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Sexuality and HIV/AIDS Sabina Faiz Rashid, PhDAssociate ProfessorCoordinator, Centre for Gender, Sexuality, and HIV/AIDSJames P Grant School of Public Health BRAC University Dhaka, Bangladeshsabina@bracu.ac.bd www.aids2010.org

HIV/AIDS and Sexuality • Research on sexuality and sexual behavior increasingly a priority • Much of the research and response has been based on biomedical model • Universal physiological drive • Rooted in shared biology/psychology as human beings • Measurable, main focus was surveys documenting statistical frequencies – use of contraception, nos. of sexual partners, risks of disease transmissions • Focus on individual

Sexuality beyond…disease Sexuality seen only as a sexual health problem (not seen beyond disease and unwanted pregnancy) Researchers argue for changing both the methodological approaches and the analytical lenses - dominating the conventional thinking around HIV/AIDS - Social dimensions of sexuality • Careful ethnographic research; Qualitative in-depth research for more nuanced, richer insights into lived experiences of sexuality/sexual behavior

CONTEXTUAL and RELATIONAL Important to pay attention to sexual cultures and the broader socio cultural context, political economy in which sexuality is embedded, constructed, and lived Macro socio economic conditions in fostering unsafe sexual relationships deserves greater attention • Migration, Economic marginalization, poverty, • market economies • Lack of options for men and women • Commercialization and commoditization of sex • Multiple partnering and frequent partner exchange • Local cultural context, differing perceptions of risk among women/men, gender and power relations Research evidence highlights, situation is complex, different kinds of vulnerability for women and men

Women’s vulnerability • Culture of silence around sex ‘good woman’ expected to be ignorant of sex and passive in sexual interactions • Makes it difficult for women to be informed about risk reduction or even proactive in negotiating safer sex • Norms of virginity (restricts ability to ask for information) • Risk of alternative sexual behaviors, anal sex • Motherhood feminine ideal • Women’s economic dependency increases vulnerability • Exchange sex for money, for favors • Unprotected sex • Experience Violence (Geeta Rao Gupta, 2000)

Men’s vulnerabilities • Greater power, vulnerability • Men expected to be more knowledgeable and experienced about sex • Risk of infection • Experimenting, don’t seek out information or help • Variety in sexual partners is essential • Sexual domination messages contribute to homophobia and stigmatization of men who have sex with men (Geeta Rao Gupta, 2000)

Research evidence from social context?...continued Research study on social constructions of sexuality among migrant workers wives inMexico (Hirsch et al, 2002) • Male migrants leave communities to travel to US to find work, engage in extra-marital and unsafe sex. When they return home they are said to be ‘honeymooning again.’ • Younger Mexican women expressed a marital ideal of mutual intimacy, communication, joint decision making and sexual pleasure with husbands • ‘Intimate sex’ = no condom use, mutually pleasurable sex, heart of marriage, • Denial of infidelity • Asking for condom use implies infidelity; a lack of love

…continued Younger Mexican Women • Wives practice monogamy (as advised by health centers); safe Older women – most important financial support and respect in terms of faithfulness, sexual behavior secondary concern • Drinking and NOT working seen as worst traits in males • Men viewed as having needs, and may seek others, does not impact on marriage (Hirsch et al, 2002) Differing perceptions of sexual risk among younger and older women, among men

Research evidence…continued Sexual behavior among truck drivers in Pakistan(Sohail Agha, 2002) • Do not believe AIDS exist in country as government efforts to address interventions for sex workers industry till mid 90s, • Love of adolescent boys common theme in literature, poetry, but no social acceptance; • in NWFP, acceptable to have young male lovers among Pathans • Sexual relations forbidden, multiple sexual partners common with both men and women • Access sex workers (in groups or alone) • Lack of opportunities to have sex with females, cannot afford female sex workers – sex with males • Desire/want to have sex with males (young boys as helpers)

…continued • Don’t necessarily identify as homosexual behavior • Married, with children • Fulfilling desires, need for pleasure • Did not use condoms with wives; low condom use in sexual encounters • Risks – immediate threat to life (accidents, injuries) rather than AIDS; • “AIDS affects immoral and or dirty persons”, consider selves as moral

