Abstract
Since the 1980s studies on men have frequently utilized Connell’s framework of hegemonic masculinities. We critically appraise this framework in the context of a population-based HIV pre-exposure prophylaxis study in Eswatini. Our findings highlight that men confidently show variation in their behavior and choices, which manifest across different men and within the same men acting in particular situations and over the life course. This led us to interrogate the hegemonic masculinities framework on the following grounds: Men’s choices and behavior do not seem to fit the model of aspiring to a hegemonic ideal; the delineation of masculine traits as hegemonic or subordinate remain vague in terms of “responsibility,” “fidelity,” and “consideration for others”; the binary gender concept underpinning hegemonic masculinities seems outdated. Building on the work of Hirsch and Kachtan, we propose cultural repertoires as an alternative framework which also bridges the gender divide.
Introduction
Pre-exposure prophylaxis (PrEP), as a prime tool for acting on sexual opportunities without increasing one’s own risk of an HIV infection, and the setting of Eswatini, a country where polygamy is practiced by the King and where gender equality is only slowly establishing itself, could be a potent combination for men to act on hegemonic masculinity ideals. Our findings suggest that the ideals men embrace are diverse and do not easily fit into a hegemonic hierarchy, nor is it clear how the pinnacle of this hierarchy should be defined. Our study queries the usefulness of the concept of hegemonic masculinities for understanding men’s aspirations and behavior, and proposes to use a cultural repertoire model as an alternative framework for studying men’s behavior and men’s aspirations.
Since the 1980s, the study of men and masculinities has been chiefly influenced by Connell (Connell, 1998, 2005; Connell & Messerschmidt, 2005; Kessler et al., 1985; Nascimento & Connell, 2017). In particular, Connell’s concept of a hierarchy of masculinities, with “hegemonic masculinities” at its pinnacle (Connell & Messerschmidt, 2005), has been applied widely to study the behavior of men in various academic disciplines such as educational studies (Martino, 1995; Skelton, 1993), social studies (Beasley, 2008; Hirsch & Kachtan, 2018; Kimmel, 1990), and public health, where the concept of hegemonic masculinities is often employed to examine and understand the risk-taking or the (non)-health-seeking behavior of men (Courtenay, 2000; Fleming et al., 2019; Seymour-Smith et al., 2002; Wehner et al., 2015). For example, HIV-infected men typically link to the health care system in the advanced stages of infection (Drain et al., 2013) as many perceive health care-seeking behavior as less “manly” (Adams & Zamberia, 2017; Siu et al., 2013). The charm of hegemonic masculinities across disciplines lies and lay in trying to understand male behavior in relation to the notion of “real men” and the perpetuation of male dominance through social practice (Ganle, 2016). “Effectively, it becomes the way that men or at least the vast majority of men with all their differences align to a normative and authoritative masculinity as re-presented in and through a cultural situation” (Howson, 2014, p. 24). Linking the perpetuation of hegemonic masculinities to patriarchy, with men dominating not only over women but also over other men who personify “subordinate masculinities” and “marginalized masculinities” (Connell, 2005), seemed to ring true in many societies. Connell understood “subordinate masculinities” in her context as real or perceived “homosexual masculinities” (Connell, 2005, pp. 78, 79), and defined “marginalized masculinities” in terms of class and race (Connell, 2005, p. 80).
In this article, we critically appraise the framework of hegemonic masculinities as an overarching explanation for men’s decisions, behaviors, and social relations in the context of PrEP, that is, HIV-negative persons taking antiretroviral drugs to prevent an HIV infection (World Health Organization, 2016, p. xiv). Specifically, our approach suggests the need for a shift in our understanding of hegemonic masculinities and health. Elias and Dunning argued that dominant theories change when they increasingly fail to provide the framework for solutions (Elias and Dunning, 1993 cited in Even-Zohar, 1997). In our view, there are several emerging anomalies that limit the utility of hegemonic masculinities as an explanatory model: Men’s behavior and choices, as we intend to show, seem to be situation-specific, can change during the life course, and depend on more factors than simply aspiring to and acting on hegemonic ideals. In addition, we see an overall problem with describing what exactly these “hegemonic ideals” are meant to be. What notions of masculinity would constitute these ideals and who defines them? If the concept of hegemonic masculinities is so broad that it includes male idealized behavior from notions of dominance and control to taking responsibility and showing consideration for others, then the theoretical framework is led “ad absurdum.” If only notions of “dominance” and “control” are regarded as “hegemonic,” then the framework fails to explain how men can draw on notions of “control,” “responsibility,” and “consideration for others” without clearly aligning themselves to “hegemonic” or “subordinate” masculinities. Based on the findings of a general population study of PrEP service delivery in the North-West region of Eswatini, we build on Hirsch and Kachtan’s application of the concept of “cultural repertoires” (Even-Zohar, 1997; Hirsch & Kachtan, 2018; Swidler, 1986) to the study of masculinities (Hirsch & Kachtan, 2018, p. 703) and propose a shift from hegemonic masculinities to cultural repertoires. Cultural repertoires can be perceived as a pool of possible responses from which men and women can draw “strategies of action” (Swidler, 1986, p. 273), see Figure 1.
Cultural Repertoire
After a short introduction to “gender and hegemonic masculinities” and “HIV and PrEP in relation to men who have sex with women (MSW),” 1 we present the methods and main findings in relation to MSW’s PrEP choices in Eswatini. We then explore MSW’s choices and behavior in relation to dominant masculinities using case studies to support and discuss the concepts of “cultural repertoires” and “situated selections.”
