Helzner lecture 11102020

Judith F. Helzner
Bixby Lecture
November 10, 2020
Gender Power Dynamics in Sexual &
Reproductive Health in the Global
South

In this lecture
 Gender norms
 Evolution of attention to gender in family
planning discourse and institutions
 Evolution of “male involvement” in
sexual/reproductive health
- Frameworks
- Interventions
- Interagency Gender Working Group
 Power in sexual relationships
Judith F. Helzner Bixby Lecture UCLA November 10 2020 2

What are gender norms?*
 …“the collective and often unequal expectations about how women
and men should behave, feel, think and interact in a given society”
 “Gender scripts” - enforced through social sanctions which effectively
limit behavior to actions aligned with ideas of masculinity or
femininity.
 Gender norms inform health outcomes in sexual and reproductive
health. “Hegemonic” norms of masculinity can encourage male sexual
risk taking, dominance in relationships. Gender norms can predispose
women to passively accepting risks such as intimate partner violence,
unprotected intercourse, STI/HIV acquisition.
 (Early) adolescence is a crucial period when gender norms are
internalized (eg, see Global Early Adolescent Study www.geastudy.org)
*from: Moreau et al. “Measuring gender norms about relationships in early adolescence: Results from the
global early adolescent study.” SSM-Population Health. 2019.

How can gender norms change?*
 Gender norm change takes time and effort
 Programs (generally reach a limited number of people)
 Government mandates, initiatives, and policies (e.g.,
Quebec’s non-transferable parental leave for fathers)
 Social movements
 Informational campaigns (e.g., radio soap operas)
 Innovations and technology (e.g., anti-harassment
apps)
* https://promundoglobal.org/what-works-beyond-programming-to-shift-gender-
norms-on-a-large-scale/

Gender equality is a driving goal
– not “male involvement” per se
 Chapter IV of the report of the 1994 International Conference on
Population and Development (ICPD) ('Gender equality, equity, and
empowerment of women’) contains a section on 'Male responsibilities
and participation’:
'. . . the objective is to promote gender equality in all spheres of
life…and to encourage and enable men to take responsibility for their
sexual and reproductive behaviour and their social and family roles.’
(Paragraph 4.25)
 “Gender analysis” of family planning/reproductive health programs
was considered radical or unnecessary in the past
- Methodology developed for agriculture and other male-dominated
development programs
- “Family planning is already focused on women, they give birth!”

Gender in family planning institutions
 Just because family planning organizations deal with women, it
does not necessarily mean they are by nature gender-sensitive,
gender-transformative, or feminist.
 Gender power dynamics play out in multiple aspects of SRH:
- Philosophy of programs: early “target mentality” focused on
numbers, versus later human-centered “reproductive health and
rights” approach
- Contraceptive use (male-dependent methods, or men’s decisions
about a woman partner’s method choice) - some forms of 'male
involvement’ can result in men usurping what was formerly women's
territory, worsening existing male dominance.
- Men having higher/more paid and governance positions than women
in service delivery or other institutional settings → lower levels of
women’s decision-making power and influence

Examples of my published analyses of changing
gender power dynamics in family planning:
 About men: “Men's Involvement in Family Planning,” Judith Frye Helzner, Reproductive
Health Matters, Vol. 4, No. 7, May, 1996.
 About institutions where I worked:
- Pathfinder: “The Feminist Agenda in Population Private Voluntary Organizations,” with
Bonnie Shepard, in Women, International Development, and Politics: The Bureaucratic
Mire, Kathleen Staudt, Editor. 1990.
- IPPF/WHR: “Opening Windows to Gender: A Case Study in a Major International
Population Agency,” with Adriana Ortiz-Ortega, in Social Politics, Barbara M. Hobson,
Sonya Michel and Ann Shola Orloff, Editors. 2003.
+ Policy changes from the top (minimum 50% women on governing boards)
+ Program additions – quality of care, integration of gender-based violence
screening into clinics, work on sexuality
+ Outreach to feminists in the region and gender training for IPPF affiliates

Institutional change example: building links between
feminists & family planners in Latin America/Caribbean
 Affiliates of International Planned Parenthood Federation/Western Hemisphere Region
(IPPF/WHR) needed to move from a male-dominated, primarily medical model to a
more woman-centered, gender-sensitive model in their service delivery, staff, etc.
 With funds from Ford Foundation and MacArthur Foundation in the 1990s:
- developed a gender training course and involved Latin American feminists as co-
trainers;
- organized 3 consultations with 3-5 countries each, where feminists and IPPF affiliate
staff or board members expressed their views (including negative stereotypes) about
each other and got acquainted personally;
- brought feminist leaders to NYC headquarters for a month at a time to interact
informally with staff who had little or no experience with them.
 Overall objectives: (a) with feminists: reduce tensions and misperceptions, promote
understanding and collaboration (b) within IPPF affiliates: improve gender awareness
of staff and in program design.

