Men and sexual and reproductive health: the social revolution.

An overview of the state of men's sexual and reproductive health since the 1994 Cairo Conference is presented. Men's involvement in contraception and family planning, paternal involvement, and violence toward women are noted. The five articles in this special issue are introduced. The authors conclude, "Cairo gave us our blueprint for action. The examples here [the five articles] give voice to the slow but important progress of engaging men in achieving this vision of true gender equality."

Keywords: International Conference on Population and Development, ICPD, Cairo Conference, men, sexual, reproductive, health, gender revolution, gender equality

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In 1994, delegates from 180 countries met in Cairo at the International Conference on Population and Development (ICPD, or the Cairo Conference). These delegates included leading advocates in the field of sexual and reproductive health nominated by their governments as well as official representatives from national-level governments. Reflecting and deliberating on the field of sexual and reproductive health, the delegates included in the Plan of Action the following statement:

   Special efforts should be made to emphasize men's shared
   responsibility and promote their active involvement in responsible
   parenthood, sexual and reproductive behaviour, including family
   planning; maternal and child health: prevention of STIs, including
   HIV; ... shared control and contribution to family income,
   children's education, health and nutrition: and recognition ... of
   the equal value of children of both sexes. Male responsibilities in
   family life must be included in the education of children from the
   earliest ages. Special emphasis should be placed on the prevention
   of violence against women and children. (United Nations. 1994)

While the Cairo Conference was seen as focusing on sexual and reproductive health, and much of it did, the Plan of Action was no less than a manifesto for a gender revolution: namely, men should be fully engaged in achieving gender equality in their family lives and intimate relationships. The Cairo Conference is rightly considered a fundamental moment in the growing international field of promoting men's positive involvement in sexual and reproductive health. It was, and still is, for those of us who are advocates in the field of engaging men in achieving gender equality, our rallying cry.

When we consider the domain of reproductive and sexual health, women's concerns have always been at the forefront. Maternal mortality and morbidity, family planning and contraception, sate and legal abortion services, and reproductive tract infections are issues that have traditionally been associated with women. Men's concerns seem to appear only when sexually transmitted infections and HIV/AIDS or adolescent health are added to this list, and even then, their inclusion has been limited. Men have sometimes been included in these issues because in many parts of the world they largely control women's decision-making related to health care and decisions related to sexuality and reproductive health. Thus some programs have sought to encourage "appropriate" influence or behavior on the part of men without questioning underlying structural gender inequalities. This limited instrumental approach for engaging men has been rightly criticized for maintaining the status quo of gender equality.

However, the Cairo Plan of Action is a manifesto--not for merely "involving" men in instrumental or small-scale ways--but for true gender equality. The Cairo Plan of Action is based on the principles of equal human rights for all, of nondiscrimination and equality of women, and the elimination of all forms of violence and coercion. These principles draw their inspiration from the Universal Declaration of Human Rights, the international Covenant on Economic Social and Cultural Rights, and the Convention on the Elimination of all Forms of Discrimination against Women, among others. The Cairo Plan of Action thus represents the application of human rights principles to population and reproductive health-related programming. The call for gender equity and equality and involvement of men is grounded in the principles of human rights and the belief and assertion that all human beings are equal in dignity and rights. In sum. Cairo does not merely call for engaging or involving men in sexual and reproductive health, but in overturning the inequitable gender order.

Eleven years out from the Cairo Conference. the relevant question before us is: Have we achieved the goals set out in the Cairo Plan of Action for engaging men fully in family life and in sexual and reproductive health? The answer is complex, but the short response is: We've come a long way, but we still have a long way to go.

If we take men's use of contraceptives as one indicator of gender inequality, we find that women continue to bear the burden. Currently, the four methods of contraception that require male cooperation or male initiative are condoms, vasectomy, withdrawal, and periodic abstinence. Worldwide, among women using contraception, about one in every four, or 26 percent, say they are relying on a method used by their male partner. Seven percent rely on vasectomy, another seven percent on condoms, and 12 percent rely on either periodic abstinence or withdrawal. The majority (74 percent) of currently married women worldwide who use any contraceptive method use a female contraceptive method. Of these, female sterilization is the most common at 33 percent (U.S. Agency for International Development, 2000).