Gender and Hegemonic Masculinities
Gender, unlike sex, is a social construct and refers to “the cultural and social classification of masculine and feminine” (Nanda & Warms, 2007, p. 260). Masculinity and femininity are therefore not static; rather they are molded through relationships by both women and men. Masculinity (and femininity) can be defined as “a place in gender relations, the practices through which men and women engage that place in gender, and the effects of these practices in bodily experience, personality and culture” (Connell, 2005, p. 71).
Drawing on Gramsci, who understood “cultural hegemony” not only in terms of force but also of consensus and internalized power relations (Bates, 1975), Connell defined the term “hegemonic masculinity” (HM) in the 1980s (Connell & Messerschmidt, 2005) as “the configuration of gender practice which embodies the currently accepted answer to the problem of the legitimacy of patriarchy, which guarantees (or is taken to guarantee) the dominant position of men and the subordination of women” (Connell, 2005, p. 77), see also (Berner-Rodoreda et al., 2021). HM, for Connell, becomes “the most honored way of being a man” (Connell & Messerschmidt, 2005, p. 832), see also (Berner-Rodoreda et al., 2021). HM allowed for variation in masculinities, focused on relationality, and a context-specific hierarchy of masculinities (Hirsch & Kachtan, 2018).
The concept has, however, been criticized for its “dualism between hegemonic and non-hegemonic masculinities” (Demetriou, 2001, p. 355), for vilifying men, and attributing hegemonic masculinity features only to men when they could also be used for women (Collier, 1998, p. 20). It was further seen as unspecific in denoting “cultural norms and ideals, powerful men and patriarchal authority or both” (Flood, 2002, p. 204). Connell and Messerschmidt acknowledged that their initial concept was too simple a model for explaining the dominance of heterosexual men over women or homosexual men (Connell & Messerschmidt, 2005, pp. 846, 847) and reacted to the critique by arguing that “masculinities are configurations of practice that are accomplished in social action and, therefore, can differ according to the gender relations in a particular social setting” (2005, p. 836). This allowed for variance across different settings, yet it did not address the issue of “a fixed understanding of hegemonic masculinity” (Morrell et al., 2012, p. 25) expressed in one particular society. The association of dominant masculinities with social power was seen as problematic (Beasley, 2008), and the concept of hegemonic masculinity was felt to be unsuitable for understanding the diverse and often contradictory lived experiences of men (Moller, 2007). Perhaps the most fundamental criticism of the concept was that it was “treated as a self-evident principle that requires no proof of its existence” (Howson, 2014, p. 20).
Taking the concept and its criticisms into account, we will explore the choices men make in connection with PrEP in Eswatini and assess to what extent the concept of hegemonic masculinities as ideals that MSW strive toward is helpful in understanding MSW’s response to PrEP. PrEP can be seen as a tool that could enable MSW to live the ideals of sexual freedom and virility without endangering their own health. We would like to point out that it is the model of HM we are concerned about as a model for understanding masculinities in relation to PrEP in Eswatini. We clearly do not dispute that women struggle to be granted the same rights and freedom as men in Eswatini (see study setting and discussion).
HIV and PrEP in Relation to MSW
Historically, HIV policies and interventions hardly mentioned MSW (Higgins et al., 2010; Mills et al., 2012). While MSW’s role in preventing HIV in women was highlighted (Amaro, 1995), MSW’s own susceptibility to HIV remained largely unacknowledged (Dworkin, 2015), see also (Berner-Rodoreda et al., 2020, 2021). MSW were “relegated to the margins of a health care and service field that was developed historically within a context which privileges the priorities of gay men and heterosexual women” (Antoniou et al., 2012, p. 8), thus positioning MSW at the bottom of a gender hierarchy with regard to accessing health services. Not until the second decade of the 2000s did MSW become acknowledged as an important target group in the context of HIV (Higgins et al., 2010; Sileo et al., 2018, 2019; UNAIDS, 2017; Wyrod, 2011). MSW lagged behind women in making use of HIV prevention and treatment services (Baker et al., 2014; Cornell et al., 2015, 2011; Huerga et al., 2016; Novitsky et al., 2015; Varga, 2001), which manifested itself in a male gender gap in accessing health services (Addis & Mahalik, 2003; Courtenay, 2000; Galdas et al., 2005; Mahalik et al., 2007; Seymour-Smith et al., 2002).
Risky sexual behaviors, that is, multiple and concurrent sexual partners, a reluctance to use condoms, and alcohol consumption, are viewed as being based on masculine norms that expose men and their sexual partners to the risk of an HIV infection (Bowleg et al., 2011; Fleming, DiClemente, et al., 2016; Nyanzi et al., 2009; Pulerwitz et al., 2010; Sileo et al., 2019). The second Swaziland HIV Incidence Survey conducted in 2016 and 2017 indicated that more than 50% of married men have extra-marital relationships, and more than 70% use condoms for their extramarital partners (Ministry of Health, 2019). A study comparing data from 37 sub-Saharan African countries over the period 1995-2020 on the use of contraceptives among women aged 15 to 49 found contraception to be generally low (22%) with a clear preference for injectables (39%), followed by implants (26.5%), and condoms (17.5%) as the least popular contraception method (Boadu 2022). A need for intimacy, negative perceptions of condoms, heightened sexual pleasure, and demonstration of masculine power were reasons for young people’s reluctance to use condoms in a South African study (Duby et al., 2021).
