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Gender, Youth and HIV Risk
by Nikki Kumar, June Larkin and Claudia Mitchell
Les auteures assurent que le genre a un rôle à jouer dans la transmission du vih et reconnaissent la vulnérabilité biologique des jeunes femmes au virus. Cet article fait la promotion de programmes préventifs qui seraient sensibles à la dimension sexuelle du vih/sida et qui considéreraient la violence et l'inégalité dans les relations hétérosexuelles comme un obstacle pour les jeunes filles à des relations sexuelles protégées.
HIV/AIDS is fast becoming a global crisis and young people worldwide, are one of the most vulnerable groups. Within the youth population, there is strong evidence that girls are particularly at risk (UNAIDS). Our interest in gender, youth, and HIV risk was inspired by the work of the Canada South African Management Program (CSAEMP), a partnership of CIDA, McGill University, and the National Department of Education in South Africa. Through CSAEMP, Mitchell and Larkin worked with South African educators and learners on the development of the educational module, Opening Our Eyes: Addressing Gender-Based Violence in South African Schools (Mlamleli, Napo, Mabelane, Free, Goodman, Larkin, Mitchell, Mkhize, Robinson and Smith), a document designed to educate teachers about issues related to gender-based violence. This CIDA-funded project brought to light the link between gender and HIV, a connection we are now applying to our understanding of HIV risk in Canadian youth.
The AIDS crisis in South Africa is particularly acute: the national rate of prevalence is 22.8 per cent with infection rates rising at an alarming rate, most significantly in youth (Anthropology News). In Canada, however, the number of reported HIV infections is also on the rise with more teens infected than ever before (Health Canada 2000). With the stark increases in incidence among women in both the industrialized and the developing world, there is growing acknowledgement that HIV/AIDS is a highly gendered disease (Simmons, Farmer and Schoepf; unaids). The rise in the HIV incidence rate of both women and youth suggests that young females may be a particularly vulnerable group (Grierson; White; Wingwood and DiClemente). In South Africa, for example, the HIV incidence rate among South African girls is three to four times higher than boys (Brown).
Across the world, more than four-fifths of all HIV-infected women have contracted the virus through heterosexual transmission (Health Canada 2001; Larkin 2000; Wingwood and DiClemente). Although their political and economic situations vary, women are linked by their subordinate status in heterosexual relations. For young women, a combination of biological and social factors increases this risk (Mlamelli et al.). These factors are the focus of this article. This work has grown out of our involvement with the Gendering Adolescent AIDS Prevention (GAAP) project, a newly formed group of Canadian and South African researchers working in the area of gender, youth, and HIV/AIDS. Our first efforts have focused on exploring gender as an HIV risk factor in the heterosexual encounters of youth. This information will provide the background for achieving our larger goal: the development of gender-sensitive HIV/AIDS prevention programs for Canadian and South African youth.
Young Women and HIV Risk
Biologically, young women are more vulnerable to HIV infection than young men. The risk of HIV infection during unprotected vaginal intercourse is as much as two to four times higher for women (UNAIDS). During heterosexual sex, the exposed surface area of the vagina and labia is larger in women than the vulnerable surface area in men (Simmons et al.). Semen infected with HIV contains a higher concentration of the virus than female sexual secretions. In general, the male-female transmission of HIV is much more efficient than female-male transmission. A single episode of unprotected intercourse is risky for women who may be receiving infected semen from a male partner. Young women are particularly vulnerable to infection through intercourse prior to menstruation when the lower reproductive tract is still developing (UNAIDS).
The presence of an untreated STD can increase the risk of HIV transmission. Women are more likely than men to have an undetected std because the sores and symptoms may be mild or difficult to recognize (UNAIDS). Infection rates for stds, which have increased since 1997, are highest in the 15-19 age group with girls being infected far more than boys (Picard). Thus young women, for whom general rates of chlamydia and gonorrhea are increasing the most, are at particular risk for contracting HIV during unprotected heterosexual intercourse (Sanford).
