1WHAT ABOUT BOYS?

A Literature Reviewon the Health and Development

of Adolescent Boys

WHAT ABOUTBOYS?

WHO/FCH/CAH/00.7Original: English

Distribution: General

Department of Child andAdolescent Health and DevelopmentWorld Health Organization

2 WHAT ABOUT BOYS?

WHO/FCH/CAH/00.7

Copyright World Health Organization, 2000

This document is not a formal publication of the WorldHealth Organization (WHO) and all rights are reserved bythe organization. The document may, however, be freelyreviewed, abstracted, reproduced or translated, in part orin whole, but not for sale nor for use in conjunction withcommercial purposes.

The views expressed in documents by named authors aresolely the responsibility of those authors.

Editor: Mandy MikulencakCover Photo: Straight Talk Foundation, UgandaDesigned by: Ita McCobbPrinted in Switzerland

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ACKNOWLEDGMENTS 5

INTRODUCTION 7

CHAPTER 1Adolescent Boys, Socialisation and Overall Healthand Development 11

CHAPTER 2Mental Health, Suicide and Substance Use 23

CHAPTER 3Sexuality, Reproductive Health and Fatherhood 29

CHAPTER 4Accidents, Injuries and Violence 41

CHAPTER 5Final Considerations 49

REFERENCES 53

table of contents

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5WHAT ABOUT BOYS?

acknowledgements

The author of this review is Gary Barker, Director of Instituto PROMUNDO, Rio deJaneiro, Brazil.

The helpful suggestions and contributions to the document by the following people are gratefullyacknowledged: Paul Bloem, Jane Ferguson, Claudia Garcia-Moreno, Adepeju Olukoya and ShireenJejeebhoy (WHO); John Howard (Macquarie University, Australia); Josi Salem-Pickartz (Family HealthGroup, Jordan); Wali Diop (Centre de Coopération Internationale en Santé et Développement, BurkinaFaso); Malika Ladjali (UNESCO); Matilde Maddaleno and Martine de Schutter (PAHO); Judith Helzner(IPPF/WHR, USA); Benno de Keijzer (Salud y Genero, Mexico) Neide Cassaniga (Brazil); Robert Halpern(Erikson Institute, USA); Jorge Lyra (PAPAI, Brazil); Lindsay Stewart (FOCUS, USA); Bruce Dick (UNICEF);Mary Nell Wegner (AVSC International, USA) Margareth Arilha (ECOS, Brazil) and Margaret Greene(Center for Health and Gender Equity, USA).

Thanks are also due to the Chapin Hall Center for Children at the University of Chicago; theInstituto PROMUNDO, Brasilia and Rio de Janeiro, Brazil; and the Open Society Institute, New York,U.S., for general support to the author during work on this document.

Gratitude is due for the financial support of UNAIDS and the Government of Norway.

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7WHAT ABOUT BOYS?

introduction

Assumptions are often made about thehealth and development of adolescent boys: thatthey are faring well, and supposedly have fewerhealth needs and developmental risks comparedto adolescent girls; and that adolescent boys aredisruptive, aggressive and �hard to work with.�This second assumption focuses on specificaspects of boys� behaviour and development �such as violence and delinquency � criticising andsometimes criminalising their behaviour withoutadequately understanding its context.

These generalisations do not take intoaccount the fact that adolescent boys � likeadolescent girls � are a heterogeneous population.Many boys are in school, but too many are out ofschool; others work; some are fathers; some arepartners or husbands of adolescent girls; othersare bi- or homosexual; some are involved in armedconflicts as combatants and/or victims; some aresexually or physically abused in their homes; somesexually abuse young women or other young men;some are living or working on the streets; othersare involved in survival sex.

The majority of adolescent boys are, in fact,faring well in their health and development. Theyrepresent positive forces in their societies and arerespectful in their relationships with young womenand with other young men. However, some youngmen face risks and have health and developmentalneeds that may not have been considered, or aresocialised in ways that lead to violence anddiscrimination against women, violence againstother young men, and health risks to themselvesand their communities.

Adolescent boys � like adolescent girls �are a heterogeneous population. Some arefaring well in their health and development.Other boys face risks and have needs thatmay not have been considered, or aresocialised in ways that lead to violence anddiscrimination against women.

New research and perspectives call for amore careful and thorough understanding of howadolescent boys are socialised, what they need interms of healthy development, and what healthsystems can do to assist them in more appropriateways, and how we can engage boys to promotegreater gender equity for adolescent girls.

The purpose of this document is to reviewexisting and available literature on adolescent boysand their health and development; analyse thisresearch for programme and policy implications;and highlight areas where additional research isneeded. This document also seeks to describewhat is special about adolescent boys and theirdevelopmental and health needs, and to makethe case for focusing special attention on meetingthe needs of boys and on working with boys topromote greater gender equity for adolescent girls.

Finally, this document is limited byinformation that was available. Some of theresearch and information on programmes workingwith adolescent boys is not in print; in many cases,programme experiences are new and have notyet been evaluated or documented. In many partsof the world, studies on adolescent health focusprimarily on adolescent girls (Majali and Salem-Pickartz, 1999).

Applying a Gender Perspective toAdolescent Boys

The �why� of focusing on adolescent boysemerges from a gender perspective. The reviewof research used a gender perspective from twoapproaches � gender equity and genderspecificity.

Gender equity refers to the relational aspects ofgender and the concept of gender as a powerstructure that often affords or limits opportunitiesbased on one�s sex. Gender equity applied toadolescent boys implies, among other things,working with young men to improve youngwomen�s health and well-being, and their relativedisadvantage in most societies, taking intoconsideration the power differentials that exist in

8 WHAT ABOUT BOYS?

many societies between men and women. Acommon refrain from programmes working inwomen�s and young women�s health in manyparts of the world is that girls and women areasking for greater involvement of men andadolescent boys in themes that were once definedas �female� � particularly, reproductive health andmaternal and child health. Many advocates arguethat unless adult and young men are engaged inthese issues in appropriate ways, gender equitywill not be achieved. Thus, a gender equityperspective for working with adolescent boyssuggests that we examine how social constructionsof masculinity affect young women and how wecan engage adolescent boys in improving thewell-being and status of women and girls.

Gender specificity refers to examining specifichealth risks to women and men because of: 1.)health problems that are specific to each sex forbiological reasons (such as testicular cancer orgynecomastia for young men); and 2.) the waythat gender norms influence the health of menand women in different ways. The typicalapproach to gender specificity in healthpromotion has been to show how each sex facesparticular risks or morbidities and then to developprogrammes that take into account these specificneeds. Applying gender specificity to adolescentmales suggests that we focus our attention onthose areas where young men have high rates ofmortality and morbidity and on those areas inwhich gender socialisation influences youngmen�s health behaviour and health status (NSWHealth, 1998).

A gender equity perspective has long beenconsidered in women�s health, examining howunequal power differentials between women andmen adversely affect the health and well-beingof women. In recent years, however, a numberof researchers, theorists and advocates haveasked us to reconsider some of our traditionalnotions about gender power differentials andmale dominance. Other researchers havequestioned some of our assumptions about men,and how much we really know about thesocialisation of boys and men.

Emerging research on adolescent and adultmen has suggested that while men were oftenconsidered the default gender, they have not beenadequately studied or understood. Some authorsargue that much social science research assumesthat men are genderless (Thompson and Pleck,1995). A review of literature on delinquency andcrime � which is overwhelmingly perpetrated byadolescent and young men � concludes thatmasculinity has been seen as inherently violent andthat the impact of gender socialisation on men haslargely been ignored in the study of violence(Messerschmidt, 1993). Numerous researchershave argued that men have been treated as absentin the reproductive process, whether in researchon fertility or in programme development(Figueroa, 1995; Greene and Biddlecom, 1998).Thus, one of the compelling rationales for applyinga gender-specific perspective to adolescent boysis that while we sometimes had statistics on theirhealth conditions and health-related behaviours,we did not have an adequate understanding oftheir realities, their socialisation and theirpsychosocial development.

In the last 15 years, a growing body ofresearch on men and masculinities has contributedgreatly to our understanding and offered newinsights on men�s health-related behaviours andtheir development. Connell�s work (1994 and1996) has been important in introducing the notionof multiple versions of masculinity or manhood,recognising that manhood is not a singular entity.Connell suggests that most cultural contexts havea �hegemonic masculinity,� or a prevailing modelof masculinity against which males comparethemselves, and alternative versions of masculinity.This theoretical framework is useful in identifyingmen who find ways to be different than theprevailing norms � an important point if we seekto promote more gender-equitable versions ofmasculinity.

Research on adolescent and adult men hassuggested that while men were oftenconsidered the default gender, they have notbeen adequately studied or understood.

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While we must keep in mind that men andboys as a group have privileges and benefits overwomen and girls, new perspectives suggest thatmale privilege is not a monolithic structure thatdistributes an equal slice of advantage to eachman. Furthermore, in other cases, it may be thatthe �costs� of masculinity exceed the benefits andprivileges. Low-income men, young men, menoutside the traditional power structure, young menin some settings, men who hold alternative views,homosexual and bisexual men, and other specificgroups of men are at times subject todiscrimination. Connell�s work and that of otherauthors (for example, Archer, 1994) have calledus to examine not only how men and womeninteract, and the power differentials in suchinteractions, but also how men interact with othermen and the power dynamics and violence thatsometimes emerge in such interactions. While weshould not portray young men as �victims� , thisnew field of research on men has alsodemonstrated that while men and boys may haveaggregate privileges over women and girls,manhood generally brings with it a mix of privilegeas well as personal costs - costs that are reflectedin the mental and other health needs of men.Being socialised not to express emotions, not tohave close relationships with one�s children, touse violence to resolve conflicts and maintain�honour,� and to work outside the home at earlyages are among the costs of being a man.

Applied to the health and developmentalneeds of adolescent boys, the field of masculinitiesis helping us understand how boys are socialisedinto prevailing norms about what is sociallyacceptable �masculine� behaviour in a givensetting and how boys� adherence to theseprevailing norms can sometimes have negative

consequences for their health and development.Of course, we should be careful not to portrayboys as mere puppets to social norms, and torecognise the contextual nature of their behaviour.Nonetheless, it is clear that the versions ofmasculinity or manhood that young men adhereto or are socialised into have importantimplications for their health and well-being andthat of other young men and women aroundthem.

Finally, however, we should remember thatgender is only one variable affecting developmentand health. Social class, ethnicity, local contextand country settings are all important variablesthat interact with gender to influence health andwell-being. By focusing on gender, and specificallymasculinity, as the variable, we have to be carefulnot to lose sight of these other important variables.Some searchers and advocates have questionedwhether paying too much attention to gender maydraw our attention away from the fundamentalsocial class and income inequalities related toadolescent health and development.

It is also important to keep in mind thatlooking at what is unique about boys often requirescomparing them to girls. In this document,�making the case� for focusing on boys oftenmeans highlighting areas where boys have higherrates of morbidities or mortality compared toyoung women. However, these comparisons areproblematic for several reasons. First, comparingrelative levels of disease burden by sex is not bias-free. Issues such as women�s victimisation byviolence, women�s depression, and chronic pelvicpain related to sexual tract infections (STIs) aresometimes excluded from health statistics. Second,simply comparing relative levels of risk by sex canlead to a polarising and simplistic debate aboutwho �suffers� more or which sex faces greaterhealth risks. Third, by emphasising differences, wemay downplay the important similarities betweenadolescent women and men. Furthermore, bycalling attention to the needs and realities ofadolescent boys we should not imply that girls�needs have been adequately considered andincluded � indeed, in most cases they have not.Finally, we could lose sight of the fact thatrelationships between boys and girls are importantto their development and well-being.

New perspectives suggest that maleprivilege is not a monolithic structure thatdistributes an equal slice of advantage toeach man. Low-income men, young men,men outside the traditional powerstructure, men who hold alternative views,homosexual and bisexual men, and otherspecific groups of men are at times subjectto discrimination.

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With these caveats, this documentapproaches the health and developmental needsof adolescent boys via three questions:

❋❋❋❋❋ How do adolescent men and women differin their health needs, strengths or potentialsand risks?

❋❋❋❋❋ What are the implications of gender-specifichealth needs for health interventions foradolescent boys?

❋❋❋❋❋ Based on what we know about adolescentboys, how can we work with them topromote greater gender equity?

While a certain amount of comparisonbetween the health needs of adolescent malesand females is inevitable, the challenge is toexamine the specific realities of adolescent boysin a way that allows us both to understand theirlegitimate needs and to work with boys topromote greater gender equity. From a women�srights perspective, some advocates, researchersand health practitioners have voiced a thoughtful

While a certain amount of comparisonbetween adolescent males and females andtheir respective health needs is inevitable,the challenge is to examine the specific needsand realities of adolescent boys in a way thatallows us both to understand their legitimateneeds and to work with boys to promotegreater gender equity.

concern that calling attention to the health needsof boys and men may draw resources and attentionaway from women�s health concerns � concernsthat in some countries have only recently begunto be addressed. However, if we use this dualperspective of gender specificity and gender equity,we can potentially avoid a debilitating debate overwhose needs are more urgent and instead focuson gender equity for women and young men, andunderline this and at the same time incorporatinga concept of gender specificity when it is useful tounderstand the gender-specific health anddevelopmental needs of boys.

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adolescent boys, socialization and overallhealth and development

chapter 1

General Health Status and Health Trends

Like adolescent girls, adolescent boys aregenerally �healthy,� that is, they show low levelsof morbidity and mortality compared to childrenand adults. However, some adolescent boys facespecific morbidities and, on the whole, showhigher rates of mortality than adolescent girls.According to international health data, the majordifference between adolescent boys and girls isthat boys generally show higher rates of mortality,in some places several times higher, while girls inmost regions show higher rates of morbidity.Furthermore, there are significant differences inthe causes of mortality and morbidity that boysand girls face. Boys world-wide show higher ratesof mortality and morbidity from violence,accidents and suicide, while adolescent girlsgenerally have higher rates of morbidity andmortality related to reproductive tract andpregnancy-related causes.

This chapter reviews general healthconcerns of adolescent boys and the gender-specific challenges that boys may face as theytransition to adulthood. Health anddevelopmental concerns of boys affect their well-being during adolescence and have importantimplications for their future health and well-beingas adults. WHO estimates that 70 percent ofpremature deaths among adults are due tobehavioural patterns that emerge in adolescence,including smoking, violence, and sexualbehaviour.

Boys world-wide show higher rates ofmortality and morbidity from violence,accidents and suicide, while adolescent girlshave higher rates of morbidity and mortalityrelated to reproductive tract andpregnancy-related causes.

General Morbidity and Mortality

In every region of the world except for Indiaand China (which combined represent about one-third of the world�s population), WHO data showsthat Disability Adjusted Life Years (DALYs) lost,which take into account mortality and disabilitydue to morbidity, are higher for men than forwomen (see Table 1). As we present DALY figures,however, it is important to keep in mind that suchbroad gender comparisons sometimes downplayother health issues. While there are fewer deathsamong adolescent women world-wide, womenmay suffer from domestic violence, sexual violenceand other morbidities that are reflected poorly ornot at all in DALY figures.

In most regions of the world, adult men havehigher mortality rates from causes not specific toeither sex. Men die of heart disease and cancermore frequently than women at all ages, and untilold age, men have higher rates of accidents andinjuries. Women in most industrialised and manydeveloping countries suffer from a higherincidence of non-fatal conditions and in somesettings are more likely to pay attention to theirhealth needs. Overall, in most regions of the world,men have higher rates of fatal conditions, whilewomen have higher rates of acute illness and non-fatal chronic conditions.

According to these DALY figures, genderdifferences are highest in industrialised countries,in Latin America and the Caribbean, and in theformer socialist economies of Europe. Onepossible explanation for this gender difference inDALYs is that in countries and regions that havemade substantial advances in maternal and childhealth, the morbidities and mortalities of menrepresent a growing proportion of the public healthburden. Overall, in Latin America and theCaribbean, for example, the health burden formen is 26 percent higher than it is for women(World Bank, 1993). Examining regional andcountry-level statistics on men�s health finds thatmuch of this disease burden is due to healthproblems associated with the gender socialisation:

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traffic accidents (where bravado and alcohol usecome into play), injuries (associated with theworkplace and with intra-gender violence),homicides (the vast majority as a result of intra-gender violence) and cardiovascular diseases,associated in part with stress and lifestyles.Reviewing data from Mexico, Keijzer (1995)found that mortality rates for males and femalesare about equal until they reach age 14. At thattime, male mortality begins to increase and istwice as high overall for males among youngpeople ages 15-24. The top three causes of deathfor young men in Mexico � accidents, homicideand cirrhosis � are related to the societal normson masculinity. These trends are repeatedthroughout Latin America and in other parts ofthe world, from the Middle East, to WesternEurope, to North America and Australia (Yunesand Rajs, 1994; Commonwealth Department ofHealth and Family Services, 1997).

Limited studies using official health statisticsfrom some industrialised countries suggest thatfrom birth to age 7, boys have higher rates ofhealth problems than girls. After the perinatalperiod, boys in Finland had a 64 percent highercumulative incidence of asthma, a 43 percenthigher cumulative incidence of intellectualdisability, and 22 percent higher level of mortality.Similar trends have been reported in Australia.Some researchers suggest that there may be somebiological propensity for boys� greater rates of

health complications during childhood, some ofwhich may carry over into adolescence (Gissler etal., 1999; NSW Health, 1998).

