B OYS IN THE P ICTURE :
G ENDER B ASED P ROGRAMMING IN
A DOLESCENT H EALTH AND D EVELOPMENT
IN E UROPE
GENDER MAINSTREAMING PROGRAMME
WHO REGIONAL OFFICE FOR EUROPE
CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT PROGRAMME
EUR/00/5017720 E70882
EUROPEAN HEALTH21 TARGET 4 HEALTH OF YOUNG PEOPLE
By the year 2020, young people in the Region should be healthier and better able to fulfil their roles in society
(Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)
EUROPEAN HEALTH21 TARGET 13 SETTINGS FOR HEALTH
By the year 2015, people in the Region should have greater opportunities to live in healthy physical and social environments at home, at school, at the workplace and in the local community (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)
ABSTRACT
WHO and its UN collaborating agencies have recognized the need to
understand boys’ health and development. Boys often suffer a higher burden of mortality and morbidity due to risk taking behaviours. Gender analysis reveals that the behaviour of boys often has significant effects upon the health and development of girls. Boys are as diverse as their female counterparts and require specific interventions to address their needs. Examples of programmes which target boys, and some programmes which target both boys and girls, are given as examples to provide a foundation from which to further develop interventions to serve this important population.
Keywords
ADOLESCENCE MALE
HEALTH SERVICES - trends HEALTH STATUS
HEALTH BEHAVIOR GENDER IDENTITY EUROPE
EUROPE, EASTERN
.
© World Health Organization – 2000
All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.
CONTENTS
FOREWORD
BOYS IN THE PICTURE – GENDER BASED PROGRAMMING
IN ADOLESCENT HEALTH AND DEVELOPMENT
... 1INTRODUCTION ... 1
WHY CONSIDER ADOLESCENT BOYS? ... 1
A GENDER PERSPECTIVE ... 3
THE HEALTH AND DEVELOPMENT STATUS OF ADOLESCENT BOYS... 3
LESSONS LEARNED WORKING WITH BOYS ... 5
CHALLENGES FOR THE FUTURE... 7
SURVEY METHODOLOGY... 9
SUMMARY AND CONCLUSIONS... 10
Major themes concerning working with boys ...10
Gender as a central concept ...11
Challenges for the future ...11
Conclusion ...13
EUROPEAN DATA ON THE HEALTH OF BOYS... 14
Morbidity and Mortality ...14
Health-Related Behaviours...18
INTERVENTIONS FOR BOYS HEALTH, DEVELOPMENT AND WELL-BEING... 24
Access to Health Services...25
Loud Mouth Educational Theatre Company ...25
Mottagningen för Unga Män (MUM) (Clinic for Young Men) ...27
Social Development...28
Mediterranean YMCAs group ...28
UNICEF, Reconstructing Kosovo with youths ...30
Sexual and Reproductive Health: Exploring Gender ...33
Sex Education and Young Men ...33
Touching Reality, Working with young military cadets ...37
European Network of Male Prostitution...39
LiebesLeben “LoveLife” ...42
Cityboys: The mental health of gay and bi-sexual boys...44
Gender Based Violence ...46
White Ribbon Movement ...46
Ukraine Facts on sexual violence ...47
Boys will be boys: Prevention of Sexual Abuse...48
Family Communication ...50
Dads & Lads ...50
Internet Communications ...51
Go Ask Alice! ...51
REFERENCES ... 55
Acknowledgements:
This document was prepared by Ken Legins
Technical Adviser, Health Communications and Information Gender Mainstreaming Programme
WHO Regional Office for Europe
Thank you to the programme managers for their cooperation and time in compiling the information presented in this document.
FOREWORD
In recent years, there has been increasing recognition of the relationship between the roles of men and women, their behaviours, and the impact of their social relationships on public health problems.
Much of the attention has been related to males involvement in reproductive and sexual health, and in particular, on how men should participate in assuring that women meet their sexual and reproductive health needs.
Adolescent interventions have rarely focused on boys as a special group with unique needs. Little is known about the specific health needs boys have; what motivates them in their relationships; and what makes them engage in activities. Research and
initiatives in gender mainstreaming have led to an understanding of how we may look at boys’ health, development and protection needs, but interventions which apply this knowledge are few in number.
Making a case for increasing attention to the health, development and wellbeing of adolescent boys and young men is necessary and timely. Increasing the attention to boys is a matter of gender equity and benefits accrue not only to adolescent boys and young men, but also to adolescent girls, women, children, men and communities.
In 1998, WHO started to collect the knowledge on the health and development of adolescent boys. At the same time a survey was started in all the regions of the world, Africa, the Americas, the eastern Mediterranean countries, Asia and finally in Europe.
Far from being conclusive and exhaustive surveys of all programmes focusing on boys, the surveys provide an overview of the current state of programming for adolescent boys and tried to distil lessons learned from current practice. It was also envisaged that the network of organisations and programmes identified could pool experiences and generate concrete findings to facilitate the next phase of WHO's project of advocating for the development of boy’s focused programming. In the European Region, existing literature on the health and health care needs of boys was reviewed and a
questionnaire was designed to collect information on boys’ programmes. In addition, telephone interviews were conducted with staff working in health services for boys. A
“snow-balling” methodology was used to find additional boys’ programmes. The
programmes identified differ in their approaches, target groups and outreach activities.
