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1 Everyone has a right to information and services to protect their health. What these young people in Belize are learning about HIV and AIDS could save their lives.
© Carina Wint

Culturally sensitive approaches seek to understand the diverse meanings people give to rights, reproduction and health, and the different ways in which social groups make claims on the reproductive body, sex and childbearing. There is a wide range of discussion and dispute on these issues. It is a mistake to assume that all people within a culture have the same rationale for action, or that apparently similar cultural norms and practices have the same meanings.

To understand what is happening in other cultures requires recognition of the weight and influence of one's own framework, as well as acknowledgement that people may use entirely different lenses to interpret the same circumstances. Understanding the languages of different cultures does not mean accepting the meanings ascribed; but it can provide a useful platform for dialogue and action.(2)

Culturally sensitive approaches must be open to the unexpected. Both men and women take part in shaping the gender order and social expectations concerning the male and female body, and in varied and unpredictable ways. For example, some men become advocates for change in favour of women: Men for Gender Equality Now in Kenya is a "network of men working to end gender-based violence and the spread of HIV and AIDS through prevention, service provision to the victims and awareness-creation focusing on the role of men as agents of change".(3)

Conversely, women may share male views of practices that harm them: "Violence against women in Gaza basically means domestic violence," says research consultant Aitemad Muhanna. "Women are beaten by their husbands, beaten by their fathers, and even beaten by their brothers.… Most of this violence is hidden. It's not recorded and not discussed."

Conversely, women may share male views of practices that harm them: "Violence against women in Gaza basically means domestic violence," says research consultant Aitemad Muhanna. "Women are beaten by their husbands, beaten by their fathers, and even beaten by their brothers.… Most of this violence is hidden. It's not recorded and not discussed." Most women do not believe they are victims of violence, even though their husband may abuse them, because they consider it "a husband's right" â€“ an attitude men share.(4)

Understanding the diversities of cultural meanings is essential for designing and implementing effective cooperation for change within a cultural context. For example, all societies value children, and childlessness is often stigmatized to a greater or lesser extent. Stigma affects the identity of women as mothers rather than men as fathers, especially where childbearing and motherhood gives women their primary identity and access to economic resources.

Cultural understandings about what men and women contribute to procreation may also stigmatize women. In parts of Egypt and India, people believe that men contribute a fully formed foetus; the quality of the woman's womb and menstrual blood determines how the foetus develops.(5) Some Asian and African cultures define infertility as women's inability to produce sons. Some societies consider infertile women to have been cursed. Almost all see "barren" women in a negative way. Such notions reinforce patriarchy and perpetuate a valuation of women based on fertility. Women themselves may assess their own and other women's worth on their ability to reproduce.

Contraception is widely used in developing countries to promote reproductive health, but women who fear infertility are unlikely to adopt it. Qualitative and demographic studies of contraceptive behaviour in India show that women are most likely to accept contraceptive methods(especially irreversible ones such as sterilization) after they have achieved their desired number of children, rather than seek it as a means of spacing pregnancies.(6) Women believe that contraceptive devices preserve their reproductive potential, which is "spent" by childbearing.(7) Cultural knowledge of this sort is important for determining how to intervene in these contexts.

Female Genital Mutilation/Cutting: The Value of Cultural Knowledge
Cultural knowledge is invaluable for helping men and women make practical choices, for example, about contraception. It also provides strategic guidance in especially difficult situations. With the benefit of cultural knowledge, UNFPA has been working with partners to tackle harmful practices such as female genital mutilation/cutting (FGM/C). ´
The Programme of Action of the 1994 International Conference on Population and Development (ICPD) ranks female genital mutilation/cutting among the "harmful practices meant to control women's sexuality" and describes it as "a violation of basic rights and a major lifelong risk to women's health" (para. 7.35). The consensus is that "governments and communities should urgently take steps to stop the practice".

