EngenderHealth and the United Nations Population Fund (UNFPA), the authors of this guide, believe that it is essential to address gender norms through health programming in order to improve health and well-being within communities.

Through its Men As Partners® programme and other gender initiatives, EngenderHealth works with men to:

  • Challenge traditional gender roles and attitudes about “what makes a man”
  • Enhance men’s awareness of and support for their partners’ reproductive health
  • Increase men’s access to and use of reproductive health services
  • Mobilize men to participate in promoting gender equity and taking a stand against gender-based violence

UNFPA focuses on the interconnectivities between reproductive rights, access to sexual and reproductive health (SRH) services (including family planning), gender inequality, and population dynamics. UNFPA-supported initiatives emphasize men’s positive roles in sexual and reproductive health and rights. Various programmes target different groups of men—from husbands to fathers, from soldiers to religious leaders—to achieve different goals, from HIV prevention to greater male involvement in family life.

UNFPA engages boys and young men on gender issues and on sexual and reproductive health and rights, including through comprehensive sexuality education, to question stereotypes about masculinity and male risk-taking behaviour (especially sexual behaviour) and to promote their understanding of and support for women’s rights, especially reproductive rights, and gender equality.

Introduction

This guide is meant for anyone who may be engaged in developing or managing a project or programme to engage men in sexual and reproductive health and rights. It emphasizes the importance of using a gender lens when planning and programming men’s engagement in sexual and reproductive health and rights (SRHR), including family planning—which means engaging men as clients of SRH services, as supportive partners (to their intimate partners), and as agents of change in terms of SRHR. This guide is based on the premise that gender norms and how men and women express them can affect their SRH behaviour. Likewise, the gender attitudes and beliefs held by programme staff and health-care providers (doctors, nurses, etc.) can have an impact on how they design programmes and how they provide services. Assessing, reflecting on and/or challenging gender norms should therefore be a fundamental part of any intervention which seeks to improve SRHR, including the involvement of men. At the very least, any SRH programme should be cognizant of the impact of gender on their programme objectives as well as its influence on a community or society.

Gender inequality can impact women’s (and men’s) SRH choices and decisions. As such, understanding gender and gender norms, and how they can influence access to SRH services, including family planning, is a crucial step in any intervention to involve men in SRH as clients, supportive partners or agents of change. In fact, programmes which ignore gender norms when drawing men into SRH services might possibly end up doing more harm than good. Using a gender analysis will better ensure that efforts ‘do no harm’, as programmes that are gender blind can perpetuate harmful gender norms and stereotypes, which sustains gender inequality and has a negative impact on health outcomes. If gender inequalities persist when men are involved in family planning decision-making, for example, men may simply wind up exerting control over their partner’s reproductive choice and make the family planning decision for their partner, without acknowledging or respecting their partner’s needs. If male gender norms are not considered within interventions for preventing HIV and other sexually transmitted infections (STIs), these are unlikely to elicit behaviour change to reduce transmission. Also, programmers’ or providers’ understanding and attitudes around gender can impact the way in which services or programmes are designed and delivered.

As part of the process, this guide seeks to help readers gain a better understanding of gender, as well as reflect on gender norms in their context(s), and thus think of how a gender lens can be specifically applied to designing, implementing and evaluating programmes which constructively engage men in SRH. This guide is not meant to be comprehensive in terms of the issues surrounding SRH, HIV/STI management, family planning, male engagement in general, gender-transformative programming or gender-based violence. It is intended to provide basic programming guidance on how to involve men as users and as supportive partners in SRHR while applying a gender lens, as well as providing practical tools which can be used to accomplish such goals. Given the more limited scope, certain sections will refer to additional resources or publications which the reader can access to augment what is included here, such as other toolkits, guides and training manuals. Each section or step of this guide can be used in isolation as a stand-alone activity, or the entire guide can be used and adapted as needed in order to reach comprehensive consideration of male engagement in SRH services.

The toolkit may also be used offline on a desktop or laptop computer. Download it as a ZIP archive (1.2 mb), un-ZIP it, and then open the file "Open This First" in your web browser.

The Six Steps to Designing Programs with a Gender Lens when Engaging Men in Sexual and Reproductive Health and Rights


Much of the guidance and tools in this publication are organized around six basic steps:

  1. Understanding gender and gender programming: a precursor to engaging men in SRHR
  2. Building support for male engagement in SRHR
  3. Assessing the needs for male engagement in SRHR programmes
  4. Creating objectives and designing the programme
  5. Building staff and organizational capacity
  6. Monitoring and evaluating the programme

Users will be able to access tools and programmatic guidance for designing and implementing a programme following a step-by-step process. The six steps are an adaptation of the 10 steps to programme design included in "Getting to Outcomes", a programme planning framework which has been used successfully in multiple public health arenas. Like the “Getting to Outcomes” steps, these six steps can be utilized at different stages of programme design and implementation, including if a programme is already underway. The user of this guide can go back to revisit earlier steps when needed and can choose to use specific steps but not others. Also, it must be noted that many organizations or programmes may face constraints and realities which could/can prevent the possibility of following each step in exact order. For example, some organizations may need to develop proposals or requests for funding (which would include developing objectives) before they are able to conduct a full assessment. However, these projects can still include an assessment phase, which can be conducted after the project is approved. Even if certain/specific conditions/situations call for a different course of action than the lineal steps outlined above, the guidance and tools can still be used or can still be helpful.

Adolescent and Young Men

Though this guide refers to men throughout, the usage is meant to include adolescent and young men. That said, we do not go into depth regarding youth strategies or issues. It is important that we recognize the unique needs and issues which youth face in terms of contraceptive access and use and SRHR.

Providers need to take a holistic approach to youth’s SRHR needs, which include comprehensive sexuality education which reflects on gender norms and power. Furthermore, young people’s access to services from an early age, such as family planning and contraceptives, can prepare them for their present and future needs. Many adolescent and young couples may already be in romantic and sexual relationships in which condoms for triple protection (against pregnancy, HIV, and other STIs) and other modern methods of contraception need to be explored. In some contexts, a sizeable number of men and women may be married or in cohabitating relationships by their late teens and early 20s. Programmes which seek to involve young men will need to acknowledge this reality while giving consideration to legal issues around consent, how to organize services to be most accessible to youth, how to tailor activities and education to this age-group and how to include such programming in schools and/or other community forums to reach out-of-school youth. Lastly, comprehensive sexuality education which centres on human rights, gender and power dynamics is crucial regardless of whether adolescents are currently sexually active. By informing them about sexual and reproductive health and rights at an early age, programmers create a valuable opportunity to reach a generation of future adults. The UNFPA Operational Guidance on Comprehensive Sexuality Education provides useful guidance with regard to this issue.

Action Steps for Engaging Men as Partners in Sexual and Reproductive Health and Rights Using A Gender Lens

This guidance and tools are organized around six basic steps:

  1. Understanding gender and gender programming: a precursor to engaging men in SRHR
  2. Building support for male engagement in SRHR
  3. Assessing the needs for male engagement in SRHR programmes
  4. Creating objectives and designing the programme
  5. Building staff and organizational capacity
  6. Monitoring and evaluating the programme

The following tools and programmatic guidance for designing and implementing a programme are organized within these steps. The steps themselves are not meant to be exhaustive but are a means of organizing tools and approaches along some of the major steps in designing and implementing programming. Each step provides links to resources and tools which go into greater depth regarding engagement of men in SRHR, using a gender lens.

A) Understanding gender and gender programming: a precursor to engaging men in SRHR

This next section will look at gender and gender programming with the understanding it is not possible to design good programming with men in SRHR without understanding gender and gender programming. This next section goes over basic concepts which every programmer should understand fully before designing programming to engage men in SRHR (or when developing any SRHR programming for that matter).

1. Key Gender Concepts

Given the impact of gender on SRHR, this section presents key concepts regarding gender and programming around gender. Though the issues discussed below may not relate specifically to SRHR, keep in mind that to be able to understand gender, we need to think of it holistically. Once there is an understanding of gender—the origin of the concept and how it is reproduced, as well as how it impacts behaviours—one can then think about how it applies to SRHR.

What Is Gender?
Gender refers to the social attributes and opportunities associated with being male and female. Gender can refer to expectations which exist in a society or community around what it means to be a man or a woman.

Though the definition above is comprehensive, definitions are often not sufficient by themselves to explain a concept. The following interactive activity will help to further explain the concept of gender by engaging you in reflecting on this in greater detail.

Learning about Gender

After having completed the Learning about Gender activity, you should have a good grasp of the difference between sex and gender.

Another key concept is that of “gender norms”. Gender norms refer to the societal messages (or rules) which dictate appropriate or expected behaviour for males and females. Gender norms (or the social rules about what men and women are expected to do) help to shape behaviour and therefore relate directly to many health behaviours. This next interactive activity will help further explain gender norms for men and women and how they relate to health and family planning.

Act like a Man, Act like a Woman

The preceding interactive activities help to explain what gender is and how it is constructed, as well as expectations regarding how men and women should behave and think. The group workshop versions of both Learning about Gender and Act like a Man, Act like a Woman are included in the resource list and can be used in leading group reflections about gender norms and their impact.

