This article was downloaded by: [UNIVERSITY OF KWAZULU-NATAL]On: 22 February 2012, At: 05:35Publisher: RoutledgeInforma Lt...
African Journal of AIDS Research 2011, 10(supplement): 301–310                                                            ...
302                                                                                     Casale, Rogan, Hynie, Flicker, Nix...
African Journal of AIDS Research 2011, 10(supplement): 301–310                                                            ...
304                                                                                     Casale, Rogan, Hynie, Flicker, Nix...
African Journal of AIDS Research 2011, 10(supplement): 301–310                                                            ...
306                                                                                  Casale, Rogan, Hynie, Flicker, Nixon ...
African Journal of AIDS Research 2011, 10(supplement): 301–310                                                            ...
308                                                                                     Casale, Rogan, Hynie, Flicker, Nix...
Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting
Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting
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Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting

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It has become evident that sexual health and HIV-risk behaviours cannot be addressed effectively without paying
adequate attention to constructions of gender and sexuality. While the body of literature examining these themes
is growing and becoming more nuanced, there is still a significant gap in our understanding of the relationship
between gendered sexual identities and vulnerabilities to disease. In particular, few studies have explored how
youths themselves perceive this relationship, and how these perceptions may differ among males and females.
The purpose of this study was to investigate the differing ‘gendered’ perceptions of HIV risk among young women
and men in a high-HIV-prevalence community in South Africa. Five focus groups were conducted with youths
involved with a local school-based HIV-prevention programme in a resource-deprived, peri-urban community in
KwaZulu-Natal Province. The data were recorded, transcribed, translated and thematically coded. We used a critical
social science approach to inform our collaborative analysis. The findings reveal diverse understandings of the
relationship between gender and HIV risk. The majority of the participants felt that females are more vulnerable to
HIV as a result of gender inequalities; a minority felt that males are more vulnerable because of limited perceived
control over their sex drive. Others felt that both sexes are equally vulnerable because ‘the virus doesn’t have a
friend.’ The theme of ‘responsibility for spreading HIV’ emerged inductively from the data and also involved multiple
understandings of gendered responsibility. Explicitly engaging with youths in targeted discussions on gendered
HIV-related vulnerability and responsibility can offer an opportunity to challenge stereotypes and gender inequities,
as well as inform interventions.

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Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting

  1. 1. This article was downloaded by: [UNIVERSITY OF KWAZULU-NATAL]On: 22 February 2012, At: 05:35Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20 Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting a b c c a d Marisa Casale , Michael Rogan , Michaela Hynie , Sarah Flicker , Stephanie Nixon a & Clara Rubincam a Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu- Natal, Level 4, J Block, Westville Campus, Durban, 4041, South Africa b University of KwaZulu-Natal, School of Development Studies, Memorial Tower Building, King George V Avenue, Howard College Campus, Durban, 4041, South Africa c York University, Department of Psychology, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada d University of Toronto, Department of Physical Therapy, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada Available online: 15 Dec 2011To cite this article: Marisa Casale, Michael Rogan, Michaela Hynie, Sarah Flicker, Stephanie Nixon & Clara Rubincam(2011): Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting, African Journalof AIDS Research, 10:sup1, 301-310To link to this article: http://dx.doi.org/10.2989/16085906.2011.637728PLEASE SCROLL DOWN FOR ARTICLEFull terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditionsThis article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form toanyone is expressly forbidden.The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug dosesshould be independently verified with primary sources. The publisher shall not be liable for any loss, actions,claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly orindirectly in connection with or arising out of the use of this material.
  2. 2. African Journal of AIDS Research 2011, 10(supplement): 301–310 Copyright © NISC (Pty) Ltd AJAR Printed in South Africa — All rights reserved ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.637728 Gendered perceptions of HIV risk among young women and men in a high-HIV-prevalence setting Marisa Casale1*, Michael Rogan2, Michaela Hynie3, Sarah Flicker3, Stephanie Nixon1,4 and Clara Rubincam1 1Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Level 4, J Block, Westville Campus, Durban 4041, South Africa 2University of KwaZulu-Natal, School of Development Studies, Memorial Tower Building, King George V Avenue, Howard College Campus, Durban 4041, South AfricaDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 3York University, Department of Psychology, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada 4University of Toronto, Department of Physical Therapy, 160-500 University Avenue, Toronto, Ontario M5G 1V7, Canada *Corresponding author, e-mail: casale@ukzn.ac.za It has become evident that sexual health and HIV-risk behaviours cannot be addressed effectively without paying adequate attention to constructions of gender and sexuality. While the body of literature examining these themes is growing and becoming more nuanced, there is still a significant gap in our understanding of the relationship between gendered sexual identities and vulnerabilities to disease. In particular, few studies have explored how youths themselves perceive this relationship, and how these perceptions may differ among males and females. The purpose of this study was to investigate the differing ‘gendered’ perceptions of HIV risk among young women and men in a high-HIV-prevalence community in South Africa. Five focus groups were conducted with youths involved with a local school-based HIV-prevention programme in a resource-deprived, peri-urban community in KwaZulu-Natal Province. The data were recorded, transcribed, translated and thematically coded. We used a critical social science approach to inform our collaborative analysis. The findings reveal diverse understandings of the relationship between gender and HIV risk. The majority of the participants felt that females are more vulnerable to HIV as a result of gender inequalities; a minority felt that males are more vulnerable because of limited perceived control over their sex drive. Others felt that both sexes are equally vulnerable because ‘the virus doesn’t have a friend.’ The theme of ‘responsibility for spreading HIV’ emerged inductively from the data and also involved multiple understandings of gendered responsibility. Explicitly engaging with youths in targeted discussions on gendered HIV-related vulnerability and responsibility can offer an opportunity to challenge stereotypes and gender inequities, as well as inform interventions. Keywords: gender, intervention, prevention, qualitative research, sexuality, South Africa, youths Background Lambert & Jewkes, 2007; Harrison, 2008a; Morrell, Epstein, Unterhalter, Bhana & Molestsane, 2009; Pattman & Bhana, Gender identities, sexuality and vulnerability to HIV 2009) has demonstrated that, among some young people in infection South Africa, socio-cultural beliefs about appropriate sexual The risk factors that predispose women and girls to conduct have encouraged young women to be sexually increased risk of HIV infection in sub-Saharan Africa have available to partners and to allow male partners to have been well established in the scholarly literature. Research sexual decision-making authority. For young men, gaining on vulnerability to HIV infection cites diverse factors that respectability has often been associated with having multiple may place females at greater risk, such as biological (see sexual partners and exercising control of decision-making in Gray, Wawer, Brookmeyer, Sewankambo, Serwadda, their sexual relationships, in many contexts (Connell, 1995 Wabwire-Mangen et al., 2001), socioeconomic (Preston and 2005; Morrell & Ouzgane, 2005), including in South Whyte, Varga, Oosthuizen, Robes & Blose, 2000; Kaufman Africa (Bhana, 2005; Hunter, 2005 and 2007). & Stavrou, 2004; Hallman, 2005), cultural and contextual These conventional and well-documented understandings (Varga, 2003; Malisha, Maharaj & Rogan, 2008). In South of gendered sexual behaviour have also been challenged by Africa, a particular focus of the literature on gender has been researchers in a number of ways. Some have argued that on ‘traditional’ social norms and constructions of gender females are not always passive participants in seemingly and sexuality, and how these constructions are interpreted unequal sexual relationships but, in fact, exercise agency and acted on by young people. Recent work (e.g. Harrison, (Larkin, Andrews & Mitchell, 2006; Bhana & Pattman, 2009); 2001; Varga, 2003; Lambert & Wood, 2005; Harrison, this may be the case even in relationships between girls O’Sullivan, Hoffman, Dolezal & Morrell, 2006; Wood, and older men (e.g. the sugar-daddy phenomenon). More African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
  3. 3. 302 Casale, Rogan, Hynie, Flicker, Nixon and Rubincam recent work has further critiqued conventional understand- of Education.) The HIV-prevention programme was multifac- ings of gendered identities (e.g. masculinities and feminini- eted and used strategies targeting not only students, but ties) by pointing out that research efforts often problematise also their teachers, siblings and caregivers. The study was or pathologise young people, particularly young black males a collaborative effort involving public health researchers (Jewkes & Morrell, 2010). from one South African and two Canadian universities (cf. Recent research on gendered sexual identities in South Casale, Nixon, Flicker, Rubicam & Jenny, 2010). Africa has attempted to move beyond the somewhat essentialist understandings of masculinity and femininity Study design related to HIV risk. Jewkes & Morrell (2010), for example, This study used a critical social science approach to contextualise entrenched gendered sexual identi- inform qualitative data collection and analysis (see Eakin, ties in South Africa within the framework of ‘hegemonic Robertson, Poland, Coburn & Edwards, 1996). Such an masculinity,’ as introduced to the gender and sexuality approach emphasises the dialectical relationship between lexicon by Connell (1983, 1987, 1995 and 2005) and individual-level behaviours and the macro-level social, Carrigan, Connell & Lee (1985). Unlike many other studies political and economic contexts (Eakin et al., 1996). Figure 1Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 documenting male domination within sexual relationships, depicts the conceptual framework developed by the research Jewkes & Morrell (2010) demonstrate how gendered identi- team at the start of the evaluation to map our conceptuali- ties are not static constructions but rather dynamic relation- sation of the potential linkages between the HIV-prevention ships, albeit with embedded cultural roots. As such, a programme, HIV-risk-taking behaviour, and other areas more nuanced approach argues that gender identities can of concern. The three key cross-cutting themes were be challenged and transformed, and that progress in HIV gender, religion and youth norms. These were envisaged prevention will most likely be realised through challenging to potentially interact with individual, community-level and gender identities — together with their implications for structural forces to influence HIV-risk-taking behaviour. This sexual behaviour — rather than by focusing exclusively on conceptual framework was used as a basis for developing an sexual behaviour outcomes (Bhana & Pattman, 2009). interview guide for focus group discussions. Despite a large and growing body of literature examining gendered sexual identities among young people in South Participants and recruitment Africa, little is known about how these identities are Grade 11 students who had been involved in the constructed and how they may create vulnerabilities to HIV-prevention intervention were invited to participate disease. In particular, few studies have explored how young in sex-segregated focus groups. Informed consent was people themselves perceive the interaction between gender obtained from all students in their first