In addition, the international HIV/AIDS epidemic has wreaked havoc on individuals, communities, and public health systems; in some countries in sub-Saharan Africa, HIV prevalence rates in adults has surpassed 30 percent. As of 2002, worldwide HIV infections and AIDS deaths in men outnumber those in women on every continent except sub-Saharan Africa. More than 70 percent of HIV infections worldwide occur through sex between men and women. By the end of 1999, 10 million African men were living with HIV, as compared with 7.5 million infected men in the rest of the world combined (UNAIDS, 1999, 2000). In addition to their own risk of contracting HIV, men's greater power--physical, social, and economic--in sexual relationships and the fact that women are more biologically vulnerable to acquiring HIV during sexual intercourse mean that men's sexual behavior is key to HIV transmission in women.

Furthermore, data suggest that worldwide fathers contribute far less time to direct childcare, although there is tremendous variation across countries and among men. Studies from diverse settings find that fathers contribute about one-third to one-fourth of the time that mothers do to direct childcare (Population Council, 2001). Of course, even if not as involved in childcare, fathers make decisions about use of household income for children's well-being, education, and healthcare, in addition to direct income contributions.

Men's use of physical violence against women is another area where gender equality has not been achieved. More than 30 well-designed studies from around the world show that between one-fifth and one-half of women interviewed have been subject to physical violence by a male partner (Heise, 1994). The causes and factors associated with men's use of violence against women are multiple, complex, and interwoven. But clearly the reasons or underlying factors related to male violence against women are deeply rooted in the social constructions of masculinity and inequalities of power in family life.

If the story is mostly negative, there are some bright lights. While large-scale impact is yet to be achieved, there is a growing array of program initiatives, research, and policy initiatives seeking to engage men in meaningful ways in reducing gender inequalities. These include clinic-based efforts to engage men, either in primary healthcare or in specialized reproductive and sexual health clinics. Condom education and distribution programs now exist in virtually every country. As a result, worldwide, men's knowledge of male condoms is extremely high. National surveys with married men in 21 developing countries find that 50 percent to 99 percent of men know about condoms (depending on the country) (Drennan, 1998). However, consistent condom use in men's heterosexual relationships is low and generally associated with casual partners, including sex workers (Finger, 1998). Recent condom promotion efforts have included social marketing efforts (promoting condom sales at reduced prices through alternative means). Other projects have engaged outreach workers or peer promoters (men from the same social background engaging other men) and condom distribution to men in special-risk situations, such as men in the armed forces, truck drivers, and men who are clients of commercial sex workers (prostitutes), among others.

Men's roles as fathers have also been the subject of international seminars, program development, and advocacy. In 2003. an international summit on fatherhood, held in the U.K., brought together researchers, advocates, and program staff from nearly 25 countries. In some countries, public health facilities are encouraging men to participate in childbirth. Other initiatives engage men in promoting maternal health by educating them on warning signs of maternal complications. UNICEF and other UN agencies have begun to discuss ways to engage men more fully in promoting the health and development of their children. A handful of nongovernmental organizations (NGOs) in Latin America and parts of sub-Saharan Africa have started educational sessions, group discussions, or support groups for fathers, including both adult and adolescent fathers. Others have carried out mass media campaigns to promote positive images of men's involvement in the lives of children, images of fathers actively engaged to counter prevailing negative versions.

In terms of HIV/AIDS, programs in parts of sub-Saharan Africa and elsewhere are engaging men to prevent mother-to-child transmission, and a few organizations have started support groups for HIV-positive fathers to promote their own health and well-being but also to encourage them to support their partners and children. UNAIDS (the UN agency responsible for coordinating UN HIV/AIDS prevention efforts) focused its 2000-2001 World AIDS Campaign on men and boys with the slogan "Men Make a Difference." This campaign prompted many countries to target specific HIV prevention efforts on the sexual behavior of men (UNAIDS, 2000). In some settings, the silver lining of the HIV/AIDS epidemic has been increased attention of the need to engage men in rethinking their sexual behavior. Some of these efforts have paid off. Condom use among men has increased in many countries, particularly among younger men.

In terms of gender-based violence, in North America and Western Europe, much of the focus has been on providing legal protection for women who have suffered from violence from a male partner. However, since the early 1990s, a number of important initiatives are working with men. Many of these programs reach men who have used violence against women (via alternative sentencing, court-mandated counseling programs), but more promising still is the number of campaigns and educational activities to engage men in preventing violence against women. One important example, the White Ribbon Campaign, a movement of men working to end violence against women, started in Canada in the early 1990s, is now active in more than 30 countries.

