Family and Community Health W (FCH) H O World Health Organization / F C H / C A H / 0 0 .

9 Original: English Distribution: General

WORKING WITH ADOLESCENT BOYS

Report of a Workshop
Geneva, 17-19 May 1999

Department of Child and Adolescent Health and Development (CAH)

 WORLD HEALTH ORGANIZATION, 2000 This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced and translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. The views expressed in documents by named authors are solely the responsibility of those authors.

CONTENTS
Executive summary 1. The importance of considering adolescent boys 2. Characteristics of adolescent boys and girls 3. Sex differentials in health and development outcomes 4. What do we know about boys 5. Experiences from the field 6. Gaps in programming for boys 7. Making the case for adolescent boys - a debate 8. Towards a plan of action Annex 1 Agenda Annex 2 Participants Annex 3 Suggested readings

Executive summary
From 17 to 19 May 1999, WHO conducted a workshop in Geneva, Switzerland, entitled Working with Adolescent Boys. The aim of this workshop, as part of a project funded by UNAIDS and the Government of Norway, was to identify lessons learned in, and support mechanisms for wider attention to, programming for adolescent boys. Two products of WHO projects served as input for the discussions: an extensive literature review that focused on addressing the health and development of adolescent boys from a gender perspective, and the results from four regional surveys on projects and organizations working with adolescent boys. The workshop was organized by the Department of Child and Adolescent Health and Development (CAH) of the World Health Organization in Geneva. In addition to WHO Headquarters and Regional staff, participants included: United Nations staff: UNESCO (HQ), UNICEF (field and HQ), UNFPA (HQ), UNAIDS(HQ); Bilateral organization: Swedish International Development Cooperation Agency (SIDA); Expert institutions: Maquairie University, Australia; Population Council, Africa; Foundations: MacArthur Foundation and Ford Foundation; NGOs: Instituto Promundo, Brazil and Family Health Group, Jordan; Youth organizations: Scouts (European and Arab regional offices) and YMCA

Major outcomes involved the recognition that there is a wellestablished need to work more systematically with boys. Several reasons were identified for this need: Adolescent boys also face significant problems and risks related to their healthy development The health-related behaviours of adolescent boys have direct consequences for their future health as adults Adolescent boys health and health behaviours are directly related to the health of adolescent girls From an economic perspective, ignoring the specific health needs and health-related practices of adolescent boys results in tremendous costs to societies. Beyond these sound public health and economic reasons, attending to adolescent boys is a matter of assuring their rights - as described in, among other documents, the Convention on the Rights of the Child. A gender approach is vital in making programming for adolescent boys meaningful for the health and development of boys and girls simultaneously. Our purpose does not lie in arguing about whose needs are more urgent, but is rather to examine the health implications of gender for both adolescent women and adolescent men, and to improve the health and development of all adolescents. Programmatic implications identified in the workshop involved various parts of the programming cycle: Strengthening the evidence base: There is a lack of information on the health and development situation of boys, on their attitudes and needs,

as well as certain boys and mens health issues. The existence of this gap requires more systematic research and consistent sex-disaggregation of research findings. Effective advocacy: This approach represents the key to convincing policy makers, programme designers and others of the importance of considering adolescent boys in their work. A better evidence base will strengthen these efforts, emphasizing the fact that working with boys will improve the situation of adolescent boys and girls. Programme design and materials should be reviewed, with the participation of the boys themselves, to adapt to their particular needs. This approach includes opening of spaces, physical and conceptual, for boys within existing programmes to ensure programmes are acceptable and welcoming to boys as well as to girls. Programming should try to avoid a focus solely on problems, which can result in negative labelling of boys by linking their programmes to such behaviours as violence and substance use. Development-oriented approaches have significant advantages over problemfocused programmes. The entry point for programmes should be attractive to boys, including for example development of vocational skills or sports activities. Positive male role models for boys are an important vehicle for learning. Providing mentoring and connecting boys to other men who can provide positive role models can be effective. In general, positive

images of boys as dynamic contributors to the society should be fostered.

1. The importance of considering adolescent boys

Background
Adolescent boys have seldom been the focus of the growing attention being paid to adolescent health and development. To the contrary, many programmes for adolescents target adolescent girls. This is largely due to the higher vulnerability of women in general and girls in particular. This focus on girls is also present in attention to sexual and reproductive health issues such as unwanted pregnancy, abortion, and HIV/AIDS, all of which affect girls in particular. In recent years, there has been increasing recognition of the role of men in maintaining their own health, as well as considering this topic a factor in maintaining the health of women. Considerable attention has been paid to male involvement in health, specifically sexual and reproductive health. The emphasis in male involvement programmes has been on how men should participate in and take more responsibility for safeguarding the health of their family members, especially the sexual and reproductive health needs of women, but rarely with the intention of understanding and attending to mens own health needs. Likewise, the centre of gravity - if not the explicit focus - of interventions for adolescent sexual and reproductive health has been young women. Indeed, adolescent girls do bear the immediate consequences of unsafe and unwanted sexual behaviour to a larger extent than young men. But when we consider the broader picture of health of adolescents, it becomes clear that

there is no compelling reason to neglect the health needs of boys. Considering the mortality and morbidity statistics under some conditions, we see that the health of adolescent boys is very much affected (cf., Chapter 3). However, the fundamental importance of considering the health of adolescent boys is not epidemiology per se; nor does it lie in simple comparison with the health of girls. Rather, it is important because the evolving gender relationships of boys and girls during adolescence plays a crucial role in the development and health of both. Adolescent boys and girls have both similar and slightly different needs and vulnerabilities. In order for programming to be gender sensitive, programmes need to address the specific needs and circumstances of boys and girls. This is not only a matter of needs but also of basic rights - the right to information, protection, and health care. By more comprehensively addressing the gender-specific needs of boys, programmes will help to improve the health and development of adolescent boys, while improving the health of adolescent girls. To this end, the workshop sought to increase knowledge about working with adolescent boys to better address their health and development needs.

boys in order to identify approaches to reaching boys; and identify knowledge gaps and make recommendations for future research and activities to further programming for adolescent boys.