Though still in their initial steps, they illustrate concerted efforts to address the health development and well-being needs of boys.
We would like to thank all colleagues from WHO, partner UN agencies and NGOs who have contributed to this review.
Dr. Assia Brandrup-Lukanow Mr. Paul Bloem
Women’s and Reproductive Health Child and Adolescent Health and Development WHO European Office WHO Headquarters
BOYS IN THE PICTURE – GENDER BASED PROGRAMMING IN ADOLESCENT HEALTH AND DEVELOPMENT
INTRODUCTION
Assumptions are often made about the health and development of adolescent boys: that they are faring well, and supposedly have fewer health needs and developmental risks compared to adolescent girls; and that adolescent boys are disruptive, aggressive and
“hard to work with”. This last statement focuses on specific aspects of boys’ behaviour and development – such as violence and delinquency – criticizing and sometimes criminalizing their behaviour without adequately understanding the reasons behind it.
Such generalizations do not take into account the fact that adolescent boys – like adolescent girls – are very diverse in character and background. For instance, many boys are in school, but too many are out of school; others work; some are fathers; some are partners or husbands of adolescent girls; others are bisexual or homosexual; some are involved in armed conflicts as combatants and/or victims; some are sexually or physically abused in their homes; some sexually abuse young women or other young men; some are living or working on the streets; others are involved in prostitution.
The majority of adolescent boys are, in fact, faring well in their health and development.
They represent positive forces in their societies and are respectful in their relationships.
However, some young men face risks and have health and development needs that may not have been considered, or are raised in ways that lead to violence and discrimination against women, violence against other young men, and health risks to themselves and their communities.
Our knowledge of what adolescent boys need for healthy development and what health systems can do to help them can be improved by first of all recognizing their complexity.
This calls for a more careful and thorough understanding of how they are socialized in their communities and what health systems can do to assist them in more appropriate ways.
WHY CONSIDER ADOLESCENT BOYS?
Adolescent boys face significant problems and risks related to their healthy Development
Adolescent boys face high rates of sexually transmitted infection (STI) and HIV/AIDS, although generally at lower levels than adolescent girls. Around the world, adolescent boys also suffer high rates of injury and death related to road traffic accidents, violence and suicide, and have higher rates of tobacco use and other substance use than do adolescent girls.
In most of the world, adolescent boys have a higher risk of dying prematurely than their female counterparts – in some places several times higher. Many of these deaths are due to violence, suicide, accidents, and drug or alcohol abuse. The following graph shows that the number of Disability Adjusted Life Years (DALYs) lost, a measure that combines the adverse impact of death and disability due to diseases and injury, is higher for boys than for girls.
The health-related behaviours of adolescent boys have direct consequences for their future health as adults
The leading causes of death for men are often related to their upbringing and lifestyles, namely higher rates of tobacco and alcohol use, accidents, injuries, and violence – the kinds of health and social behaviour adopted primarily during adolescence. As a
consequence, in most regions of the world, a boy’s life expectancy at birth lags behind a girl’s by up to eight years. This gap is predicted to grow even wider by 2020.
Adolescent boys’ health and health behaviours are directly related to the health of adolescent girls
Adolescent and adult men contribute to many of the health risks that adolescent women face, including reproductive tract and sexually transmitted infections, pregnancy-related complications, and violence and abuse. In some cases, this may be the result of a lack of information on sexual/reproductive health matters among adolescent boys. Similarly, they may not appreciate the need to share responsibility for sexual health and
contraception, or they may lack skills promoting discussion and understanding in intimate relationships. Adolescent boys may not be actively involved in caring for the children they father and, in some cases, they may use violence or psychological pressure against young women.
Recognizing the important role of adolescent and adult men in improving the situation for women, the International Conference on Population and Development programme of action includes a decision to focus on promoting male involvement in reproductive health.
From an economic perspective, ignoring the specific health needs and health- related practices of adolescent boys represents tremendous costs to societies The HIV pandemic, much of it related to the sexual behaviour of adolescent and adult
Safeguarding boys’ health and healthy development is a matter of human rights
Improving and safeguarding the health and well-being of boys is a matter of human rights. The Convention on the Rights of the Child clearly states that boys need relevant information, skills and health services, just as girls do.
A GENDER PERSPECTIVE
Gender is defined broadly as what it means in a given society to be male or female and how that defines an individual’s expectations, opportunities and roles. Sex is biological, gender is socially defined. The concept of gender has long been applied to working to improve the status of women and girls and while there is still much to do, the
application of a gender perspective has been an extremely powerful tool. This tool should now be used to look at the situation of boys and men as well.
By examining men’s roles in perpetuating discrimination against women, we seek to involve men in improving the situation of women. We also seek to explore how rigid understandings of what it means to be a male can pose problems for men. Some groups of men – low-income men, homosexual and bisexual young men, men outside the traditional power structures – are at times subject to discrimination.
Even in regions of the world where women face strong prejudices in society, work and family life, and where men may benefit from these inequalities, masculinity nevertheless implies both advantages and disadvantages for young men. For example, discrimination against women in some parts of the world may mean that adolescent boys have higher self-esteem, but are more likely to report having been victims of physical violence in the home.
