The Relationship Between Gender Norms and Expectations and the Sexual Practices of Ugandan Men Margaret E. Brawley A thesis submitted in partial fulfillment of the requirements for the degree of Master of Public Health University of Washington 2006 Program Authorized to Offer Degree: Public Health and Community Medicine – Health Services University of Washington Graduate School This is to certify that I have examined this copy of a master’s thesis by Margaret E. Brawley and have found that it is complete and satisfactory in all respects, and that any and all revisions required by the final examining committee have been made. Committee Members: ________________________________________________________________________ Ann Downer ________________________________________________________________________ Hendrika Meischke Date:_________________________________________ In presenting this thesis in partial fulfillment of the requirements for a master’s degree at the University of Washington, I agree that the Library shall make its copies freely available for inspection. I further agree that extensive copying of this thesis is allowable only for scholarly purposes, consistent with “fair use” as prescribed in the U.S. Copyright Law. Any other reproduction for any purposes or by any means shall not be allowed without my written permission. Signature___________________________________________ Date______________________________________________ University of Washington Abstract The Relationship Between Gender Norms and Expectations and the Sexual Practices of Ugandan Men Margaret E. Brawley Chair of Supervisory Committee: Senior Lecturer, Ann Downer, EdD, MS Department of Health Services Men are critical to improving the health of a family in Africa, but their role is often ignored. A better understanding of men’s beliefs, attitudes and practices about health is required in order to effectively direct such efforts. However, these elements are significantly impacted by beliefs about manhood and enactments of masculinity and a consideration of the link between gender identity and specific health practices is pivotal. This paper presents the findings from focus group discussions with Ugandan men regarding how they define what it means to be a man, their common sexual practices, and their views on the role of women. Results show that manhood was framed into 10 general categories: provider, employment/income, ownership, meeting cultural norms, characteristics/age, moral values, caring figure, leadership, sexual activity and power/control. In addition, the data show a strong connection between beliefs about manhood and multiple sexual partners and faithfulness. Although a mix of masculine and un-masculine beliefs supports the act of faithfulness, the behavior of having multiple partners is a compelling representation of manhood. Condom use or lack of condom use was also associated with a mix of masculine and un-masculine beliefs. This lack of decisive sentiment toward manhood in either case may be a reason why condom use is variable. TABLE OF CONTENTS List of Figures ..................................................................................................................... ii List of Tables ..................................................................................................................... iii Chapter 1: Introduction ....................................................................................................... 1 Gender ............................................................................................................................. 1 Male Gender Identity ...................................................................................................... 2 Male Sexual Practices ..................................................................................................... 3 The Woman’s Role ......................................................................................................... 5 Chapter 2: Overview of Study ............................................................................................ 7 Purpose............................................................................................................................ 7 Conceptualization ........................................................................................................... 7 The Research Question ................................................................................................... 9 Theoretical Context......................................................................................................... 9 Chapter 3: Methodology ................................................................................................... 11 Research Location ......................................................................................................... 11 Sampling & Recruitment Strategy ................................................................................ 11 Research Team .............................................................................................................. 12 Demographics ............................................................................................................... 14 Coding & Analysis ........................................................................................................ 14 Chapter 4: Findings & Discussion .................................................................................... 16 Description of Findings................................................................................................. 16 Definition of Masculinity & What It Means to Be a Man in a Ugandan Context .... 16 What Are Common Male Sexual Practices? ............................................................. 24 What is the Role of Ugandan Women According to Ugandan Men? ....................... 29 Discussion ..................................................................................................................... 32 The Relationship Between the Gender Norms & Expectations of Ugandan Men and Their Sexual Practices ........................................................................................................ 32 Study Limitations ...................................................................................................... 42 Future Implications ................................................................................................... 43 Bibliography ..................................................................................................................... 45 Appendix 1: Focus Group Discussion Guide.................................................................... 49 i List of Figures Figure 2.1: Conceptual Framework…………………………………… 8 Figure 4.1: Theoretical Framework…………………………………… 34 Figure 4.2: Link Between Masculinities & Multiple Partners………... 36 Figure 4.3: Link Between Masculinities & Faithfulness……………… 38 Figure 4.4: Link Between Masculinities & Condom Use…………….. 40 Figure 4.5: Link Between Masculinities & Not Using A Condom…… 41 ii List of Tables Table 3.1: Sampling Framework……………………………………… 13 Table 3.2a: Marital Status ……………………………………………. 14 Table 3.2b: Number of Children………………………………….….. 14 Table 3.2c: Education Level…..………………………………….….. 14 Table 3.2d: Type of Employment……………………………….……. 14 iii Acknowledgements I would like to acknowledge the YEAH (Young, Empowered and Healthy) Campaign in Kampala, Uganda for providing me with the opportunity to conduct this fascinating research; specific thanks go to Cheryl Lettenmaier and Anne Gamurorwa. My sincere appreciation also goes out to the men and women of the research teams whose efforts and assistance allowed this research to be conducted. Finally, thank you to the Ugandan men who openly contributed their views and opinions. iv 1 Chapter 1: Introduction The gender dynamic is often overlooked by mainstream public health initiatives. Only in recent years has the recognition of gender norms and expectations in a cultural context begun to play a more valuable role in health program development, communication and HIV/AIDS in Africa. Still, much of the focus has centered on the position of women and strategies for enhancing their empowerment. Despite the fact that many Sub-Saharan African countries remain patriarchal societies and that men continue to maintain an autonomous place of power and decision-making within a given family, the possible influence of men in health initiatives continues to be largely ignored. In order to significantly impact future health interventions, it is imperative that we begin to explore the role of men in creating change for healthy behavior. An in-depth examination should ascertain men’s beliefs, attitudes and practices regarding health, as well as how these elements are enacted within a given family, community or society. Despite some initiative towards increased integration of gender and health dynamics, there is still a large gap in research aimed specifically at examining the relationship between manhood and male sexual practices. Gender The literature around gender is immense and highly complex. Biological sex is defined as the chromosomal, chemical or anatomical differences that make someone either a male or a female (Kimmel, 2004). Gender is the manifestation of social, economic, political and cultural elements, meanings or structures that are associated with being either male or female. The construction of social identity is dependent on contextual and situational changes over time (Campbell, 1997; Eckman, Huntly, Bhuyan, 2004). Although definitions of gender vary enormously (WHO, 1999; Eckman, Huntly, Bhuyan, 2004; Kimmel, 2004), they are nonetheless instrumental to our life long development. At an incredibly early age, gender enables us to develop a concept of self, and this remains a lens through which we continually filter and analyze our life experiences (Deaux & Major, 2004). This evolution continually shapes who we are and how we make decisions, as well as permitting us a perspective of the world and the 2 ability to adopt a personal sense of responsibility within that framework (WHO, 1999). Ultimately, gender identity forms a foundation for how we connect with our environment including physical and psychological development, family interactions, health, culture, education, socio-economic status and even sexual behavior, etc. (Barker, 2005). Male Gender Identity Manhood is the promulgation of beliefs that men imagine are the cornerstone of who they are. However, it is not an inherent, biological manifestation. Rather, manhood is socially constructed over time with affect from a wider historical cultural context (O’Brien, 2005). Men often wrestle with the numerous variations of manhood and their conflicting intricacies, while at the same time, requiring constant validation (Barker, 2005; Hearn & Morgan, 1990). Male gender is built around two central ideologies. “First, being a man is natural, healthy and innate; second, a man must stay masculine; he should never let his masculinity falter” (Silberschmidt, 2001, p. 667). Masculinity is defined as the enactment of a man’s belief about manhood and there is far from just one. In fact, masculinities often compete with each other – some appear dominant, while others are marginalized or stigmatized (Kimmel, 2004; Hearn & Morgan, 1990). Robert Brannon proposed that normative or hegemonic masculinity, i.e. white, middle-class and heterosexual, has four key rules: 1) Don’t be a Sissy: avoid and disparage the appearance of feminity; (b) Be the Big Wheel: maintain success and status; (c) Be a Sturdy Oak: Demonstrate toughness, independence and dependability with emotional distance; (d) Give’em hell: be aggressive and take risks (Hearn & Morgan, 1990; Jack, 2005). Although narrow in scope, he suggests that this is the defined masculinity against which all other masculinities are compared. In an African context, manhood is shaped by cultural histories, religion, interactions and power relations with other men, education, urban or rural environments, western influences and global media (Barker, 2005; UNFPA, 2000. Chapter 5). Typically, manhood might be symbolized by realizing financial independence, gaining employment or generating income and starting a family. Men’s lives are generally believed to revolve around the sphere of production, as women’s revolve around domesticity. Intertwined with the standard concept of man as an economic provider, is that of a “macho sexuality” 3 (Campbell, 1997). When the economic status of a man is threatened or no longer exists, than proof