Young women's biological vulnerability to HIV infection is increased when their sexual autonomy is compromised. Gendered power relations operate to shape and constrain heterosexual practices in ways that increase young women's risk to HIV infection. Although adolescent heterosexual relationships take place within the private sphere, they are located within complicated social networks of peers where information is exchanged and sexual reputations are constructed (Holland, Ramazanoglu, Sharpe and Thomson; Holland and Thomson; Moore, Rosenthal, and Mitchell). According to the dominant femininity script, young women are not supposed to desire sex or be sexually assertive, and are further expected to resist young men's sexual advances (Gomez). Enforced through the mechanism of sexual reputation amongst peers, a young woman can be labelled a "whore" or a "slut" if she is seen as too sexually knowledgeable or assertive by her peers or male sexual partner (Holland and Thomson). Thus, an empowered, independent young woman with her own active sexual desires, who seeks sexual pleasure and sexual safety on her own terms, is not a "normal" feminine woman, but often seen as sexually and socially deviant (Holland and Thomson). It is these distinctions and accompanying judgements that serve to disempower a young woman by limiting her scope of socially appropriate behaviours within heterosexual relationships (Travers and Bennett). Therefore, the extent to which young wo-men conform to or transgress conventional femininity in their intimate relationships depends in part on the climate of the peer culture within which they are located (Holland and Thomson).
Safer sex negotiation presents a challenge for many young women because of socio-cultural norms that have traditionally fostered female sexual passivity, innocence and/or ignorance (Suarez-Al-Adam, Raffaelli, and O'Leary). For a young woman to insist her male partner use a condom or to present a male condom to her partner is implying that she is sexually experienced and sexually assertive, and therefore, sexually promiscuous (De Oliveira). Through this deviation from the expected feminine role, she is placing herself at risk for betrayal by her male partner, either through him disclosing their sexual relationship to peers, and pegging her as sexually accessible or "easy," or insisting she is sexually experienced, and labelling her a "slut" (De Oliveira). Faced with the threat of a tarnished or "bad" reputation, many young women choose to remain submissive or ignorant with regards to male condom use and/or are coerced into sex, instances where the male determines whether or not a condom will be used during heterosexual intercourse (De Oliveira). Thus, many young women are at high risk for contracting HIV through unprotected heterosexual intercourse because they feel pressured to maintain a "good" female (sexual) reputation amongst peers.
Young women's vulnerability to HIV infection is also directly related to the structural conditions of their lives (White). Young women exist within a socially stratified system maintained by racism, economic inequality, poverty, sexism, and violence (White). Desperate economic circumstances can increase HIV risk when girls and women are forced into survival sex where condom use is difficult to negotiate. As reported by unaids, for many girls and women, "sex is the currency in which they are expected to pay for life's opportunities, from a passing grade in school to a trading licence or permission to cross a border" (3). In many circumstances, clients demand unprotected heterosexual intercourse, and may often use sexual and physical violence and/or may refuse to pay if a condom is used (Gomez; Larkin 2000). The growing demand for low-risk sexual partners has led to increased child sexual exploitation and a rise in the numbers of HIV-infected girls. Most vulnerable are girls from developing countries sold into the international flesh trade to service male sex tourists.
Throughout the developed world, unintended teenage pregnancies and the contraction of stds are most common among young women from socially deprived neighbourhoods and from minority ethnic groups, which are often disproportionately economically disadvantaged. Minority ethnic groups also suffer the health-damaging effects of explicit prejudice or more subtle forms of social exclusion, and are more likely to experience difficulties assessing health and social services or to find these services culturally inappropriate or non-welcoming (Campbell and Aggleton; Larkin 2001). These factors combined with the gender inequalities faced by many young women render them at increased vulnerability for contracting HIV through unprotected, high-risk heterosexual intercourse (Campbell and Aggleton).
Hegemonic Masculinity and HIV Risk
Hegemonic masculinity1 dominates the sexual cultures of youth. Dominant ideologies of masculinity portray young men as sexually active and aggressive (Gomez). Challenging hegemonic masculinity takes individual courage and may be punished by peers and partners (Holland and Thomson). Within peer groups specifically, sexual experience can provide young men with a passport to status and affirmation.
The dynamics of the adolescent male peer group can make it difficult for young men to demonstrate ignorance or innocence about sex to their male peers or even to their (female) sexual partners (Holland and Thomson). Furthermore, the pressure for young men to be sexually active and to have multiple (female) sexual partners may become so great, that those unfulfilling this expectation may be open to ridicule and homophobic bullying. This reinforces the stigmatizing of sexual minorities and supports the idea that multiple sexual partnerships with young women are the expected norm in heterosexual masculinity (Campbell and Aggleton; Holland et. al.; Holland and Thomson; Moore et al.).
For many young men, male condom use is associated with "gay" or "un-masculine" sexual activity. Therefore, in order to maintain a masculine heterosexual identity amongst peers, in particular with female sexual partners, condom use may be discouraged during heterosexual intercourse. As well, it is socially accepted and expected that men control the sexual decision-making, including the use of male condoms within heterosexual relationships (Garcia-Moreno and Watts). It is this social acceptance and encouragement of male promiscuity, sexual decision-making, and sexual aggression alongside female sexual passivity, innocence and ignorance that are some of the gendered factors that put women at greater peril for HIV infection ("U.N. Officials Said Violence Against Women Helps Spread HIV").
