]. My comments highlight issues addressed by these authors in conducting their research.
- Fine D.
- Warner L.
- Salomon S.
- Johnson D.M.
Interventions to increase client attendance and testing for sexually transmitted infections by males attending family planning clinics.
J Adolesc Health. 2017; 61: 32-39
A 1964 Christmas present—I was 11 years—was the Visible Man, a plastic ecorche model displaying skeleton, muscles, and viscera. My parents were foregrounding discussions of puberty and sex by appealing to my nerdy curiosity. The ruse worked—I was intrigued by the organs and their spaces as I messily glued the model and inartistically traced arteries and veins with provided red and blue paint. Painting through the groins, although, I found no penis, no scrotum—akin to the man-gendered paramour of a popular woman-gendered doll of the same era. The censorship of the model puzzled me, because I could not match the model to a reproductive and sexual capacity that I already knew to be resident in the unrepresented genitals. Two years later, however, I completed my parents' nerdy challenge and read Human Sexual Response [
] for the first time: the sexual functions of bodies became much clearer.
- Masters W.H.
- Johnson V.E.
Human sexual response.
Little, Brown and Co, Boston, MA1966
Our pervasive cultural replacement of genitals with the ellipsis of gender represents a constant challenge to our professional goals of sexual rights, sexual justice, sexual health, and sexual well-being for all young people. As an 11-year-old, I was already well-schooled in the conflation of gender and sexuality: lessons that have taken decades to deconstruct and reform. The foundation of my subsequent understanding is built from the idea of the “performativity” that separates gender from the reproductive and sexual functions of physical bodies and their associated organs. These are ideas elaborated in Bodies That Matter: The Discursive Limits of “Sex” [
] but carried forward by many others. This body of work shifts emphasis from gender as an essential, stable trait of bodies to gender as a portfolio of adaptations that changes through experience and social relationships and is continuously modified in specific contexts [
- Butler J.
Bodies that matter: On the discursive limits of “sex”.
Routledge, New York1993
]. This perspective on gender anchors my comments to follow.
- Luyt R.
Beyond traditional understanding of gender measurement: The gender (re)presentation approach.
J Gend Stud. 2015; 24: 207-226
The article by Fine et al. addresses a specific health services challenge—providing men's sexual health services in spaces traditionally reserved for women—within a larger context of gender, masculinity, sexuality, and sexual health care. Specifically, I will consider the implications of this gender-as-performance perspective for changing health care space to achieve a goal of improving young men's sexual health.
First, a brief summary of the article to identify its highlights. The authors tested an intervention to increase screening of young men for sexually transmitted Chlamydia trachomatis at community-based family planning clinics and to assess the effects on women's sexual health services in the same spaces. The intervention had five components: (1) outreach to men to encourage seeking of sexual health services; (2) community engagement to increase awareness of the availability of men's services; (3) improved clinic efficiency to reduce wait times; (4) gender sensitivity training to enhance staff awareness about distinctive qualities of men's sexual health care needs; and (5) adaptation of forms, policies, protocols, and educational material to reflect men's issues. These five components reflect documented barriers to men's sexual health care seeking: conflict of traditional masculinity with a feminized health care culture; concerns over wait times and cost; and perceived lack of community support for sexual health care seeking [
- Marcell A.V.
- Morgan A.R.
- Sanders R.
- et al.
The socioecology of sexual and reproductive health care use among young urban minority males.
J Adolesc Health. 2017; 60: 402-410
6]. The intervention was tested with a preintervention/postintervention comparison design, comparing two family planning clinics to five nonintervention clinics with similar patient demographics and services.
- Knight R.
- Shoveller J.A.
- Oliffe J.L.
- et al.
Masculinities, ‘guy talk’ and ‘manning up’: A discourse analysis of how young men talk about sexual health.
Sociol Health Illness. 2012; 34: 1246-1261
Three key findings are described in the article. First, postintervention visits by young men in the target clinics increased by 109%, compared with only 18% in comparison clinics. Second, the number of C trachomatis screening tests increased by 152% in the two intervention clinics, compared with a 6% increase in the comparison clinics. Third, there was no relative change in services provided to women during the intervention period.
We do not know which intervention components were most important to the results. However, clinic staffs—presumably reflecting the substantial representation of women in the general health care work force—were trained to be oriented toward men's health, but the intervention did not depend on the physical representation of men among the staff. In fact, confirming a cultural understanding of health care as a “feminine” domain, lay health advisers (promotoras) were hired to address men's health issues—with men—in waiting areas. In addition, women visiting the clinics were asked to encourage partners to seek care, reflecting the heteronormativity inherent in this gendered approach to health care [
- Oliffe J.L.
- Chabot C.
- Knight R.