Research evidence… Sex codes and family life among inner city youths in the USA (Elijah Anderson, 1989) Sexuality/behavior shaped by violence, poverty - Unemployed males boasted of sexual exploits, ‘more pussy’ raises status, in the absence of economic power, • Sexual prowess and having a baby - mark of manhood • Males desired sex without commitment (play the game) and girls who have sex are often viewed as ‘easy’ • Strongly committed to their peer groups; deride conventional family life

Research evidence… Sex codes and family life among inner city youths in the USA (Elijah Anderson, 1989) Young Females • Poverty • Lack of options – • Offer sex as a ‘gift’ to attract attention of males • Hope of marriage, love, having a family life • Baby means access to regular welfare check (economic security) Implications for Sexual health and HIV

…continued Sexual Behavior in Urban Slums in South Africa(Walsh and Mitchell, 2006) • Gang membership and violence defines manhood • Sex is part of life – risk of contracting AIDS seen as minor importance in the context of everyday violence/deaths, poverty, despair • Women sell their bodies in exchange for money, support, emotional relationships, protection etc

Research Evidence… Research on a Township in South Africa among young men/women(Terry Ann Selikow, 2004) • Fixed binaries define sexuality (male/female) Ingagara - ‘real man’ – has lots of girlfriends, is not employed, involved in gangs, accepted as violent and promiscuous • Opposite is isithipa –’dumb person’ - unfashionable, does not have many girlfriends, is often employed, does not do crime, wants to achieve educationally – not taken seriously as a man • Two categories of girlfriends: • Regte – right one (mother/wife) – lovemaking • Cherrie – kept secret (on the side) - fucking

Research evidence… Dominant script in many parts of Southern Africa (and other cultures) “Men at mercy of biology when it comes to sex” • Men are like bees, they need honey from many flowers (Swazi) • Men are like an axe, they must constantly sharpen their weapons (Shona/Zimbabwe) • Men cannot eat cabbage every night (Zulu/South Africa) Legitimizes polygyny; Concurrent partnerships as something natural(Suzanne Leclerc-Madlala, 2009)

Research Evidence… Vietnam, Nigeria, Cambodia • Sexual behavior and the social organization of infidelity shaped by economic inequality, market economies (consumerism), aspirations for modern lifestyles, gender disparities, and contradictory moralities

Research evidence…continued Vietnam - political economy of HIV/AIDS risk(Harriet Phinney, 2008) • New establishments selling sex for business purposes; sexualization of commercialized leisure spaces • New forms of masculinity asserted • Homo-social activities – men in groups find women to have sex with • Pressure to engage in extra-marital relations – social risks of refusing outweigh any epidemiological risks • Spaces to meet, indulge in sexual activities – karaoke bars, massage parlors, nightclubs, barber-shops, cafes, bus stations, train stations (sex workers seen as preferable to lovers)

…continued Social reproduction messages for Vietnamese women • Economic stability provided by men are core of discussions; • Whether sexually faithful not considered important - ‘shared silence’ • Accept male socializing behavior, place themselves at risk of HIV/AIDS (Harriet Phinney, 2008)

Research evidence… Study in Nigeria, found that married men seeking ‘modern lifestyles’ exacerbate their/partners risks to HIV/AIDS (Smith, 2007) • Frequent mobility and migration (hidden relationships), • ‘Sugar daddy relationships’ (gifts given, economic support given to lovers); increase social status for men • Young girls looking to increase their consumption ability; looking for ‘modern sexual relationships with rich men’ • Wives reluctant to confront - ‘failure to satisfy’ • Marriage is important, • Challenging husband/asking him to use condoms difficult, condoms seen as promoted in the context of risky sex, immoral behavior

Research evidence…continued Cambodia’s garment industry is the largest foreign currency earner One group – unmarried young women usually left out of the discussion of HIV risk in Cambodia (Nishigaya, 2002) • 135,000 are garment factory workers – • Engaged in sex work to support themselves and their families • Forms of sex work (avoid public attention): • Karaoke Singers accompany guests • Beer promoters who find customers and sell beer • Night club dancers • Bar attendants

