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RHO archives : Topics : Men and Reproductive Health

IGWG Men and Reproductive Health Subcommittee

Meeting Minutes: November 21, 2000

Attendance and logistics

The meeting room was kindly provided by CEDPA at their offices. Attending and introducing themselves were: Michal Avni (USAID), Gary Barker (Promundo/JSI), Lissette C. Bernal (AVSC International), Michele Burger (consultant), Seema Chauhan (USAID), Sam Clark (PATH), Nick Danforth (Consultant/Brandeis), Paul Feldblum (FHI), Jill Gay (consultant), Meg Greene (Population Action International), Jay Gribble (IRH/Georgetown), Alessandra Guedes (IPPF/WHR), Judith Helzner (IPPF-WHR), Jodi Jacobson (CHANGE), Mihira Karra (USAID), Tabitha Keener (USAID), Jennifer Knox (JHU/CCP), Peg Marshall (CEDPA), Elaine Murphy (PATH), Emma Ottolenghi (Frontiers), Julie Pulerwitz (Horizons), Karin Ringheim (PATH), Audrey Seger (USAID), Jeff Spieler (USAID), Kellie Stewart (USAID), Ellen Weiss (ICRW/Horizons), Amy Weissman (Save the Children).

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Working team meetings

For the first time during these meetings, time was set aside for the working teams on Research and Evaluation and on Communication to meet in the morning for 90 minutes and report back to the larger committee. The main task for these meetings was to complete and correct the annual workplan.

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Working teams report/work-plan discussion

Report Back from Research and Evaluation Working Team

The Research and Evaluation working team included Meg Greene, Chair, Gary Barker, Jeff Spieler, Jay Gribble, Tabitha Keener, Paul Feldblum, Julie Pulerwitz, Sam Clark, Amy Wiesman, Jill Gay, Emma Ottelenghi, Ellen Weiss, Peg Marshall and Karin Ringheim. Meg Greene reported. Members of the working team have drafted statements on our 3 priority topics: Jeff Spieler—dual protection; Amy Weissman and Jill Gay—adolescents and Diane Rubino and Meg Greene—gender-based violence. The plan is to circulate these within the working team (or full membership too?) for review and comment. When complete, they will be included on the Measure Gender Working Group website, used in advocacy, etc. The statements will reflect the specific gender interests of the Men and RH subcommittee in these priority themes.

The working plan includes an item to meet with experts in the field. The team felt that this is a two way street. In addition to inviting experts to present at our quarterly meetings, the Men and RH subcommittee should be represented at meetings that are of importance to our work, and where we can make presentations, provide input into action plans, etc. The team proposed that funds be allocated toward sending representatives to selected meetings, including international meetings. For example, a conference on dual protection is being planned for West Africa and it would be worthwhile to have a representative at this meeting.

The working team has commissioned a case study on each of our three priority themes. The case study on working with adolescents, particularly men, is being written by Barbara Crook, formerly of PATH Seattle, in collaboration with the Society for the Integrated Development of the Himalayas. A draft should be ready for review in January. A case study on working with men to reduce gender-based violence is being written by Benno de Keijzer of Salud y Genero in Mexico. A draft will be completed by March. The third case study on condom promotion, dual protection and safe sexual practices will describe the work of the Stepping Stones project and will be written by Gill Gordon and Alice Wellbourn, who developed the curriculum. It is anticipated that by late spring, the three case studies will be completed. A review committee of R and E team members will be assigned to each of the three case studies, and will include USAID staff. (Ellen Weiss and Julie Pulerwitz expressed interest in reviewing the Stepping-Stones case study, and Julie also expressed interest to review the Salud case study.) Those interested in reviewing a specific case study should contact Meg Greene.

