Gender attitudes, sexual violence, and HIV/AIDS risks among men and women in Cape Town, South Africa

Journal of Sex Research, Nov, 2005 by Seth C. Kalichman, Leickness C. Simbayi, Michelle Kaufman, Demetria Cherry Cain, Chauncey, Sean Jooste, Vuyisile Mathiti

HIV/AIDS is devastating South Africa, with an estimated 1,600 new HIV infections and 600 people dying of an AIDS-related illness each day. The overall HIV prevalence in South Africa is 11%, with HIV prevalence highest in townships and informal urban settlements, where as many as one in five people may be HIV-positive (Shisana & Simbayi, 2002). There is an urgent need for HIV-prevention interventions in South Africa, and the most effective interventions will be informed by careful analysis of social and behavioral factors associated with increased risks for HIV infection. The South African Human Sciences Research Council estimates that 9.5% of South African men are HIV-positive, while almost 13% of the country's women are believed to be infected (Shisana & Simbayi). As is the case in most of sub-Saharan Africa, women greatly surpass men in the number of people living with HIV/AIDS, and in many areas women double the number of men with the virus (World Health Organization/UNAIDS, 2002). Reasons for women's increased risks include biological and social risk factors (Maman, Campbell, Sweat, & Gielen, 2000). Among the factors that are most important in understanding HIV risks in South Africa are those associated with gender and power in relationships.

Gender-power differences are linked to an array of factors that increase risks for sexually transmitted infections (STI), including HIV infection. Studies conducted in the U.S. show that women in violent and abusive relationships are less likely to use condoms, more likely to incur abuse as a result of requesting condoms, and more likely to contract an STI than women who have not been in violent relationships (Kalichman, Williams, Cherry, Belcher, & Nachimson, 1998; Wingood & DiClemente, 1997). Associations between violence, particularly sexual assault, and risks for HIV/STI have also been observed in southern Africa (Ajuon et al., 2002; Garcia-Moreno & Watts, 2000). Research conducted in Kigali, Rwanda, for example, found that HIV-positive women experienced more unwanted sexual contact than HIV-negative women (Van der Straten, King, & Grinstead, 1998). Culturally-sanctioned gender roles foster power imbalances that facilitate women's risks for both sexual assault and STI/HIV (Farmer, Conners, & Simons, 1996; Jewkes, Penn-Kekana, Levin, Ratsaka, & Schreiber, 2001; Morrell, 2002; Pitcher & Bowley, 2002). When gender-power imbalances place women in subordinate roles, women can have few options for exercising personal control in their sexual relationships (Ajuwon et al., 2002; Jewkes & Abrahams, 2002; Wojcicki & Malala, 2001).

The association between control in sexual relationships and STI/HIV risks was supported by research conducted in a township in Cape Town (Kalichman & Simbayi, 2004). Women who had been sexually coerced (a total of 40% of women surveyed) were significantly more likely to have exchanged sex to meet survival needs and to have had multiple male sex partners, greater rates of unprotected vaginal intercourse, lower rates of condom use, more sexual contacts involving blood, and greater rates of STI. Women who had been sexually assaulted were also more likely to have been physically (non-sexually) abused by relationship partners and were more likely to be afraid to ask sex partners to use condoms.

Cross-cultural research suggests that South African men often hold strong traditional gender beliefs (Glick et al., 2000). Consequentially, South African women may experience multiple barriers in their efforts to reduce their risks for HIV infection, including risks for sexual violence in gender-power imbalanced relationships. The potential for women to reduce their risks for STI/HIV is, therefore, seriously limited by socially-constructed gender roles and sexual scripts. Women who suggest using condoms with a resistant sex partner may experience adverse consequences, including threatening the masculinity of their partner, raising partner suspicions about their monogamy or sexual histories, finding themselves vulnerable to further violence, being rejected, and potentially losing their partner's financial support (Ackermann & de Klerk, 2002; Maman et al., 2000; Wood & Jewkes, 2001; Wood, Maforah, & Jewkes, 1998). A study conducted by the International Center for Research on Women found that South African women do not initiate discussions about safer sex or tell their partners to use condoms because it is culturally inappropriate and also because it brings their own sexual behavior into question (Hadden, 1997).

This study used a social constructionist approach to studying gender. We conceptualized gender as a system of social classification that influences access to power, status, and material resources (Crawford, 1995; Crawford & Unger, 2004). All human societies make social distinctions based on gender, and virtually all allocate more power and higher status to men. Only recently have perceptions of gender and gender roles been examined in the context of HIV risks among men and women in southern Africa (Kalichman & Simbayi, 2004). This study examined socially-constructed gender roles at the individual level among men and women receiving STI clinic services in Cape Town, South Africa. Previous research suggested that South African men may hold negative attitudes toward women, including attitudes that may promote sexual violence, such as the acceptance of rape myths (Glick et al., 2000; Jewkes et al., 2001; Jewkes & Abrahams, 2002). Although rape myth acceptance and rape-supportive attitudes are related to sex role stereotyping, adversarial sexual beliefs, and a greater acceptance of relationship violence (Hinck & Thomas, 1999), less is known about gender attitudes in relation to STI/HIV risks. We therefore examined gender attitudes and sexual-violence supportive beliefs (i.e., acceptance of culturally-defined rape myths) in a sample of South African men and women at high risk for HIV transmission. We hypothesized that gender attitudes and rape myth acceptance would be related to greater risks for HIV infection in both men and women.