Historical and cultural studies reveal the cultural signif­icance of FGM/C. For example, some African societies consider female "circumcision" to be critical for group membership; it is a woman's initiation into adulthood. Some societies regard "uncircumcised" women as abnormal. The clitoris and labia are viewed as male organs, and a woman becomes feminine only when these organs are removed.(8) The practice is also considered important for hygiene, cleanliness and beauty.

{16} FGM/C IN CULTURAL CONTEXT

The local appellation for female "circumcision" in many of the African societies where it is practised is synonymous with the term cleanliness or purification (for example, tahara in Egypt, tahur in Sudan and sili-ji among the Bambarra in Mali). In such societies, women who have not been "circumcised" are considered unclean.

Such women, in the rare instances in which they exist, are not allowed to handle food and water. "Uncircumcised" female genitals in societies that practice female "circumcision" are further viewed as oversized and ugly…

Members of such societies generally believe that if not excised, a woman's genitals are likely to grow so long as to hang down between her legs, thus becoming unsightly.

Source: Njoh, A. 2006. Tradition, Culture and Development in Africa, p. 97. Hampshire: Burlington. Ashgate Publishing Company.

In some cultures, there is a belief that without it, babies can be damaged during childbirth as would a man's penis during intercourse. Some believe that the practice can promote fertility.

Understanding these multiple meanings is important, not for validating the practice but for acknowledging its roots and providing a basis for dialogue and action. UNFPA has found that this cultural knowledge has been essential to its cooperative strategy of finding culturally acceptable alternatives.

Cultural insights illuminate how context influences individual reproductive choices. In turn, this structures the kinds of interventions needed to accommodate mindsets and behavioural patterns. This is part of the value of culturally sensitive approaches.

In Guinea-Bissau, for example, recent (2006) indicators show that FGM/C is still widely practised: 44.5 per cent of girls and women aged 15 to 49 years are affected. Following a number of failed initiatives to end FGM/C, the United Nations Children's Fund (UNICEF) and UNFPA partnered with Tostan, a non-governmental organization (NGO) with a good track record in Senegal, Guinea, Gambia, Burkina Faso and Mauritania. Tostan's approach is to engage the community in respectful discussions on human rights. People are also encouraged to talk about concerns within the area and to review problem-solving approaches. This process of engagement often culminates with a collective decision to abandon FGM/C. Community acceptance avoids social pressures on individual families and girls.(9)

{17} HELPING GIRLS ESCAPE FEMALE GENITAL MUTILATION/CUTTING AND CHILD MARRIAGE IN KENYA

Certain groups in Kenya, such as the Somali, Kisii and Masai, practise female genital cutting as a routine process which prepares young girls for marriage (Kenyan Demographic and Health Survey 2003). Usually carried out before a girl reaches 14 years of age, female "circumcision" is seen as enabling girls to become "clean" before they enter adulthood. In its severe form every part of the genitalia is removed, without anaesthesia. The physical health risks include trauma and bleeding, and in later life difficult childbearing and heightened risk of sexually transmitted infections including HIV. Psychological damage is incalculable.

In partnership with UNFPA, the community-based project Tasaru Ntomonok Initiative (TNI) has been successful in replacing the cultural value represented by FGM/C, at the same time recognizing its importance as a rite of passage. One of the strengths of its approach has been to offer alternatives to FGM/C, in a culturally appropriate way, as part of girls' transition to adulthood. Older women continue to act as godmothers to girls when they come of age. The girls also undergo the customary period of seclusion where they are made aware of sex and reproduction, and now learn about the importance of reproductive and sexual health.

Alternative ceremonies now take place at the time when FGM/C was traditionally performed, and the women who used to do the cutting have other sources of income. Men's involvement is vital. Fathers need to be reassured that their daughters will be marriageable and a potential source of income, and young men need to understand that they will have suitable wives. If for any reason the community does not accept the alternative rite to FGM/C, TNI offers shelter to girls who request it. The project has been helped nationally by the Children's Act of 2001, which prohibits FGM/C and early marriage, with penalties of imprisonment of up to 12 months and a fine up to $735.

Source: UNFPA. 2007. "Kenya: Creating a Safe Haven, and a Better Future, for Maasai Girls Escaping Violence." Chapter 6 in Programming to Address Violence Against Women: Ten Case Studies. New York. UNFPA.