“Male involvement” in sexual & reproductive
health (SRH)
 Men ARE involved in SRH – as partners in couples, as health
professionals (clinic physicians and directors), as decision
makers on health policy (Minister of Health etc.)
 Masculine gender norms & stereotypes are linked to men’s
own general health outcomes.
 “While biological factors are involved in male-specific ill-
health, the vast majority of men’s morbidities & excess
mortality is related to health practices, & the social and
cultural influences that shape them….[M]en’s poor health is
most often driven by their efforts to live up to…restrictive
societal norms related to manhood.”*
*https://promundoglobal.org/resources/masculine-norms-and-mens-health-making-the-connections-executive-
summary/

Approaches to programming have evolved –
from “gender blind” to “gender aware”
 Gender-blind:
- Work with women alone, without addressing gender norms & power
dynamics
- Work with men alone, just on their own sexual & reproductive health
 Gender transformative:
- Concept of “gender-synchronized approaches” (developed/used from
2010 on, with a 2017 update) – defined as “working with men and
women, boys and girls, in an intentional and mutually reinforcing way, to
challenge restrictive gender norms, catalyze the achievement of gender
equality, and improve health”

PS: Webinar tomorrow morning, Nov. 11: “Sticking
with It: Engaging Men and Boys in Family Planning
across the Life Course”
- The Relationship Between Key Family Formation Events over the Life
Course
- Increasing Family Planning Uptake through Gender-Synchronized
Approaches in Niger
- Promoting Male Engagement in Family Planning through Couple
Communication in Togo
- Reducing Stigma and Increasing Access with Integrated Health Wellness
Days for Adolescents and Men in Zambia
It’s at 6 a.m. California time! But – it will be available to anyone who registers, and will
be posted to the Breakthrough ACTION and RESEARCH Facebook and Twitter accounts.

Examples of
types of
interventions
Research
Programs
Advocacy

Field Research: Household surveys on gender
 International Men and Gender Equality Survey (IMAGES) – household survey carried out in
more than 27 countries, interviews with 29,477 men and 17,566 women, ages 18 to 59
(2009-2018). https://promundoglobal.org/programs/international-men-and-gender-
equality-survey-images/
 Multi country Study on Men and Violence in Asia and the Pacific
http://www.partners4prevention.org/about-prevention/research/men-and-violence-
study
 The methodology includes both quantitative and qualitative questions including the
Gender Equitable Men Scale (GEMS) indicator, compiled/calculated from 2 subscales:
- 17 items in Subscale 1 measure agreement with statements about ‘inequitable’ gender
norms (e.g., ‘It is the man who decides what type of sex to have’)
- 7 items in Subscale 2 measure agreement with ‘equitable’ gender norm statements
(e.g., ‘A couple should decide together if they want to have children’).
- Responses are scaled as: Agree =1; Partially Agree =2; and Do Not Agree=3 for the
inequitable subscale (& scores are inverted for the equitable subscale) → higher score
for greater gender equity attitudes.

Early Program: Program H & Program M
 Group education activities: Program H for young men (hombres) - to
help change attitudes, adjust coping mechanisms, and introduce
healthier ways to deal with conflict.
https://promundoglobal.org/resources/program-h-working-with-
young-men/?lang=english . Examples of exercises:
- What Do I Do When I am Angry?
- Community Action: What Can I do to Promote Peaceful Coexistence?
 Program M https://promundoglobal.org/programs/program-m/ for
young women (mujeres): to help promote young women’s awareness
about gender inequities/rights/health and improve skills and attitudes
in relationships. Examples of exercises:
- Who am I? What would I like to do with my life?
- How women and men express themselves

