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Published in the
Bulletin of Experimental Treatments for AIDS Summer-Autumn 2001
issue, by the San Francisco AIDS Foundation.
Youth
at Risk
Summer-Autumn
2001 Table of Contents
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Adolescent
Sexuality, Gender, and the HIV Epidemic
by Kim Rivers and Peter Aggleton
Research from around the world shows a steady and significant
increase in the rates of HIV infection among women, particularly women
in Africa, Asia, Latin America, and the Caribbean. A significant proportion
of HIV/AIDS cases occurs among young (15–29-year-old) women, meaning
that many women with HIV were infected as adolescents.
Anatomical, biological, and other factors contribute to young
women’s heightened vulnerability to HIV/AIDS. Another variable,
gender—while routinely and automatically acknowledged as key—goes
beyond clinical and treatment issues, and even beyond anatomical male-female
differences. Twenty years into the HIV/AIDS epidemic, gender and the
role it plays remain unclear.
Gender identity encompasses sexual identity and is influenced
by many social and cultural factors, which themselves change over time.
Marina Laski, head of the AIDS department in the General Directorate
of Women for the city of Buenos Aires, Argentina, explains that “power
relations are constructed that are encouraged and legitimized by culture,
defining the conduct expected of each gender as natural and giving way
to gender stereotypes.” Understanding gender can help determine
opportunities and risks of many types for individuals, whether female
or male.
This edition of “Women and HIV” features a broad-based
exploration of gender itself. Elucidating gender is essential to understanding
how and why women, especially young women, are at particular risk for
HIV infection. Similarly, improved knowledge about gender will help
to formulate effective HIV prevention and even treatment strategies.
Greater awareness of gender perspectives, reflected in such arenas as
public policy, mass media, and health care, will enable women to take
a more effective stand in situations that involve the risk of HIV transmission.
Leslie Hanna, Editor
A Patterned Vulnerability
Epidemiological studies across the developing
world show that young people are not equally affected by HIV/AIDS: those
who are most socially and economically disadvantaged are at highest
risk. The risk of HIV infection for young people in developing countries
is increased by sociocultural, political, and economic forces such as
poverty, migration, war, and civil disturbance. Young people may also
face the increased risks of HIV infection by virtue of their social
position, unequal life chances, rigid and stereotypical gender roles,
and poor access to education and health services.
Major changes over the last few decades have
affected the sexual and reproductive health of young people in developing
countries. Rapid urbanization and rural-urban migration has meant that
greater numbers of young people are living in precarious and impoverished
conditions. Traditional, multigenerational extended families have been
increasingly replaced by nuclear [two-parent] families, single-parent
families and, in some cases, the complete absence of parents. Young
people are pressured to be sexually active and, in the case of boys,
to have several different partners. Evidence from a variety of countries
suggests that the age at which young people become sexually active may
be falling. Certainly young people become sexually active at an early
age in many countries. In Uganda, for example, almost 50% of young men
and nearly 40% of young women recently surveyed reported having had
sex by the age of 15 years. In Dar es Salaam, Tanzania, 60% of 14-year-old
boys and 35% of girls have reported that they are sexually active. In
a recent Brazilian school-based study, 36% of females reported having
had intercourse by the age of 13 years. In parts of the world such as
India, where there is sparse evidence about sexual activity among young
people and where it is widely assumed that sexual initiation takes place
within the context of marriage, recent studies show that approximately
one in four unmarried adolescent boys report that they are sexually
experienced.
In both developed and developing countries, a
number of obstacles make it difficult for young people to protect their
sexual and reproductive health. Young people often have less access
to information, services, and resources than those who are older. Health
services are rarely designed specifically to meet their needs, and health-care
workers only occasionally receive specialist training in issues pertinent
to adolescent sexual health. It is perhaps not surprising therefore
that there are particularly low levels of health-promoting or -seeking
behavior among young people. For example, even where they are able to
recognize signs and symptoms of STDs, young people recently interviewed
in Tanzania indicated that they were hesitant to go to public clinics
or hospitals, but were more likely to treat themselves with over-the-counter
medicines. Similarly, young people in a variety of contexts have reported
difficulty accessing contraception and condoms. Most importantly, legislation
and policies that prevent sex education from taking place, or that restrict
its contents, prevent many young women and men from maximizing their
sexual and reproductive health.