Probing Cultures
"If cultures are, in part, conversations and contestations – including about questions such as reproductive health and rights … some voices … are more privileged than others."(10) People largely accept cultural norms and conform to expected behaviours. 

Some of the most dramatic changes occur when the guardians of cultural norms and practices advocate for them. In Cambodia, Buddhist nuns and monks are prominent in the struggle to combat HIV.(11) In Zimbabwe, local indigenous leaders are in the forefront. Some of these very leaders had earlier encouraged practices such as polygamy, child marriage and a ban on contraceptives. Now, as one leader acknowledged, "We have to preach the anti-AIDS gospel if we want to remain relevant to our members." 

The leaders' new doctrine has weight within the communities and is prompting changes in attitudes and practices.(12)
It is important to build alliances with prominent and influential leaders committed to human rights, gender equality or objectives such as HIV prevention. But leaders can also use alliances to entrench their power and authority; while working towards one goal they may block change in other areas.

{18} CONTESTING CULTURES WITHIN FAITH COMMUNITIES

One by one, Annie Kaseketi Mwaba buried her husband and four of her children. Then, in 2003, Annie herself fell ill. After several months, she asked her doctor to test her for HIV. Initially, he said no. Most Zambians, after all, regard AIDS as a consequence of immoral behaviour – and Annie was a Christian preacher. Finally, though, he relented, and Annie started her long journey back to life. "I thought HIV was for people who were not going to church," says Annie. "I think I was in deep denial. I didn't want to face this HIV thing. Until one evening, I was reading the Bible.

It's like somebody shed light there. If they find you're HIV positive, your life is not in the virus, your life is in Christ." The following year, Annie's remaining son, then nine years old, underwent treatment for tuberculosis. She decided to have him tested for HIV, and he was positive, too. In fact, his immune system was more compromised than hers had ever been. Now, mother and son are on the mend, and Annie has become a powerhouse in the effort to combat AIDS in Zambia.

In a country where any mention of AIDS used to be taboo, Annie has spoken out, making her painful story the pivot of her effort to change hearts and minds.

An elegant woman of 43, she has taken on religious leaders who preached that AIDS stemmed from evil behaviour, that it was okay to let its victims die. "It's amazing how God can use my mess and make it a message," she declares. Annie talks about attending a workshop for religious leaders, where she spoke about her friend "Grace," a minister who had tested positive after losing her husband and children to AIDS. The response was harsh and unyielding. "She killed her children! She was a prostitute! Let her die!" one leader bellowed. If he were the government, this man continued, he would poison antiretroviral drugs so that AIDS patients would perish. "Then I said that was my story," Annie says softly. "I walked to him and said, ‘Do I have to die?' He said, ‘No, you don't.'" She has also reached out in the pews.

Not long after Annie discovered she was living with HIV, a woman from her church confided to her that she was HIV-positive. "I thought about my husband – he might have been positive, and he died because we were silent. How many pastors have we buried?" Annie says. "I thought, ‘HIV is very much in the church, in the pews, and we have to break the silence.' I decided the next Sunday, I will divulge my status from the pulpit." She did so, and the floodgates opened. Annie was deluged with congregants who told her that they, too, were living with HIV. "I felt that my coming out gave permission to others to share," she says. Now, Annie works full-time to mobilize Christian and Islamic faith communities to respond to AIDS, and to prevent HIV infection among children. She facilitates community-led initiatives to combat the disease, and identify and help vulnerable households and children, many of them orphans. The faith community, Annie says, now views HIV and AIDS as "not about them – but about us."

Source: The Centre for Development and Population Activities (CEDPA). 2007. "Changing Hearts and Minds From the Pulpit in Zambia: Annie Kaseketi Mwaba." Washington, D.C.: CEDPA. http://www.cedpa.org/content/news/detail/1713, accessed June 2008.

If culture is a factor in transmission and impact [of HIV], it follows that prevention and care require a cultural approach.(13)

Alliances should therefore seek broader objectives such as human rights and gender equality. These larger principles are critical in setting standards for cultural engagement.

