Literature Review on Men,
Gender, Health and HIV
and AIDS in South Africa
August 2008
Dean Peacock, Jean Redpath, Mark Weston, Kieran Evans,
Andrew Daub and Alan Greig for Sonke Gender Justice Network.
Sable Centre, 16th Floor
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S Executive Summary
T Introduction
Men, gender and health
Evaluation data on the efficacy of men and gender equality programs
International Commitments to Working with Men
E One: Gender, HIV/AIDS and Sexual and Reproductive Health 8
Sexual and Reproductive Health Rights in South Africa
Sexual and Reproductive Health in South Africa
Gender based violence and AIDS
Multiple and concurrent partners
Men and condom use
Men and HIV testing
Men's violence and women's experiences of testing and disclosure
Men and treatment uptake
Men and women living with HIV and AIDS
Male circumcision
Men, care and support in the context of AIDS
Men, maternal health and family planning
Two: Men, gender and other health issues
Men's violence against other men and boys
Men, alcohol and risk
Men, chronic disease and tobacco use
Men and occupational health
Men and care seeking
Men and education
Men and fatherhood
Health Systems Constraints
Executive Summary
Social constructions of manhood have strong effects on men's and women's health. They
affect women directly, for example, via male violence against them causing physical
and psychological harm, and indirectly through men's risky behaviour increasing their
female partners' vulnerability to sexually transmitted diseases. And they also affect
men, for whom expectations of risk-taking and taboos around health seeking heighten
exposure to injury and illness.
South Africa is far from immune to such impacts. Although attitudes are changing,
many South Africans of both sexes see men as superior to women and believe that men
should dictate many decisions that affect health, including sexual decisions. Almost
one-third of South African women are forced into their first sexual encounter - HIV
infection rates are higher among women with violent husbands. A growing body of evidence also suggests that men are far less likely than women to
access HIV services including testing, treatment and other care and support services.
Men's under-utilisation of HIV services significantly undermines prevention and
treatment efforts. However, it is seldom recognized as a priority and few initiatives are
in place to address this. Gender roles are not set in stone, however, and there is evidence from South Africa
and other countries that efforts to increase gender equality can have significant effects
on health by promoting more gender-equitable attitudes. Involving men in such
programmes is now seen as vital to success, as recognized in several key international
agreements. HIV/AIDS poses a greater burden for women than men in South Africa. Infection
rates are higher among women, in part due to gender-driven behaviour. Gender norms
allow men to dictate the terms of sex, including whether or not to use condoms.
Levels of rape are among the highest in the world (and conviction rates among the
lowest), while domestic violence is widespread. Post-exposure prophylaxis, which can
prevent HIV infection, is available to few rape survivors, and the attitudes of health
care providers deter many women who have been raped from seeking treatment.
Constructions of masculinity also encourage men to have multiple concurrent sexual
partners, which increases the risk of HIV infection both for their casual and long-term
partners as well as for men themselves. While condom use has become more common in South Africa in response to the
AIDS epidemic, gender norms continue to limit their use among some men who see
health seeking as weak, and among women who may be seen as "easy" and unfaithful
if they carry condoms. South African men are also much less likely than women to
present for HIV testing, and therefore less likely to be aware of their status, and to
access antiretroviral treatment for AIDS. This greatly increases men's risk of death
from AIDS, and it also imperils their female partners, who may be less likely to use
HIV prevention methods if unaware that their partners are HIV-positive. Women also carry by far the greater burden of care and support for those with AIDS-
related illnesses. Gender expectations mean wives, mothers, daughters and sisters serve
as primary care-givers, which reduces their own economic opportunities and ability
to attend school, as well as causing great emotional stress. Moreover, women in many
South African families are expected to remain quiet about their own health problems,
which of course means their own health needs are less likely to be met. Some groups of South African men are especially vulnerable to HIV and other health
threats. Men in prisons, for example, receive inadequate nutrition and health care and
Literature Review on Men, Gender and Health in South Africa
are at high risk of violence (including sexual assaults) at the hands of other prisoners or
staff. HIV prevalence is higher among offenders, the vast majority of whom are male,
than the population as a whole. Men outside prison are also often victims of violence,
with the country having one of the highest homicide rates in the world. Men are more
likely than women to be victims of such violence, although women are more likely to
suffer sexual abuse. Gender norms that condone male violence are largely responsible
for its perpetuation, and they are also a cause of higher rates of alcohol and tobacco
consumption among men, which have multiple negative health impacts. Much innovative work has been done in South Africa and elsewhere to shift these
gender norms and thereby improve the health of men and women. ‘Stepping Stones,'
a community training and dialogue programme, has worked in multiple countries to
reduce the acceptability of violence and promote discussion and awareness of HIV/
AIDS. Sonke Gender Justice Networks‘One Man Can' campaign uses a human rights
framework to help men and boys take action to stop domestic and sexual violence,
halt the spread of HIV/AIDS and promote healthy, equitable relationships. These
programmes have had significant impacts on behaviour and attitudes, with men
becoming more involved in family health care and parenting as well as less likely
to commit violence and more likely to protect themselves from health threats. They
have found men willing to become more gender-equitable and to share the health
care burden with women. Much of the work with men on gender and health has
been small-scale, however; expanding it will have large benefits for the health of all
members of society.
Literature Review on Men, Gender and Health in South Africa
Introduction
This literature review on men, gender and HIV and AIDS has been carried out in
conjunction with a number of policy initiatives that Sonke Gender Justice Network
has been involved in over the last 8 months. These include the development of the
South Africa Country Report to the UN Commission on the Status of Women on
Involving Men and Boys in Achieving Gender Equality; a multi-country research
project on policy approaches to working with men for gender equality and improved
men's health, coordinated by Instituto Promundo; the development of national
guidelines on men and sexual and reproductive health in collaboration with South
Africa's National Department of Health and Constella Futures; and a briefing for the
WHO on policy approaches to working with men for gender equality. The literature
review was conducted by Sonke staff, interns and consultants including Andrew Daub,
Kieran Evans, Alan Greig, Eleanor McNab, Dean Peacock, Jean Redpath and Mark
Weston. Funding for this literature review was provided primarily by Johns Hopkins Health
Education South Africa with funding from the United States President's Emergency
Plan for AIDS Relief (PEPFAR). Sonke also acknowledges partial support for staff time spent developing this guide
from Constella Futures Health Policy Initiative Task Order One, the Ford Foundation,
DFID, Oxfam GB, the London School of Hygiene and Tropical Medicine's Centre
for Research on Gender, Violence and Health and from the UCLA Program in
Global Health, drawing on funding provided to UCLA by the Ford Foundation and
the Diana, Princess of Wales Memorial Fund. The views expressed herein are those of Sonke staff and not those of the funders or any
employees of the funders.
Men, gender and health
Social constructions of manhood shape men and women's health outcomes in
important ways. In South Africa, per cent of sexually active women reported that
they had not wanted their first sexual encounter and that they were coerced into sex.
As well as the psychological effects of violence, it also harms physical health - a recent
study of over ,500 women in South Africa indicates that, "women with violent or
controlling male partners are at increased risk of HIV infection." There are also negative health consequences for men. Men in many societies adhere
to rigid notions of manhood and equate manhood with risk taking, dominance and
sexual conquest; they view health seeking behaviors, moreover, as a sign of weakness.
These attitudes put men at risk from both natural and non-natural causes. Men are
more likely to view sexual relationships as adversarial, have more negative attitudes
toward condoms and use condoms less consistently. This behaviour increases their risk
of HIV infection and other sexually transmitted diseases. Young men are more likely
than women to drive recklessly, including speeding, drinking and driving, tailgating
and running red lights, which together with their far lower rates of seatbelt use result in
young men dying in car accidents at far higher rates than women.4 Worldwide, almost
three times as many males die from road traffic injuries as compared to females.5 A reluctance to access health services is also damaging. Data from South Africa
indicate that men are significantly less likely than women to use voluntary counseling
and testing (VCT) services and account for only per cent of all clients receiving
Literature Review on Men, Gender and Health in South Africa
Only 45 per cent of those accessing antiretroviral therapy for AIDS are men, despite
roughly equal HIV prevalence rates among men and women.7 In some regions the
differences are much starker. These gender discrepancies in ART uptake reflect men's
beliefs that seeking health services is a sign of weakness.8 In South Africa, men's low
utilisation of HIV services mirrors their low use of all health services.9 Men's gendered practices are constantly changing, however, sometimes as a result of
public health interventions and sometimes because of broader socio-cultural changes.
In a study in Mexico, for example, middle class and younger men reported changes
in "how they view gender roles, including domestic tasks,"0 while in another study
almost half of the men interviewed reported being very different kinds of fathers than
their own fathers were. In South Africa, meanwhile, a survey of ,500 men and
women by the Unilever Institute (005) found that attitudes to gender are changing:
6 per cent of respondents believe men and women are equal; 66 per cent that men
and women should earn the same amount; and 50 per cent that women are treated
unfairly. There is still some way to go, however; 7 per cent of respondents still believe
that men should be the head of households and 64 per cent that they should be the
primary breadwinner in the family.
4 Literature Review on Men, Gender and Health in South Africa
Evaluation data on the efficacy of men and
gender equality programs
The question then is not whether men can change, but rather whether policies and
programs accelerate and influence that change. Recent research suggests that carefully
designed policies and interventions can bring about changes that improve men and
women's health and that they can achieve this change in relatively short time periods.
As new programs engaging men and boys have been implemented, a body of effective
evidence-based programming has emerged and confirmed that men and boys are
willing to change their attitudes and practices and, sometimes, to take a stand for
greater gender equality.
Gender transformative work with men is occurring across the world. In Nicaragua,
the Men's Group of Managua has implemented an ongoing national campaign to
prevent male violence against women with the theme, "Violence Against Women:
A Disaster that Men CAN Do Something About." In India, the Bhoruka AIDS
Prevention Project has developed strategies to change attitudes and behaviors amongst
truck drivers working on the routes between Calcutta and Katmandu. Across Latin
America, Instituto Promundo coordinates the Program H Alliance and engages
men and boys in gender transformative work. In South Africa, a number of "Men's
Marches" to end violence against women and children have been held since 997,
which have drawn thousands of men out onto the streets in a public repudiation of
male violence.4 The World Health Organisation and Instituto Promundo recently released a report
reviewing 57 interventions with men in the areas of sexual and reproductive health,
maternal and child health, gender based violence, fatherhood and HIV/AIDS
prevention. Their analysis has confirmed that such programs, while generally of short
duration, have brought about important changes in men's attitudes and behaviors.5 Of
the 57 studies included in the analysis:
• 4.5 per cent were assessed as effective in leading to attitude or behavior
• 8.5 per cent were assessed as promising; and
• 6.8 per cent were assessed as unclear.
Programs were classified based on their degree of attention to gender and orientation
towards change in gender roles.6 Programs that took an approach of addressing
gender norms – within their messages, staff training, and educational sessions with
men – were more likely to show an impact in changing attitudes and behavior.
