be adequately used for their effectiveness.

Recommendations for UNFPA Country Offices

• MI programmes, based on an understanding of gender relations and aimed at increasing gender equity and equality should be considered in all country programmes.

• The analysis of programme impact should include measurement of the impact of the programmes regarding gender relations both at the household and the community level.

• Given that much is done regarding the incorporation of gender considerations in programme formulation but that little of that gets actually implemented, much more should be done regarding the implementation of gender considerations in programmes.

• Institutionalise training in gender sensitivity, particularly for health workers.

• IEC efforts should be part of broader sexual and reproductive health programmes and not dealt with separately.

• Results of monitoring and evaluation should be used to improve programmes.

• The community should be sensitized to involve and incorporate male perspectives in RH and providers should be trained in other RH services to help provide more comprehensive RH services.

• Facilitate research and multi-disciplinary missions to address gender and socio-cultural issues for an effective and culturally sensitive strategy to involve men in SRH.

• Promote the active involvement of both men and women and integrate national policies and programmes that involve men and women in addressing male issues.

• Country programmes should adopt and apply valid indicators that measure MI and the advancement toward gender equality in all SRH interventions.

• Efforts should be made to promote programmes aiming at enhancing gender sensitivity in the school system as early as possible.

Recommendations for CSTs

• When providing recommendations to countries in male involvement (research, services, etc.), these recommendations should be as broad as possible, even if they go beyond the possible support of UNFPA.

• Encourage more collaborative and multidisciplinary work and joint missions among CST advisers and TSS specialists in order to promote the mainstreaming of MI into SRH programmes.

• Gender equality should be included in the goal statement of all UNFPA-funded programmes ensuring gender equity at the purpose and output levels of the log frame.

• Document experiences of integrating or providing male reproductive health services through the public sector and in financially constrained circumstances, as well as successes lessons learnt and interesting programmes.

• Advocate to Country Representatives and HQ the need to incorporate TSS specialists in technical backstopping at the sub-regional level in order to benefit at the field level of their experience in other regions.

Recommendations for TSS Specialists

• Disseminate updates on readily available rapid and valid methodologies related to MI in SRH.

• Make available guidelines and protocols that will help in developing IEC and advocacy that can be used in all regions.

• Compare, consolidate and disseminate to CSTs experiences - successful and unsuccessful - of integrating or providing reproductive health services that contribute to gender equality and empowerment of women and MI.

• Review research, programmes, strategies, approaches, tools and lessons learnt related to MI.

• Together with CSTs, develop both process and outcome indicators for the analysis of MI programmes, considering the experience accumulated in NGOs, including the difficulties encountered by them.

Recommendations for DONORS and UNFPA

• UNFPA representatives should be made accountable of ensuring gender equality in their programmes and projects. Mechanisms should be put into place to measure the extent to which UNFPA representatives are attempting to ensure that gender equality is being implemented at the sub-programme level.

• UNFPA guidelines for sub-programme development and project formulation should include examples, strategies, approaches and indicators related to gender equity in sexual and reproductive health (including ways to operationalize and evaluate it). Guidelines should make explicit the need to state the contribution towards gender equality in the objectives of all MI in SRH programmes.

• Members of the TSS System should be included on mailing lists of materials sent to the field related to guidelines for project development and accountability as well as to changes within UNFPA and the TSS system.

• UNFPA should allocate resources that will support reproductive health services for men and should track experiences in providing SRH services for men in terms of resources.

• Incorporate issues related to MI into UNFPA-supported regional training centres and training activities.

• Establish a web site that addresses issues for male involvement.

• Provide a mechanism and opportunity for exchange across the regions related to male involvement and gender equity, such as visiting Profamilia (Colombia) and other successful programmes.

• Support the development of rapid assessment techniques by CST and TSS.

• Organize a thematic workshop, including the three levels of the system, on sexuality, counseling and interpersonal communication related to gender equity.

• Ensure that RH programmes are developed such as to be sensitive to the needs of both men and women

• Training should be provided to CST and TSS staff and UNFPA country staff on how to develop gender sensitive programming, effective and gender sensitive MI interventions and appropriate monitoring and evaluation indicators to measure these aspects.

• Create a SCR theme group to deal with MI issues, inter alia, and devise mechanisms to actively involve CST.

• Donors supporting national surveys such as DHS may consider including issues related to MI in a country specific way.

Annex:
Why select "involvement"? Some origins of words considered ^[1]

In order to shed light on the selection process, etymologies were considered and presented here.

Responsibility

- from Latin respondere = promise in return, the notion of obligation survives in the derivative responsible.

Itself from spondere means "to make a solemn commitment of a religious nature".

Both responsible and spouse (sponsa: "promised in marriage") are from the same Latin word spondere.

The Latin word itself is derived from an Indo-European root *spend- to make a libation. This meaning is still found in ancient Greek: sponde: the wine poured out to the gods before drinking. In the plural, spondai meant a solemn treaty (because such treaties were accompanied by libations).

Participation

- made of two Indo-European roots:

1. 1. *kap = to take, has produced a vast number of words (capture, captive, anticipate, capacity, prince, accept, etc).
2. 2. *per = to produce. In Latin pars = the share given to an individual. The Latin verb parere meant to give a child to the husband, to give birth and produced words such as parent and scientific expressions such as post partum. Many other derivatives exist, such as pauper (who produces little) as well as imperare = to force to produce which gave "imperial", etc.

Involvement

- from the Latin involvere = to wrap, from volvere = to roll, turn,

itself from an Indo-European root *wol- "turn". Other derivatives from the Latin are evolution, revolve (revolution), volume (originally meaning a roll of parchment => big book) but also waltz and to wallow.

"Responsibility: appealed to many, but it is a very solemn word intimately linked to the sacred and law, responding to higher authorities and accompanied by sanctions which seemed incompatible with concepts such as equality and empowerment of both men and women.

"Participation" also has its appeal, but on closer consideration appears rather loose and associated with too many derivatives due to its double Indo-European base.

"Involvement" is perhaps, at this time, the least bad choice. The root has a narrower spectrum of derivatives. It sort of fits in between responsibility and participation; avoiding their extreme connotations while retaining an ethical dimension consonant with the ICPD Programme of Action.

It would be interesting for readers from different cultures and speaking languages other than English to conduct similar exercises in their languages and culture.

For example, in the French language, one could not use a term with the connotation or root of "roll" or "wrap" like involve in English. These have connotations of swindling, cheating! On the other hand, the French word "participation" has probably a stronger meaning than its English counterpart and could be the most appropriate word to render in this case the English "involvement".

FAO-SDWP would be interested in contributions on this issue.

1. On the basis of Dictionnaire étymologique du français by Jacqueline Picoche, Le Robert, 1992; Concise Etymological Dictionary of the English Language by Skeat, Oxford 1984 edition (first in 1882); Dictionary of Word Origins by John Ayto, Bloomsbury, 1990; Greek-English Lexicon by Liddell and Scott, Oxford University Press, 1997 edition (first in 1891).