Addressing Gender Socialization and Masculinity Norms Among Adolescent Boys: Policy and Programmatic Implications

While the health of adolescent girls has rightly been the focus of attention in global health and development agendas given their biological vulnerability and the disadvantages they face due to gender inequalities, there are several compelling reasons to also focus on adolescent boys [1LancetAdolescent health: Boys matter too. Lancet. 2015; 386: 2227Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. As boys transition into adolescence, they face distinct risk factors and health problems that shape their health trajectories throughout the life course, with interpersonal violence and injuries, HIV and AIDS, and suicide being the top causes of mortality and morbidity. Adolescent boys are also more likely to engage in alcohol, tobacco, and drug use with both immediate and long-term consequences [2Dick B. Ferguson B. J. Health for the world’s adolescents: A second chance in the second decade. 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In addition, men's perpetration of sexual violence starts during adolescence in many settings, and it has a number of adverse physical as well as mental health outcomes for women and girls [9Jewkes R. Fulu E. Roselli T. Garcia-Moreno C. Prevalence of and factors associated with non-partner rape perpetration: Findings from the UN multi-country cross-sectional study on men and violence in Asia and the Pacific. Lancet Glob Heal. 2013; 1: e208-e218Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar]. While a number of factors contribute to the health behaviors and outcomes among adolescent boys, an often ignored determinant is gender; more specifically, the gender socialization of boys to adopt unequal or stereotypical attitudes related to masculinities 10Currie C, Zanotti C, Morgan A, et al. , eds. Social determinants of health and well-being among young people. Health behaviour in school-aged children (HBSC) study: International report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, No. 6). Available at: http: //www. euro. who. int/_data/assets/pdffile/0003/163857/Social-determinants-of-health-and-well-being-among-young-people. pdf. Accessed September 3, 2017. Google Scholar, 11Mora R. “Do it for all Your pubic Hairs!”: Latino boys, masculinity, and puberty. Gend Soc. 2012; 26: 433-460Crossref Scopus (25) Google Scholar, 12Way N. Cressen J. Bodian S. et al. “It might be nice to be a girl… Then you wouldn’t have to be emotionless”: Boys’ resistance to norms of masculinity during adolescence. Psychol Men Masc. 2014; 15: 241-252Crossref Scopus (73) Google Scholar. Although gender socialization starts early in childhood, early adolescence (ages 10–14 years) is a critical period for shaping gender attitudes, particularly because the onset of puberty brings new and intensifies expectations related to gender 13Lundgren R. Beckman M. Chaurasiya S. P. et al. Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gender Dev. 2013; 21: 127-145Crossref Scopus (39) Google Scholar, 14McCarthy K. Brady M. Hallman K. et al. Investing when it counts: Reviewing the evidence and charting a course of research and action for very young adolescents. Population Council, New York2016http: //www. popcouncil. org/uploads/pdfs/2016PGYInvestingWhenItCounts. pdfGoogle Scholar. A recent systematic review on gender attitudes of young adolescents highlights that endorsement of unequal or stereotypical gender norms is already common in that age group. The review, drawing on data from 82 studies from different cultural settings, shows that boys and girls experience distinctly different pressures and sources of gender socialization [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. In this brief, we build on the findings of the aforementioned systematic review in order to draw attention to (1) the types of masculinity norms endorsed in early adolescence and (2) who or what are the key factors that shape boys' gender attitudes. We also draw on the current evidence base for promising interventions to address harmful masculinity norms and elaborate on the implications for programs and policies. As highlighted in the review [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar], young adolescents endorse masculinity norms related to: physical toughness (e. g. , showing higher tolerance for pain, engaging in fights, competing in sports) ; autonomy (e. g. , being financially independent, protecting and providing for families) ; emotional stoicism (e. g. , not acting like girls or showing vulnerabilities, dealing with problems on one's own) ; and heterosexual prowess (e. g. , having sex with many girls, exercising control over girls in relationships; For more details about the themes, see the review [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]). The review further indicates that adolescent boys are more likely to endorse unequal gender norms than girls. There are three potential explanations for this. First, in many settings norms that privilege men are seen as “normal, ” and hence, boys may not perceive the need to challenge them. Second, with onset of puberty, boys experience greater relative freedom and power compared with girls and therefore, may be less motivated to challenge the privileges conferred to them by society. And, lastly where and when boys may be willing to adopt more equitable attitudes, or if they display feminine traits (i. e. , in appearance) or engage in activities (e. g. , help with household chores) associated with girls, they face more social barriers including ridicule and labeling from peers and stigmatization from society as compared with girls [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. While there are several factors (e. g. , ethnicity, race, social class, school/school teachers, and attainment of puberty) contributing to the gender socialization of young adolescents, the review shows that there is particularly strong evidence