The theory of masculinity in studies on HIV. A systematic review

Abstract

This study aimed to describe the methodological characteristics of publications on HIV and masculinity, to identify possible information gaps and determine the main thematic areas. A systematic review was conducted of gender, masculinity, HIV infection and other sexually-transmitted infections in original articles published between 1992 and 2015. Original studies published from Pubmed and Scopus were included. A total of 303 articles were identified, of which 187 were selected. Most of the studies were qualitative and the most widely used technique was the interview. Twenty-nine-point five percent of studies were performed in South Africa, 20.8% in the USA, and 3.2% in Europe. Fifteen percent of the studies were performed in heterosexuals, 12.8% in men who have sex with men, and 60% did not specify the sexual orientation of the population. Eight thematic areas were defined, the most frequent being sexuality and risk behaviours, defined by men’s need to demonstrate they were sexually active and a breadwinner. Most studies on HIV and masculinity show a gender bias by not specifying the sexual identity of the population. Studies should consider diversity in sexual and cultural identity in different contexts, including in Europe, to carry out more effective HIV interventions from a masculinity perspective.

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The theory of masculinity in studies on HIV. A
systematic review
Constanza Jacques-Aviñó, Patricia García de Olalla, Alicia González Antelo,
Manuel Fernández Quevedo, Oriol Romaní & Joan A. Caylà
To cite this article: Constanza Jacques-Aviñó, Patricia García de Olalla, Alicia González Antelo,
Manuel Fernández Quevedo, Oriol Romaní & Joan A. Caylà (2018): The theory of masculinity in
studies on HIV. A systematic review, Global Public Health
To link to this article: https://doi.org/10.1080/17441692.2018.1493133
Published online: 04 Jul 2018.
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The theory of masculinity in studies on HIV. A systematic review
Constanza Jacques-Aviñó
a,b
, Patricia García de Olalla
a,c
, Alicia González Antelo
d
,
Manuel Fernández Quevedo
a
, Oriol Romaní
c,e
and Joan A. Caylà
a,c
a
Servicio de Epidemiología, Agència de Salud Pública de Barcelona, Barcelona, Spain;
b
Universitat Rovira i Virgili
(URV), Tarragona, Spain;
c
Epidemiología y Salud Pública, CIBER, Spain;
d
Servicio Medicina Preventiva y
Epidemiología, Hospital Vall d’Hebrón, Barcelona, Spain;
e
Medical Anthropology Research Center (MARC- URV),
Tarragona, Spain
ABSTRACT
This study aimed to describe the methodological characteristics of
publications on HIV and masculinity, to identify possible information
gaps and determine the main thematic areas. A systematic review was
conducted of gender, masculinity, HIV infection and other sexually-
transmitted infections in original articles published between 1992 and
2015. Original studies published from Pubmed and Scopus were
included. A total of 303 articles were identified, of which 187 were
selected. Most of the studies were qualitative and the most widely used
technique was the interview. Twenty-nine-point five percent of studies
were performed in South Africa, 20.8% in the USA, and 3.2% in Europe.
Fifteen percent of the studies were performed in heterosexuals, 12.8% in
men who have sex with men, and 60% did not specify the sexual
orientation of the population. Eight thematic areas were defined, the
most frequent being sexuality and risk behaviours, defined by men’s
need to demonstrate they were sexually active and a breadwinner. Most
studies on HIV and masculinity show a gender bias by not specifying the
sexual identity of the population. Studies should consider diversity in
sexual and cultural identity in different contexts, including in Europe, to
carry out more effective HIV interventions from a masculinity perspective.
ARTICLE HISTORY
Received 16 February 2018
Accepted 23 May 2018
KEYWORDS
Masculinity; HIV; gender;
sexual identity; systematic
review
Introduction
An estimated 37.9 million people live with HIV worldwide, of whom 17.2 million are men; trans-
mission in women is believed to occur mainly through heterosexual practices (UNAIDS, 2015).
In South Africa, men were found to be 25% more likely to die from AIDS than women, although
women had a greater probability of becoming infected (Dovel, Yeatman, Watkins, & Poulin,
2015). Among men who have sex with men (MSM), the HIV epidemic continues to spread in
most countries, especially in urban areas, where the prevalence of infection can be up to three
times higher than in the general population (World Health Organization, 2016). As a social deter-
minant of health, the gender perspective allows a deeper analysis of how the concept of masculinity
contributes to the spread of HIV (ECDC, 2013).
