Walking the Talk:

Inner Spaces, Outer Faces

A Gender and Sexuality Initiative

For further information, please contact:

ICRW1717 Massachusetts Avenue, NWSuite 302Washington, DC 20036 USA

Sarah Degnan Kambouskambou@icrw.org

CARE151 Ellis Street, NEAtlanta, GA 30303

Mona Byrkitmbyrkit@care.org

Veronica Magarvbmagar@gmail.com

Copyright © 2006 Cooperative for Assistance and Relief Everywhere, Inc. (CARE) and International Center for Research onWomen (ICRW). All rights reserved.

CARE and ICRW grant permission to all not-for-profit organizations engaged in humanitarian activities to reproduce thiswork, in whole or in part. The following notice shall appear conspicuously with any reproduction: “Walking the Talk: InnerSpaces, Outer Faces, A Gender and Sexuality Initiative. Copyright ©2006 Cooperative for Assistance and Relief Everywhere,Inc. (CARE) and International Center for Research on Women (ICRW). Used by Permission.”

The Inner Spaces/Outer Faces Initiative was funded by the Ford Foundation.

1 International Center for Research on Women, 2 CARE, 3 Consultant

A Gender and Sexuality Initiative

Sarah Degnan Kambou1

Veronica Magar2

Jill Gay3

Heidi Lary1

withGeetika Hora2

Aprajita Mukherjee1

My Linh Nguyen2

Jennifer Ramsey1

May 2006

Walking the Talk:Inner Spaces, Outer Faces

The authors would like to thank the Ford Foundation for its generosity. Without such funding, ISOFIwould not have transformed the lives, organizations and programs as was observed over the past twoyears. Special thanks goes to Sarah Costa for having a vision and translating it into action. Thanks also forthe insights of Susan Wood and Roshmi Goswami, program officers for Ford in Vietnam and India.

CARE India Headquarters:Steve HollingworthSmarajit JanaT. Usha KiranAJoby GeorgeSanjay KumarSiva K. KumarPhilip ViegasMadhumita SarkarRajneesh RastogiG. BalasubramanianMonica Sahni

Uttar Pradesh State Headquarters:Prabhakar SinhaShilpa NairAnupam RaizadaPratibha SharmaDharmendra PanwarInnasi A. MuthuSemant MonhantyJeet SinghRajpreet Kaur

Lucknow District Team:Suniti NeogySukhpal Kaur MarwaVinay SinghDeepak DavidJaya MenonSangeeta SrivastavaShive Bahadur Singh

Rajasthan State Headquarters:Sunil BabuPramila SanjayaDeepmala MahlaSharon ThangaduraiManita JangidJanardha RaoMadhu SharmaSubrata Das

Bhilwara District Team:Renu KambojAnil DwivediPayal RaoManjusha DoshiRajan R. KapoorJamal SiddiquiDevendra TripathiKumar BikramBalmukund Sharma

AcknowledgmentsThis work and resulting report would not have been possible without the contributions of numerous individuals. The ISOFI Core Teamwishes to acknowledge the following individuals who willingly shared their time, expertise and insights with ISOFI.

CARE Vietnam:Carol ShermanSimon EccleshallBarbara BaleNguyen Viet HaNgo Thi Kim HoaNguyen Ngoc ThangDanh QuyTruong Quang HongTran Quang TuanTran Thi Ngoc TuyetNguyen Ngoc ThuyDang Thi Khao Trang (Youth Union)

Consultants (Vietnam):Vu Song HaNguyen Thu NamHoang Tu AnhNguyen Nguyen Nhu Trang

CARE USA:Mona ByrkitDoris BartelMichael DrinkwaterSusan IgrasTony KloudaElisa MartinezEllen PierceJess Rattan

CARE Asia Regional Management Unit:Musa MohammedMichelle KendallGraeme Storer

Creating Resources for Empowerment in Action (CREA):Geetanjali MisraPramada Menon

Ford Foundation:Sarah Costa, Ford Foundation (New York)Roshmi Goswami, Ford Foundation (India)Susan Wood, Ford Foundation (Vietnam)

International Center for Research on Women (ICRW):Kathleen BarnettJoy Desmukh-RanadiveNata DuvvuryAnju MalhotraAnuradha Rajan

Talking About Reproductive and Sexual Health Issues(TARSHI):Radhika ChandiramaniGunjan Sharma

Table of Contents

Chapter 1ISOFI: An Innovative Gender and Sexuality Project................................................................................................9

Text Box 1: Collaborating Organizations........................................................................................................11Text Box 2: Vietnam Methodology..................................................................................................................13Text Box 3: India Methodology.......................................................................................................................14

Chapter 2The ISOFI Model: Creating an Enabling Environment for the Effective Integration of Gender andSexuallty..............................................................................................................................................................................16

Text Box 4: Pre-ISOFI Perceptions on Gender and Sexuality......................................................................16Text Box 5: Guiding Principles for the Design of the ISOFI Innovation System (IS).................................17Text Box 6: ISOFI's Gender Continuum.........................................................................................................19Diagram 1: CARE Vietnam: Progress Along the Gender Continuum........................................................20Text Box 7: Post-ISOFI Perceptions on Gender and Sexuality....................................................................24

Chapter 3Inner Spaces: Deeply Personal and Inherently Systemic.....................................................................................25

Diagram 2: ISOFI Vietnam Stakeholder Analysis.........................................................................................29Diagram 3: ISOFI India Stakeholder Analysis...............................................................................................30

Chapter 4Outer Faces: Field Application and Program Transformation.............................................................................34

Diagram 4: Bodymapping Exercise...............................................................................................................37Text Box 5: Imagine a World in Which... Reflection Through Storytelling in India.....................................38Text Box 6: Case Study of Youth Group Meeting on Homosexuality.........................................................43

Chapter 5Assessing ISOFI's Progess and Effect on Personal and Organizational Change.................................................46

Table 1: Staff Beliefs About Incorporating Gender and Sexuality into Programs at Baseline..................49Table 2: Staff Beliefs About Incorporating Gender and Sexuality into Programs at Endline....................49Diagram 5: Staff Skills in Gender and Sexuality, Baseline.....................................................................................51Table 3: When CARE Program Staff Take Both Gender and Sexuality into Account................................51Diagram 6: Staff Skills in Gender and Sexuality, Endline......................................................................................52Diagram 7: CARE Vietnam: Personal Tension.............................................................................................52Diagram 8: Types of Institutional Support (Endline).....................................................................................53Table 6: Support for Gender and Sexuality Integration (Baseline).............................................................53Table 7: Support for Gender and Sexuality Integration (Endline)...............................................................53

Chapter 6Conclusions, Recommendations and Next Steps..................................................................................................57References.......................................................................................................................................................................65Annex 1: PR/NA Guide............................................................................................................................................71Annex 2: EOP Methodology.....................................................................................................................................73

ISOFI: An Innovative Gender and Sexuality Project

This report details the two-year innovation phaseof ISOFI (Inner Spaces, Outer Faces Initiative), anovel project focusing on gender and sexuality asimportant factors that influence reproductivehealth outcomes on multiple dimensions. Infor-mation on the methods used by the ISOFI projectto mainstream gender and sexuality into the sexualand reproductive health work, including HIV/AIDS,of CARE in sites in India and Vietnam are discussed.It also offers analysis of evaluation data that servesto illuminate the successes and challenges of theproject.

PartnersISOFI is a project jointly managed by CARE, oneof the world’s largest private voluntary organiza-tions (PVOs) dedicated to promoting empower-ment, anti-discrimination, opposition to violence,and sustainable impact on the fundamental causesof poverty, and the International Center for Re-search on Women (ICRW), a private, non-profitorganization focused on improving the lives ofwomen in poverty, advancing women’s equality andhuman rights, and contributing to broader eco-nomic and social well-being. The Ford Founda-

How can you ask me if ISOFI has made a difference in my life? Would I have ever been allowed to leave my village without thisproject? I have spent a night away from home this past week for the first time in my life. (Married Woman, India)

I think we can only work with target groups [on gender and sexuality] if we can break the iceberg inside ourselves. (Director,Youth Union, Vietnam)

Some of us have different sexual tastes. Some of us like dillis, and some like samosas. But what if the samosa is infected? Someof us like sex with eunuchs. What is the difference between god and the devil if everything is the same? (Migrant, India)

I have changed in a positive way. I used to be very bossy. I used to look down on women, even my mother, but now I have moreappreciation towards [women]. (CARE Male Staff, Vietnam)

Sometimes I used to beat my wife. It was difficult...my ego is the main problem... Now I am practicing what I have learned in[ISOFI] trainings at my home, too. (NGO Worker, India)

I am 40 years old. I have been married for many years. This is what I have learned from ISOFI: I have the right to refuse sex, andI have the right to ask for sex. (CARE Female Staff, Vietnam)

tion, a global leader in supporting research andadvocacy on human rights, sexuality and sexual andreproductive health, provided funding to CAREand ICRW for ISOFI’s first phase. ISOFI is a com-munity-centered project seeking to address theunderlying causes of poor sexual and reproduc-tive health.

Background and ContextIn the past decade, there has been increased com-mitment by field-based organizations such asCARE to improve reproductive health and ensurereproductive rights in developing countries. How-ever, these organizations continue to struggle withthe definition and implementation of programmaticefforts that make a meaningful difference in thelives of individuals, especially women. Existingevidence suggests that in order for programmaticefforts to achieve desired outcomes, it is essen-tial to acknowledge and address gender and sexu-ality as fundamental components of reproductivehealth and rights. At a minimum, this requires un-derstanding that both gender and sexuality are so-cially defined and constructed, that institutional ar-rangements for sexual behavior (such as marriage

Chapter 1

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sexuality, preferences and power. Without provi-sion of safe venues for processing and systemicsupport, most field staff are unable to come toterms with their own internal quandaries and ques-tions, and are unable to genuinely "walk the walk"of development.

This is particularly true of HIV/AIDS programs,where staff deal with a range of issues consideredtaboo in many societies. CARE and ICRW proposedto address the identified challenge systemically,through an organizational change strategy that pro-motes deep personal learning and structural re-alignment, aiming to generate significant shifts inhow a select group of country offices undertakesreproductive health programming.

Building on Prior ResearchAs reproductive health is such a central piece ofpeople’s lives and sexual identities, the nexus ofHIV/AIDS prevention, maternal health and familyplanning is intrinsically intertwined with gender andsexuality. Or as the 2005 Millennium Project re-port on HIV/AIDS stated: “Experience has shownthat information alone is not enough....This requiresgoing beyond imparting basic facts to promoting

isting institutions and norms define knowledge, be-havior, partners, motivations and power dynamicswithin sexual relationships and behavior, and howthese factors directly affect reproductive healthoutcomes.

Gender equality means that women and men enjoy the samestatus. Gender equality means that women and men have equalconditions for realizing their full human rights and potential tocontribute to national, political, economic, social and culturaldevelopment, and to benefit from the results. (UNDP, 2003)

Within many communities across the world, con-ditions of poverty and social injustice are sustained,in part, by silence that envelops issues of gender,

greater discussion of sexuality, gender and relation-ships: silence on these matters has proved a pow-erful impediment....” (Ruxin, Binagwaho, & Wilson,2005). Scarce literature in the development andpublic health fields documents the impact of in-corporating sexuality into the work of organiza-tions. In addition, little has been written concern-ing the intersection between gender roles and sexu-ality. A forthcoming book on gender and sexualitywill add to the literature (Costa, in process). It hasalso been recognized that HIV/AIDS educationshould be broadened to include discussions of gen-der roles, sexuality and relationships (Mane, Bruce,Helzner, & Clark, 2001; Weiss & Rao Gupta, 1998).

GenderThough a 2005 review of gender mainstreamingby development institutions, UN agencies andNGOs found that most international institutionshave attempted to include gender mainstreamingin their programming (Moser & Moser, 2005),gender mainstreaming has failed to achieve its fullpotential to transform organizations, programs andcommunities. This remains true because seldomare principles and concepts translated into action-able, practical and sustainable interventions (Vlassof& Garcia-Moreno, 2002). A recent evaluation ofUNDP’s efforts to undertake gendermainstreaming concluded that: “gender main-streaming has not been visible or explicit; there is

Gender equity is the process of being fair to women andmen. To ensure fairness, measures must often be available tocompensate for historical and social disadvantages that pre-vent women and men from otherwise operating on a levelplaying field. Equity leads to equality. (UNDP, 2003)

no corporate strategic plan for putting the gendermainstreaming policy into effect; steps have beensimplistic and mechanistic and UNDP has not actedon previous assessments....” (United Nations,2005). While numerous “how to” manuals existon gender mainstreaming (Caro, Schueller, Ramsey,& Voet, 2004; CIDA, 2000, 2005; Schalkwyk,1998; SIDA, 1997), and measuring results of gen-der mainstreaming (CIDA, 2005), few reports

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systems) define gender-based power relations, andthat social norms and ideologies manifest idealizedviews of male and female sexuality. It also requiresunderstanding how in a given social setting, ex-

Text Box 1: Collaborating OrganizationsTARSHITalking about Reproductive andSexual Health IssuesNew Delhi, India

CREACreating Resources for Empowerment in ActionNew Delhi, India

CIHPConsultation of Investment in Health PromotionHanoi, Vietnam

LIFEQuality of Life Promotion CentreHo Chi Minh City, Vietnam

Maintains a sexuality resource center for the Asia region; operatesa telephone hotline that provides information and referral serviceson issues related to sexuality and reproductive health; conductstraining on gender and sexuality; publishes research on sexuality;and conducts public education and advocacy.

Conducts training on gender and sexuality; implements leadershipprograms that address women's rights; and conducts publiceducation and advocacy.

Conducts training, promotion and research based on participatoryand rights-based approaches concerning gender, sexuality andhealth.

Conducts research and training with vulnerable women and com-munities, including HIV-positive people.

SexualitySexuality has long been recognized as a key ele-ment in reproductive health (Moore & Helzner,1996; United Nations, 1994; Zeidenstein & Moore,1996).

ity are at best embryonic and at worst still to be-come visible...” (Watkins, 2004). Similarly, an evalu-ation by SIDA on its support for the promotion ofgender equality in partner countries found that“gender inequalities in health care are not addressedsystematically” (Mikelson, Freeman, & Keller,2001). In addition, policy commitments to addressgender often “evaporate in planning and implemen-tation processes” (Moser & Moser, 2005).

The literature has documented that ignoring sexu-ality issues and simply telling people to use condomsfor HIV/AIDS prevention is rarely effective(MacPhail & Campbell, 2001). A 2005 evaluationcomparing the effectiveness of methodologies toencourage condom use found that presentation ofa leaflet to promote condom use “did not result insignificant changes” (Krahe, Abraham, &Scheinberger-Olwig, 2005). Communications onissues of sexuality are key to promoting condomuse (Bruhin, 2003; Zulu, 2003; Holschnieder andAlexander, 2003). In fact, the literature notes that“social dimensions of ...sexuality, pleasure...haveto be addressed for effective condom promotion”(Khan et al., 2004). With AIDS looming as a globalcatastrophe, much is at stake (Ruxin et al., 2005).A plethora of peer-reviewed journal articles con-cerning sexuality in developing countries have fo-cused on issues of theory (Dowsett, 2003); legis-lative impacts (Amado, 2004); current practices(Wright, Plummer, Mshana, Wamoyi, & Shigongo,2006); the need for more sexuality information foradolescents (Lesch & Kruger, 2005; Ogulayi, 2005;Wright et al., 2006); the effectiveness of provid-ing sexuality education for adolescents and childrenin schools (Gay & Daniels, Forthcoming; Grunseit,1997; Grunseit, Kippax, Aggleton, Baldo & Slutkin,

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describe how specific gender mainstreaming ef-forts or gendered interventions have contributedto specific measurable outcomes. As concluded ina recent evaluation of the British government’s De-partment for International Development (DFID),“most gender evaluations have not been good atlinking institutional changes and policy to results inthe real world: available evidence from other evalu-ations suggests the benefits of gendermainstreaming and those benefits of gender equali-

ISOFI has been a collaborative venture from thestart, and has been formulated and implementedby a host of local organizations working in con-junction with CARE and ICRW. These organiza-tions have been critically important to the ISOFIprocess by bringing fresh perspectives from out-side the confines of CARE and ICRW, and provid-ing essential training in gender, sexuality and repro-ductive rights. These organizations includeTARSHI, CREA, CIHP and LIFE. Descriptions ofeach are provided in Text Box 1.

ISOFI’s objectives for these pilots included thefollowing: (1) Two CARE country offices will have

The biggest change is now we use condoms every time andpractice safe sex. We had never heard of HIV before. Welearned about HIV through the ISOFI trainings. (Male trucker,India)

In addition to HIV/AIDS risk, ISOFI emphasizessexuality as a construct that influences gender, lead-ing to increased vulnerabilities but also an increasedsense of agency (Vance, 1984). Gender power re-lations are only infrequently taken into accountwhen trying to understand human sexuality (Dixon-Mueller, 1993). Programs tend to overemphasizemale predatory behavior and female weakness,reinforcing the gendered system that ISOFI seeksto avoid through an empowerment and rights-based framework. Focusing only on risk, diseaseand danger in relation to sexuality often leads tothe polarization of male and female sexuality, whichis used to justify the need for restricting femalesexuality (Vance, 1984).

Project OverviewISOFI was initiated in pilot sites in two countries,India and Vietnam. CARE India, CARE Vietnam,CARE USA and CARE Australia have been integralactors in the ISOFI project. From its inception in1946, CARE’s approach has evolved from a needs-based to a rights-based approach -- a shift thathas become increasingly advocated in manyspheres. The Millennium Declaration, for example,describes its rights-based approach as the follow-ing: “The Millennium Development Goals are not acharity ball. The women and children who makeup the statistics that drive the Goals are citizensof their countries and of the world. ...[t]hey haverights – entitlements to conditions, including ac-cess to healthcare that will enable them to pro-tect and promote their health....” (Freedman etal., 2005). ISOFI is modeled around this rights-based approach to community empowerment, andits goal is to provide a strong foundation for inte-grating gender and sexuality into CARE’s program-matic approach to achieving reproductive health.

for sexuality training for providers (Becker &Leitmann, 1997). Only a few articles have dis-cussed how sexuality training has been effectivelyincorporated in an effort to improve reproductivehealth and reduce HIV risk, with both examplescoming from Latin America (Pick, Givaudan, &Brown, 2000; Pick, Givaudan, & Poortinga, 2003;Rogow & Diaz, 1999). Findings from the ISOFIinitiative will add knowledge to this previously ne-glected area.

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1997; Irvin, 2000; Kirby, Laris, & Rolleri, 2005);the need for sexuality education for adults (Amoran,Onakedo, & Adenigyi, 2005); how norms impactsexuality (Baylies, 2000; WHO, 2005); and meth-odologies to research sexuality (Askew, 2005).Other less recent articles have discussed the need

"Sexuality is a central aspect of being human throughout lifeand encompasses sex, gender identities and roles, sexual ori-entation, eroticism, pleasure, intimacy and reproduction. Sexu-ality is experienced and expressed in thoughts, fantasies, de-sires, beliefs, attitudes, values, behaviors, practices, roles andrelationships. While sexuality can include all of these dimen-sions, not all of them are always experienced or expressed.Sexuality is influenced by the interaction of biological, psycho-logical, social, economic, political, cultural, ethical, legal, his-torical, religious and spiritual factors." (WHO, 2006)

lives and subsequently effecting changes within theirown organization, so that CARE staff were moreeffective change agents with target populations andcommunities. Initial assessments indicated thatCARE staff experienced change as a result of ISOFIand that this, in turn, resulted in profound changesthat improved the design and delivery of repro-ductive health interventions among hard-to-reachpopulations. The goal of ISOFI was to mainstreamgender and sexuality into CARE’s global reproduc-tive health programs, thus contributing to CARE’songoing organizational transformation.

The ISOFI experience, which combines sexualityand reproductive health into an integrated model,is a unique initiative. This document attempts tocapture the initiative’s promise to the field of re-productive health by discussing how ISOFI has ad-dressed gender and sexuality issues to refine ex-isting interventions and make them more respon-sive to the realities and preferences of the com-munities they serve. Participants in the pilot sitesstated that the work of ISOFI profoundly affectedtheir lives.

People who were shy have opened up and have started sharingabout their lives, even their personal lives, their families...Thishas brought many of us closer. We have become more confident.(Vietnam)

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In Vietnam, ISOFI was piloted across the northern and southern regions in several sexual and reproductive health/HIV projects.These ranged from a youth-focused garment factory behavior-change project to an innovative project to create a human-rights-based curriculum and practicum on HIV/AIDS for students in government-run policymaker-training programs.

Gender and Sexuality Perspective BuildingThe CARE Vietnam team began ISOFI activities in October 2004 with an introductory“sensitization” workshop on gender andsexuality that brought together more than 25 team members from nine different projects. CREA facilitated this participatoryfour-day launch workshop, which was intended to enhance conceptual understanding, increase personal awareness related topower relations and raise sensitivity related to gender and sexuality.

Reflective PracticeDirectly following the initial workshop, with the support of ICRW, the CARE Vietnam team explored and reflected on theprograms that are currently being implemented. Through the Portfolio Review and Needs Assessment (PRNA), theproject teams identified a need to institutionalize gender in a more systematic manner. However, the teams also felt that giventhe sensitivities of the government on issues of human rights and sexuality, the approach to gender and sexuality integrationshould be incremental.