of his masculine identity often rests upon sexual virility, which includes insatiable sexuality, the need for multiple sexual partners and desire for pleasure. Sexuality becomes an important alternative to the creating of a masculine identity (UNFPA, 2000. Chapter; Campbell, 1997). Gender dynamics aside, new research demonstrates that manhood is fraught with negative implications for men and this alone is ample justification for increasing the focus on the health and well being of boys and men (WHO, 1999). Young men face high health risks, especially evidenced by their higher risk of dying prematurely than girls, from violent acts, suicide, accidents and drugs or alcohol abuse. The health behaviors learned and adopted in adolescence often play a pivotal role in causes of death for men later in life. The health of boys is directly correlated with the health of girls. The relationships between men and women involve intricacies of pregnancy, sexually transmitted diseases, reproductive health, violence and abuse. Finally, ignoring the role of boys and men in HIV/ AIDS and other health related practices will be detrimental to the future development of a country and will have tremendous impact on vital resources (WHO, n.d.). Under the guise of masculinity, men are vulnerable and at risk for illness and early death. The promotion of men’s health requires that we look beyond the façade of gender identity and examine the harmful elements of traditional and cultural beliefs of masculinity (Sabo, 2005). Underneath the possible justified written condemnation of men’s behavior around alcohol abuse, domestic violence and multiple partners, we must ascertain a deeper understanding of men’s roles in households and reproduction given their cultural context (Barker, 2005). Male Sexual Practices Ten million people between the ages of 15 and 24 years have HIV/AIDS in SubSaharan Africa. Seventy five percent of these people are women (UNAIDS, 2004). The statistics from Sub-Saharan Africa, suggest that between 20-80% of men have ever used a condom, however less than 40% used a condom the last time they had sex (Barker, 2005). According to the Uganda Demographic and Health Survey (2001), overall use of condoms by men is a low 15% of those surveyed (p. 187). Research shows that men also 4 tend to utilize condoms as an indicator of how serious a relationship is versus as a means of protection (Barker, 2005) and there is a visible discrepancy in regular condom use reported by Ugandan men dependent on if the partner was cohabiting - 3.9% or noncohabiting – 58.9% (UDHS, 2001, p. 189). These statistics suggest that we need to take a closer look at the relationship between manhood and sexual activity. Twelve percent of married men described having one or more partners other than their spouse or cohabiting partner in the previous year (p. 184) and eleven percent of unmarried men reported being more likely to have had multiple partners. The practice in both married and unmarried men was found to be more common in younger men (ages 15-30) and those living in urban areas (p. 185). Similar to gender, sexuality is also socially constructed. “The meanings and behaviors are constructed from images, values and prescriptions in the world around us. Such constructions are as much coerced as they are voluntary” (Hearn & Morgan, 1990, p. 97). Sexuality is continually influenced by dimensions of culture, time, society and the life of an individual (Hearn & Morgan). Research illustrates that sexuality and the ability to function sexually are inherently interwoven with a man’s experience of self, confidence, self-esteem and social value (Hearn & Morgan; Silberschmidt, 2001). Often sexual activity such as multiple partners or sexual control over women serves as compensation for the loss of masculinities in other dimensions such as economic empowerment. As a result, manhood is conceivably threatened by the mere suggestion of sexual deficiencies or problems. Masculinity in relation to sexual practice is squarely predicated on a man’s physical sexual capabilities versus mutual pleasure (Hearn & Morgan, 1990). There is evidence to suggest that a man’s sexual virility may also be compromised when a man is required to use condoms (Campbell, 1997). This is further argument for considering the important social context of masculine identities in public health interventions. Michael Kimmel makes an interesting argument about the enactment of hypermasculine sexuality in gay men, which is parallel to men within the African context. In the late 1960s and early 1970s, the masculinity of gay men suffered tremendous damage. At the time, the very concept of being gay defined these men as “failed men” since 5 having sex with men was akin to behaving like women (Hearn & Morgan, 1990). After the Stonewall riots, a new gay masculinity emerged that elevated some men to a butchlike status, utilizing more visible representations of masculine attributes including clothes, muscular tone, moustache, etc. Gay men began to enact what Kimmel calls a “hyper-masculine sexuality,” defined as plentiful, anonymous sex with little foreplay or attachment (Hearn & Morgan). These exaggerated behaviors of masculinity were “detached, phallaocentric, orgasm-focused, often anonymous, sexually adventurous” (p. 107). With the arrival of HIV/AIDS, safer sex campaigns began to encourage gay men to reduce their number of partners, avoid casual encounters, avoid dangerous sexual practices and use condoms. In short, safer –sex programs encouraged men to stop having sex like men. In a sense the term ‘safe sex’ is an oxymoron: that which is sexy is not safe; that which is safe is not sexy. Sex is about danger, risk, excitement; safety is about softness, security, comfort…If we are to make safer sex into sexy sex we must confront this issue of masculinity, just as we will need to confront the issue of masculinity to help men with sexual problems. (p. 108) This same ideology is applicable to men in Africa and Uganda specifically. Research shows that men engage in multiple partners, believe they must have regular sexual activity to maintain their health, and have a high sex drive that requires satisfaction (Silberschmidt, 2001). Maybe safe sex is simply not sexy enough for men to make a change in their behavior. Until we better understand the impact of masculinities on these various sexual practices, we could be hopelessly dispersing irrelevant and ineffective health messages and education. The Woman’s Role Under a relatively patriarchal realm, the role of women in Africa remains regulated to one of domesticity. Women are charged with taking care of the household and childbearing responsibilities. The woman is also responsible for achieving and maintaining a family’s health, although this is seldom valued. Gender bias and disempowerment have widespread detrimental affects on the health of families, but women are vulnerable to the sexual behavior of men and often lack the ability to change the power dynamic found in these relationships (Barker, 2005). 6 The role of gender norms and expectations has remained relatively unacknowledged in development. Organizations are beginning to realize that the improvement of women’s health is contingent upon male engagement. In 1994, the International Conference on Population and Development (ICPD) developed a mandate which recognized the importance of the men’s role in women’s health, as well as their own (Cohen & Burger, 2000). The mandate sought to “promote gender equality in all spheres of life, including family and community life, and to encourage and enable men to take responsibility for their sexual and reproductive behavior and their social and family roles” (Barker, 2000, p. 1) African women’s responsibilities have increased with the economic disempowerment of men. The resulting impact has been a discernable effect on men’s social value, identity and self-esteem. Consequently, sexual behaviors such as multiple partners and aggressive practices fortify beliefs in manhood. Clearly “strategies to improve sexual and reproductive health must take into account how socioeconomic changes have effected traditional gender roles and male sexual behavior” (Silberschmidt, 2001, p. 657). Altering gender roles is not something that will happen over night, and it often creates stress in an already tense environment. We must be cognizant of the fact that even those in positions to change policy can be hindered by their own gender perceptions and inherent beliefs. The idea of integrating gender needs into program development and research must be more broadly applied in order to help us reduce risky sexual behavior. Instead of identifying men as simply a problem in relation to women’s sexual and reproductive health, we should value their motives and concerns. Investment in future gender research that can be applied to practical interventions is a necessary step on the way to changing future behavior and improving the health of women and children in Africa. 7 Chapter 2: Overview of Study Purpose The government of Uganda is attempting to tackle a multitude of health risks within their borders. Improving the health of women and children is invariably linked to decreasing poverty. A lot of money has been spent on increasing access to services for women and targeted health education campaigns, but less has been directed towards men. This work has often neglected the role men have within a family and the influence they wield in regards to health matters. Men are often the decision makers and maintain control of the family finances. It is critical to consider their position. What are their attitudes, beliefs and knowledge about sex, reproductive health, and gender roles? If we can better understand how and why men behave in certain ways, we will be better equipped to provide services and information that may enable men to engage in more positive behaviors under these circumstances. This qualitative research was designed to learn how men in Uganda define what it means to be a man and to learn how these gender norms, beliefs and expectations impact their personal practices in sexual relationships. We may better serve men and their families in an attempt to improve health by learning more about beliefs in manhood or enactments of masculinities. With this insight we can create strategies, messages and services, as well as utilize appropriate communication mechanisms and community activities to directly communicate with men. We will be better informed to devise methods that integrate men in discussions about the health of their family and the role they play. Conceptualization Development of the research tools and design began under the guise that there are three primary mechanisms integral in defining a man’s masculine identity: 1) the gender norms and expectations of others (e.g. peers, family, friends, leaders); 2) cultural influential mechanisms of gender concepts including religion, historical and economic systems; and 3) the inherent, biological facets of gender. A person’s beliefs about gender 8 roles evolve through a process of socialization where people internalize what is expected of them from society. Many different elements contribute to this socialization including family, culture, education, socio-economic status, religion, ethnicity, media and environment. In turn, these beliefs about gender and the broader cultural dynamic constitute the formation of a man’s ideology about what it means to be masculine or to be a ‘real man’ and often continually reinforce that dogma. Masculine is defined as a characteristic of a man or pertaining to the male sex, but the term masculinity denotes the concept of enacting a man’s beliefs about his manhood. Consequently, the research theorizes that beliefs about manhood can influence man’s sexual practices. Figure 2.1: Conceptual Framework The basis for this conceptualization is routed in information learned during the literature review, as well as the researcher’s personal experience. The research is designed with a humanist approach. As with any study of humanity, there is an element of subjectivity. It is impossible to ascertain the intricacies and mysteries of the human brain with a single method of study. Development of attitudes, reasons for behavior and the retention of knowledge are dynamic mechanisms that interact based on how a person thinks, makes decisions and understands his/her environment. The levels of conscious and unconscious reasoning and awareness alone create complicated psychological layers. Understanding this process or gaining some insight into the larger picture requires 