Many studies find that men visit public health care facilities much less frequently than do women,^(2,3) which has some significance for the poor uptake of men in voluntary counselling and testing services (VCTs) for HIV. A number of explanations have been given for this phenomenon, some of which focus on constructions of masculinity as a barrier to seeking health care. This paper draws on a relatively unexamined reason for men’s lack of attendance in public health care facilities which resonate strongly with debates around masculinity: that men view the clinic as women’s space. As many clinics are run mainly by women, holding positions as nurses and counsellors, and are also primarily attended by women and children, men may find visiting the clinic cumbersome and embarrassing, as it challenges traditional and hegemonic notions of masculinity. This paper focuses on the particularities of masculinity and health seeking behaviour in an African context.

Gendering health seeking behaviour in Africa

Studies show that men and women make disproportionate use of public health care facilities in many parts of Africa, with women by and large much better represented in these facilities than their male counterparts.⁽⁴⁾ This phenomenon is often ascribed to the availability of reproductive and family health clinics⁽⁵⁾ which are seen to favour women given their gendered roles as care givers. Women are thus more likely to frequent public health care facilities to care for dependents, access family planning, or due to pregnancy.⁽⁶⁾ Given their bodies’ reproductive capacities, the closer contact with public health care facilities to which women are predisposed, allow more opportunities for uptake in voluntary counselling and testing services (VCTs)⁽⁷⁾ and in highly active antiretroviral treatment (HAART) programmes.⁽⁸⁾ The World Health Organisation (WHO) attributes women’s overwhelming presence in these services and programmes to their links to community networks, especially mother-to-child transmission prevention (MTCTP) programmes.⁽⁹⁾

This state of affairs is contrary to what the United Nations Programme on HIV & AIDS (UNAIDS) anticipated when antiretroviral treatment (ART) became available in sub-Saharan Africa. Concerns arose from the “feminisation” of the epidemic, i.e. that a gross proportion of those infected with HIV were women (59%), and that this group of individuals were among the most marginalised – their HIV-positive status being partly the result of their low socio-economic status.⁽¹⁰⁾ These fears were tied to the observation by UNAIDS that in Africa, gender inequalities as well as gender norms and relations, including practices around sexuality, marriage and reproduction; harmful traditional practices; barriers to women’s and girls’ education; lack of access for women to health information and care; and inadequate access to economic, social, legal and political empowerment are major contextual barriers to effective HIV prevention.⁽¹¹⁾

Women’s substantial uptake in VCTs and HAART programmes in developing countries thus belied the anticipated effects of their marginalisation – they were, in effect, more likely than men to know their HIV-status and to have access to treatment.^(12,13) To stress this point, research on combination antiretroviral therapy (cART) covering 23 cohorts in Africa has “found that men represent a significantly smaller proportion of cART recipients than women, although men made up about 41% of infected patients.”⁽¹⁴⁾ Even so, underlying HIV & AIDS policies, interventions, and efforts, was the notion that “women may not be accessing HAART programs as well as men due to personal and societal barriers” since “women in most societies contribute the largest group of socially vulnerable members.”⁽¹⁵⁾ The outcome of this notion was that most funds and advocacy groups were directed at empowering women.⁽¹⁶⁾ Edward Mills, Nathan Ford and Peter Mugyenyi bring attention to the fact that the consequence of the expectation that gender inequality favours men, has been that men receive disproportionately poorer access to HIV care than women.⁽¹⁷⁾ In this sense men have largely fallen along the wayside in HIV & AIDS prevention and treatment strategies. Not only this, but in relation to HIV & AIDS, men are often framed as the “drivers of the epidemic”,⁽¹⁸⁾ and elsewhere, as “both ‘the solution’ and the origin of the problem.”⁽¹⁹⁾

Far from completely absolving men from these labels, and implying that women experience no barriers to accessing health care, I would like to bring attention to how the male gender role determines and informs if and how men access health care, in particular HIV & AIDS tests and treatment. By labelling men as deviant and as the progenitors of the disease, the sense of urgency for any further investigation into this matter is removed, which inevitably leads to a dead end. Attempting to understand how gender roles and norms are imbedded into all behaviours – be it health seeking behaviour or even personal gait – can help to pinpoint areas on which to focus our efforts and interventions.