Infectious Disease Burden

The limited data on sex differences incommunicable and infectious diseases provideslittle evidence for sex differences. A national studyof adolescent health in Egypt found that theprevalence of parasitic diseases was 57.4 percentfor girls and 55.5 percent for boys, representingno statistical difference (Population Council, 1999).In terms of schistosomiasis, WHO data indicatesthat in affected regions, infection rates peakbetween the ages of 10-20 because of the degreeof water contact and age-related immunity. Somegender differences are found in rates ofschistosomiasis infection in specific contexts,depending on whether boys or girls are more likelyto come in contact with infested rivers and lakes(Personal correspondence, Dirk Engels, 1999). Theepidemiology of tuberculosis shows a differentpattern. Recent WHO data indicates higher TBincidence and death in girls than in boys up to theage of 14. Between 15 and 19 that the pattern isinversed and boys show higher levels. However,for most infectious diseases, large sex differencesare unlikely, except when differences in gendersocialisation affect boys� or girls� exposure toinfectious agents.

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Graph 1 Sex differences in adolescent burden of disease(DALYs for all causes in 10-19 yr olds, 1990)

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Self-Reported Health Status

From existing data on self-reported healthstatus, it is difficult to arrive at any conclusionsabout whether boys or girls have better generalhealth. Furthermore, when adolescents are askedto report their health status, their responses arelikely to be influenced in part by gender norms.In most countries, girls are more likely to beattuned to health problems, whereas boys maybe more likely to ignore them, to diminish theirimportance, not to report them and not to seekhealth services when they need them. Forexample, Thai girls were more likely than boys toreport a current health problem: 25.2 percent forfemales compared to 14.9 percent for males.However, nearly equal numbers of males andfemales reported having purchased medication forthemselves in the past month, suggesting that boysand girls face virtually equal rates of healthproblems, but that girls are more likely to reportthese problems (Podhisita and Pattaravanich,1998). A national study on adolescent health inEgypt found that 20.7 percent of adolescentsreported having had an illness in the previousmonth, the most common complaints beingcommon cough and cold followed bygastrointestinal problems. There was virtually nodifference in reported rates of illness by gender(Population Council, 1999).

Nutrition, Growth, Puberty andSpermarche

Nutrition

An analysis of existing data questions thelong-standing assumption that boys� nutritionalstatus is better than that of girls. In developingcountries for which data is available, the nutritionalstatus of boys and girls is about equal, or boys arefaring worse. The exception is India, where girls�nutritional status is markedly worse than boys.

In a review of 41 Demographic and HealthSurveys for 34 countries examining children frombirth to 5 years, 24 surveys show that boys havehigher levels of wasting than girls; 19 surveys showthat stunting levels are higher for boys, while onlyfive surveys show more stunting among girls. Thedifferences in nutritional status between boys andgirls ages 0-5 were relatively small, but the authors

conclude that, overall, girls in the countries studiedseem less likely to be undernourished than boys.Of the 34 developing countries included, theauthors did not find any country where girls hada consistent nutritional disadvantage comparedwith boys (United Nations, 1998). Otherresearchers have hypothesised that differentialtreatment for boys and girls, favouring boys interms of food allocation, should result in lowernutritional status for girls during later childhoodand adolescence. However, data has either beeninconclusive or has not confirmed this hypothesis,with the important exception of India, notedearlier.

With some exceptions, data on sexdifferences in stunting during adolescence aresimilarly inconclusive. Between 27-65 percent ofadolescents showed stunting according to datafrom 11 studies representing nine developingcountries. In Benin and Cameroon, boys showedmore stunting than girls. The authors suggest thatin these two countries, boys may be encouragedto be independent earlier than girls and are thusmore likely to have diarrhoeal diseases. In India,stunting was far more prevalent among girls thanboys � 45 percent compared to 20 percent �which is consistent with the presumed effects ofgender bias in parts of South Asia (Kurz andJohnson-Welch, 1995). In the national adolescenthealth study in Egypt, boys were more likely tobe stunted: 18 percent for boys versus 14 percentfor girls (Population Council, 1998). In seven ofeight studies presenting data, at least twice asmany adolescent boys as girls wereundernourished (Kurz and Johnson-Welch, 1995).A note of caution is needed in regard toanthropometric measures underlying stunting andwasting in adolescents. Recent work in this areaby WHO shows that both the indicators to identifywasting and stunting in adolescents, as well as thecut-off points for different degrees of theseconditions, need more research. It has not beenestablished whether sex differences play any rolein the anthropometry of nutritional status inadolescents.

In developing countries for which data isavailable, the nutritional status of boys andgirls is about equal, or boys are faring worse.The exception is India, where girls�nutritional status is markedly worse thanboys.

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Similarly, a review of data on the nutritionalstatus of adolescents in developing countriesfound that prevalence of anaemia was 27 percentfor adolescents overall, with similar rates amongboys and girls (United Nations, 1998). In Egypt,the overall prevalence rate of anaemia was 47percent, with little difference by gender. Boys hada slightly higher rate of anaemia until age 19,when anaemia for girls increased (PopulationCouncil, 1999). Adolescent girls were oftenpresumed to have higher rates of anaemiabecause of iron lost during menstruation, but boysalso have high iron requirements because theyare developing muscle mass during the adolescentgrowth spurt.

The implications of a possible nutritionaldisadvantage for boys are unclear. Some authorshave suggested that the issue is related to boys�delayed and longer growth spurt. In terms ofstunting, boys may later catch up with girls. Inany case, the existing data suggests paying closerattention to boys� nutritional status and re-examining the longstanding presumption of girls�nutritional disadvantages.

Puberty and Spermarche

Puberty is generally recognised as thebeginning of adolescence. With biologicalchanges and sexual maturation, adolescents mustincorporate their new body images, reproductivecapacity and emerging sexual energies into theiridentity and learn to cope with their own andothers� reactions to their maturing bodies. Thereare biologically-based differences for boys andgirls in the timing of puberty and socially-constructed gender differences in the meaning ofand reactions to puberty for boys and girls.

In terms of biologically-based differences,sexual development among girls generally startsat age 8 with the first stages of breastdevelopment. Menarche usually occurs between10.5 and 15.5 years with the female adolescentgrowth spurt between 9.5 and 14.5 years. Malesare slower to mature sexually, with testicularenlargement generally occurring between 10.5and 13.5 years and the growth spurt andspermarche about one year later (PopulationCouncil, 1999). Compared to growth duringchildhood, the growth during adolescence is

shorter but more intense. Most boys reachspermarche by age 14, and are about two yearsolder than girls at the height of their maximumgrowth spurt. The amount of height attained duringthe growth spurt, however, is about equal for boysand girls.

The social meaning of menarche andspermarche are often quite different. Typically, boysare not encouraged to talk about pubertal changesnor offered spaces to ask questions or seekinformation about these changes(Pollack, 1998).In contrast, menarche sometimes implies enhancedsocial status while also bringing with it increasedsocial controls over young women and theirmovements and activities outside the home.Societies seem to have developed more structuresto discuss and prepare girls for menarche than theydo boys for spermarche. However, these�structures� in some settings can be repressive foryoung women, including forced seclusion of girlsof reproductive age and even female genitalmutilation. Boys on the other hand, may be givenmore information and guidance related to sexualactivity, but not necessarily information aboutpuberty and its procreative implications. In somecases, boys have more information aboutmenarche than ejaculation, given the societalimportance attached to female reproduction.Reasonable conclusions are that puberty meansintense social pressure for both boys and girls toascribe to gender norms; that girls generally havetheir movements and activities restricted to agreater degree than boys after puberty; and thatboys in some settings may have less guidanceabout their reproductive potential.

While there are some studies aboutadolescent girls and their reactions to puberty andphysical changes during adolescence, research islacking on how adolescent boys feel about theirbodies and their ability to procreate. AmongBrazilian university students, 50 percent of youngmen had positive feelings toward their bodydevelopment and sexuality, 23 percent wereindifferent and 17 percent reported being anxious

Puberty means intense social pressure forboth boys and girls to ascribe to gendernorms.

15WHAT ABOUT BOYS?

and uncertain about physical changes duringpuberty (Lundgren, 1999). Limited research in theU.S. has examined young men�s awareness ofthemselves as procreative beings. Among youngmen ages 16-30 in the U.S., this awareness is nota major event. In fact, in their desire for sex, someyoung men even seem to repress notions orconcepts of themselves as procreative. This limitedresearch suggests the need to help young menthink about themselves as procreative and to offerthem spaces where they can discuss what it meansto be capable of procreation (Marsiglio,Hutchinson and Cohan, 1999).

Biological Differences in Development

Some research has also examined hormonaldifferences in boys and girls, particularly thepossible role of testosterone both in earlychildhood and adolescence. This limited researchsuggests that there may be significant hormonaldifferences between boys/girls and men/womenthat are still only partially understood. There maybe biologically-based differences in early braindevelopment for boys and girls which affects boys�and girls� styles of communication. Researchsuggests that early exposure to testosterone ininfant boys is associated with boys� greater levelof aggression and agitation, a lower attention spanthan in infant girls, and less visual acuity at earlyages (Manstead, 1998). The meaning and extentof these biological differences are ambiguous.Furthermore, existing research suggests that overalldifferences within sexes are often greater thanaggregate differences between the sexes. In anycase, it is important to keep in mind that thesebiologically-based differences such as thebiological tendency toward greater agitation inboys interacts with gendered-patterns ofsocialisation described below (Manstead, 1998;Pollack, 1998).

Socialisation and PsychosocialDevelopment

Gender-Specific Theories of AdolescentDevelopment

While biologically-based differences andoverall growth and nutritional differences betweenadolescent boys and girls exist, probably the mostsignificant differences, with the greatestimplications for programme and policy, are thoserelated to the gender-specific socialisation of youngpeople and the ensuing differences in theirpsychosocial development before and duringadolescence.

There is a growing body of research andtheory on the psychosocial development of boys,mainly from industrialised countries, that servesas an important complement to previous work onthe psychosocial development of adolescent girls.While there is considerable individual, local andcultural variation, there are similarities acrosscultures that allow us to begin to construct gender-specific theories of the psychosocial developmentof adolescent males.

It is important to keep in mind culturalvariations in the concept of adolescence. Thereare major cultural and urban-rural differences interms of whether the passage from childhood toadulthood is fairly short and direct, or whether itis prolonged (as in many modern, Westernsocieties) and frequently marked by extendedformal schooling and conflicting role expectations,among other common characteristics. In spite ofcultural and contextual differences, there is ageneral consensus that adolescence implies, inaddition to new reproductive capacities: 1.) anincrease in cognitive abilities, and as aconsequence, concern over future roles andidentity; 2.) greater social expectations that theyoung person contribute to household income,maintenance and production; and 3.) socialexpectations of greater economic independencefrom the family of origin and/or the formation ofa new family unit.

16 WHAT ABOUT BOYS?

Keeping in mind these cultural variationsin the concept of adolescence, emerging researchon boys� psychosocial development concludesthat boys have different potential crisis pointsduring their psychosocial development and theirown specific vulnerabilities, even though theysometimes appear and are assumed to be lesspsychologically vulnerable than girls inadolescence. New, more targeted research onadolescent boys finds that once we get beyondboys� customary silences, their �clowning� andtheir feigned indifference, boys face their shareof challenges during adolescence that have oftenbeen ignored or sometimes misdiagnosed.Another common refrain in research on boys�psychosocial development is that men�sdiscussions of identity and roles continue to belimited while 20 years of research and policydevelopment expanded women�s options androles in some areas of the world. Boys world-widereport experiencing the dual pressures to act like�real men� as traditionally defined and to be morerespectful and caring in their relationships withyoung women.

In looking at the normative pattern of boys�development in Western settings, variousresearchers argue that boys experience difficultmoments at ages 5-7 when they enter the formalprimary school and have to learn how to sit still,stay on task and operate in educational systemsthat in some ways seem more attuned to girls�overall patterns of socialisation (Pollack, 1998;Figueroa, 1997). At the same time, entering theformal school system frequently means greaterexposure to male peer groups and the �cultureof cruelty� that they can perpetuate. Certain actsand behaviours considered �feminine� can elicitharsh criticisms from the social group, includingusing stereotypes of homosexuality. One

researcher in the U.S. suggests that both in theirintroduction to school and in early adolescence,boys are pressured to achieve autonomy andseparation from familial support before they arenecessarily ready (Pollack, 1998).

In adolescence, boys often face continuingpressure from the male peer group, where sexualexperiences may be viewed as achieving ordemonstrating competence, rather than achievingintimacy and connection (Marsiglio, 1988). In lateadolescence, boys are often encouraged to furtherdistance themselves from their parents. They may,in fact, desire greater connection with their parentsor other adults but find themselves unable toexpress this desire because of social sanctionsagainst boys� expression of emotional need andvulnerability (Paterson, Field and Pryor, 1994;Pollack, 1998).

Boys and Gender Identity Formation

These new perspectives on adolescent malesbuild on previous research and theories on genderidentity development and gender socialisationduring early childhood. Many developmentalpsychologists argue that fundamental aspects ofgender identity are linked to the earliestexperiences of being cared for and to the persongiving that care. According to these theories, thefundamental task of early gender identitydevelopment for boys is to develop a separategender identity than the mother�s and thus achievea greater normative separation from the motherthan girls generally do. At the stage of separationfrom the primary attachment figure (generally themother), a boy must achieve separation andindividuation, and publicly define his genderidentity (Gilmore, 1990; Chodorow, 1978).

According to this theoretical perspective,boys become non-affective. To create an identitythat is different from their mother�s � in essence,anti- or not-mother � they frequently rejectfeminine characteristics, namely emotional displaysand affection (Chodorow, 1978; Gilmore, 1990).Furthermore, with the pressure they face to definethemselves as masculine in the public arena andbecause their male role models are often distant,boys may exaggerate their masculinity to make itclear in their social world that they are in fact �realboys� (Pollack, 1995; Chodorow, 1978). In sum,

Emerging research on boys� psychosocialdevelopment concludes that boys havedifferent potential crisis points during theirpsychosocial development and their ownspecific vulnerabilities, even though theysometimes appear and are assumed to beless psychologically vulnerable than girlsin adolescence.

17WHAT ABOUT BOYS?

numerous researchers and theorists argue that girlsdefine themselves more in relationship to othersbecause girls� intense attachment to their motherlasts longer (Gilligan, 1982; Chodorow, 1978).Several researchers assert that the clinicalramifications for men emerging from these earlypatterns are problems achieving intimacy andexpressing emotions (other than anger), andhidden depression resulting from early unmetemotional needs. This depression may bemanifested in alcoholism, abuse and anger(Levant and Pollack, 1995; Real, 1997).

Almost universally, cultures and parentspromote an achievement- and outward-orientedmasculinity for boys and men (Gilmore,1990).This achievement-oriented manhood is specificallyconstructed so that boys reach the societal goalsof being providers and protectors. Many culturessocialise young boys to be aggressive andcompetitive � skills useful for being providers andprotectors � while socialising girls to be non-violentand sometimes accepting of male violence (Archer,1984). Boys are also sometimes brought up toadhere to rigid codes of �honour� and �bravado,�or feigned courage, that obligate them to compete,fight and use violence, sometimes over minoraltercations, all in the name of proving themselvesas �real men� (Archer, 1994).

During late childhood and adolescence,boys may be more likely to accept traditionalversions of manhood, displaying �machismo,� oran exaggerated sense of masculinity. Girls,however, are more likely to question traditionalgender norms (Erulkar et al., 1998). Thus, thenormative challenges in gender identity for girlsmay be to question the limits that they perceiveare placed on them upon reaching puberty, whilefor boys, the challenge may be to prove oneselfas a �man� in the social setting, while searchingfor ways to create intimacy and connection inprivate settings. Some researchers suggest anormative pattern of gender identity developmentin which adolescent boys pass through a periodof exaggerated manhood, but then become moreprogressive or flexible in terms of their genderidentities later in adulthood (Archer, 1984).However, other research from a lifespanperspective suggests that unemployment or socialchanges (for example, women�s new roles in manysocieties) may threaten some men�s conceptions

of masculinities and lead to more rigid conceptionsof gender roles, and even to domestic violence.Thus, some men may over the lifespan becomemore flexible in gender roles, while for others, theirviews about gender roles may be situational.Additional research from a lifespan perspective isneeded to offer insights on the tendencies andpossible changes in men�s views of their roles.

Is it possible to change how boys aresocialised? First, it is important to affirm that notall traditional forms of raising boys, and viewsabout manhood, are negative, nor are all boyssocialised in the stereotypical ways presented insome research. Research suggests the importantrole of fathers and other male family members inraising boys who are more flexible in their viewsof masculinity. But all family members have animportant role in socialising boys. Mothers andother female family members may inadvertentlyreinforce traditional views about masculinity bynot involving boys in domestic tasks, orencouraging them to repress emotions or not tocomplain about health needs. Mothers, fathers,other family members, teachers and other adultswho interact with young people may worry moreabout girls during puberty, believing that boys canmanage without guidance. Research finds thatwhen boys interact with adults and peers whoreinforce alternative views about gender � forexample, men involved in caring for children orin domestic tasks, or women involved in leadershippositions � boys are more likely to be flexible intheir views about gender roles (Pollack, 1998;Barker and Loewenstein, 1997).