Standards should also ensure spaces for dialogue with community members, so that efforts to push for change are not overlooked. In China, UNFPA supports transport workers by providing HIV and AIDS education to migrant travellers. In Belize, UNFPA works with local community organizations, such as 4H, the Cornerstone Foundation, the Cadet Corps, the United Belize Advocacy Movement and the Young Women's Christian Organization to reach community members, particularly children in school, with important messages about HIV prevention. UNFPA supports the everyday activities of barbers in Belize, who speak to customers about HIV.(14)

Comprehensive, culturally sensitive approaches are necessary for HIV prevention. Healthlink Worldwide, a health and development NGO working with vulnerable communities in developing countries, has outlined four reasons why culturally sensitive approaches must be part of a global HIV and AIDS strategy:

  • Cultural approaches to HIV and AIDS have built trust and engagement at the community level, increasing the likelihood of prevention.
  • Cultural approaches to HIV and AIDS are gaining currency because they interact with the values, beliefs, traditions and social structures – the "webs of significance" – in which people live.
  • Where a cultural approach is used in HIV and AIDS communication, there is evidence of wider impact on awareness and attitudes, of stigma reduction, and of more inclusion of people living with HIV and AIDS.
  • Culture can offer a real benefit to global strategy for HIV and AIDS if it is re-cast as an opportunity for action and engagement with communities, rather than as a barrier to prevention and bio-medical approaches.

Religion has a privileged place in a wide range of cultures, and people willingly accept – or at least observe – systems of religious belief. Religion is central to many people's lives and influences the most intimate decisions and actions.

Religious meanings of reproduction and reproductive health differ, even within religions, depending on who provides the interpretations. For instance, some cultures interpret the Biblical encouragement to be fruitful and multiply to mean that women should bear as many children as their bodies will allow. In others, the injunction does not prevent individuals or couples from choosing the number and spacing of their children. It is difficult to work with cultures without understanding their debates over religion.

Honour is to live as it is ordered by our religion. The borders of honour should not be passed. I mean, honour is to keep oneself away from the places forbidden by God, not to try to cross the borders. For example, not only his wife, but also his mother, his sister and his neighbour are a man's honour. A man should be careful to protect the honour of others, as he is protecting his own.

—Adana, male, age 30, imam(15)

Because people often regard religion as authoritative, a spurious appeal to religion can be used to justify harmful practices, even crimes. In some societies, "honour" crimes and crimes of passion are regarded as sanctioned by religious precepts.

The United Nation's Secretary-General's report, In-depth Study on all Forms of Violence Against Women,(16) notes that crimes against women committed in the name of "honour" may occur within the family or within the community. In some Kurdish communities, for example: "Honour crimes take many forms including ‘honour killings', forced marriage, coerced marriage to an alleged rapist, unlawful confinement and strict restrictions on women's movement." (17)

People in societies where these practices are common may disagree among themselves about what "honour" implies, but the view of some – the most powerful actors because they are prepared to use violence to bolster their arguments – is that male honour depends on controlling women, particularly in regard to their sexuality. A woman can be dishonoured in a range of situations, such as conducting an extramarital relationship, initiating separation or divorce, an unmarried girl's entering a relationship without permission, or being the victim of rape or kidnapping. All these actions can incur violent retribution on a woman by men in her family, often with the support of women relatives.

{19} THE SOCIAL AND PERSONAL COSTS OF OBSTETRIC FISTULA

The majority of family members confirmed that women with fistula experienced isolation, mainly as a result of shame, but also due to the fear of harassment or ridicule, or physical weakness that compromised a woman's ability to walk.

A minority of family members explicitly mentioned the sadness of living with fistula. For example, one set of parents reported that their daughter experienced sadness and loneliness, and another set of parents said that their daughter was always unhappy because she could not walk properly and could not visit relatives or friends because of shame.