Changes in women’s roles and status in some countries may lead many adolescent boys to ask what it means to be a man. Two questions relate to how we can help young men find positive, caring, socially aware models of masculinity.
• What are the implications of sex-specific health needs for adolescent boys, and what can be done to improve their health?
• How can we work with adolescent boys to improve the health and well-being of adolescent girls, and to promote greater equality between the sexes?
It is vitally important to work on both issues simultaneously. The goal is not to argue over whose needs are more urgent, but instead to examine the health implications of gender for both sexes and to improve the health of all adolescents.
THE HEALTH AND DEVELOPMENT STATUS OF ADOLESCENT BOYS
A number of issues emerge where special attention for boys is required.
The socialization of boys. In many settings, boys are generally raised to be self-reliant and independent, not to show emotions and not to be concerned with or complain about their physical health, nor to seek assistance during times of stress. These beliefs, and other factors, significantly affect boys’ access to health care.
Other research suggests that boys, like girls, face stresses during specific moments in adolescence – stresses that may be ignored because boys are more likely to repress their emotions and not to seek help. Programmes around the world report that
adolescent boys seldom use health-care services.
Sexuality and reproductive health. Research on the early sexual activity of
adolescent males suggests that patterns of viewing women as sexual objects, viewing sex as performance-oriented and using pressure or force to obtain sex begin in
adolescence and may continue into adulthood. This provides a strong argument for working with young men as they form attitudes towards women and develop ways of interacting in intimate relationships.
Alcohol and other substance use often accompany the early sexual experiences of young men and increase the risk of STI, HIV infections and unwanted pregnancy. Boys also frequently pretend to be sexually experienced and to be very knowledgeable about the reproductive process. This attitude frequently masks the fact that boys may actually lack information on their bodies, their sexuality and reproductive health. While condom use is increasing among adolescent boys, young men too often delegate sexual and reproductive health concerns to women, including responsibility for condom and contraceptive use.
Adolescent boys’ sexual health problems may be more widespread than commonly thought. For example, the number of young men contracting chlamydial urethritis, which displays no symptoms in up to 80 percent of cases, is increasing. Frequently, sexually transmitted infections are being ignored. In other cases, boys rely on home remedies or self-treatment, increasing the risk of HIV infection.
Finally, while there is much less research on the sexual experiences of homosexual adolescent males, recent findings provide some insights on the challenges they can face. Some of the same issues raised above are involved in male-to-male sexual activity, whether or not the boy sees himself as homosexual, bisexual or heterosexual.
Mental health. Young men also have unmet mental health needs, but frequently do not seek mental health services, nor do they discuss their concerns with others during times of stress. In parts of the world, boys cannot take advantage of traditional systems of care used during times of stress and trauma because work often separates them from these extended family and kinship networks. Three times as many men as women commit suicide worldwide, although up to three times more women than men may attempt it.
Violence, physical abuse, sexual abuse and dating/courtship violence. Injuries from violence (followed closely or led by accidents in some regions) are among the chief causes of death and ill health for adolescent males. Reports from many countries
confirm the increase in the number of boys committing acts of violence.
Despite violence and aggression being associated with males, there has been only limited research that seeks to understand which aspects of masculinity are associated with violent behaviour. While there may be some evidence for a biological and
temperamental link to aggressive and risk-taking behaviour, the majority of male violent behaviour is explained by environmental factors during childhood and adolescence.
some cultural settings. It can be a way of maintaining status in the male peer group and of preventing violence against oneself.
Adolescent males are usually studied as perpetrators rather than as victims of violence.
However, increasing attention is being paid to their victimization. Because they spend more time outside the home in most cultures, boys are more likely to be exposed to or to witness physical violence outside the home. There is also growing concern about the psychological impact of exposure to violence, particularly in countries where boys have been involved as combatants in civil wars. Young (and older) homosexual men are frequently the target of violence, at times leading to death.
Limited research on dating or courtship violence finds that males report being
perpetrators, and sometimes victims, of such violence. There is also evidence of boys being physically or sexually abused in early childhood and later having difficulty talking about the abuse. Higher percentages of boys report physical abuse while higher
percentages of girls report sexual abuse. Boys sometimes have more difficulty than girls expressing victimization and finding persons in whom to confide about abuse; especially so when they are the victim of sexual or sexuality-related violence.
Substance use. In many parts of the world, boys are more likely than girls to smoke, drink and use drugs. Substance use, particularly alcohol use, is frequently part of a wide range of risky behaviours by young males, including violence, involvement in dangerous situations leading to traffic accidents, and unprotected sexual activity.
Use of existing health services. Young men in many regions often resort to self- medication or ignore their health needs all together. There are reports that boys often want many of the same things in health services as young women: high quality service at an accessible price, privacy, staff who are open to their needs, confidentiality, the opportunity to ask questions, and a short waiting time. Young men, however, sometimes encounter hostile attitudes in clinics, or they view mother and child health clinics and family planning centres as “female” spaces. Some even report being turned away from clinics.
Adolescent fatherhood. Adolescent fathers, like adolescent mothers, may face social pressures to drop out of school to support their children and are less likely to complete secondary school than their non-parenting peers. Other young men may deny
responsibility and paternity, in large part because of the financial burden associated with caring for a child. Programme experiences with adolescent fathers suggest that when given special support, young fathers generally want to and benefit from being involved with their children.