around the key role of parents and peers (for more details about the themes see the review [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]). Parents' contribute to gender socialization through both direct and indirect communication with their children in terms of different rules and sanctions and expectations from boys and girls. However, the review does not provide clarity on whether this influence is mediated through parents own endorsement of stereotypical or equitable gender attitudes, division of labor in the homes, linked to the family structure (two parent vs. single parent homes), or shaped by the mothers' or fathers' attitudes [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. As boys transition into adolescence, peers appear to be especially central in shaping and perpetuating masculinity norms. Male peers contribute to the upholding of prevailing masculinity norms by challenging each other physically and verbally or encouraging risk-taking practices (e. g. , alcohol, drug use, and unsafe sex). They also challenge each other to show their masculinity through early sexual conquest of girls. Any violation of masculinity norms is penalized by ridicule including homophobic insults and bullying [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. There is also some evidence (based on studies from high-income settings) that schools, including communication by teachers and in some settings the provision of comprehensive sexuality education, shape gender attitudes in early adolescence. The evidence on the influence of the media is still emerging [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. However, given the increasing engagement of adolescents with social media and mobile phones, the influence of sexually explicit pictures and messages on their gender attitudes and related risk behaviors needs further investigation. Interventions to change masculinity norms that perpetuate unequal power relations have mainly been developed and piloted in the context of HIV and gender-based violence prevention. Most of these programs have focused on older adolescent boys and young men aged 15 years and above. A much smaller number of programs have addressed young adolescent boys, presenting a clear gap with regards to what works for the 10- to 14-year age group [14McCarthy K. Brady M. Hallman K. et al. Investing when it counts: Reviewing the evidence and charting a course of research and action for very young adolescents. Population Council, New York2016http: //www. popcouncil. org/uploads/pdfs/2016PGYInvestingWhenItCounts. pdfGoogle Scholar]. We draw upon three reviews of interventions that sought to transform and build equitable gender norms by working with adolescent boys and young men. A review examining the effect of 15 interventions targeting sexual behaviors, violence perpetration and gender attitudes among boys and men (aged 13 years and above) found that small group participatory activities to generate critical reflection about unequal gender norms are promising [16Dworkin S. L. Treves-Kagan S. Lippman S. A. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS Behav. 2013;: 2845-2863Crossref PubMed Scopus (188) Google Scholar]. Of the 12 evaluations that measured gender attitudes, 11 found significant improvements in this outcome; however, fewer studies showed improvements in sexual behaviors or reductions in violence perpetration [16Dworkin S. L. Treves-Kagan S. Lippman S. A. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS Behav. 2013;: 2845-2863Crossref PubMed Scopus (188) Google Scholar]. Another systematic review of 65 sexual violence prevention interventions with boys and young men aged 11 to 26 years also found that small group participatory interventions hold promise in building equitable gender attitudes. However, in this review the results were less robust and only seven out of 25 interventions that measured gender attitudes showed improvements and very few (one out of nine) impacted behavior (i. e. , boys' or men's perpetration of sexual violence) [17Ricardo C. Eads M. Barker G. Engaging boys and young men in the prevention of sexual violence: A systematic and global review of evaluated interventions. Promundo, SVRI, Washington DC2011http: //reliefweb. int/sites/reliefweb. int/files/resources/menandboys. pdfGoogle Scholar]. These two reviews highlight that it is possible to build equitable gender attitudes within short time frames, but that such improvements do not necessarily translate into behavior change. The third review of violence against women prevention programming with men and boys offers the following lessons. First, building equitable gender attitudes and sustaining broader social change in masculinity norms requires programming not only with boys and men, but also with girls and women. Second, it also requires working with families and communities, and at the broader societal level. And third, there is not only a need to challenge norms of male entitlement, privilege, power, and control over women and girls, but to also respond to boys' and men's own victimization, trauma, social exclusion, and marginalization [18Jewkes R. Flood M. Lang J. From work with men and boys to changes of social norms and reductions of inequities in gender relations: A conceptual shift in prevention of violence against women and girls. Lancet. 2015; 385: 1580-1589Abstract Full Text Full Text PDF PubMed Scopus (410) Google Scholar]. With regards to the 10- to 14-year age group, three examples of interventions that significantly improved gender attitudes of young adolescents are: (1) Gender Equity Movement in Schools program in India [19Achyut P. Bhatla N. Khandekar S. et al. Building support for gender equality among young adolescents in school: Findings from Mumbai, India Internet. ICRW, New Delhi2011http: //www. ungei. org/resources/files/GEMSBuildingSupportforGenderEqualityAdolescents. pdfGoogle Scholar]; (2) the Gender Roles, Equality and Transformation project in Northern Uganda [20Institute for Reproductive Health (IRH) GREAT Project: End line Report. Georgetown University, Washington DC2016Google Scholar]; and (3) the Choices intervention in Nepal [13Lundgren R. Beckman M. Chaurasiya S. P. et al. Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gender Dev. 2013; 21: 127-145Crossref Scopus (39) Google Scholar]. All three interventions were implemented with both, boys and girls and included participatory and emotionally engaging curricula to stimulate discussions about gender roles and unequal power relations. The Gender Equity Movement in Schools program, which also targeted parents and school authorities, found significant positive and sustained changes in gender attitudes over a period of 2 years among participants in the intervention group as compared with the control group [19Achyut P. Bhatla N. Khandekar S. et al. Building support for gender equality among young adolescents in school: Findings from Mumbai, India Internet. ICRW, New Delhi2011http: //www. ungei. org/resources/files/GEMSBuildingSupportforGenderEqualityAdolescents. pdfGoogle Scholar]. Evaluation of the Gender Roles, Equality and Transformation project, implemented with adolescents aged 10 to 19 years showed significant improvements in gender-equitable attitudes and communication between adolescent boys and their dating partners. It also increased participation of boys in household chores, and improved contraceptive use among older adolescents [20Institute for Reproductive Health (IRH) GREAT Project: End line Report. Georgetown University, Washington DC2016Google Scholar]. The Choices intervention showed significant improvements in equitable gender attitudes and behaviors (e. g. , increased participation of boys in household chores and tasks done mainly by girls) [13Lundgren R. Beckman M. Chaurasiya S. P. et al. Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gender Dev. 2013; 21: 127-145Crossref Scopus (39) Google Scholar]. Early adolescence is a critical window of opportunity for influencing adolescent boys' gender attitudes and building equitable norms. Developmentally, children begin to develop semi-abstract thinking, feelings of empathy for others, and to understand concepts of fairness and equity [13Lundgren R. Beckman M. Chaurasiya S. P. et al. Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gender Dev. 2013; 21: 127-145Crossref Scopus (39) Google Scholar]. Masculinity norms that encourage physical toughness, emotional stoicism, and heterosexual prowess provide an explanation for boys' higher propensity for substance use, engagement in early, and unprotected sexual activity, as well as their use of violence with girls and with other boys. They also explain why boys may not seek help early and why mental health disorders in boys may not be easily recognized or addressed. Changing masculinity norms requires motivating boys to challenge the power and privilege conferred to them, as well as addressing the social ridicule and stigmatization of those that fail to live up to ideals of masculinity. Approaches that show promise in changing boys' gender attitudes within a short intervention time frame include small group participatory curricula to generate critical reflection about unequal power relations. However, transforming norms and sustaining broader social change requires taking a socioecological approach that targets not only individual boys but also peers, parents, and schools and mobilizes entire communities. The current evidence base highlights several research gaps that need to be addressed to strengthen programs. First, much of evidence on gender socialization comes largely from high-income countries, signaling the need to build a more robust evidence base in peer-reviewed literature from low- and middle-income countries. Second, the measurement of gender attitudes in adolescence varies across studies, and there is a clear need for reliable and valid measures in this age group that can be consistently used across studies [15Kågesten A. Gibbs S. Blum R. W. et al. Understanding factors that shape gender attitudes in early adolescence globally: A Mixed-Methods systematic review. PLoS One. 2016; 11: e0157805Crossref PubMed Scopus (206) Google Scholar]. There is also a need for better evaluation designs with longer time frames to be able to assess how changes in gender attitudes are sustained over time to generate broader social norm change and how they influence the health and behaviors of adolescent boys [16Dworkin S. L. Treves-Kagan S. Lippman S. A. Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS Behav. 2013;: 2845-2863Crossref PubMed Scopus (188) Google Scholar]. Third, while there is clarity that parents have a role to play, there is a need to unpack what aspects of parenting are important in shaping gender attitudes of adolescents. Fourth, more robust evidence is needed on school-based approaches although the evidence on positive impacts of sexuality education curriculum with content on gender equality is encouraging [21Haberland N. The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies. Int Perspect Sex Reprod Health. 2015; 41: 31-42Crossref PubMed Scopus (155) Google Scholar]. Fifth, given the increasing importance of media including social media in the lives of adolescents, we need to better understand the negative influence, and the potential uses of different media approaches to promote gender-equitable attitudes in this population. Finally, addressing gender socialization by working with adolescent boys should go hand in hand with efforts to address gender socialization among adolescent girls, empower them, and build their self-esteem and agency. Addressing gender socialization and masculinity norms among adolescent boys will not only improve their own health and their trajectories into adulthood but also contribute toward the health of women and girls. It will also likely have multiple spill-over benefits in terms of broader social well-being of families and communities.