Socialisation Outside the Home and theMale Peer Group

Studies from many parts of the worldconclude that from an early age, boys generallyspend more unsupervised time on the street or

Studies from many parts of the worldconclude that boys generally spend moreunsupervised time on the street or outsidethe home than do girls. This time outsidethe home represents both benefits and risksfor adolescent boys.

18 WHAT ABOUT BOYS?

outside the home than do girls, and participatein more economic activities outside the home(Evans, 1997; Bursik and Grasmick, 1995; Emlerand Reicher, 1995). During adolescence, theamount of time adolescent boys spend outsidethe home increases further. In Latin America, forexample, an important share of the economicallyactive population is between ages 15-19. Whilelabour force participation is increasing amongfemales and decreasing for males, it continues tobe substantially higher for males. In Ecuador, forexample, 44 percent of boys and 19 percent ofgirls from low-income families studied wereengaged in wage-earning activities. In fivedeveloping country studies reviewed, girls weremore likely to do work in the home while boyswere far more likely to work outside the home(Kurz and Johnson-Welch, 1995). In Egypt, one-third of adolescents work, with one out of everytwo boys involved in economic activities outsidethe home compared to one in every six girls. Also,48 percent of boys went out with friends the dayprior to the interview compared to 12 percent ofgirls (Population Council, 1999).

This time spent outside the home representsboth benefits and risks for adolescent boys. Whilefreedom of movement is generally a benefit, andprovides boys with opportunities to learn socialand vocational skills useful for their development,it also brings risks and costs. The primary risk isrelated to the kinds of behaviour and socialisationpromoted by the male peer group. These peersmay encourage health-compromising behaviourssuch as substance use or may promote traditional,restrictive male behaviours such as the repressionof emotions.

Because of the time they spend outside thehome, in many cultural settings, girls� role models(mothers, sisters, aunts, other adult women) arephysically closer and perhaps more apparent forgirls, while boys� same-sex role models may bephysically and emotionally distant. Accordingly,some researchers have suggested that the malepeer group is the place where young men �tryout and rehearse macho roles,� and that the malestreet-based peer group judges which acts andbehaviours are worthy of being called �manly�(Mosher and Tomkins, 1988). However, theversions of manhood that are sometimespromoted by the male peer group can be

homophobic, callous in their attitudes towardwomen, and supportive of violence as a way toprove one�s manhood and resolve conflicts.

While the male peer group is not the causeof males� aggressive attitudes or of macho attitudes,greater association with an oppositional, street-based peer group is correlated with academicdifficulties, substance abuse, risk-taking behaviourin general, delinquency and violence (Archer,1994; Earls, 1991; Elliott, 1994). Furthermore,while the male peer group is often studied for itsnegative influences on boys, there are alsoexamples of male peer groups that have positive,prosocial influences on boys. A positive male peergroup can serve several important functions: 1.) itprovides a sense of belonging as boys seek or areencouraged to seek independence, 2.) it providesa buffer against a sense of failure that some low-income boys may experience in the school setting,and 3.) it provides boys with models for maleidentity, which may be missing in some homes.

It is interesting to note that some researchsuggests that this differential socialisation � girlscloser to home and female role models, and boysoutside the home � also leads to different kinds ofcognitive development or �intelligences� for boysand girls. Consistently, women have a greaterability to read emotions and a greater ability todecode non-verbal messages (Manstead, 1998).Some researchers suggest that girls develop more�emotional empathy� � the ability to �read� andunderstand human emotions � while boys develop�action empathy� � the ability to �read� andinterpret action and movement (Pollack, 1998).

Boys and School Performance

Emerging data on school performance andenrolment suggest that boys face special challengesin completing their formal education. In a 1994UNICEF meeting, researchers from the Caribbean,North America, parts of South Asia and someurban areas in Latin America reported that insecondary schools in several countries in theregion, young men currently comprise fewer than50 percent of students in secondary schools (Engle,1994). While female disadvantage in the educationsector is stil l prevalent in many regions �particularly South Asia, Africa and some rural partsof Latin America � in other areas, girls�

19WHAT ABOUT BOYS?

disadvantage has diminished substantially andeducational inequality based on socio-economicstatus is more prevalent than gender imbalancesin education enrolment and attainment (Knodeland Jones, 1996). Where the structural barriersto girls� access to formal education have beenovercome, there is increasing evidence that boysface gender-specific educational challenges.

Throughout Western Europe (with theexceptions of Austria and Switzerland) girlscurrently outperform boys on standardised tests,graduate from secondary school in highernumbers and are more likely to attend university(Economist, 1996; Pedersen, 1996). In the U.S.,national figures show that boys score higher onstandardised tests in math and science, but girlsscore higher on writing and reading, arguably themost important skills for academic success(Ravitch, 1996). In low-income, urban areas inmany industrialised countries, the differencesbetween girls� and boys� academic performanceare even more accentuated. In Brazil, as of 1995,95.3 percent of young women ages 15-24 wereliterate compared to 90.6 percent of boys. Inaddition, 42.8 percent of girls in this age rangewere enrolled in school compared to 38.9 percentof boys. Boys are also more likely to repeat a grade(Saboia, 1998). The most frequent explanationfor boys� lower school enrolment and achievementis that boys begin working outside the home atearlier ages and their work outside the home mayinterfere with school.

Similarly, by age 19, girls in the Philippineshad on average 10 years of education comparedto 8 years for boys. Girls also spend more timeeach week in school. As in Brazil, researchershypothesised that boys were being taken out ofschool to work, but respondents felt that boys�

higher rates of school drop-out were related togender issues within the school environment,namely that girls� behaviour patterns were morein tune with school norms (Kurz and Johnson-Welch, 1995). It is important to note that boysdropping out of school in order to work is notalways perceived as negative. In certain parts ofNigeria, cultural practice requires boys to end theirschooling around age 13 to become highly valuedapprentices with trading masters. Women,therefore, are the majority at universities.

Researchers in parts of North America, theCaribbean, Australia and Western Europe arebeginning to ask what specific factors impedeboys� � and particularly low-income boys��academic achievement. This research has focusedon several issues, including the possibility thatsocialisation in the home for girls encouragespositive study habits, and that the schoolenvironment is more conducive to �female� waysof thinking and interacting. In Jamaica, where girlsare outperforming boys at the secondary andtertiary levels, boys are generally socialised to runfree while girls are confined to the home. As aresult, girls may learn to concentrate on tasks, sitstill for longer periods of time and interact withgreater ease with female authority figures.Research from North America and the Caribbeanon low-income boys suggests that teachers (themajority of whom are women at the primary level)sometimes possess stereotypical images of boys,creating self-fulfilling prophecies � i.e. they thinkthat boys will act out and, in turn, boys act out(Figueroa, 1997; Taylor, 1991). Qualitativeresearch is also examining the dynamics of genderrelations in low-income, urban settings where malepeer groups may be ambivalent to schoolcompletion, and where school systems expel thosechildren and youth who do not conform to itsmodes of authority and interaction � in mostinstances, these are more likely to be boys.

In Western Europe, Australia, NorthAmerica, Caribbean and parts of Latin America,researchers are also examining learning disabilitiesthat may impede boys� academic performance,including attention deficit hypertensive disorder(ADHD) � also known as hyperactivity or attentiondeficit disorder � which is more prevalent amongboys that girls (Pollack, 1998). Boys also havehigher reported rates of conduct disorder in school,

Data on school performance in WesternEurope, Australia, North America, partsof Latin America and the Caribbeansuggests that where the structural barriersto girls� access to formal education havebeen overcome, boys face gender-specificeducational challenges.

20 WHAT ABOUT BOYS?

a factor associated with lower educationalperformance (Stormont-Spurgin and Zentall,1995; Pollack, 1998). Boys who rated high onstereotypical �masculine� behaviours had thehighest rates of externalising behaviour andconduct disorder, which in turn are associatedwith higher rates of school difficulties (Silvern andKatz, 1986).

While this research on boys� experiencesin the school system is far from definitive, anumber of compelling questions arise. One is thecost of boys� oppositional and aggressivebehaviour in terms of their early educationalachievement. At the primary school level, thecontrol mechanisms that educational systemshave over disobedient, troublesome or aggressiveboys or those who are not performing at academiclevels are various: placing boys in slower trackgroups, retention, or labelling them as havingsome specific problem, the most common beingADHD. While some boys have a neurologicalpredisposition that warrants both the term andtreatment associated with ADHD, someresearchers and commentators have questionedthe sometimes overzealous tendency to use thisdiagnosis in some Western settings (Mariani,1995; Pollack, 1998). Researchers haveconfirmed a connection between early conductdisorder and ADHD and later involvement indelinquency and problems in the school setting(Moffitt, 1990; Cairns and Cairns, 1994). Whatis not clear is whether these boys havebiologically-based temperamental traits thatpredispose them to ADHD and aggressivebehaviour, or whether being labelled as�troublesome� or delinquent leads boys tobecome delinquent and have difficulties in school.

Boys� school performance has importantimplications in terms of individual developmentand health. Research from North America hasfound that school performance as well as thedegree of �connection� to the school areprotective factors against health�risk behaviours.Youth who do better academically and who feelconnected to their school display fewer riskbehaviours, including substance use, early andunprotected sexual activity, and suicidal thoughts.(Resnick et al., 1997).

Boys and Health-Seeking and Help-SeekingBehaviour

The pressure to adhere to traditional andstereotypical norms of masculinity has directconsequences for men�s mental and other health,and for their health-seeking, help-seeking and risk-related behaviour. A national survey of adolescentmales ages 15-19 in the U.S. found that beliefsabout manhood emerged as the strongest predictorof risk-taking behaviours; young men who adheredto traditional views of manhood were more likelyto report substance use, violence and delinquency,and unsafe sexual practices (Courtenay, 1998).Pleck (1995) asserts that violating gender normshas significant mental health consequences for men� ridicule, family pressure and social sanctions �and that a significant proportion of males feel stressas a result of not being able to live up to the normsof �true manhood.� O�Neill, Good and Holmes(1995) suggest that the version of manhoodpromoted in many societies leads to sixcharacteristics frequently found in men: restrictiveemotionality; socialised control, power andcompetition; homophobia; restrictive sexual andaffectionate behaviour; obsession withachievement and success; and health problems.In settings where they feel comfortable expressingsuch emotions � generally outside of the traditionalmale peer group � some young men are able toexpress frustration at these rigid gendersocialisation patterns just as girls have expressedfrustration about their gender normative patterns(Pollack, 1998; Barker and Loewenstein, 1997;Gilligan, 1982).

Research confirms that boys are less likelythan girls to seek health services when they needthem and less likely to be attuned to their healthneeds. A study in Thailand found that adolescentgirls in urban areas were more likely than boys toreport having sought medical attention in the lastmonth. However, nearly equal numbers ofadolescents reported having purchasedmedications for themselves in the past month,suggesting nearly equal rates of illnesses for boysand girls (Podhisita and Pattaravanich, 1998). Ina Kenyan study, girls were slightly more likely thanboys to have used health facilities (52 percentversus 47 percent) (Erulkar et al., 1998). InJamaica, a national survey of young people ages15-24 found that young women were more than

21WHAT ABOUT BOYS?

twice as likely (29.8 percent versus 13 percent) totalk to health personnel about family life educationtopics than were young men (National FamilyPlanning Board, 1999). A nation-wide survey ofboys ages 11-18 in the U.S. found that by thetime they entered high school, more than one infive boys said there had been at least one occasionwhen they did not seek needed health care. Theprimary reason cited was not wanting to tellanyone about their problem (28 percent), followedby cost and lack of health insurance (25 percent)(Schoen et al., 1998). Other anecdotalinformation finds that young men sometimesencounter hostile attitudes in clinics, that theyperceive maternal and child health clinics andreproductive health clinics as �female� spaces, andthat they are even turned away from clinics(Armstrong, 1998; Green, 1997). Young men ina Ghana study said they were sometimes turnedaway from reproductive health clinics because oftheir age; others said they were uncomfortablewith female staff (Koster, 1998). Indeed, whilethere are health professionals who specialise inworking with girls and women, such as agynaecologist, there is no such professional foradolescent and adult men.

How might boys be encouraged to makegreater use of existing health services? Whenasked, boys often say that they want many of thesame things in health services that young womenwant: high quality service at an accessible price;privacy; staff who are open to their needs;confidentiality; the ability to ask questions; and ashort waiting time (Webb, 1997; Site visit toCISTAC, Santa Cruz, Bolivia, 1998).

Research also suggests that gendersocialisation is related to boys� limited help-seekingbehaviour. Boys are generally socialised to beself-reliant and independent, not to showemotions, not to be concerned with or complainabout their physical health, and not to seekassistance during times of stress. Research inGermany with boys ages 14-16 found that in timesof trouble, 36 percent would prefer to be aloneand 11 percent said they needed no comfort; 50percent of boys turned to their mothers, and fewerthan 2 percent said they turned to their fathers(Lindau-Bank, 1996). Among low-income youthin the U.S., girls more frequently learn how toand are allowed to process pain and emotions

brought on by the frustrations of living in a low-income and violent setting (Nightingale, 1993).Researchers have concluded that the ability toprocess and express emotional stress in non-violentways protects against a number of developmentaland health problems. Thus, boys are at adisadvantage if they have fewer opportunities andfeel constrained to express emotions associatedwith adverse circumstances and stressful life events(Cohler, 1987; Barker, 1998).

Boys� difficulties in seeking help andexpressing emotions have importantconsequences for their mental health anddevelopment. Where boys are working in largenumbers or spend their time outside the homeand school settings, boys may also be less likelythan girls to be connected to informal and formalsupport networks. While male kinship and peergroups may provide a space for socialisation andcompanionship, they may provide limitedopportunities for discussions of personal needsand health concerns.

Implications

Summing up, the literature suggests that thebiological differences that exist between boys andgirls affect their health and development in a morelimited way than differences due to gendersocialisation. The literature identifies two keytrends in the socialisation of adolescent boys withdirect implications for their health and well-being:1.) a too-early push toward autonomy and arepression of desires for emotional connection;and 2.) social pressure to achieve rigidly definedmale roles. In some low-income areas � whereaccess to other sources of masculine identity, suchas school success or stable employment, are harderto achieve � young men may be more inclined toadopt exaggerated masculine postures that involverisk-taking behaviour, violence or sexist attitudestoward women, and violence against other menas a way to prove their manhood.

The literature suggests that the biologicaldifferences that clearly exist between boysand girls affect their health and developmentin a more limited way than differences dueto gender socialisation.

22 WHAT ABOUT BOYS?

The implications of this research include:

Programme Implications

❋❋❋❋❋ The need to sensitise health personnel andothers who work with young people on therealities and perspectives of boys, and howto encourage boys to seek health servicesand help when they need it. This may alsoinclude engaging health personnel andother youth-serving staff in discussionsabout their own possible stereotypes aboutboys.

❋❋❋❋❋ There is a need for health educators andother youth-serving staff consideralternative spaces for boys to discussnormative developmental milestones suchas spermarche and puberty, and otherissues.

❋❋❋❋❋ There is a need to sensitise teachers andeducation personnel on the possiblegender-specific challenges that boys,particularly low income boys, mayencounter in school .

❋❋❋❋❋ There is need for creative approaches inhealth service delivery for adolescent boys,taking into account their expressed desiresfor confidentiality, staff who are sensitiveto their needs, waiting areas that arewelcoming, and accessible hours.

❋❋❋❋❋ There is a need to engage boys, parents,communities, health and educationalpersonnel and youth-serving personnel inopen discussions about longstanding ideasabout manhood, recognising both thepositive and negative aspects of traditionalaspects of gender socialisation.

Research Implications

❋❋❋❋❋ There is a need for additional informationon young men�s attitudes toward existinghealth services to find ways to confrontchallenges to access and encourage youngmen to utilise existing health services.

❋❋❋❋❋ There is a need for additional research ongender socialisation and boys� schoolperformance, and the implications of boys�apparent school difficulties and mentalhealth and well-being.

❋❋❋❋❋ The need for additional research on howboys are socialised in various settings, andadditional qualitative explorations thatincorporate boys� voices and theirinterpretations of gender, equity,masculinity, roles and responsibilities.

❋❋❋❋❋ There is a need for additional research onthe changing nature of masculinities andgender roles and boys� perceptions of thesechanges. More must be understood abouthow boys are responding to changes inwomen�s roles and changes in gender rolesgenerally.

❋❋❋❋❋ There is a need for additional research onwhere boys �hang out,� the meaning of theirtime use in different settings, their socialnetworks and implications for theirdevelopment and socialisation. Thesestudies should also examine moreadequately the meaning and impact of boys�greater socialisation outside the home.

23WHAT ABOUT BOYS?

mental health, coping,suicide and substance use

chapter 2

The previous chapter highlights a numberof mental health issues related to gendersocialisation, particularly the lack of perceived andreal opportunities for young men to seek assistanceduring stressful moments; boys� tendencies not totalk about emotions and personal problems;difficulties admitting mental health needs; andrigid pressures to adhere to traditional gender rolesand norms. Substance use should be added tothis constellation of young men�s commonreactions to stressful situations, and viewed as arisk-taking behaviour sometimes used as a wayto prove one�s �manhood� or fit in with the peergroup. Similarly, there are gender-related patternsin suicide that emerge from patterns of malesocialisation.