The following are some main points to remember regarding gender:

  • Socially constructed — Gender is not biological or natural but is constructed from the images, messages and expectations we see around us. These include the messages which we may give to those around us.
  • Contextual/time-specific — Expectations about what it means to be a man or woman can vary over time and depend on context. There may be regional or national differences in how gender is expressed; more important, there are many different contexts within any one country. Over time, we can see that gender norms (expectations about male and female roles) have changed, especially in terms of expectations about the role of women, which have occurred largely as a result of the efforts of the women’s rights movement. Even at an individual level, we can see that the values and attitudes which we publicly express can vary depending on the setting we are in: We may express either more equitable views or less equitable views than we truly hold, depending on the setting (among friends, co-workers, or family, among people of the same sex or the opposite sex, etc.).
  • Changeable — Expectations about male and female roles can and do change, and we can promote that change.
  • Dominant or hegemonic masculinity/femininity —There is often a dominant version of what it means to be a man (sometimes referred to as hegemonic masculinity or dominant masculinity) and a dominant version of what it means to be a woman (sometimes referred to as hegemonic femininity or enhanced femininity). The dominant version guides and also limits our expression of ourselves as men or women. That dominant version is not a “script” which everyone follows, but it represents an expectation or set of expectations which we cannot avoid confronting. Societies conforming strongly to dominant gender identities may alienate many people who express other gender identities, including caring and nurturing roles among men and decision-making among women. Each individual plays a direct role either in deconstructing or challenging these norms or in supporting and perpetuating them. Still, gender theorists often refer to various masculinities, femininities or gender identities to highlight the many expressions of gender and to deconstruct what is often referred to as a gender binary.

The main message is that if gender norms are something individuals participate in constructing, then they are also something that can be changed. In other words, more equitable attitudes can actively be promoted.

Finally, it is important to recognize that other factors interact with and frame gender in each individual’s life; these, which may include age, race, poverty, ability, class and sexual orientation, should not be excluded from any analysis of gender. Programmers need to think of how these factors interact in their context, as inequalities around age, race, poverty, class and sexual orientation can be just as relevant as inequality based on gender.

What Is Sexuality?
Sexuality is related to but distinct from “sex” (referring to biological differences determined by genitalia) and “gender” (referring to the sociocultural construct of personality traits associated with being male or female). Sexuality is “…a central aspect of being human throughout life [which] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” “Explicit and implicit rules imposed by society, as defined by one’s gender, age, economic status, ethnicity and other factors, influence an individual’s sexuality.”

Some key concepts in regards to sexuality:

  • Gender expression refers to all of the external characteristics and behaviours which are socially defined as either masculine or feminine, such as dress, grooming, mannerisms, speech patterns and social interactions. This social definition of whether something is masculine and feminine and how that is valued is defined by gender norms.
  • Sexual orientation is understood to refer to each person’s capacity for profound emotional, affectional and sexual attraction to, and intimate and sexual relations with, individuals of a different sex or the same sex or more than one sex. Someone who is attracted to people of the same sex as their own may identify as gay or lesbian, while someone who is attracted to the opposite sex may identify as straight, and someone who is attracted to both sexes may identify as bisexual, but there are many other ways of identifying one’s sexual orientation.
  • Gender identity is understood to refer to each person’s deeply felt internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance or function by medical, surgical or other means) and other expressions of gender, including dress, speech and mannerisms. For example, people who identify with their sex assigned at birth are known as cisgender, and people whose gender identity or expression is different from those typically associated with the sex assigned to them at birth are known as transgender.

For more information, please see the following resources:

2. Key Gender Programming Concepts

Gender Continuum for Programming

Now we will look at some basic concepts around how to address gender within health programming. One tool for doing this is known as the Gender Continuum.

Since 2000, the gender continuum has been used as a framework to assess how health programmes address gender. This tool has been invaluable in helping practitioners assess how their programmes can better incorporate gender to achieve greater impact. Understanding this continuum will help illustrate how to bring men into SRHR services in constructive and positive ways. The following image demonstrates the continuum.

Gender Continuum Chart

Source: Adapted from Geeta Rao Gupta. 2000. Gender, sexuality, and HIV/AIDS: The what, the why, and the how. SIECUS Report Vol. 25, No. 5, 2001.

The different steps along the continuum are as follows:

  1. Gender-Exploitative: Programmes which are exploitative purposefully use gender stereotypes to reach their objectives. These types of programmes are actually damaging because they take advantage of harmful gender roles and norms.

    Example of a gender-exploitative program: A condom campaign which pictures men as having multiple partners or as warriors/conquerors in order to interest them in using condoms.

    How could this be exploitative? Promoting men as warriors or as having many sexual partners can pique some men’s interest in the advertisement, but it could also reaffirm the view that sex is about domination or violence. Promoting multiple partners reaffirms a common gender norm, that of the man needing to have many sexual partners to be a “real” man, and it represents a double standard about male and female sexuality.

    The programme designers may not have actually perceived these stereotypes as harmful, but they may perpetuate or affirm detrimental attitudes about women and sexuality.

    Therefore, this strategy should never be used.

  2. Gender-Neutral (or Gender-Blind): These programmes do not take gender into account. They ignore the fact that gender norms in any given community impact health outcomes and programming, and they ignore how programming itself can impact gender relations. Programmers may either be unaware of the impact of gender norms or simply choose to ignore them in service provision.

    Example of a gender-neutral program: A condom campaign which targets the general population equally and simply provides the information that condoms are effective at preventing HIV, other STIs and unplanned pregnancy

    Why is it neutral? Such a strategy does not deal at all with the gender norms and inequities in relationships which often underlie low condom usage (i.e., a woman’s inability to negotiate condom use with her partner).

    Why would someone want to use this tactic? Maybe they do not understand or feel comfortable dealing with gender issues in programming. Alternatively, some may interpret gender equality to mean being neutral and not taking a person’s sex into account. Or they may not believe that gender norms contribute to their programming.

    Programmes which are gender-neutral will often miss the opportunity to explore gendered attitudes or behaviours which are directly tied to programming objectives. They can also inadvertently propagate negative stereotypes and gender inequalities.

    This strategy is not recommended for programming to actively engage men in SRHR.

  3. Gender-Sensitive (or Gender-Accommodating): These programmes recognize and respond to existing gender norms and inequities and seek to implement strategies which adjust to these norms. They seek to meet the different needs of women and men. These projects do not actively seek to change gender norms or to address the balance of power in relationships. However, they try to mitigate any harmful impact on gender relations. Regardless, this type of programming is essential and can be a first step toward gender-transformative programming.

    Example of a gender-sensitive program: An initiative to make SRH clinics more male-friendly—i.e., to make sure that the facility itself and staff attitudes are accommodating to serving men in addition to women

    Why is it gender-sensitive? This effort seeks to address a gender imbalance in terms of utilization of SRH services. It recognizes the gender disparity in the use of SRH services (the fact that fewer men access these services) and aims to address service delivery barriers which contribute to men’s low use of services. It also may or may not promote broader reflection by programmers or health providers on the gender norms and attitudes which they hold that can influence how they design or implement programming.

    Why is this gender-sensitive, and not more? This programme does not necessarily deal with the actual gender norms which prevent men from seeking SRH services or which prevent them from seeing SRHR as a shared responsibility.

    Gender-sensitive programming can be an effective framework to use when engaging men and boys in SRH services.

  4. Gender-Transformative: Gender-transformative programming seeks to promote equitable gender norms which will support gender equality and which will lead to improved SRHR. These programmes actively and explicitly examine and try to change existing and harmful gender norms to achieve both health and gender objectives. Gender-transformative approaches encourage critical awareness among men and women about gender roles and norms. In turn, such a process supports the empowerment of women by challenging the distribution of resources and allocation of duties between men and women and by addressing the power relationship between the two.

    Example of a gender-transformative program: A condom campaign which promotes gender-equal relationships with shared decision-making and respect along with discussion around sexual and reproductive health and fertility intentions

    Why is this gender-transformative? The campaign seeks to challenge inequitable gender norms which are barriers to condom usage in a community. It promotes mutually supportive and equitable relationships, along with providing information about and access to condoms. Though increasing condom usage may be the primary objective, the campaign challenges several inequitable norms (such as that men are the primary decision-makers in the household, that men should exert control over their partner, or that prevention of pregnancy is primarily the woman’s responsibility).

Gender-transformative programming is the gold standard for addressing gender norms, and it has been shown to yield greater impact than either gender-neutral or gender-sensitive approaches. A review of 58 programmes conducted by the World Health Organization found that of the 27 programmes rated as gender-transformative, 41% were deemed effective (based on the reported impact on behaviours and the rigour of the evaluation), compared with 29% of the programmes reviewed as a whole. However, not all gender-transformative programming is the same. There is a great deal of variety in terms of programme approaches, programme design, or the size and reach of interventions which are gender-transformative. In other words, there may be many different strategies for challenging gender norms, roles and responsibilities, including many strategies which have yet to be identified.

While transformative programming is the gold standard, not all programmes can be gender-transformative. Designing and implementing a gender-transformative programme requires commitment, resources and technical capacity, which not all programmes or institutions may have. If this is the case, it is important to design programming which is at least gender-sensitive (i.e., aware of how gender will influence project goals and how programming can also influence gender) and commit the organization to developing the capacity to implement gender-transformative programming in the future.

