1My presentation will focus on two themes:

• The symposium “New paradigms for male participation in sexual and reproductive health in Latin America”, that was organized in Oaxaca, Mexico in 1998 by IPPF/WHR (International Planned Parenthood Federation/Western Hemisphere Region) and AVSC International;

• The project “Promotion of men’s participation in reproductive health programs in Central America” that is being implemented by PAHO (Pan American Health Organization), the regional office of WHO (World Health Organization).

1. Symposium “New Paradigms for Male Participation in Sexual and Reproductive Health in Latin America”

2I was asked by the organizers of this colloquium to present the outcomes of this symposium since in a certain way it reflects recent thought and practice of conceptual frameworks in the Region of Latin America. First of all, let me state that it is impossible to summarize the richness of the discussion in this short period of time. Also, by summarizing and consequently generalizing the conclusions, cultural, ethnic, age, gender, economic and other diversities are not really reflected.

3The importance of the seminar conclusions lies in the reaching of general agreements among a wide variety of participants, including government representatives, NGOs, universities, advocacy groups, international cooperation agencies and others, totaling over a 100 participants.

4The seminar focused on the following themes:

• Masculinity/ies

• Male sexuality

• Prevention of STIs/HIV

• Violence

• Fatherhood

5Let me briefly share with you some of the main observations and agreements reached on these topics:

Masculinity/ies

6In Latin America current discussion in the field of masculinity focuses on the concept of hegemonic dominant masculinity as a social construction based on gender inequities that are continuously reinforced. The pattern of hegemonic masculinity is detrimental to both men and women in general and to their sexual and reproductive health conditions.

7Few men are actually able to live up to the expectations of hegemonic masculinity. The ideal of for example the men being the sole economic provider does not correspond to the reality of more and more female-headed households and male unemployment. Also, it is important to underline that “men have feelings too”.

8Men need new models of masculinities that allow behaviours and emotions that are currently forbidden, models that are not based on power differentials and dominance of men over women.

Male sexuality

9Brenda Spencer’s interesting analysis of male sexuality strongly supports the issues that I will raise.

10The hegemonic model of masculinity affects – mostly in a negative way – men’s own sexuality, and also the way men view women’s sexuality.

11The central elements of men’s sexuality from a hegemonic masculinity perspective are pleasure, guilt, performance and homophobia.

12The issue of pleasure for men is one of double standard: the concept of pleasure is not that easily applicable for women and mostly associated with sex workers and casual sexual relationships. The concept of guilt is a very central element and centuries of Catholicism have been very influential in its nourishment.

13Performance is a main concern since impotence is considered to be one of the key expressions of non-maleness. The same goes for homosexuality: the construction of masculinity is strongly based on homophobia. It is interesting to see that some research show that homosexuality is being defined by Latin American men in a different way than the classical definition. The homosexual is the person who is at the “receiving” end, the one who is being penetrated and is therefore classified as a woman, while the person penetrating some one from the same sex is still defined as a hetero sexual man.

14For men, sexuality is conceptually separated from reproduction, which is considered to be a woman’s realm. Therefore contraception is mostly seen as a woman’s concern. Condom use, for example, is acceptable and used with sex workers for STI prevention, but not as a contraceptive in steady relationships.

STI/HIV prevention

15The influence of the hegemonic masculinity model and gender inequities in the rapid increase in STIs (sexually transmitted infections) and HIV needs to be acknowledged and addressed in a much more direct way if we want to prevent STIs and HIV.

16Risk taking behavior in sexual relations (unsafe sex) responds to hegemonic masculinity traits: in fact is at the very core of traditional masculinity.

17Another problem is the stigma attached to condom use and the double standard I mentioned previously. Also, the costs are high and access is limited for adolescents, since they are not supposed to be sexually active persons.

Violence

18The hegemonic model makes violence a full part of masculine identity: violence against women and children, but also between men themselves.

19Prevention of gender-based violence is now more and more integrated into reproductive health settings. For example, there is increasing recognition of the correlation between pregnancy and the increase or start of violence against women.

20A declaration was presented at the seminar calling for the end of violence against women.