language (Zulu). constructs and the risk of contracting sexually transmitted The participants were provided with opportunities to ask infections such as HIV, and how these perceptions may questions and given time to decide on whether to partici- differ among males and females. pate; they were also informed of their right to refuse or The purpose of the study was to explore gendered withdraw from the study at any stage without any negative perceptions of HIV risk in a high-HIV-prevalence community consequences. Parental consent for the students’ partic- in South Africa. In doing so, we have attempted to move ipation was also sought using an opt-out approach beyond framing higher-risk sexual behaviour as the inevitable outcome of entrenched gender inequalities within relationships. Instead we compare the perspectives of young males and females on the enactment of masculinities Structural forces and femininities, the construction of sexual relationships, der and how, in their own words, these processes are linked Community Gen with health, generally, and HIV risk in particular. Thus, the Individual research contributes to addressing an important gap in the literature on gender and HIV by documenting gendered HIV perspectives and perceptions of HIV risk, as identified and risk taking Religion discussed by young males and females themselves. behaviour Methods You th n The analysis derives from the qualitative component of orm s a mixed-methods study, conducted in 2007 and 2008, which sought to evaluate a school-based HIV-prevention programme operating in a resource-deprived peri-urban Figure 1: Conceptual framework used to guide the data analysis: community in KwaZulu-Natal Province, South Africa. The the figure illustrates the potential linkages between the HIV-prevention programme had been operating in secondary HIV-prevention programme (the white oval), HIV-risk-taking behav- schools within the community since 2002 and involved more iour (the centre circle), and the three cross-cutting themes of gender, than 450 students in grades 5 to 9, at two schools, between religion and youth norms; these key themes are envisioned to 2002 and 2006. (The programme implementers obtained interact with individual, community-level and structural forces to approval from school representatives and the Department influence HIV-risk-taking behaviour
  4. 4. African Journal of AIDS Research 2011, 10(supplement): 301–310 303 previously used for research in this community. Parental refusing sex or requesting condom use were not available and community awareness and support for the study were options. This theme was taken up mainly by the male sought through community meetings and information letters students: sent home with the students. Ethics approval was received ‘If it’s like…if you have a relationship with a girl, a from the three partner universities. man is like…he controls the whole relationship…. They wanna show who’s boss and to their friends Data collection and analysis and stuff like that. They wanna show — She is Focus group discussions were conducted in Zulu and nothing to me, I can control the relationship. When facilitated by field research assistants who had received I tell her — Let’s go to bed, we can go now to bed training on focus-group facilitation techniques. All the focus — she’s going to agree with that. She knows if she groups were recorded and transcribed. Cross-checking doesn’t, the consequences are bad. Maybe you’re was implemented for quality control of both the transla- gonna beat her up and stuff like that….’ tions and transcriptions. A collaborative approach was used Another male remarked: by the research team to analyse the data (see Jackson, ‘Coming to women, I think the situation is difficultDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 2008). A coding framework was developed inductively, then for them because when it’s time to have sex all that piloted and refined. Each transcript was coded by at least they do is to strip off their clothes. Even if she does two researchers using NVivo software. The research team ask for a condom, the person who is sure whether then used the following analytic questions to interrogate the or not there is a condom is the guy.’ coded data reports: This view reflects the notion of male dominance over 1. What are the dominant ideas? Where is there sexual relationships and decision-making (see Varga, 2003; agreement? Harrison, 2008a and 2008b) and it alludes to women’s fear 2. Where is there disagreement? What are the unique of coercion or even physical abuse as a means for men to opposing views? Where are there contradictions? exercise this control (see Jewkes, Levin & Penn-Kekanna, 3. Are there systematic differences in the way this code 2003; Bhana, 2005; Jewkes, Dunkle, Nduna, Levin, Jama, was taken up by the different focus groups? Khuzwayo et al., 2006; Wood, Lambert & Jewkes, 2008). 4. What are the ‘silences’ in the data collected? (based on Poverty as a key risk factor was also linked to the notion our conceptual framework, illustrated in Figure 1). of males’ dominance. Several participants argued that a The findings presented and discussed in this article derive woman would be reluctant to leave a man on whom she from the qualitative data that reflect the student participants’ depended financially, even at the cost of tolerating abuse understandings and experiences relevant to the theme of and unfaithfulness: gender and HIV risk. ‘I say women are at high risk because they mostly depend on men, financially, even when they [men] Findings and discussion do bad things. But they don’t drop the man even when they find out that a man has another affair, A total of 48 students (21 females and 27 males) partici- because they are dependent upon them’ (male). pated in five sex-segregated focus groups. Three focus ‘I think HIV is spread through poverty. Let’s say groups were conducted with males and two focus groups my mother is poor and unemployed, she stays with females. The participants’ ages ranged from 16 to 23 with my stepfather who is the breadwinner. If he is years, and all identified themselves as black African. beating her up, she cannot run away because she Gendered perspectives, related to both HIV vulnera- needs the support’ (female). bility and responsibility for the spread of HIV, were raised These explanations resonate with literature highlighting frequently and often spontaneously throughout the focus social inequalities and poverty in South Africa as factors group discussions. Below, we discuss the findings related to that place women in particular at risk of HIV (e.g. Preston these two themes, followed by a discussion