The workshop was conducted in small groups as well as in the plenary reporting sessions and discussions. To facilitate the tasks, Visualizing in Participatory Planning (VIPP) methodology was used. Through the use of coloured cards displayed on the wall, discussions and ideas are visualized and equal participation of all participants is promoted. Moreover, the visualized discussions facilitate reanalysis or further interpretation of earlier work.

Applying a gender perspective to adolescent boys

A gender perspective can be applied from two overlapping and related approaches: gender equity and gender specificity. Gender equity refers to the relational aspects of gender and the concept of gender as a power structure that permeates human relations and often affords or limits opportunities based on ones gender. A gender equity perspective, applied to adolescent boys implies, among other things, working with young men to improve young womens health and well-being. Such approaches force us to consider the power differentials that exist in many societies between men and women in aggregate, and between men and women in individual relationships. Gender specificity refers to examining specific health risks for women and men because of: (1) biological factors associated with each sex; and (2) the way that gender norms are constructed in given settings. The typical approach to gender specificity in health promotion

Key objectives
The major objectives of the workshop were to: examine how working with adolescent boys can help achieve gender equality and promote the rights to health for both sexes; review the literature and research concerning the health of adolescent boys and reasons for working with boys; review and discuss the findings from the survey of projects targetting adolescent

has involved showing how each gender faces particular risks or morbidities, and then developing programmes that take into account these particular risks.

Adolescent boys: a heterogeneous population

When considering adolescent boys, it is also imperative that we understand that they - like adolescent girls - are a heterogeneous population. Many boys are in school, but too many are out of school, and others work. Some are fathers, some are partners or husbands of adolescent girls, and still others are bi- or homosexual. Some are involved in armed conflicts as combatants and/or victims. Others are sexually or physically abused in their homes; some sexually abuse young women or other young men. Some are living or working on the streets; and others are involved in survival sex. The majority of adolescent boys, however, are in fact faring well in their health and development. They represent positive forces in their societies and are respectful in their relationships with young women and with other young men. Other young men face risks and needs that may not have been considered, or are socialized in ways that lead to violence and discrimination against women, violence against other young men, and health risks to themselves and their communities. Recognizing this complexity is an important starting point.

programmatic implications that arise from the different characteristics of boys and girls. An assessment of these characteristics and the differences between boys and girls is a first step to gender-specific programming in adolescent health. Accordingly, workshop participants undertook this assessment as the starting point for further discussions. The following general overview emerged from that exercise, which can be briefly summarized under the headings:

2. Characteristics of adolescent boys and girls

The characteristics of adolescent boys, and the ways in which boys differ from girls, have implications for the approaches we use in working with boys. These characteristics can explain gender specific behaviours that influence health and development. At least as important are the

Physical: Boys mature later than girls and the events that happen, such as spermarche, are less understood - both by science and the boys themselves. Sexuality and growth is a private issue which is not easily shared with others. In contrast to girls who experience menarche, in boys there is no clear physical event that marks the entry into manhood. There are few cultures that have a rite of passage for boys to which some form of sexual education could be linked. Boys are thought and expected to be physically stronger and more active. In the acceptance of physical growth, boys are thought to be concerned with their penis size whereas girls are concerned with body weight and breast size. Overall, girls are more concerned with their appearance. Cognitive and emotional: Boys have a tendency to internalize their emotions, while girls externalize them. Boys express a smaller

range of emotion or are unable to express their emotions, while some emotions are socially not accepted. Boys have a more difficult temperament, they express more anger. Boys are more distant and do not allow intimacy as easily as girls. They are also less inclined to show intimacy with other boys because of homophobic norms. Girls have more empathy for relationships. There is not full understanding as to the extent to which cognitive differences - in terms of spatial orientation and association linked to functionalities ascribed to the left and right brain - are biologically or socially determined. However, there is emerging evidence that boys do not perform as well in multi-tasking as girls. Further to the assessment of characteristics and differences between boys and girls, the workshop also addressed the following categories of behaviour:

be more interest by boys in competition and hierarchy. Boys play is more competitive while girls are more cooperative. Girls are more protected and at the same time there are more sanctions on girls behaviours. Girls are also more disciplined at an earlier stage and possibly as a result show more prosocial behaviour. Boys are more likely to be diagnosed with problem behaviour and referred for counselling or control.

Behavioural patterns: Boys tend to take more risks and therefore are more often involved in risk behaviours than girls, although some participants argued that girls have more silent patterns of risk behaviours. Boys are also more involved in violent behaviours. Often boys are seen as perpetrators of violence and if they are victims, it is more likely to be of physical than emotional or sexual violence. There seems to

Social roles: Traditional roles assigned to boys and girls seem to apply in broad terms. In general, boys are part of the culture of the street, while girls learn through the culture of the house. However, the roles of men and women in society are changing. Girls assume more roles including traditional male ones. For boys, on the other hand, the type of accepted roles is still limited and they are thought to be less equipped for adopting multiple roles. Boys role as primary income provider is eroding in many cultures, and yet earning an income for themselves and their family is important in their perception. Some characterize this change as less need for men and this is linked to reducing opportunities for boys and increasing opportunities for girls. Along the same lines, boys behaviours are interesting to girls but not vice versa. Boys also have fewer role models than girls, because

male role models are acceptable to both girls and boys while female role models are not acceptable to boys.

Family: Boys are believed to be generally less connected to the family. While girls tend to be close to the mother, boys are more distant to the father. Father is seen as a distant disciplinarian. There is a notion that men are unsafe around children, even fathers with their own children. Overall, parents have more expectations of girls, and boys have more freedom. Boy preference was thought to be slowly diminishing.

condoned as a generally time-limited issue. Homophobia is stronger in boys than in girls. School: Several observations emerged: girls were said to drop out of school more, yet those who stay in school have higher achievement. In general, girls are improving relative to boys in science and maths. A growing percentage of girls continue their higher education, while in some countries this trend is reversed for boys. Health seeking behaviour: Boys find it harder to seek help than girls. The common notion is that boys are favoured in their access to food and health services. Boys are more likely to be referred for counselling, because they are more easily labelled as showing problem behaviours. Boys make less use of (health) services.