The Men and Reproductive Health subcommittee is also supporting the development of one of 4 workbooks for health workers and providers on working effectively with adolescent boys. These are being produced through a collaboration between IPPF/WHR and 4 NGOs, 3 in Brazil and Salud y Genero in Mexico. The initiative is being coordinated by Insituto PROMUNDO in Brazil. Each NGO is producing one of the 4 workbooks. The topics are sexual and reproductive health, fatherhood, violence, and mental health including substance abuse and suicide. The subcommittee is funding Salud y Genero to produce the latter workbook on mental health. All 4 workbooks have been drafted and are being reviewed. They are each about 75 pages and will be produced in Spanish and Portuguese and field-tested in Bolivia, Mexico, Peru, Colombia and Brazil. Gary Barker suggested that the Committee might wish to support their translation into English, for use in other parts of the world. This would be relatively inexpensive, around $10,000. It may be worthwhile to also adapt the exclusively Latin American data and examples to include some data from each region. This would increase the price of translation, but may make the workbooks more broadly useful. PAHO is interested in funding an evaluation of the workbooks. The subcommittee could advocate for PAHO to fund a longitudinal evaluation.

The Men and Reproductive Health indicators paper written by Nancy Yinger and Elaine Murphy was recently presented at APHA by Elaine and is on the PATH RHO/M&RH website (go to https://www.rho.org/html/menrh.htm ; Also it is to be published by PRB Spring 2001. Contact [email protected] . The R and E team plans to further this work by developing specific indicators on our three priority topics. Meg Greene and Tim Williams will work on developing an annex to the indicators paper.

The team discussed what our committee could do to better understand and address constraints to condom use from a gender perspective. The role of our subcommittee is not to get men to use condoms per se (which is the work of may collaborating agencies [CAs]), but to help CAs better understand the gender issues and dynamics that affect negotiating/using condoms. USAID, FHI, the Population Council and others are planning a workshop for CAs on dual protection for February 21st . It was recommended that one or more presentations include information on gender aspects of dual protection. We could be helpful in articulating how a concern with gender is translated into programs. Meg volunteered to work with Jeff on revising Ellen Weiss, Jodi Jacobson and his presentation on dual protection to include a stronger gender component. A comparative advantage for our committee would be to focus on using condoms with the primary partner, e.g., caring about and protecting one's wife or primary partner.

We discussed positive deviance approaches to addressing all three priority themes individually, as well as the intersection between adolescent boys, violence, and dual protection. The committee could potentially play a role in funding research and evaluating programs. The subcommittee could set funds aside to respond opportunistically to identify positive deviants within a particular study so as to include them in follow-up sub-studies. The subcommittee could also entertain specific proposals if such studies were not or could not be done within existing CA contracts. The subcommittee could also serve as an advocate to encourage foundations to fund more work, for example on violence. The orientation guide will be useful for this kind of advocacy work.

The work plan presently includes a literature review but the team concluded that literature reviews on all three themes were currently being done or were recently completed. These include the Horizons/Frontier review of condom use and dual protection, which should be completed by February, the review of adolescent programs done by Shanti Conly, Lori Heise's Pop Reports on violence, which has an extensive literature review, Peter Aggleton's review of a gendered approach for UNAIDS, and the update of Cynthia Green's review of male involvement for UNFPA recently done by Michele Burger. The Men and Reproductive Health section within the PATH Reproductive Health Outlook website includes an update of the literature every 6 months. The workplan should be revised to state that the team will keep abreast of the literature.

Report Back from CommunicationWorking Team

Michele Burger reported on the Communications subcommittee, which included Michele Burger, Kellie Stewart, Mihira Karra, Audrey Seger, Jodi Jacobson, Lisette Bernal, Jennifer Knox, and Elaine Murphy. In Mary Nell Wegner's absence, Michele and Audrey ran the team meeting. The Working Team spent almost an hour reviewing the workplan in detail. The committee is organizing the orientation guide training of trainers for December 1st. Joe Coyle, a consultant affiliated with the Population Leadership Program at USAID, will facilitate the training for about 15 people. A letter is being sent to about 30 organizations requesting an opportunity to present the material. The team anticipates that about 10 presentations will be made to CAs and donors by teams of trainers in the spring of 2001 and then the orientation guide will be distributed more broadly for use by CAs, Missions, etc. The working team will be responsible for developing the dissemination plan. There are already many requests to use the material. Michele Burger is the contact person and coordinator for scheduling sessions. Plans are to schedule several presentations in the next six months.