Activity PlanningThe project teams worked collectively to brainstorm, debate and develop activities to begin the process of “operationalizing”all that they had absorbed, both in terms of project activities and staffing policies. Five of the seven sexual/reproductive healthand HIV/AIDS projects designed and implemented gender and sexuality activities that are described throughout this report.

Text Box 2: Vietnam Methodology

a solid technical and programmatic strategy foraddressing gender and sexuality in future or cur-rent reproductive health field projects; (2) developand disseminate a documented approach for inte-grating gender and sexuality into reproductivehealth programming in multiple country settings;and (3) establish a synergistic, learning partnershipthat promotes and supports institutional evolutionand innovation at CARE and ICRW beyond the pa-rameters of the proposed project. ISOFI has at-

tempted to achieve these objectives by address-ing issues of gender and sexuality associated withreproductive health concerns.

Viewing gender and sexuality as interlinked con-cepts, the ISOFI initiative uses community-basedand participatory methodologies to address theunderlying, often sub-conscious, concerns relatedto gender inequality and sexuality. ISOFI’s meth-odology is two-tiered, focusing first on personal

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Text Box 3: India Methodology

In India, ISOFI was piloted in two districts: Lucknow, in the state of Uttar Pradesh (UP) and Bhilwara, in the state of Rajasthan.The platform for ISOFI’s implementation is the Reproductive and Child Health, Nutrition and AIDS (RACHNA) program, whichencompasses all of CARE India’s health, nutrition and reproductive health programs.

Orientation & Perspective BuildingCREA facilitated a workshop for staff from the pilot districts, Lucknow and Bhilwara, in August 2004. It was the first workshopfor CARE India staff on sexuality, and participants described it as a liberating experience, since they were able to discuss personaland formerly prohibited aspects of their lives related to sexuality. The workshop’s participatory approach, which included theuse of exercises and films, challenged participants to think, debate and reconcile controversial issues like prostitution, crossdressing and homosexuality.

Reflective PracticeTo build on the transformative experience gained at the gender and sexuality workshop, the teams engaged in reflective practicesto gain a better understanding of what this new learning on gender and sexuality means for them; how their values and beliefs arereflected in the way they think and program; how they are able to break the silence around sexuality at their personal level andat the program level; how to openly discuss sex and gender roles with communities; and how to address the positive aspects ofsexuality, like sexual pleasure. Once staff was oriented on gender and sexuality, an intensive Portfolio Review and NeedsAssessment (PRNA) was conducted with the two district teams and the Program Management Teams (PMT) in Uttar Pradeshand Rajasthan. The objective was to identify gaps and opportunities when integrating gender and sexuality using group reflectionand analysis around key questions.

Activity Planning* Bhilwara, RajasthanA workshop on gender and sexuality was organized for NGO partners from two regions in Rajasthan in November 2004. Onesignificant activity the team has undertaken is the integration of gender in folk media campaigns that address topics such ascelebrating the birth of a girl child, emphasis on rest during pregnancy, nutrition for the girl child, and various male and femalemethods for birth spacing. Gender and sexuality activities continued for the duration of the project, and are describedthroughout this report.

* Lucknow, Uttar PradeshNGO partners were introduced to ISOFI and identified ways in which gender and sexuality could be integrated in their reproduc-tive health programming. The team also mapped out agencies in Lucknow that are working on gender and sexuality. In additionto NGO partners, the UP team influenced the state government to nominate a gender point person from the Health andIntegrated Child Development Services (ICDS). In January 2005, a workshop on gender and sexuality for ICDS functionaries wasorganized in Lucknow, facilitated by headquarters staff. Gender and sexuality activities were designed and implemented for eachcomponent of the Reproductive and Child Health, Nutrition and AIDS Program (RACHNA). They are described in detail withinthis report.

Findings from the end of project evaluation (seeChapter 5) point to potential pathways for futureinnovation in sexual and reproductive health pro-gramming. In fact, several of the interventionsmodified on the basis of ISOFI inputs, such as in-creasing mother-daughter communication regard-ing sexuality and sexual health, are precisely whatthe literature has suggested as important avenuesfor HIV/AIDS prevention (Damalie, 2001).

The first phase of ISOFI put into practice the rec-ommendations set out in the Platforms of Actionfor ICPD held in Cairo in 1994, and the FourthWorld Conference on Women (FWCW) held inBeijing in 1995, along with the 10-year reviews ofICPD and FWCW. The Beijing Platform recom-mended addressing the problems of sexually trans-mitted infections, HIV/AIDS and sexual and repro-ductive health in gender-sensitive programs(UNFPA, 2004). The first phase of ISOFI has pavedthe way.

An overview of the ISOFI model is described inChapter 2 of this report. Chapter 3 describespersonal transformation of CARE staff as well asthe experiences and effects of this learning onCARE as an organization. Chapter 3 also providesdetails about the innovative methodologies usedby CARE staff, implementing partners and com-munities. Chapter 4 describes the field applica-tion of ISOFI learnings, with discussion of how gen-der and sexuality were incorporated into repro-ductive health interventions such as condom pro-motion, maternal health care and breast feeding,as well as how technical support was provided.Chapter 5 presents findings from the end-of-project evaluation, based on the analysis of baselineand endline survey data. Finally, Chapter 6 pro-vides a brief discussion, recommendations and nextsteps.

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CARE and ICRW are planning a second phase ofISOFI in order to answer the crucial question, “Sowhat?” What evidence can be gathered to docu-ment a positive, measurable impact on sexual andreproductive health outcomes through the sys-tematic and contextually tailored integration of gen-der and sexuality into CARE’s ongoing sexual andreproductive health programs? This anticipatedsecond phase of ISOFI will attempt to garner moreconcrete evidence than that suggested by otherdocuments addressing the issue of impact (Boenderet al., 2004). ICRW and CARE will utilize this sec-ond phase of ISOFI to conduct a well-designed op-erations research study with pre- and post-mea-surement of selected gender, sexuality and repro-ductive health outcomes.

ISOFI’s significance has been to address issues ofpower and powerlessness, pleasure and pain, intwo different Asian contexts. As village women whoparticipated in ISOFI activities stated in a focusgroup discussion:

Some in the community complain about ISOFI and say, 'these arethings done at night and behind a curtain. Their shame is theydiscuss it in the daytime. ISOFI staff have nothing better to dothan come from the city and waste their time with meetings.' Butwe have seen a lot of change because of the access to informa-tion... (Village Women, India)

Chapter 2

The ISOFI Model:Creating an Enabling Environment

for the Effective Integration of Gender and Sexuality

Over the past several years, CARE has strategi-cally committed time and resources to integratinggender and diversity into its programming prin-ciples and administrative policies. CARE undertooknumerous initiatives to integrate gender into all rel-evant functional areas of the organization. In hu-man resources, CARE instituted progressive gen-der and diversity policies and integrated relevantcompetencies into the performance appraisal sys-tem. In ongoing support to field programs, CAREprovides technical materials on gender integration,trains staff in gender analysis and supports projectsthroughout implementation. CARE also promotesthe systematic consideration of gender in projectdesign, monitoring and evaluation. In other words,

Text Box 4: Pre-ISOFI Perceptions on Integrating Gender and Sexuality

Headquarters Perspectives

...[G]ender issues usually come up once during a 'gender work-shop.' That is usually enough to spark interest (or not) incertain individuals...a once-in-a-lifetime workshop isn't enough.(CARE Advisor)

Gender is much more ingrained within and accepted by staff;it's the sexuality piece that is far, far behind. (CARE Advisor)

Traditionally CARE projects have avoided sexuality and dealtwith reproduction in a very technical or medical way. (CAREAdvisor)

I find that sexuality is often in the unspoken "assumptions"column of the log frame of reproductive health programs. (CAREAdvisor)

We need people who are comfortable and experienced withthe issues...to mentor our CARE programs. (CARE Advisor)

Field Perspectives

We've realized that we needed to change 'us' before we [could]advocate change in communities. (India)

I don't dare add another topic about sexuality. For the targetgroup, it might be sensitive. For the first step, they shouldhave basic knowledge about gender. If they are okay withgender, we go to the further step of sexuality. (Vietnam)

So for myself, I'm alone in the forest [of gender and sexuality],and I'm trying to see where is the exit. (Vietnam)

We have realized that women open up and talk about sexual-ity, but then we become hesitant. (Male Staff, India)

...[I]f I cannot convince my family [about gender equity], thenhow can I convince my project beneficiaries? I work with localwomen. They have more difficult living conditions than me -so if I can't convince my family, how can they convince theirfamilies? (Vietnam)

there has been a substantial global effort to ensurethat CARE programming is not only gender-in-formed but also gender-responsive. In light of po-litical commitment at the highest institutional lev-els and sizeable investment in systems and capac-ity, CARE expected gender to be more fully andholistically integrated into field programs by thispoint in time. In reflecting on efforts to integrategender and the added dimension of sexuality intoreproductive health and HIV/AIDS programming,staff working with ISOFI observed the absence ofsexuality in programming and expressed concernsabout integrating these concepts into programs.Examples of concerns early in the ISOFI processare provided in the text box below.

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Among other programmatic issues, these staff ob-servations reflect how divergence between per-sonally held and professionally expressed values andattitudes around gender and sexuality can affect allaspects of programming: design, implementationand evaluation. Lived experience of gender andsexuality is deeply rooted in social systems andcultural meaning, and represents an individual’sessence as a human being – it structures personallife. That lived experience of gender and sexualityoften creates tension within the professionalsphere, effectively tempering the design and de-livery of interventions framed to address repro-ductive health and HIV/AIDS, which are intrinsi-cally linked to gender and sexuality. Essentially, it isunrealistic to ask field staff to uphold and promotegender-sensitive or, even more ambitiously, gen-der-transformative principles when they haven’thad an opportunity to process and integrate thoseprinciples into their personal lives.

Finally, in the previous quotes, staff identify a fun-damental need: to open a dialogue around sex, sexu-ality and sexual health. In their experience, projecteducational materials deal with reproductive or-gans but not with the power, pleasure, pain andshame associated with those same sexual sites.Field staff promote condoms – and their effec-

tiveness with birth spacing as with the preventionof sexually transmitted infections - but overlookthe importance of intimacy in sexual relations andthe reality of gendered control over sexual encoun-ters. Project strategies are primarily framed aroundheterosexual sex and refrain from addressing lessvisible patterns of sexuality such as male-to-malesex or sexual practices deemed outside the main-stream such as male-to-female anal sex. As withgender, staff need to explore and comprehend theirvalues, attitudes and beliefs relating to sexuality aswell as their understanding of its placement withinconceptual frameworks and models of behavior

Just giving a condom and asking a person to go and explainwhat are the different methods and pros and cons - this is notgoing to work until and unless you relate to [people] as humanbeings. That is what ISOFI has done for me. I have a very, verysoft corner - a special corner - for [ISOFI]. (India)

change.

Change theory supports the creation of safe andnon-judgmental "space" where individuals can ex-amine and explore sensitive and deeply personalsubject matter. Such theory influenced the designof the ISOFI Innovation System (IS), which is de-scribed in the remainder of this chapter.

Text Box 5: Guiding Principles for the Design of the ISOFI Innovation System (IS)

· Development practitioners need space to explore and understand their own values,attitudes, beliefs and experiences of gender and sexuality.

· Personal learning and change in relation to gender and sexuality will be critical toenhancing organizational effectiveness in addressing gender and sexuality.

· Processes and practice in the professional sphere should encourage people to rec-ognize and maximize their lived experience of gender and sexuality.

17

Inquiry as Everyday Practice:The ISOFI Innovation System (IS)In response to the observations and reflectionspreviously noted, CARE and ICRW agreed to de-sign and test a field-based methodology to inte-grate gender and sexuality systematically into ex-isting reproductive health projects. Planned as afirst phase, the Inner Spaces/Outer Faces Initia-tive initially focused on personal learning andchange, and then segued naturally to organizationallearning and change. ISOFI as a methodology fea-tures structured iterative loops of reflection/learning, action/experimentation and analy-sis/assimilation. Its systemic nature means that asafe space for reflection and dialogue can and shouldbe carved out at all levels of an organization.

The ISOFI IS has a participatory evaluation mod-ule that can be applied as a mid-term process re-view or as an end-of-project evaluation. (The fiveintervention modules are described in this chap-ter, with the evaluation module described in theAnnexes.) Exercises conducted with the assistanceof these modules were the source of the numer-ous quotations and visuals appearing throughoutthis report.

With the two-year pilot now at an end, CARE andICRW have consolidated ISOFI learning and toolsinto the ISOFI Innovation System (ISOFI IS), whichhas been rigorously field tested by CARE in twocountries: India, in Lucknow District (UttarPradesh) and Bhilwara District (Rajasthan); andVietnam, in Hanoi and Ho Chi Minh City. The ISOFIIS comprises five intervention modules, the firstfour of which are administered sequentially in aninitial phase, but all of which are practiced itera-tively across the project cycle. Those five inter-vention modules are:

· Portfolio Review and Needs Assessment;· Gender and Sexuality Training· Reflective Dialogues (collective reflection);· Personal Learning Narratives (individual re-

flection);

This realization made me actually see that because of myjudgmental attitude, I tended to become dominating. I real-ized that these were shortcomings in my character, and I neededto address them. Thus, I tried to make amends. The enablingenvironment in ISOFI was instrumental in facilitating self-re-flection. Nowhere was it said that you have to change, so Ireally did not feel this was a project. The faciliation processwas excellent - always. Because of the learning environment,there is self-realization that things can improve if there ischange. (India)

There still is a contradiction between our inner and outer faces.(India)

Genesis of a Methodology

As fundamental to ISOFI’s design, CARE and ICRWincorporated principles and processes associatedwith three interrelated domains: social psychol-ogy represented by Kurt Lewin and the legacy ofhis work relating to group dynamics and experien-tial learning; androgogy, which frames educationas freedom and promotes the assimilation of learn-ing with life experience, represented by Brazilianeducationalist Paolo Freire; and Participatory Ac-tion Research (PAR), an approach noted for im-proving social practice and promoting social jus-tice, represented by diverse schools of thoughtranging from Fals Borda to Whyte to Reason andMcTaggart, and by innovative applications of PARin development practice, such as ParticipatoryLearning and Action (PLA), espoused by Cham-bers, Cornwall and Gaventa. Theory that inspiredISOFI’s overall design is summarized below andlinked to aspects of the ISOFI IS.

ISOFI Challenge #1: As adults employed by aninternational development organization in low- ormiddle-income countries, CARE staff are generallywell educated, highly motivated, seasoned andexperienced, and enjoy relatively high status within

18

· Participatory Learning and Action (appli-cation of learning to interventions)

What is an effective method for challenging adultsto think differently about profoundly sensitive is-sues such as gender and sexuality? To address thischallenge, the ISOFI team drew on the disciplinesof social psychology and androgogy.

Kurt Lewin, a social psychologist of the early 20th

century, posited that re-education may affectpeople’s cognitive structure (the organization ofideas, facts and beliefs), values and behavior. Inorder to re-educate or re-socialize adults, they mustpass through a three-phase process: unfreezing(creating internal disequilibrium); changing (find-ing a new equilibrium for themselves); and refreez-ing (re-stabilizing). As an essential first step tolearning, the unfreezing process needs to promptchange through heightened anxiety, introduce orreorganize information, and allow for safe and non-judgmental reflection. Next comes a period ofchange when individuals experiment with new be-haviors within a supportive group environment.

With time and practice, new behaviors and perspec-tives are assimilated into an individual’s personalityand life systems, and refreeze only when significantothers (e.g., spouse, kin, close friends) confirm orvalidate the changes.

Paolo Freire, a Brazilian educator of the 20th cen-tury, remarked in his classic work Pedagogy of theOppressed (1970) that, “No one can unveil theworld for another.” By striving to develop criticalconsciousness – to perceive with purpose the so-cial, political and economic injustices that serve toexclude certain individuals from society – peoplelearn to perceive and critique their own personaland social reality. For Freire, informal educationwas dialogical, involving deep respect for others’knowledge, value and contribution to society. Si-lence and complacency can be broken through col-lective reflection and dialogue, motivating individu-als to take action to transform themselves and so-ciety.

Application of Theory to ISOFI IS: All of theISOFI intervention modules are multipurpose andcontribute to learning and change at both the indi-vidual and organizational level. For this particularchallenge, given the need to “shake up” individuals(per Lewin’s unfreezing) and raise their conscious-ness (per Freire), the ISOFI team developed thefirst four of five intervention modules to be admin-

Text Box 6: ISOFI's Gender Continuum

Over the course of ISOFI, staff evaluated CARE's progress in integrating gender into its existing portfolio by assessing programstrategy against a gender continuum adapted from a model developed by ICRW . ISOFI's gender continuum is below:

1) A gender-blind approach exploits inequalities and reinforces stereotypes. An example of a gender-blind approach is using avirile, strong man to promote condom use.

2) A gender-sensitive approach recognizes that people's needs are different and accomodates societal roles without attemptingto reduce inequalities. An example of a gender-sensitive approach is promoting the "female condom" so that women can usecondoms for prevention, without having to negotiate their use with their male partners.

3) A gender-transformative approach seeks to create more equitable relationships and challenges gender and societal norms.An example of a gender-transformative appraoch is a CARE income-generation training project in Allahabad, India, wherewomen are given training in hand-pump repair rather than traditionally defined skills such as sewing or tailoring.

4) An empowering approach aims to equalize the balance of power and addresses structural and societal barriers, whichempowers vulnerable people to claim their rights. An example of the empowermnet appraoch is the Sonagachi project in WestBengal, India, where sex workers organized themselves in order to demand the right to health care.

19

their community. As in any society, their worldviewand perspectives on gender and sexuality were ini-tially shaped by prevailing socio-cultural systems,values and norms through a process of socializa-tion. Gradually, life experiences, personal inquiryand exposure to global media introduce new infor-mation on gender and sexuality that requires pro-cessing.

in relation to gender and sexuality as reflected inproject content, strategies, activities, monitoringand evaluation, staffing and partnerships. The fa-cilitators establish the parameters of the portfolioto be examined but may include current, past andpending projects and may extend across severaldevelopment sectors (e.g., reproductive health,microenterprise and food security). Facilitators

CARE Vietnam Portfolio Assessed on Gender Continuum

Before ISOFI

1

Harmful

2

Neutral

3

Sensitive4

Responsive

5

Trans-

formative

1.0 2

2

2

2.5 2.7 2.8

2.7

After ISOFI

1

Harmful2

Neutral

3

Sensitive

4

Responsive5

Trans-

formative2.8 2.9 3

3

3

3.3 3.53.5

3.5

3.5

N = 8

Range: 1.0 – 2.8

Mode: 2

Mean 2.21

N = 10

Range: 2.8 – 3.5

Mode: 3.5

Mean 3.2

Diagram 1: CARE Vietnam: Progress Along the Gender Continuum

In Vietnam, participants in the

end-of-project review assessed

progress in applying gender

across the CARE program port-

folio. Conducted in two parts,

the first focusing on pre-ISOFI

and the second on post-ISOFI,

each participant provided a

score relating to the portfolio's

performance on gender. One

participant felt that the pre-

ISOFI portfolio included ele-

ments harmful to gender, such

as promoting labor-exploitive

cooking stoves. However, all

participants agreed that CARE's

performance on gender dimen-

sions substanially improved

post-ISOFI.

lead participants through a structured reflectionexercise, working from a facilitation guide. Onekey tool adapted for the PR/NA is the "gendercontinuum" described above. Depending upon thesize of the portfolio under review, the PR/NA cantake from a half day to a full day. In most cases, itshould not extend beyond a full day, as length of a"reflection" session early in the ISOFI process couldpotentially discourage project staff anxious aboutfield activities and deliverables. As with any par-ticipatory process, length of the PR/NA should bedetermined by the staff participating in the mod-ule. A sample of the PR/NA facilitation guide usedin India and Vietnam is available in Annex 1.

The Gender and Sexuality Training proved anessential intervention module for unfreezingpeople’s perspectives, particularly those on sexu-ality. CARE and ICRW worked closely with localresource centers such as TARSHI in India to de-velop the module. Conducted over the course ofthree to four days, the curricula were contextualizedand sought to challenge participants’ preconceived

20

istered sequentially in the earliest stage of initiatingpersonal learning and change, and then to be takenup again at appropriate junctures in the projectcycle. They are:

· Portfolio Review and Needs Assessment· Gender and Sexuality Training· Reflective Dialogues· Personal Learning Narratives

The Portfolio Review and Needs Assessment(PR/NA) assembles primary stakeholders (e.g.,managers, advisors, field staff, partners) to appraisethe state of the organization’s program portfolio

As a methodology for collective reflection, Reflec-tive Dialogues are held quarterly and can involverelevant staff at multiple levels of the organization- field-level, middle management and senior man-agement. As appropriate, Reflective Dialogues mayalso involve implementing partners at each of thecorresponding levels. While thematically interre-lated, the nature of the reflection is adapted tosuit the role and responsibilities of staff and part-ners operating at each level. As NGOs focus prin-cipally on implementation – and staff often viewtime away from implementation as costly – a Re-flective Dialogue session should normally take froma half day to a full day, extending in exceptionalcircumstances beyond a full day. During ReflectiveDialogues, staff review progress against the pastquarter’s workplan and then engage in active prob-lem solving and theory building to reassess the

current situation vis-à-vis the integration of gen-der and sexuality into the project’s strategies, in-terventions, and monitoring and evaluation system.Essentially, the reflection is built around four basicoperational questions:

· What did we set out to do?· What actually happened?· Why did it happen?· What will we do to move forward?