Finally, the following characteristics were considered:

Sexuality and marriage: While age at marriage is increasing in many societies, sexual initiation occurs more and more often outside wedlock. In most places, boys initiate sexual intercourse earlier than girls. Sexual initiation is also more likely to occur among the peer group. While in girls sexual behaviour is associated with fear and guilt, in boys it is associated with manhood and triumph. Virginity is valued for girls but not for boys. In private, but not in public, boys admit to having fears and uncertainties with regard to sexuality. While in many cultures homosexual behaviours for adults are not accepted, in adolescent boys they are often

The participants made several observations about the process and the results: While all participants have experience in working with or studying the behaviours of adolescents, boys or girls, these characteristics should foremost be interpreted as the outcomes of an exercise. They are by no means complete or refined. The characteristics described, while alluding to differences between the genders that might have validity in a variety of cultural settings, should not be interpreted as generalizable or

globally valid. Indeed, they reflect a tendency to mask considerable cultural differences that exist and, in particular, could be skewed towards western-oriented concepts of youth. Discussions were conducted in two groups separated according to sex. Many of the men commented that such discussions of mens and boys realities was a new experience. It was recognized that creating spaces and opportunities for boys and men to discuss their ideas, feelings, and behaviours would be a valuable asset. This observation was echoed by programming experiences from the field, discussed later in this document. While distinctions between boys and girls where identified, participants felt that these distinctions tended to polarize what in reality are scales of characteristics in persons. They also recognized the fact that differences within genders are probably as big or bigger than between genders.

3. Sex differentials in health and development outcomes

The characteristics described above may lead to genderdifferentiated health behaviours and disease patterns. These can in turn result in differences in mortality and morbidity in adolescents when considered by gender. In general, adolescent girls are more vulnerable and disadvantaged in social and health terms due to gender roles. However, this does not preclude boys from experiencing health problems as well.

It is interesting to note the similarities among and differences between the opinions about boys and girls as expressed by adolescents themselves. These excerpts were taken from Straight Talk, a newsletter for and by young people from Uganda:

One approach to assessing the overall burden of disease, which takes into account not only mortality but also

disability due to morbidity, is Disability Adjusted Life Years (DALY) methodology. When we look at disease burden for all causes combined, the graph above shows that adolescent boys have higher DALY rates than adolescent girls in most regions, with the notable exceptions of the populous countries China (CHI) and India (IND). Significantly, it indicates that boys health is a public health concern as much as the health of girls. The following table reflects rates of suicide in the15 to 24 year age group. These data reflect both a clear difference in suicide rates between girls and boys, as well as a very marked difference between countries. Girls are believed to have higher rates of attempted suicide, whereas - for a variety of reasons boys carry out more actual suicides. Deaths due to suicide in 1024 year olds, per 100,000 population
Country Boys Girls

Source: WHO statistics, compiled from several years

One of the questions this observation raises is the extent to which these sex differences in disease burden are determined by societal factors including gender socialization of boys and girls, or by biological factors. The literature review on adolescent boys, that was presented during the workshop, provides more insight into some aspects of this question. Societal factors and gender roles clearly play a role in the sexual behaviour of boys and girls . The following box shows the age at first sex for boys and girls for selected countries through Demographic and Health Surveys (DHS).

Age at firstsex for girls and boys in selected countries

SubSaharan Africa Year Male Benin 1996 17.6 CentralAfrican 1994-95 17.4 Comoros 1996 18.1 Kenya 1993 16.3 Mali 1995-96 18.7 Uganda 1995 17.3 17.2* Republic 16.0 19.7* 17.3 15.8* 16.5 Female

B/F ratio
5 2 1 7 3 11 6 4 5 5 5

Greece Netherlands Sweden Poland Ukraine Ireland USA Canada Switzerland Australia Russian Federation Lithuania

3.8 9.1 10.0 16.6 17.2 21.5 21.9 24.7 25.0 27.3 41.7

0.8 3.8 6.7 2.5 5.3 2.0 3.8 6.0 4.8 5.6 7.9

44.9

6.7

UnitedRepublic of Tanzania 1991-92 16.9* 17.8 Zambia 1992 16.4* 16.0 Zimbabwe 1994 18.8 18.7 Latin America and theCaribbean Brazil 1996 16.5* Peru 1996 16.6* 19.7 18.8*

As reflected in the following graph, unemployment of girls also tends to be higher than that of boys; in only a few countries is unemployment among boys higher than among girls.

Median is indicated for ages 20-24 unless marked *, in whichcase, median is indicated for ages 25-29 because fewer than fiftypercent had experienced sex. Source: Selected andHealth Surveys Demographic

It is interesting to observe that while for many countries national population based data for female age of sexual initiation is available, only few have tried to find this indicator for males. The data indicates substantial cultural differences in sexual initiation patterns. In most cases there seems to be little difference in age at initiation between the sexes, but where it exists it clearly makes the case for the idea that boys and girls might be vulnerable at different times in their development and hence might need to be reached with different interventions. In the personal development of adolescent boys, education and employment are important objectives. Youth unemployment is a big problem in most societies and while absolute levels vary according to the overall economic situation in countries, invariably youth unemployment is higher than that of adults.

It is interesting to note that in these same countries the education levels of girls are equalling and overtaking those of boys. Assessing statistical data concerning the disaggregation of adolescent health and development not only by age but also by sex - is an important step towards gender-based programming. The examples cited above indicate that there are considerable gaps in our knowledge about boys, their health status, and their behaviours.

