Men and Reproductive Health Programs: Influencing Gender Norms Prepared by

Conceptual Framework

Over the past ten years, the calls for involving men in reproductive health issues have emphasized the role of men in improving the health of their families and themselves, and the importance of addressing the gender inequities underlying poor reproductive health. In response, many male involvement programs have been created. Most of these health interventions have tended to be oriented toward changing behavioral outcomes (e.g., condom use or the use of health services). Yet, shaping these outcomes and guiding much of what we do in our everyday lives are social norms, and central among these are gender norms. Gender norms are some of the strongest social influences shaping men’s and women’s lives. They provide the values that justify different and often discriminatory treatment of one or the other gender. Widespread social discrimination against women is visible in lower levels of investment in the health,² nutrition,³ and education of girls and women.⁴ Institutionalized legal disadvantages for women underpin laws that keep land, money, and other economic resources out of women’s hands,⁵ and by foreclosing protection and redress, they contribute to violence against women.⁶

Sexual and reproductive health is strongly affected by gender norms. Norms favoring male children and promoting women’s economic dependence on men contribute to high rates of fertility in many settings. Inability to negotiate sex, condom use, or monogamy on equal terms leaves the majority of women and girls worldwide at high risk for unwanted pregnancy, illness and death from pregnancy-related causes, and sexually transmitted infections. Research has consistently shown that men play key roles in the spread of sexually transmitted disease, and that women bear greater reproductive health hazards.⁷
Addressing gender norms and expectations is key to promoting behavior change and is essential to instituting equitable relations between all human beings, regardless of their gender. Clearly, the behavioral changes that interventions bring about will be relatively limited if programs do not address the underlying norms that determine them. We might think of behaviors as being overlaid onto gender and other social norms. Most programs have yet to address these norms, which cumulatively direct the entire body of norms.
One widely known example of the relative effectiveness of considering norms and not just behaviors can be observed in Uganda where efforts to reduce HIV prevalence in the 1990s encouraged behavior change from many angles. One such angle encouraged men in particular to reduce the number of sexual partners they had through “zero grazing,” a reference to the tradition of tethering an animal to a stake and allowing it to graze in a circle. In the context of gender norms that permit and often encourage men to have multiple sexual partners, the message about caring for and respecting their wives and themselves went far beyond a simple behavior change.
Altering social norms is vital to the equitable distribution of resources and rights between the sexes. Oftentimes, men act as the gatekeepers to health care for women. They can either impede or facilitate women’s health service–seeking behavior. Gender roles adversely affect men as well. Men may engage in high-risk behaviors more frequently in order to meet the perceived expectations of social norms related to gender. Men may also repress desires to display effeminate characteristics due to social prohibitions on homosexuality or social definitions of masculinity. These realities have been highlighted by the AIDS epidemic and the combination of men’s greater likelihood of having multiple partners and women’s difficulty in negotiating condom use or the conditions of sexual encounters. Men’s involvement in military campaigns and the myriad risky behaviors associated with warfare especially contribute to the cycle of infection in areas of Africa ravaged by military conflict. Altering gender norms will be particularly imperative in this context, as successive waves of demobilized troops inculcated to adopt detrimental constructions of masculinity are reintegrated into society. Furthermore, women’s socialized and coerced dependence on men both financially and emotionally, as well as women’s relative ignorance of the interplay of socioeconomic factors that increase their vulnerability to infection, further exacerbate the epidemic. These social, gender-related, and economic issues, among others, contribute directly to the epidemic and can be addressed through altering the socialized paradigms of masculinity and gender norms.
The purpose of this review is to present programs that have effectively altered social norms regarding gender. Norms are perceived shared values that are often the underlying principles motivating an individual’s outward behavior, which in turn, set the social climate. Debunking the idea of a single hegemonic masculinity is imperative to addressing the unhealthy repercussions of socially defined “maleness.” This entails the introduction of multiple and concurrent masculinities that can be assumed in various contexts to enable men to adapt to social situations with versatility to increase the probability of positive and gender-equitable decision-making. This review presents a purposive sample of programs that have affected social norms regarding gender in a manner that has been captured in an evaluation. Examples were drawn from regions throughout the world in order to present a balanced and accurate sense of current efforts to change social norms related to gender.
Most of these programs do not describe their theoretical underpinnings. However, the process of normative change—as opposed to individual behavior change—is well captured by the theory of Diffusion of Innovations (DOI) by Everett Rogers; the programs described follow this process and are at one or another of its stages. “Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system… [leading to] social change.”⁸ Initially, individuals who are open to (and sometime seeking) innovation are influenced by the new ideas and practices of opinion leaders whom they respect. These early adopters of the new behaviors tend to be leaders within their own peer groups, and therefore they bring many others to the new way of thinking and acting. When a critical mass of adopters emerges, the mainstream social group follows. Some people are late adopters, of course, and some never adopt the innovation. Successful efforts to combat AIDS have followed this approach,⁹ as have organized family planning programs.¹⁰ It should be noted that theories of individual behavior change are not incompatible with DOI theory. However, until a critical mass of individuals who have changed attitudes and behaviors emerges, society itself, and therefore social norms, will not change.
As the DOI theory well articulates, normative change hinges on the adoption of an innovative idea by individuals until a critical mass of adopters is achieved. Given this, the programs presented in this review must be viewed as methods to prompt individuals and societies to progress through the stages outlined in the DOI theory.