Source: Women's Dignity Project and EngenderHealth. 2006. "Living With Obstetric Fistula: The Devastating Impacts of the Condition and Ways of Coping." New York: EngenderHealth. http://www.engenderhealth.org/files/pubs/maternal-health/Obstetric_Fistula_Brief_3_Impacts_and_Coping.pdf, accessed June 2008.
descicrao Mother and baby in a hospital in El Alto, Bolivia. Many women prefer to give birth at home – but they need skilled care and referral to a hospital in case of need.
© Tim Weller

In accordance with the articles of CEDAW and the global consensus of ICPD, the United Nations regards "honour" killings as a clear violation of human rights, with no cultural justification. The United Nations General Assembly adopted resolution 55/66 entitled, "Working Towards the Elimination of Crimes Against Women Committed in the Name of Honour", on 4 December 2000. In this resolution, concern was expressed about the continuing occurrence, in all regions of the world, of violence against women, "including crimes against women committed in the name of honour, which take many different forms", and also expressed its concern that "some perpetrators assume that they have some justification for committing such crimes".

The implicit reference here is cultural justifications. The resolution acknowledged the importance of culture and cultural actors very specifically, by calling upon all States "to intensify efforts to prevent and eliminate crimes against women committed in the name of honour, which take many different forms, by using legislative, educational, social and other measures, including the dissemination of information, and to involve, among others, public opinion leaders, educators, religious leaders, chiefs, traditional leaders and the media [emphasis added] in awareness-raising campaigns". The italicized clause lists the actors which UNFPA, in particular, refers to as "cultural agents of change".

General Assembly resolution 55/68 adopted on 4 December 2000 puts crimes of "honour" in a broader context:

Reaffirming further the call for the elimination of violence against women and girls, especially all forms of commercial sexual exploitation as well as economic exploitation, including trafficking in women and children, female infanticide, crimes committed in the name of honour, crimes committed in the name of passion, racially motivated crimes, the abduction and sale of children, dowry-related violence and deaths, acid attacks and harmful traditional or customary practices, such as female genital mutilation and early and forced marriages....

Many of UNFPA's interventions at the country level are designed to mobilize and support community-based efforts to correct any assertions that religion, or culture more broadly, legitimizes such practices.

Culturally sensitive approaches are important for reaching other critical targets such as MDG 5, which aims for a 75 per cent reduction in maternal deaths between 1990 and 2015. Despite long efforts to reduce maternal mortality in developing countries, numbers have remained essentially unchanged at about 536,000 a year. Ninety-nine per cent of maternal deaths occur in developing countries, the majority in sub-Saharan Africa and South Asia. Cost-effective health interventions could prevent many maternal deaths, but most poor women cannot take advantage of them. There are doubts that MDG 5 will be achieved: Globally, the maternal mortality ratio decreased at less than 1 per cent between 1990 and 2005, compared with the 5.5 per cent needed to achieve MDG 5. Only a few countries have achieved a significant reduction in maternal mortality rates since 1990: China, Cuba, Egypt, Jamaica, Malaysia, Sri Lanka, Thailand and Tunisia.

Many women in the poorest countries survive pregnancy and childbirth but with serious consequences, among them obstetric fistula, anaemia, infertility, damaged pelvic structure, chronic infection, depression and impaired productivity.(18)

{20} SAFE MOTHERHOOD AND THE STATUS OF WOMEN IN SOCIETY
  • In societies where men traditionally control household finances, women's health expenses are often not a priority.
  • Women are often not in a position to decide if, when and with whom to become pregnant or to determine the number, spacing and timing of their children.
  • In countries with similar levels of economic development, maternal mortality is inversely proportional to women's status.
  • The poorer the household, the greater the risk of maternal death and morbidity.
  • Early marriages, female genital mutilation/cutting, too many childbirths and violence signal the violation of a woman's right to make decisions about her own body.
  • Source: UNFPA. n.d. "Facts About Safe Motherhood." New York: UNFPA. http//www.unfpa.org/mothers/facts.htm. Accessed March 2008.