4. What do we know about boys?

The literature provides an indication of both how much attention society devotes to adolescents boys and the issues which that attention concerns. This review of the literature sought answers to the following questions: What are the rationales and conceptual bases for working with adolescent boys? What evidence exists on the specific health needs of adolescent boys? What programming and policy implications and research questions emerge from the existing knowledge of the needs and realities of adolescent boys? Most of the available literature on adolescent boys comes from Western Europe, North America, Australia, the Caribbean, and Latin America. This seems to suggest that relatively more attention is being given to adolescent boys in those parts of the world. However, it might also reflect barriers in access to literature in languages other than English. The author of the review was able to access Spanish and Portuguese literature, but could not access sources in French, Russian, Arabic or Chinese. While this is often the case in reviews of the international literature, the result is a limited perspective on the situation and behaviours of boys and their role in society that does not necessarily reflect the realities of boys in all cultures. Attempts were made to fill the information gap in the Arabicand French-speaking regions by seeking contributions from reviewers in those regions. However, caution is advised in generalizing the findings of the following review. Moreover, there is a need for cross-cultural comparisons. Finally in this connection, it should be kept in mind that adolescent boys

comprise a heterogeneous group, and that some of the sub-groups are more vulnerable than others. With these qualifications, some of the findings from the survey of the literature regarding the health and development of adolescent boys involved: boys having different crisis points than girls; an earlier push to autonomy, and a different degree of autonomy, in boys than in girls; more pressure on boys to achieve rigid gender roles; a stronger influence of male peer group; boys having a narrow range of emotional expressions, often using negative ones; and the relatively limited self-care and health seeking practices of boys. A special theme in the literature which addresses adolescent boys is violence. Adolescent boys are both disproportionately perpetrators and victims of violence, with the exception of sexual violence. Violence within the relationships between adolescent girls and boys - dating or courtship violence - received special attention. Again, boys are victims as well as perpetrators of this form of violence. Workshop participants made recommendations in the following areas, which were subsequently taken into account in the final revision of the literature review: Methodology and coverage In the review, more literature was available from

the Americas, Asia/Pacific, Western Europe, and Arabicspeaking countries. Additional research from sub-Saharan Africa, particularly Francophone countries, is needed. There was discussion about whether the literature review should include or recommend additional research for low-income populations and/or for adolescent boys of various social classes. For example, it was suggested that while research on violence frequently focuses on low-income boys, the recent events in the US State of Colorado call attention to the fact that male violence is also often perpetrated by middle class youth. However, other participants argued that given the scarcity of resources and the multiple problems facing low-income adolescent boys, the latter should be given priority for future activity, including both research and programming.

environments learn how to nurture and care for others by virtue of being cared for in a nurturing way. The challenge thus becomes helping boys to regain or reappropriate caregiving skills that were in effect socialized out of them. Additional research is needed on those adolescent boys who seek to do the right thing for their families and partners in intimate relationships. The life stories of such young men can offer us insights as to those factors which enable young men to construct more progressive, pro-social versions of the male identity.

Individual differences in biological and psychosocial development When examining research on adolescent boys, the issue of individual differences should be considered. Much of the research on gender and gender socialization in both its biological and psychosocial aspects has found that individual differences among boys are often greater than are aggregate differences between boys and girls. Relevant for programming are the answers to the following question: has enough attention been paid and do we know enough about biological differences between boys and girls in terms of their physical, cognitive and emotional development? These differences include concerns over penis size by early adolescent boys; correct use of condoms; cognitive development and functioning underlying educational attainment or dropout rates, or violent behaviour.

Balancing boys problems and potentials The review of the literature focuses on problems or risks. By contrast, potentials and protective factors can be emphasized. A deficit perspective with regard to adolescent boys should be avoided; rather, those things they do well should be considered in addition to their needs and problems. Regarding boys from a perspective of potential rather than deficit, insights are available from the field of early childhood development. Specifically, some proponents of attachment theory argue that boys in care-giving

Violence

The issue of violence needs to be expanded to include adolescent boys who are involved in wartime situations both as perpetrators of violence in such situations and as victims of wartime atrocities. It was suggested that boys in wartime situations, such as those in the former Yugoslavia, Sierra Leone or Afghanistan, are also among the victims of wartime atrocities, including sexual abuse. While quantitative data clearly demonstrate the extent of adolescent boys victimization by violence which is generally higher than that of adolescent girls - the gender aspects of violence must be considered. While fewer young women may die as a result of violence, they nonetheless suffer greatly from domestic violence. Frequently, this violence is under-reported. When considering the issue of violence, this concept should be broadened to include the pressures that boys face by socialization. The role of religious fundamentalism and other political and environmental influences - as contributing factors to certain forms of violence - should be examined. In reviewing the literature on violence, we should also keep in mind that much of this research seeks to attribute causality to many factors which are merely correlated. In short, many factors correlate with violence, but the true causal aspects are not always clear or straightforward. Greater attention should be devoted to courtship or dating violence. This concept is not

considered in all countries and there might be a need for a clearer reference of violence of boys against girls and sometimes girls against boys within the context of relationships. Boys sexuality and reproductive health In reviewing the research on adolescent males and sexuality it is important to remember that studies on adolescent male sexual experience find that boys often have a tendency to exaggerate such behaviour. Accordingly, such self-reported data may not always be reliable. While boys may not be victims of sexual coercion to the same extent as girls during their early sexual experiences, the social pressure for boys to prove that they are sexually active could also be considered as a form of coercion. The issue of boys involved in sexual exploitation prostitution or commercial sex work needs more attention. Research on adolescent boys and condom use has often assumed that condom use was related to improved negotiation and more equitable relationships between young men and young women. However, some qualitative research suggests that adolescent boys may still hold callous views toward young women even though they use condoms, saying that they in effect use condoms and use young women. In conducting research on boys sexuality, focus is often on sexual intercourse, rather than on a range of sexual expression. A study in Sri

Lanka developed a continuum of sexual activity. The review should elaborate further on the following issues: sexual identity concerns and their impact on the development of boys; adolescent boys and their role in decision-making concerning abortion; and boys use of potency medicines.

Other health issues and behaviours Concerning substance abuse, it was suggested that while data from much research in this area is not disaggregated by sex, data on tobacco use often is. With a few exceptions, such studies generally find that more boys than girls smoke, especially in developing countries. However, smoking rates in girls tend to increase faster. The issue of suicide and adolescent boys must be considered with greater subtlety. Research on suicide is insufficiently clear to determine whether, as has been asserted, girls suicide attempts and the methods they choose are not generally intended to be fatal or final, while attempts by boys are generally fatal. Occupational health issues need to be considered in greater detail.