A speaker series on the three priority themes is being developed. The matrix that Jennifer Knox created, listing potential speakers, their affiliation, skills and person making the recommendation was presented. The list of speakers will be revised based on the following criteria: international expertise specific to the PHN sector, gender sensitive, experienced in both clinical and non-clinical settings. The primary target audience is USAID. An updated list of speakers will be circulated to the full Subcommittee with a cover note listing the criteria and asking members to either eliminate speakers who do not meet the criteria, or provide the area of expertise, affiliation, and contact information of the speakers they recommend.

The Communications team will play a leading role in disseminating the case studies and PRB will be asked to assist in disseminating the workbooks. The Communications working team also discussed the forthcoming dual protection workshop and will work with Mihira and Jeff to identify a plenary speaker who can address gender issues.

The CD-rom is being reissued. Contact has been made with those individuals who granted copyrights to request permission for an additional 1000 copies. A suggestion was made that we raise this figure.

We further discussed how the IGWG as a whole can have greater visibility at international meetings and reproductive health conferences that are likely to cover one or more of our three themes. For example, there is a forthcoming Asia Pacific meeting on Reproductive Health in the Philippines. [An abstract on the subcommittee's work was later submitted for that meeting.] Suggestions can be put forth at any time to one of the co-chairs about other meetings to which we might contribute. Sam Clark hopes to organize a panel for the spring meeting of the Psychosocial Workshop prior to PAA.

The Team agreed that promoting adoption of indicators for assessing adolescent male (AM) programs would require several steps such as disseminating the indicators, using a similar strategy as for the Orientation Guide (sending out speakers to meet with CAs to encourage them to adopt these indicators) and the active involvement of USAID.

The Working Team also agreed to work on increasing awareness among key audiences about AM services. A possible strategy is to support the participation of a resource person from the Subcommittee, knowledgeable about AMSRH, at meetings such as the upcoming conference in the Philippines. A meeting to be hosted by the Society for the Advancement of Reproductive Care (SARC) were also mentioned. Another suggestion was to support the dissemination, and if necessary the translation, of PAHO's recent multi-country qualitative research on young men.

The Team agreed it could play a role by adding a gender aspect to dual protection. Gary Barker has a proposal that he is submitting to the Research and Evaluation Working Team for supporting work on gender violence. The Population Council submitted a proposal requesting $15,000 for its meeting on Power and Sexual Relations to be held in Washington, DC March 1-2, 2001. On December 11, the Population Council is hosting a planning meeting.

A proposal was presented to hire Michele Burger for 8 days to update the RHO website.

Members agreed that links should be added to the site and that abstracts cited should be linked to papers in their entirety. Consideration should also be given to including a chart listing the various organizations working with men in reproductive health.

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Presentations

Alessandra Guedes, IPPF/WHR. "Integrated screening and services for gender- based violence within sexual and reproductive health programs in Latin America."

Following the introduction of a conceptual model of gender violence adapted from Population Reports but adding a component about men by Judith Helzner, Alessandra Guedes from IPPF/WHR made a presentation titled "Integrating screening and services for gender-based violence within sexual and reproductive health programs in Latin America." Her presentation described the results of a 3-country project to integrate gender-based violence (GBV) into IPPF clinical programs in the Dominican Republic, Peru and Venezuela. For further information on this project, please check out IPPF/WHR's website at www.ippfwhr.org .

Guedes set the stage by showing ways in which GBV is linked to reproductive health and adverse outcomes for women. Survey information from Latin America indicates that GBV is common there, and that many men find violent acts to be acceptable in various contexts. IPPF/WHR, with funding from the European Commission and the Gates Foundation, initiated the project in 1999. The objectives are to strengthen institutional capacity to offer services to victims of GBV; to increase awareness of GBV as a public health problem; to improve legal protection to survivors of GBV; and to increase knowledge about interventions that sexual and reproductive health services can undertake.

