Gender Transformative Programing in Adolescent Reproductive and Sexual Health: Definitions, Strategies, and Resources

Gender and Sexual Health Part Four

Practice Matters, January 2014

A publication of the Act for Youth Center of Excellence

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by Lori A. Rolleri, MSW, MPH

About the Author

Introduction

Gender is a socially determined construct describing the characteristics, behaviors, and roles deemed appropriate and expected of men and women (and boys and girls) by a given society. These characteristics, behaviors, and roles are learned and reinforced through a socialization process beginning early in life that continues throughout the life cycle (Rolleri, 2013a). Individual attitudes and social norms about gender are important determinants of adolescent sexual risk taking behaviors (Rolleri, 2013b). Program developers and practitioners are in a strong position to address unhealthy and inequitable gender norms, transforming them into healthy and equitable ones. This article will explore ways that adolescent reproductive and sexual health program developers and practitioners can incorporate a gender transformative approach in developing or adapting curriculum-based interventions designed to prevent adolescent pregnancy and sexually transmitted infections (STI).

Applying a Gender Transformative Approach

In 2000, Geeta Rao Gupta, then the President of the International Center of Research on Women (ICRW), presented a continuum of gender programming designed to help program developers and program practitioners better incorporate a gender perspective to achieve greater program impact (Caro, 2009). Under this continuum, four approaches to integrating gender into programs are described: 1) gender exploitative, 2) gender blind, 3) gender accommodating, and 4) gender transformative.

• Gender Exploitative: Gender exploitative programs take advantage of traditional gender roles to achieve project outcomes. Although the program's strategies may contribute to its outcomes, they are unlikely to be sustainable because they do not address root issues, and can have significant, harmful consequences. For example, a social marketing program that promotes an aggressive image of masculinity to sell condoms can be dangerous because it reinforces traditional roles of men being the dominant partner in sexual relationships. While it's possible that this type of campaign can increase condom use, it can also encourage intimate partner violence. Educational campaigns that portray men as uncaring, irresponsible, and aggressive, and women as unknowing, shy, or sexy objects, reinforce negative stereotypes and gender norms. While we would never tolerate these types of disparaging portrayals aimed at ethnic groups, some practitioners seem to tolerate these damaging caricatures of men and women (boys and girls) in prevention programs. This practice should be avoided.

• Gender Blind or Neutral: Gender blind or gender neutral programs intentionally or unintentionally fail to acknowledge the role of gender in their theory of change. Many effective evidence-based pregnancy and STI prevention programs designed for adolescents fit into this category. Gender blind programs do not necessarily do harm, but may indirectly support the status quo of gender inequality. Gender blind programs often miss an opportunity to address an important determinant that would likely add impact to their programs.

• Gender Accommodating or Sensitive: Gender accommodating or gender sensitive programs recognize and respond to existing gender norms and inequities and seek to implement strategies that adjust to these norms. These projects do not actively seek to change gender norms and inequities, but they try to limit any harmful impact. For example, a reproductive health care facility that creates a male-friendly clinic with hours when young men are likely to attend can be very effective at providing needed services, but does not necessarily work to change harmful gender norms that may be driving young men's unhealthy sexual behavior. (Some might argue, however, that simply providing quality male-oriented health care services and encouraging men to use them is gender transformative because men may view seeking health care as a sign of weakness -- a traditional and unhealthy male gender norm). Gender accommodating programs are important, but not sufficient, because they do not fundamentally alter the balance of power between gender roles and norms.
• Gender Transformative: Gender transformative interventions aim to accomplish three tasks: 1) raise awareness about unhealthy gender norms, 2) question the costs of adhering to these norms, and 3) replace unhealthy, inequitable gender norms with redefined healthy ones. Gender transformative programs often take an ecological approach -- that is, they aim to change multiple forces of a person's environment (e.g., schools, workplaces, families, health centers, media, government, etc.) that may be perpetuating harmful gender norms (ACQUIRE Project, 2008). From an ecological perspective, the forces acting on the development of an adolescent's sense of gender include:
  • Parents, family, peers, romantic partners
  • School, community, health care system, work place, faith community
  • Media, religious doctrine, laws and policies, government and politics, business and marketing

Gender transformative programs also often take what is called a "gender synchronized approach." Gender synchronization recognizes that gender is a relational concept; that is, it is difficult to change male gender norms without also changing female gender norms and vice versa (Greene & Levack, 2010).