5. Experiences from the field

In the months preceding the workshop, surveys were conducted in the Americas, Africa, the Arabicspeaking region, and Asia. These surveys sought to identify projects and programmes that targeted adolescent boys in a specific way. Selected projects were asked to provide an assessment of their activities through

a standardized questionnaire. The questionnaire focused on the issues the projects sought to address in their work with boys, what they had to do differently in order to reach and work with boys in terms of organization, staff and materials. The organizations identified in the regional surveys should not be regarded as a representative sample. There are considerable differences among the regions in programming for boys. Due to the considerable number of projects for boys in the Americas, a sample group was chosen from that region for the assessment phase. In other regions, such as Africa, it was difficult to identify a sufficiently large number of projects for boys. While this situation might reflect regional differences in the level of attention devoted to adolescent boys, it also surely resulted from limitations of the process utilized: the survey was based on e-mail, phone and fax communications. For example, although written Arabic is a highly literary and artistic form, the Arab culture is very oral. This type of survey faces major limitations in such a context. Other collaborators felt that promising programmes failed to respond due to survey fatigue. As a result of these shortcomings of the study, the African survey yielded responses from only five programmes. Consequently, no regional conclusions could be drawn. Although receiving some attention in the literature, the European region was not involved at all. The survey should therefore be seen as a first attempt to identify projects for boys, and highlight some of the lessons which have been learned about working with boys. Participants provided these comments and those on the following page concerning the survey presentations: While questionnaires were sent both to governmental and non-governmental organizations, most respondents were NGOs which

are implementing many interesting interventions. The major challenge posed thereby involves the appropriate approach to progress from projects at the NGO level to large-scale public-sector activities: i.e. how to advance from pockets of excellence to large-scale initiatives? The surveys suggest that problems facing adolescent boys, and programmes working with them, are common even in quite different contexts. Moreover, similarities were also striking between industrialized and developing regions. Among the fundamental issues which should be considered is the signficant fact that boys make less use of services even when they are available. A common finding in the Arab world was that health professionals are reluctant to deal with adolescents due to their perceived lack of knowledge and competencies. Only when these issues are addressed will quality assistance and access to relevant commodities be provided to adolescent boys and girls. An important observation was that programmes have targeted boys in contexts such as the army, truck drivers, etc., which are also important socialization environments for male behaviour, but particularly including schools, which still provide the main and traditional access route to boys.

Participants also noted in survey results: some movement away from wanting to control adolescent boys (contraception violence)

and towards care and concern for them; few policies exist to address adolescent boys; this lack is resulting in a significant impact on their health; unavailability of places/spaces for boys to discuss/ask for information; a question as to whether work with boys must be done by men; according to the participants, this is not always useful or necessary, but rather depends on culture, age specific vulnerability, setting, etc. in order to be increased in coverage, public services need to address this issue of adolescent boys, with which NGOs largely deal at present. in both NGO and public organizations are fears that boys projects could result in money being taken away from programmes for adolescent girls; this issue needs to be addressed strategically; a need for more attention to (un)employment and its effect on boys health; boys often form a large part of juvenile and child labour, especially its most hazardous forms, leading to health and development risks; the exploitation of such vulnerable groups as street boys by their employers, and sometimes their families, should receive special attention; unemployed boys could be very vulnerable to mental health problems or behavioural disorders such as violence due to their socialization and the focus on their (economic) independence; possibilities for building on the experiences gained in male involvement programmes such as the one

in Mexico; in AMRO many organisations work on issues related to boys without focusing on them; should these programmes become models for a gender-specific approach?; a shift to traditional roles in former socialist countries, after years of institutionalized gender equity, and an upsurge of violence in the Balkans; limited data on some groups of boys such as boys having sex with other boys or older men and married adolescents; the need to view working with boys as a subject, not as a special category or subpopulation but rather as a generally valid crosspopulation issue; an increasing recognition of gender differences between boys and girls, but with generally little analysis of their meaning and implications.

and education services; mixed gender teamwork (male and female staff working together). Conceptual providing positive images of boys; ensuring inclusive projects/programmes that provide a space for boys. Activities and entry points finding attractive entry points for boys, such as sports, while ensuring that boys who are not attracted to these mainstream activities feel included; providing activities meeting developmental needs, e.g, vocational training. Methodologies recognizing the importance of workers using language that is inclusive, non-sexist, and nondiscriminatory or labelling; teaching the language of emotions, and challenging their use of language that is non-inclusive, sexist, homophobic, discriminatory or labelling; utilizing peer-to-peer approaches; having boys participate in assessment, programme design, and evaluation;

The workshop participants divided into groups, to expand on the survey findings. These groups addressed the following questions: What are the lessons that have been learned from these projects? and What are the main obstacles encountered in implementing projects for boys?

Lessons learned in working with boys, concern the following issues:

Gender gender sensitivity within projects, possibly to include sensitizing staff on gender issues; active efforts to involve male staff in health

 providing mentors and

role models to stimulate connection to other men; creating special materials for boys, as for example videos. Spaces providing spaces for discussion of issues, not necessarily problems; providing boy-friendly services de-feminizing services. Programme management ensuring that programmes have a built-in self-learning capacity; i.e.,allowing boys to monitor and evaluate themselves, preferably with input from external sources such as researchers, other programme managers, and project participants. Targeting recognizing that boys can be targeted in many work settings as army recruits, sailors, construction workers in industries, truckers, etc; knowing that vulnerable boys are targeted in adverse environments, such as in prison and on the street.

the often-negative

attitudes of staff towards boys, who may see them as perpetrators of violence and chaos; the perception of young people as at the service of community rather than receiving services from it; the resultant desire - by those who see boys as a source of service to the community rather than as members of it who need attention - to control their behaviour and induce their conformity; a fear that increasing attention to boys or encouraging more boys to participate in a project may lead to girls leaving the project, families taking girls away from it, and/or girls getting hurt, i.e., the project may become unsafe for girls. Programmatically the narrow focus of certain programmes sometimes make them less interesting for boys (for example, a violence programme, where unemployment might be a root cause); the fact that staff do not always know how to deal with issues such as violence, and are therefore reluctant to take on work with such a group.

Obstacles to reaching boys

included those which involve: Perception and attitudes the common fear of boys behaviours;

Organizational difficulties in attracting men to work in areas such as the health and education sectors; in some regions, failure of NGOs and others to identify the area of programming for boys as important or relevant.

attracting boys and men to this work; lack of research on boys and girls; and linking health with economic development.