Through structured probing, staff process obser-vations and learning around gender and sexuality,as well as explore linkages of that learning to changeat the personal level (inner spaces), at the profes-sional level and at the organizational level (outerfaces). In this first phase of ISOFI, facilitators fromCARE and ICRW led the official reflective dialoguediscussions in India and Vietnam. As staff in CAREIndia became more comfortable with the exerciseand began to appreciate the power of reflection,they carried out their own reflective sessions asneeds arose. Through this methodology, partici-pants are constantly testing the logic and effective-ness of theories that are put into practice, andadapting interventions to be increasingly respon-sive within socio-cultural contexts as they becomebetter understood.

Senior Managers --> Strategy and Outcomes

Middle Managers --> Intervention Design and Outputs

Field Staff --> Activity Implementation and Inputs

We are so involved in proving our competencies that we do noteven want to honestly reflect. (India)

Finally, in order to encourage regular personal re-flection, the ISOFI team introduced the PersonalLearning Narrative, an opportunity for staff un-dergoing transition to think through the effect oflearning around gender and sexuality on their per-sonal lives. Originally conceived as periodic writ-ten reflection, the ISOFI team quickly adapted themethodology, as they realized that staff don’t havethe time (or perhaps the inclination) to write per-sonal narratives. An interview methodology effec-tively substituted for written narratives, with up

...[B]ut after ISOFI, there has been a revelation - a personaljourney within me. (India)

21

notions of gender norms and gender roles, sexualnorms and sexual identities, the role of power andcontrol, and the detrimental effect of social exclu-sion. The trainings were grounded in social con-struction theories for understanding both genderand sexuality. Facilitators relied heavily on experi-ential exercises and maintained a highly interactiveand supportive environment. The benefit of in-volving local resource centers for this particularintervention module is that staff from these cen-ters are quite up to date on the latest group com-munication techniques, and they bring a new andrefreshing perspective to the organization. Thesecenters offered periodic training courses on gen-der and sexuality, which were used to train newstaff members as they came on board.

success of a rights-based approach is the effectiveand systematic integration of gender into all aspectsof organizational culture, structure, systems andprogramming. Further, when applying a rights-based approach to reproductive health and HIV/AIDS, it is crucial to understand how sexuality in-teracts with gender to create interconnected riskand vulnerability, the ramifications of which extendbeyond public health to social and economic out-comes.

Generally, CARE staff understand well the conceptof gender, less so the concept of sexuality. Yet, asISOFI participants observed time and again, ascomfortable as they were with gender concepts,they just didn’t know “how to do” gender. Theywere even more unsure about how to broach sexu-ality with implementing partners and communitymembers.

What methodology will support CARE’s purpose-ful transition to rights-based programming whilebuilding staff capacity to concretely integrate gen-

der and sexuality into strategies and interventions?To address this issue, the ISOFI team drew fromthe teachings of Paolo Freire and from the variousschools of participatory action research and theirinnovative applications, such as Participatory Learn-ing and Action (PLA), espoused by Robert Cham-bers and Andrea Cornwall. Relevant theory andits application are summarized below.

Praxis is fundamental to Freire’s pedagogy ofemancipation. Freire argued that all action mustbe informed by social, cultural, economic and po-litical realities, and must seek to transform theworld that is. Further, this libratory action shouldstrive to increase simultaneously the community’scapacity for critical reflection and action as well asbuild its social capital. In this way, action contrib-utes to the attainment of social justice both by rec-tifying inequities through a process ofconscientization and collective action, and by con-sistently demonstrating principles closely associ-ated with social justice (e.g., respect, transparency,dignity) in daily life.

True praxis can never be merely cerebral; it must involve ac-tion. Nor can it be limited to mere activism. It must includeserious reflection. Freire regards reflection without action assheer verbalism, “armchair revolution,” whereas action with-out reflection is “pure activism,” that is, action for action’s sake.(Crotty, 1998)

With its origins in social science , Action Research,as an orientation to inquiry and social action,evolved and diversified as it integrated new do-mains. Reason and Bradbury (2001) distinguishAction Research from traditional academic re-search by emphasizing that Action Research is “aparticipatory, democratic process concerned withdeveloping practical knowing in the pursuit of

22

to three indepth interviews conducted by facilita-tors from CARE and ICRW at the conclusion ofeach Reflective Dialogue session. Given the num-ber of staff participating in ISOFI in India, for ex-ample, each individual was interviewed twice dur-ing the course of the 18-month pilot. In indepthinterviews conducted during the evaluation phaseof ISOFI, participants spoke about the degree towhich they had been able to refreeze their inter-nal frames on gender and sexuality, and analyzedthe various factors affecting their ability to stabi-lize new beliefs, attitudes and values. These find-ings are reported in Chapter 3.

ISOFI Challenge #2: Over the past 10 years,CARE as an organization has been moving steadilyfrom a needs-based approach toward a rights-based approach, which seeks to reduce risk andvulnerability by addressing underlying causes ofpoverty and of social exclusion. Central to the

action learning

reflectionanalysisassimilation

While many schools of thought abound, Whyte andothers distinguish between Action Research andParticipative Action Research (or ParticipatoryAction Research), where people from the sub-ject organization or community actively participatein framing and conducting the research, interpret-ing data, and presenting findings and recommenda-tions. As with all forms of Action Research, Partici-patory Action Research links directly to social ac-tion, and when practiced in its most genuine formis truly emancipatory. Sohng (1995) remarks: “Ide-ally, this collaborative process is empowering… Par-ticipatory research reflects goal-oriented, experi-ential learning and transformative pedagogy.”

Application of Theory to ISOFI IS: For this par-ticular challenge, the ISOFI team developed an in-tervention module based on an innovative applica-tion of PAR to development practice: ParticipatoryLearning and Action (PLA). For ISOFI’s purposes,the PLA exercises were focused around gender andsexuality as they related to the host project’s pur-pose - e.g. improving maternal health among ruralwomen or improving safe sex practices amongmobile populations. This module serves multiplepurposes: It expands and reinforces personal andprofessional learning; it deepens organizationallearning and promotes genuine partnership; it trans-fers ownership and builds capacity of communitymembers; practically speaking, it identifies specificentry points where gender and sexuality can bemore effectively addressed, and provides abundantinformation for "tweaking" project strategies, inter-ventions and project materials. PLA of various scopeand themes can be conducted throughout theproject life cycle; however, the ISOFI team under-took the first PLA as the earliest stage of personallearning was drawing to a close.

Among its principles, PLA promotes ownership,diversity of meaning and experience, collectivelearning and action, and social transformation.ICRW developed field guides for the PLAs in India;

ISOFI participants developed expertise in applying PLA tools to theissues of gender and sexuality. Here a staff member from CAREVietnam uses cartooning to depict "most significant change" as itrelates to ISOFI's impact on personal and professional spheres.

ISOFI staff adapted PLA tools in the course of their fieldwork. HereCARE India staff interview an adolescent girl on her sexual and repro-ductive health history, using a bi-directional timeline.

23

worthwhile human purposes…,” and more spe-cifically, “[i]t seeks to bring together action andreflection, theory and practice, in participation withothers, in the pursuit of practical solutions to is-sues of pressing concern to people, and more gen-erally the flourishing of individual persons and theircommunities.” Within Action Research, there areiterative cycles of action, analysis and reflection thatlead to an ever more precise articulation of theresearch problem and foster ever-increasingdepths of perception to those seeking solutionsto real-world problems. By virtue of these itera-tive loops of action and reflection, change occursthroughout the research process; the researchteam is constantly adjusting its conceptual frame-work so that it accurately reflects "reality" as lay-ers of meaning are unveiled.

managers and field staff through a structured pro-cess that focuses initially on personal learning andchange around gender and sexuality, then by de-sign helps participants move forward with organi-zational learning and change and application to fieldinterventions.

As a methodology inspired by Freire’s pedagogyof emancipation, the ISOFI IS seeks to empowerand build the social capital of all individuals involvedin its process: community members, service pro-viders, NGO partners, field staff, managers andtechnical advisors. At its core, the ISOFI IS up-holds the principles of critical consciousness, praxisand social action. ISOFI exercices prompt partici-pants to question, critique, reflect and envision.As such, participants begin to perceive their livedexperience of gender and sexuality through a newlens and, within a supportive environment, inte-grate new thinking around gender and sexuality intotheir personal frameworks as well as begin to ap-ply new principles to their work as agents of socialchange.

Text Box 7: Post-ISOFI Perceptions on Integrating Gender and Sexuality

Headquarters Perspective

I am more aware of how words reflect my subconscious atti-tudes, and how I need to be more conscious of child-learnedversus adult-learned attitudes. (CARE Advisor)

…[W]e are better at avoiding a victim perspective of women.We see women as agents able to make choices. This is aradical change. We are also better at seeing how masculinityis constructed in ways that hurt men as much as it hurts women.(CARE Advisor)

…[T]here is momentum, but it needs concerted attention.Because ISOFI was only two years, we’ve only made a dent inhow individuals within CARE look at the issues; it takes a lotlonger to get groups of individuals to change the way they dobusiness. (CARE Advisor)

Field Perspective

ISOFI started in May 2004. By September 2005 we were ableto talk very confidently about issues of gender and sexualitywith elected officials. By October 2005, we started organizingfolk shows with [themes of] gender and sexuality. (India)

…[P]ower ranking helps us to identify sub-groups inside agroup - for example, HIV-positive people. Sub-groups have dif-ferent challenges… Understanding resources and power amongthe beneficiary group[s]…helps me to [design] better inter-ventions. (Vietnam)

What [ISOFI] has given me as a person is the confidence to goahead, the opportunity where I can with my team work out, tryout, experiment and learn... make mistakes… and yet learnto do things in a different way. (India)

24

this field guide was adapted for use in Vietnam. Inkeeping with the tenets of PLA, a variety of quali-tative tools are used to collect and analyze infor-mation; recommendations focus on immediateapplication of new learning to action. Tools usedduring the ISOFI PLAs on gender and sexuality in-cluded: social and vulnerability mapping; bodymapping; Venn diagram; cartooning; bi-directionaltimeline; and stakeholder analysis, among others.Visuals developed during the PLAs appear through-out this report. Full reports from the PLAs ongender and sexuality are available from CARE Indiaand CARE Vietnam.

Conclusion: Drawing from the domains of socialpsychology, androgogy and Participatory ActionResearch, CARE and ICRW developed a field-basedInnovation System to complement and enhanceCARE’s multi-year initiative to address gender anddiversity in relevant operational and programmaticareas. As described in detail above, the ISOFI IS iscomprised of five intervention modules: PortfolioReview and Needs Assessment; Gender and Sexu-ality Training; Reflective Dialogues; Personal Learn-ing Narratives; Participatory Learning and Action

on Gender and Sexuality; and a participatory evalu-ation module. As a defined system, ISOFI guides

Chapter 3

Inner Spaces: Deeply Personal and Inherently Systemic

If you are something from inside and you portray some-thing else on the outside… you cannot do anything…(India)

…[W]hatever is there in your heart cannot actuallybe taken out. (India)

[Now] we understand each other. [ISOFI] gave us anopportunity to open our hearts and share our feel-ings. We talked about things which we never men-tioned in the past. (Vietnam)

As reflected in the quotes above, ISOFI facilitatesexamination of one’s own beliefs and attitudes withthe assumption that such inquiry leads to personaltransformation (Freire, 1985). Peter Senge andcolleagues (2004) indicate that, “in order to ‘cre-ate the world anew’ we will be called to partici-pate in changes that are both deeply personal andinherently systemic.” Indeed, a central assumptionunderpinning ISOFI is that personal change is a nec-essary component of an authentic program em-bodying transformation. One cannot challengeharmful social norms such as gender and sexualityinequities, either in communities or within CARE,without also examining one’s own subjective posi-tion. Rather than simplifying complexities of gen-der and sexuality, through ISOFI, CARE staff werecalled upon to explore, question and reflect in aniterative process, which gave way to multiple per-spectives in a variety of field contexts. That is, staffperceptions represented different views that bothchallenged and contributed to their personal de-velopment and organizational commitment.

ISOFI practices reveal that the process of reflec-tion and personal change is most effective when

tional culture (Oxfam 2003 cited in Moser &Moser, 2005). ISOFI was designed with the un-derstanding that ISOFI project staff could realisti-cally expect to achieve at the program level onlywhat they could achieve within the organizationitself. External facilitators, community membersand staff challenged beliefs and perceptions which,as predicted, led to disequilibrium in theworkspace. As Kurt Lewin (1951) attested yearsago, if people share a common objective, they arelikely to act together to achieve it. An intrinsic stateof tension within group members motivates move-ment toward the achievement of desired com-mon goals (Johnson and Johnson 1995). Reflec-tion, disequilibrium and dialogue prompts individu-als to contemplate action that is most successfulin a group setting, since it provides psychologicalsafety to "embrace" error and learn without judg-ment (Michael, 1973, 1992; Schein, 1995). Thisrepresents the heart of the ISOFI approachadopted by CARE through the support of ICRW.

strengthened through provocative training, reflec-

carried out collectively. Participating in a group thatis organized around shared meanings leads to co-ordinated and effective action (Bohm, 1985; Isaacs,1994; Jaworski, 1998). Group relationships -

tion, dialogues, supportive coaching and partici-patory interventions - form the basis of problemsolving, leading to formation of decisions, whichare best implemented by those who make themcollectively (Lewin, 1946; Schein, 1995, 2006;Trist, 1975). CARE and ICRW maintain that tan-gible progress on gender issues, such as genderequality, is intrinsically linked to shifts in organiza-

25

A sense of solidarity with beneficiaries grew asISOFI processes cultivated interdependencyamong actors. Staff observed various kinds ofcommonalities they shared with NGOs and gov-ernment partners as well as communities. Thishelped them to question socially constructed bar-riers such as class, religion and caste. The dis-tance between themselves and community stake-holders began to diminish. It became notable thatwhen ISOFI teams engaged in meaningful conver-sations with the communities, things changed.Both staff and communities developed new lev-els of trust for one another; they became morecooperative and forgiving. They engaged moreequally as members in a process. As one PLA par-ticipant from India reported, “the boundaries be-

Even if you [change your actions], you can do it intentionallyinitially, but then it becomes part of your personality. (India)

Now I argue that there should be a distinction between whatyou personally think and what is accepted at social level…(India)

The workshops and reflections helped me to understand thateach person has his/her own identity and nature and I can’tchange them according to my wish. I should accept them asthey are. (India)

themselves and their colleagues that reflectedgreater tolerance and acceptance of the beliefs,identities and behaviors of others. This meltingaway took place through participation in reflec-tive dialogues and continuous co-creating and re-creating project interventions - which ultimatelyrepresented a gateway to authentic personal andorganizational change.

As Robert Chambers (2005) describes, when alearner interacts with a poor person as teacher, thechallenge is to know how to adapt – the sheer unfa-miliarity of it all, with so much to take in, and thenafterward the opportunity to review, reflect and

26

In the beginning, I felt so uncomfortable talking to the sex work-ers when we engaged in participatory exercises. I couldn’t bearto hear their language. Although I made it through each day, Icouldn’t sleep at night. I had nightmares until I suddenly realizedthat they were like me - they were mothers with children tofeed. They had the same concerns that I had about earningenough; we were not very different from each other. I felt muchbetter, and my nightmares went away. (India)

So now I tell myself: No, I am not going to get swayed by whatmy father says. I’m not going to get swayed by what my hus-band says. I have to find my own perspective… (India)

Inner Spaces: Reflection and PersonalChangeA heavy emphasis on "unfreezing" personal beliefstook place, particularly in the early days of theinitiative. As one participant recalls, “ISOFI hasmelted a stone.” Almost all staff reported that per-sonal transformation helped them let go of oldideas, thereby influencing their behavior and hav-ing lasting effects. The reported changes becameincreasingly apparent as staff narrated stories about

tween CARE staff and community stakeholders dissi-pated.”

digest the experience – it's a powerful experience.Not only does the interaction reveal new insights,but it challenges values, beliefs and raises questionsabout the sort of people we are and want to be.

Women in ISOFI Who InquirePersonal change among CARE staff was reflected instories of familial and community relationships. Sev-eral women described ways they challenged tradi-tional norms and values within their families. Onewoman asserted the following:

ing images of the ideal man, for example, theyobserved that men also endure pressure and beara different kind of discrimination by reinforcinggender dichotomies. During this exercise, togetherwith men in the communities, CARE staff spoke ofunanticipated findings, including male burdens to

By shifting their behavior from traditional maleroles to ones manifesting emancipatory qualities,these male staff experimented with changing powerdynamics within the private domain of their homes,where gender is generally most deeply rooted.Testing new behaviors, with support of colleagues,they cultivated confidence and commitment to sup-port similar transformative processes within theirworkplace and in the communities where ISOFIoperates.

Sexuality: Learning by InquiryMany staff stated that before ISOFI they avoideddiscussing matters related to sex, since it was gen-erally forbidden to do so, even between spouses.As time progressed, however, comfort levelsbroadened as staff increasingly discussed mattersof sexuality more candidly. As one CARE Vietnamstaff reported during a reflective dialogue, “I ammore comfortable to discuss sexuality… I do not feelshy or embarrassed any longer.” Pleasure was dis-cussed in the context of decisionmaking and con-sensus between adults. Staff and project partnersdeliberated while co-producing, improvising andpromoting exploration, excitement and fun. It wasin this context that personal commitment to jus-tice and "doing what is right" evolved.

By taking stands, as reflected in the quotes above,women stepped out of traditional roles that re-portedly restrained them. Several women revealedthat they became more self-assured in both theirpersonal and professional lives. After discoveringtheir voice and understanding that it is their rightto use it, a few women revealed ways they hadtaken the initiative in seemingly insignificant ways.Female staff often spoke about having more cour-age and trust in themselves to make decisions andbe leaders. They attributed these changes to thenumerous candid discussions held with colleaguesand family members over the course of their ISOFIexperience.

It is my right to share what I want or tell to anybody with whomI am having relations. I have to share my feelings and my views.I have seen this change in me and I feel that it is because ofISOFI only. (India)

I am different now, more confident. I don’t accept roles justbecause I’m a woman. I know this is difficult in my society,since Vietnamese men are not interested in such independentwomen. But now I can’t go back to the old way. (Vietnam).

Men in ISOFI Who InquireA few men described their once-held beliefs ofgendered roles reflecting conventional attitudesabout women in relation to family responsibilities.Several participatory exercises led men through areverse analysis of gendered roles, allowing themto consider gender-biased expectations of men andnot only those applied to women.

Many male staff grappled with gender conceptsmore constructively as they became conscious ofoppressive masculinity constructs through PLAtechniques that were then strengthened by ongo-ing reflection, coaching and trainings. By depict-

impress girls, earn adequate salary and develop amuscular body. They spoke of “looking good” andthe skill it takes to “trap girls to fall in love.”

Actually, when I talk about my wife, I feel that she is alwaysconfined to the four walls of the house. I used to feel that everywoman does this for the family. But I took a decision… I wouldlook after the house the whole day today. After doing that, Irealized that I did not get even five minutes of break. (India)

In the past, I thought I would never wash my wife’s clothes. Butthe project helped me to have a broader view… (Vietnam)

Before ISOFI, I was never much into the gender thing. Now Ihave confidence in dealing with the issues related to genderand sexuality. ISOFI has brought gender into focus. (India)

27

Acceptable social norms relating to sexuality werealso challenged. For example, one staff member inIndia described a fictitious world in which a ma-jority of people identified openly as homosexual.Her colleagues contemplated how it would feel to

From Personal to Organizational ChangeTeams coalesced as trust was established. Greateropenness extended beyond gender and sexualityinequities that were specifically explored throughISOFI to include other forms of discrimination andinjustice. Several staff reported a sense of release

Once discussions of sex were normalized withinthe workplace setting and new perspectives re-garding pleasure, empowerment and meanings ap-plying to sexuality were introduced, CARE staff ex-tended these conversations to their families, a signthat new changes were in the process of refreez-ing. As one staff revealed, when referring to herspouse, “I need to be more expressive about my de-sires.” Awareness of one’s needs and one’s rightsin the context of marriage and seeing pleasure asfundamental, offered opportunities for staff to re-interpret their roles as sexual partners.

But now I can see that I have the right to refuse sex and also Ihave the right to ask for sex - because I realize that womenalso have the need of sex. (Vietnam)

I never used to ponder that sexuality can be enjoyed also…these can be very pleasurable activities not only for you, butalso for your partner. (India)

be a sexual minority (a heterosexual) if such a com-munity existed. They agreed that sexual orienta-tion and behaviors inconsistent with dominant be-liefs and norms could lead to displaced bigotry,which is antithetical to CARE’s core principles. OneCARE India staff reports her views: “I will nevermake fun of gays. Earlier I used to think that gaysare obsessed with just sex. But now I know they arenormal people.”

Challenges at HomeSome staff reported that although they themselvesare enlightened, they still struggle with encourag-ing similar change within their family and commu-nities. While they and their spouse may be moreopen to transform attitudes and behaviors, manyextended-family members continue to resistchange as shifts in power dynamics are revealed.Staff's concern over the reaction of others whengender stereotypes are challenged is raised as aconcern.