In 2012, daily PrEP—the taking of antiretrovirals to prevent an HIV infection—was added as an HIV prevention method. It is now recommended for all people at a heightened risk of HIV infection (World Health Organization, 2016). MSW’s PrEP experiences are a new and under-researched area of interest (Koechlin et al., 2017), as PrEP is only gradually being offered to the general population in high-prevalence countries. Even studies with adolescent or adult MSW published in the 2020s mainly portray MSW’s views rather than their actual experience of PrEP (Hannaford et al., 2020; Muhumuza et al., 2021; Yoshioka et al., 2020), see also (Berner-Rodoreda et al., 2020). Qualitative PrEP studies that included MSW primarily focused on serodiscordance as part of PrEP trials (Carroll et al., 2016; Nakku-Joloba et al., 2019; Patel et al., 2016; Toledo et al., 2015; Ware et al., 2012), see also (Berner-Rodoreda et al., 2020). Real-life PrEP experience of MSW outside of clinical studies has been showcased in Zimbabwe (Gombe et al., 2020) and Eswatini (Berner-Rodoreda et al., 2020) noting barriers, facilitators, and experiences of MSW in the uptake and retention of PrEP with Eswatini being one of the first countries to demonstrate PrEP use in the general population (Bärnighausen et al., 2020, Geldsetzer et al., 2020).
Method
Study Setting and Design
This study took place in Eswatini (formerly Swaziland), a Southern African country with a population of about 1.15 million (United Nations, 2019, p. 24). With 27% of the adult population being HIV-positive in Eswatini, the country notes the highest HIV prevalence in the world (UNAIDS, 2019). HIV prevalence for men in Eswatini is approximately 20.4% (NERCHA, 2017). The highest HIV incidence in men qualifying for the use of PrEP is in the age group of 30 to 34 years (Justman et al., 2017, p. 18). The vast majority of the population lives in rural areas and 70% practice small-scale farming (World Bank, 2011). Polygamy plays an important role in Swazi culture (Tobias, 2001) and is practiced by the Head of State, King Mswati III (Criado, 2013). Women were regarded as legal minors for decades (Zigira, 2000) until the Eswatini constitution guaranteed equal rights to both genders (Government of Eswatini, 2005). Men in Eswatini have thus held authority over women for many centuries (Tobias, 2001; Zigira, 2000). Eswatini High Court rulings between 2010 and 2019 have granted married women the right to property and repealed some discriminatory legislation such as the common law doctrine of marital power (Mavundla et al., 2020), but it will take time for gender equality to permeate society.
Ethical Considerations
The study was approved by the Eswatini Ministry of Health National Health Research Review Board (MH/599C/IRB0009688/NHRRB538/17) as well as the U.S. Chesapeake Institutional Review Board (Pro00021864) with an exemption granted by the Heidelberg Ethics Commission (Berner-Rodoreda et al., 2020). After being informed orally and in writing about the study, interview and focus-group participants provided voluntary written consent (Berner-Rodoreda et al., 2020). To protect the respondents’ identity, all interviews were pseudonymized.
The PrEP Intervention
The Government of Eswatini conducted a clinic-based PrEP Demonstration Project for the entire population at risk of an HIV infection in selected primary health care facilities in the Northwest of the country between August 2017 and January 2019 (Geldsetzer et al., 2020). Our qualitative study based on principles of applied qualitative research (Creswell, 2013; Pelto & Pelto, 1997) was nested within this Demonstration Project and aimed to understand PrEP views and experiences by clients, health care workers, stakeholders, community leaders, and the community to better tailor PrEP delivery to MSW (Berner-Rodoreda et al., 2020). In this article, we focus on masculinity expressions by male PrEP clients and male community members.
Data Collection and Analysis
Participants were purposively selected (Patton, 1990) to take part in semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) as has already been published in more detail (Berner-Rodoreda et al., 2020; Geldsetzer et al., 2020). Interviews with men who were offered PrEP and four FGDs with male participation were conducted between September 2017 and July 2018 and included 34 interviews with men (aged 20–65) who were informed about and offered PrEP at the clinics and accepted (n = 8; 24%), declined (n = 5; 15%), continued (n = 14; 41%), discontinued (n = 5; 15%), deferred (n = 1; 3%), or restarted PrEP (n = 1; 3%). All percentages should be understood in the context of the qualitative sample. In all, 28 MSW (82%) were between 20 and 44 years of age. In terms of education, five MSW (15%) had received no schooling, seven MSW (21%) had been to primary school, 12 MSW (35%) were educated up to high-school level, seven MSW (21%) completed tertiary education, and three MSW (9%) did not provide any educational information. Occupations ranged from being unemployed, doing manual work, to being an IT specialist or teacher. Information on relationship status could include various nonexclusive categories such as being married and having multiple partners. In all, 25 (74%) male interviewees self-declared to have a partner or to be married, three mentioned being single (9%), eight (24%) talked about having multiple partners with only one describing himself as polygamous (3%), and one MSW provided no information on his relationship status (3%). 12 MSW (35%) shared that they presently lived in a serodiscordant relationship (n = 9; 26%) or had a previous HIV-positive partner (n = 3; 9%). One man with a former HIV-positive partner declined PrEP. This left 11 MSW (32%) with present or past HIV-positive partners who had direct experience of PrEP.
