Abandoning Self-defeating Behaviors
Port-au-Prince, HAITI -- "At first, the men in our program tended to see
themselves as alone," says Gessy Aubry, director of GLAS, the Groupe de Lutte
Anti-SIDA (Group in Struggle Against AIDS), an HIV prevention program conducted at
Port-au-Prince workplaces ranging from utility companies to bottling plants.
"The men tended to be concerned only with their own welfare. They often had
dominating attitudes towards women," she says. "Then, gradually, very gradually,
they began to appreciate that they could get something for themselves by behaving in ways
that also benefited women. They also learned through their women colleagues how women
think, and began to accept them better."
Accompanying these changes in many men's hearts and minds were important changes in
behavior that served to protect them better from AIDS. The program, which ended in 1996,
consisted of four phases, but the final phase was the key to bringing about behavioral
change, says Aubry. It featured a widely-used educational tool for personal growth and
change, called transactional analysis (TA).
This psychological approach focuses on teaching adults how to abandon often painful and
self-defeating strategies, typically learned during childhood, and how to develop
different attitudes for dealing with life's problems. It also promotes clear, direct
communication.
"Although TA is well known in the developed world, many experts were unsure
whether it could be successfully used in the developing world to enrich an HIV prevention
program," says Aubry. "But after we translated the idea of TA into the native
language, taking into account our students' frame of reference, it became our biggest
success. It was the key thing that had been missing."
Gradual evolution
Overall, GLAS provided HIV prevention education to nearly 20,000 workers, predominantly
male and primarily between 15 and 49 years old.
The workplace project evolved gradually. At first, GLAS offered only a single,
hour-long session involving a general introduction to sexually transmitted diseases,
notably HIV and its prevention. A second session instructed workers on condom use.
Surveys of workers inspired a third phase of the workplace project: an open-ended
discussion hour in which workers who had participated in the first two sessions could ask
questions, analyze rumors and beliefs about HIV/AIDS, and talk about personal issues.
"This was very important for a setting like Haiti because many of the people with
whom we worked were superstitious and believed that AIDS was a supernatural disease, a
curse placed upon you by people who wish to harm you," says Aubry. "Reversing
these beliefs and replacing them with the understanding that men can protect themselves
against AIDS by changing sexual behaviors represented major progress in the work."
Still, after the three sessions, some men and women continued to put themselves at risk
for HIV infection. Puzzled by this behavior, Aubry decided that its source must be a lack
of self-esteem and poor communications skills; she decided intensive psychological support
groups featuring TA could get to the heart of the matter.
Intensive interventions such as this are rare in developing countries. "I knew,
having used TA in commu nication courses for professionals,
that it was a marvelous way to help people obtain equilibrium in their lives," says
Aubry. "TA does not consist of difficult concepts ... it simply teaches a person how
to use the powers and pitfalls of his or her unique psychological makeup to change
behavior and make better decisions."
With funding from FHI's AIDS Control and Prevention (AIDSCAP) Project, Aubry created 20
support groups (two each in 10 different workplaces) that met monthly for eight months,
during which participants learned TA. Each group included both men and women.
"Working with both men and women was very helpful in pinpointing gender
differences," says Aubry. "Men needed to be helped to put aside dominating
attitudes, but TA helped them think about -- perhaps for the first time in their lives --
the reasons for their attitudes and actions and to break behaviors down to their origins.
Also, it often gave them a sense of responsibility for their actions, a deep respect for
their partner in life and an appreciation of the importance of parenting.
"Women acquired more self-confidence and better communication skills. While TA has
been regarded as something that should only be offered to literate people, my experience
shows that the concept of TA can be understood by anyone," says Aubry. "What's
more, once it is put into practice, the change in people's lives tends to be permanent,
making these individuals better parents, workers and citizens."
A Clinic for Her, and One for Him
Bogotá, COLOMBIA -- At one time, a man seeking reproductive health services at
Clínica Piloto of the Asociación Probienestar de la Familia Colombiana (PROFAMILIA)
faced a challenge. He had to share the clinic entrance with women and walk into a waiting
room filled with women, most of whom would look at him, many of whom would stare. Clearly,
many men would feel intimidated.
Today, however, Clínica Piloto in Bogotá offers men their own all-male clinic,
focusing specifically on their needs. Since 1994, the men's clinic has even been located
in a different building, across the street from the main family planning clinic.
Efraín Patiño, a counselor at the men's clinic since it opened in 1985, says the
first men to come to the clinic, initially supported by New York-based AVSC International,
requested vasectomies. But now, on an average day, Patiño sees at least 40 men whose
visits represent an array of reproductive health concerns.
"I work with men of all ages, adolescents to men in their 80s," he says,
"and men of all incomes, education and types of personality. Despite their
differences, men know that when they come here they will get good, comprehensive care and,
when they get such care, they often are very grateful."
Services offered at the clinic include urological procedures (including in-patient
surgery), general medicine, family planning (including vasectomy and condoms), infertility
testing and treatment, STD diagnosis and treatment (including HIV testing), sex therapy,
lab services for sperm counts, and hormone, urine, and blood testing.
Men attracted to the clinics for any one of its numerous health services can also
receive counseling about reproductive health and family planning issues. One measure of
the success is that the number of vasectomies performed at PROFAMILIA clinics has steadily
risen from 1,241 in 1985 to 6,825 in 1995.