My husband and I talk very openly about sex, and he shares inthe household duties. But, I can see that the change in myfamily happens very slowly. I wonder who to convince, how totalk with other family members about gender and sexuality…you know it’s a difficult topic, especially for my mother-in-law.(Vietnam)

People around do not have the same orientation as me. Forexample, my wife’s knowledge and awareness on gender andsexuality is different than mine. She agrees that we shouldshare household duties, but says that I am the one in charge. Idon’t think that’s right. (Vietnam)

What will people think if I [a man] bring the clothes to wash inthe river, in front of all to see? (Vietnam)

28

As observed in the quotes above, ISOFI perspec-tives often enhanced relationships between sexualpartners. Moreover, individual capacities to claimagency, manifested by declaring one’s choice re-lated to both safety and desire, evolved spontane-ously.

Participants in CARE Vietnam's Gender and Sexuality Work-shop situate sites of power, pleasure, pain and shame throughbodymapping.

Diagram 2: ISOFI Stakeholder Analysis: CARE Vietnam

29

During the end-of-project workshop, participants were askedto conduct an analysis of ISOFI stakeholders at three pointsduring the project cycle: the beginning, mid-point and end.Lastly, participants were asked to envision the ideal configura-tion of partners and relationships as may be realized by 2008,given ISOFI's philosophy of empowerment. The exercise soughtto understand from the participants' perspective sources andrelationships of power and influence affecting ISOFI’s imple-mentation and evolution: who, what, when, why and how.

More specifically, the exercise led participants through a re-flection on organizational elements that could either foster orinhibit integration of gender and sexuality: Who played a cen-tral role in implementing and/or influencing the ISOFI project;what were those roles; how did relationships among stake-holders evolve during the course of project implementationand with what effect; and why did roles evolve as they did. InCARE Vietnam, ISOFI began (see above diagram) as an exter-nally prompted initiative, supported by senior managers andan ISOFI focal person. Local partners and ISOFI staff played akey role, supported by external technical resources. Key:ARMU is CARE's Asia Regional Management Unit, which isbased in Bangkok.

By the project's midpoint (see diagram above), senior manag-ers at CARE Vietnam had handed over responsibility for ISOFIto the ISOFI focal person. She in turn had increased responsi-bility in managing the project and in interacting with ISOFIcolleagues at CARE Vietnam. At this stage, technical supportbroadened to include local individuals and organizations withexpertise in gender and sexuality. Local partners became morecentral to the process as well as project beneficiaries andcommunity members. At mid-point, ISOFI participants rec-ognized that a number of CARE staff were not directly involvedwith ISOFI and were not benefitting from the opportunity forlearning and change.

ence. The Ford Foundation as a donor entered the picture asstaff were thinking of pursuing funding for a second phase.Beneficiaries and community members played a more sub-stantial role in ISOFI's implementation.

For the Vision 2008 (at right), participants indicated the im-portance of equal involvment among local partners, CARE staff,CARE senior management and the ISOFI focal point person.They felt in this manner gender and sexuality would be moreeffectively integrated into CARE systems and programming,and would be more effectively transferred to local partners.Media is introduced as a powerful communication channel fornormative change around gender and sexuality. CARE Austra-lia, CARE USA and ARMU disseminate ISOFI's learning through-out the CARE world.

By the end of the ISOFI (see diagram left), participants felt thatlocal partners had become more central to the initiative's imple-mentation and success. Non-ISOFI CARE staff were pulledcloser through outreach and curiosity about the ISOFI experi-

Diagram 3: ISOFI Stakeholder Analysis: CARE India

As explained in Diagram 2, during the end-of-project work-shop, participants were asked to conduct an analysis of ISOFIstakeholders at three points during the project cycle: thebeginning, mid-point and end. Once analysis was completed,participants were asked to envision the ideal configuration ofstakeholders to be realized by 2008. In India, CARE staff con-sider that, at baseline (see diagram right), the three mainstakeholders driving the ISOFI process are the ISOFI pointperson at CARE, the ISOFI resource people at ICRW and theFord Foundation. As a new project, the CARE Program Sup-port Unit plays an administrative role. The Bhilwara DistrictTeam that leads the ISOFI pilot in Rajasthan sees itself as dis-tant from ISOFI in the early phases of project implementation.

By mid-point (diagram left), stakeholders have shifted consid-erably. Central figures in implementation comprise a smallgroup of people and external resource organizations (e.g., ICRW,CREA and TARSHI) directly involved in creating and support-ing the learning, reflection, application on the ground and docu-mentation. Staff emphasize the critical role of the CARE coun-try director in providing feedback on the team's efforts andindicating his strong support of the initiative. At this stage, thedistrict team also names an ISOFI point person to centralizecommunications.

By endline (diagram right), NGO partners, community mem-bers and service providers play a much larger role in ISOFI'simplementation. This configuration reflects the district team'ssuccess in transferring knowledge on gender and sexuality andISOFI IS skills to NGO implementing partners, and the emerg-ing change within communities. Note as well the introductionof the CARE MOLD Unit, which is the internal learning unitfor CARE India. District team members were deeply con-cerned about documenting ISOFI's success for replication andscale up.

As a vision of an ideal configuration of stakeholders (diagramleft), the community, service providers and development ac-tors (including NGOs, government and to some extent theprivate sector) take center stage in sustaining ISOFI's imple-mentation. CARE is still centrally involved but its role shifts toone of support and accompaniment. The external resourceorganizations continue to refresh the process with new per-spectives on gender and sexuality, communication techniques,methodologies for evaluating progress, and materials. Thestaff clearly demonstrate their appreciation of a "Donor Sun"to support the initiative and help it grow.

30

As staff adjusted their life to one more consistentwith ISOFI principles, organizational change be-came inevitable. Trust and solidarity grew amongteam members as new perspectives were sharedand deliberated, and action was agreed upon col-lectively. As a result, communication among staffand with supervisors improved. But it was the staffwho changed the course of action at CARE. Su-pervisors provided and protected the space. Ex-perience revealed that shared assumptions ornorms cannot be changed one individual at a time.The critical interplay between the system and theindividual (Schein, 2006) became apparent as ISOFIproject staff observed how CARE influenced staffthrough relationships and at the same time, howstaff changed CARE as they themselves changed.

I think the best thing that happened is [ISOFI] helped in im-proving team work because the barriers diminished… it helpedin building understanding, I would say, a team able to relate toeach other. (India)

It helps us to share experiences among ourselves; that way wecan see gender, diversity and sexuality in our own organization.(Vietnam)

Our team relationship improved and became friendlier andmore open. We gained confidence and built camaraderie aroundourselves. (India)

We fear the jokes [of working on a sex project], but we alsorelish the opportunity to influence ourselves and our organiza-tion. (India)

Staff reported that they developed into more ef-fective colleagues and partners. Reflections andnew perspectives lead to actions that were notpre-determined based on conventional programpractices. Some staff expressed concern, however,about the seeming ambiguity and lack of clarity,since preset agendas and workplans were notforthcoming. They felt a need for more structureand conventional forms of program measurementand evaluation. Concerns were reported as follows:

ISOFI Timeline Rajasthan

Launch

of ISOFI

05/04

1st workshop

on G&S

06/04

2nd workshop

on G&S

07/04

PRNA

1st

RD

09/04 11/04 03/05 05/05 09/05 01/06 02/06

2nd RD

PLA in

Lucknow

3rd RD

4th RD

CARE

Summit

EOP

Workshop

31

and freedom with newfound perspectives. Theyexpressed excitement in sharing ideas, new knowl-edge and insights.

We feel liberation and wish others could become the sameway… (India)

I don't know when I started, but every night when I go to sleep,I reflect on all things that happened during the day. Since I'veworked for ISOFI, I started to think about people. (Vietnam)

I think ISOFI has created a big army of passion-driven peoplewho dream and sleep [gender and sexuality]. (India)

Mainstreaming gender and sexuality work requiresa radical change of mindset and behavior, whichplaces relationships at center stage.

But even at the first workshop or the “orientation workshop,”I wasn’t clear about the concept, because at that time theydidn’t provided the guideline of activities or objectives, and theway we integrate sexuality and gender into the existing activi-ties of our project. (Vietnam)

We need to spell out more clearly what we want. Like, youknow, the objective of ISOFI so that we can interlink it withprogramming. (India)

We were excited about working on gender and sexuality butwe also had fears and apprehensions. We asked ourselves,what should we do, what will this mean to us? What willhappen to our privacy? (India)

By and large, staff became comfortable with themurky (often perplexing) mental terrain that ac-companies critical examination of oneself and one’srelationships. Reflective practices facilitated reex-

Initially we thought [ISOFI] was going to be burdensome, but later on wewere flying. (India)

Gradually, institutional policies changed. For ex-ample, both CARE Vietnam and CARE India desig-nated a point person to lead gender and sexualityintegration activities. To ease the burden ofchildcare for staff, one of the ISOFI sites estab-lished a crèche. A community of practice was es-tablished in another ISOFI site to enhance learningamong and between CARE staff and communities.Since ISOFI did not provide directives or top-downinstructions, managers developed solutions based

There is increasingly more support among management whobelieve work on gender and sexuality are important. (Viet-nam)

I am a better supervisor now…. There are no definite answersin the realm of gender and sexuality, so we are okay withmaking mistakes. (India)

ISOFI doesn’t tell you what to do. It just lets you grow and helpsyou to learn with your mistakes. It has helped us to actuallytake ownership. I think that this is what it has done for theentire ISOFI team. (India)

We had the liberty to design and create interventions… (In-dia)

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amination of once deeply held assumptions amongmany staff members. In many cases, this producedtension and uncertainty within the group. Withinsix months, however, staff relied more on intuitionand learning through innovation and reflection thanon a fixed approach based on a conventional gen-der mainstreaming model.

While embracing new attitudes and beliefs relatedto gender and sexuality, they also adopted an au-tonomous working style. It encouraged both inde-pendent thinking and team collaboration, which in-stigated meaningful action. As a result, staff becamecommitted to the ISOFI process and more confi-dent in once unfamiliar territories. Examples in-clude:

In the beginning, I found it difficult to find the answers on myown. I wanted more guidance. But today I see the advantageof the ISOFI approach. I can do things on my own togetherwith the team. Now we would like our supervisors to havemore confidence in us to take the next steps in ISOFI. (India)

ISOFI didn’t push us to learn or integrate certain things in ourprojects… it let us feel comfortable and if we feel it isnecessary, we find a way to integrate it into our work.(Vietnam)

on reflections from staff and learning from the field.Consequently, staff claimed that supervisors be-came more supportive, and supervisors reportedthat ISOFI strengthened them in their role as man-agers.

ConclusionThe findings reveal that personal change took placeacross all ISOFI sites in India and Vietnam. Thesechanges impacted not only CARE staff but also theirfamilies, communities and the CARE organizationitself. Staff in Vietnam discussed obstacles and con-cerns they confronted, particularly in their attemptsto intervene with gender and sexuality messages intheir families and communities. In contrast, Indianstaff reported stories of change within their fam-ily, communities and their teams. In both coun-tries, the participants believed that strong supportfrom CARE and ICRW staff enabled the project tomove forward successfully. While staff from bothcountries cited that the lack of clear goals, objec-tives and outcomes represented challenges, theyalso appreciated the fluidity and flexibility offeredthrough the ISOFI approach.

During the first year, CARE and ICRW focused onfostering personal change - transforming innerspaces - through reflection. Reflective learningmethodologies first developed by Freire (1985)and Lewin (1946, 1951), gave rise to uneasiness,particularly with the introduction of sexuality in theearly stages of exploration. As staff became morecomfortable with the material and new processesof engagement, greater openness, confidence andleadership emerged, particularly among women,

who assumed the leadership role in ISOFI. Malestaff changed the way they understood and prac-ticed gender equity. Consequently, personal trans-formation lead to organizational changes, reflectedin policies such as appointing gender and sexualitypoint persons. But more importantly, staff workedmore cooperatively and thereby continued advanc-ing collective action practices that supportwomen’s rights through new understandings ofsexuality. This included working with men to re-construct masculinities that are less harmful to bothmen and women. Parallel changes among staff andthe organization present opportunities for recip-rocal learning between the individual, team and theorganization as a whole. This chapter exploredthese personal and organizational transformationprocesses that took root at CARE through ISOFI.It represents the basis for programmatic changedescribed in Chapter 4.

33

A folk theater team from Rajasthan used findings on coercivepower relations between truck drivers and cleaners to beginto address, through puppetry, the causes, manifestations andconsequences of these power imbalances in the context ofHIV/AIDS.

Chapter 4

34

Outer Faces: Field Application and Program Transformation

Before [ISOFI] a good girl was someone who stayed home andwas sweet; now we believe that standing on your feet is a goodthing. (Adolescent Girl, India)

The vagina is the future and happiness of the family. (Vietnam)

Like my father, there was no education for me or my sister, butI send my daughter to school. My father scolded me so I ex-plained it to him. (Migrant Worker, India)

IntroductionGender and sexuality-related inequities lie at theroot of poor sexual and reproductive health, in-cluding HIV/AIDS risk and vulnerability. As impliedwithin the ISOFI framework, personal learning andchange around gender and sexuality will, in turn,lead to desirable changes in field practice – andwill foster improvement in program quality whileenabling community agency. When commenting onISOFI’s effect on program strategy, a staff mem-ber from CARE India remarked, “empowermentwithin is important as we work towards empower-ment of communities.” This statement encapsulatesthe spirit of ISOFI, serving as the root of its suc-cess. This chapter focuses on “empowerment ofcommunities.” It builds on previous chapters bydescribing ISOFI field applications and their trans-formative effects on programs.

As findings from ISOFI reveal, sexuality is part oflife. Whether for physical, emotional and psycho-logical well-being or whether for livelihoods, sexu-ality is central to human existence. Sexual rightsare a precondition not only for reproductive rights,but also for gender equality (Cornwall, 2004).Viewed as a site of oppression through an almostexclusive association with disease, danger and over-population (Gosine 2004; Vance 1984; Jolly, 2004),

sexuality is largely avoided by development practi-tioners. Widely held as key preventive measuresin the larger interest of the public’s health, inter-ventions that restrict sexuality have come to theforefront in recent years.

Gender power relations are rarely taken into ac-count when trying to understand human sexuality(Dixon-Mueller, 1993). As the ISOFI pilots illumi-nate, several masculinities coexist, ranging fromdominating to accommodating ones. ThroughISOFI exercises these masculinities are examined,opening them up to reconstruction by rewardingthose masculinities that emphasize reconciliation,self-analysis and collaboration (Connell, 2000). Acombined framework consisting of both publichealth and human rights provides an opportunityto understand what is meant by women’s rightsvis-à-vis men. Understanding the ways that sexu-ality influences gender places women in a new per-spective - as resilient, rather than as victims – andprovides the groundwork for promoting womenas agents of change. Human rights principles offerstrategic tools for advancing well-being, centeringon women’s ability to set the course of their ownlives (Gupta 2003; Freedman, 1994) and men’sopportunity to explore and recreate gender andsexuality constructs that reflect cooperation andjustice.

This chapter reports on the extent to which ISOFIchanged the nature and content of CARE’s healthinterventions and influenced program implemen-tation. Findings demonstrate the ways reflectiveand participatory methodologies, when applied tointegrating gender and sexuality, lead to real, tan-

35

BackgroundIn addition to individual and organizational changeamong CARE staff and systems, changes were alsoobserved among partners and/or communities inall three ISOFI pilot sites. As reflected in the lit-erature above, gender inequities represent key un-derlying causes of vulnerability affecting reproduc-tive health and HIV/AIDS risk. A key program as-sumption – that norms of sexuality affect genderroles and behavior in SRH and HIV programs –was explored through qualitative methods de-scribed in Chapter 2. Through ISOFI, CARE andICRW found that exploration and familiarity of one’sown sexuality, for example, reduces prejudice, ex-pands comfort zones and eases communicationaround sexuality. Greater ease, in turn, enhancescounseling on condom and contraceptive use, forexample, which is often reported by field staff asan embarrassing undertaking.

As discussed in Chapter 2, ISOFI consists of a se-ries of intervention modules that enhances personaland organizational learning and change. The fifthintervention module comprises ParticipatoryLearning and Action (PLA) exercises structuredaround gender and sexuality with target popula-tions (e.g., truckers, sex workers and lactatingwomen). Building on cumulative learning generatedthrough the first four intervention modules andongoing project work, the PLA exercises are con-ducted in collaboration with implementing part-ners and target groups. Their specific purpose isto gather information around gender and sexualityas they relate to a particular theme, for example,reducing vulnerability to HIV/AIDS. During thePLA, CARE field staff are able to communicate pre-vious relevant learning around gender and sexual-

Accompaniment Through the Messinessof Altering Long-Held BeliefsOnce CARE staff were themselves more comfort-able with gender and sexuality, their roles becamethat of facilitators, supporters and innovators aspartners increasingly assumed more direct respon-sibility for the application of ISOFI to field activity.CARE staff accompanied partners throughout theirlearning process as NGOs gained new insights andcapacities through supportive coaching, co-facili-tation opportunities and joint reflective practice.NGO and government partners became moreconfident dealing with gender and sexuality as theyexplored their own internal beliefs and values re-lated to gender and sexuality. One ISOFI site inIndia established a gender and sexuality “commu-nity of practice” consisting of staff, partners andcommunity members. The members of the com-munity of practice use storytelling techniques tofacilitate dialogue and share lessons learned throughISOFI.

As with all development work that seeks to changesocial norms, critical and potentially harmful reac-tions can and do occur. Such was the case of apotentially violent incident in Lucknow, India, in-volving a young married woman previously beatenby her father-in-law for participating in an ISOFI-sponsored activity. In her determination to attendthe activities a second time, she slipped out of thehands of her father-in-law in his attempt to beather for leaving home against his orders. In responseto this and other such incidents, CARE staff re-flected carefully on whether and how to get in-volved in domestic violence within the commu-nity. Rather than advise the young woman whetheror not she should continue to attend ISOFI activi-ties, the CARE staff accompanied community

gible change on the ground. CARE works throughpartners in-country, namely government agenciesand NGOs; this chapter summarizes changes re-ported by partners in all three ISOFI pilot sites,two in India and one in Vietnam.

ity to implementing partners and target groups,while all three parties are involved in gathering in-tervention-specific information around gender andsexuality to refine project strategies, interventionsand activities.

36

their learning around gender and sexuality. As dis-cussed with ISOFI implementers, harm may arisewhen intervening in communities, not due to re-flective interventions but because of the inequitiesalready entrenched in most societies. Reflectivepractices bring these issues to the surface, pro-viding opportunities to contemplate action.

As reported by NGO partners in India and Viet-nam, ISOFI has positively influenced their perfor-mance working with the community on reproduc-tive health and HIV/AIDS interventions:

Before the training, I was ashamed of my work with sex work-ers. Now I realize how important this work is. (NGO Partner,India)

CARE partners are more confident to provide counseling, andthey are able to talk without shame and shyness. (Vietnam)

vided invaluable grounding through gender andsexuality training in the early phase of ISOFI. Theyaccompanied staff through consultations and re-views. ISOFI implementing partners consisted ofgovernment counterparts from the ministry ofhealth in India and ministry of youth and women’saffairs in Vietnam. NGO partners included thoseworking locally, consisting of health and welfareNGOs in India and youth NGOs in Vietnam. TheISOFI team aimed to influence partners on ISOFIprinciples while also building local capacities di-rected toward local contexts and needs.

Changing What We Do:New Interventions Show Promising ResultsWhen I participated in ISOFI activities, we normally talkedand shared personal opinions. So I used this same process todiscuss with the project partners and communities. (Viet-nam)

CARE staff depict ISOFI in 2004 as a CARE Jeep pulling staff, NGOpartners and community members up a steep learning curve. By2006, many individuals are comfortable with the concepts of genderand sexuality, several move fast ahead on the issues, while othersreturn to former values and norms. CARE is returning to assistmore people to transform their attitudes, beliefs and practices aroundgender and sexuality. (India)

women who were angered by the violence com-mitted against many woman in their community.The women convened to develop and implementa strategy to address male-perpetrated violenceagainst village women. Two years later, CARE staffreport a dramatic decrease in male-perpetratedviolence against women within this community. Inanother ISOFI site where violence against sexworkers was rampant, government counterpartssuch as law enforcement agencies, which are knownto perpetrate frequent and severe abuse againstsex workers, now request technical assistance fromCARE and its implementing partners to support

Voices From Field Staff and PartnersPartners have been critical to the ongoing successof ISOFI. Not only for the purpose of scaling upand enhancing the spread of innovations, but alsoto ensure continuity and connection to commu-nity systems such as the local village governingcouncils in Rajasthan or the youth unions in Viet-nam. ISOFI worked with partners on two levels -those that staff learned from and those that stafftransferred knowledge and capacity to. ExpertNGOs, including CREA, TARSHI, CHIP, LIFE, pro-

2004…

2006…

Road to Gender & Sexuality

There are many more left

CARE

CARE

37

People Change While Programs TransformHIV-infected men seem to have as much difficulty with socialcontact and relationships as women. Women do not dare toexpose themselves to other people and the community. So Ihave come up with different approaches to work with thesedifferences. (Vietnam)

But things have changed a lot for me. In the beginning, I wasn’tallowed out of the village. There were constraints on my mo-bility in this village since it’s my marital - not natal - village.So there were restrictions on where I was allowed to go. Imag-ine? I was the village Angan Wadi worker, but not allowed tovisit the homes [to do what was expected of me]… Now Ivisit all the homes. What influenced my husband was myown personal change, but also the men’s meetings also influ-enced my husband. (Angan Wadi Worker,1 India)

In addition to personal experiences that promotedcritical examination of biases, ISOFI improved pro-gram quality by enhancing behavior and socialchange approaches. For example, ISOFI-informedtraining of trainers for health service providershelped change provider attitudes toward high-riskgroups, youth in particular. ISOFI principles havebeen integrated comprehensively into capacity-building strategies rather than handling gender andsexuality as stand-alone sessions. In reference tonew and modified interventions, one staff mem-ber from CARE India reported: “We discuss every-

Diagram 4: Bodymapping Exercise

CARE field staff adapted ISOFI modules and tools to suit the needs of imple-menting partners. An ISOFI workshop designed for local NGO partners inIndia included experiential exercises exploring how sexuality mediates genderconstructs. In this workshop, staff avoided a narrow problem-focused per-spective on sexuality, concentrating more on a sex-positive approach. In thecourse of the workshop, participants defined sexuality as “whatever we feelabout sex, like singing,” “dancing, playing;” “a belief based on human values...which keeps on changing with the time.”