Research assistants recorded field notes that were used to undertake group debriefings throughout data collection (McMahon & Winch, 2018). Debriefings allowed the team to triangulate findings, identify opportunities for probing, and recognize emerging themes. All interviews were audio-recorded, transcribed, and simultaneously translated into English. We used Nvivo 12 Pro for coding transcripts and drew on Grounded Theory by assigning codes largely inductively but also deductively based on sections of the interview guide (Charmaz, 2017; Creswell & Creswell, 2018). As some interviews provided more comprehensive data, we employed case studies to provide a greater contextual understanding (Simons, 2014, p. 469) and a “nuanced view of reality, including the view that human behavior cannot be meaningfully understood as simply the rule-governed acts found. . . in much theory” (Flyvbjerg, 2006, p. 223). Conversely, we are using case studies to build theory (Merriam, 1985, p. 206).
Results
MSW’s PrEP Choices
MSW’s personal considerations for uptake or decline of PrEP could be contradictory and were linked to the concepts of virility, autonomy, consideration for others, taking responsibility, experiencing freedom and constraints, acting on fidelity or mistrust, and a desire to effectively guard against an HIV infection. MSW in a serodiscordant relationship or with a former serodiscordant partner wanted to protect themselves from seroconverting (Berner-Rodoreda et al., 2020). PrEP aspirations and concerns included the ease of sexual relations, increased libido, and a greater number of sexual partners as well as a possible negative effect on fertility and sexual performance—these hopes and fears speak to notions commonly and historically associated with masculine ideals, such as virility (Liliequist, 2007; Pleck et al., 1993). MSW’s inconvenience of daily pill-taking and frequent visits to the health center can be seen as relating to the masculine ideals of being independent, strong and healthy, and not needing medical help (Courtenay, 2000). Taking up PrEP to ensure that the partner and (future) children are protected from HIV or declining PrEP for fear of it being interpreted as a sign of cheating on the partner, are actions linked to considering the views, feelings, and safety of a partner or family. These considerations speak to the notion of taking responsibility for one’s own life and the lives of others, yet the extent to which these notions should be seen as “hegemonic” or “alternative” masculine ideals is not clear.
Table 1 demonstrates this spectrum of men’s perceptions, attitudes, and experiences of PrEP. In the uptake, decline, continuation, and discontinuation of PrEP, MSW acted on notions of what is commonly regarded as hegemonic masculine ideals such as control over women, virility, autonomy, and freedom, taking independent decisions for or against PrEP. MSW further acted on notions of support, loyalty, fidelity, considerations for the partner or family, and responsibility toward the family, that is, notions, which may or may not be regarded as belonging to masculine hegemonic ideals. Being in a long-term or married relationship was a motive for embracing fidelity as an ideal for some, a motive for additional partners for others. MSW mainly talked about the same number of sexual partners as before taking PrEP (Berner-Rodoreda et al., 2020). The picture for condom use was less clear indicating two almost equally strong tendencies to maintain present condom use because PrEP was not a contraceptive or because of not fully trusting PrEP and to reduce condoms as they were felt to be superfluous as an additional prevention method. Further reasons for reducing condom use were trying for a child or the partner’s dislike of condoms.
Gender and Masculinity Issues.
Note. Dark gray background: expressions which seem to be in line with hegemonic masculinity ideals. Light gray background: rendering the perspective of the female partner in relation to hegemonic masculinities. Light background: showing male responsibility and consideration for oneself and others which are difficult to place in a hierarchy of hegemonic masculinities. MSW = men who engage in sex with women; PrEP = Pre-exposure prophylaxis; yrs = years.
The gender context, as seen in Table 1, was described as male-dominated, yet the example given of a young MSW whose partner appreciated him taking PrEP as she distrusted him (Table 1) exemplified that the female partner was not passive and powerless but voiced her opinion and demand for having safe sexual relations. The danger of stereotyping men and women is further exemplified in the story of a young man in a focus group discussion who recounted that his girlfriend refused to test for HIV with him for two years and when they finally did, her result was HIV-positive. “She admitted that she had been cheating almost for the entire relationship because she has been thinking that since I am a kombi driver I have multiple sexual partners. But that was not true, she was just making assumptions” (MSW in FGD, 21 yrs).
Not only does this quote show that seeing MSW’s behavior as prescriptive may lead to gender misrepresentations, but it also raises the question of whether an MSW would share in a group situation that he was faithful to a girlfriend who cheated on him if he aspired to portray himself as incorporating the masculine ideal of being virile and in control. We will explore MSW’s behavior further through their life accounts.
Case Studies
The four case studies add context-specific rich accounts to the thematic analysis of IDIs and FGDs of men’s conflicting masculinity choices in the context of PrEP. MSW’s perceptions and behavior were prone to change through a different perspective or life experience as the following cases demonstrate. To protect the identity of the MSW interviewed, we use the pseudonyms Sambulo, Ati, Thandwa, and Sibusiso.
Case Study 1—From Hegemonic Control to Considerations for the Partner
Sambulo, 41 years old, married with three children, living together with his family and having multiple partners, found a PrEP consent form and pills in the bedroom. He asked a befriended woman about the pills. She informed him about PrEP and her own usage of these pills. Sambulo decided to confront his wife about the pills. He was very angry with her and assumed that she was taking PrEP to engage in extra-marital affairs. The wife tried to explain that she only wanted to protect herself, as she did not know what the husband was up to when he was not with her and that she was not having relationships on the side. Sambulo was so angry that he barely listened and told her that if he ever saw these pills again, she would be in trouble. He was close to ending the relationship. “I asked myself who is the man here, if there are things I know nothing about?” He further discovered that his wife had taken out a funeral policy without his knowledge, which made matters worse. Listening to a radio program about PrEP, he rang in to talk to health specialists and learned that the pills were for all people who are HIV-negative. He went back to his wife to ask her why she had not explained PrEP to him. She said, she had been afraid. Since this fight, Sambulo noticed that his wife took the pills out of the container and put them in a plastic bag. Sambulo and his wife went to the local pastor, as Sambulo intended to divorce her. The pastor told him that it was not right for the wife not to inform him about PrEP but that he should calm down.