Images of
Adolescence
One of the most important reasons why young people
are denied adequate access to information, sexual health services, and
protective resources such as condoms derives from the stereotypical
and often contradictory ways in which they are viewed. It is popularly
believed that all young people are “risk-taking pleasure-seekers
who live only for the present.” Such views tend to be reinforced
by the uncritical use of the term adolescent (with its connotations
of “storm and stress”) in the specialist psychological and
public health literatures. This term tends not only to homogenize and
pathologize understandings of young people and their needs, but it also
encourages a view of young people as possessing a series of deficits
(in knowledge, attitudes, and skills) that need remedy by adults and
their interventions.
Hoffman and Futterman have commented that adults
often hold ambivalent attitudes towards young people, viewing them simultaneously
as “small adults” and as “immature, inexperienced, and
untrustworthy children.” Many adults also have difficulty acknowledging
adolescents as sexual beings, and therefore adolescent sexuality is
viewed as something that must be controlled and restrained. These stereotypes
have informed much HIV-related research and practice with young people.
Warwick and Aggleton, for example, have described the central images
found in the literature on young people and AIDS. These images include
the “unknowledgeable or ill-informed adolescent,” the “high-risk
adolescent,” the “adolescent who is unduly conforming to peer
pressures,” and the “tragic but innocent adolescent”
who inadvertently becomes infected with HIV.
These powerful images and assumptions influence
policy and practice in relation to young people and their sexual health.
Some adults believe that young people are naturally sexually promiscuous,
such that giving them information about sex will make them more sexually
active. As a result, sex education in schools either does not take place
or promotes only certain risk-reduction measures (most usually abstinence).
Yet there is now clear evidence that well-designed programs of sex education,
which include messages about safer sex as well as those about abstinence,
may delay the onset of sexual activity, reduce the number of sexual
partners, and increase contraceptive use among those who are already
sexually active.
While formal health education programs have been
influenced by stereotypical attitudes about young people’s sexuality,
parents and families across a wide variety of cultures have also sought
to deny young people information about sex and reproduction. In countries
as different as India and Nicaragua, parents and children report that
they do not talk to each other about sex. Often parents and family members
do this in the belief that they are protecting young people from information
that they believe may lead to sexual experimentation. However, evidence
suggests that young people who openly communicate about sexual matters
with their parents, especially their mothers, are less likely to be
sexually active or, in the case of girls, to become pregnant before
marriage.
While young people have been commonly stereotyped
as uniformly hedonistic and irresponsible, they are in fact a remarkably
heterogeneous group. Their experiences vary widely according to cultural
background, gender, sexuality, and socioeconomic status, among other
variables. While some young people may take risks, the majority are
at least as responsible as their parents, and some even more so. Moreover,
it is important to recognize that in many developing countries, the
onset of puberty signals greater economic and family responsibility
rather than increased pleasure-seeking and risk-taking. That said, a
number of structural as well as individual factors may heighten young
people’s vulnerability to HIV and AIDS.
Unequal
Life Chances and HIV Infection
While developing countries in Asia, Africa, and
South and Central America vary in terms of culture, religion, and socioeconomic
factors, young people living in these regions share a number of experiences
that render them particularly vulnerable to HIV infection. Access to
education and information is often limited, levels of literacy lower,
and poverty more prevalent. Young people living in poverty, or facing
the threat of poverty, may be particularly vulnerable to sexual exploitation
through the need to trade or sell sex in order to survive.
Estimates suggest that as many as 100 million
young people under the age of 18 years live or work on the streets of
urban areas throughout the world, heightening their risk of acquiring
STDs including HIV. More than half of 141 street children interviewed
in South Africa, for example, reported having exchanged sex for money,
goods, or protection, and several indicated that they had been raped.
Street children in Jakarta, Indonesia, have reported that being forced
to have sex is one of the greatest problems that they face living on
the streets. In Brazil, where an estimated seven million young people
live on the streets, 1.5% to 7.5% of those tested for HIV are infected.
In addition to risk from unprotected sexual activity, rape, and coercion,
the high prevalence of injection drug use on the streets in Brazil and
in some other countries may heighten young people’s vulnerability
to HIV.