Examples of Gender Norms

Norms and beliefs about gender should be assessed for your particular community. Some examples of gender norms are:

• "Young men who have sex with many women are considered more manly."
• "Real men don't use condoms."
• "Real men can handle their alcohol."
• "Men have to have sex."
• "Preventing pregnancy is the woman's problem, not the man's."
• "Women who talk about sex are sluts."
• "Sometimes it is necessary for a man to hit his girlfriend."
• "If he does not hit me, he does not love me."

Gender Transformative Programming in Action

Sexuality education curricula that use elements of gender transformative programing include SIHLE, Gender Matters, Wise Guys 2013, and Streetwise to Sexwise. All four raise awareness about unhealthy gender norms, use interactive activities that get students to question the costs of rigid adherence to unhealthy gender norms, and support participants in redefining unhealthy gender norms into more healthy ones. They encourage participation from peers, teachers, and parents in transforming gender norms -- three important forces in a young person's environment. Gender Matters also uses gender synchronized strategies in that it works jointly with young men and women to deconstruct unhealthy gender norms and create healthy definitions of masculinity and femininity.

• Gender Matters
• SIHLE
• Streetwise to Sexwise
• Wise Guys 2013 (11th Edition)

Other Interventions that Include a Gender Perspective

Coaching Boys into Men (Futures Without Violence)

Engaging Men and Boys (EngenderHealth) - Available for free download

It's All One (Population Council) - Available for free download

Program H (Promundo) - Available for free download

Program M - Available for free download

The Strength Campaign (Men Can Stop Rape)

What's the Real Deal about Masculinity (Scenarios USA)

Mentors in Violence Prevention

Strategies for Strengthening Healthy Gender Norms, Attitudes, and Behaviors in Adolescent Pregnancy and STI Prevention Curricula

Below you will find a list of 12 strategies that program developers and practitioners can use to incorporate gender into curricula designed to prevent adolescent pregnancy and STIs. These strategies have been gleaned from the literature on effective and/or promising gender transformative programs from the United States and abroad (Rolleri, 2012).