Women workers reported varied condom use (Nishigaya, 2002) ‘they [guests] do not want to use condoms…I persuaded some of them to wear condoms…but he said to me ‘if there is a virus we will die together’ Other barriers to condom use Alcohol and drug use Violence, Rape Poverty Economic well-being – pleasing guests a priority Emotional attachments – PROMISES OF MARRIAGE Sweethearts: ‘If we love each other why do you suggest we use a condom?’ …continued

Research evidence… Sexuality and Masculinity in rural/urban Bangladesh (Rashid,SF et al, 2010; Sharful Khan et al, 2008) • Men worry about performance, worry about virility • Media, films, pornographic literature, movies • Money spent on accessing treatment from informal sector – • Not interested in condom use, focus is not on STIs but on pleasure/satisfying partner/being satisfied • Sex workers part of ritual of entertainment, space for experimentation/practice, sexual experimentation also with other males • I know I have to use a condom especially with CSW…during my last visit I started sex with a condom use but I did not get sexual pleasure. I took off the condom. I could have ‘bad sex’ with a condom but you know I paid money for enjoyable sex…’

Research evidence….continued Male Circumcision and Penis Enhancement in Southeast Asia study(Terence Hull and Meiwita Budiharsana, 2001) • To improve penile hygiene, malformations around the genital foreskin and sexual pleasure (religious reasons for Muslim males) • Safety of the procedures uncertain; deaths reported • Timor area – sifon - a few days after circumcision, when the man has developed scab on the wound he is expected to have sexual relations with a woman (not his wife) who has had a number of children; • after another period of recovery he has sex with a woman who has never had a child (scab will break and cool the wound)

…continued Male Circumcision and Penis Enhancement in Southeast Asia study(Terence Hull and Meiwita Budiharsana, 2001) • Commercial sex workers (women of the road) may provide this service, ‘widows’ • Traditional ritual reinforces health and spiritual benefits to both man and woman • Penile implants (ball bearings sewn under the skin, specially selected semi-precious stones, gold bars, or rings inserted through the glans etc – to please woman • Under researched area, but practices are prevalent and have implications for Men’s SRH and women’s health (infections, bleeding, irritation, inflammation)

Gender, power, sexuality Cross cultural study on vaginal practices - Indonesia, Mozambique, South Africa and Thailand (Hilber, 2006) • Increase female desirability, pleasure • Satisfy males (holding on to husbands, lovers); remain sexually attractive

Research evidence… Women carried out vaginal practices: • Washing, cleansing, smoking or steaming (fogging), insertion of substances, ingestion of substances for the purposes of tightening, drying and/or warming the vagina • Reasons: hygiene, increase sexual satisfaction of male partners, self satisfaction, body image (‘tight vaginas’)

…continued Health implications • Willingness to endure pain before, during and after intercourse to achieve desired effects (most likely due to abrasions, lesions, and/or the application of astringent substances on these wounds) • Less likely to use condoms to enhance ‘skin to skin’ contact • Significant use of these practices to address other SRH concerns - induced abortion, self treatment for vaginal discharge and other symptoms of STIs – significant health consequences

Research evidence… Cultural context of condom use in different countries(Ernistina Coast, unpublished; Sharful Khan et al, 2008)) • The release of semen into a woman’s body is not only for procreation but also seen as sexually more pleasurable and satisfying in Northern Tanzania • Condoms viewed as unsuitable for Maasai’s men who are circumcised; “seen as wasting sperm” • Polygyny widely practiced, men and women take many lovers, outside of marriage

Cultural context of condom use in different countries ‘Loss of semen’ • In Indian/Bangladesh context loss of semen is seen as harmful to men’s health • Semen is seen as equivalent to blood ‘one’s life force’ • Frequent condom use is seen to cause impotence in males; • Emphasis in sex - on pleasure, intimate act, trust and emotions