A study of nearly 50 Nicaraguan men who participated in workshops on masculinity
and gender equity revealed significant positive attitudinal and behavioral changes
according to both partner reports and self evaluations in a wide range of indicators
including use of psychological and physical violence, sexual relations, shared decision
making, paternal responsibility and domestic activities.7In Brazil, Instituto Promundo's intervention with young men on promoting healthy
relationships and preventing HIV/STIs, showed significant shifts in gender norms at
six months and twelve months. Young men with more equitable norms were between
four and eight times less likely to report STI symptoms.8The South African Medical Research Council's evaluation of the Stepping Stones
initiative implemented in the Eastern Cape also showed significant changes in
men's attitudes and practices. With two years follow up, men who participated in the
intervention reported fewer partners, higher condom use, less transactional sex, less
substance abuse and less intimate-partner violence.9,0
Literature Review on Men, Gender and Health in South Africa
Barker (005) has outlined several key factors that are associated with gender-
equitable attitudes and practices in men. As well as situational factors, such as men's
temporary unemployment or illness that encourages some to undertake domestic
tasks, the influence of peers and community leaders who have gender-equitable views
is also important, as is the impact of community-based intervention programs that
encourage discussion and reflection about gender norms and male identities.
International Commitments to Working with
Men
Informed by and lending momentum to the many programs working with men and
boys across the world, a growing international consensus has emerged over the last ten
years about the need to include boys and men in the promotion of gender equality.
This is reflected in a number of international commitments:
• The 994 International Conference on Population and Development affirm
Men's behaviors related
the need to "promote gender equality in all spheres of life, including family
to sexual and reproductive
and community life, and to encourage and enable men to take responsibility
health are directly related to a
for their sexual and reproductive behavior and their social and family
constellation of overall views
about gender norms.
• The Beijing Platform for Action (995) restated the principle of shared
responsibility and argued that women's concerns could only be addressed "in
partnership with men."
• The twenty-sixth special session of the General Assembly on HIV/AIDS
(00) recognised the need to challenge gender stereotypes and attitudes
and gender inequalities in relation to HIV/AIDS through the active
involvement of men and boys.4
• At the 48th session, the UN Commission on the Status of Women adopted
conclusions calling on governments, entities of the United Nations system
and other stakeholders to encourage the active involvement of men and
boys in eliminating gender stereotypes; encourage men to participate in
preventing and treating HIV/AIDS; implement programs to enable men to
adopt safe and responsible sexual behavior; support men and boys to prevent
gender-based violence; implement programs in schools to accelerate socio-
cultural change towards gender equality.
This brief introduction to men, gender and health in South Africa demonstrates three
important points:
. Men's behavior can and has changed in some contexts, sometimes as a result
of program interventions, sometimes as a result of policies, and in other cases
as a result of social trends and individual and local circumstances.
. Men's behaviors related to sexual and reproductive health are directly related
to a constellation of overall views about gender norms.
. Program and policy interventions to engage men and truly transform gender
norms that disadvantage women and girls (and at the same time leave men
vulnerable) have largely been small-scale or have not been documented.
However, many of them show tremendous potential.
6 Literature Review on Men, Gender and Health in South Africa
The main focus of the literature review is on how gender interacts with HIV/AIDS.
Part one addresses the various risk factors for HIV infection as well as gender issues
in relation to testing, treatment and care. Part two looks at other health issues that are
affected by gender, again with a focus on HIV/AIDS. Where available and useful, we
have included international data for comparison purposes with South African data.
Literature Review on Men, Gender and Health in South Africa
One: Gender, HIV/AIDS and Sexual
and Reproductive Health
Sexual and Reproductive Health Rights in South
Africa
The World Health Organisation (WHO) defines health as "A state of complete
physical, mental and social well-being." The recognition of health as a human right
took a great step forward in 948 when the newly formed United Nations adopted
the Universal Declaration of Human Rights (UDHR), which states that everyone
"has the right to a standard of living adequate for the health and well-being of himself
and of his family, including food, clothing, housing and medical care and necessary
social services." The International Covenant on Economic, Social and Cultural Rights (ICESCR)
in 966 made the right to health even more specific by mandating governments
ratifying the agreement to take steps to prevent, treat and control epidemic, endemic,
occupational and other diseases, and to create conditions which would assure medical
service and medical attention to all in the event of sickness. South Africa has signed but
not yet ratified the ICESCR; however its provisions may be employed in interpreting
the South African Bill of Rights. Sexual and reproductive health is a key component of health. The 994 International
Conference on Population and Development in Cairo defined reproductive health as:
"A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes."
Thus encompassed in reproductive rights are the rights of men and women to be
informed about and to have access to safe, effective, affordable and acceptable legal
methods of contraception and fertility regulation of their choice, and the right of
access to appropriate health care services that enable women to go safely through
pregnancy and child birth and provide couples with the best chance of having healthy
infants.
Women and men should also be entitled to sexual rights, which are distinct from
reproductive rights. The Aids Law Project has articulated sexual rights in the following
way: "All women and men are entitled to:
• Control over their own bodies
• Only have sex when, with whom and how they want to
• Live out their sexual orientation
• Not be forced to have sex through the use of violence or coercion
• Have sexual enjoyment
• Be protected from diseases such as HIV and STIs
• Exercise the responsibilities that go with sexual rights."
"The realisation of sexual and reproductive rights," it adds, "is essential to the full well-
being of men and women."5
8 Literature Review on Men, Gender and Health in South Africa
The exact ambit of sexual and reproductive rights is open to some interpretation by
the courts. In South Africa, these rights may come under the ambit of international
law such as the ICESCR as well as the rights contained in the Bill of Rights of the
Constitution, such as the rights to equality, dignity, life, privacy, access to health care
and emergency medical treatment, children's right to health care, access to information,
and just administrative action. Both the Constitution and the South African National Health Act provide that no
one may be refused emergency medical treatment. In the 998 case of Soobramoney6
the Constitutional Court confirmed that social rights, such as the rights of access to
health care and housing, are dependant upon resources available for such purposes and
the right may be limited by lack of resources. Thus in defining the ambit of "emergency
medical treatment" the court was not prepared to accept that this would include
ongoing treatment of chronic illness (in this case kidney failure) for the purpose of
prolonging life. Such treatment is to be classified as "health care" and may thus be
limited by lack of available resources and progressive realisation of the right. The case
has particular implications for the treatment of chronic life-threatening illnesses such
as HIV/AIDS. In 00, on the other hand, the TAC7 case established that children's rights to health
care (section 8 of the Constitution) and the general right of access to health care
(section 7) obliged government to make Nevirapine available for the prevention
of mother to child transmission of HIV. The case involved an appeal against High
Court findings that the government had acted unreasonably in refusing to make
an antiretroviral drug available in the public health sector, and in not setting out a
timeframe for a national program to prevent mother–to–child transmission of HIV.
The respondents argued that the government's actions amounted to a breach of the duty
imposed on all State organs to give effect to rights guaranteed in the Constitution. The provisions of sections 7 and 8 led to the question of whether government
is constitutionally obliged to plan and implement a program for the prevention of
mother–to–child transmission of HIV. The court found that the administration of
the drug would be a simple matter. It issued another order against the government in
slightly different terms from the lower court order by declaring that sections 7() and
() of the Constitution require the government to devise and implement within its
available resources a comprehensive and coordinated program to realise progressively
the rights of pregnant women and their newborn children to have access to health
services to combat mother-to-child transmission of HIV. The program must include
reasonable measures for counseling and testing pregnant women for HIV, counseling
HIV-positive pregnant women on the options open to them to reduce the risk of
mother-to-child transmission of HIV, and making appropriate treatment available to
them for such purposes. The court found that the policy for reducing the risk of mother-to-child transmission
of HIV as formulated and implemented by government fell short of compliance
with these requirements in that doctors at public hospitals and clinics other than the
research and training sites were not enabled to prescribe Nevirapine to reduce the
risk of mother-to-child transmission of HIV even where it was medically indicated
and adequate facilities existed for the testing and counseling of the pregnant women
concerned. The policy also failed to make provision for counselors at hospitals and
clinics other than at research and training sites to be trained in counseling for the
use of Nevirapine as a means of reducing the risk of mother-to-child transmission of
Literature Review on Men, Gender and Health in South Africa
Government was ordered without delay to remove the restrictions that prevent
Nevirapine from being made available at public hospitals and clinics that are not
research and training sites, to permit and facilitate the use of Nevirapine for the
purpose of reducing the risk of mother-to-child transmission of HIV and to make
it available for this purpose at hospitals and clinics when in the judgment of the
attending medical practitioner acting in consultation with the medical superintendent
of the facility concerned this is medically indicated. Government was also ordered to make provision if necessary for counselors based at
public hospitals and clinics other than the research and training sites to be trained for
the counseling necessary for the use of Nevirapine and to take reasonable measures
to extend the testing and counseling facilities at hospitals and clinics throughout the
public health sector to facilitate and expedite the use of the drug.
The court noted that these orders did not preclude government from adapting its
policy in a manner consistent with the Constitution if equally appropriate or better
methods become available to it for the prevention of mother-to-child transmission.
The TAC case has obvious implications for the rights of those infected by HIV/AIDS
and consequently sexual and reproductive health rights.
It is not just at government level that such rights need to be protected and promoted.
POLICY Project's work with traditional leaders on HIV/AIDS advocacy and human
rights has been one of the most notable projects working towards changing attitudes
and strengthening rights at community level. 6.5 million rural people in South Africa
live under the authority of traditional leaders, indicating that the latter are well placed
to address issues related to HIV/AIDS in rural communities across the country.
Thirteen three-day workshops were carried out between June and September 004,
training 50 traditional leaders. The workshops aimed to increase traditional leaders'
capacity to carry out HIV/AIDS advocacy work in their communities as well as
enabling them to establish networks with local AIDS service organisations and local
government structures.
In 005, the POLICY Project carried out an evaluation of these workshops
(interviewing 0 of those who had gone through the workshop process), looking at
the impact on the traditional leaders themselves and the effectiveness of the work they
have since carried out in their communities. As a result of the workshops, leaders'
knowledge about HIV/AIDS increased significantly and in turn this broadened their
capacity and commitment to addressing the epidemic in their communities. Almost all
of the traditional leaders interviewed for the evaluation had engaged in some type of
activity after the workshop, "ranging from calling community meetings to talk about
HIV/AIDS, to talking at funerals, running workshops for other traditional leaders and
even opening their houses to provide counselling and advice to those in need. About
,00 people were reached through these activities."8
Sexual and Reproductive Health in South Africa
At the end of 007 it was estimated that million people worldwide were infected
with HIV.9 The burden of infection is particularly high in developing countries, and
specifically in the sub-Saharan African region. South Africa has one of the most
severe HIV epidemics in the world. The country has 5.5 million people living with
HIV/AIDS – an adult prevalence rate of 8. per cent.0 Levels of HIV infection were
found to be significantly higher among women at younger ages, with male prevalence
exceeding female prevalence after age 5-9 years.
