Before database exploration, all authors thoroughly reviewed the PROSPERO registry at the end of December 2020, to verify that a systematic review focused on the nexus of masculinity norms and SRH within the Americas did not already exist. Once this was confirmed the database research commenced for this systematic review. In January 2021, the investigators scrutinized four large multidisciplinary databases: PubMed, EBSCOhost, SCOPUS, and Google Scholar. The specific databases within the mega databases of EBSCOhost that were chosen for search are detailed in Table 1. Furthermore, within PubMed and SCOPUS, advanced search filters were applied to tailor the search such that articles only focused on countries within the Americas region and published from 2010 and onward were outputted in the search results. Database access was enabled by the Universidad San Francisco de Quito’s online library services for students.

All authors collaborated in developing and finalizing the keyword formula utilized for database search. The following is the English representation of the algorithm:

This formula was translated into Spanish and Portuguese in order to broaden the number of publications found in each database. The research team consisted of native Spanish speakers as well as members fluent in Portuguese, thus a translation of the keyword formulas did not require external support. Across all databases and languages, the use of Boolean terms, truncation, and parenthesis was consistent.

In order to best understand how male-engagement interventions and internalizations of masculinities impact SRH throughout the Americas region, the keyword search was limited to literature from the timeframe range of 2010 until January 2021. Publications were excluded if they met one of the following criteria: 1) the focus of the article did not align with sexual and reproductive health topics, 2) the study’s location was outside the scope of the Americas region, 3) the publication’s content only described information collected before 2010, 4) the article’s population of focus did not fall between the ages of 15 and 24, 5) the publication was not an original science research article but rather an editorial/commentary piece or report from a governmental, non-governmental, or intergovernmental entity.

Please refer to Figure 1 for visual aid in understanding the screening process. All the investigators searched the previously explained keyword formula in three languages (English, Spanish, and Portuguese) across all four databases. The total sum of initial results was 10,721 sources. Article titles were compared to remove duplicates, resulting in 7,803 publications. However, since Google Scholar produces results that are organized by relevance according to the keyword inputs, publications listed after page number 5 of the search results were clearly beyond the scope of interest. It was deemed to eliminate these before the screening process, resulting in 7,548 articles removed from the total records. Duplicates across database results were then removed, narrowing the number of records to be formally screened to 255 articles.

Articles were scrutinized for relevance according to the pre-defined exclusion and inclusion criteria. Each of the 255 article’s basic identification information was organized into a comprehensive spreadsheet, documenting the following parameters: article link, title, abstract, authors, journal, total pages, as well as an outcome decision for the article’s inclusion in the review. After eliminating articles by reviewing the 255 articles via abstract review and application of the exclusion criteria, a total of 22 articles remained. A full-text article review of these remaining publications was performed. During the full-text review, articles were removed if they met previous exclusion criteria and were not peer-reviewed. To ensure valid decision-making, the researchers consulted all team members for clarity when a disagreement arose regarding exclusion criteria fulfillment. This full-text discussion resulted in nine other articles being excluded, leaving 13 articles for final synthesis.

In February 2021, the research team decided to implement the snowball technique in order to include additional relevant articles and expand investigation content. The applied snowball method involved hand searching all the 533 bibliographical references from the eligible 13 papers identified via systematic review. For each reference, the previously established systematic review parameters of inclusion and exclusion criteria were used. Snowball searching completed after conducting the systematic keywords formula search led to the identification of 19 additional eligible publications for synthesis. Hence, a total of 32 articles were analyzed thematically to generate findings.

The perception, influence and relationship of masculinity within sexual and reproductive health addressed in the North American articles included in this systematic review highlight important considerations as shown in Table 3.

Conventional “guy talk” boosts idealized masculine expectations and the generation of masculine norms based on men’s abilities to communicate sexual behavior with peers. Masculinity standards assign sexual health care to women and the discussion of STIs to subordinated men thus leading to the discussion of these issues in private and with people whom men consider trustworthy. ¹⁴

In terms of sexual and reproductive health, studies established the need to implement gender transformative programs that aim to reshape gender norms that encourage risky sexual behaviors, violence, and sexually transmitted infections (STIs). ¹⁵ Awareness and attitudes of gender equality in adolescent populations is key for sustainable public health interventions. ¹⁶