1. Increase knowledge/awareness about existence of gender norms (Barker et al., 2007). Assess for the common gender norms in your community and raise awareness about the existence of these gender norms for girls and boys. For example:
   • Present and discuss sex disaggregated data showing how men and women are impacted differently by certain health or social conditions (e.g., HIV, poverty, violence, etc.). Lead youth in a discussion about why they think these differences exist.
   • Present and discuss a newspaper story, video clip, advertisement, etc. depicting harmful gender norms (e.g., soap opera clip showing a man dominating or using physical violence with girlfriend). Ask youth about the messages men and women receive about being in a romantic relationship. Discuss how the media piece would be received in their social circle, school, church, or community.
   • Develop a role play or skit where harmful, inequitable gender norms are playing a role in the decision for a couple to use condoms. Ask youth to identify the gender norms being played out in the skit.
   • Show youth examples of different images of girls and boys from advertising, music, or the internet. Ask youth how boys and girls are portrayed differently and if they think these portrayals are realistic and fair.
   • Ask youth to think about a time when they believe they were treated differently (either better or worse) than someone of a different sex because of the attitudes of the people involved toward gender. Ask youth how this made them feel.
2. Increase knowledge about the costs of adhering to rigid gender norms (Barker et al., 2007). Use critical questioning to surface the reasons why these gender norms exist and what the costs are to men and women if we choose to abide by them. Critical questioning uses open-ended questions and challenges whether a belief is true, partially true, or false. Youth are encouraged to use evidence to support their point of view. Some examples of critical thinking questions are:
   • Where does the belief that men have to demonstrate their "manliness" by their number of sexual partners come from?
   • How does this belief/norm affect the health and well-being of men? Women?
   • How would life be different if men and women did not abide by these norms?
   • What are some ways to respond to others who promote this belief?
   • How fair is this to women? Men?
   • How do these beliefs put men (or women) at a disadvantage?
   • Are these differences based at all on men's or women's biology?
3. Redefine unhealthy gender norms into healthy ones (Barker et al., 2007). Create opportunities for youth to redefine harmful, inequitable gender norms into healthy, equitable ones.
   • Guide youth in the development of a role play or skit where men and women present healthy, gender equitable relationships with a post-performance discussion.
   • Invite peer leaders to talk about how they have challenged harmful gender norms and how this has affected them.
   • Teach youth new skills that will help them transform harmful gender norms, such as non-violent means of conflict negotiation, couple communication about sex/condoms/getting tested, etc.
   • After critiquing a newspaper story, advertisement, song lyrics, etc., ask youth to think about how the story could be changed to reflect healthy gender norms.
   • After reading a scenario or case study that describes an unhealthy outcome related to unhealthy gender norms, ask youth to rewrite the scenario using healthy gender norms that change the outcome of the story.
4. Increase skills needed to behave in a more gender equitable way. Even if knowledge and attitudes are changed to support more equitable gender norms, some youth will need skills to behave in a gender equitable way. For example, if girls are conditioned all their lives to be passive communicators, they will need training on how to communicate assertively. If boys are conditioned to deal with conflict using violence, they will need training on how to resolve conflict using non-violent methods.
5. Strengthen models of gender equality in the learning environment you're creating. Model gender equality and gender equity in your words and actions. Young people learn from what they observe. Some questions to ask yourself:
   • Do you encourage boys and girls to participate equally in the classroom? Are girls and boys given equal opportunity and equal time to speak? Equal chance to lead?
   • Are girls and boys who misbehave disciplined in the same ways?
   • Do you support boys and girls in pursuing a variety of goals, activities, and roles? Or do you consciously or unconsciously steer girls and boys into "traditional" roles?
   • Think about the images in your classroom, textbooks, etc. Do they portray gender equitably?
   • Think about the language you use. Do you say things like "mankind," "policeman," "man power," or "man a table?" Adopt gender neutral language like: "humankind," "police officer," "staffing," and "staff a table."
   • If you co-facilitate with a teacher of another gender do you model equitable and respectful decision-making, communication, and cooperation?
   • What do you do to make all students feel safe and comfortable enough to participate in discussions?
   • Does your school or organization have written policies about gender equality, sexual harassment, etc.? Are these policies put into practice?
   • Does your school or organization provide professional development opportunities related to gender equality? If not, is this something you could advocate for?
6. Cultivate empathy. Create situations where girls and boys are able to empathize with each other's experience. Empathy is the ability to recognize, understand, and respond to another person's thoughts or feelings. By understanding the pressures, costs, and impact of living by a set of socially constructed gender rules, youth may feel greater motivation to treat each other in gender equitable ways.
7. Integrate gender into other learning activities and content. While it is good to have a dedicated lesson(s) on the topic of gender, do not stop there. Learners' awareness of gender and questioning/challenging of gender norms will be amplified when gender is integrated into as many learning activities and topics/content areas as possible. Integrate gender into learning activities like: myths and facts, forced choices, perception of risk for pregnancy/HIV, role plays, etc.
8. Present clear, consistent, and equitable messages about gender (Kirby et al., 2011). Repeat these messages throughout the curriculum. It is best to test these messages with the youth you intend to serve to make sure they resonate before promoting them. Some examples are:
   • "Our strength is not for hurting. Show your strength -- get tested." (aimed at males)
   • "I am strong. I am powerful. I protect myself from HIV." (aimed at girls/women)
   • Messages from Gender Matters: Gender Matters Declaration of Independence (Levack, Rolleri, & DeAtley, 2013): I declare that all women and men are created equal and that we have the right to mutually satisfying and respectful relationships, good health, and the skills to make independent choices that will help us prevent pregnancy until we want to become parents. I declare that:
     • I am the boss of me.
     • I decide what being a man or a woman means to me.
     • I treat others in the way I want to be treated.
     • I make my own decision about if and when to have sex. I use protection every time I have sex.
     • I go to the clinic to get tested and protected.
9. Consider alternating between same sex and combined sex learning groups. Consider separating the sexes for some discussions and then bringing them back together to share. Same sex discussions may be appropriate when:
   • One sex is dominating the discussion.
   • Topics are sensitive and girls and boys may feel more comfortable and be more open talking in same sex groups.
   • One of the objectives of the activity is to create same-sex group support.
10. Avoid unintentional gender exploitative approaches (Caro, 2009). Avoid activities or practices that may unintentionally reinforce harmful stereotypes about gender.
    • Are the messages and images about obtaining reproductive health care services primarily targeting women in a way that characterizes reproductive health as solely a woman's concern?
    • Are men and women primarily represented in traditional gender roles? For example, women caring for children and housework? Men as providers? Men as the seekers of sex and women as the ones who set sexual limits? Women as submissive? Women as "sexy?"
    • Would you be comfortable using this activity with your son or daughter (or other teen you care about)? Or are there messages in the activity that could offend or belittle a boy or girl?
11. Consider other forces in the learners' environment. Consider ways that you can complement the curriculum with activities that impact other forces and perceptions of gender that exist in a youth's environment. For example:
    • Include a homework assignment where youth interview their parents about sex and/or gender norms.
    • Engage youth in a school-wide campaign promoting gender equitable messages.
    • Invite as speakers community leaders who will reinforce positive, equitable gender norms.
    • Consider writing a letter to the newspaper about a gender inequitable story.
12. Use a social norms approach (Kirby et al., 2011). A social norms approach involves contrasting students' perceived norms about a certain issue with the actual norms experienced among their peers. When we can demonstrate to youth that the actual norms about a particular issue (e.g., binge drinking, condom use, norms about gender) are more in sync with their personal beliefs, rather than the norms they believe to be real, they will more likely want to behave in ways that they believe are both right for them and common among their peers. One way to surface actual vs. perceived norms is through the use of classroom surveys that collect anonymous data from youth about how they think about gender norms and how they think their peers think about gender norms. This can be done using pen and paper or through automatic electronic response systems such as: TurningPoint or Qwizdom.