There are clear gender patterns in the waythat young people respond to stressful andtraumatic life events. Some researchers argue thatmen typically respond less well, face greater risksand are less likely than women to seek socialsupport during stressful life events, such as a deathin the family or divorce (Manstead, 1998). Whilewomen�s external expressions of emotion and griefduring traumatic life events were traditionallyconsidered a sign of mental weakness or evenprecursors of mental health disorders, the mentalhealth field has come to see these outwardexpressions of emotion as a sign of positive mentalhealth (Manstead, 1998).

Various studies have found that in times ofstress or trauma, boys are more likely than girls torespond to stress with aggression (either againstothers or against themselves), to use physicalexertion or recreation strategies, and to deny orignore stress and problems. Some researchers

even suggest that young men�s greater denial ofstress and problems, and their propensity not totalk about problems, may be related to men�sgreater rates of substance use (Frydenberg, 1997).

On the other hand, adolescent girls morefrequently turn to friends and pay attention tohealth needs resulting from stress. Boys are lesslikely to admit that they could not cope duringstressful moments, while girls are more likely tobe able to express their difficulties in coping,probably because they are more willing to expresshelplessness and fear (Frydenberg, 1997).However, it is important to point out that whilegirls may sometimes be more likely than boys toverbally express their stress, they may alsointernalize such feelings in the form of eatingdisorders and general aches and pains � issuesseldom reported by or observed in boys. Thus,in suggesting that boys and girls show differentpatterns in responding to stress, we should notimply which sex actually is subject to greater stress.

Suicide

These gendered patterns of coping withstress can also be seen in gender differences insuicide. Suicide is among the three leading causesof death for adolescents, and suicide rates amongadolescents are rising faster than among any otherage group. World-wide, between 100,000 and200,000 young people commit suicide annually,while possibly 40 times as many attempt suicide(WHO Adolescent Health and DevelopmentProgramme, 1998). In terms of sex-disaggregation, three times more women thanmen attempt suicide but three times as many mencommit suicide (WHO, 1998). (There are someexceptions, such as China and India, where suiciderates among women are higher. It should also bementioned that suicide rates world-wide areunderreported because suicides are often classifiedas accidents or simply not classified.)

In the U.S., where suicide is currently thethird leading cause of death among young peopleages 15-24, boys are four times as likely to commitsuicide as girls, although girls try more often

In times of stress or trauma, boys are morelikely to respond to stress with aggression(either against others or againstthemselves), to use physical exertion orrecreation strategies, and to deny or ignorestress and problems.

24 WHAT ABOUT BOYS?

(Goldberg, 1998; National Center for InjuryPrevention and Control, 1998). In addition,suicide rates for girls and boys, until age 9, areidentical. From ages 10-14, boys commit suicideat twice the rate of girls; from ages 15-19 at ratesfour times as high; and from age 20-24, at ratessix times as high as girls (U.S. Bureau of Healthand Human Services, 1991).

Girls are more likely to attempt suicide butless likely to complete the act. Because suicideattempts for some women are sometimes usedto get attention, women may choose methodsthat are deliberately ineffective (Personalcorrespondence, Benno de Keijzer, 1999). Men,on the other hand, may choose effective andterminal suicide because prevailing gender normsdo not allow them to seek help for personal stress.For young men, therefore, suicide may not be acall for help, but an effective and final end tosuffering.

However, the issue of suicide and gendermust be considered with caution. Research onsuicide is insufficiently clear to determine whethergirls� suicide attempts and the methods theychoose generally are not intended to be final. Itmay be that both adolescent boys and girls wantto end pain when they attempt suicide, but thatboys have greater access to effective andimmediate means such as firearms, or that boyshave a greater propensity for aggression and risk-taking, and can more directly act out their suicidalthoughts.

In some countries, bisexual or homosexualyouth � both male and female � constitute asignificant risk group for suicidal behaviour.Studies have found that between 20-42 percentof homosexual youth attempt suicide, with mostattempts occurring between 15-17 years of age.

Although it is difficult to assess whether suchsurveys are truly representative, evidence indicatesthat youth who identify themselves as homosexualprobably engage in higher rates of suicidalbehaviour but may not necessarily completesuicide. Comparison studies with hetero- andhomosexual youth in Australia found no significantdifferences in rates of depression, but homosexualyouth more frequently reported suicidal thoughts.A quarter of homosexual youth who had attemptedsuicide identified sexual orientation as at least partof the reason they had attempted. Overall, 28.1percent of homosexual youth had attemptedsuicide compared to 7.4 percent of heterosexualyouth (Nicholas and Howard, 1998). Similarly, 30percent of all homosexual and bisexual malesinterviewed in the U.S. report having attemptedsuicide at least once (American Academy ofPediatrics, 1993).

It is also important to note that in Australia,the U.S. and New Zealand, suicide was once morecommon among adolescent males of Europeandescent, but is becoming equally or more prevalentamong minority and indigenous populations(African-Americans and Native Americans in theU.S., Aboriginal and Torres Straight Islanders inAustralia and Maori, and Pacific Islanders in NewZealand). There is evidence of an increasingnumber of older adolescent males in the SouthPacific committing suicides by hanging, jumping,or using firearms (Personal correspondence, JohnHoward, 1998).

Substance Use

Gender also influences rates of substanceuse. While statistics often are not disaggregatedby sex, boys are more likely than girls to smoke,drink and use drugs. Currently, about 300 millionyouth are smokers and 150 million will die ofsmoking-related causes later in life. In mostdeveloping countries, boys smoke at higher ratesthan girls, although rates in girls are increasingfaster (WHO Adolescent Health and DevelopmentProgramme, 1998).

Similar trends are seen with othersubstances. In Ecuador, 80 percent of narcoticsusers are men, the majority are in the late teenyears to early 20s (UNDCP and CONSEP, 1996).In Jamaica, lifetime and current use of marijuana

Suicide is among the three leading causesof death for adolescents, and suicide ratesamong adolescents are rising faster thanamong any other age group. World-wide,three times more women than menattempt suicide but three times as manymen commit suicide.

25WHAT ABOUT BOYS?

for young and adult men is two to three timesgreater than usage rates for young women(Wallace and Reid, 1994). In Jordan, 17 percentof adolescent males ages 15-19 smoke regularly,16 percent occasionally use tranquillisers and 3percent occasionally use stimulants (UNICEF,1998). A national survey of adolescents in the U.S.found that 20.1 percent of males compared to 15.6percent of females report using alcohol two daysor more per month (Blum and Rinehart, 1997).Upon reaching high school age, boys and girlswere smoking, drinking and using drugs at similarrates, but younger boys (ages 11-14) were twiceas likely as girls to drink (6 percent of boys versus3 percent of girls) and more likely to use illegaldrugs (9 percent of younger boys versus 6 percentof girls in the same age range). Boys are also morelikely than girls to say that they use drugs to be�cool� (Schoen et al., 1998). Surveys in the U.S.find that boys and girls around age 13 engagedin nearly equal rates of �binge� drinking (definedin the study as five or more drinks in a row). Byage 18, 40 percent of boys are engaging in suchbehaviour compared to fewer than 25 percent ofgirls (Kantrowitz and Kalb, 1998). Similarly, inKenya, boys are more likely to have triedcigarettes, alcohol and marijuana than girls (38percent versus 6 percent for cigarettes; 38 percentversus 14 percent for alcohol; and 7 percent versus1 percent for marijuana) (Erulkar, et al., 1998). InEgypt, 11.2 percent of boys smoke compared to0.3 percent for girls (Population Council, 1999).

Substance use, particularly alcohol use, isfrequently part of a constellation of male risk-taking behaviours, including violence andunprotected sexual activity. In Brazil, substanceabuse among young men was associated withhaving the �courage� to propose sexual relations,and was likely to impair sexual decision-making(Childhope, 1997). In a study of adolescent malesusing family planning clinics in the U.S., 31 percent

said they �are always or sometimes high onalcohol or drugs during sex�(Brindis et al., 1998).In the U.K., one in three 15-year-old boyscompared to one-in-five 15-year-old girls reportedbeing involved in fights or arguments after drinking(Gulbenkian Foundation, 1995).

World-wide, substance use is correlated witha range of problems that are more frequentlyassociated with adolescent boys: violence,accidents and injuries (Senderowitz, 1995).Various studies suggest that substance use isrelated to lack of parental support, unconventionalgoals, negative peer group influences, exposureto violence in the home, personal frustration, lackof future orientation, and having been victims ofabuse or violence at home. Reporting substanceuse rates by sex is an important first step towardunderstanding how substance abuse differs inrates, meaning, context and sequelae for boys andgirls.

Mental Health Problems and Needs

Do boys and girls or men and women havedifferent rates of mental health disorders ordifferent mental health needs? Evidence for sexdifferences in rates of mental disorders are limited,and those studies that do exist must be interpretedwith caution. Women are more likely to bediagnosed for psychoneuroses and depression, butthese higher rates may not reflect true sexdifferences. Instead, they may reflect thewillingness of women to admit that they areexperiencing these problems. Other studies haveconfirmed biases by mental health professionalsin terms of diagnosing psychological disorders;that is, mental health professionals may be morelikely to label the externalising behaviour ofwomen, rather than the internalising behaviourof men, as a mental disorder (Manstead, 1998).Adolescent boys, on the other hand, are morelikely than adolescent girls to be diagnosed withconduct disorders and aggressive disorders. Againthese differences may reflect biologically-based sexdifferences, or may reflect gender biases in thediagnoses of mental health professionals.

The timing of mental health disorders andthe possible underdiagnosis of young men�smental health problems may be the mostimportant issues regarding adolescent boys and

In many parts of the world, boys are morelikely than girls to smoke, drink and usedrugs. Substance use, particularly alcoholuse, is frequently part of a constellationof male risk-taking behaviours, includingviolence and unprotected sexual activity.

26 WHAT ABOUT BOYS?

their mental health. Late adolescence is a timewhen some serious mental disorders such asschizophrenia and bipolar mood disorders mayinitially present, especially for young men (Burkeet al., 1990; Christie et al., 1988). Thus, whilethe overall rates of mental illness may be moreor less equal for males and females, there maybe sex differences in the timing of the onset ofmental illnesses, in the sequelae of mentaldisorders, and in the rates of young people whoseek help for mental health needs and illnesses.

As previously discussed, the generalpatterns of male socialisation suggest that youngmen may have specific mental health needs, butfrequently do not seek such services, or that intimes of stress, they do not discuss their concernswith others. Information on young men�spreferences for, use of and attitudes towardmental health and counselling services isextremely limited, but there are some indicationsthat young men would like additional services inthis area. Research in Australia, Germany andthe U.S. finds that boys are less likely to havesomeone to turn to in times of stress or depression,and that boys seem to be less willing or able totalk about problems (Keys Young, 1997). A studyof adolescent males using U.S. family planningclinics found that 46 percent reportedpsychosocial issues for which they wantedcounselling, the most common beingunemployment, followed by problems talking tofamily or friends, alcohol use, the death ofsomeone close to them and drug use (Brindis etal., 1998). In the U.S., four boys to every girl arediagnosed with an emotional disturbance(Goldberg, 1998). Girls reported feeling morestress, but 21 percent of boys compared to 13percent of girls said they had �no one� to talk toat such times (Schoen et al., 1998). Boys who

showed signs of depression were particularly at riskof lacking social support; 40 percent of boys withdepressive symptoms compared to 18 percentwithout these symptoms reported that they had�no one� to talk to when they felt stressed.

Whether boys or girls have higher rates ofmental health problems and counselling needs isunclear. A 16-country study (including NorthAmerica, Europe, Asia and Latin America) foundthat income level or social class and developmentalstatus were more important variables than genderin determining counselling needs. Youth fromimpoverished backgrounds in poorer countriesreported higher rates of personal problems. Malesreported a higher percentage of problems relatedto school than did girls, but rates of reporting ofproblems were virtually equal for boys and girls(Gibson et al., 1992).

It is likely that boys frequently feel lesscomfortable than girls in seeking out such help andthat institutions where boys are socialised � theworkplace, the school, vocational trainingprogrammes, the military, sports clubs � are lesslikely to be sensitive to the mental health needs ofboys because of prevailing gender norms.Furthermore, adolescent males may be at higherrisk of early onset of serious mental disorders.

Implications

Summing up, there are clear patterns of sexdifferences in substance use and suicide rates, withboys in developing countries generally reportinghigher rates of substance use and boys completingsuicide at much higher rates than young women.In recent years, the trend in industrialised countrieshas been toward nearly equal rates of substanceuse by adolescent boys and girls. Greater genderequality in those regions may imply that substanceuse is equally a problem for men and women.There is inconclusive evidence for sex differencesin rates of serious mental health problems. Thefollowing are implications for programmes andresearch on mental health of adolescent boys:

The timing of mental health disorders andthe possible underdiagnosis of youngmen�s mental health problems may be themost important issues regarding themental health of adolescent boys. Lateadolescence is a time when some seriousmental disorders such as schizophreniaand bipolar mood disorders may initiallypresent, especially for young men.

27WHAT ABOUT BOYS?

Programme Implications:

❋❋❋❋❋ There is a need to sensitise and educatehealth personnel about boys� commonstyles of reacting to stress, and their higherrates of suicide and substance use. Mentalhealth professionals and other social serviceprofessionals may be less likely to believethat boys have mental health needs.

❋❋❋❋❋ There is a need for special programmeattention to the issue of boys who may beaway from home due to migration for work.In many parts of the world, counselling withprofessionals or paraprofessionals is notcommonly used, and young men rely onkinship networks, family, traditional healersor elders for advice about personalproblems. However, in many parts of theworld, as young people and particularlyyoung men migrate to urban areas, they areoften physically separated from thesetraditional sources of support.

❋❋❋❋❋ There is a need for substance use preventionand treatment programmes, including harmreduction programmes to pay greaterattention to the role of gender socializationin substance use, working with boys toquestion stereotypical views of masculinitythat may be related to boys� higher rates ofsubstance use.

Research Implications:

❋❋❋❋❋ Additional research is needed to determinespecific mental health needs of boys, andto understand their help-seeking behaviour,both through new studies and throughreviews of existing data, analysed througha gender perspective.

❋❋❋❋❋ Research is needed to develop strategies forearlier identification, assessment, treatmentand care for boys� mental health needs,especially for conditions that may havegreater incidence and prevalence amonglate adolescent males (e.g. schizophreniaand bipolar disorder) and those with nogreater prevalence with boys but which arealso associated with significant morbidityand mortality (e.g. depression and itsrelationship to suicide).

28 WHAT ABOUT BOYS?

29WHAT ABOUT BOYS?

sexuality, reproductive healthand fatherhood

chapter 3

Two underlying principles about adolescentboys increasingly shape the work of those in thefield of sexual and reproductive health: that youngmen are frequently more willing than adult mento consider alternative views about their roles inreproductive health; and that adolescence is acritical time when young men begin formingvalues that may shape lifelong patterns.

Often, young men are more likely thanadult men to have time and to be open toparticipating in group sessions and educationalactivities. There is also compelling reason tobelieve that styles of interaction in intimaterelationships are �rehearsed� during adolescence,providing a strong argument for working withyoung men on reproductive health issues (Archer,1984; Kindler, 1995; Erikson, 1968; Ross, 1994).Qualitative research with adolescent males inLatin America, Asia, North America and Sub-Saharan Africa suggests that patterns of viewingwomen as sexual objects, viewing sex asperformance-oriented, and using coercion toobtain sex often begin in adolescence andcontinue into adulthood. This too provides astrong rationale for working with adolescent menwhen attitudes toward women and styles ofinteractions in intimate relationships are forming(Shepard, 1996; Bledsoe and Cohen, 1993).Adolescent males in the U.S. who used condomsduring their first sexual relations were more likelyto use condoms consistently thereafter, providingadditional evidence on the importance of earlypatterns in sexual relationships (Sonenstein, Pleckand Ku, 1995).

In the last 20 years, there has beenincreasing attention to male involvement inreproductive health. For example, promoting

greater male involvement in reproductive healthand greater gender equity in child care anddomestic tasks were endorsed at the InternationalConference on Population and Development(ICPD) in Cairo in 1994. This increased attentionhas led to new research on the sexual andreproductive health of adolescent males. However,this information has had a heterosexual bias.Information on the attitudes and behaviours ofyoung men who define themselves as homosexualor bisexual is often lacking. Homosexual andbisexual young men are often the subject ofdiscrimination or, in other cases, simply ignored.

Adolescent Boys, Sexuality and �SexualScripts�

The increased research on male reproductiveand sexual health has allowed us to describe andbetter understand what is often called the �sexualscript� of adolescent boys � the common patternsof sexual activity, including sexual initiation, foundin given venues. While such �scripts� varytremendously by individual, social class andculture, there are a number of similarities in thesexual relations, activity and attitudes of adolescentboys world-wide.