6. Gaps in programming for adolescent boys

The workshop identified a number of aspects of boys health and development that need more attention. After assessing what was being done for adolescent boys, the question was now inverted to a contemplation of which health and development needs receive insufficient attention and which intervention approaches should be developed further. The following topics were listed: positive gender socialization; sexual orientation; boys bodies; connection to other men (father/male involvement); positive role models; emotional intelligence (relationship skills); parenting skills;

language skills; negotiation skills; handling psychological needs/providing mental health services; countering the demoralization of boys; mental health; working with parents and teachers;

Among the concerns that need to be addressed, there emerged a clear emphasis on psychosocial needs, which can be summarized by the term mental health concerns. These emanate from changes in the roles of boys and men in society, accompanied by changes in developmental and economic possibilities and opportunities. A theme throughout the workshop was that of connection. First identified was the fact that one of the characteristics of boys is to be more distant than girls in their relationships, including those with the family. Helping boys to build and maintain significant relationships with other people - and especially with other males (including the father) was identified as an important programmatic effort. One element of this effort lies in providing positive male role models. Another is the challenge to attract more men to work as service providers. This approach would seek to provide opportunities for boys to be attended by a male service provider, in addition to creating role models. Concerning intervention areas, the area of skills building was identified as crucial. The types of skills identified ranged from the ability to express and interact emotionally with others, to negotiation and parenting skills.

7. Making the case for adolescent boys - a debate

A debate was organized, in order to gain a better perception and understanding of the opposition which would be encountered when promoting and defending programming for

adolescent boys. The technique employed was a premeditated debate, in which the participants were assigned to a for and against group. In this way, an effort was made to identify the opinions and reactions of policy makers, programme implementers, and donors towards programming for boys.The participants were asked to defend or oppose the statement:

15% of Brazils GDP goes to paying for costs of violence! AGAINST Limited resources should be focused on issues such as MCH, which yields greater returns. Donor interest will continue to be devoted to the faster route of educating girls. Health workers already focus on adolescents; their programmes already tend to attract boys. A focus on boys would involve retraining women to work with them, as well as recruiting and training men; the latter, however, are largely absent from the social and health work arenas. A focus on boys would reinforce their hierarchical power. Findings from the USAbased male promise keepers movement have shown that emphasis on male responsibility can result in the reinforcement of stereotypical male dominance. As a result of the debate, the participants concluded that they needed to be well prepared to make the case in their own organizations and towards donors. By way of support strategies to get boys on the agenda, advocates of programmes for adolescent boys were urged to:

FOR

Boys live in the same

world, occupy the same space and are confronted by the same problems. It would only be sound to focus on boys as much as girls, as a matter of human rights. Men/boys must be trained to share leadership and responsibilities in order to become good fathers: this will have a positive effect on boys future partners: that is, girls. Womens lives and health can be protected by focusing on mens involvement: their health would be improved by more men in positions of responsibility educated on male responsibility and womens health. The social cost of not involving boys is high; cited in this context were violence and crime: one example involved the fact that

stress that young men are a natural target group: by improving boys health we are not taking away from girls/women but actually contributing to girls health and the health of the entire community; emphasize efficiency and quality issues: this new programming approach builds on and improves the quality of existing programmes; learn from past mistakes, such as neglecting the needs of men from reproductive health: years passed before men began to be involved, and that mistake must be avoided in programming for adolescents; cite data on mortality and morbidity rates; linked to the health behaviours of boys as well as to economic implications, this is a very powerful argument and would help to make the case; provide high level advocacy to get boys health on the agenda of Executive Boards: collaborative statements from organisations, technical groups, or meetings would be powerful in stimulating action at the field level; use and refer to internationally agreed-upon language, such as the ICPD Programme of Action; document and make available, online and otherwise, success stories; and develop an advocacy kit on programming for adolescent boys.

now to advance the recognition of the need to address the health of adolescent boys. It was further agreed that this would have a positive impact on the health of girls and the broader community. Among the actions recommended were: Advocacy: The development of an Advocacy Kit, that included facts about the health status of adolescent boys and key arguments, for use in making the case for including the issue on relevant agendas of: UN agencies; Ministries and Departments of Health, Education,Youth Affairs, Juvenile Justice, and the like; and international and national NGOs. Technology transfer/dissemination: The development of a Tool Kit, including: a good practice guide; selected detailed case descriptions to enable replication and adaptation; checklists; a Training Guide for working with adolescent boys and their health; this guide could form part of the Tool Kit to assist in local, national and regional training; the identification of an effective Clearing House for information dissemination. This could be a web site, with a list addressing issues related to the health of adolescent boys; the development of a Learning Network which could be associated with the Clearing House, to facilitate and promote local, national and regional workshops on the health of adolescent boys. Pilot projects in three sites (for example, Africa, Asia and Latin

8. Towards a plan of action

The workshop participants agreed that certain actions could be taken

America) focusing on developing healthy relationships in adolescent boys, which are operationalized as negotiation, conflict resolution, acceptance of responsibility and respect. These projects could become part of an existing project or developed as part of a new one. Research: To better understand the situation of adolescent boys, to improve the efficacy of existing programmes, and to initiate new strategies, resources need to be allocated to research. This requires collating the findings of previous research and initiating new studies. Much of the known research activity to date has occurred in developed countries, and what has been undertaken in developing countries may not be widely available. Moreover, there are gaps in what we think we know and in the knowledge of how what we have found applies across cultures and settings. Promising research areas that warrant attention are briefly summarized on the following two pages. Data gathering and analysis, monitoring and evaluation: Re-analysis of existing data sets (e.g., DHS) to disaggregate data relevant to the health of adolescent boys. Inclusion of a module on adolescent boys in routine and specific surveys (e.g., DHS). Encouragement of routine collection of relevant baseline data by agencies/projects. Encouragement of all agencies and projects to have in place a plan for selflearning that routinely assesses the quality of service delivery and other activities. Quality here is taken to mean: clarity of aims and objectives and their match with the needs of adolescent boys (and girls), integrity of programme