LESSONS LEARNED WORKING WITH BOYS
The World Health Organization convened a workshop on “Working with Adolescent Boys” in Geneva on 17-19 May 1999. Participants discussed and debated background papers summarizing the literature and a brief survey of over 70 programmes worldwide involved in the promotion of health among adolescent males. A number of key findings, lessons learned as well as challenges and research topics were identified:
• Educational campaigns and group work can help to raise boys’ awareness about gender discrimination and disadvantage of girls and women. Some governmental
health, while others work to prevent violence against adolescent women. A few NGOs work with young men to discuss their potential role as fathers and seek to promote greater balance and sharing of responsibility in childcare arrangements.
• In some countries, educational campaigns, aimed largely at groups of young men, seek to target the issue of violence, including courtship violence. Activities have taken place with military recruits, in sports locker rooms or in schools. The goal is to improve men’s awareness and/or to create positive peer pressure so that young men themselves convince their peers that violent behaviour is unacceptable.
However, much more needs to be known about the social settings in which young men’s violence occurs, and about young men’s views on such violence.
• Boys are more likely to use existing health services when such services are made attractive to them. Some programmes report that having male staff to work with young men is important, while others report that the sex of the staff is not important if they are sensitive to boys’ needs. Some clinics have used sports activities and peer outreach workers to invite boys into existing health facilities.
• The choice of language used by staff is important. Non-sexist and non-
discriminatory language can influence boys positively by setting an example and helping to reduce the sense of shame and isolation often felt by boys who differ due to sexual, religious or cultural differences. It also provides messages about how young women can be viewed in non-sexist ways.
• Boys, like girls, prefer services that take into account their full range of interests and needs, such as the need for vocational training or responses to community violence.
Sport and leisure activities can be used for various educational and health promotion interventions.
• Programmes that imply that boys need to conform to a certain social mould or to be controlled or coerced are not well accepted. Greater success is achieved with programmes that reach boys in more open and less threatening ways, reducing the potential reinforcement of negative images of boys and young men.
• Boys often request or appreciate having the chance to discuss their concerns in boy-only groups, but most programmes also find it important to have boys and girls subsequently discuss their concerns together. Boys generally report a lack of spaces where they can discuss – in a non-judgmental manner – questions about masculinity, personal problems or health-related matters.
• In parts of the world where households are headed by females, boys often report the importance of interacting with positive male role models such as teachers, older male family members, health educators, youth workers or peer promoters who are non-sexist and non-violent.
• Exposure to adult male role models (i.e. fathers or other significant male adults) who are caring, flexible and involved in child rearing, helps boys grow up to be caring partners and to be more involved fathers.
•
• Boys and young men can make positive contributions in many settings and contexts – as caring partners during pregnancy and child rearing, and as peer educators and role models in health promotion and violence prevention activities.
CHALLENGES FOR THE FUTURE
The following activities were identified as important steps to overcome the many challenges to putting adolescent boys on the health and development agenda.
Advocacy
An advocacy kit should be prepared, which should include facts about the health status of adolescent boys and key arguments that can be used to convince UN agencies, international and national NGOs, Ministries and Departments of Health, Education, Youth Affairs, Juvenile Justice, and other relevant parties of the importance of working with adolescent boys. The kit should also highlight positive examples of the health and development of adolescent boys.
Data gathering, analysis, monitoring and evaluation
Existing data sets should be re-analysed, and the breakdown of data (e.g. by age and social context) relevant to the health of adolescent boys should be promoted. Modules on adolescent boys should be included in routine and specific surveys.
Further research
Areas warranting particular attention are:
• Health status and behaviours: developing a more comprehensive picture of the health and developmental status of adolescent boys.
• Care of mental health conditions in boys, especially for conditions that may be more frequent in late adolescence (e.g. schizophrenia and bipolar disorder).
• Biological factors: the identification of the role of biological influences on the development and behaviours of adolescent boys.
• Health service utilization: the analysis of whether boys are drawn to, or unwilling to use,
• particular health services for reasons that are similar to or different from those of girls. This would include looking at location, type of service, mode(s) of service delivery, characteristics of service providers, and the identification of subpopulations who use health services.
• Socialization and identity formation: the identification of factors and circumstances associated with the development of boys who are gender-sensitive and responsible.
This would include listening to the “voices of boys” – an exploration of how boys from diverse cultures and settings interpret such concepts as power, gender, equity, masculinity, sexuality, roles and responsibility.
• Resilience: to date there has been an emphasis on identifying how an adverse background can cause adolescents to underachieve or, in worst-case scenarios, lead them into violence and crime. Much more research is needed, however, to
impoverished, neglected, violent or abusive – have overcome these challenges and developed into successful, responsible men and women.
• Violence, conflict resolution and the role of masculinity: documenting effective strategies for conflict resolution; analysing the relationship between violent/sexist behaviour and the way in which boys are raised; and the identification of the effects of new and traditional media in boys’ lives.
• Adolescent boys as fathers: studies examining the identity shift from “boy” to
“father”; the identification of effective strategies for involving adolescent fathers and fathers-to-be in programmes designed to inform and support them in family planning and raising children; looking at ways to sustain this involvement, and to maintain responsible and considerate behaviour in the community.