Although there is abundant literature on the factors associated with HIV transmission, few
studies have incorporated the masculinity (Gash & Tomás, 2015). Masculinity is a social construct
that depends on both social interactions and social expectations that judge men and their behaviours
in each culture (Fleming, DiClemente, & Barringtons, 2016). That is, masculinity not only refers to
what men do but also to what they are expected to do, it is a set of beliefs and practices. This suggests
© 2018 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Constanza Jacques-Aviñó cjacques18@yahoo.es; cjacques@aspb.cat
GLOBAL PUBLIC HEALTH
https://doi.org/10.1080/17441692.2018.1493133

that a person becomes a man or a woman because he or she acts in a certain way, which is deter-
mined by a cultural pattern. On the one hand, there is conformity with traditional masculinity,
which represents an increase in health risks, a position that corresponds to hegemonic masculinity
(Connell & Messerschmidt, 2005). This masculinity is related to a reluctance to lose the status of
supremacy and to advocate greater gender equality (Welzer-Lang, 2010). From this position men
faced the ideal stereotype where physical resilience is valorised, avoiding to seek healthcare and
engage in preventing activities, since they do not want to show weakness (Jewkes et al., 2015). On
the other hand, there is subordinate masculinity, which refers to groups classified as marginal,
whether because of their ethnicity or sexual orientation and which is created as a result of compari-
son of culturally dominant ideals of masculinity, possibly leading to worse health compared with
other groups of men (Connell & Messerschmidt, 2005; Evans, Frank, Oliffe, & Gregory, 2011). In
other words, not all men enjoy the same status and hierarchy; in fact, in sexual relationships between
men, there is probably a lack of horizontality to negotiate preventive measures in collectives that
could be more vulnerable, such as immigrants or young men (Connell, 2012).
Therefore, in addition to gender, ethnic-racial origin and social class need to be considered to
understand the spread of HIV (Dworkin, 2005). This implies a consideration of gender as a social
dimension that involves power relations, the intersection of other axes of inequality and questioning
of a dual model of the sex-gender system. Masculinity is not a static category and resists a universal
reading of behaviours related to HIV transmission, such as condom use and having multiple partners
(Fleming et al., 2016). It also suggests the need to consider sexual orientation and assign visibility to
identity, since both are key factors in carrying out effective interventions in HIV prevention (Harper,
2007). In fact, gender framework that only target men as holders of power and privilege miss the
many men who do not to identify as such and who may be committed to challenging hegemonic
gender roles that negatively impact men and women (Peacock, Stemple, Sawires, & Coates, 2009).
We believe it timely to identify the ‘state of art’of a topic that has been little studied by public
health researchers. We argue that showing every topic on masculinity and HIV provides relevant
information for the critical analysis of existing knowledge. The aim of this study was to describe
the methodological characteristics and the thematic areas of studies on HIV and masculinity and
to identify missing but important factors for intervention strategies.
Methods
Search strategy: a systematic review was conducted following the PRISMA statement to identify,
evaluate and summarise the current state of a specific topic using systematic and transparent pro-
cesses (Moher, Liberati, Tetzlaff, & Altman, 2009). We searched for articles exploring HIV within
a masculinity framework published between 1992, when the first article was published, and Decem-
ber 2015. We included qualitative studies and original quantitative studies published in Spanish,
English and Portuguese.
The search was conducted in Pubmed, as the leading database for biomedical research, and Sco-
pus, from which we selected only manuscripts classified as Social Sciences. Medical subject headings
were used with the following key terms: (gender) AND (masculinity) AND (HIV OR AIDS OR ‘Viral
Sexually Transmitted Disease’OR ‘Bacterial Sexually Transmitted Disease’).
The following information was gathered from selected articles: type of study, design and data col-
lection techniques. The following information was gathered on the characteristics of the sample: age
range, according to the WHO classification, sex/gender and sexual orientation as specified in the
article. Although race is a controversial term, we decided to use the same terms as those used in
the articles to avoid altering the results; we also gathered data on whether participants belonged
to a specific ethnic group or whether they were immigrants. Information was also gathered on
any indicators of social position, such as income, occupation, educational attainment and/or a
description of the neighbourhood of the sample. Finally, we included the area (rural and/or
urban) where the study was performed and the country.
2C. JACQUES-AVIÑÓ ET AL.

Selection of reviewed studies: first, we excluded duplicate studies. Second, we excluded articles
that were unavailable or written in other languages. Third, the articles were read in their entirety
to select those including the theory of masculinity, note the methodology, and identify the thematic
area. The review was conducted by two researchers who collected the data from each manuscript in a
database. The findings were discussed to reach a consensus on the results and validate them.
Selection of themes: after reading the first 50 articles, we created 8 thematic areas, which were
adjusted during the research and triangulated with public health researchers and medical anthropol-
ogists. A narrative summary was made of quantitative and qualitative studies.
Results
A total of 303 articles were identified, of which 115 were excluded because they did not meet the
inclusion criteria. The final sample consisted of 187 articles (Figure 1). No articles were found on
masculinity and a sexually-transmitted infection (STI) other than HIV.
Most studies were conducted in urban areas (37%), followed by rural settings (20%) and, to a les-
ser extent, in both contexts (11%). The country producing the most studies was South Africa
(29.5%), followed by the United States (20.8%). The continent with the largest percentage of studies
was Africa (53%), followed by America (North America: 25.6%; Latin America and the Caribbean:
11.2%), Asia (4.3%), Western Europe (3.2%) and Oceania (2.7%) (Table 1).
Most studies were qualitative (75.4%), mainly using interviews (54.2%), followed by studies com-
bining interviews with focus groups (19.1%). Ethnographic studies were less common (16.3%).
