Gender stereotypes compromise sexual health: some experts believe traditional views should be challenged to foster safer sexual behavior.

Expectations about what it means to be a man or a woman, which are an integral part of most children's socialization, leave many adults ill prepared to enjoy their sexuality or protect their health. Gender has such a powerful influence on sexual behavior that some experts believe challenging traditional views of masculinity and femininity is essential to promoting sexual health.

Gender stereotypes of submissive females and powerful males may restrict access to health information, hinder communication, and encourage risky behavior among women and men in different, but equally dangerous, ways. Ultimately, they increase vulnerability to sexual health threats such as violence, sexual exploitation, unplanned pregnancy, unsafe abortion, and sexually transmitted infections (STIs), including HIV.

From an early age, people are socialized to believe that gender roles are "natural," which contributes to beliefs that risky sexual behavior is unavoidable, notes Dr. Jill Lewis, who coordinated The Nordic Institute for Women's Studies and Gender Research's Living for Tomorrow project with youth in Estonia from 1998 to 2000.

Projects such as Living for Tomorrow encourage men and women to question and change the assumptions about gender that govern sexual behavior. These projects are relatively new and few, but their experience suggests that young people, in particular, are open to reconsidering the gender roles that their societies have constructed for them. This openness is important because the patterns of sexual and reproductive behavior young people adopt during adolescence will have long-lasting effects on their future health and well-being. (1)

WOMEN'S VULNERABILITY

Many societies prepare girls to be "good" wives by socializing them to be submissive to men. (2) Families, teachers, and peers reinforce the assumption that girls are inferior to boys, until many young women come to believe that their unequal status is justified. (3)

Women's low social and economic status throughout much of the world poses serious threats to their sexual health. The power imbalance between men and women can make it impossible for women to refuse unwanted or unprotected sex, negotiate condom use, or use contraception against a husband's or partner's wishes. Women are also more likely to exchange sex for money or favors and less likely to leave an abusive or otherwise harmful relationship if they are economically dependent on men. (4)

Society's expection that women defer to male authority supports many practices that are harmful to women's sexual health, such as early marriage and sexual or domestic. violence. (5)

In many societies, an emphasis on preserving women's virginity before marriage actually increases their vulnerability. Fears that people will suspect they are sexually active prevent many young women from asking questions about sex, using contraceptives to prevent pregnancy, negotiating condom use to prevent STIs, or seeking reproductive health services. Some young women believe that they can remain virgins by engaging in anal sex, a practice that may increase their risk of HIV infection. (6) And in societies with high HIV prevalence, virginity may put young women at greater risk of rape and sexual coercion by men who believe that having sex with a virgin--or even an infant gift--can cleanse a man of HIV infection. (7)

Concerns about high rates of HIV and other STIs among youth and particularly young women, the prevalence of violence against women, and men's role in discouraging family planning have focused new attention on the assumptions about gender that influence sexual and reproductive behavior. Most efforts to challenge gender stereotypes have sought to empower women, but there is growing recognition that women cannot protect their sexual health without support from men. (8)

BEING A MAN

Men benefit from their privileged status in most societies, but traditional male gender roles also have their costs. Research shows that socialization of boys to repress emotion, use violence to resolve conflicts, and be independent at an early age has harmful effects on their health. (9) In a national survey of young men ages 15 to 17 in the United States, for example, those who held traditional views of manhood were more likely to report substance use, violence, delinquency, and unsafe sexual practices. (10)

Unlike their female counterparts, boys are often expected and even encouraged to be sexually active at an early age. In one study in Jamaica conducted as part of FHI's Women's Studies Project, 12-year-old boys spoke of encouragement and pressure from male relatives and peers to be sexually active. A boy's male relatives will tell him that "girls will make him feel like a big man," one boy said. (11) Young men are much more likely than young women to report having casual sex and, in some countries, may have their first sexual experiences with sex workers. (12) In many societies, having multiple sex partners is considered essential to being a "man."