Baseline KAP of service providers revealed that the majority has recently questioned clients about GBV, but a substantial minority harbor attitudes that blame the victims for the abuse. A screening tool increased the ascertainment of victims of GBV markedly at the Venezuelan site. The tool has been applied at all three sites, with the Dominican clinics reporting the highest prevalence of GBV (over 30% of new clients report emotional, physical, sexual or childhood sexual abuse) and Peruvian the lowest prevalence (7% of new clients). It is important to note, however, that these differences are likely to reflect the varying levels of implementation of screening at the different locations rather than actual differences in the prevalence of GBV among client populations. This will continue to be monitor closely as screening and services are fully integrated in the different countries.

This work in GBV suggests several dilemmas. The behaviors need to be addressed among men and male adolescents, but reproductive health services aimed primarily at women may not be well-placed to work with perpetrators, although they would be well-placed to undertake activities in the area of violence prevention through IEC and/or advocacy. Resources are scarce, and how to divide them between victims and perpetrators is not clear. And interventions to prevent GBV, while urgent, are of unknown effectiveness.

Presentation by Gary Barker, Instituto Promundo. "Men & gender-based violence: from aggressors to partners in prevention"

Gary Barker presented on the roots of men's violence against women, and implications for preventing men's violence against women. He drew on examples from his research in Brazil to highlight how this violence can be prevented, and how men could be included as "partners in prevention." Only some of the main points as well as issues not raised in the slides are presented in the notes below.

Gary proposed that men's violence stems from 3 factors:

  1. Socialization—how men are raised and expected to act. (e.g., Men's sense of entitlement toward women that men expect sex under certain circumstances, and believe it appropriate to react with violence when refused sex.)
  2. Situational Factors—current relationship and other factors. (e.g., Stress and disempowerment caused by employment, and men's reaction to this stress leading to violence expressed toward a partner, to regain power in another domain.)
  3. Individual Factors—individual variation. (e.g., Inability to control anger).

Gary spoke of the importance of the social context, particularly at a very young age, where parental and other models influence future attitudes and actions regarding violence. Gary pointed to evidence that shows that non-sexual violence in the home is most often directed at boys, and that boys who have been victims of violence need access to services, and are more likely themselves to use violence in their intimate relationships.

Learning from Non-Violent Men: Gary's dissertation research explored positive deviance among young boys—where the characteristics of young boys who manage to counter the dominant (or at least common) social norms around violence are explored. He found that young boys who refused to engage in violence often had witnessed violence, but then had witnessed a negative reaction within the family to the violence, or had somehow seen the "cost" of the violence within the family.

Gary noted that role-play exercises used in many programs often demonstrate negative relationships and difficult situations, but that they could and should act out positive, supportive and non-violent relationships as well. It is important to note that women often indicate that they do not want to leave violent spouse or partner—they just want the violence to stop. Gary pointed out the importance of strategic alliances—that the relationship between Instituto PROMUNDO and women's rights groups, and the judicial system (i.e., for referral of perpetrators of violence) have been fruitful and very important for the success of the programs. Gary concluded by asserting a need for more research on a large scale. In particular, while some research has been done in the developed world, it remains unclear what factors may lead to violence in developing countries. There is a lack of quantitative and qualitative research on men's attitudes and use of violence in intimate relationships in developing countries. There are data from a number of countries on women's victimization by domestic violence, but little research on men that would permit identification of correlates of such violence, and offer insights for prevention.

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Further Discussion

What is the appropriate role for the subcommittees in addressing men and gender-based violence?

Following up the presentations by Guedes and Barker, we had a lengthy and wide-ranging discussion about the difficulties their projects had faced, and problems faced in using an overburdened, underfunded, and untrained reproductive health system to deal with GBV.

Most thought that screening for GBV should implemented because it is at least important for women to know they are not alone in being victims of violence, that they do not deserve to be battered or raped, and that there may be some local remedies available even if a formal referral system is not yet in place. For example, interventions might be feasible by extended family or community members. Increasing awareness among all women also helps pressure leaders to improve referral systems. Before systems improve, all must be made aware a problem exists. All too often GBV is not recognized as significant.