Among quantitative studies, the most common design was cross-sectional (90.6%). Mixed studies
included cybercartography and Internet-based data collection (Table 2).
Records identified through database
searching Pubmed
(n = 189)
Screening
Included Eligibility Identification
Records identified through database
searching Scopus
(n = 114)
Studies included in
qualitative synthesis
(n =187)
Records duplicates
(n = 53)
Records screened
(n = 250) Records excluded
(n = 11)
Full-text articles excluded
by not addressing the goal
(n = 52)
Full-text articles assessed for
eligibility
(n = 239)
Figure 1. Flow chart of studies included in analysis on masculinity and HIV.
GLOBAL PUBLIC HEALTH 3

Table 1. Distribution by country of studies on HIV and masculinity
reviewed.
Country N° de articles %
South Africa 54 29.0
USA 38 20.3
Brazil 10 5.4
Zimbabwe 9 4.9
Uganda 8 4.3
Tanzania 6 3.2
México 5 2.7
Australia 5 2.7
Canada 4 2.1
Namibia 4 2.1
Swaziland 3 1.6
Kenia 3 1.6
Mozambique 3 1.6
UK 3 1.6
Dominican Republic 3 1.6
China 2 1.1
Spain 2 1.1
Malawi 2 1.1
Peru 2 1.1
Zambia 2 1.1
India 2 1.1
Thailand 2 1.1
Caribbean 2 1.1
Bangladesh 1 0.5
Democratic Republic of Congo 1 0.5
Nigeria 1 0.5
Burkina Faso 1 0.5
Cameron 1 0.5
USA /Canada 1 0.5
Guatemala 1 0.5
Jamaica 1 0.5
Paraguay 1 0.5
Puerto Rico 1 0.5
Sweden 1 0.5
Vietnam 1 0.5
Zimbabwe / South Africa 1 0.5
Total 187 100
Table 2. Characteristics of studies on HIV and masculinity according to type of research study and design.
Type of study
N(%)
Study design
N(%)
187(100%) 187(100%)
Qualitative study 141(75.4) Ethnography 1 (0.7)
Interview 76(53.9)
Focus group 14(10)
Focus group / Interview 27(19.1)
Ethnography / Interview 13(9.2)
Ethnography / Focus group 1(0.7)
Ethnography / Focus group / Interview 9(6.4)
Total 141(100)
Quantitative study 32 (17.1) Cross-sectional 29(90.6)
Longitudinal 3(9.4)
Total 32(100)
Mixed methods 14 (7.5) Cross-sectional / Interview 7(50)
Cross-sectional / Focus group 1(7.1)
Cross-sectional / Focus group / Interview 4(28.6)
Cybercartography 2(14.3)
Total 14(100)
4C. JACQUES-AVIÑÓ ET AL.

The study population consisted of men only in 66.9% of the studies, while both men and women
were included in 27.8%. Few studies included transgender persons (Table 3). Most studies (50.8%)
included age groups ranging from adolescents to adults, while no studies were found in persons older
than 60 years. There was a predominance of studies performed in heterosexuals only (15%), followed
by heterosexuals and MSM (10.7%), and MSM and homosexuals (12.8%). No information was pro-
vided on sexual orientation in 60% of the studies. Concerning ethnic-racial origin, notable were
studies performed in specific ethnic groups (21.4%), mainly from African countries, and those con-
ducted in black or mulatto populations (15.6%), mainly from the US (Table 3). Most studies (77.5%)
reported at least one indicator related to the social position of the population.
Thematic areas
The most important findings in each thematic area of the studies on HIV and masculinity are
described below (Table 4).
Sexuality and risk behaviours
A total of 41.6% of the studies on this thematic area were from African countries, 20.2% were from
Latin America and 20.2% from the US. Almost half (46.4%) of the studies did not specify sexual
orientation, while 27.4% were performed in heterosexuals only and in heterosexuals who also ident-
ified as other sexual orientations, 19% in homosexuals and MSM and other sexual orientations. In
these studies, the ideology of masculinity was related to having multiple partners and being hetero-
sexual. Sexual desire was experienced as uncontrollable, thus justifying risk behaviour. There was a
perceived invulnerability to STI/HIV transmission, correlated with condom use among only a min-
ority and its discontinuation after the early stage of a relationship. The dominant masculine norms
were related to unprotected sex, rejection of HIV tests, and not seeking help on sexual health; ‘real’
men were defined as being socially visible and the head of the family. Women were being responsible
for condom use and homosexuals for HIV transmission. Among adolescents of any sexual orien-
tation, risk behaviours were frequent, motivated by peer pressure and by early initiation of sexual
relations to conform to a hegemonic view of masculinity.
In studies in MSM or homosexuals, participants showed a preference for penetrative anal sex
when they wanted to hide their homosexuality; this form of sex was considered low-risk for HIV
acquisition. Men adopting the passive position, who were normally younger and with a more ‘fem-
inine’phenotype, had a lesser perception of control during the relationship, including their partici-
pation in the decision to use a condom. Internet sites used by men to meet bareback sex partners
were characterised by a hegemonic profile of masculinity emphasising physical appearance, and
sex with multiple partners.