Sexual Initiation and Sexual Activity as MaleCompetence

Young men often believe that sexualinitiation affirms their identity as men and providesthem status in the male peer group (Sielert, 1995).For many young men world-wide, heterosexualsexual experience is seen as a rite of passage tomanhood and an accomplishment or achievement,rather than an opportunity for intimacy.Heterosexual �conquests� are frequently sharedwith pride within the male peer group, while doubtsor inexperience are frequently hidden from thegroup. Hence, boys �effectively curtail theiropportunities to discuss their sexuality openly andhonestly with their friends�(Marsiglio, 1988).Marsiglio concludes that boys view �sex as avaluable commodity in its own right, regardless ofthe relationship context in which it might occur,

Research suggests that patterns of viewingwomen as sexual objects, viewing sex asperformance-oriented and using coercionto obtain sex often begin in adolescenceand continue into adulthood.

30 WHAT ABOUT BOYS?

that sexual activity is desirable as early in arelationship as possible, that more sex is better,and that opportunities to have heterosexualrelations should generally not be squandered.�The status that a young man achieves in his peergroup when he is involved in a sexual relationshipcan be equally or more important than theintimacy he experiences in the relationship(Lundgren, 1999).

In most of the world, boys report havingtheir first sexual experience at earlier ages thando young women. Furthermore, Demographicand Health Survey data finds that boys� ages atsexual initiation are generally decreasing in nearlyall countries for which DHS data is available,while young women�s ages at first sexualexperience had decreased in only about one-fifthof those countries. Adolescent women morefrequently report having sexual intercourse(including premarital sex) within the context of arelationship, while young men more frequentlyreport having sex with multiple partners (beforeand after marriage) and in more occasionalrelationships (Green, 1997).

Young men and young women sometimesgive different interpretations of the same sexualexperiences. In some areas of the world, youngwomen have sexual experiences nearly asfrequently as young men but young womenportray their relationships as more stable andintimate, while young men may portray the samesexual relationship as casual or occasional. Forexample, research with young people ages 15-24 in Nigeria found that the prevalence of �casualsex� for males in the preceding 12 months was35 percent, compared to 6 percent for females.Young women were more likely to report havinga regular sexual partner (80 percent) comparedto 44 percent of sexually experienced males(Amazigo et al., 1997).

For many young men world-wide,heterosexual sexual experience is seen asa rite of passage to manhood and anaccomplishment or achievement ratherthan an opportunity for intimacy.

In some cases, these more �casual� sexualrelationships for adolescent boys may includehaving their first sexual encounter (and subsequentsexual encounters) with a sex worker. For example,in urban and rural areas of Thailand, 61 percentof currently single men and 81 percent of ever-married men had sex with sex workers (Im-em,1998). In regions of India, between 19 percent and78 percent of males reported having sexualrelations with a sex worker (Jejeebhoy, 1996).

In Argentina, 42 percent of boys insecondary schools said their first sexual experiencewas with a sex worker, while 27 percent reporteda first sexual experience with a girlfriend. For girls,89 percent said their first sexual experience waswith their boyfriend (Necchi and Schufer, 1998).Boys more frequently mentioned �sexual desireand physical necessity� (45 percent) as themotivation for their sexual encounter, while girlsmore frequently mentioned the desire for a deeperintimate relationship (68 percent).Boys in Guinea(West Africa) said they frequently used falsepromises of long-term commitment to convincegirls to have sex. These boys also said theyfrequently worried that if they did not have sexwith a girl, their reputation would suffer amongtheir male peers (Gorgen et al., 1998).

The pattern of viewing sex as anachievement to present to the male peer groupemerges in adolescence, and often continues intoadulthood. In rural India, for example, men reportthat they frequently have sex with sex workers intheir early years of marriage to present a facade ofmale prowess to their male peers (Khan, Khan andMukerjee, 1998). This pressure to recount one�ssexual conquests to the male peer group has ledsome researchers to question whether young menhave had all the sexual relations they report. InBrazil, one young man told staff from an NGOthat �we lie so much (about our sexual conqueststo our friends) that we end up believing it� (Sitevisit to ECOS, Sao Paulo, Brazil, 1998).

The common sexual script of boys aroundthe world supports the myths that themasculine sexual appetite is insatiable, thatboys� need for sex is biologicallyuncontrollable, and that sex is somethingto be done, not talked about.

31WHAT ABOUT BOYS?

The common sexual script of boys aroundthe world also encourages the myths that themasculine sexual appetite is insatiable, that boys�need for sex is biologically uncontrollable, and thatsex is something to be done, not talked about �except to talk about exploits and conquests (Barkerand Loewenstein, 1997; Khan, Khan andMukerjee, 1998).In Mexico and Brazil, young mensay that once aroused, men cannot turn down asexual opportunity because such a refusal wouldbe non-masculine (Aramburu and Rodriguez,1995; Barker and Loewenstein, 1997). Boysfrequently feign the possession of vast amountsof information about sex and the reproductiveprocess. This posture frequently masks the factthat boys lack information on their bodies andreproductive health.

Another aspect of the performance-orientedadolescent male sexual script is the focus ongenitally-oriented sexual pleasure. One Mexicanresearcher concludes that male sexuality in thecontext of machismo is �mutilated� or �distorted�because the male is not allowed to enjoy any partof his body apart from his penis (Meijueiro, 1995).Prevailing sexual and gender scripts for young mensometime give the impression that their body is atool or machine, whether to be �used� in sports,work or sex (Personal correspondence, Benno deKeijzer, 1999). Young men�s perceptions of theirbodies, coupled with their lack of information onreproductive and sexual physiology, can haveramifications for their health. In India, young mencallers to a hotline on reproductive and sexualhealth did not consider STIs as a risk because theyperceived themselves as the �givers� during sexualintercourse (Singh, 1997).

Substance Use and Sexual Activity

Alcohol and other substance use oftenaccompany the early (and later) sexualexperiences of young men. In one study, Thai menreported that their sexual initiation frequently tookplace as a male peer group-influenced activityaccompanied by social drinking (Im-em, 1998).In rural Thailand, 49 percent of young men ages15-24 said they were sexually experienced. Of thatgroup, 77 percent said they had sex at some timewith a sex worker, 94 percent said they werepersuaded to visit a sex worker by male friends,and 58 percent said they were drunk before visiting

a sex worker the first time (WHO, 1997). In LatinAmerica, young men report that using alcohol orother substances helps them have the �courage�to attempt a sexual conquest (Childhope, 1997;Keijzer, 1995). Substance use is also frequentlyassociated with incidents of sexual abuse andcoercion.

Denial of Sexual Rights to Women andDelegation of Reproductive HealthConcerns

Another common feature of the male sexualscript is denying sexual rights to girls or women,and categorising women. Moroccan adolescentsof both sexes in a semi-rural town consideredfemale virginity at marriage as important, althoughfew females and almost no males were withoutsome premarital erotic experience. Males in thissetting typically had their first sexual intercoursewith a sex worker or a girlfriend. Male youthtypically had two roles: �lustful suitor� of aneighbourhood girl, and �jealous guardian� of hissisters� �virtue.� Some young men viewed theworld of unmarried females as divided into�marriageable virgins� and �unmarriageablewhores� (Davis and Davis, 1989). Similarly, youngmen in Latin America frequently value their ownsexual activity regardless of relationship context,but categorise those girls who have sex in casualrelationships as �loose� (Figueroa, 1995;Childhope, 1997 ). Adolescents in Peru concludedthat girls are identified as �good� or �bad� basedon whether they are sexually experienced. Boyson the other hand have to constantly prove theirmanhood through sexual activity, or risk beingseen as �not men� (Yon, Jimenez and Valverde,1998).

Another common refrain in research on thesexual scripts of young men is young men�sdelegation of reproductive health concerns towomen, and the lack of concern for their ownhealth, reproductive and otherwise. For urban,

Another common refrain in the sexualscripts of young men is the delegation ofreproductive health concerns to women,and the lack of concern for their ownhealth, reproductive and otherwise.

32 WHAT ABOUT BOYS?

working class men ages 20-44 in Brazil,reproductive health was seen as a woman�sresponsibility. The concept of �responsibility�applied to taking responsibility for a child or, insome cases, for helping a woman acquire anabortion (Arilha, 1998). In Bolivia, universitystudents confirmed that having an STI could beseen as a badge of honour both before one�s malefamily members (fathers in particular) and amongpeers (Site visit to CISTAC, Santa Cruz, Bolivia,1998). Boys also frequently mention their low useof health services and their reliance on self-treatment or home remedies in the case of anSTI. Among men ages 15-62 in Bihar, India, morethan half of the group had suffered an STI. Ofthis group, more than half either used a local�quack� or went untreated (Bang et al., 1997).Focus group discussions with college students inBolivia found self-treatment to be theoverwhelming medical treatment �of choice�. Oneof the young men said, �When it comes to gettingsick ...we�re all doctors� (Site visit to CISTAC,Santa Cruz, Bolivia, 1998).

Exceptions to Prevailing �Sexual Scripts�

Not all young men in a given group adhereto every aspect of the prevailing sexual script, nordo even the most traditional young men alwaysbehave in accordance with such scripts. Whilethe research reports general tendencies, there areyoung men who report different patterns in theirsexual and intimate relationships. Threecategories of young men were identified in a studyin Argentina: 1.) 40 percent of young meninterviewed fell into the category of �impulsive,�meaning they sought sexual experience at earlyages primarily for physical desire and worried onlyabout AIDS; 2.) 32 percent were categorised as�occasional,� meaning that they had a sexualrelationship mainly out of curiosity, withoutnecessarily pursuing it or planning it; and 3.) 27percent were categorised as �integrated,�

meaning that they had their first sexual encounterwithin a relationship context, with the intention ofestablishing a deeper relationship with a partner,and with negotiation over contraceptive use. Asthe authors state: �Belonging to this category(�integrated�) may imply a search for integrationof sexuality with affectivity and a greaterdemocratisation of sexual roles in this generationof young people� (Necchi and Schufer, 1998). InPeru, young women characterised some boys asbeing �sincere,� �quiet� or �respectable� � thetypes of boys with whom girls felt they could havea relationship and express feelings �without beingforced to have sexual relations with them� (Yon,Jimenez and Valverde, 1998). Similarly, inqualitative research with low-income young menin Brazil, the authors found that approximately oneor two out of every 10 young men interviewed infocus group discussions displayed a set of valuesthat were characterised as �progressive,� that isrepudiating violence toward women, advocatingfor men�s roles in reproductive health, advocatingnegotiation in relationships and generally desiringsexual activity in the context of a relationship(Barker and Loewenstein, 1997).

Same-Sex Sexual Activity and Homophobia

For many young men � regardless of whetherthey identify themselves as heterosexual or ashomosexual or bisexual � have sex with anotherman or boy is a common part of sexualexperimentation and/or of their ongoing sexualactivity. In Peru and Brazil, 10-13 percent ofadolescent males and young adult males reporthaving had both heterosexual and homosexualexperiences. In Latin America, 28 percent of youngmen reported having had sex with another male,but did not necessarily identify themselves ashomosexual. Indeed, homosexual activity, whileoften repressed or considered inappropriate inmany instances, may be considered a normal partof sexual development. However, because it isfrequently repressed or denied in many cultures,this stigma attached to homosexual activity oftencreates anxiety, leading some young men toquestion the �normality� of such activity andleaving them with few opportunities to expressdoubts or ask questions about their sexuality(Caceres et al., 1997; Lundgren, 1999).

Not all young men in a given group adhereto every aspect of the prevailing sexualscript, nor do even the most traditionalyoung men always behave in accordancewith such scripts.

33WHAT ABOUT BOYS?

And while same-sex sexual activity seemsto be a fairly common aspect of sexualexperimentation and development for manyyoung men, another frequently cited aspect of themale sexual script � both for men who have sexwith men (MSM) and heterosexual young men �is homophobia. Homophobia serves both to keephomosexual behaviour and young men ofhomosexual or bisexual orientation �in the closet,�and, in effect, to keep heterosexual men �in line.�Parker (1991 and 1998) has extensivelydocumented the meaning of various pejorativeterms used to refer to homosexual men in Brazil,and the ways such language is used to pressureyoung men and boys to adhere to specificheterosexual sexual scripts. At the same time,though, boys are permitted same-sex sexual playas long as these �sexual games� are temporarydiversions on the way to a final identity as aheterosexual male. In some areas of the MiddleEast, same-sex sexual play between boys iscommon (although seldom acknowledged)around the time of puber ty, while adulthomosexual activity is widely condemned (Davisand Davis, 1989).

While there is much less research on thesexual scripts and sexual experiences of youngmen who self-identify as homosexual or bisexual,emerging research (largely from the AIDSprevention field) has provided some insights onthe challenges that homosexual young men face.Homosexual or bisexual adolescent males face anumber of commonalities, including rejection orlack of understanding on the part of their parentsand family, an early awareness of being�different,� and the lack of individuals they couldconfide in or seek advice from about their same-sex sexual feelings or experiences (AmericanAcademy of Pediatrics, 1993).

The stress associated with this familialrejection, societal homophobia and the lack ofoutlets for expression of their sexuality are reflectedin the apparently higher rates of suicide amonghomosexual males as reported earlier. Thedevelopment of a homosexual identity may leaveyoung people feeling isolated from their peers;heterosexual young men often share their�conquests� with pride with the peer group, whilehomosexual young men often have to hide theirsexual experiences. Because of the social stigmaassociated with homosexual behaviour, theseyoung men sometimes have their first sexualexperiences in furtive or anonymous situationsand may feel unsure of the normality of theseexperiences (Nicholas and Howard, 1998).

Adolescent Boys and Reproductive andSexual Health

Boys and Sources of Information aboutSexuality and Reproduction

The sexual script of many adolescent maleswould suggest that they are well-informed aboutissues of sexuality and reproduction, but surveyresearch contradicts this. A survey of secondarystudents in Nigeria found that young women weremore likely than young men to understand thetiming of conception (fertility) (Amazigo et al.,1997). Various surveys in Latin America havefound that many men, adult and young, think theypossess adequate information about sexuality andreproduction, when in reality they have littleinformation. In surveys with adolescents andyoung adults in 15 cities in Latin America and theCaribbean, fewer than a quarter of males ages15-24 could identify the female fertile period(Morris, 1993). While young women were onlyslightly better informed, the issue is perhaps morestriking for young men who frequently claim thatthey know such things.

World-wide, adolescent boys say theylargely rely on the media and on their self-taughtpeers for information about sexuality andreproductive health. Young men ages 15-24 inJamaica were more likely to get information onreproductive health and sexuality from peers thanwere girls; young women were more likely to talkto parents (32.2 percent) and to health personnel(29.8 percent) (National Family Planning Board,

Heterosexual young men often share their�conquests� with pride with the peergroup, while homosexual young menoften have to hide their sexualexperiences.

34 WHAT ABOUT BOYS?

1999). In Kenya, girls were more likely to discusssex with parents than were boys (27 percentversus 16 percent), although friends were theprimary source of information for both males andfemales (Erulkar et al., 1998).

Even in countries where frank discussionsabout sexuality with adolescents are encouraged,such as Denmark, nearly half of adolescent malesages 16-20 say they never talk to their parentsabout sexuality (Rix, 1996). Boys may view sexeducation as irrelevant to them because it hastraditionally focused on reproductive health andcontraception, which they see as issues for girls.

Other barriers toward communicationbetween adolescent males and health educatorsinclude negative attitudes that some sex educatorsmay have in terms of adolescent males, and thesocial pressure that boys feel to act as if theyalready know everything about sex. A programmein Mexico that sought to increase parent-adolescent communication on STIs and HIV/AIDS found that such an intervention wassuccessful and useful for parents and adolescentdaughters, but that fathers and mothers haddifficulty engaging their sons in a discussion onsuch matters (Givaudan, Pick and Proctor, 1997).In general, we have few in-depth studies on howadolescent males acquire their knowledge aboutsexuality and reproductive health, the context ofthat knowledge acquisition and its meaning tothem (Greene and Biddlecom, 1998). Even whensex education is offered to boys, it often focuseson bodily functions with little attention to the issueof enjoying a healthy sex life and the full range ofhuman sexual and intimate expression.

Adolescent Boys and Contraceptive andCondom Use

Studies from various parts of the worldshow that condom use among adolescent andyoung adult males has increased in recent years

but is still inconsistent and often varies accordingto the �category� of the sexual partner. Sixty-ninepercent of sexually active males in Jamaica, 40percent in Guatemala City and 53 percent in CostaRica reported using condoms in the last month intheir sexual relations (Morris, 1993). In the U.S.,reported condom use among young males morethan doubled from about one-fifth in 1979 to morethan half in 1998. However, only 35 percent ofU.S. males said they had used a condom everytime they had sex (Sonenstein and Pleck, 1994).

Young men�s motivation for using condomsfrequently varies with their partner: with a stablepartner or girlfriend, condoms are used forcontraception; with a �casual� partner, condomsare used for STI and HIV prevention. Most often,condom use is associated with a casual partner. Asurvey with young adult factory workers inThailand found that 54 percent of young men whohad their first sexual experience with a sex workerreported using a condom on that occasion,compared to only 20 percent who said they usedcondoms on their first sexual experience when thepartner was not a sex worker (WHO, 1997).

Condom use may be higher when there ismore communication or negotiation among thesexual partners. A study of males using familyplanning clinics in the U.S. found that contraceptiveuse was higher when couples agreed on use,suggesting the importance of discussion amongcouples and young men�s involvement incontraceptive selection and decision-making evenif a female contraceptive method is used (Brindiset al., 1998). Although the effectiveness ofcondoms for contraception and STI prevention iswidely acknowledged, there are still areas whereawareness is low, such as rural areas in Africa andAsia (Sharma and Sharma, 1997).

