Transforming Gender Norms
“The global HIV pandemic in its current form cannot be effectively arrested without fundamental transformation of gender norms” (Dunkle and Jewkes, 2007: 173). The social issues women face that make them particularly vulnerable to HIV are related to gender norms that privilege men over women in most societies. Women are particularly harmed by discriminatory gender norms, although evidence is mounting that gender norms harm both women’s and men’s health (WHO, 2007a). For both women and men, gender norms are codified through public policy in a range of issues (Barker et al., 2010). Gender norms, including those that influence sexual and power relations, influence all program areas related to HIV/AIDS, from prevention of HIV for girls, to treatment, care and support.
Traditional Gender Norms Lead to Behaviors That Put Women at Risk for HIV
Women are less likely to have access to resources and more likely to depend on men for financial survival for themselves and their children. Such dependence makes it difficult for women to negotiate sex or safer sex with their partners. Women’s mobility is often curtailed. For many women, a central survival strategy for themselves and their children involves having more than one partner. For example, a study in Haiti showed that to balance the multiple demands of family and economic survival, single mothers enter into a series of sexual relationships in order to obtain food and housing for themselves and their children (Fitzgerald et al., 2000). A study in Tanzania found that 70 percent of sexually active girls reported granting sexual favors to meet their basic daily needs (Maganja et al., 2007).
In sexual relationships, women often lack power to protect themselves. A survey of 812 young women in Vientiane, Lao People’s Democratic Republic, along with 18 focus group discussions and 13 in-depth interviews found that young women lacked power to negotiate both sexual activity and condom use, with 25% reporting coerced sex and 30% of sexually active women having multiple partners in 2007 (Songbandith et al., 2008). Cross-sectional data from 135 sexually active female students at a university in South Africa found that the women’s perceptions of HIV risk were related to a feeling of lack of control over risk due to partner’s behavior, rather than the woman’s behavior. Women who had ever had a violent partner were more than two times as likely to report being at risk for HIV; women who were coerced to have sex and/or felt that their current partners would react negatively if she refused sex without a condom were more than three times as likely report being at risk for HIV (Kelvin et al., 2008). A survey of 126 people in South Africa found that women felt at risk of contracting HIV because of the multiple partnerships of their current male partner, but felt disempowered to do anything to change their risk of acquiring HIV (Ngema et al., 2008). A study of 50 low-income Chilean women found that “women who are vulnerable to HIV do not perceive themselves at risk. They believe that HIV is something that happens to homosexually active men or to [sex workers], not something that happens to women in a stable relationship” (Cianelli et al., 2008: 298).
Traditional Gender Norms Also Hurt Men
Men are also affected by gender norms that define masculinity as including early, risky sex with multiple partners (WHO, 2007a; Barker et al., 2007b). A survey of 1,268 respondents in Botswana who held three or more gender discriminatory beliefs had nearly three times the odds of having unprotected sex in the past year with a non-primary partner as those who held fewer gender discriminatory beliefs (PHR, 2007a). Homophobia makes men who have sex with men more likely to marry a woman to diminish stigma and legal or other consequences, where homosexuality is illegal (White and Carr, 2005. [See also Chapter 3B. Prevention for Women: Partner Reduction] In many settings, men also tend to be socialized to be less inclined than women to engage in health seeking behavior. Furthermore, the sexual health concerns of men living with HIV and AIDS are frequently neglected in program efforts and men often lack information on how to lead a healthy sex life (Esplen, 2007). A study in China with ten AIDS health professionals and 21 adults living with HIV found that “power differentials between men and women, men’s dominant role in sexual life and their ignorance about HIV/AIDS and its prevention contribute to the increasing HIV risk faced by women (Zhou, 2008). A survey of 185 young men and women in India found that young men were more likely to have higher AIDS knowledge, to perceive themselves to be at risk for contracting HIV, have higher self-efficacy of using condoms correctly, buying condoms, having a condom when needed, and believe that it is acceptable to have multiple partners (Seth et al., 2008). In Papua New Guinea, in-depth interviews with 86 people, half female, found that women reported that a woman’s refusal of sex would drive the husband to seek sex elsewhere (Dover and Levy, 2008).
Ideas that equate masculinity with sexual risk-taking and being in control of women have been shown to be associated with less condom use, more partners, more casual partners and more transactional sex (Greig et al., 2008). A qualitative study of six groups of 5 to 10 participants meeting once per week for three weeks in rural South Africa with sexually experienced young people ages 14 to 19 found that young men universally felt that female virginity was a desirable characteristic. However, once in a relationship, boyfriends often insisted on sexual intercourse to establish that their girlfriend was a virgin. Young women acquiesced as young women believed that their virginity should be saved for the right partner. Young women then lost their valued status as a virgin in the process of proving virginity, with some young women claiming coercion: “…he forces you to have sex to prove to him that you are still a virgin” (Harrison, 2008: 185).
Changing Gender Norms Requires Programming for Both Men and Women...Together
While numerous programs have shown results in addressing gender norms with men to reduce HIV risks (Colvin, 2009; Pulerwitz et al., 2006), these programs reach a tiny fraction of the population in need (Barker, 2009). Some programming reinforces traditional gender norms. PAHO analyzed gender roles in 200 HIV-related public service announcement TV spots from Latin America and found that TV spots reinforced the traditional gender roles that are partly responsible for the HIV epidemic, with women bearing the sole responsibility of HIV prevention and men as more interested in sex than women (Parodi and Lyra, 2008). Changing prevailing gender norms dictating multiple sexual partners for men and sexual ignorance and submissiveness for women and girls, that can lead to increased HIV rates, is critical. Research suggests that “relational gender programming” that works with both women and men together may be most successful in changing gender norms (Levack and Greene, 2010).
The role of gender norms in fueling the AIDS pandemic is clear but insufficiently addressed in programs (UNIFEM, 2008). For example, AIDS programs face a gender-related paradox that in most countries, women are more vulnerable to HIV transmission—in Africa, 61 percent of new HIV cases are in women—yet statistics on treatment show that more women than men access ARV services. Both statistics are related to gender norms that discourage women from obtaining knowledge about sex and protection and discourage men from seeking health care. “Addressing gender norms—the societal messages that dictate appropriate or expected behavior for males and females—is increasingly recognized as an important strategy to prevent the spread of HIV infection” (Pulerwitz et al., 2006: 1).
While this particular section addresses transforming gender norms, several other interventions regarding gender norms permeate the rest of the chapter as they relate to violence against women, women’s legal rights, employment, education, etc. Changing gender norms requires political will and leadership at every level, from national policymakers to community leaders. A multi-pronged approach is needed to work with men directly to support safer male sexual behavior, as well as with the media, community, religious leaders and others who can impact gender norms. Some of the most effective interventions involve working with young boys to promote gender equitable attitudes and behaviors. At the same time, attention to public policies that reinforce or transform gender norms for both women and men is critical (Barker et al., 2010).