Millions of women still do not have control over spacing or limiting pregnancies, nor access to effective contraception. This is the result of ineffective health systems, but there are also social and cultural factors involved. In many cultures, patriarchal frameworks determine notions of masculinity and femininity, as well as the meanings of sexuality, reproduction and rights. The result is that women's needs and rights are paid little attention. It is important to situate women's health within their social and cultural contexts, and to develop culturally sensitive responses.

UNFPA has a long tradition of supporting maternal health facilities and providing crucial supplies such as contraceptives and equipment for emergency obstetric care.

The World Health Organization (WHO) estimates that approximately 2 million women and girls are affected by fistula and a further 50,000 to 100,000 are newly affected annually.(19)

The Fund works nationally, internationally and with communities to improve maternal health. For example, in Nigeria, local leaders are convincing the men in their communities of the value of family planning and of caring for the reproductive health needs of their families and communities.
The Ministry of Health, with support from UNFPA, trains the leaders who then spread the messages. "Before the training, it was difficult to convince men of the importance of contraceptives," says Abdulai Abukayode, the baale (traditional leader) of Ajengule in Ogun State. "Once they knew more, that changed…. People now want less children, so they can take care of them." Contraceptive prevalence has increased dramatically in Ogun.(20)

Similarly, UNFPA is working with partners to prevent and treat obstetric fistula, and to reintegrate affected girls and women into society. Fistula is especially prevalent in poor, remote regions and among very young women whose bodies are not fully capable of childbirth. It results from extensive tissue damage during periods of prolonged and obstructed labour, which leaves a tear between the vagina and bladder or the vagina and rectum. The baby frequently dies, and the mother is left incontinent. Fistula is the cause of great shame: Husbands, families and communities may shun affected women and force them to live in isolation. Yet, obstetric fistula is preventable; it is not common in wealthier areas, where women have good access to quality maternal health care.

In the absence of close engagement with the communities concerned, obstetric fistula has been overlooked and its victims neglected. An effective response calls for culturally sensitive approaches, not only to communicate with girls and women about prevention and treatment, but also to reduce stigma and raise fistula as a policy concern. UNFPA is supporting efforts to prevent fistula and treat and rehabilitate affected girls and women. For example, in Sudan, UNFPA is supporting the Saudi Hospital, El Fasher, where girls and women benefit from reconstructive surgery.(21)

In Eritrea, UNFPA partnered with surgeons from Stanford University to strengthen national capacity to treat fistula.(22) In the Democratic Republic of the Congo, UNFPA has worked with the Ministry of Health to stage a national campaign, which included treatment.(23)

Culture, Masculinity and Sexual and Reproductive Health
Work on reproductive health and rights calls for culturally sensitive approaches because the issues go to the heart of culture. It also requires a focus on gender relations and men.

Following the United Nations World Conference on Women in Mexico City in 1975 and the United Nations Decade for Women 1976 to 1985, the Programme of Action of the 1994 Cairo International Conference on Population and Development (ICPD) challenged men to play their full part in the fight for gender equality within the framework of reproductive health and population and development. The Platform for Action of the 1995 Fourth World Conference on Women in Beijing restated the principle of shared responsibility, and argued that women's concerns could be addressed only in partnership with men.(24)  It called on men to support women by sharing childcare and household work equally, and also called for male responsibility in HIV and sexually transmitted infection (STI) prevention.

The 26th special session of the General Assembly in 2001 recognized the need to challenge gender attitudes and gender inequalities in relation to HIV and AIDS through the active involvement of men and boys. Its "Declaration of Commitment on HIV/AIDS" addressed men's roles and responsibilities related to reducing the spread and impact of HIV and AIDS, especially the need to engage men in challenging the gender inequalities driving the epidemic.(25)

25 A decade after Cairo, the 48th session of the United Nations Commission on the Status of Women in 2004 called on governments, entities of the United Nations system and other stakeholders to, inter alia, encourage the active involvement of men and boys in eliminating gender stereotypes, encourage men to participate in preventing and treating HIV and AIDS, implement programmes to enable men to adopt safe and responsible sexual practices, support men and boys to prevent gender-based violence, and implement programmes in schools to accelerate gender equality.