All this is to say that a vibrant and creative field of engaging men in achieving gender equality is emerging. There are enough of us now working with men in promoting gender equality to fill up conference halls. In many rural and urban communities, more men are coming up to fulfill their contraceptive responsibilities, participate in childcare, or speak out about violence against women.

However, engaging men in these issues is still too often seen as an appendage, as something quaint, in the field of gender studies and women's rights. There is still considerable debate among advocates in the field about the specific aims of promoting men's participation in sexual and reproductive health, some of which has already been alluded to above. There has also been concern among some organizations working on behalf of women that new resources going to programs for men's sexual and reproductive health needs would drain resources from reproductive health programs for women. There are also lingering doubts among some in the field about whether men can fundamentally change.

One major challenge that has to be addressed to give full expression to this social revolution is to bridge the gap between the personal and the public realm. The first revolution for gender equality, which was spearheaded by the women's movement, was built on this premise. Men, too, must follow a similar process. Men who are researchers, program managers, social activists, service providers, and policymakers must carry out this revolution in their personal, political, and professional lives. As men. we need to define a new vision for ourselves--a vision where men can be egalitarian, respectful, self-critical, concerned, and empathetic. Indeed, the success of the gender revolution will be in not only helping others claim a new social reality but also being part of the new reality ourselves. Clearly, the behavior of men in their intimate relations, family life, and sexual and reproductive health is rooted in how societies view what it means to be men. This change in mindset cannot be achieved or measured by interventions that simply count numbers of men adopting a particular contraceptive but by challenging existing social norms and constructing and reproducing new ones. It may also require identifying and reinforcing traditional forms of caring and gender-equitable behavior that many men already carry out.

With this introduction and within this context, in September 2003 an important cadre of these programs came together in Washington, D.C., at the "International Conference on Men and Reproductive Health" (organized by PATH, Engender-Health, the Population Reference Bureau, and other partners) to exchange lessons learned, to push the field, and to take stock of advances and lessons learned since 1994. One of the most important results of the conference was an affirmation that we have evidence that men can be engaged in sexual and reproductive health in meaningful ways and that such programs can show impact. The conference included presentations from more than 65 program experiences, the vast majority from the Southern majority world (what some call developing countries) and the vast majority of those with evaluation data. A major trend among many if not most of the presenters was that of working with men in context--that is, finding ways to redress gender inequalities at the level of families, couples, and communities and not just focusing on individual men in isolation. Indeed, ecological models have in many cases substituted overly simplistic cognitive behavior change models, recognizing the multiple ways that gender norms are constructed and reconstructed at broader cultural levels, in social institutions, and internalized in individuals.

The conference was also an important moment to take stock of our ongoing challenges. One of those is the fact that there are too few linkages between programs. Programs are too often compartmentalized--for example, focusing on men and maternal health or men and HIV/AIDS or men and gender-based violence prevention--rather than approaching these issues in an integrated way. Men are complex subjects, contradictory at times, gender-equitable in some domains, and inequitable in others. Their needs are multiple and must be approached with this multiplicity. Another ongoing challenge is that of translating small-scale program experiences into policy initiatives. Indeed, too many programs still focus on counting or promoting some narrow aspect of men's behaviors--for example, how many contraceptive methods they know or how many men came into a clinic setting, without understanding that real revolution is changing what it means to be a man.

However, there were examples of organizations that are now focusing on the root of the problem: the ways that boys and men are socialized into rigid notions of manhood or masculinities. From Nigeria to Brazil to India, a growing body of programs were described that are engaging boys and men in group educational activities or carrying out community campaigns or awareness-raising to promote more gender-equitable attitudes and behavior on the part of boys and young men. Some programs are starting this as early as age 8. Emerging impact evaluation is finding that these programs can in fact change young men's attitudes and behavior with direct implications for sexual health and reducing gender-based violence (Barker et al., 2004).

In this volume, we feature five of the approximately 65 papers presented during the Washington conference. These were selected from among program presenters who submitted a full paper to the journal for consideration; in selecting the articles, a strong emphasis was placed on programs featuring evaluation data and those that went beyond mere service provision or outreach activities to include discussions about gender norms in general.