Among non-gay-identified African-American MSM in the US, the risk of HIV infection was
related to cultural norms supporting secrecy and privacy in personal matters and to the unpreme-
ditated nature of sexual contacts with other men.
Social and interpersonal relations
More than half (55.5%) of the studies were performed in African countries. Most (66.6%) did not
enquire about the sexual orientation of the sample. Among studies providing this information,
22.2% were conducted in homosexuals and MSM. This section describes how men construct their
social identity, highlighting the social group, body image and physical strength. Hegemonic mascu-
linity was characterised by economic power and having multiple sexual partners, leading to shared
sexual but not emotional experiences among friends with little discussion about protection measures.
Among heterosexuals, reasons for having concurrent sexual relations were an inability to control
sexual desire and a lack of trust in women, who were perceived as being too empowered. Also, it
GLOBAL PUBLIC HEALTH 5

Table 3. Characteristics of populations included in HIV and masculinity studies.
Age group Sex Sexual Identity Indicator social class Race/ Ethnic /migrant
N(%) N(%) N(%) N(%) N(%)
Adolescent 13–19 years 16 (8.6) Men 125(66.9) Heterosexual 28(15) Available 145(77.5) Black & coloured 29(15.6)
Young 20–24 years 4(2.1) Women 6(3.2) MSM 18(9.6) Latino 6(3.2)
Adult 25–59 years 25(13.4) Trans
b
0(0) Homosexual 6(3.2) Black & white 6(3.2)
Aging >60 years 0(0) Men & women 52(27.8) Bisexual 3(1.6) Black, white & other 25(13.4)
Adolescent & young (13–24 years) 23(12.3) Men & trans 3(1.6) MSM
a
& heterosexual 20(10.8) Black, coloured & other 1(0.5)
Adolescent & young & adult (13–59 years) 95(50.8) Men, women & trans 1(0.5) Black & latino 2(1)
Children (<13 years) 1(0.5) Ethnic group 40(21.4)
Migrant 6(3.2)
Not specified 23 (12.3) Not specified 0(0) Not specified 112(60) Not specified 42(22.5) Not specified 72(38.5)
Total 187(100) Total 187(100) Total 187(100) Total 187(100) Total 187(100)
a
MSM: men who have sex with men.
b
Trans: Transsexual or transgender.
6C. JACQUES-AVIÑÓ ET AL.

Table 4. Thematic areas of the studies on HIV and masculinity.
Themes
N° of articles N
(%) Bibliographic references
Sexuality and Risk Behaviors 84(44.9) Aubé-Maurice et al. (2012); Baidoobonso, Bauer, Speechley, and Lawson (2013);
Bhagwanjee et al. (2013); Bhana and Anderson (2013); Bowleg et al. (2011);
J. Brown, Sorrell, and Raffaelli (2005); R. A. Brown, Kennedy, Tucker, Golinelli,
and Wenzel (2013); C. A. Campbell (1995); C. Campbell (1997); Carballo-Dieguez
et al. (2006); Chapple (1998); Clark et al. (2013); Dahlback, Makelele, Yamba,
Bergstrom, and Ransjo-Arvidson (2006); Devries and Free (2010); Do Valle
(2008); Dowsett, Williams, Ventuneac, and Carballo-Dieguez (2008); Doyal,
Anderson, and Paparini (2009); Fernández-Dávila et al. (2008); Fields et al.
(2012); Fontdevila (2006); Fordham (1995); Gonçalves and Da Silva (2002);
Graham (2015); Groes-Green (2009); Grov, Parsons, and Bimbi (2010); Guerreiro,
Ricardo, Ayres, and Hearst (2002); Halkitis et al. (2008); Harrison, O’Sullivan,
Hoffman, Dolezal, and Morrell (2006); Hegamin-Younger, Jeremiah, and Bilbro
(2014); Husbands et al. (2013); Jacques Aviñó, García de Olalla, Díez, and Martín
(2015); Johns, Pingel, Eisenberg, Santana, and Bauermeister (2012); Joshi (2010);
Junior, Gomes, and Do Nascimiento (2012); Kendall, Herrera, Caballero, and
Campero (2012); Kennedy et al. (2013); M. E. Khan, Mishra, and Morankar (2008);
S. I. Khan, Hudson-Rodd, Saggers, and Bhuiya (2005); Kogan, Cho, Barnum, and
Brown (2015); Langeni (2007); Larkin, Andrews, and Mitchell (2006); Leidens,
Estermann, Sacchi, and Montano (2004); Levinson, Sadigursky, and Erchak
(2004); Lorway (2006); Lusey, Sebastian, Christianson, Dahlgren, and Edin
(2014); Lynch, Brouard, and Visser (2010); Macia, Maharaj, and Gresh (2011);
Malebranche, Gvetadze, Millett, and Sutton (2012); Mankayi and Naidoo (2011);
Mankayi (2008,2009); Mfecane (2012); Mindry, Knight, and van Rooyen (2015);
Mufune (2009); Mugweni, Pearson, and Omar (2015); Muparamoto (2012);
Murphy and Boggess (1998); Nzioka (2001); Operario, Smith, and Kegeles
(2008); Persson and Richards (2008); Pettifor, Macphail, Anderson, and Maman
(2012); Plummer (2013); Raiford, Seth, Braxton, and Diclemente (2013);
Robertson et al. (2013); Senn, Scott-Sheldon, Seward, Wright, and Carey (2011);
Shai, Jewkes, Nduna, and Dunkle (2012); Shefer and Ngabaza (2015); Shefer
et al. (2008); Singh et al. (2010); D. J. Smith (2007); Sommer, Likindikoki, and
Kaaya (2015); Stern and Buikema (2013); Stern, Clarfelt, and Buikema (2015);
Stern, Rau, and Cooper (2014); Taquette, Rodrigues de Oliveira, Bortolotti, and
Rodrigues (2015); Uribe-Salas, Conde-González, Magis-Rodríguez, and Juarez-
Figueroa (2005); Van Tuan (2010); Walcott et al. (2014); Wamoyi et al. (2015);
Wheldon (2010); Wyrod (2011).