Sambulo then assembled the family and told the children that their mother is taking PrEP because they are not using condoms as a married couple and want to prevent an HIV infection. Sambulo thought that his son, who had recently become sexually active, might benefit from the information. He concluded that “ it is very dangerous not to disclose pills to your partner because some people may kill each other because, if I come with such pills and hide them from my wife or husband, let’s say the wife because I am carrying the pills, so it hurt the other partner who is in the dark.”
Sambulo explained that he cannot use condoms, which has restricted him in having relationships on the side. As his wife does not always want to be touched, he would like to have sexual relations with other women and feels that PrEP will give him this liberty without having to use a condom. He thinks that his wife will be happy that he is taking PrEP. She may not be happy about him having other sexual partners but since she is taking PrEP, she will also be protected.
Case Study 2—Changes in Masculine Behavior Over the Life Course
Ati had been on PrEP for 9 months and experienced some weight gain. He had a strict upbringing with a God-fearing mother. Ati had no sexual partners until university when he started to engage in sexual relations. He is not sure how he managed to stay HIV-negative and recounts one day at university when he had a competition with his friends, and they decided to have sex with all their girlfriends within 24 hours. Ati had sex with six different girlfriends. Toward the end of his time at university, he decided to get circumcised. He employs various prevention methods to avoid having to use a condom and talks about his prevention methods with his friends. He thinks one friend has taken up PrEP as well.
He has had many girlfriends and is now living together with an HIV-positive partner. Ati likes the fact that they can talk about PrEP. His partner first thought he took PrEP to have many girlfriends but now feels okay with him on PrEP. He says she is a good mother to his son and her own child. They take their pills together—she her antiretrovirals and he the PrEP pills. He mentions the joint responsibility of looking after each other and the children and making sure that everyone is safe. The burden of protecting him against a seroconversion is shared between the partner and himself.
Case Study 3—Who has the Say in the Relationship?
Thandwa, 21 years old, has a partner but is not living with her. He informed his mother about taking PrEP but not his girlfriend. He usually takes the pills at lunchtime but would sometimes forget due to being busy at work. His boss never wanted the workers to have a break, so he eventually told his boss that he had to take the PrEP pills at noon; his boss not only agreed, but also allowed him time off work for his PrEP appointments.
Thandwa’s main reason for taking PrEP lies in mistrusting his girlfriend. He has told her about his HIV status but has not asked for hers. “I just decided not to ask her because that lady is problematic.” If he discovered that she took PrEP, he would be relieved but also feel hurt. He has not told her that he is taking PrEP and thinks if she found out, it may mark the end of the relationship. The main reason for not informing her is that she would tell her family, and he would find this difficult. His brother told him to stop taking the pills as he is not sick, but Thandwa replied that he needed these pills. PrEP did not affect condom use with the girlfriend, nor the number of his sexual partners. He practiced the same sexual behavior as before, using condoms occasionally with his girlfriend.Work was the reason for Thandwa to stop taking PrEP. He did not experience side effects, but he sometimes forgot to take the pills and found he was still HIV-negative and therefore did not see the need to continue with PrEP. The extent to which his brother influenced his decision remains unclear. When asked how he would feel, if his girlfriend took PrEP and then stopped, he said, “I’d tell her, ‘I didn’t tell you to stop.’”
Case Study 4: Fidelity as a Masculine Life-Style
65-year-old Sibusiso married twice and presently lives in a serodiscordant relationship; he was interested in taking up PrEP as he could not and would not use a condom. He explained that he was already married when HIV became a challenge and that he had been faithful to his wife and therefore saw no need to use condoms. “I was never that kind of a person who has many partners or has sex with many women (…) I was only having sex with my wife up until she died.” He lost friends at the time and thinks it was because they were sleeping around and because there were not so many prevention methods available at the time.
After his first wife had passed away and prior to taking PrEP, he remarried. His new wife told him that she was HIV-positive and on antiretroviral therapy (ART). He had no problems with that. When she was pregnant, he accompanied her and was tested at the clinic and told about PrEP which he embraced as a viable alternative to condoms. He and his wife remind each other about their respective pills and take them together at the same time. He sent his wife to the clinic to get the PrEP pills for him when he ran out of them as he had work commitments that barred him from visiting the clinic. Due to clinic protocols, she was not allowed to collect the pills for him.
He informs his work colleagues that he is taking PrEP and emphasizes that it is not because he is sleeping around but because his wife is on ART. He also motivates work colleagues to take up PrEP, and he reminds those that followed his advice to take the pills daily.
The Case Studies and Hegemonic Masculinities
All four examples show that the same man can display and utilize expressions of masculinity that are commonly regarded as hegemonic as well as other masculinity expressions which the MSW did not seem to regard as subordinate, such as showing consideration for or being faithful to the partner.
For Sambulo, a fulfilled sexual life meant having sex when he felt like it and included sexual relations outside of marriage—masculine behavior, which could clearly be seen as hegemonic. Yet Sambulo ended up recognizing the same rights for his wife that he maintained for himself, that is, staying safe through PrEP. While initially exerting control at the household level, he came to support his wife and displayed attitudes of greater gender equality in terms of informing one another of PrEP so that nobody gets “hurt.” He extended the information to his children out of a concern for their protection against HIV. The pastor’s advice seems to have triggered reflection on this issue in Sambulo, who subsequently displayed a more caring and egalitarian attitude toward his wife.
