Without a gender transformative approach, male engagement interventions risk reinforcing existing gender inequalities, write Shari L Dworkin and colleagues

The 1994 International Conference on Population and Development recognised that women’s lack of empowerment had a negative impact on health outcomes. Due to patriarchal systems, “men exercise preponderant power in nearly every sphere of life, ranging from personal decisions regarding the size of families to the policy and programme decisions taken at all levels of government.”¹ With the Beijing Platform for Action on Women (1995), and more recently the Sustainable Development Goals (SDGs), increased attention has been paid to engaging men in programmes to advance gender equality and women’s health.

Masculine norms that legitimise both men’s domination over women and the power of some men over other men, not only harm gender equality, but women’s and men’s health outcomes.^2-4 Increasingly, “gender transformative” interventions are being implemented to challenge such harmful gender norms and power structures.^5-8

Where health interventions with men are explicitly gender transformative, they can contribute to modifying inequitable gender attitudes, such as a woman must submit to sex whenever a male partner decides. They can also promote sexual and reproductive health, including reducing sexually transmitted infections and risks of HIV and contribute to preventing violence against women. The largest number of gender transformative interventions are implemented in this area.^5-7

The body of evidence making the case for engaging men shows it is important to do so with the explicit intention of promoting gender equality. Key components of gender transformative interventions with men include examining the role of power relations in negatively shaping health, identifying attitudes and practices among men that harm both women’s and men’s health, and viewing men as active agents of change in advancing gender equality.^3,5 However, most male engagement interventions do not address these components and are not intentionally gender transformative.⁷

Health interventions may be designed to “engage men” but it does not mean they seek to challenge harmful gender norms or unequal power structures. Without a gender transformative approach, male engagement interventions may risk undermining women’s autonomy and reinforce existing gender inequalities. For example, interventions to engage men as allies to improve women’s access to healthcare appear to be positive. However, such programmes should include components to foster shared decision making, otherwise they may reinforce cultural norms that women need to seek permission from men before accessing care.⁷

As we mark 25 years of the Beijing Platform with a vision of “Generation Equality: Realizing Women’s Rights for an Equal Future,” we must consider next steps for gender transformative programming with men. First, working with males in a gender transformative way is an important complement to women’s health and empowerment interventions, such as to improve women’s property rights and control over resources.^9,10 Such interventions must be underpinned by a supportive policy and institutional environment for gender equality.

Interventions to engage males with the objective of improving women’s health must not be unintentionally harmful to women’s rights, autonomy, safety, and wellbeing. In addition to clarifying the content of gender transformative programming, how to engage males in a gender transformative way must also be considered.^3,5 This includes engaging men in ways that do not alienate or ignore their needs, especially to overcome potential male resistance to gender equality.^3,5

More rigorous evaluations of gender transformative programming with men to improve women’s health are needed to advance and scale up promising interventions. We know much more about interventions for preventing violence against women. We would benefit from more evidence for other women’s health outcomes, including obesity, heart disease, cancer, mental health, birth outcomes, and trauma among others.

Lastly, there is a growing knowledge base showing that health systems are gendered in ways that reinforce inequalities.^11,12 The covid-19 pandemic brings this issue into sharper focus. The global frontline health and social care workforce is predominantly female; however, males occupy the majority of leadership positions.

Special attention should be given to how the work environment may expose women to higher risk of infection as well as to their psychosocial needs. As a result of the pandemic, women are also facing a double burden of longer hours at work and additional care work at home, particularly in households marked by unequal gender relations and for women in single headed households.

Beyond covid-19, research shows that health institutions are organized in ways that reproduce harmful gender norms and impede both women’s and men’s access to and experience of quality care.¹³ Gender transformative interventions in health systems to improve both women’s and men’s health are rarely designed or implemented. This is an important area of future research.

Moving forward, health interventions engaging males must explicitly seek to counter unequal gender power structures and harmful gender norms. This will not only contribute to improving the health and wellbeing of women and girls and men and boys but will ensure women’s empowerment and autonomy are at the center of such efforts.

Shari L Dworkin, dean and professor, UW Bothell School of Nursing and Health Studies, USA.

Magaly Marques, global SRHR coordinator, MenEngage Alliance, USA.

Oswaldo Montoya, networks associate, MenEngage Alliance Global Secretariat, USA.

Anthony Keedi, program manager and gender specialist, ABAAD Middle East North Africa, Lebanon.

Avni Amin, Department of Reproductive Health and Research, World Health Organization, Switzerland.

Competing interests: None.

References

1. International Conference on Population and Development. Cairo, Egypt, 1994.
2. Barker G, Contreras JM, Heilman B, et al. Evolving Men. Initial Results from the International Men and Gender Equality Survey (IMAGES): ICRW 2011.
3. Dworkin SL, Fleming PJ, Colvin CJ. The promises and limitations of gender-transformative health programming with men: critical reflections from the field. Culture, health & sexuality 2015;17(sup2):128-43.
4. Peacock D, Barker G. Working with men and boys to prevent gender-based violence: Principles, lessons learned, and ways forward. Men and masculinities 2014;17(5):578-99.
5. Casey E, Carlson J, Two Bulls S, et al. Gender transformative approaches to engaging men in gender-based violence prevention: A review and conceptual model. Trauma, Violence, & Abuse 2018;19(2):231-46.
6. Dworkin SL, Treves-Kagan S, Lippman SA. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: a review of the global evidence. AIDS and Behavior 2013;17(9):2845-63.
7. 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;4(5):e001634.
8. Barker G, Ricardo C, Nascimento M, et al. Engaging men and boys in changing gender-based inequity in health: Evidence from programme interventions: World Health Organization 2007.
9. Selin A. The impact of a Conditional Cash Transfer study (HPTN 068) and a Community Mobilization intervention on experiences of Intimate Partner Violence: Findings from rural Mpumalanga, South Africa. SVRI Sexual Violence Research Initiative Conference Presentation, 2015.
10. Heise L. What works to prevent partner violence? An evidence overview. 2011
11. Morgan R, Mangwi Ayiasi, R Barman D, et al. Gendered health systems: Evidence from low-and middle-income countries. BMC 2018;16(58): 1-12.
12. Hay K, McDougal L, Percival V et al. Disrupting gender norms in health systems: Making the case. Lancet 2019; 393(10190):2535-2549.
13. Dovel K, Dworkin SL, Cornell M, et al. Gendered health institutions: Examining the organization of health services and men’s use of HIV testing in Malawi. Journal of the International AIDS Society 2020; 23(S2):e25517.