Social Relationships 27(14.4) Artazcoz, Moya, Vanaclocha, and Pont (2004); Bandali (2011); Shari L Dworkin and
O’Sullivan (2005); P. J. Fleming, Andes, and Diclemente (2013); P. J. Fleming,
Barrington, Perez, Donastorg, and Kerrigan (2014); García, Lechuga, and Zea
(2012); McInnes, Bradley, and Prestage (2009); Morrell and Jewkes (2011);
Muñoz-Laboy et al. (2012); Muñoz-Laboy, Severson, and Bannan (2014);
Pulerwitz and Barker (2007); Ragnarsson, Townsend, Ekstrom, Chopra, and
Thorson (2010); Ragnarsson, Townsend, Thorson, Chopra, and Ekstrom (2009);
Reihling (2013); Rich, Nkosi, and Morojele (2015); Shefer, Clowes, and Vergnani
(2012); A Simpson (2005); Anthony Simpson (2007); G. Smith, Kippax, and
Chapple (1998); Tersbøl (2006); Thien and Del Casino (2012); Townsend,
Ragnarsson, et al. (2011); Van Klinken (2012); Walker (2005); Wamoyi, Fenwick,
Urassa, Zaba, and Stones (2011).
Access to Diagnosis and
Treatment
25(13.4) Barnabas Njozing, Edin, and Hurtig (2010); Bila and Egrot (2009); Chikovore et al.
(2014); Chikovore, Hart, Kumwenda, Chipungu, and Corbett (2015); Duck (2009);
Galvan, Bogart, Wagner, Klein, and Chen (2014); Gari, Martin-Hilber, Malungo,
Musheke, and Merten (2014); Lyttleton (2004); Mavhu et al. (2010); Mburu, et al.
(2014); Mfecane (2011,2012); Nattrass (2008); Nyamhanga, Muhondwa, and
Shayo (2013); Parent, Torrey, and Michaels (2012); Pearson and Makadzange
(2008); Saleh, Operario, Smith, Arnold, and Kegeles (2011); Sikweyiya, Jewkes,
and Dunkle (2014); Siu, Seeley, and Wight (2013); Siu, Wight, and Seeley (2012,
2014); Siu and Seeley (2014); Skovdal, Campbell, Nyamukapa, and Gregson
(2011); Skovdal, Campbell, Madanhire, et al. (2011); Wyrod (2013).
Prevention and Intervention
Evaluation
15(8.0) Dageid, Govender, and Gordon (2012); Daniels, Crum, Ramaswamy, and
Freudenberg (2011); Shari L Dworkin, Hatcher, Colvin, and Peacock (2013);
P. J. Fleming, Barringtons, Perez, Donastorg, and Kerrigan (2015); Foley, Powell-
Williams, and Davies (2015); Gibbs (2015); Hatcher, Colvin, Ndlovu, and Dworkin
(2014); Jobson (2010); Kageha Igonya and Moyer (2013); Mufune (2009);
(Continued)
GLOBAL PUBLIC HEALTH 7

was a way of coping with the difficulty of complying with a hegemonic masculine role due to
unfavourable socioeconomic conditions, unemployment and low self-esteem. Men who reported
having an alternative masculinity, were those who most strongly supported gender equity.
In contrast, homosexuals who disclosed their sexual orientation were more likely to reveal their
HIV-serostatus, which was associated with better health outcomes. Latino men residing in the US
reported that factors favouring communication were acculturation to the host environment and
social support.