CARE staff also facilitated a body-mapping exercise that explored points ofpower, pleasure, pain and shame, a very popular exercise with ISOFI-trainedstaff that allows participants to reflect on personal experience. As reported byworkshop participants, body mapping serves to “decrease shyness” and pro-vide “good information about the opposite sex.”

Right, a field exericse with recently married men in rural Lucknow District, India.

We had a cross visit for the community women - a big achieve-ment. We gained huge trust from the community. Commu-nity women were allowed to go with us. It was a high. (India)

CARE staff worked differently after adopting ISOFIprinciples and practices. Members' transforma-tional experiences generated new program designsand activities, particularly behavior-change activi-ties, that were continually analyzed and reshaped.In India, staff implemented a cascade of capacity-building exercises designed to multiply ISOFI’s ef-fect across implementing partners. As CARE staffcompleted ISOFI modules and exercises, they ap-plied a similar process to their collaboration withstate-level bureaucrats and district-level govern-ment workers. In India in particular, NGO stake-holders operating in ISOFI sites participated inmost ISOFI activities and events. A state-level ad-visory committee was created in both Indian statesfor community health needs, in which gender andsexuality were included. CARE staff reached com-munities through partners. At each level, ISOFIimplementers established trust as relationshipsgrew through consistent interaction and by con-sciously acknowledging participants' local exper-tise.

1 The local health volunteer, or Angan Wadi Worker (AWW), is the infant- and child-development services field worker, sponsored by the Indian government. She receives

a token compensation for her activities at the Angan Wadi Centre (AWC),�where she provides supplementary nutrition for children and pregnant and lactating women;

immunizations; nutrition and health education. There is one AWW per AWC; there is one AWC for a catchment area of 1,000 people.�

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Text Box 5: Imagine a World in Which... Reflection through Storytelling in India

In response to entrenched attitudes among NGO implementatingpartners about sexuality and their denial that homosevuality ispracticed in India, ISOFI staff developed a series of exercisesmeant to unfreeze these attitudes. This storytelling exercisefeatured several interactive exercises on gender and sexuality.The story sparked considerable debate. During the course ofthe storytelling exercise, participants voiced the following re-actions to the scenario:They feel awkward;Will have relations with other heterosexuals secretly;Opposite situation is difficult and bad;

The Story: One day you are passing through a forest. There, amagician transports you 60 years into the future. In this new world,the majority of people are homosexual. A small percentage ofpeople are heterosexual. Heterosexuals don't disclose their sexualorientation to others, as others do not accept heterosexuality there.Your sexual identity in the future is the same as it is today. In thissituation, what will you do, and how will you feel?

By the end of the workshop, participants made the fol-lowing observations:Homosexuals can also live life freely like heterosexuals. We shouldnot discriminate against them;We should give more importance to personal feelings than socialconstraints;We shouldn't make decisions due to the fear of society.

ISOFI staff felt that the story had been very successful in open-ing channels of communication. During the ISOFI end-of-projectevaluation, many NGO participants mentioned the exercise andthe workshop specifically as signficant to their personal learn-ing and change around gender and sexuality.

No need for family planning;No pleasure;Threat to masculinity;Will change [sexual orientation] according to the situation.

thing, topics related to homosexuality, adolescent sexu-ality, extra-marital and premarital affairs.” Field staffspent evenings and weekends gathering together todiscuss gender and sexuality. Using a gender andsexuality lens in their daily work became a matterof course, e.g., in designing baseline surveys, creat-ing programs and information, education, commu-nication (IEC) materials and training new staff.

To manage sensitivities related to sexuality, CAREstaff in India focused on using sexuality concepts asa way to strengthen the family. An entry point toaddress a once taboo subject, the family repre-sented a way to remain within cultural boundaries.Within this framework, staff covered several top-ics including: communication between husband andwife, and mothers and daughters; increased nutri-tional intake for girls; sending girls to school; andviolence against women, including sex workers. Byand large, these themes represent protective be-haviors to reduce the risk of HIV transmission andimprove reproductive health. Within this context,staff and partners integrated reflections on sexual-ity and its effect on gender and health into activi-ties as a matter of course. Discussions emphasizedpleasure, not as a separate issue but within the con-text of risk reduction.

ISOFI training exercises also included explorationof the world of sexually-marginalized groups. Dis-cussions centered around sex workers, people whohave sexual relations before or outside marriage,and homosexuality. Together with implementingpartners, staff undertook various creative exer-cises, such as drawing images of the socially-de-fined “ideal man” and “ideal woman” to stimulatediscussion on norms, conformity and social pres-sure. When challenges arose in assisting NGOsand community groups, CARE staff developed newexercises to overcome these challenges. (See TextBox 5 below.)

Many partners and community members involvedwith ISOFI indicated that their inhibitions reduceddramatically. In Vietnam, monks told staff that priorto ISOFI, they felt shy when their clients visitedthe pagoda to talk about condoms and their sexualrelationships with HIV-positive people. When sexu-ality was first raised in ISOFI, they felt uncomfort-able, since it contradicted certain Buddhist tenetsrestricting monks from sexual activity. Once theyrealized that desire and pleasure are linked to lifeand death, they began to discuss sexuality withgreater ease and to value its importance when en-gaging with their communities.

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Voices from the CommunityThe barriers between castes have broken. Now we are moreof a friend. Earlier we used to discriminate a lot. As we startedcoming together and attended several meetings, all hesita-tions have washed out. To hell with the caste system. All hu-mans are alike and same, their blood, too. Then why shouldwe discriminate with others. (Young Woman, India)

ISOFI approaches are situated within local con-texts and address real-life issues. In large part theexplanation for communities' willngness to partici-pate and to endorse findings. As a dialogical pro-cess, ISOFI prompted open communication indefined and maintained “safe” spaces. As theyshared experience and insights into gender andsexuality, women’s and men’s stories spanned gen-erations and ethnic groups. These differences

Women’s storiesWe are more cohesive as a group of women. We have sessionswhere we tell stories…. We are no longer afraid. (Women,India)

We live in different corners of the village, so we don’t meetoften. Now we have met new friends. (Women, India)

ISOFI interventions with women in rural Indiancommunities focused largely on strengthening themahila mandals (women’s group) through villageAngan Wadi workers.1. One of four mahila mandals,strengthened through ISOFI, described their storyPrior to ISOFI, many of these women remainedsecluded within their homes and were not awarethat they shared comon problems with womenliving in the same village. Through ISOFI exer-cises, they became acquainted, realizing theyshared similar concerns. After reflection and dia-logue, they took collective action in their commu-nity to address their shared agenda: strengtheningfamily relationships, particularly between husbandand wife; shifting bias against the female child; andreducing violence against women. ISOFIimplementers accompanied partners and the com-munity through these processes.

Family Relationships asa Site of Resistance and ChangeA lot of things changed in me personally. There is better com-munication with my husband. At first he thought it was odd todiscuss things… the first time he laughed. CARE encouragedus; so I said to him, you won’t get angry. If we don’t talk aboutlikes/dislikes, things will go unresolved. So he likes talkingnow. [Smiles]. (Angan Wadi Worker, India)

Earlier, our husbands got angry. Now I share and he listens andhe doesn’t get angry. (Community Woman, India)

Interventions to improve family relationships oc-curred through various approaches. Staff in Indiabelieved that sexuality themes were best discussed

Resistance as a Sign of EngagementSome partners were a little skeptical because they thoughtthat we were biased towards women and were providing infor-mation in favor of women from a gender point of view. (India)

Sexuality and pleasure is very sensitive to discuss, so we don’ttalk much about sexuality. (Vietnam)

While new modes of working inspired quality pro-gramming, some staff also reported challenges.CARE staff and staff from implementing partnersoften raised challenges in relation to sexuality and,at times, gender, including concerns about howthey would be perceived by their communities ifthey were visibly supportive of gender. Sometimesstaff viewed these challenges as a setback and grewfrustrated with other, less supportive team mem-bers. A few people shifted back and forth withintheir positions on gender and sexuality, while lead-ers, passionate about recent insights, began toemerge. What did not arise, however, was heavyresistance from the field. Communities did notoppose discussions challenging entrenched beliefsregarding gender and sexuality, as was anticipated.Instead they welcomed reflective experiences, par-ticularly those that discussed social restrictions,such as caste and ethnic differences.

helped to provide a rich and diverse social con-text in which to question boundaries and restric-tions, such as those produced by caste and ethnicdifferences.

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In the earlier days, my husband wanted sex every night andwould beat me if I didn’t agree, even though I had swelling inmy groin. Now he has reduced to having sex with me everythree to four days. Now if I have pain, he stops, and doesn’tbeat me any more. I can even enjoy sex now. And I, myself,have initiated sex. This makes him happy. [Laughs]. (AnganWadi Worker, India)

The vagina is the center of the city and the rest of the body isthe suburbs… it is the site of intense pleasure but also thepain of child birth. (Sex Worker, Vietnam)

As these quotes demonstrate, several communitywomen understood sexual pleasure to be an im-

Violence Against Women and Women’s Mobil-ity: What Does Sex Have to Do With It?Staff accounts and women’s stories reflected a re-duction in violence against women in ISOFI com-munities. One village demonstrated successthrough the work of the mahila mandal. The vil-lage Angan Wadi Worker (AWW) described a casein which a man from the village battered his wifeso heatedly that the entire village could hear. Afterone particularly severe incident, the transformedmahila mandal convened in the AWW’s home. Af-ter reflection and deliberation, they concluded thatan intervention was necessary and collectively pro-ceeded to the perpetrator’s house. The AnganWadi Worker described what happened:

When we arrived, we saw that she was badly beaten and sherequested that we call the police. We took her out of thehouse. Then he went to beat her in the rescuer's home, but thewomen took a stick and threatened to beat him. He wentaway. This incident has affected other men. Seeing womentogether, the men in our village do not beat their wives somuch these days… Now I rarely hear complaints of abuse.(AWW, India)

Beating has gone down in our village. I visit homes, and nowwomen share about themselves with a smile, rather than sto-ries of being beaten [as before]. (Community Woman, India)

Women in communities frequently cited "increasein mobility" as a result of CARE’s ISOFI interven-tions. The norms governing women’s mobility inpart reflect the level of women’s autonomyDuring bodymapping in Vietnam, participants discussed parts

of the body that are generally not discussed in public. This ledto open discussions about sensitive topics.

felt that a family focus was necessary while intro-ducing potentially sensitive topics related to sexu-ality. Staff designed activities to promote couplecommunication. For example, they engaged newly-wed couples in role plays related to gender. ISOFIteams organized picnics outside the village settingwhere newlyweds felt less constrained to try onthese new roles and behaviors. Storytelling exer-cises, to share personal narratives, were also ini-tiated.

After doing the body-mapping on myself, I feel less embar-rassed to talk about sensitive body parts. Only if we can breakthe iceberg inside ourselves can we work with communities.(Youth Union Director, Vietnam)

portant aspect of strengthening the family. Aware-ness of one’s own desires while also understand-ing one’s rights helped women negotiate sexual in-teractions with their husbands. Once trust was es-tablished and facilitators gained confidence, com-munity members shared personal narratives withone another, even in villages widely held as conser-vative strongholds in Indian society. Similarly, CAREVietnam conducted participatory workshops thatrevealed the same kind of candidness withingroups, particularly once they completed thebody- mapping exercises.

in the context of the family during this entry stage.While staff were aware that traditional family mod-els were not the only way people lived, they

In the earlier days, we stayed in home. Since CARE’s work, ithelped us come out of the home and discuss issues like raisingthe girl child. The school is far (3 kilometers). Now we feelgirls can go to school - though they are scared - and not just theboys. They now go in a group accompanied by an adult. ISOFImessages encouraged this change. (Community Woman, In-dia)

The thinking of the community about women has changed.Earlier we were not allowed to go or sit anywhere. Now wecan easily go and sit where we want. (Young Women, India)

Social-mobility-mapping exercises guided discus-sions regarding restricted mobility and its link togender and sexuality. Several drawings revealedwomen moving only as far as the boundaries oftheir home and rarely outside the village. Reflec-tions on this mapping exercise illuminated inequi-ties linked to gender and sexuality that participantsconsidered when contemplating action. Severalwomen reported how they gained greater inde-pendence through resistance, and also by model-ing behavior to one another. Several women re-port:

[The husbands] let us go out. When I went to a household, Icould never see the face of women, since I was veiled. Nowwomen are unveiled in the home. Now when they go out, theywear a veil, but don’t let it cover the face. (AWW, India)

(Koenig, Ahmed, Hossain & Mozumder, 2003;Jejeebhoy & Sathar, 2001). Within Indian ISOFIsites, this translates into patterns affecting bothyoung girls and adult women. Young girls, for ex-ample, are absent from school, while adult womenare not permitted to travel outside certain geo-graphic parameters. This includes restricted move-ment within the village, and even within the bound-aries of the home. The most frequently reportedexplanation for restricted mobility is the fear thatunmarried girls would “become pregnant if travel-ing unaccompanied” and that adult women wouldbecome “out of control” or someone might “makeoffensive comments” or “touch” them which, ac-cording to a local community member, “would bea disgrace to the family, and more so to the men ofthe family.”

Young Women’s Stories

Before (ISOFI), a good girl was someone who stayed home andwas sweet. Now we believe that standing on your feet is a goodthing. (Young Woman, India).

The Youth Union and NGOs have the tools now, and use themto forge new directions. (Youth Union, Vietnam)

Young women readily adopted gender and sexual-ity concepts by resisting inequities experienced intheir families and communities. The Vietnam modelfocused on supporting local youth organizations tostrengthen civil society and ensure sustainability.Through ISOFI applications, a local youth NGObased in Ho Chi Minh City advocated for improvedsexual and reproductive health policies in Vietnam.Similarly, CARE India and partners helped formyouth groups to raise awareness of HIV/AIDS riskand reproductive health. In India, the groups wereseparated by gender. In both settings, staff andpartners integrated ISOFI principles, which led tocollective agency through strengthened capacityand expanded relationships. The following quotesreveal newly acquired values, beliefs and aspirationsamong young women.

One girl was accused of having sex with a boy. With our newknowledge about gender and sexuality, we remembered thatit’s not good to judge. It could have been me. Instead, we de-fended her from the taunts. (Young Woman, India)

We have established new friendships with other girls from dif-ferent [caste] groups. It doesn’t matter. We encourage eachother to pursue our dreams. For example, one of us wants tostudy music. (Young Woman, India)

Confidence through UnityWe are leaders in our communities because we can share thenew information and knowledge that we have. (Young Woman,India)

We now know how to talk to boys, which is a new experiencefor us. (Young Woman, India)

I used to not go out... Now we [in the village] watch each othergo out… so, now we’ve all started going out. (Woman, India)

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We changed within ourselves. Now we can talk and name ourbody parts, such as breasts. We can talk about menstruation.Now we don’t feel scared about menstruation because now weunderstand it. (Young Woman, India)

We now have access to information. Before only boys hadaccess to information on sexuality through magazines and bluefilms… The boys used to trick us, since we didn’t have theright information. (Young Woman, India)

I changed my attitude about sex before marriage. It is notsocially accepted… Doesn’t the woman get to have an or-gasm? Women want satisfactory sex [whether in or outsidemarriage]. (Youth Union Leader, Vietnam)

Using a sex-positive approach helped youngwomen and men deal with shame and guilt relatedto sexuality which inadvertently led to reinforcingand creating gender and sexuality myths. Contraryto the common practice of withholding informa-tion from girls for fear that they will become sexu-ally active, correct information on sexuality em-powered young women. Moreover, they were notcompelled to rely on their male peers as primarysources of knowledge.

In Vietnam they took this a step further. Commu-nity members explored prevailing values relatedto premarital sex. They challenged dominant be-liefs about sexual debut, particularly biases againstyoung women. As youth representatives report:

Men’s Stories and Their MythsReflective dialogues and workshops provided safespaces to dispel gender myths related to mascu-linity. They focused on subordinated masculinities,including those identifying as homosexual or beingfrom socially marginalized groups. Facilitatorsguided sensitive conversations with deference toparticipant perspectives in a balanced manner.

Depiction by an adolescent girl of an ideal couple. (India)

One girl’s parents accepted whom she wanted for her hus-band…. We also don’t want pressure to marry within our castes.(Young Woman, India)

Gaining knowledge and social cohesion throughassociation with neighboring youth were two ofthe most common factors young women cited asleading to their greater sense of agency. Increasedconfidence among young women enabled them tonegotiate independence and a sense of purpose.Several young women reported ways they beganinterpreting newfound beliefs into action, particu-larly in relation to their family and male peers.

I help my children understand. Sex outside of marriage is notaccepted in our society. But I have become more tolerant. If acouple doesn’t have premarital sex, how can they know if theyare a good sexual match? (Youth Union Director, Vietnam)

I no longer judge out-of-wedlock sex. Our goal is safe sex.(Youth Union, Vietnam)

Gender MythsI learned from [ISOFI] training that gender is socially con-structed and can be changed. I had an impression that menwho have sex with men are not good... Now we say that wehave no right to say anything or be judgmental about it. Ourthinking has changed. (NGO Worker, India)

Gender myths, portraying men as oppressors,depict a narrow view of what is actually a range ofchanging patterns and roles among most men.While ISOFI does not discount women’s subordi-nation and dominance by men, it goes further toexplore the range of masculinities that coexist and

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It was these entry points – circumstances wheregender patterns are more open to change – inwhich ISOFI implementers intervened. Men ex-ploring less dominant masculinities face criticismas described in the quote above. When workingcollectively, through reflective processes, they havebetter chances of overcoming categorical biases.As one Indian migrant reported, "Now we discussopenly and our hearts are open. We no longer feelshy and can discuss about all issues." Building aware-ness among boys and men of the diversity of mas-culinities that exist, beyond the narrow gendermodels they are familiar with, is an important un-dertaking that ISOFI implementers began totackle through PLA exercises, such as the “idealman” and “ideal woman” exercises.

Text Box 6: Case Study of YouthGroup Meeting on Homosexuality

Social and Behavior ChangeNow all of us use condoms with sex workers. And now wetalk about family planning with our wives and female rela-tives… (Migrant, India)

We do not talk about sexual pleasure with women but we dotalk about it with men, which we did not do before. This hasled us to adopt safe sex. (Male Community Member, India)

Like my father, there was no education for me or my sister,but I send my daughter to school. My father scolded me so Iexplained it to him. (Male Community Member, India)

Consequently, personal change was not only re-flected by improved relations at the householdlevel but also by desired behavior change consis-tent with desired program outcomes. As many ofthe quotes above reveal, explorations into sexual-ity played key roles in prompting change in behav-ior among men interviewed.

Change is slowOne man said, “Homosexuality is wrong, and eunuchs arewrong. Going to sex workers is wrong, but it’s okay to have fourwives as long as it’s a wife.” (Migrant, India)

We are more sensitive with our wives, but not necessarily withother women. We do force sex with sex workers. (Migrant,India)

We have learned that no one is wrong and we can talk aboutour feelings. But we don’t change overnight. (Male CommunityMember, India)

In Vietnam, the youth group organized a district meeting in HoChi Minh City with community stakeholders from the Commu-nist Party including, among others, the Secretary of the Commu-nist Party, Chairman of the People’s Committee, the head of theCommittee on Family, Population, Children, and head of the Com-mune Cell in the district. Youth from the organizing youth NGOand the local gay organization, which had until this point remainedunder-ground, spoke publicly for the first time about homosexu-ality and hardships homosexual men and women experiencethrough social exclusion. There were long deliberations repre-senting various perspectives from the community and from a fewhomosexual men who came out to the group. A nonjudgmentalatmosphere allowed people to discuss feelings, including some-times offensive biases. In response to a woman who announcedthat she believed a homosexual man can be detected by his physi-cal appearance because he is effeminate and has a small penis, agay-identified speaker calmly responded, “You see me. I am strongand manly. I have a wife and children. I’m also gay, and my sexuallife is vibrant. What you say is actually a myth.”