Ati’s story showed that some change can occur over a life course (from abstinence to many concurrent partners to living in a serodiscordant relationship with shared responsibilities). However, a concern for the partner and taking responsibility for the children was not tantamount to living monogamously, that is, Ati acted on notions of responsibility as well as freedom not only over his life course but also concurrently. By taking the PrEP pills to protect himself, he alleviated his partner of the burden and responsibility of protecting him through her conscientious taking of antiretroviral drugs.
Thandwa’s experience demonstrates that talking about one’s vulnerability and hospital appointments as a man may not have any negative consequences in the workplace. He appears not to exert any power or dominance in the relationship with his girlfriend; in fact, he seems the one who accommodates her wishes and preferences rather than vice versa. While not speaking about PrEP to his partner could be seen as being in control, his fear that she may abandon him could be regarded as expressing a subordinate masculinity ideal. Yet, Thandwa still upholds notions of control over his girlfriend, as he envisages scolding her if she were to take up PrEP and unilaterally decided to stop taking the pills.
While both Sambulo and Sibusiso mention difficulties in condom usage, for Sambulo, PrEP opens up possibilities for additional sexual relations and for Sibusiso, PrEP means better protection in a serodiscordant monogamous relationship. Sibusiso portrays his sexual life as one of fidelity to his wife; he never acted on the Swazi ideal of polygamy, or felt a need to demonstrate his own manliness in terms of additional sexual relationships which he viewed as the primary cause of an HIV infection and premature death for MSW. He has no problems talking about his fidelity with work colleagues and at the same time encouraging them to take PrEP to stay safe. Sibusiso’s case further shows that men can appear to act on hegemonic ideals (telling his wife to collect the pills for him) when these ideals align with other reasons, such as work commitments hindering him from visiting the clinic.
Discussion
PrEP and Hegemonic Masculinities
Many studies on men and health use the concept of hegemonic masculinities with the intention of improving the health-seeking behavior of men. This is done through various means: stressing men’s “agency, autonomy and self-reliance” (Sloan et al., 2010, p. 799), depicting alternative masculinities, or challenging dominant masculinities (Bowleg, 2004; MacPhail, 2003), showing that masculinities are in flux with new and old concepts being held by men (Wehner et al., 2015) or intending to improve the understanding of health personnel of men’s needs (Siqueira et al., 2014). Applied to HIV, the concept of hegemonic masculinities has been drawn upon to understand male risk-taking behavior with a view to reducing it (Bowleg, 2004; Brown et al., 2005, 2011; Ganle, 2016; Morrell et al., 2012; Nyanzi et al., 2009; Simpson, 2007). Our own approach was based on this understanding, yet the heterogeneity in men’s responses to PrEP led to doubts about men aspiring to hegemonic masculine ideals.
By presenting data from IDIs, FGDs, and case studies, we have shown that men make choices about their behavior, and these choices may change over time depending on many factors such as their upbringing, age, their relationships (serodiscordant or seroconcordant, monogamous or having multiple partners), peers and reference groups, normative expectations toward men, their own norms and beliefs, and their own understanding and knowledge of PrEP. Which type of masculinity is employed seems to be situation-specific and less based on a general aspiration to a hegemonic ideal or a need to convince other men that one’s own male behavior is in line with a hegemonic ideal.
While acknowledging that the term “masculinity” may mean different things to different people (Clatterbaugh, 1998), we concur with other authors that some behavior by men and boys puts them at greater risk of endangering their health (Courtenay, 2000; Fleming, Colvin, et al., 2016; Harrison, 2010; Mahalik et al., 2007). Within-case analysis and cross-case comparison (George & Bennett, 2005) has shown, however, that men do not always aspire to hegemonic masculinity ideals, nor do they embrace subordinate or alternative ideals; rather, they act in a particular situation, taking consciously or subconsciously into account the aforementioned factors.
Wyrod presented the areas of work, authority, and sexuality as “shaped and mediated by the practice of masculinity” (Wyrod, 2016, p. 28). We found that MSW showed a tendency to establish their authority over their partner in terms of telling her what to do, yet MSW by and large informed their partner about their own PrEP use, something they would not be obliged to do especially with non-cohabiting partners who may not notice the pills. Despite PrEP offering to MSW the possibility of living up to the hegemonic ideals of virility and autonomy by increasing the number of sexual partners while remaining protected against HIV, MSW mainly reported maintaining their sexual partners (Berner-Rodoreda et al., 2020). Figure 2 illustrates men’s behavior vis-à-vis hegemonic masculine ideals in relation to work, relationships, and sexual behavior.
Behavior in Relation to Hegemonic Masculine Ideals
As Table 1 and Figure 2 show, some MSW’s behavioral choices in relation to PrEP can be interpreted to embody hegemonic masculine ideals such as drawing on notions of greater sexual freedom and the concept of male autonomy by increasing the number of sexual partners or decreasing condom use as one feels protected through PrEP and telling the wife or partner what to do or not to do. Yet not using a condom because the partner does not like it, being told by a girlfriend that she never trusted one’s fidelity, marrying an HIV-positive partner, and informing a partner about PrEP use when one could maintain secrecy showed that men also acted on notions that express more egalitarian gender relationships that are difficult to place in a hierarchy of hegemonic ideals.