0 Literature Review on Men, Gender and Health in South Africa
Gender roles and relations are increasingly recognised as one of the fundamental
forces driving the rapid spread of HIV and exacerbating the impact of AIDS. Across
the sub-Saharan African region, gender related norms all too often condone men's
violence against women, grant men the power to initiate and dictate the terms of sex,
and make it extremely difficult for women to protect themselves from either HIV or
violence. As a result, the HIV/AIDS epidemic disproportionately affects women's lives both in
terms of rates of infection and the burden of care and support they carry for those with
AIDS-related illnesses. In many countries HIV prevalence among girls under the
age of eighteen is four to seven times higher than among boys. A study from South
Africa revealed that young women are much more likely to be infected than men, with
women accounting for 77 per cent of infections among South African youth between
the ages of 5-4. There is increasing evidence that abuses of the human rights of girls, especially through
sexual violence and other sexual abuse committed by men, contribute directly to this
In a survey of 435 men in a
disparity in infection and mortality.4 Indeed, Southern Africa has some of the highest
Cape Town township, more
reported levels of sexual and domestic violence in the world.5 A 006 SADC Expert
than one in five reported that
Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern
they had, "either threatened
Africa called for HIV prevention efforts to "address gender issues especially from the
to use force or used force
perspective of male involvement and responsibility for sexual and reproductive health
to gain sexual access to a
and HIV prevention and support, and specifically to reduce multiple, concurrent
woman in their lifetime.
partnerships, intergenerational/age-disparate sex and sexual violence.6
Gender based violence and AIDS
South Africa has among the highest rates of violence against women in the world.7
The 998 South Africa Demographic and Health Survey found that ten per cent
of women had experienced physical assault at the hands of men in the past twelve
months. Seven per cent reported having ever been forced to have sex, and a further
4.4 per cent that they had been raped.8 Levels of violence vary by location. A 006
Medical Research Council survey of 70 male volunteers recruited from 70 rural
South African villages indicated that, "6. per cent had raped a non-partner, or
participated in a form of gang rape; 8.4 per cent had been sexually violent towards
an intimate partner; and 79. per cent had done neither."9 A survey of young men in
Eastern Cape found that 4 per cent reported having used physical violence against
a female partner in the past twelve months.40 In a survey of 45 men in a Cape Town
township, more than one in five reported that they had, "either threatened to use force
or used force to gain sexual access to a woman in their lifetime."4 And in Mpumalanga
and Northern (Limpopo) Province, per cent and 5 per cent of women, respectively,
reported having been physically abused by a sexual partner.4 Globally, WHO reports
that between 0 and 69 per cent of women in 48 population-based surveys reported
being the victim of physical assault by an intimate male partner.4Conviction rates for domestic and sexual violence are amongst the lowest on the
planet. In South Africa only one in nine victims reports rape and fewer than ten per
cent of reported rapes lead to conviction. Inadequate recording of statistics makes it
impossible to determine conviction rates for domestic violence but a recent study of
domestic violence homicides in South Africa showed conviction rates no higher than
7 per cent.44 This sends a clear message to perpetrators that they are unlikely to be
apprehended or convicted and gives women little reason to believe that they can safely
leave abusive relationships - even if they suspect their partner is putting them at risk of
exposure to HIV/AIDS. The South African Law Commission's proposed alterations
Literature Review on Men, Gender and Health in South Africa
of the definition of rape are a response to this situation. Such changes would mean
that the state will not be required to prove absence of consent on the part of the
person who has been raped. In the proposed legislation marriage is not regarded as
an impediment to rape, which means that a husband can be convicted for raping his
wife.
Violence against women increases their risk of HIV infection. Sexual abuse during
childhood and forced sexual initiation during adolescence are associated with increased
HIV risk-taking among women. In Nicaragua, one study found that women who were
severely sexually abused in their childhood and adolescent years made their sexual
debut more than two years earlier and reported a higher number of sexual partners
than those who had experienced moderate or no sexual abuse.45 The latter are key
predictors of HIV vulnerability. Studies in the USA have found that among women
living with HIV infection, nearly half report forced sexual experiences in childhood
or teenage years.46Women who experience sexual assault in South Africa are at greater risk of HIV/AIDS
infection than other women.47 While the evidence is not conclusive, research suggests
that men's violence limits women's ability to affect the use of condoms in their sexual
relationships. A South African study found that women who experienced forced sex
were nearly six times more likely to use condoms inconsistently than those who did
not experience coercion. In turn, women with inconsistent condom use were .6 times
more likely to be HIV infected than those who used condoms consistently.48 Despite the alarmingly high levels of rape and HIV/AIDS, post exposure prophylaxis
(PEP) is not available to many rape survivors. A recent study found PEP readily
available in 84 per cent of hospitals but only 5 per cent of clinics. This has serious
implications given that many women have limited access to hospitals and given the
rapid reaction time that is required for PEP to be effective.49 This deficiency is largely the result of negative attitudes towards rape survivors. The
same study revealed that only 56 per cent of staff had received specialised training for
addressing survivors of gender violence. A report by the National Working Group
on Sexual Offences found that "almost a third of government health practitioners
at national rape centers said they did not consider rape to be a serious medical
condition."50 Staff at many health centers "refused to provide medical treatment in
the form of antiretroviral drugs, taken as post-exposure prophylaxis to prevent HIV
infection, if the rape had not been reported at a police station." Some women become
victims of violence while attending health centers, moreover; WHO reports that,
worldwide, tens of thousands of women each year are subjected to sexual violence
in health care settings, including sexual harassment by providers, genital mutilation,
forced gynaecological examinations and obligatory inspections of virginity.5A number of studies have been conducted to determine South African men's and
boy's attitudes to sexual violence.5 According to the authors of a 004 report based
on a survey of over 50,000 school aged youth, "In South Africa, several studies have
shown that youth are affected by sexual violence, that there is a high prevalence of
misconceptions about sexual violence and about the risk of HIV infection and AIDS,
and that responses to communication about behavior change may be less positive
than expected." The authors reveal that males were more likely than females to have
misconceptions about sexual violence and were more likely to believe that "a person
has to have sex to show love; [that] sexual violence does not include touching; sexual
violence does not include forcing sex with someone you know; girls have no right to
refuse sex with their boyfriends; girls mean yes when they say no; girls like sexually
violent guys; girls who are raped ask for it; and girls enjoy being raped."5
Literature Review on Men, Gender and Health in South Africa
Some men are keen to see reduced gender inequality, however, and reduced gender-
based violence. A 006 Sonke Gender Justice survey of 000 men in the greater
Johannesburg area suggested that about equal numbers of men support and oppose
government efforts to promote gender equality, with 4 per cent of men surveyed
saying that the government is doing too much to end violence against women and 8
per cent saying that government is not doing enough. At the same time, 50 per cent
of all men surveyed felt that they themselves should be doing more to end violence
against women.54 A study in sub-Saharan Africa of young men and violence in conflict settings identified
several factors that facilitated more gender-equitable attitudes and less violent behavior
by men, including:55
• A high degree of self-reflection and space to rehearse new behaviors• Having witnessed the impact of violence on their own families and
constructed a positive lesson out of these experiences
• Tapping into men's sense of responsibility and positive engagement as
• Rites of passage and traditions that have served as positive forms of social
control and which have incorporated new information and ideals
• Family members who model more equitable or non-violent behaviors• Employment and school enrolment (for some forms of violence and
• Community mobilisation around the vulnerabilities of young men
There have been a number of HIV-related initiatives seeking to mobilise men's support
for gender equality through work on community norms. Perhaps the best known is
the Stepping Stones community training and dialogue package. By fostering greater
community dialogue, Stepping Stones workshops in 9 countries have helped to
reduce the acceptability and prevalence of violence and to promote discussion and
awareness about HIV. By changing attitudes and behavior related to violence against
women and reducing stigma and discrimination in the community, these programs
work to lower HIV vulnerability for women.
In South Africa, the Men as Partners program uses community-based workshops to
challenge the attitudes and behaviors that perpetuate violence against women and
increase their vulnerability to HIV. Through frank discussions of gender stereotypes
and power dynamics, the program engages men and boys as positive forces for change
in reducing violence, particularly as it contributes to the spread of HIV. A preliminary
evaluation showed that workshop participants had become more likely to believe that
men and women should have equal rights and that wife-beating was wrong.
Sonke Gender Justice implements its One Man Can Campaign in all South Africa's
nine provinces and in a number of Southern African countries. The campaign "supports
men and boys to take action to end domestic and sexual violence, reduce the spread
and impact of HIV and AIDS and promote healthy, equitable relationships that men
and women can enjoy - passionately, respectfully and fully". The campaign utilises a
clear human rights framework and educates men and women about existing gender
and AIDS related laws and policies that can be used to ensure government lives up to
its commitments. Core to the campaign is an "action kit" developed to provide men
with resources to act on their concerns about domestic and sexual violence and about
Literature Review on Men, Gender and Health in South Africa
An evaluation conducted by the Centre for AIDS Development, Research and
Evaluation (CADRE) of the One Man Can initiative implemented with migrant
farmworkers in Limpopo indicates that the workshops, "had a very high impact
resulting in reported behavior change. Statements like: ‘people have changed their
high risk behaviors' and ‘the gender component has taken off amazingly' are evident of
the difference this component has had in the community. There is high dynamism as
participants develop community action teams on how to put the training into action.
The farmers are passionate about addressing gender and there is a need to build on this
response. There have been major changes reported on reduction of sexual partners
and increased demand for VCT."