• Employment, vocational training and unemployment: documenting effective ways to improve economic opportunities for boys and exploring how unemployment or underemployment can be managed.
• Ways of attracting males to work in the field of adolescent (and child) health.
Technology transfer and dissemination
• The development of a tool kit that would include the principles of “good practice”, case descriptions to enable replication and adaptation, and a training guide on working with adolescent boys.
• The identification of an effective central/global clearing house for information dissemination.
• The development of a learning network which, in association with the clearing house, could facilitate knowledge and a transfer of useful experience among those working in this field.
SURVEY METHODOLOGY
The methodology used for the European contribution to the global series consisted of a combination of literature review and questionnaire survey. The Health Behaviour in School Children longitudinal survey conducted by the WHO Regional Office for Europe in cooperation with a network of researchers from Eastern and Western Europe
provides a wealth of data on health and health behaviour of boys and girls of school age. Extracts from this survey are therefore included to give the reader an
‘epidemiological’ introduction to issues of regional concern for boys in this age group.
The second section reflects experiences of programmes addressing boys’ health through various approaches.
Programmes are illustrated that reflect concerted efforts to address the health, development and well-being of boys, mainly in the areas of sexual and reproductive health, but also more comprehensive programmes addressing needs for general counselling. Each programme has the potential to contribute to the future design of programmes which are sensitive to the unique needs of boys in the WHO European Region.
SUMMARY AND CONCLUSIONS
The projects and information presented in this document highlight the viewpoints and means of establishing interventions aimed at boys. Some major themes have emerged from the analysis of projects in the European Region as well as from the findings of similar surveys in other Regions of the world.
Major themes concerning working with boys
• Boys are more likely to use existing health services when such services are made attractive to them. Some programmes report that having male staff to work with young men is important, while others report that the sex of the staff is not important if they are sensitive to boys’ needs. Some clinics have used sports activities and peer outreach workers to invite boys into existing health facilities.
• The use of inclusive, non-sexist and non-discriminatory language by staff provides a model for boys and helps to reduce the stigmatisation and marginalization of boys who differ due to sexuality, religious or cultural
differences. It also provides messages about how young women can be viewed in non-sexist and empowering ways.
• Boys, like girls, prefer integrated services that take into account their full range of interests and needs, such as the need for vocational training or responses to community violence. Sport and leisure activities can be used for various educational and health promotion interventions.
• Programmes which do not emphasise conformity, the “control” of boys or coercion to eliminate troubling behaviour appear to reach boys in a more open and less threatening way, and lessen the potential reinforcement of negative images of boys and young men.
• Boys often request or appreciate having the chance to discuss their concerns in boy-only groups, but most programmes also find it important to have boys and girls subsequently discuss their concerns together. Boys generally report a lack of spaces where they can discuss—in a non-judgmental manner—questions about masculinity, personal problems or health-related matters.
• In parts of the world where households are headed by females, boys often report the importance of interacting with pro-social and gender-equitable male role models such as teachers, older male family members, health educators, youth workers or peer promoters.
• Exposure to adult male role models (i.e. fathers or other significant male adults) who are caring, flexible and involved in child rearing, helps boys grow up to be caring partners and to be more involved fathers, if they have children.
• Similarly, programmes on violence prevention find it is important to expose
adolescent boys to non-violent ways of expressing emotions, including frustration and anger.
• Boys and young men can make positive contributions in many settings and contexts—as caring partners during pregnancy and child rearing, and as peer educators and role models in health promotion and violence prevention activities.
Gender as a central concept
Gender is an underlying theme for all the projects and viewpoints presented. As boys mature from childhood to adulthood through adolescence, they must fulfil their “rights- of-passage” -an anthropological term defining societies process of accepting boys as men. Boys often believe, and society usually asks, that boys prove themselves to their peers, family, and community as individuals worthy of being called an adult. This
process of maturing into a man entails making independent decision, or, in some cases, taking risks, to prove one’s maturity. Getting a job, starting a family, marriage, or sex are some rights-of-passage milestones. Problems emerge when young men interpret masculinity as a justification for taking unnecessary risks or exposing others (girls and women) to risks while seeking adult confirmation.
Redefining masculinity as a tool for a transition to a healthy male adulthood is a central theme of boys health and development interventions.
New perspectives on masculinity suggest that it is not a monolithic structure that has one definition. Low-income men, young men, men outside the traditional power structure, men who hold alternative views, homosexual and bisexual men, and other specific groups of men are at times subject to discrimination. Working with these varying social definitions of masculinity is essential to defining the best means to assist boys in making a healthy transition from childhood to adulthood.
Challenges for the future
The World Health Organization convened a workshop on “Working with Adolescent Boys” in Geneva on 17-19 May, 1999. Participants discussed and debated background papers summarising the literature and a brief survey of over 70 programmes world-wide identified as having some involvement in the promotion of health among adolescent males. This publication is one outcome of that meeting. The following additional
activities were identified as important steps to overcome the many challenges to putting adolescent boys on the health and development agenda.
Advocacy
An advocacy kit which should include facts about the health status of adolescent boys and key arguments that can be used to convince UN agencies, international and
national NGOs, Ministries and Departments of Health, Education, Youth Affairs,
Juvenile Justice, and other relevant parties of the importance of working with adolescent boys. The kit should also highlight positive examples of the health and development of adolescent boys.