Research Evidence…cont Botswana 2 ethnic groups, unique culturally based sexual practices • Bakalanga ethnic group – practice of nkazana or need for a man to have a ‘small house’, another sex partner from wife’s family to provide farm labor • Sexual favors from younger sister of wife; • If wife cannot conceive, cannot satisfy sexually, then younger sibling nkazana is there • Husband does not have to go outside family to have sexual relations • Changes – nkazana also engaging in sex with others outside the ‘family’ for money, gifts, economic/social support • No condom use - pressure to bear children, sign of fertility

…continued • Bangwato ethnic group – playful sex with a blood or ethnic cousin (to regulate and control sexual behavior because of seasonal migration between different family settlements, the lands etc) • Boys and girls engage freely in in full sexual relations, acquire experiences • Sex has multiple meanings • entertainment (pleasure); sex is exchange; sex is cleansing (multiple partners, young girls)

Research Evidence… Factors that shape young peoples sexual behavior 268 qualitative studies were reviewed (1990-2004) (Marston and King, 2006) Key themes emerged impacting on sexual behavior/condom use • How well they know their partner socially, their partner’s appearance (clean/unclean) • Position, job and appearance shaped perceptions on risk free (disease free) • Trust shaped condom use, ‘one night stand may use condoms, if in a longer term relationship then on condoms • Sexual intimacy, wanting a pregnancy shape condom use • Men expected to heterosexually active, women modest, submissive (ignorant of sex, sexual matters) • Hampers communication; sexual negotiation, avoids talk of condom use • Penalties and rewards for sex (social status, marriage, gifts, money)

Complexity of Factors… • Globalization, local PE contexts, market economies, migration, transform local realities, behaviors, sexual cultures • Ideas of masculinity, femininity reinforce certain stereotypes; create new forms of behavior • Influence behavior, practices and perceptions of risks Local cultures shape contexts, meanings, behaviors and understandings of risks and so on • Patriarchy, Culture, Gender and power relations • Condom use, negotiating safer sex, meanings of marriage/partnerships, families, sexual relations…etc • Notions of pleasure, desire, pain, what is risky and not risky behavior

Lessons Learnt THERE IS NO MAGIC BULLET • Interventions need to be context specific, culturally relevant, take into consideration the manifold factors… • More attention to sex and desire in the design of HIV prevention programmes • Dealing openly and honestly with the lives that people actually lead and the sex they actually have • Instead of programmes that tell people what to do, which many are unwilling or unable to follow…prevention programmes focus on reducing risk (Berger, J, 2004)

Ways of moving forward • Discussions on sex need to be explicit, clear – men and women need to be clear to the risks of transmission, protect self • Spaces must be created for men and women to speak of their vulnerabilities/fears around sex, sexual relationships, including desires, pleasure and…negotiating safer sex • Need to begin discussions on male sexuality

What have we learned… More specific examples from Bangladesh, India, and Pakistan FP programs targeted at women, with men taking very little responsibility for condom use (unwanted pregnancy); Services targeted for women, men left out of the equation • ABC prevention model problematic – not allowing for culturally relevant, local specific approaches for risk reduction

What have we learned… Prevention programs preventing heterosexual transmission focus on married women; • Mexico study highlights the importance of paying attention to GENDER • Messages of marriage = monogamy endangers women’s lives • Need to target men - framing messages in culturally meaningful terms by using language of trust and respect to address men

Lessons learned • Sex related to economic survival (e.g. gifts, money, favors, protection) • Creating enabling environment; for example: • Legalizing homosexuality (in many countries illegal, drives behaviors underground) • Legalizing sex industry • Empowering sex workers (e.g. Sonagachi project in India).

What is needed? Future policies and programs better informed by social science evidence that captures bottom up knowledge of cultural processes, meanings, PE context and the social framings that inform peoples sexuality and sexual behavior and …HIV/AIDS.