Examples of Possible Social Norms Survey Questions

1. a) How likely do you think it is that students in your school who are having sex will use a condom the next time they have sex? (perceived norm): Highly Unlikely, Unlikely, Likely, Highly Likely

1. b) When you decide to have sex, how likely is it that you will use a condom? (actual norm): Highly Unlikely, Unlikely, Likely, Highly Likely

2. a) Most people my age who are in romantic relationships with boys have to do things sexually they would rather not do in order to keep their boyfriend. (perceived norm): Highly Unlikely, Unlikely, Likely, Highly Likely

2. b) If I were in a romantic relationship with a boy I could see myself doing things sexually I would rather not do in order to keep him as my boyfriend. (actual norm): Highly Unlikely, Unlikely, Likely, Highly Likely

Conclusion

Inequitable and unhealthy attitudes and norms about gender are important determinants of adolescent sexual risk taking behavior. There is a continuum of programming approaches that have been used by program developers to change unhealthy gender attitudes and norms ranging from "exploitative" to "transformative." Transformative approaches aim to raise awareness about unhealthy gender norms, question the costs that men, women, and communities pay by adhering to these unhealthy gender scripts, and work to replace these unhealthy norms with more equitable, healthy ones. There are multiple strategies that practitioners can use to make programs more gender transformative such as including activities that develop empathy between the sexes; critique gender messages received by family, friends, and society; and build skills that level the playing field for boys and girls.

While making more sustained change on gender often involves an ecological approach, curriculum-based interventions can play an important role within a more comprehensive campaign to promote healthy and equitable gender norms in the United States, which in turn will contribute to healthier sexual behavior among adolescents.

Resources: U.S. Organizations that Work on Gender

CHANGE Center for Health and Gender Equity

Futures Without Violence

Interagency Gender Working Group

National Council on Gender

One Circle Foundation

True Child

EngenderHealth

Men Can Stop Rape

A Call to Men

The Gender and Sexual Health Series by Lori A. Rolleri

• Research fACTs and Findings: Understanding Gender and Gender Equality
• Research fACTs and Findings: Gender Norms and Sexual Health Behaviors
• Research fACTs and Findings: Can Gender Norms Change?
• PrACTice Matters: Gender Transformative Programing in Adolescent Reproductive and Sexual Health

www.actforyouth.net/gender

This series is dedicated to the memory of Douglas B. Kirby, PhD.

References

• ACQUIRE Project. (2008). Engaging boys and men in gender transformation: The group education manual. New York, NY: EngenderHealth.
• Barker, G., Ricardo, C., & Nascimiento, M. (2007). Engaging men and boys in changing gender-based inequity in health: Evidence from programme interventions. Geneva: World Health Organization.
• Caro, D. (2009). A manual for integrating gender into reproductive health and HIV programs: From commitment to action (2nd ed.). Washington DC: Population Reference Bureau.
• Greene, M., & Levack, A. (2010). Gender synchronizing strategies: A cooperative model for improving reproductive health and transforming gender relations. Washington DC: Population Reference Bureau.
• Kirby, D., Coyle, K., Alton, F., Rolleri, L., & Robin, L. (2011). Reducing adolescent sexual risk: A theoretical guide for developing and adapting curriculum-based programs. Scotts Valley, CA: ETR Associates.
• Levack, A., Rolleri, L., & DeAtley, J. M. (2013). Gender Matters: A gender-transformative teenage pregnancy prevention curriculum. New York: EngenderHealth.
• Rolleri, L. (2012). Tips for strengthening gender inequitable norms. New York: EngenderHealth.
• Rolleri, L. (2013a, December). Understanding gender and gender equality. Research fACTs and Findings. Ithaca, NY: ACT for Youth Center of Excellence.
• Rolleri, L. (2013b, December). Gender norms and sexual health behaviors. Research fACTs and Findings. Ithaca, NY: ACT for Youth Center of Excellence.