Access to diagnosis and treatment
This topic was mainly studied in articles from African countries (84%), with most (89.5%) not
reporting the sexual orientation of the sample. Hegemonic masculinity implied that a man was
respectable, independent, and a breadwinner, which was related to resistance to self-care. This belief
was a barrier to accessing the health system for HIV tests or undergoing follow-up, since men did not
want to be identified as seropositive in their communities. HIV-seropositive was associated with
homosexuality and social stigma and with disappointing social expectations. This rejection led
men to deny their illness, with HIV-positive men only accessing the health system when they devel-
oped serious complications or were in poor general health; some even used women to obtain anti-
retroviral treatment. In contrast, facilitators to HIV-testing were the desire for good health and for a
longer life, the perception of family support, faith in a supreme being, and trust in health authorities.
Among HIV-positive men, participating in support groups represented an abandonment of hegemo-
nic masculinity and greater treatment adherence.
In the US, heterosexual self-presentation was a barrier to HIV-testing in MSM. A study in Afri-
can-American MSM who did not identify as gay revealed the huge difficulty of accessing HIV pre-
vention counselling.
Prevention and intervention assessment
A total of 60% of studies on interventions were conducted in African countries, 20% were performed
in the US and 8% in Latin-American countries. Eighty percent did not specify the sexual orientation
of the sample; among those that did, 13.3% were conducted in MSM and were carried out in
Table 4. Continued.
Themes
N° of articles N
(%) Bibliographic references
S. D. Rhodes et al. (2014); Van Den Berg et al. (2013); Verma et al. (2006);
Viitanen and Colvin (2015)
Violence 14(7.5) Brear and Bessarab (2012); Christofides et al. (2014); Clüver, Elkonin, and Young
(2013); Decker et al. (2009); Dunkle et al. (2004,2007); S. L. Dworkin, Colvin,
Hatcher, and Peacock (2012); Gibbs, Sikweyiya, and Jewkes (2014); Jewkes,
Morrell, Sikweyiya, Dunkle, and Penn-Kekana (2012); Jewkes, Nduna, Shai, and
Dunkle (2012); Mugweni, Pearson, and Omar (2012); Mulrenan, Colombini,
Howard, Kikuvi, and Mayhew (2015); Townsend, Jewkes, et al. (2011); Walsh and
Mitchell (2006)
Social Stigma 13(7.0) Balaji et al. (2012); Fields et al. (2015); Halkitis and Parsons (2003); Harrison (2000);
Herrick et al. (2013); Kisler and Williams (2012); LaPollo, Bond, and Lauby (2013);
Quinn and Dickson-Gomez (2015); Severson, Muñoz-Laboy, and Kaufman
(2014); Tapia (2015); Vasques-guzzi and Varas-diaz (2012); Verduzco (2014)
Paternity 6(3.2) Asander, Rubensson, Munobwa, and Faxelid (2013); Harrington et al. (2015);
Highton and Finn (2015); Jadwin-Cakmak, Pingel, Harper, and Bauermeister
(2015); Mbekenga, Lugina, Christensson, and Olsson (2011); Taylor, Mantell,
Nywagi, Cishe, and Cooper (2013).
Male Circumcision 3(1.6) Adams and Moyer (2015); Humphries, van Rooyen, Knight, Barnabas, and Celum
(2015); Khumalo-Sakutukwa et al. (2013).
Total 187 (100)
8C. JACQUES-AVIÑÓ ET AL.

Guatemala and the US. These studies revealed that male sexuality was based on hegemonic mascu-
linity. Studies in Africa assessed mainly educational programmes such as One Man Can and Stepping
Stones. The participants indicated that the programmes had shifted men’s attitudes to gender roles
and power relations toward greater gender equality, had improved communication with their part-
ners and reduced alcohol consumption, increased safe sex practices and reduced violence. Among
the barriers to maintaining these changes were an inability to fulfil the role of breadwinner due to
unemployment and peer pressure. It has been proposed that factors such as ethnic group and social
class should be integrated into interventions.
Studies exploring factors facilitating HIV-prevention programmes suggest the need to take into
account the price men pay when renouncing hegemonic masculinity, that is, the need to propose
alternative masculinities and include sociocultural expectations, as well as men’saffective relation-
ships. In HIV-seropositive men, steps to increase treatment access included disclosure of serological
status, as a first step in accepting the disease, and encouraging participation in support groups to
improve psychological and sexual wellbeing. In schools, the use of teaching and learning materials
that question dominant forms of masculinity has been proposed as a means to combat HIV-related
discrimination and homophobia.
Violence
Most of the studies on violence were from African countries (92.9%). None of them specified the sexual
orientation of the population, except one study conducted in heterosexual men. Research centred on
sexual violence to explain HIV transmission in women. This behaviour reinforced a model of mascu-
linity promoting recurrent sexual partners and physical violence toward women. Men internalised the
idea of having control over women and hierarchical gender roles. In these contexts, adolescent girls felt
coerced by older men wanting to buy sex and pressured by their boyfriends to have sexual relations
before they felt ready and to increase the frequency of relations. In socially disadvantaged urban
areas with a high prevalence of HIV infection, young men saw gang membership and violence as a
way of demonstrating their masculinity and position within the social order. Men with a tendency
to abuse women were more likely to be HIV-infected and to oblige women to have forced sex.