More recent programs: gender-synchronized
 SASA! Initiative in Uganda – to prevent HIV/AIDS and domestic
violence by focusing on power imbalance in intimate relationships.
4-year randomized control trial (RCT) results showed women in
intervention communities as significantly more likely to report joint
decision-making, open communication, and the ability to refuse sex
with their partners.
 Bandebereho program in Rwanda - incorporated gender-
synchronized elements in group critical reflection and dialogue
sessions for couples. RCT results showed women in the
intervention group reporting significantly lower levels of physical
and sexual violence and more male accompaniment to antenatal
care, while men and women reported significantly less violence
against children, greater male participation in household tasks, and
less male dominance in decision-making.
https://www.igwg.org/2018/09/involving-everyone-in-gender-equality-by-synchronizing-gender-strategies/

Advocacy: networks, campaigns, reports
 MenEngage - http://menengage.org/ - global alliance promoting gender justice
 MenCare - https://men-care.org/ - A “global fatherhood campaign” (in over 50
countries) whose mission is to promote men’s involvement as equitable,
nonviolent fathers and caregivers in order to achieve family well-being, gender
equality, and better health for mothers, fathers, and children.
 White Ribbon Campaign – envisions “a Future Free From Gender-based Violence”
– organizes men/boys against violence https://www.whiteribbon.ca/about.html
 State of the World’s Fathers Report (latest 2019)
https://promundoglobal.org/state-of-the-worlds-fathers-2019-report-launch/
highlights 3 barriers to men’s expressed desire to be more involved with new
child:
- lack of adequate, paid paternity leave, and low take-up of leave when it is
available;
- restrictive gender norms that position care as women’s responsibility, alongside
the perception of women as more competent caregivers than men; and
- lack of economic security and government support for all parents and caregivers.

USAID Interagency Gender Working Group (IGWG)
 IGWG Male Engagement Task Force “considers relevant efforts across
social and behavior change (including shifting social and gender
norms), services, research, and policy” on a wide range of health
issues.
 Has developed many resources including:
- Fact sheet on Do's and Don'ts of engaging men and boys (DON’T
engage men at the expense of women, DO seek to transform harmful
gender relations and norms, DO start early in the life course)
- Advancing Male Engagement in Family Planning + Reproductive Health
AN ADVOCACY TOOL (advice on Advocacy Vision and Strategic
Approach, and Developing an Advocacy Implementation Plan)
- Slide deck on Engaging Boys and Men in Contraceptive Use and Family
Planning - the next 10 slides are from that presentation

Engaging Boys and Men
in Contraceptive Use
and Family Planning
Photo © Jake Lyell/Alamy Stock Photo

In Nigeria, men who
support contraception are
five times more likely to
have spouses who desire
to use contraception.
Programs involving
men can enhance
spousal communication
and improve gender
equitable attitudes.
5x
Why involve men? Studies show that men can be the steppingstone
to couple contraceptive use and gender norm transformation.
Sources: Echezona E. Ezeanolue et al., 2015; Melanie Croce-Galis, et al. 2014.

Men’s use of contraception is low.
Other modern and
traditional methods
1%
Cooperative method
(Rhythm)
3%
Direct male methods
(Vasectomy, Male
condom, Withdrawal)
21%
Female methods (Female
sterilization, Pill, Injectable,
Implant, IUD, Vaginal barrier
methods)
75%
Global
contraceptive
prevalence, 2015
(as reported by
married women
ages 15-49)
Source: United Nations, Department of Economic and Social Affairs, Population Division, 2015

Men can choose among four male-controlled and cooperative methods.
Male Condoms
Global prevalence: 8%
Male Sterilization/
Vasectomy
Global prevalence: 2.4%
Standard Days Method
Global prevalence: 0.6%
Withdrawal
Global prevalence: 3%
Photo credits, left to right: © 2016 Radha Rajan, Courtesy of Photoshare; © Karen Kasmauski; © Mengistu Asnake (Courtesy of Photoshare); © Lindsey Leslie (Courtesy of Photoshare)

BARRIERS &
CHALLENGES

Inequitable gender norms
perpetuate stereotypes that
exclude men’s role in sexual
and reproductive health.
Photo © carol mitchell

BENEFITS OF INVOLVING
MEN AND BOYS IN
CONTRACEPTIVE USE AND
FAMILY PLANNING

Male involvement can lead to positive health
outcomes for men and their families.
Source: Gary Barker, 2014; FHI360, 2017
✓ More fulfilling relationships.
✓ Improved communication with partners.
✓ Improved mental and physical health.
✓ Improved maternal health outcomes.
✓ Improved child development outcomes.