Fatherhood

21In the hegemonic model, “father” is defined as the biological parent, financial provider, disciplinarian, strong, rational and distant teacher. At the same time however, men are unable to live up to this model as the reality of single motherhood and the lack of care for extramarital children shows.

22New paradigms of fatherhood could enrich men, women and children’s lives. Allowing men to be present during the delivery of their children, for example, could help reduce the distance and increase the bonding right from birth. Latin American public health services have not been very open to this so far.

23At the seminar the following basic principles for sexual and reproductive health programs were agreed upon:

• Treat men as individuals with their own needs, not only as partners for improving women’s health;

• Define gender equity as a program goal;

• Take a life-cycle approach to sexual and reproductive health needs, including post-reproductive age;

• Take a quality approach to both men and women’s needs and desires.

24In conclusion, the seminar has shown that the Latin American region is a rich source of theoretical discourse, research and program examples. Extensive efforts are made towards setting “male involvement” into a gender equity framework, beyond family planning or reproductive health alone.

2. Project “Promotion of men’s participation in reproductive health programs in Central America”

25This PAHO project is currently at a preparatory stage and will be implemented in seven Central American countries on a four-year period. The government of Germany is our partner in this effort.

26The general project objective is to have sexual and reproductive health pilot programs in operation at the health services and work/leisure place. These programs promote men’s participation in attending their own and their partner’s sexual and reproductive health needs and promoting the respect for sexual and reproductive rights. The focus on human rights is crucial for guaranteeing a gender perspective.

27The project has the following expected results:

• Research on men’s needs, attitudes, practices and health providers response analyzed, published, disseminated and applied;

• Pilot programs in operation that promote innovative patterns of men’s participation;

• Protocols, guidelines, training material and methodologies developed for health services and health promotion activities.

28We are currently in the process of defining our conceptual framework and I would like to share with you critical issues that I hope could serve our discussion. Based on current literature, project and program experiences and current discussions in the Region, we have identified the following issues that PAHO needs to define its position on:

29Do we focus on men as partners to improve women’s health or on men’s own health needs? This is an ideological and conceptual discussion that has real financial consequences. Since our budgets are limited, on what criteria do we prioritize one over the other? This question is especially important for us in the context of current health sector reform processes in the Region and of increasing importance given to cost-efficiency analysis.

30The previous issue is related to the question: what to do if and when men’s sexual and reproductive rights clash or oppose women’s ability to exercise their rights? Taking into consideration women’s biological higher morbidity and mortality in reproductive health and the negative impact of gender inequities on her health, certain movements call for the principle that women’s rights should be secured first. The concern is that everything that took so long to achieve in the field of women’s rights and decisions over their own sexuality and reproduction will be put at risk if we advocate for men’s involvement without a clear picture on gendered power differentials.

31I would like to present some data that shed light on the differential burden of sexual and reproductive ill health on men and women since this is an issue to take into account while defining our position on the above issues. The DALY (Disability Adjusted Life Years) is a composite measurement of lifetime lost due to premature mortality and time lived with morbidity. The DALY measurement methodology is currently being used in the 2000 Global Burden of Disease Study that WHO is undertaking. There has been a lot of criticism on the tool. However, in the field of reproductive health, it does give us some interesting data.

32It shows rather clearly that women suffer far more than men from the consequences of sexual and reproductive affections.

33In conclusion, what are the best strategies to focus on in view of our limited resources? For PAHO this includes the following:

• Government-NGOs (non governmental organizations) collaboration. Women’s NGOs in the Region, and incipient men’s groups, have extensive experience in advocacy on sexual and reproductive health. Ministries of Health will be able to institutionalize innovative pilot approaches in a more sustainable way.

• Health promotion and prevention in a broad sense. In the long run, this is what we consider that activities with men should focus on: promotion of healthy sexual and reproductive behaviors.

• Life cycle approach. Both men and women have different needs at different stages of their life. Also, we need to focus on the post-reproductive age group.

• Youth. We have to start at childhood stage and focus a lot on adolescents, because gender roles and identities are constructed and reinforced from early age on.

• Life skills and resilience. We have to strengthen and promote positive ways for individuals to realize their potential and develop themselves in a way that is respectful to others and fulfilling. This includes the development of positive communication and negotiation skills that enable both men and women to protect their sexual and reproductive health.