Campaigns/Messages Pleasure Project http://thepleasureproject.org/ The Pleasure Project makes safe sex safer and sexier. Advocate for the importance of pleasure in sexual health, by training health professionals and educators about making safer sex sexy. We are also working on building the evidence base around pleasure and safer sex, and we do condom consultancies for the erotic media.

references Sonia Correa and Richard Parker, (2004), Sexuality, Human Rights and Demographic Thinking: Connections and Disjunctions in a Changing World. Sexuality Research & Social Policy, Journal of NSRC, vol 1, no 1, pp: 15-38 Richard Parker, (2004), Introduction to Sexuality and Social Change: Toward an Integration of Sexuality Research, Advocacy, and Social Policy in the Twenty-First Century, Sexuality Research & Social Policy, Journal of NSRC, vol 1, no 1, pp: 7-14 Jennifer Hirsch et al, (2002) the Social constructions of Sexuality: Marital Infidelity And Sexually Transmitted Disease – HIV Risk in a Mexican Migrant Community, American Journal of Public Health, vol. 92, no.8, pp: 1227-1237 Elijah Andersen, (1989), Sex Codes and Family Life among Poor Inner City Youths, ANNALS, AAPSS, 501, January 1989, pp: 59-78 Harriet M Phinney (2008), “Rice is Essential but Tiresome; You Should Get Some Noodles”: Doi Moi and the Political Economy of Men’s Extramarital Sexual Relations and Marital HIV Risk in Hanoi, Vietnam, American Journal of Public Health, Vol 98, No 4, pp: 650-660 Daniel Jordan Smith (2007), Modern Marriage, Men’s Extramarital Sex, and HIV Risk in Southeastern Nigeria, American Journal of Public Health, vol 97, no 6, pp: 997-1005 Shannon Walsh and Claudia Mitchell (2006), ‘I am too young to die: HIV, Masculinity, danger and desire in urban South Africa, Gender and Development, vol 14, no 1, March, pp: 57-68 Rashid, SF et al, Unpublished research document ‘Men’s SRH concerns and Universal Access, (DFID funded, Realising Rights project), 2010. Sharful Islam Khan et al (2008), Phallus, Performance and power: crisis of masculinity, Sexual and Relationship Therapy, vol 23, no 1, February, pp: 37-49 Sohail Agha, (2002), Sexual Behavior Among Truck Drivers in Pakistan, Culture, Health & Sexuality, vol 4, no 2, April-June, pp: 191-206 Adriane Martin Hilbert (2006), Gender, Sexuality and vaginal practices study. Training course in Sexual Health Research, Geneva, 2006

References • Terence Hull and Meiwita Budiharsana, (2001) Male Circumcision and Penis Enhancement in Southeast Asia: matters of Pain and Pleasure, Reproductive Health Matters, vol 9, no 18, pp: 60-67 • Ernestina Coast, (n/d). Wasting Sperm: the cultural context of condom use among the Maasai in Northern Tanzania, unpublished report • Janice I Baldwin and John D Baldwin, (2000), Heterosexual Anal Intercourse: An Understudied, High Risk Sexual Behaviour, Archives of Sexual Behaviour, vol 29, no 4. • Cicely Marston and Eleanor King (2006), Factors that Shape young peoples sexual behavior: a systematic review, Lancet, 368: 1581-86 • Terry-Ann Selikow (2004), “We have our own special language: Language, Sexuality, and HIV/AIDS: a case study of youth in an urban township in South Africa, African Health Sciences vol 4, no 2, August. • Suzanne Leclerc-Madlala, (2009), Cultural scripts for multiple and concurrent partnerships in southern africa; why HIV prevention needs anthropology, Sexual Health, 6, pp:103-110, CSIRO • Berger J, Re-sexualising the epidemic. HIV prevention programmes: researchers need to ask difficult questions. Available online at: www.eldis.org/cf/rd/r • Geeta Rao Gupta, ICRW, (2000), Gender, Sexuality, and HIV/AIDS. The What, the Why, and the How. Plenary Address XIIIth International AIDS Conference, Durban, South Africa, July 12. • Rashid, SF et al (2010), Men’s SRH Concerns and Access to Providers (unpublished report, funded by DFID, Realising Right project Consortium), Dhaka, Bangladesh

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