2.4 The Gendered Nature of HIV and AIDS
2.4.3 Gendered Aspects of HIV and AIDS
The response to the above question is threefold. Discourses explain the reason for female vulnerability to HIV infection through their biological constitution. Phiri (2003a) and Kubai (2008:51) suggest that females naturally have a large surface area of mucosa which is exposed to the sexual secretions of the male during sexual intercourse. These secretions have a high viral load if the male is infected. In addition Phiri (2003a:9) points out that the male semen remains in the vagina for a longer period, and that the infection may continue even after the sexual act. It is therefore possible that under these conditions, the probability of being infected by sexual partner is higher for females than for males.
Secondly, discourses extensively elaborate on cultural aspects that are likely to increase the prevalence and impact of HIV in females than in males. Some of these aspects regard life in partnership and family. Myer (2010), Mills, de Paoli and Gronningsaeter (2009) include here the use of condoms. They argue that many South African men do not want to use condoms during sexual intercourse as they claim it reduces sexual pleasure (Myer, 2010:193). Other reasons that motivate them to prefer unprotected sex is the belief that they are invulnerable and thus do not need to protect themselves with condoms (Mills at al., 2009:1, 7) as well as the meaning given to the marriage as an investment in the future through children (Barnett and Whiteside, 2006:23- 24). It is argued that this refusal to use condoms may therefore play an important role in the spreading of HIV and AIDS if it takes place between polygamous partners or among those who also practice dry sex (Phiri, 2003a:10-11; Kocheleff, 2006:151).
According to Phiri (2003a), Momsen (2004:67, 141, 224), and Hawkinson (2009:2) the gendered role division in the family may also contribute to making women more vulnerable to HIV infection than men. As an example, Phiri (2003a:15) considers that gendered role assignment exposes women to HIV infection when they have to care for PLWHA while they are unaware of the fact that without protection they can be infected by the diseased person‘s blood. Further, as Hlela (2010) points out, some women who care for PLWHA in Pietermaritzburg still ignore this
44
transmission mode. This may imply that some women are being infected when caring for their household members suffering from AIDS-related diseases.
Besides the family, discourses extend the high exposure of women into the wider community.
According to the South African Police Service (SAPS), during the financial years 2010/2011 and 2011/2012, the number of reported incidents of women‘s sexual abuse respectively totalled 35,820 (2011:3), and 31,299 (n.d.:slide 38). With regard to this, Phiri (2002; 2000), Onyejekwe (2004), and Amnesty International (2009) argue that due to cultural reasons, not all cases of abuse are reported. This means that the actual number of abused women within and outside the domestic relationship is higher than the estimates based on reported cases. Connecting abuse to HIV infection, Human Rights Watch (2004:12) states that when the vagina or anus is dry, as in the case of rape, forced sex causes physical injury, thus creating the possibility for infection if the abuser or the victim of abuse is already infected. Moreover, they show that in the case of abuse, condom use is rarely an option (Human Rights Watch, 2004:13). As confirmation to this, Karim (2010:300) finds that in some locales in South Africa, HIV-positive women attending health services are ―about ten times more likely to report violence compared with similar aged HIV- negative.‖ One can therefore infer from these figures and studies that violence or abuse within and outside the family is an important factor in HIV infection among women.
Apart from women, discourses show that female children are much more exposed to HIV infection than male children. The earlier mentioned report of the SAPS (2011:11) shows that in 2010/2011, 51.9% of the contact crimes committed against children were sexual offences. Of these, 76.1% were committed against children aged between 15 and 17 years, 60.5% (for the year 2008/2009) to children below 15 years and 29.4% to children aged between 0 and 10 years of age. This situation was repeated in 2011/2012 where of 50,688 offences against children, 25,862 (51%) were sexually related (n.d.:slide 36). This shows that no single category of child is spared from sexual abuse in South Africa. And, as they explain, sexual offences against children under 18 years have been on the increase since 2008/2009 (2011:12). While these reports do not differentiate between male and female children, the study conducted on Childhood Forcible Sexual Abuse in Northern Province (Madu, 2001:1, 5, 15-16) has shown that 15.7% of girls had been abused as opposed to 8.8% for boys. These statistics add credence to the notion that female children face a higher risk of exposure to HIV than male children.