We concur with Moller who concluded in the context of a study on rugby players in Sydney that these spheres of lived experience are highly diverse but . . . the concepts of hegemonic and hierarchical masculinities do little to help researchers understand that diversity and complexity. Indeed, I think they reduce our capacity to understand the ways in which the performance of masculinity may be productive of new socio-cultural practices, meanings, alliances and feelings. (Moller, 2007, p. 275)
Who Defines Hegemonic Masculinities?
Our study showed that MSW act on notions of protection, responsibility, virility, risk, autonomy, and consideration for others yet who defines what hegemonic masculine ideals should consist of? Based on the Eswatini country context where polygamy is endorsed by the King, one could assume that this is the hegemonic masculine ideal—why then would men confidently and openly share with other men that they are faithful to their one partner?
Siu and colleagues argue that men in a Ugandan gold mining community draw and act on “dividual” notions of “reputation” (depicted as a hindrance for accessing treatment) and “respectability” (depicted as a catalyst for accessing treatment) depending on the circumstances in which they find themselves (Siu et al., 2013). Mitchell and colleagues portray HIV-negative men in serodiscordant relationships in Papua New Guinea settings as “embodying caring masculine identities” (Mitchell et al., 2021, p. 15). Our Eswatini PrEP study echoes male responses that show a variety of male behavior speaking to differing ideals in the area of work, relationships and sexuality as Figure 2 shows.
Connell’s assertion that “the concept of hegemonic masculinity presumes the subordination of nonhegemonic masculinities” (Connell, 2005: 846) was not borne out in our findings. MSW in our study who were faithful to their wives or partner or who cared about their family, were not embodying subordinate masculinities; in fact, they openly critiqued the ideal of having multiple partners as the man in an FGD showed or as the case of Sibusiso highlighted who told colleagues about being faithful to his wife. How should this be interpreted in a hegemonic hierarchy? If men like Sibusiso do not ascribe to subordinate masculinity ideals, should faithfulness to one partner and multiple sexual relationships and polygamy be seen as alternative hegemonic ideals? Connell argues that Most accounts of hegemonic masculinity do include such “positive” actions as bringing home a wage, sustaining a sexual relationship, and being a father. Indeed, it is difficult to see how the concept of hegemony would be relevant if the only characteristics of the dominant group were violence, aggression, and self-centeredness. Such characteristics may mean domination but hardly would constitute hegemony—an idea that embeds certain notions of consent and participation by the subaltern groups. (Connell 2005, p. 841)
While Connell acknowledges that “hegemonic masculinity” and “marginalized masculinities” are not fixed character types but configuration of practice generated in particular situations in a changing structure of relationships” (Connell, 2005, p. 81), the hierarchical nature of hegemonic masculinities warrants the question of who defines hegemonic masculinity and what it entails. It is difficult to perceive the usefulness of a framework that incorporates contradictory ideals and values at the same hierarchical level. If the ideal of hegemonic masculinity is so broadly defined that it encompasses male behavior from sexual freedom to monogamy, from self-centered behavior to responsibility, and a consideration for others, then its boundaries become unclear. In addition, a gendered hierarchy based on a masculine ideal of men being in charge in relationships and women as powerless perpetuates gender stereotypes, and it emphasizes outdated binary gender norms of men as strong and active and women as weak and passive. Psychological studies have long revealed that gender similarities outweigh gender differences with little evidence of distinctive gender traits, and pointed out the dire consequences for gender stereotyping in men and women (Hyde, 2005; Hyde et al., 2019).
A key concept in Connell’s hegemonic masculinities is sociopolitical power as the entire concept is based on patriarchy. In Eswatini, married women have for decades been disadvantaged legally (Zigira, 2000). While the 2005 Eswatini Constitution granted equality before the law, only the repeal of certain laws, such as the High Court of Eswatini ruling in 2019 that common law marital power is unconstitutional, granted married women the right to hold property (Mavundla et al., 2020). This will in all likelihood not immediately lead to gender equality but it will strengthen the position of women. While we regard these legal developments as long overdue, our perspective here was not that of women on men’s power and authority but of studying MSW in relation to a new HIV prevention tool (PrEP), a tool that could provide the opportunity to act on male hegemonic ideals of autonomy, freedom, and virility. We therefore base our critique of Connell’s model on our findings on MSW’s social experience of PrEP: we see MSW’s behavioral choices align with a cultural repertoire model which, while not as compelling in terms of power relationships, is more adaptable and flexible and can be used for men and women thereby cutting through the gender binary inherent in the hegemonic masculinity concept. Men and women of differing gender orientations draw on notions, norms, concepts, and strategies of action in a particular situation. This is not to diminish the fact that societal expectations are factored into men’s (and women’s) decisions on how to behave and act but the model of a cultural repertoire accounts for the variations, we found in the Eswatini study whereas the aspiration to a hegemonic ideal does not.
Beasley, Hirsch, and Kachtan critiqued Connell’s concept of hegemonic masculinities for its blurriness and, building on Flood (2002), for presenting it as a norm as well as an expression of social practice (Beasley, 2008; Hirsch & Kachtan, 2018) and recommend to use “cultural repertoire” as a more suitable concept, as it allows for “situated selections” from “both gender normativity and the heterogeneity of social practice” (Hirsch & Kachtan, 2018, p. 701).