A CLOSER LOOK:
VASECTOMY

19%
14%
9%
8%
5%
3%
3% 2%
1% 1%
Female
sterilization
IUD Pill Male
condom
Injectable Withdrawal Rhythm Vasectomy Implant Other
methods
Contraceptive prevalence by method among married women ages 15-49 years, 2015
Vasectomy remains one of the least-known
and least-used contraceptive methods.
Vasectomy

Engaging boys and men in family planning
and contraceptive use leads to improved
health outcomes for
men and their families.
Photo © Randy Plett

Power in
Sexual &
Reproductive
Health
 Still on the frontier of “sexual and
reproductive health” themes
 Includes power issues (a) between
providers and clients (clinical and
community-based); (b) within
couples, and (c) within families more
broadly
The Effect of Power in Sexual Relationships on Sexual and
Reproductive Health: An Examination of the Evidence (Ann
K. Blanc, 2003)

Judith F. Helzner Bixby Lecture UCLA November 10 2020
One aspect of
power:
“Reproductive
Coercion”
31
 Defined as “behavior that
interferes with autonomous
decision‐making in areas of
reproductive health” – a subset of
Intimate Partner Violence
 Behaviors or threats aimed at
“contraceptive use sabotage” –
e.g., prevent visit to obtain
methods, remove or puncture
condom, discard pills, etc.
 Actions or threats aimed at causing
(or preventing) a pregnancy, at
preventing (or encouraging) an
abortion
Reproductive Coercion and Women's Health,
Kathryn Fay and Lynn Yee, Journal of
Midwifery & Women’s Health, 13 August 2018

Judith F. Helzner Bixby Lecture UCLA November 10 2020
Beyond
platitudes:
“male
involvement”
is not always
simple and
straightforward
32
 Case study of effort of the IPPF family
planning association in Ecuador
- At first: Separate facilities for men only, to
serve their needs alone
- Next: Directive to “involve men 100%” in
women’s clinics –turned out to be too much,
sometimes even inappropriate (e.g., if the
man was abusing/controlling his partner)
- Finally: Nuanced approach to privately ask
the woman if she wanted the man to
accompany her into the consultation or not
Shepard, B.L. “Addressing Gender Issues with Men and
Couples: Involving Men in Sexual and Reproductive Health
Services in APROFE, Ecuador,” in International Journal of
Men’s Health, Vol. 3, #3, 155-172, 2004.

State of the art
of gender-
transformative
work with men &
boys
 For many decades, small, well-intentioned “pilot”
programs with little rigor in documentation or
evaluation of results
 Evidence and Gap Map (EGM) by Ruane-McAteer et
al*.:
- Methodology: 462 eligible systematic reviews on
engaging men/boys in SRHR were included, but
only 39 reported on gender-transformative
interventions
- Lessons learned:
+ Be “intentional” in promoting gender equality
(explicitly focus on harmful gender norms including
masculinities, and challenge unequal gender power)
+ Evaluations of interventions with men and boys need
more robust experimental designs and outcome
measures for a stronger evidence base
+ Diverse partnerships are needed – not only between
program implementers and researchers, but also
between those working on men and boys and feminist
organizations.
*Ruane-McAteer E, Amin A, Hanratty J, et al. Interventions
addressing men, masculinities and gender equality in sexual and
reproductive health and rights: an evidence and gap map and
systematic review of reviews. BMJ Global Health 2019

State of the art
with the
evolution from
“population” →
“sexual &
reproductive
health & rights”
Article: Sexual and reproductive
health and rights and population
policies: from ‘either/or’ to
‘both/and’ *
“We identify population growth and
sustainable development, people and
the planet, and reproductive and
sexual rights as the three most
important issues facing the field today
and propose responses. These three
issues once seemed irreconcilable, but
the application of comprehensive
analysis and on-the-ground experience
to ‘either/or’ dilemmas of global
development have led, and can
continue to lead, to the discovery of
‘both/and’ solutions.”
* “Viewpoint” by Carmen Barroso and Steven Sinding
in The Lancet, Vol. 394, July 27, 2019, pp. 157-158
https://www.thelancet.com/journals/lancet/article/
PIIS0140-6736(19)31280-2/fulltext
Judith F. Helzner Bixby Lexture November 10 2020

Helzner lecture 11102020

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