Speaking on the exposure of girl children to HIV infection, Phiri (2003a), Vitillo (2007:35), and Ackermann (2008:105) also refer to girl-child marriages normally arranged by families with or
45
without the child‘s consent22. Two issues link child marriages to HIV infection. Firstly, children are not able to negotiate safe sex. Secondly, a child‘s genital membranes are under-developed and likely to bleed during sexual intercourse, thus creating an entry for the HIV (Kubai, 2008:52;
UNAIDS, 2010b:132; Karim, 2010:286, 287, 294-295; Siwila, 2011:10, 34, 44-45). Linked to marriage is that of bride wealth, ilobolo. Here, Haddad (2003:152) and Dlamini (2005:61) observe that because it is expensive in South Africa,23 a man who pays the ‗bride price‘ regards his wife as his possession. Such a bride cannot negotiate when it comes to choosing safer sex. In this debate, Bruce (2003:52) points to virginity testing, a common practice in KZN. She argues that HIV infection risk resides in that girls assumed to be virgins become the targets of HIV-positive rapists who think that having sex with a virgin will bring a cure (:51-52). According to Phiri (2003b:72) and Karim (2010:299, 300), some girls opt for anal sex in order to preserve vaginal virginity, while the use of condoms is far from being an option since there is no perceived expectation of pregnancy. Therefore, although culturally privileged, these practices are likely to increase the risk of HIV infection among young women and children.
Parallel to the HIV infection among females is the HIV-related impact. Mills et al. (2009:1-3) and Human Rights Watch (2004:11-12) argue that women are the ones compelled to go for HIV testing and that once HIV is diagnosed, they become the ones blamed for spreading the virus. In order to avoid this oppression, some women do not disclose their status and keep practicing unprotected sex, which obviously worsens the situation. According to Phiri (2003a:15), some widows and women living with HIV within abusive relationships are dispossessed by their in- laws. The main problem however is that, as Mills et al. (2009:3) argue, once HIV infection is associated with psycho-socio-economic problems, HIV-positive women are more likely to develop AIDS-related illnesses than men. It is therefore noted here that as a result of a cultural worldview, gender imbalance resides not only in HIV infection but also in its impact.
The third discursive explanation of gendered imbalance of HIV prevalence and impact is found in wealth inequality. Barnett and Whiteside (2006:165) observe that as a result of an unfair economic system developed since the apartheid era, there is a noticeable wealth inequality among South Africans (:419). Consequently, poor people, especially women, desire economic mobility but they do not have the resources, a situation which often results in their becoming more susceptible to HIV infection. Such a desire for financial wealth can be seen, for example, in a young woman‘s need for expensive mobile phones, clothes, beauty lotions, cars or study fees. As
22 Forced child marriage is called ukuthwala in Eastern Cape (see Nine Campaign and Coalition for African Lesbians, 2010:2022).
23 For example in Zulu community, the bride wealth is ten cows or eleven if the girl is virgin (See Bruce, 2003:52).
46
they are not always able to afford these items, they resort to transactional sex (Carton, 2006:97- 98; Karim, Karim and Baxter, 2010:50; Baloyi, 2010; Bridget, 2011). Moreover, financial inequality impoverishes some who, in order to survive, initiate paid sexual relations. With regard to this, Myers (2010:21) found that in the higher education sector some poor South African female learners who struggle to meet the basic requirements, engage in materially supportive relationships without the power to negotiate safe sex (see also Barnett and Whiteside, 2006:89;
Karim, 2010:289). It is therefore plausible that these conditions of transactional sex are likely to expose such women to a higher risk of infection.