Cultural Repertoire and the Concepts of Situational and Situated Selection
Swidler sees “culture” as offering “the materials from which individuals and groups construct strategies of action. Such cultural resources are diverse, however, and normally groups and individuals call upon these resources selectively, bringing to bear different styles and habits of action in different situations.” (Swidler, 1986, p. 280)
The repertoire can be seen as a “‘tool-kit’ of habits, skills and styles from which people construct ‘strategies of action’” (Swidler, 1986, p. 273).
We find the concept of a cultural repertoire or “tool-kit”—to use Swidler’s terminology—more suitable for understanding masculinities: “It allows to consider masculinity both as a normalizing cultural ideal (or set of ideals) and as a relational and contextual social practice, without reducing it to either” (Hirsch & Kachtan, 2018, p. 689). Hirsch and Kachtan argue that “cultural repertoires” can include contradictions and encompass notions of “physical strength” and “autonomy” as well as “discipline” and “self-control” (Hirsch & Kachtan, 2018, p. 702). The more neutral term “cultural repertoire” can also be seen as overcoming the binary of male and female attributes; a binary challenged by feminist scholars such as Haraway decades ago (Haraway, 1990).
The term “situated selection,” which Hirsch and Kachtan employ, has been used by scholars in the field of organizational studies to describe a “situated decision-making theory of organizational choice, which integrates hierarchy, aspirations and cooperation amid conflicting interests” (Joseph et al., 2016). In social anthropology, “situational selection” has been used for many decades in referring to the selection of expressions of identity among certain population groups or indigenous populations (de la Peña, 2011; Nagata, 1974) who may choose to oscillate between various cultural norms or reference groups employing one identity in one situation and another elsewhere.
The cultural repertoire acts like a pool for the strategies of action, see Figure 1. Selections would be based on particular situations, on own ideals and convictions, perceived gender expectations and stigma considerations. MSW’s own and their partner’s HIV status, their own age, and their stage in the life course would be factored into MSW’s decisions on how to behave and act. Strategies of action could thus vary over time and with regard to the same partner as Sambulo’s story exemplified: He first opposed his wife’s use of PrEP and wanted to divorce her as he viewed her behavior as a threat to his masculinity, then saw the benefits of both of them taking PrEP as this opened new possibilities for him to engage in a sexual relationship outside marriage. The cultural repertoire accounts for change and transformation within the same relationships and across different relationships, e.g., speaking about one’s use of PrEP with one partner but not with another. Situation-specific strategies of action account for changes in behavior in a way that a framework rooted in a patriarchal system cannot. The cultural repertoire further allows for new “tools” to be added and new strategies of action to be used while others may be discarded.
MSW in Eswatini on PrEP made choices about their sexual behavior and social interactions practicing situated and situational selections. The actions sometimes looked to be in accordance with normative masculine expectations, such as foregoing condom use when on PrEP, yet could be based on the desire to have a child or not to hurt the partner rather than to increase the number of sexual partners. The agency of MSW and their PrEP-related behavior can in our view be better understood by employing a model that allows for changes in interactions within and across relationships; a model that can be applied to all gender groups recognizing the possibility of change for all.
Conclusion
In this article, we discussed men’s PrEP choices in relation to Connell’s theory of hegemonic masculinity (Connell, 2005; Connell & Messerschmidt, 2005). While the term “hegemonic masculinity” has served a useful purpose in social and public health research over the last few decades in trying to better understand male (health) behavior, and while we found that some masculine normativity such as “being in control of one’s household” or avoiding medical facilities seems to be endorsed by many men, our findings cast doubt on men aspiring to a hegemonic masculine ideal per se. As we have argued, it is furthermore unclear who should define such an ideal. PrEP could have theoretically facilitated living up to a hegemonic ideal of having multiple partners as portrayed by King Mswati III, yet we found pluralism in masculinity ideals ranging from responsibility to freedom, from self-control to virility, and situational decisions drawing on different and contradictory notions of masculinities that MSW did not view as subordinate and which cut through age groups.
Rather than seeking to align male behavior to a hegemonic ideal, we view “cultural repertoires” as a more suitable framework for understanding men’s actions and behavior vis-à-vis PrEP, a repertoire which can be extended and adapted throughout MSW’s lives with new “tools” added and outdated “tools” discarded. As Holy and Stuchlik state, “Social life is a process carried out by people in their physical and social world, and which is destined continually to create, recreate and change that very world” (Holy & Stuchlik, 1983, p. 107). To better understand this creation and recreation, we believe that a shift to “cultural repertoires” and further research on “situated or situational selections” could benefit studies on masculinities and gender. It could additionally inform health education and health service delivery for men by acknowledging MSW’s differing priorities on account of their age and peers, work, and partnership situation over the life course.
Footnotes
Acknowledgements
We would like to thank all research participants for their time and openness in sharing their views and experiences. We would further like to express our gratitude to all research assistants for their committed and dedicated work and the Eswatini Ministry of Health for their support throughout the research project. And last but not least, we would like to thank the editor and reviewer for their helpful comments.
Authors’ Note
All authors have contributed meaningfully to data acquisition, analysis, interpretation, writing, and/or editing of this article and approved its final version. This article is based on the first author’s submitted doctoral thesis.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Bob L. Herd Foundation and the Alexander von Humboldt Foundation funded this research with Till Baernighausen being supported through the Alexander von Humboldt Professor Award and funded by the Federal Ministry of Education and Research and Shannon A. McMahon being supported by the Olympia-Morata-Program. The funders had no role in the preparation of this manuscript. The content is the sole responsibility of the authors and does not necessarily represent the views of any funder. For the publication fees, we acknowledge the support of Heidelberg University and the German Research Foundation through their funding program “open access publication costs”.