9 multiple study approaches. Undeniably, it is impossible to escape the use of one’s own feeling, values and beliefs in order to understand the nature of human experience. This research used an inductive approach to better understand how beliefs that define gender impact sexual practices. The focus group questions were designed in keeping with the conceptualized idea of learning more about how beliefs in manhood are formed, what sexual practices men engage in, and, consequently, linking how enacting masculinity may influence these male sexual practices. The questions were created to capture broad, general information about these concepts without influencing the participants’ ideology or beliefs, so as to leave the data open for interpretation. The Research Question The main research question asks how do Ugandan men articulate their role as men and their attitudes, beliefs and practices towards sexual relationships? Specifically, the research aims are: How do Ugandan men define what it means to be a man or masculinity? What are common sexual practices of men? What do Ugandan men think about Ugandan women and their role in this society? How do beliefs in manhood influence men’s behaviors and practices in regards to sexual relationships? Theoretical Context The theoretical framework for this qualitative research is grounded theory. As defined by Strauss and Corbin, grounded theory is “theory that was derived from data, systematically gathered and analyzed through the research process. In this method, data collection, analysis, and eventual theory stand in close relationship to one another” (Strauss & Corbin, 1998, p. 12). The central feature of grounded theory allows a theory to rise from the data and speak its own truth, versus a truth that is heavily pre-conceived by the researcher. In a way, the process is similar to that of putting together a puzzle where an exact final picture is unavailable or unknown. One might have an idea of how the final product should look based on a description on the box or conceptions and knowledge of the world, but, inevitably, the picture is created with the integration of individual puzzle pieces. A 10 researcher examines the information collected, conceptualizes reoccurring ideas, organizes the various dimensions of the information and continually makes comparisons and asks questions. This interactive process between the researcher and the data allows a continuum of information extraction and analysis of the raw data. Data for grounded theory is processed utilizing open, axial and selective coding in order to conceptualize categories, as well as the properties and dimensions within those categories and, ultimately, integrating the categories into a theoretical framework. Open coding is a method of classification. Collected data is reviewed line-by-line for reoccurring ideas or concepts, which can be codified. These codes are representations of the story the data was trying to tell. Over time, many of these concepts are grouped together as characterizations or dimensions of a larger theme. Often these sub-elements help to explain the events by answering when, where, why, who, how and what consequences result (Strauss & Corbin, 1998). This process of linking broad categories with properties and dimensions is called axial coding. At this point the researcher examines how these various concepts relate to one another in the given situation. While immersed in the data, the researcher must maintain objectivity and sensitivity. Eventually, a level of theoretical saturation can be obtained and no new information emerges from the data. Subsequently, the researcher utilizes selective coding as a process of integrating the themes and categories into a possible theory. A theory explains phenomena via the relationships of categories, themes or concepts (Strauss & Corbin, 1998). Strauss and Corbin (1998, p. 12) suggest that “theory derived from data is more likely to resemble the “reality” than is theory derived by putting together a series of concepts based on experience or solely through speculation...Grounded theories are likely to offer insight, enhance understanding, and provide a meaningful guide to action.” 11 Chapter 3: Methodology Research Location The research was conducted in five distinct regions of Uganda under the auspices of the Young, Empowered and Healthy (Y.E.A.H.) Campaign. The Y.E.A.H. Campaign began in 2004 to address the growing need to improve health and social practices among young people in Uganda. It is a multi-channel communication campaign that combines mass media, person-to-person and community interactions to stimulate dialogue and action among communities, families, schools and health institutions and model positive practices. One of its nationwide campaigns will address gender inequities, targeting Ugandan men. This qualitative research provided baseline information needed to build the communication strategy for the intervention. Uganda is a developing country located in Eastern Africa. Its population consists of approximately 26 million people (Index Mundi, 2004). Most of the population lives in rural areas with limited access to clean water and health care. Thanks to the recent advent of Universal Primary Education, the first four children of any family are permitted free primary education. Thus a great majority of girls and boys (87-89%) attend primary school. The same cannot be said of secondary school (Ministry of Gender & Sports, 2003/4). Literacy rates in the country range from 60 % for women to 70% for men (Index Mundi, 2004). The country is an amalgamation of more than 40 different tribes and languages, although the government typically utilizes eight primary languages. In order to capture a range of responses from different ethnic groups in the country, the research was conducted in five areas with a mix of rural and urban locations. Sampling & Recruitment Strategy For the purpose of this paper, 10 focus group discussions (FGDs) with men were utilized for analysis about masculinity and the relationship to sexual relationships. Each focus group contained between 10 and 12 people. A stratified purposeful sampling framework was designed too collect input from different ethnic groups in the country in five regions in which to conduct focus groups: Southwest (Mbarara District), West (Kabarole District), North (Gulu District), East (Soroti District) and Central (Luwero 12 District). These regions were illustrative of five distinct ethnic groups, cultures, languages and various socioeconomic situations (rural vs. urban). In addition, the focus groups were stratified by gender and age groups of 18-24 years and 25-35 years to ensure a level of comfort within the participants, as well as allow the opportunity to view any notable differences in responses for these groups. The choice of participants was theoretically driven and the sample was not a measure of representative ness within the country. The research findings are not meant to be “generalizable” to the rest of the population, but rather a method of informing the audience about what some men believe to be true in regards to this subject matter. The focus group participants were recruited with the assistance of community-based organizations (CBOs) in each locale including the Kabarole Research Center, AMREF (2 regional offices), ACORD and Save the Children Foundation. The CBO managed the mobilization for that region and in conjunction with the researcher, discussed the most feasible methods for recruitment in that area. Mobilizers of the CBO were asked to recruit according to the age and gender guidelines from a large segment of the population in that community and not involve people from their own programs. Mobilizers recruited from schools, churches, health centers, community venues, local neighborhoods, businesses, etc. Recruitment was done via one-on-one interaction with the mobilizer and word of mouth. Interpersonal communication is a standard method for mobilization in this developing country. Pure economics prevents the use of advertising in newspapers and utilizing telephones, since most people will not have the financial capability to answer an ad or return a telephone call. Poor roads (or no roads) make movement difficult. The best dynamic for mobilization was to work with a person familiar with the community and its people. Mobilizers were paid a transport fee and per diem to allow them to recruit effectively and participants were given a minimal transport reimbursement, soda and snack on the day of the event. Research Team The focus groups were conducted by a team of research assistants fluent in the appropriate languages and matching the respective ethnic groups in the area when possible. The research assistants were identified from a pool of experienced individuals 13 with assistance of the project staff and the principal investigator (PI). Two male research assistants facilitated the male focus groups. One person was responsible for leading the discussion, while the other took notes and tape-recorded the session. Table 3.1: Sampling Framework Region CENTRAL SOUTH WEST EAST NORTH WEST TOTAL District/ Locale Luwero Luwero Mbarara Mbarara Soroti Soroti Gulu Gulu Kabarole Kabarole Rural/ Urban Urban Urban Urban Urban Rural Rural Rural Rural Rural Rural Language Luganda Luganda Runyankole Runyankole Ateso Ateso Luo Luo Rutooro Rutooro Male Groups 18-24 yrs = 12 pple 25-35 yrs = 12 pple 18-24 yrs = 10 pple 25-35 yrs = 11 pple 18-24 yrs = 12 pple 25-35 yrs = 12 pple 18–24 yrs = 10 pple 25–35 yrs = 11 pple 18-24 yrs = 11 pple 25-35 yrs = 11 pple 10 groups = 112 Males The researcher trained the research assistants on facilitation and documentation of the FGDs. In addition, there was a supervisor for each region to help manage the regional team and ensure the research assistants were completing their responsibilities and had adequate skills to conduct the research. The training consisted of a review of methodology and tools, practice role modeling and conducting sample FGDs in the field as a method of pre-testing the translated tools. This pre-testing activity took place in various areas of Kampala and utilized the five different languages. The pilot test ensured that the terminology used in the focus group guide was understood and the meaning was translated appropriately. The pilot test also provided a realistic time frame for these activities, as well as highlighting questions that were not well understood. A couple of weeks after the training, the teams went to the field to conduct the focus groups. The actual locations of focus groups varied in accordance with the availability of meeting spots in the community. Churches, schools or other local meeting venues were utilized. 