Social stigma
Studies on stigma were performed mainly in the US (61.5%) followed by Latin-America (23.1%), with no
studies were identified from Africa. All the studies were conducted in populations including MSM and
homosexuals. Hidden homoerotic desire led to men having fewer strategies to negotiate safe-sex prac-
tices, thus exposing themselves to STI infection. These practices produced a series of emotions such as
guilt, shame, fear and sadness that may develop into mental health issues such as depression and anxiety.
Studies focusing on African-American men in the US report that social constructs of gender led
participants to equate homosexuality with femininity, which in turn led them to adopt a hypermas-
culine and hypersexualized image with their female partners in order to meet social expectations.
Hypermasculine men showed greater internalised homonegativity. Fear of rejection or actual rejec-
tion by the social environment led to risk behaviour and a higher probability of HIV exposure. The
studies highlight the importance of adopting a traditional masculine role, with no expression of feel-
ings, despite their sexual identity, to integrate in society. Compared with groups of white men, Afri-
can-American men had a greater fear of ‘coming out of the closet’mainly due to a fear of losing the
support of the black community, in which the church plays a strong role.
Paternity
Fifty percent of the studies on paternity were performed in Africa and 33.3% in Europe. Half of the
studies were conducted in the heterosexual population and 16.6% in MSM and homosexuals.
GLOBAL PUBLIC HEALTH 9

Hegemonic notions of masculinity intersected with the belief that men needed to demonstrate their
sexual prowess and their mental and physical wellbeing; thus, siring a child became a symbol of viri-
lity with roles and responsibilities. Some fathers feared transmitting the HIV virus to their children,
generating tension in the entire family. In general, men played little part in health services related to
reproduction and child raising. HIV-positive immigrant men with children who had difficulty in
understanding medical information and who wanted to be involved in child care mistakenly feared
infecting their children. Also mentioned was the desire to be seen to be responsible and resilient and
to be a committed father as a useful strategy to combat the stigma of HIV infection.
Male circumcision
The 3 studies found on male circumcision were performed in distinct cultural contexts of African
countries. None of these studies specified the sexual orientation of the population. Some participants
considered it a threat, since it reduced sensitivity and reduced sexual pleasure and could sometimes
have irreversible adverse effects on sexual function. In contrast, elsewhere, circumcision was redu-
cing HIV transmission and even with increasing sexual pleasure, for both men and women. It has
been suggested that circumcision programmes should be culturally adapted to different contexts
and include both men and women in the target population.
Discussion
The studies reviewed highlighted a hegemonic model of masculinity characterised by men’s need to
demonstrate their sexual prowess and provide for the family. Notions of sexuality were supported by
deterministic arguments like ‘men will be men’. However, cultural norms have influenced the idea
that men are driven to seek opportunities to satisfy their sexual desires (Fleming et al., 2016). The
ability to earn money assigned value and status, making work a higher priority than health (Cour-
tenay, 2000). From this viewpoint, men take an instrumental view of health in which the body is seen
as an efficient machine with few needs for care and is resistant to disease (Möller-Leimkühler, 2002).
These traditional roles assign men qualities such as bravery, risk and other associated characteristics
that make them susceptible to contracting HIV and other STI (Möller-Leimkühler, 2002). These
behaviours are socially rewarded and may even be admired, since they are ways of achieving
power (Juliano, 2010). In this sense, the presence of women in the review was uncommon and
when it appeared was normally assuming culpability for the transmission of HIV or the place of
the victim. These patterns of violence towards women have been associated with countries where
policies with gender inequality predominate and where abuse towards women is a social norm
(Heise & Kotsadam, 2015).
Most of the studies on masculinity were conducted in sub-Saharan Africa and the US (73.6%),
while studies in Western Europe, despite the number of publications on gender and health, were
very scarce (3.2%) and the few identified were performed mainly in the immigrant population. Con-
sequently, persons of Roma ethnicity, for example, were not included in any of the articles reviewed.
Studies from the US focused in ethnic minorities (African American or Latino) and mainly con-
cerned conflicts related to same-sex attraction among men. This possible tension in gender role
led to men adopting an image of hypersexualized masculinity to gain acceptance by the community
(Zeglin, 2015). It would seem, therefore, that western Caucasian men are not seen as suitable for
study from the gender perspective. In the US, race and ethnic background have been used as
cause of discrimination, marginalisation, and even subjugation (González et al., 2003). Nonetheless,
that the invisibility of white American and European in studies of masculinity leads one to think that
cultural determinants of gender do not influence their behaviour, but that is not the case. On the
contrary, we believe that more studies are needed in this population in order to know the practices
and beliefs that are also influenced by the models of masculinity, since focusing just on ethnic min-
orities or non-Caucasian populations can promote stereotypes and prejudices towards these
10 C. JACQUES-AVIÑÓ ET AL.

communities. In this way, another notable finding was that the studies including an indicator of
social class focused on the most disadvantaged classes, suggesting that masculinity is only worth
studying in these sectors of the population. These results could be analyzed under a postcolonial
approach, when language has been predominantly attached in fixed western epistemologies of
class divisions, heterosexism, and racializing reproduction (Darder, 2018).
