Men’s Sexual and Reproductive Health: The Need for Gender Transformative Approaches Dean Peacock, Sonke Co-Director & MenEngage Co-Chair

Masculinities, SRH and HIV Ideas of manhood that equate ‘being a man’ with sexual risk-taking, and being in control, are associated with more negative attitudes towards condoms and less use, more sexually transmitted infections, more partners, including more casual partners, more frequent sex, more abuse of alcohol and more transactional sex. Men--married & single, heterosexual, homosexual and bisexual-- have higher reported rates of partner change than women. A significant proportion of men with STIs do not inform their sexual partners. Men all too often prevent women’s from determining whether or how sex takes place. In Swaziland, 34% of women reported not being permitted to use a condom by a sexual partner at least once in the past year. In Botswana, 30% of women reported that their partner alone made the decision whether or not to have sex.

South Africa Case Study: Men’s Violence Against Women MRC study: Representative sample in EC and KZN (2009) 44% self reporting perpetrating domestic violence, 14% in last year. 28% of men self reporting having raped, 5% in the last year. Almost one-third of women reported that they did not want to have their first sexual encounter and that they were coerced into sex. Women who have experienced physical/sexual intimate partner violence are 54% more likely to have HIV. Men who have perpetrated physical/sexual intimate partner violence are more than twice as likely to have HIV

Context: Violence, HIV, Alcohol and Men: In South Africa, 40 per cent of men and 15 per cent of women consume alcohol. Alcohol consumption is a risk factor for gender-based violence and for the sexual disinhibition that contributes to the spread of HIV/AIDS. Frequency of taking four/five drinks on one occasion, by sex

A significant % of men have MCP Percentage of males and females who had more than one partner in the past month, by age 25 January 2009Draft Confidential

Men and HIV testing &treatment globally Globally, men underepresented in testing and treatment ; they access ART later than women, with more compromised immune systems and at greater cost to the public health system and with significant burden on the women who usually take care of them. “Efforts to understand men’s health-seeking behaviour are poorly understood in the AIDS epidemic, and encouraging men to get tested and into treatment is a major challenge, but one that is poorly recognised. Addressing these issues effectively means moving beyond laying blame, and starting to develop interventions to encourage uptake of prevention, testing, and treatment for men—for everyone’s sake.” Expanding HIV care in Africa: making men matter. The Lancet Vol 374 July 25, 2009, Mills et al

Context: Men and PMTCT South Africa 2009 NCS: Very few men know anything about how to avert vertical transmission or about how to support their partners. New South Africa National Guidelines on PMTCT do not include any of the following words: men, male, father. New WHO PMTCT vision encourages male involvement. MaleFemaleTotal Formula feeding Exclusive breastfeeding

Economic Disempowerment Matters for Women and Men: IMAGES India Men who are economically disempowered report: Higher rates of physical IPV: 24.3% vs 16.3% Higher rates of sexual violence (IPV and stranger rape): 26.6% 13.9% Higher rates of alcohol use: 49% vs. 29.4% Lower rates of condom use

Strategies for Engaging Men and Boys

Examples of Emerging Approaches

Group Education Participatory reflection on male socialisation and costs for men and women. Focus on moving from reflection to internalisation to sustained action

Understanding men, masculinities and HIV and AIDS: Solid evidence that interventions can bring about positive gender, SRH and HIV related changes amongst men and boys Stepping Stones: after two years men reported fewer partners, higher condom use, less transactional sex, less substance abuse and less perpetration of intimate partner violence Programme H: participants between four and eight times less likely to report STIs and 2.4 times as likely to use condoms. Men As Partners and PMTCT in Ethiopia: 46% increase in men testing with their partners and 87.6% increase in the number of men joining their partners for PMTCT visits. One Man Can Workshop: 27% tested for HIV soon after the workshop and 2/3rds increased use of condoms.

Understanding men, masculinities and HIV and AIDS: 41% 29.5% Effective Promising Unclear WHO and Instituto Promundo study of 57 male involvement programmes: 53% of the programs classified as gender transformative were assessed as either promising or effective.

What Works? Key Elements in Effective Group Education with Boys and Men from 2007 WHO Report Formative research + extensive testing of messages Engage local boys/men in constructing the messages Critical reflection about masculinity Skills building/experiential learning Creating a safe space

Clear and positive messages Promoting a gender-equitable lifestyle or alternative male identity High quality media At least 4-6 months in duration sessions recommended Generally more effective when combined with media campaigns What Works? Key Elements in Effective Group Education with Boys and Men from 2007 WHO Report

Mass Media: Brothers For Life

Community Media: Radio, CTV, Murals, PhotoVoice and Digital Storytelling

Advocacy Approaches

Scale and Sustainable Impact: Developing, implementing and monitoring policies on men, SRH and HIV

Policy work needed Training for policy makers and implementers at country level on male involvement (WHO tools in development) with specific attention to: Improve access and promote greater use by men of HIV services. Linking programmes with sustainable delivery mechanisms: schools, clinics, uniformed services etc. Integrate gender equality education into Medical Male Circumcision Increased male involvement in PMTCT