Margaret E. Greene of George Washington University’s Center for Global Health Looks at Male Involvement

(November 2003) Despite increased recognition that conflicting interests and inequities between men and women pose serious obstacles to good health, reproductive health programs that attempt to overcome these inequities have been few. Traditional family planning and other programs have focused almost solely on women, often failing to involve men because of negative stereotypes about male attitudes and behavior toward childbearing and childrearing. In recent times, however, there has been increased awareness of the need to actively involve men in reproductive health programs, such as those including family planning services, prevention, and treatment of HIV and other sexually transmitted infections (STIs); and care related to pregnancy and delivery.

This awareness grew out of the 1994 International Conference on Population and Development (ICPD) in Cairo, which stressed the importance of harmonious, male-female partnerships to improving women’s and men’s health. Margaret E. Greene of George Washington University’s Center for Global Health notes that, since the ICPD, many in the international health arena have been taking a fresh look at reproductive health programs.

In an interview with the Population Reference Bureau, Greene notes, however, that despite agreement that promoting fairness in the distribution of services and in women’s and men’s responsibilities is the most effective approach, confusion about the objectives of involving men has spurred a number of programs that are not always consistent with the Cairo recommendations.

PRB: Why have men been largely left out of the reproductive health picture?

Greene: The reasons for this reflect an understanding of women as individuals, in isolation from their families and communities. Taken as a given was women’s place — in the home, rearing children — and thus their greater responsibility for contraception and child health. Sexuality, gender, and power relations between women and men were neglected.

Another reason is that language about women’s rights — including the right to make decisions freely about all aspects of their sexuality and childbearing — was not yet in currency, and there was a greater focus on women to accomplish family planning goals rather than on their individual health and rights. The final reason that men were left out of the picture is that it is easier in research and programs to treat women as representing the entire reproductive health-related side of family life.

PRB: How did the emphasis shift to involving men?

Greene: A number of changes reinforced one another in calling for drawing men into reproductive health. Family planning program staff and researchers saw that focusing on women did not fully get at ways in which decisions about sex and reproduction were actually made. These decisions are not just made by women but by partners, in-laws, and others. Also, the women’s health movement made clear how social context shapes the use of family planning and other health services and developed the idea that women’s social context is key to shaping the number of children they want and whether and how they exercise their rights.

PRB: How similar are the programs that try to include men?

Greene: Traditional family planning services were provided through maternal and child health programs and focused on achieving population targets, which included increasing contraceptive use, reducing the average number of children women have, and lowering population growth rates. For its part, the Cairo conference emphasized a multifaceted approach to improving reproductive health. However, there are big gaps between actual programs involving men and the approach laid out in Cairo, and each type of program differs in its objectives for involving men. The programs fall into one of three categories:

  • One category includes “men and family planning” programs, which have the same structure and objectives as the traditional family planning programs that focused on reducing population growth rates. These programs focus on men as contraceptive users and as decisionmakers who can allow or encourage women to use contraceptives.
  • A second type of program stresses “male equity.” These programs focus on men’s rights and reproductive health needs with little attention to the social inequities that have prevented men and women from operating on a level playing field. This approach reflects a false sense of symmetry. If “equity” in this instance is taken to mean that we spend the same amount on men as on women, we are avoiding gender differences in power, decisionmaking, autonomy, and other areas.
  • By contrast, “gender equity” programs reflect the Cairo conference’s sharp focus on the promotion of fairness and justice in the division of benefits and responsibilities as both a means and an end in health and development efforts. The idea is that population targets and objectives must be separated from the provision of health services and that substantial male involvement is needed to promote more equitable relationships and to improve men’s and women’s physical, mental, and social well-being.

PRB: What kinds of risks do program designers run in trying to involve men?

Greene: From a gender equity perspective, there are several pitfalls in involving men in reproductive health:

  • Programs can reinforce inequities between men and women. An example of this is an information, education, and communication program in Zimbabwe that underscored men’s dominant role as contraceptive decisionmakers.
  • Programs can simply redirect funds to services for men. Simply shifting the focus to men in this way was not the intent of the Cairo recommendations.
  • Programs evaluated on the same basis as before, most likely by the contraceptive prevalence rate, have difficulty taking the power imbalances between women and men into account because evaluation drives program structure and emphasis.
  • Programs can increase violence against women. Promoting contraceptive technologies may in some settings suggest the sexual independence of women and arouse men’s fears that women will seek other relationships; in Navrongo, Ghana, for example, this challenged male authority and led to an increase in violence against women.
  • A final pitfall is that involving men as health workers can entrench managerial hierarchies as men are placed in or promoted into positions of authority over long-time female employees.

PRB: How can programs avoid these pitfalls?

Greene: The Programme of Action developed at the Cairo conference gives us a powerful formulation for understanding gender relationships and their implications for program design. To be successful, programs must recognize that they cannot effectively address health without acknowledging and addressing the roles and relationships that constrain the achievement of good health. It is all about relationships, self-image, power, subordination, communication, and control of decisionmaking.

PRB: Are there examples of programs that follow the spirit of Cairo?

Greene: In an enormous range of settings, programs have identified culturally specific strategies for addressing gender-related constraints to improving reproductive health. These exceptional programs share a number of basic ingredients:

  • They look at gender socialization and ways of supporting equitable, supportive relationships between men and women. Instituto Promundo of Rio de Janeiro, Brazil, provides a good example in its work with boys and young men.
  • They cultivate peer support for positive behaviors, as in the case of Peer Advocates for Health, of Chicago.
  • They pay attention to the broad, societal context in dealing with reproductive health issues. Men Can Stop Rape of Washington, D.C., has been a pioneer in this effort.
  • They mobilize communities to counter harmful practices and to recognize how their understanding of gender roles contributes to the spread of HIV. A good example is the Stepping Stones manual and workshops, which have been used since 1995 to reduce the incidence of HIV and to promote gender equity in countries including Ghana, South Africa, Tanzania, and Uganda.
  • They also alert men to ways they can support women’s health, as in the Suami SIAGA (Alert Husband) campaign in Indonesia.
  • They educate young people to appreciate and protect the human rights of others. One example is the Conscientizing Nigerian Male Adolescents program.