The five programs presented here are illustrative of the priority regions at the conference--Africa, Latin America, Asia, North America--and of the range of program experiences, including broad-based community outreach to engage men, engaging men in traditional rites of passage settings, in clinic settings, and in schools. Bonnie Shepherd describes APROFE's experiences in Ecuador of addressing STIs through male clinics and analyses the extent to which interventions can address practical and other strategic gender interests--that is, looking at ways not only to meet the immediate needs of clients but also how to question gender inequalities in relationships. Men's own gender stereotypical perceptions about themselves as well as their dominance of women emerge as strong barriers to implementing strategies to promote gender quality. Dean Peacock and Andrew Levack present the Men-as-Partners initiative in South Africa, a large-scale, multi-pronged approach to engaging men to reduce violence against women as well as HIV. The intervention uses a human rights approach, and the paper describes the changes in knowledge, attitudes, and behavior that were documented among the participants.

Elizabeth Grant and her colleagues discuss the possibility of using the traditional seclusion period around male circumcision for health and sexuality education among adolescents in Kenya. Using ethnographic methods with a wide variety of respondents, they conclude that this tradition offers an appropriate and strategic opportunity to engage young men with messages about adopting healthier lifestyles and rethinking gender norms. The RISHTA project in Mumbai, India, is evaluating the use of the Narrative Intervention Model through an integrated community and clinical male health intervention. Stephen Schensul and his colleagues discuss the interim results of the project in terms of its potential to reduce "risky" sexual behavior and the prevalence of STIs. Finally, Pat Mosena and her colleagues describe a peer education project among African-American adolescents in Chicago. The paper discusses how the peer advocates not only emerge as effective outreach agents but also as potential role models as well. In all five papers, we find promise and remaining challenges. Men are willing to be engaged in discussing gender equality, and programs are making inroads, but much must be done to take the ideas to scale.

In sum, in these program experiences and from the 2003 conference itself, we conclude that the Cairo Plan of Action is still a dream: many of its goals seem distant still as we look at data on gender-based violence, female infanticide, rates of coerced sex, inconsistent condom use, and limited progress in reducing HIV/AIDS in some settings. Too few societies, male leaders, and organizations are willing or able yet to fundamentally question rigid views about the roles of men and women. There are also voices of dissent--conservatives in many settings who would maintain traditional gender inequalities, who do not believe that women and men are equal, or who espouse narrow religious doctrine and are unwilling to take a full public health and human rights perspective. But in communities, cities, villages, and households where real people live and negotiate their lives, the gender revolution has started. Cairo gave us our blueprint for action. The examples here give voice to the slow but important progress of engaging men in achieving this vision of true gender equality.

REFERENCES

Barker, G., with Nascimento, M., Segundo, M., & Pulerwitz, J. (2004). How do we know if men have changed? Promoting and measuring attitude change with young men: Lessons learned from Program H in Latin America. In. S. Ruxton (Ed.), Gender equality and men: Learning from practice (pp. 147-161). Oxford, UK: Oxfam.

Drennan, M. (1998). Reproductive health: New perspectives on men's participation. Population Reports. Series J, No. 46.

Finger, W. (1998). Condom use increasing. Network, 18(3), 20-23.

Heise, L. (1994) Gender-based abuse: The global epidemic. Caderno de Saude Publica. 10(1), 135-45.

Population Council. (2001). The unfinished transition: Gender equity: Sharing the responsibilities of parenthood. A Population Council Issues Paper. http://www.popcouncil.org/publications/issues_papers/transition_4.html.

UNAIDS. (1999). Report on the global HIV/AIDS epidemic. Geneva: UNAIDS. Online. (Available online at http://www.unaids.org).

UNAIDS. (2000). Men and AIDS: A gendered approach. (Available online at www.unaids.org/wac/2000/campaign.html).

United Nations. (1994). Report of the International Conference on Population and Development. A/CONF. 171/13. Cairo, September 5-13, 1994. (Available online at www.unfpa.org).

U.S. Agency for International Development. (2000) Involving men in sexual and reproductive health: An orientation guide. Washington, DC: Men and Reproductive Health Subcommittee, USAID/InterAgency Gender Working Group.

Correspondence concerning this article should be sent to Gary Barker, Superintendente/Chief Executive, Instituto Promundo. Rua Mexico. 31/1502, Bloco D. Rio de Janeiro. RJ, Brasil. Electronic mail: [e-mail].

GARY BARKER

Instituto Promundo

Rio de Janeiro, RJ, Brasil

ABHIJIT DAS

School of Public Health and Community Medicine

University of Washington, Seattle