of the implica- Whyte et al., 2000; Dunkle, Jewkes, Brown, Gray, McIntyre tions for HIV-prevention programming, especially for young & Harlow, 2004; Hallman, 2004; Kaufman & Stavrou, 2004; people. Hunter, 2005 and 2007), thus potentially reproducing dominant masculinities (Hunter, 2005). The participants’ Theme 1: Perceptions of the relationship between references to poverty as an HIV-risk factor are not surprising gender and vulnerability to HIV in this particular community, given the existing social and The findings show diverse understandings and perceptions economic conditions.1 of the relationship between gender and vulnerability to HIV An alternative discourse around poverty and sex emerged among the focus group participants. While the dominant — that is, that women might engage in transactional sex belief was that females are more vulnerable to contracting in order to support their families. Both males and females HIV infection, this coexisted with the views that males are argued that transactional sex could sometimes be the only more vulnerable or that both sexes are equally vulnerable. strategy for acquiring material goods in an impoverished setting: ‘Women are more vulnerable to HIV’ ‘I would say poverty does also spread HIV. Let’s say The majority of participants felt that females are more there is a family where no one is employed; maybe vulnerable to HIV, mostly as a result of gender inequali- parents have passed away, and there are four girls ties. For instance, women could be in relationships where and the last born is 12 years old, and relatives are
  5. 5. 304 Casale, Rogan, Hynie, Flicker, Nixon and Rubincam unable to support. One of them is likely to go into as me will get HIV. It’s only old people who are prostitution to feed themselves. Once she gets independent, like 24 upwards, and females.’ sick she will ask the younger sibling to take over…’ Such comments made by females in particular highlight (female). the perpetuation of myths that influence young people’s This view is a distinct conceptualisation of women’s simulta- understanding of gender and HIV risk (often despite having neous vulnerability and agency as it involves women received sexual health education, as the participants had). taking responsibility for others at a high personal cost to These include the incorrect belief that women have weaker themselves rather than being dependent on others. As immune systems, and that younger men are unlikely carriers Hunter (2005, p. 398) points out, many women are “quick of HIV. Interestingly, the multiple references to females’ to see the benefits of securing multiple partners” when biological susceptibility in this data set are based on generic prospects of marriage and employment are grim and where notions of physical weakness, versus a real discussion women are often aware of their partner’s unfaithfulness. of the much-documented biological factors that actually Alternative explanations for women’s higher suscepti- increase their vulnerability to HIV infection (European Study bility to HIV infection included references to high-risk and Group on Heterosexual Transmission of HIV, 1992; Nicolosi,Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 careless behaviour, such as substance abuse: Corrêa Leite, Musicco, Arici, Gavazzeni & Lazzarin, 1994; ‘You will find that she will go to a nightclub and she Chersich & Rees, 2008). drinks and does drugs; after that I’m sure she will be drunk and she will not think much about what she ‘Men are more vulnerable to HIV’ is doing, and it will be easy for boys to attack her. Conversely, a minority of the male participants felt that men They will have sex with her, and when she wakes are more vulnerable to HIV. The main reason given was up the following day not know knowing whom she their perceived limited control over their sex drive and their slept with, and she doesn’t know if she has HIV or resultant behaviour. For instance, it was suggested that not’ (female). females could easily lure men into sex, and that males were A few male participants suggested that when females lose weak and unable to control themselves in the presence of their virginity they may turn to promiscuity and higher-risk females in ‘shorter skirts’: behaviour, while males will attribute little value to virginity ‘What I can say is that boys are weak, when they… and are generally promiscuous: see a girl with a shorter skirt …the only thing that ‘We men are not bothered by virginity because comes to their mind is — Oh, I want to have sex to us that has no value. But for women, it has with this woman. That’s how they end up going so value because after having sex, they can neglect fast like this’ (male). themselves feeling that they lost virginity and they There were also references to males’ higher-risk behaviour, can just sleep around wherever they want. As men, such as alcohol abuse: we go for women and sleep with them, and more ‘The men also have a problem when they are drunk, women are then infected’ (male). they have no time to look for a condom, and that is The expressed importance of losing one’s virginity, on the where they become infected’ (male). part of young women, and the consideration of virginity The idea of men being more vulnerable to HIV infection due as a desirable characteristic in a female partner, on the to higher-risk behaviour and ‘weakness’ when it comes to part of young males, was also highlighted in qualita- controlling their sex drive was predominantly expressed by tive research by Harrison (2008a) in KwaZulu-Natal. It is male participants. Thus, notions about the dominant male not clear to what extent these ideas may resonate with as well as the weak, vulnerable male were advanced mainly an individual youth’s own sexual experience, however. by the male students. As noted by Harrison (2008a), most of the young women interviewed gave in to a boyfriend’s demands for sexual ‘Both sexes are equally vulnerable to HIV’ intercourse once they were in a relationship (in some Another perception was that both sexes are equally vulner- cases to prove their virginity), and none of the young men able to HIV because both are sexually active, possibly with or women interviewed referred to virginity as desirable for multiple partners — and the virus doesn’t distinguish. This themselves. theme was taken up by both male and female participants: The perception that women are biologically ‘weaker’ was ‘Oh good people, let’s be honest, the virus doesn’t also advanced as an explanation for their greater suscepti- have a friend, it is transmitted in the same way no bility to HIV infection, mainly by the female students: matter who you are’ (female). ‘Females have got weaknesses and males are ‘I agree with those who say it is not only women strong, as you all know that females die earlier than who’re at high risk, we are all at high risk of HIV males.’ because a girl sleeps with many boys and also boys ‘It is because our immune system is not so strong do the same’ (male). like theirs [males].’ A few participants explained how the HIV-prevention One female suggested that misconceptions about who was programme they had experienced conveyed messages and was not likely to be HIV-positive were putting girls at risk: about the equal risk of contracting HIV: ‘We have the belief that — I won’t get HIV from the ‘No one is at high risk of being infected by HIV. They boys who have the same age as mine, because say in English: you have multiple partners; it does we don’t think that boys who are the same age not matter if you are a male or female, it is the same
