Addressing Gender Issues with Men and Couples: Involving Men in Sexual and Reproductive Health Services in APROFE, Ecuador

Article excerpt

This article is based on a study of the male-involvement initiative of APROFE (Association for the Benefit of the Ecuadorian Family). It analyzes the lessons learned from a mix of strategies to increase the number of male clients attending APROFE's sexual and reproductive health services. Based on provider interviews, the study describes the gender and privacy issues that arise when treating heterosexual couples in health services and highlights the dynamics between each member of the couple and the service provider in the case of STI diagnosis. The study revealed clear benefits from male involvement -- for both members of the couple. At the same time, the limitations of the health service setting in resolving gender issues that underlie sexual health problems are clear from the findings.

Keywords: sexual health, reproductive health, male involvement, gender, sexually transmitted infections, sexual health services

This article(1) focuses on the male-involvement initiative of APROFE (Association for the Benefit of the Ecuadorian Family). The initiative began in the late 1990s and dovetailed with APROFE's efforts to become more financially sustainable, to improve quality of care, and to increase attention to gender equity throughout its national network of 20 reproductive health clinics in 17 cities.

In the male-involvement initiative, providers systematically encouraged women to bring their male partners to the service. APROFE then used mass media to encourage other men -- both individually and in couples -- to use APROFE's services. As the number of men using the services began to rise dramatically, health providers were confronted with new issues related to quality of care, gender, and users' right to privacy that had to be dealt with systematically throughout the organization, not just on an ad-hoc basis.

The data for this study comes from two main sources: APROFE documents, mainly monitoring data and gender training program reports and minutes,(2) and interviews conducted by the author in 2000 with providers of all levels at four clinics: 28 semi-structured individual interviews and four group interviews.(3) The clinics in the study represent distinct Ecuadorian cultural areas and clinic sizes, and the gender training team evaluated them all as having a positive response to gender training.

The interview guides focused on providers' experiences with and opinions about gender training as well as examples of how the staff incorporated gender issues into their daily practice. Male involvement and the issues arising during STI diagnosis emerged as a central theme in the interviews; it was not the original focus of the study.

BACKGROUND

With 13 million inhabitants, Ecuador is one of the smallest and poorest countries in Latin America. In 1998, 62.6% of the population lived below Ecuador's official poverty line, and 26.9% were classified as indigent.(4) According to UNICEF statistics for 2000,(5) the maternal mortality rate is 130 per 100,000 live births, and infant mortality is at 27. Recent studies in Ecuador show that the fertility rate has fallen to 3.4.(6) With almost universal primary school enrollment, the literacy rates for adults of both sexes are in the high 90s.

APROFE's experiences with promoting male involvement closely parallel those of the family planning field as it transformed into the field of sexual and reproductive health. From the 1970s through the 1990s, like most International Planned Parenthood Federation's (IPPF) affiliates in Latin America, APROFE concentrated on family-planning services. From 1984 through 1994,(7) most family planning agencies' initiatives on "male involvement" were limited to promoting men's increased use of birth-control methods -- condoms and vasectomies -- and their decreased opposition to women's use of contraception. Within this framework, APROFE's experiment with a male clinic to promote male family planning methods in the early 1990s did not prosper, leading them to re-think their strategy. …