CARE Vietnam staff and partners believe that the meeting onclarifying myths on homosexuality was the beginning of a longercommunity dialogue on sexual rights. According to one YouthUnion representative, “While we have long to go, we have made animportant first step by breaking the ice.”

are socially produced simultaneously. For example,sex workers told countless stories of what soundedlike aggressive (sometimes violent) male sexuali-ties coexisting with men’s desires to be nurturedand romanced. As the quotes below illustrate,ISOFI staff observed the uncertainties, difficultiesand contradictions men face, which shed new lighton preconceived notions of masculinity. Some sto-ries include the following:

I can’t grow a mustache, but my father and uncle always pesterme about it. I’m not considered [much of a man] without one.(Male Community Member, India)

Men who went through ISOFI exercises could not persuadetheir wives to let him to the housework. So men need to over-come not only themselves but also social prejudices. (KeyInformant, Vietnam)

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biases and insecurities flourish among young menwho are beginning to explore their sexualities andconflicting masculinities. According to many youngmen, sanskriti (culture) demarcates sexuality re-lated to expression, meaning and behaviors. Con-flicting beliefs about masturbation, for example,leave many young men confused. Young men havequestions about sexuality, and if not adequately an-swered, they rely on peers, magazines and bluefilms.

Masturbation is unnatural, against our culture. The most natu-ral sex is between man and woman. (Male Youth, India)

We have fears of getting a small penis and not being able togive pleasure if we masturbate. (Male Youth, India)

We want to know what is good/bad, harmful/not harmful, natu-ral/not natural. What are the answers to this? (Male Youth,India)

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ISOFI implementers also learned that gender andsexuality interventions should emphasize improv-ing women’s agency and autonomy, but not to theexclusion of men. It is not a zero-sum game. Aswomen are more empowered, men do not losepower. More work is necessary to cultivate poweramong both men and women so that dominant-sub-ordinate relationships do not persist. As the quotesabove illustrate, gender myths still exist and changeis slow. While substantial progress occurred, ISOFIimplementers learned that interventions must bepaced, beginning with small steps. The youth groups,women’s collectives and men’s groups strengthenedand generated through ISOFI activities are nascent,requiring more support before they can work with-out close accompaniment.

Male Youth StoriesParticularly tenuous were interventions with maleyouth. Given the focus on strengthening women’sagency, CARE staff and NGOs provided more at-tention to female youth groups in India. Myths,

ConclusionPatterns and themes observed across all groupsinclude enhanced confidence, group cohesiveness,awareness related to links between gender andsexuality such as mobility and decisionmaking.Most ISOFI implementers, across all sites, revealedthat participatory and action research methodsprovide opportunities for critical communicationgenerating new and often painful knowledge. As thenarratives point out, social structures producedby gender and sexuality render positions open forscrutiny through reflective practices. The key nowis to keep critical reflection and community dia-logue going.

Even where progress appeared slow and uncom-mitted, the ISOFI team consisting of CARE staffand partners, introduced the first public meetingon myths and beliefs about homosexuals from thesubject position of gay men. Diverse groups andgenders provided a rich social resource, so thatwhen effectively mobilized, it gave CARE a muchgreater capacity to transform itself. Indeed, CAREstaff, partners and communities continue to advancethis work with their commitment to reflection andaction. Their commitment to deepening under-standings of gender, sexuality and its relation topower, provides the impetus to support well-be-ing for all, not only the majority. They inspire thewider organization with their resilience, opennessto learn, and capacity to transform earlier beliefsto ones that reflect democratic ideals consistentwith CARE principles.

Personal change was not only reflected at the indi-vidual, household and organizational levels. As thischapter reveals, it shaped programs in consider-able ways. Desired behavior change, reflectingdesired program outcomes, demonstrated theextent to which action research methods improveprogram quality while also generating cross-learn-ing opportunities. While the investment is great,particularly in the early phases of the program

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External technical support stimulates broader reflec-tion within country teams and promotes sharing acrosscountry offices.

cycle, development practitioners should invest indedicated time to personal change, while also re-linquishing control of the consequences.

Practitioners engaged with gender mainstreamingstill have many challenges ahead. Gender mythskeep well-meaning practitioners locked into aframework that informs their advocacy platform.The victim narrative is indeed a compelling one. Itis not uncommon to hear staff raise concerns ofpoor suffering women "out there", that require de-velopment support to "help the feeble women outof their misery."

It is not unusual to also experience what CARE re-fers to as "gender fatigue." The role opposite tothat of female victim is that of male oppressor.Men report that this is a role they are not com-fortable with but do not have the space to voicedissent. We have learned that restrictive responsesto sexuality, defined as protecting women from thewould-be oppressor rather than protectingwomen's rights, can lead to unintended harm.While policy changes have been forthcoming whenusing such a framework, it runs the risk of mistak-enly impeding other human rights goals, particu-larly those enabling conditions that grow women'sagency, confidence, exploration and well-being re-lated to sexual exploration (Miller, 2004).

Chapter 5

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IntroductionThroughout the initiative’s two-year implementa-tion, members of the core ISOFI team conductedregular visits to ISOFI sites in India and Vietnam inorder to facilitate intervention modules such asReflective Dialogues, provide technical assistanceand monitor progress. Designed as a processproject, ISOFI captures learning and field wisdomthrough extensive documentation that encom-passes detailed implementation plans, reports,behavior-change communication materials, videos,photo archives and visual outputs from Participa-tory Learning and Action exercises around genderand sexuality (such as social and vulnerability maps).These materials have allowed the core team toassess ISOFI’s evolution as an approach to inte-grating gender and sexuality into CARE’s program-ming. As seen in this report, other qualitativemethodologies such as indepth interviews and fo-cus-group discussions collected pertinent datathroughout the project on personal learning andchange, organizational learning and change, and fieldapplications. As a capstone to its evaluation strat-egy, CARE and ICRW conducted an endline surveyto assess progress against baseline on the integra-tion of gender and sexuality into CARE’s organiza-tional fabric. Chapter 5 reports these findings, anddiscusses their significance.

MethodologyBaseline and endline surveys were developed byICRW in consultation with CARE. The survey in-struments consist of qualitative and quantitativequestions aimed at capturing CARE staff’s knowl-edge of, attitudes toward and opinions on the inte-

Assessing ISOFI's Progress and Effecton Personal and Organizational Change

gration of gender and sexuality into CARE repro-ductive health and HIV/AIDS programs.

ICRW administered the surveys electronically tothree types of CARE staff: 1) project managementstaff, 2) field staff at CARE India and CARE Vietnamand 3) global sexual and reproductive health advi-sors affiliated with CARE USA as well as regionalmanagement staff covering Asia. In India and Viet-nam, the respondents represented a cross sec-tion of CARE staff working either directly or indi-rectly with ISOFI. The sample was drawn fromdifferent levels within CARE, with key representa-tives from senior management, middle manage-ment and implementing field teams. A total of 64staff (India: 46, Vietnam: 12, global: 6) participatedin the baseline and 40 staff (India: 26, Vietnam: 8,global: 6) participated in the endline survey. Therespondents in the Endline survey were not nec-essarily the same respondents as at baseline. Re-sponses are reflections on the CARE country port-folio and are not just ISOFI-related. In drawingconclusions from the resulting data, it is importantto remember that ISOFI was piloted in India andVietnam only. CARE India, CARE Vietnam and CAREInternational staff participated in the survey and assuch, the responses from CARE Global participantswill be reflective of CARE's Global portfolio, andnot just those projects nested in India and/or Viet-nam.

The quantitative sections of the survey were en-tered into SPSS for analysis. The qualitative por-tions were closely examined for common themesand organized into matrices to facilitate analysis.

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Respondent DemographicsOut of the 64 staff who participated in the baselinesurvey, 30 were males and 34 females. Age of re-spondents ranged between 23 and 57 years, witha mean age of about 37 years. Forty-six staff werefrom CARE India, 12 from CARE Vietnam and sixfrom CARE Global.

Among the 40 staff who participated in the endlinesurvey, respondents split evenly between malesand females (20:20). The age range was similar tothat at baseline, with a range from 26 to 52 yearsand a mean age of 37.6 years. Twenty-six respon-dents were from CARE India, eight from CAREVietnam, and six from CARE Global.

Findings of the Baseline and Endline Surveys

1. Progress on Integrating Gender intoCARE Reproductive Health and HIV/AIDSProgramsIn the baseline survey, the majority of the respon-dents from Vietnam reported that gender equitywas being integrated into CARE reproductive healthand HIV/AIDS programs because both men andwomen were involved in implementing reproduc-tive health and HIV/AIDS projects, and there wasno gender-based discrimination in the selection ortreatment of beneficiaries.

Others reported that gender equity was integratedinto CARE reproductive health and HIV/AIDS pro-grams by addressing traditional gender roles andgender-based discrimination. One respondentnoted that while gender equity was integrated intoCARE reproductive health and HIV/AIDS pro-grams, more needed to be done.

In the endline survey, respondents overwhelm-ingly reported that with ISOFI’s implementation,there has been a change in CARE Vietnam’s in-corporation of gender equity in its reproductivehealth and HIV/AIDS programs. Respondents re-ported that staff were better equipped, more

knowledgeable and more aware of issues of gen-der equity following ISOFI. Two respondentspointed out that for those staff who participatedin ISOFI, change had occurred, but that amongstaff who had not participated and within the largerorganizational levels, change had not been as forth-coming.

At baseline in India, participants were dividedregarding the extent to which gender equity wascurrently being incorporated into CARE’s repro-ductive health and HIV/AIDS programs. Some par-ticipants felt that incorporation was taking place:

Increasingly there is a more deliberate and consistent approachacross CARE’s programs in ensuring that gender-based powerrelations in decision making are equitable and fair. This isacross the continuum, from access to information and aware-ness to making decisions that have implications for commu-nity, both as individuals and as a group.

Other staff reported at baseline that gender eq-uity was incorporated into reproductive health andHIV/AIDS programs but not in a strong-enoughmanner, and that the link between the conceptualand the practical application of gender equity wasnot clearly understood within the organization:

As a mission, CARE’s core values support gender equity butthis is not yet visible in practice within the organization. Theratio of men vs. women amongst our staff is an example. Simi-larly, in our programming, although we have demarcated ad-dressing gender issues as a priority, we are still groping in thedark how to go about this.

At endline in India, the majority of respondentsreported that there had been a change in CARE’sincorporation of gender equity into its reproduc-tive health and HIV/AIDS programs.

Yes, at all levels! In recruitment, amongst the NGO partners,too, we see a good gender balance and sensitivity towards theissue. Whenever we have all staff aboard, we discuss aboutthe issue and the staff shares the implementation of the gen-der-related activities in the field. The reproductive health pro-gram has gained the most – specially the high-risk behaviorgroup as we have started talking about the sexuality issueswithout being judgmental. At the national level, too, genderand diversity is addressed in all the programs.

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I think it is relatively well understood at a conceptual level inCARE that we are seeking ways to promote both the rights andempowerment of women throughout our programs. Realisti-cally, I think it’s hard for the RH programs to actualize this. Ifind that HIV and RH programs target women (and marginalizedgroups) particularly as people for whom they are hoping forbehavior change or for women to “demand their rights,” butoften fail to achieve “empowerment.” We don’t have goodconceptual grasp of gender equity as it relates to health, norways to measure it.

At endline, global staff reported that there hadbeen changes in that CARE was incorporating gen-der equity considerations more into their program-ming; however, multiple staff indicated that thiswas part of a larger shift within the organization.While the staff recognized that ISOFI had played apart in enhancing the emphasis on gender withinCARE, they mentioned that there are other sup-portive forces at play.

2. Integrating Sexuality into CARE Repro-ductive Health and HIV/AIDS Programs

In Vietnam at Baseline, staff were split regard-ing the extent to which sexuality was being incor-

However, a few respondents reported at endlineno change or no change at the country or organi-zational levels in particular. Others reported nothaving a clear idea as to whether there had beenchange or not.

ISOFI implementation has to be shared to the CARE universefor it to make a difference. It has impacted those who weredirectly involved with the program, it is these people who couldbe vehicles for transmission in all states that we work in. ISOFIneeds to be programmed/integrated more holistically withproper structures /leadership /understanding/ accountability/acceptance, and not as a one-off initiative.

At the global level at baseline, staff felt that gen-der equity was being incorporated at a conceptuallevel (i.e., during design and analysis) but that be-yond disaggregating data by gender, it has beendifficult for program managers to implement.There was also the feeling that traditionally, CAREtends to "target" women without addressing men’sroles:

porated into reproductive health and HIV/AIDSprograms. Some respondents strongly felt thatsexuality was being incorporated. Many felt thatsexuality was being incorporated but that morestill needed to take place. Other respondents feltthat there was lack of understanding among staffregarding the value of incorporating sexuality intoreproductive health programs:

Issues of sexuality are probably addressed much less clearlythan issues of gender. Whilst information in relation to sexualhealth is a key part of CARE’s reproductive and sexual healthprogramming, issues in relation to sexuality and societal andsocial norms related to sex are often not addressed special inCARE’s programming, as they are often sensitive and are alsoinfluenced by the personal opinion of staff.

In India at baseline, some respondents felt thatsexuality was being incorporated into CARE repro-ductive health and HIV/AIDS programs by address-ing such issues as the right to safe sex and repro-ductive health through IEC materials and cam-paigns, and through behavior change interventionsto reduce risky sex. The majority of respondents,however, did not think that sexuality was being in-corporated into CARE programs:

Very inadequately. Like most Indians I feel that the subject ofsex is taboo in CARE as well. CARE still does not talk of same-sex sex and has no problem for eunuchs. While CARE is com-fortable working with heterosexual prostitutes but not withmale prostitutes.

There is no specific issue to our knowledge which takes care ofthe sexuality into CARE’s reproductive health and HIV/AIDSprogram. I think only the rights to have “safe sex” have beenincorporated in the HIV/AIDS program.

All of the global respondents felt that sexualitywas not being addressed adequately in CARE re-productive health programs.

At endline, respondents were asked, “With ISOFI’simplementation do you think there has been a changein CARE’s incorporation of sexuality in its reproduc-tive health and HIV/AIDS programs? If yes, how? Ifno, why not?” Some respondents reported that

49

Table 1: Staff Beliefs About Incorporating Gender and Sexuality into Programs at Baseline

In my experience CARE programstaff believe:

That it is critical to incorporateaspects of gender into reproductivehealth and HIV/AIDS programs.

That it is critical to incorporateaspects of sexuality into reproduc-tive health and HIV/AIDS programs.

Vietnam (n=12)

36.4% always36.4% occasionally18.2% rarely9.1% never

36.4% always36.4% occasionally9.1% rarely18.2% never

India (n=46) Global (n=6)

54.3% always 33.3% always34.8% occasionally 50% occasionally8.7% rarely 16.7% never2.2% never

26.1% always 16.7% always26.1% occasionally 66.7% rarely41.3% rarely 16.7% never6.5% never

Table 2: Staff Beliefs About Incorporating Gender and Sexuality into Programs at Endline

India (n=46) Global (n=6)

65.4% always 66.7% always26.9% occasionally 33.3% occasionally3.8% never

46.2% always 33.3% always38.5% occasionally 33.3% occasionally11.5% rarely 33.3% rarely

Vietnam (n=8)

100% always

75% always25% occasionally

In my experience CARE programstaff believe:

That it is critical to incorporateaspects of gender into reproductivehealth and HIV/AIDS programs.

That it is critical to incorporateaspects of sexuality into reproduc-tive health and HIV/AIDS programs.

there had been a positive change either in per-sonal or organizational contexts, but most acrossall groups reported little organizational change.Respondents from Vietnam explained that therehad not been change with CARE systems yet, butthat the seed had been planted. Among Indianstaff, the responses were split. Many respondentsspoke of the need to extend change beyond thedistricts in which interventions had taken place.Global staff overwhelmingly answered that changewill only occur at the upper levels of management,if the issues keep being pushed forward.

I think that gender will be integrated, because it’s a priority ofboth the donor, the country office and the regional manage-ment unit. However, I’m afraid that we’ll lose the focus onsexuality unless someone pushes the idea. (Global)

Yes there has been a change in CARE’s incorporation of sexu-ality in its reproductive health and HIV/AIDS programs butthat’s limited to piloted districts only. The learnings of ISOFIare limited to district teams or Regional Managers. The higherofficials or other district team members have different view.(India)

3. Staff Commitment to Integrating of Gen-der and Sexuality

At baseline, in response to the statement that“CARE program staff believe that it is critical to in-corporate aspects of gender into reproductive healthand HIV/AIDS programs,” the majority of staff inIndia (54%) reported “always” compared to 36%in Vietnam and 33% among global respondents.The majority of staff (50%) in the global site re-sponded occasionally, compared to 36% in Viet-nam and 34.8% in India. Overall, the majority of

50

percent change - with a leap from 36.4% report-ing “always” to 100% (See Tables 1 and 2).

In response to the statement “CARE program staffbelieve that it is critical to incorporate aspects of sexu-ality into reproductive health and HIV/AIDS pro-grams,” fewer staff reported at baseline that it wasalways or occasionally critical to incorporate sexu-ality into programs. At the global and India sites,the majority of staff reported “rarely” (67% and41%) and in Vietnam 18% reported “never,” com-pared to 7% in India and 17% among global staff(Table 1 above). At endline, however, many morestaff reported that it was important to programstaff to incorporate sexuality into their program-ming. All groups had increased percentages of staffreporting “always” and “occasionally,” with the Viet-nam team boasting the most change (See Table 2).

Apart from comparing baseline to endline per-ceptions of the importance of including gender and/or sexuality in CARE programming, there are someinteresting findings on the relative importance ofintegrating the two concepts. Whereas at baselinenearly 75% of respondents said their fellow staffthought it was “occasionally” or “always” impor-tant to incorporate gender, only 45.8% could saythe same for sexuality. This relationship remainedthe same at endline, where 73% of respondentsthought staff found it important to integrate gen-der into their programming, whereas only 50%could say the same for sexuality. No association

staff across all three sites (73% in Vietnam, 89%in India, and 83% of global respondents) reportedthat in their experience CARE staff believed it wascritical to incorporate aspects of gender into re-productive health and HIV/AIDS programs (SeeTable 1).

At endline, percentages of “always” and “occa-sionally” reports of gender integration increasedacross the board, with Vietnam having the largest

seems to exist in baseline or endline data be-tween the gender of the respondent and their viewson the importance of integrating gender into pro-grams.

In order to understand whether amount of par-ticipation in ISOFI had a difference in respondents'assessment of their resulting skill levels at endline,respondents were grouped into either "direct par-ticipants" or "indirect participants." In order to becharacterized as a "direct participant," the respon-dent had to be part of the ISOFI core team. An"indirect participant" was one who had infrequentinvolvement with ISOFI.

Whether the respondent was directly or indirectlyinvolved with ISOFI did seem to have an effect ontheir views on integrating gender into CARE pro-gramming. Twenty-seven respondents at endlinereported having direct involvement with ISOFI,compared to 12 who had only indirect involve-ment. However, even those who were directlyinvolved more often reported that integrating gen-der was more important than sexuality.

At endline, there was a large difference in the per-centage of direct participants who thought it wasalways or occasionally important to integrate gen-der and sexuality into programming. While 81.5%thought it always important to integrate gender,only 48.1% felt the same for sexuality. Interest-ingly, among those indirectly involved in ISOFI, nodifference between these two variables emerged.

At baseline, all staff were asked whether they feltthey had the skills to "substantively apply bothgender and sexuality concepts in reproductivehealth and HIV/AIDS programming." Approxi-mately 48% reported that they agreed or slightlyagreed that they did have the skills. (Diagram 5).

51

Diagram 5: Staff Skills in Gender and Sexuality, Baseline

Table 3: When CARE Program Staff Take Both Gender and Sexuality into Account

Theconceptualizationof RH & HIV/AIDSprograms

The design of RH& HIV/AIDSprograms

The implementa-tion of RH & HIV/AIDS programs

Monitoring andevaluation of RH& HIV/AIDSprograms

Baseline Endline(n=12) (n=8)

27.3% always 60% always45.5% occasionally 25% occasionally27.3% rarely 25% rarely

27.3% always 37.5% always54.5% occasionally 37.5% occasionally18.2% rarely 25% rarely

25% always 37.5% always66.7% occasionally 50% occasionally8.3% rarely 12.5% rarely

27.3% always 37.5% always36.4% occasionally 37.5% occasionally27.3% rarely 25% rarely9.1% never

Vietnam India Global

Baseline Endline(n=46) (n=26)

27.3% always 60% always45.5% occasionally 25% occasionally27.3% rarely 25% rarely

27.3% always 37.5% always54.5% occasionally 37.5% occasionally18.2% rarely 25% rarely

25% always 37.5% always66.7% occasionally 50% occasionally8.3% rarely 12.5% rarely

27.3% always 37.5% always36.4% occasionally 37.5% occasionally27.3% rarely 25% rarely9.1% never

Baseline Endline(n=6) (n=6)

27.3% always 60% always45.5% occasionally 25% occasionally27.3% rarely 25% rarely

27.3% always 37.5%always54.5% occasionally 37.5% occasionally18.2% rarely 25% rarely

25% always 37.5% always66.7% occasionally 50% occasionally8.3% rarely 12.5% rarely

27.3% always 37.5% always36.4% occasionally 37.5% occasionally27.3% rarely 25% rarely9.1% never

At endline, 77.5% of all staff reported agreeingor slightly agreeing with the statement, as com-pared to the 48% at baseline. Staff who had di-rectly participated in ISOFI were much more likelyto think CARE staff had adequate skills than thosewho only participated indirectly (See Diagram 6below). Across the groups, only half of CARE Glo-bal responded "agree" or "slightly agree," comparedto 84.6% (n=22) of CARE India and 75% (n=6)of CARE Vietnam.