At least one participant felt it was not realistic for this subcommittee, which does not have a clear role in making policy concerning reproductive health training, to recommend new approaches to training reproductive health counselors. This cadre of service providers are usually already seriously undertrained and overworked, and cannot be expected to add GBV as well as sexual health counseling to their duties—in addition to reaching out to counsel men, often for the first time. The time, skills, funds, and commitment are simply not available.

Other meeting participants were more optimistic, generally agreeing that health care providers need to have at least rudimentary training in detecting and preventing GBV. There are several good models for provider training, including the two discussed above. The biggest problem in training and intervening is how to deal with GBV without further angering the abuser; women are often reluctant to report abusive husbands either because they risk more violence, or because they do not want to lose the spouse on whom they depend. In some cases in Asia, women in immigrant families have been told that abusive husbands can be deported, but those women have usually been unwilling to report husbands in fear of losing their support.

In addition to lacking time and skills, providers will have a hard time knowing what to do. Simply expelling the abusive partner from the home is a complex and difficult remedy, and there can be complications or even retribution for both the providers and the partners. Usually it is necessary for the woman involved to make the decision about how to proceed, and in most cases her opinion must be respected, but extended family, community members, and customary law may be important factors too.

Providers should remember that unless women are screened in private, they may not be able to disclose their experience with violence. At the same time, some victims of violence (in particular victims of sexual violence) indicate that they feel more comfortable undergoing gynecological examination, if they are allowed to have a partner or friend with them. Therefore, the ideal protocol should call for an intake procedure with the woman alone, at which time the health care provider can ask the client whether she would like to have her partner or friend join the consultation.

As in all programs designs, the importance of counseling and referral for GBV depends on local situations and concerns (for example, see the IPPF/WHR BASTA newsletter,  pp. 8-9. For a copy please check out IPPF/WHR's website at www.ippfwhr.org . Programs must also look beyond clinic walls, especially when reaching out to counsel men—who tend to be less likely than women to visit clinics in the first place—by communicating with men at schools, sports, in the military, the workplace, etc. Schools are important both for general education, and for GBV prevention education. A study in India showed that both boy's and girl's education levels affected the prevalence of GBV, regardless of educational content. Schools also can address general conflict resolution and communication skills not directly related to gender, helping youth understand the importance of careful communication (how to articulate, not gesticulate).

Mass media can play a key role. PCS has tested effective soap operas with men changing diapers, respecting their daughters, and opposing GBV.

GBV prevention programs are under way in many countries, and those new to this issue should be careful not to reinvent the wheel. These interventions were the main focus of an annual meeting of the NCIH, now Global Health Council, and a workshop held at the Population Council, and many recent publication by Lori Heise and others.

In some places the case for preventing GBV is already known; the challenge is to scale up smaller pilot programs to become full-fledged, continuing activities. Just as increasing numbers of family planning providers are being trained to counsel on issues of sexuality and sexual health, so are more of them recognizing and affecting GBV, linking work in different social and government agencies to produce coordination and synergy.

The following are some of the summary points for this discussion made on a flip chart. These points are not in order of priority and additional discussions are needed to determine the most appropriate investments on men and violence for RH providers.

  • Provider training is needed
  • Identify key messages for client
  • Policies/guidelines regarding females' permission to invite males into consultation.
  • Create enabling environment/address community norms (not just clinic)
  • Engage men to address GBV & men's organizations
  • Social informational campaigns, behavior change/awareness raising
  • Collaboration with girls' and boys' education sector/programs
  • Develop links with community-based approaches (links w/CBD's?).
  • Expand our knowledge re: regional issues in GBV and continue to educate ourselves from past work/conferences
  • Advocate for funding to programs addressing GBV
  • Provide seed funding and networking with men's groups
  • Education and advocacy within USAID
  • Advocate for specific activities among specific CAs; bring them together to share information.
  • Identify these programs (including small, little-known programs with men)
  • Help with capacity, evaluation, going-to-scale
  • Develop a survey instrument for men on GBV

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Updates on selected CA activities

Incorporating Gender into RFAs: Jill Gay presented examples of how the new RFA integrates gender. PRB will publish the RFA next month. It will be mailed to missions with a cover letter explaining its development and advertising the HIM CD-ROM.