The expectation that boys be sexually experienced does not mean they know how to protect their sexual health. Adults tend to assume that boys know more than they do, and boys are afraid to ask questions that reveal their ignorance. (13) Pressure from peers and adults also influences the way young men approach sexual relationships and often encourages them to engage in risky sexual behavior. For many young men, sexual initiation is seen as proof of manhood, and presenting their sexual conquests to a male peer group may be as important as the sexual relationships themselves. (14)

One tactic used to pressure young men to conform to a society's expectations of male behavior is to imply that those who do not are homosexual. (15) Prejudice against homosexual men is particularly harmful for young men who have sex with men, leading to denial of sexual risk, low self-esteem, and even suicide. But homophobia affects all men by discouraging behaviors that are considered "feminine," such as caring for others or protecting one's health. (16) Results from qualitative research among young men in nine Latin American countries found that they considered health risks to be far less important than perceived threats to their masculinity. (17)

Despite the strength of such pressures, not all men conform to traditional gender roles. And, in many parts of the world, gender roles are rapidly evolving as a result of a variety of social, economic, and cultural changes, including increasing access to education and mass media, urbanization, and participation of young women in the work force. (18) These changes often expose youth to threats to sexual health for which they are unprepared, but may help free them to consider new ways of relating to one another and different patterns of sexual behavior.

For example, results from a study of youth sexuality and sexual health in Lima, Peru, revealed high levels of unplanned pregnancy, coerced sex, STI symptoms or diagnoses, and abortion, but also indicated that some positive change might be under way among sexually active adolescents. The 16- to 17-year-old boys surveyed were half as likely as the men ages 19 to 30 to report having their first heterosexual experience with a sex worker. The 16- and 17-year-olds--particularly girls--were more likely than the young adults to report using a condom the first time they had sexual intercourse. Such results, wrote study author Dr. Carlos Caceres, suggest a sexual experience "that may be connected to love, the disposition to use protection from STDs [sexually transmitted diseases], and other dimensions of respect and responsibility." (19)

CHALLENGING GENDER ROLES

Dr. Alice Welbourn, who wrote a training package on gender and sexual health called Stepping Stones for the Strategies for Hope series of the London-based ActionAid, notes that efforts to challenge prevailing views about gender are often viewed as an imposition of values from another culture. Rather than promoting specific attitudes and behaviors, the Stepping Stones videotape and manual leave the interpretation of gender to local participants and facilitators. They present questions, stories, and exercises that challenge participants to raise concerns, analyze their attitudes, and practice new behaviors. (20)

Some groups have found that they can more effectively reach men if they adopt a nonjudgmental attitude, even toward the most unacceptable behaviors associated with traditional masculinity, such as domestic violence. (21) Others working to reduce gender inequality, such as the Brazilian nongovernmental organization Instituto Promundo, target young men who have already demonstrated an interest in changing their behavior. Its Jovem para Jovem (Guy to Guy) project in Rio de Janeiro often these young men support from peers and adults and encourages them to reflect on the potentially harmful effects of some traditionally masculine behaviors. (22)

Instituto Promundo Director Dr. Gary Barker notes that working with adolescents is important because between puberty and adulthood young people rehearse the ways they may interact in intimate relationships throughout their lives. (23) "Nevertheless, men's behaviors and attitudes can change over the course of their lives and during different relationships," Dr. Barker says. "There are also specific critical moments such as at the birth of a first child or at the beginning of a new intimate relationship--when men seem more open to adopting alternative views. Program planners seeking to promote behavior and attitude change can be attuned to these critical moments."

Instituto Promundo and three other nongovernmental organizations have designed training sessions and manuals in Spanish and Portuguese about working with young men to change health-threatening gender attitudes and related behaviors. With support from the Population Council's Horizons Project, the institute will develop and test a scale to measure changes in attitudes or behavior among young men participating in programs that use the manuals. Evaluators can also use this scale to measure statistical correlations between gender attitudes and sexual behaviors.

IMPRESSIONS FROM THE FIELD

Most interventions designed to change the gender-related attitudes and behaviors that threaten sexual health are fairly new and have not been well evaluated. It is important to note that indications of their impact are primarily anecdotal.