  6. 6. African Journal of AIDS Research 2011, 10(supplement): 301–310 305 in getting HIV. And this relates to [the HIV-prevention that’s the main thing that spreads the disease…. programme] in that we as males have always The usual way is that if he has five wives, he is believed that women should be submissive to going to have sex with all of them. If he is not males, and they [the programme facilitators] told us working here in KwaZulu-Natal and he is working that getting HIV is the same and no one is at higher in Johannesburg, if he comes back home he has risk than the other’ (male). the money and it’s not possible that he was staying ‘I will say we are equal; even [the HIV-prevention alone, because at times males are very weak programme] taught us that chances [of HIV infection] and they can’t control themselves and come back are equal’ (male). home with the disease because they did not use Thus, various references to males’ and females’ similar condoms. In that way the diseases can be spread vulnerability to HIV risk provide nuanced and potentially easily’ (female). more constructive understanding of gendered vulnerability to Several male participants advanced a more extreme disease. The comments of some participants also suggest view of males as manipulators and opportunists who take that the HIV-prevention messaging received through the advantage of females. One said:Downloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 school-based programme had contributed to these percep- ‘Males are manipulators, like X has many girlfriends tions. However, these quotes were less developed than the and they like him because he has a nice car. So arguments supporting notions of one gender being more most of these women will want to sleep with him, vulnerable than the other, so it is difficult to ascertain to what and only to find that he is HIV-positive by then, and extent they represented actual beliefs in the community, all of these women will get infected.’ rather than the repetition of information received from the One male suggested that males know only sex, not love: programme. ‘Because when they [males] have the girlfriend, the only thing they know is sleeping, sleeping. They Theme 2: Perceptions of the relationship between don’t know love…only thing they know, they know gender and responsibility for spreading HIV sex. It’s sex.’ As with the topic of vulnerability to HIV, the participants These views resonate with recent literature and popular offered multiple gendered understandings concerning discourse wherein men are primarily attributed the responsi- responsibility for the transmission of HIV, including the bility for spreading HIV. For example, in discussing the topic ideas that men are primarily responsible (dominant view), of multiple partners in a historical perspective in KwaZulu- women are primarily responsible, and both sexes are Natal Province, Hunter (2005, p. 398) referred to “women’s equally responsible for spreading the virus. This theme was often aggressive critique of irresponsible men infecting not intentionally pursued in the focus group discussions; women with HIV” and the increasing rejection, by both men instead, the idea was raised spontaneously and frequently and women, of the isoka masculinity (defined broadly as the by the participants. Zulu man with multiple sexual partners) in the context of HIV. An interesting feature of the focus-group data is that beliefs ‘Men are responsible for spreading HIV’ that males are predominantly responsible for spreading HIV The dominant view among both the male and female were expressed by both the males and females, and the students was that men are primarily responsible for participants explained this both in terms of male strength spreading HIV, due to sexual coercion and male control and dominance and in terms of male weakness (e.g. the over relationships and condom use (as reflected in various perceived inability of men to remain faithful and control their quotes above), as well as because of men’s greater promis- sexual desire). This mirrors the explanations given for males cuity and unfaithfulness: as more vulnerable to HIV. As Hunter (2005, p. 401) reminds ‘Regarding males, there is a saying that we use as us, gender is not a static, one-dimensional expression of boys, which says — There are many fishes in the male power, but also “embodied in male vulnerabilities and sea. Okay, I will have an affair with a girl, and sleep weaknesses,” and it is a combination of both dimensions with her, know how she behaves in bed, and then I of male identity that often leads to violence against women move to another one and do the same. Obviously I and sexual-risk behaviour. now have HIV and I got infected by a girl, and as I The explanations attributing responsibility to males go around I spread it, as at times we youth do not for spreading HIV in terms of both their strengths and use condoms’ (male). weaknesses suggest different forces at work. On the one ‘Most of the time males are more infected and hand, the notion of the dominant male increases men’s spread it to females…. Males will spread it to many status by positioning them as powerful and in control of females, then the rate will say females have a high sexual decision-making; however, it also indicates blame. rate of HIV’ (female). On the other hand, and consistent with widespread beliefs One point of view was that the custom of having multiple that women control men through sex (Glick, Fiske, Mladinic, wives, coupled with migration and infidelity, was a key Saiz, Abrams, Masser et al., 2000), the idea that males channel for the spread of HIV from men to women. Once can’t control their sexual urges positions men as vulner- again the notion emerged that men are ‘weak’ and unable to able while also potentially alleviating them of responsibility, control their sex drive or remain faithful: even in situations of abuse (cf. Jewkes, Penn-Kekana & ‘So we have these rural males who have this belief Rose-Junius, 2005). of having more than two, three, five wives and