Importantly, however, children and young people
who live and work on the streets of urban areas do not commonly list
HIV/AIDS as an overriding concern. Instead, the day-to-day needs for
shelter, food, and clothes take higher priority. For young people struggling
for daily survival, a disease like AIDS, which may or may not kill them
for years to come, can seem unimportant.
Not only the most socioeconomically deprived
children and young people in developing countries are vulnerable to
sexual exploitation. Other young people living in precarious economic
circumstances report having been forced to exchange sex for material
benefit. For example, two-thirds of 168 sexually active young women
interviewed in Malawi reported having exchanged sex for money or gifts,
and 18% of 274 sexually active female Nigerian University students reported
that they have exchanged sex for favors, money, or gifts.
Sometimes the exchange of sex for goods and money
may be regularized in the form of what have been called “sugar
daddy” and “sugar mommy” relationships. In Tanzania,
young girls not infrequently report having older men or Mshefas (those
who provide) as sexual partners. In Kenya, young girls report that they
are courted by older men seeking sex, and may find themselves in situations
difficult to negotiate.
Gender and
Vulnerability
Stereotypical gender roles place young women,
and to a lesser extent young men, at heightened risk of HIV infection.
As mentioned earlier, young women in many parts of the developing world
have little control over how, when, and where sex takes place. In perhaps
the majority of countries, there are strong pressures on young unmarried
women to retain their virginity. However, the social pressure to remain
a virgin can contribute in a number of ways to the risks of STDs and
HIV which young women face. In some contexts, young women may engage
in risky sexual practices such as anal sex as a means of protecting
their virginity.
The high social value placed on virginity in
unmarried girls may pressure parents and the community to ensure that
young women are kept ignorant about sexual matters. Female ignorance
of sexual matters is often viewed as a sign of purity and innocence,
while having “too much” knowledge about sex is a sign of “easy
virtue.” Young women in countries such as Thailand and Guatemala
report that being knowledgeable about sex would compromise others’
views of them.
This emphasis on so-called innocence prevents
young women from seeking information about sex or services relating
to their sexual health. Sexually active young women are also discouraged
from discussing sex too openly with their own partners, since women
are encouraged to be ignorant and inexperienced. Thus, young women are
unlikely to be able to communicate their need for safer sex with partners.
A Kenyan study revealed that young women felt that they did not have
control over their sexuality—instead, girls learned that sex was
something that happened to them: it was not something they could initiate
or actively participate in.
In addition to the emphasis widely placed on
remaining “chaste,” girls are commonly socialized to be submissive
to men. Girls report often being pressured by boys to have sex as a
proof of love and obedience. Not surprisingly, under conflicting pressures,
girls have little influence over decision-making or the use of contraception.
In a recent review of research conducted in seven countries including
Nigeria, Egypt, Mexico, and the Philippines, Petchesky and Judd concluded
that even where sexually active young women are aware of HIV/AIDS and
measures to protect against infection, they rarely have the power to
ensure that condoms are used.
While dominant ideologies of femininity promote
ignorance, innocence, and virginity, dominant versions of masculinity
encourage young men to seek sexual experience with a variety of partners.
In some cultures, boys are actively encouraged by both their peers and
family members to use their adolescent years to experiment sexually.
In Nicaragua, for example, where virginity is
highly valued among young women, having multiple sexual partners is
taken as a sign of virility in young men. Teenage boys face social pressures
from older men (including fathers, older brothers, and uncles) to have
sex as early as possible. In the recent past, it was not uncommon for
Nicaraguan fathers to arrange for their son’s sexual initiation
with a sex worker. So while for girls, public disclosure of sexual activity
leads to dishonor, bragging about sex is common for boys. Berglund and
colleagues note that for young Nicaraguan men the pressure to be sexually
active with multiple partners may be so great that those who do not
fulfill this expectation are open to ridicule by their peers for not
being “a real man.”
Similar patterns prevail elsewhere in the world.
In South Africa, for example, having many sexual partners is reported
as being equated with popularity and importance among young men. Interviews
with high school students in Zimbabwe indicate that while boys can have
(and indeed should have) many girlfriends, girls should stick to one
boyfriend. Although not all young men conform to the dominant versions
of masculinity described above, those who fail to do so are often ridiculed
and subjected to peer pressures to conform.