components, consistency of approach, integration of evaluation within the project, participation by young people in planning and service delivery, and productivity (i.e., that some positive outcomes/outputs are achieved). Socialization and identity formation, including the following topics: The socialization of boys: the identification of practices and processes associated with the development of boys who are gender sensitive and responsible. Boys voices: a qualitative exploration of the male side of gender through documenting how boys interpret such things as power, equity, gender, masculinity, sexuality, role, and responsibility. Biology: the identification of the role of biological influences in the development of behavioural difficulties. Health behaviour and developmental risk: Developing a more comprehensive picture of the health and developmental status of adolescent boys, to include the exploration of associations between poor nutrition, risky behaviours (e.g., smoking, dangerous driving), poor hygiene, accidents, injuries, limited self-care practices, etc. Health service utilization: Involving health service access, the exploration and identification of what is common and what is different in promoting engagement with and participation in health services by boys and girls, to include aspects of: location, service composition, mode(s) of service delivery, qualities of service providers, and the identification of subpopulations that use health services and those who do not.

Resilience: Resilience in the face of adversity: identifying common and different factors associated with successful outcomes for boys and girls coming from adverse environments. That which constitutes success would be determined by participants, but might include the following criteria: retention in education/training and educational/vocational achievement; non - or low level involvement in criminal activity; and/or low levels of psychopathology; and adequate coping skills and strategies. Mental health: Documenting how to improve the awareness of the existence and impact of mental health problemss among boys. This area would include the exploration of strategies for earlier identification, assessment, treatment and care, especially for: conditions that may have greater incidence and prevalence among late adolescent males (e.g., schizophrenia and bipolar disorder); and those with no greater prevalence but which are also associated with significant morbidity and mortality (e.g., depression and its relationship to suicide). Violence: This area would include the following topics: conflict resolution: the documentation of effective strategies that reduce violence as a means of conflict resolution among boys; masculinity, gender relations, and violence: a qualitative exploration of the

relationships between constructions of masculinity, the enactment of gender relations and violence against women; and globalization of violence: the identification of the effects of new and traditional media simultaneously present in the lives of boys and girls in traditional, resourceconstrained communities, and documentation of how media such as radio, TV, music, magazines and the internet present images of masculinity and how these images contrast, reflect or challenge traditional images of masculinity and gender relationships. Adolescent boys as fathers: An investigation of adolescent fathers in a variety of countries, settings, situations and contexts (e.g., rural/urban; employed/unemployed; attachment to a religious or other group/unattached), which would be undertaken: through qualitative methodologies, document meanings and influences in the identity shift from boy to father; through qualitative methodologies, identify effective strategies for engaging adolescent fathers in interventions, sustaining involvement and maintaining behaviour change; and through an action research methodology, to explore the effectiveness of interventions which aim to increase or improve parenting skills, coping strategies, sexual health, relationship quality, health- and help- seeking behaviour, and those that reduce violence. Employment: Documenting what has been found to be effective in improving the economic opportunities of boys.

Mission for the day: define the programming implications for boys Morning

Annex 1 AGENDA
Workshop on Working with Adolescent Boys Geneva, 17-19 May 1999
Monday, 17 May Mission for the day: Identify what is special about adolescent boys and what we (dont) know about the health implication Morning Session 1 Introduction 9. 00 Welcome and introduction of the participants, and the objectives of the workshop Coffee Break

9.00

Feedback Flash

Session 4 Working with boys: what is happening?

9.15 9.15 Overview of the findings of

the regional surveys of organizations working with adolescent boys 10.45 - 11:00 Coffee Break Session 5 Implications for programming for adolescent boys 10.45 Implications of boys characteristics and their health outcomes for programming for adolescent boys Afternoon Session 6 Promoting programming for adolescent boys 14.00 Drawing lessons learned from working with boys andestablishing what programming areas need to be further developed 15.30 15.45 Coffee break

10.30 - 10.45

Session 2 Why pay attention to boys 10.45 Map out the arguments for paying attention to boys Afternoon Session 3 Gaps in the knowledge about adolescent boys 14.00 Identify gaps in the knowledge about boys for further attention 15:30 - 15:45 Coffee break 15.45 Research to address knowledge gaps

15.45 Session 6 (continued) Presentations of group work and discussions

Wednesday 19 May Mission for the day: Develop next steps for working with boys in our organizations Morning

Tuesday, 18 May

9.00

Feedback flash on second day

Session 7 Next steps: What needs to be developed 9.20 Develop agenda of activities to promote programming for adolescent boys 10.30-45 Coffee Break
Dr Ayo Ajayi Regional Director, Population Council The Chancery Bld., Valley Road P.O. Box 17643, Nairobi, Kenya Tel: 254 2 - 712814; 713480 Fax: 254 2 - 713479 Email: AAJAYI@POPCOUNCIL.OR.KE Mr Gary Barker, Director Instituto Promundo Rua Resed, 30, Co 1 Lagoa, Rio de Janeiro CEP 22471-230, Brazil Tel/fax: 55 21 - 579 3529 Mobile: 55 21 - 91 68 82 55 Email: garysuy@aol.com Mr Stuart Burden The John D. and Catherine T. MacArthur Foundation, Office of Grants Management 140 S. Dearborn Street Chicago, IL 60603 USA Tel: 1 312 - 726-8000 Fax: 1 312 - 920-6258 Email: sburden@macfdn.org Ms Jacqueline Collier Director, Youth Programme European Scout Office Rue Henri Christin 5 Box 327, CH-1211 Geneva 4 Tel: 41 22 - 705 1100 Fax: 41 22 - 705 1109 Email: jcollier@euro.scout.org Mr Paul Dover, Consultant Swedish International Development Cooperation Agency (SIDA) S-10525 Stockholm, Sweden Tel: 46 8 - 698 5742 Fax: 46 8 - 698 5649 Email: dover@antro.uu.se Dr John Howard, Director Social Health Program Department of Psychology