Most of the studies (60%) contained no information on the sexual orientation of the population,
although the contents of these articles suggested that the sample consisted of heterosexuals. That is,
there is a denial of homoerotic relationships, taking for granted that men only feel attracted to and
have sexual relationships with women. This invisibility of sexual minorities, especially in research
conducted in African countries, shows how a heteronormative model is accepted by researchers
themselves. In this regard, laws and policies on acceptance or non-acceptance of homosexuality
are a structural determinant that varies from country to country, and that influence vulnerability
to contracting HIV (Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008). This gender bias has nega-
tive health repercussions, not only in gay-identifying but also in anyone belonging to an identity cat-
egory other than heterosexual. In fact, the social stigma of same-sex attraction can lead to major
conflicts and health repercussions (King et al., 2013). Therefore, the assumption of the health system
that the population is heterosexual is a barrier to prevention measures and places homosexual men at
risk. As well as men that not define themselves as homosexuals, or are not identified like MSM, but
who have sexual relationships with other men (Díaz, 1999; Souleymanov & Huang, 2016).
The lack of research on masculinity in MSM, gay collective or non-straight sexual identities,
reveals the need to gain deeper insight into their models of masculinity and how these groups
have internalised traditional models in the social fact of being male. On the other hand, the relation-
ship between sexual diversity and the cultural context should be considered. In this sense, it is impor-
tant to understand the context of sexual interactions which are necessarily social and involves the
complex relationship between sexual behaviour, sexual identity and the meaning of sexuality (Parker,
2009).
The predominance of qualitative methodology revealed the aim of articulating data within a
theoretical framework. In fact, factors such as ethnicity, economic status and sexuality were fre-
quently treated simply as variables to be controlled in the statistical analysis and were less frequently
studied from a social and gender perspective (Courtenay, 2000). Consequently, closer linkage
between epidemiology and social sciences is advisable in studies on social determinants in health
(Rhodes & Simic, 2005). From public health research it requires us to move beyond the overly
neat analytic distinctions and include community experience (Parker, Aggleton, & Perez-Brumer,
2016).
One of the limitations of this study is the lack of inclusion of other bibliographic databases that
could have increased the number of studies reviewed. However, the databases chosen are the most
widely used in biomedicine and social sciences. On the other hand, not researching the theoretical
framework used in the manuscripts was a limitation due to the use of a systematic review that puts
the accent on data collection (PRISMA) and not in a theoretical debate. Therefore, we suggest exam-
ining models that use the theory of masculinity in public health research, as well as incorporating
other disciplines that study this topic in order to learn about different ways of approaching it.
The main strength of this review is that it achieved information saturation and included many
articles, thus allowing closer assessment of the quality of the scientific literature and identification
of gaps in existing knowledge. Therefore this study differs from other reviews; this is the first exhaus-
tive review of the literature on masculinity and HIV that provide lack of relevant information in this
issue.
Currently, the challenge for public health lies in incorporating a deeper analysis of distinct mas-
culinities and their underlying power relations. Such an analysis would help to explain the morbidity
and mortality of certain health problems affecting mainly men, such as road traffic accidents and
problems with drugs (Borrell & Artazcoz, 2007). Analysis of the concept of hegemonic masculinity
is important to favour prevention by promoting a change in masculine norms, in which reflection
GLOBAL PUBLIC HEALTH 11

and dialogue are a fundamental strategy for health promotion and HIV prevention (Connell & Mes-
serschmidt, 2005; Jewkes et al., 2015). The gender perspective not only seeks to find differences
between genders but also to investigate the processes reproducing these differences (Buschmeyer,
2013). This requires an understanding of the HIV epidemic from a syndemic model, which takes
into account social interactions, social inequalities and the characteristics of HIV infection (Singer,
Bulled, Ostrach, & Mendenhall, 2017). In this regard, the perspective of Intersectionality is of inter-
est, as it proposes an analysis of power relations that can give rise to inequality, combining gender,
race/ethnicity and social class (Christensen & Jensen, 2014). We believe that both perspectives pro-
vide a good public health framework for analyzing the relationship between disease and social
research that includes social conditions, stigmatisation, or structural violence.
In summary, most studies on HIV and masculinity show a gender bias by not address the sexual
identity of the population. In addition, the most widely investigated topic was sexuality and risk
behaviour, demonstrating that men were legitimised by always being ready for sex. On the other
hand, studies on masculinity and HIV were invisible from Western culture, a classic discussion
between science and power that refers to the hierarchy between the knowledge productions. That
issue requires reflexive process into public health to promote an intercultural sensitivity in its
research and intervention. Future studies should be considered, diversity in sexual and cultural iden-
tity and European population, on the other, the mechanisms (eg, education, the media, nuclei of
sociability) through which patterns reinforcing a hegemonic model of masculinity facilitating the
acquisition of HIV and other STI.
Disclosure statement
No potential conflict of interest was reported by the authors.
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