Multiple and concurrent partners
By equating masculinity with sexual conquest, gender roles also contribute to one of
the most significant factors driving the spread of HIV across sub-Saharan Africa –
multiple and concurrent sexual partnerships.56 Having more than one sexual partner at
the same time is a strong predictor of HIV infection.57 Multiple partnering is closely
tied to constructions of masculinity, which define them as the norm for men. Ideas
and beliefs about male sexuality create expectations among men that having ‘main' and
‘other' sexual partners is both natural and central to their gender identity. Relative to
women, men are more likely to have multiple partners simultaneously, more likely to
be unfaithful to their regular sexual partner, and more likely to buy sex. In many cultures, variety in sexual partners is seen as essential to men's nature.58
However, men are more likely to hold these views than women; in community surveys
in Swaziland and Botswana, per cent of men and just per cent of women agreed
that, "it is OK to have more than one partner at the same time." In Swaziland, 6 per
cent of men and 7 per cent of women thought it acceptable for a man to find another
wife if his current wife does not bear children.59 Sexual behavior studies globally
indicate that heterosexual men, both married and single, as well as homosexual and
bisexual men, have higher reported rates of partner change than women.60A quantitative and qualitative study of young people's (8–0) sexual behavior,
undertaken by CADRE in South Africa, concluded that cultural beliefs and ideas
about masculinity and femininity interacted with underlying socio-economic contexts
and individual psychological factors related to self-esteem and fatalism, to produce
patterns of sexual relationships that can facilitate the spread of HIV.6 A South African
study found that .5 per cent of men who had had sex within the past twelve months
and .9 per cent of women had had more than one sexual partner. Younger people
were more likely to have more than one partner.6 Qualitative research has demonstrated that men are more likely to practice safer sex
with casual sexual partners than they are with their regular partners. This is supported
by findings showing that the longer partnerships progress the less condom use will be
sustained and consistent over time.6
Men and condom use
Condom distribution in South Africa has increased steadily each year. In 005, HSRC
reported, "clear evidence of excellent condom distribution systems in the country and
of the successful implementation of condom use as an HIV prevention strategy," and
that "male condom distribution by the Department of Health has increased markedly
– from 67 million in 00 to 46 million in 004."64
4 Literature Review on Men, Gender and Health in South Africa
Other sources report that condom availability has continued to increase over the last
two years, with 67 million available in 006 and 40 million in 007.65However, condom availability per person remains relatively low. In 005, the male
condom distribution rate was 8.8 per man per year.66 The 007-0 South African
National Strategic Plan draws attention to the need to improve condom distribution:
"Male condom accessibility, judged according to the quantity of condoms procured and
distributed, has significantly improved. Condoms are being distributed increasingly
via non-traditional outlets, but the number of condoms handed out at these venues
remains low compared to overall distribution." A study by Weir et al of drinking venues
in Khayelitsha supports this contention. Visits to the sites indicated that more than
90 per cent did not have condoms or any other AIDS prevention materials available
despite the fact that more than 80 per cent of the men and women there reported
"fishing" at the sites for new sexual partners.67 The South African government has made clear its commitment to increasing condom
availability. The National Strategic Plan (NSP) proposes to increase significantly the
availability of condoms to 00 condoms per male over the age of 5 by 0. In
addition, it lists specific groups to be reached. These include "higher risk occupational
groups including uniformed services, mining industry, long distance transport services,
agriculture industry and the hospitality industry." It also commits to ensuring that
men in prisons should have access to VCT, male condoms, lubricants, STI symptom
recognition and PEP and STI treatment, and draws attention to the condom needs of
men who have sex with men, transsexuals, and sex workers and their clients. A 00 study of men's attitudes towards condom use in South Africa reported that
some men associate male condoms with discomfort, distrust in relationships, undesired
interruption of sexual intercourse, and death of female sexual partners.68 More recently,
a study of men and women in Soweto by the Men as Partners programme found that
6 per cent of men thought women who carried condoms were "easy", and that 4 per
cent of women agreed.69 In a community survey in Swaziland, meanwhile, 5 per cent
of men and 7 per cent of women believe that "women should not insist on condoms
if their partner refuses."70 These attitudes are somewhat reflected in actual condom
use by men and women. A Centre for AIDS Development Research & Evaluation
(CADRE) study of 0,000 South African adults found that per cent of men but
only 5 per cent of women reported having used condoms the first time they had
sex.7 As noted above, men's attitudes towards women also influence condom use. Women
who experienced forced sex were much more likely to use condoms inconsistently than
other women, and those with inconsistent condom use were .6 times more likely to
be HIV infected.7 Qualitative data from studies in Uganda suggest that women find
it difficult to suggest or insist on condom use in face of a threat of violence.7 There is also some evidence of a link between men's use of violence and their own sexual
risk-taking. Studies show that men with more traditional attitudes toward gender
roles and relations are also more likely to have negative attitudes toward condoms and
to use them less consistently.74 There is an extensive literature on lessons learned from condom promotion, marketing
and distribution and, despite challenges to condom policy on ideological grounds,
condoms are widely acknowledged to be a central tool in the public health response
to STIs, including HIV. Condom policy should be explicitly linked to gender equity,
and initiatives and messages used to promote condoms must also promote equitable
sexual relations between women and men and not reinforce negative images of women
and female sexuality.75
Literature Review on Men, Gender and Health in South Africa
Men and HIV testing
Men in South Africa are significantly less likely than women to use voluntary
counseling and testing (VCT) services for HIV/AIDS. A recent national study of
VCT services found that men accounted for only per cent of all clients receiving
VCT.76 A study of over ,500 men and women in Soweto found that 54 per cent of
women and only 9 per cent of men had presented for an HIV test.77 Countries such
as Namibia, Swaziland and Zambia have similar gender gaps in HIV testing, but in
Uganda and Zimbabwe testing rates are more equal, albeit at low levels.78 The HSRC's 005 South African National HIV Prevalence, HIV Incidence,
Behavior and Communication Survey indicates that people who know their
status are more likely to use condoms. This remained true regardless of HIV
status. Those who knew they were HIV positive used condoms two thirds of
the time the last time they had sex compared to only a quarter of the time for
those who did not know they were positive. Amongst those who knew that
they were negative, half used condoms at last sex compared to only a third of
those who did not know their negative status.79 While these data show an association between knowing one's status and increased
condom use, many studies show that the relationship between VCT and behavior
change depends in significant ways on whether the test results are positive or negative.
A randomised trial with 0 individuals and 586 couples conducted in Kenya,
Tanzania and Trinidad found that "the proportion of individuals reporting unprotected
intercourse with non-primary partners declined significantly more for those receiving
VCT than those receiving health information, and these results were maintained at the
second follow-up."80 Weinhardt et al's meta-analysis of 7 studies on sexual behavior
outcome data reported that, "after counseling and testing, HIV-positive participants and
HIV-serodiscordant couples reduced unprotected intercourse and increased condom
use more than HIV-negative and untested participants. HIV-negative participants did
not modify their behavior more than untested participants."8 In other words, testing has been shown to reduce unprotected intercourse amongst
those who test positive. This is, of course, an important prevention goal. Testing also
serves as the gateway to a range of HIV services including treatment. It is, therefore,
critical that more men access HIV testing.
6 Literature Review on Men, Gender and Health in South Africa
Men's violence and women's experiences of testing and
disclosure
In countries with high rates of HIV, VCT services are now routinely being
incorporated into antenatal care services, which are important opportunities to
provide comprehensive HIV prevention counseling and services, including those
related to the prevention of mother to child transmission of HIV. Women, however,
are often reluctant to participate in these programs because of fear of abuse from
their male partners if they test positive. In many cases, even if women do participate
in VCT programs, they will not inform their partners or will not share their HIV
status with their partner because of fear of blame or abandonment.8 Failure to utilise
VCT services during the antenatal and pregnancy period, however, is an important
missed opportunity. If a woman does not get tested and is positive, she may miss the
chance to receive ARVs that can prevent HIV transmission to her child. She may
not receive comprehensive counseling related to breastfeeding options, safe delivery
recommendations, and linkages to care and support programs – all important ways for
her to ensure a healthy outcome for her child and support for herself. Counseling is
also essential for women who test negative because it can reinforce information about
ways they can maintain their negative status. Women's fears of violence upon disclosure are not unfounded; many women have
experienced violence or relationship break-up following disclosure.8 It is worth
noting, however, that a ten-country study on VCT and disclosure published by the
WHO in 004 found that only -5 per cent of women reported violence as a reaction
to disclosure of HIV-positive status. Although many studies show that women are
fearful of such reactions, "these fears were seldom realised among women who chose
to disclose their status."84 Assuming most men will be violent even when the data suggest the reality is more
complicated and includes a significant number of supportive men decreases the
likelihood that service providers will encourage women to bring in their partner for
testing and education. As a result, in South Africa and across the world, important
opportunities to reach men with VCT services are being lost. In 005, for example,
the Perinatal HIV Research Unit (PHRU) in South Africa provided VCT to 9,
women through its PMTCT program; however, only 64 men accessed these services
in association with their female partners.
Men and treatment uptake
The South African government lacks accurate data on how many people are receiving
antiretroviral therapy for AIDS. Although it claims that 4 per cent of those in need
are receiving treatment, independent data gathered by civil society groups suggests this
is an overestimate.85 Men are less likely than women to access antiretroviral treatment
(ART) for AIDS. Nationally, according to the World Health Organisation, 68 per
cent of those on the ART program are women (a higher proportion than in all other
high prevalence countries), despite roughly equal proportions of men and women
needing treatment.86 In some parts of the country the discrepancies are sharper still.
Research on the uptake of ART in Khayelitsha reveals that 70 per cent of those
accessing treatment were women.87 In Johannesburg General Hospital, one study
found that women accessing ART "outnumbered men by a ratio of to ."88 A similar
ratio was reported in a survey of 5,750 patients accessing a wellness clinic in North
West Province.89 Men are also likely to access antiretroviral therapy later in the disease
progression than women, and consequently access care with more compromised
immune systems.90
Literature Review on Men, Gender and Health in South Africa
Studies show that these gender discrepancies in ART uptake are not a function of the
higher infection rates amongst women. An analysis of the Actuarial Society of South
Africa's 00 survey found that, although 4 per cent of ART-eligible patients were
expected to be male, based on epidemiological estimates, only about 6 per cent of
patients accessing ART turned out to be men.9 These findings suggest the effects of male socialisation, in which health seeking
behaviors are often taken to be a sign of weakness. Nattrass cites the result of a 004
survey of 566 Khayelitsha residents that showed that two-thirds of respondents
agreed or agreed strongly with the statement that, "men think of ill-health as a sign
of weakness which is why they go to a doctor less often than women."9 Men's low
utilisation of HIV services mirrors their low utilisation of all health services. Data
from the most recent Demographic and Health Survey (DHS) carried out in 998
show statistically significant differences between men and women's use of all health
services across all racial groups.9 Men's lower than expected use of ART also reflects
the fact that many reproductive health services do not address men's HIV, STI and
other sexual and reproductive health needs. Most VCT services, for instance, are
offered in antenatal clinics which often are not welcoming to or equipped to deal with
men.94 Similarly, many antenatal clinics do not attempt to reach male partners with
VCT services. Dr Francois Venter, head of the South African HIV/AIDS Clinician's Society, makes
the point that government has a critical role to play in increasing men's use of HIV
services: "The work being done by NGOs… is making a difference in terms of how
men now relate to the pandemic, but this exercise should not fall squarely on the
shoulders of civil society groups," Venter said. "The government seriously needs to
consider new approaches if it is to attract more men to its ARV program."95
8 Literature Review on Men, Gender and Health in South Africa
Men and women living with HIV and AIDS
The recent availability of antiretroviral treatment (ARVs) will allow HIV infected
individuals in South Africa to live longer and to remain healthy. With increased levels
of health and well-being, many will continue to be sexually active for longer periods
of time than was previously the case. Research in the US has demonstrated that a
substantial proportion of those infected with HIV continue to practice unsafe sex,
despite knowing their HIV status.96 Published studies estimate that between 8 and
70 per cent of HIV infected individuals will continue to practice sexual behaviors
that may place their partners at risk of infection.97 In developing countries such as
South Africa, a higher percentage may continue to practice unsafe sex because they
are unaware of their HIV status.98 Little is known about the sexual behavior of HIV-
infected individuals in South Africa, but a single study has noted that 54 per cent of
sexually active HIV-positive adults reported unprotected sex in the six months prior
to the research interview.99 In a study of individuals either on or awaiting enrolment in ART, Eisele et al report
that about half of both the men and women had had unprotected sex with a casual
partner or a partner whose status was unknown to them and that individuals who were
uncertain about whether ART reduced risk of transmission were twice as likely to
have had unprotected sex as those who understood that ART does not eliminate the
risk of HIV transmission. Importantly, the study also makes clear the gender dynamics
informing decisions to have unprotected sex. In explaining their reasons, just over half
the men indicated that, "they did not feel it was necessary" to use condoms and just
under a quarter reported partner refusal. Of the women who had unprotected sex, just
under half reported partner refusal as the reason and just under a third felt using a
condom was not necessary. The authors conclude:
"These data reinforce the underlying inequity within this setting where men are typically in control of negotiating condom use during sex and when they deem it unnecessary, women typically comply. Secondary prevention interventions for men within this setting should therefore focus on increasing the awareness and motivation around the need to use a condom during sex, regardless of the availability of ART…Prevention interventions among HIV positive men and women should focus on increasing awareness that ART does not eliminate the risk of transmitting HIV and thus condoms should be consistently be used to reduce such risk."100
Recent improvements in antiretroviral treatment coverage for people living with AIDS
have not been replicated in the area of HIV prevention. While surveys across the
region show substantial increases in knowledge about the causes of HIV infection and
improvements in condom use, a number of countries continue to experience escalating
numbers of new HIV infections, with South African studies reporting 500 new
infections a day or nearly 500,000 new infections a year.0 The April 006 editorial
of the South African Medical Journal provides a snapshot of how this context shapes
perceptions and expectations related to male circumcision:
Literature Review on Men, Gender and Health in South Africa
"We need some brave thinking on prevention – conventional approaches alone do not seem to work, and acknowledgment of this is long overdue…We need massive and creative interventions, including looking at controversial but seemingly effective interventions such as male circumcision."102
With two decades of observational studies and meta-analyses suggesting a link
between male circumcision and increased protection against HIV transmission,0,04
and a number of studies indicating high levels of potential acceptability,05,06,07,08 three
experimental studies on male circumcision were undertaken in Orange Farm, South
Africa, Rakai, Uganda and Kisumu, Kenya.09,0 The results of the first randomised
control trial carried out in Orange Farm were released in June 005. The study of
,74 men was stopped at the interim analysis stage due to compelling evidence that
men in the intervention arm were 6 per cent less likely to have become infected
with HIV. The investigators concluded that male circumcision "provides a degree
of protection against acquiring HIV infection, equivalent to what a vaccine of high
The investigators concluded
efficacy would have achieved. Male circumcision may provide an important way of
that male circumcision
reducing the spread of HIV infection in sub-Saharan Africa."