Data gathering, analysis, monitoring and evaluation
Existing data sets should be re-analysed, and the desegregation of data relevant to the health of adolescent boys should be promoted. Modules on adolescent boys should be included in routine and specific surveys.
Further research
Funding should be directed toward research to better understand the situation of adolescent boys, to improve the efficacy of existing programmes and to identify new strategies. Areas warranting particular attention are:
• Health status and behaviours: developing a more comprehensive picture of the health and developmental status of adolescent boys.
• Mental health: strategies for earlier identification, assessment, treatment and care, especially for conditions that may have greater incidence and prevalence among late adolescent males (e.g. schizophrenia and bipolar disorder).
• Biological factors: the identification of the role of biological influences on the development and behaviours of adolescent boys.
• Health service utilisation: the identification of what is common and what is different in promoting participation in health services by boys and girls. This would include:
location, service composition, mode(s) of service delivery, qualities of service providers, the identification of sub-populations who use health services.
• Socialisation and identity formation: the identification of practices and processes associated with the development of boys who are gender-sensitive and responsible.
This would include listening to the “voices of boys”—a qualitative exploration of how boys from diverse cultures and settings interpret such things as power, gender, equity, masculinity, sexuality, roles and responsibility.
• Resilience: identifying common and different factors associated with successful outcomes for boys and girls coming from adverse environments.
• Violence, conflict resolution and the role of masculinity: documentation of effective strategies that reduce violence as a means of conflict resolution among boys; a qualitative exploration of the relationships between constructions of masculinity, the enactment of gender relations and violence against women and other men; and the identification of the effects of new and traditional media in the lives of boys.
• Adolescent boys as fathers: qualitative studies examining the identity shift from “boy”
to “‘father”; and the identification of effective strategies for engaging adolescent fathers in interventions, sustaining involvement and maintaining behaviour change.
• Employment vocational training and unemployment: documenting effective ways to improve economic opportunities for boys and exploring how unemployment or underemployment can be managed.
• Ways of attracting males to the field of adolescent (and child) health.
Technology transfer and dissemination
• The development of a tool kit that would include a “good practice” guide, case descriptions to enable replication and adaptation, checklists and a training guide on working with adolescent boys.
• The identification of an effective clearing house for information dissemination.
• The development of a learning network which, in association with the clearing house, could facilitate knowledge and experience transfer.
Conclusion
Making a case for increasing attention to the health, development and wellbeing of adolescent boys and young men is necessary and timely. Increasing the attention to boys is a matter of gender equity and benefits accrue not only to adolescent boys and young men, but also to adolescent girls, women, children, men and communities.
EUROPEAN DATA ON THE HEALTH OF BOYS
This section will illuminate the specific epidemiological data that re-enforces the expressed need to focus health and development interventions on boys. The data presented here are taken from various European surveys.
Adolescent boys face significant problems and risks related to their healthy
development. Around the world, boys suffer high rates of morbidities related to road traffic accidents, violence and suicide. In most parts of the world, adolescent boys have higher rates of tobacco, alcohol and illicit drug use than do adolescent girls. Often rates of STIs and RTIs are lower among boys, but boys attend health care facilities much less often than girls. These discrepancies in morbidity and mortality among boys and girls are apparent in Europe, and the Former Soviet Union.
Morbidity and Mortality
In most of the world, adolescent boys have a higher risk of dying than their female counterparts—in some places several times higher. The following graph shows that the number of Disability Adjusted Life Years (DALYs) lost, a measure that combines burden due to mortality and disability due to diseases, is higher for boys than for girls.
In all European countries, more boys than girls in the age group 5–14 years old died (See Figure 1). The mortality rates vary considerably between the different countries. In the Russian Federation, nearly 70 per 100 000 boys in this age group die every year, compared with 13 per 100 000 boys in Sweden. The difference is not quite so marked in girls. The biggest difference can be seen in Estonia, where the mortality rate among boys is three times higher than that in girls. The smallest difference is seen in Norway (around 16 girls compared to 18 boys out of a population of 100 000).
Sex differences in DALYs
in adolescents (10-19 yrs)
0 50 100 150 200 250 300
EME CHI FSE LA C
MEC OAI IN
D SSA World
per 1000 population
Male Femal
Figure 1. Age-sex-specific death rates (age 5–14) per 100 000 population
17
26.3 25.2
19.7 18.6 17.9 64.4
20 21.1
17 21.3 29
18.9 23.3 56.3
41
24.4 18.2
28.4
18.1 29.4
22.4 13.1 68.8
9 18.5 16.6 13.3 39.4
16.1 16.9 20.2 28.2 39.1
12.8 16.7 19.1 13.6 14
11.7 15 22.9 13.3 12.6
16.4 21.5 12 14.6
0 10 20 30 40 50 60 70 80
Austria Belgium Czech Republic Canada Denmark England and Wales Estonia Finland France Germany Greece Hungary Israel Italy Latvia Lithuania Northern Ireland Norway Poland Russian Federation Scotland Slovakia Spain Sweden
Boys Girls
Source: WHO (1998a).
In the age group 15–24 years, age-sex-specific death rates reveal a great disparity between girls and boys (See Figure 2). In various (mainly eastern European) countries, death rates for boys are nearly four times higher than those for girls.