In response to the statement “In my experience,CARE program staff take both gender and sexualityinto account during conceptualization, design, imple-mentation, and monitoring and evaluation” the ma-jority of CARE Vietnam staff at baseline respondedoccasionally to all four project phases. The major-ity of program staff in India responded occasion-ally to all but one of the phases, Monitoring and

Evaluation, which was evenly split between occa-sionally and rarely. Lastly, the majority of globalstaff reported rarely to all phases except for moni-toring and evaluation, which was split evenly be-tween occasionally and rarely (see Table 5).

SlightlyAgree

agree

Slightly

disagree

Disagree

Opinion

Pe

rce

nta

ge

Staff have the skills to integrate Gender & �

Sexuality at Baseline

05

101520253035

52

Diagram 7: CARE Vietnam Personal Tension

5. Institutional Commitment to Integrationof Gender and SexualityOn issues relating to CARE’s institutional com-mitment to integrating gender and sexuality in itsreproductive health and HIV/AIDS programs, themajority of staff across all three sites at baselineagreed with most of the items endorsing CARE’scommitment. Staff were asked to what extent they

4. Tension between the Personal and Profes-sional SpheresAt Baseline, staff were asked to respond to thestatement “I experience tension between my per-sonal beliefs and my professional approach to genderand sexuality.” The majority of staff in Vietnamand India disagreed (67% and 60% respectively)and Global staff were evenly split.

Staff were asked in the Endline survey to describeif they had “more/the same degree/or less tension intheir own personal beliefs on gender and sexuality asa result of participating in ISOFI." Those directlyinvolved overwhelmingly reported less tension intheir own personal beliefs as a result of participat-ing in ISOFI (19/25) whereas those indirectly in-volved, did not (4/9). It is interesting to note thatsome staff did report having more tension in theirpersonal beliefs (4/33). As a result of a cross-groupcomparison, it emerged that Vietnam staff re-ported more tension for both gender and sexual-ity whereas global and India groups reported lesson average (See Diagram 7).

Diagram 6: Staff Skills in Gender and Sexuality, Endline

were “encouraged," “rewarded for” and “held re-sponsible” for integrating gender and sexuality intotheir programs.

Most respondents from Vietnam and India(100% and 60% respectively) agreed that CAREprogram staff are encouraged to apply gender andsexuality concepts into reproductive health andHIV/AIDS programming. The majority of globalstaff (67%) however disagreed. While the major-ity of Vietnamese respondents (64%) agreed thatCARE program staff are rewarded for their appli-cation of gender and sexuality concepts, the ma-jority of Indian and global respondents disagreed(63% and 83% respectively).

Lastly, 100% of Vietnamese staff agreed thatCARE programs staff were held accountable bytheir supervisors for application of both genderand sexuality concepts into reproductive health andHIV/AIDS programming, whereas the majority ofrespondents in India (63%) and the Global site(83%) disagreed.

In the endline survey, almost 90% of all staff re-ported that they were encouraged to integrategender and sexuality into programs. Over 80% ateach site indicated that they were encouraged, and60% and nearly 80% of Vietnam and India staff,respectively, indicated they were rewarded and heldaccountable for integration. Interestingly, the glo-

Staff have the skills to integrate

Gender & Sexuality

0102030405060

Agree Slightlyagree

Slightlydisagree

Disagree

Opinion

Pe

rce

nta

ge

Direct

Indirect

4

0

2 2 2

0

1

2

3

4

5

6

Nu

mb

er

of

Re

sp

on

de

nts

More Same Less

Amount of Tension

Personal Tension with Gender & Sexuality

Personal Tension with Gender

Personal Tension with Sexuality

6

Diagram 8: Types of Institutional Support

Table 6: Support for Gender and Sexuality Integration (Baseline)

In my experience, CARE:

Has made adequate financial re-sources available (either CARE'sown funds or other donor funds)to support the integration of bothgender and sexuality into its repro-ductive health and HIV/AIDS pro-grams.

Senior Management in my setting(for example, my country office)clearly endorses the importance ofaddressing both gender and sexu-

ality

Vietnam (n=12) India (n=46) Global (n=6)

34.9% Agree 16.7% Agree66.7% Slightly agree 37.2% Slightly agree16.7% Slightly disagree 20.9% Slightly disagree 33.3% Slightly disagree16.7% Disagree 7% Disagree 50% Disagree

41.7% Agree 47.7% Agree33.3% Slightly agree 40.9% Slightly agree 50% Slightly agree41.7% Slightly disagree 6.8% Slightly disagree 16.7% Slightly disagree

4.5% Disagree 33.3% Disagree

In my experience, CARE:

Has made adequate financial re-sources available (either CARE'sown funds or other donor funds)to support the integration of bothgender and sexuality into its repro-ductive health and HIV/AIDS pro-grams.

Senior Management in my setting(for example, my country office)clearly endorses the importance ofaddressing both gender and sexu-

ality

Vietnam (n=8) India (n=26) Global (n=6)

25% Agree 69.2% Agree37.5% Slightly agree 26.9% Slightly agree 33.3% Slightly agree37.5% Slightly disagree 3.8% Slightly disagree 33.3% Slightly disagree

33.3% Disagree

25% Agree 53.8% Agree 50% Agree62.5% Slightly agree 34.6% Slightly agree 33.3% Slightly agree

11.5% Slightly disagree 16.7% Slightly disagree12.5% Disagree

Table 7: Support for Gender and Sexuality Integration (Endline)

53

bal staff reported much lower levels of rewardingand accountability for integrating gender and sexu-ality concepts into reproductive health and HIV/AIDS programs, though the majority slightly agreedthat they were rewarded (Diagram 8).

At endline, respondents were asked to rateCARE’s financial commitment to gender and sexu-ality with the following question: “CARE has madeadequate financial resources available (either CARE’sown funds or other donor funds) to support the inte-gration of both gender and sexuality into its repro-ductive health and HIV/AIDS programs.” The major-ity of staff in Vietnam and India (66.7% and72.1% respectively) agreed, whereas the major-ity of global staff disagreed 83%.

Respondents were also asked, at baseline, to re-spond to the following question: “CARE Senior Man-agement in my setting (for example, my country of-fice) clearly endorses the importance of addressingboth gender and sexuality.” The majority of staff fromVietnam and India agreed (75% and 89% re-

Types of Institutional Support

(At Endline)

0

20

40

60

80

100

Vietnam India Global

Sites

Encouragement

Rewards

Accountability

6. Discussion

Enablers and Barriers to Integrating Genderand Sexuality at CAREUpon review of the qualitative and quantitative data,participant perspectives emerged on the enablersand barriers to effective integration of gender andsexuality into programs. In 2004, an analysis ofenablers and barriers was carried out with all staffacross all three ISOFI sites. Two years later at theend-of-project workshops, enablers and barrierswere assessed once more.

Enablers and Barriers in 2004CARE leadership and commitment emerged asbeing critical to the integration of gender and sexu-ality into CARE’s reproductive health programmingin all three sites. In India, CARE leadership’s com-mitment to the ISOFI process was perceived byCARE staff to extend from the country directorthrough all levels of senior management to imme-diate supervisors. In Vietnam, only those who par-ticipated in ISOFI trainings felt the same urgencyand commitment to the incorporation of genderand sexuality.

A 2004 analysis of enablers and barriers garneredfrom a portfolio review and needs assessment un-dertaken in each site found that support fromheadquarters, team bonding and sharing ideas andwork contributed to the success of ISOFI. Partici-pants also reported that the process of personallearning that was facilitated by ISOFI, as describedin chapters 2 and 3, further contributed to ISOFI’ssuccess.

54

spectively), whereas global respondents wereevenly split between agree and disagree (see Table6 below). At endline, staff from India and globalagree with the statements, whereas Vietnam staffreported less agreement than at baseline.

Barriers reported by Uttar Pradesh participantsincluded peer pressure, the heavy workload andbarriers in communication due to initial inhibitionregarding sexuality. CARE’s hierarchy also pre-sented a barrier, along with the fact that ISOFI wasnot part of staff performance review. Rajastan par-ticipants noted that CARE’s field presence andcredibility, CARE’s sexual harassment policy andthe different skills represented in the team con-tributed to ISOFI’s success. Barriers included lim-ited funds, lack of local experts and high staff turn-over. In Vietnam, a barrier was that gender andsexuality were not seen as core skills within theorganization.

Enablers and Barriers in 2006By February 2006, end-of-project workshop par-ticipants found that CARE’s policies contributedto the success of ISOFI. In Bhilwara, India, partici-pants cited CARE’s gender and diversity policy. InLucknow, India, participants found that involvementwith gender and sexuality issues created impor-tant career opportunities. Vietnamese participantsnoted as barriers that gender and sexuality werenot explicit project objectives, not part of CARE'smandate and that sexuality in particular was notnormally prioritized by donors.

CARE’s links to the communities it serves wasimportant to the success of ISOFI. Participantsfound that CARE’s long history of work and thetrust that had been built up over numerous yearsbetween CARE staff, these service providers andthese communities formed an important basis tomove forward the more sensitive issues of genderand sexuality.

The Indian sites indicated that the camaraderie ofthe CARE staff team charged with implementingISOFI was very important to the success of ISOFI.

Integrating Sexuality into CARE ReproductiveHealth and HIV/AIDS ProgramsResponses to whether issues of sexuality had beenincorporated into CARE programs following ISOFIimplementation were less positive overall. Thoughstaff from Vietnam and India reported positivechange within the pilot sites and staff, the majorityfrom these two groups and all the CARE Globalstaff reported little, if any, organizational changehad occurred. Findings from the end-line qualita-tive survey data as well as the end-of-project IDIsand FGDs support staff assertions that incorpo-rating issues of sexuality into programming is muchmore challenging and takes more time and effortthan does incorporation of gender concepts. Onepossible reason for this could be that whereasmessages regarding gender equity can filter downthrough staff channels - with those directly involvedpassing on the messages to those not directly in-

55

7. Conclusion

Progress on Integrating Gender into CAREReproductive Health and HIV/AIDS ProgramsThe data indicate a definite increase in staff per-ceptions of how well gender equity is being incor-porated into reproductive health and HIV/AIDSprogramming. Though some respondents in allsites reported that CARE had already been incor-porating elements of gender equity in its programs,most agreed that ISOFI had served to enhancethat situation. In fact, data from the end-of-projectworkshops, indepth interviews, focus groups dis-cussions and endline surveys indicate that staff defi-nitions of “gender” and “gender equity” havegreatly evolved and been strengthened followingtheir participation in ISOFI. Though the majorityof respondents felt more needed to be done, par-ticularly with integrating gender into the CAREsystems and management levels, the general con-sensus was that gender issues and gender equity,in particular, had been incorporated more fully thanbefore ISOFI’s implementation.

volved - sexuality messages may be harder to dif-fuse. If sexuality is perceived as a more taboo sub-ject, it is realistic to think that there may be lessdiscussion and diffusion of relevant ideas to staff,particularly across hierarchical organizational lev-els. If discussing sexuality with a partner or friendis not usual practice, then expecting a local staffperson to feel free enough to bring the issue up ata staff meeting in front of his/her supervisor mightnot be recognizing the reality of the situation. Thefollowing quotation illustrates this possibility:

Sexuality has been a much harder sell. Our understanding,biases, assumptions and cultural rules about sexuality areprofoundly powerful. It is a very difficult thing to explore, spe-cifically as relevant to development programming, even withinthe safer context of SRH. Many frontline staff who have re-peatedly reflected over the last year and half understand itsrelevance, but more senior staff who have not benefited fromthis repeated exploration have not integrated sexuality intotheir own paradigm. (Global)

Staff Commitment to Integrating of Genderand SexualityWhen analyzing data on respondents’ views of theircolleagues’ incorporation of gender and sexualityinto programming, a trend similar to integratingsexuality can be seen. Though staff across all groupsreport increased need to incorporate both aspects,at baseline and endline, gender is much more em-phasized than sexuality. At baseline, India and glo-bal staff report it being twice as important to inte-grate gender as to integrate sexuality. Though allgroups report a positive increase at endline, thisrelationship remains the same.

An important lesson emerges from these data.Future interventions seeking to address gender andsexuality at both personal and organizational levelsneed to create a broad, enabling environmentwithin the organization. This can be achievedthrough an institution-wide program of exposureto the concept of sexuality and its role in affectinggender and reproductive health outcomes. Thedata suggest that ISOFI made considerable

Vietnam staff did internalize quite a bit of the ISOFImessages regarding sexuality and gender, but manyare still processing this information, and haven't yet"re-frozen" their internal frames on gender and sexu-ality.

Institutional Commitment to Integration ofGender and SexualityThough at baseline a very large percentage of staffat CARE Vietnam reported being encouraged andheld accountable for integrating gender and sexu-ality into their programming, India and global staffdid not respond nearly as positively. However, atendline, CARE India and CARE Global staff reportedmuch more positively that they were encouragedand held accountable and, to a lesser extent, re-

56

progress in this area, given that at endline, 81% ofthose directly involved compared with 48% ofthose indirectly involved reported it “always” im-portant to integrate sexuality into reproductivehealth and HIV/AIDS programming.

At endline, the majority of staff reported positivechange in the situation regarding CARE staff’s in-corporation of gender and sexuality into projectconceptualization, design, implementation andmonitoring and evaluation. CARE Vietnam andCARE India staff at endline had a higher percent-age of positive responses for each item than atbaseline. Among CARE International, on the otherhand, no staff reported “always” in the endline, butthese results must been analyzed carefully, as thesample size for the global group is small (n=6).Global respondents do not report decreased per-centages of “rarely” and “never” for all items.

Tension between the Personal and the Profes-sionalWhereas CARE India and CARE Global staff re-ported less overall personal tension with regardto issues of gender and sexuality, Vietnam reportedmore. Qualitative data support the fact that CARE

warded for their efforts. Interestingly, the per-centage of CARE Vietnam's staff who reportedbeing encouraged, held accountable for and re-warded declined by endline. A possible explana-tion is that at baseline, staff did not have a clearidea of what the integration of gender and sexual-ity actually entailed, and as their understanding,grew through the project, their perceptions onmanagement's response shifted.

When asked whether CARE had made adequatefinancial and senior management support available,CARE India and CARE International staff reportedmore support, in both forms, at endline than atbaseline. However, CARE Vietnam staff reportedmore support at baseline than at endline.

Creative use of learning materials such as modeling clay prompteddeep reflection on gender and sexuality as illustrated by these ex-amples from the gender and sexuality workshop in Vietnam.

Chapter 6

57

Conclusions, Recommendations and Next Steps

ISOFI: An OverviewISOFI was conceived as a collaborative learningpartnership between CARE and ICRW, and basedupon years of field experience working to improvethe impact of development programs. ISOFIsought to address what the partners had identi-fied as a key barrier to program performance: di-vergence between personally held and profession-ally expressed values and attitudes around genderand sexuality. In other words, an individual’s livedexperience of gender and sexuality creates tensionand ambiguity for the individual when she or he isoperating within the professional sphere. CAREand ICRW considered that this divergence tem-pered the effectiveness of a wide range of inter-ventions: from behavior-change communicationaround condoms, family planning and breast-feed-ing, for example, to outreach and service deliverytargeting youth, women and socially marginalizedgroups like sex workers or migrants. Conse-quently, CARE and ICRW developed and assesseda field-based approach to improve the effective-ness of CARE project staff and implementing part-ners in conceptualizing, designing and implement-ing reproductive health and HIV/AIDS interven-tions that are informed by and responsive to pre-vailing constructs of gender and sexuality.

Over the past several years, CARE has undertakena substantial effort to ensure that supportive poli-cies, principles and procedures are in place glo-bally to promote gender-responsive humanitarianand development programming. As CARE contin-ues to shift from a needs-based to a rights-basedorientation, it is challenged like, so many develop-ment organizations, to operationalize gender in the

first instance and sexuality in the second. Throughaccess to training and educational materials, CAREstaff can define these concepts and link them theo-retically to development outcomes. In their ownwords, most staff feel, however, that they cannot"do gender," much less understand and apply con-cepts of sexuality to programming. CARE andICRW felt that it was critical to take on the chal-lenge of learning how to more effectively applyconcepts of gender and sexuality to programming,in light of CARE’s capacity to reach millions of im-poverished and socially marginalized women, menand children across the globe.

As a groundbreaking effort to integrate both gen-der and sexuality into reproductive health and HIV/AIDS programming, the ISOFI team drew uponlessons learned from gender mainstreaming mod-els past and present. In addition, the team reviewedrelevant theories of social change and pulled con-cepts and methodologies situated within the do-mains of social psychology, androgogy and partici-patory action research. True to a rights-basedorientation, ISOFI was framed as an empowermentmodel and seeks through iterative loops of reflec-tion and learning, action and experimentation, andanalysis and assimilation to unveil the social, politi-cal and economic injustices that serve to excludeindividuals from society. Fundamental to its de-sign, ISOFI is anchored in the following principles:

• Development practitioners need spaceto explore and understand their ownvalues, attitudes, beliefs and experi-ences of gender and sexuality;

• Personal learning and change in relation

to gender and sexuality will be criticalto enhancing organizational effective-ness in addressing gender and sexual-ity; and,

• Processes and practice in the profes-sional sphere should encourage peopleto recognize and maximize their livedexperiences of gender and sexuality.

ISOFI is a systemic approach to organizationalchange, first promoting and supporting personallearning and change around gender and sexuality,then accompanying individuals as they explore or-ganizational culture and constructs defining genderand sexuality, before launching into field-based ap-plications. Once implanted in field practice, ISOFIcontinually enhances program interventionsthrough short, iterative learning cycles incorpo-rating reflective practice with gender analysis aswell as analysis of social and cultural contexts. Asneeds arise, it is always possible to return to com-ponents focusing on personal and organizationallearning and change around gender and sexuality.CARE and ICRW consider that ISOFI, unlike manyother gender mainstreaming models, offers an ac-tionable, practical and sustainable system forproject staff, implementing partners and commu-nity members to grapple with the issues of gen-der and sexuality.

As described in Chapter 2, the ISOFI InnovationSystem comprises the following six modules:

• Portfolio Review and Needs Assess-ment assists stakeholders to appraise theorganization’s program portfolio in relationto gender and sexuality as reflected inproject content, strategies, activities,monitoring and evaluation, staffing and part-nerships;

• Gender and Sexuality Training is essen-tial to “unfreezing” and expanding people’sperspectives on gender and sexuality;

• Reflective Dialogues provide “safe space”for collective reflection, allowing groups toconstantly test the logic and effectivenessof theories that are put into practice, andadapt interventions to be increasingly re-sponsive to socio-cultural contexts as theybecome better understood;

• Personal Learning Narratives promoteregular personal reflection, and allow indi-viduals to analyze factors affecting theirability to stabilize new beliefs, attitudes andvalues around gender and sexuality;

• Participatory Learning and Action(PLA) is not only central to operationalizinggender and sexuality in very practical andpragmatic terms within local contexts, butalso to empowering staff, implementingpartners and community members asagents of social change. As Freire pro-fessed, for true praxis, all action must beinformed by social, cultural, economic andpolitical realities. PLA identifies specificentry points where gender and sexualitycan be more effectively addressed, andprovides information for engenderingproject strategies, interventions and ma-terials;

• Participatory Evaluation provides amodel for participatory interim process re-view or for endline evaluation.

The ISOFI IS prompts participants to question,critique, reflect and envision. With time and ex-perience, individuals begin to perceive their livedexperience of gender and sexuality through a newlens. Within a supportive environment, they inte-grate new thinking around gender and sexuality intotheir personal frameworks, as well as begin to ap-ply new principles to their work as agents of socialchange.

ISOFI: Progress to DateISOFI provided CARE staff with time and space

58

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for reflection and experimentation, tools and ap-propriate technical support for the effective inte-gration of gender and sexuality issues into theirpersonal lives, their professional work lives andtheir program planning and implementation.Change at a personal level took place across allISOFI sites in India and Vietnam. Staff cited per-sonal learning as key to the process, and perceivedgreat benefits to themselves and to the communi-ties they served. Differences in experience withpersonal learning and change were noted in rela-tion to India and Vietnam. For example, personalchange reported by staff in Vietnam was limited toindividual experiences, and in a limited number ofcases to their sexual partner. Staff in CARE Viet-nam were often frustrated by a general lack of re-ceptivity when they attempted to communicategender and sexuality messages to their families andcommunities. In contrast, Indian staff reported sto-ries of greater change within their family and com-munities. The important role of the prevailing so-cial, cultural and political context is emphasized bythis example.

In both countries, participants believed that strongsupport from CARE and ICRW carried the projectthrough to a successful conclusion. Survey dataindicate substantial progress in integrating gendercompared to, as anticipated, a lesser degree ofprogress in integrating sexuality into reproductivehealth and HIV/AIDS programs. As a result of theinitiative, staff commitment to integrating genderand sexuality increased considerably, and those whoparticipated in ISOFI reported less tension betweentheir personal beliefs and their professional ap-proach to gender and sexuality. The majority ofstaff perceived positive change regarding incorpo-ration of gender and sexuality into projectconceptualization, design, implementation, andmonitoring and evaluation. CARE staff cautioned,however, that the challenge remains to integrategender more systematically into CARE systems andmanagement levels at the level of the country of-fice. Also, the majority of staff from CARE Viet-

nam and CARE India, and all of the CARE Globalstaff, reported little, if any, progress in integratingsexuality into CARE programming.