Practicing and foregrounding hegemonic masculinity

Although the categories of “men” and “women” are spoken of in seemingly homogenous terms, there is great differentiation and diversity pertaining to health seeking behaviour within these two groups. These are often tied to the degree of agency an individual enjoys within his or her particular society, which is in turn informed by how the different characteristics of the individual is perceived – either curbing or allowing more freedoms to the individual. A case in point is how “female gender” as a category privileges women from southern Africa when it comes to HIV & AIDS health care, while women in North Africa experience the exact opposite due to institutionalised proscriptions on their gender.⁽²⁰⁾

Brown, Sorrell, and Raffaelli talk about the plurality of masculinities present in all societies, each differing depending on characteristics such as race, class, age, religious background, and geographic location.⁽²¹⁾ The authors maintain that the masculinities which arise and take on particular nuances because of these characteristics are not all equal.⁽²²⁾ “Instead, cultural groups construct ideal notions of masculinity”, and these ideal notions of masculinity bring into existence the hegemonic masculinity – the masculinity “that men measure themselves against, and are measured against by others.”⁽²³⁾ This hegemonic masculinity thus dictates, proscribes, and values certain beliefs, behaviours and desires in men, thereby establishing undesirable masculine traits and femininities as its opposite and “other”.⁽²⁴⁾

Will Courtenay identifies some hegemonic masculinity ideals as they relate to health related behaviour and studies show that these ideals may be almost universally present. Unsurprisingly, health seeking behaviour of men in New Zealand⁽²⁵⁾ and the United States of America⁽²⁶⁾ have much in common with the behaviour of men in parts of Africa. These hegemonic masculinity ideals are: “the denial of weakness or vulnerability, emotional and physical control, the appearance of being strong and robust, dismissal of any need for help, a ceaseless interest in sex, and the display of aggressive behaviour and physical dominance.”⁽²⁷⁾ By upholding and conforming to these masculine ideals, men are able to assert their difference from women, and “reinforce strongly held cultural beliefs that men are more powerful and less vulnerable than women; that men's bodies are structurally more efficient than and superior to women's bodies; that asking for help and caring for one's health are feminine; and that the most powerful men among men are those for whom health and safety are irrelevant.”⁽²⁸⁾

In this context, men are more likely to delay seeking help for medical problems as health-seeking behaviour has become “feminised” and admitting illness or weakness challenges their position as “men.”⁽²⁹⁾ Hegemonic masculinity is therefore useful for understanding why men are sicker when they are admitted to ART programmes⁽³⁰⁾ and for understanding why even though they are less susceptible to the disease than women, they are more likely to die because of it.⁽³¹⁾

Furthermore, it has been shown that hegemonic masculine traits are more accentuated in circumstances where men experience feelings of powerlessness due to poor socio-economic conditions or marginalisation.⁽³²⁾ Given that the hegemonic masculinity ideal constructs men as breadwinners, men who are unable to successfully provide for their families may find other avenues in which to conform, such as engaging in risky sexual practices.⁽³³⁾ Sexual prowess, fatherhood,⁽³⁴⁾ and even sexually transmitted diseases (STDs) and HIV & AIDS⁽³⁵⁾ are seen as markers of masculinity under such conditions. The implications of these forms of resistance against being seen to exhibit anything other than the hegemonic masculinity, thus further put men’s health at risk.

Dealing with discomfort and disclosure: Views of the clinic as women’s space

Given the above discussion surrounding men, masculinity and their poorer health seeking behaviour, I now examine another avenue which may account for their poorer attendance at health care facilities – that men view clinics as women’s space. Much of the literature on this topic focuses on research conducted in South Africa, but arguably resonates and has some significance to other countries in Africa and across the globe. A report by the Sonke Gender Justice Project maintains that in the context of the often overburdened and under-resourced public health clinics in South Africa, neither men nor women view the clinic as a “friendly” space, but that both groups view the clinic largely as women’s space.⁽³⁶⁾ The availability of reproductive and family planning services for women mean that HIV & AIDS prevention, testing and treatment programmes are often incorporated into these clinics, rather than emerging on their own. For men to access these services, thus requires them to attend antenatal clinics (ANCs) or other services which deal with reproduction. A Tanzanian study points to the poor utilisation by Tanzanian men of STD and HIV tests precisely because it was conducted in ANCs.⁽³⁷⁾