  7. 7. 306 Casale, Rogan, Hynie, Flicker, Nixon and Rubincam ‘Women are responsible for spreading HIV’ ‘Both sexes are equally responsible for spreading HIV’ A minority of the (mainly male) focus group participants cited Finally, the focus-group data also reveal the participants’ women as responsible for the spread of HIV. One reason belief that both men and women are equally responsible given was that women could be promiscuous to obtain for spreading HIV as a result of higher-risk and careless material goods. This view was distinct from the one offered behaviour. This theme was taken up by both males and with respect to females’ higher HIV risk in connection to females. The reasons offered were similar to those provided transactional sex (discussed above), since these explana- to explain vulnerability to HIV. One explanation was that tions were based on enhanced agency among women (e.g. both males and females engage in higher-risk sexual females ‘luring’ men into sex to obtain material items) rather behaviour in pursuit of pleasure. For example, a person may than their lack of agency (e.g. due to financial depend- have multiple partners in order to increase their options and ency), thereby referring to females’ desire for fashionable might move quickly from one partner to the next: non-essential goods, versus a pursuit of basic necessities: ‘I’m going to talk about the youth because nowadays ‘When a woman who has no money sees another boys and girls have a belief of having more than two woman wearing fancy clothes, she will prostitute boyfriends and girlfriends, saying that they shouldDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 herself and go out with all these guys, so many of balance, because if you are a person you should them are doing prostitution in town. Women are not stand on one foot…. You will take all his disease in trouble because they sleep with all these men’ and infect other people. When you break up, you will (male). go and have another relationship and infect other ‘Maybe he is driving a Hummer [fashionable people’ (female). vehicle] and you will get to sit on the front seat, ‘It is equal getting HIV, as boys enjoy having many and he will drop you off here at school and drop girlfriends and girls also do the same’ (male). someone at the college. That’s the way that HIV is One male pointed out that ‘guys too, they can get the spread’ (female). disease when they get raped.’ A further explanation for Once again, the idea that women begin to engage in casual equal culpability was that both males and females can be sex once losing their virginity was related to responsibility dishonest with their partners by failing to disclose their HIV for spreading HIV: status: ‘I think the loss of virginity means a lot to a woman; ‘I think it works both ways. When the man is and they feel that it is the end of the world, and they HIV-positive, he does not tell the woman; and when just sleep around’ (male). the woman is HIV-positive, she does not tell the The participants also referred to women having sexual man’ (male). relationships with men in order to feed their self-esteem: Similar to comments about the sexes’ equal vulnerability ‘I disagree with that [that women are financially to HIV, the participants’ views about males’ and females’ dependent on men], because nowadays youths are shared responsibility for spreading the virus were less covered financially: they want clothes from parents dominant and developed than the arguments that attrib- and they buy for them. It means it can happen that uted greater blame to one or the other sex. As a result, women depend on men, but not most of the time. it was difficult to ascertain to what extent the participants But my point, from the first time is, girls do sleep had effectively processed and internalised these positions. with many guys just because they think they are Nevertheless, as with notions about the sexes’ equal vulner- beautiful’ (male). ability to HIV, the idea of equal blame or shared responsi- There were isolated references to women being dishonest bility for transmission is a positive phenomenon that could and hiding their HIV status from men, which mirrored to facilitate engagement with youths around issues of gender some extent the notion of men as manipulators: and HIV. ‘You find that a boy falls for a girl and she does not disclose that she is HIV-positive and they sleep Conclusions together, and still she does not disclose; and they date for months, and when he finally goes to test, Diverse and common understandings of the interaction he finds that he is HIV-positive’ (male). between gender and vulnerability to HIV Importantly, the perceptions discussed in this section Referring back to our conceptual framework (Figure 1), this largely contrast with the ‘expected’ or ‘traditional’ gender study has highlighted the importance of gender constructs stereotypes reflecting so-called hegemonic constructions of in shaping youths’ perceptions of HIV-risk factors, as well masculinities, as widely discussed in the literature (Connell, as being motivators of actual sexual decision-making and 2005). Instead, they accentuate female agency in sexual behaviour. Gender constructs are closely linked to youth relationships (cf. Larkin et al., 2006; Bhana & Pattman, culture and, on a broader level, interact with structural 2009). While both male and female participants had referred forces within the community, such as poverty. The analysis to poverty and women’s financial dependency as determi- presented here demonstrates diverse views among the nants of HIV risk for which women had limited agency, the participants regarding the relationship between gender roles quotes above allude to situations of women being in control or identity and HIV risk, both in relation to vulnerability to or even strategically manipulating men (e.g. by choosing to contracting the virus and the unsolicited theme of responsi- engage in sexual activities to obtain non-essential items or bility for spreading HIV. These findings bring to mind recent social status) (Glick et al., 2000). literature describing the complexity and nuances of gender