Even when a programme is gender-sensitive or gender-transformative, it still needs to constantly analyse its messaging or programming and make sure that it does not reaffirm negative gender stereotypes or attitudes at any point. There are many examples of programming which sought to be sensitive or transformative but which might still have inadvertently reinforced some inequitable gender norms. Systematically applying a gender analysis to every new tool or message and critically assessing the impact of the gender programming can diminish the risk of negative reaffirmations.

Throughout this guide, gender-sensitive and gender-transformative programming are the preferred options for involving men in SRHR. Gender-transformative programming is the best approach, since involving men in SRHR without challenging harmful and/or inequitable norms has the potential to do harm.

Closing

Some concepts and tools for reflecting on gender and gender programming have just been presented in order to help build a “gender lens”. The following sections will take the reader through major steps in designing and evaluating a project intended to engage men in family planning while using a gender lens.

B) Building Support for Male Engagement in Sexual and Reproductive Health and Rights

International commitment to involving men in reproductive health has been affirmed through various international conferences and statements, including the International Conference on Population and Development (ICPD) Programme of Action in 1994 and the Beijing Platform of Action in 1995. The ICPD Programme of Action calls for the innovative and comprehensive inclusion of men and boys to help achieve gender equality and presents men primarily as allies in this endeavour. The Beijing Platform of Action reaffirms this.

Some specific statements drawn from international commitments

ICPD

Chapter IV: Gender Equality, Equity and Women’s Empowerment

  • Male responsibilities and participation. Governments should promote equal participation of women and men in all areas of family and household responsibilities, including, among others, responsible parenthood, sexual and reproductive behavior, prevention of sexually transmitted diseases, and shared control in and contribution to family income and children's welfare.

Chapter VII: Reproductive Rights and Reproductive Health

  • Reproductive rights and reproductive health.… Innovative programmes must be developed to make information, counselling and services for reproductive health accessible to adolescents and adult men. Such programmes must both educate and enable men to share more equally in family planning and in domestic and child-rearing responsibilities and to accept the major responsibility for the prevention of sexually transmitted diseases.
  • Family planning. Actions are recommended to …increase the participation and sharing of responsibility of men in the actual practice of family planning.
  • Human sexuality and gender relations. Recommended actions include giving support to integral sexual education and services for young people… that stress male responsibility for their own sexual health and fertility and that help them exercise those responsibilities.

Beijing Platform for Action

Mission Statement:… This means that the principle of shared power and responsibility should be established between women and men at home, in the workplace and in the wider national and international communities… A transformed partnership based on equality between women and men is a condition for people-centred sustainable development.

41. The advancement of women and the achievement of equality between women and men are a matter of human rights and a condition for social justice and should not be seen in isolation as a women’s issue. They are the only way to build a sustainable, just and developed society. Empowerment of women and equality between women and men are prerequisites for achieving political, social, economic, cultural and environmental security among all peoples.

Sources: UNFPA. 1995. International Conference on Population and Development (ICPD) Programme of Action in 1994. New York; and UN. 2005. Summary of the Programme of Action of the International Conference on Population and Development. New York: Department of Public Information.

How to Complete This Step

This section focuses on how to build commitment and relationships which support programming to involve men in SRHR effectively. To develop or to implement a programme, you will first need to build commitment—in other words, secure support and commitment at all levels of the health sector (clinic, hospital, municipal, state or national health centre, etc.), including at higher levels, which have the greatest influence on procedures and funding. If the needed investments in terms of training, staff support and commitment to making changes (including in rules and procedures) are not going to materialize, then it will be very difficult to implement an effective programme. Building commitment can also include reaching out to stakeholders in the community. Part of this process can involve identifying persons who can play the role of champions for male involvement in SRHR or who serve as “gatekeepers” at the community level (such as community leaders, religious leaders, local government), as well as being prepared to respond to concerns and some opposition to working with men.

Other publications may deal more directly with how to build commitment and integrate changes within health centres and systems, so this guide will try to focus on issues relevant to the involvement of men in SRHR.

Important Principles For Engaging Men Constructively

Before involving men in SRHR, it is important for one’s organization to reflect on and agree to some basic principles. These principles should guide the organization’s work on gender and reflect a rights-based and gender-equitable approach to SRHR, including family planning. The principles should be developed and owned by each individual organization. Below is a sample set of principles which can serve as inspiration.

  • View men as clients of SRH services with a right to the highest attainable standard of health, aside from their role in supporting the health of their partner or family.
  • View men as part of the solution and work to increase their sense of ownership of new initiatives which promote gender equality and women’s empowerment.
  • Question rigid gender norms and promote more equitable behaviour among staff and clients.
  • Ensure that funding efforts to involve men do not detract from ongoing and planned work with women and girls.
  • Assure women the choice as to whether to include their partners in reproductive and sexual health counselling, service delivery and treatment. Staff must be trained to be able to counsel couples and recognize possible controlling or violent behaviour by a partner.
  • GBV, including physical violence and sexual harassment, can never be tolerated. It must be recognized in programming (at the very least through referral relationships).
  • Ensure that SRHR and reproductive rights of everyone are respected irrespective of sexual orientation and gender identity.
  • Ensure that rights-based community values and experiences are respected.
  • Involve men from a positive perspective, understanding that they can play a positive role in their partner's health and in their own SRHR.
  • Encourage relationships between men and women based on mutual trust, respect, ownership of decisions and their outcomes, shared benefits and equal opportunities.
  • Ensure that positive changes which can result from involving men are extended to women.

Discussing Your Programming with Stakeholders and Partners

Key to building relationships and commitment is the ability to discuss programming strategy and to anticipate and respond to concerns regarding working with men in SRHR including family planning which may arise. Also, if programming is gender-transformative or gender-sensitive, there may be some push-back from people or institutions who do not understand it, are not necessarily supportive of gender equality or who may not trust the validity of the approach. Other concerns may come from people or institutions which support gender equality but are specifically concerned about how working with men may impact women, especially how a new/expanded programming focus can detract from the need for continuing work and funding for programmes with women and girls. Some may also have negative attitudes with regard to men and their ability to change and/or to be caring and supportive partners. An important first step is to recognize and be able to discuss the benefits of engaging men in SRHR. The following text box presents how men can benefit from utilizing SRH services.

How Men Can Benefit From Utilizing SRH Services

It is important to understand and be able to communicate to men some of the benefits of utilizing SRH services. These benefits include:

  • Information and screening for HIV, STIs, and other health issues
  • An opportunity to discuss and get information about sexuality, sexual performance, optimal SRHR, infertility, and anatomy and/or physiology
  • An opportunity to discuss and receive diagnosis for sexual dysfunction and other psycho-sexual problems
  • An opportunity to discuss and receive information about family planning generally, as well as about specific family planning methods
  • An opportunity to learn how to negotiate and discuss decisions pertaining to sexuality, contraception, procreation, STI testing and childbearing with an intimate partner
  • Increased contraceptive use by the couple, leading to a greater ability to attain desired family size
  • Access to low-cost or no-cost condoms
  • Referrals to other health services

Note: Adapted in part from: UNFPA. 2003. It Takes 2: Partnering with Men in Reproductive and Sexual Health. Program Advisory Note. New York.

Another important step is to recognize the possibility of dealing with opposition with regard to gender-transformative programming. In every context, the opposition and issues will differ; thus, it is recommended to facilitate a workshop activity to help participants (including health outreach workers, programme managers, providers, etc.) reflect on reasons why institutions or individuals may oppose male involvement. Such reflective practices may help your institution prepare for the types of disagreement they might encounter when trying to engage men and boys in SRHR, including family planning. This sort of activity will help participants practise some strategies and build skills for responding to possible community opposition to engaging men in SRHR. It is important to take note of the concerns and then demonstrate how the programme reflects the values of the community and culture—and is focused on improving health outcomes.

It is also recommended to keep notes during the activity so that afterwards, your institution can write up a “statements and responses” sheet. Depending on your brainstorming activities during the activity, participants should come up with short and simple responses justifying gender equality through the framework of engaging men and boys in SRHR, including family planning. For example:

  • Statement: Family planning is the woman’s responsibility.
  • Response: Men can play an important and supportive role in family planning. They can (and should) share the same responsibilities with regard to caring for their family. There are very important family planning methods which are male-centred, notably condoms and vasectomy, and men can support their female partner to effectively use whichever family planning method she chooses. When men are equitably involved and supportive with regard to family planning, the couple is better able to achieve their desired family size and to effectively use contraception.

Determining institutional commitment is a key step before one can develop a programme or conduct an assessment. Securing support is fundamental from the very beginning of the project, not only to ensure sustainability, but also to create an enabling organizational environment and maintain the morale of staff directly involved. Create an internal working group with representatives of all key internal departments, to ensure collective understanding of what is involved and why it is important. Such groups can also have the valuable added benefit of helping to build support for the approach being taken and encouraging a sense of collective ownership of the process from the outset. Develop an internal communications plan to explain to staff, board members and volunteers the value of engaging men in SRHR. Coordinate work to review and develop gendered policies. Male involvement efforts must be more than a series of separate programme activities. The ultimate goal is for institutional architecture of policymaking to recognize gender equality as “a central foundation for any effective response,” rather than as a discrete issue considered by and of interest only to specialists. Ensure that resources (financial, capacity-building) are devoted to men and gender equality.