Barriers to young men�s use of condomsinclude availability, cost, the sporadic nature oftheir sexual activity, lack of information on correct

The sexual script of many adolescentmales would suggest that they are well-informed about issues of sexuality andreproduction, but research contradictsthis.

Studies from various parts of the world haveshown that condom use among adolescentand young adult males has increased in recentyears but is still inconsistent, and often variesaccording to the �category� of the sexualpartner.

35WHAT ABOUT BOYS?

use, reported discomfort, social norms that inhibitcommunication between partners and rigid sexualscripts or norms about whose responsibility it is topropose condom use. Young men�s sexual scriptsoften suggest that because reproductive health isa �female� concern, the woman must suggestcondom use or other contraceptive methods. Atthe same time, the sexual script frequently holdsthat it is the male�s responsibility to acquirecondoms, since for a female to carry condomswould suggest that she �planned� to have sex andis �promiscuous� (Webb, 1997; Childhope, 1997).If a young man responds to a woman�s requestthat he use a condom, this may imply that he isallowing her to have �control� of the relationship.Condom use also requires a young man to placeless emphasis on his sexual pleasure, and thusrequires him to control his sexuality and considerhis health. However, as previously mentioned,male sexuality is often defined by its uncontrollednature and by not worrying about health and bodyconcerns. The sexual activity of unmarriedadolescent males and females tends to besporadic, a factor probably related to inconsistentcontraceptive use. Urban youth in Brazil did notalways identify themselves as �sexually active�because their sexual activity was infrequent(Childhope, 1997).

Research and programme development onadolescent men�s use of contraceptives has oftenfocused on condom use, but it is important toconsider adolescent male attitudes and practicesrelated to other contraceptive methods. Youngmen in many countries report withdrawal as acommon, traditional contraceptive method. Whilewithdrawal is considered an ineffectivecontraceptive method, and has often been ignoredor even condemned by many organisationsworking in the reproductive and sexual healthfield, some researchers have suggested thatwithdrawal can be a reasonably effective methodfor pregnancy prevention (and more effective thancommonly presented), could be promoted to boysin stable relationships when more widely as abackup method when condoms are not available(Rogow, 1998). Indeed, more research is neededon young men�s attitudes about othercontraceptive methods; about their attitudestoward young women�s use of contraceptivemethods, including the female condom; and aboutnon-penetrative sex.

STIs and HIV/AIDS

Adolescent boys and young men often havehigh rates of STIs, but young men frequentlyignore such infections or rely on home remediesor self-treatment. In rural India, 80.7 percent ofthe men ages 15-44 were found to have somereproductive-related morbidity, 22.3 percent ofwhich were STIs. The rates of reproductive healthmorbidities for men were nearly identical to ratesfound among women in research carried out bythe same authors (Bang et al., 1997). In the samerural region of India, 83 percent of men reportedsome reproductive health-related complaint in thelast 30 days; 98 percent said they were open totalk about reproductive health, but said that suchproblems are generally �embarrassing� to talkabout and reported that public health serviceclinics and doctors tended to focus on familyplanning for women (Bang, Bang and Phirke,1997). Some adolescent boys � perhaps becauseof their earlier sexual activity, or their sexualactivity with sex workers � have higher reportedrates of STIs than do adolescent girls. In one study,3 percent of Thai adolescent males have had anSTI compared to only 0.3 percent for youngwomen.

WHO-sponsored research on STIs hasfound an increasing number of young men arecontracting chlamydial urethritis, which isasymptomatic in up to 80 percent of cases.Prevalence studies on chlamydial urethritis in Chilewith 154 asymptomatic adolescent males foundthat 3 percent of sexually active males testedpositive. Adolescents may also comprise morethan 50 percent of new cases of gonorrhoea andsyphilis (WHO, 1995). Research with maleindustrial workers and students in South Koreafound that 3-17 percent said they have had anSTI. In Kenya, 44 percent of STI patients are 15-25 years old (Senderowitz, 1995). Studies in theU.S. have found that 10-29 percent of sexuallyactive adolescent women and 10 percent of boystested for STIs had chlamydia (Alan GuttmacherInstitute, 1998). In Brazil, nearly 30 percent ofsexually active adolescent males in low-incomeareas said they have had an STI at least once; ofthose, about a third said they resorted to self-medication for treatment (Childhope, 1997). InZambia, young people said that when they hadan STI, they used home remedies first and formalhealth services �as a last resort� (Webb, 1997).

36 WHAT ABOUT BOYS?

There has been limited discussion of therole of young and adult men in the transmissionof human papilloma virus, which can betransmitted even with condom use. An estimated10 million women, the majority in their late teensand early 20s, have active HPV infections. In partsof Africa and Asia, where regular Pap testing isless common than in industrialised countries,cervical cancer from HPV is the most commoncause of cancer-related mortality. HPV isimplicated in 95 percent of cervical cancer. Inmen, HPV is frequently asymptomatic, meaningthat young men can and do infect young womenwithout knowing it. HPV is associated withprecancerous lesions of the penis and with penilecancer, although at extremely low rates. Becauseheterosexual men seldom suffer consequencesfrom HPV, there is an issue of gender equity foryoung men to consider how their sexual activityplaces women at risk. Limited research also findsa growing incidence of HPV in MSM; studies inthe U.S. have found that 95 percent of HIV-positive men have HPV, which is associated withanal cancer. Some health professionals workingwith MSM recommend anal pap tests as a routinescreening procedure (Groopman, 1999).

These relatively high rates of STIs amongadolescent boys are linked to the increased riskof HIV infection. Presently an estimated one infour of all persons infected by HIV/AIDS in theworld is a young man under age 25 (Green,1997). In Zimbabwe, 26 percent of all pregnantwomen age 15-19 were HIV positive. InBotswana, the figure was 31 percent. Adolescentboys in these countries, however, are much lessaffected than girls, who are four times more likelyto be HIV positive. Besides having a higherphysiological risk of infection, girls seem to beinfected by older men. Adult men�s behavioursand attitudes � including their higher number ofsexual partners on average than women, theirhigher use of alcohol and other substances, andtheir generally greater control over sexual relations

than women � are directly related to the spread ofHIV/AIDS. Encouraging boys to engage in safersexual behaviour has an important potential forreducing their own risk of HIV, but also can leadto lasting changes in adult men�s sexual behaviour(Meekers and Wekwete, 1997).

Research from the HIV/AIDS prevention fieldhas provided many insights on the sexual scriptsand behaviours of young men reported previously,as well as on couples� patterns of negotiation, orlack thereof, and on the identity formation andbehaviour of men who have sex with other men.Many individuals and organisations in thereproductive and sexual health field have calledfor greater co-ordination between adolescentreproductive health and HIV/AIDS preventioninitiatives, including those for adolescent men. Itis also important to mention the association of HIVand Hepatitis B and C with increased injectabledrug use and unprotected sex among men whohave sex with men, an issue that has emerged inthe U.S., Australia and other regions (Personalcorrespondence, John Howard, 1998).

Other Sexual and Reproductive HealthConcerns and Needs of Young Men

Discussions of the sexual and reproductivehealth needs of adolescent boys have often focusedon contraception, condom use and STIs. However,boys also express other concerns and face otherneeds related to their sexual and reproductivehealth. When offered the chance to discusssexuality and reproductive health, boys aresometimes more interested in issues such as penissize, maintaining erections, anxiety about meetingthe expectations of sexual partners, gettingerections at inappropriate times, fertility, potencyand premature ejaculation (Population Council,1998). Existing research on boys and sexualityoften focuses on indicators such as age at firstsexual experience, sexual partners, condom useand frequency of sexual activity, but doesn�tadequately examine the quality of and feelingsassociated with young men�s early sexualexperiences. What worries or concerns do theyhave? Who do they talk to about these worries?Who would they have liked to have talked to beforehaving their first sexual experience? Are theysatisfied with their sexual experiences? Boys�concerns during their first sexual experience may

Research in various parts of the worldconfirms that adolescent boys and youngmen often have high rates of STIs, and thatyoung men frequently ignore suchinfections or rely on home remedies orself-treatment.

37WHAT ABOUT BOYS?

be similar to those of young women. When askedabout their first sexual experience, young men inArgentina frequently said that it was pleasurable/satisfying (62 percent); however, 48 percent ofyoung men also reported anxiety or nervousness,15 percent reported confusion and 12 percentreported fear (Necchi and Schufer, 1998). Boysfrequently lack opportunities to discuss doubts oranxieties associated with their first sexualexperiences or to discuss fully their own sexualdesire. In some parts of the world, manyadolescent males are married, yet their specificconcerns have rarely been discussed in sexualhealth programming.

Other sexual health issues for young meninclude the issue of circumcision. There is anunresolved debate about whether malecircumcision promotes greater genital hygiene andreduces the risk of some STIs including HIV, orwhether it inflicts unnecessary pain on young boys.WHO currently has no official position on malecircumcision.

The question of penis size and adolescentboys� use of condoms is also unresolved. Somepublic health sectors have introduced a smallercondom (49 mm diameter versus the 52 mm) withthe assumption that adolescent boys requiresmaller condoms, but existing research has notconfirmed whether this an appropriate response.Unpublished research from Brazil on adolescentboys using the 49 mm condom finds that someboys report discomfort in using the smallercondoms, but the results are unclear (InstitutoPROMUNDO and NESA, 1999).

The issue of declining sperm counts alsoneeds greater discussion. Exposure to varioustoxins could be related to male infertility(Lundgren, 1999). Declining sperm counts havebeen noted in parts of Europe, but the implications

are unclear, as is the issue of whether this manifestsitself in adolescence or adulthood. In some partsof the world, boys face possible negative sideeffects from potency medicines, or may not beaware of the risks of some such medicines.

Access to Reproductive and Sexual HealthServices

The general tendency for young men toview reproductive health as a �female� concernmeans that even when specific services exist foryouth, the majority of clients of such services areyoung women. In turn, public health workers mayperceive that young men are disinterested inreproductive health issues and target their effortsto young women. Research from Sub-SaharanAfrica, Latin America and North America confirmsa pattern of low male attendance at adolescentclinics, including adolescent sexual andreproductive health clinics. Young womenrepresented 76-89 percent of all adolescent healthclinic users in Ghana (Glover, Erulkar andNerquaye-Tetteh, 1998). In addition to perceivingreproductive health as �female concerns,� youngmen often perceive clinics as �female� spaces,given that most clients and service providers arewomen. Clinic staff may also have difficultyreacting in positive ways to the styles of interactionand the sometimes aggressive energy that youngmen bring to the clinic setting.

The Needs of Boys Involved in Sex Workand in Other High Risk Settings

While young women�s exploitationinvolvement in and exploitation in sex work hasreceived increased attention in recent years, thereis little attention given to young men involved insex work or exploited through sex work. Limitedresearch from Sub-Saharan Africa, Asia and LatinAmerica found that it is difficult to estimate thenumber of young men involved in such activity,that such activity is typically covert, and that youngmen involved in sex work may lack power tonegotiate condom use and other forms of self-protection � all issues similar to those faced byyoung women who are exploited through sexwork. Depending on the region and setting, youngmen involved in sex work may be more or lessvisible than young women engaged in the same

When discussing reproductive health, boysare sometimes more interested in issuessuch as penis size, maintaining erections,anxiety about meeting the expectations ofsexual partners, getting erections atinappropriate times, fertility, potency andpremature ejaculation.

38 WHAT ABOUT BOYS?

activities, and the sexual activity may havedifferent implications in terms of self image andmental health.

Some young men interviewed in parts ofsub-Saharan Africa also report that thephenomenon of �Sugar Daddies� (older menwho pay or exchange favours with young womenor girls for sex) also works in reverse with adultwomen (�Sugar Mommies�) sometimes payingadolescent males for sex (Barker and Rich, 1992;Mbogori and Barker, 1993). Some �SugarDaddies� prefer boys as sexual partners. Ahandful of studies in Brazil have focused onadolescent males who are sexually exploited.Some of the young men involved in such sexualexploitation ended up on the streets because theywere rejected or expelled from their homesbecause of homosexual activity (Larvie, 1992).Overall, there is a need for more attention to thespecial needs of young men involved in sex work,including a need for research that seeks to identifythe scope of the issue.

There is also a need for greater attentionto the sexual health needs of boys and youngmen in high-risk settings, including boys detainedin juvenile (and adult) detention facilities, boyswho work away from home and young men inthe military. Young men who migrate for work,or live away from home, including those in themilitary, may engage in higher rates of sexualactivity with sex workers and use substances,including alcohol, as a way to cope with the stressof living away from home � both behaviors thatincrease their risk of STIs, including HIV. Studieswith young men in the military, for example,consistently find higher rates of HIV prevalencethan the overall population (PANOS, 1997).Boys in same-sex institutions, including juveniledetention facilities, may engage in both forcedand consensual sex with few options for STI orHIV prevention.

Adolescent Fatherhood

Researchers, programme planners andpolicymakers, including UNICEF and WHO, havebegun to call attention to fathers� roles in childdevelopment and child rearing, including the rolesof young fathers. Part of this attention is drivenby women�s increasing participation in the formal

workplace � and a greater demand on men to takeresponsibility for child-rearing-, but has also beenspurred by research showing that an increasingpercentage of fathers around the world are notliving with their children. Numerous studies haveunderscored the increase in men�s migration forwork, the instability of men�s employment and theimpact of these trends on men�s roles andparticipation in the family (Bruce, Lloyd andLeonard, 1995; Barroso, 1996). These trends haveled to increased discussions of men�s child supportobligations in various countries, and in some casesto insightful research on the dynamics of men�slack of involvement with their children, particularlyas it relates to their inability to find stableemployment and achieve the socially proscribedrole of provider.

While interest in adolescent fathers is limited,there have been some important programmemodels developed in the Americas region, NorthAmerica and Western Europe and discussion ofthe issue at seminars in various parts of the world,including India (Lyra, 1998; Personalcorrespondence, John Howard, 1998). Variousreproductive health surveys have asked young menwhether they have ever impregnated a partner,but research on young men�s attitudes towardfatherhood, their involvement as fathers, or theirdesire for involvement as fathers, is lacking.

With the stigma associated with adolescentpregnancy, unplanned pregnancy or pregnancyoutside of formal unions, young men may bereluctant to establish legal paternity or toacknowledge having fathered a child. Some youngmen may not be aware they have fathered a child.Adolescent fathers, like adolescent mothers, mayface social pressures to drop out of school tosupport their children and are less likely to completesecondary school than their non-parenting peers(WHO, 1993). Young men may deny responsibilityand paternity in large part because of the financialburden associated with caring for a child (Barker

Adolescent fathers face some of the sameissues that young mothers face: too-earlyrole transition from adolescent to parent;social isolation; unstable relationships; andsocial and family opposition to theirinvolvement as fathers.

39WHAT ABOUT BOYS?

and Rich, 1992). In Mexico, adolescent fathers�employment and financial situation wereimportant factors in determining how they viewedthe pregnancy and whether they were activelyinvolved as fathers (Atkin and Alatorre-Rico,1991). Still another issue related to adolescentpregnancy is young men�s involvement in abortiondecision-making. Various qualitative andquantitative studies have found that young menoften play a key role in the abortion decision-making process and that male attitudes toward apregnancy are important in whether a youngwoman decides to seek an induced abortion.

In some parts of the world, boys havebenefited from and continue to benefit from socialnorms that allow them to stay in school afterfathering a child, while teenage mothers were andin some settings still are expelled from school.Many adolescent fathers do not participate inproviding for or caring for their children. At thesame, however, research in some settings (the U.S.for example) finds that adolescent fathersfrequently provide some support and seek tomaintain relationships with their children even ifthey are not living with the mother and the child(Barret and Robinson, 1982). As in the case ofadolescent mothers, adolescent fathers, comparedto their non-parenting male peers, are more likelyto have had mothers who were themselvesadolescent mothers, and to have hadunsatisfactory relationships with their fathers(Gohel, Diamond and Chambers, 1997).

An adolescent father�s parents, the parentsof the child�s mother, the mother of the child andservice providers frequently hold numerous deep-rooted stereotypes about adolescent fatherhood.There are widespread beliefs, for example, that aadolescent father who does not marry the motheris �irresponsible,� when, in fact, his motivationsare often complex. Some adolescent fathers mayin fact be avoiding responsibilities, while othersmay want to be involved with their child but arenot allowed to by the child�s mother, or do notfeel they have the right to interact with the child ifthey cannot provide financial support. Suchnuances have not been studied adequately andare often neglected in discussions about adolescentfathers (Lyra, 1998). Adolescent fathers, albeit indifferent ways and to different degrees, face someof the same issues that young mothers face: too-

early role transition from adolescent to parent;social isolation; unstable relationships; and socialand family opposition to their involvement asfathers (Elster, 1986).

A few programmes and researchers in LatinAmerica and elsewhere call attention to the needfor more positive and less deficit-drivenapproaches to adolescent fathers (Lyra, 1998).Researchers argue that, for some young men, theact of fathering can be a powerful maturationalprocess, a strong source of positive identity andan opportunity to organise one�s life and priorities.These researchers have subsequently argued forthe role of programmes, families and schools toassist adolescent fathers in being more involvedand supportive of their children (Rhoden andRobinson, 1997).