Homophobic bullying of the form that implies
that any man who fails to conform to the dominant gender stereotype
must be “homosexual” is but one of the many tactics employed
in this process. Not only does such behavior stigmatize sexual minorities,
it serves to police the boundaries of a heterosexual masculinity in
which multiple partnerships with women become the norm.
While gender norms dictate that girls and women
should remain poorly informed about sex and reproduction, young men
are expected to be more knowledgeable, often as an indication of their
sexual experience. However, research in a variety of contexts shows
that they may be often poorly informed, but because sexual ignorance
is not socially acceptable young men are reluctant to admit that they
are lacking in knowledge. So while young women risk their sexual health
because they must appear to be ignorant and so cannot openly seek information,
young men risk their sexual health because they must appear to be knowledgeable
and thus cannot openly seek information either.
The HIV/AIDS epidemic has served to further entrench
some gender inequalities that place young women at increased risk of
HIV infection. Central among these is the tendency for some older men
to seek partners who are less likely to be sexually experienced or,
in their eyes, infected with HIV. This places young women at increased
risk of becoming infected by older men who may have wide sexual experience.
Many young women who have HIV infection have had only one sexual partner,
namely their husband. Furthermore, families affected by HIV/AIDS may
seek economic security by marrying their very young daughters to older
men. Doing so may have serious implications for the sexual and reproductive
health of the young women concerned, and may also cut short their education
and delay social development.
Sexuality
and Vulnerability
While male-to-male sex exists in every culture,
the activities concerned are rarely understood as “homosexual,”
and still less often as “gay.” More likely than not, male-to-male
sex will not be widely discussed, or named only within local vernaculars
often inaccessible to outsiders. That said, in many countries of the
world, a substantial number of young men have their first sexual experience
with other men. For some this may be the beginning of a longer-lasting,
bisexual behavioral repertoire. For example, 50% of male university
students recently interviewed in Sri Lanka reported that their first
sexual experience had been with another man, and there are well-documented
studies of behavioral bisexuality among men in countries as diverse
as the Philippines, India, Morocco, Brazil, the Dominican Republic,
and Peru. While it would be inaccurate to view male bisexuality as a
purely adolescent phenomenon or as triggered by men’s lack of access
to women, the restrictions many cultures place on socialization between
the sexes may have an important role to play in facilitating this alternative
means of sexual expression.
For a few young men, trading or selling sex to
other men may offer a means of survival. In countries such as Sri Lanka,
Thailand, Mexico, and Peru, male prostitution or sex work may take this
form, with young men selling sex in order to provide for themselves
and their families. Not all male sex workers are ignorant of the risks
of STDs and HIV infection, and some may be better informed than other
young people of a similar age. Still, not only is such behavior illegal
and/or heavily stigmatized in many societies, the ability of young men
to communicate and negotiate for safer sex with older male partners
may be limited by inequalities of status and power. Where anal sex is
practiced, the unavailability of condoms and lubricant may compound
the risks some young men face.
Much less is known about current patterns of
homosexual and bisexual behavior among young women, although such behaviors
should be assumed to occur not only during youth and adolescence, but
also for some women as part of a longer-lasting lifestyle. The role
of such behavior in contributing to or protecting against HIV-related
risk requires further investigation. It seems reasonable to suppose,
however, that the stigmatized, denied, and marginal status of their
behavior makes it difficult for young homosexually active women in developing
countries to access the full range of information or resources to protect
their sexual health.
Age and
Vulnerability
Inequalities of age interact with the inequalities
of socioeconomic background, gender, and sexuality to determine young
people’s vulnerability to STDs including HIV. As discussed earlier,
this is the case for younger women who may be sought as sexual partners
by older men in the belief that they are less likely to be infected.
Yet age and generation just as strongly influence the vulnerability
of young men, not only those who sell or trade sex, but also those who
engage in sexual activity as a means of gaining adult status and the
privileges it offers. For example, recent research in Tanzania has suggested
that young men may attempt to address intragenerational inequalities
through engaging in sexual activity, which represents adulthood and
enhanced social status.