14 Demographics A total of 112 men participated in the focus group discussions. The majority of men were either single or married and the number of children ranged from zero to five. Most men had some level of either primary or primary and secondary education and generally considered themselves to be employed in the agricultural field. Tables 3.2a-d: Demographic Statistics 3.2a. Marital Status 3.2c. Level of Education Single Married Separated, Divorced, Widowed None Some or All Primary Some or All Secondary Other: University or Tertiary 39% 54% 7% .5% 51% 44% 4.5% 3.2b. No. of Children 3.2d. Type of Employment None 1-2 3-5 6-10 Agriculture Professional/Sales Skilled or Casual Manual Labor Unemployed 40% 28% 25% 7% 70.5% 11.6% 11.6% 6.3% Coding & Analysis The data was collected via written notes of the research assistants, which were later turned into typed reports, as well as tape recordings. The recordings were transcribed in the vernacular languages and subsequently translated back to English and checked. This process, which utilized three different groups of people – transcribers, translators and checkers, was established to ensure accurate replication of the conversations in each focus group with little personal interpretation. Nonetheless, this procedure of passing information through multiple hands inevitably lead to some loss of information and data reduction. The data was conceptually rich, but the context of how the information was collected and processed was an important consideration throughout the analysis. The coding process consisted of open, axial and selective coding. Initially, a basic thematic coding process was utilized in Uganda directly after the data had been collected. A team of three people – female and male, Ugandan and American - identified potential 15 categories or themes that might emerge from the data. As the transcripts were read, these initial categories were expanded, collapsed and integrated to accommodate the story of the data. The process was interactive and continuously evolving throughout the analysis of the data. A few months later, the transcripts were reviewed again and a formal codebook of categories and properties was developed utilizing the prior work as a foundation. The codebook is in fact an integral link to the theoretical framework. The framework was constructed to explain what external influences impact masculine identity and male sexual practices. The codebook is an outline of broad categories concerning definitions of masculinity was defined, sexual practices of men and the role of women, followed by dimensional, descriptive elements within each of these categories. The Atlas.ti v.5 was the tool employed to organize the data. Transcripts and codes were entered and subsequent coding was initiated line by line. Little time was spent on the analysis of actual words used, given that the words could have been modified or misinterpreted in the process. However, linguistics were considered in some instances in order to clarify the meaning of a word. For example, the terms of ‘house’ and ‘home’ have distinct meanings in a Ugandan cultural context and this was an important concept to be aware of during analysis. But generally, the focus remained on broad conceptual terms. This research was an inductive approach to understand how beliefs that define a gender impact the practices and behaviors in everyday life. It is important to note positionality of the study (i.e. how the researcher might influence the design and interpretation of the data). In this case, the researcher was a white, American female and the participants were black, Ugandan males. Although there was no direct interaction between the two, and although the researcher took some steps to utilize Ugandan men in the analysis, as well as to continually inhabit a role of objectivity and sensitivity, there was nonetheless a variation in cultural, social and economic dynamics that could influence how information is perceived during the analysis. 16 Chapter 4: Findings & Discussion Description of Findings Many assumptions have been made about why men act and behave the way they do and how this ultimately impacts their own health and those of their families. Surprisingly, few have taken the time to ask men about these issues. These research results outline the descriptions, experiences and stories that men used to explain what it means to be a man in Uganda, common sexual practices and their view of women. By no means are the results meant to be representative of all men in Uganda. Rather, this research provides a snapshot of beliefs, attitudes and practices from a few men in different regions of the country that may illuminate a better understanding of men and gender issues Definition of Masculinity & What It Means to Be a Man in a Ugandan Context Masculinity is a multi-dimensional, monolithic, subjective and linked inextricably with cultural norms and expectations and gender dynamics. Not surprisingly, there was a proliferation of ways that Uganda men defined masculinity or what it meant to be a ‘real man.’ Masculinity was regularly associated with direct physical acts, as well as specific characteristics or ways of being and routinely quantified with individual experience, as well as the perceptions, encounters and attitudes of fathers and male role models. The Ugandan men from the focus groups identified a series of elements that they deem significant to manhood or enacting masculinity. These elements can be categorized into the following 10 overarching themes: Provider: caring for your wife, children and other relatives by providing a home, food, clothes, school fees, school supplies, health care expenses Employment/Income: generating an income by way of a job, business or ingenuity; demonstrated attempt to work hard and make a living. Ownership: Financial ownership of a home, farm animals, transportation and/or land Meeting Cultural Norms: in keeping with long-standing cultural and tribal beliefs, men should be married and have many children 17 Characteristics/Age: displaying specific characteristics (well-mannered, respectful of others, not lazy, greedy or jealous) and obtaining a certain level of maturity denoted by age Moral Values: upholding moral values such as honesty, not stealing, not being adulterous, following religious teachings and not participating in witchcraft Caring Figure: maintaining a loving, caring relationship with your wife and children; being involved in their lives and knowing problems/issues that arise Leadership: demonstrating an involvement in community activities; people seek you out for advice and assistance; providing guidance Sexual Activity: men have an inherent right to engage in sex as illustrated by a high sex drive and natural, uncontrollable lust; engaging in regular sexual activity that is pleasurable and satisfying; sexually satisfying your partner; demonstrate virility; desired by wives; remaining faithful/ability to control sexual urges and sexual responsibility. Power/Control: position of authority in the community; managing people; control of sexual relationships including instigation & length of the relationship and contraception use; designated authority figure and decision-maker in the family. The average Ugandan male embraces or laments his masculinity on a daily basis in the constant struggle to provide for his family. Undeniably, this is the most prominent distinction of male capability, which is publicly flaunted via spouse(s) and children. The type of food a family eats, if the children attend school, what type of home is provided, the manner of clothes worn by family members and meeting health care needs are all standard indications that determine if a man is meeting his primary responsibility. Providing for a family is also the cornerstone of a man’s masculinity. Ugandan men, not unlike other men in the world, have been raised to believe that providing for their family is largely a function of what it means to be a man. Thus, if provision is perceived to be insufficient, a man is disgraced and generally believed to be less of a man. When you become a man, you look for money and when you get it, you look after your family. – Mbarara 25-35 years You should have money, provide medical care for the children, clothe and educate them. – Gulu 18-24 years 18 Subsequently, adequate provision of a family is recognized by peers, family and neighbors and becomes a driver of a man’s respectability within his community. At the same time, not providing for your family holds negative consequences and often in order to avoid humiliation, a man will take steps to keep the reality a secret or drown his shame, embarrassment and guilt with alcohol or drugs to allow a moment respite. You have to take care of your home, clothing your wife and the more you dress her the more you get respect. – Luwero 18-24 years …(if) you have failed to support your family, it can make you to be less like a man. Even if it is clear that a man has really failed to support his family, such a man cannot admit because he knows that his friends can make fun of him. – Soroti 25-35 years Providing for one’s family has a direct correlation with being employed, earning an income and working hard. Ugandan men believe they should continually demonstrate initiative in this regard, and, if possible, improve the lives of their family members at an economic level. Sustaining some level of employment is a key piece to the puzzle, but men also reference the importance of meeting financial obligations, paying government taxes, engaging in financial planning and not carelessly wasting generated income. However, a man is not required to be rich to prove his manhood in this regard or even to hold down a regular job. Men are very aware of the difficulties in the Ugandan economy, so at a minimal level men should appear to be making diligent, concerted and honest efforts to try and earn money to support their families. …if you have a job and come home with a loaf of bread that makes you respectable. – Kabarole 18-24 years …if he is a farmer, he wakes up very early in the morning and goes to the garden to dig. When he gets the harvest he uses for feeding his family. He does not waste, he apportions it accordingly. (This) man plans well on how to cultivate his crops. – Soroti 25-35 years If a man has a job, money and is better than you, you admire him. – Kabarole 18-24 years Further along this continuum of providing for a family and generating an income is the concept of ownership. Owning a house, farm animals, land or a car is justifiable 19 evidence of man’s ability to provide for his family and his own independence. Ownership brings status and respectability. As an indication of wealth, ownership of property or the like is widely respected and admired because it is something most men are eager to gain themselves. Furthermore, it is a clear indication of a man’s personal achievement and success. I think one turns into a man when he constructs a house. (Until then) you can be a man, but not a full man. – Luwero 25-35 years What we value most is land because all the wealth comes from land. – Soroti 25-35 years Yes, even just dressing – the way I look at it I am not doing well on my side, but the dress code of my neighbor is good. So I imagine the way I can get the wealth I want to be in, but there is no way I can get to it. – Soroti 18-24 years Fulfilling cultural obligations is another piece of masculinity. Getting married and having children are common directives that Ugandan men feel obliged to follow. Men may not necessarily pick a spouse from a love match, but rather from the needling pressure to meet the marriage demand. Marriage is often contrived as a duty and responsibility to your tribe. Thus, it is important to find a wife who can shoulder the domestic burdens, bear many children and obey and honor her spouse. Ironically, marriage can often not be achieved unless a man has met the previous requirements of earning an income and ownership of animals or property. Many of the younger men complained of having to face great community pressure to marry, yet being financially unable to pursue this option. If a man has his family and children, people respect him. – Kabarole 18-24 years If you have a house, whether rented or built, you have to have a woman and get married. (Then) produce children and you will look after them. – Mbarara 25-35 years Children, even more so than a wife, are a physical measurement of a ‘real’ man in Uganda. There is ornate prestige centered about the number of children a man has sired. 20 The more children a man has, the more sexually virile and strong he appears. Having many children earns him respect from others. You can produce about six children, and the other thing it is prestigious. Women will refer to you as a powerful man. – Luwero 18-24 years The first thing is to make a woman pregnant and the second thing is that they have 40 children. (laughter) – Mbarara 25-35 years The context of having a large number of children has important historical context. Farmers needed a large number of children to help cultivate and harvest crops. Children were commodities necessary to achieve survival. Over time, this has transformed into a representation of sexual validity and domination for men. …they consider children as wealth, so if you are married and you are not able to produce you become a laughing stock. – Soroti 25-35 years Being a Ugandan man requires a mix of personality traits and characteristics. A man who behaves well towards others through honesty, good manners, not gossiping, not using vulgar language, not engaging in witchcraft, stealing or fighting with his wife is a deemed a worthy male model. Men say repeatedly that they admire other men with “good moral values.” Good moral values seem to encapsulate the above and also indicate a level of religious belief and involvement. To be a man depends on how you behave, when you have a family, and when you have good manners, when you have a job, then you are a man. – Kabarole 18-24 years Men were equally quick to identify characteristics that were unseemly and unmanly including: laziness, jealousy, being rude, greedy or being bigheaded. …even laziness. Laziness also makes him weak...if you do not want to work, it makes you weak. – Kabarole 18-24 years Next is being selfish and greedy. This makes a man to be less like a man and people even ridicule you. – Soroti 25-35 years One characteristic especially noted as important for men was the ability to emotionally care about others, his wife and children. Men generally believed that a real man loves and 21 respects his wife, advises his children and is knowledgeable about matters that are occurring with his children and other family members. In addition, you get involved in their lives, like find what problems they have, how are they doing in school, etc. You also make sure that your children are safe - Kabarole 25-35 years Finally, most Ugandan men seem to agree that the move from ‘boy’ to a ‘man’ occurs between the ages of 16 and 20 years. Some men suggested that the maturity of a boy plays a more pivotal role in determining his manhood versus age. A male’s interaction with his community, contributing to perceived “adult” discussions, seeking advice, advising others and his relative independence from his family are all signs of a blossoming maturity that is highly valued for men. The role of leadership within a community is a well-respected masculine attribute. Men who are involved in community activities, listening to, advising and uniting people, solving problems and generally showing respect to others are trusted and admired by other men. It is a feature beyond simply caring and seems more akin to the ability to actually help other people and invoke a sense of trust, which encourages people to seek out these men. (these men) have good personalities, talk well to people and even give people very good advice. They are not the kind of men who give wrong advice for example telling someone that ‘my friend, your wife is a very nagging woman, beat her and chase her away’. Or ‘ your brother is a pain, do such thing to him.’ They are men who give good advice about how to manage a home. – Gulu 18-24 years It is that one who maintains the road, supports those who lose their loved ones and keeps the night vigil by the fireplace and being helpful to others when you become a man. – Mbarara 25-35 years Men are positively defined by these efforts. The combination of good character, moral values, leadership and others elevates men to a higher level of popularity and thus, grants him more recognition. Like a man has a good job or dresses very well, why do you respect those things? Because those things make you popular and therefore, people respect him. – Kabarole 18-24 years 22 Such things give you recognition. For instance, if you are someone’s boss, one can say pass through so and so’s home. You become a directory. – Kabarole 1824 years Sexuality is an integral piece of a man’s self-awareness and his own personal empowerment. Dependency on sexuality to illustrate one’s masculinity becomes even more significant when that man believes he is failing on an economic level. Although the link to sexuality and masculinity may appear obvious, the dimensions of what is required from a man to maintain that masculine image can be encompassing. First and foremost, most men believe it is their natural inherited right to go forth and enjoy the fruits of sexual encounters. Sex gives them great pleasure and men typically describe themselves as having a higher sex drive than women and a “natural lust,” which must be satisfied. Second to that is the importance of a man’s sexual performance or virility. The ability to perform sexually and to do so, on a frequent basis is representative of a strong stamina and a powerful man. Physical evidence of this behavior amounts to the creation of many children with your wife and the sexual interaction with additional women. The behavior of multiple partners is further justified by myths or cultural dynamics that suggest women are not sexually aggressive and lack a sex drive, there are less women than men, women are exhausted by continual sex acts and when pregnant or for weeks after delivery, couples should not engage in sex. Often the men describe these as reasons why they feel compelled to seek out sexual fulfillment from other partners, but satisfying a partner’s needs and the appearance of being wanted sexually by your wife is important component to men’s masculinity. Men report feeling shamed and disgraced if their wives refuse to engage with them sexually. You feel vulnerable when you provide your wife with everything but sometimes when you come back home with an urgent sexual urge she turns her back to you. This brings shame. – Gulu 18-24 years Men also suggest that there is a small amount of attention paid to sexually satisfying your partner, remaining faithful or monogamous and being sexually responsible (i.e. using condoms if you have sex with women other than your co-habitating partner). Furthermore, not having sex or the perception to that effect has direct consequences on a man’s masculine appeal. It is generally assumed in these cases that the man suffers 23 from sexual problems such as impotence or disease or that the man is just sexually weak. The possibility of defamation is clearly feared by men and causes them to speak in serious, reverent tones. …being impotent, a man will always fear to say that he is impotent in public and also when he is with a woman he will always give lame excuses that “I have a hydro cell, so I can’t have sex with you” because he knows the moment he discloses this to people, they will make fun of him. Then also when a man contracts an STD, e.g. gonorrhea, he can not disclose to his family or friends because they will ridicule him and he gets ashamed, but later when the signs show up he will have nothing to do. – Soroti 2535 years Being a man means you as a man first of all have your male sexual organ. Secondly, if you go to bed with a woman, your thing (penis) will not embarrass you. That to me is what is meant by being a man. – Gulu 25-35 years Power – whether an illusion or real - is an important backdrop of masculine identity on several levels. First, there is the power and control associated with economic empowerment. One’s ability to gain wealth, influence and direct other people and the independence to control your own path is widely wished for. Men often cited the admiration for men with “government” jobs, as these are generally believed to be secure, well-paid positions with authority. Second, there is the feeling of power obtained when men play the role of the strong, dominant sexual initiator. It’s the combination of perceived sexual know-how and control of the encounter – from instigation to use of contraception to continuation of the relationship. Third, there is great weight attached to a man’s ability to “control” or maintain authority over his family – even if it is just the appearance of authority and it is not accompanied by personal responsibility for the family. This level of control can often be undermined by marital discord, frequent arguing or a disorganized household. Appearances are significant in Ugandan society. A wife is viewed as the physical extension of a man. Should his wife appear dirty, unclean, poorly dressed, greet guests inappropriately or be negligent with her domestic responsibilities, the man takes this as a direct offense to his own personal dignity and presentation to the community and thus, will take immediate steps to solve the situation. 24 ...a man must have strong control over his family...he must ensure that he settles any problem that his household may suffer because a woman may not be able to solve it. – Gulu 25-35 years Power denotes a level of strength and control, which is often found at the heart of masculinity. The men in the focus groups regularly disparaged those who abused substances such as alcohol and drugs. The resulting negative behavior, such as urinating or defecating in public, passing out on the side of the road and fighting, represents a loss of control that reflects badly on your manly image. A man in such a state has no ability to reason and thus, appears powerless. Also another bad characteristic of men is - they consider drinking alcohol as the most important thing in their lives. When they get drunk, they start quarreling, fighting and even urinating in the trousers. They forget about providing for the family and responsibilities...like farming. – Soroti 25-35 years What Are Common Male Sexual Practices? When it comes to sex and sexual relationships, men engage in having sex with multiple women, practice faithfulness, use condoms or don’t use condoms. It is important to note that the term faithfulness can have different meanings. In this research the term faithfulness, as discussed by the men, signified the notion of a man being monogamous, i.e. having sexual relations with only one woman over a given period of time. Each of these sexual interactions has implications on the health of men and women, and they are influenced by multiple dimensions of gender beliefs, cultural traditions, religion and masculinity. The practice of men having multiple wives has a lengthy historical context in Uganda. In earlier times, farmers had multiple wives to help them with the planting and harvesting crops, as well as to produce children to assist in this endeavor. More laborers meant more production and ultimately, more success for the farmer. Although there is less need for this situation now, the justification of multiple partners has distorted to the belief that these relationships are necessary to prove a man’s self-worth and masculine virility. A man’s manhood is substantiated by having multiple partners. The actions have a connotation of prestige, garner respect and earn admiration from both men and women. 25 Most men have many sexual partners to show their manhood. – Gulu 18-24 years Traditionally having many wives was prestigious; men have many sexual partners for prestige. – Gulu 18-24 years Engaging in multiple sexual relationships is further warranted by the belief that men have a natural, often uncontrollable lust, which gives them a higher sex drive than women. Men feel an innate right to fulfill their sexual desires, which is often fortified with religious teachings, for example “when God was creating a woman she came from a man’s rib” (Luwero, 25-35 years) or “In the bible, the woman came last. Therefore, she has to be under the man” (Luwero, 18-24 years) or the idea that women were simply born for sex. There also seems to be a general impression that there are many more women than men in the country and it would be shameful to let a woman suffer from sexual neglect. In fact, the percentage of men to women in Uganda is 49.9% to 50.1%; not a large differential (Index Mundi, 2004). The combination of these convictions reinforces the use of multiple partners. Some men are naturally promiscuous, whereby a character is just in born with them. – Soroti 25-35 years Some men have a very high sexual urge and then his wife on the other hand has a low sexual drive, so this one woman alone can not satisfy a mans desire, this makes a man to look for other women in order to satisfy himself sexually. – Soroti 25-35 years Some men claim that women purposefully incite their lustful disposition by dressing seductively or in a sexually suggestive manner. This apparel invites a sexual feeling, which they feel powerless to ignore. Yet other men simply claim some men lack the will to resist and they define these men as desperate, loose, greedy, heartless and fake. Other times, these men are thought to be dangerous or mentally disturbed since the perception is that they are failing to consider the consequences of their actions. The use of multiple partners is also a method of sexual exploration and discovery. Men claim they want to sleep with different types of women in order to learn new sex 26 styles or tricks. They want to know the sexual differences between women of diverse clans, tribes or races. Some men do it for adventure, others want to discover the difference in sweetness in different races. – Luwero 18-24 years Money is a conduit to having multiple partners. There is an unequivocal correlation between the two. If a man is wealthy, men presume he has multiple partners. If a man has multiple partners, men assume he is wealthy. However, these presumptions are predicated on belief and not fact. …you find that those with money always spend it on women. They normally want to have women in each and every center. – Soroti 25-35 years This theory also holds true in the reverse. Faithful men are believed to be relegated to this condition because they have no money. Being poor does not allow them to keep multiple women. Alternatively, faithful men are thought to be misers or saving money for their family. A man’s relationship with his wife also plays a pivotal role in the pursuit of multiple partners or lack thereof. A woman is required to meet several conditions in her role as a wife. She must be obedient, respectful and loving, satisfy a man’s sexual needs, fulfill her domestic responsibilities, remain attractive and young in appearance and produce many children, especially boys. Failure to do so on any of these fronts gives the man justification to satisfy his needs elsewhere. (He) may also be married to a barren wife and yet the meaning of marriage is children. This makes a man to look for other women to have children. - Luwero 18-24 years Men also claim that having multiple sexual partners is a way of disciplining their wives for bad behavior or to earn their respect and obedience. Often this is a learned behavior from their fathers, which hints at the importance of role models for sexual behavior in future interventions. On the other hand, a wife can also be blamed for a man’s faithfulness. Some men claim that faithful men are either bewitched or controlled by their wives. Only a few men acknowledged that some men are faithful because the couple loves and respects each other. 