Young men and young women may have a vested interest in not communicating about sex in early sexual encounters. Silence surrounding heterosexual activities can maintain an ambiguity between partners as to whether sex will actually happen. To mention condoms presumes that sexual intercourse will be occurring, thereby opening the possibility of sexual rejection towards the male, and an unfavourable sexual reputation for the female (De Oliveira). The risk of acquiring a tarnished sexual reputation among peers, therefore, exists for both the young man and the young woman. However, in the absence of communication, the meanings and associations of conventional masculinity and femininity tend to fill the silence, overshadowing the needs and desires of the individuals involved and concerns for sexual safety. Through "spontaneous," unprotected heterosexual intercourse, then, the young man maintains his masculine sexual dignity, while the young woman maintains her proper maintains her proper sexual role through sexual passivity, innocence and/or ignorance (Suarez-Al-Adam et al).
In this absence of communication, the past sexual histories of the partners become silenced as well. Thus, the lack of knowledge surrounding her male partner's past sexual exploits alongside her socially expected sexual passivity prevents opportunities for condom negotiation and increases the risk for HIV infection.
(Hetero)sexuality and the Privileging of Male Desire
Many young men have learned to approach sex from the position of sexual actor, whereas young women see themselves as the objects of sexual acts and the targets of male desire. Young women may enter heterosexual relationships aware of the sexual needs of men but without a clear sense of their own sexual self-interest (Holland and Thomson). For instance, heterosexuality and heterosexual intercourse have become based on a masculine understanding and definition of sex (Wallace and Wolf). Consequently, sexual intercourse becomes defined as solely vaginal penetration where women become perceived as passive recipients of the sexual act, of sexual expression, and objects of male desire (Holland et. al.; Wallace and Wolf). Thus, many young women find it difficult to articulate their own agency in sexual encounters, and frequently describe sex as something that happens to them (Holland and Thomson).
Michelle Fine has written extensively about the absence of a discourse of female desire in the domi nant language and perspectives of sexuality. According to Fine, when the expression of female sexuality is limited to a male-defined terrain, girls' sexual agency can be reduced to saying yes or no to sexual intercourse, a practice that may not be generated from their own sexual desire. Through being positioned as objects of male sexual desire, young women can be rendered as passive in heterosexual sexual relationships, irrespective of the existence of force or pressure on the part of male partners. The emphasis on male sexual needs, pleasures, and desires combined with a lack of discourse on heterosexual pleasure for women through which young women can both locate and further develop their own sexuality, cause many young women to collude with men in promoting and maintaining male heterosexual dominance (Holland et. al).
Being the object of male desire can effectively silence female desire and lead to sexual self-surveillance on the part of the young women (Puri). Self-surveillance can be manifested as "nurturance" (fulfilling the needs of their male partner) and/or pragmatism (accepting that consent to sexual experience may be easier than offering resistance) (Holland and Thomson). Furthermore, young women may have internalized beliefs about the priority of male sexual pleasure (Holland and Thomson). This, in turn, places young women in a risky situation for having unprotected heterosexual intercourse and hence, increases her chances in contracting HIV. For example, if a young woman does not derive pleasure from penetrative sex and has no discourse within which to locate her own sexuality, than the use of condoms makes little difference to her own enjoyment of sex. Thus, it becomes easy for her male partner to insist on unprotected heterosexual intercourse because he finds it sexually pleasurable, and she feels she must please him.
Accounts given by young women of their first sexual experiences illustrate the differently gendered worlds in which adolescents become sexually active. For example, some young women recall their first experience of heterosexual intercourse as something that which they "rushed" through, or wanted to get it "over and done with," all the while focusing on wanting to please their male sexual partner. Moreover, many young women believed that they were "in love" with their male partner, and therefore, engaged in unprotected heterosexual intercourse because they trusted their male partner to be safe from HIV, especially when located within steady, preferably monogamous, relationships (De Oliveira; Holland et. al; Holland and Thomson). However, through this "relinquishment of (sexual) control in the face of love" with male partners, young women place themselves at increased risk for contracting the fatal virus (Campbell and Aggleton, De Oliveira; Holland et. al; Holland and Thomson).