"provides a degree of
Given the limited impact of other HIV prevention methods across the region, these
protection against acquiring
findings led to considerable excitement about the potential for male circumcision to
HIV infection, equivalent
reduce new infections. Dynamic simulation models indicate that full roll-out of male
to what a vaccine of high
circumcision would lead to dramatic reductions in HIV infection rates and associated
efficacy would have achieved.
mortality. Assuming full coverage of MC is achieved over the next ten years, Williams
et al report that:
"Male circumcision could avert 2.0 million new HIV infections and 0.3 million deaths over the next ten years in sub-Saharan Africa. In the ten years after that, it could avert a further 3.7 million new HIV infections and 2.7 million deaths, with about one quarter of all the incident cases prevented and the deaths averted occurring in South Africa.112
In some countries, news of the probable protective effect of circumcision combined
with donor and NGO advocacy led to sudden waiting lists for the procedure. At the
same time, concern was raised about whether publicity about the results might lead
to "disinhibition", with men misinterpreting the results and reaching the conclusion
that the increased protection offered by circumcision allowed for more risky sexual
behavior, such as less consistent condom use and more concurrent partners.4 Analyses and studies of disinhibition amongst circumcised men are inconclusive. In
the Kisumu study, individuals in the control group were found to practise safer sexual
behaviors: "Notably greater proportions of circumcised men reported riskier behaviors,
although the differences were small and not significant."5 Agot et al report on a
study of 648 men and find, "no excess of reported risky sex acts among circumcised
men. Similar results were observed for risky unprotected sex acts, number of risky sex
partners, and condom use."6In March 007, the WHO and UNAIDS jointly issued a set of recommendations on
male circumcision which included guidance on how best to integrate male circumcision
into other HIV services. The relevant section reads:
0 Literature Review on Men, Gender and Health in South Africa
"Male circumcision should never replace other known methods of HIV prevention and should always be considered as part of a comprehensive HIV prevention package, which includes: promoting delay in the onset of sexual relations, abstinence from penetrative sex and reduction in the number of sexual partners; providing and promoting correct and consistent use of male and female condoms; providing HIV testing and counseling services; and providing services for the treatment of sexually transmitted infections."117
Despite the compelling evidence that male circumcision provides significant levels of
protection against HIV infection, the South African National Department of Health
is yet to develop policies that could take male circumcision to scale. It has only recently
begun consultations on circumcision policy. In Swaziland, Lesotho and Zambia, senior
health ministry officials coordinate national taskforces on male circumcision.
Men, care and support in the context of AIDS
Lack of access to AIDS treatment has especially disastrous consequences for women
and girls in terms of the burden of care and support it forces them to carry. As the
epidemic progresses and as more and more people become seriously ill, the impact
on women and girls in South and Southern Africa becomes more apparent and the
consequences more devastating.8 Cross-cultural research makes clear that women are more likely than men to serve as
the primary caretakers of sick relatives and to remain silent about their own health
problems when other family members are in need of caring. Women frequently
provide this care for people living with HIV/AIDS, although they are not assured of
care to the same extent.9 In Africa, there is widespread evidence that men leave the
burden of caring for the sick and dying at household and community levels to women,
and that this is regarded as a female role.0Taking on this socially prescribed female role of caring often has a serious impact
on women's lives. Carers report that looking after people living with HIV/AIDS
has drained them both economically and emotionally. For women living with
HIV or AIDS, the time and resources they spend taking care of a sick male partner
typically means being unable to meet their own health needs, thus creating additional
vulnerabilities to opportunistic infections.
A national survey in South Africa of how 8,500 households divide their time showed
that women perform eight times more care work than men. School-aged girls are
increasingly pulled out of school to take care of the sick and to assume household
responsibilities previously carried out by their mothers. In Swaziland, for instance,
school enrolment has fallen by 6 per cent with girls more affected than boys.
Carers report that looking after people living with HIV/AIDS has drained them both
economically and emotionally.4 Desmond and Desmond (005) argue that high HIV/AIDS related mortality amongst
women requires that men play a more active role in meeting the psychosocial needs
of AIDS-affected children. They provide an analysis of parental presence when one
parent has died and show that where the mother is not alive only 0 per cent of
surviving fathers are present, but when the father is not alive 7 per cent of surviving
mothers are present.5 Not all care is provided by women and girls, however. A Kaiser Foundation survey
Literature Review on Men, Gender and Health in South Africa
found that per cent of care in South Africa is provided by men.6 Other literature
reveals that at least some men want to be more involved in providing care and support
to those infected and affected by HIV/AIDS, but are prevented from doing so by
cultural pressures. In 998, a UNAIDS study conducted with men in Tanzania found
that some men were willing to do more to support their partners when they fell ill, but
were inhibited by culturally prescribed gender roles and expectations.7 An evaluation
of the Men as Partners program in South Africa bears this out. The program reports
"In focus groups conducted in Soweto in March 2003, many men identified traditional gender roles and the fear of losing respect from their peers as a significant deterrent to participating in care and support activities. When asked what might prevent other men from playing a more active role, men identified a number of obstacles. In one group, men answered that some men would see doing work traditionally performed by women as an "affront to their dignity". Others answered that many men simply did not have the knowledge or skills necessary to provide support or to be more involved in domestic activities and would not want to risk being seen as ignorant or incompetent. Additionally, some men discussed being afraid that their involvement in care and support activities might create the perception that they themselves were HIV positive, which they feared might lead to stigma and social exclusion. 128
Montgomery et al's qualitative study of households affected by HIV/AIDS in
KwaZulu-Natal describes a "disjuncture" between "how men's activities are talked
about and what some men are observed to be doing for their own or other households"
(italics in original text). They argue that whilst there is a "linguistic and conceptual
locus for the discussion of ‘deficient' men, no such language appears to exist to talk
about men who are positively involved in their families." Their study revealed that
men were involved in care giving activities. However, these activities were seldom
acknowledged by community members or by the field workers conducting research
who continue to hold the perception that "men are not caring for their families because
they are irresponsible and profligate." The authors call for more research on men's roles
in the family and argue that this has the potential to "inform the development of new
programmatic approaches that might feasibly engage men's concerns and needs, and
more effectively involve men as actors in community coping strategies."9
Men, maternal health and family planning
Most men in South Africa are not actively involved in the reproductive health care
of their partners and do not typically participate in family planning or antenatal care
consultations with them. Most are also absent during labor and delivery.0 This has
negative consequences for men and women. It decreases the likelihood that men
will know how to provide support and reduces the chances that men will learn of
health care services that they might benefit from themselves. In the context of sexual
and reproductive health, some analysts have argued that men are "the forgotten
clients." When given the opportunity, many men wish to be positively involved in reproductive
health decision-making, including in the use of services, to contribute to positive
health outcomes not only for themselves but also for their families and communities.
Literature Review on Men, Gender and Health in South Africa
In a pilot PMTCT program implemented by the Horizons project in Kenya that
sought to increase partner involvement in PMTCT, the proportion of male partners
who used VCT services as a result of being involved in the program doubled in
one site and increased by 50 per cent at another site. In a study conducted in
South Africa on men's attitudes to care and support, findings illustrated that men
were willing to participate in antenatal care but felt they did not have the necessary
skills. Focus group discussions held with urban and rural men in KwaZulu-Natal in
00 indicated that men had an interest in using family planning to avoid unwanted
pregnancies and control the future. They also expressed a desire for low family sizes
and the responsibility of procuring contraceptives for their sexual partners. Reporting on the findings from their "Men in Maternity" study carried out in KwaZulu-
Natal, Mullick et al argue that it is "indeed acceptable and feasible to involve men in
the reproductive health care of their partners." After interviewing and following over
000 women and more than 500 men, the investigators reported that "the intervention
was feasible, relevant and effective in significantly changing communication patterns,
TIn a study conducted in South
encouraging partner assistance during emergency, and highlighting condoms as a dual
Africa on men's attitudes to
protection method." They suggest that, "had the intervention been in place for a longer
care and support, findings
period and supported by mass communication efforts to encourage men to come to the
illustrated that men were
clinic, we may have seen a much bigger impact."4 "In order for male involvement in
willing to participate in
the maternity care of their partners to be successful," the authors argue, "the following
challenges need to be addressed:
antenatal care but felt they did not have the necessary skills.
• Undertaking wider community education so that more men can be
persuaded to participate in their partners' maternity care;
• Addressing infrastructural health service issues and timings of services to
facilitate the involvement of working men;
• Training more health providers to serve couples, conduct couples counseling
and provide male-friendly reproductive health services;
• Integrating other reproductive health services such as STI, family planning,
voluntary counseling and testing, and prevention of mother-to-child
transmission with antenatal and postnatal care."
Men in prisons
Some men are particularly vulnerable to HIV infection because of the circumstances
of their lives. As of 007, South Africa is home to over 60,000 offenders and an
overcrowding rate of approximately 40 per cent.5 Men make up nearly 70 per
cent of the incarcerated population.6 Overcrowding in correctional facilities is an
especially worrisome issue when viewed in relation to South Africa's health challenges.