A popular service offered at the men's clinic in Bogotá is sexual dysfunction
consultation. Says former clinic director Dr. Juan Carlos Vargas: "Our staff includes
sex therapists who are considered the country's best experts on sexual dysfunction. Demand
for such consultations channels many men to the clinic, at which point we can address
overall reproductive healthcare." PROFAMILIA staff also visit places that men
frequent, particularly workplaces, to discuss reproductive health matters and sometimes
perform exams.
Men's special needs
Separate facilities or services are not the only way to reach men. PROFAMILIA offers
men-only clinics in two large cities, yet has found the number of male clients increasing
at its clinics in smaller cities, where separate facilities are impractical. Much of the
credit goes to staff who are sensitive to men's complex needs. In the male clinic in
Bogotá, counselor Patiño spends approximately 15 minutes with each client, discussing
concerns before and after guiding the client to an appropriate provider.
Traditional ideas about the roles and responsibilities of men often are barriers to
helping men obtain the best reproductive health services. "Men tend not to admit that
they are ignorant about matters concerning sex or reproductive health," Patiño says,
"although it is often clear during counseling sessions that they are learning
something completely new."
"Also, if they have a health problem, they tend to try first to go to the pharmacy
and get drugs that may or may not work. Furthermore, men are not as direct as women and
tend to minimize problems. It is not unusual for a man to tell me he has a small amount of
secretion that he is not at all worried about; yet, the doctor who examines him is
astonished at how advanced the problem is."
"Building confidence is the key. I try to keep up regular contact with clients,
particularly those with ongoing problems. One of my greatest satisfactions is to meet
former patients later and have them remember me. In this way I know I've had an impact on
their lives."
Note: More information about this topic is found in Profamilia's Clinics for
Men: A Case Study. Men as Partners in Reproductive Health. New York: AVSC
International. 1997.
Games of Risk for Men at Risk
Gettysburg, PA, USA -- In an outdoor area known as "the minefield," an odd
assortment of items have been randomly placed, ranging from cuddly stuffed animals to
mousetraps. Some have signs saying they are harmless, but others are labeled as posing
risks for sexually transmitted diseases (STDs).
A group of young men pair off with each other, then one verbally guides his blindfolded
partner around the risky items. In this game, points are given whenever a blindfolded man
touches a "risky" item, and accumulating so many points results in an
"infection." Generally, about 20 percent of the teenagers have
"acquired" an STD by the end of the game.
This exercise is just one of several activities in the Adolescent Male Involvement
Program (AMIP) in Gettysburg, a small city near Washington best known to Americans as the
site of a battlefield during the American Civil War. The games help young men understand
reproductive health risks, says Marianne Crouthamel, program coordinator.
At the heart of the small program is the idea that youth drawn to impulsive and risky
behaviors can learn to respect risks and prepare for them through challenging physical
activities and mentors whose professions are naturally dangerous.
AMIP meets weekly for seven sessions and involves up to 12 young men who attend
alternative education classes for teenagers whose behavior has resulted in their removal
from traditional schools. "These are young men, mostly 16 to 18 years old, who are
not functioning well in a traditional school setting, possibly are on probation, may have
had drug or alcohol problems, or may have family issues such as neglect, abuse or
violence," Crouthamel says. "Many have responded very positively and I believe a
more mainstream group of young men might react even more enthusiastically." With a
grant from the Pennsylvania Department of Health and the Family Health Council of Central
Pennsylvania, the Family Planning and Health Center in Gettysburg conducts the program.
"One thing we quickly figured out was that male adolescents, unlike females, have
trouble relating to each other on a chatty, intimate basis. Young men respond to an
action-oriented format," she says.
To that end, the initial sessions take place at a series of outdoor obstacles at
Gettysburg College called the Challenge Course. The college helps organize activities
designed to develop skills in team-building, resisting peer pressure and accepting
personal responsibility. Team-building skills, for example, are developed in the minefield
exercise. Later, the young men work on platforms and climbing apparatus, which heightens
the sense of risk. If they continue to progress as a team, they eventually have the
opportunity to climb a 40-foot tower.
During these initial sessions of practicing techniques to keep themselves safe, the
young men also are taught about sexual risk reduction by two certified paramedics.
"Because we were dealing with youth who were risk takers, we very much wanted to
involve as mentors men whose occupations involved risk-taking, but in a positive
sense," says Crouthamel.
Says Scott Anderson, a paramedic who works with the program: "They could not
understand why risk reduction would be important to them personally. Information is not
enough if individuals cannot envision a future for themselves worth protecting. True
understanding was not possible without first addressing on the obstacle course the central
concept of self-esteem."
Clinic visits
The young men receive information about contraception, prevention of STDs and social
skills to help them negotiate and maintain healthy relationships. Final sessions include
visits to a family planning clinic and a health clinic. Coordinated by a physician, the
tours include an opportunity to be tested for an STD. Dr. Kenneth Stephan, the physician,
is a familiar figure to the young men since he occasionally participates in earlier
sessions.
"The boys seemed nervous with my presence at first, but warmed up," Dr.
Stephan says. "I feel that having a physician involved plants the seed for the youth
to be comfortable with doctors or clinics. Then, they will be willing to make use of us
without fear." During the last session for one group, seven of 10 young men requested
STD testing and a few requested HIV testing.
"We were extremely surprised and pleased that these kids were now self-assessing
their risk and acting responsibly upon their assessments," says Crouthamel.
"Furthermore, the young men who requested STD testing wanted to receive the test
results in the group, not privately. They obviously felt there was strength for them in
the group, that they had worked hard together and would share the results, regardless of
their outcome."
-- Kim Best
For more information, visit Family Health International's Website at www.fhi.org
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