  8. 8. African Journal of AIDS Research 2011, 10(supplement): 301–310 307 roles and identities (Varga, 2003; Morrell & Jewkes, 2010) of male circumcision, despite it being a key current topic and also expose the gendered nature of the perceptions of debate in academic and media circles. This lack of recorded, because not all the themes were understood or engagement with biology is surprising and could reflect explained by the males and females alike. an important knowledge gap among these young people. While our analysis reinforces the dominant ideas Similarly, references to sexual pleasure and its implica- expressed by the youths, alternative and contradicting tions for HIV risk were also conspicuously absent from the positions emerged for each theme. The dominant ideas data, despite evidence that sexual pleasure can be associ- emerging from the focus groups mainly represent ‘expected’ ated with safer-sex practices, the ability to avoid unwanted or ‘traditional’ gender stereotypes reflecting hegemonic sexual relationships, and less likelihood of vaginal tearing constructions of masculinity (see Connell, 2005; Jewkes which facilitates HIV transmission (Jackson, 1998; Philpott, & Morrell, 2010). Examples include references to males’ Knerr & Boydell, 2006). However, the absence of discus- control over sexual relationships and condom use, as sion about sexual pleasure and intimacy does resonate well as to females’ dependency and submissiveness. with the findings of qualitative work conducted by Harrison Importantly, however, these views coexisted with alterna- (2008a) among adolescents in KwaZulu-Natal, whichDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 tive and contrasting ideas, such as that of female agency highlighted the dominant ideologies of ‘good behaviour’ in sexual relationships, which are compatible with examples and ‘sex is wrong.’ given in recent literature challenging the stereotypical notion of women as passive sufferers in sexual relation- Limitations of the analysis ships. Moreover, the various references to similar respon- This analysis draws from a larger evaluation of a school- sibility for and exposure to HIV risk among both the males based HIV-prevention programme conducted with youths and females provide further nuanced and potentially more in KwaZulu-Natal. Therefore, all the students who partici- constructive — albeit less dominant — understandings of pated in the focus groups for our study had also attended gendered vulnerability to sexually transmitted disease. the HIV-prevention-programme evaluation, which may Interestingly, these diverse views were expressed have influenced their views on the themes discussed. by participants from the same community, with similar However, the diversity of understandings emerging from socioeconomic backgrounds, all attending the same the data suggests that this influence likely existed but school, and all having received the same school-based had not become dominant. Another implication is that the HIV-prevention programme messaging. This does not rule larger study was not singularly focused on the relation- out that the intervention may have influenced gender-related ship between gender identity and HIV risk, which is the key understandings among some of the youths; in effect, several analytical theme explored in this article. Thus, additional participants suggested that the intervention’s messaging questioning on these themes may have revealed deeper contributed to their perception of males’ and females’ shared explanations for the reported perceptions. However, this responsibility. may also be viewed as a strength of the study, in that all Not all the themes were taken up by both sexes in the the representations included here emerged spontaneously same way: while males and females expressed similar in response to broad, open-ended questions. Lastly, we did views on some themes, other themes solicited quite not collect information about the sexual experience of the different views from the two groups. For example, both focus group participants, as we believed it would have been male and female participants highlighted the relevance of inappropriate to discuss individual and sensitive information poverty in putting women at risk of exposure to HIV, and within a focus-group setting in a school context. However, both groups asserted the dominant notion that men are the quantitative survey data pertaining to all Grade 11 mainly responsible for the spread of HIV. However, the students (n = 667) at the four schools where we conducted notion that females are more vulnerable to HIV due to male the research shows that over half of the male survey partic- power and dominance was a theme taken up predominantly ipants (n = 207; 69.5%) and just under half of the female by the male participants, as was the notion that females are participants (n = 174; 47.2%) reported ever having had mainly responsible for spreading HIV (e.g. due to transac- sexual intercourse. tional sex for luxury goods, their ability to manipulate and ‘lure’ men, or their perceived all-or-nothing approach to Implications for HIV-prevention programming maintaining their virginity). However, ideas about men as The study has various implications for youth-oriented sexual manipulators and men as more vulnerable to HIV HIV-prevention programming. In particular, the findings both due to both their high-risk (promiscuous) behaviour as well reinforce the need to create adequate space to engage as their ‘weakness’ in controlling their sex drive, were also with issues of gender and sexuality within HIV-prevention predominantly expressed by male participants. programming (Bhana & Pattman, 2009) as well as highlight Two notable ‘silences’ in our data were: 1) little engage- potential channels or opportunities for this engagement. ment with the biological causes of increased vulnera- First, explicitly engaging in frank discussions that allow bility to HIV infection, and 2) lack of references to sexual youths to express and discuss common and conflicting pleasure. As alluded to above, there was no discussion of views can be an important opportunity to challenge stereo- the biological factors that increase females’ vulnerability to types and gender inequities and to better inform health HIV infection (see European Study Group on Heterosexual education programmes (cf. Morrell & Jewkes, 2010). As Transmission of HIV, 1992; Nicolosi et al., 1994; Chersich indicated by Morrell & Jewkes (2010), we are unlikely to & Rees, 2008). Nor was there any reference to the benefits achieve progress in HIV prevention in sub-Saharan Africa