In the prison setting, HIV transmission and vulnerability are exacerbated by poor
nutrition, inadequate condom provision, and little to no distribution of disinfectant
products or condom lubrication.7 It is widely acknowledged that: "The quality of
prison health care, compared to that available to the general public, is deplorable, and
there is little reason to assume that the care specifically for those who are HIV positive
is an exception."8A National Inmate Survey of 46 State and Federal Prisons carried out in 007
found that 4.5 per cent of inmates reported sexual victimisation while in prison. This
translates into a nationwide estimate of 4 incidents of sexual victimisation per ,000
inmates. Over half of this victimisation was carried out by members of staff. In some
correctional facilities, the proportion of inmates reporting abuse exceeded 0 per
Literature Review on Men, Gender and Health in South Africa
Chapter 8 of the Jali Commission presents evidence that rape is widespread in prison
and calls for action from Government:
"If the Department [of Correctional Services] keeps on ignoring the fact that sexual abuse is rife in our Prisons and that there is an extreme likelihood that prisoners who are exposed to violent unprotected sex will in all likelihood contract AIDS, then it is effectively, by omission, imposing a death sentence on vulnerable prisoners."140
HIV infection rates among offenders are higher than those among the general
population. A study of over 0,000 prisoners nationwide found HIV prevalence of
9.8 per cent (the national HIV population average is 6. per cent). 94 per cent of
infections were found among men, and just 6 per cent among women - this despite
men making up just 70 per cent of those in correctional facilities.4 A country profile
on drugs and crime recorded a 484 per cent increase in deaths in South African prisons
between 995 and 000. According to post-mortems conducted, most of those deaths
are believed to have been the result of HIV/AIDS.4
4 Literature Review on Men, Gender and Health in South Africa
Two: Men, gender and other
health issues
There is a growing recognition that gender norms, and the violence that is used to
maintain gender inequalities, harms more than men's sexual and reproductive health.
Men's violence against other men and boys
Both worldwide and in South Africa, male-on-male violence is widespread. For males
aged 5-9 years old, interpersonal violence (most of it at the hands of other men) is
the third leading cause of death worldwide.4 In 00, the National Injury Mortality Surveillance System found that roughly seven
times as many South African men as women died as a result of homicide. The South
African Health Review reports that in the year 000, homicide was the second most
common cause of premature mortality for men (and the seventh for women). It is
important to understand such male-on-male violence as a form of gender-based
violence; much of the violence carried out by men against other men serves as a way
to assert male dominance.
Violence is not just a matter of individual acts and behavior, however. Violence is
institutionalised and rooted in histories and structures of inequality and oppression,
including patriarchy, colonialism, racism, and economic exploitation. Some
commentators have described the suffering caused and inequalities maintained
by public policy and the institutions that make such policy as forms of structural
violence.44 The violence of individual men must be understood and addressed in this
broader context of the violence used by dominant groups to maintain their power over
subordinate groups, and the institutions through which this violence is exercised -
schools, the health system, the workplace, the military and law enforcement systems. Such assertions of dominance are evident in the sexual violence that men do to other
men and boys. A lack of research makes it hard to ascertain an accurate picture of boys'
experience of child sexual abuse in this country, yet a review of studies from twenty
countries, including ten national representative surveys, has shown rates of childhood
sexual abuse of –9 per cent for boys (compared to 7–6 per cent for girls).45An
analysis of the Stepping Stones dataset of 68 men shows that per cent had been
"persuaded or forced to have sex when they did not want to" by a man and 0 per cent
had experienced this abuse by a woman. In total per cent of men reported sexual
coercion in response to either of these questions or one that asked whether before
the age of 8 they had had sex with someone (gender unspecified) because they were
threatened or frightened or forced (unpublished data)."
Men, alcohol and risk
Patterns of drinking are embedded in the social, cultural and gender relations of a
society. Historically, drinking has been socially acceptable primarily for men. In some
societies, alcohol use has taken on a symbolic role as a marker of gender difference.
Alcohol use is linked to social reputation, for both men and women, and in some
societies is associated with the gender regulation of the public face of people's lives.
Men can drink in public, but women more often drink in private. Drinking behavior
can also be gendered in relation not only to where drinking takes place, but how
much is drunk. Binge drinking that leads to drunkenness is much more common
and acceptable for men. The reasons that people drink can also be distinctly gendered.
Literature Review on Men, Gender and Health in South Africa
Alcohol consumption has long been used by men as a way of expressing masculinity.
Drinking alcohol is a practice that not only reflects gender norms about appropriate
and desired male behavior, but also produces and reproduces those norms. According to the 00 World Health Report, men are likely to drink more heavily
than women and more likely to be habitual heavy drinkers46 In South Africa, 40 per
cent of men and 5 per cent of women consume alcohol. This widespread alcohol
consumption is rising, especially in the adolescent community. It has been noted
that adolescents who consume alcohol are prone to "violence, vehicular accidents,
uncontrolled sexual behavior and its consequences and drinking to stupor/coma."47The table below shows the tendency to drink or engage in risky drinking is also gendered
in South Africa (risky drinking is defined as 5 or more standard drinks per day for men
and or more for women). In all age groups, all provinces and all population groups,
a much higher proportion of men than women drink. Among drinkers, however, the
gender gap is narrower in terms of risky drinking, with roughly equal proportions of
male and female drinkers engaging in risky drinking. Rural African women with little
education are the riskiest drinkers.
Table 1: Percentage of males and females (=15 years) reporting current
use of alcohol, and percentage of current drinkers engaging in risky
drinking
Background
Total sample
Current drinkers
(5 574 males and
(2 478 males and 1 321 females)
7 962 females)
Drink now
Risky drinking -
Risky drinking
(Current drinking)
weekdaysa
-weekendsa
Residence
Province
6 Literature Review on Men, Gender and Health in South Africa
Education
Population group
Source: Department of Health 's 1998 South African Demographic &Health Survey
Alcohol consumption is a risk factor for gender-based violence and for the sexual
disinhibition that contributes to the spread of HIV/AIDS.48 The Medical Research
Council's National Trauma Research Program reported that 67 per cent of domestic
violence in the Cape Metropolitan area was alcohol related. In another study of
women abused by their spouses, 69 per cent identified alcohol or drug abuse as the
main cause of conflict leading to the violence.49 Further studies in South Africa
have drawn a correlation between alcohol consumption and the likelihood of men
and women engaging in unprotected casual sex, particularly in spaces associated with
alcohol consumption such as shebeens or taverns.50A qualitative study by Morajele et
al in taverns and bars in Gauteng suggests a relationship between the use of alcohol
and risky sex, especially among casual sexual partners.5 In studies conducted in Cape
Town and Durban secondary schools, 66 per cent of male students and 48 per cent of
female students in Grade reported binge-drinking.5 The link with HIV infection,
moreover, is strong – a CADRE study in South Africa found that people who regularly
had five or more drinks at a time were more likely to be HIV-positive.5Efforts to reduce alcohol consumption have spanned behavioural and structural
approaches. Behavioural approaches attempt to help people understand the links
between alcohol and health, but in general, structural approaches have proven more
effective. These include those related directly to alcohol and those aimed at changing
people's environment so that drinking will be a less attractive option.
Taxes on alcohol are a widely used structural deterrent. Tax increases do reduce
consumption,54 but in countries where the rule of law is weak the availability of cheap
illicit alcohol reduces the scope for raising tax. Fiscal policies therefore need to be
accompanied by effective targeting of illegal vendors. Legal constraints are a further structural tool. Raising the minimum legal drinking
age,55 reducing legal blood alcohol concentration limits for drivers, installing breath
testing checkpoints and banning alcohol advertising have been among the most cost-
effective legal measures.56 Reducing the availability of alcohol also has a significant
effect on consumption. A high density of outlets is associated with increased drinking
and negative alcohol-related behaviors such as violence.57
Literature Review on Men, Gender and Health in South Africa
Training those who serve alcoholic drinks has been shown to help tackle both excessive
consumption and underage drinking.58 Perhaps the most radical structural option is nationalisation of alcohol sales.
Nationalisation is unpopular with international financial institutions such as the
International Monetary Fund (IMF), but it has proven effective in curbing consumption
and reducing alcohol-related problems.59 State monopolies allow governments more
easily to restrict outlet numbers and hours of sales, and by reducing the profit motive
and removing competition they eliminate the need for advertising and other forms of
marketing, which have been shown to encourage consumption.60 It is not only governments that can address excessive alcohol consumption. Community
mobilisation, according to the World Health Organisation, is "among the most
powerful catalysts in developing societies, as in the developed world, in reducing rates
of alcohol-related problems."6 The Communities Mobilising for Change on Alcohol
(CMCA) project in the US, for example, helped cut consumption among young
people and reduced drinking and driving arrests and disorderly conduct violations.
The project was run by communities, and included alcohol-free events, monitoring of
alcohol outlets that sold to young people, training for servers and reductions in hours
of alcohol sales.6
Men, chronic disease and tobacco use
Men's vulnerability to chronic disease is significantly worsened by their level of alcohol
and tobacco consumption. Men lose many more disability-adjusted life years than
women to chronic diseases related to such behaviors.6 There is some evidence to
suggest that men and women experience cancer differently, for example.64 More men
than women get cancer, more men than women die from cancer, and men usually
adapt less well than women after a cancer diagnosis.65 These outcomes have been linked to the pressures that men face to adhere to notions
of gender difference, and the impact of these on men's risk behaviors, screening, early
detection, symptom recognition, and help seeking and psychosocial adaptation.66
In most societies, both smoking and drinking are heavily gendered behaviors, as is
evident from the messages about and images of masculinity that are used to market
alcohol and tobacco. As with alcohol advertising, tobacco use is portrayed as a manly
habit linked to happiness, fitness, wealth, power and sexual success. Advertisements
often show men in rough terrain, undertaking risky sports (sometimes in industry-
sponsored competitions).67 Tobacco use in many cultures marks the transition to
manhood.68 Globally, over 80 per cent of smokers are men.69 More than 5 per cent of all South African men currently smoke. In most countries,
the poor are more likely to smoke than the wealthy. Those who are less educated are also
more inclined to smoke.70 As well as the health risks, the opportunity costs of tobacco
use can be very high for poor people. Household expenditure surveys in countries
such as Bulgaria, Egypt, Indonesia, Myanmar and Nepal, show that low-income
households spend 5–5 per cent of their disposable income on tobacco, with many
poor households spending more on tobacco than on health care or education.7 Tobacco kills one in two long-term users.7 It is responsible for more deaths worldwide
than any other risk factor bar high blood pressure. Consumption of cigarettes trebled in
the developing world between 970 and 000. Some of the problems caused by tobacco
affect men and women equally, including lung cancer, upper aerodigestive cancer,
several other cancers, heart disease, stroke, chronic bronchitis and emphysema.
8 Literature Review on Men, Gender and Health in South Africa
Other problems, such as reduced fertility and sexual potency, are specific to men, while
smoking causes pregnancy-related problems in women. Profound legislative changes have occurred since 994 in relation to tobacco.