Lastly, stakeholders need to be engaged from the beginning. Generally, it is good practice for all stakeholders to participate at all stages in policy development, review and implementation. Stakeholders include internal stakeholders (staff, volunteers and board members of your own organization) and external stakeholders (organizations and individuals who might have an interest in proposed policy objectives and how they are delivered in practice). With regard to male involvement, external stakeholders should include women’s rights organizations and youth organizations, but possibly others as well. Involving stakeholders in the policy development or review processes will help to ensure that policies reflect multiple perspectives, not just those of the policy originators, and will generate a sense of ownership among those who will be involved in implementation. The process of engaging stakeholders should be properly planned, with clear objectives and named responsibilities, a timetabled action plan, training for staff who will lead the consultation and clear explanations of the issues and process for those being consulted. Stakeholders should ideally be involved in the design of the evaluation approach, not only in performance monitoring or data collection.

Stakeholder Mapping

Source: International Planned Parenthood Federation (IPPF) and MenEngage. 2010. Men-streaming in sexual and reproductive health and HIV: A toolkit for policy development and advocacy. London: IPPF, Module E, p. 21.

The above suggestions can be used as part of a process to build support for change, but they will not be sufficient on their own. Building commitment is a continuous process and requires consistent efforts. Organizations may need to focus on this issue and pull from other resources with regard to engaging with stakeholders and building relationships and commitment for change. Note that the assessment (next step) phase will also contribute to this process of building support.

For more information, please see the following RESOURCES

C) Assessing the Needs for Male Engagement in SRHR Programmes

The final decision to involve men in programming should only be taken after an assessment to understand gender barriers and norms, which can hinder or support involvement of men in SRHR. This includes reflecting on the possible consequences and benefits of involving men in SRHR and confirming whether involving men in a specific family planning programme or centre is appropriate at the specific moment. The assessment phase can consist of qualitative or quantitative research into gender norms among men and women and how they impact contraceptive utilization, access to SRHR information and services, and discussion and decision-making around SRHR. It could include reviewing recent studies or literature on gender and SRHR in the programme area (or if not available in similar contexts), assessing clinics to determine how friendly their services are to women and men, assessing staff and provider knowledge, attitudes and skills, and determining the level of commitment within a service for working with men in a gender-equitable framework.

Assessment is a crucial step, as it will inform what service gaps, gender norms, health issues and barriers to SRHR need to be addressed in programming. For example, if it is found in the literature review that GBV prevalence is very high in the country and that indicators around gender equality are poor (such as around decision-making in relationships), then the project may want to consider how this might affect an effort to involve men directly in family planning decision-making (couple communication or counselling) and how addressing norms (possibly in partnership with other organizations) would be an important component to reaching men. Also, it is important to ensure that safeguards are in place to avoid negative outcomes. The organization may still be able to involve men in providing information and services to address their own SRHR needs.

How to Complete this Step

The tools mentioned in the assessment phase can be used not only for formative research to develop an intervention, but also for evaluation or documentation of the project’s impact. As mentioned in the introduction, different tools can be used at different points of programming. Some of the tools in this section may be applicable and others may not, depending on the type of programming the organization carries out.

One of the first steps in an assessment should be to look at the data that is available and relevant to family planning and gender issues. These may include government statistics on available services for women, men and couples, use of family planning services, method mix, and attitudes towards SRHR, gender norms and male participation. See the text box below for some links to data sources.

Sources for SRHR and Gender Statistics

The Demographic and Health Survey (DHS) program provides invaluable information from around the world; it gathers data on family planning, reproductive health, gender equality (including decision-making in the home) and gender-based violence (attitudes about and prevalence of GBV). This information (if available for your country) can be accessed from www.measuredhs.com/.

DHS also has a specific Gender Corner at www.measuredhs.com/Topics/Gender-Corner/.

The World Bank’s Gender Stats page also includes disaggregated data from many sources and countries. It is available at http://go.worldbank.org/T1WTTF4II0.

The Population Reference Bureau provides statistics on reproductive health and other health and development issues at www.prb.org/Datafinder.aspx.

The International Men and Gender Equality Survey (IMAGES) includes extremely detailed information about men, women and gender, though it has been implemented in only a limited number of countries: www.icrw.org/publications/international-men-and-gender-equality-survey-images.

The UN Gender Inequality Index provides an index for ranking countries in terms of gender equality, with 1 being most equitable: http://hdr.undp.org/en/statistics/gii/.

The World Values Survey data provides global insight into how people’s values and beliefs systems change over time, based on socio-political impacts: www.worldvaluessurvey.org/

It is possible that data or information about gender norms and their impact on family planning may not be easy to find for every country or setting. If the global databases mentioned in the text box do not contain the information which you need, your organization will need to search more actively. Even if the databases provide the information, it is still important to conduct one’s own formative research, especially since many of the databases mentioned in the text box do not focus solely on gender norms. Qualitative tools can help to get a more diverse and complex picture of gender norms in a particular context.

Key Informant Interview

One simple qualitative tool is the key informant interview. Your organization might consider reaching out to various organizations and potential stakeholders through such interviews. These can help flesh out information which was identified in the literature review, detect other issues of concern for the key informants in terms of involving men, find other sources of information which the literature review did not identify and ascertain other issues/concerns around gender equality which could impact male involvement in SRHR.

The Needs Assessment Package for Male Engagement Programming provides key informant interview guides for different key informants (government officials, staff at non-governmental organizations, researchers and health staff) to better understand opinions and attitudes. The questions are focused on engaging men in HIV, so the questionnaires will need to be adapted to include information on SRHR and will also need to be adapted to one’s context and programming needs.

Potential sources of key informants include:

  • Women’s rights organizations
  • Women’s associations (including labour or work-related associations, church-related associations, micro-credit associations, etc.)
  • Family planning associations (i.e., International Planned Parenthood Federation [IPPF] affiliates) and HIV service providers
  • Ministries or other government agencies which work on gender (i.e., Ministry of Gender, Ministry of Women, Ministry of Family or other variations)
  • Ministry of Health, Ministry of Youth and other agencies which work on reproductive health
  • Relevant UN agencies (UNFPA, WHO, UNICEF, UNAIDS, UN Women, UNDP, etc.)
  • Bilateral funders which may work on gender (i.e., SIDA, NORAD, USAID, GIZ, Spanish Cooperation, etc.)
  • Non-governmental organizations (local and international) working on gender or gender-related issues and SRHR
  • Organizations which work with men to promote gender equality and prevent violence
  • Associations which include large numbers of men, including labour and sporting associations
  • Networks of people living with HIV and organizations focusing on key populations
  • Academic departments or research units which focus on gender within universities and colleges
  • Traditional, cultural or religious leaders within the communities where you intend to work
  • Members of the MenEngage network (country or regional networks)

For programming which includes youth, engaging youth stakeholders is key.

Another way to gather information about gender norms and their relationship to family planning in your community may be through a focus group discussion. Depending on the sensitivity of issues in your context and the questions you want to ask, it may be more appropriate to use single-sex groups, mixed groups or a combination of both types of groups. There is no set rule for this, though in some settings men and women will feel more comfortable discussing these issues in single-sex groups. Keep in mind that you will need to develop the objective of the focus group discussion and adapt the questionnaire to be sure it helps address that need. The number of focus groups which you conduct will depend on the funding and time you can dedicate to this, as well as the issues you will discuss (for example, more than one focus group discussion guide may need to be constructed for different themes) and what groups of people you feel you need to speak to (for example, you may want to assess clients, potential clients, partners of clients, providers of family planning services, other providers, young men and/or women, etc.).

After conducting and analyzing key informant interviews or focus group discussions, you can determine the need for other assessment tools. One tool for assessing service sites is Creating a Male-Friendly Environment: Clinic Walk-Through, which can be found in Engaging Men in HIV and AIDS at the Service Delivery Level: A Manual for Service Providers, on page 103. The clinic walk-through, which is primarily a checklist for assessing the male-friendliness of a clinic, can be adapted to focus on SRHR and family planning and can also be adapted to look at gender inequities in the clinic which impact women. It can also be part of project activities—for example, this tool can be used as part of a capacity-building and service provision project, to identify service gaps and to think of ways to address those gaps. Providers use the tool to walk through their clinic with a checklist which assesses whether the clinic or service site is male-friendly. Please keep in mind that you should adapt this tool to fit your context and objectives.

Some projects may have the resources to conduct quantitative surveys. One relevant resource for quantitative assessments or evaluations is the C-Change Gender Compendium, which lists various scales that have been used to measure attitudes around gender (such as the Gender-Equitable Men [GEM] Scale). These scales are used in a quantitative assessment or evaluation of programming and are often part of a questionnaire which also asks questions about specific behaviours. The attitudes can then be correlated with specific behaviour (such as use of family planning, GBV, etc.). Using the tools in the C-Change Gender Compendium to develop survey questionnaires will require experienced staff who understand quantitative methods, including sampling methodology, and who can perform data analysis of the scales. One option to carry out surveys can be to partner with a research organization in your country or region which can help to design and conduct assessments and evaluations. Finally, the tools listed in the C-Change Gender Compendium will also need to be adapted to the culture and context where they are being used and tested.

TOOLS

RESOURCES

D) Creating Objectives and Designing the Programme

This section introduces some steps for developing programming around engaging men in SRHR. These programme design steps include: 1) defining what we mean by constructively engaging men in SRHR and what that programming might look like; 2) conducting a gender analysis of possible programme strategies; 3) developing a logic model (including the creation of SMART objectives); and 4) selecting programme activities and approaches. Several of the tools presented here are not specific to working to involve men but are examples which can be used at this stage. Other similar tools could be used just as easily. It is crucial that this step be grounded in the results of assessments and/or based on available evidence and research (either in-country or from similar contexts), as discussed in the previous chapter.