- et al.
Women on men’s sexual health and sexually transmitted infection testing: A gender relations analysis.
Sociol Health Illness. 2013; 35: 1-16
Focusing health services and spaces to appeal to specific gender, age, sexuality, or cultural backgrounds is a well-used approach for addressing health inequities for persons who feel marginalized, invisible, or even rejected in traditional health care spaces [
]. Clinics themselves serve as safe, affirming, and orienting spaces in many communities: they are in fact “places.” The renowned geographer Yi-Fu Tuan wrote: “Places are centers of felt value where biological needs, such as those for food, water, rest, and procreation, are satisfied” ([
- Newman C.E.
- Persson A.
- Paquette D.M.
- Kidd M.R.
The new cultural politics of the waiting room: Straight men, gay-friendly clinics and ‘inclusive’ HIV care.
Sex Res Social Policy. 2013; 10: 87-96
], pg. 4). Regendering of reproductive health care space into a place for men's sexual health resembles challenges faced on other contexts: for example, the significant need for women's sexual and reproductive health services in Veteran's Administration facilities during the past three decades [
- Tian Y.-F.
Space and Place: The Perspective of Experience.
University of Minnesota Press, Minneapolis, MN1977
]. The effects of health care space on service utilization are well familiar to adolescent health providers: “adolescent” or “youth” friendly services are essential concomitants of effective health care delivery for young people [
- Vogt D.S.
- Stone E.R.
- Salgado D.M.
- et al.
Gender awareness among veterans administration health-care workers: Existing strengths and areas for improvement.
Women Health. 2001; 34: 65-83
- Tylee A.
- Haller D.M.
- Graham T.
- et al.
Youth-friendly primary-care services: How are we doing and what more needs to be done?.
Lancet. 2007; 369: 1565-1573
- Haller D.M.
- Sanci L.A.
- Patton G.C.
- Sawyer S.M.
Toward youth friendly services: A survey of young people in primary care.
J Gen Intern Med. 2007; 22: 775-781
This leads to critical questions of how gender is performed in health care spaces: what are men's subjective experiences within clinics that enhance gendered perceptions of safety and acceptance [
]. For example, patient-provider discussions of sexual health could be more easily engaged in such spaces, even with women staff, if men perceive the acceptability of explicit discussion of their vulnerable sexual bodies and potentially stigmatized behaviors. This means that clinics become places for demonstrations of masculine identities that contradict traditional themes of hegemonic masculinity such as invulnerability and sexual prowess [
- Tyler R.E.
- Williams S.
Masculinity in young men's health: Exploring health, help-seeking and health service use in an online environment.
J Health Psychol. 2014; 19: 457-470
- Hasan M.K.
- Aggleton P.
- Persson A.
Rethinking gender, men and masculinity: Representations of men in the South Asian reproductive and sexual health literature.
Int J Men's Health. 2015; 14: 146-162
I would like to return to the topic of heteronormativity within the man-focused, regendered sexual health space. Heteronormativity emphasizes a man-woman sexual binary as a normal, unchallenged default status. Questions about sexual identity or same-sex partners—or the presence of people of diverse sexual identities—may be challenging in gendered clinic spaces because many straight men believe their identity is self-evident and are threatened even by questions that affirm identity [
]. It seems likely that men—sensitized by their presence in a family planning clinic—read the physical space for potential threats to their sexual identity. It may be that implicit confirmatory signals of heteronormativity are as important as explicit gender-focused signs for increasing young men's sexual health care within traditional reproductive health care clinics.
- Knight R.
- Shoveller J.A.
- Oliffe J.L.
- et al.
Heteronormativity hurts everyone: Experiences of young men and clinicians with sexually transmitted infection/HIV testing in British Columbia, Canada. Health: An Interdisciplinary Journal for the Social Study of Health.
Illness Med. 2013; 17: 441-459
It is important to note that the intervention implemented by Fine et al. was not limited to the clinic space itself. Clinic staff made presentations to local community-based organizations and agencies to advertise availability of men's sexual health services at the family planning clinics. After all, knowledge about the existence and accessibility of services is requisite for decisions about seeking health care, especially in an age of digital help-seeking [
]. Since family members—mostly mothers—and partners are often involved in young men's decisions about sexual health care [
- Best P.
- Gil-Rodriguez E.
- Manktelow R.
- Taylor B.J.
Seeking help from everyone and no-one: Conceptualizing the online help-seeking process among adolescent males.
Qual Health Res. 2016; 26: 1067-1077
], community engagement seems essential for supporting young men's use of services within family planning settings. The challenge of stigma—of being recognized in a clinic that provides sexual and reproductive health services—is one that still challenges community-engaged sexual health care settings [
- Fortenberry J.D.