Implications

Summing up, research on the sexualbehaviour of adolescent boys provides insights onhow boys are socialised and pressured to adhereto prevailing sexual scripts. As highlighted here,young men often describe pressure from their malepeers to have sexual relations at a relatively youngage as a form of sexual coercion. In somecountries, young men describe being taken to sexworkers by male relatives when these malerelatives determined that the time was appropriate.This subtle and not-so-subtle peer and societalpressure on young men to prove their sexualcompetency has important and often negativeconsequences to how young men construct theirsexual identity and styles of interaction in intimaterelationships.

The research presented in this chapter alsoprovides a strong rationale for engaging adolescentboys on these issues as a way to affect thebehaviour of men when they are adults. Viewingwomen as objects, viewing sex as a competencyrather than an opportunity for intimacy, feelingthat they are �owed� sex by girls and women, anddisregarding their sexual health are patterns thatoften emerge in adolescence and continue intoadulthood. Adolescent boys are also likely tointernalise the styles of male-female interactionthey see around them. Young men who weredisrespectful in relationships with young womenoften have experienced similar relationships in

40 WHAT ABOUT BOYS?

their homes or had negative relationshipexperiences in their families. Where male-femalerelationships are characterised by conflicts overresources, many young men lack internalisedmodels of positive, mutually supporting male-female relationships. These examples confirm thatpromoting greater gender equity in male-femalerelationships must include working withadolescent boys.

The review of literature presented in thischapter highlights a number of areas whereadditional information and programme andpolicy development are required, and yieldsimportant implications for current and futurework:

Programme Implications:

❋❋❋❋❋ Programmes need to offer boys moreinformation on sexuality and reproductivehealth. This information should take intoaccount their concerns and realities andshould be provided in open, non-judgmental settings

❋❋❋❋❋ Given the prevailing views about sexualactivity as a competency rather than anopportunity for intimacy, there is a needfor programmes to engage adolescent boysin wide-ranging discussions about sexuality,including sexual health and safer sex, butalso including boys� other sexual healthconcerns (e.g. concerns over satisfyingtheir partner, penis size, etc.), and workingwith boys to question some of the �myths�about male sexuality.

❋❋❋❋❋ There is a need for greater programmeattention to the concerns of adolescent boyswho identify themselves as homosexual,and to confront widespread homophobia,which has negative implications for menhaving sex with men and for heterosexualboys and young men.

❋❋❋❋❋ Given the increasing rates of HIV in someregions of the world, and the important roleof men and adolescent boys in the spreadof HIV, there is an urgent need to engageadolescent boys in discussions about safersex, particularly condom use and use theirparticipation in the design of safer sexprogrammes for boys.

❋❋❋❋❋ There is a need for increased voluntary andconfidential testing and counseling for STIs,including HIV, for adolescent boys, given thehigh rates of STIs, including HIV, amongadolescent boys, and the asymptomaticnature of many STIs.

❋❋❋❋❋ There is a need for greater programmeattention to the realities of adolescent fathers,and to engage all adolescent boys indiscussions about their potential roles asfathers. Boys are generally not socialised tonurture or care for young children; engagingboys in discussions in these issues while theyare adolescents provides an importantopportunity to encourage greater maleparticipation in caring for children.

Research Implications:

❋❋❋❋❋ There is a need for research to consider thefull range of sexual expression for young andto work on several fronts to broaden ourdefinitions of sexual expression and intimacyin research on adolescent sexuality.

❋❋❋❋❋ There is a need for more research on theconcerns and unmet health needs ofadolescent boys who self-identify ashomosexual or bisexual who have fewspaces to discuss their sexual identities andexperiences, and face considerable socialand familial prejudice in nearly all parts ofthe world.

❋❋❋❋❋ There is a need for more research on therealities of adolescent fathers, and boys�attitudes about fathering.

❋❋❋❋❋ There is a need for additional research onwhich interventions are most effective inencouraging boys to be more genderequitable and sensitive to their partners�needs in terms of their sexual behaviour

41WHAT ABOUT BOYS?

accidents, injuries and violence

chapter 4

Accidents, injuries and violence are theleading causes of death and morbidities inadolescent boys world-wide. Boys� behaviour andsocialisation often put them at high risk of beingvictimised by violence and injuries, and boys arealso perpetrators of violence and traffic-relatedinjuries and deaths. Yet, despite these two facts,most reports of violence have not considered theissue of gender. There is a great need tounderstand and address how gender socialisation� how boys are socialised to be boys � influencesboys� victimisation by violence, injuries andaccidents, and their perpetration of violence.

Accidents, Injuries and OccupationalHealth

Road Traffic Accidents

Road accidents are the main cause of deathof young men world-wide; many of theseaccidents are related to drug and alcohol use(WHO Adolescent Health and DevelopmentProgramme, 1998). For every young person killedin traffic accidents, another 10 are seriously injuredor maimed for life. Traffic safety conditions aremore precarious in developing countries, wherethere has also been an increase in number ofvehicles. Road traffic mortality increased morethan 200 percent in Africa and 150 percent inAsia between 1968 and 1983. In Thailand, nearlytwice as many boys as girls have been involved ina traffic accident and 48.5 percent of urban-basedboys report having been in an accident in the lastthree years (Podhisita and Pattaravanich, 1998).In the United Arab Emirates, 70 percent ofemergency room visits involved boys, with themost common causes of trauma being road trafficaccidents, injuries from sharp objects, fights andsporting accidents (Bener, Al-Salman and Pugh,1998).

Boys are at higher risk of road traffic accidentsthan girls for a number of reasons. As previouslynoted, boys often spend a larger proportion oftheir time outside of the home, and spend moretime in or around streets and public thoroughfares.Use of alcohol or other substances combined withreckless use of motor vehicles are behaviours thatthe male peer group often condone.

Injuries and Occupational Health

In developing countries in particular, a largenumber of adolescents work outside the home tocontribute to their own and their family�s income.In these countries, boys are more likely than girlsto work outside the home. While additionalinformation is needed, limited data suggests thatmany boys in resource-poor countries work inoccupations or tasks that present risks to theirhealth, work on the streets where they are exposedto environmental hazards and traffic-relatedaccidents, or work with hazardous materials. Aspreviously noted, in some parts of the world,adolescent boys and young men work in transientsettings away from their families and may beexposed to higher risk of STIs, including HIV.Substance use in the workplace, or substance useto endure difficult work conditions, is anotheroccupational-related health hazard that youngmen sometimes face.

While sex-disaggregated data onoccupational health hazards is limited, a fewstudies suggest that boys may be more likely toface work-related accidents, injuries oroccupational health problems. In Thailand, nearlytwice as many males as females reported work-related accidents: 13.9 percent for urban malesand 17.5 percent for rural males, compared to5.7 percent for both urban and rural females(Podhisita and Pattaravanich, 1998). Similarly, inItaly, 90 percent of the work-related injuries tochildren and youth were among males (Pianosiand Zocchetti, 1995).Road accidents are the main cause of death

of young men world-wide; many of theseaccidents are related to drug and alcoholuse.

42 WHAT ABOUT BOYS?

Violence

Boys as Perpetrators of Violence

Boys are far more likely than girls to beperpetrators of violence according to numerousreports from various countries. Studies on bullyingbehaviour in the United Kingdom find that onein eight primary school students and one in 14secondary school students said they took part inbullying activities; boys are disproportionatelyrepresented both as victims and perpetrators(Utting, 1997). A survey of youth in a low-incomecommunity in Brazil found that 30 percent hadbeen involved in fights, the vast majority of thoseboys (Ruzany et al., 1996). In the U.S., 14.9percent of males compared to 5.8 percent offemales reported engaging in at least one formof delinquent behaviour in the last year, includingless violent forms, such as vandalism (U.S.Department of Justice, 1997). The U.S. NationalLongitudinal Study of Adolescent Health foundthat more than 10 percent of males compared to5 percent of females reported having committeda violent act in the past year (Resnick et al, 1997).Boys in the U.S. are four times more likely thangirls to have been involved in fights (Centers forDisease Control and Prevention, 1992).

What are the reasons for boys� higher ratesof violent behaviour? Specific traits in boys�temperaments � higher rates of lack of impulsecontrol, ADHD and other traits such as sensation-seeking, reactability and irritability � may beprecursors to aggression (Miedzian, 1991; Earls,1991). As early as four months of age,temperamental differences can be detectedbetween boys and girls. Boys show higher levelsof irritability and manageability, factors that areassociated with later hyperactivity and aggression(Stormont-Spurgin and Zentall, 1995). All of theseprecursors may dispose some males to become

aggressive, violent or risk-seeking. However, thesefactors are not conclusive explanations. Otherresearchers have looked at the role of testosteronein aggression, but existing evidence suggests thatthe effect of sex hormones on levels of aggressionis limited; this issue is further complicated by thefact that violent and aggressive behaviour cancause serum testosterone levels to rise, thusconfusing cause and effect (Miedzian, 1991). Whilethere may be some evidence for a biological ortemperamental link to aggressive and risk-takingbehaviour, most researchers conclude that themajority of boys� violent behaviour is explainedby social and environmental factors duringchildhood and adolescence (Sampson and Laub,1993).

It is important to note that aggression andviolence are not merely male domains.Comparative studies with boys and girls aroundthe world find that boys are more likely to usephysical aggression, while girls are more likely tobe indirectly aggressive � telling lies, ignoringsomeone or ostracising others from the socialgroup. Furthermore, some of the supposedbiological bases for boys� aggressive behaviour �ADHD and personality disorder, for example � maythemselves be subject to gender bias. ADHD,personality disorder and conduct behaviourdisorder are all diagnoses based on behaviouralassessments. It may be that some of the sexdifferences found in reported rates of suchdisorders are due to the tendency of researchersand clinicians to measure and note the physicalaggression of boys but not the indirect aggressionof girls. Some researchers have suggested thatfemale aggression in the U.S. may have increasedas social stereotypes for gender roles there havechanged, allowing and even encouraging girls toact in more �masculine� and �violent� ways, butnot the other way around (Renfrew, 1997).

The emerging consensus is that socialisationof boys in the home � for example, encouragingmore rough and tumble play with boys than withgirls � interacts with genetic factors to producehigher rates of aggressive behaviour in boys(Boulton, 1994). For some boys, aggressivebehaviour can lead to acts of violence againstothers depending on environmental factors, suchas the nature of the relationship with parents orother important adults and exposure to violence

While there may be some evidence for amale biological and temperamental link toaggressive and risk-taking behaviour, themajority of boys� violent behaviour isexplained by social and environmentalfactors during childhood and adolescence.

43WHAT ABOUT BOYS?

in the home or community. Having been a victimof violence is strongly associated with beingviolent. Research in a number of countries findsthat boys are more likely than girls to have beenvictims of physical (non-sexual) abuse in theirhomes and physical violence outside the home(Blum et al., 1997;UNICEF, 1998).

While witnessing violence is stressful for bothboys and girls, they may manifest this stress indifferent ways. For boys, the trauma related towitnessing violence is more likely to be externalisedas violence (U.S. Department of Justice, 1997).Some researchers suggest that most boys aresocialised to believe that it is inappropriate forthem to express fear and sadness but appropriatefor them to express anger and aggression. Indeed,depression and psychological pain are commonprecursors to both violence committed againstother young men and violence committed by menagainst women (Personal correspondence, Bennode Keijzer, 1998).

Overall, early childhood anti-social,biologically-based tendencies (temperament,aggressiveness, and hyperactivity) are weakpredictors of future violent behaviour for mostadolescent boys. While there may be someevidence for the early biologically-basedpropensity of violent behaviour, researchersbelieve the majority of violent behaviour isexplained by social factors during adolescence andchildhood. For example, poverty and structuraldisadvantage influence delinquency by reducingthe capacity of families to achieve effectiveinformal social controls. Distressed parents aremore likely to use coercive discipline against boys,thereby contributing to antisocial behaviour asboys rebel against this authoritarian parenting.Early conduct disorder and ADHD or hyperactivityin some boys may be linked to later violentbehaviour, but it is unclear if these early traits�cause� violent behaviour per se. Parents andteachers might label these behaviours astroublesome, as we have previously seen, andreact in authoritarian ways that create a chain ofexpectations and reactions that indeed lead todelinquency (Sampson and Laub, 1993). Boys�higher rates of victimisation by physical abuse inthe home, and the documented connectionbetween having been a victim of abuse in thehome and subsequent par ticipation in

delinquency and violence, lends additionalsupport to this argument.

Violence has a survival and status functionfor young men in some low-income communitiesin some cultures. For many low-income males,with the absence of clear social roles, violence isway to maintain status in the male peer groupand to prevent violence against oneself (Majorsand Billson, 1993; Anderson, 1990; Archer, 1994;Schwartz, 1987; Zaluar, 1994). Emler and Reicher(1995) conclude that for some low-income youngmen in the United Kingdom and the U.S.,delinquency and violence against other males andagainst females become ways to affirm theiridentity.

Various studies also provide a compellingrationale for working with boys at early age toprevent violence. Some boys, after committing afew delinquent acts in early adolescence, aresubsequently labelled as delinquent andeventually accept the label and identity ofdelinquent. Delinquent behaviour for many boysstarts early in childhood and is strongly related tothe peer group (Elliott, 1994). In addition, theearlier the onset of violent behaviour, the greaterthe probability of continued violent behaviour intoadulthood.

Boys as Victims and Witnesses of Violence

Young men are more frequently studied asperpetrators rather than as victims of violence.However, some researchers and programmepersonnel have begun to emphasise that youngmen are also victims and that, when allowed toexpress it, young men are often fearful of thepotential for violence within themselves and ofthe violence inflicted or threatened by other youngmen.

Health statistics from many parts of worldconfirm that injuries resulting from violence areamong the chief causes of mortality and morbidityfor adolescent males. Available statistics indicatethat the most violent region in the world is theAmericas region, with a regional homicide rate ofabout 20 per 100,000 inhabitants (World Bank,1997). In some Latin American countries, publicand private costs associated with violencerepresent up to 10 percent of gross domestic

44 WHAT ABOUT BOYS?

products (Fontes, May and Santos, 1999).Throughout the region, the highest rates ofhomicides are among young men ages 15-24(PAHO, 1993). In Colombia, between 1991 and1995, there were 112,000 homicides. Youngpeople accounted for 41,000 deaths � the vastmajority males (World Bank, 1997). Homicide isthe third leading cause of death in adolescentsage 10-19 in the U.S. and accounted for 42percent of deaths among young black males inthe last 10 years (U.S. Department of Health andHuman Services, 1991). In Brazil, between 1988and 1990, Federal Police confirmed that 4,611children and youth were victims of homicide; themajority of these were male and 70 percent werebetween the ages of 15-17 (CEAP, 1993; Rizzini,1994).

Because they spend more time outside thehome in most cultures, boys are more likely to beexposed to or to witness physical violence outsidethe home. In a number of regions, public healthofficials are concerned about the psychologicalimpact of exposure to violence, both in low-income urban areas, and also in countries wherechildren and youth have been involved ascombatants in civil wars or exposed to ongoingarmed conflicts. In the Gaza Strip, for example,21.5 percent of children and adolescents (ages9-13) reported anxiety as a result of witnessingviolence and experienced stress associated withsocio-economic conditions (Thabet and Vostanis,1998). In the U.S., 27 percent of children andyouth in a low-income, violent urbanenvironment met the diagnostic criteria for post-traumatic stress disorder (American Academy ofPediatrics, 1996). Of course, not all children oradolescents exposed to violence manifest thesepsychological sequelae, but research from variouswar zones and low-income, violent urban areashas found that several disturbances are oftenassociated with exposure to violence, includingsubstance use, sleep disorders, psychic numbing,avoidance behaviours, depression and suicidalbehaviour.

More than 100 million young people arecurrently affected by armed conflict, either assoldiers, civilians or refugees. Young men are morelikely than young women to be involved ascombatants � some voluntarily, others against theirwill, often encouraged by political leaders (WHOAdolescent Health and Development Programme,1998).

Boys as Perpetrators and Victims of Datingor Courtship Violence

Studies with high school and college studentsin New Zealand and the U.S. have found thatbetween 20 and 59 percent of both males andfemales say they have experienced physicalaggression during a dating relationship (Jezl,Molidor and Wright, 1996; Magdol et al., 1997).While nearly equal numbers of males and femalesreport having been victims of dating violence, maledating violence against women tends to be moresevere and males tend to initiate this violence.Concern over dating violence or courtship violencein North America, Western Europe and Australiahas led to the creation of educational campaignstargeted largely at young men.

In response to men�s violence againstwomen, including violence by young men againstyoung women, some researchers and programmepersonnel have begun to ask: What are we doingdirectly with men, including young men, to preventthem from being violent to women? Manyindustrialised countries have long used court-mandated therapy for men, including adolescentmen, accused or convicted of domestic violenceor sexual assault. In North America, Australia andWestern Europe, and to a limited extent in someparts of Latin America, there are now discussiongroups working on date rape awareness anddomestic or courtship violence. Some of thesegroup activities have taken place with militaryrecruits, in sports locker rooms or in the schoolwith the goal of increasing men�s awareness aboutsuch issues, or with the idea of creating positivepeer pressure so that young men themselvesconvince their male peers that such behaviour isunacceptable. In a few countries in Latin America,NGOs have started voluntary discussion groupswith men, including young men, who want to workin a group setting to discuss their past acts ofviolence against women and their desire to preventsuch acts in the future.