A study is under way to assess the impact of adaptations of the Stepping Stones training package in South Africa. Meanwhile, anecdotal evidence from youth and adults who have participated in Stepping Stones workshops in different countries and cultural contexts suggests that such attitudes and behaviors can be changed. Changes reported in group discussions and questionnaire responses include improved communication between parents and children, less gender-based violence, reduced use and abuse of alcohol, greater demand for condoms, greater self-confidence, and more respect between men and women. Some young women say that they are able to say "no" to unwanted sex, and some young men report resisting peer pressure to have sex. (24)

A program for adolescent boys in southeastern Nigeria seeks to help them challenge traditional gender assumptions through continuous involvement in their lives. These young men are beginning to treat women more respectfully. Meanwhile, adolescent girls in a sister project called the Girls' Power Initiative (GPI) are using their new knowledge and skills. During one of the "checking in" sessions that begin each weekly meeting, a girl reported quizzing a boy who asked to be her friend and then informing him that she was not ready for the kind of "friendship" he had in mind--a sexual relationship. The boy's response was one the other girls recognized: "Why do GPI girls ask all those questions?" (25)

Young people in the Living for Tomorrow project in Estonia also said that their peers had noticed a change in their perspectives and in their ability to speak up for themselves. Addressing young people's concerns about gender and sex was the key to these and other behavior changes, says Project Coordinator Dr. Jill Lewis. "If you can raise these gender issues, you are tapping into a whole set of anxieties, questions, and hopes that become a rich soil in which messages about sexual safety can take root," she says.

REFERENCES

(1.) Mensch B, Bruce J, Greene M. The Uncharted Passage: Girls' Adolescence in the Developing World. New York: Population Council, 1998; World Health Organization. What About Boys? A Literature Review on the Health and Development of Adolescent Boys. Geneva: World Health Organization, 2000.

(2.) Mensch.

(3.) Irvin A. Taking Steps of Courage: Teaching Adolescents about Sexuality and Gender in Nigeria and Cameroun. New York: International Women's Health Coalition, 2000.

(4.) Rao Gupta G. Gender, sexuality, and HIV/AIDS: the what, the why, and the how. XIIIth International AIDS Conference, Durban, South Africa, July 9-14, 2000.

(5.) Mane P, Aggleton P. Gender and HIV/AIDS: what do men have to do with it? Curr Soc 2001;49(4):23-37.

(6.) Weiss E, Whelan D, Rao Gupta G. Gender, sexuality and HIV: making a difference in the lives of young women in developing countries. Sex Rel Ther 2000;15(3):233-45.

(7.) Rao Gupta; Pitcher JG, Bowley DMG. Infant rape in South Africa. Lancet 2002; 359(9303):274-75.

(8.) Rivers K, Aggleton P. Working with Young Men to Promote Sexual and Reproductive Health. London: Department for International Development, 2002.

(9.) World Health Organization.

(10.) Courtenay WH. Better to die than cry? A longitudinal and constructionist study of masculinity and health risk behavior of young American men [dissertation; University of California at Berkeley]. Dissertation Abst Int 1998;59(08A0). In Barker G. Gender equitable boys in a gender inequitable world: reflections from qualitative research and program development with young men in Rio de Janeiro, Brazil. Sex Rel Ther 2000;15(3):262-82.

(11.) Jackson J, Leitch L, Lee A, et al. The Jamaica Adolescent Study Final Report. Research Triangle Park, NC: Family Health International and the University of the West Indies, 1998.

(12.) Barker.

(13.) Rao Gupta.

(14.) Barker.

(15.) Rivers K, Aggleton P. Adolescent Sexuality, Gender and the HIV Epidemic. New York: United Nations Development Programme, 1999.

(16.) Rao Gupta; Rivers and Aggleton, 2002.

(17.) Rivers and Aggleton, 2002.

(18.) Mensch.

(19.) Caceres C. Sexual cultures and sexual health among young people in Lima in the 1990's [dissertation]. Berkeley, CA: University of California, 1996.

(20.) Welbourn A. Gendo;, Sex and HIV: How to Address Issues that No-One Wants to Hear About. London: ActionAid, 2000. Available: http://www.talcuk.org/stratshope/sstantqu.html or http://ww.steppingstonesfeedback.org.

(21.) UNAIDS. Working with Men for HIV Prevention and Care. Geneva: Joint United Nations Programme on HIV/AIDS, 2001.

(22.) Barker.

(23.) World Health Organization.

(24.) Initial Feedback from Stepping Stones Users. Unpublished report. London: ActionAid, 1997. Available: http://www.talcuk.orgistratshope/SSrep97.html.

(25.) Irvin.