Amendments to the Tobacco Products Control Act 8 of 99 have resulted in
the prohibition and restriction of smoking in public places, the prohibition of the
advertising and promotion of tobacco products; the prohibition of advertising and
promotion of tobacco products in relation to sponsored events; and the prohibition of
the free distribution of tobacco products.7Another strategy used by the government to control the use of tobacco and indirectly
raise revenue to meet some of the social costs associated with tobacco use is that of
excise taxes on tobacco products (Customs and Excise Act 9 of 964).
These twin strategies of tobacco control legislation and rapidly increasing excise taxes
have been remarkably successful. As van Walbeek notes:
In the education sector,
"Between the early 1990s and 2004 aggregate cigarette consumption
gender-sensitive tobacco
in South Africa decreased by more than a third and per capita cigarette
education should be
consumption decreased by about half. Smoking prevalence decreased
incorporated in life skills and
from 32 per cent in 1993 to 24 per cent in 2003. The average number
gender awareness training for
of cigarettes smoked by smokers decreased from 229 packs in 1993
to 163 packs in 2003. Africans, males, young adults and poorer people
experienced the most rapid decreases in smoking prevalence, while the decrease was less pronounced among whites, females, and older and more affluent people."174
A recent WHO meeting75 considered the WHO Framework Convention on Tobacco
Control (FCTC) in the context of gender. It made the following recommendations
• Establish national focal point(s) for gender in multi-sectoral tobacco control
• Involve NGO groups, especially women's groups• Develop and include indicators to measure the gender-responsiveness of
national plans of action
• Include Ministries that work on women's affairs in national planning for
• Include gender components and sex-disaggregated data in Conference of
the Parties (COP) reports
• Carry out a gender-specific tobacco control situation analysis every -
• Establish a gender-responsive infrastructure• Appoint gender focal points within COP Committees and committees
monitoring the WHO FCTC
• Ensure the presence of women's groups, youth groups and health
professionals in national coordinating mechanisms
Action at many other levels is also needed to reduce tobacco consumption. In the health
sector, gender-sensitive smoking cessation advice should be included in other health
promotion campaigns. In the education sector, gender-sensitive tobacco education
should be incorporated in life skills and gender awareness training for young people.
Banning tobacco advertising, meanwhile, has been found to reduce tobacco use,76 and
policies to ban smoking in the workplace and other public buildings have also proved
Literature Review on Men, Gender and Health in South Africa
Men and occupational health
It is also important to recognise the relationship between gender norms and occupational
health. Worldwide, men are over-represented in nearly all forms of injury. This is
related both to their gender and their class position, given the relationship between
the gendered division of labor and occupational risk of injury, as men account for the
majority of morbidity and mortality from road traffic accidents (including among truck
and taxi drivers), falls (men make up most of the construction workforce) and other
accidents at work. It is also about the gendering of occupations, such that masculinity
becomes equated with a willingness to do the dangerous jobs that ‘lesser' men would
be afraid of doing.78 In South Africa, for example, miners, the vast majority of whom
are men, are at risk of pulmonary tuberculosis, whose prevalence has doubled since
989, and silicosis, which affects 47 in every 000 miners each year and is becoming
Globally, there are many examples of policies and programs to reduce road traffic
injuries, including driver education programs; limiting the number of hours truck
drivers can drive to reduce driver fatigue; drinking and driving laws and laws to
promote seatbelt wearing. However, there is still little regulation of driving practices
in most countries (whether occupational or domestic). Where regulations do exist,
enforcement remains weak.
Men and care seeking
Gender norms of masculinity are also implicated in men's reluctance to seek medical
care. Men's low use of HIV services in South Africa has already been noted and is
a serious cause for concern. Cross-cultural evidence suggests that, in many societies,
masculinity is associated with a sense of invulnerability, and with men being socialised
to be self-reliant, not to show their emotions, and not to seek assistance in times of
need. This reluctance to seek health advice and health care has been noted in the
accounts of men with prostate cancer80 and severe chest pain8 It has been suggested
that delays in seeking and using health care may be related to men's beliefs about
masculinity.8, 8 A UK study of men with testicular cancer found that men regarded
help-seeking as not masculine and defined the "male" approach as being independent
and being able to deal with problems on one's own.84 The impact of gender norms on
men's health-seeking behavior must be an important focus of policy on men, health
and gender equality. Some of this reluctance is spurred by the fact that health services are often not set
up to cater to men's needs. Reproductive health services continue to be provided for
and by women, and men often report difficulty in accessing such services. Even those
services that are most directly targeted at men, namely STI services, often fail to
respond adequately to men's own expressed needs and concerns. Psychosocial issues
often predominate when men are asked about their sexual health concerns, yet they are
rarely addressed by sexual health services. Analyses of large numbers of studies carried
out in Europe and the USA among community and clinic-based samples found a
consistent proportion of men who self-report psychosexual concerns of premature
ejaculation (5–8 per cent), male erectile dysfunction (4–9 per cent), and inhibited
male orgasm (4–0 per cent).85,86Certain groups of men may find it particularly hard to access health services, and
especially sexual and reproductive health services. Men from poor communities that
are underserved by clinical health services often lack the means to pay for transport to
clinics and hospitals.87
0 Literature Review on Men, Gender and Health in South Africa
Men who have sex with men face both stigma and a lack of knowledge among health
care providers of how to treat infections associated with male-to-male sex.88 Young
men often face stigma and censure at the hands of service providers,89 and men in
prisons often receive weaker health care than their free counterparts.
Men and education
Education reduces women and girls' risk of HIV infection, decreases the likelihood
that they will engage in risky sexual behaviors, and enhances their ability to discuss
HIV and condom use with a partner and negotiate sex.90,9,9,9 Gupta et al's
analysis of eight sub-Saharan African countries indicates that women with eight or
more years of schooling were 47-87 per cent less likely to have sex before the age of
8 than women with no schooling.94 Similarly, Hargreave and Glynn's review of
educational attainment and HIV infection in developing countries revealed reduced
HIV prevalence amongst individuals with more education in Uganda, Zambia and
Thailand.95 Education has the potential to play a critical role in reducing women's
vulnerability to gender-based violence.96,97 The WHO's multi-country study on
women's health and domestic violence against women indicates that the strongest
evidence for a link between young women's education and their reduced vulnerability
to intimate partner violence is to be found among those who have attained post-
school leaving qualifications.98 Higher educational attainment is also associated with
women's greater ability to leave abusive relationships.99,00,0 Across Sub-Saharan Africa, school-aged girls have worse educational outcomes than
their male counterparts. They also have fewer educational opportunities, with many
girls remaining at home to help out with domestic tasks, and priority to receive an
education given to boys. South Africa has made great strides in focusing education
policy on increasing female outcomes and creating more parity amongst boys and girls
within the schooling system. As a result, more women are joining the labor force and
entering male-dominated fields. The Department of Education Gender Parity Index (GPI) shows a GPI in 00 of .00
indicating that school-aged boys and girls have equal access to the school system.0
All provinces within South Africa had a GPI close to .00 with only KwaZulu-Natal
and Mpumalanga showing ratios less than .00, meaning more boys have access to the
education system than girls in these provinces. There are other educational outcomes
which have not been similar for boys and girls. The National Department of Education
revealed that although fewer girls are enrolled in primary school, there were 0 per
cent more female learners than male learners at the secondary level,0 with 9 per cent
of girls transferring to secondary school, compared to only 90 per cent of boys.04 However, there are several issues that continue to undermine efforts to create equality
in education. Women and girls face more discrimination in school and within the work
environment, with sexual violence in school settings a problem. Unterhalter notes that,
"the high levels of sexual violence reported in schools is one feature of ways in which
participation in education is not a simple process of enrolment and retention and
passing exams. Sexual violence in school intersects with political and cultural forms
of subordination." A recent national survey in South Africa that included questions
about experience of rape before the age of 5 years found that schoolteachers were
responsible for percent of disclosed child rapes.05 Human Rights Watch has
documented extensive sexual abuse and harassment of girls by both teachers and other
students. In each of three South African provinces they visited, they documented
cases of rape, assault, and sexual harassment of girls committed by both teachers and
Literature Review on Men, Gender and Health in South Africa
male students. Girls who encountered sexual violence at school were raped in school
toilets, empty classrooms and hallways, and hostels and dormitories. Girls were also
fondled, subjected to aggressive sexual advances, and verbally degraded at school.06
A 998 Medical Research Council survey found that among those rape victims who
specified their relationship to the perpetrator, 8 per cent said their schoolteacher or
principal had raped them.07 A report released by the South African Human Rights
Commission on violence in schools indicated that, "schools have become unsafe places
for substantial numbers of learners."08 The report also suggested that schools were the most likely place where children would
become victims of crime, including crimes of sexual violence, assault and robberies.
In a study conducted to examine the prevalence of bullying behavior in adolescents
from Cape Town and Durban it was found that 6 per cent of students were involved
in bullying behavior, 8 per cent as bullies, 9 per cent as victims and 9 per cent as
bully-victims (those that are both bullied and bully others). Male students were most
at risk of both perpetration and victimisation, with younger boys more vulnerable to
victimisation.09 Policies related to teen pregnancy are often a further problem. Teen pregnancy has
proven to disrupt school-going girls' education. Nationally, the proportion of women
aged 5-9 who are mothers or who have ever been pregnant is 9 per cent.0 A study
using 00 data from KwaZulu-Natal found that per cent of 4–9-year-olds
who had ever been pregnant were currently attending school. In several qualitative
studies, it was also found that girls who had dropped out of school due to pregnancy
were less likely to return to complete their matriculation. In South Africa evidence suggests youth begin sexual relationships with limited
health knowledge and insufficient access to health services. The 005 HSRC survey
indicated that the median age for sexual debut for male and female youths is 7,
with about 0 per cent more female youths under 5 engaging in sexual activity than
males. In a large study that examined knowledge of HIV/AIDS and sexual risks
amongst school-going adolescents, 49 per cent of nearly 8,500 learners from across
South Africa indicated that they were sexually experienced. Only half indicated that
they had used a condom during their last sexual experience.4 Evaluations of life
skills programs implemented collaboratively by the Department of Health and the
Department of Education indicate that these are not well implemented and have
little effect on behavior. Describing an outcome evaluation conducted in 4 schools in
Gauteng province, Visser reports:
"Learners' knowledge of HIV/AIDS increased and their attitudes were more positive although the changes may not be attributed to the program alone. In the post-test more learners were sexually active, although preventive behavior did not increase… Results showed that the program was not implemented as planned in schools due to organisational problems in the schools, lack of commitment of the teachers and the principal, non-trusting relationships between teachers and learners, lack of resources and conflicting goals in the educational system".215
Although efforts have been made to use education to prevent violence, there is as yet
little conclusive evidence that this approach works.6 Developing and implementing
violence prevention curricula, whether as a formal part of the mainstream curriculum
or an extra-curricula activity, is a common strategy. Evaluations of such curricula
suggest that experiential learning is vital, in order to move beyond the transfer of
knowledge to focus on attitudes and skills as well. Programs are most effective when
Literature Review on Men, Gender and Health in South Africa
they begin early, involve both girls and boys, and seek to create an alternative peer
environment supportive of gender equity and non-violence.