1) What do we mean by “engaging men,” and what might that look like in terms of programming?

Constructively engaging men often focuses on three specific potential areas for male involvement: men as clients, men as supportive partners and men as agents of change. However, it is not limited to these areas.

Men as Clients

Often, men underutilize reproductive health services because they cannot conceptualize that such places facilitate services which are readily available to them. An approach to engaging men in SRHR is to encourage the use of the services for themselves and to recognize that they too have sexual and reproductive health issues and needs. For example, in terms of family planning, some programmes focus on getting men to take an active role through the use of vasectomy, while in terms of HIV, the focus may be on getting men to test for HIV and use condoms.

Men as Supportive Partners

Often, men are not involved in decision-making processes or in the supportive aspects of SRHR or family planning issues. They may, for example, see this as an area which is exclusively their partners’ responsibility. Programmes which address men as supportive partners see the positive influence that men can have on women’s SRHR. Such programmes recognize that men can play a major role in making decisions, planning and allocating resources needed for women’s health issues. Programmes using this approach target men to influence them to become supportive partners in a variety of areas, including maternal health, family planning, neonatal care and HIV.

Men as Agents of Change

While this guide is geared towards service delivery programmers rather than social change writ large, this third approach is more transformative. In comparison to other male engagement approaches, the emphasis is on addressing the norms which put women and men at risk (e.g., norms around multiple sexual partners, non-use of contraception, abuse of alcohol, violence, etc.). Programmes which fall into this category explicitly focus on identifying and addressing the key gender and social norms which contribute to gender inequality and may result in adverse health outcomes. An implicit assumption about these programmes is that more progressive norms around masculinity and gender will translate into improved SRHR outcomes. Programmes using this approach also ask men to engage other men in their communities to promote gender equality, including in relation to reproductive health.

Constructively engaging men also does not have to mean just targeting men. Programming with men should always be done in consultation with women and ideally in conjunction with programming with women. In fact, the best results may be achieved with programmes which are gender-synchronized—i.e., which work “with men and women, boys and girls, in an intentional and mutually reinforcing way that challenges gender norms, catalyzes the achievement of gender equality and improves health.” Though this guide focuses mostly on men, much of its guidance can be adapted to apply to programming which is gender-synchronized (especially since gender-synchronized programming implicates engagement of men as well as women).

How do we constructively engage men?

The Examples of Ways to Help Men in the text box demonstrates a variety of ways in which health providers can engage men in SRHR using a gender lens. These are only a few examples intended to generate thought about the type of programming strategies one can consider when engaging men in SRHR.

Some Examples of Ways to Engage Men

Providers can serve men both as supporters of female partners and as clients.

Encourage Couples to Talk
Couples who discuss family planning—with or without a provider’s guidance—are more likely to make plans which they can carry out.

Providers can:

  • Coach men and women on how to talk with each other about sex, family planning, HIV and other STIs.
  • Encourage joint decision-making about sexual and reproductive health and rights matters.
  • Invite and encourage women to bring their partners to the clinic for joint counselling, decision-making, and care (if providers are trained and ready to conduct couples counselling).
  • Suggest to female clients that they tell their partners about health services for men, and give them informational materials to take home, if available.

Provide Accurate Information
To inform opinions and decisions, men need to receive accurate information and to have their misperceptions corrected. Important topics include:

  • Family planning methods, both for men and for women, including safety and effectiveness
  • STIs, including HIV—how they are or are not transmitted, signs and symptoms, testing and treatment
  • The health benefits of waiting until the youngest child is 2 years old before a woman becomes pregnant again
  • Male and female sexual and reproductive anatomy and function
  • Safe pregnancy and delivery

Offer Services or Refer
Important services which many men want include:

  • Condoms, vasectomy, and counselling about other methods
  • Counselling and help for sexual problems
  • STI/HIV counselling, testing and treatment
  • Infertility counselling
  • Screening for penile, testicular, and prostate cancer

Like women, men of all ages, married or unmarried, have SRHR needs. They deserve high-quality services and respectful, supportive and non-judgemental counselling.

Source: World Health Organization (WHO). 2011. Family planning: A global handbook for providers (2011 update). Baltimore and Geneva: WHO Department of Reproductive Health and Research and Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs.

Addressing challenges to engaging men in family planning

Even though the goal of this guide is to involve men in SRHR, some important challenges need to be recognized. These challenges will make it clear that men’s access to services for themselves and as half of a partnership needs to be provided in a manner which promotes gender equality and which “does no harm.” In the case of family planning, this means ensuring that women’s (including adolescents’) access to and ability to use contraception and plan pregnancies is not negatively impacted and that women’s consent is ensured before involving their partners or relatives. The challenges described below help to highlight why programmes which involve men in family planning should be gender-transformative (or at least gender-sensitive) and should seek to promote gender-equitable/shared decision-making.

Male Control and Decision-Making

Many male-female relationships are still affected by power dynamics. In certain contexts, especially in terms of resources, men are considered the primary decision-maker. For example, in a context where men exert control over their partner’s family planning decision, involving men in family planning through couples counselling has the potential to negatively impact women’s ability to access or use contraception. In other words, if men and women believe that the man has the final say, then engaging men in SRHR may result in men’s having the final say in this domain as well, unless those norms are questioned.

Programming considerations: By promoting discussion, negotiation and shared decision-making, programmes can go a long way towards addressing some of the above concerns. Programme managers should ensure that involving men will not impair women’s access to family planning. They can require that providers obtain the woman’s consent individually prior to allowing a partner or other person to the counselling session. They can also seek to assess gender norms around SRHR (by reviewing studies and reports about gender in their context, or by conducting focus groups, key informant interviews with stakeholders or quantitative surveys). If in a specific context gender norms are highly inequitable, then the programme can decide to focus first on promoting equitable gender norms, addressing men as clients of SRHR directly and addressing attitudes regarding SRHR and sexuality among men and women. At a later stage, it can turn towards strategically involving men in couples counselling and SRHR decisions.

Differing family size preferences

In many countries, men report desiring a larger number of children than do women., If men favour larger families than their partner, they can attempt to prohibit contraceptive use, take steps to impede or limit their partner’s access to contraception or in general be unsupportive or uncooperative in terms of family planning use.

Programming considerations: Programmes which involve men in SRHR may need to overcome resistance to family planning from men within some contexts. They will need to provide information on the health and other benefits of birth spacing, as well as promote gender equality and respect for their partner’s right to use family planning and control the number of children s/he has. They will also need to recognize that women need to be empowered to make their own decisions regarding family size and contraception.

Couples Counselling and Individual Choice in Family Planning

Male involvement in family planning counselling and in the overall family planning decision can improve access, adoption and ongoing use of contraception. However, caution must be taken to ensure that the push to provide family planning counselling to couples does not undermine individual choice. For instance, given the points made above regarding men’s ability to influence or limit women’s reproductive choices and the possibility of men in some contexts desiring more children than women, couples counselling at times can risk obstructing the ability of a woman to use family planning. The same applies to couples counselling for HIV testing and counselling and STI management, which have the potential to raise even more issues, given the sensitivity to issues such as infidelity (or the perception of it), stigma associated with HIV and sensitivity to discussions about intimate relationships. Lastly, any couples counselling project has to realize that in many contexts, a significant percentage of women are in physically or emotionally abusive relationships, which can make couples counselling a dangerous or ineffective strategy for those women.

Programming considerations: A woman (or man) should be given the option to engage her (or his) partner in the family planning counselling session, but it must be solely the client’s decision whether to invite her (or his) partner to participate. If a client shows up with a partner, spouse or family member, the provider should speak with the client individually to make sure that he/she wants to have someone else participate in the family planning counselling session. Depending on the context, it may be appropriate to utilize short screening questions as part of a larger programming strategy to address coercion or abuse. The same principle can be applied when dealing with HIV and STI services as well.

Male Health-Seeking Behaviour

Male gender norms often include a bias against seeking health services. Some men still see health-care seeking as a sign of weakness and will delay accessing care, often only until after becoming very ill.,, Gender norms may likewise discourage men from talking about sex with their partners, may inhibit them from getting tested for HIV or other STIs or may frame sexual and reproductive health as being only the woman’s responsibility. Therefore, involving men in SRH services will require some work to overcome such perceptions and expectations.

Programming considerations: Challenging male gender norms around health seeking is a crucial component of a gender-transformative male engagement project. The Act like a Man activity in this guide can help to get men to reflect on the costs of inequitable gender norms. However, this guide does not provide a full curriculum for addressing male gender norms (or male and female norms) in a community, which would be crucial. Other programming resources (Men As Partners®, Program H, One Man Can, Gender Matters, among many others mentioned here) include specific activities which address men’s attitudes towards health seeking in general. Some relevant links can be found at the end of the sections. These strategies can be adapted to help develop schemes to begin to shift gender norms in communities.