Figure 2. Age-sex-specific death rates (age 15–24) per 100 000 population
116.3
102.1 98.2 92.8 74.2 73
234.1
93.3 102.1 88.9 97.8
88.8 79.7 90.1 239.1
195.3
103.4 72.5
111.4 100.2
91.7 87.3 55
29.4 39.7 36.6 32.8 29.5 27.9 63.9
26.2 34.8 34.1 27.7 33.7 29.9 29 69.2
52.6
30.4 30.1 34.1 94.5
36.3 27.5 28.1 21.8 334
0 50 100 150 200 250 300 350
Austria Belgium Czech Republic Canada Denmark England and Wales Estonia Finland France Germany Greece Hungary Israel Italy Latvia Lithuania Northern Ireland Norway Poland Russian Federation Scotland Slovakia Spain Sweden
Boys Girls
Gender differences are apparent not only when we look at total mortality but also, and above all, when we analyse causes of death. Injuries account for the bulk of deaths, and neoplasms are the second most frequent cause of death.
In Figures 3 and 4, the contributions of causes of mortality are each represented
proportionally by sex. The figures clearly show that mortality is higher among boys than among girls.
Gender analysis suggest examining the relationships between the boys and girls who died. For example, were boys present at the girls death and vice versa?
Figure 3. Age-sex-specific death rates (15-24) for traffic accidents per 100 000 population
47.3 45.8
27.5
14.6 33.2
17.7 49.4
18
39.8 40.3 54.2
30.6 23.5
40.6 68.6
40.3
20.7 20.5 35.4
42.3
19.9 32.4
11.6
10 14.8 10.7 3.7 7.6 4.9 12.6 5.2 11.1 11.7 9.9 8.2 6 8.9 18.6 10.1 7.4 5.4 8.5 13.3 8.2 7.9 4.1
0 10 20 30 40 50 60 70 80
Austria Belgium Canada Czech Republic Denmark England and Wales Estonia Finland France Germany Greece Hungary Israel Italy Latvia Lithuania Northern Ireland Norway Poland Russian Federation Scotland Spain Sweden
Boys Girls
Source: WHO (1998a).
The significance of accidents in terms of mortality has already been pointed out. But mortality data give only a limited picture of health status regarding injuries, in that mortality rates in young age groups are very low.
Apart from two exceptions, the HBSC study shows that in all countries more boys than girls had accidents over a period of one year. Figure 4 shows the proportional incidence of 15-year-old girls and boys reporting a serious accident last year.
Fig. 4. 15-year-old students who reported severe injuries during the previous year (%)
28 20
32 32
22 15
20 37
11 16
22
17 18
32
17 15
13 30
14 13
17 38
24
11
20 23 22
8 11
30
11 13 13
9 13
19
14 12
7 18
9 7 9
23
0 10 20 30 40 50 60
Austria Belgium, Fl. Belgium, Fr Canada Denmark Estonia Finland France* Greenland Hungary Israel Latvia Lithuania Northern Ireland Norway Poland Russian Federation* Scotland Slovakia Spain Sweden Wales
Boys Girls
France and the Russian Federation are represented only by regions.
Source: King et al. (1996).
Apart from injuries, there is also a clear gender-specific difference in the prevalence of suicide. A closer look at suicides shows that, apart from in male adolescents from the Russian Federation, Lithuania and Latvia, the suicide rate is outstandingly high among boys from Finland (See Figure 5).
Figure 5. Age-sex-specific death rates (15-24) due to suicide per 100 000 population
25.8
16.7 24.7
18.4 13.2
9.7 28
36.6
16.1 13.3 19.2
9.8 7.1 37.8
48.6
19.220.8
16.5 19.6
12.6 7.6
13.2 14.4
2 8.4 7.5 3 9.8 2
4.4
53.7
2.3 3.3
3.5 3.5
3.6 1.8
6 4.4 4.2 1.4
3.8 0.8 3.9 6.8 4.3
4.9 4.2
0 10 20 30 40 50 60
Austria Belgium Canada Czech Republic Denmark England and Wales Estonia Finland France Germany Greece Hungary Israel Italy Latvia Lithuania Northern Ireland Norway Poland Russian Federation Scotland Slovakia Spain Sweden
Boys Girls
Source: WHO (1998a).
The gender-specific differences in causes of death determined by behaviour are particularly marked, but there are also typical gender differences in other causes of death. In nearly all European countries, boys more frequently die of malignant
neoplasms, for example. Young people from eastern European countries, in particular,
are affected by malignant neoplasms, a finding which also applies to all other causes of death (See Figure 6). Male adolescents, particularly from Estonia and also from the Russian Federation, Latvia and Hungary, outstandingly often die of cancer. This is also true of boys from Northern Ireland and girls from eastern Europe. The than young
people from all other European countries. As a rule, the northern European countries have lower than average mortality rates (with one exception, suicide rates in Finland). What applies to all countries is that significantly more boys than girls die of all considered causes of death.