Gendered power relations also places pressure on young men to establish themselves as sexually masculine, and many times, this is through silencing female sexual desire and needs. Through the privileging of male sexual pleasure, it becomes clear the expression of power in sexual relationships resides with the males. One expression in this privileging is the definition of what counts as sex.
When the prevalent definition of "real sex" is the act of vaginal penetration and male ejaculation and/or orgasm, non-penetrative sexual activities are relegated to the category of foreplay (Holland et. al). Thus, sexual practices such as touching, mutual masturbation, and oral sex are seen either as a precursor or as an afterthought to "real" sex which is interpreted as heterosexual intercourse (Holland and Thomson). This places young women at a significant disadvantage in negotiating safer sex because male partners may insist and/or female partners may believe that heterosexual intercourse is the essence of sexuality. Thus, because the use of condoms may disrupt or lessen the pleasure for males, unprotected heterosexual intercourse can become a necessity for "real" sex to occur, placing pressure on young women to engage in unprotected, heterosexual intercourse with potentially HIV infected partners, and thus, increasing their own chance of becoming HIV infected.
Violence Against Young Women
Dealing with sexual violence is considered to be a key factor in the fight against AIDS (Mlamelli et al.). In South Africa, for example, the legacy of violence that underpinned the apartheid state has led to extremely high levels of violence. A history of oppressive political practices has embedded violence as a normal part of gendered relations. The rapid spread of the HIV virus across the country and the disproportionate infection rate in females, have been linked to the high incidence of rape (Human Rights Watch; Mlamelli et al.). While it can be dangerous to generalize from one cultural setting to another, it is important to recognize that the connection between AIDS and gender violence is not limited to the African context. Sexual violence is a problem for women worldwide and the statistics show that Canadian women are no exception. As Holland et al, point out,
On a global scale, heterosexual intercourse has emerged as a means through which HIV is now transmitted, and it appears that transmission is very widely facilitated by social factors which constrain women's control of heterosexual encounters.... ( 458)
A critical constraint experienced by young people wishing to practice safer heterosexual intercourse consists of the degree of control they have within sexual encounters. In general, young women have far less control over their sexual encounters than do young men. One obvious way power is manifest in heterosexual relationships is through the presence or threat of violence against young women by young men.
Sexual pressure from male sexual partners, ranging from rape to persuasion, is common in adolescent heterosexual relationships (Holland and Thompson). For many young men, sexual persuasion is a legitimate (and even requisite) component of the masculine sexual role (Holland and Thomson). However, the degree of persuasiveness determined by the male can vary, from the consistent pestering of their female partner for sexual intercourse to actual rape. For some females, sexual assault can become integrated with socially-constructed roles of proper masculine sexual behaviour and feminine sexual behaviour. The threat or actuality of sexual violence, combined with a greater biological vulnerability to infection than her male partner, renders a young woman at increased risk for HIV transmission during unprotected heterosexual intercourse. For example, the potential tearing and bleeding that occurs in the vaginal tract from forced intercourse increases the risk of HIV infection.
For young women who are particularly vulnerable to HIV infection, gender inequality in heterosexual relationships has become a serious health risk.
Conclusion
With the sharp increase in std rates in youth, young people have become a group at high risk for HIV infection. To curb the spread of the disease, HIV/AIDS prevention programs must consider the many risk factors affecting youth. Considering that girls are particularly vulnerable to std infection, including HIV, highlighting the role of gender in HIV transmission is crucial. In addition to acknowledging young women's biological vulnerability to HIV infection, programs must consider the ways violence and inequity in heterosexual relationships limit young women's ability to practice safer sex. This is the focus of the gaap project. By developing ways to incorporate a gender perspective in HIV/AIDS prevention programs for youth, we are hoping to take an important step in stopping the spread of the HIV epidemic.
The authors acknowledge the support of the Social Science and Humanities Research Council (sshrc).
Nikki Kumar is a MSc student in Exercise Sciences and Women's Studies at the University of Toronto. She would like to thank Amy Andrews, Garry Gray, and Neel Khurana for their valuable feedback.
June Larkin is the coordinator of the undergraduate women's studies program in the Women and Gender Studies Institute, University of Toronto.
Claudia Mitchell teaches in the Faculty of Education, McGill University. She conducts research in youth, AIDS and gender, South African young adult literature, visual studies and teacher identity, and girls'popular culture.
1 Hegemonic masculinity, according to Holland and Thomson, is a socially shared understanding of successful masculinity, constituted in opposition to femininity and other forms of masculinity including homosexuality (64).
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This article is published in the Canadian Woman Studies/les cahiers de la femme "Woman and HIV/AIDS" issue (vol 21 no2).