Receptiveness of Sexual and Reproductive Health Services

Even when the environment seems conducive to involving men, there are several difficulties in bringing men into SRH services. For one, men often see reproductive health services as being meant for women; as a result, they do not see a place for themselves in those services. This perception is often based on the reality that many SRH service sites promote themselves mainly to women and predominantly organize their facilities to attend to women (displaying posters of only women and children, featuring reading materials for women, having opening hours which may not be convenient for men and having staff who are not comfortable providing SRH services to men).

Programming considerations: An important step in making health services more gender-friendly (addressing gender inequities in how services are used and provided) is to train health-care staff to provide services to men and recognize inequities in how services are provided to women. Changing the physical environment to be welcoming to men as well as to women, and potentially creating special hours for men, can help address this issue and increase male access, while at the same time making positive changes for female clients. Some of the programming tools and resource links in this publication offer strategies for making services more gender-friendly and for attracting men to SRH services.

Negative attitudes towards male involvement

Service providers or programme designers may perceive men mostly as a barrier to women’s health and/or as potential aggressors or abusers. Alternatively, they may simply not have experience with serving male clients and therefore may be less comfortable with addressing their health needs. Overcoming negative attitudes is a significant part of increasing men’s participation in SRHR. At times, the attitudes are affirmed by the behaviour of some men or by the lived experiences of providers or programme designers. These attitudes can repel men who want to participate equitably in SRHR decisions, and they can keep men from being able to access family planning or SRH information or services for themselves.

Programming considerations: Efforts to address concerns that providers or programme staff may have about involving men in SRHR should make clear the benefits of doing so and how challenges can be overcome. Some of the tools in this guide represent activities for improving their attitudes towards involving men in SRHR, from a positive perspective, understanding that such men can become champions in promoting women’s, newborns’ and children’s health, in addition to meeting their own legitimate health needs.

Violence and Coercion

Though it is crucial to involve men from a positive perspective, acknowledging that most men seek caring and healthy relationships, it is also important to recognize that violence and/or coercion can be present within relationships and to understand how that can influence the provision of SRH services.

Programming considerations: Health units and staff must consider how they can deal with violence and coercion and how they can begin to develop procedures for responding to clients who have experience with violence in their relationships. Programme managers should seek out information related to the prevalence of domestic violence in their country or community and understand the laws which govern violence against women, including whether there are reporting requirements for health-care workers. Staff should also identify organizations to which they can refer survivors of intimate partner violence/domestic violence, including women’s shelters, legal aid organizations, counselling services, women’s rights organizations/activists and law enforcement. If the violence is recent, women can be referred to medical forensic officers or to a doctor trained in forensics, depending on the laws or procedures for medical investigation of crimes in each country and whether there are laws or forensic procedures regarding violence against women.

Health units should be prepared to deal with clients who report being in violent relationships, including how to make referrals and how to provide family planning options for women specifically in these situations (see Text Box on Covert Contraception). Health units should likewise have protocols specifically prohibiting and addressing sexual harassment and/or coercion of any type within the workplace and towards clients. Though this is an important area to address, the tools and guidances are very complex. One document to highlight is the WHO publication Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines, which can be a useful resource.

Programme managers should also consider how to address GBV prevention in their communities and how to change male attitudes towards violence, decrease justification of violence and reduce perpetration of violence. One option can be to partner with other organizations which focus on GBV prevention.

Heteronormativity

Heteronormativity refers to promoting or seeing heterosexuality as “normal” or preferred. This topic can be controversial in some contexts; it may not come across clearly to some as an important point to consider when involving men in SRHR. However, it does have a clear impact on the way in which programmes and services are delivered. Heteronormativity impacts everyone as it is closely aligned to dominant constructions of masculinity and femininity and helps dictate what is acceptable and expected from men and women in general. Heteronormativity (and homophobia) are also very effective at keeping men and women from stepping outside of what is expected of them and therefore traps them into rigid gender roles and responsibilities (for example norms that state that family planning is a woman’s sole responsibility or that men don’t feel they need health services as much). In other words, if a program promotes heteronormativity, it is likely to also promote rigid gender norms and stereotypes.

Also, providers need to be prepared to deal with the SRHR needs of all individuals regardless of their gender identity or sexual orientation. For example, negative provider attitudes can keep some individuals from being able to discuss their full SRHR needs.

Programming considerations: Ensure that programming never promotes any negative views towards any individuals irrespective of their gender identity or sexual orientation. Ensure that staff training includes reflection about sexual orientation and gender identity (as facets of every person’s life), and reflect on attitudes which they may have towards some individuals and how those can impact their provision of services and programming. Begin to ensure that providers feel comfortable counselling clients of any sexual orientation.

This not a comprehensive list of challenges, and programme managers/designers should continuously perceive challenges as they come up and consider how to address them.

Lessons Learned

Some general lessons learned through the experience of involving men in SRHR can help orient our work. These lessons include:

  • Work with men where they are: Programmes which are most successful are those offered where men and young men gather, such as the workplace, sports arenas, taxi stands and markets.
  • Offer services at times when men are available.
  • Understand the social-political-cultural context and its consequences through the lens of gender: One needs to understand the norms, resources and power in the reproductive sphere and how these play out in different geographical and cultural contexts.
  • Use a holistic, multi-pronged approach: Partnering with men from a gender perspective is a multi-dimensional concept (for example, even if services are provided to men, issues around community norms and community outreach also need to be addressed).
  • Train health service providers to become more gender-sensitive: Appropriately trained staff—from managers and administrators to receptionists and guards—are crucial. Training in male reproductive health and gender should be provided on an ongoing basis.
  • Detect unintended gender biases or consequences of messages in mass media campaigns: Mass media messages should not reinforce inequitable gender roles.
  • Be vigilant that programmes involving men do no harm to women: Providers are responsible for ensuring women’s reproductive health, rights and autonomy while addressing the health needs of men as equal partners.

Covert Contraception

Covert (or clandestine/hidden) contraceptive use occurs when an individual decides to utilize contraception without the full knowledge of his/her partner. While male involvement in SRHR is promoted in this guide, the fact remains that some husbands or male partners will not be reached by efforts to engage them or will continue to exert control over their partner’s family planning options. Reasons for covert contraceptive use among women can include the fact that men may be opposed a priori to contraception (based on misconceptions about faithfulness and family planning or other biases against family planning). Men may want to have more children than their partner, there may be problems communicating between the partners or there may be violence or the threat of violence in the relationship.

Involving men in SRHR and improving couple communication and equitable decision-making have great potential to reduce covert contraceptive use and to improve a client’s ability to achieve her reproductive intentions. Respect for the individual’s right, including the woman’s right, to access and use family planning must remain paramount, as must the ability to guarantee confidentiality in family planning services. Providers should be ready to discuss contraceptives and their covert usage with clients and to help them select the method which will work best for them. Since side effects are one of the reasons why women abandon contraceptive use, especially when they are trying to use it covertly (due to fear of discovery), providers need to pay special attention to discussing side effects and helping clients prepare for and deal with them. Providers also need to help clients think through potential consequences if their covert contraceptive use is discovered.

 

2) Gender Analysis and Gender Impact of Health Programmes

After brainstorming some programming options, it is important to think of the impact of these potential programming options on women and men and ensure that specific programming is sensitive to gender norms. This process should be informed by the data found during the assessment phase. Though it is probably intuitive that health programming is affected by gender norms, it may be less so that programming can also impact gender norms in a community. Health services or non-governmental organizations which are conducting any social and behaviour change communication (SBCC) activities may impact gender norms, possibly reinforcing negative norms, even if that is not their intent. As one simple example, reproductive health clinics which target outreach mostly or almost exclusively to women and do not really reach out or provide information to men can reinforce the stereotype that family planning is mainly a female responsibility, even if that is not the intention. As a result, it must be noted that all programming (including programming which seeks to be gender-sensitive or gender-transformative) needs to pay attention to what it is communicating, intentionally or unintentionally, to avoid reinforcing negative or rigid gender norms.

One tool for assessing the potential impact of gender on health programming and of programming on gender is to use gender analysis. The Gender Analysis Approach can help programmers to apply a gender analysis to possible programming strategies before these are implemented. This tool is basically a questionnaire which can be used to inform a process of analyzing possible programme impacts, as well as the way in which prevalent inequalities could impact the programming strategy. In the end, gender analysis is something which should be applied at all stages of programming, from design to the roll-out of specific programme activities.

This gender analysis is built around two key questions:

  • How will the different roles and statuses of women and men within the community, political sphere, workplace and household (for example, roles in decision-making and differential access to and control over resources and services) affect the work to be undertaken?
  • How will the anticipated results of the work affect women and men differently?

The purpose of the first question is to ensure that: 1) the differences in roles and statuses of women and men are examined; and 2) any inequalities or differences which will impede achievement of programme or project goals are addressed in the planned work design. The different roles, responsibilities and statuses of men and women within the community, political sphere, workplace and household (e.g., roles in decision-making and different access to and control over resources and services) must be addressed.

One of the objectives of gender analysis is to explicitly include reflection on the potential impacts of a programme on gender within a community or context, even if gender is not included as a strategy or primary outcome. Further questions which could be added to the gender analysis tool and to inform programme design include:

  • How might the project affect (positively or negatively) women’s access to services or resources? What about men’s access?
  • How might the project affect attitudes and perceptions regarding male and female gender roles?
  • Is it possible that the project could reinforce some inequitable gender norms or perceptions (for example, by reinforcing rigid expectations for men and women)?
  • How might the project impact the ability of women and men to make decisions about SRHR?
  • Could engaging male partners potentially reduce women’s ability to make decisions regarding their own SRHR?
  • What stakeholders have been engaged? Have women’s rights organizations been involved, to hear their perception of the potential project impact? Have women and men been heard from, to understand how they may perceive project messages?
  • What impact could the project have on community perceptions regarding sexuality, including sexual diversity? Does it reinforce attitudes which discriminate?