Beyond these behaviors—which carry clear
HIV-related risks—are others no less embedded in local cultures
and traditions. These include female genital mutilation (FGM) and male
circumcision, both of which are perpetrated upon young people by those
who are older. When practiced as part of group initiation ceremonies
or in ways involving the sharing of razors, knives, and other cutting
instruments, the risk of HIV infection being transmitted from one person
to another can be considerable. The World Health Organization (WHO)
and other bodies have condemned the practice of FGM on both medical
and human rights grounds and, in 1993, passed a resolution at the 46th
World Health Assembly calling for member states to act to eliminate
harmful traditional practices. Where male circumcision continues to
take place, it should be practiced in ways commensurate with the need
both to prevent HIV and other blood-borne infections and the rights
of young people to be involved in decisions about their bodies and what
becomes of them.
Principles
for Success
A number of principles can be identified for
future work to prevent HIV infection among young people in developing
countries:
- Prevalent ideologies of masculinity and femininity
that pre- scribe virginity in unmarried girls and promiscuity for
boys facilitate the transmission of HIV to young women and young men.
These ideologies need to be challenged at policy and program levels,
as well as in the media, family, and community.
- Negative stereotypes about young people and
adolescent sexuality inform the attitudes of parents, other adults,
and even those involved with HIV prevention. Wherever possible, program
designers should attempt to challenge these stereotypes, since they
serve as an obstacle to the development of appropriate and relevant
programs of sex and HIV-related prevention.
- Evidence suggests that young people across
the world are having sex earlier than in the past. It is important
then that sex and HIV-related education are provided in a timely manner.
The widespread denial of adolescent sexuality leads to attempts by
adults to constrain and control young people’s sexual behavior.
Since this is often unrealistic, it means that young people are denied
access to information, services, and resources that help them to protect
their health.
- Young people benefit from open and honest
communication with adults, something that is absent in many cultural
contexts and declining in others. It is important that programs encourage
better and more open forms of communication within families, and between
families, communities, and young people. Some evidence suggests that
the epidemic of HIV infection may itself provoke increased awareness
among parents about the importance of helping young people to protect
their sexual health.
- Formal programs of sex education and HIV-related
education are most successful when they include messages about safer
sex as well as abstinence. Convincing messages that inform parents
as well as policy makers that timely and relevant sex education does
not propel young people into premature sexual relationships must be
disseminated.
- Teachers also require training in delivering
sex education and developing confidence in talking to young people
about sex. Supportive environments, including support from policy
makers and educators, are important in helping teachers deliver effective
programs of HIV-related education.
- Evidence suggests that peer education programs
support young people in making changes to their behavior.
- Programs can provide opportunities to address
issues relating to gender, social status, and sexuality in order to
promote young people’s sexual and reproductive health.
- Program designers and others concerned with
HIV infection must promote a greater awareness of structural issues
affecting sexual and reproductive decision-making, including rights
and protection for young people, as well as improved access to education
and health services.
- Young people living in developing countries,
particularly girls and those young people living in especially precarious
circumstances, need protection from rape and sexual exploitation and
coercion. Communities and governments must mobilize to take action
to ensure that all young people can enjoy increased safety and freedom
from sexual abuse.
- More work with young men is required to enable
them to rethink their roles in relation to both their own sexual health
and that of their partners, as well as improving programs for young
women. Additionally, programs should target adult men (and the wider
community) in order to help them to reduce the pressures on young
men who are still developing their masculine identities.
- Programs serving particularly vulnerable young
people, including those who live on the streets, must address the
daily risks that these persons face. Those concerned with the prevention
of HIV also must work with policy makers to reduce the hardships faced
by street children.
- Work should be undertaken to reduce the marginalization
of young men who have sex with other men, along with preventive work
to ensure that young men are accurately informed and have access to
health services and resources such as condoms.
- Improved access to nonjudgmental and user-friendly
sexual health services is crucial for young people. Training in adolescent
health issues should be provided to health-care workers in the field
of sexual and reproductive health.
Kim Rivers and Peter Aggleton are from the
Thomas Coram Research Unit at the Institute of Education, University
of London (UK).
The original text of this article and a complete
listing of references can be found at www.undp.org/hiv/publications/gender/adolesce.htm.
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last updated 25 October 2001
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