While staff from both countries reported that lackof clear goals, objectives and outcomes for ISOFIcreated challenges for them, they appreciated thefluidity and flexibility offered through the ISOFIapproach. Respondents in all groups reported en-hanced confidence and self-esteem as a result ofparticipating in the project. More importantly,through participation in ISOFI, staff learned towork more cooperatively and will hopefully con-tinue to undertake collective action to realize hu-man rights in light of their expanded understand-ing of gender and sexuality.

As a methodology, ISOFI laid the groundwork forCARE staff to promote change in the community,so that, with time, women were not viewed asvictims but as agents of change, and men werenot considered oppressors but allies in promot-ing community and family well-being. ThroughISOFI, CARE staff and partners transformed in-terventions to be more gender equitable and sus-tainable, for example, by understanding genderdifferences in the needs of HIV-positive men ascompared to HIV-positive women, or promotingwomen’s agency and mobility so that women couldmore freely access health services while men vali-dated women’s need to use health services. Fur-ther, the model effectively addressed sexualitythrough exploration of power and powerlessness,and pleasure and pain, rather than simply detailingthe links between sexuality and disease. When at-tempting to address issues of sexuality, CARE staffin India choose to frame interventions initially asstrengthening the family and promoting safe, plea-surable sex. In Vietnam, CARE staff, in collabora-tion with the Youth Union, addressed homopho-bia head-on through community dialogue. Anec-dotal information in all three sites indicates emerg-ing positive trends in reproductive health behav-iors, such as condom use, reduction of number of

sex partners, immunization and reduction in gen-der-based violence.

ISOFI: Next PhaseWith the successful conclusion of ISOFI’s firstphase behind them, CARE and ICRW have agreedto engage further on issues of gender discrimina-tion and other forms of social exclusion that havedirect effects on reproductive health, poverty andsocial justice. ISOFI I operated under the hypoth-esis that the integration of gender and sexualityinto sexual and reproductive health programswould have positive effects on a range of cogni-tive, behavioral and health outcomes. Since CARE,its donors and implementing partners tend tomodify their policy and program frameworks morereadily in light of research evidence, in a secondphase of ISOFI, CARE and ICRW will seek to an-swer the critical question: “So what?” What doesthe systematic and contextually tailored integra-tion of gender and sexuality into CARE’s ongoingsexual and reproductive health programs mean interms of transforming gender relations, improv-ing women’s agency and most of all, showing evi-dence of a positive, measurable impact on sexualand reproductive health outcomes? CARE, as wellas the broader development community, needs toanswer these fundamental questions so that re-sults-driven programming can also accommodateempowering processes that lead directly to peoplesecuring their right to health. With the momen-tum and interest generated by ISOFI’s first phase,there now exists within CARE an opening forbroader engagement, for providing evidence thatsuch an approach leads to greater impact in sexualand reproductive health programming, for arriv-ing at a clearer understanding of how to addressgender and sexuality issues in CARE’s developmentand relief work, and for sharing this knowledgewith the broader community.

RecommendationsThe following is a discussion of five broad recom-

mendations to advance the discourse on integrat-ing gender and sexuality more effectively into healthand development programs. Briefly, these rec-ommendations comprise the following:

• Integrate critical reflection with analysis ofsocial and cultural contexts to realize afundamental shift in development practice– from a needs-based to rights-based ap-proach.

• Merge results-based programming withparticipatory processes to design inter-ventions informed by and responsive toprevailing constructs of gender and sexu-ality.

• Move beyond a biomedical model of dis-ease prevention, treatment and mitigationto address underlying causes of poor re-productive health, i.e., gender and sexu-ality.

• Stimulate and support on-going personaland collective learning and change aroundgender and sexuality at all levels of theorganization.

• Fund further research and programming inthe area of gender and sexuality.

Integrate critical reflection with analysis ofsocial and cultural contexts to realize a fun-damental shift in development practice – froma needs-based to rights-based approach.In CARE’s view, a rights-based approach leads tosustainable development, as those who are em-powered can continue to advocate for their needsand rights long after external development agen-cies have moved on to other sites and issues. AsLynn Freedman stated: “...[T]he embrace betweenpublic health and human rights creates what ispotentially one of the most powerful sets of theo-retical, practical and organizational tools for ad-dressing the issues that loom largest in the inter-national women’s health arena at the dawn of the

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twenty-first century” (Freedman, 2000: 429). Con-sequently, shifting staff perspectives on how and whyto do development is a critical factor in re-orientingorganizational culture and practice to a rights-basedmodel. While gender and sexuality are pertinent toprogramming in all sectors of development, they aremost visibly and directly implicated in strategiesaddressing reproductive health and HIV/AIDS.

As one approach to understanding and addressingthe underlying causes of poverty and poor health,ISOFI demonstrated the effectiveness of support-ing exploration into lived experiences of genderand sexuality. By broadening and deepening per-sonal horizons, individuals could then more genu-inely empathize with others when dealing withcomplex community issues such as HIV and AIDSor maternal health. Further, ISOFI provided toolsand processes (see Chapter 2) by which CAREstaff, implementing partners and community mem-bers could drill down and tease apart the tangle ofsocial and cultural factors that contribute to height-ened risk and vulnerability, particularly among so-cially marginalized groups. Most importantly, thoseinvolved with ISOFI reported increased confidence,self-esteem and sense of self as well as greater tol-erance toward alternative lifestyles, identities andperspectives. They felt, in their own words, “lib-erated” and “empowered.” CARE and ICRWwould suggest that empowered individuals, rep-resenting various sectors of society, are effectiveagents of social change individually and, when work-ing as a group, more likely to build an authenticand sustainable foundation for rights-based devel-opment in communities.

Merge results-based programming with par-ticipatory processes to design interventionsinformed by and responsive to prevailing con-structs of gender and sexuality.Much of development assistance is currentlyframed as results-based or target-driven – evalu-ated ideally by outcome indicators such as HIV inci-

dence, maternal mortality and nutritional status, butmeasured more commonly by output indicators, likenumber of youth reached with HIV preventionmessages, number of children immunized or num-ber of girls attending schools. Results in theirdeconstructed form as targets are not inherentlybad – they provide focus and direction, and intro-duce accountability and facilitate planning. In theirmost intense form, however, targets drive imple-mentation, creating undo pressure on staff, part-ners and communities to focus only on meetingimmediate numerical targets rather than promot-ing sustainable long-term change. Targets becomean end in and of themselves, squeezing out timeand space for reflection, creativity, adaptation andexperimentation. In effect, in the blur of achievingtargets, many staff lose sight of the result to whichthose targets contribute. The experience of manydevelopment projects would indicate that this isnot a pathway to success.

Making progress on addressing root causes of pov-erty and poor health goes beyond a mechanicalapplication of public health best practice. It requiresan inductive approach that allows people to peelaway the layers of complex social issues to per-ceive and then understand how causal factors in-terrelate, for example how social restrictions onwomen’s agency and mobility can negatively affectreproductive health. When an issue has beenframed as holistically and as comprehensively aspossible, the next step is to identify points of en-try for the delivery of evidence-based strategiesfor action. Contrary to common opinion, integrat-ing participatory processes into results-based pro-grams does not imply delays or interruptions inprogrammatic activity. Rather, participatory pro-cesses ensure that strategies and interventions aredesigned as close to the problem as possible. Par-ticipation creates collective ownership, trust andengagement – and can open previously hidden orclosed channels of communication. ISOFI holdsthe promise of genuine shifts in behavior change

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rather than more transitory results usually achievedthrough target-driven development models. Asnoted by Rosalyn Petchesky (1998) : “Research-ers and research groups interested in women’sreproductive and sexual health/rights as an aspectof development should value the process at least asmuch as the outcomes of their research.“

Move beyond a biomedical model of diseaseprevention, treatment and mitigation to ad-dress underlying causes of poor reproductivehealth, i.e., gender and sexuality.To date, most public health work has engaged in adiscussion of sexuality from a narrow biomedicalviewpoint focusing on the intersection betweensexuality and disease. ISOFI presents a very prac-tical way to address sexuality in a manner that goesbeyond a biomedical model and begins to addresspeople’s personal concerns about sexuality: powerand powerlessness, and pleasure and pain. Othermethodologies, such as Stepping Stones, have beencritical in promoting a more holistic model of inte-grating gender and sexuality meaningfully into re-productive health programs (Welbourn, 1995). Asdiscussed in Chapter 1, condom promotion strat-egies that do not address the concerns faced byboth men and women as they consider condomuse, the need for intimacy and sexual pleasure, andpower relations will not be as persuasive as pos-sible in promoting condom use for HIV preven-tion. Regrettably, couple communication, which iscritical to improving a range of reproductive healthoutcomes (Varkey et al., 2004; Zulu, 2003;Holschneider and Alexander, 2003), is often ig-nored in many public health initiatives.

Grounded in a rights-based philosophy, ISOFI hashelped to advance the gender discourse withinCARE from one of women as victims and men asoppressors to one of women as agents of theirown development and men as vulnerable, givensocially restrictive norms and identities. This two-year experience of purposefully exploring beyond a

biomedical model in pilot sites in India and Vietnamserved to anchor CARE’s transition to a rights-basedframework as it relates to reproductive health andHIV/AIDS programming. The challenge remains tobring the initiative to scale within CARE India andCARE Vietnam, and to influence the discourse ongender and sexuality within CARE globally andthroughout the development community.

Stimulate and support ongoing personal andcollective learning and change around genderand sexuality at all levels of the organization.ISOFI engendered organizational evolution. CAREand ICRW’s experience over the past two yearssuggests that the creation and maintenance of a“safe space” within the organization is instrumen-tal in evolving an institutional discourse on genderand sexuality. Within this non-judgmental space,people expand their perspectives on gender andsexuality through training, exchange and dialogue,and critical reflection on their personal attitudes,beliefs and practices. Designed as an interventionto “shake up” staff on their long-held perspectiveson gender and sexuality, the ISOFI-sponsoredtrainings and reflective dialogues allowed staff toprocess their own issues with gender and sexual-ity prior to addressing gender and sexuality withimplementing partners and community members.As discussed in chapters 1and 2, numerous orga-nizations conduct gender training for staff. Rarelydoes this training extend beyond a one-time event,and therefore many organizations have been dis-appointed with the results.

A key lesson learned from ISOFI: It is crucial tocreate space for learning, exploration and reflec-tion at each level of the organization. People atthe executive level, in senior and middle manage-ment and in field implementation should accom-pany one another through this change process.As such, a system-wide enabling environment iscreated, facilitating relevant discussion on genderand sexuality in all operational spheres.

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Fund further research and programming in thearea of gender and sexuality.The Ford Foundation is an acknowledged leader inpromoting work on gender, sexuality, reproduc-tive health and human rights. Apart from the FordFoundation, few other donors provide significantresources for research on sexuality or on the in-tersection of gender, sexuality and disease, despitethe fact that sexuality is key to turning the tide onthe AIDS pandemic. As discussed in chapters 1and2, many organizations have gender policies andundertake gender mainstreaming to some degree;few have effectively incorporated gender, muchless sexuality, into their programming. Gender andsexuality are not a new frontier in the develop-ment arena, but their pertinence to human healthand well-being is more sharply focused by theworld’s commitment to the Millennium Develop-ment Goals. Resources are urgently required toposition gender and sexuality more strategically andproductively within global efforts to eradicate pov-erty.

Next StepsIn light of the pilot’s success as a collaborative learn-ing initiative, CARE and ICRW have agreed to buildupon the prolific learning generated during ISOFI’sfirst phase to deepen their understanding of theeffect of systematically integrating gender and sexu-ality into development programs. As a result, CAREand ICRW will undertake the following steps:

1. CARE and ICRW will conduct an OperationsResearch study in collaboration with a CAREsexual and reproductive health project to mea-sure how the systematic and contextually tai-lored integration of gender and sexuality intosexual and reproductive health programs trans-forms gender relations, improves women’sagency and, most of all, achieves positive,

measurable impact on reproductive health out-comes.

2. The ISOFI core team will disseminate the end-of-project report widely within CARE andICRW, and ensure that the tools developedunder ISOFI are made available to CARE coun-try offices. Further, the core team will advo-cate for institutional commitment to expandthe ISOFI experience to new CARE countryoffices. CARE and ICRW will promote ISOFIas an emerging promising practice to relevantforeign assistance agencies, donors and thedevelopment community at large.

3. CARE and ICRW will broaden their experiencewith the ISOFI methodology by replicating itas a rights-based approach to sexual and re-productive health programming in other cul-tural contexts (e.g., African countries) and byadapting it to other contexts of social exclu-sion (e.g., HIV-positive women and men or ex-combatants in post-conflict settings).

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Annex 1: PR/NA Guide

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Overview and PurposeThe Portfolio Review and Needs Assessment allowsone to take a look at programs that are currentlybeing implemented, programs that have recentlyended and programs that are in the pipeline. An ex-amination of how they are oriented and structuredis conducted with a focus on looking for any gapsthat may exist.

MethodologyIn the context of ISOFI, through the use of a fieldguide, CARE and ICRW staff led a half-day discus-sion with project staff to identify current programstrengths and gaps in order to identify opportuni-ties for integration and entry points for gender andsexuality in the project cycle. In the case of bothIndia and Vietnam, the field team developed a de-

tailed plan of action, which focused initially on learn-ing and critical personal reflection and then movedto involving partners in the iterative learning pro-cess.

Tools/GuidelinesA set of reflections were used with the groups toexplore the gaps and learning opportunities in theexisting program portfolio to integrate gender andsexuality. It specifically looked at the following:- Current level of integration of gender and sexuality in the existing portfolio- Necessary conditions for integration of gender and sexuality including stakeholder analysis and ways to build ownership- Existing learning mechanisms to foster un derstanding on gender and sexuality

ISOFI Portfolio Review and Needs Assessment

Question Guide

1. In what ways are gender and sexuality being currently implemented in programs andwithin the organization?

2. What are the current mechanisms within the organization that have an explicit learningpurpose?

3. What kinds of new knowledge are generated?

4. Who contributes to generating new knowledge and who benefits from it?

5. Is learning being documented and shared? If so, how?

6. How is learning currently applied?

7. If you could redesign or adapt your project to more effectively integrate gender andsexuality issues, what would you do and why?

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Throughout ISOFI, the monitoring and evaluationsystem collected both quantitative and qualitativedata. Qualitative data was collected across manydifferent venues and constructs. During the end-of-project evaluation, in addition to using in-depthinterviews and focus groups discussion data, allproject documentation and outputs from the end-of-project workshops were analyzed qualitatively.Quantitative data was collected in the form ofbaseline and endline surveys anonymously admin-istered to CARE staff. The qualitative data wasused to triangulate findings and inform the resultsfrom the quantitative data and served to providerich contextual data that answers “why" - contextthat is often unobtainable from quantitative find-ings. The data collection process took throughoutthe project. The survey data analysis is presentedin Chapter 5 of this report. All other qualitativedata has been incorporated throughout the report.

In-depth Interviews and Focus Group DiscussionsQualitative data was collected from all ISOFI sites(two in India, two in Vietnam) and included in-depth interviews (IDIs) with CARE staff, key infor-mant interviews with partner staff and focus groupdiscussions (FGDs) with community groups. TheISOFI evaluation team conducted a total of 20 in-depth interviews, eight in Vietnam and 12 in India,and 11 key informant interviews with staff fromNGO partners and health workers: One in Viet-nam and the rest in India. Ten FGDs were com-pleted in India with groups of adolescent girls andadolescent boys, migrant workers, truckers, sexworkers and young mothers.

Annex 2: EOP Methodology

ISOFI End-of-Project Evaluation Methodology

A sampling frame consisting of a complete list ofnames, positions and genders of CARE staff directlyand indirectly taking part in the ISOFI project at allthree sites was developed. Participants were se-lected from the list based on gender (equal num-bers of men and women) and management level(participants were selected across managementlevels within the organization to ensure a repre-sentative sample and degree of participation withinISOFI). In India, participants were interviewed byphone; face-to-face interviews were conducted inVietnam.

The ISOFI evaluation team obtained informed con-sent before conducting all indepth and key infor-mant interviews. The interviews and focus groupdiscussions were based on a field guide highlight-ing topics for discussion and suggested probes.

Interview data were first reviewed by the researchteam for main themes and then were coded forretrieval and analysis using the NUD*IST program.

Documentation of Project ActivitiesProject-generated qualitative data also includes acollection of project documentation, including re-ports of Participatory Learning in Action exercisesaround gender and sexuality; portfolio review andneeds assessments; detailed implementation plans;trip reports; and reflective dialogues. Findings de-scribed in these sources have been integrated anddiscussed throughout the report.

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End-of-Project WorkshopsFinally, qualitative data was collected from threeend-of-project (EOP) workshops conducted inFebruary 2006 in three ISOFI sites: Rajasthan andUttar Pradesh in India, and Hanoi in Vietnam. Theworkshops sought to capture the learning fromthe ISOFI implementation experience in each ofthe locations, and designed to assess programmaticimpact of ISOFI in order to draw lessons for fu-ture interventions. The workshops were structuredaround a participatory methodology to allow forand encourage maximum participation and feed-back from participants. A total of 32 staff par-ticipated (Vietnam: 9; Lucknow, India: 13; Bhilwara,India: 10). Workshops were facilitated by VeronicaMagar, Sexual and Reproductive Health Asia Re-

gional Advisor for CARE, and Sarah DegnanKambou, Director for HIV/AIDS and Developmentfor International Center for Research on Women.

Workshop participants reviewed key benchmarksduring the two-year implementation period; con-ducted a stakeholder analysis to analyze key rela-tionships, power relations and their transforma-tion during ISOFI; changes in staff’s personal livesor the lives of the communities where CAREworks; progress in incorporating gender and sexu-ality during the course of ISOFI; enablers and bar-riers to incorporating gender and sexuality; and,finally, recommendations for ISOFI’s next phase.

The EOP Workshop evaluation plan is annexed inthis report.

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Session Session Title Purpose/Objective Methodology

1 Welcome To open the workshop offi cially Remarks before plenary audience

2 Introductions To ensure all participants/facilitators are familiar with each other; to break the ice; to set the stage; to stimulate active participation

Any workshop game or icebreaker that communicates name, title, responsibility, involvement with ISOFI and something interesting about the person

3 Workshop Objectives and Methodology

To orient participants to the purpose and objectives of the workshop so they can meaningfully contribute to discussion and required outputs

PowerPoint of purpose and objectives and methodology, followed by questions and comments

4 ISOFI: Timeline To elicit from participants their perspective on the project’s key events/benchmarks and the relation of those events/benchmarks to the evolution of ISOFI and its impact within CARE

Small group work (3-4 participants per group) using Timeline tool; group work: 20 minutes; report back in plenary for 10 minutes per group; add’l questions/discussion from facilitators and the group

5 Tea and coffee break

6 ISOFI: Stakeholder Analysis

To understand sources and relationships of power and infl uence effecting ISOFI’s implementation and evolution from the participants’ perspective; who, what, when and why: who played a key role in implementing and/or infl uencing the ISOFI project; what were those roles; how did relationships among stakeholders evolve during the course of project implementation and with what effect; and why did roles evolve as they did.

Small group work (3-4 participants per group) using Venn Diagram tool; group work: 30 minutes (10 mns: project start up phase; 10 mns: mid-point; 10 mns: fi nal phase); report back in plenary for 15 minutes per group; add’l questions/discussion from facilitators and group

7 ISOFI: Most Signifi cant Change

To understand what participants perceive to be the Most Signifi cant of all Changes over the course of the ISOFI project. (Note: We are collecting individual perceptions of MSC through the endline survey. This exercise will ask individuals to share MSC stories, then to rank them so that the “most signifi cant of all change” is identifi ed.)

Small group work (3-4 participants per group) using Storytelling tool; group work: 30 minutes; report back in plenary 10 mns per group; add’l discussion and fi nal ranking

8 Lunch

9 CARE Reproductive Health: Portfolio Review

To assess the extent to which and in what way CARE reproductive health projects are integrating gender and sexuality in light of the presumed diffusion of ISOFI fi eld experience, tools and lessons learned

Plenary discussion; brainstorming exercise followed by an anonymous G&S scorecard exercise conducted in plenary

10 Gender & Sexuality: CARE’s Structural and Cultural Environment

To assess change in enablers and barriers to the integration of G&S identifi ed during the baseline Needs Assessment, and to identify emerging enablers and barriers for the second phase

Small group work (3-4 participants per group) using Force Field Analysis; group work: 30 minutes; report back in plenary 10 mns per group; add’l discussion

11 Envisioning the Next Phase of ISOFI

To elicit recommendations on “where CARE should be/what CARE RH programming would look like” at the end of ISOFI Phase Two

Three groups: 1st Group) Desired ISOFI Stakeholder Relationships at end of Second Phase using Venn Diagram; 2nd Group) ISOFI Footprint or “legacy” at the end of Second Phase using Cartooning; 3rd Group) Recommen-dations on addressing existing and emerging enablers/barriers (identifi ed in Session 10)

12 Summary To summarize the workshop’s proceedings, explain Next Steps Remarks in plenary; reference to fl ip charts

13 Closing

End-of-Project Workshop Agenda