27 Some men will respect him because he is faithful but some will say that the wife made him stupid, she bewitched him. – Kabarole 25-35 years If your woman does everything well like cooking nice food, nothing can come into your mind to go and eat from the market, you will always come back home. – Soroti Male 25-35 years A man’s religious faith is often an instigator of sexual practice as well. Uganda is 16% Muslim, 33% Roman Catholic, 33% Protestant and 18% indigenous beliefs (Index Mundi, 2004). The religion of Islam subscribes to the practice of polygamy, which has been a widely accepted practice in the past. Although, societal support of this practice is slowly decreasing the religion is still held up as a rationale for maintaining multiple partners. On the other hand, Christian religions advocate for faithfulness between partners. Some men adhere to this principle in order to remain true to their religious teachings and their marriage vows. Other men believe that such a man is faithful and loves his wife. Men in the community always respect such a man citing that, “this is the only upright man with good manners in this community.” – Soroti 25-35 years Sexually, faithfulness can often have a negative connotation for men. Faithful men are sometimes believed to have sexual problems such as impotence or an inability to perform. These problems or the fear of HIV/AIDS prevent them from pursuing other women. Condom use or lack thereof is another sexual practice frequently discussed by men. While there are both positive and negative views on condoms, men seem to be well aware that determining whether or not to use a condom strengthens men’s dominance and power in a sexual encounter. Men explained that women are often more desperate to maintain a partner out of financial need and thus, will cooperate in any way necessary to fulfill his sexual desire. Nonetheless, several men indicated that they would be agreeable to women playing a larger role with condom use in the future. Men, in most cases, they use condoms. However when it comes to women, their bargaining power in using a condom is weak as compared to men and this puts them at a high risk of getting infected than men. Most women 28 think that when a man refuses to use a condom and she gives up so easily with the fears that, a man can chuck her. – Soroti 25-35 years Men know that condoms can be used to prevent the spread of HIV/AIDS and STDs. However, a consortium of factors seems to contribute to preventing the regular, institutional use of this preventive measure. Men state they do not engage in this practice because they do not have the money to buy condoms, can not access a supply, do not want to lose pleasure in the sexual act, believe that condoms simply do not work or claim to be impaired by drugs and alcohol and forget to use them. After getting drunk one forgets to use them and they are in the shirt. – Luwero 18-24 years As for me in my community, men don’t usually use condoms. They have (a saying) that “if you have to eat a sweet do you eat with its wrappings? How then will you derive its sweetness?” – Soroti 25- 35 years Condom use seems more likely in encounters with women outside of marriage, to prevent pregnancy and in the event of family planning with your wife. Otherwise, condom use with your wife is deemed unnecessary and represents lack of trust in the relationship. This trust element also plays a crucial role in the initial stages of a sexual relationship with girlfriends. The men indicated that condoms are important for early sexual encounters as the relationship is blossoming, but eventually the relationship becomes more permanent and requires a level of trust that allows one to disregard condom use. The timing of this more permanent relationship seems to vary from man to man – one week to two months. This trust seems predicated on the fact that the woman has an outward healthy appearance, belief that the woman is speaking the truth about any disease she might have and is willing to be in a relationship with the man and have sex. There is relatively little discussion of sexual history or HIV/AIDS testing. Interestingly, condoms seem to represent and magnify the idea that one or both of the people in the sexual encounter have an unsafe sexual history. Just the mere suggestion of use by either a man or a woman incites a reason not to trust that person. 29 Finally, it is important to acknowledge that some men are fearful of HIV/AIDS and the suffering that it causes. However, often the way these men cope with the fear is to ignore the fact that HIV/AIDS exists at all. This method of escape allows them to enjoy pleasure with little thought about the consequences of their actions. It is also believed that some men, who are infected with the virus and aware of their status, fear dying alone. It is thought that these men purposefully sleep with many women to spread the disease. Some boys run many relations because you find that they are HIV positive and they have that stupid thinking of saying “I can’t die alone.” So he goes on a rampage seducing any girl or woman he comes across to infect, so he ends up in many relations since he wants to die with other people. – Soroti 18-24 years Some men want to spread HIV to other families and people. When he knows that he is sick he wants to spread it. – Kabarole 25-35 years What is the Role of Ugandan Women According to Ugandan Men? Men clearly view a distinguishable difference between the role of men and women in Ugandan society. This begins at a very early age as young girls are made to be involved with domestic chores such as cleaning, cooking, getting water or firewood, sweeping, greeting guests, etc. and young boys are more or less required to tend cattle/goats. The way you raise a girl child you should correct her and teach her how to stay in someone’s home because she will marry, you can’t raise her without teaching her how to cook, or to dig because she is going to be cooking. Her mother should teach her how to cook when visitors have come. – Kabarole 18-24 years I have produced boys and girls, but the first important thing is to see that a boy child, you teach him about being a man i.e. manhood e.g. every morning you have to take animals for grazing, then you also teach him farming. On the side of education you have to endeavor to find out whether he is interested in studies and his ambitions. On the side of the girl, one is supposed to grow up knowing what her mother does e.g. being involved in domestic chores like cleaning the house, cooking, washing dishes, etc. This way is good because each child grows knowing his duties as a man and a woman in a home. – Soroti 25-35 years 30 There is a general belief that it is more important to educate boys because they must learn to survive on their own. Girls, on the other hand, are often absorbed into another family and continue with their domestic abilities. It is not as vital to forward their education since ultimately they will marry out of the clan. The family continues to support this notion because with that marriage comes a pay off for the family. Traditionally boys were cared for more than girls with the reason that girls would later get married off. That a boy is the pillar of the home. So boys were more loved more than girls, but I guess every homestead has its ways of doing things. – Gulu 18-24 years A commonplace practice in Uganda is the bride price. Prior to marrying a woman, a man must meet the financial demands of his bride’s family. This is often a lengthy negotiation process where money, cattle, goats, food and household supplies are bartered in return for the family’s agreement to the marriage. Men may take several years to save up enough money before initiating initiate this process. Bride price is a historic institution and it has influenced the perceived role of a woman in a marital relationship. As indicated by the research data, bride price equivocates women to property -- property of men. In many ways, this is how they are valued in a relationship. When I marry you and dowry is given, then I have paid for you. Did I pay for you so that you come and relate with other men?…You as a woman are supposed to listen to what I say because I have married you. – Soroti 1824 years (Women) are born for sex. That’s why they don’t even live long at their (parents’) home. – Gulu 25-35 years A woman is expected to fulfill domestic responsibilities which include working in the fields, keeping the house clean, cooking, washing clothes, bearing and raising the children, as well as satisfying her husband’s sexual demands. Our culture teaches us that it is the woman’s responsibility to manage a home. – Gulu 18-24 years. In addition, she should listen, consult and obey her husband on all counts. Not doing so, can have dire consequences for herself and her children. 31 I have a wife. She opted for an operation to block the fallopian tubes. We had the ratio of boys to girls not balancing and I wanted to balance. When I discovered it I wanted to even kick the scars, blaming her. I got another wife now. (Laughter) – Luwero Male 25-35 years …you may leave orders for the wife to do some things, but she will neglect you for more than once and you have the option of sending her back to her parent’s home… - Luwero Male 25-35 years The ability to control your wife and family life is tethered tightly to a man’s masculinity as explained earlier. Some men fear the loss of that control as it represents a loss of his power. Sometimes women bear the brunt of that fear and are considered almost malicious in their actions. I think that too much power has been given to women. Some women who have grown horns should have their horns trimmed off because they have grown too many of these horns (laughter). Men should be given more powers and be allowed to control women. – Gulu 18-24 years When men describe women and their role in society, there are diverse points of view. On the one hand, some men acknowledge the hard work their wives do to fulfill their domestic responsibilities and praise their ability to act as a support system for the family, for example, giving emotional love and care to the children. At the same time, since the wife is viewed as an extension of the man, she is a representation of him to the broader community and has the power to make him look less like a man. If a wife she does her job well, the husband will look good too. Alternatively, some men view some women as merely wanting money their money and being untrustworthy people. Women are also occasionally viewed as children. Men of this opinion think women are uneducated, ignorant and in need of continual guidance and clearly unable to control their emotions. Men also recognize women as sexual beings, but believe that they are not aware of their own sexual power or have little control over their sexual urges. As a result, they must be watched and monitored closely. There are some women who are very difficult, in one day she can have sex with ten men. Therefore, you cannot manage her. – Kabarole 18- 24 years Most men argue unequivocally that women should only have one partner. Multiple partners for a woman simply create family disunity, invite disease into the household, 32 create uncertainty about the true father of a child, encourage men fighting and callously dishonor the notions of the bride price. If she happens to be with very many men, when she goes back to her husband, she may not satisfy him in love because she is thinking of the others. It is not right for the lady. – Luwero 18-24 years Discussion