Within the African American populations studied, masculinity is highly related to cultural and community standards; this relationship can be measured by a Masculine Attributes Questionnaire (MAP). ¹⁷ Young African American men have a higher incidence of sexually transmitted infections than any other population in the United States which may be due to the influence of “perceived peer norms” related to risky sexual behaviors such as the wrong and “shameful” use of condoms. ¹⁸ Social recognition for having multiple partners, intertwined social networks, limited community of sexual partners along with the lack of relationship commitment are important determinants of masculinity expression in these populations. ^{19 – 21}

In terms of contraception, one study centering on African American men recognized their lack of knowledge regarding contraceptive methods besides condoms. ²² Also, it was found that condom use errors were frequent and included failure to review some type of condom damage, conscious use of damaged or expired condoms, lack of discussion about the use of condoms, problems with condom sensation, adjustment, ruptures and premature removal. ²³ These mistakes were associated with African American men with multiple sexual partners. This population along with a sample of young aboriginal Canadians asserted women as the primary active negotiators of condom use. ²⁴

Men’s romantic relationships in early adolescence increase the influence of sexual health and develop a process characterized by curiosity and anticipation of sexual behaviors. ²⁵ Preventive clinical interventions must extend beyond mere recommendations of condom use or abstinence, including the promotion of strategies that help young men self-assess “personal disposal” for sex. ²⁶ The development of values as well as sexual and romantic relationship dynamics in adolescence occurs alongside family and peer experiences. ²⁷ These fundamental components of a sexual history implicate the risk of STIs as well as early fatherhood. ^{26 , 27}

One study associated the influence of the perception of young African American on their partner’s desire to conceive their child and the practice of risky sexual behaviors as a tool for compensating masculinity in the context of lack of schooling or job opportunities that prevents them from expressing other male responsibilities such as financial or sentimental support. ²⁸ Then, the development of couple communication skills regarding pregnancy intentions plays a crucial role in pregnancy prevention interventions and father’s involvement during pregnancy, and thus future child health and social outcomes. ²⁹

Adolescent parenthood is filled with life development limitations such as decreased years of schooling, decreased human capital and balk psychological development. ^{20 , 30} These factors may contribute to dysfunctional atmospheres and may start an intergenerational cycle of early fatherhood in which children are raised in low-income environments and are exposed to abuse and neglect. ^{31 , 32}

Adolescent men have less involvement with primary health systems and unmet health care needs. ³³ Non-clinical youth-serving professionals represent a bridge between adolescent primary close up to sexual health and their access to clinical interventions; however, there are multiple gaps that limit this linkage such as the poor training of these professionals in terms of sexual health. ³⁴

Adolescence is a period of transition in which the personality is influenced by hegemonic masculinities and intersectionality. ³¹ Understanding how risk factors such as poverty, school failure, drug use and abuse, and sexual abuse contribute to early parenthood is the first step to prevention. ^{31 , 35} The construction of identities at this stage should encourage adolescent men to understand the sense of responsibility of parenthood and promote their talents. ³³

Furthermore, one particular study showed that there is a greater range of participation in education campaigns and prevention of sexually transmitted diseases when applying social activities. ³⁶ The role of media campaigns and the use of social media and networks that support health interventions can contribute to community acceptance and the reduction of stigma of certain aspects of sexual health. ³⁶

The masculinity in adolescent relationships of the African Americans studied set precedents for their adult relationships. ²⁷ Difficulties in regulating emotions were associated with the practice of risky sexual behaviors. ²¹ Redefining masculinity towards egalitarian terms that promote healthy sexual practices, prevent violence, reduces the transmission of HIV and STIs and enhances the physical and mental health of both men and women. ^{37 – 39}

One article based within Panama represents the results of the Central American region and shows important considerations reflected in Table 3.

A “real man” within the Panamanian sample studied represents a sexually active, independent, dominant male. Adolescents of Bañado Sur tend to replicate this socially acceptable masculine role exclusively with casual relationships or peers even if these behaviors do not match their personal beliefs. Men that do not follow acceptable masculinity trademarks are related to a certain degree of exclusion or homosexual tags. Family and support networks influence adolescent sexual behaviors directly. In the context of the Panama sample studied, adolescents attribute their risky sexual practices and promiscuity to poor parent and school sexual health education which has motivated them to experiment these topics by themselves. Machismo and taboos are important determinants of risky behaviors and can reflect relationship dynamics such as sex restriction until marriage and trivialization of sex. ⁴⁰

Two articles within the context of Cuba and one in Jamaica represent the results of the Caribbean region and show important considerations reflected in Table 3.