Male power – patriarchy – continues in many cultures. Some analysts(26) acknowledge that the "… ongoing challenge to the reproductive health framework is how to characterize men's possible influences and to assess their impact on women's and children's health." However, men are also subject to culture, which calls for closer attention both to men's experiences of gender and its inequalities and their responsibility for it.

The next best thing to avoiding obstetric fistula is surgery to repair it. Rupbahar is one of the lucky ones, seen with her mother in a fistula camp in Bangladesh. The next best thing to avoiding obstetric fistula is surgery to repair it. Rupbahar is one of the "lucky" ones, seen with her mother in a fistula camp in Bangladesh.
© UNFPA

The evidence suggests that cultural pressures around gender increase men's vulnerability to sexual ill-health. Social constructions of masculinity and sexuality can increase risk-taking and reduce the likelihood of men seeking help. According to national surveys of men aged 15 to 54 over the past 10 years in 39 countries, men's sexual initiation tends to be earlier than women's, and men have more sexual partners, both outside and within marriage.(27)

In almost all of the countries surveyed, most men 20 to 24 years old report sexual initiation before their 20th birthday. Although this varies significantly by region, in some countries up to 35 per cent report sexual initiation before their 15th birthday. These data, however, do not include all groups in all regions, leaving out industrial countries and key groups such as unmarried men, men in prison, the military, migrants or refugees, many of whom are sexually active. Many cultures see variety in sexual partners as essential to men's nature, so that men will inevitably seek multiple partners for sexual release.(28) Global sexual behaviour studies indicate that heterosexual men, both married and single, as well as homosexual and bisexual men, have higher reported rates of partner change than women.(29)

There has been increasing interest in understanding this behaviour in gendered terms. Seeking common themes, some research suggests that traditional notions of masculinity are strongly associated with a wide range of risk-taking behaviour, and that "… cultural and societal expectations and norms create an environment where risk is acceptable and even encouraged for ‘real' men".(30)

A qualitative research project in nine Latin American countries found that young men aged 10 to 24 years were far more concerned with achieving and preserving their masculinity than their health.(31)

Cultural pressures around masculinity that fuel men's need to prove sexual potency can encourage seeking multiple partners and exercising authority over women.

{21} INVOLVING MEN IN PROMOTING GENDER EQUALITY

"Program H" promotes gender-equitable norms and behaviours among young men in low-income settings, helping them to reflect upon and question traditional norms of "manhood". The programme, developed by Instituto Promundo based in Rio de Janeiro, Brazil and three other NGOs in Brazil and Mexico, identified two factors: gender-equitable male role models and peer groups; and reflecting on the consequences of violence. Programme staff developed a manual of activities on gender, sexual health, violence and relationships.

The manual addressed sexism and homophobia, which is also directed at non-macho men and independent women. At the same time, a social marketing campaign portrayed gender-equitable behaviour as cool and hip, using radio, billboards, postcards and dances.

In Brazil, the intervention showed significant shifts in gender norms at six months and 12 months. Young men with more equitable norms were between four and eight times less likely to report STI symptoms, with additional improvements at 12 months after the intervention. Program H (the "H" refers to homens, or "men" in Portuguese) relies on research to understand the variations of gender attitudes and practices among its target audience, and communicates through media drawn from and appealing to youth culture.

Source: Pulerwitz, J.; G. Barker, and M. Segundo. 2004. "Promoting Healthy Relationships and HIV/STI Prevention for Young Men: Positive Findings from an Intervention Study in Brazil". Washington, D,C.: Population Council/Horizons Communications Unit

This can lead, for example, to men forcing sex on unwilling partners as a result of a perceived need to prove themselves.(32)

As one young man noted, "Unless a woman cries while having sex, your masculinity is not proven." Pressures around masculinity, coupled with sexual repression, result in increasing rates of rape and other forms of violence against women. The results can damage not only women's health but their social acceptance. The raped woman may even be encouraged to marry her rapist to avoid the scandal of being "deflowered". Married women who bring charges of rape have sometimes found themselves imprisoned for adultery.