  9. 9. 308 Casale, Rogan, Hynie, Flicker, Nixon and Rubincam without working to change gender constructs (cf. Kirby, within the idealisation of abstinence (when it is not reflected Laris & Rolleri, 2007; UNESCO, 2007; Campbell, Gibbs, by the reality of youths’ sexual behaviour). Only by providing Maimane, Nair & Sibiya, 2009; Hanass-Hancock & Casale, youths with accurate information and encouraging more 2010). Moreover, our analysis reinforces the importance of openness to discuss sexuality (Harrison, 2008a) will we be working closely with males, especially around concepts of able to tackle the stigma, silence and higher-risk behaviour masculinities (cf. Campbell, 2004) as the results suggest that place predominantly young women at risk of contracting that young males play a stronger role in perpetuating HIV. hegemonic masculinities, including stereotypical notions Lastly, our analysis shows that the question of ‘who is of weaker, submissive women, as well as in externalising responsible for spreading the virus’ was a key concern among responsibility for HIV risk. both the male and female youths in this community, and the As the data collected for this study have shown, gender issue appeared central to shaping their views on gender in constructs and beliefs may not be homogenous across relation to HIV risk. While it could be argued that this ‘blame or even within groups of youths with similar backgrounds game’ is not particularly useful or constructive, it is precisely and experiences. When planning HIV-prevention interven- for this reason that the issue of responsibility needs to beDownloaded by [UNIVERSITY OF KWAZULU-NATAL] at 05:35 22 February 2012 tions for young people, it is therefore important to create explored within HIV-prevention programmes. This issue is an adequate space to explore perceptions of gender identi- clearly important to youths, and, if not addressed, may create ties in relation to HIV vulnerability and responsibility for HIV further divisions and ‘othering’ of responsibility. We need transmission among the particular groups that the interven- to move beyond this type of censure to constructively deal tions intend to reach (Kirby et al., 2007; UNESCO, 2007). with socio-cultural gender identities and to arrive at general This should take into account the dominant understandings accountability for behavioural choices. HIV-prevention and experiences of young people in a community, as well programmes, particularly longer-term and holistic ones, may as alternative views that may require a safe environment provide an important opportunity to do this. and time to emerge (Larkin et al., 2006; Hanass-Hancock The school context represents an especially important & Casale, 2010). This approach will also allow for better space and opportunity for HIV-prevention and sex-education understanding of the key gaps, challenges and areas that initiatives, as it allows for continuity and long-term interven- programmes need to prioritise among specific groups. tions to take place. It also provides the opportunity to In so doing, it is important to recognise where youths are address gender norms with individuals at a young age and expressing ‘idealised behaviour’ (e.g. sexual abstinence) among school peers and teachers who interact on a daily that may not reflect the reality of their lives, and to provide basis. However, our experience of working in resource- opportunities to question and unpack these contradictions deprived schools in South Africa, and anecdotal evidence about HIV vulnerability and responsibility for infection. from youths and school representatives, has highlighted for Similarly, myths and misconceptions about vulnerability to us the likely challenges of implementing effective longer- disease will also need to be addressed. term programmes in these schools. Problems include Second, providing adequate space to explore areas of limited financial resources, space and privacy, and, not least consensus and disagreement among youths, as pertains of all, the need to create safer environments where students to gender and HIV risk, can uncover starting points or can critically discuss the issues raised. Anecdotal evidence opportunities for programmes to challenge dominant views, of high levels of gender-based violence among students in myths and stereotypes. In this study, the consensus among these schools suggests the need for counselling skills and/ both males and females (albeit a minority) about notions or a good referral system to be in place to address issues of gender-equal vulnerability and responsibility is encour- that may come up during discussions of sensitive topics. aging and provides a perspective on which to build. While Furthermore, reports of stressed and overburdened teachers recognition by both the males and females of the impact and some who continue to approach discipline with threats of structural factors (such as poverty) on HIV risk is a of corporal punishment, indicate that work also needs to be potentially positive phenomenon, HIV-prevention interven- done with teachers, and that particular attention needs to tions can have limited impact on these factors, yet they be paid to the question of who should best facilitate these need to take these realities into account. However, the programmes. It is important that programme implementers participants’ recognition of agency — in particular women’s not only be equipped with the necessary factual knowledge, agency in sexual relationships — indicates an area of but also possess appropriate attitudes and sensitivities for opportunity for affecting change. sexual health education (Ahmed, Flisher, Mathews, Jansen, Similarly, the ‘silences’ in the data expose likely gaps Mukoma & Schaalma, 2006). Moreover, interactive and that merit further attention within sexual health and creative approaches to engaging with youths on the topics HIV-prevention programmes. For example, the absence of of gender and HIV should be explored to ensure credibility discourses on biology as a gendered HIV risk, and the lack and effective two-way communication (Hanass-Hancock & of references to sexual pleasure, suggest key gaps in the Casale, 2010). youths’ understanding of sexual and reproductive health The suggestion that the school-based HIV-prevention and sexual intimacy. Conversely, these gaps represent programme received by these youths may have contrib- an opportunity for behavioural interventions to explicitly uted to their understandings of shared responsibility and engage with these topics, despite the challenges. As noted common vulnerability is encouraging, as it points to the by Harrison (2008a), it is difficult to address HIV prevention potential for other HIV-prevention initiatives to do the same, in the absence of a healthy discourse about sexuality and building on common ground. As the literature reminds us,

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