Maria Faull posits that “because clinics are dominated by women, they have potentially become a hostile environment for men.”⁽³⁸⁾ Women “dominate” clinics, because they are often the majority of staff in the clinic (holding positions as nurses or counsellors), and they, along with children, are also the most frequent users of public health care facilities.⁽³⁹⁾ For men to attend the clinic is then not only to acknowledge weakness – a feminine trait – but also to associate as a “regular-user” of public health which is a “feminine subject position.”⁽⁴⁰⁾ In the clinic, men may have to divulge personal information to the female health care practitioner or counsellor and here openness and honesty is required. Among the native Xhosa-speaking inhabitants of South Africa it is “not seen as culturally appropriate for men to talk to women about certain problems – such as sexual or genital problems.”⁽⁴¹⁾ In addition, Faull’s research showed that there was a general mistrust among men of women in the clinic – men thought that women would gossip and “would expose...medical secrets publicly.”⁽⁴²⁾ This shows the vulnerability men experience when visiting the clinic, as they become subject to a world in which they are not dominant. In the female dominated clinic, men thus lose the opportunity to enact their hegemonic masculine traits and must conform to more submissive female traits. This, even as they find themselves in a space which has already conferred on them these perceived lesser, female traits. For many men, visiting the clinic is thus an emasculating experience.⁽⁴³⁾

Concluding remarks

This CAI paper has drawn attention to reasons for men’s poorer uptake in HIV & AIDS prevention, treatment, and care programmes in Africa. The success of pilot all male clinics⁽⁴⁴⁾ stress men’s discomfort with having to attend public health care facilities seen to cater mainly for women, children and their needs. It has been shown that although African women are thought to be among the most vulnerable when it comes to HIV & AIDS incidence, prevalence and access to treatment, they are more easily taken up in VCTs and ART programmes due to their often closer relationship with public health care facilities.^(45,46) The result of the mistaken belief which assumes men’s privilege in matters of health has been that HIV & AIDS programmes and studies focused solely on men are in the minority when contrasted with HIV & AIDS programmes and literature aimed at or dealing solely with women. In addition, many studies, rather than examining the reasons for men’s poorer uptake in HIV & AIDS programmes, merely label men as the source and spreaders of the disease.⁽⁴⁷⁾ As such, the reasons for men’s poorer uptake in these programmes do not receive enough attention and are accordingly not adequately addressed in many African countries’ public health care decisions.

Understanding how gendered norms and values in any given society determine the health outcomes of individuals is thus important for pinpointing interventions and attaining that ideal of equal access to treatment for all. Understanding the universalities and particularities of health seeking behaviour, access and utilisation of health care services in different settings can help us identify groups and individuals who fall through the cracks, and interventions which target the cause, not merely the symptoms of issues.

NOTES:

(1) Contact Hanlie Myburgh through Consultancy Africa Intelligence's HIV and AIDS Unit ( hiv.aids@consultancyafrica.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
(2) Kuwane, B., andet al., 2009. Expanding HIV care in Africa: making men matter in Johannesburg. The Lancet, 374, p.1329.
(3) Braitstein, P., et al., 2008. Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. Journal of Women’s Health, 17(1), p.53.
(4) Mills, E.J., Ford, N., and Mugyenyi, P., 2009. Expanding HIV care in Africa: making men matter. The Lancet, 374, p.275-276.
(5) Braitstein, P., et al., 2008. Gender and the use of antiretroviral treatment in resource-constrained settings: findings from a multicenter collaboration. Journal of Women’s Health, 17(1), p.53.
(6) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4),p.19-36.
(7) Sonke Gender Justice Project, ‘Men for change, health for all: A policy discussion paper on men, health and gender equity’, prepared for the South African National Department of Health, November 2008, pp. 1-43, http://www.iasociety.org.
(8) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4), p.21.
(9) Ibid.
(10) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4), p.19.
(11) Ibid.
(12) Sonke Gender Justice Project, ‘Men for change, health for all: A policy discussion paper on men, health and gender equity’, prepared for the South African National Department of Health, November 2008, pp. 1-43, http://www.iasociety.org.
(13) Mills, E.J., Ford, N., and Mugyenyi, P., 2009. Expanding HIV care in Africa: making men matter. The Lancet, 374, p.275.
(14) Ibid.
(15) Muula, A.S., et al., 2007. Gender distribution of adult patients on Highly Active Antiretroviral Therapy (HAART) in Southern Africa: a systematic review. BMC Public Health, 7, unpaginated.
(16) Mills, E.J., Ford, N., and Mugyenyi, P., 2009. Expanding HIV care in Africa: making men matter. The Lancet, 374, p.275.
(17) Ibid. pp. 275-276.
(18) Ibid. p. 276.
(19) Brown, J., Sorrell, J., and Raffaelli, M., 2005. An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, Health & Sexuality, 7(6), p.586.
(20) Remien, R.H., et al., 2009. Gender and care: access to HIV testing, care, and treatment. Journal of Acquired Immune Deficiency Syndrome, 51(3), p.106-110.
(21) Brown, J., Sorrell, J., and Raffaelli, M., 2005. An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, Health & Sexuality, 7(6), p.586.
(22) Ibid.
(23) Ibid.
(24) Courtenay, W.H., 2000. Constructions of masculinity and their influence on men's well-being: a theory of gender and health. Social Science and Medicine, 50, p.1388.
(25) Noone, J.H., and Stephens, C., 2008. Men, masculine identities, and health care utilization. Sociology of Health and Illness, 30(5), pp.711–725.
(26) Krawczyk, C., Funkhouser, E., Kilby, J.M., and Vermund, S.H., 2006. Delayed access to HIV diagnosis and care: special concerns for the Southern States. AIDS Care, 35(suppl 1), pp.35-44.
(27) Ibid. p. 1389.
(28) Ibid.
(29) Sonke Gender Justice Project, ‘Men for change, health for all: A policy discussion paper on men, health and gender equity’, prepared for the South African National Department of Health, November 2008, pp. 20, http://www.iasociety.org.
(30) Mills, E.J., Ford, N., and Mugyenyi, P., 2009. Expanding HIV care in Africa: making men matter. The Lancet, 374, p.275.
(31) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4), p.30.
(32) Colvin, C.J., and Robins, S.L., 2009. Positive men in hard, neoliberal times: engendering health citizenship in South Africa. In J. Boesten, and N.K. Poku, eds.Gender and HIV/AIDS: Critical Perspectives from the Developing World. Farnham: Ashgate.
(33) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4), p.20.
(34) Brown, J., Sorrell, J., and Raffaelli, M., 2005. An exploratory study of constructions of masculinity, sexuality and HIV/AIDS in Namibia, Southern Africa. Culture, Health and Sexuality, 7(6), p.594-595.
(35) Leclerc-Madlala, S., 1997. Infect one, infect all: Zulu youth response to the AIDS epidemic in South Africa. Medical Anthropology, 17, p.363-380.
(36) Sonke Gender Justice Project, ‘Men for change, health for all: a policy discussion paper on men, health and gender equity’, prepared for the South African National Department of Health, November 2008, pp. 23, http://www.iasociety.org.
(37) Mlay, R., Lugina, H., and Becker, S., 2008. Couple counselling and testing for HIV at antenatal clinics: views from men, women and counsellors. AIDS Care, 20(3),p.356-360.
(38) Faull, M., 2007. The clinic as a gendered space: an exploratory study examining men’s access to and uptake of voluntary counselling and testing services (VCT) in the context of a male-friendly health facility. Dissertation: Faculty of Humanities, UCT.
(39) Ibid.
(40) Noone, J.H., and Stephens, C., 2008. Men, masculine identities, and health care utilization. Sociology of Health and Illness, 30(5), p.717.
(41) Faull, M., 2007. The clinic as a gendered space: an exploratory study examining men’s access to and uptake of voluntary counselling and testing services (VCT) in the context of a male-friendly health facility. Dissertation: Faculty of Humanities, UCT.
(42) Ibid.
(43) Ibid.
(44) Ibid.
(45) Sonke Gender Justice Project, ‘Men for change, health for all: a policy discussion paper on men, health and gender equity’, prepared for the South African National Department of Health, November 2008, pp. 1-43, http://www.iasociety.org.
(46) Nattras, N., 2008. Gender and access to antiretroviral treatment in South Africa. Feminist Economics, 14(4), p.21.
(47) Mills, E.J., Ford, N., and Mugyenyi, P., 2009. Expanding HIV care in Africa: making men matter. The Lancet, 374, p.276.

Written by Hanlie Myburgh ⁽¹⁾