In Cuban samples where sex-related roles were assigned, women were labeled as dependent, “soft,” and sentimental whereas men represented power and resistance. Within these populations, men have a low incidence of condom use. Knowledge about sexual education is minimal and mostly acquired in out-of-school settings. In terms of contraception, it was found that, for some men, willingness to engage in safe sex practices such as the use of condoms was only related to STI prevention and not pregnancy prevention. Men’s tendencies to practice condomless sex, deny readiness for parenting responsibilities, and consider pregnancy as primarily a woman’s responsibility. ⁴¹ Men attributed their lack of condom use specifically at loss of pleasure and were more likely to engage sexual practices with older women who prefer condomless sex. The relationship between dominance/virility and procreative desire can be measured by a “Macho Scale” described within the Jamaican study included in this systematic review. ⁴²

One investigation that occurred in Chile and another which took place in Paraguay represent the results of the South American region and show important considerations reflected in Table 3.

Based on results from the two South American publications selected, evidence demonstrates that several programs with goals of advancing SRH have been carried out focusing solely on female populations. The article from Chile investigates masculinity perceptions as related to participation in SRH services. It includes the perceptions of healthcare personnel and that of male adolescents about masculinity and its link with SRH services. Likewise, it is appreciated that the variable masculinity or ideology of masculinity intervenes in several aspects such as the use of condoms, contraceptives, in general to the SSR. The context of creation of friendly spaces is relevant to understand the sense of masculinity in young people nevertheless, despite the existence of these spaces, young men go to hospitals and clinical spaces in cases of extreme urgency only. ⁴³ According to the findings of a study conducted in Paraguay, young people believe stereotypes and openly express them. The study points out that gender, relationships, and masculine norms interact in a similar way in disadvantaged and marginalized communities all around the world. ⁴⁴

This systematic literature review is the first study that has explored the role and influence of masculinity in adolescent sexual and reproductive health in the Americas in the three most popular languages of this continent: English, Spanish, and Portuguese. The traditional belief in the role of women as solely responsible for sexual health has stagnated male involvement in family planning, contraception, communication skills between partners, prevention of sexually transmitted diseases and pregnancy. ⁴⁵ For these reasons, the need to implement gender-transformative interventions is an opening to the practice of safe sexual behaviors that will decrease the prevalence of STIs and gender-based violence.

In this study, we took into consideration the geographical and cultural context of the results since harmful masculinity foundation goes beyond sexual health education. In fact, it includes the beliefs, perceptions, and social practices that men have regarding their sexuality as reflected in past research. ⁴⁶ Under the social pressure to become a “real man”; understood as a sexually active, dominant masculine type; men’s support networks are important as they exert a significant influence on sexual behaviors. The influence can represent a place free from social constructions that stigmatize and affect men’s health or maximize harmful gender norms. ^{14 , 37}

Considering the cultural background of the populations studied in the articles helped us identify the risk of STIs in minorities. The results positioned African American and Canadian aboriginal young males as more pressured to have a hypersexual state and not use condoms, respectively. ^{21 , 18} Hence, we recommend that further strategies for targeting minorities should include a global understanding of the socio-cultural and economic context of specific populations.

Our findings enhance the importance of innovative educational interventions. School sexual education remains as the most used tool to identify focal groups of young males and create support systems that strengthen non-toxic masculinity perceptions. However, in today’s global context, it is crucial to use educational platforms that can be spread throughout social media. ¹⁹ This strategy will allow rapid dissemination of information on STIs, pregnancy prevention programs and beneficial gender perceptions.

Unlike past reviews related to this topic, the search terms were translated to the three most populous languages in the Americas (English, Spanish and Portuguese). While searches in Spanish and Portuguese did not produce many additional results, it clarifies that the literature is largely published in English, followed by Spanish. Additionally, the consulted search engines were four reliable public health and social science research databases. The precision of specific inclusion and exclusion criteria allowed the search to reveal the most pertinent information for future community health practice in the topic area of adolescent SRH. We included the latest data using studies performed since 2010 in order to provide an update on our topic. A “snowball approach”, utilizing the referenced citations of searched publications allowed for a more complete review of the relevant literature.

Since many studies initially produced by database search were eliminated due to not meeting the inclusion criteria, the research team questioned whether the focus of the systematic review was too narrow. The rigid search criteria, while positing only the most rigorous results, may exclude important strides in the work of interest completed through thesis or dissertation studies as well as through government and/or non-governmental research reports. Certain search terms such as “gender equity,” “gender transformative,” “sexual and reproductive rights,” among others could have been added to broaden relevant language to the study’s interest. An expanded search of current literature might be specifically helpful in regions of the Americas where such little original research has been published on the topic, specifically Central and South America.