Injuries resulting from violence are amongthe chief causes of mortality and morbidityfor adolescent males.

45WHAT ABOUT BOYS?

For the most part, though, research has notadequately informed us about the settings in whichyoung men�s violence against young womenoccurs and young men�s perspectives on thisviolence, nor offered ideas for prevention. Limitedresearch from Africa and Latin America confirmsthat many men, adult and adolescent, seedomestic or courtship violence as part of aninformal marriage or cohabitation contract (Ali,1995; Brown et al., 1995, Barker andLoewenstein, 1997; Njovana and Watts, 1996).Other young men may also condone this courtshipor dating violence, providing mutual support foreach other. Models of intervention and researchon how to work with young men to preventdomestic violence, dating or courtship violence,and sexual coercion are still lacking.

Boys as Victims of Physical and SexualAbuse and Sexual Coercion

A number of studies have providedinformation on the extent that adolescent boysare victimised by physical and sexual abuse. Moststudies confirm that girls are more likely to bevictims of sexual abuse or sexual coercion thanare boys, but numerous studies confirm that largenumbers of boys also suffer from sexual abuse. InBrazil, 20 percent of sexually active youth saidthey had been forced to have sex against theirwill at least once, with girls reporting about twicethe rate of boys (Childhope, 1997). In the U.S.,3.4 percent of males and 13 percent of femaleshad experienced sexual assault defined as�unwanted but actual sexual contact� (U.S.Department of Justice, 1997). In the Caribbean,16 percent of boys ages 16-18 reported beingphysically abused and 7.5 percent reported beingsexual abused (Lundgren, 1999). In Canada, one-third of men surveyed reported havingexperienced some kind of sexual abuse (Stewart,1996, in Lundgren, 1999).

In Kenya, a national survey of youth foundthat 28 percent of boys and 22 percent of girlsreported that forced sex was attempted with them.In addition, 31 percent of boys and 27 percent ofgirls reported having been pressured to have sex.For both males and females, that pressure comeslargely from adolescent and adult males. In thisstudy, the authors state the idea of �force� in sexualrelationships is likely to be experienced differently

by boys than girls. In this same study, when askedabout their most recent sexual activity, 66 percentof boys and 51 percent of girls reported that theyhad actually wanted to have sex, suggesting that�desire� and consensus for sexual activity arecomplex issues for boys and girls (Erulkar et al.,1998).

In Nicaragua, 27 percent of women and 19percent of men reported sexual abuse in childhoodor adolescence. In Sri Lanka, 7.4 percent of youngmen surveyed reported having been coerced intosex by an older male when they were young. InZimbabwe, 30 percent of secondary study studentsinterviewed reported that they had been sexuallyabused; half were boys being abused by femaleperpetrators (FOCUS, 1998).

A national survey in the U.S. found that 13percent of high school-age boys reported physicalor sexual abuse (including abuse in the home andin intimate relationships), compared to 21 percentof high school girls. Abused boys were more thanthree times as likely to report mental healthproblems than were non-abused boys; fewer thanhalf of abused boys told someone about the abuse(Schoen et al., 1998). This same U.S. study foundthat abused boys reported nearly twice as manysuicidal thoughts as did abused girls. Indeed, fromvarious parts of the world, there is evidence fromclinical mental health settings that boys physicallyor sexually abused in early childhood havedifficulty talking about the abuse later on. Whileyoung women often face similar difficulties intalking about past victimisation, there is evidencefrom Australia and North America that boys haveeven more difficulty expressing this victimisationand finding persons in whom to confide aboutabuse, or even finding adults who willacknowledge that they experienced abuse (KeysYoung, 1997).

Other health consequences of sexual abuseinclude physical injury, STIs and unwantedpregnancy for girls. Some studies also find thatsexual abuse is linked to subsequent high-risksexual activity for both boys and girls. Victims ofsexual abuse are generally less likely to use self-protective behaviour and less likely to feel theyhave power in sexual relationships. An ongoingcomparative study of sexual violence duringadolescence in South Africa, Brazil and the U.S.

46 WHAT ABOUT BOYS?

has found that sexual coercion and violence inadolescent intimate relationships are associatedwith lower condom use (Personalcorrespondence, Maria Helena Ruzany).

While girls are more likely than boys to bevictims of sexual abuse, a number of studiessuggest that boys are more likely than girls to bevictims of other forms of physical abuse in theirhomes. In Jordan, boys were more likely to bephysically abused in the home and more likely tobe victims of violence resulting in injuries, whilegirls were more likely to be victims of verbal abuse(UNICEF, 1998). Of officially reported cases ofchild abuse in Jordan, males under age 19 wereseven times more likely to be victims of physicalabuse resulting in injuries than were girls (UNICEF,1997). In Brazil, 61 percent of boys ages 11-17reported having been victims of physical violencefrom their parents, compared to 47 percent ofgirls (Goncalves de Assis, 1997).

Boys as Perpetrators of Sexual Coercion

A 1992 national survey of U.S. adolescentsages 15-18 found that 4.8 percent of males, ascompared to 1.3 percent of females, reportedhaving forced someone into a sexual act at leastonce. Sexually aggressive adolescents werethemselves more likely to have been sexuallyabused, to have witnessed abuse of a familymember, and to have used drugs or alcohol(American Academy of Pediatrics, 1997). Severalstudies from Western Europe and North Americafind a strong link between a young man havingbeen a victim of abuse in the home, includingsexual abuse, and his subsequently carrying outsexual assault or dating violence. This evidencesupports the need for services for young men whohave been victims of physical and sexual abuseas a form of treatment, but also as an importantelement in preventing potential sexual or datingviolence against others.

There are difficulties in documenting boys�acts of sexual assault and dating violence. Becauseof societal norms in some regions, sexual coercionmay be seen as part of boys� �normal� sexual script.For example, after a widely publicised event inKenya in 1991 in which 71 young women wereraped and 19 died from a group attack from theirmale classmates, school officials treated the eventas �boys will be boys� behaviour (Senderowitz,1995). A few studies have looked at the socialsetting in which domestic violence, dating violenceor sexual coercion takes place, seeking tounderstand how dating violence and sexualcoercion may be reinforced in the male peer group(Katz, 1995; Barker and Loewenstein, 1997). Thislimited research suggests that there is a strongconnection between boys� socialisation and thecoercive or aggressive behavior of some boystoward girls. In many settings, some boys feelthemselves entitled to young women�s sexualfavours, however defined, and thus feelempowered to use pressure, coercion and directand indirect violence to obtain these sexualfavours. In many settings, this behaviour istolerated on the part of boys, as suggested above,while girls who dare protest sexual violence areoften accused of having provoked boys.

Implications

Summing up, in most regions of the world,violence and traffic-related injuries account for themajority of mortality of adolescent males. Researchand interventions related to violence often focuson boys as perpetrators of violence. However,young men are also victims of violence. Havingbeen a victim of or witness to violence, either in oroutside the home, is a factor associated withcarrying out violence. The research presented inthis chapter also provides a compelling case thatthe causes of boys� higher rates of some forms ofviolent behaviour are found in the ways andconditions in which boys are socialised. Examiningand considering the ways that boys� violence isembedded in gender socialisation is an importantstarting point in designing more effective violenceprevention strategies.

The research presented here also suggeststhat we should keep in mind that violence is notmerely associated with low-income adolescentboys, although much research on violence has

While girls are more likely than boys tobe victims of sexual abuse, a number ofstudies suggest that boys are more likelythan girls to be victims of other forms ofphysical abuse in their homes.

47WHAT ABOUT BOYS?

focused on low-income young men. Poverty isitself a form of social violence, but poverty shouldnot be considered a cause of violence. Middle classadolescent boys are also involved in violence, andare also socialised to use violence to expressemotions and resolve conflicts, just as many boysin low-income areas are not perpetrators ofviolence. In studying and responding to violence,it is imperative not to stigmatise or label low-income boys, or boys in general, as inherentlyviolent, and to recognise that most boys are notperpetrators of violence.

The following are other implications of theexisting research on violence and adolescent boys:

Programme Implications:

❋❋❋❋❋ There is a need for youth-servingprogrammes to offer young men alternativeways of resolving conflicts, developingtheir identities and expressing emotions.Limited interventions along these lines haveconfirmed that young men respond wellwhen offered opportunities to discuss theirvictimisation by violence and their fear ofviolence and to reflect about the ways thatviolence is often part of male socialisation.

❋❋❋❋❋ There is a need for more programmeattention to the issue of relationship ordating violence. A few programmeexperiences cited here have sought toengage boys in discussions about theseissues, but more programme developmentis needed in this area.

❋❋❋❋❋ There is a need for more programmaticattention to boys as victims and witnessesof violence by offering formal and informalopportunities to discuss the violence boyswitness and to reduce the stress associatedwith victimisation.

❋❋❋❋❋ There is a need to establish programmesin settings where violent and delinquentbehaviour by boys is prevalent and theseshould target boys at an early age.Interventions working with boys in violenceprevention should not assume that boys arepotentially violent or label them as

delinquent, but instead should seek toengage them in positive ways with theircommunity, family, pro-social peers andnon-violent male role models.

❋❋❋❋❋ There is a need for programmes to sensitiseand educate parents, teachers, healthpersonnel and other youth-servingprofessionals about the possible roots ofsome boys� violent behaviour, helping themto effectively engage boys rather thanresponding in mainly punitive ways.

❋❋❋❋❋ There is a need for additional and expandedcampaigns to raise awareness about roadtraffic accidents, occupational healthhazards and injuries among adolescentboys.

Research Implications:

❋❋❋❋❋ There is a need for additional research toexamine how the socialisation of boys islinked to sexual coercion and other formsof violence against women, and on thefactors that may prevent this violence.

❋❋❋❋❋ There is a need to examine more explicitlythe role of gender socialisation in reinforcingmale violence. Young men are oftensocialised to see anger and aggression asthe only appropriate �male� emotions. Orto see violence as a way to define theiridentities.

❋❋❋❋❋ There is a need for additional research onhow the media influences violent behaviourby boys. This might offer insights on howto work with young people to developcritical attitudes toward the media.

❋❋❋❋❋ More research is needed on alternative, non-punitive approaches to violence prevention,including effective conflict resolution trainingmethodologies. The literature reviewed heremakes a strong case for taking a humandevelopment and human ecology approachto violence prevention, exploring sourcesof social and family support, the subjectiveexperiences of youth and the role of gendersocialisation in violence.

48 WHAT ABOUT BOYS?

49WHAT ABOUT BOYS?

final considerations

chapter 5

Research on adolescent boys, as foradolescents of both sexes, tends to focus onproblems and risks. In examining the researchreviewed here, we may be left with the impressionthat adolescent boys are �walking problems.� Thechallenge is to recognise and understand theproblems and risks that boys face � and the harmthey sometimes do to themselves and others �without merely seeing boys in deficit terms. Wemust also look at the positive ways that boyscontribute to their families and societies, andidentify the potentials they represent.

The field of child development offers ussome ideas on how to do this. For example, somechild development theories suggest that alladolescents � boys and girls � have the ability tonurture and care for another human being if theythemselves were adequately nurtured. In studyingadolescent boys and men, we sometimes assumethat boys and men lack the ability to care forothers. Child development theories suggest thatinstead of seeing boys as inherently lacking suchcaregiving skills, it is more appropriate to see boysas being socialised to repress their inherent abilitiesto emotionally bond to other human beings. Inthis perspective, the challenge becomes helpingboys regain or reappropriate caregiving andnurturing skills that were, in effect, �socialised outof them� (Pollack, 1998).

The research presented here argues that theways boys are socialised strongly influences theirbehaviours and determines their health risks.Changing how societies and families raise boys

The challenge is to recognise andunderstand the problems and risks thatboys face � and the harm they sometimesdo to themselves and others � withoutmerely seeing boys in deficit terms. Wemust also look at the positive ways thatboys contribute to their families andsocieties, and identify the potentials theyrepresent.

will be not be easy, but it is possible, necessaryand in some places already happening. We havestrong evidence of changing behaviours and rolesrelated to views about women�s roles in society inthe last 20 to 30 years. There is also someevidence that boys� and men�s attitudes are in factchanging, and that young men are more flexiblethan the previous generation with regard to genderroles. Even in areas of the world characterised bytraditional patriarchal values, there is someevidence of changes in gender roles and men�sattitudes, driven perhaps by changes in women�sroles in society. While young women have hadsome spaces and opportunities to construct newroles for themselves, boys and young men havefew spaces in which to react to changingexpectations and in which to discuss new identitiesand ways of being young men, but urgently needsuch opportunities.

Experiences in Engaging Boys

Rather than sounding utopian, it isimportant to point out that there are alreadyprogramme experiences from around the worldthat have engaged boys in these kinds ofdiscussions. As mentioned at the beginning of thisdocument, one of the assumptions often madeabout adolescent boys is that they are �hard towork with� and difficult to engage in healthpromotion. However, the experiences in workingwith adolescent boys already offer lessons abouthow to engage and attract adolescent boys intoexisting health services and health promotionactivities:

❋❋❋❋❋ Boys are more likely to use existing healthservices when such services are madeattractive to them. Some programmes reportthat having male staff to work with youngmen is important, while others report thatthe sex of the staff is not important if theyare sensitive to boys� needs. Some clinicshave used sports activities and peeroutreach workers to invite boys into existinghealth facilities.

50 WHAT ABOUT BOYS?

❋❋❋❋❋ Program staff also report that boys, likegirls, prefer integrated services and activitiesthat take into account their full range ofinterests and needs, such as the need forvocational training or responses tocommunity violence.

❋❋❋❋❋ Boys often request or appreciate having thechance to discuss their concerns in boy-onlygroups, but most programmes also find itimportant to have boys and girlssubsequently discuss their concernstogether. Boys generally report a lack ofspaces where they can discuss � in a non-judgmental manner � questions aboutmasculinity, personal issues or health-related matters.

❋❋❋❋❋ In parts of the world where households areheaded by females, or where adult menand fathers may be physically distant, boysoften report the importance of interactionwith positive male role models, such asteachers, older male family members,health educators or peer promoters.

❋❋❋❋❋ Boys may require counselling and mentalhealth services, but are reluctant to seeksuch services. Often, teachers and othersocial service staff may not recognise signsand symptoms of boys� needs for suchattention. When staff are adequatelysensitive and sensitised to boys� ways ofexpressing stress, trauma and psychologicalpain, and staff approach boys in ways thatrespect their silences, results have shownthat boys will make use of mental healthand counselling services in greaternumbers.

❋❋❋❋❋ When exposed to fathers, adult men orimportant role models who are caring,flexible, and involved in child rearing, boysare more likely to grow up to be caring, tonegotiate in their intimate relationships andto be more involved fathers, if they havechildren. Similarly, programmes working inviolence prevention have found theimportance of exposing adolescent boys tonon-violent ways of expressing emotions,including frustration and anger.

❋❋❋❋❋ Experiences in conflict resolution, violenceprevention, sexuality education and familylife education have found that the school isan important setting for carrying out suchactivities because large numbers of youngpeople attend school. However, becausesome adolescent boys with the most urgentneeds may be outside the school setting, theymust be reached in those settings where they�hang out� � the street, sporting activities,the community, in military barracks, attransportation hubs, and, in some cases, atfacilities for juvenile offenders.

❋❋❋❋❋ There is a strong rationale for reachingadolescent boys at an early age and to keepreaching them. Young men have been foundto have high levels of participation inorganised sports and youth groups. Thisprovides an opportunity to reach theseyoung men with preventive messages relatedto sexual health before they start their sexualactivity . Boys change their attitudes overtime, and behaviours vary as situations,partners and peer groups change. Thus,programmes cannot assume that a youngman, once engaged in a programme, doesnot need to be engaged again. Furthermore,programme experiences suggest thatinterventions should have flexible age limits.Some programmes end when a youngperson turns 18. Experience suggests thatprogrammes must meet the varied andchanging needs of young men over time,and not use mandatory age cut-offs that maynot follow developmental needs of youngpeople.

51WHAT ABOUT BOYS?

Final Comments

Summing up, there are importantprogramme experiences that offer us ideas on howto engage boys in ways that promote their healthand development. Similarly, the body of literatureanalysed here provides a strong basis for designingmore effective policies and programmes relatedto adolescent boys. Taken together thisinformation helps us confront and overturn someof the assumptions about boys. First, boys can

The research cited here confirms thatadolescent boys have gender-specificpotentials and risks, just as adolescentgirls do. In virtually every culture weexamine, being a boy brings with itadvantages and disadvantages.

be engaged when we listen to their needs andconcerns and approach them in positive ways.Secondly, instead of assuming that boys do nothave problems, the research cited here confirmsthat adolescent boys have gender-specificpotentials and risks, just as adolescent girls do. Invirtually every culture we examine, being a boybrings with it advantages and disadvantages. Evenin regions of the world where structural biasesagainst women continue to be strong and wheremen, on aggregate, benefit from gender inequities,masculinity nonetheless implies both benefits andcosts for adolescent boys and adult men. Thechallenge before us is to offer young menopportunities to explore their past and currentroles and expectations as men, and to engagethem in ways that promote healthy developmentand well-being for them, their partners and theircommunities.

52 WHAT ABOUT BOYS?

53WHAT ABOUT BOYS?

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