The tool Tips for Developing Gender-Equitable Information, Education, and Communication (IEC) Materials applies gender analysis specifically to the development or revision of SBCC materials, to help ensure they are more gender-equitable. It can also be used during programme design or during project implementation, depending on whether you will develop new materials or simply revise materials which are already being used. It gives some recommendations on how to integrate gender into SBCC materials for different levels of programmes which are gender-neutral, gender-sensitive or gender transformative. This can be an example of a relatively low-cost way to begin to integrate gender into programming and to ensure that engagement of men in SRHR is done in way which promotes gender equality.

SBCC Materials Gender-Sensitivity Checklist

This checklist points out some areas in which SBCC materials can inadvertently reinforce harmful or traditional gender norms. It can be used when developing new materials, when selecting among existing materials and/or when adapting or revising existing materials or drafts. Reproductive health programmes with minimal gender experience may want to consider partnering with a women’s rights organization or other organizations with experience in gender equality to get their feedback on draft materials. This checklist can be used to generate reflection and discussion during the development of SBCC materials.

After deciding what types of programming activities you feel work best, based on your organization’s capacity, the context and the assessment(s) and gender analysis which you performed, the next step is to develop clear project objectives for the programme activities. Utilizing the SMART Objectives tool is a simple way to help think through the development of project objectives.

3) Developing a Logical Framework

Following the development of the programme’s objectives, the next step is to create a logical framework for planning, monitoring and evaluation. Such a framework presents key information about the project (e.g., goals, activities, indicators) in a clear, concise, rational and systematic way. The framework should be completed in partnership with donors, beneficiaries and other stakeholders prior to the onset of activities. It is important to keep in mind that the framework should not be set in stone—it should be flexible enough to accommodate changes or adaptations which may be deemed necessary during the monitoring process or during consultations with donors, beneficiaries or others throughout the life of the project. One example of a logic model is the Behaviour-Determinant-Intervention (BDI) Logic Model.

4) Selecting Programme Activities and Approaches

This step, which is often done together with or soon after development of the logical framework, entails selecting activities and approaches which will affect the determinants and behaviours and will lead to the health outcomes as defined in the logical framework. This section can give some ideas of different activities, but in the end it cannot be an exhaustive list. There is a good amount of research around different gender approaches and the text box Lists of Literature Reviews on Gender Programming (2004-2015) provides links (click on titles) to different literature reviews of gender programming which can give further ideas for programme designers.

Organizations can also use the following tool to begin thinking of potential interventions. Engaging Men in Reproductive Health Services: A Continuum of Programme Activities provides a list of different tasks, ranked from lowest to highest effort, which can form part of an intervention to engage men in SRHR. It captures the increasing amount of effort which would be needed to move from gender-neutral programming (or gender-sensitive programming) to gender-transformative programming. This can be used together with the text box on Ways to Engage Men, with literature reviews and along with the results from the assessment phase to brainstorm interventions for engaging men in SRHR.

Engaging Men in Sexual and Reproductive Health Services: A Continuum of Programme Activities

This tool seeks to show different programming options for engaging men in SRHR services, with some potential activity mixes for each stage of effort, from left (low effort: gender-neutral to gender-sensitive programming) to right (high effort: gender-transformative programming). The suggested actions are by no means exhaustive and can be done together or separately. They are only meant to spur thought about specific actions which programmers can consider. Programme designers will need to be creative, understand what will work in their context and adapt tools/methodologies appropriately.

Another crucial step in selecting activities and approaches is to make sure that programming is adapted to the cultural context, while still promoting rights-based and evidence-based programming. The text box below demonstrates some important steps for designing culturally sensitive programmes.

The following are some tips for designing culturally sensitive programmes. They are excerpted from UNFPA’s Working from Within: 24 Tips for Culturally Sensitive Programming. These guidelines for development practitioners can help them think of strategies for more effective and efficient project implementation:

  1. Invest time in knowing the culture in which you are operating
  2. Hear what the community has to say
  3. Demonstrate respect
  4. Show patience
  5. Gain the support of local power structures
  6. Be inclusive
  7. Provide solid evidence
  8. Rely on the objectivity of science
  9. Avoid value judgements
  10. Use language sensitively
  11. Work through local allies
  12. Assume the role of facilitator
  13. Honour commitments
  14. Know your adversaries
  15. Find common ground
  16. Accentuate the positive
  17. Use advocacy to effect change
  18. Create opportunities for women
  19. Build community capacity
  20. Reach out through popular culture
  21. Let people do what they do best
  22. Nurture partnerships
  23. Celebrate achievements
  24. Never give up

Source: UNFPA. 2004. Guide to working from within: 24 tips for culturally sensitive programming. New York.

TOOLS

  • Engaging Men in Reproductive Health Services: A Continuum of Programme Activities
  • Gender Analysis Approach
  • Tips to Developing Gender-Equitable IEC Materials

RESOURCES

E) Building Staff and Organizational Capacity

Though selecting concrete objectives and designing a strong project are important steps along the path to developing programming to involve men in SRHR, for programme designers and providers to be able to accomplish this, they will need specific skills and capacities. Paramount among these capacities will be sensitivity to gender and how to perceive and address gender inequities during service provision.

Many programme strategies may include group education or health worker training on gender sensitivity. Others may include working with outreach workers or developing communication strategies to address gender norms. These types of interventions will need to have skilled facilitators who are experienced and who have a solid grasp of gender norms in their community and how to promote gender equality within a group environment (see Minimal Requirements for Facilitators of Gender-Transformative Curricula). If no facilitators are experienced, then they will need to be trained, possibly by outside organizations or consultants.

Some projects may have specific training needs and objectives for providers as a result of male engagement in SRHR. For instance, service providers may need the capacity to run counselling services for men and couples. Couples counselling will be different, depending on the type of counselling (i.e., couples family planning counselling will differ greatly from HIV testing and counselling for couples or from antenatal care counselling for couples); providers will need tools specific to the type of counselling they will conduct. Providing counselling to couples must also include an awareness of related issues, such as power inequalities in the relationship, the potential disclosure of sexual activity such as infidelity, men’s lack of interest (or perceived lack of role) in SRHR, the tendency for some men to make SRHR decisions for their partner, and the potential presence of coercion and/or violence in a relationship. Providers need to deftly handle complex issues such as whether to include the female client’s partner in counselling and how to conduct couples counselling which effectively engages both individuals while ensuring that the woman is able to make SRHR decisions freely and without coercion. Also, programmes would need to develop protocols and clear expectations as to providers’ roles in regard to couples counselling.

 

Minimal Requirements for Facilitators of Gender-Transformative Curricula

Facilitators should:

  • Have had a chance to analyse and reflect on their own attitudes and behaviours in regard to gender equality, women’s rights, sexuality, sexual diversity, violence and coercion in relationships, and male and female engagement in non-traditional gender roles.
  • Feel comfortable discussing and leading discussions on the themes mentioned above.
  • Have seen the activities modelled and have practised those activities until they feel comfortable facilitating them.
  • Be able to comfortably model non-traditional or flexible attitudes and behaviours, so they are less likely to unintentionally reaffirm rigid gender norms.
  • Be able to engage participants in open, honest and non-judgemental discussions and reflections around gender norms.
  • Be aware of gender norms and major issues in terms of gender inequality and health in the context in which they are working.
  • Be aware of resources available for any person who might come forward needing support for issues with gender-based violence (past or present).
  • Demonstrate basic group facilitation skills, including the ability to lead a group discussion, follow a curriculum design/steps with fidelity, manage time, deal with challenging situations, etc.

Steps for capacity-building

There are four major steps for building staff capacity: 1) assessing capacity; 2) developing capacity-building tools, including training manuals; 3) implementing trainings and the capacity-building process; and 4) evaluating capacity and adjusting programming. Capacity-building includes training staff, but also involves post-training work, such as mentoring staff, holding practise sessions (such as mock client visits, where a staff person pretends to be a client and allows the provider to practise the skills that were taught), practising supportive supervision and conducting debriefs with other staff to discuss challenges and ways to address them.

Assessment was discussed in the assessment section of this guide, so our focus here will be on the development and implementation of capacity-building tools (specifically, training tools). Which training tools you use will depend on the needs which are identified during the assessment and the objective(s) which were defined during project design and are reflected in your logic model.

The group versions of the Learning about Gender activity and the Act like a Man, Act like a Woman activity which appear in Section A: Understanding Gender and Gender Programming in interactive versions are available in their original workshop versions in Engaging Boys and Men in Gender Transformation: The Group Education Manual. These activities are examples of the types of gender-transformative activities which can be conducted in a group setting. Similar types of activities are included in many different curricula, which can be adapted for capacity-building and for addressing gender norms among providers, clients and communities. Links to some of these curricula are provided at the end of this chapter. What is included here does not represent an exhaustive listing of capacity-building or training manuals around gender.

Also, regardless of what tools the programme designers select, they will still need to adapt activities when designing trainings for providers and staff. To help think of how to adapt different manuals or programme tools, a list of steps for the adaptation of materials to involve men in SRHR is provided here.