Figure 6. Age-sex-specific death rates (15-24) for malignant neoplasms per 100 000 population
4.8 5.6 10.4
7.9 5.9 5.4
4.6 5.3 5.3 6.5
8.9
5.4 7.3
9.3 8.3 10.7
4.6 7.8
9.7
4.6 8.5
6.6 4.6
3.4 4 8.5
6.2
4.7 4.3 4.8
3.2 3.4 3.7 4.2 4.7 5.4 4.3
8.4 6.8
5.7 4.1 4.7
7.5
3.3 5 4.5
2.6 15.9
0 2 4 6 8 10 12 14 16 18
Austria Belgium Canada Czech Republic Denmark England and Wales Estonia Finland France Germany Greece Hungary Israel Italy Latvia Lithuania Northern Ireland Norway Poland Russian Federation Scotland Slovakia Spain Sweden
Boys Girls
Source: WHO (1998a).
Health-Related Behaviours
The health-related behaviours of adolescent boys have direct consequences for their future health as adults. The leading causes of death for men are often related to their socialisation and lifestyles, namely higher rates of tobacco and alcohol use, accidents and injuries, and violence—the kinds of health and social behaviour adopted primarily during adolescence. As a consequence, in most regions of the world, a boy’s life expectancy at birth lags behind a girl’s life expectancy by up to 8 years. This gap is predicted to grow even wider by 2020.
Smoking
Data from the HBSC reveals that more girls than boys smoke in Western Europe as compared to Eastern Europe and the NIS. The only exceptions in Western Europe, where more boys smoke than girls are Belgium, Ireland, Israel, and Portugal (See Figure 7). Researchers have suggested that with gender equality proceeds equality in risk taking.
Figure 7. 15 year old students who report smoking daily (%)
25
20
25 26 24 24
20 24
21 20 23
16 14
21
12 14
17
10 14
11 16
8 7
10
6 22
29
20 20 19
21 19
16 18
21 18
22
15 27
20 17
20
13 16
10
17 17 15
13 19
0 5 10 15 20 25 30 35
Germany Hungary France Austria Scotland England Finalnd Norhern Ireland Norway Belgium Wales Ireland Poland Denmark Latvia Russian Federation Switzerland Slovakia Greece Czech Republic Sweden Estonia Israel Portugal Lithuania
Girls Boys
*France, Germany and Russia are represented by regions.
Source:HBSC 1997/98
Alcohol
However, when looking at alcohol consumption there are no borders. Boys drink more than girls in all countries surveyed (See Figure 8).
Figure 8. 15 year old students who report drinking beer, wine or spirits at least weekly (%)*
36 38 36
31 22 23
20 19 24
16 22
15
12 11 10 12
9 8 10 9 12 11
9 8
53 46 47
52
38 39 33 32
28 32
29 31 27 29
26 28 29
20 21 19
16 17 16 11
0 10 20 30 40 50 60
Wales Denmark England Greece Belgium Austria Northern Ireland Czech Reptublic Russian Federation Slovakia Germany France Ireland Hungary Israel Latvia Portugal Poland Estonia Switzerland Norway Sweden Lithuania Finalnd
Girls Boys
*France, Germany and Russia are represented by regions.
Sexually Transmitted Infections (STIs) and Contraceptive Use
Adolescent and adult men contribute to many of the morbidities that adolescent women face, including RTIs, STDs, pregnancy-related complications, and violence and abuse.
Adolescent boys may lack information on sexual/reproductive health, may not
adequately participate in sexual and reproductive health matters, may lack skills and attitudes promoting negotiation in intimate relationships, may not be actively involved in caring for children they father, and, in some cases, may use violence or coercion
against young women.
Data from UNICEF International Child Development Centre MONEE Programme reveals two trends in STIs. First, in some countries the disparity of the burden of STIs is decreasing, due to a decrease in the rates of STIs among girls and not boys, as seen in Belarus (See figure 9). And secondly, the rates of STIs are increasing for both boys and girls in countries where reproductive and health care services cater to the health needs of girls and women, possibly creating an artificial disparity due to under-reporting of STIs among boys (See figure 10).
Figure 9. Gonorrhoea case rate (per 100,000) among 15-19 year olds, Belarus.
0 100 200 300 400 500 600 700
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Girls Boys
Source: UNICEF ICDC, Country Statistical Reports, 1999.
Figure 10. Syphilis rates (per 100,000) among 10-19 year olds, Turkmenistan.
0 5 10 15 20 25 30 35
1989 1990 1991 1992 1993 1994 1995 1996 1997 Girls
Boys
Source: UNICEF ICDC, Country Statistical Reports, 1999.
Condom use prevalence in the transitional countries is low. As the latest data on contraceptive prevalence reveals, in South Eastern Europe the range of contraceptive prevalence is from 8% in Albania to over 80% in Croatia. However this data includes all forms of contraception, and in some cases, includes rhythm method and abortion. As IUDs are often the most common form of contraception, and condom use is only a proportion of the overall contraceptive prevalence, further studies are needed,
especially among boys, to determine the exact extent of condom use prevalence. (See figure 11).
Figure 11.
Source: WHO EURO, Family Planning and Reproductive Health in the CEE and NIS,2000.
1995 199
7 199
7 1995
1997 199 7
1997 1997
1994
0 10 20 30 40 50 60 70 80 90
Albani a
Bosnia & Herz Bulgaria
Croat ia
Poland Rom
ania Slovak
ia Slovenia
FYROM Contraceptive prevalence rate in %
(Latest available data)