10.45 Comparative advantage of organizations to address priority agenda 12.30 Closing of the meeting

Annex 2 LIST OF PARTICIPANTS

Macquarie University Sydney, NSW 2109, Australia Tel: 61 2 - 9850 8093 (0); 9363 5460 (H) Fax: 61 2 - 9850 8062 E-mail. jhoward@bunyip.bhs.mq.edu.au Ms Gabi E. Kupfer Programme Assistant Human Development & Reproductive Health The Ford Foundation 320 East 43rd Street New York, NY 10017, USA Tel: 1 212 - 573 4846 Fax: 1 212 - 351-3660 Email: g.kupfer@fordfoun.org Dr Mahmud Omar World Organization of the Scout Movement Arab Regional Office P.O. Box 1384, Cairo , Egypt Tel: 20 2 - 2633 011 Fax: 20 2 - 2633 314 Email: momar@mednet2.camed.eun.eg Dr Josi Salem-Pickartz Coordinator, The Family Health Group P.O. Box 1073, Marj El-Haman Amman, Jordan Tel: 962 6 - 5930 751 Fax: 962 6 - 5930 751 Email: josisalem@index.com.jo Ms Helga Serrano* World Alliance of YMCAs 12 Clos Belmont 1208 Geneva, Switzerland Tel: 41 22 849 5100 Fax: 41 22 849 - 5115 UNAIDS Ms Aurorita Mendoza, Gender Adviser 20 Avenue Appia, CH-1211 Geneva 27 Switzerland Tel: 41 22 - 791 4508

Fax: 41 22 - 791 0746 Email: mendozaa@who.ch Mr Mark Connolly*/Ms Tamar Renaudt Health Promotion Adviser, Dept of Policy, Strategy & Research Nations Programmes on HIV/AIDS 20 Avenue Appia, CH-1211 Geneva 27 Switzerland Tel: 41 22 - 971 2707 Fax: 41 22 - 791 0746 Email: connollym@who.ch UNESCO Dr Malika Ladjali United Nations Educational, Scientific and Cultural Organization 7 Place de Fontenoy F-75700 Paris Tel: 33 1- 45 68 10 00 Fax: 33 1- 45 67 16 90 Email: mladjali@unesco.org UNFPA Ms Delia Barcelona Senior Technical Officer Coordination Branch Technical and Policy Division 220 East 42nd Street New York, New York 10017 Tel: 1 212 - 297 5221 Fax: 1 212 - 295 4915 /212-370 0201 Email: barcelona@unfpa.org UNICEF Dr Bruce Dick, Senior Adviser Youth Health Health Section 633 3rd Avenue New York, N.Y. 10017, USA Tel: 1 212 - 824 6324 Fax: 1 212 - 824 6464 & 6460 E-mail: bdick@unicef.org Ms Elaine King, Project Officer Caribbean Area Office, PO Box 1232 Bridgetown, Barbados Tel: 246 - 436 2119 / 436 2810 Fax: 246 - 436 2812 Email: eking@unicef.org WHO Secretariat Dr Jim Tulloch, Director Department of Child and Adolescent Health And Development (CAH) Family & Community Health WHO, 20 Avenue Appia

CH-1211 Geneva 27, Switzerland Tel: 41 22 - 791 3306 Fax. 41 22 - 791 4853 Email: tullochj@who.ch Mrs Adjoa Amana Adolescent Health Adviser UNFPA Country Support Team for East and Central Africa P.O. Box 8714, Addis Ababa, Ethiopia Tel: 251 1- 51 12 88 Fax: 251 1- 51 71 33 E-mail: amana@unfpa.org Mr Paul Bloem, WHO/CAH Family & Community Health Tel: 41 22 - 791 4256 Fax. 41 22 - 791 4853 Email: bloemp@who.ch Ms Jane Ferguson, WHO/CAH Family & Community Health Tel: 41 22 - 791 3369 Email: fergusonj@who.ch Dr Claudia Garcia-Moreno Evidence and Information for Policy Tel: 41 22 - 791 4353 Fax. 41 22 - 791 0746 Email: garciamorenoc@who.ch Dr Shireen Jejeebhoy Reproductive Health and Research Family & Community Health Tel: 41 22 -3348 Fax. 41 22 -0746 Email: jejeebhoys@who.ch Dr Adepeju Olukoya WHO/CAH Family & Community Health Tel: 41 22 - 791 3306 Email: olukoya@who.ch Mr Robert Thomson, WHO/CAH Family & Community Health Tel: 41 22 - 791 3447 Email: thomsonr@who.ch

Annex 3 SUGGESTED READINGS

Additional WHO documents on adolescent boys: Boys in the picture. WHO/FCH/CAH/00.8 What about boys? A literature review on the health and development of adolescent boys. WHO/FCH/CAH/00.7 Working with adolescent boys survey of programme experiences (in English, Spanish, and French). WHO/FCH/CAH/00.10 Consolidated findings from regional surveys in Africa, the Americas, Eastern Mediterranean, SouthEast Asia, and Western Pacific Gender and health in adolescence WHO Policy series Health Policy for children and adolescents issue 2, EUR/ICP/IVST 060305B, 1999 Boys in the picture: gender based programming in adolescent health and development. WHO Europe, 2000 Documents from other organizations: Achieving gender equality in families: the role of males. UNICEF Innocenti Global Seminar Summary report. Prepared by John Richardson, Florence, Italy, 1995. Sexuality education for adolescent boys. Erik Centerwall; RFSU, Swedish Association for sex education. Reports on sexuality and reproduction. Stockholm, Sweden, 1995. New perspectives on mens participation, Population Reports, Series J, Number 46, Baltimore, Johns Hopkins Unicversity,1998. AIDS and Men: Taking Risks or Taking Responsibility? Martin Foreman, Panos, London, December 1998. Moving Forward in Mens Health. New South Wales Health Department, March 1999. http:// www.health.nsw.gov.au/ Reaching Young Men with Reproductive Health Programs. Focus on Young Adults Programme http://www.pathfind.org/IN FOCUS/ReachingYoungMen.doc Mens voices, mens choices. SIDA - Regional seminar, Lusaka: January 1999. Young males and risk taking project. September 1999 Australia Institute for International Health Men and AIDS: a gendered approach. UNAIDS, 2000 World AIDS Campaign, 2000. Men, Masculinities and Development. Broadening our work towards gender equality. UNDP, 2000. http://www.undp.org/gender/programmes/men/men_ge.html