The Relationship Between the Gender Norms & Expectations of Ugandan Men and Their Sexual Practices The aim of the research was to learn how men in Uganda articulate their role as men and their attitudes, behaviors and practices about sexual practices. Within that broad question, the purpose was to identify what masculinity means to men, what are their common sexual practices, how they view the role of Ugandan women and then ultimately, discern possible interactions between these elements. The data indicate a connection between masculinity and male sexual practices in Uganda especially in regard to the issues of multiple partners and faithfulness. The strength of the connection is difficult to quantify from this research, but there is indication that masculinity has a strong influential force on a man’s reasoning, which in turn leads to specific sexual actions. First, the data suggest that a variety of external factors are influential not only to the development of a masculine identity, but also to the sexual behaviors and practices of men (see Figure 4.1). These include the learned gender beliefs and behaviors taught to boys by family members, friends, role models and leaders; cultural beliefs and traditions such as the importance of marriage and quantity of children; perceived societal roles for men and women; religion; mind-altering substances including alcohol and drugs; and inherent biological pre-dispositions. For example, boys are responsible for caring for livestock and helping with farming while girls are required to assist with cooking and cleaning. This is often complemented by the phenomena that families preferentially send boys to school in deference to girls because it is believed that a boy extends the lineage of a clan and should be educated enough to financially support this extension. In other 33 words, boys have a higher realm of responsibility. From an early stage, this thought process encroaches on the development of masculine identity and encapsulates a differentiation in the gender roles – that of provider for the male and one of supporter for the female. This also establishes a power dynamic between boys and girls, which suggest that boys are stronger, smarter and more important than girls. In cultural terms, men are expected to get married and produce many children (especially boys) to continue the lineage of the clan or tribe. This concept reinforces the idea that one becomes a man when he has achieved these milestones. The man may have sexual relations with other women in order to accomplish that goal in the event that his wife is unable to produce children or produces few boys. A third example is the perceived societal/cultural element that men go to work and earn money and women stay home and take care of the house and children. This external influence again underpins the belief that having a job and providing for a family is instrumental to manhood. At the same time, having money is often referenced as an enabler for taking on multiple partners. Masculinity or masculine identity is also a powerful, influential mechanism for male sexual practices and vice versa. The relationship of external influences, masculine identity and sexual practices can be represented in a triad formation (see Figure 4.1). According to the data, masculinity is multi-dimensional. In summary, enacting masculinity can be initiated in the following contexts: Provider Employment/Income Ownership Meeting Cultural Norms Characteristics/Age Moral Values Caring Figure Leadership Sexual Activity Power/Control The primary sexual behaviors and practices that emerged from the male focus group discussions included engaging in multiple partners, remaining faithful or monogamous to one partner and the use or lack of using condoms. The relationship between masculine identity and sexual practices can be illustrated via each identified facet of sexual practice. When asked why some Ugandan men have multiple partners, men recalled a variety of reasons for this behavior. Each of these reasons for action can be supported by masculine beliefs they identified (see Figure 4.2). This suggests that some attitudes and beliefs Figure 4.1: Theoretical Framework of External Influences, Masculinities & Male Sexual Practices 34 35 about what it means to be a man contribute to men engaging in sexual relations with multiple partners. In fact, men may feel propelled or obligated to participate in multiple sexual encounters in order to enact masculinity. This can be illustrated with several examples. One reason men said that they have multiple sexual partners is because they have a natural lust and a high sex drive with sexual needs that they believe can not be satisfied with one woman. In addition, men like to explore by learning new sex tricks and being involved with different types of women (e.g. race, tribe, clan). These behaviors are supported by one of the key components for enacting masculinity, which indicates that ‘real men’ have sex often and have satisfying sexual encounters. Another cause for engaging in multiple partners is when men run into problems with their wives such as if a wife is barren or has produced only girls, if a man finds his wife unattractive or old, if the wife no longer maintains her domestic responsibilities, or if a wife no longer respects her husband and no longer provides sexual satisfaction. A ‘real man’ is required to be married and have children. Children are signs of sexually virility, which is a masculine trait. The masculine identity suggests that a man should also be sexually satisfied and his wife should take care of his home and children properly. So when these factors are not being met, a man feels he is within his right to look elsewhere for this satisfaction and continue to prove his masculinity to the outside world. A final example can be demonstrated with the issue of money. Men explained that having money enables a man to have multiple sexual partners. Men feel obligated to buy trinkets, food or beverages for these partners and/or support their living expenses. He must generate income in order to do so. Making money or having a job is a key trait of masculinity. Thus, having multiple partners is actually a way of demonstrating your masculinity, by showing the world that you have money. Others… when they are drunk they start boasting around that, “Money is not my problem! I can spend any amount on a woman.” – Soroti 25-35 years The fascinating thing about the behavior of having multiple partners is that every reason men stated for engaging in this action can be supported by masculine attributes. Figure 4.2: Link Between Masculinities & Multiple Partners 36 37 There was no indication in the research that any un-masculine beliefs are tied to this practice, and therefore, having multiple partners may be an extension and overt demonstration of manhood. Utilizing multiple partners is heavily reinforced by masculinity, but the same cannot be said about faithfulness (see Figure 4.3). The reasons for being faithful (i.e., monogamous) are reinforced by a mixture of masculine and un-masculine beliefs. For example, men stated that a man is faithful because he is poor and is not able to perform sexually, whether due to impotence or another sexual problem. All of these of these stated reasons are sustained by very un-masculine qualities. In other words, a man who does not work hard and make money is not considered a “real man.” The thought of a man being faithful because he has no money is consequently viewed unfavorably and unmanly, just as having satisfying sexual experiences frequently is pivotal proof of manhood. The implication for monogamous men is that they are not having sex often, so they must have a sexual problem like impotence, which is clearly not masculine. Men also proclaim that men are faithful when their wife is controlling or bewitches them and yet, a man is supposed to be the powerful, dominant force in a relationship and retain control of his wife, as well as his sexual needs. The mere appearance that the opposite is true proves a man to be feeble because he lacks capability and masculinity. There are a few reasons for faithfulness that are supported by masculine beliefs. Men say they are faithful in order to abide by their religious beliefs or marriage vows and having good morals is widely respected in men. Other men state that they remain faithful because they love their wives and they fulfill the men’s sexual needs and take good care of the households. Again, this reasoning is influenced by the importance placed on a man having sexual satisfaction, perceived control of his household and being married. Finally, some men believe that faithful men are of good character and worthy of their respect. A man who is considered well mannered and is admired in the community epitomizes a true man. The research clearly demonstrates that the strong impetus of masculinity fortifies men’s reasons for having multiple partners, but a combination of masculine and unmasculine beliefs underline the reasoning for faithfulness. Thus, if a man is eager to Figure 4.3: Link Between Masculinities & Faithfulness 38 39 prove his masculinity, it is likely that he may be more easily persuaded to engage in having multiple partners, since the behavior itself is literally built upon the defining foundation of manhood. On the other hand, remaining faithful or monogamous in a relationship is conflicted with both masculine and un-masculine supports. A man engaging in faithfulness might be more likely to face negative feedback for his actions and attacks on his masculinity, since the behavior is not 100% supported by masculine attributes. A man who is faithful may find that he must defend or justify his masculinity in other ways. The connection between masculinity and Ugandan men’s use or non-use of condoms is more tenuous relationship. Men noted that they use condoms primarily when they are planning their family, don’t trust their partner, fear HIV/AIDS or other diseases and if they have money available to purchase condoms. The last three items are supported by the masculine beliefs that “real men” should have money, they must have lots of satisfying sexual encounters and it is important that they remain in control of a sexual situation and execute power. On the other hand, family planning is certainly not supported by a critical element of a masculine identity, which is to have many children. This is decidedly un-masculine (see Figure 4.4). A more convoluted situation can be found in the illustration for men who do not use condoms (see Figure 4.5). Men explained that they don’t use condoms because they want children, trust their wife or partner, don’t believe that AIDS exists or believe death is inevitable in any case, so why worry. These four reasons for not using condoms are endemic of the masculine beliefs that: men should have many children; men should be sexually satisfied; men should have control over their wives and families and men are powerful and fearless. On the other hand, men also claim that they don’t use condoms because the condoms prevent them from having pleasure, they lack the money to purchase condoms or alcohol or drugs cause them to lose control and forget about this measure. These reasons for not using a condom are supported by traits considered unmasculine: not being sexually satisfied, not having money and lack of power or control. It is not as easy to see a prominent connection between the enactment of a man’s masculinity and whether or not he uses a condom. But in fact, this could be one Figure 4.4: Link between Masculinities and Condom Use 40 Figure 4.5: Link Between Masculinities & Not Using a Condom 41 42 explanation for why there are inconsistencies in condom use with Ugandan men. Condom use or not using a condom can not be equivocally linked to masculine beliefs. If condom use was identified by men as a masculine practice there might be larger proportion participating in the behavior. This action may also be confounded by other environmental or situational considerations. Study Limitations There were two study limitations worth noting. First, the focus group guide contained too many questions. A total of 26 questions were used (see Appendix 1), however, many of the main questions contained a subset of additional follow up questions. The objective was to ensure that a wealth of information was captured; however, these layers of questions complicated the facilitation process and tired the research assistants. An examination of the transcripts revealed that some research assistants moved quickly and haphazardly through the last few questions. In addition, due to the size of the study and the number of languages involved, a multitude of translators and transcribers were used. The final transcripts exposed some inconsistencies with the translation. Despite, pretesting and many levels of checking translation and back translation, inevitably there was some fluctuation in the final wording used by the research assistants, which amounted to some data reduction. Second, the research assistants utilized for the project could have benefited from additional training. The original training was conducted over a 3-day period in English and five vernacular languages. One supervisor per region was hired to monitor the regional team, advise on facilitation techniques and prevent or correct language difficulties in the discussion guide and on-site meetings. Utilizing five supervisors created some inconsistency in the level of monitoring. Transcripts revealed that probing in some groups was limited, other times participation from all group members was not achieved and occasionally, research assistants subtly injected their own opinion into the facilitation. That being said, it is difficult to ascertain the precise extent of the problem since there were other players (i.e. transcribers and translators) instrumental in the data collection, which could have also impacted the results. 