Health care-seeking behaviors related to sexually transmitted diseases among adolescents.
Am J Public Health. 1997; 87: 417-420
- Lichtenstein B.
- Hook 3rd, E.W.
- Sharma A.K.
Public tolerance, private pain: Stigma and sexually transmitted infections in the American Deep South.
Cult Health Sex. 2005; 7: 43-57
One may ask if the intervention to increase men's sexual health care utilization had other outcomes. A negative potential outcome might be attraction of patients from other service providers such as publicly funded sexually transmitted diseases clinics serving the same communities. In most communities, however, I suspect it is better to have a selection of venues for care. It also seems possible that better mixing of reproductive and sexual health services could improve attitudes to gender equity with a given community, as has been shown with integration of family planning into HIV services in western Kenya [
]. It has not been shown, however, that such integration improves contraceptive behaviors by men. We still have ways to go in finding equity in our patients' lifelong work of maintaining sexual and reproductive health.
- Newmann S.J.
- Rocca C.H.
- Zakaras J.M.
- et al.
Does integrating family planning into HIV services improve gender equitable attitudes? Results from a cluster randomized trial in Nyanza.
Kenya AIDS Behav. 2016; 20: 1883-1892
One may also ask why the task of improving young men's sexual health should bear the weight of all these thorny issues of gender and sexuality. After all, the intervention reported by Fine et al. was a straightforward and reproducible approach to achieve a simple goal of improving sexual health of young men. In fact, a key outcome of the intervention—increased screening for genital C trachomatis infection—is easily accomplished by a urine sample that can be obtained almost anywhere. The answer—my answer at least—is drawn from lessons of the Visible Man of my youth. Its absent genitals—so often the physical target of men's sexual health—are in fact the lesser challenges of men's care. The larger challenge to those of us who design and deliver services for youth is to think of gender as flexible assets in health care, rather than as a liability fixed in a rigid binary gender system that can never truly serve a commitment to sexual well-being.
- Interventions to increase client attendance and testing for sexually transmitted infections by males attending family planning clinics.J Adolesc Health. 2017; 61: 32-39
- Human sexual response.Little, Brown and Co, Boston, MA1966
- Bodies that matter: On the discursive limits of “sex”.Routledge, New York1993
- Beyond traditional understanding of gender measurement: The gender (re)presentation approach.J Gend Stud. 2015; 24: 207-226
- The socioecology of sexual and reproductive health care use among young urban minority males.J Adolesc Health. 2017; 60: 402-410
- Masculinities, ‘guy talk’ and ‘manning up’: A discourse analysis of how young men talk about sexual health.Sociol Health Illness. 2012; 34: 1246-1261
- Women on men’s sexual health and sexually transmitted infection testing: A gender relations analysis.Sociol Health Illness. 2013; 35: 1-16
- The new cultural politics of the waiting room: Straight men, gay-friendly clinics and ‘inclusive’ HIV care.Sex Res Social Policy. 2013; 10: 87-96
- Space and Place: The Perspective of Experience.University of Minnesota Press, Minneapolis, MN1977
- Gender awareness among veterans administration health-care workers: Existing strengths and areas for improvement.Women Health. 2001; 34: 65-83
- Youth-friendly primary-care services: How are we doing and what more needs to be done?.Lancet. 2007; 369: 1565-1573
- Toward youth friendly services: A survey of young people in primary care.J Gen Intern Med. 2007; 22: 775-781
- Masculinity in young men's health: Exploring health, help-seeking and health service use in an online environment.J Health Psychol. 2014; 19: 457-470
- Rethinking gender, men and masculinity: Representations of men in the South Asian reproductive and sexual health literature.Int J Men's Health. 2015; 14: 146-162
- Heteronormativity hurts everyone: Experiences of young men and clinicians with sexually transmitted infection/HIV testing in British Columbia, Canada. Health: An Interdisciplinary Journal for the Social Study of Health.Illness Med. 2013; 17: 441-459
- Seeking help from everyone and no-one: Conceptualizing the online help-seeking process among adolescent males.Qual Health Res. 2016; 26: 1067-1077
- Health care-seeking behaviors related to sexually transmitted diseases among adolescents.Am J Public Health. 1997; 87: 417-420
- Public tolerance, private pain: Stigma and sexually transmitted infections in the American Deep South.Cult Health Sex. 2005; 7: 43-57
- Does integrating family planning into HIV services improve gender equitable attitudes? Results from a cluster randomized trial in Nyanza.Kenya AIDS Behav. 2016; 20: 1883-1892
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- Interventions to Increase Male Attendance and Testing for Sexually Transmitted Infections at Publicly-Funded Family Planning ClinicsJournal of Adolescent HealthVol. 61Issue 1