Many cultures associate masculinity with a sense of invulnerability, and socialize men to be self-reliant, not to show their emotions and not to seek assistance in times of need.(33)

Data from South Africa indicate that men are much less likely than women to use voluntary counselling and testing (VCT) services. Men account for only 21 per cent of all clients receiving VCT(34) and only 30 per cent of those in treatment.(35)

Men access antiretroviral therapy (ART) later than women in the disease's progression, with more compromised immune systems and at greater cost to the public health system.(36) These discrepancies appear to reflect men's belief that seeking health services is a sign of weakness, rather than higher infection rates among women.(37)

Cultural pressures around masculinity can also give rise to feelings of anxiety among men about their sexuality. Men are more likely to mention concerns about sexual performance than STIs or HIV. This may be especially true for young men, who are discouraged by families, teachers and others from talking about their bodies and issues such as pubertal changes.(38) Boys may know more about women's bodies than about their own. Boyhood ignorance can translate into lifelong difficulties in talking about sex and finding out facts.

Cultural pressures and expectations, ignorance and anxiety encourage risk-taking, and expose not only boys and men but also their sex partners to sexual and reproductive ill-health. However, many men do not consider their behaviours to be risky; they may understand their sexuality as a natural drive and sex as a biological necessity, which obviates the sense of risk.

It is also important to put notions of risk in their social and economic contexts. For example, the city of São Paulo has the highest prevalence of HIV infection in Brazil, but young men from low-income communities are probably less afraid of AIDS than of accidents, violence or drugs.

Culturally sensitive approaches must acknowledge the contexts within which boys and men operate. Conventional explanations suggest that young men get their ideas of sexual entitlement from unequal gender relations that privilege men over women; male power makes gender violence normal. Culturally sensitive approaches go beyond this explanation to investigate the relationship between social and political contexts and resulting cultural norms, and the conditions under which men and women resist them. For example, it is possible to link young men's sexual violence in apartheid South Africa with the system's political coercion.

Similarly, work on gender norms with low-income young men in Rio de Janeiro should acknowledge the violence and trauma that many of them experience as they grow up, which is related to racism, economic inequality and state violence. Brazil has one of the highest rates of homicide in the world, and rates of homicide for men are over 12 times higher than for women. Men of African descent have a 73 per cent higher rate of homicide than men of European descent. Culturally sensitive approaches avoid the tendency to separate the cultural from the political, and consider instead how they interact. This enables a much more effective response to men's differing needs in differing contexts.

Culturally sensitive approaches recognize that generalizations about boys, girls, men and women, groups and communities, mask important diversities. Culturally sensitive approaches are interested in these diversities, and the diverse solutions that individuals and communities evolve. Culturally sensitive approaches to issues such as infertility, fertility and maternal health appreciate why people make the choices they do within their social and cultural contexts; what responses are already on the ground; what sorts of alliances are available; what sorts of interventions are appropriate; how to communicate for maximum impact; and how to allow that knowledge to inform programming, rather than impose pre-defined solutions.


{15}  THE SOCIAL STIGMA OF INFERTILITY

The medical definition of primary infertility is inability to produce offspring after a year of cohabitation. After the birth of a child, reproductive tract infections may result in secondary infertility. Although infertility can affect both women and men, women experience most of the fears and social costs of secondary infertility.  Infertility remains an unrecognized reproductive rights issue. Despite high prevalence in many poor regions of the world, particularly in sub-Saharan Africa,* infertility is not considered a matter for public health policy. Planners concerned with reducing high fertility ignore infertility, though the two are connected.** Infertility carries a high social cost for individuals, especially women, and couples who are unable to bear children.

*Source: Feldman-Savelsburg, P. 2002. "Is Infertility an Unrecognised Public Health Problem: The View from the Cameroon Grassfields," Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, edited by M. Inhron and F. Van Balen. Berkeley: University of California Press.
Source: Inhorn, M. and Van Balen, F. 2002. Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies. Berkeley: University of California Press


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