In collating the above insights, it appears that HIV and AIDS is a gendered issue in South Africa, with women the most vulnerable to HIV infection and its impact, while biological, cultural and economic factors play an important role in this imbalance. Nevertheless, King (1995) remarks that because the gender concept includes women and men at the same time, a holistic anthropology of gender must pay attention to both females and males (:6). Therefore, since women constitute a higher vulnerability to HIV and AIDS than men, the following question must be asked: What is the status of men with regards to HIV and AIDS?
While systematic studies on HIV in women started in the early 1990s (Gouws and Karim, 2010:58-59), studies on men have always been selective and limited (Snow, Madalane, and Poulsen, 2010:1060). Soon after the discovery of the first AIDS cases amongst homosexuals in 1982, this population held the attention of researchers for a while (Karim, and Baxter, 2010a:39).
However, since heterosexuals were also found vulnerable to HIV infection, researcher shifted their attention to focus predominantly on women, especially those attending ANCs (Whiteside and Sunter, 2000:47-53). The few men who were of particular interest to researchers during that time were those closer to sex workers in the mining and transport industries, even though population-based surveys initiated since the 1990s confirmed that both males and females were vulnerable to the pandemic (Gouws and Karim, 2010:59-60). However, the few studies on HIV in males have uncovered significant realities which expose the need for further research within this category. These researches have been grouped into three areas, namely HIV prevalence, factors playing a role in HIV infection, and the impact of HIV and AIDS.
With regard to prevalence, it was noted earlier in this chapter how the study on truck-stops found HIV prevalence to be 56% among male drivers (Ramjee, 2010:337). Three recent studies conducted by Lane et al. (2011:626), Rispel et al. (2011:69), and Baral et al. (2011:1) also found a high prevalence of HIV in male homosexuals: 33.9% in Soweto, 49.5% and 27.5% in
47
Johannesburg and Durban as well as 25.5% in peri-urban Cape Town. This sample shows that men are not exempt from HIV infection but are also infected and suffering.
Secondly, discourses allow for the identification of factors that play a role in exposing men to HIV infection. Hunter (2008:567) notes that a traditionally respected and courageous Zulu man, isoka, can marry and support many wives. Likewise, Hadebe (2010:40) has demonstrated that manhood in traditional Zulu culture is marked by aggression, authority and violence. These ‗ideal virtues‘ of masculinity have been proven to be the very ways by which HIV infects males (and females). It was explained earlier how men are reluctant to use condoms during intercourse for socio-cultural reasons (Mills et al., 2009:7; Barnett and Whiteside, 2006:23-24; Myer, 2010:193).
However, in a study conducted in Cape Town, Kalichman (2005:299, 302) found that 16% of men had been subjected to sexual assault and more than one in five had participated in sexual assault. Another study by Kalichman et al. (2006:551) also discovered that coital bleeding and HIV risks in Cape Town were associated with some factors that included having multiple partners and unprotected sexual intercourse. Also in Cape Town, the study of Kenyon et al.
(2010:35, 37) showed that 21% of young men between the ages of 14-25 had already engaged in concurrent sexual partnerships. In KZN, Hunter (2008:569-571) discovered that because of poverty, the meaning of isoka had shifted from being the man able to take care of many wives to being the man able to woo many girlfriends, which is much more likely to expose men to HIV infection than ordinary polygamy because of the instability of the relationships with girlfriends (Denis, 2003). In the Eastern Cape, the study by Dunkle et al. (2006:2107) found that 31.8% of men in their sample had committed physical or sexual violence against numerous partners, a behaviour associated with the high risk of HIV infection. From these studies, it is fairly reliable to assume that the above cultural ‗ideal virtues‘ have lured men into the trap of HIV infection.
Thus, it can be said that men are victims of culture.