Among limited examples of successful educational programs in South Africa is
the program developed by Resources Aimed at the Prevention of Child Abuse and
Neglect (RAPCAN) for young boys aged -5 to develop resilience in them in order
that they can play a positive and meaningful role as men in society. The program
used psycho-educational group work to target boys within the school system. The
program challenged learners to look at their behavior in relation to the rest of the
world. They were encouraged to consider whether this behavior was a strength or a
weakness, and thereby engage with the cause and effect of their actions. A program
evaluation showed that girls were appreciative of the different way in which boys who
had gone through the program responded to them, and that boys generally showed
greater empathy for others.7
Men and fatherhood
Richter identifies a number of direct and indirect ways in which father involvement
improves health outcomes for children. Men are better paid than women and bring
more income into the family. Men's status in the community allows them to access
and share resources and protects their children. When fathers live with their children,
"it confers social value on the children," especially in societies like South Africa where
most children grow up without a father in the home. Fathers and step-fathers who
live with their children are also likely to spend more money on them than they would
if they lived apart.8 In healthy relationships, women who live with partners "report
being less stressed about childcare." Richter points out that men's involvement is not
automatically positive, however. Many men commit violence against women. There is
also an urgent need for men to become more involved in childcare activities. Time-use
studies show men spend only "a tenth of the time, compared to women, performing
childcare tasks for children under seven years of age."9 There is a large body of research showing the positive impacts of men's involvement
as parents on the development of their children. The engagement or presence of a
father or father figure in their life is said to positively affect children's life prospects,
academic achievement,0 physical and emotional health and linguistic, literacy and
cognitive development. Children's psychological, social and cognitive development,
moreover, has is hampered by paternal abandonment and a lack of emotional and
material support. Studies in Central America and the United States have found that paternal
abandonment or neglect can result in poor educational performance and school drop
out (including early entry into the labour market to help families financially), teen
pregnancy, and drug and alcohol abuse. Fatherless children in the US are more prone
to suicide.4 Fathers' negative behaviors have further impacts. Men who are violent, aggressive or
alcoholic are more likely to have children, particularly boys, who behave in a similar
way.5 Conversely, fathers with gender-equitable attitudes to childrearing are more
likely to pass on those values to their sons and daughters and to spend more time with
them.6 Men's participation as parents can also be positive for the health and well-being of
women. It may lead to men assuming more responsibility for child care and domestic
tasks, which would be in women's interest as fathers currently only contribute about one-
third or one-fourth of the time that mothers contribute to the care of children.7
Literature Review on Men, Gender and Health in South Africa
Active fathers also provide financial support to their families. Women with children are
more vulnerable to poverty if fathers neglect their financial responsibilities.8 Some
mothers are forced to remove their children from school and send them to work.9
Taking children out of school, of course, may harm the long-term economic prospects
of both the children and their mothers. Fathering can be a useful entry point for working with men on gender equality.
In contexts where men have scant engagement with childrearing, expanding and
increasing their involvement in the lives of their families can change gender behaviors
and attitudes more generally.0 As the awareness of men's needs in relation to their
wives and children increases, traditional ideas about men's role and behaviors are being
challenged. Research conducted in Sweden and the UK found that as men participate more in
sharing domestic work and involve themselves more with children their ideas of
masculinity and childcare change, along with their view of their role as fathers.
In India and Pakistan a study of how men have changed through becoming fathers
(particularly of girls) found that men became more aware of gender issues such as
sexual harassment and inheritance law, and that they tried to shift the laws, policies
and social pressures that enforced gender inequity.Desmond and Desmond (005) estimate that only 48 per cent of fathers in South
Africa are present in the homes of children under the age of 8 compared with 80 per
cent of mothers. They add that, "in 96 per cent of households headed by men, a female
spouse of the head was also present, compared to only per cent of female-headed
households that had a male partner of the head present." Their data also indicate a
strong relationship between household expenditure and father involvement irrespective
of racial group with fathers present in only 8 per cent of households spending less
R 400 per month compared with 9 per cent father presence in households with a
monthly expenditure totaling over R 0,000.4 Richter concludes, "Despite widespread father absence and neglect, we should not
make the mistake of underestimating the actual and potential contribution, interest
and impact of non-resident and low-income or unemployed fathers and, in doing so,
marginalise them further…The concept needs to be fostered that increasing men's
exposure to children, and encouraging their involvement in the care of children, may
facilitate their own growth, bring them happiness and gratification, and foster a more
nurturing orientation in general."5Research also suggests that health services are not well attuned to the roles that men
can play in maternal and child health. A study in the UK has noted the range of and
potential conflicts between male roles in antenatal screening, diagnosis and subsequent
decision-making. The research found that men can play inter-linked roles: as parents,
bystanders, protectors and supporters, gatherers and guardians of fact, and deciders
or enforcers. These may be roles they have chosen or which are assigned to them
intentionally or unintentionally by others (their female partner or health professionals).
Men's status and feelings as fathers are sometimes overlooked or suppressed, or may
conflict with their other roles, particularly when screening detects possible physical or
mental problems with the baby.6Men often welcome opportunities to learn more about the importance of fathers to
children, and to discuss how they would like to interact with children and the ways in
which, in being more attentive parents, they can promote gender equality.7 If given
the necessary support and opportunities, there is evidence that many men can play a
greater role in more gender equitable parenting. However, many men lack the skills, knowledge and opportunity to change how they
4 Literature Review on Men, Gender and Health in South Africa
act as parents. They lack positive role models and support in adjusting to a new role as
fathers. Their negative experiences with their own fathers can make it hard for them
to talk about fatherhood.8 Programs working with fathers often begin from women's
perspectives about what men should be doing, rather than from men's self defined
role as fathers.9 Women may perpetuate behavioral patterns that marginalise men
from full participation with their children.40 Activities such as breast feeding, for
example, can affect fathers' positive feelings towards infants unless they are able to
have exclusive time with babies and, where possible, open and honest discussion with
their partners about parenting processes.4 Social structures may also prevent men from taking a more active role as fathers,
including work practices and the gendered distribution of labor and remuneration,
as well as an absence of social support.4 The economic security of families often
dictates who stays at home to look after children and whether men take parental
leave.4 This can cause difficulties for fathers as they struggle to balance home and
work commitments.
Peer education programs to promote men's role as parents have achieved some success.
For example, the Society for the Integrated Development of the Himalayas in India
has attempted to bring about changes in fathering by working with men who are the
exceptions to the uninvolved norm. It attempts to find those men who assist their
wives and can be called upon to speak up about their alternative points of view.44 A few impact evaluation studies have been conducted of programs seeking to increase
father involvement. They have shown improved service satisfaction by fathers, greater
assistance by fathers of mothers in breast-feeding, and improvements in child-father
relationships based on father self-reports.45 Among the indicators of effective work
with men on fatherhood, the following appear to be most useful:
• Preventing negative behaviors by fathers (such as abandonment and alcohol
• Knowledge (about childbirth, early childhood development, child health)• Sense of preparedness for fatherhood and perceived paternal competence• Process indicators (levels of participation)• Presence and involvement at birth• Impact on children (cognitive development, school readiness, school
• Paternity establishment• Time spent interacting with and caring for children.
Literature Review on Men, Gender and Health in South Africa
Health systems constraints
In developing policy that addresses the gender determinants of men's health-seeking
behavior, including men's use of health care services, it is important to locate such
policy initiatives within the broader context of severe health systems capacity
constraints. Studies show that health systems in Southern Africa are "buckling"
due to a range of factors, including a dramatically increased workload due to AIDS;
AIDS related morbidity and mortality amongst health care workers; emigration of
nurses and doctors due to poor pay and difficult working conditions; national policy
barriers that prevent task shifting; inadequate national and international attention to
the health care worker crisis; and a lack of donor funding for recurrent human resource
costs. These problems have been reflected in the failure to expand sufficiently HIV
testing and to provide antiretroviral therapy for AIDS to more than a small fraction
of those who need it. Findings from a recent report from Medecins Sans Frontieres
(MSF) make clear the health systems capacity limitations across Southern Africa.
The study shows that whereas the US and the UK have 47 and doctors per
00,000 inhabitants respectively, South Africa has on average 74 doctors per 00,000
inhabitants. The number of nurses per 00,000 in the UK is ,70, in the US 90, and
in South Africa 9.46 These deficiencies highlight the need to prevent rather than cure health problems that
arise because of gender differences. As many of the examples presented above show,
civil society, communities and businesses can do much to relieve the pressure on public
health services. By working with men and boys to tackle harmful gender norms and
attitudes, such work can have positive impacts on the health of all South Africans,
male and female.
Conclusions
Although much good work has been done to engage men in efforts to reduce gender
inequality, most programs have been small in scale and had limited sustainability. Most
have focused on running workshops and community education events. Rare exceptions
like Soul City in South Africa have been national in scale or reached large numbers
of men. Indeed, few program coordinators and staff engaged in such programs are
thinking beyond small-scale public health interventions to the larger scale of policy
levers and initiatives that lead to larger, faster and broader change in men's behavior. There is potential for far deeper and more wide-ranging change if existing efforts are
scaled up and replicated in more sites. Measurement of impact is crucial to effective
rollout – in a field where few initiatives have a long history, it will be important to
establish which methods work and which do not in order to design successful scale-up
strategies and tailor programmes to different environments. Those campaigns that have
achieved results so far have shown that many men are willing to help promote gender
equality and that this in turn can improve women's and men's health. If South Africa
wishes to stop the spread of HIV/AIDS and enhance the physical and psychological
health of all its people, it is time to bring men on board.
6 Literature Review on Men, Gender and Health in South Africa
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Literature Review on Men, Gender and Health in South Africa
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Bio/Pharma Quarterly Journal Volume 10, Issue 4 December, 2004 Division of Bio/Pharmaceutical Sciences Society of Chinese Bioscientists in America (SCBA) Princeton, NJ 08643 Chief Editor Lu-Hai Wang, Ph.D. Mount Sinai School of Medicine E-mail:[email protected] TEL: (212) 241-3795 FAX: (212) 534-1684 Editors Flora W. Feng, Esq.
MEANJIN – Arts & Humanities Journal (ISSN: 0025-6293), Vol 6 Issue 1 (2014) PP: 13-24, www.meanjin.xp3.biz Creativity in research and development environments: A practical review Joachim Burbiel Fraunhofer-Institute for Technological Trend Analysis Appelsgarten 2, 53879 Euskirchen, Germany ABSTRACT Creativity is of paramount importance to the innovation process. Therefore the findings of creativity research should be thoroughly considered in organisations where innovation processes are required. This review summarises the literature in the field of work place creativity, with special attention given to R&D environments. Current theoretical models of creativity are discussed and a literature review of the influence of (i) motivation, (ii) interaction within work groups and between group leaders and members, and (iii) organisational culture and environment on creativity is undertaken. Practical advice is derived from literature findings wherever possible.