Population Council Meeting on Power in Sexual Relationships: Ann Leonard informed members that the Population Council will be hosting a meeting on Power and Sexual Relations March 1-2, 2001 in Washington, DC They will invite about 100 people and are looking for a venue in D.C. that will not use a lot of resources. A planning meeting will be held December 11. Input from members is welcome in terms of agenda items and possible presenters.

HORIZONS Gender and Sexual Relations Research Tools: Julie Pulerwitz distributed copies of a web page HORIZONS developed as a research tool for data collection instruments and methods related to gender and sexual relationships. Julie asked for input from members. The page will be posted in the near future.

JHU/CCP: HIM CD-ROM: Jennifer Knox reported that JHU/CCP is in the process of collecting permission to produce additional copies of the HIM CD-ROM. To date they have received 50% approval. There are currently 291 requests for the CD-ROM and they receive about 10 requests per week. Plans are to get approval to reproduce an unlimited number of CDs in order to avoid having to seek permission every time it needs to be re-issued.

Overview of APHA Task force on Men and Reproductive Health: Sam Clark gave a brief overview of the APHA meeting and informed members that abstracts on papers related to Men and Reproductive Health are available on the APHA website: www.APHA.org/meetings/ . He mentioned there were interesting sessions on dual protection including papers that present detailed gender analysis on condom use. Sam congratulated Judith Helzner and Meg Greene on becoming elected to the APHA Population, Family Planning and RH Section leadership positions. Some thought was given to how APHA and the Subcommittee could collaborate. For the time being, both organizations agreed to cross-reference each other as much as possible.

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IGWG steering committee report/other business

Update on Steering Committee Meeting

Audrey Seger reported on the last Steering Committee Meeting. Scott Radloff is now serving as Senior Advisor to the Gender Working Group and Mary Knox as the Permanent Representative of the WID office. Judith Helzner and Sam Clark presented the two modules of the Orientation Guide. The initiative to train trainers came out of that presentation.

The IGWG website maintained by PRB is being updated. A mailing was sent out through the listserv asking for suggestions for making the website more useful. The Gender Guide is being coordinated with the MAQ exchange since there is an overlap with the Quality of Care. The GAP Subcommittee is receiving training from CEDPA on gender training.

One of the major issues discussed by the Steering Committee is the next step for the Gender Working Group. Topics discussed included membership, need for support and front office endorsement; need for a plenary session to assess if objectives were met and to develop new ones. The plenary session is scheduled for March 22, 2001. All Subcommittee members are invited. There will be an effort to cast a wider net to attract individuals from CAs that are not currently participating. Audrey requested that Subcommittee members send her names of people to invite to the plenary session.

The agreement to carry out an operations research study in Bolivia with PROCOSI was signed and the study is moving forward.

Gender Portfolio Review

The Office of Population went through a review in which three themes were considered: PAC, MAQ, and Gender. They examined work undertaken by CAs that take gender approaches. Estelle Quain, Michal Avni and Audrey Seger made a presentation on gender to the Office of Population. The CAs highlighted in the presentation are those that participate in the Gender Working Group.

Website

Audrey asked members to submit items for the IGWG website to Brit Herstad, the manager of the site at PRB. See the website at: www.prb.org/IGWG.

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Next meeting/plus-delta exercise

Sam Clark agreed to follow up with Subcommittee members about their preference for the next meeting. [The next meeting is set for March 12, 2001.]

Plus (to do again next meeting)    

  • Master stroke—AM working groups—good structure
  • Good amount of time for discussion of presentations
  • 2 excellent presentations
  • PPT worked
  • J. Helzner good focus management for discussion.
  • Organized
  • "Blue" Background Sheet
  • "in-house" access to food
  • Venue—thanks CEDPA
  • Food was good.
  • Sam's attention to detail/preparation.
  • Finishing on time!

Delta (to change)

  • Lose people by the PM inevitable.
  • Increase time for discussion by PPT ? working teams.
  • Have examples of some of the products we have produced, especially for newcomers.
  • Expand on acronyms list

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For more information

For more information, please review the minutes of other past Subcommittee meetings.

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