Last, but not least, studies identify the negative impact of HIV on the lives of men. Hunter (2008:569-571) demonstrates that HIV and AIDS has brought humiliation and shame upon men who are no longer able or free to perform what they view as ideal for manhood, namely, having many sexual partners. Likewise, Mills et al. (2009:5) depict men‘s humiliation resulting from their portrayal as the purveyors of HIV and women as the victims. For Mills et al., this humiliation and shame also instil in men the fear of being tested, utilising medical services for HIV prevention or treatment, and seeking any other assistance when needed, thus preventing them from participating in addressing the disease (:5). This observation is also shared by Fitzgerald et al. (2010:355), Snow et al. (2010:1060), and Venkatesh et al. (2011:151). This reiterates the
48
conclusion that men in South Africa are suffering like their female counterparts. It also appears that although they are viewed as agents of women‘s high vulnerability to HIV and AIDS, they are under the constant pressure of culture and they also need help. This implies that although a gendered issue with women as being the most affected, HIV and AIDS is a threat to both men and women in South Africa. As a consequence research has to increasingly document strategies to complementarily involve and assist both women and men.
In summarising, the analysis has confirmed that women are proportionally the most affected by HIV and AIDS. Considering practices such as virginity testing, child marriage, rape, gender- based violence, role division, the practice of unsafe sex and wealth inequality, cultural practices are likely to conspire and promote HIV infection and impact mostly on females rather than males. Looking at public health services provided to ANC attendees, women benefit the most from government systems that address the HIV and AIDS pandemic. For this reason, this is the only category in which the HIV prevalence is declining. With regard to the virtue of having sex with many women and issues of masculinity in South Africa, men are the most likely victims of the invisible pressure of culture while they publicly appear as perpetrators and bear this shame.
Drawing on these insights, this thesis argues that both males and females in South Africa suffer from HIV and AIDS because of a culturally-established worldview. It is also clear that, because men and women are in permanent interrelationships, strategies that neglect any gender-based struggle are not likely to eradicate the pandemic. In this regards, Karim (2010) makes a valid point that, ―if we are to make an impact on the current trajectory of this epidemic we will need to adopt more gender-sensitive approaches in all aspects of our response to the HIV epidemic‖
(:285).24
24 While speaking about the influence of the culture on HIV infection and impact among men and women in South Africa, it is also important to note the interaction and shared perception between the culture and the church with regard to the pandemic. This interaction was underlined by Velayati, et al. (2007:491) who inform that over 80% of residents in sub-Saharan Africa affirm drawing their moral and behaviour standards – including those related to HIV and AIDS – from established belief. Some aspects of such interaction are also observed in South Africa. In this regard, whereas the above analysis unveiled men‘s reticence of using condoms advocating that they hamper sexual pleasure and the affirmation of manhood, Joshua (2010) realises the same attitude in Catholic church in KwaZulu- Natal but the reason advanced here being that they contribute to sexual immorality and to the spread of HIV.
Catholic Church rather encourages abstinence, a position displayed also in the idea of cultural value of virginity. Like Catholic Church, Methodist Church of Southern Africa (Sigaba, 2011:64) and Shembe church (Krakauer and Newbery, 2007:31) restrict members to sexual relations within marriage. In addition to sexual practice, the church, like the culture, in South Africa conceives roles that men and women are expected to play as well as the power relationships that govern them within the family ans the community. Hadebe (2012) assesses here that some churches in South Africa still support male professional and relational hegemony. Church and culture therefore have some commongrounds and influence each other in perceptions and practices regarding HIV and AIDS. However, studies still need to specify the extent of this influence. In chapters 5 and 6, some aspects of the mutual influence between the culture and FMCSA in perceiving and responding to HIV and AIDS also emerge.
49
In the light of the above analysis, the next section will focus on how the FMCSA has responded to the HIV and AIDS pandemic that is threatening South Africa‘s social fabric and geographical context. It will also consider the available literature on the subject.