43 Future Implications The link between masculinity and health warrants further research. Closer examination of the link between manhood and individual health behaviors, as well a better understanding about why men sometimes do not take initiative to protect their own health or that of their partners could be instructive. The knowledge of changing gender dynamics could be better informed by understanding how men form masculine beliefs and how those beliefs change over time in a given cultural context and examination of why certain men are more inclined to accept changing gender norms versus other men who feel inclined to resist. It would also be interesting to explore men’s beliefs in context with their marital status. In other words, do single men regard sexual relationships in a different manner or practice different sexual behavior than married men and if so, how? Future health interventions targeting men should integrate elements of gender norms and expectations. Enacting masculinity is a critical mechanism of manhood, and utilizing masculine attributes may be a pivotal instrument for behavior change in men. It is important not to carelessly lump all elements of a masculine identity together because there are conflicting notions of masculinity and its impact is variable on different practices. It is critical – via research with men - to understand how masculinity is tied to individual behaviors. Additionally, many health promotion approaches are based on the assumption that individuals will respond or change their behavior once they have the ‘correct’ knowledge. These approaches suggest that individuals have complete control over their own health and can simply make a change, and in fact, this is not the case. Future methodologies must consider the interaction between the environment, gender dynamics, masculinities and the impact on sexual behaviors (Silberschmidt, 2001). As one of the men from the focus groups aptly stated, “…sensitize in a way that shows if you do this one thing, it won’t change the man. He is still a man.” This is a pivotal insight into how future health interventions targeting men should be constructed. If interventions are meant to be influential, they should be fashioned in a way that encourages male involvement and male behavior change without emasculating the man himself. Alternatively, initiatives that are traditionally considered unmanly or unmasculine, might be reconstructed to appeal to men with a more masculine pretense. 44 Gender roles are grounded in deep-seated cultural and historical context. Change in these dynamics only occurs over a long period of time. Interventions should make a concerted effort to initiate discussions within a community, small groups and even the individual level in order to bring attention to this topic. Men need to be given the opportunity, in a safe and comfortable forum, to talk about their roles as men in the society, the pressures and expectations they face, the problems they experience and the possible coping mechanisms or solutions to these problems. In addition, men seem particularly influenced by role models, such as family members or leaders in the community. A mixed approach of discussion and role-modeling might begin to allow men the opportunity to critically think about their own, the impact of their behavior on family members and friends, how to make improvements or changes in behavior, as well as to challenge many presumed cultural or societal assumptions of what it means to be a man or a woman in Uganda. At the same time, interventions about women’s personal and economic empowerment should continue. There should be a balanced approach that addresses both genders and allows the genders, separately and together, to critically examine assumptions about gender roles and cultural traditions. More interventions should emphasize, encourage and instigate communication between couples and the sexes. There is a cultural divide that often keeps men and women separate. 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Retrieved April 19, 2005 from http://www.unfpa.org/swp/2000/english/ch05.html. WHO. (n.d.). Boys in the picture. Retrieved April 21, 2005 from http://www.who.int/child-adolescent-health/publications/ADH/ WHO_FCH_CAH_00.8.htm. WHO. (1999). What about boys? A literature review on the health and development of adolescent boys. Geneva: WHO Department of Child and Adolescent Health and Development. 49 Appendix 1: Focus Group Discussion Guide DISTRICT: __________________ FGD: MALE FEMALE DATE:___________ AGE: 18-24 yrs 25-35 yrs FACILITATOR:_______________________________________________ NOTETAKER:________________________________________________ BACKGROUND INFORMATION Before we begin, we would like to know a little more about each of you. Could you please raise your hand to answer the following question? (Researchers should collect this information, i.e. number of people in each category): 1. ETHNICITY: How many people are from the (___) tribe? (researchers ask about specific tribes to the area and note below; assure people that tribe does not affect their attendance at the focus group. What is important is that they speak the language.) Tribe: __________________ ________ Tribe:__________________ ________ Tribe:__________________ ________ Tribe:__________________ ________ 2. EDUCATION: How many people have: No education ____________ Some university _________ Some primary ___________ University degree ________ All primary _____________ Masters degree __________ Some secondary _________ Ph.D. __________________ All secondary ___________ Tertiary ________________ 3. MARITAL STATUS: How many people: Single ________ Separated________ Married _______ Divorced ________ Widowed________ 4. CHILDREN: How many people have: No children ______ 1-2 children ______ 3-5 children ______ 6-10 children _____ More than 10 children _______ 50 5. EMPLOYMENT: How many people work in: Agriculture ________ Professional/technical ________ Sales/service ________ Other ________ Skilled manual labor ______ Casual manual labor _______ Unemployed _______ DISCUSSION QUESTIONS 1. Think about the men in your community that you admire. Describe them. Prompt: What are their qualities? How do they interact with other men? How do they treat women? What do other men think of them? What do women think of them? 2. What are the most highly valued “male” characteristics? Why are these characteristics highly valued? Prompt: What types of things about men do people like? 3. What are the least highly valued “male” characteristics? Why are these characteristics the least valued? Prompt: What types of things about men do people not like? 4. When and how does a boy become a man? How does a young man acquire respect? Prompt: Are there specific events/markers that define manhood? If so, what are they and please describe them. 5. Are there certain expectations for how men should act? What type of responsibilities do men have? Prompt: What expectations are there for men about work? Finances? Relationships? 6. What expectations do your families have about you? Prompt: What do your mother and father expect from you? What does your wife expect from you? What do your children expect from you? 7. What are the biggest problems that you and other men face in your community? Prompt: Are there places where men can find support for their problems? If so, where and what kind of support is provided? 8. Who has been your role model(s) for what it means to be a man? What makes this person a role model? 9. What does it mean to be a woman in your community? 51 Prompt: How are women treated in your community? What kinds of problems do they face? How do they cope with these problems? Do you think it is easy to be a woman? 10. What are the differences in the way boys and girls are raised? Prompt: Is this a good way to raise children? Should boys and girls be raised in the same way? Why or why not? 11. What does it mean to be a man? A husband/partner? A father? 12. Are there things that you believe you cannot do or say because it would make you look less like a man? If so, what? Prompt: Are there any times when you acted in a certain way or said something and your friends and family ridiculed you or made fun of you. 13. What makes a man feel vulnerable or ashamed (weak, helpless, defenseless) in his relationship with his wife? What can be done to overcome these feelings? 14. What does sex mean to men? 15. Do men generally have many sexual partners? If yes, why? Who is more likely to have multiple sexual partners – single men, married men or both? Why? 16. Is it ok for a woman to have as many partners as men do? Why or why not? 17. Consider a man who has only 1 sexual partner and he remains faithful to her. What do men think of him? What do women think of him? Prompt: Is this behaviour respected by men? Women? Why or why not? How does a man learn to have only 1 partner and be faithful to her? 18. Consider another man who has multiple sexual partners or many casual partners. What do men think of him? What do women think of him? Prompt: Is this behaviour respected by men? Women? Why or why not? Who influences a man to have multiple partners? How does a man learn that it is ok to have multiple partners? 19. What do you think about situations where young women will date and/or have sex with older men (“sugar daddies”) in exchange for gifts, money, etc? Prompt: Are young men engaged in these activities? Is it acceptable behaviour? Why or why not? 20. How involved should men be in raising their children? What types of things should men be doing? Prompt: Why are some men more involved in raising their children (i.e. providing money and caring for the children) but other men are not involved in their children’s lives? What or who influences a man to be a more involved father? 52 21. Do you think men in your community worry about STDs or HIV/AIDS? Why or why not? 22. Do you think men in your community worry about getting a woman pregnant? Why or why not? 23. Do men use condoms? Why or why not? In sexual relationships, who usually decides if the couple uses a condom? Prompt: Is it ok for a woman to suggest using a condom? Why or why not? 24. Do you believe it is important for men to be involved in the health issues for his family? (i.e. discuss reproductive health issues with their partners, use contraception for family planning and to prevent disease, visit the health centre with their partners) Why or why not? Prompt: In your opinion, are the majority men involved in health issues with the family or do the majority leave this up to their partner? Why? 25. Are men in your community violent? If yes, please describe the type and cause of violence. Prompt: Do men get into fights? Over what? How common? Do men in community carry weapons? Engage in criminal activities? What is the response of the police to these acts of violence? 26. Sometimes men are violent with their partners (i.e. sometimes a man hits a woman). Why does this happen? Prompt: Why do men act this way? Is this behaviour acceptable? Why or why not? Are there times when it is ok to act this way and other times when it is not? Have you seen this kind of violence in your community? In what situation? What would you do if you saw a man using violence against a woman?