Part of the process of working with SRH providers includes addressing their attitudes and concerns regarding involving men in SRHR. Most of the suggestions are intended for a group environment and are derived from the EngenderHealth Men’s Reproductive Health Curriculum. Group environments such as a training or workshop can be a space for health providers and programme designers to reflect about their own attitudes regarding gender equality and providing services to men and women. It is also important to engage programme designers and providers more deeply in thinking about the challenges they may experience while working with men. Providers must think through how they can respond effectively to issues which may arise when counselling couples on a variety of SRHR issues. Providers and programme designers need also to reflect on how to handle a client’s consent to engaging his or her partner, as well as how to invite clients’ partners to an SRH centre. This can assist the provider to assess whether to include the spouse/partner in family planning counselling and also to what extent the client may need to pursue contraceptive usage without his or her partner’s knowledge. It is also essential that service providers reflect on their own assumptions, so that they are aware of them and can avoid having their expectations or prejudices influence service provision.

Besides training around curricula, programme designers need to ensure that protocols and procedures are in place which support gender-sensitive programming. This example describes just some of the issues which need to be addressed when deciding to implement couples counselling. These would need to be reflected clearly in a service site’s procedures.

TOOLS

RESOURCES

F) Monitoring and Evaluating the Programme

Evaluating or documenting programme experiences is key to any project. Because so many different evaluation materials are available, this section will only suggest some specific considerations related to evaluating the engagement of men in family planning.

As a resource for developing quantitative survey questionnaires, please see the C-Change Gender Scales, which can be used to measure changes in attitudes and reported behaviour related to gender as a result of a project. The justification for using scales is well-stated here: “Because there is no single ‘gold standard’ for measuring gender norms, gender attitudes, women’s empowerment, and other aspects of gender, researchers often use multiple measures. Using a single measure is not possible because gender operates in multiple spheres and has many facets.”

The scales can be used or adapted as pre- and post-test questionnaires to measure changes in men’s or women’s attitudes and to see to what extent a shift to more gender-equitable attitudes influences family planning behaviour or beliefs. For example, any discernible change in attitude can be used in conjunction with reported behaviour around contraceptive use, desired family size and other indicators, to see if there are correlations.

Measuring change in behavior, and especially change in regard to gender norms, can be difficult. It is important to note that change in terms of gender norms in a community can take place quite slowly. Programme designers and donors need to expect that the process will take time (and may extend beyond short-term planning and expectations). It will also depend on various other societal factors which can impact gender norms, as mentioned in the discussion of the ecological model in the Introduction. This is why it is important for programmers who seek to promote gender equality to engage with other civil society actors and take a holistic view of gender equality.

Conclusion

This guide is only an introduction to the many issues and practices around gender responsive engagement of men in SRHR. The resources listed in this guide will serve to give further depth and experience to readers, but in the end, actual training with a skilled facilitator may still be the best way to ensure that staff and providers have the opportunity to fully reflect and develop the skills needed to effectively engage men in SRHR in a gender-equitable manner. It is important to keep in mind that this is an iterative process and that programme designers and managers will continue to learn by practising and by reflecting on their experiences. It is hoped this guide and the resources contained here will support that process.



Footnotes

  1. Wandersman, A., et al. 2000. Getting to outcomes: A results-based approach to accountability. Evaluation & Program Planning 23(3):389–395.
  2. Khan, S., and Mishra, V. 2008. Youth Reproductive and Sexual Health. DHS Comparative Reports No. 19. Maryland, USA: ICF Macro.
  3. Office of the Special Advisor on Gender Issues and Advancement of Women. 2001. Gender mainstreaming: Strategy for promoting gender equality. New York: United Nations.
  4. Connell, R. W., and Messerschmidt, J. 2005. Hegemonic masculinity: Rethinking the concept. Gender and Society 19(6):829–859.
  5. World Health Organization (WHO). 2006. Defining sexual health: Report of a technical consultation on sexual health, 28–31 January 2002. Geneva.
  6. Gupta, G. R. 2000. Gender, sexuality, and HIV/AIDS: The what, the way and the how. Plenary address at the XIIIrd International AIDS Conference, June 9–14, Durban, South Africa. Washington, DC: International Center for Research on Women.
  7. Human Rights Campaign. [no date]. Sexual orientation and gender identity definitions.
  8. The Yogyakarta principles: Principles on the application of international human rights law in relation to sexual orientation and gender identity. Adopted March 2007. Accessed at: www.yogyakartaprinciples.org.
  9. The United Nations Free and Equal campaign provides more information about sexual orientation and gender identity and LGBT rights. See: https://www.unfe.org/
  10. The continuum is based on original work by Geeta Rao Gupta and has been shaped by others over the last 12 years. Gupta, G. R. 2000. Gender, sexuality, and HIV/AIDS: The what, the way and the how. Plenary address at the XIIIrd International AIDS Conference, June 9–14, Durban, South Africa. Washington, DC: International Center for Research on Women.
  11. UNFPA. 1995. International Conference on Population and Development (ICPD) Programme of Action in 1994. New York.
  12. United Nations. 1995. Beijing Declaration and Platform for Action. Fourth World Conference on Women. New York.
  13. Adapted in part from: UNFPA. 2003. It Takes 2: Partnering with Men in Reproductive and Sexual Health. Program Advisory Note. New York.
  14. Adapted from: Smith, N. 2010. Men-streaming in sexual and reproductive health and HIV: A toolkit for policy development and advocacy. London: International Planned Parenthood Federation (IPPF).
  15. Greig, A., Peacock, D., Jewkes, R., and Mismang, S. 2008. Gender and AIDS: time to act. AIDS 22(Suppl.):S35–S43.
  16. Adapted from: Smith, N. 2010. Men-streaming in sexual and reproductive health and HIV: A toolkit for policy development and advocacy. London: IPPF.
  17. Nanda, G. 2011. Gender-Equitable Men (GEM) scale. Washington, DC: FHI 360/C-Change. The GEM Scale, which was developed by the Population Council (under the HORIZONS Project) and Promundo, is intended to provide information around community gender norms, as well as the effectiveness of any programme that strives to address them. More information can be found at:
    https://www.popcouncil.org/Horizons/ORToolkit/toolkit/gem1.htm.
  18. Adapted from: Greene, M., Mehta, M., Pulerwitz, J., et al. 2006. Involving men in reproductive health: Contributions to development. Background paper prepared for the United Nations Millennium Project.
  19. Greene, M., and Levack, A. 2010. Synchronizing gender strategies: A cooperative model for improving reproductive health and transforming gender relations. Washington, DC: Interagency Gender Working Group.
  20. A comparative report of Demographic and Health Surveys in developing countries, mostly in sub-Saharan Africa, showed that in some countries men desire 1.8 to 3.8 more children than do women. (Westoff, C. F. 2010. Desired number of children: 2000–2008. DHS Comparative Reports No. 25. Calverton, MD: ICF Macro.)
  21. Conversely, in the European Union, men state a slightly lower ideal number of children than women—2.25 among men and 2.29 among women—though there is no country in the European Union where women desire a significantly larger family than men. (Testa, M. R. 2006. Special Eurobarometer—Childbearing preferences and family issues in Europe. Brussels: European Commission.)
  22. Kutcher, S., et al. 1996. Mental health concerns of Canadian adolescents: a consumer’s perspective. Canadian Journal of Psychiatry 41(1):5–10.
  23. Addis, M. E., and Mahalik, J. R. 2003. Men, masculinity, and the context of help seeking. American Psychologist 23(1):5–14.
  24. Hudspeth, J., et al. 2004. Access to and early outcomes of a public South African adult antiretroviral clinic. Southern African Journal of Epidemiology and Infection 19(2):48–51.
  25. Depending on the country, laws that deal with violence against women may use different terminology to address similar issues of violence—for example, domestic violence, violence against women, and intimate partner violence. Even though each term is different, only one term will likely be used in a country’s legislation and policy.
  26. World Health Organization (WHO). 2013. Responding to intimate partner violence and sexual violence against women. WHO clinical and policy guidelines. Geneva.
  27. Khan, S., and Jolly, S. 2005. Sex, gender and development: Challenging heteronormativity. Brighton, UK: Institute of Development Studies (IDS)
  28. Adapted in part from: UNFPA. 2003. It takes 2: Partnering with Men in Reproductive and Sexual Health. Program Advisory Note. New York.
  29. SBCC refers to the use of communication strategies—mass media, community-level activities, and interpersonal communication—to influence individual and collective behaviours that affect health.
  30. Adapted from: USAID. 2010. Guide to gender integration and analysis. Washington, DC.
  31. EngenderHealth developed this tool specifically for this guide.
  32. Adapted from: Laver, S., and Noubary, B. 2009. Guidance document: Developing and operationalizing a national monitoring and evaluation system for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. New York: United Nations Children’s Fund (UNICEF).
  33. EngenderHealth developed this tool specifically for this guide.
  34. Examples include EngenderHealth’s Men As Partners® manuals, the Program H Manual, Stepping Stones, SAS!, One Man Can, ISOFI, It’s All One, and many others.
  35. A scale is a numerical score aggregating multiple indicators believed to reflect an underlying concept.
  36. Nanda, G. 2011. Compendium of gender scales. Washington, DC: FHI 360/C-Change.